Columbia tBnihtvsiity in tfje Citj> otMt'm ^orfe College ot ^ijpsiciang anb ^urgeong l^eferente Eibrarp ;g^>r •^- .• Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/manualofpsycholoOOmann Plate I. Dementia. General Paralysis. Frontispiece. From photographs taken by the author. See appendix B. A MANUAL Psychological Medicine J>r.Chas,K,MUt0 AND ALLIED NERVOUS DISEASES. CONTAINING THE DESCRIPTION, ETIOLOGY, DIAGNOSIS, PATHOLOGY, AND TREAT- MENT OF INSANITY, WITH ESPECIAL REFERENCE TO THE CLINICAL FEATURES OF MENTAL DISEASES, AND THE ALLIED NEUROSES, AND ITS MEDICO- LEGAL ASPECTS, WITH A CAREFULLY PREPARED DIGEST OF THE LUNACY LAWS IN THE VARIOUS STATES RELATING TO THE CARE, CUSTODY, AND RESPONSIBILITY OF THE INSANE. DESIGNED FOR THE GENERAL PRACTITIONER OF MEDICINE. By EDWARD C. MANN, M.D., Memder of the New York Medico-Legal Society, Etc. WITH PHOTO-TYPE PLATES AND OTHER ILLUSTRATIONS. PHILADELPHIA: P. BLAKISTON, SON & CO., IOI2 WALNUT STREET. 1883. P'ntered according to Act of Congress, in the year 1S83, by P. BLAKISTON, SON & CO., J 11 the Office of the Librarian of Congress at Washington. SHERMAN * CO.. PRINTEHS, PHILADELPHIA. PREFACE. I HAVE endeavored to present to the profession the subject of in- sanity, and allied nervous diseases, in a scientific, clinical, and fo- rensic light, and in so concise a form as to be available for the student and general practitioner. The many kind words of encour- agement which have attended my professional labors, researches and monographs, proceeding as they have from friends occupying high positions in the profession, notably the generous interest and recognition from Prof. Oliver Wendell Holmes, Dr. Pliny Earle, and others in this country, also from Dr. L. S. Forbes Winslow, London, England, encourage me to believe that this book on in- sanity and allied nervous diseases, the outcome of practical ex- perience in the field of psychiatry and neurology, will be welcomed by general practitioners and students of medicine, and, I trust, may not be entirely devoid of interest to those in the same specialty as myself — neurology. Psychological medicine occupies a position of authoritative science, to the elaboration of which has been directed, and is still being directed, the great ability of many of the most distinguished men in the ranks of medicine. Psychological research commands the respect of the enlightened world, because, industriously pursued from small beginnings and unsettled propositions, it has grown to the propor- tions of a well-defined and harmonious system of science. It has become the adjunct of jurisprudence in settling a class of difficult and otherwise inexplicable questions which arise in the administra- tion of justice. The importance of psychology is evinced by the significant fact that the necessities of medical education demand that it shall be taught in the schools. Journals are especially devoted to its investigation, and, aided by hospitals and enlightened treatment, it has declared to the world that a large percentage of persons re- cently insane have been restored to their friends and society who, without such timely assistance, would have passed into the advanced stage of mental unsoundness. A very important point relating to IV PREFACE. the prevention of mental disorders and the modern nerv^ous diseases is, that the growth of mental function is as gradual as that of bodily power, and that brain-tissue degenerations and mental diseases may be separated by long intervals of time from the too premature and intense stimulation of the brain in school children which causes these nervous diseases. We meet with the preponderance of ner\^ous dis- eases in the refined and cultivated classes, where, b}^ premature and stimulating processes of education, there has been forced an elabora- tion of brain-structure, hastening the functional activity of the brain, with no due regard to the law of evolutional precedence. Normal growth and development will give us healthy mind, while a struc- turally degraded centric nervous system, or an altered quality of blood, and secondary disturbance of nerve-function, will antagonize healthy mental manifestation. If we have want of sleep, a defective genera- tion of nerve-force, an unstable condition of the nerve-centres, an incomplete development of any part concerned in mental action, all of which Dr. Blandford, of England, has ably shown to be causes of mental disease, we cannot expect healthy mental function. Alcohol and opium are to-day responsible for much deterioration of brain. Dipsomania and the opium habit being on the increase among Ameri- cans, there is a greatly increased nervousness and an increasing in- herited disposition to the different neuroses ; and the condition known as cerebral hyperjemia, an increase in the quantity of the blood within the capillaries of the brain, or rather one form of it, of vaso-motor origin, resulting from overwork and mental strain, is greatly on the increase. In diseases of the brain both the regional diagnosis and the pathological diagnosis are to-day attracting much attention, and the brilliant work of such writers as Drs. H. Charlton Bastian, L. S. Forbes Winslow, Bucknill and Tuke, Prof. Krafft-Ebbing, Drs. A. Voison, Foville and Luys, Clouston and Blandford, Loggia, Hitzig, Ferrier, Charcot and Lusanne, Brown-Sequard, and Hughlings Jack- son, in England, Germany, France, and Italy, with the able work of our neurologists and asylum superintendents at home, makes the writer only too conscious of his own defects in this field of research. Insanity is not onl}- appearing at an earlier age than formed}^, but there is also a decided increase of insanity disproportionate to the increase of population. Educational pressure on the young, to the neglect of physical exercise, the increasing artificial and unnatural habits of living, the great excitement and competition in business, are • PREFACE, V all tending to induce and multiply nervous diseases, many of which must terminate in mental diseases. As to men, I think, modern nervousness is largely due to mental anxiety respecting business, the abuse of alcohol and tobacco, and sexual excess. These three things, in combination, will break down and shatter the strongest constitu- tion, and induce ataxy, paresis, and insanity in those who inherit weak nervous systems from their progenitors. Regular hours, amuse- ments to divert the mind from the cares of business, freedom from alcoholic stimulants, nourishing food at regular hours and properly digested, abstinence from tobacco during the years previous to puberty and until twenty years, and daily attention to the bowels, with free bathing, will keep most men in robust physical and mental health. Herbert Spencer, in his " Social Statics" page 413, speaks thus re- specting the wise severity of nature's discipline: " Partly by weeding out those of lowest development, and partly by subjecting those who remain to the never-ceasing discipline of experience, nature secures the growth of a race who shall both un- derstand the conditions of existence, and be able to act up to them. And by multiplication of such warnings (the warnings of ignorance, and its consequence, sickness and pain) there cannot fail to be generated in all men a caution corresponding to the danger to be shunned. Are there any who desire to facilitate the process? Let them dispel error ; and, provided they do this in a legitimate way, the faster they do it the better." Any work that we as physicians do towards influencing the public to study the laws of health, to reform their habits of living, to promote the use of baths, to encourage tem- perance, ventilation, and due exercise, and to further a knowledge of the human organism and the laws which regulate it, and in dif- fusing a knowledge of all the means necessary for the preservation of good health, will produce its exact equivalent of results in the -^prevention of insanity. We shall thus develop in the masses an in- telligent, self-helping character, tending to robustness of body and robustness of mind. Nature has attached to ignorance of her laws or their non-observance certain penalties, and she always punishes every breach of these laws. All measures which we take to replace ignorance by wisdom will inevitably check the growth of insanity. From our long experience and repository of facts, it is inexcusable if we cannot obtain some information, or if knowledge cannot be in some way secured, to check the increase of insanity. We, as physi- cians, must make it our concern, charge ourselves with this specific VI PREFACE. duty, and continue it from year to year, and, although each individ- ual's work may be small, the aggregate result will be immense for our fellow-men. While I have freely expressed my own ideas on those diseases with which I am most conversant, and recommended the treatment which in my hands has proved the most successful, I would earnestly advise young practitioners to be guided in their treatment of both mental and nervous diseases by the symptoms and individual charac- teristics of each case, and not to adopt any routine treatment, if they would make successful practitioners. I have to express my warmest thanks to friends for aid rendered me in various ways, but more especially to Dr. Robt. J. Hess of Phila- delphia, and to William J. Mann, Esq., of the New York Bar. The former has kindly made a most careful study and critical analysis of the book, and has favored me with valuable suggestions respecting the arrangement of my work of which I have taken advantage, and by correcting the sheets during their progress through the press has laid me under many obligations. The latter gentleman, my brother, kindly consented to prepare the entire abstract of the laws relating to the care and protection of the insane in every State of the Union, greatly increasing the value of the book, especially to the legal pro- fession, giving it a medico-legal importance which otherwise it could not have had. 28 West Thirtieth Street, New York, Oct. ist, 1883. CONTENTS. CHAPTER I. PAOE ON INSANITY IN GENERAL, ITS HISTORY AND CLASSIFICATION, . .37 CHAPTER II. THE ETIOLOGY OF INSANITY, AND THE IMPORTANCE OF ITS EARLY RECOG- NITION AND REPRESSION IN THE INCIPIENT STAGES. Insanity caused by defect of nerve-force and an unstable condition of the cerebral centres — By incomplete development — By ill health — Intemperance — Grief — Loss of friends — Mental anxiety and sleeplessness — ■Blovi's on the head, etc. — Causes, predisposing and exciting, ......... 52 CHAPTER III. PREVENTION OF INSANITY, . . I 64 CHAPTER IV. DIAGNOSIS AND PROGNOSIS OF INSANITY, 67 CHAPTER V. CIVIL INCAPACITY — LEGAL TESTS OF RESPONSIBILITY — HINTS FOR GIVING TESTIMONY, EXPERT TESTIMONY, AND THE FUNCTIONS OF EXPERTS IN INSANITY, 86 CHAPTER VI, GENERAL PARALYSIS OF THE INSANE (DEMENTIA PARALYTICA), . . 95 CHAPTER VII. IDIOCY — DEMENTIA — FOLIE RAISONNANTE (REASONING MANIA). Moral and affective insanity — Impulsive insanity, • . ...... 105 CHAPTER VIII. MENTAL RESPONSIBILITY AND THE DIAGNOSIS OF INSANITY IN CRIM- INAL CASES, 119 Vlll CONTEXTS. CHAPTER IX. PAGE THE HISTOLOGY AND FUNCTIONS OF THE BRAIN, . . . . • I3I CHAPTER X. THE PATHOLOGY AND MORBID HISTOLOGY OF ACUTE AND CHRONIC INSANITY. The membranes— Epithelium — Nerve-cells— Nerve-fibres— Special morbid condi- tions of gray matter — The neuroglia — Sclerosis— Bloodvessels and sympathetic nerve-cells — Examination of blood and urine from the insane, . . . 139 CHAPTER XL CASES ILLUSTRATING PATHOLOGY AND MORBID HISTOLOGY OF IN- SANITY, 153 CHAPTER Xn. TREATMENT OF INSANITY. General observations — The brain to be looked at as a whole, and medicines must be calculated to act upon it through the general system — Insanity a curable disease if promptly treated at the outset of the disease — If neglected, soon tends to induce organic degeneration, which renders it incurable — Moral treatment — Choice of asylum — Proper attendants— Food — Work — Amusements — Me- dicinal treatment — Question of non-restraint — Home treatment of the quiet in- sane as private patients in private dwellings — Dr. Maudsley's opinion — Lunacy Commission — Opium— Hydrate of chloral — Hyoscyamia — Digitalis — Ergot — Bromide of sodium — Bromide of lithium — Bromide of zinc — Phosphorus^ Strychnia — Iron — Calomel^Tincture cannabis indica and sodium bromide — Prolonged warm baths with cold to the head — The galvanic current of elec- tricity in congestive states and as a tonic to the central nervous system— Opium effectually antagonizes suicidal melancholia when used in connection wtth pro- longed warm baths— Tincture black hellebore and apiol as emmenagogues — Combinations of sedatives in insanity generally the best practice — Monobro- mide of camphor — Fothergill's solution of hydrobromic acid — Chloro-phos- phide of arsenic (Routh's formula) — Conium — Cases illustrating the treatment of insanity— Views of Dr. Pliny Earle, Dr. John P. Gray, Dr. I'homas S. Kirk- bride, Dr. Henry P. Stearns, Dr. Nichols, and others, 157 CHAPTER Xni. INSANITY IN THE MIDDLE STATES. Insanity increasing disproportionately to the increase of population —New York: Utica Asylum — Hudson River State Hospital at Poughkeepsie— The State Homceopathic Asylum for Insane at Middletown— Buffalo State Asylum for Insane— New York State asylums for die chronic insane: The Willard Asylum at Ovid and the Binghamton State Asylum for the Chronic Insane— Kings CONTENTS. County Lunatic Asylum at Flatbush-New York County asylums on Ward', and Blackwell's Lslands-The New Jersey State Lunatic Asylum at Trento-" N. J._The new asylum at Morristown, N. J._The four Pennsylvania State hospitals— Insane m Delaware, in almshouses, etc., CHAPTER XIV. PROVISION FOR THE CHRONIC INSANE. I^arge, expensive institutions a mistake. IX PAGE 266 271 CHAPTER XV. LUNACY IN ENGLAND AND SCOTLAND. The views of the late Dr. Forbes Winslow on the treatment of insanity, . . 275 CHAPTER XVI. THE NECESSITY FOR A NEW METHOD OF INTRODUCING EXPERT TESTIMONY IN CRIMINAL TRIALS WHERE INSANITY IS ALLEGED AS A DEFENCE. States should be districted and a physician in lunacy appointed for each district by the Governor-This board of psychological experts should constitute a State lunacy commission and examine all cases before trial— Dr D Hack Tuke's opinion-Laws of Austria-Laws of France-Law of insanity should be more conformable than it is with medical science-The immense medico-legal im- portance of the recognition of the mental condition that is the precursor of decided insanity: Depression, unwonted excitability, disregard of the minor proprieties of life, change of affections, sleeplessness, change of character, loss of self-control, and, finally, the downfall of the integrity of the intellect, . 296 CHAPTER XVII. CODIFICATION OF THE COMMON LAW AS TO INSANITY. Lord Justice Bramwell's opinion-Lord Justice Blackburn's opinion-Opinion of tlie Lord Chief Justice of England and of Lord Moncrief, the Lord Justice Clerk of Scotland-Of the late Dr. Ray-Sir Fitzjames Stephen's attempt to codify the common law of England on insanity-The physiciai. studies the whole history of his patient and his ancestiy and searches for the causes of any bodily and mental changes that he finds, and thus arrives at the true pa- thology of the disease ; while the lawyer and jurist are mainly interested in the existence of mental disease, its degree, and its influence on conduct-Why the apparent unwillingness to recognize disease in the homicidal act when the physician and jurist alike are willing to recognize disease m the suicidal act? -We must look at these questions by the aid of the light of modern pathology as the Lord Chief Justice of England has done already-People born with a predisposition to insanity manifest slight symptoms for years, but not sufficient to induce their friends to treat them as insane-When an overt act is com- mitted, who can question the value of a careful examination of the past life and acts of the accused ?-His life has exhibited the natural history of insanity CONTENTS. — The psychological expert can point out clearly to the jurist the unmistakable evidences of mental disease, which the latter, necessarily, alone and unaided, could not discover — There should be no rule of law that conflicts with the elementary truths of insanity, on which only such rules should be founded, . 302 PART II. INTRODUCTORY CHAPTER ON MODERN NERVOUS DISEASES. Neurotic affections increasing and multiplying — We have, as Americans, a morbid nervousness which is a new state of the system — Our increased nervousness evinced by the connection with, and influence of the ner\'0us system on other diseases not properly nervous — Increased consumption of neurotic remedies in this country — The neurotic circle in society constantly increasing, out of proportion to the increase of population, equally with the distinctly insane circle of society, causes increased complexity of the central nervous system and of life — -Probable elaboration in structure of the brain due to the demands of a modern civilization upon it — Modern system of education influential in the production of nervous and mental disorders of a grave type — Brain exhaus- tion and organic disease thus induced — The exhaustive effects of excessive and ill-directed brain work in our modem schools — The whole future com- plexion of mental Ufe in great part determined by the impressions made on the sensory centres of the brain when they are undergoing development — The dif- ficulty of making even cultured people understand that brain-tissue degenera- tions and mental diseases may be separated by long intervals of time from the too premature and intense stimulation of the brain which causes these nerve and brain diseases — Brain disease much increased in our period of civilization as compared with a former and more primitive period — By cautious stimulation of the brain we bring it to its highest development; by undue haste we ruin its functional activity forever — Wakefulness and restlessness to be met by promptly leaving one's business and taking complete physical and mental rest — Mental anxiety, by producing sleeplessness and unrefreshing sleep, quickly disturbs the normal balance of the ner^-ous system and deranges its functions — Syphilitic nervous disease and its diagnosis, . . . . . . • 311 CHAPTER XVIII. GENERAL CONSIDERATIONS ON THE DEVELOPMENT OF THE NERVOUS SYSTEM BY EVOLUTION, AND THE CONDITION OF THE BRAIN IN HEALTH AND DISEASE, AND GENERAL REMARKS ON THE REGIONAL DIAGNOSIS OF DISEASES OF THE SPINAL CORD AND BRAIN. The simplest nervous apparatus, one ganglion situated in the neighborhood of the mouth, in the mantle, and giving off cords which proceed to the sense and di- gestive organs of the ascidian mollusc — The echinoidea, the annulosa, having a chain of ganglia running the whole length of the body, united by nervous cords — The insecta, having two cords passing backwards from the cephalic CONTENTS. XI PAGE above the ventral ganglia, and giving off branches to them and to the body walls — This the most rudimentary form of the cerebro-spinal system — The vertebrata — The lancelet, the vertebrate with the simplest nervous system — The renal axis of this animal, a delicate tract of nucleated cells, surrounded by a covering of pia mater, and fifty or sixty pairs of nerves given off laterally — Lamp7-eys possess a higher organization, as they have a cartilaginous cranium, with a spinal cord extending anteriorly — The cod and shark higher yet; the posterior fissure widens, and the halves of the cord expand — Two lateral , columns project into the ventricle from the conjoined restiform and posterior pyramidal tracts — Cerebellum and crura cerebelli added next in process of evo- lution, etc. — Crocodile — Bird— Dog — The cerebra AtyrtAo^ pari passu with the animal's degree of intelligence — Multiplication of ganglia always accompanied by a corresponding differentiation of ganglionic functions, some being devoted to sight, others to controlling muscular tissue, etc.^The nervous system always adapted to the general structure of the animal — The pre-oesophageal ganglion of the annulosa the direct homologue of the vertebrate brain — In the highest vertebrates reflex movements take place through the brain, spinal cord, and sympathetic system — These govern the visceral functions, and are connected with the voluntary actions of life — In the evolution of the nervous system the brain or cephalic ganglion is gradually increased in motor and sensory power, and the non-cephalic ganglion relatively lessened, the nervous apparatus grad- ually gaining in complexity, until man is reached, where we find the nervous system comprising the cerebrum and cerebellum, with the various ganglia and commissures which belong to these bodies, the medulla oblongata, the spinal cord, the sympathetic ganglia, and the nerves which, springing from these several sources, are distributed throughout the organism, etc. — -General consid- erations on the diagnosis, pathology, and treatmejit of nervous diseases — Gen- erally, a perfect accord between the cortkfal lesion in the brain and the periph- eral and functional lesion, and we find the same parallelism between the- in- tensity of the lesion of movements and the gravity of the lesion in the cortical motor zone — From the region of the body where the convulsive movements commence in nervous disease, we may, with certainty, diagnosticate the cortical brain-centre primitively and principally affected, which will be that correspond- ing to the group of muscles earliest brought into action — Rules for localizing chronic lesions of the nervous centres — The appearance of synchronous and symmetrical paraplegia — Paraplegia of the legs — Cerebral paraplegia — Ta- betic symptoms — Progressive muscular atrophy— Hemiplegia with opposite hemiansesthesia — Bilateral tabetic neuralgia of the legs and arms in central neuroses — Progressive paralysis of cerebral nerves — Paraplegia of the tongue (alalia) — Hemiplegia, with opposite facial or oculo-motorius paralysis — Hemi- plegia, with hemianjesthesia of the same side — -Hemiplegia, with incomplete facial paralysis (the upper branch rero^aining free) — Hemiplegia, with convul- sions — Diseases of the meninges — Static vertigo — Contractions of central origin — Tremors — Influence of sensorial irritation upon phenomena due to motor irritation — Phenomena of motor irritation from centric causes — -The diagnosis of diseases of and injuries to the spinal cord — Paralysis of voluntary move- ments, of the muscular sense, of the vaso-motor nerves, hypersesthesia, ocular and facial s3'mptoms on both sides of the body, ansesthesia in one lateral half of the body — We can make an exact diagnosis as to the seat of the lesion : Xll CONTEXTS. PAGE Lesion in the pons varolii, lesions in the crus cerebri, lesions in the optic thal- , amiis, lesion in corpus striatum, lateral ventricles, lesions in the anterior, middle, aftd posterior parts of the cerebral hemispheres — Symptoms of critical affections of the brain— Lesions of the cerebellum — Pathological diagnosis — Sudden haemorrhages — Prognosis in cerebral haemorrhages — To avert threat- ened cerebral hsemorrhages, .......... 319 CHAPTER XIX. DIPSOMANIA. Dipsomania, a true periodical insanity, a form of physical disease — Differs from the physiological state in which the individual merely chooses to indulge in liquor to excess — The great diagnostic point of the disease, the irresistible impulse, by which the patient is impelled to gratify his morbid propensity, being, during the paroxysm, blind to all the higher emotions, and pursuing a course against which reason and conscience alike rebel — These paroxysms preceded by con- siderable disturbance of the nervous system, etc. — Treatment, judicious re- straint — A permanent recovery depends on allowing sufficient time for restora- tion of the nerve-power, mental tone, and physical vigor, and for complete re- cuperation of the will-power, etc. — Nervous exhaustion and premature mental decay from dipsomania, and its treatment, etc., ...... 354 CHAPTER XX. HYSTERIA. Causes, symptoms, pathology, diagnosis , prognosis , a?id treatment — Principal charac- teristics of hysteria consist in an exaggeration of involuntary motility, and a diminution of the power of the will — Voluntaiy movements not properly exe- cuted, while the reflex sensational and emotional movements are abnormally active — The will determined by the ideas, feelings, and fancies — The patient cares nothing for her duties, and takes pleasure in exaggerating all her slight discomforts and annoyances, and by her suspicious, exacting, and unreasonable behavior makes life generally uncomfortable to her friends — ^Hysterical patients must be unconsciously guided away from self, and into new grooves of thought, feeling, and action— Electricity, exercise, tonics, etc. and removal from home — The psychical treatment, away from home, of primary importance, . . 376 CHAPTER XXL EPILEPSY. Definition — Causes — Symptoms — Pathology — Diagnosis — Prognosis — Treatment, . 417 CHAPTER XXH. HYSTERO- EPILEPSY. Symptoms — Pathology — Diagnosis — Prognosis — Treatment — History of a very un- usual case of hystero-epiiepsy, with removal of both ovaries, .... 442 CONTEXTS. XI 11 CHAPTER XXIII. CHOREA. PAGE Symptoms — Causes — Pathology — Diagnosis- — Prognosis and Treatment- — Chorea occurs at a time when the nutrition of the brain is passing through a state of transition, from that of infancy or early childhood to that of the adult period — The lesion one of mal- nutrition and irritation — Treatment must be tonic and bracing to the nervous system, cold sponge baths, chalybeates, quinine, and other metallic tonics — A tendency in the worst cases to run into one or other of the inflammatory diseases of the brain and spinal cord — General unilateral ten- dency of chorea — Symptoms connected with a morbid irritability of the cere- bral convolution, ganglion at the base of the brain, the pons, the medulla and the spinal cord — The disease depends upon hypersemia and mo'bid irritability of the nervous centres — Hereditary chorea, ....... 449 ■ CHAPTER XXIV. VERTIGO. Definition — Causes — Varieties — Prognosis — Treatment, ..... 462 CHAPTER XXV. STATES OF UNCONSCIOUSNESS. Somnambulism — Catalepsy — Trance and Trance Coma, ..... 466 CHAPTER XXVI. CEREBRAL AND SPINAL ANEMIA. Frequence among American women — A disease of capillary contraction and blood- lessness — Symptoms of cerebral irritation present — May be great disturbances of sensibility — If not checked, lapses into melancholia and dementia, ending in psychical torpidity and intellectual decay— The state of ansemia, if carried beyond a certain point, will destroy functional activity and the activity of the brain — Treatment — Psychical and medicinal — Electricity, etc., must improve quantity and quality of blood circulating in the brain and spinal cord, . . 490 CHAPTER XXVII. INFLAMMATORY DISEASES OF THE BRAIN AND ITS MEMBRANES. Periphery of brain very sensitive, and injuries of this portion attended with very serious results — Inflammation of membranes followed by formation of pus or effusion of serum or of lymph — Idiopathic encephalitis very rare — All external injuries to head of great importance owing to anatomical relationship between the pericranium and the dura mater — Stage of invasion and stage of effusion in meningitis — Rigors, pain in head, intolerance of light and noise, and irritability of temper — Symptoms — Differential diagnosis at onset of typhoid fever and delirium tremens, . . . , . . . . . . . .496 XIV CONTENTS. CHAPTER XXVIII. NEURALGIA. PAGE General tonsiderations, varieties and treatment — Pathology of neuralgia consists in the functional impairment of the sensor}' nerve-cells of the central sensory tract of the nervous system which is the seat of ner\'ous sensibility — In neu- ralgia of extremities we should search for trouble or injur}- to the trunk of the nerve whose sentient extremities are affected^Exit of the cranial nerves, neu- ritis and neuralgia — Visceral neuralgias — Hypodermics of atropia — Neuralgia sometimes dependent upon peripheral vaso-motor disturbance, but the nei-ve- ceiitres generally the seat of the disease — Neurasthenia or ner\-ous exhaustion the most important predisposing cause— Tendency of neurasthenia toward in- cipient insanity — Motor phenomena, loss of muscular power and endurance — The secreto-motor part of the nervous apparatus disturbed — Hemorrhoids, impacted faeces, and affections of the urinar}' organs causes of visceral neural- gias — Diseased ovaries — Exostoses in frontal sinuses or in the ethmoidal or sphenoidal bones, or on the roots of the teeth — Treatment — Professor Erb, of Heidelberg, on electricity as a therapeutic agent in neuralgia — Static electricity and continuous galvanic current, ......... 501 CHAPTER XXIX. LOCOMOTOR ATAXLA. (POSTERIOR SPINAL SCLEROSIS) CEREBRAL HVPER.EMIA, CEREBRAL SOFTENING, AND CEREBRAL SCLEROSIS. Description— Symptoms — Clinical history and treatment — Premonitor}' symptoms of posterior spinal sclerosis — Paroxysms of pain of a neuralgic character, wan- dering and of a stabbing, boring nature, generally in the feet and legs — Dimi- nution of the patellar tendon, vesical, rectal, and pupillary reflexes, and plantar anaesthesia — Crises gastn'ques of Charcot — Osteo-arthritic changes — Treatment, . . . . . . . . . . . . .518 CHAPTER XXX. ELECTRICITY IN DISEASES OF THE NERVOUS SYSTEM. The Faradic current — The constant or galvanic current and static electricity — When indicated and how to be used — Dr. J. Russell Reynolds, Dr. A. D. Rock- well, Dr. Wilks, Dr. Poore, Dr. Buzzard, and Dr. Althaus, on clinical uses of electricity, ............. 546 CHAPTER XXXI. SPINAL CONCUSSION. Viewed in a scientific, clinical, and forensic light — Eflects as a rule remote rather than immediate — The mind affected quite as seriously as the body — Medico- legal relation and significance — The spinal cord may be functionally disturbed and even organically diseased from any and all such spinal shocks and inju- ries—Local and constitutional immediate and remote effects from these inju- CONTENTS. XV ries — Primary effects due to molecular changes — Secondary effects of an in- flammatory nature — The length of time that may elapse between the injury and the development of symptoms — Meningitis — Myelitis and meningo-myelitis — Necessarily fatal injuries to the spine from indirect vialence — Variation in pa- ralysis — Slowly developed spinal meningitis from spinal injury in railway col- lisions terminating in death eventually — Paraplegia and slow recovery — Inju- ries to the back without apparent mechanical lesion — Slight injuries followed by fatal results — Sensory disturbances — Nervous shock, no immediate effects and chronic meningitis with imperfect recovery — General shocks the result of railway collision, etc. — Treatment, ........ 608 CHAPTER XXXII. THE PSYCHOLOGY OF CRIME. The degree of responsibility which attaches to the class who are periodically or con- stantly impelled to commit crime — A pathological state of the brain connected with a peculiar skull development (shortening of the occiput, anterior vertex steepness, ^'^ scheitelsteilheit^'' asymmetry, and flattening of occiput) — Professor Moriz. Benedikt's researches — The varieties of skull development which play a part in the natural history of crime — An anthropological change lies at the foundation of criminal propensities — A deficient organization lies at the base of criminal natures and is the cause of the abnormal moral constitution — Exam- ination of four criminal brains by Professor Benedikt — Want of prominence of the extei-nal occipital protuberance and flatness of occiput — -Vertex steepness (rising up from before backwards), present in 55 per cent, of habitual thieves' skulls — (The highest point of the crown generally stands a little higher, one and a half centimetre, than the boundary line between the part of the fore- head covered with hair and that which is uncovered — The proportion is altered in habitual thieves, and there are differences amounting to seven centimetres— The frontal diameter at the top of the crown is broad, and broader than that of the forehead ; and, lastly, the highest protuberance of the two parietal bones lies commonly in such an oblique horizontal line that one end of it lies before and the other behind the ear) — Murder often the result of ethical weak- ness or imbecility because the materials for the formation of the higher feelings are absent — Construction of the skull proportionate to the whole anthropologi- cal organization in animals and man — The ethic constitution or development is wanting which is necessary to the foundation of the feeling of what is right — There is a predisposition to crime as to insanity — The brain comes into the world with the same imperfections and deficiencies, the same irresistible ten- dencies to disease or perversity of action, which have long been observed with regard to other organs — Imperfection, deficiency or obliquity are the result of organic influences, and abnormal mental and moral phenomena rjsult — The necessity for moral pathology to be raised to a science — An irresistible impulse to do or say a thing abhorrent to one's own idea of fitness or morals, significant of the inheritance of a tendency to mental disease — The mental responsibility of those with the peculiar cerebral condition which is produced by tendencies to disease or ancestral vices — The laws of hereditary transmission imperfectly understood — The conditions of mind implying abnormal imperfection of XVI CONTENTS. the brain very imperfectly studied and understood — Science claims recognition of the fact that the course of thought, the sense of moral distinction and con- duct are greatjy affected by congenital imperfections of the brain — Responsi- bility to depend on this fact — A family saturated with insanity will generally exhibit some criminal moral obliquity, frequently witnessed in abnormal mental states — Legal responsibility only to be ascertained by a thorough inves- tigation of the circumstances of each individual case — A good physical edu- cation and sound mental discipline necessary to antagonize diseased tenden- cies, etc., . . . . . . . . . . . . .617 APPENDIX. A. An Abstract of the Laws Relating to the Care and Custody of the Insane in the various States of the Union. By William J. Mann, Esq., of the New York Bar, 631 B. Form for Recording Cases of Insanity to Insure Uniformity of Statistics, . . 672 c. Resume of the Treatment of Insanity, ...,..,,. 675 D. Explanation of Frontispiece, .......... 679 E. Bibliography, ............. 680 Index, 693 INTRODUCTION. A PERFECT state of the organization of the nervous system and freedom from any pathological condition are required for the perfect performance of its functions. Any pathological state of the brain or spinal cord changes the normal function of the nervous system and produces disease. The seat of the intellectual and emotional functions is in the con- volutions of the cerebrum; the cerebellum and the central masses of gray matter being the seat of motion, which may be excited by the desires and by impressions upon the sensory and excito-motory nerves. The medullary substance of the brain is but a series of con- ducting fibres, and pathological conditions of the white substance in the cerebellum, the corpora striata and thalami frequently exist with- out affecting the mental functions. Such diseases will affect sensa- tion and motion, but judgment, memory, and emotion will probably be left unaffected. Conversely, disease may be limited to portions of the brain which either conduct impressions to or from the brain, or which subserve the function of muscular activity. We may have cerebral paralysis without mental disease, although an effusion of blood in the white substance may produce loss of mental function when it at first takes place, from the pressure on the gray matter of the convolu- tions. The mental power soon returns, however, while paralysis of motion remains until the integrity of the injured brain-substance is re- stored. Pathological states of either the gray or white substance of the brain often extend from one to the other by continuity or sympa- thy, as they are so intimately connected, although differing in function. The causes of diseases of the nervous system are like the causes of all diseases— predisposing and exciting. The first or predisposing cause comprises the conditions which so modify the health of a person as to predispose him to the acquisition of nervous diseases. They are: the influence of age, with the important physiological epochs that pertain to the different periods of life ; difference in the organiza- tion of the sexes ; personal peculiarities, comprising the influence of heredity, with its transmission of peculiarities, tastes, and tendencies to disease, such as insanity, epilepsy, hysteria, and neuralgia; occupa- 3 34 INTRODUCTION. tion, habits of life, and effects of previous disease, which man}- times engender a liabiKty to recurrence of the same or aUied neuroses ; and, finally, influence of climate and atmospheric changes and temperature. The second or exciting causes of nervous diseases maybe divided into three classes — mechanical, chemical, and vital, ist. ]\Iay be mechan- ical, or pertaining to abnormalities in anatomical structure of the nervous system or interference with it, as thickening or contraction of bloodvessels by pressure on them or from obstructions in them ; impediments to the transmission of nerve currents along the nerves ; dilatations of arteries, and extravasations or effusions of the blood or serum. 2d. The chemical causes of ner\'ous diseases include all that may be traced to the action of poisonous substances, whether derived from the inorganic or organic kingdoms : thus muscular tre- mors may indicate mercurialism ; and dropped hand, lead poisoning. The effects of stimulants, narcotics, and tobacco are also included. The retention in the system of poisonous effete matter, owing to the defective action of the excretory organs, are among the most impor- tant of the chemical causes of nervous disease, and depend upon inefficient action of the kidne}'S, liver, lungs, and skin. The brain being so abundantly supplied with bloodvessels, is liable to all abnor- mal conditions which irregularity in the quantity or quality of the blood can occasion. It is exposed to the effects of ansemia and h3''per- aemia, the latter being sometimes accompanied by organizable or inorganizable exudates. If there is excess of carbonic acid or defi- ciency of oxygen in the blood circulating through the brain, it is immediately affected by it. The brain is also disturbed through sym- pathy by injuries of or poisonous influences applied to the peripheral portions of the nervous system. 3d. The z'ita/ causes of nervous dis- eases are those which implant themselves in our bodies, and grow and multiply, producing certain characteristic symptoms. They may be palpable, actual, living objects, as parasitic animals and vege- tables, or they may be the infectious matters to which the exanthe- matous fevers are due ; or the poison of malaria, on which ague and intermittent fever depend, which closely resembles the contagia of fever. The nervous s}'stem is especially liable to disease, as its supreme controlling centre, the brain, is liable to conditions of exhaustion to a greater extent than any other organ of the body. The overtasked brain cannot, as can other organs, gradually gain an increase of power to perform its task, but if tasked to such a state of exertion, by any cause or set of causes, that such exertion fails to be INTRODUCTION. 35 followed by sleep, rapid exhaustion follows, with excitement of, and perhaps irregular and disproportionate activity of its func- tions. The brain-cells derive nutritive renovation from the blood principally or entirely during sleep, and anything that directly inter- feres with the uniform and healthy interchange of nutritive plasma passing from the vessels to the cells, and of the fluid cell-contents in a state of involution or degenerative metamorphosis passing from the cells to the vessels, deranges the intimate connection between the nervous and vascular systems through which their most important functions are performed, producing at once grave disturbances of the nervous system, which may eventuate in insanity. The elementary disturbances of the cerebral functions which we meet with in our clinical studies in psychiatry, involve processes in the emotional sphere; processes in the sphere of the conceptions, comprising the reason, memory, and phantasy; and, finally, processes in the psycho- motor sphere, the impulses, and the will. Among emotional disturb- ances we find the two extremes of morbid depression and morbid exaltation, and also the conditions of abnormal excitability and abnormal absence of emotion. The morbid processes in the con- ceptioftal sphere involve and affect the duration, association, intensity, and reproduction of conceptions, and also comprise the delusions of the insane, or false conceptions. The morbid processes met with in the psycho-motor sphere cause the morbid desire for food char- acterizing the insane and the refusal of food by melancholiacs ; affections of the sexual propensities, either loss or abnormal excita- tion ; the various morbid impulses associated v/ith insanity; also, dis- turbances in speech. We have elementary disturbances of conscious- ness in diseases of the mind, such as epileptic states, ecstasy, somnambulism, various states of altered consciousness, and the bewildered state of the mind in paralytic dementia. We have also sensory disturbances, as anaesthesia and hypersesthesia ; motor dis- turbances ; vaso-motor disturbances, such as cerebral anaemia, cere- bral hyperaemia, venous stasis, and oedema of the cortex, and a great many changes in arterial tension, resulting in sudden cardiac disturb- ances in the insane. We have also trophic disturbances, such as the herpes and rhagades of melancholiacs and patients with dementia; abnormal pigmentations, etc. We find also miany anomalies of the vital functions — the temperature, the pulse, digestion, assimilation, respiration, general nutrition, and sleep. As psychiatry is the broadest field of medicine, and is beginning 36 INTRODUCTION. to attract general medical attention, and as we must look to the gen- eral practitioners for practical aid in stemming the great and growing tide of insanity, and depend upon their intelligent efforts to avert it through the prevention of hereditary transmission, which threatens family deterioration, this book is presented to them in the belief that it will be acceptable to them. The general or family physician is interested in the early recognition and repression of the first sign of mental disorder, and he is to be the psychological physician of the near future. To the authors of those works quoted or to which I have referred, and to many miscellaneous writers whose writings have been of ser- vice to me, I acknowledge my indebtedness, and especially to Mauds- ley, J. Russell Reynolds, J. Hughlings Jackson, Drs. Ramskill, Char- cot, Bastian, Duchenne, Skey, Radcliffe, Begbie, Trousseau, Niemeyer, Bristowe, Bouchard, Romberg, Lancereaux, Moreau, Goebel, Brown- Sequard, Wilks, Broadbent, Kirkes, Rilliet et Barthez, Durand-Fardel, Todd, Doussin, Maisonneuve, Pritchard, Falret, Briquet, Landouzy, Bucknill and Tuke, Parchappe, Griesinger, Clouston, Leidesdorf, Griffin, Valleix and Remak, Krafft-Ebing, Esquirol, and Ray. Respecting the medical treatment of insanity in our public institu- tions, I would say that I deem the great necessity of the day to be for greater individual consideration, special treatment, and remedial care of the insane. The theory that the course of insanity is scarcely ever arrested or shortened ought to date its death-blow from 1852, when the eminent Dr. Forbes Winslow, of London, England, wrote as follows : It is a lamentable error to suppose — and a dangerous, a false, and unhappy doctrine to promulgate — that the disordered affections of the mind are not amenable to the recog- nized principles of medical science. I again declare it to be my positive and deliberately formed opinion that there are few diseases of equal magnitude so susceptible of success- ful medical treatment in the incipient form as those implicating the normal action of thought. The vast amount of incurable cases of insanity which crowd the wards of our national and private asylums is pregnant with important truths. In the history of these unhappy persons — these lost and ruined* minds — we read recorded the sad, melan- choly, and lamentable i-esults of either a total neglect of all efficient curative treatment at a period when it might have arrested the onward advance of the cerebral mischief and maintained reason upon her seat, or of the use of injudicious and unjustifiable measures under mistaken notions of the nature and pathology of the disease. ,In no class of affec- tions is it so imperatively necessary to inculcate the importance of early and prompt treatment as in the disorders of the brain affecting the manifestations of the mind. I can- not close my eyes to the fatal consequences which have so often ensued from a belief in the incurability of insanity by medical means. In all grades of society we witness the pernicious, the fatal, the disastrous effects of this dogma, etf., etc. PSYCHOLOGICAL MEDICLNE. CHAPTER L HISTORY AND CLASSIFICATION OF INSANITY. The earliest mention made of insanity is about 145 1 B.C., when Moses declares to the children of Israel that if they disobey the law given to them they will be smitten with madness. David's feigned insanity occurred about the year 1062 B.C. He evidently simulated dementia to exempt him from punishment at the hands of Achish. Ulysses, 11 84 b.c, feigned madness to escape service in the Trojan war. Euripides, in his writings, alludes to the power of the god Bacchus to produce madness. Cambyses was looked upon as insane before his devastation of Egypt, during which time he plunged his dagger in the sacred bull Apis, for which sacrilege he was divested of all reason. Nebuchadnezzar, the great Babylonian king, v/as in- sane, and left the haunts of men, leading the life of a beast, — a form of madness called lycanthropy. The ancients from their descriptions were acquainted with insanity, and the earlier Greek historians make mention of it as affecting the Greek mythological personages. Thus Ajax killed all the sheep in the camp, under the delusion that they were enemies, and favored the cause of his rival Ulysses. Upon re- covering his reason he committed suicide through mortification at what he had done. Even Hercules was said to suffer from insanity. Juvenal, 300 years B.C., mentions hellebore in his writings as the specific in insanity, and it was by this remedy that Melampus is said to have cured the three daughters of Proetus, who became insane through failure to worship the god Bacchus. The heathen philoso- phers believed that the devil took up his abode in the soul, and that the insane person became thus possessed. They believed that he forced an entrance into the soul from without the body. Although in the New Testament we find accounts of insanity, possession of the devil was regarded as synonymous with lunacy. In Matthew 4 : 24, 38 PSYCHOLOGICAL MEDICINE. the Apostle distinctly says that they brought to Christ, those who were lunatic and those who had the palsy; and he healed them. From the earliest period in the history of medicine mental diseases have been recognized, more or less classified, and treated as a rule as worthy of the utmost attention that science and humanity could dictate. As far back as the days of Hippocrates, insanity was recognized as appearing under different forms and conditions of mind. Hippocrates, in writing of insanity, mentioned three states in which mental disease was manifested : mania, melancholia, and dementia. Celsus also recognized three kinds of insanity. The old Roman laws divided the insane into two classes : furiosi, those who were vio- lent and maniacal; and meiite r^a/z'/, those who were suffering from dementia, or weakness of intellect. The ancient writers, although very crude in their ideas of insanity, recognized as a rule the differ- ent mental states accompanying mania, melancholia, and dementia. Different writers in modern times have attempted various methods of classification, but the simple and yet comprehensive one of Pinel has really been the foundation-stone on which all succeeding writers have reared their modern systems of classification. The classification just alluded to includes the four great primary mental states or con- ditions of insanity, namely : mania, melancholia, dementia, and idiocy. As most writers on insanity prefer to enlarge on such simple classifications and elaborate them somewhat, the question arises, what are the best grounds on which to found our classification ? This question has been ably answered by many writers. The aetiology or causes of insanity has been made the basis of two very excellent classifications, the first by Dr. Morel in his Traite des Maladies Men- talcs, published in i860, and the second, a later and more elaborate one, by Dr. Skae. The International Congress of Alienists, at their meeting in Paris, in 18-67, adopted a combination of the setiological and symptomatological methods under seven heads : i. Simple in- sanity. 2. Epileptic insanity. 3. Paralytic insanity. 4. Senile de- mentia. 5. Organic dementia. 6. Idiocy. 7. Cretinism. Drs. Bucknill and Tuke, in their Mamtal of Psychological Mediciiie, have adopted a combination of the symptomatological and psychological method of classification. They have divided it under five heads or divisions, as follows : I. Idiocy, imbecility, and cretinism ; states of undeveloped intel- lectual power. HISTORY AND CLASSIFICATION OF INSANITY. 39 II. Dementia ; a state in which the intellectual power has been destroyed. III. Delusional insanity ; under which head they embrace all the states in which marked delusions are present — melancholia, with delusions ; monomania, with delusions ; and homicidal and suicidal insanity, with delusions. IV. Emotional insanity, or morbid states of the emotions without delusion, whether attended by melancholia or excitement. V. Mania. In conclusion it is remarked that " all these forms or varieties of insanity are liable to complication with epilepsy, or, if acquired, with general paralysis." In moral and intellectual idiocy, and imbecility, and cretinism, we find an absence or arrest of the development of the intellectual and moral faculties, while cretinism is characterized also by a character- istic vicious conformation of the body — an arrest of development of both body and brain alike. We have mania from many causes. We find hysterical mania, amenorrhoeal mania, puerperal mania, the mania of pregnancy and of lactation ; climacteric mania, occurring at the change of life ; mania due to ovarian or uterine disease; senile mania; phthisical mania; metastatic mania; traumatic mania; syphilitic mania ; delirium tre- mens, and dipsomania ; together with the distinct mania of alcohol- ism, mania after fevers, mania depending upon oxaluria and phos- phaturia, general paralysis with mania, and idiopathic mania. These different forms of mania do not necessarily have their own special psychological character, because, for instance, in puerperal insanity we may find in one case melancholia as the mental state, and in another case mania. It is important in studying mental disorders — in treating them, also — to look to the bodily origin of the disease and remove the morbid condition upon which the insanity often entirely depends. We must be careful, however, not to ignore psy- chical causes of insanity, as mania has frequently an emotional as well as a physical cause. Metaphysically speaking, ist. Insanity affects the intellect or the ideas; 2d. The feelings and moral sentiments; and 3d. The propen- sities or instincts. Among the curable forms of insanity we have the insanity of preg- nancy, insanity of childbirth, insanity of lactation, climacteric insanity, insanity from uterine disorder, insanity from tuberculosis (?), insanity 40 PSYCHOLOGICAL MEDICINE. from masturbation, insanity from alcoholism, delirium tremens, dip- somania, hysterical insanit}', and post-febrile insanity. The forms of insanit}" generally styled incurable include paralytic insanity, epileptic insanity, senile dementia, and organic dementia. Dr. Auguste Voison, however, takes an altogether more hopeful view than is held by the profession generally of the curability oi gen- eral paralysis, even in confirmed cases, and reports ten cures on record where there could be no doubt of the diagnosis. In treating of the pathology' and therapeutics of cerebral disease, we may, I think, advantageously combine a method alike adapted to the student of medicine and to the general practitioner, combining a classification which, although it is artificial, aims at presenting to the view a series of mental pictures displaying certain types or forms of disease and such canons of treatment as may remain in the memory and constitute starting-points for subsequent illustration and investi- gation, with a mode based on clinical experience, which, even though it fails perhaps to corroborate the dicta of nosologists, is equally valuable. I have aimed to teach the necessity of examining carefully ever}"- case as it arises, and not to accept blindly and bind the mind down to any preconceived ideas derived from the authority of books, how- ever well written. 3.1y experience in the treatment of diseases of the mind and nervous system has convinced me of the fallacy of almost all our attempts to establish unerring principles of nosological ar- rangement or to establish dogmatic principles of treatment. For the student of mental disease who desires to study a classification of insanit}', I present the classification of one of the most eminent teach- ers of clinical psychiatry in Germany, and one of the most eminent of the new school of German alienists, Professor Krafft-Ebing. His fundamental classification of the insanities is into the psycho- neuroses and the psychical degenerative .states, and to this he adds, as equivalent groups, the cerebral diseases associated with predominat- ing psychical symptoms and the conditions of arrested development. Classification of Insanity. The Psycho-neuroses. I. Primary curable forms. A. Melancholia. 1. Melancholia. 2. ^Melancholia attonita. HISTORY AND CLASSIFICATION OF INSANITY, 4 1 B. Mmiia. 1. Simple maniacal excitement. 2. High maniacal exaltation, with great motor excite- ment and often with furor. C. Primary dementia [StupiditcEt). 11. Secondary incurable conditions of psychical weakness. A. Chronic mania, with a loss of power of creating systematic delusions, found as a sequel of uncured primary forms {Sec2mdiBre verruecktheit) . B. Terminal dementia. 1. Dementia, with excitement and confusion. 2. Apathetic dementia. Tlie Psychical Degenerative States. A. Constitutional affective insanity [Folic Raissormante). B. Moral insanity. C. The monomanies, or Folie systematisee {Primcere Verruecktheii), 1. With delusions. a. Of persecution. b. Megalomania. a. in. Religiosa. b. in. Erotica. 2. With imperative conceptions [Zivangsvorstelhingen). D. Epileptic insanity. 1. The psychical degenerations of epileptics, or ep. dementia. 2. The transitory epileptic psychical disturbances which pre- cede, or follow, or take the place of convulsions. a. Epileptic stupor. b. States of imperfect and dazed consciousness. a. With fright {petit nial intellectual). b. With frightful deliria and hallucinations {grand mal intellectual). c. With religiously expansive deliria. d. Dreamy stupor. e. Dreamy stupor, with excitement. 3. The epileptic psychoses. E. Hysterical insanity. I. Transitory forms. a. With fright. b. Hystero-epileptic deliria. 42 PSYCHOLOGICAL MEDICINE. c. Ecstatic visionary forms. d. Moria-like conditions. 2. Chronic forms. a. Hystero-melancholia. b. Hystero-mania. c. Degenerative states, with hysterical basis. F. Hypochondriacal insanity. G. Periodical insanity. I. Of idiopathic origin. 1. In the guise of a psycho-neurosis. a. Mania periodica. b. Dipsomania. c. Melancholia periodica. d. Circular insanity. 2. In the guise of delirium. II. Of sympathetic origin. a. Periodical insanity of menstruation. TJie Cerebral Diseases zvith Predominating Psychical Symptoms. A. Dementia paralytica [Progressive paresis). B. Cerebral syphilis. C. Chronic alcoholism and its complications. 1. Delirium tremens. 2. Pathological intoxications [mania a potii). 3. Hallucinatory conditions. 4. The alcoholic psychoses. a. Mania gravis potatorum. b. Alcoholic melancholia. c. Alcoholic insanity, with delusions of persecution. d. Alcoholic paralysis. 5- Alcoholic epilepsy. D. Senile dementia. E. Acute delirium [Congestive mania and typho-manid). The Psychical States of Arrested Development — Idiocy and Cretinism. It should be understood that the psycho-neuroses are those insani- ties which attack an intact brain, and the psychical degenerative states are those affecting the brain injured by hereditary or acquired vices of conformation or mal-nutrition. HISTORY AND CLASSIFICATION OF INSANITY. 43 ^ In our examination and study of cases of insanity we may with advantage take up, 1. Anthropometry, or study of the cranium. 2. The face : physiognomy, breadth of forehead, shape of ears. 3. The trunk : shape of thorax, muscular development, amount of adipose tissue. 4. Upper limbs : comparison, abnormal states, etc. 5. Lower limbs : size of muscles and symmetry. 6. Psychical functions: ideation; memory; language, whether defective or not ; neatness of pronunciation. 7. Functions of relation : sensibility — tactile, dolorific, and ther- mal, electric sensibility ; the special senses ; mobility of pupils ; paresis or paralysis. 8. Vegetative functions, whether normally performed. 9. Examination of urine. In making autopsies in cases of insanity, we should examine, 1. Cranium: the bony case, whether thick or thin. Diploe ; lon- gitudinal suture, Avhether straight, or turning to right or left. 2. Cerebrum : conformation and development of hemispheres, whether alike in size. Dura mater and pia mater, whether adherent to hemispheres. Vessels of the pia mater, whether injected beyond normal. Convolutions, whether developed sufficiently, particularly the ascending parietal and the ascending frontal. In epilepsy the most internal part of the ascending parietal has been found to be atrophied and indurated to cartilaginous consistence as far as its em- brochure in the fissure of Sylvius ; also, the ascending frontal and foot of the third frontal. Base of the cerebrum : open lateral ventri- cles and examine thalami optici and corpora striata. Weight of hemispheres. 3. Mesocephalon : cerebral peduncles, pons, medulla, hemispheres of cerebellum. 4. Medulla spinalis : comparison of two halves. 5. Thorax; lungs; bronchi; heart, aortic walls for atheroma; valves of heart. 6. Abdomen; liver, size, consistence, anaemic or congested, etc.; spleen, size and consistence ; kidneys, size, glomeruli and pyramidal substance ; gastro-intestinal tract. 7. Microscopic examination of brain. Definitions of Insanity. — It is almost impossible to give a good definition of insanity. Many have endeavored to do so, but none of 44 PSYCHOLOGICAL MEDICINE. them have as yet succeeded. Locke said that "madmen do not appear to have lost the faculty of reasoning, but having joined to- gether some ideas very strongly, they mistake them for truths and err as men do who argue from wrong principles." Cullen called insanity a "lesion of the intellectual faculties without pyrexia and without coma." Dr. Combs's definition of insanity, was, that " it is a prolonged departure, and without an adequate external cause, from the state of feeling and modes of thinking usual to the individual who is in health, that is the true feature of disorder of mind." He also speaks of insanity as " a morbid action in one, in several, or in the whole of the cerebral organs, and, as its necessary consequence, functional de- rangement in one, in several, or in the whole of the mental faculties which these organs subserve." Dr. Conolly says : " Insanity is an impairment of one or more of the faculties of the mind, accompanied with or inducing a defect in the comparing faculty." Guislain says : " Insanity is a derangement of the mental faculties — morbid, apyrexial, and chronic — which deprives man of the power of thinking and acting freely as regards his happiness, preservation, and responsibility." Morel says : " Insanity is a cerebral affection, idiopathic or sym- pathetic, destroying the individual's moral liberty and constituting a derangement of his acts, tendencies, and sentiments, as well as a general or partial disorder in his ideas." Dr. Bucknill says : " Insanity is a condition of the mind in which a false action of conception or judgment, a defective power of the will, or an uncontrollable violence of the emotions and instincts have separately or conjointly been produced by disease." It is very much easier to describe than to define insanity. A fair medico-legal definition may be found, however, I think, in the fol- lowing: Insanity is a disease of the body affecting the mind by de- ranging its faculties and causing such suspension or impairment of the action of the healthy intellect, emotions, or the will, as to render the individual irresponsible. Ancient and Modern Classifications. — It is understood that Hippoc- rates recognized mania, melancholia, and dementia, although he did not classify insanity in this manner. Celsus recognized phrenitis, accompanied by fever, as one form of insanity; second, mental disturbances without fever, characterized HISTORY AND CLASSIFICATION OF INSANITY. 45 by melancholy and caused by black bile ; and third, a form which he separated in two subdivisions, " for some err in having false images, and not in their whole mind, as Ajax and Orestes are repre- sented in poetic fables; in others, the whole mind or judgment is affected." Aretseus recognized mania, melancholia, and dementia, but con- sidered melancholia as only the initial stage of mania. Ca^lius Aurelianus recognized mania and melancholia as the two forms of insanity. Galen classified insanity into amentia, imbecility, mania, and melan- cholia. Sauvages, in 1763, wrote on the " vesanicB," which he subdivided into the halhicinationes, inorositatcs, and deliria. Linnaeus, in 1763, wrote on i\].e'' mentales," and psychologically divided them into the three classes of the ideales, imaginarii, and pathetici. Vogel, in 1764, recognized mania, melancholia, and amentia. Cullen placed insanity in the class Neuroses and under the order Vesanice. His four great divisions were amentia, melancholia, mania, and oneirodinia. This last division included sornnambulism and nightmare. Dr. Arnold, in 1782, divided insanity into ideal, notional, and pathetic insanity. Crichton, in 1798, adopted Cullen's method of placing mental dis- eases in the class Neuroses and under the order Vesanics, and divided the latter into delirium, hallucinatio, and amentia. Mason Good made the order Phrenetica, in the class Neurotica, and subdivided it into ecphronia (mania and melancholia), empathema (un- governable passion), alusia (illusion), aphelexia (reverie), paronina (sleep disturbance), and vioria (fatuity). Pinel divided insanity symptomatologically under the four divi- sions of mania, melancholia, dementia, and idiotism. He used the term idiotism as indicating an advanced dementia. Esquirol, the pupil of Pinel, thus divides and classifies insanity: " I. Lypcmania (melancholy of the ancients): disorder of the faculties with respect to one or a small number of objects, with pre- dominance of a sorrowful and depressing passion. "2. Monomania: in which the disorder of the faculties is limited to one or a small number of objects, with excitement and predomi- nance of a gay and expansive passion. 46 PSYCHOLOGICAL MEDICINE. "3. Mania: in which the delirium extends to all kinds of objects and is accompanied by excitement. " 4. Dementia : in which the insensate utter folly, because the organs of thought have lost their energy and the strength requisite for their functions. " 5. Imbecility or idiocy: in which the conformation of the organs has never been such that those who are thus afflicted can reason justly." Guislain classified insanity as follows : Phrenalgia or melancholy ; phrenoplexia or ecstasy ; hyperphre- nia or mania ; paraphrenia or folly ; ideophrenia or delirium ; aphre- nia or dementia. Dr. Conolly writes of insanity under Pinel's heads of mania, mel- ancholia, dementia, and idiocy, etc., and says that insanity is de- pendent upon " a state of increased, or diminished, or unequal excitement of the nervous system." Professor Laycock makes a physiological classification, and his principle is that the order of morbid phenomena of insanity is similar and identical with that of healthy phenomena modified, and patho- logical facts should be classified in the same way as the physiologi- cal. He wrote, therefore, on disease of " (l) The encephalic centres subservient to the instincts and animal propensities, /. e., the medulla oblongata, cerebellum, and posterior lobes of hemispheres ;. (2) Those centres subservient to the emotions and sentiments, /. c, the ideagenic or sensorial substance of the cerebellum and hemispheres; and (3) Those subservient to the knowing and representative faculties (intel- lect), i. t\, the nerves of the senses, their ganglia, and the ideational centres in the cerebral (and cerebellar?) hemispheres. Imbecility, melancholia, mania, etc., characterize defective or morbid states of the structure, and therefore of the function of the localities men- tioned."* ]\I. Parchappe's classification of insanity was founded on pathology * Bucknill and Tuke suggest that if physiological and psychological functions of the brain are only diS"erent aspects of the same anatomical substrata, we might classify men- tal disorders in two great divisions, Sensory Psychoses and Alotor Psychoses. The former including all forms of insanity in which feeling and emotion and the power of sensory perception and ideation are more particularly involved (hallucinations and conduct de- termined thereby), the posterior parts of the brain being the centres; while \h^ Alotor Psychoses would comprise those forms in which the higher intellectual faculties are affected as afto motor power, the anterior lobes, here, being in all probability the centres. HISTORY AND CLASSIFICATION OF INSANITY. 47 alone, as follows : Monomania, acute mania, acute melancholia, in- sanity with paralysis, insanity with epilepsy, and chronic insanity. M. Aug. Voison classifies insanity also on a pathological basis. Among the German alienists, Heinroth, Ideler, and Hoffbauer classify insanity psychically, while others classify it somatically.* Dr. Pritchard classified insanity psychologically, and divided men- tal disorders into two great groups. The first embraced moral in- sanity, or pathomania; the second, intellectual insanity, comprising monomania, mania, incoherence, or dementia. Dr. Noble and Dr. Henry Mones adopted a classification of insanity, ranging it in three classes — emotional, notional, and intelli- gential. Griesinger wrote on the basis of psychology, and made two great divisions— Emotional and Intellectual disorders, and associated the will under the last head. Three states were recognized, — the state of mental depression, or melancholia; the state of mental exaltation; and the state of mental weakness. Under the first state Griesinger put hypochondriasis, simple melancholia, melancholia with stupor, melancholia with destructive tendencies, melancholia with persistent excitement of the will ; under the second state, mania and monoma- nia ; and under the third state, chronic mania, dementia, idiocy, and cretinism. Also disorders of sensation and sensations of movement were treated of Dr. Maudsley's mode of classifying insanity was formerly to dis- tinguish the two great classes of intellectual or ideational, and the emotional or affective. Under the first head he placed mania, mel- ancholia, monomania, dementia, general paralysis, idiocy, and imbe- cility; under the second head he placed maniacal perversion of the affective life or mania sine delirio, melancholic depression without delusion (simple melancholia), and moral alienation proper, in close contiguity to which is the insane neurosis of some families. More lately, however, we believe he has adopted Dr. Skae's classification, founded upon causes. Dr. Skae's classification is as follows — Dr. Clouston, by the way, designates it as a system founded upon the principle of " the exclusion of everything mental or psychical con- nected with insanity." The first group in this classification is Moral and Intellectual Idiocy and Imbecility; the second is Epileptic Insan- ity; the third, Insanity of Masturbation; the fourth, of Pubescence. * Max. Jacobi, Ilasse and Friedrich. 48 PSYCHOLOGICAL xMEDICIXE. Then follow: Hysterical mania. Amenorrhceal mania. Post-connubial mania. Puerperal mania. Mania of pregnancy. Mania of lactation. Climacteric mania. Ovario mania (utero mania). Senile mania. Phthisical mania. ^Metastatic mania. Traumatic mania. Syphilitic mania. Delirium tremens. Dipsomania. Mania of alcoholism. Post-febrile mania. Mania of oxaluria and phosphaturia. General paralysis, with insanity. Epidemic mania. ^ . r Sthenic, Idiopathic^ , ^, ^ [ x\sthenic. Dr. Skae was right in this classification in so far that he recog- nized that insanity exists only as the result of disease, either func- tional or organic, in some part of the human body ; but he was wrong in that he claimed that each of these groups presented psychological features peculiar to and characteristic of it, and he was also wrong in ignoring the psychical or emotional causes of insanity, which I consider very numerous, and which act with great virulence on a brain at all weak in its natural development or in one in whose family insanity, epilepsy, or consumption is to be found, i. e., in a brain not perfectly intact, but injured by a hereditar}^ vice of nutri- tion. If Dr. Skae had added a group of psychical or emotional insanity, and had omitted the claim of " psychological lineaments " for each group, he would have given psychologists a strong classifi- cation. As it is, he has not.* We cannot ignore psychic causes in * As ^ve naturally take the full history of every patient into account, as well as the existing mental symptoms, I think Dr. Skae's classification practically useful, as it directs our attention to the bodily cause of the patient's insanity which it must be our aim to HISTORY AND CLASSIFICATION OF INSANITY. 49 the classification of insanity. One great predisposing cause of in- sanity is the insane diathesis, so that a comparatively slight exciting cause will precipitate mental disease upon such a person. The insane diathesis itself is not a disease, but rather the existence of the constitutional tendency to it. We can recognize this neurotic dia- thesis, Dr. Anstie tells us, " I. By the premature occurrence of puberty. Sexual precocity. " 2. By the unexpected development of intense artistic feeling in children born of a naturally commonplace family. " 3. Convulsions during teething without adequate cause. "4. The development of a habit of lying and stealing in well- trained children." Dr. Anstie thinks that an active hereditary insane neurosis always originates in a family stock from either drink, sexual excesses, habit- ual want, or from mental vacuity from entire want of education. In Bucknill and Tuke's Manual of Psychological Medicine both Dr. Tuke and Dr. Bucknill give their own classifications. Dr. Tuke gives two, the first a classification on a metaphysical basis, embracing three great classes: i. The intellect or the ideas (intellectual insanity); 2. The feelings and the moral sentiments ; and 3. The propensities (or will), instincts, or desires, the two latter classes coming under the general head of emotional and volitional insanity. The second clas- sification is one from a somato-aetiological point of view, and this Tuke prefers himself as the more practical working classification. He says that " under the first division of the following list of forms of insanity we ought, therefore, to recognize a number of important cases which arise from excessive action or otherwise of the mental functions themselves, the brain being injured thereby. We might, perhaps, comprise this class in the general term, 'psycho-cerebral insanity,' or psychic insanity. Under this head would come acute dementia induced by mental shock, as fright ; insanity induced by excessive study," etc. The following is the classification : remove. We can then investigate as to whether disease has attacked an intact brain or one predisposed to insanity by reason of inherited or acquired vices of nutrition or con- formation, and finally investigate the psychical state, and by observing the state of mental exaltation, depression or weakness in our patient, diagnose the case as one of melancholia, mania or dementia, or idiocy, as the case may be. We have to consider the indications presented in each individual constitution. We must know the present state of the patient's mind, homicidal or suicidal, etc., and as the result of some practical experience the author of this work does hot adopt any one classification exclusively, and does not recommend the general practitioner, for whom this work is especially intended, to do so. It is practically impossible. 4 50 PSYCHOLOGICAL MEDICINE. I. Insanity or Mental Deficiency caused by Primary Disease or Defective Development of the Encephalic Centres [Protopathic hisanity). 1. Congenital or infantile deficiency. 2. Traumatic insanity. 3. General paresis. 4. Paralytic insanity (insanity with ordinary paralysis). 5. Epileptic insanity (when of central origin). 6. Senile insanity (insanity from old age). II. Insanity caused by Disorder of, or Developmental Changes occur- ring in other Organs than the Encephalic Centres {Deuteropathic Insanity). 7. Pubescent insanity. 8. Masturbatic insanity. 9. Uterine and ovarian insanity (in early or later life). 10. Hysterical insanity. 11. Insanity of gestation or pregnancy. 12. Puerperal insanity (proper). 13. Insanity of lactation. 14. Climacteric insanity. 15. Intestinal, vesical, and hepatic insanity. 16. Post- febrile insanity. 17. Rheumatic and choreic insanity. Gouty insanity? 18. Tubercular insanity. 19. Syphilitic insanity. III. htsanity caused by Alcohol and other Poisons {Toxic Insanity). 20. Alcoholic insanity. 21. Pellagrous insanity, 22. Cretinism. " Insanity may be epidemic. With any of the foregoing may be associated, as a predisposing cause, the insane diathesis." The above classification of mental disorders from the purely somato-setiological point of view is very excellent. It is an ap- proach to an anatomo-pathological classification, but perhaps lacks the psychological method. It is, however, in strict conformity with the somatic school of German psychology represented by Max Jacobi, Nasse, and Friedrich. Clinically, when we have a case of insanity to deal with we natu- HISTORY AND CLASSIFICATION OF INSANITY. 5 1 rally ask first, with a view to the patient's probable course : Has the mental disorder attacked an intact brain or not? or, is it a brain whose conformation and nutrition were probably defective? Then we naturally search for a cause, which may be purely psychic in the first instance, or which may depend on disease of a functional or organic character in some part of the body, which, acting on the brain, has produced either congestion or anaemia of that organ which ministers to the manifestations of mind. Then we want to know the psychical state of our patient, to ascertain whether he will be dan- gerous to himself and others. Has he mental depression or melan- cholia, mental exaltation, or mania, or monomania, or has he mental weakness? We are desirous to be perfectly informed about all this. Then we want to know whether the intellect or the ideas, the feelings and the moral sentiments, or, finally, the propensities, instincts, or desires are principally affected. We see, therefore, that for clinical purposes, which, after all, are the most important, we need in a work- ing classification, a combination of pathological, psychological, symp- tomatological, and setiological systems which it is next to impossible to attain in any one system of classification, however good it may be. The various authors of these different classifications all deserve the greatest respect and credit for their laborious exertions in behalf of practical psychiatry. The physiologist will say : " I regard insanity as divisible from my standpoint according as it arises from disease of the cerebral heinisplieres alone, as we see in idiocy, imbecility, de- mentia, etc., or from diseases combined with disorder of the sensory ganglia or nerves, as exhibited in hallucinations and illusions, or from such defect or disorder combined with disturbances of the motor gan- glia, indicated either by their excessive action, as in mania, or by their depression and disorganization, as in general paralysis, or compli- cated with an affection of the sympathetic or vaso-motor system and marked by vascular disturbance." From his standpoint he is quite right. My metaphysical friend says : " Insanity affects the intellect, the emotions, or the will, and I can always put cases, according to their prominent character, under one or other of these heads." Very true; if you are an experienced psychiatric physician, you probably can. The psychologist says : " All insanity can be classified under intel- lectual and emotional heads and under the psychical states of depres- sion, exaltation, or mental weakness." He is quite correct, also. The somato-setiological physician says : " Every case of insanity has 52 PSYCHOLOGICAL MEDICINE. its physical cause, and I put every case under its special cause." Quite correct, if you can verify it. The pathologist says : " All insanity can be grouped under the heads of arrested or impaired development of the brain — idiophrenic, sympathetic, anaemic, diabetic, toxic and metastatic, phrenitic, enteric, rheumatic, and pellagrous insanity." These views are certainly sound from a pathological standpoint. Dr. Schrceder van der Kolk says : " All insanity is either idiopathic or sympathetic." He is certainly correct. All are right, and yet none of them, when taken singly and alone, makes a complete and exhaustive classification of insanity. Dr. Bucknill has a very good, although complicated, classification, consisting of the combination of psychical characters or phenomena with pathogenetic relations and pathological conditions, the first form- ing the classes ; the second, the orders and genera ; and the third, the species. The classes of psychical phenomena include melancholia, mania, and dementia, with sub-classes of psychical combinations and trans- mutations. The orders of pathogenetic relations include simple, allied, sequen- tial, concurrent, egressing, metastatic, and climacteric insanity. ^\\& genera of pathogenetic relations comprises the subdivisions of the orders. The species of pathological conditions differentiating the genera by pathological conditions of the brain and nerves, of the blood and the nutrition, he divides into neurotic, haemic, and trophic, with appropriate subdivisions. CHAPTER II. ETIOLOGY OF INSANITY AND THE IMPORTANCE OF ITS EARLY RECOGNITION AND REPRESSION IN THE INCIPIENT STAGE. Insanity grows out of a violation of those physical, mental and moral laws which, properly understood and obeyed, result not only in thehighestdevelopmentof the race, but the highest type of civilization. During the past twenty years there has been a decided increase of insan- ity in our country, disproportionate to the increase of population. The increase of insanity over that of population amounts to about ETIOLOGY OF INSANITY. 53 12 per cent. In the foreign element, this is due to marked changes in habits of living, the changes in food, increased intemperance, working more indoors, living in badly ventilated tenements, disap- pointment in not succeeding in business, etc., as they had expected to do in America, all of which causes combined tend to impair health, break down the nervous system, and tend insensibly toward insanity in the offspring. Respecting increased intemperance as a cause of insanity, the 34th annual report of the Crichton Royal Institution shows a rapid increase in insanity from drink as follows : 1869, 8 per cent.; 1870, 16 per cent.; 1871, 23 per cent; 1872, 29 per cent.; 1873, 35 per cent. Dr. Gilchrist remarks that "doubtless a more minute analysis would largely increase the proportion of those in which the excessive use of stimulants, by the patients them- selves or by their parents, constitutes an important if not the pri- mary factor in the production of mental disturbance." Casper said that one-third of all patients in the Berlin pauper asylum were there from drink. At the Bicetre, M. Contease found one thousand cases of alcoholic insanity out of five thousand two hundred and thirty-eight cases. Dr. Voison, of France, says, that during the last eighteen years, cases of insanity from drink have more than doubled. The increase of insanity among our own population is due largely to a change from a vigorous, well-balanced organization to an undue pre- dominance of the nervous temperament, which is gradually taking place in successive generations. The. educational pressure on the young to the neglect of physical exercise. The increasing artificial and unnatural habits of living, the great excitement and competition in business, are all tending to induce and multiply nervous diseases, many of which must terminate in insanity. These causes and the evils resulting from them, are propagated by the laws of inheritance in an aggravated and intensified form. It is an interesting fact which I have observed from an extended examination of the reports which have been sent to me from the various insane asylums through- out our country, many of which I have examined from the com- mencement of such institutions up to the present time, — that insanity is appearing at an earlier age than formerly. These reports show that in former years the average time at which the greatest num- ber became insane, ranged between the age of thirty and forty, but an analysis of statistics shows that this average age is now coming on at an earlier period of life, generally appearing between the ages of twenty and thirty. This is supposed by the highest authorities to 54 PSYCHOLOGICAL MEDICINE. be owing to hereditary influences, which have gradually become in- tensified by violation of physical laws in early life, want of proper training or too high pressure in education. From these preliminary remarks, we proceed to the investigation of the predisposing and ex- citing causes of insanity. The first and great predisposing cause is hereditary predisposition. This has been noticed from the earliest history of the study of in- sanity. Esquirol pbserved and traced hereditary predisposition in about one-fourth of all his cases of insanity. Guislain estimated he- reditary predisposition at 30 percent, of all cases of insanity. Michet gave the opinion that at least one-half, if not three-fourths, of all the insane have either had at some time past, or have at the present time, some cases of insanity in their families. At the York Asylum dur- ing twenty-seven years, from 1846 to 1872, hereditary predisposition was traced in 3 1 per cent, of all the admissions.* With regard to he- reditary predisposition, it has been determined that, as a general rule, if the mother is insane, the disease is more frequently transmitted to the offspring than if the father be affected ; and also, the mother's influence in transmitting insanity to girls is much more to be dreaded than if the offspring be a boy; likewise as regards the father, insanity being much more certain to appear in male offspring, the father being affected, than in the female. There are, of course, many exceptions to this rule; but the laborious researches of Mr. Bail- larger have been accepted by the best authorities as highly probable, if not conclusive. t It has also been proved that the lower forms of insanity, as imbecility, and also depression of mind, are in a marked degree hereditary. It has been remarked that the outbreaks of in- sanity in persons who inherit a predisposition to it, generally make their appearance, and seem to be in some manner connected with the growth and process of evolution of the individual at the period of puberty, childbirth, climacteric period, etc. Most people ignore the law of progressive development, and find it difficult to believe that an attack of insanity coming on in maturity, may have originated in the parent or grandparent, in whom it gave very little, if any, ap- preciable trace of its existence. Yet this is a fact, and is often the result of a lowered vitality or abnormal organic development of the * Guy's "Hospital Reports" for 1877 show that, at Bethlem Hospital, Dr. Savage has traced hereditary predisposition in 34.9 per cent, of 1072 admissions. Out of 901 ad- missions to the Crichton Royal Institution, Dr. Stewart found 447 cases, or 49.61 per cent., whose parents or collateral relatives were affected. f These conclusions were deduced from 600 cases of hereditary insanity. .ETIOLOGY OF INSANITY. 55 nervous system, that has descended from generation to generation, gaining in intensity until it manifests itself by an outburst of insanity in children. One very important organic law which should be uni- versally understood, is, that morbid impulses and characteristics and insane traits may disappear in the second generation, and break out with renewed intensity in the third. It is doubtless true, however, that a tendency or predisposition to mental disease may be trans- mitted to the offspring, and, under good hygienic and other favora- ble conditions, die out, and fail to be transmitted any further. Insan- ity also may appear in the same form in succeeding generations, or it may assume an entirely different form or even assume another form of nervous disease. Thus, it is common to see cases in which, the patient suffering from mania, the offspring may develop symp- toms of epilepsy or chorea. Some authors have held that noth- ing was transmissible to the offspring but an aptitude or predisposi- tion to some disease of the nervous system, and that the develop- ment of any particular type or form of nervous disease was largely the result of circumstances subsequent to birth. The diseases most frequently presenting themselves as the result of hereditary predis- position, have been found to be, aside from the typical forms of in- sanity, hypochondriasis, apoplexy, paralysis, epilepsy, convulsions, chorea, hysteria, and neuralgia. Undoubtedly, next to hereditary predisposition, may be marked in the present day as a predisposing cause of insanity, the great mental activity and strain upon the nervous system that appertain to the present age and state of civilization. The same feverish haste and unrest which characterize us as a nation to-day, and the want of proper recreation and sleep, tend to a rapid decay of the nervous system, and, sooner or later, the most overworked and over- strained minds stagger beneath the excessive burden ; and, one by one brilliant intellects and sterling men are lost to the world, who, if they had exercised moderation in their respective pursuits, might have been spared for years to enjoy the fruits of their industry. Among other predisposing causes may be mentioned those included by the International Congress of 1867, namely, great difference of age be- tween parents; influence of sex; of surroundings ; convulsions or emotions of the mother during gestation ; epilepsy ; other nervous diseases; pregnancy; lactation; menstrual period ; critical age ; pu- berty ; intemperance ; venereal excess, and onanism. Among the ex- citing causes of insanity may be mentioned, trouble and excessive grief; intemperance ; excessive excitement of whatever kind; epilepsy; 56 PSYCHOLOGICAL MEDICIXE. disordered functions of menstruation ; pregnancy ; parturition ; lac- tation ; fevers ; injuries to the head or spine, and overwork.* Intemperance. — It is impossible to estimate the complex influences that intemperance exerts in the production of insanity. All obser- vers agree that it is intimately connected with, and is one of the main exciting causes of insanity. Lord Shaftesbury, in his evidence before the select committee on lunatics in 1859, expressed his opinion that fifty per cent, of the cases admitted into English asylums are due to drink. Many superintendents of foreign asylums have estimated the admissions from intemperance at twenty-five per cent, or higher, including not only the proximate, but remote cause of the disease. This percentage will be largely increased if we take into account the great number of cases in which the intemperance of parents causes the insanity or idiocy of their offspring. I have traced intemperance as a cause in a great many cases of general paralysis that have come under my care, and other superintendents of insane asylums have observed the same thing. M. Lunier estimates that fifty per cent, of all the idiots and imbe- ciles to be found in the large cities of Europe have had parents who were notorious drunkards. Of 350 insane patientsadmitted during two years at Charenton, in Europe, insanity was attributed to drink in 102 instances. We have three forms of insanity resulting from the abuse of alcohol either in the individual himself or his progenitors, and these should, I think, be all included under the general term of al- coholic insanity. As this term is at present, however, synonymous with chronic alcoholism, we must find some more fitting term, I suppose, to include these three manifestations. They are as follows : First, delirium tremens or mania a potu, which is the acute and tempo- rary form of mental derangement caused by intemperance. Secondly, dipsomania, which is characterized by an irresistible impulse to in- * Hereditary predisposition in respect to marriage ; persons with an insane diathesis should never marr)- ; hysteria is not generally benefited by marriage ; epileptics should not marry. We are not in a position to-day to say what cases of insanity will or will not recur after marriage. The danger to neurotic subjects is that of insanity, hysteria, or epilepsy as a result of the marriage. Marriage may or may not be beneficial in hysteria. Among the great evils of the day, which should be stamped out mercilessly, are fruitful marriages among those belonging to insane families. An insane diathesis may or may not be hereditary. This diathesis is marked by an excitable, nervous, melancholic tem- perament. Respecting consanguineous marriages, experience shows the injurious influ- ence of such unions, for if there is a taint of insanity it will be intensified. It is not the fact of relationship, but the chance, of both having " similar vitiations of constitution." ETIOLOGY OF INSANITY. 57 dulge in alcoholic stimulants — an impulse which the intellect seems powerless to control, being overborne by the superior force derived from disease. It becomes, therefore, properly speaking, a form of moral insanity. Excluding the symptoms of delirium tremens, which are too familiar to bear repetition, we have in the other two forms of insanity from intemperance, hallucinations of sight and hearing, confusion of thought, perversion of feelings, suicidal tenden- cies, tremor of the facial muscles and tongue, at times anaesthesia of the extremities, with paralytic symptoms, ending in general paralysis. It is a fact of importance that the children of habitually intemper- ate parents often inherit a predisposition to mental diseases, which generally appear in the form of weakened mental faculties, as in de- mentia, or that they are entirely wanting, as in idiocy.* Domestic troubles and griefs are a frequent cause ; and it is roughly estimated that fromtwelveto fifteen percent, of admissions are from this cause. Under the head of exciting causes are also included physical causes, as artificial deformities of the cranium, organic disease of the brain, etc. There are few of our asylums where, in the annual report, there does not appear a table setting forth the causes of the mental attack. For myself, I do not regard these facts of the highest value when accumulated year after year, or that they furnish very impor- tant data. They do not demonstrate, to me at least, the aetiology of insanity. In the first place, these reports are compiled on no com- mon plan, and therefore the statistics cannot be reliable. For each case of insanity, in an asylum case-book, a single cause or two causes are allotted. It is decidedly the exception, I think, to find a single cause producing insanity in any given case, and we entirely lose sight of the collateral causative influences of the attack of the cerebral disease, which to me is very important, and is, I think, to any thoughtful physician. Instead of finding out one cause which I can say is the cause of a given patient's insanity, I prefer primarily to know whether hereditary tendency has contributed to the production of the mental disorder, and then to be acquainted with all the influences which have been concerned in the production of the mental disease. I think that, in most cases of mental disorder, we are apt to find severali-3.ztox°, which * Dr. Crichton Browne, in vols. i. and ii. of the " West Riding Lunatic Asylum Re- ports," says that the fact of the greater size of the head in civilized races, ufiaccompanied by a proportionate increase in the pelvic diameters, is an influence operating, to a great extent, in the production of idiocy, imbecility, and insanity. Dr. Down says that the greater difficulty of parturition and the exalted emotional life of the mother is the main cause of the danger to mental power in the eldest child. We think him right. 58 PSYCHOLOGICAL MEDICINE. we cannot separate properly, and that rt//have played a part in inducing cerebral disease. Statistics, therefore, of the causes of insanity, are too apt to be inadequate and unsatisfactory to the student of psychological medicine, and he will gain more by studying the detailed records of individual cases, and extracting his facts from such study. When we see how readily and inevitably the future mental state and characteristics of the next generation are determined by the health and the proper mode of living of the present one, it behooves all physicians, who, perhaps more than any class of men, are placed in the closest and most confidential relations to their fellow-men, to en- deavor to promote such modes of living and thinking, that the de- scendants of the present generation may be the gainers and not the losers by their advice. The very mental states and emotions of a pregnant woman are indelibly impressed upon the offspring, and how important it is that the condition of such a woman should be that expressed by the old motto mens sana in corpore sano ! Herbert Spencer, in speaking of the emotions, remarks, " We know that emotional characteristics, in common with all others, are heredi- tary, and the differences between civilized nations, descended from the common stock, show us the cumulative results of small modifications hereditarily transmitted. And, when we see that between savage and civilized races, which diverged from each other in the remote past, and have for a hundred generations followed modes of life becoming even more unlike, there exist still greater emotional contrasts, may we not infer that the more or less distinct emotions which characterize civilized races are the organized results of certain daily repeated combinations of mental states which social life involves? Must we not say that habits not only modify emotions in the individual, and not only beget tendencies to like habits and accompanying emo- tions in descendants, but that, when the condition of the race makes the habits persistent, this progressive modification may go on to the extent of producing'emotions so far distinct as to become new; and if so, we may suspect that such new emotions, and by im- plication all emotions, analytically considered, consist of aggregated and consolidated groups of these simpler feelings, which habitually occur together in experience ; that they result from combined experi- ences and are constituted of them." Respecting the cause of insan- ity among Americans to-day, I do not hesitate to say, that inherit- ing a delicate nervous organization, far in excess of physique, as a rule, gives rise in modern society to a great increase of the neuro- ETIOLOGY OF INSANITY. 59 pathic constitution. I have found overstrain of the brain and ex- cessive use of stimulants to be two of the principal causes of insanity, and also of diseases of the nervous system generally. For a moral cause to produce insanity seems to me to necessitate an organic predisposition to it, although no doubt sometimes a nutritive distur- bance of the brain may be produced by shock to the nervous sys- tem, which may result in mental disorder in a previously healthy per- son. This, I think, however, is a rare occurrence.* The Importance of the Early Recognition and the Repres- sion OF Mental Disease in its Incipient Stages. There exists in insanity, in common with other cerebral diseases, a stage of incubation, in which the insanity is not yet characterized, and in which it commences with incomplete manifestations. It is an equivocal state, differing but little from perfect sanity, but it is the earliest phase of mental alienation, and if recognized by the general practitioner, and promptly treated in this incipient stage, subsequent trouble might be averted. As a primary proposition for the consid- eration of the general practitioner, who must, for the prevention of insanity, understand the principles which are the foundation of psy- chological medicine, we would say, that in his relations with the young in the educational period, he should remember that precocity is a sign of biological inferiority, and that the precocity of organisms and organs, is in an inverse ratio to the extent of their evolution. The psycho-neuroses which attack an intact brain, often commence in intellectual exertion of the exhausted brain, the exhaustion being * Respecting the relations of the seasons to mental disturbance, Parchappe, Guislain, Aubanel, and Thore all agree that there is a greater frequency of attacks of insanity during the summer months, while periodical insanity appears in the spring. As to the influence of civilization as a cause of insanity, Drs. Bucknill and Tuke say that insanity attains its maximum developm ent among civilized nations, remai ning at a minimum among barbarous nations, the unfavorable causes being principally, the increased susceptibility of the emo- tions to slight impressions; the abuse of stimulants ; the overwork of the brain, especially in early life, by an overwrought system of education ; and that condition of the lower classes which is a constant attendant upon civilization — the higher emotions or moral sen- timents, the lower propensities and the intellectual faculties, being thus all subjected, separately or combined, to an amount of excitement unknown to savage tribes. From all the preceding it does not necessarily follow that civilization carried to its perfect develop- ment, a civilization that would exactly temper the force of the emotions, moderate intellec- tual exertion, and banish intemperance, would generate mental disease. We must educate the lower classes and moderate the intellectual strain on the higher classes, to antagonize insanity and prevent it. 6o PSYCHOLOGICAL MEDICINE. induced by taking up too great a variety of subjects for study during the educational period of life. We have, as a result, a passive dilata- tion of the bloodvessels of the brain, connected with disturbances of nutrition, and anaemia of the brain which may produce grave nutri- tional disturbances in the ganglion cells of the cortex of the brain. We get, as a result of either of these states, habitual headache and a loss of intellectual tone. Perhaps these slight disturbances may not attract particular attention, or such cases may be dismissed with some simple prescription, but we must remember that one of the gravest and most incurable of nervous disorders, progressive paral- ysis, commences in just this insidious manner, as a vaso-motor dis- turbance of nutrition of the cortical portion of the brain, where the vessels of the pia mater soon get into a state of passive dilatation, and the disease thus established proceeds to its termination. Great attention should, therefore, be paid to the very earliest indications of brain exhaustion, whether in school children, or the young during the whole educational period of life, or in those of more advanced age where the earliest symptoms are those of nervous exhaustion, which, if not checked, rapidly lapses into actual mental disorder. The brain may not be intact, but may be predisposed to the acquisi- tion of mental disease by hereditary or acquired vices of conforma- tion or nutrition, and then constitutional affective insanity, moral in- sanity, the monomanias, epileptic insanity, hysterical insanity, hypo- chondriacal insanity, or periodical insanity may result, if nervous exhaustion should appear and run an unchecked course, or if the early symptoms of these states be disregarded as matters of slight importance. If a patient complains of general malaise, impaired nutrition and assimilation ; if we find muscular atonicity changing the facial expression; if neuralgia is present; if we find cerebral anaemia; if we find our patient manifests mental depression, and above all if he is sleepless, we have, indeed, a rapid state of nervous prostration which may soon precipitate the patient into active insanity, if these symptoms are not most effectively combated. Irritability and distrust are grave psychical symptoms in asthenic cases. If we have cerebral hyperaemia in our patient, headache may then be a prominent symptom. We must recognize these symptoms as those of a grave nervous prostration, which unchecked lapses into actual insanity with great readiness. I never like to see neuralgia develop- ing in such cases, as it is, when not malarial, very often a premoni- tory symptom of impending mental disturbance, when associated ETIOLOGY OF INSANITY. 6 1 with other symptoms of nervous prostration. Profuse perspirations also are found in connection with nervous prostration, and occur at any hour of the day or night. A loss of the normal elasticity of the skin is another prominent symptom of disorded nervous action. Arsenic as a remedy in this latter class of cases is very valuable. In children, or young people from fifteen to twenty years old, very grave psychical disorders may appear, which require the promptest treat- ment. The history of such patients will usually be, that during childhood they have been excessively nervous, and have, perhaps^ had convulsions in infancy. They have been very emotional chil- dren, suffering from night terrors. There are periods of marked mental inactivity, alternating with a hyper-activity of the mental functions, and such patients do not take or manifest a normal healthy interest in their surroundings. If hysterical girls, they may neither eat nor sleep for some days at a time. There are no suicidal or homi- cidal tendencies in these cases, but a disposition to recurrent mania. In the menstrual psychoses of young girls and women, the psychic disorders which come on at these times in many of them, are, I think, more than a natural exaggeration of the nervous excitability which we may naturally expect in a female at this period. It is a true periodic insanity in many cases, an acute psychosis, with the intellectual centres involved. They are vaso-motor neuroses with recurrent cerebral h^^peraemia. We find this form of periodical in- sanity at any epoch of sexual life, and there is marked physical and mental prostration in the intervals between the paroxysms, and we should combat these states by every means in our power. I remove uterine trouble, if any exist ; use the constant current of electricity to the central nervous system to improve its nutrition, and give sodium bromide (grains, 6d) and fluid extract ergot (5/^), in combi- nation, thrice daily. The monobromide of camphor, in Clin's cap- sules of 4 grains each, is also very valuable in some of these cases, given twice daily, the last dose just before retiring. I also, for one week preceding the appearance of the menses in such women, epi- ploy cerebral electrization daily, using the constant current, which possesses the power of combating and perfectly antagonizing the various congestive states, which, unchecked, lead to insanity. Of all the cases in which I am accustomed to use electrization of the brain, none give more gratifying results than these periodic menstrual psychoses in women. A marked tendency to sleep, even in cases which have been sleepless for days, follows these applications. I 62 PSYCHOLOGICAL JIEDICIXE. have never seen any evil results from the use of moderately strong currents judiciously applied; on the contrary, I have more than once prevented the access of insanity by this means.* Certainly, I know that in many cases where there had been a recurrent menstrual psychosis, or mania, this treatment has resulted in my hands in the complete cure of the patient, when conjoined with the proper medici- nal treatment, so that I most earnestly, and from experience, advo- cate its use. I shall, in a subsequent chapter in this volume, give my views at length on the subject of the value of the constant or galvanic current of electricity as an application to antagonize the various congestive states of the brain. I would insist upon the point, that in young ladies, especially, the mental future depends very largely upon the nervous and physical strength which they attain before the age of twenty-one. Many patients are brought to me suffering from nervous prostration and protracted headaches, during the monthly menstrual epoch, all on account of too great intellectual exertion, inducing a very nervous and hysterical con- dition. These are the young ladies who stand high in their classes at schools and seminaries. We too often sacrifice the constitution to what we deem educational Jiecessitics. I deem the necessity in a young girl, to have plenty of bone, blood, and muscle, and to be well developed, with an accurate balance between the physique and the nervous system, and if something has to be sacrificed, let it be some of her educa- tion, and not some of her mental or physical health. Insanity will just as surely follow neglect of mental hygiene, as the zymotic dis- eases follow neglect of sanitary precautions ; and we too often forget this fact, for the reason that the incubating stage of insanit)'- may be, and often is, long and insidious, and easily overlooked by one who is not a student of psychological medicine. It is very easy to ruin the delicate tissue of the brain by overstraining it when exhausted. * The writer has at present under his care a case illustrating the power of the galvani- zation of the brain in -a young married lady, who from neurasthenia passed into a state of mental disturbance, and thought it her duty — so she said — to murder her husband and chil- dren, to whom she is devotedly attached. She had not menstruated for several months, and her physician told her that she was suffering from " change of life." Her age was thirty- six. A course of hot baths with cold to the head, centric galvanization and electrization of the brain daily, with the citrate of iron and quinine and the liq. acid, phosph. comp. re- moved the amenorrhoea, so that at the end of three weeks my patient was menstruating. The cerebral hypersemia was thus relieved, the idea of homicide vanished like dew before the sun, and my patient is to-day, five weeks after the first day of treatment, a perfectly sane woman. She was also treated in her own home, wMch 1 regard as the severest test of treatment, as such patients need a change of scene and surroundings. ETIOLOGY OF INSANITY. 63 There are too many young brains, not strong and vigorous, but un- stable and subject to irregular and uncertain action, which have been rendered so by an entirely false system of education. There is a great deal of brain fatigue among professional and business men, resulting from a preponderance of waste over repair, which induces grave nervous prostration. Such patients complain of a loss of physical and mental power, and of an inability to do what they could when well; and these same patients exhibit exaggerated sensibility, being very easily affected by trivial impressions. Such patients suffer much from vertigo and confusion of mind, owing to an im- paired nutrition of the brain and spinal cord and a diminution of vascular tonus. One very important set of symptoms to early recog- nize and combat, is that characteristic of cerebral syphilis. In these cases we have a deepseated headache, of extraordinary inten- sity, with nocturnal exacerbations and of long duration. The head- ache is the premonitory symptom of very grave cerebral mischief, which we may ward off if we recognize its significance. As the re- sults of the cerebral congestion of specific origin, we have vertigo and mental dulness, temporary disorders of the special senses, and momentary impairment of the intellect. These symptoms, at first transitory, may become permanent by inattention. Congestive attacks of greater intensity, even attaining the grade of apoplectic fits, may now occur, and attacks of intermittent paralysis. In the gravest forms of specific cerebral disease, an apoplectiform seizure, followed by fatal coma, may usher in the attack with no premonitory symptoms. Epilepsy, if commencing aftej' tzventy years of age, is due, probably, to specific brain disease, and is often preceded by the pre- monitory headache of which I have spoken. In these cases I always put a patient immediately on energetic antisyphilitic treatment, as I care little about the history. The epilepsy is to me evidence of the existence of the disease. The mental symptoms, when insanity appears, are those of exaltation, delirium, and mania. The gravest forms of this disorder often yield rapidly to appropriate treatment. If we find in a patient, a male more particularly, persistent mental dulness, and muscular feebleness, existing as vague undefined symptoms, it is always well to examine his history pretty thoroughly, and a specific course of treatment may very likely prevent, in such a patient, the invasion of insanity. We must not promise perfect recoveries in these cases of cerebral syphilis, for some never recover, and there may be incomplete recoveries. In a certain proportion of cases, 64 PSYCHOLOGICAL MEDICLXE. however, we make a rapid and brilliant cure. Cold douches are very valuable in cerebral s}-philis as an adjuvant to specific treatment, and should never be omitted. I am more inclined to think that syphilitic brain disease is overlooked, than that it is so very rare as some authors claim. I have detailed the symptoms of the gradual breaking down of the nervous system, causing nervous prostration and incipient insanity, and would now briefly state my treatment of such states. The treatment of insanity in general will occupy a separate chapter in the course of this volume. We must secure for our patient good refreshing sleep, and take him away for a time from business cares and anxieties, and, if a woman, give her rest. If the condition is asthenic, alcoholic stimu- lants are indicated, to ward off the cerebral anaemia, which, if not relieved, will bring on an attack of mania. Strychnia is also indi- cated in these anaemic states. I usually use the citrate of iron, qui- nine and strychnia, rest, massage and electricity, together with a milk punch three times a day. If there is cerebral congestion, I employ, as I have said, the constant current of electricity to the brain, to antagonize the congestive states. The bromide of zinc, commencing with y^ to I grain doses, and the hydrobromate of quinine, are both useful in cerebral congestion, also Fothergill's solution of hydro- bromic acid in 15 to 30 minim doses. We are more apt to have an anaemic and asthenic condition of the system, especially in women. In these conditions quinine is one of the best nerve tonics, and may be given in i or 2 grain doses before each meal. Arsenic in Fowler's solution, 5 minims after each meal, continued for some weeks or months, is also very valuable indeed. By appropriate and judicious treatment we may get a perfect cure in the incipient stages of insanity, and generally with no fear of a relapse, unless it is strongly hereditary. CHAPTER III. PREVE^;TION OF INSANITY. Insanity is often a preventable malady. Primarily we must not exhaust the brains of children by a cramming process in education, which cannot fail to injure the nutrition of the brain and impair it. An immense harm is done in this way by producing premature men- tal decay and nervous exhaustion, appearing about the age of puberty. PREVENTION OF INSANITY. 65 The body must be developed in all its parts and organs if we want healthy minds. At present we are developing a race of children whose nervous system is far in excess of their physique, who are predisposed to the acquisition of nearly all the various forms of ner- vous disease upon slight exciting causes, and many of these types of nervous disease readily lapse into insanity. See to it, you who are family physicians, that the children who grow up under your care are developed physically, even if it be at the expense of the neglect of early education. It is not the precocious child who makes the strong man mentally. Discourage all precocity, and keep such chil- dren from study until they have a sound healthy body for a founda- tion, and then avoid overstimulating the mind by too many studies at once.* A young girl recently came under my care for complete nervous exhaustion, who was trying to master thirteen different branches at once, in her most trying period of bodily development. A system of education which allows such nonsense cannot be too severely condemned by physicians. It is absurd for young girls to be put through a cramming process of education, which, at the critical period of life, cannot fail to weaken their nervous system ; and, when this is combined with a society life, the result is a super- ficial education, a broken-down nervous system, and an inability as women to go through the trying duties of maternity. It is for the family physician to say which children shall study hard, and which shall not. Teachers of the young are not qualified to give any such advice. The prevention of such disease should be the highest aim of the physician. Too often an indifference is displayed by him respecting his duties, as a farnily adviser, in such matters. Insanity is also to be prevented by such an education of the masses, as will make them understand sanitary and hygienic laws, and live in accord- * The general pi'actitioner, for whom this book is especially intended, is in a position to check the sources of insanity at their very beginnings. By carefully directing the mental and physical life of the pregnant woman he may form the future mental complexion of the unborn child. He may watch over the child's brain during the early formative period of infancy and childhood, and so advise the parents that they may guide their children in the paths which lead to mental stability. He may recognize the insane diathesis, and by intelligently recognizing that a person is more liable than others to mental disease may apply " a wise culture to the erring emotions, and discipline to the conduct in the early years of life while they are yet applicable, and the fearful heritage may oftentimes be avoided." Moral treatment here is the prevention of insanity. It has been well said that " the celibacy of the insane is the prophylaxis of insanity in the race." Treatment at the outbreak, away from home and under nurses who have patience, endurance, temper and health, would often prevent lifelong insanity. 5 66 PSYCHOLOGICAL MEDICINE. ance with them, so that they may develop the highest moral, physical, and intellectual health. Respecting men, I think that modern nervousness is lai-gely due to mental anxiety about business, the abuse of tobacco, and sexual excess. These three things in combination, especially if the use of stimulants be indulged in, will break down and shatter the strongest constitution, and induce ataxy, paresis, and insanity in those who inherit weak nervous systems from their progenitors. Regular hours, amusements to divert the mind from the cares of business, freedom from alcoholic stimulants, nourishing food at regular hours, properly digested, abstinence from tobacco during the years previous to puberty and until twenty years of age, and daily attention to the bowels, with free bathing, will keep most men sound and healthy. The subject of education in its relations to mental disease is a very interesting one. It is very important, as the elaboration of cerebral structure is taking place in childhood and youth, that suitable exer- cise and stimulation should be carefully applied, so that the brain may be brought to its highest possible development. While we must remember that brain-centres that are not properly stimulated and exercised do not develop, and must consequently insist on proper physical and mental education, and moral and religious training, we must, on the other hand, as carefully avoid undue educational pres- sure and brain-fatigue and exhaustion by overstimulation, especially in badly nourished or sickly children, or in those who are precocious and excitable, as too many American children are. It must be carefully borne in mind that injudicious stimulation of the brain in the teaching of children, may not only induce nervous- ness but even structural disease itself. While I believe most firmly in the advantages accruing from stimulation of the nervous centres by education wisely applied, in those who are strong and vigorous, and consider that ignorance produces a poor development of imper- fectly acting brain-tissue which tends to degenerate, I deprecate the present cramming process so common, which too often menaces the mental integrity of naturally delicate children, who, in a great many cases, have inherited a disproportionate development of the nervous system at the expense of their physique. I DIAGNOSIS AND PROGNOSIS OF INSANITY. 6/ CHAPTER IV. DIAGNOSIS OF INSANITY. There is probably no disease which presents greater difficulties in the way of diagnosis, than insanity. In most diseases we examine physical signs and symptoms, and we determine by our senses the existence of such diseases. In insanity, on the contrary, we have to be guided chiefly by our knowledge of the normal functions of the mind, and in our examination we have to rely on our intellect rather than on our senses, although of course the latter are called in to assist us. It is, however, very often extremely difficult to decide with certainty, as we are expected to do, as to the existence of mental disease, and we assume a great responsibility, whichever way our decision may be given. We either give the patient liberty to take his place in society, and thus expose society to the consequences if he prove to be insane, or we place him in confinement in some insti- tution for the treatment of the insane, thus depriving him of his lib- erty and his family of his support. It becomes then a matter of great importance to decide rightly as to the existence of mental disease, for if this is not rightly done, we shall expose ourselves to the risk of great mortification, and also to the loss of professional reputation. Before going to see a patient who is to be examined for the existence of insanity, it is advisable to find out all one can from the friends and relatives ; but in accept- ing such statements it is wise to allow a wide margin for their infor- mation in regard to hereditary predisposition, as most people, fool- ishly considering the existence of insanity in their family a disgrace, will pertinaciously conceal and deny this fact. Another reason for this concealment may be, that the members of such families are not infre- quently odd and eccentric in their behavior even when perfectly sane, and do not care to have their peculiarities attributed to hereditary taint of insanity, and therefore endeavor to mislead their physician on a point which is to him of the utmost diagnostic importance. Indeed, this and the question of previous attacks, are perhaps the two most im- portant points in the diagnosis of any given case. We should en- deavor when we are called to our patient, to gain his confidence, and from a general conversation lead him cautiously to his state of health and mental feeling. If we are abrupt and wanting in tact we shall 6S PSYCHOLOGICAL MEDICINE. probably defeat our object, and the patient, if displeased, will either refuse to listen to or answer our questions, or will become very angry at our conspiring to deprive him of his liberty. If we are fortunate enough to get a history of the patient, we can generally determine easily, the existence or non-existence of insanity, by the patient's appearance and conversation. Many times, however, we have to rely alone on the conversation, general appearance, and conduct of the- patient, unaided by any other resources. After having gained our patient's confidence and having drawn him into a pleasant conversa- tion, we should first inquire about previous attacks, then into his hereditary history, then into any predisposing causes, such as intem- perance, vocation, habits, etc., which may have operated in the pro- duction of insanity. Also as to injuries to the head or spine which may have occurred, sunstroke, etc. We should then systematically, but carefully and cautiously, examine into the vegetative and repro- ductive functions, and then carefully examine the nervous system for the existence of such lesions as paralysis, epilepsy, catalepsy, hysteria, and allied affections. We should next examine the different senses, beginning with sight, and in this way we shall find out if our patient has good vision, if the retina is normal, and, what is more important, we may discover if he has hallucinations or illusions pertaining to this sense. We may then proceed to the sense of hearing, examin- ing for deafness, and also to discover any hallucinations or illusions of hearing. Proceeding to the sense of smell, we shall discover if it is normal, and also if there are any hallucinations or illusions con- nected with it. Taking up the sense of taste, we may inquire as to the existence of hallucinations or illusions. Patients often complain of their food being poisoned, or that they are eating injurious and hurtful things with their food. The last of the senses, that of touch and nervous sensibility, may be examined for imaginary sense of pain, the existence of reflex action, hypersesthesia, and lastly, for halluci- nations and illusions pertaining to this sense or referring to internal organs of the body. The mental symptoms unconnected with the special senses and pertaining to the intellect, the emotions, or the will, may finish the examination. Whether the diagnosis of insanity present itself to the physician in a purely medical or in a medico- legal point of view, the principles of diagnosis are the same, and we must pursue our examination in precisely the same manner. The first thing we are generally called upon to decide is, whether the patient can be treated at home, or whether it is necessary to place DIAGNOSIS AND PROGNOSIS OF INSANITY. 69 him in an asylum, and we are also probably asked for a prognosis, which latter cannot be too guarded, whatever may be our own im- pression at the time, about the patient. Let us consider for a moment the first question, that of the propriety of removing our patient from his own home, either to some private retreat or to a public asylum. For those who can afford the expense I prefer a residence away from home in some private retreat where but few patients are admitted, for the reason that they unquestionably can have much greater care and attention bestowed upon them than in the congregate plan of treat- ment. If they cannot afford this, a residence in any well-regulated public asylum, where, as a rule, the superintendents are earnest, thoughtful men, careful for their patients' welfare, is to be desired as soon as possible, while the disease is in its early curable stages.* In- sane patients are, by the very nature of the disease, inclined to do mischief They are controlled in their actions by delusions which are to them vivid realities, and no one knows what they may con- sider "it right and proper to do when under the influence of such delusions. Some of the most fearful crimes have been committed by those who have previously been regarded as harmless patients, and no one, therefore, should take upon himself the responsibility of advisingthatapatient whomhe is called to see should be kept at home. The mere moral effect of a residence in a well-regulated asylum for a time, at the onset of insanity, has an immense effect on the mind of a patient, and may prevent consequences that might prove most disas- trous were he to be at home and exposed to the many causes of excite- ment from which he is sheltered in an asylum. We must also decide what form of insanity the patient is laboring under, and in a medico- legal case must give our diagnosis as to the insanity of the patient in its relation to his civil capacity and responsibility for criminal actions, and also as to feigned and concealed insanity. In the latter class of cases, medico-legal cases, it is of the utmost importance for every physician to understand that a man is not irresponsible for crimes which he com- mits, from the fact that some of his ancestors have been insane. The question to be determined here is, whether the hereditary taint, by being transmitted to the individual in question, has influenced or * It should be borne in mind that much of the popular prejudice against hospitals for the insane springs from unfounded statements made by persons who have been inmates of such institutions, and who have been discharged before they were fully restored to reason. A person who has made a complete recovery generally entei tains, not hostility, but the liveliest feelings of gratitude, towards those who have been Instrumental in the restoration of reason. v 70 PSYCHOLOGICAL MEDICINE. determined at all his volitions, impulses, or acts. If, on the one hand, he has been noticed for displaying such peculiarities as usually proceed from hereditary taint, and if the crime was apparently unac- companied by any adequate incentive, doubts of his legal guilt are then to be carefully considered. On the other hand, if the criminal act appears to have been rationally performed, and with some ade- quate and usual incentive, and if the individual has previously been free from mental infirmities or peculiarities that might be attributed to hereditary transmission, then we cannot justly advance insanity as a plea for defence from the consequences of crime. Mental unsound- ness, if unconnected with the testamentary disposition, should not destroy testamentary capacity. If the will is not affected by, or is not the product of insane delusion; if the testator has not ignored the claims of near relationship or of natural affection ; and if his mental faculties are so far normal that he understands the nature of the act and the consequences arising from it ; and if he has a clear idea as to the amount of property he is disposing of; and if in making the will he has not manifested any insane suspicion or aver- sion, the will should be regarded as valid. The diagnosis of insanity is at times ver}^ easily made. Thus, if we find our patient, from having been previously moral, affectionate, and industrious, has become immoral and dissolute, exhibits aliena- tion of affections and neglects his business, all without adequate cause, it is of course easy to determine his insanity, although of course changes may take place in the character of individuals with- out any suspicion of insanity being excited. A great many cases, however, are on the border line which separates sanity from insanit}^, and it often requires the nicest discrimination to determine whether such a patient shall be placed under treatment or not. It now remains to consider the diagnosis of the different forms of insanity which we meet with. In mania the physiognomy is gener- ally distinctiv^e. The countenance is furrowed, the eye wild and vacant, and there is generally a peculiar want of agreement in the expression of the features. The hair often becomes harsh and brist- ling, and the ears may become shrivelled. The actions, demeanor, and dress of an insane patient are generally indicative of mental peculiarities, and oftentimes the latter maybe indicative of the nature of the patient's delusions, or, if not, it may display marked eccen- tricity. In acute mania, it is generally easy to discern in the countenance DIAGNOSIS AND PROGNOSIS OF INSANITY. 7 1 the presence of some strong emotional characteristics, such as pride, hatred, or anger. It has been remarked that insanity anticipates the effects of years and prematurely imprints upon the countenance the facial lines characteristic of habitual emotions, while in lunatics of advanced age, these are observable in a greater degree, and are more deeply marked than they ever are in sane persons. In this form of insanity — acute mania — the bowels are generally constipated, the urine is loaded with phosphates, and the patient suffers from pro- tracted loss of sleep, which is diagnostic of acute mania, and which is a symptom that cannot be feigned by an impostor. Patients of this class pass several days without sleep, and sometimes weeks with but a few hours of sleep in the course of the whole time. Halluci- nations of sight and hearing are far more frequent in this than in any other form of insanity. There may be also rapidly changing delu- sions, and there is generally an intense muscular restlessness, which manifests itself either in destructive impulses, or in continual motion, which rapidly induces dangerous exhaustion, if not properly treated. In melancholia, the most noticeable symptoms will be despondency, fear, and despair, and the expression of the mental states are de- picted in an unnatural degree of intensity upon the countenance of the patient. The patient generally wishes to be alone, is gloomy and depressed, has delusions of fear and persecution, imagines he has committed unpardonable sins, and in the acute cases of melancholia no more pitiable spectacle can be imagined, and the expression of terrible apprehension and fear which occupies the countenance is not easily forgotten. The skin is generally dry, harsh, and muddy, and the bowels constipated. It is such cases as these which have to be carefully watched lest they give way to the suicidal tendencies which are generally present. In dementia, the lines of expression are more or less obliterated, and the vacant, meaningless expression and smile or laugh are in- dicative of this form of insanity. When the mind is tested, the power of memory, attention, and comparison will be found to be partially or entirely wanting. It is only in primary dementia that the practi- tioner will find difficulty in reaching a decision, and sometimes these cases are very difficult to determine. In such cases one of the most valuable symptoms is loss of memory. The patient may, in his con- duct and conversation, exhibit no marked peculiarities, but when the powers of his mind are tested as to the recollection of past events, or even as to the conversation of a few minutes previous, it will be 72 PSYCHOLOGICAL MEDICINE. found that he has entirely forgotten these things. This form of in- sanity is generally unaccompanied by hallucinations or delusions, and is nearly always due to some exciting cause, such as injuries to the head, attacks of apoplexy, or strong emotional disturbances. There is another variety of dementia which is secondary to acute attacks of insanity, and which differs somewhat from primary dementia. In this form of dementia we meet with the remains of the delusions of acute mania, and we also find an exaggerated state of emotional feel- ing which remains after the storms of acute mania have blown over, and the functions of the mind are beginning to suffer decay. The diagnosis of general paralysis is very easy after we have become ac- quainted with the disease. In the early stage the most marked symp- tom is a thickness of articulation, particularly noticeable when the words articulated by the patient are composed of several consonants, when these will be shuffled over in a very characteristic manner. The lips of the patient while he is speaking will be seen to tremble, and likewise the tongue, if it is protruded from the mouth. The gait of these patients is very characteristic and peculiar. They shuffle along in a manner that denotes at once the want of co-ordination in the muscles of the limbs. Later in this form of insanity the power over the sphincters is lost, the patient has to be cared for like an in- fant, and becomes a great trouble to his attendants. There is another class of patients whose only manifestation of in- sanity consists in an abnormal condition of the moral power, and who exhibit no obvious intellectual aberration or impairment. The symp- toms of the mental disease in these cases are limited to the exhibi- tion of morbid impulses which the intellect seems powerless to con- trol. These C2^'s,q.'s, oi moral insanity ■a.x^ sometimes difficult to dis- tinguish, and the laity generally attribute such manifestations to total depravity. In such cases, we must compare the patient with himself when in a state of health and not with any imaginary standard of sanity or insanity. We should bear in mind in this class of cases the excellent definition of Dr. Combe, who says : " It is the prolonged departure, without any adequate external cause, from the state of feeling and modes of thinking usual to the individual when in health, that is the true feature of disorder of the mind." We have thus far considered the diagnosis of insanity only in its relation to the existence of the disease. Let us finally look at the diagnosis of recovery, which oftentimes becomes a very delicate and DIAGNOSIS AND PROGNOSIS OF INSANITY. 73 difficult task for the examiner.* We are to determine whether the patient has recovered so far as to leave no trace of insane ideas and delusions. We must compare the man with his former self in a measure, and see if his natural tastes, affections, impulses, and mental powers have been restored. Of course we must make an allowance for a certain amount of weakness in his intellectual functions, just as we expect to find a man weak bodily after an attack of typhoid fever or other severe disease. We must determine whether the man's intellectual faculties, his memory, reason, and judgment are in a state to enable him to take his place and position in active life. We must observe also whether his conduct is reasonable and quiet. In homi- cidal or suicidal cases we must assure ourselves of the disappearance of the propensity. There are many patients who, although not re- covered, are in such possession of their intellectual faculties as to become very impatient of restraint and confinement, and no amount of reasoning can make them appreciate the necessity for further de- tention in an asylum. A marked case of this character was formerly under my care, and illustrated forcibly this class of patients, who, if exposed to the excitement of society before a thorough cure has been effected, would almost inevitably have a relapse. This patient would argue for an hour at a time very sensibly and forcibly upon the injus- tice and oppression of keeping him longer as a patient, and would chal- lenge any proof of his insanity, and probably nine out of ten physicians not acquainted with him would have said that the man was sane. He would converse rationally upon all subjects until the subject of religion was introduced, when he would immediately reveal gross delusions, and would maintain with the utmost sincerity that he could perform mir- acles, and that he was frequently the subject of them. This shows the importance of examining a patient upon all conceivable topics before pronouncing him cured. These are the cases that generally make their friends and relatives, and particularly strangers, feel that they are un- justly detained, and are the ones who, if they obtain their release in any way, publish their wrongs, and create in this way ill-founded prej- * Dr. Ray says a beginner in this department of our art hails every improvement as the commencement of convalescence, and is apt to regard the appearance of a few healthy traits as the unquestionable presage of recovery. It is not until a later period that he be- comes acquainted with that peculiar oscillation which marks the movements of mental disease and fully comprehends the fact that serious disorder may exist in connection with many sound, healthy manifestations of character. A person may be unequivocally insane, retaining some flagrant delusion, and yet be calm and apparently rational. With this ex- ception his views are correct and clear. 74 PSYCHOLOGICAL MEDICINE. udices against institutions for the care of the insane. Generally speak- ing, if a person who has been insane expresses himself as having been unjustly treated and detained, and denies the fact of his insanity, we may be pretty sure that he has not fully recovered, as persons who are really convalescent are generally fully convinced that they have been in- sane, and are generally very grateful for the care and attention that have been bestowed on them, and express themselves so. Such patients are nearly always willing to be guided by their physician's opinion as to the proper time for their discharge, and do not, as a rule, ex- hibit that intense restlessness and desire to return home which is so apt to characterize doubtful recoveries. The first symptoms of re- covery are the return of natural tastes, inclinations, and affections in the patient. Drs. Bucknill and Tuke, in speaking of symptoms of recovery, lay down the following excellent rules as evidences of res- toration of the mind : 1. A natural and healthy state of the emotions. 2. The absence of insane ideas or delusions. 3. The possession of sufficient power of attention, memory, and judgment to enable the individual to take his part as a free member of society. 4. Tranquil and reasonable conduct; and say regarding them, " when these four symptoms of recovery coexist there can be no doubt that recovery has taken place."* Prognosis. The chances for cure are much greater in recent than in chronic cases. When treatment is delayed the patient's chances diminish greatly, and when treatment is delayed for twelve months, not more than twelve per cent, generally recover their mental health. On the other hand, statistics show that, when the disease is treated promptly, about fifty per cent, may be cured. The results of treatment in cases of insanity resulting from sexual vice are very unsatisfactory, the disease tending toward dementia rapidly. Doubtless a certain * Dr. Ray believes that it is not safe to discharge a patient while he continues to be- lieve in the reality of any single notion or occurrence that was entirely the offspring of fancy, because such a belief indicates morbid action, which, however circumscribed at present, is ever liable to spread, and induce farther mental disorder. Indeed, the evil is seldom so limited as it seems to a casual observer. A very marked remission, amounting, perhaps, to a complete disappearance of ever)' trait of disease, occurs within the first month of an attack, and is often followed by a renewal of the disease. This is the result in by far the greatest number of cases. DIAGNOSIS AND PROGNOSIS OF INSANITY. 75 percentage of cases relapse, and there is a greater tendency of hered- itary insanity to relapse than in any other forms, hereditary predis- position being very unfavorable to permanent recovery, although you may get good results and cures at first. The influence of epilepsy is very unfavorable, and of course idiocy and imbecility present an unfavorable prognosis. General paralysis is, perhaps, the. most unfa- vorable form of insanity and is very fatal, cases generally dying in about three years, although death may occur at a much earlier and also at a much later period of the disease. Dementia, with the ex- ception of primary dementia, is also regarded as incurable. Delu- sional insanity and hallucinations and illusions of the senses are rather unfavorable than otherwise, as regards prognosis. Acute mania is a favorable form of insanity and is recovered from, and also acute melancholia. Climacteric insanity presents usually an unfavorable prognosis. Hysterical insanity is very curable. Puerperal insanity is also very curable if seen at once, and a full mercurial cathartic given to commence the treatment, as the cause of the disease is sep- ticemia, caused generally by absorption of retained products of the placenta. Post-febrile insanity is not very favorable as regards prog- nosis. Successive attacks diminish chances for ultimate recovery, although you may have repeated relapses and recoveries ensuing. The prognostic value of difference of the pupils in insanity is not great, according to most authorities, and does not seem to justify an unfavorable prognosis ; paralytic cases are excluded in these remarks. Cleanliness, restored affections, return to ordinary tastes or habits, are very favorable symptoms, and also the return of suspended secre- tions. Prolonged insomnia is an unfavorable symptom. Insanity occurring in the young some time before puberty, I believe to be very unfavorable, and to tend to imbecility. Respecting menstruation in women, the function may be restored without any corresponding im- provement in mind, or the mind may be restored and the menses re- main suppressed ; Dr. Ray says, of the return of the menses, that " we may certainly regard it as a ground of hope in reserve." Dr. Blandford, of England, in writing on the prognosis of insanity, says: i. " The general prognosis of insanity will depend on the dura- tion of the existing disorder. Perhaps the best established fact of all is, that the chances of recovery diminish in direct proportion to the duration of the malady, and that it is, consequently, of the ut- most importance to place a patient early under adequate and appro- priate treatment. If a twelvemonth elapses without appreciable im- 76 PSYCHOLOGICAL MEDICINE. provement, the chances are decidedly unfavorable. If delusions or hallucinations remain fixed and unchanged at the end of a year, es- pecially if there be hallucinations of hearing, the prognosis is bad. The chief exception is where there is marked melancholia. Patients will recover from this after long periods ; whereas such recoveries are seldom found in insanity when depression is absent. 2. " When the cause of the insanity has been of long duration, the prognosis is less favorable than when it is a passing or accidental form. 3. " Is the prognosis unfavorable in hereditary' insanity? So much of the so-called simple insanity is hereditary, that we must admit that recoveries from it are not infrequent, for it is from this simple in- sanity that recoveries chiejfly take place. Hereditary insanity is brought about by very slight causes, and thus the prognosis is often favorable, and recovery takes place ; but relapse is to be feared, and the prognosis in a second or third attack is not nearly so good. In this hereditary insanit}^, too, we frequently meet with the cases of recurring and ' circular ' insanitj% the progress of which is most un- favorable. Both Ray and Griesinger have remarked that the prog- nosis in hereditary insanity is favorable only where the individual has previously been of normal mind. When he has always been eccentric or semi-insane and undoubted insanity at last manifests itself, the prognosis is very bad. 4. " The more acute the symptoms, the greater the cerebral distur- bance and insomnia, the more favorable is the prognosis, if the case is recent. Conversely, the prognosis is bad when there is little bodily disturbance, where sleep is present, the appetite normal, and the se- cretions unaffected, especially if persistent delusions or an entire moral change are found. 5. "As all deviation from the ordinary mental state and disposi- tion is indicative of insanity, so any return to it is a favorable sign, however trifling the circumstance may be. 6. " Improvement, however slow, is a good sign if it be progres- sive. So long as this goes on, recovery may take place ; but many patients improve up to a certain point and then go no farther. 7. " The age of the patient must be considered. Young people recover in greater numbers than those advanced in life. The latter recover if their insanity be melancholia; but if it be mania with hal- lucinations and delusions, and obscene conduct and ideas, recovery DIAGxXOSIS AND PR0GN0SI5 OF INSANITY. J J is rare, especially if the memory is impaired and signs of approaching dementia are present. 8. " All periodicity in the disease, such as exacerbation and re- missions on alternate days, is unfavorable." Drs. Bucknill and Tuke in their manual oi Psychological Medicine say, respecting the diagnosis of insanity, that no disease is so varied in its manifestations as insanity. That in no other diseases do we meet with such an infinite variety of light and shade belonging to their own nature, or to their intermixture with other maladies, or to the influence of temperament, of individual peculiarities of habit, or of social position, and that, therefore, the diagnosis of no other class of diseases taxes nearly so much the ingenuity and patience of the physician. The physician is compelled to bring to the inves- tigation of mental disorders, a clear analytical conception of those functions which collectively constitute mind. The diagnosis of in- sanity presents itself either in a strictly medical or in a medico-legal point of view. If the question is of the former character, not alone the kind of medical treatment, but also, the question as to whether the patient has to be deprived of his liberty comes up. If the question is medico-legal, we may have to appear either in civil suits and proceed- ings or in criminal trials. In civil suits the distribution of property to a vast amount, the validity of wills, contracts and of other social and commercial acts often depend upon the decision of the physician ; and in criminal trials the frequent issue of the question is the awful one, whether a human life shall be sacrificed with violence and igno- miny, or spared by establishing the plea of not guilty, on the ground of insanity. Whether the question be purely medical or medico-legal, in its bearings and apparent consequences, the grounds of the diagnosis must be the same, for, although in criminal trials the nature of the crime itself, and the manner in which it has been effected, must often be allowed to have no inconsiderable weight in the formation of the judgment, yet, these circumstances are essentially no other than a part ■of the conduct of the patient; and the conduct must be carefully es- timated, even v.^hen the question is most purely medical. The phy- sician is called to see a patient whose symptoms have caused alarm and anxiety to his friends. They wish to insure both his safety and their own, and to provide immediately the treatment which affords the best promise of recovery, and above all, to have the momentous ques- tion decided for them of confinement in an asylum or of treatment at home. yS PSYCHOLOGICAL MEDICINE. T/ie diagnostic value of liereditary tendency is great. The insanity of one parent indicates a less degree of predisposition than that of a parent and an uncle, and still less than that of a parent and a grandparent, or of two parents. The insanity of a parent and a grandparent with an uncle or aunt in the same line, may be held to indicate even stronger predisposition than the insanity of both pa- rents. The influence of the insanity of parents in creating a predis- position will depend, to a great extent, upon whether it has taken place before or after the state of parentage commenced. The in- sanity of a parent occurring after the birth of a child, if it arose from a cause adequate to excite it without previous predisposition, would, of course, be held as of no value in the formation of heredi- tary tendency. The insanity of brothers and sisters maybe of much or of little value as evidence of predisposition, according to the cir- cumstances under which it has shown itself If several of them, both older and younger than the patient, have become insane, the fact tells strongly in favor of predisposition, although neither parent nor grandparent may have been insane ; since it is well known that other conditions in the parent, besides that of actual insanity, may create this predisposition ; for instance, violent and habitual passion, the debility of old age, and most of all, habits of intemperance at the time of procreation. Tlie diagnostic value of previous attacks is considerable, as few dis- eases more frequently recur than those which affect the mental func- tions of the brain. A slight and transient attack, however, respect- ing the real nature of which there may have been some difference of opinion, will be of very different import from a prolonged attack of decided character. The greater the length of time which has elapsed since any previous attack has been recovered from, the less will be the value of it as an indication of the nature of the existing disease. TJie diagnostic value of change of habit and disposition is very de- cided. A comparison of the present behavior and habits of his patient with those which existed in a state of health often will afford the physician a most satisfactory evidence of morbid change in the brain. The natural character of a man who is insane is either changed or exaggerated. The vagaries of hysteria in a woman must not be mistaken for actual insanity. The physician may see in his patient one of four things : first, a vacant and meaningless expression, and a childish absurdity of action, the signs of dementia, of imbecility, or those of general paralysis ; or secondly, a facial expression of deep DIAGNOSIS AND PROGNOSIS OF INSANITY, 79 and concentrated sorrow ; or thirdly, indications in physiognomy, or demeanor, of strangeness and irregularity ; or fourthly, no outward indication of mental disease. In melancholia the patient will readily converse on his mental symptoms. In imbecility and early dementia his apprehension is not sufficiently alert to place him on his guard ; and in mania, he either suffers from head symptoms, respecting which he will readily talk with the physician, or his mind is actively engaged on some project or object, which will afford the physician appropriate topics for conversation. The most difficult cases are those in which differ- ences of opinion and of interest exist among the members of the patient's family, and the patient has been quietly told that it is wished to prove him insane and to place him under confinement, and that the doctor is coming to examine him for that purpose. There is often a diagnostic value in peculiarities of residence and dress. The author had a case of general paralysis brought to him for diagnosis. The patient, a man of wealth, had tliree handsome neck-scarfs on and several valuable scarf-pins, and informed us of his desire to send us one thousand boxes of cigars as a present. Said he felt magnificently , that there were few stronger men in New York than himself. At that time he was advanced some thirteen months in the course of this intractable malady, and had the shuffling gait and the diagnostic hesitating stammering speech of a general para- lytic. He was full of delusions of wealth and grandeur. The diagnostic value of peculiarities of bodily condition is prac- tically nothing. There may be emaciation from loss of rest, derange- ment of the alimentic processes, a quicker pulse than normal, and a tongue coated in the centre. The skin as a rule is harsh and dry and the complexion muddy. We frequently find disordered states of the abdominal viscera in insanity, and we may not unlikely dis- cover gastric or hepatic disorder. Uterine disease is very frequently present. The outward expression in the patient's features and ges- tures of his inward psychical state of sadness, melancholy, despon- dency or despair, may be very striking at times. Intensified expres- sions are seen in insanity of the various emotions, such as pride, anger, fear, jealousy, and the patient with partial insanity may exhibit an unvarying and intense expression of any one particular emotion. In mania the attitude is restless, the motions quick and expressive of various and chang-eful emotions, while in melancholia the attitude is So PSYCHOLOGICAL MEDICINE. apt to be fixed and the gestures slow. In imbecility and dementia we see slovenly postures and undecided and aimless movements. Respecting the physiognomy of insanity, the extreme distortion of the features produced by acute mania, or acute melancholia, is un- mistakable. There is a much greater expression of intense pain in cerebral inflammation, attended by maniacal symptoms, and a more prominent bloodshot eye than in mania alone. In the delirium of fever the countenance indicates low emotional force, while in the de- lirium of mania the facial expression of emotional force is highly ex- aggerated. If there is mobility of the facial muscles in the delirium of fever it is tremulous and feeble, indicating want of power, while in mania the play of these muscles is full of expression and power. It is vigorous and tense, indicating a concentration of nervous force. The wrinkles in the delirium of fever are the result of emaciation, while in the face of the insane man they are caused by the tense contraction of the muscles of expression. There is an apparently causeless and motionless play of features often seen in the insane. In melancholia the facial expression is emotional. In mania it is emotional and intellectual, and marked by the above characteristics of changeableness and inconsistency. In dementia all expression has disappeared, and the physiognomy is vacant and meaningless, showing an absence of thought and desire. General paralytics ex- hibit trembling lips, drooping brows, and features expressive of a mingled state of imbecility and excitement, eyes with pupils of unequal size, all of which constitute a tout enseinblc perfectly diag- nostic to the experienced alienist. In primary dementia it is some- times difficult to make a decided diagnosis. The demeanor and con-a duct are very slightly changed, there is nothing strange in thej appearance, but a great diagnostic sign is loss of memory for very recent events. In conversing with the patient he may not be ablej to remember what he has been talking about a few minutes previ-j ously. Injuries to the head and apoplexy most often cause it, and] fever and emotional disturbances, especially grief, will also cause it.j There is absence of delusion, or hallucination. The physiognomy may be silly and meaningless, and the eyes may have a meaningless look, and there may be a vacant smile on the lips. The patient may also lose not merely the power of understanding anything like an intricate account, but the value of very simple numbers. These facts account for the reckless expenditures of patients with recent insanity. DIAGNOSIS AND PROGNOSIS OF INSANITY. 8 1 Acute and chronic mania, and also incomplete mania, may be easily- recognized, or in the latter case the diagnosis may be extremely difficult, and we may have absolutely nothing but uncontrolled pro- pensities and extraordinary conduct to guide us. In chronic mania, especially with lucid intervals, we may find a remarkable strength of all the intellectual functions, in so far as they are not affected by delusions. The perceptive faculties are retained in all their activity, and the memory is very good, and even the judg- ment on matters unconnected with the delusive opinions and perverted emotions peculiar to the case, may not be greatly affected. The delu- sions may be numerous or they may be few. There is grave emotional perversion. In incomplete primary mania, there may be a decidedly abnormal state of the emotions and sentiments without marked intellectual lesion. This symptom is constant. Friends and relatives are de-: tested and abused, and the objects of natural affection overwhelmed with invective, and, perhaps, sacred things made the subject of blas- phemy. This moral perversion clearly indicates insanity, but there are slighter shades of perverted emotion which require all the adroit- ness of the experienced alienist to discover. Absurd opinions are generally allied to perverted emotions. Exaggerated hysteria may confuse the diagnosis, and it may be mistaken for incomplete primary mania, but the age, sex, constitution, and character of the patient will generally reveal the nature of hysterical attacks when they occur. I had an hysterical patient who feigned that she had the delusion that there was an animal in her abdominal cavity, and this was in strict keeping with the tenor of her life, for she feigned everything ; she, however, made a beautiful recovery by the use of the wire brush electrode with the strongest induced current. In making the men- tal examination we test the fundamental faculties, the attention, the memory and the judgment, and lead the patient to give an ac- count of his own powers of body and mind with reference to health, to exercise, diet and study. Thousands of delusions are entertained by insane people upon these subjects. A conversation respecting the patient's possessions, his means of livelihood, and his hopes of advancement will lead up to delusions of pride, ambition, and ac- quisitiveness, if such exist, carrying the conversation on to his near relatives, and friends, birth and parentage, and the patient's belief whether his parents were his actual and real parents will lead up to delusions respecting imaginary greatness, and any perverted emotions 82 PSYCHOLOGICAL MEDICINE. towards those who ought to be dear to him. His religious observ- ances may be inquired into with the expectation of finding insane delusions on this subject. Politics and science may be made the topic of conversation with an educated man, and if insane he will hardly stand the test of discriminating inquiry on these and similar subjects. Indecorous conduct towards the opposite sex, perverted appetite and unnatural habits we must learn of from those who have opportunities to discern them. The diagnosis of eccentricity is only likely to be brought up in cases of disputed wills or in criminal cases where eccentric conduct is utilized to support the plea of insanity. There are two forms of eccentricity. The one arising from an excess of individuality, where the individual is often endowed with more than an average portion of good sense and of moral courage, although his sense is founded ^pon reasons marked out by his own mind, upon propositions laid down by himself, and adverse to the common-sense of those among whom his lot is cast, and his moral courage is displayed by adhesion to his own opinions, and by setting at naught the ill-founded ridicule of the world. An eccentric man of this type is further removed from the chances of insanity than most of the sane people upon whose prejudices and fancies he sets his heel. His intelligence is not made the sport of his passions, his emotions are under control ; in short, he has superior intelligence. In the second form of eccentricity the man deviates from the ordi- nary observances of society from weakness of judgment, from love of applause, and the desire of drawing upon himself the attention of others. His conduct is ill-regulated and influenced only by vacil- lating emotions, strong or weak, according to the caprice of the hour. He has intellectual powers of low order, great desire of approbation, and little individuality. This form of eccentricity is often nearly allied to insanity, and is often premonitory to it. Its subjects are to be found in families tainted with hereditary predisposition to mental disease, and it merges so gradually and insensibly into mental disease that the lines of demarcation are traceable only with the greatest diffi- culty, and, indeed, often are not to be traced at all. In many cases, however, the transition is marked by perversion of the emotions ; by unfounded suspicions, anxieties, and antipathies ; and also by signs of physical disturbance, by sleeplessness, and general feverisliness. The diagnostic symptoms of nielancliolia are despondency, fear, and despair, existing in a degree far beyond the intensity in which DIAGNOSIS AND PROGNOSIS OF INSANITY. 83 these emotions usually affect the sane mind, even under circumstances most capable of producing them, and in numerous instances existing without any commensurate moral cause and often without any moral cause whatever. The sad and anxious eye, the drooping brow, the painful mouth, the attenuated and careworn features, the muddy complexion and harsh skin, the inertia of body, the stooping and crouching postures, the slow and heavy movements, speak of dis- tressing oppression of the faculties and intense wretchedness. In other cases fearful anxiety is observed, and the eye becomes bright, the nostrils dilated, the movements quick, irritable, and often im- passioned under the influence of some vague terror. If the physi- cian can note the above symptoms and can trace them to a cause productive of insanity, he will have little difficulty in pronouncing his patient insane, although he can discover no trace of delusion. In many cases the patient is painfully aware of the nature of his malady, and seldom attempts to conceal his consciousness of it from any considerate and sympathizing inquirer. Generally, in melan- cholia, there are intellectual errors displaying themselves by false sensation, perception, or conception ; in illusion, hallucination, or delusion proper. There is first emotional and secondly intellectual disturbance in melancholia. Respecting the differential diagnosis between hypochondriasis and melancholia Prichard said " that a hypochondriac is in full possession of his reason, though his suffer- ings are not so dangerous or so severe as he supposes; but if he de- clares that his head or his nose has become too large to pass through a doorway, or displays any other hallucination, he has become a lunatic ; his disorder has changed its nature, and this conversion takes place occasionally, though by no means so frequently as is supposed." The apprehensions of the hypochondriac are confined chiefly to his own feelings and bodily health. On other subjects they converse cheerfully, rationally, and justly, while melancholiacs view all things through a gloomy medium. The cause of hypochon- driasis is generally dyspepsia or some morbid state of the digestive organs. The love of life and fear of death characterize hypochon- driasis, while a frequent symptom of melancholia is disgust of life, attended with desire to commit suicide, which, when motiveless, is one of the surest marks of insanity. The diagnosis of monomania is easy, from the prominence of the single intellectual error. The great majority of cases are sequences 84 PSYCHOLOGICAL MEDICINE. of or transformations from melancholia. The emotional disturbance comes first ; the intellectual afterward. The diagnosis of moral or emotional insanity proper is sometimes very difficult. This is, according to Blandford, a disorder of mind shown by an entire change of character and habits, by extraordinary conduct and acts, extravagance or parsimony, false assertions and false views respecting those nearest and dearest, but without absolute delusion. It may follow epileptic or apoplectic seizures, or may be seen after a period of drinking. Its approach is gradual, as a rule, rather than sudden, and the extraordinary character of the acts may not at first be so marked as subsequently. Friends wonder that a man should say this or that, or should do things so foreign to his nature and habits, but some time may elapse before they can con- vince themselves that such conduct is the result of disease; and the acts may be such that many will look upon them, even to the last, as signs merely of depravity. Such insanity, of course, varies in degree. When it is well-marked and the conduct is outrageous there will be no difficulty in the diagnosis. But it may be less marked. It may consist of false and malevolent assertions concerning people, even the nearest; of little plots and traps to annoy others, in which great ingenuity and cunning may be displayed ; and there will be the greatest plausibility in the story by which all such acts and allj other acts will be explained away and excused. It would seer sometimes as if a universal badness had taken possession of the indir vidual, yet a badness so inexplicable that it can only be looked upor as madness. Much examination and opportunity for examinatior may be needful before we can sign a certificate, for such people are often very acute and quite on the alert. They have no scruples] about falsehood, and will deny or justify everything with which theyj are taxed. And where the insanity is manifested in conduct, thej medical man may never be a witness of it, and is obliged to receive on hearsay that which the patient strenuously denies. Careful in- quiry, however, will probably reveal the origin and cause of theJ change ; there may have been a period, though short, of acute insanity, — as acute mania or melancholia, — which passed away an( left this as a permanent condition ; or it may be the precursor of more advanced stage of insanity marked by the ordinary symptoms of delusion and hallucination. If the change has been rapid ane progressive, and more and more outrageous and eccentric, it is likelj that in a short time unmistakable insanity will be displayed. The DIAGNOSIS AND PROGNOSIS OF INSANITY. 85 one constant and marked feature of this insanity is the absence of delusion, but we are not, on this account, to argue that the intellect is sound. " The hardest form of moral insanity to estimate and diagnose is the congenital moral defect — the moral imbecility occasionally met with in cases of this reasoning mania. These patients are utterly incapable of telling the truth or of understanding why they should do so. These are the cases that commit crimes and are very dangerous to the community in which they live. They may have considerable intellectual ability. The diagnosis of general paralysis is easy to one familiar with the disease. The best symptom for early diagnosis is the modification of the articulation. It resembles the thickness of speech in a drunken man, and depends upon loss of power over the co-ordinate action of the muscles of vocal articulation. Words composed of numerous consonants, with few vocalic sounds, are articulated in a shuffled manner that is perfectly characteristic. In speaking, the lips are tremulous, as if the patient were about to burst into tears. Protru- sion of the tongue is difficult, and it cannot be long protruded, and while protruded it quivers. The brows droop, and the contraction of the iris under the stimulus of light is often different in the two eyes. The voice has a peculiar tremor, and the gait is stumbling and shuffling. Later on the power over the sphincters is lost, and finally the patient may choke to death by the stoppage of food in the pharynx. The psychical symptoms are generally delusions of wealth and grandeur. There is a universal extravagance of ideas. There is loss of excito-motor sensibility. The detection oi feigned insanity is very important. Those who feign insanity generally overact their part. The long-continued sleeplessness of mania cannot be feigned. Neither can the restless, continued agitation; the rapid pulse; the foul tongue; the dry, harsh, inelastic skin. If the skin feels healthy and sweaty from the exertion of the pretender, and if he sleeps soundly and composedly we may be pretty sure he is feigning. Chronic mania is more easily simulated and more difficult of detection. Sibbald says, respecting these cases, that before deciding upon the reality of any doubtful case of insanity all the physical conditions of the individual, such as the amount of sleep, the state of the pulse, skin, tongue, and diges- tive system generally, the conduct and the state of health immediately preceding the signs of insanity should be ascertained. The effect of 86 PSYCHOLOGICAL MEDICINE. remarks made within hearing of the suspected person should be ob- sen-ed. One who proclaims his own insanity should be distrusted.* The diagnosis of concealed insanity may, at times, be made by inducing a patient to write to some friend, when things that he would not speak of he may write of at some length, and his delusion be made very apparent A patient's conduct should be watched by night as well as by day to discover concealed insanity. CHAPTER V. CIVIL INCAPACITY — LEGAL TESTS OF RESPONSIBILITY HINTS FOR GIVING TESTIMONY — EXPERT TESTIMONY, AND THE FUNCTIONS OF EXPERTS IN INSANITY. Civil Incapacity — Legal Tests of Responsibility — Hints i?i giving Evide7ice. — Respecting the civil incapacity of an alleged insane man, Sibbald says that tlie acts of any person either in or out of an asylnm may, hozvevcr, be declared invalid, if it can be shotvn that, at the time they were performed, the person labored under such an insanity as rendered him incapable of performing them ratio?ially and without injurious con- sequences. On this principle any person may be found to have been incapable of contracting marriage, of executing a deed, contracting a debt, making a will, or giving credible evidence. The principle, it must be carefully noted, is not that the mere existence of insanity in the person performing them invalidates such actions, but that if the insanity has materially affected the character and quality of the actions, they may be thereby invalidated. This is one of the most important principles that a medical jurist has to keep in mind, as it is not an unfrequent mistake to suppose that a person is necessarily incapacitated for the performance of every civil act, the moment he * If the simulator refuses to answer all questions, refuses food, has a stupid expression of face, and remains obstinately silent, it may be at times difficult to detect the simulation. Bucknill and Tuke say that the most important diagnostic mark of feigned insanity is a want of coherence in its manifestations ; their unconformity, not only with mental disease in general, but with the form or variet}' of insanity which is feigned in particular. The simulator mixes the forms of insanity together. CIVIL INCAPACITY — LEGAL TESTS OF RESPONSIBILITY, ETC. 8/ can be proved to labor under any condition to which the term in- sanity may be applied. Perhaps the case in which the validity of a civil act is most easily endangered by the existence of any form of insanity is the contract of marriage. This proceeding is supposed to so affect all the relations of life, that almost any form of unsound- ness of mind may be sufficient to interfere with that intelligent and deliberate consideration, which is essential to the giving of rational consent. In these cases — medico-legal cases — it is chiefly impor- tant that the practitioner should distinguish, ist. Diseased perver- sion of the mental faculties. This includes all kinds of insanity which are the result of active disease, such as the simple form of delirium, mania, melancholia, and monomania. 2d. Weakness or enfeeblement of the mental faculties, resulting either from defective development, disease or decay. This includes congenital imbecility, .and all the forms of what is called chronic dementia, all those enfee- blements of mind which are sometimes the remaining effects of acute disease, sometimes the concomitants of chronic disease, and sometimes only the mental phase of senile decay. In order to es- tablish the incapacity of a person said to labor under any of these forms of disease, it must be necessary that an experienced physi- cian should not only be able to detect their characteristic symptoms, but also to show that the performance of the duties, or the exercise of the rights under consideration, would be modified or obstructed by the existence of such disease. Marriage. — As has been already stated, the mere existence of any form of insanity in one of the parties, may render a marriage contract void. Civil Contracts may be held binding although made by lunatics. If the person with whom a contract is made had no knowledge that the person contracting was insane, and if no attempt was made to take undue advantage of him, the contract would be held good. Wills. — A person is considered to be of a disposing mind, that is, capable of making a valid will, if he knows the nature of the act which he is performing and is fully aware of its consequences. It is in regard to the making of wills that the law has carried out most thoroughly the principle that the validity of an act ought to be maintained in cases of insanity, unless at the time the act was per- formed the state of mind of the agent can be shown to render him unfit to perform that particular act in a rational manner. Persons have made valid wills while immates of lunatic asylums. And 'one 88 PSYCHOLOGICAL MEDICINE. will was held to be good, though the testator had committed sui- cide within three days after its execution. The existence of de- lusion, which has been regarded by lawyers as of such importance in cases of alleged insanity, does not invalidate a will; for it has been declared to be " compatible with the retention of the general pow- ers of the faculties of the mind," and to be " insufficient to overthrow the will, unless it was calculated to influence the testator in making it." [We had, recently, under our professional care, a young lady of wealth, a case of chronic mania with lucid intervals, in whom the natural affections were more than usually lively, who possessed a perfectly clear idea of the amount of property she possessed, and the way in which she proposed disposing of it in the event of her death, and whose will, as dictated by her, was as sane a document as we ever examined. Her testamentary capacity, although an incurable case of insanity, was perfectly good, and her will perfectly valid.] On the other hand a will may be invalidated on account of the ex- istence of mental states which would not be regarded as insanity from either a legal or medical point of view. Drowsiness and stupor re- sulting from erysipelas or fever, extreme weakness from cholera and failure of memory in old age, have all been found sufficient to void a will. If a physician is called on to be a witness to a will, it is his duty to satisfy himself as to the testamentary capacity of the testa- tor. His subsequent evidence in regard to this, will, in case of dis- pute, be of almost decisive influence if he has taken prpper means of forming an opinion. In all cases, therefore, where there may be a possibility of doubt, it is well to require the testator to show that without extraneous aid, and without referring to the document itself, he remembers and understands all the provisions of the deed. Evidetice of the Insane. — Lunacy was, until a recent date, regarded by the law as incapacitating a patient from giving evidence in court. But according to the much more extended significations which the term lunacy has received, it now includes states of mind which are compati- ble with testimonial capacity. Where the judge is satisfied that the lu- natic understands the obligation of an oath, and can give a rational account of such things as happened before his eyes, the evidence may be admitted. But the weight to be attached to such evidence will still depend on the extent to which it fulfils the conditions com- monly required to constitute credibility. It has been held, however, that when a person has suffered from an attack of insanity between CIVIL INCAPACITY LEGAL TESTS OF RESPONSIBILITY, ETC. §9 the occurrence of a transaction and the time he renders his testi- mony, his evidence cannot be admitted. Management of Property. — Where persons are supposed to be un- able, from unsoundness of mind, to undertake the management of their own property, it may be necessary that they should be placed under the protection of the court; but this proceeding is not usually had recourse to, unless, there is urgent necessity, or there is a strong probability that the person's incapacity will be permanent. It is re- sorted to principally in chronic or congenital cases, where there is no room for doubt as to the mental condition of the individual ; and in cases of recent insanity, where it is necessary to have recourse to an asylum for the protection of the individual, it may also be nec- essary to obtain protection for his propert}^ by the aid of the court. In giving evidence or framing a statement in such a case, it is im- portant, if incapacity is to be proved, to show that the individual has been found, when placed in circumstances requiring such ca- pacity, unable to perform the acts which the management of property necessitates. In cases of active insanity, it is especially required to show not merely that there is delusion or other symptom of insanity, but that the insanity is of such a nature as specially to disable the person from duly performing the duties which would be required of him. Difficulties most frequently occur in cases of imbecility and dementia; but the verdicts in such cases, when disputed, will gen- erally be found to rest rather upon the impression produced by evi- dence of the actual behavior of the individual than the mere medical view of his mental condition. The most effectual aid that his medi- cal witness can render in such case, is to show whether there are or are not such peculiarities in the conduct of the person under inqui- sition, as are known to be characteristic of imbeciles or demented persons. In undisputed cases, where the duty of the physician consists merely in making an affidavit, there is special difficulty to be en- countered. Brevity, scrupulous accuracy, and attention to the fact that such unsoundness of mind as involves incompetency to manage property must be established, are the most important requirements. In England, a person found by the court to be incapable, is placed under the control of a " committee of the person," and the property under a " com^mittee of the estate." In Scotland, an application to the Court of Sessions for the appointment of a curator bonis, takes the place of the English inquisition. The chief peculiarities of the Scotch process are, that it is cheaper, more easily effected and more go PSYCHOLOGICAL MEDICINE. easily annulled, and that it does not affect the person of the lunatic. By the provisions of a recent act, the person of an insane man in Scotland may be placed under the guardianship of the nearest male relation found competent. Legal Tests of Responsibility. — Bucknill and Tuke say in respect to this, that although in practice the plea of insanity in criminal cases is in a large number of instances not determined according to the law laid down by judges, but according to the higher law of hu- manity, that it is important that students of psychological medicine should know what unfortunately continues to be the main legal test of responsibility in criminal cases, — the consciousness or knowledge of right or wrong; instead of being, as it should be, whether in con- sequence of congenital defect or acquired disease, the power of self- control is absent altogether, or is so far wanting as to render the individual irresponsible. As has again and again been shown, the unconsciousnes of right and wrong is one thing, and the powerless- ness through cerebral defect or disease to do right is another thing. To confound them in an asylum would simply have the effect of trans- ferring a considerable number of the inmates thence to the treadmill or the gallows. For cases in which the prisoner was acquitted on the ground of insanity, although knowing the nature and quality of the act and quite conscious of the difference between right and wrong, the reader is referred to Taylor's Medical Jurisprudence, 4th ed., p. 768. For cases in which the plea of irresistible impulse was admitted, see p. 760, also p. 262-3 o^ Bucknill and Tuke's Manual of Psychological Medicine, 4th ed. Also refer to " the case of Henry Galbites," by Dr. Kitching {Journal of Mental Science, July, 1867) ; the same wri- ter's lecture on moral insanity {Brit. Med. Journal, 1857) ; " The Legal Doctrine of Responsibility in Relation to Insanity," by S. VV. North, M.R.C.S. {Transactions of the Social Science Association, 1864) ; " In- sanity and Crime," by the editor of the Journal of Mental Science, 1864 (Townley's case); "Etude Medico-legale sur la Folie," par M. Tardieu, 1872; the work of Esquirol and Marc, Brierre de Bois- mont, De la Folie, Raisonnante, etc., 1867; " De la Monomanie de Persecution au point de vue de la Medecine legale " {Ann. d'Hyg., pub. 1852), and Lasegue, " Memoire sur la Delire des Persecutions" {Arch. Gen. de Med., torn. 27). A case of delusion of persecution ending in homicide and acquittal, in which the judge's common-sense and humanity got the better of his law, will be found in the Journal CIVIL INCAPACITY LEGAL TESTS OF RESPONSIBILITY, ETC. 9 1 of Mental Science, for July, 1872. For cases proving the presence of the homicidal impulse without other symptoms of insanity, see article by Dr. Needham in the same number; and for the important cases of Edmunds and Watson, see April, 1872. For case of in- sane infanticide and the judge's summing up, see April, 1871. Mr. J. B. Thompson's article in the Journal, January, 1 870, and also the succeeding one in the October number, which should be read in con- nection with Despine's work, Psychologic Natiirelle, 1868. Hints in Giving Evidence. — Bucknill and Tuke say respecting this part of medical jurisprudence : 1. That a medical man is obliged to make known, if asked in court, the statements or confessions made by a patient to him {Peake on Evidence, p. 88 ; Starkie on Evidence, p. 105 ; Shelf ord, p. 81). 2. If a medical witness believes a criminal to be insane and is called upon to give evidence to that effect, he must not be content with stating his opinion, but must be prepared to state the reasons upon which that conclusion is based. For aid in arriving at a judg- ment the reader is referred to the chapter on the Diagnosis of In- sanity. 3. The medical witness should confine himself to a simple state- ment of facts, and not allow himself to be drawn into a metaphysical discussion, or an attempt to define insanity. 4. If a medical witness sometimes wishes to fortify his view of the case by inducing the counsel to read from medical works, and the question arises whether this can be legally done. It has been de- cided in one case that " counsel was at liberty to read as part of his speech, the opinions of a medical work, but the jury would not have to decide the case upon medical criticism, but upon the case and the facts." The counsel in the case alluded to then read from a book on medical jurisprudence, in order to show that certain cases recorded there were similar to the one before the court. It would appear, from R. V. Crouch, i Cox, C. C, 94, that the opinions of a medical writer cannot be stated in an address to the jury, but the judge in the case alluded to did not distinguish between these and cases. 5. In regard to any notes the medical witness may have taken of the prisoner's state, he may only make use of those in court which he has committed to paper at the time he examined the prisoner. 6. It must not be forgotten that the prisoner may be sane when examined by the physician, and yet may have been insane when he committed the deed, and vice versa. 92 PSYCHOLOGICAL MEDICINE. Expert Testimony and the Functions of Experts. — Many of the com- munity, as the late Dr. Ray has shown, completely ignore the exact purpose of skilled testimony in a judicial proceeding and the func- tions of an expert. They are apt to bring forward the timeworn objection to expert testimony, viz., that as the experts are engaged by one or the other of the litigant parties they thus necessarily testify under a bias, and consequently are not trustworthy. This would imply that there is a distinct understanding as to what any given expert shall say, before he has heard a word of the evidence on either side. An expert's opinions, as Dr. Ray has said, are worth money, but it does not follow that his opinions are corruptly bought. Why should a fair reward for professional services obscure an ex- pert's perception of truth ? Experts necessarily, according to the present law, which we hope to see reformed (see chapter on " the necessity for a reform in the introduction of expert testimony where insanity is alleged as a defence"), testify in the interest of a party; but that fact Dr. Ray conclusively proved does not imply an unwor- thy bias. The counsel lay before the expert the evidence to be pro- duced before him as far as they can, and the honest expert invaria- bly tells the counsel either that if he can prove the facts as he states them he has a good cause, or he tells him that even if he does prove such facts they would not warrant the construction he wishes to put upon them, and that his — the expert's — testimony would not help him. Generally speaking, it is as Dr. Ray said, that if an expert's testimony is wholly and unconditionally in favor of one side only, it is merely because this result is warranted by the facts. An honest expert will moreover warn the counsel that the evidence as brought out on trial may oblige him to modify his opinion. An expert is one who gives his time and attention entirely to a particular pursuit, and he is, therefore, to be recognized as an expert in questions relating to that pursuit, to the exclusion of those who have attended to it incidentally as a subordinate part of a more gen- eral department of inquiry. Tlie functions of an expert are to appear in court to give an opin- ion, based either on his acquaintance with the party whose mental or physical condition is under investigation, or upon a medical ex- amination of him which he has made, or upon a hypothetical case stated to him in court. The expert is wanted in court to give his opinion on facts proved or upon a case hypothetically staged. An opin- ion, I should define, as the statemejit of what certain facts indicate to CIVIL INCAPACITY — LEGAL TESTS OF RESPONSIBILITY, ETC. 93 the expert himself. Therefore, on a trial, I do not think an expert should give his opinion upon facts proved by a witness unless he hears all the testimony of such witness. The old practice where the expert heard all the evidence given at the trial, and then was asked for his opinion founded on that evidence, supposing it to be true, was, I think, better calculated to elicit a well-considered opinion than the new change, where the counsel on each side, out of the facts that have ap- peared in evidence, construct a hypothetical case as fairly as will best serve their purpose, and no more. In such cases the expert may be obliged to assent to the propositions of both sides, as Dr. Ray has shown, and thus apparently stultify himself. This is due to a twist- ing and coloring of facts. Sometimes unfortunately the manner in which an expert's opinion is elicited is deliberately calculated to over- whelm it with discredit. Able counsel use all their professional as- tyteness to deprive of its proper weight with the jury, says Dr. Ray, the most honest and truthful expressions of opinion, and if we had a healthier public sentiment which would make the judge keep a cross- examination within its proper limits and restrain the license of counsel, the public would have less reason for distrusting and sneering at ex- pert testimony. The judge's question to determine whether a witness offered as a mental expert has the legal qualification to entitle him to testify as such should be : " Do you give your time and attention en- tirely to a particular branch of medicine, and is that mental or psy- chological medicine ?" This, and nothing else, is needed to consti- tute an expert in mental medicine. He should then in any given case, give his opinion on the case from the examination he has made ; his observation, experience and professional reading. He necessarily forms an opinion from this combination. Dr. Ray recommended, in 1873, that the testimony of experts be given in writing and read to the jury without any oral examination. It would thus, he said, be deliberately prepared, its explanations well considered, and its full force and bearings clearly discerned. It would go to the jury on its own merits, no advantage being gained by either party by the superior adroitness of counsel in embarrassing the witness and pushing his statements to a false or ridiculous con- clusion. It would work no injustice to either party, and it could be managed without additional inconvenience. There could be no dif- ficulty in civil cases where both parties consent to such an arrange- ment. Dr. Ray says : " Judges should not, as they sometimes have been known to do, disregard their proper functions and assume the 94 PSYCHOLOGICAL MEDICINE. part of an expert, and, in cases of disputed sanity, pronounce a man to be sane and safe to be at large in spite of the declarations to the con- trary of men long conversant with the discourse, conduct, ways, and manners of the insane." The whole subject of expert testimony needs to be lifted up to a higher plane than it now occupies, by the mutual efforts of lawyers, physicians, and public sentiment. The revolution in the management of the insane has produced among its legitimate effects a better knowledge of insanity. Respecting written testimony I would add that in the celebrated Parish will case, reported by Ray in his Contributions to Mental Pathology , p. 316, where Henry Parish, a prosperous New York merchant, made his will in 1842, being then fifty-four years old, on trial the surrogate wisely determined that the opinions should be given in writing, with the understanding that, though not clothed with the authority of legal evidence, they would be carefully considered and credited with all the weight to which they were really entitled. This enabled the expert to utter, as Dr. Ray showed, what is impossible in the usual method of examination and cross-examination, his opinions and the reasons for opinions, with that coherence and logical relation absolutely necessary to show their full force and significance. Mr. Parish made his will, in 1842, disposing of some $750,000. He went to Europe in 1843, and had an apoplectic attack, from which he shortly recovered and con- tinued as well, apparently, as ever, both in body and mind, until the 19th of July, 1849, when he had another apoplectic attack, much more severe. In about a fortnight he was out of immediate danger, but never recovered his ordinary condition. His right side, including the upper and lower limbs, was found to be somewhat paralyzed ; the power of articulation was lost ; and his natural elasticity and vigor were gone. These traits continued with little change until he died, in 1856. Epileptic fits occurred within a few months of the apoplec- tic attack of July, 1849, ^^ intervals ranging from eight days to six months or more. On the 29th of August, 1849, he subscribed his cross in lieu of a signature to a codicil to his will. On the 15th of September, 1853, a second codicil was subscribed in like manner, and on the 15th of June, 1854, a third codicil, substituting his wife in place of Daniel and James Parish as residuary legatee. These codicils were contested in the Surrogate's Court on the ground that when they were made the testator had not a testamentary capacity. His mental condition during the period between the attacks in 1849 and his death in 1856 was that of but a small measure of mental GENERAL PARALYSIS OF THE INSANE, 95 capacity. He was reduced to an almost vegetative existence. There was ample proof of mental infirmity, of dementia, or imbecility. He was plainly an insane man, without mind enough left to constitute testamentary capacity. CHAPTER VI. GENERAL PARALYSIS OF THE INSANE. (Syn. — Paralytic Dementia ; Progressive General Paresis ; Paralysie general des alien is.) In writing on this very interesting form of mental disease we may define it as a disease characterized by general and progressive loss of co-ordinating power over the muscles, especially those of speech and locomotion, combined with mental enfeeblement, always tending to dementia, and characterized by a sense of well-being or actual delu- sions of an exalted character. It is doubtless true that, in certain states of the brain, mental action or the actions of the higher centres of the brain may become at times automatic, and be performed with- out the intervention of consciousness. A constant repetition of any given mental action causes it to become organically registered in the brain centres, so that while at first a series of thoughts is performed consciously by the individual, it ultimately becomes reflex, respond- ing to the recognized stimulus without consciousness and indepen- dent of any effort or intervention of consciousness. It is to some injury of this mind-power that we must look for an explanation of the mental symptoms of general paralysis.* Two classes of mental actions will necessarily be involved in this disease. First, those which are of so recent an origin as not to have become organically registered ; and second, those which are still unable to be performed without conscious interference. One of the * General paralysis may be due to excessive mental labor, great anxiety, alcoholic or venereal excess, or to any great and continued strain upon the centric nervous system. Blows on the head and sunstroke may produce it, and it attacks by preference males be- tween thirty and fifty years of age. Sleeplessness, restlessness, depression followed by exaltation, enfeeblement, and extravagance of thought and action are early and marked symptoms. g6 PSYCHOLOGICAL MEDICINE. most prominent instincts or ideas in the human mind is the import- ance of self. In a healthy state we draw up and surround ourselves with an ideal self which, if we are healthy-minded, finds no expres- sion. If the power to which all mental processes are due be im- paired, those actions, among others, will be affected which are the most detailed and elaborate, the most varied, the least rigidly defined, and the least organically registered. Of all mental processes those involved in the consideration of self are at once the most general, extensive, and complicated, as well as the most vague and undefined. Self occupies in the mind the widest, most frequent, and most capri- cious attention. As in general paralysis this mind-power is the seat of the main lesion, the psychical processes concerned in the con- sideration of self will be the first involved, and will present the most prominent symptoms. In general paralysis the ideal self runs riot; the man is not as he is, but as he has pictured himself and as he would have himself be. In the inception of his disease the patient feels himself "bang-up" and "perfect." Everything is "elegant" and rose-colored. His wealth is unbounded, and he orders " a million " cigars and orders palaces built of gold and diamonds with the utmost indifference and nonchalance, thoroughly believing in his capacity to do all these things. The patient's delusions are markedly progres- sive in number, absurdity, and exaggeration. Being rather feeble, he imagines himself capable of immense sustained exertions. In gen- eral paralysis the mental processes which are the most automatic are the last to be affected, and the patient entertains perfectly reasonable ideas about his actual self, and, although possessing thousands of ideal dollars and estates, will tell you correctly that he earns but ten dollars per week, as this idea has, from frequent and constant repeti- tion, become automatic. In the same manner a patient under my care tells me correctly that his suit of clothes cost him fifteen dollars in London, and in the same breath says that he has ordered a silk- velvet suit with diamond buttons. At the present moment he con- siders his health perfect, but acknowledges that in the past he has had many sicknesses and infirmities. Matters of recent occurrence, which have not had opportunities for repetition, and so have not be- come organically registered and automatic, and that consequently involve consciousness, are far more dependent upon mind than mat- ters of earlier date w^hich have been so frequently repeated as to acquire automaticity. The patient, therefore, while stating with accuracy events and detailed accounts of the past, can give but a very GENERAL PARALYSIS OF THE INSANE. ^7 vague and confused account of the events of the last few days or weeks. This defect in memory is consequently one of the most noticeable symptoms in the early stage of the disease, and we observe it particularly in persons of methodical habits. Leaving this inter- esting field of the psychology of general paralysis, we proceed to notice its pathology. Pathology of General Paralysis. — The pathology of general paraly- sis is very obscure, and invites especial attention at the hands of the profession. Dr. Magnan, a distinguished physiologist and psycholo- gist, the superintendent of a Paris insane asylum, considers that the fundamental lesion of this disease is a generally diffused interstitial encephalitis, which involves accessory structural changes of various character. He regards the primary and most palpable form of the interstitial degeneration as colloid, where the transformed matter is presented under the aspect of a hyaline substance, semi-transparent, slightly refractory, and at certain points of a bluish tint. When ex- isting in isolated masses of small size, it preserves the form and aspect of whatever cerebral elements it may have invaded. This pro- duct of inflammation, which Dr. Magnan does not claim to be tu- bercular, is not of a fatty nature, because insoluble in ether or chlo- roform. It is not amyloid, because unaffected by tincture of iodine or solutions of potassa and soda, and is dissolved in strong acetic acid. It is not organic, as there is no reaction with hydrochloric acid. Its solubility in hot water, especially when potassa or soda is added, is supposed to establish the possession of a peculiar chemical composition. In examining the cerebrum as the principal seat of paresis, Magnan claims priority in having determined the ependyma of the ventricle as the centre, or perhaps one of many centres, of that destructive process which is indicated by the symptoms of general paralysis, which affects all parts of the encephalon and produces those secondary pathological appearances that have previously been identified as the cause of the disorders of mobility and sensibility. The progress of the morbid degeneration from the point where the ventricles have become dilated, their ependyma thickened, when their surface, especially in the fourth ventricle, is covered with granula- tions, is probably upwards along the connective as well as involving all tissues, and is gradual and insidious, and can only be traced by the more advanced alterations in structure. (It is proper to state here that Dr. Boyd, late physician and superintendent of the Somerset County Lunatic Asylum, in England, disputes Dr. Magnan's claim 7 98 PSYCHOLOGICAL MEDICINE. to the priority in the discovery of the pathological changes in gene- ral paralysis, calling attention to his observations, made about thirty years ago, in the second annual report of the Somerset County Asy- lum.) This interstitial irritation of the brain in general paralysis, however it is disseminated, is propagated by nuclear proliferation, and invades the white matter in common with the cortical substance, and also the capillaries, which are thickened, tortuous and massed together. The cells of the cortical portion are sometimes found infiltrated with granulations, but preserving their form. This is found in the third stage of the disease. It is in the middle and inferior portions of the gray matter that the cells are observed to have brilliant nuclei tending toward colloid, while their normal aspect is preserved. The walls of the cells nearest the lesion are transformed into a shining, refractory, hyaline substance, the colloid infiltration having been propagated to both. The microscopic, as well as the naked-eye appearances, may appear first in the brain and subsequently in the medulla, or they may appear first in the medulla and afterwards in the brain ; and they may also appear in both simultaneously. If the brain is primarily attacked the psychical signs predominate or are exclusively manifested. If the medulla be the primary seat of the disease, muscular pain, tremor and ataxic symptoms, spreading gradually to the lips and tongue, dis- turbance of the internal viscera corresponding to the portion of the spinal column involved, precede alienation and increase the difficulty of diagnosis. Finally, when the whole cerebro-spinal axis participates at once in the colloid degeneration, the characteristic indications of paresis will appear simultaneously or in rapid succession. It is impor- tant for us to bear in mind that the colloid degeneration upon which Magnan insists is far from being constant in paresis, and we meet with it in other diseases remotely connected, or perhaps in no degree con- nected with paresis. For instance, the ependyma of the fourth ventri- cle has been found to be the seat of the same changes as in paresis after muscular atrophy, chronic alcoholism, senile dementia, tetanus, and also after tubercular meningitis. I will now cite as concisely as possible the opinions of the highest authorities relative to the pathol- ogy of the disease under question. Bayle designated the disease chronic arachnitis. Calmeil considered it as a diffused chronic peri- encephalitis, and held that it was of inflammatory origin. Baillarger observed two sets of anatomical alterations, congestion of the mem- branes and chronic hydrocephalus, with atrophy and softening of the brain. Burnet and Lancereaux speak of a neo-membrane, or a pachy- GENERAL PARALYSIS OF THE INSANE. 99 meningitis, the formation of which they explain by the exudation of a parietal layer from its walls, which is insensibly organized and which bears the marks of fatty degeneration. The rupture of these vessels leads to the occurrence of arachnoid cysts. Erlenmayer ex- plains the atrophy which has been noticed by the successive and repeated effusions of serum, the nervous elements being replaced by an amorphous substance. Frerichs considers the induration of the gray matter as connecting the pathological condition with sclerosis. The alterations in the white matter consist of hardening or softening, increase of fluid of the ventricles and thinning of their parietes, which resemble indurated ependyma. M. Luys, a very able French investigator, believes that in the softening of the cortical substance of the cerebellum may be discovered the source of general paralysis, but Magnan asserts that this conviction of M. Luys is founded on exceptional cases. M. Luys gives as the result of his microscopic investigations the following results, viz. : The vessels of the pia mater are of considerable size, the walls of the capillaries incrusted with granulations, the surface of the pia mater presenting scattered cell- granules and molecules and extravasated blood-globules. The gray substance is greatly developed, with palpable vascular arborizations, often in the form of a plexus. The calibre of the capillaries is almost always contracted by the incrustation of minute granules, or by cells, deposited chiefly at the bifurcations, which are of irregular shapes and break down and discharge their contents. The nerve- tubes are malformed, their contents escape, and they present little more than a mass of debris. Rokitansky has detected three distinct pathological appearances : 1st. Where a mass of connective tissue embraces in its network the nervous element, and in chronic cases is stiff, fibrous, and induces ad- hesion of the pia mater. 2d. The tubes are varicose and broken, while the cells appear swollen. 3d. The presence of amyloid or col- loid bodies. Wedl's observations are as follows : That contraction of the capillaries and small bloodvessels, in consequence of the cells upon their walls, leads to obliteration, their conversion into bands of connective tissue, and the consequent impairment of the nutrition of the part. Dr. Ertzbischoff attributes the hypersemia of the cortical layers to the extreme development of the embryoplastic element in the capillaries, which, by compressing the vessels without and within, diminishes and ultimately destroys the cavity. This stasis necessi- tates granulations and adhesion. The majority of the German pa- lOO PSYCHOLOGICAL MEDICINE. thologists localize the disease in changes of the walls of the vessels and in the development of the connective tissue. Meschede sees the essential characteristics of paresis in the degeneration of cerebral cells, especially those of the cortical substance, Avhich he depicts as of abnormal shape and filled and surrounded with fatty and pigmen- tary granulations. Lockhart Clarke speaks of the conversion of the cells of the convolutions into pigmentary bodies, irregularly shaped and about to break up. Contemporaneously with this change, the spinal marrow, especially in chronic cases, is softened to the consist- ency of cream, or there may be a granular degeneration in its gray matter or in its surroundings. Westphal has discovered in some cases granulations in the posterior columns of the spinal cord, which did not extend higher than the peduncles of the cerebrum, so that the alteration could not be regarded as secondary, or as proceeding from the pathological condition of the convolutions.* The course of general paralysis may very properly be divided into four stages : 1. That of delirium, with or without slight physical lesions. 2. That of defective co-ordination of movement, exaggerated sen- timents, alterations in the secretions, with continued delirium. * Although we have the greatest respect for the opinions and observations of all the distinguished observers we have mentioned, we think they have all paid too little atten- tion in their researches to the condition of the spinal cord in general paralysis ; our own investigations have been limited to perhaps too few cases to draw forcible deductions from, but they have convinced us, personally, that whether primarily or secondarily to cerebral change the spinal cord is always affected, and that the changes in it are constant and peculiar. We think these changes often primary. We call attention to one of the micro- photographs in this work, showing atrophy of nerve-cells of the posterior columns, with plates of new connective tissue of irregular size. The lateral columns are also affected in their posterior section ; and the posterior columns and the posterior part of the lateral columns may be unitedly affected. We also call attention to another micro-photograph depicting a change not unlike that we meet with in myelitis, with marked softening, evi- dently succeedmg an inflammatory process of the posterior cornua. We think decidedly that pathological conditions of the cerebral capillaries are phenomena primary to the morbid changes in the cerebral cells in this disease ; but it has not seemed that the cere- bral changes were so invariable and constant as the spinal ; and we think careful obser- vation will in the future show shrinking and atrophy of the spinal cord. We think the changes in the brain congestive and hypersemic and not generally inflammatory, and we think the psychical symptoms are immediately dependent upon the disturbances in the circulation, which accelerates, impedes or interrupts the nutrient supply of the cerebral cells. We see first, exalted functional excitability and activity, and secondarily, destruc- tion of this excitability and activity with dementia, indicative of degenerative changes in the brain-cells. GENERAL PARALYSIS OF THE INSANE. ICft 3. That of special dementia, with greater stupidity and degradation than in other forms, the control of muscles diminished, habits dirty. 