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REPORT

PATHOLOGICAL DEPARTMENT

Central Indiana Hospital
for Insane

iBoa-iaafi

INDUNAPOLISi

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CONTENTS.

Statement of George F. Edenliarter, M. 1)., Superintendent, to the Board

of TruBtees.
Summary of three years' work in the Pathological Department, by Charles

F. Neu, M. D.
Papers read before the Marion County Medical Society.

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REPORT

Pathological Department,
Central Indiana Hospital for Insane,

September 30, 1907.
To the Uonorahle Board of Trustees:

GentJemeu- — We present for your consideration a summarj- of
three years' worii in our Patliological Department. This was
prepared by Charles P. Neu, M. D., after he left our service, and is
practically a review of the work done by him. We congratulated
him upon the excellent showing made.

Before taking it up in detail, however, we ask your indulgence
to introduce some statements as to our object and methods con-
cerning this department.

This report to yon is substantially a reiteration of the opinions
we held and expressed in former years, at the very beginning of
our work in this field, and which time has not changed.

Our views relating to the importance of a Pathological De-
partment in a state hospital were incorporated in a letter written
by me to Gershom H, Hill, M. D., now of Des Moines, Iowa.

This letter was read at the meeting of the chief executive
ofBeers of the State institutions of Iowa with the Board of Con-
trol, March 18, 1902, and is here partially presented :

Perhaps a few lines may not be amiss and may be of interest or assist-
ance to you in explajniug the photographs, plans and work of our pa.thological
department submitted for the inspection of the conference, during an unoc-
cupied interval or after your regular program has been completed.

It is hardly worth while for me to present a reason for the need of sueh
a department — I feel safe in saying that all of you gentlemen recognize its
importance.

For those who are interested in the upbuilding of the various institutions
(but not directly connected) who do not feel the great necessity for audi

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has certainly been of great benefit to the atudent.i of this State who attend
i>ur medical eoIJeges. And here I wish to again emphasize that the greater the
knowlMse of the outside practitioner upon these matters, the less risk tbat -
rntny cases will be deprived of theii lights in the community oi their power
of self-mainteiutnce and theiefoie the State vrill economize hy the release fiom
tlie burden of caie of these individuals.

Students, ua a rule, contemplate the study of some specialty. General
hospitals and medical colleges, recognizing this fact, arrange their courses of
instruction to nccom:nodate this demand. Hospitals for the insane, especially
those supportect by the State, should, for reasons economic as well as human-
itarian, grasp the situation and encourage every eflort upon the part of the
medical student to engage in and become proficient in the diagnosis and treat-
ment of diseases of the mind and nervono system. I repeat that this policy,
inaugurated and continued, will furnish every community in the State with a
number of practitioners specially prepared to render early and skillful assist-
ance to those mentally afflicted; will provide a large number of graduates
fully qualified from which to select hospital physicians, and, will result in a
saving of money to both the patient and the public.

The Pathologii-al Department at this tnHtitution, as outlined in the begin-
ning of our work in tliis direction, was established for the purpose of provid-
ing the hospital staff with the facilities tor scientific work directly connected
with their cases on the wards — BBsentially as an aid to diagnosis.

In addition, it was deemed advisable to extend its opportunities to the
outside physicians and the students of our medical colleges. I give you a brief
description of our system, anticipating our annual report.

"Two objects have been constantly in mind in developing the work of the
laboratory during the past year:

"First — That of enabling the members of the resident medical staff to
conditct their ntudy and treatment of the cases committed to the care of the
hospital with a knowledge of the pathological basis of disease and a more
intimate knowledge of the structure and functions of the nervous system as
revealed by recent scientific researches in this field.

"Second — That of placing upon a thorough systematic and working basis
the study of the nervous system and organs of those eases upon which an
autopsy is allowed.

"In carrying out the former the following methods have been adopted:
Each morning for two hours, from ten to twelve, three members of the
medical staff are engaged in the study of the normal and diseased organs.
Tn these morning classes the work is individual and inductive. In study-
ing an organ, stained, injected and digested sections are first drawn with
different magnifications and then descriptions of the same written without
the aid of books or teaching. The gross anatomy and anatomical relations
of the organs are then reviewed. When this work has been accomplished
a pathological section of the same organ is given without the student
knowing its designation. From this drawings and written descriptions are
made of those parts differing from the normal sections before studied.
This bavins Ijeen donp the pathologist goejs over the section with him,
correcting the work where necessary and pointing out those parts of more
importance, and together they arrive at a diagnosis of the diseased con-
dition. l''rom the changes found, the student then constructs the gross

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appearance of the organ t.hua diaeased and describes the clinical aymptoins
which would he mogl iikelj present during life in a patient 30 afflicted.
The process of reasoning in this work, it will be seen. Is practically the
same as that which the physician pursues in diagnosing hia case upon the
wards: here, however, he starts with the diseased organ and builds up his
clinical symptoms; there, he arrives at the changes in the organs from the
clinical evidence. Incorporated with this work there ia constantly a re-
view of the anatoniical and physiological relations of the organs studied.

"Besides these morning classes, two evening courses of lectures have
been given, the first on 'Clinical Anatomy,' the second on 'The Finer An-
atomy of the Nervous Systems.' In the former, which extended over a
period of two months, the time was spent in the study of the normal rela-
tions and positions of the abdominal and thoracic organs, the staff outlining
these by clinical methods on living subjects after the position of each had
been indicated by drawings and upon a skeleton.

"To the second series of lectures, the physicians of the city were also
invited. This course extended over a period of three months, the attendance
varying from seven to twenty-seven. At these lectures the following subjects
were studied in the fourteen lectures:

"1. The Neurone Concept. The work of Deiters, Golgi, Cajal, Kolliker,
Ehrlich, NissI, etc.

"2, The External Morphology of Neurones, Cell Body, Dendrites,
Axonea, etc.

"3. The Internal Morphology of Neurones. Work of Nissl, Held,
Schultze, etc.

"4. Embryology and Development of the Nervous System.

"5. Histogenetic Relations of Neurtaiea.

"6. The Degeneration, Regeneration, Physiologic and Trophic Functions
of Neurones.

"7- The Peripheral Sensory Neurones, Structure, Function, Peripheral
Distribution and Endings.

"8. The Central Prolongation of the Peripheral Sensory Neurones,
Sensory Tracts in the Cord, Medulla, Pons, Cerebrum and Cerebellum.

"9. Functions of Sensory Tracts as revealed by (a) Disease e.g.. Tabes,
Syringomyelia, Pressure, etc. (b) Experimental Section.

"10. The Clinical Evidence of Pathological Conditions of the Peripheral
Sensory System in the Different Parts of the Central System.

"11. The Visual Neurones; Origin, Structure and Course, from Retina
to Pallium. Evidence of Leaiona of this in Different Parts of its Course.

"12. Auditory and Olfactory Neurones; Origin, Structure, Course and
Lesions.

"13. Gustatory and Central Sensory Neurones.

"14. Review and Comparison of Sensory Neuronea and Primary Motor
Neurones.

"These lectures were illustrated by drawings, dissections, fresh and stnineil
sections of the different systems, and by large drawings of Miss Sabin's model
of the Medulla, pims and midbrain. I'he autopsies were also used for cim-
firmation of the anatomical and pathological studies in which the staff were
[aged."

"Last year a systematic course in the pathology of insanity was scarcely

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pos-tibk tlii« nar liowoei the 'iubjeit «is taken up before eneh class under
the f'lllouing headings

1 A suncy ul the neurone theorj

2 Lesions of the ••calp and cranium anujiij maane

3 ].e>iiODs of the Jura and pia niater uinoiif; iiisniie

4 Leaions of the blood le^sels among insane

' 5 MieroBcopie lesion* of the cerebrum anions' insane

5 Ihe normal histoiogv of the cpIU of the eeiebral eurtcN

7 The general pathological ehnnses found in these (ells in inaaiiity.

h Ihe jiatholo^ of general parah^iH

I Ihe pithulogi of insanities nisoemted mth {"niss lesiim-i
10 Ibe pntholo)^ of epiIepHv

II Tbe patholoyj of toxit iiisimtiei

I'acb lecture was illustrated uith „'ro<is iiid niiti i-j ipi al p p rnt ni>
frnni the collections >f tbe laboratorj

1 mail you blue prints and photo^aph'4 of the libirjtor 1 1 ng an

invoice of tbe equipment I shall also take the liberty uf tending a photo< rapb
blue print and short de-icnption of our new hospital for the s ck insane
Capacity KM) patients, cost, $1101)00, exclusive of equipment

Ihe relationship of this building to the Institution »ill be practically that
of a general hospital to a tit^ and is just as neces'aary to properU earr\ on our
work as a pathological depart<nent Vhen this hospital is orciipied a sufli-
eient number of trained (.linical assistants employeil a tiainin^ SLhiiol for
nurse* established and v nen si -tern of ciimtal remrds maintained then we
hope to lecompliab cood work in our laboratorj

In my opinion, the patholof^&t can not do gaod work at an institution of
this rhdiactei unless he has as a starting point a complete clinical history,
and the iloser his personal knowledge of this history the better

Witb us these two departments, viz , the hospital and the laboratory, must
work together The pathologist, at the request of the physician, visits cases
and becomes acquainted with then condition durmg life

The polici<is outlined in the abstract given have been adhered
to, and now, after the lapse of some years, it is encouraging to
realize that this department is achieving its purposes in a manner
which is creditable to the institution and beneficial to those par-
ticipating in its privileges.

"We have done all iu our power to extend its advantaj^es to the
medical profession and the students of our colleges, tbe idea
in view being to familiarize them with tbe underlying principles
of this branch of professional work, in the hope of enabling them
by early recognition and appropriate treatment to keep many
cases from being committed to this institution or institutions of
like character within our State.

To express it differently, we have created a center for scien-
tific investigation around which members of the profession may
as.':emble and obtain information — both didactic and clinical— at

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the Iinnds of compi'tent itiHtnictors, eotieerninfj tht^ diseases with
which we deal.

Physicians are at all tinier welcome to visit this department.
and every effort is made — not only to impress them with the im-
portance of a knowledge of laboratory and clinical methods, but
also to properly direct their effort in research in any desired
direction.

We have tried to build up a teachinjr hospital, because we
believe that all public hospitals should be medical educational
centers.

The results obtained from the policies and methods pursued
at this institution have made it perfectly clear to my mind that a
clinical investipltitHi of any given ease for teaching purposes, by
a professionally-ambitious, wide-awake, and ccnnpetent lecturer
in the presence of the hospital staff, outside practicing physicians,
and students, is by far the most painstaking, thorough, and scien-
tifically accurate examination that will be made.

Therefore, such clinical teaching is encouraged.

The more searching the effort the greater good results to the
patient, which is after all the end and aim of all genuiae hospital
work.

In addition to the clinical research, afforded during the life
of the patient, the hospital extends the privilege to the same
classes to witness the pathological examination of the same cases
should death intervene.

This continues their inquiry and grants an opportunity to
verify or disprove the conclusions reached by the clinician.

At autopsy, the pathological conditions are demonstrated,
comparison of diseased organs made with normal specimens in
the museum collection, sections of various tissues and organs are
taken as well as specimens of the different fluids for chemical,
bacteriological and microscopical examination.

The findings are later made a matter of record and are avail-
able to those desiring them.

The only way, then, in onr judgment, that will enable the State
to successfully contend with the alarming conditions conftronting
us in our specialty is to teach physicians and students of medicine
how to recognize, how to treat, and how to prevent these diseases.

They in turn should instruct the people how to act, how to
avoid, and how to live, not only for their own present good, but
for the future benefit of their posterity.

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It is the duty of these institutiona to arouse the interest of the
medical men in these matters.

It is the duty of the medical men to instruct and educate the
citizen.

If the individual can be taught and induced to care for himself
properly, much will be accomplished.

It is "worth while" beyond all question; therefore, this insti-
tution will continue its effort.

In other words, we will strive to create a condition in Indiana
that will provide early and competent medical service for all
cases of mental and nervous diseases. Dr. C. H. Hughes, of St.
Louis, Mo., in a letter to us, under date of December 3, 1899,
used the followiDg language:

"The braiu broken and prostrate with psychic perversion
should be under proper management and treatment at once. It
is in the prodromal and'ineipient stage that the best rescue work
can be done. When the psychiatric fire molders before it has
broken out into destroying conflagration, it is time for the ad-
vice and service of the alienist and neurologist or the man who
has added some of the knowledge of alienism aad neuriatry to
bis general knowledge."

"We advise, encourage, and appeal to the general practitioner
to seek this knowledge.

"We offer him the opportunity, and provide the place and ma-
terial for study.

The public soon appreciates that he is preparing himself, by
special work and study, to be of efficient service in cases of
mental derangement.

This fact will favor and be a strong inducement to early con-
sultations.

The advice of these men will be solicited in many instances
before there is serious evidence of disease or marked departure
from the normal. We believe that great good can be accom-
plished in these cases by intelligent treatment and care ontside
of these institutions.

But we also believe that greater good will accrue to the pa-
tient by an early commitment to some hospital.

This would be especially true of those institutions which are
fortunate enough to possess a separated detention or receiving
hospital, where the acute and borderland cases can be received,
isolated, studied, treated, and classified. The treatment at a hos-

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pital may not radically differ, but there is a change of environ-
ment. The patient is removed from the many scenes and causea
which impress him unfavorably.

This change, also, relieves him of the possibility of the dire
consequences which so often follow the misguided acta, of rela-
tives or friends.

We insist that the earlier the ease is committed, the greater
is the chance for recovery, .
. "The golden opportunity for the patient is the first Haee
mouths of his malady." (Dr. Hughes.)

The people have to a large degree overcome their antipathy
to the general hospital, and are now quite willing to send their
relatives to them for treatment, at the earliest manifestation
of disease. The prevalent idea that it is an additional stigma tn
commit their relatives to a hospital for the insane must be
eradicated. They must be taught to recognize the advisability
and necessity for an early commitment. To teach them the
great importance of this, throngb the physicians of the State, is
a part of our educational effort.

The authorities of these State institutions should be insistent
and aggressive in their demands for all that is essential to the
proper treatment and care of the unfortunate individuals who
are placed in their charge.

The State deprives these patients of their homes, their fami-
lies, and their liberties, as much for the benefit of the ctmununity
as for ttie benefit of the patients, and is therefore in duty bound
to provide for their needs. These needs are not confined to mere
custodial care, nursing, good food, and clothing, but include
every equipment, device, or article which experience has proven
to be of benefit in assisting the recovery or ameliorating the con-
dition of the patient.

These needs, also, embrace all scientific equipment which will
in the least degree assist the medical staff to study and diagnose
with accuracy the disease or lesion present and to determine the
cause or causes of the various conditions found.

It is of the highest importance for the successful prosecution
of this work, that the management be provided with ample
funds to employ and retain the best service, not only in the
Medical and Scientific department — hut in ail others as w^U.

It is the duty of the institutional authorities to indicate to ,tht
State the methods that will accomplish the best results. Thf

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.14

aggressiveness heretofore mentioned, on the part of the authori-
ties, should be chiefly manifested in the education and or^anlza-
iton of their forces.

Agitate, Educate, Organize — in season and out of season —
until your purpose has become an accomplished fact.

Petty jealousies must be eliminated, selfish motive and ambi-
tion throttled, and the good of one made the concern of all.

Reasonable and demonstrable requests, sustained by the
wishes of the people, to the authorities will overcome all ob-
stacles. The effort necessary to enlist the people, in behalf of the
cause of these poor unfortunates, should command every energy
at our disposal.

The Marion County Medical Society has held a number of
meetings in this department.

These occasions were largely attended and marked by an
awakening of professional spirit that was extremely gratifying.

It has been the policy of the hospital to have each of these
meetings addressed by an eminent medical man.

The first was addressed by Prof. L. Hektoen, of Chicago, upon
"The Contributions of Anatomy and Pathology to the Nervous
System."

The second, by Jos. G. Rogers, M. D,, of Logansport, upon
"The First Aid to the Insane."

The third, by C. B. Burr, M. D., of Flint, Michigan, upon
"The Care of the Recent Case."

The fourth, by Lewellys F. Barker, M. D., of Chicago, on
"The Importance of Pathological and Bacteriological Labora-
tories in Connection with Hospitals for the Insane."

The fifth, by Stewart Paton, M. D., of Baltimore, upon "The
Recent Advances in Psychiatry and Their Rela-tion to Internal
Medicine."

The sixth was for the purpose of dedicating the new hospital.
The attendance at this meeting was the largest of any, there being
present upward of three hundred prominent persons.

The seventh, by F, W. Langdon, M. D., of Cincinnati, upon the
" Cardio-Vascular and Blood States, as Factors in Nervous and
Mental Diseases."

The regular courses of the didactic and clinical lectures to the
students of the medical colleges were commenced in 1900 and
have been continued each year.

The lecture course for the session of 1907-8 is as follows:

The Medical College of Indiana (the niedical department of

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Purdue University) will present a course of lectures for 1907-
1908, Professor E. G. Beyer, M. D., and Professor A. B. Sterne,
M. D. (alternating), representing the college, their lectures des-
ignated by "B."

In connection therewith Oiarles C. Manger, M. D., Ph. Q.,
the Pathologist of the Institution, will deliver a course in Neuro-
pathology, designated by "A."

1907.
September 17th, 2 p. m.—

A. Development of the Nervous System.

B. Claaslficfltion of Insanity; Deflnitions.

Cases illustrating: Hallucinations, delusions, mental Inco-ordl nation,
exaltation, depression, apathy, the stigmata or degenera-
tion, etc. Professor Reyer.

"September 24th, 2 p. m. —

A, Anatomy and Physiology of the Spinal Cord.

B. Manic-depressive Psychosis.

Cases Illustrating; Simple, agitated, stuporous melancholia;, hypo-
chondriasis, etc. Professor Sterne.

October Ist, 2 p. m. —

A. Anatomy of the Brain.

B. Manic-depressive Psychosis.

Cases Illustrating: Simple, acute, subacute and chronic mania.
Professor Reyer.
Octol)er 8th, 2 p. m.—

A. Anatomy of the Brain, and Cerebral Localisation.

B. Acute Confusional and Stuporous Types.

Cases Illustrating same. Professor Sterne.

October 15th, 2 p. m. —

A. Circulation In the Brain and Cord.

B. Insanity of the Recurring Types.

Cases Illustrating: Periodical and circular forms.

Professor Reyer.
October 22d, 2 p. m.—

A. Pathology of Spinal System Dlseafles:
1st, Tabes dorsalls.

2d, Tjaterlal sclerosis.
3d, Combined sclerosis.
4th, Hereditary ataxia.

B. Paranoia, and Paranoiaes Generally.

Cases Illustrating : Paranoia and pseudo-paranoia.

Professor Sterne,
October 29th, 2 p. m.—

A. Patboic^y of Spinal System Diseases:
6th, Acute anterior pollomyelltiB.

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6th, Subacute and chrouic i>olioiiiyelttlfi.
Tth, Amyotrophic lateral sclerosltt.
8th, Prt^resalve muscular iitroiihles, mid »iystr(ii)hiea
B. Insanities Associated with the Neuroses and Psycho-ii
Cases illustrating: Epileptic, Liysterlc, ueuraesthenic Cunus, etc.

Professor Reyer.
November 5th, 2 p. m. —

A. Pathology of Diffuse or General Spinal Diseases :
1st, Myelitis.

2d, Multiple sclerosis.

3d, Syringomyelia.

4th, Hypertrophic cervical pacbyiueiiiiiKltls.

5th, Syphilitic meningitis.

B. Dementia Pavetica Progressiva.

Cases illnstratlug same. Professor Sterne.

November 12th, 2 p. m. —

A. Pathology of Diseases of the Brain.
Ist, Aua^nia.

2d, Hemorrhage.
3d, Softening.
. 4tb, Syphilis.

B. Insanities Associated with Gross Lesions of tbe Brain.

Cases Illustrating: Cerebral hemon-hage, the scleroses, tumors, lu-
xuries, etc. Professor Beyer.

November I9tb, 2 p, m. —

A. Pathology of:

1st, Brain tumors.

2d, Bulbar paralysis.

3d, Neuritis and multiple neuritis.

B. Toxic Insanities.

Cases illustrating: Alcohol and drug habits, post fehril cases, puer-
peral, choreic, etc. Professor Sterne.

November 26th, 2 p. m. —

A. Neuro-Patbologlcal Demonstration — Selected.

B. Terminal Dementia. Professor Reyer.

December 3d, 2 p. m. —

A. Neuro-Pathologlcal Demonstration — Selected.

B. Psychiatry — Miscellaneous Subjects — Clinical.

Professor Sterne.
December 10th, 2 p. m.—

A. Neuro-Pathological Demon stration^Sclected.

B. Psychiatry — Miscellaneous Subjects — Clinical.

Professor Reyer.
December 17th, 2 p, m. —

A. Neuro-Pathological Demonstration^Selected.

B. Psychiatry — Miscellaneous Subjects — Clinical.

Professor Steme,

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The Indiana University School of Medicine will present the
following course of lectures for 1908. Professors F. P. Hutehins
and R. N. Todd will represent the University, their lectures being
designated by "B."

In connection therewith Charles C. Manger, M. D., Ph. G.,
the Pathologist of the Institution, will deliver a course in Neuro-
pathology, designated by "A."
January 10th, 2 p. m. —

A. Development of the Nervous System.

B, Manic-depressive Insanity. States of Mental Depression. Mel-

ancholia.
Frescutatlou of simple, delusional, hypochondriacal, 'agitated and
stuporous cases.
January ITth, 2 p. m. —

A. Anatomy and Pbysiology of the Spinal Cord.

B. Manic-depressive Insanity. States of Mental Exaltation. Mania.
Presentation of simple, acute, and chronic cases.

January 24th, 2 p. m. —

A. " Anatomy of the Brain.

B. Psychoses of E3:haustion.

Presentation of acute confusionaJ and stuporous cases.
January Slst, 2 p. m.—

A. Anatomy of the Brain and Cerebral Localization.

B. Psychoses following Cheralcal Poisoning.

Presentation of alcohol, opium, cocaine, and other cases of rarer forms.
February 7th, 2 p. m.—

A. Circulation In tlie Brain and Cord.

B. Psychoses following Bacterial and Toxalbumic Poisoning.
Presentation of puerperal, acute dellrla and febrll deliria cases.

I'^bruary 14th, 2 p. m. —

A. Pathology of Spinal System Diseases ;
1st, Tabes dorsalis.

2d, Lateral sclerosis.
3d, Combined sclerosis.
4th, Hereditary ataxia.

B. Psychoses following Autogenic Poisoning.

Presentation of cases with uraemia, arthritis, cholaemia, rayxoedeme,
and exophthalmic goitre.
February 21st, 2 p. m. —

A. Pathology of Spinal System Diseases :
5th, Acute anterior poliomyelitis.

6th, Subacute and chronic poliomyelitis.

7th, Amyotrt^hie lateral sclerosis.

ath, Pn^resaive muscular atrophies and dystrophies,

B. Paralytic Demraitla.
Presentation of cases with various forms.

[2—18438]

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February 28th, 2 p. m.—

A. Fatbology of DifCu^e ur GeuernI Spinal DiEeases:
1st, Myelitis.

2d, Multiple sclerosis.

3d, Syringomyelia.

4tli, Hyi)ertroi)hlp PoiTicnl piicliynipnlnfritls.

5tli, Sypbilitic meningitis.

B. Psyc^boses of the Psychical Degenerate,
Presentation of paranoia and other cases.

March Otb, 2 p. in.—

A. Pathulogj- of DiscHfM's of tlie Rnihi,
Iflt, Anemia.

2d, Hemorrhage.
3d, Softening.
4th, SyplilUs.

B. Psychoses due to Cereliral Ijcsions.

Presentations of syiihilitic, demented, senile, atropliic, traumatic arid
Mher organic cases.
March 13th, 2 p. m.—

A. Pathology of:
1st; Brain tumors.
2d, Bulbar paralysis.

3d, Neuritis and multiple neuroxes.

B. Psychoses following Constitutional Neuroses.
Presentation of epileptic neuraesthenic and hysterical cases.

March 20th, 2 p. m.—

A. Neuro-patiiologlcal Demonstration. Selected.

B. Psyciioses due to Arrested Psychical Development.
Presentation of various illustrated eases.

March 27th, 2 p. ni.—

A. Neuro-pathologlcal Demonstration. Selected.

Treatment and Care of the Insane.

Presentation of methods, feeding and humane restraints.

A COL'KSE IN MENTAL PATnOLOQY.

Special clinics are provided for those who desire to take in-
struction in Mental Pathology. This course will be in charge of
Professor E. H. Lindley of Indiana University.

These clinics are designated to demonstrate those phenomena
of insanity which are especially instructive to students of
psychology.

The course this year will include the following:

1. The form of insanity:

Melancholia, mania, dementia. Idiocy, imtipcillty, dementia praecox, im-
pulsive and compulsive insanity; paranoia, paralytic dementia, and
senile dementia.

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2. I'syclio-pafhologv

H. Disturbiiiuen of iteneiitlon (lUuslouh pseudo-bulliuliiatlous and

liallu(iuiitlous)
li. Dit>tiirbitn(.-cH of menbil eliibiiriitiou (iimiieBl i iniriumiehl i losx of

orleutintlou iimlformtitlou of ideas and nju(*pth distuilniKtw

of Judgment and lenBouing disturbances of self-iiHistuuBiit,"!-*

retardation and flight of idetis ete )
c' DIsturbauL'es of the emotions (anbedonla delusions sjionidic ind

R\ sterna ti^cd)
d. Dlsturbauces of volition and actiou | litiimi'dh e and (oiiipulbii e

Ideal e<.bu-iiraxlb uegatiilsui steieot^pihui ibull i et( )

Cases iUiistiAti\e of the above will be presented to the classes.
Members of the hospital statt will alternate in ai ranging cases
for all the ciiiiicai lectmef.

Tile following general rults will govern the course
Ail students must be In their seats prorairtlj at the bour stheduled.
Questions will be furnished by the Pathologlwil Department in the
dnal exami nations

Due notice of auto|nles will l)e gi\en the class by telq>bone to college.
Ceititlcutes of attetidimi'e nill be Issued by the i-oilege for these lec-

Studentx umst miuiitalD quiet » bile in the ^.r >uiids >r 1 uildlii;.<>
SmoLiug in the dei>artment i« prohibited

These lectures are free to practitioners and studmts of medi-
cine. Others will not be admitted except upon special permission
by the Superintendent or Lecturer.

The program for each lecture day will be :
Didactic- lecture, one hour.
Clinical lecture, one hour.
I'atbolojiicaJ demonstration, one hour.

Records of these lectures are made and filed showing:
Date of elluU;.
Subject of lecture
Number of cliuic

\unib«r of phvsici ui^ and students in iittendauce.
Name of patient presented
riassification of insanity
Intercurrent disease oi (H)niplicatirn
Name of lecturer

Name of staff | hvsii lan furnishing tlie canes.
Presented to the class — les or No
Itemarkb
Pathological denioustutlou

1 Character of —

2 Mlscellaiieous notes
* 3. Patbological No.

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With each patient presented to the elasis the following form is
used and furnished by the member of the staff having charge of
the case :

Case number.

Name of the pntieut.

Age.

Sei.

Date adjudged iusane.

Admitted to hoBpltal.

Synopsis of coumiitnieiit record.

Personal observfitioiis :

1. Mental.

2. Pbyalcal.
Remarks :

Patient of M. I),

Presented to class by M. D.

Clilef of clinfc M. D.,

Assistant Pliysiclan.

The staif meetings, for consultation and clinical examination
of patients are held three times a week and are a great stimulus
to the study and treatment of the individual — this being of the
greatest importance.

The following forms are used for "case histories" and the
clinical examination of patients :

tal

Fi^m what County

Good.

NumtH

r ot tiniB

in otii

r liospitals . .

Physical vanditinn

Impro

«d.

\o M

attacks

■ ^^„

fi.st attack

R in

ed f 1 tu 1

u t

rniy«

cal

Suppoatd cause of insanity

-, He

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Deformed?...
Epileptic?. _.
HystflriQfllf-.

Talkative? Ans,: :.. Profane? Ana.:....

Silent? ' Obstene?

Noisy? Filthy?

Quiet? Intemperate?

Cheerful? Sleepless? I«me?

Melancholy? Homicidal? MuwT

BsBtleM? Suieidal? ParalyaedT.

^^olentf Criminal? Phtliiaical?.

Destructive?. DlindT Scrofutous?.

Secluflive? Choreic? SyphiUtic?.

Dull?

Dues or has indulged in any venereal excess? Answer; .. .

Was feeble-minded in infancy? Answer:

Hasi had, to what extent and when, any dieease of the hi

organs of |i;eneratioii, stomach, bowels, bladder, kidneys or skin? Answer:.

itions, have been int«mperat« ii

Reads and write)
NoedumtioD...
Unascertained . .

Phthi«cal?
Feeble of min

Sjphilitit

Results Unimprove
Not insane

Previous Registered No

PRESENT CONDITION:

. .Mo day, IBO. .

; Weiglit, ; Complexion...

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P.mil, JDil»leii. O.H.
"I'Ms, IContiwteJ. C). H.
I Irregular. O. D.

Abiliiineii and V

B, f haile, Positiun ^it Ornans, Ten.

Headache, Veil

Evidfflir;eB o( Iniiiry, DetormitLes, Marks, Hears, Hu|j

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General Cn-ordLnation

Muscular Twitdunga, etc

Muscular Strength

Sensation:— Tactile: Thermal: Muscular Sense. e(

LABORATOR'V RECORD.

~ J. I I I I - . I . I f 6

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..,,..„>«„„...«,

Datb.

An additonal outline is sent to the Pathologist with each ease
for post-mortem as follows :

Name

Age Date of Admiesion

Pbysical condition ou Admission

Pbysical Condition prior to Admission

Mental Condition on Admission

Mental Condition prior to Onset of Mental Disturbance

Date of Onset, Character and Course of Mental Disturbance prior to Ad-
miesion '...'.

Course of Mental Disturbance since Admission

Course of Phjsleiil Condition since Admission

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Date of Ouset aui3 Muiiffestntlous of Illness Proving Fatal..

Most PROMINENT Manifestations of Recent Illness..

Date of Death Time of Death . .

Cause of Death

Adtlltloual Remarks :

Dnte of Eeiwrt..
Time of Report..

Assistant Pbysician.

Autopsies are made as thorough as possible, and a complete
record of the findings is kept under the following definite head-
ings:

Name, Age. Sex.

Hospital. Case book. Volume. Page.
Date of death. Time of death.
Date of autopsy. Time of autopsy.
Fonn oC mental disease on admission. At death.
Ca se f death Cll i 1 notes.

b t nal xamin ti n Height, weight, llvor and rigor mortis, etc,
h t n 1 sign f disease.
1 t ual ign f jpbills.
(_ dlti f vtalp J s ears and nose.
I.ocomotory system. Bones, muscles and cartilages.
Circulatory system r Pericardium, heart, aorta, other arteries and veins.
Rcppiratory system ; Nares, larynx, trachea, lungs and plurae.
Alimentary system: Mouth and fauces, pharynx, esophagus, stomach,

small and large intestines, pancreas and ducts, gall-bladder and ducts.

Liver and ducts. Peritoneum.
IJro-geiierative system: Kidneys, ureters, bladder, ovaries, tubes, uterus

and vagina. Testicles, scrotum and penis.
Blood and Glandular system : Spleen, adrenals, thyroid and lymphatic

glands.
Nervous system : Scalp, skull, dura mater, pla mater, pacchionian bodies,

arteries, cranial nerves.

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Encephuloii, cortes, white luattpr, veutrli'le«, choroid plexuscR, banal jjaii-
glia, tfreliflluiii. pons and nKidulla, Eplpliysis, hypophysis, vertebrae,
cord, nerve roots and gauglta. Sjuipathetlc system.

Microscopical examination.

Ilacterloiogk-al reiwrt.

Pathologleni dingnost<s.

As indicated elsewhere, the Assistant Physician who has had
charge of the case asiists the Pathologist at the autoi>sy.

A review of the record of the work dcm© in this department
from September 1, 1903, to October 31, 1906, shows:

1. That ihe laboratory facilities were in daily use for the ex-

amination of specimens of blood, urine, sputum, etc.

2. That one hundred and forty-seven autopsies were held and

the findings demonsti*ated.

3. That many sections of various tissues and organs were pre-

served for chemical, bacteriological and microscopical
examination.

4. That eighty-nine gross specimens were prepared and placed

in the museum.

5. That ten pap^-s were furnished and read before the Marion

County Medical Society.

6. That three hundred and fi,fty-four staff meetings were held

at which over four hundred cas^ were presented for
clinical examination,

7. That one himdred and twenty six lectures — sixty-three di-

dactic and sixty-three clinical — were given by the col-
leges to the classes.

8. That sixty lectures upon neuropathology, with as many

pathological demonstrations, were given to these classes
by the pathologist.

9. That four hundred and thirty cases were taken before the

college classes for clinical demonstration.

We 'take from our annual report of 1905 some reasons for
maintaining our Patholog:ical Department, and assert tiiat tiie
work hereinbefore outlined, as well as the results summarized by
Dr. Neu, could not have been accomplished without it.

THE PATHOLOGICAL DEPARTMENT.

1. Stimulates the individual members of the staff to greater

professional effort.

2. Creates a demand for accurate case and clinical histories;

this requires more attention to the individual patient.

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Incites to study and systematic investigation, by having at
hand the requisite appliances, boc4£S, models, charts, etc.

Enables the institution to offer something to the ambitious
student seeking an opportunity for medical advance-
ment.

Provides instruction to the physicians and the students in
the State, prepares tiiem to render early skilled atten-
tion to the mentally afflicted in their community. This
directly benefits the citizen.

Increases the ability of the outside phsreician to deliver an
intelligent judgment in insanity inquests and dictate a
description of the case of value to the hospital.

Economizes for the counties and State ultimately, by de-
creasing the number of persons annually committed to
this or institutions of like character.

Actuates some students to undertake a special study of
mental and nervous diseases. With additional oppor-
tunities given, these, for clinical observation and for
practical work in the laboratory, will eventually de-
velop material from which to select physicians for posi-
tions in ^e hospital.

Establishes a valuable medium to create harmonious rela-
tions between the out^de members of the profession
and the institution,

Affords the hospital staff the benefits of consultations with
specialists in all lines of practice.

Collects pathological data for the records and specimens for
the museum which will be of incalculable value for fu-
ture reference and study.

Assists in educating the public to the needs of the hc^pital
and arouses an interest in its behalf.

Furnishes the medical coUeges with clinical advantages un-
obtainable without the aid of an institution of this char-
acter.

Extends its influence in time to the individual of every com-
munity; it teaches that "prevention is better than
cure," and tiiat, if the people really desire to impede
the "onward march to the hospitals for the insane" in
future generations, they must begin at once to heed the
advice given, assist in locating and studying the causes
and by precept and example lend every influence to-
ward their removal.

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These have been inserted in the hope that, with the other
material of these reports, some authorities will be inSueficed to
lend their assistance in establishing similar departments in insti-
tutions where they are now lacking.

From the foregoing it is apparent that tb« main object of our
work in this direction is to provide the best medical service pos-
sible for the mentally afflicted individual, within or without the
hospital.

It is also evident that this was the prime motive for the instal-
lation of this department and its equipment of scientific appurte-
nances.

When the nature of a disease has been determined, the most
important step towards its rational treatment has been achieved.

Should additional results be obtained from this source, either
for us or others, it will only be another reason — but not a greater
one— why it should be continued and maintained.

To render the work effective ^ong the lines indicated the
State must provide beds in advance of the probable demand for
the commitment of patients.

1 recognize the fact that repetitions have been many ; no at-
tempt has been made to avoid them.

We are indebted to the members of the Marion County Medical
Society for the hearty support accorded in advancing the interests
of this movement. The Indiana Medical Journal and the Medical
and Surgical Monitor have assisted us at every step in the inaugu-
ration and prosecution of this work and we feel deeply grateful
to their editors and management.

Drs. W. B. Fletcher and H. M, Lash (now deceased) and Prof.
Frank B. Wynn, M, T>., were among the first who delivered lectures
to the college classes in this department.

In conclusion, it is but just that I record your hearty endorse-
ment of all plans submitted to you for the development of the
scientific work of this Institution.

Your attitude has been one of great encouragement, and I as-
sure you of my heartfelt appreciation.

The summary of Dr. Neu follows, and presents the work in
detail. Sincerely yours,

GEORGE F. EDENHARTER, M.D.,

Superintendent

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SUMMARY

CHARLES F. NEU, M. V.,

Work Done by the Pathological Department
Central Indiana Hospital for Insane

September i, 1903, to October 31, 1906.

MEDICAI, STAFF DURING ABOVE PERIOD.

Georce F. Edenharteb, M. D., Su|)evintendeiit,

Assistant I'HysiciAns.
Department for Men- — Department for Women—

P. J. Wattebs, M. D. Sarah Stockton, M. D.

F. M. Wiles, M. D. Maj( A. Bahb, M. D,

A. K. Leuke, M. D, Robert N. Todd, M, D.

J. A, MacDonai.d, M. D. J. J. Hoffman, M, D.

CiiAKLES F. Netj, Pathologist.

J. J. Grauliko, Aselstaut.

E. D. Martin, M. D.. Assistniit.

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SUMMARY OF WORK DONE BY PATHO-
LOGICAL DEPARTMENT.

BY CHAS. F. NEU. M. D.

Dr. G. F. Eilenliniicr, Hapcrintcniifiif Crnlroi Iniliann Hoxpital fm llio

Inxane ■

I>«ir Sir— I befi to submit herewith thp following resume of the work
done under tlie management of the iHitlioIogical labomtory wbile In my
clmrpe from Sejitember 1, 1003. to October 31, lEKKl.

During this time permission was obtained for and autopsy performed
upon 147 l>odies. The eilulrai report submitted by the rrfiyslclnn lit eharge
together with a report of the gross and mlerosi'Opicnl findings in each case,
was recorded in the regular records for that purijose. Apjiended hereto
will be found a syuojislH of tbose reiK>rts, together with a summary of
the more Imiwrbint features of it. Attendance at tiiese autopsies was
always open to niemlters of tbe mediciii prufeasion and to the students of
medicine.

From tbe various pntiiologicai conditions nfCectlng tlie different or-
gans, gross specimens of the more important and interesting were selected,
pr^mred and placed in the museum collec-tion. Tlie list, consisting of
eighty-nine speclmeiis. will also be found aiii)ended hereto.

Microscopii^al examinations were made of all the organs Id each case,
for wbich purjioi'S sections were removed and placed either Into formalin
solutl<m or Zenlter's tluid for fixation and preservation. The routine of
examination was somewhat as follows ; Slides were prepared in all
cases, stained with the usual haemotoxylln and eosln method. In addi-
tion to this the various parts of the nervous system, by the usual special
methods, consisting of Nisal's cellular stain of methylene- blue, I'al-Weigert
medullary sheath stain, Mallory's neuroglia stain, and Alarchi's osmic acid
stain. Whei'e definite pathological changes were observed slides were
preserved and placed in a cabinet used foi' that purjtose.

Where It seemed to be specially indicated, and the time necessary for
it was possible, bacteriological and eheniiral examinations were made in
addition to the above.

Examinations were also made of the urine, sputa, blood and spinal
fluid, etc., submitted by the assistant physicians wlieiiever they had not
tbe time to do so themselves, or where a sjiecial examination was required.

Beginning Octolier ], llXKl. and contiiiuhig until the last of DecemlxT
of the same year, a series of lectures and demDustrntions was Klveu to
the assistant physicians on the anatomical relations and tbe physiological
functions of the various parts of the nervous system, on tlie different
changes pi'odured by the different pathological conditions that were liable
to involve them, and upon tlie ciniical symptoms manifested by such in-
volvement

;30)

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After the lat ot January, 1904, regtilar staff meetings were itisHtutecl
and held tliree tluten weekly, namely. Monday, Wednesday and Friday
mornings from 10:30 to 12 a. m. At these meetings tlie assistant physi-
cians alternated In presenting one i>r more fHses. A systematic exnmt-
natlou was made of the mental condition and also of the plijalcal condi-
tion, where this Iiad not l)een done Iwforeliand, by the assistant physician,
or where some special condition was reiwrted by the iiiiysiclaii In charge,
followed by a discussion of the cane by tliose In attendance. In all 354
meetings were held, and 400 or more cases preseuted. A syuoi>slR of the
more Important clinical features of each case, tc^etber with a summary
of the clinical manifestations, wilt also be found appended hereto.

The object of these meetinss was to creiite a nucleus ui>on which more
complete clinical rei-ords could be built, and for this purpose a short re-
port was made and filed away of each case, pointing out the prouiinent
and characteristic features of the individual cases presented. An endeavor
was also made to determine the uuderlylnK conditions tiiat were the proli-
able factors in bringing al>out the mental disturbance. This problem was
found to he an extremely difficult one. Many important factors came into
consideration when an attempt was made to bring about a solution of tins
problem which were most difficult to r^ulate and control, Id many cases
wholly Impossible, and tended to make this part of the work a source of
discouragement and in many respects very unsatisfactory. One of the
first essentials in the study of all pathological conditions, whether mental
or physical, is, of course, to have a correct conception of the normal, or
what is regarded to be as nonual, in the individual case. Without this
one cannot arrive at a definite conclusion as regards the degree and ex-
tent of the abnormal conditions that develoi>ed or that may do '^o. In
the majority of cases presented very little iiifonnation was obtainable,
apart from that of the commitment record, or from the i>atients them
selves. The former reports, unfortunately, were very incomplete, and
the latter almost invariably were more or less distorted or modified by
the trend and coloring of the mental disturbance existing. Consequently,
any conclusions arrived at can only l>e of corresponding value. In addi-
tion to this, it is of the greatest importance to have a full report of the
heredity, early education, training and envii-onment of each ease in order
to understand and appreciate the character and nature of the disturbances
that may be nianifi'sted. And fimilly, there la requisite a full report of
the results of a coniplete examination of the patient's condition at the
time of admission, or as soon thereafter as possible, lx»th mentally and
physically, togetlier with a record of the case while In the Institution.
Without these data it is impossible to place the pathological work in Its
proper relationship to tlie clinical aspect, or to place the latter ujion a
definite pathological basis.

A considerable number of patients were seen in consultation with the
different physicians whenever It was thought nei'essary by then).

During the medical college term of liMKi and liKH, a series of lectures
and demons! ratiuis was given to the students of the two medical colleges
upon the anatomical relations of the various jiarts of the nervous system,
and a resume of the more important pathological conditions Involving
them, with a presentation of specimens, gross and microscopical, wherever

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thiB was poBslbie. Duriug tUe reuiUiiIng terms, thiit is. fcir 1904 iiiid JOOTi.
1005 aud 1906, and for the term of 11)00 nud 1007, up to tlie time of resig-
nation, the fQllowIng course of lectures was given In connection with those
given by the various professors of clinical psychiatry:

1. '1 be evolution of the nervous system,

2. The development of the nervous system.

3. The surface anatomy of the brain and Its relations to the external

surfaces of the skull.

4. The fntemai anatomy of the brain.

5. The anatomy and physiology of the spiniil cord.

6. The blood and lymph circulation of the nervous system.

7. The pathological conditions involving the gray matter of the Bpiiuil

cord, and their clinical signlllcance.

8. The pathological conditions involving the white matter of the spinal

cord asd their clinical manlfentattona.

9. The connection of the spinal cord with the various parts of the brain.
10. Pathological conditions involving some of the most Important bundles

of fibres connecting different parts of the brain and their clinical
signlfleaace.

The following papers were presoiited and ciises ri^jiovted before the
members of the Marlon County Medical Society, viz. :

1. The relation of the peripheral nerves to the central nervous system.

2. Brain tumors: Their etiology and puthologlcai efEect.

3. Brain tumors: Their clinical miuiifestations, diagnosis and treat-

ment, with a report of six cases.

4. Report of a case of acute baemorrhagic pancreatitis wltb comments.

This was published In the Journal of the American Medical As-
sociation.
5 Report of three cases of acute suppurative meningitis of pneumococ-
cus origin.

Report of fiftj fl^e autopiio* perf rmed at the Oentrii Indiana llos

pital for The Insane for the >ear ending Odober t1 lOM

7 Report of a lase of rupture of the aorta ind haemorrhige into the

pericardium

8 Reixirts of two case* of brain tumor The tllmcal report of tlic e

(Hses was Rhen bj Dr Matdomid one of the aisistint [li\'>i
cians who had charge of them while in tlie Institution Tlie re
port of one of these was publlshtd in the Journal of the 4merl
can Medical Association

1 Rc[K>rt (fa case of death by coma of about eight hours duration

coming on suddenly without any premonitory stmptoms In which
was found extensive tubercular Involvement of the lungs and
Intestines
10 i' iKiit of eight Lase*: of brain tumor with comment was prewnted
at the State Medical Associitlon and is contained in the report
of its proceedings
CoiiiLs of these papers n 111 be found appended hereto

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List of gross Bpeclniens prepared and placed in the museum collection :
Sarcoma of the brain Involving the left optic thalmus.
Sarcoma of the brain involving tlie inferii>r vermis of the cerebellum
with atrophy of the left cerebellar and right cerebral hemispheres.

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39. Diffuse anourieui of tbe aorta.

40. Pericardium witli jwufli-like iiiiiteuili.'t,

41. Oesopliagus of acute araetilcal ix>isoi)iiig.

42. Stomach of acute arsenical poiRoniitg.

43. Iiitestioal gougrene due to volvulus.

44. Vermiform api)endI.Y as a direct t'outiiiuatinii of tlie cacciini.

45. Acute enteritis.

46. Chroulc colitis.

47. Tongue-lilte iH-olougutioii of tlic left lol)e of the liver.

48. Hypertrophy of tlie Ijiadder,

49. Chronic interstitiai iiepiiritis aud liepatk- cirrhoxlH.

50. Smaii white kidney.

51. Acute n^britis.

52. Carcinoma of the ceiTi.v uteri iiivolviiij; tiii> liliuldcr.
5it. Enlarged middle lol)e of the prostate ^inud.

54. Cystic thyroid glands.

55. ■ Abscess of the lung of pneumococ-at nrlgln.

56. Carcinoma of the prostate gland.

57. Perforation of the bladder.

58. Extensive tubercular ca»tly formation of tlie lung.

50. Extensive pulmonary anthrjicosis with tulu'W-uiai- involvement.

00. Carcinoma of the prostate.

61. Pulmonary infarct.

62. Pulmonary tlirombus.

63. 'I uberoulosis of the caecum and apiH-ndix.
C4, Carcinoma of the caecum and upjiendix.

05. Extreme dilatation of the lateral ventricles.

66. Acute pericarditis.

07. Rupture of the aorta.

68. Hypertrophy of tiie lieart witii associated sclerotic kidney.

6!J. Miliary tuberculosis of the lungs of a guineapig following intra-
perioneal injection of creamy material from a psoas abscess.

70. Perforation of the venniform appendix.

71. Angiosarcoma of tbe brain.

72. Acute myocarditis. '

73. I'ouch in the interventricular septum of the hcnrt [irotruiliug into

the right nurlculo- ventricular [■eptum,

74. Multiple uterine flhroid tumors.

75. Uniting fracture of a rib.

7G. Bnchondroma of tlie internal surface of the frontal regioii of thi^
skull.

77. I.*ft cerebral hemisphere showing atrophy friiin pressure of an in-

tracranial en chondrom a.

78. Extensive chronic nephritis with cyst formation,
70. Gastric carcinoma.

SO. Osteo-chondroniatous deposit in the pleura.

81. Extensive cardiac hypertrophy with chronic i)ericardiai adhesions

obliterating the pericardial cavity.

82. ICidneys of a case with extensive cardiac liyi>ertropIiy and pericar-

dial adhesions obliterating the cavity.

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Chronic diffuse, uephrlds

Tumor of the corpus calloauin (Ghomatous.)

Thrombo'^is o£ the '!ur>erior mesenteric artery.

Kldneji of a case of Intracranial encbrondonia. one of whicli i

reseuted almost nliollv by a ini
Thrombosis of ttip iiiiddle 'orebraL

supplied l>y it
TtiroiniKiais of the iiiiterior cerebnl nrteri vitli aoftening and

tial fltrophv of the parts auppl ed 1 it
I»ft kidney slunving extensive

in tlie peivle nali.

of fatty tissue.

rcrv with softening of the parts

^nicareous deiiosit

GEXERAL rATIIOl-OGlCAI, ItRI'OIiT OF TIIR AUTOI'SIKS.

Numlier of iintoiisii'ii 147

Sex —

Males / TO

Females 71

Knee —

White 140

Negro 7

Age — Males. Females. -

Under the age of 20 2

Betweeo the apes of 20 aiid Hi 4 4

Between the i^es of ^0 and 40 14 5

Between the age^ of 40 and 50 JO 17

Between the nses of W and 00 24 10

Between the a^es of (lO and 70 7 17

Over the age of 70 r; 1)

Total 70 71

Number of admissions— Males. Females.

First admission ."ri) C2

Second admission i;i

More than two adniisslons 3 3

Not Insane I

Total 70 71

Form of psychosis as per record — :M.iles. Females.

Acute melancholia 3 n

Chronic melancholia T !)

Agitated melancholia 1

Hecurrent melancliolia' ...'.■■- 1 1

Acute mania 4 4

Chronic mania T 21

Hecurrent mania 2

Acute confusional insanity 2

Epileptic insanity IT 14

)v Google

Toxic insanity

Circular iDsanity

Generai paresis lO

Tal)o-parealB

Chronic paranoia 1

Senile paranoia 1

Primary dementia 4

Secondary deuientlii .'(

Organic dementia 4

Senile dementia 2

Not Insane 1

Total ,

Cause Of deatli —

Tuberculosis 26

Pneumonia 25

Pulmonary oedamn 12

Pulm(mary Infarct 1

Ciironic myocarditis 5

Acute endocarditis 2

Acnte pericarditis 1

Cardiac dilatation '. 1

Angina pectoris 1

Asphyrla 17

Convulsions 10

Bxbaustlon 4

Generai peritonitis 4

Intestinal gangrene 2

Colitis 3

Gastric carcinoma

Gallstone obstruction

Acute liuemorrbagtc pancreatitis

Mammary carcinoma

Uterine carcinoma

Rupture of tlie aorta

Brain tumor

Haemorrhiglc cyst of the bruin

Cerebral haemorrhage

Cerebral meningitis

Transverse myelitis

Abscess of the liver

Chronic nephritis

Pyaemia

Arsenical poisoning

Shocic from injury associated with brain tumor

)vGoo'^lc

ACUTE MELANCHOLIA.

Male

Female

Male

Female
Male

Female

Male

Female

Male

Dwoiion oj
Illness.
7 months
6 months

15 months

Cou-^eo! De„lli.
Aspliyxia by hanging.
Pulmonary oe.iema.
Pyaemia due to acute Buppjrati .e a
l> months Acute arsenical poisoning.
7 months Awphyxia by stranjj'.ilatiim
IS innnths Asp)iy\ia by hangi'ie.

CHRONIC MELANCHOLIA,

m years Pulmonary tuberculoais,

4} years Uraemic convulsions.

Not given Shock from being thrown out of a c

2 years Pulmonary tuberculosis.
7J years Pulmonary tuberculosis.
6 years Pulmonary tuberculosis.
6 years Hypostatic pneumonia.
5 years Hypostatic pneumotiia,

3 years Uterine carcinoma.
5 years Lobar pneumonia.

5 years Asphyxia'by strangulation.

13 years Pneumonia and pulmonary gangrene.

13 years Pulmonary tuberculosis.
20 years Cardiac dilatiaton.

1 j^ar Lobar pneumonia.

5J years Rupture of the aorta and haemoiH"

AGITATED MELANCHOLIA,
li years Asphyxia by hanging. '

RECURRENT MELANCHOLIA.

14 months Acute malignant endocardilis ami s.

tonitis.

Male

6 months

Asphyxia by hanging.
ACUTE MANIA.

Femalp

3-4 weeks

Exhaustion anil p\i\rru

MsU(

13 months

General tuberculosis.

Female

100 days

Angina pectoris.

Male

4:-.

17 days

Maniacal e.'^haustion.

Male

8 months

Haeraorrliagic leptomf

Female

2 months

Maniacal e.\haiistioii.

Male

3 weeks

Pulmonary oedema.

Female

4 weeks

B ronchopneumonia.

„ Google

CHRONIC MANIA.

Duration of

Sex, Age. Ititiess. Ciuse oj Death.

female 67 Hi years ( erebral liaemorrhagc

Female 67 BJ years Itroncliopneumoma

Female '72 16 years Puimonarv tuberculosis

Female 55 10 years ^cute haemorrliagic panert otitis.

Hide 60 3i years Pulmonary oed( m i

Female 43 12 years Pulmonary tuberouioaia an 1 acute myelitis

Female 53 24 years Carcinoma of the breast

Male 50 1} years Il^postatie pneumonia

Female 63 19 years Pulmonaiy tubercuioBis

Female 50 17^ years Oalhtone obstruction

Female 50 12 years Puimonarv tubereulo<ii-(

Female 65 20i years Pyaemia due to multiple alfficess.

Female 42 18 years Abscess of the liver

Female 64 18 years Cerebral haemorrhage

Female 67 24 years Pulmonary tuberculosis

Female 56 16 years Acute suppurative meningitia

Female 65 18 years Tubercular pneumonia

Female 50 16 years Pneumonia and acute suppurative meningitis.

Male 58 2 years Convulsion and hypostatic pneumonia.

Male 44 6 years Cerebral haemorrhage

Male 55 7 years Pulmonary tuberculosis

Female 52 24 years Pulmonary hypostacis and subacute myelitis.

Male, 56 21 years Pulraonary tuberculosis

Female 51 24J years Carcinomo of the breast

Female 66 29 years Acute pericarditis

Fein^e 29 5 years Pulmonary tuberculosis

Female 86 12 years Chronic myodnlttis

Male 58 10 years Pulmonary oedema

RECURRENT MANIA.

Male 65 13 months Intestinal volvulus and gangrene.

Male 66 Not given. Acute malignant cnilocarditiB.

CIRCULAR INSANITY.

Female CO Not given Septic peritonitis.

TOXIC INSANITY.
15 months Gastric cj

ACUTE CONFUSIONAL INSANITY.
3 months Pulmonary tuberculosis.
6 months Lobar pneumonia.

„ Google

Dumtion oj

Sex.

Age.

lUmss.

Malo

4 years

Male

8 years

Male

3i years

Female

11 years

Female

'6 years

Male

15 years

Male

10 years

Female

4i years

Female

7 months

Female

2i years

Female

7i years

Female

9 months

Female

lOi years

Male

2 years

Female

12 years

Male

3 years

Male

3Syeara

Male

Not given

Male

Not given

Female

Not given

Male

12 years

Male

10 years

Male

6 years

Male

4 years

Male

7} years

Female

16 years

Female

32 years

Female

2yeare

Male

4 years

Female

14 years

Male

15 years

Female

.24 years

Female

16 months

Mate

2 years

Male

3 years

Male

22 years

Male

3i years

Male

10 montlis

Male

3 years

Male

15 months

Male

1 year

Male

2 years

Male

2 years

Male

2 years

Male

15 montliB

EPILEPTIC INSANITY.

Cause of Death.
Status epilepticus and hypostatic pneumonia.
Status epilepticus and pulmonary oedema.
Asphyxia during a convulsion.
Asphyxia during a convulsioo.
Asphyxia during a convulsion.
Chronic nephritis.
Asphyxia during a convulsion.
Status epilepticus.
Status epilepticus.
Status epilepticus.
Carcinoma of the uterus.
Status epilepticus.
Status epilepticus.
Lobar pneumonia.
Status epilepticus.
Status epilepticus.
Asphyxia.

Hypostatic pneumonia.
Pulmonary oedema.
Asphyxia.

Status epilepticus and hypostatic pneumonia.
Pneumonia.

Status epilepticus and hypostatic pneumonia.
General tuberculosis.
Asphyxia during a convulsion.
Asphyxia during a convulsion.
Asphyxia during a convulsion.
Hypostatic pneumonia.
Hypostatic pneumonia.
Pulmonary tuberculosis,
.\cutc cardiac dilatation during a convulsion.

GENERAL PARESIS.
Hypostatic pneumonia.

Paretic convulsions and pulmonary oedema.
Hypostatic pneumonia.
Pulmonary tuberculosis.
Paretic convulsions.
Paretic convulsions.

Paretic convulsions and pulmonary oedema.
Paretic convulsions with asphyxia.
Lobar pneumonia.

Paretic convulsions anil pyonephritis.
Cerebral concussion and asphyxia.
Paretic convulsions.
Paretic convulsions.
Pulmonary infarct.

)v Google

JhiTotion of

Sex.

Age.

lUness.

Hale

21 years

Male

2 years

Male

3 yea™

Male

U years

Male

5 years

Male

2 months

Male

1 year

Cause of Death.
Paretic convulsions and exhaustion.
ExhauEtion.

Epileptic coDvulsions and pulmonary oedauia.
Tubercular pneumonia.
Convulsions.
Pulmonary oedema.
Pneumonia.

TABOPARESIS.

2 years Exhaustion.

CHRONIC PARANOIA.

Not given Gastric c:

SENILE PARANOIA.
Not given Chronic myocarditis.

PRIMARY DEMENTIA.

3 months Septic peritonitis.

3i years Pulmonary tuberculos

Male

2 years

Pulmonary tuberculosis.

Male

3 years

Chronic peri- and myocardiiiK.

SECONDARY DEMENTIA.

Male

23 years

Chronic nephritis.

Female

2i years

General tuberculosis.

Male

16 years

General peritonitis.

Male

21 years

Intestinal gangrene.

Male

61 years

Pulmonary tuberculosis.

SENILE DEMENTIA.

Male

6 years

Asphyxia by choking on a pit^ee of meat

Male

2 years

Pulmonary oedema and lobular piieumii

Female

2i years

Chronic myocarditis.

Female

13 years

Acute enteritis and pulmonary tubcrciil'

Female

2 years

Septicaemia decubitus.

Female

li years

Acute colitis.

Female

lyear

Lobar pneumonia.

Female

7 months

Chronic colitis.

Female

2 years

Entero-colitis.

Female

41 years

Acute septic peritonitis.

ORGANIC DEMENTIA.
4} years Sarcomatous' tumor of the brain.
2 months Multiple syphilitic tumors of the brain.

„ Google

thtmtion oj

lUness.

Cause oj Death.

1 week

Sarcoma of the brain and haemothorax.

9 months

2 years

Brain tumor and chronic myocarditis.

NOT INSANE

8 hours

General tuberculosis.

In gumming up tlie most prominent of tlie various pathological <
ditious it Is found that the various organs showed definite visible sti
tural alterations as follows:

Cranial bonea 46

Meninges 127

Calcareous deposit In the meninges 9

Cerebro-spinal fluid 113

Brain :

Atroptiy 65

Softening 11

Haemorrhage 10

New growths 9

Ventricles 45

Choroid plexus 28

Eirendyma 30

Spinal cord .■ 11

Craiiifil nerves 4

Thyroid gland 26

Thymus gland 9

Pericardium 34

Heart :

Myocardium 38

Endocardium 12

Hypertrophy 51

Dilatation 36

Valvular involvement 70

Blood-v^sels 132

Aortic dilatation 19

Pleura ;

Adhesions on the right side 95

Adhesions on the left side 87

Obliteration of the cavity, right side 11

Obliteration of the cavity, left side 12

Hydrothorax 14

Pyothorax 10

Haemothorax 1

Lungs:

Tuberculosis 55

Oedema 48

)v Google

Pneumonic consolldatloo (hi

Empbysenia 22

Infarction 3

Collapse 13

Bronchi 37

Broncbial gInudK 53

Peritoneum 2:2

Peribepatitis 35

Cirrhopls 25

TutierculoHls 4

Syphilis ]

Carcinoma 4

Fatty 20

Passive congeslion 33

Amyloid deposit 3

Atiscess 1

Gallbladder 22

CholellthlaalB 18

Pancreas 8

Spleen 34

Kidneys 120

Renal calculus 2

Adrenals 7

Ureters 9

Bladder 14

Proatate ' 15

Urethra 1

Testicles 4

Ovaries 22

Fallopian tuljes S

Uterus ." 21

Oesophagus 2

Stomach 24

Intestines 2(i

Appendix 5

Mammary gland 2

Tlongue 1

Eyes

Cataract 3

Trachea 4

Larynx 3

Ear 1

New growtlis present 30

MallRnant growths present 20

Cranial iume changes In 1 acute and 4 chronic iiieiiincholln ; in 3 acute
and 4 chronic mania ; 14 epllfptlc Insnnity ; !) geticral and 1 tabo-paresis ;

1 primary. 4 senile. 2 seconiiary. iiiiil 1 orKniiic dcnicntin ; In 1 senile
paranoia.

)v Google

Duijil (.hnuges In 1 Jitute 10 dironk 1 imitated iind 2 reiurreni
ineliini-liolla in 3 acute 15 chroiik ind 2 recurrent mania m 17 epil«4>
tic. 1 circular and I coufustonal iii«antt} In 13 genera) x)!"*^'^ ia 1
smile and 1 clironic paranoia In 1 primary t secondary S eenlle and 1
organic dementia

Arachnopial changes in 3 acute 10 chronic 1 agitated and 2 recur
rent nielancholln in 4 acute 19 chronic and 2 recurrent mania In 24
epileptic 1 circular and 2 confusloiinl insanity in 19 j,eneral and 1 tal>o
IMiresls tn 1 senile and 1 chr<mlc piiranola in 2 primarj 5 secondarj 1
seulle and 2 org<iDlc dementia

Cerebrospinal changes in 4 acute " chronic and 2 recurrent melan
eholla; in b acute 17 cbrouit and I recurrent m»nia in 21 epileptic
acute eonCusional 1 circular and 1 toxic Insanlti in 20 general and 1 tabo
]>arM!lB la 1 senile p^ianola In 3 primary 4 aeccndary 12 senile and '
organic dementia

Meningeal or cerebral haemorrhage In 1 chronic melancholia hi 1
acute and 4 chronic mania in 2 epileptic insanity in 1 secondary and 1
senile dementia

General ceieliral atrophy in 2 acute S chronic and 1 recurrent melan
eholla In 1 acute 15 chronic and 1 recurrent mania in 8 epileptic 1
circular and 1 totic Insanitj in 12 general and 1 tabo pareele In 1 senik
l>aranoia in 1 primary 4 secondary 1 seulle and 1 organic dementia

Choroid plexua changes In 1 acute 6 chronic and I recurrent melan
cholia in 1 acute 3 chronic and 1 recurrent mania In 2 epileptic 1 clr
eular and 1 tosic iuBanit^' In 3 general and 1 tabo paresl<i In 1 senlU
paranoia in 1 secondary 3 senile and 1 organic dementia

Ependymal granulations m 1 acute and 1 chronic melancholia in 1
acute, 4 chronic and 1 recurrent mania In 5 epileptic and 1 circular In
sanity In 11 general and 1 tabo-paresls in 1 piimary and 1 oi^anlc de
mentia

Dilatation of the cerebral ventricles in 2 acute and 4 chronic melan
eholla In 4 thronl minia In 6 epileptic Insanltj In 10 general and I
tabo-paresi« In 1 senile paranoia tn 1 primarj 1 secondary 3 senile and
a organic dementia

Tumor of the brain in 1 chronic mania in 1 epileptic insanity in 1
genera] paresis in 1 secondnr\ and 4 organic dementia

Cerebellar tumor In 1 chronic melancholia

Cerebelhr cvst In 1 senile dementia

Acute suppurative meningitis of pneumococcal origin In 1 chronii
melancholia In 2 chronic mania

Pineal gland changes in 2 chronic mania In 1 epileptic insanity

Spinal cord changes In 2 chronic and 1 recurrent mania In 1 epilep
tic Insanity in 2 general and 1 tibo paresis in 1 secondary and 1 organk
dementia |

Cranial nerve involvement in 1 agitited meianoholia In 1 epllepti<
tneanltj in 2 general paresis m 1 =enl!e dementia

Eye Imolvement in 1 chronic melancholia, In 1 recurrent mania, ir
1 epileptic Insanity; In 2 generni paresis; in 1 senile paranoia; in 1 sec
ondary and 1 senile dementia.

)v Google

Thyroitt gliiurt oUaiigi's in 1 acute, 1 chroaie and 1 flultated melftii-
rholia ; Jn S chronio niauia : in 15 *i>ilei)tic. 1 circular aud I toxic Insanity ;
in 1 in^uernl parexih; in 1 secondary and 2 senile demcntiii.

Thymus gland present In 2 chronic niclnncliolin ; in 7 c|)ilciitic in-
sanity.

Pericardial alterations In 4 chronic melancholtu ; in 1 acute, R chronic
aud 1 recurrent mania; in 2 epileptic anil 1 (osic Insanity; In 1 general
paresis ; in 1 chronic and J senile paranoia ; in 1 secondary aud 2 senile
dementia ; in 1 not insane

Cardiac hypertrophy In 3 acute, 7 chronic and 1 recurreut melau-
eliolia ; In 1 acute, 5 chronic and 2 recurrent mania ; In 13 epileptic and 1
circular Insanity; in .1 general paresis; in 1 primary, .'> senile and 2 or-
ganic dementia.

Cardiac ditatiilion In 1 acute, ;{ chronic and 1 recurreut melancholia;
in 1 acute, 4 chronic and 1 recurreut mania; In S epileptic aud 1 toxic
Insanity; in 2 genera! and 1 bilK>-|iaresls ; lu t senile paranoia; in I prl-
mary, 2 secondary, :! senile and 1 organic dementia ; In 1 not insane.

Myocardial changes in 1 acute, 4 chronic and 1 recurreut melancholia ;
in 1 acute, 6 chronic and 1 recurrent mania ; lu 2 epileptic insanity ; In ;1
general and 1 tabo-paresls ; In 1 senile aud 1 chronic paranoia; in 4 senile
•and 1 organic dementia.

Valvular disease In 1 acute. R chronic and 1 recurrent melancholia ;
In 5 acute, 12 chronic, and 1 recurrent mania; in 8 epileptic, 1 circular
Insanity ; '.> fajneral paresis ; In :i f-ccondary, 7 senile and 2 organic de-
mentia.

Vascular changes in 5 acute, 14 chronic ; 1 agitated, and 2 recurrent
melancholia; 8 acute. iJ chronic, and 2 recurrent mania; in 2G e^iileiitlc. 2
circular, and 1 toxic Insanity ; in 19 general paresis ; in 1 chronic and 1
senile paranoia; in 2 primary, -'> secondary, 10 senile, and 5 organic
dementia.

Aortic dilatation In 1 chronic and 1 recurrent melancholia ; In 2
chronic mania; in 1 circular Insanity; in rt general paresis; In 1 Henllc
paranoia; in 2 secondary, 1 senile and 1 organic dementia.

Patent foramen ovale in 1 epileptic and 1 toxic Insanity ; in 1 general
paresis.

Atheromatous d^eneration of the arteries in 3 acute and S chroni.'
melancholia ; in 2 recurrent melancholia ; In 5 acute, 15 chronic mania ;
in 10 epileptic Insanity; In 13 general parcels; In 1 chronic and 1 senile
paranoia ; in 2 secondary, 4 senile, aud 3 organic dementia.

Calcareous infiltration m 1 acute. 5 chronic and 2 recurrent melan-
cholia ; in 2 acute, 4 chronic and 1 recurrent mania ; in 3 epileptic insanity ;
in C, general paresis ; In 1 senile and 3 organic dementia.

Fatty Infiltration of the heart in 2 acute and 1 chronic melancholia ;
tn 1 acute and 5 chronic maula; In 11 epileptic and 1 circular insanity;
In 4 general and 1 tabo-paresls ; in 1 secondary and 1 organic dementia.

Pleuritic adhesions on the right side in 4 acute, n chronic, 1 agitated
aud 2 recurrent melancholia ; in 4 acute. 22 chronic and 2 recurrent mania ;
in 21 epileptic, 1 circular, 3 acute confusional anil 1 toxic insanity : In 10
general paresis; In 1 senile paranoia: in 2 primary. ;! KCcondaiy. S senile
and 4 organic dementia ; In 1 nut Insane,

, Got>^lc

I'kiiritU a<ilic«tiii[is on tlio left skIp in Ti acute luid G chronic inolnii-
cliolia ; ill 8 mute il diroiik and 2 rei'urrent mtiiiia; in 21 epileptic, 1
ciivulnr nnd 2 atiite coufuslonal in^anitv, In 8 general paresis; in 1 senile
and 1 chronic paranoia , la 2 primary S secondarj', 4 senile and 2 organic
dementia, in 1 not Insane

Pleural tavitj- obliterated on tlie right Bide In 2 recurrent melancliolla ;
In 3 chronic mama , in 1 epileptic insanity ; in 2 general paresis ; in 1 pri-
mary, 1 fecondarj and 1 senile dententia : in 1 not insane.

Pleural cavity ohliterated on the left side in 1 chronic and 1 recurrent
melancholia , in 2 chronic mania , In 1 general [larealB, In 1 chronic par-
anoi 1 in 1 prinmri and 2 sw-ondarv deiiientln In 1 not insane

HvdrothoraY in 1 acute aiid 3 clirouic melan< holla lu 1 acute,
hroni and 1 recunent mann in J ipllepti md one to\U insaiilly; in
1 'ffoiidnr\ and 2 oipmlc dementia

Pjothonix on the right side in 2 ihroiilc inelaiKhotla in I acute. 3
chionic and 1 recurrent mania In 1 epileptic insftnltv in 2 primary
dementia

Protliorait on the left side in 2 chronic melancholia in 1 aiute and 1
Lhronie mania m 1. epil^tic insanity in 1 secondary dementia

Haemothorax In 1 oi^anic dementia

Lohar pneumonia in 1 acute and 2 chronic melancholia In 4 chronic
■md 1 recurrent mania In 2 epileptic and 1 anite confneional Insanity ;
in 4 seneral paresis in 2 senile dementia

Broncho pneumonia In t a<-nte and 1 chronic nielancholin in H acute
and 4 chronic mania In 3 epileptic Insanl^ in 1 primary and 2 senile
dementia

Hypostatic pneumonia In 1 atute 5 chronic and 1 recurrent melan-
cholia In 2 icute 4 chronic and 1 recurrent mania in 10 epileptic, 1 cir-
cular and 2 acute confusional Insanity In 5 general and 1 tat>o paresis;
in 1 prlmar\ 3 secondarv 2 senile and 1 orsanic dementia

Pulmonary oedema In 2 acute 'i Chronic nnd 1 recurrent melancholia;
in 2 acute S chronk and 2 recurrent mania in 17 epileptic insanity : in
7 general paresis In 3 primarj 1 secondary and 2 senile dementia.

Pulmonary emphysema in 2 acute and 4 chronic melam holla; in 1
aiute 3 chroniL and 1 recurrent mania in 5 epileptic insanlt* In 1 gen-
eral paresis In 1 chronic paranoia in 1 primary 5 «enlle lud 1 organic
dementia

Pulmonary collapse in 1 acute ind 1 recurrent melancholia; in 2
(bronli and 1 recunent m inli in 1 epileptl insanity In 1 chronic par-
Pulmonary gangrene In J chronic melancbjiia in 1 chronic and 1
recurrent mania tn 2 epileptic Insanity

Pulmonary infarft In 1 chronic and 1 recurrent melancholia; in 1
recurrent inanla in 1 general paresis

Pulmonary intliricosis tn 1 epileptic Insanity In "I chronic paranoia;
In 1 not Insane

Pulmonary tuberculosis In 1 acute and 7 chronic melancholia; In 2
acute 17 chronic and 1. recurrent mania In 11 epileptic 1 acute confn-
slonal and 1 to\h Insanity Ip 3 general piresls in ] chronic paraonla ;
In 2 prhnary 4 secondary 3 senile and 1 organic dementia in 1 not insane.

)v Google

I'ulinuuitry tubei-t-ulur (.'iivity roriiiittioii on tli« rlzlit Hldu in 'd <;hrouli.'
melancholia ; In 8 <.-hri>nk' ninuiu ; In 'i eiilleptlc lusanlty ; iu 1 primary,
] secondary itnd ] senile Ufuieutla. Tbe snnie on the left side In 1 chrunlc
melancholia; in 4 chrouic uaula; in 1 eiiileiitk- Insanity; In 1 generiil
paresis ; 1 primary, 1 secondary and 1 senile dementia.

Bronchial changes in 1 acute, 5 chronic and 2 reciirreut inelaucholia ;
1 acute, 6 chronic and 2 recurrent mania; in 11 ^lileptic insanity; in 2
general parei^ls; in 1 chronic paranoia; In 4 primary, 1 senile and 1 or-
j;anlc dementia ; In 1 not Insane,

Bronchia! gland changes In 1 acute, S i-hronlc. 1 acUated and 1 recur-
rent melancholia; iu 1 aL-ute, IG chronic and 1 recurrent mania; in 11
eplleptio, 1 circular. 1* acute confusional and 1 toxic insanity; in 13 gen-
eral and 1 tafjo-pa reals ; in 1 chronic paranoia; In 1 primary. 5. secondary,
4 senile and 1 organic dementia ; in 1 not Insane.

Perotoneal changes In 1 chronic and 1 recurrent melancholia ; In 3
chronic and 1 recurrent mania; in 1 epl!ei)tic, 1 circular and 1 acute con-
fusional insanity; in 1 tabo-paresis ; in 3 secondary and 2 senile dementia;
In 1 not insane,

Hydroperitoneum in 2 chronic melancholia ; in 1 chronic and 1 recur-
rent mania; in 1 epileptic and 1 toxic Insanity; In 1 organic dementia.

I*yoperil:oueuni In 1 chronic and 1 I'ecurrent melancholia; iu 1 acute
and 1 recurrent mania ; In 1 acute confusional Insanity ; iu 1 primary, 2
secondary and 1 senile dementia.