4. Perception of impressions by external senses abolished ; insen- sibility to pain; extinction of functions of relation and organic life; disturbance in circulation ; complete adynamic ataxy and marasmus. Optimism and ambitious ideas, as I remarked in the first part of this chapter, constitute the essential mental characteristics. Pre- vious to the establishment of complete delirium or delusions there may be traced deviations from healthy mentalization, which, though faint or latent, should be accepted as prodromata. There is no doubt that the gradual evolution of physical and psychical symptoms cor- responds intimately with structural alterations in the nervous centres. Owing to having em.ployed galvanization of the cervical sympathetic nerve with temporary beneficial results in some cases of general paral- ysis, the following question has presented itself to my mind : Whether some of the principal changes occurring in general paralysis may not. have their origin in a congestion originating in the ganglia of the sympathetic, transmitted along the spinal cord, ultimately involv- ing every tissue within the cranium, and eventuating simultaneously in the degeneration of bloodvessels, cells, and nerve-tubes, and the mental and motor perversions which distinguish in so marked a manner general paralysis from all other diseases of the same class ? The diagnostic symptoms of general paralysis, aside from the exalted notions, are difficulty in articulation, with a trembling of the tongue when the attempt is made to protrude it beyond the teeth, often a turning to one side and a general inability to use it freely, as if it were too large for the mouth or too heavy for use, very flabby, and easily indented by the teeth ; a peculiar dragging of one of the feet or legs ; and added to these symptoms will be found a heavy, dull expression of countenance, and an unusual appearance of the eyes^ and, almost invariably, an unequal contraction of the pupils. It requires careful observation to detect these symptoms in the early stages, and careful treatment may relieve them temporarily ; but although we may retard the issue of the disease by careful watching and skilful treatment, it inevitably advances insidiously to paralysis of the tongue and limbs and progressive enfeeblement of the mind. In the last stages, which sometimes last for years, emaciation suc- ceeds obesity. Sometimes there is intense restlessness, but generally we find lethargy of body as well as of mind, this lethargy being dis- turbed by twitchings or epileptiform convulsions. These often ter- 102 PSYCHOLOGICAL MEDICINE. minate life, but the most frequent causes of death are sheer exhaus- tion and tubercular disease. With regard to the condition of the retina, we find the nerve changes generally proportionate to the con- traction and dilatation of the pupils, the contraction of the pupil cor- responding to the early or the hyperaemic stage, and the dilatation of the pupil to the white atrophic condition of the optic disk. With regard to the temperature, I have always noticed, as an unvarying symptom, that there is always a higher temperature in the evening than in the morning. Seldom less than one degree, and, in excited cases, sometimes a difference of two degrees, and we may, by the thermometer, discover the progress of the disease when we cannot do it satisfactorily by any other means. In sleepless and destructive cases the temperature is higher than it is in quiet cases. We may consider the average duration of general paralysis as about thirteen months, and very few patients live more than three years after the development of well-marked symptoms. Dr. Auguste Voisin, in his Tj-aite de la Paralysie Generale des Alienes, says that in the first period of general paralysis the principal, persistent, and most valuable symptoms may be said to be : 1. Loss or diminution of the sense of smell. 2. Tremulous speech. 3. Fibrillary twitchings of the lips and the facial muscles. 4. The pupillary phenomena, and 5. The existence of fever. The points he makes in regard to the temperature are : 1. That in general paralysis the average temperature is below the normal. 2. That every eight or fifteen days it rises above the average. 3. That it stays above the normal mean sometimes for only one day, sometimes for many days consecutively. 4. That in cases in which this elevation of temperature continues for several days the elevation of temperature is always highest in the evening. 5. That the increase as well as the decrease of the temperature is sudden. 6. The figure indicating the temperature is never high. It rarely attains 102.2° F., and more frequently is between 100.04° and 100.4° F. The psychic changes are only an exaggeration of those of the prodromal and intermediate periods. Sometimes there is no delirium, GENERAL PARALYSIS OF THE INSANE. IO3 but only an enfeeblement of the intellect and perversion of the feel- ings, but in others, and the majority of cases, there is either the ordi- nary expansive mania, so often described by writers on this disease, or a melancholic form, recognized by Falret, Calmeil, Pinel, Lunier, Baillarger, and others, and which is hardly ever found with the same characters in any other disorder. The melancholic type of mental disorder is to be separated in five special clinical forms : a. Melancholia with agitation, which is distinguished from a simi- lar state in other forms of mental disease by the elevated tem- perature. b. The melancholia with stupor, the patient not preserving the obstinate silence nor presenting the facial muscular contraction usual in such cases with other relations. c. Religious melancholia ; a rare form. d. Melancholia with ideas of persecution, and sometimes e.. Ideas of poverty, in which the patients refuse to eat because they are too poor or because food is too dear. Voisin also makes three varieties of the hypochondriac form of depression, viz. : a. The denial of the possession of certain organs. b. The negation of existence, and c. Micromania, or belief of the patients that they are infants or children. The suddenness of the appearance of these forms, their absurdity, and the variable character of the delusions, as in other forms of mania, in paralysis, he thinks sufficiently separate these varieties of hypochondria from the non-paralytic forms. Voisin recognizes five varieties of general paralysis : 1. The acute and rapid form (acute periencephalitis). 2. The ordinary form, with grand delirium. 3. The senile form, characterized by progressive enfeeblement of the intellect, and of long duration — six, eight, and ten years. 4. General paralysis with all the characters of dementia. (Voisin's own discovery.) 5. Spinal general paralysis, or paralysis without alienation. M. Auguste Voisin takes an altogether more hopeful view than is generally held by the profession of the curability of general paralysis, even in confirmed cases, and reports ten cures on record. The best plan of treatment he considers to be exercise, the prohibition of 104 PSYCHOLOGICAL MEDICINE. mental labor, bromides and cannabis indica, leeches to the anus, pur- gatives in first and second stages of the disease, and also sinapisms and warm foot-baths. He also recommends blistering the scalp and nucha, actual cautery along the spine, and cold h^!^^?, par excellence^ I have given a full description of M. Voisin's ideas relative to gen- eral paralysis, because of the deep interest which pertains to this rebellious form of mental disorder, and because of my sincere admira- tion of his masterly handling of this difficult subject. In closing this chapter on general paralysis there are three ques- tions which are very interesting to psychologists, and to which I would invite their attention : 1. Are the psychical excitement, exaltation, and delusions of general paralysis to be regarded as the factors or promoters of the physical degeneration ? 2. Are we entitled to hold, in remissions in general paralysis, that the physical degeneration was stayed or disappeared during the cessation of mental disease, giving place to healthy structure ? 3. Are we entitled to hold, in general paralysis, that the resump- tion of apparently healthy action was compatible and coexistent with persistent structural degeneration ? * In our own treatment of general paralysis we employ centric galvanization, cold baths, and we think highly of the following pill, to be administered every two hours. It calms nervous excitability and supports the vital powers. U. Zinci Valerianat., ...... .^j. Ext. Belladonnse, ...... gr. iss. M. et ft. pill No. XXX. At night, if the patient is sleepless, we give the following, the dose to be repeated in one hour if the patient is not asleep. R. Chloral Hydrat., Qij. Sodii Bromid., ...... ^j. Morph. Sulph., ...... gr. ^. Syr. Zingib, Aquae, aa, . . . . . . . i"^]. M. et ft. sol. S. Tablespoonful at bedtime. IDIOCY— DEMENTIA — FOLIE RAISONNANTE. lof CHAPTER VII. IDIOCY DEMENTIA — FOLIE RAISONNANTE. (Syn. — Moral or Affective Insanity.^ An idiot, according to Lord Coke's definition, is " one who from his nativity, by a perpetual infirmity, is 7ion compos mentis^ Idiocy is a condition in which the intellectual faculties have never been developed sufficiently to enable the idiot to acquire such an amount of knowledge as persons of his own age, and placed in similar circumstances with himself, are capable of receiving. This latter is essentially Esquirol's definition of idiocy. The progress of modern science is such, however, that we no longer believe that the faculties of the idiot must remain stationary. In idiocy there is an impairment of the functions of organic and animal life. Any of the special senses may be more or less involved. There are various de- grees of idiocy, from the idiot who exhibits nothing beyond reflex action to those whose ideas produce some intellectual operations and consequent will. In deciding whether a child is idiotic we must ex- amine the special senses, sight, hearing, smell and taste, the general aspect of the child, the form of the head, whether microcephalic or hydrocephalic. Most cases of idiocy present more or less malforma- tion of the skull. The ears should be examined, as in idiocy they are large and ill-formed. The eyes in idiocy have a vacant stare and do not follow objects held before them. The hand of an idiotic child will not grasp your fingers properly. The grasp is feeble and pow- erless and the hands are cold and blue. If old enough to talk, notice the character of the vocal sounds. In the treatment of idiocy we must rescue the child from a soli- tary life and surround him by influences calculated to make existence pleasant. " We must attain to the happy combination," says an eminent authority, " of medical, physical, moral, and intellectual treatment." The highest possible health is the great desideratum. The dietary must contain a fair supply of nitrogenous elements, and at the same time be rich in oleaginous and phosphatic substances. The daily use of sponge baths is of paramount importance, as there is a peculiar exhalation from the skin of imbeciles. As regards physical training the attenuated muscles should be carefully and fully exercised, to obviate the simple automatic movements so com- mon to the imbecile and idiot. The moral education must inculcate I06 PSYCHOLOGICAL MEDICINE. obedience, although corporeal punishment should never be resorted to. The idiot should be made to understand that right is productive of pleasure, and wrong followed by the reverse. Study the peculiari- ties of the patient, and you can then control him morally. The in- tellectual training must teach the idiot the qualities, form and rela- tion of objects, by the sense of touch; color, size and shape by the sense of sight, and the varieties of sound by the ear. The idiot must be taught habits of neatness. Imperfect speech is best overcome by a series of tongue gymnastics. We must provide varied amuse- ments, especially of an object-teaching character, and we can get good results by patience and perseverance.* Dejiieiitia. — The chief moral cause of acute or primary dementia is mental inanition or monotony of thought or feeling. If our men- tal food is not varied it ceases to nourish us, and we pine into demen- tia. Acute dementia follows exhausting disease frequently, and right here let me say that at such times, to prevent brain wasting, the chlo- rophosphide of arsenic (Routh's formula) is invaluable, in doses of five drops in water, gradually decreased to two drops, three times a day, and persisted in for months. Acute dementia- begins in one of two ways, either gradually, by imperceptible encroachments, or by maniacal excitement. The acme of dementia is a mental state of profound stu- pidity. The pathology of dementia is generally a venous congestion which affects the whole encephalon, but the frontal and parietal lobes are chiefly implicated. The vessels are cedematous from the accus- tomed want of tone ; this causes pressure on the brain, and if of long continuance atrophy results. Acute dementia, therefore, is a disease of venous congestion.f * J. Langdon Down very truly says of idiocy that the lesion is not only a psychical one, but profoundly affects the physical and frequently the moral life. The stature is less than normal, with great tendency to assume a stooping posture. The circulatory system is weak, the lungs liable to inflammatory attacks, the gastro-intestinal tract liable to derange- ment, the sexual functions often abnormal, the motor functions are abnormal ; there is diminished sensibility, speech is defective, sight defective, sense of smell is lessened, and no discrimination of odors ; the faculties of observation and attention are limited ; there is very little imagination or power of abstract thought. We may classify it into I. Congeni- tal; 2. Developmental ; and 3. Accidental idiocy. The first class exhibit signs of defec- tive mental power at birth. The second class manifest an average intelligence through infancy, but break down during one of the developmental crises, these being the first den- tition, the second dentition, or at puberty. The third class are born with a normal nervous system free from defect, but a fall, a fright, epilepsy, the sequelae of measles, scarlet fever, meningitis, etc., may lead to a mental break down and accideiitalx&xozy. J Primary or acute dementia may be accompanied by the most profound vacuity, accord- ing to Blandford, and abeyance of all the mental faculties, and yet yield to treatment. IDIOCY — DEMENTIA — FOLIE RAISONNANTE. lOf Folie Raisonnante, Synon., Moral or Emotional Insanity Proper. — There are equivocal states of mental alienation or so-called reason- ing insanity (folie raisonnante), which may exist alone and disappear before the appearance of the ordinary attack. The slightest form of folie raisonnante is that in which the patient is more or less aware of the morbid conception. If he conceals it we are unable to detect it; if he acknowledges it, it is in such a way that we hesitate to believe him insane. A more decided form is that in which the patient is just conscious of his insanity. He accepts the insane notion, but understands that it is for his interest to hide it. Still farther along the same patient does not conceal his delusion. Those pa- tients who remain very long in an uncertain mental condition are those who most frequently manifest abnormal forms of insanity. There are prolonged lucid intervals in every kind of mental aliena- tion. Between reason and confirmed insanity there is every shade of reasoning power. Bucknill and Tuke say in speaking of these cases that " they are mainly of a destructive character, and may be distinguished from emotional disorder of a melancholy and exalted character by the term ' emotional insanity proper,' or moral insanity." There are congenital cases of defect or disease of the moral facul- ties, and others in which this condition of mind comes on or is first exhibited in adult life. Respecting the former class of cases Buck- nill and Tuke say : " The most striking feature of insanity in gen- eral, and the strongest proof of the presence of any of its forms, is the change which takes place in the individual's character and habits." To cases of congenital deficiency of the intellect, however, whether altogether idiotic or only partially imbecile, it is at once manifest that this test does not and cannot apply. In such instances the natu- ral character is itself in an abnormal condition, and ceases to be the standard of health. This observation applies with peculiar force to leaving the patient sane. The patients are young persons — boys and girls. There is a collapse of all mental power; the face is vacant, with a fatuous grin, and often the saUva dribbles continuously and the patient has to be tended like a baby ; the hands and feet are blue with cold ; the tongue is pale and flabby, and the pupils are dilated. Dementia is more often secondary ; that is, occurring after mania, melancholia, monomania, than primary. We have in primary dementia a rapid suspension of the intellectual, moral and instinctive faculties — a state which is curable. In treatment abundant nutrition, stimulants, warmth, mild exercise, cold baths or the shower bath, the patient standing in warm water, central galvanization, and iron and quinine, or a combination of iron, phosphorus, zinc, and strychnia, are all indicated to restore lost nerve tone. Ordinary dementia is very in- curable. I08 PSYCHOLOGICAL MEDICINE. the matter now under consideration. If there ever be, congenitally, a condition of the moral sense analogous to imbecility, it is impossi- ble to apply, in such instances, the test referred to — a test which is alone applicable to mental disease when acquired. We have seen several well-marked examples of lunatics, who, on arriving at man- hood, were placed under restraint, because age brought with it a cer- tain legal responsibility, the absence of which, in early life, rendered the patient's friends willing to content themselves with their own sur\'eillance. In such cases, parents assert that the child, the boy, the young man, alike presented the symptoms of an inert moral na- ture, and of an activity of the animal propensities, over which threats, rewards or punishments exercised a very trifling control. There was a patient formerly at the Richmond Lunatic Asylum, Dublin, whose case illustrates this class. We are informed that " he exhibited a total want of moral feeling and principle, yet possessed considerable intelligence, ingenuity and plausibilit}^" " He has never," says Dr. Crawford, "been different from what he now is; he has never evinced the slightest mental incoherence on any one point, nor any kind of hallucination. He appears, however, so utterly cal- lous with regard to every moral principle and feeling, so thoroughly unconscious of ever having done anything wrong, so completely des- titute of all sense of shame or remorse when reproved for his vices or crimes, and has proved himself so utterly incorrigible throughout life, that it is almost certain that any jury before whom he might be brought would satisfy their doubts by returning him insane." A very remarkable, and in some respects analogous, case is reported in the American Joiirnal of Insanity (October, 1846). A girl, eighteen years of age, guilty of arson, is represented to have been quite des- titute of the moral feelings. " She possessed quick perceptions, good reflective capacity, and a large share of ideality, etc. ; but no human kindness had she, nothing human indeed, but her form." She is stated to have resembled a serpent in her movements. " Her skin was cold — circulation very slow; her skin was spotted like a common species of snake." Dr. Davey has expressed himself very decidedly in favor of the union of moral idiocy with intellectual ability, in an interesting paper in the Associatioti Med. Journal (September 13th, 1856) ; and although we hesitate to admit what can properly be called moral idiocy apart from more or less lesion of the intellect, we fully grant that there may occasionally be good intellectual abilities in as- IDIOCY DEMENTIA FOLIE RAISONNANTE. [O^ sociation with congenitally feeble moral powers and volition (a moral insensibility), and therefore a proportionate irresponsibility. We may mention the case of a patient admitted into an asylum at the age of seventeen, laboring under moral insanity and epilepsy. He possessed decided intellectual vigor, united with an exceedingly obtuse perception of moral responsibility. His father stated that his character had been the same " from the cradle." At nine years of age he endangered the life of a little boy, his play-fellow; subse- quently at school he was characterized by similar mental qualities, learning more quickly than other boys, yet committing many acts of violence. He was, consequently, obliged to leave several schools. We know of another well-marked case of peculiarity in the temper and moral disposition, manifested from the earliest infancy, in which the intellectual faculties are not only equal to but above the average. The disease or defect was hereditary. The patient has been in an asylum for years. The same author speaks thus of the condition of mind (moral or affective insanity), when first exhibited in adult life: " Here the standard of mental health may justly be sought for in the natural and habitual character of the patient." This it is which is now altered, and the symptoms by which it is rendered manifest may next be considered. Usually the change in the feelings and conduct of the patient is gradual. Frequently, he is more ab- sorbed and reserved, and on any provocation, however slight, is un- reasonably irritated. He becomes suspicious, liable to attribute false motives to his friends and others, and to cast ungenerous reflections upon his nearest relatives. The husband suspects the fidelity of the wife, the wife that of the husband, without the slightest foundation. The patient is observed by strangers to be morose, and as the cloud gathers his acquaintances become conscious that he is somehow or other an altered man, without knowing why, and very probably with- out once supposing the man to have become insane. At last the storm bursts, and some act is committed of an outra- geous character. He is then regarded as either insane or criminal : the former, probably, if the act does not make him decidedly amena- ble to the laws of his country, and his destination is the asylum ; the latter, most probably, if the act has been homicidal, and he is con- signed to the executioner. In other cases an individual has been subjected to overexertion of mind, his powers overtasked, or his feelings put upon the stretch in consequence of anxiety or unaccustomed responsibility. He then no PSYCHOLOGICAL MEDICINE, finds himself susceptible to the slightest mental emotion, loses his sleep and rest, is conscious of more or less uneasiness about the head, a sense of tension and dull, aching pain, is probably troubled with palpitation of the heart, and finds himself unequal to the discharge of his usual duties. His digestive organs are also often disordered, his appetite uncertain, the secretions depraved. In addition to all this, he may be distressed by certain impulses and tendencies which are alike repugnant to his reason and to the dictates of his moral nature. Often the impulse " is to do violence to himself or others, or simply to break glass or articles of furniture." Pinel was the first to call these cases " reasoning madness," while Pritchard preferred the term " moral insanity." Ray tells us that " the affective as well as the intellectual faculties are subject to derangement." There are cases where there is the presence of homicidal impulse and also cases of suicidal impulse, without other symptoms of insan- ity. I think a close examination would reveal an insane taint in the family history could it be brought to light. Dr. Blandford, of England, says : " Under the names of moral in- sanity, emotional insanity, impulsive insanity, affective insanity, has been described the disorder of certain patients, which is manifested by insane actions and conduct rather than by insane ideas, delusions, or hallucinations. Such persons are sometimes said to be of whole and perfect intellect, though unsound in the moral and emotional part of their brain. They come under the notice of medical men not so much for purposes of treatment as for diagnosis. Their conduct being chiefly displayed in foolish or violent acts, they require to be restrained, and the question arises : Is this conduct badness or mad- ness ? Are they responsible for it or not?" There is in all the cases of this form of insanity that the author has met with a total absence of delusion, and this may, perhaps, be said to be the great diagnostic mark of reasoning mania, or moral or affective insanity, whichever we may please to term it. There is in these cases an entire change of character and habits, evinced by ex- traordinary acts and conduct. There are false assertions and false views concerning the best friends and relatives. The approach of this form of insanity is not sudden, but rather gradual and impercep- tible. The strange character of the acts is not at first so marked as it is afterwards. It generally takes some time before the patient's friends can convince themselves that such conduct is the result of disease, and many will look upon such an insane person's acts IDIOCY — DEMENTIA FOLIE RAFSONNANTE. Ill as the signs of depravity. After a time the insanity becomes well- marked, and overt acts are committed which leave no difficulty in making a diagnosis. False and apparently wicked assertions con- cerning the nearest relatives, or plots to annoy, may constitute almost the only symptom, at times, of this form of insanity which the public can see or hear of, particularly if the nearest relatives carefully con- ceal from the world all outrageous conduct which is shown at home. Such patients deceive the public by their plausibility and their ready excuses for their conduct. Dr. Blandford very truly says : " When we can ascertain that the condition of things is something which has come over the patient, being formerly absent, and that a man is altogether changed, we may suspect insanity." These patients are very acute and cunning, and most unmitigated liars. There may sometimes be in the history of these cases a period, though short, of acute mania or acute melancholia. This may also be a precursor of a marked insanity with delusions and hallucinations. In this vari- ety of insanity a man may squander all his property or he may be- come a dipsomaniac. This form sometimes constitutes one period of circular insanity, where periods of depression alternate with those of excitement, with exaggerated conduct and absurd acts. The responsibility of the class who have been from birth odd and peculiar, and who seem incapable of acting and behaving like other people, is sometimes difficult to estimate. They have a congenital moral defect ; they never tell the truth ; they are, so to speak, moral imbeciles, and it is very hard to say just how far they are responsible. Guiteau was just such a case. They are generally the offspring of parents tainted with insanity. C. H. Hughes, M.D., St. Louis, Missouri, says, respecting moral (affective) insanity : Notable instances of the subversion of mind, without accompaniment of mental per- version, are found in those cases of gangliopathy which proceed to the extent of fainting, epilepsia, chorea, etc., in which either volition or both the will and consciousness are subverted. The ganglionic (visceral) origin of certain forms of hypochondria, melan- cholia, and hystero-mania has been admitted since the time of Hippocrates. Morbid states of the reproductive system have long been deemed sufficient sources of certain forms of mental derangement, in which the feelings rather than the reasoning processes are disordered. It is conceded that kleptomania, pyromania, dipsomania, homicidal and suicidal im- pulses, and the morbid displays of pregnant women, and the mind disorders connected with the critical periods of woman's life, may have their starting-point in uterine disorder, even with more unanimity and certainty than puerperal mania, for the latter is often as much an insanity of general hsemic and neuric exhaustion— anaemia and shock— as of 112 PSYCHOLOGICAL MEDICINE. reflex irritation. And, if reflex insanity be conceded, the possibility of moral insanity must be admitted, for the concession acknowledges the varj'ing shades of mental involve- ment, depending upon the degree and source of the reflected irritation, from the insane longings and freaks of pregnancy to the infanticidal and other morbid impulses of post- partum cerebrasthenia. To concede the possibility of a homicidal or other morbid impulse not founded in delusion (and psychiatry furnishes abundant proofs of such impulses), is to admit the basis fact of moral insanity as it is clinically observable, namely, insanity not the result of reason pei*verted by disease.* \Vhen ganglionic disease is great and the morbid consequences profound enough to involve the intellectual faculties in marked disorder, those who deny the possibility of insanity existing without appreciable lesion of the intellect, now willingly admit the exist- ence of mental disease, and wiwittiugly, in those minor degrees of eccentric irritation connected with the period of utero-gestation and manifested in peevishness, and insa- tiable longings and changes of temper, they charitably concede that the patient is to be excused for not putting as complete a rein upon the display of eccentric feeling and action as would be considered the proper thing in one not enceinte. The intellect may appear intact or coexistent with a minor degree of moral or emotional perversion, and the perverted moral feeling excused or extenuated, if indulged ; yet, if we pass a few steps further and venture to saj' that a seemingly resistless impulse, to which the will yields while the intellect disapproves, is insanity, then their theoretical conception of the unity of mind — it being impossible for them to understand how emotion, volition, and thought can be separate — leads to the rejection of one of the most demonstrable facts in practical psychiatry, as well as one of the most demonstrable facts in our every-day inter- course with minds that are not insane. Persons in the best of health are constantly acting from impulse, prejudice, or passion, conforming to society's usages and the dictates of fashion or feeling without sufficient thought. The emotions and the intellect are not twin-born, though they mutually influence each other. They do not always go hand-in-hand or dwell harmoniously, though tenanted together in the brain. In good cerebral organizations they are often at war with each other. The things which even sane men ought not to do they often do, and those they ought to do they sometimes do not. The Apostle Paul confesses this of himself. If a saint can concede this much of a healthy mind, a sinner can do no less for the victim of disease. Paul was a good psy- chologist, and discerned, though unconscious of their physiological foundation, the gan- glionic source of certain encephalic states. He was " constantly at war with his mem- bers." When he " would do good, evil was present with him." ■=^ Tilt saw a case where pressure upon an inflamed ovary excited epileptic fits. I have seen a vaginal injection cause a maniacal paroxysm, some of the injected fluid having passed up into the uterine cavity. Sir Benjamin Brodie brought on a fit of chorea by gentle pressure over the stomach, and the effect of a smart blow in producing faintness is so well known to the prize-ring that it is considered foul to hit below the- belt. Even death has resulted from violence done to the semilunar ganglia. But these eff"ects are not more singular than the irritation of dentition, or worms, or undigested substances in the alimentary canal causing infantile convulsions; the effect of a fistula in causing mel- ancholia with impulse to suicide — passing away after a successful operation ; the many eccentric sources of epilepsia, tetanus, cerebral irritation, hypersemia, etc. Tait excises an ovary and cures an epilepsv ; Charcot compresses one ; and Kussmaul a testicle, causing reflex hystero-epilepsy ; and the temporary subversion of mind from wound of testicle was well known before Charcot, Kussmaul, Tait, Brodie, or Tilt were known to fame. IDIOCY — DEMENTIA FOLIE RAISONNANTE. IIJ I commend St. Paul as a psychologist to certain of our confreres. May the convincing light of truth shine upon them as it did upon the persecutor of the proto-martyr on his way to Damascus, and by way of contrition for the wrong they have done and may yet do that least commiserated of all the mentally afflicted, — the emotional, the impulsive, and the morally insane, — may they speedily make amends by renouncing their heresies and, embracing the true faith, become followers of the faithful Rush, Pinel, Prichard, Maudsley, Bucknill, Tuke, and Ray. Stephen had been stoned, it is true, but there still remained others to be saved. Many an honest Saul in our ranks, consenting to this wrong, remains to be converted. If there be any who, in perfect health, has not yielded to the dominion of impulse, emotion, or passion, let him cast the first stone at the victim of mental disease, whose intellect, while it does not restrain, yet seems not touched by the morbid process which has de- ranged the affections, the emotions, and the will. Insanity of the emotions, propensities, and passions, in which the intellect, if at all dis- ordered, is not app7'eciably so, or only 7Jiomentarily so by being in abeyance or unable, through some want of connection of the will or controlling power of the latter over the impulses and passions, is a fact, however it tnay clash with theories of the so-called unity of mind. It is a fact as much so as ecstasy or hypnotism, somnambulism or dreaming, which are not completely harmonious and united actions of all the mental powers. As much a fact as prejudiced, or biased, or unconscious cerebration in the healthy, working state of mind. As much a fact as the many varieties of aphasia without intellectual impairment, which the great Trousseau rejected, because he was biased in judgment by the dominant theory of Condillac and Warburton, that the mind could only think in speech. As much a fact as certain illusions or hallucinations in which the intellect does not concur, though during the formation stage of these mental spectra the reason may be in momentary abeyance. We should recognize the fact, though in so doing we may have to mend our theories or even abandon them. We should never whittle down facts to preconceived metaphysical notions. All observation of the varying degrees of emotional, impulsive, and intellectual life in different persons and in the same person at different ages of life attest the possibility of disorder of the emotions, propensities, or passions, without more appreciable intellectual lesion than we see in persons who are regarded as right-minded. Though insanity is marked generally by change of character, that change is seldom manifested in augmenting the power of the intellect and the will over the emotions or passions. On the contrary, the latter often subvert the former. Usually the disease, beginning with moral or emotional perversion, gradually involves or undermines the rea- son and judgment. It is thus that, in the early stages, moral, emotional, and impulsive disorder is mainly divorced from the intellect (if the two are ever then truly wedded), and what begins with an insanity of the feelings, propensities, or passions, usually goes on (if not arrested by timely medical interference) to the graver forms of more general mental involvement. These cases may even pass, if not cured, into the stages of delu- sion and dementia, a fact which has led some writers to doubt their existence unless associated with intellectual involvement, but which really proves the kinship of these contested varieties of mental derangement, even where neither delusion or other intel- lectual lesion appears, with universally recognized forms of insanity, just as the insane heredity of moral mania often establishes in our mind the fact of insanity as contradis- tinguished from uncomplicated vice when we are in doubt. Men in their sanest states are often more influenced by their feelings, prejudices, and passions than by their judgments. Insanity generally expresses itself more in action than in speech. The restlessness and constant muscular activity of many lunatics is not always 114 PSYCHOLOGICAL MEDICINE. the expression of disordered intellection so much as it is an accompaniment simply of morbid feeling or irritation of psycho-motor centres, and sometimes the acts of the insane, if their after confessions in seemingly lucid intervals may be taken as even approximately true, are not infrequently independent of both conscious thought and feeling. They appear often as blind freaks of disease or mental caprice, in which the highest intellectual centres seem only unconsciously involved. That vigorous thinker, John Locke, who was not a mere surface observer, though he looked at insanity rather too superficially for a practical alienist, was led to the conclu- sion — not strictly true, but not altogether erroneous — that the insane did not so much " appear to have lost the faculty of reasoning, but, having joined together some ideas very wrongly, they mistake them for truths, and they err as men do who argue right from wrong principles, for by the violence of their imaginations — having taken their fancies for realities — they make right deductions from them. Thus you shall find a distracted man fancying himself a king, with a right inference requiring suitable attendance, respect, and obedience ; others, who have thought themselves made of glass, have used the cau- tion necessary to preserve such brittle bodies. Hence it comes to pass that a man who is very sober and of a right understanding in all other things may, in one particular, be as frantic as any in Bedlam if either by any sudden, very strong impression, or long fixing his fancy upon one sort of thoughts, incoherent ideas have been cemented so powerfully as to remain united." Locke here has reference to the deluded or delusional insane, and is only in part correct, for the insane do often both reason illogically and incoherently and establish wrong premises, from which their reasoning proceeds. Doubtless the cor- rect reasoning manifested sometimes in the affective insanities contributed to the forma- tion of his only partly correct opinion, for in the next sentence he says, " There are degrees of madness as there are of folly — the disorderly jumbling of ideas together is in some more, some less," and in some (he might have concluded, had he been as familiar with the insane as they should be who aspire to correct notions respecting them) there seems to be no appreciable lesion of the reasoning faculties. Locke's idea of insanity was that it must always be intellectual aberration, and yet his observation taught him, despite his philosophical bias, — a bias in which many mental philosophers of the purely psychical school still share, — that 7nany h^cnatics reasoned well. It never occurred to him to deny the existence of insanity in such, but to assume that they joined some ideas wrongly together. With reference to another observation of Locke's, viz., " that reverence gives beauty and prejudice deformity to our opinions," it may assuredly be said with equal truth that intellectual processes in both the sane and the insane are incited to action and influenced by moral or other emotions, excited either by example of others or by disease. Those who deny the existence of moral insanity insist that there always exists a certain degree of intellectual acquiescence that entitles it to be termed intellectual insanity, though that intellectual perversion may be and often is no greater than that which is ■ found in the naturally immoral and depraved ; but, if one concede this, there yet remain cases of moral and emotional disease where the intellect not only does not acquiesce in, but actually discountenances and seeks to be restrained from, the morbid impulse, or to subvert the morbid feeling. Momentary impulses and suggestions of a morbid kind* obtrude themselves upon * The great Mare relates of himself how he withdrew from a bridge he was about to cross, lest he should yield to the impulse which came upon him to precipitate himself into the Seine. How many persons have confessed to feeling a disposition to precipitate themselves into the water when looking over a steep precipice, or the sides or steiui of a steamer. IDIOCY — DEMENTIA — FOLIE RAISONNANTE. II5 many healthy minds, like the vague feelings of unreasonable unrest and depression which obtrude unbidden into the neural chambers of the cerebral cortex. Facts like these, and a hundred others needless to enumerate, show the capability of the mental faculties to become partially involved in aberrant action without notable de- rangement of the reason. Men are not considered insane because they do not act wisely ; why should it be in- sisted upon that the intellect should show disorder before insanity is recognized in those whose impulsions are undoubtedly of morbid source, and why should the intellectual im- plication, when it is found, though it be no greater than that of some men moved by passion, be insisted upon as the essential feature of the disease ? How, then, can we doubt the possibility of forms of emotional and impulsive insanity, in which the moral faculties are so involved by disease as to cause the individual to appear depraved? The converse, too, is true. There may be moral exaltation from disease as well as from intellectual conviction, even from sexual excitation (excessive or suppressed gratification) religious exaltation may result, as Dr. Workman and others have shown, and that, too, without ecstatic visions or special delusions. Dr. Benjamin Rush* noted long ago that a morbid state of the sexual appetite " becomes a disease both of the body and mind." This pioneer in American psychiatry and close observer of the insane, readily discerned that the will might be deranged even " in many instances of persons of sound understandings and some of uncommon talents, the will becoming the involun- tary vehicle of vicious actions through the instrumentality of the passions,"-}- under which head he included what he termed the lying disease, which " differs from exculpative, fraudulent and malicious lying, in being influenced by none of tlie motives of any of them." " Persons thus diseased," he says, " cannot speak the truth upon any subject, nor tell the same story twice in the same way, nor describe anything as it has appeared to other people. Their falsehoods are seldom calculated to injure anybody but themselves, being, for the most part, of a hyperbolical or boasting nature. "J He inferred it to be "a corporeal disease," from its sometimes appearing in mad people, who are remarkable for veracity in healthy states of their minds, several instances of which he saw in the Pennsylvania Hospital. He recognized certain stages of intemperance as a disease of the ■will, and was the first to propose a hospital for inebriates, or " sober house," as he termed it, comparing the weakened will of a drunkard to a paralyzed limb. Rush also believed in a derangement of the principle of faith, or the believing faculty, caused by disease, also in derangement of memory, under which head he includes some instances of aphasia, without the accompaniment of intellectual aberration. He was an unequivocal believer in derangement of the moral faculty, conscience, and the " sense of Deity," and notes especially the case of a boy of thirteen years, in Bethlehem Hospital, described by Has- 1am, " who was perfectly sensible of his depravity, and often asked why God had not made him like other men." In the course of his life. Dr. Rush was consulted in many of " those cases of total perversion of the moral faculties." " Oife of them was addicted to every kind of mischief. Her wickedness had no intervals while awake, except when she was kept busy in some study or difficult employment." This great observer concluded that in these cases " there is probably an original de- fective organization in those parts of the body which are occupied by the moral faculties of the mind,"g though he could not determine where to draw the line which divides free agency from necessity, and vice from disease. He discourses further as follows : " In whatever manner this question may be settled, it will readily be admitted that * New Obs. and Enquiries, 1812, p. 347. | Op. cit., p. 264. X Op. cit., p. 265. g Op. cit., p. 360. Il6 PSYCHOLOGICAL MEDICINE. such persons are, in a pre-eminent degree, objects of compassion, and that it is the busi- ness of medicine to aid both religion and law in preventing and curing their moral alien- ation of mind."* Thus did one of the fathers of American medicine contribute in the beginning of the present century to the overthrow of that opprobrious doctrine of diabolical possession, or moral depravity, which has led many a hapless lunatic to the stake or the gallows, and to give us in its stead the conception of moral mania, a form of insanity just as real as the demonomania which overtook unfortunate old women past the menstrual climacteric m Cotton Mather's day, and resulted in their being drowned for witchcraft, and which, notwithstanding the reality of disease for its cause, finds even now in some quarters neither commiseration nor extenuation, being regarded as the manifestation of a wicked and devilish spirit, entitling its possessor to the punishment of the gallows or the peni- tentiary, rather than the restraint and treatment of the asylum for the insane. The ex- istence of the knowledge of right and wrong with the judge, the absence of appreciable intellectual disorder with the physician, are regarded as incompatible with their ideal conception, not of what insanity is, but of what it to them ought to be, and the penalty for this theoretical misconception of the real nature of mind is visited on the unfortunate victim of disease, whose bad luck it is to be afflicted in a manner theoretically proscribed. Theoretical views and metaphysical conceptions of mind have too long stood in the way of true progress in psychological knowledge. To this has been due the fact that physi- cal disease, as the basis of all forms of mania, now a generally accepted truth, was so long controverted. To this stumbling-block are we indebted for the inhuman treatment the insane received in the time of Galen, and up to that comparatively recent period when Pinel immortalized himself and lifted humanity to a higher pedestal by striking the shackles from the madmen in the dungeons of Bicetre. There is a somatic as well as a psychic element in mind as we are permitted to see it, to be taken account of in all study of psychical display, whether in health or disease, though what mind is we do not know, and perhaps we may never completely compre- hend, save in its manifestations. All that we can see of mind is displayed in the opera- tions of the intellect, the emotions, feelings, and the v.ill. There is a time in life when we see but little of the former, and a time when we see more of it than of the two latter attributes of the accompaniments of mind. The emotions and the will are part of the mind, as it manifests itself to us; and whatever may be our preconception of the impos- sibility of their being separated, if we see them practically severed by disease, it is only just to acknowledge the fact. To assert that the doctrine of moral insanity is a dangerous one, from which society may suffer, as Mayo and his followers have done, is to render science subservient to social polity, illogical, cowardly, and, of course, unscientific, whereas social polity should be ever subservient to scientific truth, whatever that may be revealed to be. Let us, always speak according to our convictions. If we trim and prune truth so that we may adopt it to social expediency, we become false lights; we degrade science, the sceptre of influ- ence falls from us, and judicial wrongs, even murder perpetrated by strong-handed Law upon the weak and miserable, will continue to be committed in our name, and be the lasting monument of our disgraceful surrender of truth. There is moral perversion and degeneration resulting from disease, with but little, if any, appreciable intellectual lesion, less intellectual lesion oftentimes than we find in those whose lives have been given up to vice, through self-will, or parental coercion, or evil communication. Then let us, when occasion demands, tell the courts so, and not * Op. cit., p. 300. IDIOCY — DEMENTIA — FOLIE RAISONNANTE. 11/ say we cannot conceive it possible for moral derangement to exist without concomitant intellectual aberration, while observable facts confute such theories, and let us turn our attention to searching out, for the aid of jurists, instead of ignoring the line of demarca- tion between responsible and irresponsible vice ; the characteristics of disease on the one hand, and on the other, voluntary moral depravity coupled with a body sound and a mind free to choose. Moral insanity constitutes an observed and observable fact of psychology; let us not seek to theorize it out of existence. The metaphysical conception of mind, the abstraction made into an entity, as Maudsley justly observes, "has overridden discerning observation" in some quarters, and eminent and observing men have thus suffered their judgments to become biased by the idea that the faculties of the mind cannot act separately ; that to derange one must necessarily and appreciably disorder others. On this reasoning, many eminent men believe the existence of moral insanity impossi- ble, while others, among them the lamented Ray, not so biased, following in the footsteps of Prichard, who first promulgated the doctrine, see no more difficulty in recognizing insanity of the moral feelings, and of other impulses, propensities and passions, without necessary involvement of the higher faculties of reasoning in appreciable disorder, than the great Pinel did long before them in discerning what, up to his time, was regarded as equally inexplicable, namely, mania without the delirium of madness. Dr. Mayo,* who made the first and strongest assault on the doctrine of Prichard, has unwittingly admitted, as indeed all close observers of insanity know, " that the earliest indications of approaching insanity are moral," and he makes the further fatal admission, " that at every period of the actual presence " of insanity " the powers of self-control are interfered with, the affections suppressed or altered, the passions excited or perverted." All practical observers concede a frequent gradual change of feeling and conduct in prodromal insanity preceding the culmination of intellectual aberration, and some who deny the possibility of moral insanity make a classification of moral imbecility, conces- sions which logically debar all opposition to moral insanity. Whatever the stage at which we view mental disease, whether initial or terminal, in- sanity exists, as much so, as fever at any stage of typhoid or typhus is fever. If a change of moral conduct have disease for its cause, it is as much entitled to be called insanity as the morbid aversions, antipathies, fears, or acts, not brought about by delusion, are to be classed among the recognized evidences of mental derangement. Blandford's searching analysis of Prichard's cases, while it divests many of them of the vestments of uncomplicated moral insanity, leaves a number that cannot be elsewhere placed, " good examples of what may be called moral insanity, if the term is to be used at all," as Blandford himself confesses, one of which he concedes deserves to be called morally insane. j Those who engage in the study of morbid mental phenomena with the preconception that the intellect must be always synchronously deranged in all morbid mental expression, must consistently regard every act or feeling of the insane person " as plainly the out- come of some idea present for the moment, but present, possibly, but for the moment, and then so obliterated that the individual has lost all trace of it,"J in certain morbid impulsions or feelings. Those who think " the intellectual and emotional functions of the mind cannot be divorced, that the ideational portion of the mind is so intimately joined * Elements of the Pathology of the Human Mind, Medical Testimony and Evidence in Cases of Lunacy. By Thomas Mayo, M.D., F.R.S., London, p. 64. f Cases 4 and 5, p. 317. Insanity and its Treatment, 1871. % Ibid., p. 319. Il8 PSYCHOLOGICAL MEDICLXE. in operation to the emotional — the stored ideas of the brain are so influenced by the feelings of the moment, whether these arise from within or without — that the two must be sound or unsound together," will be reluctant to concede the demonstrable fact that the aftective life may be greatly changed by disease, while the intellectual processes re- main intact, so far as may be discernible by any known methods of testing the integrity of the reasoning powers ; slow to recognize those cases in which the will and not the reason is weakened and perverted. Yet the morbid impulsions arising in neuropathic organisms, often reasoned against and sometimes resisted, but finally surrendered to, stand out m practical refutation of the impossible conception of the invariable unity of mind disturbed by disease. The dipsomaniacs, the kleptomaniacs, and sometimes even pyromaniacs, yielding to im- pulses against their reason, are examples no less destructive to this hypothesis than the auto-amnestic acts and impulses of hypnotism, somnambulism, and certain epileptoid states. To gauge insanity by the integrity or non-integrity of the reasoning processes alone would make the automatism of certain manifestations of alcoholism, epilepsia and mesmerism normal mental states. The reasoning faculties in moral insanity often appear to act as correctly as in the most perfect cerebral automatism. If there is lesion short of intellectual disease and beyond that of pure derangement of the moral faculties, and there usually is in this as there is in all insanity, a degree of auto-amnesia by which the affected individual does not discern the change that has taken place in himself, it is simply an impaired or lost appreciation of the transformation in his character, which has been brought about bj^ disease, but many sane persons also fail to discern their descent into vicious ways. However, if this degree of involvement of the comparing faculties be deemed sufficient to ally it to insanity in general (and it does on the basis of a part of Conolly's definition), and thus to rescue a real mental disease from the theoretical assaults made upon it, we cheerfully concede it, for it is a fact that the morally insane, like most other insane persons, usually do not see themselves as others see them. But there are cases where the search must be exceedingly close to reveal any greater lesion. Normal mind is the sum of the aggregate display of the cerebro-psychic functioiis con- stituting the natural " ego," abnormal mind consists of such disorder of one or more of the cerebro-psychic functions as causes so marked a change in the psychical characteris- tics of the individual, whether principally involving the emotions, the reasoning powers, or the will, as to make an inconsistency and inharmony in the person's character explica- ble only by disease. Moral insanity is as clearly comprehended in this definition as other forms of mental derangement, and as much entitled to be recognized as a distinctive appellation and form of disease as the many other mental affections that are named on account of their promi- nent symptomatic feature or features. Not to recognize it in the present state of cerebro-mental pathology would in certain instances prove disastrous to the rights of the insane before the courts, and to their wel- fare elsewhere. MENTAL RESPONSIBILITY, ETC., IN CRIMINAL CASES. I I9 CHAPTER VIII. MENTAL RESPONSIBILITY AND THE DIAGNOSIS OF INSANITY IN CRIMINAL CASES. At the present day medico-legal cases are becoming very frequent in which it is necessary to ascertain as to the insanity of a person accused of a criminal act in its relation to his civil capacity and responsibility for criminal actions, and also as to feigned or concealed insanity. It becomes, therefore, a very interesting question what test of insanity the law should recognize as a valid defence in crimi- nal cases. This question — although one which it seems difficult to settle satisfactorily, and which judges, lawyers, and medical experts are constantly disputing about — assumes, every day, greater interest and wider significance owing to the increase of insanity in our coun- try disproportionate to the increase of population which has taken place during the past twenty years, and which will continue to take place. Without inserting dry statistics, it is sufficient to say that a comparison of the increase of population from 1850 to 1870 with the increase of the number of the insane during the same period reveals an increase of insanity over that of population of about twelve per cent. The increase of insanity among our own population is due largely to a change from a vigorous, well-balanced organization to an undue predominance of the nervous temperament which is gradually taking place in successive generations. The educational' pressure on the young to the neglect of physical exercise, the increasing artificial and unnatural habits of living, the great excitement and competition in business, are all tending to induce and multiply nervous diseases, many of which must terminate in insanity. These causes and the evils resulting from them are propagated by the laws of inheritance in an aggravated and intensified form. Insanity is also appearing gradually at an earlier age than formerly. This is due largely to the great mental activity and strain upon the nervous system that appertain to the present age and state of civilization, and which tend to a rapid decay of the nervous system. With many persons it is but a step from extreme nervous suscepti- bility to downright hysteria, and from that to overt insanity. The question of mental responsibility in its relation to criminal cases is I20 PSYCHOLOGICAL MEDICINE. one of great interest, and presents a wide field for study and investi- gation. The facts of criminal psychology have led the writer to regard the impulse of criminal natures in the light of natural laws, and there is, beyond all doubt, an anthropological change which lies at the foundation of criminal propensities.* There is a deficient cere- bral organization which lies at the foundation of these criminal na- tures, which occasions the disposition to an abnormal moral consti- tution. The dislike of work and the love of enjoyment are impulses which, when combined, lead especially to crime, when that ethic con- stitution or development is wanting which is necessary to the foun- dation of a powerful feeling of what is right. A further fundamental element, which stands in psycho-physical contrast to dislike of work, is an excessive physical consciousness of strength, which leads to arrogance and thereby to the pleasure of misusing strength against the weak. This impulse leads to the love of bullying, cruelty, and murder, if the higher intellect is absent which should turn the feeling of strength in a right direction, and there is also absent a complete ethical consciousness which should prevent misuse of power. This ethical weakness may be congenital, as has been remarked, or it may arise from deficient education. In the domain of vices we meet with a peculiar condition of the central nervous system, which results in a temporary criminal im- pulse returning with a certain regularity. Such criminals are tem- porarily seized with the deepest remorse and are fortified with the best resolutions. They behave for a time in the most exemplary manner, until they relapse again, which relapse is unanimously attributed by them to an irresistible impulse. This state of moral epilepsy is of great significance in the psychology of crime, as a physi- ologist is led to institute a comparison between such cases and sev- eral states of disease in which a peculiar type is observable, consisting in the fact that attacks of illness of more or less duration alternate with more or less long and, generally, for a time, preponderant, healthy intermissions. In a broad sense, one may designate all these pathological states as epileptiform, hence the term " moral epilepsy," which has been adopted above. Leaving this interesting question of the psychology of crime, we would ask if the true basis for jurists to proceed upon is not the protection of the existence of normal persons against the ethically degenerate ? And the necessary degree of this * Benedikt has shown this conclusively, and the reader is referred to the last chapter of this work for the full consideration of this most interesting question. MENTAL RESPONSIBILITY, ETC., IN CRIMINAL CASES. 121 protection is, most certainly, an essential measure for the severity of the punishment. The first trial of note where there was the question of insanity advanced was in 1723, when the trial of Arnold for shoot- ing at Lord Onslow occurred. Although it was shown that Arnold had been of weak understanding from his birth and that he was doubtless insane, the jury brought in a verdict of guilty, and Arnold would have been executed had it not been for the intercession of Lord Onslow. The language of the charge to the jury in this case was in con- formity to the rule laid down by Lord Hale, that partial insanity does not excuse a person from the consequence of his act, and that a total deprivation of reason can furnish such an excuse. In the year 1800 the celebrated trial of Hatfield for shooting at the King, in Drury Lane theatre, excited much interest. Although it was proved that in 1793 Hatfield, who was a dragoon, had received a number of severe wounds which had caused partial insanity, so that he was dismissed from the service, and since that time he had had periodic attacks of insanity, and had been confined as a lunatic, the prosecuting attorney laid down the established rule that a total absence of memory and understanding could alone shield the prisoner from punishment, and appealed to the jury for a conviction on that ground. It was only through the brilliancy of the advocate (afterward Lord Erskine) that the prisoner was acquitted. This trial had a good effect upon the judiciary, as in the year 18 12, in the trial of Bellingham for the mur- der of Spencer Percival, Lord Mansfield laid down the law that the capability of distinguishing between right and wrong was the test for determining the prisoner's responsibility, thus discarding the old theory of an entire absence of all mental power and substituting this in its place. Afterward the theory of a general knowledge between right and wrong was modified, and the element introduced that the prisoner must know the difference between right and wrong at the time of and with regard to the particular act for which he is on trial in order to render him responsible, and this test has been preserved to the present time. In the early history of our own country the same barbarism in the treatment of the insane prevailed which darkens the pages of English history. In Governor Winthrop's History of New England the case of Dorothy Dalbye is mentioned. She was executed for killing her child. She was, beyond all doubt, an insane woman, but this fact was not recognized by Governor Win- throp, who says of her ; " She was so possessed with Satan that he 122 PSYCHOLOGICAL MEDICINE. persuaded her by his delusions, which she hstened to as revelations from God, to break the neck of her own child, that she might free it from future misery^" Such was the ignorance and prejudice of the early history of our country''. We are at the present day very far from a correct understanding of the workings of the insane mind, for in the recent trial of Scan- nail, the law was laid down as enunciated by the Court of Appeals in 1865, in the case of Willis v. The People, which held that a person was not insane who knew right from wrong, and that the act he was com- mitting was a violation and wrong in itself This theory of right and wrong is utterly inadequate to meet a large class of cases. There are certain cases familiar to all specialists in insanity, which suffer from impulsive insanity with a homicidal or suicidal mono- mania. These patients, without appreciable disorder of the intellect, are impelled by a terrible vis a tergo, a morbid, uncontrollable im- pulse to desperate acts of suicide or homicide. These patients are often fully aware of their morbid state, appreciate perfectly the nature of the act toward which they are impelled, and feel deeply the horror of their situation, and yet if not prevented by restraint will inevita- bly commit acts of suicide or homicide. A very remarkable case was under the care of the writer, of a man who would at stated times acknowledge that he felt an irresistible impulse to kill some one, and would voluntarily enter an asylum and remain there until this morbid impulse had passed away, which was generally a period of one or two months. He has often told the writer that his life was made miserable by the idea that at some time this overwhelming impulse would come upon him so suddenly that he should commit some desperate homicidal act, but is not pre- pared to voluntarily incarcerate himself in an asylum for life, as his lucid intervals sometimes lasted for months at a time. The law, as laid down at present, would not decide this man to be insane, as he fully appreciates the difference between right and wrong, and the nature and consequences of any homicidal act that he may in the future commit. Such cases, which are not at all uncommon, serve to show what fearful injustice may be done under the name of justice, when the conclusion is based upon a metaphysical test which is proved by medical observation to be false in its application to the unsound mind. There is still another form of insanity denominated " moral insanit}'-," in which the intellectual faculties are intact, no de- lusions or hallucinations existing, but where the normal sense seems MENTAL RESPONSIBILITY, ETC., IN CRIMINAL CASES. 1 23 utterly obliterated. Such persons have no true moral feeling. This is disorder of the mind produced by disease of the brain, and it is an unquestionable form of insanity, as it often precedes other forms of insanity, in which intellectual derangement is well marked, as acute mania or general paralysis. In some of these cases there is a modified responsibility, the degree of such responsibility being de- termined by the particular circumstances of each individual case. One difficult but important question to be solved, is the civil and criminal responsibility of women who plead insanity before courts of justice, and who are often afflicted with kleptomania, pyromania, or who are infanticides, as a result of sexual trouble and disease of the pelvic organs. Such women under all reasonable conditions are en- titled to the benefit of the doubt, because of their defective mental integrity, caused perhaps by pregnancy or by the subsequent emo- tional excitement attending parturition, which intensifies the cerebral disorder in a brain already morbidly active. With women, extreme nervous susceptibility readily lapses into insanity. " In the sexual evolution, in the parturient period, in lac- tation, strange thoughts, extraordinary feelings, unreasonable appe- tites, criminal and suicidal impulses may haunt a mind at other times innocent and pure. It is probable also that young unmarried women, guilty of killing their own new-born offspring, are so distracted by conflicting feelings, sharpened to morbid acuteness by the great physiological movement of parturition, as to be hardly responsible for their acts." We come now to the question of the diagnosis of insanity. In making an examination of a person accused of crime, and in whom insanity is suspected, the person should be visited by the medical examiner, who should draw him into a pleasant conversa- tion, and inquire as to previous attacks of insanity, hereditary his- tory, then into any predisposing causes of insanity, such as intem- perance, vocation, habits, etc., which may have operated in the production of insanity. Also as to injuries of the head or spine which may have occurred, sunstroke, etc. The nervous system should then be examined for the existence of any such diseases as paralysis, epilepsy, catalepsy, or hysteria. The different senses, be- ginning with sight, should be examined, and in this way it may be discovered if there are hallucinations or illusions pertaining to any of the senses. A great many cases are on the border line which separates sanity from insanity, and it often requires the nicest dis- 124 PSYCHOLOGICAL MEDICINE. crimination to determine whether such a patient has passed this bor- der Hne. The writer would suggest a series of eight questions, which, if adopted by jurists in criminal cases, would prove a most efficient and just test as to the existence of insanity in any given case, viz. : 1. Have the prisoner's volitions, impulses or acts been determined or influenced at all by insanity, and are his mental functions, thought, feeling and action, so deranged, either together or separately, as to incapacitate him for the relations of life ? 2. Does the prisoner come of a stock whose nervous constitution has been vitiated by some defect or ailment, calculated to impair its efficiency or derange its operations ? 3. Has the prisoner been noticed to display mental infirmities or peculiarities, which were due either to hereditary transmission or present mental derangement ? 4. Has the prisoner the ability to control mental action, or has he not sufficient mental power to control the sudden impulses of his dis- ordered mind, and does he act under the blind influence of evil impulses, which he can neither regulate nor control ? 5. Has the act been influenced at all by hereditary taint which has become intensified, so that the morbid element has become quick- ened into overpowering activity, and so that the moral senses have been overborne by the superior force derived from disease ? 6. Was the act effected by or the product of insane delusion ? 7. Was the act performed without adequate incentive or motive ? 8. Does the prisoner manifest excitement or depression, moody, difficult temper, extraordinary proneness to jealousy and suspicion, a habit of unseasonably disregarding ordinary ways, customs and ob- servances, and habitual extravagance of thought and feeling, and in- ability to appreciate nice moral distinctions ; and, finally, does he give way to gusts of passion and reckless indulgence of appetite ? Some or all of these are found generally in connection with trans- mitted mental infirmity. It may be argued that these mental defects signify not mental unsoundness but human imperfection. Certainly if we take these manifestations, any one of them singly and alone, we cannot claim such a one as invariably an indication of insanity, but on the other hand, under certain circumstances, each one of them may be an unmistakable sign of insanity, or rather of a morbid cerebral state which may readily lapse into insanity. The disap- pointments and calamities of life obviously act with greater effect upon an unstable mental organization, these causes of disturbances MENTAL RESPONSIBILITY, ETC., IN CRIMINAL CASES. 12$' meeting with a powerful co-operating cause in the constitutional predisposition. Sometimes a crime even when there have been no previous symptoms to indicate disease, marks the period when an insane tendency has passed into actual insanity, when a weak organ has given way under the strain put upon it. There is a class of per- sons with a peculiar nervous temperament who inhabit the border- land between crime and insanity, one portion of which exhibit some insanity, but more of vice, and the other portion of which exhibit some vice, but a preponderance of insanity ; and it is very difficult to form a just estimate of the moral responsibility of such persons, especially when we reflect upon the fact that moral feeling is a func- tion of oganization, and is as essentially dependent upon the integrity of that part of the nervous system which ministers to its manifesta- tions, as is any other display of mental function. The writer has met with cases in which, as a result of parental in- sanity, there has been a seemingly complete absence of moral sense and feeling in the offspring, and this has been a true congenital dep- rivation, or a moral imbecility so to speak; of course such children can hardly fail to become criminals. In this connection, it is inter- esting to note that moral degeneracy often follows as a sequence upon disease or injury to the brain. A severe attack of insanity sometimes produces the same effect, the intellectual faculties remain- ing as acute as ever, while the moral sense becomes obliterated. When such persons are acquitted, on trial, of a criminal act on the ground of insanity, they should be remanded to medical custody, and should never be set at liberty until the medical superintendent of the asylum deems them fully recovered; but the commonest justice plainly indicates that such custodial restraint be of a medical and not of a penal nature. It is a very difficult thing for the laity to recog- nize how sane a person may be who, all the while, has a greater derangement than was ever suspected until something happens to elicit the evidence of it, such as an attack of illness or severe mental strain, and some unconquerable impulse seizes him, and some homi- cidal or suicidal act results, to the great surprise of every one. In the same manner inebriety often appears in maturity as a result of ill-health, mental shock, etc., and it becomes an interesting ques- tion as to the degree of moral and criminal responsibility which attaches to inebriates, as inebriety often depends upon an abnormal organic development of the nervous system that has descended from generation to generation, gaining in intensity until it manifests itself 126 PSYCHOLOGICAL MEDICINE. in active inebriety, and there must certainly be a modified responsi- bility when homicidal or suicidal acts are committed during periods of such abnormal cerebration. In such cases a criminal act may be committed in consequence of cerebro-mental disease, without any ap- parent lesion of the perceptive and reasoning powers. In these cases, also, the mental disorder is of a sudden and transitory character, not preceded by any symptoms calculated to excite suspicion of insanity. It is a transitory mania or sudden paroxysm, without antecedent manifestation, the duration of the morbid state being short and the cessation sudden. In these cases the criminal acts are generally monstrous, unpremeditated, motiveless, and entirely out of keeping with the previous character and habit of thought of the individual. Such attacks are transient in proportion to their violence, and transi- tion occurs on the completion of the act of violence. There is an instantaneous abeyance of judgment and reason, during which period the person is actuated by mad and ungovernable impulses. Closely allied to this state of which I have been speaking is that peculiar psychological state — the trance state — which also occurs in inebriety. There has been very little medical study of these cases, although they are of great medico-legal importance. Crimes com- mitted in this state are purposeless, and there exists no recollection of them in the mind of the sufferer. By " trance state," I mean a state where there exists loss of memory and consciousness for a time, varying from minutes to days, the patient giving no evidence by his acts of his real condition, and very likely attending to all of the duties of his business in a quiet, mechanical way. The mind may, however, in this trance condition, act in iinacaistomed lines of thought and action, and, in certain cases, the criminal impulse may dominate the mind. As a rule, in these trances, it is probable that the mind acts, as before, with the same discretion, although the per- son himself can give no account of what has happened during this mental blank, during which the mind acts automatically. During this state a person may get into a dangerous mental condition, in which impulses of every description may take possession of and con- trol his actions. It is a condition of irresponsibility. In these cases there is generally a neurotic constitution inherited from the ances- tors, and a careful examination, which should never be neglected, will generally reveal either intemperance, insanity, or phthisis in the ancestors. The great diagnostic point which I would insist upon is that there is absolutely no recollection of what happens in this trance MENTAL RESPONSIBILITY, ETC., IN CRIMINAL CASES. 12/ state, and this want of memory cannot be successfully feigned so as to deceive a careful expert in inebriety and insanity. When a per- son, either a secret or an open inebriate, commits an unusual or crimi- nal act (not during intoxication), and retains no recollection of the event, he should be most carefully examined for the existence of the trance state, which, if it can be proven, markedly lessens the respon- sibility of his crime. The impulse to crime in these cases may develop in different ways. There may be suicidal or homicidal impulses, or buildings may be burned, or sexual assaults may be made, or be apparently very mali- cious. In all these cases medical care is plainly indicated. Persons unacquainted with this state may reason that because these crimes are committed in a way and manner perfectly cool and free from excitement, that they are evidences of a sane mind, but they are greatly mistaken, as it is the rule, and not the exception, to find these deeds performed in a cool, quiet manner, with no excitement. The deeds, however, are, to the person affected, an unusual course of action, utterly at variance with the previous character and habits. It is not right for inebriates who commit sudden, purposeless crimes to receive the full measure of punishment at the hands of court or jury without a proper study of their case by one who has studied these cases intel- ligently. Proper medical study would enable courts and juries to understand the mental conditions which causes these motiveless and purposeless crimes in inebriates. His act is not a vice, and you can neither assume his perfect sanity nor a capacity to reason clearly. The person in this trance state is not cognizant of his acts, neither, as I have said, does he retain a7iy recollection of them afterward. There is absolute irresponsibility, and it should be made clear to both court and jury. The idea in these cases should not be to try to work on the sympathies of the jury, but to show them the existence of this trance state and the irresponsibility arising from it. In these cases we must prove that inebriety, as a disease, exists, and that it has affected intellect, manner, temper, disposition, habits, and character, and then that the trance state has supervened. We will consider, finally, the medico-legal importance of epilepti- form attacks, which may be partial in character, and which may not reach convulsive activity except so far as the mind is concerned. These attacks always display periodicity, and after the paroxysm there is an intermediate stage, during which, in most cases, the per- son remains in a confused state, perhaps for some hours, and is apt 128 PSYCHOLOGICAL MEDICINE. subsequently to retain only a vague and general notion of the pre- ceding events. Thus in a homicide by shooting, the murderer would be likely to be roused by the sound of the pistol-shot and to remem-- ber it, although he would not very likely remember the altercation at all, or what passed between himself and his victim. A case occurred recently, of considerable interest from a medico-legal point of view, in which a murder was committed during an epileptiform seizure which was the result of a previous sunstroke, the immediate exciting cause being an attack of illness and the taking of a small quantity of alcoholic stimulus, which, it is well known, acts as a poi- son upon persons who have been sunstruck. This state of what, perhaps, I may not improperly call moral epilepsy, in which the man was of whom I shall presently speak, is a morbid affection of the mind centres which destroys the healthy co-ordination of ideas and occasions a spasmodic or convulsive mental action. The will cannot always restrain, however much it may strive to do so, a morbid idea which has reached a convulsive activity, although there may be all the while a clear consciousness of its morbid nature. The case just referred to had complained of pains in the head and sleeplessness, which had displayed marked periodicity and which had been accom- panied with great irritability of temper, excited by trifles and seem- ingly unconnected with personal antipathies. As has been previously stated, the person alluded to had been suffering from quite a severe illness, and, after taking a small quantity of alcoholic stimulus, went out to walk. He met a friend with whom he had been familiar for years, and a discussion arose as to the respective merits of certain politicians, when, the discussion becoming excited, the man pulled out a revolver and shot his friend. He then went, in a confused and dazed state, and sat for some hours on a dock near a river, and sub- sequently went home, and burst into tears, and informed his wife of the sad occurrence, and gave himself up at the police-station. There was no simulation of insanity by pretending to be incoherent or by strange actions, and no attempt, either on the part of himself or wife, to pretend that the act was an insane one. There was, however, a total blank in the prisoner's mind respecting the events preceding the pistol-shot, which seemed to have aroused his attention at the time, and he had no recollection of the fact that he had sat on the dock for some time afterward, as he was seen to do. I was consulted by Judge , who appeared for the defence, and, upon ascertaining the prisoner's previous history, gave it as my MENTAL RESPONSIBILITY, ETC., IN CRIMINAL CASES. 129'' Opinion that there had existed, for months previous to the occurrence, a profound moral or affective derangement, which, from its marked periodicity, was evidently epileptiform in character, and that the sud- den homicidal outburst supplied the interpretation of the previously obscure attacks of recurrent derangement. There had evidently been induced by the sunstroke in this case an epileptiform neurosis, which had been manifesting itself for months, chiefly by irritability, suspi- cion, moroseness, and perversion of character, with periodic exacer- bations of excitement, all foreign to the man previous to the attack of sunstroke. It is well known among specialists in insanity that this epileptiform neurosis often exists for a long time in an undevel- oped or masked form, and that this neurosis is, moreover, connected with both homicidal and suicidal mania. Such attacks are often noticed to occur periodically for some time before the access of gen- uine epilepsy. I have often witnessed, in cases under my care, abortive or incomplete epileptiform attacks, where there were no con- vulsions and where there was no complete loss of consciousness. I have noticed in such cases, either a momentary terror, slight inco- herence, a gust of passion, or a mental blank, the patient perhaps stopping in the middle of a sentence. The patient would then be himself again, quite unconscious of what had happened to him. Accompanying this confusion of ideas may be, as I have remarked, instantaneous impulses, either of a suicidal or homicidal nature. Owing to the writings of Hughlings Jackson, Maudsley, Russell Reynolds, Hammond, Trousseau, Falret, Esquirol and others, epilep- tic vertigo is a recognized disease. There is abundant testimony to show that during such seizures persons may perform actions, and even speak and answer questions automatically. There are numer- ous examples in the works of the above authors, proving that in an unconscious condition persons can progress from odd or eccentric actions to deeds of violence, suicide or murder — being unable to re- member the circumstances afterwards and, therefore, irresponsible for their actions. This class of patients I have always found irritable, easily excited, very emotional without adequate external cause, easily losing their train of thought, and often unable to collect or fix their thoughts. Such cases have told me that they felt impelled to strange and violent acts by some power which they could neither understand nor resist. Such patients may entertain delusions of fear and per- secution, and commit criminal deeds as a result of such delusions. When such cases, in their terror or distress of mind, commit some 9 130 P3VCH0L0GICAL MEDICINE. violent deed, they either experience immediate relief, as was the case with one patient under my care, who was only relieved by breaking out a pane .of glass, when his paroxysm would subside, or they con- tinued in a state of excitement, unconscious, or very imperfectly con- scious of the gravit}^ of their acts. When they become conscious again their memory is apt to be very uncertain as to preceding events.* Griesinger says : " Individuals hitherto perfectly sane and in the full possession of their intellects are suddenly and without any assignable cause seized with the most anxious and painful emotions, and with a homicidal impulse as inexplicable to themselves as to others." ]\Iaudsley says : " Let it be borne in mind then, that there are latent tendencies to insanity which may not discover the least overt evidence of their existence, except under the strain of a great * The reader must distinguish between such cases as the above and cases of true homi- cidal mania, which latter, as Bucknill and Tuke have shown, may be classified under two heads : i. Those cases in which there is no marked disorder of the intellect, examples of emotional insanitj'. 2. Those in which such disorder is more or less apparent. The former class may be subdivided according as there is or is not evidence of premeditation and design. In the latter class we include cases marked by deficiency of intellect, as idiocy, imbecilit)', and a degree of mental feebleness not amounting to either of these states, while other cases in the second class are rather indicated by a state of exaltation, shown by delusions or hallucinations which may constitute the motive, ^^^len any per- son says that they had not the slightest motive for a homicidal act I always stispect masked epilepsy even if there is no proof of it, although there is, of course, a morbid, overpower- ing impulse to take life, without intellectual disorder, and with intact perception and reasoning powers. There has been petit mal in nearly every case of transitoiy mania that we have knowledge of. Griesinger has truly said that we may have a morbid mental state which may present no external manifestation. Legrand du Saulle's case of a young man, " Theodore," of twenty-six years, who assassinated two men without premeditation, without motive, and without apparent excuse, was undoubtedly a case of epilepsy com- plicated with transitory mania. Castelman, Devergie, Calmeil, Tardieu, Marce, have all reported cases of this nature. A young man of education placed himself voluntarily under our professional care acknowledging impulses to commit homicide, and said that he did not like to have razors or knives around him for fear that he should be unable to resist these impulses. " I never feel sure of myself," he told me. He evidently felt himself to be irresponsible, and expressed himself forcibh* to me on this point. I urged him to volun- tarily place himself in a well-regulated asylum for the insane, but neither himself or his family would acquiesce in this measure of preventive medicine, and he is still at large. He said he had received a blow on the head and had also suffered from heat prostration to the extent of insensibility, and complained of cephalalgia. I have had an opportu- nity of studying another case of what I think is pure moral insanity, where there is an utter moral insensibility, and where the whole channel of thought runs in the direc- tion of how to successfully commit homicide; There are sexual perversions in this case. There is marked sleeplessness, but the perceptive and reasoning powers are veiy good. There is premeditation and cunning de:>ign, and a knowledge of right and wrong. This patient has also suicidal impulses. THE HISTOLOGY AND FUNCTIONS OF THE CEREBRUM. I3I calamity, or of some bodily disorder, and that the outbreak of actual disease may then be the first positive symptom of unsoundness." The question as to the degree of mental responsibility attaching to such cases is one of great interest to psychologists and also to jurists, and one to which it is hoped, in the future, much more attention may be directed than has been given to it in the past. CHAPTER IX. THE HISTOLOGY AND FUNCTIONS OF THE CEREBRUM. The study of the histology and functions of the cerebrum — not alone, of the several ganglionic centres, but also of the different layers of the great " hemispherical ganglia " formed by the convolutions of the cerebrum — has as yet been little prosecuted. It presents a wide field for investigation, experimental inquiry and discovery; and al- ready such investigators as Dr. Ferrier, Sir Charles Bell, Dr. Carpen- ter, Dr. Brown-Sequard, Charcot, Pitres, Maragliano, and Tambu- rini have thrown great light upon the localization of brain functions. We may now regard it as established that the ascending parietal convolution of the brain is connected in its innermost and superior part with the motility of both the upper and lower limbs ; in its middle part with the motility of the fore-arm and head, and in its external or inferior part with the facial muscles. Also, that the as- cending frontal convolution in its most external or inferior part, where the third frontal has its origin, is the motor centre for the mus- cles of the lips and the tongue, a function which is also shared in by the foot of the third frontal convolution. In these last-named corti- cal centres, the transformation of ideas and verbal images into motor impulse towards the muscles destined for the pronunciation of words takes place. Paralysis, atrophy, and convulsive movements will pre- vail in any given case as a rule, in the limb or limbs whose cortical centre is most profoundly affected by destructive disease, while in epi- lepsy, from the region of the body where the convulsive movements commence, which open the epileptic access, we may with security diagnosticate the cortical centre primitively and principally affected, 132 PSYCHOLOGICAL MEDICINE. which is that corresponding to the group of muscles earliest brought into action. The functions of the cerebellum are supposed to be related to co- ordination, as in cerebellar affections we have a sort of reeling gait, with severe vertigo, and perhaps also severe and continuous vomit- ing, while psychic disorders are lacking, except in general atrophy of the cerebellum. These symptoms, however, cannot be considered as pathognomonic always, as they are also present in other central nervous affections. Respecting the pons varolii, we may diagnose with certainty recent hsemorrhages into this part where its especial cross paralysis is pres- ent, and we may diagnose the same, with probability, when the apo- plectic attack is accompanied with general convulsions, contraction of the pupils, and death occurs in a few hours. Respecting the medulla oblongata, it is only with approximate cer- tainty that we can diagnose lesions here. The various cranial nerves are implicated, producing dysarthria, anarthria, dysphagia, aphonia, and disturbances of respiration and circulation. We may find either hemiplegia or paraplegia, but very little aneesthesia, as a rule. In lesions of the crura cerebri we find a paralysis of the motor oculi, generally affecting all its branches on the same side with the lesion and opposite the contralateral hemiplegia of the extremities. In these cases the paralysis both of the extremities and of the motor oculi is sudden and simultaneous. Respecting the corpus striatum we know that by far the greater number of cerebral hsemorrhages take place into this ganglionic cen- tre, and we accordingly find generally as the symptoms of lesions here the typical hemiplegia. We have, however, lesions affecting different localities of the corpus striatum as laid down by Nothnagel and Charcot. Lesions affecting the lenticular nucleus ; the caudate nucleus ; the anterior portion of the internal capsule ; the posterior portion of the internal capsule ; and finally, lesions affecting only the lenticular nucleus, or the optic thalamus, or the adjoining part of the island of Reil. The hemiple- gia produced by haemorrhage into the corpus striatum may gradually disappear if the lenticular or the caudate nucleus alone is involved. It is permanent if the internal capsule is affected either alone or with the gray. nuclei. In these lesions of the internal capsules with the permanent paralysis we frequently find secondary contractures. Respecting the cortex of the brain we may say that psychic dis- THE HISTOLOGY AND FUNCTIONS OF THE CEREBRUM. 1 33 orders in general point to a cortical lesion, and dysphagic and apha- sia phenomena also point in the same direction. The third left frontal convolution may be supposed to be affected in simple ataxic aphasia. The third temporal convolution may be supposed to be the seat of the lesion in word-deafness. As I have previously stated, the motor disorders accompanying cortical lesions give evidence of the locality of the latter. The forms of paralysis which we meet with as a result of cortical lesions are monoplegias, partial hemiplegias, isolated paralysis of the facial and hypoglossal nerves, of the arm, and rarely of the leg. As the result of haemorrhage, softening, or the development of a tumor, we find certain forms of motor irritative phenomena — partial and limited convulsions. In cases where the motor irritative phenomena take on the character of epileptic attacks, the typically recurring spasm always begins in the same group of muscles in one extremity or one half of the face. We know very little positively of the different operations of psy- chological and intellectual life, the phenomena of which have been but slightly noticed, and are open to discussion. Mental diseases depend upon a physical lesion of the central nervous system, and as there is a very close relation existing between the regular functional activity of a normal brain and the diverse functional manifestations in insanity, the study of the structure and functions of the successive ganglia which compose the brain is a matter of deep interest as well as necessity to students of psychology. The white substance of the hemispheres consists of medullated nerve-fibres of about 0.0026 to 0.0067 mm. in diameter, while at the surface of the larger ganglionic masses and towards the cortex some non-medullated fibres are seen. The fibres of the white matter are separated from one another by bands of delicate connective tissue — fibrillated sustentacular matter, in which are situated, at intervals, round or oval nuclei, smooth in contour and measuring 0.0093 to 0.0075 ^'^- These fibres of the white matter may be divided very properly in two classes: i. Those having a radiating and converging direction or course; and 2. Those uniting the two halves of the cerebrum and forming the corpus cal- losum, which is properly to be looked upon as a physiological as well as an anatomical commissure, and it is often found to be absent in congenital idiots. The cortex of the cerebrum or gray matter of the convolutions is divided into several layers or laminse, the number being variously estimated by different observers, among whom are 134 PSYCHOLOGICAL MEDICINE. Koelliker, Arndt, Meynert, and Frey. The latter regards the cortex as divisible into six laminse. The general plan of structure of the gray matter of the cerebrum is, primarily, a wide-meshed network of medullated fibres, in whose interstices ganglion cells are situated. We also find that very delicate network of fine fibres met with in the gray matter of the spinal cord, first discovered by Deiters, which consist of very delicate fibrillae, springing from the broad protoplasm processes of the ganglion cell. These fibrillae Deiters regards as a system of secondary axis cylinders for the most delicate nerve-fibres. Gerlach first described the network as occurring in the cortex of the cerebrum as in the spinal cord. The remainder of the gray matter is made up of the delicate sustentacular substance before alluded to as intervening between the fibres of the white matter. In the super- ficial layers of the convolutions the cells are small multipolar nerve- cells, analogous to the small cells in the posterior cornua of the cord, while in the deeper stratum, or fourth layer of Frey, are found large multipolar ganglion cells 0.025 to 0.040 mm. in diameter, presenting oval or roundish nuclei. These large cells correspond to the large cells in the anterior cornua of the spinal cord, which, it will be remem- bered, send out " axis cylinder processes," which are prolonged into the nerve-fibres of the motor roots. In like manner we observe, under the microscope, an " axis cylinder process " given off from these multipolar ganglion cells of the deeper layers of the convolu- tions of the cerebrum, which process is prolonged into one of the nerve-fibres of the corona radiata. It is, I think, demonstrable that there is a lateral anastomosis between the cells of each layer or lamina, and also anastomoses between the successive layers of the convolutions. Of course it is impossible to limit exactly the special attributes of any particular group of cells in the convolutions of the cerebrum, yet, by comparing them with the elements of the spinal cord, it certainly seems possible to make certain legitimate inductions relative to their diverse activities. I have just stated that the large nerve-cells of the convolutions cor- respond to the multipolar ganglion cells of the anterior cornua of the spinal cord, which cornua are connected with the motor roots of the spinal nerves, while the small and superficial cells of the convolutions are analogous to the small cells of the posterior cornua of the cord, which are connected with the sensory roots of the spinal nerves. We have also seen that in both the multipolar ganglion cells of the deeper layers of the convolutions of the cerebrum there exist pro- THE HISTOLOGY AND FUNCTIONS OF THE CEREBRUM. I ^5 cesses which become the axis cylinders of nerve-fibres. I think, therefore, that we may fairly conclude that the superficial layers or laminae of the convolutions of the hemispheres disseminate the im- pression of general sensibility, and that the deeper layers, containing the larger multipolar ganglion cells, originate motor impulses. It will be understood that in speaking of the structure and functions of the gray matter of the hemispherical convolutions I refer to the histo- logical elements, the functional activities of which we are as yet com- paratively unacquainted with. The cerebral ganglia whose structure and functions remain to be considered are the corpora quadrigemina, thalami optici, and corpora striata. The structure of the corpora quadrigemina consists of a white layer overlaid with a zonal stratum of nerve-fibres. Under- neath them the crura cerebelli and corpora quadrigemina pass on to reach the cerebrum, and should more properly be called, as Frey remarks, crura cerebelli ad cerebrum. Laterally there enter the cor- pora quadrigemina, from below, the two lemnisci arising from the motor tract of the medulla oblongata, and traceable back to the same tract or part of the medulla. In the anterior tract of the corpora quadrigemina, a root of the optic nerve, coming from the corpus geniculatum internum, terminates. Small nerve-cells are seen in the internal gray substance of the quadrigeminal bodies, with larger mul- tipolar and fusiform ganglion corpuscles, the latter being said by Meynert to be found in the deeper layers of the anterior bodies about the aqueduct of Sylvius. The functions of these bodies are tolerably well understood, as they give rise to the optic nerves and act as the ganglia of sight, from which they have also been called " optic gan- glia." Destruction of these bodies causes complete blindness. They thus serve as nervous centres for the perception of light, and a reflex action also takes place through them, by whiclj the amount of light admitted to the eye is regulated to accommodate the sensibility of the pupil. The structure of the optic thalami, like the corpora quadrigemina, consists of a white layer overlaid with a zone of nerve-fibres. The posterior end of these ganglia has been termed the pulvinar. Inter- nally to it, and more posteriorly, is situated the corpus geniculatum internum, and, externally, the corpus geniculatum externum. Into the latter a portion of the optic tract passes on its way to the pul- vinar. Fusiform cells are found more deeply colored than those of the corpora quadrigemina. The cells of the corpus geniculatum exter- 136 PSYCHOLOGICAL MEDICINE. num are found to be frequently pigmented, and the internal genicu- late body also contains fusiform cells. The thalamus receives numer- ous white fasciculi coming from the hemispheres. They run towards the superior surface of the thalamus, to the superior and internal border, and the pulvinar, and are ultimately lost in the same manner as are the fibres continued from the crus cerebri into the corpus striatum ; that is, by a subdivision into close plexuses of extremely delicate nerve-fibres. The functions of the optic thalami have been but little understood, and there is still a great difference of opinion respecting the function of this great basilar ganglion. I regard it as the centre of general sensibility, and it is certainly a fact that all the sensory fibres go to terminate in the optic thalamus. It would seem proper, as Luys has done, to subdivide the optic thala- mus into four special centres or ganglion tracts. Luys considers that the optic thalami receive, preserve, and transform the sensorial impressions previous to their definitive irradiation to the cortical periphery. The anterior ganglion tract, he considers, is undoubtedly connected with olfactive impressions. The middle ganglion tract receives the nerve-fibres of the second pair, and may properly be called the optic tract. The posterior ganglion tract, from its connec- tion with the- perception of sounds, may be called the acoustic tract. And there is undoubtedly another tract of the optic thalamus, which, from its close relation to the sensitive fibres of the convergent sys- tem, may be called the tract of general sensibility. Ferrier, who had, as a result of its destruction experimentally, produced anaesthe- sia of the opposite side, held it as a centre of conveyance, or an interrupting ganglion of the sensitive fibres, through which might pass all the fibres of the sensory nerves which have their origin beneath the cerebral peduncles. Crichton Brown, on clinical facts, regards it as the centre of general sensibility. Nothnagel, in his series of experiments, has not found, after destruction of the optic thalamus, lesion of sensibility or of voluntary motility. Meynert thinks, as the result of anatomical researches, that in the optic thalami the sensory impressions coming from the periphery are transformed into movements, so that the thalami would be automatic centres of reflex unconscious movements, and would also stand in some relation with voluntary movements. Flourens, Longet, and Schiff, as a result of experimental research, have attributed motor functions to the thalami. If this was so, and especially if, as has been claimed by Lusanna and Lemoigne, the optic thalamus, with its THE HISTOLOGY AND FUNCTIONS OF THE CEREBRUM. l^f median fascicles, was the centre for movements of the arm and hand of the opposite side, it would be a true secondary motor centre, subordinate to the, psycho-motor centres of the cortex. The structure of the corpora striata consists of a collection of gray matter, nerve-cells, and of fine nerve-fibres. They contain two larger nuclei, respecting which little has been known, and it is only lately that we have subdivided the corpus striatum into the lenticular and the caudate nucleus, with also the internal capsule and its function- ally distinct sections, which were pointed out by Charcot. The greatest interest attaches to the corpus striatum, for it is here, as I have previously remarked, that by far the greater number of cerebral haemorrhages take place, giving rise to the typical hemiplegia. The system of nerve-fibres is derived from the crura cerebri, running par- allel in a straight direction, entering both nuclei, and ultimately lost in these nuclei. The surface of the corpora striata is gray, and in the gray matter we observe multipolar ganglion cells and smaller cells. The neuroglia is analogous to the neuroglia of the cortex of the cerebrum. There is also another set of fibres, proceeding probably from the medullary substance of the hemispheres, which ramify in the large nucleus of the corpus striatum. These fibres differ from those derived from the crus cerebri, which in this location are ex- tremely attenuated and present a plexiform arrangement. Physiolo- gists in the past have supposed the functions of the corpus striatum to have some connection with sensation and volition, although they have not attempted to explain the nature of the connection. As experimental observations have proved that destruction of the corpus striatum results in motor paralysis, with the preservation of intelli- gence, depending on the extent of the lesion ; and also, as cases have occurred in which the functions of the corpus striatum having been not destroyed, but impaired by compression or degeneration of its elements, there have resulted disturbances in the motor sphere, may we not reasonably infer that the corpora striata are undoubtedly the centre of the reception, regulation, and elaboration of voluntary motor impressions emanating from the deep layers of the cortical matter whose large cells originate them ? Such is the conclusion of Luys, and it is, I think, the correct one, judging from my own researches and observations. There is no question more interesting to the student of mental pathology than that of the connection between nerve function and nerve organization, and it is only by the better knowledge of the 138 PSYCHOLOGICAL MEDICINE. physiological laws of the brain that we can determine that connec- tion ; and it is only by patient experiment and observation that we are to fully understand the nature of the relation between the his- tology of the brain and the physical functions. It is impossible to fully appreciate the pathological changes met with in the brain until we are in full possession of all the available knowledge of cerebral histology and of the knowledge of the normal functional activity of nerve-cells, and we certainly cannot understand defective intellect unless we are thoroughly acquainted with the ordinary and normal manifestations of intellect. We must, therefore, clearly understand the physiological laws of healthy mental action before we can com- prehend any departure from the healthy working of such laws. With this end in view have my efforts in the direction of the study of the physiology and pathology of the central nervous systems been made. With respect to the functions of the cerebrum we should remem- ber that we can, in early life, direct the growth of function. Dr. William B. Carpenter, of England, in writing on " The Hereditary Transmission of Acquired Psychical Habits," says: "It is when the brain is growing that the direction of its structure can be most strongly and persistently given to it. Thus the habits of thought come to be formed and those nerve tracts laid down which (as the physiologist believes) constitute the mechanism of association, by the time that the brain has reached its maturity ; and the nutrition of the organ continues to keep up the same mechanism in accordance with the demands upon its activity, so long as it is being called into use. Further, during the entire period of vigorous manhood, the brain, like the muscles, may be taking on some additional growth, either as a whole or in special parts, new tissues being developed and kept up by the nutritive process in accordance with the modes of action to which the organ is trained ; and in this manner a store of ' impres- sions ' or ' traces ' is accumulated, which may be brought within ' the sphere of consciousness whenever the right suggesting strings are touched.' " THE PATHOLOGY AND MORBID HISTOLOGY OF INSANITY. 1 39 CHAPTER X. THE PATHOLOGY AND MORBID HISTOLOGY OF ACUTE AND CHRONIC INSANITY. OPHTHALMOSCOPIC APPEARANCE AND EXAMINATION OF BLOOD AND URINE. Membranes, Epithelium, Nerve-cells, Nerve-fibres, Special Morbid Conditio7is of Gray Matter, etc. — The morbid histological changes occurring in insanity are, at the present day, undergoing microscopi- cal investigation at the hands of many very skilful observers, both in our own country and in Europe, and these assume great importance when we reflect upon the fact that the pathological phenomena dis- covered in the brains of persons dying insane, all have for their basis interference with the due nutrition, growth and renovation of the brain cell, which by interrupting the nutrition, stimulation and repose of the brain, essential to mental health, results in the impress of a pathological state in the brain and disordered mental function. The investigation of both the normal and the morbid histology of the brain is a work requiring great labor, patience and perseverance, and also judgment in the recording of observations; and even by the most careful and conscientious microscopists, mistakes may be made at times as to the nature and value of appearances met with in histo- logical research. We may fairly divide the pathological changes met with in insanity into three classes, according to the plan of M. Parchappe, the Inspector-General of Asylums in France, who has made very careful and thorough investigations : First. Those which may be considered accidental. Second. Those which are found in other diseases, yet appear to be concerned in the production of insanity. Third. Those essential to mental disease. In the first class we may enumerate cerebral haemorrhages, soften- ing of the white substance, and disease of the cerebral vessels. In the second class we meet with thickening and opacity of the arachnoid, hyperasmia of the pia mater and of the brain, serous in- filtration of the pia mater, and collections of fluid in the arachnoid cavity. In the third class, or the changes essential to mental disease, we find sub-arachnoid ecchymosis and a partial punctiform injec- 140 PSYCHOLOGICAL MEDICINE. tion of the cortical surface, with or without softening; extended softening- of the middle portion of the cortical substance; adherence of the pia mater to the surface of the brain ; different discolorations of the cortical substance ; loss of color of the cortical substance ; atrophy of the convolutions ; and lastly, induration of cerebral tissue. The naked-eye appearances which we meet with in the bodies of those dying insane, are chiefly peculiarities in the form of the cra- nium, of which the most frequent is want of symmetry between the two sides ; the shrunken and shrivelled ear in chronic insanity, con- sequent upon haematoma auris ; variations from the normal standard in the thickness or thinness of the cranium ; changes in the mem- branes ; and finally, changes in the cerebral substance itself In acute insanity the changes or prominent alterations in the brain — as will be seen in the appended cases illustrative of the pathology and morbid histology of insanity — met with by the writer, have been : hyperaemic conditions of the brain and its membranes, which latter are often thickened and opaque; injection and softening of the corti- cal substance and pigmentation of the cortical gray substance. While the dura mater is very rarely thickened, its vessels are found to be dilated and irregular, and the coats of the vessels much hyper- trophied. The arachnoid I have found to be thickened, to be the seat of haemorrhage, and have often found it covered with fine gran- ulations on its surface. The bloodvessels of the brain I have found to present thickening of the coats, thickening of the sheath or hya- line membrane, deposits between the adventitia and sheath, and pro- liferation of nuclei. The neuroglia has been found to be the seat of various lesions in insanity, the principal of which are disseminated sclerosis or gray degeneration, atrophy, miliary sclerosis and colloid degeneration. The cerebral cells have been found to be the seat of atrophy, pig- mentary or granular degeneration, calciferation and hypertrophy. In chronic insanity the changes chiefly met with in the brain, have been atrophy of the convolutions and brain itself, induration of both white and gray matter, thickening and opacity of the membranes, chronic hydrocephalus, effusions into the sub-arachnoid space, pig- mentation of the cortical substance, and extended and profound scle- rosis of the brain. The pia mater is found to be thickened and adhesive to the brain, and its vessels tortuous and thickened in their walls. I have also noticed atheromatous and fatty degeneration of the walls of the cerebral capillaries. THE PATHOLOGY AND MORBID HISTOLOGY OF INSANITY. 141^ Having devoted considerable time and thought to the microscopic investigation of both the normal and morbid histology of the brain, I desire to call particular attention to an appearance which I have noticed in the brains of those dying insane, and to which my atten- tion has been drawn, from the interest it assumes when viewed in the light of the probable ultimate cause of the nutritive defect which results in chronic insanity. We know that, for the proper nutrition and healthy functional activity of the brain-cell, is required the pro- per nutrient supply, and that we cannot have healthy mental func- tion without a due supply of healthy blood to normal and healthy brain-substance. We also know if any agent operates to influence the circulation unfavorably, so that a morbid condition of the cere- bral capillaries is induced, that we shall inevitably have resulting morbid changes set up and maintained in the cerebral cells. In pre- vious writings on insanity I have called attention to the fact that a microscopic examination of blood from insane patients, as compared with an examination of blood from the same number of healthy per- sons, revealed in the blood of the insane a marked increase in the number of white blood-corpuscles. In making microscopical examinations of brain-tissue from chronic insanity, I have noticed repeatedly in different cases lymphoid cells or white corpuscles, and also red corpuscles in small numbers in the membranes and in the substance of the brain itself, evidently having emigrated from the bloodvessels. From what I have ob- served, I think that, under conditions of inflammatory irritation of the brain, an emigration of lymphoid cells takes place on a large scale, the cells or corpuscles, by virtue of their vital contractility passing through the walls of the vessels and penetrating into the brain-tissue. It will be remembered that both Dr. Bastian and Dr. Blandford have noticed a plugging up of the bloodvessels by small embolic masses composed of aggregations of white corpuscles in insanity. Ekker found that the vessels of the gray matter were generally dilated in insanity, and Ramaer also noticed the same thing in the vessels of the pia mater, while Dr. Major has described a di- latation of the arteries in " brain wasting," a condition which apper- tains to chronic insanity. We have here two factors which operate, I think, in the production in the pia mater and the brain, of the lym- phoid cells and in some cases of the red corpuscles; first, the undue predominance and accumulation in the bloodvessels of the white corpuscles which obstruct the capillaries, giving us as a result an im- 142 PSYCHOLOGICAL MEDICINE. peded circulation and an increased pressure in the coats of the ves- sels ; and second, the dilatation of the vessels before alluded to. These two conditions are favorable to the rapid emigration of the white and the red corpuscles through the walls of the vessels ; and also perhaps the same condition may be produced at times by the ob- struction in the capillary vessels becoming great enough to rupture them. The lymphoid cells must act undoubtedly as foreign bodies and a slow course of inflammation is set up. Such an inflammatory pro- cess must necessarily be of slight intensity and of long duration, and these collections of lymphoid cells undoubtedly tend to become de- veloped into a fibroid structure, resulting in the induration of the brain which we meet with in chronic insanit}-'. I am also forcibly impressed with the idea that we have here the solution of the problem as to the relation which exists between tuberculosis and insanity. Dr. Clouston, in the Jownial of Mental Science for April, 1863, showed that of 828 patients who died with tubercular diseases at the Royal Edinburgh Asylum, 153 passed rapidly into the state of chronic in- sanity, the acute stage being of very short duration, the patients all manifesting a decided tendency towards chronicity. He also noticed that the prognosis relating to mental recovery was eminently unfa- vorable, and that apparent recoveries proved to be only remissions. In these cases, where the development of the two diseases seemed to Dr. Clouston to be nearly contemporaneous, was not the tuberculosis the result primarily of the escape or emigration of the lymphoid cells into the connective tissue of the lungs owing to this state of leuco- cythaemia in the patient ? I think that this condition occurs more fre- quently than we are aware of, especially in persons who inherit the predisposing neurotic element or morbific force. That there exists such an hereditary neurotic or morbific element or force, present in both insanity and phthisis, I most firmly believe ; and I also believe that there is a correlatmn of morbific force which renders these dis- eases mutually convertible. I have repeatedly seen this borne out by undeniable facts, children of one family being affected with both insan- ity and phthisis in many different instances. This theory that "he- reditar}' diseases " depend on a correlation of morbific forces was first advanced by Dr. Winn, of London, England, in 1869, in his treatise on the Nature and Treatment of Hereditary Diseases, zuith Reference to a Correlation of Morbific Forces. To return, however, more immediately to our subject. Respecting the dilatation of the vessels which I have before alluded to, it appears THE PATHOLOGY AND MORBID HISTOLOGY OF INSANITY. 1 45 to me that the general obstruction in the capillaries of the brain causes primarily, probably, a compensatory hypersemia, and as this gradually becomes permanent the small arteries would naturally be- come enlarged, as they have been found to be by Ekker, and Dr. Major, and also myself; and their walls would become thickened, as we find them to be in post-mortem, in chronic insanity. Such long- continued mechanical hyperaemia causes an impairment of vitality and function, and this we find exemplified by the retrogressive changes which occur in the substance of the brain in chronic insanity, viz., atrophy, induration, and degeneration of the nervous elements of the brain. With the exception of cases of apoplexy in which large clots have been discovered post-mortem, I am not aware that any observer has described any such lymphoid deposit in the brain, which may or may not have undergone fibroid metamorphosis or degeneration. I think, therefore, that from both a physiological and pathological standpoint, these observations become of the highest clinical signifi- cance. (I desire not to be misapprehended as regarding the presence of the lymphoid deposits in the brain as the ultimate cause of insanity.) I do, however, think that by their presence we are enabled to explain many of the changes incident upon chronic insanity, and think their presence must affect very materially the ultimate molecu- lar changes in the brain, upon which its functional activity depends, and regard it as a very strong probability that such foreign deposits in the brain may, by interfering with the molecular changes just alluded to, destroy both functional excitability and activity. It would appear very probable that the prominent alterations taking place in chronic insanity, viz., atrophy of the convolutions and of the brain itself, and induration of the two substances, with degenera- tion of the nerve-cells, may fairly be considered to depend upon this abnormal relationship between the blood and the tissues, which be- comes the ultimate cause of the nutritive defect which results in chronic insanity. Ophthalmoscopic Appearances in Insanity. — The ophthalmic appear- ance is reported by Klein* in 134 patients, of whom 42 were affected with general paralysis, 19 with mania, 19 with epilepsy, 17 with alco- holism, 4 with apoplexy, 6 with melancholia, i with locomotor ataxia, and 26 with divers forms. In 89 cases positive results were obtained, which he divided into two categories — one of 3 1 and the * Wien. Med. Presse, 1877, No. 3 (Abstr. in Central Blatt., No. 29). 144 PSYCHOLOGICAL MEDICINE. other of 58 cases. In the first class Klein found 9 times retinitis, 8 times discoloration of the optic nerve, 6 times atrophy, and 8 times hyperaemia of the retina. The second class consisted of 29 congeni- tal anomalies and 29 cases of a peculiar opacity, resembling the senile metamorphosis of the retina. Since this change was found in 18 cases out of 42 of general paresis, Klein terms it retinitis paralytica. During an epileptic attack he observed retinal ischaemia and clonic spasm of the iris. The conditions of the retina in acute dementia and atonic melancholia are those of anaemia, the optic disks being pale, the tint of the choroid being lowered, but not resembling atrophy. In atrophy there is more of a sharpness and brilliancy of pallor than in dementia and melancholia. The retinal vessels are small and shrunken, but no trace of previous tortuosity is apparent, as is often seen in atrophy. In senile atrophy of the brain the cells, through the entire depth of the cortical layer, are morbidly affected ; in the larger nerve-cells the process is one of granular degeneration, but in the smaller cells there is simple atrophy without degeneration. The nuclei of the cells are degenerated, and ultimately become destroyed ; also the branches of the large cells at an early period. The large vessels and capillaries are dilated, and the vascular canals are enlarged, and the surrounding cerebral substance is indurated. The fibres are abnormally coarse and tortuous, and, in some parts, broken down. The neuroglia, which includes the delicate, almost homogeneous matrix supporting the nerve elements, is in a state of atrophy and degeneration, and the corpuscles increased in number, but they eventually shrivel and atrophy.* Examinatioii of Blood and Urine. — A microscopical examination of blood from insane patients as compared with an examination of blood from the same number of healthy individuals revealed, in the blood of the insane, a condition of leucocythsemia, or a marked increase of the number of white corpuscles. This condition has also been remarked by other observers, and Dr. Charlton Bastian and Dr. Blandford have described a plugging up of the cerebral vessels by small embolic masses composed of collections of white corpuscles in cases of acute mania and delirium. It has been found that, during the period of maniacal excitement, there is a ma:rked diminution of * Acute cerebral hypersemia may induce a congestion of tiie optic papilla. I have failed to find in mania, melancholia, and dementia, any constant reliable changes in the eye, while in general paralysis of the insane, I have seen atrophy of the optic nerve fre- quently. THE PATHOLOGY AND MORBID HISTOLOGY OF INSANITY. 1-^5 fibrin in the blood, and during convalescence the amount of fibrin is increased to the normal standard. These results have been con- firmed by the recent researches of Hittorf, Erlenmayer, Michea, and Dr. Marcet. Examination of the urine in insanity has shown that in acute mania there is an excessive elimination of the phosphates, as a rule, while in dementia, general paralysis, and chronic mania the amount of phosphates eliminated is generally below the average. There has been some difference of opinion in different observers as to the reaction of the urine in insanity, Erlenmayer claiming that it is generally alkaline in recent cases of mania, while Dr. Sutherland, who has paid great attention to the condition of the urine, found that, in 125 cases of recent mania, the urine was acid loi times, and alka- line 13 times, and gave a neutral reaction once. In our investigations we have found the reaction to be acid in the majority of cases of those affected with acute and chronic mania and dementia.* The small amount of time at the disposal of a physician in charge of an institution for mental diseases, and the difficulty of making an ex- tended course of investigation in the analysis of blood and urine which is so desirable, and also the difficulty of making microscopical researches, are causes which have combined heretofore to deter the superintendents in this country from giving to the profession the results of their valuable experience, and it is therefore to be hoped that the time is not far distant when every asylum shall possess the services of a skilled pathologist and chemist. Dr. J. Batty Tuke, in writing on the morbid histology of insanity, says : " One great difficulty which presents itself to the mind of the cerebral pathologist is to determine whether the morbidities which are apparent on microscopic examination are of a primary or secon- dary nature; whether they have been efficient causes of insanity, or whether they are merely the results of malnutrition of the brain, and, as such, efficient causes of chronic lunacy. There exists an unde- termined point in anatomy which, until settled, must leave the ques- tion, to a certain extent, open ; that point is the presence or absence * 1 have seen the most intense melancholic depression, associated with the persistent presence of oxalate of lime in the urine, and the melancholia has rapidly dissappeared upon the free exhibition of the dilute nitro-muriatic acid, which caused a disappearance of the crystals of the oxalates in the urine, as viewed under the microscope. In cases of languor, depression, and melancholia, with perhaps, slight vertigo, we should always look for the oxalate of lime with the microscope. We do not think there is an increased quan- tity of phosphates in the urine in healthy individuals after brain work. The turbid urine is due to diminished acidity. 10 146 PSYCHOLOGICAL MEDICINE. of cerebral lymphatics. When it is considered that the brain is an exceedingly active organ, performing many and various functions, and when it is further considered that it can obtain no vicarious aid in the performance of those functions, -^that it cannot, like the lungs, seek assistance from other systems, — it must be at once apparent that the question of its possession of an overflow for getting rid of superfluous plasm and waste products is of paramount importance. Fohman and Arnold demonstrated to their own satisfaction the ex- istence of a system of lymphatics in the pia mater, and His, Ober- steiner, and Boll believe that the pia matral envelope of the cerebral arteries (hyaline membrane) exercises the function of a lymphatic duct. The ver}^ existence of such a sheath or envelope has been called in question, but comparatively slight study is needed to make its demonstration certain. Although differences of opinion exist as to its relations and manner of debouchment, we believe that it ter- minates by funnel-shaped openings into the spaces which exist over the sulci, between the pia mater and the so-called arachnoid mem- brane. Kolliker has pointed out that the connection between the pia mater and arachnoid over the convolutions is so complete and perfect that only in parts, namely, over the sulci, a distinct space can be shown to exist. It is questionable whether the arachnoid should not be considered to be merely the outer layer of the pia mater. In prosecuting the study of the morbid histology of the brain and spinal cord two methods of investigation should be adopted : i. The ex- amination of the tissues in a fresh state. 2. The examination of the parts in situ by means of sections made after submission of portions of nervous tissue to hardening agents. The condition of the con- stituents of the recent brain can best be observed by coloring small specimens with rosaniline. The modern method of freezing and section by means of the microtome designed by !Mr. Bevan Lewis, has rendered the investigation of histological brain changes a com- paratively easy task. The Membranes. — The dura mater is, comparatively rarely, thick- ened by proliferation of its elements. The vessels are found to be irregularly dilated and tortuous, with thickening of their walls. The arachnoid and pia mater are in such close anatomical relation on the convexity of the hemispheres that they can be best described together. Between them, supported by a delicate connective tissue, lie the bloodvessels, which dip into the sulci, carrying with them an invest- ment of pia mater, which gives prolongations to accompany them THE PATHOLOGY AND MORBID HISTOLOGY OF INSANITY. I47 when they pierce the cerebral substance and form the so-called hyaline membrane. Over the sulci are the spaces usually termed subarach- noid, which communicate with each other by conduits accompanying the vessels. The microscopic appearances of " milky arachnoid " have not been thoroughly described. Both membranes are often thickened, presenting a laminated appearance, and the connective tissue supporting the bloodvessels is considerably increased, as well as the pia matral prolongations accompanying the bloodvessels into the cerebral substance, which loses its hyaline character and becomes distinctly fibrous. Extensive but thin blood-clots are occasionally found within the arachnoid and pia mater, while more rarely extrava- sations of blood are found between the pia mater and the cerebral substance. Deposits of hsematoidin often surround the vessels, and their coats are frequently hypertrophied. Crystals of triple phosphate have been seen on the visceral surface of the pia mater. Lymph has been found between the pia mater and the spinal cord; the membrane was thickened, and internal to it were numerous distinct laminae of a finely fibrillated material, in some places 2oo"^h of an inch in breadth. The Epitheliian. — The ground-glass appearjince frequently seen in the ependyma of the ventricles is due to three different morbid con- ditions, which are, in the order of their frequency, proliferated epi- thelium, lymph exudations, and crystalline deposits. When change in the epithelium is the cause of the granulations, a vertical section shows simply a proliferation of cells projecting into the ventricle like villi. When lymph exudations have pushed the ependyma upwards it presents the appearance of rough, irregular, bulls-like nodules, con- sisting of the layer of proliferated epithelial cells and a greenish, homogeneous stroma, which together overlie the pia mater ; the same material can be frequently seen infiltrating the subjacent cerebral tissues. Deposits of phosphate of lime have been recorded as occur- ring beneath the ependyma of the lateral ventricles in general paraly- sis, and Bergmann discovered a formation of pretty large crystals of " double phosphate " in both plexus choroidei in a case of mania with mental weakness. A proliferation of the columnar epithelium of the central canal of the medulla oblongata is not unfrequent, caus- ing its occlusion. The Nerve-cells. — The changes in the nerve-cells are most marked in the anterior two-thirds and superior parts of the hemispheres, as 148 PSYCHOLOGICAL MEDICINE. in this situation they are usually most numerous and large in size. In the depending portions of the hemispheres and the occipital lobe few, if any, changes have been noticed. The special morbid condi- tions of the nerve-cells are : a. Atrophy, or pigmentary, granular, or fuscous degeneration, b. Hypertrophy, calcification. Pigmentary, fuscous, or granular degeneration is a very common condition in many forms of insanity, particularly senile insanity and general paralysis, and is probably, to some extent, a normal senile change. Dr. Major distinguishes three stages : i. The cells lose their sharply- defined, triangular outline, and become swollen or inflated in appear- ance; the process running towards the periphery of the convolution usually remains distinct, but the other processes disappear and the cell becomes rounded off; the nucleus becomes swollen and more or less round or oval, and the nucleoli are seen with great distinctness. 2. A deposit of granules takes place, either external to the cell and pressing upon it, or in its interior, until it becomes more and more \'ellow and opaque ; or both these conditions may occur together. 3. The cell goes on to destruction, breaking down and shrinking, leaving the nucleus surrounded only by a mass of granules, and forming a gap in the cerebral tissue formerly occupied by the swol- len cell ; still later the granules entirely disappear, leaving the nu- cleus free. He has not observed the nucleus actually undergoing disintegration, but often no trace of it is to be found in the mass 01 granules left by the degenerated cell. Hypertrophy of the large pyramidal cells of the inner layer has been observed in senile atro- phy and general paralysis ; as the name implies, they are large, ab- normally distinct, and swollen in appearance, often presenting granular masses in their interior ; the processes are increased both in size and number ; and the angles of the cells may be greatly pro- longed, or swollen and stunted. Calcification of the cells by the deposit of phosphate of lime within their walls has been observed, according to Blandford. Tlie Nerve-fibres. — The chief changes in nerve-fibres, apart from their disintegration by apoplexies, softenings, etc., are coarseness, irregularity, and twisting of outline, and their power, in the fresh state, of resisting pressure under a covering-glass, some being readily ampullated. They may be affected by a pigmentary degeneration similar to that occurring in the cells ; and, finally, they may present fusiform or oval swellings, which tint strongly with carmine, and give rise to the appearance known as amyloid bodies. THE PATHOLOGY AND MORBID HISTOLOGY OF INSANITY. 1 49 Special Morbid Conditions of ihe Gi'ay Matter. — In many subjects, when the pia mater is thickened and hyperaemic, a condition of the gray matter closely resembhng gray degeneration in the white mat- ter is often found ; it differs from the latter by the absence of prolif- erated nuclei, and is strongly suggestive of lymph infiltration, which has gradually caused atrophy and absorption of the normal struc- tures. Circumscribed spots of yellow softening show under the microscope ragged fibres, colloid bodies, and granular corpuscles at the base of the diseased tract. Local atrophies of the convolutions are pretty common. Under the microscope a thin layer of indurated gray matter, presenting no trace of normal structure, may be found. In other cases there is simple absence of the gray matter, the white matter in both being unaffected. The Neuroglia. — This substance undergoes inflammatory changes of a subacute or chronic nature, with the results of which we are familiar as more or less diffused sclerosis. Together with the other elements of the cerebral tissues, it undergoes atrophy in the brain wastings of senility, and especially of senile dementia ; it is also liable to special forms of degeneration, which have been called miliary scle- rosis and colloid degeneration, though those terms are somewhat misleading, as the changes in question differ entirely from those generally described by these names. General Sclerosis has only been observed in one case, which is fully detailed in ^h^ Journal of Anatomy and Physiology, May, 1873. Disseminated or Partial Sclerosis, or Gray Degeneration, is a lesion frequently met with in the brains of old-standing cases of insanity, especially in general paralysis. Its most frequent seat is the white matter of the motor tract; less frequently it is met with in the hemi- spheres. In the pons varolii, medulla oblongata, and spinal cord of epileptics, patches of this disease are of common occurrence, and in an extreme degree. When a fine section of nerve-tissue affected by this disease is examined by the naked eye, circumscribed opaque patches can be seen ; in colored sections these tracts are strongly tinted. As a rule, they are found contiguous to a vessel, whose nuclei are much proliferated and around which considerable prolifer- ation of the nuclei of the neuroglia exists. Under the microscope the nerve-fibres are seen to be partially or completely atrophied ; the axis cylinders and sheaths are destroyed, and the field is occu- pied by a finely molecular and fibrillated material imbedded in a cloudy, homogeneous plasm. In this matrix the proliferated nuclei 150 PSYCHOLOGICAL MEDICINE. exist, somewhat enlarged sometimes, slightly granular in appearance ; but around the implicated spot they are to be seen in much greater quantity and not actively diseased. The atrophied nerve-fibres occa- sionally project raggedly into the gray matter, where they are lost. Rokitansky believes this to be essentially a primary increase of the neuroglia. Leyden thinks it occurs secondarily to the atrophy of nerve-fibres, while Rindfleisch and others are of opinion that the first stage is marked by proliferation of the nuclei of the vessels, which is followed by an increase of the neuroglia and the development of a morbid plasm, which is, in all probability, modified neuroglia. Miliary Sclerosis. — For the full details of this remarkable lesion the reader is referred to the Edinburgh Medical Journal for Septem- ber, 1868, and to the British and Foreign Medico- Chirzirgical Review, July, 1873. The following is a short account of its principal features: It is not confined to any one class of mental disease, but has been found best marked in cases accompanied by paralysis or epilepsy. It differs from all other lesions termed sclerosis in not being preceded, attended, or followed by proliferation of the nuclei ; it is a circum- scribed lesion, occurring in patches from 4'Q^th to ts^oo"^^^ of an inch in length, not involving surrounding tissues except by displacement, diffusing no morbid plasm beyond its own area, and not connected witli the bloodvessels. It is essentially a disease of the nuclei of the neuroglia, and its progress is marked by three stages : i. A nucleus becomes enlarged and throws out a homogeneous plasm of a milky color, and apparently of a highly viscid consistence, forming a semi- opaque oval spot, usually unilocular ; but by aggregation the spots may be bilocular, or, more rarely, multilocular ; in the centre of these spots a cell-like body containing a nucleus is discernible — the origi- nal dilated nucleus of the neuroglia. 2. The morbid plasm becomes distinctly molecular and permeated by fine fibrils ; as it advances, the plasm around the periphery of the spot becomes more dense and a degree of absorption of the nerve-fibres around it .takes place. 3. The molecular matter contracts on itself, becomes more opaque, and often falls out of the section, leaving ragged holes.* Colloid Degeneration may be either a primary or a secondary pro- duct; that is to say, there is reason for believing that in certain forms of insanity it is the primary pathological change, and that it is * The reader is referred to the micro-phctographs, where one of them, marked "sec- tion of brain from case of chronic insanity, " taken from a case of homicidal mania, where there was suspected epilepsy, shows this lesion very markedly in the third stage. THE PATHOLOGY AND MORBID HISTOLOGY OF INSANITY.' I5I also to be met with in the brains of chronic cases, a result of long- continued perverted vascular action. It has been produced artifi- cially in the brains of pigeons by incising them and allowing them to heal. This degeneration should be searched for in recent specimens. It consists of round or oval bodies from ^^'^o^h to ^oVc^^ of an inch in diameter, and bounded by a distinct wall containing a homoge- neous, transparent, and colorless plasm ; sometimes it is somewhat granular. The general appearance of a section may be compared to a slice of cold sago pudding ; it cannot be colored by carmine. The condition may be regarded as a degeneration of the nuclei of the neuroglia, and is found in both gray and white matter. The Bloodvessels. — When we examine an injected preparation of the substance of a cerebral convolution and witness the perfection and delicacy of its circulatory apparatus, and when we reflect on the results of the phenomena of congestion, stasis, and anaemia on the functions of other organs, we have little difficulty in comprehending the influence such conditions must have upon the highly complex elements which make up the organ of the mind. It is certain that in most cases of recent insanity disturbance of the cerebral circulation is one, if not the essential, pathological factor, and if such disturb- ance is of long continuance, permanent lesions of cells, fibres, and nuclei, and, as a consequence, chronic insanity in some form must result. The examination, therefore, of the cerebral vessels is of pri- mary importance. The following is the method of examination adopted by the writer : After noting the degree of engorgement or anaemia in the centrum ovale, and whether, on section, the vessels are dragged out by the knife, vessels of moderate size should be dis- sected out, and carefully washed with camels-hair brushes, and then submitted to the microscope. By this mode of procedure the follow- ing changes may be discovered : {a}j Thickening or degeneration of one or other of the coats. (^.) Thickening of the sheath or hyaline membrane. ((T.) Deposits between the adventitia and the sheath. (<^.) Proliferation of the nuclei. (a.) Thicke7iing' or degeneration of the coats. The inner fibrous coat has been found thickened and more fibrous than in health. The musadar coat is often hypertrophied, especially the circular fibres ; it is best marked in general paralysis and epilepsy. The adventitia is occasionally thickened. The whole of 152 PSYCHOLOGICAL MEDICINE. the coats sometimes undergo a hyaloid or vitreous change, which is probably allied to lardaceous dis- ease.'^ (b.) The hyaline mevibrane or sJieath is often thickened and fibroid, enveloping the artery in a loosely sacculated manner.* (c.) Deposits between the adventitia and the sheath are of two kinds, but neither is peculiar to insanity, being found in the brains of persons who have died of fever or Bright's disease with cerebral symptoms. The first is a finely molecular material of a pale yellow^ tint, or more often colorless, closely resembling in appearance the spores of the favus fungus, and refracting light highly; it undergoes no change when treated with the ordinary oil tests, and is found in the smallest capillaries. The particles vary in size from ^-g-'Q-Q-th to ^-^-^\h. of an inch. The second form of deposit consists of irregular crystals of hsmatoidin, distributed pretty equally over the vessels, except at the bifurcations, where they are aggregated, (d.) Proliferation of tlie «?/r/^7 usually accompanies prolifera- tion of the nuclei of the neuroglia ; they do not seem to increase to the same size as those of the neuroglia, but become oval or irregular in shape. Fine sections of hardened tissues are necessary for the demonstra- tion of the following vascular changes : (d'.) Abnormalities in direction. (/^) Dilatation, microscopic aneurism, and apoplexies. (^.) Perivascular spaces, (/z.) Syphiloma. The sympathetic ganglia undergo a pigmentary degeneration in various forms of cerebral disease. The fact of Dr. Tuke being one of the most talented of cerebral pathologists will account for the length with which his observations have been cited. * Both of these appearances will be found typically displayed in our micro-photograph, showing the thickened bloodvessel in the thickened and infiltrated pia mater. Prolifera- tion of the nuclei is also seen. p Explanation of Plate of Microscopical Sections of Brain and Spinal Cord. No. I is a section of the normal spinal cord, for purposes of comparison with the dis- eased cord in General Paralysis. Xo. 2 depicts the microscopic appearance in a case of chronic insanity, with the "cribriform" appearance of the brain, produced by the pushing out or dilated condition of the brain tissue by dilated blood-vessels in repeated attacks of cerebral congestion. No. 3 represents the same portion (anterior cornua) of the cord from a case of Syphilitic Insanity. We see a loss of the nerve cells and also destruction and breaking up of the nerve substance. No. 4 also represents the brain with attached Pia Mater, from a case of chronic mania. The Pia Alater A is seen to be thickened and infiltrated while the brain tissue exhibits the condition of the brain tissue surrounding blood-vessels, resulting from long-continued congestive dilatation of vessel. No. 5 represents loss of nerve cells and elements in posterior column of spinal cord. In the place of the nerve cells is seen a new connective tissue-like substance, which lies imbedded here and there in irregular plates. No. 6 depicts miliary sclerosis of the brain in a case of chronic insanity. This is a disease of the neuroglia of the white matter of the brain. This microscopical section represents the disease in its third stage, when the molecular matter con- tracts on itself, becomes more opaque, and falls out of the section, leaving ragged holes. Miliary sclei'osis is a circumscribed lesion not in\olving sur- rounding tissues. ■'jatd attac: 'later, fVc rs im Close Plate II. Micro-photographs of the Brain and Spinal Cord, taken by the author. ILLUSTRATIVE CASES. I 53 CHAPTER XI. CASES ILLUSTRATING THE PATHOLOGY AND MORBID HISTOLOGY OF INSANITY. The following cases are some of those in which I have had an opportunity of making a post-mortem examination, and will, there- fore, be of practical interest to the profession : Case I. Melaiicliolia ivith Delusions. — Death resulting from chronic meningitis. C. McC, male, aged 44 years; single ; occupation, porter. Upon his admission to the asylum he was noisy and maniacal. The state lasted but a few days, and he then became depressed and mel- ancholy. He refused food for a number of days and had to be fed artificially. The melancholia assumed an acute form and he had hal- lucinations of sight and hearing, causing, at times, great terror and mental excitement. At such times, when he imagined he saw devils in the ward, his face would assume an aspect of the utmost fear and distress. He often expressed a wish to commit suicide. He died quite suddenly about five months after his admission, having eaten and slept but little for some days previous. Post-mortem : Upon removing the calvarium the dura mater was found to be adherent to it ; the pia mater was thickened, infiltrated, and hyperaemic ; the arachnoid was clouded and covered with granulations ; the brain was hyper- aemic and the cortical substance softened ; the lateral ventricles were filled with fluid; the lungs revealed commencing tuberculosis; the kidneys, spleen, and liver were normal. Case II. — M. H., male, aged 31, single, and by occupation a laborer. He suffered from melancholia. He had delusions of fear and persecution, and suicidal impulses. Often refused food, saying he wished to die. The mental faculties were very feeble, and the enfeeblement gradually increased. The bladder became paralyzed and the health gradually failed for about eight months, when he died from exhaustion. Post-mortem : The membranes were found to be adherent to each other, and the pia mater was thickened and adhe- rent to the surface of the brain. Throughout the brain were small miliary tubercles ; the substance of the brain was softened near the base; there was also considerable effusion about the base of the brain and effusion in the lateral ventricles ; lungs normal ; kidneys con- gested; spleen, liver, and heart normal. 154 PSYCHOLOGICAL MEDICINE. Case III. Melancholia zvith Religions Delusions and Hallucinations of SigJit afid Hearing. — Death resulting from acute tuberculosis and rupture of pulmonary artery. J. S., aged 20, single ; occupation, laborer. Upon admission to asylum was in poor physical condition, having never regained his strength since an attack of pneumonia some months previous. There was dulness at the apices of both lungs, and a prolonged expiratory murmur, with difficult respiration. He was very much depressed and melancholy, and said that he had committed unpardonable sins and should be eternally lost. At night he imagined he was visited by evil spirits, who tormented him. He died suddenly five months after admission to the asylum of which he was an inmate. Post-mortem : Dura mater firmly adherent to the skull ; the meninges were congested and the vessels enlarged ; the brain revealed softening of the cortical substance and effusion of fluid in the lateral ventricles. Examination of the lungs revealed the ex- istence of tuberculosis. The upper and the middle lobes of the right lung were partially destroyed, and the sudden death was found to be the result of rupture of the upper branch of the right pulmonary artery in the middle lobe of the right lung. Case IV. Dementia and Paresis. — Death resulting from pulmo- nary haemorrhage. T. A., male, aged 22 years, single ; occupation, wagon-maker. Upon his admission to the asylum was demented, with symptoms of paresis. Laughed vacantly when addressed, and stared unmeaningly about him. No appreciation of condition or surroundings. His gait was staggering and his lips and tongue were affected with muscular tremors. He never spoke but once, and that was upon the occasion of a visit from his brother. His speech at that time was hesitating and trembling. He had an attack of sub- acute meningitis four months after his admission, and died three months later from an exhausting haemorrhage from the lungs. Post- mortem : The membranes were found to be adherent to the skull ; there was subarachnoid effusion and a large effusion between the pia mater and the brain ; the pia mater was thickened in patches ; there was effusion at the base of the brain, fluid in the spinal canal, and the spinal cord was atrophied ; there was a miliary tuberculosis throughout the brain. Upon making an examination of the chest the left lung was found to be partially destroyed by the breaking down of the caseous products of pneumonia, as a result of which large cavities were formed. The heart gave evidence of recent endo- carditis. The surface of the heart and endocardium were covered ILLUSTRATIVE CASES. 155 with miliary tubercles. The walls of the heart were atrophied, and exhibited traces of fatty degeneration. The kidneys, spleen, and liver were all normal. Upon hardening the spinal cord, and making thin sections, and employing carmine staining, there was found to be, upon microscopical examination, atrophy and degeneration of the nerve-elements of the posterior columns, with increase of connective tissue. Sections of hardened brain-tissue being made, there was ob- servable in the cerebral cells of the frontal convolutions (after stain- ing) a diffused granular degeneration ; also diffused collections of the lymphoid cells, alluded to previously, most of which had undergone a fibroid metamorphosis. No change could be detected in the cells of the cervical sympathetic, which was carefully examined. Case V. — M. A. R., female, aged 29, single ; occupation, servant. Admitted to asylum with dementia, which ended in paresis. Speech was slurring and hesitating, and her gait was staggering. She suf- fered from gradually progressing paralysis, which involved the sphinc- ters of the rectum and bladder. The cutaneous and muscular sensibility was impaired, and there was loss of electro-muscular contractility, so that disease of the antero-lateral and posterior col- umns of the spinal cord was diagnosticated before death. The paresis was attributed to spinal injury received when quite young. She died from exhaustion four months after her admission to the asylum of which she was an inmate. Post-mortem : The dura mater was firmly adherent to the cranium, the pia mater was thickened and infiltrated, and the arachnoid thickened and opaque. The convolu- tions of the brain were atrophied and the brain-substance indurated. There was fluid in the spinal canal and the cord was slightly atro- phied and softened in patches. The uterus was in a rudimentary condition, apparently never having been developed properly. The spinal cord, after being hardened and sections made, revealed, upon microscopical examination, loss of neuroglia and connective tissue, degeneration of the posterior columns, and loss of nerve-tubules of white substance. The ganglion cells of both anterior and posterior cornua were atrophied and disintegrated, and granular and fatty matter occupied their place. Case VI. Dementia and Epilepsy. — Death taking place after a suc- cession of paroxysms. O. M. S., male, aged 19; occupation, gardener. Was admitted to the asylum of which he was an inmate with epilepsy associated with mania, which preceded and followed the paroxysms, requiring sometimes mechanical restraint. Dementia soon resulted 156 PSYCHOLOGICAL MEDICINE. from the mental deterioration. The patient had epileptic fits nearly every day, which condition had been going on for years. He also inherited the predisposition to epilepsy. During the mania he imag- ined himself to be the Emperor of Germany. The paroxysms in- creased in frequency and intensity, in spite of all medication, for eight months, when he had a succession of fits lasting thirty-six hours, during one of which paroxysms he died. Post-nwrtejn : Membranes of brain thickened ; arachnoid and pia mater thickened ; brain atro- phied and indurated ; lateral ventricles filled with fluid ; spinal cord normal. Upon hardening the brain-tissue and medulla oblongata and examining microscopically, there was seen to be some vascularity in the fourth ventricle, which extended through the medulla, the cap- illary vessels of which were somewhat thickened and enlarged. The cervical sympathetic was also subjected to a careful microscopical examination, but without satisfactory results. Many more interesting cases might be given, but want of space forbids. In closing this record of examinations I desire to insert the post-mortem appearances of a very interesting case, in which insanity and phthisis were contemporaneous in their development : Girl, aged 23. Dementia, paresis, tuberculosis. Fost-mortcm : Pulmonary tuberculosis, with cavities at apices of both lungs. Brain atrophied, ansemic, and indurated, being the result of the lymphoid deposit, as proved by microscopic examination. Upon hardening the cord the posterior sections of the lateral column were found to be affected. The posterior column presented atrophy and disinte- gration of nerve elements and plates of connective tissue in different places. In the postero-lateral columli were granular and fatty cor- puscles and new bands of connective tissue. It being a rather diffi- cult matter to harden the very delicate tissue of the brain so as to be enabled to cut sufficiently thin sections for demonstrating the finer structural relation of the tissues, the writer gives the formula employed by him for a hardening fluid for the brain and spinal cord, which in its effects surpasses any other, and better prepares the tis- sues for the reception of staining fluids. It is as follows : JJ. Bichromate of ammonia, . , .. . .160 grs. Metliyl alcohol, lo oz. Distilled water, 30 oz. M. TREATMENT OF INSANITY. 1 5/ CHAPTER XII. TREATMENT OF INSANITY. General Principles — Necessity of Prompt Treatment — Curability of In- sanity — Statistics of various Asylums and their Views of Treatment — Moral Treatment — Food, Work, and Amusements — Clinical Lectures in the State Hospitals for the Insane — Mechanical Re- straint— Maudsley s Viezvs — Dr. Isaac Ra/s Views — Medicinal Treatment — Cases Illustrating Treatment. General Principles. — The indications for treatment in mental disease are, as Dr. Blandford has admirably shown, " To restore to health the disordered brain ; to cause the incessant waste to cease ; to promote a storing and not an expenditure of nerve-force. The brain must be nourished by healthy blood. The quantity of the latter when in defect must be increased ; when its quality is in fault, it must be im- proved, and when the blood-flow is in excess, it must be checked ; while all causes of disturbance reacting upon the brain from other organs of the body must be removed. Fresh scenes and faces, and the cessation of work and worry will often effect a cure." The re- moval of the patient suffering from mental disease from his imme- diate surroundings, although not necessarily to an asylum, is gene- rally necessary for his cure, as the outbursts of anger and the delusions connected with those nearest and dearest are antagonized by the moral effect of the change ; and if the case is promising and early treatment adopted, a cure will probably result. As a rule, pa- tients are not placed promptly enough under adequate and appro- priate treatment. A great deal of painful emotional distress is avoided by removing the patient to fresh surroundings as quickly as possible, and one of the greatest essentials is good and abundant food, to which allusion will be hereafter made in this chapter. If the patient is dangerous to himself or others, a well-regulated public or private hospital is evidently the appropriate place for him. The tendency of nature in this disease is to restore herself to the normal, we must therefore check the great expenditure of nerve material and see that the food contains as far as possible, and in a readily assimila- ble form, all the materials required to supply this waste. We must remedy impaired digestion, build up the nervous centres, regulate 158 PSYCHOLOGICAL MEDICINE. vitiated secretions, see that our patient gets plenty of sunlight and pure air, and above all, our patient must have time for nature to build up nerve-cells capable of functional energy. If many patients took no medicine, but merely submitted themselves to hygienic conditions and surroundings, and took the necessary rest and time, during which there should be no demand upon the nervous energies, and took food suitable for their nervous centres, nature would, I think, antagonize the atonic functional state of the whole nervous system, in many in- stances, and might make good recoveries. The use of nerve-foods, dietetics, and hygiene, and above all, moral treatment, are perhaps somewhat underrated in the treatment of diseases of the mind, and it certainly requires a good deal of wisdom to know when not to interfere with Nature in her effort to restore the mental equilibrium of a case of insanity. Nature, by her own laws, is capable in some cases, if not too much interfered with, of disintegrating and recon- structing cellular material that'has become unfit for the manifestation of vital phenomena, and restores lost psychical as well as physical force. If we remedy the inadequate nerve nutrition, which is the cause of the cerebral neurasthenia, which is the first link in the chain of mental disorder, we may trust to time and nature to accomplish much for our patient. There is a power in music, color, beauty, to tranquillize excitement, reanimate hope, diffuse joy, and dispel per- version of thought, all of which is manifested in the re-establishment of sanity. These agencies have power to reach consciousness and overthrow diseased action. The physician should be the counsellor, companion, and friend of the patient mentally diseased, and he will certainly have to exer- cise forbearance, attention, and sleepless watchfulness towards his charges if he is to restore order where there is mental chaos. The motive, impulse, and conduct of the patient mentally diseased re- quire to be analyzed by the physician in charge. The patient must be taught to discriminate as soon as possible between what is sound and sane and what is diseased and abnormal, and the mental and moral nature guided aright. He needs the highest intelli- gence and sympathy of his physician, whose very presence should suggest hope and cure, as much as he needs drugs and therapeutic agents. In the treatment of mental disease it is as important to reach the external senses by which moral agents may travel, as it is to reach the nutritive and assimilative functions which may convey physical agents into the system. In treating those who inherit their insanity, TREATMENT OF INSANITY. 159 we should remember that we must set in action for our patient new forces to counterbalance those already set in action before them, and so find a new equilibrium for our patient, so that he is once more in harmony with his surroundings. We have to meet the potentiality of force in these cases and neutralize or counterbalance it by setting some new force in action. We can greatly modify inherited tenden- cies, and by continuous effort other forces may be brought to bear upon the centric nervous system until a radical change in the whole system is brought about. We shall have to teach our patient very often to conquer his lower impulses, and to struggle with natural tendencies so as to diminish their effect upon his mental nature, and he must be taught to reason as to the ultimate consequences of his conduct. The theory of localization of brain function does not throw as much light as we could wish, or lead to much practical benefit in the treatment of cerebral diseases. In treating such diseases we must look upon the brain as a whole, and our medicines must be calcu- lated to act upon it through the general system. Even when we can localize we have to combat disease of the brain by therapeutical measures acting upon the whole of the cerebral structure. Gout and syphilis often give rise to cerebral disturbance of an obscure nature. In the former case a gouty affection of the joints may throw light on the diagnosis ; or, if the urine is carefully examined, chemically as well as microscopically, its undue acidity or the presence of uric acid crystals may afford assistance in diagnosis. In the latter case, where the cerebral phenomena are obscure and perplexing, the lib- eral and continued use of iodide of potassium and protiodide of mer- cury (the latter in small doses) will often relieve the symptoms and clear up the doubtful diagnosis. I think the effects of constitutional syphilis in the brain often consist in gummatous deposits in. the dura mater or in the brain itself, and these melt away under the combined influence of mercury and iodine.* Both the alvine and renal excre- * Moxon and Broadbent have shown that syphilis attacks the surface of the brain and its membranes. It attacks them in limited spots and it spreads slowly. The morbid changes are, on the one hand, adhesion of the membranes to each other and to the surface of the brain, by means of an exudation which may invade and destroy the gray matter, in- terfere with the supply of blood, and, when it occupies the membranes at the base of the brain, surrounds and involves the nerves in the intracranial part of their course ; or, the syphilitic deposit may take the form of a gummy tumour. The brain or spinal cord may be invaded by gummatous tumors springing from the dura mater, or from bones, or there may be syphilitic disease of the walls of cerebral vessels. When we find syphilomata in l60 PSYCHOLOGICAL MEDICINE. tions should be examined with care in mental disorders. They are rarely found normal as regards quantity and quality. The bowels are constipated or the stools are wanting in bile, although diarrhoea is present. The urine is very seldom in a natural state. It is thick and turbid, of a high specific gravity, and abounds in the salts of urea. In cases of melancholia the urine contains oxalic acid or ox- alate of lime crystals. The body is poisoned by the retained nitro- genous material, and we must primarily rid our patients of all such substances. This can be effectually done by administering ten grains of calomel, followed by salines, which prepares the system for other treatment. The administration of nitro-muriatic acid, in water, after m'eals will speedily rid the nervous system of the poisonous effects of the oxalate of lime if it is found to exist in the urine, and I have seen the most intense depression, bordering on an attack of mania, speedily cured by relieving the oxaluria which had caused this state of melancholia. The Necessity of Prompt Treatment. — Although it is not generally so regarded, insanity is one of the most curable of serious diseases if promptly cared for and treated. The mistake which is committed every day by foolish friends and relatives of keeping secret as long as possible the fact of the patient's insanity, thereby depriving him of the necessary care and treatment at the outset of the disease, is often fatal to the prospects of recovery of the unfortunate patient, who is only sent to an asylum when he has become perfectl}^ unman- ageable and the disease has become deeply seated. It has been stated by eminent authority that if persons who are attacked by this disease were cared for as promptly as if they were suffering from an attack of dysentery or fever, eighty or ninety per cent, could be restored to health and usefulness. There is no disease, however, which develops more rapidly if not treated, and tends to induce organic degeneration, which renders it incurable. From a financial point of view it pays well to restore the insane as soon as possible to usefulness and health, and thereby save the commonwealth the cost entailed by the loss of his labor, and also the amount that has to be paid for his board and clothing, which, at the lowest estimate, the brain, they are usually located in the gray matter of the corpora striata and thalami. I have seen convulsions, paralysis, and the most varied intellectual and moral distur- bance, from syphilitic disease of the surface gray matter of the brain. We may have syph- ilitic epilepsy, cerebral disease in infantile syphilis, and syphilitic thrombosis of cerebral arteries. Headache and giddiness are prominent symptoms of cerebral syphilis, with great intellectual dulness and muscular weakness. TREATMENT OF INSANITY. -■* l6l amounts to not less than ^^156 per year, or I3 per week. Dr. Ed- ward Jarvis, of Dorchester, Massachusetts, who has made very labo- rious investigations upon the subject, in a paper entitleed "The Political Economy of Health," presents the following view of the gain or loss entailed upon the State or family of an insane man by his cure or by his remaining a lunatic for the period of life left to him after his attack. According to Mr, John L. Copeland's table, showing the average longevity of the insane from any given age, it is seen that a man of 20 years of age, if sane, has an average life of 39.48 years, while if insane he has but an average life of 21.31 years if not restored to health. Dr. Jarvis has estimated that, leaving out of sight the ten or twenty per cent, of the insane who are incurable, the average time for restoring to health the insane who apply for treat- ment upon the early symptoms of disease is twenty-six weeks. At $4 per week, which was the average cost in the three State lunatic asylums in Massachusetts for the past year, this amounts to ^104, to which is added ^30 for each patient for the cost of rent, or interest on the value of the hospital, etc., for six months, making an average cost of 1 1 34 for restoration to health. If not restored to health, the family or State must be at an expense of ^156 a year for 21.31 years, and must also lose the patient's earnings for the 39.48 years which he would have made if well. The cost of the patient's support is estimated at ^2121, while the loss of his future labor, if he becomes insane at 20 years of age, is estimated at ^2665.37, making a total loss of ^4786.37 if not cured, while, if cured in the average time of twenty-six weeks, at a cost of ^134, there will be a gain to the family or to the State of ;^4652. The foregoing is an admirable argument for sending insane patients to be treated in the early and curable stage of the disease, and, if acted upon, would reduce by a large per- centage the incurable cases which are now to be found in such great numbers. In ancient times the insane were regarded as possessed with devils, and were accordingly fastened with chains, handcuffs, and fetters, and confined in cages or dungeons to drag out their miserable lives as best they could. In 1689, Johannis Helfrici, in writing on insanity, says: " Sfevere discipline — chains and stripes — to cure the fury and depress the elation of mind." Formerly the miserable insane were crowded together pell-mell and without any distinction, exasperated by the bru- tal rudeness of their attendants and subjected to the vain caprices and arbitrary orders of an unfit or negligent superior, and were constantly 1 62 PSYCHOLOGICAL MEDICINE. in a state of agitation and continually uttering complaints, lamenta- tions, and loud cries, while to-day every patient enjoys the degree of liberty accordant with his personal security and that of others, while, instead of being shut in cells, they are permitted to promenade freely in a spacious and agreeable inclosure, taking the precaution of having attendants employed especially in watching them, while exercise and labor are fundamental rules in treating insanity in our hospitals for the insane. Curability of Insanity. — As I have just stated, insanity is a curable disease if properly treated, but experience shows that very often the disease has been permitted to become permanently fixed before it is subjected to a curative process, and thus the proportion of incurables received at our asylums has been constantly increasing in the prog- ress of years. The next national census will show that the num- ber of the insane in the United States is nearly twice as large as has generally been supposed ; and in the State of Massachusetts, for instance, where the estimated proportional number of the insane has been in years past about one to every thousand of the popula- tion, there are known to be nearly three to every thousand. We need, what we are beginning to have, a reformation in the statistics of insanity, so that we can see what the effects of treatment and other circumstances are on the health of patients and in regard to cure. We want to know how many patients recover permanently or for a long period of time, not how often a patient discharged from an asylum as recovered returns to the same asylum to be again discharged as recovered in a few months. A great many cases in our State hospitals for the insane, which are discharged as recovered in the course of any given year, are patients who have previously recovered from earlier attacks, and are relapsing cases, nearly all of whom will probably become again asylum patients. Even among the primary recoveries many will relapse. I think there is no rea- sonable doubt of the fact that insanity, as it is seen in our public institutions, is far less susceptible of cure than the profession has heretofore been led to believe. All readmissions of patients to asy- lums should be tabulated by the superintendent, as it is only in this way that accuracy respecting true recoveries can be arrived at. One of the ablest investigators. Dr. Pliny Earle, the Superintendent of the Massachusetts State Lunatic Hospital at Northampton, in his last annual report of that institution, gives the following results in 1879-80, at the ^Massachusetts State hospitals, which, as relates to TREATMENT OF INSANITY. 1 63 the curability of insanity, has an important bearing, as it shows the very misleading method of reporting recoveries which almost uni- versally prevails in our public institutions : The adoption last year by all the State hospitals for the insane in Massachusetts of the new series of statistical tables prepared by tne Board of Health, Lunacy, and Charity, has given us an advantage never before enjoyed. It has enabled us to show very nearly, if not positively, just what was done by those institutions in the course of the official year 1879-80 towards the restoration of the insane and the diminution of their number within the Commonwealth. At the four State hospitals, at Worcester, Taunton, Northampton, and Danvers, in the course of the year ending with September 30, 1880, the number of persons admitted was 1092, — persons, or individuals, be it understood, because it not infrequently happens that one and the same person is admitted more than once in the course of a year. Out of this number of persons, and those who were in the said hospitals at the beginning of the year, the number of persons discharged recovered was 283. This makes the recoveries, calculated on the admissions — the method which approximates most nearly the truth — equal to 25.91 per cent., or a small fraction more than one-fourth of the whole. Such, then, are the results for one year at our curative State establishments. I have here stated them in the way that similar results have always, prior to the year 1880, been reported at the institutions for the insane throughout the United States. Even as so reported, giving to them all the advantage derived from a broad general statement, with no examination into the detail of modifying facts and conditions, they yield no evidence of a great degree of curability of the insane. The curable three-fourths of former faith dwindles very nearly to one-fourth in absolute practice. The hospital at Danvers, the newest of the four institutions mentioned, and situated nearest the populous centres of the Slate, received nearly all of the recent cases from Boston during the past year. It probably also received all which were committed from Lynn, Salem, Lowell, and Lawrence. But as that hospital has been only a short time in operation, I disregard it in the showing that I am now about to make, and take the three other hospitals, which have been in operation different periods, varying from twenty- three to forty-eight years. Those three older hospitals, at Worcester, Taunton, and Northampton, admitted during the official year 1879-80, 521 persons. They discharged recovered 118 persons, making a percentage of recoveries of 22.64, ^ noteworthy fraction less than one-fourth of the number admitted. But let us look a little farther. The three hospitals discharged 118 persons recovered ; but they admitted 55 persons whom they had previously discharged recovered. Conse- quently the actual gain, in the course of the year, of recovered persons in the commu- nity was only 1 18 minus 55, which is 63. This is only 12.09 P^'^ cent., or less than one- eighth of the number of persons admitted. It is an average of 21 gained recoveries at each of three large hospitals, the average number of the patients of which was, for the year, equal to 503 for each. A fact yet unmentioned gives, at first view, a still more discouraging aspect to the case. The 55 persons readmitted after previous recovery had been discharged recovered, not alone once each, making 55 recoveries, but a total of 115 times. The public had been told in the reports of 115 recoveries of those 55 persons. Hence, if recoveries, and not persons, be considered, the three hospitals issued 118; but they took back 115 164 PSYCHOLOGICAL MEDICINE. which had been previously issued, leaving in the general population a gain of only three, or an average of one for each hospital. It is not improbable, however, that the excess of recoveries (115) over that of persons (55) readmitted was counterbalanced by a similar excess of recoveries over that oi persons (118) discharged. For example, if one of the 55 persons readmitted had previously been discharged recovered five times, there may have been, among the 118 discharged recov- ered, one who had previously been discharged recovered an equal number of times. The statistics just given in aggregate for the three institutions were specifically, for each one of them, as follows : At the Worcester Hospital, the oldest of the three, although its present building is the newest, the number of persons admitted was 222. The number discharged recovered was 41, which is 18.46 per cent., or less than one-fifth of the admissions. But among the admissions were 25 persons whom it had previously discharged recovered. Hence the actual gain of recovered persons outside of the hospital was only (41 minus 25) 16, or 7.2 per cent, of the number admitted. The 25 persons readmitted had been discharged recovered a total of 58 times. At the Taunton Hospital, 1S4 persons were admitted and 49 discharged recovered, a percentage of 26.62. Of those admitted, 19 had previously been discharged recovered, so that the gain of recovered persons in the general population was only (49 minus 19) 30, or 16.3 per cent, of the admissions. The 19 persons readmitted had been discharged recovered 35 times. At the NorthanTpton Hospital, the number admitted was 115. The number discharged recovered was z8, equal to 25.22 per cent. But of the persons admitted there were 11 who had previously been discharged recovered. The' gain of recovered persons in the community was, therefore, only (28 minus 11) 17, or 14.78 per cent, of the number ad- mitted. The II persons readmitted had been discharged recovered a total of 22 times. It is believed that from this exposition it will be apparent that the method still almost universally prevalent of reporting recoveries is, except in a technical or medical sense, very fallacious and deceptive ; and that, until some other method, similar to the new one in Massachusetts, be adopted, those statistics will be worth next to nothing in the study of the problems of social science. At the Danvers Hospital, the number of persons admitted in the official year was 571. The number discharged recovered was 165, or 28.89 ps'^ cent. The proportion of recent cases received at that institution was unquestionably, and for obvious reasons, larger than at either of the other three. That hospital had been in operation less than eighteen months at the beginning of the official year in question ; hence it could not be expected that, among the persons admitted, there should be many who had previously been discharged from it recovered. And yet there were some such readmissions the report does not state how many ; but it was of so many persons that their total of recoveries was 18. A Glance at Great Britain. — Having shown the results at the State hospitals of Mas- sachusetts, perhaps it may be permitted to extend our observation to some of the similar institutions abroad, for the purpose of further illustrating the subject, as well as showing the advantages of our recently adopted method of reporting recoveries. At the British asylums the method of reporting the statistics has always been essen- tially the same as it is in the United States. We, indeed, followed their example. But it has heretofore been my impression that the proportion of patients readmitted, after having been discharged recovered, was much smaller there than in this country. I have supposed that the British patients remained longer in the hospitals than do the Amer- TREATMENT OF INSANITY. ' 165 ican, and that thus their recoveries were so confirmed that relapses, or subsequent attacks, were comparatively infrequent. From information recently received, I infer that, at least to a certain extent, I was mistaken, and that there is no very great difference in these respects between the two countries. Dr. Clouston, of the Royal Edinburgh (Morningside) Asylum, in his report for 18S0, has introduced tables by which the same light is thrown upon his statistics of recoveries as upon those, of the Massachusetts institutions by the new and recently-adopted method of reporting, with the exception that he does not clearly discriminate between cases (or patients^ and persons. The admissions at Morningside, in 1880, were 347. Of these patients, the number suffering from the First attack of the disease was . . . , . . . .231 Second attack, ........... 58 Third attack, ............ 24 Had had several attacks, . ... . . . . . .26 Congenital, ............ 8 Hence it appears that, of the 347, no less than 108 (58 plus 24 plus 26), or nearly one- third of the whole, were readmitted after recovery from one or more former attacks. On the supposition that the word "several " means three (it probably, as used above, means more), those 108 patients had already been discharged " recovered " a total of 184 times. So much for the patients admitted. The number of patients discharged recovered, was 165, which is 47.55 per cent., as calculated "on the admissions. Of these 165, there were who Recovered for the first time, . . . . . . . . -97 Had recovered in former years, ; . . . . . . .63 Recovered more than once in 1880, . i ..... 5 Total, 165 At the close of the year no less than nine (9) of these had already been brought back to the asylum, and still remained there or had been removed tinrecovered. If the figures in these two tables represent /f;'j£i/«.y, we derive from them the following result : The asylum discharged recovered, 165 ; but it took back, of persons who had formerly been discharged recovered, 108. Consequently the actual gain of recovered persons in the general population was only 57 (165 minus 108). This is only 16.42 per cent, of the admissions. The movement of the population at the Morningside Asylum is very rapid. Many of the patients apparently remain in the institution but a comparatively short time. For these reasons it is believed that the proportion of patients returning to it after having been discharged recovered is larger than at most of the British asylums. In his report for 1880 of the Derbyshire (England) County Lunatic Asylum, Dr. J. Mur- ray Lindsay states that in 20 per cent, of the admissions " there had been previous attacks of insanity." At the Richmond District Asylum, Dublin, Ireland, in 1880, the admissions were 420, of which 65, or 15.47 per cent., were "relapsed cases." The number dis- 1 66 PSYCHOLOGICAL MEDICINE. charged recovered was 167 ; but the gain of recovered persons in the general population was only 102 (167 minus 65). The British Medico- Psychological Association. — The most striking evidence of pro- gressive thought relative to the general subject under consideration is the fact that, at the annual meeting of the British Medico-Psychological Association, which was held in Lon- don in August last, the statistical committee of that society recommended for adoption some new tables, as well as alterations in some of those already in use, so modifying the series, as a whole, that the statistics of the asylums can be reported with essentially the same detail and the same perspicuity in regard to recoveries as is found in the new tables of the institutions in Massachusetts. After a brief discussion, it was decided to postpone for one year the question of their adoption, for the purpose of giving the members an opportunity to study them and to dis- cuss their merits at the quarterly meetings. But there can hardly be a doubt as to the result. The proposed alterations will be adopted. In the present state of things — when, in consequence of the existence of various organizations for the promotion of the objects of social science, the call, outside of the profession, for information in regard to insanity is tenfold greater than it was forty years ago — the members of the British Association can- not afford to refuse to display their statistics in such manner as will render them valuable to the members of those organizations. The present /if,^7z;nVfl/ truthfulness of those sta- tistics must be expanded into an absolute truthfulness in regard to the relation between the disease and individuals, or the most important part of the statistics themselves will soon become entirely, as they even now are essentially, valueless. Dr. Clouston is not going to recede from the position gained by the step in advance taken at the time of mak- ing the report just passed under review, — a position in which he could show not alone what his institution had accomplished during the year in relation to disease, but also to what extent its beneficial influence had affected his fellow-vien. There are many others among his colleagues in the specialty in England and Scotland who are even now ready to follow his example. The rest will doubtless mostly be ready at the expiration of the appointed year. Let them remember that, no less than forty years ago, a reformation in the statistics of insanity was called for by an Englishman whose keen and comprehensive intellect and whose soundness of judgment were second to those of no one of his coun- trymen who have written upon the subject : I allude to the late Samuel Tuke. In the thoughtful and excellent article used as an introduction to his translation of Dr. Maxi- milian Jacobi's treatise on the construction and management of institutions for the insane, he wrote as follows : " The whole subject of the mode of reporting the results of our institutions for the insane calls loudly for attention, if we would arrive at any useful statistical comparisons as to the effect of treatment and other circumstances on the health of the patients and in regard to the cure of this greatest of all human maladies. The subject would not be unworthy of a special consultation amongst the professional men who are devoted to this department of the medical art." It appears to me, from the very wording of this extract, that its author had in view the specific changes — perhaps with others — which it is intended to accomplish by the adop- tion of the proposition now before the Medico-Psychological Association. Shall his sug- gestions be permitted to lie under the dust and ashes of a half century before they are carried into effect? Old but Valuable German Statistics.— Kt the Siegburg Asylum, in Rhenish Prussia, an institution which at that time was under the superintendence of Dr. Maximilian Jacobi, the statistics of recoveries from January ist, 1825, to December 31st, 1845, a period of twenty-one years, were as follows: 79 48 127 5 6 ir 34 30 64 39 i8 57 43 25 68 8 4 12 TREATMENT OF INSANITY. 1 6/ Men. Women. Total. Whole number recovered, 377 284 661 Living at the end of the period, and have had no relapse, 169 153 322 Relapsed and recovered again at the asylum, . Relapsed and not yet cured, Relapsed and become incurable, .... Relapsed and died insane, ..... Died without a relapse, ...... Not heard from, ....... The number of patients admitted in the course of the period is not given, and, conse- quently, the percentage of recoveries cannot be obtained. The statistics are valuable chiefly for the purpose of ascertaining to what extent the recoveries were permanent. At the time of the close of the twenty-one years, 259 of the 661 persons had " relapsed," or, as it is generally stated in this country, had had a second attack. This is equivalent to 39.1 per cent., or a slight fraction less than two-fifths of the whole. But these are not final results. Within the ten years next following the close of the period the number of relapses would be large, especially among the patients who recovered in the last half of the period. If about ^z«;t>-fifths of the whole relapsed within the period, it appears, per- haps, more than probable that cK^-fifth (or half as many more) would relapse afterwards. Supposing this estimate to be accurate, the whole number of persons relapsed would be equal to three-fifths of the whole number of persons recovered. This corresponds with Dr. Thurnam's well-known formula, derived from his investigation of the subsequent history of patients recovered at the York Retreat. In regard to the proportion of the persons recovered who would ultimately die insane, it will be perceived that, at the close of the period, it was still too early to furnish the data for a very accurate estimate. Something, however, in that direction may be done. Already the number who had relapsed and died insane was 57. The number who had relapsed and become incurable, and who would consequently die insane, was 64. This gives a total of 121, or a little less than o«f -fifth of the whole, whose deaths, while insane, were assured. According to the above-mentioned formula, two-Wi\hs of the whole should die insane. Hence we must find a little over ^w^-fifth, or, in actual numbers, 143 inore who would die insane. These must be looked for (i) in the 322 who had not relapsed, but many of whom undoubtedly would relapse ; (2) in the 127 who had relapsed and recov- ered again, and, judging by what we know in regard to the liability to repeated relapses, a very large proportion of whom would relapse again ; and (3) in the 1 1 who had relapsed and were not yet cured. Of these 460 persons it would not be surprising if 143 should die insane. An Echo from the Antipodes. — There are two lunatic asylums in South Australia. They are under the general supervision of a board of visitors, of which Dr. Alexander S. Paterson is chairman. The report for 1880 of this board, signed by the chairman as colo- nial surgeon, is before me. It deals with the subject of recoveries with a commendable extent of detail, although it fails to discriminate between /ifr^t^wj- and cases, and to give the number of attacks and of recoveries of those patients who have been readmitted after: recovery. At the two asylums, Adelaide and Parkside, the aggregate number of admissions in 1880 was 223. The number of patients discharged recovered was 90, which is equal to 40.35 per cent. But of the patients admitted there were 35 who had previously been discharged recovered. The two institutions gave to the people 90 recoveries, but they received back from the people 35 former recoveries. Therefore the gain of recoveries among the people was (90 minus 35) only 55. This is 24.66 per cent, of the admissions. 1 68 PSYCHOLOGICAL MEDICINE. Five of the patients readmitted returned to the hospital within a month from the time at which they were discliarged recovered. As miglit be expected in a country so recently settled as South Australia, a large pro- portion of the recoveries were from cases originating in intemperance. In no less than 25 cases of males the form is called alcoholistnus. The patients recovered in 24 of them. Eight of these were in tire asylum less than a month each, and the average time of treat- ment of the 24 was only one month and seven days. Athenian Success. — I now approach a " study " from the consideration of wliich I would gladly be released; but, in the discussion of this subject, it is proper that all falla- cies should be exposed, and all sources of error pointed out. Furthermore, I have been criticised for the assertion, in the pamphlet on the Curability of Insanity, that the medi- cal officers of institutions for the insane are men "with like passions as other men," and, therefore, the introduction here of any evidence that sustains the truth of the assertion is more than justifiable. That the reader may enter more intelligently upon the matter, it may be remarked that, in Ohio, the superintendents of the State institutions for the insane are among those per- sons whose offices are the " spoils " which belong to the victors in politics. The mere statement of this fact is sufficient for the present purpose. Any attempt to present in detail the evils consequent upon such a state of things would be irrelevant. In his report for 1880 of the State Asylum for the Insane at Athens, Ohio, Dr. H. C. Rutter, who had but recently been appointed to the office of superintendent, mentions the discussion of the curability of insanity begun in the reports of this hospital, and, after stating that it has been taken up by alienists all over the world, gives the following con- firmatory evidence of the truth of one of my " conclusions :" " It has frequently happened that the same person has been discharged more than once during one year, and that each discharge has been reported as a separate cure. One person in Ohio is reported to have recovered seven times in one year, and, while he fig- ured in the annual report as seven ' recoveries,' was actually a patient in one of the wards at the time the report was made out." After some further remarks, he proceeds as follows : " It has also been charged that these ' cures ' are flexible, and can be increased by the superintendent whenever occasion arises to prove his superior fitness and qualifications as a specialist. This charge has been made repeatedly, and by many distinguished mem- bers of the profession, who have been disgusted with the idle talk about cures made by political superintendents for the purpose of gaining cheap notoriety through the secular press. We have, perhaps, felt this in Ohio to a greater extent than in almost any other State in the Union. To show that these charges are not made M'ithout some foundation, and that some reason for the demand that is being pressed for a reform ih our asylum statistics does exist, I will quote some interesting cures from the general register of this asylum. " During the two years previous to May 20th, 1880, we find among the ' cures ' the fol- lowing remarkable cases. I quote from the male register, and presume the female regis- ter shows an equal proportion of remarkable cures : Cures. " Duration of insanity over 50 years, ........ i " " " 20 " 6 " " " 18 " 3 " 15 " 3 " " " 12 "..,..... 3 " " " 6 " 16 Total over six years, . . . . . . . . . 32 " TREATMENT OF INSANITY. 1 69 Thus in the course of two years, and from the men's department alone, thirty-two cases were discharged as recovered, in no one of wliich had the disease existed less than six years. In one it had existed fifty years, and the average duration for the whole was more than twelve years. " Four of these," continues the doctor, " were cases of chronic dementia ; four were epileptic, with duration of insanity ranging from seven years to twenty-one years." No man who has had any considerable experience in a hospital for the insane can fail to instantly perceive the preposterous absurdity of such statistics as these. By a proba- bly low estimate there are now in the public institutions of Massachusetts not less than fifteen hundred insane pei-sons who might be set at liberty and reported as " cured " or " recovered " with as much propriety as were those thirty-two patients at the Athens Asylum. But by those thirty-two cases — together, undoubtedly, with similar ones from the female department — the superintendent increased the proportion of his " cures " to 63.50 per cent. I am still of the opinion that " the medical officers of institutions for the insane can claim no exemption from the common weaknesses of human nature;" that "they are men with like passions as other men," and that the degree of confidence which is to be placed in their statistics depends, to a large extent, upon the temperament and character of the individual from whom they come. Other statistics are as follows, at hospitals for the insane who base their calculations on cases discharged : Statistics of Utica, N. ¥., Asybim. — -'The Fortieth Annual Report of the New York State Lunatic Asylum, at Utica, which, owing to the politeness of Superintendent Dr. John P. Gray, I have before me, shows that during the year 1882 there were treated 1038 cases — 508 men and 530 women. The number at the commencement of the year was 626. Received from September 30th, 1881, to Sep- tember 30th, 1882, 412 cases. The daily average under treatment was 621. There were discharged, recovered, 109 cases; improved, 46 cases; unimproved, 235 cases; not insane, 13 cases; died, 57. The thirteen cases were not insane when admitted. Dr. Gray has some excellent remarks upon early treatment, which we insert as follows : Dr. Gray deprecates the remarks of Dr. Pliny Earle, showing that insanity is not so curable as was formerly supposed, and says, " he takes the results growing out of the public policy of indifference and neglect, instead of basing his calculations upon what a wise and humane policy could effect," etc. Dr. Gray thinks the apparent increase of insanity in New York State is due to accumulation. He has also some wise remarks relative to the premature removal of pa- tients from asylums. His remarks on the necessity of statutes making provision permitting persons to be voluntary applicants for admission to asylums, are worthy of remark. We certainly need such statutes. I/O PSYCHOLOGICAL MEDICINE. A man who feels his brain out of order is just as much entitled to be a voluntary applicant as a man with a broken limb. Dr. Gray says : Importance of Early Treatment. — I deem it proper to say that a greater propor- tion than in any previous year of the cases admitted belong under the head of chronic insanity. In my last annual report statistics were presented showing the percentage of patients, for each year, for the ten previous years, who had been insane a year or more before admission. I continue this table, as it not only shows how large a proportion are practically chronic cases when admitted, and that the evil practice of delay is in- creasing : Year. Whole number admitted. Found not Insane. Number Insane One Year and over. Percentage Insane One Year and over. 1871, .... 516 13 212 42.14 1872, 399 17 143 37 43 1873. 1874, 1875, 1876, 410 368 432 436 13 6 15 8 142 117 136 35 32 32 32 76 32 61 24 1877, 460 13 149 33 33 1878, 1879, 1880, 427 418 468 10 16 II 125 135 177 29 35 38 97 58 73 1881, 411 8 190 47 14 1882, 412 13 190 47 61 5.157 143 1,854 36-97 As of further and important interest in this connection the following table has been prepared, to show how wide a difference exists between the recoveries in recent cases and n those not placed under treatment until the disease was fully established : TREATMENT OF INSANITY. 171 1 >t s 8 « %.> *>. ^ « V lij 'll byi ■^ 5? s? *i "lu !C i^ "3 ■^ Si ^ ^ ^ ^-0 is ■^. •^ '^ IS 1 "!0 <0 si tn ^J 'U !s <-5 'S « '^ ^.S ^ V "^ K ^ to •S3U3 -A0D3J JO aSBjusoja^j H NO 'ssaj JO sqjuora xis auBS -ui U33q pi3q oqM P3.13A0034 J 3 q UI n J^ t^ CN ■* r^ ONMD 00 N i-i r^ 00O^OO•-ll-l>-|^^ O^CO M •SS3] JO sq^uora XIS au-esui — pajjiuipB jaquin^ M ON CO crivo 00 li-) r~ w N u-) •^vo 1J-) M rooo 00 00 •S3U3 -A003J JO sSejuaojaj; CO ^ 00 1000 U-) HI 6 ■^ONN N rooo* r--o6M3 VO •JB3A 3U0 UEqi SS3I 3UBS -UI U33q pEq oqAV P3J3A0D3J J 3 q UI n ^ N 0\iH NVOMD rorOt-^ OOMN-0 fOON 10 ^00 0\ ON ONVO 00 i-i fO •S3U3 -A033J JO 33b;U33J3 J 00 \0 -^ OnvO ■^ n vn m Os^'^t^^M Tt-M ro rfi-I m'^'^'^co w rovo MWMI-tWM MHi fO N •J3A0 pUB JBSK 3U0 SUES -ui U33q psq oqAV p3J3AO03a J 3 q ui n j^ ©•^I-IOC^COIHMION NMNNNh-IMC^Nt-l CO M •J3AO puB JE3^ 3U0 3UESUI — psjjiuipE Jaquin^ N t^vo 00 On 10 i/^ l~~ •^-1-1 ^o^^^^^ rot^ONON ON ON ''^ M •S3IJ3 -A033J JO 33BJU3bj3jJ J>- On^O i-h h-i 10 On !>• ro rOiH t^rO'^trjfOi-i t^ •p3J3A003J psSjEqosip Jsquinjsj M ro N M 00 ■^ M inoo On M •pSJlIUipB auBsut JO jsquiri]^ t^ N r^oo r^ r^ N t^ to on CNMD 1- c^j-nTm OvoO On ON OS < > t^ r-^ f^ r^ r^ f^ t^oo 00 00 oooococoooooooooooco 1/2 PSYCHOLOGICAL MEDICINE. It -n-ill be seen from the above table that the average percentage of recoveries on the admissions for the past ten years is 32.55, while the percentage of recoveries of those vi'ho were retained at home without treatment until their insanity had continued a year or longer is only 12.34. To exhibit more clearly the importance of early treatment, a computation of the recove- ries of those admitted during the same period who had been insane less than a year, shows the percentage of recoveries increased over the general average of 32.55 to 44.06, and the percentage of recoveries of those brought within six months of the attack rises to 46.01. It will be observed that out of the 4129 insane admitted during the last ten years 1499 were not brought to the asylum until after their insanity had lasted a year or more. If they had been brought within a year of the beginning of the attack, instead of a per- centage of recovery of 12.34 it would have been 44.06, amounting to 475 more persons cured. To say nothing of the individual and family sorrow entailed by such neglect, the sub- ject possesses an economic aspect which demands consideration. At a low estimate the individual expectation of life of those 475 cases is 15 years. Estimating the average yearly cost for their support at §150, the expense to the public or their friends would reach the sum of ^1,068,750. These figures, far more forcibly than words, show the evils of delay in placing the insane under treatment, and I am forced to the conclusion, from experience and observa- tion, that the unjust crusade against asylums is largely responsible for this wrong inflicted on the insane, and for the increase of chronic insajie with the public and private burdens it imposes. Bearing in mind what has already been stated, that the tendency to delay has recently been growing instead of decreasing, for the tables show that for the past two years the percentage of chronic cases admitted has risen from an average of 34.08 to over 47 per cent., the outlook for the insane and for those upoa wliom their support will fall is not encouraging. Dr. Gray's remarks on restraint and seclusion are based on the broad grounds of the welfare of the patient and his care and speedy cure, and are given as follows, as his wide experience entitles such remarks to be attentively considered. His interesting remarks on the Commitment, Detention, and Discharge of patients are also given in the few following pages, and will repay careful reading : Restraint ajid Seclusion. — Two years ago, I submitted to the board of managers, in compliance with their request, as an appendix to my annual report, a paper on the custody and treatment of the insane, which included a full presentation of the status of profes- sional opinion at that time on the question of mechanical restraint, with an analysis of the recent discussions on the subject held at meetings of the medico-psychological so- cieties of Germany and France, whose members are principally superintendents of insti- tutions for the insane. In these discussions both sides of the question were thoroughly explored, and the verdict to which the evidence led was simply that restraint is not to be used for its own sake or for the mere convenience of officers and attendants, but as the interests of the patient alone required, to facilitate his proper treatment and recover)'; that the minimum of restraint consistent with the welfare of the patient and the safety of those around him should be aimed at, and that the nature of the restraint required in TREATMENT OF INSANITY. 1/3 each particulai- case, whether by camisole, seclusion, padded rooms, shower baths and packing, dry or wet, must be determined, like the prescription of therapeutic remedies, solely by the judgment of the medical officers who were responsible for all branches of treatment. All the participants in the discussion allowed — even those who proclaimed themselves to be the warmest advocates of non-restraint — exceptional cases which cover the whole ground of the principle under discussion, and in fact narrow down the whole debate to the simple question whether seclusion or solitary confinement, with hands and limbs in free and violent motion to do what the patient may be driven to do by his dis- ease, or forcible restraint by the hands of attendants, is better than the open association and intercourse with other patients and liberty to move about the wards, only with hands rendered incapable of doing harm by some mechanical means. This is a question which experience alone can determine, and I have no hesitation in declaring that experience by all means favors society as against seclusion in such cases. It was shown in this same paper that the so-called * abolition of restraint ' in the English asylums must not be understood in an absolute sense; for whatever theory or line of practice has been adopted, we find there are still cases which require ' strong dresses,' 'endless sleeves,' 'camisoles,' 'tied hands," 'forcible holding by attend- ants,' ' wet or dry packing,' or ' seclusion in dark or padded rooms,' and the reasons generally given for any of these forms of restraint are for ' surgical purposes,' or ' vio- lence and destructiveness,' or ' picking the face,' or ' to prevent suicide,' or ' self- irijui-y and mutilation,' or ' persistent destructiveness,' or ' self-denuding,' etc. I sum- med up that paper with the following conclusions, which I wish here to reiterate, as what every passing year's experience has only served to confirm and corroborate. " It would seem that the English superintendents and the commissioners have the same exceptional classes to deal with, and that they find in practice some mode of protective restraint must be resorted to. Their variations of practice would indicate that, instead of a settled conviction of the benefit of some particular method, they were disposed rather by a variety of means to apply whatever might be the best to accomplish the de- sired object of necessary protective control with the least discomfort and risk to the pa- tient. We are obliged to take it for granted that those who have figured as advocates of non-restraint do not really mean the abandonment of all coercive measures, for, after all, seclusion against the will of the patient, or the use of padded rooms, wet and dry pack- ing, showering and manual force of attendants, can be regarded in no other light than as restraint. " I think it must be admitted from the foregoing that there is no real difference in prin- ciple among experienced professional men who have devoted their lives to this branch of science applied to the practical ends of humanity and benevolence. Compared with the manner in which the insane were treated in former times, the present system is indeed one of ' non-restraint.' Intelligent medication, exercise in the fresh air, good and abun- dant food, moderate and pleasant amusements, congenial occupation as far as practicable, combined with comfortable surroundings, have proved a sufficient treatment for the greater proportion of the insane, so far, at least, as to make the necessity of forcible means and mechanical appliances the ' exception to the rule.' But as these exceptional cases do exist, on the universal confession, and always will, they require exceptional treatment. How their best and most humane care can be accomplished is the serious problem that brings itself to every conscientious mind. The principles on which all must agree are simply these : the guiding object should be the welfare of the patient (not forgetting also the safety of those about him), his care and cure in the surest and speediest manner possible. The responsibility of all measures to these ends must rest upon medical decision and judgment alone ; whether control over extreme violence, 1/4 PSYCHOLOGICAL MEDICINE. manifesting itself suicidally or homicidally, shall be established by the simplest mechani- cal restraint, or by drugs, or by the application of water in shower-baths, or by wet pack- ing, or by the hands of attendants, with all the risks of personal struggles, or by seclusion in rooms with or without clothing or bedding, with the risk of self-injury by such means as still remain to the patient, or by any other measures known to science and experience, must all depend ultimately upon what the medical man on the whole shall deem best for the patient. All this must come under the one head of medical care and treatment, pre- cisely as is the case with the physicians in general practice in the treatment of other dis- eases, or the treatment of any disease in any ordinary hospital, with this difference, per- haps, that whatever the physician in the case of the insane in hospitals advises, he is ex- pected to see carried out. Wherever the question of restraint arises in connection with any individual case among his patients, he must judge of the nature and extent of that restraint, and he must be presumed to know and be able to judge between what is cruel and what is humane, protective, and curative, as well as the surgeon knows and judges in his operations between necessary pain and useless barbarity." In view of the continued agitation of this subject, I have only the following considera- tions to add : Nobody disputes that mechanical restraint could be wholly abandoned. So could the administration of medicine be wholly discontinued. There may be those who are prepared to take this extravagant ground in regard to both ; but the real question, at least among experienced men, is whether restraint should he abandoned; whether such a course would be best for the insane. It is upon this test our practice must depend, whether in itself the practice be agreeable or disagreeable. I stated in my annual report more than twenty years ago (i860), before most of the agitators of the present day came upon the stage, that restraint and seclusion were in themselves inadmissible, and only to be used as a necessary and indispensable means of treatment. There is abundance of experience on record in regard to this subject. The discussion of restraint on its merits has long since been so exhausted as to render all that can now be said mere repetition and altogether inadequate as a means of new notoriety. The conclusions of the Association of American Superintendents, of the Psychological Society of Paris, and the German and English authorities who represent experience with the insane, have settled every princi- ple in this matter, and left only the discretion of reducing the minimum to nothing. But the fact is restraint has never been wholly abandoned either in England or any other country. The most that can be said is that certain persons say they do not use it. Their real practice is open to the inquiry whether their substitutes are better for the patient or worse. The practice of not using a remedy which all admit to be only for exceptional cases may conform to a dogma by a physician more than it contributes to the comfort or recovery of a patient, which latter are liable sometimes to be lost sight of in the ardor of defending a theory.