(laemopcritoneum in 2 chronic mania ; In 1 circular insanity ; in 1
secondary dementia.

Perilit^])atitia in 1 acute, 3 chronic and 1 recurrent melancliolla; in
1 acute and 5 chronic mania; in 5. epileptic and 2 acute confusional In-
sanity ; In 1 secondary, 4 senile and 1 organic dementia ; iu 1 not Insane.

Hei)iitic cirrhosis In 12 chronic and 1 recurrent melancholia; in 2
acute, 5 chronic and 1 recurrent mania; in 7 epileptic Insanity; In 3 gen-
eral and 1 tabo-paresis ; in 1 senile and 1 chronic paranoia ; In 2 secondary.
4 senile and S organic dem^itia.

Fatty liver In 4 acute, 3 chronic and 2 recurrent melanchoila ; In 2
acute and 5 chronic mania ; In 5 epileptic and 1 acute confusional insanity ;
In 1 general paresis ; In 1 primary and S organic dementia ; In 1 not insane.

Syphilis of the liver In 1 epileptic insanity.

Amyloid disease of the liver In 1 chronic melancholia; In 1 chronic
mania; in 2 primary dementia.

Carcinoma of tlie liver in 1 cbrouic melancholia ; in 2 chronic mania ;
In 1 epileptic Insanity. In all cases secondary to carcinomatous disease
primarily elsewhere.

Ahseess of the liver In 1 chrouic mania.

Tubei-cuioeis of the liver in 1 acute mania; in 1 epileptic insanity;
in 1 primary dementia.

Qall-bladder changes in 3 chronic mania ; In 2 epileptic insanity ; in
1 primary, 1 secondary and 1 senile dementia.

Cholellthiagis in 2 chronic melancholia; In 1 anite and 5 chronic
mania ; In 4 epileptic and 1 circular insanity ; in 1 general paresis ; in 1
primary, 1 secondary and 2 senile dementia.

Splenic changes In 1 acute, 7 chronic and 2 recurrent melancholia;

Diqmzec by Google

In 2 acute, 9 chronic and 1 recurrent mania ; In 7 epileptic and 1 circular
Insanity ; in 6 general and 1 tabo-paresis ; in 1 prlinarj, 3 secondar3', 2
senile and 2 organic dementia ; in 1 not Insane.

Pancreatic changes in 2 chronic melancholia ; In 3 chronic mania ; in

3 epileptic and 1 circular insanity ; in 1 secondary and 1 organic dementia.

Adrenal changes In 2 chronic raelaDcholla ; in 1 acute and 3 chronic
manlu ; In 1 epileptic Insanity.

Portal phlebitis in 1 recurrent melancholia.

Renal changes In 5 acute, 14 chronic, 1 agitated and 2 recurrent
melancholia ; in 9 acute, 25 chronic and 2 recurrent mania ; In 2C epileptic,
2 acute confusional and I toxic lusanitj' ; in IS general paresis ; In 1 senile
and 1 chronic paranoia ; In 2 primary, 5 secondary, 8 senile and 4 organic
dementia.

Ureteral chauRca in 1 chronic mania; iu 1 epileptic and 1 circular
Insanity; in 5 general paresis; In 1 secondary dementia.

Vesical changes In 1 chronic melancholia : In 2 chronic mania ; In 1
circular and 1 acute eonfuslonal Insanity; In o general paresis; In 1
primary and 1 secondary dementia.

Urethral stricture in 1 circular Insanity.

Testicular changes la 1 recurrent mania; In 3 eiiileptic Insanity; In
1 not insane.

Ovarian changes apart from senile atrophy in 1 chronic and 1 recur-
rent melancholia ; in 2 acute, 10 chronic and 1 recurrent mania ; in 3 epilep-
tic and 2 acute eonfusional insanity ; in 1 secondary and 1 senile dementia.

Fallopian tulje changes In ;l chronic mania ; In 1 epileptic, 1 acute <'on-
fuslomil and 1 toxic insanity ; in 1 secondary dementia.

Uterine changes In 3 chronic, 1 agitated and I recurrent melancholia ;
In 2 acute and 6 chronic mania ; In 4 epileptic and 1 acute coafusional
Insanity; In 1 tabo-paresis; In 3 senile and 1 organic dementia.

Prostate gland changes In 2 chronic melancholia ; In 1 chronic mania ;
iu 4 general paresis; in 1 senile paranoia; in 1 senile dementia.

t i b nges in 4 acute, 2 chronic and 1 recurrent melancholia ; In

4 I 1 man a; in G epileptic insanity; iu 5 general paresis; in 1 sec-
nd y d m n la.

G st 1 ca clnoma in 1 epileptic and I toxic insanity; In 1 senile and
h ut pa nola.

Intestinal hanges in J acute and 2 chronic melancholia ; in 4 chronic
mania; in epil^Uc Insanity; In 1 general imresis; In 1 secondary and 5
senile dementia; in 1 not insane.

Vermiform appendix changes in 1 chronic mania; in G epileptic insan-
ity; In 2 general paresis; Iu 2 secondary and 1 organic deuieiitia ; in 2
cliFonlc melancholia.

Mesenteric gland ehanses in 7 chronic molancholln ; In 3 acute and
chronic mania; in S epilei>tic and 1 toxic insanity; In 5 general paresis; In
1 senile and 1 chronic paranoia ; In 1 primary. 4 secondary, 4 sanile demen-
tia; In 1 not Insane; In 1 acute and 1 agitated melancholia.

Uterine fibroids in 3 chronic, 1 agitated and 1 recurrent melancholia ;
in 3 acute mania; in 5 epileptic and ] acute eonfusional insanity; In 1
senile and 1 organic dementia.

Malignant disease In 3 chronic melancholia; In 1 acute and 4 chronic

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mania; In 4 epileptic and 1 toxic iusnnltr; in 1 general paresis; in
2 senile and 1 chronic paranoia ; in 1 secondary aiul 4 oi'pinli' denicutlii.

Benign tumors were present in the lirHin iu -i i-iines ; tliyrold glaud 5 ;
in the stomach 1 ; in the intestine 1 ; in the kidney 1 ; In the adrenal 1 ;
in the uterus 14 ; In the ovary 12 ; in the subcutaneoua tissue 1.

Intestinal gangi'ene was present In 2 cases of chronic mania, in one
due to volvulus, iu the other due to thrniolibals of the superior mesen-
teric artery.

The stomach occupied a vertical position In 4 coses.

The colon occupied a U-aha|)cd position, ita tower iMirtloii lyini; in tlie
pelvic cavity in S cases.

The stomach was extremely contriictcd.in S fuses.

I'viniary cnrcimnua was present in 15 cases distributed as follows:
Tongue 1 ; face 1 ; thyroid gland 2, breast 2, stomach 4, intestine 1, uterus
2, prostate 2. The following organs were involved secondarily : thyroid
gland 1, lungs 3, liver 3, adrenal 2, appendix ].

The vermiform appendix hung over the pelvic lirim In 42 cases.

A right inguinal hernia was present In 2 cases.

The cerebral blood vessels showed definite structural changes in 70
eases and in 2 of these there was uo evidence of vascular disease else-
where.

1'he anterior cerebral arterj' was occluded in 1 case (left), the left
middle cerebral In 1 case, and the right posterior cerebral in 1 case.

The largest brain was In a case of syphilitic guunna and weighed
1880 grms. The smallest was In a case of general piircsis iu a female and
weighed 880 grms. The average weight of all the brains was about 1290
grms. Two were less than 1000 grms, Eight between 1000 and 1100 gnus.,
twenty-seven between 1100 and 1200, thirty-eight between 1200 and 1300. .
thlrty-nlue between 1300 and 1400, seventeen between 1400 and 1500. seven
between 1500 and 1600, three between lUOO and 1700, one- over 1700.

ACUTE MELANCHOLIA.

84. Female. Age 42 years. First admission. Reported melancbollc,
restless, suicidal and homicidal ; has made several attempts to
drown herself ; believes that she is doomed to die and tliat her
sister will be charged with the murder ; wants to choke persons to
death ; worries a great deal over trivial things ; complains much
of pain in the head ; hag lost 30 pounds In three months previous
to admission.

Duration of psychosis : Seven months.

Cause of death r Asphyxia by hanging.

Clinical report : Admitted October, J903. Following admission was
exceedingly Irritable and agitated; was continually picking at her
clothing and person, presenting a state of mental pain and
anguish ; never gave any evidence of suicidal Intent, but felt that
she would never recover, so would be better off dead. Had delu-
sions of self-depreciation and unworthiness and doomed to ever-
lasting puoiahment. Suffered a great deal from insomnia, rarely
sleeping without medicine. ManiteEted no physical disturbance,
other tban constipation.

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Pathological report: Brain — Weight, 1300 grma. Extensive pachy-
and leptomeningitis, extensive calcareous deposit in tlie walla ot the
superior iongitudiuai sinus and the adjoining faix cerebri. In-
crease in the amount of the subdural and subaracbsoldean fluid,
oedema of the grain substance. Heart-~Weigbt, 270 grms. E}xten-
aive atheromatous plaoques in the mitral and aortic valves, foci
of baemottbagic sul)endoeardlaI extravasation, moderate athero-
matous degeneration of the arteries. Lungs — Weight, right, 370
grms.; left, 340 grms.; moderate oedema. Liver — Weight, 1700
grma. Spleen— Weight, 250 grins. Kidneys — Right. 150 grms.;
left, 140 grma. Ail the above organs more or lees congested.
Thyroid gland — Slight enlargement of the left lobe. Mesenteric
glands— More or less enlargement

Microscopical report : Chronic inflammatory thickening of the men-
inges; moderate distension of the perivascular and pericellular
spaces in the brain substance; fatty Infiltration of the heart;
extensive endarteritis and patches of atheromatous degeneration
In the wails of the arteries; extensive engorgement of tbe other
organs.

Male. Age 50. First admission. Reported suffering from acute
melancholia.

Duration of psychosis: Six months.

Cause of death : Pulmonary oedema.

Clinical report: Suffering from typical acute melancholia. Sup-
posed cause, 111 health.

Pathological report: Brain — Weight, 1175 grms. General atrophy,
widening of the sulci and fissures, dura of tbe middle fossae red.
granular and adherent; escess of subdural and subarachnoidal
fluid; left frontal eminence prominent, right receding; left malar
eminence more prominent ttian the rigiit; left ear egg-shaped,
right oval, Darwinian tubercle well marlted on the latter; 1am-
doidat suture very irregular; occipital bone projecting about 5mm.
beyond tbe parietal ; cranial bones dense, firm and heavy. Smalt
fatty tumor, subcutaneous, non-adherent, encapsulated, situated
over the anterior part of the right shoulder. Pericardium — Con-
tains a small quantity of serous fluid. Heart — Weight, 325 grms.
Slore or less fatty Infiltration; thickening of the walls; alight
aortic sclerosis. Lungs — Weight, left, 355 grms. ; right, 580 grms.
Chronic pleuritic adhesions bilaterally, more or less general
oedema with areas of pneumonic consolidation In the lower lobes.
Bronchial glands enlarged and deeply pigmented. Liver — -Weight,
1625 grms. Chronic perihepatic thicliening. moderate fatty ap-
pearance, numerous wbitisb areas varying in slae from a pin
point to a pin head ; also a small cystic cavity filled with fatty
debrts, 10 mm. in diameter, and encapsulated. Spleen — Wei^t,
200 grms. ; deeply fissured In the anterior mai^ln, malphigian
bodies prominent. Kidneys— Weight, left, 280 grms.; right 190
grms,; pale in color, rather firm, small quantity of pelvic fat,
some increase of fibrous tissue. Mesentery of tbe sigmoid colon
over 13 cm. long, mucosa of the caecum reddenett and oedematona,

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and covered with a viscid mucoid secretion. Bladder and ureters
distended with urine. Moderate oedema of the lower extremities.

Microscopical report : General diffuse stflining of the nerve celle,
extensive fibrous thickening of the iileura, cbronlc bronchltlB and
peribronchial consolidation In the lungs, extensive fatty dCRenerii-
tion of the liver and chronic venous congestion, extensive diffuse
nephritis the parenchymatous changes predominating, chronic
venous engoi^ment of the spleen.

Female. Age 50. First admission. Reported acutely melancholic.
refusing food at times, thinks her friends are nbtiNing her. Is rest-
less, sleepless. lame and delusional.

Duration of Psychosis: Fifteen months.

Cause of death : Pyaemia from acute suppurative arthritis.

Clinical report: Admitted August. 1003. Married thirty-two ypiirs.
Had six children. After admission improved and was fnrloughed
but was returned In a condition worse than at the first admission.
Had injured the knee aixiut one and oue-lialf years previously,
and it had gradually grown worse. Within the last two months
the patient has grown more restless, persisted in walking about
so that the knee became acritely intiametl, swollen, reddened and
tender. She fell and Injured the kuee after which she was con-
finde to bed until death.

Pathological report : Oedema of both lower limbs, the right heiow
the knee, the left up as far as the hip; extensive acute suppura-
tive inflammation of the left knee, ilisorganlzntlon of all the
structures entering into the formation of the Joint and Involving
the adjoining tissues for a considerable extent, extensive necrosis
of the ends of the lower end of the femur and of the upper end of
the tibia. Cranial hones cancellous, dura thickened and somewhat
adherent to the bones and to the frontal loi)es; diffuse opacity and
Increased thickness of the nraehnopia mater ; moderate Increase
of subdural and snhnracliiioideal fluid. Brain — Weight. 1195 grms.
Genera] atrophy of the convolutions, widening of the sulci ond
fissures. Lungs — Weight, left, 1EI5 grms. ; right, 250 grms. Some
chronic pleuritic adhesions over the right lower lobe, tliickening
and eleatrleial contraction of the left apical pleura, slight doughy
consistency of the lower lobes. Bronchial glands — Enlarged and
deeply pigmented. Heart — Weight. 220 grins. ; extensive eplcardial
fat, extensive atheroma of the arteries with a tendency to ulcera-
tion at places and some calcareous inflltratlon. Spleen— Weiglrt.
100 gnns. Malpighlan bodies swollen and prominent, numerous
areas of a nodular consistency, pyramidal In shape, base toward
the periphery, consistency soft and easily lacerahle. Liver — Weiglit.
1440 grms. Capsule somewhat thickened, cut surface rather yel-
lowish in appearance and oily, consistency somewhat softer than
normal. Gall-bladder contained 1 calculus. Kidneys — Weight, left,
125 grms.; right, 107 gnus. Firm on section, grate some on cut-
ting, considerable pplvlvc fat, cortical striatlon poorly marked.
cajffiule removed with difficulty and teiirs the suiislance.

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Mi<Tos«)[)k- reiHU't: l»iffiiBe stiiiiiliig of the uerve (.■ells with more
or letta ilet'eiierutlvt; ctiiiugee ; f:itty [Dliltrotion of tbe benrt ; sonic
chronic mj-otarditia ; chronic fibroid thickenlug of the pleura ;
hyperjilasla of the lymph follicios oC the bronchijil glands with
mure or less difCnse blackish pigmentation ; extensive atheromatous
dt'geiieratiMi of the arteries; vetious engorgement of the liver;
engorgement oE the spleen with hyperplasia o( the malpighlan
bodies, several foci of Infarction ; moderate dilCiise nephritis.

Age ."iC. Brewer. MarrleU 5 years. No children, tteiwrted restless,
sleepless, secluslve and melancholy ; uot suicidal nor homicidal ;
no hereditiiry history; imagined that i>eop!e were after him, feared
tlTat they would kill him ; said he was a sinner ; was Incoherent in
speech.

Duration of psychosis : Seven months.

Cause of death : Aspliyxia by strangling.

Clinical report: After adniissioii was quiet and secluslve until a
short time before death when he became talkative. Was auxious
to get out on detail work. Ate and slept well.

I'atbologEcal report : Cyanosis of the head, face, ears, lips, Angers
and toes ; a depressed baud more or less nbraided encircling Ihe
neck. Some opacity of the arachnotiia mater; slight Increase of
the subdural and subarachnoldeau fluid. Brain — Weight, 1G2U
grms. liateral ventricles small. Lungs — Weight, left, 311 grins. ;
right, 380 grins. Firm bands of chronic pleuritic adhesions bilat-
erally, a few caseous nodules in tbe right apex, more or less
fibroid, diffuse pigmentation, some general ■ congestion. Heart — ■
Weight, 370 grms. Hyiiertrophy mostly of the left ventricle, mod-
erate sclerosis of the larger arteries. Spleen— Weight, 220 grms.
More or less engorgement ; nialplghlan liodies prominent. Liver —
Weight, 18!X> grms. ; considerably congested. Kidneys— Weight,
left, 185 gnus.; right, ISO grms.; congested.

Microscopical report : I>lffu^e staining of the nerve cells, fibroid
thickening of the pleura, venous congestion of all the organs,
slight eudarteritic thickening of the arteries.

Female. Age 51. Single. Tliird admission. Ite|)orted much de-
pressed, with pronounced suicidal tendencies, for six montiis pre-
vious to admission. Had delusloua that her best friends were
plotting against her. Threatened tbe life of those about her.

Duration of psychosis: Six months.

Cause of death : Acute arseniciil poisoning.

Clinical report : Just before leaving home to be taken to the hos-
pital she requested iiermission to get some articles from her rooni
and while there swallowed some iNirlw green which had been se-
creted In her iMMiroom, but said nothing alMjut it until on the way
to the hospital, when she was taken violently ill, vomiting and
excruliating pains, etc. On admission there was nausea, vomiting
of blood, intense gastric pain and distress, great thirst, cold
clannny perspiration, rapid feeble pulse, anxious, collapsed expres-
sion, with dentil following soon after admission.

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Patbolof:lcal r(."i)ort: Moderate oodema of tlie lower extrcinitleB.
Brain — Weight, 1350 grins. Opacity nloiij: the piiil veMsels of lurRi^r
size. Luugs — Finn chronic pleuritic ndlieslouB Ihrougboiit the
left pleural cavity. Heart — Some cardiac hypertrophy and fatty
luUtratlon, namerous subendocardial Laemorrhaglc extravasations
in tbe left ventricle and aoiiie small foci In the outer coat of the
aorta. Irregular areas In the middle third of the oesophagus and
throughout Its lower tbird, of extensive haemorrhagic extravasa-
tion. Couteuts of the stomacb and intcstlues grumous and green
color, most marked In the stomacb and In the duodonmii. mucosa
swollen, piile color, softened aud covered with a viaclil mucoid
scci-etlon. A|)iit>ndlx hanging over the pelvic hrim. Spleen —
. Weigbt, 120 gruis. Liver— Weight, 1T70 grins.; moderate con-
striction running trnnsvei-sely about the center of both lobes, dif-
fuse yellowisb red in mlor, lobular outline indistinct, consistency
somewhat softer than normal. Kidneys — Welgbt, left, 130 gnus. ;
rlgbt, 130 grms. ; pale in color, moderate quantity of pelvic fat,
capsule of the right somewhat adherent Ovaries firm white and
atrophic.

Microscopical rei)ort : Extensive degenerative changes in the nerve
tissues; numerous spherical hyaline bodies in the cborold plexus;
slight chronic myocarditis ; small areas of pneumonic, consolida-
tion of the luuga; cloudy appeiivani-e of the cortical («lls in the
middle zone of the adrenals with foci of round cell liiQltratiOu In
the medulla; extensive fatty iutlltrntion and swelling of the livec
c'elis with some cirrhosis ; e.\tensive diffuse chronic nephritis ;
engorgement of the spleen with extensive sclerosis of the splenic
arteries; extensive submucus iiaemorrhagic Infiltration of the
oesophagus and stomacb, swelling of tbe mucosal cells aud begin-
ning round cell Infiltration of the muc()sa.

Male. Age 50. Pfrat admission. Farmer. Married. Reported
sleepless, nervous, hyiwcbondriacni and suicidal. At times excit-
able, claiming that he was losing bis mind.

Duration of [wycbosls: About one year.

Cause of death : Asphyxia by hanging.

Clinical report : Admitted September, lOOG. Physical condition at
the time of and (or two years prior to admission had been very
poor, mostly dependent upon gastro-inlestlnal disturbances. The
mental condition during tills time was one of hypochondriasis,
feeling that he would never get better and as a consequence he
would not be able to provide for his family, thus bringing them to
want and suffering. This induced In biiu thoughts of destruction
of them as well as himself to prevent such a condition of affairs
coming to pass, feeling that in destroying them he would assure
their happiness oven tliough it meant the loss of ills own happi-
ness and soul. After struggling against this for some time he
finally carried out the deed one night by killing them, striking
them on the head with a hatchet when asleep, then pouring Itero-
sene over the beds and setting fire to It in order to make sure of
their death following which he attempted to commit suicide by

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remaining in the. burning building liut wns driven out by the ex-
treme hesit After mailing several atteuipts to retiini into tlie
burning building, but being driven back by tlie heat be started
to go down the road when be was taken into custody by the neigh-
bors until brought to the Institution. After adniieglon he Improved
considerably, both piiysically and mentally, to such an extent, that
after about three months be stated that be had lost ail thought of
self-destruction : was exemplary in his actions and conduct for
over two months ; but one morning, after assisting to wash up the
breakfast dishes, he was allowed to go Into the bathroom ,un-
watched, when he hnng himself.

Pathological reiKirt; Band of constriction etx'lrcllng the neck, some-
what depressed and more or less abrjidod. Brain — Weight, 1410
grms, IJura finnly adherent to the skull, moderate increase of .
subdural and subaraehnoidean fluid, numerous small pysts of the
choroid plexus. Lungs— Weight, left, 300 grms. ; right, 350 grtns.
Extensive firm pleuritic adhesions of the right side and! a few on
the left, some marginal emphysema more or less lobular, venous
engorgement of both lower lobes. Heart — Weight, 320 grms. ;
hypertrophy of the left ventricle, some dilatation of the right ven-
tricle and distension with blood, some yellowish placques In the
body of the mitral valves, slight sclerosis of the aorta most marked
about the coronar.y oritices and over the convo.tlty of the arch, tUe
large veins of the thorax distendetl with blood. Spleen. — Weight,
210 grms. Engorged. Pancreas — Weight, 14C grms. Llvei^
Weight, 1890 grms.; considerably engorged. Kidneys — Weight,
left, 160 grms. ; right, 135 grms. ; considerably engorged, glomeruli
prominent, some pelvid fat, cortico-medullary junction pale in
color. Stomach — Considerable submucus haemorrbagic extravasa-
tion most marked about the cardiac orifice, mucosa thickened and
covered with a thick, viscid mucoid secretion. A similar condi-
tion scattered throughout the small intestine.

Microscopical report ; Diffuse staining of tlie nerve cells, blood-ves-
sels of the nervous tissues well filled, perivascular spaces promi-

■ nent, immerous concentric hyaline bodies In the choroid plexus,
epthetlum of the pineal gland more or less alveolar and the gland
contains numerous liyallne bodies and irregular calcareous masses;
thyroid gland vesicles irregular in size and shape, many of the
smaller more or leas filled with desquamated and proliferated
cells; fatty Infiltration of the right ventricle of the heart; mod-
erate endarteritis of the arteries ; intense engorgement of the
pulmonary capillaries ; some chronic pleuritic thickening ; in-
tense engorgement of the spleen ; liver shows Intense engorge-
ment and small foci of round cell collection and slight Increase
of fibrous tissue in the portal fissures; Intense engorgement and
extensive diffuse nephritis; Intense engorgement of the stomacli
and intestines, some proliferation of the mucosal epithelium.
hyperplasia of the lymph follicles, foci of submucosal round cell
Infiltration.

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CmtO.N'lC MKIANL'IIOLIA.
Fpiimle. Ajst' CO. Siiijilf. IteiKirted niolanchollf. Onset iibimt one
year befoi'c iidniiBfiion. Adinitted June, 18!^:!. [luiigloed that sbe
had In her body sucb animals as skunks, dogs, monkeys, etc. Waa
at times nieliincholy, at others talkative. Attempted suicide.
When depressed would only answer questions by a silly laugh
or nod at tlie liead. Had pulmonary tuberculosis.

Duration of psychosis : Eleven and one-fouvth years.

Cause of death : Pulmonary tuberculosis.

Clinical report: As al«ve.

I'atbologlcal report: Durii thickened and adliereut to the frontal
and i>ariotal bones and to the |)la itraclmoid on each side of the
sui)erior lonsitudiual Assure, increase of aulidurai and subarach-
noldean fluid. Brain — Weight, 12C10 grnis. ; general atrophy most
marked over the occipital lobes, a Ann baiidlike adhesion iietween
the wails of the rifsht laleral ventricle at the outward bend'uf the
anterior horn, a few Guiall cysts of the choroid plexus. lAtnun
— Weight, left, ■HO grmis. ; right, 730 grms. Dense firm adhesions
throughout both pleural cavities, iileura thickened, lobes adherent
to each other, Ixith lungs dilTuscly nodular throughout, nodules
varying in size from a pinhead to 1 em. In diameter, left aiiei
hard, cieutricial and deeply pigmented, mottled gniy color on sec-
tion, dilatation of the Intei'venlng lobules. Bronchial ghinds en-
larged, |)igmentod and caseous. Heart—Weight. 280 grms. ; con-
siderable epicardial fat, nmscle fiabby, mitral valves thickened
with numerous warty granular vegetations ou the auricular sur-
face, yellowish atheromatous patches of the arteries. Stomach
occupying a vertical iiositioii in the abdominal cavity, its greiiter
curvature lying to the left of the anterior axillary line, to tlie iliac
crest below, and to the umbilicus to the right. Spleen — Weight,
105 grms. : easily lacerahle, malplghian bodies prominent. Liver
—Weight, 1000 grms. ; rather nutmeg in apt^aiimce. Kidneys —
Weight, left, 90 grms. ; right, 80 grms. ; fimi. whitisli color, scy-
eral small subcapsular cysts, considerable pelvic Tat, capsule strips
with difficulty leaving a rough surface. Adrenals — Left -has sev-
eral small cheesy nodules at the corticn-medullary junction. Small
intestraes — Numerous typical tubercular ulcers In various Stages
of softening and ulceration, peritoneal coat overlying studded with
small tubercules most marked in the lower part of the ileum.
Pancreas — Weight, 50 grms. Mesenteric glands enlarged and
caseous. Uterus— Several small suhinucus polypi, fibroid In struc-
ture. Ovaries hard, white and atrophic.

Microscopical report ; Diffuse staining of the nerve cells, perivas-
cular spaces prominent; heart muscle-fibres small and atrophic
with some fragmentation; moderate atheromatous degeneration
of the arteries; extensive fibrosis of tlie lungs with diffuse foci
and areas of typical tnl>ercular consolidation in various stages of
Qbrodis, pigmentation and caseation ; diffuse pigmentation and
caseation of the bronchial glands ; chronic venous congestion of
the liver and atropliy of the liver cells ; engorgement of the ■'

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spleen witli dlffase tnflltratloa of suiall tubercular [ocl ; typi^^'
tubercular nodules of the adrenala ; estenBlTe diffuse nephritis
with ttie Interstitial Increase predominating and tilBO some tuber-
CHlar Inflltratlon of the cortex, and tendency to cystic dilatation
of some of the tubules ; extensive hyperplasia of the lymph folli-
cles ot the stomach and Intestines with typical tubercular hyper-
plasia and ulceration of the small intestine in various stages ;
flbro-uiyomatous polypi ot the uterus.

Male. Age 57. Soldier. Widower. First admission. Reported
nielaucholy, sleepless, suicidal. Onset four years previous to ad-
uiiselon. Cause uuUnown.

Duration of psycbosEs : Four and three-fourths years.

Cause of death : Uraemic convulsions.

Clinical report : Improved some In his mental condition for some
niontlis after admission, when epileptoid convulsions developed,
which increased in frequency and intensity, until twelve hours
iiefore death be developed a condition of status.

I'athologlcai rejiort ; I^eft pupil dilated. Copper-colored patches on
the anterior surfaces of both tibia. Cranial bones firm and compact ;
firm adhesion of the dura to the sliull over tbe frontal and parietal
hones, dnrii thickened and contains considerable calcareous deposit
in the walls of the superior longitudinal sinus, great Increase of
the subdural and subarachnoidean fluid, diffuse thicitenlng and
opacity of the arachno-pla mater. Brain — Weight, 1350 gnna.
General atropliy, numerous small calcareous bodies in tbe choroid
plexus, extensive atlieroma of the cerebral arteries. Heart —
Weight, 500 grms. ISxtenslve hypertrophy, considerable eplcardial
fut, sclerosis o( the mitral and aortic valves with some calcareous
deiwsit in the body of the aortic cusps, extensive atheromatous
di>generation of the arteries with considerable calcareous deposit
ill ilie walls of tbe larger vessels. Lungs — Welglit, left, 700 grms;
riglit, 455 grms. Extensive firm adhesions throughout tbe whole
left pleural cavity, pleura over the left lung thickened, extensive
oedema throughout both lungs, most marked on the left side, more
or less congesllon of the tracheal and bronchial mucosa. Liver-
Weight, 1405 grms. Moderately fatty and engorged. Spleen —
Weight. 255 grms. Considerably engorged, a cicatricial scar on
tbe outer convex surface. Kidneys — Weight, left, 145 grms,;
right, 155 grms. Firmly adherent to the perirenal- fat, firm on
section, i)ale In color, striation poorly marked, excess of pelvic
fat, cai)sule adherent, several rather large cortical cysts. Adrmals
— Medullary portion pulpy and soft. Pancreas— Weight, 150 grms.
Bladder distended with urine. General enlargement of the
lymphatic glands of the mesentery. Right aMoniinol ring patent
and admitting tlirco fingers. Left lobe of the thyroid gland some-
what enlarged.

Microscopical report: Diffuse degeneration of the nerve cells;
hyaline bodies In the choroid plexus; moderate fatty inflltratlon
of the right hetirt ; extensive atheromatous degeneration of the
arteries: extensive oedema of the lungs, many of the alveoli con-

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talning more or loss le\ic<H'ytes mill suuie desquamntpil oells ; some
fatty inflltratiou of the liver; hji^rplnsla of tbe miilplgblaii
iMMlies ot the spleen; moderate Interstitial nephritis, most inarkeil
sulxiipsulary ; hyperplasia of tlie mesenteric glands ; nioderiite
general arterlo-nclerosis.

Female. Age 48. First admission. Reiwrted melancholy and ani-
cldal.

Duration of psychosis : One year.

Cause of death : Sbo<.'k from Injury and brain tumor.

Clinical report ; Onset of the mental dIsturlMineo about one year ■
before udniission by false Imaginations, fearing that someone
would barm her, defecating' and urinating on the floor. While
being taken to the hospital the patient was thrown from the car-
riage, receiving a severe eoncusslou and shaking up. On admission
there was some evidence of shock and some complaint of gen-
eral Boreues.s, hut nothing special was discovered. After being
put to bed she felt quite comfortable, but died suddenly a few
hours after lieing in bed.

Pathological reiMjrt : Moderate oedema of tlie lower extremities.
Brain — Weight, 1240 grins. Moderate quantity of subdural and
subarachnoidean fluid, the right cerebral hemisphere somewhat
smaller than the left, most apparent in the occipital lobes, the
left cerebellar hemisphere only about half the size of the right,
the Inferior vernds occupied by a more or less circumscribed mass,
somewhat nodular, brownish-red in color, portions somewhat gela-
tinous in appearance and consistency, extending and infiltrating
into both lateral hemispheres for about half their diameter, Is
somewhat. adherent to the floor of the fourth ventricle; the cere-
bral ventricles extensively dilated, the optic nerves, commissure
and tracts grayish and atrophic. Lungs — Weight, left, 275 grms;
rlglit, 2S5 grms. Small quantity of serous fluid In both pleural
cavities, slight doughy consistency of the lungs, moderate subpleural
blackish pigmentation, atelectatic areas in the margins of the
lower lobe on the left side. Broncbial glands — Hyperplasia, pig-
mentation and caseation. Heart— Weight, 260 grms. Pericardial
cavity contains 100 cc. of serous fluid, considerable eplcardial fat,
slight arterial sclerosis. Peritoneal cavity contains a moderate
quantity of serous fluid. Spleen — Weight, 205 grms. Engoi^ed
soft and easily lacerable. Liver— Weight. 1480 grms. Soft and
rather friable. Adrenals, puliiy consistency of the medullary part.
Kidneys— Weight, left, 100 grms.; right, 155 grms. Firm on
section, pale color, striation Indistinct, considerable pelvic fat,
capsule strips with difflculty and tears the kidney substance. Gall
bladder contains 8 calculi, varying in size, smooth, facetted and
brown in color. Mucosa of the stomach and the first portion of
the duodenum thickened, swollen and granular. Ovaries small,
white and granular.

Microscopical report : Some cbromatolytle changes In the nerve
cells; engorgement and hypostatic pneumonia of the lupgs; con-
siderable peribronchial consolidation and caseation; extensive

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engoreemeut of the spleen ; extreme fatty inflltratlou of tlie liver

. flud nioiierute periportal fibrous tissue Increase anil small round
cell collection ; catarrhal thickening of tbe gastric and duodenal
mucosa; pxtenslvo neplirltls with eugorgement of the capillaries;
tubular changes predominating, and localized areas of dense
fibrous tissue and round cell infiltration.

Female. Age 52. Second admi^ion. Admitted as a Chronic mel-
aochollc.

Duration of psychosis: Twentj--two years.

Cause of deiith : Pulmonary tuberculosis.

Clinical rer>ort: Admitted November, 1882. Age 30. Onset a few
weeks before by wandering about, following the stock through
the fields and making companions of them, saying that she wanted
to go home, that her home is in heaven ; tried to make pictures
of the angels.

Pathological report: Cranial liones thickened and cancellous; ex-
cess of sulHlura! and subarachnoidean fiuid. Brain — Weight. 1210
grms. ; diffuse opacity of the arachnopia-niater ; thrombotic co-
agulura in the superior longitudinal sinus over the parietal emi-
nence 3 cm. long ; general cerebral atrophy, widening of the sulci
and fissures; numerous small cysts of the choroid plexus. Heart
— Weight, 180 grms. Muscle, pale and fiabby. Lungs — Weight,
left, 635 grms. ; right, 90O grms. Both pleura firmly adherent
throughout, except at tlie lower purt of the left, which is occu-
pied by a circumscribed cavity containing over 1500 cc. of yellowish,
bloody, creamy, cheesy fluid, with walls of almost cartilaginous
consistency, extending to the level of the fifth interspace above,
the sterno-cartilaginous Junction anteriorly, and to the vertebral
column posteriorly ; lobes firmly adherent to each other, exten-
sively nodular thniughout, nodules being dark-red in color and
bloody on section ; the left upper lobe is occupied by a large ulcer-
ating cavity traversed by fibroid bands containing the blood-
vessels; a smaller Irregular cavity In the apex of the right lung;
in tbe lower right lobe are several necrotic sloughs bathed In a
dark sangninous fiuid: the bronchioles exude a purulent frothy
fluid ; the bronchial mucosa is covered with a viscid purulent exu-
date and is reddened. Bronchial glands enlarged, pigmented and
extensively caseated. Caecum distended and extending into and
filling the left pelvic cavity. Stomach occupying a vertical posi-
tion, extending below the level of the umbilicus, bending rather
sharply at the Junction of the middle and pyloric thirds, with
the pylorus lying just above the umbilicus ; considerable sub-
mucus ecchymosis. Spleen— Weight, 120 grms. Rather firm.
Liver — Weight, 1350 grms. Adherent to the diaphragm, capsoje
thickened and cuts firmly. Kidneys— Weight, left, 120 grma ;
right, 160 grms. Firm on section, pale in color, striation poorly
marked, considerable pelvic fat, capsule strips readily. Small
cheesy nodules In both adrenals. Ovaries bard, white and atro-
phic. Left leg oedeniatcHs and the left side of the pudendum ex-
tensively swollen, reddened and congested.

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Itlirroscopic rejiort: Mufd or loss i-liroinutol.vtic Oepcneralivc
changes in the nerve cells ; uuidernle degree of fulty inflltratinu
of the heart; extensivp idourltlc tbk'kcDing with foci of tuber-
• cular luiisses ; extensive tubercnlur i-onsolidation of langs witli
areas o( all stages of deccncrutton ; chronic tuliercular liron-
chitfs: byper)i]nsfa, plpnentation and cai^^itlon of the bronchliil
glandR; extentiive fatty iiitiltration of the liver witti considerable
amyloid deposition ; amyloid deposit in the sitleen and the biil-
neys ; e\tenBive . diffuse nephritis with the iwrenchyiuatniis
changes perdomimiting; Hironiv ciilarrbnl condition of the pistric
and Inteiitinal mucosa.

Female. Age 41. first admission. Admitted with a |isychi>sis of
acute melancholia.

Duration of psychosis : Nine and one-half years.

Cause of death : Pulmonarj' tulierculosis.

Clinical report : .\dinltted March, 1900. In a condition of acute luel-
nncholia. which gradually assumed a chronic character. Began
three years l)efore admission. N'othing Is known prior to her ad-
mission. AlHiut one year before death she liegan cougliing and
losing flesh, ex pef'to ration l>ecomlng niuco-inirutent. She gradu-
ally became more emaciated, hectic and having attacks of gastric
Irritability and diarrhoea.

I'atboltwicii! report: Extreme emucialloii. costal cartilages of the
third ribs unduly prominent, alKloniinal tvuipanitis, unili Ulcus
slightly to the rlKht of the median line, oedema of the lower limbs.
Dura slightly adherent, some increase of subdural and sulmrach-
noldean fluid, diffuse thickening and opacity of tlie arachnopia
mater. Brain — Weight, 1380 gnns. General atroiAy, widening
of the sulci and fissures. Heart — Weight, 225 grcns. Pericardiuui
contains about 200 cc. of serous fluid ; aljout the center of tlie
right border of the cavity Is a small o[>ening 5 inui. in diameter
leading; into a pouch-like sac containing a similar fluid, its walls
similar to and continuous with the general pericardial cavity ;
mane fibroid thickening of the margins of the mitral valves, short-
ening and thickening of the chordae tendlnae, moderate sclerosis
of the arteries. Lungs — Weight, left, 770 grms. ; right. lOJiO grms.
Left pleural cavity obliterated by (Irm adhesions throughont. the
right cavity contains about 200 cc. of turbid fluid, bus several
bands of fibrous adhesions, and the 8urfa<-e Is covered with a
firbriuous exudate; lotK-s of the lungs firmly adherent to each
other, pleura dilfusel,v tbickeued. irregularly nodular throughout,
the nodules vurj'ing In size, also varying In all stages of degenera-
tion with cavity fonnation in the upi»er lobes, the cavities vary-
ing In size and intersected hy blood-vessels. Bronchial mucosa
swollen and congested, the smaller ones softened and filled with
a mucopurulent fluid. Bronchial glands enlarged, more or leas
caseatcd and infiltrated with calcareous material. Peritoneal
cavity contains over 2,000 cc. of turbid, purulent, creamy fluid,
with masses of fibrin ; adhesions liotween the omentum and coils
of tlic Intestines; stotnacii and Intestines dilated and distended

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with gas, the Rtoniacii lying anterior to the transverse polon with
the pyioiTis lying beside the gallbladcler. Typical tubcrmlar ulcer-
ations involviuK the wliole canal from the Jejunum to the sigmoid
folon ; extensive hyperplasia and caseation of tlie uieseuterlc
glands. Spleen — Weight, 250 gnus. Hyperplasia of the mal-
pighian bodies. Liver — Weight. 1450 grms. More or less fatty
and oily on sertiou. Kidneys — WelRiit, left. IfiO grms. ; right lOO
gnus. Ruiargcd, firm on section, pale in color, cortex widened,
increased pelvit fat, CH[)Sule strips wltli difflcuky aiid tears the
kidney suliBtttnce. Ovaries cystic

Misci-oscopical report. Moderate diffuse chroma toly tic changes In
the nerve ceils Extensive tubercular consolidation of the lungs
with areas of necrosis and softening. Ilyperplasin of the mesen-
teric and brouclilal glands with tul>ercular infiltratlou; tyi)lcal
tui)eifular Inflltrallon of the intestinal walls with hyiterplasla of
the lymph-foUieles ; extreme fntty degeneration, veiions conges-
tion, aud tubercular nodular inSltratlou of the liver; tuliei-cular
infiltration of tlie spleen; subacute diffuse nciihrltls

Male. Age S4. First admission. Eeported restless, sleepless, seclu-
slve, aud melancholic. Imagined that he luid inherited an Incur-
eble disease, that tie could not find work, and would have to go
without food.

Duration of psychosis: Six years.

Cause of .death : Pulmonary tnbercniosls.

CItnical reiwrt: Admitted Febniary. 189D. Age 2!). With a psy-
chosis of agitated nielanctiolta. Onset one year before admission.
After admission there was gradual physical failure, with cough
and emaciation. The most prominent features manifested were .
cough, pain in the chest, and development of einjiyaeuiia.

Tatiiological i-eport: Extreme eniucintion. slight oedema of the
lower limbs. Cranial bones thick aud cancellous. So:ne ilural
adhesions over the frontal lobes, dura slightly tlilckencd, diffuse
thickening aud opacity of the nraclmopla mater, some increase of
subarachnoidean fluid. Brain — Weight, 14!)0 grms. Pia-mater
firmly attached, the convolutions api)ear somewhat liattened.
Heart — Weight. 290 grms. Enlarged, somewhat dilated: moder-
ate general arterio-sclerosis. Lungs — Weight, left, 1200 grms.
Right pleural cavltj' contains over 3.0(10 cc, of foul -sine Jling,
creamy, purulent fluid, a thick purulent exudate covering both
surfaces of the pleura ; left pleural cavity contains a small quan-
tity of serous fluid. Right lung is compressed into a flat, spongy.
rather airless nias« containing some small abscess cavities filled
with cheesy material. Left lung is doughy, of a boggy consistency,
crepitation Is decreased, niottle<l light and dark red color, cheesy
nodules in tiie apes of the upper lobe, Breneliiai mucosa swollen
and congested. Bronchial glands enlarged, pipmented and coseated.
I'eritoneal cavity contains over 1000 cc. of straw-colored fluid,
firm adhesions liehveen the liver and diaphragm. Liver — Weight,
1740 gnns. Capsule thickened, consistency Increased. Spleen —
Weight, inO gnns. Moderately firm but exudes considerable blood

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on section. Pnncreas — Wt'icbt. 110 gnus. Kidoeytt — Weight, left,
1!M) gruis. ; rlgtit. 22(1 griiiH. Kxude coiisiiU'riililt.- Iilond on ne<-Mi)ii.
pale in color, striatiou fairly dletlnct, cai>sule tears tlit; kiJiii'..'
substance slightly (m removal. Appendix hanging over the pelvic
brIiD.

Microscopical report : Diffuse cliromatolytle changes In the nerve
cells ; extenelve red and gray beputiKation of the left lung, uiore
or less tubercular Infiltration and chronk- ttbroxis of the right
lung; chronic tuliercular purult'iit plouritin; nio<lerate eudarlevitic
proliferation of the iutima of tho larger arteries and some thick-
ening of the media; cbniiiic bronchitis: byiierplasin, plgmentn-
tiou and ciisealion of the bronchial glands; extensive fatty InBI-
tration of the liver; extensive parenchymatous nephritis; slight
chronic myocarditis.
132. Female. Age CT. First aduiission. Reported mclunciioiy, restless,
sleepless, very obstinate, refusing food, tendency to wander from
home, answers questions written in an Incoherent manner. Phys-
ical health good. Is a deaf mute.

Duration of psychosis: Six years.

Cause of death : Hypostatic pneumonia.

Clinical report: Admitted June, 1S09. Age CT. With a psychosis
of acute melancholia, beginning six moutlis prior to aSmisston.
Physical condition was good up to October, 1!KH, when she fell
and fractured her hip. Mentally there was a gradually pro-
gressive dementia.

Fafbologlcal report; Considerable discoloration and ecchymosis
about the lett hip, fracture oi the neck of the left femur with rota-
tion outward and 25 cm. shortening; a small bedsore over the
sacrum. Cranial bones cancellous; dura (Irmly adherent over the
frontal and parietal bones, dura thickened, diffuse tlik-kening and
opacity of the arachnopia, increase of tlie subdural and subarch-
notdeau fluid. Brain — Weight, 1210 grma. Moderate atrophy of
the convolutions, wideuing of the sulci and Assures ; left verte-
bral artery very large, the right small ; right posterior cerebral
artery very large, the left very small ; right i)osterior communicat-
ing artery small, the left large and apparently coming from the
left internal carotid; the right anterior cerebral artery small.
the left very large ; extensive dilation of the ventricles. Heart-
Weight, 350 grms. Several sclerotic patches In the epicardlum;
extensive hypertrophy, slight dilatation, thickening and calcareous
infiltration of the mitral and aortic valves; a small atheromatous
ulcer on the posterior mitral cusp; e.tteusivc atheromatous
and calcareous infiltration of all the arteries, Lun^— Weight,
left, 300 grms, ; right, 310 grms. Firm pleuritic adhesions at the
base of the right lung; posteriorly both lungs are of a cyanotii-
red color, doughy in consistency, crepitation Is decreased, has a
spienic-llke appearance on section, and the cut surface exudes a
frothy, bloody fluid. Spleen — Weight, CO grms. Firm on section,
cut blood vessels projec-t beyond the surface and remain patent,
trabeculae are prominent. Liver — Weight, 900 grms. Firm on

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Becttou. Pancreas — Weight, W grms. Finn. 'Ktaneye — Weight,
left, liO grnis.; right, 90. Firm on section, moderately adher-
ent to the surrounding perirenal (at, pale in color, strlatlou indis-
tinct, cortex very narrow, considerable pelvic fat, capsule strips
readily hut leaves a rough, granular- feeling surface. Stomach Is
contracted to the size of the colon.

MicroBcopicul report : Extensive 'chroraatolytic changes In the nerve
cells ; gasserian ganglia and the choroid plexns contain numerous
concentric hyallue bodies. Estenaive chronic Interstitial myocar-
ditis, Bngoreemeiit of the pulmonary alveolar capillaries, con-
siderable blackish pigmentary Infiltration of the alveolar walls ;
bronchioles and peribronchial alveoli filled with leucocytes, des-
quamated and degenerated epithelium cells. Chronic venous con-
gestion of the liver. Chronic interstitiiil pancreatitis. Moderate
diffuse nephritis, the interstitial and the arterlo-sclerotic changes
predominating. Numerous foci of round cell collection lu the
medullary portion of the adrenals.

Female. Age 69. First admission. Reported restless, sleepless,
melancholic, dull, seclusive, very stuperous.

Duration of psychosis ; Five years.

Cause of death : Hypostatic pneumouia.

Clinical report; Admitted November, 1904. Very feeble and tremu-
lous debilitated, with profound dementia. No family history ob-
tainable. Insanity dates from June, 1899, following an Injury, in
which she suffered from concussion of the spine. Married forty-
five years. Five children, youngest age 31. Three weeks after ad-
mission there developed dyspnoea, increased respiration, Increased
vocal fi'emitus, dullness on percussion, harsh breathing, rales
posteriorly, the condition gradually growing worse until she died.

Patholi^cal report: Considerable emaciation; moderate oedema of
the lower limbs ; fairly large ulcer on the anterior surface of thi'
lower end of the left tibia with considerable brownish discolora-
tion about It. Cranial bones thlcl< and cancellous. Dura firmly
adherent to the Inner surface, a large calcareous plate in the
anterior portion of the falx cerebri Involving tlie anterior portion
of the superior longitudinal sinus, diffuse thickening and opacity
of the arachno-pla mater, moderate increase of the subdural and'
subarachnoidean fluid. Brain — Weight, 1030 gms. General atrophj-
of the convolutions ; a small focus of softening in the upper half
of the pons on the right side just below the tegmentum ; simllai'
foci of softening in the posterior portion of the superior frcmtnl
posterior part of the collosal, paracentral, quadrate, upper half
of the ascending fronbil, ascending parietal, superior parietal,
superior aud middle occipital convolutions, the external capsule
and adjoining claustrum, and lenticular nucleus on the left side :
pia mater rather firmly adherent throughout ; extensive athero-
matous d^eneration and calcification of the arteries; the left
vertebral three times the size of tlie right, the left posterior In-
ferior cerebellar twice the size of the right, the right posterior
cerebral very small, the basilar practically continuing as tlie left

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piiBterlar r^rebral. the left iwtrterlor eouimiinloatln); very smHll,
the right Inrge Hnd prni'iloiilly conthiulii): as the rlglit posterior
cerebral, tlie rlglit nnterlor p<'i-ebra1 Bniall helng supplied beyoiKl
the anterior ii-oiniiiuutcattng by tlie left nnterlor i-erebral. Heart —
Weight, 290 grms. Some hyp«:rtroi>liy and dllntntloii. some seler.isif
of the aortic valves, extensive atheroma loiif< degeiwnitloii of the
arteries with coiisldenihie oali-areims iuSltratlon. nuineroua athero-
matnus ulcers iu the larger or(t'rle«. I.uiigs — Weight, left, 450
gius. ; right. 520 gtiis. I^)iver lobes dilTusely itodillnr, nodules
dark red In color, somewhnt splenic-like apiiearauce on section ;
a cheesy, eircuuiscribed calcare<iu8 mass In the under surface of
the lower lobe on the left side; cIcutrU-liil poutnKllou i)f the an-
terior surface of the umiei right lobe. Iininobial glands consid-
erably enlargeil, Omentnui adheivnt to the Hign)ol<l colon ; the
appendix bunging into the [lelvic cavity lying lietween the blad-
der and uterus. Spleen — Welf-lif, TH gnis. Dark red in color and
exudes considerabie blood on section. I-iver — Weight. 90B gma.
Small areas at fatty necrosis. I'ancreas — Weight. (10 gins. Rutlier
flrni on section. Kidneys — Weight, left, 75 gnis; right, TO gms.
Finn on section, pale in color, cortex thfiiiied, blood-vesaela rigid.
nuiuerouB subcapsular cysts, some pelvic fat, capsule adherent.
Uterus atrophied and contains several subperitoneal fibroids, some
of which are calcified. Ovaries firm, wiilte and utroiihlc.

Microscopical report: Fatty infillration of the heart, moderate
chronie interstitial myocarditis witli foi-1 of round cell tnflitmtlon.
Engorgement of the pulmonary capillaries, alveoli flled with de-
generated leucocytes, desquamated epithelial cells and granular
debris ; dilatation of the sub|)leural vesicles. Increased fibrous
tissue and irregularity in slae of the tiiyrold vesicles. Extensive
engorgement, thickening of the cai>sule, I'ciative decrease In the
malplghiun bodies in the spleen. Some fliirous tissue increase and
fatty infiltration of ttie punci-eas. Engorgement and degenei'ation
of the adrenals. Extensive diCfufe iiei>hrltis, the interstitial and
vascular wall changes iiredouiinating. Extensive engorgement and
fatty Infiltration of the liver. Extensive atlieromatous degenera-
tion of the arteries.

Female. Age 64. First admission. Reported melanciioiie, restless,
sleepless, seclusive, tiomicidai. with delusions tliat she was being
constantly pursued by men for immoral i)uriM»ies ; tliiit someone
was chloroforming her. Was incoiieivnt.

Duration of psychosis; Six years.

Cause of death : Carcinoma of the uterus.

Clinical report: Admitted September. 1901. Age (14. Witli a psy-
chosis of chronic melancholia which liegan three years before.
On admission there wei-e depivssion, dclnsions of a selt-d^recia-
tory and seJf-accusatory cimti'Ut. also liclusions of a persecutory
content. The first pliysicai disturliiince was shown in Decem-
l)er. 1904, by uterine haemorrlinge, i-onsideralile pain over the
pubic region, especially when tiie bladder became distended.
Examination revealed an Irregular, cauliflower-lilie mass filling

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the vagiiinl <:iiuiil, bleediug reiKlUy ou miiiilpulution, tbe iwlvle
strwctures fixed, tender and painful to pressure.

I'litbologlctil report: Cranial boues soft and (cancellous. Durii
thickened and Amily adherent to tbe bones; slight opacity of the
arachuoplamater ; moderate increase of the snbarachnoldean fiukt.
Brnln — Weight, 1240 gms. Slight general atropby of the eonvo-
lutions. Lungs — Weight, left. 200 gms. ; right, 350 gras. B'iriu
pleuritic adhesions througbout the whole right cavity and on the
posterior surface of the left upper lobe; slight doughy consistency
of the right lung, conaiderahte blackish subplenral pigmentation,
scattered diffusely are finu, challiy, blackish nodules, varying iu
sisie from a pinheud to a pea ; in the anterior margin of the left
upper lobe is a calcareous mass, coneshaped, with its base at the
periphery apex extending inward about 3 cm with contraction of
the adjoining tissue. Heart — Weight, 300 gms. Somewhat en-
larged; moderate sclerosis of the large arteries. Colon U-shaped,
Its lower border lying over the pelvic brim. Spleen— Weight, 100
gms. Moderately firm. Liver — Weight, 1040 gms. Right lobe ex-
tending to tbe Iliac crest and constricted at the junction of the
lower and middle thirds, thickening of the capsule at the seat of
contraction on the under surface of the right lobe, near the an-
terior margin la a small white, firm nodule projecting somewhat
bej'ond the general surface, about G mm In diameter. Kidneys —
Weight, left, l!i5 gms.; right, IM gms. Firm ou section, pale iii
color, striatiou poorly marked, numerous subcapsular cysts, c;ip-
Rule strips easily but leaves a rough surface, pelvis dilated und
filled with rather turbid urine. Ureters both dilated and walla
somewhat thinned. Bladder dilated and distended with turbid
ammoniacal urine, the posterior wall adher«it to the sigmoid
colon, thickened at its posterior and lower segment, mucosa thick-
ened and reddened. Ovaries extremely atrophic. Cervix, lower
segment of tbe uterus and tlie adjoining portion of the vagina
infiltrated with a caul Itlower-I Ike mass, which also Involves the
rectum and bladder. I'elvlc and retroperitoneal glands eulnrgcd
and infiltrated witii firm white circumscribed nodules. Pyloric end
of the stomach lying in the longitudinal fissure of the liver.

Mk-ropcoplcul report: Extensive atrophy and degeneration of tbe
nerve cells. Chronic pericardial thickening, fatty inBltratlon of
tbe heart and chronic intei'stltlal myocarditis. Dilatation of some
of the pulmonary alveoli, engorgement of the capillaries, irregular
focal round ceil (■otlections and masses of epithelial cells. Ex-
teosive trat)ecular increase in the spleen. Chronic venous con-
gestion, some i>eriportal fthroiis tissue Increai-e, and a small focus
of epithelial cell collection resembling the cells of the pelvic
growth. Diffuse nephritis, the Interstitial chanjies predominatinj:.
Fatty degeneration of tbe medullary zone of the adrenals wit'i
some fibi-ous tissue increase. Tbe cauliflower-like mass of the
uterus made up of masses of epithelial cells arranged more or
less Into alviiili with areas of di^ceneratlon and round cell Infll-
t rati on.

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Female. Age 42. First adnilpslon. Reported restleas, sleepless,
melancholic, destructive, sulcldul, depressed. Indifferent and emo-
tional; shows lack of Interest In herself and her surromidlngs ;
believes that she Is iieiug talked about and ridiculed; complains
of pain In tbe head ; was deserted by her husband.

Duration of psychosis : Elglit months.

Cause of death : Lobar pneumonia and acute suppurative menin-
gitis fcerebro-splnal).

Clinical report: Admitted January. I'MH, with a psychosis of acute
melancholia. A history of Indlsestlon and constipation. Onset
of the trouble six montbs prior to admission. Always was quiet.
and rather seelusive. On iidmisslou was depn'ssed and apathetic,
with delusions of a self depreciatory content. In March, 1905,
was taken with a severe pain in and to the right of the epigas-
trium, followed by a coated tongue, tenderness over the liver,
acute gastric disturbance, loss of appetite, disgust for food, and
later a slight bronchial cough. On examination on the tlfth day
after the onset she bad the ai>pearance of a profound sepils, In
tense jaundice, rigidity and tenderness over the alidomen, more
so on the right side, temperature ranging between 101 and 104 F.,
rapid puse, clayey stools, urine albuminous and containing bile,
and the signs and symptoms of a welt-marked lobar pneumonia
on the right Side a day or two after the examination. Death fol-
lowed within a week.

Pathological report; Intense general jaundice; slight oedema of the
lower limbs. Frontal sinus extensive In the vertical portion of the
frontal bone ; dura thickened with Its inner surface covered witii
a purulent creamy exudate. The archno-pia deeply Injected and
covered with a fibrmous purulent exudate. Considerable increase
of subdural and suharaehnoldean fluid, both being turbid, yellow-
ish and purulent. Brain— Weight, 1.T50 gms. Convolutions swol
len, oedema tons and somewhat softened. Heart — Weight, 215
gms. Left side of the pericardium deeply Injected and adherent
to tiie adjoining pleura by a flbrlno-plastic exudate ; extensive
fatty inflltrntion of the right ventricle; moderate sclerosis of
the arteries. Lungs— Weight, left, 250 gms. ; right, S40 gms.
Sumil quantity of bloody fluid in the loft |)ieural cavity, fibrinous
adhesiims at the base of the lower left lobe ; strong fibrous band-
like adhesions oier the anterior surface of the right upper lobe,
the remainder of the right lung covered with a fihrino plastic
exudate, it t>elng somewhat encapsulated over the base and lower
portion of the lower lobe Right lung has no middle lobe, la in
a condliion of red and gray hepatization. In the apex is a cal-
eai-cous nodule 1 cm. in diameter, with a ciciitriei.ii scav overlying
it. 'i he bronchial and lower portion of the tracheal mucosa Is
swollen and congested. Left lower lobe is somewhat congested and
the pleura over the base and that adjoining the pericardium Is red-
dened, congested and roughly granular in appearance. Bronchial
glands are somewhat enlai^ed. Spleen— Weight, 240 gms. Engorged,
friable, deep red color, malplghian bodies swollen and prominent.

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A small accessory spleen lying iMWteriorly. LIveiv-Weigbt. 1360 ,
gma. Diffuse mottled pele red color on section, lobules appear swol-
len and poorly defined, gall bladder contains fire small caienil, one
lying In the commencement of the cyetlc duct Kidneys — Weight,
left, 170 gms. ; right, 180 gnia. Soft on section, pale In color, con-
gested In the pyramids, whicb are deep red In color; considerable
pelvic fat Pancreas — Weight, 85 gins. Firm and nodular
throughout.

Microscopical report ; Swelling of the dura with a layer of small
ronnd cells varying In thickness and In varying stages of d^enera-
tion. with some Rbrinoiis material diffused through it. The same
aK>earanee of the arachnopla. Distension of the blood-ves-
sels with blood: swollen appearance of the nerve cells. Ex-
tensive fatty inflitration of the heart; moderate endarteritlc
proliferation of the intima. Acute fibri no-purulent lnflammatl<m
of the pleura ; moderate blackish pigmentary inflitration of the
alveolar walls, foci of dilatation of the air vesicles, the remainder
In a condition of red and gray hepatization. Venous congestion
with some cloudy swelling of the liver. Extensive diffuse nep-
ritis witb parenchymatous changes predominating. Hyperplasia
and engorgement of the spleen. Cbronie Interstitial pancreatitis
with more or'less fatty d^eueration.

Male. Age 41. Third admieslou. Reported restless, sleepless and
melancholy, suicidal. ' Has delusions that people are against him,
are trying to get his property, that he must come to want, that
he was becoming feeble-minded.

Duration ot psychosis: Five years.

Cause of death ; Asphyxia by strangling.

Clinical report: Admitted October, 1903. Tried to starve himself
to death. Eventually hung himself with a shoe string.

Pathological report : Band of constriction encircling the neck. Scalp
bleeds freely on section. Dura moderately adherent; moderate
diffuse thickening and opacity of the arachno-pia. Brain —
Weight 1410 gms. Lateral ventricles moderately dilated and filled
with fluid ; grayish red area in the white matter of the left occipital
lobe. Heart— Weight, 265 gms. Moderate sclerosis of the larger
arteries with some atheromatous sclerosis. Lungs — Weight, left, 330
gms.; right, 360 gms. Irregularly scattered firm pleuritic adhe-
sions bilaterally ; numerous snbplenral blackish pigmented nodules
Size of a pen, some of which are calcareous ; cicatricial contrac-
tion of the right apex, with some nodular inflitration, some of
which are cUeesy on section. Omentum adherent nt the right
abdominal ring ; tip of the apiienflix hanging over the pelvic brim.
Spleen — Weight, 270 gms. Consistency soft and friable, the pulp
bulging beyond the capsule when cut malplghlan bodies prominent.
Two small accessory spleens lying posteriorly. Liver — Weight,
1840 gms. Capsule thickened and adherent to the diaphragm,
colon, duodenum and kidney; Arm on section, strands of flbroufi
tissue enclosing groups of lobules, some of which bulge. Kidneys
— Weight, left, 100 gms.; right. 150 gms. Dark red on section,

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ooze consldernble blood, moderate qunntlty of pelvic tat. Pan-
creas— Wei glit, ]00 gniB. Some lobules In tbe head of the orgaa
Dmier thnu the remainder. Gaetrlc mucoRa eomewhat swollen,
softened, with nnmeroiis scattered haemorrhaglc extravasations.

Microscopical reimrt : Diffuse chromatolytlc chanees In the nerve
cells. Numei-ouB tijailne bodies In tbe choroid pleine. Extensive
fatty inflltration of the heart, moderate chronic Interstitial myo-
carditis; considerable endarteritic proliferation of the Intima.
Moderate epithelial cell inflltration of the colloid material of the
smaller vesicles of tbe thyroid gland. Diffuse nodular tubercular
inflltration of the lungs In various stages of degeneration ; moder-
ate perivascular pigmentary Inflltration. Chronic venous conges-
tion of the liver with numerous foci or tubercular Inflltration;
considerable portal cirrhosis. Moderate diffuse nephrlOa, the tu-
bular changes predominating.

Male. Age 65. First admission. Reported melancholy, restless,
sleepless, profane, homicidal and suicidal. Cruel to his wife;
threatened his wife and family.

Duration of psychosis : Thirteen years.

Cause of death: Broncho and hypostatic pneumonia; pulmonary
gangrene.

Clinical report : Admitted July, 1902, with a psychosis of melan-
cholia. After admission the development of dementia was pro-
gressive. Became semt-comatose fifty hours before death.

I'athologlcal report : Extensive decubitus over the loft trochanter.
Head markedly brachycephalic in type; malar eminences promi-
nent ; inferior maxilla distinctly prognathous ; supraorbital ridges
very prominent Dura flrmly adherent to the skull, Its inner
surface over the left hendsphere covered with a haemorrhaglc
flbrlnous exudate several mm In thickness, over the right hemis-
phere a diffuse ecchymosls ; diffuse opacity and Increased thick-
ness of the arachnopla mater ; some increase of the subarachnold-
ean fluid. Brain — Weight. 1340 gms. Basilar vessels extensively
atheromatous; consistency of the brain substance decreased. Irreg-
ular areas of softening In the corpus striatum and the optic thala-
mus ; also a small focus In the left side of the pons near the
median line midway l)etween the ventral surface and the reticu-'
lar formation; a small haemorrhagic extravasation In the upper
left segment of the floor of the fourtli ventricle. Heart— Weight,
— — -. Very much enlarged and hypertropbied, with considerable
dilatation; mitral valves thicltened and calcareous; aortic valves
thickened and margin fenestrated; muscle pale red in color and
streaked with whitish strands ; extensive dilatation of the arch of
the aorta ; extensive atheromatous degeneration of the arteries.
Lungs — Weight, left. l-"00 ews. ; right, 1455 gms. Right pleural
cavity obliterated by firm adhesions; crepitant anteriorly but
doughy ; base of the upper lobe, apex and posterior portion of
the lower lobe solid, a few small abscesses in tbe apex of the
lower lobes ; the remainder of the lower lobes bluish-red in color,
semifluid and grumous, emitting a foul-smelling foetid odor.

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Bronchioles exude a dirty, grayish, sanguinous, purulent, viscid
fluid; muoosa swollen, Bofteued and dark red in color. Tracheal
and laryngeal mucosa covered with a viscid inuco-purulent exudate,
mucosa swollen and softened; Bronchial glands eularged, pig-
mented and softened. Thymus exists, as two elongated tougup-tike
masses. Spleen — Weight, 170 gins. Capsules thickened, consistency
nodular, nodules being cone-shaped, with the bases toward the
margin, blood-vessels project beyond the general surface and re-
main patent. Liver — Weight, 1570 gms. Moderately firm, rather
nutmeg In appearance and oozes coiisiderable blood. Pancreas —
Weight, 90 gms. Kldueys— Weight, left, 160 gms. ; right, 150 gms.
Firm on section, pale In color, pelves full of fat, capsule strips
readily. Prostate enlarged. Appendix adherent to the posterior
surface of the cae<'Hm, is somewhat thickened, its tip lylug Just
beneath the gall-bladder aud over th» kidney.

Microscopical report : Extensive diffuse degeneration of the nerve
cells. Numerous hyaline bodies and thickening of the vessels of
the choroid plexus. Extreme fatty infiltration of the right ventri-
cle; diffuse chronic interstitial myocarditis, Irregular endarteritic
proliferation and atheromatous degeneration of the intima with
fibrosis of the middle and external coats. Intense engorgement of
the palmonary capillaries with rupture of some, filling the alveoli
with blood ; many oC the alveoli are filled with degenerated leu-
cocytes and desquamated epithelial cells ; considerable perivascular
pigmentary infiltration ; bronchioles filled with degenerated leu-
cocytes and epithelial cells. Bronchial glands enlarged, pigmented
and fibroid. Chronic venous congestion, slight fatty infiltration
and some cirrhosis of the liver. Engorgement of the spleen, with
liyi)erplasia of the malpighian bodies. Considerable chronic Inter-
stitial pancreatitis. Interstitial increase and extreme pigmenta-
tion of the medullary portion of the adrenals. Extensive chronic
diffuse nephritis.

Male. Age 50. First admission. Reported violent. Admitted from
the penitentiary where he had been committed for some time.

Duration of psychosis ; Thirteen years.

Cause 01' death: Pulmonary tuberculosis.

Clinical report-T None given.

Pathological report : General anasarca. Slight increase of sub-
dural fluid. Brain— Weight, 1350 gms. Moderate general atrophy ;
moderate sclerosis of tlie basal arteries ; some dilatation of the
lateral ventricles, grannlatioiis of the ependyma of the fourth
ventricle; considerable fibrinous exudate in the spinal peridural
space. Heart — Weight, 240 gms. Pericardial cavity contained lyO
cc of serous fluid, and is adherent to the adjoining right pleura ;
epicardium thickened over the grooves, muscle pale red color,
some yellowish placques in the bodies of tiie mitral valves, mod-
erate sclerosis of the arteries. Lungs — Weight, left, 730 gms. ;
right, 230 gms. Left pleura contains 500 cc of sero-fihrinous fiiiid
with a (ew firm adhesions at the base; the right cavity contains
1500 cc of sero-fibrino-purulent fiuld with some firm adbesions ;

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left lung Is soroewbat empliysenialouB nnd dougb;. dlffuBely In-
filtrated with small hard nodules. \>^a Bl;!e, oozes a frothy fluid
oD section and is mottled gray lii color. Right lung la collapsed
and airleKB, firm on i^-cUon. B|)lenio-llke appearance, mottled red-
disb gray color, many of tlie gray areas softened ; lu the apex
of the upper lobe Is a rather larjie cavity containing a foetid,
grayish, grunious. Bemlfluid material, a dirty grayish membrane
covering the Inner surface ot the cavity. Bronchial glands con-
siderably enlarged. Peritoneal cavity contains over 1000 <x of
sero-Rbriuuns fluid, t^iileen — Weight 120 gnis. Capsule thiclceoed,
firm on section, trabeculae ptomiuent. Liver — Weight, 1400 gms.
I^wer margin extending midway between the costal margin and
the lilac crest, the left lolie prolonged into a toogue-llke process
adherent to the under surface of the ^)leen ; oozes considerable
blood on section, oonsisteucy somewhat softened. Kidneys —
Weight, left, 1T5 gms.; right, ISO gms. I'ale on section, rather
firm, striatton Indistinct, marginal zone almost white, some {telvic
fat, capsule strips readily leaving a smooth surfa<-e. Pancreas
small and rather firm. Gastric and colonic mucosa thickened and
granular Id appearance.

Microscopicai reiiort ; Diffuse chroiiintolytlc changes in the nerve
cells; central cnnal of the cord filled. with proliferated epithelial
cells. Sllgbt chronic myocarditis; considerable eudarteritic pro-
liferation of the Intlma. Diffuse consolidation of the lungs In
various stages of degeneration and fibrosis. Bronchioles filled
with desquamated epithelial cells. Extensive pigmentation and
tubercular infiltration of the bronchial glands. Most of the vesi-
cles of the thyroid gland filled with proliferated epithelial cells.
Venous congestion, some fatty infiltration, e.\tenslve diffuse cir-
rhosis with considerable round cell Infiltration iibout the bile-
ducts of the liver. Extensive engorgemeut, diffuse yellowish pig-
mentary Infiltration, moderate hyjierplasla of tbe malplghian
bodies of the spleen. Extensive dlltuse nephritis. Eugoi^ement
of the adrenals with foci of round cell Infiltration.

Female. Age 5C. B'lrst admission. Reported acutely melancholic,
attributed to erysipelas and disappointment In love.

Duration of psychosis: Tweutj- years.

Cause of death ; Dilatation of the heart.

Clinical report: Adiaitted March, 1885, with a psychosis of acute
melancholia, beginning six months before. Course was that of
progressive dementia to complete loss of mentality. Octol>er 1,
1905, thei-e was manifested dyspnoea, temperature 100 P., a feeble,
rapid pulse, and signs of cardiiic enlargement. October 10th there
was posterior tlioracic dullness biiaterally, numerous crepitant
rales, bronchial breathing, marked dyspnoea and a temperature
of 103 F.

Pathological rei>ort : Cranial Imnes soft and cancellous. Dura thick-
ened and firmly adherent over the frontal bones. Diffuse opacity
and Increased thickness of tbe arachuo-pla ; moderate Increase of
subdural and subarachnoldean fiuld. Brain — Weight, 1050 gms.

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GeQeral atrophy ; basal Teasels extenglvely atheromatous ; ven-
tricles dilated and filled with fluid : bruin substance somewhat
softened; choroid plexus quite cystic; pineal gland enlarged.
Heart — Weight, 270 gms. Mucb enlarged, cavities dilated and dis-
tended with blood ; mitral valves greatly thickeued and sclerotic,
oarrowlng the orllice so that it only admits one fluger ; consid-
erable subepicardial fat on the right side ; extensive atheromatous
degeneration of the arteries with numerous foci of ulceration in
the larger vessels. Lungs — Weight, left, 270 gms. ; right, 400 gins.
About 1,000 cc serous fluid in botli pleural cavities ; a few bandlike
adhesions on the viglit side ; lower left lobe somewhat collapsed and
airless, yet rather doughy; at the anterior margin is an area of
consolidation, well -circumscribed, deep red in color, with a throm-
bus occluding the artery supplying that part. A similar area is
present in the anterior margin of tlie right upper lobe. There are
aiso some scattered areas of consolidation through the right lower
lobe. Bronchial glands enlarged. Spleen— Weight, 90 gms. Firm
on section, trabeculoe propiinent, contains a small white body of
cartilaginous consistency, 3 lum. in size and easily separated
from the splenic substance. Liver— Weight, 660 gms. Firm on
section and rather nutmeg In appearance. Kidneys— Weight, left,
70 gms. ; right, 70 gms. Firm on section, pale in color, striation
poorly marked, no pelvic fat, capsule adherent. Pancreas — Welgbt,
60 gms. Soft and contains numerous small foci of haemorrhagic
extravasations. Appendix tip enlarged and thickened. Ovaries
flmi, white and atrophic.

Microscopic report : Diffuse degeneration of the nerve cells. Be-
ginning hyaline formation iu the choroid plexus. Vascular en-
gorgement and cellular iullltration of the vesicles of the thyroid
gland. Extensive fatty Infiltration of the heart with some chronic
myocarditis. Moderate endarteritic proliferation of the intima.
Vascular engorgement, emphysema and pneumonic consolidation
of the lungs, the latter in the Infarct area. Engorgement of the
spleen with hyperplasia of the malplghian lx)dies. Chronic venous
congestion of the liver with some fatty inflltration. Extensive
diffuse nephritis with tendency to cyst formation.

Male. Age GO. First admission. Reported confused, despondent,
melancholy, irritable and profane ; imagined that some people
were watching him.

Duration of psychosis: Two years.

Cause of death : Lobar pneumonia.

Clinical report : Admitted February, 1905, with a psychosis of three
months' duration. After admission the course was one of pro-
gressive dementia. Physically on admission hia health was good.
After, he complained some of kidney trouble. There was gradual
loss of body weight. In November, 1905, he was talten with a
high temperature, rapid breathing, rapid pulse and died the fol-
lowing day.

Pathological report: General jaundice. Brain — Weight, 1320 gms.
Slight opacity of tiie arachnopla, left vertebral artery one-third

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as large as tbe right moderate atheroma of the basal vessele
moderate dilatatlim of the \eQtrlcles considerable ^^■*t foriua

tloii of the (lior>i<l |U\us <.'uiisl>-l<.ii( } of both front il bonei some
what iiirrea^ied the riRht more so thaii the left hiving a \ellou
ish sligbtb gelatinous aiii>earniice Heart — tt tight, MO gms
Hrijertruphlc enlargemeut i.on'.ldertble subepicardial fat con
siderable s<leriitlc thiikenins uf the mitral vthes aortit iahe'<
thickened rigid InAltrated nith calcireous matter ihe orl£oe unr
loned. uiih admitting one finger inter\aUular septum calcareoun
foramen ovale partlallv potent moderate stlero'^ia and atherom i
of the arteries the con mart e\feiiBheh mt luiics — -Weight left
UiO gms right 102(1 gnis V fen firm adhesions in the left pleu
lal cavltj posterior portion of the lett loner lobe bluixh in color
doughy conslsteiii.} pits on pie>«ure cut surface oozes an abund
nnt frothj fluid upjter and niiddlt ught lohes oedematous lonii
right lol)e polid throughout deet) red In color quite friable In its
anterior portion la a taetous nodule 1' cm in diameter more or
less Inftltrited with talcareoua salt^ Bronchial and loner trach
eat mucosa deepiv Injeited and covered with i trothv sanguln
ous viscid mucoid aecittiwi Bronchial glands enlarged and deep
ly pigmented Colon U shaped its loner margin below the Iliac
trests Spleen- — height 2S0 gms f ipsute tbiLktned oozes ion
siderable blood on settion ek«lly frlihle Liver — \Velght 1580
fim-i liiirly Ann on se<tnii milmeg in appearance PaiiereTi—
Weight 85 gmi Itathei tirm Kidnej s— ft eight left 1 J* gms
right 1J8 gins Kither pale m color on section considerable pel
vie fat, (.apsule sllghtU adhereut Gastilc mucosa thickened and
somen hat granular Appendix hanging ovei the pelvic brim

Micro^eoplcal report t-^tensive chroiuatolj tic degeneration of the
nerve cells Extensne chronic Interstitial nivotardltis Evtensive
difTuse eudartentR prollfeiatloii and atheromatous degeneration
of tbe deeper liyers of the arterle-: Intense engorgement ind
V irloua stages of pneumonic cousolldution of the lungs ^ a'li.ular
eugorgenient of the tratlii i bronchi and oesophagus Hvper
plaBia of the Ijnipli follinles eugoigemeiit and diCfu<§e plgmentit
tion of the bronchial glands Moderate diffuse inttrstitlil pin
ereafltle Vastulai engorgement of the idrenals Intensf en
Borgement relative trabecular Increase and relative decrease of
the malpighian hodles of the spleen Chronti venous congestion
slight periportal flbrous tissue mciease and some round ceil in
filtration of the liver Evteiislie diftu<ie neihiitia with consid
erihle vasculai engorgement

Male \ge 5S Second admission Rci>orte(l pre fiuiiiili melan
cholic

Duration of psychosis About si\ jeais

Cause of death Ruiiture of the aorti with haemoperh ardium

Clinical leport Admitted Septenihei 1901 vvifh a psvchowls of
melmchohfl II id leen in the hcspltal the preceding year Un
derweist no mailed change vvhlip In the hospital Physically his
health prior to and at the time of admibsion was falrlv good.

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After admission he oomplainecl occasionally of heart trouble. On
January 2il and January 7th lie had several attacks of aevere
pain which were considered that of angina pectoris. On the day
of death he had been moving about the ward as usual, had 6<"'e
to the dining room for dinner and on sitting down was aeen tii
slide off the chair to the floor and died in a few minutes.

Pathological report : Cranial Imnes hard, heavy and dense. I>ura
firmly adherent throughout ; arachnopia diffusely and moderately
opaque ; great increase of subdural fluid. Braln^ — Weight, 1450
gms. Basal vessels greatly thickened, right vertebral artery twice
the size of the left, the right posterior cerebral very small, right
posterior communicating arises from the Internal carotid, Is very
large, and apparently takes the place of the posterior cerebral ;
ventricles dilated ; the choroid plexns cystic. Heart — Weight, 600
gms., with attached vessels. Pericardium bulging, veins distended,
cavity filled with a mass of coagulated blood surrounding the
whole heart, the cavity communicating with the aorta by an irreg-
ular tagged opening S nmi In diameter situated between the pul-
monary artery and the left auricle, the surrounding tissues Infil-
trated with bhDod. Heart contracted, wails greatly hypertrophied,
considerable fatty Infiltration of the right ventricle, margins of
the mitral valves thickened and fibroid with some yellowish
plaequea in the bodies, aortic valves fenestrated at their margins
and contain some yellowish placques in the bodies. Considerable
dilatation of the aorta, some thinning of its walla, considerable
atheromatous degeneration. Apparently beginning In the upper
part of the left coronary orifice is a tear estending along the
coronary artery for a distance of 5 mm, also bilaterally 2 cm in
each direction, also along the aortic axis more or less <*liquely
for 8 cm., its lower extremity leading into the pericardial cavity.
Lungs — Weight, left, :100 gms. ; right, 350 gms. Bandilke pleuritic
adhesions over the anterior surface of the right upper lobe. Spleen
— Weight, 220 gras. Capsule thickened and rough, cuts firmly.
Liver — Weight, IfiSO gms. Capsule thickened, consistency in-
creased. Pancreas — Weight. 85 gins. Head firm and nodular,
body and tall like a flbrons cord with very little pancreatiOc tis-
sue. Kidneys— Weight, left, 280 gms. ; right, 270 gms. Firmly
adherent to the perirenal fat, surface Irregular, firm on section,
deep red in color, rough granular feel, strlation indistinct, large
quantity of pelvic fat, numerous cystlike cavities scattered through
the substance, capsule (strips witli difficulty and leaves a rough
torn surface. Prostate considerably enlarged. Gastric and Intes-
tinal mucosa somewhat thickened ; appendix directly continuous
with the tip of the caecum, which is conesbapod, and Is directly
curled uimn itself. Mesenteric glands enlarged.

Microscopical rei>ort ; Moderate chromatolysis of the nerve cells ;
central canal of the spinal cord, particularly In the cervical region,
filled with proliferated epithelial cells and the central gelatinous
substance Infiltrated with them; in the lumbar region the canal
Is enlarged, crescent shaped with a pedunculated mass ailing the

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rarity. Its central stmctnre similar to and dir«ctlj cootinnoos
witb the ^nrrriimdiDg' gelatiooos mbetaDce: Dnmermis coDceatric
bfalioe bodies Id th@ choroid pteTns. Fibroid tbicbeotne of tbe
perinardiam ; fatty iDfiltratiMi of tbe riebt venlricle; eitensive
cbronic interstitial myocarditis ; exteoslTe atheromatons de«en-
eration of tbe thli-keoed intinia : more or less fibroid tbicfcening
of tbe media, fibroid tbiiL-kenlng of tbe pleura ; ensiorgement of
tbe pnlmotiarr capillaries, witb some thiekeniDg of tbe alreolar
walls; moderate pigmentary infiltration perlrascnlarly. Intense
engorgement; eitensive pigmentary infiltration and byperplasia
of the lymp follicles of tbe broncblal glands. Irregular size of
the thyroid vesicles witb cellnlnr filllDg ot maoy of tbe small ones.
Considerable bjiwrplasia of tbe lympb follicles of tbe alimentary
canal. Intense engorgement and foci of round cell coltectioD of
the adrenals. Intense engorg^aent and byperplasia of tbe mal-
plgblan bodies of the spleen. Intense engorgement, flbroid thick-
enli^ of tbe capsule, extensive cirrhosis of the liver. Intense en-
gorgement and extensive diffuse nephritis.

AGITATED MELANCHOLIA.

Female. Age -IS. First admission. Reported depressed, moaning,
agitated, n-rlnging her hands ; imagined that tbe Lord was against
her, that she had committed a great sin, that God tells ber that

- she must take her own life, so attempted soicide.

Duration of psychosis: Twenty months.

Cause of death : Asphyxia by hanging.

Clinical report : Admitted January. 1906. with a psychosis of acute
agitated melancholia beginning about one year before as atxive.
Mental condition prior to this was good. Was well educated.
Visual dlslurbances beginning many years before had rendered
ber almost blind. Otherwise the physical condition prior to and
at the time of admission was good. After admission there were
occasional complaints of dizziness, Insomnia, palpitation of the
heart and constipation. The patient was always sad and dejected,
generally seclusive and apprehensiTC. believed everybody was
against her, feared puiiislmient for ber misdeeds, had some insight
Into her condition, stating that she wis going hopelessly insane.
The eyegrouuds showed extensive retinitis pigmentosa. Committed
suicide by banging.

Pathological report ■ Depressed band partiv abraded encircling
the neck Cranial bones soft and (.ancellou*! osteoplastk projec-
tions on the inner surface of the frontal bones to whiih the dura
Is firmly adherent calcareous deposit in tbe wall* of the superior
longitudinal sinus o\er the parietal eminence and ettending aiouE
the falY cerebri f(r '.(me distance Brain— Weight 1300 gins.
Slight opacitj of the arachnopia optic nerves commissure and
tracts firm small and white lungs— Wei^,ht left 180 gins.;
riKht 200 gijis I imi pleuritic adhesions surrounding tbe upper
rlj,ht lotte extensive subpleural blackish pigmentary Infiltntion ;

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lobes of tbe rigbt luDg adherent to each other; a few scattered
calcareous nodules In the substance of both lungs. Heart— Weight,
270 gms. Falty iufiltratlon of the right side ; moderate sclerosis
and some atheroma of the arteries, the orifices of the coronary ar-
teries extensively so, almost occluding the opening. Thyroid
gland Shows some enlargement of the right lobe and is some-
what cystic. Spleen — Weight, 150 gms. Oozes considerable blood,
easily friable, matplghian bodies prominent. Liver — Weight, 1250
gms. Nutmeg in appearance. Pancreas — Weight, 110 gms. Kid-
neys — Weight, left, 160 gnis. ; right, 135 gme. Ooze considerable
blood wheu cut. deep red color, moderate amount of pelvic fat,
capsule tears the kidney substance when removed. Moderate
haemorrhagic extravasation in the snbmucosa of tbe stomach and
the small intestine. Ovaries Bmall. firm and white. Uterus has
numerous small fibroids, subperitoneal, submucua, interstitial
and Interligamentous.
Microscopical -report : Moderate chroma toly sis o£ the nerve cells ;
pericellular and perivascular spaces well marked ; extensive vas-
cular engorgement ; central canal of the cord filled with prolif-
erated epithelial cells, which also infiltrate the central gelatinous
substance. I'utty infiltration of the right ventricle of the heart
and some perivascular increase of flbrous tissue; considerable en-
darteritic proliferation of the intima, most marked in the medium-
sized and small arteries with some jierlvascular round cell infil-
tration of the external coat. Dilatation of some of the vesicles
of the thyroid gland with cellular infiltration of some of the
smaller ones. Emphysema of some of the pulmonary alveoli. Ex-
tensive pigmentary Infiltratluu and central fibrosis of tbe bron-
chial glands. Intense engorgement and foci of round cell infil-
tration of the posterior portion of the pituitary body. Intense
engorgement, vacuolation and Irr^ular staining of many of the
cortical cells of the adrenals. Intense engorgement and small size
or the malplghlan bodies o( the spleen. Intense engorgement,
vacuotation and Irregular staining of the liver cells. Thickening
of the capsule, extensive engorgement and extensive diffuse iufiam-
mation of the kidneys.

RECURRENT MELANCHOLIA.

Female. Age 58. Second admission. Reported -melancholy, restless,
sleepless, apprehensive, moaning and groaning, wringing her
hands, wanting to run away, threatened to kill herself. At times
dull with loss of memory.

Duration of phychosls : Fourteen months.

Cause of death: Acnte malignant endocarditis.

Clinical report ; Recommitted July, 1905, with a psychosis of acute
melancholia beginning two months before admission, with depres-
sion and suicidal Inclinations, which continued until death. On ad-
mission was fairly well nourished but sallow. Examination Fel>-
ruary, 1908, revealed considerable emaciation. Jaundice, skin flab-

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by, dry and finely scaly, marked dyspnoea, slight oedema, of the
ankles, some butglnt; of the abdomen, a more or less oval tumor
in the left lumbar region movable in all directions, more upward,
8ll£:htly tender on pressure, some epigiistric tenderness and resist-
ance, Bu irregular mass in the right lumbar region, also slightly
moTable. Some weeks later the mass on the left side was found
to be larger and diagnosed as the spleen. Tht-re had developed
a well marked mitral systolic murmur ; increase of the epigastric
tenderness and resistance, general anasarca, extreme dyspnoeii,
cyanosis, cardiac enlargement and arrhythmia, Jaundice, gradual
emaciation and exhaustion.

Pathological reiMrt: K.\leiisive oedemii of the lower limhs; abdo-
men distended and bulging; bulging of the left side of the thorax
from the second rib above to the sixth rib below, and from the
left half of the sternum to the nipple line. Heart— Weight, 325
gms. Hypertrophied and somewhat dilated ; smuU warty reddish
granular vegetations on the auricular surface of the mitral valves ;
some sclerotic thickening of the mitral and aortic valves ; a few
reddish ulcerating foci in the endocardium of the left auricle ;
heart muscle pale yellowish red color, consistency somewhat soft-
ened; extensive atheromatous degeneration with considerable cal-
careous inliltration of the arteries, the coronary vessels being espe-
cially Involved, their orifices almost occluded. Lungs — Right pleu-
ral cavity obliterated by firm adhesions ; rather extensive firm ad-
hesions on the |)osterior surface of the lower lobe of the left side;
lower lobes on both sides moderately oedemalous congested and
doughy, ooKe considerable frothy blood on section ; marginal in-
farct In the anterior margin of the left lobe. Bronchial glands en-
larged and deeply pigmented. Several thousand cc of sero-puru-
lent fluid in the peritoneal cavity, with considerable flbri no-plastic
lymph about the gall-bladder and in the pelvic cavity ; rather firm
adhesions on tlie dorsum of the liver, about the gall-bladder, and
on the dorsum of the spleen ; peritoneum throughout deeply in-
jected and somewhat granular In appearance. Spleen — Weight,
350 gma. Extends as low as the lilac creat; Is freely movable;
capsule Is thickened; Is firm on section and of a deep red color,
LI ver^ Weight, 1C50 gms. Capsule thickened, firm on section, mot-
tled light-red aud yellowisli color. Intersected by small strands of
fibrous tissue, which Is also Increased about the larger bile ducts ;
bile ducts and povtal vessels dilated aud distended, their walls
thickened, the Intima of the portal vessels deep red In color ; gall-
bladder and ducfs extensively thickened and more or less adher-
ent to the suriMundlng structures aud filled with a grumous, brown-
hlack, viscid semifluid material. I'ancreas — Weight, 100 gms.
Firm, almost cartilaginous consistency in the head and tail. Kid-
neys— Weight, left. 120 gms.; right, 120 gms. Firm, pale. Indis-
tinct strlation, pyramids very pale, no pelvic fat, capsule adher-
ent. Gastric mucosa thickened and granular. Ovaries white and

. atrophic. Uterus contains numerous small fibroids, submucus,
subserous aud interstitial.

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M 1 (TOSCO pirnl rejiorf: A<iite vp^ptntlvp endnfarilitis: chronic myo-
citrdltiR. Tul>erful!n- fii<-l of ciiiisoliiliilioii in tlif luiiirs; Intense
vasculiir engorgt'ment of some iMirlloiis. with rupture of the capil-
Inries and filling of some of the jilveiill with Irtood. Intense vas-
cular cugorgenient, relative intrense of the trabeculae and de-
crease of the mal))ighlaii bodies of the splei^n. Extensive chronic
pancreatitis. Extensive diffuse, subacute and chronic nephritis.
Extensive fatty Inflltration; foci of necrosis; dilatation of tlie
portai and biliary vessels ; considerable periportal fibrous tissue
increase with more or less round <'ell Infiltration in the liver.
Moderate endarterlfic proliferation of the arteries. Proliferation
of the gastric and intestinal mucosal epithelium, witb hj'perplasia
of the lymph follicles.

Male.^ Age 05. Second admission. lieported depressed, melancholic,
suicidal and homicidal, witti delusions that he had been cheatwl
and that his family would come to want.

Duration of psychosis : Seven months.

Cause of death : Asi>hyxla hy strangulation.

Clinical refwrt: Admitted September, IftOG. with a psychosis of
subacut« melancholia, beginning sis mouths before. On admission
there was moderate depi-ession, with amnesia for recent events
and delusions of personal unworth. Previous admission took
place from Novenil)Pf. 1882, to January, 1SS3, for a similar do-
pressed condition. After admission there was apparently gradual
Improvement, becoming more cheerful and clearer mentally. Phys-
ically there was marked evidence of senility, weakness, dyspnoea,
some oedema of the feet, marked artcrio-sclerosis, cyanosis ou
exertitm. Was confined to bed almost a year prior to admission
because of kidney trouble. Since admission there has been grad-
ual failure, frequent fainting attactis with liradycardia. cyanosis
and arrhythmia, physical signs of myocarditis and cardiac dilata-
tion. Committed suicide by tying a handkerchief about his neck
and tying it to a bedpost.

Pathological report; Well marked arcus senilis, cyanosis of the
fliigers. Cranial Iwnes hard and thick; dura slightly adherent;
moderate opacity and thickening of the araehnopla ; some Increase
of the subdural fluid. Brain— Weight, 1440 gms. Extensive atli-
eroma of the basal vessels; consistency of the hrain much soft-
ened; an area of reddish punctate sclerosis In the anterior por-
tion of the left temporal lobe. Heart — Weight, 340 gms. Dilateil
and liypertrophied ; considerable epicardlal fat: yellowish placques
in the iwdies of the mitral and aortic valves : marginal fenestra-
tion of the aortic valve; aorta moderately dilated; moderate ath-
eroma of the arteries, the coronary vessels beiiig extensively in-
volved, r.ungs — Weight, left. 240 gms.; right, 270 gms. A few
calcareous nodules, pen size, scattered through the substance.
Bronchial glands enlarged and pigmented. Spleen — -Weight, 270
gms. Dense, band-like adhesions to the diaphragm at the upper
end; (■ai>sule thickened, quite firm; oozes considerable blood ou
section. Liver — Weight, 1520 gms. Some thickening of the cap-

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sule ; firni on section ; diffuse pale red color ; oozea considerable
blood. Pancreas— Weight. 150 gms. Batber drm. Kidneys —
Wpight. left, no gnis. ; right. 170 gma Fairly adherent to the

jtcrii-eiinl fat; firm on section; ooze considerable blood, dark red
ill color; rough granular appearance; pelres full of fat; stripped
capsule leaves a rough surface; numerous cysts scattered tbrough
the substance. Gastric mucosa deep red in color and covereil
with a thick, viscid, mucoid secretion.
Microscopical reports ; Extensive chroma tolysls of the nerve cells.
Central canal of tlie cord filled with proliferated epithelial cells,
u'hicb also Infiltrate the central gelatinous substance. In the
sclerotic area of the left temporal lobe the blood-vessels are ex-
tensively dilated and engorged with blood; the neuroglial tissue
Is Increased, and diffused through it are numerous hyaline bodies.
Extensive fatty Infiltration of the heart ; moderate chronic pevi-
carditis and myocarditis. Extensive endarterltic proliferation of
the arteries with more or less atheromatous degeneration. Some
emphysenia of the lungs. Dilatation of many of the thyroid vesi-
cles, vi'lth a tubular character of others, the latter containing no
colloid material. Numerous hyaline bodies in the choroid plexus.
Moderate chronic pancreatitis. Intense engorgement of the spleen.
Intense engorgement of the liver, with slight portal cirrhosis. In-
tense engorgement of the adrenals with foci of granular d^enera-
tion of the cortex and foci of dense round cell Infiltration of the
medulla. Extensive diffuse i-hronle nephritis, the Interstitial and
a rterio-scl erotic changes predominaling.

ACUTE MANIA.

Female. .\ge 51. First admission. Reported profane, obsceue.
hysterical, homicidal; threatened the lives of her children; wan-
dered away from home.

Duration of psychosis : One hundred days.

Cause of death ; Angina pectoris.

Clinical report: Admitted September, lti03, as a case of acule
mania. After ndnilsslou was quiet and undisturbed for about one
week, when she suddenly became acutely excited without appar-
ent cause; was boisterous, destructive, tearing her clothing and
bedding, and for ten mlnnles was extremely restless and excited.
While tlie attendants were putting on a camisole she suddenly
expired.

Pathological report; Several areas of haemorrhagic extravasatio.i
beneath the scalp; dura slightly thickened and adherent; some
increase of subdural and sulwrachiioidean fluid. Brain — Weight.
1240 gms. Somewhat congested; consistency slightly decreased;
choroid plexus somewhat cystic. Heart— Weight, 22(1 gms. Mitral
valves sclerotic and covered on the auricular surface with small
warty, granular vegetatliai'!; moderate atheroma of the aorta.
Lungs— Weight, left, .'iCO gms. ; right, .'i!)0 gms. Firm pleuritic

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■ 77

adheslone over the upper lobe of the left lUDg; left upper loin
contracted and airless, elze of a man's fiat, fibroid on section,
deeply pigmented; several areas Id both lower lobes in a condi-
tion of red consolidation. Bronebial glands enlarged and pig-
mented. Spleen — Easily lacerable. Liver — Weight, 1240 gma.
Somewhat softened and cloudy. Gall-bladder walls thickened and
contains numerous small brown Ish-blacfe calculi. Kidneys — Weight,
left, 130 gnis. ; right, l-'W gnis. Adherent to the perirenal fat,
strlaflon Indistinct, considerable pelvic fat, numerous small cysts
scattered through the cortex, capsule adherent. Pancreas —
Weight, 95 gms. Ovaries small and atrophic. Uterus contains
several small fibroid tumors, subperitoneal and interstitial ; cervix
projecting at the vaginal orifice, hypertrophied, bluish-red color,
congested mucosa thickened and covered with a viscid secretion.
Microscopical report : Cloudiness and swelling of the nerve cells.
Some chronic interstitial myocarditis, most marked near the en-
docardium. Fibrosis of the upper lobe of the left lung, consoli-
dated areas In a condition of red hepatization. Engorgement ol
the spleen. E^Qgorgement and fatty Infiltration of the liver. En-
gorgement of the pancreas. Tubercular infiltration of the adrenals.
DifEuse, subacute and chronic nephritis, the parenchymatous
changes predominating.
Male. Age 45. First admission. Reported Incoherent, restless,
wildly excited, continually singing and dancing; imagined himself
exceptionally bright, a great preacher and eloquent : very talkative, *
Duration of psychosis : Seventeen days.
Cause of death : Maniacal exhaustion.

Clinical report : Admitted Septeml>er, 1903, with a psychosis of acuti
mania, said to have followed the death of his wife. Merchant by
occupation. Onset quite suddenly as above. In addition he pro-
posed to all the women he would meet, attributed their refusal tti
the will of his wife which allowed him only a life Interest In her
property. Was found dead in bed with his head hanging over th<'
side.
Pathological report: Extravasation of blood about the left eye,
more or less discoloration of the surrounding and overlying skin,
numerous discoloration s from bruising scattered over his whole
body. Cranial bones hard and brittle. Brain— Weight. 1536 gms.
Slight Increase of cerebi»splnal fluid ; blood vessels congested ;
slight lessening of the consistency. Heart — Weight, 3H gms.
Pericardial cavltj- almost entirely obliterated by firm adhesions;
some hypertrophy and dilatation; some fatty infiltration; mod-
crate arterio-sclerosls. Lungs — Weight, left, 275 gms.; right, 320
gms. Firm pleuritic adhesions at the base and apex of the lefl
lung. Bronchial glands enlarged and deeply pigmented. Spleen —
Weight, 150 gms. Moderately firm, the malplghian bodies promi-
nent as whitish points. Liver — Weight, 1400 gms. Slightly greasy
on section. Kidneys— Weight, left, 170 gma ; right, 130 gms. Pale
on section; considerable pelvic fat; capsule slightly adherent.

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78 .

Adrenals softened in llie meiliilliiry portions. Pnncreas — Welgbt.
iW gma. Pale and quite firm. Diffusely scattered eccliymotic foci
In tlie jjtastrle and duodenal mucosa ; general enlargement of the
megenterie glands.

Microscopical report : General cloudiness of the nerve cells. Chronic
pericarditis. Rndarteritlc rn'olir^^fatlon ol the intiiua of the blood
vessels. Hjperplasia of the nuUpighiaii bodies of the spleen. Slight
fatty infiltration of tbe liver. Venous engorgement and swollen
appearance of the tubular epithelium of the liidneys. Fatty de-
generation of the cortical cells of the adrenals. Hyperplasia of
the lymph follicles of the meseutrlc glands. Hyperplasia and in-
tense blackish pigmentary infiltration of the bronchial glands.

Male. Age 40, First admission. Iteported melancholy, restless, de-
structive, not suicidal uor homicidal.

Duration of psychosis; Eight months.

Cause of death : Convulsions.

Clinical reiMjrt ; Admitted September. l',X)3, Was in poor health for
years. Was exceedingly nervous. In 1901 went west tor his
health, and while there is said to have had an attack of paralysis,
limited to one side of the body. Returned home la August, 1903.
Was incoherent, cheerful, talkative, active, inclined to wallc a
great deal. Onset of present attack one month before admission.
After admission his physical liealth gradually failed. He had oc-
casional convulsions during January, February and March of
1004. In the early part of April he had an outbreak of acute
excitement, during which lie died in a convulsion.

Pathological report: Pupils Irr^ular. Dura tense and bulging,
the subdural space filled with a rather firm fibrinous layer over
lioth cerebral hemispheres, that on the left side being haemorrhagie
in character and somewhat adherent to the dura ; tbe arachnopia
somewhat thickened and quite firmly adiierent. Brain — Weight,
1130 gms. Some general atrophy; some granulations of the fourth
ventricle. Heart — Weight, 2:w gms. Muscle firm with streaks of
fibrous tissue scattered through it; some thickening of the mitral
and aortic valves ; extensive atheromatous degeneration of the
arteries. Lungs— Weight, left, 400 gms, ; right. 300 gms. The left
pleural cavity obliterated by firm adhesicais, the right almost com-
pletely so. Pleura thickened, considerable subpleural blackish pig-
mentation, lobes adherent to each other, the posterior portion of
the right upper lolJe cyanotic, red in color and oozes considerable
blood on section. Spleen — Weight, GO gms. Firm, dense, malpig-
hlan bodies distinct. Liver — Weight, 8.50 gms. An extensive cicatrix
on the dorsal surface of the right lobe. Arm on section, oozes con-
siderable blood on section. Kidneys — Weight, left, 135 gms, ; right,
110 gms. Firm on section, several small cortical cysts, cortex pale
in color, pyramids dark, considerable pelvic fat, capsule adherent
General enlargement of the mesenteric glands.

Microscopical report: Chronic pleurisy. Areas of red hepatization
in the lungs. Chronic myocarditis. Endarteritic proliferation in

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the arteries. Considerable engorgeineiit and moderate periportal
cirrbosis of the 'liver. Moderate diffuse nephritis. Hyperplasia
of the jnesenterlc glands.' Considerable engorgement of the other
abdominal viscera.

Female. Age 35. First admission. Reported restless, noisy, de-
structive, and delusions that she Is to marry one of the house phy-
fiidaiiB.

Duration of psychosis : Two months.

Cause of death : Maniacal exhaustion.

Clinical report : Admitted August, 1904. with a psycliosis of acute
mania, beginning four weeiis prior to admission. On admission
was acutely excited, iu a state of continued psycho-motor activity ;
had frequent vilsuai lialluci nations und delusions. Physically
had lateral and posterior curvature of the spine, contraciure and
anchylosis of the lower limbs. Is said never to- have walked.

Pathological report : Extreme emaciation ; legs flexed ou the thigh
and the thigh flexed on the at)domeu, left foot rotuted inward, the
right outward, ituee Joints firmly anchylosed, the ankles and hip
joints less so; thoras barrel shaped, shoulders drawn upward
and the lower part protruding, the spine curved posteriorly In
the upper dorsal region and to the left ; small ulcerating bedsore
over the sacrum, left elbow, and left great trochanter ; a granu-
lating, suppurating ulcer over the left temporal fossa, with mar-
gins thickened and indurated, the surrounding tissues Infiltrated,
the base firmly adherent, surface covered with a dirty, grayisb
slough. Head wide, short and shallow; iwlatine arch very low;
teeth large and protruding; chin projecting; forehead low, face
small, nose flat, cranial bones soft and cancellous; dura firmly
adherent to the bones throughout; arachnopia diffusely opaque;
great increase of subdural and subarachnoldean fluid. Brain —
Weight, 1265 grms. Basal vessels extensively atheromatous; ven-
tricles extensively dilated, ependyma more or less granulated
throughout, more or less general atrophy of the convolutions. Ribs
cancellous and fragile, costal cartilages calcareous, Luuga —
Weight, left, 250 grms.; right, 250 grms. Firm pleuritic adhe-
sions over the apes of the lower lohe of the left lung and of the
adjoining portion of tlie base of the upper lobe. Firm nodules la
the apices of each lutig, which are more or less caseous on section,
the ixisterior portion of both lungs are cyanotic-red in color, more
or less doughy in consistency and ooze considerable blood on sec-
tion. Bronchial glands enlarged, pigmented and flbroid. Heart —
Weight, IDO grms. Sclerosis and some athei-oma of the mitral
valves with calcareous deposit iu the lx)dy of the anterior mitral
cusp; moderate sclerosis of the arteries. Spleen — Weight. 55
grms. Trabecuiae prominent. Liver — Weight, 630 grms. Rather
nutmeg in appearance. Kidneys — Weight, left, SO grms, ; right,
90 grms. Firm on section, pale iu color, striation Indistinct, con-
siderable pelvic fat, capsule adherent, uumerous small cysts scat-
tered through the eubstaace. Ovaries cystic A pedunculated

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fibroid OB the posterior surface of the uterus. App^idlx directly
continuous with the tip of the caecum which tapers to a cone-
shaped extremity.
Microscopical report : Diffuse chromatolysls Of the nerve cells. Vas-
cular engorgement of the pituitarr body, with an alveolar arrange-
ment of some of It, some of the alveoli being filled with hyaline
material, others with granular deljris. Extensive chronic inter-
stitial myocarditis. Chronic pleurisy. Foci of tubercular consol-
idation of the lungs in various stages of degeneration ; the Inter-
vening vesdcles emphysematous. Increase of interglanduiar tissue
in the thyroid with an irregularity In the size of the vesclcles.
some of the smaller ones filled with proliferated epUliellal cells.
Chronic venous congestion and some fatty infiltration of the liver.
Relative trabecular increase in the spleen. Extensive chronic pan-
creatitis. Extensive diCEuse nephritis. Engorgement of the ad-
renals. Cystic formation of the ovary.
Male. Age W. First admission. Reported acutely maniacal.
Duration of psychosis : Three weeks.
Cause of death : Oedema of the lungs and exhaustion.
Clinical report: Admitted August, 1!)04, with a psychosis of acute'
mania, beginning one week before admission. Imagined his horses
worth millions; otherwise wild on the subject of horses. Com-
plains of being abused, starved and subjected to persecution. Re-
fuses food. Occupation, horse trader.
Pathological report : Sordes on the teeth ; bedsore over the sacrum ;
numerous bruises over various bony projections of the body. Dura
somewhat adherent to the bones ; considerable diffuse opacity and
increased thickness of the arachnopia ; moderate increase of sub-
dural and subarochnoidean fluid. Brain — Weight, 1270 grros.
Mesial surfaces of the two cerebral hemispheres adherent over the
anterior two-thirds ; small subplal cyst over the under surface of
the posterior part of the left temporosphenoidai lobe ; a few small
cysts of tlie choroid plexus; some atrophy of the convolutions.
Heart— Weight, 250 grms. Some sclerosis of tlie mitral cusps;
moderate atheroma of the arteries. Lungs — Weight, left, 440
grms. ; right, 670 grnis. Doughy consistency, ooze a large quantity
of frothy fluid on section. Bronchial glands enlarged. Spleen —
Weight, 115 grms. Capsule extensively thickened ; over the upper
half of tbe dorsum is of cartilaginous consistency and firmly ad-
berent to the diaphragm, firm on section ; malpighian bodies
prominent. Liver^Welght, 1400 grms. Consistency rather finn.
Kidneys — Weight, left, 110 grms.; right, 120 grms. Cortex pale,
medulla dark-red in color, small amount of pelvic fat; capsule
strips readily. A fairly large blood vessel entera the lower ex-
tremity of the right kidney. Stomach contracted to the size <)f the
colon and the umcosa deep red In color. The following ribs were
fractured, but the pleura not punctured; fifth, sixth, seventh,
eighth, ninth, lenth, anteriorly, beginning about the midaxillary
line below and running obliQueiy up and forward to the nipple
line; also the eleventh and twelfth, posteriorly, at tlie line of the

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angle on the rlgbt side. On the left side the tenth, eleventh and
twelfth, posteriorly, near the angle, the eighth, Dlnth, tenth and
eleventh, anteriorly, as on the right side.

Microscopically : Moderate end.irteritlc proliferation of the intima,
with some atheromatous degeneration of the deeper parts. Mod-
erate authracosia of the lungs and rather extensive engorgement.
Estensive subacute, diffuse nephritlB. Moderate flljroais of the
spleen. Hyperplasia of the bronchial glands.

Female. Age 47. First admission. Reported acutely maniacal.

E>uratioa of psychosis ; One month.

Cause of death : Acute broucho-pneumonia.

Clinical report: Admitted Seplember, ]1>04, in a oonditlou of marked
emaciation. Exhaustion and stupor, said to have followed an
acute maniacal outbreak beginning alxtut three weeks before.
Became more or less comatose and was seized with convulsions
alKiut ten days after admission, which were confined to the right
side and occurred about four times daily, and were associated
with a rise of temperature. Said to have had a transieut hemi-
plegia two weeks l>efore the onset of the acute manifestations.
Pneumonia developed during the last week of illness. The whole
family said to tie of a neurotic tendency. Patient had rheuma-
tism ten years before, being quite helpless for six weeks.

Pathological report ; Sordes on the teeth, large bedsore over the
sacrum and over the great trochanter. Diffuse opacity of the
arachnopta; Increase of subdural and sutwrachnoidean fluid.
Braln^Welght, 3310 grma. Cranial bones soft and cancellous;
some bony projections on the inner surface of the vertical portion
of the frontal bones. Heart — Weight, 160 grms. Dull, reddish-
yellow, color; some sclerosis of the mitral valves; moderate
sclerosis of the aorta. Lungs — Weight, left, 360 grms, ; right,
260 grms. Numerous firm adhesions scattered throughout both
pleural cavities; pleura thickened; diffuse irregular areas of con-
solidation in both lungs, which have a splenic-like appearance on
section. Bronchial mucosa congested; bronchial glands enlarged
and deeply pigmented. Spleen— Weight, 150 grms. Rather soft
and oozes considerable blood. Liver — Weight, 900 grms. Dull,
mottled-red color, firm on section. Kidneys — Weight, left, HO
grms. ; right, 100 grms. Firm on section, pale in color, moderate
quantity of pelvic fat, capsule adherent. Pancreas — Weight, 90
grms. Cystic condition of the right ovary.

Microscopical report : Extensive ehromatolysls and diffuse staining
of the nerve cells. Lungs In a condition from intense engorge-
ment to gray hepatization. Intense engorgement of all the other
oi^ans.

Male. Age 42. Negi'o, First admission. Reiiorted restless, sleep-
less, melancholic and at times violent. Has threatened wife and
family. Has religious delusions; is full of the Holy Ghost; has
made many converts.

Duration of psychosis ; Thirteen montlis.

Cause of death : General tubercuiosia.

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Clinical report : Admitted with a psycboEiR of acute maola. 'Tbert*
is moderate emaciation ; mental condition one uf moderate gen-
eral weakening ; some exaltation of personality ; no retrospective
or present inslgiit; some ideas of persecution as regards family
and cooimitnient ; denies sypbllis ; admits alcoholism ; dates the
present condition to a long Illness the previous winter, said to have
l)e^i pneumonia. Complained of pains, neuralgic In character,
in l>otb legs ; pulse and respirations accelerated ; heart enlarged,
action Irregular ; dullness and rales on botb sides of the thorax
with bronchial breathing. Moderate distension of the al>domen
with fluid, some tenderness ; oedema of the ankles ; puffliit; of
the eyelids ; enlarged liver.

Pathological report: I'upils diluted. Cranial bones hard. Slight
opacity of the arachno|>ia along the blood vessels. Brain — Weight,
1310 grms. Generally softened; a nodular mass more or less
caseous In the spinal peridural space at tiie upper level of the
lumtmr. ettlargment on the left side extending about 3 cm. longi-
tudinally and about two-thirds of the circumference. Heart —
Weight, 385 grms. Pericardium contains 200 cc. of serous fluid ;
hypertrophy most marked In the left ventricle ; moderate sclerosis
of the arteries, with considerable atheromatous degeneration and
more or less calcareous infiltration. Lungs — Weight, left, 850
grms.; right, 795 grms. Both pleural cavities obliterated hy dense,
firm adhesions; pleura thickened, that over the lower left lobe
being about 4 nuu. in tlilcliness and of a cartilaginous conslsteucy ;
lobes firmly adherent to each other, of an Irregular consistency,
doughy, oozing an abundant, frothy fluid on section. Bronchial
mucosa congested and covered with an abundant frothy mucoid
secretion. Bronchial glands enlarged. Considerable oedema of
the mediastinal tissues. A small ulcerating grayish nodule on the
posterior surface of the lower fourth of the oesophagus. Peri-
toneal cavity contains IMO cc. of yellowish, transparent fluid.
Omentum shriveled Into an irregular mass. Peritoneum studded
with small, whitish noduies and also Intensely Injected over the
spleen and beneath the right lobe of the liver. Spleen — Weight,
1110 grms. Surfa<-e nodular, nodules varying in size from several
mm. to 2 cm. in diameter projecting from the surface ; whole organ
moderately firm on section. Liver— Weight, 2900 grms. Capsule
thickened, consistency firm, small whitish noduies as In the spleen
scattered throughout its substance. Kidneys — Weight, left, 200
gmis. ; right, 200 grms. Considerable oedema of the perirenal
tissue, pale on section, striation iKwrly marked, small quantity of
pelvic fat, several small whitish nodules scattered through the
substance. Similar nodules In the right adrenal, mesenteric and
retroperitoneal glands, which are extensively enlarged. Pancreas
— Weight, 150 grms. Rather firm. All the nodules are firm and
show no tendency to softening.

Microscopical report: Diffuse staining and extensive chromatolytic
changes In the nervjT cells. Extensive Interstitial myocarditis.

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Diffuse endnrteritic rroliferotlon of the iirteries. FibroicI thick-
eniug of the pleura, Rxtcusive tulierculiir uiilhu-y inhltnitioii of
the lungs. Intense engorgement iiud proliferntion of the bronchiiil
mui\»^a. IIyx>erplnRla untl pigiiieutarjr Infiltration of the bronchial
glfliids. Viisculnr engorgement, irregularity in size of the vesicles
of the thyroid gland wlili ceilulai- proliferation in the smaller
ones. Engorgement, diffuse nephritis, the parenchymatous changes
predominating. Engor};eii^ent of the adi'enals. Chronic venous
congestion of the liver. Intense engorgment of the spleen with
hyperplasia of the innlpighlan bodies. Extensive tubercular Infil-
tration, miliary In character, of the spleen, liver, kidneys and
adi-enals. Hyperplasia of the lymph follicles of the intestinal
canal nnd of the mesenteric lymphatic glands. Chronic catarrhal
colitis. Tubercular ulcer of the oesophagus.

Female. Age 50. First admission. Reported acutely maniacal,
restless. Incoherent, shouting, destructive, violent, great psycho-
motor activity.

Duration of psj-chosis: Two weeks.

Cause of death: Maniacal exhaustion.

Clinical report: Admitted June, liWti, with a psychosis of acute
mania, l)eglinilug one week before admission in a sudden outbreak
of maniacal excitement. I'or several weeks the patient had been
more active than formerly in religions uiattiTs, devoting all her
spare time to the work, to the e.\tent of silting up at night to read
for It. The meal previous to the outbreak it was noticed that
there was more Irritability than was her nature. On admission
there was such pronounced psychomotor activity that she refused
food and could only be quieted by large doses of hyoscine. Was
married twenty-five years, had no children, passed the menopause
five years before, lias one sister.

Patholi^ical report : Bedsores over the sacrum and the trochanters.
Pupils unequal. Sordes on the teeth. Slight opacity of the aracli-
nt^la along the Sylvian lissure; moderate iiicreafle of the sub-
dural and subarachnoidean iluid. Itraln — Weight, 1210 grms. Gen-
eral atrophy of the convolutions. Heart- — Weight. 330 grnis. Ex-
tensive epicardial Eat, hyiwrtrnpliy of the left side, dilatation of
the right ventricle, mitral valves p.ttenslvely thickened and fibroid,
chordae tendlnae shortened, mitral orifice contracted, aortic
vaives slightly sclerotic, moderate sclerosis of the arteries. Lungs
—Weight, left, 500 grms.; right, 400 grms. Extensive pleuritic
adhesions throughout the left pleuritic cavity ; lower lobes poste-
riorly of a cyanotlc-red color, doughy consistency, oozes consid-
erable blood on section: bronchial mucosa deeply congested.
Spleen — Weight, 100 grms. Mottled light and dark red In color;
malpighian bodies prominent. Liver — Weight. 1210 grms. Pale
in color and rather greasy In appearance. Pancreas — Weight, 70
grms. Kidneys — Weight, loft, 125 grms. ; right. 130 grms. Pale
In color, considerable pelvic fat, capsule adherent, small cyst in
the loner segment of the anterior part of the right 2 cm. In dlfliu-

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eter. Left ovary cvsiic. Several subnmcUB uterine fibroids aud
a pt'duiKHilated cervical polypus. Appendix hanging over the
pelvic brim.
MI<!roB<'oplcal report ; Moderate ebromntolydf chaneea In tlie nerve
cells ; extensive vastular engorgement ; cellular iufiltratlon of
some of tlie perivascular spaces ; central canal of the cord filleij
with proliferated epithelial cells. Extensive fatty Infiltration of
the heart ; extensive diifuse chronic tdterstitial myocarditis ;
moderate eiidarterltic proliferation of the intima, with perivascu-
lar round cell infiltration of the adventitia. Foci of round cell In-
filtration In the Gasaerlan ganglia. Intense engorgement of the
spleen with hyperplasia of the nialplghlan bodies and of the
splenic pulp. Intense engorgement of the liver with cloudy
swelling of the liver cells and some periiwrtal round cell Infiltni-
tlon. Extensive nephritis with intense engorgement and cotiiiid'
erable round (ell perivascular infiltration. Moderate emphysema,
moderate perivascular pigmentation, viiscular engorgement and
foci of consolidation.

CHRONIC MANIA.

Female. Age <u. Second admission.

Duration of psychosis: Eleven years.

Cause of death : Cerebral hemorrhage.

Clinical report: Admitted July, 1881, with a psychosis of chronic
melancholia which dei-eloped Into a secondary dementia. In Octo-
ber, 1903, examination showed marked emaciation, general anar-
saca, temjierature i>0 F., pulse 04, regular, soft and compressible ;
lespirations 10 per minute, sounds feeble, movements more lieavy
than expanding. Expression dull and stupid. Dullness toward tlie
Inner end of both clavicles, cardiac dullness extending 1 cm, to
the left of the anterior axillary line, abdominal muscles rif;ld and
pressure seems to cause pain, tlrlne negative. Had been declin-
ing in health for three months, with evidence of pulmonary tu>>er-
culosla and dropsy of the lower extremities. For a few days prior
to death she suffered from aimte entero-colitis, stools being fluid,
foetid and tinged with blood.

Pathological report : General oedema, extravasation of blood be-
neath the scalp over the lamda. Cranial bones soft and cancellous.
An extensive bloodclot covering the right cerebral hemisphere ex-
tending down to the right crus and pons and slightly upon the
upper surface of the cerelKsIlnm, apparently arising from the
branch of the middle cerebral artery going to tlie supramarglnal
convolution. Moderate diffuse opacity of the arachnopla mater
and some increase of tliickn^s. Slight increase of subarach-
noldean fluid. Brain — Weight, IITO grms. General atrophy of
the convolutions ; vessels extensively atheromatous ; Irregular
foci of softening scattered through the whole substance. Heart —
Weight. 225 gnus. Pericardium adherent to the anterior thoracic
wall and to the two adjoining surfaces of the pleura. Sclerotic

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patcbeB of tbe mitral and aortic valves ; moderate chronic inter-
stitial myocardltla ; extensive athennatous degeneration of tbe
iirtertes. Lungs — Welelit, left, 430 grms. ; rigbt, 400 grma. Scat-
tered bandlllie pleuritic adhesions; more or less cicatricial oon-
trnctlon of tlie left upper iol>e, its anterior margin over an area
!>-2 cm, collapsed and airless ; areas of consolidation scattered
througU tx)th lungs right apet more cicatricial than the left and
contains n cn'eouH nodule Infiltrated with calcareous material
considerable otdenn if the lower right lolie Bronchial gtande
eulirfeed |!;anen[(d and < iseous Thvrold gland— Weight 62
grms Both litt-rai lole« enlarged and some tendencv to cjst
formation gelatinous looking on section Omentum iidbereut 1 1
the pelvic brim and to the anterior abdominal wail o^erljlng the
l)elvl8 con«ideralile straw colored fluid In the peritoneal cavity
Spleen — ^ eight, '' i griiis Capsule adherent thickened firm on
section tral)eculae piomiuent Liier— Weight 740 grms Cip
sule thickened and adherent to the diaphragm firm on section
Kldnejs — 1\ eight lett 90 grms right 80 giras Firm on section
pale in color «triation indi^tintt excess of pelvic fat capsule ad
berent several small cjsts scattered through tbe substance Mu
cosa of the lower part of the ileum reddish color rough and
grnuular looking Muiosa of the ascendine c)lou swollen and cov
ered with considerable \lficld seiretion Mesenteric glands en
larged and some are caseated

Microscopic report F xtensiie fhromc myocardlti'. < hronu
pleurlsv Chronic hhroll tuberculosis of tbe lunti Tubertulai
softeuliii, of the bron hill glands Intestinal epithelium swollen
and cloudy with hjperpla'.ia of the lymph follicles Chronic
venous congestion it the li\er and sj leen Chronic parenchyma
tous nephritis

Female. Age Td, I^irst admission.

Duration of psychosis : Six and tiiree-fourths years.

Cause of death : Hypostatic pneumonia.

Clinical report: Admitted Febniary, 1897, with a psychosis of
chronic mania. After admission there was gradual and pro-
gressive dementia. September 23. 1003, she was tripped by another
patient and in falling frac^tured the neck of the left femur as
shown by crepitus, rotating outward, shortening and flexion fol-
lowing, but she was allowed to sit up daily until October, wiien
weakness conflned her to bed.

Pathological report ; Thorax barrel sliaped ; well inarlied promi-
nence of tbe costal cartilages, more marked on tbe right side;
ununited Colic's fracture of the right radius; fracture of the neck
of tlie left femur ; bedsore over the Racruni. Cranial bones thick-
ened and cancellous ; diffuse opacity of the arachnopla ; moderate
increase of the subdural and subarachnoidean fluid. Brain —
Weight, 1210 grms. Basal vessels extensively atheromatous, pitu-
itary body slightly enlarged, ventricles sliglitly dilate, choroid
plexus somewhat cystic, general atrophy of the convolutions.
Heart — Weight, 244 grms. Considerable epicardial fat; consid-

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prable st-lerosls rif the mitral nn<l aortio vnlves, extensive atheromn-
tous degeneration of the arteriea. with iiiimerons foi'i of iilcerntlmi.
LungK— WelKlit, left, 450 grnia. ; right, MS gruis. Bniidllkit
pleuritic adhesions In both pleuritie cavities ; posterior jrartlim
of both luDgB cyaiiotic-red color, doughy consEstency, ooze consid-
erable blood, most marked on the left side, several iiard nodules
in the left lung, calcareous centrally with a fibrous capsule. Bron-
chial glaods eularged, deeply pigmented with areas of caseation.
Spleen — Weight, 170 grniR. Firm, inalplghlan bodies prominent.
Liver — Weight, 1230 gi'ms. Rather oily on section and nutmeg lit
apj)ertrance. Kidneys — Weight, left 05 grms. ; right, tW grms.
Xuuierous small subciipsulai' cysts, firm on section, striatton indis-
tinct, Inr^e amount of pelvic fat, capsule adherent.

Mici'ORCopicnl report ; Extensive diffuse staining of the nerve cells.
Numerous hyaline bodies in the choroid plesus. Some fatty iufll-
tratlon of the right ventricle of the lieart; moderate chronic
myocarditis ; extensive endarterllic proliferation of the lutima
with foci of atheroma touB degeneration and ulceration ; si)me
thickening of the middle and external coats. Pulmonary em-
physenia; chronic Interstitial lobular pneumonia; chronic tuber-
cular ulceration of the bronchial glands. Chronic venous conges-
tion and fatty infiltration of the liver. Chronic splenitis. Ex-
tensive diffuse clironic nephritis.

Female. Age 72. First admission. Reporte'd as Imving hallucina-
tions of sight, aud general sensation ; tendency to wander away
from home; religious delusions.

Duration of psychosis : Sixteen years.

Cause of death : Pulmonary tuberculosis.

Clinical rejjort: Admitted March, 1887, with a psychosis of acute
mania following the loss of some money. Talked of seeing angels,
praying all the time, thinks that she is moved by electricity, thluks
that iKJtatoes ai-e washed in tlie blood of Christ, are put lu a beer
bucket for that purpose, wanders away from home. One step-
brother insane.

Pathological rciwrt ; Dura firmly adliereut to the Inner surface of
tlie cranial bones and to some extent to the arachnopia ; arachnopia
thickened and opaque, slight Increase of subdural and subaracli-
noldean fluid. Brain — Weight, 1200 grms. General atropliy of the
convolutions, extensive atheroma of the basal vessels. Heart —
AVelght, 325 grms. Ilyijertrophy most marked of the left ventricle,
sclerotic tblckening of the mitral valves, sclerotic thickening and
calcareous infiltration of the aortic valves, extensive atheromatous
degeneration of the arteries, the coronary vessels extremely so,
with extensive calcareous Infiltration. Lungs — Weight, left, 440
grms., right, 575 grm». Extensive firm pleuritic adhesions In both
pleuritic cavities ; pleura thtcliencd, lobes adherent, nodular con-
solidation throughout wltli considerable cavity fonnation and
more or less caseation. Bronchial muciisa congested and covered
with n viscid mucosanguinous secretion. Broncijlal glands en-
larged and deeply pigmented. Spleen — Weight, 1500 grms. Nu-

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tueroas flmi whitlab nodules scattered through Its substance.
Liver— Weight, 1070 grnis. Lower niarglu at the iliac crest,
tougue-iilie process extending froui Ijoth right and left lobes, Qut-
meg in appearance. (J ail -bladder contains two calculi. Paucreas
— Weight, 100 grniB. Stomach contracted to the size ot the colon.
Kidneys — Weight, left, 112 grms. ; right, 100 grma. Numerous
sniuil subcapsular cysts, several cortical cicatrices of the capsule,
pale on section, striatlon poorly marked, capsule adherent. Nodu-
lar hyperplasia of the mesenteric- glands.

Microscopic report : Chronic myocarditis. Chronic pleurisy ; em-
physema, pigmentary infiltration and irregular tubercular infil-
tration of the Imigs in ail stages of degeneration. Hyperplasia,
pigmentation and tubercular infiltratiou of the bronchial glands.
Chronic venous congestion and cirrhosis of the liver ; clivonic
venous congestion of tlie spleen. Fatty degeneration and foci of
haemorrhage into the piincreiis. Engorgement ot the stomach and
hyperplasia of the lympiiatic tissue. Engorgement aud diffuse
chronic nephritis, with the arterio-scl erotic changes predominating.

Female. Age 55. Second admission. Reported sleepless, restless.
dull and melancholy ; having delusions of persecution and hallu-
cinations of sight and hearing.

Duration of psychosis: Ten years.

Cause of death : Acute haemorrhagic pancreatitis.

Clinical report: Admitted ten years before in the condition re-
ported above. Said to have been dissoulte. Immoral aud addicted
to tlie use of morphia previously. After admission her physical
health was good, except for a moderate constipation. Mentally
she manifested some retardation, with periods of irritability, quar-
relsomeness, obscene and Immoral talk. Upon arising the morning
of March 14 she complained some of feeling ill and suffered some
froui nausea and vomiting, but was about until 11 a. ni., when
she began to complain of great pain and distress In the region
of the stomach, aggravated by lying on the back, and of more or
less tenderness on examination, and required an opiate for relief.
At 6 p. m. the temperature was 102.6 F., pulse 130, with but little
change lu her local or general condition. Vomiting still continued,
the vomited 'matter being bile-stained. The folowing momiog there
was considerable tympanitis, rigidity and tenderness most marked
in the epigastric region and general jaundice. The vomiting had
lessened and the pain was dull and boring. While attempting to
get out of bed at 11 a. m. she suddenly became comatose and died
within a few minutes.

Pathological report : Excess of subdural and subarachnoidean fluid.
Bralu — Weight, 1150 grms. Basal arteries sclerotic with patches
of atheroma. Lungs — Weight, left, 230 grms. ; right, 300 grms.
Diffuse pleuritic adhesions ou the right side, and at tlie base of
the upper lobe posteriorly ou the left side; some emphysema;
the lower lobe on the right side contracted into a cicatricial mass
and airless. Brouchial glands enlarged aud deeply pigmented.
Heart^Welght, 315 grms. Hypertrophy, some fatty Infiltration,

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atberomatouB placques In the l>ody of the mitral and aortic valves ;
estensive atberomatons degeneration ot the arteries, the coroiiiiry
vessels being extremely so. I'eritonenl cavity filled with a dark-
red, odorless, bloody fluid, the peritoneum congested and red, con-
Blderable swelling aud oedema of all the tissues, most extensively
Involving the transverse colon, pyloric end of the stomach, the
duodenum and the head of the pancreas. The colon, stomach and
duodenum were pushed forward by a rather flrni, dark-red mass
consisting of coagulated blood iuflltrating the pancreas. Diffusely
scattered throughout the peritoneal cavity and over the omentum
are small whitish foci of faltj' necrosis most marked immediately
souroundlng the pancreas. Spleen — Weight, 110 grms. Adherent
to the stomach and diaphragm, and somewhat softened. Liver-
Weight, 1050 grms. Engorged and softened. Gall-bladder con-
taining numerous rather soft calculi. Kidneys — Weight, left, 11.')
grms. ; right, 115 grms. Several small subcapsular cysts, dark-
red color on section, strlation indistinct, ooze considerable blood.
Walls of the stomach, duodenum and sourroundlng intestines
swollen, soft and oedematous, numerous foci of haemorrbaglc ex-
travasation in the submucosa and subserous tissues, tilood- vessels
congested. General eniargeoient of the mesenteric glands. Ovaries
cj-stic bilaterally, the right fallopian tube, ovary and parovarium
forming a cystic mass the size of a goose egg.

Microscopic report: Chronic myocarditis. Estensive endarteritic
proliferation of the Intima with considerable atheromatous de-
generation. Chronic pleurisy. Vascular engorgement of the lungs.
Cloudy and swollen appearance of the liver cells with considerable
portal cirrhosis. Esleusive arterio-sclerotif and interstitial
nephritis with vascular engorgement and cloudy swelling of the
tubular epithelium. E.xtenslve haemorrbaglc infiltration of the
pancreas with fool of necrosis. Catarrhal cholecystitis. Cloudi-
ness and swelling of the walls of the stomach and intestines.
Hyperplasia of the lymph follicles of the mesenteric glands,

Male. Age 60. First admission.

Duration of i)sychosis : Three years.

Cause of death ; Oedema of the lungs.

Clinical report; Subject to epileptic attacks, some of which were
followed by confusion or excitement. Was quite nervous and rest-
less at night ; otherwise was (juiet, and never appeared to be verj-
insane.. Died during a series of convulsions.

Pathological report: Mouth and nose filled with froth, face in-
tensely cyanosed. Some dural adhesions, extensive diffuse opacity
and increased thickness of the arachnopia, excess of subdural and
subarachnoldean fluid. Brain — Weight, 1255 grms. General atro-
phy of the convolutions, more or less granulations of tlie epend.vma
throughout. Heart — Weight, 510 grms. Firm pericardial adhe-
sions over the posterior surface of the right ventricle; extensive
hypertrophy, large quantity of epicardial fat, moderate sclerosis
of the aortic valves, moderate nrterio-sclerosis. Lungs — Weight,
left, 900 grms.; right, 950 grms. Considerable serous fluid In

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both pleiiml cavities, extensive oedema of both lungs, a few small
calcareous nodules scattered throughout their substance. Bron-
chioles filled with a frothy mucoid secretion. Bronchial glands
enlarged and pigmented. Some serous effusion In the peritoneal
cavity. Spleen^Weight, 200 firms. Ooozes considerable blood.
Liver— Weight, ISTiO grins. Moderately engorged. Kidneys —
Weight, left, 105 grms. ; rlgbt, IHO grnis. Surface lrr<«ular, firm
on section, dark-red In color, strlntion indistinct, cai>sule adherent.

Microscopical report: Diffuse staining iind extensive chromatoiysis
of the nerve cells. I' roll fern t ion of the ependymal epithelium,
thickening of the walls of the cerebral blood vessels. Chronic
myocardltltls. Extensive eudiirlcritlc proliferation of the intlma
and sclerosis of the middle and outer coats of the blood vessels
aad considerable atheromntous degeueratlon. Brnphysema and In-
tense engorgement of tlie luugs. Hyperplasia and diffuse pig-
mentation of the bronchial glands. Chronic venous congestion
and some fatty InHltration of the liver. Chronic glomerular ne-
phritis and considerable arterio-sclerotlc changes. Engorgement
and arlerio-sclerollc changes in all the other organs.

Female. Age 43. F'lrst ndinission. Reiiorled sleepless, restle^ ex-
cited, not suicidal nor homicidal ; imagines that the btoo<l of
Christ has been instilled into her veins, that people call lier names.
At times becomes very noisy.

Duration of psychosis: 'I ivelve years.

Cause of death: Acute myetltlH and pulmonary tuberculosis.

<!llnical report : Admitted January, 1892, with a psychosis begin-
ning alxrat one week before as an acute mania. After admission
her physical health was good. Mentally was In a condition of
chronic mania of a mild type. On January 1, 1904, she complained
of gastric pain, numbnes^a and tingling of the lower extremities
and abdomen, loss of aiiperlte, evening rise of temiwrature to
102 F. and a feeling of weakness In the lower limbs. She de-
clined rapidl.v, hecfiming hedfast about the latter port of Feb-
ruary. On e.tamiantion there was found almost complete paraly-
sis of the lower limhs, no resjionse to tou<*h, pain, heat or cold-
loss of paterrlni' reliex, Bablnski's plietiomenon and plantar re-
flex present, muscular atrophy, paralysis of the sphincters, for-
mation of bedsores over the sacrum, and evidence of consolida-
tion In the right lufraclaviculur region.

Pathological report : Extensive iiedsores over tlie sacrum. Cranial
bones thick and compact; extensive duiiil adhesions to the bones;
patchy ojtoclty of the aracUiiopia ; iucreiise of subdural and sub-
arachnoideaii fluid. Itrtiiu — Weighl, 1040 grms. General atrophy
of the convolutions; spinal dura more or less firmly adherent to
the vertebra, particulorly to the first thoracic, which Is very
prominent. Beneath the adhesions to the latter is a necrotic
cavity, the cord underlying It is soft, the grny and white matter
iiidlstingnishnlile more or lesK throughout, more so in the lower
cervical and upper dorsal region, the gi'ay matter being rather
teddish in color. Heart— Weight, 2o0 grms. Moderate sclerosis

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of thP Jirtert<«. Lungs— Weight, left, 230 grms. ; rlgbt, 235 gnuB.
Firm pleuritic ndbeslone in both pleurnl cavities, pleura thick-
ened; Qodular iDfiltrntion of both lungs, with more or less de-
generation of the nodules; several enmll marginal Infarcts.
Bronchial glands enlarged, more or less pigmented and caseous.
Thyroid gland — Weight, 90 grms. More or less cystic. Peritoneal
coat of the intestines more or less pinkish and grnnular. Spleen
—Weight, 40 grins. Firm on section, dark-red In color, trnbeculae
prominent. Liver— Weight, J310 grms. Considerably engorged
and rather nutmeg In appearance. Kidneys — Weight, left, 155
grms. ; rifilit, 160 (trma. Pale In eolor ; scattered throiigh the
substance are numerous small whitish foci, most marked in the
medullary portion near the pelvic cavity ; slrlatlon Indistinct,
capsule adherent, pelves distended. Pancreas— Weight, 90 grms.
Ovaries white and atrophic. Nunierous small subserous and in-
terstitial fibroids of the uterus. Walls of tlie small intestines
swollen and oedematous.

Microscopical reimrt : Chronic myocarditis ; moderate arterio-
sclerosis. Chronic pleurisy ; diffuse miliary tuberculosis of the
lungs. Chronic venous congestion of the liver. Chronic splenitis.
Chronic gastritis. Diffuse chronic nephritis with numerous foci
of dense round cell Infiltration and Intense vascular engorgement.
Spinal cord more or less engorged, and almost complete destruc-
tion, showing only as a granular, debris like formation.

Female. Age 53. First admission. Reported irritable, violent,
sleepless and requiring close watching.

Duration of psychosis; Twenty-four years.

Cause of death: Mammary carcinoma.

Clinical report: Admitted October, 1880, with the above report.
After admission ttiere was gradual and progressive deterioration
of mentality. Usuall.y very talkative, hut well -bell a ved. No ten-
d«icy toward depression or exaltation. In September, 1903,
there was noticed a slight swelling on the right breast, with
swelling of the right arm. Carcinoma was diagnosed. There was
retraction of the nipple, prominence of the veins over the right
side of the thorax, enlargement of the glands of the right side
of the neck, development of emaciation and cachexia. Two days
before death there was dyspnoea, ditflcuity In deglutition, and
moist rales in both sides of the chest.

Pathological report : A firm nodular mass involving the right mam-
mary gland with an eroding ulcer Involving the nipple, the whole
mass firmly adherent to the underlying structures. Enlarged
lymphatic glands in the infraclavicular region, In the anterior
triangle of the neck and in the axillary region on both sides.
Oedema of the right arm. Brain- -Weight, 1230 grms. Heart-
Weight, 32."i grms. Moderate hypertrophy, considerable eplcardial
fat; moderate aclerouls of the aorta. Lungs— vVeight, left, 300
grms. ; right, 310 grms. Extensive firm pleuritic adhesions
bilaterally; pleura thickened, lobes adherent, numerous whitish
bard circumscribed nodules scattered through both lungs, more

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BO In the right ; posterior surface of both lungs ol a cyanotlc-
red color, doughy eouslsteuoy, and ooze considerable blood on
section. Brout-liliil glands enlarged, some are caseous, others In-
filtrated witb firm whitish nodules similar to ttiose In the lungs.
Blgbt Jobe of the thyroid gland enlarged and cysWc and more
or [ess infiltrated with calcareous matter. Spleen — Weight, 110
grms. Liver — Weight, ]!150 grms. Firm adhesions to the dla-
phrngm. extensive diffuse infiltration with firm whitish nodules
and masses more or less circumscribed. Kidneys — Weight, left,
150 grms. ; right, 140 grms. Firm on section, dark-red in color,
Btrlatlon indistinct, capsule adhei'ent. Adrenal infiltrated with
firm wtaitlsb nodules aluiost wliolly displacing the normal tissue.
The retroperitoneal glands infiltrated ivith nodules similar to
those in other parts. Ovaries small and atropliie. Several
fibroids of the uterus projecting from the posterior wall and upper
border, some being petlunc-ulated and more or less infiltrated with
calcareous matter.

Microscopical report ; Moderate sclerosis of the arteries. Areas of
intense engorgement of the lungs, areas of pneumonic consolida-
tion, infiltration with masses of epithelial cell collections. Chronic
bronchitis. Tuberculosis of the bronchial glands. Chronic spleni-
tis. Extensive fatty infiltration of the liver witb collections of
masses of eiiltbelia! cells, with but little stroma, and tending
to follow the course of the interlobular fissures. Carcinomatous
Infiltration of the adreuals, the broucluaJ, the retroperitoneal
glands, the axillary and cervical glands, and the thoracic walls.
Extensive diffuse nephritis. Cystic degeneration of the thyroid
gland and infiltration of the coimecth-e tissue framework of the
right lobe. Calcareous Inflltratiou of the uterine fibroids. Typical
so-called scirrhous carcinoma of the mammary gland.

Male. Age 50. First admission. Iteported as having grandiose de-
lusions.

Duration of psychosis ; Eighteen months.

Cause of death ; Hypostatic pneumonia.

Clinical report; Admitted February, 3903. Single. Occupatirai
farmer. Deaf. Lame. I'lrst manifestations were shown in Sep-
tember, 1902, by the purchase of many uunecessary articles, by
thinking that women bad taken a special liking for him. Was
talkative, active mentally and physically. Was good-natured and
had a feeling of general well-being and contentment No history
of syphilis or alcohol. Supi>osed to l>e due to masturbation and
a constant desire for sexual gratification. During the autumn
of 1003 he had a series of mild convulsions. In April, 1904, while
walking about the grounds he was given a push by another pa-
tient, aud In falling backward he struck the right hip, fracturing
the neck of the fenjur. A few weeks after a condition of status
developed, whicli terminated fatally In a few days.

Pathological report ; Right leg rotated outward, flexed on the thigh
and the thigh on tlie abdomen, hip flattened, trochanter broadened
and carried up and back, leg shortened 3,75 c. Dura Qnnty ad-

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herent to tbe Inner surface of tbe skull and tblckeued, dlftu^c
opacity and thickening of the arachnopia over the SylTlnn fissure
and along the superior longitudinal 8lnus. Great increase of sub-
dural and Bubarachnoidean fluid. Brain — Weight. 1300 gms. Gen-
eral atrophy of the convolutions. Lungs — Weight, left, 450 gma. ;
right, 825 gms. Firm, band-like adhesions over the lower and
middle lobes on the rlgbt side, and ou tbe posterior surface and
base of the lower lobe on the left side. Pleura thickened ; lobes
adherent to each other; considerable oedema of both lungs; nodu-
lar areas of consolidation in the lower and middle lobes on the
right side; considerable hyposlasis. Bronchial mucosa congested.
Bronchial glands enlarged and deeply pigmented. Heart — -Weight,
220 gms. Considerable epicardlal fat ; right side of the heart
considerably distended. Extensive atheromatous degeneration of
the arteries ; dilltation of the thoracic aorta. Oesophageal mucosa
covered with fleshy colored, foci with more or less softening of It
and the submucosa. Transverse colon U-shaped, its lower extrem-
ity lying below the umbilicus, its extremities lying behind the
lower end of the sternum and to the left of tbe median Hue be-
hind tbe costal cartilages. Mesentery of the sigmoid colon 13
cm long. Spleen — Weight, 155 gms. Has a tongue-lite projection
extending from Its lower and anterior border, is soft and ooaes
considerable blood on section. Liver — Weight, 1660 gms. Oozes
considerable blood on section and has rather an oily appearance
on section. Kidneys— Weight, left 200 gms. ; right, 185 gras. Ad-
herent to the perirenal fat, pale in color on section, atriatlon in-
distinct, capsule adherent, pelves dilated and distended with
muco -purulent fluid, mucosa thickened and cougested. Ureters
dilated and distended with purulent looking fluid. Bladder di-
lated, its walls thickened and tlie eaVity contains purulent urine.
Prostate enlarged. Gastric mucosa thickened. Mesenteric glands .

Microscopical report: Chronic myocarditis. Intense engorgement
of the lungs, portions showing capillary rupture and filling of the
alveoli with blood. Hyperplasia and diffuse pigmentation of the
bronchial glands. Extensive endarteritlc proliferation of. the in-
tima with atlieroniiitous degeneration of the deeper portions. En-
gorgement of the spleen. Chronic vecous congestion of the liver
with slight portal cirrhosis. Moderate dlHuse chronic nephritis,
with foci of dense round cell infiltration diffused through the sub-
stance, most marked perivascutarly and toward the pelvis ; ca-
tarrhal pyelitis; chronic cystitis. Slight chronic gastritis. Diffuse
staining and chromatolytic changes in the nerve cells.

Female. Age 63. First admission. Iteported restless, sleepless,
hysterical, suicidal and homicidal; having hallucinations and de-
lusions.

Duration of psychosis ; Nineteen years.

Cause of death : Pulmonary tuberculosis.

Clinical report: Admitted July. 1885, witli a psychosis of acute
mania as above, beginning three weelts before admission. Mar-

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rled forty-one years. Six children. Toungeat 22 years. Courae
of the mental condition wns one of progressive dementia. Physl-
cally. the pulmonary tuberculosis was of unknown duration. In-
testinal tubenmlosia was manifested about one month by gastric
Irritability with attacks of diarrhoea and constipation alternating,
gM^Kl marasinua. Cough, mucopumlent expectoration and grad-
ual decline.
Pathol(^cal report; Bed sores over the sacrum and the great
trochanters. Cranial ttones thin and rather cancellous. Dura
slightly adherent over the frontal lobes, diffused opacity and ip-
creused thickness of the arachuopla, considerable increase of the
subdural and subarachnoldenn fluid. An haemorrhagic fibrinous
membrane covering the right cerebral hemisphere. A partially
organized clot filling the superior longitudinal sinus from tbe ver-
tex back to the termination and extending into tbe parietal and
occipital veins. Considerable atropliy of the cereliral convolu-
tions. Lungs — Welgbt, left. 280 gms. ; right. 975 gms. Firm pleu-
ritic adbesions on the right side throughout, and on tbe posterior
surface of the left apes. Lungs diffusely and irregularly nodular
throughout, the right oue extensively so ; the intervening lung
tissue crepitant, on section some of the nodules are dark-red in
color and solid in consistency, others are in various stages of de-
generation and softening: In the apex of the right lower lobe and
adjoining portion of tbe upper lobe are several irregular cavities.
- Pleura thickened and tbe lobes adherent. Bronchial mucosa thick-
ened, congested and the lumen filled with muco-purulent secretion.
Bronchial glands enlarged, pigmented, some are more or less cas-
eous and infiltrated wltb calcareous material. Heart— -Weight,
190 gms. Considerable epicardlal fat; several patches of epicar-
dlal sclerosis. Moderate arterlor-sclerosis with more or less ath-
eromatous degeneration. Stomach occupied a vertical position, its
lower margin on a level with the Iliac crests, the pylorus in the
metilan line just above the umbilicus, a sharp bend at the junc-
tion of the middle and pyloric thirds. The transverse colon lying
4 cm below tbe umbilicus. The peritoneal cavity contains a small
quantity of serous fluid. A few stray adhesions between the
right fallopian tube and ovary,, some coils of small intestines and
caecum. Spleen — Weight, 180 gms. Easily laeerable. numerous
small bodies scattered through its substance, matpigbian bodies
prominent. Liver— height, 1380 gms. Lower margin 2 cm below
the Iliac crests, its left margin lying in the left nipple line ; rather
nutmeg and wasy in appearance. Gall-bladder contains two black-
ish calculi about 2 cm in diameter. Kidneys — Weight, left, 110
gms. ; right, 110 gms. Firm on section, pale in color, striatlon in-
distinct considerable pelvic fat, capsule adherent. Some tblck-
enlng of the pyloric end of tbe stomach with considerable sub-
mucus congestion. Diffuse and extensive tubercular nodules and
ulceration of the Intestines, most marked in the ileum. Ovaries
small, white and atrophic.

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Microscopical report; Diffuse staining and moderate chroniatolytlc
d^eneratlon of the nerve cells. Moderate t-hronic inyiicarditis.
Modenite .irterlor-sclerosls uiid iithei'oniutous degeneration of the
ni'terles. Partly orgiiiilzed tliroiiibuB of tbe superior iougltudloal
sinus. Extensive tubercular conHolldHtiou of the lungs in all
stages of degeneraliOD. Chronic bronchitis. Hyperplasia, pig-
mentary lnfilti";ition, tul>er<'ular degonerutlon and calcareous In-
liltratlon of the bronchial gliinds, Tuberculnr nodular Infiltnition
of the spleen. Chronic venous congestion of the liver, with cim-
sidi-rable fatiy inflltratlou. Extensive diffuse nephrltlx. Chronic
gastritis. Tubercular InHItration of the intestine in nil stages of
degeneration and ulceration.

Female. Age 51). Second admission. Reconiiiiitted in October.
lS9a. as violent at times.

Duration of psychosis; Seventeen and oiie-linlf years.

Cause of death; Giill-stone obstruction.

Clinical reiwrt : None given.

Pathological reiwrt ; General jaundice. Abdomen distended and
typmpanitic. Cicatricial scare on the anterior surfaces of both
tibia. Sllgbt oedema of the lower limbs. Occipital boue consid-
erably depressed beneath the parietal, but the inner surface
,3Uioutb. Small quantity of subrtrachnoidcan fluid. Brain-
Weight, 1250 gms. Lungs — Weight, left, fiOO gnis.; right, ItuG gms.
Firm pleuritic adhesions on the posterior surfaces of both upper
lobes. Lungs dull-red in color, donghy consistency on pressure,
ooze considerable frothy fluid on Kectiou, calcareous nodule In the
apex of the lower right lobe. Bronchial glands enlarged, pig-
mented and more or less calcareous. Heart — Weight, 428 gms.
Extensive hypertrophy and some dilatation of the right ventricle;
extensive sclerosis of the mitral valves, with narrowing of tlie
orifice ; chordae tindinue shortened and thickened ; cuusiderable
epicardial fat; extensive arterio-sclerosla, with more or less ath-
eromatous degeneration. Intestines distended with gits ; walls of
the- small intestine congested; small quantity of blood-stained
fluid in the peritonea! cavity. Spleen — Weight, 145 gms. Mod-
erately firm. Liver — Weight, 1070 gms. Numerous adhesions to
the diaphragm and of the.sali-bladder to the colon; rather soft on
section, oozes considerable blood, biliary staining about the biliary
capillaries, foci of a whitish -yellow color, and somewhat softer in
consistency ; gal 1-1)1 udder distended aud dilated to about five times
Its normal size and filled with yellow brownish viscid bile, con-
tains one calculus 2 cm In diameter ; the cystic duct dilated to
1 cm and the hepatic duct to 1.5 cm in diameter, the common duct
to 2 cm, and its opening into tlie duodenum obstructed by a cal-
culus over 1 cm in diameter. Kidneys — Weight, left, 130 gins. ;
right, 110 gms. Firm on se[>;ioii. pyramids dark red in color, ooze
considerable blood, stria t ion Indistinct, considerable pelvic fat,
capsule adherent. Hyperplasia of the lymphath- glands in the gas-
trohepiitic ouientum. Appendix hanging over the pelvic brim.