* I have heard some say they would not under any circumstances prescribe chloral, and others say the same of alcoholic stimulants. Such utterances may be honest. It does not, however, follow that they are wise. They do not make their * Note. — Dr. Tuke, in the " History of the Insane," etc., already referred to in the account of Broadmoor Asylum, says there is no mechanical restraint resorted to, but adds, "some patients are, of course, secluded in a single room in which a bed made on the floor is the only furniture allowed, and in which the window is protected by a shutter if the patient breaks glass. The room is, when the shutter is closed, only partially dark, as there are two small windows near the ceiling out of the patient's reach. By the side of the door is an inspection plate, or narrow slit in the wall, with a movable glazed frame, opening outwards, through which the occupant of the room can be observed when nec- essary." TREATMENT OF INSANITY. 1/5 authors safe guides. Evils are said to grow out of the medical use of many remedies. The use and recognition of opium by medical science as a valuable remedy in certain cases to relieve pain, to secure sleep, etc., gives it an indorsement which does not, how- ever, warrant its indiscriminate use. Persons may use it, even medically, when it should not be resorted to, but even this is no argument against its proper use in the hands of the experienced for the relief of human suffering. So of any other remedies, such as the bromides, very common remedies liable to abuse. Their safe administration is looked for only at the hands of experienced and conscientious men. The question is, why should not this same principle govern the use or non-use of mechanical restraint in the treatment of the disease, insanity ? We are not advocates of restraint any more than we are advocates of cutting off limbs. Neither is to be resorted to, except as medical treatment. Commit7nent, Detention, and Discharge of Patients. — When abroad, in 1879, I gave special attention to the questions of commitment, detention, and discharge of patients ; also to the general management, internal and otherwise, of hospitals for the insane, privi- leges granted, occupation, treatment, etc. I had the honor and good fortune to meet some of the Commissioners in Lunacy, and among them the distinguished chairman, the Right Honorable the Earl of Shaftesbury ; also some of the most prominent present and Ex-Chancery Visitors in Lunacy, and many of the medical superintendents. From these gentlemen, as well as from^ personal observation, I was able to obtain knowledge of the law and practice obtaining, and of the government, general and internal, of hospitals for the insane. I was strongly impressed with the close resemblance of the law and practice to the State of New York in regard to the admission and discharge of patients, the guaran- tees, however, being greater in New York than in Great Britain, especially in respect of medical certificates and official magisterial interference. The New York law and prac- tice in respect of discharge are also much simpler in regard to both private and public patients. In the appendix of my report for 1878 I presented the resemblances and dif- ferences in these and other respects between the English I^unacy Statutes and those of New York. I beg to present here the opinions on the English and Scotch laws, in their practical application, on the most important matters which concern the insane, which were given before a Parliamentary Commission of 1877, under a resolution of Parliament ordering ' that a select committee be appointed to inquire into the operation of the lunacy law, so far as regards the security afforded by it against violations of personal liberty.' I might have summarized the matter and thus brought it into briefer space, but it seemed best, as far as possible, to give the exact language used. I have drawn from the testimony of men of large experience and great distinction in connection with the care of the insane and managment of hospitals, as well as from the testimony of officials exer- cising governmental supervision, and it is an interesting and significant fact that the opinions expressed before that commission by the distinguished medical men called before it, were fully indorsed by Lord Shaftesbury, a man of such vast experience and such illustrious name in the annals of philanthropy in connection with the care of the insane. The unanimous opinion of the law held by such men on all vital points covering the care of the insane, and indorsed by such an authority as Lord Shaftesbury, should be conclu- sive of its wisdom and practicability. The English law in regard to medical certificates is much simpler and much less guarded than that of the State of New York. Two medical certificates are required in cases of private patients, and but one in the case of paupers, and no medical certificates in the case of chancery patients. All the qualification required is that the medical men * shall be registered physicians or apothecaries.' They are not required to be approved 1/6 PSYCHOLOGICAL MEDICINE. by any judicial or other authority. In New York the law requires in all cases, pri- vate or public, two medical certificates, and these must be made under oath by med- ical men, authorized as examiners, and the certificates must be approved in writing by a judge. Mr. Perceval, Secretary of the Lunacy Commissioners, on his examination before the Parliamentary Committee of 1877, testified, in answer to the question, 'Is it necessary that the two medical men who sign the certificates should be qualified practitioners ? ' that up to 1S58 there were no qualifications specified; that patients could be sent by a physician, apothecary, or surgeon; that the medical act of 1858 provided for the registra- tion of all medical practitioners, and when the lunacy acts were last amended, in 1862, advantage was taken of that circumstance to get a proper definition of the words 'phy- sician, apothecary, or surgeon.' These words throughout the lunacy acts now mean medical practitioners registered under the Act of 1858, and no other person can sign a certificate. " Q. He may be a physician, surgeon, or apothecary ? " A. He may be a physician, surgeon, or apothecary. We do not care what he is, so long as he is a registered medical practitioner. He has such a qualification as entitles him to be on the register, and that is sufficient. " The English law provides that the medical man must have seen a patient within seven days before admission; copies of the certificates are sent to the Commissioners in Lu- nacy within twenty- four hours after the admission of the patient, and any defects may be remedied within fourteen days after being issued, and the certificates must always be in form. The New York law provides that the certificates must be in form as required by the Commissioners in Lunacy, and must be completed and approved by the court within five days. " Mr. Perceval testified in regard to private patients that two medical certificates and a request, or order, by some friend or acquaintance, are all that is required ; in regard to public patients an order of the magistrate accompanied by one certificate. To the ques- tion whether the certificates should not be countersigned by some public officer, he answered : ' I do not think there would be any additional protection to the patient at all ; but there are of course two sides to every question, and you would interpose an addi- tional difficulty, no doubt, if that is your object, upon that which is hard enough already.' " Q. I -wish to know whether you do not think there should be some public officer, or some public record of the incarceration of people against their will? " A. You have a public record, and I do not personally think that the intervention of a public officer would be of any material value at all to the liberty of the subject. It would certainly not be a material guaranty, and it would oppose an additional difficulty to the earlier treatment of insanity, which is so very important. " Q. Are there different forms of insanity, some of which may be aggravated by early treatment, and others cured ? " A. That is a medical question which I leave, if you will allow me, to the medical wit- nesses." " Mr. "Jaines Wilkes, one of the Commissioners of Lunacy, in answer to the question : ' Do you think the protections which the law at present provides against the detention of persons who are not lunatics are quite sufficient to protect the interests and person of the subject ? ' replied : ' I think they are ; I must say that if I myself were to be insane, or had any one belonging to me afflicted in that way, I should place perfect reliance in the present safeguards which the certificates and orders provide ? " Q. Do you regard the medical certificate as in itself a pei'sonal protection to liberty ? " A. Of course it would not be, apart from the order and statement, but it is a most TREATMENT OF INSANITY. 1 77 important thing in deciding on the insanity or not of a patient, and as to the propriety of placing that patient under care and treatment. " Q. Do you think the precautions which the law at present provides sufficient ? " A. Yes, sir. " Q. The certificate now is permanent, lasting until the patient is discharged ; do you think that is a good thing, or that the certificate ought to be for a limited time and renew- able? " A. I do not think there is any necessity for renewing it. Many of the patients in licensed houses are very poor; they are received and kept really at rates which are little above pauper rates, and any additional certificate would be a tax upon the friends, for I presume it would fall on the friends, and I really do not know what good it would do. " Q, I understood you to say that you think it desirable in all cases that they should be very early treated? " A. I think so. " Q. You make no exception ? " A. No, sir. There may be an exception as to the period ; it depends upon what is called early treatment. There might be some very slight insanity, a first attack, which gets well very rapidly, perhaps before any one would think of removing a patient to an asylum. " Q. You think there are no cases of a very excitable temperament, in which, being sent to those places, might increase the complaint and tendency to mania ? "A. No, sir; I do not think so. I think the removal from home associations and from the exciting causes of the disease, tends very rapidly to the recovery of the patient." Dr. y. Lockhart Robertson, one of the Lord Chancellor's visitors in lunacy, and previously a medical superintendent, was examined. To the question as to qualifications of the physician, he replied : " I do not think a special knowledge of lunacy is so im- portant as being a well-educated physician. " Q. Are you of the opinion that the present mode, by the certificate of two medical men, surgeons for instance, or apothecaries, is a sufficient safeguard to the liberty of the subject. " A. I think it is. I think the difficulty is to get the certificates. I think medical men are so afraid of actions that the great difficulty is to get the certificates signed. In an urgent case early treatment is, of course, of great importance to the patient. " Q. You are decidedly of the opinion that the safeguards against the improper ad- mission and detention of persons in asylums, hospitals, and licensed houses are practi- cally sufficient, and that a more complicated system of checks would do more harm than good ? " A. Yes, decidedly." Dr. Robertson expressed the opinion that it might be desirable to have some official order by a magistrate in cases of private patients. This would give protection to the friends as well as the physicians making the certificates. Dr. y. Crichton-Browne , Lord Chancellor's visitor in lunacy, and previously a med- ical superintendent, was examined. " Q. I will ask you the same question that I asked Dr. Robertson. Are you deci- dedly of the opinion that the safeguards against improper admission and detention of persons in asylums are practically sufficient, and that a more complicated system of checks would do more harm than good ? " A. I am. " Q. That is an opinion based on your experience in your official capacity, and also on your previous experience ? 12 178 PSYCHOLOGICAL MEDICINE. "A. It is. " Q. I do not know whether you concur with Dr. Robertson in the opinion that the additional order, or inquiry, before a magistrate might be desirable in the case of private patients, generally speaking. " A. Before a magistrate ? " Q. Yes; such a one as is now in use with regard to pauper patients? " A. I really do not believe that there would be any additional security in such a pro- vision; in signing the orders for pauper patients many magistrates regard it, if a certificate is in due form, as a ministerial act. They sign the order merely as a matter of course. Such an arrangement with reference to private patients might cause delay, as it does some- times in the case of paupers, when there is a difficulty in finding a magistrate. I think, also, it might increase the prejudice against asylum treatment. The public would look upon insanity as in some way connected with crime, if a patient had to be taken before a mag- istrate. " Q. Would you recommend that the certificates should be renewed from time to time ? "A. I have thought over that, and I do not think that would be any additional safe- gxiard. " Q. Might not some system of medical referees in such a case possibly be established instead of taking any chance medical man that comes first ? Might there not be some persons who would pass an examination in mental diseases to whom all these cases might be referred instead of taking the first chance medical man ? «' A. It might be so, but I think it would tend rather to diminish public confidence to have specialists signing certificates. The public would come to associate them with mad doctors, and my impression is that it is better to have general practitioners sign the cer- tificate. The public have more confidence in the decision of the ordinarj' family doctor." Dr^ Browne's testimony was that early treatment was of the greatest possible value. Dr. John Charles Bucknill, over eighteen years a medical superintendent, and Lord Chancellor's visitor in lunacy thirteen and one-half years, testified : " Q. With reference to the admission of private patients into asylums and their dis- charge, what do you think the principle of that ought to be ? "A. I think the principle should be to make the admission as easy as possible in order to provide for early treatment, and to make the discharge as easy as possible in order also to provide for early treatment, for if there is difficulty in getting a patient out of asylums there will be a disinclination to send them in. That is a point which has been very well worked out by the Scotch Commissioners in Lunacy, and they have proved it by statistics." Dr. Bucknill expressed the opinion that with the medical certificates in case of private patients the law should provide that the person who gave the order should bear some relation to the patients, sapng : " As to the person himself, the statute gives no indication as to who the person should be, and, in point of fact and practice, the most improper persons may sign the order. A gentleman's footman may sign for the gentleman's son ; a foreigner will sign for his lunatic friend and leave the countiy immediately; a solicitor's clerk will sign ; all manner of people will sign — people who cannot be held responsible. " Q. You think the order is considered more as a matter of form, and that the certifi- cate of the medical man is really relied upon ? "A. Xo ; the real power is possessed by the man who signs the order. The certificate and the order go together. With regard to the admission : the patient once admitted, the man who signs the order holds the staff to such an extent that the patient cannot be removed from the asylum unless the person who signed the order is incapable. If he becomes incapable by disease or by insanity, or if he is dead or has left the country, then the statute lays down the rule that certain other persons may order the discharge; but TREATMENT OF INSANITY. 1 79 otherwise, if he is not incapable, no one but the person who has signed the order can pro- cure the discharge of a patient once admitted into a licensed house or a hospital. " Q. What remedy would you propose for such a state of things as that ? " A. It is very difficult to meddle with the existing forms without increasing the difficulty of obtaining early treatment; I think that the rule which has been laid down with regard to the discharge of patients from asylums, namely, that if a man who signs the order is incapable, then the husband or wife could act, and if there be no husband or wife, then the father or mother, or the next of kin may very well be introduced in the order for admission; that if a patient has a husband or wife he or she should sign the order, or, in default, the father or mother, or next of kin, or a solicitor could for any of these or in case of a lunatic who has no relative to be found, I think a solicitor might be employed to act for any friend. " Q. You have travelled a good deal in America and examined the state of things there ; can you tell us what the American law is in regard to the admission and deten- tion of persons in asylums ? "A. It varies in every State. A good deal of change has taken place quite recently; the State of New York seems to have made the best change. There the certificates before the year before last could be signed by any two men calling themselves medical men. The new law requires that they shall be qualified medical men and that they shall also have a certificate from some judge of a court of record, to whom they are personally known as competent for their duties. An attempt is being made to create a class of medical men who understand something about insanity and are capable of giving certificates. " Q. Have you considered whether easy discharge from asylums would tend to the more frequent admissions to the asylums in the early stages of the disorder and to the early treatment of the disease ? " A. vSir James Coxe has clearly pointed out that not only the highest percentage of cases but the shortest duration of treatment in Scotland is found in the Renfrewshire asy- lums, which are parochial asylums, in which the inspectors of the poor can put a patient on the outbreak of insanity without any difficulty, and also remove him without any diffi- culty whatever. He points out that the authorities of asylums might, perhaps, unwillingly increase the indisposition to place patients in asylums by throwing impediments in the way of their easy removal from asylums. I take it that the succession of events which Sir James points out is this, — that you get easy discharge from these Renfrewshire paro- chial asylums ; therefore you get early treatment and a much larger percentage of cures effected in short time. " Q. You think that in all cases it is a great object to get early treatment ? " A. Yes ; I think that is the greatest point to aim at. " Q. Therefore, if the facility of obtaining the discharge would induce the people to send all patients in the early stages to the asylums, the percentage of cures would be greater and the cures would be more rapid ? "A. Yes; that is exactly what I mean." Sir yames Coxe, of the Board of Lunacy in Scotland, testified : " Q. In the report of the General Board of Commissioners of Lunacy for Scotland, for the year 1859, signed by yourself, there are one or two paragraphs which I should like to read to you : ' It cannot be too often repeated that, in the treatment of insanity, loss of time is unfavorable to recovery, or that every impediment that is thrown in the way of immediate treatment acts most prejudicially upon the patient by tending to render perma- nent the aberration from normal action which, under favorable circumstances, would speedily have subsided.' Is that your opinion ? " A. Yes, sir. l80 PSYCHOLOGICAL MEDICINE. " Q. ' We are therefore of opinion that asylums are capable of rendering to mankind far greater services than they have yet achieved ;' is that also your opinion now ? " A. Yes, sir. Sir James Coxe testified that the medical certificates were acted upon in Scotland by the sheriff.* ' In the case of the sheriff there is no reference to any inde- pendent medical man at present.' " Q. The sheriff himself determines for himself whether the grounds stated by the medical men are sufficient ? "A. Yes. " Q. He does not refer it to any independent medical man ? "A. No; he judges for himself. " Q. In your judgment, would it be an improvement that the certificates, before being acted upon, should be, if necessarj', canvassed, and further inquiry directed by some independent medical official ? " A. I think it would merely complicate matters. " Q. You think, in practice, it is a sufficient precaution, the sheriff examining the cer- tificates and the grounds stated in them ? " A. I think so." Dr. Ha7-7-ington Tukt, Fellow of the Royal College of Physicians of London, having had practice at Han\vell, under Dr. Conolly, and at present having charge of a private asylum at Chiswick, testified : " Q. Would you suggest that no certificates should be signed except by medical men who had special practice in lunacy ? "A. I would rather suggest that the knowledge of lunacy should be made more gen- eral than it is. " Q. You would not have a special class of medical men for lunacy cases ? " A. No ; I think not. " Q. We have had the opinion already expressed both ways, that there should be a special class of medical men, skilled in lunacy, who should sign one of these certificates, and also that it would be a mischievous thing to have any special class of that sort ? " A. I think there would be less confidence of the public in specialists in any particular class than any two physicians taken at hazard, but I think that the physicians should be better trained. " Q. Are you of opinion that it would be desirable, also, that the medical certificate should have a temporary effect, or that the certificate should be signed by medical men who had special knowledge of lunacy ? " A. No, I am not so ; the result of giving it to special medical men would lead to still greater distrust than there is at present, because, as far as I have seen, the ignorance of medical men leads them to refuse to sign medical certificates. " Q. Would you not think it desirable to limit the effect of the certificate ? " A. No, it would lead to so much mischief in so many cases that I doubt its efhcacy. It would do so much mischief to the patient by the necessity of a fresh examination, and then there are actually so few cases where there is any doubt, that it would be a great pity to make a general rule for them. " Q. Do you consider that if any obstacles were placed in the way of the committal of the insane to public or private asj^lums that would have a tendency to interfere with the cure and with that early treatment which, we have some evidence, is thought to be necessary for cure ? * Note. — The sheriff in Scotland approves certificates instead of the judges, as in the State of New York. His office is still that of a local judge, and not merely ministerial, as in England. TREATMENT OF INSANITY. l8l " A. Any delay in instant medical treatment is most disastrous. Dr. Conolly and my- self went over the statistics of three asylums with which we were connected. We found that seventy-seven per cent, that were treated under three months recovered; those that were treated later diminished in an absolutely geometrical ratio, until at last it sank to, after twelve months, something like twenty per cent, fully cured. I think any obstacle in the way of medical treatment, either in an asylum or otherwise, most injurious. Dr. Henry Maudsley, a physician, practicing in London, testified that, in his opinion, the law, " with regard to the admission of patients is sufficiently stringent and quite as stringent as can be properly consistent with the treatment of insanity in its early stages." He testified that if insanity was to be cured, the person must be put under treatment early, " because recoveries are entirely in proportion to the early stage at which treat- ment is adopted. If regulations are made more stringent than they are now (and, in- deed, the present regulation operates to some extent in that direction), the friends of patients will, instead of sending them from home, as is almost essential in the case of in- sanity — unlike, in this respect, other diseases — keep them at home under improper con- ditions, and so very much injure the chance of recovery." As to any alteration in the law touching the certificates he testified : " I have considered the matter. If it is considered desirable, as I have heard suggested, that the certificates should go before some public official before they were acted upon, it seems to me that no public official would be in a better qualified posttion, to judge of the value of the cer- tificates, than the commissioners, to whom exact copies are sent within twenty-four hours ; indeed, not really so much so. If he entered really into the matter in each case, it would be a very anxious responsibility and a formidable matter for him to undertake ; and, if he did not, would simply become a mere matter of routine, adding to the publicity, add- ing to the expense, and adding to the delay of getting a patient under care, and would make the early treatment more difficult than it is." Again, he testified that people " would shrink very much indeed, according to my ex- perience, from having a public officer come in to proclaim, say a young lady of eighteen, a lunatic, or a wife after childbirth who is insane, perhaps, for a month or two. To a professional man such a public thing might be almost ruin." " Q. Would there be greater publicity in that way than there would be from a certifi- cate given by a medical man in the neighborhood ? "A. Yes, it would be thought so; because, as a matter of fact, certificates are often given in this way : The medical man of the family, who is in regular atlendance, gives one of the certificates. He calls in a physician in consultation, who then sees the case separately afterward and gives the second certificate. There is no alarm of the patient. It is simply an ordinaiy matter of consultation as it appears to him." Dr. Duckworth Williatns, medical superintendent of Sussex County Asylum, Hay- ward's Heath, testified : " Q. Do you attach importance to the pauper lunatics being sent early to the asylum ? " A. Very great. " Q. From the lunatic wards of the workhouse ? " A. They should be sent at once, in my opinion, without going to the lunatic wards at all. " Q. You think that as soon as the ordinary forms are complied with the paitient should go at once to the asylum and not go to the workhouse first ? "A. Certainly. " Q. Do you say that because you think there is more chance of cure in such cases ? " A. Because there is more chance of cure, and also on the score of economy." Dr. Williams testified to the evil of the insane being taken to the workhouses without any 1 82 PSYCHOLOGICAL MEDICINE. certificate, which was the common custom, and in condemning this, he spoke the opin- ion of all the authorities. The Right Honorable the Earl of Shaftesbury, attended before the committee by per- mission of the House of Lords, and was examined. He testified that he had been a member of the lunacy commission " now close upon fifty years. I was associated with Lord Gordon on the first committee of inquiry in 1828, then in 1829 in bringing in the first bill received ; since that time for twenty years I was in the habit of visiting con- tinually." He was permanent chairman from 1845. He testified to the law generally, and to changes from time to time in the statutes. " Q. Do you consider that the facility with which patients are admitted into asylums is not too great at the present time ? " A. No, certainly not. I think that the whole of our experience confirms us in the opinion that it is not. We stated so in 1859 and we state it still more emphatically now. I cannot recollect a single instance in which a patient has been brought into any asylum in whose case there were not sufficient grounds for saying that he was a proper subject for cure and treatment ; I can hardly recollect a single instance. I see, by referring to the evidence which has already been given before your honorable committee, that such is the testimony of every man of experience who has been consulted on the matter. It was likewise the opinion of the committee that sat in 1859, for they reported in that sense. " Q. At the same time there is a feeling which has been expressed, not only generally, but by witnesses before the committee, that a large number of persons are admitted to the asylums in a state of sanity and kept there ? "A. I have no doubt those statements would be made, because I never knew the case of a patient, either under confinement or after confinement, who did not say that he had been most unjustly confined. I hardly know an instance. I do not know that any in- stances have been adduced to prove the truth of that allegation. " Q. At any rate, it is your Lordship's opinion that the admission of patients into an asylum is now sufficiently guarded ? " A. I think so. " Q. Would you say the same with regard to their detention there? Is it not the case that they are sometimes kept there longer than is necessary ? "A. I do not think they are so now; it was rather my opinion in 1859 that, under some circumstances, they may have been detained beyond the time that it was absolutely necessary, but then I think that a great deal was to be said in extenuation of that. It is a great responsibility to send out a patient upon the world, both with respect to the pa- tient himself and in respect to society, before you are satisfied that he is cured or, at any rate, in such a state that he can be safely trusted. Since 1859, I should very much modify the opinion I then gave. " Q. Does your Lordship consider that many of the stories that we hear, from time to time, of conspiracies and of ill-treatment are themselves delusions in the minds of people who are intending to say what is accurate ? " A. I think so ; and it is a very remarkable thing that in many instances one of the first indications that a man gives, or a woman gives, of a state of aberration, is the belief of a conspiracy. I have never heard of a conspiracy being formed for a purpose of that description." In regard to chronic cases and others being taken first to the workhouse, his Lordship testified: "I think it highly necessary that in every instance the patient should go to the asylum first, and pass from the asylum to the workhouse, and not from the workhouse to the asy- lum, %^'hich is very often the case. He gets into the workhouse and there is detained, TREATMENT OF INSANITY. " 1 83 when if he went to the asylum it would be adjudged at once whether he was a fit case for the asylum ; and if not, he would be sent back to the workhouse. In that way a great number of the recent cases are kept back to a very late period, when they might have been treated and sent back to the world perfectly well. " Q. The practice is exactly the reverse of what it ought to be ? «'A. Yes." He testified concerning suicidal and homicidal cases to show the absolute necessity of taking those cases in due time. After dealing with the statistics of suicide at large, he stated that there were then in confinement in the various asylums, six thousand and ninety-six suicidal patients. Refer- ring to the criminal asylum at Broadmoor, he s^iid that, leaving out all that were there for minor causes, " there were one hundred and forty-five men charged with murder. In seventy-five cases the insanity was not recognized before the commission of the crime. In twenty-nine, insanity was recognized, but the persons were reputed harmless. In thirty-three, the insanity was recognized in the persons, not probably recognized as being altogether harmless, but insufiicient precautions were taken. In eight, exact circum- stances were not known." Of ninety-eight " charged with attempts at murder, maiming, or stabbing, in forty-two the disease was not recognized before the commission of the crime; in twenty-nine they were reputed harmless ; of twelve insufficient care was taken ; and in fifteen the exact circumstances were not known. When you come to the women, there are seventy-one women charged with murder; in twenty-eight the insanity was not recognized before the commission of the crime ; in thirteen the insanity was recognized, but the persons were reputed harmless ; in twenty-three the insanity was recognized and the persons were not regarded as altogether harmless, but insufficient precautions were taken. Then you come to the stabbing; in four the insanity was not recognized; in six they were reputed harmless; in two sufficient precaution was not taken." He adds: "This is a very important matter, because it shows the very large number of cases in which, through inattention, the insanity is not detected till an overt act has been committed. That is the evil way in which a large proportion of the public judge of sanity or insanity. They will never hold a person to be insane until some overt act has been committed, and that is always, invariably, the case before juries. Then an overt act having been committed furnishes a proof that the disorder is very far advanced, almost to be inveterate, and consequently incurable. What I state shows the absolute necessity of great precautions, the absolute necessity of paying attention to the earliest stage of the disorder, and though I could by no means render admission into the asylums more easy than it is, I most un- doubtedly would not render it more difficult, because I am certain society is in very great danger. We always have felt, as commissioners, that we have a double duty. We have a duty to the patient and a duty to society. We have a duty to the patient to see that he is not needlessly and improperly shut up ; but we have also a duty to society to see that persons who ought to be under care and treatment should be under care and treatment, and, moreover, that they should not be set at large before they can be consid- ered safe to mix in society. " Q. Do not these facts, which are very remarkable, point rather to a want of knowl- edge of lunacy among medical men ? " A. No ; I think not. I am not going to say that there is sufficient knowledge of lunacy among medical men, but such cases as this have never been brought under their observation; they have been suffered to roam about; nobody has taken any trouble about them ; in the case of many of them the family did not suspect the madness ; they might have thought the man was queer, and they never thought of consulting a doctor 184 PSYCHOLOGICAL MEDICINE. on the matter. I have no doubt a great number of medical men, if they had seen such a case at an early period, would have come to the right conclusion about it. As I was saying, the large mass of society, even educated persons, are wholly unable to form an opinion unless they see something that is very decided ; that they consider an aben-ation ; something very peculiar ; something out of the common way ; another is this, — it very often happens a great change of character is very often the indication of coming insanity, and then many people say, and very naturally, ' What is the matter with this person ? he is getting very cross ; he is quite a changed man ; he is not half as good-humored as he used to be ; he has become crabbed and ill-tempered ;' they do not see that this very often is an indication of his approaching insanity ; they put it down to a sudden change of temper. " Q. Has your lordship any suggestions to make upon that point ? " A. No ; I have no suggestions to make, because I am very unwilling to say anything that should restrict in any way, more than is now restricted, the person or liberty of the subject; I only wish to call greater attention to these things, that people may have their eyes open, and then they may put their heads together and see if they can devise some- thing by which a remedy may be applied, but I have no particular suggestion of my own to make ; I only give it as a very striking fact, and one that should put us on our guard very much against juries, because they never deal with the matter unless there is an overt act, which overt act, ninety-nine cases out of one hundred, is a proof that the disorder is incurable." In regard to medical certificates his lordship testified : " It is very remarkable, taking it altogether, that the certificates have been so sound, considering the great number that have been given every year. Of course, we must admit that they have been signed by medical men who have no very extensive knowledge of lunacy, but it is certainly very remarkable that the number of certificates which have passed through our hands since 1859 — the date of the last committee — amounts to more than 185,000, and yet of all those certificates I do not think so many as half a dozen have been found defective. It sounds very well to say that persons acquainted with lunacy should be the only persons to sign certificates, but the fact is, as matters now stand, that a great amount of scientific knowledge as to lunacy is not possessed by many people ; there are a certain number who are well-informed, but the great mass of the community know very little about it, and with the large number of the insane — dispersed, as they are, all over the country — you must trust to the medical men of the several districts. I have a very strong opinion on this point. The certificates hitherto have been very cor- rect, and I am quite certain that, out of the 185,000, there was not one who was not shut up upon good, fair, prima facie e'v'idence that he ought to be under care and treatment; such is the testimony of all the physicians of note who have been sum- moned before this committee; for what does that arise from — it does not arise from the great knowledge of the medical men of the lunacy that they handle, but it arises in a great measure from the habit of keeping back the patients so long, because the parents and friends do not like to admit to themselves that the patient is affected, and so delay to call in a medical man. And then begins, when the medical man is at last called in, the fear and apprehension that the patient may be sent to a lunatic asylum and the whole affair become public; so that when the final examination is made by the medical man, who has to sign the certificate to send them to an asylum, the symptoms are so evident and so pronounced that few people can mistake them. I have very little doubt that such is the case and such is the reason why we have so few faulty certificates. But, on the other hand, what follows from that course ? Why, that the cases are very far advanced, and have got pretty nearly in the category of the incurable. TREATMENT OF INSANITY. 1 85 " Q. And this is not very satisfactory ? " A. Very far from it." His lordship testified against special doctors making certificates : "I think something has been said about having what they call a system of special doctors. I confess to you that I have a very great fear of a special doctor. But, assum- ing them to be good, in the first place they must be very numerously spread over Eng- land and Wales, because they are wanted at the instant, and were there not an ample supply of them you have to send a great distance to reach these special doctors. I should like to see how Parliament would define a special doctor before I can give an opinion. I confess I should be very much alarmed if there were persons who kept them- selves exclusively to that study without a constant experience of both, of all the various circumstances that beset lunacy at large and under confinement, moral as well as physi- cal, that attend it; all the social circumstances, the ten thousand other circumstances. .... I remember the case very well of a medical man, a doctor, an excellent man, who thought that I had some influence in obtaining the appointment of medical men to the commission. I knew him very well. He came to me and told me what he wished. To show his extraordinary knowledge of the subject he gave me a sheet of paper as big as that, with a list of the forms of insanity. 'My dear sir,' said I, 'this will never do. If you reduce your principles to practice you will shut up nine-tenths of the people in England ;' and so they would. If you have special doctors they would shut up people by the score. " Q. There was another proposal, which was to require a certain knowledge of lunacy on the part of the medical officers of health, and who are scattered over the country, and to employ them as checks upon the asylums and as a kind of deputy visitors, to supple- ment the visits of the commission ? " A. To that I should very much object. I wish to speak with the greatest respect of them, but I think medical officers of health, to a great extent, are young men and unin- structed men who have taken the office merely because they think it gives them a posi- tion and qualifies them to get on in their profession. They are not likely to have any great knowledge of lunacy. Then, again, being local people, they would be in friend- ship or in antipathy with the superintendents of asylums. Consider another point : we must do everything we can to keep the best medical men in the service and to get them to sign the certificates. I am sorry to say that now the very best medical men refuse to have anything whatever to do with the certificates, they are so afraid of the responsibility and of being ' hauled over the coals,' as the phrase is, that they will not do it. " Q. Another proposal was to take a person whose mind was affected to a hospital where he would be treated as he would be in any other hospital, and that afterward, provided he became fully insane, he should go to an asylum, but that otherwise he might be restored to society without having any taint of insanity upon him ? " A. I think it would eventually come to the same thing. These probationary asy- lums would be considered lunatic asylums, and it would be said of the people taken there : ' Oh, you know he escaped going to the asylum, that is true, but he was in a probationary asylum. He was so queer and so odd that they were obliged to send him there.' The taint of lunacy, which I see this committee is so justly afraid of, would be as much fastened on him as if he had gone direct. " Q. In process of time the hospital would get the character of a lunatic asylum. " A. Yes, they would be called semi-lunatic asylums and all that sort of thing. They would come under the same category at last." In regard to certificates his Lordship further testified : 1 86 PSYCHOLOGICAL MEDICINE. " Q. Should you not think it an additional security to the freedom of the subject if one of the signers of the certificates was a person in some official capacity ? Now, as your Lordship is aware, there are two medical men — they may be surgeons, apothecaries, or physicians — who sign the certificates. Do not you think it would be an improvement if one of the signers of the certificates was in some public capacity ? " A. No, sir. In the first place I should be sorry not to have two medical certificates for the confinement of any patient in a licensed house. I do not know where we could find a public man who was also a medical man. " Q. By a public capacitj' I meant an officer connected with the union, or somebody responsible to the public. " A. I think it was the right honorable chairman who put the question to me the other day on that subject. I said I strongly objected to an officer of the union. He was not a man of sufficient standing. Oftentimes he has merely taken his place because it gives him a status. He is not a man of sufficient standing. Some of the medical men who sign the certificates are of verj' high standing and degree, and you could not allow them to be overruled by an inferior officer. " Q. Do you not think that it would be an improvement if the certificates did not par- take of the final character they now assume ; that they should be of a more temporary character than they are now ? " A. I do not think so. " Q. We \^-ere told that in Scotland the patients cannot be sent to the lunatic wards of workhouses without a certificate. Does your Lordship consider this a good plan ? " A. An excellent plan ; it is not the same with us. "Q. In England, of course, a lunatic may be sent to the lunatic ward of a workhouse without any certificate at all ? " A. Yes; the relieving officer may send him in, or any one may send him in. " Q. He only wants a certificate signed when he goes into an asylum from the lunatic ward ? "A. Quite so. " Q. You think the Scotch plan of requiring the certificate upon the lunatic going in the lunatic ward of the workhouse is preferable ? " A. Very much preferable. " Q. We have had evidence from the Scotch Commissioners in Lunacy, in which com- parisons very favorable to the Scotch system have been drawn, with regard to the interven- tion of the sheriff. Your Lordship has, I think, already expressed an opinion with regard to the inter\'ention of a public authority. Would you consider that the prospects of cure derived from placing a patient under early treatment would be considerably interfered with if the law were altered so as to necessitate the intervention of the magistrate in this country ? " A. Most undoubtedly ; the great fear in England of so many people is publicity, and anything that tends to bring the patient before the public and to make the case of a pa- tient notorious, would induce people to keep that patient so long as they could before they submitted him to the treatment of an asylum or of a single house. It would inter- fere very materially with it.* " Q. On the whole, your opinion is most decided that the intervention of the magistrate * In the present movement toward lunacy reform in our own country, all sides of the question should be attentively weighed and considered, and especially the above point of the possibility of doing the patient himself great harm by measures intended for his wel- fare bv reformers. TREATMENT OF INSANITY. ' 1 8/ would be injurious to the person, as regards his recovery, and no protection to him as regards his liberty ? " A. None whatever. I think it would take away nine-tenths of the protection he now has. I cannot conceive anything which to my mind would be worse. I will do any- thing that I can in the world to protect the patient, but I know if I were to assent to what is proposed I would assent to that which would be irreparable injury. " Q. I think your Lordship is under some misapprehension as to the part that the sheriff acts in the matter: he has the option of acting according to his own discretion, either ministerially or judicially. He may judge, and usually does, of the fitness of the evidence upon which the medical men grant the certificate, or he may not do so. He may judge, and usually does, of the fitness of the persons to give evidence under the circumstances; for instance, relationship, or anything of that kind, might be regarded as a disqualifying characteristic in a person signing a certificate ? " A. That is what we should object to ; we should object to any inexperienced layman taking upon himself to reverse the decision of the medical man. " Q. He would not, in that case, reverse their decision. He would merely remit it to other medical men, who, in his opinion, were competent to grant the certificate. " A. It is all very right that it should be so, but then see what it ends in. It ends, after all, in the opinion of a medical man, for it is only one set of medical men against another set." Hospital Ward for Sick Men. — In my report for 1854 I stated: "Our arrangements for taking care of the sick, though probably as good as those of any other similar insti- tution, must be regarded as very imperfect. All sick patients should be immediately removed from the wards to a hospital department properly arranged, where every atten- tion demanded by their condition could be bestowed ; where the physician could visit them frequently during the day and in the night, if necessary, without disturbing others ; where those very ill could be visited, and, if advisable, nursed by their friends, and the dying be administered to without exciting the fears of others." I have in several reports since recommended the erection of a hospital for the sick. In the second annual report of the State Board of Charities, in referring to the asylum, they say : " There should be erected two small wards, one for each sex, for the treatment of the sick and feeble, that their friends may be able to visit them and remain near them without disturbing a large number in a general ward. This improvement is demanded, not only by humanity, but decency, especially in the case of female patients, who are frequently admitted to the asylum in a condition which justifies and demands seclusion and the most tender care." In my report for 1872 this matter was again urged upon the legislature and the atten- tion of the governor and comptroller was called to this point when they visited the insti- tution, and they approved the application. Finally, in 1875, an appropriation was made for a special hospital building for sick women. These arrangements have proved most satisfactory. There should be hospital wards for sick men also. This is a great defect which should be remedied. The facts and reasons heretofore given in support of the measure have increased weight, with the enlargement of the institution. I sincerely hope the legislature will make the necessary appropriation. A small two-story build- ing, placed a little back of the front wing and connected by a corridor, for this purpose, would not cost over $15,000, and would make provision for fifteen patients and the necessary attendants, bath-rooms, etc. Atmisetiients. — Amusements are conceded to be a very necessary feature in connection with the modern hospital for the insane, and undoubtedly a very important means of comfort, enjoyment, and recovery. Few of the institutions in America are adequately 1 88 PSYCHOLOGICAL MEDICINE. equipped in tliis respect. Amusements are universally considered an important auxiliary in the treatment of insanity. In the early history of the institution theatrical and other entertainmehts -were held upon the wards by the erection of a temporary' stage, taken down from time to time. These, however, were limited quarters, and there was but room for a veiy small proportion of the patients to attend. Later a small theatre room was arranged in the attic of the central building, which, though a very great improvement on the former accommodations, has two very serious drawbacks. First, the limited capacity of the room, it not being large enough to accom- modate more than one-third of the patients at a time ; second, its loeation in the attic of a building four stories high. The amusement halls of American institutions are in sad contrast with those in Great Britain. Dr. Bucknill, in his visit to this country in 1875, was present at one of our entertainments, and very justly says in his remarks upon this insti- tution : " I assisted, by my presence, at some capital amateur theatricals in which the amateurs were patients and attendants, and the audience of lunatics were neither dull nor disorderly. The recreation room, however, is not worthy of the asylum, and the governors would do well to provide a better one." In connection with this institution and the class of patients we receive, a recreation hall should be built large enough to ac- commodate the whole household, and should be built upon the ground floor, that all the old or feeble persons and all patients who could reasonably control themselves could be present at entertainments. Such a building could be erected without great cost in the rear court-yard which persons could reach from all parts of the building, and where there would be no uneasiness or anxiety in regard to escape in case of any accident. A plain structure in accordance with the surrounding rear buildings could be put up at an expense of not to exceed $10,000. Statistics of Bloojningdale, N. Y., Asyliwi. — The annual report of the Bloomingdale Asylum for the Insane, New York city, for which we are indebted to Dr. Charles H. Nichols, the medical superinten- dent, shows that during the year 1882 there were treated in this in- stitution 330 patients, — 157 men and 173 women. The number of patients under treatment on the ist of January, 1882, was 224; ad- mitted during the year, 106. The discharges were : recovered, 39; improved, 34; unimproved, ii ; died, 23 ; remaining at end of year, 223 patients. Ninety-two of the admissions, or 87 per cent, of the whole number admitted, were first attacks. Respecting restraint. Dr. Nichols says : " I am in full accord with what may be properly called the American doctrine and practice in the use of mechanical restraint and seclusion in the treatment of the insane, which is, as I understand it, that neither mode of treatment shall ever be resorted to, unless, in the opinion of a competent and responsible medical officer, protection, in particular cases, against violence, exhaustive activity, the removal of surgical dressings, etc., etc., can be effected more easily, completely, and beneficially to the patient than the nec- essary end can be attained by either the hands of attendants, medici- nal agents, shower and douches, which I consider inadmissible, ex- TREATMENT OF INSANITY. " 1 89 cept in a very limited number of cases, or ' pack,' wet or dry, which are obviously a very positive form of mechanical restraint, although their therapeutical advantages may now and then be superior to any substitute for them, and that it is the duty of the practitioner to re- sort to mechanical restraint or seclusion whenever he clearly sees that it is needed, upon the grounds stated. Of course, the actual practice in the use of restraint varies more or less in different institu- tions like this, as I believe it does, actually and necessarily, in every other enlightened country, and is governed, as are other measures of treatment, by the training and character of the medical officers in charge, the opinion and support of trustees, the number and charac- ter of patients with respect to the extent and quality of their accom- modations, proportion of attendants to patients, scale of expenditure, and other agencies of treatment. The restraint heeded in the same institution will vary greatly, according to the varying condition of patients. While I still conscientiously entertain the views just ex- pressed, in common with the great majority of my American breth- ren, and am entirely unwilling to be governed by a prohibitory dogma or an arbitrary proportion to patients in the use of restraints, I am of the opinion that the circumstances that justify its average use in more than 2 or 3 per cent, of the cases under treatment must be quite exceptional." The Twenty-third Annual Report of the State Asylum for Insane Criminals, at Auburn, N. Y., for which we are indebted to the cour- tesy of Dr. C. F. MacDonald, the superintendent, shows by its statis- tics that, from the opening of this asylum in February, 1859, ^P ^^ October l, 1882, the total number admitted was 629 ; the total num- ber discharged, 488 ; the total number discharged recovered, 166; the total number discharged improved, Gy ; the total number dis- charged unimproved, 116; the total number discharged not insane, 57. Speaking of the criminal insane. Dr. MacDonald says: T/ie Criminal Insane. — A great deal has been said in recent times respecting the psy- chology of crime and its relations to mental disease. Theories have been advanced by various writers to show that tendencies to crime and criminal propensities are frequently inherited conditions. Extremists on the one hand have told us that all criminals are vic- tims of mental disease, or infirmity, and consequently not responsible for their acts ; while on the other hand, certain writers have proposed that lunatics should be held accountable for acts of violence, and some have even gone so far as to suggest that dangerous insane men should be disposed of in the same manner as are hydrophobic dogs. From a somewhat extensive observation of several years, respectively, of the criminal and non-criminal insane, I am led to believe that the element of crime, when interwoven with insanity, exerts a modifying influence upon the mental manifestations of that dis- 190 PSYCHOLOGICAL MEDICINE. ease, and that to this extent, in a large proportion of cases, the criminal insane, medically speaking, may be regarded as a distinct and separate class, the analogue of which is not found among the ordinary insane. They present certain characteristic mental peculi- arities which experience in observing this class enables one to recognize as the indelible stamp of crime, and although the line of demarcation may not always be apparent to the casual observer, its existence, as a rule, can be discovered and demonstrated, if time and facilities for careful observation be had. In my experience with the criminal insane, now nearly five years, I have been struck with the frequency of cases in which there was an absence of expressed delusions, al- though the manner and conduct of the individual was clearly indicative of a delusional state. Comparing these individuals with their former selves, we find undoubted evi- dences of a departure from their normal mental state. They have become sullen, mo- rose, and morbidly irritable. They rebel against the ordinary rules of discipline, and make unprovoked assaults upon those around them, without apparent motive and without offering any explanation therefor. That they are suffering from impairment of bodily functions is shown by sleeplessness, loss of appetite, coated tongue, foul breath, consti- pation, a "greasy" condition of the skin, and a livid, puffy appearance of the extremi- ties, indicating a relaxed state of the bloodvessels. They are generally coherent in con- versation, do not complain of being ill, nor apply for medical treatment. They frequently continue in the performance of their allotted tasks in prison for months before the atten- tion of those in daily contact with them is attracted to their mental disturbance. From this condition they either recover or gradually drift downward to complete dementia, with no outward exhibition of delirium or mental excitement, to max'k the course of their disease. The occurrence of acute, delirious mania, according to my observation, is ex- ceptional among the criminal insane, melancholia, and dementia, with an occasional case of subacute mania, being the predominant types of insanity observed here. A certain proportion of cases" and usually those of hardened criminals, are characterized, in their mental manifestations, by the most pronounced vicious tendencies, their insanity appar- ently expressing itself in a marked exaggeration of the depravity and vice displayed by them prior to the onset of their disease. On the mental side, this is substantially the only evidence of disease which these cases present. Physically, however, their condition is marked more or less by the signs of bodily impairment above referred to. Being known to the authorities as abandoned and depraved individuals, it is not surprising that their insanity is not recognized by casual observers, when it expresses itself in the man- ner I have indicated. We may readily admit such cases into the category of mental disease, without in any way countenancing the dogma that insanity and crime are convertible terms. The con- duct of such cases, when first admitted to the asylum, is characterized by the most strik- ing evidences of depravity. They are profane and obscene in language ; tear and destroy clothing, bedding, and furniture ; strike, steal, lie, and soil themselves and their surround- ings, apparently from mere wantonness. They sleep badly, and display the resistance to the effects of sleep-producing remedies common to lunatics. They are, generally, alike indifferent to coercive measures and to comfort, and it is only by constant and persistent en- deavor, firmly but kindly applied by those in immediate charge of them, that they can be trained into decent habits and deportment. From the foregoing it might naturally be infer- red that the successful management of the criminal insane would involve greater difficulties than are encountered in the care of the ordinary insane. And such was my belief in the early period of my experience with this class, but further observation and experience have served to convince me that, with facilities specially adapted to its needs, an asylum for the criminal insane can be conducted on the same general principles, and with as 1 TREATMENT OF INSANITY. ' I9I good results, except in the matter of cures, as are hospitals for the ordinary insane. Visitors passing through the wards of this asylum are struck by the marked absence of noise or disturbance of any kind, this being the usual condition night and day. They not unfrequently ask to be shown " the violent cases," and " those you have to keep tied up in their cells," or in "strait-jackets;" and when informed that no mechanical re- straint of any kind is used here; that we have no cells; that there is no "disturbed" ward, and that the patients they have seen are the worst cases we have, they are apt to look incredulous and doubting, apparently being unable to realize that criminal lunatics are controlled by kindly influences, and that order and quietude prevail among what they had supposed to be the most violent class of insane. The principal difficulties encoun- tered in the management of this institution are, the prevention of escapes, and a pro- pensity of certain hiomicidal patients to obtain and conceal articles for the purpose of using them as weapons of assault. To prevent these occurrences involves the exercise of constant care and vigilance. Cases of simulated insanity are obviously of much more frequent occurrence here than in general asylums. They, of course, are troublesome while they remain with us, but detection is not difficult, and is immediately followed by a return to prison. If it were the rule, and generally so understood in the prisons, that a convict detected in an attempt to feign insanity, would forfeit the commutation of sen- tence allowed him for good conduct, it would, I believe, render such attempts of rare occurrence. Insane criminals, particularly of the convict class, in their efforts to escape, frequently display a wonderful combination of shrewdness, cunning, and ingenuity. Patients of both classes, who have committed crimes against the person, are more dangerous, but less inclined to escape than are those who have committed crimes against property. Owing to the low walls inclosing the grounds about the institution and the absence of guards upon them, together with the other difficulties referred to, it is obvious that the privileges allowed patients here have to be more restricted than would be necessary in other institutions for the insane. In connection with this subject, and illustrating, in a general way, some of the princi- ples I have endeavored to carry out here, the following extract from the third annual report of the State Board of Health, Lunacy, and Charity of Massachusetts, respecting a recent visit of observation made to the asylum by a committee of that board, may be of interest : " The only criminal asylum similar to those in Great Britain which has been in opera- tion for any considerable time in the United States, is that maintained by the State of New York in connection with the State prison at Auburn.* The Auburn Asylum was visited during the summer by the Inspector of Charities, and again, on the 9th of Novem- ber, 1881, at the special request of the board, by Dr. Hitchcock, Dr. Walter Channing (who had been for more than two years a medical officer of this asylum at a former period), and by the Inspector of Charities. From the notes made at these visits, and from the published reports of this asylum, the following statements of fact and opinion are drawn : " The State Asylum for Insane Criminals was opened in connection with the Auburn State Prison* on the 2d of February, 1859, and has had an average number of patients, during the twenty-two years following, of something less than loo, although of late years (since 1874) the number of patients has averaged more than 100, and, in 1880, rose to * This is an error. The asylum bears the same relation to Auburn prison that it does to the other prisons of the State. It has a separate organization and is separated from the prison by a high wall. — C. F. M. 192 PSYCHOLOGICAL MEDICINE. 142. At the last visit of the Inspector of Charities it contained 135 p^ients, 10 of whom were women, the average number having fallen a little during 1881. The whole num- ber of patients admitted since February 2d, 1859, does not much exceed 600, and of those less than 40 have been women. Upon inquiring of Dr. MacDonald, the present super- intendent, why the State of New York, with a population of more than 5,000,000, should have so small a population in its only criminal asylum, he stated that the period of deten- tion for his patients was too short, and that there were, in the State of New York, several hundred of the criminal insane, practically of the same class as those at present under his charge, who, in his opinion, ought to be in such an asylum, provided it were large enough to contain them. He even thought the number of such patients, if the laws were so modified as to allow their detention in his asylum, might, in a few years, reach 500. But among those, he supposed that the proportion of women might be no greater than it had been among the actual patients of the asylum ; that is, less than one m fifteen. " Previous to the first appointment of Dr. MacDonald as Superintendent, in April, 1876, the management of the asylum seems to have been complicated with the manage- ment of the prison — both being guided too much by political consideration. Dr. Mac- Donald's appointment was non-political, and under his administration much has been done to improve the treatment of the patients and the character of the attendants who take charge of them. At the present time the patients in the Auburn Asylum, although to a large extent belonging to the woi'st class, both of criminals and of the insane, appear to be treated with as little harshness and with as much success in regard to recovery, rate of mortality, etc., as is found in the ordinary insane asylum, where chronic patients largely predominate. " ' We found one or two patients secluded and one undergoing mechanical restraint,' is the statement made by the gentlemen who visited the asylum on the 9th of November. A considerable number of the patients labor regularly outside of the wards, and a sepa- rate ward has lately been constructed for the residence of these daily workers. The average cost of each patient in the asylum, which has ranged, during twenty-two years, between $150 a year and ^600, now stands at about ^200, or a little less than $4. a week, yet the food, clothing, and general care of the patients seem to be as good as in the ordi- nary asylum. " The three gentlemen who visited the Auburn Asylum in November say : " ' As the general discipline and surroundings of the patients there have improved, the amount of restraint has decreased. In former years harsh treatment, amounting even to the severity of prison discipline, was practiced, and restraint by handcuffs and other means rose to ten per cent. The average has steadily fallen, year by year, since Dr. MacDonald took charge, in 1876, and one may almost predict that its entire discontinu- ance will soon be the rule.* For sixteen months, we were informed, there had been no escapes, in spite of the remarkable propensity of insane criminals to make attempts. Vigilance is partly the explanation of this long period of immunity, but it is also, and perhaps chiefly, due to the feeling of confidence and goodwill engendered in the pa- tients by the spirit of kindness and trust pervading the asylum. Under the former prison plan of treatment every evil impulse was kept alive, and such patients as were able exhausted the whole strength of their minds in planning escapes. " • We observed a considerable number of patients out at work, most of them assisting the gardener. Two or three were laying a pavement, one was carpentering, one was assisting the baker, and several others were at work in the laundry, in the engine-house, and kitchen. These men were steady and regular workers, as a rule, * No form of mechanical restraint has been used since March, 1882. — C. F. M. TREATMENT OF INSANITY, 1 93 and perhaps even better workers than the average of insane men. In the sewing-room ■we found a discharged criminally insane woman employed as seamstress, and we were told that a criminally insane man had, after recovery, been employed as steward, and had done the M'ork remarkably well. It may be said here that the number of persons taken out to work is necessarily somewhat limited, the garden being so small. "With a farm, a large number of patients could be employed to do common work. " ' It might, at first sight, be supposed that the number of feigners would be large in the Auburn Asylum, since its comfort would be favorably commented on among the con- victs and lead some to simulate insanity for the purpose of becoming patients. Such is not now the case, since the asylum's reputation for pleasant surroundings is coupled with a reputation for the quick perception and prompt return of the dissemblers to prison. In this connection it may be said that the prison authorities have, in titnes past, taken advan- tage of the nearness of the asylum to transfer feigners, who would not have been so trans- ferred had the asylum been more remote. This fact appears to offset the apparent advan- tage which would be found in early transferring from the prison to an asylum close by those convicts really insane whose insanity for some time may escape notice in a prison.' " Dr. Walter Channing, in a recent article on " Buildings for Insane Criminals,"* says : " How much may be accomplished by proper treatment may be seen at Auburn, where the worst class of the insane give but comparatively little trouble and are Subjected to a minimum of mechanical restraint, and yet are as comfortable and contented as patients in an ordinary hospital for the insane. We find the patients well fed and clothed, and receiving the most thorough medical care; but combined with this treatment there is exercised an amount of disciplinary care, without being obtrusive, which would be im- possible in an ordinary hospital. As illustrations of this I may mention the following examples: wearing a uniform dress, which, however, is not a uniform ;-j- retiring at 7 P.M., summer and winter; using no tobacco; carrying no knives, and, as a rule, using none at table ; being thoroughly searched when entering the wards from out of doors ; using no furniture in the room besides a bed, etc. These and other simple regula- tions the patients readily yield to, and are thereby happier themselves, as well as more manageable. It is but proper to state, in this connection, that the wards of the Auburn Asylum are to-day as bright, and cheerful, and attractive as any I have seen in twenty hospitals, and the diet better than is furnished in some State hospitals." Dr. Kirkbride' s Pennsylvania Hospital for the Insane. — The Report of the Pennsylvania Hospital for the Insane, under the able manage- ment of Dr. Thomas S. Kirkbride, to whom we are indebted for the report, shows that it began in 1841, with 97 patients, received from the old hospital, which was established in 1752, and that since its opening in 1841 up to 1882, 8480 patients had been received. Of these, 3825 have been restored to their friends cured, 2044 have been discharged in various states of improvement, 1098 left without ma- terial improvement, and 1 115 died. The last report, for 1882, shows that at the end of 188 1 there were * Read at the .Conference of Charities in Chicago, June nth, 1879. I Navy blue sack coat, gray casbimere pants and vest. — C. F. M. 13 194 PSYCHOLOGICAL MEDICINE. 398 patients in the institution. During 1882, 193 patients were ad- mitted, and 183 were discharged or had died, leaving 408 under care at the end of the year. Total number of patients in the hospital during the year was 591. The highest number at any time was 431 ; the lowest was 385, and the average number 408. There were dis- charged cured during 1882, 66 patients; much improved, 22; im- proved, 43 ; stationary, 29 ; died, 23. Of the patients discharged " cured," 22 were residents of the hospital not exceeding three months ; 24 between three and six months; 13 between six months and one year, and 7 for more than one year. Of the "improved," 16 were under care less than three months; 9 between three and six months; 9 between six months and one year, and 9 for more than one year. The statistical tables of this institution are peculiarly valuable, as relating to over eight thousand patients, and I therefore give them for their intrinsic value and for the conclusions the profession may draw from their study. I would call especial attention to table viii., showing the supposed cause of insanity. It will be seen that ill- health, intemperance, mental anxiety, grief, loss of friends, etc., the puerperal state, religion, excitement, loss of property, and injuries to the head, rank, in the order in which I have given them, as causes of insanity. Doubtless 90 per cent, of these cases, could they be truly traced, were due primarily to an inherited insane taint. The 3366 cases unascertained would naturally all come under this head. To the remarks of Dr. Kirkbride, who is one of the most distin- guished authorities on mental diseases in this country, I would call the especial attention of the profession. Statistical Tables. — The tables in this report embrace all the cases received into the hospital since its opening in its present location on the first day of 1841. The number of patients included in the tables given in this report is 8673, and the period of observa- tion is forty-two years. As every year adds to the number of patients who have been under treatment, so it increases the value of the tables, which are prepared with as much care as possible. Much of the information on which these are based must necessarily come from the state- ments furnished by the friends of the patients ; and, without much caution and a careful cross-examination, there is often a great possibility of being led into error, although it may be unintentionally, upon the reception of a patient. At a later period of treatment, and with a greater familiarity with the case, it is often quite practicable to correct these errors, and to make as near an approach to entire accuracy as possible. Most of the- tables are merely statements of facts, about the accuracy of which there can be no ques- tion, but there are others that must always be matters of opinion, and the value of which must depend upon the care with whi^h they are made, and the ability of the observer. TREATMENT OF INSANITY. 195 Table I. — Showing the nujtiber and sex of the ad?nissions and discharges since the opening of the Hospital, and of those re/naining at the end of the year. Admissions, Males. Females. Total. 4669 4486 4004 3779 8673 8265 Discliarges, Remain, 183 225 408 Table II. — Showing the ages of 86'/^ patients at the time of their admission. M. F, T. M. F. T. Under 10 years, . , . 2 3 ,s Between 50 and 55, . . 3.34 262 596 Between 10 and 15, I^ 19 34 " 55 and 60, 225 169 394 " 15 and 20, 237 225 462 " 60 and 65, 166 131 297 " 20 and 25, 636 S23 IIS9 " 65 and 70, 92 81 i«3 25 and 30, 667 617 1284 " 70 and 75, 75 75 ISO 30 and 35, 622 ci46 1 168 " 75 and 80, 31 21 52 35 and 40, 662 498 1 1 60 " 80 and 85, 7 12 19 " 40 and 45, 477 454 931 " 85 and 90, 3 I 4 " 45 and 50, 418 356 774 " 90 and 95, I I 196 PSYCHOLOGICAL MEDICINE. Table III. — Showing the ocacpation of 4.66g male patients. Farmers, 496 Insurance Agent, I Merchants, 452 Hairdressers. . 3 Clerks, 546 Police Officers, 10 Phj-sicians, 103 Machinists, 74 Lawyers, .... 112 Plane-maker, . I Clergymen, 57 Iron-masters, . 2 Masons, . ZZ Weavers, . 48 Umbi-ella-makers, 7 Bricklayers, 17 Printers, . 51 Brick-makers, . 9 Teachers, 56 Sail-makers, 7 Officers of the Anny, 10 Coopers, . 5 " " Navy, 17 Jewellers, 23 Students, . 87 Potters, . 3 of Medicine, 23 Chair and Cabinet-makers 41 of Law, . 12 Blacksmiths, 48 of Divinit}', 14 Watchmakers, . II Saddlers, . 17 Hotel Keepers, 70 Peddlers, . 21 Second-hand dealers, 4 Tobacconists, . 30 Cap Manufacturer, . I Carpenters, 155 Locksmiths, 4 Bakers, 23 Millers, . 21 Seamen and Watermen, 76 Glassblowers, . 4 Planters, . ZZ Wheelwrights, . 8 Manufacturers, loS Gardeners, 30 Coachmen, 9 Chemists, 5 Druggists, 44 Print Cutters, . 2 Laborers, . 338 Curriers, . 2 Engineers, 31 Tailors, . 49 Plasterers, 20 Shoemakers, 109 Bank Officers, . 2 Brokers, ... 17 Conveyancers, . 12 Waiters, . 4 Bookbinders, . 19 Stove-makers, . 3 Hatters, , 12 Dentists, . 4 Rope-makers, . 3 Victuallers, 23 Tinmen, . 25 Soldiers U. S. A., . 19 Painters, . 40 Brewers, . 4 Brush-makers, . 3 Coach-trimmers, 2 Paper-hangers, 4 Auctioneers, 3 Boat-builder, I Plumbers, 7 Carvers, , 4 Type Founders, 3 Confectioners, . 14 Telegraph Operators, 7 Coach-makers, . 9 Whip-maker, . I Public Officers, 8 Silversmiths, 3 Shipwrights, 4 Photographer, . • I Collectors, 2 Wire-worker, . I Nurses, 2 Upholsterers, . 4 Soap-maker, I Drovers, . 6 Contractors, 6 Brass Founder, I Authors, . 4 Pattern-maker, I Editors, . 8 Comb-maker, . I Railroad Conductor, I Grocers, . 9 Apprentices, 3 Cigar-makers, . 2 • Musicians, 6 Glove-makers, . 3 Coppersmith, . I Errand boys. 4 Tanners, . 8 Engravers, 7 Artists, 25 Electrician, I Dyers, 2 i Reporters, 3 Gold-beater, I No occupation, 1 685 TREATMENT OF INSANITY. 197 Table IV.—. Showing ^he occupation of 4004 female patients. Seamstresses or Mantua-makers, 342 Dau^ ^hiers of Author, I Storekeepers, . . . . 28 ' "Victuallers, 5 Attendants in stores, 35 ' Saddler, I Cigar-makers, . . , . 4 ' Coach-makers, 4 Teachers, 114 ' Contractors, 2 Domestics, 354 ' Tinman, I Nurses, 33 ' Mason, I Artists, . 5 ' Hatters, 2 Factory Girls, . 21 Publisher, I Physician, I ' Painters, 4 Sister of Charity, I ' Glassmakers, 2 Clerks, . 9 ' Shipbuilders, 3 Actress, . I ' Caterers, 2 School Girls, . 3 * Grocer, I Hair-dresser, . I OftheiK ^arried, similarly situatec , were— Box-maker, I Wivt s of Clerks, 122 Of the Single females, not pursuing a reg " Teachers, . 25 ular occupation, were — a Farmers, . 263 Daicghters of Farmers, 176 " Brass Founders 4 " Merchants, . 239 Gardeners, 9 " Masons, 4 Saddlers, . 5 " Bank Officers, . 10 " Printers, . II " Weavers, 20 « Machinists, 42 '• Laborers, . 41 Masons, . 7 " Sea Captains, 6 Painters, . 7 " Auctioneer, I " Stage Owners, . 2 " Innkeepers, 12 " Cutler, . I " . Teachers, . 17 Bank Officers, 16 " Carpenters, 23 Innkeepers, 46 " Paper-makers, 2 Bookbinders, 4 . " Physicians, . 23 Tinmen, , 5 " Planters, 33 Editors, . 8 " Watchmaker, I " Plasterers, 5 " Curriers, 3 Engineers, 22 Clerks, 42 Artists, . 13 " Engineers, , 3 Bricklayers, 2 " Clergymen, 27 " Paper-makers, 3 Miller, I « Collectors, 5 Public Officers, . 24 Brick-makers, . 8 " Officers of Army, 2 " Seamen, . 14 Navy, I « Merchants, 273 " Lavsryers, 32 Physicians, 30 " Machinists, 9 Lawyers and Ju dges. 59 " Bricklayers, 2 " Shoemakers, 46 " Chairmakers, 2 " Hatters, . 6 " Manufacturers, . 21 " Cabinet-makers 20 " Tailors, 8 Laborers, 229 " Watermen, . 2 " Grocers, . 12 " Bakers, 7 Clergymen, 38 " Printers, II " Tobacconists, . 12 " Shoemakers, 6 " Weavers, 21 Druggists, . 4 Sea Captains, . 5 " Artists, 4 Victuallers, 12 " Brick-maker, I " Brush-makers, . 2 " Blacksmiths, 2 " Tailors, . 32 " Musician, . I " Millers, . 12 " Dentists, 4 Police Officers, II " Tanner, I " Carpenters, 57 198 PSYCHOLOGICAL MEDICINE. Table IV. — Co7itiniied. Wives of Druggists, 16 Widows of Shoemakers, . 27 " Huckster, I " Clerg}'men, 7 " Planters, . 15 " Farmers, 72 " Paper-hanger, . I " Coopers, 3 " Ship-builder, . I " Laborers, 44 " Livers'-keeper, . I " Manufacturers 16 " Peddlers, . 8 '' Law3-ers, 12 '' Coachmen, 4 " Carpenters, 8 " Manufacturers, 74 " Clerks, . 19 " Brokers, . 5 " Tanners, 2 " Tanners, . 14 " Teachers, 2 " ^lusicians, 4 " Planters, 6 " Conveyancers, . 8 '' Bricklayers, 3 " Officers of Array, 13 " Painters, 3 " " Navy, 4 " Seamen, 9 " Plumbers, 3 " Engravers, 2 '' Blacksmiths, . 17 '' Engineers, 7 " Bakers, . 6 '' ]\Iachinists, 6 Waiters, . 3 " Masons, . 2 '' Confectioners, . 4 " Printer, . I " Hairdressers, . 2 " Blacksmiths, 3 " Contractors, 7 Bakers, . 5 " R.R. Conductors, . 9 " Druggists, 4 " Dentists, . 6 ' '' Musician, " Watchmakers, . 6 " Interpreter, " Public Officers, 17 " Tailor, , " Brewers, . 4 " Dentists, 2 " Optician, . I '' Tinman, " Ironmasters, 3 " Confectioner, " Perfumer, I '« Silversmith, " Gold-beater, . I '' Barber, . " Jewellers, 2 '' Brickmaker, " Architect, I '' Coachman, '' Carriagemaker s, 2 Of the Widows, similarly situated. " Army Officer, were — " Plasterer, Widows of Merchants, 78 " Tobacconist, " Physicians, 17 " Weaver, Public Officers, 12 " Contractor, " Sea Captains, . 8 '' Conveyancer, I " Hotel Keepers, 6 Peddler, Table V. — Showing the number of single, mai'ried, widows, and widowers i?i Sdyj patients. Females. Total. 1645 3917 1866 4016 493 493 247 Single, Married, Widows, W^idowers, Males. 2272 2150 247 TREATMENT OF INSANITY. 199 Table VI. — Showing the nativity of 86yj patients. Nat ves of Pennsylvania, . 4622 Nat ives of Scotland, 56 New Jersey, . 393 ' Ireland, . 1079 Delaware, 209 ' ' Germany, 465 Maryland, 253 Poland, . 10 Virginia, H3 ' Prussia, . 18 North Carolina, 73 ' Switzerland, . 10 South Carolina, 61 ' Bermuda, W. I., 3 Georgia, . 40 ' Jamaica, " 2 Alabama, 19 ' St.Domingo, " 4 Tennessee, 31 ' Barbadoes, " 4 Indiana, . 15 ' Cuba, " 18 Kentucky, 40 ' Guadaloupe, " I Dist. of Columbia, 24 ' Martinique, " I Maine, . 22 ' ' St. Croix, " I Massachusetts, 99 ' ' St. Thomas, " 3 Connecticut, . 49 ' ' Island of Madeira, . I Missouri, 20 ' ' Isle of Man, . I Ohio, 64 * Spain, 3 New Hampshire, 14 ' Italy, 6 Louisiana, 26 ' Denmark, 4 Rhode Island, 17 Holland, 5 New York, 288 ' Russia, . I Mississippi, 14 ' ' Austria, . 6 Vermont, 7 ' Bavaria, . 4 West Virginia, 6 ' Venezuela, S. A., . I Michigan, 4 ' Norway, . I Iowa, 3 ' Japan, I Texas, 5 ' Costa Rica, 2 Illinois, . 14 ' St. Kitts, 2 Florida, . 5 ' Mexico, . I Wisconsin, 4 « Brazil, , 2 Sicily, I ' ' Belgium, I Nova Scotia, . 2 ' ' Buenos Ayres, I Canada, . 19 ' China, I France, . 27 ' Ceylon, . I ' England, 348 Bor n at sea, .... I Table VII. — Showi ng the residence of 86'/ j patients. Residents of Pennsylvania, 7052 Resid ents of New York, , 207 ii New Jersey, . 304 ' Florida, 6 a Delaware, 192 ' ' Wisconsin, . 3 " Maryland, 192 ' ' California, . S it Virginia, 78 ' Oregon, I (( West Virginia, 9 ' Minnesota, . 4 " Dist. of Columbia, 41 ' Kansas. 5 " North Carolina, . 67, ' Montana, 2 " South' Carolina, . n ' Colorado, 2 li Georgia, 39 ' Nebraska, . I " Alabama, 23 ' Jamaica, W. I., . 2 it Louisiana, 47 ' Barbadoes, " 4 " Tennessee, 22 ' Cuba, 14 " Kentucky, 25 ' St. Croix, " I a Arkansas, 4 ' St. Thomas, " 4 " Mississippi, IS ' Island of Madeira, I " Vermont, 5 ' Germany, 3 ci Texas, . 14 ' Venezuela, S. A., 2 (C Illinois, 28 ' England, 7 " Michigan, 10 ' ' Norway, 2 " Ohio, . 61 ' Costa Rica, . 2 " Indiana, 18 ' Mexico, 3 • ( Missouri, zz ' ' Canada, 9 « Massachusetts, 24 ' Japan, . =' . I «' New Hampshire, . I * ' Nova Scotia, I (f Iowa, . 9 « Brazil, -2 " Connecticut, 16 ' Italy, . I <( Maine, 3 ' ' Sandwich Islands, I 11 Rhode Island, 8 200 PSYCHOLOGICAL MEDICINE. Table VIII. — Showing the supposed causes of insanity in 86^3 cases. Ill health of various kinds, Intemperance, Loss of property, . Dfead of poverty. Disappointed affections, Intense study, Domestic difficulties. Fright, .... Grief, loss of friends, etc., Intense application to business, . Religious exciterhent, . Political excitement, Metaphysical specula- tions. Want of exercise. Engagement in duel, Disappointed expectat'ns. Nostalgia, Stock speculations. Violent boating exercise. Want of employment, . Mortified pride. M. F. T. 864 746 1610 798 65 863 233 55 2S8 4 3 7 33 68 lOI 41 13 54 53 120 ^1Z 20 55 75 90 314 404 73 19 92 9b 147 243 14 14 I I 6 2 8 I I 14 22 36 . . . 10 10 2 2 I I 53 3 56 2 I 3 Celibacy, Anxiety for wealth. Use of opium. Use of tobacco, Lead poisoning, . Use of quack medicines Puerperal state, Lactation too long con tinned, Uncontrolled passion. Tight-lacing, Injuries of the head. Masturbation, Mental anxiety. Exposure to cold, . Exposure to direct rays of the sun. Exposure to intense heat, Exposure in army, Old age. Sudden acquisition of wealth. Unascertained, M. 116 96 193 5 79 I 1730 319 14 7 •5 334 7 1636 T. I 3 35 17 I 4 319 14 13 I 123 lOI 527 6 82 2 8 7 T 3366 Table IX. — Showing the ages at which insanity first appeared in 86yj patients. M. F. T. M. F. T. Under 10 years, . 21 6 27 Between 50 and 55, 232 199 431 Between 10 and 15, 73 72 14s 55 and 60, . 163 I3« 301 15 and 20, 447 .375 822 60 and 65, 116 87 203 20 and 25, 801 70s 1506 65 and 70, 55 37 92 25 and 30, 809 703 1512 70 and 75, . 30 28 5« 30 and 35, 574 5S2 1 126 75 and 80, 16 9 25 35 and 40, S82 426 1008 80 and 85, 3 10 13 40 and 45, 418 3«4 802 85 and 90, I I 45 and 50, 328 273 601 Table X. — Shoiving the forms of disease for which 8 6"/ j patients wet'e admitted. Mania, Melancholia, Monomania, Dementia, . Delirium, . ^ Males. Females Total. 1996 1899 3895 1063 I32I 2384 705 447 1152 890 332 1222 15 5 20 TREATMENT OF INSANITY. 20 1 Table XL — Showing the duration of the disease at the time of admis- sion in 862J patients. Males. Females Total. Not exceeding 3 months, ....... 2039 2173 4212 Between 3 and 6 months, 404 339 743 " 6 months and one 3 ^ear, 596 467 1063 " I and 2 years, 640 396 1036 " 2 and 3 " 324 181 505 " 3 and 4 " 179 no 289 " 4 and 5 " 109 73 182 " 5 and 10 " 201 142 343 " 10 and 15 " 75 57 132 " 15 and 20 " 34 30 64 " 20 and 25 " 34 17 51 " 25 and 30 " 16 10 26 30 and 35 " 7 5 12 " 35 and 40 " 5 5 " 40 and 45 " 4 3 7 " 45 and 50 " 1 I 2 " 55 and 60 " I I Table XII. — Showing the nurnber of the attack in 86'jj cases. M. F. T. In the periodical cases, M. F. T. First attack, . 3453 2820 6273 loth 10 m. 7 f., nth 5 m. 4 f., 15 II 26 Second " 677 713 1390 I2th 4 m. 3 f., 13th 3 m. 2 f., 7 5 12 Third " 212 249 461 14th 3 m. 3 f., 15th I m. I f.. 4 4 8 Fourth " "5 95 210 i6th I m., 17th 2 m., . 3 ■\ Fifth " 51 52 105 i8th 4 m., 19th 2 m., . 6 6 Sixth 66 19 85 20th and 2ist each i m. and I f.. 2 2 4 Seventh " 32 7 29 22d I m., and to 26th each I f., . I 5 6 Eighth « 14 10 24 27th 2 f., 29th if.,. 3 3 Ninth " 9 5 14 30th, 31st, 32d, 33d, each i f., 4 4 Table XIII. — Showing the state 0/826^ patients who have been discharged or died — their sex, and the forms of disease for which they were admitted. .2 0) n! [A X. rt B "3 S "3 .2 '3 C c C B 3 Cured, § fe EH S S s P 1975 I916 3891 2157 1077 537 117 3 Much improved, , 262 400 662 277 249 92 44 Improved, . 817 630 1447 503 427 256 261 Stationary, . 771 3S6 II27 369 265 I3« 354 I Died, .... 661 477 II38 479 241 45 357 16 202 PSYCHOLOGICAL MEDICINE. Table XIA^. — Showing the Jiumber of admissions, discharges , cures, and deaths in each month since the opening of the hospital. Admissions. Discharges. Cures. Deaths. 1st month, 679 743 309 109 2d " 645 524 249 84 3d - 766 614 280 90 4th « 855 635 294 103 5th " 874 744 341 no 6th " 829 705 333 72 7th " 728 782 371 102 8th " 6S7 728 341 "5 9th " 660 716 346 97 loth " 680 737 373 89 nth " 637 678 320 83 i2lh " 632 659 334 84 Evening Entertaintnents. — Occupation and A?nusement of the Patients. — The year just closed has made a record quite equal to any of its predecessors in regard to the mat- ters coming under the heading of this section of the report for 1882. None of the old modes of amusement, occupation, or evening entertainments have been abandoned or lessened in frequency, while several new ones have been introduced, to the great grati- fication of those for whose benefit they were originally provided. This year, it may be said, with some allowable pride, is the fourteenth, during which, at one department, there has not been the omission of a single evening, and almost the same is true of the other, during the nine months which have always been regarded as the extent of the regular course. Beyond the fact of this work having been done, it is pleasant to know that, with very few exceptions, there has been a general recognition of its value, and that its performance has been regarded as involving no more labor than that of carrying out the most ordinary daily duties of the institution. At the department for males all the varie- ties of active outdoor exercise, and the different games heretofore used, have been steadily resorted to, while within doors everything has been introduced that seemed to be available and likely to make a stay in the hospital less irksome. At the department for females, besides all the customary modes of occupation and amusement, special sewing-classes have been introduced by ladies who were here for the benefit of their own health, and in a manner which has given particular interest to them, among their fellow-patients. The modelling in clay, under the direction of J. Liberty Tadd, has been a very success- ful experiment, and some of the products of that workroom have been most satisfactorily successful. Those who have taken instruction in oil-painting, under the direction of the same able artist, have also shown the value of all of this class of occupations, and some patients have developed a capacity for that kind of work that had not been supposed to exist. In summer the successful cultivation of flowers by the ladies in the garden placed under their immediate control, was very satisfactory, and a source of great pleasure to those who have thus spent hours of many days in this form of employment in the open air. To the ladies who originated all of these forms of occupation, and whose zealous prose- cution of them induced so many to unite with them in these pleasant modes of passing the time, we feel under great obligation for the good results of their intelligent sugges- tions and active participation in the work. There has been a steady effort to increase the amount of time spent in the open air, and in suitable exercise, by all patients whose physical condition would enable them to work, TREATMENT OF INSANITY. 203 ride, or walk. The kindness of our friends has increased the number of our vehicles for riding, and we hope that the number of suitable horses and ponies will also be made greater from the same source, while our roads, we trust, will gradually be made just as good as their proper construction can make them. A small gift from a friend for the special purpose, enabled us to make a beginning of having music on the lawns in the summer afternoons, or in the evenings during the officers' tea parties, and which gave so much pleasure to the large number who wea-e thus enabled to have this enjoyment while in the open air, that it is hoped hereafter there will be a material extension of this mode of passing a portion of the summer days, when the patients generally can be out of doors and get equal benefit from it. To those not familiar with the ordinary routine of our evening entertainments, it may be mentioned that they embrace, besides whatever novelties we can secure, lec- tures, readings, concerts, exhibitions of very fine dissolving views, gymnastic exercises, officers' tea parties once a week during the entire year, and whatever else our means and the kindness of our friends may place at our disposal. Dr. Kirkbride's remarks on the necessity for prompt treatment are especially valuable, and are as follows : While there are so many causes for feelings of gratification at what has been done, it must be acknowledged that there is abundant evidence of losses sustained by a ne- glect to adopt a prompt course of judicious management for those who are suffering from forms of mental disease, that when neglected, are pretty sure — sooner or later — to lead to results of the most melancholy character. It is certain, too, that while so many of the insane are permitted to wander at large, unprotected and uncared for, there will be not only a steadily increasing list of incurable patients, but there will also be a daily record of melancholy events, which a rational course of care would, probably, have prevented. As long ago as twenty-seven years, after- careful obser- vation, the writer of this report ascertained that, in a particular year, the number of persons whose lives were sacrificed or jeopardized by the insane, who were allowed to be at large, in the United States, was equal to those lost by all its railroad acci- dents. Since that time the extension of railroads has made the accidents connected with them undoubtedly increase in a greater ratio than those that have come from the course of persons responsible for the care of the insane, but neglectful of their obvious duties ; but even now, any one who will read for a short time the regular daily summaries of such occurrences, and of the accidents throughout the country that may be found in some of our newspapers, will be astounded not only at their number, but at the horrible character of many such events detailed there. Among these, it is hardly necessary to say, are intended to be included a large proportion of the cases of suicide, which are clearly the results of disease, and which, with proper care, would have been prevented and in all human probability these unfortunates would have been restored to their families, relieved of this dreadful propensity. A general knowledge in the community of facts like these, as well as of the risks of delaying treatment till the probable period of its being successful has passed, would lead those having control of families to seek early counsel from their medical advisers on the occurrence of symptoms of mental aberration, and these could not fail to feel the respon- sibility of promptly adopting the only course that is likely to give protection equally to patients, their families, and the community. It has been common to urge, in documents coming from this institution, not only the importance of a more thorough study of mental diseases in the medical schools, — 204 PSYCHOLOGICAL MEDICINE. because it is, in a large majority of cases, from the family physician that counsel is first asked on the indication of such a trouble, — but also, that in colleges and all the higher institutions of learning, as well as in ordinary schools, there should be taught at least a general idea of the functions of the brain, the courses of life likely to lead to their disturbance, as well as those that would probably maintain them in their integrity, some of the indications of commencing disorder, the importance of prompt treatment, and especially of steady perseverance in it, under wise counsel, when once undertaken. If such knowledge were generally diffused, it would be not only directly advanta- geous to those who are suffering from mental disorders, but it would put an effectual check to the extravagant plans constantly urged upon the attention of legislatures, not only in regard to the construction of hospitals, but to their government and to various details, which properly can only be left to the executive authorities of such institutions. Legislators, then, would have no difficulty in deciding for themselves on the pretensions of those whose schemes have nothing but novelty for their recommenda- tion, and which are opposed by the results of all careful experience. No one who has had much to do with giving counsel to those who have had their dearest friends threatened with this class of disorders, or who are themselves actually sufferers from some form of them, but must have recognized how much distress would have been saved to all concerned, by a veiy moderate amount of such sound knowledge of the malady as has been referred to, as well as a general idea of the kind of treatment in hospitals, that to be successful, is often unavoidable, and some of the reasons for its adoption. There is a picture constantly to be met with where individuals with more than the average mental intelligence and a general familiarity with ordinary topics and business, come for counsel, with feelings of depression and utter hopelessness far beyond what are commonly connected with the occurrence of any ordinary malady. Acknowledging a profound ignorance of the whole subject, the declaration is made that the existence of such a trouble is wholly unaccountable, no one in the family having ever suffered from any mental disorder, and, while prepared to make every sacrifice to secure the restora- tion of the patient, before doing so they very properly desire some explanation of the nature of the disease, the chances of a recovery, and the reasons for plans of treatment so different from what are commonly adopted in the management of ordinary sickness. Then come the dread of leaving home and losing all the kind attentions there com- monly given, dislike to the idea of entering an institution of the character of which little is known, and where it is supposed all classes of invalids are mingled together ; and all this is accompanied by an utter inability to comprehend how, under any classification, one person with a disordered mind can fail to be of disadvantage to another if living in the same building, no matter how extensive it may be or how complete may be the arrange- ments for a thorough separation of the different classes of patients. To those who have such impressions and such a want of knowledge on the entire sub- ject, it can only be answered that insanity is a disease from which no one, under certain circumstances, can claim exemption ; that if no individual belonging to a family has ever had such a form of sickness it is only a matter for profound gratitude, and that such a degree of permanent good fortune can hardly be expected to continue indefinitely. By many heredity is regarded as the prevalent cause for the development of mental dis- orders, and that without it there is little danger of its occurrence. Although hereditary influence is often an important element in the production of mental, as of other diseases, still the extent of it has unquestionably been often greatly exaggerated. That this is so may reasonably be inferred from the fact that of the first 5381 cases suffering from a TREATMENT OF INSANITY. 205 primary attack of insanity admitted here, there were only 434 in whom there could be traced any hereditary influence worthy of record. It should be a comfort, too, for such inquirers to be assured, as our experience here fully justifies us in saying, that where simple, uncomplicated cases of insanity are properly and promptly treated, and the treatment duly persevered in, they are just as curable as are other ordinary serious disorders, and that when entirely cured, where a thorough obedience to natural laws and common sense are subsequently observed, there is no more reason to anticipate a return of the disease than there would be in other maladies under similar circumstances. The day should now be passed when any one of intelligence and cultivation should regard it as a reproach to have suffered from impairm.ent of health and to have resorted for treatment to an institution, without which course, there was good ground to believe, the chances of restoration would have been greatly diminished. As there could be no reproach in suffering from an illness for which there was no responsibility, so, very clearly, there could not be in taking advantage of every means for the restoration of one's health that the most widely-extended experience had given reason to believe would be suc- cessful. Beyond this, if it were wanted to discover those who had been sufferers from this class of affections and had been restored to health and usefulness through hospital treatment, there need be no difficulty in finding such among the best and most cultivated men and women of the land, and whose hospital experiences had rendered them prepared for a wider degree of enlightened usefulness than they could otherwise have possessed. Another important result of careful investigation that should always be given to those who are seeking information on the subject is that universal experience has shown that the most important elements for securing a restoration to health are the prompt resort to an intelligent course of treatment and a steady persistence in it till the complete recovery of the patient. While they may be assured that it is not necessary that every person who is suffering with an unsound mind should leave home for treatment, there can be no ques- tion but that the general experience is positive that, for a very large number of those who are thus affected, this is a painful necessity, and must be joined to the patient's being placed under the care of those who have made a special study of the whole subject, strangers though they are likely to be, if it is desired to give them the best chances for a restoration. So, when they plead for a mode of care in their homes and with their families, they are to be reminded that "home treatment" and "family care," with all the kind atten- tions which are connected with such a mode of providing for the unsound of mind, have almost always been tried and have failed before the removal from home is even brought up for consideration. So, too, as among the results of the disease itself, they need hardly to be told, is often found an utter want of appreciation of the kindest attentions from the dearest of friends, and all the blessings of home and its surroundings are as likely as not to be completely ignored or not appreciated. It may also be asked why, when no hesi- tation is felt in leaving home to secure perfect rest, and change of scene, climate, and occupation, when these have been found beneficial in other maladies, those who suffer from mental illness should not avail themselves of any change, although different in kind, which rarely involves such an expenditure of means, risk, and anxiety, and the results of which have been found to be at least as favorable by an almost universal experience Many of those who thus come for counsel have never even seen the interior of a hos- pital, and have derived most of their ideas in regard to such institutions, not only of their management but their construction, from works of fiction or the sensational articles so often found in certain portions of the public press, bringing, therefore, with them preju- 2o6 PSYCHOLOGICAL MEDICINE. dices of the most extravagant kind. Before such as these are allowed to decide upon placing their friends under the care of an institution, they should be shown through the different parts of the building, have its arrangements explained, and be enabled to see for themselves that the patients are classified so as to do most good, or, at any rate, the least possible harm, to each other, and that this mode of separation may be made almost as com- plete as that of families living in contiguous buildings of a square in a city, where all are liable to meet in their walks in the streets or in the pai'ks, at places of amusement, lec- tures, or religious services, but not otherwise unless voluntarily. In regard to entering hospitals, it is, indeed, a matter of surprise that patients are often so far in advance of their families and friends in indicating the proper course to be pur- sued on the occurrence of a case of insanity, and, after recovery, there is nothing more pleasant than, as is often the case, to have those who have been so fortunate as to secure this result from hospital care, ask that, should they ever have a recurrence of the disease, they should be again promptly placed under the same form of treatment. Report of Statistics of the Hartford Retreat for the Insane, Hartford, Conn. — The Fifty-ninth Annual Report of the Retreat for the Insane at Hartford, Conn., for which we are indebted to Dr. Henry P. Stearns, the superintendent, shows : that on the 31st day of March, 1882, the vvrhole number in the Retreat was 122, — 58 men and 64 women. There were 78 admissions during the year. There were 74 dis- charges and 9 deaths. The whole number under treatment during 1882 was 200; there were discharged recovered, 26; much improved, 1 1 ; improved, 6 ; stationary, 22 ; died, 9 ; remaining at end of the year, 126. Since April ist, 1844, there have been admitted 641 pa- tients between 20 and 25 years of age, 647 patients between 25 and 30 years of age, 650 patients between 30 and 35 years of age, 603 patients between 35 and 40 years of age, 553 patients between 40 and 45 years of age, and 434 patients between 45 and 50 years of age. " From this period of life," says Dr. Stearns, " the number rapidly diminish, and there have been only 150 persons admitted during the whole thirty-eight years who were known to be over seventy years of age ; and only 316 below twenty. It thus appears, so far as these statistics of the Retreat are evidence, that there exists a considerably uniform average as to the ages of persons who become insane from twenty up to forty or fifty years, and that a larger number are affect- ed between twenty and forty, and also during any number of these years than there are during any equal number at other periods of life. It will be observed that these are the periods during which the brain comes into its largest activity and responsibility. The indi- vidual no longer enjoys the support and protection of the parental home ; his relations to society and the public then become more fully declared, and his business cares and anxieties greater ; besides there i TREATMENT OF INSANITY. 20/ exists a larger measure of uncertainty as to success and failure in all the avocations and employments of life than is the case either earlier or later. It is during this period that such habits and customs of life as are unfavorable to the continuance of mental integrity are usually formed and more fully take possession of the individual, especially in relation to the passions and the use of alcohol and tobacco. More- over, it is at this time that failures in business, disappointments in relation to plans and purposes, and anxieties in relation to children and the support of families are generally greater than at other periods. Especially is this the case with those classes (already large in this country, and yearly becoming larger) which have never thoroughly learned any trade or employment, and are obliged to depend on doing so while employed for wages. Such conditions of life and experi- ences, together with a larger measure of brain-susceptibility and ac- tivity than exists later in life, are some of the causes why insanity affects a larger number of persons between twenty and forty than be- tween forty and sixty years of age. After forty the brain is less sensi- tive to external influences and occupations; the relations of the indi- vidual to society and occupations are generally settled, and he is much less liable to be affected by failure or success in the pursuits of life than he is at a younger age." Dr. Stearns further says: "In my report for 1876, I presented some statistics from the history of recoveries in the Retreat since its opening to the year 1875, and showed that there had been a some- what uniform diminution in the percentage of recoveries up to that time, and reiterated a previously-expressed opinion that the nature of the causes of insanity were becoming somewhat changed or in- tensified, so that insanity is less curable than it was during the early history of the Retreat. Since that time the whole subject of the curability of insanity has been treated in a very thorough manner by Dr. Pliny Earle in several of his yearly reports, and the conclu- sions at which he arrives tend strongly to confirm the opinion then advanced." Statistics of the McLean Asyhmt for the Insane, Somerville, Mass., Department of Massachusetts General Hospital. — The sixty-fifth an- nual report of this institution, for which we are indebted to Dr. Ed- ward Cowles, the medical superintendent, shows : that there were in this asylum, January 1st, 1882, 155 patients, — 63 men and 92 females. The admissions for 1882 were 82 in number. The whole number of cases within the year, 237 ; discharged recovered, 26 ; much improved, 208 PSYCHOLOGICAL MEDICINE. 7; improved, 14; unimproved, 15; deaths, 8; patients remaining December 31st, 1882, 167. During the year no person was twice admitted. The average duration, from the beginning of attack, of all persons recovered was 10.54 months, and the average duration of their hospital residence was 8.86 months. The percentage of recov- eries on admissions was 30.48. The number of recoveries was larger by five than in any year since 1870. Dr. Cowles has some excellent remarks respecting the care of the insane, which we insert as follows: There has, of late, been much discussion of the question of the curability of insanity; and the results of the treatment of the insane in large and well-managed hospitals, like those in Massachusetts, are still disappointing as compared with results reported to be gained in the early days of the older and smaller hospitals. A reduction from 75 per cent, to 20 per cent, of recoveries is perhaps due to something more than the errors of the older statistics. It is probably true that the majority of the insane can be best and most practicably treated away from their homes and in hospitals, and these are not yet accomplishing what has been hoped of them in curative results. Instead, however, of treating this fact in terms of reproach, it should not be forgotten that mental disease in- volves the disorder of an organ of a highly complex and delicate structure, and compar- isons between its diseases and those of other organs of the body should not be drawn un- fairly. It has its own physiological and pathological laws ; and, at the best, its diseases may have to be regarded as largely incurable. The fact that the insane are treated mostly in hospitals and become burdens upon the State gives them prominence, because of their economic relations. Let us suppose that tubercular diseases are to be regarded as infectious, and their subjects are to be put into hospitals. What public alarm would be aroused by the great number and fatality of cases of this disease, now unrealized, or by the burden of the care of its chronic forms ; and how soon would it become the fashion to reproach those who treat it because of its incurability ? The insane must be cared for with due regard to public and private economy, and the system now common to all civilized countries of collecting them in large hospitals is held to be on trial. It is, at all events, imperative that no possible effort should be spared to get curative results from the treatment of the insane. Curability certainly diminishes with duration of mental disease, and its earliest stages should be most thoroughly studied and treated. The smaller hospitals are endowed with greater facilities for individualizing cases, and for treatment ; and, therefore, a great responsibility lies with them for making the best use of those facilities. They should encourage the admission of acute cases, and devote their best energies to their study and care. It seems to me that in such hos- pitals, where the means and the opportunity are liberally given, while due regard is to be had to a proper conservatism, it is a special duty to explore new paths, if any there be, beyond the beaten ways of procedure in the management of the insane. To stand still is to fail, when progress is demanded and is possible; for even negative results are val- uable. It is also a duty to report experiments for the later tests of criticism and experi- ence, and hence this may be deemed a fitting time and place for putting on record some of the results of the study of the problems of hospital management in this asylum during the past three years. Developing a homelike aspect of the hospital, destroying the suggestion of insanity as differing from other diseases, individualizing the patients, and perfecting the conditions for moral treatment are of prime importance. The truth goes further, and includes TREATMENT OF INSANITY. 2O9 the essential fact that we are treating sick people, and are, after all, dealing with a hospital. One of the first considerations, therefore, was the quality of the nursing of the sick. The aim has been to introduce the best methods of the general hospitals, by promoting the growth of the spirit that prompts devotion to the sick; requiring constant personal attention to them as individuals, by companionship as well as nursing ; introducing ward-maids to perform duties that distract the attention of nurses from more important ones ; increasing the number of nurses on duty at night, so that most of the patients can have the doors of their rooms unlocked, and all noteworthy events can be observed and systematically reported; employing experienced night supervisors to see that all medical directions are properly carried out, and that everything is done to promote the com- fort and cure of the sick ; in short, by providing a service qualified for the task of treat- ing a houseful of acute cases. This is the beginning of what it is believed can be accom- plished as the result of the recent employment of a superintendent of nurses, and of a systematic course of training and instruction which is to be adopted for them. To one who has employed in hospital wards intelligent and well-trained nurses who have an interest in their work as a profession, their value in the companionship as well as the care and treatment of the insane needs no commendation. In the direction of developing the hospital element of the work, the employment of an ample medical staff has given increased satisfaction during the past year. An assistant physician for each service, male and female, is a liberal allowance for a total of one hun- dred and seventy patients ; but, in an asylum of this kind, much attention must, or can well be bestowed upon individuals. The continued employment of a house-pupil for each service, to do the work of clinical clerks, as in general hospitals, is a valuable ad- dition to the organization. It is understood that the time thus gained by the assistant physicians from clerical and other duty shall be employed in professional work. And, to facilitate this, a room has been fitted up fora laboratory and the use of the microscope; and a systematic course of study, begun a year ago, is now going on under the direction of Dr. Gannett, of Boston, who is also employed as the pathologist of the asylum. Aloral Treatment. — A consideration of the moral treatment of insanity of course leads over ground that is not new, but it may be permitted to restate a few propositions. It is important, at the outset, to establish the principle which shall serve as a basis for the moral treatment of the insane person as an individual. The underlying principle in the whole matter is, that the patient should be treated as a reasoning being. In other words, from the moment he enters the hospital, it should be assumed that he will understand more or less correctly all that is said or done to him. Therefore, he should be treated as if he were expected to act rationally, and led to see that, after his failure to do what is expected of him, he brings upon himself friendly advice, criticism, reproof, and, if need be, restriction. On the part of others, while the attitude toward him of physicians and nurses should be as toward a rational man, the fact of his illness and mental obscura- tion should be kept in view ; and the conditions of his daily life should be made easy by conforming them as nearly as possible to those of his ordinary experience. His clouded and perverted understanding should be given as few unaccustomed problems for compre- hension as possible in his new mode of life in the hospital. The physiological basis of all moral treatment of the insane is the fact that the normal functions of the cerebral organ may be only temporarily disturbed or only partially im- paired, whether by temporary disorder or pathological change, and the consequent fact that in most cases some degree of normal function remains. This principle cannot be better stated than by Dr. Gairdner, in his presidential address to the British Medico-Psy- chological Association last August. 'Speaking of the improved treatment of the insape, 14 2IO PSYCHOLOGICAL MEDICINE. begun in the time of Pinel and Tuke, he says it has gradually come to be regarded as the truth that "the unsound mind, like the unsound body, can only be regarded as an instance of disordered function ; and that, however great the disorder, the functions are still there, and may be roused into more or- less healthy activity by exactly the same phys- iological stimuli as are available in the state of health." He would name as the most important gain of modern physiology and pathology for the healing art, the modern con- ception or theory of disease, — that " disease is, for the most part, normal function acting under abnormal conditions." He argues, therefore, that the insane mind is not aliena metis, hut has like passions- and emotions with the sound mind; and that the sound ele- ments still remaining must be carefully respected, strengthened, and built up again, if possible. All moral treatment, then, should be addresssd to the purpose of calling into normal exercise the rational part of the disordered mind. The patient should be assumed to be capable of some degree of understanding of the fact that he is ill; and all the conduct of others towards him should frankly and consistently declare this, before as well as after his entering the hospital. The fact should be made as plain as possible to him that his commitment by the court is according to law, and based upon medical opinion outside of the hospital. There are few patients who cannaot be beneficially impressed in this way, however much they may contest the correctness of the judgment upon them. Once within the hospital, the conduct of physicians and nurses toward the patient should show that he is regarded as simply ill, and as having no reason for being ashamed of his illness. Therefore, he should always be called a " patient," and not a " boarder," as is the custom in some hospitals, and has been in this one from its earliest days. This latter t-erm implies an evasion of the fact of illness, as if it were a disgrace, and by a euphem- ism fosters the very feeling of which we are trying to disabuse the patient. Dr. Kirk- bride has pointed out the same effect as inherent in the use of the word " asylum " for " hospital." For the same reason, the word "attendant" is unfortunate, although it is so much better than the older terra, " keeper." It would be only the truth to call them " nurses." While everything should be done to make the place homelike and cheerful, with pleasant parlors, books, pictures, music, diversion, and occupation suited to the individual, the idea of the hospital is in it all, and no attempt should be made to ignore it. It should appear rather that active attention is being given to the business of curing the sick. " Attend- ants " may attend the infirm and incurable; but "nurses" attend the sick, and the ex- perience of I'ecovery from illness is so common that the very idea of the presence of a nurse logically carries with it the other idea that something is being done to promote re- covery, and that itself inspires hope and is curative. The keynote of all that is addressed to the patient on this subject should be, " You are ill ; you may get well." In practically working out the general principle that has been stated, it is believed that successful results have also been gained in two other experiments during the past three years. One of these is the employment of female nurses in men's wards, as described in my report of last year. For the majority of insane men this is practicable; and every day's experience with it teaches me to prize more highly its value. To put a man accustomed to the comforts, or even if no more than to the habits, of domestic life, into a restricted association with men, would be to him an experience of which he probably has had no previous conception. Such a way of living would be unnatural and unattractive to most men, and to the sick man, whose mind is already disturbed, a cause of added discomfort. In such an association of men alone the inevitable tendency is to degenerate in manner of speech and conduct; and this is true, both of the patients and what is very important, TREATMENT OF INSANITY. 211 of the men nurses also. There is something lacking after all efforts to make the wards homelike and agreeable. The presence of female nurses in most of the wards, and of young women as ward- maids, is as easily managed as in the wards of a general hospital. Although some of the conditions differ, there is much to prove the practicability of this in ordinary hospitals, in the successful management of all the men's wards of the Mount Hope Retreat at Balti- more by the Sisters of Charity. The insane man coming into such a ward is restrained and softened, and practices instinctively a degree of self-control that he would not have thought of ti-ying to exercise in the presence of men alone. His first impressions upon entering the asylum are far more agreeable than in the former case and continue so. The special qualifications of women for the care of the wards and the sick are of great value, and the moral and curative influence of their habitual presence in our wards for men is positive and would not be willingly given up. The good results that have followed this practice flow directly from its influence in stimulating the exercise of the remaining sound elements of the mind, and of healthy and decent habits of thought and conduct. The other experiment, which is believed to have given some special and good results, is in regard to the freedom of communication between patients and their relatives or friends, by visiting or correspondence. It is now two and a half yeai's since my former liberal practice grew into the adoption of the present rule for the following reasons. Few of the insane have their understandings so confused and clouded as not to leave enough of normal mental function to conceive of the reasonableness of removing a sick person to a hospital. There is often on the part of persons so removed a consciousness of the pro- priety of this actioia, even in those who will not confess it. Even in cases of maniacal excitement and melancholia with stupor, we may rely upon being able to instil into the mind some degree of consciousness of the true nature of the act of removal to a hospital. When, however, we come to abruptly separate the insane person from all communication with relatives and friends, we institute a condition of things which is the more difficult to understand as the patient is more insane. The patient probably knows the usual fact, that the distance is not great from home and friends. Enforced separation and interdiction of communication beget suspicion of those friends, if it has not been entertained before, or of the physicians of the hospital. It is of the first importance not to increase or arouse this suspicion, and to convince the patient of the desire to treat him with generous fair- ness and indulgence. Therefore the rule is that, from the outset, the relatives or friends shall be allowed to visit the patient. Care is taken to have it understood by all con- cerned that the physician will see no objection to such visiting until the patient shall give cause for it. This is the rtile ; but, like all rules, it has its exceptions. The patient who has an an- tipathy and delusion regarding relatives might not be allowed to receive visits for some time after the first one, or even the first might be denied ; but it is remarkable how few patients there are who require this restriction. In this asylum, of one hundred and sixty- seven patients present, there are only three who do not receive visits from relatives quite regularly. One man with chronic mania refuses to see them because of a violent antipa- thy ; and the relatives of the two other men with mania have to refrain from visiting on their own account, but visits are made by friends. It has been observed that if excite- ment attends the first visit, M'hich should be made early, it is as a rule no greater than attended contact with friends at the home recently left; and, in fact, this visit is regarded as a necessary part of the process of accommodating the patient to the new situation and aids it. The first visits often have a remarkable effect in disarming the patient of fast- forming suspicions as to the purposes of friends, and help to inspire him with a salutary confidence, which aids in leading him to accept sooner the role of an invalid. The 212 PSYCHOLOGICAL MEDICINE. friends, and this term is used to include relatives, learn by these visits to render valuable aid in the management of the case, and most readily accede to the proposition that they should refrain from %asiting, if it has proved not to be good for the patient. This practice stands the test of the continuance of the visits, even though, as is some- times the case, the first ones are attended with some degree of excitement. The visits are almost invariably desired by the patient, who soon comes to understand, if need be, that they are allowed or denied according to his conduct, and thus a means is given for stimulating self-control. Sometimes, the desire to see friends can be aroused when it has been absent ; and a curative result is gained by the exercise of a normal function of the mind in the gratification of the desire. In other exceptional cases, as of acute mania, or others with mental confusion or stu- por, the seeing of friends may seem to give negative results, and little notice may be taken of the visitors ; but, in these conditions, it is well known that impressions may still go in upon the obscured perceptions, when no outward sign is given, and are remem- bered. As far as moral treatment goes, in these cases of mental confusion as well as in others, efforts calculated to arouse into activity the normal elements of the mind are often of in- estimable value, though no evidence of the good impressions thus made appears till long afterward. What more potent means of arousing healthy mental action than is found in the exercise of the natural affections and emotions, and the consciousness of the occa- sional presence of friends whom the patient has been accustomed to love and trust ? The fact that patients who have been studiously separated from friends for a long time may have had relapses from convalescence almost established, following wearily longed- for visits from relatives, is not a conclusive argument to prove that the visits were made too soon. It is a fair question whether the excess of emotion, naturally aroused by a meeting after long separation, may not produce in such cases a disaster which might be averted under the opposite plan of training the patient from the outset to receive calmly the visits, by the deprivation of which he has not been allowed to become distressed. Another important consideration is that, when the relatives also are wearied by long separation, they are apt to remove too soon a half-convalescent patient, at first sight of the improved condition, whereas by the other plan they act more understandingly and with calmer judgment. As a matter of fact, it rarely happens under this practice that too early removal of convalescents is urged. In regard to correspondence, the rule is also a most liberal one, as far as the asylum is concerned. The patient and friends are carefully informed at the outset that no writings of the former, sealed or unsealed, will be intercepted by the asylum authorities, who pre- fer to be relieved of that responsibility. The patient is told that whatever he writes ^^^ll be sent to the persons who are to be regarded as the natural or legal guardians, or to other proper persons agreed upon. Most patients readily join in this compact, if made at the outset ; and the attitude thus taken by the superintendent increases greatly his influence over the patient in advising or checking him in regard to writing. It often happens that what one is free to do he does not care to do, or, if he becomes dissatisfied sometimes with the action of friends in arresting letters, — as of course must be done for the protec- tion of the patient from consequences he would afterwards regret, — there is, as a rule, a good reason to be given. At all events, it is found that dissatisfaction is reduced to a minimum ; and it is made clear that there is no reason known, as far as the asylum is con- cerned, why all letters should not go from it. It is easy to gain through friends the valu- able information concerning the state of the patient's mind afforded by his letters; and the friends, being taken into the management of the case throughout, have a better under- standing of their duty to the patient when his home relations are resumed. TREATMENT OF INSANITY. 213 One more important point is that every well-behaved visitor, if it is desired, is allowed to go to the room of any patient it is proper for him to visit, with due regard to the com- fort of others. The nurses are trained to expect this at any time, and it is demonstrated to all concerned that there are no dark places in the asylum to be concealed. In thus setting forth the working of what is, theoretically and virtually, a removal of restrictions that have been regarded as peculiar to hospitals for the insane, the aim is to show that this is justifiable as the logical sequence of the carrying out of the principles recited in the beginning of this discussion. As a practical demonstration of the results of the effort being made to put this asylum on the basis of a general hospital, particularly as to its being an open and accessible institution, it is shown by this report that the twenty- six recoveries of the last year were possible under the liberal rule which permitted, from the beginning of the treatment of these cases, including various types of acute mania, melancholia, etc., regular communication with relatives and friends, guarded by a careful study of its effects and its occasional limitation. It was the influence of the growth of the principles cited that wrought the improve- ment in asylum management from the days of Pinel and Tuke to the present time. It is not so many years since it was believed that there was a special curative influence in en- tire separation of the majority of the insane from friends for long periods, and in their strict seclusion in asylums. Not only was rest in bed enforced by mechanical restraint to prevent exhaustion in maniacal cases, but many appliances were employed to keep quiet the restless sufferers from nervous irritability. It has gradually come to pass that, at the present time, large freedom is accorded to the insane ; and the former practice of seclusion from friends and interdiction of communication is greatly modified, and in some instances reduced to small proportions. The practice is not uniform in this regard, how- ever ; and there is reason to believe that the views held by many alienists are but a modi- fication of the former ones as to the curative effect of strict seclusion in hospitals, although some have gone so far in this direction as to practically abandon it. The truth lies somewhere between the older view and a modern one, in regard to the treatment of the insane at their homes. It is believed that the line may be drawn at the point of the removal of the patient to hospital and his separation from home and the former "moral and physical surroundings," and that beyond this point, the accepted rule of practice should be that liberal communication with friends is to be used as a therapeutic means. Some evidence of a negative character is available in support of this proposition. It appears not only that the growing liberality of modern times- in this regard is doing no harm to the insane, but that there is some special evidence to show that in the treatment of melancholia, which includes so large a class of cases, the methodical employment of seclusion and rest outside of hospitals for the insane has actually failed to be of benefit. While the older views of seclusion and rest have been undergoing modification leading to practical abandonment by some of those who have treated the insane, one of the most important contributions to the healing art in modern times is that made by Dr. Weir Mitchell in the well-known doctrine of " Rest Treatment " by means of " seclusion, rest, massage, electricity, and overfeeding," so successfully employed' in the treatment of nervous exhaustion. If, then, "seclusion" and " rest" are of such essential value in fehe- treatment of ner- vous exhaustion in persons not insane, why are they not also of value in insanity, which often is simply a greater degree of the same disorder of the nervous system ? The ans-wer is, possibly, that in the former case the functions of the reasoning faculties are so nearly in a normal state as to permit " seclusion " to be regarded and accepted by the patient as a reasonable necessity,, and the path upward toward health is from a point where the 214 PSYCHOLOGICAL MEDICINE. mind is not controlled by delusions or given up to despair. After the mental functions are unbalanced we have to deal with a new set of conditions, and our efforts must be more largely addressed to the moral treatment of the disordered and weakened mind. In experiments with the rest treatment here, during the past three years, it has been found necessary to modify it. Cases of mental depression are apt to have this increased by rest in bed, and, to those in which melancholia is accompanied by a state of nervous irritability and constant uneasiness or anguish, enforced rest is intolerable and positively harmful. While rest is useful in some conditions of melancholia and other cases, and benefit has been derived from massage by producing tissue waste and improving nutrition, and from the other means of treatment, " seclusion " has been almost entirely abandoned as not useful and as depriving the patient of what is beneficial. Interesting and valuable evidence on this point is generously afforded me by Dr. Mitchell, who has given me per- mission to quote from a recent letter some statements which he has never published. He says that in the treatment of " not a small number of cases of melancholia with bad nutri- tive breakdown, in which I attempted to relieve by rest, etc., I made some successes, but more failures — made, in fact, so many that I gave up at last the effort to treat in this way distinct cases of melancholy." " I may use massage or electricity in melancholy, but I do not seclude or rest these cases." The rest treatment has been for some years extensively and most successfully employed by Dr. W. S. Playfair, in England. He says, in the London Laiicet, December, 1881, of the cases that are likely to lead to disappointment, that one class is of those in which there is some definite mental disease, and, after a short tidal in melancholia, he felt bound to relinquish the treatment. Wliat is true of " seclusion '"' in the treatment of melancholia has also been observed here to be true of other forms of insanity, and concurrent testimony is not lacking from those who treat the insane in hospitals. While there is unquestionably a growing liberality in the matter of freedom of commu- nication with the insane in hospitals, it is to be recognized that more will be accomplished in this direction by acting upon a correct theory and with a clear purpose. Instead of a modification of the old rule, its reversal is advocated, and the making of limitations of communication the exception to the rule. The point now desired to be made is that there is a scientific reason for putting the insane sick person upon the same basis, both as to medical and moral treatment, as the general hospital patient; and, in regarding him simply as the subject of a disease in which normal function is acting under abnormal conditions, it is, therefore, good practice to unhesitatingly foster, encourage, and, if need be, stimulate the exercise of all normal mental functions, being guided by symptoms as they appear as to all modifi- cations of the general principle in regard to change of residence, restriction of liberty, and seclusion, as well as medical treatment proper. Statistics of the North Caroli^ia Lisane Asylum, Dr. Eugene Gnssoin, Superintendent. — The annual report of this institution for 1882 shows that the total number of admissions since the opening of the institu- tion, in 1856, amounts to 1467. The total number discharged, for the same time, is 11 89. Of these, 385 were discharged as cured, 151 were improved, 225 unimproved, and 429 died. There are now under treatment 278 cases. There was a total of 334 cases treated during the year 1882. TREATM.ENT OF INSANITY, " 21$ Statistics from many more asylums might be given, and such reports as I have before me all testify ^o the highest degree of con- tinuous and faithful labor among the insane, for their welfare and cure, by the superintendents of the asylums in the different States of the Union, but want of space forbids the insertion of any more. To all these men is due from the profession a generous recognition of their services in the -field of psychiatry and in the cause of humanity. The .ratio of recovery in insanity 'depends largely upon the charac- ter of the diseases and the ages of persons received in ouc asylums and hospitals; also upon the length of time the disease has existed, a-nd upon the degree with v/hich it has affected the system. Persons in whom mental disease has existed for several years, or who have ■experienced several attacks, or persons beyond sixty years of age, or, finally, those affected with organic disease of the -nervous system, rarely recover, and, consequently, when any of these characters of disease largely prevail the percentage of recoveries becomes less. There is very little doubt that, in an increasing n-umber of cases, insanity is dependent upon organic changes in the brain and spinal cord. If this be so, it will not tend either to a diminution of the number or to an amelioration in the character of the -mental disor- ders of those who are now sent to our State institutions for treatment There seems to be a thorough ignorance among the general popula- tion of the primary laws and conditions of mental health, and the greater part of the peof)le neither understand nor practice such hygi- enic regulations as are necessary for its preservation. Educated men, professional men, clergymen, lawyers, and physicians do not seem to understand that the laws of mental health imperatively demajid chd^nge and variety, failing which, the brain inevitably succ-umbs. Our women, too, need more change, rest, and recreation, especially those who live in the country districts, to change the ceaseless current of thought, care, anxiety, and household work. Pinel's and Esquirol's Improvements. — As Pinel was one of the first to properly recognize and classify insanity, so, in speaking of treat- ment, we would refer to him in his humane endeavors and successful efforts to do away with the beating and cruel treatment of the insane. He has elsewhere aptly been termed, " The Father of the Modern Treatment of Insanity." His pupil, Esquirol, also, was the most suc- cessful of his immediate successors in carrying out Pinel's ideas in treating insanity and in advancing the scientific knowledge regarding it. The treatment of insanity has improved up to the present day, 2l6 PSYCHOLOGICAL MEDICINE. and the success which has been reached in abridging maniacal attacks and warding off dangerous excitement gives us a much different class of patients, both in behavior and appearance, than could have been found fifty years ago. This change, which has taken place gradu- ally as the natural result of improved modes of treatment, has not been fully recognized by the profession at large. Kindness and moral and hygienic treatment have achieved great triumphs over the cruel, harsh, and unsympathizing methods which characterized for- mer times. One great rule to be observed in the management of the insane is that they are invariably to be treated with kindness and consideration. Their peculiarities should never be lost sight of, but should never be made the topic of conversation or ridicule. In the excited state of the nervous system in the insane a careless or an un- kind word is often deeply felt, and all efforts toward a cure may be rendered futile by the patient perceiving in his physician the want of sympathy and kindness of heart which he, above all others, has a right to expect and demand from us. The insane are as amenable to kindness, as a rule, as sane people, and will almost invariably repay it by good behavior, while the opposite course is quite as sure to counteract all our efforts in their behalf. As in all other diseases, hygienic influences must be insisted on, and pure air, pleasant sur- roundings, and good food are of great importance. The mind, to be normal, must be associated with a healthy physical state, and we must,, in the treatment of the insane, attend primarily to these things, aad not, by any means, regard them as beneath our notice. Home T^-eatinent, or Treatment away from Home. — Many persons question the propriety of confining a patient in an asylum, private or otherwise, maintaining that if they can afford to keep the patient at home and provide medical attendance, and an attendant for him, he is much better taken care of. This, with the exception of a limited class of cases in the incipient stages of insanity, is a very mistaken idea, and one very injurious to the patient hiiYiself. One of the most marked characteristics of the insane man, is his intense egotism, if it may be so called ; or more properly speaking, it consists, in the lan- guage of Dr. Blandford, in an " extreme concentration of the whole thought and ideas on self and on all that concerns self" At home he is more or less the master of the house, and regards himself, when restrained, as a deeply injured man, and chafes much more, and is more truly a prisoner in his own home than when allowed the com- TREATMENT OF INSANITY. 21/ parative liberty of a well-regulated private or public hospital for the insane. When in such a hospital he loses or merges his identity more or less with his companions, which is an excellent thing for him, as he ceases to be the centre of observation and remark, and is treated and noticed precisely in the same way as are the thirty or forty other pa- tients who are his companions. A very striking instance of this kind occurred in a patient of good education, who, upon becoming insane, imagined himself the Supreme Being, and insisted upon ex- ercising all the fancied prerogatives of such a being. He became very troublesome and dangerous to those about him, and was entirely absorbed in the contemplation of his own greatness, which idea was fostered by the attention he received, and the pri- vate room in the asylum of which he was an inmate. He was ac- cordingly removed from his room to a ward in the asylum contain- ing twenty or thirty other patients, and was given to understand that the amount of his liberty and the privileges which he enjoyed would depend entirely upon his behavior. He at once perceived and at first angrily remonstrated against the want of attention paid to his whims and caprices, but soon understood that he was not regarded by the attendants as in any way superior to the other patients, and in their treatment of him was manifested no attention at all to his delusion. Finding his endeavors to exercise his authority fruitless, he gave up his imperious and unrestrained demeanor, and soon sub- mitted quietly to the order and discipline of the institution, and was afterwards one of the best-behaved patients in the ward, rarely re- curring to his delusion. Moral Treatment. — Regarding the moral treatment of the insane, the physician's attributes have been well defined by Drs. Bucknill and Tuke as follows : " The physician who aims at success in the moral treatment of the insane, must be ready ' to be all things to all men, if by any means he might save some.' He must, nevertheless, have a good backbone to his character, a strong will of his own, and with all his inflections be able to adhere with singleness of pur- pose and tenacious veracity to the opinions he has on sound and sufficient reasons formed of his patient, and the treatment needed to be pursued towards him. With self-reliance for a foundation to his character, it requires widely different manifestations to repress ex- citement, to stimulate inertia, to direct the erring, to support the weak, to supplant every variety of erroneous impression, to resist 2l8 PSYCHOLOGICAL MEDICINE. ever}'- kind of perverted feeling, and to check every form of pernicious conduct." Clinical Instruction in Hospitals. — In connection with the subject of the treatment of mental disorders, I think there is a much needed reform, which, if carried out, would make mental disorders far better understood by the medical profession generally than they are to-day. The trustees and managers of our lunatic hospitals are too often opposed to reforms, and wish no changes or improvements ; but I think the change I propose is due both to the general medical profession and to the public who support them, so that the general practitioner may be so educated that he may recognize the first symptoms of insanity, and be able to cure it in its incipient stages, without perhaps having recourse to a State hospital for the insane at all. I refer to a proper provision, which ought to be made in every public hospital for the insane, for both clinical and pathological instruction, by lectures by the physician in chief and others, to diffuse a thorough knowledge of the disease and its treatment throughout the medical profession. With such knowledge as could easily be acquired in this way, physicians could probably cure many patients in the early stages of the disease, so that it would be unnecessary to send them to a hospital at all. Insanity is much more important than many diseases which receive very careful study in our medical schools, and I think it of equal importance at least that this class of cases should receive a due amount of study. It is a great mistake to erect such large and ex- pensive buildings, costing three or four thousand dollars for each pa- tient; making efficient administration very difficult; abuses more likely to occur; aggregating great masses of mentally diseased per- sons, so that both the per cent, of cures is less and the rate of mor- tality greater than in smaller hospitals ; making good ventilation next to impossible, and also rendering efficient drainage and sew- erage very difficult ; and making daily remedial exercise in the open air for all the inmates, when possible — a most important therapeutic measure — very difficult indeed. We should have smaller hospitals and more of them, and the insane would then have more employment, more liberty, — and, in my opinion, a better chance of cure than when confined in an overcrowded hospital. Food, Aimisenie7it, Work, etc. — In treating the insane, the great ne- cessity is for better food, more amusements, which draw off the mind from the delusions which occupy it, and combat depression of mind TREATMENT OF INSANITY. 2I9 by bringing before it new scenes and objects, and lastly, more free- dom and liberty and less mechanical restraint. We have improved the condition of the insane materially during the past few years, and have rendered a residence in an asylum less irksome and more bene- ficial for those who are obliged to resort to such institutions. We have abolished mechanical restraint, except in rare instances where it is necessary for the patients' safety or of those about them ; have abolished all forms of punishments, and have improved the quality of food and clothing. The insane should be encouraged to go out- side of the walls of the institution of which they are inmates, as far as is practicable, for work or pleasure, when their behavior justifies this measure. In this way they are put on their honor and good be- havior, and where one may occasionally escape, doing but little in- jury, thousands will be essentially benefited, and, in some cases, cured for life. The physician should ascertain what bodily and intellectual exercises have been pursued by his patient in early life, and should endeavor, by proper appliances, to bring these external causes to bear appropriately upon each particular case. Attempts may also be made to restore the healthy function of mind by recommending such lite- rary studies and accomplishments as have been known to previously interest and amuse the patient. The treatment must be of a varied character to meet the requirements of each case at different periods. We must remove the disease, build up the health, draw off the mind from morbid fancies, and lead our patients to brighter and more healthy views of life and its surroundings. We must combat dis- eased actions, produce sleep, and strengthen the whole system. We must lead our patient to a careful, regular, and more healthy course of life. In insanity we have an abnormal state of nervous tension and pent- up nerve-force, which must expend itself in some direction, and must generate an equivalent manifestation of force, either m feeling, thought, or bodily action. If, then, we cause the nervous excitement or pent-up nerve-force to be expended in bodily or muscular action by means of employment, we shall decrease correspondingly the morbid thoughts and feelings which are caused by the intensity of the cere- bral excitement. If we allow our patients to remain idle, the whole pent-up nerve-force is expended and concentrated upon thoiiglit and feeling, which become morbidly intensified and perverted, and at last produce incurable and organic changes in the brain, which might have been arrested by drawing off the nerve-force in the channels of 220 PSYCHOLOGICAL MEDICINE. labor and employment, and giving a new direction to the thoughts and feelings. Out-of-door work is very valuable for patients in pro- moting assimilation and digestion, and strengthening the muscular system, and should be employed whenever practicable. Light work gives the patient something to think about, and occupies his mind in a healthful manner, while being shut up constantly indoors tends to enfeeble the body, and the mind is occupied too often in revolving the delusions which it should be the aim of the physician to banish as far as possible. As it is impossible for the majority of patients to be employed in this manner, it is desirable to find some light em- ployment indoors. While it is comparatively easy to find employ- ment for women, such as sewing, knitting, washing, and making dresses, the men are not so favorably situated, as the expense of fit- ting up workshops is so great that in most instances it is not con- sidered a sufficiently valuable adjunct to justify the necessary outlay. They may be taught, however, to do light work, such as cane-seating chairs, etc., and in such ways occupy their minds and afford them some muscular exercise, however slight. The foreign asylums have systematized manual labor to a much greater extent than in this country; and some of them, as the Asylum of Ouatre Mares, near Rouen, do a great deal of work in all the trades. There was, a short time ago, an interesting exhibition for the public in the lunatic asylum at Briinnfeld, near Vienna. The objects exhibited were di- vided into three classes, the first comprising 215 articles made en- tirely by the patients ; the second, articles destroyed by them in their maniacal excitement ; and the third, models, etc., showing how they are lodged and clothed. Among the articles in the first class are delicately-carved meerschaum pipes, lace, picture-frames, and a re- markable collection of paintings by Kratky, who, before he became insane, was a celebrated artist at Vienna. These paintings show no sign of his insanity, and one of them was a wonderfully life-like representation of the insane hearing mass in the chapel attached to the asylum. Next to these specimens of the constructive skill of the inmates are placed huge iron bars bent double, spoons and iron plates broken to pieces, and doors split in half. The favorite occupation was writing and drawing, in which some of them had become very proficient. Recreation is also more indulged in abroad than in our asylums. At the Fisherton Asylum, near Salisbury, England, which is a private institution, accommodating about six hundred patients, a separate brick building was erected for TREATMENT OF INSANITY. 221 the purposes of recreation. It is one hundred feet in length by- thirty in width. At one end of the interior of this building is a stage, fitted up with all the accessories for private theatricals. At the Prestwick Asylum, near Manchester, is a very large and hand- somely-painted room, which is devoted to music and theatricals. At the lunatic asylum at Ghent, the Hospice de Guislain, are four hun- dred and seventy male patients, who are variously employed in shoe- making, bookbinding, combing flax, making twine, weaving cloth, and in carpenter-work and work out of doors. There are also rooms for music and smoking. At the asylum at Clarendon, near Paris, are six hundred patients of the paying class, for whose amusement are provided a library and billiard room. The best of our ov/n asy- lums afford, however, as good facilities for amusements as the foreign ones, if not on so extended a scale, while the condition of the pa- tients and their care and treatment are, as a general rule, superior to those of the foreign asylums. There is a very interesting colony of about thirteen hundred lunatics at Gheel, in Belgium, which, in 185 1, was placed under governmental control. The following interesting description of it is from the Brussels correspondent of the Pall Mall Gazette : Yesterday an excursion to the lunatics' colony at Gheel was undertaken by about forty members of the International Medical Congress. Gheel is situated in the province of Antwerp, and in that portion of Belgium known as the Campine, a flat country, with fine bracing air. We started early in the morning for Herenthals, which by railway is at a distance of two hours and forty minutes from Brussels. From Herenthals a drive of one hour and forty mmutes by car took us to Gheel. Near a country inn, at about a league distance from Gheel, we were already met by one of the lunatics. Dr. Bulckens, the director of the Gheel colony, under whose guidance the excursion was made, presented him to us. He answered very intelligently all the questions put to him. He had been a schoolmaster, and was now giving private lessons in French, Latin, and other subjects in the farmers' houses of the neighborhood. He begged not to be detained long, as his pupils were waiting for him. The poor schoolmaster's madness was of a religious kind. He told us that he was quite happy, and did not wish ever to leave. On arriving at Gheel we were received at the asylum — a fine red-brick building, surrounded with nice planta- tions — by Dr. Peters, the assistant of the director. In the committee-room Mile. Bulck- ens, the director's daughter, invited us to take the usual Belgian morning refreshment — Madeira and cakes; and then Dr. Bulckens gave explanations concerning the colony. It is of very ancient origin : a legend places it as far back as the seventh century, attribut- ing it to Sainte Dymphne (Dymphna or Digna), the daughter of an Irish king, who came to live at Gheel, where she also underwent martyrdom, and became then the protectress of the insane. However, it is proved that as early as the twelfth century foreign lunatics were sent to Gheel, for the sake of the special treatment given there. This treatment differs from that in use everywhere else. The lunatics are not kept in an asylum, but hoard and lodge with the inhabitants. In 1851 the institution was reorganized and placed 222 PSYCHOLOGICAL MEDICINE. under the government. Since then a great increase has taken place in the number of pa- tients sent there. The commune of Gheel, with its outlying hamlets, is very extensive. It covers i i,ooo hectares, and the number of inhabitants is also about i i,ooo. The luna- tics number now about 1300 of both sexes. The commune is divided into four sections. At the head of each is placed a medical man and an overseer. The patients are froon all nations and all ranks of society, and they receive accommodation according to their means. The wealthy are placed with the wealthier class of inhabitants, and the poor with the poorer. The pauper lunatics, for whose support their respective communes have to pay, belong to the last category. The more dangerous class of lunatics are placed in the outlying isolated hamlets. They are divided into sections according to the na- ture of their disease, and the Walloon patients are kept in two separate hamlets (Gheel is a purely Flemish place, but most people understand French), so as to be companions to one another. The 11,000 inhabitants are, so to speak, all engaged in the surveillance of the patients, which makes about nine overseers for every patient. The surveillance, not being perceived by the patients, of course does not irritate them. The commune earns directly more than 500,000 francs annually through the keeping of the lunatics, and in- directly also a great deal through the cheap work of ail kinds which the patients perform for the mhabitants. It is the personal interest of the inhabitants to do their duty well by the patients, as these are intrusted only to people whose moral fitness and means of existence are approved. In fact, a family at Gheel is not considered respectable if luna- tics are not intrusted to it, and the withdrawal of them from its care constitutes a heavy punishment. The children of the inhabitants, living from their earliest childhood with lunatics, become attached to them, do not find anything ridiculous in them, learn how they are to be treated, exercise through their company a very soothing influence on them, and are, of course, not in the least afraid of them. When young people get married they ask from the authorities as a favor and a sort of dowry the care of a patient. On their arrival at Gheel, the lunatics are kept at the central asylum for observation as long as the director deems necessary. In case of acute disease they are brought back there. It also serves as the house of correction, the privation of liberty being felt as a severe pun- ishment by the patients. In cases of great debility they are also brought there. Many lunatics, when feeling the approach of a paroxysm, demand themselves to be sent to the asylum. When a cure has been effected, the caretaker receives as a reward another pa- tient, and if many cui-es occur at his house he is rewarded with the care of a wealthy patient. The number of cures averages from sixty-five to seventy-five out of the hun- dred. Patients with radically immoral or highly dangerous tendencies cannot be kept at Gheel, the central asylum being only a depot. The number of lunatics under tempo- rary coercion is generally twelve out of the 1300. W^e visited now the infirmary, the cells, and the halls, where the lately arrived are kept under observation. The very dirty patients, who cannot be placed with the inhabitants, have their own rooms, with suitable arrangements. We found everywhere exquisite cleanliness, and good air and light; the patients seemed to relish their dinner well ; they enjoy, even in the asylum, a great deal of liberty, and if a lunatic asylum could be called a cheerful place, the one at Gheel is, perhaps, the only one to which that term could be applied. Good paved roads traverse the commune, and many houses are really fine villas, with large gardens in the rear. The first house which we visited was the house of poor people. We found the family, composed of man, wife, and three young chil- dren, and their two lunatic boarders, seated round the table at dinner. The children seemed to be quite unaware that they were sitting at the side of lunatics, nor would a stranger entering unprepared ever have thought of the presence of such persons. After some more visits of the kind, we went to the principal tavern, to which a fine large hall TREATMENT OF INSANITY. 223 is attached, where there are fStes, concerts, and dancing every Sunday, Some of the houses of the wealthier classes were now visited. They offer all the comforts that can be desired for ladies and gentlemen. The apartments are large, well furnished, and the patient may install in them librari-es and whatever is allowed by the director. We found there persons of very high social rank, and others of great accomplishments. In the streets we met at every moment lunatics lounging before the doors of the houses, smoking pipes or cigars, playing with the children, or otherwise amusing themselves. Among the wealthier class of patients at Gheel it is nothing uncommon to find persons who spend there from ;^300 to ^600 a year. Some keep cars and horses for their use. The au- thorities watch carefully that the patients are not imposed upon, and that they receive its value for the money which they spend. Cases of misconduct of any kind toward a patient are, however, exceedingly rare, and the punishment of being declared unworthy to keep patients is considered a fearful disgrace. We visited the Church of St. Dymphne, the Irish princess and protectress of the lunatics. In the seventh century there existed on the spot a chapel dedicated to St. Martin, surrounded by a dozen houses forming then the village of Gheel. The style of building of the present very spacious church points to the twelfth century, the time of transition from the Roman to the Gothic style. Some parts, however, were added later. The central chapel of the diambulatorium contains a remarkable work of art, the history of St. Dymphne, carved in wood. It is divided into eight parts. The figures, painted and gilt, are of good proportions, and the faces won- derfully expressive. The parts represent : i. The birth of St. Dymphne, who is handed over by her mother to St. Gerebert. 2. The death of the Queen, the mother of St. Dymphne. 3. The devil suggesting bad thoughts to her father, the Irish king. 4. St. Dymphne embarking with St. Gerebert for Belgium. 5. The king seeking his daugh- ter. 6. The wicked king who has had St. Gerebert beheaded, beheading himself hzs daughter, as nobody else would serve as executioner. 7. Priests carrying in procession the relics of St. Dymphne. 8. A demon leaving the head of a lunatic woman, cured by prayer, and a lunatic in chains waiting his turn for deliverance. I ought to add that during our visit we met from the excellent director, Dr. Bulckens, the parish priest, and everybody we came in contact with, the most exquisite courtesy and willingness to give us information. Mechanical Restraint and Seclusion. — Respecting the question of non-restraint in the treatment of insanity, I think it is possible to bring the treatment of the insane to that state of development when all mechanical restraint may be dispensed with advantageously. I feel sure that the complete non-restraint system will be adopted in future, but the necessary conditions for this are that our asylums must not be overcrowded, as they are to-day, and that the patients must be under constant medical supervision. Perfect non-restraint has been adopted, I think, at Hamburg, Gottingen, Berlin (Charite),, Halle, Marburg, Heidelberg, Eberswalde, Keppenheim, Werneck, Munich, and Alt Scherbitz, besides all the asylums of Switzerland; also in Scotland, in some instances, and recently in England, although in the latter I am not sure that the unqualified adoption of non-restraint has met with success. I think, wherever the system of non-restraint has been properly carried out, there have, with few exceptions, no doubts been e?itertained of its advantages in the treatment of mental disorders. 224 PSYCHOLOGICAL MEDICINE. Respecting the home treatment of private patients in private dwellings, Dr. Henry Maudsley says, referring to the condition of the numerous chancery patients in England who are living in private houses : " I have the best authority for saying that their condition is eminently satisfactory, and such as it is impossible it could be in the best asylum," Dr. Bucknill, in his recent essay, " On the Care of the Insane, etc.." speaks as follows respecting the private care of the in- sane, and, as I think, very wisely : " It is not merely the happy change which takes place in confirmed lunatics when they are judi- ciously removed from the dreary detention of the asylum into domes- tic life, it is the efficiency of the domestic treatment of lunacy during the wJiole course^' of the disease which constitutes its greatest value, and of this the author's fullest and latest experience has convinced him, that the curative influences of asylums have been vastly over- rated, and that those of isolated treatment in domestic care have been greatly undervalued." Respecting the treatment of the insane without mechanical re- straint,t Dr. Henry Maudsley says : It should be borne clearly in mind that the abolition of mechanical restraint is not itself a principle, but a detail of practice founded on the principle which inspires what is called the non-restraint system. A very bad system of moral management might prevail where no actual corporeal restraint was used ; and, on the other hand, it is possible, though not probable, that means of restraint might be used occasionally and yet the management of patients be in other respects good. To scold, bully, or punish an insane patient would be almost as injurious to him, and certainly as contrary to the true principle of the non- restraint system, as to apply mechanical restraint. Experience proves most decidedly how beneficial is the influence of a good attendant, how pernicious is the influence of a bad attendant on a patient suffering from mental disorder; the patient will degenerate under the influence and harsh usage of an ill-tempered person as plainly as he will im- prove under the sympathy and gentle behavior of a kind and considerate person. He * Italics are mine. ■j- Some American alienists consider that the English run great risks by their total non- restraint, and that, owing to insanity being of a more severe type in America, that total non-restraint is alike unwise and oftentimes prejudicial to the best interests of the patient. — E. C. M. During a recent visit to Philadelphia, we talked with Dr. Henry B. Nunemaker of the Philadelphia Hospital for the Insane upon this point, and he seemed to be decidedly of the opinion that insanity is gradually assuming a milder type in our own country, which had made itself very manifest during the past five years. This is a very important fact, as, if correct, it will lead rapidly to the abolition of restraint. It has been claimed that the type of insanity in England is much milder than with us, while in France, it approxi- mates more nearly the American t)'pe of insanity. Climate and national temperaments are assigned as predisposing causes of the prevailing type in any country. TREATMENT OF INSANITY. 225 has more than once known instances of patients who have, without exaggeration, been cured by judicious change of attendant. The greatest of difficulties, indeed, in the treat- ment of the insane, is to obtain suitable persons to fill this trying and most responsible position. Qualities of head and heart are demanded such as would secure for their pos- sessor higher remuneration and less onerous duties in a more eligible vocation. The accidents and injuries in asylums, which have lately excited so much attention, have in- dicated the weak point in asylum management — the want of a properly trained and high class of attendants, and of -an adequate supervision of these immediate guardians of the insane by officers of a higher standing. It is to be feared that patients are, in some in- stances, left too much at the mercy of attendants. Now, to place an insane person at the mercy of a coarse, violent, and ignorant attendant is to adopt the surest way of ren- dering him furious, unmanageable, and finally incurable. With his delusions of suspicion or fear he mingles inseparably the realities of the treatment to which he is subjected, and if this be at all harsh and unsympathetic he naturally becomes furious, and resists it with all the energy of his frenzy. His delusions are thus strengthened and fixed ; whereas, by gentle usage and sympathetic attention, his confidence is gained and they are gradu- ally undermined. Angry usage — nay, even an angry word — sometimes does incalculable mischief. It is easy to perceive that if a patient imagines himself to be in hell or about to be murdered, and those around him to be devils or murderers, as happens now and then, he is not likely to be disabused of his morbid idea by devil-like treatment. The principle of the non-restraint system, in the true acceptation of the term, is, whilst avoid- ing a meddlesome interference, to make all the surroundings of the poor lunatic as tran- quil, as orderly, as gentle as may be consistent with his proper care, to counteract the commotion in him by an absence of commotion in what is around him. The lunatic cannot, any more than the sane person, resist the steady influence of his surroundings; he assimilates them unconsciously, and they modify his character for good or for evil. How little a system of mechanical restraint fulfils the conditions of the just principle of treatment is so plain that a wayfaring man, though a fool, can hardly fail to see it. An excited, active patient, urged by an uncontrollable instinct of movement, desiring and needing, above all things, freedom of limbs, is secured, hand and foot, by inechanical appliances; with what result? That he is provoked into furious mania, expends his energy in shouting and raving, and becomes dirty in his habits. Dirtiness in some shape is, in fact, unavoidable under such circumstances. But it may be argued, as it is some- times argued, that it would be better for the patient to be so restrained mechanically than to be restrained by the efforts of attendants who, in the excitement of struggling, are apt to overpass the limits of a temperate exercise of force, and to proceed to passionate acts of violence. No doubt, if it were necessary to have such struggles where restraint was not used, and not necessary to have them in order to apply restraint, there would be something to be said in favor of its use. But it is very seldom necessary to have a physi- cal contest with a patient ; indeed, if contests of the kind were of frequent occurrence, it would be strong evidence of a bad moral tone in the management, and of a neglect of proper medical treatment. If the whole treatment of acute insanity consisted, as some persons seem to imagine, in mastering the patient by physical force and in endeavoring to stifle excitement by means of opium and other sedatives, there can be little doubt that violent struggles and restraint, in some form or other, would be found necessary. But if an indiscriminate use of sedatives be avoided and a rational medical treatment be directed to the bodily disorder which will commonly be found to accompany mental derangement, and if, furthermore, the moral management be sympathetic and prudent, it will be seldom necessary to resort to physical violence. Let it not be supposed, moreover, that the imposition of mechanical restraint does away 15 226 PSYCHOLOGICAL MEDICINE. with scenes of violence. Far from it; it encourages them. Much violence must usually be used in order to apply the means of restraint, a desperate contest occurring before the patient is overpowered and left helpless, exhausted, and furious, with a bitter sense of degradation. Such straggles breed similar struggles, and the restraint used necessitates a frequent recurrence to it. There can be no greater fallacy than that of supposing what is called a moderate use of mechanical restraint to be consistent with a general plan of treatment in other respects humane and beneficial. It must be dispensed with altogether, or deterioration will ensue in the patient, and all kinds of neglect and tyranny will be engendered by degrees, until restraints become the usual substitutes for forbearance and watchful attention. As one great argument against slavery was that it demoralized the slaveholder, so a very bad effect of the employment of restraint in dealing with the insane is that it demoralizes attendants. And on this ground, if there were no other grounds, it is necessary that the abolition of restraint should be absolute to be efficient; the principle of the non-restraint system will admit of no compromise. It must be allowed that when called to treat an acute case of insanity in a private house, it is not always so easy to do without restraint as it is in an asylum, where there are suitable appliances for meeting the difficulties which the excitement and violence of a patient may present. But if a medical man finds it absolutely necessary to employ mechanical restraint, he should, if he has the welfare of his patient at heart, send him elsewhere, for, either it is not a fit case for private treatment or he is without the requisite assistance and qualifications for treating it properly. The attendants on whom he de- pends are probably ignorant and incompetent. It should be clearly understood by those who feel any doubt of the value of the non- restraint system that, although it is not fully adopted in foreign asylums, it has been warmly advocated by the most eminent foreign alienists who have witnessed it in opera- tion in English asylums. Morel, of Rouen, after living some time in an English asy- lum, in order to make himself practically acquainted with its working, became, and has since been, one of its warmest supporters. The late Professor Greisinger, who, once an opponent of non-restraint, made a journey to this country especially to exam- ine into its merits and alleged demerits, became an earnest defender of it, and applied it with great success in the asylum connected with the Charite at Berlin. Ludwig Meyer introduced it with the most beneficial results into the asylum at Hamburg, over which he formerly presided. Others have followed and are following in the wake of these distinguished men. With such testimony coming from abroad, it is somewhat sad to find that doubts should arise in the country in which the non-restraint system had its birth and has attained its fullest development. Our author cannot think that, in face of the irrefu- table evidence of experience, they will have a long vitality, and he certainly does not hesitate to express a strong personal conviction that the use of mechanical restraint in any asylum, public or private, is an indication of a badly-managed institution, and that its use, m the treatment of private cases, is unnecessaiy and prejudicial. Where it is entirely dispensed with there will be less excitement, fewer scenes of violence, less need of secluding patients, and earlier and more numerous recoveries than where it is in use. For it is not only an evil itself, but it is the fruitful parent of a multitude of ills, not the least of which is the certain deterioration of all who have any part in its employ- ment, whether suffering or doing. The late Dr. Isaac Ray, of Philadelphia, in writing on the manage- ment of hospitals, speaks thus of mechanical restraint and seclusion, and the general welfare of the insane : TREATMENT OF INSANITY. 22/ The reformer's creed frequently contains but a single article of belief, namely, this : because a thing is bad, therefore the directly opposite thing is necessarily good. The effect of this fallacy has been strikingly manifested, for instance, in the controversy, not yet settled, respecting mechanical restraint as applied to the insane. Everybody admits that it has been grossly abused, but an immense difference prevails as to the practical infer- ence that should be drawn from the fact. While it leads one party to use it for proper purposes and in a judicious manner, so as to secure its benefits and avoid its evils, it leads another to disuse it altogether as an unmitigated wrong. Of course, abundant rea- sons are offered for the correctness of each of these conclusions, and they are not without their force; but — in accordance with a common phasis of belief — they have probably less to do with actual opinions than a state of feeling antecedent to all reasons. This accounts for the difficulty of arriving at the truth in all questions of practical reform ; but the number of those who learn from it a lesson of caution against hasty conclusions will always be small. In the present case there is a touch of the romantic in the idea of managing the insane entirely without mechanical restraint, and solely by moral suasion or the gentle laying on of hands ; and when first announced it is not strange that it was taken at once into public favor. It had all the eclat of a great discovery, worthy of being compared with that of anesthetics or the vaccine virus; and in England, where it origi- nated, it needed more than an average share of moral courage to regard it with the slight- est distrust. One thing leads to another ; and the idea of complete non-restraint was followed, in the fulness of time, by that of banishing all those distinctive architectural arrangements supposed to be indispensable to the proper care and custody of the insane. Open fires on the hearth, windows without guards, and doors without locks, have been adopted in one or two hospitals lately erected in England. It is not surprising that men of a san- guine, philanthropic temper, should hail such innovations with their warmest approval, and that under the pressure of public sentiment they should be sustained, temporarily at least, at all hazards. The careful observer, who studies insanity like any other object of scientific investigation, will hardly be satisfied with the reasons offered for such a radical reform ; and though willing to accept results as the proper tests of their soundness, he will require that the experiment shall be tried on a large scale, by various parties, and its indirect and contingent, as well as immediate results, be fairly taken into the ac- count. No experiment in the management of the insane can be considered successful, merely because no indications of failure are visible for a limited period, or under peculiar circumstances. For the very object may be, not to prevent an evil which otherwise would be sure to happen, but to meet a contingency that may never occur. The mere fact that it does not occur has no necessary connection with the means of prevention. No one at all conversant with hospitals for the insane can have failed to see that, in some degree, their results are apparently a matter of chance. To attribute them entirely and exclusively to management would be no mark of wisdom. The man who congratulates himself on the success of his measures for preventing suicide, on account of entire ex- emption for several years, will find his self-complacency somewhat ruffled when, without any change of practice, several cases occur in rapid succession. So, too, he may find that the large proportion of recoveries, and the small proportion of deaths and casualties, which for a time seemed to be indisputable proofs of his skill, are attributable to causes over which he had little or no control. Now, to ascertain how far this element of chance prevails, must always be a work of time; and we may fairly challenge the soundness of any conclusions where sufficient account has not been made of its influence. Another error very incident to measures of reform in our specialty is to mistake indi- vidual traits for general conditions, and thus conclude, prematurely, that what is appli- 228 PSYCHOLOGICAL MEDICINE. cable to one case is no less applicable to all. Diversities of disease, of previous manage- ment, of natural character, may all be ignored, and some procrustean plan regarded as embodying all the wisdom worth retaining. A patient long subjected to mechanical restraint improves under its disuse ; therefore no patient requires it, and complete non- restraint must be the unexceptionable rule. Another is annoyed by the sight of locks and guards, which, in fact, are unnecessary for him ; therefore they are annoying to all and unnecessary for any. Another desires to go out unattended, and undoubtedly is all the better for the privilege; therefore unrestricted freedom in this particular should be the general rule. Deductions like these may seem somewhat puerile, but they are scarcely exaggerations of what have actually been made. Now, with all admiration for the spirit underlying these projected reforms, I am still obliged to doubt whether they do not ex- hibit some confusion of thought, both as to the ends which are proposed and the condi- tions of a successful experiment. These two questions it may be well to consider for a moment, beginning with the latter. Morbid movements of the nervous system often require considerable time for their completion, and are marked by a certain periodicity not apparent in other affections. What we happen to see may be but a single phasis of the movement, to be followed by others equally prominent before the morbid cycle is completed. What it may reveal precisely, we cannot predict before it is completed. Now, a kind of management that may be very proper in regard to one of these phases may not be so in regard to another, because the wishes and feelings of the patient, the force of his impulses and the gravity of his disease, may present the utmost possible difference. An inflexible rule of manage- ment, by ignoring these diversities, must necessarily occasion much mischief, directly or indirectly; and not more does the individual differ from himself at different periods, than does the general condition of the house. The expediency of non-restraint, for instance, might be very differently manifested, even in the same establishment, at different periods, inasmuch as several months of complete disuse of restraint might, very properly, be fol- lowed by as long a period of its abundant use. We should not suppose we had cured a case of epilepsy or hysteria merely because the period since the last fit has been much longer than any previous interval ; or that a maniacal patient had recovered, because the high excitement had passed away and he replied to a few questions correctly ; why, then, should we be required to accept any principle of management which has been tried, however successfully, on a limited scale and for a limited period ? It is no satisfactory reply to the patent objections that lie against this or that aiTangement, to say that no harm has arisen from it, so far. Great care, aided by great good luck, may unquestionably save us sometimes from the legitimate effects of a faulty arrangement. But in any provision relative to the management of the insane, it should be implicitly required that its operation should depend as little as possible on the chances of fortune or the short- comings of men. Its merit should consist, in a great measure, in its independence of these contingencies. Success, in spite of manifest danger, would be a very feeble argument in favor of repeating the experiment. To say of it that we have got along under it without any untoward event, is to render but a vulgar estimate of success, though one most intelligible, perhaps, to the multitude. Let us bear in mind, too, that a broader field of trial, a wider scope of comparison, a more impartial judg- ment of results, is necessary, than any single individual can fairly claim. Much error has been committed on this subject, in consequence of misunderstanding the proper ends of any reformatory measure in the management of the insane. The phil- osophical test of social and political reform — the greatest happiness of the greatest number — must not be exclusively adopted here. A provision is not to be hastily discarded merely because it has been attended by abuses, or because its evils, on the whole, seem to over- TREATMENT OF INSANITY. 229 balance its benefits. The careful inquirer will first ascertain whether, by some adminis- trative change, the former may not be prevented, and the latter retained. To give up a provision which is known to serve an excellent purpose, because in the hands of the careless and heartless it has been made an instrument of wrong, may be wise under some circumstances, but can hardly be considered a triumph of professional skill. True sci- ence, true skill, consist in meeting the exigencies of each particular case ; and though these must sometimes be subordinate to the general good, this necessity must be regarded as a defect rather than a merit. The question we have to deal with is, how we can best reach the needs of each one of those individuals who make up the collective body under our charge; and so long as we keep this end before us, we may be sure we are on the right course. When, however, we strive after something above and beyond this, seek- ing, for instance, to establish some general rule or practice calculated to strike the fancy and to win the applause of the inconsiderate, there is great danger that the other and more important end will come to hold an inferior place in our regard. There may be- no incompatibility between these ends, for many, I doubt not, are steadily keeping them both in view ; but there is a natural tendency to seek that which is most easily appre- ciated by all who look only on the outside, and which, by such, would be regarded as in- dicative of originality and vigor. We see it in the idea, too often put forth, of claiming merit for encountering great risks with but little actual damage. So many epileptics have frequented a room having an open fire, so many uneasy, discontented patients have been allowed to go and come as they please, so many pugnacious ones have mingled freely with the rest, so many homicidal ones have been intrusted with edge-tools ; and yet nobody has fallen into the fire, nobody has eloped, nobody has been struck, nobody has been killed or wounded. As if such a result might not possibly have been a re- markable instance of good fortune rather than the sign and seal of a blessed reform ; and as if the welfare of the individual patient were a matter of little concern compared with the working of a general rule. I would not be understood as saying, that in the management of the insane we are to incur no risks whatever; in other words that we are to withhold from them every privilege and the slightest measure of freedom, be- cause they might possibly abuse them. The whole theory of modern management implies risk, to be avoided, however, as much as possible, by the exercise of discern- ment and tact. Sometimes, indeed, a desirable end can be obtained only through more or less risk, and on the general question there can be but one opinion. But such risks must be carefully distinguished from those which involve the welfare of others, or tend only to glorify individuals. If an attempt to benefit a particular patient by some exercise of risk, applicable solely to him, fail, he alone is affected ; and if the circum- stances fairly justified the attempt, he cannot complain. But if,, while it is applied to one person, its consequences fall upon another, then the latter has good reason to be aggrieved. When a sanguine believer in non-restraint systematically exposes his pa- tients to the assaults of those who are inclined to such mischief, in the vain expectation that any practical amount of vigilance can obviate actual harm, he will hardly be able to justify the occurrence of unpleasant casualties by pleading the common good. The sufferers would reply, and very properly too, that they were placed under his care for their own particular good, and not for the purpose of enabling him to work out some fa- vorite theory. And they might also say that they were so placed, mainly for the purpose of being saved from themselves and others. I believe that the reasons urged in favor of some of these reformatory measures are founded in incorrect notions of insanity, and especially of the thoughts and feelings of the insane. It is contended that the safeguards which have been placed around the pa- tient should be removed, because they are supposed to annoy him by constantly remind- 230 PSYCHOLOGICAL MEDICINE. ing him of his infirmity, and proclaiming from ever}' door and window that he cannot be trusted. Unquestionably, in a small proportion of cases, restraint of any kmd is disa- greeable, and, perhaps, unnecessary' ; but it is equally certain that to many patients it is not even a source of discomfort. The latter class have an habitual sense of insecurity, fear to be left to themselves, and welcome the means of restraint. Many of those, even, whose form of disease is marked by high excitement, feel at times a consciousness that they are unfit to be at large, and recognize the necessity of those abridgments of their freedom which a hospital involves. Much of the repugnance which the insane are sup- posed to feel to the restrictive arrangements of a hospital may be fairly attributed rather to that captious, fault-finding spirit so common in the disease, than to any keen sensibili- ties in the matter. When restraint of any kind is required, let it be applied, we are told, by the look and the touch of an attendant, not by barbarous implements of wood and iron. Mistakes have been made, no doubt, as to the amount of interference compatible with the best interests of the insane, but we ought not to err very widely as to the amount of care and vigilance that may be reasonably expected of attendants. Natural disposition and temperament, tact and culture, may affect the result somewhat, but we well know that beyond a cer- tain point these qualities, in their best estate, are perfectly impotent. For a short period and an imminent emergency, we may be warranted in relying upon them implicitly. But lengthen the period, or render the contingency more remote and uncertain, and to that extent personal vigilance becomes unreliable. An attendant placed in charge of a pa- tient incessantly bent on self-destruction may be safely relied on for several hours ; but let it be his sole business to prevent a patient from striking when the impulse comes, which may be but once in two or three months, and who that knows anything of the subject supposes that the blow will not be struck at last? The continuity of attention required for this purpose may not be impossible, but in practice it would be idle to ex- pect it. In fact there is really no relation between the ends and the means. The question is not which of the two kinds of restraint, personal or mechanical, is preferable in this case, but whether the latter is not the only one capable in the nature of things, of effecting the purpose. Considering the matter in reference to its immediate effects on the patient, and unconnected with theories or biases, it seems difficult to conceive how there could be two opinions about it. And in the class of cases where either would be admissible, I have been led by twenty years' experience to believe that a simple contrivance of leather or cloth placed on the limbs, performing its service quietly and steadily., is infinitely pref- erable to an array of attendants holding the hands and feet, and at every relaxation of their efforts provoking renewed straggles from the patient. It has been of late years somewhat fashionable to ignore some prominent traits of in- sanity, or at least to suppose that they may be kept in abeyance by devices of manage- ment. The insane should be treated more like the sane, trusted with responsible duties, and thrown much upon their own power of self-control. No one would dissent from the general principle implied in this statement, because it is characteristic of all humane and intelligent management ; but unquestionably some have been disposed to carry it to an almost unlimited extent. Among them was one whose name was intimately associated with the histor}' of our specialty in this countrj'. His practice was to treat his patients as if governed by the principles, motives, and impulses of sane men, until the contrary appeared. Very brilliant results sometimes followed this management, and some not so well calculated to recommend it for general adoption. He was fond of taking visitors to a window and showing them three or four patients mowing together in an adja- cent field, all of whom had committed homicide. There was something very extraordi- nary, no doubt, in such an exhibition. To those who are governed by appearances merely. TREATMENT OF INSANITY. 23 I it indicated the triumph of the strong will and the commanding presence, over the lower instincts of a diseased mind, and excited the usual admiration produced by the mar- vellous. No good can come by shutting our eyes to an old truth, merely because it is old, and believing that the world has always been mistaken in the idea that a disposition to mis- chief is a frequent element of insanity. Tamed, diverted, modified it certainly may be ; but there can be no graver error than to suppose that, by any system of treatment, it may be utterly extinguished. And even if it were possible to eradicate this element of the disease, there remains another which should prevent us from relying too much on the discretion of the insane. The guiding, determining power of the patient — the balance- wheel, if I may use the figure, which regulates the mental niovement — is generally more or less impaired, and some power must, to that extent, take its place. For this reason the patient is taken from home or his customary surroundings, where he is following the bent of his disordered fancies, and placed where his liberty of action is greatly curtailed, and his movements directed by others. To some, scarcely anything more is necessary than the unavoidable restrictions of the hospital. In others, the gravity of the disturbing ele- ment may call for the utmost amount of restriction at our disposal. In some shape or other, restriction is an essential element in all hospital management of insanity ; but it would be preposterous to contend that just so much or so little is the exact measure best suited to all cases alike, or to any considerable proportion. In the above remarks it has been my intention to indicate the only channels which the course of improvement can possibly take, and to state my reasons for dissenting from some current opinions on this subject. I am not disposed to anticipate only failure from the most skilfully managed experiments, nor to regard free and full inquiry in any direc- tion as useless. What may be accomplished hereafter must be a matter of speculation, but probably the future will be much like the past. Men will continue to jump at con- clusions, to imagine that they have found some royal road to the desired object, and that their own new ways are better than any old ones. One project after another will pass away, but not without leaving some pregnant suggestion behind. In the mean time, let us be less anxious to discover new truths than to turn the old ones to the best possible account, and then we need have no apprehension that the dark ages will return. The latter object is within the reach of all ; the former is reserved for the gifted few. The subject, which is of great importance, applies I think equally well to the large class of the chronic insane who are incurable and harmless and who, under the official inspection of the State Commis- sioner in Lunacy, could advantageously be treated in private fami- lies with the blessings and comforts of home life, and with important financial results to the commonwealth ; and this would at once re- lieve our overcrowded lunatic asylums, and I think there would be a difference of a large per cent, in the expenditure to the State. Our present large and expensive asylums often require an investment of three or four thousand dollars for the accommodation of every indi- vidual patient, and aires, where such large masses of the insane are aggregated, and individuality and personality lost, cannot reach the same per cent, as when the physician can carefully and personally study and treat each individual case. In order that the system I 232 PSYCHOLOGICAL MEDICINE. have spoken of should be efficient, the person taking charge of an insane patient in a private house should be required to cause the pa- tient to be visited at least once a fortnight by the medical attendant ; and the physician who makes the visit should be obliged at each visit to enter in a book, to be kept at the house, the date of his visit and also the state of health, mentally and bodily, of the patient, and the general condition and the circumstances of the patient and the house. A duplicate of this report should be forwarded by the phy- sician to the State Commissioner in Lunacy or to the person dele- gated by him, or better yet to a regular district physician in lunacy, who could be appointed by the governor. The State could be di- vided into four or more districts, and a physician in lunacy appointed for each district by the governor. This board of physicians, who should be specialists in nervous and mental diseases, could constitute a lunacy commission to also visit and report as to the condition of lunatic hospitals, and protect the rights of those who are incarcerated in public asylums, and also strongly support the medical superin- tendents who, as a rule, exhibit skill and wisdom of the highest order. The public would feel more assured, perhaps, that no evils or abuses could spring up in our asylums, and also that if there is any room for improvement it will be immediately seen by the com- mission in lunacy if it escapes the superintendent's eye. The Lunacy Commission of Great Britain has been of great benefit both to the officers and the patients of the English institutions, and would, I think, do the same in our own country, and would dispel the prejudice existing against our asylums and their managers. Such a commission in lunacy could also instruct the public as to the pre- vention of insanity, etc. As there is a lymch-needed reform as to a netu vietliod of introducing expert testimony in criminal tiials where in- sanity is alleged as a defence, tins same lunacy commissioii migJit be of great value in examining such cases and giving testiinojiy upon such trials, it having been provided in the statute by ivhich such commission should be established, that the counsel for the prisoner in whose behalf the plea of insanity is proposed to be brought forward should be com- pelled to notify such board of such proposed pl^a. This board of experts shoidd examine the prisoner's mental state, discuss the question, make their conclusions, and should take zuritten memoranda of such examina- tion. They tJien should appear in cornet at the trial, to testify as to the prisoner's sanity, or irresponsibility if they find Idyn insane. 'I consider that this ivoidd be a very important medico-legal reform, as it woidd TREATMENT OF INSANITY, 233 place rich and poor on the same footing if they were on trial for their lives, accused of mnrder. Of course, both the prosecntio7i and defence could call in other experts, as noiv ; but this hmacy commission report woidd be entirely impartial, and the public woidd know it to be so. All the factors tending to the comnnssion of crime woidd be attcTitively weighed, and certain penalties woidd not be ififticted on the unhappy victims of diseased imagination. Medical Treatment of Insanity. — The medicinal treatment of in- sanity consists in removing, as far as possible, all functional derange- ments of the system by attending to the proper performance of the functions of the body. We must relieve ansemia and hyperaemia of the brain so far as we are able, and treat symptoms as they appear in the course of the disease. Among the most valuable remedies for use in the treatment of insanity may be mentioned opium, hydrate of chloral, hyoscyamia, digitalis, ergot, the bromides of sodium, lithium, and zinc, tincture of cannabis indica, stimulants, and the use of pro- longed warm baths, with cold to the head, and the galvanic current of electricity to antagonize the various congestive states in the in- cipient stages of mental diseases. It is, I regard, a good practice in the therapeutics of insanity, to give 5 to 10 grains of calomel to begin treatment, followed by salines, which prepare the system for whatever after-treatment is indicated. For an overworked business man on the verge of insanity, whose whole system is probably disordered, in whom anxiety has caused loss of appetite and inability to sleep, and in whom the integrity of the nervous system has been gradually deteriorating for some time, as well as for patients whose conduct and conversation are beginning to attract attention, such an initial treatment as I have described, fol- lowed by the administration of 30 grains of bromide of sodium and 30 drops of tincture of cannabis indica thrice daily, in combination with warm baths at bedtime, cold affusions to the head, and galvan- ization of the brain — which latter controls the cerebral congestion — will be found by the profession, as I find it in the treatment of such cases, to be followed by prompt and gratifying recoveries. Many such patients are far better in their own homes, treated by this plan, than when carried away from home to an asylum, where, instead of rest, which is one of my great therapeutical reliances in early mental disease, the patient finds excitement and is apt to become worse. I do not at all underrate the good work done at our asylums by able superintendents by the foregoing remarks. Where there is exhaus- 234 PSYCHOLOGICAL MEDICINE. tive mania, with high excitement and cerebral anaemia, wine or whis- key I have always found to be the best calmative and soporific. I have often induced and kept up sleep for hours by the administration of half an ounce or ounce of fine old whiskey; but I always give the whiskey with a carminative, so that the patient may not know what he or she is taking. Food must be given regularly and systematically, to support strength and prevent exhaustion. A pulse of 150 will come down to 80 under this stimulative treatment in exhaustive mania, and a quiet, refreshing sleep and a good recovery will result. Rest, nourishment, positive food, — such as milk, eggs, beefsteak, lamb, well-cooked vege- tables, and fruit, — sleep, and time, are all required for the cure of insanity. Restraint, I think, is grossly abused ; and yet there are cases in which the camisole (a soft canvas jacket, which is all the restraint ever necessary in any case) is temporarily needed, but this should never be at the option of a nurse. Opium has been called " the sheet-anchor of the alienist physician." The doses of opium require to be large, as the nervous system is singularly tolerant to large doses in acute mania and in some forms of melancholia, where it acts specifically by antagonizing the mental state of melancholia and depression, while in advanced dementia and general paralysis the experience of observers warns us to be careful in its employment. The dialyzed opium, which is of the same strength as laudanum, and the bimeconate of morphia are the best preparations to use. With either of these we avoid many of the un- pleasant effects of opium in other forms. I commence with 20 minims of the London preparation of dialyzed opium, three times a day, and gradually increase the dose until one drachm or more is administered, three times a day. Guislain recommends large doses, but commences with 2 grains, which he increases to lO or 15 grains as required. Drs. Bucknill and Tuke relate the case of a carpenter's wife who was affected with suicidal melancholia and was cured by the administration of large doses of morphia, and who was obliged to take 8 grains of the muriate of morphia daily. When taking this enormous dose she was cheerful and enjoyed good health, her tongue being clean and the pulse good, but when the dose was diminished she again became depressed. I had recently a case of suicidal melancholia in the person of a young lady of New York, who became insane by reason of her lover leaving her and marrying another young lady of his acquaintance. TREATMENT OF INSANITY. 