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Mlcroscopleal report: Chronic pleurisy. Some pulmonary emphy-
sema. Chronic myocardltie ; some fatty infiltration of the right
ventricle : moderate arterlor-sclerosls with considerable atheroma-
tous degeneration. Extensive parenchyma tons nephritis. Chronic
venous congestion of the liver with some fatty Infiltration and
some cirrhosis and acute in9iimmatlon of the biliary vessels.

Female. Age 50. First admission. Reirorted destructive, restless,
violent, not suicidal or homlcidnl, Supjiosed cause gi'en was that
she could not get married.

Duration of psychosis : Twelve years.

Cause of dealh : Pulmonary tuberculosis.

Clinical report : Admitted October, 1802, with a psychosis of acute
hysterical mania, i>eginning two weeks before admission with the
above report Has been noticeably declining for the last year,
extensively so for the last two months. Has had persistent
cough, witli considerable expectoration, which she mostly swal-
lowed ; progressive emaciation, Intermittent attrtcks of diarrhoea.

I'atlioioglcal report : Extreme emaciation ; extensive bed sores over
the sacrum. Criinlal bones cancellous ; slight opacity of the araeli-
nopia, some increase of the subdural aud subarachnoidean fluid.
Brain — Weight. 1140 gms. General atrophy of the convolutions,
cystic condition of the choroid plexus, dilatation of the central
canal of the spina! cord most marked in the dorsal r^lon. Heart —
Weight, 245 gms. The pericardial cavity obliterated by diffuse
firm adhesions. Lungs — Welghl, left, 850 gms. ; Tight, 960 gms.
Firm pleuritic adhesions on the left side, to the upper part of the
pericardium, and to the adjoining margin of the right pleura. On
the left side anteriorly some recent adhesions. In the posterior
part of the left cavity is a large cavity limited by rather firm ad-
hesions containing purulent material. General tubercular con-
solidation with extensive cavity formation in the right apex and
numerous small ones throughout. Bronchial glands enlarged and.
caseated. Peritoneal cavity contains some serous fluid. Appendix
banging over the pelvic brim. Transverse colon U-shaped and
lies 2 cin below the Iliac crests. Spleen— Weight, 05 gms. Mod-
erately firm, numerous small whitish bodies scattered through its
substance. Liver— Weight, 070 guia. Moderately firm on section.
Kidneys — Weight, left, ]();i gms.; right, 90 gms. Firm on section,
pale in color, strlatlou moderately distinct, considerable pelvic
fat, capsule adherent. Moderate enlargement of the mesenteric
and retroperitoneal glands. Bladder distended with urine.

Microscopical report; Chronic pericarditis. Chronic myocarditis.
Diffuse tubercular consolidation of the lungs with foei in various
stages of degeneration and abscess formation. Hyperplasia and
tubercular Inflltration of the bronchial glands. Chronic venous
congestion aud foci of tubei'cular Infiltration of the liver. En-
gorgement and tubercular infiltration of the spleen. Chronic
parenchymatous nephritis. Diffuse staining and chromatolytic
changes in the nerve cells.

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123. Female. Age 65. First admission. Reported acutely mnnlacnl.

Duration of psychosis: Twenty and one-half years.

Cause of death : Pyaemia.

Clinical repoit : Admitted June, 1S84, with a psychosis of acute
mania. Six months l>efore death subcutaneous abscesses began
to appear over various parts of the body.

Pathological report : EJxtensive bed sores over the sacrum, over
both trochanters, and over both anterior lilac spines. Numerous
cicatrices and sinuses discharging purulent matter leading to
large subcutaneous and Intermuscular cavities, most prominent
over the lumbar and gluteal regions. Occipital bone below the
level of the parietal at the lambdoid suture and at the left pos-
terior inferior angle of the parietal bone. Cranial bones soft and
cancellous. Dura moderately adherent to the bones ; diffuse opac-
ity and increased thickness of the arachnopla, Increase of the
subdural and subarachnoidean fluid. Brain — Weight, 1165 gms.
General atrophy of the convolutions. Irregular atheromatous de-
generation of the basal Tesscls. Lungs — Weight, left, 300 gma. ;
right, 380 gms. Thorax barrel -ah aped. A few Arm pleuritic ad-
hesions over both apices. Lungs cyanotic-red color posteriorly,
somewliat doughy, cicatrical contraction of the apices, numerous
small nodules In the left apex, some of which are caseous. Heart
— Weight, 230 gms. Some epicardial sclerosis over the right ven-
tricle, some atheromatous ptacques in the bod; of the mitral
valves, 'moderate atheromatous d^eneration of the larger ar-
teries. Spleen — Weight, 120 gms. Soft and friable. Liver —
Weight, 1430 gms. Firm on section, and rather nutmeg In ap-
Itea ranee. Gall-bladder represented by a firm cicatricial mass
of fibrous tissue. Kidneys — Weight, left, 110 gms.; right, 100
gms. Firm on section, pate in color, striation poorly marked, con-
siderable pelvic fat. Medullary portion of the adrenal soft and
pulpy. Ovaries bard, wliite and atrophic.

Microscopical report : Diffuse staining and extensive chromalytic
changes in the nerve cells. Chronic nodular tubercular Inflltra-
tion of the lungs centrally degenerated. Intense engorgement
and beginning consolidation of other portions of the lungs. Fatty
inflltration of the right ventricle Of the heart. Moderate fatty
Infiltration of the liver with more or less biliary cirrhosis. En-
gorgement of the spleen. Engoi^ement of the kidneys with con-
siderable parenchymatous in 8 a mm a ti on.
134. Female. Age 39. Second admission. Reported as a chronic maniac,
restless, sleepless and incoherent.

Duration of psychosis : Nineteen years.

Cause of death: Multiple abscess of the liver.

Clinical report: Admitted September, 1888, witb a psychosis of
chronic mania. First admission two years before. Mentally has
heen very active and required restraint often. Physical condi-
tion was good until al)out sis weeks before death, when she began
to decline, suffered from anorexia, uncontrollable vomiting, tem-
perature ranging from 100 to 102 F. ; pulse from 90 to 110, resplra-

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tfoiis toward the last from 40 to 45. There developed cough,
dyspnoea, slgno of pleurisy with efTuelon. attacks of diarrhoea
and oedema of the lower limbs. Patient was In the habit of
Introducing foreign snhstaiices luto rectum. One uncle insane.

Pathological report; Abdomen distended and tense; oedema of the
lower limbs. Cranial hones hard. Dura firmly attached to the
aracbnopia on each side of the superior lon)i:ltudlnftl sinus ; dif-
fuse opaclly of the arachnopla. Bruin — Weight, 1240 gins. Lungs
—Weight, left, 430 gms. : right. 245 gms. Right pleural cavity
contains 1500 cc of trnnspnrent yellowish fluid; firm adhesions
ut the base ; left iung cyanotie-red color, doughy consistency, oozes
considerable frotliy bloody fluid on section; right lung collapsed
and airless except the apex of the upper lobe and the anterior two-
thirds of the middle lobe ; Irregular nodules In tlie apex of the
lower lobe, some of which are caseous. Heart — Weight, 180 gms.
Pericardial cavity contains a siuail quantity of serous fluid; mod-
erate atheromatous degeneration of the arteries. Bronchial elands
enlarged aud plgiuented. reritoiical cavity filled with a yellowish
transparent fluid. Colon distended with gas. - Small intestines
lying In the pelvic cavity. Liver — Weight, 2650 gms. The lower
mai^ln at the iliac crest, left margin of the left lohe In the left
mldaxillary lino imd of the right lobe in the left parustemai line,
moderately adherent to the diaphragm, firmly so to the colon and
right kidney, numerous whitish nodules appear on the surface of
the right lobe which Is more or less fluctuating on its dorsal sur-
face, the greater part of the right lobe Is occupied by cavities vary-
ing In size and coutaiuing a creamy fluid, some of the nodules are
more or less caseous, some more semi-fluid, musliy in consistency.
Spleen — Weight, 200 gms. Fairly flrm in consistency, malplghian
bodies prominent. Kidneys — Weight, left, 170 gins. ; right, 165
gms. Finn on section, glomeruli prominent, considerable pelvic
fat, capsule adherent and leaves a rough surface ou removal.
Pancreas — Weight, TO gms. Rather firm.

Mlci'OScopical rejiort: Very slight irregularity In the staining of
the nerve cells. Moderate clirouic myocarditis. Collapse, engorge-
ment and chronic tubercular areas in the lungs. Chronic pleurisy
with consolidation of tlic underlying vesicles. Extensive tubercu-
lar infiltration of tlie liver showing zones of degeneration sur-
rounded with fibroid wallR, outside of which there is intense vas-
cular engorgement. Chronic venous congestion of the spleen. Es-
tensive chronic nephritis, jjortious showing parenchyma tons
changes, others In which the interstitial changes predominate.

Female. Age ((5. Second admission, Reiwrted violent and at times
destructive.

Duration of psychosis ; Eighteen years.

Cause of death ; Cerebral haemorrhage.

Clinical report; Xo report of the condition prior to or at the time
of admission. Haemorrhage resulted from a fall, in which she
struck the occiput, dying In a few minutes.

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Pathological report: ElxtraTasatlon of blood beneath the scalp over
the right occipital r^ion. Cranial bones thin and cancellous.
Firm dnrai adhesions over the frontal lohes, slight increase of
subdural fluid and mixed with considernble blood over the parietal
and occipital lobes, diffuse opacity of the arachnopla, oonsiderablo
Increase of subarachnoldean fluid and on the right side is also
mixed with blood which extends subtentorialty around the pons
and the medulla. Brain— Weight, 1230 gms. Blood vessels ex-
tensively atheromatous, brain substance generally softened, an
haemorrhagic extravasation in the right cms, beginning beneath
the anterior quadrigenilna, lying Just below tlie canal of Sylvius
and extending back as far as the junction with the pons. Lungs — ■
Weight, left, 520 gms. ; right, 580 gms. Cyanotic red color, doughy
in consistency, oozes considerable frothy, bloody fluid on section.
Heart— Weight, 300 gms. Some hypertrophy, considerable epicar-
dial fat, atheromatous placques In the body of the mitral valves ;
moderate atheromatous degeneration of the arteries Involving the
coronary, extensively so. Spleen — Weight, 140 gms. Malplghlim
bodies prominent, oones considerable blood on section. Liver — ■
Weight 1830 gms Firmly adherent to the colon duodenum ind
the rls,ht Lldae\ oozes cjnsiderable blood on section Kidney —
Weight left 115 gms right llo gms Intimately adherent to the
perlrenti fat numerous subcarsular cysts flrm on section reddish
granular nppearai ce lower end of the r^ramids pale glomeruli
prominent ci n^dderable pelvic fat carsule idherent and levies a
rough surface I ancrea* — -tt eight 100 gms Appendix hanging,
into the pelvic civity Ovaries and uterus atrophied

Microscopical reiK>rt Lxtenaive fatty Infiltration of the right \ n
tricle; chronic iniocraditis Extensile atheromatous degeneratitu
of the arteries Intense engorgement of the pulmonary capillaries
with rupture of s<:me fllllug the vesicles with blood other veskles
filled nith grinular debris Irregularity In size and shape of the
thyroid vesides many of tbem tending to become cvstic Hjper
plasia of the malpighlan bodies of the spleen Liver fells stain
irregulnrlj numerous fofi of round cell infiltration m the portal
fissures and ibout the bile ducts Foci of round cell Infiltration
In the medullary portion of the adlenals Modertte Interstitial
nephritis

lemale Aj,e C7 First admission Reported melancholy restie«s>
and Meepless Marred but serarated from her husband an I ibil
dren

Duration of psychosis Twenti four years

Cause of death ( arcinom i of the tongue

Cliultal rei ort Adm tted \ugust 1S84 with j psjUi ms it liioui
mint I Nothing given ot lier condition prior to idmission oi it
the time Has been profoundly demented for many lears II is
had pulmonarj tuberculosis for many \ears nith more or less
Irr^ular temperature c ugli e\ pet tor it ion raj d heirt acti n
general emaciation and enfeeblement

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Pathological report: Extreme emncialion; catnrnct In troth eyes; no
lobule to the ears : tongue iirotrudlng from the mouth, dry. dark-
red ill color, uiucli enlarged and quite nodular posteriorly : IdHI-
trated by a Brm whitish mass; on the right marglu toward the
posterior portion there Is a raj^ed, irregular, dirty-colored ulcer;
tongue iR Urnily adhereut to the door ot the mouth and the latter
extensively infiltrated with the nodular masses. Cranial bones
soft and cancellous ; dilTus-e opacity of the arachnopia ; slight in-
crease of subdural and rather extensive increnRe of the subarucli-
noidean fluid, Braiu — Weight. 1180 guis. General atrophy of the
convolutions; moderate atheromatous degeneration of the basitl
vessels. Heart — Weight, 2(K) gms. Considerable epicardinl fat;
extensive atheromatous d^enerutiou of the arteries. Lungs-
Marked depression beneath tlie clavicles; firm pleuritic adhesions
over the posterior surface of both lobes of the left lung, the right
cavity entirely obliterated ; lobea of the lungs firmly adherent,
considerable marginal cmphj'sema, numemus foci of purulent
softening with very little surrounding consolidation; bronchioles
filled with a purulent secretion. Broiicbial glands enlarged, pig-
mented and mure or less caseated. The upper portion of the
larynx and the adjoining portion of the pharynx extensively In-
filtrated with nodular masses, continuous with those of the tongue
and the iloor of the mouth. The lymphatic glanda on the right
side of the neck also infiltrated with similar nodular mosses. The
transverse colon occupies an oblique iwsitiou e.-ctendlng from the
right iliac crest ti> the tenth costal cartilage on the left side.
Spleen— Weight, 05 pns Lower extremity lobulated, capsule
thickened, malplgbian bodies distinct, moderately flrni. Liver —
Weight, ]()()0 gms. Constriction of both lobes at the Junction of
the lower and middle thirds, oozes considerable blood on section.
Pancreas— Weight, 80 gms. Kidneys— Weight, left, 90 gms. ; right
80 gms. A few subcapsular cysts, firm on section, paie in i-olor,
striation liidistinct, very little pelvic fat, capsule tears the sub-
stance on removal, surface has a rough gi'Unuiar appearance.
Stomach contracted to the size of the colon. Ovaries small and
atrophic Several small fibroid tumors of the posterior wall of
the uterus.

Microscopical report; Diffuse staining and extensive chrvmatolytic
changes of the nerve cells. Fatty infiltration of the right veutri-
ele. chronic lavocarditis. Extensive atheroraatims degeneration
of the avieries. Diffuse foci of round-cell Infiltration in the lung's
surrounded by a Kone of intense vascular engorgement, some areas
showing more or less degeneration and softening ; bronchioles
filled with degenerated lewwytes and proliferated epitliplial cells.
Hrouchial glands enlarged and deeply pigmented. Great irregu-
larity in size of the thyroid vcicles with many of the ^nailer ones
filled with epithelial cells. Mnlpighian bodies of the spleen dense
and stain deeply. Chronic venous congestion of the liver. Foci
of round cell infiltration In the adrenals. Extensive diffuse nepb-

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rltls jjpioal squnmous epithelioma of tlip tongue Epithelioma
tous Infiltriitioii of tlie lirjnx pharynx and i^rvical iTuiiihutK
elands

149. leiuale A„p ob 1 Irfct admlsekn Ktiiortwl sleejiiess itstless

melancholy Thinks that her soul Jud bodv »ie sppirated that
spirits take hold of aud control ber that some o1 the iieit,hl>uis
are ^ing to kill her and cnes most of the tmie

Duration of psjohosls Sixteen \ears

Cause of death \(ute suppwrathe laenlDgltls

Clinical report Admitted Jum. 1889 witb n p^vchosls of amte
mania beginning fl\e neeks httore aduilssion with the atK>\e re
port In March I'KFJ an ilhieia be^an with lassitude a tendeurv
lo lie ibout suk, at the stoiuai h and some "rise of teiiipei ituie
dvnig la four days without an\ othei uianlfehtntlons lathei
insine one biother feebleminded

Pathological report Slight lauudi e i-ordes on the teeth Ihiia
thickened moderitelv adherent to tliL hones itii liiuei suifu-e
co\ered with a thin turbid puinient exudate Subdural fluid
turbid and purulent arathnopla dlFfuseii thickened and opaque
deepli Inleitid considerable fibrino purulent subl^achnoide^u
fluid Brain— Weight 1310 gnis Surface co\ered with a librino
purulent exudite conslatenty of the brain substance moderately
firm Heart — Weight 2'iO gms About 50 tt of seious fluid In
the pericardial canty conslstewy of the heart mustle rather
soft moderate aiterio sclerosis lungs — Weight left 2C0 gius
right oSI> gms. left pleural ctwltv contains alx>ut 100 cl of
serous fluid posterior portion of both lungs cj inotlt red in color
doughs consistence oozing considerable blood on section Bron
Lhial glands enlarged and deepU pigniented Spleen — Weight ItiO
gms Soft oo/es considerable blood malpighi^n bodies distinct
Li vei ^Weight 1460 gm& Uather soft pale nutmeg color center
of the lobule depre«ised Tanercis — W eight 90 gms Kidneys —
Weight, left 145 gms. right 13B gms Adherent to the pertrenil
tisMie rather soft pile in toloi <K/e considerable blood, cwsld
eiable pelvic fat

Ml roscoplcal report UifCiise sta ning of the ner\e tells Lhr mic
inMjcarditls I \ ten sue aittnos leu sis Intense engorgement of
the alveolar apiUanes with rupture of some and filling or the
pulmonary vesicles with blood diffuse Infiltration n Ith nodules of
tubercular formation some being moit, or leas degenerated Great
Irregularity in sl/e of the thyroid vesicles with cellular filling of
the smaller ones Intense ent,orgeinent of the spleen Extensive
yellowish pigmentation of the adrenals In the medullan portion
Lhronlc \enous congestion of the luer cloudiness o( the liver cell
ili^t [wrtil dnhosls Bxtenone engoi^euient of the kidney dif
fuse arterio silero Ic and interstitial nephritic the latter coudl
tlon more or less, localized

150. Female \ge On First idmKsIon Reported sleepless restless pro-

fane lias 1 annus delusions Heirs \oitefi from imaginary per
sons.
Duration of psychosis: Eighteen years.

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101

Cause of death : Purulent broncho-pneumonia.

Clluical report : Admitted November, 1887, with n psychosla of acute
manlH. Was in good health physieally until about one year ago.
when there were symptoms of ruplure of a pulmonary abscess,
with progressive failure of health. One sister insane.

Pathological report : Slight oedema of the lower limbs. Left leg
rotated out. Lateral curvature of the spine, doraal region to the
right, lumbar lo the left. DifCusp adhesions of the dura to the
skull and to the arachuopia over the parietal vertices, diffused
opacity and increased thickness of the arachnopia, some in-
crease of the subdural and subarachnoidean fluid. Brain —
Weight, 1105 gms. Basal vessels arterlo-scl erotic and somewhat
atheromatous; general atrophy of the eouvolutions, lateral ven-
tricles dilated and flllPd with fluid, septum lucldum very thin.
Heart — Weight, 295 gms. I^eft ventricle hypertropbied, the right
ventricle dilated; moderate sclerosis and atheroma of the artpries.
Lungs — -Weight, left, ;iOO gms. ; right, 42o gms. Firm pleuritic ad-
hesions throughout the left pleural cavity and over tbe anterior
surface of the right upper Johe. Lower left lobe collapsed and
airless except a small portion of tbe anterior margin; is spleen-
llice in appearance on section, and has numerous caseous and cal-
careous foci ; the upper Jeft has numerous emphysematous lobules
projecting from its surface. Right lung is somewhat similar e.t-
cept the areas of consolidation are somewhat larger. Bronchial
mucosa is deep red in color and covered with a viscid bloody secre-
tion. Bronchial glands enlarged, pigmented and more or less
caseous. Appendix hanging into the pelvic cavity. Spleen —
Weight, 170 gms. Capsule thickened and adherent to the dia-
phragm, consistency softened, oozes considerable blood. Liver- — -
Weight, 9iQ gms. Capsule tiiickened, several cicatrices on the
dorsum, flrin on section, rather oily in appearance. Pancreas —
Weight, 100 gms. Kidneys— Weight, left, 120 gms, ; right. 100
gms. Pale in color, moderate quantity of pelvic fat, capsule ad-
herent. Smali parovarian cyst on the right side.

Microscopical report: Diffuse staining and moderate chromHt<)lylic
degeneration of the nerve cells. Extensive fatty Inflltratlon of the
right . heart. Sloderate arterio-sclerotic degeneration of the ar-
teries. Chronic pleurisy, ^ubpleural consolidation of the pulmo-
nary vesicles. Bronchioles filled with more or less degenerated
cells. Considerable peribronchial pneumonic consolidation. Hyper-
plasia of the lymph follicles of the bronchial glands with diffuse
pigmentation. Irregular size of the vesicles of the thyroid gland,
with the smaller ones mostly flllejl with proliferated epithelial
cells. Intense venous engorgement and slight cirrliosis of the
liver. Rxtensive chronic diffuse nephritis. General hyiwrpiasia
of the splenic corpuscles. Hyiierplasia of the lymph follicles of
the alimentary canal.

Female. Age 50. '! bird admission. Reported boisterous most of
of the time.

Duration of psychosis : Fifteen years.

Cause of death; Pneumonia and acute cerebro-splual meDlngltla.

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Clinical report : Admitted Septenilier, 1890, with a psychosis 'of
recurrent mania. Was an iuniate in 1885, aad in 1889, for acute
mania. Mental course was one of progressive dementia, wltlj
occasional maniacal outbrealis. In January, 1005, tbere developed
a right apical pneumonia, which was diagnosed as tubercular uud
wbici) toolt on a chrouie course. In March, 1905, there developed
a sudden rise of temperature to 103 F., respirations l>e<:ame rapid
and diDicult, considerable dyspnoea was manifested and a short
liacking cough, rapid and feeble pulse. Tbe process gradually ex-
tended throughout the whole right lung and terminated fatally
in three weeks. One second cousin insane.

Patbological report ; Slight Jaundice. Nose flat with a small ulcer
on the right aln. Sordes on tbe teeth. Some swelling of tlie
lower limbs. Cranial bones hard. Dura thickened Qod its inner
surface covered with a yeilowisb fibrluo-puruleut exudate, nu-
merous vascular connections witb tbe arachnopla; subdural fluid
increased and puruieut. Diffuse opacity and congestion of the
arachuopia, subarachnoldeau fluid increased and purulent. Brain-
Weight. 1300 gms. Appears swollen and consistency softened.
Pituitary body somewhat enlarged. Spinal membranes and cord
similar to the brain. Lungs — Weiglit, left, 390 gms.; right, 1190
gnis. Bight pleural cavity obliterated by adhesions readily brol^eii
down ; over the lower portion of the lung is a cavity fliled witb a
flbrino -purulent exudate and tbe underlying lung is collapsed.
Left pleural cavity bas a few flhrous bands on the posterior sur-
face of the apex, night lung is solid throughout, of a mottled
dark-rfed to a dirty grayish color, numei'ons cavities In the upper
lobe, varying in size, tilled witb semi-fluid puruieut matter; bron-
' cbloles deeply injected, mucosa swollen and covered with a viscid
mucopurulent secretion. Jjower lobe and the posterior portion of
the upper lobe on the left side of a cyanotic red color, doughy
consistency and oozes considerable frothy bloody fluid on section.
Bronchial glands enlarged, softened uud pigmented. Heart —
Weight, 185 gms. Right side somewhat dilated ; some sclerotic
patches in tbe bodies of the mitral valves; moderate sclerosis
of tbe arteries. Liver— Weight, 1320 gms. Some constriction of
the right lobe at the junction of tbe lower and middle thirds ;
consistency somewhat softened. . I'aocreas — Weight, 85 gms.
Spleen— Weight, 130 gms. Rather firm, malpighlan bodies promi-
nent. Kidneys — Weight, left, 145 gms. ; right, 135 gms. Apices
of the pyramids pule, atriation indistinct, considerable pelvic fat.

Microscopical report : Dura swollen, thickened and engorged, more
or less iuflltrated with round cells and a layer of more or less de-
, generated leucocytes on the Inner surface. Diffuse staining and
considerable chromatolytic degeneration of the nerve cells. In-
tense vascular engorgement of the lungs with pneumonic consoli-
dation in various stages and areas of softening and abscess forma-
tion. Hyperplasia of tbe malpigliian bodies of the spleen witb
foci of round cell inflltratlon. Foci of round cell infiltration in
tlie medullary portion of the adrenals. Acute suppurative pleurisy.

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Moderate nrterlo-scleroBla. Cloudy appearance o( itii liver cells
and of the tubular epitliellum of tbe kldneyB.

Male. Age 58. Flrat admission. Reported melancholy, resaess,
sleepless, profane and intemperate. Was In the penitentiary twice.

Duration of psychosis: Two years.

Caose of death : Hypostatic pneumonia with convulsions.

Clinical report : Admitted July, 100,3, with a psychosis of mania be-
ginnig two weeks before admission. Cause unknown. Has served
several terms in the penitentiary. Was taken with convulsions,
which continued several days until death.

Pathological report; Cranial bones cancellous. Dura slightly ad-
herent, slight Increase of subdural fluid, yellowish sero-fibrinous
exudate covering the Inner surface of the riglit hemisphere with
numerous foci of haemorrbaglc estravasatlon. Diffuse opacity
of the arachnopla, some Increase of tbe subarachnoldean fluid.
Brain — Weight, 1450 gms. Surface veins distended, basal vessels
arterio-Bcletotic, localized accumulation of fluid over tbe anterior
part ot tbe right frontal lobe causing depression of the convolu-
tions of the midfroutal area. On the Inner surface of the dura
over the anterior Inferior portion of the right frontal lobe Is a
small seml-solld tumor 1 cm. in diamater, 5 mm. thick, eneap-
suled, yellowish and fattyilke. Consistency of the brain sub-
stance somewhat softened, lateral venirlclea dilated and distended
with fluid, puncta vflsculosa prominent. Lungs — Weight, left, 900
gms.; right, 1180 gms. Eight pleural cavity obliterated by firm
adhesions, except at the inferior part, Arm adhesions surrounding
the left upper lobe. Lobes adherent to each other, doughy con-
sistency, cyanotic red color, solid posteriorly ; ooze considerable
bloody fluid on section, apices nodular and more or less caseous
centrally. Bronchial mucosa swollen, softened, dark-red hi color,
covered with a grayish mucopurulent secretion and emit a foetid
odor. Bi'onchial glands enlarged and softened. Heart — Weight
335 gms. Moderate hypertrophy and considerable dilatation, mus-
cle apparently softened ; moderate sclerosis and atheromatous de-
generation of the arteries. Spleen — Weight, 90 gms. Capsule
wrinkled, trabeculae prominent. Liver— Weight, 1660 gms. Some-
what softened. Pancreas — Weight, 85 gms. Kidneys — Weight,
left, ICO gms. ; right, 140 gms. Moderately ttrm on section, glom-
eruli rather prominent, considerable pelvic fat.

Microscopical report : Extensive round eel! Inflltratlou of tbe arach-
nopla, of the perivascular spaces and along tbe plal processes ex-
tending into the brain substance, in some places completely occlud-
ing tbe lumen of the vessel. Moderate chromatolytic changes In
the nerve cells. Extensive fatty inQltration of the beart, chronic
myocarditis ; considerable arterio-sclcrosis and more or less athero-
matous degeneration. Numerous hyaline bodies In the choroid
plexus. Intense vascular engorgement, considerable perivascular
and alveolar pigmentary Inflltration, red and gray hepatization of
the lungs. Irregularity In size of tbe vesicles of the thyroid gland
with a tendency to dilatation in some and cellular Infiltration ot

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many of Oie sinnller ones. Vascular engoreemeQt of the pituitary
body. Chronic pancreatitis. Extensive diffuse interstitial uepli-
rltla, most marked subcnpsularly. Cloudy appearance of the liver

Male. Aj^ 44. First iiduilasion. Reported sleepless, secluslve, In-
temperate, very nervous and e."(pltable. incoherent and Irrational.
Has many delusions, thinks that he Is a policeman and has been
with a show. Physically and mentally weak.

Duration of psychosis; Sl.t years.

Cause of death : Cerebral haemorrhage.

Clinical report: Admitted May, 1005, with a psychosis Of maniacal
exaltation dating back six years and following a blow on the head
with a hammer. Since admission has been very active, talkative
and restless, more extensively so the afternoon preceding death.
Was found dead in bed. Father and grandfather intemperate.

Pathological report: Pupils irre^'ular and dilated; lips blanched;
general enlargement of the lymphatic glands. Cranial bones soft
and rather thin, subdural space filled with blood covering the
sides of both hemispheres, filling the anterior and middle fossae,
the Bubarac'hnoidenn space surrounding the circle of Willis, sur*
rounding the crura cerebri, the cerebellum, pons, medulla and
extending down the spinal cord, filling the ventricles. Brain —
Weight, 1350 gms. Basal vessels atheromatous ; lateral ventricles
dilated ; posterior columns of the cord gray. Heart — ^Wetght, 430
gms. Considerable hpertrophy and some dilatation, atheromatous
placques in the body of the mitral valves; extenalve arterio-
sclerosis with atheromatous degeneration and calcification and
numerous foci of ulceration. Lungs — Weight, left, 490 gms. ; right,
510 gms. Firm adheslons-on the posterior surface of the left
apex ; extensive subpieural pigmentation, nodular masses In both
apices more or less caseous on section. Bronchial glands enlarged
and deeply pigmented. A small calcareous nodule between the
tenth and eleventh rings of the trachea. Spleen — Weight, 200
gms. Capsule thickened, fairly rough. Arm on section, oozes con-
siderable blood, a small accessory spleen posteriorly 2 cm. In di-
ameter. Liver— Weight, 1580 gms. Firm on section and rather
oily In appearance. Pancreas — Weight, 110 gms. Head feels
somewhat nodular. Kidneys— Weight, left. 175 gms.; right, 165
gms. I>eep-red color, moderate quantity of pelvic fat. capsule
slightly adherent. Bladder dlsteiided with urine. Gastric mucosa
thickened, dirty grayish in color, considerable submucus ecchymo-
sls, walls thickeiied, tendency to polypoid arrangement of the mu-
cosa, particularly toward the pylorus. Slight enlargement of the
mesenteric glands.

Microscopical report : Subdural space of the cord filled with blood ;
central canal filled with proliferated epithelial cells; cerebral cap-
illaries engorged, i>erivascular and pericellular spaces prominent,
a few foci of round cell infiltration in the perivascular spaces,
slight chromatolytic changes in the nerve cells. Vascular engorge-
ment of the pituitary bodj-. Chronic pericarditis, with more or

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lees round cell luflltrntlou. Slight fatty inflltratloa of the benrt.
Extensive arterlo-sclei'osis with marked periarteritis, prolifera-
tion of the endothelial cells in the perivascular Bpacea and exten-
sive hyaline appearance of the intlma. Pulmonary capillaries en-
gorged, alveolar walls thickened, peribronchial and perivascular
pigmentary infiltration; localized areas of peribronchial cellular
consolidation and some Interstitial increase. Extensive engorge-
meot of the broDcblal glands. Intense engorgement and hyper-
plasia of the maiplghlan bodies of the spleen. Vesicular a|^>ear-
ance of the cortical cells o£ the adrenals. Vascular engorgement
and diffuse interstitial nephritis.

Male. Age 55. First admission. Reported restless, sleepless, vio-
lent and destructive, almost blind, rather deaf, wants to flght con-
stantly.

Duration of psychosis : Seven years.

Cause of death : Pulmonary tuberculosis.

Clinical report; Admitted May, 1000. Single. Insane seven years.
Was shot la the right eye. Blind, rather deaf and somewhat

Pathological report : Right eye represented by a cicatricial mass of
BhrouB tissue and imbedded in the posterior part of the orbital
ti^ue is a flattened piece of lead encapsuled by fibrous tissue.
Oedema of the right liand and both legs. Acute balanitis with a
purulent discharge from tbe urethral canal. Head asymmetrical
and cone-shai>ed, elongated occlplto-mentally ; left parietal emi-
nence much more prominent than the right, cranial bones com-
pact; inner surface of the dura covered with a thin fibrinous mem-
brane more marked on tbe right side; of a diffuse brownish color;
subdural Huld Increased ; extensive diffused opacity and increased
thickness of the araehnopla. Bralit — Weight, J310 grms. Basal
vessels considerably thickened and sclerosed ; pia adherent to
the optic nerves, commissure and tracts ; right optic nerve half
the size of the left aud grayish In color; lateral and third ven-
tricles extensively dilated ; pineal gland cystic nearly 2 cm. in
diameter. Lungs — Weight, left, 770 grms. ; right, 1700 grms. Ex-
tensive pleuritic adhesions over the right upper lobe. Extensive
diffuse nodular infiltration throughout both lungs In all stages
of degeneration and softening, with extensive irregular cavity
formation in the right upper lobe. Bronchial mucosa swollen,
softened and covered with a mucopurulent secretion. Bronchial
glands enlarged, caseous and some calcareous. Bilateral ulcera-
tion of the posterior portion of the vocal cords which also ex-
tends into the right lateral laryngeal walls. Heart — Weight, 2fi0
grms. Sclerosis of the mitral and aortic valves ; moderate athero-
matous degeneration of the arteries, the coronary vessels exten-
sively so. Spleen— Weight, 140, grms. Rather soft and oozes con-
siderable blood on section. Liver — Weight. 1400 grms. Ixiwer
margin lies at the iliac crests, tbe longitudinal fissure 3 cm. to
the left of the umbilicus. Gall-bladder lies In the median line
just above the umbilicus. Rather flnn on section, dlffuBe nut-

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meg Id color, walls of tbe gall-bludder thickened, the cystic duct
contains a brownish calculus 3-2 cm. about midway to the Juuctlon
with the hepatic duct. Pancreas — Weight, 00 grma. Rather nodu-
lar. Kidneys — Weight, left, 150 grois. ; right, 130 gnus. Pale
In color, marginal zone almost white, considerable pelvic fat.
Thlckeolng of the pyloric eod of the stomach ; on Ihe posterior
and inferior wall Is a small circular ulcer opening into an irreg-
ular suppurating cavity, surrounding the pylorus, burrowing be-
tween the muscular and suhmucus coatG. Numerous tubercular
nodules and ulcers scattered tbrough the jejunum and ileum. An
irregular absceess cavity on the left side of the rectum discharg-
ing by several sinuses.

Microscopical report : Central canal of the cord enlarged and filled
with proliferated epithelial cells. Vascular engorgement of the
cerebrum ; slight ehromatoljtic changes in the nerve cells. Ex-
tensive fatty infiltration of the right ventricle; chronic myo-
carditis; extensive arterlo-sderosis, with some atheromatous
alteratioue. Chronic pleurisy. Vascular engorgement and dif-
fuse tubercular infiltration of tbe lungs. Tubercular infiltration
of the bronchial glands, of the larynx and Intestines and stom-
ach. Extensive fatty inflitration of the liver, chronic venous con-
gestion, tubercular infiltration, periportal and peribiliary round
cell Infiltration. Intense vascular engorgement with extensive
arterio-sclerolic nephritis. Intense engorgement of the adrenals.
Vascular engorgement and hyperplasia of the malpighian iKidies
of the spleen ; chronic interstitial pancreatitis.

Female. Age 52. First admission. Reported restless, destructive,
homicidal, violent at times, threatening herself and others;
thiulis people are imposing upon her; wanders away froiu home.

Duration of psychosis ; Twenty-four years.

Cause of death : Subacute myelitis and hypostatic pneumonia.

Clluieal report: Admitted April, 1889, with a psychosis of acute
mania, begiiming eight years t>efore. Physically,, the general
health was poor for several years. About one year before death
she t>egan to have rheum a Cold-like pains affecting the left scapular
region, the trunk and the lower extremities. Ten days before
death she developed complete paraplegia with incontinence of
urine and faeces. Two days before death urine was 1010, con-
tained a large amount of albumen. One brother, one sister and one
cousin insane.

Pathological report : Bed sores over the sacrum. Greenish discol-
oration over the abdomen. Enlarged thyroid gland, the left lobe
extensively so. Intraocular tension almost goce. Cranial bones
cancellous. Some increase of subarachnoideau fiuld. Brain-
Weight, 1210 grms. General atrophy; some sclerosis of the basal
vessels. The right aide of the last cervical and the first dorsal
vertebra and the adjoining lamina and pedicles soft, pulpy and
cancellous, apparently continuous, with the posterior surface of
the thyroid gland. Spinal cord opposite this is small, deep red in
color, soft and rather pulpy, i)ecoming less so upward toward the

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medulla an<\ (lonnntrd to the lower extremity Heart — Weight
270 grills Slime fliir ild thickening of thp mitral find lortic vihes
moderate sclerosis, of the nrterlee foramen ovale patent b\ twc

small openlii(!B it the anterior part I ungs — Welglit left 34t
grms right SQO grnis Some firm pleuritic adhesions oier th<.
posterior surface of the left lung Luns« cyanotic red color
posteriorly doughy consistem^ ooze an abmidint frrthj bloodj
fluid on section Thyroid gland— Weight 160 gmis Contains a
lanse calcareous mn'S in its lower and posterior part tnd Internal
to this Is a soft pulpy mass Irregular in outline and somewhal
Infiltrating the surrounding tissues Spleen~^\ eight 250 j,rms
Soft and rather friable oozes considerable blood milplgblai
bodies fairly prominent I her — Weight 1120 grms Seyera
band like idhehltns to the diaphragm firm on section strand
of fibrous tissue eepirating the lobolea into groups of nrlous size
Pancreas — Weight '*5 gmis Firm on section Kidnejs — Weight
left 165 grnis right 145 grms Firm on seittoD pale in toloi
some haemorrhagic e-^trayasatlons beneath the pelyic submucosa
considerable peliic fat capsule tears the substance on rcmoyal
Appendix hanging almost wholh into the pelrlc cavity Ovarlef
atrophic

Mlcrostoplcil report Extensive degenerative changeK In the nervi
cells Cord at the seat it compression shows no nervous struc
ture mostlj a degenerated granulir debris The graj matter of
the cord otherwlw more or less structureless and granular « ith
considerable \ascunr engorgement White matter shows degen
eratlve changes in both directions Extensive fatty Infiltration
of the right ventride moderate chronic myocarditis some endar
terttic thickening of the aorta with capUlarv engorgement of the
capillaries of the outer coats Engorgement of the pulmonirj
vessels with rupture of some of the capillaries and filling of some
of the aheoll with blood Pionchioles filled with more or less
epithelial cell proliferation Chronic \enous congestion and
cirrhosis of the lUer Extensile diffuse nephritis Intense en
gorgement of the spleen Chronic pancreatitis Hypertrophy ol
the walls of the appendix Chronic catarrhal appendicitis The
mass In the thyroid gland and infiltrating the adjoining tissue'^
causing erosion of the vertebrae consists of a tubular arrange
ment of epithelial like cells extenslveh infiltrated with bljod ii
very vascular

Male Age 56 Second admission

Duration of ps\chfsis Tnentj-one years

Cause of death Pulmomn tuberculosis

Clinical report Admitted March 1884 nith a psychosis of recur
rent mania After admission the course w is one of graduallj
developing dementia Phjslcallv the health was good nntll Julj
1904 when cough gcncnl emaciation and gradual failure of
health supervened

Pathological report E\tremeU large thin flat ears Inequality
of the pupila the left being dilated pronounced qtcua seiiillg.

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cranial bones cancellous. Slight oimclty of tbe arachnopia. Mod-
erate Increase of the siibarachnoldean fluid. Bralu — Weight, 1310
grme. General atrophy of the convolutions; coDsiderable athero-
matous degeucration of tbe hasal vessels ; tbe right anterior and
the right posterior comniunicating are very small ; the left an-
terior cerebral divides into two branches ot almost equal size,
which are joined by the anterior communicating, after which they
continue as the two cerebrals. Two foci of softening in the left
hemisphere, Irregular in outline, situated in the white matter of
the bottom of the fissure of Rolando. Lungs— Weight, left, 580
grms. ; right, 1030 grms. Left pleural cavity obliterated by firm,
dense adhesions; the right cavity has diffuse adhesions over the
posterior surface easily broken down, and contains over 100 cc.
of seropuruient fluid. Left lung is contracted into a more or leas
solid uoncrepitant mass, with irregiilar-slzed ar^as of fluctuation ;
the pleura is extensively thickened ; the root of the lung con-
sists of a uiass of fibrous tinsue of almost cartilaginous consistency,
containing blood ^es'«l•^ and bronchi with walls extensively thick-
ened the remamder of the luni; consists of irregular cavities
ramlfled b\ the fibrous cords of blood vessels the walls of tbe
cavities are covered with a dirty gray sloughing membrane The
lobe*- of the right lung are adherent to each other [.leura thick
ened ejanoticred color posteriorli diffusely nodular throughout
the intervening tissue being doughy numerous irregular tavities
through the urper lobe containing treami purulent fiuld and
several smaller ones In tbe lower and middle lobes considerable
engorgement of the lower lobe bronchial mucosa thickened and
lumen contains a mucoi urul iit sc retion Bioncbtal glands en
larged softened nud more or less caseous Left margin of the
right lung extends to th« left margin of the sternum Heart —
Weight 250 grms \eri much enlarged and cavities all dilated
and distended with Hood some atheromatouw placques in the
bodies of tlie mitral vihes sime marginal fenestration of the
aortl \ahe? exteusne itheromitous degenerition of the arteries,
the cantids and coionaries being eitremely so Spleeu^Weight
liO grms Numerous flbDus cordlilie adhe'^ions to the diaphragm
rather flim Liver — Weight 11S5 grms Left margm extends to
the left atiilarj hue distinctly nutmeg in appearance and rather
firm Kidneys — Weight left J05 grms. right 110 grins Firm
on section pale in color Indistinct strlatlon small amount of pelvic
fat Pancreas — Weight ""5 grms Fxtenslve enlargement of the
mesenteric glands,
MkroRCoplcal report Estensne diffuse degeneration of the nerve
cells perivascular and pericellular spaces prominent central
canal of the crrd filled with cells Miderate chronic mjocarditiB
extensive arterio sclerosis of the arteries with considerable
atheromatous degeneration Diffuse tutercuHr Infiltration of the
lungs with intenise engorgement of the alveolar capill iries Tuber
cular luflltratloi) of the bronchial glands Chronic venous con

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gestfon of the liver. Rstenslre difftisc nephritis with intense en-
i^orgeinent. Tubercular Involveineut of tbe mesenteric glands.

Female. Age 51. First adiiilsBlon. Itfported furious and more or
less destructive at times. Maniacnl desire to marry one or a
number of men.

Duration of psychosis : Twenty-five yeiirs.

Cause of death : Mammary carclnomu.

Clinical rei>orI: Admitted December, 1881, with a psychosis of acute
mania beglimhif! three months iDefore admission. Physical i-'<in-
dltlon was i^ood until a mamnmry carflnonm developed on the
right side, which underwent «xteiiNive uk'eratlon and led to
general emaciation and exhaustion. Mentally was more or less
maniacal throughout.

Pathological reiwrt: General cachexia. Right arm swollen ami
oedematous ; veins on the right side distended ; fullness of tlie epis-
temal notch. On the right side of the thorax a diffusely nodular
mass with numerous foci of ulceration and sloughing over an area
from the right side of the sternum to the anterior axillary line
and from the clavicle to the seventh rib, more or leas adherent
to the underlying thoraelc walls, exposing the slith rib in the
ulpple line, inJiKrntlng more or less nil the tissues. Abdomen
prominent and tympiinitic. Sloughing bed sore over the KHcrum.
Oedema of the lower limbs. Cranial bones compact; frontal sin-
uses large; dura moderately adherent to the bones. Its inner sur-
face covered with a thin membrane-like exudate, the underfylng
surface of a yellowish-brown color and numerous foci of ecchymo-
sis; diffuse opacity of the arachnopia with more or less adher-
ence to the brain substance. B ruin— Weight, 1290 grms. Gen-
eral atrophy, some dilation of the ventricles, ependyma granular.
pineal gland cystic, pituitary body softened. Lungs — Weight, 450
grms. each. Firm pleuritic adhesions at the left base, and the
cavity contains some serous fluid ; the right pleural cavity filled
with a seto-flbtl no-purulent flocculent fluid divided Into three
compartments by dens<- liiirous band-lilte adiiesions ; pleura ex-
tensively tlilcbened and covered with a dirty grayish-yellow ex-
udate. Lobes firmly adherent to eai'h other, diffusely nodular
infiltration with more or less cavity formation. Bvonchinl walls
thickened and the lumen filled with a muco-purulent secretion.
Bronchial ghmds enlarged and cai'eated. Heart— Weight, 200
grms. Heart pushed to the left, tlie pericardium thickened and
the cavity filled with a finid similar to that In the right pleural
cavity; eplcardium thickened and covered with a grayish exudate;
muscle of a pale yellowish-red color, moderate arterlo-sclerosis.
Spleen — Weight, 05 grms. Slottled light and dark red color, mod-
erately firm. Liver — Weight, li;f5 grniH. Numerous whitish
nodules on the surface firmer in consistency tlian the intervening
substance, dlfCuseiy nodular throughout, varying In size, circum-
scribed, firm and white. I'ancreas — Weight, 95 grms. Moderately
firm. Kidneys — Weight, left, 145 grms, ; right, 145 grms. Pale

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m (olor striatloii poor in oci^isfonal email cvht capsule adher
Lilt btuiuiRli lud liite^tlneH dlRteiideil with gas gastric niucobii
thkkeued Usuries and uteius atropbk Thyroid gland eii
liirg«d and coutiilns several small white uodulcs In the rlt,ht lobt
Iimiihiitk glands ot tbe light side of tbe neck of both axtllu
of the mediastinum and of tbe retroperitonenin enlarged

Ultroflcopical rep(rt Some degeiierutne changes in the nerve cells
fci. tensive fatty luflUration ot tlie heart cbrouit myocarditis
extensive pericarditis considerable arterlo sclerosis most marked
in tbe intlnift Acute fibrino purnlent pleurliy some chroni
lileur]s> Intense tlteolar engorgmeut of tbe pulmonary caiilllaries
fibroid tblikenhiK «f the al\iolar ualle perhiiscular and i>Lrlbroii
Lliial pigmtntatioii imtuliir masses of epithelial cells mora or
less arranged into alveoli with foci of degeneration and lii'atiiii i
tion lu uiabscs of round cell infiltration Irregular size of tin.
thyroid leslcles some tendency to cjst formation mauj of tin
smallei ones Qlled nltb proliferated epithelial cells Chroiii
\euous i-ontestitu ot the llitr infiltration with uoduiar misses it
epithelial c-ells some moie or less arranged alveotarly othets
plugfeiut the portal vessels or Infiltrating the liver lobules Thkk
enlng of the capsule and hjperilasia of the maipighian bodies
of the spleen loci of round lell infiltration ind epithehal tell
collection in tbe adrenals \rterlo-9cl erotic and Interstitiii
nephritis Can er mass t^piciUj scirrhus with tendency to cyst
formation

Female Age bt> First admission

Duration of psjcbo'^is iweiitj nuit, jetrs

Huae of death Acute perii'arditis

Lhnical report Admitted April 1S87 with a psychosis of m mi i
Alter admission the inentil condition was one of gradually !»
creasing dementia rbtsitilly the health was good nhlle le
turning from the dining loom she was tiiken with a sudden it
tatk of dyspnoea rapidly became unconscious djing withni i
few minutes

I'atbological report Marked cyant»sls distension of the veins
oedema of tbe lowei limbs Firm dural adhesions some inciease
of subdural and suharichnoldeaii fluid Brain— Weight ]]2()
grnis Rasal lessela evtensively atlieiomatous arnchnopia firnil
attached to the brain substance general atrophj of the briln
Itself He irt— Weight 'VIO giins with attached vessels I'tu
cardium cont uns nlHJut Oil <-< of reddish seious fluid n itii
numerous fibrinous shredK |iei l<-ardlum reddened roughened
co\ercd vltb a fibrinous plastic c\udate gluing the surfaces U
nether L\teusive hvpertroplii and some dilatation muscle some
what softened mottled yellowish red color some sclerosis of the
mitral valves moderate sclerosis of the arteries Lungs — -Weight
left 2S5 grms right 370 gmis Both pleuril (.avitic contil i
ilfout iM It of sero fihi in< IIS fluid a ftw firm idhesions o\(i
tbe left apet I he base of the lower lobe and the tip of the
anterior inferior margin of the upper lobe on the left side col

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Inpsed and airless. Tbe posterior portion of the base of the rlgbt
lower lobe similar to the left and containe a cheesy, calcareous
Dodule 2 cm. in diameter.- In the center of the right upper lobe
Is au area of pneumonic eoiiBoiidation dark red in color. Spleen
Weight. 140 grms. Capsule thickened, maipighlan lK>dics promi-
nent. Liver — Weight, I0S5 grms. Slightly nutmeg in appearance.
I'ancreas — Weight, 110 grms. Kidneys — Weight, left, 150 gims. ;
riglit, 135 grms. , Fairly firm on section, pale In color, capsule
adheiviit, large quantity of pelvic fat. Ovaries afr<^hied.

Microscopical report ; Extensive chromatolytic changes in the nerve
cells, some perivascular round cell infiltration, involving most
of' the medium sized vessels; central canal of tbe cord fllied with
proliferated epithelial ceils. Acute fibrinous pericarditis. Exten-
sive fatty iuflltration of the right ventricle, moderate diffuse in-
terstitial myocarditis. " Tlilckening of the alveolar and vascular
walls, moderate perivascular blackish pigmentary infiltration,
some emphysema, chronic bronchitis with thickening of the walls
and peribronchial peneumonic consolidation of a tubercular char-
acter. Dilatation of many vesicles of the thyroid gland, the col-
loid content of many being more or less vesicular and many of
tbe smaller vesicles filled with proliferated epithelial cells. Con-
siderable vascular engorgement of tbe intestinal walls. Intense
engorgement and foci of dense round cell infiltration of the
medullary portion of the adrenals. Intense engorgement and
dense staining of the malpighlan bodies of the spleen. Moderate
periportal cirrhosis and chronic venous coiigestlon of the liver.
Intense engorgement, moderate diffuse interstitial and arterio-
sclerotic nephritis.

Female. Age 29. First admission. Reported Incoherent in speech
and action, flighty in ldea«, with acute maniacal psychomotor
restlessness.

Duration of psychosis : Four years.

Cause of death : Pulmonary tuberculosis.

Clinical report; Admitted May, 1002, with a psychosis of acute
mania, beginning three months liefore admission, with the above
report. The course ot the disease was one of progres^ve deteriora-
tion. On admission tliere was a discharging sinus about 1 cm.
above the center of Poupart's ligament on the right side leading
down to the iJelvlc cavity. Aiwut November, 1905, symptoms of
pulmonary tuberculosis developed, with cough, chilis, anorexia,
emaciation, coated tongue, evening temperature and pliysical mani-
festation of consolidation, dullness, crepitant rales, bronchial
breathing, increased vocal and tactile (reraitus.

Pathological report: Bed sores over the siicrum and left great
ti-ochanter. Discharging sinus above tlie center Of Poupart's liga-
ment on the right side leading downward over the pelvic brim Into
the pelvic cavity. An old operation scar 4 cm. long 4 cm. above
and running panillol with Poupart's ligament. Moderate oedema
of the lower limbs. Brain — Weight, 1340 grins. Lungs — Weight,
left, 700 grms. ; right, 1040 grms. Both pleural cavities obliterated

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by dense, firm adhesions. Pleura thickened, lobes adherent, dif-
fusely aad irregularly nodular throughout, mottled gray to light
and dark red color, diftuse foci of softening and abscess foriuatlou,
varying in size and shape with irregular cavity formation,
doughy consistency of the Internodular portiun. Bronchial mucosa
softened and svvoiieu and the lumen contains a muco-puruleut
secretion. Hroncbiat glands enlarged, pigmented and caseated.
Thyroid gland small and nodular. Omentum adherent to the an-
terior pelvic wall from the posterior surface of the bladder near
the apex to tiie pelvic brim, rectum and uterus drawn over to the
right half of the pelvic cavity and IJrmly bound by a mass of ad-
hesions fllling the whole pelvic cavity. The left tube and ovary
are iiubedded In a cyst-like mass. The sinus on the right side
divides Into two branches, the anterior passing down to the
posterior surface of the bladder into a supiHiratIng cavity and
opens into the bladder just above the trigone. The posterior
branch runs between the tayei-s of the broad ligament where it
terminates in an irregular abscess cavity. There is a cystic-like
mass in the parovarium. Both tubes are dilated and contain a
pumleut-looking Buid. The ovary is slightly cystic. The bladder
mucosa is swollen, thickened and softened, the posterior wall is
perforated by an Irregular opening and the surrounding portion
Is acutely Inflamed. Spleen — Weight, 240 grms. Rather soft,
oozes considerable blood, an Infarct on the posterior margin.
Liver — Weight, 1525 grms. Firm, band-like adhesions to the
diaphragm, firm on section, capsule thickened, strands of fibrous
tissue running through its substance. Pancreas — Weight, 115
grms. Kidneys — Weight, left, 100 grms, ; right, 125 grms. Pale
in color, capsule adherent and tears the kidney substance on re-
moval. Appendix lying on the pelvic brim. Its terminal 2 cm.
dilated and filled with a ci-eamy fluid.

Microscopical report; Moderate degenerative changes in the nerve
cells, perivascular and pericellular spaces prominent, pituitary
body conslderahly engorged. Atrophy of the cardiac muscle, some
perivascular fibrous tissue increase, uioderate arterio-scierotic
changes. Moderate arterlo-sclerosls. Intense engorgement of the
alveolar capillaries, with rupture of some, filling the surrounding
vesicles with blood, foci and masses of tubercular consolidation
In various stages of degeneration In the lungs. Estensive pig-
mentation and tubercular infiltration of the bronchial glands.
Moderate chronic pancreatitis. Engorgement of the spleen, mal-
pighlan bodies sniaii, relative Increase of trabecular tissue. Ex-
tensive venous congestion, fatty Infiltration of the periphery of
the lobules, considerable periportal cirrhosis and foci of round
cell infiltration of the liver. Also diffuse tubercular Inflltratlon In
various stages of degeneration. Chronic Interstitial nephritis.

Female. Age 85, First admission.

Duration of psychosis: Ten or more years.

Cause of death ; Chronic myocarditis.

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Cltufcal report: Admitted September, 1896, with a psyehoBls o(
chronic munii). After admission she wns at times ooisy and
violent, gradually undergoing a progressive dementia. Physically
Uer health was fairly good at first, but later had attacks of
dyspnoea, cardiac failure and exhaustion, I>eath occurred sud-
denly with apparent collapse.

Pathological report; Intense cyanosis. Prominent arcus senllla.
Lessened Intraocular tension. Oedema of the lower limbs. Cranial
bones cancellous, osteophytie outgrowths on the inner surface of
the frontal bones ; dura thickened and flrmly adherent to the
bones and moderately ao to the arachnopla ; some increase of
subdural flnld ; moderate opacity of the arachnopia. Brain —
Weight, 1300 grms. Extensive atheromatous degeneration of the
basal vessels, with Irregularity in size, 'ihrombotic closure of the
left middle cerebral at its commencement with soCteiiing of the
area supplied by it. Lungs— Weight, left, 490 gi-ina. ; right, 540
gnus. Costal cartilages of the third, fourth and fifth ribs abnor-
mally prominent, more ao on the left side. Firm adhesions be-
tween the left lung and the pericardium. Lower lobes and the
posterior portion of the upper lobes cyanotlc-red color, doughy
consistency, oo'i^e an abundant, frothy, bloody fluid on section, the
right side moi-e extensively than the left. Heart — Weight, 240
grms. Fibroid nodular thiekeulng of the margin of the mitral '
valves with some atheromatous deposition in the body of the
valves. Chordae thickened and shortened. Aortic valves thick-
ened with calcareous deposit In the bases. Considerable epicardial
fat. General dilatrttlou of the aorta, extRUSive atheromatous degen-
eration of the arteries, the coronary, carotids and the vertebrals
extremely so. Thyroid gland — Weight, 50 grms. Right lobe con-
siderably enlarged, somewhat cystic and contains a firm, flesh-
colored, encapsuled nodule. Firm perihepatic and perisplenic
adhesions. Cyanotic red color of the ileum, caecum and sigmoid
colon ; walls soft and oedematous. Appendix hanging wholly
into tlie pelvic cavity. Spleen— Weight, 190 gnns. A whitish
patch of cartilaginous consistency of irregular outline varying in
thickness from 1 to 3 cm. on the dorsal surface ; malpighian bodies
prominent. Liver — Weight, 950 grms. Firm on sectlo^i, rough
appearance of the surface. Gall-bladder represented by a cicatri-
cial mass of fibrous tissue and flrmly adherent' to the surrounding
tissue. Pancreas — Weight, 100 grms. More or less nodutat and
occupied by fatty tissue. Ifidneys — Weight, 150 grms each. Firmly
adherent to the perirenal fat, firm on section, pale In color, strla-
tion indistinct, considerable pelvic fat, capsule more or less ad-
herent leaving a rough surface, a number of cortical cysts. Blad-
der distended wltii urine. Ovaries atrojihled. General enlarge-
ment of the mesenteric glands.

Mlcropscoplcal re|X>rt : Some degenerative changes of the nerve
cells ;■ vascular engorgement and some perivascular round cell
infiltration. Moderate fatty infiltration of the heart and con-
siderable perivascular fibrous tissue increase. Bxtenalve prollfera-

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tlon of the intlma, thickenlog of (he media flnd adventitla, with

considerable atheromatous degeueratiou and focal iuflltratiou <if
round cells in the outer coats. Extensive fibrous tissue increase
iu the thyroid ghiud, at places almost homogenous in appearance,
due to masses of hyaiine-like material eontainlue collections of
epitbellat cells, some places formlofi; apparent nests, at others
arranged into tubules or alveoli, the cells appearing fragmentary
and staining deeply, many cyst-fike spaces containing no colloid
material, at places the tissues appearing more or less oedematous.
Chronic Qbrold thickening of the pleura. Intense engorgement
of the alveolar oapillarieB with rupture of some, filling the sur-
rounding vesicles with blood ; some alveoli filled with leucocytes
and proliferated epithelial celts. Considerable subpleural blaclfish
pigraeotury infiltration ; extensive thickening of the blood vessel
walls. Hyperplasia of the lymph follicles of the bronchial gland
with considerable pigmentary inaitratioD, Fibroid thlekeuiiig of
the adrenal capsule with foci of round cell Infiltration lit the
medullary portion. Spleenic capsule thickeiied by dense fibrous
tissue formation, malplghian bodies prominent, some increase of
splenic corpuscles. Moderate engorgement of the liver wltli e.'i-
tensive cirrliosis, foci of round cell collections and some prolifera-
tion of the bile ducts. Capsule of the kidney thickened, extensive
diffuse interstitial nephritis, with foci oE dense round cell collec-
tions and extensive tubular and glomerular changes. Walls of
the renal cysts consist of dense fibrous tissue outside of which
Ib a zone of dense round cell collection; blood vessels thickened
and engorged.

Male. Age f>8. First admission. Reported weak-minded, morally
bad and Intemperate, indolent, preaching, singing, flghtitig and
attacking those about him.

Duration of psychosis Seventeen ^ears

Cause of death Pulmonary oeilema

Clmi(.al report \dmitted October 1810 with a r'-vehoois of sub
acute mania t}^inning some time in IbSa His pievious lite wd'-
more or less thtt of a tramp dirtv filthy indolent weak minded
Immoral Intemper ite spending his time wandering about the
country bometlmes flshlug After admission there nas a rapid
disappearance of the iioknce and uoisineas, hallucinations of
sight and hearing developed but he became quiet and he worked
considerably about the wards His ph\sical health was good
until about ten days before death when a carbuncle developed
on the haik of the neck but he did not complain of anything else
On the morning of his dodth he complained of heln^ skk and of
dyspnoea when he arose for breakfast Immediately theieifter
he returned to l)ed The dyspnoea bectme extreme lud he l>t
came restless persplied fieely rolliug and tossing about until
death

I'lthologi ^1 report Well maiked anus senilis rrothj fluid esc ip
iiig from the mouth A dee(. ul er m the posterior inferior cervi
cal region with edges uuderiulned and ragged tuatglns indurated

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lurfitc si ngliiiig iiirt Weedhic 'r nHI I oms tlii k iiml cnn
letlons iniro finiiti ullieient to tlic boues l.'iteuslie diffuw
opiicltj aud iiicrciiwd tliickiioRS of the araclinopia In rease of
subduml nnd RularntbDoldeau fluid Brain — Weight 1350 griub
General atrophj of tlie i-ou\olutioiis Lxtenslie ntheroma of the
I nsnl arteries Numenus foci of &oftenlng senttered over the
cortex and throughout the '.ul)stance Choroid plexus Lvstic
lloor of the fourth (entrkle grauulnr Heart— Weight 4oO
giras F\teiiBiveiy bjpertrophled Fitrold tiiickening of the
iiian<ins iiid atherouiatons lutcheR in the Iwdy of the mitral
iiil> es f \teiisi\ e si leroslM f the aortic i aU es witb a en!
Miieous plate iii tlie bine of tiie posterior cii'p I \.t<iislve atlieri
mut< US dcguier ilion of tbe aorta with numerous foci of ulcera
tion tbe oiiHi-eB of tlie coronnrj arteries tieing almost oc-cluded
Dilatation of tbe commen emeut of the left orotid Lungs —
Welglit left l(ro gill" right 1000 grins Lohes idiierent on the
rigbt side dougliy (ousisteucj oo/e a large quantity of frothy
fluid on ».ection Bronihi trachea and larjnx filled wItb frothy
fluid Bronchial gland eiilirged md pigmented Thyroid glaud
— Weight 110 grins Generally enlarjied Colloid material prowi
iitnt In the right lolie is a circumscribed whitish mass c\st
like in appearince and more or lest infiltrated with caicareon
material Spleen— W eight 275 srm« Rather soft and friable
oozes tonsiderable 1 lood on section malplgbian bodiesi prominent
I iver — Weight 410 griiis Large radiating scat ' n the dorsum
flrui on section dull red In color lohules Indistinct numeious
strands of fibrous tissue Pancreas — Weight 340 grnis Kldnejs
—Weight left JiH) grms right 210 grms i irmly attached t
the iieriient! tissue Hnn on section deep red in i-olor considerable
pelvic fat caiisule 'itrips readilj Bladder walls thickened and
full of urmc the urine containing sugar Gastric mucosa thick
ened and gianular looliiiig and cwicred nith a thick mucoid
secietion lymphatic glanU throughout the body enlarged
Microscopical report Pxtensive chroniatoh tie cbinges in the iiene
cells walls of tbe blood vessels e^tensiveiv thickened consider
able vascular engor)!;eineut diffuse foci of round cell infiltration
points of Mtlero^is irolifetation of tbe ependymai cells Chronic
interstitial mjo< irdi Is ExteiiBisie endarteritic proliferation of
the iutini I Mtth more or less atheromatous d^eneratlon fxl
of round cell infiltration in the middle and outer coats Lmph\
"etna and moderate |ulm)nar\ fibroid increase proliferatl n of
the broncbiil muc s i and considerable peribronchial and perl
1 as( ular blackish pigmentarj Inflltration Hi perplasia of the
hmpta follicles of the bronihial glands nith consideriLle pit,
mentarv iiiftltiatiou Numerous concentric hjaliae and calcareous
bodies in the pineal gl ind with intense engorgement and some
fibrous tissue increase Hiffuee interstitial fibrous tissue increase
ill the tbir id gland numeioui foci of rrund cell coliectioni ex
tci-i\e 111 t ition I f Si II e of the iCM Ics «itb M)me of the smaller
ones filled with jroiiferated epitiielnl cells Hyperplasia of the

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lymph follicles of the Intestines. Intense engorgment nnd foci
of round cell infiltration of the adrenals. Intense enporgemi'iit
Of the spleeii, ilifCuse incrense of splenic corpusetes, the malpighinu
bodies small nnd ataln deeply. Extensive engorgemeni oE the
liver with considerable cirrhosis and round cell Infiltration, the
protoplasm of the liver cells cloudy and vacuohited. Extensive
diffuse nephritis at places forming dense nias-sefi of fibrous tissue,
at others more cellular, most of the glomeruli move or lees fibroid,
many whorl-llke. cyst-like dilatation of h-ome of the tubules, the
epithelium In one being more or less granular, walls of the hloort
vessels thickened, extensive engorgement.

RE< UIIREM M\NIA

Male, Age 55. Second admission Reported uolsy, quarrelsome,
Sleepless, violent toward the Eimlly

Duration of [sichosis Ihlrteen months

Cause of death Intestinal volvulus

Clinical report idmitted October ) >U4 i& a recuireut m\nn
Married Octupatlon unknown Onset one month bef )rL adnns
Blon talkative gesticulating wildly violent tow ird the familj

Pathological report Mirked general cyanosis Abdomen distended
and tjmpHmtlc Liver dullness otllterated CraniJl Ixmes thin
and hard Duru slightly adherent to the bones Arachnopia
diffusely opajue Aloderate Imrense f suharaclmoide'm fluid
Bralu — Wtlj,bt ]Si<i grms ModeiateU firm Lungs — Weight
left 440 grms rifeht 4Sft grms 1; irm pleuritic adhesions over the
outer and i ostcrlor burface of tbe lower rigbt lobe Extensive
subpleural blaikish pigmentation Lungs of a light graj coltr
doughy In consistency ooze considerable trotliy fluid on section
anterior tno thirds of the right middle lol e collapsed and air

less Bronchial gland sllghth enl irged Heart- — W eight

Hjpertrophled stme atheromatous pluques in the body of the
mitral valves md the bases of the aortic ^aUes Moderate sclero
Bis of the arteries with onslderible itberomatous degeneration
Peritoneal cavity contains seieral hundred cc of thm blool^
fluid Intestine distended with t,as Jejunum ileum cie hi i
ascending and ttanstorse colon lying under the right costal carti
lij,es and ribs being torn from their attichments the ascendin„
cilou under the diaphragm then down behind the coils of smalt
Intestine Into the pehlc cuttj then up to the duodenojejunal
Junction where a twist exists between the two obstructing both
The whole of the distended bowel Is dirk red in color almost
black the wills thinned and softened ei^ilv lacerated and th<
lumen contains a grumous blood> semi fluid material Spleen
— Weight, 130 grms Capsule thickened and roughened consid
erable subcapsular ecch^nusls moderttcly firm Llver^ — Weight
12(iO grms Somewhat nutnieg In appearance Kidneys — Weight
left IW grms n^ht l^.'i gnns Modernteh firm pale in color
strlation poorly marked ^ety little pelvic fat, cut surface has a

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granular look and feel. Pancreas— Weight, 100 grme. Slight
atrophy of the right testit-le.

Microscopical report ; Doffuse staining and extensive degenerative
changes in the nerve cells. Chronic myocarditis, most marked
about the perivasc-ular spaces. Numerous hyaline bodies Id the
choroid plexus. Chronic pancreatitis. Diffuse glomerulai- and
interstitial nephritis. Vesicular staining o( the fasciculate zone
of the adrenals. Eugorgemetit of the gastric walls with hyper-
plasia of the lymph follicles.

Male. Age C5. Fourth aduiisslon. Ileporfed excitable, sleepless.
Incoherent, violent, destroying his clothing, dancing, singing,
swearing; homicidal, requiring restraint.

Duration ot pwycliosls ■ Five years

Cause of death Acute malignant endocarditis

Clinical report Admitted March 1001 With a psjthosis of a<ute
mania beginning one month before admission After admission
he w as very noisj and extifed wttb Intense p^^cho motor activity
requiring restnimt div and night Physically his heilth was
good until a month before deith Toward the latter part of No-
vember JOOT he bec^lne >erj quiet sat bj the radiator most of
the time couiplamed of pain on the left side of the chest of
dvspuoea and cough \\ it married Fainter by otcupation Had
cataract In bi>th eje-- Cja\e a history of svphllli and several at
tatks of gonorrhoea

PatbologiLal reiKrt Pupllb dllaled < ataiact In both e\es Cranial
bones hard DurT firmly adherent Increase of subdural and
subarachnoidenn fluid Slight opa* i{3 jf the iraclinopia Some
Increase of subdural and subaiaihnoidcan fluid Brain — Weight
1J60 grms General atrophy of the comolutlons Lateral ven
tricles dilated fhoroid piexu's cystic and the right contains a
eakareoui plate 10 5 1 mm Heart Weight TOO grms with at
tacbed pericardium I'erkardlum flrmly adherent throughout,
heart dilited and b\pertrophied sclerosis ot the mitral and aortic
valves with atheromatouH p^tches in the bod> of the mltraK
Co*eiing the apical half of the inner isHiface of the left ventiicle
is a ia^er of fibrin flesh-colored and more or less adherent the
underlying muscle subftance Is (ellowUh \\lth a llbroid biels
the surfate of a deep red color rough and granular looking
Muscle generally Is yellowlih and softened Aortd. uniformly
dilated Extensive arteriosclerosis of the irteri^ and athero-
matous degeneration and calcareous inliltratlon Lungs — Weight
left 550 grms right SOO erms Both pleural civities contain
about 1500 11 of serous fluid and i few scattered adhesions on
the left side Pleura thickened lobea adherent doughy con
slstenn pit on pressure oo7e considerable frothy fluid on sec
tlon Bronthnl niucosi tongested and the lumen filled with a
frothy fluid Bronchi il glands enhrged and pigmented 'Ipleen
— Weight I'O grms rip<:ule thickened the greater part of the
dorsal «uifice consisting of j white hard cartilaginous mass
Splenic substance firm ou section Liver — Weight, 1330 crms

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tiisulf thl<Keiic<1 ml illiirtnt lo the dliphrnfrm distinctlj nut
niei. ru a||< luin c ii < tliii Kidiitv* — Weight left 1(1 griiis
rl^ht 14) grmB I^lrn on settl in stiiitiou indistinct sniill
iiujintitj of pelvic fat Fancreis — Weight 00 grins Appei (li\
hanRiiig into tlie pehl<. cnvit*
Microscopicjil report Moderate degenerutl\e tlianges iu the nerM
celiB t,entral canal of tliL cord filled with proliferated epitheli I
cells and tlie centra) gelatinous sul stau e infiltrated Viith theui
E\tensl\e subacute perkarditlh Acute mjocarditis Atute nia
llgnant ulcerative endocarditis. F\teasiie arterio-BtleroBls with
atheroniiitous degeuetatlou iind <■ Icnreoua Infiltration (onskl
irable I'ellulnr Infiltiatlon of the snnllei xeskies of tlie thyroid
gland Buiplivenia (apillaii cngoigenient and oedenii of the
lungs Intense engoi^eincnt and increase of fibrou<! tissue in tlic
pituitary Ixidy Fxtensive fibroid tlikkenlng of the i ii>sule of tliL
bpleen nith cun^ideralle engorgement hvperplasla of the malj ig
hian bodies ind iplenlc pulp cells Intense engorgement of tlie
liver n ith foci of no rosis and some tirrliosis Modente diffuse
nephritis,

cpiLEPaic i\svMi"r

1 eniale \ge 4_ I irst adniif-slou

Duration of its\cho&is Seventeen luotitlis

Cause of deatb Vitus eplleitlcun

( llnlcal report Admitted Bebruary 1002 with a probible pHjtbo=is
of I uresis There was noted a | aralvtic (.-onditl m general tremor
dementi I and ejikptoid sei^uies I here were frequent periods
of evaltatlon In Isei teinbei ]0()1 convulsions occurred imol*
Ing the left side of the head neck arm and thorat with aoinc
twitching of the o[ poslte aide These recurred at Intervals Dt
from two to foui minutes with varying intensity The following
day the respirations became irregular pulse rapid and weik
slight use of temperature e\eB deviating to the right pupils ui
iquai imd Irregnl ir conjmictha injected lower left limb semj
fie\ed alight oedema of the lower limbs urine negative gradnallv
increasing coma ind rise of temperature

1 athological report Bed sore over the right trochanter Oedema
of the loner limbs ( raniaJ bones thickened forming Irregular
ridges and projecting on the Innet surface of the frontal bones
Dura fitnily adherent over the frontal and parietal bones Diffuse
irregular opacltv and inei eased thickness of the arachnopla
Con&lderable In -rease of subdural and subarachnoldfiftn fluid
Brain — Weight 1250 grms loci of haemorrhage ler the frontal
nnd p irietal lobes pia hrmly attached to the brnm substance
Heart — Weight 240 ginis (^ onsi leral le epicardlal fat ■Vegeti
tions on the auricular surfa<e of the inner mitral valve Slight
sclerosis of the aortic values Heart muscle tlabb\ Moderate
sclcrosl*" of the nrterips the coronary orifices extenslvelj In
lohed lungs — Weight left 420 grms right 5tjO grms Cva
notic red color and doughy consistency posteriorly irregular areas

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more or less solidlHed scatterocl through the suhstance, cheeay
nodule in the right apex, dllatiitiiin of suiiic of tlie lohules. Bron-
chial niut'oi^a c-oiitcested. Broix-liliil ghmdH eiilnrKed and pig-
mented. Spleen — Weight. IK) gruiN. Firm on tHH'tlon. unilpighian
bodies (IiKti!ii.-t. Iilvcr — Weight, !)S() gnus. Distinctly nutmeg In
apiiearuni-e. Kidneys — Wiilgbt, left, 110 grms. ; right, 100 grms.
Strintiou iKXirly marked ; some pelvic ful. capsule Mtrljiping

Microstopii-al report; Extpuslvt' degenemtlve chnngi'S in the nervt-
cells. Extensive fntty degeneriitlon of the lifiirt with some fiittj'
degeneration of the mus<'le heucatli the eudocardium. Engorge-
ment of tlic pulnionury capillaries with rupture of some, filling the
vesicles with blood, ethers ttiie<l with leucoi'.vteK and proliferated
epithelial cells. iSome pulmonary emphysema. I>aren<^liyuiatous
hyperplasia of the thyroid with Increased vascularitj'. Fatty in-
flltratlou and engorgement of the liver. .Uelatlve trabecular in-
crease of the spleen. VeKiculjir iipiiearant-e of Ihe cortical cells
of the adrenals. Engorgement and considerable arterlo-sderottc
nephritis.

Female. Age 44. First admission.

JJuration of psychosis: Two and one-liaif years.

Cause of death : Asphyxia during convulsions.

Clinical reiK>rt: Admitted October, 1001, with a psyclioals of epi-
leptic maniii, beginning thirteen montlis l)«fotv iidniisslon. She
set the house on (ire; failed to recogniae tlie family; imagined
that everyone was mistreating and making fuu of her ; was abiior-
niaily interested in street gossip. Was found tying dead on the
Hoor beside the i>ed. Father and two uncles Intemtierate. Mother
and one cousin Insane. One i.-ouHln epileptic. One brother tuber-
cular. I'atlent was a prostitute.

Pathological rei>ort: Several bruises albout the head and face, nltli
extravasation beneath the skin ; blood in l>oth nostrils ; fracture
of the nasal cartilages. Pupils unequal. Marke<l t-yaiiosiM.
Cranial bones compact. Brain — Weight, l^iiT) grms. Ini-rease of
HulMJural and subarachnoidal n fluid. Pituitary iwdy enlarged.
Luugs — Weiglit, left, ;140 grnis. ; right, 450 grms. Extensive
pleuritic adhesions bilaterally. I'osterioriy the lungs are of a
cyanotlc-red color and of a dougliy consistency ; lolies adherent,
several (nilcareous nodules in the left apex : some dilutntion of
the marginal lobules, doughy portion oozes ciinsidoral>le frothy,
bloody tluld on se<-tion. Itronchinl glands enlarged auii pigmented.
Heart — Weiglit, 25)1) grma. Considornble e|)icardiai fat. some en-
largement due to dilatation ot ail of the cavities. Motleratc arterio-
sclerosis of the larger arteries. Spleen — Weiglit, 12-" grms. Mal-
pighian IhmIIch distinct. Pancreas— Weigh 1. UN) gr:ns. .Vdrenals
— Weight, 20 grnis. eacli. Medullary jicirtlon Ivniken down and
pulpy. Kidneys— -Weight, left, l.'tO grins.; right. i;iO gnns. Firm
on section, ookc ccaisiilcrable IiIihhI. cii|>siile adherent. IJver—
Weight, V2'Ti gi'ms. OoKes omslilerable lilood on section. Itntlier
nutmeg in appearance. Bight tui)u and ()vary iyiiig in tlie rigtit

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tllac fosaa behind tbe caecum. Small cyst Id the right parovariunl.
Utertoe endometrium covered with viscid mucopurulent secretion,
the mucosa thickened, a small interstitial fibroid in tlie posterior
wall.

Microscopical report ; Moderate degenerative fhangea In the nerre
cells. Slight fatty inHltratlon of the heart. Moderate arterio-
sclerosis. Intense engorgement of the pulmonary capillaries with
rupture of some and consequent filling of tbe adjoiuing vesicles ;
in other portions more or less emphysematous dilatation of the
vesicles. Intense engorgement of the spleen. Intense engorgement
of the liver with some fatty infiltration. Extensive chronic In-
terstitial nephritis. Acute eudometrltis.

Female. Age 41. Second admission. Reported abusive, quarrel-
some, profane, with periods of excitement and outbreaks of vio-
lence. More or less delusions.

Duration of psychosis ; Seven and one-half years.

Cause of death ; Carcinoma of the uterus.

Clinical report : Admitted September, 1897, with a psychosis of
epileptic mania. Discharged February, 1898, as improved. Re-
admitted March, 1899, and reported as liaving convulsions, mostly
of the petit mal type, at which times slie had mental disturbances
as above. Physical examination September, 1003, following a
history of profuse uterine liaemorrhage, disclosed a large, soft
mass filling the vaginal canal posteriorly, easily laeerable, bleeding
readily and extending into tbe uterine cavity, Infiltratiug the
vagSnnl walls, more or less adherent to the surrounding struc-
tures. Uterus enlarged and fixed. Inguinal and pelvic lymphatic
glands enlarged. General cachexia.

Pathological report: Extreme emaciation. Cranial bomfls com-
pact ; numerous bony outgrowths on the inner surface of the
frontal, parietal and upper surface of the petrous portion of tbe
temporals. Slight opacity, of the arachnopia, some Increase of
subarachnoldean and subdural fluid. Brain— Weight, 1200 grms.
Lungs — Weight, left, ItiO grms. ; right, 350 grms. Moderate dif-
fuse pleuritic adhesions iiilatcrally. Lobes of the lunga adherent
to each otjier. Slight hypostasis of the right lung. Heart —
Weight, 180 grms. Slight oedema of the right anterior ventricular
wall. Thyroid gland slightly enlarged. Spleen — Weight, IIX)
grms. Kidneys — Weight, left, IfiO grms, ; right, 80 grms. Left
pale in color, slight amount of pelvic fat. Right pelvis and uretef
dilated and distended with opaque fluid, cortex and medulla
thinned, striation indistinct, pale in color. Liver— Weight, 1040
grms. Small, whitish nodule in the dorsum of the right lobe.
Gall-bladder contains one caJcu'us, dark-brown iu color, 1 cm. In
diameter. Pancreas — Weight, 50 grms. Stomach diluted. Uterus
enlarged, contains a large cauU flower-like mass filling the cavity
and Infiltrating the walls of the uterus Itself, the cervix, vagina
and surrounding pelvic structures, obstructing the right ureter.
Secondary Infiltration of the pelvic, inguinal, retroperitoneal and
axillary lymphatic glands.

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Microscopic report; Extensive degenerative changes Id the oerve
cells. Chronic pleuritic thickening. Fibroid thickening of some
of the alveolar walls, others dilated and walls thinned. Chronic
venous congestion of the Itver, with localized carcinomatous Infil-
tration. Caret noma tous Infiltration of the adrenals and of the
lymphatic gland. Estensive diffuse nephritis with the parenchy-
matous changes predominating. The uterine mass made up of
epithelial cells arranged more or less into alveoli.

Female. Age 44. First admission. Reported as having periods of
violence followed by stupor.

Duration of pskthosis Nine and one-hilf months

Cauie of death Status epllepticua

(.llnltal report Admitted with a psychosis of chronic melancholia
Has hid epilepti attaiks tt inegular intervals Appears to be
well nt times \t others she Is violent and these ilolent periods
are followed bv a stuiKirous condition Thire was evidence that
She had had a convulsion during the night which was followed bv
the usual stupor H'ld another the followmg da\ after dinner
from which she passed into coma and died during the afternoon
Mother and uncle insane Patient had had in opeiatlon (or the
relief of ovarian trouble

Pathological report Extensiie cvanosl" Operation ecar In the
median tine of the abdomen between the umbllicns and pnbes
Brain surface dry convolutions flattened right olfactory bulb
and tract small gray and atrophic a small reddish nodule at
tached to the right optic nerve of rather firm couslsteniv and
hohiogeneouR (ontlnuous with a similar mass extending back
along the bt^e of the Sylvian fissure apparently continuous with
the posterior portion of the frontal lobe structure on the right
side of the interiieduncular space grayish and atrophic floor of
the third ventricle bulges is thin and some wh it trinsparent On
the left Bide a whitish spherical mass projects out from the frontal
lobe and extends backward about 4 cm Heart — Weight 315
grms Concentric ^^pe^trcphJ slight sderosls of the mitral
valves moderate arterlo si lerosls I uiigs — « eight left 460
grms right 430 grms Pleuritic adhesions throughout the right
cavity and at the bas-e of the left cavlt\ Pleura on the outer
surface of the right lower lobe densely cartilaginous and infil
trated n ith calcareous matter lobes adherent Irregular areas
more or less dark red in color and solid oozing considerable
bloody fluid on se*tion Bronchial glands enlarged deeply pig
metited and some more or less caseouH Omentum firmly adherent
to the peUk structures pelvic Irlm and to tbe small intestines
Iving In the pelvic cavity Spleen — Weight ISO grms Soft and
very friable liver — Weight ]4'<0 grms Firm adhesions to the
..diaphrngm capsule thickened pile color on section somewhat
softer than normal Kidnevs — W eighf left 160 grms right 165
grms Dark red In color Pancreas — Weight 130 grms Medul
larj portion of the adrcmls softened 0\arles and tubes absent,

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General eiilnrgement of the mesenterie glnndn wtth more or less

MUroscoiucnl rei>ort fonBiderahle fntti inflltratl< ii of the heart
Moderate iirterlosilerosls nifh •time atheromatous <leReneratioii
of tlie arteries Intenwe engorsetnent of the pulmonary avHlI
vklth rupture of some nith lllllnii: uf the adjolnlnf: veilcleH wilh
hloiHl Mtiiie \eBicIes tlltiitett nml nalEi tlilntie<l H^perpliitln iif
the iMiiph foliides of the broii<liUil aii<1 iiietH ntei k Ktniuls nitli
more or le^s cascntion Intuao engorsen ent of all the nth r
organ R

Male Age 17 1 irst admission Reported nolfc,\ rtiitructlie talki
tl\e Kith Veligious delusloiii

Duration of psychosis : Two yearn.

Cause of death ; Jjotiar pneumonia.

Cilnienl reimrt: Admitted with a psycliosis of religlims mauia Iw-
ginning several weeks before as above. When having tlie con-
vulsions did not seem to know anytlilnR. Never tiecame violent.
In the Intervals was a model patient. Was confined to l>ed only a
couple of days, complaining of jwiin over the liver. Was single.
Had epilepsy fifteen years.

Pathological report: Cranial bonca liard and thick. Brain — Weight.
V.ilO gnns. Lungs — Weight, left, r.25 grma. : right, 1810 grms.
Firm adhesions throughout the right pleural cavity and at the
base of the left. Left slight doughy eonslstoncy, ooze considerable
frothy, bloody fluid on section, lllght has a sero-flbrinous exudate
on the surface, pleura is red and granular looking; lung Is solid
tUtougbout. grayish color, mottled with more or less reddish
areas, granular appearance. Heart — Weight, 330 grnis. Consid-
erable hypertrophy. Moderate arteriosclerosis of the arteries.
Bronchial glands enlarged and deeply pigmented. Spleen — Weight.
155 grms. Soft and congested -looking. Liver — Weight, IfKiO grms.
Kather soft in consistency. Kidneys— Weight, left, 2G0 grms.;
right, 250 grms. Pale hi color, soft in consistency, strlatloii In-
distinct, capsule stripping readily ; considerable pelvic fat.

Microscopical report ; Gray hepatization of the right lung ; en-
gorgement of tlie left. Moderate endarteritis. Cloudy swelling
of the liver. Slight interstitial increase In the kidney, with foci
of round cell collections, more or less cloudy ; swelling of th»
tubular epithelium.

Female. .\ge 4;i. First admission

Duration of psycliosis Ten and one half jears

Cause of death ; Epileptic statu'^

Clinical report: Onset of mentil disturbmie ihout sin \eirs Ix
fore admission Imagined thnt ''he talked with God that shi
siiw her children in heivcii that she «hook hands with iwrstms
not present, cried one moment and laughed the ne\t Has had
epileptic convulsions oier ten lears At times became violent
Wanders about half-clad Threatens suicide and bomuide

Pathological reiioit I.eft leg snolhn pitting consideratiU on pres
sure, oozes an abundant vellonish naten fluid on section sub

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' tIsHiie liifiltnited with this (■\iiiJatc. Iiiguuiiil irlniiils
enlargetl. t'niiiial Ixinps tliickeiicd unci dPiiwe. Diii'n tliii*kt'tieii
and sllKbtly adlierent. Diffuse opiii'ity of tlio uracil iii>i)i a -lunter.
Large quuntity <jC subarachuoldean Huld. Brain— Weight, 1215
gpms. Marked depression and atrophy of the c-onvolutions on the
posterior surface of the left superior frontal hilie, it tew haemor-
rhnglc extra vasntloDS over the left temporo-spheiioldal convolu-
tion, ependyina of the fourth ventrk-le granutnr. Luugs — Weight,
left, 300 griUR. ; right. 470 j^riiiii. Firm pleuritic iidliesioiiB In l>oth
cavities. Lobes adherent to CJicli other, scattered foei of sub-
pleural ecchynioses, some oedenia and scattered patches of (."oii-
aolldfttion throughout both luugw. Heart — Weight, 270 grnis. I'eri-
cardium adherent to the margin of the right luug. Considerable
epicardial fat, slight BcleroslH of Ihe mitral valves, Konie hyi>er-
trophy, moderate arterlo-solerosis of the arteries. Bronchial
glands enlarged and dee|)ly pigmented. Omentum adherent to the
left broad ligament and to the iieritoueuin. Spleen^ — Weight, IIM)
grms. Oozes considerable blood ou section. Malplghlan bodies
prominent. Liver — ^Weigbt, 1370 grms. Numerous fibrous cord-
like adhesions to the dlaphragii), some constriction across the
center of both lobes, small whitish foci scattereil through Its sub-
stance. Kidneys — Weight, 150 grms. each. Dark red on section,
the pyramids more so than the cortex; considerable pelvic fat;
capsule adherent ; left jjelvis dilated. Dense, firm adhesions unit-
ing the i)clvic Btrui-tures, both tubes dilated and distended with a
turbid viscid fluid, cysts In both ovaries, that on the left side the
size of a hen egg, that on the right side the size of a duck egg.

Microscopical report; Eitensjve degenerative changes in the nerve
cells. Fatty Infiltration of the heart ; mustle fibres show some
fragmentation. Moderation arterlo-sclerosis. Chronic pleurisy.
Pneumonic consolidation. Chronic bronchitis. Engorgement of the
spleen. Intense engorgement and moderate glomerular nephritis.
Chronic venous congestion, some fatty Infiltration and extensive
cirrhosis of the liver. Chronic suppurative salpingitis. Multllocu-
lar cysts of the ovaries.

Female. Age 2G. I'irst admission. Reported violent, sleepless,
melancholy. Imagined that she was under the control of spirits.
Was disappointed In a love affair.

Duration of psychosis ; Twelve years.

Cause of death : Epileptic status.

Clinical report: Admitted with a psychosis of cj)ileptic uuinia be-
ginning four years iR'fore admission as abi)ve. The epilepsy was
manifested in three ways: 1. (irand mill tj-pe of three stages.
tonic, clonic and stertor. 2. I'ctit mnl typo of only muscular
twitchings and slight disturbance of consciousness. 3, Purely
psychical symptoms of sudden wild maniacal outlireaks, becoming
violent and destructive, requiring restraint to prevent bodily in-
Jury to herself and to others, Tlie same aurae were present in
all three tyiies. On May 8, 1004, the patient had from siK to eight
seizures of the grand mal type bruising herself severely, but re-

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gaining consolonsneae In tlie interval und was able to be alK>iit
the ward. The followlug day BtntUfi develojied with stupor aiid
relaxatli>ii. gradually becoming cometose witb loss of reflexes.
Incontinence of urine and faeces, and apparent paralysis of one
side of tlie i>ody (left). One uucle insane.

Patliological report : Bed sore over the sacrum. Numerous bruises
over various parts of the body. Slight oedema of tlie lower limbs.
Cranial bones thick and dense. Slight Increase of subdural and
considerable increase of snbaracbnoldeiiu Huid. Brain — Welgbt,
1210 grms. Heart— Weight, 2;!U grms. Considerable epicardlal
fat. Moderate arterlo-sclerosis witb slight patchy atberointitous
degeneration. Lungs— Weiglit, left, 160 gnus.; riglit, 200 grms.
Extensive baud-like adhesions over both pleural cavities. Some
marginal emplij-seuia. Spleen — Weight, 140 grms. Dark red in
color and oozes considerable blood. Liver — Weight, iMO erms.
Oozes considerable blood on section, numerous yellowish patches
scattered through Its sulwtance. Kidneys — Weight, left, 130 grms. ;
right. 120 grms. Cortex pale, pyramids deep red In color, con-
siderable pelvic fat, capsule slightly adherent. Some submucus
haemorrhagic eictriivasatious In the stomach. Appendix hanging
Into the pelvic cavity. Two fibroids in the anterior wall of the
uterus, one interstitial, the other subserous.

Microscopical report: Chronic myocarditis. Moderate arterio-
sclerosis. Dilatation of some of the thyroid vesicles, with foci
of round cell Infiltration. Chronic venous congestion and some
fatty Infiltration of the liver. Engorgement of tlie spleen. En- ■
gorgenient of the kidneys, with some glomernhir nephritis.

Male. Age 80. First admission.

Duration of psychosis : Three years.

Cause of death : Epileptic status.

Clinical report : Admitted with a psychosis of epileptic mania, be-
ginning about two weeks before admission, by trying to iirranse
to start a sanitarium for tbe treatment of epilepsy, by writing
people to come to his house and see It burn as he intended to set
fire to It, by Imagining that be bad an Infallible cure for epilepsy,
that he was a candldiite for mayor, by carrying his bible al>out
with hhn and i)reiichlng on the streets, by working at various
vegetable decoctions. Occupation, carpenter. Married. Father
Intemperate. Father and mother tubercular.

Pathological report: Cranial bones somewhat thickened. Brain —
Weight, 1620 grms. Some opacity of the arachnopla. Some iu-
crease of subdural and aiibarachnoldean fluid. Heart — Weight,

■ . Considerable e|)icardlal fat. Moderate sclerosis of the

larger arteries. Lungs — Weight, left, 375 grms. ; right, 300 grms.
Consistency doughy, ooze conaiderable fluid on section. Bronchial
mucosa congested. Bronchial glands enlarged and deeply pig-
mented. Spleen — Weight, 210 grms. Dark red in color, soft and
rather friable, oozes considerable blood on section. Liver — Weight,
1000 grms. Somewhat congested. Kidneys— Weight, left, 190
grms. ; right, 205 grins. Firm on section, dark red In color, con-

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125

siderable iwlvic (nt, ooze considerable blood, capsule flrmiy adher-
ent. Pancreas^ — WelKht, 135 gruis.

Microacoplenl report : Some chroma to lytic changes in the nerve
cells. Oedema of the lungs. Engorgement of the other organs.
Moderate arterio-scleroais. Chronic parenchymiitous nephritis,

Male. Age 31. Fii-at admission.

Durition of paj hosis Three and one h ilf years

Cause of death Asph(xia iJuriug a convulsion

t linical report None given

Pathologiml leport Slight opadlj of the anthnopia along the
lai^r blood vessels borne Increise of 'iubarat.bnoideaii fluid
Brain— « eight J555 firm'* I uugs— Weight left 680 grms right
785 grms Unn iileuiitii adheoions over the upper and iniddli
lobes of the right lung Lobes adberent on tiie right side Lungs
cyanotic red In color dou^hv consistency ao<^e a large quantity of
frothy bioodj fluid on seLtiou brontliial wali<f congested and the
lumen filled n ith considerahle froth; fluid Bionthial glands eu
larged ind pigmented Heart — Weight i50 grms Hj^iettrophj
of the left ventritle modeiate arterio sclerosis most marked about
the coronarj orifice Spleen — ^ eight 150 grms Dark red m color
oozes (onsiderable blood on section Liver — Weight ISiO grms
Considerably engorged Kidneys — Weight left 180 grms right
180 grms Reddish in color marginal zone white In color small
liuantitv of pelvic fat Right ureter dilated. Bladder dilated and
distended nith mine

MltrosLopIial rtport lutt> Infiltration of the heart Moderate
arteiio scleiosia Chronic pleurisy Fngorgeuient of the alieolar
capillaries of the lungs vs ith dilatation of many vesicle Cloudy
appearance of the li^ei cells Engorgement of tie kidneys

Male Age 42 ibirst admission Reported demented

Duration of psychosis Jvot given

Cause of death Hypostatic pneumonia

Clinical repoit Admitted in a demented mental condition Has
suffered fioni periodical st^"'^ since boyhcod during which he
was iiTLtabic erratic had convulsions of a mild type epileptoid
ill character au otcis-ional one being severe Recently they be-
came more frequent He stated that in childhood he tell receiving
a severe injury to the head followed bj unconsciousness for five
hours since which he has been subject to thesie spells Has been
In the habit of leiilug lionie ivitliout cause oi motive and remain
ing anay for from four to twehe iveeks

Pathological repoit Ceneral Jaundice Lranial bones cancell>us
Dura firmly adticreiit to the araclmopia o(ei the parietal verices
Diftuse opacity and in rea <d thickne'.s of tlio ara hnipla Some
incieaee of subduial and subiri hnold an fluid lirni adhesions
Of the ar ichnopii at the bi=e of the tenipor isphenoid il and frontal
lobes Brain— Weight 1100 grms General atrophy of the convo
lutions Left lateral lentrlcle evtensivelv dilate!. Heart — Weight
270 grms ConsiderUile epicardial fat Extensive atheromatous
degeneration of the arteries Lungs — Weight left 575 grms ,

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right. 000 griiiB. Chronic pleuritic adliesious over both iileunil
ciivitles. Cyan otic-red ooloi" of Itoth ItiiitEs posteriorly, pleurii thk'l;-
ened, lol>es adherent, doughy consistency, ooze iin nbundaut bloody
fluid ou section. Bronchial glands eularged, pigmented and soft-
ened. Spleen — Weight, IIO grnis. Firm on section, trabeculae
proiuiiient, blood vessels thickened and project. Liver— Weight,
1550 grms Film ndlie^ioi s t the Ui iphrngoi capsule thkkenetl
firui on secti<n Kidneva — Weigtit left 140 grms right 110
grms i irm on •-» tion pale in color striatlon Indistinct coi Md
erable pelvic fat Iiilestlnes cintuin several round norms

MlLTOscoplcal report ExteiiRlve (hroinatol\tl<. (.hnnges In the nerve
cells EYtenri\e atlieroinUous degeneration of the iiteries
Clironic pleurisj Intense engorgenieiit oC the pulniomrj tipll
laries with rnpliiic of some nith filling of the surrounding vcii
cles Willi blood Chronic veuouH <-oiigcstlon of the lUer Chioiiic
splenitis CUrouic paren<h>mntous nephritis

Male Af,e 24 1 Irst admission Rejwrtcd tailvative nieltntlioh
suli-idal and epikptic

Duration of psychosis Not given

Cause of deuth , Asphyxia during a convulsion.

Clinical n^iort: Admitted with a psychosis of epileptic insanity. i>e-
ginning about one year before admission. Would talk about God,
spirits, eti.'. At times melauclioly, at others violent. Attempted
suicide and threatened those about him. Occupation, fanner.
Single.

I'athologlcal reiwrt; Extensive cyanosis. Narea and mouth contain
blood. Tongue lacerated on tiie left margin. Cranial bones can-
cellous ; frontal sinuses large, extending along the horizontal por-
tion, causing convexity and grooving of the cranial surface. Dura
thickened and adherent to the bones and to the arachnopla over
tlie fronial and parietal lobes. Diffuse opacity of the arachnopla
along the vessels. Brain — Weight, 1420 grms. Generally soft-
ened. Lnngs — Weight, left, 480 grms. ; right, OOO grms. Diffuse
band-like adhesions in both cavities, I'leura thicltened. Iiobes ad-
herent, cyanotlc-red color, dougiiy consistencj-, ooze couslderiihle
frothy, bloody fluid on section ; Irregular nodules In both apices
caseous centrally, fibrous peripherally. Bronchial mucosa deeply
congested. Bronchial glands enlarged and deeply pigmented.
Heart— Weight. 310 grms. General hypertrophy, moderate amount
of epicardlal fat, patent foramen ovale. Moderate atheromatous
degeneration of the arteries. Thymus gland preseut. Spleen-
Weight, 2T0 gnus. Softened and oozes considerable blood. Liver —
Weight. 1410 grins. Oozes considerable blood, cut surface rather
oilv ill appeirance Kldneyi — Weight left 140 grms ■ right 150
grms Eairly lirm on settlm d(ep led in color Bleed fither
rreei\ when cut iinjll amount of pehli fat Mesenteric glands

Mici scopital n port ( hronic pieurisT Oedema of the lungs with
foil of tubercular infiltration nnie or less degenerated Moderate
atheromatous degeneration of the arteries Moderate diffuse neph-
ritis More or less engorgement of all the organs

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127

Female. Age 29. First admission. Reported deBtructlve, seclusi»e,
violent, suicidal, homifidal, acrofulona. Memory poor, laiigbs al-
most incessantly, wanders from home, imagines tliat her parents
want to kill ber.

Duration of psycboBls ; Not given.

Cause oE death : Asphyxia during convulsion.

Clinical report: Admitted with a psychosis of epileptic insanity
with the above report. Convulsions said to have commenced at
six months, then ceased until about the age of 15, after which they
l)ecame more frequent as she became older. Was bright as a child.
One brother and two sisters insane. One paternal uncle intem-
perate.

Pathological reimrt: Extensive cyanosis. Dried blood in the nasal
and oral cavities. Dura slightly adherent over the vertex. Diffuse
opacity of the araclinopia over the fissures. Increase of subdural
and subarachnoldean fluid. Brnlu — Weight, 1250 grms. Left lat-
eral ventricle larger than the right. Lungs — Weight, left, 350
grms. ; right, 380 gruis. Slightly doughy in consistency, ooze con-
siderable frothy fluid on section. Heart— Weight, 250 grms. Con-
siderable epicardial fat. Thyroid gland slightly enlarged. Thymus
gland persistent. Spleen— Weight, 160 grms. Liver— Weight, 1090
grms. Pancreas — Weight, 00 grms. Kidneys — Weight, left, 90 grms. ;
right, 110 grms. Considerable pelvic fat. All the organs consid-
erably engorged. Scattered foci of submueus eccliymosis iu the
stomach and intestines. Several small cysts In the left parovarium.

Microscopical reiwrt; Moderate chroinatolytlc changes in the nerve
cells. Falty inflltrntion of the heart. Emphysema and oedema of
the lungs. Some arterio-sclerosls nephritis. More or less engorge-
ment of all the organs.

Male. Age Gl. First admission. Reported restless, destructive, pro-
fane, at times homicidal, threatened to shoot his wife. Imagines
that shadows on the walls are spirits. Hiis epile])tlc convulsions.

Duration of psychosis ; Four years.

Cause of death: Hypostatic pneumonia.

Clinical report: Admitted with a psychosis of confusional Insanity
plus dementia. Had been conflned to the house because of gen-
eral weakness and convulsions. Mental history dates back four
years, with a history of alcoholism and pltimblsm. One week
prior to death he was taken with convulsions with the develop-
ment of monoplegia, coma and the physical symptoms of broncho-
pnenmonla.

Pathological report : Pupils contracted. Dura firmly adherent to
the bones throughout. Diffuse opacity and thickening of the
nrachuopia, I>iirge quantity of subdural and moderate (|uantlty
of subarachnoldean fluid. Bra Iu— Weight, 1325 grms. Arteries
extensively atheromatous and calcareous, the left anterior cerebral
very small, the right large and really continues as both anterior
cerebrals beyond the anterior communicating, the left posterior
oommunlctitlug is very small, the right large. General atrophy
of the convolutions. Numerous foci of softening scattered
throughout the hrain substance. Choroid plesus cystic and con-

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tains numerous calcnveous bodies. In tbe lower part of the pons
S mm. from the ventral surface and 3 mm. from the median line
on tbe right aide Is a small focus of haemorrhage. Some diffuse
cnleareons Infiltration hetween the dentate nucleus and the cortex
of the right cerebellar hemiaphere. Extensive c«rdiac hypertrophy,
diffuse opacity of the pericardiuni, sclerosis of tbe mitral and
aortic valves. Extensive arterio-sclerosis of the arteries with
atheromatous and calcareous degeneration. Lungs— Weight, left,
390 grms. ; right, 710 grms. ■ A few firm adhesions over the an-
terior surface of the right middle lobe. Posterior portion of the
lower left lobe and of the lower and base of the upper right lohes
dark red In color, more or less solid, pit slightly on pressure, ooze
a bloody fluid on section, bronchioles exude a viscid purulent
fluid. Bronchial glands enlarged and deeply pigmented. Spleen-
Weight, 95 grms. Capsule roughened, firni on section. Liver —
Weight, 1500 grms. Distinctly nutmeg In color. Kidneys —
Weight, left, 85 grins. ; right. 95 grms. Adherent to the perirenal
fat, firm on section, pale red color, no striation visible, lai^e
amount of pelvic fat. capsule very adherent, numerous cortical
cysts. Prostate enlarged, the middle lobe projecting into the neck
of the bladder. The right adrenal has a small white nodule at-
tached to its upper extremity. The transverse colon lying at tlie
level of the umbilicus. Diffuse submucus ecchymosls in the stom-
ach and duodenum. Pancreas Arm on section, the splenic artery
very tortuous, atheromatous and calcareous.

Microscopical report : Advanced chromatolytic changes in the nerve
cells. Numerous hyaline bodies in the thoroid plexus and tlie pit-
uitary body. Fatty infiltration of the heart. Extensive arterio-
sclerotic changes in the arteries with atheromatous and calcareous
changes. Intense engorgement, beginning consolidation and exten-
sive perivascular pigmentation in tbe lungs. Chronic venous con-
gestion and moderate fatty Infiltration of the liver. Diffuse pro-
liferation of the Splenic corjuisdea. Extensive diffuse nephritis.

Male. Age 52. First admission. Reported restless, sleepless, de-
structive, epileptic. Threatened to kill his wife. Was struck on
the head when 12 years of age.

Duration of psychosis; Eight .years.

Cause of dc^th Pulmonarj oedema and status

Cllntcil report Admitted with i psvchosis of e^iileptic mama Dura-
tion of epilepsy not giien Mental dL=turbances tegan one week
before admission After admission there nas i gradual develop-
ment of dementia leading to Imbeiility with outbreaks of msnl-
acal excitement Four divw befote death serial convulsions set
in and pulmonarj >edema deieloiied which r«»pidh e'litended

Pathological rep)rt Right leg 4 cm shorter than tbe left the great
troihanter flitftned ind turned upward and hi k the limb ro-
tated outw ird Thi left testicle atiophled Duri moderately ad-
herent to the skull and somewhat to the arichnopln Diffuse
opacity and increased thickness of the arachnopla Considerable
increase of subaracbnoldenu fluid. Brain — Weight, 1380 grms.

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Mexlal surfaces adhereut. brain substance generally softened, Beml-
fluid consistency of the left frontal lobe Involving the anterior
part of the superior frontal convolution, extending to the lower
part of the mesial surface of the lolje, and affecting the greater
part of the white matter; several cortical cysts of the posterior
part of the convolution. Extensive atheromatous degeneration of
the cerebral arteries. Heart-— Weight, 350 grms. Thick layer of
epieardlal fat anteriorly, irostcriorly both layers are reddened.
rough and granular looking and deeply Injected. Lett ventricle
hypertropliied, both sides somewhat dilated, some sclerotic placques
In the body of the mitral valves. Moderate atheroma of the ar-
teries, the coronary vessels extensively so. Lungs—Weight, left,
480 grms. ; right, 650 grms. Dark red In color, doughy tn consist-
ency, a large quantity of frothy, bloody fluid oozes on section.
Spleen —Weight, 185 grms. Fairly firm on section and oozes con-
siderable blood. Liver— Weight, 1380 crais. Moderately firm, cut
surface rather oily. Kidneys— Weight, left, 150 grms; right, 125
grms. Firm on section, pale in color, large quantity of pelvic fat,
capsule adherent, right pelvis dilated, numerous cortical cysts.
Prostate enlarged. Left testicle atrophied.

Microscopical report: Advanced chromatolytic changes Id the nervs
cells. Intense engorgement of the pituitary body. Moderate fatty
infiltration of the heart. Moderate atheromatous degeneration of
the arteries. Intense engorgement of the alveolar capillaries, soms
peribronchial consolidation, more or less perivascular and jterf-
bronchlal pigmentation. Extensive cirrhosis of the liver with
foci of necrosis. Extensive diffuse nephritis with the arterio-
sclerotic and interstitial changes predominating. E^ngorgement and
perivascular fibrous tissue increase in the spleen.

Male. Age 40, First admission. Reported restless, sleepless, de-
structive, melancholy anil epileptic. Has delusions that some one
is after him.

Duration of psychosis : Three and one-half years.

Cause of death ; Asphyxia during a convulsion.

Clinical report : Admitted with a psychosis of epileptic mania aa
above. Has had epilepsy since childhood. Is single. Was found
dead In bed with face burled in the pillow.

Pathological report: Pupils dilated. Estensive cyanosis. Slight
opacity of the arachnopla along the larger blood, vessels. Slight
increase of subarachnoldean fluid. Brain — Weight. 1390 grms,
Heart— Weight, 290 grms. Moderate subendocardial haemorrbagi*
ecchymoses In the papillary muscles of the left ventricle; moderate
nrterlo-sclerosls. Lungs — Weight, left, 030 grms. ; right. 660 grms.
Cicatricial s<'ar on the posterior surface of the right upper lobe,
lobes adherent, doughy consistency, ooze a large quantity of frothy,
bloody fluid on section. Bronchial glands enlarged. Thyroid gland
slightly enlarged. Spleen^Weight. 230 grms. Soft, pulpy and fri-
able, oozes considerable lilood on section. Liver — Weight, 1370
grms. Moderately ttrm, oozes considerable blood on section, Kid-
neys—Weight, left, 180 grms.; right. 140 grms. Firm on section.

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pale In color; considerable quantity of pelvic fat. AdrmalB —
Weight, JO grms. each. Pancreas — Weight, 120 grms. Appendix
hanging into the i)elvic brim. Considerable submucus ecchymoslB
of the stonmch and lotestines.

MlcroBcopicnl report : Diffuse staining of the nerve cells with NlBal's
stain. Some fatty Infiltration of the heart. Moderate arterio-
sclerosis of the arteries. Some tendency to erapbyseiua. extensive
perivascular pigmentation, irregular masses of tubercular infiltra-
tion tending to central d^eneratiou, and some filirosia. Dilata-
tion of some of the thyroid vesicles. Iiitense eneorgement of the
liver and spleen. Inten.«e engorgement and diffuse nephritis.

Female, Age 45. Negress. First admission. Reported restless,
destructive, violent, homicidal, epileptic. Imagines that she Is be-
ing mistreated by her friends, that Bhe belongs to secret societies,
and seeks their protection.

Duration of psychosis ; Eleven years.

Cause of death : Asphyxia during a convulsion.

Clinical report: None given.

Pathological report: Extensive cyanosis. Well marked arena se-
nilis. Some bloody mucus in the mouth. Cranial bones thick and
dense. Dural adhesions to the frontal bones and numerous vas-
cular connections to the arachnopia, several bony outgrowths pro-
jecting inward on each side of the superior longitudinal sinus, a
large bony plate 2-2 cm. in the lateral wall of the sinus between
the parietal vertices. Slight diffuse opacity of the arachnopia.
Brain— Weight, 1200 grms. Basal vessels atheromatoas. Consist-
ency of the brain substance rather firm, several small cysts In the
substance of the parleto-occipital lobes, semilunar or spherical shape
ijetween 1 and 2 cm. iu size. Heart — Weight, 200 grms. Some
v^etations on the margins of the mitral valves, fenestration of
the margins of the aortic valves. Extensive atheromatous degen-
eration of the arteries. Lungs— Weight, left, 450 grms. ; right,
510 grms. Moderately extensive pleuritic adhesions In l>oth pleu-
ra] cavities. Pleura thickened, lobes adherent, extensive sub-
pleural pigmentation. Lungs extensively diffusely nodular, the
intervening portion being dougliy, many of the nodules being case-
ous and semifluid, some Infiltrated with calcareous material. The
intervening tissue oozes an abundant frothy, bloody fluid. Several
small cavities In the apices. Bronchial mucosa swollen and ©ede-
matous. Bronciilal glands enlarged, pigmented and easeooa.
Spleen — Weight, 200 grms. Soft and friable, parenchyma bulges,
oozes considerable blood, malpighian bodies prominent, an occa-
sional whitish nodule more or less circumscribed. TAver — Weight,
1280 grms. Firmly adherent to the diaphragm, firm on section,
several whitish nodules scattered through its substance, one of
which Is calcareous. Kidneys — Weight, 104 grms. each. Firm on
section, deep red color of the cortex, marginal zone pale, very
liltle pelvic fat, iielvic iiiucosa congested, capsule adlierent. Pan-
creas — Weight, 100 grnis. Thyroid gland, 70 grms. Tendency to
systlc formation. Tliymus gland persistent. Ovaries atrophied.

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Microsc(«)ical report; Diffuae chromatolytic changes In tlie nerve
cells. Considerable fatty infiltration oC the heart, with more or
less vaacnlar engorgement. Extensive atheromatous degeneration
of the arteries. Chronic pleurisy. Alveolar and perivascular pig-
mentary Infiltration of the lungs. DifCnse tubercular consolldafion
with areas lu all stages of degeneration. Engorgement and early
portal cirrhosis of the liver. Intense engorgemeat and diffuse in-
terstitial nephritis. Intense engorgement, hyperplasia of the nial-
pighlan bodies and foci of tubercular Infiltration of the spleen.
DilatatloD of some of the thyroid vesicles.

Female. Age 36. First admisslou. Reported restless, sleepless, de-
structive, suiciiiai, homicidal and epileptic. Imagines that her
friends are against her and want to kill her. threatens to kill
them and to burn the house. Has frequent outbrealts of violence.
Is morose and sullen.

Duration of psychosis; Six years.

Cause of death : Asphyxia during a convulsion.

Clinical report; Admitted with a psychosis of epileptic mania.
Physical healtli was good. Mental disturbance said to have com-
menced two years before by maniacal manifestation. Had been
having a series of convulsions for some time. Was sick and con-
fined to bed. Complained of spots before the eyes. Had mitral
regurgitation. Mother tubercular.

Pathological report : Extensive cyauosia. Conjunctiva congested.
Mouth filled with a frothy, bloodff fluid. Cranial bones thin.
Slight opacity of the arachnopia. Small amount of subaraehnoi-
dean fluid. Brain — Weight, 1320 grnis. Basal vessels moderately
arterio-sclerotic. Heart— Weight, 250 grms. Some small, fleshy,
warty vegetation on the mitral and aortic valves. Moderate
arterio-sclerosls. Lungs — Weight, left, 400 grms. ; right, 420 grms.
Oyanotic-red color, dougliy in consistency, ooze considerable frothy,
bloody fluid on section. Bronchial, tracheal and laryngeal mucosa
deeply congested. Bronchial enlarged and pigmented. Spleen —
Weight, 320 grms. Soft, friable, bleeds considerably, malpighlan
bodies prominent. Liver — Weight, 1200 grms. Goacs considerable
blood on section. Kidneys — Weight, left, 120 grms. ; right, 125
grms. Cortex pale in color ; no- pelvic fat, capsule strips readily.
Pancreas— Weight, TO grms. Appendix hanging into the pelvic
cavity. A small fibroid in the anterior wall of the uterus. Several
small cysts of the ovaries. Moderate submucus ecchymosls of
the stomach.

Microscopical report: Extensive fatty Infiltration of the heart.
Moderate endarteritis. Intense engorgement of all organs.

Male, Age 47. Second admission. Reported destructive, homicidal,
syphilitic and epileptic.

Duration of psychosis: Fifteen years.

Cause of death : Chronic nephritis.

Clinical report: Admitted as an epileptic mania with a history of
twenty years' standing.

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133

bodies or the spleen Chronic veQous congestion and some portal
clrrhoRls of the ll4er Extensive diffuse uLphiitls Intense eii
goigeiueiit and fo<.i of dense round cell infiltrntlou lu the adreiiiils

Male A;,e 45 1 irst admlasion Kepjrtel melan holy restless
homkldil \loloiit and epileitie "sees spirits night tnd diu

Duration of psjchoais Ten jears

Cause of deatti A>qjhi^ia during a contulsiun

Clinical report Admitted with h psjclwMa of epileptic mania Wjw
found dead in hed

Pathological report E\tenNlve cjanoiis Craniil bones hard and
beaiv Dura slightlv adherent Slight imretac of subdural fluid
Slight opacltv of the aracbnopia Brain — Weight 1500 trms
Moderate sderosis of the basal ves&els Numerous fo<.i of eichy
riiosls In tlie floor of the fourtli ventricle I ungs — Weight left
iJ'i ^nns right 495 gnn^ A few flrin i>teiiriti<. adbeKlons uu
thL right side Lungs cvanoticrel color diiughy In (.onslstent^
oo/ing Lonsiderabie frothy bloody fluid on section diffusely plb
niented a fen calcareous nodules in both apices Bronchial glands
enlarged and some of them Infiltrated with calcareous material
Hearts Weight 330 grms Moderate h\pertrophy considenble
epl< irdial fat Moderate arteilo stlerosls Thyroid gland —
U eight 25 grma bpleeu — Weight, 210 grms Soft, friable and
bleed"- freelj river — Weight 1230 grnis Oozes considerible
bliod Kidneja — weight left 105 grma right 110 grms Firm
on section deep red In color considenble pel\lc fat bleed rather
freely Pa ncreas^'W eight 110 grms Numerous ei-cbvnioses in
the stomach

Mil rostopical report Modente chiomatoljtic <.bange3 In the nerve
cells Considerable fatty infiltration of the heart some ihronic
myocarditis Moderate arterlo sclerosis involving mostly the In
tliua Intense engorgement and diffuse pigmentary infiltration of
the lungs 1^ ith some chronic tubercular Inflltratiou of the apices
Intense engorgement oC the liver Some chronic interstitial pan
creatltis Intense engorgement moderate arterio schlerotlc and
tubular nephritln Hvperi>lasia of the muscular walls and of the
ljm|)h structure of the appendix

female A)!e 40 First admission Reported restless melanchoh
intohercnt at times rambling His delusions that her fatbei
wants to kill her thit her father and mother have killed some of
the neighbors etc

Duration of psychosis Four and one half years

fause of death Status eplieptlcus

Clinical report Admitted with a psjchoais ot epikptlc mania
After admission the general health nas good Mental enfeeble
ment gradually developed Two dais before death status de-
veloped Tirymg In degree qnd Intensity One sister tubercular

Patliological report Intense cvanisls Bloodt fluid running from
the nose and moulh Might oedema cif the lower extremities
Cranial bones canc'cllous Firm dural adhesions most marked
uver the frontal lobes, bxtenstve bony deposit In the walls of tbe

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134

superior longitudinal sinus and the falx cerebri. Brain— Weight.
1040 grms. Liitenil ventricies somewbat dilated. Heart — Weight,
295 grnis. Eiiljirged and cavities dilated. Slight arterio-sclerosls.
Lungs — Weight, left, 505 grms. ; right, 5!)0 grms. Extensive firm
pleuritic adhesions on the right side. Lobes on the right side ad-
herent. Lungs cyanotlc-red In color, doughy in consistency, numer-
ous email calcareous pigmentary bodies scuttered through the sub-
stance. Bleed considerably. Thyroid gland — Weight, 85 grms.
Uniformly enlarged. Spleen — Weight, 125 grms. Soft and dark
red In color. Llvev — Weight, 3000 gmis. Soft and dull yellowish
in color. Kidneys— Weight, lett, 145 grms. ; right, 140 grms. Soft
on section, cortex pale, medulla deeii i-eU in color, strlation indis-
tinct, some i)elvlc fat, cairsule adherent I'ancrena — Weight, 90
grms. Gall-bladder contracted llrmly uiion a mass of calculi.
Adrenal softened and finnly adherent to the adjoining tissues.
Small cyst involving the left fallopian tube.

Mici'oseopicai rei>ort i Extensive diffuse degenerative chanses in
the nerve sells. Rod-like bacilli tilling the vessels and diffused
through the tissue generally. Intense engorgement and moderate
falty infiltration of the heart. Emphysema of some of the lung
vesicles, Intense engorgement of the alveolar capillaries with rui>-
ture of some, filling the surrouading vesicles with blood ; some
vesicles filled with leucocytes and desquamated epithelial cells.
Bxtensive blackish pigmentary iullltratlon. Numerous hyaline
bodies in the choi'oid plexus. Intense engorgement of the pineal
gland. Intense engorgement of the liver, most of the cells more or
less degenerated so that nothing but the nuclei are visible. Fatty
infiltration of the pancreas with considerable chronic pancreatitis.
Diffuse degeneration of the kidneys, with considerable interstitial
increase. Extensive cyst formation in the thyroid gland.

Male. Age 27. Second admission. Reported as answering ques-
tions in a rambling way. Imagined that be had committed some
horrible crliue. Exiiected to receive money from some of his
relatives. Assumed a peculiar attitude.

Duration of psychofla: Eleven years.

Cause of death; Status epileptlcus and hy|iostatic pueumoiiin.

Clinical report ; Admitted with a psychosis of epileptic mania;
Was later discharged, but was again recommitted In a condition
of maniacal e.Ycltement. He has been subject to outbreaks of
post-maniacal excitement for eleven years. Frequently necessitated
his confinement to Jail because of violence, destructiveness, and
danger to bis surroundings. He underwent a gradually developing
progressive dementia. On admission his physical health was good,
but he soon began to lose fiesb and grow weak. In October he be-
gan to have convulsions more frequently and was almost con-
tinuously excited, lost control of his legs and could not walk
without assistance. A month later he fractured a rib while strug-
gling. Was In a condition of status two days before death.

Patiiological report : Conslderflhle cyanosis. Forehead slanting.
Pupils unequal and the left Irregular. Mucoid bloody fluid in the

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135

mouth Cranial bones rather hard Dura moderately adherent
to the arachnopia over the parietal vertites Moderate increase
of BularachnoKlein fluid Brain — Weight 1375 jirms Basal vet.
sels moderately arteriosclerotic Heart— T\ el^ht 340 grme Nu
merous foci of haemorrhagk CKtravasation beneith the epitardium
It the base at the heart and around the IntraperiLardial vessels
lIjpertroph\ of the left ventriLle Moderate arterlo sclerosis
I ungs— W eight left jM grms right 790 grms Pleura over the
luuth rib on the left aide roughened over both surfaces Lungs
cj luotie red in tolor doughv in consistency ooze an abundant
frothv bloody fluid on section Fracture of the ninth rib on the
left aide in the posterior axillaiy hne and Is surrounded by con
slderable callous Thyroid gland — TV eight 35 grms Spleen-
Weight 100 grms Moderately firm Liver — Weight 1650 grma
Moderately firm rirm adhesions between the gall bladder colon
duodenum and p\lorus of the stomach Pantreas — 'ttelgbt 100
grms Kldnej s— Weight left 170 crms right 160 grms Pale in
color moderate quantity of t>e\\ It fat capsule adherent

Microscopit il report Moderate chrtmatolytlc chant,es in the nervL
(.ells Central canal of the cord filled with proliferated epithelial
cells Fattv Infiltration of the heqrt M>derate chronic myocar
ditis Moderate arterio sclerosis Considerable irregularity of size
in the thvroid vesicles with Infiltration of the colloid material In
the smaller ones Intense capillary engorgement of the lungs with
rupture of some and hlling of the vesicles with blood Some con
twining leucocytes and desq.uamated epithelial cells More or less
diffuse pigmentan infiltration of the perivatcular tissue Intense
engorgement of the bronchial glands with diffuse pigmentar\ In
filtration considerable tuben ular infiltration and some calcareous
deposit Intense engoigement of the apleen with relative trabec
ular increase and proliferation of the splenic corpuscles Chronic
lenous congestion of the liver with some portal cirrhosis DlfEu'^e
engorgement of the kidneys with moder ite diffuse inter«titi il
nephritis

Male Age 37 Secciid idmisslon Repirted Irritable violent de
stru tiie and imbecile Desdoped ejillepst at the age of 16 At
triluted t< sunstroke ind lending to more or less Imbecility

Duration of ps\chosis Se\en \eais

Cause of death Pneumonia

Clinical report Admitted with a psj<hosis of epileptic Insanltv
Mas later discharged and again readmitted ^o report of anj
severe Illness or injury during childhood At the age of 16 de-
leloped epilepsy which was attributed to sunstroke Ten years
later the left evcbill began to bulge but wis not considered of
importance Pcur years later right hemiplegia developed Seiz
ures had no discoverable aurae and no local prodromatn Mental
State nas one ot nrrested development Wcs irntatle before
seizures often violent following them Amiable In the interval
Powerfully built Bulging of the crtnium over the left orbital
area Percussion note flat A sense of resistance on pressure

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Not Bensitive. Both ejee prominent, the left more so. Pupile
unequal and react slowly to light. No ocular paralysis. Optic
atrophy extreme. Mouth drawn to the left. Speech limited to
a half a dozen words. Partially recovered right bemlpteglfl. Con-
tracture of the right band and foot. Exaggerated Icneejerk, An-
kleclonus on tbe right side, Bahinskl's phenomenon present.
Marked dementia. About a week before deatli he fell and frac-
tured the rigbt inferior masllla near tbe angle. Three days later
serial convulsions developed and pneumonia followed.
Patbological report: Head brachycephallc. Prominence of the left
frontal region. Protrusion ot both eyeballs, the left more so tban
the right. t«ft pupil dilated, Ijinear scar over the rigbt inferior
maxilla, 3.5 cm. long, lying parallel with Its long axis. Fracture
of the underlying maxilla with a soft callous surrounding it.
Cranial bones hard, irregular and unequal in thickness. Frontal
sinuses in the right frontal bone large. I^eft temporal bone thinned
at its upper part and thickened at the lower part by two cone-
like projections protruding Into the cranial cavity, having broad
expanding bases. The door of the anterior and middle fossa on
tbe left side are depressed, widened and thinned crackling under
slight I reiHure The leaser wmg of the sphenoid is represented bv a
mere ridge The anterior clmoid process the left side of the bodj
of the sphenoid the posteiior Imold process and the petrous por
tion of the temporal are more or less destioyed by atrophy from
pressure Attached to tbe inner surface of the left frontal and
the adjoining portion ot the temporal Is a firm white nodular
irregular mass ftels,hlng when removed 575 grms and measuring
16-12 9 cm of a cartilaginous appearan e and consistency with
local are'i'i of calcareous infiltratltn whiih projects into the
cranial c»%iti pressing upon and ctusing atrophy of the cranial
contents itttchtd to the inner surface of the squamous portion
of the left temporal bone just anterior to the petrous portion and
about 1 cm above tbe floor of tbe middle fossa iij a (.econd nodule
3 2 5 cm in size 'Similar in structure to the former Brain^
Weight, Iffio grms General consistency rather si ft C< mplett,
atrophy of the left frontal lobe of the anterior part of the parietal
and of the greater part of the anterior tliree- fourths of the tein
poro sphenoidal lobe evcept a thin laver on the inner and lower
part of the hemisphere i arming In thlckne^is from one to several
tm Meninges somewhat adherent to the mass The left toipus
striatum and optiL thalimus decreased in size and displaced doitn
ward anl innard The first second third fourth fifth sitth
seventh and eighth cranial nerves on the left side are small gray
and atrophic The optic commissure and truts are simllarij iif
fected the left more so than the right The left lateral lentricle
almost obliterated the right extensively dilated The cranial bones
\re Irresularlj thinned «tnd thickened the latter being paitlculirlj
marked along the sutures and grooves for the meningeal arteries
Lungs^Weigbt left, 320 grms rlj,ht 100 grms Firm pleuritic
adhesions In both Laxities Pleura over the right lower lobe red

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137

denea, congested and coTered with a fibrino-plastie exudate. Pleu-
ra thickened. Lobes adherent. Base of the lower left lobe of a
eyanotic-red color, doughy in consistency, pits on pressure, oozes
considerable frothy, bloody Huid on section. The whole right lung
solid except tlie apex and the anterior margins of the upper and
middle lobes, of a mottled dark-red to gray color on section, gran-
ulai In appearance. Bronchial mucosa congested and swollen.
Heart — Weight, 2S0 grms. Moderate amount of eplcardial fat.
.Moderate arterio-sclerosis. Thyroid gland enlarged and more or
less cystic. Spleen — Weight, 160 grms. Moderately firm, dark
red in color. Liver— Weight, 1360 grms. Pancreas— Weight, 120
grms. Kidneys — Weight, 180 grma. ; right, 85 grms. The left is
pale in color; several small cysts scattered through its substance;
capsule strips with some difficulty but leaves a smooth surface,
'i he right is firmly adherent to the perirenal tissue, firm on sec-
tion, pale la color; pelvis dilated, sacculated; mucosa thickened;
cavity contains a small calcylus ; capsule adherent; surface rough-
ened. Dreter dilated.

Microscopical report : Extensive ebromatolytie changes in the nerve
cells. Central canal of the cord fliled with proliferated epithelial
cells which also inflltrate the surrounding central gelatinous sub-
stance. Fatty inQltration of the right heart Some chronic myo-
carditis. Moderate arterio-sclerosis involving mostly the Inner
coat. Cystic dilatation of many of the thyroid vesicles with cellu-
lar Infiltration of the colloid material of many of the smaller ones.
Intense engorgement and relative decrease in size and number of
the malplghian bodies of the spleen. Chronic venous congestion
and slight portal cirrhosis of the liver. Extensive pigmentation
with foci of round cell infiltration in the adrenals. Extensive dif-
fuse nephritis with a more or less acute process superadded In the
right side. Chronic pleurisy on the left side. Acute fibrinous
pleurisy on the right side. Hypostatic congestion of the left lower
lobe. Hed and gray hepatization of the right Bide. Tumor mass
consists of typical hyaline cartilage with foci of slight calcareous
Infiltration.

Male. Age 19. First admission. Reported dull of expression, sub-
ject to outbreaks of violence and to the practice of selC-abuse
Shows mental feebleness.

Duration of psychosis : Three years.

Cause of death ; Status epilepticus.

Clinical report : .\dmitted with a psychosis of epileptic insanity be-
ginning three years before admission. Convulsions began six
years before admission. Conversation, actions and appearance
indicate lueotal enfeeblemeut. Was in status three days.

Pathological report : Pupils unequal. Left ear larger than the right
and differently shaped. Extensive cyniiosis. Bed sore over the
sacrum. Cranial bones thin and soft. Brain — Weight, 1450 grms.
Heart— Weight. 230 grms. Lungs— Weight, left, 540 grms. ; right,
520 grms. Finn pleuritic adhesions in the left pleuritic cavity.
Pleura thickened on the left side, lobes of the lung adherent.

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Posterior portion of both lungs cyanotic reel In color, doughy Id
consistency, ooze an nbundaut frothy, bloody fluid <ai section.
Bronchia! and tracheal mucosa deeply injected. Bronchial glands
enlarged, deeply pigmented and the larger oues caseous. Thyroid
gland — Weight, 35 grnis. Thymus gland persistent Spleen-
Weight, 100 grms. Dark red In color, soft on section, bleeds rather
freely. Liver — Weight, 1540 grms. Foci of fatty necroslB mostly
on the surface and more or less wedge-shaped. Kidneys — Weight,
left, 150 grms; right, 125 grms. Pale in color, no pelvic fat, cap-
sule Strips readily. Bladder distended with urine. I'aacreas—
Weight, 85 grms.

Microscopical report ; Kxtenslve chroma toly tic changes lu the nerve
cells with Intense vascular engorgement aud dilatation of the
perivascular siiaces. Fatly Infiltration of the right ventricle aud
some fibrous tissue Increase In the myocardium. Intense engorge-
ment of the pulmonary alveolar capillaries with rupture of some
and Ailing of the vesicles with blood. Some vesiclps filled with
leucocytes, and epithelial cells more ot less degenerated. Some
vesicles emphysematous. Intense engorgenient of the spleen, mal-
pigbias bodies small ; many represented by only a few «ells sur-
rounding the arteriole. Intense engorgement of the liver with
fod of necrosis. Intense engorgement of the kidneys with con-
siderable diffuse nephritis, the parenchymatous changes predomi-
nating. Intense engorgement of the intestines with some catarrhal
changes In the mucosa and proliferation of the lymph follicles.

Male. Age 40. First admission, Kei>orted restless, sleepless, de-
structive, homicidal, feeble-minded from one year of age. rolh)wing
a severe illness.

Duration of psychosis : Not given.

Cause of death r General tuberculosis.

Clinical report; Admitted with a psychosis of epileptic insanity.
Occupation, farmer. Single. At one year of age he had a severe
illness, following which it was noticed that he was not like other
children ; never learned to talk distinctly ; could apparently hear
and understand; laughs at times; never cries; shows no incli-
nation to play ; was amused with small objec'ta. At times becomes
violent toward those about him. On admission the mental con-
dition was one of Imbecility. Epileptic seizures were frequent.
In the summer of 1904 he developed a left cmpyaemla for which
a resection of rib was done, which healed and there was fair
expansion of the lung. Four months before death there was loss
of weight and tubercular involvemeut of the lungs became appar-
ent. As the tubercular condition advanced the epileptic seizures
became more frequent and uncontrollable.

rathological report: Facial and cranial asymmetry. Face small.
Head brachy cephalic. Operation scar over the eighth left rib in
the iKJst-axillary Hue. Left testicle smaller than the right. Beil
sore over the left great trochanter. Cranial bones hard. Dura
firmly adherent to the hones and to the arachnopia along the
superior longitudinal sinus. Extensive diffuse opacity of the

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arachnopia. Brain — Weight, 1380 grms. Hemispheres adherent on
their mesial eurfaeee of the froiitnl lobei<. Bueal vessels thickened.
General atrophy of the convolutionH. Elxteusive dilatation of the
veiitvldes and disteuaion witli fluid. Greater iwrtion of the aeptmn
lueidum destroyed. Foramina Of Munroe dilated. Choroid plexus
slightly eyatic. Ki>endyuia granular throughout. Numerous aub-
arachnoidean cysts most marked over the anterior and Inner sur-
face of the left frontal lobe. A small haemorrhaglc focus over
the fissure of Sylvius on the left side involving the tip of the
teniporosphenoidal lobe. I'oaterior columns of the cord gray in
the Imubar region. Lungs — Weight, left, 430 grms. ; right, 400
grins. Firm pleuritic adhesions on both sides, the left almost
wholly obliterated except for a small cavity underlying the point
of operation, where there is a fair-sized cavity which eontains a
creamy purulent fluid. Pleura thickened. The rlglit lung rather
solid In consistency with intervening areas of a doughy character,
solid areas of a pneumonic appeiirnnce. f.obes flrmly adherent.
The left forms a dense fibrous mass with only alight crepitation,
mottled grayish color, nnmeroua foci of eoCtenlng and caseation
with some calcareous deposition. Bronchiolea filled with a muco-
purulent secretion. Bronchial glands enlarged and pigmented.
Heart — Weight, lOO grms. Moderate arterlo-aclerosis with con-
siderable atheromatous degeneration. Spleen— Weight, 110 grms.
Malpighiau bodies prominent. Liver — Weight, 1130 grms. Lyower
margin reaches the iliac crest Rather waxy In appearance with
numerous foci of necrosis. Kidneys — Weight, 120 grms each.
Pale on section. Bladder distended. Left testicle smaller than
the right. Pancreas — Weight, 85 grms. Sigmoid colon lying over
the caecum and is adherent to the right abdominal wall. Exten-
sive tubercular involvement of tlie small intestines with ulceration
and nodular Infiltration.
Microscopical leport: Moderate chromatolytic changes in the nerve
cells. Bstenaive thickening of the arachnopia over the left teni-
poroaphenoidal cortex by round cell accumulation involving the
vascular spaces, extending into iind through the cortex with thick-
ening of the vessel walls, particularly the media. In the tip of
the convolution there ia diffuse aubpial haemorrhage extending
Into and infiltration of the cortex and underlying white matter.
In other portions the perivaaculnr spaces and blood vessels show
a leucocytic accumulation and Infiltration. Epithelium of the
e|>endynia more or less proliferated with increase of subpial
fibrous tissue. Chronic myocardltia. Moderate arterio-scleroais.
Portions of the lungs show dense tubercular infiltration with more
or leas degeneration. Other portions show intenae engorgement'
of the vesals with nipture of some and filling of the vesicles with
blood. Other portions more or less emphysema. Considerable
perivaacular and peribronchial pigmentary infiltration. Chronic
bronchitia and peribronchial consolidation. Chronic tubercular
pleurisy. Hyperplasia of the lymph follicles and tubercular In-
filtration of the bronchial glands. Hyperplasia of tbe malplghian

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bodlpH of the !ipl<>en. Moderate jxirtal clrrhoBls with foci of tuber-
(Tilar Infiltration inoi-e or less degenerated. Chronie difEuse ne-
phritis. Tuberc-ulur Infiltration and ulceration of the Intestines.

Male. Age 52. First admission. RejKirted restlees, sleepless, pro-
fane. Has visual hallucinations. Has delusions that the world is
coining to an end.

Duration of psychosis: About seven years.

Cause of death : Asphyxia during a convulsion.

Clinical report : Admitted with a psychosis of epileptic Insanity,
dating back four months before admission. After admission the
mental condition underwent a gradual and progressive deteriora-
tion, rhj-sically his health was good. Precedinj; and followiuK
the seizures he manifested Increased Irritability, some elondinj:
of consciousness and at times oulhreake of violence. Found dead
in bed, face buried in the pillow.

Pathological report : Extensive cyanosis. Blood In the nasal cavi-
ties. United fracture of the left tibia. Lyeft testicle smaller than
the right. Dura moderately adherent to the aracbnopla over tlie
parietal veitices. Slight diffuse opacity of the arachnopia. Bniin
—Weight, 1470 grms. Consistency generally softened. Basiil
vessels atheromatous. J^eft posfprior cerebral half the slwe of
the right, Iieft posterior coraniunlcallng three times the size of
the right, Ependyiua of the fourth ventricle granular. Several
foci of ecchymosis in the floor of the fourtb ventrk-le. Heart —
Weight, 370 gi'nis. Sclerotic area on the anterior surface of the
left ventricle : considerable epicardial fat, hypertrophy of the
left ventricle. Moderate atheroma of the arteries. Lungs —
Weight, left, 590 grms. ; right, 750 grms. Firm pleuritic adhe-
sions in both cavities. Pleura thickened ; some adhesions between
the lobes; lungs eyanotlc-red in color, doughy in consistency, ooze
considerable frothy, bloody fluid on section, cicatricial contraction
' of the left apex. Bronchial aiuiflsa congested. Bronchial glands
enlarged and deeply pigmented. Tliyroid gland — Weight, 55 grms.
Right lobe enlarged and contains a cyst 2 cm. In diameter. Thymus
gland persistent. Some serous fluid in the peritoneal cavity.
Mucosa of the stomach and small intestine thickened and rongli-
looklng. About four feet from the caecum a loop of the ileum
was firmly adherent on the peritoneal surface, and beneath was
a firm white nodule aliout'1.5 cm. In diameter involving only the
serous and nniscular coatw. Mesenteric glands slightly enlarged.
ApiiMidlK rudimentary. Spleen — Weight, 340 grms. Bleeds freely
on section, malplghlan bodies prominent. Liver — Weight, KiiX)
grms. Capsule thickened, rather firm on section. Pancreas —
Weight, 110 gnus. Splenic artery extremely tortuons. irregularly
dilated and e.\tenHively atheromatous. Kidneys — Weight, left, 180
grms.; rljjlit, l.'JO grms. Moderately adherent to the ))erirenal tis-
sues, bleed fii-cly. reddish i[i i-olor. considerable pelvli- fat, ciip-
sule adherent.

Microscopical report : Moderate chromntolytic changes In the nerve
cells, considerable vascular engorgement. Fatty infiltration of

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the heart with more or less chronic myooariJltis. Diffuse Irregulsi
arterlo-seleroslB with considerable perlraacular round cell tnfiltra
tion In the external coat. Diffuse fibrous tissue Increase in tht
thj-roid gland, oj'stic dilatation of some of the vesicles and cellulai
inflltratioii of some of the smaller Vesicles. Chronic pleurisy.
Intense vascular engorgement of the lungs, some alveoli filled wltli
blood, others with leucocytes, interlobular septa thickened, perl
vascular pigmentary infiltration. Hyperplasia of the lymph folll
des of the bronchial glands, with fibrosia of the central portloo
and diffuse pigmentation. Intense engorgement of the spleen
Intense engorgement of the liver with foci of portal round cell in-
filtration. Chronic Interstitial pancreatitis with intense engorge
nient. Extensive diffuse nephritis.

Female. Age 55. First admission. Reported eicltable. destructive
violent and melancholy.

Duration of psychosis : Not known.

Cause of death ; Asphyxia during a convulsion.

Clinical report : At the time of admission was Id a condition oi
maniacal excitement, following which she underwent rapid and
progressive dementia. Convulsions occurred on an average ol
two per day. Had several attacks of status, but recovered. Dietl
while sitting In a chair during a convulsion.

I'athologlcal report: Extensive cyanosis. Decreased intraocular
tension. Ca'taract in both eyes. Arcus senilis well marked. United
fracture of the radius at the wrist. Oedema of the lower limbs.
Cranial bones lancellous. Diffuse dural adhesions to the bones
and to the intlmi pla over the parietal vertices. Diffuse opacity
of the ara(.hnopia Considerable Increase of the subarachnoideaii
fluid. Brain— Weight 1070 grms. Basal vessels eitensively
atheromatous Choroid plexus moderately cystic. Lungs — Weight,
left, 260 grms.; right, 2!l0 grms. Firm pleuritic, band-like adhe
sions in both pleural cavities. Cicatricial contraction of the apes
of the right lung. Heart — Weight, 280 grms. Considerable epl-
cardial fat. Moderate sclerosis of the mitral and aortic valves.
Moderate ■ arterio-sclerosis of the arteries extensively involving
the coronary vessels. Bronchial glands moderately enlarged and
pigmented. The large veins of the mediastinum distended with

, blood. Thyroid gland very small, represented by only a few
lobules. Liver — Weight, 1180 grms. Lower margin of the livet
at the iliac crest Numerous adhesions to the diaphragm. Con-
striction at the Junction of the lower and middle thirds. Capsule
thickened beneath the constriction, the portion overlying the gall-
bladder consisting of dense fibrous tissue. Liver nutmeg In ap-
penrance. Gall-bladder enlarged, its walls thickened and adherent
to the surrounding structures. Cavity contains thirteen brownish
facetted calculi. Cystic duct dilated and partially occluded by a
calculus 2 cm. from its Jmic-tlon with the hepatic duct. The
mucosa of the portion attached to the liver substance has an
ulcerating surface, its margin thickened and Indurated, its surface
covered with a yellowish exudate. Spleen — Weigbt, 110 grmil.

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Finn on section. Malpighian bodies prominent. Pancreas —
Weight, 80 grnis. B'irm on section. Kidneys— Weight, left, 110
grms. ; right, 100 grms. Deep red color, small quantity of pelvic
fat, capsule adherent at places. Stomach mucosa thickened and
granular looliing, deep red in uolor. Neiir the pylorus on the
posterior wall is a Srm nodule, 1 cm. in diameter, white in section
and firmly adherent to the must^liir wall. Diffuse enlargement of
the mesenteric and retroperitoneal ginnds. Caecum walla thick-
ened, its mucosal surface appears worm-eaten, ulcerated, extend-
ing upward several inches, portions being nodular and Indurated,
other portioDs being undermined. Surrounding the Ueo-caecal and.
appendo-caecal orifices is a pnpillomatouB cauliflower-like mass
Infiltrating all the walls and extending up the appendix canal
for several co. The terminal 2 cm. of the appendix hang into
the pelvic cavity; Its walls thickened and lumen contains in-
spissated mucus and faecal matter ; 3 cm. from Ita termiuatian
is a constriction which is whitish on section and the mucosa proxi-
mal to It is congested. Ovaries are small and atrophic.

Microscopical report: Moderate ciiromatolytic changes In the nerve
cells. Central canal of the cord filled with proliferated epithelial
cells. Extensive fatty infiltration of the heart and some chronic
Interstitial myocarditis. Extensive arterio-sclerosls, mostly In-
volving the Intima. Tul)ercular infiltration of the bronchial
glands. Areas of pulmonary vesicles filled with leucocytes and
some epithelial cells. Engorfjeinent of the spleen and hyperplasia
Of the malpighian bodies. Intense engorgement of the adrenals
with foci of round cell collections in the cortex and gfanular de-
generation of the medullary portion. Chronic pancreatitis. Ex-
tensive perihepatitis, extensive fatty Infiltration, extensive cirr-
hosis and proliferation of the bile duots of the liver. Extensive
diffuse nephritis. Chronic gastritis. Focal epithelial prolifera-
tion In the submucus tissue surrounded by masses of round cells.
Adenomatous Infiltration of the walls of the caecum and appendix
with localized areas of inflammatory cells and hyperplasia of the
lymphoid tissue.

Female. Age 62. First admission. Reported violent and maniacal.

Duration of psychosis : Not given.

Cause of death ; Asphyxia duriug a convulsion.

Clinical report: Admitted with a psychosis of epileptic mania. Coa-
vulslons began twenty years ago whenever she had a miscar-
riage. Periods of maniacal excitement occurred at each epileptic
attack. Physical condition was good throughout Was found dead
in bed lying on her back, one limb hanging out of bed, face cov-
ered and mouth filled with frothy mucus. Father intemperate.
One sister deformed.

Pathological report: Extensive cyanosis. Pupils unequal. Opacity
of the right lens. Slight oedema of the lower limbs. Cranial
bones cancellous. Dural adhesions to the bones and to the arach-
nopia over the parietal vertices. Moderate increase of subdural

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and Bubaraehnoldean fluid. Diffuse opacity of the arachnopia.
Brain — Weight, 1130 grma, G«ieral atrophy of the convolutione.
Moderate atheromatous degeneration of the basal arteries. Small
cyst of the choroid plexus. Heart — Weight, 425 grms. Consider-
abie epicardial fat. Left side hypertropliy and right side dilata-
tion. Considerab]*" sclerosis of the mitral and aortic valves with
calcareous Infiltration o£ the former. Extensive atheromatous de-
generation of the arteries. Lungs — -Weight, left, 1010 grms.;
right, lOiM) grms. Firm pleuritic adhesions on the left side.
Pleura thickened. Lobes adherent. Lungs oC a cyanotic red
color, doughy consisfencj, ooze an abundant frothy fluid on sec-
tion. Bronchial and tracheal mucosa deeply congested and the
lumen filled with a frotliy mucoid secretion. Bight lung has no
middle lobe. Bronchial glands enlarged, pigmented, caseous and
calcareous. Left lobe of the thyroid gland enlarged and con-
tains a small cyst 2 cm. in diameter. Spleen — Weight, 240 grms.
NmnerouB band-lil;e adhesions to the diaphragm. Capsule thick-
ened. Soft on section, rather friable, oozes considerable blood.
Liver — Weight, 1770 grms. Numerous band-llbe adhesions to the
diaphragm, capsule thickened, coiistricllon .about the center, firm
on section, bleeds rather freely. Pancreas — Weight, 100 grms.
Rather firm. Kidneys—Weight, left. 125 grms. ; right, 140 grms.
Firm on section, pale in color, considerable pelvic fat, capsule ad-
herent Ovaries email and atrophic. Appendix 15 cm. long, lying
beside the caecum and extending to the under surface of the liver
and is attached to the omentum at the hepatic flexure of the

Microscopical report ; Moderate chromatolytlc changes in the nerve
cells. Central canal of the cord fliled with proliferated epithelial
cells. Fatty iaflltration of the heart. Chronic myocarditis. Ex-
tensive arteriosclerosis, with areas of atheromatous and granular
d^^aeration and perivascular round cell infiltration in the ad'
ventitia. Most of the pulmonary vesicles are fliled with granular
material and a few leucocytes and epithelial cells. Hyperplasia
of the lymph follicles of the bronchial glands with diffuse pig-
mentary infiltration and tubercular involvement. Dilatation of
some Of the thyroid gland vesicles. Intense engorgement of the
spleen with hyperplasia of the malpighian bodies. Diffuse chronic
interstitial pancreatitis. Moderate engorgement of the liver with
some portal cirrhosis. Extensive diffuse nephritis. Numerous
hyaline t)odies in the pineal gland and the choroid plexus.

Female. Age 34. First admission. Reported as having outbreaks
of violence, refusing to eat or speak, confused in action and ideas,
loss of memory, incoherent in talk.

Duration of psychosis : Not given.

Cause of death: Hypostatic pneumonia In status.

Clinical report : Admitted with a psychosis of epileptic insanity.
Has had epileptic convulsions for several years. Began to draw
linlves and cevolvere on people, Became sullea, aud at times tIo-

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lent and coofosed. Reported Bj-philitic. After admission waa
rather qoiet, but Irritable and quarrelsome. Geueral health was
good. Had coiivult^ions several days bc-fore death. Single.