235 A fire broke out at night, in her home, at the time of the menstrual period, and she ceased menstruating and soon became maniacal. The family physician did all in his power for her, but finally sent her to me. Upon admission she was entirely incoherent except in her desire to commit suicide. She refused food, and had neither eaten nor slept for ten days previous to her admission. The tongue was dry, the teeth covered with sordes, and she was fast lapsing into typho-mania. I fed her sixty-three days, thrice daily, with the stomach-tube, using beef-tea, milk, milk-punch, etc., and, having thoroughly evacuated the bowels and washed out the kidneys with a diuretic, I put her on a treatment consisting only of prolonged warm baths daily, of half an hour's duration, at ioo°, and the hypo- dermic use of morphia. I commenced with 5 minims of Magendie's solution, thrice daily, and gradually increased until I was giving 30 minims, thrice daily, and continued that dose for about thirteen weeks. She gradually improved, and at the end of four months had made a perfect recovery. I used the tincture of black hellebore as an emmenagogue, which restored the menses to their normal condi- tion. Two years have elapsed since her cure, and she has mani- fested no symptoms whatever of a relapse, and, as there is no insanity in her family, I anticipate none in the future. The hydrate of chloral has proved to be a very valuable remedy in the treatment of insanity, and also in delirium tremens, often procur- ing refreshing sleep, when all preparations of opium fail. It has been shown to be most useful in mania with sleeplessness and restlessness, in doses of from 15 to 30 grains, in combination with either hyoscy- amus or morphia and sodium bromide. In delirium tremens the doses must be much larger, but half-ounce doses of tincture of digi- talis with a half ounce of gin, have my preference in this latter dis- order. As a therapeutic agent, chloral in doses of from 15 to 30 grains is an excellent hypnotic, causing sound and refreshing sleep, without the digestive disturbance which usually follows the use of opium. It is one of the sheet-anchors in our asylum. The great advantages that it possesses are, that it does not constipate the bowels, does not disturb digestion, the doses do not require to be increased, as is the case with opium, and the sleep produced by it resembles natural sleep more than that produced by most other narcotics. If pure chloral hydrate be used, it is one of our most valuable remedies, but as there have been many impure prep- arations sold in the market, and as the public have manifested 236 PSYCHOLOGICAL MEDICINE. gross carelessness in using this dangerous — if abused — agent, there has grown to be an unreasoning prejudice against it. Chloral should always be freshly prepared, should not be kept for any length of time in a cork-stoppered bottle, and only preparations made by the most reliable chemists should be used, and finally, ex- cept in delirium tremens, it is rarely wise to give more than from 15 to 30 grains at a dose. The following is an excellent prescription to combat sleeplessness with maniacal excitement, and produces a long, natural, healthy sleep, from which the patient awakens refreshed and invigorated, and after a few repetitions on successive nights, the symptoms have disappeared or have been greatly relieved. R. Chloral Hydrate., ^ij. Sodii Bromid., .......... ^j. Morphine Sulph., . Z^'- H- Syr. Zingib., Aquse, aa . • f §j- M. et ft. Solutio. S. Tablespoonful at bedtime, to be repeated in half an hour if patient is not asleep. In the daytime to produce quiet, the following pill is good : R. Zinci Valerianat., ......... 3J- Ext. Belladomii^, gr. jss. ]M. ft. Pill Xo. XXX. Sig. Pill every two hours. This is a very useful pill in general paralysis of the insane. The following is also a ver}' excellent sedative mixture at night : R. Sodii Bromid., Chloral Hydrat., aa ........ . .^jss. Dialyzed Opium (London Preparation), ; . . . . ^v. Fl. Ext. Gelsemii, ^v. Aquse Dest., Syr. Aurantii, aa . . . . . . . q. s. ad ^vi. M. et sig. half teaspoonful in water. Also the combination of 30 grains of chloral with a half ounce of fine old whiskey, or with two fluid drachms of tincture hyoscyamus, are excellent indeed to produce refreshing sleep. Chloral having no influence over sensory nerves, has no power per se of relieving pain, and is therefore useless in that class of cases where opium is of such signal service. Chloral, weakening cardiac action, must not be given where we have any reason to suspect an TREATMENT OF INSANITY. 23/ enfeebled state of the heart's action. Its physiological effects on the nervous system are, first on the brain and next on the spinal cord. Chloral produces an. anaemic condition of the brain and thus causes sleep, by imitating the natural anatomical arrangement of that process. The reflex action of the spinal cord is much lessened, and the respiratory centre becomes weakened and eventually paralyzed. The vaso-motor system is enfeebled, but no special effects seem to be produced on other nervous structures, unless it is considered that any part of the loss of muscular power, sometimes observed in those who have taken chloral for a long time, is due to an action on the motor nerves. Perhaps this may be so. As re- gards the circulatory system, chloral has a powerful action on the heart, lowering and weakening its action by paralyzing its contained sympathetic ganglia. We should give chloral cautiously, and should bear in mind that strychnia stimulates the respiratory and vaso- motor centres in the cord, and thus opposes and counteracts the most dangerous tendency of chloral narcosis. Atropia also counteracts the cardiac and respiratory depression caused by chloral, as well as by morphia, which constitutes the danger of their use in man. Hyoscyamia. — The therapeutical effects of this drug in acute mania are very important and valuable. Given hypodermically in doses of -j^Q- of a grain, it quiets restlessness and produces sleep with cer- tainty and efficiency. Dr. E. C. Seguin has very well summed up the experience of all observers with reference to the physiologi- cal and therapeutical effects of this drug, and his conclusions as re- gards its use in insanity are, that hyoscyamia is indicated in mania, restlessness, delusions of persecution, dementia with agitation and destructiveness, epileptic mania, insomnia, rapid action of the heart, status epilepticus, chorea, paralysis agitans, hysterical spasms, neu- ralgia, tremor, etc. That in mania and allied states it produces sleep as certainl)^, or even more certainly, than chloral, without any bad effect, unless it be occasional gastric disorder. It is not claimed that its curative powers are great, but it is to be looked upon, Dr. Seguin thinks, as a narcotic, often speedier, more complete and less objec- tionable than morphia and chloral hydrate. I doubt very much, however, that it is in the main less objectionable, as I have known of one or two instances in which the lio^th of a grain has produced dangerous and almost fatal symptoms. One of the cases was the wife of a physician, who administered it himself and was much alarmed at the effect it produced. In acute mania, however, I 238 PSYCHOLOGICAL MEDICINE. should certainly advise it, as I have seen very excellent results from it. I have used the solution Dr. Seguin advised, namely : R. Hyoscyamias (Merck's crystallized), . . . . . • gr- j- Glycerine, Aquae dest., aa . . . . . . . . . . m. c. Acid. Carbol., ,,........ gr. ss. M. fillra. Sig. mj = gr. 77^;^. Two minims a moderate dose; four minims a full dose. TJie Bromides and Cannabis Indica. — One of the most charming combinations to reduce maniacal excitement with which I am ac- quainted, and one which I use a great deal, is a combination of so- dium bromide, lithium bromide, and tincture cannabis indica, — 15 grains of each of the former and 30 minims of the latter may be given three times a day, for a long time if necessary, with no ill ef- fects. I premise the treatment with a mercurial cathartic, followed by salines, and the system is then freed from the often long-retained excrementitious matters, and is ready for treatment. Warm baths of a half-hour's duration of 98° to 100° are ordered at bedtime, with cold towels on the head. This mixture of the tincture of cannabis indica and the bromides of sodium and lithium should be made at the time of administration. It does not disturb digestion, it quiets the nervous system better, in most cases, than chloral or opium, and its long-continued use does not injure the patient at all. On the con- trary, patients gain health, strength, appetite, and weight. The dose can be increased to oj of the bromides (30 grains of each, or 60 grains of one singly) and 60 minims of tincture of cannabis indica, if neces- sary, with no fear of evil results. In melancholia, even in the worst cases, with suicidal impulses, I have had rapid cures from persistent warm-bath treatment, pills of aloes, and ox-gall and opium in gradually increasing doses. In puer- peral insanity we have a condition of septicsemia from the absorption into the blood of some of the retained products of conception, and here a full dose of calomel will, in nine cases out of ten — if the in- sanity is not hereditary — start our patient on the road to recovery. It must be given at once, and be followed by salines and appropriate sedatives, and I have seen, in a few days, rapid progress toward recov- ery. In cases of hysterical mania, in young unmarried women, we often have at first, for a few days, a wild mania, and I have known some specialists give a very unfavorable prognosis, which was not TREATMENT OF INSANITY. 239 at all to their credit. These cases, if properly managed, are very curable, and if they are not cured, it is generally owing to the pa- tient's being allowed to remain at home instead of being removed to some private institution. Fothergill's solution of hydrobromic acid, in half-drachm doses at bedtime after a warm bath, with cold to the head, and the monobromide of camphor (Clin's capsules), in four-grain doses three times a day, seclusion of the patient at once away from her friends, with a well-trained nurse, who will in moral treatment carry out your orders to the letter, will generally produce marked results. In the worst case of hysterical mania I ever saw, I had my patient under the charge of one of the best-trained nurses at my disposal, and in a very few days she was down-stairs, and made a rapid and complete recovery. This case was pronounced incurably insane by a physician in charge of one of our institutions for the insane, and this assertion was made in my presence. In these cases, where the emotional faculties are so involved, every- thing depends upon prompt seclusion and rest for the patient. I never treat such patients at home, but insist upon their being brought to me and placed under experienced nurses in my private hospital, and always see prompt recoveries. Within the past few days I have seen a case in consultation with my friend Dr. Nathan Bozeman, of this city, under whose able care the lady in question has been for some time. She suffered from prolapse of the uterus, and a pro- lapsed and imprisoned ovary. This condition had been skilfully treated and cured by Dr. Bozeman, but the patient's health having been undermined by the practice of self-abuse, she developed hysterical mania. She shuts herself up, will not go out, will not allow herself to be bathed, will not attempt to dress or undress herself, and the nurse spends several hours in performing these oper- ations. She screams violently if any attempt is made to make her walk or to exert herself in any way. She is in fair flesh, and eats and sleeps well. The mother became perfectly exhausted by attendance upon this daughter, and has been sent away from home to preserve her own failing health. The family is rendered miserable by the continued hysterical insanity, and the first indi- cation is evidently, in this case, to remove the patient from her maids and her relatives to seclusion and rest, and put her under the care of a quiet, determined nurse, who will follow instructions im- plicitly. A course of warm baths, actual cautery to the nape of the 240 PSYCHOLOGICAL MEDICINE. neck, monobromide of camphor in four-grain doses of Clin's cap- sules three times daily, and Fothergill's solution of hydrobromic acid nightly, with the application of the constant or galvanic current of electricity to the central nervous system, will result in a speedy and complete cure in a short time. No anxious and sympathizing rela- tives are to be permitted to see her at all until a cure is well under way, or the good effects of treatment will be rendered futile. I think it is only when these patients are allowed to be with their friends that their trouble becomes permanent, or where the physician does not understand the kind of case he has to deal with. About two years ago I was called in consultation to see a young New York lady with violent hysterical mania, the result of emotional excitement. I found her perfectly naked, the clothes having been pulled off prob- ably as the result of a morbid hypersesthesia of the whole bod}^, and she was in a state of wild maniacal excitement. Upon consultation, it was decided to remove her to my private hospital, where she was placed under one of my best nurses, who kept her in strict seclusion for about a week, while the treatment I have before detailed was faithfully carried out. She made a good recovery, and at the end of four months went home perfectly well, has never suffered any relapse, and has since married happily, and enjoys excellent health. Digitalis. — The use of digitalis has been advocated by Dr. Lock- hart Robertson and by Dr. Duckworth Williams, his successor at Hayv/ard's Heath, England. They claim that digitalis is a valuable sedative in both recent and chronic mania, and also when these forms of insanity are complicated with general paresis and epilepsy. The dose they employ ranges from half a drachm to one drachm of the tincture, this dose being continued for some days and then gradually decreased. Stimulants are necessary to ward off the dangerous exhaustion which accompanies or follows acute maniacal excitement, and are contraindicated only where there is excessive plethora. Coniiun. — Conium in insanity, in doses ranging from n^ xx. to a drachm of the fluid extract, will produce general muscular relaxation, and, subsequently, quietness, followed by calm and refreshing sleep, the whole motor-nerve system being quieted. The influence of co- nium is upon the motor centres of the brain, the corpora striata being chiefly affected. It quiets irritability and excitement of the motor centres and leaves no feeling of weakness or oppression behind, and is therefore very valuable in certain cases of mania. The pulse TREATMENT OF INSANITY. 24I and temperature are both reduced, and a gentle perspiration covers the whole body as soon as the physiological effects are produced. Among the physiological effects may be noticed dimness and con- fusion of vision, muscular weakness, slowness of mental processes, a feeling of calm tranquillity, lowering of pulse and temperature, and finally, refreshing sleep, followed by no disagreeable after-effects. Conia, neutralized by acetic acid to prevent irritant effects, may be used hypodermically in doses of from one-tenth to one minim, and as it acts upon the purely motor centres, and as morphia acts as a sedative to the sensori-motor and ideo-motor centres, a combination of the two, using the tartrate of morphia in solution with the conia, acts very well in reducing maniacal excitement, and is a valuable remedy, especially in aggressive outbursts of excitement in the ex- cited wards of asylums, or where danger is threatened in the home treatment of the insane. Caution must be used in using new speci- mens until their strength is ascertained. Conia should be prepared from the seeds of the uncultivated plant. Ergot in the Treatment of Insaitity. — It was proved years ago, by the researches of Brown-Sequard and others, that ergot possessed the power of producing contraction in the vessels of the spinal cord, and it accordingly occurred to Dr. Browne, of the West Riding Asy- lum in England, that it might possess a similar control over the vessels of the brain, and thus be made to modify or remove the ac- tive cerebral congestion which is an attendant upon so many phases of insanity. Upon a thorough investigation, he found that there were three varieties of insanity in which it was eminently useful, namely, recurrent mania, chronic mania with lucid intervals, and lastly, epi- leptic mania. Dr. Browne and other observers, who have adopted the use of ergot in the treatment of insanity, have found that in the varieties above mentioned it was uniformly successful in reducing excitement, in shortening the attacks, in widening the intervals be- tween them, and sometimes in preventing their recurrence entirely, and in warding off the dangerous stage of exhaustion by which maniacal excitement is so often succeeded. The way in which ergot operates upon the contractile coats of the vessels has been proved to be by its influence upon the non-striated muscular fibres and cells contained in their coats, thereby exercising a controlling power over the calibre of the intracranial vessels. In the three varieties of in- sanity before referred to, — in recurrent mania, in chronic mania with lucid intervals, and in epileptic mania, — we find that the lesion con- 16 242 PSYCHOLOGICAL MEDICINE. sists essentially in cerebral hypersemia. We find, although the symptoms differ in these three forms of mental disease in which ergot is useful, that there is present in each form increased arterial pulsation, flushing of the face, suffusion of the eyes, dryness of the mouth, and cephalalgia. The disappearance of these phenomena in the intervals of the paroxysms proves that they are dependent upon functional and not organic changes in the brain, in which latter case we should not expect to find any marked efficacy from the use of ergot, and, indeed, we often meet with instances in which the con- trolling power of ergot is, after a time, lost, as organic degeneration gradually follows as a sequence upon repeated attacks of mania. In epileptic mania, it will be found that a combination of bromide of sodium with ergot will materially aid the action of the latter in widen- ing the intervals between the fits and in modifying the attacks when they occur. This combination will also often arrest paroxysms in the incipient stage. The stage of excitement which often precedes and ushers in the attack, and which sometimes succeeds it, is markedly diminished by the combination of bromide of sodium and ergot. The bromide of sodium will be found to be preferable to the bromide of potassium, as it is pleasanter to the taste and causes less constitutional disturbance than the latter when given in large doses. Dr. Browne remarks that " it is in epileptic mania that ergot has been found pre-eminently valuable, in allaying and abolishing excite- ment and in conducing to a healthier tone of mental action. In the outbursts of violent agitation which precede or follow a fit or group of fits which occasionally take their place, and which have been pro- nounced by all authorities to be of so dangerous a character, it exerts a prompt and energetic effect. We may presume that these out- bursts are dependent upon a want of equilibrium in the intracranial circulation, primarily disturbed by the epileptic seizure or condition. The distension of the vessels which succeeds their spasmodic con- traction and produces coma, subsides so far as to allow the resump- tion of activity by the higher centres, but only in an irregular and disturbed way. And we may presume, further, that the soothing and rectifying effects of ergot are due to its power of re-establishing that disturbed equilibrium. A thorough trial of the ergot treatment has satisfied me of its efficacy, and the following clinical cases will serve to illustrate its beneficial action. The doses of ergot used in the fol- lowing cases have been from oss. to 5j. of Squibb's fluid extract, three times a day, and in cases in which ergotine has been employed, TREATMENT OF INSANITY. 243 from 5 to 10 grains have been given. No unpleasant effects have ever followed even prolonged administration of the ergot, and from our experience with it, it would seem that the danger of injurious effects from its continued use has been greatly overrated by the ma- jority of the profession. Dr. Browne, who has used the ergot treatment for many years in many hundreds of cases, says: "Indeed, so little have injurious effects of any kind followed even the prolonged exhibition of what might be termed enormous doses of ergot, that doubts might have arisen as to whether it were possible to produce that train of symp- toms described as ergotism, by means of the medicinal preparations of secale cornutum." Case I. — Miss , with recurrent mania, aged 22 years, was very noisy and maniacal when first seen ; was very incoherent in speech and boisterous, and had no realization of her condition or surround- ings. She entertained the idea that people were trying to kill her and get her property. She destroyed her clothing, broke the win-" dows, did much damage to the furniture, and imagined that she saw snakes and devils in her room at night. She continued in this state for some time with no mental improvement. She commenced by my advice to take the fluid extract of ergot in 5j- doses, three times a day, and had only taken a few doses before beneficial results were very apparent. The excitement subsided, and she became quiet and peaceable. The congestion of the head and face, which was very marked, has nearly entirely disappeared. Her pulse was reduced from 145 to 90. The temperature in the axilla from 99y^^° to 98°, and her tongue, which w^as thickly furred, presents a normal appearance. Case II. — Miss M. K., aged 28 years, who suffered from chronic mania with lucid intervals. She was very violent and abusive, would bite and strike her nurses. Her face was deeply congested, eyes in- jected, tongue coated with a thick white fur, pulse 130, and tempera- ture 99°. Having continued in this excitable state for some days with no evidence of improvement, was ordered 5j. of the fluid ex- tract of ergot, three times a day. By the 24th of June she began to show decided signs of improvement, and in place of being filthy and abusive in language and conduct was polite and neat in her habits. She also began to sleep at night, which she had not done before, although medicine had been given for that purpose. Her pulse was lowered to 85. Her temperature decreased, the suffusion of the eyes 244 PSYCHOLOGICAL MEDICINE. disappeared, and at the present time she has had no relapse of mani- acal excitement. Case III. — Mr. E. Z., a native of Germany, aged 27, was, when I first saw him, suffering from an attack of acute mania caused by over- work and mental anxiety. Had always been a healthy man, and there was no trace of insanity in the family history. He was noisy and maniacal. He was ordered a warm bath, which relieved him for about half an hour, when he again became maniacal and dangerous. Was given chloral and hyoscyamus, and passed a restless night. In the morning he presented ver}^ much the same appearance as on the preceding evening. Face and eyes suffused and congested, pulse 100, and temperature heightened; tongue thickly coated, and mouth dry; was put on o]- of the fluid extract of ergot three times a day, with chloral and hyoscyamus at night. In a few days the excite- ment began to subside, and in less than two months he was com- paratively quiet, and in fifteen days more the pulse was 80, the tem- perature was 97/0°, and the appearance normal. Has remained quiet up to the present time, with good appetite, sleeping well, and very cheerful. Case IV. — Aliss S. H., aged 25, was suffering from epileptic mania. From September to June she had a great many epileptic seizures, which were preceded and followed by attacks of maniacal excite- ment, which rendered her a dangerous patient. In July she became very noisy and excited, as was her habit before her fits, threat- ening to kill her nurse and those about her. Her eyes were suf- fused, the mouth dry, the pulse 140, and the tongue furred. She was put on 5j. doses of fluid extract of ergot, three times a day. After taking the ergot for two days she became quiet, and the epi- leptic seizure which followed was very mild as compared with pre- ceding ones. The ergot was continued, and since that time she has had no return of the maniacal excitement. The fits have decreased in frequency and intensity, and are not followed as formerly by any mental excitement. Her physical condition has also been markedly improved since she has taken the ergot. The pulse is 75, and the temperature in the axilla 98°, and she eats and sleeps well. Case V. — Mr. C, aged 30, was first seen with epileptic mania. He was a strong muscular man and had been subject to epileptic fits for some time. For a period of from a week to two or three days preceding the fits was entirely unmanageable, and a very dangerous man to deal with. He was also accustomed to have a period of TREATMENT OF INSANITY. " 245 maniacal excitement following the epileptic seizures, which lasted for a variable period, during which time his pulse would range from lOO to 1 20, and the face would be deeply congested. Was put on 5j. doses of fluid extract of ergot, three times a day, and this dose con- tinued for a period of two months, sometimes omitting the medicine for a week and then resuming it. The fits immediately decreased in both frequency and intensity, and the maniacal excitement entirely disappeared. Pulse and temperature became normal, and he made a very good recovery. Several other cases of mine have exhibited as marked improvement under the ergot treatment as the foregoing, but want of space forbids their insertion. Last, but not least, may be mentioned the use of zvarm baths, which are of inestimable value in the treatment of nervous and mental dis- eases. The tranquillizing effect of a warm bath in relieving cerebral irritation and in promoting sleep, especially when conjoined with cold to the head at the same time, either by a wet towel or still better by cold affusions, is often wonderful after all other means have failed. Patients with excessive maniacal excitement, hot head, dilated pupils, tongue thickly furred, and a high temperature in the axilla, have re- peatedly passed a comfortable night, after having remained for half an hour in a warm bath at a temperature of 100°. In acute mania, baths prolonged for some hours, with cold to the head, have accomplished wonderful results. This, in connection with a dose of chloral and mor- phia or hyoscyamus, will often suffice for the relief of acute mania if repeated on successive nights, if good refreshing sleep can be induced. Enough has been said, however, to show clearly that we can lay down no definite plan of treatment for any number of cases, but must in every instance, if we expect to accomplish a cure, study the con- stitution and idiosyncrasies of our patient and treat him accordingly. By so doing, we shall often have the satisfaction of seeing apparently hopeless cases restored to society, and families rendered happy which had been broken up by the visitation of this fearful disease. Cases Illustrating the Treatment of Insanity. — Case I. — Mr. , aged 30 ; a native of England. When first seen was suffering from acute mania, resulting from abuse of alcohol. No insane relations. Said he left England to get rid of his wife, who tormented him. Said he knew he was insane when he left, but that destitution and hard drinking had made him worse. Toward night became acutely maniacal and very boisterous. Tore up everything within reach, and was incoherent and vulgar in speech. Had no appreciation of his 246 PSYCHOLOGICAL MEDICINE. condition or surroundings. Quoted almost continually from Shake- speare and showed that he had received a liberal education. Said he burned Spurgeon's Tabernacle. Eyes suffused and pulse full and bounding. Was ordered Vv-arm baths every night, lasting half an hour, with cold affusions to the head, with chloral and morphia at bedtime, the dose of chloral being twenty grains, combined with one-fourth grain of morphia. He was fed liberally, and as he was always quiet in the morning was ordered fluid extract of ergot in oj- doses, twice every afternoon when he became excited. Under this treatment he quieted down and soon began to appreciate his condi- tion and take an interest in his surroundings. He improved gradu- ally and made a good recovery. Case H. — Aliss , aged 39. Was, when first seen, suffering from melancholia, resulting from syphilis. She was uneasy and restless at night and would get out of bed, suspicious of injury from unseen persons, who, she said, were anxious to kill her. Was depressed, melancholy, and very suspicious of all about her. Imagined her food was poisoned. Complained of great pain in her head, and was pale and anaemic. She ate and slept but little. Was put on a nour- ishing diet, with milk punch, and was given the bichloride of mer- cur)?-, in one-fifth grain, and the iodide of potassium, fifteen grains three times a day, with tincture hyoscyamus oj., and 20 grains chloral hy- drate at bedtime. Upon this treatment her general health improved very much. She began to eat and sleep, but would sit alone all day and cry over imaginary troubles. She improved slowly but surely; her delusions gradually disappeared; she became more cheerful and happ3% and made a good recovery. This is a very interesting and unusual case, as syphilitic insanity is a very rare disease, some authorities claiming that not more than one or two per cent, of all cases present this complication. The most frequent form of syphi- litic insanity is dementia. The above-mentioned case was probably the result of a simple irritation of the central nervous system due to the cerebral anaemia caused by the syphilitic virus. In another case the symptoms occur- ring in a young gentleman were profound mental dulness, incapacity to grasp thoughts and ideas, a desire to commit suicide, and symp- toms of compression of the brain, due, I presume, to the thickening of the dura mater by a gummatous deposit. iMercury and large doses of the iodide of potassium effected a cure. Another case, where a clear syphilitic history was obtained, occurred in a woman aged 29, TREATMENT OF INSANITY. - 24/ a native of France, with no insane relations. This patient's hmbs were covered with secondary sores and the head was affected with gummy tumors. She soon passed into most profound dementia, associated with epileptiform convulsions. She was treated with a combination of mercury and the iodide of potassium, but remained a case of chronic dementia, defying all treatment. As I have before remarked, as the results of the cerebral congestion of specific origin, we have vertigo and dulness, temporary disorders of the special senses and momentary impairments of the intellect, and these symp- toms lapse from transitory into permanent symptoms. Persistent mental dulness, and muscular feebleness exist as vague undefined symptoms before the invasion of actual insanity, with headache fol- lowed by exaltation, delirium, and mania, which rapidly lapse into dementia, or we may have a primary dementia without the stage of mania. Case III. — Mr. , aged 25 years; single. When first seen was suffering from melancholia, bordering on dementia, caused by intem- perance and vicious indulgences. He denied insanity in the most positive manner, but complained of severe pain at the back of his head and over the frontal region. The faculties of the mind were much enfeebled. Would burst out laughing and laugh incessantly for some minutes, and upon being questioned subsequently had no remembrance of doing any such thing. Had a delusion that he had been reduced to half his size by divine assistance. Saw visions at night. Was feeble and anaemic. Had attacks of mental excitement about once a fortnight, in which the bodily temperature would be much increased and the eyes suffused. At such times was very homicidal in his impulses, requiring, often, seclusion in his room. Was put on nourishing diet and tonics, the most valuable of which was my favorite tonic, the chloro-phosphide of arsenic (Routh's form- ula), in ten-drop doses, after each meal, with fluid extract of ergot 5j-, three times a day, and warm baths at bedtime, when he could not sleep. There was no perceptible mental improvement for some months, but the general health was much improved and he slept much better. The attacks of cerebral congestion decreased in frequency and intensity, and finally ceased altogether. His sleep ceased to be dis- turbed by visions. His appetite became good, his mental faculties began to be restored to their normal state, and his delusions disap- peared. He made a good recovery, with no trace of insane ideas or delusions, his conduct for some months having been reasonable and 248 PSYCHOLOGICAL MEDICINE. quiet. It is proper to mention that the ergot in this and other cases was never continued for more than two or three weeks without sus- pending its use for a week or two, and using it in this way no inju- rious effects have ever followed its employment. Case IV. — Mr. C, aged 26 years ; single. Was first seen suffer- ing from an attack of acute mania, the result of ill-health and over- work associated with intemperance. Upon admission was thin and anemic and was rambling and incoherent in speech. Said he was married to the Queen of Heaven. Was sleepless ; ate but little and was very destructive in his impulses, tearing up clothing, etc. The eyes were injected and the pupils widely dilated. Was given bromide of sodium in fifteen-grain doses three times a day, which was in- creased to twenty grains, with full doses of chloral and tincture hyos- cyamus at bedtime. Full nourishing diet. Soon became quiet and polite, and with the increased health and strength his mind became normal and his delusions disappeared. Case V. — Mr. F., aged 23 years; single. Was suffering from an attack of recurrent mania when first seen. He was depressed and sullen and would not answer questions. His tongue was thickly furred and the bowels constipated. He was ordered a laxative and warm baths at bedtime, as he said he did not sleep well. In a few days the eyes became injected, the pupils dilated, head hot and speech wild and incoherent and movements restless and excited. Said he had a worm inside him that was eating him up. Thought the food was poisoned and refused to eat. Was ordered warm baths, fluid extract ergot, in one-drachm doses, three times a day, and chloral, 20 grains, combined with one-quarter grain of morphia, at bedtime. In a few days the cerebral congestion abated, and he went on until the next month when he had a recurrence of the mania, which was preceded a few hours, as before, by melancholia and constipation. The same treatment was employed and the maniacal attack lasted but twenty- four hours. The ergot was continued through the lucid interval, and was discontinued at the end of four weeks, as he had no symptoms of another attack. He remained w^ell until January, 1875, when he had a recurrence of the mania, which was treated as before, with the addition of bromide of sodium, in 20-grain doses, three times a day. This was his last attack. He improved steadily in health and strength ; his delusions disappeared, he began to show an interest in his surroundings, and made a good recovery. Case VI. — Miss N., aged 20 years ; single. Was suffering from an TREATMENT OF INSANITY, 249 attack of acute mania when first seen. Previous to this attack she had been a remarkably well-behaved and quiet girl, and had been rea- sonably healthy. She was acutely maniacal, with rapidly changing delusions. Saw devils, snakes, and angels, in rapid succession, and said the Virgin Mary visited her every night in her room. Pulse rapid, tongue thickly furred, bowels constipated, and eyes injected, with the pupils dilated. Destroyed everything within her reach. The display of muscular strength which she exhibited was something remarkable. She was put in warm baths, with chloral and morphia internally at bedtime, but did not sleep. Refused food and was so violent that the attempt to feed her artificially was for the time abandoned. None of the usual remedies seemed to quiet her in the least, and she seemed likely to die of exhaustion from the violence of her mania, when she was ordered the monobromide of camphor (Clin's capsules, made in Paris), in doses of four grains three times a day. This remedy acted charmingly. After the third day's trial the temperature in the axilla became reduced from 102° to 99^°. The pulse was reduced in frequency and the suffusion of the eyes dis- appeared. The pupils were reduced to their normal size. She be- gan to sleep and eat, and at the end of ten days was quiet and tran- quil. The doses were reduced to two grains three times a day as the mania decreased, and were continued for about a month. The mental faculties improved, the appetite returned to its normal condi- tion, she began to take exercise in the open air, and finally made a good recovery. From my experience with the use of the monobro- mide of camphor (Dr. Clin's imported preparation), I believe it to be an excellent sedative of the cerebral system, and at times a decided hypnotic. In epilepsy and hysterical mania it has acted as a nervous sedative and antispasmodic, with good effects, in doses of from two to four grains, three times a day. Case VII. — Miss G., aged 1 8 years; single. Was seen suffering from acute mania. Was noisy and boisterous and a dangerous pa- tient. Was homicidal in her impulses. The pupils were widely dilated ; head hot, and she complained of intense pain in frontal region at times. Was incoherent in speech and had no appreciation of her condition and surroundings. Was thin, and ate and slept but little. Was ordered warm baths at a temperature of ioo° every afternoon, and cold affusions to the head, at the same time with chloral and mor- phia at bedtime. She was also given thirty grains of the bromide of sodium twice a day. In a short time she became quiet and re- 250 PSYCHOLOGICAL MEDICINE. mained so for three months, during which time she had various delu- sions and retained her homicidal impulses. At the end of that time she became acutely maniacal, and was put on fluid extract of ergot and warm baths, with cold applications to the head, and chloral and hyoscyamus, in full doses, at bedtime. In a week she began to im- prove, and her appetite, which had been poor since her admission, became good. She realized her situation and thanked the doctor and her nurses for their care of her. She no longer wished to injure those about her and continued to improve daily. Her insane delu- sions totally disappeared, and she has made an excellent recovery and has had no relapse. Case VIII. — Miss K., aged 24 j^ears; single. When first seen was suffering from suicidal melancholia, and had a great many delusions of fear and persecution. Said that everybody wanted to kill her, and so she had better kill herself Got very angry at trifles, and swore, and struck those about her. Had no appreciation of her mental condition. Was put on a full nourishing diet, with dialyzed opium (London preparation, same strength as laudanum) in gradually in- creasing doses, and warm baths, with bromide of sodium (30 grains) at bedtime. She was kept on this treatment for some weeks, with gradual improvement. The dialyzed opium was carried to the extent of 60 minims, three times a day, with excellent effects. The appe- tite was stimulated, and she became cheerful and realized her condi- tion and surroundings. She slept well, and the desire to commit suicide disappeared. The amount of opium was gradually decreased as the mental condition improved, and was finally withdrawn alto- gether. She made a good recovery. Case IX. — Miss M., aged 24 years ; single. AVas first seen suffer- ing from acute mania. Was very much excited, eyes injected, and pupils widely dilated. Head hot and face flushed. Had slept none for a week, and had eaten nothing for the same length of time. Was given a warm bath, and milk-punch, and, at bedtime, 20 grains of chloral, with one-fourth grain of morphia. Slept part of the night. The next day she was maniacal, and imagined all her food was poi- soned. Was fed on milk-punch, and had a prolonged warm bath, with the chloral and morphia repeated at bedtime. She slept bet- ter than on the preceding night. During the next three weeks the same treatment was persisted in, resulting in gradual improvement. She retained the delusion respecting the food. She had new attacks of mania, recurring about once in three days, at night, when she ^ TREATMENT OF INSANITY. 25 1 would see visions of angels, etc. She was put on fluid extract of ergot, 60 minims, thrice daily, with decided improvement. She im- proved rapidly. Began to eat all that was given her, slept quietly all night, and soon made an excellent recovery. Case X. — Mr. B., aged 36 ; occupation, architect. When first seen was suffering from acute mania, which followed repeated attacks of delirium tremens. Nervous system very much broken down. Thin and anemic, with poor appetite. Slept but little. Was put on a nourishing diet and pills of phosphate of zinc with the extract of nux vomica (nine-tenths of a grain of the former and one-fourth grain of the latter), thrice daily. Also, pepsin and bismuth before meals, as the digestion was impaired. He had warm baths, and chloral and hyoscyamus in full doses at bedtime. He soon began to improve. The hallucinations of sight and hearing with which he had been affected disappeared. The general health improved, and in two months from the time when he was first seen, made a good recovery, having gained markedly in flesh. Case XL — Mr. P., aged 16, was seen in a state of great exhaustion from acute mania, threatening death. Tongue and lips dry and black, eyes deeply injected and pupils widely dilated. Had not eaten nor slept for over a fortnight. Was acutely maniacal, although so much exhausted. Was put to bed and given a full dose of brandy, which was followed by a dose of chloral and morphia. He slept part of the night. The next day he was freely stimulated and fed with beef-essence, and eggs beaten up raw. This treatment was fol- lowed up for a week, with chloral and morphia at bedtime, with the happiest results. He became quiet and slept well. The sordes dis- appeared from the teeth and tongue, and he asked to see his mother, and recognized her. Talked incoherently for some time, but real- ized his condition and surroundings in his lucid intervals. Was put on phosphide of zinc, in one-tenth grain doses, three times a day, with good results. The appetite increased, the mental faculties im- proved, and he continued to convalesce, and made a good recovery. The cause of the insanity was thought to be the immoderate use of tobacco, which acted very injuriously upon a defective organization and weakened nervous system, inherited from his father, who was an intemperate man and died of phthisis. Many more cases might be noted, but want of space forbids their insertion. Phosphorus and the chloro-phosphide of arsenic (Routh's formula, the imported preparation) have been largely used by us in the 252 PSYCHOLOGICAL MEDICINE. convalescence in mental disorders, and also cod-liver oil and quinine in 2-grain doses. The foregoing cases illustrate the necessity of repressing cerebral excitement ; inducing sleep, by which the brain- cells are renovated ; and restoring the functions of the body, which are often disordered in mental disease. In addition to these meas- ures, if we provide cheerful surroundings, new objects of attention and interest, and can induce a healthy train of thought, we shall very often have the pleasure of seeing our patients make a good recovery. The Vaj'ieties of Insanity in Relation to Treatment. — The general practitioner should bear in mind that with him rests a great respon- sibility, as it is during the early stages of insanity that he, if intelli- gently informed as to mental disorders, may successfully check their progress or ward them off. He should, therefore, carefully study and recognize every deviation from the healthy mental standard of disease, indicating the necessity for medical treatment and advice, and it is to be hoped that, in the near future, no medical college shall be granted a charter which does not provide a chair for instruc- tion in mental diseases, with especial reference to their early diag- nosis, and to the therapeutics of insanity by practical alienists. Of what immense advantage to the profession would it have been had they been able, during the past twenty-five years, to have had the theory and practice of psychiatry expounded to them, both in col- leges and in the wards of our insane hospitals, by such men as the late Dr. Ray, Dr. Kirkbride, Dr. Pliny Earle, and many others, who are sound, practical psychologists and alienists. How can a man igno- rant of the first principles of psychological medicine intelligently sign a certificate of insanity consigning a human being, perhaps for life, to an insane asylum ? There is no disorder of mind without disorder of brain, and it is the great medical evil of the day that at present, in our medical colleges, very little attention has as yet been paid to the study and treatment of such disorders. The profession and medical students have a right to demand that, as they as medi- cal men will be required by the legislatures of the respective States in which they practice medicine to sign certificates of insanit}', and that as to their care will be committed many in the early, curable stages of insanity, they shall be taught in medical colleges, by a spe- cial professor : I. The healthy functions of a healthy brain; the structures which form the cerebrum ; the nerve-cells and nerve-fibres ; the neuroglia, TREATMENT OF INSANITY. 253 in which the cells are imbedded, and the bloodvessels and lymphatics. The nerve- cells are gathered together in the great nerve-centres, and, as an electrical battery sends the current of electricity along the connecting cord to the electrode, so, in like manner, by means of the nerve-fibre, does the nerve-cell communicate with the organs of spe- cial sense, with the sensory ganglia and spinal cord, with each other, and, finally, with the nerve-cells of the convolutions of the other hemisphere. The phenomena of healthy mind include sensation, feeling, and consciousness. These the student may study subject- ively, and then he will be prepared to be taught objectively, 2. The abnormal functioning of an unhealthy, diseased brain. Re- specting the subjective study, the remarks of the great philosopher Seneca are very appropriate, where he says : '' What does it profit us to master our appetites without understanding the when, the what, the how, and other circumstances of our proceedings ? For it is one thing to know the rate and dignity of things and another to know the little nicks and springs of action." Seneca also truly said : " Philosophy is the health of the mind. Let us look to that health first," etc. Of such a one (a philosopher) he says : " He studies to fill rather his mind than his coffers. His life is ordinate, fearless, equal, secure. He stands firm in all extremities, and bears the lot of his humanity with a divine temper." I fancy that a thorough study of this great philosopher might not be utterly inappropriate to those who desire to understand and master the hidden springs of human action, and that an acquiescence in his teachings might, by teaching us how to best master our hopes and fears, how to tune our affections and keep ourselves constant to ourselves, how to measure our appetites so as to know when we have had enough, and by making us understand that " the good of life does not consist in the length or space, but in the use of it," operate in the direction of the prevention of much insanity. Seneca was a wise psychologist when he said : " Let us rather study how to deliver ourselves from sadness, fear, and the burden of all our secret lusts. Our duty is the cure of the mind rather than the delight of it ; but we have only the words of wisdom without the works, and turn philosophy into a pleasure that was given for a remedy." Could the masses be taught to gov- ern their hopes and fears, their anxiety of thought and their per- petual disquiet, there would soon cease to be an increase of insanity disproportionate to the increase of population, as now exists, and observance of hygienic laws would soon become a matter of habit. 254 PSYCHOLOGICAL MEDICINE. Respecting the phenomena of diseased mind or unhealthy brain function, the student will learn that there may be impairment or ces- sation of nerve-function, and that this is generally ushered in by sleeplessness and marked nervous exhaustion ; that there is a pro- dromic period, marked by distinct psychic signs, during which period there is a defective generation and supply of nerve-force. He will be taught clinically that there is often an initiatory stage of depres- sion before a maniacal attack. He will also be taught that there is very often cerebral hyperasmia, evinced by a hot head, sleeplessness, cephalalgia, flushed face, and injected conjunctiva. A person may not sleep or even eat for some days while in this condition. Clinically he will see, in the wards of an insane hospital, the gloom oi melancholia ; the delirium, violence, excitement, and incoherence o'i mania; and the silly, vacant, meaningless behavior of the patient with dementia. The melancholiac may evince much distress, will be full of gloomy fore- bodings, will have a great weariness of life, and very likely will have attempted self-destruction. He will be told that the patient's bowels are torpid, and that very likely there is lithaemia. The treatment very likely has begun with an aloetic and mercurial cathartic, and this may have been followed by a course of warm baths and opiates, and in a few months the insanity, if not hereditary, will have yielded to this treatment, and the patient have returned home cured. The maniacal patient will be violent in conduct, abusive in lan- guage, and angry and wilful, perhaps very obstinate. There will be great restlessness and delusions, and perhaps he may have been homicidal. The head may be hot and the conjunctiva suffused, and the muscular movement violent. Or the head may be cool and the pulse small and quick. In such a case a mercurial cathartic may have been used to prepare the system for further treatment, which may be ether 5j.; tincture opii Tt^. xxx. to xl., ter die. Under the in- fluence of this treatment, the patient may have improved rapidly, with good food and plenty of fresh air and occupation. In this case, also, very likely the prolonged warm bath with cold to the head for half an hour, has been frequently used. The case of demcjitia with a weak mind, and who has been foolish and irritable, and inattentive to the calls of nature, and mischievous, and whose memory seems quite gone, has been treated by tonics, and perhaps the chloro-phos- phide of arsenic in 5-minim doses ter die, and gradually decreased, and perhaps has had croton oil rubbed on the shaven scalp. Under TREATMENT OF INSANITY. 255 this treatment she may have made a good recovery, particularly if the dementia has followed some exhausting and prostrating disease. The student will be told that in sthenic mania, the continued warm bath of from half to one hour or more, with cold to the head, the ad- ministration of a mercurial cathartic, the induction of sleep, occupation and exercise in the fresh air, and time, will often effect a cure in appar- ently very unpromising cases ; while in asthenic cases, stimulants are well borne, and are necessary with tonic treatment. He will learn in the wards of an insane hospital, what is perhaps new to him, that opium is the physiological antagonist to the psychical states of gloom and despair, with suicidal tendencies, seen in melancholia. He will also learn that the lucid interval of chronic mania is very far from the recovery it sometimes appears to be, and that the case of reason- ing mania, who has committed some crime, exhibits not the slightest remorse, such as a sane person would suffer from. That such a pa- tient is very plausible, cruel, treacherous, lies on all occasions, when- ever it serves his or her purpose, and always justifies the acts performed and considers them quite praiseworthy. The intellect seems quite acute, and the patient probably roundly abuses those who are work- ing for a cure, and is considered as the mischief-maker of the ward of which he or she is an inmate. No treatment will avail in this case, as the student of psychiatry will be told that there is here a congenitally diseased brain, with a total absence of all moral sense — a true moral imbecility. The feelings and moral sentiments have been affected in this case, the emotional insanity finally taking on a de- structive character. This patient will have been the scourge of his or her family from childhood. This is a case of moral or emotional insanity proper, with an exalted emotional condition. The affec- tions and dispositions are perverted. Dementia may appear as the patient advances in years, and the insane hospital is the only safe and proper place for such a one. Of the various forms of insanity in relation to treatment, we have shown the student the clinical phases of mania, melancholia, dementia, and moral insanity, or rea- soning mania. General Paralysis of tJie Insane. — We shall see the general para- lytic, or case oi paralytic dementia, exhibiting a general and progres- sive loss of co-ordinating power over his muscles (we shall rarely see a female with this disease), and exhibiting clinically a mental fee- bleness bordering on dementia. The poor fellow, who is doomed, probably, for this is one of the most incurable forms of insanity, will 256 PSYCHOLOGICAL MEDICINE. tell US that he feels in perfect health, is worth millions, and has other delusions of grandeur. As he is talking, we notice the tremor of his lips and tongue, and as he walks we see that his gait is very un- certain. As we look closely at him, we see that his pupils are un- equal, but this condition may be present or absent. The motor, sen- sory and psychical functions generally are performed sluggishly, and paralysis of the sphincters comes on and the patient dies of exhaus- tion. The patient may have had maniacal attacks during his illness. If he is inclined to be excitable and restless, we may give him a com- bination of chloral, sodium bromide, and morphia at night, with a pill every two hours of valerianate of zinc and belladonna, and cold baths with central galvanization. This may relieve symptoms very markedly, and in the early stages may possibly do more than this, but the prognosis is very gloomy indeed. The evening temperature is always higher than the morning. We may diagnose this disease by the thermometer, as the rise will be seldom less than l°, and in de- structive cases may be as high as 2°. Epileptic Insanity. — We shall find this patient presenting a history like the following : There will be a maniacal attack accompanying the fit, lasting for a few hours, and it may appear again after the fit any time within a few days. There are likely to be instantaneous acts of violence committed by this patient, and especially in non-con- vulsive cases. The higher the epileptic excitement the less likely is the patient to be dangerous, as the morbid impulses towards hom- icide more frequently accompany the milder attacks, where the patient is apparently very mild and tractable. There is an uncon- sciousness of acts performed, as there is unconsciousness in all true epilepsy. There is vertigo, injection of the conjunctiva, dilatation or alternate dilatation and contraction of the pupils, and a slow res- piration. The temperature may be below the normal, except about the time of the paroxysm, when it becomes heightened, as does the pulse. There is, sometimes, a heavy drunken sleep before the re- turn to sanity and consciousness. It is extremely important, from a medico-legal standpoint, to re- member the violence and the unconscious states of epileptics, and the existence of temporary mental disorders occurring after epileptic paroxysms. The mental condition of epileptics has received too little attention. The best treatment in these cases has seemed to us to be a combination of sodium bromide, 30 grains, and fluid extract of er- TREATMENT OF INSANITY, 25/ got 5ss. to 5j. ter die, occasionally intermitting the treatment, with plenty of outdoor exercise and carefully regulated diet. Insanity of Pubescence. — This form of mental disease resembles in its clinical features moral or emotional insanity proper, and rarely comes under treatment, as the parents fail to recognize the case as one of insanity. The great diagnostic mark is here the abnormal mental condition occurring during the evolution of the reproductive system at the time of pubescence. The treatment of the case if for- tunately recognized as disease instead of depravity, should be mainly moral, with quiet and rest.* Insanity from Masturbation. — These cases exhibit, clinically, delu- sions of fear and persecution, while the manner and conversation is pretty normal. The extremities are apt to have a cool, clammy feel. Such cases are sulky and disagreeable in the wards of an asylum, and we shall notice an evasive look in the face, and a failure of the patient to look you squarely in the eyes, and that he seems afraid. The prognosis is very gloomy. They are apt to be incurable cases. A combination of quinia, i grain, strychnia, eV g^sii^> with the com- pound tincture of gentian, ter die, is the best tonic. These cases tend to become demented. NympJiomania and Hysterical Insanity. — These forms of insanity present every phase of mental alienation, and are best treated with central galvanization. The monobromide of camphor in 4-grain capsules ter die (Clin's capsules) and arsenic. The application of the cautery to the nape of the neck occasionally is good practice. Also, Fothergill's solution of hydrobromic acid, 15 to 30 minims, after a warm bath, at bedtime, with cold to the head. Insanity of Gestation or Pregnancy. — This is a rare disease. If a woman is predisposed to insanity, she may become so in her first pregnancy, but I think it rarely occurs without such predisposition. There may or may not be recovery at parturition, and the patient may pass into chronic insanity. The psychical state is generally that of melancholia. * We have a case of this form of mental disease at present under our care in a girl of sixteen years, with marked excitability at each menstrual epoch and decided erotic ten- dencies. She will be very affectionate towards her mother, and then, with no provocation, strike her violently. She also is very profane at times, although she has been brought up in the most careful manner. We anticipate a speedy cure. At the time of writing this we have just been consulted relative to another case of a girl fifteen years of age, with pubescent insanity. Overstudy and grief at the loss of a brother, together with the excitement attendant upon the critical period, induced the attack. 17 258 PSYCHOLOGICAL MEDICINE. Puerperal Insanity. — This form of mental disease occurs after par- turition, generally, we think, owing to the absorption into the system of some of the retained products of conception, and therefore, on this principle, we have been accustomed to administer promptly a strong mercurial cathartic, 20 grains of calomel, followed by salines and min- eral acids, and a course of hot baths, with cold to the head, and perfect rest and quiet. Acute mania and melancholia are the most frequent types of this insanity. The lochia are diminished or suppressed, and the milk sometimes. Among the exciting causes, Bucknill and Tuke rank mental shock of any kind, distress of mind, especially in unmar- ried women, a tedious exhausting labor, flooding and the use of the lancet for puerperal convulsions. Hereditary predisposition is of course, in many cases, a prominent feature. The prognosis is very favorable unless it assumes an inflammatory or typhoid type. I should confidently expect, under proper treatment, to see at least two-thirds of such patients recover in six months or in less time. Insanity of Lactation. — The symptoms are of an asthenic type, and the patients are markedly anemic. Full feeding, stimulants and ferruginous tonics are indicated. Melancholia is the most frequent psychical symptom. It is a disease of anaemia and exhaustion. The prognosis is good. The great majority of cases became insane after the fifth month of nursing. Climacteric Insanity. — At least 6 per cent, of neurotic women at this period of life become insane. From 44 to 48 years of age is the age specially liable to these attacks. The cause of this type of insanity is a pathological condition of the uterus and ovaries. The record of 159 cases admitted into the West Riding Asylum, taken from the West Riding Med. Reports, vol. vi., for 1876, shows that the principal psychical symptoms in all these cases were delusions of fear and persecution, with depression. There were found cases of simple depression without hallucinations and with the intellect intact, but in some instances with great nervous irritability and general hyperaes- thesia. Another class of cases presented depression combined with affec- tions of the emotions and the intellect, hallucinations of sight and hearing, and delusions of a depressing character being present. Another class of cases presented delusions of fear, suspicion and persecution, as the most typical symptoms, with hallucinations of sight and hearing and maniacal excitement. A case now under our treatment is connected with the cessation of the catamenia. The TREATMENT OF INSANITY. 259 lady is 47 years of age. It is the first attack, and no hereditary his- tory of insanity can be discovered. The disease or mental derange- ment commenced with simple depression, sluggish bowels, furred tongue, loss of appetite and of sleep, and hallucinations of hearing. She told me that she heard people in the house talking about her constantly, accusing her of appropriating things that did not belong to her, etc. She also imparted to me very confidentially in a whis- per, that there had been secreted in a lounge in the room she occu- pied a fuse, which was connected with some explosives, and that the gentleman who owned the house was about to cause a great explo- sion, which would kill every one in the house. She would walk out, wring her hands and cry bitterly, lest herself and husband should become the victims of this " conspiracy," as she termed it. I sug- gested the advisability of a change of residence, to which she promptly acceded, and the treatment was commenced by a mercurial cathartic followed by salines. Vaginal examination revealed dis- placement of the uterus with engorgement and inflammation. The nurse was directed to use the hot vaginal douch of two gallons daily, and a pledget of absorbent cotton steeped in glycerine was inserted daily and left for four hours in contact with the uterus. The dis- placement was remedied, and the left ovary, which was enlarged and tender, thoroughly blistered. Continued warm baths of a tempera- ture of 100°, with cold to the head, were ordered and continued daily for three weeks. A tonic of iron and quinine was ordered ter die before meals. Static electricity was employed, the patient being placed on the insulated platform and sparks taken from the spine, which was tender and irritable. This patient has now been under treatment for six and a half weeks. Her delusions and hallucina- tions have entirely disappeared ; she eats well, sleeps well, with her night mixture of chloral hydrate 15 grains and fluid extract hyos- cyamus gtts. x., and is cheerful and happy and constantly busy. I think she will make an excellent recovery, and if so will probably have no relapse. Insanity from Abdominal Disorders. — These cases, which are usu- ally referable to morbid states of the colon and liver, are character- ized by melancholia and general wretchedness. They are very apt to be, we think, cases who inherit a tendency to insanity. This con- dition is very well illustrated by the following case, about which we were recently consulted : A gentleman of perhaps 60 years, by occupation a teacher, and a very close student, has been for years 260 PSYCHOLOGICAL MEDICINE. gradually lapsing into insanity. There has been chronic constipa- tion for years, due probably to defective action of the muscular coats of the colon, a condition which Professor Samuel G. Armor, of Brooklyn, ably explained in an article on " ]\Iorbid States of the Colon," published a few years ago. The patient's father committed suicide years ago. For some time — two or three years — the gentle- man referred to has been rendered most miserable by the idea that he was a very wicked man ; that he had committed unpardonable sins, and should be eternally lost. His life has always been excep- tionally correct. He now has no ability to apply his mind, and these self-tormenting accusations never leave him, and he meditates suicide to escape from his misery. We advised opening the bowels thor- oughly with seven grains of calomel, followed by salines, to be fol- lowed by a pill of aloes 2 grains and ox-gall 4 grains ter die, until he was thoroughly purged and all excrementitious matter removed. To act on the liver, a course of dilute nitro-muriatic acid, Ti^xv. ter die, to be given, and a continued course of warm baths, with gradu- ally increasing doses of opium, commencing with 20 minims of dialyzed opium, which is of the same strength as laudanum, ter die, and increase it to that point where the gloom of melancholia should yield to cheerfulness. He has started for the mountains to pursue this treatment, and will doubtless improve very much, but the fact of the strong direct inheritance makes perfect recovery problem- atical. Post-Febrile Insanity. — Bucknill and Tuke, Nasse, Sydenham, Pinel, Baillarger, Aubanel, Thore, Falret, Sauret, Griesinger, and Hanfield Jones all report cases of this type of insanity. These cases are as- thenic in t}^pe, and require quinine, arsenic, the mineral acids, and stimulants, with a generous diet. Insanity may be the result of rheumatism and cardiac disease. There may be melancholia, mania, or chorea-like attacks. The urine may be loaded with lithates. The choreic movements, paraly- sis of motor power, hallucination of the senses, poor memory, de- lirium, with high temperature, the symptoms all decreasing as the temperature subsides, point to a poisoning of the cerebral centres by a vitiated blood plasma. Specific treatment by alkaline and sali- cylic acid for the rheumatism, the carbonate or citrate of lithia and the free use of Poland water, with tonics, should give good results. The insanity of cardiac disease is associated with endocarditis or pericarditis, and is only temporary generally. The psychical symp- TREATMENT OF INSANITY. 26 1 toms are those of a taciturn melancholy and hallucination. It is, according to Dr. Burman, a hypochondriacal melancholia, or a monomania of suspicion, and the patients are sullen, morose, or impulsive. Insanity has been found to be associated with gout in some in- stances, the prevailing type being melancholia. Dr. Savage and Dr. Bertheir report cases, the latter saying that sometimes the gouty symptoms disappear and become lost in the insanity, which then passes into the choreic and incurable stage of dementia. He also says that it shows a preference for the form of general mania. Buck- nill and Tuke say that cases are frequently met with in society which are marked by symptoms of unfounded dread, especially on awaking from sleep in the early morning, in which there is a gouty diathesis, and suspicion is aroused that there is a causal connection between the bodily condition and the mental anguish. This suspicion is con- firmed by the marked success of treatment founded upon this sup- position. Phthisical Insanity. — There is a very close relation existing between phthisis and insanity. So often have I seen this that I invariably in- quire if there is consumption in the family, and I think that in almost half my cases I have found this disease tyi\st\r\g, instead of a neurosis, in a family strongly tainted with insanity. I have also known of a tendency to phthisis disappearing upon marriage and the family neurosis taking its place in at least two instances. I think that in- sanity, associated with phthisis, is most apt to be associated with melancholia, with a tendency to dementia. At least, such has been my own experience. Dr. Clouston thinks that the maniacal cases are the most apt to end in dementia and the melancholic cases to remain stationary, and his experience doubtless includes many more cases than my own, and I therefore regard it as more valu- able, as his researches in this direction have been very valuable to the profession and have been watched by myself with great interest. He speaks of the acute stage of mania or melancholia as being of short duration and succeeded by an irritable, excitable, sullen, and suspicious state. There is a want of fixity, he says, in their mental condition, unaccountable little attacks of excitement, lasting only a short time, unprovoked paroxysms of irritability and passion in a subdued form. There is a disinclination to enter into any kind of amusement or continuous work, and if this is overcome, there is no interest manifested in the employment. It might be 262 PSYCHOLOGICAL MEDICINE. called, he says, a mixture of subacute mania and dementia. The depression is general, and there is no fixed delusion. If there is any single tendency that characterizes these cases, it is to be sus- picions. From my own experience, I think Dr. Clouston's excellent de- scription of the mental symptoms of insanity associated with phthisis, is perfectly diagnostic, and the profession owes him thanks for his laborious researches in this field. Twenty-five per cent, of Dr. Clous- ton's cases exhibited a suicidal tendency. The px-ognosis is bad. Cod- liver oil and full feeding, with mountain air or any climate where the patient can live most of the time out of doors, with port wine at meals, offer the best chance of cure in the early stages, together with the phosphates. I generally use the liquor acid, phosphorici comp., Dr. William Pepper's formula, and I give morphia to those suicidally inclined. Syphilitic Insanity. — This comparatively rare form of mental dis- ease presents itself, according to Drs. Bucknill and Tuke, under two forms : congenital weakness of mind and acquired insanity. The most frequent symptoms are those of progressive dementia, with considerable loss of memory, but without expansive ideas, preceded by a period of hypochondriacal melancholy. During the early form of it we may meet with all the known forms of mental disease, but rarely acute mania. In addition to the pains in the head, there may be affection of the motor or sensory centres, the former present- ing many symptoms in common with general paralysis. This in- sanity may come on immediately after infection, according to the same authority, or be preceded by cerebral attacks, either of an epi- leptic or apoplectic nature, dementia gradually and insidiously super- vening. Wille gives three forms: ist. The irritative simple form, generally due to an anaemic state. 2d. A state marked by general mental disorder, due to meningitis and softening; and 3d. A state characterized by psychical disturbance, due to circumscribed inflam- matory softening, atheroma of the vessels, and gummous neoplasm of the brain and membranes. Dr. Mickle gives the following symptoms as occurring in his cases : Convulsive symptoms of various kinds, dementia and hemiplegia, apoplectic symptoms or coma, drowsiness, somnolence, especially in the latter periods, with a great variety of mental symptoms occurring during the earlier periods. Headache, aphasia, difficult articulation, and paralysis of cranial nerves are often found, and vomiting, blind- TREATMENT OF INSANITY. 263 ness and optic neuritis are not infrequent. The principal features are: ist. A marked tendency toward mental deterioration, the pre- dominance of negative intellectual symptoms, associated with weak- ness or loss of the moral sense and a general inclination to a degraded state of feeling. In some cases early ok intercurrent outbreaks of maniacal symptoms appear; in a few cases there is causeless depres- sion, fear, or emotional weakness, 2d. Motor symptoms, of the para- lytic or convulsive type. 3d. Sensory symptoms ;. great nocturnal pain, especially in the head ; a-naesthesia occurs rarely, and sometimes impairment of sight, blindness, or unilateral deafness at times, and very seldom hallucinations. If, after death, no intracranial syphil- itic lesions are found, we cannot with accuracy attribute the origin of the insanity to syphilis, even though the patient may have con- tracted the disease and his insanity has occurred weeks or months subsequent to such infection. The differential diagnosis between syphilitic insanity and paralytic dementia is, that in the former, hypochondriacal feelings and ideas are more often noticed at the very first, yielding gradually to dementia. In the former, prior to severe apoplectiform and other attacks, the loss of memory, confusion of thought, and tendency to fatuity are less marked, advanced, and fixed than in paralytic dementia, there is more an obscuration than a destruction of mind. Paroxysmal outbreaks of excitement are rather more frequent in the syphilitic cases, and also such symptoms as convulsions, spasms, paralyses, and sensorial disorders. Insomnia and mental irritability are more marked in the syphilitic patient, but to this there are exceptions on both sides. When delusions of grandeur are present, cases of syphilitic insanity are to be diagnosed from general paralysis from the history and symptoms of syphilis ; the preceding cranial pains, nocturnal and in- tense ; the exaltation is less marked ; paralysis of one or several cranial nerves, or hemiplegia, paraplegia, etc., having the character of syphilitic paralysis ; the greater frequency of optic neuritis, early amaurosis, deafness, local anaesthesia,, vertigo or local rigid contrac- tion ; speech not accompanied by marked facial or labial tremors > by cerebral or spinal meningitis ;, the variety of the motor and sensory symptoms ; and finally, by the effect of antisyphilitic treatment. Dr. Clifford Allbutt, Dr. Erlenmeyer, Dr. Hughlings Jackson, Dr. Wilks, Dr. Batty Tuke, Dr, Buzzard, Dr. Clouston, and Dr. Dowse have all written ably on this form of insanity. Drs. Bucknill and Tuke say that the first point in treatment is to determine whether 264 PSYCHOLOGICAL MEDICINE. the syphilitic condition present is secondary or tertiary. If second- ary, as indicated by the presence of affections of the skin and the mucous membranes, or by iritis, or pains in the muscles, joints, and bones ; by periostitis and nodes, — a condition in which the venereal poison still exists and may be transmitted, — then mercury is bene- ficial, and iodine is of little or no service. If the pathological con- ditions present are those which indicate tertiary syphilis, in which the venereal poison no longer exists in a form which can be trans- mitted to others ; a state of cachexia, which is indicated by inflam- mations of the fibrous membranes ; by caries and necrosis of bone ; by rupia and sloughing ulcers of the skin and other soft parts ; by deposits of imperfectly-organized fibro-plastic lymph in the areolar tissue of various parts and organs ; in such cases the remedies re- quired are iodine and sarsaparilla, and mercury is dangerous. Mr. Lane says, respecting treatment, that the iodide of potassium should be given in from three- to ten-grain doses in a third of a pint of the simple or compound decoction of sarsaparilla as a vehicle, alternat- ing with a pill of two grains of quinine and three grains of confec- tion of opium, also taken thrice daily. Exceptional cases may re- quire the iodide to be increased to fifteen or twenty grains, and an additional dose of opium at night will often be found necessary. Opium allays pain and irritability, and moderates all excessive secre- tion, preventing unnecessary waste. Alcoholic Insanity. — This insanity is very different from dipso- mania, which is characterized by the irresistible craving for and peri- odical indulgence in drink to the point of complete intoxication. Alcoholic insanity may be characterized by mania, melancholia, or chronic mania lapsing into dementia. Hallucination of sight and hearing, taste and smell may all be present. The patient may have no memory, no appreciation of his condition or surroundings, and his speech and gait may be strongly suggestive of a general para- lytic. He may have delusions as to place, and insist he is at some quite different locality from the one he occupies. He may pass his time in a stupid delirium or he may be quite furiously maniacal. There may be fatty degeneration and atheroma in the nerve-centres, or there may be diffuse interstitial sclerosis. The treatment should consist of broths, easily digested food, with quinine and strychnia for nerve tonics. These two remedies in combination have seemed to me in connection with the liquor acidi phosphoric, comp. and the oxide of zinc, in 2-graiii doses, to be better adapted to antagonize TREATMENT OF INSANITY. 265 the morbid condition present and to lead to a recovery than any- other plan of treatment. Kleptomania and Pyromania have been recognized by Mare, Crich- ton Browne, Dr. Savage, Dr. Steinau, Tilt, Dr. Burman, Jessen and Ray as states of undoubted insanity. Bucknill and Tuke would prefer to include pyromania under the head of destructive insanity. That these acts may arise out of a purely diseased mental condition ■ there is abundant proof in the writings of the authors referred to. We should look in these cases, say Drs. Bucknill and Tuke, for hereditary predisposition to insanity ; evidence of mental derange- ment prior to the development of the propensity ; the earliest symp- toms of general paralysis ; the occurrence of any physical disorder, as brain fever; the suppression of any discharge, or an injury to the head, puberty, pregnancy, the absence (in most cases) of any induce- ment to steal ; the general conduct of the individual during and after the act, and especially (although cunning and concealment are consistent with this form of mental disorder) voluntary restitution of stolen goods. Mare says, respecting pyromania, that incendiary acts are chiefly manifested in young persons, in consequence of the abnormal development of the sexual functions, corresponding with the period of life between twelve and twenty. We should, there- fore, in these cases inquire as to whether there exist any general symptoms indicative of irregular development, or of critical changes in the evolution of the reproductive system, whether signs were present before the incendiary act of approaching menstruation, its derangement or suppression, whether in epilepsy or catalepsy or an irregular pulse, vertigo, headache, etc. Very often there is a change in the character, such as a tendency to sadness, insensibility, and other symptoms of disordered cerebral functions. Mare relates the case of a boy who struggled for a year against such an impulse, finally setting fire to his father's house. Ray writes of a girl who heard voices commanding her to burn ; also of another girl who had an apparition constantly before her impelling her to pyromania. 266 PSYCHOLOGICAL MEDICINE. CHAPTER XIII. INSANITY IN THE MIDDLE STATES. Insanity is in the Middle States, as in the other States, increasing disproportionately to the increase of population, and it also seems to be appearing at an earlier age than formerly, which latter fact is probably due to hereditary influences which have gradually become intensified by violation of physical laws in early life, want of proper training, and too high pressure in education. This feverish haste and unrest which characterize us as a people, the undue predominance of the nervous temperament, and the want of proper recreation and sleep, tend to a rapid decay of the nervous system and to insanity as a necessary sequence. It is much to be deplored that intemperance is operating more and more each succeeding year as a formidable cause in the production of insanity. At least twenty-five per cent, of all cases of insanity admitted into the asylums of our Middle States is due either proximately or remotely to intemperance, which has produced a permanently diseased state of the brain, due to the interference in the nutrition, growth and renovation of the brain- tissue. The evil does not stop here ; for the offspring of intemperate parents are grooving up in our midst with weakened if not actually diseased nervous systems, and will inevitably in time become insane, diseased or idiots. The census returns for 1870 of the United States showed an in- crease of insanity of 55 per cent., while the increase of the general population had been 22 per cent. The proportion of insane to sane population has increased from i860, when it was shown that the entire population of the United States was 31,443,231, with an in- sane population of 23,999, ^r one insane person in every 13 10 of the whole population; up to 1875 inclusive, when, by bringing up the calculation at the same rate of increase for both sane and insane population as obtained between i860 and 1870, we find the former to be 42,115,896, and the latter or insane population 44,148, or one insane person to every 953 of the whole population of the United States. It may not be uninteresting to glance for a moment at the propor- tion of insane to sane population in other countries as compared with our own. In England there is one insane person to every 403 of the INSANITY IN THE MIDDLE STATES, 26/ whole population, or more than double the proportionate number of the United States. In France there is an average of about one in- sane person to every 600 of the whole population. In Scotland there is one insane person to every 336 of the sane population, while in Ireland there is one insane person in every 302 of the population. In the United States, California has heretofore exhibited the great- est proportion of insane to sane population, there being one in every 484. This is due to local causes. Massachusetts has shewed the next greatest proportionate number of insane, while the New Eng- land States, as a whole, have a greater relative increase in the pro- portion of the insane to the sane population than has been observa- able in either the Middle, Southern, or Western States. In the care in the treatment, in finely appointed institutions, and in scientific in- vestigations into the causes of insanity, the Middle States hold a place of which they may be very justly proud. The forthcoming national census is about to reveal that the pres- ent number of the insane, within the United States, is nearly twice as large as has generally been supposed. In the State of Massachu- setts, for example, where thirty years ago there was one insane in every thousand, there are now nearly three to every thousand, and other States show the same proportion. Nezv Yo7'k. — The New York State asylums or hospitals for the acute insane, in the order of their organization, are: The State Lu- natic Asylum at Utica ; the Hudson River State Hospital for the Insane at Poughkeepsie ; the State Homoeopathic Asylum for the Insane at Middletown ; and the Buffalo State Asylum for the Insane at Buffalo. The Utica Asylum had 626 patients in its care October ist, 1881, and it received 412 during the year ending September 30th, 1882. This gave a total of 1038 patients under treatment during the year, the daily average being 621. There were discharged, recovered, 109; improved, 46; unimproved, 235.; as not insane, 13; died, 57. Re- maining September 30th, 1882, men, 291 ; women, 287; total, 578. The Hudson River State Hospital at Poughkeepsie is only partially completed, and has accommodations for 300 patients. The whole number under treatment during the year ending September 30th, 1 88 1, was men, 220; women, 210; total, 430. The highest number in the asylum at any one time was 280, and the average was 256. Of those under treatment during the year 22 recovered, 28 were 268 PSYCHOLOGICAL MEDICINE. discharged improved, and 80 unimproved, i as not insane, and 26 died. Average weekly cost of support, ^5.87 per patient. The State Honiceopathic Asylnvi for the hisane at Middletown. — This institution is now practically completed, and it receives the acute in- sane whose friends desire their treatment in accordance with homoe- opathic principles, from all parts of the State. It has accommoda- tions for 400 patients. 340 patients were treated here during the year ending September 30th, 1881, the average number under care being 213. There were discharged, recovered, 61 ; improved, 18; unimproved, 30; died, 15. The average weekly cost the past year was $^.tj. The Buffalo State Asylum for the Insane is only partly completed, the centre and one wing being as yet erected. It was opened in January, 1881, and the number of patients admitted from that date to September 30th was men, 122; women, 97; total, 219. There were discharged, recovered, 19; improved, 11 ; unimproved, 10; as not insane, i; died, 22; leaving 156 under treatment September 30th, 1 88 1. The total capacity' at present of the several New York State hos- pitals for the acute insane is for 1600 patients. When, according to the plans adopted, the Hudson River State Hospital and Buffalo State Asylum are completed, 2200 acute insane can be cared for. The counties of New York, Kings and Monroe, embracing a popu- lation of 1,951,028, provide for their acute as well as their chronic insane in local institutions, presently to be described, under special statutes. This leaves the State to provide only for the acute insane arising in the other counties, having a population of 3,133,954. The New York State Asyhinis for the Chronic Insane are, the Wil- lard Asylum for the insane at Ovid, and the Binghamton State Asy- lum for the chronic insane at Binghamton. These institutions are designed for the chronic pauper insane, transferred from the county poor-houses or the various State hospitals for the acute insane as not cured. The State is districted between the two institutions. The charge to the counties for maintenance and care is restricted to the actual expense. The Willard Asylum has accommodations for 1800 patients. There were 1735 patients here September 30th, 1881, of whom 814 were men and 921 women. Average number under care 1695, and average weekly cost $2.6y. The Binghamton Asylum for the chronic insane was formerly INSANITY IN THE MIDDLE STATES. 269 the State Inebriate Asylum, converted to the care of the chronic in- sane in 1880. It was opened for patients October 20th, 1881. There were 66 patients here December 31st, 1881. This institution can accommodate 325 patients. The New York State asylums for the chronic insane can, there- fore, accommodate 2100 patients. Respecting the care of idiots, there are the New York Asylum for Idiots at Syracuse, and the custodial branch at Newark. The Syra- cuse institution had 292 inmates October ist, 1880, while at Newark, Wayne County, there were 98 inmates October ist, 1880. The number of the insane in the various State institutions October 1st, 1881, was 10,057, ^s against 9537 October ist, 1880, and 9015 October ist, 1879; of these 4458 were males and 5599 females. With a population according to the last Federal census of 5,082,982, the proportion of insane of this State October ist, 1881, was i to every 505 inhabitants. Kings County provides for her insane in the Kings County Lunatic Asylum at Flatbush, and has about looo or 1300 patients. The total annual cost is about ^92,400. The New York County asylums are the New York City Asylum for the insane, and the New York Lu- natic Asylum on Blackwell's Island, The total annual cost for the New York City Asylum for the insane on Ward's Island is ;^5 3,504, and on Blackwell's Island ^89,420. The State Asylum for insane criminals at Auburn, New York, was erected in 1859, ^^ a cost of ^125,000, and has 842 acres of land at- tached to it. The cost of subsequent additions has been ;^5 2,000, making the total cost of the present building ^177,000. The annual expense per patient is ;^208. The State appropriates ;^ 16,000 annu- ally for this institution. The total annual cost is ^24,544. On Ward's Island is also situated the State Emigrant Insane Asylum, which provides for the insane emigrants for the term of five years from the time of their landing in this country. This asylum fur- nishes accommodations for 200 patients. The annual expense per patient is ;^I50, and the total annual cost ^22,500. Nezv Jersey. — The New Jersey State Lunatic Asylum, at Trenton, New Jersey, was erected in 1848, and has attached to it 170 acres of land. It has a capacity of 500 patients. The original cost of the building was ^100,000, and the cost of subsequent additions has been ^178,000, making a total cost of ^278,000. The per capita cost of building is estimated to be ^556. The State appropriates, annually, 2/0 PSYCliOLOGICAL MEDICINE. ;$8ooo for the asylum. Five-sixths of the patients are paupers, at ;^4.50 per week, paid by counties. Among the patients in this asy- lum are included the convict insane, who have been transferred to the institution from the State prison by virtue of the twelfth section of the Act of the Government and Regulation of the State Prison, approved March 26th, 1869. The new asylum is situated at Morristown, New Jersey, and has been erected at a projected cost of ^2,250,000, and is one of the finest large institutions in this country, if not in the world. The site is admirably selected, and covers about 400 acres of land, Avhich cost about ^80,000. The asylum has a capacity of 800 patients. The per capita cost of building is estimated at I2802. The water-works cost ^20,000, and the water supply is said to be four times enough to meet the ordinary wants of the institution. The building has a frontage of 1250 feet, and it is a mile and a quarter around it, outside of the foundation line. It is a four-story, semi- Gothic structure, built of syenitic granite, quarried on the grounds. All the main" materials for the building were also obtained on the grounds — the stone, the clay for brick, etc. Brick was made at the rate of 80,000 per day, about 15,000,000 having been used in the construction. Pennsylvania. — Pennsylvania has five State hospitals, — Dixmont, Norristown, Harrisburg, Warren, Danville — for the insane, each of which provides accommodations for 500 patients, and another is to be erected in Philadelphia. There is also a Friends' hospital, at Frankford, Pennsylvania. The city of Philadelphia is entitled to the credit of making the first regular provision for the insane ever made in America. In 175 1 the Pennsylvania Hospital, at Philadelphia, was incorporated by the Provincial Assembly, for the purpose of providing for the indigent sick and for the care and cure of the insane. The first patient placed for treatment of insanity was admitted to that hospital February nth, 1752. The second institution was the asylum at Williamsburg, Virginia, opened 1773. At the present day we have in operation in the United States, I think, seventy-six hospitals for the insane, which will accommodate 29,000 patients. Since the establishment, in 175 1, of the Pennsylvania hospital, with its sound declaration of principles, which, even at that time, recognized insanity as a physical disease capable of cure, up to 1805, when Dr. Benjamin Rush delivered lec- tures on insanity, with clinical instruction in his wards, and down to the present time, when the hospital is presided over by the able PROVISION FOR THE CHRONIC INSANE. 2/1 specialist in mental disorders, Dr. Thomas S. Kirkbride, and when the State laments the loss of the late eminent alienist, Dr. Ray, Penn- sylvania has maintained a position in the application of State medi- cine to the treatment of insanity of which she may be justly proud. A separate institution is much needed in this State, for the criminal insane. It is estimated that in June, 1883, there will be 6093 insane persons living under the present system of treatment. The insane in Delaivare are scattered all over the State in alms- houses, jails, etc., and many of them are provided for in the Penn- sylvania hospital. In this connection it is both appropriate and proper to say a word in remembrance of the late Dr. I. Ray, of Philadelphia, by whose knowledge and experience so many of us have profited. He was born at Beverly, Massachusetts, January i6th, 1807. Graduated at Harvard Medical School in 1827. In 1841 he was appointed super- intendent of the Augusta, Maine, State Hospital for the Insane, remaining there until 1846, when he assumed charge of the Butler Hospital, at Providence, Rhode Island, where he remained until 1867, when, by reason of failing health, he resigned and moved to Phila- delphia. He did a great deal for the medical profession by his able, scientific, and learned writings, and was an expert of vast knowl- edge and ripe experience in mental medicine. He was one of the pioneers in psychological medicine in this country, and it is owing to him that much advance has been made in the right direction. His works are written in beautiful English, and will take their place as classical treatises on psychological medicine. He died March 31st, 1881. CHAPTER XIV. PROVISION FOR THE CHRONIC INSANE. From a thorough and extended examination of the reports of our insane asylums — and these remarks cover not only the Middle States, but apply equally as well to all of the States — it seems to be very evident that we are building large, expensive institutions, fitted up with all the appurtenances demanded by modern science for the 2/2 PSYCHOLOGICAL MEDICINE. treatment and cure of insanity, and that, as soon as such institutions are opened for the reception of patients, they become filled up with a class of cases three-fourths of whom are chronic and hopelessly insane patients. It is no less evident that if proper provision is not made for this class of the insane each State must build, every few years, a very expensive institution, for which every city and town must be heavily taxed. What are we going to do to relieve this rapidly increasing difficulty ? If this class of the chronic insane are well taken care of they are going to live in this hopelessly insane state — from which, at the utmost, not more than lo per cent, will ever recover — for years, costing for their maintenance not less than ;^3.50 per week. It is a fact that every medical superintendent of an institution for the insane must have noticed, that the presence of this incurable class of patients exercises a very depressing and unfavor- able effect upon the minds of the recent and acute cases. If a patient perceives upon admission that the population is made up principally of patients who have been inmates for years and for whom no hope of cure is entertained by the medical officers, and that few patients go out restored to health, the moral effect must necessarily be de- pressing and disastrous upon the mind of such a patient and tend to retard his own recovery. At present many large, fine institutions, instead of being, as they were originally intended to be, hospitals for the treatment and aire of the insane, are merely asylums and recep- tacles for the retention of patients at an enormous expenditure of money for architectural display. The overcrowding of such institu- tions by the retention of the chronic insane precludes the possibility of proper classification or proper ventilation. By transferring this class of the chronic insane and leaving the class of recent and curable insane, we derive many advantages. First and most important, the patients understand that they are in a hospital, that they come to be cured of a physical disease, and that, by submitting to the treatment and discipline of the institution, they ivill be cured. Secondly, the superintendents will have at their disposal ample room for proper classification, good ventilation, amusements, and recreation. The present system of asylum management is defective and expensive be- yond the ability of the State to meet the demand, and tends directly to increase the number of the chronic insane, as 90 per cent, of the capacity of all of our State institutions is now occupied by the chro- nic insane to the exclusion of recent and curable cases. This class of cases often become chronic and incurable cases in many of our PROVISION FOR THE CHRONIC INSANE. 2/3 States before they can obtain the proper curative hospital treatment, which, if applied in time, would have resulted in a speedy cure and restoration to their families, and a saving of their productive power to the commonwealth. From an extended examination of the sta- tistics of the State insane asylums in the United States in 1875, I found that the total cost of 55 of these institutions was not far from ;^29,879,258. This made an average cost for each of these institu- tions of ^543,259, and an average per capita cost of ;^I074 for each of the asylums in our country. Now I maintain that no State can afford to provide for the chronic insane at such a per capita cost of hospital construction when they can be provided for at a per capita cost of construction of ^300 by providing for them plain, substan- tial buildings. It would be very easy and practicable to erect such buildings, accommodating 50 patients, for ;^i 5,000 each, while no building accommodating the number that four such cottages or build- ings would provide for could be built for less than ;^200,ooo. For the chronic and harmless insane, we do not need so many attendants or such costly accommodations as for acute and recent cases. For the chronic insane we need plain but substantial build- ings, which should, I think, be located on a large farm, so that the patients could be employed out-of-doors. In this way these patients could be made producers, and could be supported at comparatively little cost to the State, and at the same time they would have the benefits accruing from a good, plain, country style of living, with an abundance of fresh air, sunlight and regular and systematic occu- pation. By such a course of treatment many would improve in gen- eral health, and some would probably recover who would never have been benefited if they had been confined in an asylum. Of the thousand patients admitted to the asylum for the chronic in- sane at Tewksbury, Mass., during the eight years of its existence, about one hundred have recovered or improved by outdoor work, and the experiment is regarded as a decided success. The ex- pense has averaged, I think, not far from ^100 a year for each in- mate, and it is stated by competent authority, that the patients are as well cared for as they were previous to their admission. The estab- lishment in 1869, of the Butler Asylum for the chronic insane in Rhode Island, was found to be a very successful experiment. It is a well-managed institution, and the trustees say regarding it, that "its result is to enlarge the capacity of the hospital for the treatment of recent cases of insanity, and thereby to increase its beneficial 274 PSYCHOLOGICAL MEDICINE. agency as a curative institution." Quite a number of patients have recovered through the agency of the outdoor work, and it is stated that the patients are better cared for than before coming to this in- stitution. The annual saving to the State of Rhode Island is stated to be over ;^ 12,000, while the amount saved annually to the State of Massachusetts by the establishment of the Tewksbury Asylum, is stated to be ^25,000. The Willard Asylum for the chronic insane at Ovid, New York, re- garded by many as an experiment of doubtful expediency, has proved, under the skilful management of its able medical superintendent, Dr. John B. Chapin, to be a highly successful measure. The trustees say, " The idea heretofore promulgated that the chronic insane could not be so Avell cared for in a separate asylum, and that it was better to retain them in a hospital with recent and acute cases, has proved on trial here to be a fallacy." To deal with the steadily increasing mass of lunacy is a problem which, as time goes on, becomes, by its magnitude, more and more difficult of solution. There can be no doubt that the only way of checking the growth of lunacy, is by treating, in properly organized hospitals, the recent cases as they occur, and that cannot be effectively done until our present asylums are eased of some of the dead weight of chronic insanity which fills their wards and hampers their curative powers. The great objection which has been urged by those op- posed to the separation of the recent and chronic insane, has been that the latter, in institutions designed for them alone, would be neglected and abused, and they would not receive proper medical attention and care. The results thus far have not confirmed these fears. Under all circumstances such an institution should be presided over by a medical superintendent of equal ability and capacity to those at the head of hospitals for the recent insane, and no attempt should be made to put such patients on a poor, meagre or insufficient diet, and they never should be neglected or abused. By having these asylums located on large farms, we secure to the patients, as I have previously remarked, occupation, fresh air and sunlight, and a good nourishing country style of living, and if there are any possibilities of recovery in any of the patients, such a plan of treatment will develop them. LUNACY IN ENGLAND. 2/5 CHAPTER XV. LUNACY IN ENGLAND. In the year i860 the total registered number of the insane in Eng- land and Wales was 38,058 ; in 1870, 54,713; and in 1880, 71,191. Insanity, however, has not doubled, but there has been an increas- ing readiness to place persons as lunatics in establishments. In England 43 per cent, of the private patients are in private asylums. There are sixty county and borough asylums in England, containing 40,000 beds. The average cost per bed has been not quite ;^20O. The weekly cost of each patient is los., andthe yearly cost ;!{^40. They are governed by a committee of the Justices of the Peace, under the control of the Secretary of State for the Home Department. Two of the best of the English county asylums, are that for Sussex at Hayward's Heath, and that for Surrey at Brookwood. The State Asylum for the criminal insane is located at Broadmoor. The four great metropolitan asylums, which hold 6600 lunatics, are situated at Planwell, Colony Hatch, Banstead and Wandsworth. There are also in England fifteen insane hospitals, including the idiot asylums at Earls- wood and Lancaster, where the insane of the upper and middle classes are treated. Lunacy in Scotland. — In 1858' the Commissioners in Lunacy for Scotland entered upon their duties, at which time the insane regis- tered population amounted to 5823 persons. On January ist, 1881, there were under treatment a total number of 10,012 patients. There have been several important improvements introduced in Scotland, in the mode of treating patients; the abolition of walled airing courts ; the disuse of locked doors; and the extension of the practice of giv- ing liberty on parole. In the Fife and Kinross Asylum, containing 330 inmates, only two wards, one for 20 female patients and one for 30 male patients, are kept locked. In the Barony Asylum at Lenzie, which contains 500 patients, there is free communication between all the wards, as well as free egress from each of them to the general grounds of the asylum. The Commissioners of Lunacy are united in their commendation of 2/6 PSYCHOLOGICAL MEDICINE. the arrangements existing in the private asylums of Scotland, and in no single instance has any complaint been made, either against the administration or the building. The following are the revised orders respecting the case-books in English asylums : "The Commissioners in Lunacy, by virtue of the power vested in them by the act of Parliament, passed in the session holden in the 8th and 9th years of the reign of her present ^Majesty, entitled 'An Act for the Regulation of the Care and Treatment of Lunatics,' do hereby order and direct — "That the medical ' case-book,' by the said act directed to be kept in every licensed house and hospital, shall be kept in the form here- inafter mentioned, viz. : " First. A statement to be entered of the name, age, sex and pre- vious occupation of the patient, and whether married, single or widowed. " Secondly. An accurate description to be given of the external ap- pearance of the patient upon admission; of the habits of body, and temperament, appearance of eyes, expression of countenance, and any peculiarity in form of head, physical state of the vascular and respi- ratory organs, and of the abdominal viscera and their respective functions, state of pulse, tongue, skin, etc., and the presence or ab- sence, on admission, of bruises or other injuries to be noted. " Thirdly. A description to be given of the phenomena of mental disorder, the manner and period of the attack, with a minute account of the symptoms, and the changes produced in the patient's temper or disposition ; specifying whether the malady displays itself by any, and what, illusions or irrational conduct, or morbid or dangerous habits or propensities ; whether it has occasioned any failure of memory or understanding, or is connected with epilepsy, or ordinary paralysis, or symptoms of general paralysis, such as tremulous move- ments of the tongue, defect of articulation, or weakness, or unsteadi- ness of the gait. " Fourthly. Ever}' particular to be entered which can be obtained respecting the previous history of the patient ; what are believed to have been the predisposing and exciting causes of the attack ; what the previous habits, active or sedentary, temperate or otherwise ; whether the patient has experienced any former attacks, and if so at what periods; whether any relative has been subject to insanity' ; and whether the present attack has been preceded by any premoni- LUNACY IN ENGLAND. 2// tory symptoms, such as restlessness, unusual elevation or depression of spirits, or any remarkable deviation from ordinary habits and con- duct ; and whether the patient has undergone any, and what pre- vious treatment, or has been subject to personal restraint. " Fifthly. During the first month after admission, entries to be made at least once in every week, and oftener where the nature of the case requires it. Afterwards, in recent or curable cases, entries to be made at least once in every month ; and in chronic cases, subject to little variations, once in every three months. " In all cases an accurate record to be kept of the medicines ad- ministered and other remedies employed, with the results, and also of all injuries and accidents. That the several particulars hereinbe- fore required to be recorded be set forth in a manner so clear and distinct as to admit of being easily referred to and extracted when- ever the commissioners shall so require." — Office of Commissioners in Lunacy, 19 Whitehall Place. The work of freeing the insane from mechanical restraint is due primarily to Dr. John Conolly. Dr. Paget, in his Harveian oration, in England, in 1866, thus speaks of it: "In June, 1839, Dr. Conolly was appointed resident physician at Hanwell. In September he had abolished all mechanical restraints. The experiment was a trying one, for this great asylum contained 800 patients. But the experiment was successful ; and continued experience proved incon- testably that in a well-ordered asylum even the strait- waistcoat might be entirely discarded. Dr. Conolly went further than this. He maintained that such restraints are in all cases positively injuri- ous ; that their use is utterly inconsistent with a good system of treatment ; and that, on the contrary, the absence of all such re- straints is naturally and necessarily associated with treatment such as that of lunatics ought to be, — one which substitutes mental for bodily control, and is governed in all its details by the purpose of preventing mental excitement, or of soothing it before it bursts out into violence. He urged this with feeling and persuasive eloquence, and gave in proof of it the results of his own experiment at Han- well, for, from the time that all mechanical restraints were abolished, the occurrence of frantic behavior among the lunatics became less and less frequent. " Thus did the experiments of Charlesworth and Conolly confirm the principles of treatment inaugurated by Daquin and Pinel, and prove that the best guide to the treatment of lunatics is to be found 278 PSYCHOLOGICAL MEDICINE. in the dictates of an enlightened and refined benevolence. And so the progress of science, by way of experiment, has led men to rules of practice nearer and nearer to the teachings of Christi- anity. To my eyes, a pauper lunatic asylum, such as may now be seen in our English counties, with its pleasant grounds, its airy and cleanly wards, its many comforts, and wise and kindly superinten- dence, provided for those whose lot it is to have the double burden of poverty and mental derangement — I say this sight is to me the most blessed manifestation of true civilization that the world can present." The English lunacy law, setting aside the special statutes dating from King Edward II., regulating the proceedings in chancery, are the result of the legislation of 1845, ^^'^ consist chiefly of acts amendmg other acts. It is considered in England that a bill for the general consolidation and amendment of these several statutes is an urgent necessity. The government of Lord Beaconsfield announced in her majesty's speech from the throne, on the opening of Parlia- ment in February, 1880, that such a measure was in preparation. It is earnestly desired in England that the government should give the question of lunacy law reform their early and careful attention. It has been suggested by Dr. C. Lockhart Robertson, Lord Chancellor's Visitor in Lunacy, that a royal commission should be issued to in- vestigate and report on the working, in detail, of the lunacy law, and to make suggestions for its consolidation and amendment. What seems to be desired for one thing, is a cheap and speedy method of placing the property of lunatics under the guardianship of the Lord Chancellor. It seems to many in England desirable that, as in Scot- land, the whole lunacy of the kingdom should be under the control and cognizance of the lunacy board. Dr. Robertson says : " The whole future efficiency of the English county asylums depends upon the right adjustment of the relative control given to the local au- thorities through the new county boards and to the central govern- ment through the commissioners in lunacy." There seems to be an idea that the present lunacy commission of England requires both extension and remodelling, although great confidence is expressed in England in the ability, industry, and in- tegrity with which the existing lunacy law is administered by the commissioners. The English Government needs to pass a wide and comprehensive measure of lunacy law reform, so as to extend to the insane of England the fullest amount both of protection and liberty. LUNACY IN ENGLAND. 279 The Royal Edinburgh Asylum at Morningside, is under the able management of Dr. Clouston. This institution has beds for two hundred private and six hundred pauper patients. These two classes are assigned to separate buildings. For the private class there are two or three cottages, and also Craig House, which ac- commodates twelve or fifteen of the best-paying patients. Those patients of the private class who do not pay much more than the in- stitution receives for charity patients, live in the same buildings with the latter class, but have a separate dining-room and a better dietary than the pauper class. The main building is in excellent condition, and has fine dining-rooms, off from which run conserva- tories filled with plants and flowers. There are also glass corridors about the building for exercise in bad weather. There are open-grate fires in the wards. The patients are employed about the grounds. Dr. Clouston treats his excited patients by keeping them out all day in the open air, and gives a warm bath, followed by the bromides, at night. No mechanical restraint is used. There are padded rooms for violent cases, but Dr. Clouston believes in full liberty and little seclusion. The three Middlesex asylums are Hanwell, Colney Hatch, and Banstead. Dr. Raynor is the medical 'superintendent of Hanwell, and his patients are mostly acute and recent cases. Nearly all of his patients are kept employed in some manner. He uses no me- chanical restraint, but canvas suits are used for destructive patients. In cases of great excitement, he employs extra attendants. There are padded rooms for violent cases. Dr. Raynor uses few sedatives, but keeps his maniacal cases in open air. At Colney Hatch, Dr. Marshall has the superintendence of the female department, and Dr. Shephard of the male side. No me- chanical restraint is used, but they have strong rooms and also padded rooms. Sedatives are seldom used. Dr. T. Claye Shaw is the medical superintendent of the Banstead Asylum, and he treats his patients on the non-restraint system. The patients are made to work whenever possible. They have mittens and padded rooms for bad and destructive cases. In Bethlehem and St. Luke's Hospitals, the patients receive few sedatives, and are treated on the non-restraint system. They have padded rooms and canvas clothing for destructive patients. At Beth- lehem there is one attendant for every six patients. Dr. Richard Greene is the superintendent of the Northanipton 280 PSYCHOLOGICAL MEDICINE. County Insane Asylum at Berrj^wood near Northampton. The building accommodates 600 patients. There is one attendant for every 15 patients. Close shutters- close all the windows in the single rooms, and the other windows have stops, which prevent their being either raised or lowered more than about half a foot. There are padded rooms and also rooms with double doors. The suicidal cases are placed in one ward every night, and are specially watched. The patients occupy single rooms with doors of open woodwork to make surveillance easy. The patients are all made to work, and all the shoes and clothes of the male patients are made in the shops by male patients. Sedatives and the wet pack are used as required. The Manchester Royal Asylum at Cheedle is run on the extreme non-restraint system. There are no walls about the asylum as is customary in England. Both pay patients and charity patients are received. Many patients have their own private parlors besides their sleeping-rooms, which are one stor}^ higher up. In maniacal cases dark and padded rooms are used. Sedatives are used when- ever needed. Nothing but mittens are used in the way of mechani- cal restraint. Mr. Bailey is the superintendent of St. Andrew's Hospital at Northampton, and the patients come entirely from the upper and middle classes. There are many acres of ground, beautifully laid out in fine lawns and gardens, and the accommodations within are spacious and first-class in every respect. Mechanical restraint is un- known, attendants taking the place of restraint. Sedatives are freely used. Dr. Yellowlees is the able superintendent of the Royal Glasgow Asylum at Gartnarel. The pay patients and charity patients are separated in different buildings. The private patients take their meals in the corridors, and the charity patients have a large common dining- room. The lowest price for patients is, I believe, two guineas per week, while charity patients are paid for by their parishes at twelve shillings per week. The asylum is run on the non-restraint system. Sedatives are freely used when necessary. Dr. Yellowlees secures the clothing on destructive patients by locked buttons and buckles. There are many open fire-places. Dr. C. H. Skae is the superintendent of the Ayr District Asylum, which holds 300 patients of the lower classes. Dr. Rutherford is the able superintendent of the Barony Parochial Asylum at Lenzie near Glasgow. The buildings will accommodate LUNACY IN ENGLAND, 28 1 500 patients. There is one attendant for every 12 patients. Open fire-places are in use, and all able-bodied patients work outside. The non-restraint system and unlocked doors are the rule. There are workshops for all the trades. They have a farm of four hundred acres, and there are no fences about the grounds. Very few seda- tives are used here. Maniacal patients are kept in the open air; of course escapes are frequent. Some of the hospitals have sum- mer houses, where small parties go out, stay for two or three days or weeks, and return again, fresh sets of patients being allowed to go out in the same manner. This is true of the Edinburgh Asylum, the Bethlehem Hospital, and the Asylum at Cheedle. In Scotland moleskin garments are used for destructive patients who tear their clothing. In 1881, 310 escapes were made from Scottish asylums; of these 206 were brought back within twenty- four hours, 61 in less than a week, and 21 after more than seven days. The re- maining 22 did not return. Accidents during 1881 were 141; 11 ending fatally.* With regard to the increase of lunacy in Scotland the commis- sioners say : " The figures in the table do not indicate any steady or appreciable increase in the admission of private patients into asylums, while there is a very considerable increase in the number of pauper lunatics registered during the last year. This increase exceeds that during any year since the establishment of the board, and amounted to 333, the number being 337 pauper lunatics over and 4 private pa- tients under the number for 1880. The distribution also of pauper patients in private dwellings continues to show considerable increase, the number for the period under review being 52 ; it should be re- membered, however, in this connection, that in Scotland no pauper lunatics are accommodated in private asylums, the public establish- ments alone receiving them. The admission of voluntary patients in the year amounted to 38, this number 11 less than in 1880, and the same figure under the average admission between 1 875-79. ^^ have for some years been able to say that nothing has occurred to indicate any difficulty or disadvantage traceable to the presence of * hisanity in France.. — The four Parisian asylums are the Bicetre, Salpetriere, Char- enton, and St. Anne. All the inmates live much in the open air. Water, as a means of treatment, is much used, and elaborate means for this are provided. Restraint is freely used. Insanity is more active in France than in England and there is more agitation. At Lausanne, in Switzerland, no restraint is used. Maniacal attacks are milder here than in France and Italy. At the asylum at Heidelberg, in Germany, leather mittens and the wet packare used.to restrain patients. 'The policy of Germany is that of non-restraint. 282 PSYCHOLOGICAl! MEDICINE. this class of patients in asylums ; and we continue to be of opinion that it is a useful provision of the law which permits persons who desire to place themselves under care in an asylum to do so in a way which does not require them to go through forms from which the}^ naturally shrink, and yet affords sufficient guarantee against abuse. At the visits of the medical commissioner to asylums all voluntary' inmates are seen, and they have then an opportunity of making statements in regard to their position, should they desire to make any. Where there is reason to suppose that they in any way fail to understand the conditions of their residence, we consider it proper to explain these conditions ; but we have never found that the nature of their position has been intentionally concealed from them. Discharges numbered among recovered patients, no fewer than 1x88; 206 private and 982 pauper. These figures are both higher in respect to annual rates and to averages." The thirty-sixth report of the Commissioners in Lunacy in England yields confirmatory evidence respecting the suspected increase in lunacy in that country. " The large increase noticed in the number of lunatics last year is almost entirely among the pauper classes, the private patients remaining comparatively stationary. The figures for 1 88 1 show an increase of iSoi as compared with those relating to 1880; the average annual increase of pauper patients for the preced- ing years having been only 1 507." During the year dealt with in this report 17 deaths by suicide occurred in county and borough asylums. In three cases the patients were away on trial. Dr. G. H. Blandford, of England, in writing on the treatment of insanit}' says : " Our object should be to restore to health the disor- dered brain, to cause the incessant waste to cease, to promote a stor- ing and not an expenditure of nerv^e-force. The brain must be nourished by healthy blood. The quantity of the latter when in de- fect must be increased ; when its quality is in fault it must be im- proved ; and when the blood-flow is in excess it must be checked ; while all causes of disturbance reacting upon the brain from other organs of the body must be removed." He also wisely says : " Many persons at the very outset of insanity' may by removal and judicious treatment be cured, if their friends will only open their eyes and acknowledge the threatening evil, and not wait, as they so often do, till compelled by circumstances to interfere, etc. Patients' friends con- stantly make a mistake ; they keep the patient out of an asylum at the time asylum treatment would cure him, and send him there LUNACY IN ENGLAND. 283 when all hope of cure is over, and when as a chronic lunatic he would be just as well off out of one." " To procure sleep no drug in his experience approaches chloral in value, and few are the cases where it is totally inefficacious. He has failed to perceive the pernicious effects attributed to it by some writers, and the results both in severe and slight cases have been most satisfactory. In the melancholic and non-excited cases the preparations of opium are of great service, alone, or in combination with chloral. In excitement, bromide of potassium is valuable, alone, or in combination with chloral, Indian hemp, or henbane. Calabar bean is useful in general paralysis. Good and abundant food is an essential in the treatment of the insane ; stimulants are required in many cases, particularly the depressed and anaemic forms, but in the opposite, though often useful, they in some cases produce or in- crease excitement, especially in the early stage. With the food tonics should be given, and those best suited are, in the writer's ex- perience, the mineral rather than the vegetable, and chief of all, the preparations of iron." I regard the following, written thirty years ago by the late emi- nent Dr. Forbes Winslow, as very valuable to the profession, and accordingly insert it : On the Medical Treatment of Insanity. — It is necessary that we should, before being able to appreciate the effect of medical treatment, entertain just and enlightened views as to the curability of hisanity. I now speak from a somewhat enlarged experience, from much consideration of the matter, and I have no hesitation in affirming that, if brought within the sphere of medical treatment in the earlier stages, or even within a few months of the attack, insanity, unless the result of severe physical injury to the head, or con- nected with a peculiar conformation of chest and cranium, and an hereditary diathesis, is as easily curable as any other form of bodily disease for the treatment of which we apply the resources of our art. It is a lamentable error to suppose, and a dangerous, a false, and unhappy doctrine to promulgate, that the disordered affections of the mind are not amenable to the recognized principles of medical science. I again declare it to be my positive and deliberately-formed opinion that there are few diseases of equal magnitude so susceptible of successful medical treatment in the incipient form as those implicating the normal action of thought. The vast amount of incurable cases of insanity which crowd the wards of our national and private asylums is pregnant with important truths. In the history of these unhappy persons — these lost and ruined minds — we read recorded the sad, melancholy, and lamentable results of either a total neglect of all efficient cura- tive treatment at a period when it might have arrested the onward advance of the cere- bral mischief and maintained reason upon her seat ; or of the use of injudicious and unjus- tifiable measures under mistaken notions of the nature and pathology of the disease. In no class of affections is it so imperatively necessary to inculcate the importance of early and prompt treatment as in the disorders of the brain affecting the manifestations of the mind. I do not maintain that our curative agents are of no avail when the disease has 284 PSYCHOLOGICAL MEDICINE. passed beyond what is designated the " curable stage." My experience irresistibly leads to the conclusion that we have often in our power the means of curing insanity, even after it has been of some years' duration, if we obtain a thorough appreciation of the physical and mental aspects of the case, and perseveringly and continually apply reme- dial measures for its removal ; but I cannot dwell too strongly upon the vital necessity of the early and prompt exhibition of curative means in the incipient stage of mental derangement. I believe insanitj^ (I am now referring to persistent insanity, not those transient and evanescent forms of disturbed mind occasionally witnessed) to be the result of a specific morbid action of the hemispherical ganglia, ranging from irritation, passive and active congestion, up to positive and unmistakable infia}7imatory action. This state of the brain may be confined to one or two of the six la3'ers composing the hemispherical ganglia ; but all the laj'ers are generally more or less implicated, in conjunction with the tubular fibres passing from the hemispheres through the vesicular neurine. This specific inflam- mation, from its incipient to the more advanced stage, is often associated with great vital and ner^'ous depression. It is, like analogous inflammation of other stiuctures, not often accompanied by much constitutional or febrile disturbance unless it loses its specific fea- tures and approximates in its character to the inflammation of active cerebritis or menin- gitis. This state of the hemispherical ganglia is frequently conjoined with active san- guineous circulation and congestion, both of the substance of the brain and its investing membranes. The morbid cerebral pathological phenomena, viz., the opacity of the arachnoid, the thickening of the dura mater, its adhesions to the cranium, the depositions so often observed upon the convoluted surface of the hemispheres and on the meninges, the hypertrophy, scirrhus, the cancerous affections, the induration, the depositions of bony matter in the cerebral vessels and on the dura mater, the serous fluids in and the ulcera- tions upon the surface of the ventricles, the alterations in the size, consistence, color, and chemical composition of the vesicular neurine and fibrous portion of the brain — are all, in my opinion, the results, the sequels, more or less, of that specific inflammatory condi- tion of the hemispherical ganglia to which I have referred. It does not necessarily fol- low that the fons et origo mali of insanity is invariably to be traced to the brain. The preliminary morbid action and irritation are often situated in the heart, the stomach, the liver, the bowels, the lungs, or the kidneys, the brain being secondarily affected ; never- theless, in all cases inducing actual insanity, the hemispherical ganglia are involved in the morbid action. The most recent pathological doctrine propounded to explain the phenomena of insanity — I refer to the views of a recent writer — that derangement of mind is the effect of " loss of nervous tone^'' and that this loss of nervous tone is " caused by a premattire a7id abnormal exhaustibility of the vital powers of the sensorium " — con- veys to my mind no clear, definite, or precise pathological idea. It is true that we often have, in these affections of the brain and disorders of the mind, " loss of nervous tone " and " exhaustion of vital power," but, to my conception, these are but the effects of a prior morbid condition of the encephalon, the sequelcB of specific inflammation of the hemispher- ical ganglia. To argue that insanity is invariably and exclusively the result of "loss of nervous tone," is to confound cause and effect, 'ih^ post hoc with the propter hoc ; and would, as regards therapeutical measures, act as an ignis fatuus, alluring us, as patholo- gists, from the right and legitimate path. I feel anxious that my views upon this important subject should be clearly enunciated and not open to misconception. I think much mischief has arisen from a belief ii the existence of active ordinary cere- bral inflammation in cases of insanity, for it has led to the adoption of treatment most destructive to life and has seriously interfered with the permanent restoration of the reasoning powers. Nevertheless, insanity is occasionally complicated with acute LUNACY IN ENGLAND. 285 cerebral symptoms sufficient to justify us in the cautious use of somewhat active meas- ures for its removal. We must avoid the fatal error of a too rapid process of gen- eralization, and be careful of not looking to symptoms instead of to the disease itself, and of permitting ingenious and well-constructed a priori theories of the nature of insanity to dazzle our imaginations and abstract the mind from the steady and patient investigation of pathological science and individual cases of disease. If we allow our judgment to be warped by the inflammatory theory on the one side (I am now speaking of ordinary not oi specific inflammation), and conclude that the excitement of mania is to be subdued by copious depletion or the administration of antiphlogistic measures ; or if, on the other hand, we adopt the speculative opinions of those who belive that in every case of insanity, irrespective of its origin, its progress, or its character, there exists " mere loss of nervous tone " caused by " a premature abnormal e.xhaustibility of the vital powers of the senso- rium," how lamentably shall we be misled as to the real character of insanity and in the application of our therapeutic agents ! These circumscribed and partial views of the pathology of insanity often, alas, lead to serious solecisms in practice. In 90 per cent, of the cases of acute mania there is found in the brain and its meninges a state of san- guineous congestion, particularly of the hemispherical ganglia, combined with alterations in the gray nervous matter. In forming an opinion of the actual pathological condition of the cerebral substance we should remember that, particularly in public asylums, it is a rare occurrence for recent cases to be admitted ; that the acute and subacute active cerebral conditions have subsided and the disease has assumed a chronic form before the patient is examined and placed under treatment ; consequently many deductions recorded by pathologists have been based upon the study of chronic and not of acute mania. A large percentage of the cases, before admission into our national asylums, have passed through the primary and acute stages, and have probably been subjected to medical treatment. This fact must never be lost sight of in forming our opinion not only of the nature of the disease itself, but of the medical treatment necessary for its cure. In private practice the acute foiTns of insanity are often met with, but even with the advantages which the phy- sician can command of investigating the earlier stages of deranged mind, he often dis- covers that the mental affection has been allowed to exist and slowly progress for a con- siderable period, no treatment, either medical or moral, having been adopted for its removal. If the incipient form of insanity, particularly when it manifests itself in pleth- oric constitutions, has been sudden in its development, is the result of physical causes, and is connected with the retrocession of gout, or is rheumatic in its character, there can be no doubt the nature of the changes induced in the brain is more allied to that of inflammation than that of nervous exhaustion. The attacks from the slow and insidious operation of moral causes are less likely to be accompanied by active symptoms. In many instances the maniacal excitement is asthenic or atonic in its character, resembling the delirium of the last stages of typhus fever. The most simple classification of insanity — the one best adapted for useful and practical purposes — is its division into the acute 2lxA chronicioxvas,; the insanity ushered in by excitement or by depression into mania and melancholia — amentia and dementia. The mmute divisions and subdivisions, the complicated and confused classification to be found in books may serve the ostentatious purposes of those desirous of making pompous dis- play of scientific lore, but I think they have tended to bewilder and obscure the under- standing of the student and lead the man in search of practical truth from the investiga- tion of the disease itself to the mere study of it^ symptoms and to the consideration of unessential points and shades of difference. Adhering to this division of the subject, each form should be viewed in relation to its complications as well as to its associated diseases. Among the former are epilepsy, suicide, homicide, paraplegia, hemiplegia, and general 286 psycholoctICAl medicine. paralysis. The associated diseases implicate the lungs, heart, liver, stomach, bowels, kidney, bladder, and skin. Before speaking of the preliminary examination of the patient supposed to be insane and the prognosis in cases of insanity, I would premise that those inexperienced in the examination of this class of cases would often arri\'e at false and inaccurate conclusions if they were not cognizant of the fact that the insane often describe sensations which they have never experienced, and call attention to important symptoms which have no exist- ence except in their own morbid imaginations. A patient will tell you that he has a racking headache or great pain and tenderness in the epigastric region, both symptoms being the fanciful creations of his diseased mind. This is particularly the case in the hysterical forms of insanity, in which there always exists a disposition to pervert the truth and exaggerate the symptoms. Again, serious bodily disease may be present, the patient not being sufficiently conscious to comprehend the nature of the questions asked or able to give intelligible replies to the anxious interrogatories of the physician. Insanity often masks — effectually obscures — other organic affections, tha greater malady overpowering the lesser disease. When Lear, Kent, and the Fool are standing alone upon the wild heath, exposed to the merciless pelting of the tempest, Ke7it feelingly implores the king to seek shelter from the " t}"ranny of the open night" in an adjoining ho^•el ; it is then that Lear gives expression to the psychological truth just referred to : " Thou think'st 'tis much that this contentious storm Invades us to tlie skin; so 'tis to thee; But where the greater malady is fixed. The lesser is scarce felt ; The tempest in }?iy mind Doth from my senses take all feeling else Save what beats there" Disease of the brain may destroy all apparent consciousness of pain and keep in abey- ance the outward and appreciable manifestations of other important indications of organic mischief. Extensive disease of the stomach, lungs, kidneys, bowels, uterus, and heart have been known to have progressed to a fearful extent without any obvious recognizable indication of the existence of such affections. Insanity appears occasionally to modify the physiognomy and symptomatology of ordinary diseases and to give them peculiar and specific characteristic features. Again, it is necessary for the physician to watch the operation of medicine in mask- ing important diseases. The different forms of narcotics, if given in heroic doses, often mislead us in our estimate of the nature of bodily diseases not directly connected with the mental affection. The most essential preliminarj' matters of inquiry have relation to the age, temperament, previous occupation and condition in life of the patient. It will be necessary to ascertain the character and duration of the attack; to ascertain whether it has resulted from moral or physical causes ; if of sudden, insidious, or of slow growth; whether it has an hereditarj' origin, or is the effect of a mental shock, or of mechanical injur)-; whether it is the first attack, and, if not, in what features it differs from pre^^ous paroxysms. It will also be our duty to inquire whether it is com- plicated with epilepsy, paraplegia, or hemiplegia, suicidal or homicidal impulses. If any prior treatment has been adopted we must ascertain its nature ; whether the patient has suffered from gout, heait disease, rheumatism, cutaneous affection, or syphilis. It is im- portant, in cases of females, to obtain accurate information in relation to the condition of the uterine functions and to ascertain the state of the moral affections. We should also inquire whether the patient has been suspected of habits of self-abuse. Ha\'ing obtained LUNACY IN ENGLAND. 28/ accurate information upon these essential points, our own personal observation will aid us in ascertaining the character of the mental disturbance ; the configuration of the head, chest, and abdomen ; the gait of the patient, the degree of sensibility and volitional power manifested ; the state of the retina, the pulse, the urine, and temperature of the scalp and body generally ; the condition of the skin and chylopoietic viscera ; the action of the heart, lungs, and nature of any existing disease of the uterus. If a patient complains of any local mischief, however imaginary it may appear to be at the time, it is essentially necessary that we should clearly satisfy our minds upon the point before dismissing it as not entitled to serious investigation. A patient once bitterly complained of retention of urine; upon examination, the bladder was found to be distended and the man had passed no urine for twenty-four hours. I was about to enter a catheter, when the patient burst into a fit of laughter and immediately emptied his bladder. Esquirol relates the case of a merchant who, whilst suffering from melancholia, declared that some foreign body was sticking in his throat. No notice was taken of this supposed fanciful idea. The patient died, and an ulcer was discovered at the upper third of the oesophagus. A patient com- plained of devils being in his stomach and bbwels, and declared that they were acted upon by electric, magnetic agencies. After death he was found to have scirrhus of the stomach and chronic inflammation of the bowels. A patient refused to eat ; he said he could not swallow his food without great pain. As he had exhibited other symp- toms of a disposition to suicide, it was thought by myself and others that his obsti- nate refusal of food was associated with ideas of self-destruction. He died, and at the post-mortem examination a stricture in the pylorus was discovered. These illus- trations, and they could easily be extended, will prove the importance of paying minute attention to particular delusions with the view of ascertaining whether they have not a particular and actual physical origin. The prognosis in cases of insanity will mainly depend upon the duration of the attack, its character and origin, and the diathesis of the patient. The prognosis is generally unfavorable if the disease is hereditary — if the symptoms are similar in char- acter to those exhibited by other members of the family when insane. Insanity, accompanied by acute excitement, is, ccBteris paribus, more easy of cure than when it has been of slow and gradual growth and is marked by great mental depression. The prognosis is favorable in cases of puerperal mania ; it is unfavorable when there exists a want of symmetry between the two sides of the head, with small anterior and large posterior cerebral development. Any great inequality in the cranial conformation would be a suspicious indication. The existence of any malformation in the development of the chest is also an unfavorable sign, and would induce us to give a guarded prognosis. Dr. Darwin says, when a person becomes insane who has a small family of children to absorb his attention, his prospect of recovery is but small, as it establishes that the ma- niacal hallucination is more powerful than those ideas which usually interest us most. The prognosis is unfavorable when patients are under the morbid delusion that they are poisoned and are constantly suffering internally from peculiar sensations. Religious de- lusions are more difficult to eradicate than other morbid impressions. The age of the patient will materially guide us in forming a correct prognosis. Hippocrates says the insane are not curable after the fortieth year ; Esquirol maintains the greater portion recover between the ages of twenty and thirty; Haslam between the ages of ten and twenty. As a principle, we may conclude that the probability of recovery in any given case is in proportion to the early age, physical condition, and duration of the attack. When a patient has youth and a good constitution to aid him, and is advantageously placed, having at command remedial measures, and is excluded from all irritating cir- cumstances, the prognosis may be favorable. I have seen patients after the advanced age of 288 PSYCHOLOGICAL MEDICINE. sixty and seventy recover, and cases of cure are upon record where insanity has existed for ten, fifteen, and twentj' years. In forming our prognosis it is important to ascertain the educational training of the patient. Has he been in the habit of exercising great self- control ? Has his mind been well-disciplined ? Has he kept in abeyance the passions, or have the motions and impulses of his nature obtained the mastery over him ? He who has been taught to practice self-denial and self-control in early life is, ccBteris pari- bus, in a more favorable position for recovery than he who has permitted himself to be the willing and obedient slave of every passion and caprice. Insanity accompanied with criminal propensities is said to be incurable, because, as Ideler urges, such patients " can- not bear the torments of their consciences, and relapse into the stupefaction of insanity to flee from the consciousness of their guilt." The prognosis is unfavorable when the insanity is complicated with organic disease of the heart and lungs, with deafness, and paralysis in any of its forms. Lesions of the motor power are very unfavorable indica- tions. Great impairment of mind, accompanied with delusions of an exalted character and associated with paralysis, is generally incurable. Esquirol says, epilepsy, if asso- ciated with insanity, places the patient beyond all prospect of cure. I should be loath to adopt this sweeping condemnation. I have seen cases of epilepsy, combined with men- tal derangement, recover, although, I admit, they constitute a difficult class of cases to manage. — Lancet, October 8th, 1852, p. 321. [As it would be impossible to describe in detail the particular class of remedial agents adapted to each class of deranged minds, in the succeeding lecture the subject has been generalized, — the most prominent kinds of insanity, and the difficulties of their manage- ment, only being discussed.] In regard to the treatment of acute mania, the importairi; and much-litigated question at issue among practitioners of all countries, is that relating to the propriety of depletion. Need I direct your attention to the conflicting and contradictory opinions entertained by eminent writers on this important and much-vexed therapeutical point ? Whilst some practitioners of great repute and enlarged experience fearlessly recommend copious gene- ral depletion for the treatment of insanity, and refer to cases in which this practice has been attended with the happiest results, others, equally eminent, and as much entitled to our respect, denounce the lancet as a most fatally dangerous weapon, and shudder at the suggestion of abstracting, even locally, the smallest quantity of blood. In avoiding Scylla we must be cautious of being impelled into Charybdis. The error consists in a vain effort to discover a uniform rule of treatment, and attempting to propound some specific mode of procedure adapted to all cases. He who maintains that bloodletting is never to be adopted in the treatment of mania, without reference to its character, its origin, the pecu- liar constitution of the patient, and the existence of local physical morbid conditions, which may be materially modifying the disease, and giving active development to delusive impressions, is not a safe practitioner. Neither would I confide in the judgment of the physician who would, in every case of violent maniacal excitement, attempt to tranquil- lize the patient by either general or local depletion. In attacks of insanity, when the symptoms are acute, the patient young and plethoric, the habitual secretions suppressed, the head hot and painful, the eyes intolerant of light, the conjunctiva injected, the pupils contracted, the pulse rapid and hard, and the parox- ysm sudden in its development, one general bleeding will often arrest the progress of the cerebral mischief, greatly facilitate the application of other remedies, and ultimately pro- mote recovery. In proportion as the symptoms of ordinary insanity approach those of phrenitis, shall we be justified in the use of general depletion. Although it is only occasion- ally, in instances presenting peculiar characteristic features, — cases occurring in the higher ranks of life, where the patient has been in the habit of living above par, and is of a san- LUNACY IN ENGLAND. 289 guineous temperament, — that we are justified in having recourse to the lancet, there is a large class of recent cases presenting themselves in the asylums for the insane, both pub- lic and private, in the treatment of which we should be guilty of culpable and cruel negligence, if we were to omit to relieve the cerebral symptoms by means of the local abstraction of blood. It is, alas ! the fashion and caprice of the day to recklessly decry the application of cupping-glasses or of leeches in the treatment of insanity, in conse- quence, I think, of the slavish deference shown to the opinion of a few French patholo- gists of eminence, who have, by their indiscriminate denunciation of all depletion, fright- ened us into submission, and compelled us to do violence to our own judgment. The local abstraction of blood is, in the hands of the discreet and judicious practitioner, a powerful curative agent ; and yet it is the practice of some men, and men, too, of position, to discard altogether the remedy. I will briefly refer to the kind of case in which the local abstraction of blood will be found most beneficial, if proper regard be had to the temperament, constitutional condition, and the local circumstances modifying the character of the attack. In insanity, when the exacerbations occur at the menstrual period, cceteris paribus, leeches to the vulva and thighs, with the use of foot-bath, and the exhibition of aloetic purgatives, will be attended by the most favorable results. In irregular and obstructed menstruation, the local abstrac- tion of blood will be very serviceable. In suppressed haemorrhoids, leeches to the neigh- borhood of the sphincter ani will greatly benefit in unloading the hsemorrhoidal vessels, and relieve the brain of undue excitement. In cases of nymphomania, leeches to the vulva are indicated, and have been known to greatly benefit. In cases of intermittent insanity, the paroxysm may often be cut short by relieving the overloaded state of the ves- sels of the head by means of cupping or the application of leeches. In some instances, I have tried Dr. Wigan's plan, and have applied leeches to the Schneiderian membrane, particularly for the treatment of insanity of early life, and connected with conduct evi- dently the effect of cerebral irritation. I have seen this mode of procedure of essential benefit in persons of plethoric constitution and of sanguineous temperament. Occasion- ally the insanity is found to be associated with active visceral disease, or with hypertrophy and other affections of the heart. Under these circumstances, when there exists great tenderness over the region of any of the visceral organs, and we are satisfied, by a care- ful stethoscopic examination, that hypertrophy of the heart is present, leeches applied over the seat of the local mischief, conjoined with other appropriate treatment, will ma- terially aid us in subduing the maniacal affection. In cases of illusions of hearing, or of vision, it will often be necessary to apply -leeches behind the ears, or over the superciliary ridges. I have known this practice entirely remove the morbid illusions which had been embittering the person's life. But apart entirely from the local affections to which I have referred, for the treatment of idiopathic insanity, apparently without any complications, or modified by any of the associ- ated diseases, the careful and temperate local abstraction of blood, when general depletion is inadmissible, will often materially shorten the duration of an attack of insanity, and restore the mind to a healthy condition. I am anxious to record my favorable opinion of this mode of treatment, because I have witnessed so many sad results from an opposite, timid, and reprehensible neglect of the means placed within our power for the treatment of the varied forms and degrees of mental derangement. Sad consequences have un- doubtedly followed the indiscriminate use of depletory measures ; the presence of violent mental excitement has occasionally led the practitioner to the conclusion that the disease was of an active character ; and in the attempt to allay the undue cerebral excitement by means of antiphlogistic measures, the patient has sunk into incurable and hopeless de- 19 290 PSYCHOLOGICAL MEDICINE. mentia. But recognizing an anerseve7-ingly given until the nervous system is completely under its influ- ence. I have witnessed the most distressing attacks of suicidal mania yield to this treat- ment, when ever)' other system has failed. I could cite the particulars of numerous cases of this form of insanity radically cured by the occasional local abstraction of blood from the head, the administration of alteratives, the warm bath, and sedatives. In the use of this powerful curative agent, our success will often depend upon a ready adaptation of the kind of sedative to the descriptio7i of case in which it may be deeified admissible, and a judicious combination of various kinds of sedatives. I do not think we pay sufficient attention to such combinations. I have often seen an apparently incurable and unman- ageable case yield to several kinds of sedatives combined, when it resisted the operation of any one or two. The extract of conium is often of service in cases of insanity com- bined with epilepsy; conjoined with mineral tonics, conium is occasionally of benefit, particularly in melancholia connected with chronic diseases of the digestive organs and with neuralgia. In cases of uterine irritation, I have seen great good result from the combination of hops, camphor, and hyoscyamus. In illusions of vision, belladonna, commencing with quarter-grain doses, will be found a useful remedy. In insanity complicated with dysmenorrhoea, the combination of camphor with hyoscyamus, opium or conium, may be given with great advantage. The hydrochlorate of morphia, in union with dilute hydrochloric acid, is said to be useful in cases where the seda- tive treatment is desirable. I am often in the habit of exhibiting sedatives and tonics in a state of combination, particularly conium with iron, opium with quinine, or with the infusion or compound decoction of cinchona. In debility, with irritability of the nervous system, accompanied by restlessness, Battley's solution, with the preparations of cinchona, will often prove of great benefit. The tincture of sumbul I have occasion- ally administered, and I think with advantage, in paroxysmal or convulsive forms of in- sanity. I have given to the extent of one or two drachms for a dose. In hysterical de- rangement, the tincture of Indian hemp will occasionally allay the excitement, and produce sleep more rapidly than any other form of sedative. The valerianate of zinc has not answered the expectations of those who have spoken so highly of its medicinal vir- tues. Tincture of opium with camphor, and the tartrate of antimony, is an excellent com- bination in cases of doubtful cerebral congestion. Tincture of hops, in doses of from one to four drachms, it will be necessary to give when no other formulae are admissible. As a mild form of sedative, compound ipecacuanha powder is occasionally recommended; but a good substitute for Dover's powder is a pill composed of opium, ipecacuanha, and soap. In treating the more chronic forms of insanity, particularly melancholia, it will be es- LUNACY IN ENGLAND. 293 sential to bear in mind that they are difficult of cure, because, owing to the slow, obscure and insidious character of the disease, the mental affection has been of some duration before the attention of the practitioner has been directed to its existence. As this form of derangement generally exhibits itself in trifling perversions of the affections and pro- pensities, leading to little acts of extravagance and irregularity of conduct, associated with great depression, we often find the attack has existed some years before a necessity is felt for any medical advice or treatment— perhaps a suicidal propensity has manifested itself, this being the first apparent overt act of the insanity. It is necessary, before suggesting any course of treatment in melancholia, to ascertain whether any latent visceral disease be present. Occasionally the local irritation will be found either in the liver, or the stomach and bowels, and in women the uterine functions are frequently disordered. In the religious and other forms of melancholia in females, the delusive ideas are often associated with uterine irritation ; and under such cir- cumstances, if actual physical derangement of an active character exists in this organ, the best treatment will be, the application of leeches to the neighborhood of the uterus, combined with warm hip-baths, sedatives and mineral tonics. In cases of melancholia, the digestive functions are often much vitiated, the circulation languid, the skin cold and flaccid ; and these symptoms being conjoined with a general loss of physical tone, such patients require generous diet, good air, gentle exercise, and occasional stimuli. When dyspeptic symptoms are combined with an inactive state of the bowels, I have often ad- ministered the compound tincture of guaiacum with great benefit. It is important to watch the particular features in these cases, and to improve the general health by the ex- hibition of mild alteratives and vegetable tonics, with alkalies. I have occasionally ad- ministered, with success, in this form of insanity, apparently associated with an abnor- mal condition of the nutrition of the brain, cod-liver oil, with preparations of iron. My time will not admit of my submitting for your approval the treatment best adapted for those forms of mental disease associated with an atrophied or softened condition of the nervous matter. I think more is to be done for the cure of these cases than the writings of medical men would lead the student to suppose, particularly if the disease be seen and subjected to treatment in the early stages. I have recorded the details of several instances of cerebral disease, exhibiting all the legitimate features of ramollissement, and yield- ing to the persevering administration of the preparations of iron, phosphorus, zinc and strychnia, combined with generous living, and the occasional application of a leech behind the ear, should indications of cerebral congestion be present. I have also derived benefit in these cases from the use of the milder forms of mercury, associated with cinchona. In cases of impairment of the mind, loss of memory, defective power of attention, occasional par- oxysms of mental paralysis, unconnected with lesions of the motor power, I have found a solution of the acetate of strychnine, and a solution of the phosphate of strychnine, of great advantage. In some chronic forms of insanity, in dementia, and persistent monomania, connected, as it was supposed, with morbid thickening of the dura mater, and with interstitial infiltra- tion of the membranes, as well as with exudations upon its surface, I have occasionally had the head shaved, and have perseveringly rubbed over the scalp a strong ointment of the iodide of potassium combined with strychnine. In other instances I have kept the head painted with the mixture of iodine. I have seen marked benefit from this mode of treatment. In several cases where the mental symptoms were supposed to be associated with effusions of serum, I have ordered the iodine to be applied externally, at the same time exhibiting minute doses of calomel, or mercury with- chalk, to slightly affect the system ; this, conjoined with occasional tonics, diuretics, and stimuli to support the 294 PSYCHOLOGICAL MEDICINE. vital powers and enable the patient to undergo this treatment, is occasionally productive of considerable benefit, in cases apparently placed quite beyond the reach of improvement or cure. I have only briefly spoken of two distressing and often unmanageable forms of insan- ity — viz., of suicidal mania, and of those cases where the patient obstinately refuses to take either food or medicine. In insanity associated with suicidal tendencies, it will be important to ascertain whether any cerebral congestion exist, as such is often the case. A few leeches applied to the head, followed by an active cathartic, will relieve the local irritation, and often dissipate the idea of self-destruction. In the absence of any posi- tive active cerebral symptoms, the prolonged hot bath, and the persevering exhibition of some form of sedative, is the best treatment to be adopted. I have seen the suicidal impulse removed after the administration of a few doses of belladonna ; but the meconile and hydrochlorate of morphia, if given for a sufficient length of time, will, in the great majority of cases, distinct from actual incurable visceral or cerebral disease, effect a cure. Occasionally the shower-bath, and counter-irritation in the vicinit)' of the head, will aid us in re-establishing health. Cases sometimes present themselves where the patient de- terminately refuses to take either food or medicine. This character of case gives those who have the care of the insane much anxiety. The refusal of food may be connected with the determination to destroy life, or it may be associated with delusive impressions. I am inclined to believe that in the majority of these cases the symptom is the result of some local mischief remote from the brain, and sympathetically affecting the organ of thought. Upon examination we often find, in these cases, great gastric derangement, obstinate constipation, considerable tenderness upon pressure in the epigastric region, hepatic disease, the tongue foul, breath offensive, and other symptoms of derangement of the chylopoietic viscera. The determination to resist nourishment arises, under such cir- cumstances, irom^ a. positive loathing of food — a want of all inclination for it. I have seen cases of this description, where it has been deemed necessary, in order to prolong life, to introduce food forcibly into the stomach, speedily cured by the adoption of means for improving the state of the general health and digestive organs. Mild alteratives, vege- table tonics, blisters over the region of the stomach, if the patient complains of pain in that region upon pressure, the warm and shower-bath, — is the most successful treatment to adopt in cases connected with obvious visceral derangement. Instances sometimes occur, where the refusal of food is clearly traceable to a delusive impression — an halluci- nation of taste, which makes eveiything appear to the patient bitter, disgusting and poi- sonous. The unhappy patient imagines that he is commanded, either by good or evil spirits, not to eat. These unhappy persons must be treated upon general principles, and the remedies be adapted to the peculiar character of each individual case. Under such hallucinations of taste, patients often swallow the most extraordinarj' articles. The case of a lunatic is recorded, who imagined that his stomach required to be strengthened with iron. He was seized with inflammation of the oesophagus of which he nearly died. He then confessed that he had swallowed the blade of a knife. After his death, there were found in his stomach seven oxidated lath nails, each two inches and a half long ; thirty- three nails, two inches long ; forty-nine smaller iron nails and rivets ; three pieces of wound-up iron wire ; an iron screw, an inch long ; a brass image of a saint ; part of the blade of a knife ; and other articles, amounting in number to lOO, and weighing about twenty ounces. It will be necessary, in cases like those to which I have been referring, to ascertain whether the determination not to eat is the eftect of such perversion or hal- lucination of taste. The time will only admit of my alluding generally to the importance, as a principle of LUNACY IN ENGLAND. 295 treatment, of the administration of tonic remedies, active exercise in the open air, and to good and generous living. It is rarely necessary, in the treatment of insanity, to de- prive the patient of animal food. Individual cases occasionally come under our notice, in which it is necessary, for a time, to enforce a farinaceous diet; but such is not often our duty. Among paupers, insanity is frequently cured by the free use of good animal food, and a generous supply of porter. Even when we are satisfied of the necessity of local depletion, it will often be necessary to give wine, and allow the patient a gener- ous diet. There are many other essential points in connection with this important, this vast sub- ject, which I am reluctantly compelled to pass entirely over. When I had resolved to bring this matter before the profession, I quite despaired, in the time allotted for one lec- ture, of being able to skim even upon the surface of the many deeply interesting points involved in the inquiry ; but feeling — deeply, earnestly feeling — that, in relation to my own specialty, the subject of the medical treatment of 'insanity was of the first moment, of the most vital importance to the profession as well as to the public, I did not hesitate in selecting this topic for one of my lectures, feeling assured that you would kindly make allowance for all imperfections, and generously appreciate the difficulties I had to en- counter in concentrating in one short lecture a faint glimpse or shadow of a subject re- quiring, for its successful exposition, nine or ten lectures, equal in length to the one I have had the honor of reading this evening. I may have formed an extravagant and exaggerated conception of this subject, but I cannot close my eyes to the fatal consequences which have so often ensued from a belief in the incurability of insanity by medical means. In all grades of society, we witness the pernicious, the fatal, the disastrous effects of this dogma. We see it influencing the conduct of county magistrates in the architectural pro- portions, medical organization, and general arrangements of our great national asylums. We also perceive the consequences of the error operating in many of the private institu- tions for the treatment of the insane. Alas ! are we not compelled to confess that many of the asylums for the insane constitute mere places of detention, — model prisons, — and not what Government ought to insist upon making them — hospitals for the cure of the in- sane, under the government of medical officers, well trained by preliminary education, for their important vocation, acquainted with the philosophy of the human mind, and fitted by the character of their heart, as M'ell as by their intellect, for the right perform- ance of the solemn and responsible duties intrusted to them by the public and the legislature ? 296 PSVCHOLOGICAL MEDICINE. CHAPTER XVI. THE NECESSITY FOR A NEW METHOD OF INTRODUCING EXPERT TES- TIMONY IN CRIMINAL TRIALS, WHERE INSANITY IS ALLEGED AS A DEFENCE. It would be a reform in our laws relating to insanity, if New York, and other States likewise, could be divided into four or more districts, and a physician in lunacy appointed for each district by the governor. This board of physicians, who should be experts or specialists in nervous and mental diseases, should constitute a State lunacy commission, to visit and report as to the condition of luna- tic hospitals, to protect the rights of those who are incarcerated in public asylums, and also strongly support the medical superinten- dents, who, as a rule, exhibit skill and wisdom of the highest order. The public would feel more assured, perhaps, that no evils or abuses could spring up in our asylums, and also that, if there is any room for improvement, it will be immediately seen by the commissioners in lunacy, if it escapes the superintendent's eye. The Lunacy Commission of Great Britain has been of great benefit, both to the officers and the patients of the English institutions, and it would, I think, be the same in our own country, and would dispel the prejudice existing against our asylums and their managers. As there is a much-needed reform as to a new method of intro- ducing expert testimony in criminal trials where insanity is alleged ,as a defence, this same lunacy commission of experts might be of great value in examining such cases and giving testimony upon such trials.; it having been provided in the statute by which such com- mission should be established, that the counsel for the prisoner, in whose behalf the plea of insanity is proposed to be brought forward, should be compelled to notify such board of such proposed plea» This board of experts should have every facility accorded to them, and should then examine the prisoner's mental state, discuss the ques- tion, make their conclusions, and should take written memoranda of such examination. They then should appear in court at the trial to testify as to the prisoner's sanity, or irresponsibility if they find him insane, give their written memoranda of the prisoner's examination, and of their opinion of the state of the prisoner's intellect and emo- EXPERT TESTIMONY IN CRIMINAL TRIALS. 29/ tions, the nature of the mental disorder and its amount, and whether and in what degree the mental disorder has existed at the period when the crime was committed. In submitting a written statement by the experts, we secure a calm and impartial statement, which may be supplemented in court afterwards, by questions by the judge and counsel. This board of experts should have full power to cause the temporary removal of the prisoner to an asylum, so as to have every opportunity for his examination between the time of his arrest and the trial. If this board of experts decide that the prisoner is insane, the judge and jury at the trial would doubtless accept their verdict as final, and the prisoner would then be remanded to an asylum, and in such cases as Guiteau's, to an asylum for the chronic insane (as such cases are incurable), there to remain for life, or in cases of ordinary insanity, until a competent superintendent aided by the lunacy com- mission unanimously pronounced him recovered. I consider that this would be a very important medico-legal reform, as it would place rich and poor alike on the same footing if they were on trial for their lives, accused of murder. Of course both prosecution and defence could call in otJier experts as now, if thought best, but this lunacy commission report would be entirely impartial, and the public would know it to be so. All the factors tending to the commission of crime would be attentively weighed, and certain penalties would not be inflicted on the unhappy victim of a diseased imagination. Dr. D. Hack Tuke of England, the eminent alienist, wisely says: "Infliction of punishment must depend upon accoun- tability, and accountability e stininlants, and not nerve tonics in the pro- per sense of the term. Electricity is a remedial agent which furnishes us with the means of modifying the nutritive condition of parts deeply situated, and of modifying the circulation to a greater extent, I think, than by any known agent. By the judicious employment of the constant and induced currents, we have it in our power to hasten the process of nerve-growth and nerve-repair, and thereby indirectly hasten the acqui- sition of nerve-power. The use of electricity does not, I think, act by contributing anything directly to the growth or repair of nerve-tissue. Its action, it would seem most probable, is to stimulate and quicken those processes on which the material and functional integrity of the nervous system depends. The action of electricity is always followed in my practice by an increase of strength and nerve-force, and the results gained are gradual and permanent; while the use of nerve stimulants has always seemed to me to primarily excite the nerve activities proper, and not the nutritive processes upon which the acquisition of power depends. The deceptive results obtained from the use of nerve stimulants, depends upon the excitation of nerve activities and the resultant expenditure of nerve-power, which is followed by a period of exhaustion, varying in degree and duration. DIPSOMANIA. 375 The careful use of electricity has always led in my hands to an in- crease of nervous energy, while the employment of nerve stimulants has appeared to me to lead, in many instances, ultimately to a waste and diminution of nervous energy. In cases of dipsomania we have, as I have already remarked, abnormal nervous excitability conjoined with cerebral exhaustion, and the two indications which are urgent are, primarily, for increased rapidity and effectiveness as regards the process of nerve nutrition ; and, secondarily, to secure freedom from excitement and diminution of nerve activity, and thereby to check the waste of nerve structure and of power. These indications we can fulfil by the judicious use of electricity and nerve-tonics more certainly than by any other means, there being no other such com- bined sedative, restorative and refreshant, to the central nervous sys- tem, and we can thus successfully meet all the indications in cases of cerebral exhaustion and threatened mental disease, except that of affording direct nutriment to the brain, which, as I have before stated, I endeavor to obtain by rest, cod-liver oil, phosphorus, etc. The use of electricity seems to supply to the nervous system, in cases of inebriety, the stimulus which has been withdrawn, my patients having repeatedly told me that, while under treatment, they expe- rienced little, if any, of the terrible feelings produced by its with- drawal under ordinary circumstances. I have seen this so often that I advance it as a proven scientific fact, and not as an untested theory. I have generally used both currents, the constant and the induced ; in the former case using the negative electrode at the pit of the stomach, and, in the latter case, placing the negative electrode at the lower end of the spine, in both instances applying the positive pole to the crown of the head ; cervical sympathetic nerve, reached by passing the electrode down along the anterior border of the sterno-cleido-mastoid muscle in neck ; the cilio-spinal centre, or region over or on each side of the seventh cervical vertebra ; and up and down the spine, making a seance of perhaps fifteen or twenty minutes daily, and in some cases twice a day. This adds very much to the trouble of caring for these cases, as it requires much time and patience on the part of the physician, but the results obtained amply repay one for the extra time expended. I have obtained such ex- cellent results from its use that I hope other physicians, presiding over institutions similar to mine, may be induced by my success to give this very important remedy an extended trial, after which I feel sure that they will never willingly relinquish so effective an agent. 3/6 PSYCHOLOGICAL MEDICINE. CHAPTER XX. HYSTERIA. Anything that weakens a woman generally may, by altering the relation of the several nervous functions, bring about the condition of nervous disturbance known as hysteria. Our women are the more readily becoming hysterical by reason of the absence of a pliysique and stability of nerve-tissue capable of meeting successfully the de- mands that our climate and civilization make upon them. The vital temperament is deficient in the American woman, and the nervous temperament is too predominant and too active, so much so as to require an undue proportion of the nutrition of the body. If we are to avoid an aggravated type of hysteria in the girls of the rising generation, we must, by great and continual attention to the subjects of diet, fresh air, sleep, and tranquillity of life of the young endeavor to produce a better type of physical development and mental stamina. What is especially needed is a greater harmony between the physical and mental organization. Our American women need a better devel- oped physical system, more evenly balanced in all its parts or organs, with a greater harmony in the performance of all its functions. The principle characteristics of hysteria consist in an exaggeration of invol- untary motility and a diminution of the power of the will. The vol- untary movements are not properly executed, while the refle.x, sensa- tional, and emotional movements are abnormally active. The will is determined by the ideas, feelings, and fancies. There is a malnutrition of the nervous system, so distinct that the higher functions are im- paired. The lower functions exhibit increased activity, while the higher exhibit diminished power. Hysteria is pre-eminently a disease of females, and is induced by want of occupation, real or fancied, morbid states of the reproductive organs, conflicting emo- tions, disappointed affections, late hours, and unhealthy and per- verted manner of life. It is sometimes met with in males as the result of over-mental work, worry, and excitement, or dissipation. Hysteria appearing in women generally comes on, for the first time, between the age of commencing puberty and twenty-five years. It may, however, come on at any time during the life of the individual. Of the cases that have been under my treatment, I have traced emotional disturbance as the principal cause in the production of the HYSTERIA. 377 hysteria, and the majority of the cases that I have had under treat- ment have been young unmarried women. I have found the ovaries involved more often, also, than the uterus. The evidence of this may be found in the fact that they are painful upon pressure. The mental condition of a woman affected with hysteria is somewhat pe- culiar. The patient, when the hysterical feelings come upon her, does not feel disposed to make the slightest effort to resist them, and yields to her emotions whatever they may be. She will laugh or cry on the slightest provocation, and is very nervous and excitable. She cares nothing for her duties and seemingly takes pleasure in ex- aggerating all her slight discomforts and annoyances, and by her suspicious, exacting and unreasonable behavior makes life generally uncomfortable to those about her. She indignantly resents all at- tempts and efforts for her comfort and cure, and discards all advice from her best friends, but will eagerly listen to the counsel of the many friends who come in to pity, sympathize and condole with her. She will say that for her to do certain things is absolutely impossible, but under the stimulus of strong desires or wishes, will, if unobserved, do precisely the things declared to be impossible. I have repeatedly known hysterical women under the influence of a dominating idea, to undergo severe fatigue, and even privation, that a healthy per- son would find most arduous and difficult of accomplishment, and upon my next visit, the same person would declare that the slightest effort to move her limbs was excruciatingly painful. I have also had patients declare that they were suffering the most frightful neu- ralgia, and exactly simulate a neuralgic attack of great severity, al- though the placid countenance and expression of the mouth was a convincing proof to the contrary. As a rule, I have observed no marked disturbance of the menstrual functions, although my patients generally attribute a very undue prominence to them when stating their cases to me. I have also failed to see that hysteria in women could be traced to sexual excess. One of the earliest symptoms of hys- teria is a condition of hyperaesthesia or exalted sensibility. All the senses seem to be preternaturally acute, — hearing, sight, smell and taste. Patients also complain of pain, which they locate on the top of the head, in the mammary region, the hypogastric or sacral region or in the various joints. It is a noticeable fact that, although a slight touch on the joints is much complained of, that pretty active motion will be borne without discomfort. Hysterical anaesthesia I have also found existing in the same instances. As regards 3/8 PSYCHOLOGICAL MEDICINE. the muscular system, we may find an increase of involutary mus- cular activity and a diminution of the voluntary movements. We find at times in hospital patients, partial paralysis of the va- rious limbs. Thus the leg or arm will appear to be paralyzed, or the patient will feign paraplegia, and she generally watches very carefully the effect of her performance upon the bystanders. Such a patient will tumble down and recover herself as a paraplegic pa- tient could not do. The nutrition of the affected limbs does not be- come impaired as it does in actual paralysis, and as a rule there is unimpaired electric sensibility and contractility. We may find in- definite disturbances in all parts of the body. The general health may be good, and the body very well nourished, or there may be a condition of ill health and general delicacy. The disturbances of digestion are generally traceable to a foolish diet and an excess of stimulants. This excess of stimulants not un- frequently in cases coming under my care from the higher classes of society, has gradually led to dipsomania, which exists at the time the patient comes under treatment, and requires to be combatted and cured. Excessive indulgence in opium especially in the form of morphine, to the extent of the opium habit, I have also seen several times complicating the state of hysteria. In the hysterical convul- sions which occur, there is no sudden loss of consciousness. The patient will inform her nurse or whoever is near that she "' is going to have a fit," and a general theatrical effect follows. There is no distortion of the features as in epilepsy, neither is there dilatation of the pupil. The eyelids quiver, and the patient sees and often watches the effect of her " fit " upon her friends or attendants. There may be foaming, but the tongue is not bitten unless purposely to deceive the physician, as I knew one patient to do. The patient often utters a loud scream as she falls, but is very careful to fall so as not to hurt herself The presence of the hysterical aura, commencing often in the iliac region, spreading to the epigastrium, causing nausea or vomiting; to the chest, causing palpitation of the heart ; to the throat, giving rise to globus hystericus ; and finally to the head where it induces noises in the head, dimness of vision and clavus : generally precedes the hysterical convulsion, and serves to distinguish between it and the epileptic convulsion. The larynx and air passages may be in- volved to the extent of aphonia and dyspnoea. Very often there is a loud barking cough which has a very characteristic sound. The uri- HYSTERIA. 379 nary organs may be affected, and we may find either retention of urine or a large secretion of pale limpid urine. As regards the re- productive system I have found, as I have remarked, that many hys- terical women are quite free from menstrual disorders. We may, however, find amenorrhoea, dysmenorrhcea, menorrhagia and other menstrual troubles. Hysteria as a nervous disease of the brain may appear in children, and is a general psychoneurosis with them. Its principal predisposing cause in children is a nervous constitution or temperament, while the most important exciting cause is disturbance of the sexual organs. It is hereditary and comes from parents and grandparents. It depends on the mental and bodily education of the child. Physical disturbances, such as bad treatment, fright or fear, are excitants. Also, overstraining of the mind at school, and a very important exciting cause is seeing other children in hysterical at- tacks. The questions in diagnosis are whether the child is predis- posed to hysteria, and whether there is any good reason for simula- tion. The general prognosis is not good, as the symptoms tend to increase at puberty, and the severest forms of hysteria in adults I have traced back as beginning in childhood. We have completely developed hysteria occurring both in boys and girls many years be- fore puberty. It is rare, however, and the ground for it may be an- aemia, chlorosis or hereditary nervousness. As to the treatment of the hysteria of childhood, the symptoms may disappear under a purely psychical treatment, but we must look to the general constitu- tion and build it up with protocarb. of iron, associated with other tonics, good diet, fresh air, cold sponge baths with friction, and r&move all predisposing and exciting causes. We must look out for habitual headaches in school children, as they lead to poverty of blood, loss of cheerfulness and mental vigor, and we may get trophic changes in the ganglion cells of the brain cortex, caused by anaemia and passive dilatation of the cerebral bloodvessels and consequent stasis. Closely allied to hysteria are the nervous disorders dependent upon a morbid condition of emotion, of idea and emotion, or of idea alone. Dr. J. Russell Reynolds has shown that some of the most serious disorders of the nervous system, such as paralysis, spasm, pain and other altered sensations are thus dependent. These symptoms, he says, often exist for a long time, appearing as complicated diseases of the brain or spinal cord. They resist many different kinds of treatment, and are alike unaffected by seda- tives or irritants, by attention or neglect, and disappear entirely upon 380 PSYCHOLOGICAL MEDICINE. the removal of the erroneous idea. They occur independently of hysteria, and are often associated with debility. They are also some- times associated with real disease of the nervous centres, so that the practitioner may be perplexed to know how much of a given case is due to organic lesion and how much to morbid ideation. He cites the acute effects of idea and emotion as appearing in the case of the butcher who was agonized almost past endurance by the fact that a flesh-hook had caught itself, not in his skin, as he thought, but only in his sleeve. He says very truly that we often overlook the "chronic" effects of idea and emotion when they take the form of muscular and sensory disturbance. The case of a young lady is cited, who was admitted into his London Hospital with paraplegia. She had become so gradually, and had lost flesh generally and to a considerable extent. For two or three months she had been quite unable to stand even for a moment, and upon her admission lay in bed almost entirely. She thought she might get better. The pa- ralysis was quite complete; she could just move her toes or raise either heel separately from the bed, while lying on her back. There was, however, no want of control over the sphincters, no local change of nutrition, the cutaneous sensibility was perfect, the electric con- tractility and sensibility were perfect ; there was no spasm either tonic or chronic ; there was no pain either spontaneous or produci- ble by movement of limb or pressure on the spinal column, there was no evidence of tubercular or other cachexia, there had been no blow, and there was no hysteria. Dr. Reynolds did not consider that this case could be placed under any of the forms of spinal dis- ease, and he diagnosed it as ideal paralysis. Her father had become paralytic suddenly, and she had nursed him carefully, had worked hard and constantly with the idea of paralysis constantly on her mind, and as her limbs often ached from weariness and her brain was tired, she became possessed with the idea that she might become paralyzed like her father. She gradu- ■ally lost power in her legs, and finally was carried to the hospital. She was told confidently that she would soon be well, and was given a mild tonic and — merely for the mental impression as the electric contractilit}^ was perfect — faradization of the legs. Her back and limbs were rubbed and she was taken between two nurses, who acted as crutches, and was walked five minutes e\'ery four hours. The second day after treatment was commenced she could stand with a HYSTERIA. 381 little support, at the end of four days could walk fairly well, and at the end of a fortnight v/as as strong and well as ever. Another case fifteen years of age, had been " paralyzed " for two years, after typhoid fever. She was thin, but bright and merry. She had never been hysterical. She was partially hemi- plegic. Could not stand a moment. Her legs would double up under her, and she would drop upon her knees. When lying on her back she could draw her knees upward briskly and strongly. She could throw the foot down with vigor and could move along the floor briskly on her hands and knees, dragging the legs after her, with the feet turned downward and the toes inward. The sensibility and electric contractility were perfect everywhere. She was put on mild tonics, the legs were faradized for the mental impression, and she was walked between two nurses for five minutes every few hours. In one week she could walk well with no assistance. Those patients whose symptoms are the result of idea or imagi- nation believe utterly in the reality of their symptoms, and will fol- low out earnestly any plan of treatment, when in genuine hysteria the patient often wishes to and actually deceives those about her. These apparently absolute paralyses co-exist with perfect sensibility of skin, electro-muscular sensibility and contractility, with unimpaired nu- trition of the muscles and the skin, and with no sign of disease in the spinal bones, and in treatment, while we may get no result from ordinary therapeutics, we get immediate cure when we adopt methods which are directed to the alteration of the patient's ideas. We must make such patients walk at once, at stated periods, with support on each side, this support to be diminished day by day. We must use faradization of the muscles of the limbs for its mental effect on our patient's mind, and make those muscles contract vigorously which the patient uses least. Massage and friction of the limbs may also be "used, and we can always get prompt cures in these cases. I have found a very interesting letter from London, written in the year 1680, by Dr. Thomas Sydenham, on hysteria, and it is interesting to see that even at that early day Dr. Sydenham recognized the ex- istence of hysteria in men. I think the description can hardly fail to be of interest, and before proceeding to the question of treatment I accordingly insert the most interesting parts of this letter. " This disease, if I calculate right, most frequently occurs of all chronical diseases ; they are half the chronical diseases. For very few women, which sex is the half of grown people, are quite free from every 382 PSYCHOLOGICAL MEDICINE. assault of this disease, excepting those who, being accustomed to labor, live hardly; yea, many men that live sedentary lives, and are wont to study hard, are afflicted with the same disease. And though hysteric symptoms were heretofore supposed to come from a vicious womb, yet if we compare hypochondriac symptoms, which were thought to proceed from obstructions of the spleen or bowels, or from some other I know not what obstruction ; an egg is scarce more like an egg than these symptoms are to one another in all respects. But it must be confessed that women are much more inclined to this disease than men, not because the womb is more faulty than any other region of the body, but for reasons to be shown hereafter. Nor is this disease only frequent, but so strangely various that it resembles almost all the diseases poor mortals are inchnable to; for in whatever part it seats itself it presently produces such symptoms as belong to it ; and unless the physician is very skilful, he will be mistaken and think these symptoms come from some essential distemper of this or that part, and not from any hysteric disease. For instance, sometimes it possesses the head, and causes an apo- plexy which also ends in an hemiplegy, and is exactly like the apo- plexy whereby corpulent and old people are destroyed ; and which happens because the animal spirits are stopped, the cortex of the brain being stuffed by a great deal of phlegm ; from which cause the apoplexy of hysteric women does no way seem to arise ; for it seizes such very often presently after delivery, a great quantity of blood being at the same time evacuated ; or it proceeds from hard labor or some violent commotion of the mind. Sometimes it occasions vio- lent convulsions much like the falling sickness ; the belly and bowels swelling towards the throat, the sick struggling so violently, that though at other times her strength is but ordinary, she can now scarce be held by all the strength of those that are about her, and she mutters some odd and inarticulate sounds and strikes her breast. Women that are wont to have this disease, commonly called mother- fits, are generally very sanguine, and have a habit of body almost like that of a virago. Sometimes it seizes the outward part of the head between the pericranium and skull, causing violent pain con- tinually fixed in one part, which may be covered with the top of your thumb, and violent vomiting accompanies this pain. I call this kind claims hystericus, chiefly affecting those that have a chlorosis. Some- times falling on the vital parts, it causes so great a beating of the heart that the women who are troubled with it verily believe that HYSTERIA. 383 those that are near may hear thumping on the ribs. This kind chiefly seizes those that are of a thin habit of body and of a weak constitution, and who look consumptive, and also young virgins that have the green sickness. "Sometimes it seizes the lungs and the patient coughs almost with- out intermission, but expectorates nothing, and though this sort of cough does not shake the breast so violently as that which is con- vulsive, yet the explosions are much more frequent. But this kind of hysteric cough is very rare, and chiefly invades women that abound with phlegm. When this disease seizes on one of the kid- neys it plainly represents, by the pain it causes there, a fit of the stone, and not only by that sort of pain and by the place it rages in, but also by violent vomitings which accompany it, and also for that the pain sometimes extends itself through the passage of the ureter, so that it is very hard to know whether these symptoms proceed from the stone or from some hysterick disease, unless, perchance, some unlucky disturbing of the woman's mind a little before she was taken ill, or the vomiting up of green matter shows that the symp- toms rather proceed from an hysterick disease than from the stone. Neither is the bladder free from this false symptom, for it not only produces pain there, but it also stops the urine just as if there were a stone, whereas there is none. But this last kind, seizing the bladder, happens very seldom, but that which resembles the stone in the kid- neys is not so rare ; both are accustomed to invade those women who are much weakened by hysterick fits coming frequently, and whose health of body is much impaired. Sometimes, falling upon the stomach, it occasions continual vomiting, and sometimes a diar- rhoea when it is fixed upon the guts, but no pain accompanies either of these symptoms, though frequently in both the green humour ap- pears. Both these kinds are familiar with those that are much weak- ened by the frequent coming of hysterick fits, and as this disease afflicts all the inward parts almost, so sometimes the outward parts are also seized by it, and the musculous flesh, occasioning pain, and sometimes a tumor in the jaws, shoulders, hands, thighs, legs, in which kind the tumor which swells the legs is more conspicuous than the rest; but whereas, in hydropsical tumors, these two things may be always observed, namely, that the swelling is most in the evening, and being pressed by the finger a pit remains. In this tu- mor the swelling is most in the morning ; neither does it yield to the finger, or leave any mark behind it, and for the most part it only 384 PSYCHOr.OGICAL MEDICINE. swells one of the legs. As to other things, if you observe the large- ness of it, or its superficies, it is so very like hydropsical swellings that the patient can scarce be persuaded to believe that it is any other disease. Neither are the teeth, which you will scarce believe, free from the assault of this disease, though they are not hollow and though there is no apparent defluxion that may occasion the pain, yet it is no whit gentler, nor shorter, nor easier to be cured. But those pains and tumors that afflict the outward parts chiefly fall upon those women that are in a manner quite destroyed by a long series of hysterick fits and by the force of them. But among all the tor- ments of this disease there is none so common as a pain in the back, which most certainly all feel how little soever they are afflicted with the disease. IMoreover, this is common to the above-mentioned pains, that the place on which they were cannot bear touching after they are gone, but is tender and aches just as if beaten soundly ; but this tenderness goes off by degrees. And this is worthy of observa- tion, that often a notable cold of the external parts makes way for these symptoms, which, for the most part, goes not off till the fit ends, which cold, I have observed, is almost like that by which a carcase grows stiff; and yet the pulse is good. And, moreover, almost all hysterick women whom I have taken care of hitherto com- plain of a dejection and sinking of the spirits, and when they would show the place Avhere this contraction or sinking of the spirits is, they point to the region of the lungs. Lastly, it is known to every one that hysterick women sometimes laugh excessively and sometimes cry as much without any real cause for either. But among all the symptoms that accompany this disease this is the most proper and almost inseparable, viz.: an urine as clear as rock-water, and this hysterick women evacuate plentifully, which I find, by diligent inquiry, is in almost all th.Q pathognomojiick sign of this disease which we call hysterick in women and hypochondriack in men ; and I have some- times observed in men, that presently after making water of a citron color (yea, almost the next moment), being suddenly seized with some violent perturbation of the mind ; they presently void water as clear as crystal and in great quantity, with a violent stream, and con- tinue ill till the urine comes to its wonted color, and then the fit goes off.* * Within a week I have been consulted by an eminent Southern physician for relief of his nervous symptoms, and the most prominent of them all was a sudden, violent gush of pale, limpid urine, in large quantity, whenever anything disturbed his mind. He was HYSTERIA. 385 "And it happens to all hysterical and hypochondriacal people when the disease has been long upon them, that sometimes they belch up ill fumes as often as they eat, although they eat with moderation and according as they have an appetite; and sometimes the wind that comes from the stomach is sour, just like vinegar, when it comes into the mouth, the concoction being much decayed and the juices quite changed from their natural state. Nor are they unhappy on this account, viz. : that their bodies are so disordered and, as it were, tottering like ruined houses, for their minds are worse affected than their bodies, for an incurable desperation is mixed with the very nature of the disease. They are very angry when any one speaks ever so little of the hopes he has of their recovery, easily believing that they undergo all the miseries that can befall a man, foreboding the most dreadful things to themselves ; entertaining in their restless and anxious breasts, upon small occasions and perchance for none at all, fear, anger, jealousies, suspicions, and worse passions of the mind, if any can be worse; abhorring all joy, hope, and mirth; and if any of these chance to happen, 'tis very rare and soon flies away, and yet does not less disturb the mind than the sorrowful passions ; and they never keep a Mean — constant only to inconstancy. Sometimes they love above measure and presently hate the same without any reason. Sometimes they intend to do this or that, and then presently alter their intentions and begin quite the contrary, and yet they do not do that either ; so wavering are they that their minds cannot be at all at rest. " A day would scarce suffice to reckon up all the symptoms belong- ing to hysterick diseases, so various are they and so contrary to one another that Proteus had no more shapes nor the chameleon so great variety of colors, and I think Democritus was pretty right (though he mistook the cause of the disease) when he wrote in an epistle to Hippocrates that the womb was the cause of six hundred miseries and of innumerable calamities. Nor are they only very various, but also so irregular that they cannot be contained under any uniform type, which is usual in other diseases, for they are, as it were, a dis- orderly heap of phenomena, so that it is very hard to write the his- tory of this disease," etc., etc. From this interesting account given by Dr. Sydenham, in 1680, of the symptoms of hysteria, we see that, in many respects, it was suffering from what an eminent authority had diagnosed as congestion of the spinal cord but which was decided hysteria and hypochondriasis. — E. C. M. 25 386 PSYCHOLOGICAL MEDICINE. pretty v/ell understood even at that early day. Dr. Sydenham evi- dently considered hypochondriasis and hysteria as identical, whereas we know now that the former has for its chief manifestation mental depression, occurring without adequate cause, and our hypochrondriac patient believes that he is the victim of some organic disease, and, furthermore, that this disease is markedly hereditary, and comes from a strong hereditary taint of insanity. It also appears in middle life, whereas the latter, hysteria, comes on generally between the ages of fifteen and thirty, and occurs in women or men not especially descended from markedly insane families. The following case of general hysterical paralysis very well illus- trates this type of the disease as it not unfrequently appears, and I accordingly insert it : Miss , of Mississippi, aged twenty, was brought to my private hospital for nervous diseases by her family physician and her brother in the month of April last. She had never been in robust health, and during the last two years gradually lost the power over her arms and legs, to such an extent that she was not able to walk at all, even when supported, and had to be carried upstairs to her room by two nurses. She was entirely incapacitated from doing any work what- ever. She first menstruated at the age of fourteen, but has always been vtxy irregular, and generally has suffered from amenorrhoea. Eight months ago the menses ceased altogether, and from that time she became nearly idiotic. She has had hysterical mania, during which time, for a week, she screamed almost continuously, according to her brother's account. Her feet and hands were cold upon ad- mission ; there was considerable dilatation of both pupils; she spoke only in the faintest whisper, and even then very rarely. She had no appetite, and the bowels were obstinately constipated. She had been under medical treatment for a long time, but without any benefit. She had some retroversion of the uterus to left side, and some vaginitis. Examination by the aesthesiometer revealed that she could not distinguish whether she was touched by one point or two. The muscles were atrophied all over the body, the fingers were flexed in the palms, and the patient made no attempt to attend to the organic functions of the body. I prescribed a pill of aloes, iron, quinine, arsenic, and strychnia, to act on the bowels and as a tonic, and fed her with milk and beef essence, made in the house, until the constipation was relieved. I used three times a week the continuous galvanic current from thirty-two cells of a freshly-charged battery, HYSTERIA. 387 the negative pole to the neck, and the positive to the sacrum, for fifteen minutes. The sensation of burning was evidently well marked, as the patient drew herself away and tried to evade the contact of the electrode. The muscles of the calves of the legs were faradized daily for ten minutes. The pill, before mentioned, was kept up thrice daily, and massage diligently and faithfully applied by a good nurse. ' After four weeks' treatment, she was so much improved that she could walk about her floor, and now walks, August ist, all over the house. The amenorrhoea yielded to the exhibition of capsules of apiol. She was very listless, had a vacant look, and was nearly, as I have said, idiotic. She regained her speech, and was discharged in perfect health, the muscular and nervous systems having become perfectly restrung. Ti^eatmcnt. — The treatment of aggravated hysteria is almost im- possible in the home of the patient and in the midst of the usual surroundings, as the moral and bodily constitution rapidly deterio- rates under the influence of the pity, sympathy, and over-attention which hysterical patients live for, and which they are constantly laying plans to attract from their friends. There is no radical cure for hysteria but judicious firmness of management, combined with kindness and friendliness of manner on the part of the physician. This is much more easily accomplished by a change of scene and surroundings. In addition to improving the general health and bringing up the general nervous tone, regulating the menstrual function, relieving ansemia and constipation, and local symptoms of hysteria, the patient should be made to take an interest and pleasure in some occupation, intellectual recreation, or study. We must en- deavor to remove the mental or emotional cause of the disease, and particular attention must be paid to diet, rest, exercise, and recrea- tion. The class of patients whom we, as physicians, principally see, are women, who, from their social position and surroundings, have really no object in life but to amuse themselves. They have, as a rule, been spoiled and petted since childhood, and as their nervous system is developed far in excess of their physique, they become, as they grow up, capricious and hysterical. Their imag- inary ailments are undoubtedly the cause of much distress to them, for to a person with highly strung nerves a slight pain seems a severe pain, and discomfort is magnified into pain. One of my last cases, who had an income of six thousand dollars, and who had nothing to do, and who had consequently become an aggravated 388 PSYCHOLOGICAL MEDICINE. case of hysteria, would have been, as a physician who was also a pa- tient with me, remarked, " a splendid woman if she had to live on twenty-five hundred dollars a year." It is certainly true that nothing to do, and nothing to profitably occupy the mind with, are strong provocations to hysteria in a person predisposed to it. Occasionally hysteria assumes a grave form and becomes hysterical mania, a con- dition requiring great care and attention. Such a case came under my care not long ago. The patient was a young lady, twenty-four years of age, and upon her admission she was acutely maniacal, with no appreciation of her condition or surroundings. She was a girl who had a highly sensitive nervous organization, and who, being a Catholic, had attended all the Lenten services, and, after attending the " General Confession," had arrived at a state of emotional frenzy which passed into hysterical insanity. She was entirely incoherent with delusions relating to religious subjects, and also relating to per- sons. The physical condition was very fair. She was given a warm bath, followed by one fluid drachm of Fothergill's solution of hy- drobromic acid. This was followed in four hours by a 4-grain cap- sule of monobromide of camphor, and the patient slept well. For a week after admission, rest in a darkened room, with monobromide of camphor thrice daily, and Fothergill's solution, following the use of the prolonged warm bath, was employed. At the end of that time the delusions had disappeared, the mania had subsided, and the patient made her appearance in the family circle. Electricity, in the form of central galvanization, was applied daily. Daily exercise was insisted upon, and due remedial treatment continued, and in a short time a perfect recovery took place. The lady has since married, and has enjoyed perfect health up to the present time. Hysterical patients require to be watched, attended to and uncon- sciously guided away from self and into new grooves of thought, feeling and action, at once interesting to the mind, while not fatiguing to the body ; and this can be done, not by harshness or discipline, but by kindness, firmness and wise regard to the feelings of the pa- tient. We must supply some purpose or motive in life which can easily be done by studying patients' characters, thus stimulating them to make co-operative endeavors for their own cure, unknown to themselves. All this requires strong will and great patience on the part of the physician, but success is certain if such treatment be per- severed in and is not interfered with by over-anxious friends or relatives. With regard to the medicinal treatment to be pursued, I have used HYSTERIA. 