Pathological report: Mouth filled with a frothy secretion. Xn-
rneroue bmiees aliout the beud and face. Xose b^it to the left
and the nares filled with blood. Cranial bones thickened and
cancellona. Dura slightly adiierent to the arachnopia over the
parietal rertlcea. Moderate opacity of the arachnopia. Brain —
Weight. 150 grms. Basal vee-^ls atheromatous. Esteosive grann-
latlons of the floor of the fourth ventricle. Heart— Weight, 200
grms. Considerable epicarilinl fat Extensive atheromatous de-
generation of the larger arteriei^. Lungs — Weight, ^0 grms.;
right, T30 grms. Firm pleuritic adhesions on the left side. Pleura
thickened and the lobes adhereut. Apti'ea firmly nodular, some of
which are caseous. I'osterlor portion cyauotlc-red color, doughy
in consistency, ooze a frothy, bloody fluid. Bronchial glands en-
larged, pigmented and caseous. Thyroid gland^ Weight, 90 grms.
Left lobe more enlarged than the right. I'ersisteut thymus gland.
Spleen— Weight, 120 grms. Firm baud-like adhesions to the dia-
phragm, capsule thickened, consistency soft and friable, bleeds
freely. Liver — Weight, 1180 grms. Finn cord-like adhesions to
the diaphragm, firm on section, several whitish nodules centrally
caseated. Pancreas — Weight, 90 grms. Kidneys^ Weight, left,
145 grms. ; right, 120 grms. Pyramids dark-red in color, small
quantity at pelvic fat, capsule slightly adherent. Omentum firmly
adherent to the right cornu of the uterus. Fallopian tubes en-
larged and distended with a clear fluid, the tip of the left tube
and the left ovary buried In a mass of adhesions. Several small
cysts in the left broad ligament

Microscopical report: Chromatolytic changes in the nerve cells.
Considerable vascular engorgement, pericellular and perivascular
Kpaces prominent. Chronic pericardial thickening, fatty infiltra-
tion of the heart and more or less chronic myocarditis. Consid-
erable a rterio- sclerosis with atheromatous degeneration and foci
of round ceil Infiltration in the outer coat. Intense engorgement
of the alveolar capillaries with rupture of some and filling of
the surrounding vesicles with blood ; chronic pleurisy ; diffuse, ir-
regular tubercular infiltration iu various stages of degeneration
and caseation; fibrosis pigmentation and cellular degeneration.
Chronic bronchitis and peribronchial consolidation. Intense en-
gorgement, pigmentation and tubercular inflifration of the bron-
chial glands. Great irr^jularitj' iu size of th& thyroid vesicles
with more or loss cellular Infiltration of the colloid content of the
smaller ones. Intense eneorgement of the spleen with hyperplasia
oC the malpighlan bodies. Intense engorgement of the liver, ex-
tensive diffuse infiltration with masses of inflammatory corpuscles
between the individual cells and group of liver cells, between the
Individual lobules and groups of iolmlea, wholly displacing the
normal structure, with more or less degeneration of the mas.ses
centrally, surrounded by a zone of fibrous tissue and cells, strands

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146

Of fibrous ttiBue following more or le<"B the course of the portal
flBSures Proliferation of the bile dutts at placts Walls of tbe
blood yesselsp thl'kened and otcluilon of nome Intense engorge-
ment of tbe kidneys with moderate dl&use interstitial aephrltis

Male Age 53 First admission Reported maniacal irrational
incoherent In conrersatlon at times violent.

Duration of psithosls Four jear?

Cause of death Hypostatic pneumonia while in status

Clinlcai report Occupation laborer \dmltted with a psychosis
of acute maniical ex<ltement Convulslon& said to have existed
sii \ears Onset (t mental disturbance about one year before ad
mission by periods of maniacal excitement followm^ the epileptic
seizures st indiiig ariund forgetting things At times would be
\iolent at others stuporous and morose Imiglntd things that
were not so and acted according^ Serial convulsions existed two
dajs before death

Pathological repoit T nunited fra< ture of the metacarpal bone of
the little linger of the lett hand Chronic uWr on the dorsum
of the terminal phalanx of the right thumb L-ranial bones cancel
loua Dura flrmlv adherent to the arachnopla over the frontal
lobes and the parietal ^eitlces Brain— Weight 13o0 grms Right
hemisphere larger thaa the left moderate diffuse opacity of the
arachiiopia slight Increase of subiracbuoidean fluid extensive
atheroma tou-5 degeneration of the basjl arteries Right posterioi
cerebral almost entirely occluded bj an athpromatous patch about
1 cm from its origin right posterior communi atlng abcut twice
the fcize ot the left Jnd takes the place of the corresponding pos
terior cerebril General atrophj of the convolutions Ventricles
dilated Choroid plexus cystic Grauulitlm lu the floor of the
fourth \eutricle Heart— ^^ eight 440 grms Extensive hjjiertm
phj some sclerosis \nd thickening of the eplcardium considerable
cardial fat sclerosis of the margins of the mitral valves with
atherom itous patches m the body of the valves some sclerosis of
aortic valves shortening and thickening of the chordae tendlnae
and papillary muscles Pxtenshe atheromatous defeneration of
the arteries lungs — Weight left 4fi0 grms right 490 grms
Extensive pleuritic adhesions in both pleuritic cavities Right
Side contains several hundied cc of seropurulent fluid Pleura
tbi kened lobes adherent the posterior and lower portion of tbe
right lower lobe collapsed and airless leatherv and splenic like
on section The remainder of tbe posterior portion of the right
lung and also of the posterior portion of the left lung is cvanotic
red In color doughy in c-onsfstencj bleeds freely Minv of the
lobules anterlorh are dilated Numerius smtU nodules scattered
throufjh the substince which are more or leas calcareous and
caseouH Bronchial mucosi awolli n and ( ongested Bronchia!
Uands enlirted plsinented softened and ciseous lh\r<id gland
—Weight OO j,riiis Enlirgemcnt invohmg mostly the mi idle
lobe md the hner pirts of the lateral lobes Spleen— \\ eight
4W) grms Soft friable bleeds freelj mal[igbian bodies proml

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Dent. Liver — Weight. 1610 grms. Oozes considerable blood on
section. Gall-bladder contains II facetted brownlab calculi. Kid-
neys — Weight, left, 135 grms. ; right, 125 grins. Firmly adherent
to the perirenal (at, strlation poorly marlted, considerable pelvic
fat, capsule adherent, a small wliitish nodule 1 cm. in diameter
in the upper and anterior portion of the rigbt liidney. Pancreas —
Weight, 80 grms. Appendix hanging into the pelvic cavity, and
has a constriction 2 cm. from its extremity aod is represented by
a mere fibrous cord.

Microscopical report ; Well marked chromatolytlc changes in the
uerve cells, perivascular and pericellular spaces prominent, tbict-
ening of the walls of the blood-vessels witb eonsideriible narrow-
ing of ttie lumen. Engorgemeot and fibrous tissue increase In the
pituitary body. Chronic pericarditis, extensive fatty inflitratlon
of the heart, consideraljle chronic myocarditis. Extensive diffuse
arterio-sclerosls with irregular atheromatous degeneration. In-
tense engorgement of the liver. Chronic pancreatitis. Foci of
round cell Infiltration in tiie medullary portion of the adrenals.
Cellular infiltration of the smaller vesicles of the thyroid gland.
Chronic pleurisy. Extensive perivascular and subpleural black-
ish pigmentary infiltration. Intense engorgement of the alveolar
capillaries many of the vesicles filled with blood, others tilled with
leucocytes and epithelial cells, others witb granular debris. Ex-
tensive diffuse nephritis witb the interstitial changes predoniinnt-
Ing. 'nie nodule In. the rigbt liidney Is made up of a mass of epi-
thelial-like cells, arranged more or less into alveoli with a distinct
fibrous framework. Alveoli are Irregular in size and shape and the
cells resemble those of the cortical cells of the adrenals. A distinct
fibrous capsule surrounds the mass.
208, Female. Age 52. First admission. Reported sleepless, violent, de-
structive and homicidal. Insane three years before admission.
Married seven years. No children.

Duration of psychosis : Fourteen years.

Cause of death ; Pulmonary tuberculosis.

Clinical report: Admitted witb a psychosis of maniacal excitement
beginning three years before admission. Since admission has been
very much demented, scarcely uttering an intelligible word. Has
bad on an average two seizures a day and has bad attacks of
status four or five times during the last five years. At times she
was noisy and destructive. Frequently required restraint on ac-
count of filthy habits, soiling the clothing and eating the faeces.
During the last year the patient has been gradually declining
witb cough, expectoration, continuous temperature running from
101 to 103 F., rapid pulse, tenderness on pressure over the abdo-
men, profuse semi-fluid stools, which were extremely offensive,
resisting almost wholly medicinal treatment. Had no seizures
during the last six weeks.

Pathological report: United fracture of the nose. Bed sores over
the sacrum and both trochanters. Cranial bones thick and can-
cellous. Dura adherent to the arachnopla over the parietal ver-

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tices. Opacity of the araobnopia. Moderate increaBe of tbe aub-
arachnoidean fliiid. Brain — Weight, 1100 Erms. General atrophy.
Ijeft hemisphere smaller Uian the right, LiiiigR — Weight, left, 690
grms. ; right, IdO grms. Right pleural ciivity obliterated by firm
adhesions, extensive firm adhesions on the left side. Pleura thick-
ened, lobes adherent, a local collection of purulent fluid in the
lower and posterior portion of the right pleural cavity. Extensive
diffuse, irregular nodular infiltration, with extensive degenera-
tion and cavity formation. Portion ot the base of the right lower
lobe underlying the purulent collection is collapsed, airless and of
a splenic-!lke consistency. Bronchial and tracheal nmcosa swol-
len, thickened, congested and covered with a viscid mucopurulent
secretion. Bronchial glands enlarged, pigmented and easeate.
Heart— Weight, 210 grms. Slight fatty InHltratlon of the right
ventrical. Slight arterlo-sclerosis. ITiyroid gland—Weight, 00
grms. Slight enlargement, mostly of the middle iohe. Omentum
adherent over the outer and lower portion of the caecum, separa-
tion opening a cavity containing purulent matter lying behind the
caecum in which lies the appendix: swollen, thickened and ulcer-
ated. Spleen — Weight, 270 grms. Moderately firm. Liver —
Weight, ICOO grms. Moderately firm and of a waxy consistency
and appearaiice. Kidneys — Weight, 140 grms, each. Cortex pale
in color, small amount of pelvic fat, pyramids deep red in color.
Pancreas— Weight, 90 grms. Gastric mucosa rough, granular
and thickened. Numerous tubercular ulcers and nodules
throughout the small Intestines, caecum and ascending colon. Dif-
fuse enlargement of the mesenteric glands. Several interstitial
flbroide of the uterus. Granular ulceration of the cervix.

Microscopical report : Chronic pleurisy. Extensive massive tutwr-
cular infiltration of the lungs, some intervening emphysema, en-
gorgement of the alveolar ciipillarles. Chronic bronchitis. Hyper-
plasia of the lymph follicles, pigmentation and tubercular infil-
tration of the bronchial glands. Brown atrophy and some frag-
mentation ot the cardiac muscle. Some endarteritis. Extenslvo
increase ot fibrous tissue in the thyroid gland, vesicles small and
mostly filled with proliferated epithelial cells, a clrcumserlbed
mass made up of epithelial cells arranged more or less into alveoli,
with a fibrous tissue framework carrying the blood-vessels, sur-
rounded by a capsule of fibrous tissue. Intense engorgement and
fibrous tissue increase In the pituitary body. Hyperplasia of the
splenic corpuscles. Slight diffuse increase of fibrous tissue In-
crease in the pancreas. Extensive fatty degeneration of the fiver,
with diffuse infiltration of foci of tubercular nodules more or less
degenerated. Chronic parenchymatous nephritis, with foci of
round cell infiltration.

Male. Age 5fi. First admission. Reported restless, sleepless, mel-
ancholic, not inclined to talk much, but when doing so Incoherent,
wanders about, profane. Intemperate, at times violent, threatening
those about him.

Duration of psychosis: Fifteen years.

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riiuM> <>r il<>itli \<ut< <tllitiil>ii of the riiclit licart

lliiiliiil re|Hirt t>>>u]Mll<>ii mriKiilfr Vdiiiltlid with tUe iiIhim
reimrt Atlcr ii(liiii«iii)ii utKkrntnt u ur iilua! progress-lve ile-
inentla with <>(■( iiiunnl [Hrlods nf conruHiun a<.tnui|>iinring the
eiiUeptk wlKure^ OL'-tt of inent»l dlHturh iiir e occurred about
two veir-. before foUowiuc lu iltxk of In grippe Phjeicil
heiiltta nas fair Ihe i^iilleptlc stl^uroR nerp of the grand mal
U|>e ociurrliig lu groups of three or four mid lit lutervala of
seierul luoutlis tour iiioiilh-t liefore he contrai ted septic lutlaiu
inatiOD of Iht leg nhitti hdiiid iiiiiie tluie liefore deiith On the
luoraing of bis death lie hud a seieic Hel/ure and nlxiut uoon
aiiotlier durlni; nlikh lie dlid "Mitral uiutes liitemiierate Pa
tient addicted tu luurplila

I'atbologicat report : Arcus vi-ii1I1k well marked. Opai'lty of the
right lens. Consldcrnbie cyaiiOHis. Cranial bones cancellous. Dura
flrmty adherent to the arachiiopla over the parietal vertices. Ex-
tensive opacity of the ararelmoiiia. .Moderate increase of sub-
dural fluid. Brain — Weight. I'JSM grniB. Basal vessels atheroma-
tous. General atrophy of tlie convolutions. Lateral ventricles
diluted exiensively. E|)endyiiia grauuliir throughout. Pineal glaud
enlarged and ealcareous. Hearl— Weight, 410 grms. Left side
exteiuilvely hypertropbicd, tbc right e.\tremely dilated ; consid-
erable scterosiH of the eplcardiiim, mitral vulvee extensively thick-
ened forming a dentfc ring narrowing the orifice so that It admits
only one finger, left auricle dilated and walls thickened, aortic
valves thickened and Infiltrated with calcareous matter. Exten-
sive arterio-sclerosls and atheromatous degeneration, the coronary
vessels extremely ho, almost occluding the lumen at places. Lungs
— Weight, loft, 440 grms. ; right, SfiO griiiw. Extensive pleuritic
adhesions in both cavities. Pleura thickened. Lobes adherent.
Lungs cyauotic-red in color, doughy in consistency, irregular
masses dark-red In color and firmer than the intervening sub-
stnn<'e, and somewhat granular In apiiearancc. In the apex of
the right lower lolre is a mass of consolidation, dark-red in color,
caseous centrally, surrounded hy a zone gangrenous and semi-
solid, emitting a foetid odor, Kurroundlng wliicb is a zone of pneu-
moni<! consolidation. Bronchial mucosa swollen and congested.
Bronchial glands enlarged and pigmented. Tliyroid gland some-
what enlarged. Spleen — Weight. n20 grms. Soft, friable, bleeding
freely on section, nialplglilan bodies prominent. Liver — Weight,
1410 grms. Firm on section, rough In npjiearance. Kidneys —
Weight, left. 100 grms. ; riglit, 175 grms. Moderately adherent to
the perlreiial tissues, firm on section, pide red In color, conslder-
erable pelvic fat, several cortical cysts, eapwule strips, but leaves
n rough surface. Bladder distended with urine. Prostate en-
lai^ed. Pancreas — Weight, 85 grins. Firm and white on section.
Gastric mucosa thickened, rim^'h and granular looking and cov-
ered with a viscid secretion.

Microsi-opical report : Moderate ehromatnlytic changes In the nerve
cells; ix-rivascular and pericellular spaces large, some filled with

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dense round iwll collections. Ceiitnil cuiml of the cord filled with
Iiroli tern ted epithelial <i;lls. Kngorgement of the blood-vesaelB,
thickening of tbe iirterial walls. NumerouB hj^allne iKxliea in tbe
choroid plexus. Plneol gland made up of epithelial cells arranged
more or less Into alveoli and contains numerous hyaline and cal-
careous bodies. Chronic pericarditis with foci of dense round cell
collection. Moderate fatty infiltration of the riebt ventricle of
tbe heart, considerable chronic myocarditis. Extensive arterio-
sclerosis with more or less atheromatous degeneration. Chronic
pleurisy. E.tteusive suhpieural blacliish pignientary infiltratiwi.
Intense engorgement, thickening of the vascular walls ; extensive,
diffuse, fibrous tissue Increase; masses of consolidation, many
vesicles lilted with blood, others with a more or less degenerated
debris. Increase of fibrous tissue in the thyroid gland with dila-
tation of many vetltles. many of the smaller ones filled with pro-
ilfen\te epithelial cells. Intense engorgement of the spleen and
hyperplasia of the splenic corpuscles. Chronic interstitial pan-
creatitis. Extensive diffuse cirrliosis of the liver. Moderate dif-
fuse nephritis. Intense engorgement and foci of dense round cell
infiltration of tlie medullary portion of the adrenals.

ClUCULAR INS.\NITY.
2]I>. Female. Age GO. First admission. Reiiorted as bnving periods of
melancholic depression alternating with periods of maniacal ex-
citement, the latter predominating.

Duralion of psychosis ; Not given.

Cause of death ; General septic peritonitis.

Clinical report: Admitted with a psychosis of melancholic depres-
sion. After adniipsion this gave way to a period of maniacal ex-
citeinent. Tbese periods alternated at Irregular intervals. About
ten days before death she was taken with a complete left hemi-
plegia, which disappeared in about three days. She recovered
sufficiently to be able to l>e about when she was seized with an
attack of severe entero-coiitis, temperature 102, stools containing
siome blood. Tills subsided in about five days. On the mwTiing
pre(«ding death It was found that she could not urinate. Cathe-
terization was tried, but failed, Siipraptiblc aspiration was per-
formed and about 75(> cc. of purulent, thick ammonlacal urine
was taken away. Later she became comatose, which deepened
until death ensued.

I'af hologlcal report : Abdomen distended and tympanitic. Throe
punctate openings in the median line of the abdomen above tbe
pubis. Cranial bones rather hard. Frontal sinuses very large In
the vertical portion of the frontal bones. Moderate dural adhe-
sions to the arachnopia over the parietal vertice. Diffuse opacity
of the araclmopia. Some increase of subdural fluid. Braln^ —
Wpiglit, lliiO grms. General atrophy of the convolutions. Basal
vessels ntiieromatous. Ventricles dilated. Ependyma granular
throughout. Heart — Weight, 210 grms. Moderate amount of epl-

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cardial fat. Some utheroiuatous degeueratlou of the luitrul valves.
Extensive aterlo-SL-lerosls. with irreguliir iitlieroiiiatous ilegeiwrii-
tiou. Lungs— Welgbt, left, 3*M grms. ; right, 3iO grius. Esteusive
Hriii pleuritic adlieeious ou the right i^iiie, Ooslul curtlluges o«ai-
fled. Posteriorly cyaootic-red lu color aad doughy cmiBisteucy,
apical and marginal enipbyseiun, several scattered foci of cal-
careous intlltration. Bruuchial glaud»t enlarged and pigmented.
Thyroid gland small. Omentum adherent over the pelvic cavity,
and on separating a bloody, auiniouiacul, purulent, foul-aiuetllug
Huid escapes, wliich Is found to permeate the whole peritoneal
cavity. The peritoueum and omentum are deeply injected, aud
covered with a yeliowisti white plastic exudate cementing all the
structures together. Spleeu — Weight, 00 grms. Dark red In color

. and moderately firm. Liver — Weight, 1200 grms. Pule yellowisii
color. Gall-bladder contains one soft brown calculus. Kidneys —
Weight, left. Its grms.; right, 150 gnns. Adherent to the peri-
renal tissues, large amouiit of i>eivic fat, diffuse whitish foci scat-
tered througli the substance, capsule adlierent, pelvis contained a
bloody fluid like that in the general peritoneal cavity. Ui-eters
dilated, congested and fliled with a similar fluid. Bladder dis-
tended and filled with a similar fluid, its walls thickened, the
mucosa congested and granular looking. Near the upper part of
the posterior wall is an area 2 cm. in diameter, grayish-i'ed in
color, perforate<l by several small openings and the surrounding
tissue infiltrated with recent extravasations ot blood, continuing
into the anterior abdominal wall. Urethra constricted 1 cm. from
its orifice, admitting only a small probe. Pancreas — Weight, 90
grms. Appendix hanging into the pelvic cavity. Peritoneal coat
of the intestines injected, covered with a plastic exudate cement-
ing them more or less together.

Microscopical report; E.\teusive round cell Infiltration of the arach-
nopia, most marked about the i>lood- vessels, the Inflltration fol-
lowing the pial strands into the brain -cortex, plugging some of
the vessels, fliling the perivascular spaces more or less ; walls
of the blood-vessels thickened more or less. Extensive chromatoly-
tlc change In the uerve ceils. Moderate fatty infiltration of the
heart. Extensive rfironic myocarditis. Extensive arterio-sclerosis
with more or less atheromatous degeneration. Most of the small
vesicles of the tliyroid glaiid fliled with epithelial cells. Numer-
ous hyaline bodies in the choroid plexus. Pineal gland made up
of epithelial ceils more or less arranged iuto alveoli and infll-
trated with numerous hyaline and calcareous bodies. Chronic
pleurisy. Some emphysema. Some interatitial alveolar increase.
Chronic bronchitis. Diffuse pigmentation of the bronchial glands.
Extensive hyperplasia of the mesenteric lymph glands. Chronic'
gastritis. Intense engorgement of the spleen with hyperplasia of
the malpighian l)odies. Chronic venous congestion of the liver with
some portal cirrhosis. Engorgement of tiie kidneys, slight Inter-
stitial increase, foci of dense round cell collections in the medul-
lary portlcm. Engorgement and foci of round cell iuQltratiou in

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the adrenals. Acute peritonitis. Acute appendicitis. Acute cys-
titis witli focal necrosis superadded upon a chronic crstitis. Fi-
broid stricture of the urethra. ,

ACXJTB CONFUSIONAL INSANITT.

Female. Age 67. First admission. Reported continuously excited,
wandering away from home, untidy iu her habits, destructive to
her ctotblDg, in it state of continual motor activity. Eats and
sleeps poorly.

Duration of psychosis: Three months.

Cause of death : Pulmonary tuberculosia.

Clinical report: Admitted with a psychosis of maniacal confu-
sion beginning two months iDefore admiBsion with the above re-
port. On admission was greatly emaciated in a state of collapse,
puise feeble and rapid, tongue coated, extremities cold, in a state
o( mental confusion, not being able to recogoize time, place or
members of her own family. Apparently improved for a few
days after admission, but had an evening rise of temperature from
101 to 103, suffered from retention of urine and pain over the
bypogastrlnm. Urine contained considerable sediment and mucus.
There was dullness on percussion below the right clavicle, vesiculo-
bronchial breathing on both sides, breathing generally shallow.
Gradually underwent more and more emaciation and exhaustion.

Pathological report ; Extensive emaciation. Diffuse opacity of the
arachnopla, great increase of subdural and subarachnoidean fluid.
Brain — Weight, 1255 grms. Heart^Welght, 230 grms. Extensive
arterio-sclerosis. with Irregular patchy atheromatous degeneration.
Lunga^ Weight, left, 325 grms. ; right, 190 grms. Extensive firm
pleuritic adhesions in both cavities. Pleura thickened and the
lobes adherent, nodular infiltration of all of the apices, some of
which are caseous and calcareous, some hypostatic congestion of
the right lung posteriorly. Bronchial mucosa congested. Bron-
chial glands enlarged, pigmented and caseous. Caecum and ap-
pendix lying in the pelvic cavity. Liver — ^Weight, 950 grms. Nut-
ra^ In appearance. Kidneys — Weight, 110 grms. each. Striation
indistinct, pale in color, pelvis dilated and filled with a grumous
bloody fluid; mucosa thickened, reddened, granular appearance
with numerous baemorrhagic foci. Ureters dilated, walls thick-
ened and the lumen filled with fluid similar to that in the pelves
of the kidneys. Bladder mucosa thickened and reddened, the cav-
ity containing a bloody purulent fluid. Cysts in the left ovary
and parovarium. Numerous fibroids of the uterus subserous, in-
terstitial and submucus.

MIci-oscopieal report: Extensive chromatolytic changes in the nerve
cells. Chronic myocarditis. Moderate arterio-sclerosls and Irreg-
ular atheromatous defeneration. Pulmonary emphysema of the
portions between the areas of consolidation. Diffuse miliary tu-
bercular infiltration, more or less degenerate centrally. Hyper-
plasia of the lymph follicles of the bronchial glands with pigmen-

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tation and caseation. Chronic venouB congestion of the liver.
Small foci of heamorrhaRC Into tbe pancreas. Diffuse acute nepli-
ritis with dense cellular Infiltration la the medullary portions fol-
lowiDg more or less the course of the tubules. Acute pyelitis.
Acute ureteritis. Acute cystitis.

Female. Age '2i. First admission.

Duration of psychosis : Six weeks.

Cautie of death : Acute lobar pneumonia.

Clinical report: Extremely emaciated when admitted, skin hot and
drj-. Tongue dry and furred. Face congested. Temperature
103.3 F. Incrensed pulse aud respiration. Dullness on percussion
over the right lung except over tbe atjex and anterior margin.
Increased vocal fremitus. Broiicblal breathing most marked over
the apes of the lower lobe. Bubbling rales. Left side hypertes-
onant. Bronchlal-vesic'ular breathing. Pulmonary second sound
accentuated. Considerable cough. Mental condition one of active
delirium. Considerable confusion. Could concentrate herself to
answer questions only with difficulty in regard to herself and
family.

Pathological report: Extreme emaciation. Pupils dilated. Teeth
covered with sordes. Tongue furred. Cranial bones thick and
compact I>ura adherent to the archnopia over the frontoparietal
vertices. Diffuse opacity of the arachnopla. Slight increase of
subdural and subarachnoldean fluid. Brain — Weight, 1180 grms.
Convolutions pale aud appareutly flattened. Lungs — Weight, left,
200 grms.; right, 850 grms. Firm pleuritic adhesions In the left
cavity. Acute fibriuo-plastic adhesions ob the right side. Pleura
on the left side thickened. A few calcareous nodules in the left
apes. Right pleura acutely inflammed, lobes adherent, lung solid,
except tie apex and the anterior margin of the upper and middle
lobes. Cut surface of a mottled grayish-red color, moist granu-
lar looking blood-vessels filled with coagulated blood. Bronchial
mucosa on the right side congested. Bronchial glands enlarged
aud softened. Heart — Weight, 220 grms. Enlarged right side
dilated and distended with blood. Heart muscle soft aud flabby.
Spleen— Weight, 100 grms. Malpighlan bodies prominent. Liver
■ — Weight, 1100 grms. Dull yellowish -red color. Lobules indistinct.
Kidneys— Weight, left, 120 grms.; right, 130 gnus. Cortes pale
red color, pyramids dark-red. Bladder distended with urine.
Pancreas — Weight, 85 grms. Stomach contracted.

Microscopical report: Gray hepatization of tbe lungs. Hyperplasia
of the lymph follicles of the bronchial glands. Hyperplasia of the
malpighlan bodies of the spleen. Cloudy swelling of the epithelium
of the liver and kidneys,

TOXIC INSANITY.
Female. Age 45. First admission. Reported restless, sleepless,
melancholy, seclusive. Imagined tliat people were making fun
of her and enjoying her mlsfoitune. Becomes very angry. Is
emaciated and complains of gastric distress. Uses morphia.

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153

Duration of pByphosis; Fifteen months.

Cause of deatb: Gastric carcinoma.

Cliiiicnl report: Admitted with a psyclioBiB of morphinomanla.
I'bysical manifestations of emaciation, general debility, vomiting
after meals. Said to hare had stomach trouble oyer a year,
Jlentally bad persecutory delusions, beginning one month prior to
admission. On admission there coutd be felt a nodular mass fllllng
the epigastrium, trausmitting the aortic pulsations, abdomen was
tense and tender, and carcinoma was diagnosed.

I'athological report: Extreme emiiciatlon. Pupils dilated. Small
ulcer of the left nares. Tongue furred. Right lobe of the thyroid
enlarged. Some oedema of the lower limbs. Cranial bones thin
and compact. Increase of subdural and subarachnoidean fluid.
Brain — Weight, 1250' grms. ' Choroid plenus cystic. Heart —
Weight, 190 grms. Pericardial cavity contained aljout 50 cc. oC
serous fluid. Considerable epicardifll exudate. Patent foramen
ovale. Extensive a rterio- sclerosis, with Irregular patchy atheroma-
tous degeneration. Lungs — Weight, . Firm pleuritic adhe-
sions in both pleural cavities, left cavitj' contain 500 cc. of serous
fluid, while the right contains ]0CO cc. of the same fluid. The
posterior portion of the left lower lobe is collapsed and airless.
The right lung is diffusely nodular throughout, with more or less
caseation. In the anterior part of the right up|>er lobe is a large
cavity. Bronchial mucosa swollen and the lumen fliled with a
niuco-purulent secretion. Bronchial glands enlarged, pigmented
and more or less caseated. Right lobe of the thyroid gland cys-
tic. Peritoneal cavity contnins several hundred cc. of creamy
imnilent fluid, numerous firm adhesions In the upper abdominal
and pelvic region. A large irregular nodular mass occupying the
epigastric region and extending into the hypocboudrlal and um-
bilical regions with extensive adhesions to and between ail the
stmctures. Spleen — Weight, 14S grms. Firmly adherent to ad-
joining stiTjctures ; capsule thickened, moderately firm on section.
Liver — Weight, lOTO grms. Firm adhesions to the diaphragm
alwve and to the underlying structures, capsule thickened, mod-
erately firm on section. Gall-bladder adherent to the adjoining
structures and covered with a fibrinous yellowish exudate, and
contains five small brownish calculi. Kidneys — Weight, 150 grms. ;
right, 125 grms. Cortical strtatlon Inillstlnct, pale in color, cap-
sule adherent. Bladder adherent to a mass on the posterior sur-
face, consisting of looiis of small Intestines, I'ectum, uterus, tubes
and ovaries, Ulenis retroflexed, tubes dilated and distended with
a puriilent fluid and tlie walls thickened. Stomach firmly adher-
ent to the adjoining structures,, the pyloric end thickened and nod-
ular, cavity contains considerable grumous material. Completely
encircling the lumen and occupying the pyloric third, the mucus
surface has a warty, ca nil flower-like appearance, its margins rather
sharply defliied, the walls thickened and nodular, the pyloric orl-
Hce narrowed. On Us lower border about 5 cm. from the orifice is
an Irregular opening couunun lea ting with (he duodenum. On the

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anterior wall is another opening communicating with the colon.
The mass infiltrates tbe duodenum and the colon. Mesenteric
and retroperitoneal glands enlarged and firm, rather whitish on
eecttoo.
Microscopical report ; Extensive chromatolytlc changes in the nerve
cells. Prelvascular iind jterlcellular spaces prominent. Central
canal of the cord filled with cells. Numerous hyaline bodies lo
the choroid plexus and in the pineal gland. Moderate fatty Infll'
tratlon ot the heart. Chronic bronchitis, with considenible peri-
bronchial pneuinonlc consolidation and more or less degeneration
and some ulceration. Cystic distension of some of the thyroid
vesicles. Chronic venous congestion of the liver. Chronic gas-
tritis. Encephatoid and alveolar carcinoma of the stomach. Sec-
ondary carcinomatous InBltratlon of the duodenum, colon, mesen-
teric and retroperitoneal glands. Chronic diffuse nephritis.

GENERAL PARESIS.

Male. Age 4G. First admission. Re[)orted ns a general paretic.

Duration of psychosis : Two years.

Cause ot death ; Hypostatic pneumonia.

Clinical report ; Admitted with the typical symptoms of general
paresis. Delusions of great wealth. Very destructive to his
clothing. Restless and a tendency to wander. Onset five months
before admission by general apathy, inattention to self and his
surroundings. Imagines that he has great business enterprises,
important positions, large poultry farms. Has a general feeling
of well being, is emotional, incoherent, somewhat confused in
thought and actions, and is subject to outbreaks of violence. Mar-
ried. Occupation, railroad watchman.

Pathological report : Pupils unequal and dilated. Cranial hones
thickened and cancellous. Dura adherent over the frontal and
parietal bones and to the arachnopia over tiie parietal vertices.
Diffuse opacity of the arachnopia. Great Increase of subdural and
suharachnoidenn fluid. Brain— Weight, 1200 grms. General atro-
phy of the convolutions. Basal vessels moderately atheromatous.
Ependyma granular. Heart — Weight, 450 grras. Generally hyper-
trophied. Moderate sclerosis of the aortic valves. Moderate s
terlo-sclerosis. Lungs — Weight, left, 350 grms. ; . right, 500 gm
Cyanotic-red color posteriorly, doughy In consistency, bleeding
freely from the doughy porlions on section. Bronchial glands e
larged and pigmented. Omentum adherent over the pelvic stn;
tures, deeply congested at its lower part. The pelvic cavity co
tains a yellowish -amber colored fluid. Peritonenm deeply cci
gested and somewhat granular in apimarance. Spleen^ Weight, 70
grms. Firm on section. Liver— -Weight, 1300 grms. Somewhat greasy
on section. Kidneys— Weight, left, 195 grms.; right, 170 grms.
Pale in color, striation fairly distinct, several cortical cysts, nu-
merous foci of submucus ecchymosis In the pelves, capsule adher-
ent. Colla of the small intestines hanging into the pelvic cavity,

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deeply Injected and granular-looting on the peritoneal anrface.
The posterior wall of tlie bladder presents an Irregular opening.
ragged, margins slightly imjnrated and thickened, the eurronndlng
tissue inflamed and softened, surface somewhat worm-eaten in
appearance. Bladder mucosa swollen, deeply congested and soft-
ened.

Microscopical report : Extensive ehromatolytic changes in the nerve
cells. Numerous hyaline bodies in the choroid plexus. Sclerosis
of the arterial walls. Proliferation of the ependymal epithelium.
Chronic myocarditis. Moderate a rterlo -sclerosis. Intense alveolar
engorgement with rupture of some of the capillaries and filling
of the vesicles with blood, some leucocytes and epithelial cells.
Intense engorgenient of the spleen, Oliroiiic venous congestion of
the liver. Extensive diffuse nephritis. Acute cystitis with ulcera-
tion of the posterior wall.

Male. Age 55. First adniiaaion. aborted violent in his conversation.
Imagined that dudes and slick people were after him, that his
wife was trying to poison him, that he had an income of 59 dollars
per minute, that he was a candidate for the presidency, that be
must murder certain people to protect himself and so wants to
injure those with whom he comes In contact.

Duration of psychosis : Three years.

Cause of death : Pulmonary tuberculosis.

Clinical report : Admitted with a psychosis of general paresis upon
a tabetic basis with the above report. On admission he com-
plained of severe pains in the feet, at times had ulcers, could not
control the bladder, suffered from diarrhoea ; had the typical walk
of locomotor ataxia, which gradually grew worse. Married. Oc-
cupation, salesman.

Pathological report ; Bed sores over the sacrum and trochanter.
Cranial bones cancellous. Dura adherent over the frontal and
parietal hones. DltfuRe opacity of the arachnopja, which is more,
or less adherent to the brain substance. Great Increase of sub-
dural and subaraeh not dean fluid. Bra I n^ Weight, 1280 gtms.
General atrophy. Consistency firm. ^'eHt^lclea dilated. Ependy-
ma granular throughout. Posterior columns of the cord gray,
most marked in the lumbo-sacral enlargement. Cord small and
firm, bungs — Weight, left, 815 grms.; right, 800 grms. Thorax
barrel -shaped. Kx tensive pleuritic adhesions throughout both
pleural cavities. Pleura thickened and the lobes adherent. Ex-
tensive diffuse consolidation, with more or less caseation and cav-
ity formation In both apices. Bronchial glands enlarged, pig-
mented and more or less caseous. Bronchial mucosa swollen and
congested and the lumen contains a muco-puroleut secretion.
Heart — Weight, 220 grins. Patent foramen ovale. Moderate
sclerosis of the mitral and aortic valves. Muscles firm and numer-
ous : whitish streaks through tlie substance. Extensive arterio-
sclerosis and atheromatous degeneration of the arteries. Spleen —
Weight, 240 grms. Splenic artery large, tortuous, thickened and
atheromatous and calcareous. Liver — Weight, 1315 grms. Nutmeg

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Id a[iii«araiy:«: pt)l-Ks'H*-r containiii! twy irii-u:!. Kiilue,v:i —
W^jgliL krlt. y^l grmt^-: rrfit, !.■» em;*. I'.-iSe iu ivj-.r. nniiterous
rtink-aJ c-j>i^ <vti-;<i^ral']<f |«Hvit fat. '.-jjiiuV ftiii* re*dily. Pan-
iT*au' — \Vpi:rlii. 110 znus, SutiifT'-Ms lu*":-r.-u:ar n<"lules and aloere
w-ailercd Ibriru^lfitn itw Ha.tll iiitestin*i. iin:«*T ii:arked in the

Mi'rrrj«i>i4<a! n^-on : Eilrn'ivp '■hiV'Uial'JrTlc change* in Ihe nerre
<*;i«. Hr<>lifera;ii'n 'ff ihe epeudvma ep:ilie!inni. S*'leni«is of
tbe pnwieri'jr <.itluniiiB of ihe oord and of the pr«terii>r roots and
eaneiU. Cbronic myocarditis. Estentiive anerio.(ii:-;erosls and Ir-
T^gular atherouiat'iu" degenerati.in of ihe arteries. Chronic tn-
berimlar plenrliy. Eitensive invrular in:i<ieft of toti«riiili)r con-
wtliilatioa of ibe lunpt in all sraspii of ik-seiioration. Eitr^ue
fatir iiifiltrution of the liv«-. Extensive diffuse nejihritis. the
ancrio-w-leroti<? iiiid iKireni-liyuuiion^ i-iiau^e^ |>reiIominatin^ Hy-
ijerpluKla of Iht- iii:il|-i^)ii:in Ix.xhiv of tlie ^pltvn wiih nodules of
tuberiniliir inflltniiion i^howiui; more or less degeneration. Fatty
de^neration of tbe panereas. Tuheronlar infiltraiion and alcera-
lion of the intestines.

Feniaie. Age -l-'I. First adniis.sioa. Reporied .icutely maniacal.

Duration of pe.vchosis: Two and one-lialf yeiirs.

Cause of denth : Hypostalic pneumonia.

Cllnfi^l reiiort: Admitted in a $laie of acute uianiacal psychomotor
activity. Sis weeks after admi^ion tieeame depressed, remaining
HO for several wet*s. During the last year of her illness tliere
develofMfd qci.sricity in gait, exaggerated retleses, .irgyle-Robertson
pupi), general tremor, ankle clonus ; s|>eech and writing defect
characteristic of paresis. Was seized with severe couTlusious.
wlifcb were followed by stupor for several days, after which there
was a marked Increase of all the physical and mental mauifesta-
tloriM with rapid and progressive decline.

Pathological report : Irregular pupils. Incised wound over the
right Inguinal region beneath Poupart's ligament, discharging
purulent material. Extensive sacral decubltu!<. Cranial bones
thin, but compact. DifFuse opacity of the meninges. Great in-
crease of sulMlural and subarachnoidean fluid. Brain— Weight.
mM} gmi». General atrophy of the convolutions, \'entricles di-
lated. Choroid plexus cystic. E^eodyma granular throughout.
Blood-vessels atheromatous. Heart — Weight. 1T5 gnus. Some
sclerosis of the mitral and aortic valves. General arferlo-^lerosis
with irregular atheromatous degeneration. Lungs — Weight, left,
310'grmH. ; rigbt. 260 grms. Firm pleuritic adhesions at the base
of the right lung, posterior portion of the lungs of a cyanotic-red
color, slightly dougliy, ookc considerable bloody ttuld. Llver^ —
Weiglit. VM5 grms. Several cicatricial scars on the dorsum of
the right lobe. Firm on section. A small cyst on the anterior
surface filled with clotted, bloody fluid. Kidneys — Weight, left,
115 grms.; right, 300 grms. Firm on section, pale red color, cap-
sule stripping readily. Spleen rather tirm on section. Inguinal
glands enlarged. Right tube and ovary absent Ijeft ovary cystic.

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MicroBcoplcal rejiort : Extensive I'hroinatolytic cbflngea In the nerve
cells. Bloi)d- vessels ihickeued. Moderate arterio-selerosis and Ir-
regular fltlieromatous degeneration. Cloudy appearance of the
liver cells. Capsule thickened and some portal cirrhosis. Mod-
erate diffuse nephritis; intense engorgement of the pulmonary
capillaries and peribronchial pneumonic consolidation.

Male. Age 53. First admission.

Duration of psychosis : Twelve years.

Cause of death : Paretic convulsions.

Clini<'al report : Admitted with a dementia of ten years' standing.
Had been in failing health several months. Had severe attacks
of diarrhoea for several mouths and ended with pulmonary fail-
ure and weak pulse.

Pathological report; Cranial bones thin and compact. Dura mml-
erately adherent to the cranial bones. Diffuse opacity of tlie
araehuopla. Great Increase of the subdural and subarachnoidean
fluid. Bralu^ — Weight, 1350 grms. General atrophy of the convo-
lutions. Extensive atheromatous degeneration of the basal ves-
sels with considerable calciflcatlou. Heart — Weight, 460 grms.
Considerable eplcardlal fat. Extensive atheromatous degeneration
of the arteries. Lungs— Weight, left. 880 grms. ; right, 1240 grma.
Posteriorly dusky-red in color, bleeds freely when cut, consistency
livery throughout. Bronchial glands enlarged and deeply pig-
mented. Spleen — Weight, 200 grms. Malplghian bodies prominent.
Consistency similar to that of the lungs. Liver— Weight, 1900
grms. Kidneys— Weight, 190 grma each. Pale In color. Arm on
section, considerable pelvic fat, capsule adherent. Body embalmed
some hours Iwfore autopsy.

Male. Age 30. Third admission. Reported talkative, noisy, with
delusions of grandeur and a sense of well-being.

Duration of psychosis : Three and a quarter years.

Cause of death : Paretic convulsions.

Clinical report : Admitted with a psychosis of melancholia and de- .
lusions of fear. Furloughed in September and readmitted in De-
cember, with delusions of grandeur and with slight loss of weight.
Furloughed again and readmitted in August. Had frequent con-
vulsions, increasing in severity.

Pathological report: Extensive decubitus. Cranial bones compact.
Diffuse opacity of the arachnopia. Great Increase of subdural and
subaraehnoldean fluid. Braln^ — Weight, 1350 grms. General atro-
phy. Heart — Weight, 250 grms. Sloderate sclerosis of the aorta.
Lnngs — Weight, left, 230 grms. ; right, 250 grms. Considerable
subpleura! pigmentation. Transverse colon U-sliaped and lying
midway between the pubes and umbilicus. Liver — Weight, 1350
grms. Firm adhesions to the diaphragm. Capsule thickened.
Spleen— Weight, 1!I5 grms. Rather firm and relative trabecular
Increase. Kidneys — Weight, left, 135 grms. ; right, 125 grms. Mot-
tled light and dark red color, of the cortex. Arm on section, very
little pelvic fat, capsule adherent.

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Microscopical report : Brain and cord not examined. Moderate
arterlo-scleroeis. Chroulc perihepatitis. Estenslve dItCuse neph-
ritis.

Mule. Age 37. Flrat admission. Rei>orted restless, aleeples-s, melan-
choly. Complains of pain in tlie liead. Is nlwa.vs in a deep study.
Does not recognize his friends. Cause 8uinx)sed to be due to an
Injury to the head and to tbe loss of Ills position.

Duration of psychosis : Ten months.

Cause of death: Paretic convulsions and puliiioiiary oedema.

Clinical report: Admitted with a psychosis of general paresis. l>e-
glanliig one month before admission. On tidmisslon was fairly
well nourished. Had the pupillary signs of jmresla, well-uiarked
motor paresis, mental weakness, megalomania uud complete dtS'
orientation. After aduilsp>l<)n thei« were iMjrloda of excilement
followed by exhaustion, EpileptoiU convulsions. llespiratory
emharrassment. I'ulraoiiaiy dullness posteriorly. Broncho- vesi-
cular breathing. Moist rales and cyanosis.

Pathological report: Cranial bones cancellous. Diffuse opacity and
Increased thickness of tlie arachnopia with adhesions to the brain
subsfanee. Considerable Increase of subdural and subarachnoidean
fluid. Brain— Weight, 1380 grnis. General atrophy of the convo-
lutions. Lungs — Weight, left, &10 grms. ; right, 780 grnis. Firm
pleuritic adheslou» at tbe base of the right lung. Lungs of a
cyanotic red color, doughy In consistency, bleed freely on section.
Bronchial and tracheal mucosa congested. Ileart^Weight, 310
grms. Sclerotic patches In the eplcardium. Hypertrophy of the
left ventricle. Moderate arterio-sclerosis with patciiy atheroma-
tous degeneration. Spleen — Weight, 110 grms. Moderately finn
on section. Liver — Weight, 1000 grms. Pancreas — Weight, 125
grms. Kidneys — Weight, left, ItiO grms. ; right, 145 grms. Small
quantity of pelvic fat, capsule stripes readily. Considerable en-
largement of the prostate.

Microscopical reiwrt: lOxtensive chroma toly tic changes In the nerve
cells. Intense rouud cell infiltration of the pla and moi^e or less
of the plal prolougations into the brain substance. Many hyaline
bodies la the choroid plexus. Moderate arterio-sclerosis. Involving
mostly the Intlma. Intense engorgement of the alveolar capil-
laries, with rupture of some and hlllng of the surrounding vesi-
cles with blood. Vesicles geuerally dilated and some C'ontaln many
leucocytes and desquamated epithelial ceils. Chronic venous con-
gestion of the liver. Arterlo-sclevosis and relative trabecular In-
crease in the spieeu, Extensive diffuse nephritis. Foci of round
cell Infiltration In the adrenals. Glandular hyper|)lasla of the
prostate gland with tendency to cyst formation.

Mate. Age 43, Second admission. Reported unruly, Irritable and
destructive, Kefuses to eat or to answer questions. Sits and
stares upon the floor for hours.

Duration of psychosis: Three years.

Cause of death : Asphyxia during a convulsion.

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159

Clitiicnl report: Admitted with a psychosis of dementia said to
have started two years before admission. Was hypochondriacal
and neurasthenic. There was progressiTe motor paresis, involving
phonatlon and deglutition, particularly. Supposed cause was Ill-
health. Occupation, physician.

Pathological r^ort : Marked cyanosis. Pupils dilated. Cranial
l>ones thick and dense. Numerous vascular connections to the
arachnopla. Diffuse opacity of the arachnopia. Slight increase
of the subdural fluid and great increase of the subarachnoidean
fluid. Brain — Weight, 1440 grms. Some general atrophy of tlie
convolutions. Granulations of the fourth ventricle. Lungs —
Weight, left, 320 grms.; right, 430 grms. Firm pleuritic adhe-
sions throughout both pleural cavities. Doughy in consistency,
ooze considerable frothy fluid on section. In the anterior part of
the right upper lobe Is a solid mass the size of a goose-egg more
or less caseated. Moderate enlargement of the bronchial glands.
Heart — Weight, 370 grms. Several large sclerotic patches In the
eplcardlum, hypertrophy of the left ventricle. Moderate arterio-
sclerosis. Spleen— Weight, 170 grms. A large cicatricial scar on
the dorsum. Moderately firm on secllon. Liver — Weight, 1610
grms. Bleeds considerably on seetlon. Kidneys — Weight, left,
185 grms. ; right, 145 grms. Firm on section, pale In color, several
cortical cysts, very little pelvic fat, capsule strips readily. Ure-
ters dilated. Pelves dilated. Bladder walls thickened. Prostate
enlarged. Appendix hanging into the pelvic cavity. Its terminal 4
cm., dilated and filled with a gelatinous material, Pancreas-
Weight, 110 grms.

Microscopical report': Well-marked chromatolytie changes in the
nerve cells. Moderate a rterio -sclerosis involving mostly the In-
tima. Tendency to parenchymatous cyst formation in the thyroid
gland. Typical miliary tubercular infiltration in the lung. Ex-
tensive diffuse subacute nephritis. Chronic Interstitial pancre-
atitis. Intense engorgement of the spleen. Cloudy appearance of
the cortical cells of the adrenals.

Male. Age 50. First admission. Repoiled restless, syphilitic and
intemporate. Has delusions about running a shoe factory.

Duration of psychosis : Fifteen months.

Cause of death : Lobar pneumonia.

Clinical report : When admitted talked loudly and acted strangely.
Has always been intemperate. Eitremely untidy. Partial spastic
paraplegia. Urinary incontinence. Small pupils. Dementia.

Pathological report : Extreme eraaelatlon. Extensive sacral de-
cubitus. Cranial bones thick and heavy. Numerous vascular con-
nections of the dura to the arachnopia. Extensive diffuse opacity
of the arachnopia and increased thickness. Large quantity of
subdural and subarchnoldean fluid. Brain— Weight, 1425 grms.
General atrophy of the convolutions. Extensive atheromatous de-
generation and thickness of the basal vessels. Ventricles ex-
tremely dilated and distended with fluid, there being a layer of

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tlssu*^ of only I cm. in thicfeness between the Inner surface of the
ventricles and the external surface of the cerebral hemlspbereB,
particularly over the parleto-occipltal region. Septum lucldum
very thin and absent at tbe posterior portion. Foramina of Mun-
roe 1 cm. in diameter. Ependyma granular throughout. Choroid
plexus cystic. Heart— Weight, 300 grms. Several sclerotic patches
of the pericardium on the anterior surface of the heart, consid-
erable eplcardlal fat, hypertrophy of the left ventricle, sclerosis of
the margins of the mitral valves and In the bodies of the aortlcs,
patent foramen ovale, considerable dilatation of the ttvst and sec-
ond portions of the arch of the aorta. Estensive atheromatous
degeneration of the arteries. Limgs — Weight, left, 430 grms. ;
right, JlOO grms. Firm pleuritic adhesions In both pleural cavi-
ties, pleura thickened, lobes adherent, right lung and the upper
left lobe more or less oedematous and congested, several cicatri-
cial nodules In the left apes, the lower left lobe la solid through-
out Id a condition of gray hepatization. Bronchial mucosa on the
left aide swollen and congealed and llie lumen filled with a frothy,
bloody secretion. Bronchial glands fnlarged and pigmented, those
on the left side somewhat softened. Thyroid gland somewhat
cystic. Spleen — Weight, 60 grms. Moderately firm on section,
malpighinn Ijodles prominent. Liver — Weight, 1400 grms. Mod-
erately firm on section, Panci-eas — Weight, 80 grms. Splenic
artery large walls thicliened tortuous and atheromatous Kidneys
—Weight left 100 grms right l^iO grm-^ FIrmlv adherent to the
perirenal tissue pale In color strntion poorlv marked con'iiderihle
pelvic fat capsule strips readily but lenea a roush surface nu
inerous cortical cvsts Ureters dilated ind distended with urine
Bladder dilated and distended reaching the umbilicus its walls
hypertrophied Prostate enlarged Appendix lying on the pelvic

Microscopifal rej ort DIfCuse staining ind extensive chromatolytic
changes In the ner\e cells Intense engorsement of the pulmonary
capillaries the vesldes In a condition of red and gray hepatlza
tltm 4tute bronchitis H\pprplap.la of the splenic tissue Ex
tensive diffuse nephritis Fott of round cell inflltntion in the
medulla of the adrenals I xtenslve itberomatous degeneration of
the arteries

Male Age 4r First admission Reported restless sleepless de
structivp melnncboh prof me intemperate Imagines that he is
a great and constant sufferer lalks lufoheretitiy night and day
Thinks that he is compelled to do some harm to himself Threat
ens suicide.

Duration of psychosis ; One year.

Cause of death- Paretic convulsions and acute suppurative neph-
ritis.

Clinical report: Reported intemperate and syphilitic. Onset three
months bpfore admission as above. Occupation, mason. One sis-
ter insane. Father intempernte.

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161

Pathological report: Cyanosis. Ears asymmetrical. Extensive
taenia versicolor over the slioulders. Abdomen distended aod tym-
panitic. Cranial bones compact Dura firmly adherent. Diffuse
opacity of the arachnopla. Great Increase of subdural and sul)-
araclinoidean flald. Brain — Weight, 1220 grms. General atrophy
of the convolutions. Ependyma granular in the floor of the fourth
ventricle. Moderate nrterio-sderosis of the basal vessels. Lungs —
Weight, left, 340 grnis. ; right, 315 grms. Left pleural cavity ob-
literated by dense Arm adhesions. Left pleura thi<;k,ened. Lungs
slightly doughy in consistency, ooze considerable frothy fluid on
section. Uronchlal glands enlarged and pigmented. Heart —
Weight, 320 grms. Left ventricle hypertropbied. Right ventricle
dilated end contains a pinkish-looking coagiilnm more or less firmly
adherent to the endocardium. Slight sclerosis of the mitral valves.
Eitensive arteriosclerosis with more or less patchy atheromatous
degeneration. Spleen — Weight, 145 grms. Moderately flrm on
section. Liver — Weight. 1570 grms. Oozes considerable blood on
section, cut surface of a mottled yellowish-red color showing
areas of fatty degeneration. Kidneys — Weight, left, 140 grms. ;
right, 145 grms. Several cortical cys1», moderately firm on sec-
tion, pale in color, pelves dilated, pelvic mucosa congested, cap-
sule strips readily. Ureters dilated with turbid urine. Bladder
walls thickened, mucosa swollen, urine turbid. Prostate enlarged.

Microscopical report: Extensive diffuse chromatolysis in the nerve
cells. Extensive perivascular round cell Infiltration practically oc-
cluding some of the vessels. Numerous hyaline bodies In the cho-
roid plexus. Extensive s<'lerosEs of the blood-vessels. Intense alve-
olar engorgement of the lungs with well-marked peribronchial con-
solidation. Jinny vesicles of the thyroid gland filled with prolif-
erated epithelial cells. Engorgement of the liver. Hyperplasia
of the malplghian bodies of the spleen. Hyperplasia of the lymph
follicles of the intestines. Foci of round ceil infiltration in the
adrenals. Chronic dlffuitc nephritis.

Male. Age HX. First admission. Reported restless, sleepless, de-
structive, profane, and syphllltc. Has delusions of wealth, that
he is making piles of money, that he has interests In whole blocks
of property. Manifests a change in disposition and manner.

Duration of pHychosis; Two years.

Cause of death: Cerebral concussion and asphyxia.

Clinical report : Admitted with a psychosis of acute mania. Was
found dead at the foot of the stairway lying upon the side of the
neck with the twdy doubled over on the side.

Pathological report: Pupils dilated. Some c>anosis. Dura firmly
adherent to the cranial bones and to the arachnopla over the parietal
vertices. A thick bony plate in the walls of the superior longl-
tundinal sinus premising upon the underlying brain-substance In-
volving the posterior part of the superior frontal, the upper part
of the ascending frontal and parietal, the anterior part of the
superior parietal convolutions. Diffuse opacity and Increased

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thlckneea of tbe arachnopla. Brain — Weight, 1400 grms. Marked
Increase of subdural and subaracbnoldean Huld. General atropb?
of the convolutions. Lunga— Weight, left, 220 grniB.; right, 260
gnne. Sligbtly doughy, aome lobular dlBteneion. Bronchial glands
enlarged and pigmented. Heart — Welgbt, 300 grmB. Moderate
arterJo-Bcieroslfl of the arteries. Spleen — Weight, 110 grma.
Bleeds considerably, malplghian bodies prominent. Liver — Weight,
1700 gruns. Capsule thickened. Rather oily appearance on eec-
Uon. Kidneys— Weight, left, 180 grms.; right, 170 grms. Deep
red in color on section, bleed freely, some pelvic fat, capsule adher-
ent. Spinal fluid contains some blood.

Microscopical report: Moderate chromatolytic changes In the nerve
cells. Perlvascnlar and pericellular spaces prominent. Central
canal of the cord filled with proliferate epithelial cells. Numer-
ous hyaline bodies in the choroid plexus. Extensive fatty infil-
tration of the heart. Moderate arterio-scierosis. Foci of fatty
necrosis in the liver with round cell infiltration about tbe bile
ducts. Hyperplasia of the malplghian bodies of the spleen. Foci
of round cell infiltration in the adrenals. Engorgement of the
kidneys with some parenchymatous changes.

Male. Age 65. Third admission. Reported sleepless, nervous, epi-
leptic. Imagines that he is pursued by a mol>.

Duration of psychosis ; Two years.

Cause of death ; Paretic convulsions.

Clinical report ; None given.

Pathological report : Intense i^yanosla. Diffuse opacity and In-
creased thickness of the arachnopia. Brain — Weight, 1320 grms.
General atrophy of the convolutions. Pla rather firmly attached
Basal vessels atheromatous. Lateral ventricle dilated. E])en-
dyma granular. Lungs — Weight, left. 070 grms. ; right, 650 grms.
Scattered pleuritic adhesions, In both cavities. Pleura thickened.
Lungs doughy, areas deep red In color and firmer in consistency
than the Intervening tissues ; oozes considerable bloody fluid. Bron-
chial and tracheal mucosa congested and covered with a viscid
frothy secretion. Bronchial glands enlarged and pigmented. Heart
— Weight, 380 grms. Some hy|iertropUy of the left ventricle, both
sides considerably dilated. Atheromatous patches in the body of
tbe mitral and aortic valves. Some subendocardial ecchymosls in
the left ventricle. Moderate arterio-aclerosls of the arteries.
Omentum adherent to the right Internal abdominal ring. Spleen —
Weight, 200 grms. Capsule thickened, firm on section. Liver —
Weight, 14C0 grms. Mottled pale nutmeg in color. Kidneys-
Weight, left, 145 grms,; right. 270 grms. Right bleed considerably
on section, some pelvic fat. capsule slightly adherent. Left firmly
adherent to the perirenal tissue, pelvis dilated, its mucosa thick-
ened, congested, grayish in color and covered with calcareous mat-
ter. Very little kidney substance is visible, and where it is, con-
sists almost wholly of cortical substaiice. Left ureter dilated and
thicliened. Prostate enlarged and nodular, extendinp; to the left
and upward, filling the left side of the pelvic cavity, obstructing

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163

the left nreter, pressing upon the slgmolil coloa and rectum. No-
dules are firm aud wUite on section. Pancreas — Weight, 05 grins.
Itather firm on sectlou.

Microscopical report : Numerous small hyaline bodies suhendoear-
diall.v in the musL-le fibres of the heart on the left side. Moderate
arterlo-selerosis with eoine atheromatous degeneration and foc-1 of
round cell infiltration In the outer coat. Intense engorgement of
the pulmonary alveolar cnpiltnries with rupture of some and flllltig
of the vesicles with blood, some iwrtlons showing early pneunionle
changes. Diffuse pigmentation of the broiicbial glands. Tcudeucy
to cystic dilatation of many vesicles of the thyroid gland. In-
tense engorgement of the liver with sonie cirrhosis. Intense en-
);orgement of the kidneys with moderate diffuse nephritis. Sub-
stance of the left bidney almost wholly destroyed with Inflam-
matory tissue. Hyperplasia of the glandular elements of the pros-
tate gland, dilatation of many alveoli aud epithelial cell Infiltra-
tion of the general tissue and filling of some of the alveoli.

Mule. Age 35. First admission. Reported restless, profane. Has
delusions of gi'audeur, streugtb aud wealth. Extremely nervous
In speech and action. Threatens to harm those about him.

Duration of psychosis: Two years.

Cause of death : Paretic convulsions.

Clinical report : Admitted with a psychosis of general paresis. One
sister insane.

Pathological report; Extreme emaciation. Limbs fixed in a position
of flexion, legs addueted and rotated to the right, 'i'endency of
the thorax to rotate to the right, causing fiattenlng of the left side
and projection of the right side. Abdomen flattened. Extensive
decubitus. Cranial bones heavy and dense. Diffuse opacity of the
arachnopia. Increase of subdural and subarachnoideau fluid.
Brain- — Weight, 1130 grms. General atrophy of the convolutions.
Extensive dilatation of the ventricles. Granulations of the epen-
dyma throughout. Heart — Weight, 210 grms. Sclerotic patches
In the epicardlum. Lungs — W^eight, left, 470 grms. ; right, 640
grms. Extensive pleuritic adhesions in both pleural cavities.
Pleura thickened, lobes adherent, extensive nodular infiltration
with considerable hypostasis posteriorly, nodules more or less
caseated and softened with considerable cavity formation. Bron-
chial glands enlarged. Spleen — Weight, 120 grms. Moderately
firm on section. Liver — Somewhat nutmeg In appearance. Kid-
neys — Weight, 125 grms. each. Firm on section, pale in color, no
pelvic fat, capsule adherent. Ureters dilated. Pelves dilated.
Bladder walls thickened. Prostate enlarged. Left adrenal con-
tains a small whitish nodule 1 cm. In size, right twice the size of
the left and contains numerous whitish foci. Pancreas— Weight,
70 grms. Mesenteric glands enlarged.

Microscopical report : Extensive degenerative changes in the nerve
ceils, pfrivascular spaces prominent, areas of round cell infiltra-
tion of the pia and surrounding the plal sheath into the brain
substance. Central canal of the cord filled with cells. Engorge-

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meut at the pituitary bod;. NuiiierouR hyaline bodies In the cho-
roid plexus. IlyiH-iiiliiHia o( tht^ lyinph follicles of the luteKiiues.
Diffuse lulliury tiilH-n'ulosis at ilio luiigM, with t-xtenalve diffuse
inlillratiou and di-Keiieration iiiid lasoiitlon. Clirouic iileurisj-.
Chronic Uroucliitls. Sioilerote urterlo-nclerosis. Cliroule paren-
chymatouB, hyperplasia of tlie thyroid gljind. lIyi>erplHsia of the
malplgbluii bodies of the spleen. Eujcorgetnent and moderate dif-
fuse iK-phritls. Chronic veuous ciingt'Btlou uud slight cli'rhosis
of the liver. Vascular eugort;eiuent uud tut)erculaF infiltration of
the adrenals.

Male. Age 53. First admission. iCn'orled restteRK. sleepless, melan-
cholic and syphilitic. Sliftht panilysla uf the tongue. Mental eu-
feeblement. Progressive pareHiw. Talkative, incoherent. Wan-
ders from home.

Duration of psyciiosls: Fifteen uiontliK..

Cause of death: I'ulinonary in la re (ion.

Clinical reiiort: Aduiltled with ii imycliosla of parcais, IwginnlnB
three mouths liefore aduiission. The courHO was one of progres-
sive mental deter! oriitiou, lui^a Ionian In, dementia, weakness, trem-
ulousness, ]>are[tis of co-ordination and sgieclai movements of the
bladder causing dribbling of the urine and involuntary urination.
Gangrene develo|)ed In both feel. Had aerial convulsions which
were always relieved by inmbar puncture. Twenty-four hours
l)efore death there was a rise of tcmi>cr:iture. dyspnoea leading to
a diagnosis of bronciio-pneuniunia.

Pathological i-eporti K.\t«i8ive decubitus. Right leg amputated
below the knee. Cranial boneH moderately cancellous. Diffuse
opacity and increased thickness of the arachnopia. Increase of
subdural and subarachnoldean tiuld. Brain — Weight. 1380 grms.
General atrophy of the convolutions. Pia moderately attached,
basal vessela extensively atheromatima. extensive dilatation of the
i-entriclfs, the canul of Sylvius and of the foramina oC Muuroe.
Choroid plexus (■ystic. EJpendyma granular throughout. Irregular
brownish-red areas in the dorso-cervicai region of the spinal cord.
Lungs— Weight, left, .■'.'iO grnis.; right, 310 grms. Firm pleuritic
adh<>sionH In liuth nivltleH. I'leura thickened, lobes adherent. Sev--
eral marginal areas in the lower lobe on the left side and the
upiwr and lower lolies on the right side cyanotic-red in color, air-
less, spleuic-liko in <:onsistency. shan>ly defined from the adjoin-
ing tissue with the vessel leading thereto filled with thrombi, mod-
erately firm and somewhat adherent. Some lobules distended.
Bronchial gland enlarged and pigmented. Heart — -Weight, 210
grms. Small <|uantlty of pericardial fluid. Some ejilcardlal fat.
Extensive atheromatous degeuerntion of the arteries. Considerable
dilatation of the ascending portion and arch of the aorta. Spleen-
Weight, 110 grinw. Firm on section, trabeculae i>roiniueut. Liver —
Weight, o:y> grniK, Finn on section, strands of llbronK tissue mi-
dosing grouits of lulmles, portal radii-les widely ffllated. Pancreas
—Weight, 1)0 grms. Kathcr firm on section. Kidneys— Weight,

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110 grma. each. Firm on section, imle in color, striiitlou scnrcely
visible, lurge iiuioout of pelvic fat, cripsule aillierent.

Microscopical report; Extensive ciiromatolytic changes in the nerve
cells, intense vuscutat eneorgeiuent. Numerous hyaline bodies Id
the cboroid plexus. Sloderate fatty infiltration of the heart.
Chronic moycarditis. Bstensive atheromatous degeneration of tiie
arteries with extensive perivascular and intravascular round cell
infiltration of the vaso vasorum. Areas of intense vascular en-
gorgement and filling of the vesicles with blood. Areas of tuber-
cular consolidation with central degeneration. Ciironlc broiichitia
with peribronchial fibrous ti^ue increase. Cellular infiltration of
many of the smaller thyroid vesicles. Chronic pancreatitis with
considerable fatty Infiltration. Arterlo-scierotic spleen. Cliroulc
venous congestion of the liver with considerable cirrhosis. Ex-
tensive diffuse neplirltis.

Female. Age 35, Second admission. Reported restless, sleepless,
destructive, suicidal and homieiilal. Threatening herself and her
little daughter.

Duration of psychosis : Sixteen months.

Cause of death : Paretic c-onvulsions and pulmonary oedema.

Clinical rejKirt : Admitted in May, 1903. Discharged in November,
1903, as recovered. Readmitted in May, 1904. At the time of the
first admission was in a state of acute maniacal escitemeut and
again so at ber second admission. The latter attack was followed
by progressive dementia and all of the classical symptoms of gen.
eral paresis with tabes. Oonvuiaions set in, involving mostly the
left side of the body, predom inn ting in the left upper extremity
and lasting more or less continuously for several days. This was
followed by a hemiplegia lasting two days, then vomiting set in,
which lasted more or less until death

Patbologi(.al report Moutli full of frothy grumous * iseid fluid Se\
eral external haemorrhoids Lranial bones cancellous Mi*derile
diffuse opacity of the archiiopia feoine increa-ie of sulidurui ind
subaiachtioldean fluid Brain — Weight 1240 grms General atro
phy of the convolution'* Ba«iii arteries exttnsivelj atheromatous
Iieft vertebral three times the '.Ize of the right Right anterior
cerebral almost twite the size of the left Lateral ventricles di
lated Extensive granulations of the ependjma loa eilorcolumus
of the cord gray the right lateial columns slight \ so in the dorsal
region Lungs — Weight left 500 grms right 480 grms Cica
triclal contraction of the pleura o\er the center of the upper left
lobe with small cakareou'* deposits beneath otbciwtsc both lungs
are doughy and ooze an \hundaiit fluid BronUii and trachea
are filled with frothy iisLid secretion Bronchial glands enlniged
and pigmented Heart — Weight 320 grms Slight hipertrophv
Moderate scler)Sis of the mitral valves Moderate arteiio sclerosis
with some atheromatous Ueteneintion 'Stomach enorniousiv di
lated filling almost tlie whole of the abdtminal ca\ity evtendlng
down to the iieivic brim and to the right nipple line fepken^
Weight 7C grms i irm on section Trabecule prominent. Liver —

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Weight 1015 rnB I'inifivusi— Weight, 75 grnis. Kidneys—
Weigtit ieft 1 gr a ; right, 120 srms. Firm on aectioD, pale
in eolo striatio indl tinct, rery little pelvic fat, capsule adherent.
Firat aecoDd aiid pa t of tiie third portion of the duodenum es-
fensl ely dilated anl -alls thinued. Appendix hanging Inio the
pelvic tavlty. ihjroid gland — Weight, 25 grms.

Microscopical report: Moderate chromntolytlc degeneration of the
nerve cells, considerable rouud ceil intlltnitiou in the pla. blood-
vessel walls thickened, perivascular spaces prominent and mostly
filled with round cell collections. Central canal of the cord fllleil
with proliferated epitheliiil cells, which also extend into the cen-
tral gelatinous substance. Toaterior columns of the cord sclerosed,
the right lateral column siighlly so in the dorso-cervical region.
Intense engorgement and some fibrosis of the pituitary body. Ex-
tensive chronic myocarditis. Moderate arterlo-scierosis. Intense
engorgement, moderate emphysema, some filirosls, some vesicles
filled witli leucocytes and epitliellal cells, extensive perivascular
pigmentary inflltration of the lungs. Increase of fibrous tissue in
the thyroid gland with some dilatation of many vesicles and some
cellular infiltration of the smaller vesicles. Extensive venous en-
gorgement of the liver with some portal cirrhosis. Intense en-
gorgement of the kidneys with extensive diffuse nephritis. Foci
of round cell .Infiltration of the medullary portion of the adrenals.
Chronic interstitial pancreatitis. Hypertrophy of the muscular
wails of the appendix with hyperplasia of the lymph follicles.

Male. Age 54. First admission. Reported restless, sleepless, pro-
fane and homicidal. Has delusions of being a traveling salesman,
of owning race horses of great value and having great speed, and
of holding various bonds.

Duration of psychosis ; Two and one-half years.

Cause of death : Paretic convulsions and exhaustion.

Clinical report : Admitted with a psychosis of general paresis be-
ginning three months before admission with delusions of grandeur
which mostly disappeared afterward. There was some apparent
improvement for some months, hut a feeling of general well being
persisted throughout. Later there developed general tremor, paresis,
speech, writing and pupillary defect, maniacal outbreaks, pro-
found dementia and great emaciation. Married, Occupation, car-
penter.

Pathological report: Pupils dilated. Some decubitus. Cranial
bones hard. Dura firmly adherent, most marked over the frontal
bones. Extensive diffuse opacity and Increased thickness of the
arachnopia. Increase of subdural and subarachnoidean fluid.
Brain — Weight, 14^0 grms. General atrophy of the convolutions.
Pia firmly adherent. A small fleshy nodule, 1 cm. in diameter, whol-
ly encapsuled by pla lying over a sulcus on the convexmesial sur-
face in the posterior part of the right frontal superior convolution.
Ventricles dilated. Epeudyma granular. Lungs— Weight, left, 300
grms. ; right, 450 grms. Cjanotic-red color, doughy in consistency
posteriorly, ooze an abundant frothy, bloody fluid on section.

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Bronchial glands enlarged and pigmented. Heart — Weight, 240
grms. Estensive atheromatous d^eneration of the arteries, the
coronary vessels extremely so. The arch of the aorta consider-
ably dilated. Liver— Weight, 1240 grms. Somewhat nutmeg in
appearance. Spleen— Weight, 160 grms. Bleeds considerably on
section. Kidneys— Welglit, left, 150 grms. ; right. 130 grms. Red-
dish color, no pelvic fat, several cortical cysta, capsule strips read-
ily. Pancreas — Weiglit, 80 grms. Soft in consistency. Splenic
artery extensively atheromatous, calcareous, thickened, tortuous
and greatly enlarged. Thyroid gland — Weight, 20 grms. Appendix
hanging over the pelvic brim.

Microscopical report : Extensive diffuse degeneration of the nerve
cells, moderate round cell Infiltration of the pla and of the perl-
vascular spaces. Central canal of the cord filled with proliferated
epithelial cells. Intense engorgement of the pituitary body with
an alveolar arrangement of the cells and some of the alveoli filled
with colloid material. Chronic myocarditis. Bxtaisive arterlo-
sclerosis and atheromatous degeneration of the arteries. Intense
alveolar engorgement of the lungs with rupture of some of the
capillaries and filling of the vesicles with blood. Areas of pneu-
monic consolidation. Cellular infiltration of many of the smaller
vesicles of the thyroid gland. Extensive chronic pancreatitis.
Venous congestion of the liver with some portal cirrhosis. Intenat'
engorgement of the iiidneys and extensive diffuse nephritis.

Male. Age 50, First admission. Reported despondent, intemperate,
hypochondrlcal, sleepless, .irritable, at times greatly excited. Fell
that he would live to lose his mind. Imagined that the doctors
were trying to poison him. Indulged In eexual excess.

Duration of psychosis : Four years.

Cause of death : Exiiaustion.

Clinical report : Occupation, farmer. Oue uncle and one cousiii
insane. One cousin epileptic. Reported as having suffered fron

, sunstroke in early life and again two years before admission.
Used alcohol moderately until four years ago, since which timf.
he has used It to excess. Married four times. One child said to
be hydrocephalic. Onset of the present disturbance began foui
years ago as above reported. He became irritable, inclined to eX'
cesses in manner and habits, and complained considerably of pain
In the head and back of the neck. A few months later these con-
ditions became exaggerated, talked continuously and somewhal
incoherently, the content usually referring to business affairs ;
asked that something be done to make him cease talking and al
times placed the hands over the mouth to stop it. He threatened
to shoot himself if it could not be done. Later he imagined thai
the doctors were trying to poison him. On admission he was
greatly emaciated .and had pronounced ataxia In gait and station ;
gait was tremulous, knee Jerks faint, speech thick, pupils unequal
and irregular, reacting slightly to light. Ophthalmoscopic exami-
nation showed slight optic neuritis. The condition became more
and more exaggerated, paralysis of the sphincters superveiied. de

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cuhitue developed and a constaot muttering delirium, whlcti lasted
uutll death.

Patbologlcal report : Extreme emaciation. Pupils unequal. Bare
asymmetrical. Teetb covered wUli sordes. Sacral decubitus. Dura
moderate!.!' adherent to the cranial bones and rather intimately
attached to tlie arcbnopta over the parietal vertices. Extensive
diffuse opacity and Increased thickness of the arachnopla. Great
Increase of subdural and subarachnoidean fluid. The inner sur-
face ot the dura lined by a thin, flbrinoua meinbrane-tlke exudate.
Brain — Weight, 1550 grms. Some. general atrophy of the convo-
lutions, iMisal vessels atheromatous, ventricles dilated and filled
wltli fluid, epeudyma granular more or leas tbroughout, son»e yel-
lowish foci of softening scattered through the substance. Heart —
Weight, 250 grms. Patches of eplcardinl sclerosis. Atheromatous
patches In the mitral valves. Extensive atheromatous degenera-
tion of the arteries. Lungs — Weight, left, 280 grms.; right, 300
grms. Extensive flrm adhesions in the rigbt pleural cavity. Lungs
cyauotic-red in color posteriorly, slightly doughy In consistency,
bleed considerably on section. In the posterior part of the lower
right lol>e la au area of pneumonic consolidation. Spleen — Weight,
110 grms. Sfoderately firm, trabeculae prominent. Liver — Welgbt,
1310 grms. Extends to the crest of the ileum. Kidneys— Weight,
left, 155 grms. ; right, 145 grms. Firm ou section, pale in color,
veiy little pelvic fat, capsule strips readily. Pancreas — Weight,
95 grms. Thyroid gland— Weight, 30 grms. Costal cartilages cal-
cified.

Microscopical report! Considerable chromatoljtlc degeneration of
the nerve cells. The perivascular spaces filled with round cells.
Moderate chronic myocarditis. Extensive atheromatous degenera-
tion of the arteries. Some emphjsem^ and patches of early pneu-
monic consolidation. Irregular siae of tlie thyroid vesicles and
cellular Infiltration of the smaller ones. Venous congestion of the
liver. Chronic pancreatitis. Intense engorgement of the spleen
with relative trabecular increase. Engorgement of the kidneys
with extensive diffuse suiwcute nephritis.

Male. Age 47. Negro. Second admission. Reported extremely
violent, dangerous to himself and to his surroundings. Imagines
himself possessed ot great wealth and Influential friends.

Duration of psychosis: Two and one-half years.

Cause of death : Pulmonary oedema.

Clinical report: First admission was In May, with a psychosis of
general paresis. Discharged in August as Improved. Readmitted
the following Jiinuary with a psychosis of acute maniacal ex-
citement b^inning about one month liefore admission, with de-
lusions of wealth, no idea of his whereabouts, loss of memory,
violent and destructive. Physically he was very weak. There
was Rome slow iind gradual improvement. In the forenoon pre-
ceding his ili'ath he was seized with an epUeptold convulsion from
which he promptly recovered. The following day he had another,
following which he rapidly passed Into profound coma.

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Pathological report r Slight opacity of the arachuopla. lloderate
quantity of subarachnoidenn fluid. Braia — Weight, 1290 grms.
General atrophy of the convolutions. Basal vessels moderately
atheromatous. Lateral ventrlrlea dilated. Lungs — Weight, left,
750 gnns. ; rigiit, 910 grms. Firm, pleuritic adhesions In both
cavities. Pleura thickened. Ijobes adherent, cyanotic red colpr,
doughy consistency, bleed freely on section, cicatricial contraction
of the left apex, some dilatation of the marginal lobules. Bron-
chial mucosa congested and the Hmen filled with a frothy viscid
secretion. Heart — Weight, 430 grms. Several sclerotic patches in
the eplcardlum, considerable fatty lufiltratlon of the right ventri-
cle, atheromatous nodules iu the mitral valves. Extensive dilata-
tion of the aorta. EKtenaive nodular atheromatous degeneration
in the arteries, the coronary vessels extremely so, almost occluding
the orifices. General hypertrophy of the heart. Spleen — Weight,
90 grma. Firm on section, capsule thickened. Liver— Weight,
1170 grma. Rather oily in appearance. Kidneys— Weight, left,
210 grms. ; right, 190 grms. Firmly adherent to the perirenal tis-
sue, firm on section, considerable pelvic fat. Bladder distended
with urine. Prostate enlarged. Pancreas— Weight, 120 grms.

Microscopical report : Extensive chromatolytic changes in the nerve
cells. Extensive round cell Inflllratiou of the arachnopia, most
marked about the blood-vessels surrounding the pial septa and the
blood-vessels entering the brain substance, completely filling the
perivascular spaces and the vessels in many cases occluding them.
Many of the perivascular spaces throughout the cortex distended
with these round cell collections. Blood-vessels more or less en-
goi^ed. Intense engorgement of the pituitary body. Moderate
fatty Infiltration of the heart. Some chronic myocarditis. Extensive
arterlo- sclerosis, with considerable atheromatous degeneration and
foci of round cell Infiltrations in the outer coat. Some portions
of the lung more or less emphysematous. Other portions intensely
engorged and many vesicles filled with blood, other alveoli con-
taining leucocytes and some epithelial cells or homogeneous ma-
terial. Malpighiau bodies of the sjjteen and numerous foci of
haemorrhaglc Infiltration. Chronic venous congestion of the liver
and alight cirrhosis, intense engorgement of the kidneys with
extensive diffuse nei>brltls.

Male. Age 4S. Second admiasioQ. Reported sleepless and excited.
Claims to see unearthly things. Thinks his brothers are perse-
cuting him.

Duration of psychosis : Three years from second admission.

Cause of death : Lobar pneumonia.

Clinical report: Admitted first with a psychosis of acute mania.
At the second admission he had hallucinations ot sight, delusions
of persecution and wealth. Claimed that he was God. Physically
his healtli was fairly good, but soon began to decline, lost strength
and weight. Refused food because of loss of appetite. Several
months before death a cough developed which cootluaed until

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death. Fatlent had a severe attack of typhoid fever about one
rear before the ouset of the meutal dlEturbance.

Pathological report : Crauial bones thick and compact Firm dural
adhesions. Moderate diffuse opacity of the articbnopia. Moderate
Increase of subdural and subarachnoidean fluid. Brain — Weight,
1215 gnaa. General atrophy of the convolQtioQB. Basal vessels
atheromatous. Ventricular ependyma granular. Central canal
of the cord dilated In the lumbar region. Heart — Weight, 280
grma. Slight sclerosis of the mitral and aortic valves. Moderate
arterlo-sclerosis of the artefies. Lungs — Weight, left, 260 grms.;
right, TEiO grms. tiixtensive pleuritic adhesions In both pleural
cavities. Left lung diffusely nodular, many of which are caseous.
Right lower lobe, apes of the middle lobe and the base of the
upper lobe are dark-red In color, solid in consistency, sptenlc-like
appearance on section with several areas soft, pulpy, grumous and
seuil-ttuld and gangrenous. Pleura covering the solid portions of
the lung deeply injected. Bronchial mucosa congested. Bronchial

, glands enlarged and pigmented. Liver — Weight, 1440 grms. Left
lobe prolonged into a tongue-like projection 8-3-1 cm. in size. Kid-
neys — Weight, left 170 grms. ; right. 100 grms. Firm on section,
pale in color, cut surface granular in appearance, considerable
pelvic fat, capsule strips, but leaves a rough surface. Spleen —
Weight, 150 grms. Appendix banging over the pelvic brim.

Microscopical report : Extensive chromatolytic changes in the nerve
cells. Central canal of the cord in the cervical and dorsal regions
Slled with proliferated epithelial cells and the central gelatinous
substance infiltrated with them. In the lumbar region the caual
is dilated and triangular in shape. The pneumonic portion of the
lung is mostly In a condition of red hepatization with beginning
gray. The nodules show diffuse tubercular eonsolidation, more or
less degenerated, mostly peribronchial. Some emphysema. Con-
siderable perivascular and peribronchial pigmentary infiltration.
Bronchial glands diffusely infiltrated with tubercular masses.
Fatty infiltration of the heart Chronic myocarditis. Slight fatty
infiltration and chronic venous congestion of the liver. Intense
engorgement of the spleen, of the adrenals and of the kidneys. Ex-
tensive diffuse subacute nephritis, with areas of dense round cell
Infiltration.

Male. Age 28. First admission. Reported as talking incoherently.
Imagined that he was possessed of great wealth, that he was king
of the clouds, that he was constantly in communication with the
Almighty, and that he was being persecuted. Is subject to out-
breaks of violence.

Duration of psychosis ; Not given.

Cause of death ; Pulmonary oedema and pneumonic consolidation.

Clinical report : Admitted with a psychosis of genera! paresis. Was
very weak and helpless, more or leas in a maniacal state, rapidly
and gradually becoming wealter ; developed stupor, coma and symp-
toms of pneumonia. Said to have had a fracture of the skull six

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years before, from which he appnrently completely recovered. Sh
gle. Occupation, car builder.

Pathoiogical report: Rigbt eye absent. (Operative.) Moderate en
largenient of the lymphatic glands. Cranial bones hard. Deprea
Bion of the bone above and to the posterior of the left mastoit
process over an area 4-5 cm, and about 1 cm. above the level of th<
ear. Moderate adhesions of the dura. Diffuse opacity of thf
nrachnopia. Brain — Weight, 1460 grms. Right optic nerve and
tract gray and atrophic. Right vertebral artery one-third the si»
of the left. Right posterior cerebral small. The rigbt posterioi
communicating four tiroes the size of the left and takes the placf
of the posterior cerebral. Depression of the posterior part of thi
left parietal lobe at its lower portion and of the adjoining portion
of the temporo-sphenoidal corresponding to the depression of thi
bony vault. Lungs — Weight, left, 600 grms.; right, 540 grms
Cyanotlo-red in color, most marked posteriorly, dougby In consist
eney, ooze an abundant frothy, bloody fluid on section. Bronchial
and tracheal mucosa deeply congested and covered with a frothj
viscid secretion. Broncblal glands enlarged and pigmented. Hearl
Weight, 290 grms. Moderate arteriosclerosis of the arteries
Spleen— Weight, 120 grms. Moderately firm. Liver— Weight, 16H
grms. Capsule thickened, moderately tirm. Kidneys — Weight,
left, 185 grms. ; right, 170 grms. Cortes pale In color, pyromldt
dark-red, no pelvic fat, capsule strips readily. Pancreas — Weight,
120 grms. Numerous foci of submucus ecchymosls In the etomnch.

Microscopical report: Extensive cbroraatolytle changes In the nervi
cells and considerable vascular engorgement. Central canal ol
the cord filled with proliferated epithelial cells. Pineal glauc
made up of a mass of epithelial cells arranged more or less int<i
alveoli and Infiltrated with numerous calcareous bodies. Some
fatty infiltration of the heart. Chronic myocarditis. Moderati
arterio-ficlerosls with more or less atheromatous degeneration.
Cellnlar infiltration of the vesicles ot the thyroid gland, many oi
them being entirely filled. Intense engorgement of the nlveolai
capillaries of the lungs with rupture of some and filling of thi
vesicles with blood, some areas of red hepatization. Hyperplasif
of the nialpighlan bodies of the spleen. Moderate portal cirrhosis
Moderate chronic pancreatitis. Intense engorgement of the kid
ueya with moderate arterio-sclerotic and Interstitial nephritis
Chronic gastritis.

Male. Age 41. First admission. Reported acutely depressed, rest
less and Incoherent. Imagined that he had committed a crimi
and feared starvation.

Duration of psychosis : Five years.

Cause of death : Convulsions.

Clinical rt^wrt : Admitted with a psychosis of acute melancholia
beginning four months before admission, by Imagining that be bac
committed a crime, that he would starve, that be was being pur
sued and would receive bodily harm, that his own health was ^

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tirely loBt. that his wife wnn insane. He graduatl}' ttecame worse,
filthy, destrucllve, subje<-t to outbreaks ot violence, developed pro-
Dounced speech lleftwL't^ nianifettted Increiising and progressive de-
mentia. A right hemiplegia dei'eloped. wbl'-li gradualiy subsided.
Received an injury to the bend which rendered blui unconscious,
after which he alwnys complained.

Pathological report ; I'urulent <lischarge from both ears. Froutal
sinuses large. Firm dural iidiiesions. Large quantity of subdural
and subaracbnoidean fluid. A reddish, fibrinous, membrane-like
exudate covers the right hemisphere and base of the left, which
Is more or less adherent, more bo to the arachnopia than to tbe
dura. 'Ihe inner surface of tbe dura of a mottled brownish-yellow
color. Diffuse opacity and ini-reiised thickness of the arachnopia.
In tbe posterior fossae on each side of the foramen magnum are
several whitish areas lielween the dura and bone which are more
or less calcareous. Brain— Weight. ll.'iO grms. General atrophy
of the couvoiutioas. T^eft hemispliere xnialler than the right. Left
hemisphere collapses as the fluid escapes from the ventricle. Ex-
tensive dilatJition of all of the vcutricles. Foramina of Munroe
1 cm. In diameter. Seplum Lucidum absent at its posterior part
Choroid plexus cystic. Heart — Weight, 2S0 grms. Some sclerosis
of tbe mitral valves. Considerable dilalation of the right side.
Considerable nrterio-sclerosis and some atheromatous degenera-
tion, (he coronary ves-sels extensively so, almost occluding the
lumen. Lunge^Welght, left, 180 grms. ; right, 430 grms. Lower
right lobe and tbe base of the upper lobes dark red in color, granu-
lar in appearance, when cut bleed considerably, rather doughy in
consistency. Bronchial glands enlarged. Spleen^ Weight, 110
grms. Moderately firm. Liver— Weight, 1250 grms. Nutmeg in
appearance. Kidneys — WelRht, left, 115 grms.; right, 110 grms.
Moderately firm on section, pale in color, striation indistinct, con-
siderable pelvic fnt, a few cortii^ai cyMts. Pancreas^ Weight, 80
grms. Appendix hanging over the pelvic brim.

Microscopical report : Diffuse degenerative changes in tlie nerve
cells, consideralile eogorgenient, the perivascular spaces more or
less filled with round cell infiltration, completely plugging some
of the vessels, l^onslderahle obliterative endarteritis. Fatty in-
filtration of the right ventricle of the heart. Emphysema of some
of the pulmonary alveoli, b^inning pneumonic consolidation of
other portions, extensive perivascular blackish pigmentary infiltra-
tion. Extensive difCuFe nephritis, with liwal areas of dense round
cell infiltration. Engorgement of the other organs, with marked
artcrio-scl erotic changes.

Male. Age 41. First admission. Reported restless, sleepless, melan-
choly, talking incoherently, walking constantly abont the room.
Imnglneit that there was something in his head, that some one
was after him. Has the general appearance of apathy. Has hal-
lucinations of hearing. Manifests change of character.

Duration of psychosis: Ten months.

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CaURe oC deatb ; Pneumoula.

Clinical report : Admitte*! witli n iisj'chfiMls of nc'ute luelancholia,
beginuing three months before admission. Afterward there was
a progressive failure of tlie mental faculties, leading to complete
dementia and helplessness. Pliyslailly on admission there was
weakness and emaciation, coarse tremor of the mouth and face,
defective spei'ch, nonreaction of the pupiis to light, impairment
of the vesical and rectal sphincters. Several days before dejitii
marked cyanosis and dyspnoea. Occupation, baker.

I'atholt^lcal rejwrt : Extreme emaciation. Extensive decubitus.
Head braehyceiihaltp, i>OHterior contour Irregular. Crania] bones
thin and comtiact. Durat adhesions to the bones and to the aracli-
nopla. Diffuse opacity and increased thickness of the arachnopia.
Increase of suMural and subarachnoldean fluid having a cystic-
like formation at places. Brain — Weight, 1350 grms. General
atrophy o£ the convolutions. Atheroma of the basal vessels. Iiat-
eral ventricles dilated. Erxindyma granular throughout. Pineal
Kland cystic. Foci of softening scattered through the basal gnng-
lla. The lower dorsal and upper two or three lumbar vertebra are
firmly ossified and project p«teriorly. Heart — Weight. 20(> grms.
Extensive Irregular patchy atheromatous degeneration of the ar-
teries, some showing a tendency to ulcerate, others covered with a
fieshy, worty, granular mass, rather soft and more or less firmly
attached. I-ungs— Weight, left, 5fl0 grms. ; right, 620 grms. Firm
pleuritic adhesions on the left. side. Pneumonic consolidation of
the lower lobes and the bases of the upper lobes on both sides.
Bronchial mucosa congested. Bronchial glands enlarged, pig-
mented and some are caseous. Spleen — Weight, 95 grms. Rather
firm on section. Liver — Weight, 13G0 grms. Pancreas — Weight.
80 grms. The splenic artery extensively atheromatous and cal-
careous. Kidneys — Weight, 120 grms each. Pale on section, no
pelvic fat, capsule adherent. Thyroid gland-— Weight, 35 gnns.
Chronic gastritis.
Microscopical report: Diffuse chroma toly tic changes in the nerve
cells, pla thickened and its deeper layers Infiltrated with rouud
cells, most marked about the blood vessels, many of the perivascu-
lar spaces being entirely filled with them, most marked In the
parietal lobes. Central canal of the cord tri-star shaped in the
lumbar region, is filled with proliferated epithelial cells which also
infiltrate the central gelatinous substance. Chronic myocarditis.
Extensive arterio-Bcierosis with irregular atheromatous degenera-
tion and ulceration and perivascular round cell Infiltration in the
outer and middle coats. Some fibrous tissue Increase, more or
less Irregularity in si7* of the v^icles and cellular Infiltration of
most of the smaller vesicles of the thyroid gland. Pineal gland
made up of epithelial cells more or less alveolated and Infiltrated
with numerous hyaline bodies. Numerous hyaline bodies in the
choroid plexus. Intense engorjiement of the spleen, with liyper-
plasia of the matpighlaa bodies. Venous congestion of the liver.

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Intense engorgement ol the kidneys, with dllTuBe interstitial
uepbrltls. Solid iwrtions of the lung In ali stages of pneumonic
cimsolidatlon. OonsklernWe i*rlvnBcular blackish pigmentary iii-
tiltmtJou, Aciite bronchitis In the Inflamed portions of the lung.

TABO PAKBSIS.

Female. Age 3(i. First admission. Reported sleepless, melancholy,
emotional, with ideas of persecution, grandiose ideas of wealth, ab-
sence of lEuee-Jerk. Argyle-Robertsoti pupil, scanning speech.

Duration of i)sychosl3 : '1 wo and one-half years.

Cause of death : Exhaustion.

Clinical report : I>isturbanee iK«an about one and one-half years
before admission as alwve report. After admission there was
gradual but progressive deterioration. Mentally, as a rule, was
cheerful, but was subject to outbreaks of violence and abusive to
those about her. A left hemiplegia developed, trophic disturbances
appeared and pronounced difficulty in speech. Later loss of control
of the sphincters followed with involuntary urination and defeca-
tion. She finally lapsed into a comatose state with fibrillary
twltchings of the left side of the body.

Pathological report r Pupils unequal. Slight oedema of the lower
liml)S. Cranial bones hard. Brain — Weight, 1100 grms. General
atrophy of the convolutions. Extensive diffuse opacity and in-
creased thickness of the arachuoplu. Great Increase of subaracli-
nofdean fluid, In some places collected into cyst-like formations.
Basal vessels irregularly atheromatous. Extensive dilatation of
the ventricles. Ependyma granular throughout. Posterior columns
of the cord gray and sclerotic. Lungs — Welghl, left, 330 grms :
right, 340 grms. Cicatricial contraction of the left apex, In which
are numerous calcareous nodules. Posteriorly of a cyanotic red
color, doughy in consistency, bleed freely on section. Heart —
Weight, 220 grma. Sonic sclerosis of the mitral and aortic valves.
Moderate arteriosclerosis with irregular atheromatous degenera-
tion, extensively involving the coronary vessels. Transverse colon,
caecum, appendix and most of the small Intestines tying In the
pelvic cavity. Spleen — Weight, 50 grms. Firm on section. Liver
—Weight, 1040 grms. Moderate constriction of both loljea slightly
below the center, capsule thickened beneath the scat of constric-
tion, moderutely firm on sei'tloii. Kidneys— Weight, left, 80 grms. ;
right, 100 grniH. Firm on section, piile in color, moderate quantity
of pelvic fat, capsule adherent. Thyroid gland very small. Uterus
retroflexed. Ovaries small, white and atrophic.

Microscopical report; Irregular diffuse chromatolytlc degeneration
of the nerve cells. I*la thickened by an irregular diffuse round
ceil infiltration, also extendiog into the brain -substance along the
pial septa and along the blood vessels, coifipletely occluding somi-
of the vessels and [lerlvaseular spaces, and all of the perivascular
spaces fiiore or less tilled with thefn. Central canal of the cord
filled with proliferated epithelial cells and the central gelatinous

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substance more or less loflltrated with tbem. Gxtensiye arterio-
sclerosis with irregular atheromatous degeneration Involving most-
ly those of the brain and kidneys. Fatty Infiltration of the heart.
Some emphysema of the luugs. other portions showing intense en-
gorgement with fllllng of the surrounding alveoli with blood and
some epithelial cells and leucocytes. Bxteusive perivascular pig-
mentary Uiflltratlon. Chronic bronchitis. Interstitial fibrous
tissue increase of the thyroid gland with cellular inflltration of
the smaller ones. Chronic pancreatitis. Chronic splenitis. Ex-
tensive ciiThosis of the liver. Extensive arterlo-sclerotic and dif-
fuse interstitial nephritis.

CHRONIC PARANOIA.
Male. Age 41. First admission. Reported paranoiac with delusions

of haying estates in Europe, ranches In the west, going to marry
the president's daughter, being descended from a noble family,
etc., beginning two years before admission and continuing until
death.

Duration of psychosis : Two and one-half years.

Cause of death : Gastric carcinoma.

Clinical report ; Physically his health prior to admission was poor,
due to chronic rheumatic illness leading to anchylosis of all of the
Joints In the lower limbs. Before admission' he had undergone a
successful operation for the straightening of the right knee and
hip. The left leg was bent on the thigh and the thigh on the ab-
domen. In addition to the joint trouble he had cardiac hyper-
trophy and polyuria with numerous hyaline casts. Evidence of
pulmonary tuberculosis developed during several winters before,
but disappeared. Six months before his death there developed
subacute gastritis, epigastric tenderness, anorexia, vomiting of
large quantities of turbid reddish fluid containing blood, great
pain and evidence of pyloric obstruction. Ijiter this was relieved
and was followed by enteric stools, passing into an uncontrollable
diarrhoea, intermittent- vomiting, emaciation, cachexia, palpable
tumor and general anarsaca. Blood examination gave the charac-
teristics of secondary anaemia. Examination of the stomach con-
tent gave free hydrochloric acid, much mucus and excess of lactic
acid. Urinary examination gave albumen and hyaline casta.

Pathological report : Extreme emaciation. General anasarca. An-
chylosis of the joints of the lower limbs, the right In an extended
position, the left in a flesed poslticai. Pressure ulcer over the
right heel. Operation scars over the right trochanter and the
right knee. Cranial bones hard. Extensive dural adhesions.
Slight opacity of the arachnopia. Brain — Weight, 1350 grms.
Basal vessels irregularly atheromatous. Choroid plexus cystic.
Heart— Weight, 2m grms. ; 150 cc. of serous fluid in the pericardial
cavity. Sclerotic patches in the mitral valves. Extensive arterio-
sclerosis and irregiUar atheromatous degeneration of the arteries.
Langs— Weight, left, 310 grms. ; right, 400 grma. The

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left plearal cavity obliterated by dense firm adhesions.
Between the layertt is a cartllatElnouB mase i cm. wide
and i cm. thick, more or less cvescent-Bbaped. following
the contour of the thorax, beginning anteriorly at the level
of the third rib in the nipple line, pusaiug down and out, then
upon and in, terminating about the lower end of tbe scapula In the
posterior n.\iliary line. Iieft luiii; more or less Hbrold and solid,
the right luirg dougtiy and gray. Ilroiiciilal glands enlai^ed and
pigmented, IJver — Weight, 1110 grms. Moderately firm, cut sur-
face rather oily. Kidneys— Weight, left, 140 grms.; right, 120
grms. Firmly adherent to the perirenal tissue, Arm on section, pale
in color, striatlon scarc'ely visible, large quantity of pelvic fat,
capsule strips readily. I'ancreas — Weight, 80 grms. Thyroid gland
—Weight, 25 grins. Stomach contracted. On the posterior in-
ferior surface of the mucosa is a nodular, caulltlower-llke mass,
irregularly oval, 4-8 cm. in size, with un ulcerating center, in-
durated at the periphery, gradually merging Into the normal mu-
cosa, firm on section, nodules whitish-red centrally. The central
ulceration Just beginning to perforate the peritoneal coat. En-
largement of the mesenteric, retroperitoneal and some mediastlnai
glands.
Microscopical report : Extensive chromatolytic changes in the nerve
ceils. The perivascular spaces in the brain sulwtance prominent.
The central canal of the cord filled with proliferated epithelial
cells and the central gelatinous substance Infiltrated with them.
Irr^uiar chronic pericarditis. Fatty infiltration of the heart and
moderate chronic myocarditis. Moderate arterlo-sclerosis and some
atheroma tons degeneration. Chronic pleurisy. Some pulmonary
emphysema, Some blackish pigmentary infiltration of the perl-
vascular tissue in the lung. Extensive fibrous tissue Increase In
tbe thyroid gland, with some tendency to cyst fonnation and infil-
tration of the smaller vesicles with epithelial cells. Engorgement
of the pituitary body, witii tendency to cyst formation. Chronic
catarrhal enteritis. Chronic pancreatitis. Venous congestion of
the liver. Extensive diffuse nei>hritls. Chronic splenitis. Chronic
bronchitis, with peribronchial, tubercular pneumonic consolida-
tion. Alveolar carcinoma of stomach. Carcinomatous infiltration
of the mesenteric and retroperitoneal glands.

seniijE paranoia.

Male. Age 77, First admission. Iteported as a well -systematized
paranoiac with inoderate increase of psycho-motor activity and
egotism, violent, destructive, homicidal. JIade repeated threats
to take his wife's life. Refused to eat the food prepared by her.
Writes letters to the president and other national officers.

Duration of psychosis ; Not given.

Cause of death ; Chronic myocarditis.

Clinical report: Admitted with a psychosis of well -systematized
delusions. After admlssloD he became quieter, but retained bis

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paranoid delnsioiiB. His physical condition was tliat of general
senile debility, considerable arhytbmia of the beart, dyspnoea and
oedema of the lower limbs. His general ttealth improved some
and the dyspaoea lessened. On arising to urinate one nigbt, and
while doing so, he fell forward, striking his head against the bed,
inflicting a small cat through the scalp, 1 cm. long, over the riglit
side of the forehead.

Pathological report: Prominent arcoB senilis. Cataract in both
eyes. Scalp wound over the right frontal region. Slight oedema
of the lower limbs. Cranial bones thick and bard. Firm dural
adhesions to the twnes and numerous Obrous cord-like connections
to the aruchnopia. Diffuse opacity and increased thickness of the
arachiiopia. Modevate Increase of subdural and great increase of
subarachnoidean fluid. Brain — ^ Weight, 1440 grms. Extensire
atheromatous degeneration of the basal vessels, irregular aneurys-
mal dilatations of the right vertebral and of both internal carotids.
The right posterior communicating very small. General atrophy
of the convolutions. Dilatation of the ventricles. Choroid plexus
cystic. Sclerosis of the left occipital lobe. Several foci of ecchy-
mosis in the floor of the tourth ventricle. Heart — Weight, 350
grms. Small quantity Of serous fluid in the pericardial cavity.
Left aide byiwrtropliy. Right side dilatation. Large quantity of
epicardlal fat. Moderate sclerosis of the mitral and aortic valves.
Some atheromatous patches In the l)ody of the mltrate. Marginal
fenestration of the aortic valves. Considerable ditataticoi of the
aorta. Extensive sclerosis and Irregular patchy atheromatous
degeneration with nuuierous foci of ulceration of the arteries.
Lungs— Weight, left, 250 grms,; right, 345 grms. A few Arm
pleuritic adhesions about both apices. Several small calcareous
nodules la both apices and some cheesy-like foci. Considerable
fluid In the peritoneal cavity. Firm adhesions between the gall-
bladder and the adjoining structures. Uver — Weight, 1215 gnus.
Capsule thickened, surface rough and irregular, 8rm on section,
strauds of flbroua tissue Inclosing various sized groups of lobules.
Spleen — Weight, IGO grms. Capsule thickened. Firm on section.
Kidneys — Weight, left, 130 grms. ; right, 155 grms. Surface un-
even and irregular, firm on section, strlation fairly marked, large
quantity of pelvic fat, capsule adherent Prostate enlarged.
Stomach contracted. A nodular mass occupying the posterior and .
Inferior wall of the mucosa and muscular parts, Irregular in out-
line, tending to ulcerate, extending to within 1 cm. of the sphincter,
encircling the stomach for two-thirds of its circumference. Nodules
are hard, white, of almost cartilaginous consistency. Surround-
ing lymphatic glands inflltrated with small nodules of similar ap-
pearance to those of the mass in the stomach.

Microscopical report : Moderate chromatolytic changes in the nerve
cells. Hlxtensive arterio-sclerofils of the blood vessels. Numerous
hyaline bodies and foci of round cell Infiltration In the Gasserlan
ganglia. Central canal of the cord filled with proliferated epi-
thelial cells and the central gelatinous anbstance infiltrated with

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them. Conelderable engorgement and several crat'llke cavities at
the Junction or the two portions of the pituitary body. Extensive
fatty laflltration of the riglit side of the heart. Chronic myocar-
ditis, Bxtensive arterlo-scletosls of the vesBels involving all of
the coats with Irregular atheromatous degeneration. Chronic
btonchitla. Couslderable vesicular emphysema. Considerable
perivascular and peribroncblnl blackish pigmentary infiltration.
Hyperplasia of the bronchial giaDd lymph follicles, with diffuse
pltcmentary Infiltration and numerous foci of tubercular infiltra-
tion with more or less central degeneration. Engorgement of the
spleen with liyperptasia of the malplghinn bodies. Chronic venous
congestion of the liver and estenalve cirrhosis. Extensive diffuse
nephritis. Masses of epithelial cells more or less aiveolated, with
a fibrous tissue framework InfiltratlDg the walls of the stomach.
with more or less round cell infiltrations surrounding, Tbe super-
ficial epithelial cells are more or less degenerated. Secondary
epithelial cell infiltration of the lymphatic glands resembling very
much the primary mass in the stomach.

PRIMARY DEMENTIA.

Male. Age 32. First admission. Reported melancholy, restless,
sleepless, Intemperate. Wanders about Was shot In the shoulder
some years ago.

Duration of psychosis : Three months.

Cause of death : Septic peritonitis.

Clinical report ; Admitted with a psychosis of melancholia begin-
ning about eight weeks before admission. A few days before he
died he tell upon his abdomen, rupturing a distended bladder, utHin
which developed a septic peritonitis. Cause given as intemperance.
One cousin epileptic. Four aunts and grandfather tubercular.
Occupation, laborer.

Patlioiogical reiwrt : Moderate general Jaundiced appearance. Ab-
domen distended and tympanitic. Cranial bones moderately firm.
Slight opacity of the arnchnopia. Slight Increase of subarachnoi-
deaa fluid. Brain— Weight. 1400 grms. Heart— Weight, 330 grms.
Some hypertrophy of the left ventricle. Considerable epicardial
fat. Moderate arterlo-selerosls. Lungs — Weight, left, ,720 grms.;
right. 750 grms. Cyanotic red in color, lower lobes and the pos-
terior portion of the upt)er lobes of a flrmer consistency than the
remainder and of a dark red color, ooze an abundant frothy, bloody
fluid on section. Bronchia! mucosa congested. Peritoneal cavity
contains about 600 cc. of turbid, purulent fluid, is Intensely in-
jected, covered with a flbrino-plastic exudate cementing together
the peritoneum, omentum and intestines. Walls oC the Intestines
swollen and oedematous. Spleen — Weight, 180 grms. Moderately
soft. Liver— Weight, 1900 grms. Diffusely mottled, dull white
and pale red in color, consistency somewhat softened. Gall-blad-
der contains a calculus 2 cm. In diameter. Kidneys — Weight, 180
grms each. Pale In color on section, striatlon indistinct, small

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qmintity of i>elvlc fat. Bladder contracted and einptj, a lacera
tlon in the posterior wall beginning near the summit and passing
down about 2.5 cm. Just about in the median line, Its margins
Irregular and its surrounding parts acutely inflanied.

Microscopical I'eport : Weli-marked chroniaf olytlc changes In the
nerve cells. Bound ceil infiltration of the pia and ot the piai septa
entering the brain-cortex and of the perivascular spaces throughout
the cortex. Moderate endarteritis. Intense engorgement oC the
pulmonary capillaries, rupture of some fllling many of the veaicles
witli blood, some vesicles filled witli leucocytes and epithelial cells.
Intense engorgement of tbe spleen. Clironic venous congestion of
tlie liver and some cirrhosis. Chronic pancreatitis. Acule peri-
tonitis. Acute cystitis, with more or less necrosis of the margins
of the lacerated openlug.

Male. Ago 40. First admission, Reiwrted melancholic, restless,
sleepless and intempei'ate. At times violent and threatens the
family. Fell on bis head at the age of 20. Was overheated short-
ly before tbe onset of the present trouble.

Duration of psychosis : Three and one-haif years.

Cause of death : Pulmonary oedema and broncho-pneunionia.

Clinical rejwrt: None given.

Pathological re|)ort : Esteiisive cyanosis. Extensive decubitus.
Copper-coloi-ed ulcers on the dorsum and inner surface of the left
tibia. Dura moderately adherent. Slight diffuse opacity of the
arachnopla. Some increase of subdural and subarachuoidean fluid.
Brain — Weight. 1200 grms. Some thickening of the basal vessels.
Ventricles dilated. Kpendymn granular. Choroid plexus cystic.
Lungs— Weight, left, 5T0 grms, ; rigbt, GtiO grms. Right pleural .
cavity obliterated by flvm dense adhesions. Pleura of tbe right
lung thickened, lobes adherent, lungs cyanotlc-red In color, doughy
in consistency, bleed freely on section. The upper right lobe Is
irregularly nodular, nodules of a dark red color and of a firmer
consistency, of a 8i)lenic-llke ap|)earance. In the anterior part
of the lol)e is a small abscess cavity. Bronchial mucosa congested
and the lumen filled with a yellowish, viscid purulent secretion.
Heart — ^\'eight. 290 grms. Moderate arterio-scleroals of the ar-
teries in general. Spleen — Weight, 220 grms. Sott on section,
very friable, inalpighian bodies prominent. Liver— Weight, 1520
grms. ICngorged and cut surface rather oily. Kidneys — Weight,
left, 140 grms.; right, 130 grms. Pale in color, moderate quantity
of pelvic fat, capsule strips readily. In the right kidney pelvis
is a turbid, purulent-looking fluid, the mucosa is deeply injected
and the cavity contains a small irregular calculus In ita lower por-
tion. Pancreas— Weight, 90 grms.

Microscopical reiwrt : Moderate diffuse nephritis. Chronic venous
congestion and cirrhosis of the liver. Intense engorgement of the
pulmonary capillaries, irregular masses of tubercular Infiltration
and of pjirly pneumonic conaoiidntion ; exten,»ilve perivascular and
alveolar pigmentary infiltration. Moderate endarteritis. Intaise
engorgement of the spleen.

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1(J4. Male, Agp 1», First ndmission. Her"'''<'d restless, Bwliisive, dull
and v?ry nervous. Thloks tlint he Is niistreatefl. Is not iQolliied
to tnlk. WaatH to leove home. Is addicted to masturhation.

Duration of psychosis : Two years.

Cause of death : Pulmonary tuberculosis. •

Clinical report: None given.

Pathological reixirt ; Cranial Ikiiii-s ililn. Sltglit diiral adhesions ti>
the bones aud to (he iirai'hnopia owe the iinrielnl vertices. Brain
— Wi'lglit, IV.fft gnus. Hear! — Weiftlil. 2!H) grms. llfjirt cnlargtHl.
cavities (lllnle<l, in<Hlerntt> quantity of cpU-nrdial fut. Lungs —
Weight, left, i;!ll<l grnis; right, ISTiO grnis. Firm adhesions in the
right pleural cavity and several hundred ti-. of purulent fluid.
Pleura thickened, rj>hes adlu'rent, mottled cyanotic light and
dark red In color, diffusely and irregularly nodular, doughy oon-
sislcney of the intervening tlKRuc, numerous areas of caseation
and cavity foniiatlon containing a trenniy fluid, irregular cavi-
tieH In the baxes of tlie upiNtr lobea and in the apices of tlie adjoin-
ing lower lobOH. Itroiiflilal niui'osii congi-sleil. swollen unil Kolteiieil.
covered nith a nuico-purulent vlar'id •-(■iTetion. 'rriu-heal aud
laryngeal muowa congested. Bronchial glands enlarged, pigmented
and softened. Mediastinal glands enlarged and some are <>aKeous.
Spleen — Weight, SOO grnis. Rather soft and friable, bleeds con-
siderably on section, malpighian l>odles prominent. Liver — -Weight,
1050 grms. Foci of a dull yeiiowish-red color, consistency softened.
Kidneys — Weight, left. 140 grms. ; right, 110 grms. Moderately
firm on section, pale in color, sniail quimtlty of i)elvic fat. In the
cortex of the right is a small, flrra nodule, white centrally, sur-
rounded by a zone deeply injected, not encapsuled. Extensive
tubercular nodules arid ulcers scattered throughout the small In-
testines, most marked In the ileum. Diffuse enlargement of the
mesenteric and retrojwrltoneal glands. 'I'hyroid gland— Weight,
'M grms.

Microscopical rpiH)rt: Extensive degenerative changes In the nerve
ceiie. Chronic myocarditis. Chronic pleurisy. Diffuse miliary
and chronic tubercular areas of pneunionic consolidation. Ten-
dency- to cystic dilatation of the thyroid vesicles. Chronic bron-
chitis. Tubercular infiitration of the bronchial glands. Slight
difTuse nephritis. In om; is a mass of epithelial cells more or less
alveolated with a fibrous tissue stroma, circumscribed by a more
or less deeply engorged fibrous capsule, cells resembling the corti-
cal cells of the adrenals. Chronic venous congestion, some fatty
infiltration and some portal cirrhosis of the liver. Intense engorge-
ment of the spleen and hyperplasia of the malpighian bodies.
Typical tubercular Infiltration of the Intestines in all Stages of
formation and degeneration.
221. Male. Age 38. First admission. Reported feeble-minded. Intem-
perate. With a mania tor breaking glass.

Duration of psychosis : Not given.

Cause ol death : Pericarditis amj myocarditis,

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Clinical report: Attmltted witli a psycbosig of primary dementia.

Occupation, laborer. After admission there were several periods
of mild excitement, witU several attempts at suicide. Physical
health was good until several months before death, when oedema
of the feet appeared and later ^general anasarca, dyspnoea, etc.

Pathologlfal report : Marked cyanosis. Pupils dilated. General
anasarca. Cranial bones thick and heavy. Firm dural adhesions.
Increase of subdural and siibarachnoldean fluid. Brain — Weight,
1.S60 grms. General atrophy of the convolutions. Basal vessels
atheromatous. Heart — Weight, 310 gnus., with attached peri-
cardium. Pericardial cavity obliterated by dense adhesions. Gen-
eral hypertrophy and dilatation. Some sclerosis of the mitral
valves. Moderate dilatation of the aorta. Moderate arterio-
sclerosis. Lunt;s — Weighl, left, 755 grms. ; right, 795 grms. Left
pleural cavity obliterated by dense. Arm adhesions. On the right
side some Arm adhesions, and that over the lower lobe covered
with a fibrino-purulent exudate and the underlying pleura deeply
injected. Pleuiii thickened and the lobes adhei-ent. Lungs dark
red color, douRhy coneisteiK-y, oosie an abundant frothy, bloody
fluid on section. I'erltoneal cavity contains several hundred cc,
of serous fluid. Liver — W^ght, 1700 grins. Right lobe extends
to the level of the iliac crest. Firmly adherent to the colon in die
region of the gall-bladder. Pancreas — Weight, ]80 grms. Rather
Arm and considerably Infiltrated with fatty tissue. Kidneys — '
Weight, left, 235 grms.; right, 220 grms. Firmly attached to the
perirenal tissue, firm on section, reddish granular in appearance,
large quantity of pelvic fat. capsule strips readily. Prostate slight-
ly enlarged. Spleeu^ Weight, 245 grms. Moderately firm. Tliy-
rold gland— Weight, 40 grms. Slightly cystic.

Microsi-oplcal report : Intense engorgement of the brain tissue, some
round cell Infiltration of the perivascular spaces, moderate chro-
matolytic rliauges in some of the nerve cells. Intense engorgement
of the alveolar capillaries In the lungs, diffuse alveolar pigmentary
Infiltration, some of the vesicles filled with leucocytes and epi-
thelial cells. Parenchymatous enlargement of some of the vesicles
of the thyroid gland. Subacute pericarditis. Chronic myocarditis.
Moderate arterlo-sderosis. Ohronie interstitial and fatty pan-
creatitis. Chronic cholecystitis. Venous congestion, cirrhosis and
foci of fatty necrosis in the liver. Intense engorgement of the
spleen with hyperplasia of the malpigblan bodies. Extensive diffuse
nephritis, the parenchymatous changes predominating.

SECONDARY DEMENTIA.

Male. Age 39. Second admission:

Duration of psychosis: First admission, six and one-half years; sec-
ond, not given.

Cause of death : Pulmonary tuberculosis.

Clinical reiHirt : Second admission — Imagines that he has three pairs
of ^es, that the oculist disconnects one pair and connects tbe

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otLers nt liis ausgestion. (hut lie is a ineinl>er of n ci'i'taln wealthy
family of tlie city aurf uiirteavors to collect tnonoy of them. Has
outbreaks of violence.

I'athologic-al reiwrt: Large tirown cicatrix over tbe anterior surface
of the right tihia. Ui)i)er and outer quatlrant of the right iris
reiiresented by a mere wlillish tag. Extreme emaciation. Slight
opacity of the arachuopla. Increase or subdural and subaracb-
uoidean fluid. Brain — Weight. i:t8U grms. General atrophy. A
Email subpial cyst on the under surface of the left temporo-
spbenoldal lobe. I'osterlor columns of the cord fiiray, most marked
In the luniliar region. Lungs— Weight, left, 1400 grnis, ; right,
590 gPuiB. Firm pleuritic adhesion s-urvoundiiig the right apex
and throughout the whole of the leit wide, dividing the latter into
several irregular cavities cuiUaiiiing a sero-purnlent or creamy
fluid with flbrinous fiocculi and shreds. Hetweeu the perlcurdluiii.
sternum and left lung are a nuuihcr of smaller cavities contain-
ing a similar fluid and commuulcating with the pleural cavities.
Left luug collapsed and airless, llbroid, dark red in color on sec-
tion. Lower lobe of tbe right luug doughy, upper and middle
lobes nodular, more or less caseous and creamy, with an irregular
cavity formation In tbe upper lobe. Bronchial mucosa swollen
and the lumen filled with a viscid muco-purulent secretion. Bron-
chial glands enlarged, plgmenlcd and more or less caseous and
softened. Heart — Weight, '2fM gnus. Left side of the iwricai-dluni
thickened and forms part of tlie wall of the abscess cavities de-
scribed with the jileura. I'cricardial cavily contains about 50 cc.
of serous fluid. Heart Is situated iu the median line. Moderate
atheromatous patches of llie arteries, the coronary vessels being
extensively Involved. Mediastinal tlsRues infiltrated wllh consid-
erable serous Huld and more or less boggy and swollen. Liver —
Weight, 2850 gnus. Lower margin 2 cm. below the iliac crest,
rather firm and of a waxy consistency. Spleen — Weight, 250 grms.
firm and waxy hi consistency and appearance. Kidneys — Weight,
left, 250 grms.; right, 240 grms. Firm on section, iiale In color,
waxy consislency, caj>sule striis readily. Appendix hanging Into
tbe i>elvic cavity. General enlargement of the mesenteric glands.

AIIcrosco|>lcnl reiiort : Extensive chromatolytle changes in the nerve
cells. Sclerosis of the posterior columns of the cord. Moderate
diffuse nephritis. Extensive amyloid Infiltration of all of the or-
gans. Moderate a rterlo -sclerosis, with irregular atheromatous de-
generation of the arteries. Extensive diffuse tubercular consolida-
tion of the lujigs in all stages of degeiierallon. Chronic bronchitis.
Chronic fibriiio-puruleut pleurisy and i>erlcarditis.

Female. Age 55. First admls.<:ion. Reported very noisy, destructive,
excitable, violent and lioniicidal. Said to have had a similar at-
tack two years previously.

Duration of psychosis : Tweuty-lliroe years.

Cause of death : Haemorrlmgie c-erebral cyst. -

<;liiiical report; Admitted witii a psychosis of acute mania. After
admission the course was one of gradually increasing dementia,

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with an absolute loss of mentality during the last four years. Two
years before death there developed a transient hemlplegic attaclt.
Since then there have been about six similar attacks, all lasting
from forty-elgbt hours to four months, with complete recovery.
From the last attack recovery did not take place. There was loss
of motioD, and so far as ascertainable loss of sensation on the
right side of the body. There were repeated convulsive seizures,
usually beginning on the right side but becoming general. The
pupils were generally dilated and unequal, the tongue deviated to
the left, there was impairment of deglutition, exaggeration of the
right bnee-jejrk, no clonus and no Babinski reaction.

Pathological report; Extreme emaciation. Extensive decubitus.
Atrophy and flabbiness of the muscles on the right side of the
body. Slight Increase of subdural fluid. Dura firmly adherent
over an area 3 cm. in diameter, overlying the lower end of the
fissure of Sylvius on the left side. Bia in.— Weight, 1150 grms.
General atrophy of the convolutions. EKteuslve atheromatous de-
generation of the basal vessels. The inner surface of the dura
over the area of adherence has attached to it a brownish-yellow
granular mass 1 cm. in thickness, and beneath this is a cavity
containing about 25 cc. of a clear amber-colored fluid which coagu-
lates spontaneously, gives a violet reaction with Febling's solution.
The cavity is about 7 cm, in diameter, extending mostly upward
and backward, uudenuining the posterior part of the third frontal,
the lower part of the ascending frontal and of the ascendiug parie-
tal, and the anterior inferior part of the supramarginal convolu-
tions. The floor Is smooth and formed by the posterior portion
of the frontal and of the anterior inferior portion of the parietal
and the Island of Reil. . Heart— Weight. 215 grms. Extensive
atheromatous d^eueration of the arteries. Dilatation of the arch
of the aorta. Lungs — Weight, 280 grms. each. Marginal infarct
of the right lower lobe. Bronchioles exude a muco-purulent look-
ing fluid. Bronchial glands enlarged. Spleen — Weight, 90 grms.
Firm on section, blood vessels project beyond the cut surface,
trabeeulae prominent. Liver— Weight, 920 grms. Pancreas-
Weight, 85 grms. Kidneys— Weight, left, 100 grms.; right, 90
grms. Moderately firm, pale in color, moderate quantity of pelvic
fat, capsule adherent. Appendix hanging into the pelvic cavity.

Microscopical report : Extreme d^enerative changes in the nerve cells.
Extensive arterio-sclerosis of the arteries and moderate athero-
matous degeneration. Tubercular infiltration of the lungs in nod-
ules and masses In all stages of degeneration. Diffuse pigmentary
.inflltration of the bronchia! glands with hyperplasia of the lymph
follicles and tubercular infiltration. Foci of round cell inflltration
in the adrenals. Engorgement and a rterio .sclerosis of the spleen.
Intense engorgement, foci of fattv necrosis, foci of round cell in-
filtration and some bile duct proliferation in the liver. DlfCuse
arterio-sclerottc and Intei'sfitlal nephritis.

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Male. Age 48. First admiBslon. Reported melanchotlc, vloleot. sui-
cidal, homicidal, at times uolsy, eKi^itnble and Irritable. Rarely
speatis.

Duration of psychosis : Twenty-live years.

Cause of death : General perllonltls.

Clinical report: Admitted with a psychosis of chronic mania be-
ginning about seven years l)efore. After admission was noisy, vul-
gar and abusive, easily angered, refused to walk. Underwent
gradual dementia. Before his death he refused to get out of tied,
complained of pain lu the abdomen and groin, of naui^a and
voinltlne, which later became stercoraceous. Lyegs were flexed
upon the abdomen and complained of iniense abdominal pain when
lying uiKin his back. Single. Occupafiou, laborer.

Pathological report: Slight general Jaundice. Cataract in the right
eye. External haemorrhoids. Ci'anlal bones hard. Diffuse opac-
ity of the arachnopla. Increase of subarachnoidean fluid. Bruin —
Weight, 1175 grins. General atrophy of the convolutions. Pituitary
body enlarged to twice its normal size. Heart — Weight, 290 grms.
Some sclerosis of the aortic cusps. Below aud between the right
and posterior cusps Is a circular opening 1 cm. In diameter leading
into a poucb-Uke membranous cavity slightly larger, which projects
into tlie right auriculo- ventricular septum. Irregular patchy ather-
omatous degeneration of the nrteries. Lungs — Weight, left, 390
grms. ; right, 660 grms. Firm pleuritic adhesions in both cavi-
ties. Pleura thickened. Lobes adherent, some dilatation of the
marginal lobules, right lung doughy in consistency, the bases and
posterior portion of both lungs cyanotic-red in color, ooze an
abundant frothy, bloody fluid on KOction, Peritoneum red and In-
tensely congested, most marked in the lower part and In the pelvis,
several hundred cc. of a reddish colored fluid. Omentuni and in-
testines more or less cemented together by a fibrlno-plastle exudate.
Spleen — Weight, 70 grms. Moderately firm in consistency. Liver
— Weight, 1220 grms. Some firo) adhesions to the diaphragm
Capsule tlitcbened, firm on section, portal radicles dilated, gall-
bladder contains one large rough calculus. Kidneys — Weight, 140
grms each. Moderately adherent' to the perirenal tissue, firm on
section, considerai>Ie pelvic fat, capsule strips with some difficulty
and leaves a rough surface. Small Intestines distended with gas.
Caecum distended with gas and lying in the pelvic cavity ; the
appendix tiehlnd the caecum and against the posterior wall of the
bladder, is somewhat enlarged and presents an Irregular opening
about 2 em. from Its extremitj' ; Is united to the posterior surface
of the bladder by a fibrinous exudate. Purulent fluid filling the
appendix and some in the caecum. Mesenteric and retroperito-
neal glands enlarged. In the prevesical space anterior to the peri-
toneum is a cavity containing a brownish, slightly grumous fluid
with purulent shreds, its walls lined by a purulent exudate, extend-
ing as high as the pubes and communicating with the bladder by
an Irregular opening about 2 cm. long In the anterior wall of that

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viscus, tts margins acutely inflained, the bladder contracted and
empty. Pancreas — Weight, 100 grms.

Mlcroscoplf^al report: Considerable chromatolytic changes in the
nerve cells. Numerous hyalhie hodtes in the choroid plexus and
ealcareouB bodies iu the pineal gland. -Considerable tatty tnflltra-
tion o£ the heart Slight cbronic myocarditis. Moderate arterio-
sclerosis and Irregular atheromatous d^ieneratioD. Intense en-
gorgement of the pulmonary capillaries with rupture of some, and
filling of the vesicles with blood. Some vesicles filled with leu-
cocytes and epithelial cells. Relative trabecular increase in the
spleen. Malpighian bodies dense. Extensive perihepatitis. Chronic
venous congestion and extensive cirrhosis of the liver. Intense
engorgement of the Itidneya and diffuse nephritis. Acute conges-
tion of the omentum. Acute cystitis. Acute peritonitis. Acute
ulcerative appendicitis.

female. Age 32. First admission. Reported aciitely and profound-
ly meiancliolic with loss of Interest In herself and her surround-
ings.

Duration of psychosis : T*vo years.

Cause of death : General tuberculosis.

Clinical report : Admitted with a psychosis of acute melancholia
b^lnulng sis months before admission. After admission the de-
pressed state continued for some time, after which she became
acutely maniacal, which was followed by a gradual dementia.
Physically on admission there was evidence of pulmonary tuber-
culosis, reported as having begun about one year before admis-
sion. Intestinal trouble developed with severe diarrhoea, which
could not l>e controlled by medicati<)Q. For several mouths the
course was rapidly and pit^ressively downwards, cough, high tem-
jierature, rapid pulse, profuse perspiration, profuse espeetoration,
diarrboea at times containing blood, rapid respirations, dullness
on percussion over both lungs with areas of tympanitic resonance
over the upper portion of the left lung anteriorly, numerous vesi-
cular murmurs, bubbling rales, broncho-cavernous breathing as-
sociated with gurgling rales over the cavity,

I'atliologlcal report : Extreme emaciation. Pupils unequally dilated.
Cranial bones thin. Finn dural adhesions over the parietal v^-
tices. Slight opacity of the arachuopia. Brain — 1100. grms. Pi-
neal gland enlarged and hollow. Choroid plexus cystic. Lungs —
Weight, left, 420 grms. ; right, 480 grms. Both pleural cavities
obliterated by firm dense adhesions. Pleura thickened, lobes ad-
herent Diffusely nodular and irregular cavity formation through-
out Heart — Weight, 110 grms. Small quantity of serous fluid In
the pericardia! cavity. Some sclerosis of the mitral valves. Mod-
erate arterio-sclerosls, Thyi-oid gland represented by a Qbrous
mass containing a few irr^ular lobules. Several hundred cc. of
purulent fluid In the peritoneal cavity. Omentum adherent over
the caecum. Peritoneum covei'ed with small whitish tubercles,
pin point In size. Oolls of the small intestines matted together.

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Caecum overlying and Intimately adherent to the pelvic structures.
Numerous tulwrculor nodules and ulcers involving the small in-
testines, caecum and ascending colon. In the caecum the ulcers
coalesce and form an Irregular ulcerating surface. Spleen-
Weight, 170 grms. Numerous band-like adhesions to the dia-
phragm, capsule thickened, consistency soft and fragile. Liver-
Weight, llUO grms. Numerous band-like adhesions to the dia-
phragm. Constriction of the right lobe at the Junction of the lower
and middle thirds. Capsule thickened. Kidneys— Weight, 90 grma.
each. Firm on section, pale in color, small quantity of pelvic
fat, capsule strips readily. Both fallopian tubes dilated, dis-
tended with a purulent fluid and their walls thicliened, the right
extending to the lliue fossu, more or less firmly adherent, and
lying behind the caecum. Right ovary enclosed in a mass of In-
flammatory tissue. The sigmoid flexure of the colon and the rec-
tum adherent to the right side of the pelvis, to the caecum and
the right cornua of the uterus. Appendix rudimentary. Pancreas
— Weight, 45 grms. Rather firm in consistency.

Microscopical report: Moderate degenerative changes In the nerve
cells. Moderate a rterlo -sclerosis. Extensive diffuse and miliary
tubercular Infiltration of the lunijs with emphysemii of the Inter-
vening alveoli. Extensive pigmentary infiltration of the lungs.
Hyperplasia of the lymph follicles of the bronchial glands with
extensive central degeneration and more or less fibrosis and pig-
mentary infiltration. Chronic venous congestion of the liver with
extensive fatty Infiltration, foci of fatty necrosis, moderate cir-
rhosis and numerous foci of typical tubercular foci of infiltration.
Engorgement of the spleen, hyperplasia of the malplghtan bodies
and numerous foci of tubercular Infiltration. Diffuse nephritis.
Extensive tubercular infiltr.atlon of the various parts of the intes-
tines in all stages of degeneration and ulceration. Tubercular In-
volvement of the fallopian tubes.

Male. Age 70. First admission.

Duration of pivchosis- More than twenty years

Cause of death Tntchtlnal gangrene

Cllnicil report The deieloinient of dtmentia has been progressive
for yeirs Hjs been actiielj en(,iged about the Institution He
was taken with an attick of mild entero-COHtls followed bv pro-
gre^sne emaciation md physical nenkening He complained of
some tenderness oter the abdomen mucopurulent stools ocLaslon-
ally strealied w itb blood

Pttholofclcal report F\treme emaciation Well marked arcus se-
nilis Bulging of the lower part of the liadomen Cranial bones
hard and deii>.e Dura flrmlv adherent to the bones and to the
araclmopia over the parietal lertices Diffuse opiclty and in-
creased thick uess of the arachnopia Increase of subdural
and subarachnoldein fluid Attached to the anterior portion of
the right side of the fals cerebri is a small nhite firm nodule at-
tached by a h^o^d bise Biam — tt eight 3460 grms Basal ves-
sels extensi\cly atheiomatous ihe posterioi poitlon of the cor-

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pus ctiUosuHi is tiiickeued, sofieneiJ eentrnllj, fleshy in color, the
mass extending downward and backwari] on botb sides, gradually
fusing with the normal brain substance. Lungs — Weigbt, left, 300
grms. ; rigbt, 510 grms. Firm pleuritic adhesions in both cavities.
Pleura thickened. Lobes adiierent. Marginal lobules dilated,
cicatricial contraction of the pleural surface about the apices,
nodular inOltration of the apices with more or less caseation. Bron-
chial mucosa congested and covered with a viscid muco-purulent
secretion. Bronchial glands enlarged, deeply pigmented and irreg-
ularly caseated. Thyroid gland enlarged and cyslic. Heart —
Weight, 270 grms. Sclerosis of the mitral valves, with a calcare-
ous plate in the base uf the posterior cusp. Sclerosis, marginal
fenestration and calcification of the aortic valves. Dilatation of
the aorta. Extensive atheromatous degeneration of the arteries,
'ihe peritoneal cavity contains a small quantity of bloody fluid
in the right lower portion. Peritonuem is injected. Omentum ad-
herent and intensely congested. The intestines below the umbilicus
are dark-red in color, dilated and distended, containing grumoua
matter and Involving the greater part of the ileum, the caecum
and part of the ascending colon. The appendix hanging into the
pelvic cavity. The mesenteric artery la dilated, thickened, tor-
tuous and calcareous, its lumen filled with a fleshy-looking mass
quite firmly adherent on its posterior surface and extending along
the lumen for a distance of (i cm. Some blood partly coagulated
fills the lumen below this, too, the giving ot¥ of the large branch
going to the gangrenous portion of the intestines, where there is
another fleshy mass completely occluding the lumen. Spleen-
Weight, 140 grms. Capsule thickened and rouglL Parenchyma
soft and friable. Liver — Weight, 1100 grms. Capsule thickened,
firm on section. Pancreas — Weight, 75 grms. Irregularly nodular.
The splenic artery ■thickened, tortuous. Irregularly dilated and cal-
careous. Kidneys-— Weight, left, 100 grms. ; right, 120 grms. Firm
on section, pale in color, large quantity of pelvic fat, capsule
strips readily. Gastric mucosa thickened and somewhat granular-
looking. Retroperitoneal glands enlarged and some caseous.
Microscopical report ; Moderate degenerative changes in the nerve
cells. Central canal of the cord filled with proliferated epithelial
cells and the central gelatinous substance Infiltrated with them.
The brain-tumor mass consists of a loosely-arranged stroma with
foci of round cells varying In size, numerous blood-vessels with
fairly well-formed walls, and areas of apparent granular degen-
eration. The oval growth on the falx consists mostly of spindle-
shaped cells, more dense some places than others, infiltrated with
hyaline bodies. The pituitary body contains numerous alveolar
spaces at the Junction of the two portions, filled with homogen-
eous material in some of them. Moderate fatty Infiltration of the
heart. Extensive chronic myocarditis. Moderate arterlo-scierosls
and Irregular atheromatous degeneration. Emphysema of the
lungs with extensive perivascular and peribronchial blackish pig-
mentary infiltration. Fibrosis pigmentation and tubercular lufll-

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tratlon of the bronchial glands. FarenchymntouB and Interstitial
enlargement of the tbyrold glund with iireae of adenomatous fov-
mation assuming malignant featuren. Chronic pancreatitis. Foc-t
of round cell and h Hemorrhagic Infiltration in tlie adrenals.
Chronic venous congestion and cirrhosis of the liver. Extensive
diffuse nephritis.

SENILE DEMENTIA.

Female. Age 83. First admission.

Duration of psychosis : Four and one-halt years.

Cause of death : Acute peritonitis.

Clinical report: Admitted with a psychosis of senile dementia. Two
weeks before her death was taken with an attack of severe vom-
iting, epigastric tenderness and constipation, pulse becoming weak
and rapid with Intense gastric irritability.

Pathologlciil report: Cruniul hones soft and cuuii'Ilous, Dura ttrui-
Ij adiierent over the frontal bones. Diffuse opiicity of the arach-
nopia. Large <iuantity of subdural and subaruclmoidean fluid.
Brain — Weight. 075 grnis. General atrophy of the convolutions.
Extensive atheromatous degeneration of the basal vessels. Choroid
plexus cystic. Heart^Welgbt, 300 grme. Sclerotic patches in
the eplcardium. Extensive fatty Infiltration. Chronic myocarditis.
Marked sclerosis of the mitral and aortic valves with extensive
calcareous intlltratlon at the bases. Extensive atheromatous de-
generation of tlie arteries with extensive calcareous Infilfratloii
and numerous foci of atheromatous ulceration. Lung^-r- Weight,
left, 2ti5 grms. ; right, 2:30 grms. Firm pleuritic adhesions in the
right side. Cicatricial contraction of the right apex, calcareous
nodules In both apices, dilatation of the machinal lobules. BroU'
chial glands enlarged and deeply pigmented. Peritoneum and
walls of the Intestines deeiily congested, a small quantity of yel-
lowish turbid fluid in the pelvic cavity. I'rojecting from the left
broad ligament, attached to it and apparently taking the place of
the ovary is a hard nodular whitisli mass lying to the outer side
of the sigmoid colon and upon the pelvic brim, with numerous
blood-vessels ramlfyliig over Its surface. Numerous Arm adhesions
of the under surface of the liver to the underlying omentum and
hepatic tlexure of the colon. Spleen— Weight. 80 grms. Rather
firm on section. Liver —Weight, 10r)5 gmis. Rather soft In con-
sistency. Kidneys — Weight, left, 90 gruis. ; right, 100 grms. Firm
on section, pale in color, striatlon indistinct; considerable pelvic
fat, numerous cortical cysts, capsule strips readily. In the anterior
wall of the stomach is a small white nodule about 1 cm. in diame-
ter situated near the greater curvature slightly caseous and in-
filtrated with calcareous matter. Right ovary atrophic. Several
small utelne fibroids. Bones soft and very fragile.

Microscopical report : Extensive chronic myocarditis. Extensive
atterio-sclerosls and atheromatous degeneration, calcareous In-
filtration and ulceration of the arteries. Chronic venous conges-
tion of the liver and some cirrhosis. Extensive diffuse nephritis.

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Chronic gastritis with a tub«rcular nodule involving tbe enbrnu-
cosa. Fibroma o£ tlie left ovary.

Femiile. Age 78. Secoud admission. Reported as usually quiet, at
times talkutlve and restless, manifested by undressing and pack-
ing her clothes. Does not recognize members oC her family. Im-
agines that she can communicate with relatives long since dead.

Duration of psychosis : Tweuty-flve months.

Oause of death : Bntero-colitla and pulmonary oedema.

Clinical report: Admitted with a psychosis of senile dementia, as
reported above. Later she became fretful, complained of nausea,
abdominal pain and tenderness, diarrhoea and tympanitis Cor a
few days, which gradually subsided. Has had repeated attacks of
syncope, in one of which she died.

Pathological report: Marked depression of both parietal eminences.
Cranial bones cancellous. Dura diffusely adherent throughout.
Diffuse opacity of the arachnoplu. Increase of subdural and sub-
aracbnoidenn fluid. Brain — Weight. 1260 grms. General atrophy
of the convolutions. Bony plates In the anterior walls ot the
superior longitudinal sinus. Basal vessels estensively atheroma-
tous and calcareous. Lateral ventricles dilated. Choroid plexus
cystic. Lungs — Weight, left, 340 grms.; right, 450 grms. Firm
, pleuritic adhesions in Ixtth cavities. About SOO cc. of serous fluid
in both cavities. Apices nodular and caseous, lower lobes of a
doughy consistency, cyanotlc-red in color, ooze considerably frothy,
bloody fluid on section, a considerable mass of consolidation In
the apex of the right lower lobe, dilatation of some of the mar-
ginal lobules. Bronchial glands enlarged and caseous. Heart-
Weight, 380 grms. Sclerotic patches in the epicardium. Consid-
erable eplcardial fat. General hypertrophy. Atheromatous patches
in the ijody of the mitral and aortic valves. Extensive atliero-
matous degeneraliou and calcareous Infiltration of the arteries.
Small quantity of serous fluid in the peritoneal cavity. Spleen-
Weight, 180 grms. Kather soft and friable. Malplghian bodies
prominent. Liver — Weight, 12W) grms. Band-like adhesions to
the diaphragm, Arm on section, capsule thlclceiied. Kidneys —
Weight, left, 150 grms. ; right, 180 grms. Firm on section, darlt-
red in color, the pyramids more so than the cortex, no pelvic fat,
capsule adherent and tearing the substance on removal. Walls of
the large bowel and of the lower portion of the Ileum thickened,
the mucosa thickened and rough, somewhat congested. Appendix
hanging into the pelvic cavity. Ovaries atropbied. Bones soft
and fragile.

Microscopical report : Fatty infiltration of the heart. Chronic myo-
carditis. Extensive atheromatous degeneration and calcareous
infiltration of the arteries. Chronic tuberculosis of the lungs. Por-
tions of the lungs eniphyseuintous. Intense congestion of the alve-
olar capillaries with rupture of some and filling of the vesicles
with blood, 'i ubercular Infiltration of the bronchial glands. Chron-
ic venous congestion of the liver. Extensive arterio sclerotic and
diffuse nephritis. Chronic catarrhal colitis.

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Female. Age 74. First admlsaloii. Iteported reslless. slecpleu^, ii cl-
ancboly. as having deinsloaB and lin 1 1 urinations. Is In constant
fear of deatti.

Duration of psycboBla ; Seven montbs.

Cause of deatti : Clironic dreentery.

Cllnloal report; Admitted with a psycliosis of senile dementia.
After admission had obstinate diarrhoea, partly controlled by medi-
cation and diet. Abdomen was tender on pressure, sunken and
retracted. Heart Irregular in action. An aortic systolic murmur.
Syncopal tendency upon assuming the erect posture. Pulse small,
weak and irregular. Kadial arteries thickened. Venous stasia in
the euperflclal vessels. Oedema of tbe lower limbs. Coldness oC
the hands and feet. General emaciation. A few mucus rales in
tbe lungs.

Pathological report: E.vtreuie emaciation. Cranial liones cancellous.
Dura Urnily adlierent. Diffuse opacity of tbe arachnopla, In-
crease of subdural and subaruchnoldean fluid. Brain — Weight,
1000 grms. General atrophy of the convolutions. Extensive ath-
eromatous degeneration of the basal vessels. Left vertebral ar-
terj- very small. Extensive dilatation of the ventricles. Sand-
like particles In the choroid ple.iiis. Heart — Weight, 225 grms.
Considerable eplcardlal fat. Considerable sclerosis of tbe mitral
and aortic valves, wltb eitenslve calcareous infiltration of the
aortlcs. Extensive atheromatous degeneration and calcareous in-
filtration of the arteries. Numerous foci of atheromatous ulcera-
■ tion. Tbe coronary vessels extremely Involved, almost occluding
their lumen. Lungs — Weight, left, 210 grms. ; right, 380 grms. A
small quantity of serous fluid in both pleural cavities. Bight lung
cyanotic-ved color, posteriorly, doughy In consistency and ooeing
considerable frothy, bloody fiuld on section. Bronchial glands en-
larged and pigmented. Thyroid glands— Weight, GO grms. Both
lobes enlarged and sliowing tendency to cyst formation. In the
left lobe is a calcareous mass 2 cm. in diameter. Transverse colon
U-shaped and lying 2 cm. below the iliac crest. Spleen — Weight,
60 grms. Fairly firm on section. Liver— Weight, 780 grms. Firm
on section, nutmeg in appearance. Kidneys — Weight, left. 150
grms. : right, 135 grms. Firm on section, dusky-red In color, cor-
tex pale, striatlon invisible, considerable pelvic fat, capsule strips
readily. Gastric mucosa thickened. Walls of tbe large intestines
thickened, most marked toward the rectum, numerous irregular
ulcers scattered over the surface, some undergoing active ulcera-
tion, others more or less healing and cicatrization.

Microscopical report: Extensive degenerative changes In tbe nerve
cells. Numerous hyaline bodies In the choroid plexus. Chronic
myocarditis. Extensive arterlo-sclerosls and atheromatous de-
generation of the arteries. Intense engorgement of the pulmonary
capillaries with a tendency to pneumonic consolidation. Cystic
dilatation of many of the thyroid gl:md vesicles. Intense engorge-
ment of the spleen. Extensive fatty inflltration of the liver and
considerable venous congestion. Extensive diffuse nephritis. Ex-

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tensive diffuse Inflammatory thickening of the walls of the large
intestine, catarrhal proliferation of the mucosa and areas of de-
generation and ulceration.

Female. Age 79. First adnilssiou.

Duration of psychosis: Ten years.

Cause of death : Lobar pneumonia.

Clinieal report: Admitted with a psychosis of senile dementia. Had
been In declining health for several years. Was taken with severe
diarrhoea, which persisted until death, but was more or less inter-
mittent, with stools watery and yellowish. During the last tew
days prior to death there developed labored respiration, weak
pulse and weak heart action.

Pathological report: Elxtreme emaciation. Slight decubitus. Cran-
ial bones cancellous. Moderate diffuse dural adhesions. Diffuse
opacity of the arachnopia. Increase of subdural and subarach-
noidean fluid. Bralu — Weight, 1040 grms. General atrophy of the
convolutions. Basal vessels extensively atheromatous and calcare-
ous. Lungs— Weight, left, 300 grms. ; right. 565 grms. Some small
dark-red areas of a more or less solid consistency in the lower left
lobe. On the right side a flbrtno-plastic exudate In the pleural
cavity cementing the surfaces together. The greater portion oC
the lower lobe, the posterior three-fourths of the upper lobe and
the apex of the middle lobe on the right side solid and In a con-
dition of red and gray hepatization. Bronchial mucosa congested.
Bronchial glands deeply pigmented and enlarged. Heart — Consid-
erable epicardial fat. Some sclerotic patches in the eplcardium.
Some sclerosis of the mitral and aortic valves with calcareous in-
filtration in the latter. Moderate dilatation of the ascending por-
tion of the arch. Extensive atheromatous degeneration of the ar-
teries with irregular calcareous infiltration and numerous foci
of atheromatous ulceration, the coronary vessels being extremely
involved. Stomach occupies a vertical position, its lower margin
lying below the level of the anterior spines of the Ileum, Its pyloric
extremity Just above the umbilicus In the median tine and the or-
gan having a sharp curve at the Junction of the lower and middle
thirds. St)leen — Weight, 5Ti grms. Soft on section and friable.
IJvei- — Weight, (KM grms. Rather soft in consistency. Kidneys — ■
Weight, left, 80 grms. ; right, 75 grms, I'irm on section, pale In
color, striation indistinct, considerable pelvic fat, capsule adherent,
numerous cortical cysts. Intestinal mucosa more or less congested
and covered with a viscid mucoid secretion. Genera! enlargement
of the mesenteric glands.

Microscopical report: Acute fibrinous pleurisy. Red and gray hepa-
tiiiation of the right lung. Intense engorgement of the left limg.
Extensive atheromatous degeneration of the arteries with calcare-
ous infiltration. Extreme fatty iufiltrntion of the liver and venous
congestion. Extreme diffuse nephritis.

Female. Age (i2. First admission. Reported restless. Unable to
recognize friends. Wanders from home.

Duration of jisychosis: Fifteen months.

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Cause of deatli ; Acute colitis.

Clinical report: Admitted with a psychosis ot senile dementia. One
brother insane. Ciiuse said to be heredity and involution. After
admiBsloQ presentod the ordinary features of senile dementia. Has
had several attncks of colitis, the last one proving fatal, after an
illness of ten days.

Pathological report: Oedema of the lower limbs. Thorax barrel-
shaped. Cranial bones cancellous. Dura moderately adierent.
Some increase of subdural and subarachnoidean fluid. Brain-
Weight, 1110 grms. General atrophy of the convolutions. Ex-
tensive atheiomatous'degeneration of the basal vessels with con-
siderable calcareous Infiltration. Lungs— Weight, left, 320 grms.;
right, 565 grms. Extensive firm pleuritic adhesions on the right
side. The iHJSterior portion of the . right lower lobe collapsed,
leathery and airless. The anterior portion of the right lower lobe
of the posterior part of the upper and middle lobes, and of the
posterior portion of the left lung In a condition of liypostatlc con-
gestion. Moderate dilatation ot some of the marginal lobules.
Bronchial glands enlarged and pigmented. Heart — Weight, 275
grms. Some sclerotic patches in the epioardlum, considerable epi-
cardlal fat, atheromatous plaeques In the jnltral and aortic valves.
Extensive atheromatous dt^eneration and calcareous infiltration
of the arteries, S]>l sen— Weight, 55 grms. Firm on section.
Liver — Weight, 910 grms. Capsule thickened, mottled nutmeg ap-
pearance on section. Kidneys— Weight, left, 80 grms. ; right, 75
grms. Firm on section, pale In color, strlatlon poorly marked,
considerable pelvic fat, capsule adherent. Pancreas— Weight, 90
grms. Firm on section. Numerous small whitish bodies In the
adrenals. Ovaries atrophic. Walls of the large Intestines thick-
ened, nuicosa swollen and congested, numerous foci of ulceration
in the descending and sigmoid colon.