389 with benefit monobromide of camphor, two or four-grain pill thrice daily, Fothergill's solution of hydrobromic acid, the chloral-phos- phide of arsenic (Routh's formula), the bromide of lithium and the constant current of electricity. Niemeyer said : " There is no doubt but that the morbid excitement of the motor nerves which gives rise to hysterical spasms, proceeds from the spinal marrow and medulla oblongata." And this morbid excitement is, in my experience, very markedly relieved by the employment of the constant current in the manner I have spoken of. It is certainly one of the most effectual nervines and affords radical relief in most cases, instead of the merely palliative effects obtained from many drugs. The psychical treat- ment is, however, of primary importance. By the use of the gal- vanic or constant current of electricity, we modify the circulation and nutrition of the whole body, and from my experience with it, I am more and more satisfied, as Niemeyer said : " that in the constant current, we have a means more powerful than any other of modifying the nutritive conditions of parts that are deeply situated." When hysteria is caused by uterine disease or by anomalies of menstruation, the original cause must, of course, be removed, if pos- sible, by appropriate treatment. In several cases I have discovered the existence of dysmenorrhoea, which I have entirely cured by the fluid extract of viburnum prunifoHum in i-fluid-drachm doses. This in some cases is a very valuable remedy. In cases where the hys- terical state seems to depend upon chronic uterine disease, in mar- ried women, when there is a condition of malnutrition and passive congestion, to improve the uterine tissues and to excite reflex ac- tion, so that the nerves accompanying the distended vessels will cause contraction, and thus restore the natural tonicity, I direct the prolonged application, by the nurse, of hot-water vaginal injections, with local application of electricity as an adjunct. By -this means we are generally successful in combating the state of chronic inflamma- tion that exists in such cases. In conclusion I would say, study the uterus and ovaries and see that existing diseases, if there be any, are remedied. Examine the eyes, if you find head symptoms in hysteria and neurasthenia, and I would place the utmost stress on the systematic treatment by rest, seclusion from society, full feeding, massage and electricity. This treatment, if carefully carried out by trained nurses, will restore many women to health who are entirely discouraged by the failures of their 390 PSYCHOLOGICAL MEDICINE. physicians to cure them, and many of whom are on the borderland of insanity. Nervous affections, and especially hysterical disorders, are very con- tagious. The following interesting case illustrates this fact. The inland market-town of Pledrau, in France, has inhabitants who lead a very primitive mode of life, and who are very ignorant, credulous and simple. Any unusual occurrence is attributed to an occult influence. They are under the exclusive control of their cure. Near this town live the Marcet family, in which were seven children, a few months ago, said to be ''possessed by spirits T February 23d, 1882, Marie Jean Marcet had a nervous attack, Vv'ith pain in the head and sick- ness, and hysterical paralysis, lasting four days, and chorea-like move- ments. They soon ceased, and did not appear again until the 21st of April. On the 22d of April, the third child, Pierre, aged ii years, was suddenly attacked, and his attack lasted four hours ; twelve days after he had a second hysterical fit, and since then he has been very nervous and excitable, and very irritable. On the 23d of April, -the second daughter, aged 13 years, had a nervous attack resembling in all points that of her sister. Next day, that is the 24th of April, the fifth child, Anne Marie, aged 6 years, had an attack of unconscious- ness. On the 28th, still another of 4 years showed hysterical symp- toms, and finally another child suffered from unmistakable hysteria. This is a very remarkable instance of the contagiousness of nervous affections, as this hysteria major evidently appeared in this family as a small epidemic. Dr. Samuel "VVilks, Physician to Guy's Hospital, has said : In women at the climacteric period we see the effect of lowering of the nervous influ- ence in the fluttering of the heart, and the sickness, sighings, headache, etc. Probably no other invalids really feel so ill as these patients ; the whole bodily functions are dis- turbed, and consequently a depression is experienced far exceeding that which accompa- nies any real organic disease. Such patients describe their feelings with the utmost despondency; they experience successive changes of temperature, which they style flushes of heat; they complain of anorexia, of flatulence, and of irritation of the bowels, uterus, or urinary organs. In fact, there is not a single viscus which does not suffer dis- turbance, so that every disease in the nosology may, in turn, be supposed to be present. Why one organ should suffer more than another, or why a morbid sensation should be experienced in this part of the body rather than in that, is probably to be explained by the anatomical distribution of the nerves ; but we certainly find that, probably owing to the large supply of the sympathetic nerve in the abdomen, greater depression is expe- rienced in abdominal than in other forms of disease, and that in all low conditions of the nervous system morbid sensations are very often referred to this region of the body. Thus, we cannot but contrast the cheerful disposition of the phthisical patient, when on the brink of the grave, with the depression observed in one who has but a temporary HYSTERIA. 391 disturbance of his stomach, liver, or bowels; and another indication of the same fact is the placing of the emotions in these parts, as expressed by the term " boM-els of com- passion." Under the most varied conditions, both in men and women, when life is low, a number of morbid sensations arise. In a state of health man should be as happy and joyous as the lark flying in the heavens; he should have a keen sense of animal enjoyment, and he should feel nothing of the working of the machinery within him ; but when his nervous system is depraved he becomes conscious of all these movements, he feels his heart beat, his head throb, and his back ache. A study of these nervous symptoms would probably S'how in what order they appear; I think that they commence, especially in women, with a pain in the left side, and that this is followed by pains on the top of the head, and in the back, at the epigastrium, over the collar-bones, etc. I feel uncertain whether these pains are altogether subjective or due to some prior alteration of function in the parts whence the pain proceeds. This question, however, is one of very great importance in practice ; for we often find that, by attempting to relieve symptoms, we gain no headway towards overcoming disease, whilst by altogether disregarding them, and having re- course to a general tonic plan of treatment, we can ensure a cure within a certain period. At the same time it cannot be denied that the application of remedies to the spot to which the morbid sensation is attributed is frequently attended with success. Thus, plas- ters to the side, sedatives to the stomach, etc., do give relief. Relieving the local symp- toms in this way is not, however, incompatible with a treatment directed to the restora- tion of the nerve centres themselves. In practice, we have almost every hour of the day to endeavor to discover whether morbid sensations in and disturbances of the viscera are due to anorganic cause or to the mere failure of the regulating power of the nerves ; that is, whether the disease is organic or functional. In such cases the diagnosis is doubly difficult in females, because symp- toms resembling those of almost every form of disease may be produced by their more delicate nervous organization. We can imagine, by way of analogy, that in the case of a steam-engine working irregu- larly we might for a time be at a loss to discover whether the derangement was owing to some material deficiency in the valves or joints, or whether it was due simply to an irregu- lar supply of steam. Or, again, we can picture to ourselves a clock perfect in all its parts moving too slowly, from the simple fact of the weight having nearly run down. In the cerebro-spinal system, again, an exaltation or a depression of function is con- stantly witnessed. Such conditions are observed in chorea, in hysteria, and in various passions of the mind. Miiller speaks of the nervous principle in the medulla oblongata .as being in a state of tension and always ready to act, and he says that the slightest change in its condition excites a discharge of nervous influence, as is manifested in laughing, sneezing, etc. Thus every mental impulse to motion disturbs the balance of this tension and causes a discharge of nervous influence in a determinate direction. He also compares the nervous system to a musical organ, with its bellows charged and ready to force a stream of air in any direction, according to the particular key that may be touched. Using this illustration, we may imagine the air either to rush out with a scream, or to be hastily allowed to pass off by the larger tubes, or to be diffused melodiously through a series of musical pipes. In a similar way the superfluous nerve-force may dis- play its operations in various ways, according to the sex, age, and temperament of the patient. For example, I have seen the same cause produce hysterics in a mother and chorea in her child, the one disease being almost peculiar to the adult period of life, the other to childhood. The same fright which excited so great an amount of nerve- force in the mother as to cause the explosion known as hysterics operated on the 392 PSYCHOLOGICAL MEDICINE. child in a slower manner, and gave rise to the less violent action known as chorea. The spinal system was excited to over-action by the cineritious substance above, which had been unduly stimulated by a mental shock, and remained temporarily impaired until the disease was cured. The explosion of nerve-force by an hystei-ical attack acts as a kind of safety-valve, protecting the internal machinery from danger ; and although all are not alike impressionable, there is scarcely an individual who may not be in need of it when acted on by a sufficiently powerful stimulus. Even in the strong-minded Napo- leon a fit is said to have been excited by passion. More commonly, however, relief to an over-excited nervous system is afforded by laughing or crying. Thus, as Byron ob- serves, the power which women possess, as compared with men, of being able to pour their troubles into their pocket-handkerchiefs, is no doubt often very beneficial to them, so far as their health is concerned. A woman who is excited, if she do not go into hysterics or have a good cry, often allows the redundant nerve-force to escape through that unruly member the tongue, and thus an extreme volubility of utterance perhaps saves her from further unpleasantness. Of course, tlie talk which flows from her lips is altogether dif- ferent from the result of an intellectual process ; and thus it is still true now, as it was in ancient times, that "anger is a short madness." In Switzerland, last summer, I met an Irish gentleman, who told me that he could make his wants known without a knowledge of the language, but that when he was irritated and wanted to swear he would sometimes give all he possessed to understand German. In other cases, again, the superfluous force escapes by the limbs ; thus an angry person slams the door, or destroys even her own property. A man of better sense, when vexed, takes a walk, and thus gets rid of his extra nerve-force ; or, if the irritation and its results are more chronic, sits down, takes up his pen, and by publishing " the whole correspondence " eases his mind. — Guys Hos- pital Repoi-ts, vol. xii., 1866, p. 247. Dr. F. C. Skey, Esq., F.R.S., Consulting Surgeon to St. Bartholo- mew's Hospital, has said in respect to hysteria: In the whole range of practical surgery there is, perhaps, no one subject that claims your earnest study more important than that which I have selected for this and the fol- lowing lectures. It is not a question of diagnosis between two diseases more or less resembling each other. It is a question of disease or no disease, of reality or imitation, of true or false — of whether your purgatives, your bleedings, sweatings, irritants and counter-irritants, and your whole battery of antiphlogistics, shall be launched against a true disease in the flesh, or its ghost — whether you are to contend with a reality or a shadow. This absence of discrimination between two conditions of disease and no dis- ease is painfully frequent among medical men, especially among those to whose charge is assigned the care of local and surgical diseases. " In one shape or another," ob- serves the greatest of modern surgeons, " you will meet with them at every turn of your future practice." It may be asserted with truth that every part of the human body sup- plied with nerves, be they cerebral, spinal, or ganglionic, may become under provoca- tion the seat of local symptoms so closely resembling those of the real disease to which that part of the body is liable, as to appear identical with it, and the resemblance to which is so perfect as to deceive the best of us. They are not cases of occasional or rare occurrence. They come before us in the daily and hourly walks of professional life. They monopolize a share, and not a small one, of all cases under treatment, whether medical or surgical, but the latter predominate. The closer you scrutinize them, the more penetrating your inquiry — looking into, and not at them — the more per- fect will be your diagnosis, and the more you will be astonished that a form of disease HYSTERIA. 393 so remarkable and so common should have hitherto occupied so little of your thoughts. It is well to call your attention to tliis description of malady at the early stage of your career. Many men pass through life, engaged in active warfare against disease, on whose convictions this variety has scarcely dawned. And this is a truly remarkable fact, which owes its existence to the predominating influence which the heart and the arterial system exercise over the judgment of the profession at the expense of a system yet higher in the scale of organization, more sensitive, and more liable to morbid im- pressions' — -viz., the cerebro-spinal nervous system. "Whenever a new case of disease presents itself to us we jump to the old doctrines of inflammation, we talk of congestion, and of capillary action, and of deposits of lymph, and we refer the attendant pain and heat to an inflammatory condition, of which the local nervous derangement is an ordinary symptom. We should endeavor to assign to each system its proper place in the pathological scale and to discriminate more accurately than is generally done the indications which belong to the morbid condition of each, whether existing in combination or separately ; for be assured they do exist, both sepa- rately and in combination with each other. You may have varieties of inflammation in which the local pain is trivial when compared with its severity in other cases, while, on the other hand, examples daily occur in which local as well as general derangement of the nerves, whether of the part or of the whole body, exists as a condition entirely inde- pendent of the vascular system. Nor is this derangement confined to the sensory nerves. If we have local pain as the indication of excessive activity of the nerves of sensation, we have spasm and convulsions, indicating derangement of the nerves of motion, each of which, or both, may prevail without heat, or redness, or swelling. We daily see severe forms of nervous exacerbation without the slightest corresponding increase of action in the vascular system. There is this important difference between the morbid states of the vascular and nervous systems, that, while local inflammations are dependent on local causes, aggravated only by the impaired condition of the general health, local nervous diseases for the most part oi-iginate in the centres of nervous power, the effects of which are exhibited in remote parts of the body — it may be in a pain localized in a given spot, whether on the surface or in deeply-seated parts which, to our senses, holds no especial relation to its nervous centre ; it may be in a temporary, or spasmodic, or permanent contraction of the voluntary muscles bending the joints of the extremities in permanent flexion, or obliquely drawing the head upon the trunk, or involving the whole motor sys- tem, as in tetanus. No known nerve that conveys sensibility from its centre to its per- iphery, no motor nerve that carries volition from the brain or spinal cord to a voluntary muscle, is exempt from this morbid tendency. The vascular system, consisting of arteries, capillaries, and veins, has its own special diseases, peculiar to the structures engaged in the circulation of the blood. The attend- ant symptoms are heat, redness, pain, and swelling, the latter symptom being due to a sepai-ation from the capillary system of some constituents of the blood, whether in a fluid or solid form, while the morbid condition of the nerves and the structures in which they originate are characterized by simple aggravation or excess of the functions of the nerves affected, the natural sensibility of the sensory nerves running into pain, and the moving power of motor nerves into convulsions, or spasm, or permanent contraction. In diseases of the vascular system we have changes of structure ; in the latter, not. It is necessary to make very clear the line which separates the two classes of disease, lest we fall into the common error of applying to both the remedial agents which are applicable to one only. The diseases originating in or involving the vascular system we treat locally by various agents — leeches, blisters, etc. ; in diseases confined to the nervous system these local remedies are useless and even injurious, and we treat them through the constitution. 394 PSYCHOLOGICAL MEDICINE. In cases of tic do we derive benefit from leeches, or blisters, or from other forms of deple- tive agents ? Assuredly not. Now the disease which forms the subject we have to consider belongs to the nervous and not to the vascular class, and I select from this variety that occasionally known under the term " hysteria," than which no name can be more inappropriate or objection- able. It may well be doubted whether, except under very occasional circumstances, such a relation holds between the womb and this remarkable train of symptoms as to jus- tify the employment of the term hysteria. In the large majority of cases there is no con- nection between them beyond that which the disease holds with the other organs of the body. In the name of a disease we are supposed to recognize its form and nature, whereas the term I have quoted conveys to the mind no distinct idea of either one or the other. And there is a positive objection to the resort to it in the fact that the word car- ries with it the association of a malady of small and insignificant dimensions, while the malady itself is of great magnitude. We associate with it the idea of " hysterics " and " vapors," as they were formerly called. I wish to raise your attention to the level of a great malady, and not of a trivial derangement of the hour. I remember a law case in which the counsel challenged a medical witness as to the name of the disease, and he replied, hysteria. "Hysteria!" said the learned counsel, addressing the jury, " we all knov\' what hysteria means. My client has come into court to obtain compensation from a jury of his country for a permanent injury by which all his prospects are blighted, etc., etc., and the gentleman in the witness-box, with no sympathy for his misfortune, pro- claims the disease to be a case of trumpery hysterics !" and the jury, with rod in hand, let it fall heavily on the defendant's back. But there is a more solid objection than these, viz., that it is founded on a false pathology, in the employment of a term that conveys an impression of its source and nature founded in error. The disease consists in the local evidence of some irritation or derangement of one or the other of the nervous cen- tres of the body, viz., the brain or the spinal cord — at least, such is the received pathol- ogy. But the subject is a very obscure one. We have no very definite idea of what we mean by " irritation." We all employ it, and so general is its use that I don't know how we can get on without it. " Irritation of the nervous centres" is a useful and not ill- sounding phrase, though somewhat mysterious, but it is no reflection on medical science that we can't explain all the phenomena of life, and as the term is somewhat wide in its ap- plication and does not commit its employer to any very defined opinion on obscure mat- ters, on which it is verj' difficult to form any opinion at all, I pi-esume we shall retain it. One good reason that may be assigned for the persistent employment of the term hysteria — a term we all know to be objectionable — is the difficulty of finding a substitute for it. We call the disease "local nervous irritation." It is " exalted nervous sensibility," but in naming a disease so definite as this we require a term equally pointed and definite with the thing itself. That we have not got. Sir B. Brodie says : " I employ the term hys- teria because it is in common use, but the etymology is calculated to lead to great misap- prehension." Failing the name, let us look at the thing, and if it be so critical as I have assured you, let us attach to it the great impoitance its frequency and its magnitude demand. It may be asserted with truth that every part of the body may become, under provoca- tion, the seat of an apparent disease that in reality does not exist ; that it may, and often does, assume all the attributes of reality with an exactness of imitation which nothing short of careful and accurate diagnosis can distinguish from the real disease. You think this is impossible. Surely you know a diseased knee-joint when you see it. You find severe pain, aggravated by the slightest movement. The temperature of the joint may be raised, and it is slightly swelled. You leech, you blister, you employ an iodine lini- HYSTERIA. 395 ment (few cases escape it), you may even resort to issues, but the evil remains in spite of all your remedies, which have been applied to the wrong "system." It is the nervous, not the vascular that is involved, but the nervous has imitated the vascular, and deluded you, and led to the employment of false remedies, which have failed to reduce the pain or give mobility to the joint, and the general influence of which on the health of the patient cannot be said to have proved eminently serviceable. The case, on more perfect investigation, proves to be one of local nervous irritation or hysteria. You think you will not be again deceived, but you are mistaken. A single error, corrected by the experience of another, will not teach you hysteria. You are con- sulted by a lady in reference to a daughter of i8 or 20 years of age, who has exhibited failing health for some time, and now complains of her inability to walk in consequence of a pain in her back. You examine her, and discover that she suffers extremely on pres- sure over two or three of the lower dorsal vertebrse or on any other of the twenty-four. You repeat the examination with the same result, and you make a report to the mother that her daughter has " spinal disease." The result of your opinion is two or more years' confinement to her couch, coupled with the usual allowance of restricted diet, alterative and other depletive medicines, leeches, blisters, and issues. Suppose these structures which you have declared to be the seat of organic disease to be examined under a micro- scope, what would you discover ? Nothing. There is no disease whatever. As the nature of this malady dawns upon you, now awakening to a conviction of its frequency, you resolve to be more wary in your future diagnosis. You are now consulted by an- other young female patient on account of a tendency in one or more fingers to close in flexion. In the attempt to straighten them you cause intense pain, and, if persisted in, the consequences may be serious. Your patient appears in fair average health, and all her functions are regular and healthy, while the hand, for all ordinary purposes, is use- less. Under ihe idea that she may have some chronic inflammation of the theca or of the palmar fascia, you treat it with the usual remedies. But your remedies produce no im- pression on the finger, which continues obstinately flexed as before. You adopt another principle of treatment, founded upon a more correct diagnosis, and your patient recovers. These cases sound strange to your limited experience. You think they are rare, and brought forward from a distance and with an effort. By no means. They are cases of daily occurrence. If you could suddenly throw off that nebulous vision of vascular dis- ease which years of bad pathology have impressed upon your judgment, you would see them in their true light. You may deem them to be exceptional. I assure you they con- stitute the rule of disease, and not the exception. Real disease is the exception. Speak- ing of one variety, and they have all characters in common. Sir B. Brodie, a man who rarely committed an error in diagnosis, says : " I do not hesitate to declare that, among the higher classes of society, at least four-fifths of the female patients wlio are commonly supposed to labor under diseases of the joints labor under hysteria, and nothing else." I would venture to enlarge this statement as regards the " upper classes " by including a large proportion of the lower, for much of my own experience of hysteria has been ob- tained from the wards of St. Bartholomew's Hospital, and in reference to spinal affections in young persons, I unhesitatingly assert that real disease is not found in a greater pro- portion than one case in twenty, and even this is a liberal allotment. Have you never experienced the difficulty of discovering an object floating in the air, such as a bird sing- ing overhead or an early star in the evening ? When once the object becomes visible the eye is readily adjusted to it, and when you look again in the right direction it is the first object that strikes the eye. And so with this class of diseases. They are not seen, because they are not looked for. If you will so focus your mental vision, and endeavor to distinguish the minute 396 PSYCHOLOGICAL MEDICINE. texture of your cases, and look into and not at them, you will acknowledge the truth of the description, and you will adopt a sound principle of treatment that, meets disease face to face with a direct instead of an oblique force, which far too generally claims the credit of a success for which nature alone is responsible. I have selected above three varieties of this local hysteric affection. Let us consider them a little more in detail, with a vaew to detect the fallacy which classes them under diseases of the first or vascular division, by which I mean an abnormal condition of the bloodvessels leading to changes of structure or altered relations, whether by suppuration or ulceration, or fibrinous deposit, or local death of the tissues involved. In the first case the knee is the seat of pain. The subject is a j'oung female. What evidence do we commonly look for when the joint is really diseased? We look first for a cause. Diseased joints don't occur without a palpable one, and particularly in young persons. There has been no violence, no fall or blow, to which to attribute it. Had there been, the nature of the disease is obvious enough. There is no considerable increase of heat, and, if inflammation is present, perceptible increase of heat is constant. There is no effu- sion into the joint ; the fonn of the articulation is unchanged. . The pain and the immo- bility or stiffness of the joint remain, notwithstanding your remedies. Local depletion relieves the pain of inflammation, but not of hysteria. But }'ou persist in your principle, and the depletive principle is continued, and thus months elapse — yes, even years. I was once told by a young lad)' that she had applied twenty-seven blisters to her knee- joint, from which she could not say she had derived any benefit. Now, it ought to be obvious that if a painful joint, occurring in a young female without local cause, is un- altered in form or size, and is free from heat or redness, and that the chief and almost the only symptom, that of pain, varies in degree at different times and is fluctuating in character, the disease is not of the inflammatoiy class, and if not, it must be nervous, and you cannot cure pain with leeches. You know that pain alone, which consists in an exalted nervous sensibility, does not constitute what we strictly understand by the term disease, although we apply it generally to any deviation from health, whether local or constitutional. At length the truth is brought home to you. You change j-our treat- ment by the substitution of local sedatives and general tonics, and )'our patient moves forward in the direction of recoveiy. Take the second case. You have declared your opinion that this girl is the subject of disease of the spine upon the evidence of local pain pi'oduced by pressure of the fingers on the spinous processes of the vertebra. It has escaped your observation that this pain is equally severe, whether pressure is slight or not, that, in fact, the degree of pain in- dicated by either writhing or exclamation holds no relation to the force of the pressure made. The slightest touch creates as much suffering as the greatest pressure of the hand, and often more. It is on this evidence alone you have founded your opinion of disease of the bony structure of the spinal column. It is on this evidence you have consigned this young lady to two years' confinement to her couch, to the loss of education, to restricted social and domestic intercourse with her family and friends, and to much moral and phj'sical suffering. Now, when you talk of disease of the spine, what do you mean? ^^Tiat structure is diseased, and what form of disease is present? Is it seated in the body, or in the processes of the vertebrae, or in the entire bone ? And what description of disease has invaded the particular vertebra of the twenty-four ? Is it inflammation, or caries, or necrosis ? Caries, you will say, and you select this fomi, because, and only because, you know the spinal column is the subject of carious disease under conditions favoring it. But there is this remarkable feature in carious disease of bone well worthj^ of notice — viz., that it is almost destitute of pain, that there exists no relation between the extent of the disease, which may be great, and the pain attendant HYSTERIA. 397 on it. It is not like inflammation of bone, whether simple or severe, or necrosis. Pre- suming this statement true, can you, in reason, feel satisfied with the evidence of disease obtained by manual pressure ? Then, again, where is the disease situated ? If in the body of the vertebra, is it not almost absurd to suppose you can detect it by the slight pressure of the finger on the sunimit of the spinotis processes, which are themselves rarely involved. Fifty or sixty years ago, a provincial surgeon of some note recommended the applica- tion of a hot sponge to the spine, with a view to detect disease of the bodies of the ver- tebrse. There was some excuse for ignorance on this subject at that time ; there is none now. Of all the fallacies that cling to professional practice, of all the false doctrines which the pardonable ignorance of a former generation has entailed on modern surgery, none can surpass that which affects to detect carious disease of the body of a vertebra by drawing the fingers down the spine. It is only not ludicrous, because the consequences are so serious to the victim. It would be a bold assertion that such morbid changes in the spinal column cannot occur ; but I do think humanity would be a gainer, if all teachers concurred in asserting that they could not, so rare is the real disease, and so palpable to the eye when present. Suppose a young person, in moderately good health, and occupied in daily exercise, complained of a pain in the condyle of the femur, wdth- out any other indication, should you be warranted in declaring she had serious disease of the bone ? Look to the functions of this important column ; how is it possible it can support the body in the upright posture, if one or more of the component bones of the pillar are destroyed ? And yet I have known many examples, in which the subject of this imaginary disease has joined a party, and danced for the whole evening. One wonders that such a person did not drop into pieces. For myself, I candidly declare that I have scarcely ever seen a case of true disease of this form. I can bear testimony to spinal af- fections and destructions of bone to any amount in psoas or lumbar abscess, or in angu- lar curvature, or of damage done to the column by local injury ; but to these suppositi- tious cases, which exist only in the brain of the surgeon, I am a stranger, and if they exist otherwise than as rare examples of spinal disease, I have much to learn. Have you ever seen a person recover from actual disease of the spine ? I do not mean to infer that death inevitably follows, though that result is by no means uncommon ; but I allude to recovery without some distortion, or some permanent evidence of past disease. And yet you may be surprised when I assure you that all these young people recover sooner or later — sooner, if the surgeon in attendance is familiar with hysteric affections ! later, if he is not. Thirty or forty years since, these cases were, happily for our time, far more common than at present. At that date, and for how many years anterior I know not, all the seaside towns were crowded with young ladies, between seventeen and twenty-five years of age and beyond it, who were confined to the horizontal posture, and were wheeled about on the shore in bath-chairs, on the supposition that they vi^ere the subjects of spinal disease. They were placed under much medical and dietetic discipline, not of the most invigorating character, and the large majority carried a pair of handsome issues in the back ! Brighton, Worthing, Hastings, and other places on the south coast were tenanted largely by these unfortunate females, to which a moderate sprinkling of young gentlemen was added. What has become of all these cases ? They appear to have vanished just in proportion as the eyes of the surgeons have opened to the absurdity of inferring that pain alone, which locates itself with remarkable precision in hysteria on a given vertebra can indicate the presence of organic disease of the body of the bone with- out collateral evidence in its favor. When the spinal column is really diseased the case is obvious at a glance ; the health is degenerate, and the whole system proclaims to the 398 PSYCHOLOGICAL MEDICINE. eye of the surgeon the presence of a great evil. These examples are but a miserable mockery of the reality and a fraud on the judgment of the ignorant. With regard to the third example, that of permanent flexion of the fingers, it is appa- rently so truly local an affection that there is some excuse for error, but only because hys- teric affections are not half studied. When one or more of the fingers is permanently flexed from local causes, the seat of the disease will be found in the fascial structures of the hand or in the finger itself, or a joint may have been diseased or dislocated ; but here there is no thickening, nor hardness, or other morbid change of structure. The finger is simply bent, and the attempt to straighten it is painful. The cause of this morbid con- dition of the flexor muscle is referred to its nervous centre placed in the cervical portion of the spinal cord. It is not an easy task to select the class of constitutions most liable to hysteric diseases. Probably under certain conditions of impaired health the large proportion of the com- munity would give evidence of its presence. Certainly it is uncommon in the lower class of males, and among those who occupy the beds in our public hospitals. We know, on the other hand, that it is most prevalent in the young female members of the higher and middle classes, of such as live a life of ease and luxury, those who have limited responsi- bilities in life, of no compelled occupation, and who have both time and inclination to indulge in the world's pleasures — persons easily excited to mental emotion, of sensitive feeling, often delicate and refined. Such are among the mental attributes of hysteria. But hysteric diseases are not confined to the young. I have seen many examples in fe- males of 40 to 50. Do not imagine hysteria is a disease of persons of weak minds. It will often select for its victim a female member of a family exhibiting more than usual force and decision of character, of strong resolution, fearless of danger, bold riders, hav- ing plenty of what is termed nerve. If you tell such young people they are nervous, they take offence, because they misinterpret the meaning of the word, and so may you. And they may well misinterpret it, for, like the word, " irritation," its popular meaning is both various and indefinite. It is essential that we attach a definite idea to this term in its different applications, and I must digress for a moment to endeavor to explain them. I have already used it in one sense. 1st. The word nerve is used to express the mental condition of vigor, boldness, and resolution — as when a man's nerves are strung up to meet danger ; so ladies are said to ride with more or less " nerve." 2d. We employ it in its physical sense as a part of the general system of the nerves of the body. 3d. We have the terms " nervous system," which may be not inappropriately defined as holding the same relation to the " system of nerves " in its physical sense that the physiology of a part holds to its anatomy. Yet this definition is imperfect, because the properties of the nerves of the cerebro-spinal system, with the small exception of those of specific sensibility, such as sight, smell, taste, etc., begin and end in the functions of mo- tion and sensation. By the term " nervous system " we understand the general influence which the nerves in a physical sense exert on the constitution, the healthy or tonic con- dition of which is in a ratio with the combined force of the two systems — viz., the arte- rial, or circulation of blood, and the nervous. Health depends on the coincidence of these systems in perfect action. If the circulation fails in power, the consequence of this weakness falls on the nervous system, which is dependent on the circulation for its health and vigor. Failing an adequate supply of blood, this system is unstrung, and morbid sensations, endless in variety, take the place of real ; and of all consequences, hysteria is the most common. In the defficient supply of blood to the brain the faculties of the HYSTERIA. 399 mind are involved. Confidence of strength gives place to fear, mental vigor to weak- ness and irresolution. Such indications as are untrue to the real character of the indi- vidual as the physical sensations are false and deceptive. Such is the nature of the large proportion of cases of persons who come into courts of law for compensation for what are erroneously deemed permanent injury, bringing with them headaches, spinal pains, tingling of the extremities, impaired vision, loss of memory, and many other symptoms of an unstrung nervous system — a series of grievances of the incurable nature of which an acute lawyer takes care to provide himself with ample testimony, and which will al- ways be obtained so long as the diseases of the vascular system and their consequences monopolize a too prominent share of the attention of our profession. I have traced sev- eral of these persons in their after career, the large majority of whom entirely recover. I believe it is to the prevalence of error in the early management of these persons, who are almost invariably subjected to depletive treatment, and to the imperfect knowledge of nervous diseases which prevails in the profession, that large sums are awarded for in- juries erroneously supposed to be permanent and incurable. Can it be reasonably ex- pected that the truth will be brought home to the mind of a lawyer so long as our own opinions are yet uninstructed upon it? Sooner or later their true nature will become established facts in the minds of our profession, and we shall no longer hear the painful discrepancies of opinion among medical men that now prevail. The light of improved knowledge will dissolve the daily mysteries which surround these cases in the form of supposed spinal concussions, partial paralysis, effusions into the theca vertebralis, thicken- ing of the membranes of the brain, spinal cord, and lesions of this organ or that. These, as Dr. Sydenham declares, are but imitations and resemblances, and not realities, and that they deceive the multitude is undoubted. When real disease prevails there is no difference of opinion among medical men as to its existence. It is a very interesting question, to investigate how far the functions of the mind are involved in hysteric disease, and how closely it is connected with it, whether the relation between them is direct and immediate, or remote. In cases of local pain, and also the local contraction of muscles, arising either from an excessive action of one muscle, or from the loss of harmony of action with its antagonist, as in a permanently flexed forearm or finger, it seems difficult to identify the evil with that part of the brain which we believe to be the seat of mind. And yet an inquiry into the past history of such persons will often reveal the fact that they have been at one time or other the subjects of general or paroxysmal hysteria, or, in other words, that they have had hysteric fits ; ancLas mental emotion is more or less associated with this form of hysteria, it would appear not unreason- able to infer some remote relation between the mind and this variety of a disease appa- rently simply local in its nature. There is something in the mental development of these young persons very characteristic. They are quick and excitable, liable to sudden emo- tion without adequate cause. In very young persons the local disease maybe developed before the mental character is fully matured, but advancing years will exhibit its peculiar features. It is curious to observe the influence which the nervous system exerts on the daily con- dition of us all. When unstrung it preys upon ourselves. It is not in the varying force in our pulse, for that gauge is not sufficiently fine to detect the variations of health, that we can refer in consciousness of strength and vigor on one day that fails us on another. It is that our nervous system is more or less unstrung. There is a real illness and a fac- titious illness, and in this we observe the remarkable influence of mind in exercising a controlling power over the body. People without compulsory occupation, who lead a life of both bodily and mental inactivity — people whose means are sufficiently ample to in- dulge in, and who can purchase the luxury of illness, the daily visit of the physician, and, 400 . PSYCHOLOGICAL MEDICINE. not the least, the sympathy of friends — these real comforts come home to the hearts of those ornamental members of society who are living examples of an intense sensibility, either morbid or genuine, who can afford to be ill, and will not make the effort to be well. They are, in truth, well or ill, as you choose to take it, and they are only ill because they fail in mental effort, that mental resolution which is sufficiently powerful to rouse the dormant energies of the body and throw off the sensations of lassitude, of unreal fatigue and weariness of body and mind. A poor man cannot afford this indulgence, and so he throws the sensations aside by mental resolution. There is a real fatigue and a nervous or unreal fatigue. A lady will tell you she was so tired that she could not walk another step. She thinks so, and without an adequate motive she cannot make the required effort. Give her the motive, such as the sudden ill- ness of a relative or friend at a distance, and she will extend her walk to miles without effort or subsequent fatigue. How is this ? It is that by a great motive acting through her mind she has called upon those dormant powers of her system which are possessed by all of us to be employed on critical occasions. Rarely, if ever, is the body subject to a degree of fatigue so great that an adequate motive will not obtain renewed exertion. When a lady tells you she can only venture on a walk of half a mile, you will understand that this effort is determined, by the ordinary, not the extraordinary motive. It is your duty as her medical attendant to place before her such inducements to a greater effort as shall call on the exercise of her dormant power, the reserve fund of physical strength, and she will walk four times the distance without fatigue. A poor man runs a race against time, and reaching the goal he drops from fatigue. Offer him at the moment _^ioo if he will run one hundred yards farther. He will accept the offer, run the re- quired distance, and then drop. This is resolution acting on his muscular powers through his nervous system, screwed up by an extraordinary effort. And this law of Natm-e is applicable to us all in our daily intercourse with the world. A man resolves to accomplish a certain amount of work on a given day, and he com- pletes the task he has assigned himself by virtue of his resolution. Such resolution is eminently protective against fatigue. A question arises to one's mind — Is hysteria what is termed a specific disease, or is it the invariable result of a condition of health into which all persons pass in reduced states of bodily vigor, but only modified in degree ? I presume it is associated with a peculiar organism common to man, but not involving all, as some persons amenable to the influence of mesmerism pass readily into profound sleep, while others are entirely unaffected by it. It notoriously is far more common in women than in men, and in young persons from the age of 17 to 30, in the unmarried than in the married. We do not associate hysteric affections with persons of either sex who are characterized by vigor of mind, of strong will, of strength and firmness of character. Such persons may be reduced by protracted illness to a condition of weakness both bodily and mental, but they do not in their re- duced strength, so far as I know, exhibit any of the peculiar features of hysteric affections. There is a remarkable form of hysteria which affords evidence on this subject. It is notorious that the sight of a person under an hysteric attack has a tendency to involve other hysteric persons around her. It has happened to me several times in my hospital career to witness the contagious, or rather the imitative, form of active or paroxysmal hysteria on a large scale. On one of these occasions, in a ward of twelve females, no less than nine young women were affected at the same time. Several were so violent as to call for the assistance of sisters, nurses and other servants of the establishment to re- strain them ; and inasmuch as a person under the influence of hysteria brings into action all the latent strength of her muscular frame, which is greatly in excess of her apparent strength, the services of these attendants were scarcely sufficient for the purpose — several HYSTERIA. 401 requiring three or four strong men to prevent injury to their persons. The attack com- mences in the person of one girl, who may have been the subject of some trivial operation, or been brought under the immediate influence of the disease by mental emotion. No sooner is the condition of this patient observed by her fellow-patients than her influence is felt throughout the ward, and the second subject may become involved, occupying a bed at the remote end of the room, and thus it passes irregularly from bed to bed, each patient appearing to take the disease in the order of their constitutional liability. In the course of an hour, more or less, it subsides, and tranquillity is restored, but the evil only slumbers, and on the following day the same scene may recur — less violent, pehaps, but acted by the same persons as at first. Some of these patients, who were not affected to violence, were affected to tears and wept in silence, while some few were not implicated at all, nor did they show any tendency to sympathize with the disease. These curious attacks, though they appear to the subjects of them 'irresistible, are yet but the result of what has been termed a surrender, and might be prevented by an adequate motive. The mode adopted to arrest this curious malady consists in bringing these persons under the influence of some powerful mental emotion, and in making some strong and sudden im- pression on the mind, through the medium of, probably, the most potent of all impres- sions, fear. They are not lost to consciousness, and for the moment, except in the in- tensity of their paroxysm, they will listen to the voice of authority. Sympathy and kind- ness, or tenderness of voice and manner, are worse than useless. They rather aggra- vate than mitigate the evil. Ridicule, to a woman of sensitive mind, is a powerful weapon, and will achieve something, but there is no emotion equal to fear, and a threat of personal chastisement will not necessarily be required to be carried into execution. On two of the occasions I have referred to, a few quarts of cold water suddenly thrown on the person of a chief delinquent instantly brought the ward to a state of reason and tranquility. The disease succumbed to the indignity of the treatment. There can be no doubt, then, that a malady spreading by sympathy and cured by fear, has its origin in the mind. I think you will find, on close inquiry, that nearly all cases of paryoxysmal hys- teria originate in some form of mental excitement, and that of a depressing character, such as sorrow or disappointment. It is not the result of mere emotion. Joy, gladness of heart, or a sense of pleasure rarely produces it; yet it is difficult to explain either its im- mediate or proximate origin in attacks occurring during sleep. Sometimes these patients suddenly awake from sleep with severe palpitations of the heart leading on to a direct attack. What can be their immediate cause ? There is no disease of the agents of circu- lation, or any suspected variation in the quanity of blood thrown upon the heart by which to explain it. Whence, then, the eccentric action of this organ ? Possibly some mental emotion in the form of a forgotten dream or some other occult mental operation which escapes cognizance, such as occurs in cases of somnambulism. In these current remarks on general hysteria we must not lose sight of the subject taken in a surgical point of view. I have stated, both in this and in the last lecture, that, under the condition of impaired health, the nerves of a part of the body may be- come the subject of a deranged action by which, as Dr. Sydenham has declared, and we in our generation almost daily observe, so many symptoms of actual disease of that part may appear as to give the exact appearance or verisimilitude of local organic change of structure, when such disease is entirely absent. There may be nothing apparent on a first inquiry to associate the case with hysteria, whether local or general. It is not ne- cessarily nor commonly preceded by hysteric paroxysms. There may be no appearance of illness, no heat or undue excitement of the system, nothing, in fact, to connect it with hysteric disease ; yet, it is nothing but local nervous exacerbation, and, from the want of a better name, we call it hysteria. You must not confound it with simple neuralgia, 26 402 PSYCHOLOGICAL MEDICINE. and, with still less reason, with epilepsy. It is not, however, always easy to draw a dis- tinct line between neuralgia and hysteria, for both may have a constitutional origin, and be amenable nearly to the same treatment. In neuralgia, however, we have a more gen- erally local and more persistent affection of the nerve. The disease appears to be limited to the nerve itself, the course of which may be traced by the pain, which is often exces- sive ; whereas, in those cases of hysteria marked by local pain, the pain is general, in- volving the structures around in common with real disease of the part affected. In neu- ralgia the disease is placed on a recognized nerve, and a person is said to have neuralgia of a given nerve, such as the frontal, mental, or digital. In hysteria any locality may be affected without reference to the distribution of nerves ; while epilepsy is characterized by well-marked symptoms clearly of a cerebral origin. If you amputate a limb for hys- teric pain, you throw the disease back on its nervous centre, and you kill your patient. In the early part of my hospital career, I have seen this fact more than once exemplified. In such cases operative surgerj' is entirely out of place. Now, before I proceed to illustrate these statements by reference to cases, of which T have an ample supply, I wish to make a few remarks on the relation between local hys- teria and the nervous centres — viz., the brain and spinal cord. Any facts that tend to throw even a gleam of light on the connection between them must be interesting. I re- fer to the influence of anaesthetic agents, especially of opium and chloroform. In cases of hysteria marked by local pain, relief is given by the application of opium to the affected part — a fact which does not confirm the generally-entertained opinion that the local af- fection is dependent on irritation of the nervous centre. Select a case of hysteric con- traction of the muscles of a joint — the elbow or fingers. If you administer chloroform, the contraction of the muscles, which may have existed for months, and which has re- sisted repeated attempts to extend them, will now yield to a gentle effort of extension, and the limb is immediately restored to apparent repose. Supposing this morbid con- traction of one or more muscles to be caused, as we believe, by irritation of the nervous centre, how does opium or chloroform affect it ? The effects of chloroform on the circu- lation are assuredly not in the direction of health, for it converts arterial into venous blood, or, at least, it gives to arterial blood the dark color of venous, and we can hardly believe impaired circulation of a part of the body compatible with its improved function, and yet the disease subsides. This " irritation of the nervous centre," as I told you, does not convey a very clear idea of the nature of the relation between the respective parts — viz., the seat of the disease, and its source or centre. Perhaps, the nearest approach we can make to a solution of the difficulty is by saying that these two agents — opium and chlo- roform — suspend for the time the influence of both sensory and motor nerves, under which suspension the local pain or the erring muscle partakes of the general influence of the ansesthetic. To bring this morbid state of the muscle within the influence of the mind as its cause is almost of necessity to infer the local evil to be wilful ; but if it were so, the state of unconsciousness during sleep would remove it, which it does not, for the contraction is constant by night and day, while the specific influence of the chloroform suspends the disease, if it does not cure it, and the renewed, though partial, contraction of the muscle is now prevented by mechanical agency. The remarkable circumstance consists in this, that a disease of long standing, which incapacitates for exercise and oc- cupation, is removed in a few minutes by the agency of chloroform, and the patient placed at once on the high road to recovery. Is this curious fact confirmatory or other- wise of the origin of the disease in the nervous centre ? Unfortunately, hysteric persons have no exemption from real disease, and when the two are found in combination, a difficulty in diagnosis will frequently occur to test the pathological knowledge of the surgeon. The local disease is accompanied by symptoms HYSTERIA. 403 of an eccentric character that do not legitimately belong to it. Local pains are aggravated in the active stages, and do not subside in a degree proportionate to the local improve- ment. A small malady, such as a sprained wrist or ankle, is magnified into a large one. The constitutional symptoms take the direction of hysteria instead of fever. The vascu- lar system indicuted by the state of the pulse, the skin, etc., is less involved than the nervous, and months will often expire before recovery is complete. To a surgeon, not familiar with hysteric disease, who practices his profession with reference to one only of the two systems of which the body is composed, these cases will always be obscure and difficult of management. When an injury occurs to the person of a young female, and to many others neither young nor female, hysteric symptoms are almost certain to de- velop themselves in some form or degree before recovery is complete. [It is an indisputable fact that any part of the body can be the seat of such local de- rangement, either of the nerves of sensation or motion, as shall actually represent disease in that part, when no disease, properly so called, exists.] Cases of real hysteria maybe reckoned by hundreds in the practice of any one surgeon. The more common seats are the female breast, the side of the trunk, under the ribs, the whole spinal region from the atlas to the sacrum ; any joint, but especially the knee ; the stomach, the bladder, and the ovaries; the muscular system of the extremities, indicated by spasm or permanent contraction, and the muscles of the larynx. But no part of the frame has exemption from liability, so far as I am aware. I will first quote a very simple case of hysteria, the evidence of which is immediate and the attack transient. In some slight forms, the patient loses all command over the voice, which suddenly sinks to an almost inaudible whisper, without any other accompa- nying symptom. I have seen many examples, but that I give occurred under my own observation, as it has probably in some form occurred under that of others, for it is as old as history. The subject was a young lady, of about 20, as Sir B. Brodie observes, of pale complexion, and having cold hands and feet. While I was engaged in conversation rel- ative to her health, I somewhat imprudently remarked that a mouse was running about under the table at the end of the room. She uttered an exclamation of alarm, and in an instant so entirely lost the power of audible speech, that I was obliged to approach her, and to put my ear close to hear her. The ferocious cause of the mischief having paid the penalty of its intrusion by the loss ?tia of the brain. In man, and in most, if not in all, warm-blooded animals, a rapid and very copious haemorrhage usually causes convulsions. Kussmaul and Tenner state ( Ott Epileptic Convulsions from Hcemorrhage, New Sydenham Society, 1859) that, in numerous cases of dogs, cats, and rabbits, they observed, without a single exception, violent and general convulsions preceding death from loss of blood. In order to produce this result, the haemorrhage must be rapid. If it occurs slowly, so that the vital powers are gradually consumed, death then occurs with swooning, drowsiness, and delirium, without convul- sions. The same observers found that an interruption in the supply of blood to the head of a rabbit, by ligature or compi-ession of the arteries, produces epileptic fits as surely as haemorrhage does. In about one hundred rabbits, they ligatured or compressed the carotids and subclavians, from which, be it remembered, the vertebrals proceed, and in every instance, except that of one very old, lean, and feeble rabbit, convulsions occurred. In order to produce convulsions, it was necessary to close all the four arteries which supply the brain. If but one carotid or one subclavian remained pervious, the animal was enfeebled and more or less paralyzed, but not convulsed. And again, if during the height of a convulsion the ligature is removed from one carotid, the convulsions generally cease immediately, and there is a sudden change from the most frightful spasm to com- plete relaxation of the muscles. The description of the convulsions thus artificially pro- duced in these animals, shows that they were essentially the same as epileptic convulsions in the human subject. There was the dilated pupil, the tonic spasm, quickly succeeded by clonic convulsion, so violent as to throw the animal forcibly forwards to a distance of one or two feet, and sometimes even over the shoulders of the experimenter. These experiments suffice to show the fallacy of the explanation which Dr. Brown-Sequard and others have given of the clonic convulsions in man. It has been supposed that the clonic convulsions are a consequence of the circulation of black blood which results from the tonic spasm of the respiratory muscles. Now it is manifest that, in these animals with ligatured arteries, no black blood could reach their brain. In them, therefore, the clonic convulsion, as well as the preceding tonic spasm, must be due to want of blood, and not to the altered quality of blood in the brain. These experiments obviously cannot be repeated on the human subject; but Drs. Kussmaul and Tenner describe the effects of compressing the carotids in six men. In all the face turned pale ; the pupils first contracted and then dilated ; the respiration became slow, deep, and sighing; then there was giddiness, staggering, and unconscious- ness, and the patients would have fallen had they not been supported. " In two subjects, of weak intellect and moderately ansemic, in whom, notwithstanding the above symptoms, the compression was continued, a choking sensation, attended by vomiting and general convulsions, came on, which, however, did not attain an aggravated form; for, on with- holding the compression, they disappeared in a few seconds." ( Op. cit., p. 28.) Compressing the carotids does not, of course, entirely cut off the supply of arterial blood to the brain; but these experiments render it probable that sudden occlusion of all the arteries of the head will as certainly excite epileptic convulsions in man as in the lower animals. EPILEPSY. 43 1 There is a class of cases in which a sudden arrest of the blood in its passage through the kings causes convulsions and speedy death. I mean cases in which the circulation is arrested by the admission of atmospheric air into the veins — cases of embolism of the pulmonary artery ; again, cases in which the flow of blood through the lungs is stopped by the injection of certain salts into the veins; and, lastly, cases of acute apncea. When animals are killed by blowing air into the veins, the breathing becomes hurried, the animal falls down, and usually dies in convulsions; the contents of the bladder and rectum being frequently expelled at the time of death. Dr. John Reid states that, " in a very few cases only, is death from this cause not preceded by convulsions." ^Physiological, Anatomical, and Pathological Researches.^ The immediate cause of death in these cases is the arrest of the frothy mixture of air and blood in its passage through the minute pulmonary arteries (the air rarely reaches the left side of the heart) ; and, as a result of this arrest, there is, of course, ansemia of the brain and of every other organ supplied by the systemic arteries. In man, it appears that death from the admission of atmospheric air into the veins has been less frequently preceded by convulsions. Probably the chief reason of the less frequent occurrence of convulsions in the human subject is, that the amount of air acci- dentally admitted is less, and death, consequently, is less rapid than when air is forcibly driven into the veins of an animal. It would probably be found, on a careful inquiry, that the occurrence of convulsions in tkese cases depends upon the circulation being suddenly and completely arrested. Convulsions are mentioned in only five out of fifteen cases collected by Amussat ; but, Dr. Reid remarks, " sevei"al of the cases, as we might have expected, are very imperfectly reported ; for it is not to be supposed that the surgeon or his assistants should possess the coolness and time to watch narrowly the phenomena, when their minds were agitated by the threatened sudden dissolution of their patient, and their attention distracted by anxious attempts to save him." For the same reason, the record of cases of pulmonary embolism is very imperfect; but, in some instances, it has been observed that death was preceded by violent convulsions ; and Virchow noted, amongst the results of artificial embolism of the pulmonary artery in animals, convulsions and dilatation of the pupil. — Des Einboles Pubnonaires. Par B. Ball, p. 129. Again, Blake found that an injection of a solution of soda or its salts into the veins of a dog, destroys life by arresting the flow of blood through the lungs. The left side of the heart is found empty and the right distended. Death occurs in about forty-five sec- onds, and is preceded by violent opisthotonos. — Edinburgh Medical and Surgical your- nal, vol. liv., p. 343. Blake attributes the nervous symptoms to the venous pressure on the brain, but they may, with much more reason, be attributed to the arrest of the arterial supply to the brain. When, from any cause, the blood is arrested in its passage through the lungs, it is obvious that distension of the systemic veins must have, as its necessary correlative, comparative emptiness of the systemic arteries ; the one will be an index and a measure of the other. Lastly, we have the convulsions which occur in almost every case of acute apnoea or sudden suffocation. It is generally supposed that the convulsions of apnoea are excited by the circulation of black blood through the brain, but they are more probably due to the rapid and extreme anaemia of the brain consequent upon the impeded transit of blood through the lungs. When the air is excluded from the lungs the circulation is rapidly arrested by the contraction of the minute pulmonary arteries. That this is the true ex- planation of the convulsions of apnoea is rendered highly probable by an observation of Kussmaul and Tenner [op. cit., p.' 75) to the effect that " the approach of convulsions in 432 PSYCHOLOGICAL MEDICINE. strangulation can be accelerated if the arteries are simultaneously compressed." It is obvious that, if the presence of black blood in the brain were the cause of the convul- sions, their approach would be retarded and not accelerated by compression of the arte- ries which supply the brain. The facts are consistent only with the theory that the im- mediate cause of the convulsions in cases of suffocation is a rapidly increasing cerebral anjemia, resulting from the arrest of the pulmonary circulation. Black blood, in so far as it is deficient in oxygen, is equivalent to no blood. Probably it is rather by its nega- tive quality of being unoxygenized than by any positively noxious properties, that it is unsuited to maintain the functions of the brain. It is probable, too, that the minute cerebral arteries resist the passage of black blood, and so increase the anaemia of the brain. If the circulation of dark blood through the cerebral vessels would excite con- vulsions we should expect to find this symptom of common occurrence in cases of emphy- sema with bronchitis. I have now referred to instances of epileptiform convulsions occurring under a consid- erable variety of circumstances, but all agreeing in this one condition, namely, that the convulsions are associated with a defective supply of arterial blood to the brain. Let us now proceed to inquire whether the phenomena of epileptic convulsions, as they ordina- rily occur in the human subject, are consistent with the theory of ansemia. It is a matter of general observation that, at the very commencement of an epileptic fit, the face is pal- lid. There is anaemia of the superficial vessels, and with this there is probably associated anaemia of the intracranial vessels which supply the brain itself. The pallor is, in most cases, soon succeeded by lividity, owing to venous engorgement consequent upon the impeded respiration and pulmonaiy circulation. It is very remarkable that, while the face is pallid, the heart and the carotids are beating strongly. It is probable, therefore, that there exists some impediment to the flow of blood through the minute branches of' the arteries. To explain this impediment Kussmaul and Tenner suggest that the minute arteries, both the superficial and the intracranial branches, contract so as to bar the pas- sage of blood. Hence arise the pallor of the face and the epileptic convulsion. In some cases it is said that the face is more or less livid at the very commencement of the fit. The probable explanation of this is that the respiratory muscles are convulsed and there is a consequent venous turgescence before the spasm affects the facial arteries. The spasm of the facial arteries, though usually present, is obviously not the cause of the fit. The early implication of the respiratory muscles is clearly shown in those cases in which the "epileptic cry" — a result of spasm of the glottis — is the first indication of the fit. Kussmaul and Tenner endeavored to support the theory of arterial spasm by experi- ment, and to some extent they succeeded. In each of three white rabbits they ligatured the two subclavians and one carotid ; the cervical sympathetic was then exposed and galvanized, with a view to excite contraction of the arteries by the stimulus conveyed through the vaso-motor nerves. In two animals no effect was produced, but in the third rabbit the background of the eye became completely pale, the pupil dilated so that the iris could scarcely be seen, the neck was drawn back, and violent convulsions occurred. The electrodes being removed, the spasm ceased, the pupil contracted, and the back- ground of the eye became red, but the animal continued in a swooning condition. After some minutes electricity, applied to the sympathetic nerve, produced the same effects as at first. A third attempt did not succeed. The authors suggest that these experiments deserve repetition, with the view of ren- dering certain what at present is probable, namely, " epileptic convulsions can be brought about by contraction of the bloodvessels induced by the vaso-motor nerves." According to this theory, then, epilepsy is a result of sudden ansemia of the brain ; and EPILEPSY. 433 this ansemia, when not caused by haemorrhage or by a mechanical impediment to the cir- culation outside the cranium, is due to an extreme contraction of the minute cerebral arteries. With reference to this theoiy of arterial contraction, all cases of epilepsy may be arranged in two distinct classes: i. C'ases in which the arterial contraction is the result of a purely nervous or reflex influence. 2. Cases in which the arterial spasm is a result of blood-poisoning. In the first class are included all cases of epilepsy which are due to emotional influence, sudden terror, or anger, or long-continued anxiety and sorrow, perpetuated and intensi- fied often by nocturnal dreams, and frequently recurring nightmare; also cases associated with those disordered states of the nervous system which are the result of vicious sensual habits ; cases, too, in which the disease is hereditary. This class also includes cases of epileptic convulsions from the irritation of the gums during dentition ; of the kidney, or the ureter, or the gall duct by a calculus ; and of the alimentary canal by worms. Again, the cases in which convulsions result from tumors or other organic disease of the brain are included under the head of epilepsy from a reflex influence. The structural change in the brain is not the proximate cause of the epilepsy; it excites the epileptic convul- sions through a secondary reflex influence upon the bloodvessels. Dr. Brown-Sequard's guinea-pigs, rendered epileptic by injury to the spinal cord, are also included in this class of cases. The injury to the cord probably acts by increasing the reflex excitability of the nervous centres, so that a trifling external irritation suffices to excite a fit. In the class of toxsemic epilepsy are included those cases in which noxious materials in the blood are the immediate exciting cause of the arterial spasm — ursemic convulsions and all cases of convulsions from retained excreta; convulsions resulting from the ad- mission into the circulating blood of unwholesome and undigested food ; the convulsions which result from alcoholism ; the convulsions which sometimes occur during the initia- tory stage of certain of the acute febrile exanthemata, more especially small-pox; the convulsions which are occasionally associated with pyjemic infection ; and the convul- sions resulting from a poisonous dose of prussic acid. In each and all of these cases it is probable that the immediate cause of the convulsion is anaemia of the brain, resulting from contraction of the cerebral arteries, the arterial spasm being excited by the presence of morbid blood in the vessels. In the hypertrophy of the muscular walls of the arteries of the pia mater, which we have recently observed in cases of Bright's disease, we have evidence of a continual resistance to the passage of the deteriorated blood through these vessels. This resistance probably explains some of the cerebral symptoms of Bright's disease, but a convulsive seizure must be due to a sudden temporary increase of arterial contraction — this sudden contraction differing as much from the continuous tonic contraction of the vessels as the cardiac spasm of angina pectoris differs from the regular strong contractions of a hyper- trophied ventricle. With reference to the action of prussic acid upon the bloodvessels, it is noteworthy that Blake, having killed a dog by injecting prussic acid into the jugular vein, observed that, after the animal had ceased to struggle, the dynamometer in the femoral artery still indicated a considerable increase of pressure. This fact is explicable only on the supposition that the prussic acid excited unusual contractions in the minute systemic arteries; and this contraction of the cerebral arteries would account for the con- vulsions in cases of prussic acid poisoning. Again, the symptoms which result from an over-medicinal dose of prussic acid are such as might be occasioned by a less degree of obstruction to the cerebral circulation. These symptoms, as described by Pereira, are the following: " Disordered and laborious respiration (sometimes quick, at others slow and deep), pain in the head, giddiness, obscured vision, and sleepiness. In some instances faintness is experienced." These symptoms are remarkably like those of the epileptic 28 434 PSYCHOLOGICAL MEDICINE. vertigo, ox petit mal, as it is called, and, like them, they are probably due to a temporar}' and partial interruption of the cerebral circulation by arterial spasm. The poison, being very volatile, is quickly exhaled by the lungs, and the symptoms soon cease. In accord- ance, then, with this theory of arterial contraction, epilepsy might be designated cerebral collapse ; and, on the other hand, the arrest of the circulation by the contraction of the pulmonary arteries in the collapse of cholera may be looked upon as a form oi pulmottaty epilepsy. Without doubt, the true key to the pathology of both these awful diseases — epilepsy and cholera — is to be found in this doctrine of arterial spasm. The two classes of epileptic cases— the purely ner%'Ous and the toxsemic — have their analogues in the two varieties of larj'ngeal spasm. Spasm of the larynx may result from irritation of the brain, or of the gums, or of the alimentary canal ; in short, it may be a purely nervous reflex laryngismus stridichis, which is closely allied to epilepsy. On the other hand, laryngeal spasm may be excited by a crumb of bread or a grain of salt, or other irritant, within the larynx; and this is analogous to the arterial spasm which is excited by toxsemia, and which may result in an epileptic fit. There are various forms of what may be called partial epilepsy : sudden and transient impairment of motor power, or irregular spasmodic movements limited to a particular set of muscles; various disordered sensations in limited portions of the skin; derangements of the special senses ; sudden perversion of taste, or snrell, or sight, or hearing ; sudden impairment of speech ; vertigo; confusion of thought ; temporary delirium; and mental excitement. One or more of these symptoms may occur singly or variously combined in different cases, the onset and the departure being often equally sudden. In explanation of these phenomena. Dr. Hughlings Jackson has, with much ingenuity, suggested that they may result from a sudden temporary interruption of the blood-current through one or more branches of the cerebral arteries by spasm of their muscular walls ; so that the brain-tissue, within a circumscribed " arterial region," having its nutritive supply arrested or limited, would suff"er a suspension or impairment of its proper functions. This appears to be a very probable explanation of the curious phenomena in question. It must be borne in mind, that the brain is not one organ, having a simple function, like a lung or a kidney; but that it is a congeries of complex organs, having very diverse functions. It seems probable that the physiological co-operation of all these cerebral organs may require that the blood-supply to the various regions of the brain should be specially regulated by certain branches of the arterial tree, under the guidance of the vaso-motor nerves ; and this regulating power residing in the arteries properly renders them liable to disorderly action under the disturbing influences of disease. It is not now my intention to enter into details as to the treatment of epilepsy; but there are two remedies upon which I desire to say a few words, namely, chloroform and bromide of potassium. It is a well-known fact that chloroform inhalation has a remark- able power of arresting epileptic convulsions. Its action in warding off" a threatened fit, and in cutting short a violent and prolonged paroxysm, is uniform and certain; as uniform and as certain as the influence of sudden and extreme anaemia in exciting convulsions. I for a time supposed that the chloroform acts by relaxing the cerebral arteries ; Kuss- maul and Tenner have shown that animals, when etherized, get no convulsions while being rapidly bled to death, or when their arteries are ligatured. It is probable, there- fore, that an?esthetic vapors prevent or stop convulsions by lessening the leflex excitability of the nervous system, so that convulsions do not occur in etherized rabbits, even though the brain be rendered extremely anfemic by haemorrhage or by arterial obstruction. Recent experience has amply proved that the bromide of potassium, in full and frequent doses and sufficiently long continued, is of great value in the treatment of epilepsy. The known physiological action of this medicine renders it probable that its curative effect in EPILEPSY. 435 epilepsy is a result of its soothing, sedative, anaesthetic influence upon the nervous centres, whose reflex excitability it lessens. In short, its action in jDreventing convulsions is analogous to that of chloroform, differing in being less powerful and rapid in its opera- tion, yet, by frequent repetition, its influence may be rendered more durable and more permanently beneficial. On the treatment of epilepsy, Dr. Samuel Wilks, Physician to Guy's Hospital, says: As regards the treatment of epilepsy, it must be considered entirely empirical. The term rational can scarcely be introduced even in the minor questions of diet, air, etc. I have certainly known patients reduce their amount of food and drink, especially in the article of meat, and with a corresponding diminution in the number and severity of fits ; but, on the other hand, 1 know other cases where a generous diet has been equally neces- sitated. It is just one of those cases where particular drugs may be of service, and beyond their administration we can do little. If any old woman had the possession of an herb or a salt which could antagonize the disease, her knowledge would be worth more than that of the whole College of Physicians, I am happy to say that this does not apply to many other diseases, where the knowledge you have acquired of their nature will serve you far more than all the medicines in the Pharmacopoeia. The remedies, then, ai'e empirical ; those that have hitherto been most in vogue have been the metallic tonics. It is remarkable that such class of drugs seemrs to have more efficiency in morbid states of the nervous system than those which have a more direct physiological effect. In the whole range of nervous affections you will find this to be the case. In my own experi- ence, the only remedies of this kind M-hich I have seen useful have been belladonna and nux vomica — ^drugs having different physiological actions. I have had cases where both remedies have been apparently beneficial. The metals have been used with a certain amount of success from time immemorial, such as arsenic, silver, iron, and zinc. Some years ago I used all these remedies largely amongst the out-patients, and should certainly give the preference to zinc; I know now more than one case of epilepsy where the patient is always better on the resumption of this remedy. If you suspect any local cause in the brain, you may adopt other measures ; thus I have seen a case apparently cured by mercury. Those which were benefited by iodide of potassium had no doubt a syphilitic origin. It was whilst I was examining the effects of the various remedies that I discovered the very superior value of the bromide of potassium. I was at that time trying this remedy against the iodide in bronchocele and some other disorders, and being in the habit of often using the iodide in epilepsy, I substituted the bromide for it. I was at first under the impression that it was acting as an absorbent, and was picking out for its operation those cases where the disease had a syphilitic or local origin; but when the cures came to be numerous, the explanation would not apply, and it was evident that a very valuable specific remedy had been obtained. Various writers had certainly mentioned the drug with a host of others, but only to again lay it on the shelf with them. I was not aware at that time that Sir C. Locock had recom.mended its use, for it does not appear that his observations had been specially brought before the profession, much less been confirmed by others. As far as I know, it was when Sir C. Locock was President of the Royal Medical and Chirurgical Society, on the occasion of Dr. Sieveking reading a paper on epilepsy, that he made the following remarks, and which I quote from the Lancet of May, 1857: "Some years since he had read in the British and Foreign Medical Review an account of some experiments performed by a German on himself with bromide 43^ PSYCHOLOGICAL MEDICINE. of potassium. The experimenter had found that when he took ten grains of the pi-epara- tion three times a day for fourteen days, it produced temporary impotency, the virile powers returning after leaving off the medicine. He (Dr. Locock) determined to try this remedy in cases of hysteria in young women unaccompanied by epilepsy. He had found it, in doses of from five to ten grains three times a day, of the greatest service. In a case of hysterical epilepsy, which had occurred every month for nine years, and had resisted every kind of treatment, he had administered the bromide of potassium. He commenced this treatment about fourteen months since. For three months he gave ten grains of the potassium three times a day. He then reduced the amount, and the patient had no epilepsy since the commencement of the potassium. Out of fourteen or fifteen cases treated by this medicine, only one-half had failed." It was in the early part of i860 that I commenced to use it; in the following year about a dozen cases were pub- lished in the Medical Times and Gasette, being the first series of cases systematically described (that I can find) in which the remedy had been found eminently successful. It was thus evident that the bromide was not simply supplanting the iodide in the cure of some special form of the complaint, but that the drug had some remarkable influence over the pure and simple form of epilepsy. This has now been confirmed by others, and even by those who had previously merely administered the bromide, as they had done many other remedies, without sufficient trial, and had discarded it. Of course, like every other remedy, its success has been overrated, and thus the disappointment which natur- ally accompanied the reaction of opinion, more especially when it was employed for almost every disease in the nosology. As regards drugs, then, I should say that zinc and the bromide are the most important; but you will have no lack of opportunity of trying the effects of remedies, for epileptics often insist on being physicked year after year when absolutely nothing is being done for them. I ought to mention the occasional value of counter-irritants to the back of the neck, and of setons. I well remember two men who some years ago attended at the hospital, and whilst tlie seton was open the fits were absent ; when this dried up they returned. I have seen other cases of the kind since this time. I have already mentioned the case of a man whose life was saved by bleeding. I do not know that it is a remedy against the disease, but that it acts in the most beneficial manner if the paroxysm is long continued I have no doubt. In the case I referred to, the man had had a succession of fits for some hours, had swallowed nothing, and must shortly have died from congestion of the lungs, had not the lancet relieved his circulation and almost immediately restored him to con- sciousness. I think it very probable that in those cases in former times which were con- sidered apoplectic, and in which recovery rapidly took place after bleeding, epilepsy was the real disease. I am convinced that I have seen several such, and therefore think they cannot be uncommon. A man, for example, is seized with a fit; you are called to him, and find him comatose, with stertor and apparent paralysis of one side ; you consider it to be a case of apoplexy, and recommend bleeding ; he soon afterwards recovers his consciousness, and after a few hours the weakness of the limb has passed, and the pa- tient is comparatively well. Whatever the diagnosis, the remedy has succeeded, and thus, in a severe fit of epilepsy which becomes protracted, I have no hesitation at all in recom- mending you to open a vein. It might appear strange, after declaring that an epilepti- form fit may be induced by loss of blood, immediately to recommend venesection as a remedy, but it does not folldw that the theory and the treatment are antagonistic, for whatever may be the immediate cause of the seizure the result is a spasm of the chest, which, ending in congestion of the lungs, is best relieved by liberating the blood from the overcharged venous system. I ought not to forget to mention the remarkable circumstance of our capability of arrest- EPILEPSY. 437 ing the attack by acting on the spot whence the aura proceeds. If the attacks were due to an irritation reflected from one spot, then the removal of this cause would stop the fit, as in the case of the child I mentioned, whose father assured me that the application of laudanum to a sore spot on the face would arrest or mitigate the paroxysm. But when the sensation on the surface is altogether subjective, a great difficulty in the explanation arises; unless we are content with supposing that as one portion of the brain must be more especially involved in order for the sensation to be felt in one part of the body rather than another, so some external application to that part may cause a corresponding reflection backwards, and arrest the process that had already commenced. Dr. Walter Tyrell, in treating epilepsy by strychnia, gives a case as follows : A. C, aged eighteen, a girl of dull complexion and low nervous temperament, has suffered from epileptic attacks from eight years of age, but much more severely since the appearance of the catamenia, which have been irregular. During the past two years the attacks have recurred every four or five days and oftener at the menstrual period. They are violently convulsive, but are not preceded by any aura or other warning. Her memory is much impaired, and she suffers from almost continual headache. I here commenced with Jjjth grain of strychnia, and it was only necessary to increase it to j^-jjth, as the good effects were at once perceptible in an improved state of health, regularity of the uterine functions, and an entire cessation of the fits ; in fact, only two, and those at intervals of fourteen days, have occurred since she first commenced the medicine, and she has now been perfectly free for five months. In this case also, cold bathing, walking exercise, and early rising were made adjuncts to the treatment. Both in this and the following case the reason of the rapid success of a comparatively small dose is that the predisposing cause of the attacks was but slight, and that consequently an increase of nervous power being supplied to the medulla oblongata enabled it not only to restrain the irregular dis- charge of nervous power, but also to restore the healthy functions of the uterus. A. B., aged twenty-three, a dull, phlegmatic looking girl, with low, retreating fore- head, has been the subject of epileptic attacks for eight years; but latterly they have become much more severe in all their characteristics. The catamenia have never been regular. In this case I commenced with ^oth of a grain of strychnia, which dose she continued to take for nearly two months, when it was increased to ifh. Under this (in combination with cold affusion and outdoor exercise) her health rapidly improved, and the attacks to which she was subject about every ten days, decreased both in number and severity. She has now been entirely free from attack for more than four months, and has discontinued the medicine for nearly half of that time. I have now been watching the effects of strychnia upon various forms of epilepsy since i86i, and I have no hesitation in affirming, that in a large majority of cases its effect is most beneficial; at the same time, I would not be at all understood to vaunt it as spe- cific, per se, in all cases. I think that its value lies in the effect it has in deadening that condition of "exalted sensibility" and activity of the medulla oblongata which Van der Kolk (and, I imagine, most recent authors) considers the predisposing cause of the dis- ease. That this is the effect of strychnia is, I think, proved by cases narrated in my former papers, but especially by the case which I mentioned in my last paper, a few points of which I will recapitulate, as it affords a capital illustration of my meaning : A gentle- man, aged forty, had suffered for sixteen years from violent convulsive epilepsy. The attacks varied from fifty to sixty in the month, and occurred chiefly at night. His mental faculties were little if at all impaired, and his general health perfectly good. No excit- 438 PSYCHOLOGICAL MEDICINE. ing cause could be discovered, and he had used every variety of means without benefit. The only fact which had any bearing on the case was that, previous to the commence- ment of the attacks, he had been subject to frequent and severe epistaxis, on the stop- page of which the attacks apparently came on. Now, here was a case which would undoubtedly belong to that group which Dr. Reynolds, in his valuable work on epilepsy, has classed as most intractable and least amenable to treatment. Yet from the first day of this patient's commencing strychnia the attacks diminished, both in number and severity, in the mo-t remarkable manner, so that in the first month of treatment the attacks were only eleven in number against fifty-one in the previous month, and this without any in- crease of severity. Nor has this result been merely a temporaiy one ; but the patient, who is still under treatment, has gone on progressing, and I heard from him only a few days since, to say that he had had an interval of eleven days without any attack. I single out this case, as it was one of unusual severity, was due to no special exciting cause, and belonged to a class of cases which are gerierally admitted to be very intract- able, yet it yielded at once to the plan of treatment I mention. This might be called a case of pure epilepsy, for the disease was due to no exciting cause, and this would proba- bly account for the strychnia alone being sufficient to produce such favorable results. In most cases, where various exciting causes are at work keeping up the sensibility of the medulla oblongata, it is necessary to remove them at the same time that we are restoring the healthy condition of the nervous centre by strychnia. The stomach, uterus, pharynx, kidney — in fact, almost any organ — may be the seat of these exciting causes ; and I think that, in the treatment of epilepsy, the grouping of the cases according to the nature and locality of their exciting causes, offers the best prospect of success. Thus, I would in all cases give strychnia to remedy the predisposing cause, and at the same time endeavor to discover and treat the exciting cause or causes. In a large class of cases, the exciting causes of irritation will be found to lie in the gastric branches of the pneumogastric nerve, and it is in these cases that nitrate of silver, sulphate of zinc and copper are so useful, and they act, I believe, by deadening the sensibility of the nerves of that part. In irritation proceeding from the uterus and sexual organs the bromide of potas- sium is very useful, coupled often with aloes and other emmenagogues. In many cases, where I have found the disease coupled with irregular pulse and signs of cardiac de- rangement, I have found digitalis to act well. With regard to diet, I find that almost all cases of epilepsy bear a libei-al diet, with a fair amount of stimulant, and I have often seen marked improvement follow a change from a spare to a full diet; of course, atten- tion must always be paid to the prevention of anything like a heavy meal, more espe- cially in those cases in which gastric irritation would appear to be the exciting cause. I have, since writing my last paper, seen several cases of petit inal in children, and in all of which I have found strychnia successful; and I may here mention, that I think some distinction may be drawn between these attacks w^hen they occur prior to puberty, and when they are present in adults. I think that in childhood they are less destructive in their effects upon the mind, and they certainly yield much more readily to treatment. J. K., eleven, a not unhealthy-looking boy, has been subject for five years to attacks of petit mat, with occasional severe fits of convulsive epilepsy, the latter having usually come on after an excess in eating, though twice they have occurred at night. He had convulsions in infancy. In the slighter attacks he would lose himself for a few mo- ments, would stop talking, or would talk incoherently in the middle of some sentence, would occasionally turn his head over his right shoulder, and in some cases his counte- nance would become livid. His memory was not affected, and he was very fond of poetry and of books generally. I commenced to treat him in July last, enjoining great care in diet, that it should be liberal, plain, but never in great quantity at once. I gave EPILEPSY. / 439 him Jyth of a grain of strychnia in solution twice daily ; the attacks yielded almost at once, and he has now been perfectly well for nearly six months. The attacks of petit vial were here very frequent; sometimes as many as three and four would occur in one day. The above cases are merely selections from a number, and are chosen as presenting features very commonly met with — a plan which I consider more likely to be useful than the narration of cases which present symptoms but rarely met with. I may say that, in all the cases in which I have used strychnia, I can find but three cases in which it has not produced any favorable result; and, on the other hand, I have seen no case in which it has produced an unfavorable effect. With regard to the doses, in severe cases I am in favor of giving a medium quantity for a lengthened period, rather than carrying the dose very high at first. Iii one case, narrated in a previous paper, the dose taken reached as high as ^th of a grain, twice daily, and this was continued for some three weeks without any bad effects being perceptible. But I find that quite as good results are ob- tained by a long continuance of a medium quantity, say from ■^^'^'Cn to ^th of a grain, the system appearing to regain its nervous strength under the continued use of the medicine. On the treatment of epilepsy by belladonna, Dr. J. S. Ramskill, Assistant Physician to the London Hospital and Physician to the Hospital for Epilepsy and Paralysis, says : Concerning the treatment by, and action of, belladonna in epilepsy, I will give you, in a short compass, the results of my experience in its use. First, you must not always, nor even usually, look for immediate and palpable beneficial results. The number of fits at first may not lessen in equal times ; very frequently, the reverse obtains ; and you may ex- pect, for three or four weeks after commencing it, even in the most appropriate cases, a complaint that the patient gets worse ; but after six -or eight weeks, if any amelioration occur, it will be decided and progressive. At first the dose should be very small, and gradually augmented until the pupil shows signs of its action, and the patient complains of both alteration in sight and dryness of throat. Having obtained this result, and maintained it for some weeks, the dose may be gradually diminished ; but its effects on eye and throat are not to be so diminished as to become imperceptible to the patient, but only so far lessened as to cease causing absolute discomfort. The other toxic effects of belladonna are wholly uncalled for. Patients vary greatly, both as to susceptibility in the action of the drug, and in other respects. The annoyance as to dry throat and disturbed vision, which, at the expiration of a month, may be said to be unendurable, will now and then cease, the dose being the same, or even slightly increased ; but I may remai'k, these cases always improve most rapidly. I prefer to give the drug in an eighth of a grain dose three times, or only twice, daily, for a week ; then a quarter of a grain for four- teen days; a third for the next fourteen days, at which time its physiological action will in most cases be manifest. I think it wise to halt at this dose for two or three months, slightly increasing the dose if the patient shows diminished susceptibility to its influence, decreasing it if the reverse happens, and then gradually dropping it to the quantity first administered. I have given as much as four grains for a dose, but very rarely. I think it imperative to say, that I have never been able to give in epilepsy the large doses which Dr. Fuller has succeeded in administering in other diseases of a con- vulsive character. In this remark I am supported by the authority of my colleague, Dr. Brown-Sequard, who has arrived at the same conclusion. One objection to the use of belladonna, when you cannot see your patient at regular intervals, arises from its uncer- 440 PSYCHOLOGICAL MEDICINE. tainty of strength and corresponding difference of action. To those who wish to use a preparation of uniform strength, having similar, and, in some cases, improved properties of belladonna, the salts of atropia are now easily procurable. The best of these is the valerianate of atropia; the commencing dose a hundred-and-twentieth of a grain. Hith- erto, I have preferred belladonna, having had a strong desire to find 'what it could, and if possible, what it could not accomplish in the treatment of epilepsy. It is right to say there are different methods of administering belladonna. Trousseau gives a centigramme of the extract and an equal quantity of the powder of belladonna for the first month, in the evening of each day. He gives it at this time because of the frequent nocturnal character of epilepsy, and partly because of the disagreeable effect on the sight and throat during its early administration. During the second month he gives two such pills at the same time, and during the third month three pills. If, at the end of six or nine months, the frequency of the fits is decreased, he increases the dose. He asserts that, of 120 patients, he has cured twenty. A most important question now arises, — Do we know anything of the nature of the action of belladonna beyond the empirical results obtained in treatment ? If a drop of solution of belladonna or atropine be dropped on the foot of a frog properly prepared, and fixed on the field of a microscope, the bloodvessels will be seen to contract, and they will remain in this condition for a considerable time. For comparing the action of opium, a solution of the latter, similarly prepared, was applied to another part, and the vessels were immediately dilated. Now, belladonna, internally administered in medicinal doses, causes, first, dilatation of the pupil, with dimness of vision; secondly, dryness of throat and difficulty of swallowing; thirdly, increased tone of involuntary muscle ; fourthly, it relaxes the bowels, and cures incontinence of urine, arising from weak sphincter vesica. As dilatation of pupil is one of the earliest phe- nomena, let us see if we can account for it. There are two sets of fibres in the iris. It is well known that the sympathetic is the motor nerve of the external longitudinal fibres of the iris, which radiate from the centre to the circumference. The branch of nerves supplying these fibres comes from the cervical ganglia of the sympathetic. Excitation of this nerve, from any cause, will cause a contraction of these longitudinal fibres, and a corresponding dilatation of pupil. There is also a circular set of fibres immediately sur- rounding the margin of the pupil. This set is under cerebral control ; that is to say, its motor supply comes from a branch of the third nerve. Any irritation in the brain or along the trunk of the nerve, or an excitation by light on the retina acting in a reflex manner, will stimulate this branch of the third to action, and cause contraction of pupil. But we may have dilatation of pupil without increased action of the sympathetic ; it may be acting normally, then the third nerve must be supposed deficient in power. This is a common result observed in compression of brain. On the other hand, contraction of pupil may be present without abnormal activity of the third being necessarily supposed. This condition is invariably produced by section of the sympathetic in the neck. Dila- tation of pupil may, in short, depend upon the action of the sympathetic being in excess, or in diminished power of the cerebral nerve. In epilepsy it is easy to observe, from collateral symptoms and the general condition of the patient, that dilated pupil, when it exists, which is much rarer than a normal condition, is usually caused by an active sym- pathetic overpowering the third nerve. The same dilatation may be observed in most convalescents after acute disease, and in most affections involving extreme debility ; but here it would be more correct to say that the dilatation was rather the effect of a com- pressed condition of the third cerebral nerve accompanying a normal sympathetic than of an active sympathetic accompanying a normal condition of the cerebral nerve. I have said the branches of the sympathetic nerve which go to the iris come from the cervical sympathetic. Dr. A. Waller, with Professor Budge, have made experiments which seem EPILEPSY, 441 to prove that the nerve-fibres of the cervical sympathetic, which go to the iris, originate from the spinal cord, between the sixth cervical and the fourth dorsal vertebrje. Dr. Brown-Sequard has ascertained that the origin of the fibres of the sympathetic going to the iris are still more extended. I have mentioned that division of the cervical sympa- thetic allows the ilncontrolled third cerebral nerve to contract the iris. Dr. Brown- Sequard has shown that a section of the spinal cord, as high as the level of the fifth cer- vical or as low as the ninth or tenth dorsal vertebrse, affects the iris in the same manner but in a less degree than section of the sympathetic. On the other hand, Schiff has shown that some of the fibres animating the iris ascend the cervical part of the spinal cord, and most probably go up to the medulla. I may also say here that the sympathetic is the motor nerve of the bloodvessels, supplying various parts of the head. It is espe- cially interesting to know the origin of these vaso-motor nerves, especially in relation to loss of consciousness, the initial movement of a fit of epilepsy, and also in regard to the pathology of the/f/'?V nial, as well as the great light such knowledge would throw on the action of belladonna in epilepsy. Dr. Brown-Sequard discovered, some years ago, that the motor nerves of the bloodvessels going to various parts of the head come out chiefly from the spinal cord by the roots of the last cervical and first and second dorsal nerves. He thinks, however, their real place of origin to be partly the spinal cord, partly the higher portions of the encephalon, but chiefly the medulla oblongata and the neigh- boring parts of the encephalon. In the case of R. P., it will be remembered the ferrum candens was applied to each side of the spine, opposite the last cervical and first dorsal vertebrae. The reason will now be apparent. The vaso-motor nerve fibres are able to contract the bloodvessels directly, when excited. We hope, by frequently cauterizing the tissues opposite the seat of exit of these nerves from the spine, to effect some change in the nutrition of the parts to which these nerves are distributed. We can now under- stand the nature of the action of belladonna in producing dilatation of the pupil, and, from its effect on the iris, we can deduce a strong probability of the nature of its action in epilepsy. It is a stimulant to the sympathetic, the motor nerve of the bloodvessels, and it is only on this supposition we can account for the other physiological effects of the drug. I would add, although experience shows belladonna is one of the most powerful con- tractors of the bloodvessels of the spinal cord and its membranes, it has a comparatively feeble action on those of the brain. I speak of its administration in medicine, not in poisonous or fatal doses. Hence arises its extraordinary adaptability in epilepsy, where we have dilatations of vessels or turgescence in the medulla and its neighborhood ; of its still more marked efficacy in inflammation and congestion of the spinal cord and its membranes, as well as of its comparative inutility (administered alone) in those cases of morbid activity of brain, connected, as we think, with more or less congestion of gray matter, in some forms of incipient insanity, associated with sleeplessness and suicidal tendency, as well as in some other cerebral diseases. 442 PSYCHOLOGICAL MEDICINE. CHAPTER XXII. HYSTERO-EPILEPSY. It has been claimed by some neurologists that the term hystero- epilepsy was a misnomer, that the disease in question was really hys- teria major, as differing from the hysteria minor of every day prac- tice. Prof. Charcot himself, we think, takes this view, that what at first glance is evidently epileptic is epileptic only in outer form. The case which forms the text for this chapter has proved to me, how- ever, that there is epilepsy present in certain grave cases of hystero- epilepsy, and that there is also organic lesion of the brain connected with it, sclerosis, as in old cases of uncomplicated epilepsy. My case had been apparently cured by central galvanization, followed by general faradization, nerve tonics, full feeding and rest ; the convul- sions had ceased, although the patient did not remain under treat- ment as long as we desired, when after a lapse of some months the disease reappeared, and the patient finally died at home. The lesions found on autopsy were those which I correctly predicted would have been found if the case had gone on to a fatal termination in- stead of making, as I trusted she had, a recovery while in New York. The history of this very interesting case is as follows : During the latter part of April, 1880, I was called in consultation by my friend Dr. J. Marion Sims, to see a case of hystero-epilepsy. I found a lady of twenty years of age, who was suffering from cerebral and spinal anaemia ; who was having terrific convulsions day and night, which were aggravated, both in duration and intensity, by anything that disturbed her very excitable nervous system. Her history, as given by the mother, was as follows : During childhood she had very severe convulsions with every infantile disease, and also whenever she was in an anaemic condition. This points decidedly to epilepsy. These convulsions from infancy, presented an epilepti- form type. When she was ten and a half years old menstruation appeared; and at the menstrual periods thereafter, until she was four- teen years old, the convulsions were of the severest type, exhausting her very much. Another unfavorable symptom, for periodical neu- roses are notably intractable to treatment. She was treated by nearly all the physicians of eminence, both at home and abroad, but with very little success. While abroad, occupied with sight-seeing HYSTERO-EPILEPSY. 443 and taking a great deal of exercise in Switzerland, she had almost absolute freedom from the convulsions, although she was very thin. This is still another fact confirmatory of the existence of true epi- lepsy, as my experience has taught me in treating epilepsy that my patients who took long walks out of doors, suffered the least from the epileptic seizures. Sir Thomas Watson gave it as his opinion that the convulsions would disappear of themselves as she grew older, and gave the diag- nosis of hystero-epilepsy. He suggested no treatment. The mother and daughter returned home, and on their arrival in America the con- vulsions reappeared with renewed intensity. The patient would sometimes have forty convulsions in the twenty-four hours. The mother applied to Dr. W. A. Hammond, and he sent her to Dr. Sims for his opinion relative to the propriety of performing Battey's opera- tion of oophorectomy, hoping that this would give relief There was a distinct epileptic aura at this time, starting from the uterus and ra- diating towards each ovary, where it sometimes stopped, but, if it reached the epigastrium it always resulted in a terrific convulsion. Pressure on the uterus and ovaries by conjoined manipulation caused the sensation of the aura, but failed to produce or check actual con- vulsions. She never, I think, absolutely lost consciousness during the seizures. As no treatment had heretofore given any relief, Bat- tey's operation was determined upon and was performed by Dr. Sims, January nth, 1880. The ovaries were found to be diseased, having undergone cystic degeneration. The patient soon recovered from the effects of the operation, but her convulsions were not controlled by it. I think, however, that by this operation Dr. Sims laid the corner-stone of the improvement which I afterwards obtained, as I do not believe that with diseased ovaries I could have been as suc- cessful as I was. It was decided that the patient should be placed under my care, and I accordingly took charge of her May 2 2d, 1880, at my private hospital for nervous diseases. At this time she had, as I have said, terrific convulsions night and day, the element of epilepsy predomina- ting. There was no epileptic cry, properly speaking, but she would call out " Mamma!" and become very pale ; there would be a twist- ing and squinting of the eyes and terrible convulsive movements of the legs and arms, strongly impressing one with their close alliance with the most aggravated movements in the worst cases of chorea. She would come out of a severe convulsion instantly, with panting breath, as if she had just come in from an excessively long walk. In a few 444 PSYCHOLOGICAL MEDICINE. seconds she would feel comfortable again. The thumbs were not folded into the palms of the hands. It was decidedly the most unique exhibition I have ever witnessed in the whole course of my practice. She differed entirely from most patients with hysteria, in that she suf- fered mentally very much, fearing in her own mind that she had true epilepsy, and at times would grow quite morbid about it. At such times I tried to raise her spirits by telling her that she would certainly recover in time, and she then would become more cheerful and make every ef- fort to fight off the convulsions. I questioned the mother closely about hereditary predisposition, but she denied any hereditary taint of nervous disease, or anything else that could even remotely have influ- enced the child unfavorably. I questioned her, also, very closely about her own mental condition while pregnant, as it is my firm belief that the future life of an unborn babe is strongly affected by the mental state of the mother during gestation ; but she could recollect no dis- turbing circumstances, even of a trivial character. The mother was a woman of more than ordinary mind and of a remarkably equable dis- position. I came, therefore, to the conclusion that the pathology of the case I had to deal with, was that of an unstable nerve element ; and that the seat of the disease was in the nerve centres, with, very probably, the principal irritation in the cortical motor zone of the central nervous region. There was marked anaemia of the nervous centres. Upon what pathological process in the brain the convulsions in her infancy depended, it is hard to tell, although I presume it would be fair to consider it a lesion of irritation of the cortical motor zone of the cerebrum from innutrition, depending upon anaemia of the brain and cord. When she was about ten years old there was gastric disturbance, and for three years she ate scarcely anything at all. Primarily, I had nerve cells to feed in order to restore the integrity of the nervous system, and I accordingly fed her with milk very plentifully, and gave her phosphorus and the animal fats in abundance. I made her rest nearly all the time at first, until her muscular strength returned, when I had her take a very moderate amount of exercise daily. I gave her, to quiet the neuralgic pelvic regions, which distressed her very much, hypodermic injections of atropia -g-V grain each, with almost instantaneous relief every time. I administered the galvanic current daily for half an hour in the form of central galvanization, the negative pole being placed on the pit of the stomach, and the positive over the top of the head, the cervical sympathetic, and on each side of the seventh cervical vertebra, using a moderately strong HYSTERO-EPILEPSY. 445 current which could not be disagreeable to the patient. I considered this indicated to improve the nutrition of the deeper tissues of the nervous system, and to combat the spinal anaemia and irritation which existed. I also gave her iron and nux vomica. As she slept very badly, waking perhaps twenty times in the night with convulsions, I gave her a night mixture of sodium bromide, 60 grains, and tincture of cannabis indica, 30 minims, with a warm bath three times a week at night. I soon began to see a marked improvement. The com- bination of sodium and cannabis indica enabled the patient to sleep, whereas, previously she had lain awake nervously waiting for the return of the next convulsion. Making her sleep without disturbing her digestion was a great point gained. Duquesnel's aconitia was given once a day in doses of y|-g- of a grain, and after about two weeks of its administration I gave hypodermic injections of Fowler's solution until the physiological effects of arsenic appeared* when I stopped it. I diluted the Fowler's solution one-half with water to prevent the forma- tion of abscess, commencing with 3 minims and running up to 20 minims (or 40 in all including the water). I did this because the nature of the convulsions suggested chorea, and I determined to combat any such influence in the central nervous system. It miust be remembered that almost from infancy my patient had been taking some drug or other, until she had taken almost every- thing. She had never taken aconitia, atropia, arsenic, or the sodium and cannabis indica mixture before ; neither had she ever had elec- tricity properly applied. I had also to treat an inflammation of the cervix uteri, which I did by making a cup of absorbent cotton wrung out of warm water and filled with glycerole of bismuth, which, for three weeks, I applied every day, at last completely curing that source of irritation to the nervous system. The patient began to gain in health and appearance, and evinced a desire to eat heartily and take exercise, and a flush of healthy color began to show in her lips and cheeks. The convulsions steadily diminished in frequency and also in intensity. I now substituted general faradization for central gal- vanization, and the improvement still continued. In this connection I would say that I am sure, from the results of several cases of epi- lepsy that I have treated by the induced current and strychnia, that the induced or faradic current possesses a special power for good over the nervous system in such cases. The convulsions at the end of two months had completely left her during the daytime. I had now dropped the arsenic and aconitia, still adhering to electricity, the sodium bromide and cannabis indica at night, and the warm 446 PSYCHOLOGICAL MEDICINE. baths, together with phosphorus and cod-liver oil after each meal. She was now having perhaps seven or eight seizures at night, but slept soundly between them. These grew less in frequency and in- tensity, and at the expiration of three months I sent her home to the West altogether a very different looking girl from what she was in May. She had gained some twenty pounds of flesh, and felt very well. There was still remaining some convulsive twitching of the muscles at night, but nothing like a true convulsion as before. The patient was obliged, for family reasons, to return to the West at the beginning of September, although she ought to have remained under treatment until at least six months had elapsed; and had she done so, the gratifying results which I had obtained might have been made per- manent. The cod-liver oil, which she took in teaspoonful doses, was of immense benefit to her, as it always is, in my experience, in the class of hereditary diseases to which epilepsy belongs, as it seems to exert a special prophylactic effect. Respecting the cerebral localization in this case, my opinion was expressed as follows before the patient left for home, and the subse- quent events confirmed the correctness of my opinion : That the upper and lower limbs, the forearm, the hand, and the facial muscles were all affected by the convulsions. There was an alteration in speech — a deficiency of impulse and some difficulty in the conduction of speech — at times ; in other words, partial and in- complete verbal paralysis. The brain disease evidently affected the ascending parietal convolutions, which are the cortical centres for motility — in the innermost and superior part for both upper and lower limbs ; in the middle, for the forearm and head; and in the external or inferior part, for the facial muscles. The most inferior part of the ascending frontal convolution and the foot of the third frontal con- volution, which are the motor centres for the muscles which affect the pronunciation of words, I considered also as undoubtedly affected, leading to the alteration and deficiency of impulse of speech. I also considered it probable that there was bilateral circulatory disorder of the cornu ammonis, which, I said, if the case had progressed for the worse, would undoubtedly have proceeded to atrophy and scle- rosis. The cornu ammonis has this relation, histologically, to the motor functions, that its cellular elements consist of a cortical stra- tum of grand pyramidal nerve-cells, analogous to the structure of all the central motor nervous regions. Charcot, in his Lectures on the Diseases of the Nej'vons System, speaks of a case of hystero-epilepsy, where he found bilateral HYSTERO-EPILEPSY. 44/ sclerosis of the cornu ammonis ; and in autopsies in cases of epi- lepsy, Foville, Bouchet, Mynert, and Pfleger all unite in describing this lesion of sclerosis and atrophy of the cornu as of frequent oc- currence. On the other hand, the physiological results in Kussmaul and Tenner's experiments on epilepsy in animals, where epileptic convulsions were artificially induced, seemed to show that ablation of the cornu ammonis had no effect on the general convulsions. We, as physicians, however, are more concerned with clinical and patho- logical than with physiological results, however important the latter may be. The pathology of this interesting case of hystero-epilepsy I therefore considered, when the patient left me, to have been a circu- latory disorder, accompanied by great irritation of the cortical motor zone of the central nervous regions, which, if the case had progressed unfavorably — as after a lapse of some months it did — would have led to atrophy and sclerosis of the ascending parietal convolutions, the most inferior part of the ascending frontal convolution, and the foot of the third frontal convolution, and of the cornu ammonis. This was what I put on record concerning this case when she went away. The ac- companying letters from her mother, and one from the physician who at last made the autopsy, show the redevelopment of convulsions, the lesion of irritation ending in atrophy and sclerosis of the cortical motor zone : "January 25TH, 1882. " Dr. Mann: " My dear Friend. — Your kind letter reached me some time since and would have been answered immediately could I have obtained the information you desired. Yester- day I received a letter from Dr. Gapen, with many apologies for the delay, and the wrif- te7i examination, of which I send you a copy. He has never attended , and all he knows of her he has gathered from other physicians and my family when I was absent. I had indeed hoped that would grow out of her troubles ; and as her general health seemed at times to be almost perfect, I felt I had good reason to hope. Her brain grew more and more active,* and she was greatly changed. She read a great deal ; was always busy and hopeful, most of the time very cheerful. She grew very appreciative of what was done for her, and up to the last spared me all shq pould from sharing her bad feelings. For more than a week before she died I was aware that there was a change in her symptoms, and hardly knew what to look forward to ; but, basing my hopes upon the many things that had been told me, I looked upon any change as favorable. Last winter she was as bad, seemingly, as she was this time, with this exception, there was no visible sign of congestion of the brain, as at this time. Then, when I felt she was surely dying, she dropped into a sleep which lasted two nights and one day without awakening, —for three days she did not speak, — then she got up and dressed herself, and sat down in a little chair by the window, and, looking up at me, she said : ' Mamma, I never looked at you before with the thought of how you looked. Everything seems so different to me from what it ever did — my room — all my friends — everything.' She had not been able * Her mind, up to the time she came to New York, had been that of a child, — unde- veloped. 448 PSYCHOLOGICAL MEDICINE. to lie do\Yn without feeling badly. Now she could lie or sit, and it all seemed so lovely to her. She went on improving in strength, and with everything so natural that we both felt paid for all we had done' and all we had suffered. This state of things lasted for two months, and then came a return of the old symptoms. The spasms increased from one a week to one a day, and then three, and so on, to sixteen or twenty duriiig the twenty-four hours. Sometimes she would go for a week without any exhibition of nerv- ousness, etc. " As ever yours, ." After death, the following appearances were found by the very able and intelligent physician who made the autopsy, and who kindly forwarded the results to me : " Post-moriefn Exami7iation of the Body of Miss Twenty four hours after Death. — Found atrophy of the uterus, with absence of the ovaries. Wounds made in the removal of the latter perfectly cicatrized. Evidences of severe general peritonitis, in adhesions of the intestines, both to the abdominal walls and to each other. Nothing abnormal in stomach or intestinal lining. Lungs and heart also normal. On opening the calvarium, the brain was found gorged with venous blood. Every vein and sinus was distended to its fullest capacity. There was no effusion of blood either on the sur- face or into the tissue of the brain. The dura mater y^zs, glued down to the pia mater over a large space, covering nearly the whole of the top of the brain, by a thick and strong effusion of lymph. These adhesions were very firm, especially along the borders of the longitudinal fissures. On the left side nothing further than this was found abnormal, but on exposing the 7-ight hemisphere, the eye was at once attracted by a very marked depres- sion, extending over an irregular area of nearly two inches in diameter, and involving the second frontal, ascendiiig frontal, and ascending parietal convolutions. This area was apparently depressed about J^ inch below the surface ; was flat, the interspaces between the convolutions being filled with lymph, and the pia mater translucent over the depres- sion from the effusion of lymph into it. To the touch this part was very much firmer and denser than the rest of the brain. The borders of the hardened area were sharply defined to the touch. This indurated condition extended through the entire thickness of the gray matter and into the white matter below, being in all about half an inch in depth and continuing the same in extent and in the sharp definition of its borders. On laying back a layer of the brain deep enough to include the entire induration and in- cludino- it between the fingers, the sclerosed part was so much harder than the surround ing parts as to seem like a foreign body. In the absence of microscopic investigation, which is yet unfinished, I can only add that the lesion seemed a sclerosis, which -was probably the result of chronic inflammatory action. The lesion furthermore belonged to the irritative as opposed to the destrtictive class, as there is no evidence of any marked loss of function of this part of the brain. If, as I anticipate, the lesion proves to be irri- tative wholly in its character, it will be the most extensive and important of its class ever reported. When the microscopic work is finished, I will take pleasure in adding to this report such additional facts as may be thereby brought to light. " Yours very respectfully, Clark Gapen." In hystero-epilepsy the influence of nitrate of amyl in mitigating or temporarily postponing convulsions is incontestable, even although the progress of the disease may not be interfered with. Applications of ice, and especially pressure, should be made in the region of the ovaries, where we find almost invariably hyperaesthesia with semi- CHOREA. 449 anaesthesia on the opposite side. These appliances, if resorted to contemporaneously with the aura, prevent the fit, and if during the attack, they arrest it oftentimes. The close of the various steps and stages of hystero-epilepsy terminating in recovery may sometimes be very abrupt, even when the disease has lasted for years. These cases generally, although not always, occur in sensitive, self-willed, and parentally indulged girls, who have been subject, in early life, to convulsions. They prefer to any duties, solitude, secret reading, and reverie, taking little food and less sleep. We may have fever, inco- herence, convulsive crisis, somnambulism, and catalepsy and choreic movements, all making their appearance in this disease. Perfect recovery will follow wise treatment in the cases in which the element of hysteria predominates over that of epilepsy. CHAPTER XXIII. Chorea (St. Vitus's Dance). Chorea is a disease of the nervous system, of a convulsive nature, belonging principally to early life, and characterized by irregular and spasmodic movements of the voluntary muscles. These move- ments take place against the will of the patient, and are usually more marked on one side of the body than the other. They soon become general, however, and are increased by the patient's attempting to exercise his will or by emotional excitement. The disease generally begins very gradually, and is not noticed for some time. Chorea has a very intimate connection with acute rheumatism and cardiac disease, and many choreic patients will be found to present, upon examination, an irregular action of the heart, an anaemic murmur at the base of the heart, or evidence of endocarditis, pericarditis, or both. Rheumatism, therefore, and more especially rheumatism compli- cated with pericarditis or endocarditis, may be regarded as one of the prominent causes of chorea. Among other causes that may be men- tioned, sudden fright rannks foremost, while anxiety, overwork, and 29 450 PSYCHOLOGICAL MEDICINE. ill-health are also predisposing causes. There is also more or less paralysis in chorea, which is indicated by the loss of facial expression, loss of speech, loss of the power of swallowing, dragging of the limbs, inability to hold out the limb without its falling, the readiness with which patients become tired, and the soft, flaccid state of their mus- cles. Some degree of paralysis is, indeed, quite a marked feature in chorea. A child affected with chorea has a dull, listless expression, avoids associating with other children, does not evince the customary interest in his games and amusements, and becomes incapable of learning his lessons correctly or recollecting with any degree of ac- curacy. There is an apparent mental deficiency and there is more or less emotional disturbance, excessive timidity, capriciousness, and fretfulness. The child is restless and fidgety, and ungracefulness of movement becomes very conspicuous. He does not sit still long in one place, but is constantly changing his position. He stumbles in going about, up or downstairs, cannot hold or pass dishes at the table, and generally knocks whatever he holds against something else. The choreic movements usually begin on one side ; either the face or else one hand and arm are affected. These movements soon involve the whole of one side, and, after a few days or weeks, extend to the other side, involving the whole body. If the attack comes on during an attack of rheumatism, no prodromal symptoms may be seen, or if the attack is induced by a sudden emotion the onset is sudden. The convulsions are very peculiar, and affect to a greater or less extent the whole body, and are of a disorderly, not a rhythmical nature. They consist of sudden impulsive movements. They are clonic spasms, which are not stopped until sleep comes. The speech is usually thick and confused, but not lost. When the patient endeavors to answer questions the convulsive movements of his face and mouth become much worse, and he finds it very diffi- cult to articulate. The words come out with a peculiar drawl or stammer. The difficulty of speech may depend upon the respiratory muscles and larynx being affected as well as upon the convulsive action of the lips and tongue. As a result of the respiratory muscles being in- volved, the breath is often drawn through the larynx with a sudden- ness that produces a strange, grunting noise. The convulsive action of the muscles of the head and neck is as irregular as those of the face, so that the head is jerked from one side to the other. The con- vulsive movements of the upper extremity are more striking than CHOREA. 45 1 those of the lower. The shoulders are hitched, the arms are moved to and from the side, the forearm is pronated, supinated, and flexed, and all sorts of grotesque movements executed. It is very difficult for the patient to hold a glass or cup of liquid to the lips, and it is carried in all directions before it reaches its intended destination. The legs are affected like the arms, and as soon as the patient tries to use them their action becomes very jerky and uncontrollable. The body is twitched about very violently into odd and eccentric attitudes. In most of the cases the features, head, and neck are in continual motion. The body is doubled up and writhed around in strange contortions, and the patient's condition is very pitiable to see. The vacant, imbecile aspect of the patient increases as the disease continues, and depends very much upon the involvement of the mus- cles of expression. Functional or organic disease of the different organs of the body may supervene during an attack of chorea. The leapings and dancings of the religious enthusiasts, as the "jumpers" and the " convulsionnaires," should properly be classed in the cate- gory of choreic affections. The people who, in Scotland, were affected with the leaping ague and with convulsions and dancing fits also come under this head. Prognosis. — The prognosis is, in the majority of cases, favorable. Although chorea has a long average duration, it tends toward a natural recovery. The general length of time for an attack is from four to six weeks to three or four months. In a small minority of cases the disease lasts for many years, or even a lifetime. In the few fatal cases, the convulsive paroxysms become aggravated and the spasms are incessant. The patient dies of exhaustion. In the ma- jority of cases, recovery is thorough and complete if the patient is judiciously treated, and the child recovers his mental and physical health, although occasionally the implicated muscles remain feeble, and atrophy or contract. Pathology. — Several hypotheses respecting the morbid anatomy and pathology of chorea have been advanced by different observers of more or less ability. One, which originated with Dr. Kirkes, and has since been supported by Dr. Hughlings Jackson, adopts the theory of embolism. Dr. Kirkes did not indicate what part of the nervous system he considered to be the seat of the disease, but said that he considered chorea to be "the result of irritation produced' in the nerve-centres by fine molecular particles of fibrin, which are set free from an inflamed endocardium and washed by the blood into the 452 PSYCHOLOGICAL MEDICINE. cavities of these centres." Dr. Hughlings Jackson, adopting and enlarging on the theory of Dr. Kirkes, endeavors to show that the emboH are lodged in the vessels of the nerve-tissue forming the convolutions near the corpus striatum, the blood supply of which is derived from the middle cerebral artery, and that a condition of under nutrition is induced from a diminished supply of blood. Dr. Radcliffe accepts Dr. Hughlings Jackson's views so far as clinical evidence can be adduced, and says: "Taking chorea of one side of the body, hemichorea, as the simplest form of chorea, and putting it side by side with hemiplegia, the result of embolism, good reason is found for believing that the disorder of movement and the palsy both point to the region of the corpus striatum as the seat of mischief If this be the seat of mischief in hemiplegia, why not in hemichorea? The muscles moved in hemichorea are those most palsied in hemiplegia. In hemichorea, as in hemiplegia, the arm, as a rule, is more affected than the leg. In right hemichorea, as in right hemiplegia, the speech is generally very much affected. Again, hemichorea is always more or less mixed up with and sometimes ends in hemiplegia; and, on the other hand, hemiplegia, from various causes, is not infrequently attended by chorea or movements of some kind or another. The fact that the face is involved in chorea, shows that the seat of the disorder must be above the spinal cord. The facts which have been instanced, point to the convolutions near the corpus striatum rather than in any part of the brain as the part affected." Dr. Broadbent also accepts the theory of embolism of the fine vessels of the sensori-motor ganglia as the principal cause of chorea. It does not seem to me that the pathological facts which have been elicited by morbid anatomy justify the theory that chorea is produced by, or is dependent on, inflammatory processes in the brain or cord. Tremor, convulsion, and spasm do not necessarily depend upon inflammation, but may depend much more readily upon irritation, and this irritability may, I think, exist just as well in the thalami optici, corpora quadrigemina, pons varolii, or in the medulla or spinal cord, as in the corpora striata. The appearances in the nervous system after death, of embolism as a cause of chorea, and the morbid appearance being located in the sensori-motor gan- glia, are too few to support this theory successfully, and morbid appearances which are discovered do show that all parts of the nervous system may become affected in the course of chorea. The cord is- very often found affected, and particularly the posterior CHOREA. 453 columns, almost enough to suggest a relationship between this dis- ease and locomotor ataxia. Inflammation cannot be essential to chorea, for in some cases there are no traces of inflammation. Ner- vous shock is very often the real cause of chorea, and in these cases there would be no lesion whatever, unless it be said that the shock or violent emotion produces an asthenic or worn, irritable condition of the sensori-motor ganglia of the central nervous system. It has been suggested that the very great comparative frequency of chorea in childhood stands in some relation with the active func- tional state of the sensori-motor ganglia during this stage of exist- ence, this view perhaps explaining the rarity of this disease in infancy when these centres have not entered on active work, and also in adult life when their period of extraordinary activity has passed. The most reasonable theory regarding the production of chorea seems to the writer to be that it primarily proceeds from a morbid irritability of the nervous centres, and that in the subsequent course of the disease any or all parts of the nervous system may become involved in an inflammatory process, but not necessarily so. In many cases there is an inherited irritability of the nervous system, which is easily proved by inquiring into the family history of our patient. Dr. Radcliffe himself says, that in the more aggravated cases of chorea there is a tendency to run into one or other of the inflammatory diseases of the brain and spinal cord. The general unilateral ten- dency of chorea, which, so far as it goes, is acknowledged by the writer to point toward disease of the crus cerebri, corpus striatum, or cerebral hemisphere, is offset by the involvement of the muscles of the eyeballs and of the muscles supplied by the upper portions of the facial nerves, which, as a rule, are not involved in organic lesions of this part. The tendency of chorea to implicate the whole body, and the muscles of deglutition and respiration, is also adverse to this hypothesis, and, as I have said, the general resemblance in many points of the convulsive movements to those of locomotor ataxia point to a lesion in the posterior columns of the cord. The objection to this would be, however, that if the cord were affected, the disease would not manifest a unilateral tendency. Another very decided objection to the theory of embolism is the fact of the absence of the disordered movements during sleep. If embolism were present, owing to plugging up of minute cerebral arteries, the lesion would be a constant one, and if this were the cause of the convulsive movements, there could be no remission, neither could they abruptly cease, as 454 PSYCHOLOGICAL MEDICINE. I have seen them do under treatment. Another objection is, that chorea is much more frequent in girls than in boys, while rheuma- tism, which, by inducing vegetation upon the valves of the heart, is adduced to be the cause, is most frequent in males. Again, the embolic theory entirely fails to explain those cases which are due to fright or anxiety, where the heart is perfectly sound, and in my own practice, chorea has, so far as I have been able to trace the influ- ences that caused it, been very often due merely to nervous shocks, w^hich had set up the chorea by virtue of the sensorial and spinal irritability induced by the shock. I conclude, therefore, that in a great many, and I am inclined to think in the majority of cases, that chorea depends merely upon irritability of the hemispheres and cord, due, in very many cases, to debility or deficiency of nutritive vigor as the predisposing cause. The symptoms of chorea are undoubtedly connected with a morbid irritability of the cerebral convolutions, the ganglia at the base of the brain, the pons, the medulla, and the spinal cord. The disease itself is often associated with rheumatism and cardiac disease, but it depends upon hypersemia and morbid irritability of the nervous centres, which is produced by the rheumatic condition, or by mental or reflex ner- vous irritability or irritation. There is a general tendency to dilata- tion of the smaller vessels, and these arterial dilatations are attended with exudation into the tissues immediately surrounding them, and the sclerosis, which is thus induced in the tissues surrounding the vessels, explains the wasting of the muscles, rigidity of the limbs, and permanent paralysis when it supervenes upon chorea. Dr. Huntington, of Ohio, described, in 1872, an interesting form of hereditary chorea which has prevailed among a few families for a long time, through several generations, on the east end of Long Island. These families regard it with horror, rarely allude to it ex- cept by necessity, and then speak of it as ''that disorder^ Dr. Pom- eroy speaks of the disease as " attended generally by all the symptoms of common chorea, only in an aggravated degree, hardly ever mani- festing itself until adult or middle life, and then coming on gradually but surely, increasing by degrees, and often occupying years in its development, until the hapless sufferer is but a quivering wreck of his former self. It is as common, and is indeed, I believe, viore common, among men than women, while I am not aware that season or complexion has any influence in the matter. There are three marked peculiarities in this disease: 1st, its hereditary nature; 2d, CHOREA. 455 a tendency to insanity and suicide; 3d, its manifesting itself as a grave disease only in adult life. " 1st. Of its hereditary nature. When either or both of the parents have shown manifestations of the disease, and more especially when these manifestations have been of a serious nature, one or more of the offspring almost invariably suffer from the disease if they live to adult age. But if by chance these children go through life without it, the thread is broken, and the grandchildren and the great-grand- children of the original shakers may rest assured that they are free from the disease. This, you will perceive, differs from the general laws of so-called hereditary diseases, as, for instance, in phthisis or syphilis, when one generation may enjoy entire immunity from their dread ravages, and yet, in another, you find them cropping out in all their hideousness. Unstable and whimsical as the disease may be in other respects, in this it is firm; it never skips a generation to again manifest itself in another; once having yielded its claims, it never regains them. In all the families, or nearly all, in which the choreic taint exists, the nervous temperament greatly preponderates ; and in my grandfather's and father's experience, which, conjointly, cover a period of seventy-eight years, nervous excitement in a marked degree almost invariably attends upon every disease these people may suffer from, although they may not when in health be over- nervous. " 2d. The tendency to insanity, and sometimes that form of insanity which leads to suicide, is marked. I know of several instances of suicide of people suffering from this form of chorea, or who belonged to families in which the disease existed. As the disease progresses, the mind becomes more or less impaired, in many amounting to insanity; while, in others, mind and body both gradually fail until death relieves them of their sufferings. " 3. Its third peculiarity is its coming on, at least as a grave disease, only in adult life. I do not know of a single case that has shown any marked signs of chorea before the age of thirty or forty years,, while those who pass the fortieth year without symptoms of the dis- ease are seldom attacked. It begins as an ordinary chorea might begin, by the irregular and spasmodic action of certain muscles, as of the face and arms, etc. These movements gradually increase, when muscles hitherto unaffected take on the spasmodic action, until every muscle in the body becomes affected (excepting the involun- tary ones), and the poor patient presents a spectacle which is anything 456 PSYCHOLOGICAL MEDICINE. but pleasing to witness. I have never known a recovery, or even an amelioration of symptoms in this form of chorea; when once it be- gins it clings to the bitter end. No treatment seems to be of any avail." Dr. Huntingdon says that ordinary chorea is of exceedingly rare occurrence in this section, and he does not remember a single instance of its occurring in his father's practice. He suggests noth- ing as to its pathology. I have met with one instance of chorea minor in a father, son and grandson, but it acted very differently from the form described above. In the son and grandson it appeared in early life, and I do not see that it has ever assumed grave propor- tions in either, although the nervous system preponderates in all. Treatmoit. — There are few diseases of the nervous system so easy to treat successfully as chorea in its ordinary form, and few in which so many remedies have been employed. Dr. Sydenham says, " For- asmuch as this disease seems to me to proceed from some humor rushing in upon the nerves, which provokes such preternatural mo- tions, I think the curative indications are first to be directed to the lessening of those humors by bleeding and purging, and then to the strengthening the genus nervosum, in order to which I use this method : I take seven ounces of blood from the arm, more or less, according to the age of the patient," etc., etc. This old treatment has been abandoned, although Sir Thomas Watson recommends local bleeding when there is a fixed pain in the head, and he also uses iron which is the favorite medicine in cases of chorea, with English prac- titioners and Dr. Elliotson especially ; forty cases of cure being re- ported by this mode of treatment. It has appeared to me that the good accruing from the use of iron is that obtained from improving the general health of the patient, and in this way, as iron is an important tonic, it undoubtedly does good, although I do not think it should be regarded as exerting any specific action in chorea; sulphate of zinc in increasing doses, com- mencing with one grain three times a day has been employed. Strychnia has been employed, especially in France, where it was in- troduced as a remedy for chorea by Trousseau, who commenced with doses of 2V in children, gradually increasing it until the full physiologi- cal effects of strychnia were produced, maintaining them for awhile. The iodide and bromide of potassium have also been used, but with- out practical results. The various narcotics have been tried, with ho good results. In my own treatment of these cases I endeavor to give the nervous system rest and nutrition. I obtain the former by CHOREA, 457 avoidance of excitement, early hours, and the calmative influence of warm baths at bed-time ; the latter by using phosphorated cod-liver oil, or the oil in connection with the phosphide of zinc, tV grain, in pill three times a day. Gentle gymnastic exercises are very valuable, and should by no means be neglected. My favorite remedy, and the one which seems to be the nearest to a specific in chorea is arsenic, which I use hypodermically in the shape of Fowler's solution. I use a mixture of equal parts of Fowler's solution and water, to avoid any local irritation which might be produced by the undiluted solu- tion. In children I rarely see any want of toleration of the drug in the system, and rarely also, in those of older years. I have found that very rapid improvement generally takes place under this treat- ment from the first, and my patients gain flesh. I generally use electricity in the form specially indicated in individual cases as an im- portant adjuvant in improving the whole nervous and physical con- dition of my patients. I commence with three minims of Fowler's solution and inject, subcutaneously, for a week, every other day, and in the second week increase the dose to five minims every other day, increasing two minims each week, and in a month or six weeks a cure will be obtained, while in old cases sixty or seventy days may elapse before a cure is complete. Marked improvement is always noticed from the first by this plan of treatment. By this method the gastric disturbances which are produced when the medicine is given by the stomach are avoided, and the good re- sults which we can obtain are very much more rapid. I advise this plan of treatment in chorea by general practitioners, believing that they will find it, as I have, most efficacious. In 1849 there was reported in the London Medical Gazette, of April 27th, the second Lumleian lecture, by Dr. R. B. Todd, of England, on chorea. Many of the remarks there found are equally sound to- day. He remarks that the most common exciting cause of chorea is fright or strong mental emotion. He cites a case of one of his patients, a girl, nineteen years of age, who was rudely accosted and laid hold of in the street by a person under the garb of a gentleman, and she became greatly alarmed and escaped to the house of a rela- tion. Next morning the symptoms of chorea showed themselves. In this lecture Dr. Todd drew the following conclusions respecting the pathology, and considering how long ago this was, we must ad- mit that they were peculiarly good and correct : 458 PSYCHOLOGICAL MEDICINE. 1. That chorea is a disease occurring at a time when the nutrition of the brain is passing, as it were, through a state of transition, from that of infancy or verj' early childhood, to that of the adult period, when that organ is peculiarly prone to suffer from mental shock, or other causes of disturbance of the system, and more especially when the blood is in an unhealthy state, deficient in some of its staminal principles, or con- taining some morbid element. 2. That the part of the brain mainly affected is the centre of emotion, but that the extent to which it suffers is sometimes limited to one side of that centre, sometimes to both, again extending to the cerebellum or to the corpora striata or optic thalami. 3. That the nature of the cerebral affection is one of weakened nutrition, with some degree of irritation; as poor blood, rendered perhaps impure by the presence of the matter of scrofula, or of rheumatism, or by some morbid matter peculiar to chorea, ex- cites the nervous battery, and causes it to generate its force feebly and irregularly. The centre of emotion thus feebly excited, and irritated by the presence of an abnormal ingre- dient in the blood, extends its feeble and irregular polarity to that portion of the centre of implantation of the nerves which, as the polar slate of the conductors of the battery is regulated by that of the battery itself, exhibit the same enfeebled polarity as the centre in which they are implanted. Lastly. The disease is one of depraved general nutrition, which must be set right before these symptoms which arise out of the local disturbances can be removed ; and this is the point of practical interest which must regulate our treatment of the disease. These conclusions, respecting the pathology of chorea, receive confirmation from the facts to which I have already alluded — namely, that choreic movements occur in certain gouty states, and also in white softening of the brain arising from diseased arteries. Under both these conditions the nutrition of the brain, as well as that of the nerve and muscles, must be depraved and weakened ; depraved, especially in the former instance, by the matter or poison of gout; weakened in both. Dr. Todd speaks of the treatment as one which should be ehmi- natory and corrective of the various secretions, and at the same time tonic and bracing to the nervous system, by the free application of cold water to the surface, by a nourishing diet, and by chalybeates, quinine, and other metallic tonics. He also recommended galvanism. On the treatment of chorea Dr. Samuel Wilks, physician to Guy's Hospital, says : It might be thought bj' the inexperienced that those drugs which exert a physiologi- cal action over the nervous system would be those which would arrest the complaint known as chorea, but, as a matter of fact, this is not the case, so that I have almost given up looking for a remedy in the direction of this class of medicines. I do not despair, however, of finding some drug which might counteract that morbid condi- tion of nervous system which is present in very bad cases, but in the absence of such remedy our ordinary curative means are of little avail, seeing that they can act only slowly and tend to produce a change long after the time at which the acute form of the disease would prove fatal. In these very severe and bad cases we can only hope to preserve the life of the patient sufficiently long for the most approved tonic remedies to act. For example, in such cases as I mentioned just now of children suffering from acute chorea induced by fright, a fatal termination may occur in a few days, and in these CHOREA. 459 the direct sedatives are suggested. Morphia, as far as I have seen, is useless. I can call to mind two cases vi'here large doses were given, but the effect was only transitory. The same with chloroform ; the vapor produces but a temporary tranquillizing effect, and our experience of it is not encouraging either in chorea or in the allied disorders, tetanus and hydrophobia. I have never seen strychnia of any use in the acute affection ; and the same of belladonna and conia. In the less severe cases it is possible that one or two of these medicines may be useful, but I feel convinced that the class of medicines of which I speak — those which have a physiological action on the nervous system — are far less efficacious than the metallic tonics. It would seem that in order to produce a cure, a bracing up or restoration of the original nerve-power is necessary, and that the mere sub- dual of symptoms in no way tends to cure the complaint. When I say this I speak with some little hesitation of the effects of belladonna and conium, both of which remedies I have seen apparently useful. I remember, when at Paris some years ago, hearing Trous- seau give a lecture on this disease and warmly recommend belladonna. On another occa- sion he was declaring that there was no drug in the Pharmacopoeia equal to strong coffee, and on a third occasion he was vaunting the new gymnasium at the Hospital for Sick Children as the best therapeutic agent he knew. I mention this to show you that there really is no specific treatment for the disease. I might say that we thought we saw some benefit in one case after the use of cannabis indica, but none whatever in four cases in which we tried the physostigma. I believe I can tell you something very positive about the treatment of chorea, and I only wish I was enabled to make the same boast in reference to some other diseases. Many years ago, seeing that every medicine in the Pharmacopoeia as well as several others out of it, were said to be equal to the cure of chorea, I determined to watch the disease untrammelled by medicine, and I found that in many cases a speedy recovery took place without the administration of any medicine whatever. The cases which did best were the severe ones, excepting always those w^.icli were of the most violent and acute de- scription. The first case which I watched was a little girl who had severe chorea ; she was too bad to be able to stand, and was obliged to have sideboards to her bed to pre- vent her wriggling out of it. This child began to improve in a day or two, and went out well in a month. This is only one example of several of the same kind. I take it that the patient, being subject to constant excitement or improper treatment at her own home, has her disease there perpetuated, whereas, when brought to the hospital, being under the influence of strangers who endeavor to make her suppress the movements, and by the additional advantage of good living, she begins to recover. I should say that a weakened condition of the nervous centres being at the root of the malady, good nourishment and the tonic plan are necessary. After having learned the fact that the tendency of the disease is towards recovery as soon as all the circumstances which for- merly surrounded the patient were removed, I soon afterwards learned that the cure is expedited by tonic medicines of the mineral kind, and this is the experience of the ma- jority of the profession. I have put the treatment before you in this way to prevent you supposing that such remedies as iron or zinc act in any specific manner; they are useful, but operate as nervine tonics. I believe Dr. Elliotson, many years ago, acquired great fame by his success in the treatment of chorea, his remedy, as you know, being the red oxide of iron. We still give it, and it is one of the best of remedies ; our children very willingly take half-drachm doses in treacle. Probably an equally favorite remedy here is the zinc — in fact, it is the medicine most commonly given, beginning with grain doses and increasing to any amount, as a scruple three times daily. A favorite remedy of my late colleague Dr. Hughes was rhubarb steeped in port wine ; the children were 460 PSYCHOLOGICAL MEDICINE. thus well kept up at the same time that the stomach and bowels were improved in con- dition. In very chronic cases, and those where a part of the body only is affected, medicines are of little use. In some of these electricity has sometimes been curative ; in some cases shower-baths have acted with the best success. One writer has advocated the use of liniments, as of chloroform, to the spine. Often nothing less than a thorough change of scene will suffice to break the habit. If this opportunity do not occur, gymnastic ex- ercises are of use. They not only strengthen the muscles and nerves, but thej' break tlie bad habit; they convert, in fact, an irregular movement into a regular one. If the arms are constantly moving, and are then employed in grasping a beam for swinging, a new and altered condition of the whole machineiy accrues, and in time the habitual ir- regular actions are worn out. I am sorry that we have not a gymnasium here, and therefore, all I am able to do is to order my patients a skipping rope. I believe the only method by which chorea, which at one time prevailed in religious houses, was sometimes able to be cured was by making the ladies dance to the notes of music. On the use of Indian hemp in chorea, Dr. Douglas, Vice-Presi- dent of the Medico-Chirurgical Society of Edinburgh, says : Dr. Russell Reynolds, who writes one of the most recent, and one of the best exposi- tions of the value of this remedy, tells us, as the result of a manifestly practical and thoughtful experience, that " it is a soporific, anodyne, and antispasmodic ; and that it re- lieves pain and spasm ; that it does nc^t leave behind it headache or vertigo ; nor does it impair the appetite, nor confine the bowels." [The patient, a girl 13 years of age, was admitted into the Chalmers Hospital on the 15th of October last. A month previous to admission she had been taken with an attack of rheumatic fever. No sjonptoms of cardiac inflammation occurred. The choreal ac- tion had existed about a fortnight.] During the day immediately succeeding her admission, a rapid change occuiTed in the degree of the choreal movements, and in the state of the heart's action. The latter be- came so disturbed, feeble, and excited, with feeble arterial pulse, as to cause serious anx- iety' for the safety of the patient, and at the same time the choreic agitation increased with such violent restlessness and rolling in bed that excoriations occurred over the sacrum and both nates, while contortion of the features and tossing of the extremities, especially when their movement was attempted, continued excessive. The articular effects of rheumatism decreased, temperature became more natural, the urine healthy, but the bowels became torpid. The arsenic was persevered with, and a few 30-grain doses of bromide of potassium were given. Each dose was followed by a short period of qui- escence, but, on the 20th, the excitement of the heart's action became so alarming that 25-minim doses of tincture of India hemp were administered, followed by apparently marked but only transient abatement of the spasmodic movement, which, as Dr. Hogg, the resident physician, reported, seemed to recur subsequently with increasing and dis- tressing severity. On the following day — that is, the sixth of her residence in the hospital — her condi- tion seemed desperate, chiefly on account of the protracted and uncontrollable hurry of the heart's action. She was ordered to have six minims of the tincture cannabis every hour, the arsenic and other remedies being intermitted. The bowels were now well reg- ulated, the excoriations of the back and nates had increased so as to form superficial sloughs of considerable extent, the pulse was small and so rapid as not to be counted, and the heart's action was still feeble, rapid and disturbed. She had four ounces of CHOREA, 461 brandy per day. On the following day, having had twenty doses of the tincture, there was a marked and increasing improvement. The violence of the tossing and rolling had diminished materially, though still it was necessary to have her secured in bed to prevent her falling or rolling over. From this time till the 15th day of her residence in the hos- pital, the tincture was administered from hour to hour, and she continued to make daily and progressive improvement. At that date (the 28th) she had been free of all the more violent spasmodic movements for two days ; the heart's action was quiet, pulse about 80, appetite good, bowels regular. She still presented a degree of the peculiar grimace, with awkvvrardness in protruding the tongue, and in movement of the arms and hands. There was a great mental lethargy, with languor and exhaustion, which made it impossible for her to be out of bed. The tincture of hemp was now discontinued and arsenical solution in four-minim doses resumed. The subsequent progress of the case, though tedious, and so far disappointing, may be told in a few sentences. On the 1st of November, and on several occasions during the rest of that month, there occurred a renewal of the choreal state, which had not, indeed, absolutely disappeared, though it was often so trivial, and even absent, as to encourage the hope of an early recovery. Arsenic was perseveringly employed, with a carefully-reg- ulated diet and general management, but on each occasion, of which three were noted, when an exacerbation of the choreic condition arose, a marked abatement of the muscu- lar action resulted from the administration of small and hourly-repeated doses of tincture of hemp, relief sometimes arising so speedily as within six or eight hours. On one occa- sion the improvement was not detected for three or four days. In the beginning of December, rheumatic symptoms recurred, with slight febrile action and articular pains, and renewal of choreic agitation. At the same time, marked excite- ment of the heart's action was renewed, and now, for the first time, a faint, soft diastolic murmur, indicative of aortic regurgitation, was with difficulty perceived. A weak solu- tion of acetate and nitrate of potash was administered, and grain doses of opium four or five times in twenty-four hours. Pain and fever abated, but not the spasmodic move- ment, and on the third day afterwards six-minim doses of tincture of hemp were given every two hours, followed by an immediate decrease of the chorea, which at once de- clined to the slightest degree in two or three days. The patient now presented more marked indications of returning health. The state of mental lethargy into which she had early lapsed was now passing off; her appetite was revived, and on the 20th December she was able to be out of bed and to walk with assis- tance. Small doses of the iodide of potassium with the infusion of quassia were given, and improvement went on uninterruptedly ; she did not, however, cast off the choreic jerk and awkwardness till the second week of January, 1869. She has since had a very comfortable convalescence, but the diastolic murmur noted above continues strongly developed. The impression which the case leaves on my mind is, that cannabis has a peculiar value and power in controlling the irregular movements of chorea, which ever and again are terribly distressing, and possibly even dangerous, to the patient ; and it would be of no small moment to determine the extent and limit of its influence, and to ascertain whether dr not choreic action, even in slighter cases, might not be moderated by this remedy. As to the mode of administering the remedy, small and frequent doses proved both safe and effective, and great advantage appeared to arise from increasing the frequency of the dose rather than its amount. Believing, as I do, that cannabis indica is a remedial agent of value in many and various maladies, I am prepared to recommend this mode of seeking its eifects by frequent rather than by larger doses at longer intervals. Such a 462 PSYCHOLOGICAL MEDICINE. mode of prescribing it has not been usual ; but I find, quoted from an American source, the account of a case of hiccup treated in this way by eight-drop doses of a fluid extract, administered hour by hour, in which recovery from an attack that had defied treatment for five days took place in a few hours. CHAPTER XXIV. VERTIGO. Vertigo consists in the sensation of giddiness or moving, or the appearance of moving, of external objects when there is no real ex- istence of movement. The patient is very much distressed by a sense of a want of equi- librium, of falling or turning round, and the things which are about him appear to swim and oscillate before his vision. The condition varies from a slight sense of unsteadiness or oscillation to such a de- gree of vertigo as altogether destroys equilibrium, and the patient falls to the ground unless he takes hold of something to prevent him from falling. This sensation is the most powerful when the patient is standing up, but may come on while he is lying down, and even when the eyes are shut. Patients suffering from vertigo complain of tinnitus aurium (various kinds of noises), which, although nearly always present until recovery, is more pronounced during the attacks of vertigo. The cause of vertigo is primarily a disordered and dis- turbed circulation in the brain, which is proved by the fact that it attends both cerebral ansemia and cerebral hyperemia. It is very often dependent upon a disordered state of the blood itself, as in fever and in various inflammatory diseases. It may also appear as the result of blood-poisoning, from malarial poisoning, and the injurious effects of tobacco and intoxication. It may be associated with — and generally is connected with — epilepsy, convulsions, and organic lesion in the body. It is very often dependent upon functional dis- orders of the stomach. It attends disease of the cerebellum and of the cerebro-spinal system. Diseases of the eye and ear are also attended very^ frequently with vertigo. The vertigo appears in the affections of the eye, when its muscles are involved, and especially VERTIGO. 463 in afifections of the ear, when there is disease of the semicircular canals. In disseminated sclerosis the vertigo is an early symptom, and is gyratory, and comes on in paroxysms, and is occasionally almost continuous. The differential diagnosis between ordinary vertigo dependent upon simple disordered circulation of the brain or functional disorders of the stomach and the vertigo of disseminated sclerosis would be that in the latter case our patient would present rhythmical tremors, affections of the eyes, defect of speech, and an early paresis of the limbs. Contraction of the limbs and changes in the mental condi- tion and expression also are seen in sclerosis. In tumors of the brain vertigo is one of the most constant symptoms, and it is associated with headache and vomiting. In order to understand the cause of vertigo in any given case, we must carefully study the accompanying symptoms. The suppression of either a haemorrhage of long stand- ing or of a chronic skin disease are both common causes of vertigo. Vertigo, then, may depend on functional disorders of the viscera, or upon organic or functional brain disease, or blood-poisoning, or it may depend upon a weak heart with a dilated right ventricle. The most common kind of vertigo which we meet with in practice arises from disordered digestion, and can be referred to the stomach, or functional derangement of the liver, or may occur suddenly, either at day or night, and is very distressing to the patient from its violence. This variety depends upon a sudden arrest of the process of di- gestion, which produces a temporary functional disturbance of the brain and its circulation. The utmost that any of my patients have ever complained of has been a mere uneasiness over the epigastric region. They have denied the presence of pain after food has been taken into the stomach. In women, we often find associated with this form of vertigo, leucorrhoea, menorrhagia, obstinate constipa- tion, and amenorrhoea, and the fact that after these diseases are re- lieved the vertigo remains proves the stomachal orgin of it. In this form of vertigo we never find a loss of consciousness, as we may when it depends on organic brain lesions. The patient sometimes is perfectly free from it ; an empty stomach and excitement make it worse. Stimulants relieve it, and closing the eye so as to shut out all external objects relieves it. Although a few patients complain of a constant slight sense of vertigo, most of them will give a his- tory of several successive daily attacks, lasting generally a few min- 464 PSYCHOLOGICAL MEDICINE. utes, accompanied by a distressing heaviness in the head. In hard drinkers, we often find the vertigo may last for days, and render them unable to move. The disease depends, in these cases, upon struc- tural alteration of the capillaries, and the symptoms present are nau- sea and aversion to food. This form of vertigo of which we have been speaking — that arising from disordered digestion — may be effectually relieved by the following treatment : The patient, if a man, must be free from the care and anxiety of business. Upon arising in the morning, a cold sponge or plunge bath, with subse- quent friction on the surface of the body with a Turkish towel. No malt liquor must be indulged in. The diet must be plain, regular, and well masticated. Vichy, with a very little brandy, may be used as a drink. The patient must retire early, and sleep in a large, cool room. The following may be taken before meals : R.— Pulv. rhei, . . . . . . . ^ . . 5J. Sodse carbonat., . . . gij. Pulv. gentian, . . . . . . . . . • ^^• Aquae menth. pip., Aquae dest., . . . • aa 3iij. M. S. — Tablespoonful thrice daily before meals. Or, five drops of the tincture of nux vomica, a remedy which is an efficient tonic to the whole gastro-intestinal tract, may be given in a little water before each meal. In some cases, an examination of the urine microscopically will reveal oxalate of lime, which produces oxaluria, and may give rise to vertigo. This can be readily relieved by fifteen drops of dilute nitro-muriatic acid, given in water thrice daily before meals. In individual cases with individual complica- tions, relieve these first and improve the general nutrition, and then direct the treatment directly to the vertigo. A great many cases of vertigo depend for their cause upon drink and mental anxiety. These attacks are of comparatively short dura- tion, and occur every few hours or days. At first the sensations are referred to external objects, and occur only when the patient is mov- ing. As it becomes more frequent, there is an internal feeling of dizziness, which lying down generally relieves. In the male, it is associated with stomach disorders, and in females, with menstrual disorders. The principal symptoms are want of clearness of intel- lect, incapability of sustained mental effort, with headache. There may be, in cases where oxaluria is present, great irritability of tem- per, depression of spirits, sleeplessness, and impaired nutrition. VERTIGO. 465 A great many cases of vertigo are connected with lithaemia, and Dr. Da Costa, of Philadelphia, in his able monograph on The Nerv- ous Symptoms of Lithcemiay ranks it as one of the principal nervous symptoms of that state which is characterized by the abundance of lithic acid or lithates in the urine. These attacks of vertigo may be violent, and repeated often, perhaps twice or more in the twenty-four hours. Confusion of mind and failure of memory are apt to co-. exist with the vertigo. Also shooting pains in the limbs and joints. In this vertigo of lithaemia, " objects seem to whirl around the suf- ferer." The special senses, when the vertigo is frequently repeated, also suffer, and there is apt to be much neuralgia, affecting the bra- chial, intercostal, and sciatic nerves; and also gastralgia, sleeplessness, languor and lassitude, depression of spirits, and great irritability of temper characterizes these cases. To cure this form of vertigo, we must cure the lithaemia, which is the cause of it, by a strict diet, eliminating all but the white meats and poultry, making the patient rest from work, exercise freely in the open air; use alkaline purgative waters — Poland water, which neutralizes the uric acid by its alkalinity, and acts freely as a diuretic, as does also the Saratoga Vichy — and citrate of lithia as a medi- cine, with a course of small doses of arsenic. If such patients are sent where they can live in clear bracing mountain air for a few months, taking exercise, they will make a good recovery and the vertigo will disappear. Vertigo may be associated with brain disease, and the movements may be gyratory, or a falling backward or forward. Vertigo accom- panies nearly all of the organic lesions of the brain, and nearly all of the acute inflammatory affections of it. In the treatment of ver- tigo from overwork and anxiety, rest, and freedom from all care and work is an essential part of our treatment. If oxaluria is suspected, as I have said, the administration of fifteen drops of the dilute nitro- muriatic acid before each meal will generally effectually remove it, and the bromide of ammonium may be advantageously administered. The treatment of vertigo, complicated with brain troubles, must be guided by the particular group of symptoms which present them- selves in any given case. The application of the galvanic current of electricity in all forms of vertigo will be found to be of great service as central galvanization, or by the application of both poles on each side of the sixth and seventh cervical vertebrae, using from twelve to twenty cells, as the case may be. 30 466 PSYCHOLOGICAL MEDICINE. CHAPTER XXV. STATES OF UNCONSCIOUSNESS — SOMNAMBULISM — CATALEPSY, ETC. There is great interest and importance attaching to this subject, but we are accustomed to very vague and undefined ideas respecting it. My effort in this chapter, aside from treating of the diseases of somnambuhsm and catalepsy, will be to contribute, in however slight a degree, to the knowledge of the more exact relations of the human mind and of human acts to responsibility. We have been accustomed to regard the partial interference with sensibility and mobility, and the resulting limitation of will in trance, trance-coma, somnambulism, catalepsy, and epilepsy, as curious physiological states rather than as diseased states of the nervous system requiring medical treatment, and also seriously affecting mental and legal responsibility. It is only in the most perfectly- balanced minds, where there is an accurate balance between the sub- jective and the objective faculties, that consciousness is never im- paired, and where there are no breaks in the continuity of perception and memory, during which time the connection of the individual with the thing done or said is no longer reliable or distinct. Even in men of the strongest mental calibre such obliviousness sometimes occurs. In whatever these intercurrent spaces of non-existence may have originated, whether from unfettered determination, or the idle Avandering imagination, or from the brain-wasting following moral or intellectual hard work, it is certain that occasionally they pass be- yond the power and in defiance of the will, and should be classed under the head of morbid nervous affections, if not with actual men- tal disorder.* Men of lofty intellect and vigorous and acute minds, by excessive and continuous application, overtaxing their attention and introspection, and confining the exercise of their intellect and memory within a narrow range, weaken their observant powers, and by concentrating their minds upon particular objects, produce, often- times, grave disorders of the nervous system. Sir Joshua Reynolds and Sir Isaac Newton are prominent examples of attention so long fixed and contemplation so intense as to render them entirely oblivi- ous to self and surroundings and to disturbances in perception. * This was clearly laid down in the London Journal of Psychological Medicine by Dr. Forbes Winslow some years ago. STATES OF UNCONSCIOUSNESS SOMNAMBULISM — CATALEPSY, ETC. 467 After Sir Joshua Reynolds had been for hours occupied in painting and walked out into the street, the lamp-posts seemed to him to be trees, and the men and women moving shrubs. He had fixed his attention for such a length of time on the picture before him that he could not direct it to other objects of sensation. A very remarkable instance of forgetfulness and absence of mind occurs in the biography of Hookham Frere, the scholar and man of letters, who, handing the Countess of Errol to supper, drank the negus he had prepared for her, and altogether forgot the object of their visit to the dining-room ; and who, on the day of his marriage with the same lady, had no recollection, until the evening, that he had promised to accompanj^ his bride to the country, having occu- pied the intervening time in reading his poem to his publishers. It is a psychological fact, that after the attention has been for a great while intensely fixed upon particular objects, the person cannot di- rect it at will to other objects of sensation. Any occupation or ex- ercise which narrows the scope of intellectual exercise, which nulli- fies the influence of the emotions or contracts the mental forces, is directly prejudicial to mental health, by giving undue prominence to certain faculties and allowing others to fall into disuse and apathy, overstimulating some regions of the brain and probably producing undue or defective nutrition in certain parts of the brain. It is the peculiarity of all these states, when they are not merely temporary effects of overwork, that they essentially consist in such consequen- ces of bodily or mental degeneration as, robbing the thinking part of our nature of its nobler endowments, leave it in the impoverish- ment of an appetite, a peculiarity, or a single all-embracing thought. The morbid element consists chiefly in fixedness — in the inability of the will to substitute another train of reflection or perception. The will, though feeble and fickle, is not entirely extinct, as it serves to guide in the direction of the predominating, if not constantly per- manent, notion or incentive. It seems to me that we must class such states in the same category as the preoccupation of the insane, whose disordered imaginations can admit of nothing but the present ruling impulse, and with the absorbing and exclusive anguish of the melan- choliac. In all these cases there exists, in different degrees, a sus- pension of consciousness. These spaces of non-existence are on the border line which divides sanity from insanity. The morbid states of the brain which may be induced are exemplified in a marked degree in the lives of ascetics and ecstatics, and in those 468 PSYCHOLOGICAL MEDICINE. whose intense devotional feelings, as in the convulsionaries and Brahmins, extend, for the time, to enfeeblement of volition and to diseased functions of motivity and sensibility, manifested in violent convulsions and complete loss of sensation. In somnambulism, the first of the morbid states which I propose to consider, we have, as the constant and unvarying state, a morbidly profound sleep, in which " the sceptre of reason is surrendered to a physically directed fancy." It is due, probably, either to an over- loaded stomach pressing on the solar plexus of nerves, producing a partial paralysis in the coats of the arteries, and so in the circulation of the brain ; sleeping with the head too low, and strong mental emotion. It is a peculiarity of somnambulism that even after the removal of the cause, the habit, once established, is apt to remain. It is most frequent in youth, and about the age of puberty. In the states of unconsciousness accompanying somnambulism, the senses are awake and preternaturally alive. The muscles are regulated, and regulated, too, with wonderful precision and power. There is a purpose, and there is a coordination of acts for its accomplishment ; but conscious- ness is still asleep, and memory retains no record of the transaction, although it may have been prejudicial in the highest degree to the interest of the actor or of others. In many states of unconscious- ness the mind is forced to think or feel in a particular way, and is forced to instigate certain deeds in flagrant opposition to its ordi- nary character and tendencies, and in utter disregard of the prompt- ings, or of the resistance of other motives and considerations. There is a very close relation between acts committed during states of un- consciousness and mania transitoria, epileptic paroxysms, and the ir- resistible impulses of insanity. They have, in common, irresisti- bility, suddenness and rapidity. They are alike unannounced and of short duration. They are alike characterized by the exercise of free-will being fettered or perverted, and there are, undoubtedly, dis- tinct morbid conditions in all of these different states. If we exam- ined with sufficient care, cases in which unconsciousness occur, I feel quite sure we should discover the prodromic signs which have been observed to usher in other species of the neuroses. Somnambulism may be hereditary, but it is not inconsistent with fair health. It is apt to become periodical, patients having attacks once a week, fort- night or month. The treatment of somnambulism consists in preventing the very deep sleep, in which the phenomena of somnambulism are exhibited. STATES OF UNCONSCIOUSNESS — SOMNAMBULISM CATALEPSY, ETC. 469 The patient should be awakened one or twice a night before the phenomena begin to appear ; soon after retiring and again after four or five hours sleep, will usually answer. Patients should dine in the middle of the day, and while taking care that all meals should be light and digestible, we should be particularly careful not to over- load the stomach at night. The use of electricity and nerve tonics to bring up the general health to the highest point are indicated. Friends should be cautioned not to awaken the patient while walk- ing, as the fright may act prejudicially. He should be quietly put back to bed. The head should be well propped up by pillows, and too great a weight of clothes must be avoided. Catalepsy. — I find an excellent definition of catalepsy in Dr. Boer- haave's aphorisms, published in 1755. He graphically describes it as "that disease in which the patient becomes of a sudden unmoved, void of feeling, and retains the same posture and action of all the parts of his body which it was in when the disease seized him first." It is a disease of central innervation of the nervous system, and may be ac- companied by or accompany many forms of insanity. In a cataleptic paroxysm, the state of unconsciousness is characterized by the limbs of a patient remaining in the position in which the patient had placed them before the inception of the paroxysm, or in which any by- stander may place them during the paroxysm. Consciousness and sensibility are entirely suspended. Catalepsy may accompany in- sanity and chorea, and many of the neuroses. If death is simulated, the existence of muscular contractility under the Faradic current, and also the dark eschar of the cautery, are tests which may be ap- plied to determine life. The patient's will is powerless to act dur- ing the paroxysm, by reason of the muscular contraction induced by excitement of the motor nerves, proceeding from the spinal cord. The paroxysm is preceded by dizziness, headache and a very irrita- ble state of the general nervous system, and begins very suddenly. There is apt to be a vague uneasiness and sleeplessness. A pa- tient of mine presented the following typical symptoms and manifes- tations of a cataleptic attack in my presence. The lady in question, who was from North Carolina, while in the act of conveying a morsel of food to her mouth, became suddenly rigid and pale, the arm being arrested in its passage and being immovably fixed, with the fork in the hand a few inches from the mouth. The whole body was as mo- tionless as if the patient were carved out of stone. The eyes pre- sented a widely opened, staring condition, and consciousness and 470 PSYCHOLOGICAL MEDICINE. sensibility were entirely suspended. Respiration could not be de- tected and the pulse-wave could not be felt at all. In about four minutes the patient sighed deeply, made a full inspiration, and re- sumed her meal, quite unaware of what had happened to her. The cataleptic trance may last for some hours possibly, and in extreme cases may last for days. Patients remember nothing of an attack or what transpires during the trance-like state. Catalepsy, although not necessarily connected with insanity, is, I think, very often dependent upon an insane temperament or neurosis. It has been stated that catalepsy is generally a complication of hys- teria, but the results of one hundred and forty-eight cases collected by Dr. Fuel, in which sixty-eight occurred in males, would seem to disprove the assertion. An interesting case of this rare disease was reported by Dr. S. S. Cornell, of Toledo, Ont., not long ago. The catalepsy came on after the second confinement, before which the patient was very nervous. After the confinement there was a chill followed by sharp febrile action, with pain and tenderness over the re- gion of the uterus. There was some delirium and suppression of lo- chia. This condition, however, disappeared, but was followed by a cataleptic, state, which I give in the Dr.'s own language : " Now comes the sequel. The patient passed the next forty-eight hours most beautifully, except on the night of the 30th she could not sleep ; otherwise the nurse thought she was doing extremely well. A pecu- liar change was soon discovered taking place with the patient ; her acuteness of hearing was extremely great ; could hear and reiterate the sentiments of persons in the adjoining room, who conversed, as they declared to me, in a low whisper, and that they conceived it impossible for a person to hear a word whispered six feet from them ; yet this patient at a distance of twenty feet or more, with closed doors, could tell the sentiments exchanged. This was done several times, and finally the patient called her husband to her, kissed him ; then called her little boy three years old, and her infant, kissed them and then bade her friends adieu. This procedure of my patient awoke a deep interest in the minds of the nurse and friends, who now be- came alarmed. The nurse persuaded the friends to leave the room to her and the patient, as she thought after a little, Mrs. H. would fall into a repose ; but instead of sleep, our patient lay speechless and motionless, with eyes staring wide open, no signs of respiration ; they opened her mouth to see if she would swallow, but in vain ; her lower jaw remained depressed as the nurse had left it. Attempts STATES OF UNCONSCIOUSNESS — SOMNAMBULISM — CATALEPSY, ETC. 4/1 were now made to rouse her by calling loudly in her ear, but to which she paid no attention. They thought her dead, and that it was useless to send for medical aid ; thus passed away twelve hours, when her husband dispatched a messenger for me. When I arrived and entered the room, I was shocked to see what struck my fancy to be a waxen figure or a frozen corpse in lieu of my former patient. There she lay with under jaw depressed, eyes staring and wide open, without winking, the pupils a little dilated, skin cool, almost the feel of a corpse before stiffening, pulse 122, feeble, no sign of respiration. In examining the pulse I raised the arm to see if that would cause any difference in the pulse. There it remained for nearly an hour, when I put it down by her side. There was but little resistance offered to any change of her limbs or person ; but whatever attitude a limb was placed in, there it remained. I now brought her under jaw up to its place and it remained. I was importuned to do something for the patient. What to do was with me a paramount question. The thought occurred to me that I might administer an enema of strong solution of assafoetida, which I did to the amount of a quart ; and this was very easily done as there was not the slightest resistance. Still the patient lay as lifeless as ever for about an hour, when a few slight convulsive movements were observed, and she roused to consciousness. She looked about her, asked what had been done with her corpse, as it appeared to her that her friends desired her to remain for a season, but her judgment dictated to her to again depart and take her infant with her. I gave her several doses of assafoetida, fluid extract of valerian, beef tea, etc. She now desired to be left alone, as she said she had an important duty to perform, and the presence of persons, however nearly related, was detrimen- tal to her welfare. She was satisfied for me to remain with her alone, as she said, " from the days of antiquity, deference had always been paid first to the priest and then to the doctor." She remained quiet for, in all, a period of six hours, taking beef tea, valerianate of am- monia, assafoetida and bromide of potassium. Soon she drew the sheet over her face, and then placed her arms over her chest and lay straight in bed ; she lay so quiet and still that I felt induced to re- move the sheet, when, as I had feared, I found her in a second trance (?). Eyes wide open, pupils a little dilated, but would contract under the influence of strong light ; skin cold, of a death-like feel, no rigidity of the muscles; pulse 112 and very feeble; not the first sign of res- piration, no movements of the nostrils, I now lifted her body up to 4/2 PSYCHOLOGICAL MEDICINE. an obtuse angle with her lower limbs, I next raised one armandthen the other, and in this position I left her for several minutes. I now stepped back, gazed upon my patient, who, in a semi-sitting posture, with staring eyes, with outstretched arms and a lifeless appearance, appeared as though a corpse had thus been placed and left to stiffen. I then laid her down upon the pillow, raised her body up, having her head on the pillow in the attitude of opisthotonos, and thus she remained; after a period of twenty minutes, I gave her a slight push and she fell on her left side with her body still having the same curve, I now straightened her out in bed, spoke loudly to her several times, but no response. I again repeated the assafoetida injection, containing ol. terebinthinae. To please her friends, I tried several times to have her swallow, but all to no purpose. I held to her nose strong aqua ammonia, which affected her in no perceptible way. In this state she lay about eight hours ; when consciousness re- turned she related what she saw while in the other world. This time she was not so composed and tranquil as when she came out of the first trance (?). Her symptoms now assumed more the character of h\'Steria, her limbs were affected with convulsive twitchings, and she screamed loudly without giving utterance to any cause for so doing. When she went into the second state of mental abeyance, my views were, as soon as consciousness returned, that she should be brought under some powerful anaesthetic, whereby her mental state might recuperate. Whether this should be produced by chloroform, ether or hydrate of chloral v.-as not fully settled in my mind. I therefore sent for Dr. Addison of Farmersville, who arrived just after her im- perfect return to consciousness. It was decided at once to give her hydrate of chloral, of which she took seventy grains in the space of an hour, after which she fell into a profound sleep and did not awaken for twelve hours. Her convalescence then commenced." These cases are of interest to the practitioner, although compara- tively rare, as the cataleptic paroxysm or fit annoys or disturbs the patient's mind, lest they should come on while travelling or away from home and friends. Although the fits generally last but a few minutes they may possibly last for several hours or even days. The chief indication for treatment are to improve the general nervous tone by nerve tonics and electricity ; induce the patient to lead an outdoor life, eat regularly, avoid rich indigestible food ; to retire early ; and if the patient complain of a sleepless condition to admin- ister the ammoniated tincture of lupulin, made by William Neergaard, STATES OF UNCONSCIOUSNESS SOMNAMBULISM — CATALEPSY, ETC. 4/3 the chemist of this city, in twenty-minim to one-drachm doses, or Fothergil's solution of hydrobromic acid in thirty-drop doses, in water, at bed-time. I have found the constant current of electricity useful in the form of centric galvanization. To recapitulate : Cata- lepsy comes on suddenly, generally after mental or emotional dis- turbances ; the body becomes corpse-like and pale, the respiration being slow, and the pulse very soft and, perhaps, not discernible. The patient cannot be roused, and sensibility is lost. The stiffness of the muscles is a diagnostic feature of the disease, which is such that if a limb be put forcibly into any position it retains it. Patients remember nothing of any attack or what transpires during its con- tinuance. In all states of unconsciousness, where there is disseverment of the will from the organs habitually acted on by it, and during which odd, eccentric or dangerous acts are committed, it would seem most probable that while memory is annihilated, the acts are the outcome of the sensations, ideas, emotions, acts and events of antecedent life, and not inventions new to the senses. I doubt if the mind ever ac- tually ceases in its operations or workings ; and it is probable that actions analogous in kind although variously altered in operation, occur in the brain, alike in unconscious and conscious states, in much the same manner as they occur in the sleeping and in the waking brain. It is a very difficult matter to try to define or explain mental action in these states, because there are as many forms and degrees of dis- ordered mental action in states of unconsciousness as of the intellec- tual and moral qualities in their sane state. The confused and per- verted notions of right and wrong in opium habitues, where the opium dulls and deadens the moral sense without seeming to dis- turb the intellectual faculties — owing to the close relation between opium and consciousness — have a very interesting medico-legal bearing, as these cases inhabit, more or less of the time, a realm of partial unconsciousness ; but this subject is too complex to admit of further mention in this paper. The instigation to give way to inexplicable and ungovernable im- pulse, to cry out or shriek, to perpetrate a homicide or suicide, or to commit some motiveless act of violence or otherwise, and some of the acts of kleptomaniacs, come under the head of states of uncon- sciousness.* In families where madness is hereditary, there would * At the time of writing this a patient, 15 years of age, tells us that she should feel " so much better if she could only kill somebody." Who, she cares not. There is a strong impulse to commit the act. 474 PSYCHOLOGICAL MEDICINE. seem to be a similarity or identity of the inner nature of different members of the same family, which would appear to incite them to the act of self-destruction without any appreciable incentive to the act. The suicidal act or deed in such instances is probably com- mitted during a temporary partial state of unconsciousness. In the case of the young English lady of wealth and refinement who, while expensively dressed, took a greasy piece of meat from a butcher's shop, placing it between her velvet jacket and her silk dress, and walked off with it — is it rational to suppose that she was con- scious of what she was doing ? There is certainly a modified state of consciousness in kleptomania which makes the victim of this un- happy disease but very imperfectly conscious of the nature of the act. When this morbid propensity appears, it generally comes on sud- denly, and is, I think, owing to some peculiar change in the nervous constitution of the woman — for it is generally women who are af- fected with this type of nervous disorder. An uncontrollable im- pulse seems to usurp the whole mind for the time being, and efface all other impressions. It seems to annihilate personality by exclud- ing all the relations which determine it. I have in my own mind, determined the invasion of insanity in patients who acknowledged such instigations as I have spoken of, to homicide or suicide, which they had not given way to, but which had excited their amuse- ment rather than their appreciation, as in a sound mind would be the result. A patient of mine, who appreciated his own condition, con- fessed to me that he dreaded to look at children, because, although he was very fond of them, he felt irresistibly impelled to kill them. He related to me a struggle in his own mind which occurred upon seeing a child on the deck of a steamer, in which he successfully re- sisted the impulse to throw the child overboard. He said that he experienced a dreadful mental contest, and that his head swam and everything looked black before his eyes. He knew perfectly well that it would be wrong to commit such an act, but his will- power was very nearly overthrown by the disease. A lady, who was under my care, was irresistibly impelled to suddenly shriek aloud at any moment, and struggles hard against these impulses. She is accustomed to have momentary periods of insensibility — caused, I think, by anaemia of the brain — in which she steadies her- self by a table or chair, and generally manages to avoid the obser- vation of those in the room. This lady, although sane in the eyes of the world, has twice attempted suicide, and in common with other insane acts these attempts have never caused her a moments' regret, STATES OF UNCONSCIOUSNESS — SOMNAMBULISM — CATALEPSY, ETC. 475 although I have repeatedly endeavored to elicit such an expression from her. There is a taint of mental disorder in the family. An- other lady lately came to this city from Massachusetts to consult me about an irresistible impulse to throw herself from any horse car, steam car, steamboat or moving vehicle she was in. She deeply deplored this impulse, but it completely overpowered her, and she lived in fear that she should give way to the impulse. She had a lady friend accompany her constantly. In this case the cause was evidently dependent upon anaemia of the brain and spinal cord. An appropriate course of treatment cured her. There was not the element of in- sanity in her case. She complained, however, of lack of complete consciousness at such times, which fact she appreciated, and, there- fore, never trusted herself alone. I desire to call especial attention to the fact that there are, preceding many states of unconsciousness, premonitory conditions of sadness, peevishness, irritability, quarrel- someness, torpidity of conception, failure of memory, obtuseness of ideas, hebetude and prostration, followed, as the climax appears, by excessive gayety, excessive exaggeration of physical strength, rest- lessness, vertigo, and passionate outbursts of fury. There are also in these states headache, vomiting, and neuralgia. These constitutional states of morbid action show us that it would be very difficult for the mind to act calmly or clearly, and they also show a predisposition to actual mental disorder. These premoni- tory symptoms should always be inquired after in medico-legal in- vestigations, as they are really a part of the diseased state of the nervous system, and often precede the outward explosion for months. They constitute a part of the disease in the same way that the pre- monitory aura constitutes an integral part of the epileptic fit, when it is present. I think more importance should be attached to the subject of un- controllable impulse, and the legal profession should believe in its existence. At present, acts of unconquerable and destructive im- pulse occurring in persons whose sanity has never been disputed, are generally visited by the extreme penalty of the law. These per- sons, however, I think, suffer from a condition not unlike the first stage of epilepsy when pallor of the face occurs. In these cases of uncontrollable impulse, there is a condition of vascular tonus causing pallor of the face before the act, and the impulse ceases upon the commission of the act. I contend that in many of these cases there is disease of the brain, and that many of these persons are morally irresponsible, especially as it has been shown that these impulses are 476 PSYCHOLOGICAL MEDICINE. recurrent. The uncontrollable impulse is unlike epilepsy in that there is no complete and sudden loss of consciousness, while it re- sembles it in the recovery' being rapid, and in the fact of the patient having no remembrance of the attack in many cases. These pa- tients will tell you that they feel an ungovernable impulse to " do something." If the " doing something " consisted of undressing and shrieking from the top of the house, you would all say, " poor crea- ture ! she is insane ;" while, on the contrary, if the same person seized a knife and committed a murder, the people would assuredly hang her, although the deed would be equally that of a temporarily insane woman, committed during a state of partial unconsciousness — for I hold that these individuals are only very imperfectly conscious of their deeds. I consider these attacks as closely analogous to incomplete and abortive epileptiform attacks, and this should be accepted, I think, as their medico-legal significance. In these in- complete epileptiform attacks there are no convulsions and no com- plete loss of consciousness, the period being a mental blank to the patient, or a gust of passion, or a slight incoherence, or slight vertigo perhaps. I think that there is a functional brain disturbance in these cases of uncontrollable impulse, consisting of disturbance of the vaso- motor nerves, which are distributed to the bloodvessels of the brain and form their calibre, the disturbance consisting of a condition of spasm of the bloodvessels and temporary anaemia of the brain, evinced by the pallor of the face, which, as I have said, accompanies the uncontrollable impulse and generally characterizes it. The difference between the epileptic state and that of the brain in uncontrollable impulse is, that in the latter case the state of anaemia is not followed by the congestion and hyperemia, which in epilepsy immediately follows, as a rule, the state of anaemia. The motor tract of the brain and spinal cord is probably not affected as in epilepsy. If this uncontrollable impulse led to suicide, would you not consider it as the deed of a person who temporarily was of unsound mind? If so, should not the impulse leading to murder deserve any amenity and leniency in treatment? I think that uncontrollable impulse, in common with epilepsy, insanity, chorea, etc., has a common origin, that origin being constitutional disease, or hereditary disease, which has been transmitted from some member of the family, more or less remote, to the patient under obser\'ation. It is a medico-legal point of great importance which should be borne in mind, that there is a correlation of morbific forces — first thoroughly demonstrated bv Dr. STATES OF UNCONSCIOUSNESS — SOMNAMBULISM — CATALEPSY, ETC. 4// J. M. Winn, of London, England — which applies to a large class of hereditary diseases, making them mutually convertible ; in other words, that there is, in hereditary disease, a latent morbific force, which accumulates, perhaps gathering intensity during the latent period, and finally manifesting itself outwardly by a maniacal attack, in the convulsive movements of epilepsy, in consumption, in a suicidal act, or in the giving way to an uncontrollable impulse to jump from a house, kill a child, or violently swear and use obscene language when the general moral character may have been for months most unexceptional. It is a terrific thunderstorm of the mental and moral nature, due to the explosion of this subtle morbific force, which may have remained latent for a long time. The point which I desire to impress is this: that if, in medico-legal investigations, the judiciary in all such cases will take the same trouble to institute close inquiry that an experienced physician does, they will, in many cases, easily discover the existence of hereditary disease, which greatly modifies the prisoner's moral and legal responsibility; and surely every pris- oner is entitled to the benefit of such an investigation, if it is claimed that the criminal action was the offspring of disease which was not under the control of the unhappy sufferer. I hope I shall so con- vince my readers that it may be said in after years, that the medical profession is entitled, to the credit of inaugurating in this country the reforms so much needed. I have been told once or twice by legal friends that these were dangerous doctrines; but I hold that a scientific truth is never a dangerous doctrine, and I do not believe it right ever to sacrifice a human life to a cautious conservatism that fears to accept a truth because that truth may be in opposition to traditional dogma. I come, finally, to the most important of the states of unconsciousness, that connected with the disease of epilepsy. Epilepsy is a functional disease of the nervous centres, the phe- nomena of which morbid state consists in seizures, generally sudden in their invasion, and preceded, as a rule, by a well-marked pro- dromal period, characterized by loss of consciousness, coming on suddenly, and attended by peculiar involuntary muscular movements, which are highly spasmodic and convulsive in nature. There is great medico-legal importance attaching to epilepsy, from the reason that there have probably been more grave crimes cormnitted by persons epileptically insane than during all other states of unconsciousness put together in the annals of medicijie and law. I will go farther, and say that I believe most of the revolting and motiveless crimes in the annals 4/8 PSYCHOLOGICAL MEDICINE. of history to be due to the epileptic state. Revolting and motiveless crimes often form substitutes for the epileptic paroxysm, just as periods of faintness or automatism often take the place of a fit. Whether or not the tragedies, like the one I shall shortly relate, are ever premeditated in imagination during the period of incubation of the fits, is, I think, a very difficult question to answer. The state of unconsciousness occurring in epilepsy may be substituted by any grade of sudden acts of fury and violence, homicide or suicide. A premonition of an epileptic fit has been followed by a state of uncon- sciousness, during which, instead of having the convulsion, persons have walked long distances, in one instance as far as eight miles. The recollection in this instance was a complete blank. If any catas- trophe had been the result of this period of walking coma in these cases, during which time there was a total suspension of present knowledge and memory, I am afraid that the plea of temporary unsoundness of reason would have been looked upon with decided suspicion; yet the series of psycho-physical disturbances in these cases, whether apart or identified with an epileptic diathesis, directly affects the soundness of mind. The most insidious of these states of unconsciousness is, that which dates from the close of the grand mal, or fully developed epilepsy, with convulsions. This state may continue for some days after an epileptic convulsion, and the patient appears so much like himself as to deceive even his friends into the belief that he is mentally normal. This state seems to be compatible with many rational actions, and its existence is not generally sus- pected until the commission of some crime, like the poisoning about to be spoken of, which succeeded a nocturnal fit of epilepsy. My opinion is, as it will be seen in the narration of this case, that there should be immunity of punishment to epileptics for criminal acts committed within three days before or after an attack, such act being evidence to me of mental unsoundness. In conclusion, I will speak of the psychological aspect of the Laros case, on the trial of Allen C. Laros, at Easton, Pennsylvania, for the murder of his father, Martin Laros, by poison, the defence being based upon the allegation of epileptic insanity. The history of this very interesting case was kindly given me by my friend Henry W. Scott, Esq., of the Pennsylvania bar, to whom I am indebted for it. The Laros family lived at Mineral Spring, situated on the Dela- ware River, in Northampton County, four miles above Easton, Penn- sylvania. The little hamlet consists of a tavern and the homes of STATES OF UNCONSCIOUSNESS — SOMNAMBULISM — CATALEPSY, ETC. 479 seven or eight families, near together, along the river road. Martin Laros, the father of the family, was fifty-seven years old, and his wife was fifty-one. They had lived at Mineral Spring for thirty years. He taught school during the winter months, worked his farm in the summer, and at the same time was employed as undertaker and cabinetmaker. He was quiet, unobtrusive, and respected in his neighborhood. Mrs. Laros was a woman of domestic habits and . lively temperament. They have had seventeen children, thirteen of whom are now living. Several of them have been school-teachers. Some are living in the neighborhood, and others have removed to a distance. At the time of the poisoning, the family consisted of the father and mother, Allen (the prisoner), Erwin, Alvin, Clara, Alice, and a very young grandchild. Moses Schug, also a member of the household, was a bachelor, sixty-two years old. He assisted Martin Laros on the farm and in the shop. One evening, while the family were at the supper-table, they were, one by one, taken violently ill. Neighbors came in to do what they could for the sick, and physicians were summoned. Allen also assisted in caring for the sick; he was taken sick later in the evening. Mrs. Laros died at seven o'clock the next morning. Mr. Laros also died on the same day, about noon, and Moses Schug at three o'clock on the following afternoon. The other members of the family re- covered in about a week. The fatal supper was partaken of on Wednesday. The coroner's inquest was begun on Thursday after- noon, and on Saturday the following verdict was rendered: "That the said Martin Laros, Mary Ann Laros, and Moses Schug came to their deaths from the effects of arsenic poison, administered in coffee, on Wednesday evening, May 31st, 1876, and that we believe the same was administered by Allen C. Laros." A warrant was issued at once. Young Laros was arrested as he lay sick in bed, and taken to the county prison at Easton, Pennsyl- vania. The prisoner was about twenty-six years of age, a little under the medium height, and slightly built. He had received an ordinary common-school education, and was fairly intelligent. He was temperate, industrious, and moral, and was a church member. He was always disposed to be somewhat reticent, and spent much of his time alone. He was of respectable parentage, of healthful sur- roundings, of good moral and intellectual training, a teacher of the young in one of the public schools in his own township. He was, however, an epileptic, the epilepsy manifesting itself more than four 480 • PSYCHOLOGICAL MEDICINE. years before the poisoning took place, and had continued, by succes- sive steps of longer or shorter duration, until the time of the poison- ing. For three weeks before this time, almost daily, he Avas so afflicted with epileptic convulsions as — so counsel for defence claimed — to dethrone his reason and destroy the powers of his mind. It was claimed and proved that, on the Saturday previous to the crime, he was afHicted with convulsions ; that he had them on Sunday, Monday, Tuesday (the day the Commonwealth claimed he bought the poison), on Wednesday (the day of the poisoning), and on Thurs- day and Friday, immediately after it. After his confinement in pri- son he was similarly affected by these convulsions, varying in dura- tion from a few minutes to several hours. During the continuance of the convulsions he was totally unconscious. Before and since his confinement, for a period of several hours after these convulsions had passed away, his mind was cloudy and confused, and his conversation and acts not responsible. My own opinion has always been that, in the event of a criminal act by an epileptic, we should suspect mental disorder, and that, in the absence of any strong personal motive, there should be immunity of punishment to epileptics for acts committed within three days be- fore or after an attack, such insane acts being to me the evidence of an insane mind. Such persons are, I think, able to conduct their business, and perform their duties, and continue their pursuits in all respects like other people, except at the time of seizure. In the case of young Laros there was an inherited tendency to insanity and ner- vous diseases for several generations, and in many branches of the family of the prisoner — grandfather, grandmother, and maternal aunt. These circumstances all contributed to lower the grade of his offence, even if it was not the offspring of decided insanity. While young Laros was in prison awaiting trial every possible ex- periment was tried to ascertain if he were conscious while in the con- vulsion, and every conceivable test applied to see if the prisoner were feigning. The prison physician, during the first paroxysm he wit- nessed, suddenly thrust the blade of a sharp knife into the prisoner's hand, and no sensation was manifested. A heated key was next ap- plied. Then the flame of a lighted lamp was held to the sole of his bare foot, and still not a quiver of sensation followed. Melted seal- ing-wax was dropped upon the bare skin so that the sealing-wax burned into the skin, and no indication of pain was shown. Nothing that science could suggest was left untried to detect imposture, if any STATES OF UNCONSCIOUSNESS — SOMNAMBULISM — CATALEPSY, ETC. 48 1 existed, but all these tests failed to detect any feigning on the part of the prisoner. At the trial, Dr. John M. Junkin, of Easton, Penn- sylvania, testified that he was called upon to visit Martin Laros on the morning of June ist. Reached there about three o'clock and, concluding from the symptoms that they were all suffering from ar- senical poison, he gave stimulants and hydrated peroxide of iron. He found his patients vomiting and purging, and gave it as his opinion that the death of Martin Laros was caused by arsenic. During the pro- gress of the trial various persons testified to having been aware of the prisoner's infirmity, and the deputy warden of the county prison testi- fied as to the nature of the attacks while Laros was in prison. He described finding the prisoner " struggling in his cell in a fit," with his face very white, eyes partly closed, the hands clenched, with the thumbs inside, and that he heard the prisoner's teeth gritting. He also described incoherent and apparently insane conversation of the prisoner, and hallucinations of sight. The prison physician also tes- tified that he found him — with a weak and feeble pulse and cool, pale skin — acting in a wild, incoherent manner ; talking about fish- ing, seeing water-snakes, and other nonsenical, insane conversation. Any bright object, he would endeavor to get hold of His pockets were stuffed with bits of paper and such things. He tried to get the warden's shoe-buckles and the bright tips of the doctor's shoestrings. The doctor also testified that he, the prisoner, did not appear to have good control over his muscular movements. The doctor also de- scribed various epileptic convulsions which he witnessed, and testi- fied as to the total unconsciousness of the prisoner during the parox- ysms. He also testified to seeing the prisoner six to eight hours before an attack, when he appeared dull, and gave imperfect answers, and complained of pain in the head. The prisoner's condition while under observation, coupled with the testimony of his friends as to his previous symptoms and condition, led all unprejudiced observers to believe that he was mentally unsound. Dr. John Curwen, the Su- perintendent of the Pennsylvania State Lunatic Asylum, testified that he considered frothing, swelled veins in the neck, and lividity of face as essential symptoms, and without these he would doubt the genuineness of the epilepsy, although, on re-examination by counsel for defence, he admitted that these signs might possibly be absent in cases even of pure epilepsy. Dr. Curwen was expert for the Commonwealth of Pennsylvania. The jury in this case rendered a 31 482 PSYCHOLOGICAL MEDICINE. verdict of murder in the first degree, and the prisoner was duly sen- tenced to be hung. The death-warrant was signed, but a writ of error was sued out in the Supreme Court of Pennsylvania, which operated as a supersedeas, and the governor recalled the warrant. The counsel for the defence then presented to the court a petition alleging mental unsoundness, and asked for a commission to inquire into the matter and ascertain whether the prisoner was a proper subject for capital punishment. The commission appointed by the court consisted of Dr. William Pepper, of Philadelphia, Dr. S. Preston Jones, also of that city, asso- ciated with Dr. Kirkbride, at his asylum, and Hon. Henry A. Ross, a lawyer of Pennsylvania. The commission spent a month or more in taking testimony and making a personal examination of the prisoner. They made a unanimous report to the court that he was an epileptic and men- tally irresponsible, that he should not be visited with capital punish- ment, and recommended his removal to an asylum. Thereupon the court ordered him to be removed to the State Lunatic Asylum, at Harrisburg, Pennsylvania, of which Dr. Curwen is superintendent. After confinement for a period of about two years he escaped, and subsequently was captured in Arkansas, or, rather, he surrendered himself to the authorities and requested them to " send him back to this country to be hung." He didn't want to be returned to the asylum. He was returned to the asylum, and about six months ago he escaped from there a second time, and nothing is now known of his whereabouts. The able efforts in his behalf and in the cause of humanity are owing to the exertions of his counsel, Henry W. Scott, Esq., of Eas- ton, Pennsylvania. Upon his examination the prisoner declared that his father and mother were both living and that his father was making a door when he left home. One of the prisoner's brothers was, up to the time of his death, a quiet, uncommunicative, and retir- ing man, and he died by hanging himself without apparent motive or cause. Young Laros was a person of uniformly mild and tractable disposition, who was brought up amid the softening and restraining influences of a pious and affectionate family and away from demoral- izing surroundings or vicious companions. This outrageous and enormous crime was very likely the outcome of mental disorder which had depraved and eclipsed the moral faculties. Yet the judge and jury deliberately arrived at a verdict which doomed this unhappy STATES OF UNCONSCIOUSNESS — SOMNAMBULISM — CATALEPSY, ETC. 483 creature to the scaffold. In reviewing this case psychologically we have, as I have said, a mild-mannered boy, of previous exemplary behavior, uniformly kind and affectionate, suddenly developed into an inhuman monster of depravity. For four years he had been afflicted with epilepsy, and we must bear in mind the tendency of epilepsy to generate the insane impulse to crime. We must also bear in mind that there are on record many homicides committed by epileptically insane persons under every circumstance of apparent motive and design. There was a rapid succession of the spasms shortly before and after the Wednesday night on which the family were taken sick. These attacks had been noticed more particularly during the few months preceding the tragedy, and they had occurred with startling distinctness and frequency, and on the very evening of the murder he was unquestionably under the influence which pre- cedes and follows the epileptic paroxysm of epileptic insanity. The experts for the Commonwealth in this case adopted the typical case of epilepsy as the unvarying standard by which the disease is to be ascertained, and it was only under the most rigid cross-examination that they would modify, in some degree, this position. The symp- toms of epilepsy are not, however, invariable. There may be every variety, from the simply vertiginous to the most demonstrative mus- cular and nervous spasms. The epileptic may be pallid or purple- hued, the pupils may contract or dilate, the fingers may be clenched or extended, there may be foaming at the mouth or it may be absent. That some of the symptoms of the most decided and impressive type are not present is no proof that the disease is not epilepsy. The disorder of the intellect which accompanies epilepsy is similar to that we meet with in chronic insanity, and while, of course, it is not the invariable rule, yet in my own practice I have, in the great majority of cases, observed enfeeblement of memory and intellectual powers amounting to insanity. While an epileptic may be very intelligent, I do not believe that, either during the attack or for an indefinite period subsequently, the mental faculties are under the control of the patient. The patient, particularly as the effect of the lighter seizures, becomes very irritable indeed, and there are in- stinctive impulses, I think, to acts of violence. The confused rec- ollection of what has happened and the unconsciousness of the gravity of his acts is, I think, diagnostic of the mental state of the epileptic, and should be considered as the essential characteristic of it. The epileptic, in the majority of cases, seems to automatically 484 PSYCHOLOGICAL MEDICINE. obey the impulses generated by his disease, and seems utterly power- less to resist them, even though they impel to criminal deeds. This constant disturbance of the affective and intellectual faculties which is manifest after the paroxysm, may last during the greater part of the interval between the fits, and this is a medico-legal point of great importance. There may be abortive epileptiform attacks, where there are no convulsions and where there is no complete loss of conscious- ness, — a sort of epileptic vertigo, — and yet such persons have com- mitted sudden deeds of violence, and were utterly unable to remem- ber the circumstances afterwards. I think there are cases where the petit inal of epilepsy may con- tinue for hours, where no overt act happens, and where there is no motive for falsification. There is also, dating from the close of the grand inal an insidious and obscure state resembling healthy men- talization, and differing from it only by a complete unconscious- ness compatible with many rational doings. This state follows the convulsion, and is very dangerous to those around the patient. The acts in this state are closely allied to the state of unconsciousness in somnambulism. There is no knowledge or recollection of events that occur, or of overt acts that may be committed during this state. Baillarger relates the case of a vine-dresser near Lyons, France, who was seized with a fi.t of shivering, and who took up a mattock and killed three of his children, and not but a few rods from that spot he killed his wife and last child. He was much attached to his wife and children. Falret relates a case of a youth liable to vertiginous seizure, so severe as to occasion him to grasp the nearest object for support, who attempted to poison himself, was not excitable, would leave his business abruptly, walk seventy-five miles from Paris, taking no food for forty-eight hours, would forget his ordinary work, would walk during the night, wounded a lady in the street and re- membered nothing of the assault. The unconsciousness or mental weakness the sequela of epilepsy permits of the existence of delu- sions — morbid mono-ideaism, irresistible impulse, and murderous in- stincts, Avhich regulate automatically the volition and acts of the patient. This is a scientific and well-attested fact. There is only partial responsibility in this state. The Mental Condition in Hypnotism.'^ — Dr. D. Hack Tuke, in his address on this subject before the Medico-Psychological Association * I would define hypnotism as a morbidly profound sleep of the cortex of the brain while the basal ganglia remain unaffected and in their normal condition. STATES OF UNCONSCIOUSNESS — SOMNAMBULISM — CATALEPSY, ETC. 485 in London, February 21st, 1883, said that he had tried to form a clear idea as to the cerebro-mental condition of hypnotized persons. The data upon which we have to form an opinion or construct a theory are : 1st. The condition necessary to induce the state in question. 2d. The objective symptoms of the hypnotized so far as we can observe them ; and, 3d. The subjective state experienced and described by himself (the hypnotized person), in those instances in which memory, more or less distinct, is retained of what has been present to the mind during the hypnotic condition. I . As to the Condition Necessary to Induce the Hypnotic State. — Star- ing at a disk or some well-defined object is a very frequent method. Other methods are also effective. The monotonous sensory impres- sions produced by passes, by counting up to several hundred figures, by listening to the ticking of a watch, etc. We may throw ourselves into an hypnotic state in attempting to go to sleep. The principles common to the various modes of hypnotism is on the physical side, the stimulation, more or less prolonged, of a sensory nerve in close relation to the brain, calcidated to idtimately exhaust some portion of that organ, and on the mental side, the riveting the attention on one idea. Looking at an object is not essential, for a blind person may be hypnotized, and in susceptible persons the merely expecting to be hypnotized is sufficient to induce it, the expectation in this case involving the con- centration of the attention to one point. Mr. W North, Lecturer on Physiology at Westminster Hospital, thus describes his own feelings while hypnotized : " I have not the smallest doubt, that at first I succeeded in abstracting myself, as it were, from surrounding circumstances. I had been reading very hard for days past on the subject of intestinal digestion in relation to the bacteria produced, and I pictured to myself the interior of the intestine and its contents ; then I tried to picture a special form of bacteria, and while I was engaged in contemplating its changes of form I seemed to lose all consciousness of persons around me." On a subsequent trial being made he looked at his boot, and thus de- scribed the process : " I ultimately succeeded in fixing my attention on six points of light reflected upon my boot, and having some minute resemblance in position to the constellation Orion. After looking fixedly at this for what seemed to me a very long time, the idea of the constellation vanished, and its place was taken by the outline of 486 PSYCHOLOGICAL MEDICINE. the lower part of the face of a friend. All I could see was his beard and mouth and part of his nose and one cheek, the rest was cut off by a broad black area; the details were tolerably vivid." The voluntary surrender of the will — the subject placing himself passively in the hands of the operator, is also an important factor in nearly all the processes. It is the initial step to the subsequent abandonment of the will of the subject to that of another. M. Richet, of the Salpetriere, has shown that the subject may be sur- prised, and even rendered cataleptic, the moment his attention is in the least arrested. He is seized, and, as it were, instantaneously petrified, whatever efforts he makes to resist the influence. M. Richet constantly produces hypnotism by throwing a brilliant electric light upon the face of persons not expecting it, or by striking a gong which had been concealed. An hysterical or neurotic subject has been transformed into a statue by a blow or the concealed gong at the Salpetriere. 2. The Objective Symptoms of the Hypnotized. — These vary with the stage or type. Charcot, Richet, Tamburini, and Sepelli recog- nize three fundamental types, the cataleptic, the lethargic, and the somnambulistic. In the first the limbs retain the positions in which they were placed, for a considerable time and without effort; in the second (the lethargic), the muscles which are relaxed are found to have the remarkable property of contracting in a most definite way under gentle mechanical application ; in the third (the somnambu- listic), the state of the subject answers much more to what is un- derstood, as the so-called magnetic or mesmeric sleep. Contraction of the limbs can be produced, but they are of a different character from those in the cataleptic form, or the excitability of the muscles in the lethargic state. Pupils. — The pupils exhibit strabismus and contraction, and after- wards are widely dilated and sluggish, an indication of the func- tional activity of the medulla, as regards the sympathetic as well as the respiratory centre. Cerebral Circulation. — Ophthalmoscopic examination by Professor Forster of Heidenhain's patient showed that there was no contrac- tion of the vessel as Heidenhain expected to find, as his theory had been that anaemia caused the sleep. That hyperaemia of the brain is not inconsistent with hypnotism was proved by hypnotizing a gen- tleman (Heidenhain's brother), who had inhaled nitrite of amyl. The respiration and pulsation are quickened at first. Professor Tam- STATES OF UNCONSCIOUSNESS SOMNAMBULISM — CATALEPSY, ETC. 48/ burini used the pneumograph, and he found the frequency of respi- ration to be doubled at first, and the inspiratory pause suppressed. These tracings are useful in detecting simulation. With the cata- leptic subject the tracing is uniform in character from beginning to end. With the simulator, on the contrary, it is composed of two distinct parts. At the beginning, respiration is regular and normal ; in the second stage, that which corresponds to the indications of muscular fatigue, irregularity in the rhythm occurs with deep and rapid depressions, manifest indications of the disturbance of the res- piration caused by the effort to simulate. Professor Tamburini made careful pulse tracings also. The rise in the pulse is 100 per cent. The myograph, the pneumograph, and the sphygmograph are most valuable means, placed at our disposal by modern invention, for ob- taining trustworthy records of the objective symptoms of hypnotism. There is heightened reflex action. The tendon reflexes may be normal or exaggerated. Richer states than in the lethargic type they are much exaggerated, in the cataleptic type they are dimin- ished, and in the somnambulistic type normal. There is galvanic reaction. 3. Subjective Symptoms described. — Sensation of pain is deadened or suspended. Anaesthesia is produced. Mr. North said that a pin plunged into his hand nearly up to its head, felt as if a match or some blunt instrument were pressing against the hand. When he was roused it hurt him considerably to withdraw the pin. The spe- cial senses are interfered with or abolished. They may be either heightened or abolished in different cases. Sight, is partially affected. The subject sees, though confusedly, that which is immediately around him, but has a very vague or no perception at all of what is beyond this range. Some subjects describe a play of colors before the eyes. Hearing is not affected. Taste is suspended. There may be no unconsciousness whatever in some instances, and the subject may appear like other people. A certain susceptibility to impres- sions on the mental side and to rigidity of the limbs on the physical side may be all that marks the state of the subject. Is it that the cerebral cortex is just sufficiently weakened in function to have lost its supremacy, without parting with its more secondary offices? Volition. — There is no spontaneity* in hypnotized persons. Voli- tion is suspended. Extreme Susceptibility to Outside Suggestions. — The subject hyp- notized is without any will-power, and at the mercy of any sugges- 488 PSYCHOLOGICAL MEDICINE. tions however absurd. Hallucinations are easily induced. A person may eat heartily while hypnotized, and their visceral sensations will not suffice to inform them, so that they will wish for the next regular meal as if they had not eaten. Richet, of France, says : " The som- nambulist has a perfect memory, a very lively intelligence, and an imagination which constructs the most complex hallucination." The great fact in mesmeric sleep is that will and consciousness are sus- pended, and the brain placed in the condition of the true spinal or reflex S3-stem. There is a reduction to a mere automatic condition. Heidenhain holds that the cause of the phenomena of hypnotism lies in the inhibition of the activity of the ganglion cells of the cere- bral cortex by prolonged stimulation of the sensory nerves of the face, or the auditory or optic nerve. A sensory nerv^e may certainly inhibit the brain centres, and this inhibition is the starting-point of hypnotism. Coiicliisio7is. — I. There may be consciousness during the state of hypnotism, and it may pass rapidly or slowly into complete uncon- sciousness as in the somnambulistic state ; the manifestations not being dependent upon the presence or absence of consciousness, which is merely an epiphenomenon. 2. A'oluntar}' control over thought and action is suspended. 3. The reflex action, therefore, of the cerebral cortex to sugges- tions from without, so long as any channel of communication is open, comes in play. 4. While the consciousness is retained, the perception of the reflex or automatic cerebral action conveys the impression that there are two egos. 5. Some of the mental functions, as memory, may be exalted, and there may be vivid hallucinations and delusions. 6. Unconscious reflex mimicry may be the only mental phenomena present, the subject copying minutely everything said or done by the person with whom he is en rapport. 7. Impressions from without may be blocked at different points in the encephalon, according to the areas affected and the completeness with which they are hypnotized ; thus, an impression or suggestion may take the round of the basal ganglia only, or may pass to the cor- tex, and, having reached the cortex, may excite ideation and reflex muscular actions, with or without consciousness, and wholly inde- pendent of the will. 8'. There may be in different states of hypnotism exaltation or de- STATES OF UNCONSCIOUSNESS —SOMNAMBULISM — CATALEPSY, ETC. 489 pression of sensation, and the special senses. There is a peculiar abnormal mental condition presented in hypnotism, closely allied to mental disease, and full of interest to students of mental science. The subject has been scientifically studied by James Braid, of Manchester, in 1843 ; Esdaile, in India, in 1846 ; Girard Teulon and Demarquay, in i860; Richet, in 1875; Charcot, in 1878; and, in or about 1880, by the late Dr. George M. Beard, Drs. Weinhold, Preyer, Berger, Griitz- ner, and Heidenhain, and Dr. H. Charleton Bastian. We may fail at first with a subject, and after a few trials he may make an excellent subject for experimentation. Bastian says that persons, who have been once hypnotized, can in general be again brought with comparative ease into the same condition, and the facility of hypnotizing such persons goes on increasing after each operation, owing to the exist- ence of a predisposing mental state. A condition of excited expect- ancy is a decidedly favoring mental state. The simplest condition necessary to induce the hypnotic or trance-like condition is to make the subject look fixedly for a few seconds at a bright object, held by the operator at about eight to fifteen inches above the eyes, at such a distance above the forehead as may be necessary to produce the greatest possible strain upon the eyes and eyelids, and enable the patient to maintain a steady, fixed stare at the object. We must tell the subject to keep his eyes steadily fixed on this object and his mind riveted upon the image of it. In some persons, after fifteen or twenty seconds, we shall find a decided cataleptic state induced, so that the limbs have the tendency to re- main in the position in which we place them, and, if not, we may gently request the patient to keep his limbs in the position in which we have placed them. The pulse now quickens and the limbs shortly become rigid. By prolonging this process we induce a profound sleep, or trance, in which there is complete anaesthesia. Esdaile, in India, performed numerous operations on Hindoos with absence of all pain while hypnotized. The therapeutic value of hypnotism has never yet been thoroughly tested, and the future may develop facts of much interest and value. 490 PSYCHOLOGICAL MEDICINE. • CHAPTER XXVI. CEREBRAL AND SPINAL ANEMIA. The occurrence of cerebral and spinal anaemia is becoming so fre- quent among American women and is the cause of so much of their ill health and lassitude, that I propose to investigate in this chapter its symptoms, causes, morbid anatomy, and treatment, feeling sure that so common and troublesome an affection cannot fail to be of in- terest to the majority of the profession. We are applied to for treatment by pale, colorless women, with cold skin, complaining of headache of a limited nature, usually re- lieved by lying down, and exaggerated by either physical or mental effort. These patients have little muscular power ; and we sometimes find symptoms of anaesthesia. The patients all complain of drowsi- ness. The majority of these patients will be found, when spinal anaemia is present, to have tenderness over one or more points of the vertebral column, which is increased by pressure. The pain de- veloped by such pressure may be either dull or sharp in nature. We may, in rare cases, find tenderness, on pressure, over the entire spine. Neuralgia is also a very prominent symptom, and may be experi- enced in the head, face, neck, shoulders, and upper extremities when the cervical and dorsal regions of the spinal cord are implicated ; while the neuralgic pain attacks the pelvis and the lower extremities when the anaemia implicates the lumbar region of the spine. If the neuralgic pain is in the head, it may vary in its location, being some- times in one part of the head or face and sometimes in another, and sometimes on one side only. In the head, it may be limited to a small spot. This pain is relieved by lying down and keeping per- fectly still. It may be very continuous and exasperating, and may be accompanied by nausea and vomiting. The extremities are veiy apt to be cold, and sleep is restless and disturbed. These patients look very worn and thin. These patients may have prolonged mus- cular contractions, especially oFthe lower limbs and of the hands. I have at present a lady from Mississippi under my care who suffers from spinal anaemia and hysteria, and who, before leaving her home in Mississippi, had been for a week in a cataleptic state, whose fingers and thumbs are tightly closed upon the palms, and have been so for some months. This contraction is with her, as it is with all cases, CEREBRAL AND SPINAL ANEMIA. 49 1 painless. It came on suddenly, and I have confidently predicted that when the spinal anaemia is cured it will cease as suddenly as it came on. This young lady was suffering from complete hysterical paralysis when she entered my hospital, and had not spoken for a long time. The muscles were attenuated by disuse, her expression was idiotic, and she could not walk a step and would not utter a sound. Under the constant galvanic current, the negative pole to the sixth cervical vertebra and the positive pole to the coccyx, the ascending current from thirty-two cells being used; hypodermics of strychnia; the actual cautery to the neck twice ; a full diet, blisters to the spine, and tonics ; she now walks well ; her muscles have regained their tone ; she reads well ; can write a little, although she holds a pen very clumsily, owing to the contraction, and is making an excellent recovery. Re- specting this patient's obstinate silence, I received the following from her family physician, under date of August /th, 1882 : Dear Doctor, — Your favor of the 25th inst. reached me seven days ago, but urgent professional engagements have interfered with my answering it sooner. Miss 's silence, to which you refer, and ask if she has " ever had any dominant idea or emotion " which would account for it, has been for years a marked peculiarity, and, as far as I know, has been a habit with her among strangers. I am not aware of any depressing " emotion or idea" which might explain it, or of any taint ofinsanity in her family. In a general way, I am inclined to fall back on the idea of family taint to explain her peculiarities. I think those who have known best would say that she is a " girl of peculiar mental con- stitution, even when well," as you suggest, etc., etc. It is evident, from this letter, that my patient was one of those in- dividuals who had inherited a marked nervous constitution. An- other similar case from Missouri had prolonged muscular contrac- tions of the lower limbs. She had marked spinal anaemia. The contractions suddenly disappeared as she got better, she made an excellent recovery. At times we find hyperaesthesia existing, either of the whole or of a part of the body, or limited, in some cases, to the organs of special sense. Occasionally we see convulsive movements, and also affec- tions of the larynx and air-passages, and alimentary canal. Some patients with cerebral anaemia give a history of attacks of dizziness and fainting fits, while others complain of intense irritability and disturbances of sensibility. These latter patients are very sensitive to light and sound, and have flashes before the eyes. There may be delirium, convulsions, and coma, and even attacks of acute mania, in the worst cases of cerebral anaemia. Patients are very apathetic, 492 PSYCHOLOGICAL MEDICINE. and they have much mental lassitude. They are inclined, as I have said, to sleep, but their sleep is of a disturbed character, and they are annoyed by frightful dreams. In nearly every case of cerebral anaemia, we meet with disturbances of the mind ranging from slight hysterical symptoms to acute maniacal paroxysms. We also find disturbances of the digestive organs, of the genito-urinary organs, and of the heart and circulation. Also, we find in cerebral anaemia that many visceral diseases are simulated by this affection. The neuralgia, before alluded to, has the peculiarity of shifting its seat quite suddenly from one place to another, and this is one of the principal diagnostic features of spinal anaemia. These neuralgic pains are increased by physical or mental effort, and relieved by lying down, when the contracted and bloodless cerebral and spinal vessels become filled with blood. As a rule, we do not find that our patients complain of pain in the spine. We more generally find that a sense of weight and heat in the spine is due to spinal conges- tion, and not to anemia. We often have complaints, as I have said, of nausea and vomiting. We sometimes find weakness, but no true paralysis. The affections of various parts of the body and the vis- cera, in cerebral and spinal anemia, are due probably to the fact of the sympathetic system of nerves being affected. This system of nerves, as it is well known, is closely interwoven with the spinal sys- tem, each spinal nerve receiving branches from, and transmitting branches to, a neighboring sympathetic ganglion. The sympathetic system of nerves regulates the shortening and lengthening of all organic muscular fibres ; it controls the contraction and dilatation of the bloodvessels, and consequently the amount of blood supplied to different parts, and the rapidity of its flow through them, and in this way, in a certain degree, it regulates the nutrition and functional ac- tivity of the organs and their temperature. It is also probable that the sympathetic system exerts a direct influence over the glandular organs of the body. This affords a rational explanation of nutritive and functional difficulties occurring in the course of cerebral and spinal anaemia, — functions of different parts and organs being im- paired, exalted, or perverted. Spinal anaemia is a disease of capillary contraction and bloodless- ness of the spine. It is a functional disease, and there are, so far as present knowledge exists, no morbid structural changes. In making a diagnosis between anaemia and other morbid states of the spinal cord, such as spinal meningitis and spinal congestion, we must bear in mind CEREBRAL AND SPINAL ANEMIA. 493 that in the latter diseases the spine is not tender on pressure. If there is disease of the vertebrae, we have spinal tenderness ; but such disease is usually found under the age of fifteen or twenty years. Again, if there should chance, in spinal ansemia, to be an apparent projection of the tender vertebrae, which would lead us to suspect caries of the vertebrae, we shall find that it is not a real projection, displacement, or curvature, but merely a simulation, depending on puffing out of the ligaments and investments of the spine. If there were diseased vertebrae, we should find paralysis of the lower limbs in all probability, while we almost never find this in spinal anaemia. Another diagnostic point of importance is the fact that spinal anse- mia is relieved by lying down, while in spinal congestion, meningitis, and myelitis, the symptoms are all worse after a night's sleep. It has also been claimed that hypodermic injections of strychnia will relieve spinal anaemia, while they intensify the symptoms of conges- tion, meningitis, and myelitis. As I have before remarked, the pro- longed muscular contractions in anaemia are painless, while in mye- litis they are accompanied with great suffering. Cerebral anaemia is a decrease in the amount of blood circulating through the brain in a given space of time, the dilating and contract- ing power of the bloodvessels altering their calibre, and thus permit- ting a diminution in the flow of blood. During sleep, there is a period of temporary quiescence of the brain, during which time it is pale and bloodless. Alterations in the vascularity of the brain are due partly to the presence of the cerebro-spinal fluid, the brain be- coming more vascular as the amount of the fluid is diminished, and as the vascularity decreases, the bulk of the fluid increases. As I have stated elsewhere, the amount of blood going to the brain is a fifth of the whole bulk of the blood ; a reduction, therefore, in the usual supply of blood will soon become apparent in the cerebral cir- culation. As an illustration of this, may be mentioned constant drains on the system, such as morbid growths, imperfect nutrition, and dyspepsia. Spanaemia is a cause of cerebral anaemia, arising, as it does, from mala- rial poisoning, lithiasis, and prolonged administration of certain drugs. Cerebral anaemia may be produced by unfilled vessels, heart disease, organic disease of the cerebral vessels, venous stasis, apoplexy, and vaso-motor disturbances of the cerebral vessels. The principal causes of anaemia of the brain are, as I have remarked above, those that diminish the entire amount of blood in the brain, such as haemor- 494 PSYCHOLOGICAL MEDICINE. rhage, exudation, and fevers ; the congestion of the other organs of the body ; the compression or obstruction of arteries supplying the brain, mental excitement, which causes innervation or spasmodic contraction of arteries ; diminution of the space in the skull by ex- udations, extravasations, or tumors ; and leucocythsemia. The causes of spinal ansemia may arise from congenital predis- position, and include everything which tends to induce a nervous temperament, and all things that tend to exhaust vital power. Cere- bral ansemia may come on quite suddenly and severely, or it may come on slowly and be less severe. In cases of the former descrip- tion, patients are attacked with sudden dizziness, become insensible to impressions, and cannot move. They faint away, with slight spas- modic movements. When the cerebral anaemia comes on slowly, we find symptoms of irritation and, subsequently, paralysis. When the anemia does not attain a high grade, only the symptoms of cere- bral irritation are noticeable. Sometimes there are great disturbances of sensibility. Such patients complain of much headache in the fore- head or occiput, and sensitiveness to light and sound, so that even daylight admitted into the room causes them great discomfort, and slight sounds are insupportable. These patients have flashes before their eyes, noises in the ears, and vertigo. We see this in women with metrorrhagia and other losses of blood. In the case of cere- bral ansemia in children, we find that motor disturbances are most noticeable. At times, the symptoms of cerebral ansemia may be almost wholly confined to the mental functions. The mental action in cerebral anaemia, when disturbed, is quick, irritable, and tending to convulsive irregularities. The state of ansemia, if carried beyond a certain point, will destroy functional excitability and the activity of the brain. In cerebral anaemia, when the mental functions are affected, we see a pale face, cool head, and weak pulse, the cerebral organs being in a state of irritable weakness, easily excited by action, the action, how- ever, being powerless and irregular. Some of the most violent maniacal attacks I have ever seen were in cases of insanity, when the pathological state was one of ansmia of the brain. Examination of the heart in these cases reveals systolic and diastolic bellows- murmurs, heard most plainly at the base of the heart, and also venous murmurs. Prognosis. — The prognosis in cerebral ansemia and spinal anaemia is generally good, if no organic disease exists; but if ansemia of the CEREBRAL AND SPINAL ANEMIA. 495 brain depends on diseased vessels, or organic disease of the heart, the prognosis is bad. Cerebral anaemia, if not checked, passes on to melancholia and dementia, ending in psychical torpidity and intel- lectual decay. The dementia resulting from cerebral anemia begins in one of two ways, either gradually, and at first by imperceptible encroachments, or by maniacal excitement. Its acme is a mental state of profound stupidity. In cases of dementia, the amount of cerebral atrophy which ensues may be calculated upon by the enfee- blement of mental power. We certainly have some atrophy, and this amount will generally be found to correspond with the degree of mental decadence present. Treatment. — The treatment must be psychical and physical. With regard to the first, as soon as the system is somewhat improved, change of scene, travelling, and cheerful society are to be recom- mended, while the physical or medicinal treatment consists in pri- marily toning up the system, and improving both the quantity and quality of blood circulating in the brain and spinal cord. If our patients are much debilitated, we must keep them in a recumbent position, and obtain vest for body and mind. All emotional disturb- ances must be carefully removed. Iron, in combination with the chloro-phosphide of arsenic (Routh's formula), 5 minims ter die, may be given, and alcohol must be freely administered. Old rye whiskey is the most eligible form in which to give alcohol. The constant galvanic current is a valuable remedy, the ascending current from sixteen to thirty cells being used, the negative electrode being placed at the base of the brain, while the positive is placed at the coccyx. Strychnia, in ^Vgi'ain doses, is one of our most valuable medicines, and it may with advantage be combined with iron and quinine. I have found a very eligible and pleasant preparation to be the elixir of the phosphate of iron, with quinine and strychnia, made by Wm. Neergaard of New York. Each teaspoonful contains 2 grains of the phosphate of iron, i grain of quinine, and gV grain of strychnia. Practitioners can easily combine formulas to suit themselves. To lay down a general plan of treatment for cerebral anaemia would include the administration of stimulants, tonics, and plenty of milk, eggs, and beef. Cod-liver oil with phosphorus is indicated. In cases of spinal anaemia and irritation, the first great means of cure resides in the judicious employment of counter-irritation to the affected por- tion of the spine; and I have found the compound mustard liniment, made up with fresh oil of mustard, so that the liniment possesses a 49^ PSYCHOLOGICAL MEDICINE. strong pungent odor, applied on flannel or cotton-batting to the affected region of the spine, and the whole covered with oil silk, the most efficacious method of counter-irritation, and have obtained excellent results from its use. Blistering the spine and the actual cautery are both very useful at times when indicated. Besides putting patients suffering from spinal anaemia on a full nourishing diet, I am in the habit of prescribing stimulants in liberal doses. In using the constant current of electricity to the spine, I apply the current twice a day for a few minutes at each sitting. Phosphorus is best adminis- tered in the shape of phosphide of zinc, I think, as the combination is very stable, and the phosphorus does not become oxidized as in other preparations. -jV ^*^ 5 of a grain in pill form is my usual dose, which contains j^ to -5^0 of a grain of phosphorus. Thompson's solution of phosphorus, and phosphorus administered in cod-liver oil, are both eligible. From 33- to ^-^ of a grain of phosphorus, thrice daily, is my usual dose. The cod-liver oil acts on the nutrition of the central nervous system, which it tends to preserve in its organic integrity, while the phosphorus is nerve food and builds up the exhausted nervous system, having a special stimulating power. A combination of strychnia, quinia, and tincture ferri muriat., with glycerine as a menstruum, has given me good results. By judicious treatment, and the removal of all causes calculated to keep up cerebral and spinal anaemia, we shall get the most gratifying results; our patient will improve in personal appearance and weight, the spinal tenderness and the attendant neuralgic pains will disappear, the mental irrita- bility and pain in the head will be a thing of the past, all the symp- toms will decrease in intensity and finally disappear, and a permanent cure will be obtained, to the satisfaction alike of the physician and of the patient. CHAPTER XXVII. INFLAMMATORY DISEASES OF THE BRAIN AND ITS MEMBRANES. The periphery of the brain is very sensitive, and injuries or dis- eases of this portion are attended with very serious results. Inflam- mations of the membranes of the brain, especially of the arachnoid and pia mater, are consequently very fatal. These inflammations of INFLAMMATORY DISEASES OF THE BRAIN AND ITS MEMBRANES. 49/ the membranes of the brain are followed by the formation of pus, or the effusion of serum or of lymph. The diagnosis during life is exceedingly difficult between inflam- mations of the substance of the brain, cerebritis or encephalitis, and that of the membranes, meningitis. Idiopathic cerebritis is, however, an exceedingly rare disease, and, with the exception of cases of idio- pathic cerebritis, caused in the tropics by exposure to the sun; cere- britis from severe injuries, such as concussion of the brain; cerebritis from cranial bone disease, and that resulting from the overwhelming effect of alcohol, of which I have seen a few, we rarely meet with cases of cerebritis at all, except as secondary to inflammation of the membranes.* The effusions of pus, serum, or lymph in meningitis, pressing in the brain-substance, produce the gravest symptoms, and are fatal, unless relieved by medical or surgical means. Although we very rarely see the dura mater affected by inflammation, as an idiopathic disease, it may readily become so as a result of injuries to the scalp, owing, I suppose, to an extension, by sympathy, of inflam- mation of the pericranium, which is the external periosteum to the dura mater, which is really the z;z/^r;/«/ periosteum of the skull, lying, as it does, between the bony cranium and the arachnoid membrane. The anatomical structure of these membranes is the same, and there is a very close relation existing between them, as a vascular commu- nication exists between them through the medium of the cranium. We find, therefore, that injuries that affect the external covering of the skull are often followed by inflammation of the dura mater. Thus a comparatively slight scalp wound may be followed by the most serious consequences, perhaps of a fatal nature. I regard, therefore, all cases of external injury to the head as of great impor- tance when we bear in mind the above anatomical relationship be- tween the pericranium and the dura mater. The early symptoms are not readily recognizable, but those of the resulting effusion are those indicating compression of the brain, the patient becoming * Dr. Jonathan Hutchinson, of England, says it may perhaps be doubted whether the occurrence of diffuse inflammation of the brain substance as an acute disease has as yet been proved, excepting as a result of wounds. Even as a traumatic lesion, he says, its special features have by no means been accurately studied. It is, however, highly prob- able that after penetrating wounds of the brain, its substance may inflame, just as the cellular tissue of a limb may, the inflammatory processes beginning at the site of the wound and rapidly spreading through a large part of the hemisphere. It is probably in the perivascular spaces that the process chiefly spreads, and it is in these that the micro- scope will detect the most abundant results. 32 498 PSYCHOLOGICAL MEDICINE. Stupid, sleepy, and lethargic, passing into a state of coma, from which he can be roused with difficulty, or not at all. The breathing is heavy and stertorous; the pupils contracted or dilated; the pulse is full and strong and slow; the bowels act involuntarily; and retention of urine is often found. If after even a slight injury to the head our patient becomes dull, sleepy, and comatose, and the other symptoms I have spoken of, w^e should suspect effusion on the surface of the dura mater, we should apply cold to the head, open the bowels by croton oil dropped on the tongue, keep the patient perfectly at rest, and exclude light from his room. The trephine offers us, however, the only means of relieving the compression, although it is extremely difficult to determine with accuracy the exact seat of the effusion. In inflammations of the arachnoid and pia mater, which are so intimately united together that inflammation in one necessarily affects the other, the effusion of pus is rare, and the effusion of serum very common, varying in amount from an ounce to two or three pints. The effusion of lymph is usually found at the base of the brain, about the commissure of the optic nerves, the pons varolii, and the medulla oblongata, and we may also find it in large quantities over the surface of the brain, and running along the course of the fissure of Sylvius. We have, in meningitis, the stage of invasion and the stage of ef- fusion, but, as I have said, the first stage is not easy of diagnosis, as the symptoms are often obscure. In a typical case we have rigors, pain in the head, intolerance of light and noise, and irritability of temper. In a child, the attack may begin with a violent scream or cry, and the head is tossed around in every direction. The heat of the head is increased, and the tem- perature considerably increased. The skin is hot and dry and the pulse quick and strong. The urine is scanty and high-colored, and the bowels either constipated, or, if open, the stools are pale in color and offensive. The two most marked symptoms, and those on which I would lay special stress, are the existence of contracted pupils and vomiting. If these two symptoms co-exist, the diagnosis is certain when the other symptoms I have enumerated are present. These are the symptoms of the first stage of meningitis. In the secondary stage, or stage of effusion, our patient falls into a comatose and le- thargic condition, with a full, slow pulse, and dilated pupils — the latter symptom indicative of effusion. We may have squinting, con- vulsions, rigidity of one extremity, perhaps, involuntar)'' discharge of faeces and urine, jactitation, and finally death. Sometimes, in spite INFLAMMATORY DISEASES OF THE BRAIN AND ITS MEMBRANES. 499 of the most desperate symptoms, we shall get a cure, if we treat our patient skilfully, and with due regard to his diathesis. We must direct our treatment to the constitutional taint. Thus, if we are treating a rheumatic patient, we should give him colchicum and salicylic acid. If he is scrofulous, we should give him cod-liver oil and iron, and if syphilitic, the iodide of sodium or potassium and mercury. In other cases, antiphlogistic treatment, calomel in re- peated doses with saline purgatives, and early bloodletting, if it Is decided to bleed at all, at the very outset of the symptoms. In children, we may put leeches on the temples and a bladder of ice on the head, open the bowels by salines, and give calomel in re- peated doses, which will result, I think, in positive benefit. In the stage of effusion, with dilated pupils and coma, although the patient will probably die, we may blister the back of the neck to promote absorption of the effused fluids, calomel in grain-doses for some time, and the iodide of sodium or potassium five-grain doses three times a day, and we may possibly save our patient. Typhoid fever, as it is well known, presents very often at its outset the most marked cerebral symptoms, and is liable, perhaps, in some cases, to be mistaken for inflammation of the substance of the brain, or cerebritis. We may be called to see patients who may present most of the symptoms belonging to inflammation of the brain, namely, hot head, violent delirium, hot skin, full and rapid pulse, great thirst, and furred tongue, but, on very careful examination of the body, we may detect one or two of the characteristic rose spots which will en- able us to pronounce the case one of typhoid fever, and to give a favorable prognosis. It is often very difficult to detect typhoid fever, for the rose rash is apt, I think, to be very scanty, perhaps limited to one or two spots, and these attacks are likely to prove the most se- vere. I perhaps have spoken too hastily when I say we can give a favorable prognosis in these cases, for the presence, as I have just said, of a very few rose spots indicates an attack of great severity, and death sometimes rapidly ensues in these attacks. Respecting delirium tremens, we must diagnose between this dis- ease of debility and inflammation of the brain. The head in delirium tremens, instead of being hot and dry, is cool and moist, and the skin bathed in perspiration. The delirium, instead of being furious, is low and suspicious ; the tongue, instead of being dry, is coated with a moist, creamy fur, and, if death ensues, there is very likely nothing 500 PSYCHOLOGICAL MEDICINE. visible in the inter-cranial structures. While we treat an inflamma- tion of the brain by ice to the head, leeches, by low diet, calomel, and purgatives, we, on the other hand, treat delirium tremens by an entirely different plan — by nourishment, perhaps by stimulants, sed- atives, and careful watching and nursing. In acute mania, the inflammatory symptoms of cerebritis are want- ing, and the existence of a furious delirium is the only thing in com- mon in the two diseases. In the inflammation of the brain, or cere- britis attending concussion of the brain, in which the whole brain is very much shaken, capillary congestion takes places, and the inflam- matory process passes on to its destructive stages. In these cases, about forty-eight hours after the receipt of the injury, vomiting oc- curs, severe pain in the head, the pupils are contracted, the scalp is hot, there is intolerance of light and noise, the pulse is full, hard, and strong, and we have a violent delirium. In inflammation of the brain from disease of the cranial bones, of which I have spoken, we find a young person, probably of a stru- mous diathesis, who very likely has had, for a long time, a discharge from the ear, suddenly seized with a pain in the head, vomiting, de- lirium, contracted pupils, hot skin, loaded tongue, and the other symptoms of cerebritis, and this is a very fatal form of the disease. The treatment of these latter cases is very unsatisfactory, but where there is a discharge from the ear, we should encourage the discharge, apply blisters behind the ear, and employ a mild antiphlogistic plan of treatment. When the cerebritis is the result of the immediate effects of alco- hol, if our patient has a hot head, furious delirium, bloodshot eyes, we are, I think, in some cases, perfectly justified in abstracting blood, but never where, as in delirium tremens, which is not an inflammatory disease, our patient is broken down by previous excesses. Ice to the head, and saline aperients and tranquillizing measures are also necessary in these cases. NEURALGIA. 50I CHAPTER XXVIII. NEURALGIA. I THINK the nervous pain, resulting from a morbid exaltation of sensibility, which is to-day affecting so many people, and particularly so many American women, is, perhaps, in its treatment, and sometimes, also, in its diagnosis, very troublesome to the general practitioner. These nervous pains may simulate very serious organic trouble, and I have been consulted by more than one able physician, who thought that he was suffering from organic brain, or spinal cord disease, when really a nervous prostration had been the cause merely of an invet- erate neuralgia of great intensity, and where rest, change of scene, nervines and the constant current of electricity accomplished a speedy cure. In neuralgia, sensibility is both perverted and exalted. There is no inflammation, no fever, but the severity of the pain may be in- tense. The irritation causing neuralgia may be located in the brain, in the spinal cord, or in the trunk of the nerve that supplies the affected part, i. e., in the sentient extremity of a nerve-trunk. An aneurism of the femoral artery has given rise to excruciating pain in the knee, and I have seen numerous instances since the late war, where musket-ball wounds have healed nicely, but have left very se- vere neuralgia in the extremities. In neuralgia of the extremities, therefore, we should search for trouble or injury to the trunk of the nerve, whose sentient extremities are affected, and, if we then find no source of irritation, we may suspect the spinal cord or brain as the seat of irritation. The violent pains of neuralgia are situated either in the trunk or branch of a nerve, and occur in paroxysms of irreg- ular duration, and at either regular or irregular intervals. Among the most intense neuralgias may be mentioned tic douloureux or fa- cial neuralgia, affecting the facial branches of the fifth pair of nerves. In this form of neuralgia, the patient will writhe with the agonizing pain in the side of the face, beginning near the eye or ear, the pain being of an acute, stabbing, lacerating character, and darting like an electric shock into the upper and lower jaw, lips, eye, forehead, and scalp, and a strong light, a loud noise, a draught of air, or a mental emotion — all tend to aggravate this most intolerable disorder. We have to soothe the over-excited, central, nervous apparatus, and ex- amine for impairment of the digestive, assimilating and excreting 502 PSYCHOLOGICAL MEDICINE. functions. There are no structural changes to be found in the tri- facial nerve or its ramifications, the ophthalmic, superior maxillary, or inferior maxillary branches of the fifth pair of nerves. The infra-orbi- tal branch is the one I have generally found to be the oftenest af- fected as it passes from the foramen, the pain starting and radiating from this point on the cheek of the patient. All the cranial nerves may be, and are, peculiarly susceptible to neuralgia : the olfactory nerves, the exit of which is the cribriform plate ; the optic nerves, the exit of which is the optic foramen ; the motor oculi, the exit of which is the foramen lacerum anterior ; the trochlearis, having the same exit; the ophthalmic branch of the fifth pair of nerves, having the same exit ; the superior maxillary branch of the fifth pair, the exit of which is the foramen rotundum ; the inferior maxillary branch of the fifth pair, the exit of which is the foramen ovale ; the sixth pair — ab- ducens — of which the exit is the foramen lacerum anterior ; the seventh pair — facial nerves — the exit of which is the meatus auditorium in- ternum ; the eighth pair — auditory nerves — the exit of which is the same as the seventh pair; the ninth pair, glosso-pharangeal, the exit of which is the foramen lacerum post; the pneumogastric, or par vagum, the exit of which is the same, as also it is of the eleventh pair of cranial nerves, the spinal accessory; and, lastly, the hypo- glossal nerves, or twelfth pair, the exit of which is the anterior con- dyloid foramen. The neuralgic pain varies in character, is always excessive, and returns at irregular periods. It may be related to functional disturbance or irritation of the Gasserian ganglion, which we must soothe by Duquesnel's aconitia in g-g- ^-gr^in doses, and feed by cod-liver oil in small doses, as the nerve-cells of the whole central nervous system have to be fed in neuralgias. We should bear in mind that if we find redness, heat, or swelling of an affected part, we have to deal with a 7ie2iritis, not a neuralgia. Thus the pressure of a gravid uterus, in a patient recently under my care, produced a pressure on the pelvic nerves, principally in the sciatic, occasioning acute lancinating pain and partial paralysis. It was a case of puer- peral neuritis, of extreme intensity, and the first severe case I had ever met with. There was a fixed pain, tension, swelling, and ten- derness on pressure, and the pain increased when the muscles sup- plied by the sciatic were contracted. In the neuromata, or nerve- tumors, we may find a chronic neuritis. These tumors are formed on nerve-trunks, or branches, and vary in size from the size of a pea to that of an egg, and these tumors may be multiple. They are hard NEURALGIA. 5O3 and firm to the touch, very painful on pressure, and the pain extends to the peripheral terminations of the affected nerve. These cases may be treated by small blisters in the affected course of the nerve, by anodyne fomentations, and by the constant current of electricity, and internally by anodynes and alteratives. Extirpation of the tumor becomes advisable in a certain class of cases. If in the neuralgias other treatment fails, and our patient has a furred tongue and loaded bowels, and no appetite, an alkaline course of treatment and purgatives may sometimes accomplish a cure, and we must treat the diathesis of the patient. Among the neuralgias may be enumerated gastrodynia, angina pectoris, neuralgia of the kidneys or nephralgia, hemicrania, sciatica, visceral neuralgias, and intercostal neuralgia. I have recently seen rather an unusual case of intercostal neuralgia, in a lady about fifty years of age, in whom I found both disordered digestion and very marked spinal irritation. The pain, which was located in the ninth intercostal space, was in- creased by a full inspiration and by coughing. It also extended to the spine and was sharp and darting. This lady had suffered from repeated attacks of great severity, which had uniformly been treated with opium and without success. I found this patient's tongue heavily coated, a foul breath and constipated bowels, and very marked ten- derness on pressure in the dorsal region of the spine. I accordingly suggested a plan of treatment consisting of rhubarb and soda, made palatable by the addition of cinnamon and sugar; also the application to the tender spots in the spine of the compound mustard liniment, made up with the freshly prepared oil of mustard, to be applied on a small folded piece of absorbent lint, to be covered with oiled silk, and this to be repeated every night; also cod-liver oil in teaspoonful doses, and a tonic mixture containing strychnia in -^-grain doses ; also electricity in the form of central galvanization. I am informed that this plan of treatment resulted in a rapid cure. Phosphorus and cod-liver oil, in such cases, together with electricity, should be em- ployed for months to restore the impaired nutrition of the central nervous system. In sciatica, which is most frequent in wet and stormy weather, we find intense pain in the course of the sciatic nerve, generally downward along the posterior surface of the thigh to the popliteal space, and very frequently extending down the tibial nerve. It is generally worse at night, and there are remissions more or less complete in character. We may have partial paralysis of a limb, with emaciation, and also dfagging of a limb. In addition to 504 PSYCHOLOGICAL MEDICINE. correcting any disordered state of the digestive organs, and building up the general health, we may employ a series of small fly blisters, use deep hypodermics of morphia and atropia, apply ice on the affected part or a cold douche over the hip and leg, a solution locally of cyanide of potassium, 5j to ovi of water, applied by friction on the course of the nerve, or, finally, the constant current of electricity. The hypodermic injection of atropia in one injection of j^- of a grain, which will cause some delirium, has cured entirely some cases that had resisted all other treatment. In lumbago, allied to neuralgia, the inhalation of ether will afford great relief In the visceral neu- ralgias, especially of the uterus and ovaries, the hypodermic use of atropia is decidedly the most efficacious mode of treatment at our command, using from y^ir to ^-^ of a grain according to circumstances. Also the constant current of electricity locally over the hypogastric region, or locally as the circumstances of the case may dictate. In neuralgia of the stomach there is nothing at all comparable to a combination of bismuth, carbonate of iron and morphia in powder, administered three times a day. In angina pectoris the nitrate of amyl, or nitro-glycerine pills, are indicated. In hemicrania, a neu- ralgic headache of one side of the head, when periodical, as it often is, a course of Fowler's solution, with laxatives, will accomplish a cure, as will also quinine, in many instances, when malaria is the cause, as very frequently is the case. In cases where hemicrania is not strictly periodical, I regard as by far the most valuable remedy cannabis indica in full doses. In the forms of visceral neuralgia, met with in hypochondriacal or hysterical cases, we must combat the asthenic condition usually existing by iron, quinine, and strychnia, or arsenic, and quiet the morbid exalted sensibility by a course of warm baths; a course of electricity is also of value in these cases.* The pathology of neuralgia consists in the functional impairment of the sensory nerve-cells of the central sensory tract of the nervous system, which is the seat of nervous sensibility, which functional disease consists of a worn, irritable, and hypersensitive condition, as Professor J. S. Jewell has ably demonstrated. The nutrition of the cortex of the brain is at fault, and there is often an anaemic state of the brain and cord to be combated. Neuralgic pain may doubtless, in some instances, be dependent upon peripheral vaso-motor disturb- ance, but the nerve-centres are generally the seat of the disease, and the lesion a lesion of nutrition. I regard the most important pre- * The galvanic current and static electricity are here indicated. NEURALGIA. 505 disposing cause of neuralgia to be neurasthenia, or nervous exhaus- tion, which, by impairing and lowering vitality, inducing an irritable state of the brain, causing sleeplessness and getting up a general asthenic state of the whole system, predisposes directly to neuralgia, by inducing the very lesions of nutrition in the brain, which I have just been speaking of We find, as the result of excessive mental labor, anxiety, depressing mental emotions, hsemorrhages, and sleep-^ lessness, a state of things which, in women, is associated with uterine displacements and spinal irritation, and, in men, by irritability, mental depression, and impending mental disorder. Malaria may also de- velop an extensive state of nervous exhaustion, exhibiting almost an incredible number of nervous phenomena. Professor Austin Flint, in his able writings on the periodical fevers, has very correctly, according to my experience in nervous diseases, pointed out that paroxysms of neuralgia will at times seem to take the place of the paroxysms of intermittent fever, recurring with the same regularity after intervals corresponding to those in the different types of inter- mittent fever, and a cure is effected by quinia or arsenic, which destroys the morbific agent, the cryptogamic vegetable organisms, which causes the malaria. For the general nervousness resulting from malaria, there is no known remedy comparable to arsenic. Too early educational pressure also operates in the production, as the child grows up, of exhaustive nervous neuralgia. The loss of nerve- tone in neurasthenia, or nerve exhaustion, affects the kidneys, and we often get obscure attacks of drowsiness as the result of deranged functional action of the kidneys and great excess of urea. As a result of nervous exhaustion, cerebral hyperaemia and anaemia may follow with their symptoms ; profuse perspirations also accompany marked nervous exhaustion, and the natural elasticity of the skin is lost. These cases of nervous exhaustion, or neurasthenia, furnish a great many cases of neuralgia, as a result of the impaired nutrition, and therefore I have classed neurasthenia, or nerve exhaustion, as the first great predisposing cause. There is one point of great importance to be spoken of here, and that is, that the tendency of neurasthenia is toward incipient insanity, and that if the physician notices in his patient, suffering from nervous exhaustion, mental depression and insomnia, and wishes to prevent active insanity taking the form of melancholia or mania, he must at once prohibit any further mental work, and prescribe a change of air and scene for his patient, taking him altogether away from business cares and anxieties for at least 506 PSYCHOLOGICAL MEDICINE. one month. Constant change of scene, as in travel, tires and exhausts rather than rests our patient with nervous exhaustion, and rest and nutrition are the two cardinal points in treatment, with quinine and arsenic as nerve-tonics, together with a course of electricity. The motor phenomena in these cases consist in a loss of muscular power and endurance. The circulation is also affected by exaltation of vaso-motor reflex excitability, so that palpitations occur, as the result of disturbed action of the heart. The vaso constrictors and the vaso- dilators, the two kinds of nerve-fibres connecting the peripheral vaso- motor mechanisms with the spinal cord and medulla, are also affected in a reflex way in nervous asthenia, causing circulatory disturbances, varying in extent and degree. The disturbances in secretions, to which I have alluded, are evidence of disturbance of the secreto-motor part of the nervous apparatus. There is inabilit}' to sustain prolonged mental effort, and the memory is defective. This is all indicative of brain-fatigue or brain-waste, and in these states the chloro -phosphide of arsenic will give good results if used for some weeks judiciously. I prefer beginning with 5 minims of the chloro-phosphide (Routh's formula) thrice daily after meals, and gradually decrease it until 2 minims are taken thrice daily, and order this continued for some time, and finally drop the arsenic altogether. At the end of about six weeks of arsenical treatment, the patient experiences a general sense of well-being, the elasticity of the skin returns, and the physical and mental tone returns. These cases all give the same history of being unable to do or en- dure, either mentally or physically, what they did in health ; and also that they are much more easily affected than when in health. They will also, very often complain of irregular action of the heart ; and a general diminution of vascular tonus makes them complain of vertigo, dimness of vision, and even syncope, from a change of position, such as getting out of bed to a standing position. We may also see, in asthenic cases, certain morbid psychical symptoms, distnist being one of the most prominent, and perhaps even gravest psychical symptoms. I have been thus explicit in my remarks on nervous exhaustion because very often, to cure neuralgia, you must first remove this influential predisposing cause. It was Rom- berg, I think, who defined neuralgia as the " prayer of a nerve for healthy blood," and it is a very good definition. Finally, among the remedial agents to be used in neuralgia, we may enumerate cod-liver oil and the whole series of animal fats, NEURALGIA. 50/ Thompson's solution of phosphorus, Duquesnel's aconitia, commenc- ing with one-two-hundreth-grain doses, and carefully increasing until physiological effects are produced, arsenic, quinine, gelsemium, can- nabis indica, the cautery, the galvanic or constant current of electricity, and the hypodermic use of morphia and atropia. By judicious treatment, even in the worst cases of facial neuralgia, we may accomplish perfect cures by carefully studying each indi- vidual case as it presents itself for treatment, and noting the patho- logical causes and associations of neuralgia. Thus, a cerebro-spinal neuralgia may depend upon inflammatory action in a limited portion of the cord or of the theca vertebralis. We may see intense neural- gia with caries of the spine ; also in the spinal nerve, situated at the seat of the disease. The neuralgia caused by carious teeth, and caries and exfoliation of bone, will cease upon the removal of the cause. I have met with many cases of severe visceral neuralgias where the trouble was evidently local and not the effect of a pre-existing morbid condition of the central nervous system, as in haemorrhoids, impacted faeces, and affections of the urinary organs, when, upon the removal of the pathological cause, the neuralgia disappeared and did not return. I have seen violent malarial neuralgias completely cured by a single twenty-grain dose of quinine after a purgative had been administered. Tumors of the brain, ossific deposits in the pia mater and near the base of the brain, exostoses and caries of the cranial bones, are all pathological causes of inveterate protracted neuralgia. The pain in these cases is dependent upon irritation of a portion of the trunk or ramifications of the affected nerve. I have a case at present under observation where the neuralgia, which is very severe, is dependent upon disease of the jaw. The exostoses, when they are the patho- logical cause of neuralgia, are situated in the frontal sinuses, or in the ethmoidal or sphenoidal bones, or on the roots of a tooth. Superfi- cial injuries, punctures, or cicatrices have also often occasioned neu- ralgia of a severe type. Sudden and forcible extension of nerves by tumors, aneurisms, or dislocations are also causes of neuralgia. Also contusions of the nerves may cause severe neuralgias ; punctures of the nerves occasion often terrible neuralgia, lasting long after the injury, and associated with tremors and even convulsions of the mus- cle supplied by the injured nerve. The fibrous enlargement which is left after the inflammation has subsided may give rise to the most serious neuralgia, which nothing 508 PSYCHOLOGICAL MEDICINE. but division of the nerve will relieve. If a nerve becomes involved in the cicatrix of a wound or burn, severe neuralgia will result; also if a nerve be severed by an injury. Chloroform is one of the most valuable topical irritants in neural- gia that we possess, and the profession is probably familiar with M. Brown-Sequard's conclusion recently advanced, " That chloroform applied to the skin of an animal produces a local anaesthesia without passing through the circulatory system." It must be applied so as to intensely irritate the extremities of the peripheral cutaneous nerves, and even in the severe pains of locomotor ataxy, through the rela- tions of the peripheral sensitive nerves with the posterior spinal roots, it alleviates these pains very markedly. The treatment of neuralgic pains by mechanical vibrations is of much interest now, being ad- vanced by Dr. Vigoroux, of France ; and from my own experience with localized faradization, irritating the skin by the mechanical vibrations of the induced current of electricity in cases of sciatica and locomotor ataxia, I can partially confirm his theor}^ as a practi- cal one. I have certainly seen rapid relief of pain by such peripheral irritation. The galvanic current also relieves pain by its revulsive effect when other agents have proved ineffectual. Dr. Vigoroux's experiments in treating and relieving pain by the vibrations of the tuning-fork, causing an anaesthesia in recurrent neuralgias, I have not yet employed. Dr. Vigoroux claims that the vibrations of the tuning-fork have the same physiological action in alleviating pain as has electricity. The action of the vibrations is localized by arming the terminal point of the tuning-fork with a wooden button, which is applied over the nerve which is the seat of pain, the terminal disc not to be of a diameter exceeding one centimetre. The effects are said to be the most rapid when the applications are over a sensitive nerve-plexus. When applied near the foramina, where the branches of the fifth pair of nerves pass out, the relief from the pain is rapid. Also in hemicrania or migraine, when the vibrations were communi- cated to the cranial walls rapidly, the pain was quickly relieved. I have no doubt at all of the truth of these statements, as they accord entirely with my own series of experiments with the induced or magnetic current of electricity for the relief of facial neuralgia and migraine. In my experiments I have not found that the rapidity of the vibrations seemed to matter much, local anaesthesia and analge- sia being produced in typical cases of neuralgia of the fifth pair of nerves, and also in migraine, in both instances. NEURALGIA. 509 In concluding this article on neuralgia, I wish to allude to nerve- stretching for the relief of the neuralgic pain in locomotor ataxy. The nerve should be reached by an incision two and a half inches long; a grooved director, with the convexity upward, is then to be passed under the nerve to be stretched, and then, by grasping the two ends of the director, traction may be made on a line perpen- dicular to the axis of the nerve, with sufficient force to lift it about two inches. There is no danger of injuring the nerve by this opera- tion, which I propose to have performed, in all cases of mine here- after, whenever necessary to relieve the " lightning " pains of loco- motor ataxy. The sciatic, crural, median, and radial nerves may all, I think, be very advantageously stretched in these cases, not only with great relief to pain, but with great improvement to incoordina- tion ; and, I think, this comparatively new operation will have great success in the hands of skilful operators. Professor Erb, of Heidelberg, in writing on the diagnosis and treatment of neuralgia, speaks as follows respecting electricity as a therapeutic agent in the treatment of neuralgia, and my own experi- ence certainly confirms the truth of his statement : Electricity has recently become the most important remedy in the treatment of neural- gia in consequence of the brilliant success that has attended its application in many dif- ferent forms of the disease, and in no other disease are the results of electro-therapeutical treatment so certainly established as in neuralgia. Of the two kinds of electricity now in constant use, the galvanic current (continuous current) is found to be the more active and applicable to a greater variety of forms of disease than faradic electricity. Faradic electricity (the interrupted current) is chiefly useful in peripheric neuralgia, when the* nerves can be reached by the current, and in cases where no remarkable anatomical change, as neuritis or the like is present, and thus especially in the so-called purely idio- pathic or " habitual " neuralgia. The galvanic current has at least the same action upon peripheric neuralgia, whilst, in addition, it is very effective in the central and deep-seated forms of the disease (cere- bral and spinal neuralgias and neuralgia of the roots of nerves). Moreover, by its " cata- lytic" effects, — that is to say, by its influence on the vessels, upon exudation and the pro- cesses of nutrition, — it exerts a wide effect on those neuralgias which are influenced by the faradic current. There are two methods of applying faradic electricity (interrupted current) : a. By conducting a strong current of the secondary spiral for a few minutes through the nerve by means of moist electrodes, one of them being placed on the nerve- trunk as near as possible to its central origin ; this plan must, for the most part, be fre- quently repeated, b. By producing energetic irritation of the skin with an electric brush, in the region of the distribution of the nerve at its point of emergence and over the points douloureux. The application of galvanic electricity is especially intended to modify the nutritive processes taking place in the nerve, to produce the so-called cata- lytic effects, and to lower the irritability of the nerves. The result of its application, either according to the polar or the direction method, seems to be equally good. In the polar method, the anode (positive electrode) is applied first upon the nerve trunk (when 5IO PSYCHOLOGICAL MEDICINE. possible, in the immediate vicinity of the proper focus of the disease) and then upon the point douloureux, and the cathode (negative electrode) upon some indifferent point. In the direction method, the descending direction is used by preference,.and the anode (positive electrode) is then to be placed upon the plexus or upon the roots of the nerve, and the cathode (negative electrode) is to be placed upon the nerve-trunk and the pain- ful points. As a rule, the duration of the sitting should be short, extending over from two to eight minutes, and repeated daily, or every other day. The strength of the current must in general be moderate. The effects are usually ex- perienced at once, and continue for a variable period, from two or three to twenty-four hours, ultimately, after a variable number of sittings, becoming permanent. On cases treated successfully by the spine-bag, Dr. John Chap- man, Physician to the Farringdon Dispensary, London, says : The cure of neuralgia, whether the disease be treated by drugs given internally, or by applications of various kinds at the seat of pain, or by the two methods conjointly, is confessedly almost always difficult, and in a large proportion of cases impossible. The cases reported below have been treated by a method altogether new. By stating each case with extreme brevity, I am enabled to present at one view within a small compass the results of several experiments; and I do this in the hope that they may produce such an impression on the minds of professional readers as may impel them to acquaint them- selves with the pathological and therapeutical principles of which these results are an expression. I shall hereafter publish an exposition of those principles, illustrated by reports of cases hi extenso, and shall then give a full description of the treatment adopted. 1. Facial Neuralgia. — T. H., a gentleman, aged 35, who had been suffering during the previous fortnight, requested my advice March 18, 1865. He was in great pain, which had been continuous from the previous day, and which had wholly deprived him of sleep. The pain was chiefly on the right side of the face and head; but during the morning preceding my visit the left side had become invaded. The affected parts were verj' tender, and somewhat swollen. The head was rather hot, the face flushed, the tonoTie thinly coated with whitish fur ; pulse 92, full and strong. Several medicines pre- scribed by two phy^-icians in succession had proved of no avail. I applied a ten-inch spinal water-bag, containing water at 130° F. to the cervico dorsal region, and shortly afterwards left the patient's room. Within half an hour I returned, •when I found him asleep. The treatment was continued for two days by means of heat ; afterwards I used ice (at first in the lumbar region), and from the time he first fell asleep he continued free of pain, which has not since returned. 2. Facial Neuralgia. — Fraulein S., aged about 25, consulted me February 3, 1867, on account of neuralgia affecting the infra-orbital and dental branches of the trifacial nerve. The pain was not confined to one side of the face, but was sometimes most acute on one side, sometimes on the other; it increased at night, and kept her awake the greater part of each night. She had been suffering in this way for about three weeks before I saw her. Her general health was good. The affected part presented no trace of hyperaemia. She was treated by means of ice, and experienced almost immediate relief. After three days of treatment she felt and slept very much better; and before the end of the fifth day the pain had wholly ceased. Nearly a year afterwards she told me that it had never returned. 3. /a«,7/A>wrff/^za.— Mademoiselle M., aged 20, consulted me in August, 1867, when she was suffering from acute facial neuralgia, the chief foci of which were the infra- NEURALGIA. 5 1 1 orbital foramen and the mental foramen of the right side. The extreme pain came on in fits, sometimes at 8 a.m., sometimes at 2 p.m. ; but between the paroxysms the face continued to ache, and at times the patient had pain at the back of the head. She had suffered in this way about a fortnight before coming to me, and had had several similar attacks during the preceding year. The treatment consisted in the application of the double-columned hot water-bag. The malady was immediately subdued ; no distinct paroxysm occurred after the first application of heat ; all pain rapidly and completely subsided, and since that date has not returned. 4. Dettial Neuralgia. — A. W. B., a Russian gentleman, suffering from dental neu. ralgia, consulted me in September, 1867. The malady was chiefly confined to the teeth of both upper and lower jaw, but no particular tooth or teeth seemed to be especially affected. The pain was intermittent, and so severe as to interfere seriously with the patient's daily occupation. No cause of the disorder, which had continued some weeks, could be discovered ; and the face, so far from showing any sign of hyperemia over the seat of pain, seemed cooler than normal. In the course of the first day of treatment by means of the spinal ice-bag, the pain was completely subdued ; the cold was persisted in for some time, and during the remainder of the patient's stay in England he continued free from suffering. 5. Dental Neuralgia. — H. E., female, aged 21, suffering from violent and continuous pain, spreading over the teeth and gums of both the upper and lower jaw, consulted me January 17, 1868. The pain was most intense in the lower jaw and on the left side; she had intense headache also. The forehead and cheeks were notably hotter than normal, and she complained of great heat in the roof of the mouth as well as in the gums, which were swollen and sore. During the previous week she had had several teeth stopped with gold ; one of them became most especially painful ; and there was threatening of an abscess at its root. The treatment consisted in the application of cold across the occiput, and of heat over the cilio- spinal region, — in the first instance separately, and afterwards simultaneously. The pain was speedily and completely annulled ; it recurred, and was again annulled by the same method on several occasions. The patient volunteered the statement that, during the application of the heat, her mouth became perceptibly cooler. 6. Facial and Brachial Neuralgia. — Mary A. T., aged 44, first consulted me at the Farringdon Dispensary, December 28, 1867, when .she was suffering from neuralgia of the right side of the head, face, and neck, and along the right shoulder and arm, extend- ing to the fingers. The right half of the tongue was also affected. The pain, which was exactly limited to the median line, was described by the patient, " like as if some- thing is pulling the flesh off the bone, it's so dreadful, and sometimes as if the parts were screwed up in a vice." She was treated by means of ice applied along the whole spine. She improved imme- diately and rapidly, and, as early as January 15th, informed me that she had not had " a bit of neuralgia" during the whole of the preceding week. Up to this date (February 22d), the pains have not returned. 7. Intercostal attd Hypogastric Neuralgia. — Miss E., who first consulted me January 14, 1865, complained of extreme pain on the right side of the lower dorsal and upper lumbar vertebrae, extending outwards and thence forwards to the right hypogastric region. The pain had continued every day and night, with occasional intervals of three or four hours' release from suffering, and had lasted about twenty years. The pain was so dis- tressing and wearing that the patient's strength had become much impaired, especially by loss of sleep, and she was unable to undertake any regular occupation. The only sleep 512 PSYCHOLOGICAL MEDICINE. she could get was induced by brandy and narcotics. She suffered also nearly every morning, and frequently throughout the day from nausea, and occasionally vomited " water." I directed the patient to leave oif brandy, opium, and morphia at once and entirely, and treated her chiefly by means of ice along the lower half of the spine. As early as February 14th, the patient was enabled to say to me, — " During the last few nights I have slept throughout the night without being disturbed at all, an experience quite new to me." On the first of the following April she informed me that she had already been many days absolutely free from pain. The nausea and vomiting had ceased, and the bowels had become " open every day — quite a new feature." I have since heard from time to time that this patient continues well. 8. Intercostal Neuralgia. — A man came to the Farringdon Dispensary, October 21, 1867, and complained to Dr. Drysdale, whose patients I was seeing with him, of acute pain along one side of the chest ; no assignable cause for it could be detected, and we regarded it as a case of intercostal neuralgia. I recommended the application of the spinal ice-bag along the dorsal spine twice a day. " Sometime afterwards," as Dr. Drys- dale related to the Harveian Society, " the man returned to the dispensary looking so delighted that the doctor asked him what was giving him so much pleasure ? when he replied that the ' ice-bag had done him a world of good ; it had taken away all his pain with wonderful quickness.' " 9. Intercostal Neuralgia. — Mary B., aged 51, first seen by me November 27, 1867, complained of intense pain over the right shoulder, between the scapulae and along the right side of the chest. During the attacks of pain, which came on and went away sud- denly, the flesh, she said, quivered and tingled. She felt her body bent down as if she could not move it for fear of the pain. She was treated by the application of the spinal ice-bag along the lower half of the spine during an hour twice a day. The patient was surprised to find herself already quite free from pain during November 29th and 30th. Early in December it recurred very slightly, but on the 18th she said she remained free from neuralgia, except slight pain in the even- ing when fatigued by her work; she became much stronger, and was not so "nervous;" by December 28th all pain had gone ; and February 26th, when I last saw her, it had not returned. 10. Chest-Ache. — October 21, 1867, I was asked at the P'arringdon Dispensary by Dr. Drysdale to prescribe for one of his patients, Maria Williams, aged 22, who was then suffering from continuous aching beneath the right clavicle, together with " dreadful pains" in the head, dizziness, heaviness in the morning, and profuse leucorrhoea, which had lasted several months. I prescribed the application of a narrow 16-inch ice-bag along the spine during 30'' twice a day, — the bottom of the bag being placed on a level with the fourth lumbar veitebra. October 26th. The patient reported that the ice-bag had done her " a wonderful deal of good;" that the leucorrhoea had stopped, and that «// her head symptoms had van- ished. I requested her to persist in the treatment previously prescribed. By November 2d the pain beneath the right clavicle had quite ceased, and no one of all her troubles previously got rid of had recurred. 11. Mammary, Ovarian, and Uterine Neuralgia. — H. M., a girl aged 17, who was first seen by me February 24, 1863, and who was suffering from daily attacks of epilepsy {petit mal), complained of extreme pain in the region of the left ovary, which was tender on pressure, and increasingly so immediately before the patient's menstrual periods ; also NEURALGIA. 513 of pain in the right mamma, which was considerably larger than the left, and of " fearful cutting pains" in the womb during menstruation. I treated this case chiefly by means of iced-water applied along the spine. The result was complete cessation of the mammary, ovarian, and uterine pains ; the mammae be- came of equal size ; and the epileptic vertigo, which had continued many years, ceased entirely a month after the treatment began, and has never recurred. 12. Neuralgia of the Legs. — I was consulted June 25, 1867, by Mr. , M.P., aged 49, who complained of excruciating neuralgia in the legs. The pain was of the ordinary tearing, shooting, and stabbing kind, sometimes in one limb, sometimes in the other, and affecting one heel almost continuously. This was often so acutely tender that he could not bear to touch the ground with it. As a rule the patient suffered most at night, and could rarely get any refreshing sleep. The malady came on about sixteen years ago, and had recurred at intervals ever afterwards. Until the morning he came to me he had never been free of intense pain for nineteen days. The patient was in the habit of drink- ing daily about a pint of sherry, which I advised him to give up. The treatment consisted in the application of a spinal ice-bag along the lumbar and the lower half of the dorsal vertebrae. The patient informed me, July 25th, that, "prac- tically speaking," he had had no pain since he began the treatment, and that he had slept well. I advised perseverance with the ice, and abstinence from wine. The patient wrote to me, August 21st, " I continue to receive great benefit from the ice application, and shall continue it." The pain afterwards recurred in a mitigated form, but was greatly subdued by the ice, and, I incline to believe, would be quite cured if the patient would wholly abstain from wine. 13. General Neuralgia. — June 22, 1855, I was consulted by Lord — — , on account of neuralgia affecting different parts of the body ; the walls of the chest and the lower ex- tremities were chiefly involved. The attacks generally came on suddenly, and lasted about fifteen hours, sometimes longer. The pains were of an acute, stabbing, and seem- ingly spasmodic character, and were often brought on by vigorous muscular exercise, especially deer-stalking, which his lordship is very fond of, but which his attacks either cut short or prevented him from indulging in. I prescribed the application of ice along the spine, and five graiins of citrate of iron and quinine during a few days at a time occasionally. When I saw the patient again, April 27, 1866, he informed me that he had applied the spinal ice-bag as directed during several weeks at a time at three successive periods since he consulted me. He declared himself so greatly improved that he had been quite free from his malady for long periods together ; that, when it had recurred, the pains had been comparatively slight ; that he could resume violent exercises, including deer-stalking, without bringing on an attack ; and that in his opinion, had he continued the treatment regularly for a longer time, he should have been completely cured. 14. General Neuralgia. — Hannah E. complained to me, January 4, 1868, at the Far- ringdon Dispensary, of great pain in all the four limbs, but most especially in the fingers and toes, and in the left side over a spot about the size of half-a-cijown ; of headache each morning; of "dreadful" backache; and of excessive irritability of the bladder, involving the necessity of urinating about every five minutes. She was treated by the application of the lumbar ice-bag, 90^, twice a day. Within a week the pain in the limbs was almost wholly gone. By the 15th of January it, as well as her headaches, had quite ceased; her back was much better; and she was obliged to micturate only about every hour. On the 5th of February she reported herself free from every pain on account of which she had consulted me, and the irritability of the bladder was so much lessened, that she was only troubled with it at intervals of about 90'. i2> 5 14 PSYCHOLOGICAL .MEDICINE. On certain forms of visceral neuralgia, Dr. Clifford Allbutt, Leeds, says : [Neuralgia of internal organs has only lately received the attention which it deserves.] Gasiralgia is, perhaps, the commonest form of pain, from which some neurotic patients suffer, and it really is so easy to distinguish from dyspepsia, that one regrets the more they. so commonly are confounded. Its occurrence in the persons I have described makes it scarcely necessary to add that it is far commoner in women than in men. I do not re- member ever seeing it as a lai-val fot m ni malarious disease. Our present physiological knowledge discredits its supposed connection with the cceliac plexus, and refers the seat of pain rather to the vagus ; this, indeed, our clinical knowledge supports, for Anstie has shown that gastralgia often runs with angina and with asthma. It occurs mostly after the following fashions : Sudden and violent pain may seize the gastric region, sometimes biting right into the epigastrium, sometimes darting through to the back, sometimes gnawing at almost all the sternal region, sometimes twisting and griping from the epigastrium round the false ribs to the left. The attacks may come on so suddenly as (in one case now un- der my care) to interrupt the sufferer in conversation, and drive him into another room to writhe in secret, or they may come on more gradually, and never reach any great degree of intensity. In either case they have periods of greater and less severity, and of actual remission, long or short. Pressure, as in colic, generally relieves rather than ag- gravates, and the attack passes off to recur at intervals which seldom seem to observe any remarkable constancy. With the sensory disturbances are often associated motor disorders. In one marked case — that, to which I have already alluded — the stomach is the seat of volcanic movements of a flatulent character, as flatulence is associated also with abdominal colic. Twistings and irresistible gatherings of wind, which belch loudly from the throat, may accompany, follow, or replace the gastralgia, are dreaded by the patient as much as the pain, and are amenable to like palliatives, — to subcutaneous morphia, for instance, — while they set all alkalies, carminatives, antiseptics, and stomachics at utter defiance. In other instances some catarrh of the stomach is associated with gastralgia, a5 diarrhcea may accompany " interalgia," but this is less common. More common is vomiting, which may be spasmodic, or may be a revolt of the hypersesthetic stomach against the touch of the food. In the case of Sarah S., which I shall presently describe, the vomiting was a very prominent symptom. In some cases functional disturbances, elsewhere seem not .only to be an outcome of the same general habit, but to be directly consequent upon the gastralgia itself, though, of course, this is hard to prove. Irritable heart and wiry pulse, however, are very often associated with gastralgia in a way which seems rather direct than indirect. Asthma and angina seem rarely to have the direct but often the indirect connection, as they occur, not at the same time, but at different times in the same person. Spasm of the abdominal walls is often present ; perhaps we should always find it if we stripped the patient. The recti abdominis are knotted and the belly and epigastrium are nipped into hollows. This is mainly a reflex act, and the parts are at once released (as I have had occasion twice to notice) by a few whiffs of chloroform. "Points douloureux " seem scarcely to exist; certainly the epigastrium is rarely so tender as in dyspepsia and gastritis. Most persons, unless of a verj' vigorous and hard condition, have occasional tender vertebrre; and few women will not complain of differences in places when the spinous processes are successively pressed. The parox- ysms may give way as suddenly as they came, or they may vanish slowly ; the intervals are generally complete, or nearly so, but the motor disturbances may intervene and the interval be diversified by uncontrollable belching or capricious vomiting. Nausea, I think, is rare. Now, from what has gone before, it will be seen that the confusion be- NEURALGIA. 5 I 5 tween gastralgia and dyspepsia is not to be excused. There is no sharp pain from the epigastrium to the shoulders, consequent only upon injection of food, and relieved by vomiting or the prone position. The pain takes its own times of ebb and flow quite in- dependently of digestion, for in some cases indeed food gives relief; not long ago I almost cured a gastralgia by advising a patient, who had been starved for dyspepsia, to go home and live as generously as he could for a fortnight. He was utterly amazed to find that, so far from being the vi'orse for it, he was actually better and better. Nor are there any truly dyspeptic -symptoms; the tongue is rarely coated; red at tip and edges it may be, but often it is of thoroughly normal aspect; nor do the other symptoms, as observed in the secretions, in abnormal vomits, risings, acidity, and the like, bear out the supposition of present dyspepsia. At the same time, the mucous membrane of these neurotics is often irritable, and may also be subject to intercurrent catarrh. In the va- porous neuralgics the tongue is frequently large, flabby, and white at the back, the breath rather faint in odor, and constipation invariable ; while, in the irritable neu- rotics, the tongue is nearly always small and often red at the tip and edges, the breath, however, being sweet, and the motions, though often constipated, yet often again run- ning into diarrhoea. Bismuth, with small opiate additions, or oxide of silver are not uncommonly necessary in the kind of dyspepsia which may undoubtedly complicate gastralgia. It is with unusual pleasure we enter upon the treatment of gastralgia, for, instead of admitting our weakness, here we are certainly strong. Individual cases may, indeed, thwart us; but, as a rule, we can hardly fail to bring considerable relief. The continu- ous current I have rarely tried in visceral neuralgias, and, gastralgia being so often a complaint of women, it is seldom convenient to make any local application of this rem- edy. The first step to be taken, after forming a diagnosis, is to assure the patient that his complaint is not dyspepsia but neuralgia, and to put him upon diet as liberal as the worried stomach will tolerate. This must be done carefully. There are to be no large full meals, but small quantities of light nutritious food at frequent intervals during the day. Rum and milk in the morning, a little meat for breakfast, without much slop, a raw egg or a basin of soup at noon, a chop at the luncheon hour, with a glass of sherry and vegetables in moderation, tea and bread and butter at five, meat and light pudding at half-past six, with another glass of wine, and before bed a small cup of revalenta, with a biscuit. Cod-iiver oil will in most or many cases be required. And the patient, being released as to diet, must now be strictly warned as to the real causes of his ailment ; anxiety in home or business, many important engagements, prolonged suckling, teaching in schools during hours due to relaxation, reading at night, social dissipations; all these causes of "wear" must be inquired into and disposed of. The next important indica- tion is to administer such medicines as the case seems to call for on more general grounds. Anaemia,, which cannot alone cause gastralgia, but often favors its manifestation, must be met by steel and aloes. I think Dr. Anstie has said that the tincture of the sesquichlo- ride of iron seems to have a .special power over neuralgia, — a power which can scarcely be due to a mere improvement in the blood. This may be so ; certainly in one case of ob- stinate frontal neuralgia, with a white lock of hair, which was long under my hands, and in which everything, galvanism included, had failed ; in this case, large doses of the tincture of the sesquichloride succeeded better than any other remedy. But the same thing used to be said concerning the carbonate of iron, and probably with equal truth ; so that the special virtue, if any, resides in the metal, and not in one of its salts alone. It would appear, then, that in iron we have two kinds of value ; its value in ordinary small doses and in mild forms, when it removes simple anaemia, and its value in large doses, — doses such as half a drachm to a drachm of carbonate of iron, or of twenty tO' 5l6 PSYCHOLOGICAL MEDICINE. thirty drops of the sesqui chloride tincture, — when it seems, apa.rt from the presence of any definite anaemia, to have a special effect in modifying the morbid state of nerve-tissue- The same is true in some sense of quinine. This drug may be used in common doses of about a grain as a simple tonic, or in doses of ten to thirty grains as an anodyne. But I have here to refer to its use in the former way only, for large doses of quinine seem to have little palliative value in gastralgia, a fact which surprised me, seeing that the trigeminal centre and the vaso-motor centre, over which they have such power, are close to the nucleus of the vagus. Probably, however, quinine governs trigeminal neu- ralgia indirectly through the intermediation of vaso-motor change. Be this as it may, small doses of quinine with strychnine make a capital chronic medicine for gastralgia; but large doses, as rapid agents, in this ailment seem impotent. In the above combina- tion the strychnine is, however, the more valuable element, and few cases of gastralgia get on altogether without it. It probably acts best when given under the skin; but, until baffled in other attempts, one scarcely resorts to this form of administration. In the few instances where I have thus tried it, I have seen excellent results. Small doses should be repeated daily for several days, and the medicine carefully strengthened, if necessary, as its effects are seen. But of all the remedies for gastralgia arsenic is king, and to the use of arsenic I was led, when ignorant of its use by others, by noting the frequent con- currence of certain skin affections with gastralgia. Eczema, psoriasis, lichen, herpes, urticaria, all run with gastralgia in the irritable neurotics, and the eruptions generally occur in active, spreading, itching, hypersemic, symmetrical forms. In gouty persons, on the contrary, they are generally circumscribed and chronic. Arsenic, then, has some remarkable power, not over skin affections in general, but as they occur in these neu- rotics ; and it likewise cures or relieves their migraine, their tics, their asthma, their an- gina, their gastralgia, their colic, their capricious diarrhoea. Arsenic has not any specific power over skin affections merely as such, and hence the frequent disappointment of those who so use it ; but it is a remarkable modifier of a certain peculiar constitutional habit, of which, probably by way of the nervous system, it obviates the morbid tendencies. I always prescribe Fowler's solution in any simple water, a dose of which, containing three to five drops of the solution, is taken largely diluted thrice daily with meals. It should be carefully pushed to the edge of its physiological effects. The only palliative remedy of any importance is morphia used hypodermically, and of this I shall treat when I come to speak also of ovaralgia ; of the lesser palliatives the best, I think, are ether and chloro- form given internallj' in small doses. Respecting the treatment of " epileptiform neuralgia," Francis E. Anstie, M. D., F. R. C. P., Senior Physician to the Westminster Hos- pital, has made some important remarks upon the treatment in the earlier stages of that terrible kind of facial neuralgia to which Trous- seau gave the name of " epileptiform." Trousseau has described, with the brilliant eloquence so peculiarly his own, the tragic prospect which the sufferer from spasmodic tic has before him ; how hopeless it is that he should obtain a cure, and how certain that any relief obtained by remedies will be followed by a return of all his sufferings. He has laid it down as an absolute law that we are to expect nothing but a temporary respite or alleviation ; and he then proceeds to say that this minor amount of good is to be procured by very large and increasing doses of opium better than by any other means. There is no doubt that Trousseau's description of spasmodic facial neuralgia, as a dis- NEURALGIA. 5 I / ease hopeless of cure, was, at the moment, nearly correct. He is evidently speaking of a malady quite different from the milder neuralgia which may occur at any time of life, — a neuralgia which is rare, is confined to certain highly neurotic families, and which, among those families, only attacks a limited number of individuals who have passed the prime of life and entered upon the period of organic degeneration. The pain is of frightful severity, and is all the more difficult to bear because of the agonizing sudden- ness with which it darts through the affected nerve, perhaps aroused by some trifling and necessary muscular movement, such as mastication. That very large doses of opium are required to produce any great impression on the disease, if the medicine be given by the stomach, is also perfectly true. These doses must be continued, and rapidly increased, with the unfailing effect of seriously disordering the functions of digestion and assimila- tion. And, after all, the best result attainable is, that for a few weeks or months there may be a notable diminution of the severity of the pain, but with the certainty that, sooner or later, it will revive in all its intensity, and that then opium nor anything else will produce any perceptible impression upon it. The remainder of such a patient's life is rendered additionally miserable, in most cases, by a total derangement of digestion and consequent failure of nutrition. Dr. Anstie believes that a very miich better result than this may be obtained if the mal- ady be treated, from an earlier stage, according to the following plan : i. Counter-irrita- tion of a peculiar kind. 2. Nutritive tonics. 3. Subcutaneous injection of morphia, or of atropia, according to circumstances. I. Counter-irritation, to be useful in epileptiform facial tic, should not be applied to the branches of the fifth, but to those of the occipital nerve, at the nape of the neck. A blister in the former situation is as often hurtful as useful ; in the latter it is sometimes strikingly effective in gaining a short respite. And this is of very great importance in this awful disease, for the mere fact of such pain being allowed to continue is itself the worst possible omen. 2. The assiduous use of cod-liver oil, or of some fatty substitute for it, should be insisted on from the first, and is of the highest consequence. 3. Subcutaneous injection places us in a totally different position toward the use of opium in spasmodic tic. There is no longer any excuse for the use of enormous doses of opium from the first. It will be sufficient to commence with the use of one-sixth of a grain of morphia twice daily, increasing this, if necessary, to one-fourth and one-half a grain, and, in rare cases, to one grain. If this produces, along with the other measures, a notable remis- sion of the pain, it should be cautiously and steadily decreased, as circumstances may admit. In cases where morphia fails, atropia may be tried, in doses commencing at one- sixth of a grain. The injection of a less quantity than this would probably be useless in severe tic. Hopeless as was the cure of this form of neuralgia under Trousseau's plan, or any other which might be directed to the object of deeply narcotizing the patient, the pros- pect is by no means so cheerless when the subcutaneous injection is employed, with the precautions above mentioned. Although Dr. Anstie cannot say that he has ever seen a positive and complete cure of a facial neuralgia setting in under the conditions which have been described as peculiar to this disease, it is certain that the experience of those who have used the subcutaneous method extensively has proved that the attacks may be kept at bay, and their severity greatly mitigated when they occur ; witii this general re- sult, that the setting in of a facial tic in the later period of life, even in a patient whose family and constitutional history is of the worst augury, is no longer a fatal warning of life-long and scarce endurable misery. The economy in the necessary use of opium effected by the use of hypodermic rather than gastric administration is enormous ; and this not merely for the purpose of producing a given effect by a single dose, but also 5l8 PSYCHOLOGICAL MEDICINE. (which is most important in regard to the preservation of digestion and nutrition) with regard to the rate of increase in the doses. In the above remarks reference has only been had to those modes of treatment which are within the reach of every practitioner. It is necessary to state, however, that for those who are so circumstanced as to be able to provide themselves with proper apparatus for the generation of a constant galvanic current, the prospects of effecting good in even the most seemingly hopeless cases of spasmodic facial tic are very greatly increased. It is impossible for any candid person to study carefully the treatise of Benedikt without coming to the conclusion that we have in the constant current a remedy capable of effect- ing much more, in these severe cases, than any treatment by drugs, or any other means. A low-tension current from a Daniell's batcery (using from five to fifteen cells, according to circumstances) applied daily in seances of a few minutes, appears sometimes to entirely arrest facial neuralgia of the worst type, and commencing under the most unfavorable omens. Especially may we indulge hope, as it seems to me, in regard to the results which may be obtained from the galvanization of the sympathetic, in cases which would other- wise afford no rational hopes of more than the most trifling amendment. Any very con- densed account of this mode of treatment would be likely to mislead. To those who possess the requisite preliminary knowledge of electricity and electro-physiology, and also the opportunities of providing themselves with the somewhat expensive and troublesome luxury of a really effective constant battery, our author urges 'the necessity of a careful study of the English treatise of Althaus, and the German treatises of Remak, Benedikt, and Meyer, upon the medical uses of electricity. They will find facts therein which will at once arrest their attention, and engage them seriously in a most important branch of the therapeutics of nerve-pain. CHAPTER XXIX. LOCOMOTOR ATAXIA, CEREBRAL HYPER^EMIA, CEREBRAL SOFTENING, AND CEREBRAL SCLEROSIS. Locomotor ataxia, or posterior spinal sclerosis, is a disease of the nervous system, characterized in its inception by paroxysmal wander- ing " lightning pains;" by a diminution of the patellar tendon reflex, so that, if a quick tap is made midway between the lower end of the patella and the tuberosity of the tibia, the quadriceps extensor femoris does not contract as it does normally, and we get no jerk of the leg as we should do ; by diminution of the vesical and rectal reflexes, so that both micturition and defecation are impaired; im- pairment of the pupillary reflex, paralysis of the ocular muscles, and incoordination of the muscles. There is also plantar anaesthesia. The incoordination of movement is frequently so great that the LOCOMOTOR ATAXIA — CEREBRAL HYPEREMIA, ETC. 519 patient cannot walk without assistance. We may also find in loco- motor ataxia the crises gastriques of Charcot, attacks in which there is pain in the stomach and chest, with continual retching and vomit- ing- occurring at irregular intervals. There is apt to be distension, with pain in the stomach, and griping and flatulent eructations. To recapitulate, these patients have a staggering gait, diplopia, inability to stand with the eyes shut ; pupils insensitive to light, and analgesia of the extremities. There is a peculiar arthropathy, or osteo-arthritic change, apt to occur in locom.otor ataxia, in which we meet with great disorganizations of certain joints and spontaneous fractures, owing to an alteration of nutrition in the osseous tissue, dependent upon an influence of the nervous system. There is also an extremely rapid wearing away of the articular extremities. This extremely interesting subject of the osseous and articular lesions of locomotor ataxia has as yet received very little attention except from Dr. Charcot, of Paris. In this condition of the wearing away of the articular extremities of the long bones they can be knocked together audibly and without pain. There may be also extensive painless swellings of the joints, not confined to the joints, but extending down the long axis of the limb. As a result of the erosion and absorption of the head and neck of bones dislocations frequently occur. These spontaneous fractures generally take place while the patient is walking or making slight movements. There maybe great distension of joints, with relaxation of the ligaments and deformities from the removal of natural eminences and the deposit of masses of the bone. These arthritic changes are neurotic, and are essentially different from those of chronic rheumatic or osteo- arthritis, which attacks the larger in preference to the smaller joints. The fluid effused is of great quantity, and not limited to the joint, but, as I have said, expands underneath the muscles extending down the long axis of the limbs. The head of a bone in ataxic arthrop- athy is destroyed with great rapidity. The synovial membrane and • .bone are alike affected. The incoordination of this disease is prob- ably to be accounted for by the inequality of tonicity of different groups of muscles, and also the loss of the muscular sense. It may, perhaps, be partly due to a limited muscular paralysis. Respecting the therapeutics of this disease, we have as yet failed in classing it among the curable affections of the nervous system, although there are a few cases on record of cure. Personally I have obtained great relief from the use of the constant current of electricity — galvanic 520 PSYCHOLOGICAL MEDICINE. current — using the negative pole at the sacrum, and rubbing the positive pole, to which is attached a sponge electrode up and down the spine, and on either side of the sixth and seventh cervical ver- tebrae, so as to quiet the irritation of the posterior roots. I think in one case, by counter-irritation, by small fly-blisters along the. course of the spine, by the constant current applied as I have de- scribed, and by the use of the chloro-phosphide of arsenic — Routh's formula — in 5-minim doses, thrice daily, I succeeded in curing one case in its incipient stage, making my patient use crutches. I also gave cod-liver oil freely, and the patient was made to rest as much as possible. The nutrition of the spinal cord was markedly increased by these means. In my case there was no incoordination, and no loss of the pupillary reflex, but the patellar tendon reflex was much diminished, and the lightning pains and partial amaurosis were pre- sent. I think if we could see this disease in its incipient stage, which we seldom do, that we might hope, by appropriate treatment, for better results than we generally obtain. To relieve the pains, both the galvanic and faradic currents are sometimes very useful, as are also the hypodermics of morphia, and sometimes chloroform locally, a lock of cotton being saturated with it and placed under a watch- glass on the affected part. The tribasic phosphate of silver has lately been recommended by Dr. Allan McLean Hamilton as a remedy, in ^-grain doses, with the effect, it is claimed, of relieving pain and in- coordination.* Nerve-stretching is also, I think, destined to play an important part in relieving the terrible lightning pains of locomotor ataxia. I think that the incessant pains, which undergo exacerbations, can be * Dr. J. Lockhart Clarke speaking of the prognosis and treatment of this disease says, that the prognosis is generally very unfavorable. An early diagnosis is of the greatest importance, as it is chiefly at the first invasion of the disease that the patient is most benefited by treatment. An important object is to protect the patient from cold and wet and keep him in an equable temperature. The whole of the body should therefore be enveloped in flannel. A good and generous diet, with wine or beer, seems best suited for the patient. Of the diff"erent medicines that have been used, nitrate of silver seems to have the most specific influence on locomotor ataxy, -^th of a grain gradually increased to one grain three times a day, after meals, is the best mode of exhibition. If it should irritate the bowels or bladder, it may be combined with morphia, cannabis indica, or bel- ladonna. The oxide of silver is a useful substitute for the nitrate, when the latter dis- agrees. Dry cupping along the spine has been found useful. For the relief of the severe limb-pains there is nothing so efficacious as the subcutaneous injection of morphia. Dr. Clarke has always found that constipation aggravated the pains. He recommends cod- liver oil, phosphorus, rest and the constant or galvanic current of electricity. LOCOMOTOR ATAXIA CEREBRAL HYPER.EMIA, ETC, 52 I very much relieved, and that after either the sciatic, crural, me- dian, or radial nerves are reached by incision, they should be lifted about two inches, as, by M. Gillette's operation, recently performed in Paris on M. Debore's patient, the traction on the nerve being made in a line perpendicular to the axis of the nerve. There is no fear .of injuring the nerve, and experience teaches that the incoordi- nation is greatly improved, and that immense relief to the pains is afforded, and they may even entirely cease. I would insist on the fact, and Dr. Radcliffe, of London, also advances it in his writings that, in some cases of locomotor ataxia, we may get a very decided amend- ment in the symptoms of the disease. The disease is generally, I think, confined to the lumbo-dorsal portion of the cord, and rarely ascends so as to implicate the cervical portion of the cord. Loco- motor ataxia may be distinguished from common chronic paraplegia by the fact that in the former disease there is no true paralysis either in the lower extremities or anywhere else. The gait is also very different, — in locomotor ataxia the heels come down at each step with a stamp, while in paraplegia the toes, as a rule, touch the ground first; and the gait, instead of being precipitate and staggering, is difficult and slow. The frequent impairment in sight or hearing, the strabismus or ptosis, injection of the conjunctiva, and the character- istic neuralgic pains of a boring and shooting character, are not found in chronic paraplegia. In diseases of the cerebellum, although we find a reeling and rolling gait, we do not notice the precipitate, staggering gait of locomotor ataxia ; neither do the heels come down with a stamp. If a careful examination is made, I see no opportu- nity for a careful physician to make a mistake in the diagnosis of this disease. It is of great importance that an early diagnosis be made in this disease if we are to get better results from treatment than formerly. We should remember, therefore, that we have in the first or pre- monitory stage of locomotor ataxia, paroxysms of pain of a neural- gic character, wandering, and of a stabbing, boring nature, generally in the feet and legs, a diminution of the patellar tendon, vesical, rectal, and pupillary reflexes, numbness in the feet and legs, a plantar anaes- thesia more particularly. As the disease progresses, we see the peculiar gait and the char- acteristic incoordination of movement, so that the patient is obliged to use a stick in walking; strabismus, ptosis, injection of the con- junctiva and perhaps contracted pupils, and in some cases some 522 PSYCHOLOGICAL MEDICINE. mental impairment, although this, I think I am right in saying, is rather a rare symptom. Dr. Rumpf, of Dusseldorf, has exhibited to his medical society a typical case of locomotor ataxia beginning with shooting pains in the legs, then weakness in walking, abnormal sen- sation in the feet and hands, tightness around the waist, and weakness of the bladder, passing at last into ataxia of the upper and lower extremities, with muscular force little impaired, but diminished sen- sation of the whole body, both to impressions of touch and heat and cold. Dr. Rumpf first saw the man, who was 40 years of age, on the 29th of July, and on the 29th of September following he was quite relieved and able for work. The only treatment used was the interrupted current, — the positive pole applied to the sternum and the electrode of the negative pole applied to the back and down the ex- tremities. The strength of the current was strong enough when applied to the median nerve to cause convulsions (by which is prob- ably meant powerful contractions). The applications were ten min- utes long and every other day. The improvement began at once. The pains disappeared, the sensibility returned, and the feeling of tightness disappeared also. The galvanic current was used at the beginning of September, alternating with the faradic. This case was reported in the jfoiirnal of Mental Science of July, 1882. Dr. Buzzard, of London, has exhibited to the Pathological Society of London three typical cases suffering from osseous and articular lesions in the course of locomotor ataxia. The first of these was a man in whom the right hip-joint was completely disorganized, the head and neck of the femur having entirely disappeared within about three months. The second case was a woman of 50 years of age, who was a patient of the National Hospital for the Paralyzed and Epileptic. This patient had suffered for about eleven years from tj'pical " lightning " pains in her legs and arms, and had been affected for about the same time with attacks of the crises gastriqiies of Char- cot, — attacks in which there is pain in the stomach and chest, with continual retching and vomiting, occurring at irregular intervals, some- times as many as four in four months, the longest period of exemption having been eight months. The other symptoms she exhibited were an ataxic gait, very small pupils not reacting to light, analgesia of extremities, defective muscular sense, and absence of patellar tendon reflex. One day, while walking along her ward in hospital, her right femur fractured through its neck. About one year later, while vom- iting in bed, her left hip-joint suddenly " bulged out." Since then LOCOMOTOR ATAXIA — CEREBRAL HYPEREMIA, ETC. 523 she has been unable to use either leg. Upon careful examination the movements of both hip-joints were found free, but limited in some directions, with crepitation more marked in the right than in the left. On the right side the top of the great trochanter was nearly- level with the anterior superior spinous process, and on the left the trochanter is extremely prominent and the bone enlarged. The conditions observed might be due, it was thought, either to spon- taneous fracture of the neck of the bone on each side, or to complete disorganization of the joint, with atropic changes and absorption of the neck and head of the bone on the right side, and similar changes on the left, associated with enlargement of the great trochanter from throwing out of new bone. The third case was that of a woman of 36, married, and an out- patient of the National Hospital for the Paralyzed and Epileptic. She had been a patient of Professor Henry Smith's in the King's College Hospital. This patient had for ten years been subject not only to the typical lightning pains in her extremities, recurring at intervals of a month or two and lasting three or four days, but also had had very characteristic crises gastriqiies. These had occurred at irregular intervals, between which she had felt quite well. She had never passed six months without an attack. She had distension, pain, vomiting, and retching and griping, and flatulent eructations, recurring daily for weeks at a time. Her other symptoms were stag- gering gait, diplopia, inability to stand with eyes shut, partial color- blindness, pupils insensitive to light, and analgesia of extremities. Three years ago her right leg became red and swollen, but not pain- ful, and these symptoms subsided under rest. In June, 1878, they recurred, and in September the swelling had gone down, but the knee-joint was useless. At the same time, the left leg began to swell, and was larger than natural when she was admitted into King's College Hospital at the end of the year. At that time the right knee-joint was found to be disorganized. There was grating, but no pains on moving the ends of the bones. The internal condyle was enlarged, and projected inwards. The external condyle could not be felt. The patella rested on the outer surface of the lower end of the femur, the ligamentum patellae being wasted. There was fluctuation in the joint. The left leg was swollen, and this knee-joint, which was ap- parently not affected on admission, became enlarged, and the leg dislocated outwards and backwards during the patient's stay of one month in the hospital. The muscles of the lower extremities were 524 PSYCHOLOGICAL MEDICINE. wasted. She was discharged at the end of January with leather supports to each knee, which enable her to move about with help. There has since been swelling and crepitation of the right shoulder- joint. At the last report, it felt as though all ligamentous connec- tions had disappeared from the right knee-joint. The ends of the bones could not be brought into apposition, and they were so loosely connected that the patient, before she put on the leather casing, had to splice them together with a bandage. They can be knocked to- gether audibly, and without pain. It seemed as though the condyles had been levelled off and the end of the femur turned into a rounded and smooth stump, whilst the upper end of the tibia is bevelled off inwards. The patella lies two inches above and to the outside of the end of the femur. Along the outer side of the inner hamstring was a firm, smooth, rounded mass, one inch by half an inch. On the left side the tibia and fibula were dislocated backwards and slightly out- wards. The condyles were rounded off, the inner one being enlarged. The patella lay over the end of the femur in front. These are very rare and interesting cases, and I am indebted for them to the Report of the Pathological Society of London, of which J. Hutchinson has been the president. Charcot first described this ar- thropathy occurring in tabes about fourteen years ago, but little attention has been paid to it here. The first case described in England was one by Clifford Allbutt, in 1869. The second one was reported by Dr. Buzzard, of London, in \}i\Q Lancet oi 1874. In France, cases have been described by Vulpian, Richet, Dubois, Bourneville, Voisin, Bourceret, and Tala- mon. The great disorganization of some of the joints, and the mul- tiple spontaneous fractures, depend primarily upon an alteration in the nutrition of the bone, dependent upon nervous influence, and are in themselves secondary to this faulty osseous nutrition. The very rapid erosion and absorption of the ends of the bones is very dis- tinctive. Dr. Buzzard, of London, has suggested that, as the gastric symp- toms might, with some confidence, be ascribed to sclerosal invasion of the roots of the vagus, very probably a change in some structure contiguous to these in the medulla oblongata might be discovered to be the lesion giving rise to the altered nutrition in the osseous system. Charcot, of Paris, had one case of a patient suffering from loco- motor ataxia, in whom the head of the humerus, apparently unaltered LOCOMOTOR ATAXIA — CEREBRAL HYPEREMIA, ETC. 525 in shape, was displaced under the clavicle, and projected strongly under the skin ; the bone was quite loose, with free and painless mobility. The opposite humerus was dislocated on to the dorsum of the scapula, and one knee was dislocated, the tibia and fibula being twisted and displaced up behind the femur, which was deformed from the loss of its outer condyle. In all these joints there was, accord- ing to Professor Charcot, remarkable freedom of mobility and absence of pain, and the femur was greatly altered in form. Respecting progressive locomotor ataxy, Dr. C. B. Radcliffe, Phys- ician to the Westminster Hospital, and to the National Hospital for Paralysis and Epilepsy, etc., says : This malady was discovered seven or eight years ago by M. Duchenne (de Boulogne), and described under the name of ataxic locomotrice progressive. In it there is no de- ficient action of the will upon the muscles individually, and no loss of muscular force or change of muscular structure ; but there is deficient action in that involuntary in- stinctive coordinating power by which various groups of muscles are made to work har- moniously together in such acts as standing, walking, or handling. The term ataxy (o, primitive, and Ta\Li, order), which has reference to the deficiency in proper coordinating power, is not very fortunate, for the adjective ataxic is very commonly used in a different sense, as in ataxic fever, where what is meant is low fever, in which nervous exhaustion is the predominant condition. To meet this difficulty other names have been suggested, but the satisfactory name has yet to be found, and for the present, therefore, we must be content to use the one employed originally, and call the disease in question ataxic loco- motrice progressive, or progressive locomotor ataxy, or ataxy simply. Until M. Duchenne (de Boulogne) drew attention to it, ataxy was confounded with spinal paralysis in general, and especially with that vague form of this paralysis which is known under the name of tabes dorsalis. The disorderly movements of the muscles were regarded as symptoms of paralysis.. It was not perceived that the muscles in which these disorderly movements were manifested were healthy, and behaved well in all respects ex- cept when they were called upon to act in concert. Moreover, it was not known that this loss of coordinating muscular power simply was associated with other symptoms in a definite category. In a word, to M. Duchenne (de Boulogne) must undoubtedly be ascribed the honor which belongs to him who discovers a disease, sufficiently definite in its character, which had been confounded previously with other and very dissimilar dis- eases. The case which serves me for a text is now in the wards. It is that of J. C, a sailor, thirty-four years of age, living at Islington, and admitted into the National Hospital for Paralysis and Epilepsy, on the 3d of April, 1865. The notes I have run thus : Present Conditio7t. — J. C. is a man somewliat under the average height and weight, well-proportioned, well-developed as to muscle, especially in the upper parts of the body, with scarcely any subcutaneous fat, with abundance of brown hair on the head and face, and with a complexion much dried and browned by long exposure to sun and sea. He is capable of walking without a stick, but his gait is peculiar — staggering, precipi- tate, the legs thrown about vaguely and spasmodically, and the heel brought down with force at each step. With his eyes shut, or in the dark, he reels over at once, and would fall helplessly unless prevented from doing so. In the sitting posture he can lift either 526 PSYCHOLOGICAL MEDICINE. leg steadily into any position, and keep it there ; and when the leg is put out in this man- ner he can keep it extended, in spite of a very strong effort on my part to flex it. In order to this, however, he must see what he is doing, for, if his eyes are shut, the leg at once becomes unsteady, and little force, comparatively, is required to bend it. The right leg is a little weaker than the left, but not to any very considerable degree. He finds it very difficult to come down stairs, or to quicken his pace much, and he is speedily fatigued by the acts of standing or walking. On being told to shut his eyes, and touch his nose with his forefinger of each hand in turn, he did so with tolerable accuracy, especially with the forefinger of the left hand. On being told to stretch out his arms, and keep them outj he did so quite well, but only so long as he was allowed to see what he was doing, for on holding a book before his eyes, his arms, shoulders, and neck and head — the upper part of his body generally — at once became affected with convulsive titubation. When the book was taken away these movements speedily came to an end, but not be- fore they had issued in a fit of crying and sobbmg, which was not a little distressing to witness. This fit took the patient quite by surprise ; and it could not be accounted for by the examination having been conducted roughly, or carried on for an undue length of time; indeed, the holding of the book before the eyes, which was its immediate cause, did not occupy more than a minute at the most. The muscles of the lower limbs generally are less developed than those of the upper limbs and trunk, but there is no appearance of wasting in them. Their electro-contrac- tility is perfect ; they stand out firm and hard when made to contract by the will, and the contraction seems every whit as strong as it ought to be. Indeed, as has been stated al- ready, when the leg is put out and stiffened, it is not in my power to bend it against the will of the patient, except by the exercise of great force. There is no tremulousness anywhere ; and no marked reflex movements are produced by tickling the soles of the feet. What the patient complains of chiefly, are excruciating, stabbing, boring, nipping pangs of pain, flitting from one spot to another in a very erratic manner, in paroxysms lasting from a few minutes to twelve, twenty-four, or forty-eight hours ; and generally fixing upon one spot only in any single paroxysm. These pangs are most frequently felt in the two feet, especially about the outer side of the metatarsal bone of the little toe ; they are also felt not unfrequently at the back of the thighs, in the nates, and in the upper arm about the lower part of the belly of the biceps. They are scarcely ever absent, especially at night; at night, too, there is often a sensation of great coldness, with some degree of con- striction, in the painful parts. Measured by the compasses, tactile sensibility is found to be much impaired in the feet (especially in the soles), in the lower halves of both legs, and to some degree, also, in the back of the thighs, in the nates, and in the palms of the hands. The ground is felt veiy obscurely, but so far as it is felt the sensations' are accurate — that is to say, it does not seem to the patient as if there were elastic cushions, pebbles, or other imaginary bodies, or as if there was nothing at all, under the feet. Very rough pinching is scarcely at all felt in the benumbed parts, but elsewhere the sensibility to painful impressions is keen enough. In the benumbed parts-, also, and in a lesser degree in some other parts, muscular sen- sibility (and with it probably the proper sensibility of the joints and bones) is manifestly diminished. In bed, for example, when there is no light, J. C. says that he cannot clearly tell where his feet are, and that not unfrequently his legs get quite out of bed without his knowledge. There is also very little feeling of pressure when the muscles of the feet and legs are squeezed with considerable force ; and in the arms, as well as in the legs, the faculty of measuring and adjusting the amount of muscular action necessary for any given LOCOMOTOR ATAXIA CEREBRAL HYPERiEMIA, ETC. 52/ act is evidently not as much alive as it should be. For instance, when two weights are placed in his hand, one after the other, one of them being at least a pound heavier than the other, he finds it difficult to say with certainty which is the heavier of the two. The sight of each eye is defective, and glasses afford no relief. The pupils are equal in size, and respond fairly to the light. The conjunctivas are injected. There is no arcus senilis. There is no squinting or ptosis. The heai-ing of each ear is so dull as to make it necessary to speak in a very loud tone in order to be heard. There are also constant singing and booming noises in the ears — " almost like the wind in the shrouds," he says. The memory is bad, the spirits are very despondent, the head generally " feels very heavy," and of late (this statement is volunteered by the patientj there has been a frequent temptation to commit suicide. The pulse is feeble, and about 70 in the minute. The appetite is good. The bowels are somewhat constipated. In any case a long time is spent over a stool ; " it won't come out," is the patient's own description of the trouble in this quarter. The urine is also voided slowly and with difficulty, although the urethra is free from stricture, and now and then it escapes in bed at night. Sexually, the state may be spoken of as approaching to, if not amounting to, spermatorrhoea. Previous History. — Five years ago J. C, it appears, began to suffer from pains in the legs and back, and to be unsteady in his gait ; about the same time, also, his sight and hearing began to fail, and from that time to this he has continued to get gradually worse and worse. Four years ago he had a sun-stroke in the West Indies, of which the imme- diate symptoms were violent agitation and shaking, without loss of consciousness, and for which he was taken into an hospital and bled ; but this accident was twelve months after his present malady had commenced, and, therefore, it is not possible to look upon it as a cause of this malady. C. was at sea seventeen years in all, chiefly in hot climates, as the West Indies and West Coast of Africa, and he continued at sea three years after he had begun to suffer from unsteadiness of gait and from the other symptoms which have just been mentioned. Once during the time he was at sea he had chancres, without secondary symptoms, and repeatedly he had the diarrhoea, but, with these exceptions, his health on all occasions appears to have been very good. He says that he was always very careless, often sleeping almost without clothes upon the bare deck or upon the ground, and that he was always " too much given to drink and women." For the last two years the sexual power has been much damped ; but before this time, according to his own showing, he appears to have been little better than a very satyr. Two years ago, when obliged to abandon his calling as a sailor, he was for a while treated in the hospital at Quebec for rheumatism. After- wards he found his way to this country, and became an out-patient first at one hospital then another. During this time he appears to have been frequently blistered along the spine, and on one occasion to have been salivated. For the rest I have only to add that his father died early in life of consumption, that his mother died young from some un- known chronic disease, and that a brother, the only member of the family besides him- self, is now dying of the disease which proved fatal to his father. M. Duchenne, whose description is the best as well as the first, marks out three stages in the course of the malady, of which this case is an example. In the first stage, the patient suffers from paralysis, often temporary only, of one or other of the motor nerves of the eye, from some degree of amaurosis, usually accompanied by unequal pupils, and from the peculiar boring, erratic pangs of pains from which C. suffered. In the second stage, in addition to the symptoms of the first stage, the characteristic unsteadiness of gait begins to show itself, together with diminished sensibility to touch and pain in the skin 528 PSYCHOLOGICAL MEDICINE. of the lower parts of the legs, in the skin of the soles of the feet especially, the interval between the first stage and the second varying in length from a few months to several years. In the third stage, the malady becomes more profound and general, the disorder in involuntary coordinate movement increasing in the legs and extending to the upper parts of the body, the anaesthesia increasing m the parts first affected and extending to other parts, not of the skin only, but even to the muscles, joints, and bones. M. Duchenne does not consider the affections of the bladder, the rectum, and the genital apparatus as essential symptoms of the disease in any one of these three stages ; he speaks of them as " epiphenomenes " only. So far as it goes, the history of C. does not tally with this division of the disease into stages, for in it the failure of sight, the pains, and the irregularity of instinctive coordinate movement are seen to have made their appearance together. Nor is this history altogether exceptional in this respect; and therefore the only conclusion to be drawn is that there are some cases, perhaps the majority, in which the symptoms admit of being grouped in the three stages indicated by M. Duchenne. In the majority of cases, undoubtedly, the principal symptoms of ataxy agree with those which are met with in C.'s case. There is the same irregularity of involuntary coordinate movement in muscles perfectly healthy in other respects, the same peculiar pains, and the same anaesthesia. Still there are other cases in which the pains or the anaesthesia are either not very conspicuous phenomena or else absent altogether. Thus, I have met with four cases out of seven, not very advanced in degree it is true, in which there were no pains to speak of, and with two cases (out of the same seven) in which there was no anaesthesia. In the majority of cases, perhaps, the eyesight fails at an early period, and in many cases this failure is associated with some paralysis, often transitory, of the motor nerves, one or other, of the eye, or of some branches of the motor nerves of the face ; but there are other cases in which none of these phenomena are present. In a word, the affections of the bladder, rectum, and genital apparatus are not the only features which must be looked upon as accidental, as " epiphenomes;" and the simple truth is, that the idea of the disease becomes clearer just in proportion as this fact is clearly realized. Ataxy, it is said, may be confounded with several diseases, especially with simple loss of muscular sensibility, with disease of the cerebellum, with general paralysis of the in- sane, with general spinal paralysis and common paraulegia, with saturnine paralysis, with Cruveilhier's disease, with paralysis agitans, and with chorea and some other affections of the kind ; but fortunately, as a rule, very little attention will serve to prevent such confusion. Simple loss of "muscular sense" has been supposed to be the cause of ataxy, and undoubtedly this is a malady frequently associated with ataxy, and most easily confounded with it. In simple loss of muscular sense, however, the sight can supply what is lost ; and thus, when the eye is open and the attention alive, the involuntary coordinate move- ments, as well as the voluntary movements of the affected muscles, are all executed regularly. In disease of the cerebellum there appears, at first sight, to be the same disorder in muscular movements as in ataxy, but this similarity is deceptive. There is now, curiously, in the same ward, and also under my care, a boy in whom there appears to be some congenital defect in the cerebellum, want of due development probably. This boy has had a very peculiar gait; he reels and rolls about in walking as if he were giddy or drunk ; there is nothing peculiar in the way in which he plants his feet ; and this way of walking is precisely that which appears to me more or less characteristic of disease in the cerebellum. In ataxy, on the other hand, the gait, as has been said, is staggering, precipitate, the legs thrown about vaguely and spasmodically, and the heels brought down LOCOMOTOR ATAXIA—CEREBRAL HYPEREMIA, ETC, 529 with force at each step. There is something very peculiar in the way in which the feet are planted ; the gait does not give the idea of giddiness; there appears to be some want of balance between the flexors and extensors in each leg, the flexors having the advantage ; and, in addition, the muscles, when they act, seem to contract with a sort of jerk, — spas- modically. In certain diseases of the cerebellum, also, other symptoms are likely to be present which will assist in the formation of a correct diagnosis, especially violent pains, augmented by movement, in one or other part of the head, and frequent and obstinate vomiting. Moreover, in these diseases the onset is generally sudden, and the progress uncomplicated with the peculiar pains and anaesthesia of ataxy proper. In general paralysis of the insane, the hesitation in speech, the tremulousness of the lips and tongue, the general tremulousness, the true paralytic weakness of the muscles as to voluntary movement, and the mental condition of the patient, must readily serve to prevent the unsteadiness of gait and other evidences of disordered co-ordinate movement from being confounded with those which occur in ataxy ; and in other respects, also, the features of the two diseases are sufficiently distinct. In general spinal paralysis and in common paraplegia there is true paralysis, more or less complete, of the muscles as to voluntary power; and the muscles, moreover, are much damaged as to their nutrition and contractility, and generally as to their sensi- bility, too. In the majority of cases, also, formication is associated with numbness, and, what has never yet been noticed in ataxy, the sensibility to difference of temperature is much impaired or altogether lost in the paralyzed parts. Vei'y generally there is tender- ness in some part of the spine, and not unfrequently pain in the same region or in the paralyzed parts; and, if there be pain, it is, as a rule, more like dull rheumatic aching than like the peculiar excruciating, stabbing, boring, nipping pangs of pain, flitting from one spot to another in a very erratic manner, and occurring in paroxysms of varying duration, which are present in C.'s case, and which are rarely absent in cases of the kind. And, in those cases where progression is possible, the gait is almost always suffi- ciently characteristic — not staggering, precipitate — the legs thrown about vaguely and spasmodically, and the heel brought down with force at each step, as in C.'s case and in other cases of the kind, but hampered and slow, partly from want of voluntary power over the legs, and partly from the muscles becoming stiff in moving, each leg being brought forward with evident difficulty, even with the help of an upward hitch of the whole side of the body belonging to it, and the part of the foot first brought in contact with the ground being as a rule, not the heel, but the toes. In saturnine paralysis it is the voluntary power over ceiiain muscles which is impaired and gone, and the muscles are atrophied and deprived of electric contractility when the malady has reached its height. Indeed, it is difficult to understand how this affection can be confounded with ataxy. In Cruveilhier's disease, as I showed in a former lecture {^Lancet, January i6, 1865), the wasted muscles are changed in great measure into fat, and, as it were, dissected away, and any errors in movement are such as may be accounted for by this atrophy and ab- sence ; whereas in ataxy the muscles are plump, and to all appearance perfectly healthy, and the errors of movement are those which refer to want of proper involuntary coordi- nating power. Moreover, in Cruveilhier's disease the pains and anaesthesia of ataxy are not met with. In chorea there is great want of coordinating power in muscular movement, but the rest of the history is quite different from that of ataxy, so different and so well known as to make it altogether unnecessary to recall it to your memory. And so likewise in regard to those other affections which come into the same category as chorea. And lastly, in paralysis agitans a mistake cannot well be made, for the general features 34 530 PSYCHOLOGICAL MEDICINE. of the disease are more akin to those which are present in general paralysis than to those which are characteristic of ataxy. In some cases Duchenne's disease has been associated with other diseases of the nervous system, as with Cruveilhier's disease, or with general spinal paralysis or common para- plegia, and in these cases the distinctive characters of the disorder may be somewhat masked; but in ordinary cases there can be but little difficulty in arriving at a correct diagnosis. The pathology of ataxy is yet in its infancy. The most marked change detected after death as yet is degeneration and disappearance, more or less complete, of the posterior columns and of the posterior roots of the nerves of the spinal cord. Mr. Lockhart Clarke has shown me some beautiful microscopic slides, which furnish most conclusive proof of this fact. But I am not prepared to think that these are the only changes to be met with. On the contrary, I fully believe that corresponding changes will eventually be found in those parts of the cerebrum, wherever they are, which have specially to do with the co- ordination of muscular movements. The prognosis is full of gloom. The progress of bad to worse may be slow, very slow, but as yet there is too much reason to believe that the term " progressive," in the sense, of going on from bad to worse, is not misapplied. Still I know of two cases which jus- tify a much more hopeful opinion. The treatment in C.'s case consists in good food and rest, in hypophosphite of soda and cod-liver oil, and in the electrifying of the region of the cord with free positive elec- tricity, and we shall see in time whether any good will come out of it. I am not very sanguine ; at the same time I have this to encourage me — that this is the kind of treat- ment which has done and is doing good in the two cases to which I have just referred. Dr. Julius Althaus, Physician to the Royal Infirmary for Diseases of the Chest, City Road, says : [This disease, recently described by French physicians as progressive locomotor ataxy, was first described more than thirty years ago as tabes dorsalis, yet the nature of the complaint and the connection which exists between the symptoms manifested during life and the structural changes found after death have, until quite recently, been mis- understood.] Tabes dorsalis is first spoken of in the works of Hippocrates, and was by the father of medical literature believed to arise from excesses in sexual intercourse, the chief symp- toms of the disease being spermatorrhoea, marasmus, and hectic fever. This meaning of the term, however, has gradually changed, and those authors who wrote on tabes in the first decennia of this century understood by it atrophy of the posterior portion of the spinal cord, brought on, not merely by sexual exhaustion, but also by exposure to wet, rheuma- tism, gout, and other causes, the chief symptom being a peculiar form of paraplegia. The disorder was chiefly investigated by English and German physicians, such as Aber- crombie, Hufeland, Steinthal, Romberg, and others. Their descriptions, although in some instances most eloquent, were, however, to a certain extent, wanting in accuracy, inasmuch as several different affections of the cord were comprehended under the name of tabes, and a clear distinction was not drawn between tabes and pai^aplegia. It was only after a more careful clinical study of the symptoms had been made, and after patho- logical anatomy, aided by the microscope, had stepped in, that a peculiar disease of itself, and one characterized by uniform structural lesions, could take its place in our nosologi- cal system. The chief credit of the anatomical investigations is due to Professors Vir- chow, Tiirck, Rokitansky, and Leyden, and in this country to Dr. Gull and Mr. Lockhart LOCOMOTOR ATAXIA — CEREBRAL HYPEREMIA, ETC. 53 I Clarke, who have shown that, in well-marked cases of tabes, an actual waste of nerve- fibres of the posterior columns of the spinal cord takes place, together with the formation of amyloid corpuscles and considerable proliferation of connective tissue. The first who drew a distinction between this disease and paralysis was Dr. Todd. He said in an article on the nervous system in his Cyclopcedia, that two kinds of paralysis might be noticed in the lower extremities ; the one consisting simply in the impairment or loss of voluntary motion ; the other distinguished by a diminution or total absence of the power of co-ordinating movements. In the latter form, while considerable muscular power remained, the patient found great difficulty in walking, and his gait was so totter- ing and uncertain that his centre of gravity was easily displaced. In these few words we have a good description of the system of ataxy, upon which lately so much stress has been laid by French physicians. The term " ataxy " is as old as that of " tabes," for it also originated with Hippocrates ; and it has likewise entirely changed its meaning in the course of time. Some authors have applied it to chorea, others to fevers, others to various nervous disorders. At present, however, we understand by ataxy, not a disease of itself, but merely a symptom to which various disorders may give rise, and which es- sentially consists of a want of co-ordination of voluntary movements, and a tendency on the part of the patient to lose his balance, but without actual loss of power, and apart from tremor, chorea, and paralysis. This symptom may be observed in disease of the cerebellum, and in poisoning by alcohol, lead, and mercury; but it is more especially connected with that disease which has been long familiar to us as tabes. The best clinical study of this symptom we owe to M. Duchenne de Boulogne, who, from 1858 up to this time, has published a number of memoirs, in which he described what he thought to be an entirely new disease, which he called "progressive locomotor ataxy," and which he believed to be a functional disorder of the cerebellum. His apparent discovery was hailed as a real one in P'rance, and Professor Trousseau actually proposed to call the new stranger " Duchenne's disease;" but, on looking more closely into the matter, we find that Duchenne's description is altogether applicable to our old friend, tabes. I have not the slightest hesitation in acknowledging the great ability and originality of M. Du- chenne's researches, which were perhaps more strikingly displayed in this case just on account of his being unacquainted with the previous literature on the subject ; yet, if I thought it desirable to attach a proper name to this affection, I should prefer calling it " Todd's disease," as Todd first drew the distinction between ataxy and paralysis eleven years previous to Duchenne. But the best plan is, perhaps merely to drop the term " tabes,"' as being too vague, and to call the disease under consideration " progressive locomotor ataxy, or wasting of the posterior columns of the spinal cord." The following details of a case of this affection, which I have had under my obser- vation for about five years, are well suited to illustrate the symptoms and progress of the disease : R. B., a commercial traveller, aged 37, a tall and rather spare man, with a sallow complexion, first consulted me in February, i860, when he gave me the following his- tory. His mother had always beeia healthy, but his father had for the greater part of his life suffered from epilepsy, and died in a fit. The patient was brought up to the law; but in consequence of a disappointment he left that profession, and enlisted as a soldier. He served in Australia and Canada, and during that time suffered much from rheuma- tism. He never exceeded in drinking, but occasionally in sexual intercourse. He twice had gonorrhoea, but no syphilis. He suffered for a long time from haemorrhoids, for which, in 1855, he underwent the operation by ligature, and he ascribed the commence- ment of his present illness to that operation, saying that he never felt quite the same man after the hsemorrhoidal flow had ceased. He left the army in 1856, and married. He is 532 PSYCHOLOGICAL MEDICINE. now father of a healthy child. For the last eighteen months he has been a commercial traveller, and as such he is always on the move, and frequently exposed to cold, damp, and great fatigues. In January, 1857, he first noticed that his sight became weak, and he had some difficulty in writing and reading small prints. Soon after he felt pains of a peculiar character, which he described as electric shocks through the legs, and as if the muscles were being rent asunder. These shocks came every two or three minutes. He underwent treatment by liniments and other external applications, but without relief. His gait now became tottering, and he had considerable difficulty in walking. He never goes out without a stick, and sometimes he is obliged to use two. In the summer of 1859 he consulted the late Dr. Todd, who told him that his case was incurable, and that he would have to be on the sofa for the rest of his life. He prescribed strychnine and iron, and after having taken it for some time the patient felt rather stronger, but there was no improvement in the special symptoms of the disease. Present State. — February 14th, i860: The patient's intellect, memory, and speech are quite normal. He does not suffer from headache, giddiness, strabismus, or ptosis. Both pupils are enlarged, the left more so than the right. He complains of weak sight, and the ophthalmoscopic examination shows the arteries of the optic nerve smaller than usual. His senses of hearing, smell, and taste are natural. Respiration and heart-sounds nor- mal ; pulse at the wrist rather feeble, but quite regular. His digestion is tolerably good. Tongue clean, appetite satisfactory, but bowels rather costive. He complains of a sensa- tion as if a net were tightly drawn round the abdomen. He is occasionally troubled in passing the urine, but there is no stricture. The urine is of 1030 specific gravity, and contains a sediment of urates, but no excess of phosphates, and no albumen or sugar. The sexual power has not notably diminished of late. On examination of the back by pressure, percussion, galvanism, and hot sponges, no place can be discovered which is particularly sensitive. The patient complains of numbness in the hands, more especially in the third and fourth fingers of the left hand. He can distinguish heat and cold, and feels the prick of a pin and pressure distinctly ; yet the sesthesiometer shows a consider- able diminution of tactile sensibility in the fingers. The upper extremities are pretty well nourished, and the muscles answer well to a galvanic current of moderate power. He can bend and stretch the arms with force, but he finds it difficult to button his shirt and to feed himself. The lower extremities are more affected than the upper ones. The patient has had sensations of " pins and needles " in the feet, but these have for some time past given place to numbness. He says that in walking he has a sensation as if the steps rose under his feet. He must continually look at his limbs in order not to lose his balance, and can scarcely walk at all in the dark. If told to shut the eyes or stand with both feet together, he begins to stagger. In walking he throws the legs forwards with a jerking motion ; and, as he cannot measure his distance from the ground, he puts his foot down with great force. If lying down he can bend and stretch the legs with con- siderable power ; but he seems to exaggerate every movement, all muscular contraction being, not slow and equable, but violent, sudden, and jerking. I ordered the patient thirty minims of the syrup of iodide of iron three times a day, sulphur baths twice a week, and a pill of aloes and myrrh at bedtime. After having used these remedies for about a month, there was a marked improvement in every respect. The pains were nearly gone, the sight was rather better, the walking decidedly steadier, and less fatiguing, and the feeling of numbness slighter. He went on favorably until March, 1861, when, having a long and very laborious journey to perform, he returned con- siderably worse, and from that time the disease gradually gained upon him in spite of all treatment. In 1863 he had a course of nitrate of silver, but the affection was then evi- dently too far advanced for any medication to do good. The sight got rapidly worse, LOCOMOTOR ATAXIA — CEREBRAL HYPEREMIA, ETC. 533 and he became at last completely amaurotic. The sensation in the lower extremities was also entirely lost. The patient was now confined to his room, and during the last six months of his life he never left his bed. His intellect remained unimpaired to the last, and his disposition was always cheerful. He died in January, 1865, of a sharp attack of bronchitis. [The author then describes in detail the anatomical changes which are found in patients who have succumbed to this disease ; after which he proceeds to an elaborate analysis of the special symptoms, laying chief stress on the affection of the cerebral nerves and the pains in the first stage, and on the symptoms of ataxy and the loss of the different kinds of sensibility in the second stage of the disorder. The causes generating ataxy are then mentioned, and the diagnosis is fully gone into. He then continues :] The prognosis is not favorable, for up to the present time not a single case is on record in which perfect recovery has ensued. Indeed, as late as 1851, Romberg wrote that there was no hope for patients of this class, that a fatal issue was inevitable, and that it was but common humanity to inform them that therapeutic interference could only injure. This sad confession of impotence need no longer be made, and we may certainly con- gratulate ourselves on having far more control over the disease than we had formerly. Moreover, its progress is seldom rapid, although acute intercurrent disorders, such as ery- sipelas, bronchitis, and pneumonia, are grave complications, which may carry the patient off suddenly. Much must depend upon the period at which the case comes under treat- ment. If all the symptoms of the disorder are fully developed, the hope of a cure may be slight, although even then much may be done to alleviate the patient's suffering. The case is different if the patient presents himself in an early stage of the disorder. The fact that the cerebral nerves, with the exception of the optic, generally recover from their af- fections in the course of the disease, goes far to prove that previous to the structural changes in the cord there is a functional stage, in which much may be done by medi- cines. Moreover, we must bear in mind that Messrs. Charcot and Vulpian have found nervous fibres in the pi-ocess of reparation in the cord of a man who had died from ataxy ; and that therefore even at a later time we must not give up hope altogether, especially if the patient is placed in favorable circumstances. I now come to the treatment of ataxy, and will first say a few words about diet and regimen. This must depend a good deal upon the condition in which the patient is at the time he comes under treatment. If he is in a weakly state, plain and nourishing diet^ with iron, quinine, and cod-liver oil, should be prescribed. I have never seen a case in which lowering did any good. Hippocrates has recommended milk diet in erotic tabes, and Eisenmann speaks highly of the same in progressive ataxy. I have often given milk and brandy, two and even three times a day, with decided benefit to the general health, but have never found it expedient to insist on an exclusive milk diet. Exercise should be very moderate, and, for those who have undergone great fatigue, rest is most beneficial. Counter-irritants to the spine have been used by many physicians, but, as a rule, the benefit obtained has not been proportionate to the sufferings inflicted by their application. The moxa, the hot ii-on, issues, blisters, and leeches have been employed. I give the preference over all of these to the continuous galvanic current, applied to the lower and middle portion of the spine. It has in several cases seemed to me of decided benefit in lessening the pains, and also the disagreeable feeling of constriction which is often felt at the abdomen and the chest. The action of this agent is as rapid as that of the iron ; its application entails far less trouble and suffering than the latter ; and its efficacy is superior to that of issues, blisters, and leeches. Dry cupping on both sides of the spine is also useful. Iodide of potassium has been recommended by Duchenne and others; but no cases 534 PSYCHOLOGICAL MEDICINE. have been published in which this remedy has proved successful. On the contrary, sev- eral are on record in which it seemed to accelerate the progress of the disease. I have given it in two cases, but without any effect, and am certainly not in favor of its admin- istration. Iodide and bromide of iron are useful, but do not effect a cure. Mineral waters have been very frequently employed, both externally and internally ; and it seems that for a time they do good. Amongst the French spas, Bareges is one of the most recommended ; amongst the German waters, Marienbad and Wiesbaden have a special reputation ; while chalybeates and indifferent thermal springs, which often prove useful in certain forms of paralysis, have entirely failed in ataxy. On the whole, I should be averse to sending atactic patients on a journey to some distant spa, as rest at home, with certain remedies to be mentioned hereafter, is more beneficial than all the mineral waters in the world. If, however, there should be costiveness and abdominal plethora, Carls- bad, Marienbad, or Kissingen water may be drunk at home with benefit. Sulphur baths may also be taken at home, and I think highly of them. I have never employed them alone ; but they certainly seemed, in conjunction with other remedies, to do much in re- lieving the pains and diminishing the numbness. The patients feel more brisk and supple after the baths, and are almost always desirous of repeating them as often as possible. A sulphur bath may be prepared by dissolving from three to six ounces of the sulphuret of potassium in two pints of warm water, and adding this to the bath. Vapor baths and Turkish baths should be avoided. Nux vomica and strychnine have frequently been used, but generally seemed to do harm. Duchenne recommends faradization, and the late Professor Remak, of Berlin, praised galvanization as a curative agent. From faradization I have never seen any benefit; galvanization has proved useful at my hands, not only in the pain and feeling of constriction, but also in the affections of cerebral nerves, which are so frequent in the commencement of ataxy ; on the other hand, it has been powerless against the disease itself, more especially against the symptom of ataxy. Amongst the other remedies which have been used in this affection without much re- sult I will mention opium, bromide of potassium, secale cornutum, essence of turpentine, and arsenic. The only remedy which seems as yet to have done some good, in a very large proportion of cases, is the nitrate of silver, given in doses of one-tenth to a half grain two or three times a day. Professor Wunderlich, of Leipzic, was the first who employed silver in seven cases of this disease, in none of which, it is true, he obtained an actual cure, but in most of them considerable improvement. In 1862, Messrs. Charcot and Vulpian, in France, took up Wunderlich's idea, and used the nitrate in five other cases, and in each of them there was much amendment. Since then this remedy has been em- ployed in most cases of ataxy, and with somewhat variable success. In some it has so disagreed with the patients that it was necessary to discontiuue its use ; in others it had little or no effect; while in the majority of cases the remedy has proved, if not curative, at least very useful, and it is the one upon which most reliance can be placed in the treat- ment of this disease. I am in the habit of giving the silver combined with the hypo- phosphite of soda, and it seems to do far more in this combination than either of these remedies singly. I have, indeed, now a case of ataxy under my care in which the im- provement has, for the last six months, been so considerable under this medication that I am hopeful of a cure. Certain precautions should, however, be taken in administering the nitrate. I generally employ it for four or six weeks consecutively, and then discon- tinue it for a fortnight or three weeks, giving in the meantime a slightly aperient mineral water. After this the use of the remedy may be safely recommenced, and continued for a month or so. The gums must be inspected from time to time, as the peculiar colora- tion which silver produces in the long run fiist appears in the mucous membrane, and LOCOMOTOR ATAXIA — CEREBRAL HYPEREMIA, ETC. 535 only afterwards in the skin. With the precautions mentioned, however, no disfigurement of the patient need be feared. I have never gone beyond the dose of half a grain, and perhaps this is another reason why in my cases the remedy has been borne without any inconvenience. I should, however, not recommend all cases of ataxy to be treated alike; in this affection we must, as in every other, study each individual case by itself, and advise for it v^'hat seems, under the special circumstances, most likely to do good. Thus hysterical or hypochondriacal patients in whom ataxy may supervene will require a different treatment from plethoric persons, or such as have long suffered from rheumatism, or have been subject to privations and anxiety. Much is, therefore, left to the tact and discrimination which, together with knowledge, should in all cases brought before him, guide the doings of the physician. Dr. Johnson, at King's College Hospital, says : [The disease known as locomotor ataxy has been much discussed within the last few years by Duchenne and others, under the name of " ataxic locomotrice." This disease had until recently been included in the class Paraplegia ; but in well-marked cases there is no actual paralysis of the muscles, but loss of power to guide them. The patient is obliged to " lean on his eyesight as on crutches;" and if he shuts his eyes he stops, and sometimes falls. The posterior column of the cord is the part diseased. The following is the account of a case in a man forty years of age. He had from boyhood been engaged in the cod-fishery off Iceland, and thus for the greater part of the year was much exposed to wet and cold. The symptoms of the disease dated four years back.] On. admission, he was noted as a short, well-built, powerful man; no loss nor thick- ening of speech, and no deafness. He seemed to be intelligent, and gave a clear account of himself. The most characteristic point was his walk. He could stand very well with his feet apart, but when he put them close together he could not maintain his position, even when looking on the ground. On taking a step, he would advance in a hesitating, tottering manner. He always leaned forwards, and seemed to have some difficulty in balancing himself, especially when turning round. These points were better seen when he shut his eyes, for he was only able to totter a few yards, and then would fall. He walked pretty well when his eyes were off the ground, as when he was looking at the ceiling; but directly he closed his eyes he seemed to lose all confidence, and reeled like a drunken man. Although there was this loss of power in coordinating his movements, there was no loss of muscular power. He would lift heavy weights, and even carry patients round the ward. When sitting in a chair with bent knees, he could resist all attempts to straighten the legs. There was no muscular atrophy, and but slightly dimin- ished sensation in the left hand. The left side was rather more affected than the right. It appears he had a chancre four years ago, but it came on after the first appearance of numbness in the leg. There were some syphilitic patches on the tongue. There was no sore-throat nor rash on the skin; no nodes, nor glandular swellings anywhere. Lung and heart-sounds healthy. Urine pale; specific gravity loio; no albumen. Does not pass urine more than three or four times a day. His intellectual faculties do not seem impaired; he has slight loss of memory. His sight is not quite so good as it was. He has no pains in his head nor down the spine. Hearing and speech good. No affection of the cranial nerves apparently. Appetite good. Bowels open; no loss of power over the sphincters. He was put on a liberal diet, and treated with iron and quinine. Galvanism was applied daily, with apparent benefit. During his stay in the hospital he seemed to improve a little. At times he would walk 536 PSYCHOLOGICAL MEDICINE. fairly well, but on wet days he was always worse, and depression of spirits would come on. He was discharged Feb. Sth, 1866. In a case of progressive locomotor ataxy, under the care of Dr. Hughlings Jackson, at the London Hospital, he observed that this was one of the most interesting cases of locomotor ataxy that he had ever seen : The patient was 39 years of age. The first symptoms obsei'ved, when 14 years of age, was I'jss of sight; but this improved so that in nine weeks he was able to see tolerably. He then became almost quite deaf, and then the senseof smell was lost. Taste has never been affected. There was also clear evidence of diminished sensation in the legs. The patient is liable to sudden and violent pains in the legs. The patient can get along when his eyes are open ; but his gait is precipitate, and he staggers. \Yhen he shuts his comparatively good eye, he can only manage to keep his legs for a moment. It is scarcely right to say that he can stand; a fairer description would be, he does not fall at once. He cannot stir a step with his eyes shut. Dr. Jackson particularly drew our attention to the fact that this patient could manage to walk when looking at the ceiling, although, of course, not so well in so awkward a position. He (Dr. Jackson) told us that a year ago he had had under his care a man suffering from locomotor ataxy who could walk whether he looked on one side or at the ceiling. And he remarked that, although most patients suffering from ataxy say they " must look at their feet,"- some can walk without doing so if their eyes are open. The last-mentioned patient could walk with his eyes shut if he merely touched a wall with his fingers without resting any of his weight on it. Another patient, who was quite blind, and whom we saw with Dr. Jackson at the Hospital for Epilepsy and Paralysis, averred that he could walk for a long distance in the park if he just touched the railing with one hand ; and, on trial, it was found that he could get along much better than we could have expected in this way. More than one patient has said that, when they shut their eyes, they " feel as if there was nothing under them." It seems only necessary in these cases. Dr. Johnson said, for the patients to establish some definite relation with the objects about them. The patient's wife said that he began to stumble about a year after the blindness. He had first pain in his back, and there were some lumps on it; but no precise information could be obtained on these points. The patient has had difficulty with his bladder eleven years, and this may possibly be essentially a motor defect. If so, it is the only paralysis. The patient can stamp well with his legs, can resist flexion and extension fairly, and his legs are well nourished. There is no paralysis of any one of the cranial motor nerves, nor any history of squinting. The man seems intelligent. His talk is rather odd, but there is none of the thickness of general paresis about it. He talks in the loud harsh way some people, who have long been very deaf, get into. He was so deaf that it required much patience to obtain a few facts from him. Dr. Jackson at first tried to communicate with him by writing words of monstrous size on paper. In this way he got to know that the patient denied sexual excesses, and that he used to drink hard, and also, a fact that is worth notice, that he had smoked an ounce of tobacco a day for eighteen years. LOCOMOTOR ATAXIA — CEREBRAL HYPEREMIA, ETC. 53/ GENERAL OBSERVATIONS ON ABNORMAL STATES OF THE BRAIN; CONGESTION, SOFTENING, AND SCLEROSIS. I. Cerebral Hyper(Einia or Congestion. — This state consists in an increase in the quantity of blood contained in the capillaries of the brain. It may be active or passive ; the former, when the capillaries are filled with rapidly moving arterial, oxygenated blood; the latter, when from venous obstruction the capillaries contain slowly moving blood of a venous character. A man who is plethoric, or a child with a sensitive vaso-motor system, may have active cerebral hy- peraemia, owing to increase of blood-pressure; or the man may have an active arterial dilatation of vaso-motor origin from prolonged mental work, severe moral emotion, sunstroke, gastro-hepatic dis- turbance, or from toxic poisoning, as by alcohol, etc., or an increased atmospheric pressure, or lying with the head too low. We may get a partial active cerebral congestion from disease of cerebral blood- vessels or organic disease of the brain. Passive cerebral hyperaemia generally is the result of impeded return of blood from the head, due either to mechanical pressure on the veins, to tricuspid insufficiency with the associated condition of the lungs, or a diseased heart. Cerebral thrombosis in a vein, or a morbid growth or tumor exercising pressure on a cerebral sinus, may also be the cause of passive congestion. Clinically, when we are called upon to see a case of cerebral hyperaemia, we shall find a good deal of mental irritability in our patient. Slight causes may cause quite an explosion of anger. If we evert the lower eyelid, we shall find dilated and tortuous blood- vessels, which indicate very well the condition of the cerebral circu- lation. The conjunctiva may be suffused, and the patient will com- plain of headache, which may be slight or intense, and of flashes of light before the eyes, noises in the ears, and there may be nausea. There may be also confusion of mind and sleeplessness. The patient complains of a feehng of fulness or of throbbing in the head, and the head is hot, and the face of a deep-red color perhaps. The pulse is rapid and irritable, or slow and labored, and the pupils contracted, and the sight dim and defective. Motor power is lessened, so that the patient feels unequal to even slight exertions. Patients are unani- mous in giving a history of a heavy, unrefreshing sleep, if they do sleep, and of feeling much worse in the morning, and they complain of numbness in the extremities. Patients who pursue their ordinary 538 PSYCHOLOGICAL MEDICINE. avocations do their work mechanically, and feel as if they were semi- conscious, and pay, perhaps, very little attention to what you say, owing to the overwrought condition of their nervous system. This state may last, if not relieved, for days, weeks, or months, and there is a convulsive form in which there are slight muscular spasms, with or without loss of consciousness. A maniacal delirium may develop, as the result of a subinflammatory irritation of the brain, set up by the hyperaemic state of that organ, although there is a distinct de- lirium of congestion of the brain found only in advanced years. If cerebral hyperaemia is not relieved, there is danger of apoplectiform attacks, in which Russell Reynolds and Bastian have shown that sensation, consciousness, and power of motion are lost. The patient's senses are temporarily in abeyance, and the pulse and respiration are disturbed for a few moments. These symptoms pass off in a half- hour, but if they recur are more prolonged, both in duration and intensity. In the preliminary or premonitory stage the patient, be- sides motor weakness and irritability, may complain of pains simu- lating the pain of locomotor ataxia. They differ in not being so severe, but they sometimes are very annoying, and I have known physicians to be much disturbed by them. They often, I think, accompany neurasthenia, with an overwrought state of the nervous system, and are merely dependent upon the hyperaesthetic state of the whole cerebro-spinal system, as they entirely disappear as the patient recovers. The symptoms of cerebral congestion from the presence of alcohol are often very severe. The delirium may be very violent, the patient very aggressive, with no conception of his condition or surroundings, and there are often delusions relating to place, the patient fancying himself in some other locality. The face is of a dusky red color, and the pulse generally very quick, and vomiting is often present. It has so happened that the majority of cases that we have personally come in contact with have been those of active arterial dilatation of vaso-motor origin, in business and professional men, due to overwork and overstrain of the brain, with symptoms of premature mental decay. There has been in all these cases an overwrought state of the nervous system, owing to excessive care, worry, or mental anxiety, combined with overwork. Dr. Rus- sell Reynolds and Dr. Bastian speak of the final symptoms as being a condition of torpor and inactivity: "The mind becomes a blank. There is profound coma, stertorous breathing, and involuntary evacu- ations of both bladder and rectum. Sensibility, both general and LOCOMOTOR ATAXIA — CEREBRAL HYPEREMIA, ETC. 539 special, is lost, and voluntary muscular power reduced to a minimum. Convulsions may occasionally disturb the calm, or there may be fitful and momentary mutterings of unintelligible sounds; but usually in this latter stage the patient lies quietly, with labored pulse and breathing, and with flickering contractions of the muscles of the limbs until he dies." Treatinejit. — Of course, the indications for treatment are to control the amount of blood existing within the cranium, by bringing to bear antagonistic agents to the congestive state. Of course, we must order prompt cessation of the prolonged study and over mental work of professional men, and rest, both for them and the overworked business man. We must also, in cases where the congestion is due to mechanical impediments to the proper return of blood from the brain, do all in our power to keep the heart and lungs working normally. We must warn our patient to avoid great elevations and alternations of tem- perature, exposure to the sun's rays, alcohol, and sleeping with the head too low. Dry cupping at the back of the neck, placing the feet and hands in hot mustard water, an ice-cap to the head, ice held directly on the nape of the neck, the induction of free diuresis, un- loading a packed colon, the administration of the fluid extract of ergot in Jss to 3j doses ter die, in combination with the bromide of sodium, Fothergill's solution of hydrobromic acid, and last, but not least, the use of cerebral electrization, as described in the chapter on electricity, are all to be used/r*? re nata. The cautious use of stimulants is indicated when there is a feeble pulse and pale surfaces, as sometimes happens in asthenic cases. Many cases need a tonic after the first symptoms have been con- trolled, and there is none better in the case of overworked profes- sional and business men than " Warburg's tincture " in 5j doses be- fore breakfast daily. It is disagreeable, but should be taken clear on an empty stomach. It may be taken in divided doses in capsules, to obviate the disagreeable taste. The elixir of the phosphate of iron, quinine, and strychnia is also good, or the liquor acid. phos. comp. with five-minim doses of the tincture of nux vomica before each meal, the acid to be taken after meals. The advantage of static electricity as a nerve sedative I believe to be very great, and general faradization as an excellent tonic and refreshant to the system. Per- sons living by the sea should seek mountain air, avoiding too high altitudes, while those living inland and in the south will be bene- 540 PSYCHOLOGICAL MEDICINE. fited by a residence by the seaside during the summer months. Rest for body and mind is imperative. 2. Cei^ebral Softening — Brain-softening should be a symptom of senihty, associated with a general enfeebled condition and impaired nutritive power. The general failure of cerebral power is often thus found in the aged, with rigid arteries and arais senilis. It is, how- ever, we believe, becoming, owing to the complex influences of our modern civilization, a much more frequent occurrence in business and professional men than formerly. There is a premature mental decay, the result of the combined effect of overwork, mental anxiety, and loss of rest (the brain-cells missing the proper time for their nutritive renovation, which is during sleep), which is pre-eminently an American disease, the premonitory signs of which I have seen in many comparatively young men. Softening of the brain is aptly defined by Reynolds and Bastian as a disease characterized during life by impairment of mind, sensi- bility, and motility, and after death by diminished consistence and degeneration of the cerebral substance. I think that sometimes an erroneous diagnosis is made by confounding with cerebral softening, the state of brain-wasting accompanied by cerebral atrophy and hardening of brain-tissue. The seat of the morbid change is more frequently the cortex of the brain, the corpus striatum, and the optic thalamus. It has also been found in the pons, medulla, and in the cerebellum, and may be found anywhere in the brain. There is diminished consistence of the brain-tissue wherever we meet with this lesion. If the softening be due to embolism, we shall very likely find no symptoms but heart lesions, with the exception of momentary attacks of faintness. If the softening is due to arterial disease, Gowers has shown that we get mental deterioration, numb- ness, pains in the limbs, or slight local weakness. We may have hemiplegia and aphasia occurring in embolism, with mental deteri- oration. There may be apoplectic attacks, with slight loss of con- sciousness and the quick disappearance of the apoplectic symptoms, or there may be convulsive or delirious symptoms at the onset of cerebral softening. There is a class of cases, illustrated by the one we are about to give, not uncommon. Mr. , aged 38, had had domestic trouble and grief; had been addicted to rather free use of alcohol, and gave a history of what we presume was acute cerebral congestion, the re- sult of the combined effect of mental worry and alcohol, but which LOCOMOTOR ATAXIA — CEREBRAL HYPERiEMIA, ETC. 54I he designated as " brain fever." Upon coming under our care we carefully examined him, and found mental dulness, loss of memory, especially for recent events, the emotional nature very easily excited, the motor power much weakened, great disinclination for mental or physical effort, headache, articulation at times rather indistinct. Sight and hearing were good, there were no symptoms of paralysis and the reflexes were normal. Just previous to my seeing him, a small quantity of alcohol had produced a transient delirium, of which my patient had no recollection at all. He said, when I questioned him, that he was angry because one of his relatives had counter- manded his order for some whiskey, but had no recollection of having drank the liquor and the state of delirium it had induced. Respect- ing all this his mind was a perfect blank. He would read a newspaper for an hour and be utterly unable to tell in two hours what he had been reading. Although there was this profound affection, there was great mental improvement under the influence of electrization, the chloro-phosphide of arsenic (Routh's formula), iron, and strych- nia, and cod-liver oil. So much so that we discharged the patient, and he has passed the last six months in the country, living much out of doors and enjoying life very well. I do not consider that in his case or any other, that damaged brain- tissue can ever regain its lost functional power, but we may check the progress of the disease, in some cases, by strict hygienic regula- tions for our patient, and by rest, together with a similar course of treatment to that I have described. The premonitory symptoms of the apoplectic form of cerebral soft- ening are, according to Russell Reynolds and Bastian, those of tran- sient excitement, talkativeness, irritability, or wandering of thought, amounting to mild delirium lasting for a few minutes. He may then fall to the ground and remain partially or wholly insensible for a few moments, owing either to cerebral congestion or anaemia. Subse- quently to this he may be hemiplegic and, aphasic, or chronic soften- ing may go on, the patient becoming imbecile and powerless. The premonitory symptoms of the convulsive form and of the delirious form are stated by the same authorities to be in the former, a peculiar drowsiness, listlessness, weariness, impatience, or some flaw in memory, with distinct but momentary incapacity to under- stand what is said. There may be a slight hesitancy in speech, mis- pronunciation of a few words, a little weakness of one side, numb- ness, vertigo or faintness, until the convulsion occurs resembling an 542 PSYCHOLOGICAL MEDICINE, epileptic convulsion and makes the grave nature of the case clear. The patient lies in a semi-comatose state and has a succession of fits, which may leave the patient hemiplegic. The prognosis in these cases is very grave. In the latter, the delirious form, which gene- rally occurs in the aged, " the patient suddenly ' wanders ' in his talk, becomes loquacious or restless, is busy in manner, exerts himself, seems tired, and falls asleep. He wakes up somewhat confused, but appears to be himself again for a few days or even weeks, when the confusion and delirium reappear, and are more persistent. There is no complete restoration, but gradually one side is found to be para- lyzed, or to be slightly weaker than the other. The delirium alter- nates with coma, more or less profound, and the patient passes into a state like that following the apoplectic form." The final symptoms of brain softening are those of coma and death, quiet and painless. Precocious children are said by Duparque to develop brain soften- ing with the intellect intact, and with exaltation of the special senses and general sensibility. There is no fever, delirium, or convulsion, but after death there is distinct cerebral ramollissement. Brain-softening in comparatively young men I should consider as owing to a premature failure of the proper activity of the cellular ele- ments of the brain tissue, with very likely disease of the coats of the capillaries and small arteries, commencing with cerebral hypersemia and subinflammatory irritation. The cerebral softening of the aged is due generally to vascular obstruction in the brain, either arterial or capillary. Thrombosis, with vascular degeneration, and embolism, with valvular disease of the heart, are doubtless the most frequent causes of softening of the brain. Disseminated Sclerosis of the Brain and Spinal Cord. — Syn. " Scle- rose en plaques disseminees " (Charcot). — To Professor Charcot be- longs the credit of first recognizing this disease, which consists in the development of patches of sclerosis of a roundish shape, and dense and hard, gray in color, looking like the gray matter of the brain. These patches, which are of varying size and shape, are scattered throughout the brain, or the brain and cord, in different localities, and more often in the brain and cord together. These patches vary in size, according to Bastian, from that of a pin's head to that of a large pea or bean in the spinal cord, while in the brain or cerebellum they may be still larger. The medulla, pons, and cerebral peduncles may be affected, and any part of the cerebrum LOCOMOTOR ATAXIA — CEREBRAL HYPER^.MIA, ETC. 543 and cerebellum. Microscopically, there is a hyperplastic overgrowth of the neuroglia, which exists normally around and between the nerve-elements. In employing carmine staining, the new growth takes up the coloring-matter very intensely. When the lateral columns of the cord, the medulla, and the pons are affected, which are special seats of election for these patches of sclerosis, Bastian gives the following as the clinical symptoms: A slowly ensuing paresis of the lower extremities begins, first in one limb, and then, after a time, it involves the other. During this time the paresis develops into a more and more marked paralysis, though the sensi- bility of the limbs remains almost completely unaffected, nothing more than a temporary numbness being complained of in the ma- jority of cases, whilst lightning-like pains and girdle sensations are altogether absent. After an interval, first one and then another upper extremity may become weak, and subsequently more or less paralyzed. During these early stages of the disease, more or less distinct remissions of symptoms may occur from time to time. Meanwhile, a most typical sign soon shows itself in the paretic or semi-paralyzed limbs, in the form of a marked trembling or shaking of those muscles or parts of a limb which are called into voluntary action with any intensity, although these phenomena immediately subside when the voluntary exertion ceases. The involuntary move- ments consist either of extremely well-marked tremors, like those met with in some cases of paralysis agitans, or else of movements of greater range, more resembling those of chorea. A patient lying in bed quietly, when told to sit up, will exhibit shakings and tremors in all parts of the body until he lies down again. In writing, almost every letter registers fine tremors, and in the advanced cases writing is impossible or illegible. The tendon reflexes are exaggerated, both the patellar tendon and the ankle clonus Contractions and rigidity come on late in the course of the disease. The tremors, which are rhythmical, of the head, neck, trunk, and limbs, cease when the patient is asleep, as well as when he lies quietly at rest. There is a difificulty of speech, the utterance being slow and drawling, while the lips and tongue are tremulous. There is apt to be double vision, also indis- tinct, hazy vision, and nystagmus (oscillations of the eyeballs) is frequently present. Vertigo of a gyratory nature, frequently im- peding locomotion, exists as an early symptom. Mental failure in cases where the brain is affected is a late symptom, accompanied at times, according to Bastian, by a subacute maniacal condition, or by 544 PSYCHOLOGICAL MEDICINE. delusions of wealth and grandeur, like those of paralytic dementia, or by a profound melancholia. Apoplectiform or epileptiform attacks may now occur from time to time, and death may take place in one of them. The course of the disease may be from five to ten years. When the disease affects the brain particularly and principally, vertigo, mental disturbance, nystagmus, and the "scanning" speech will be the chief symptoms, beside the rhythmical tremors. Paresis of the limbs, commencing, as we have said, in one leg, is an early symptom. A case recently came under our notice of a gentleman of forty-two years, plethoric, a high liver, with a fair family history, who devel- oped this disease, and who died in about three years from the time the first symptoms manifested themselves. Vertigo was the earliest symptom he complained of, and it was this that first led him to apply to a physician for relief, as he would fall down from the gyratory nature of it. The small oscillation of the eyeballs (nystagmus) was very marked. Paresis terminated in complete motor paralysis. Speech was affected. Sensibility was normal. Trembling on vol- untary^ movement was most marked. Xo treatment had any effect. Electricity, strj'chnia, and various combinations were all tried, and all failed. The case was under the care of one of our best neurolo- gists. Locomotor ataxia, terminating as general paralysis of the insane, was reported by Charles K. Mills, M.D., of Philadelphia, before the American Neurological Association, June 20, 1883. Dr. Mills said that the relation between locomotor ataxia and general paralysis of the insane has been a problem of interest to neurologists and alienists since the investigations of Westphal, in 1863. He related the following case : P , aged 47, at the time of coining under observation, was a man of good consti- tution, noted for his strength and endurance, but for three years he had not been well, during most of which time he had been treated by different phj'sicians for •' rheumatism." He was addicted to venereal excesses, and used and abused alcohol occasionally. Many years before he had had a chancre; but had not, subsequently, had any of the ordinary evidences of secondary or tertiary syphilis. He had first suffered from darting or shoot- ing pains in his feet and legs ; soon he experienced sensations of numbness and tingling in his feet, and later, in the little and ring fingers of the left hand. For a short time he was troubled with double vision, and his sight had diminished a little in acuteness. The results of an examination made during the first week he was under observation were as follows : No paralysis was made out ; galvanic and faradic irritability were well preserved. He could not walk well after dark. He swayed and tottered on trying to LOCOMOTOR ATAXIA — CEREBRAL HYPEREMIA, ETC. 545 stand with his heels together, or with his eyes shut ; and he could barely manage to stagger a few steps with his eyes closed. Paroxysms of sharp, sudden pain in the limbs were more frequent. He was awkward with his hands in dressing. A peculiar sense of constriction or drawing in the lower part of the abdomen had annoyed him for several months ; sexual desire had diminished. He had no delusions, and was fully able to attend to his business, which required a large amount of physical and mental exertion. Under the use of nitrate of silver, galvanization of the spine, and faradization of the extremities, continued for several months, he improved remarkably; but, after remaining better for a few months, he again relapsed, and now he got steadily worse. Occasionally, however, he would temporarily improve. The anaesthesia of his feet and hands deepened ; the staggering gait returned and grew worse ; every two or three weeks he would have frightful attacks of lancinating pains. Decided mental symptoms first began to make their appearance two years after first coming under treatment. He spent his money very freely upon others, as well as upon himself. His ideas became queer and lofty; but the delirmm of grandeur did not de- velop thoroughly until nearly a year later, when he began to talk and act in the most pre- posterous manner. About the same time a peculiar stagger in his speech, a slight twist- ing of the mouth to one side, and some tremor of the tongue and lips became noticeable when he talked. Nearly three years after the notes first made, and almost six years after the develop- ment of ataxic pains, he was sent to the insane department of the Pennsylvania Hospital, where Dr. Mills occasionally visited him. His delirium became of the wildest character, and he became irritable and hard to manage. Anaesthesia and tremor of tongue increased. On two occasions he had slight apoplectiform attacks, once accompanied by a slight spasm. Later he was removed to the State Hospital for the Insane at Danville, Pennsylvania, where he remained until his death, which occurred five years and four months after first coming under care of Dr. Mills, and about eight years after he was first affected with ataxic pains. A post-mortem examination of the brain and spinal cord was made. The pia mater over both cerebral hemispheres, particularly in the postero-frontal and parieto- temporal regions, was opaque, congested, and adherent at points; decortication being marked. Convolutions were atrophied. The pia mater of the cerebellum, especially over the superior vermiform process, was deeply congested and adherent. The pia mater of the spinal cord was thickened, and the cord presented an irregularly shrunken appear- ance. Microscopic examination showed marked sclerosis of the posterior columns of the spinal cord throughout its whole extent, and that inflammation and thickening of the pia mater were also present everywhere. The sclerosis was most pi'onounced in the lumbar region, decreasing in intensity as the cord was ascended ; but it was well-marked through- out, both in the columns of GoU and in the posterior root zones. The medulla oblongata on one side was much sclerosed, and slightly so on the other. Sclerosis was also present in the pons, crura, optic thalami, and convolutions examined, and in the cerebellum. The pathological appearance shown by the microscope corre- sponded closely to those mentioned by Westphal as occurring in the spinal cord in de- mentia paralytica. According to him, the posterior columns show few or no sections of nerve fibres, and their place is taken by a connective tissue substance. In the cervical region Goll's cuneiform columns are especially affected ; in the dorsal and lumbar regions, 35 54^ PSYCHOLOGICAL MEDICINE. however, the entire area of the posterior columns is involved. In fresh preparations, numerous granular fat-cells and corpora amylacea are found. In this case the spinal symptoms were the first to appear. Three )-ears before coming under the care of Dr. Mills he began to suffer with the lancinating pains of posterior sclerosis. Although when first seen by him, and until he improved under treatment, he suffered at times from mental anxiety and sleeplessness, apparently the result of the pain and other distressing symptoms of the ataxia, no typical mental symptoms appeared until more than two years later, and more than five years after the appearance of the first symp- tom of spinal trouble. Dr. Mills referred to the views of various authorities with reference to the relation of locomotor ataxia and general paralysis of the insane. According to Westphal, with whom Hammond agrees, no direct relation exists between the morbid process in the cord in pos- tenor spinal sclerosis, and that in the brain in general paralysis of the insane. Accord- ing to these authorities neither disease is secondary to the other. They simply coexist as the expression of an excessive proclivity to diseases of the nervous system, just as any other two diseases may be present, one in the brain and the other in the cord, without there being any direct interdependence between them. Locomotor ataxia is by no means un- common in patients affected with the other forms of insanity. Hamilton {^New York Medical Record, July 29, 1876), discusses the relation of these two affections. Leidesorf has related one case in which general paralysis was preceded by spinal symptoms. Maudsley speaks of other cases. Calmiel says that, in many cases, the changes proceed from the cord upward, and Baillarger indorses his views. Charcot has proved, very conclusively, that disseminated sclerosis can exhibit all the symptoms of general paralysis of the insane. Cases reported by Obersteine, Hamilton, Plaxsen, Mickle, and others, were also re- ferred to. CHAPTER XXX. ELECTRICITY IN DISEASES OF THE NERVOUS SYSTEM. We have three kinds of electricity at our disposal in the treatment of nervous and mental diseases, — the constant or galvanic current, the induced or faradic current, and static electricity. In the former, the constant current, we have a means more powerful than any other of modifying the nutritive conditions of the central nervous system. It possesses great efficiency to antagonize the various congestive states of the brain in nervous and mental disorders, and in incipient insanity. By its use we are enabled to secure a proper tonic con- traction to cerebral bloodvessels habitually dilated, and we can also antagonize by its use the symptoms of failing memory, weakened power of attention, and vertiginous sensations, if we use it daily for ELECTRICITY IN DISEASES OF THE NERVOUS SYSTEM. 547 some time to the head, avoiding injuriously strong currents. The gravest disorders of the nervous system commence often with hyper- semia of the brain and cord, which ends in psychical disorders of varied nature, and this hypersemia we can effectually remove by the application of the constant current to the brain. Grave brain ex- haustion and the mental and nervous debility of overworked busi- ness and professional men will yield rapidly to electricity in this forrri and to centric galvanization, using the negative electrode at the pit of the stomach while the positive pole is applied to the crown of the head or cranial centre, the cervical sympathetic nerve on each side of the neck in front of the sterno-cleido-mastoid muscle, and on either side of the sixth and seventh cervical vertebrae. It is but a short time since I discharged from treatment, com- pletely cured, a young merchant of New York, who was in the in- cipient stage of insanity. The bloodvessels of the dura mater, the pia mater, and of the brain itself, I considered in this case to be probably habitually dilated, causing marked congestion or hyper- semia, and the indications for treatment were to secure a tonic con- traction of these vessels. I used a galvanic battery with clock machinery attached to it — a balance clock — the isochronous beats of which establish and interrupt the communication between the poles at intervals of fifteen seconds. The galvanic current, when slowly interrupted in this way, produces a more energetic contraction of the cerebral bloodvessels than when it is not interrupted. The positive pole I placed at the level of the first cervical vertebra, and the nega- tive pole at the level of the superior ganglia of each of the cervical sympathetic nerves in turn. The sittings lasted five minutes each time. Beyond this electrization of the brain I did nothing beyond prescribing a course of warm baths at bedtime, with a dose of thirty grains of sodium bromide and thirty drops of cannabis indica in half a glass of water after the bath, and friction with flesh gloves over the whole surface of the body. In the inception of treatment I also cleared out the system by a mercurial cathartic, followed by salines, which is an excellent preparatory method of treatment in the incipi- ent stages of mental disorder. Each seance produced a marked and immediate amelioration, lasting longer and longer each time, and my patient described a sense of weight as lifting from the verti- cal region of the head, at which point he had persistent headache, which had lasted for months, I could recount many similar cases, if necessary, but the above is 548 PSYCHOLOGICAL MEDICINE. a typical one, in which we find our patient restless, sleepless, and with eyes suffused and conjunctiva congested, and confusion of mind. The grave cases of neurasthenia, associated with cerebral hypersemia, exhibit impaired nutrition and assimilation, impaired intellection, melancholia, mental depression, muscular atonicity, irritability, and inability to bear stimulants without distress in the head. These patients exhibit morbid psychical symptoms and get up a religious melancholy, — if naturally of religious tendencies, — and there is often a change in the sentiment. In female patients there is menstrual suppression, but local treatment is not called for here, as electricity and the proper constitutional treatment will cure the patient. Sleep- lessness, perspiration, and a loss of the elasticity of the skin are all present in these cases. Professor Roberts Bartholow speaks thus respecting the influence of the galvanic or constant current in affecting the brain and cord : " Galvanism can alone be used to affect the condition of the brain and spinal cord. Faradism does not pass the barrier of the bony envelope of these parts, but galvanism has been experimentally shown to do so. That galvanism and not faradism should be used when it is proposed to reach these parts, seems therefore conclusive. There can be little question that galvanism is highly serviceable in certain vascular states of the intracranial organs. We must bear in mind how galvanism affects the vessels in order to apply it correctly. We possess no agents which can act on the contractility of the vessels with the promptness and efficiency of galvanism." By securing a proper tonic contraction to cerebral bloodvessels habitually dilated, Vv^e ward off mental disease in a great many in- stances. We should, I think, use the positive pole of the constant current at the level of the first cervical vertebra, and the negative pole at the level of the superior ganglia of one of the cervical sympa- thetic nerves. The current should be frequently interrupted, for experiments show that* vascular contraction is produced most mark- edly at the opening and closing of the circuit. The number of cells employed must vary with the constitutional susceptibility of indi- viduals. Other therapeutical applications of the constant current are used to suit different symptoms in different cases. The experiments of Ch. Latournian, of France, on the application of the galvanic current to the brain and its membranes are very con- clusive and easy to verify. A kitten is taken about one month old, in which the cranial wall is still very thin and easy to cut, and a por- ELECTRICITY IN DISEASES OF THE NERVOUS SYSTEM. 549 tion on the left side is cut out, exposing the dura mater. It will then be very easy to see with the naked eye, or with a magnifying glass, the arterial and venous branches which ramify upon the surface. The positive pole of the galvanic current is then to be placed behind the right ascending ramus of the inferior maxilla, and the negative pole upon the anterior cranial region, above the eyes. Twelve sec- onds after the closing of the circuit the periarterial branchings of the dura mater become less and less visible, and a little later the venous branches themselves become pale. At each interruption of the. current the anaemia increases for an instant and then the vessels grow a little larger. This experiment can be repeated as often as necessary, and will always give the same results. The dura mater may then be cut out and the pia mater exposed, when its vascular branches — arterial and venous — will be visible upon the gray ground of the cerebral substance. The same observations may be made on it as on the dura mater, and with the same results, of obtaining at will a contraction of the cerebral vessels. The therapeutic value and practical bearing of these facts, as applied to diseases of the nervous system and to psychological medicine, are immense. About the only medicines that we need to employ with cephalic electrization, are the sodium bromide and cannabis indica mixture, referred to before in this volume, which I claim is the most valuable combination to soothe and tranquillize the cerebral nervous system that the general practitioner possesses in the incipient stages of insanity, and very many cases might be cured in their own homes without ever going to an asylum by this treat- ment, conjoined with perfect rest. 30 grains of bromide of sodium, and 30 minims of a reliable tincture of cannabis indica, thrice daily, in water, is the minimum dose, while the maximum dose is 60 grains of the sodium bromide and 60 drops of the tincture of cannabis indica; while to prevent brain-wasting, and as a general tonic to the exhausted nervous system, Routh's formula of the chloro-phosphide of arsenic, commencing with 5-minim doses and gradually decreasmg^ is an excellent adjunct. The value of arsenic as a nerve-tonic of great efficacy is not thoroughly appreciated by the profession at large. The subject of the electro-therapeutics of the diseases of the nervous system is full of interest. The constant current is extremely useful in antagonizing pain, and is sedative, restorative, and refreshing in its action. I have found it of the greatest use in neuralgia of the solar plexus, the cardiac plexus, in gastrodynia, and in ovarian neu- 5 so PSYCHOLOGICAL MEDICINE. ralgia. I always put the electrode of the positive pole over the seat of pain, and the negative either on the spinal cord or at some indif- ferent spot. I have seen ovarian neuralgia of extreme intensity, which had resisted any safe amount of morphia and atropia hypo- dermically, give way to the galvanic current when a current from thirty-two cells was applied locally to the abdominal region. Centric galvanization, which affects the brain, spinal cord, and cervical sym- pathetic and pneumogastric nerves, gives us the most powerful tonic and reconstituent means at our command over the whole central nervous system ; while, to promote greater activity in the nutritive functions generally, we can, by the proper and judicious use of the faradic current of electricity, exercise all of the muscles of the body daily and improve nutrition very markedly. The galvanic current, however, possesses much more power over the nutrition of organs and tissues, owing to its action on the circulation. In the amyo- trophic paralysis from disease of the anterior cornua of the spinal cord, where the muscles waste very rapidly, if we do not arrest the trophic degeneration, we shall find very probably the reactions of degeneration, so that there is no contractility of the paralyzed mus- cles, as in infantile paralysis, to the induced or faradic current. The galvanic current, both in these cases and also in facial paralysis, will cause movements of the muscles, and we have to use this current, therefore, until the contractility of the faradic current is restored, and until the muscles have recovered their normal volume and con- tractility. In hemiplegia, if electro-contractility is not lost and the muscles not wasted, electricity need not be used at all. In paraple- gia, if the lesion is above the dorso-lumbar enlargement of the cord, electro-contractility is preserved; if the lesion is at the nerve-centres, or the dorso-lumbar enlargement, we get the reactions of degenera- tion and loss of electro-contractility, and must then use slow inter- ruption of the galvanic current. In the treatment of sciatica, in common with other neuralgias, it is important to bear in mind that pathological causes which irritate the ner\-e high up in the trunk, produce pain at the peripheric distribution, and sensations excited by irritation of the origin or nucleus of a sensory nerve are uniformly referred to the periphery. The great predisposing cause of sciatica, in common with the other neuralgias, is hereditary predisposition, which results in the transmission of an imperfect nervous system, — a neurotic constitution. Sciatica is one of the most curable of neural- gias, if properly treated. If injudiciously treated, it is often very ELECTRICITY IN DISEASES OF THE NERVOUS SYSTEM, 55 1 intractable. We have as forms of sciatica, aside from a simple neuralgia, syphilitic and rheumatic forms of the disease, the former .occurring very frequently; and in obstinate cases, which have resisted all other treatment, we may get brilliant cures by giving iodide of potassium in combination with small doses of bichloride of mercury. The irritation set up by obstinate constipation, the puerperal state, where the enlarged uterus produces an irritative pressure, or a tumor pressing on the nerves in the pelvis, may all cause sciatica. The worst cases we meet with in practice occur between forty and fifty years of age. Primarily, rest is the great therapeutic agent. Our patient must not be allowed to walk, as muscular movements are very injurious, as the nerve is pulled upon by the muscles and the pain thus aggravated. The patient must also be kept warm, and wear silk drawers if he can afford silk underclothing, and the bowels kept carefully regulated. When the paroxysms of pain come, we may alleviate them temporarily by hypodermics of morphia and atropia, and we may paralyze the sensibility of the peripheral nerves by local application of aconite liniment or cyanide of potassium, as spoken of in the chapter on neuralgia. The use of the constant current of electricity, by its stimulating and catalytic effects, will enable us to get that perfect cure which should be our aim. The negative pole of a battery of thirty-two cells should be placed oppo- site the roots of the nerves which form the sciatic, and the positive pole is applied at the seat of pain, I make this application twice daily, and, by keeping up the nutrition of the central nervous system at the same time, I obtain the most gratifying results even in cases of years' standing. The nutrition of the sciatic nerve is much im- proved, and there is a healthy change induced in the entire nerve. I have also cured some cases of sciatica by static electricity, using the Touplar or improved Holtz machine, charging the patient, and then drawing powerful sparks along the course of the affected nerve by the wire brush or other electrode. If we wish to be successful with static electricity, we must have great tension and quantity. In severe lumbago, affecting the dorsal muscles and the intercostals, with severe, excruciating pains, making the patient bend almost double, I have experienced uniformly good results in every case from the use of the constant current to the affected region, together with slight ether inhalations. We certainly get a specific effect from the use of the constant current in nearly all the neuralgias, and static electricity from a good machine will, from the stimulating effects of 552 PSYCHOLOGICAL MEDICINE. a thick spark on the deep tissues, also give good results. In facial neuralgia the constant current is very useful. In paralysis from brain disease, particularly in hemiplegic cases where we find absence of any decided mental disturbance, slight thickness of speech, more or less deviation of the tip of the tongue to the paralyzed side when it is protruded, partial and incomplete paralysis of the facial muscles on the side on which the paralysis of the limbs exists, more or less complete loss of voluntary power over the left arm and leg, if the lesion is in or near the right corpus striatum, loss of sensibility and numbness on the paralyzed half of the body, and slight elevation of temperature on the paralyzed side, if the contractility of the muscles be peifect, the use of electricity is coiitraindicated. When, in paralysis, we meet with the reactions of degeneration, wasting of muscles, or loss of normal muscular irritability or con- tractility, the galvanic or constant current is then indicated, and after we get by this current an irritability which responds to the induced or faradic current, we may proceed with that current to the ultimate restoration or cure of the paralysis. In hysterical paralysis, where the patient has no zvill to move her muscles, we may get a rapid and brilliant cure by the induced current, or by static electricity. In neuralgia or hyperaesthesia of the testes, which is a very painful neu- rosis, we have a perfect means of relief in the constant current of electricity, conjoined with laxatives, followed by tonics. In hyperaesthesia or irritable state of the uterus, a very trouble- some neurosis, we apply a cup-shaped electrode, attached to the negative pole, to the os uteri, and the positive to the hypogastric or sacral region, with uniform good results. A very good local seda- tive consists of 5j of morphia to oj of unguentum belladonnse, and a little pill of this rolled up and introduced into the os. This is also a very valuable remedy in hysteria. The patient can hardly sit down, and coition is impossible in true hyperaesthesia of the uterus. It results, I think, from neurasthenia. Nervous cardiac pain near the apex of the heart is a common and distressing neurosis, and this cardiac irritability is alleviated by cen- tric galvanization. This form of application also relieves neuralgia or hyperaesthesia of the stomach, in which the vasomotor nerves and the tone of the arteries are impaired. Spinal hyperaesthesia is also very amenable to treatment by the constant current. We al- ways find that neurotic pains of the spine are, as a rule, much more severe than those accompanying serious organic trouble. Neuralgia ELECTRICITY IN DISEASES OF THE NERVOUS SYSTEM. 553 or hypersesthesia of the breast in women is readily cured by the judicious use of the constant current. In cerebrasthenia or nervous prostration, we have a hypersesthesia or neuralgia of the entire brain. This condition may lead to insanity if not checked, and cephalic electrization is our most important thera- peutic measure. The brain is enfeebled and hyperaesthetic, and the daily use of cephalic electrization will soon improve its nutrition and tone, and we shall cure our patient. In all cases we must build up and improve the nutrition of the central sensory nerve-cells, as it is this condition of imperfect nutrition which causes neuralgia and hypersesthesia. In the early stage of progressive or general paraly- sis, we may sometimes gain great benefit from centric galvanization, and cut off the wearing impressions which are transmitted practically, without cessation, to the brain. In using electricity, we should remember, in contracted muscles, to apply the faradic current to the antagonistic or extensor muscles, and use the galvanic current to the flexor muscles. In this way we may successfully treat the late rigidity of hemiplegia. In infantile paralysis, the electro-contractility is diminished, the muscles waste and undergo fatty degeneration, and are affected by secondary contractures. They will not react to the faradic cur- rent, but will to the interrupted galvanic current, and are very sensitive to it, therefore we must first use this and afterwards the faradic current. As long as there is response to the faradic current, we should use it in preference. We must not use electricity too soon in paralysis from cerebral disease, and the same remark applies to strychnia. As I have previously stated, the amount of contractility will show us how much good electricity will do. If it is normal, elec- tricity will do no good; while if the electro-contractility is markedly impaired, much good may be done by it. In all cases we may im- prove the nutrition of the muscular system. As a general rule, we must treat the muscles by the current to which they will most readily respond. In paraplegia from myelitis, meningitis, or hsem- orrhage into the cord, electricity must not be used while the active lesion exists. We may then — after the active lesion has subsided — use the interrupted constant current until the farado- contractility is restored, and the faradic current, or both combined. In gunshot wounds and injuries of nerves, followed by paralysis, faradization is invaluable. In local paralysis from cold, or lead-poisoning, we use 554 PSYCHOLOGICAL MEDICINE. the interrupted galvanic current, and subsequently the two forms combined. Galvanism is also very useful in atonic dyspepsia, writer's cramp, muscular atrophy, spinal irritation, aphonia, insomnia, diphtheritic paralysis, locomotor ataxia, paralysis agitans, myalgia, impotence, epileptiform neuralgia, torticollis, etc. The good effects of electricity in nervous diseases is readily un- derstood when we reflect upon the influence of the sympathetic or ganglionic nervous system on the vascular system, and secondarily on blood, nutrition, and secretion, and also its influence on thoracic, abdominal, and pelvic viscera, except the vascular system. When the cervical sympathetic is galvanized in the neck, the pupil dilates and there is contraction of the bloodvessels of the correspond- ing side of the head, and a diminution of the temperature, if this had previously been raised by section of the nerve. There is dimin- ished supply of blood, and diminished temperature. By the use of electricity we affect the circulation very powerfully, as it is under the control of the central nervous system, which we act directly upon by the electric current in two ways, first, through the vasomotor nerves, and second, through the cardiac branches of the sympathetic and pneumogastric nerves ; we also influence powerfully the excita- bility and vitality of the parts owing to the control which the sympa- thetic, through its vasomotor action, has over these processes. The action of electricity over the abdominal and pelvic viscera is through its action on the branches of the sympathetic distributed to the se- creting organs to regulate the supply of blood, and control their ac- tivity, while for the intestines and genito-urinary apparatus, it stimu- lates peristaltic action or simple contraction. By galvanization of the solar plexus we can effect peristaltic movements of the large intes- tines. I think that galvanism may, as it is used mildly or energeti- cally, either exalt or depress the functions of the nervous centre on which it acts. I cannot explain the reason of this, unless it depends upon the ganglionic centres through which the electricity, analogous to nervous force, passes before it reaches the final distribution of the nerves to the contractile or secreting elements. Charcot considers that static electricity is very useful in hysterical and hystero-epileptic cases, in peripheric facial paral3'-sis, paralysis agitans, spinal irritation, dyspepsia and dysmenorrhoea ; cutaneous anaesthesia, the numbness and anaesthesia of hemiplegia, paraplegia, neuralgia, and rheumatic affections, are also favorably influenced by the stimulation of the pe- ripheral nerves by the electric spark, spray, or electric wind of the im- ELECTRICITY IN DISEASES OF THE NERVOUS SYSTEM. 555 proved Holtz machine. We also get sedative and tonic effects from static electricity. We can also get muscular contraction with less pain with the induced current. We insulate our patient by placing him on an insulated platform, which is connected with one pole of the machine, and then either treat him by insulation alone for the simple tonic effect on the whole nervous system, or we " draw " sparks by an electrode attached to an earth connection. The electrodes are balls of metal or wood for the spark, the electric brush for the elec- tric " spray," or a metallic sharp point for the electric " wind," all on glass handles. We use, in our private hospital, for nervous and men- tal diseases a large improved Holtz machine with great success, a cut of which we give, and cordially recommend it to the profession. The faradic or induced current of electricity is, when used as general faradization, a general muscular and nerve tonic. It should never be used sufficiently strong to be disagreeable to the patient. I apply the negative pole to the coccyx, and then apply the positive pole, 55^ PSYCHOLOGICAL MEDICINE. using a sponge electrode, to the top of the head or " cranial centre," to the cervical sympathetic nerve in the neck, and on each side of the sixth and seventh cervical vertebrae, and finally up and down the spine. I also, in nervous exhaustion of women, have the entire surface of the body rubbed with the positive pole to which is attached a broad sponge electrode, by an experienced nurse, so as to exercise the fibrillae of each individual muscle, an electro-massage. Respecting the clinical uses and forms of electricity, Dr. J. Rus- sell Reynolds, F.R.S., Professor of the Principles and Practice of Medicine in University College, says : With regard to treatment by electricity, I have a few general remarks to make. You can sometimes actually and immediately cure a patient. There are cases in which the only symptom that may be presented to you — I do not say the whole morbid condition, but the only symptom — is loss of voice. Sometimes one single application of electricity will remove it completely, and in that instance you do apparently cure the patient. There are other diseases which you cannot be said to cure, but which you may relieve by elec- tricity. By its application you may, in many instances, again and again, relieve pain; you may, in like manner, relieve spasm ; or you may slowly diminish, and even ultimately remove, paralysis. In these cases you assist, by electricity, the processes which lead to the removal of the pain, paralysis, or spasm ; you put the patient, by electrical appliances, into a better position to improve, or be cured by the agencies of food, medicines, rest, and time. Lastly, there is a group of cases in which, though you cannot cure or even re- lieve the symptoms, you may yet arrest the progress of disease. Sometimes, for exam- ple, in a child with so-called " essential paralysis," you may prevent deformity, though you cannot cure the paralysis. In certain cases of lead-poisoning, muscular atrophy, etc., although you cannot recall the muscular substance, you may prevent the atrophy from increasing. I think it is necessary for me to say a few words as briefly as possible, about the sev- eral forms of electricity which are now in common clinical use. You constantly hear of " faradization," " electrification," "galvanism," and so on; of " battery-current," " con- tinuous current," and the like ; and it is probable that some of you may not have perfectly clear ideas as to the meaning of these terms, or, at any rate, ideas which are precisely the same as mine, and I should like us to have a common starting-point, in a clear compre- hension of the meaning of the words we use. {a) Many years ago, it was the therapeutic fashion to put the legs of patients into buck- ets of torpedoes, or electric eels ; but this practice has become obsolete, and there are now only three forms of electrical appliance in common clinical use. One is that of the old-fashioned " electrical machine," either a cylinder or plate of glass, which, by friction, produces a certain amount of electrical disturbance, one of the results of which you col- lect on an insulated piece of brass called a " prime conductor." This is the oldest mode of applying electricity which is now in force in our hospitals. In the present day it is sometimes called "static" electricity; and in speaking of the use of static electricity, what is meant is that the person is charged, like that " prime conductor," with electricity of that particular kind. It has also been called " frictional " electricity, from the mode of its production; and also " Franklinic " electricity, or " Franklinism," in memory of the individual who — I will not say discovered it, but who — made out more about it than any one else at the time that he worked at the subject. ELECTRICITY IN DISEASES OF THE NERVOUS SYSTEM. 55/ 1. There are three modes in which that electricity is applied. One is simply to make the patient, as it were, a part of the prime conductor, and charge him full of electricity. You insulate your patient by placing him upon a glass-legged stool, taking care that he is not in contact with any conducting substance ; then you connect him by a brass chain, by his own hand, or by any other mode you like, with the prime conductor; you set the machine in action, and fill him full of electricity, do nothing more. That is the simplest mode of applying static electricity. In certain diseases it is curious what this will do, without putting the patient to the least discomfort. Probably the only thing he will be conscious of is that his hair seems to be " standing on end;" this'is neither painful nor even uncomfortable, but it is wonderful how much that simple " charging " a patient will effect in some forms of disease. I have known it absolutely remove, in a few seconds, a "tic" that had lasted for days. Pain in the sciatic nerve, many odd and disagreeable sensations, unpleasant flutterings about the heart, depending on weak innervation, and tremor of the limbs, may all be removed by simply " charging " the patient. 2. Another mode of using this Franklinic electricity is to apply a " spark" to a particu- lar part. You may have a movable, insulated brass knob in connection with a prime con- ductor, and you direct it to the larynx, or some other part, and let the spark go into the skin. Or you may put the patient on a glass-legged stool, and charge him or her in the way I have described, and take a spark out of the larynx or the limb with your knuckle or with a rounded knob. In some cases of aphonia, where the aphonia depends on a special condition, you may insulate the patient and charge him with electricity without the slightest benefit ; but take a spark out of the larynx, or put a spark in, — whether posi- tive or negative, it matters not, — and that particular condition of aphonia may be cured directly. This I have known to occur when much more painful processes of electrifica- tion had been previously tried, and without effect. 3. A third mode of using Franklinic electricity is that of sending the shock from a charged " Leyden phial " through the part that you wish to affect. This has occasionally produced curative results when other modes have failed ; and it is in obstinate nervous aphonia that its influence has been the most distinctly seen. But, short of being hanged, I do not imagine that anything could be much more pleasant. [d) The next form is what has been called galvanism. It is the form of which one hears so much, in the present day, under the name of the " continuous current," or " bat- tery current," or, as it has been sometimes called, with a Hibernian misuse of words, the "interrupted continuous current." By all these terms is meant that form of electricity which is developed by chemical decomposition. The particulai- form of battery does not matter, so far as the quality of the electricity is concerned. Wherever you have chemi- cal decomposition in progress, there also is some electrical change going on ; and the only object a medical electrician has, in choosiirg any particular form of battery, is to catch the electricity as best he may. This form of electricity is characterized by the following features : It is of low " intensity," so far as regards its action upon nerve and muscle, but it is in considerable " quantity," and it produces " chemical " results, and results on temperature, "thermic" results, that are not approximated by the Franklinic electricity. I am not now going to describe to you the batteries, of which there are numberless kinds. The choice among them is guided chiefly by considerations of cheapness, porta- bility, the ease with which the machine can be kept continuously in order, the bulk of the battery, and the readiness with which its strength of action can be regulated. What you vs^ant is a current that shall play evenly, and at a measurable strength, for a certain length of time. It is convenient to have a battery that is portable, and it is a great point to have one that does not require everlasting looking after. The battery in our electrical room in this hospital (Elliott's) is not portable, but the majority of our patients are ; it will act 558 ■ PSYCHOLOGICAL MEDICINE. very steadily for three or four months ; it is tolerably cheap ; it can be verj- readily put in work- ing order by a person who does not need a great amount of electrical skill ; and you can easily regulate the strength of the current you employ. 1. There are two modes in which this kind of electricity, or galvanism, is used. In one of them the current is " continuous," in the other it is not. A really continuous current may be passed through the body, or part of the body ; and this is accomplished by intro- ducing the whole or a portion of the human body into the circle of the battery, and then letting the current play through it. This will do the following things : it will relieve spasm of certain kinds ; it will relieve pain of certain kinds, and this sometimes in a few seconds, and the effect is as obvious and distinct as is that following the administration of an emetic. A person may have a particular kind of headache ; you pass a continuous cur- rent, as it appears, through his head, and sometimes in a few seconds the pain is gone. It will also remove some forms of tremor and of spasm. I want you to bear in mind certain points respecting the effects of the continuous cur- rent upon the limbs, according to the direction in which it is passed thiough those limbs. Supposing I have the positive end of the battery connected with a person's left hand, and the negative end connected with his right, the current, passing from the positive to the negative pole, goes up the person's left arm to the trunk of the body, and down the right arm to the machine again. The cun-ent passing up the arm has been called the " inverse," and that coming down the arm has been called the " direct." In the arm in which the current is passing upwards the " irritability " of the muscle and nerve is gradually in- creased; in the other arm, in which the current is passing downwards, the irritability is gradually diminished. You may test this fact by now and then breaking and remaking the continuous current; and you will find that in the two arms two different degrees of irritability exist, according to the direction in which the current had been passing, whether up or down. One arm will act more, the other less readily than in health. The difference thus produced between them is sometimes highly marked. It may occur to you to ask, " If that be the case, which current should I use to relieve pain and spasm, the direct or the inverse ?" All I have to say is, that so far as I have seen, it does not make the smallest difference. Theoretically it should make a very great difference, but practically it makes none. I have seen pain or spasm relieved as well by the current in one direction as in the other, and this whether the spasm has been clonic or tonic, or whether there has been merely tremor. The continuous current, when weak, produces little or no pain. The patient feels nothing, or next to nothing. If it be strong, he feels a tingling or burning at the points of contact, and a sensation of lightness and tension in the part, between the points of con- tact, that is very disagreeable, or, indeed, intolerable. 2. Another mode of using the battery current is by interruptmg it — making it not con- tinuous. This may be done in various ways. You may take the two sponges attached by wires to the two ends of the battery, place one sponge on the upper part of the man's leg, and interrupt the current by occasionally dabbing the other sponge on the leg at a more or less distant point. By that means you " make " and " break " the current. Or you may have a simple piece of apparatus attached to the battery, — a cogged wheel, with alternating conducting and non-conducting materials ; which wheel can be rotated, and so interrupt the cuirent, while the sponges are maintained in place. Or you may use a little vibrating wire, which makes and breaks contact rapidly, as in one of Pulvermacher's interruptors. In thus applying the battery current you will notice this further fact, namely, that the " direct " application produces more obvious effects upon the muscles (z. e., in- duces a more marked contraction) than does the "inverse" or "indirect." You will find, for example, that an interrupted batterry current, — say of ten cells, — which, when ELECTRICITY IN DISEASES OF THE NERVOUS SYSTEM. 559 sent down the arm produces distinct contraction of the muscles, may elicit no contraction, or very much less contraction, when it is sent up the arm in the opposite direction. It is important to bear this in mind when thus using galvanism for the purposes of either diagnosis or treatment, as I shall hereafter show you. ( 1966, 2001, 2002.] The State Asylum is managed by five trustees, appointed by the governor with the consent of the Senate. Immediately after the appointment by the court of any guardian for a lunatic or insane person, such guardian shall take steps to have the person thus placed in his charge ad- mitted into said asylum, and on application on behalf of a person for admission into the asylum, the superintendent and board of trustees, if they think that such person ought to be admitted, may receive him as a patient therein, if the person making the applica- tion shall execute and deliver an obligation, with sufficient security, payable to the trus- tees of said asylum, for the payment of such sums of money as may be agreed on be- tween them for the maintenance and care of such lunatic while in the asylum, and for his removakthereto or therefrom when necessary. — /^ev. Stat., sec. 320. Said superintendent and board of trustees shall also receive all persons who may have been acquitted of crimes and misdemeanors on the ground of insanity, or who may be imprisoned for crimes and misdemeanors, upon the certificate of the judge of the circuit court before whom such persons have been acquitted or are arraigned for trial, that such persons are insane and should be received in such asylum, where they shall remain until restored to their right mind. — Rev. Stat., sec. 321. If friends of any lunatic neglect to place him in asylum and permit him to be at large, it is the duty of the circuit court of the county, on the suggestion in writing of any citizen of the county, to direct the sheriff, by writ of lunacy, to summon twelve discreet men to make inquisition thereto on oath. If the person said to be a lunatic is adjudged by said inquest, or a majority of them, to be insane, the court shall order him to be placed in an asylum. 632 APPENDIX A. Guardians are appointed for the insane, who must give suitable bonds, and have the charge of the persons and estates of their wards. The circuit courts have jurisdiction to appoint and superintend and control such guardians. CALIFORNIA. [See Hittell's Codes and Statutes of California, with supplement to 18S0, Title V., chap, i., of Political Code, sees. 2136-2222. Sections 11,763-11,766, 13,361, 14,367, l'4.373. etc- Supplement, sees. 10,372, 10,794, 11,763, etc.. Statutes and Amendments to Code, 18S1, chap, ix., p. 7; Statutes and Amendments to Code, 1883, chap. Ixi., p. 2oo,J The State Asylum is under the management of a board of five directors, appointed by the governor witli advice of the Senate. Whenever it appears, by affidavit, to the satisfaction of a magistrate of the county, that any person within the county is so far disordered in his mind as to endanger health, per- son or property, he must issue and deliver to some peace officer for service, a warrant, directing that such person be arrested and taken before any judge of a court of record within the county for examination. — Political Code, sec. 2210. The judge must issue subpoenas to two or more witnesses best acquainted with such insane person, and to two physicians to appear before him. The physicians must hear the testimony and make an examination of the alleged insane person. If they believe such person to be dangerously insane, they must make a ceitificate showing as nearly as possible : 1. That such person is so far disordered in his mind as to endanger health, person, or property ; 2. The premonitory symptoms, apparent cause or class of insanity, the duration and condition of the disease ; 3. The nativity, age, residence, occupation, and previous habits of the person ; 4. The place from whence the person came, and the length of his residence in this State. The judge, after such examination and certificate, if he believes the person insane, must make an order that he be confined in the asylum. A copy of such order shall be filed with and recorded by the county clerk of the county, and the county clerk shall keep an index book, showing the name, age sex, of each person so committed, together with the date of the order and name of asvlum. — Political Code, sees. 2210 -22 1 7. (As amended 1881.) Guardians may be appointed to take charge of the persons and property of the insane, subject to the customary safeguards and supervision. Every person guilty of any harsh, cruel or unkind treatment of, or of any neglect of duty towards any idiot, lunatic, or insane person, is guilty of a misdemeanor. — Penal Code, sec. 13,361. COLORADO. [See General Statute (1877), chap. Ixi.; Session Laws, 1879, pp. 87-92; Session Laws, 1881, pp. 131 and 141; Session Laws, 1883, p. 32.] The management of the State Asylum is by a superintendent and a board of three com- missioners appointed by the governor. — Laws, 1879, p. 87. Whenever any reputable person files a verified complaint in the county court, alleging that any person is insane, and has personal or real property, and is incapable of taking care of the same, thejudge shall thereupon summon six jurors to pass upon the case. If said jury find that such person is so insane as to be unfit to manage his estate, it is the duty of said county court to appoint a conservator thereof. _ If complaint is made that any person is so insane or distracted in mind as to endanger his own person or property, or the person or property of others, the judge shall issue an order for the apprehension of such alleged lunatic, and, if he so elects, an inquest shall be held as set forth in the preceding paragraph. ABSTRACT OF LAWS RELATING TO THE INSANE. 633 \ If the jury find that the complaint is well founded, it is the duty of the court to iomrait such lunatic to the county jail or other convenient place, except that such lunatic sViall be delivered into the custody of any relative or friend who shall make application therefor, and shall be shown to be a proper and suitable person. The complaints mentioned alcove may be joined and one inquest may determine the matters charged m both complaints. No inquest of lunacy shall be held without ten days' notice to the alleged lunatic and to the guardian ad litem, to be appointed by the court. Laws of 1879, p. 90, Amending chap. Ixi., of the General Laws Concerning Lunatics. CONNECTICUT. [See General Statute of Connecticut (Revision of 1875), PP- 96-99- Laws, 1877, pp. 248, 254. Laws, 1878, pp. 327, 343. Laws, 1879, chap. 71.] The trustees of the State Flospital for the Insane may authorize the superintendent to admit patients into the hospital under special agreements when there are vacancies. Sf.c. 6. Any insane person may be put in any suitable place of detention, on the pres- entation of a certificate, made within thirty days, signed by some reputable physician, that he has made a personal examination of such person within one week prior to the date thereof, and that such person is insane, which certificate shall be sworn to before some officer authorized to administer oaths in the State where it is given, who shall cer- tify to the genuineness of the signature thereto, and respectability of the signer; and any such person may be removed by the person placing him in such place of detention. — General Statute, p. 98. Sec. 7. On a written complaint, made to any judge of the superior court, that a person named therein is insane and unfit to go at large, such judge shall immediately appoint a committee, consisting of a physician and two other persons, one of whom shall be an at- torney at law, judge, or justice of the peace, who, after such person has been notified ac- cording to the order of such judge of the superior court, shall inquire into such complaint, and report to him the facts of the case and their opinions thereon ; and if, in their opinion, such person should be confined, such judge shall issue an order therefor. — General Statitte, p. 98. Any dangerous insane person who shall go at large, may be confined by order of a justice of the peace and the first selectman of the town, after a physician's certificate, or after complaint to, and a hearing before, any justice of the peace. For proceedings to commit an insane pauper or indigent person, see Public Acts, 1878, P-327-. Any judge of the superior court, on information that any person is unjustly detained or confined in any insane asylum, may appoint a commission of not less than two persons to investigate the case and report. If, in their opinion, the party is improperly or illegally confined, the judge shall order his discharge. — Public Acts, 1878, p. 343. DELAWARE. [See Revised Code, 1852, as amended, etc., 1874, chap., 49 ; chap. 397, Vol. 1 1 (eleven). Laws of Delaware ; chap. 57, Vol. 14, Laws of Delaware, amended by Laws of 1881 ; Laws of 1875, Vol. XV., Part I., chap. 57 ; Laws of 1881, Vol. XVI., Part II., chap. 378.] The court of chancery has care of insane persons above the age of twenty-one years, so far as to appoint trustees to take charge of them and manage their estates. A writ must first issue to inquire and determine by jury whether the person is insane. Upon application by relatives or friends of any indigent lunatic or insane person to the chancellor, with certificate of two physicians practicing in the county where such per- son resides, the chancellor, if satisfied of the insanity and indigency oi^ such person, shall recommend in writing to the governor his removal to such asylum, hospital, or institu- tion lor the insane, in Pennsylvania, as the governor shall select. 634 APPENDIX A. The governor shall request from such asylum an annual report, with full details, as to inmates sent from Delaware, and transmit the same to the legislature. The court may, upon motion of the attorney-general, order any person who has been charged with a crime punishable with death, and acquitted on the ground of insanity, to be committed to any lunatic asylum in the United States, and may appoint a trustee to contract for the support of such person. DISTRICT OF COLUMBIA. [See United States Revised Statutes, 1S73-74, Part II., Title LIX., chap, iv., sees, 4838-4S58.] There sball be in the District of Columbia a Government Hospital for the Insane, and its objects shall be the most humane care and enlightened curative treatment of the in- sane of the army and na\y of the United States, and of the District of Columbia. — United States Revised Statutes, sec. 4838. The superintendent of the Government Hospital for the Insane is appointed by the Secretar}' of the Interior. Nine citizens of the District of Columbia, appointed by the President, constitute a Board of Visitors for the Hospital for the Insane. Such board, subject to the approval of the Secretar}' of the Interior, may make any needful by-laws for the government of themselves and of the superintendent and his employes, and of the patients, not incon- sistent with law ; they must also visit the hospital at stated intervals. Admission of Patients. I. The superintendent, upon the order of the Secretary of War, of the Secretary of the Xavy, and of the Secretary of the Treasury, respectively, shall receive and keep in cus- tody, until they are cured or removed by the same authority which ordered their recep- tion, insane persons of the following description : First. Insane persons belonging to the army, navy, marine corps, and revenue cutter sers'ice. Second. Civilians employed in the Quartermaster's and Subsistence Department of the army, who maj' be, or who hereafter may become, insane while in such employment. Third. Men who, while in the service of the United States, in the army, navy, or marine corps, have been admitted to the hospital, and have been thereafter discharged from it on the supposition that they have recovered their reason, and have within three years after such discharge become again insane, from causes existing at the time of such discharge, and have no adequate means of support. Fourth. Indigent insane persons, who have been in either of the said services, and been discharged therefrom on account of disability arising from such insanity. Fifth. Indigent insane persons who have become insane within three years after their discharge from such service, from causes which arose during, and were produced by, said service. — United States Revised Statutes, sec. 4843. II. The .-ecretary of the Interior may giant an order for the admission into the hospital of any insane person not charged with a breach of the peace, when he shall receive the certificate of any judge of the Supreme Court of the District of Columbia, or of any jus- tice of the peace of the District, and an application in writing by a member of the Board of Visitors, requesting that such order may be issued. It must appear by such certificate that two respectable physicians, residents of the Dis- trict, appeared before said judge or justice, and deposed, in writing sworn to and sub- scribed by them, that they knew the person alleged to be insane, and from personal ex- amination believed such person to be in fact insane, and a fit subject for treatment in said hospital ; also, that such person was a resident of the District at the time he or she was seized with such mental disorder. It muse further appear by such certificate, that two respectable resident householders appeared before the judge or justice, and deposed that they knew the person alleged to be insane, and. from a personal examination of his or her affairs, they believed said person to be unable to support himself or family, and unable to pay board and other expenses in the hospital. ABSTRACT OF LAWS RELATING TO THE INSANE. 635 The application by a member of the Board of Visitors must be made within five days after the date of the affidavits aforesaid, and it must appear therein to be made after in- spection of the affidavits and certificate. A patient able to pay part of the expenses in said hospital may be required to do so after investigation by the Board of Visitors. Indigent insane persons, non-residents at the time they became insane, may, upon ap- plication of the governor of the District, and certificates and application as above, be ad- mitted into the hospital with a view to their return to their friends or place of residence. — United States Revised Statutes, sees. 4844-4S50. III. Whenever there are vacancies, private patients from the District may be received at a rate of board to be determined by the Visitors ; to be in no case less than their actual support. In this case there must be the certificate of two physicians stating that they have personally examined the patient and believe him to be insane at the time of giving the certificate, and a fit subject for treatment in the institution, accompanied by a written request for the admission from the nearest relative, legal guardian, or friend of the patient. The request for admission must be made within five days of the date of the certificate of insanity. — United States Revised Statutes, sees. 4853-54. IV. Inmates of the National Home for Disabled Volunteer Soldiers, becoming insane, will be received as patients in the Government Hospital. — See United States Statutes, 1881-82, Vol. 22, Part I., p. 330. V. As to admission of insane criminals, or persons charged with crime, see United States Revised Statutes, sees. 4851, 4852; United States Statutes, 1881-82, Vol. 22, Part I-, p. 330. FLORIDA. [See McClellan's Digest of the Laws of Florida, chap. 147, page 746.] Whenever it is suggested, by petition or otherwise, to any judge of the circuit court of the State, that there is an insane person within the limits of such judicial circuit in- capable of taking care of himself or of his property, it is the duty of said judge to issue a writ to the sheriff, and cause such alleged lunatic to be brought before him. If such person is found, upon investigation, to be insane, the judge shall pass such order or de- cree as is usual or necessary in such cases. If it appear that such lunatic has an estate, the decree shall bind said estate. If destitute, then the judge shall order the sheriff to transport such lunatic to the asylum for indigent lunatics of the State of Florida : Pro- vided, however-, tliat the judge, in his discretion, may direct said lunatic to be delivered to any other person for his care, custody, and maintenance. For such care, etc., the said person shall receive not exceeding ^150 per annum. The comptroller,, once in every six months, must send to the State attorney of each cir- cuit a list of the lunatics in the care of private pei'sons, and an investigation shall be made into each case by the grand juries of the several counties. By proceedings had before the judge of the circuit court the custody of such lunatics may be changed; or they may be discharged from custody, or transferred to the State Asylum. The estates of insane persons are managed generally by guardians, who may, upon formal application, sell the real estate of their wards, and may make contracts relating to the person and estate of their wards, if approved by the judge of the circuit court. GEORGIA. [See Code of the State of Georgia (1882), sees. 1852 to 1864 inclusive; sec. 4666; sec. 331 ; sec. 4299; sees. 4695, 1658, 2735, etc ; also, as to asylums, ^ecs. 1341 to 1373 inclusive.] The ordinaries of the several counties may appoint guardians for the insane. — Code, Sec. 1852. Proceedings. — Upon petition and proof of ten days' notice to relatives of the alleged lunatic, the ordinary issues a commission, directed to any eighteen discreet and proper persons — one of whom shall be a physician — requiring any twelve of them, including the 6-X,6 APPENDIX A. physician, to examine by inspection the person for whom guardianship (or commitment to the asylum) is sought, and to hear and examine witnesses, if necessarj". Upon return of such commission finding the person to be as alleged in the petition, the ordinary shall appoint a guardian for him (or commit him to the lunatic asylum). Appeal lies from this decision to the Superior Court. — Code, sees. 1853 et seq. ; 64 Ga., 301 ; 17 Ga., 595- 597 '■> 59 Ga., 675-680; Cobb's Anah'sis, p. 684. Guardians of insane persons are authorized to confine them or place them in the asy- lum, if such a course is necessar)- either for their own protection or the safety of others, and a guardian wilfully failing to take such a precaution with his ward shall be responsi- ble for injuries inflicted on others by such ward. — Code, sec. 1863. Where there is no guardian for an insane person, or the guardian fails to confine his ward, and any person shall make oath that such insane person is dangerous, or should not be left at large, the ordinary .shall issue a warrant, and, after investigation, may commit such insane person to the lunatic asjdum. — Code, sec. 1864. Courts of ordinar}' have jurisdiction over all matters appertaining to the estates of lunatics. — Code, sec. 331. The State asylum is under the management of five trustees, appointed by the governor, one of whom shall be a competent physician. A pay patient, resident of this State, shall not be admitted unless accompanied by authentic evidence of lunacy according to law, or there is produced the certificate of three respectable pi-acticing physicians, well acquainted with the condition of the patient, or one from such physicians and two respectable citizens stating the cause of the appli- cation. — Code, sec. 1357. A demand for trial by jury of the question of lunacy may be made before or after ad- mission to the asylum by the alleged lunatic or his frends, and such trial must be had. ILLINOIS. [See Revised Statutes of Illinois (Cothran's Annotated Edition, 1881), chap. 85, page 950; Laws of Illinois, i88i,pagei5i ; Revised Statutes, 1880 (Hurd), pages 197, 198, 593, 580, 694, 734.] Each asylum for the insane is managed by a board of three trustees, appointed by the governor with consent of the Senate. When an}' person is supposed to be insane or distracted any near relative, or in case there be none, any respectable person residing in the county may petition the judge of the county court for proceedings to inquire into such alleged insanity or distraction. For the hearing of such application and proceedings thereon the county court shall be con- sidered as always open. — Rev. Stat. (Cothran's ed.), p. 950. Such person alleged to be insane shall be brought before the court and witnesses shall be subpoenaed. Trial shall be had by a jury of six persons, one of whom shall be a physician, and in the presence of the alleged lunatic, who maj' be assisted by counsel. If the jury find that such person is insane the court shall issue an order of commitment to a State Hos- pital for the Insane. Pending trial the court may order the alleged lunatic to be temporarily detained by the sheriff, jailer, or other suitable person. No person shall be received or kept in custody in any asylum or hospital for the in- sane until after the verdict of a jury and by order of the court. Any superintendent or officer of an asylum recei^-ing or detaining a person without such verdict and order is liable to imprisonment for one year or to a fine not exceeding $500 ; can be held civilly for damages by the person injured, and, if connected with either of the State hospitals, shall be discharged. Upon proper proceedings the courts will appoint conservators for the insane, to take charge of their person and property and care for their children in certain cases. ABSTRACT OF LAWS RELATING TO THE INSANE. 63/ INDIANA. [See Revised Statutes of Indiana, i88i,secs. 2835-2879, 5142-5150, 2546, 1764, 1765.] The hospital for the insane is managed by a board of trustees, two of whorh must visit it together monthly. Proceedings for Commitment. A respectable citizen of the proper county must, upon oath and in writing, make a statement before one of the justices of the peace of said county, such statement to con- sist of full answers to a long series of questions provided by the statutes touching the history, condition, heredity, etc., of the person alleged to be insane. The justice with whom said statement shall have been filed, together with another justice of the peace and a respectable practicing physician other than the medical attendant of the alleged lunatic, and selected by the justice, shall immediately thereupon visit and examine said person alleged to be insane. Subpoenas shall then be issued for all witnesses supposed to be cognizant of the facts, including the regular medical attendant. Formal certificates provided for by the statute must be given by the medical attendant and also the medical examiner. The justices then make a formal finding provided by the statute, and the same is deposited with the clerk of the circuit court of the proper county. Such lunatic may then be committed to the asylum, provided, that if the proper friends of such lunatic prefer to place him in a private asylum, they shall be granted a written authorization so to do by the clerk of the circuit court. Dangerous insane persons found at large may be committed to the asylum by any jus- tice of the peace after proper complaint and trial by a jury of six citizens. Guardians may be appointed for the insane after proceedings provided by statute, in- cluding trial by jury. IOWA. [See McClain's Annotated Statutes, 1880, sections 1383-1445, 2272-2279, etc.; Re- vised Code of Iowa (Miller, 18S0), sections 1383-1445, 4620-4028.] Each hospital for the insane is under the charge of five trustees, two of whom may be women. In each county there shall be a board of three commissioners of insanity. The clerk of the circuit court shall be a member of such board and the clerk thereof. The other members shall be appointed by the judge of said court and shall be one of them a prac- ticing physician and the other a practicing lawyer. Applications for admission to the hospital must be made in the form of an information verified by affidavit, alleging that the person in whose behalf the application is made is believed by the informant to be insane and a proper subject for custody and treatment. Upon the filing of such information the commissioners may examine the informant under oath, and if satisfied there is reasonable cause therefor, shall at once investigate the grounds thereof. They may issue their warrant and cause the alleged lunatic to be brought before them, and may provide for his suitable custody pending the proceedings. They must take such testimony as may be offered for and against the application, and the parties may be represented by counsel. Personal examination of the alleged lunatic must be made by a physician, and such physician may or may not be one of their own number, and his certificate must be taken. If the commissioners find such person insane they shall order his commitment to the hospital for the insane. An appeal lies to the circuit court from the finding of the commissioners. The commissioners may upon application and after proper proof provide for the re- straint, protection, and care of persons alleged to be insane, whose admission to the hos- pital is not sought. Any person having care of an insane person, and restraining such person, whether in the hospital or elsewhere, either with or without authority, wdio shall treat such person 638 APPENDIX A. with wanton seveiuty, harshness, or cruelty, or shall in any wa}' abuse such person, shall be guilty of a misdemeanor, besides being liable in an action for da.ma.ges.—JlfcC/am's Annotated Stats., ?,e:.c. 1415. There shall be a visiting committee of three, one of whom at least shall be a woman, appointed by the governor to visit the insane asylums of the State at their discretion, and without giving notice of their intended visits, who may, upon such visit, go through the wards unaccompanied by any officer of the institution, with power to send for persons and papers, and to examine witnesses on oath to ascertain whether any of the inmates are improperly detained in the hospital or unjustly placed there, and whether the inmates are humanely and kindly treated, with full power to correct any abuses found to exist ; and any injury inflicted upon the insane shall be treated as an offence, misdemeanor, or crime, as the like offence would be regarded when inflicted upon any other citizen out- side of the insane asylum. They shall have power to discharge any attendant or em- ploye who is found to have been guilty of misdemeanor meriting such discharge ; and in all these trials for misdemeanor, offence, or crime, the testimony of patients shall be taken and considered for what it is worth, and no employe at the asylum shall be allowed to sit upon any jury before whom these cases are tried. Said committee shall make an annual report to the governor. The names of this visiting committee and their post-office address shall be kept posted in every ward in the asylum, and every inmate in the asylum shall be allowed to write once a week what he or she pleases to this committee. And any member of this com- mittee who shall neglect to heed the calls of the patient to him for protection, when proved to have been needed, shall be deemed unfit for his office, and shall be discharged by the governor. Every person confined in any insane asylum shall be furnished by the superintendent or party having charge of such person, at least once in each week, with suitable materials for writing, inclosing, sealing, and mailing letters, if they request the same, unless other- wise ordered by the visiting committee, which order shall continue in force until counter- manded by said committee. The superintendent or party having charge of any person under confinement shall re- ceive, if requested to do so by the person so confined, at least one letter in each week addressed to one of the visiting committee, without opening or reading the same, and without delay to deposit it in a post-office for transmittal by mail, with a proper postage stamp affixed thereto, and to deliver to said person any letter (^without opening or read- ing the same) written to him or her by one of the visiting committee. But all other letters written by or to the person so confined may be examined by the superintendent, and, if in his opinion the deliver}^ of such letters would be injurious to the person so confined, he may retain the same. — McClaui' s Annotated Stats., sees. 1435-1438. A commission may be appointed by a judge of the district or circuit court of the county to inquire as to the sanity of any person confiired in the hospital. If upon the report of such commission the judge shall find the person not insane he shall order his discharge. All persons confined as insane are entitled to the benefit of the writ of habeas corpus. Guardians are appointed for the insane with like provisions as in cases of guardians for minors. KANSAS. [See Compiled Laws of Kansas (by C. F. W. Dassler, 1881), sees. 435-453, 3060- 3120, 3416, 4757.] The go^'ernment of the insane asylums of the State shall be vested in the board of trustees of the institutions for the education of the blind, the deaf and dumb, and the asylums for the insane. — Compiled Laws of Kan., sec. 435. The board of trustees shall designate the superintendent of one of the insane asylums, to whom all applications for the admission of insane persons shall be made, and who, under such rules as may be made by the board of trustees, shall designate to which asylum each applicant shall be admitted. — Compiled Laws of Kan., sec. 436. If information in writing is given to the probate court that any one in its county is an idiot, lunatic, or person of unsound mind, or an habitual drunkard, and incapable of managing his affairs, and praying that an inquiry thereinto be had, the court, if satisfied ABSTRACT OF LAWS RELATING TO THE INSANE. 639 that there is good cause for the exercise of its jurisdiction, shall cause the facts to be inquired into by a jury. — Compiled Lazvs of Ka7i., sec. 3060. The jury shall consist of six persons, one of whom shall, be a practicing physician. The person alleged to be insane has the right to be present and assisted by counsel. If it appear that the person is insane and a fit person to be sent to the asylum, the court shall enter an order of commitment; and if it be found by the jury that the person is of unsound mind and incapable of managing his or her aifairs, the court shall appoint a guardian of the person and property of such person. Such guardian must give suitable bonds, and is under the full control of the probate court. In cases of dangerous insanity, it is the duty of the giiardian, or other person in whose care such lunatic may be, to cause him to be confined in some suitable place until pro- ceedings can be commenced in the probate court of the county, which shall make such order for the restraint, support, and safe -keeping of such insane person as circumstances require. KENTUCKY. [See General Statutes of Kentucky (B. & F., 1881), chap. 73, pp. 642-652; chap. 53, pp. 534-541 ; Civil Code of Ky., sees. 489-498.] Each lunatic asylum of the State is under the management of a board of nine com- inissioners, who shall be "discreet business men," appointed by the governor with the consent of the Senate. They are required to hold regular meetings at the asylum once a month, and one of them shall visit the asylum once a week, two in each month, a majority in each quarter, and the whole board once in six months. No private patient, who has not been found to be insane by regular inquest, shall be received into either of said asylums. — Gen. Stats., p. 649. In order to relieve the State from an undue accumulation of patients, the several asylums may send to their respective counties or places whence they came patients who, in the judgment of the commissioners and superintendent, are harmless and governable. The several com-ts of the State having general equity jurisdiction, have power and jurisdiction within their respective counties over the care and custody of the persons and estates of idiots and lunatics. — Gen. Stats., p. 534. If any person be of unsound mind, it shall be the duty of some court of the county in which he resides, having general equity jurisdiction, upon the application of the attorney of the Commonwealth, or, if he be absent, of the county attorney, to cause an inquest by a jury to be held in open court to inquire into the fact. — Gen. Stats., p. 537. The court appoints counsel for the alleged lunatic, and it is the special duty of the attorney for the Commonwealth, or for the county, to prevent the finding of any person as an idiot or lunatic who, in his opinion, is not such. If upon such inquest any person is found to be of unsound mind, and incompetent to manage his or her estate, the court will appoint a committee for such lunatic ancl may or- der his commitment to an asylum. The power and duty of the committee of a lunatic or imbecile is the same as that of the guardian of an infant, except as to education. But the court may appoint a person other than the committee to take charge of the person of the idiot or lunatic when not confined in an asylum, and make the necessary orders for his support upon the committee. The officer who presides at the inquest shall endeavor to ascertain and draw up a brief history of the patient's case, embracing points provided by the statute, and such statement, or a copy, shall be sent with the record to the asylum, if the lunatic is sent. No person not otherwise insane shall be sent to an asylum merely because he is subject to epileptic fits, or thereby rendered helpless. — Gen. Stats., p. 541. LOUISIANA. [See Voorhies's Revised Statutes of Louisiana, 1876, sees. 1760-1780.] The State asylum is under the management of a board of five administrators, appointed by the governor with the advice and consent of the Senate. At every regular meeting the board shall appoint two of its members, who shall visit 640 APPENDIX A. said asylum at least once a week. The board shall furnish a report to the legislature at each session. Upon petition and oath of any individual, and after " proper inquiry into all the facts and circumstances of the case," the district or parish judge may cause any lunatic to be committed to the insane asylum. The board of administrators have authority to receive insane persons, not sent to the asylum by a district or parish judge, on such terms and conditions as they may deem fit to adopt. Prisoners acquitted on the ground of insanity may be sent to the asylum until restored. A curator or guardian may be appointed for an insane person, who shall have the care of the person and property of such interdicted person or ward. — Voorhies''s Revised Statutes, sees. 1095 to 11 13 inclusive; and Revised Civil Code of Louisiaria, Title IX., P- 50- MAINE. [See Revised Statutes of Maine (1871), chap. 143, pp. 927-933; also pp. 58, 533, 534, 540, 537, 643, 694, 632, 770, 651, 652, 749, 898, 899, 923; Laws of 1872, chap. 54; Laws of 1873, chap. 151 ; Laws of 1874, chap. 256; Laws of 1876, chap. I17; Laws of 1877, chap. 188; Laws of 1879, chap. 160; Laws of 1880, chap. 184.] The government of the Maine Insane Hospital is vested in a committee of six trustees, one of whom shall be a woman, appointed by the governor, with the advice of the council, and commissioned to hold their office during the pleasure of the governor and council, but not more than three years under any one appointment. — Lazvs 0/ 1S80, chap. 184. In all cases of preliminaiy proceedings for the commitment of any person to the hos- pital, the e\'idence and certificate of at least two respectable physicians, based upon due inquiry' and personal examination of the person to whom the insanity is imputed, shall be required to establish the fact of insanity, and a certified copy of the physician's certifi- cate shall accompany the person to be committed. — Laws of 1876, chap. 117. A committee of the council, consisting of two, with whom shall be associated one woman, shall be appointed by the governor annually, who shall visit the hospital at their discretion to ascertain if the inmates thereof are humanely treated, and they shall make prompt report from time to time of every instance of intentional abuse or ill-treatment to the trustees and superintendent of the hospital, who shall take notice thereof, and cause the offender to be punished as required by section twenty-eight, chapter one hundred and forty-three of the Revised Statutes. — Laws of 1S74, chap. 256, sec. 4. If any wilful injuiy shall be inflicted by any officer, attendant, or employe of the hos- pital, upon the person of any patient therein, and knowledge thereof shall come to the said committee of visitors, they shall report the fact immediately to the said trustees and superintendent ; and if the superintendent fails forthwith to complain thereof, as required by the statute aforesaid, one of the said visitors shall enter a complaint thereof before the court having jurisdiction of such offence, and, on conviction, the offender shall be pun- ished as provided by lav.-. And in all trials for such offences, the statement of any patient cognizant thereof shall be taken and considered for what it may be worth, and no one connected with the hospital shall be allowed to sit upon the jury which shall try the case. — Laws of 1874, chap, 256, sec. 5. In case of the sudden death of any patient in the hospital, under circumstances of reasonable suspicion as to the innocent cause thereof, a coroners inquest shall be held, as provided by law in other cases, and the committee of visitors shall cause a coroner to be immediately notified for that purpose. — Laws of 1874, chap. 256, sec. 6. If the committee are satisfied that any inmate has been improperly committed, or is unnecessarily detained, they shall make application to the proper judge for a writ of habeas corpus, who, after a full hearing, shall order the discharge of such inmate, if con- vinced that he is not a proper subject for custody. — Laws of 1874, chap. 256, sec. 8. The names of the committee of visitors shall be posted in the wards, and easily acces- sible locked letter-boxes provided, and the inmates shall be provided with writing mate- rials and allowed to write what and when they may please to any member of such visiting committee. No officer or attendant of the hospital shall be allowed the means of reaching the contents of such boxes. Letters shall be delivered to patients without being opened, if forwarded by the com- ABSTRACT OF LAWS RELATING TO THE INSANE. 64 1 mittee, or directed to such inmate as the committee have authorized to receive or send letters without their inspection. — Laws of 1874, chap. 256, sees. 9-10. Hospital to be visited at least once a month, at irregular intervals and without notice, but as far as possible unexpectedly, by a member of committee, who shall not be' accompanied by any officer or employe of the hospital when making his visits, except upon his special request. The committee of visitors shall report annually, and as much oftener as necessary, to the governor and council. — Laws of 1874, chap. 256, sees. 11-12. The judge of probate may appoint a guardian for any insane person, and such guardian has the care of the person and estate of his ward, subject to the control of the court. — Rev. Stats., chap. 67. As to commitment to asylum of person indicted and acquitted on ground of insanity, or against whom the grand jury omits to find for same cause, see Laws of 1879, chap. 160. Proceedings for transferring insane inmates of State prison or county jail to asylum, see Laws of 1877, chap. 189. MARYLAND. [As to the Maryland Hospital for the Insane, see Revised Code of Maryland, 1878, Ar- ticle 26, p. 242; Laws of Maryland, 1880, chap. 314. Generally as to care and mainte- nance of the insane, see Revised Code of Maryland, 1878, Article 53, and Maryland Code Public General Laws, i860. Article, 16, sees. 79-87. As to insane or lunatic convicts. Revised Code (1878), Article 6, p. 62.] A court of equity may, on the application of any trustee of a person no7i compos f?ientis, and receiving proof that it is necessary and proper to confine such person, direct such trustee to send the person under his charge to any hospital in the vicinity of the city of Baltimore, provided he can be there received, to remain until the further order of the court. — Rev. Code, Art. 53, sec. i. When any person is alleged to be a lunatic or insane pauper, trial by a jury shall be had before such person is committed to an asylum.— TPfz/. Code, Art. 53. Prisoner acquitted on ground of insanity shall be confined in some suitable place until he shall have recovered his reason, and be discharged by due course of law. — Rev. Code, Art. 53. ■ The courts have full power to superintend and direct the care of the insane, both as to their person and the management of their property, and appoint a committee or a trustee or trustees for such persons. MASSACHUSETTS. Following are public statutes of the Commonwealth of Massachusetts, enacted Novem- ber 19, 1 88 1, to take effect February i, 1882. General Duties of State Board. Chapter 87, Section i. The State board of health, lunacy and charity shall act as commissioners of lunacy, with power to investigate the question of the insanity and con- dition of any person committed to any lunatic hospital or asylum, public or private, or restrained of his liberty by reason of alleged insanity, at any place within this Common- wealth ; and shall discharge any person so committed or restrained, if in its opinion such person is not insane, or can be cared for after such discharge without danger to others and with benefit to himself. State Lunatic Hospitals. Sec. 4. The government of each of the State lunatic hospitals, at Worcester, Taunton, Northampton, and Danvers, shall be vested in a board of five trustees, appointed and commissioned by the governor with the advice and consent of tire council, subject to re- moval only for sufficient cause. 41 642 APPENDIX A. Commitments to Hospitals. Sec. II. a judge of the supreme judicial court or superior court, in any county where he may be, and a judge of the probate court, or of a police district or municipal court within his county, may commit to either of the State lunatic hospitals, any in- sane person, then residing or being in said county, who, in his opinion, is a proper sub- ject for its treatment or custody. Sec. 12. Except when otherwise specially provided, no person shall be committed to a lunatic hospital, asylum, or other receptacle for the insane, public or private, with- out an order or certificate therefor, signed by one of the judges named in the preced- ing section, said person residing or being within the county as therein provided. Such order or certificate shall state that the judge finds that the person committed is insane, and is a fit person for treatment in an insane asylum. And said judge shall see and ex- amine the person alleged to be insane, or state in his final order the reason why it was not deemed necessary or advisable to do so. The hearing, except when a jury is sum- moned, shall be at such place as the judge shall appoint. In all cases the judge shall certify in what place the lunatic resided at the time of his commitment ; or If the con- finement is ordered by a court, the judge shall certifiy in what place the lunatic resided at the time of the arrest in pursuance of which he was held to answer before such court ; and such certificate shall, for the purposes of the preceding section, be conclusive evi- dence of his residence. Sec. 13. No person shall be so committed, unless in addition to the oral testimony there has been filed with the judge a certificate signed by two physicians, each of whom is a graduate of some legally organized medical college, and has practiced three years in the State, and neither of whom is connected with any hospital or other establishment for treatment of the insane. Each must have personally examined the person alleged to be insane, within five days of signing the certificate, and each shall certify that in his opinion said person is insane and a proper subject for treatment in an insane hospital, and shall specify the facts on which his opinion is founded. A copy of the certificate, attested Jjy the judge, shall be delivered b)- the officer or other person making the com- mitment to the superintendent of the hospital or other place of commitment, and shall be filed and kept with the order. Sec. 14. A person applying for the commitment or for the admission of a lunatic to a State lunatic hospital, under the provisions of this chapter, shall first give notice in writing to the mayor or one or more of the selectmen of the place where the lunatic re- sides, of his intention to make such application, and satisfactory evidence that such notice has been given shall be produced to the judge in cases of commitment. Sec. 15. Upon ever}' application for the commitment or admission of an insane person to a hospital or asylum for the insane, there shall be filed with the application, or within ten days after the commitment or admission, a statement in respect to such person, show- ing, as nearly as can be ascertained, his age, birthplace, civil condition and occupation, the supposed cause, and the duration and character of his disease, whether mild, violent, dangerous, homicidal, suicidal, paralytic or epileptic, the previous or present existence of insanity in the person or his family ; his habits in regard to temperance, whether he has been in any lunatic hospital, and, if so, what one, when, and how long, and if the patient is a woman, whether she has borne children, and, if so, what time has elapsed since the birth of the youngest; the names and address of his father, mother, children, brothers, sisters or other next of kin, not exceeding ten in number, and over eighteen years of age, when the names and address of such relatives are known by the person or persons making such application, together with any facts showing whether he has or has not a settlement, and if he has a settlement, in what place ; and if the applicant is un- able to state any of the above particulars, he shall state his inability to do so. The state- ment, or a copy thereof, shall be transmitted to the superintendent of the hospital or asylum, to be filed with the order of commitment or the application for admission. The super- intendent shall, within two days from the time of the admission or commitment of an insane person, send, or cause to be sent, notice of said commitment in writing, by mail, postage prepaid, to each of said relatives, and to any other two persons whom the person committed shall designate. Sec. 16. After hearing such other evidence as he may deem proper, the judge may issue a warrant for the apprehension and bringing before him of the alleged lunatic, if in his judgment the condition or conduct of such person renders it necessary or proper to do so. Such warrant may be directed to and be served by a private person named in said warrant, as well as by a qualified officer ; and pending examination and hearing, ABSTRACT OF LAWS RELATING TO THE INSANE. 643 such order may be made concerning the care, custody or confinement of such alletred lu- natic as the judge shall see fit. '^ _ Sec. 17. The judge may, in his discretion, issue a warrant to the sheriff or his deputy directmg him to summon a jury of six lawful men, to hear and determine whether the alleged lunatic is insane. Sec. 19. The judge shall preside at such trial and administer to the jury an oath faithfully and impartially to try the issue, and the verdict of the jury shall be final on the complaint. Sec. 25. When the State board has reason to believe that any insane person, not in- curable, is deprived of proper remedial treatment, and is confined m an almshouse or other place, whether such insane person is a public charge or otherwise, it shall cause appli- cation to be made to a judge for the commitment of such person to a hospital in the manner herein prescribed. Sec. 26. The superintendent or keeper of any lunatic hospital, including the McLean Asylum at Somerville, may receive into his custody and detain in such hospital or asy- lum for a period not exceeding five days without an order of a judge as provided in sec- tion eleven, any person as insane, whose case is duly certified to be one of violent and dangerous insanity and emergency by two physicians, qualified as provided in section thirteen, which certificates shall be separately made and signed, and shall conform in all other respects to the provisions of section thirteen. In addition to such certificates, an appli- cation signed by one of the selectment of the town, or by the mayor or one of the aldermen of the city in which such insaue person resides or is found, shall be left with the superin- tendent of the hospital or asylum in which the insane person is received, and such ap- plication shall contain the statement in respect to such insane person which is required by section fifteen, and a further statement that the case is one of violent and dangerous insanity. Sec. 27. When an insane person is committed to a lunatic hospital or asylum in ac- cordance with the provisions of the preceding section, the party committing such person shall give a bond in the sum of one hundred dollars to the treasurer of such hospital or asylum, with condition that he will, within five days, procure an order for the com- mitment of said patient as provided in section eleven, or failing thereof will remove him. Sec. 28. The superintendent or keeper of any hospital as aforesaid, may receive and detain therein, as a boarder and patient, any person who is desirous of submitthig himself to treatment, and makes written application therefor, but whose mental condition is not such as to render it legal to grant a certificate of insanity in his case. No such boarder shall be detained for more than three days after having given notice in writing of his intention or desire to leave such hospital. Sec. 29. When a patient is received into any such hospital upon his own application or under the provisions of section twenty-six, the superintendent thereof shall give imme- diate notice of such reception to the State board of health, lunacy and charity, stating all the particulars of the case, including the legal settlement of the person so received, if known; and said board shall immediately cause such cases to be investigated and a record to be made of all the facts pertaining thereto. Sec. 30. Any physician who wilfully conspires with any person, unlawfully or im- properly, to commit to any lunatic hospital or asylum in this State, any person who is not insane, shall be punished by fine or imprisonment at the discretion of the court. Certain Privileges of Patients in Hospitals, Sec. 35. An attorney-at-law regularly retained by or on behalf of any person com- mitted to a lunatic hospital, asylum or receptacle for the insane, shall be admitted to visit such client at all reasonable times, if, in the opinion of the superintending officer of such hospital, asylum or receptacle, such visit would not be injurious to such person, or if a judge of the supreme judicial court, superior court or probate court in any county first orders in writing that such visits be allowed. Sec. 36. All patients in any lunatic hospital, asylum or receptacle for the insane shall be allowed to write monthly to the superintendent and to the State board ; and they shall be furnished by the superintendent with all materials necessary for such corre- spondence. A locked box shall be placed in each ward, in which each writer may de- posit his letters, and the boxes shall be opened and the letters distributed monthly by the State bo^rd. 644 APPENDIX A. Transfer and Discharge of Lunatics. Sec. 40. Any two of the trustees of a State Lunatic Asylum, on an application in writing or of their own motion, or any judge of the supreme judicial court, at any time and in any count}", or the judge of the probate court for the county in which the hospital is situated, or in which the patient had his residence at the time of his commitment or ad- mission, on such application, and after such notice as the said trustees or judge may deem reasonable and proper, may discharge any person confined therein, if it appears that such person is not insane, or, if insane will be sufficiently provided for by himself, his guardian, relatives or friends, or by the citj- or town liable for his support, or that his confinement therein is not longer necessar}' for the safety of the public or his own welfare. Sec. 41. Any two of the trustees may also remove any person confined therein, to the city or town in which the judge committing him certified that he resided at the time of the order for commitment, or to the place of his settlement, when, in their opinion, he ceases to be dangerous, and is not susceptible of mental improvement at the hospital, if such city or town does not remove him after reasonable notice in writing. Sec. 42. Any person may make written application to a judge of the supreme judicial court at any time and in any county, setting forth that he believes or has reason to be- lieve that a person therein named is confined as an insane person in a lunatic hospital or other place, whether public or private, and ought not longer to be so confined, and stat- ing the names of all persons supposed to be interested in keeping him in confinement, and requesting his discharge. Sec. 43. The judge, upon reasonable cause being shown for a hearing, shall order notice of the time and place of hearing on said application, to be given to the superintend- ent in charge of the hospital or place of confinement, and to such other persons as he deems proper, and such hearing when ordered shall be had as speedily as conveniently may be, before any judge of the supreme judicial court in any county. The alleged in- sane person may be brought before the judge at the hearing upon a writ of habeas corpus, if anj" person so requests and the judge deems it proper, and an issue or issues maj- be framed and submitted to a jurv' hv direction of the judge or on the request of any person who appears in the case. The jurors may be those in attendance on said court, if in session at the time of the hearing, or may be summoned for the special purpose on venires issued by the clerk of said court upon the order of the judge, substantially in accordance with the provisions of chapter 1 70. Sec. 44. If it appears upon the verdict of the jur}-, or in the opinion of the judge, if not submitted to a jur\% that the person so confined is not insane, or that he is not dan- gerous to himself or others, and ought not longer to be so confined, he shall be discharged from such confinement. County Receptacles. Sec. 46. There shall be in each county within the precincts of the house of correction, or if in the judgment of the county commissioners it cannot be conveniently provided within the same, then in some other building or buildings, to be deemed a part of the house of correction, a convenient apartment or receptacle for the confinement of insane persons not furiouslj" mad. Sec. 4S. Any judge authorized under this chapter to commit lunatics may, in his dis- cretion, commit an insane person not furiously mad, and having a settlement in this State, to the county receptacle aforesaid. Sec. 49. Provision shall be made for the comfortable support of all persons confined in said receptacles, and they shall be governed or employed in such marmer as the county commissioners may, in the exercise of their discretion, deem best. Such sum a week shall be allowed and paid for the support of the persons so confined as the com- missioners shall direct, and the same may be recovered of such person, or of any parent, kindred, master, guardian, cit}' or town bound by law to maintain him. Sec. 50. Any insane person confined by legal authority in a jail, house of correction, or such count)- receptacle, may be removed therefrom to either of the State lunatic hos- pitals, or to any other jail, house of correction, or other suitable place, by order of the governor, when it appears to him that such removal would be expedient and just ; and the sheriff of the county in which such person is confined shall execute such order and convey the insane person to the place therein designated. Sec. 51. Any person confined by virtue of section 48 may be discharged, when, in the opinion of a judge authorized to commit insane persons, such discharge would be for the benefit of such person, or when in his opinion such person would be comfortably sup- ABSTRACT OF LAWS RELATING TO THE INSANE, 645 ported by any parent, kindred, friend, master or guardian, or by any place in which he has a legal settlement. Private Insane Asylums. Sec. 53. The governor and council may license any suitable person to establish and keep an asylum or private house for the reception and treatment of insage persons, and may at any time revoke such license. And such asylum or private house shall be subject to vis- itation by the governor and council or any committee thereof, and by the judge of the probate court of the county wherein the same is situated. Sec. 54. Whoever establishes or keeps such an asylum or private house without a li- cense, unless otherwise authorized by law, shall forfeit a sum not exceeding five hundred dollars. Chap. 213, Sec. 15. When a person held in prison on a charge of having committed an indictable offence, is not indicted by the grand jury by reason of insanity, the grand jury shall certify that fact to the court, and thereupon the court, if satisfied that he is in- sane, may order him to be committed to a State lunatic hospital, under such limitation as may seem proper. Sec. 30. A judge of the supreme judicial court sitting for the arraignment of a person charged with murder shall have the same power to commit such person to a lunatic hospital, if found by him to be insane, as the court would have if sitting at a regular term thereof. Chap. 214, Sec. 16. When a person indicted is, at the time appointed for the trial, found, to the satisfaction of the court, to be insane, the court may cause him to be re- moved to one of the State lunatic hospitals for such a term and under such limitations as it may direct. Sec. 19. When a person is acquitted by the jury by reason of insanity, the jury shall state that fact to the court, and thereupon the court, if satisfied that he is insane, may order him to be committed to a State lunatic hospital, under such limitations as may seem proper. Sec. 20. When a person indicted for murder or manslaughter is acquitted by the jury by reason of insanity, the court shall order such person to be committed to one of the State lunatic hospitals during his natural life. Sec. 21. Any person committed to a State lunatic hospital, under the preceding section, may be discharged therefrom by the governor, by and with the advice and con- sent of the council, when he is satisfied, after a hearing of the matter, that such person may be discharged without danger to others. Chap. 215, Sec. 34. If a person convicted of a capital crime is, at the time when mo- tion for sentence is made, found, to the satisfaction of the court, to be insane, the court may cause such person to be removed to one of the State lunatic hospitals for such a term and under such limitations as it may direct. Sec. 35. If it appears to the satisfaction of the governor and council that a convict under sentence of death has become insane, the execution of said sentence may be respited by the governor, by and with the advice of the council, from time to time for stated periods, until it appears to their satisfaction that the convict is no longer insane. Removal of Insane Prisoners. Chap. 222, Sec. id. The State board of health, lunacy and cliarity shall designate two persons, expert in cases of insanity, to examine convicts in the State prison or reformatory prison alleged to be insane. When any such convict appears to be insane, the warden or superintendent shall notify one of the persons so designated, who shall, with the physician of the prison, examine the convict, and report to the governor the result of their inves- tigation. If upon such report the governor deems the convict insane and his removal expedient, he shall issue his warrant directed to the warden or superintendent, authorizing him to cause the convict to be removed to one of the Slate lunatic hospitals, there to be kept until, in the judgment of the superintendent and trustees of the hospital to which he may be committed, he should be returned to prison. When the superintendent and trustees of the hospital have come to such judgment, the fact shall be certified upon the warrant of the governor, and notice shall be given to the warden or superintendent of the prison, who'shall thereupon cause the convict to be reconveyed to the prison, there to remain pursuant to the original sentence, computing the time of his detention or confine- ment in the hospital as part of the term of his imprisonment. Sec. 12. When a convict in a house of correction or prison other than the State prison or reformatory prison appears to be insane, the physician in attendance shall make a re- 646 APPENDIX A. « port thereof to the jailer or master, who shall transmit the same to one of the judges men- tioned in section li, chapter 87. The judge shall make inquiry into the facts, and, if satisfied that the convict is insane, shall order his removal to one of the State lunatic hospitals pursuant to the provisions of sections twelve and thirteen of said chapter. Sec. 13. If any person so removed becomes sane before the e.xpiration of his sentence, he shall be forthwith returned to the prison or house of correction from which he was removed, there to remain, pursuant to his original sentence, computing the time of his confinement in the hospital as part of the term of his imprisonment. Sec. 14. When a person held in any jail for trial or for sentence, except for a capital crime, appears to be insane, he may be removed to one of the State lunatic hospitals as a convict may be removed from the house of correction under section twelve. When a person so removed is, in the opinion of the trustees and superintendent of the hospital, restored to sanity, he shall be forthwith returned to the jail from which he was removed, where he shall be held in accordance with the terms of the process by which he was orig- inally committed thereto. MICHIGAN. [See Public Acts, 1877, PP- 215-226, 120, 168, 203, 204. Public Acts, 1S81, pp. 267- 26g, 247, 139, 231. Compiled Laws, 1872, sees. 4822, et seq. Howell's annotated stat- utes (i8S2)pp. 513-529-] Each State asylum is under the control of a separate board of six trustees, appointed by the governor with the consent of the Senate. They have power to establish by-laws regulating the conditions of admission and dis- charge of patients. They are required to maintain an " effective inspection " of the asylum, and to visit it at stated times. When a person in indigent circumstances, and not a pauper, becomes insane, applica- tion may be made in his behalf to the judge of probate of the county where he resides; and said judge of probate shall immediately notify such alleged insane person of such application, and of the time and place of hearing to be held thereon ; he shall also call two respectable physicians, and other credible witnesses, and also immediately notify the prosecuting attorney of the county, and the supervisor of the township or ward in which such insane person resides, of the time and place of such hearing, whose duty it shall be to attend the examination and act in behalf of said county; and said judge of pro- bate shall fully investigate the facts in the case, and either with, or without, the verdict of a jury, at his discretion, as to the question of insanity, shall decide the case as to his indigence, but the decision of indigence shall not be conclusive in such county ; and if the judge of probate certifies that satisfactory proof has been adduced, showing him insane, and his estate insufficient to support him and his family, or, if he has no family, himself, under the visitation of insanity, on his certificate under the seal of the probate court of said county, he shall be admitted into the asylum, and supported there at the expense of the county to which he belongs, until he shall be restored to sound- ness of mind, if effected in two years, and until otherwise ordered. The judge of pro- bate in such case shall have power to compel the attendance of witnesses and jurors, and shall file the certificates of the physicians, taken under oath, and other papers, in his office, and enter the proper order in the journal of the probate court in his ofiice. The judge of probate shall report the result of his proceedings to the supervisors of his county, if such person belongs to that county, whose duty it shall be, at the next annual meeting thereafter, to raise money requisite to meet the expenses of support accordingly. — Public Acts, iSSi, No. 147, amending section 26, of Act No. 194 of ses- sion 1877. ^Vhen an insane person in indigent circumstances shall have been sent to the asylum by his friends, who have paid his bills therein for three months, if the superintendent shall certify he is a fit patient, the supervisors of the county of his residence are au- thorized and required, upon an application under oath in his behalf, to defray the ex- penses of his remaining there until otherwise ordered. — Public Acts, 1877, No. 194, sec. 29. The relatives or friends of any insane person may apply to the judge of probate to have a guardian appointed for him. The judge shall cause fourteen days' notice of the hear- ng to be given to such alleged insane person. If, after full hearing, it appears to the ABSTRACT OF LAWS RELATING TO THE INSANE. 647 judge that such person is insane and incapable of taking care of himself and manao-- ing his property, he shall appoint a guardian, who shall have the care and custody of the person of his ward, and the management of his estate. — Cojnpiled Laws, sees. 4822 et seq., and Public Acts, 1877, No. 130. MINNESOTA. [See Statutes of Minnesota (1878), pp. 454-459, 598, 958.] The State Asylum is under the control of a board of seven trustees, appointed by the governor, with the advice and consent of the Senate. The probate judge, or, in his absence, the court commissioner of any county, upon in- formation being filed before him that there is an insane person in his county needing care and treatment, shall cause the person so alleged to be insane to be examined by a jury consisting of two respectable persons besides himself, one at least of whom shall be a physician, to ascertain the fact of his insanity ; and if the said person is found to be in- sane, he shall, upon the written certificate of the judge, directed by a majority of the jury, issue duplicate warrants, committing the person so found insane to the care of the super- intendent of the hospital, and shall place the warrant in the hands of the sheriff", or some other suitable person, whom he shall authorize to convey the said insane person to the hospital. — Ge7ie7-al Statutes of Mhttiesota, 1878, p. 455. The relatives of any person charged with insanity, or who shall be found to be in- sane under section seventeen of this act, shall, in all cases, have the right to take charge of and keep said insane person or persons, if they shall desire so to do, but the pro- bate judge or court commissioner may require a bond of such relatives, conditioned for the proper and safe keeping of such person or persons ; and if the relatives or friends of any patient kept in the hospital, shall ask for the discharge of such patient, the super- intendent may, in his discretion, require a bond to be executed to the State of Minne- sota, in such sum and with such sureties as he may deem proper, conditioned for the safe keeping of such patient : Provided, that no patient that may be under the charge of, or convicted of homicide, shall be discharged without the consent of the superintend- ent and board of trustees. — General Statutes of Minnesota, 1878, p. 456. The governor shall appoint two members of the State board, who shall serve for the term of one year, and who, together with the superintendent of the hospital for the in- sane, constitute a commission, whose duty it is to visit the asylum at least once in every six months, to ascertain whether any persons are in the asylum who ought not to be there, and are not insane, and, if they find any such to order their discharge. The superintendent of the Minnesota Hospital for the Insane is hereby required, on the first day of each month, to make out a report in writing, showing the condition of each patient in said hospital (separately), with reference to bodily health; appetite; sleep; mental symptoms, generally ; particular symptoms ; mental state; habits and inclinations ; prospect of restoration; and shall forward by mail to the next of kin of each of such patients, respectively, a copy of such report, without charge, within the first week of each month. — General Statutes, i88i,p. 458; Laws, 1872, chap. 17,^ i. In cases of partition and division of estates, guardians are appointed for insane persons. MISSISSIPPI. [See Revised Code of Mississippi, 1880, chap. 13, sees. 642-668, inclusive; Laws of 1882, pp. 61, 62, 63, 64; also, as to guardians for the insane, see Code, sees. 21 18-2122, inclusive.] The State Asylum is under the management of a board of five trustees, appointed by the governor. The governor is, ex officio, president of the board. The trusteesare required to keep a bound record of all their doings, and one or more of them to visit the asylum at least once a month. The governor has the appointment and removal of the medical superintendent. The superintendent and board of trustees may, upon application, receive a patient 648 APPENDIX A. who they think ought to be admitted, even though no proceedings in lunacy have been instituted. It is the duty of the clerk of the chancery court of any county where a lunatic is allowed to be at large to direct the sheriff by writ of lunacy to summon the alleged lunatic, and six discreet persons to make inquisition thereto. If such inquest, or a majority of them, adjudge that such person is a lunatic, he shall be committed to the asylum. The chancery courts of the State may order an inquisition and appoint a guardian for any insane person. Such guardian has the care of the person and estate of the lunatic, and must give bonds, and is accountable to and under the control of the courts. MISSOURI. [See Revised Statutes of Missouri (1879), sees., 4102-4159, 5787-5837. Laws of i88x, pp. 123, 141. Laws of 1883, pp. 78, 79.] The State lunatic asylum is under the control and direction of a board of nine managers, three of whom shall be competent physicians, appointed by the governor, with the advice and consent of the Senate. Two of the managers shall, together, visit the asylum monthly ; a majority of them, together, quarterly; and all the managers, together, shall make a visit once a year. Pay patients, or those not sent to the asylum by order of the court, may be admitted on such terms as shall be, by this chapter and the by-laws of the asylum, prescribed and regulated. — Revised Statutes, sec. 41 19. Preparatory to the admission of such a patient, the superintendent shall be furnished with a request, of the form seen in section four thousand one hundred and twenty-one, under the hand of the person by whose direction he is sent, stating his age and place of nativity, if known, his christian and surname, place of residence, occupation, and degree of relationship or other circumstances of connection between him and the per- son requesting his admission ; and, second, a certificate of the form seen in section four thousand one hundred and twenty-two, dated within two months, under oath, signed by two physicians, of the fact of his being insane. Each person, signing such request or certificate, shall annex to his name his profession or occupation, and the township, county, and State of his residence, unless these appear on the face of the document. Before any private patient shall be received into the asylum, there shall be produced to the superintendent a receipt from the treasurer of the asylum, acknowledging the payment to him of at least thirty days' charges in advance, and a suf- ficient bond to said treasurer, conditioned tliat the obligor or obligors will secure the pay- ment of charges incurred in behalf of and on account of said patient ; said bond, with satisfactory securities, shall be of the form and contain the provisions as provided in section four thousand one hundred and twenty-three. No part of said thirty days' payment shall be refunded if the patient making such pay- ment shall be taken away within that period, uncured, and against the consent of the su- perintendent. — -Revised Statutes, sec. 4120. Form of Request for Admission. To the Superintendent of the Missouri State Lunatic Asylum : The undersigned, of the county of , is desirous of placing in the State Lunatic Asylum, at Fulton, and hereby requests the admission therein, of , a resident of the county of , who is aged — , and has been [here state what the occupation of the person has been]. He [or she] is a native of , in the State of , and is [here state what the relationship or circumstances of connection may be] of the under- signed ; [then should follow a written history of the case, including the alleged cause of insanity, when it commenced, and all the particulars thereof.] Dated, day of , 18 — . Form of Physician's Certificate. State of ") County of' . \^^' We, , and , of the County and State aforesaid, physicians, do hereby certify that we have this day seen and examined [here insert the name of the ABSTRACT OF LAWS RELATING TO THE INSANE. 649 patient], of the county of , and believe — to be insane, and a proper patient to be sent to the State lunatic asylum. (Signed) The above named, , and , being duly sw^orn, say that they are prac- ticing physicians, of the county aforesaid, and that the facts stated in the above certifi- cate, by them subscribed, are true, according to the best of. their knowledge and belief. (Signed) ^^^^ ' Sworn to and subscribed before me, this day of , 18 — . , J. P. Patients may be sent by the county court to said asylum, upon application or state- ment filed with the clerk of the county court, stating insanity, indigence, etc., and after proper investigation before the court, or court and jury, and examination of witnesses, including at least one physician. After trial by jury in the probate court, a guardian may be appointed of the person and estate of the person so found to be insane. — -See Revised Statutes, sees. 5787, 5837. NEBRASKA. [See Compiled Statutes of Nebraska (Guy A. Brown, 1881), chap. 40, pp. 300-308, and p. 292; Appendix to same, chap. 40, p. 867; Laws of Neb., 1883, chaps. 48 and 49, pp. 234 and 235.] The State hospital, located at Lincoln, is under the charge of three trustees, but the governor of the State appoints the superintendent, and may appoint two assistant physicians, one of whom shall be a woman. — See Compiled Stats., p. 300, and App., p. 897. In each county there shall be a board of three commissioners, composed of the clerk of the district court, a physician, and a lawyer. Said commissioners regulate admissions to the asylum and the general safe-keeping of insane persons within their county. Upon the filing of an information with affidavit, alleging the insanity of the person in whose behalf the application is made, the commissioners will make an investigation. They have power to subpcena witnesses, administer oaths, and do any act of a court necessary in the premises. A physician (who may be one of their own number) must be appointed to examine the patient and make a certificate. The person alleged to be insane may appear and resist the application, and the parties may be represented by counsel. If the commissioners find that the person alleged to be insane is insane, and a fit subject for treatment, they may issue a warrant and cause his removal to the asylum. No female person shall be thus taken to the hospital without the attendance of some other female, or some relative of such person, and the friends or relatives of any person so found insane have the privilege of executing the warrant of removal to the asylum instead of the sheriff, if they so request — See Compiled Stats., pp. 302-303. In each case of application for admission to hospital, correct answers, so far as possible, to a series of questions pi^ovided by the statute must accompany the physician's certificate. No person supposed to be insane shall be restrained of his or her liberty by any other person, otherwise than in pursuance of authority obtained as herein required, excepting to such extent and for such brief period as may be necessary for the safety of persons and property, until such authority can be obtained. Any person having care of an insane person and restraining such person, either with or without authority, who shall treat such person with wanton severity, or harshness, or cruelty, or shall in any way abuse such person, shall be guilty of a misdemeanor, besides being liable in an action for damages. — Coinpiled Stats., p. 305. Privileges of Inmates. That henceforth there shall be no censorship exercised over the correspondence of inmates of the hospital for the insane in this State, but their post-office rights shall be as free and unrestrained as are those of any resident or citizen of this State, and be under the 650 APPENDIX A. protection of the same postal laws. And every inmate shall be allowed to write when and whenever he or she desires to any person he or she may choose. And it is hereby made the duty of the superintendent to furnish each and every inmate of each and every insane asylum in this State with suitable material, at the expense of the State, for writing, inclosing, sealing, stamping, and mailing letters, sufficient for writing at least one letter a week, provided they request the same, unless they are otherwise furnished with such material ; and all such letters shall be dropped by the writers thereof, accompanied by an attendant when necessary, into a post-office box, provided by the State at the hospital for the insane, and kept in some place easy of access to all the patients ; and the contents of such post-office box or boxes shall be collected once every week by an authorized person, and by him placed into the hands of the United States mail for delivery. And it is hereby made the duty of the superintendent of every hospital for the insane in this State, either public or private, to deliver, or cause to be delivered, to said person any letter or writing to him or her directed, without opening or reading the same, or allowing it to be opened or read, without the consent of the recipient of such letter, or the request or the consent of the writer. [Section one of "An act for the protection of the inmates of the hospital for the in- sane," took effect February 27, 1883.] — See Appc7idix io Compiled Stats., p. 867; and Gen. Laws, 1882-3, chap. 40, p. 300. Penalty. That any person refusing or neglecting to comply with, or wilfully and knowingly violating, any of the provisions of this act, shall, upon conviction thereof, be punished by imprisonment in the penitentiary for a time not exceeding three years nor less than six months, or by a fine not exceeding five hundred dollars, or both, at the discretion of the court, and by ineligibility to any office in the asylum afterward. — Id., \ 2. Act to be Posted. A printed copy of this act shall be framed and kept posted in every ward of every hospital for the insane, both public and private, in the Slate of Nebraska. — Id., § 3. Upon proper proceedings, guardians may be appointed for the insane by the probate court. — See Compiled Stats., p. 292. NEVADA. [See Compiled Laws of Nevada (1873), sees. 3740-3745, and sec. 845; Statutes of Nevada, 1S81, chap. 42, p. 59; Stats, of Nev., 18S3, chap. 76, p. 102.] A board of commissioners, consisting of the governor, lieutenant-governor, State controller. State treasurer, and two others, has, by statute, the full power and exclusive control over the State asylum. Upon the application of any person under oath to the judge of the district court, setting forth that any persoir is insane, said judge shall cause such person to be brought before him, and shall also summon one or more licensed practicing physicians, who shall proceed to examine the person alleged to be insane. If said physicians shall, after a careful examination, certify upon oath that the charge is correct, and the judge is satisfied that it is unsafe for such person to be at large, he shall cause such insane person to be committed to the asylum. If such person is indigent and without relatives in the State, his support at the asylum shall be at the expense of the State. Paying patients shall pay according to the terms directed by the board of commissioners; but the statute provides that the insane poor shall, in all respects, receive the same medical care and treatment and good, wholesome food. — Lazvs of 1881, chap. 42. Upon application and proper proceedings before the probate judge, a guardian may be appointed of the person and estate of any person who shall appear to be insane and incapable of taking care of himself and managing his property. — Cofiipiled laws, p, 206, sees. 845 et seq. ABSTRACT OF LAWS RELATING TO THE INSANE. 65 1 NEW HAMPSHIRE. [General Laws of New Hampshire (1878), chap. 10.] The Asylum for the Insane. Section i. The asylum for the insane at Concord is a corporation under the name of the New Hampshire Asylum for the Insane. Sec.. 2. The government of the asylum is vested in twelve trustees, appointed and commissioned by the governor, with advice of the council; and all vacancies shall be filled in the same manner. Sec. 7. The trustees may make such regulations for their own government, for the management of the asylum and all persons connected therewith, and for the admission and care of patients, and the same, from time to time, alter, as convenience may require. Sec. 9 (abst.). The trustees shall report annually to the governor and council. Sec. id. The governor and council, president of the Senate and speaker of the House shall constitute a board of visitors of the asylum ; shall visit and inspect the same when necessary ; examine into the condition of the patients, and the regulations and general management of the asylum ; see that the design thereof is carried into full effect ; and make to the legislature, biennially, a report, which shall be furnished to the secretary of state on or before the 20th day of April next before the June session. Sec. 12. If any insane person is in such condition as to render it dangerous that he should be at large, the judge of probate, upon petition by any person, and such notice to the selectmen of the town in which such insane person is, or to his guardian or any other person, as he may order, — which petition may be filed, notice issued, and a hear- ing had in vacation or otherwise, — may commit such insane person to the asylum. Sec. 13. If any insane person is confined in any jail, the supreme court may order him. to be committed to the asylum, if they think it expedient. Sec. 14. Any insane pauper supported by any town may be committed to the asylum by order of the overseers of the poor, and there supported at the expense of such town ; and such expense may be recovered by such town of the county, town, or person chargeable with the support of such pauper, in the same manner as if he had been sup- ported in and by the town. Sec. 15. If the overseers neglect to make such order in relation to any insane county pauper, the supreme court, or any two judges thereof in vacation, may order such pauper to be committed to the asylum, and there supported at the expense of the county. Sec. 16. Any insane person committed to the asylum by order of the supreme court, such person having been charged with an offence the punishment whereof as prescribed by law is death or confinement in the State prison, shall, during his confinement in the asylum for the insane, be supported therein at the expense of the State. Any insane person committed to the asylum by any court, except as herein provided, or by any judge of probate, sliall be supported by the county from which he was committed. Sec. 17. The parent, guardian, or friends of any insane person may cause him to be committed to the asylum, with the consent of the trustees, and there supported on such terms as they may agree ; but the city of Concord shall not, in any case, be liable for the support or maintenance of any person committed to said asylum, except from said city. Sec. 18. No person shall be committed to the asylum for the insane, except by the order of the court or the judge of probate, without the certificate of two reputable physi- cians that such person is insane, given after a personal examination made within one week of tlie committal ; and such certificate shall be accompanied by a certificate from a judge of the supreme court or court of probate, or mayor, or chairman of the select- men, testifying to the genuineness of the signatures and the respectability of the signers. Secs. 19, 20 and 21 (abst.). Person committed shall be supported by his county if with- out means or relatives of sufficient ability. Sec. 22. Any person committed to the asylum may be discharged by any three of the trustees, or by any justice of the supreme court, whenever the cause of commit- ment ceases or a further residence at the asylum is, in their opinion, not necessary ; but any person so discharged, who was under sentence of imprisonment at the time of his commitment, the period of which shall not have expired, shall be remanded to prison. 652 APPENDIX A. Sec. 23. Some one of the board of trustees of the asyhim shall, without previous notice, visit the institution at least twice every month, and give suitable opportunity to every patient therein who may desire it to make to him, in private, any statements such patients may wish to make ; and, whenever in his opinion it may be deemed proper, he shall call to his aid two other members of said board, who shall, with him, make a further examination of such patient and of the statements by him made. If, in their view, the cause of commitinent no longer exists, or a further residence at the asylum is not necessary, it shall be their duty to discharge such patient. Should they deem the treatment of any patient injudicious, they shall order such an immediate change of the same as to them seems proper; and, in case of failure to secure it, they shall at once summon a meeting of the whole board, whose duty it shall be to take such measures as the exigency of the case demands. Sec. 24. It shall be the duty of the superintendent to furnish stationery to any patient who may desire it, and to transmit any letter such patient may address to the board of trustees, to such member as said board shall have designated to receive such correspond- ence, and all such letters shall be promptly transmitted without inspection. Sec. 25. In event of the sudden death of any patient in the asylum, a coroner's inquest shall be held, as provided for by law in other cases. Sec. 27. The governor, with the advice of the council, may remove to the asylum, to be there kept at the expense of the State, any person confined in the State prison who is insane. Sec. 28. The sum of six thousand dollars is annually appropriated for the maintenance of indigent insane persons belonging to this State at the asylum, for such and so many as the governor may from time to time approve, not less than two-thirds of which sum shall be applied annually to the support of private patients exclusive of paupers maintained at public charge; and the sum of one hundred dollars is annually appropriated toward the support and increase of the library for the insane. Laws of j88i, Chapter 1^0. Joint Resolution Authorizing the Governor to Appoint Suitable Persons TO Examine into the Condition of Insane Persons in the County Alms- houses in this State. Resolved, by the Senate and House of Representatives , in General Assembly convened : That the governor, with the advice of the council, shall, on or before the first day of October next, appoint three competent persons, of whom one shall be a physician, one a lawyer, and the third a mair of general business experience, whose duty it shall be to visit the several county almshouses in the State, examine into the condition of every insane person there detained; and report to the governor and council, on or before the first day of May, 1S83, the number, condition, the manner of care, and treatment of all such persons, together with such recommendations relative to a modification or improve- ment of the same as from their investigations they may deem necessary; which report, with such suggestions as he may think advisable, the governor shall cause to be printed and laid before the legislature at its next session. The persons so appointed shall receive no compensation for their services, but shall be paid their necessary travelling expenses from the treasury of the State. (Approved August 18, 1881.) Laws of iSyg, Chapter g2. Joint Resolution relating to the Price of Board in the Asylum for the Insane. Resolved, by the Senate and House of Representatives, in General Assembly convened : The governor and council are hereby directed to take immediate steps to cause a reduction in the board at the insane asylum to four dollars per week : Provided, That this resolution shall not be construed to forfeit the charge and payment for necessary attendance and expense required by any patient in case of severe sickness or accident. (Approved July 19, 1879.) ABSTRACT OF LAWS RELATING TO THE INSANE. 653 NEW JERSEY. No person shall be admitted into the State asylum for the insane unless by order of some court or judge authorized to send patients, without lodging with the superintendent. First, a request for admission, under the hand of the person by whose direction he is sent, stating his age, place of nativity, residence, occupation, degree of relationship, etc., and second, a certificate dated within one month, under oath, signed by one respectable phy- sician. — New Jersey Revision, 1877, sec. 17, page 623. Insane paupers may be sent to State asylum by order of court after examination and certificate of one physician called by the court, and are supported by the county of their residence. Persons in indigent circumstances, not paupers, may, upon application to the court and after investigation and examination by one reputable physician called by the court, and either with or without the verdict of a jury, be sent to the State asylum and supported at the expense of the county. — New Jersey Revision, 1877, p. 624. When a person shall have escaped indictment or have been acquitted of a criminal charge upon trial on the ground of insanity, the court shall inquire whether his insanity in any degree continues, and if it does shall order him into safe custody. — New Jersey Revision, 1877, p. 625. Persons confined in jail who shall appear to be insane may, after proper investigations and proceedings, be sent by the court to the insane asylum. — Ibid., p. 625. Any two justices of the peace of the county in which any lunatic too furiously mad or dangerous to be permitted to go at large shall be found, may cause such person to be ap- prehended and kept safely locked up and chained if necessary in some secure place until the last legal settlement of such person can be ascertained; or if such information cannot be obtained such person may be conveyed to any place in the county provided for the reception of maniacs or lunatics, or, in the absence of such place, may be conveyed to the county jail. This not to restrain or abridge the power or authority of the chancellor, orphans' court, or guardian touching such person, or to prevent any friends or relatives of such person from taking him under their protection.— A^w Jersey Revision, 1877, p. 605. Board of managers to maintain effective inspection of the State asylum, and one or more of them to visit it at least once a week, two or more at least once a month, a ma- jority at least once in three months, and the whole board once a year at the times and in the manner prescribed in the by-laws. Managers to note in a bound book their visits, with remarks, and this to be inserted in their annual report to the governor. — New Jer- sey Revision, p. 622. ^ NEW YORK. [See Laws of 1874, chap. 446; Laws of 1875, chap. 574; Laws of 1876, chap. 267 ; Laws of 1878, chap. 47 ; Laws of 1880, chap. 423; New York Revised Statutes (sixth edition. Banks Bros.), vol. ii., page 841, et seq. ; New York Code, Civil Procedure, sees. 2320-2364, and 1590; New York Penal Code, sees. 377 and 445.] Commitment of the Insane. Laws of 1874, Chapter 44.6, Article /, Section i. No person shall be committed to or confined as a patient in any asylum, public or private, or in any institution, home, or retreat, for the care and treatment of the insane, except upon the certificate of two physicians, under oath, setting forth the insanity of such person. But no person shall be held in confinement in any such asylum for moi-e than five days, unless within that time such certificate be approved by a judge or justice of a court of record of the county or district in which the alleged lunatic resides, and said judge or justice may institute inquiry and take proofs as to any alleged lunacy before approving or disapproving of such certificate, and said judge or justice may, in his dis- cretion, call a jury in each case to determine the question of lunacy. Sec. 2. It shall not be lawful for any physician to certify to the insanity of any person for the purpose of securing his commitment to an asylum, unless said physician be of 654 APPENDIX A. reputable character, a graduate of some incorporated medical college, a permanent resi- dent of the State, and shall have been in the actual practice of his profession for at least three years, and such qualifications shall be certified to by a judge of any court of record. No certificate of insanity shall be made except after a personal examination of the party alleged to be insane, and according to forms prescribed by the State commissioner in lunacy, and every such certificate shall bear date of not more than ten days prior to such commitment. Sec. 3. It shall not be lawful for any physician to certify to the insanity of any person for the purpose of committing him to an asylum of which the said physician is either the superintendent, proprietor, an officer or a regular professional attendant therein. Sec. 4. Every superintendent of a State asylum or public or private asylum, institu- tion, home, or retreat for the care and treatment of the insane, shall, within three days after the reception of any patient, make or cause to be made, a descriptive entry of such case in a book exclusively set apart for that purpose. He shall also make entries from time to time of the mental state, bodily condition, and medical treatment of such patient, together with the forms of restraint employed, during the time such patient remains under his care, and in the event of the discharge or death of such patient, the superin- tendent aforesaid shall state m such case-book the circumstances appertaining thereto. Sec. 5. The county superintendents of the poor of any county or town, to which any person shall be chargeable, who shall be, or shall become a lunatic, may send any such person to any State lunatic asylum by an order under their hands, and in compliance with the provisions of this act. Sec. 6. In case of the refusal or neglect of any committee or guardian of any lunatic, or his relatives, to confine and maintain him, or where there is no such committee, guar- dian, or relative of sufficient ability to do so, it shall be the dut)^ of the overseers of the poor, or constables of the city or town where any lunatic shall be found, to report the same forthwith to the superintendent of the poor, who shall apply to the county judge, special county judge or suri-ogate, who, upon being satisfied upon examination that it would be dangerous to permit such lunatic to go at large, shall issue his warrant, directed to the constables and overseers of the poor of such city or town, commanding them to cause such lunatic to be apprehended and to be sent within the next ten days to some State lunatic asylum, or to such public or private asylum as may be approved by any standing order or resolution of the supervisors of the county, to be there kept and main- tained until discharged by law. Sec. 7. It shall be the duty of the overseers of the poor or constables to whom such warrant shall be directed, to procure a suitable place for the confinement of such lunatic as therein directed pursuant to the preceding section, but in no case shall any lunatic be contined in any other place than a State lunatic asylum or a public or private asylum duly approved as aforesaid, for a longer period than ten days. Sec. 8. No person, who by reason of lunacy or otherwise, is so far disordered in his mind as to be dangerous to himself or others shall be committed as a disorderly person to any prison, jail, house of correction, or confined therein unless an agreement shall have been made for that purpose with the keeper thereof; and no such lunatic or person disordered in his mind shall be confined in the same room with any person charged with or convicted of any crime, nor shall such lunatic be confined in any prison, jail or house of correction for more than ten days. Sec. 9. If any person being of disordered mind and committed as a dangerous lunatic to any prison, jail, or house of correction as set forth in the preceding section shall con- tinue to be insane at the expiration of ten days he shall be sent forthwith to some State lunatic asylum, or to such public or private asylum as may be approved as aforesaid. Sec. 10. Any overseer of the poor, constable, keeper of a jail, or other person, who shall confine any lunatic in any other manner, or in any other place than such as are herein specified, shall be deemed guilty of a misdemeanor, and on conviction thereof shall be liable to a fine not exceeding two hundred and fifty dollars, or to imprisonment not ex- ceeding one year, or to both, at the discretion of the court before which the conviction shall be had. Sec. II. If any lunatic, committed under the provisions of this article, or any friend in his behalf, be dissatisfied with any final decision or order of a county judge, special county judge, surrogate, judge of the superior court, or court of common pleas of a city, or police magistrate, he may, within three days after such order or decision, appeal there- from to a justice of the supreme court, who shall, thereupon, stay his being sent out of the county, and forthwith call a jury to decide upon the fact of lunacy. After a full and fair investigation, aided by the testimony of at least two respectable physicians, if such ABSTRACT OF LAWS RELATING TO THE INSANE, 655 jury find him sane, the justice shall forthwith discharge him, or, otherwise, he shall con- firm the order for his being sent immediately to an asylum. In case any county judge, special county judge, surrogate, judge of the superior court or common pleas of a city, or police magistrate, refuses to malce an order for the confinement of any insane person proved to be dangerous to himself or others if at large, he shall state his reasons for such refusal in writing, so that any person aggrieved may appeal therefrom to a justice of the supreme court, who shall hear and determine the matter in a summary way, or call a jury, as he may think most fit and proper. Sec. 12. If such lunatic is not possessed of sufficient property to maintain himself, it shall be the duty of the father, mother, or children of such lunatic, if of sufficient ability, to provide a suitable place for his confinement, and to confine and maintain him in such manner as shall be agreeable to the provisions of this act. But in case his rela- tives are not of sufficient ability to maintain him, then the superintendent of the poor of the county shall, upon his order, send such pauper lunatic to any State asylum, or to such public or private asylum as may be approved by a standing order or resolution of the supervisors, within ten days. Sec. 13. The overseers and superintendents of the poor shall have the same remedies to compel such relatives to confine and maintain such lunatic, and to collect the costs and charges of his confinement, as are given by law in the case of poor and iinpotent persons becoming chargeable to any town. Sec. 14. When a person in indigent circumstances, not a pauper, becomes insane, ap- plication may be made in his behalf to any county judge, special county judge, judge of a superior court or common pleas, of the county where he resides, and said judge shall fully investigate the facts of the case, both as to the question of his indigence as well as to that of his insanity. And if the judge certifies that satisfactory proof of his insanity has been adduced, and that such person has become insane within one year next prior to the granting of the order of admission, and that his estate is insufficient to support him and his family (or, if he has no family, himself), while under the visitation of insanity, then it shall be the duty of any judge, before whom an application for that purpose is made, to cause reasonable notice thereof, and of the time and place of hearing the same, to be given to one of the superintendents of the poor of the county chargeable with the expense of supporting such person in a State asylum, if admitted, and he shall then pro- ceed to ascertain when such person became insane, and shall state in his certificate that satisfactory proof has been adduced before him that such person became insane within a year next prior to the date of such certificate. On granting such certificate the judge may, in his discretion, require the friends of the patient to give security to the superin- tendent of the poor of the county to remove the patient from the asylum at the end of the two years, in case he does not sooner recover. When a patient who is admitted into an asylum on the certificate of any judge, given as hereinbefore recited, has remained in such asylum two years, and has not recovered, the superintendent of the asylum shall send a written notice to the county judge of the county from which he was sent, that such patient has remained in the asylum two years, and has not recovered, and that, in case he is not removed therefrom, the expense of his support will be chargeable to the county until he is so removed, and such expense shall be chargeable to the county accordingly. But in every case where a patient, admitted into an asylum as hereinbefore provided, shall have remained there two years, and has not recovered, the managers of the asylum may, in their discretion, cause such person to be returned to the county whence he came, and charge the expense of such removal to the county. The judge granting said order of indigence, shall file all papers belonging to such proceedings, together with his de- cision, with the clerk of the county, and report the facts to the supervisors, whose duty it shall be, at their next annual meeting, to raise the money requisite to meet the expenses of support of such indigent lunatic. Sec. 15. When an insane person in indigent circumstances, not a pauper, shall have been sent to any State asylum by his friends, who have paid his bills therein for six months, if the superintendent shall certify that he is a fit patient, and likely to be bene- fited by remaining in the institution, the supervisors of the county of his residence are authorized and required, upon an application under oath in his behalf, to raise a sum of money sufficient to defray the expenses of his remaining there another year, and to pay the same to the treasurer of the asylum. And they shall repeat the same for one year more, upon like application, and the production of a new certificate of like import from the superintendent of such asylum. Sec. 16. The expense of sending any lunatic to a State asylum, and of supporting him there, shall be defrayed by the county or town to which he may be chargeable. If charge- 656 APPENDIX A. able to a county, or to any town whose poor-moneys are required to be paid into the county treasury, such expense shall be paid by the county treasurer out of the funds ap- propriated for the support of the poor belonging to such county or town, after being al- lowed and certified by the county superintendents. If such lunatic be chargeable to a town whose poor-moneys are not required to be paid into the county treasury, such ex- pense shall be paid by the overseers of the poor thereof. Sec. 17. The overseers of the poor of any city or town shall have the same remedies to compel the committee or guardian of the estate of any lunatic to confine and main- tain such lunatic, and to collect of such committee the cost and charges of his confine- ment and support, as are given in the preceding sections against the relatives of such lunatic. And the court of general sessions of the peace of the city or county shall make orders against such committee personally, and enforce them in the same manner as against the relatives of any poor person, so long as such committee has any property in his hands, for the support of such lunatic. Sec. 18. None of the foregoing provisions shall be deemed to restrain or abridge the power and authority of the supreme court, the superior court, and the court of common pleas of the city and county of New York, or the superior court of the city of Buffalo, or the city court of Brooklyn, or any county courts, concerning the safe keeping of any lunatics, or the charge of their persons or estates. Sec. 19. The county superintendents of the poor shall have all the powers and authority herein given to overseers of the poor of any town. Form of Medical Certificate. State of New York, \ County of . J ^^' I, , a resident of , in the county aforesaid, being a graduate of , and having practiced as a physician, hereby certify, under oath, that on the day of , I personally examined , of , [here insert sex, age, married or single, and occupation,] and that the said is insane, and a proper person for care and treatment, under the provisions of chapter 446 of the Laws of 1874. I further certify that I have formed this opinion upon the following grounds, viz. : [here insert facts upon which such opinion rests.] And I further declare that my qualifications as a medical examiner in lunacy have been duly attested and certified by [here insert the name of the judge granting such certifi- cate.] Sworn to and subscribed before l me this day of , 188 . j Judge's Certificate of Qualification. Iss. State of New York, County of . I hereby certify that , of , is personally known to me as a reputable physician, and is possessed of the qualifications required by chapter 446 of the Laws of 1874. Licenses for Private Asylums. Laws 0/18^4, Chapter 44.J, Title Ninth. Section i. No person or association shall establish or keep an asylum, institution, house or retreat for the care, custody, or treatment of the insane or persons of unsound mind, for compensation or hire, without first obtaining a license therefor from the State commissioner in lunacy, provided that this section shall not apply to any State asylum or institution, or any asylum or institution established or conducted by any county; and provided, also, that it shall not apply to cases where an insane person or person of un- sound mind is detained and treated at his own house or that of some relative. Sec. 2. Every application for such license shall be accompanied by a plan of the prem- ises proposed to be occupied, describing the capacities of the buildings for the uses in- tended, the extent and location of grounds appurtenant thereto, and the number of pa- tients of either sex proposed to be received therein ; and it shall not be lawful for said commissioner to grant any such license without having first visited the premises proposed to be licensed, and being satisfied by such examination that they are as described, and are otherwise fit and suitable for the purposes for which they are designed to be used. ABSTRACT OF LAWS RELATING TO THE INSANE. 65/ State Commissioner in Lunacy. Laws of i8y4, Chapter 44J. — Title Tenth, as amended by Lazvs of i8y6, Chapter 267. Section i. The governor shall nominate, and by and with the advice and C(;nsent of the Senate, appoint an experienced and competent physician, who shall be designated as the State commissioner in lunacy, who shall hold his office for five years and receive an annual salary of four thousand dollars, and travelling and other incidental expenses not to exceed one thousand dollars, and a sum not to exceed two hundred dollars to pay office rent and fuel, to be paid on presentation of vouchers to the comptroller. Sec. 2. It shall be the duty of such commissioner to examine into and report annually to the legislature on or before the fifth day of January, the condition of the insane and idiotic in this State and the management and conduct of the asylums, public and private, and other institutions for their care and treatment. The duties of said commissioner in regard to the insane shall be performed so as not to prejudice the established and reason- able regulations of such asylums and institutions aforesaid ; and it shall be the duty of the ofiicers and others respectively m charge thereof, to give such commissioner, at all times, free access to and full information concerning the insane, and their treatment therein. It shall also be the duty of such commissioner to inquire and report, from time to time, as far as he may be able, the results of ihe treatment of the insane of other States and countries, together with such particulars pertaining thereto as he may deem proper. Sec. 3. The said commissioner shall have power to make and use an official seal, and all copies of papers and documents in his possession and custody may be authenticated in the usual form under his official seal and signature, and used as evidence in all courts and places in this State, in like manner as similar certificates emanating from any other public officer. Sec. 4. The said commissioner is hereby empowered to issue compulsory process for the attendance of witnesses and production of papers, to adm.inister oaths, and to ex- amine persons under oath, and to exercise the same powers as belong to referees ap- pointed by the supreme court, in all cases where, from evidence laid before him, there is reason to believe that any person is wrongfully deprived of his liberty, or is cruelly, negligently or improperly treated in any asylum, institution or establishment, public or private, for the custody of the insane; or whenever there is inadequate provision made for their skilful medical care, proper supervision and safe keeping ; and if the same shall be proved to his satisfaction, he is further empowered to issue an order in the name of the people of the State and under his official hand and seal, directed to the superin- tendent or managers of such institution, requiring them to modify such treatment or ap- ply such remedies, or both, as shall therein be specified. And in case such order is dis- obeyed, or negligently executed, the commissioner may, and it shall be his duty to pre- sent such order, with a statement of the facts duly verified upon which it was made, to a justice of the supreme court, who may thereupon, by order, require such superintendent or manager to show cause before such or some other justice of the supreme court at a place in the judicial district where such asylum, institution or establishment is situated, and at a time specified in such order, not less than two days after the service thereof, why an order should not be made dn-ecting performance of such order of the commis- sioner, and on failure to so show cause, the said justice shall make such order, and, for any disobedience of any order made pursuant to the provisions of this section, the same pro- ceedings may be taken to compel performance thereof, or to punish for contempt for such disobedience, as may be had for such purposes in civil actions. General Statutes, i8y8, Chapter ^7. Section i. The State commissioner in lunacy is hereby empowered to ernploy a steno- grapher, whenever any testimony is to be taken before him in the discharge of his official duties, and the charges of such stenographer shall be paid by the comptroller upon pre- sentation of vouchers duly attested : Provided, such charges shall not exceed ten dollars per day for the time actually employed, nor one thousand dollars in any one year in the aggregate. Sec. 2. Whenever the said commissioner shall undertake any investigation into the general management and administration of any asylum, institution or establishment, pub- lic or private, for the custody of the insane, he shall give notice thereof to the district- attorney of the county in which such asylum or institution is situated, and it shall, thereupon, be the duty of such district-attorney to appear at such investigation in behalf of the people, and to examine all witnesses who may be in attendance thereat. 42 658 APPENDIX A, Committees for the Insane. See the N'e-cu York Code of Civil Procedure. — Title VI. Proceedings for the appointment of a committee of the person and of the property of a lunatic, idioi or habitual drunkard; general powers and duties of the committee. — Sees. 2320-2344. _ . The provisions of this title are founded mainly upon Laws, 1874, chap. 446, but are extended to habitual drunkards. Disposition of the Real Property of the Insane. See the A'e-u) York Code of Civil Procedure. — Title VII. Proceedings for the disposition of the real property of an infant, lunatic, idiot, or habitual drunkard. — Sees. 2344-2364. NORTH CAROLINA. [See Laws of North Carolina 1881, chap. 133; chap. 206; chap. 297.] For admission to asylum, some respectable citizen residing in the county of the alleged insane person shall make and file with the justice of the peace of the county, an affidavit, stating that he has carefully examined the alleged lunatic and believes him to be insane and a tit subject for admission to the asylum. Such alleged lunatic is then brought before the justice, who shall associate with him- self two or more justices of the county, who, together, shall proceed to examine into the condition of such person, and shall take the testimony of at least one respectable phy- sician. If any two of the justices decide that such person is insane, and some friend will not give security to take proper care of him, then the justices shall cause such person to be removed to an asylum. The board of directors of the asylum have discretion to determine who are proper persons to receive. If a person found to be insane has sufficient property and expresses a wish to be placed in some asylum outside of the State, and the justices and physicians who have examined such person deem it proper, he may be sent to the asylum so chosen as a patient. It is the duty of any person having the legal custody of the estate of such lunatic to supply the funds for his or her support in such asylum if they are sufficient for that pur- pose, over and beyond maintaining those who may be legally dependent on said estate. OHIO. [See Revised Statutes of Ohio (1S80), sees. 698-751, 6302-6316, 7242. Laws of 1881, pp. 62 and I02; Laws of 1S83, p. 103.] Each State Asylum is under the charge of a board of trustees. For the admission of patients to any of the asylums for the insane the following pro- ceedings shall be had ; some resident citizen of the proper county shall file with the pro- bate judge of such county, an affidavit, substantially as follows : State of Ohio, County ■ \ss. the undersigned, a citizen of County, Ohio, being sworn, says that he believes is insane (or that in consequence of his insanity his being at large is dangerous to the community). He has a legal settlement in township, m this county. Dated this — day of , A.D. . . When the affidavit is filed the judge shall cause the person alleged to be insane to be brought before him, and witnesses, including one physician, to be summoned. If any ABSTRACT OF LAWS RELATING TO THE INSANE. 659 person disputes the alleged insanity, such witnesses shall be subpoenaed as are demanded on behalf of the person allegtd to be insane. If by reason of the condition of the alleged insane person, it is deemed improper to bring him into the probate court, the judge shall personally visit such person and certify that he has ascertained the condition of such person by actual inspection. If after hearing the testimony the judge is satisfied that the person is insane, he shall cause a certificate to be made by the medical witness in attendance, which shall set. forth full details concerning the patient as specifically provided by the statute, and the judge may then issue a warrant of commitment to the asylum. The relatives of any person charged with insanity or found to be insane, shall in all cases have the right to take charge of and keep such insane person charged with insanity if they desire so to do, and in such case the probate judge before whom the inquest has been held, shall deliver such insane person to them. For Admission of Inmates into Longview Asylum. Some resident citizen of Hamilton County must file with the probate judge thereof, an afi&davit substantially as follows : State of Ohio, 1 Hamilton County, j^' The undersigned, a citizen of Hamilton County, Ohio, being sworn, says, that he believes to be insane, and a fit subject for the lunatic asylum ; he is a resident of Hamilton County, has a legal settlement in township. These facts are known by and (naming at least two persons). — J^ev. Stats., sec. 738. Proceedings will then be had substantially as given above. The probate court, upon satisfactory proof, will appoint a guardian for any insane person, which guardian, by virtue of such appointment, shall be also the guardian of the minor children of his ward, unless the court appoint some other person as their guar- dian. — Rev. Stats., sec. 6302. I OREGON. [See Laws of Oregon, 1878, p. 72; Laws of Oregon, 1880, p. 49.] The county judge of any county in this State, upon application of any two house- holders in his county, in writing under oath, setting forth that any person, by reason of insanity, as the case may be, is suffering from neglect, exposure or otherwise, or is unsafe to be at large, shall cause such person or persons to be brought before him at such time and place as he may direct; and said county judge shall also cause to appear at the same time and place, two or more competent physicians and the prosecuting attorney of his judicial district or his deputy, or (in the event of his absence or inability to attend) some practicing attorney of the State, whose duty it shall be to represent the State and protect its interests, who shall proceed to examine the person or persons alleged to be insane or idiotic, and if the said physicians shall certify upon oath, that the said person or persons are insane or idiotic, as the case may be, and the county judge shall find, from the con- sideration of the said certificate and the testimony that may be produced before him, that the said person or persons are insane or idiotic, then said judge shall cause the said in- sane or idiotic person or persons to be conveyed to and placed in charge of the parties contracting to keep and care for the insane and idiotic of this State : Provided, that an ap- peal shall lie from the decision of the said county judge in such cases, in the same manner as is provided for appeal from the judgments of county courts in other cases, which appeal may be taken either by the householders making such application, or by or on behalf of any person who shall be adjudged to be insane or idiotic ; or the same may be taken by the State whenever, in the judgment of the prosecuting attorney for the district, the in- terest of the State requires such appeal to be taken : Provided further, that the county judge shall make diligent inquiries, and when any insane or idiotic person committed under this act, shall be found to own any estate, real or personal, said judge shall im- mediately, without further petition or notice, appoint a guardian for the estate of such person, who shall execute his trust under the direction of said court, make the same re- 66o APPENDIX A. turns and give the same security as in case of the estate of a minor, and such estate shall be liable to the county for the cost of such commitment, and to the State for the costs of conveying such insane or idiotic person to the asylum. — Lazvs of 1878, p. 72. The governor, secretary of state and State treasurer were, in 1880, designated as commissioners for the purpose of erecting a suitable State Insane Asylum. — See Laws, 1880, p. 49. PENNSYLVANIA. [See Laws of 1S69, No. 54, and "An act relative to the supervision and control of hospitals or houses in which the insane are placed for treatment or detention." Approved the 8th day of May, 1883.] Sections 1-6, inclusive, refer to the appointing and managing of the members of the State Board of Charities, and their Committee on Lunacy, their duties, etc. Sec. 7. The board shall have power from time to time, with the consent of the chief justice of the supreme court and of the attorney-general, to ordain rules and regulations on the following matters, so far as the same are not inconsistent with any laws of this Commonwealth then in force and of any provisions of this act. (l.) The licensing of all houses or places in which any person can be lawfully detained as a lunatic or of unsound mind, upon compensation paid to or received by the owner or occupant of such house or place directly or indirectly for the care of such lunatic, and also of all houses or places in which more than one person of unsound mind is detained or resides : Provided, That this clause shall not extend to any gaol or prison ; and pro- vided also, That the board, with consent as aforesaid, may from time to time exempt any particular hospital established by the State or under any municipal authority, or any eleemosynary institution, from the obligation to apply for or obtain a license ; and no such institution now existing shall be required to take out a license until required to do so by the board with the consent aforesaid. (2.) Regulations to insure the proper treatment of persons detained in anv house or place, whether licensed or not, that are subject to the provisions of this act, and to guard against improper or unnecessary detention of such persons. (3.) Regulations of the forms to be observed warranting the commitment, transfer of custody, and discharge of all lunatics other than those committed by order of a court of record, and as to these, with the consent of the presiding judge of the court under whose order the person is detained. (4.) The visitation of all houses or places licensed under this act, or in which any persons are detained as lunatics, and of all persons detained therein. (5.) The withdrawal of such licenses, and the imposition of conditions under which they shall continue. (6.) Reports and information to be furnished by the manager or managers of all houses or places, subject to the provisions of this act and by the boards of visitors. (7.) Reguladons as to the number of persons that may be detained and the accommo- dations to be provided, and food, clothing, fuel to be furnished in any house or building subject to the provisions of this act, the manner of such detention and the restraints imposed, the means of communication by those detained with the relatives, friends, and other persons outside the houses and places of detention. Sec. 8. There shall be appointed boards of visitors of all houses or places licensed under or subject to the provisions of this act, or in which any person of unsound mind is detained, and for the care or custody of whom compensation of any kind is received, or where more than one such person is detained. One such board shall be appointed in every county in which there is a house or place subject to the provisions of this act, of not less than three persons, and in each county, where there are more than one such house or place, the number constituting the board of visitors of such county shall be increased in the discretion of the committee on lunacy. Sec. 9. The members of the board of visitors shall be appointed by the board in each year, and shall continue until their successors are appointed, and the board may remove the visitors and fill vacancies in the office. Sec. 10. Women may be appointed members of the board of visitors, and at least once a year these boards shall be filled up so that members who have failed to act shall be removed. ABSTRACT OF LAWS RELATING TO THE INSANE. 66l Sec. II. It shall not be lawful for any person or persons, or corporation, not excepted from the obligation, to obtain a license under this act to keep or maintain a house or place for the reception or custody of persons of unsound mind without having received a license under this act, nor when such license has expired or been withdrawn, or sus- pended ; and the manager and occupant of any such house, within which more than one person shall be detained as being a person of unsound mind, for compensation re- ceived, and the manager and occupant of any such house or place, wherein more than, one person is received and detained, with or without compensation, and while there is no license in force authorizing the keeping of such house or place, shall be deemed guilty of a misdemeanor. Sec. 12. Any person having charge or control of any house or place subject to the provisions of this act, used for the detention, care, or custody of a lunatic, who shall violate or omit to observe any regulation of the committee on lunacy authorized by this act, after a copy of the same has been left at the said house or place, or delivered to the person named in the license, or to the manager of such house, shall be deemed guilty of a misdemeanor, and all common-law rights of action or indictments are also reserved. Sec. 13. The Board of Public Charities shall from time to time provide for an effectual visitation of all persons confined as insane in all places over which they are given juris- diction by this act, and an inspection of such houses or places of confinement and of the mode of treatment of the insane. Sec. 14. The board shall make rules to insure to the patients the admission of all proper visitors, being members of their family, or personal friends, agents, or attorneys, and compel obedience to such regulations. Sec. 15. The detention of any person as insane in any house or place made subject to the provisions of this act, without compliance with the requisitions of this act, shall be a misdemeanor on the part of any person concerned in such detention, who has omitted or permitted the omission of any of the requirements, and the party aggrieved shall also be entiiled to his action for damages. Sec. 16. No verdict or judgment shall be entered in any action, nor shall any judg- ment be entered on any indictment for such detention as against any person or persons who are subject to the regulations and provisions of this act, who shall have complied with the requirements of this act, unless the judge, after trial and verdict, shall certify that there was proof to his satisfaction that the party charged acted with gross negligence or corruptly, or that he acted without reasonable or probable cause, or was actuated by motives other than the good of the person restrained. Sec. 17. In all buildings or establishments where an insane person is detained, which are subject to the provisions of this act, there shall be kept the following books, which shall be at all times open to the inspection of any member of the committee on lunacy, or the board of visitors of the proper county. An Admission Book. A Discharge Book. A Case Book, in which there shall be regularly entered all the facts bearing on each patient and his case. A Medical Journal, in which there shall be at least once a week .a statement written of all matters which are of special importance bearing on the treatment and condition of the patients. Sec. 18. No person shall be received as a patient for treatment or for detention into any house or place where more than one insane person is detained, or into any house or place where one or more insane persons are detained, for compensation, without a cer- tificate signed by at least two physicians, resident in this Commonwealth, who have been actually in the practice of medicine for at least five years, both of whom shall certify that they have examined separately the person alleged to be insane, and, after such an ex- amination had, do verily believe that the person is insane, and that the disease is of a character which, in their opinion, requires that the person should be placed in a hospital or other establishment where the insane are received for care and treatment, and that they are not nearly related by blood or marriage to the person alleged to be insane, nor in any way connected as a medical attendant or otherwise with the hospital or other establishment in which it is proposed to place such person. Sec. 19. The certificate above provided for shall have been made within one week of the examination of the patient and within two weeks of the time of the admission of the patient, and shall be duly sworn to or affirmed before a judge or magistrate of this com- monwealth, and of the county where such person has been examined, who shall certify to the genuineness of the signatures and to the standing and good repute of the signers. 662 APPENDIX A. And any person falsely certifying as aforesaid shall be guilty of a misdemeanor and also liable civilly to the party aggrieved. Sec. 20. No person alleged to be insane shall be received into any house for treatment or for detention unless at the time of such reception the person or persons at whose instance the person is received shall^ by a writing signed, state that the person has been removed and is to be detained at his or her request under the belief that such detention is neces- sary and for the benefit of the insane person. Sec. 21. There shall also be delivered to the person or persons having supervision or charge of the house a written statement of the following facts relative to the person to be detained, signed by the person or persons at whose instance the insane person has been removed and detained, or if the facts be not known it shall be so stated: i. The name. 2. Age. 3. Residence for the past year, or for so much thereof as is known. 4. Occupation, trade or employment. 5. Parents, if living. 6. Husband or wife. 7. Children. 8. Brothers and sisters, and the residence of each of these persons. 9. If not more than one of these classes is known, the names and residence of such of the next degree of relatives as are known. 10. A statement of the time at which the in- sanity has been supposed to e.\ist, and the circumstances that induce the belief that in- sanity exists. II. Name and address of all medical attendants of the patient during the past two years. Sec. 22. Should the person in charge of the house have reason to believe that any of these statements have been omitted through ignorance, and that the answers will be imme- diately furnished, and no reason existing to doubt the good faith of the parties, after inquir- ing of the person intended to be detained, it shall be lawful to detain tlie person alleged to be insane for such furtlier period as shall be necessary to obtain the said statements complete, but not exceeding seven days. Sec. 23. Within twenty-four hours after any person is received into any house for deten- tion as an insane person, the person in charge there shall enter or have entered in a book kept for that purpose, all the facts stated in the certificate or documents required to be ex- hibited at the time of receiving the patient, and shall file the originals and preserve them. The regular medical attendant of the house shall, within twenty-four hours after the re- ception of any patient, examine such patient and reduce to writing the results of such examination, and enter the same upon a book to be kept for that purpose, together with the opinion formed from such examination and from the documents received with the patient. Sec. 24. In case the said medical attendant is of the opinion that the detention is not necessary for the benefit of the patient, he shall notify the person or persons at whose instance the patient is detained, and unless such person shall without a delay not exceeding seven days exhibit satisfactory proof of such necessity, the patient shall be discharged from the house and restored to his family or friends. Sec. 25. At the time of such examination the medical attendant shall himself cause the patient distinctly to understand, if he or she is capable of doing so, that if he or she desires to see or otherwise communicate with any person or persons, means will be provided for such interview or communication, and said attendant shall personally see that proper means are taken to communicate this fact to the person or persons indicated by the patient, and any proper person or persons not exceeding two shall be permitted to have a full and unrestrained interview with the patient. Sec. 26. The statements furnished at the time of the reception of the patient, and at the examination of the patient by the medical attendant of the house, shall be forwarded by mail to the address of the committee on lunacy within seven days from the time of the reception of the patient, which shall by them be entered in a book, wdiich they shall keep for this purpose, and at least once in six months there shall be a report made by tlie medical attendant of the house on the condition of each patient, together with such other matters relative to the case as the said committee may require, and at any time such re- port shall be made upon the request of the committee on lunacy. Sec. 27. During the detention of any person as insane any medical practitioner desig- nated by him or by any member of his family or " near friend," with the sanction of a judge of a court of record of the county in which such insane person resided at the time of his removal and detention, shall be permitted at all reasonable hours to visit and ex- amine the patient, and such medical attendant shall, unless objected to by the patient, be permitted, by request of his or her family or " near friend," and with the consent of the physician in chief of the establishment, to attend the patient for all maladies other than insanity, in the same manner as if the patient were in his own home. Sec. 28. All persons detained as insane shall be furnished with materials and reason- ABSTRACT OF LAWS RELATING TO THE INSANE. 663 able opportunity, in the discretion of the superintendent or manager, for communicating, under seal, with any person without the building, and such communication shall be stamped and mailed. They shall have the unrestricted privilege of addressing communications, if they so desire, not oftener than once a month, to any member of the committee on lunacy. Sec. 29. The provisions of this act in respect of the admission or discharge of patients shall not extend to insane criminals in custody. Such persons shall not be received ex- cept when delivered by a sheriff of tire county or his deputy, together with an order of the court of the county in which he was arrested or convicted, having jurisdiction of the offence, under the seal of the court, and signed by a law judge, nor shall such criminals be dis- charged from a hospital or other place of detention for the insane saving on a like order, and to the sheriff or his deputy producing such order, and while detained as an insane person, such criminal shall be so kept as to insure his detention until duly discharged. Whenever any person detained in any gaol or prison is insane or in such condition as to require treatment in a hospital for the insane, it shall be the duty of any law judge of the court under whose order the person is detained, upon application, to direct an inquiry into the circumstances, either by a commission or otherwise as he shall deem proper, with notice to the committee on lunacy, and if the judge shall be satisfied that the person con- fined requires treatment in a hospital, he shall thereupon direct the removal of the said person from the gaol or prison to a state hospital, which order shall be executed by the sheriff of the county or his deputy, and the actual expenses of such removal and the ex- penses of maintaining the person in the hospital shall be paid by the county liable for the maintenance of the said person in the gaol or prison from which he is removed. Sec. 30. The trustees, managers, and physician of any hospital, in which a criminal is confined by order of any court, or in which a lunatic has been committed after an ac- quittal of crime, shall not discharge, release, or remove the prisoner or lunatic, without the order of a court of competent jurisdiction ; and in case such lunatic, whether a con- vict or acquitted, is not set at large, but is to be removed to any place of custody, other than a hospital, the order for removal shall not be made without notice to the committee of lunacy, and time given them to investigate the case and be heard on the application. Sec. 31. All persons that have been detained as insane (other than criminal insane, duly convicted and sentenced by a court) shall, as soon as they are restored to reason, and are competent to act for themselves, in the opinion of the medical attendant of the house, be forthwith discharged, and any person so detained shall at all times be entitled to a writ of habeas corpus for the determination of this question; and, on the hearing, the respondent in that writ shall be required to pay the costs and charges of the proceed- ing, unless the judge shall certify that there was sufficient ground, in his opinion, to war- rant the detention and put the petitioner to his writ. In case the discharged patient be in indigent circumstances, such person shall be furnished with necessary raiment, and with funds sufficient for sustenance and travel to his home, to be charged to the county from which such patient was committed. Sec. 32. The committee on lunacy shall be notified of all discharges within seven days thereafter, and a record of the same shall be kept by the committee. Sec. 33. The committee on lunacy may at any lime order and compel the discharge of any person detained as insane (other than a person committed, after trial and conviction for crime, or by order of court), but such order shall not be made, unless notice be given to the person having charge of the building in which the patient is detained, and to the person orpersons at whose instance the patient is detained, and reasonable opportunity given them to justify a further detention; and the committee shall not sign an order of discharge unless they have personally attended and examined the case of the patient. Sec. 34. Persons voluntarily placing themselves in any of the houses provided for in this act, may be detained for the time they shall specify by an agreement signed by them at the time of their admission, but not exceeding seven days, and they may from time to time renew the authority to detain them for a time not exceeding seven days from such renewal. But no agreement shall be deemed to authorize a detention unless signed in the presence of some adult person, attending as a friend of the person detained, in the presence of, and also by the person in charge of the house, or the medical attendant. Sec. 35. So much of the act entitled '' An act to provide for the admission of certain classes of the insane into hospitals for the insane in this Commonwealth, and their dis- charge therefrom," approved the twentieth day of April, Anno Domini one thousand eight hundred and sixty-nine, number fifty-four of the Pamphlet Laws of that year, as pro- vides " that insane persons may be placed in a hospital for the insane by their legal guar- dians, or by their relatives or friends, in case they have no giiardians, but never without 664 APPENDIX A. the certificate of two or more reputable physicians, after a personal examination made within one week of»the date thereof, and this certificate to be duly acknowledged and sworn to, or affirmed, before some magistrate or judicial officer, who shall certify to the genuineness of the signatures, and to the respectability of the signers," is amended, and the persons thereby authorized to place an insane person in a hospital are required to observe the forms and conditions required by this act in exercising the powers conferred by the said act of the twentieth day of April, Anno Domini one thousand eight hundred and sixty-nine, when the insane person is placed in any house, hospital, or place which is subject to the provisions of this act. Sec. 36. So much of said act as provides by section second, " That it shall be unlaw- ful, and be deemed a misdemeanor in law, punishable by a fine of not exceeding one hundred dollars, for any superintendent, officer, physician, or other employe of any in- sane asylum, to intercept, delay, or interfere with, in any manner whatsoever, the trans- mission of any letter, or any other written communication, addressed by an inmate of any insane asylum to his or her counsel residing in the county in which the home of the patient is, or in the city or county in which the asylum is located," is hereby amended so that the same shall extend to the superintendents, officers, physicians, servants, or other employes of all hospitals, houses, or places which are subject to the provisions of this act. Sec. 37. So much of the said act as provides by section ten, " If the superintendent or officers of any hospital for the insane shall receive any person into the hospital, after full compliance with the provisions of this act, no responsibility shall be incurred by them for any detention in the hospital," as applies to the superintendent or officers of any hos- pital, house, or place made subject to the provisions of this act, is repealed, and, in place of the provisions of that act for the protection of such superintendents or officers, the pro- visions of this act for that purpose are substituted. Sec. 38. The managers and officers of any licensed hospital, or licensed house, or place, shall not be liable to the penalties imposed by this act, and shall be entitled to all the pro- tection of this act in case of receiving for detention a lunatic, or alleged lunatic, without complying with the requisitions of the act, if the judge trying the cause shall certify that the said officers and managers had good reason to believe that such receiving and de- tention were necessary for the safety of the lunatic, or other persons, and that the delay required to comply with the requirements of this act would have been injurious to the person detained, or to other persons, and that there is no reason to believe that they or any of them were actuated by improper motives. And within forty-eight hours after any person is thus received all the requisitions of this act to authorize a detention shall have been complied with, or the person discharged from custody, and the officers of the hos- pital or place where such lunatic has been thus received, shall forthwith notify the Board of Public Charities of the facts connected with the reception and detention. Sec. 39. Whenever any person shall be found by inquisition to be insane, the com- mittee of the person, or of the estate, and also the clerk of the court into which the in- quisition has been returned, shall thereupon forthwith send to the committee on lunacy at their principal office, a statement in writing, signed by the committee of the lunatic, of the name, age, sex, and residence of the lunatic, and the residence of the committee, and upon any change in the residence or place of detention of the lunatic, shall forthwith notify the committee of lunacy of such change. The committee on lunacy, or any one or more of the members of the committee, shall have power to visit and examine the said lunatic, and authorize such visiting and examination by their secretaiy, or any board of visitors, or one or more members thereof, and by a physician, and the said committee are authorized to apply to any court having jurisdiction over the committee, or to a judge of a court of common pleas of the county in which the lunatic is a resident or detained, to make such orders for the maintenance, custody, or care of the said lunatic, and for the care and disposition of the property of the lunatic, as the case may require. From any order, final or otherwise, thus made, an appeal may be taken to the supreme court, but such appeal shall not be a supersedeas, unless so ordered by the court making the order, or by a judge of the supreme court, on application and a hearing. Sec. 40. This act shall go into operation, etc. ABSTRACT OF LAWS RELATING TO THE INSANE. 665 RHODE ISLAND. [Public Statutes of Rhode Island, 1882, title xii., chap. 74.] Any trial justice oi- clerk of a justice court, upon complaint in writing, under oath, that a person within the county is a lunatic, or is furiously mad and is at large, shall cause such person to be apprehended and brought for examination before the court. If the court adjudge such complaint true, it shall commit such person to a hospital or asylum for the insane, unless a satisfactory recognizance be given that such person shall not be permitted to go at large. Upon proper petition under oath, setting forth that any person is insane, any justice of the supreme court may appoint not less than three commissioners to investigate and report whether such person should be placed in a hospital or asylum for the insane. Such commissioners shall be sworn to the faithful execution of their duties, shall give notice to person complained of as to time and place of hearing that he may defend him- self by counsel or otherwise, and said commissioners may summon witnesses, and shall hear all evidence offered on either side. The justice may cause such person complained of to be apprehended pending the inquisition of the commissioners. The justice may confirm or disallow the report of the commissioners, and may order the person complained of to be confined in an asylum, or may dismiss the petition alto- gether. Any person so committed to an asylum may be discharged by an order of any justice of the supreme court, although not restored to sanity, upon the written recommendation of the trustees and superintendent of such institution. Insane persons may be placed in State asylums by their relatives or friends, or, if paupers, by the town authorities; but the superintendents of such asylums or hospitals shall not receive any person into custody without a certificate from two practicing phy- sicians of good standing that such person is insane. Upon the application of a relative or friend, and with the written approbation of the visiting committee of the trustees, the superintendent of such institution may discharge any patient not committed by process of law. Any justice of the supreme court may, in his discretion, upon petition, setting forth that a person is improperly detained in an insane asylum, appoint commissioners to in- vestigate such case. No notice is served upon the person confined, and neither the petitioner nor his counsel has the right to visit or examine said insane person except by permission of the superintendent of the asylum, or by special order of the justice issuing the commission. The personal examination by said commissioners must take place at the institution where such person is confined, and, if the commissioners prefer, without the presence of the superintendent. Such commissioners shall report to the justice, who may either confirm or disallow the same, and order the discharge of the person detained, or dismiss the petition, in his discretion. The writ of habeas corpus not to be impaired or abridged by anything in this chapter. Whenever, on the trial of any person upon an indictment, he is acquitted, on the ground of insanity, the juiy shall so state, and the court, if the going at large of such person is deemed dangerous, shall certify its opinion to that effect to the governor, who may cause such person to be removed to an asylum and detained during the continuance of such insanity. Any justice of the supreme court may, upon proper petition, order an examination of any person confined in any jail or prison, and if such person is found to be insane or idiotic, or in such a state of impairment of mind or body as tends directly thereto, may order the removal of such prisoner to an asylum. Upon restoration to reason or health, such person may be remanded to the place of his original confinement by any justice of the supreme court. The agent of State charities and corrrection and the secretary of State shall constitute a commission to receive and examine all complaints and letters from or in relation to any inmate of any insane asylum, or any person alleged to be insane restrained of his liberty. They may, in their discretion, cause an examination to be made, and may petition a supreme court justice for a formal investigation. Such justice may thereupon, in his discretion, cause such person so restrained to be discharged. 666 APPENDIX A. Such commission from time to time, in its discretion, shall visit all asylums or institu- tions for the insane and examine into the condition and complaints of anyone so confined. Superintendents and others in charge, where any insane person is confined, must in no way hinder or prevent any person so confined from communicating with said commission, and must forward all communications to such commission without delay. Whenever the agent of State charities and correction shall make complaint to the supreme court that any person, reputed to be idiotic, lunatic, or insane, is not humanely or properly cared for, or is improperly restrained of his liberty, the court shall cause examination to be made, and, if found true, such person shall be removed to the State Asylum for the Insane. — Sees. 1-40 inclusive. SOUTH CAROLINA. [See General Statutes of South Carolina, 1882, sees. 52, 899, and 1584-1604 inclusive; also sees. 2697-269S; also Code of Civil Procedure, as adopted, 1881-1882, sees. 37 and 70.] South Carolina Lunatic Asylum is in charge of and controlled by nine regents ap- pointed by the governor. — Gen. Stais., sees. 1584 et seq. Admission to asylum shall be as follows : 1. All persons who shall be found idiots, or lunatics, by inquisition from the probate or circuit courts, or on trials in the circuit where the court shall order such admission. 2. Where it shall be requested under the hand of the husband or wife, or (where there is no husband or wife) of the next of kin of idiot or lunatic. 3. All persons who shall be declared lunatics, idiots, or epileptics, after due examina- tion by one trial justice and two licensed practicing physicians of the State. Where the subject is a pauper, the admission shall be at the request of the county commissioners of the county wherein such pauper has a legal settlement; otherwise the admission shall be at the request of the husband or wife, or, where there is no husband or wife, of the next of kin of the idiot, lunatic, or epileptic. — Gen. Stats., sec. 1586. In criminal cases, judges may send persons 7ion covipos 7nentis to asylum. — Gen. Stats., sec. 1589. The judge of the probate court may commit to the asylum any dangerous lunatic. — Gen. Stats., sec. 1590; Code of Civil Procedure, sec. 70. No person committed after examination by trial justice and two physicians, or who shall be sent from a sister State, shall be retained more than ten days without an order for his retention, entered in the records of the institution, after examination by the medical attendants and at least three of the regents ; all papers must then be sent to the probate judge of the county where such lunatic resides. — Ge)t. Stats., sec. 1 591. , It is the duty of the regents to dismiss and cause to be indicted any person employed in the asylum who shall assault or use unnecessary violence towards any inmate. — Gen. Stats., sec. 1596. Every judge of probate in his county has jurisdiction in cases of lunacy, and in relation to the appointment and removal of guardians for the insane, and the care and disposition of the estates of their wards. — Code of Civil Procedure, sees. 37 and 38. TENNESSEE. [See General Statutes (Revision, 1871^ sees. 1517-1564, and sees. 3681-3719; Laws of 1871, p. 159; Laws of 1877, p. 71 ; Laws of 1883, p. 195.] The management of the State asylums is vested in a State board of nine trustees, appointed by the governor, by and with the advice and consent of the Senate. — Laws of iSjJ, p. 71 ; and Laws of 1883, p. 195. For admission of a paying patient to the asylum, thirteen weeks' charge must be paid in advance, a bond given for further necessary payments and expenses, and a certificate by at least one respectable physician must be filed with the superintendent. ABSTRACT OF LAWS RELATING TO THE INSANE. 66^ Form of Certificate. The undersigned, being a physician in regular practice, hereby certifies that on the day of , 18 — , I personally examined , of County, State of Tennessee, and pronounce insane, and a fit subject of care and treatment in a hospital for the insane. The patient is years of age ; is free from infectious disease; has been insane for ; the disease is (or is not) hereditary; the supposed predisposing and exciting causes are ; is not subject of epilepsy; has (or has not) attempted to commit violence on self or others. This certificate should contain all facts known to the maker regarding the insanity of the patient, and should be signed and attested by a justice of the peace. For admission of non-paying patients, a statement having beexi filed with the justice of the peace, alleging the insanity of the patient in question, and giving the names of witnesses, including one physician, who can prove the sanne, the justice shall issue sub- poenas to the witnesses named, and such others as he may deem proper. If, after such inquest, the justice is satisfied of the truth of the allegations set forth in the statement, he shall cause the physician in attendance to make out a certificate, shall himself certify to his inquest, and attest the signature of the physician under seal, and transmit the same to the clerk of the county court, who shall take the necessary steps for the commitment of such insane person to the asylum. — Laws of 1871, pp. 159-163. For proceedings for appointment of guardians for lunatics, see Gen. Stats., sec. 3681 et seq. TEXAS. [See Laws of Texas, third edition. Vol. II.; Paschal's Annotated Digest, sees. 5828- 5835; and p. 1 115, art. 5, sec. 7; and sec. 5462. Laws of 1876, chap. 95.] If information in writing be given to any county judge that any person in his county is a lunatic, and requires restraint, and said county judge shall believe such information to be true, he shall order such person to be brought before him, and a jury to be sum- moned. If the jury find that such person is insane, he shall be sent to the asylum, unless some friend will give a bond to restrain and take proper care of such lunatic. A copy of all the proceedings shall be forwarded to the superintendent of the asylum before sending a patient there. The district court has exclusive jurisdiction over the estates of the insane. Guardians are appointed, who have the care of the persons and estates af the insane, subject to the control of the courts. VERMONT. s [Revised Laws of Vermont, 1880. Laws of 1882, pp. 54-58.] Supervision ok the Insane.. Sec. 2897. The general assembly shall elect biennially, three supervisors of the insane, who shall hold their offices for two years commencing on the first day of the next De- cember ; and the governor may fill any vacancy in the board during said term. Two of said supervisors shall be physicians, and none of them shall be a trustee, superintendent, employe, or other officer, of an insane asylum in the State. Sec. 2898. The supervisors shall visit every asylum for the insane in the State as of- ten as occasion requires, and one of the board, as often as once a month, shall examine into the condition of said asylums, the management and treatment of the patients there- in, their physical and mental condition and medical treatment, hear the grievances of the patients apart from the officers and keepers, and investigate the cases that in their judg- ment require special investigation, and particularly shall ascertain whether persons are confined in any asylum who ought to be discharged, and shall make such orders therein as each case requires. Sec. 2899. '^^^ supervisors shall make report biennially to the governor and the gen- 668 APPENDIX A, eral Assembly of their doings, and the conditions of the asylums and patients therein, their physical and medical treatment and the discipline thereof, and of such matters as they deem advisable. Sec. 2900. The supervisoi-s may administer oaths, summon \\-itnesses before them in any case under investigation, and discharge by their order, in writing, any person confined as a patient in any asylum for the insane, whom they find on investigation to be wrongfully confined, or whom they find so far sane as to waiTant the discharge. But convicts sent to an asylum from the State prison or house of correction who are found sane before expira- tion of their sentence, shall not be discharged, but the supervisors shall order them re- turned to the prison or house of coiTection. In no case shall the supervisors order the discharge of a patient without giving the superintendent of the asylum an opportunity to be heard. Sec. 2901. The governor may refer the case of any patient in the asylums for the in- sane to the supervisoi"S for their investigation. And the supervisors shall investigate such cases, and by their orders grant such relief as each case requires ; but if they have not the power to grant the necessary relief, they shall, if the patient is one of the insane poor of the State, at the expense of the State, cause such proceedings to be commenced in court as are required to obtain the necessary relief and promote the ends of justice and humanity. Sec. 2902. The friends or relatives of a patient in an asylum for the insane may ap- ply to the supervisors, by petition or otherwise, to inquire into the treatment and con- finement of sucli patient, and the supervisors shall take such action upon such application as it requires. Sec. 2903. If in their judgment an investigation is necessary, they shall appoint a time and place for hearing, and give such friends and relatives, and the supeiintendent of the asylum reasonable notice thereof, and at the time appointed shall hear such friends or relatives and superintendent, and make such lawful orders as the case requires. But in no case shall the supervisors order a discharge of a patient without giving the super- intendent an opportunity to be heard. Sec. 2904. If a person legally summoned as a witness before the supervisors in be- half of State, or summoned bj' other parties, with a tender of his fees, wilfullj' or wrong- fully refuses to attend or testify, he shall be punished as provided in section 1546 (sec. 16&1J. Sec. 2905. If a trustee, superintendent, employe or other officer of an as)dum for the insane, wilfully and knowingly neglects or refuses to discharge a patient after such pa- tient has become sane or after the supervisors have ordered his discharge, such trustee, superintendent, employe or other officer shall be fined not more than five hundred dol- lars. Regul.^tioxs Conxerning Admission to Insane Asylums. Sec. 2906. No person, except as hereinafter provided, shall be admitted to or detained in an insane asylum as a patient or inmate, except upon the certificate of such person's insanity made by two physicians of unquestioned integritj' and skill, residing in the probate district in which such insane person resides, or, if such insane person is not a resident of the State, in tlie probate district in which the asylum is situated, or if such insane person is a convict in the State prison or house of correction, such physicians may be residents of the probate district in which such place of confinement is situated ; and the two phvsicians making such certificate shall not be members of the same firm, and neither shall be an officer of the insane asylum in tins State. [As amended by Laws of 18S2; also see AWc'.] Sec. 2907. Such certificate shall be made not more than ten days previous to the ad- mission of such insane person to the asylum, and, with a certificate of the judge of pro- bate of the district in which the physicians reside, that such physicians are of unques- tioned integrity and skill in their profession, shall be presented to the proper officer of tlie asylum at the time such insane person is presented for admission. Sec. 2908. The certificates of the physician shall be given only after a careful exami- nation of the supposed insane person made not more than five days previous to making the certificate, and the physician who signs a certificate without making such previous examination, shall, if the person is admitted to an asylum upon the certificate, be fined not less than fifty dollars nor more than one hundred dollars. Sec. 2909. A person may be leceived into an asylum without a certificate, upon the order or sentence of the supreme or county court, upon the presentation of a certified copy of the order or sentence. ABSTRACT OF LAWS RELATING TO THE INSANE. 669 Sec. 2910. A person admitted to an asylum agreeably to the provisions of this chapter shall be deemed insane and shall be subject to the control and sanitary treatment of the trustees of the asylum, until sufficiently sane to warrant his release, or until removed by his friends or guardians, or otherwise discharged. Sec. 291 1. A trustee or other officer or employe of an insane asylum who admits or detains a person in an asylum, contrary to the provisions of this chapter, shall be im- prisoned in the State prison not more than three years. Sec. 2912. The secretary of state shall prepare and have printed and furnished to each probate judge, blank certificates for the use of such judges and physicians in carry- ing out the provisions of this chapter. Chap. 87, Sec. 1702. When a person held in prison on a charge of having committed an offence is not indicted by the grand jury by reason of insanity, the grand jury shall so certify to the court, and thereupon, if the discharge or going at large of such insane per- son is deemed manifestly dangerous to the community, the court may order him confined in the county jail or in the insane asylum at Brattleboro, or some other suitable place, at his own expense, if he has estate sufficient for that purpose, and if not, at the expense of the State. Sec. 1703. When a person tried on an indictment or information for any crime or of- fence is acquitted by the jury by reason of insanity, the jury, in giving their verdict of not guilty, shall certify that it is given for such cause, and thereupon, if the discharge or going at large of such person is considered dangerous to the community, the court may order him, in its discretion, to be confined in the State prison or in the insane asylum at Brattleboro, on such terms as the court directs. Also see Laws of 1882, No. 49. Note. Laws of 1S82, No. 48. Sec. 2. The next friend or relative of a person whose insanity is certified to as above provided, may appeal from the decision of the physicians so certifying him to be insane to the supervisors of the insane, which appeal shall be noted on the certificate. The su- pervisors shall, when such appeal is taken, forthwith examine the case, and, if in their opinion there was not sufficient ground for making such certificate, they shall avoid the certificate, otherwise they shall indorse their approval upon it. Such examination by the supervisors shall be had in the town where the appellant resides. Sec. 3. When the next friend or relative of such a person takes an appeal as above provided, he shall not be received in an insane asylum while the appeal is pending before the supervisors. And a trustee or other officer or employe of an insane asylum who re- ceives or detains a person in such asylum vi'hose insanity is not attested by a legal certifi- cate which has not been appealed from, or by a certificate duly approved by the supervi- sors on appeal, shall be imprisoned in the state prison not more than three years. Sec. 4. Idiots and persons non compos, who are not dangerous, shall not be confined in an asylum for the insane. And if any such persons are so confined the supervisors of the insane shall cause them to be discharged. For special act to prevent the going at large of lunatics see Laws of 1882, No. 47. VIRGINIA. [See Code of Virginia, 1873, Title 24, chap. 82, p. 714; Title 55, chap. 201, sec. 14, p. 1241; Title 55, chap. 202, sec. 17, p. 1247; Acts of Assembly 1874, chap. 26; Acts of Assembly 1881-2, chap. 133.] Each lunatic asylum in the State shall be under the management of a board of eleven directors, appointed by the governor. The directors may examine persons brought to the asylum as lunatics, and order those found to be such to be received. Any justice may cause any person suspected of being a lunatic to be brought before him, and he and two other justices shall inquire into the case, and for that purpose summon the physician of such person (if any) and other witnesses. Questions to be asked such witnesses are prescribed by statute. If the justices decide that such person 670 APPENDIX A. is a lunatic, and ought to be confined, they may either surrender him to some person who will give a sufficient bond for his care, or cause him to be removed to an asylum. Upon the arrival of such patient at the asylum, the board of directors is assembled, and, if they concur in opinion with the justices, the patient is received. A committee shall be appointed for any person found insane, and such committee shall be entitled to the custody and control of his person when not confined in an asylum or jail, and shall take possession of and manage and care for his estate. Where a court sees reasonable ground to doubt the sanity of a person held for trial, it shall suspend the trial and order a special jury to inquire into the fact. If the jury find the accused sane at the time of their verdict, no other inquiry is made and the trial pro- ceeds ; if they find him insane, they then inquire whether he was so at the time of the alleged oftence. If they find that he was, the court may dismiss the prosecution ; if they find that he was not, the court shall commit him to jail or asylum until he is so restored that he can be put upon his trial. — Code, p. 1247, chap. 202, title 55. WEST VIRGINIA. [See Revised Statutes of West Virginia {1879), chap. 108 (chap. 58 of Code), p. 673; Acts of W. Va., 1881, p. 266; Acts of W. Va., 1882, pp. 133-137.] The State Asylum is under the control of a board of nine directors, appointed by the governor, with the advice and consent of the Senate. Any one or more of the directors, together with the superintendent (who is a physician), shall constitute an e.Kamining board, and may examine persons brought to the asylum as lunatics, and order those found to be such to be received. — Acts of IV. Va., 1882, p. 135. Any justice suspecting a person in his county to be a lunatic, may issue a warrant and cause such person to be brought before him, and an inquiry to be had, after summoning a physician and any other witnesses. If such person be sent to the asylum, and the examining board refuse to receive him, because, in their opinion, he is not a lunatic, they shall so certify, and such person shall be conveyed back to the county in which he was examined and there discharged. — Ibid. The courts may appoint a committee for any insane person. Such committee is entitled to the custody and control of the person of his ward, when he resides in the State and is not confined in the hospital or jail, and to the care and control of his estate. Suitable bonds must be given, and such committee is under the supei"vision and control of the courts. WISCONSIN. [See Revised Statutes of Wisconsin (1878), sees. 580-609; Laws of 1880, chap. 266; Laws of 1881, chap. 202 and chap. 298; Laws of 1S82, chap. 283; Laws of 18S3, chap. 35.] The State asylums are under the control of the " State Board of supervision of Wiscon- sin charitable, reformatory and penal institutions." The board consists of five members who receive salaries, and who are appointed by the governor with the advice and consent of the Senate. Said board act as commissioners of lunacy, and have full power with or without expert assistance to investigate as to the condition of any inmate of a State asylum, to hear complaints, etc. Inmates of asylums may send sealed letters to this board. — Laws of 1 88 1, chap. 298. AVhenever any resident of this State, or any person found therein whose residence can- not be ascertained, shall be or supposed to be insane, application may be made in his behalf, by any respectable citizen, to the judge of the county court, judge of the circuit court, or any judge of a court of record, in and for the county in which he resides, or, in case his residence is unknown, the county in which he is found, for a judicial inquiry as to his mental condition, and for an order of commitment to some hospital or asylum for the insane. The application shall be in writing, and shall specify whether or not a trial by jury is desired by the applicant. On the receipt of said petition, the judge to whom it is addressed shall ABSTRACT OF LAWS RELATING TO THE INSANE. 67 1 appoint two disinterested physicians, of good repute for medical sl-:ill and moral integrity, to visit and examine the person alleged to be insane, and such physicians shall proceed, without unnecessary delay, to the residence of the pei'son supposed to be insane, and shall, by personal examination and inquiry, satisfy themselves fully as to his condition, and report the result of their examination to the judge. — See Lazvs of 1883, chap. 35. Such report must be substantially in the form of answers to a series of full questions concerning the patient, provided specifically by the statutes. — See Laws of 1883, chap. 35 ; and Lazvs of 1881, chap. 202. Upon receipt by the county judge of such application or petitioi^ he may, if he deems the public safety requires it, order the sheriff to take and confine such alleged lunatic, pending further proceedings, in a specified place.— Zawj' of 1 881, chap. 202. Upon receipt of the report of the examining physicians, the judge may, if no demand has been made for a jury, order the commitment to an asylum of the person in question, or, if not fully satisfied, may make additional investigation of the case. At any stage of the examination, the person alleged to be insane, or his friends, may demand a jury trial, and have the right to be assisted by counsel. — Laws of 1880, chap. 266. Upon application by any i-espectable citizen, there may be a rehearing and further inquiry as to any person confined in an asylum, or other place of confinement, upon commitment as an insane person. — Laws of 1S81, chap. 202. No physically infirm or mentally imbecile person, not deemed to be dangerous when at large, shall be committed as an insane person to any hospital or asylum for the insane solely because of such infirmity or imbecility. — Laws of 1881, chap. 202, sec. 6. Guardians may be appointed for the insane, by the county courts, to take care of the estates of their wards. — J^ev. Stats., sec. 3989 et seq. Abuse or neglect of inmate of any hospital for the insane is punishable by imprison- ment for one year, or by fine of two hundi-ed dollars. — Kev. Stats., sec. 4389. APPENDIX B. r , SUNNYSIDE -p, Admitted. ^ MEDICAL RETREAT. Discharged. Name. Age. Nativity. Date. Disease. Date. Name. Quei'ies for Patients' Fj'iends to a7iswer, to instire ufiifonnity of results by Physicians in keeping record of cases. QUERIES. ANSWERS. I. What is the name of the patient ? Age? Place of birth ? Residence? 2. Is the patient married, or single, or wid- owed ? How long since first married or widowed ? If patient has had children, state their num- ber, and the date of the birth of the last. 3. What is the profession or occupation, and reputed pecuniary circumstances of the patient ? If a female, state profession or occupation, etc., of father or husband. L 4. Is the patient a professor of religion ? 5. What is the original disposition and intel- lectual capacitj' of the patient? Mention general habits of life, predominant passions or prejudices, and any habitual vice, or intemperance ; does the patient use ardent spir- its, opium, tobacco, etc.? 6. Horn long'h-zs, the patient been insane? Did the disorder come on gradually or sud- denly? 7. Has the patient been insane previously? If so, specify the date, duration, ajiiyorm of each previous attack. SUNNYSIDE MEDICAL RETREAT. 673 QUERIES. ANSWERS. 8. How long before accession of insanity were any such precursory symptoms observed as the following, viz. : unusual depression or eleva- tion of spirits, or any remarkable alteration in temper, disposition, feelings, opinions, conduct, sleep, appetite, state of the bowels, or health of the patient ? Previous to these symptoms, had the patient been remarkable for any degree of oddity, eccen- tricity, or mental infirmity ? 9. What have been, or are, the prominent symptoms of the malady? Has any obvious change in its form occurred ? Does it appear to be increasing;, decreasing, or stationary? 10. Are there lucid intervals or any great re- missions or exacerbations, and do such changes occur at uncertain times, or at stated periods? II. Does the patient rave indifferently on various subjects, or chiefly on one ? What is that subject? Mention particularly any permanent or re- markable illusions. 12. Has the patient ever threatened or at- tempted to commit suicide or any act of self- injury ? By what means ? Is the propensity now active? 13. Does the patient manifest any disposition to injure other persons, and how ? Or cherish any malicious design? Is the morbid train of thought excited by any particular subject or event ? 14. Is the patient inclined to tear clothes or to break windows or furniture ? 15. Since the commencement of the insanity, what have been the patient's habits ? _ State particularly whether the patient is atten- tive to the calls of nature. 43 6/4 APPENDIX B. QUERIES. ANSWERS. i6. What is supposed to have been the excit- ing cause of the insanity ? Is it a moral cause, such as disappointment, fright, love, etc., or a physical cause — fever, the immoderate use of any intoxicating agents, bodily injuries, serious illness or accident afifect- ing the nervous system, etc, ? 17. Does any constitutional or hereditary pre- disposition exist in the family of the patient to nervous affections ? Were any relatives of the patient ever insane? If so, state particularly whether on the father's or mother's side, or both. 18. Was the head of the patient ever severely injured? ig. Is the patient subject to periodical attacks of any other malady ; to anj- unusual discharge, or to suppression or obstruction of any custo- mary discharge ; to sores, eruptions, rupture, epilepsy, or palsy ? Specifj- any bodily infirmitj' or disease of the patient. 20. What has been done for the recovery of the patient ? And with what effect? Mention particularly whether depletion by blood-letting, leeches, cathartics, low diet, etc., has been employed, and to what extent? 21. Has the patient been subject to any me- chanical restraint ? If so, specify the length of time and the man- ner in which the restraint was applied. 22. Has the patient ever been treated for in- sanity in any other asylum for the insane ? If so, how often and how long on each occa- When, in what state, and, if not cured, for what reason was the patient discharged ? 23. You are requested to state any other cir- cumstances which you may think of interest or importance. APPENDIX C. RESUME OF TREATMENT OF THE INSANE. Priviarily, give plenty of nutritive food, and give barks, wine and iron, or malt liquors, when indicated. Warm clothing and bedding, and a moderately warm and dry atmosphere, and plenty of occupation and exercise, — a sine qua non in the treatment of the insane, and change of scene and surroundings. R. Fl. Ext. Hyoscyami, . . gtt.x. Am. Tinct. I.upulin, . ■ SJ- Camphorse fNeergaard), . gr. V to X. Syr. Aurantii, , . • S'J. Aquse Camph., • 5^1- M. et ft. haust. Useful in asthenic cases as narcotic and sedative. A good sedative pill in general paralysis of the insane, and in incipient mental disor- der, with some excitability, is the following ; R. Zinci Valerianat., ......... ^J* Ext. Belladonna, gr- ij- M. et ft. pil. No. 30. Sig, Pill every 2 hours. Narcotic friction of scalp with Ungt. Bellad. Comp. is also old, but useful at times. R. Ext. Belladonna (Allen's), ■^]. Morphia Sulph., . . . . . . . . • 3J- M. et ft. unrt. To subdue inordinate excitement, use the prolonged warm bath with cold effusions to head, protracted an hour or two, and followed, if necessary, by pill of camphor, turpen- tine and hyoscyamus. Narcotic baths of albs, of henbane, belladonna, hemlock, and cherry laurel leaves, in- fused in hot bath, are excellent, even though old. Tinct. digitalis, carried to 60 minims ter die, after a mercurial cathartic, produces sleep, quiet, and restoration to health in subacute mania. In delirium tremens ^ -ounce doses of digitalis, or R. Chloral Hyd., ^ij. Tr. Hyoscyamus, ......... _::^ss. Syrupi, giv. M. et sig. Dose, tablespoonful, to be repeated as necessary. Monobromide of camphor in puerperal mania, after 10 grains of calomel, followed by a saline, is a specific. 6j6 APPENDIX C. In nymphomania, 4 grains camph. monobromide everj^ three hours after regulating se- cretion will suon cure the patient. If nymphomania is accompanied by clitoric irritation, we may, with advantage, re- move the clitoris. In uterine irritation in insanity, which keeps up sleeplessness, use suppositories of I grain stramonium at bed-times. It quiets ganglionic nerves of uterus efficiently, and have displacement and flexion remedied at once. In dysmenorrhoea in insanity use Schiefflin's fluid extract viburnum prunifolium (black haw) ^:^ss to 3J every hour until relief is experienced. Very valuable in ordinarj' dys- menorrhoea. In hysteria and hysterical mania, the introduction of a litlle pill of ungt. belladonnas comp. into the os uteri acts like magic. R. Ext. Belladonn^e (Allen's), gj. Morph. Sulph., ^j. M. et ft. ungt. A combination of iron, phosphorus, zinc and strychnia, antagonizes cerebral degenera- tion in insanity. R. Ferri Redact., . . . . . . . . . gr. ii. Zinci Phosphidi, . . . . . . . . • g^- xV '^° 3* Sti7chniffi Sulph., gr. ^1^ to -J^. M. et ft. pil. No. I, t. i. d., after meals. With a moist, relaxed state of the skin, cold extremities, shrivelled surface, pale com- plexion, and feeble circulation, use stimulants and full diet, and centric galvanization, carb. am. or old whiskey or port. In gi"eat depression, melancholia, especially if religious or suicidal, a course of pro- longed warm baths, with gradually increasing doses of morph. hydrochlorate, will antago- nize the morbid psychic state and cure the patient quickly. Enveloping the whole person in a sheet wrung out of hot mustard water, and putting the patient to bed is a valuable sedative measure, with dry cupping at back of neck. Use all your mental resources to weaken and dissipate false ideas, a happy mixture of kindness and firmness. Remember, that hallucinations may be troublesome and disturb repose, but if the indi- vidual acknowledges their falsity, he or she is sane. Prolonged dry cupping may re- lieve this symptom. We can control those tearing everything to pieces leaving themselves naked, which is due to hypersesthesia of the body, by monobromide of camph., Clin's capsules (4 grs.) ter die. Fluid extract ergot (Squibb's) in 2;ss. to ^j. tlirice daily, is the physiological antagonist to states of recurrent mania and chronic mania with lucid intervals, and also to epileptic mania; may be combined with the bromides. In states of great motor excitement with homicidal impulses, fluid extract conium m^^ to 3 }4 doses, or ^j, may be used to quiet motor brain centres ; produces quiei and mus- cular relaxation. Puerperal mania is generally due to the absorption of the retained products of concep- tion, which causes sepiicsemia, and we therefore give a mercurial cathartic, followed by salines, and 4 grains monobromide camphor ter die. In hallucination with excitement, dn- cups at back of neck, prolonged warm baths, and 30 grains sodium bromide, with ^o minims tinct. cannabis indica in combination, ter die, will produce quiet and tranquillity. In dementia can. indica has noeftect. N^onrishment. — The nourishment of a sane man is generally insufficient for an insane. Full feeding means tranquillity ; insufficient diet, excitement. Diuretics. — When the urine of the insane is scanty and high-colored, use diuretics, such as sp. ether., nit., lig. am. acetat., or inf. of digitalis. Carefully examine daily the state of the pulse and skin, the head, the extremities, the tongue, the bowels, the urine, and regulate the catamenia. If the action of the liver is sluggish, give dilute nitro-muriatic acid, 15 gtt. in 'Z^] of tinct. gentian, comp., ter die. Restraint. — The entire disuse of restraint will soon be possible, as insanity is gradu- ally assuming in our country a milder type than formerly. The disuse of restraint should be the rule and system. RESUME OF TREATMENT OF THE INSANE. 6/7 Occupation and exercise in the open air for the insane cannot be insisted on too strongly This, with full feeding and warm baths, together with change of scene, will cure many patients. . Epileptic and suicidal patients should always be watched throughout the night by a night attendant. Sleep. — We should remeiriber that sleep is the first of medicines as a physiological an- tagonist to the states of an inordinate degree of excitement and over activity of nervous system or mental anxiety. yl/rt'ji'a^e and f/^r^reV/Zy are of inestimable service in the neurasthenia which is often the incipient stage of insanity, and rest for the overworked brain ; the galvanic current antagonizes congestive states of the brain. Proper diet and exercise, change of air and scene, and useful and agreeable occupation of the mind, I have come to believe, by observation, to be the most valuable means at our command in the treatment of insanity. By the foregoing we do not at all undervalue the medicinal therapeutics of insanity when judiciously applied. Disorders of the digestive organs, indicated by coated tongue, constipation, flatulence and morbid appetite, may be regulated by mist, rhei, sodje and gentian, or the triplex pill, when well made. In recent cases, rapid recovery may follow copious evacuations of the bowels and free diuresis, followed by a course of prolonged warm baths. The latter calms general mental excitement wonderfully. The subsidence of excitement is not always the immediate precursor of convalescence. Having removed from your patient all moral causes of excitement, do not administer narcotics in large doses, but be content to apply remedies calculated to correct the dis- orders of the other bodily functions, and time, with good hygiene, will often cure your patient. Sleeplessness, accompanied by high nervous excitement, is more safely combated by pro- longed warm baths, with cold to the head, than by medicine, and tranquillity and unin- terrupted rest will often follow. Insanity is a disease generally accompanied by bodily disorders, and these we must remedy. When the digestive organs have resumed their healthy condition, when the pulse becomes natural, and there is no unusul heat or dryness of the skin, we must rely on time and moral treatment to cure our patient. Importance of Good Nurses. — Have no nurse for your sick insane patient, either male or female, with whom you could not place your wives, brothers or sisters, and always treat your patient with the utmost attention, delicacy and respect. They always respond to such treatment. When the mind is weak, but slowly recovering its vigor, a good nurse will keep a pa- tient ordinarily cheerful and happy, while a poor one will throw the patient into a state of anxiety and depression. A good nurse will have the confidence, respect and affection of her patient. W^e must remember that a suicidal patient is a recoverable case, but they are always on the look-out for means of self-destruction, and the nurse must exercise unremitting vigilant watching; when the suicidal act has once been vci&i]\\.2X^A, it is an imperative . duty to watch such a patient. While we can often trust the veracity of the insane, as to going and coming punctually, it is not safe to do this when the hazard is that of life in a suicidal patient. Such patients often throw the inexperienced and unskilled off their guard and commit suicide. We can inculcate self-respect and self-control more often in mental disease than many imagine. Hardly any insane man or woman is beyond the reach of a motive if rightly presented. The wfird of a violent patient to be quiet, industrious, and orderly, is often to be relied on in hospital treatment, and we thus avoid the use of restraint. I have often heard the insane express regret for their acts and language, and have seen them behave afterwards with perfect propriety. In matters of religion and morality we should treat the insane as sane while under hospital treatment, and inculcate self-respect and self-control constantly. Inculcate in such patients all the habits of rational life. Treat them kindly and politely, inquire after their health, hear patiently their stories, and we shall thus gain their affection and confidence. Respect your patient, and he or she will respect themselves. Treat them as rational beings, and they will re-pond every time. Trust your patient, unless suicidal, and he will rarely abuse your confidence. Let 6/8 APPENDIX C. your intercourse with your patient be familiar and parental, and use a mild and gentle tone in speaking to them. Encourage and cheer them when despondent ; soothe and calm excitement, and do not leave your patient, if possible, until you have done this. Never lay violent hands on any patient, except in self-defence, which is very rarely necessary; and never cower or allow yourself to be looked out of countenance. See that patients have a pleasant and comfortable temperature and light cheerful games and amusements. Provide neatly furnished rooms to add to your patients' self-respect, and provide good garments for them. Finally, provide easy and pleasant occupation for your patients, and they will be contented and happy. APPENDIX D. CASES ILLUSTRATED BY THE PORTRAITS IN FRONTISPIECE. No. I, in the upper left-hand corner, is the portrait of a case of suicidal melancholia, in an Italian forty years of age. The cause of the insanity was supposed to be grief on account of an unfortunate love affair in Italy, after which he came to this country, and soon after landing became insane. No family history could be obtained. He refused all food, tried to starve himself to death, and was fed by the stomach-tube for sixty-three days. No. 2, in the upper right-hand corner, is the portrait of a case of dementia, following acute dementia, she was very violent and dangerous at times. Was suspicious and watchful, with delusions of fear and persecution while maniacal. Her face exhibits her disposition very well. Sullen, taciturn, and ever ready for mischief. No. 3, in the centre, represents a case of epileptic mania, iji a German twenty-eight years of age, on the verge of dementia. Has been epileptic from youth up, and has violent maniacal attacks preceding the epileptic paroxysm, during which he is homicidal, requiring restraint. In the interval between the paroxysms, he worked in the wards of the asylum of which he was an inmate, and was quiet and polite unless instated or annoyed. No. 4, in the lower left-hand comer, is the portrait of a case of dementia, having passed through the stages of depression and mania. She was good-natured and happy, always laughing, but had not the slightest trace of intellectual power left. No. 5, in the lower right-hand corner, is the portrait of a case of general paralysis of the insane, or paralytic dementia. He was a typical case, having the shuffling gait, the slurring speech, the delusions of wealth and grandeur, and more or less delirium at times. Every portrait in this plate expresses very well the physical state of the individual it depicts. The physiognomy of the insane is here seen most typically. APPENDIX E. LITERATURE OF DISEASES OF THE MIND. 1689. Johannis Helfrici — Praxis ]\Iedica. Articles — Mania and Melancholia. 1 71 2. EtmuUer — EtmuUerus abridged, etc., translated 1712. Article — Deficiency of Rational Operations. 17 16. Salmon — The Practice of Physic, etc. Articles — Hypochondriac Diseases in Men and Hysteric in Women and Madness. 1730. Shaw — A new Practice of Physic, etc. Articles — Madness and Hypochondriasis. 1763. Sauvages — " Nosologia Methodica." 1 763. Mead — The Medical Work of Dr. Richard Mead. Articles — Madness and Hypo- chondriasis. 1765. Brookes — The General Practice of Physic, etc., by R. Brookes, M.D. Articles — Hypochondriasis and Madness. 1773. Gregory — -Manuscript Notes on the Lectures of John Gregory', M.D. Articles — Mania and Melancholia. 1791. CuUen — First Lines on the Practice of Phj'sic. By Win. Cullen, Prof, in the University of Edinburgh. Articles — Mania and Melancholia. 1792. Daquin — La Philosophic de la Folic, etc. Physician to Hospital for Insane and Hotel-Dieu of Chambery. 1792. Fodere — On Cretinism. 1797. Darwin — Zoouomia, etc. By Erasmus Darwin, M.D. Articles — Insanity and Hypochondriasis. 1 801. Motherby — A new Medical Dictionary, etc. Article — On Insanity. 1802. Villermay — Recherches Historiques et Medicales sur L'Hypocondrie, etc. By Sec. Louyer Villermay, Physician, etc. 1802. Denman — An Introduction to the Practice of Alidwifery. Article — On Mania. 1806. Co.K — Practical Observations on Insanity, etc. Second edition. 1806. Reese — On Melancholia, in a Practical Dictionary, etc. 1809. Pinel — Traite Medico-Philosophique sur I'alienation Mentale. By Ph. Pinel, consulting physician to his Majesty the Emperor, etc. Second edition. Also in 1809 Hofifbauer of Halle on " Psychology in its Chief Applications to the Administration of Justice." 1809. Ha on Puerperal Insanity. Franque, Arnold von — On Insanity of Gestation or Pregnancy. Wurzburgher Med. Zeitschrift, 1863. Dr. P'raser — On Idiocy. In Journal of Mental Science, July, 1876. Fredrich — On the Bodily Causes of Insanity, 1836 and 1839. Galen — On Classification ; on the Influence of the Moon on Hypochondriasis. Gall — On Idiocy ; on Insanity. Dr. Gasquet — On Pellagrous Insanity. Journal of Mental Science, 1872, p. 582. Georget — On Stupidite (Acute Dementia). Gerlach — On the Cortex of the Cerebrum. Dr. Gooch — On Puerperal Insanity. Dr. Grabham — Remarks on the Origin, etc., of Idiocy, 1875. Greding — On Special Changes in Insanity. Dr. Giiggenbuhl, of Switzerland. On Cretinism, Dr. Guy — Forensic Medicine. Hseser — Geschichle der Epidemischen Krankheiten. Halford, Sir H. — Essays on Insanity. Haller — On Insane Brains. Elements of Physiology. Hecker — The Epidemics of the Middle Ages. Heinroth — On Insanity. Helm— On Puerperal Insanity, 1 840. Hule — On Morbid Histology. Hildenbrandt — ^De la Syphilis dans ses rapports avec 1' Alienation Mentale. Hittorf — On the Blood of Insane Patients, p. 597, 4th ed. Bucknill and Tuke's Manual of Psychological Medicine. Hofifbauer — On Insanity. Hoffman — On Post-febrile Insanity. Giinsburg Zeitschrift, iv. Hood, Sir Charles — Statistics of Bethlem Hospital. Dr. Howden — On Epileptic Insanity, Journal of Mental Science, January, 1873 ; on Kidney Disease in the Insane, Reports of Montrose Asylum : on Granular Degeneration of Cells (paper). Dr. Hun — Hematoma Auris, American Journal of Insanity, July, 1870; on Pulse in Insanity, American Journal of Insanity, January, 1870. Dr. Magnus Huss — Alcoholic Insanity. Hutcheson — On Dipsomania. William J. Hutcheson — On the Teeth and Syphilis, and Idiocy. Dr. A. H. Huth^-The Marriage of near Kin, 1875. LITERATURE OF DISEASES OF THE MIND. 68/ Dr. W. W. Ireland — Idiocy and Imbecility, 1877. Jackson, Dr. Hughlings — On Mental Automatism. (West Riding Medical Reports, Dr. Max Jacobi— On bodily causes of Insanity, 1836-39 ; on Relapses ; on the Pulse in Mania ; on Treatment. Dr. Jarvis — On Consanguineous Marriages ; Sex and Study. Dr. Jenner — On the use of Antimony to the shaven scalp. Dr. Jessen — On Pyromania. Die Brandstiftungen in Affecten n. Geistesstorungen (Kiel, i860). Jones, Dr. Hanfield — On Post-febrile Insanity. In Brit. Med. Journal, January 12, 1867. Fibroid and allied Degenerations, No. 27, Med. Chir. Review. H. Josionck — On Morbid Histology. Archiv der Heilkunde, Bd. xix., Heft 3, p. 223, 1878. Dr. Kirkbride — On Intemperance. Report for 1 87 1 of Pennsylvania Hospital for the Insane on Recoveries; Report for 1873, of 2994 patients. Dr Kiching — Lecture on Moral Insanity (British Medical Journal, 1857). Mr. Lane — On Treatment of Syphilitic Insanity. British Medical Journal, October nth, 1873. Larrey — On Insanity. Lavater — On Physiognomy of Insanity. Dr. Lawson — On Pupils in General Paralysis. West Riding Medical Reports, vol. vi. On Perception of Pain in General Paralytics. Same article. Dr. Laycock — On Insanity. Nervous Diseases of Women. Legrand, du Saulle — On the Insane in Paris, during 1870-71. Report in Annales, May, 1872, p. 413, of case of Theodore, a case of Transitory Mania; On Alcoholic In- sanity. Annales Med. Psych., October, 1859. Leidesdorf — On Insanity of Gestation or Pregnancy. Journal of Mental Science, Jan- uary, 1873. M. Lelut — On Pathology. The Value of Cerebral Alteration, in Acute Delirium and Insanity, 1836. M. Leuret — The Moral Treatment of Insanity. Leubuscher — On Syphilitic Insanity, 1861. Leyden — On Disseminated Sclerosis. Linnaeus (1763) — On Insanity. I^ombroso-^On Insanity. Louis — On Insanity subsequent to Fever (torn. ii.). Dr. J. Luys — On Mental Diseases, 1881. Lucas, P. — On Heredity (De I'Hereditej. Lugony, Dr. — On Cretinism. Lunier — On Intemperance. Annales Medico-Pyschologiques for 1872. On War, in same journal. Number of Insane in France ; Annales Med. Psych., January, 1870. On Cretinism, 1867-68. Loggia, Prof., of Italy — Progressive Paralysis of the Insane. Translated by Dr. Nork- man, in No. 3, vol. iii. of Alienist and Neurologist. Dr. A. E. MacDonald — General Paresis. Am. Journal of Insanity, April, 1877. Dr. James MacDonald — On Puerperal Insanity. Dr. Macintosh — On Opium in Insanity. Article in Practice of Physic. Dr. Magnan — Experimental and Clinical Investigation of Alcoholism. On Hsemato- ma Auris, Annales Medico-Psychologiques, May, 1871. Dr. Major — On Causes of Insanity. Journal of Psy. Med., 1877, and Wakefield Asy- lum Report, 1877. West Riding Asylum Reports, 1874. Histology of the Morbid Brain; On Hypertrophy of Cells. West Riding Asylum Report, vol. iii., p. 109. Marc — On Homicidal Insanity (vol. i., p. 56); On Monomania (vol. i., p. 244); On Uterine Insanity (vol. i., p. 317) ; On Insanity, op. cit. Marce — Des Maladies Mentales, 1862. Marcet — On Chronic Alcoholic Intoxication. Marshall— On the Brains of two Idiots. Phil. Trans., 1864, p 526. Dr. Macintosh — On Hypodermic Injection of Morphia, paper in Journal of Mental Science for October, 1861. Mead — De imperio solio et lunae in corpore Humana et Morbis. Dr. Mason — On Dipsomania. Mendel — On Syphilitic Insanity, 1868; On General Paralysis of the Insane. Meeson — On Climacteric Insanity. (West Riding Medical Reports, vol. vi., 1876). 688 APPENDIX E. Meschede — Articles on General Paralysis in Journal of ^Mental Science ; Pigmentary- Degeneration of Cells, Virchow's Archiv, 1865. Meyer — Syphilitic Insanity, 1861. Miche — Treatise on Hypochondriasis ; also on the Blood in General Paralysis. Dr. Julius Mickle — On General Paralysis, Journal of Mental Science, April, 1878; on Syphilitic Insanity, Brit, and For. Med.-Chir. Review, July and October, 1876, and April, 1877. Mierzejewski — On Lesions in General Paralysis, Archiv de Physiologie, 1875. Mr. Millard — A Manual for the classification, etc., of the Feeble-minded'; Imbecile and Idiotic (Duncan and Mjllard, 1S66); the Idiot and his helper, Mr Millard, 1864. Dr. Hugh Miller — On Temporary Kleptomania, in the Lancet, June 15, 1878. Dr. W. Julius Mickle — General Paralysis of the Insane, 1880. Dr. Minchin — On Scalp and Cranium, in Dublin Medical Journal. Dr. A. Mitchell — On Consanguineous Marriages, paper in Statistical Society's Jour- nal, June, 1875. ^''^ Relapses, contributions to the Statistics of Insanity, Journal of Mental Science for 1877. On Idiots, Journal of Mental Science, July, 1876. Dipso- mania, same Journal, October, 1872. Monti, Dr. — De TOphthalmoscopie dans les Maladies Mentales, ]Memoir a Pellagrous Insanity. Moreau — On Hereditaiy Transmission (L'Union Medicale, No. 48). Mr. Morell — Speculative Philosophy of Europe (Powers of the Human Mind), Morgagni — On iklelancholia (De Sedibus et Causis Morborum, epist. viii.). Nasse — On Bodily Causes of Insanity. 1836-39. Moral and Physical Causes, Zeit- schrift fiir Psychiatric, 1S70; on Post-febrile Insanity. Dr. Needham — Statistics (see Tables in Report of York Asylum for 1873) ! ^^ Homi- cidal Impulse, Journal of Mental Science, July, 1872. Dr. Noble — On Opium, 23d No. of Journal of >Iental vScience. S. W. North — The Legal Doctrine of Responsibility in Relation to Insanity (Trans- actions of the Social Science Association, 1864). Obeisteiner — On Morbid Histology. Wien Stzb. d. k. Akad. Wissener, Bd. Ixi., I Abth., January, 1S71. Dr. Orange — On Epilepsy. Report of Broadmoor, 1877. Dr. Ordroneaux — Moral Insanity. Am. Journal of Insanity, January, 1873. Sir James Paget — Cerebral Atrophy. Lectures on Pathology. Senile Gangrene, see same work, p. 463. Parcheppe — On Insanity. Paulus ^Egineta — On Lycanthropia. Dr. Peacock — On Idiocy, Pathological Society's Reports, 1858-59. Notes on Pellagra, Brit, and For. Medico-Chir. Review, January, 1863, Peddie, Dr.— On Dipsomania. Parrish, Dr. — On Dipsomania. Treatise. Dr. Pedler — On Puerperal Mania, Medical Reports, 1872, vol. ii. Dr. Perfect — Annals of Insanity. Poincare — Pigmentary Changes in Ganglia of Sympathetic. Pommerol's Recherches sur la Synostose des Os du Crane, Paris, 1869. Portal — On Mental Diseases. Dr. Prichard — Treatise on Insanity; also on the different forms of Insanity, Ramaer — On the Bloodvessels in Insanity. Rav, Dr. — On the Prognosis of Insanity (Am. Journal of the Med. Sciences, October, 1870)', Ripping — Die Geistesstorungen der Schwangeren, Wochnerinnen n. Saugenden, 1877. Dr. Lockhart Robinson — Essay on the Moral Management of the Insane, etc. On Suicide, Report for 1862. On Treatment, paper in Brit. Med. Journal, October 3d, 1863, and in Journal of Mental Science, No. 48, p. 547. Rokitansky — Pathology of Insanity. Romberg — Nervous Diseases. Article on Mania and Melancholia. Roussel— De la Pellagra, Paris, 1862. Rutherford — Pathology of Insanity. Rush— Medical Inquiries, etc. Saleno — Report of Asylum of San Serrola, Venice. Salvatori of Moscow — On Dipsomania, in Coinment. Soc. Phys. Med. apud Univ. Mosquens Instit., 1807, vol. ii.,part i., pp. 260-290. Sauder — On Idiocy. Archiv fiir P.sychiatrie, 1868, LITERATURE OF DISEASES OF THE MIND. 689 Dr. Sankey — On General Paralysis, and Lectures, 1866. Dr. Saunders — On Chloral. Report. Dr. Savage— Hereditary Predisposition, Guy's Hospital Reports, 1877; on Klepto- mania,- Consideration on the Cures of Insanity, pp. 29, 30; on Insanity with Paralysis, Journal of Mental Science, January, 1878; Chloral, Journal of Mental Science. Dr. Schule — Hirn-Syphilis und Dementia Paralytica. Seguin — The Moral Treatment, Hygiene and Education of Idiots, 1846; New Facts and Remarks concerning Idiocy, 1870. Seymour, Dr. — Opiate Treatment. Medical Gazette. Lord Shaftesbury — On Intemperance and Lunacy. Dr. T. Claye Shaw — Journal of Mental Science, July, 1876. On Idiocy. Dr. Sibson — Temporary Insanity, with Taciturn Melancholy and Hallucinations. Reynolds's System of Medicine, p. 286. Sir J. Simpson — On Puerperal Insanity. Dr. Skae — On the Classification of the Various Forms of Insanity, 1863. Solly — On the Brain. Dr. Julius Steinan — On Hereditary Diseases. Dr. Edward C. Spitzka — A Contribution to the Question of the Mental Status of Gui- teau, and the History of his Trial. Alienist and Neurologist, vol. iv., No. 2, and other monographs. Sepelli and Marogliam — Studies on Cerebral Thermometry in the Insane (in this re- lation see work of Albes of Bonn, 1861). Dr. H. Sutherland— Menstrual Irregularities, in West Riding Asylum Medical Reports, vol. ii., 1872. Sydenham — Articles on Hypochondriasis, Suicides, Febrile Insanity, Gouty Insanity. Thierri — On Pellagrous Insanity. Paris, 1775. Dr. G. Thompson — On Pulse Tracings in Gesieral Paralysis, vol. i. of Reports of the Wakefield Asylum; in Epileptic Insanity, West Riding Reports, vol. ii. Mr. J. B. Thompson^ — Crime and Insanity. The Hereditary Nature of Crime, in Journal of Mental Science, January, 1870, and a succeeding paper in October number on same subject. MM. Thore and Aubanel — Statistics of the Bicetre. Dr. Thorne — On Mental Automatism. St. Bartholomew's Hospital, 1870. Dr. Thurnam — Statistics of Insanity. Dr. Tilt — Diseases of Women. Article on Climacteric Insanity, and Remarks on Kleptomania. Dr. D. Hack Tuke — Manual of Psychological Medicine. Bucknill and Tuke.. Dr. Batty Tuke-— Histology of Insanity. Manual of Psychological Medicine. Dr. T. Harrington Tuke — Oq General Paralysis, 466, 467, 468. Bucknill and Tuke on Forced Alimentation, 745, same edition. Virchow — Cellular Pathology. Vogel (1764) — On Mania, Melancholia, and Amentia. Westphal — Articles on General Paralysis, in Journal of Mental Science, Nos. 66 and 68; on Syphilitic Insanity. 1864. Dr. Wigan— On the Duality of Mind. Dr. Wille — On Syphilitic Insanity. Report of Rheinan Asylum, near Zurich. Die Syphilitschen Psychosen. Allgemeine Zeitschrift fiir Psychiatric, 1872, p. 503. Dr. Duckworth Williams — On Treatment, No. 56 Journal of Mental Science; Journal of Mental Science, April, 1873. Also No. 51 of savne journal. Dr. L. S. Forbes Winslow — Journal of Psychological Medicine. Articles. Dr. Wolff — On the Pulse in the Insane. Allgemeine Zeitschrift fiir Psyc-hiatrie, 1867-9. Dr. Wright — Report of Royal Edinburgh Asylum for 187 1. Insanity from Abdominal Disorders. . Dr. Yellowlees — Homicidal Insanity. Edinburgh Medical Journal, 1862. Bechterew and Heboid — Temperature in Insanity. Archiv iiir Psychiatric, Band xiii. Dr. R. W. D. Cameron — On Restraint. Journal of Mental Science, January, 1883. Dr. Savage — Moral Insanity. Journal of Mental Science, 1881-2. The following, which does not claim to be complete, comprises some of the more im- portant pamphlet literature which has appeared during the past few years in this country. 44 690 APPENDIX E. For the remainder, the reader is referred to the American Journal of Insanity, the Alienist and Neurologist, and the Journal of Mental and Nervous Diseases. Dr. E. H. Van Deusen — Paper in the American Journal of Insanity for April, 1869, on Nervous Prostration, Neurasthenia. Importance of a Knowledge of Insanity by the General Practitioner of Medicine, and General Paresis. Papers by Ira Russell, M.D., before Worcester North District Medical Society. Emotional Insanity. Paper by J. K. Bauduy. The Structure of the Vessels of the Nerve-centres in Health, and their Changes in Disease. American Journal of Insanity for July, 1877, and January, 1S79. The Problems in Insanity. Paper by the late Dr. George M. Beard, read before the Medico-Legal Society, j\Iarch 3d. The Simulation of Insanity by the Insane, Dr. C. H. Hughes. The Rights of the Insane, Dr. C. H. Hughes. The Special Therapeutic Value of Hyoscyamine in Psychiatry, Dr. C. H. Hughes. Acute Dementia occurring in an Old ^lan, etc., Dr. C. H. Hughes. On the Essential Psychic Signs of Neurasthenia, Dr. C. H. Hughes. The Therapeutic Value of Cephalic and Spinal Electrization, Dr. Charles H. Hughes, and other various valuable articles on psychiatric subjects. The American Journal of Neurology and Psychiatry. McBride, Gray, and Spitzka. Dr. Edward C. Spitzka — The Somatic Etiology of Insanity, Evidences of Insanity discoverable in the Brains of Criminals, etc.. Insane Delusions, and other papers. Prof. C. K. Mills — Cerebral Localization, chiefly with Reference to Idiocy. Paper before the Association of Medical Ofificers of American Institutions for Idiotic and Feeble- minded Persons, October, 1882. Dr. Workman — -Moral Insanity, what is it ? Canadian Practitioner, January and Feb- ruary, 1883. Dr. W. A. Hammond — The Influence of Age upon the Mind and Body in relation to Mental Derangement. Alienist and Neurologist, April, 1883. Dr. J. G. Kiernan — Folic a Deux, its Forensic Aspects. Alienist and Neurologist, Katatonia, etc., etc. Dr. Godding — Two Hard Cases. Dr. Turnbull— ^On Sphygmograms in Progressive Paresis. Boston Medical and Sur- gical Journal, ^lay 20, 1882. Allan McLane Hamilton — On the Case of Guiteau, Boston Medical and Surgical Journal, March 9th, 1882; Syphilitic Hypochondriasis, vol. i., No. i, Alienist and Neur- ologist. Dr. Folsom — Article on Guiteau. Boston Medical and Surgical Journal, February 9th, 1882. Dr. George M. Beard — The Guiteau Case. 1882. Dr. Nathan Allen — Insanity in Relation to the Medical Profession and Lunatic Asy- lums. Paper before American Association for the Protection of the Insane, etc., 1882, and numerous other papers on kindred subjects. Dr. E. C. Seguin — Insane Asylums of Spain, Journal of Nervous and Mental Dis- eases, July, 1883; The Function of a Consulting Staff" to Lunatic Asylums, paper be- fore National Association for the Protection of the Insane and the Prevention of Insanity, and other papers of interest, 1882. Dr. J. C. Shaw — On Restraint, etc., paper before National Association for the Protec- tion of the Insane, etc. 1882. On Hyoscyamine, paper. Dr. C. L. Dana — The Asylum Superintendents on the Needs of the Insane ; Statistics of Insanity in the United States, etc. Paper before National Association for the Pro- tection of the Insane, etc., 1882 ; and other papers. The American Psychological Journal, Dr. Parrish. The Medico-Legal Journal of New York. Isaac N. Kerlin — The Epileptic Change and its Appearance among Feeble-Minded Children. Paper in No. 3, v(}l. iii.. Alienist and Neurologist, p. 329. Also Illustrations of Juvenile Insanity, p. 348, Alienist and Neurologist, vol. i., No. 3. Dr. J. Draper — Insanity in Great Britain and upon the Continent of Europe. Paper in No. 3, vol. iii.. Alienist and Neurologist, p. 375. Autopsy of Guiteau. Official report of Dr. D. S. Lamb, p. 468, Alienist and Neurol- ogist, July, 1882. LITERATURE OF DISEASES OF THE MIND. 69 1 Illustrations of Juvenile Insanity ; Morbid Juvenile Pyrophobia caused by Malarial Toxaemia. Willis P. King, M.D., Alienist and Neurologist, vol. i.. No. iii., p. 345. On the Propositions of the Association of Medical Superintendents of American Hospi- tals for the Insane. John Curren, M.D., Alienist and Neurologist, vol. i., Nos. i, 2 and 3. Dr. H. P. Stearns — Monograph on Insanity. Pliny Earle, M.D. — Subsequent History of twenty-five persons reported recovered from insanity in 1843, vol. i., No. i, Alienist and Neurologist. Also The Curability of Insanity vs. Recoveries from Mental Diseases. Dr. E. M. Nelson — Translation in vol. i.. No. I, Alienist and Neurologist, of psychia- tric proceedings of the Ii^ternational Medical Congress at Amsterdam. Dr. J. S. Jewell — The Influence of our Present Civilization in the Production of Ner- vous and Mental Diseases. Paper in vol. vi., No. i. Journal of Nervous and Mental Dis- eases, and numerous other valuable pajjers. Dr. W. J. Morton — The town of Gheel, in Belgium, and its Insane, etc. Paper in vol vi.. No I, same joarnal. Dr. Dewey — Management of the Insane. Vol. iii^ No. i, Journal of Nervous and Mental Diseases. Dr. Clark Gapen — Some Exceptions to the Present Management of Plospitals for the Insane. Vol. iv., No. 3, Journal of Nervous and Mental Diseases. Dr. J. L. Teed — Mind, Insanity, and Criminality. Vol. v.. No. I, Journal of Nervous and Mental Diseases. Dr. II. M. Bannister — Emotional Insanity in its Medico-Legal Relation. Vol. v., No. I, same journal. Dr. Landon Carter Gray — Cerebral Thermometry. Vol. iv., No. I, same journaL Reference to the American Journal of Insanity, since its establishment, will reveal to the student of psychiatry much of great value in the way of original articles, that we have not time to tabulate, but -which compare favorably with transatlantic work in the same field. With respect to the anatomy and physiology of the nervous system — the pathology of the nervous system and mind and pathological anatomy — and the therapeutics of the ner- vous system and mind, the student will be amply repaid by the careful perusal of the many articles contributed to these departments by Drs. Ray, Kirkbride, Earle, Dr. J. S. Jewell, Dr. H. M. Bannister, Dr. Wm. A. Hammond, Dr. Meredith Clymer, Dr. S. Weir Mitchell, Dr. E. vSeguin, Dr. Charles H. Hughes, Dr. Edward C. Spitzka, Dr. James J. Putnam, Dr. Samuel R. Webber, Professor E. T. Mills, Dr. Amidon, Dr. A.J. C. Skene, Dr. Landon Carter Gray, Dr. J. C. Shaw, Dr. J. M. Da Costa, Dr. R. Bartholow, Dr. J. Marion Sims and others, whose indefatigable labors in this field command an equal re- spect with those of Westphal, Prof. Erb, Charcot, Kifafft-Ebiag, Hughliags Jackson, Wins- low, and Bucknill and Tuke abroad. , ■ PLATE in. /^' '-Uit- .ym/^^^^^a^ (j/r^ Letter written by a pirson SUFFERING FROM AcUTE MaNIA PLATE IV. 'Jjo J- nnjxjuqxij Letier written by an Epileptic with Congicnitai. Feeble Intellect. INDEX. Abdominal disorders, insanity from, 259 Abstract of Lunacy Laws in every State of the Union, see Appendix, 631 Active hereditary neurosis, 49, 54 Acquittal on the ground of insanity, cases of, 90 Acute insanity, pathology of, 139 Etiological classilication, 47 Etiology of insanity, 52, 53, 54, 55, 58 Affective insanity, 107 Age, influence of, 55 Ajax, his insanity, 37 Alalia, 329 Alcohol as a cause of insanity, 56 Alcoholic insanity, 264 Allbutt, Dr. Cliftbrd, on visceral neuralgia, SH Alleged increase of lunacy, 52 Althaus, Dr., on electricity, 603 American asylums, statistics of, 163, 169, 188, 193, 206 Amidon, 335 Amusements for the insane, 187, 202, 218 Ancient classifications, 44 Anaemia, cerebral and spinafl, 490 Anaesthesia, 331 Anstie on insane diathesis, 49; on neural- gia, 516; on electricity, 590 Appendix, 631 Arachnoid, appearance of, in insanity, 140, 146 Arnold, trial of, 121 Arsenic, chloro-phosphide, 251 Arthritic insanity (see Insanity from rheu- matism and gout), 261 Asylums, care and treatment in, 209, 216, 217, 218 Asymmetry of skull, 619 Attendants, 209 Austria, laws as to mental responsibility in, 298 Autopsies, examination, what to observe, 43 B. Baillarger on paralytic dementia, 103 Bartholow, Dr. Roberts, 335 ; on electricity, 548 Bastian, Dr., on bloodvessels in insanity, 141 Baths, 245 Bannister, 335 Bayle on pathology of paralytic dementia, 98 Benedikt, Dr., on criminal psychology, 120 Blandlord, Dr., on diagnosis of moral and emotional insanity, no; on bloodvessels, 141 ; on treatment, 157, 282 Blood, examination of, 144 Bloodvessels (cerebral) in insanity, 141, 151 Brain fatigue, 63 Brain, criminal, formation, 626 Brain, normal structure of, 133; changes in insanity, 139 Broadbent on cerebral syphilis, 160, 315 Bromide of sodium, 233, 238 British asylums, statistics of, 164 Browne, Dr. Crichton, treatment, 242 ; on size of fcetal head, 57 ; on optic thalami, 136; on admission to and detention in asylums, 177 Bucknill and Tuke, legal tests of responsi- bility, 90; hints in giving evidence, 91 ; classifications, 38; Bucknill's definition, 44; Tuke's classification, 49 ; Bucknill's classification, 52 ; on diagnosis, 77 ; on moral or emotional insanity proper, 107 ; Dr. Bucknill on commitment, detention and discharge of patients, 178; on syphi- litic insanity, 263 ; on kleptomania and pyromania, 265 Buzzard, Dr. Thomas, on centric galvaniza- tion, 587 ; on electrical examination and treatment in peripheral paralysis of the facial and oculo-motor nerves, 596 Causes of cerebral haemorrhage, 340 Causes of insanity (see /Etiology), 52-58 Calmeil on general paralysis, 98 ; on epi- leptic insanity, 130 Cambyses, his insanity, 37 Camphor, mono-bromide, 239 Cannabis indica, 233, 238 Capacity, testamentary, 70, 87 Carpenter, Dr., on hereditary transmission of acquired psychical habits, 138 Case Book, form of (see Appendix B). Cases illustrating treatment of insanity, 243, 245. Cases illustrating pathology and morbid his- tology of insanity, 153 694 INDEX. Catamenia in prognosis in insanity, 75 Catalepsy, 469 Cells, degeneration of cerebral, 147 Cellular pathology. 147 Celsus, his classification, 38 Cerebellum, functions of, 132; lesions of, jo7. Cerebral and spinal anaemia, 490 Cerebral electrization, 61 Cerebral embolism, 339; softening, 340,540 Cerebral haemorrhage, localization of lesion, 341 Cerebral hyperaemia, 537 Cerebral localization, 325 Cerebral syphilis, 63,317; diagnosis and prognosis of, 317 Cerebritis or encephalitis, 496 Certificates of lunacy (see Appendix, Ab- stract of Laws), 176, 177, 178, 180, 181 Change of character in insanity, 70, 78 Charcot, Dr., on localization of brain func- tion, 131 ; on locomotor ataxia, 519; on static electricity, 554 Charenton, asylum at, 281 Chloral, 235 Chemical causes of ner\'ous diseases, 34 Chorea, 449 Chronic mania, 81 Civil incapacity, 86 Civil contracts, 87 Civilization, influence of, 59 ; foot-note, 55 Clarke, Dr. Lockhart, on general paralysis, 100 Classification of mental diseases, 40; Forbes Winslow on, 285 Climacteric insanity, 258 Clinical instruction in hospitals, 218 Clouston, Dr., on tubercular insanity, 142 ;. on epilepsy, 425 Coke, his definition of idiocy, 105 Colloid degeneration in insanity, 150 Colon, insanity proceeding from, 259 Codification of the common law as to in- sanity, 303 Commissioners in lunacy, necessity for State boards, 296 Combe's definition of insanity, 44 Concealed insanity, 86 Congenital idiocy, 106 Congenital moral defect, 85 Congestion, cerebral, 537 Contractions, 330 Conium, 240 Commitment, discharge and detention of the insane, 175 Conolly, Dr., his definition of insanity, 44; his abolishment of restraint, 277 Corpora quadrigemina, functions of, 135 Consanguineous marriages, 56 Cortex of the brain, lesions of, 132, 133 Corpus striatum, lesions of, 132; functions of, 137 Cottage treatment of the chronic insane, 271 Cowles, Dr. Edw^ard, on management of hospitals, 208 Cranial nerves, exit of, 502 Cranium, 43 Cretinism, 38, 42 Crichton royal institution, 54 Criminal lunatics, 189; their characteristic mental peculiarities, 190, 625 Criminal skull formation (criminal psy- chology), 618 Crime and insanity, 618 Crura cerebri, lesions of, 132 Curability of insanity, 162, 207, 208 Curable forms of insanity, 39, 75 Da Costa on vertigo, 465 David, 37 Definitions of insanity, 43, 44 Delinquency often the result of cerebral im- perfection, 109, 618 Delusions of the insane, 69, 96, 243, 245 Demeanor towards a patient, 158 Dementia: primary, 106; secondary, 106; diagnosis, 71, 80 Dementia paralytica (see General paralysis), 95 ... Deuteropathic insanity, 50 Development of the nervous system by evo- lution, 319 Diagnosis, pathology, and treatment of nerv- ous diseases, 322 Diagnosis of insanity, 67 ; in criminal cases, 123 mania, 70, 79 melancholia, 71, 79 dementia, 71, 80 monomania, 83 eccentricity, 82 general paralysis, 72, 79, 80, 85 feigned insanity, 85 concealed insanity, 86 recovery, 72, 74 incomplete mania, 81 chronic mania, 81 incomplete primary mania, 81 moral or emotional insanity proper, 72, 84 congenital moral defect, 85 moral imbecility, 85 Diagnostic value of hereditary tendency, 78 previous attacks, 78 change of habit and dis- position, 78 peculiarities of residence and dress, 79 Diathesis, insane, 49 Differential diagnosis betvv'een syphilitic in- sanity and paralytic dementia, 263 Digitalis, 240 INDEX. 69s Dipsomania, relations to insanity, nature, pathology, treatment, 354; premature mental decay in, 363 ; diagnosis of, 354 ; psychic symptoms of, 364 ; responsibility, 368 Dissection of bodies of the insane, 43 Disseminated or partial sclerosis in insanity, I49> 542 Domestic treatment of the insane, 224 Donn, Dr., on idiocy, 106 Dress, peculiarities of, 79 Dura mater, appearance of, in insanity, 140, 146 Eads, Dr., 335 Earle, Dr. Pliny, on curability of insanity, 162; opium, 163 Earl of Shaftesbury on the admission, de- tention, and discharge of insane, 182 Early treatment, importance of, 157, 160, 203 Eccentricity, diagnosis of, 82 Education in its relations to insanity, 66 Edinburgh asylum (Morningside), 279 Electricity in neuralgia, 509 Electricity in the diseases of the nervous system, 546 Ekker on vessels of brain in insanity, 141 Emotional insanity, 47 England, insanity in, 275 Epilepsy : cause, pathology, treatment, 417, 562 ; cases, 422 ; effect on mind, 256, 305 Epileptic insanity, 129, 256; case of homi- cide, with epileptiform attack, 128; un- conscious states in, 256, 305 Epithelium in insanity, 147 Ergot (fl. ext.) in insanity, 241 Erlenmeyer, 145 ; on paralytic dementia, 99 Ertzbischoff, Dr., on pathology of paralytic dementia, 99 Erotomania (nymphomania), 257 Esquirol, his classification, 45 ; his improve- ments, 215 ; on epileptics, 306 Etiology (see ^Etiology), 52-58 Evidence, hints in giving, 91 Evidence of those mentally diseased, 88 Examination of cases, study, 43 Examination of the insane, 68, 81, 2S6 Exciting causes of insanity, 55 Excitement in relation to recovery, 74 Expert testimony, necessity for a new method of introduction of, 296 Expert testimony and the functions of ex- perts, 92, 304 P. Falret on epileptic vertigo, 129; on para- lytic dementia, 103 Fear and fright as causes of insanity, 49 Feigned insanity, diagnosis of, 85 Ferrier, Dr. David, on lesions of the Con- volutions of the brain and cortex cerebri, 349; on localization, 131 ; on optic thala- mi, 136 Fever as a cause of insanity (see Post-feb- rile insanity), 260 Flint, Dr. Austin, on neuralgia, 505 Folic raisonnante, 107 Fournier on cerebral syphilis, 319 Food and work and amusement for the in- sane, 218 Frerichs on pathology of paralytic demen- tia, 99 France, insanity in, 281 ; law as to mental responsibility in, 298 Full feeding for the insane, 234 G. Galvanization of sympathetic, 554 Galen, 45 General practitioner's duty in checking in- sanity, 65, foot note General paralysis of the insane, 95, 255 ; cause, 95 ; psychology of, 95 ; mental processes in, 95 ; prognosis, 95 ; tempera- ture, pathology, 97 General sclerosis, 149 Gestation, insanity of, 50, 257 Gesture, peculiarities of, 70 Gheel, lunatic's colony at, 221 Gouty insanity, 261 Gray matter of brain, morbid histology of, in insanity, 149 Gray, Dr. John P., on curability and treat- ment, 169; on commitment, detention, and discharge, 175 ; on restraint and se- clusion, 172 Grief as a cause of insanity, 57 Griesinger on classification, 47 Guislain, his definition, 44 H. Hamilton, 335 Hsemorrhage, cerebral, 340 Hallucinations of the senses, 68 Hammond, 335 Handwriting and composition of the in- sane (see Appendix) Hartford retreat for insane, 206 Hardness of feeling exhibited by the insane towards friends, 69, foot note Head and spine, affections of, as causes of mental disease, 56 Hebephremia, or pubescent insanity, 50, 257 Headache (see Neuralgia) Hemiplegia, 329 Hereditary insanity, 54 ; predisposition as a cause, 54; affecting diagnosis, progno- sis, treatment, 54 696 INDEX. Hereditary transmission, 56; of allied but different neuroses, 56 Hints in giving evidence, 91 Histology and functions of cerebrum, 131 Histology (morbid) of mental diseases, 139 Hippocrates, writings, 38 Homicidal insanity, 130, 183, 301 Hospital wards, necessity for, in asylums for the insane, 187 Hospitals for the insane, 69, foot-note ; 208, 216, 226, 272 Hughes, Dr. Chas. H., on moral or emo- tional insanity proper, III Hyoscyamus, 237 Hyperaemia (cerebral), 537 Hypochondriacal melancholia, 260 Hystero-epilepsy, 442 Hysteria, history, pathology, and treatment, 376 Hypersesthesia, 331; of testes, 552; of uterus, 552 Hysterical insanity, 257 Hypothetical cases, 93 I. Ideational or intellectual states, 49 Idiocy, 105; classification of, 106; prog- nosis, 105 ; definition, 105 ; treatment, 105 Idiopathic or primary insanity, 42, 48 111 health as a cause of insanity, 60 Impulsive insanity, 127 Importance of early recognition of mental disease, 59 Impatience in relation to recovery, 72, 74 Imbecility, 42 Increase of insanity, 266 Inebriety, its cause, pathology and treat- ment, 354; its seat, 359 Indian hemp (see Cannabis indica), 233—238 Inflammatory disease of the brain and its membranes, 496 Inflammation and congestion of the brain tissue in mental disease, 1 00 Incurable forms of insanity, 40 Insanity in general, 37; clinical view of, 354 Insanity in the Middle States, 266 Insane, their condition before the era of hospitals, 161, 216; abstract of the com- mon law on their confinement in different States of the Union (see Abstract in Ap- pendix) ; can distinguish between right and wrong, 300 ; some apparently recover and deny they have ever been insane, and are bitter towards all who treated them as insane, 255 Insanity of pubescence, 257 ; from mastur- bation, 257; of gestation and pregnancy, 257; of lactation, 258; from abdominal disorder, 259 Insanity, its connection with organic qual- ities of the brain overlooked, 252; dis- tinguished from depravity, 255 ; remis- sion in the early stage, 73, 74 Influence of the seasons on insanity, 59 Intemperance as a cause of insanity, 56 International congress of alienists, their classification, 38 Injuries to the back without apparent me- chanical lesion, 614 Irresistible impulse, 122, 303 Irritative lesion of the brain, 353 Jackson, Dr. Hughlings, chorea, 451; ex- perimental researches, 354 ; on epilepsy, 129, 420 Jewell, 335 Judges should not assume the functions of experts, 93 Juvenal, his mention of hellebore, 37 Kirkbride, Dr. Thomas, statistics, etc., asy- lum, 193 ; on prompt treatment, 203 ; management and curability of mental dis- eases, 203 Klein, Dr., on ophthalmoscopic appearance, 144 Kleptomania, 118, 265, 306, 474; Mare, Browne, Savage, Ray, Tilt, etc., on, as a state of undoubted insanity, 265 Kolk, Van der, 427 Krafft-Ebing, Dr., his classification, 40, 42 Kussmaul and Tenner, experiments on ep- ilepsy, 432 L. Lactation, insanity of, 48, 258 Lancereaux on pathology of paralytic de- mentia, 98 Larceny in general paralysis, 306 Laycock's physiological classification, 46 Laros case, 478 Legal enactments in reference to insanity (see Appendix) Legal tests of responsibility, 90 Lesions of the brain, 337, 349 ; pons, 332; crus cerebri, 3^3 '■■ optic thalamus, 334; of hemispheres, 335 ; of cerebellum, 337 ; of motor zone, 350 ; of sensory zone, 352 Lightning, case of stroke, and markings by, 607 Localization of chronic lesions of nerve- centres, 329, 331 Localization of brain functions, 131 Locomotor ataxia, nature and pathology, 518; Radcliff on, 525 INDEX. 697 Longevity of the insane, 161 Lord Moncrief of Scotland, on lunatics, 303 Lord Justice Blacl<;burn on homicide, 303 Lord Chief Justice of England on responsi- bility ,_ 303 Lunacy in England, 275 Lunacy laws, see Abstract of, in Appendix, 631 Lunatics, laws relating to (Appendix), 631 Lunacy, English commissioners of, 232 Luys, on pathology of paralytic dementia, 99 . Lungs, disease of, in insanity, 261 Lunier, on intemperance as a cause of in- sanity, 56; paralytic dementia, 103 Lypemania, 45 M. Magnan on general paralysis, 98 Major, Dr., on brain wasting, 141 ; on de- generation of brain cells, 148 Management of property of the insane, 89 Management of hospitals for the insane, 209, 216, 218, 224, 226 Mania, diagnosis of, 71, 81 ; treatment of, 254; acute, 254; chronic, 81 ; transitory, 130 Mare on pyromania, 265 Marce on epilepsy with transitory mania, 130 Marriage, iniluence of, 56, foot-note ; mar- riage contracts, 87 ; its impropriety when insanity is in the family, 56 Marriages of consanguinity, 56, foot-note Masked epilepsy, 129, 130 Masturbatic insanity, 257 Mauriac, Dr. Charles, on syphilis of nervous centres, 317 Maudsley, Dr. Henry, on treatment, 224 ; classification, 47 ; on commitment, de- tention and discharge, 181 McLean Asylum, Somerville, Mass., 207 Medico-legal importance of epileptic at- tacks, 477 Mendacity of the insane, 49 Menstrual periods accompanied by increase of excitement, 61 Mechanical restraint and seclusion, 223 Medulla oblongata, lesions of, 132 Medical certificates of lunacy (see Abstract of laws in Appendix), 631 Medicinal treatment of mental disease, 233 Mental responsibility in criminal cases, 119, 129, 297, 307 Melancholia, diagnosis of, 71, 79; treat- ment of, 254; suicidal melancholia, 235, 250 Membranes, morbid histology of, 146 Mechanical cause of nervous diseases, 34 Menstruation (see Catamenia), 75 Menstrual psychoses, 61 Meynert on optic thalami, 136 Metaphysical theory of insanity, 39 Methomania (see Dipsomania and In- ebriety), 353 Miche on the blood in general paralysis, 145 Mickle on syphilitic insanity, 262 Miliary sclerosis, 150 Mills, 335 Modern classifications of insanity, 44 Modern nervousness of men, 66 Monomania, diagnosis of, 83 Modern nervous disease, 31 1 Moral causes of insanity, 105 Monoplepia, 351 Moral imbecility, 108, 251;, 624 Moral insanity, 107; synonyms, 107; seti- ology, diagnosis, 72 ; nature, 107 ; ad- mitted by the best observers. Dr. Hiighes on, III, 624 Moral treatment of the insane, 209, 216, 217 Morbid histology, 145 ; of acute and chronic insanity, 139 Morel, his classification, 38; definition, 44 Motor zone of brain, 349 Motor irritation, 330 Music, color, beauty, etc., as curative agents in insanity, 15S N. Nature of brain lesions, 338 Nature, her efforts to restore mental equi- librium, 158 Nebuchadnezzar, insanity of, 37 Nerve fibres in insanity, 148; nerve-stretch- ing, 509 . . Nerve-cells in insanity, 147 Nervous diseases (modern), disorders of, in general, 312 Neurasthenia, signs of, 60 ; motor symp- toms of, 506 ; physical signs, 506 Neuralgia, 501 Neuralgia of brain in insanity, 149 Nichols, Dr. Chas., opinions on treatment of insanity, and statistics of insanity, 188 Non compos mentis, 105 Northamptom Lunatic Hospital (Mass.), Nosology of insanity (see Classification), 40, 44 Nothnagel, on optic thalami, 136 Non-restraint, 172, 188, 224, 227 Nymphomania, 257 Occupation, influence of, 202, 219, 220 Occupations, particular, 219 698 INDEX. Occipital flatness, 621 Ophthalmoscope in mania, melancholia, etc., 143 Ophthalmoscope in diagnosis, 323 Opinions, medical, given in writing, 93, 94 Opium in the treatment of insanity, 234 Optic thalami, functions of, 135 Oxaluria, mania of, 145, foot-note Parish will case, 94 Paralysis from brain disease, 331 Parchappe, pathology, 139; classification, 46 Partial insanity, 81, 301, 303, 305, 308 Parturition, insanity of, 258 Paraplegia, 329 Pathological classification, 46 Pathology of insanity, 139, 153 Pathological diagnosis in brain diseases, 339 Peculiarities (see Diagnosis), 79 Pennsylvania Lunatic Hospital at Philadel- phia, statistics of, 193 Periodical insanity, 243 Persecution, delusions of, 258 Phthisical insanity, 142, 261 Phthisis in insanity, 142 (also see chapter of cas.es), 261 Phy.4ognomy in insanity, 70, 71, 80 Physiological classification, 46 Pia mater, changes in insanity, 140, 146 Pinel's and Esquirol's improvements, 215 Pinel on classification, 38 Pons varolii, hsemorrhage into, 132 Population, proportion of insane to the, 162 Poore, Dr., on electricity, 584 Post-febrile insanity, 260 Provision fv-r the chronic insane, 271 Pregnancy, insanity of, 257 Previous attacks, 78 Prevention of insanity, 64 Progressive muscular atrophy, 329 Prodromic stage of insanity, 302 Proportion of sane to insane at home and abroad, 162 266 Premature mental decay in inebriety, 363 ; bram changes, 366 Prichard, Dr., on classification, 47 Private patients, treatment of, 224, 231 Prognosis of insanity, 74-77, 287. (Prob- ability of recovery in any given case is in proportion to the early age, physical con- dition and dui'ation of the attack.) Progressive general paresis (syn. paralytic dementia), 95 Protopathic insanity, 50 Prognosis in cerebral hgemorrhage, 341 Psychical school of alienists, 47 Psychological classification, 47 Psychology of crime, 617 Pubescent insanity (hebephremia), 50, 257 Puerperal insanity, 258 Pulse in insanity, 243 Pupils in insanity, 243 Purgatives in insanity, 233 Pyromania, 118, 265 Ramskill, Dr. J. S., on epilepsy, 439 Ray, Dr., on insanity, 93, no; in memo- riam of, 271 ; on epilepsy, 305 ; on restraint and seclusion, 226 ; on pyro- mania, 265 Reasoning mania or monomania, 107 Recovery often confounded with improve- ment, 73 Restraint, true doctrine of, Ray on, Nichols on, 226 Rest in insanity, 158 Recovery, diagnosis of, 72, 74 Recurrent mania, 243 Regional diagnosis of spinal cord and brain lesions, 319 Reform in the method of introducing expert evidence, 232, 296 Religious excitement as a cause of insanity, 260 Removal from an asylum, 72, 74 Remission, its occurrence in the early stages of insanity, 309 Reproductive organs, diseases of, in insan- ity, 257 Reynolds, Dr. J. Russell, on electricity, 556; on epileptic vertigo, 256; on chorea, 460 Responsibility of inebriates, 363 ; of the insane, 302-309 Rheumatic insanity, 261 Rindfleisch on disseminated sclerosis, 150 Ro'vitansky on pathology of paralytic de- mentia, 99 Rush, 270 Sanity, diagnosis of mania from, 70 Scalp and cranium, 43 Sciatica, 503, 550 Science, changes in laws should keep pro- gress with the advancement of cerebral pathology, 304 Sclerosis, 421 Sedatives in insanity, 2QI Secretions (see Examination of blood and urine), 144 Seguin, 335 Self-control, absence of, in insanity, 300, 303 Sensory zone of brain, 352; sensorial irri- tation, 330 Sex, influence of, in insanity, 55 Sibbald, civil incapacity, 86 Simulation of insanity can be detected, 85 ; how distinguished from real insanity, 85 INDEX. 699 Pkae, Dr., his classification, 47 Skey, Dr. F. C, on hysteria, 392 Skin, 79 Skull formation in criminals, 618 Sleep, 75 Small hospitals for the insane, Dr. Cowles on, 208 Somatic school of alienists, 50 Somato-setiological classification, 48, 49 Softening of brain, 540 Somnambulism, 468 Special pathological changes in insanity, 146 Spencer, Herbert, on the emotions, 58 Spinal concussion, its medico-legal rela- tions, 608 Spinal cord, lesions of, 331 Spitzka, 335 Statistics of different asylums : Blooming- dale, 188; New York State, 169; Penn- sylvania hospital, 193; three State hos- pitals of Massachusetts, 163; etc., in general, 58 States of unconsciousness, 466 Stomach and intestines, diseases of, in in- sanity, 259 Suicidal insanity, 294 Suspicion a common trait of insanity, 262 Sutherland, Dr., on the urine in insanity, 145 Sydenham, Dr., on hysteria, 381 Sympathetic insanity, 42 Symptomatological classification, 45 Syphilitic insanity, 159; foot-note, 262 Syphilitic nervous disease, 315, 317 Tables of causes often unreliable, 57 Temperament, insane, 49 Testimony, skilled, charged with being con- tradictory, etc., 92 Testamentary capacity, 70 Tests of responsibility, 307 Temperature of body in cerebral hsemor- rhage, 340 Therapeutics of insanity, 233 Toxic insanity, 50 Trance state, 126 Transitory mania, 122, 126 Treatment of insanity, 157 Treatment of inebriety, 361, 372 Trembling, 330 Treatment of cerebral hsemorrhage, 343 Trouble and grief as causes of insanity, 57 Trousseau, 129 Tubercular disease in insanity, 261 Tuke, Dr. J. Batty, his histological re- searches in insanity, 145 Types of insanity, see frontispiece Ulysses, feigned insanity, 37 Unconsciousness, states of, 466 Uncontrollable impulse, 474, 475 Unnatural and motiveless crimes diagnostic of epilepsy, 305 Urine in insanity, 144, 145 Uterine disorders as a cause of insanity, 293 Utero-mania, 257 Varieties of insanity in relation to treat- ment, 252 Vertigo, nature and treatment of, 462 ; sta- tic, 330 Vertex steepness, 621 Vital causes of nervous disease, 34 Visceral disease in insanity, 293 Visceral neuralgias, 504 Voison, Aug., on general paralysis, 102 ■w. Warm baths, prolonged, in insanity, 245, 290 Webber, 335 Weakness of mind (see Idiocy, Dementia, and Epilepsy) Westphal, on general paralysis, 100 Wills of the insane, 87 Winslow, Dr. Forbes, on insanity and its treatment, 283 ; on simple classifications, ■ 285 Winn, Dr., on correlation of morbific forces, 142 Willis., case of, 122 Wille on syphilitic insanity, 262 Wilks on epilepsy, 435; on hysteria, 411 ; on electricity, 579 Work in the treatment of insanity, 202, 219, 220 CATALOGUE NO. 1. SEPTEMBER, 18S3, CATALOGUE EDicAL. Dental, Pharmaceutical AND SCIENTIFIC PUBLICATIONS, PUBLISHED BY P. BLAKISTON, SON & CO.. (SUCCESSORS TO LINDSAY & BLAKISTON) 1012 WALNUT STREET, PHILADELPHIA. These publications may be had through Booksellers in all the principal cities of the United States and Canada, or any book will be sent, postpaid, by the publisher, upon receipt of price, oi will be forwarded by express C. O. 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BLAKISTON; SON &- CO:S ACTON, THE REPRODUCTIVE ORGANS. The Functions and Disorders of the Reproductive Organs in Childhood, Youth, Adult Age and Advanced Life, considered in their Physiological, Social and Moral Relations. By William Acton, m.d., m.r.c.s. Sixth Edition. 8vo. Cloth, $2.00 " In the work now before us, all essential detail upon its subject matter is clearly and scientifically given. We recommend it accordingly, as meeting a necessar>- requisition of the day, refiising to join in that opinion^-hich regards the consideration of the topics in question as beyond the duties of the medical practitioner." — Thj London Lancet. " On the subjects of Impotence and Spermatorrhosa, those bugbears of so many weak and foolish persons, and sources of inexhaustible wealth to the quack fraternity, Mr. Acton discourses with good sense, and indignantly exposes the nefarious tricks of the scoundrels who, on the pretence of curing a disease which often exists only in imagination, extract enormous sums from their unwary victims. He seems to regard the spermatorrhoea-phobia, as we may term it, to be a species of monomania : but he judiciously advises that to a patient laboring under this form of mental malady, the tone adopted should be one of sympathy and attention ; and that by tne employment of appropriate moral and therapeutical means, a healthy and hopeful tone of mind be restored. — The Medical Times. AGNEW, ON THE PERINEUM AND FISTULA. Lacerations of the Female Perineum and Vesico-vaginal Fistula. Their His- tory and Treatment. With many Illustrations. By D. Hayes Agnew, m.d.. Professor of Surger)', University of Pennsylvania. 8vo. Cloth, Price $1.25 So many applications having been made for these papers, as originally issued, the author has thought best, after a thorough revision, to place them before the profession in book form. ALLEN, COMMERCIAL ORGANIC ANALYSIS. An Introduction to the Practice of Commercial Organic Analysis. By Alfred H. Allen, f.c.s. Vol. i. Cyanogen Compounds, Alcohols and their Deriva- tives, Phenols, Acids, etc. 8vo. Price $3.50 Vol. H now ready. 8vo. Price $5.00 Being a treatise on the Properties, Analytical Examination, and Modes of Assaying the various Organic Chemicals and Preparations employed in the Arts, ^Manufactures, ^Medicine, etc. ALLAN, FEVER NURSING. Notes on Fever Nursing. Addressed to nurses in hospital and private life. By James W. Allan, M.D. i2mo. Illustrated. Price .75 ALLINGHAM, DISEASES OF THE RECTUM. Illustrated. Fistula, Hcemorrhoids, Painful Ulcer, Stricture, Prolapsus, and other Diseases of the Rectum, their Diagnosis and Treatment. By William Allingham, F.R.C.S. Fourth Edition, enlarged. Price, Paper covers, .75; Cloth, $1.25 London Edition, thick paper and larger- type , $2.00. " He is in charge of the only hospital in the world ' " This book has always been a great favorite, and ('St. Marks) devoted exclusively to diseases of the deservedly so. It is practical in tone and character, rectum, and he is recognized, both in this country' and magisterial in its teaching, and valuable in showing in Europe, as the highest authority upon diseases of operative results. It is by an author who, as an this class." — LouisTrille Medical Herald. authority, has no superior." — Gaillard's Medical jfournal. " No book on this special subject can at all approach I "It is, as indeed the verdict of the profession has Mr. AUingham's in precision, clearness and practical ! already pronounced it, one of the very best works on good sense." — London Medical Times and Gazette. | Disease.'^ of the Rectum." — Antericcm Journal 0/ I Medical Science. ALTHAUS, MEDICAL ELECTRICITY. A Treatise on Medical Electricity, Theoretical and Practical, and its Use in the Treatment of Paralysis, Neuralgia, and other Diseases. By Julius Althaus, M.D. Third Edition, Enlarged. 246 Illustrations. 8vo. Price 56.0c In revising this new edition the author has carefully brought each section up with the latest knowledge of the subject. PUBLICA TIONS. 5 ANSTIE, STIMULANTS AND NARCOTICS. With special researches on the Action of Alcohol, Ether and Chloroform on the Vital Organism. By Francis E. Anstie, m.d. 8vo. Price $3.00 " He is an original worker and independent thinker. His opinions and conclusions are valuable, and cannot be neglected." — American Medical yournal, ATTHILL, DISEASES OF WOMEN. Clinical Lectures on Diseases Peculiar to Women. By Lombe Atthill, m.d. 5th edition, revised and enlarged, with numerous illustrations. i2mo. Cloth. Price ^1.25 " It is the concentrated essence of the knowledge of one who has become wise by reason of long and well- digested experience in the subjects X.xe^zXe.A." —A^nerican yournal of Medical Science. " The work is one of great value to the general practitioner." — American yourna-l of Obstetrics. AITKEN'S PRACTICE OF MEDICINE. New Edition. The Science and Practice of Medicine. By William Aitken, m.d., f.r.s. London, Professor of Pathology in the Army Medical School, etc. Seventh Edition. To a large extent rewritten ; enlarged, remodeled and carefully revised throughout. In Two Volumes. 196 Engravings on Wood, and a Map showing the Geographical Distribution of Diseases, and Copious Index. Octavo. Cloth, ^12.00 ; Leather, $14.00 BALFOUR, ON THE HEART AND AORTA. Clinical Lectures on Diseases of the Heart and Aorta. By G. W. Balfour, M.D. Illustrated. 2d Edition. Price $5.00 " The whole work reflects muchcredit on its author, and firmly establishes his reputation as an authority on the important diseases of which he treats." — Lotidon Practitio7ier . BARTH AND ROGER, AUSCULTATION AND PERCUS- SION. A Manual for the Student. By M. Barth and M. Henri Roger. Trans- lated from the 6th French Edition. i2mo. Price $1.00 BIBLE HYGIENE; Or, Health Hints. By a Physician. This book has been written, first, to im- part in a popular and condensed form the elements of Hygiene ; second, to show how varied and important are the Health Hints contained in the Bible, and third, to prove that the secondary tendency of modern Philosophy runs in a parallel direction with the primary light of the Bible. i2mo. Paper, .50; Cloth, $1.00 ■' The scientific treatment of the subject is quite abreast of the present day, and is so clear and free from unne- cessary technicalities that readers of all classes may peruse it with satisfaction and advantage." — Edinburgh Medical yournal. BIDDLE, MATERIA MEDICA. Ninth Edition. [Contains all the changes in the Sixth Revision of the New Pharmacopoeia.^ Materia Medica. For the Use of Students and Physicians. By the late Prof. John B. Biddle, m.d.. Professor of Materia Medica in Jefferson Medi- cal College, Philadelphia. The Ninth Edition, thoroughly revised, and in many parts rewritten, by his son, Clement Biddle, m.d.. Assistant Surgeon, U.S. Navy, assisted by Henry Morris, m.d. Containing all the additions and changes made in the last revision of the United States Pharmacopoeia. The Botanical portions have been curtailed or left out, and the other sections, on the Physiological action of Drugs, greatly enlarged. Octavo. Cloth, M-oo; Leather, $4.75 " The additions are valuable, and we must congrat- ulate the author upon having improved what was already so useful a work, both to the student and phy- sician." — Phi/a. Medical and Surgical Reporter. " It has been the design of the author to present in his work a text-book for the student. It is brief, and yet sufficiently comprehensive. His style is clear and yet succinct. He covers the ground — covers it well, 'and cumbers his work with nothing superfluous." — Atlanta Medical and Surgi^:al yournal. ! Canada Lancet. " One thing that particularly recommends this work to the student is, that the book is not so large as to dis- courage and cause him to fee! that it is impossible for him to get over it and so much else in the short time before him." — St. Louis Medical and Surgical your- nal. " It contains, in a condensed form, all that is valu- able in materia medica, and furnishes the medica! student with a complete manual on this subject." — p. BLAKISTON, SON &- CO:S BREWING, DISTILLING, ETC. The Brewer, Distiller and Wine Manufacturer ; a Handbook for all interested in the Manufacture and Trade of Alcohol and its Compounds. Edited by John Gardner, Fellow of the Chemical Society of London. Illustrated. Cloth, $1.75 Synopsis of Contents. — Alcohol, its Preparations, etc. ; Alcoholometry ; Brewing and Beers; Varieties of Malt Liquors; Malt; Raw Grain; Sugar; Hops; Arrangement of a Brewery; Different Processes; Chemical Changes during Washing, Boiling, Cooling, Fermentation, etc., etc. ; Storing and Clari- fying, Porters, Ales ; Analysis of Beers, Ciders, Perry, Mum ; Liquors and Cor- dials, giving over 80 preparations. Other sources of Spirituous Liquors ; Dis- tillation of Alcoholic Liquors, including Rums, Brandies, Whiskies, Gins, etc. ; Wine and Wine Making ; Tests for Adulterations ; Remarks on the Cultivation of Grapes, etc.; Imitation of Wines. BLOXAM. CHEMISTRY,Inorganic and Organic. Fifth Edition. ■ With Experiments. By Charles L. Bloxam, Professor of Chemistry in King's College, London, and in the Department for Artillery Studies, Wool- wich. Fifth edition. With nearly 300 Engravings. Cloth, ^4.00; Leather, $5.00 A most complete Text-Book for Schools and Colleges. " Professor Bloxam has given us a most excellent and useful practical treatise. His 656 pages (now 700) are crowded with facts and experiments, nearly all well chosen, and many quite new, even to scientific men . . . It is astonishing how much information he often conveys in a few paragraphs. We might quote fifty instances of this." — Chemical I^eivs. BLOXAM, LABORATORY TEACHING. Fourth Edition. Progressive Exercises in Practical Chemistry. By Charles L. Bloxam, Professor of Chemistry in King's College, London, etc. Fourth edition. With 89 engravings. i2mo. Price ^1.75 This work is intended for use in the Chemical Laboratory, by those who are commencing the study of Practical Chemistry. It contains : — I. A series of simple Tables for the analysis of unknown substances of all kinds. 2. A brief description of all the practically important single substances likely to be met with in ordinary analysis. 3. Simple directions and illustra- tions relating to Chemical Manipulation. 4. A system of Tables for the detec- tion of unknown substances with the aid of the Blowpipe. 5. Short instructions upon the purchase and preparation of the tests intended for those who have not access to a Laboratory. " A great amount of valuable practical information is here condensed into a book of 260 pages, such as only a practical teacher could prepare." — Ne2u England ycnirnal of Education. BRUEN. PHYSICAL DIAGNOSIS. A Pocket Book of Physical Diagnosis, for Physicians and Students. By Edward T. Bruen, m.d., Asst. Prof, of Clinical Medicine, University of Penn'a. Illustrated by Original Wood Engravings. i2mo. Extra Cloth. Price %i.oo BENNETT. NUTRITION IN HEALTH AND DISEASE. A Contribution to Hygiene and Clinical MediK;ine. By J. Henry Ben- nett, M.D. Third Edition, Revised and Enlarged. Cloth. Price $2.50 BY SAME AUTHOR. THE TREATMENT OF PULMONARY CONSUMPTION BY HYGIENE, CLIMATE AND MEDICINE. With an Appendix on the Sanitaria of the United States, Switzerland and the Balearic Islands. Third Edition much Enlarged. Price $2.50 "Any physician may take it up with every feeling of confidence that the views enunciated by the author will be found to be able, honest and orthodox." — Medico- Chirurgical Review. BERKART, ASTHMA. The Pathology and Treatment of Asthma. By Joseph B. Berkart, m.d.' 8vo. Price $2.50 PUB Lie A TIONS. BEALE ON SLIGHT AILMENTS. New Edition. Just Ready. Slight Ailments, Their Nature and Treatment. By Lionel S. Beale, m.d., F.R.S., Professor of Practice, King's Medical College, London. Second Edition. Enlarged and Illustrated. Price, Cloth, $1.25 ; Paper covers, .75 cents. Fine Edition, Heavy Paper. Extra Cloth, Price ^1.75 OUTLINE OF CONTENTS. Introductory. The Tongue in Health and Slight Ailments. Appetite. Nausea. Thirst. Hunger. Indigestion, its Nature and Treatment. Constipation, its Treatment. Diarrhoea. Vertigo. Giddiness. Biliousness. Sick Headache. Neuralgia. Rheumatism. The Feverish and Inflammatory State. Of the Actual Changes in Fever and Inflammation. Common Forms of Slight Inflammation, etc., etc. "We venture to say that among the numerous medical publications issued during 1880, there has been none which will prove more useful to the young general practitioner, for whom it is really intended, than this volume, while the time of the older physician might be much more unprofitably spent." — American yournal of Medical Science. BY SAME AUTHOR. ON LIFE AND VITAL ACTION IN HEALTH AND DISEASE. i2mo. Price $2.00 THE USE OF THE MICROSCOPE IN PRACTICAL MEDI- CINE. For Students and Practitioners, with full directions for examining the various secretions, etc., in the Microscope. Fourth Edition. 500 Illustrations. Much enlarged. 8vo. Price $7.50 " We have before us Prof. Beale's work. The Micro- | " As a microscopical observer, and a histological scope in Medicine, a book which it gives us pleasure to manipulator, his (Dr. Beale) skill and eminence are recommend to every student of microscopy, whether he generally conceded." — Popular Science Monthly. be a physician or naturalist." — Jour^ial of the Fratik- lin Institute, Philadelphia. \ HOW TO WORK WITH THE MICROSCOPE. A Complete Manual of Microscopical Manipulation, containing a full descrip- tion of many new processes of investigation, with directions for examining ob- jects under the highest powers, and for taking photographs of microscopic objects. Fifth Edition. Containing over 400 Illustrations, many of them colored. Octavo. Price $7.50 " The Encyclopaedic character of this last edition of Dr. Beale's well known work on the Microscope renders it impossible to present an abstract of its contents ; suffice it to say, that anything in his department upon which the physican can desire such information will be found here, and much more in addition. It is, moreover, a store- house of facts, most valuable to the physician, and is indispensable to every one who uses the microscope." — Atnerican Journal of Medical Science. BIOPLASM. A Contribution to the Physiology of Life, or an Introduction to the Study of Physiology and Medicine, for Students. With numerous Illustrations. PROTOPLASM; or MATTER AND LIFE. Third Edition, very miich enlarged. Nearly 350 pages. Sixteen Colored Plates. Part I. Dissentient. Part 11. Demonstrative. Part iii. Suggestive. One volume. Price $3.00 LIFE THEORIES ; Their Influence upon Religious Thought. Six Colored Plates. Price $2.00 ONE HUNDRED URINARY DEPOSITS, On two sheets, for the Hospital, Laboratory, or Surgery. Each Sheet $1.00, or on Rollers, Price $1.25 BERNAY, CHEMISTRY. Notes for Students in Chemistry. Compiled from Fowne's and other manuals. By Albert J. Bernay, PH.D. Sixth Edition. i2mo. Price $1.25 BENTLEY'S STUDENTS' BOTANY. The Students' Guide to Structural and Physiological Botany. By Professor Robert Bentley. Illustrated by nearly 500 Wood Engravings. In Preparatioti. p. BLAKISTON, SON &- CO.'S BEASLEY. THE BOOK OF PRESCRIPTIONS. Containing over 3100 Prescriptions, collected from the Practice of the most Eminent Physicians and Surgeons — English, French and American ; a Com- pendious History of the Materia Medica, Lists of the Doses of all Officinal and Established Preparations, and an Index of Diseases and their Remedies. By Henrv Beasley. Sixth Edition, Revised and Enlarged. Price $2.25 BY SAME AUTHOR. THE DRUGGIST'S GENERAL RECEIPT-BOOK. Comprising a copious Veterinary Formulary; numerous Recipes in Patent and Proprietary Medicines, Druggists' Nostrums, etc.; Perfumery and Cos- metics; Beverages, Dietetic Articles and Condiments; Trade Chemicals, Scien- tific Processes, and an Appendix of Useful Tables. Eighth Edition. Price $2.25 THE POCKET FORMULARY and Synopsis of the British and Foreign Pharmacopoeias. Comprising Standard and Approved Formulae for the Preparations and Com- pounds Employed in Medical Practice. Tenth Edition. 511 pp. i8mo. Price $2.25 BENTLEY AND TRIMEN'S MEDICINAL PLANTS. A New Illustrated Work, containing full botanical descriptions, with an account of the properties and usesof the principal plants employed in medicine, especial attention being paid to those which are officinal in the British and United States Pharmacopoeias. The plants which supply food and substances required by the sick and convalescent are also included. By R. Bentley, f.r.s., Professor of Botany, King's College, London, and H. Trimen, m.b., f.h.s.. Department of Botany, British Museum. Each species illustrated by a colored plate drawn from nature. In Forty-two parts. Eight colored plates in each part. Price $2 each, or handsomely bound in 4 volumes. Half Morocco, $90.00 " It would be impossible to enumerate all the new i " This work may be recommended as a most useful planLs that are here delineated. The result is a work I one to druggists, and all who desire to be familiar which, from all points of view, is a credit to the scientific I with the Botany of Medicinal Plants." — Druggists' literature of the day." — London Lattcei. Circular. "It is an indispensable work of reference to every one | "The work when complete (it is now complete) interested in pharmaceutical Botanj-." — London Phar- \ will be the most valuable corapend of Medical Botany THoceutical yournal. \ ever published." — Boston your 7ial nf Chemistry. BRUBAKER, PHYSIOLOGY. A Compend of Physiology specially adapted for the use of Students and Phy- sicians. " No. 4, ? Ouiz-Compend Series ?" i2mo, Cloth. Price $1.00 " Dr. Brubaker deserves the hearty thanks of medical students for his Compend of Physiology. He has arranged the fundamental and practical principles of the science in a particularly inviting and accessible manner. I have already introduced the work to my class." — Maurice N. Miller, M.D., Demonstrator of J-'/':\siology, Medical Depart7ne7it University oj" the City of New York. BYFORD. DISEASES OF WOMEN. New Revised Edition. The Practice of Medicine and Surgery, as applied to the Diseases of Women. By W. H. Byford, a.m., m.d.. Professor of Obstetrics and The Diseases of Wo- men and Children, in the Chicago Medical College. Third Edition. Revised and Enlarged, much of it rewritten, with numerous additional illustrations. Price, in Cloth $5.00; Leather, $6.00 " The treatise is as complete a one as the present " The author is an experienced writer, an able teach- state of our science will admit of being written. We I er in his department, and has embodied in the present commend it to the diligent study of everj' practitioner work the results of a wide field of practical observa- and student, as a work calculated to inculcate sound ' tion. We have not had time to read its pages critically, principles and lead to enlightened practice. — jS'eiu but freely commend it to all our readers, as one of the York Medical Record. ' most valuable practical works issued from the Ameri- can press." — Chicago Medical Examiner. BY same author. ON THE UTERUS. The Chronic Inflammation and Displace- ment of the Unimpregnated Uterus. An Enlarged Edition, with Illustrations. 8vo. Price $2.50 "A good book from a good man." — American yournal Medical Science. " It is a sensible, practical work, and cannot fail to be read with interest and profit." — Boston Medical and Surgical yournal. PUB Lie A TIONS. BRAUNE, TOPOGRAPHICAL ANATOMY. An Atlas of Topographical Anatomy. Thirty-four Full-page Plates, Photo- graphed on Stone, from Plane Sections of Frozen Bodies, with many other illus- trations. By WiLHELM Braune, Professor of Anatomy at Leipzig. Translated and Edited by Edward Bellamy, f.r.c.s., Lecturer on Anatomy, Charing Cross Hospital, London. Quarto. Price, Cloth, ^8.00 ; Half Morocco, $10.00 "As a whole the work cannot fail to meet with a hearty reception by every progressive student of the human body. To the surgeon it is a contribution to the study of topographical anatomy which needs to be known to be properly appreciated To such practitioners who reside in large cities, where anatomy can be studied upon the cadaver, it will afford a valuable aid, while to those who are without such means of study it is an almost indis- pensable addition to a working library." — New York Medical Record. " We commend the book most heartily to the Profession." — Ainerican yournal 0/ Medical Science . BUCKNILL AND TUKE ON INSANITY. A Manual of Pyschological Medicine : containing the Lunacy Laws, the Nosology, (Etiology, Statistics, Description, Diagnosis, Pathology (including morbid Histology), and Treatment of Insanity. By John Charles Bucknill, M.D., F.R.S., and Daniel Hack Tuke, m.d., f.r.c.p. Fourth Edition, much enlarged, with twelve lithographic plates, and numerous illustrations. Octavo. Price $8.00 " We have read no book in any language, and certainly none in English, which ought to be preferred to this for a text book, by those who wish to make a thorough study of the subject. — Edinburgh Medical yournal. " We can heartily commend the work. — American yournal of Insanity. BURDETT, HOSPITALS. Pay Hospitals and Paying Wards throughout the World. Facts in support of a rearrangement of the system of Medical Relief. By Henry C. Burdett. Svo. Price $2.25 " Mr. Burdett displays and discusses the whole scheme of Hospital accommodation with a comprehensive understanding of its nature and extent. — American Practitioner. BY SAME author. COTTAGE HOSPITALS. General, Fever, and Convalescent : their Progress, Management, and Work. Second Edition, rewritten and much Enlarged, with many Plans and Illustra- tions. Crown Svo. Price $4.50 Contents. — Chap. — i. Origin and Growth of the Cottage Hospital System. 2. Comparative Success of Treatment in large and small Hospitals. 3. Finance. 4. Cottage Hospital Construction and Sanitary Arrange- ments. 5. The Medical and Nursing Departments. 6. Domestic Supervision and General Management. 7. Cottage Hospital Appliances and Fittings. 8. Cottage Fever Hospitals. 9. Midwifery in Cottage Hospitals . 10. Remunerative Paying Patients. 11. Convalescent Cottages . 12. Cottage Hospitals in America. 13. Mortu- aries. 14. A more Detailed Account of certain Cottage Hospitals, with Plans and Elevations. 15. Selected and Model Plans criticised and compared, with a detailed description of various Hospitals. 16. Peculiarities and Special Features in the Working of Cottage Hospitals. With an Appendix containing much statistical and useful information. " Mr. Burdett's book contains a mass of information, statistical, financial, architectural, and hygienic, which has already proved of great practical utility to those interested in cottage hospitals, and we can confidently recom- mend this second edition to all who are in search of the kind of information which it contains." — Lancet. BUZZARD, NERVOUS DISEASES. Clinical Lectures on Diseases of the Nervous System. By Thos. Buzzard, M.D. Illustrated. Octavo. Price $5.00 CARPENTER, THE MICROSCOPE. Sixth Edition. The Microscope and its Revelations. By W. B. Carpenter, m.d., f.r.s. Sixth Edition. Revised and Enlarged, with over 500 Illustrations. Price $5.50 " Not only the student of medicine, but amateurs, I "As a text book of Microscopy in its special relation and others interested in the study of natural history, to natural history and general science, the work before will find this volume one of great practical value." — us stands confessedly first, and is alone sufficient to N^■w York Medical yournal. supply the wants of the ordinary student." — American "It is by far the most complete and useful treatjse yournal of Microscopy. now accessible to the student." — The Technologist. I 10 p. BLAKISTON, SON &- CO:S CARTER, EYESIGHT. New Edition now ready. Eyesight, Good and Bad. A Treatise on the Exercise and Preservation of Vision. By Robert Brudenell Carter, f.r.c.s. Second Edition, witla 50 Illustrations, Test Types, etc. i2mo. Price, Cloth, $1.25 " It is written in a lucid and agreeable style, conveying an easily comprehensible account of the structure of the eye and the function of vision, and gives a description of the principal anomalies of the latter, at the same time inculcating such salutary advice as may be beneficial for the preservation of sight." — London Medical Times a^id Gazette. " There is much wholesome advice given on the ' Care of the Eyes in Infancy and Childhood,' and ontliis account, if no other, the book should be in the hands of everj' parent and teacher." — St. Louis Courier of Medicine. CARTER, PRACTICE OF MEDICINE. Elements of Practical Medicine. By Alfred H. Carter, m.d., London, Member of the Royal College of Physicians ; Physician to the Queen's Hos- pital, Birmingham, etc. Crown 8vo. Price I3.00 " The object of this volume is to provide the student with a general introduction to the study of Medicine, and to bring the essentials of the subject, so far as required for the ordinarj' medical qualifications, within the grasp of those who have not the time or leisure to read the larger and more elaborate works on Practice." — Preface. " Dr. Carter is favorably known as a London physician of learning and experience, and a clear writer. He aims to give a judicial epitome of practical medicine, and this is a well-prepared book." — Philadelphia Medi- cal and Surgical Reporter. CULLINGWORTH, ON NURSING. Illustrated. A Manual of Nursing, Medical and Surgical. By Charles J. Culling- WORTH, M.D., Physician to St. Mary's Hospital, Manchester, England. With eighteen Illustrations. i2mo. Cloth, $1.00 CAZEAUX'S GREAT OBSTETRICAL TEXT-BOOK. A Theoretical and Practical Treatise, including the Diseases of Pregnancy and Parturition. By P. Cazeaux, Adjunct Professor in the Faculty of Medi- cine of Paris, etc. etc. Revised and Annotated by S. Tarxier, Former Clini- cal Chief of the Lying-in-Hospital, etc., etc. Sixth American from the Seventh French Edition. Translated by Wm. R. Bullock, m.d. One volume. Royal Octavo, over iioo pages, with Lithographic and 175 other Illustrations on Wood. Price, Cloth, $6.00; Leather, $7.00 M. Cazeaux's great work on Obstetrics has become classical in its character, and almost an Encyclopsedia in its fulness. Written expressly for the use of students of medicine, and those of midwifery especially, its teachings are plain and explicit, presenting a condensed summary of the leading principles established by the masters of the obstetric art, and such clear, practical directions for the management of the pregnant, parturient, and puerperal states, as have been sanctioned by the most authoritative practitioners, and confirmed by the author's own experience. Collect- ing his materials from the writings of the entire body of antecedent writers, carefully testing their correctness and value by his own daily experience, and rejecting all such as were falsified by the numerous cases brought under his own immediate observa- tion, he has formed out of them a body of doctrine, and a system of practical rules, which he illustrates and enforces in the clearest and most simple manner possible. "The edition before us is one of unquestionable ex- " It is unquestionably a work of the highest excel- cellence. Everj' portion of it has undergone a thorough lence, rich in information, and perhaps fuller in details revision, and no little modification ; while copious than any text-book with which we are acquainted, and important additions have been made to nearly ' The author has not merely treated of every question ever\- part of it. It is well and beautifully illustrated ! which relates to the business of parturition, but he has by numerous wood and lithographic engra%"ings, and in typographical execution wiil bear a favorable com- parison with other works of the same class.".(4>«friV:a« Medical yournal. " The translation of Dr. Bullock is remarkablj' well done so with judgment and ability." — British and Foreign Medico- Chirurgical Revieiu. " No work, in our estimation, bears any comparison to Cazeaux, in its entire perfectness ; and if we were called upon to rely alone on one work on accouch- done. We can recommend this work to those espe- i ments, our choice would fall upon the book before us ciallj- interested in the subject treated, and can espe- | without any kind of hesitation." — U'est. your.ofMed- cially recommend the American edition." — liledical ; iciiie and Surgery. Times and Gazette. i << -We know of no work on this all-important branch " We do not hesitate to say that it is now the most of our profession that we can commend to the student complete and best treatise on the subject in the Eng- or practitioner as a safe guide before this." — Chicago lish language." — Buffalo Medical journal. | Medical jfouryzal. PUBLICA TIONS. CHARTERIS, PRACTICE OF MEDICINE. Hand-Book of the Practice of Medicine. By M. Charteris, m.d., Member of Hospital Staff and Professor in University of Glasgow. With Microscopic and other illustrations. Price $1.25 " We have not often met with a book which can be so confidently recommended to physicians or tnen in general practice . ' ' — Lancet. " The style in which it is written is clear and attractive. The illustrations are a marked feature in it. It can be recommended as a very reliable, handy book, well adapted for ready reference." — New Remedies. CHAVASSE ON CHILDREN. The Mental Culture and Training of Children. By Pye Henry Chavasse. i2mo. Price, Paper covers, .50; Cloth, $1.00 The mental culture and training of children is of immense importance. Many children are so wretchedly trained, or rather not trained at all, and so mismanaged, that a few thoughts on this subject cannot be thrown away, even upon the most careful. CLAY ON OBSTETRIC SURGERY. Third Edition. A complete Hand-Book of Obstetric Surgery, with Rules for every Emergency and Descriptiens of the more difficult as well as the every day operations. By Charles Clay, m.d., with numerous Illustrations. From the Third London Edition. i2mo. Paper Covers, .75 ; Cloth, $1.25 " It is a useful and convenient book of reference ; the illustrations are good, and the book will be found of value to the student and young practitioner, as well as to the skilled Obstetrician." — American journal of Obstetrics. CLEVELAND, POCKET DICTIONARY. A Pronouncing Medical Lexicon, containing correct Pronunciation and Defi- nition of terms used in medicine and the collateral sciences. By C. H. Cleve- land, m.d. Twenty-ninth Edition. i6mo. Price, Cloth, 75 cents ; Tucks with Pocket, $1.00 This is a most convenient size for the pocket, and contains all the principal words in use, together with rules for pronunciation, abbreviations used in prescriptions, list of poisons, their antidotes, etc. COHEN, INHALATION. Enlarged Edition. Inhalation, its Therapeutics and Practice, including a Description of the Ap- paratus Employed, etc. By J. SOLis Cohen, m.d. With cases and Illustrations. A New Enlarged Edition. 8vo. Price ^2.50 " The book has the merit of containing much information that cannot be found elsewhere." — N. Y. Medical yournal. " One of the best treatises we have seen on this subject."— Jlledicat Times and Gazette. BY SAME AUTHOR. CROUP, In its Relation to Tracheotomy. 8vo. Price |i.oo CLARKE, SURGERY. Outlines of Surgery and Surgical Pathology, including the Diagnosis and Treatment of Obscure and Urgent Cases. By F. LeGross Clarke, f.r.s. Second Edition. 8vo. Price |2.oo COBBOLD, PARASITES. A Treatise on the Entozoa of Man and Animals, including some account of the Ectozoa. By T. Spencer Cobbold, m.d., f.r.s. With 85 illustrations. 8vo. Price $5.00 p. BLAKISTON, SON &> CO:s COLES, THE MOUTH. Third Edition, just ready. Deformities of the Mouth, Congenital and Acquired, with Their Mechanical Treatment. By Oakley Coles, d.d.s. Third Edition. 83 Wood Engravings and 96 Drawings on Stone. 8vo. Price $4.50 "Altogether we must heartily congratulate Mr. Coles on this creditable completion of a work which cannot |ut redound to his credit wherever it is known." — British yournal of Dental Science. " We recommend this book to the study of both surgeons and dentists." — London Lancet. BY SAME AUTHOR. A MANUAL OF DENTAL MECHANICS. Containing much information of a practical nature, upon the Materials and Appliances used in Mechanical Dentistry. For Practitioners and Students. Second Edition, with 140 Illustrations. i2mo. THE DENTAL STUDENT'S NOTE-BOOK. A new Edition. i6mo. Price |i.oo CORMACK, CLINICAL STUDIES. Illustrated by Cases Observed in Hospital and Private Practice. By Sir John Rose CoRMACK, M..D., K.B., etc. Illustrated. 2 vols. 1,127 pp. Price 55.00 COURTY, THE UTERUS, OVARIES, ETC. A Practical Treatise on Diseases of the Uterus, Ovaries, and Fallopian Tubes. By Prof. A. Courty, of Montpelher, France. Translated from the Third Edition by his pupil and assistant, Agnes McLaren, m.d., m.k.q.c.p.i. With a Preface by J. Matthews Duncan, m.d., ll.d., f.r.s., Obstetric Physi- cian to Saint Bartholomew's Hosnital, London. With 431 Illustrations. One Vol., 8vo. Price, in Handsome Cloth, $6.00 ; Full Sheep, Raised Bands, $7.00 OUTLINE OF CONTENTS. TPODUCTION. — On the Anatomy, Physiology, and Teratology of the Organs of Generation. Part i. — General Survey of Uterine Diseases. Diagnosis of Uterine Diseases in General; Treatment of Uterine Diseases in General; General Characteristics of Uterine Diseases. Part ii. — Uterine Diseases IN Detail. Functional Disorders ; Changes of Position ; Morbid States without Neoplasm ; Organic Alterations; Diseases of the Uterine Appendages; Pelvic Hemorrhages and Peri-uterine Haematocele; Cyst of the Ovary and Genito-pelvic Tumor; Sterility, etc., etc. Index. " Courty's work has, since its first publication, been recognized everywhere. In France, its position is attested by the sale of two editions, numbering, I am told, ten thousand copies, and by the appearance of another, the third edition. I recommend to the careful study of my professional brethren a book which has already been crowned by the Institute of France." — J. Matthews Duncan. CURLING, ON THE TESTIS. A Practical Treatise on the Diseases of the Testis, Spermatic Cord, and Scrotum. By T. B. Curling, m.d., f.r.s. Fourth Edition, Enlarged and Il- lustrated. 8vo. Price $5.50 " We believe this work to be the most trustworthy that can be consulted in this Department of Surgery, his pages abound with valuable suggestions and cautions that mark his intimate knowledge of the subject."- — Lcmdon Practitioner. COOPER'S SURGICAL DICTIONARY. A Dictionary of Practical Surgery and Encyclopaedia of Surgical Science. By Samuel Cooper. New Edition, brought down to the present time. By Samuel A. Lane, f.r.c.S., assisted by various eminent Surgeons. In two vols. Price $12.00 COTTLE, ON THE HAIR. The Hair in Health and Disease. By E. W. Cottle, m.d. Partly from the notes of the late George Nayler. i8mo. CORFIELD, DWELLING HOUSES. The Sanitary Construction and Arrangement of Dwelling Houses. By W. H. CoRFiELD, m.a., m.d. Enlarged Edition, with Plans and Illustrations. I2mo. Price $1.25 PUB Lie A TIONS. n COULSON, THE BLADDER. Sixth Edition. Diseases of the Bladder and Prostate Gland. By Walter J. Coulson, f.r.c.s. Sixth Edition. Revised and Enlarged, with 22 Engravings. 8vo. Price $6.40 CRIPPS, THE RECTUM. Cancer of the Rectum. Its Pathology, Diagnosis and Treatment. By. W. Harrison Cripps, f.r.c.s. Illustrated by Plates. 8vo. Price $2.40 DAY ON CHILDREN. Second Edition. Just Ready. The Diseases of Children. A Practical and Systematic Treatise for Practi- tioners and Students. By Wm. H. Day, m.d. Second Edition. Rev/ritten and very much Enlarged. 8vo. 752 pp. " Believing the work well adapted to meet the wants of the Student as well as the Practitioner, I will recom- mend it to the classes of Rush Medical College." — ■ DeLeskie Miller, m.d., Chicago. " On the whole, we must confess we are pleased with this book and can heartily recommend it — a recommen- dation which it does not appear to need, as it has already reached its second edition." — Atnerican jour- nal of Medical Science. DAY ON HEADACHES. Fourth Edition. The Nature, Causes, and Treatment of Headaches. Fourth Edition. Illus- trated. By Wm. Henry Day, m.d. Octavo. Paper Covers, 75 cents; Cloth, $1.25 Summary of Contents. — Headache from Cerebral Anaemia, Cerebral Hypersemia, Sympathetic, Congestive, Dyspeptic or Bilious Headaches, Headache from Plethora, from Exhaustion, from Change in Cerebral Tissue, from Affections of the Periosteum, Nervous and Nervo-Hyperaemic Headache, Toxaemic, Rheumatic, Arthritic or Gouty Headache, Neuralgic Headache, and Headaches of Childhood, Early and Advanced Life. "Well worth reading. The remarks on treatment are very sensible."— .ffoj/ow Medical and Surg, yournal. DALBY, ON THE EAR. The Diseases and Injuries of the Ear. By W. B. Dalby, m.d.. Surgeon and Lecturer on Aural Surgery, St. George's Hospital. With Illustrations. i2mo. Price $1.50 Price, Cloth, $5.00; Sheep, $6.00 " Dr. Day brings to his task a large experience, and evidences a very thorough knowledge of the literature, native and foreign, pertaining to this special branch of medicine. The book has been written with great care, and the author is a good writer. The publisher's part of the task has also been excellently performed." — Boston Medical and Surgical Journal. 'A safe and readable introduction to aural surgery." Medical Press and Circular. " Dr. Dalby has presented us with a very readable little book, which is destined to render ranch service in the saving of ears." — N. Y. Medical Journal. "The lectures occupy 2e6 pages, are clearly and consisely written, contain a number of good illustrations, and are well worth the careful study of both student and practitioner. To aurists the work will be most welcome and valuable." — Sj>ecialist. DILLINGBERGER, WOMEN AND CHILDREN'S DIS- EASES. A Hand-Book of the Treatment of the Diseases Peculiar to Women and Chil- dren. By Dr. Emil Dillingberger. i2mo. Price $1.50 " It is a magnum in parvo. The style is simple, clear, lucid, and free from theoretical discussion. No one will regret the small outlay for this volume. — Richmond and Louisville Medical Journal. DUNGLISON, THE PHYSICIAN'S REFERENCE BOOK. The Practitioner's Ready Reference Book ; a Guide in OfRce and Bedside Prac- tice ; containing Therapeutical and Practical Hints, Dietetic Rules, and General Information. By Richard J. Dunglison, m.d. Fourth Edition. 8vo. Price $3.50 " We can heartily commend this book as one that I " The demand for a second edition so soon after the must prove very useful to the general practitioner."— publication of the first volume shows that this work is The Medical Record. \ appreciated by the profession." — Caiiada Lancet. DURKEE, VENEREAL DISEASES. Sixth Edition. Gonorrhoea and Syphilis. By Silas Durkee, m.d. Sixth Edition. Revised and Enlarged, with Portrait and Eight Colored Illustrations. 8vo. Price $3.50 " We may, finally, recommend Dr. Durkee's book as eminently practical, well written, full of excellent counsel, and worthy of being cors ilted by every member of the profession. A late number of the London Medical Times and Gazette also speaks of the book in terms of the highest approval." — Bjston Medical and Surgical Journal 14 P. BLAKISTON, SON &- CO.'S DAGUENET, OPHTHALMOSCOPY. A Manual of Ophthalmoscopy, for the Use of Students. By Dr. Daguenet. Translated from the French, by Dr. C. S. Jeaffreson, f.r.c.s.e. Illustrated. i2mo. Price $1.50 "Its portable size, the condensed nature of its text, and the admirably systematic arrangement of its contents, render it extremely useful as a pocket manual for Students. — Translator' s Preface. DOBELL, "WINTER COUGH AND CATARRH. On Winter Cough, Catarrh, Bronchitis, Emphysema, Asthma, etc. By Horace Dobell, m.d.. Lecturer at the Royal Hospital for Diseases of the Chest. Third Edition. With Colored Plates. 8vo. Price $3.50 BY SAME AUTHOR. ON LOSS OF WEIGHT. Revised Edition. Blood Spitting and Lung Disease. Colored Frontispiece of Lung. Tabular Map, etc. Second Edition Enlarged. 8vo. Price I4.00 DOMVILLE, ON NURSING. A Manual for Hospital Nurses and others engaged in attending to the sick, 4th Edition. With Recipes for Sick Room Cookery, etc. Price .75 DRUITT'S MODERN SURGERY. Eleventh Edition. The Surgeon's Vade Mecum; a Manual of Modern Surgery. By Robert Druitt, f.r.c.s. Eleventh Enlarged Edition, with 369 Illustrations. 864 pp. 1878. Price $5.00 This is a most complete, accurate, and trustworthy Hand, or Text-Book of Sur- gery. Unrivaled as a book for the Student. Fully illustrated, and brought up to the present state of the science. In use in many Medical Colleges. DULLES, ACCIDENTS. What to Do First, In Accidents and Poisoning. By C. W. Dulles, m.d. Second Edition, Enlarged, with new Illustrations. Cloth, .75. " Its usefulness entitles it to a wide and permanent circulation." — Boston Gazette. " A complete guide for sudden emergencies. — Phila- delphia Ledger. " So plain and sensible that it ought to be introduced into every female seminary. — Evening Chronicle, Pittsburgh. EDWARDS, BRIGHT'S DISEASE. New Edition. How a Person Affected with Bright's Disease Ought to Live. By Jos. F. Ed- wards, M.D. Second Edition. i2mo. Price .75 " Physicians, as well as laymen, will find the work interesting, and will obtain many valuable hints as to the proper hygiene to be observed in this disease." — Cincinnati Medical Ne-ws. BY SAME AUTHOR. CONSTIPATION. New Edition. Plainly Treated and Relieved Without the Use of Drugs. Second Edition. i2mo. Price .75 MALARIA. Malaria : What It Means ; How to Escape It ; Its Symptoms ; When and Where to Look for It. i2mo. Price .75 VACCINATION AND SMALL-POX. Showing the Reasons in favor of Vaccination, and the Fallacy of the Argu- ments Advanced against it, with Hints on the Management and Care of SmaH- Pox patients. i6mo. Price .50 These are invaluable little treatises upon subjects that enter painfully into the life experiences of a large majority of the human family. Dr. Edwards shows not only how they ftiay be avoided, but in plain and simple language he tells those already afflicted with them how they may find relief. PUBLIC A TIONS. IS ELLIS, DISEASES OF CHILDREN. A Practical Manual of the Diseases of Children, with a Formulary. By Ed- ward Ellis, m.d. Late Physician to the Victoria Hospital for Children, London. Fourth Edition Enlarged. Now Ready. Price $3.00 BY SAME AUTHOR. WHAT EVERY MOTHER SHOULD KNOW. i2mo. Price .75 " It is only too true that our children have to dodge through the early part of life as through a labyrinth. We must be thankful to meet with such a sensible guide for them as Dr. Ellis." — Pall Mall Gazette. FLUCKIGER, THE CINCHONA BARKS. The Cinchona Barks Pharmacognostically Considered. By Professor Fried- RiCH Fluckiger, of Strasburg. Translated by Frederick B. Power, ph.d., formerly Professor of Chemistry, Philadelphia College of Pharmacy, now Pro- fessor of Materia Medica and Pharmacy, University of Wisconsin. With 8 Lithographic Plates. Royal Octavo. hi Press. FENNER, ON VISION, Second Edition, Enlarged. Vision ; Its Optical Defects, the Adaptation of Spectacles, Defects of Accommo- dation, etc. By C. S. Fenner, m.d. With Test Types and 74 Illustrations. Second Edition, Revised and Enlarged. 8vo. ' Price $3.50 FENWICK, THE PRACTICE OF MEDICINE. Outlines of the Practice of Medicine. With Appropriate Formulae and Illus- trations. By Samuel Fenwick, M.D. , Physician to the London Hospital. i2mo. Price $1.25 " This little work displays a sound judgment in the arrangement of its subject matter, and an intimate acquaint- ance with the practice of medicine possessed by but few writers, and should have been elaborated into a more comprehensive work. Of all the hand-books we have seen, this is certainly one of the best." — Medical Herald. " It is an eminently practical little treatise, pervaded with much common sense, and will doubtless be found useful, particularly by advanced students." — Boston Medical and Surgical Journal. BY SAME AUTHOR. ON THE STOMACH. Atrophy of the Stomach and Its Effect on the Nervous Affections of the Digest- ive Organs. 8vo. Price $3.20 FOTHERGILL, ON THE HEART. Second Edition. The Heart and Its Diseases. With Their Treatment. Including the Gouty Heart. By J. Milner Fothergill, m.d., Associate Fellow of the College of Physicians of Philadelphia, Second Edition, Entirely Re-written. Octavo. Price $3.50 " It is the best, as well as the most recent work on the subject in the English language." — Medical Press and Circular. " The most interesting chapter is undoubtedly that on the gouty heart, a subject which Dr. Fothergill has specially studied, and on which he entertains views such as are likely, we think, to be generally accepted by clinical physicians, although they have not before been stated, so far as we are aware, with the ■ same breadth of view and extended illustration." — British Medical Journal. " To many an earnest student it will prove a Kght in darkness ; to many a practitioner cast down with a sense of his powerlessness to cope with the rout and demoralization of Nature's forces, a present help in time of trouble." — Philadelphia Medical Times. " The work throughout is a masterpiece of graphic, lucid writing, full of good, sound teaching, which will be appreciated alike by the practitioner and the stu- dent." — Students' Journal. FULTON, ON PHYSIOLOGY. A Text-Book of Physiology. By J. Fulton, m.d.. Professor at Trinity Medical College, Toronto. Second Edition, Illustrated and Revised. 8vo. Price fi4-oo i6 P. BLAKISTON, SON 6- CO:S FLO^VER, DIAGRAMS OF THE NERVES. Diagrams of the Nerves of the Human Body. Exhibiting their Origin, Divisions, and Connections, with their Distribution to the various Regions of the Cutaneous Surface, and to all the Muscles. By William H. Flower, f.r.c.s., F.R.S., Hunterian Professor of Comparative Anatomy, and Conservator of the Museum of the Royal College of Surgeons. Third Edition, thoroughly revised. With six Large Folio Maps, or Diagrams. Royal Quarto. Price $3.50 "Admirably arranged, and will be of incalculable aid to the student of anatomy. Eacb of the large and , beautiful plates is accompanied with explanatory' text." — N. Y. Medical Record. " The nerves and ganglia are clearly represented. The impressions are well made, and no doubt the diagrams will prove useful." — Medical and Surgical Reporter. FLAGG, PLASTIC FILLING. Plastics and Plastic Filling; As Pertaining to the Filling of all Cavities of De- cay in. Teeth below Medium in Structure, and to Difficult and Inaccessible Cavities in Teeth of all Grades of Structure. With some beautifully executed Illustrations. By J. Foster Flagg, d.d.s.. Professor of Dental Pathology and Therapeutics in Philadelphia Dental College. Octavo. Price $3.00 FOX, W^ATER, AIR AND FOOD. Sanitary Examinations of Water, Air and Food. By Cornelius B. Fox, M.D. 94 Engravings. 8vo. Price $4.00 FOSTER, CLINICAL MEDICINE. Lectures and Essays on Clinical Medicine. By Balthazar Foster, m.d. Illustrated. 8vo. Price $3.00 "No one can peruse_ the thoughtfiil comments of our j " Tt is the record of honest work, such as Dr. Foster author upon everj' subject he considers, without feeling I may be proud of ; we can recommend it to the profession; himself a wiser man for his pains." — N. Y. Medical \ it maj' be read with profit and advantage by both prac- yournal. \ titioner and student. — Edinburgh Medical yournal. FOX, ATLAS OF SKIN DISEASES. Complete in Eighteen Parts, each containing Four Chromo-Lithographic Plates, I'jiyith Descriptive Text and Notes upon Treatment. In all 72 large colored Plates. By Tilbury Fox, m.d., f.r.c.p., Physician to the Department for Skin Diseases in University College Hospital. Folio Size. Price $1.00 each, or complete, bound in cloth, $20.00 No Atlas of Skin Diseases has been issued in this country for many years, and no complete work of the kind is now procurable by the Profession. This one, brought out under the editorial supervision and care of Dr. Tilbury Fox (the most distin- guished -WTiter on Cutaneous Medicine now in the English language), is partly based upon the classical work of Willan and Bateman (now entirely out of print), but com- pletely remodeled, so as to represent fully the Dermatology of the present day. '■' Preference wiU be given to this work over Hebra ; not simply, however, because it is a home production, but by reason of the manner of its execution, the excellent delineation of disease, and the natural coloring of the plates. . . The letter-press is entirely new. In the accuracy of the latter the subscriber may have the fullest confi- dence, since it is from the pen of Dr. Tilbury Fox." — British and Foreign Medico-Chirurgical Reznew. FRANKLAND, WATER ANALYSIS. Water Analysis, For Sanitary Purposes, with Hints for the Interpretation of Results. By E. Frankland, M.D., F.R.s. Illustrated. i2mo. Price |i. 00 "The author's world-wide reputation will commend | "The work is one which physicians practicing ia this manual to all sanitarians, and they will not be dis- I the country and in villages and towns remote from appointed in finding all the essentials of the important ! medical centres cannot afford to be without." — Medical subject of which it treats." — The Sanitarian. \ and Surgical Reporter. BY SAME AUTHOR. CHEMISTRY. How to Teach Chemistry; being Six Lectures to Science Teachers. Edited by G. George Chaloner, f.c.s. Illustrated. i2mo. Price $1.25 PUB Lie A TIONS. 17 GILLIAM'S PATHOLOGY. Illustrated. The Essentials of Pathology ; a Handbook for Students. By D. Tod Gilliam, M.D., Professor of Physiology, formerly Professor of Pathology, Starhng Medical College, Columbus, O. With 47 Illustrations. i2mo. Cloth, $2.00 GALLABIN, DISEASES OF WOMEN. The Student's Guide to the Diseases of Women. By A. Lewis Gallabin, m.a., M.D., F.R.c.P. Illustrated with 63 Engravings. i2mo. Price $1.25 BY SAME AUTHOR. A MANUAL OF MIDWIFERY. For Students and Practitioners. Illustrated. In Press. "**Prof. Gallabin is Obstetric Physician to Guy's Hospital, London, and occupies the chair of Midwifery in that Institution. His work in this department has been noted for its perfection and practical character. GROSS, BIOGRAPHY OF JOHN HUNTER. John Hunter and His Pupils. By S. D. Gross, m.d.. Professor of Surgery in Jefferson Medical College, Philadelphia. With a beautifully executed full length Portrait of the Author in his Study. A Handsome Octavo volume. Bound in Beveled Cloth. Price $1.50 " It is refreshing to read the story of a life so fully devoted to science, and the reader will readily appreciate Professor Gross's enthusiasm for his subject, which led him to extend what was originally intended for an essay to its present size. " The phototype of Sharp's well-known engraving of Sir Joshua Reynold's portrait is an excellent reproduction, and forms a fitting and handsome frontispiece. " The volume will prove an ornament to the study table, where it will be a constant incentive to whatever 'vi best and noblest in a noble profession." — Bjsto?i Med. and Surgical yournal. BY SAME AUTHOR. AMERICAN MEDICAL MEN. American Medical Biography of the Nineteenth Century, with portrait of Di. Benjamin Rush. Large 8vo. GLISAN, TEXT-BOOK OF MODERN MIDWIFERY. A Text-Book of Modern Midwifery. By Rodney Glisan, m.d.. Emeritus Professor of Midwifery and Diseases of Women and Children in the Medical Department of Willamette University, Portland, Oregon, and Late President of the Oregon State Medical Society. With 129 Illustrations. One Volume, octavo, 624 pp. Price, in Cloth ^.oo; in Leather |5-CX3 GILL, ON INDIGESTION. Third Edition. Indigestion ; What It Is ; What It Leads To ; and a New Method of Treating It. By John Beadnell Gill, m.d. Third Edition. i2mo, |i-25 GANT, ON THE BLADDER AND PROSTATE. Diseases of the Bladder and Prostate Gland and Urethra, including a Practical View of Urinary Diseases, Deposits and Calculi. Fourth Edition, Revised and Enlarged, with New Illustrations. i2mo. Price $3.00 GIBBES, STUDENT'S PATHOLOGY. Practical Histology and Pathology. By Heneage Gibbes, m.b. i2mo. Cloth. Price ^2.00 Chap. i. Introduction. 2. On Preparing Tissues for Examination. 3. On Cutting Sections. 4. On Staining, 5. On Double Staining. 6. On Mounting. 7. Method of Obtaining Animal Tissues, etc. Practical Histology, Pathology, Memoranda and Formulae. " This excellent little work is admirably adapted to fulfill the purpose for which it has been written. It is short, clear, and eminently practical. The author is evidently an accomplished histologist, and his book conveys the impression that it is based upon his own personal experience." — The LondoK Medical Record. p. BLAKISTON, SON &= CO:S GODLEE'S ATLAS OF HUMAN ANATOMY. Illustrating most of the Ordinary Dissections and many not usually practiced by the Student. Accompanied by References and an Explanatory Text. Com- plete. Folio Size. 48 Colored Plates. By Rickmax John Godlee, m.d., F.R.c.S. Forming a large Folio Volume, with References, and an Octavo Volume of Letter-press. Price of the two Volumes, Atlas and Letter-press, Cloth, $20.00 " It is likely to prove as useful to the physician and ] " The explanatory' text is concise, well written, and surgeon as to the anatomist." — Medical Times and I contains many valuable suggestions for the surgeon." Gazette. | — London Lancet. GOWERS, SPINAL CORD. Diagnosis of Diseases of the Spinal Cord. With Colored Plates and Engrav- ings. A Second Edition. Revised and Enlarged. By William R. Gowers, M.D., Assistant Professor Clinical Medicine, University College, London. 8vo. Second Edition. Price ^1.50 BY SAME AUTHOR. OPHTHALMOSCOPY. A Manual and Atlas of Medical Ophthalmoscopy. With 16 Colored Auto" type and Lithographic Plates and 26 Wood Cuts, comprising 112 Original Illus- trations of the Changes in the Eye in Diseases of the Brain, Kidneys, etc. 8vo. Price $6.00 EPILEPSY AND ITS TREATMENT. Epilepsy and other Chronic Convulsive Diseases : Their Causes, Symptoms, and Treatment. Octavo, ynst Ready. Price, Cloth, $4.00 NERVOUS DISEASES. A Manual of Diseases of the Nervous System, for Practitioners and Students. In Press. "Dr. Gowers, while profoundly conversant with the literature of his subject, has not allowed himself to be influenced to an undue extent by the writings of others, but while fairly stating their views, where this is neces- sary, he at the same time brings to bear upon them the experience derived from his own extensive observations, and when, consequently, they receive confirmr-,tion or not at his hands, they are all the more valuable as being the outcome of the most searching and unbiased criticism. It would be impossible, within the limits of a short re- view, to convey an adequate idea of the extent of Dr. Gowers" work." — Edinburgh Medical journal. G»REENHOW, BRONCHITIS. On Chronic Bronchitis, especially as connected with Gout, Emphysema, and Diseases of the Heart. By E. Headlam Greenhow, m.d. i2mo. Price $1.50 BY S.A.ME AUTHOR. ADDISON'S DISEASE. Being the Croonian Lectures, delivered before the Royal College of Physi- cians, London. Revised and Illustrated by Plates and Reports of Cases. 8vo. Price $3.00 "The book forms a most interesting and valuable monograph, comprehensive and exhaustive." — British Medical yournal. HUGHES, COMPEND OF THE PRACTICE OF MEDICINE. A Compend of Practice. By Daniel E. Hughes, m.d., Demonstrator of Clinical Medicine at Jefferson l\Iedical College, Philadelphia. In two parts — Part I. — Continued, Eruptive, and Periodical Fevers, Diseases of the Stom- ach Intestines, Peritoneum, Biliary Passages, Liver, Kidneys, etc., and General Diseases, etc. Part II. — Diseases of the Respiratory System, Circulatory System, andj Nervous System ; Diseases of the Blood, etc. Price of each Part, in Cloth, $1.00; interleaved for the addition of Notes, $1.25 %* These little books can be regarded as a full set of notes upon the Practice of Medicine, containing the Synonyms, Definitions, Causes, Symptoms, ProgI nosis. Diagnosis, Treatment, etc., of each disease, and including a number of new prescriptions. They have been compiled from the lectures of prominent Professors, and reference has been made to the latest writings of Professor^ ■Flint, Da Costa, Reynolds, Bartholow, Roberts and others. PUBLICA TIONS. 19 HABERSHON, ON THE STOMACH. On Diseases of the Stomach— The Varieties of Dyspepsia — Their Diagnosis and Treatment. By S. O. Habershon, m.d., f.r.c.p., Senior Physician to, and Late Lecturer on, the Principles and Practice of Medicine at Guy's Hospital. Third Edition, Revised. Crown 8vo. Price ^1.25 "As an expression of the results of long personal experience in both hospital and private practice, conveyed in agreeable though not always perspicuous diction, this contribution of Dr. Habershon's has special value of its own, and is so far entitled to the favorable consideration of the practitioner, as is already testified by a demand for a third edition." — American yournal of Medical Sciences. HALE, ON CHILDREN. The Management of Children in Health and Disease. A Book for Mothers. By Mrs. Amie M. Hale, m.d. Abounding in valuable information and com- mon sense advice. New Enlarged Edition. i2mo. Price .75 " We shall use our influence in the introduction of this work to families under our care, and we urge the pro- fession generally to follow our example." — Buffalo Medical and Surgical yournal. HORWITZ, COMPEND OF SURGERY. A Compend of Surgery, including Minor Surgery, Amputations, Fractures, Ligatures, Dislocations, Surgical Diseases, etc., with Differential Diagnosis and Treatment. By Orville Horwitz, b.s., m.d., with Illustrations. i2mo. Cloth, $,\.QO HARDWICKE, MEDICAL EDUCATION. Medical Education and Practice in All Parts of the World. Containing Regulations for Graduation at the Various Universities throughout the World. By Herbert Junius Hardwicke, m.d., m.r.c.p. 8vo., Price $3.00 " Dr. Hardwicke's book will prove a valuable source of information to those who may desire to know the conditions upon which medicSl practice is or may be pursued in any or every country of the world, even to the lemotest corners of the earth. Thework has been compiled with great care, and must have required a vast, amount of labor and perseverance on the part of its author." — Dublin Medical yournal. HARLEY, ON THE LIVER. Illustrated. On Diseases of the Liver, with or without Jaundice. Diagnosis and Treat- ment. By George Harley, m.d. Author of the Urine and Its Derangements. With Colored Plates and Numerous Illustrations. Royal Octavo. * Price, Cloth, $5.00 ; Leather, $6.00. " It is one of the freshest, vtost readable , and most instructive medical books that have been laid upon our table during the present decade. . . In conclusion, we commend again most heartily Dr. Harley's extremely valuable book." — Philadelphia Medical Times. " The work is far in advance, in original and prac- tical information, of any treatise on the subject with rt'hich we are acquainted, and is worth many times its cost to any physician treating hepatic troubles." — Chicago Medical Times. " The whole subject-matter is treated in a masterly manner, and the work is destined to find a place among the classics." — Medical Herald, Louisville , Ky. " It is the outcome of a mind that went to its task amply equipped therefor. It is the product of long thinking and ripe judgment. . . . We must con- tent ourselves with this bare statement, hoping that those who read the book will derive as much benefit as ourselves." — JVew Orleans Medical and Surgical yournal. HOLDEN, HUMAN OSTEOLOGY. Sixth Edition. Comprising a Description of the Bones, with Colored Delineations of the At- tachments of the Muscles. The General and Microscopical Structure of Bone and its Development. By the Author and A. Doran, f.r.c.s., with Lithographic Plates, etc. By Luther Holden, f.r.c.s. Numerous Illustrations. Sixth Edition, carefully Revised, Price $6.00 BY SAME author. ANATOMY. Manual of Dissections of the Human Body. Fourth London Edition. With 170 Illustrations. Price $5.50 LANDMARKS. Landmarks, Medical and Surgical, Third London Edition. Revised and Enlarged. Price 5]ii. 00 "Mr. Holden is the happy possessor of the faculty of writing interesting works on Anatomy. A part of the charm consists in the frequent references to practical points, and in the explanation of the advantages ail' objects of details of structures." — Boston Medical and Surgical yournal. 20 P. BLAKISTON, SON &^ CO.'S HEATH'S OPERATIVE SURGERY. A Course of Operative Surgery, consisting of a Series of Plates, feach plate containing Numerous Figures, Drawn from Nature by the Celebrated Anatomi- cal Artist, M. Leveille, of Paris, Engraved on Steel and Calored by Hand, under his immediate superintendence, with Descriptive Text of Each Operation. By Christopher Heath, f.r.c.s., Surgeon to University College Hospital, and Holme Professor of Clinical Surgery in University College, London. One Large Quarto Volume. Price $14.00 The author has embodied in this work the experience gained by him during tiventy years of surgical teaching. It comprises all the operations that are required in ordinary surgical practice. He has selected for illustration and description those methods which appear to give the best results in practice, referring to the errors likely to occur and the best methods of avoiding them. BY SAME AUTHOR. THE STUDENT'S GUIDE TO SURGICAL DIAGNOSIS. i.imo. Price §1.25 " Mr. Heath is so well known, both as a practical surgeon, teacher and writer, that anything from his pen re- quires no introduction from the hands of reviewers, and scarcely any notice but the announcement of the fact that he has written a book." — Medical Record. A MANUAL OF MINOR SURGERY AND BANDAGING. Sixth Edition, Revised and Enlarged. With 115 Illustrations. i2mo. Price |2.oo "This excellent work should not be termed a ' Minor' Surgery, but it really consists of the sum and substance of Practical surgerj'. We would not exchange it for any book in our possession." — Scuthern Clinic. HEATH'S PRACTICAL ANATOMY. Fifth London Edition. Practical Anatomy. A Manual of Dissections. Fifth London Edition. 24 Colored Plates, and nearly 300 other Illustrations. Just Ready. Price I5.00 INJURIES AND DISEASES OF THE JAWS. The Jacksonian Prize Essay of the Royal College of Surgeons of England, 1*867. Second Edition, Revised, with over 150 Illustrations. Octavo. Price 14-25 HOOD, ON GOUT AND RHEUMATISM. A Treatise on Gout, Rheumatism, and the Alhed Affections. Their Treat- ment, Complications, and Prevention. By Peter Hood, m.d. Second Edi- tion, Revised and Enlarged. With some Considerations on Longevity. Octavo. Price $3.50 " The Observations on Treatment are specially to be commended." — London Lancet. HOLDEN, THE SPHYGMOGRAPH. The Sphvgmograph. Its Physiological and Pathological Indications. By Edgar Holden, m.d. Illustrated by Three Hundred Engravings on Wood. 8vo. Price $2.00 HOLMES, THE LARYNGOSCOPE. A Guide to the Use of the Laryngoscope in General Practice. By Gordon Holmes, m.d.. Physician to the Throat and Ear Infirmary. i2mo. Price |i.oo BY SAME AUTHOR. VOCAL PHYSIOLOGY. Vocal Physiology and Hygiene. With reference to the Cultivation and Preservation of the Voice. Illustrated. i2mo. Price ;g2. 00 HOFF, ON HEMATURIA. Hcematuria as a Symptom of the Diseases of the Genito-Urinary Organs. By O. HoFF, m.d. Illustrated. i2mo. Price .75 PUB Lie A TIONS. HUNTER, MECHANICAL DENTISTRY. A Practical Treatise on the Construction of the Various kinds of Artificial Dentures, with Formulae, Receipts, etc. By Charles Hunter, d.d.s. igo Illustrations. i2mo. Price ^r.50 " It is the outcome of his own experience of some twenty years as a Mechanical Dentist, and contains, moreover, much derived from practical knowledge of other dentists. The value of the book is also much added to by illus- trations. It will be very useful to the Dental Student, and to all Mechanical Dentists." — London Medical Times 4.nd Gazette. HUTCHINSON'S ILLUSTRATIONS OF CLINICAL SUR- GERY. First Volume Complete. Consisting of Plates, Photographs, Woodcuts, Diagrams, etc. Illustrating Surgical Diseases, Symptoms, and Accidents; also Operations and other Methods of Treatment. With Descriptive Letter-press. By Jonathan Hutch- inson, F.R.C.S., Senior Surgeon to the London Hospital, Surgeon to the Moor- fields Ophthalmic Hospital, and to the Hospital for Diseases of the Skin, Black- friars. In Quarterly Fasciculi. Imperial 4to. Volume i. (Ten Fasciculi) bound complete in itself. Price $25.00. Parts Eleven to Fifteen of Volume 2, Now- Ready. Each, $2.50 HEWITT, DISEASES OF WOMEN. Fourth Edition. The Diagnosis, Pathology, and Treatment of Diseases of Women, Including the Diagnosis of Pregnancy. Founded on a Course of Lectures Delivered at St. Mary's Hospital Medical School. By Graily Hewitt, m.d., Lond., m.r.c.p., Physician to the British Lying-in Hospital ; Lecturer on Midwifery and Diseases of Women and Children at St. Mary's Hospital Medical School; Honorary Secretary to the Obstetrical Society of London, etc. The Fourth American Edition. Revised and Enlarged, with New Illustrations. Octavo. Price, Paper, IS1.50; Cloth, $2.50 " Readers of the former editions will not require to be told that the additions now made are of the highest possible excellence." — Titnes and Gazette. " It is one of the most useful, practical, and compre- hensive works upon the subject in the English language, a true guide to the student, and an invaluable means of reference for the teacher." — N. Y. Medical Record. " The excellent work of Dr. Hewitt presents — in a form well adapted to conduct the student to a knowledge of the Diseases of Women, and to assist the young practitioner in his study of these diseases at the bedside of the patient — a very full and clear exposition of the views entertained by the most authoritative teachers as to their pathological treatment and their correct Diag- nosis." — Amer. Med. jfournal. HAY, SARCOMATOUS TUMOR. History of a Case of Recurring Sarcomatous Tumor of the Orbit in a Child. By Thomas Hay, m.d. Illustrated. Paper. Price .50 HEWSON, EARTH IN SURGERY. Earth as a Topical Application in Surgery, Being a Full Exposition of its Use In Cases Requiring Topical Applications. By Addinell Hewson, m.d. Illus- trated. 8vo. Price $2.50 HODGE, ON ABORTION. On Foeticide or Criminal Abortion. By Hugh L. Hodge, m.d. Price, Paper, .30; Cloth, .50 HODGE, CASE-BOOK. Note-Book for Cases of Ovarian Tumors. By H. Lennox Hodge, m.d. With Diagrams. Price, Paper, .50 HIGGINS, DISEASES OF THE EYE. Now Ready. A Hand-Book of Ophthalmic Practice. By Charles Higgins, f.r.c.s. Ophthalmic Assistant Surgeon at Guy's Hospital. Second Edition. i6mo. Price .50 Contents. — Section i. Discharge from the Eyes. ii. Intolerance of Light, iii. Iritis and Glaucoma, iv. Diseases of the Eyelids, v. Watering of the Eye. vi. Acuteness of Vision, Field of Vision, Anomalies of Re- fraction, Astigmatism, Accommodation, Presbyopia, vii. Disturbance of Vision, Use of the Ophthalmoscope; Normal and Morbid Appearances, vm. Injuries. "We have rarely seen so much important information condensed in so short a space." — American Medical journal. 22 P. BLAKISTON, SON &- CO.'S HARRIS, THE PRACTICE OF DENTISTRY. Tenth Edition. The Principles and Practice of Dentistry. Tenth Revised Edition. In great part Rewritten, Rearranged, and with many new and important Illustrations. By Chapin a. Harris, m.d., d.d.s. Edited by P. H. Austen, m.d.. Professor of Dental Science and Mechanism in the Baltimore College of Dental Surgery. With nearly 400 Illustrations. Royal Octavo. Price, Cloth, ^6.50 ; Leather, I7.50 This new edition of Dr. Harris' work has been thoroughly revised in all its parts, more so than any previous edition. So great have been the advances in many branches of dentistry that it was found necessary to rewrite the articles or subjects, and this has been done in the most efficient manner by. Professor Austen, for many years an associate and friend of Dr. Harris, assisted by Professor Gorgas and Thomas S. Latimer, m.d. The publishers feel assured that it will now be found the most complete text-book for the student, and guide for the practitioner in the Enghsh language. BY SAME AUTHOR. MEDICAL AND DENTAL DICTIONARY. Fourth Edition. A Dictionary of Medical Terminology, Dental Surgery, and the Collateral Sciences. Fourth Edition, Carefully Revised and Enlarged. By Ferdinand J. S. Gorgas, M.D. , d.d.s., Professor of Dental Surgery in the Baltimore College, etc. Royal Octavo, Price, Cloth, $6.50; Leather, $7.50 This Dictionary, having passed through tAree editions, and been for some time out of print, has been again carefully revised by F. J. S. Gorgas, m.d.. Dr. Harris" successor as Professor of Dental Surgery in the Baltimore College of Dental Surgery. In his preface to this new edition, the editor says : — " The object of the reviser has been to bring the book thoroughly up to the pres- ent requirements of the profession, the Medical portion having been as carefully re- vised and added to as that devoted more especially to Dental Science, while a number of obsolete terms and methods have been omitted. In nearly every one of the seven hundred and forty-three pages of the former edition corrections and addi- tions have been made, and many new processes, terms and appliances described, some of which are not found in any other work published." HANDY, ANATOMY. Text-Book of Anatomy and Guide to Dissections. For the Use of Students. By W. R. Handy, m.d. 312 Illustrations. Price S3.00 HILLIER, DISEASES OF CHILDREN. A Clinical Treatise on the Diseases of Children. By Thomas Hillier, m.d. 8vo. Price $2.00. HUFELAND, LONG LIFE. The Art of Prolonging Life. By C. W. Hufeland. Edited by Erasmus Wilson, m.d. i2mo. Price $1.00 " We wish all doctors and all their intelligent clients would read it, for surely its perusal would be attended -A'ith pleasure and benefit." — American Practitioner. " It certainly should be in the library of every physician." — Medical Brie/. HUNTER, PORTRAIT OF. Portrait of John Hunter. From Sharp's well-known Engraving ; a copy of Sir Joshua Reynold's Portrait. For Framing. Large size, 9x11; sheet 16 x20. Price, in the Sheet, sent free by mail, 50 cents ; or, Handsomely Framed^ Price ;fS2.oo PUBLICA TIONS. 33 HEADLAND, THE ACTION OF MEDICINES. Ninth Edition. On the Action of Medicines in the System. By F. W. Headland, m.d. Ninth American Edition, Revised and Enlarged. 8vo. Price $3.00 " It displays in every page the evidence of extensive knowledge and of sound reasoning; it will be useful alite to those who are just commencing their studies, and to those who are engaged in the active pursuits of pro- fessional life." — Medical Times. " The very favorable opinion which we were amongst the first to pronounce upon this essay has been fully confirmed by the general voice of the profession, and Dr. Headland may now be congratulated on having pro- duced a treatise which has been weighed in the balance, and found worthy of being ranked with our standard medical works." — London Lancet. JAMES, SORE THROAT. On Sore Throat, Its Nature, Varieties and Treatment, Including its Con- nection with other Diseases. By Prosser James, m.r.c.p. Fourth Edition, Revised and Enlarged. With Colored Plates and Numerous Wood-cuts. i2mo. Price $1.25 " We can confidently recommend his therapeutic teachings as well worthy of the careful consideration of the Profession, for they set forth the practice of an enthusiastic worker, whose special experience has been large and lengthened." — British Medical yournal. " The practitioner who buys Dr. James' unpretending little book will provide himself with a wise and practical clinical commentary, and with a well arranged digest of long and varied experience." — IVestnzinster Meview. BY SAME AUTHOR. LARYNGOSCOPY AND RHINOSCOPY. Including the Diagnosis of Diseases of the Throat and Nose. Third Edition. With Colored Plates. i8mo. Price $2.00. " It gives in a succinct form the approved methods of examination and treatmen t of diseases of the nose, throat, and larynx. The plan pursued is one well adapted to the needs of the general practitioner." — American Medical yournal. JONES, AURAL ATLAS. An Atlas of Diseases of the Membrana Tympani. Being a Series of Colored Plates, containing 62 Figures. With appropriate Letter-press and Explanatory Text. By H. Macnaughton Jones, m.d., Surgeon to the Cork Ophthalmic and Aural Hospital. 4to. Price ^4.00. " The cases are well selected, the drawings executed from life, highly artistic and very conscientious, and the commentaries indicate familiarity with the subject and good judgment in dealing with it." — British Medical yournal. BY SAME AUTHOR. AURAL SURGERY. A Practical Hand-book on Aural Surgery. Illustrated. ' Second Edition, Re- vised and Enlarged, with new Wood Engravings. i2mo. Cloth. Price $2.75 JONES, SIEVEKING AND PAYNE, PATHOLOGICAL AN- ATOMY. A Manual of Pathological Anatomy. By C. Handfield Jones, m.d., and Edvitard H, Sieveking. m.d., Physician to St. Mary's Hospital, A New En- larged Edition. Edited by J. F. Payne, m.d., Lecturer on Morbid Anatomy at St. Thomas' Hospital. With Numerous Illustrations. Demi 8vo. Price $5.50. JONES, ON SIGHT AND HEARING. The Defects of Sight and Hearing, their Nature, Causes, and Prevention. By T. Wharton Jones, m.d. Second Edition. i6mo. Price .50. KIRBY, ON PHOSPHORUS. Fifth Edition. Phosphorus as a Remedy for Functional Diseases of the Nervous System. By E. A. KiRBY, m.d. Fifth Edition. 8vo. Price ;^i.oo KOLLMEYER, KEY TO CHEMISTRY. Chemia Coartata, or Key to Modern Chemistry. By A. H. Kollmeyer, m.d. With Numerous Tables, Tests, etc. Price $2.35 KIRKE, PHYSIOLOGY. Revised and Enlarged. A Hand-book of Physiology. By Kirke. Tenth London Edition. By W MoRRANT Baker, m.d. 420 Illustrations. Now Ready. Price $5.00 " This is undoubtedly the best work for students on Physiology extant." — Cincinnati Med. News. 24 p. BLAKISTON, SON &^ CO.'S KANE, THE OPIUM, MORPHINE AND SIMILAR HABITS. Drugs that Enslave. The Opium, Morphine, Chloral, Hashisch and Similar Habits. By H. H. Kane, m.d., of New York. With Illustrations. Price I1.25. " It contains a large amount of information collected with much labor and presented In a systematic manner. The subject of the chloral habit has not been investigated by any one, we believe, so thoroughly as Dy Dr. Kane." — Medical Record. " It deserves to be raad by those who feel an interest in discouraging the use of these dangerous drugs. The book is embellished by an excellent phototype frontispiece of Laocoon." — American yournal of Pliar»tcu:y. "A work of more than ordinary ability and careful research. . . . For the first time, reliable statistics on the use of chloral are classified and published, . . . and it is shown that the use of c^orsX^ causes a more complete and rapid ruin oftnitid and body than either opium or morphine." — Druggists' Circular and Gazette.- KIDD, THERAPEUTICS. The Laws of Therapeutics ; or, the Science and Art of Medicine. By Joseph KiDD. M.D. i2mo. Cloth. Price ^1.25. " Dr. Kidd acknowledges two laws — that oi contraria contrariis and similia similibus ; but the cases he giTes in his chapter on ars 7nedica show that, like a sensible practitioner, he does not allow himself blindly to follow either the one or the other, but seeks out the cause of disease, and tries by rational measures to remove it. The cases are the most valuable part of the book." — London Practitioner . LANDIS, A COMPEND OF OBSTETRICS. Illustrated. A Compend of Obstetrics ; especially adapted to the Use of Students and Physicians. By Henry G. Landis, m.d.. Professor of Obstetrics and Diseases of Women in Starling Medical College, Columbus, Ohio. Illustrated. 12 mo. Cloth. Price gi.oo; interleaved for the addition of Notes, $1.25 " The questions are well chosen, the answers clear, concise, and well up to the present state of obstetrical science. It v.-ill be a handy book for reference for practitioner as well as student." — Prof. E. O. P. " It is complete, accurate and scientific ; the very best book of its kind." — Pro/, jf. S. Knox, Rush Medical College, Chicago. " I have been teaching in this department for many Roler, Chicago Medical College. years, and am free to say that this will be the best " I have observed no statement to the correctness assistant I ever had. It is accurate and comprehen- of which I could take exception. There are very few sive, but brief and pointed." — Prof. P. D. Yost, St. practitioners who cannot be instructed by its perusal." | Louis. —David Wark, 31. D., U. S. Medical College, New York. \ LEGG, ON THE URINE. Practical Guide to the Examination of the Urine, for Practitioner and Student. By J. WiCKHAM Legg, m.d. Fifth Edition, Enlarged. Illustrated. i2mo. Price .75 This little work is intended to supply the Physician or Student with a concise guide to the recognition of the different characteristics of the urine, and though small and well adapted to the pocket, contains, probably, everything that could be gleaned from a larger work. LEARED, IMPERFECT DIGESTION. The Causes and Treatment of Imperfect Digestion. By Arthur Leared, M.d. The 7th Edition. Revised and Enlarged. i2mo. Price $2.00 LIEBREICH, ATLAS OF OPHTHALMOSCOPY. An Atlas of Ophthalmoscopy, containing 12 Full-page Chromo-Lithographic Plates, with 59 Figures. By R. Liebreich, m.d. Second Edition, Enlarged. Large Quarto. Price ^12.00 LIVEING, ON SICK HEADACHE. Megrim, or Sick Headache and Some Allied Disorders. By Edward Live- ING, M.D. With Plates. Tables, etc. 8vo. Price $5.50 LEBER AND ROTTENSTEIN, DENTAL CARIES. Dental Caries and Its Causes. An Investigation into the Influence of Fungi - in the Destruction of the Teeth. By Drs. Leber and Rottenstein. Illustrated. 8vo. Paper Cover 75 cents ; Cloth, $1.25 " The work gives the result of patient observation, presents the deductions of its authors with a perspicuity and modesty calculated to secure for its positions a thoughtful consideration. We heartily commend it a* an educa. tional work." — Dental Cosmos. PUB Lie A TIONS. 25 I.EWIN, ON SYPHILIS. The Treatment of Syphilis. By Dr. George Lewin, of Berlin. Translated by Carl Proegler, m.d., and E. H. Gale, m.d., Surgeons U. S. Army. Illus- trated. i2mo. Price $1.25 " When such authorities as Dr. Drysdale (as we quoted a few weeks ago) condemn the use of mercury in syphilis as " too dangerous," while, on the other hand, eminent surgeons, such as Professor Gross, will not treat a case without that drug, general practitioners will gladly welcome any media via which gives us all the good effects of mercurials without any danger of their ill results appearing. This is what is accomplished by Dr. Lewin." Philadelphia Medical a7id Surgical Reporter. LIZARS, ON TOBACCO. The Use and Abuse of Tobacco. By John Lizars, m.d. i2mo. LONGLEY, POCKET MEDICAL LEXICON. Students' Pocket Medical Dictionary, Giving the Correct Definition and Pro^ nunciation of all Words and Terms in General Use in Medicine and the Collate- ral Sciences, with an Appendix, containing Poisons and their Antidotes, Abbre- viations Used in Prescriptions, and a Metric Scale of Doses. By Elias Longley. 24mo. Price, Cloth, #1.00; Tucks and Pocket $1.25 This is an entirely new Medical Dictionary, containing some 300 compactly printed 24mo pages, very carefully prepared by the author, who has had much ex- perience in the preparation of similar works, assisted by the Professors of Chemistry and of Botany in one of our leading medical colleges. " It is, we believe, also the only lexicon in existence in which the pronunciation of words is fully and dis- tinctly marked." — Canada Medical Review. " This is a very compact and complete little diction- ary. We commend it as particularly useful to students." — N'eiv York Medical journal. " This little book will be welcomed by students in medicine and pharmacy as a convenient pocket com- panion, giving the pronunciation, acceptation, and definition of medical, pharmaceutical, chemical and botanical terms." — Atnerican yournal of Phartnacy. " It would seem to be just the book for dental and medical students." — Dental Advertiser. MAYNE, MEDICAL DICTIONARY. Fifth Edition. A Medical Vocabulary, Being an Explanation of all Terms and Phrases used in the Various Departments of Medical Science and Practice, Giving their Deri- vation, Meaning, Application, and Pronunciation. Intended specially as a Book of Reference for the Student. By Drs. R. G. and J. Mayne. Fifth Edition. Revised and Enlarged. Cloth. . Price ^4.00 THE POLYCLINIC. A Monthly Journal of Medicine and Surgery, conducted by the Faculty of the Philadelphia Polyclinic and School for Graduates in Medicine. Sample copies free. Terms, per Annum, |i.oo An invaluable Monthly Reference List for Librarians, Professors, Specialists, and all wishing to keep acquainted with the Medical Literature of the day. MACDONALD, MICROSCOPICAL EXAMINATION OF WATER. A Guide to the Microscopical Examination of Drinking Water. By J. Do Macdonald, m.d. With Twenty Full-page Lithographic Plates, Reference Tables, etc. 8vo. Price ^^2.75 " The volume is an excellent Aand-book and will greatly facilitate the study of the sviVyftQX.."^— Popular Science Monthly. yiPCl'S,, THE THERAPEUTIC FORCES; Or, The Action of Medicine in the Light of the Doctrine of Conservation of Force. By Thomas J. Mays, m.d. i2mo. Price #1.25 26 p. BLAKISTON, SON hia Medical Times. BY SAME AUTHOR. THE PHARMACOPOEIA of the Hospital for Diseases of the Throat and Nose. The Fourth Edition, much enlarged, containing 250 Formulae, with Directions for their Preparation and Use. i6mo. Price $1.25 GROWTHS IN THE LARYNX. Their History, Causes, Symptoms, etc. With Reports and Analysis of one Hundred Cases. With Colored and Other Illustrations. 8vo. Price $2.00 MACNAMARA, DISEASES OF THE EYE. A Manual of the Diseases of the Eye. By C. Macnamara, m.d. Fourth Edition, Carefully Revised ; with Additions and Numerous Colored Plates, Dia- grams of Eye, Wood-cuts, and Test Types. Demi 8vo. Price $4.00 "As a book of ready reference on diseases of the eye it has no superior, and we may safely say, no equal in our language." — Cincinnati Lancet and Observer. BY SAME AUTHOR. ON THE BONES AND JOINTS. Lectures on Diseases of the Bones and Joints. Second Edition. Demi 8vo. Price $4.25 MADDEN, HEALTH RESORTS. Health Resorts for the Treatment of Chronic Diseases. A Hand-Book, the result of the author's own observations during several years of health travel in many lands, containing also remarks on climatology and the use of mineral waters. By T. M. Madden, m.d. 8vo. .Price ^2.50 " Rarely have we encountered a book containing so much information for both invalids and pleasure seekers." — The Sanitarian. MEDICAL REGISTER. Directory of Physicians in Philadelphia. Octavo. New Editio7i in Press. PUBLICA TIONS. rj MARSHAjLL & SMITH, ON THE URINE. The Chemical Analysis of the Urine. By John Marshall, m.d., and Edgar F. Smith, m.d., of the Chemical Laboratory, Medical Department, University of Pennsylvania. Illustrated by Phototype Plates. l2mo. Price ;^i.oo MARSHALL, ANATOMICAL PLATES; Or Physiological Diagrams. Life Size (7 by 4 feet) and Beautifully Colored. By John Marshall, f.r.s. An Entirely New Edition, Revised and Improved, Illustrating the Whole Human Body. The Set, Eleven Maps, in Sheets, Price ^50.00 " " handsomely Mounted on Canvas, with Rollers, and Varnished, Price $80.00 An Explanatory Key to the Diagrams, Price .50 Dr. Marshall's Plates, from their size and perfection of drawing and coloring, excel any diagrams that have been published. They have proved invaluable in Medical Schools and Lecture Rooms. The low price at which they are offered brings them within reach of all. No. I. The Skeleton and Ligaments. No. 2. The Muscles, Joints, and Animal Mechanics. No. 3. The Vis- cera in Position— The Structure of the Lungs. No. 4. The Organs of Circulation. No. 5. The Lymphatics or Absorbents. No. 6. The Digestive Organs. No. 7. The Brain and Nerves. No. 8. The Organs of the Senses and Organs of the Voice, Plate i. No. 9. The Organs of the Senses, Plate 2. No. 10. The Microscopic Structure of the Textures, Plate i. No. 11. The Microscopic Structure of the Textures, Plate 2. MARSDEN, ON CANCER. A New and Successful Mode of Treating Certain Forms of Cancer. By Alex- ander Marsden, M.D. Second Edition. Colored Plates. 8vo. Price $3.00 MARTIN, MICROSCOPIC MOUNTING. A Manual of Microscopic Mounting. With Notes on the Collection and Ex- amination of Objects, and upwards of 150 Illustrations. By John H. Martin. Second Edition, Enlarged. 8vo. Price $2.75 MORRIS, ON THE JOINTS. The Anatomy of the Joints of Man. Comprising a Description of the Liga ments, Cartilages, and Synovial Membranes; of the Articular Parts of Bones, etc. By Henry Morris, f.r.c.s. Illustrated by 44 Large Plates and Numerous Figures, many of which are Colored. 8vo. Price $5.50 MUTER, MEDICAL AND PHARMACEUTICAL CHEMIS- TRY. An Introduction to Pharmaceutical and Medical Chemistry. Part One. — Theoretical and Descriptive. Part Two. — Practical and Analytical. Arranged on the principle of the Course of Lectures on Chemistry as delivered at, and the Instruction given in the Laboratories of, the South London School of Pharmacy. By John Muter, m.d.. President of the Society of Public Analysts. A Second Edition, Enlarged and Rearranged. The Two Parts bound in one large octavo volume. Price $6.00 Part Two. — Practical and Analytical. Bound Separately, for the Special Con- venience of Students. Large Svo. Cloth. Price $2.50 MAC MUNN, THE SPECTROSCOPE. The Spectroscope in Medicine. By Chas. A. Mac Munn, m.d. With 3 Chromo-lithographic Plates of Physiological and Pathological Spectra, and 13 Wood Cuts. Svo. ■ Price $3.00 " This book is, without question, the best that has yet been published on the subject ; to those not familiar with Physiological Spectroscopy it will prove interesting, while to those who are working in this field it is a neces' Sity," — New York Medical journal. 28 p. BLAKISTON, SON &- CO:S MANN, PSYCHOLOGICAL MEDICINE. 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BLAKISTON, SON &- CO.'S BY SAME AUTHOR. THE UNOFFICIAL PHARMACCPCEIA. Comprising over 700 Popular and Useful Preparations, not Official in the United States, of the various Elixirs, Fluid Extracts, Mixtures, Syrups, Tinct- ures, Ointments, Wines, etc, etc., in constant demand throughout the country. Thick i2mo. S^S PP- Half Morocco. Price $3.50 "This volume is one of the most practical and valuable contributions to Pharmaceutical work of recent publica- tion. It has received high commendation from many of our best pharmacists " — Laze//, Marsh &' Gardiner, Wholesale Druggists, New York City. OTT, ACTION OF MEDICINES. The Action of Medicines. By Isaac Ott, m.d., late Demonstrator of Experi- mental Physiology in the University of Pennsylvania. With 22 Illustrations. 8vo. Price $2.00 PAGE, INJURIES OF THE SPINE. Injuries of the Spine and Spinal Cord, without apparent Lesion and Nervous Shock. In their Surgical and Medico-Legal Aspects. By Herbert W. 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For 25 Patients weekly, interleaved, tucks, pockets, etc., - - - - 1.25 50 " " " •• << .« .... 1.50 r^ «« •< ^ ,.„i^ fjan. toTune] „ 5° 2^°^^- i July to Dec.} .... 3.00 PERPETUAL EDITION, WITHOUT DATES AND WITH SPECIAL MEMORANDUM PAGES. SAME SIZE AS THE 25 PATIENTS, INTERLEAVED. Price, ^^1.25 The Visiting List contains a List of New Remedies, a Diagram of the Chest, Upper Abdomen ; a New Table of Poisons and their Antidotes. The Metric or French Decimal System of Weights and Measures. Posological Tables, showing the relation of our present system of Apothecaries' Weights and Measures to that of the Metric System, giving the Doses in both. This last is a most valuable addition, and will materially aid the Physician. So many writers now use the metric system, especially in foreign books and journals, that one not familiar with it is constantly confused, and in many cases unable to understand the measurements or doses. " It is certainly the most popular Visiting List ex- tant." — New York Medical Journal. " Its compact size, convenience of arrangement, dur- ability, and neatness of manufacture have everywhere obtained for it a preference." — Canada Lancet. "The book is convenient in form, not too bulky, and in every respect the very best Visiting List published." — Canada Medical and Surgical Journal . "This standard Visiting List, for completeness, com- pactness, and simplicity of arrangement, is excelled by none in the market." — Nevj York Medical Record. 32 P.BLAKISTON, SON &- CO:S POWER, HOLMES, ANSTIE AND BARNES {Drs.). Reports on the Progress of Medicine, Surgery, Piiysiology, Midwifer}-, Dis- eases of Women and Children, Materia IMedica, Medical Jurisprudence, Ophthal- mology', etc., etc. Reported for the New Sydenham Society. 8vo. Price §2.00 PURCELL, ON CANCER. Cancer. Its Allies and other Tumors, with Specia Reference to their Medi- cal and Surgical Treatment. By F. Albert Purcell, m.d , m.r.c.S. Surgeon to the Cancer Hospital, Brompton, England. 8vo. Price $3.75 RADCLIFFE, ON EPILEPSY. On Epilepsy, Pain, Paralysis, and other Disorders of the Nervous System. By Charles Bland R,\dcliffe, m.d. Illustrated. i2mo. Price $1.50 " To no authoritj' can the medical inquirer turn for an analysis of the phenomena of epilepsy with more satisfac- tion than to the admirable essay of Dr. Radcliffe." — Atnerican yournal Medical Sciences. ROBERTS, MANUAL OF MIDWIFERY. The Student's Guide to the Practice of Midwifery. By D. Lloyd PvOBERTs, M.D., F.R.C.P., Physician to St. Alary's Hospital, ]Man Chester, etc., etc. Second Edition. With 95 Illustrations. i2mo. Price §1.25 "As an obstetrical manual, we think that of Dr. Rob- "The present edition has been verj* thoroughly re- erts one of the best now offered to the Profession, as it vised, some chapters having been entirely re -written, comes with authority, and he possesses the ability to For its size, it forms a remarkably complete compendi. condense, and at the same time present a subject clear- um of the subject, and can hardly be surpassed in the Ij'." — Atnerican yournal of Medical Science. ' simplicity and clearness of its explanations." — Obstet- " Concise, clear, and practical." — Medical Press rical yournal of Great Britain and Ireland, and Circular. | REYNOLDS, ELECTRICITY, Lectures on the Clinical Uses of Electricity. By J. Russell Reynolds, m.d., F.R.s. Second Edition. i2mo. Price $1.00 " It is thoroughly reliable as a guide, very concise, and will be found exceedingly useful to the general practi- tioner." — Canada Lancet. RICHARDSON, MECHANICAL DENTISTRY. Third Edi- tion. 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In its Social, Moral and Physical Relations and Diseases of' the Urinary- Organs. By Michael Ryan, m.d. Member of the Royal College of Physicians, London. i2mo. Price $1.00 PUB Lie A TIONS. 33 ROBERTS, PRACTICE OF MEDICINE. Fourth Edition. The Theory and Practice of Medicine. By Frederick Roberts, m.d. Third American, from the Fourth London Edition. 8vo. Price, Cloth, I5.00 ; Leather, $6.00 Recommended at the University of Pennsylvania, Yale and Dartmouth Colleges, University of Michigan, and many other Medical Schools. The unexceptional large and rapid sale of this book, and the universal commen- dation it has received frorrt the profession, seems to be a sufficient guarantee of its merits as a Text-book. The publishers are in receipt of numerous letters from Professors in the medical schools, speaking favorably of it, and below they g-ive extracts from the medical press, American and English, attesting its superiority and value to both student and practitioner. The present edition has been thoroughly revised and much of it re-written. "The best Text-book for Students hi the English | "To the student it will be a gift of priceless value." language. We know of no work in the English Ian- ■ — Detroit Revieiu of Medicine. guage, or in any other, which competes with this 1 « Wg heartily recommend it to students, teachers, one.' —Edinburgh Medical Journal.^ I 3^^ practitioners."— ^orf^« Medical and Surgical " It is a remarkable evidence of industry, experi- i journal. ence, and research."— Practitioner. << jj i^ of ^ much higher order than the usual compi- " Dr. Roberts' book is admirably fitted to supply ations and abstracts placed in the hands of students." the want of a good hand-book, so much felt by every 1 — Medical and Surgical Reporter. medical iX^xAexit."— Student's Journal and Hospital .< j^ jg unsurpassed by any work that has fallen into Gazette. lour hands as a compendium for students." — The " It contains a vast deal of capital instruction for : Clinic. the staAexii."— Medical Tunes and Gazette. i " We particularly commend it to students about to " There are great excellencies in this book, which enter upon the practice of their profession." — St. Louis will make it agreat favorite with the student." — Rich- Medical and Surgical jfournal. vwnd and Louisville fournal. \ RINDFLEISCH, GENERAL PATHOLOGY. General Pathology; a Handbook for Students and Physicians. By Prof. Edward Rindfleisch, of Wurzburg. Translated by Wm. H. Mercur, m.d., Edited and Revised by James Tyson, m.d., Professor of Morbid Anatomy and Pathology, University of Pennsylvania. Octavo. Cloth, In Rapid Preparation . RINDFLEISCH, PATHOLOGICAL HISTOLOGY. A Text-Book of Pathological Histology. By Dr. Edward Rindfleisch.' Translated by Drs. Wm. C. Kolman and F. T. Miller. 208 Illustrations. Svo. Recommended as a Text-Book at the University of Pennsylvania and other Med- ical Schools. " To be up with the times, our Pathologists must make themselves familiar with the thorough, clear, and al- most exhaustive teachings of Professor Rindfleisch." — Ohio Medical and Surgical Reporter. ROYLE AND HARLEY, MATERIA MEDICA. Sixth Edition. A Manual of Materia Medica and Therapeutics. By Dr. J. Forbes Royle. Sixth Edition. Edited by John Harley, m.d. 840 pages and numerous Illus- trations. Demi Svo. ' Price |;5.oo RUTHERFORD, PRACTICAL HISTOLOGY. Outlines of Practical Histology ; being the Notes of the Course of Practical Physiology given in King's College, London, and the University of Edinburgh. By William Rutherford, m.d., f.r.s., Professor of the Institutes of Medicine in the University of Edinburgh (with additional leaves for Notes). Third Edi- tion. Illustrated. \^In Press. " To the student and teacher of Practical Histology, this work can hardly help being a great boon. It is complete, yet short, perfectly clear and simple, and moreover every line bespeaks the outcome of an extensive practical acquaintance with the subject." — Medical Times and Gazette, London. 34 P- BLAKISTON, SON &- CO.'S SANDERSON AND FOSTER, THE PHYSIOLOGICAL LA- BORATORY. A Hand-book of the Physiological Laboratory. Being Practical Exercises for Students in Physiology and Histology. By J. Burdon Sanderson, m.d., E. Klein, m.d., Michael Foster, m.d., f.r.s., and T. Lauder Brunton, m.d. 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SAVAGE, FEMALE PELVIC ORGANS. Author's Edition. The Surgery, Surgical Pathology and Surgical Anatomy of the Female Pelvic Organs. In a Series of Colored Plates taken from Nature, with Commentaries, Notes and Cases. By Henry Savage, m.d., f.r.c.s. New Edition. Issued by arrangement with the Author, from the original Plates. Quarto. Price $12.00 SAVORY & MOORE, DOMESTIC MEDICINE. A Condensed Compend of Domestic Medicine, and Companion to the Medi- cine Chest. By Drs. Savory and Moore. Illustrated. i6mo. Price .50 SCHULTZE, OBSTETRICAL PLATES. Obstetrical Diagrams. Life Size. By Prof. B. S. Schultze, m.d., of Berlin. Twenty in the Set. Colored. Price, in Sheets, $15.00 ; Mounted on Rollers $25.00 SCANZONI, DISEASES OF WOMEN. A Practical Treatise on the Diseases of the Sexual Organs of Women. By Dr. F. W. Von Scanzoni. Translated by A. K. Gardiner, m.d. 8vo. Price $5.00 SIEVEKING, LIFE ASSURANCE. The Medical Adviser in Life Assurance. By E. H. Sieveking, m.d. i2mo. 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A Manual of Dental Anatomy and Surgery, Including the Extraction of Teeth. By H. E. Sewell, d.d.s., m.d. With yj Illustrations. i2mo. Price $1.25 " A valuable book for the general Practitioner who " It will be found useful to the general Practitioner in te in want of a practical manual relating especially to | themanagement of many incidental affections connected diseases of the teeth." — Medical Brit-f. • with the teeth and mouth, which cannot always be ) handed over to the speciahst." — Pacific Med. yournal. STILLE, ON MENINGITIS. Epidemic Meningitis, or Cerebro-spinal Meningitis. By Alfred Stille, m.d., Professor of Practice at the University of Pennsylvania. 8vo. Price $2.00 " The name of the author is a sufficient guarantee that this monograph is elegant in style, exhaustive of its sub- ject and rich with practical suggestions.'' — Philadelphia Medical and Surgical Reporter. STOKES, DISEASES OF THE HEART. The Diseases of the Heart and Aorta. By William Stokes, m.d. Thick 8vo. Price I3.00 SWAIN, SURGICAL EMERGENCIES. Surgical Emergencies: Concise Descriptions of the Various Accidents and Emergencies, with Directions for their Treatment. By Wm. Paul Swain, f.r. C.s. Eighty-two Illustrations. l2mo. Price $2.00 Contents. — Chapter I. Injuries to the Head. II. Injuries to the Eye. III. Injuries to the Mouth, Pharynx, CEsophagus, and Larynx. IV. The Chest. V. The Upper Extremity. VI. The Abdomen. VII. The Pelvis. VIII. The Lower Extremitj'. IX. Emergencies connected with Parturition. X. Poisoning. XI. Antiseptic Treatment. XII. Apparatus and Dressing. " Many surgeons will thank Dr. Swain for the trouble he has taken to put them easily in possession of this re- ftesher of /z«^ forgotten knowledge. — The Practitioner. SWERINGEN, REFERENCE BOOK. A Pharmaceutical Lexicon or Dictionary' of Pharmaceutical Science. Contain- * ing explanations of the various subjects and terms of Pharmacy, with appropriate selections from the Collateral Sciences. Formula for Officinal, Empirical, and Dietetic Preparations, etc., etc. By Hiram. V. Sweringen, m.d. 8vo. Price, Cloth, $3.00 ; Leather, $4.00 " It is worthy of a welcome, and sure of a ready recognition of its merits." — LoTidon Pkarmaceiitical journal. " It will prove of great service to the pharmaceutical student, apprentice, pharmacist, druggist and physician, as a book of ready reference and as an aid to the study of scientific works." — American Journal of Pliarmacy. THOMPSON, LITHOTOMY AND LITHOTRITY. Practical Lithotomy and Lithotrity ; or, an Inquiry into the best Modes of Removing Stone from the Bladder. By Sir Henry Thompson, f.r.c.s.. Emer- itus Professor of Clinical Surgery in University College. Third Edition. 8vo. With 87 Engravings. Price $3.50 " The chapters of most interest are those in which Bigelow's operation is discussed, and the final one, in v/hich is a record of 500 operations for stone in cases of male adults under the author's care. Such a table has never before been compiled by any surgeon." — Laficet. BY SAME AUTHOR. URINARY ORGANS. Seventh Edition. Diseases of the L^rinary Organs. Clinical Lectures. Seventh London Edition. Enlarged, with 73 Illustrations. Price, Cloth, 11.25 I Paper, .75 ON THE PROSTATE. Diseases of the Prostate. Their Pathology and Treatment. Fifth London Edition. Svo. With Numerous Plates. Price, Cloth, gi. 25 ; Paper, .75. CALCULOUS DISEASES. The Preventive Treatment of Calculous Disease, and the Use of Solvent Remedies. Second Edition. i6mo. Price $\.oo " Catholic in his investigation of the fruit of the labor of others, cautious in all his deductions, rejecting all spe- cious theories in the effort to obtain practically useful results, as clever with his pen as he is with the sound or lithotrite, one can scarcely wonder that he is esteemed the master that he is." — American Journal af Medical Science. PUBLICA TIONS. 37 THOMPSON, COUGHS AND COLDS. The Causes, Nature, and Treatment of Coughs and Colds. By E. S. Thomp- son, M.D. i6mo. Price .60 THOROWGOOD, MATERIA MEDICA. The Student's Guide to Materia Medica. By John C. Thorowgood, m.d. Illustrated. 318 pages. i2mo. Price ^2.00 BY SAME AUTHOR. ON ASTHMA. The Forms, Nature, and Treatment of Asthma. i2mo. TUSON, VETERINARY PHARMACOPCEIA. A Pharmacopoeia, Including the Outlines of Materia Medica and Therapeu- tics. For the Use of Students and Practitioners of Veterinary Medicine. By Richard V. Tuson, f.c.s. Third Edition. i2mo. Price $2.50 " Not only practitioners and students of veterinary medicine, but chemists and druggists will find that this book supplies a want in veterinary literature." — Druggist and Chemist. THUDICHUM ON THE URINE. Second Edition. The Pathology of the Urine and Complete Guide to Analysis. By John L. W. Thudichum, m.d. Second Edition. Enlarged and Illustrated. 8vo. Price $5.00 "The treatise of Dr. Thudichum is well known as one of the medical classics of the language, and in com- pleteness, thoroughness, and originality, the volume before us has few rivals in any branch of our science. For the specialist, for the physiological chemist, for the physiologist, the volume of Dr. Thudichum is a sine qua lion, and to such the new edition must be a most welcome guest." — Philadelphia Medical Times. TROUSSEAU, CLINICAL MEDICINE. Lectures on Clinical Medicine, Delivered at the Hotel Dieu, Paris, by A. Trousseau, Professor of Clinical Medicine to the Faculty of Medicine, Paris, etc., etc. Translated from the Third Revised and Enlarged Edition by P. Vic- tor Bazire, m.d , London and Paris ; and John Rose Cormack, m.d., Edin- burgh, F.R.S., etc. With a full Index, Table of Contents, etc. 2 vols. 8vo. Sold by Subscription only. Price, Cloth, ^8.00; Leather, ^10.00 Sydenham Edition, Same Work. 5 Vols. 8vo. Large Print. Price $15.00 Trousseau's Lectures have attained a reputation, both in England and in this country, far greater than any work of a similar character heretofore written. In order to bring the work within the reach of all the profession, the publishers now issue an American edition, containing all the lectures as contained in the five-vol- ume Sydenham edition, at a much lower price. Below are a few only of the many favorable opinions expressed of the work : — " a clever translation of Prof. Trousseau's admirable and exhaustive work ; the best book of reference upon the Practice of Medicine." — hidiana Medical Gazette. TEST TYPES. " We scarcely know of any book better fitted for presentation to a young man when entering; upon the practical work of his life." — Londoti Medical Times and Gazette. Selections from Snellen's Test Types mounted upon heavy card board ; suit- able for hanging in the office. • Price 50 cents TIDY, MODERN CHEMISTRY. A Hand-Book of Modern Chemistry. Organic and Inorganic. By C. Mey- MOTT Tidy, m.d. 8vo. Price $5.00 "We doubt if any other chemical work containing so large an amount of information could be procured." — Ihiblin Medical journal. p. BLAKISTON, SON <&- CO:S TILT, THE CHANGE OF LIFE IN WOMEN. The Change of Life in Health and Disease. A Practical Treatise on the Diseases incidental to Women at the Decline of Life. By Edward John Tilt, M.D. Fourth London Edition. 8vo. Price, Cloth, $1.25; Paper cover, .75 " We believe Dr. Tilt brings much more than ordinary merit to bear on his subject, and handles it accord- ingly. Few books are issued that are more indispensable to the general practitioner." — Phila. Med. Times. " Dr. Tilt's clear and concise style makes the book at once a pleasant one to read and an ea.sy guide to follow, and we are quite sure it is the most valuable one we have on the subject." — Boston Med. &" Surg, jfoumal. " The best work on the subject." — London Lancet. TOMES, DENTAL ANATOMY. Second Edition. A Manual of Dental Anatomy, Human and Comparative. By C. S. Tomes, D.D.s. With 179 Illustrations. Second Edition. i2mo. Price ^.25 TOMES, DENTAL SURGERY. A System of Dental Surgery. By John Tomes, f.r.s. The Second Edition, Revised and Enlarged. By C. S. Tomes, d.d.s. With 263 Illustrations. i2mo. Price J5.00 " We rejoice that such books as these (Dr. Tomes' Works) are demanded by the profession, and that the men to write them are furnished by the profession." — Dental Cos}kos. TAFT, OPERATIVE DENTISTRY. Fourth Edition. A Practical Treatise on Operative Dentistry. By Jonathan Taft, d.d.s. Fourth Revised and Enlarged Edition. Over 100 Illustrations. 8vo. Price, Cloth, $4.25 ; Leather, 5.00 "All the important operations, in all their modifica- i " It is a thorough and complete treatise on the Art f;ons, are clearly discussed by the author, and the ' of Practical Dentistry." — London Medical Times and work is highly practical throughout." — Dental Regis- Gazette. ter. TANNER, INDEX OF DISEASES. Second Edition. An Index of Diseases and their Treatment. By Thos. Hawkes Tanner, m.d., F.R.C.P. Second Edition. Revised and Enlarged. By W. H. Broadbent, m.d. With Additions. Appendix of Formulae, etc. 8vo. Price $3.00 By this useful hand-book the character of any disease may be determined in a moment, and the general outline of treatment pursued by the best authorities made apparent. " This work, like others from the gifted author, has j " Finally, a chapter on the climates, countries, mine- already won for itself a reputation." . . . " It is ral springs, etc., best adapted to the various classes of in truth what its title indicates." — New York Medical invalids, makes this work the most complete practi- Record. tioner's manual that we have yet seen. — Chicago Medi- \ cal Tiines. BY SAME AUTHOR. THE DISEASES OF INFANCY. A Practical Treatise on the Diseases of Infancy and Childhood. Third Edi- tion. Carefully Revised and much Enlarged. By Alfred Meadows, m.d. 8vo. Price $3.00 Recommended as a Text-book at Jefferson Medical College and other schools of Medicine. "One of the most careful, ornate, and accessible | " We consider the views of the author on the subject manuals on the subject." — London Lancet. of therapeutics as rational in the highest degree." — I Boston Medical a7id Surgical yournal. MEMORANDA OF POISONS. A Memoranda of Poisons and their Antidotes and Tests. Fifth American, from the Last London Edition. Revised and Enlarged. In Press. This most complete Toxicological Manual should be within reach of all physi- cians and pharmacists, and as an addition to every family library, would be thc means of saving life arid allaying pain when the delay of sending for a physician would prove fatal. PUBLICA TIONS. 39 TIBBETS, MEDICAL ELECTRICITY. A Hand-book of Medical Electricity. Giving full directions for its Applica- tion, etc. By Herbert Tibbets, m.d. 64 Illustrations. 8vo. TRANSACTIONS OF THE COLLEGE OF PHYSICIANS. The Transactions of the College of Physicians of Philadelphia. New Series. Vols. I, II, III, IV. 8vo. Price, per volume, I2.50 Vol. V. Containing Articles and Discourses by Drs. Atlee, DaCosta, Mills, A. V. Meigs, H. C. Wood, Cohen ; Profs. Tyson, Gross, Bartholow, Allen, Leeds and others. Just Ready. Cloth, Gilt Top, ^3.50 TYSON, BRIGHT'S DISEASE AND DIABETES. A Treatise on Diabetes and Bright's Disease. With Especial Reference to Pathology and Therapeutics. By James Tyson, m.d.. Professor of Pathology and Morbid Anatomy in the University of Pennsylvania. With Colored Plates and many Wood Engravings. 8vo. Price $3.50 " This volume is the outcome of some fifteen years' special study and observation, and will be found to be a very well prepared monograph His direc- tions are clear and minute. — Med. and Surg. Reporter. " The symptoms are clearly defined, and the treat- ment is exceedingly well described, so that every one reading the book must be profited " — Cinchinati Lan- cet and Clinic. BY SAME AUTHOR. GUIDE TO THE EXAMINATION OF URINE. A Practical Guide to the Examination of Urine. For the use of Physicians and Students. With Colored Plates and Numerous Illustrations Engraved on Wood. Fourth Edition. i2mo. Price $1.50 Advantage has been taken, in bringing out a new edition of this work, not only to correct the previous one, but to make such additions of new Facts and Processes as would add to its value without materially increasing its size. "Dr. Tyson commences with a short account of the theory of renal secretion, the physical and chemical charac- ters of the urine, and the reagents and apparatus used in its analysis. Excellent rules are then given for detecting the presence of albumen, sugar, coloring-matters, bile, urea, uric acid, chlorides, phosphates and sulphates ; and minute instnictions for approximative and quantitative determination of most of those ingredients by volumetric analysis are supplied." — Philadelphia Medical Times. " We have experienced both pleasure and profit ftom the perusal of this book. It is agreeably written, contains much practical information, and is, we believe, a rehable and satisfactory guide to the clinical examination oJ arine. We can recommend Dr. Tyson's book as one that amply supplies the clinical needs of the physician." — Dublin yournal of Medical Science. THE CELL DOCTRINE. Second Edition. The Cell Doctrine. Its History and Present State. With a Copious Biblio- graphy of the subject. Illustrated by a Colored Plate and Wood Cuts. Second Edition. 8vo. Price ^2.00 TURNBULL, ARTIFICIAL ANESTHESIA. The Advantages and Accidents of Artificial Anaesthesia ; Its Employment in the Treatment of Disease ; Modes of Administration ; Considering their Rela- tive Risks; Tests of Purity; Treatment of Asphyxia; Spasms of the Glottis; Syncope, etc. By Laurence Turnbull. m.d., ph. g., Aural Surgeon to Jeffer- son College Hospital, etc. Second Edition. Revised and Enlarged. With 27 Illustrations of Various Forms of Inhalers, etc. i2mo. Price ^1.50 " Ansssthesia is a subject of great interest and importance to physicians and dentists, and everything that will aid them in better understanding the subject is sought with great avidity. This work we regard as the best aid in the study of the subject, and it presents the subject up to the present hour." — Dental Register. TEALE, DANGERS TO HEALTH. Third Edition. A Pictorial Guide to Domestic Sanitary Defects. ByT. Pridjin Teale, m.d., F.R.c.s. With Colored Plates. 8vo, Price f 3.30 40 P. BLAKISTON. SON c- CO:S VACHER, CHEMISTRY. A Primer of Chemistry, Including Analysis. By Arthur Vacher. i8mo. Price .50 VIRCHOW, POST-MORTEM EXAMINATIONS. Second Edi- tion. Post-mortem Examinations. A Description and Explanation of the Method of Performing them in the Dead House of the Berlin Charite Hospital, with especial reference to Medico-legal Practice. By Prof. Virchow. Translated by Dr. T. P. Smith. Second Edition. i2mo. With 4 Plates. Price $1.25 / "A most useful manual from the pen of a master. ' " Its low price and portabilitj' make it accessible and .... For thorough and sj'Stematic method in \ convenient to every surgical registrar and practitioner." the performance of post-mortem examinations, there is | — British Medical Journal. no guide like it." — Lancet. \ WAGSTAFFE, HUMAN OSTEOLOGY. The Student's Guide to Human Osteology, By William Warwick Wag- STAFFE, F.R.c.s. With 23 Lithographic Plates of the Bones, Showing Muscle Attachments, and 60 Wood Engravings. i2mo. Price I3.00 WALTON, DISEASES OF THE EYE. Third Edition. A Practical Treatise on Diseases of the Eye. By Haynes Walton, m.d. Third Edition. Rewritten and Enlarged. With five plain and three colored, full-page Plates; and many other Illustrations, Test Types, etc. Nearly 1200 pages. 8vo. Price $9.00 WARNER, CASE TAKING. The Student's Guide to Medical Case Taking. By Francis Warner, m.d., M.R.C.P., etc. i2mo. Cloth. Price $1.75 General Diseases. — Class i. Class 2. Arthritic Diseases. Diseases of the Ner\'ous System. Of the Vas- cular System. Of the Respiratory System. Of the Digestive System. Of the Liver. Of the Urinary System. Instruction for Case Taking. WATERS, DISEASES OF THE CHEST. Second Edition. The Diseases of the Chest. Their Clinical History, Pathology and Treat- ment. By A. T. H. Waters, m.d., Fellow Royal College of Physicians. With Numerous Illustrative Cases and Lithographic Plates. 8vo. Price $4.00 " The present edition contains new chapters on hsemopt^-sis, hay fever, aortic regurgitation, mitral constriction, thoracic aneurism, and the use of chloral in certain diseases of the chest ; other chapters have received additions of cases and remarks on treatment. Some characteristic sphygmographic tracings have also been added." — Bos- ton Medical and Surgical your?iul. WOOD, BRAINWORK. Brainwork and Overwork. By Prof. H. C. Wood, Jr. 32mo. Price, Paper cover, .30; Cloth .50 WEDLS, DENTAL PATHOLOGY. With Special Reference to the Anatomy and Physiology^ of the Teeth. With Notes by Thos. B. Hitchcock, m.d., of Harvard University. 105 lUustra- trations. 8vo. Price, Cloth, $3.50; Leather, M-5o WHITTAKER, ON THE URINE. Student's Primer on the Urine. By J. Travis Whittaker, m.d., Physician to Anderson's College Dispensary. With Illustrations Etched on Copper. i6mo. Price S1.50 Physiological Study of Urine — Sensation in Passing. Quantity. Color. Odor. Speciiic Gravity. History and Behavior. Sediment or Deposits. Chemical Study of Urine— Reaction. Albumen. Chlorides. Ammonia. Urea. Phosphates. Blood. Sugar. Bile. Microscopical Study of Urine and Urinarj- Deposits — Amorphous Urates. Uric Acid. Triple Phosphates. Phosphate of Lime. Feather>' Phosphates. Oxalate of Lime. Urate of Soda and of Ammonia. Cystine. Tyrosine. Leucine. Cholesterine. Epithelium. Fat Globules, etc. "The plates are possessed of great versimilitude, as well as in other respects admirable."— yl/^t/. Times. " Neat and concise, and the illustrations are very good testimony of the claim which he makes of the suitability •if the etching needle for delineation of microscopical appearances." — Boston Med. and Surg. Journal. PUBLICA TIONS. 41 WEST, THE DISEASES OF WOMEN. Fourth Edition. Lectures on the Diseases of Women. By Charles West, m.d. Fourth London Edition. Revised and in part re-written by the Author. With Numer- ous Additions by J. Mathews Duncan, m.d., Obstetric Physician to St. Bar- tholomew's Hospital 8vo. Price ^5.00 Drs. West and Duncan are, perhaps, the most celebrated London physicians giving attention to the Diseases of Women, and together have made a most com- plete work, either for the physician or student. WILKS, PATHOLOGICAL ANATOMY. Lectures on Pathological Anatomy. By Samuel Wilkes, f.r.s. Second Edition. Revised and Enlarged by Walter Moxon, m.d., f.r.s.. Physician to and Lecturer at Guy's Hospital, London. 8vo. Price $6.00 BY SAME AUTHOR. DISEASES OF THE NERVOUS SYSTEM. Lectures on Diseases of the Nervous System, Delivered at Guy's Hospital, London. New Edition, with Additions, Numerous Illustrative Cases, etc. 8vo. Cloth, $6.00 "A book of great value, embodying as It does the results of the experience and observation of one of the most accomplished of the London Hospital Physicians." — American yournal of Medical Science. WRIGHT, ON HEADACHES. Ninth Thousand. Headaches, their Causes, Nature and Treatment. By Henry G. Wright, M.D i2mo. Price .50 WILSON, ON DRAJNAGE. Drainage for Health ; or, Easy Lessons in Sanitary Science, with Numerous Illustrations. By Joseph Wilson, m.d., Medical Director United States Navy. One Vol. Octavo. Price $1.00 "Dr. Wilson is favorably known as one of the lead- I " Easily understood, and briefly and concisely pre- sented." — Providence yournal. " Will be found of value." — Boston Transcript. "Worthy of praise as a popular statement of the subject." — Boston journal of Chemistry. " Will be sure to be a harbinger of good in every fam- ily whose good fortune it may be to possess a copy." — Builder and Wood Worker. ing American writers on hygiene and public health. The book deserves popularity." — Medical and Surgi- cal Reporter. "Well written and well illustrated. Attention to its teachings may save much disease and perhaps many lives." — Cincinnati Gazette. "Interesting as well as useful." — Philadelphia Led- ger. BY SAME AUTHOR. NAVAL HYGIENE. Naval Hygiene, or. Human Health and Means for Preventing Disease. With Illustrative Incidents derived from Naval Experience. Illustrated. Second Edition. Svo. Price $3.00 WILSON, HOW TO LIVE. Health and Healthy Homes. A Guide to Personal and Domestic Hygiene. By George Wilson, m.d., Medical Officer of Health. Edited by Jos. G. Richardson, m.d.. Professor of Hygiene at the University of Pennsylvania. 314 pages. i2mo. Price $1.00 Chapter i. — Introductory, page 17. 11. The Human Body, 33. iii. Causes of Disease, 66. rv. Food and Diet, 119. V. Cleanliness and Clothing, 169. vi. Exercise, Recareation and Training, 187. vil. Home and Its Surroundings, Drainage, Warming, etc., 221. viii. Infectious Diseases and their Prevention, 269. " A most useful, and in every way, acceptable book." — New York Herald. " Marked throughout by a sound, scientific spirit, and an absence of all hasty generalizations, sweeping asser- tions, and abuse cf statistics in support of the writer's particular views. . . . We cannot speak too highly of a work which we have read with entire satisfaction." — Medical Titnet and Gazette. BY SAME AUTHOR. A HAND-BOOK OF HYGIENE And Sanitary bcience. With Illustrations. Fourth Edition. Revised and Enlarged. Svo. Price $2.75 42 p. BLAKISTON, SON &^ CO:S WILSON, HUMAN ANATOMY. Tenth Edition. The Anatomist's Vade-Mecum. General and Special. By Prof. Erasmus Wil- son. Edited by George Buchanan, Professor of Clinical Surgery in the Uni- versity of Glasgow ; and Henry E. Clark, Lecturer on Anatomy at the Royal Infirmary School of Medicine, Glasgov/. Tenth Edition. With 450 Engravings (including 26 Colored Plates). Crown 8vo. Price $6.00 Recommended as a Text-book at Rush Medical College, Chicago ; Bellevue Hos- pital, New York; St. Louis Medical College; Yale and Dartmouth Schools, and many other Colleges. BY same author. HEALTHY SKIN. Eighth Edition. A Practical Treatise on the Skin and Hair ; their Preservation and Manage- ment. Eighth Edition. i2mo. Paper. Price $1.00 WILSON, SEA VOYAGES FOR HEALTH. The Ocean as a Health Resort. A Hand-book of Practical Information as to Sea Voyages, for the Use of Tourists and Invalids. By Wm. S. Wilson, l.r.c.p. Lond., m.r.c.s.e. With a Chart showing the Ocean Routes, and Illustrating the Physical Geography of the Sea. Crown 8vo. Price $2.50 Chapter i. Curative Effects of the Ocean Climate. 2. The Various Health Voyages. 3. Time of Starting — Choosing a Ship. 4. PreUminary Arrangements. 5. Life at Sea. 6. Climate and Weather. 7. Management of the Health at Sea. 8. Occupations and Amusements at Sea. g. Objects of Interest at Sea. 10. End nf the Voyage — Future Plans. 11. The Homeward Voyage. 12. Australia: its Climate, Cities, and Health ResortB. 13. South Africa and its Climate. 14. The Meteorology of the Ocean. Appendix A. — Outfit Required for a Voyage to Australia. B. Names and Addresses of some of the Principal Shipping Firms. " All the information is supplied by, or based upon, the actual experience of the author ; and the book may be confidently recommended to all who have to undertake, without previous experience, a sea voyage of any length. Medical men may consult it with advantage, and commend it to those patients whom they may advise to try the effect of a long voyage at se.3.." —Medical Times and Gazette. " We have read every page of this book, and have derived both instruction and amusement." — La?tcet. WELLS, OVARIAN AND UTERINE TUMORS. Just Out. The Diagnosis and Surgical Treatment of Ovarian and Uterine Tumors. By T. Spencer Wells, m.d. Illustrated. 8vo. Price, Cloth, $7.00 So long a time having elapsed since Dr. Wells has collected the results of his large experience in book form, the present volume will be eagerly looked for by all interested in this very important subject. WOLFE, ON DISEASES OF THE EYE. A Practical Treatise on Diseases and Injuries of the Eye. Being a Course of Systematic and Clinical Lectures to Students and Medical Practitioners. By M. Wolfe, f.r.c.p.e.. Senior Surgeon to the Glasgow Ophthalmic Institution, etc. With 10 Colored Plates, and numerous other Illustrations. Octavo. Price ^7.00 WALKER, INTERMARRIAGE. Intermarriage, or, The Mode in which, and the Causes why. Beauty, Health and Intellect result from certain Unions ; and Deformity, Disease and Insanity from others. Illustrated. i2mo. Price $1.00 WARD'S COMPEND OF CHEMISTRY. A Compend of Chemistry for Chemical and Medical Students. By G. Mason Ward, m.d.. Demonstrator of Chemistry in Jefferson Medical College, Phila- delphia. Containing a Table of Elements and Tables for the Detection of Metals in Solutions of Mixed Substances, etc. i2mo. Cloth. Interleaved for the addition of Notes, I1.25 ; plain, $1.00 PUBLICA TIONS. 43 WOODMAN and TIDY, MEDICAL JURISPRUDENCE. Forensic Medicine and Toxicology. By W. Bathurst Woodman, m.d., Physician to the London Hospital, and Charles Meymott Tidy, f.c.s., Pro- fessor of Chemistry and Medical Jurisprudence at the London Hospital. With Chromo-Lithographic Plates, representing the Appearance of the Stomach in Poisoning by Arsenic, Corrosive Sublimate, Nitric Acid, Oxalic Acid ; the Spectra of Blood and the Microscopic Appearance of Human and other Hairs ; and 1 16 other Illustrations. Large octavo. Sold only by Subscription. Price, Cloth, #7.50; Medical Sheep, $8.50; Law Leather, $8.50 " Wc have no hesitation in pronouncing the work to be one of unusual merit. More readable than Taylor, more systematic in its arrangement, and more practical in its instruction, it will prove to the medical jurist, not less than to the general practitioner, a storehouse of useful knowledge, conveyed in an unusually graphic style." — Dtiblin yournal of Medical Science. " The authors of this truly great work have largely supplied the want felt, sooner or later, by almost every doctor." — Cincinnati Lancet and Observer. " All the best known works on Medical Jurisprudence have been laid under contribution for the production of the present volume. It contains almost everything that can be found in other works on the subject ; but it is no mere compilation. Dr. Woodman and Dr. Tidy have both thought out the subject for themselves, and, with rare industry and acumen, have brought together a mass of facts which is little short of astounding. The book is worthy to take its place alongside of any work on the same subject, and must prove of great use to all who prac- tice in criminal courts, and to all medical practitioners. We have no hesitation in recommending it to our read- ers." — London Lancet. "Altogether the work will rank with the best of its class as a medico-legal hand-book, and cannot fail to gain a wide popularity." — Neiv York Medical Record. " It cannot be otherwise than a valuable contribution to the boundless subject of medical jurisprudence." — Albany Law Journal. "The scope of this book is very wide, and its execution worthy of all commendation." — Philadelphia Legal Intelligencer. WYTHE, ON THE MICROSCOPE. The Microscopist. A Manual of Microscopy and Compendium of the Micro- scopic Sciences, Micro-Mineralogy, Micro-Chemistry, Biology, Histology, and Practical Medicine. By Joseph H. Wythe, a.m., m.d. Fourth Edition. 252 Illustrations. 8vo. Price, Cloth, ^3.00; Leather, I4.00 An Index and Glossary have been combined in this edition, so as to be a source of valuable information. Notices of recent additions to the microscope, together with the genera of microscopic plants, have been given in an Appendix. " From what we knew of the author of this work, as i " This is one of the most valuable text-books on mi- a skilled practical Microscopist, a successful teacher of j croscopy ever offered to students or practitioners of the science, and a practitioner of medicine and surgery of long and varied experience, we had a right to expect a good book from his hands. Our expectations are fully realized in the volume before us. The style is clear and distinct, and one reads the book with the utmost facility of comprehension. It is the more valuable to the physician and medical student on account of its closer application of the microscope to medical subjects than we find elsewhere. The numerous plates, many of which are beautifully colored, are not to be excelled. We feel proud of it as an American production." — Pacific Medical and Surgical Journal. medicine. This edition has been greatly enhanced in value by the addition of chapters on the use of the microscope in pathology, diagnosis, and etiology, and numerous new illustrations, some of which are from Rindfleisch. " The author very carefully brings out every neces- sary fact and principle relating to the use of the micro- scope, and now that this instrument has become an es- sential part of every practitioner's armamentarium, a practical guide and reference book is also a necessity, and we are fully warranted in reiterating the statement that this is one of the most valuable text-books ever offered to students and practitioners of medicine." — The Cincinnati Lancet and Clinic. BY SAME AUTHOR. DOSE AND SYMPTOM BOOK. Eleventh Edition. The Physician's Pocket Dose and Symptom Book. Containing the Doses and Uses of all the Principal Articles of the Materia Medica, and Original Prepara- tions. Eleventh Revised Edition. Price, Cloth, $1.00; Leather, with Tucks and Pocket, $1.25 " The chapter on Dietetic Preparations will be found useful to all practicing physicians, most of whom have but little acquaintance with the mode of preparing the various articles of diet for the sick." — Boston Medical and Surgical Journal. " Many a hard-worked practitioner will find it a useful little work to have on his study table." — Canada Medical and Su> gical Journal. 44 P. BLAKISTON, SON &- CO:S PUBLICATIONS. WHEELER, MEDICAL CHEMISTRY. Medical Chemistry, Including the Outlines of Organic and Physiological Chemistry. By C. Gilbert Wheeler, m.d. Second Edition. i2mo. Price $3.00 WOAKES, ON DEAFNESS AND GIDDINESS. On Deafness, Giddiness and Noises in the Head; or. The Naso-Pharj-ngeai Aspect of Ear Disease. By Edward Woakes, m.d , Senior Aural Surgeon to the Hospital for Diseases of the Throat and Chest. Third Edition. Revised and Enlarged, with Additional Illustrations. i2mo. " Xo brief summary of his views could do full justice to the cogency and subtlety of his reasons. We prefer to commend the whole work to the thoughtful perusal of all intelligent medical practitioners who desire to rise above the level of mere routine empiricism." — Lancet. BY THE SAME AUTHOR. WOAKES, ON NASAL CATARRH. Post-nasal Catarrh. Its Causes, Consequences and Treatment. In Press. ILLUSTRATED BOOKS. MEDICINAL PLANTS. Being Descriptions, with original Figures, of the Principal Plants employed in Medicine, and an account of their Properties and Uses. By Robert Bentley, F.L.S., Professor of Botany in the King's College, and to the Pharmaceutical Society, and Henry Trimens, m.b., f.l.s., late Lecturer on Botany at St. Mar)''s Hospital Medical School. In 42 Parts, each, S2.00, or in 4 vols., large 8vo, with 306 Colored Plates, bound in half morocco, gilt edged. $90.00 AN ATLAS OF TOPOGRAPHICAL ANATOMY. After Plane Sections of Frozen Bodies. By William Braune, Professor of Anatomy in the University of Leipzig. Translated by ED\yARD Bellamy, f.r.c.S., Sur- geon to and Lecturer on Anatomy at Charing Cross Hospital. With 34 Photo- lithographic Plates and 46 Wood cuts. Large imp. 8vo. % 8.00 ATLAS OF SKIN DISEASES. Consisting of a Series of Illustrations, with Descriptive Text and Notes upon Treatment. By Tilbury Fox, m.d., f.r.c.p., late Physician to the Department for Skin Diseases in University College Hospital. With 72 Colored Plates. In 18 Parts, each, gi.oo or, i Vol., Royal 4to, Cloth. $20.00 AN ATLAS OF HUMAN ANATOMY. Illustrating most of the ordinary- Dissections, and many not usually practiced by the Student. By Rickmax J. Godlee, m.s., f.r.c.s.. Assistant Surgeon to University College Hospital, and Senior Demonstrator of Anatomy in Universi- ty College. With 48 imp. 4to Colored Plates (112 Figures), and a volume of Ex- planatory Text. {^20.00 A COURSE OF OPERATIVE SURGERY. By Christopher Heath, f.r.c.s., Home Professor of Clinical Surgery in Uni- versity College, and Surgeon to the Hospital. With 20 Plates drawn from Nature by M. Leveille, and colored by hand under his direction. 4to. $14.00 ILLUSTRATIONS OF CLINICAL SURGERY. Consisting of Plates, Photographs, Wood cuts, Diagrams, etc., etc., illustrat- ing Surgical Diseases, Symptoms, and Accidents ; also Operative and other Methods of Treatment, with Descriptive Letterpress. By Jonathan Hutchin- son, f.r.c.s.. Senior Surgeon to the London Hospital. Vol. I, containing fas- ciculi I to X, bound, with Appendix and Index. $25.00 , Fasciculi XI to XV. Ready. Each, $2.50 NOW READY, THE SEVENTH REVISED EDITION. MEIGS AND PEPPER, ON CHILDREN. THE MOST THOROUGH, COMPLETE AND PRACTICAL WORK ON THE SUBJECT NOW BEFORE THE PROFESSION. A PRACTICAL TREATISE ON THE DISEASES OF CHILD- REN. By J. Forsyth Meigs, m.d., one of the Physicians to the Pennsylvania Hospital, Consulting Physician to the Children's Hospital, etc., and William Pepper, m.d.. Professor of Clinical Medicine, University of Pennsylvania, Provost and ex-officio President of the Faculty, Physician to the Philadelphia Hospital, Fellow of the College of Physicians, etc., etc. The Seventh Revised and Improved Edition. In one volume of over i loo royal octavo pages. Price, handsomely bound in Cloth, $6.00; Leather §7.00. The rapid sale of six large editions of Drs. Meigs and Pepper's work on Children, and the demand for the new edition now ready, is sufficient evidence of its great popularity. The large practice, of many years' standing, of the authors, imparts to it a value unequaled, probably, by any other on the subject now before the profession. The entire work has been now again subjected to an entire and thorough revision, some articles have been rewritten, many additions made, and great care observed by the authors, that it should be most effectually brought up to the light, patliological and therapeutical, of the present day. The publishers have very many favorable notices of the previous editions, re- ceived from numerous sources, foreign and domestic. They append a few from lead- ing journals, which will give a general idea of the value placed upon it, both as a Text-Book for the Student and a work of reference for the General Practitio7ier. " It is the most complete work upon the subject in our language ; it contains at once the results of peraonal and the experience of others ; its quotations from the most recent authorities, both at home and abroad, are ample, and we think the authors deserve congratulations for having produced a book unequaled for the use of the student, and indispensable as a work of reference for the practitioner." — American Medical yoiirneil. " But as a scientific guide in the diagnosis and treatment of the diseases of children, we do not hesitate to say that we have seldom met with a text-book so cornlete, so just, and so readable, as the one before us, which in its new form cannot fail to make friends wherever it snail go, and wherever great erudition, practical tact, and flueat and agreeable diction are appreciated." — American yournal of Obstetrics. " It is only three years since we had the pleasure of recommending the Fifth Edition of this excellent work. With the recent additions it may safely be pronounced one of the best and most comprehensive works on diseases of children of which the American Practitioner can avail himself, for study or reference.'' — TV. K. Med. yournai. " It is not necessary to say much, in the way of criticism, of a work so well known. But it is clinical. Like 'so many other good American medical books, it marvelously combines a rtsuvit of all the best European literature and practice, with evidence throughout of good personal judgment, knowledge, and experience. The book also abounds in exposition of American experience and observation in all that relates to the diseases of children. We are glad to add it to our library. There are few diseases of children which it does not treat of fully and wisely, in the light of the latest physiological, pathological, and therapeutical science." — London Lancet. P. BLAKISTON, SON & CO., Publishers, Successors to LINDSAY & BLAKISTON, 1012 WALNUT STREET, PHILADELPHIA. NOA A^ READ Y. Diseases of the Liver. BY GEORGE HARLEY, M.D., F.R.S., Etc, Author of " The Urine and Its Derangements," and " Diabetes, Its Various Forms and Tieatment." On Fine Paper, from Good Type, with Colored Plates and Thirty-six Wood-cuts. Bound in Heavy Cloth, Beveled Edges, $5.00/ Leather, ivith Raised Bands, $6.00. THE Publishers call special attention to this work, the only thorough book now before the profession. The reputation of its distinguished author is a guar- antee of its merits. THE AUTHOR, IN HIS PREFACE, SA^b: THIS NE W TREA TISE, which I have thought fit to entitle Diseases of the Liver, with and without Jaundice, with special apphcation to Diagnosis and Treatment, embodies within it the whole substance of my original monograph on Jaundice and Diseases of the Liver ; though greater than it, both as regards its scope and materials, and the large amount of clinical and scientific data that has nevei before been collected together into one volume; while in a great many instances it gives a new rendering to old clinical facts, by presenting them to the reader in the light of modern pathological science. As I think time is quite of as much value to the professional as it is to the mercantile man, I have endeavored to condense my materials to the utmost, without running the risk of endangering their perspicuity. Added to which, as this treatise has not been penned either for the use of the tyro or the dilettante in medicine, but for that of my qualified brethren, I shall neither waste time by entering into detailed accounts of the literature, nor give tedious, and probably at the same time profit- less, discussions of the theories of the mechanism of jaundice in hepatic derange- ments. Taking care, however, in order that it may carrj'- more weight with it in the eyes of the reader, to illustrate it freely with cases reported by indepen- dent observers, both at home and abroad. While, in order, again, that the reader may be able to see for himself, at a glance, how many of the old-fashioned theories of the patholog\' of jaundice have been abandoned, as well as how many new ones have been espoused, I have put my views, in accordance with the facts and arguments expressed throughout the body of the volume, into a concise and diagrammatic tabular form. '■ [ WOULD DIRECT th.& special attention of my readers to the chapter devoted to treatment, as well as that at the end of the book, entitled Hints on Diagnosis. SYNOPSIS OF THE CONTENTS. Introduction, giving a general view of the scope of the volume, and the application of Physiological Chemistry to the diagnosis and treatment of Hepatic affections. Chemistry, Physics and Physiology of the Liver and its secretions. Etiologj' of Jaundice — different kinds — causes pro- ducing th -m — treatment. Si^as and Symptoms of Liver Diseases. "^General remarks on all kinds of Hepatic Remedies. Special Hepatic Medicines ; their modes of action and uses. Mineral Waters, Wines and Foods; treatment of Pyrexia, Cerebral complications, etc. Congenital and Hereditary Liver Diseases, Bilious- ness ; Its Varieties and Treatment. Jaundice from Enervation, all its forms explained and their different Treatments Different forms of Inflammation of the Liver and their Treatments. Jaundice caused by Disease Germs, Yellow Fevers, Contagious and Eoidemic Jaundice, different kinds and •iieir Treatments. ' Diagnosis. Jaundice of Pregnancy. Index. Different forms of Hepatic Atrophy and Ascites. | Biliary Concretions, Inspissated Bile, Gall-Stones o/ every kind and form, direct and indirect effects of, their Symptoms and Treatment, \CTy fully gone into. Different kinds of Colics, etc. Catarrhal Jaundice. Jaundice from Poisons. Different kinds of Jaundice from Permanent Obstrnc- tions. Physiological Chemistry of the Excretions, Urine and Stools, as a Guide to Diagnosis and Treatment. All kinds of Abscess, Tropical, Pyasmic, iMetastatic, etc. Different kinds of Cancers of the Liver and its Appen- dages. Hydatid and Cystic Diseases of the Liver ; Syphilitic and Fibroid Diseases of the Liver. Embolisms, Fatty, Amyloid and other Degenerations of the Liver. Traumatic Diseases of the Liver. Diseases of the Gall Bladder. A concluding chapter, entitled Hints on Differential This work is now ready, and will be sent by mail, postpaid, upon receipt of price. (Cloth, $5.00. Leather, $6.00.) PRESS NOTICES AND RECOMMENDATIONS OF Dr. George Harley's New Book on Diseases of the Liver. " The Medical Profession, botl ' n Englani and Amer- ica, has for some time been on '^^.-i qui vive v^x this new work on the Liver, both because hepatic literature is mea- gre in the extreme, and because it was well known that Prof. Harley was specially qualified to write an authorita- tive work on the subject. . . . The author has unques- tionably written the most valuable work on hepatic dis- eases that has yet appeared. We must confess that we have tried, and tried hard, to find some error in the work, to preclude the charge of partiality being made." — Vir- ginia Medical Monthly. " It is one of the freshest, most readable, and most instructive medical books that have been laid upon our table during the present decade. ... In conclusion, we commend again most heartily Dr. Harley's extremely " valuable book." — Philadelphia Medical Times. "The work is far in advance, in original and practical information, of any treatise on the subject with which we are acquainted, and is worth man)- times its cost to any physician treating hepatic troubles." — Chicago Medical Tivtes. " The whole subject-matter is treated in a masterly manner, and the work is destined to find a place among the classics." — Medical Herald, Louisville , Ky. " It is the outcome of a mind that went to its task amply equipped therefor. It is the product of long think- ing and ripe judgment. . . . We must content ourselves with this bare statement hoping that those who read the book will derive as much benefit as ourselves." — NeUi Orleans Medical and Surgical yournal. " The work before us is one of the most thoroughly scientific ever offered to the medical profession upon the diagnosis and treatment of diseases of the liver. This book will prove especially valuable to the Southern prac- titioner, who, on account of climatic influences, is daily forced to combat these ailments. In this section of country hepatic disorders are not only common as inde- pendent conditions — diseases per se — but they form im- portant factors in the production of, and are ordinary concomitants of, most of our malarial diseases." — The Missi*-*ippi Valley Medical Monthly, Memphis, Tenn. " The work of Dr. Harley is the most complete work upon diseases of the liver now before the profession. It embodies not only the results of his own large experience and observations, but also exhibits the researches of oth- ers in the same class of diseases. As a scientific treatise of hepatic affections and their treatment, it will certainly hold a first position among the standard works." — Cin- cinnati Medical N'ezus. " We regard it as one of the most valuable of the recent additions to medical literature." — Southern Practitioner, Nashville, Tenn. " His especial point, as mdicated in the titie, is to bring prominently forward the relations of physiology to the forms of disease. Too exclusive attention, he thinks, has been paid to pathology. It has been regr.rded as a science apart. The great truth has been overlooked that the same fundamental laws regulate the phenomena both of health and disease. " With this as his guiding principle, he approaches the complicated problem of ' liver complaints' and ' bilious ness' with a much stronger hand than his predecessors in that field. Aflflicted as many districts of our country are. with many and puzzling forms of these maladies, we be- lieve Dr. Harley's volume will be a welcome addition to many a library." — Philadelphia Meidcal and Surgical Reporter. " We have read the volume before us with peculiar in- terest, and it will be read especially by Southern doctors, who, although they do not have a monopoly of diseases of the liver, by reason of semi-tropical malarial climate encounter a large proportion of such diseases. . . . We most heartily commend this book to our readers as a val- uable addition to the working volumes of their libraries ; for without any exception it is the most entertaining and instructive volume we had the pleasure of reading for many years." — North Carolina Medical Journal. " The author has succeeded admirably in the work he has undertaken, and has placed before the profession a work that will be of inestimable value to the practi- tioner." — Nashville Journal of Medicine and Surgery. " His chapter on ' Hints to Aid in the Diagnosis of Liver Disease,' is one of the best in the book, and will amply repay any one for its perusal." — Indiana Medical Journal. " With unusual gratification we have received this most excellent work, and present it to the niedical profes- sion with an unqu.alified endorsement. We know of no work of the kind, as this, based upon the unvarying rela- tion between physiology and pathology, the only avenue of approach to the cause of disease and proper treat- ment." — Missouri Valley Medical Journal. " Those features which are the most noteworthy from their novelty, or as showing individuality in treatment,* are to be found in the chapter on ' The General Treat- ment of Hepatic Disease,' and in that on the ' Chemistry of the Excretions.' In the former the author takes up the most prominent articles in the materia medica having a reputation in this class of diseases, and considers their chemistry, their mode of action, and the conditions which seem to indicate their employment, after adding brief cases in illustration." — New York Herald. " We commend the book to the profession as eminently worthy of study, and one that should be in the library of evry physician." — Southern Medical Record. PRICES: Heavy Cloth, Beveled Edges i?S oo Full Leather, Raised Boards 6 cxj Will be sent, prepaid, by mail or express, upon receipt of either of the above prices. P. BLAKISTON, SON & CO., 1012 Walnut St., Philadelphia, A NEW OCTAVO SERIES OF Standard Medical Books. PRICE OF EACH, IN STRONG PAPER COVERS, 75 CTS.; CLOTH, $1.25. Well Printed, from Clear Type, on Good Paper, and Strongly Bound; Uniform in Size, Price and Binding. SPECIAL NOTICE. — These books contain all in the original and inore expensive editio^is, the illustrations and text being the same, excepting when the author has revised or enlarged thein. Each is completed -with a good index. 4^ SENT, POSTPAID, ON RECEIPT OF PRICE. BEALE ON SLIGHT AILMENTS. SLIGHT AILMENTS: Their Nature, Causes, and Treatment. By Lionel S. Beale, m.d., F.R.S., Professor of Practice in King's Medical College. Second Edition, Revised and En- larged, with Illustrations. Octavo, yust ready. Price, in Strong Paper Covers, 75 Cents; Cloth, $1.25 A finer edition of this work is also printed, on thick paper, bound in Extra Cloth, price Si. 7 5 Outline of Contents. — Introductory'. The Tongue in Health and Slight Ailments. Appetite. Nausea. Thirst. Hunger. Indigestion, its Nature and Treatment. Constipation, its Treatment. Diarrhoea. Vertigo. Giddiness. Biliousness. Sick Headache. Neuralgia. • Rheumatism. The Feverish and Inflammatory State. Of the Actual Changes in Fever and Inflammation. Common Forms of Slight Inflammation, etc., etc. " We venture to say, that among the numerous medical publications there has been none which will prove more useful to the young general practitioner, for whom it is really intended, than this volume, while the time of the older physician might be much more unprofitably spent." — American yournal oj" Medical Science. TILT ON CHANGE OF LIFE IN WOMEN. THE CHANGE OF LIFE IN WOMEN, IN HEALTH AND DISEASE. A Clinical Treatise on the Diseases Incidental to Women at the Decline of Life. By Edward John Tilt, m.d., Past President of the Obstetrical Society. Fourth Edition, Revised and Enlarged. Octavo. Noio ready. Price, in Strong Paper Covers, 75 Cents; Cloth, $1.25 " Few books are issued which are more indispensable to the general practitioner." — Phila. Medical Times. " This is unquestionably the best work extant on this interesting subject. . . . It is a repertory of informa- tion." — American Practitioner. AGNEW ON THE FEMALE PERINEUM. LACERATIONS OF THE FEMALE PERINEUM AND VESICO- VAGINAL FISTULA. Their History and Treatment. With 75 Illustrations. By D. Hayes Agnew, M.D., Professor of Surger}', University of Pennsv'lvania. Octavo. Ready. Price, in Strong Paper Covers, 75 Cents; Cloth, $1.25 So many applications haring been made for these papers, as originally issued, it has been thought best to bring them before the profession in the present form. " The literature of the subject, its historj', causes, complications, and various modes of treatment, -re given. The various methods of radical cure are classified." — Indiana. Jourral of Medicine. " These two monographs will merit this more durable and convenient form." — A/n. journal 0/ Cbstetrtc^. DAY ON HEADACHES. THE NATURE, CAUSES AND TREATMENT OF HEADACHES. By W^illiam Henry Day, m.d., author of a " Treatise on the Diseases of Children." Fourth Edition, with Illustrations. Octavo. Just Ready. Price, in Strong Paper Covers, 75 Cents; Cloth, $1.25. Sl-mmajry of Contents.— Headache from Cerebral Ansemia, Cerebral Hypersemia; S>Tnpathetic, Congestive, Dyspeptic or Bilious Headaches; Headache from Plethora, from E.xhaustion, from Change in Cerebral Tissue, from Affections of the Periosteum ; Nervous and Neri-o-Hypersemic Headache ; Toxemic, Rheumatic, Arthiitic or Gouty Headache; Neuralgic headache, and Headaches of Childhood, Early and Advanced Life. ALLINGHAM on DISEASES of the RECTUM. FISTULA, HEMORRHOIDS, PAINFUL ULCER, STRICTURE, PROLAPSUS, .;nd all other Diseases of the Rectum. Their Diagnosis and Treatment. By William Allingham, m.d. Fourth Enlarged and Improved Edition, with Illustrations. Octavo. Just ready. Price, in Strong Paper Covers, 75 Cents; Cloth, $1.25 *^* The publishers have also a few copies of a much finer edition of Dr. Allingham's book. Printed in London, on thick paper, from large tj-pe, the illustrations being printed on separate sheets. Price, Extra Cloth, ^3.00. " No book on this special subject can at all approach Allingham's in precision, clearness and practical good sense." — London Medical Timesfand Gazette. " It is, as indeed the verdict of the profession has already pronounced it, one of the very best works on Diseases oi the Rectum." — American yournal of Medical Science. j^^No subscribing nuisance is connected with this series, each volume is sold separately, 01 the five -will be sent, postpaid, upon receipt of 35.00, for Cloth Binding, or for S3.00 in Paper Covers, P. BLAKISTON, SON & CO.. 1012 WALNUT STREET, PHILADELPHIA '^^i Y,CQ»o ■*'"*"vV W« '-3 ", .'<^"v -i ■'"^^ j'^'^SiJ^ ^'^1 i.v '^; . /^■'' '-■ -^>t i