Microscopical r^ort ; Extensive chromatolytlc changes in the nerve
cells. Chronic myocarditis. Extensive athoromatous degenera-
tion and calcareous Inflltration of the arteries. Vesicular emphy-
sema of the lungs. Some oedema with beginning consolidation.
Chronic venous congestion of the liver with considerable fatty
Infiltration. Engorgenient of the spleen. Extensive arterlo-scler-
otic and interstitial nephritis. Acute ulcerative colitis.

Male. Age Tti.- First admission.

Duration of psychosis ; Two years.

Cause of death : Pulmonary oedema and pneumonia.

Clinical report : Admitted with a psychosis of senile dementia, ban-
ning six months before. On admission the condition was one of
pronounced a rterio-spl erotic changes. Gangrene of the right sec-
ond toe. Pneumonia of the lower left lobe of the luncs. Relative
dullness over both lungs. Broncho- vesicular breathing. Crepitant
and subcrepitant rales.

Pathological report: Sacrnl decubitus. Amputation stump ot the
second toe of the right Coot. Well-marked arciis senilis. Some
dural adhesions. Diffuse opacity and increased thickness of the

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arachnopla. Moderate increase of saMural and anbaractmoldean
fluid. Brain — Weight, 1320 grnis. ConvolutlonB somewhat flat-
tened. Basal vessels thickened. Ventricles dilated and lilled with
fluid. Lungs — Weieht, left, 470 grms. ; right. 530 grma. Both
pleural cavities almost wholly obliterated b; dense, Arm adhesions.
Pleura adherent to the pericardium. Pleura thickened. Lobes
adherent Lungs dark-red in color, doughy In consistency, more
or less nbrold, except the lower left lobe, which is solid through-
out. In Its anterior margin Is a wedge-shaped area partly disinte-
grated, grayish In color, exudes a muco-purulent fluid from the
bronchioles, the latter being surrounded by a reddish zone. Bron-
chial glands enlarged and pigmented. Heart — Weight, 470 grras.,
with attached pericardium. Pericardial cavity obliterated by firm,
dense adhesions. Hypertrophy of the left ventricle. Moderate
thickening of the aortic valves. Extensive atheromatous degen-
eration of the arteries, with considerable calcareous Infiltration
and atheromatous ulceration. Liver— Weight, 1300 grms. Dense
adhesions to the diaphragm. Firm on section. Spleen — Weight,
110 grms. Firm on section, malpighian bodies distinct. Kidneys —
Weight, left, 160 grms.; right, 150 grms. Firm on section, mod-
.erate pelvic fat, nunierous cortical cysts, capsule adherent and
leaves a rough surface. Appendix hanging Into the pelvic cavity.

Microscopical report ; Extensive d^eneratlve changes In the nerve
ceils. Chronic pericarditis. Chronic myocarditis. Extensive en-
darteritis and atheromatous degeneration. Chronic pleurisy.
Chronic bronchitis. . Broncho-pneumonia. Diffuse anthraeosla.
Chronic venous congestion of the liver and moderate cirrhosis.
Estenslve a rterlo-scl erotic nephritis. Cystic dilatation of some
of the thyroid vesicles.

Female. Age 67. First admission. Reported as having various
delusions. Fell when quite young and Injured her hip.

Duration of psychosis : 'i hirteen years.

Cause of death : Acute enteritis and pulmonary tuberculosis.

Clinical report ; Admitted as a chronic mania. After admission
there was gradual and progressive dementia. Acute enteritis de-
veloped, characterized by profuse diarrhoea, pain and tenderness
In the abdomen. For about a year previously there had been a
gradual det-llne In her pliyslcal condition and tubercular involve-
ment of the lungs was suspected.

Pathological report ; Extreme emaciation. Severe decubitus. Mod-
erate swelling of the right hand. Oedema of the lower limbs.
Right leg abducted, rotated out, leg flexed on the thigh and the
thigh upon the abdomen, trochanter flattened, carried up and for-
ward, and the leg al>out 4 cm, shorter than the other. Cranial
bones cancellous. Moderate dural adhesions. Moderate diffuse
opacity of the arachnopla. Some increase of sul>dural and sub-
arachnoidean fluid. Brain — Weight, 1310 grms. General consist-
ency soft and mushy. Lungs — Weight, left, 800 grms. ; right, 960
grms. Both pleural cavities obliterated by firm dense adhesions. Pleu-
ra thickened. r>obes adherent. Irregular areas of consolidation

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throughout the lunga with the Intervening tissue oedematouB and
boggy. The solid areas are dark red in color, splenlc-llke In ap-
pearunce and conaUtency on section. la the middle and lower right
lobea are several Irregular cavities fliled with dark-red gnimoua
material and the walls lined with soft, pulpy, shreddy tissue. Bron-
chial glands enlarged, black and softened. Heart — Weight, 255
gnus. Several sclerotic patches In the epicardluni. Some athero-
matous patches In the mitral valves. Moderate arterio-sclerosls
and atheromatous degeneration. Most of the Intestines lying in
the pelvic cavity, the walls swoll«), deeply Injected and tbe con-
tents dark red and grumous. Spleen — Weight, 154 grms. Bleeds
conslderatily ; malplghian bodies prominent Liver — Weight, 1310
gnns. Capsule thickened. Arm on section. Gall-bladder contains
one small calculus. Kidneys— Weight, left, 13 grma.; tight, 160
grms. Firmly adherent to the pelvic fat, firm on section, mottled
pale to dark red in color, considerable pelvic fat, capsule adher-
ent. Pancreas — Weight, 80 grms. Uterus retroflexed and firmly
adherent to the posterior pelvic wall. Several interstitial fibroid
tumors in the posterior wall. A calcified mass, 2-5 cm., in tbe right
broad ligament

Microscopical report : Extensive chromatolytlc changes in the nerve
cells. Numerous hyaline bodies In the choroid plesus. Engorge-
ment of the pituitary body and some of tbe spaces fliled with
hyaline material. Vesicular emphysema of the lungs. Early pneu-
monic consolidation. Areas of gray hepatization. Extensive oi-
darterltls and moderate atheromatous degeneration of tbe arteries.
Chronic myocarditis. Chronic pericarditis. -Chronic pleurisy. Ex-
tensive diffuse nephritis. Moderate hyperplasia of tbe malplghian
bodies of the spleen. Acute enteritis.

Female. Age 74. First admission.

Duration of psychosis: Two years.

Cause of death ; Decubital aeptieaemla.

Clinical report: Admitted with a psychosis of dementia, first mani-
fested abolut six months before admission. Was poorly nourished
when admitted. After admission tbe physical and mental failure
was progressive. Was In bed for a year. About one month before
her death she b^an to manifest gastric and intestinal disturb-
ances, with evidence of developing pulmonary oedema. Extensive
bed sores with sloughing, gangrene and a general septic condition.
During the last two weeks sinking spella due to heart trouble.

Pathological report : Extensive areas of subcutaneous ulceration,
sloughing and gangrene, mostly over the back, gluteal .region and
back of limbs. Cranial bones cancellous. Moderate dural adhe-
sions. Considerable opacity and thickening of the aracbnopla.
Some increase of the subdural and eubarachnoldean fiuld. Brain —
Weight, 1000 gnns. General atrophy of the convolutions. Basal
vessels extensively atheroma tons. Left posterior cerebral to the
junction with the left posterior communicating very small, the
. communicating very inrge and apparently continues as the pos-
terior cerebral. The uuder half of the right cerebellar hemisphere

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Is [►ccupied by a cystic cavity, the heniispliere 1b small, both middle
iwduncles are small. The veutrlcles are extensively dilated. Pit-
uitary body soft and friuble. Luugs— Wulglit, left, 215 grms. ;
right, 240 grme. Firm pleuritic adhesions iu both pleural cavities.
Pleura thickened. Lobes more or less adherent Some of the mar-
ginal lobules dilated. Heart — Weight, 250 grme. Extensive ath-
eromatous denegeratiou of the arteries with considerable calcare'
ous infiltration. Aorta considerably dilated. Clver— Weight, 1100
grms, Finn adhesions to the diaphragm. Capsule tliicliened. The
gall-bladder firmly contracted into a cicatricial mass, and, together
with the adjoining liver, firmly adherent to the colon and duode-
num. The common, hepatic ducts and radicles dilated and walla
thickened. Pancreas — Weight, 90 grms. Splenic artery thickened,
tortuous, dilated and calcareous. Kidneys — Weight, 00 grms.
each. Firmly adherent to the perirenal tissue, firm on section,
almost white iu color, large amount of pelvic fat, atriation indis-
tinct, capsule strips readily, but leaves a rough surface. Ovaries
and uterus atrophied.

Microscopical report; Moderate diffuse degenerative changes iu the
nerve cells. Moderate anthrocosls. Chronic myocarditis. Exten-
sive atheromatous degeueratiou of the arteries. Interstltlat In-
crease of the thyroid gland, with dilatation of some of the vesi-
cles, and cellular infikration of others. Engorgement aud arterio-
sclerosis of the spleen. Chronic venous cougestiou, considerable
fatty Infiltration and some cirrhosis of the liver. Extensive ar-
terio-sclerotic and interstitial nephritis. Extensive hyperplasia of
the lymph follicles of the intestines.

Male. Age 79. Second admission. Reported destructive, dirty.
Threatened suicide. Refuses to eat. Constantly tallcing to himself.
Feeble mentally and physically.

Duration of psychosis : Six years.

Cause of death : Asphyxia by choking on a piece of meat.

Clinical report : After admission was accustomed to sit in a comer
by himself, constantly talked about the work he was golug to do
when the contractors gave him a chance, yet Is physically unable
and acknowledged himself so. Says there is no use In him wash-
ing himself, constantly asks where he Is. Died while eating, due
to a piece of meat lodging in his throat.

Pathological report: Moderate odema of the lower limbs. Cran-
ial bones moderately hard. Dura adherent throughout. Diffuse
opacity and Increased thickness of the arachnopia. Increase of
subdural and subaracbnoldean fluid. Brain — Weight, 1125 grms.
Extensive general atrophy of the convolutions. Extensive athero-
matous degeneration of the basal vessels. Occlusion of the right
posterior cerebral. The area supplied by the occluded artery en-
tirely destroyed and represented by a cystic-like formation. Its
walls formed by the arachnopia. Numerous foci of softening scat-
tered throughout the cortex aud diffuse through the substance,
varying in size aud shape. Heart — Weight, 300 grms. Several
sclerotic patches In the eplcardlum. Lett side hypertrophled.

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Right side dilated. Moderate Bcleroels of the mitral and aortic
valvee. Extensive atheromatous degeneration and caloareona In-
filtration of arteries, the curoiiiiry vesaels extremely 80, almost
occluding the lumen. Lungs — Weight, left, 320 gnns, ; right, 340
grms. Extensive firm, dense pleuritic adhesions In both pleural
cavities. Pleura thickened. Lol)es adherent. Extensive subpleu-
ral blackish pigmentation. Bronchial glands enlarged and deeply
pigmented. The larynx occluded . above the thyroid cartilage by
a mass In the oesophagus n-blch proved to be a piece of meat.
The oesophagus below the obstruction Is dilated and filled with
partly masticated food. Spleen— Weight, 65 grms. Firm on sec-
tion, capsule thick and rough. Liver— Weight, 1250 gnns. Firm
adhesions to the diaphragm. Firm on section. Kidneys— Weight,
left, 155 grnis. ; right, 145 grms. Moderately firm on section, cor-
tex pale, medulla deep-red color, considerable pelvic fat, capsule
strips readily. Prostate enlarged, the middle lobe projecting into
the neck of the bladder.

Microscopical report : Extensive chronic myocarditis. Extensive
atheromatous degeneration of the arteries. Some pulmonary
emphysema. Extensive peribronchial and perivascular pigmentary
Infiltration. Most of the thyroid vesicles filled with proliferated
epithelial cells. Arterlo-solerosis of the spleen. Chronic venous
congestion and cirrhosis of the liver. Extensive diffuse nephritis.
Chronic pancreatitis. Foci of round cell Infiltration in the adrenals.
Numerous hyaline bodies in the choroid plexus. Extensive de-
generative changes in the nerve cells.

Female. Age 83. First admission. Reported restless, sleepless,
vulgar, vicious, at times violent. Incoherence In speech and ac-
tion. Talks of living in he!!. Wants to get back to heaven. Im-
agines that some of the family are abusive to her. Manifests loss
of memory.

Duration of psychosis ; Three years and more.

Cause of death ; Chronic myocarditis.

Clinical report ; Admitted with a psychosis of senile dementia.
After admission had periods of more or less excitement, alternat-
ing with those of stupor, which became progressively Increased.
Physical condition was frail and She underwent gradual exhaus-
tion.

Pathological report; Right eye absent. Cataract in the left eye.
Bars asymntetrlcal. Sacral decubitus. Uterine prolapse. Cranial
Iwnea cancellous. Extensive diffuse dural adhesions to the bones
and to the arachnopia. Diffuse opacity of the arachnopla. In-
crease of subdural and subarachnoldean fluid. Brain — Weight,
1210 grms. General atrophy of the convolutions. Basal vessels
extensively atherotuatous and calcareous. Right optic nerve and
tract gray, and atrophic. Lungs — Weight, left, 300 grms. ; right,
450 grms. Firm pleuritic adhesions in botii pleural cavities.
Pleura thickened. Lobes adherent. Dilatation of some of the
mai^nal lobules. Bronchioles exude a muco-purulent fluid. Bron-
chial glands enlarged and deef.ly pigmented. Heart— Weight, 350

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gnus. Fivm iwric-nrdlHl aUliesious nt the biise and surrounding tlie
gi-eat vessels. Ilyperti-opliy and dilatation of both sides. Consid-
erable epicardial fat. Considerable sclerosis of the mitral valves
Extensive atheromatous degeneration and calcareous inflltratiou
of the aortic valve. Considerable dilatation of the aorta. Ex-
teoaive atheromatous degeneration and calcareous inflltratiou of
the arteries. Thyroid gland — Weight, 40 grms. Firm and rather
lobular. Spleen^Weight, 110 grms. Firm on section. Liver-
Weight, 10(jO grms. Moderate construction of botli lobes at their
center. Muddy-red in color. Soft in cousietency. Pancreas —
Weight, 70 gnus. Splenic artery rigid, dilated, tortuous and cal-
careous. Kidnej's— Weight, left, 125 grms. ; nght, 140 grms.
Firmly adherent to the perirenal tissue, firm on section, pale In
color, striation indistinct, no pelvic fat, capsule adherent, pelvis
dilated. Ureters dilated aud filled with purulent fluid. Appendix
banging iuto the pelvic cavity. Ovaries ati'ophied. Uterus elon-
gated, cervix hypertrophied, exposed surface gangrenous. Bones
fragile.
Microscopical report : Extensive fatty infiltration of tbe heart. Ex-
tensive chronic myocarditis. Extensive endarteritis ; atheromatous
degeneration and calcareous iuflltvatiou of the arteries. Moderate
pulmonary empiiysema. Chronic bi'onchitiR. Peribronchial tuber-
cular consolidation and pigmentary infiltration. Alveolar engorge-
ment of the lungs. Dilatation of some of the vesicles of tbe thy-
roid gland with cellular infiltration of many of them. Venous
congestion aud extensive eirrhosis of the liver. Chronic pancre-
atitis. Foci of round cell infiltration in the adrenals. Extensive
diffuse nephrills. Hyperplasia of the lymph follicles Of the ap-
pendl.\, with thicliening of the mucosa.

ORGANIC DEMENTIA.

Female. Age 55. First admission. Reported acutely melancholic,
with delusions of a persecutory nature.

Uuraticm of psychosis : Four and one-half years.

Cause of death : Sarcoma of tbe brain.

Ciluical report : After admission there was prouounced emotional
instability aud confusion, forget fulness, repetition of questions
and answers, inability to recognize those about her ; complains
of a feeling of fullness aud pressure In the head, amounting at
times to great pain, dizziness, Indistinctness of vision, mental dis-
tress, marited tremor of tlie hands, staggering gaint, bilateral
weakness of the voluntary muscles, exaggerated kuee Jerlts, slight
tendency to Bablnsbi's reaction, slight manifestations of R»m-
bei^'s phenomenon and some veal muscular weakness. These were
more marked on the right side. Cloudiness of fiie optic disks.
Blood and urine examinations negative. The course was progres-
sive, leading to Stupor, coma and death.

I'athologicfll report : Sacral decubitus. Cranial bones thick and
heavy. Bralu — Weight, 1250 grms. Convolutions flattened. Lat-

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eral ventricles ililnted. On the floor of the posterior portlOD ot
Hie Jefl luterul reutricle is an Irr^uiar ulceratecl surface ZS cm.
iu diameter, several mm. deep, covered with a graylah exudate.
Uuderlfing Is a ftmi reddish-gray mass occupying the posterior
part ot the 0|>tic thulatnus, Involving the adjoining occipital lobe,
Ihe posterior imrtiou of the foniyx, corpus cnllosutn and the mesial
Kurface of the right optic tlialamus. The choroid plexus cystic.
Heart — Weight. 300 gnus. Hy|iertrophy of the left ventricle, con-
sidernble epicardlnl fat. some atheromatous i>atches In Ihe body of
the mitral valves. Moderate arterlo-sclerosis and patchy atheroma-
lous degeneration of the arteries. Lungs — Weight, left, 275 gnus.;
right, 300 gnus. Slightly dougliy. Bronchial glands enlarged and
l>lgiiiented. Spleen — Weight, 95 grms. Moderately arm. Liver —
Weight, 1520 grms. Moderately firm, cut surface oily. Kidn^fs—
Weight, 170 grms. each. Pale on sectiou. considerable pelvic fat,
capsule strips readily. Pancreas — Weight, 105 grms. Aiqtendix
hanging into the iielvic cavity. Ovaries atrophic. Small fibroid lo
Ihe left broad ligament.

Microscopical report: Diffuse chromatolytic changes in the nerve
cells. Hyaline bodies iu the choroid plexus. Fatty infiltration of
the heart. Cousiderable eudarterltls and patchy atheromatous
d^eneration of the arteries. Chronic venous congestion and eon-
aiderable fatty infiltration of the liver. Chronic venous conges-
tion of the spleeu. Moderate diffuse nephritis. Tumor mass of
Ihe brain consists of a mixed-cell sarcoma.

Male. Age 42. First admlseion.
Duration of psychosis : Two months.

Cause of death ; Syphilitic brain tumor.

CIlDlcal report: Admitted with a psychosis regarded as geueral
paresis beginning several weeks before. Came home from work
one evening staggering as If drunk, seemed tired, conversation In-
coherent and somewhat childish, unable to swallow. Later there
developed general muscular tremor, ataxia and luco-ordlnatiou,
speech and writing defect, food collected Ijetween the teeth and
cheeks, exaggerated knee jerks, aukleclonus, Bablnskl and Rom-
bent phenomena. Mentally he was stupid, confused and mani-
fested pronounced dementia. The course was rapidly progressive,
tiecomlng rather maniacal at times toward the latter end. Engi-
neer by occupation. Five years previously he received an injury
to the head which rendered him unconscious for a time, blood
escaping from his nose and mouth. Wife had noticed some un-
certainty in gait for two years. Fellow workmen had noticed
some peculiarity in action for several weeks.

Pathological report : Dura firmly adherent to the archnopla over
the anterior surface of the left frontal lobe. Thickening of the
arachnopia over the anterior surface of the left frontal lobe, over
the lower part of the Rolandic area on the right side involving
the ascending frontal, the ascending parietal and the anterior in-
ferior part of tlie supramarginal convolutions. Beneath the pia
in both of these places is a mass of apparently inflammatory tls-

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Bue wltb foci of caseation or fibroela Irregular in outline, causing
depression ol the underlying convolutions. In the substance of
the left optic tbalamna la a mass similar in apxiearance and struc-
ture 2 cm. in diameter. Tbe spinal cord !s soft and congested.
No subdural or subaraclinoldean fluid. Brain — Weight, 1880
grms. Heart — Weight, 380 grms. Large quantity of ^icardlal
fat. Hn>ertrophy of the left Teutricle. Moderate irregular ath-
eromatous degeneration of the arteries. Lungs^-Welght, left, 610
grms. ; right, 6T0 grmti. Firm pleuritic adhesions on the right sida
Right pleura thickened and the lobes adherent. Both lungs cya-
notlc-red color posteriorly, doughy In consistency, bleed freely on
section. Liver — Weight, 1850 grms. Soft ou section. Spleen —
Weight, 480 grms. Bleeds freely on section. Kidneys — Weight,
left, IGO grms. ; right, 200 grms. Pale In color, very little pelvic
fat. capsule strips readily. In the lower portion of ttie left Is a
small, whitish, firm nodule, Iiyallne 1u appearance, 3-5 mm. In size.
Omentum adherent to the sigmoid colon.

Microscopical report: Moderate chromatolytic changes In tlie D»rve
cells. Fatty Infiltration of tlie heart. Moderate endarteritis. Cir-
rhosis of the liver. Moderate diCCuse nephritis. Hypostatic pneu-
monia. Tumor masses and arachnoplal thickening, made up of a
syphilitic granulomatous tissue.

Male. Age 30. First admission. Reported restless, sleepless, at
times violent. Talks on religious subjects. Wanders from home.
Palls to recognize family. Becomes much excited. Seems to be
BufTerlng pain.

Duration of psychosis: One week.

Cause of death : Brain tumor and haemothorax.

Clinical report: Admitted with a psychosis of acute melancholia
beginning one week before. On admission it was seen that he was
suffering pain. Was much excited. On examination there was
found fracture of ribs on the left side and some fiuld In the pleural
cavity. Patient died twenty-four hours after admission.

Patholi^Ical report ; Slight Jaundice. Brain bulged when tbe dnrn
was opened. Brain — Weight, 1550 grms. Surface dry, convolu-
tions flattened. In the substance of the right cerebral hemisphere
occupying the posterior part of the parietal lobe la a soft gelatin-
ous haemoirbaglc mass taking tbe place of tbe brain substance,
lying anterior to the parieto-occipital fissure, 5 cm. transversely,
G cm. antero-posteriorly on the convex surface and above the cal-
loso-marglnal fissure on the mesial surtace, its margins fairly
well defined, but infiltrating somewhat the brain substance, ex-
tending into the hemispheres Irregularly from 1 to 5 cm. ; has a
similar appearance on section, and is surrounded by foci of haemor-
rhage. Lungs — Weight, left, 200 grms. ; right, 310 grms. Some
blood in tbe left pleural cavity. The parietal pleura is lacerated
opposite the eighth rib In the mid axillary line, where the frac-
tured ends of the rib project. The seventh and ninth ribs are also
fractured. The visceral layer of the pleura la abraded over the
seat of the fracture of the ribs and there Is sMne subpleural

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eccbymoBls. Heart — Weight, 260 grms. Moderate arterlo^cleroela
of tbe nrteries. Spleen — Weight, ICiO gnus. Adbereat to the dia-
phragm, capsule thickened, somewhat aottened beneath the seats
of adhesions. Liver— -Weight, 1005 grms. Rather soft. Kidneys —
Weight, 145 grm$. each. Pale In color, bleed freely, email quantity
of pelvic fat, several cortical cyste, capeule strips with difflculty.
Bladder diateaded with urine. Appc^ndix hanging Into the pelvic
cavity.

Microscopical report ; Well -marked chroma toly tie changes in the
nerve cells. Moderate endarteritis. Engorgement and some arterio-
scierosifi of the kidneys. Engorgement of the other organs. Tumor
mass made up of a glia-sarcotuatous structure.

Male. Age 55. N^ro, First adinlasloii. Reported restless, melan-
choly, destructive, intemperate. Refuses to answer questions. Is
unable to concentrate his thoughts. Wanders From home. Is
physically weak.

Duration of psychosis : Nine months.

Cause of death : Hypostatic pneumonia.

Cliuical report ; Onset began nine months prior to admission with
exaggerated Ideas of wealth, wandering at niglit, confusion, vio-
lent outbreaks. , Five weeks prior to admission there was mani-
fested gradual failure of co-ordination of all of the limbs, spastic
gait, exaggerated left knee jerk, weak, coarse, general tremors;
right pupils smaller than the left, optic atrophy, facial expression
mask-like. Complete dementia, dullness on percussion, suppressed
breathing on the left base extending upward and to the right base.
Had one attack of pulmonary oedema during the stay in the hos-
pital.

Pathological report: Extensive decubitus. Crania) bones hard and
heavy. Several osteophytic projections on the inner surface of
the frontal iKmes. Dura thickened and the inner surface cov-
ered "-Ith a fibrinous membrane-ltke exudate, freely movable. Dif-
fuse opacity and thickness of the arachnopia. Great Increase of
subdural and subarnchnoidean fluid, the latter forming foci of
cystiike accumulations. Brain — Weight, 1040 grms. Basal vessels
thickened. Right frontal lobe smaller than the left. On the un-
der surface of the right cerebral hemisphere, about midway be-
tween the extremltes of the teuiporo-sphenoldfll and occipital
lobes, is a quadrangular area SA cm. in length, of a mottled dark
red color, lying immediately over the collateral fissure, extending
over the lateral margin about 1 em.; is seml-soiid in consistency,
dark-red In color, on section, infiltrates the brain substance for
]-2 cm. ^'entriclea dilated. E|iendyma granular throughout. Heart
— -Weight, 2(iO grms. Several sclerotic patches In the eplcardium.
Moderate atheromatous degeneration of the arteries. Lungs —
Weight, left, 750 gmis. ; right, 700 grms. Firm plenrltlc adhesions
In both pleural cavities, with that over the lower lobea Intensely
congested and covered with a flbrino-plastie exudate cementing
the surfaces together, more so on tlie left side. '' he whole of the
lower lolie and the bawe of the upper lobe on the left side and

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the posterior and lower two-tblrds o( the lower right lobe in a
condition of red and gray hepatization. In the anterior portion
of the left lower lobe Is a seml-tlactaatlDg cavity containing gni-
mous, brolien-down material with a very otteneive odor. Consid-
erable dllatattoi) of the marginal lobules. Bronchial mucosa con-
gested and tbe lumen tilled with a muco-purulent eecretlon. Bron-
chial glands enlarged and softened. Thyroid gland — Weight, 45
grms. Appendix hanging into the pelvic cavity. Sple«n — Weight,
80 gnna. Moderately firm on section. Liver— Weight, 1420 gnus.
The left lobe extending aa a tougue-llke projection 7.5-7 cm. Kid-
neys — Weight, left 178 grms.; right, 130 grms. Very little pelvic
fat. Ciipsule strlpa readily. I'ancreas — Weight, 80 grms. Diffuse
enlai^meut of the inesenteric glands.

Microscopical report; Extensive diffuse chroma tolytlc changes in
the nerve cells. Tumor mass Is a gllo-sareoma with foci of haemor-
rhage In the adjoining tissue. Extensive endarteritis and athero-
matous degeneration of the arteries. Chronic pleurisy with an
acute flbrluo plastic inflammation superadded. Pulmonary empiiy-
sema. Chronic bronchitis. Red and gray hepatization and gan-
grene of the lungs. Tendency to cystic dilatation of the thyroid
vesicles with flillug of the smaller ones with proliferated epithelial
cells. Intense engorgement of the spleen with hyperplasia of the
malplgtaiau bodies. Chronic venous congestiou of the liver. Ex-
tensive diffuse nephritis.

Male. Age 7ti. First admission. Reported as having a mental cou-
ditlon of general weakening, memory being specially defective.
Disposition as a rule good, with periods of despondency.

Duration of pss'chosls : Two years.

Cause of death ; Chronic myocarditis and brain softening.

Clinical report: Admitted with a psychosis of organic dementia
l)egl)ining one week before admission. Cause given was an apo-
plectic stroke, the date of which whs not given. On admission
there was right hemipl^la, motor aphasia, speeiL-h being limited
to "yes" and "no." which were indistinctly iM-onounced. Paralysis
of the leg recovered sultlciently to enable the i>atient to get about
with tiie assistance of a cane. There was pronounced cardiac
liypertrc^hy, arhytlimia, increased pul^ tension, periods of dysp-
noea, convulsions of the grand mal type at Irregular Intervals, but
not accomponied by signs of exaggeration of the paralytic condi-
tions. A few days before death following a convulsion there was
rapid failure of streitgth, with more marked cardiac arhythmla .
and dyspnoea. £>eath was sudden.

Pathological report : Flabblness and atrophy of tbe right arm and
I^. A small reducible Inguinal hernia on tbe left side. Cranial
hones thick and cancellous. General atrophy of the convolutions.
Increase of subdural and subarachnoldean fluid. " hrombosis of
the left anterior cerebral artery, with complete destruction of the
whole frontal lobe exceirt a small portion of the Inferior frontal
convolution, a small part of the posterior portion of the superior
frontal and about half of its mesial Inferior portion. Considerable

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serous fluid in botb pleural cavltlee. Some Arm adbeelone in tbe
rigbt pleura. Some calcified uodulei scattered tbrongh tbe aub-
Btanc« ot both lungs. Some emphysema of the marginal lobules.
Heart — Weight, 740 grms. Estenelve hypertrophy and some dila-
tation. Slight sclerosis ot the mitral aod aortic valves. General
dilatation of the aorta. Extensive atberoniatous degeneration of
the arteries, with numerous toci of ulceration. Some serous fluid
In the general peritoneal cavity. Liver— Weight, 1880 grms.
Coarsely granular on section and more or less oily. Pancreas —
Weight, 80 grms. Spleen — Weight, 300 grms. Firmly adherent
to the diaphragm. The entire anterior surface of tbe capsule
thickened, hard, glistening white. In places uodular. Soft on
section. Kidneys— Weight, left, 330 grms. ; right, 340 grms. Firm-
ly attached to tbe perirenal tissue, striation Imperfect, much pelvic
fat, capsule strips readily, but leaves a rough surface, numerous
cortical cysts. The left kidney is represented by a mass of fatty
and fibrous tissue, with very little kidney substance visible and
tbe pelvis dilated.
Microscopical report: Extensive chronic myocarditis. Estensive
atheromatous degeneration of the arteries. Intense engorgement
of the alveolar capHlarles of the lun^. Some vesicular emphy-
sema. Chronic (jronchids. Extensive jjeribronchial and perivas-
cular piguieutjiry inflltration. Intense engorgement and foci of
round cell InQltration in the adrenals. Extensive perisplenitis and
arterlo-sclerosis ot tbe spleen. Chronic veuous congestion and
cirrhosis of the liver. Extensive diffuse nephritis.

NOT INSANE.

Mule. Age 2T. Single. Occupation, attendant.

Clinical report : About two weeks before death he complained of
having a cold and some cough, tor which be was given some medi-
cine and reported marked improvement. On the afternoon pre-
ceding death he went to the city, attended the theater in the even-
ing, returning about 11 :30 p. m. Before retiring he sat beside the
radiator for a time, going to bed about 12:30, apparently feeling
iis usual, .\bout 4 :30 his room-mate awakened, and hearing him
breiilbing heavily, attempted to awaken him but failed. The doc-
tor was immediately called and found him comatose and ater-
lerous, weak pulse, contracted pupils. The stomach pump was
used. Coffee and stimulants given, but the coma deepened until
death sui>ervened at 9 a. m. It was leamed that three years be-
fore lie had gone west for pulmonary trouble, and while there
bad undergone several aspirations of the pleural cavities, but never
was confined to bed.

Pathological report; Some cyanosis. General surface blanched.
Extravasation of blood in the left testicle. Slight increase of
subarachnoidean fluid. Brain — Weight, 1340 grms. Heart —
Weight, 250 grms. External surface of the pericardium adherent
to the pleura. Lungs — Weight, left, 646 gnns. ; right, 700 grms.

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203

Botti pleuriil cnvtties oblltemtei) by Urm, dense adbeslons. Pleura
thlcbcDed. Lobes adberent. Bxtenelve siibpleural blacklaU pig-
mentary 111 nitration. Lungs oC a shotty nodular conaisteney
tbrougbout, grating on section, blacklsb appearance, diftuse with
small wbltlab points. Bronchial mucosa cocgeated. Bronchial
glands enlarged. Omentum firmly adherent to the underlying
RtructnreB. Appendix hanging Into the pelvic cavity. Extensive
tubercular nodules and ulcers of the smell Intestines, most marked
In the lower part of the Ileum. Spleen— Weight. 310 grms. Ad-
herent to the diai)bragm, capsule thickened, bleeds freely on sec-
tion. Liver — Weight, 1740 grms. Capsule thickened, bleeds freely..
Kidneys— Weight, left, IBO gnus.; right, 125 grms. Considerable
pelvic fat. Pancreas — Weight. 90 grms. Mesenteric glands en-
larged
Microscopical report : Central caual of the cord filled with prolifer-
ated epitheria! cells. Slight fatty Infiltration of the heart. Slight
endarteritis Chronic pleurisy. Extensive diffuse miliary tubercii-
losls of the InngB. Extensive pulmonary anthracosls. Consider-
ible engoigement of the spleen, with hyjierplasla of the malplghian
bodies and diffuse tubercular nodules scattered through its sub-
stance. Couslderabie tubercular nodular Infiltration of the liver.
Moderate diffuse nephritis, the interstitial changes predominating.
Pixtenslve hyperplasia of the intestinal lymph follicles, with tuber-
cular Infiltration and ulceration. A few cyst-like spaces in the
pituitary lK>dy.

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SHORT CLINICAL REPORT OF THE CASES PRESENTED
AT THE STAFF MEETINGS.

1. Male. Age 35. Occupation, miner. Married.

Onset of mental disturbance, three months before aduilsslon by try-
ing to aeclude and bide himself, by constantly worrying over bis
affairs, by imagiQlng ttint he bad committed n serious crime and
tlint he heard [leoplc talk alKiut bim, by refuRing to work.

I'atlenl well developed and well nourished. Swede by birth. Scarce-
ly understands English. Facial expression is one of depression,
apathy and at times of apprehension. Apparently takes no Inter-
est In bis surroundings. Appeal's somewhat confused in manner
and action. Movements and actions are slow and sluggish, wltb-
o«t euen,T or vigor. Says that he does not feel strong enough to
work l>ecause he has lung trouble. Respiratory sounds In the left
apex are suppressed and modified by moist rales. In the right
apex the sounds are harwh and broncho -vesicular. Rarely coughed
since adnilt-sion.

Diagnosis : Ilypochondriiical melancholia.
'± Female. Age 35. Married. Youngest child two years of age.

Onset about two years before by Imagining that some one was going
to harm her. by talking Incessantly, by picking up blank pieces of
paper and reading of plots to hang her, by wandering from house
to house asking the neighliors if they have heard of such plots,
by I'eemlng forgetful the most of the time, by imagining that her
hlooil was boiling and rushing to her head all of the time. Com-
plained of lieadache. Threatened to kill herself. Has had stomach
trouble tor a long time and an eruption on the tai/e and body.

I'atient is well developed, moderatel}- ni)url8hed. Is apprehensive.
Emotionally usually depressed with some tendency to agitation.
Has considerable Insight Into her own condition. Traces her con-
dition to her last confinement, be^^innlng about two weeks after
with severe headache, blindness, a feeling as if the eyes Jerked,
and nervous spells in whicli she became unconscious. Memory
is apparently more impaired for recent than remote events. Some
difficulty to concentrate her thoughts upon one subject for any
length of time, as it wearies her, as does also pliyslcal exercise.

Father died of Rright's disease oi-er 60 years of age. Mother of
rectal carcinoma. One sister of epilepsy with mental disturbance.
Her oldest child has nervous spells.

Diagnosis : Agitated melancholia.
;!. Male. Age .'i3. Occupjitlon, lalM>rer. Married.

Onset one year before admission. Was restless, sleepless, seclusive
and melancholy. Imagined that he possessed large amounts of
property, that lie did not need to work and that people were going
to kill lilm for his money. Some months after admission he was
discharged apparently recovered, with complete insight into his
condition, Imt was I'ecommlttecl within a month after, due to his
wiindering about aimlessly.

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205

I'litient is welt developed uiid well nourished. Manifests some re-
tardation both lu^itiilly und physically, sllgbt Irrelevancy and in-
coherenc-y. apprehension and suspicion, Ideas of persecution in that
he has not been Buccesatul because lie has been kept down by
various agencies, etc. Is somewhat exalted emotionally. Has
pronounced Ideas of persecution extending throughout life, but
more particularly so since his marriage because of objections to
his wife. Has had hallucinations o( hearing. Rather difficult to
ascertain whether he is confused or has some dementia.

One brother tubercular.

Diagnosis: I'aranoid dementia praecox.

Female. Age 26. Single.

Onset five years before admission. Thought some one was going to
Injure her. Feared some one would break into her room when
asleep. Carried a revolver and threatened to shoot her father.
Is very suspicious. Eavesdrops on her neighbors.

Patient is well developed and well nourished. Is of a very nervous
temperament. Has pronounced ideas of iwrsecutlon in that her
father has never treated his children as he should, and her in
particular; that neighbors are being Influenced against her by her
fatiier. Is very suspicious. Has no insight into her condition.
Is depressed emotionally. Her general tone of feeling is one of
depression.

One maternal uncle, mother, three brothel's and one sister tubercular.
I'atlent herself has latent pulmonary disease.

Diagnosis: Paranoid dementia praecos.

Male. Age 53. Occupation, school teacher. Single.

Onset sis months before admission by wandering through the coun-
try in an attempt to escape from an imaginary mob who wished
to do him harm. Attempted suicide.

Patient is well developed. Rather anaemic from the loss of blood,
following an attempt to commit suicide by cutting off bis riglit
foot at the metatarsal boues. Has well-founded delusions of per-
secution and of impending danger, the latter referring to the sexual
organs, based upon pronounced hallucinations of sight and hear-
ing, misinterpreting every incident and circumstance ,a8 referring
to tiie subject of his delusions. Has considerable insight into his
condition, yet Is extremely auspicious and somewhat apprehensive.
Says he can only decide his course In the future according to
the treatment given him. Says that the suicidal attempt was in-
stigated by the fear of hann and the desire to escape It. Also
says that it has always been one of his cardinal principles never
to remain longer than one year at any one place, l)ecanse one of
a forcible nature must necessarily make bad friends, and chang-
ing enables one to escape conflict in consequence of it. 'iraoes bis
delusions of [lei'secutioii bock several years. Is irritable and erao-

Two maternal cousins committed suicide. One brother has nervous

spells.
Diagnosis : Paranoia.

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206

Male. Age 33. Oocapation, laborer. Single.

Onset sis weeks beFore BdmlRsion, by becoming violent, by talking
of great inventions, of prospects for wealth and eminence, by mani-
festing lack of self-control and rapid cliange of feeling. Was In-
temperate in tbe use of alcohol and tobacco.

Patient Is well developed and fairly well nourished. Was In a aanl-
tarlum for three months four years before admission. Was first
admitted in 1894. Furlougbed In 1896. Readmitted In 18»7. Dis-
charged after some months. Readmitted 1900. Discharged in
1901. Readmitted in 1906. Since admission Is cross and Irritable.
Imagines that patients are talking about him. Has spells In which
he falls off the couch or bed apparently nnconsclons. If noticed
he acts as If dying. If not noticed he gets up and walks about.
Has considerable insight Into his own condition. Is rather talka-
tive. Prompt In response to external Impressions. Somewhat sus-
picious. Has some Ideas of erotism.

Father intemperate. Two brothers suicidal. Patient Intemperate.
Uses cigarettes to excess.

Diagnosis : Recurrent mania.

Female. Age 27. Single.

Onset about five weeks before admission, following the death of ar;
uncle. Began talking disconnectedly and excitedly; restless; sub.
ject to outbreaks of excitement and anger. Imagined that her
family were against her. Refused to go borne. Talked (ffofanety.
Acted foreign to herself.

Patient Is well developed and well nourished. Dates her condition
back six years, at which time she had an attack of so-called
nervous prostration tasting from March to September. Ideas of
persecution are well systematized but not definitely motived. In-
volving many persons In general and no one in particular. Is sus-
picious, fault-flnding, complaining, irritable and excitable. Sub-
ject to Impulslveuess aud outbreaks of violence. Had an acute
outbreak about five weeks before admission, following the death
of an uncle, and seems to have more or less amnesia for her ex-
periences during the time, attributing that condition to her hav-
ing been drugged.

One uncle died of paresis.

Diagnosis ; Paranoia.

Female. Age 45. Widow.

Onset about one week before admission ; melancholy ; continuously
rubbing out her hair ; at times irritable, vulgar and destructive ;
thinks people hove pulled out her hnlr and whip her If she does
not do enough work. At times Incoherent.

Patient is poorly nourished, shows well marked arterlo-sclerosls of
the radial and temporal arteries. Climacterium began about six
months before. Has well marked ideas of persecution and some
of hypochondrlaeal content. Traces ber persecution back about
one year. Does not base them upon anything special. Attrlbules
no special motive. Has fonnulnted no definite system. Upon these

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207

delusions or persecutiooB she bases tbose of hypoehoudrlacal con-
tent relative to poor bealtb. Her brotber reports tbat Ideas of
persecution have existed for many years. Patient Is apprehensive,
resentful, at times becomes agitated. Has uo Insight into her own
condition.
Father had a paralytic strotce. Mother was tubercular. A'nlece has

Diagnosis: Climacteric, or arterio-sclerotlc. paranoid condition.

Male. Age 33, Occupation, laborer. Married.

Onset one year before aduilssion. Reported melaucholy, restless,
sleepless, secluslve ; Imagined tbat be owned a large amount of
property and will not work, that people are going to kill him for
his money. Was discharged about five months after admission as
recovered, but was readmitted the following month.

Patient Is well developed and well nourished; rather talkative; at
times irrelevant and disconnected ; somewhat exalted emotionally ;
definite ideas of persecution traceable to marriage due in part to
objections to wife and in part to a former trust company, at head
of which was bis father, wboai he regards as one of bla chief per-
secutors at present. All have combined to prevent him from suc-
ceeding In making a success of life. Has auditory hallucination
in tliat he hears his wife and child catling for him to come home.
Movements and actions correspond only In part to his delusions,
as he manifests only some suspiciousness and apprehension.

Diagnosis : Paranoid.

Female. Age 50. Married.

Onset about two years before admtssiou; became suspicious; Imag-
ined nelghlxirs and passers-by were engaged In a plot against her ;
were trying to Injure, morally and physically, herself and daugh-
ter; birds brought messages to her informing her of the plots
against her; has estranged all her f ends becomes obscene and
profane In her language ; threatens o de roy he property and en-
danger the lives of her neighbors n erp e s everything as hav-
ing special reference to herself ; has ha uclnat on of bearing. Hears
people talking about her; some on h onlng sand on the aide of
the house.

Patient Is well developed and well nou bed, ra her talkative; some-
what exalted emotionally ; makes tight of and treats as a Joke the
facts of the commitment records ; refers only Indirectly to her
persecutory Ideas ; declines to give expression to them, saying that
she does not feel that she Is Justified In doing so, but questioning
closely reveals the fact that she fears to some extent the criti-
cism In regard to them ; admits the auditory hallucinations at
borne; is secretive in regard to the delusions, and very suspicious.
Maternal uncles intemperate, one cousin f^ble-niinded.

Diagnosis : Paranoid.

Male. Age SB. Salesman. Married.

Onset several months l)efore admission by talking Incoherently. b.V
being nervous, exalted by failure to recognize anyone. Iniaitiips

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that he Is being perBe<-uted; that be wob Wtlliam Penn, King
Deneno; that lie owned all rijHrondB. niaile all the world, owned
nil the world, etc.

I'atient Is well developed, well uourlalnHi. Appareutly absorbed iu
his own thoughts. I'lays with his uiuxtuche. Rocke his body bsck
and forth, tapping on the floor with one foot, talking to himself.
Oecaeionall; whistling to hlmselC. When called by his own name
he resents It and says he Is King Deneno; Bpeaks of owning the
whole world, of having manufactured It, having owned It for a
100 million decllllcm of years ; never had a father or mother, never
was married. Is Inattentive and apparently nontrtjservant. Uses
odd espressions, such as "sokohodlu,'' which he said meant "some-
one was trying to do a thousand things to him," etc. Pupils are
unequal, right dilated, react slowly to light. Lips tremulous.
Slight dlOlculty and hesitation In speech. Hands tremulous. In-
creased by effort Writing tremulous, with repetition and elision
of letters and syllables. Knee Jerks unequal; both exaggerated,
the left more so. Complete Incoherency and disorientation.

Diagnosis : General paresis.

Male. Age fiS. Occupation, gas fitter. Single.

Onset one month before admlsaiou, by disconnected religious talk.
Imagined that he was the son of God; that he did not have to
work, as it was against the will of God; that the American flag
must be displayed at all times. Hears a crowd cheering him.
Wants to have immoral relations with his sister. Threatened peo-
ple about him.

Patient Is well developed and well nourished. Attention somewtiat
divertlble toward religious Ideas. Is very talkative. Manifests
slight acceleration in the How of thought. Is unstable emotionally,
tending to be exalted. Has partial Insight Into his condition. Ex-
plains bis peculiar actions as having been compelled by something
within Ijimself which felt like a breeze through all of his thoughts
and Ideas, Religious coioriug is based upon Ideas of doubt, and
hinging about the Masonic obligation.

One brother and several .cousins died of tuberculosis. Wife died of
general paresis. Patient had a penile sore at the age of 20.

Diagnosis :

Male. Age 58. Occupation, painter. Single,

Onset in 1883, following a fall on the head. Talked fllghtily on re-
ligious subjects. Imagined that he was the embodied God, and so
empowered to siive the world ; that angels and devils were with
him ; that his spirit leaves his body and goes to heaven. Sees
sitlrlts and angels. Boards up the house to keep out the devils.
', hreatens violence to his surroundings.

Patient is well developed and well nourished. Is very unstable
emotionally, corresponding to the content of his thoughts. Has
marked delusions of perseoutiou, grandiose Ideas in regard to him-
self, extreme grandiose ideas of religious content. Has hallucina-
tions of sight, bearing, taste and general sensation, those of hear-
ing being most pronounced and Influencing his manner and action

)v Google

to the .extent that he shot his brother In obedience to a coiiimii.>d
from a spirit. Has altered personality la that a spirit tflkea pos-
session of his body and compels him to do things at Its bidding.

One maternal uuut insane. Patient contracted syphilis twenty years
ago. Has rather extensive arterlo-sclerotic involvement and some
renal disturbance.

Diagnosis : Hallucinatory paranoia.

Mate. Age 40. Occupation, laborer. Single.

Onset three months before admission, by having spells o£ crying und
anger. Imagined that bis family and nelghixirs were scheming
against him and trying to get him out of the way. Has been
nervous, despondent and at times melancholy. At times maniacal
and subjeet to outbreaks of violence.

Patient is well developed and well nourished. Is very nervous and
somewhat despondent. Apart from a slight persecutory tendency
in the content of thought his mental condition seems to be about
normal. Has been repeatedly furloughed but always readmitted
in a short time because of outbreaks of apparent maniacal excite-
ment, in which acts of violence towards others and threats of
suicide are prominent.

One brother and one sister died of tuberculosis.

Diagnosis: Hecurrent mania.

Male. Age 82. Occupation, liveryman.

Onset about one year before admission, with Ideas of persecution
and threats of violence toward his surroundings. Melancholy.
Complained of pain in the head. Threatened suicide. Subject to
outbursts of anger.

Patient is well developed and well nourished. Has pronounced ideas
of injustice and persecution, motived by the wish to gain posses-
sion of property that may possibly be willed to him at the death
of a relative. Suicidal tendency Is induced by the feeling that
there is nothing to live for. Facial expression is apathetic. Is
rather indifferent to his surroundings. Is very nervous and tremu-
lous. Siieecii is sliijjitiy thick? Writing tremulous.

Mother died of a uterine growth. Father died of apoplexy. Three
brothers of tuberculosis. One matemfll cousin has tubercular
trouble. One paternal cousin is an idiot. Patient had a sunstroke
about twelve years ago; is more or less addicted to drink and has
followed a roving life.

Diagnosis : Paranoid dementia praecux.

Male. Age 49. Occupation, laborer. Married.

Onset about one year before admission. Was Incoherent In talk and
action. Content of thought was of a religious nature. Imagined
that he had devils in his hair, that If he had wings he could fly
to heaven. Had delusions of jealousy in regard to his wife, with
outbreaks of violence.

Patient is well developed, moderately nourished and of slim build.
Is very loquacious. Attention very easily diverted. Flow of
thought accelerated. Some flight of ideas. Tendency to Inco-
hereucy. Emotionally exalted. Somewhat egotistical. MovtniatM

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210

nnd actions accelerated correspoudlog to tbe cootent of Uls ego-
tistical and self-important ideas. Some mnnlfeetatlone of erotism.
piagDOSle : Subacute maula.

Male. Age 20. Fanner. Single.

Onset one year before admission. Was despondent. Refused to talk.
Had Ideas of persecution. Outbreaks of Tlolenee. Acts of vio-
lence and destruction. Attempted suicide.

Patient Is well developed. Has prominent Ideas of persecution. Is

' out of liarmony with everybody and everything In general. Has

pronounced ideas of self-importance and egotism, manifested in

Ills facial expression, mauuer of speech, movements and actions.

Some tendency to atereotopy.

Two paternal uncles intemperate. Father iutemperate. Motlier
subject to nervous spells.

Diagnosis i Paranoid dementia praecox.

Male. Age 46. Farmer, Married.

Onset one year before admission. Was melancholy, depressed, emo-
tional ; feared tbot he would commit suicide or kill someone.
Imagined tbat he was falling In business; that he was losing hla
property ; tbat he was losing his manhood, bis mental and phyai-
cnl capacity ; that he was unable to perform any mental or physi-
cal labor, and that he was absolutely wortbless to himself and to
others.

Patient is well developed and moderately nourished. Is very nerv-
ous, emotionally depressed, very Irritable, greatly worried by triv-
ial affairs. He attributes his condition to masturbation. Has pro-
nounced hypochondriacal ideas with a tendency to suicide.

One maternal uncle Insane. One sister tubercular. Patient lias
slight increase of the knee jerks, some haziness of the optic disks.

Diagnosis : Hypochondriacal melancholia.

Male. Age 54. Policeman. Married.

Onset one mouth before admission by incoherent talk and action.
Imagined that he was a great orator. About three months before
admission lie began to sp^d what little money he had as If be
were very wealthy; thought he bad great schemes tor making
money. Would stop people on the streets, insist upon making
speeches, have outbreaks of violence. Was discharged, but soon
recommitted with delusions of great wealth, of having prominent
public positions, and of oratorical ability.

Patient Is a powerfully built man, well developed and well nour-
ished. Facial expression flabby and expressionless. General mus-
cular tone flabby. Manifested tremor about the mouth and in the
hands. Speech tremulous and rather difficult Writing tremulous
with elision of letters. Knee Jerks exaggerated. Intense optic
neuritis, more marked on the inner side of the disk. Attention
in very divertible. Emotions exalted and unstable. Is very lo-
quacious, incoherent and irrelevauL Manifests marked accelera-
tion in tbe flow of thought, flight of Ideas. No Insight Into bis
condition. Impairment of memory and judgment. Movements
and actions are rapid and prompt. Actions are demonatratlve.

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211

childish and silly. HRt> extensive grattdloee and exalted deluBlons
of probable wetiltb, of power, of position, ot fame, of persona!
ability, etc.

One paternal uncle and cousin insane. One maternal aunt insane.
Tuttecculosls, inflammation of the brain and spinal affections
amongst brothers and sisters. Patient Intemperate.

Diagnosis : General paresis.

Male. Age 42. Farmer. Married.

Onset two months before admission, by loss of Interest In his affairs,
sleeplessness, melancholy, hallucinations of sight, mistaking per-
sons of bis surroundings. Complained of severe headache. Says
that bis brains have been taken out and scraped. Has outbreaks
of violence.

Patient is well developed, strongly built. Manifests no particular
interest in what Is being done, yet makes side glances indicative
of suspicion and apprehension. Actions and manner seem to Indi-
cate hallucinations of sight and hearing of persecutory content.
Has marked delusions of persecution. Ills answers to questions
are frequently associated with and colored by the content* of his
delusions. Elmottons are somewhat depressed. Has no insight Into
bis condition. Tends to t>e Irritable, unapproachable and violent
Imagines that his Inner man has been stolen ; that he only has
part of his brain ; that he has been making brains for the coun-
try; that his body has been cut up 350 times; that he Is not en-
titled to any brains himself, etc. Has rather prominent ideas of
negation and to some extent of nothingnei^s.

Diagnosis : Manic-depressive insanity.

Male. Age 27. Engineer. Single.

Onset a week before admission, by carrying electrical fixtures from
the factory, talking and planning about building bouses, light and
ice plants, constructing and operating such plants, the enormous
profits he would make. Stays up at night. Claims to have special
Inventions, to possess special genius and ability, etc.

Patient is well developed and well nourished. Has a feeling of
general well-being and contentment. Is very talkative and emo-
tionally exalted. Expansive and grandiose In bis ideas. Has no
Insight Into his own condition or Into that of his surroundings.
Has extensive grandiose Ideas in regard to his ability, power and
wealth, etc. Has hallucinations of hearing. Is subject to out-
breaks of excitement. Has paraesthesia of the lower limbs, slight
tremor of the tongue and lips, difllculty i\nd hesitation in speech,
tremor of the hands, tremulousness of writing, slight exaggeration
of the knee jerks.

Paternal grandfather, uucle and father Intemperate. Paternal
grandfather tubercular. Patient intemperate.

Diagnosis; General paresis.

Male. Age 28. Barl)er. Single. Negro.

Onset about two weeks prior to admission, by strange actions. Im-
agined tliat someone was pulling at bis feet. Eilther talks Inco-
berently or not at all. Sits and groans. Imagines that someone

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\b after blin, Aseuinen strained poRltloiiB for taours, not moving

or speaking.

Patient is well developed iiiid well nourisbecl. Intemperate In tbe
uee of alcohol and toliac<.-<i. Hae been subject to spasms since a
boy. Began to move from place to plate. Thought that he was
not an ordinary negro, that he had a renowned ancestry. Would
not associate with his fellow-negro ossodntes. Would hear people
talking about him and beard sounds referring to him. Has hal-
lucinations of sight and hearing. Has delusions of self-importance,
of ancestry, of birth, of spirit possession. Has no Insight Into
his condition or that of his fellow -patients, la subject to out-
breaks of excitement, Induced by ha Hue! nut ions of hearing. Is
secluelve. Has a feeling of general well-being.

Diagnosis ; Dementia prnecox. Epileptic Insanity.

Male. Age 4(!. Laborer. Married.

Onset by grumbling and Incoherent talk. Imagined that he was a
brother to tbe James boys; that he could not be killed; that some
water he drank was dru^ed; that money will be so plentiful
that It will not be worth nnytliiug; that his wife had been stolen,
and threatens to kill two men because of It.

Patient is well developed and well nourished. Is somewhat exalted
emotionally. Has a feeling of general well-being. Is perfectly
satisfied and contented with bis present condition. Is very talka-
tive. Has well marked flight of ideas. Tendency to incoherency
and irrelevancy. Has no insight into his own condition or into
that of his surroundings. Has delusions of altered personality, of
self-importance, of persecution, of being poisoned. Has halluci-
nations of hearing, siglit, taste and of organic sensations. Some
tremor oC tbe bands. Writing tremulous, bold and distinct.

Diagnosis: Incipient paresis,

Male. Age 33. Fireman. Married.

Onset four weeks before admission, following an Injury to the back,
which rendered him nnconscous. Was Incoherent in talk and ac-
tion, nervous, irritable. Had delusions of being wealthy and of
impending harm.

Pntient la well developed and moderately nourished. General tone
of feeling is one of satisfaction and good nature. AttentliMi is
dlvertible. Talk incoherent. Has pronounced delusions of wealth
and slight ones oC persecution. Right eye Is egg-shaped. Has the
Argyle-Robertson pupil, tremor of tbe tongue, some difflculty in
speech, inco-ordi nation and ataxia of tbe hands and feet, Rbwu-
l)erg's swaying, absent knee Jerks, superflcinl reflexes decreased,
sonic iktraentbesla.

Diagnosis: General paresis. (Traumatic basis.)

Male. Age 28. Miner. Single.

Onset about six months before admission. Was restless, sleepless,
seclusive and talkative. Spent tbe most of his time in an old va-
cant house. Would stand in a rigid state for hours gazing upon
tbe ground or upon some object. Was subject to outbreaks of
anger and violence.

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213

Patient !b fairly well nourished and well developed. Attention Is
divertible. Is talliative. Has ftightlness of Ideas, tending to in-
coherency and irrelevancy. Has no Instgbt Into his condition or
his surroundings. Has delusions in re^rd to his family relations,
of altered personality, and to some extent of persecution. Had
hallucinations of hearing. Has a mitral systolic murmur.

Father and one brother Intemperate.

Diagnosis :

Male. Age 29. Laborer.

Onset three weeks before admission, by a change In disposition,
sleeplessness, restlessness, and becoming esdted. Has outbrealis
of violence. Wanders away from home. Has hallucinations of
bearing. Has delusions of wealth. Reported as having heart,
stomach and bowel trouble.

Patient assumes a listless attitude. Facial expression is flaccid
and vacant. Is well developed and well nourished. Attention is
divertible. There is complete disorientation. Apparent loss of
memory for recent experiences. Pronounced dementia. Well
marked tremor of the tongue and lips. Well marked speech defect.
Tremor of tlie bauds and well marked writing defect. Ineo-ordl-
natlon and ataxia of all voluntary movements. Exaggerated knee
jerks. Pronounced delusions of wealth and personal ability. A
well marked feeling of general well being.

One maternal cousin insane. Mother tubercular. Patient bad
sypbllis eleven years ago.

Diagnosis: General paresis.

Female. Age 41. Married.

Onset about four weeks before admission. Was restleas, talkative.
Incoherent, violent and destructive. Thought someone was trying
to undermine the house, that someone would harm her or her
family, that her father was dying, that her daughter was trying
to control her. Uas outbreaks of violence.

Patient Is well developed and well nourished. Is talkative and ex-
alted. Tends to be irrelevant. Somewhat egotistical. Has well
marked hallucl nations of bearing and of general sensation. Has
delusions of Impending harm and of persecution. Is subject to
outbreaks of violence due to her delusions. Has no insight into
her condition. Is susj)ltlous and apprehensive.

Diagnosis : Paranoia.

Male. Age 40. Laborer. Married.

Onset about three months before admission, witb a convulsion ap-
parently epileptic, following which he was morose, sullen, tending
to be abusive and violent. Talked incoherently. Manifested
marked loss of memory. Imagined that he was to get one million
of dollars.

Patient la well developed. Slim build. Manifests very little interest
in what is transpiring about him. Answers questions in a low,
monotonous and mumbling tone exc^t when spoken to sharply. Is
unapproachable, suspicious, apprehensive, irritable, resents inter-
ference. Has no Insight into bis condition. Manifests marked

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214

lotiH of mraior.v. Huh 1den8 of mistaken pereonalltf. Some thick-
ness of speech. Some tremor of tbe hnnds. Sllgbt decrease of
rellesee. Is ilull nnd stupid, except when irritated ; then he be-
comes violent.

Diafmosls:

Male. Age 44, Farmer. Single,

Onset ten days before admission. Was nervous, excitable, irritable,
talkative. Imagined that he was being conspired against; that
someone was trying to injure him ; that he was Higaged In busi-
ness. Was riolent nnd destructive. Hnd been In ill-health for -
several years. Said to be feeble-minded.

Patient is very talkative, with some tendency to Irrelevancy and In-
coberency. Some flight of Ideas. Well marked ideas of persecu-
tion, conspiracy and impending harm. Has no Insight Into hia con-
dition. Is completely disoriented. Is very suspicious. E>motlon-
ally exalted, 7et Irritable and apprehenaire. Attention Is flighty
and dlvertlble. Has delusions of physical well-being. Delusioos
are changeable and transient. Movements and actlona are prompt
and accelerated corresponding to the content of thought and the
flight of Ideas.

Patient r^iorta having had gonorrhoea some years ago. Radlals
somewhat sclerotic. Reflexes are decreased. Hands tremulous.

Diagnosis : Acute mania.

Male. Age 45. Carpenter. Married.

Onset two weeks before admission. Was sleepless, unconcerned as
to his surroundings, talkative. Made threats of violence toward
his family. Had delusions of persecution.

Patient is well developed and fairly well nourished. Has pronounced
delusions of Infidelity on tbe part of bis wife, based upon hallu-
cinations of Bigbt nnd bearing. Interprets ordinary incidents and
events as indicating tbe trutbfulness of his assertions. Has marked
delusions of persecution on the part of his family, neighbors and
lodge, all done to cover the defect at borne. Manifests a feeling
of general well-being, talkativeness and instability of rather ex-
alted emotions. Hiis no insigbt into bis condition. Has el(q>ed
from the institution sevwal times, but has always been returned
because of threats and acts of violence toward bis surroundings.
Is reported intemperate.

Diagnosis: raninoin. (Possibly upon an alcoholic basis.)

Male. Age 55. Traveler. Married.

Onset three years before admiBslon, following an Injury to the head
during a cyclone. Two years later he was tbrown from a wagon
by ligbtning. Some time later he fell froiii a hay loft, striking
on the bPad both times. Patient was morose, melancholy, secre-
tive. Had delusions of impending danger. Had outbreaks of vio-
lence toward himself and others.

Pnfient is well developed and well nourished. Professes a total nm-
nesia as regards the mental disturbances, but on close questioning
admits having requested his wife to move because of imaginary
danger. Physically there is an aortic systolic murmur.

Diagnosis :

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215

2. Mal€. Age 41. C'nGbier, Sliigle.

Outiet four weeke before admlBslcm, following tbe sluking of a boat
la which he was nearly drowned. Talks wUdl; and Incoherently.
Had hallucinations. Imagined that he was full of electricity, pos-
sessed magical powers, had wonderful ability, could control people
by writing. Had perverted sexual feelings. Shot himaelf fifteen
years ago, and some time later cut his wriat in attempted suicide.

Patient is tali, slim, moderately nourished. Indifferent and unob-
servant of hla surroundings. Attention is not well -sustained. Emo-
tionally is unstable, usually esalted. Has exalted Ideas In regard
to himself. Has feeling of general well-being, both physically and
mentally. Is very talkative, more or less incoherent and Irrele-
vant. Shows impaired memory. Judgment and intellecL Has
grandiose delusions. Has hallucinations of sight and hearing. Is
subject to outbreaks'of violence and maniacal excitement. Mani-
fests tremor of the lips, tongue and hands. Speech slurring with
elision of tetters and syllables. Writing tremulous with repetition,
elision of letters and syllables. Absent knee-jerks. Rbomt>erg's
phenomenon present. Arteries thickened. Pulse incompressible.
Patient alcoholic. Had luetic infection at the age of 19.

Family refiorts that a change In character was noted at least six
months before admission.

Diagnosis : General paresis.

3. Male. Age 30. Laborer. Single.

Onset two weeks before admission. Extreme nervousness, violent
headache, incoherent talk and action. Imagined that there were
people in the room to harm him, that the room was infected witli
snakes. Has outbreaks of violence. Made threats to kill persons
of his surroimdlngs.

Patient Is iworly nourished. Mental conditiou is one of profound
dementia and childishness. ■ Shows bilateral paralysis of the ex-
ternal ocular muscles. Bilateral paralysis of the facial muscles.
Pronounced paraphasia. Advanced atrophy of the optic disks. Im-
paired vision. Gives a history of severe headaches; syphilis at
the age of 20. Has exaggerated knee-jerks, more marked on the
left side.

Diagnosis: Orebra] syphilis.

4. Male. Age 45. S'armer. Married.

Onset six months before admission. Was talkative, noisy, vulgar.
Had delusions of wealth, of impending harm. Had outbreaks of
violence. Made threats against his surroundings.

Patient Is well developed and well nourished. Was discharged and
readmitted. Beports having had a hemipiegic attack with the face
drawn to one side opposite to that of the paralysis, with disturbed
sensation of the paraly7.ed side and disturbed vision of the opposite
side. Has delusions of persecution, based upon the envy and
Jealousy of others. At time of examination no evidence of paraly-
sis. Has no insight into bis condition at the height of the acute
mautfeatatlons.

Diagnosis: Acute mania. (Possibly incipient paresis.)

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216

i. Male. Age 2;t. Farmer. Single.

Oaeet one year before adiulaelou, wltli delusioDH o( persecutiou, out-
breaks or Tloleaee, threats against hie aurroundingB, and deetruct-
Ireuess. Has spells of uncoQBclousnesB.

Patient Is iu good health physically. Has a I'omplete amnesia for
the acute stage of the attack. States that he has spells coming
on with headache laeting two to three weeks, In which he does
not know what he la doing. Some are more severe than others.
Occasionally vomits during the spell. Usually has o hot feeling in
the head 15 to 20 niinutes before.

One slaler has cross eyes. One sister has weak eyes.

Diagnosis : Epileptic Insanity.
i. Male. Age 38. Preacher. Married.

Unset two years before admission by strange actions. Loss of In-
terest in everj'thlng. Obscene and immoral language. Imagined
that his wife was wrong In everything, that she was against him.
'i his led him to abuse her, to encourage his children to abuse her.
Imagined that she was untrue to him. Masturbated In the pres-
ence of his children, Attempte'd to cohabit with the servants. Has
a chronic skin affection.

Patient is well developed and moderately nourished. Has well-
marked delusions of pei'secution and infidelity. Manifests some
acceleration in the flow of thought. Is very talkative. During
the last two years he has been constantly changing his occupation
and seenis to be out of harmony with his surroundings in general.
Claims to have been continuously nieetlug difficulties and opposi-
tion. Denies almost wholly the report of his commitment In
i-egard to his conduct and action. The patient has a chronic scaly
skin affection distributed over the whole surface of the body, most
prominent on the head and on the exterior sun'ces of the ex-
tremities, with no involvement of the flexor surfaces, palms, soles
or mucus surfaces ; margins are well defined ; scales silvery and
rest upon a reddened base.
One paternal uncle intemperate. Tubercular heredity on the paternal
side. One brother tubercular. One sister epileptic.

Diagnosis : Paranoia.
7. Male. Age 18. Lalwrer. Single.

Onset about five weeks before admission, by an attempt at suicide.
Refused treatment. Itefused to eat, drink or talk. Was melan-
choly. Threatened his own life and those about him.

Patient is well developed and well nourislied. Present condition (s
apparently norma!. He attributes everything to his having been
under the influence of alcohol and not knowing what he was doing.

Diagnosis : Dementia praecox.
5. Male. Age 47. Farmer. Married.

Onset about four months before admission. Became sleepless, mel-
ancholy. Imagined that his business was ruined, that he was los-
ing all of his property, that he had done some great wrong, and
that people were plotting against him. Threatened suicide.

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217

Patient U well developed and moderately nourlebed. Manifests twth
mental and pbyslcal depression and retardation. Has mnie insight
into bis condition. Manifests some confusion In regard to bis re-
tention In tbe hoBpital.

Two maternal uncles, one auut and mother tubercular. One sister
Insaue.

Diagnosis :

Female. Age 39. Married.

First admission followed a change of residence. Could not eat nor
sleep. Would neither take medicine nor <1o what was requested
of her. Was not satisfied with anything that was done For her.
Had delusions of fear and Imaginary enemies. Said the world
was on fire, that everytiilng wiiB going to be burned up. Is con-
tinually talliing incoherently and disconnectedly. Has spells of
excitement in wbicb sbe runs about the house screaming, pulling
her hair, etc., which were followed by periods of depression, in
which sbe remained mute, stared as if Into vacancy, refused food,
etc. Threatened violence to those about her and also suicide.
Four months after admission was discharged as recovered. Read-
mitted ten years later. On second admission was emaciated,
anaemic, disoriented as to time, consciousness was clouded and
confused. Had only slight Insight Into her own condition, as she
realized that something was wrong, but could not tell what it was.
Had delusions of Impending harm, with a persecutory coloring.
Some Ideas of self-accusation, saying that if she has sinned tbe
fault did not lie within herself. Is fearful, suspicious, and some-
what confused. Responses, Iwtli mentally aud physically, are slow
and delayed, particularly those de|)endent upon volitional incita-
tlon, but are coherent and relevant. Emotional attitude is change-
ful with a mild degree of hebetude noticeable, and slight tendency
to mutism. Manifests some difficulty in arriving at conclusions.
General tremor affecting chiefly the hands and tongue. Slight
static and motor Inco-orfll nation. Active plantar and patellar re-
flexes. Some disturimnee of color vision as regards yellow and
green. General venona stasis. Facial expressions downcast and
rather auKlons. Thinking and acting require visible effort and
seem to cause fatigue. Blood pressure in the right arm iu the
sitting posture after the examination was 115 mm. per Janeway,
with a pulse rate of 80.

Diagnosis : Regarded as manic-depressive Insanity.

Female. Age ST. Married.

Onset followed active part taken in religious services. Became great-
ly worried alwut her spiritual welfare, more or less agitated, wau-
dered about the streets, said that the last days would see signs and
wonders of the end of the world. Had auditory and visual hal-
lucinations. Would talk of seeing pictures In books when there
were none. Would butt her head against anything solid in the
attempt to commit suicide. On examination appeared to take
no notice of her surroundings. Did not appear to understand what
was being said and done. Only the simpler questions are an-

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218

swered relevantly and only tbe simpler ordws carried out OthOT<
wise was confnsed and uncertain, wltb a tendency to mutism and
negatlrlem. The condition of memory was difficult to determine.
Was very apprehensive. Said that ahe ought to be burned for her

Physically Is auaemic, apparently proatrated. Tongue tremulons.
ReHexes exaggerated. Movements slow and tremulous. Blood
pressure per Janeway in the sitting posture after the examination
105, pulse rate 85, temperature 90-100 F. Said to have always
been Gubject to hysterical outbreaks.

Uotlier losaue.

Diagnosis : Acute hallucinatory paranoia.

Female. Age 43. Married.

Onset followed a fire In tbe house one week after. Oreat psychical
and motor restlessness, Incohereucy and irrelevancy in conversa-
tlon, which was mostly of religious content. Thought it was her
duty to preach and wanted to do so continually. There Is com-
plete disorleutatlon. General emotional elation and instability.
Has delusions of a persecutory and religious content. Hallndna-
tlous of hearing. Attention Is easily dlvertlble. Memory impaired
for both recent and remote events. Association of Ideas is change-
able. Flow of thought accelerated, with a tendency to witticisms
or to make remarks impressive. Has no Insight Into ber own
condition. Has lost control of ber thinking and acting, the latter
tending to be impulsive.

Physically is well developed and well nourished. Pupils react slug-
gishly, Irregularly and unequaly. Right iris more deeply pig-
mented tban the left. Redexes diminished. Some tremor of the
tongue and liands. Some muffling and indistinctness of the mitral
systolic sounds. Some irregularity of the menstrual function.

Father died of lung trouble. Motlier of asthma. Botli over 70,

Diagnosis : Mania, (Probably climacteric.)

Female. Age 23. Single.

Onset by a feeling of depression, headache and backache, attributed
to a failure of menstruation. The spells of depression are asso-
ciated with crying, Incoherent and disconnected talk and some
motor unrest, giving expression to anxious thoughts aud feelings,
of self-accusa(ory and religious content. Has delusions of having
committed the unpardonable sin of having joined the church when
not fit, of not being St to live, of being despised by family and
friends, with actions corresponding to the content of her thought
and tending to suicide. Knee jerks.

Diagnosis : Agitated meltmcholla.

Female. Age 32. Married.

Onset after childbirth, by irritability, ideas of peisec I n in tha
her husband and relations were against her. Beca ue indlff ent
to home and surroundings, carrying furniture ou f b h use
allowing her hair to become matted together and f u 1 g t allow
any one to comb It out. Threatened tbe life of h sel and hlld
At tbe time of esaminntion perception and concep Ion appa ently

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uoriiial. Gave a history at auditory and visual halluciuations.
Dtilusions of u persecutory (?onteut. Ideas of appi-eUeualou. Iin-
agiued altered personality ou the part of ber father. Tliese were
followed by spells of exaltation, siukImk at tlie top of ber voice.
tatliatlveiieBa, tinged witb uiore or less obscenity and profanity,
accelerated flow of tbousht, ijtc. Later this was followed by a
feeling of general well-being and coutentnient,

riiyslcally there was some irregularity of the menstrual functious.

Two paternal ancles and one cousin iutemperate. One maternal
iiuut and a half-sister Imbecillc. One maternal cousin, one sister
and the patient herself probably bysterlcal.

Patient uuderweut a complete recovery.

Diagnosis: Mania.

44. Female. Age 22. Single.

Onset by delusions of (he loss of ber soul, of Impeudiug deatli, etc.
Manifested pronounced suicidal tendencies. Had ideas of a self-
accusatory content, of havlug committed the unpardonable sin.
Worried and cried continuously. Used profane language. Par-
ticipated In Immoral tendencies. Patient manifests delay In per-
ception and conception. Has partial Insight into ber condition.
Emotions are changeable. Has delusions of Impending harm, of
conjugal iufldelity, of persecutioa and of somatic disturbances.
To some extent she tblnks they are real, although admitting that
they were more distinct during the sleeping periods. Emotions de-
pressed as shown in her attitude, conversation and facial expres-
sion. For several weeks there were absolute mutism and to some
degree stupor, almost complete, which she now explains by tbe feel-
ing of throat trouble that she had, and thought that by not talk-
ing It would hasten the cure, and that It would also not require ber
to answer the many questions which she thought foolish that
were asked. Her refusal (o eat was because she was not
hungry. Did not attend to her housework and to herself because
she was too ill and not strong enough. Frequently complained oi
a sense of heaviuess in lier throat which threatened to shut off her
breath.
Diagnosis : Melancholia. Kxhaustlon iisychosis,

45. Female. Age 28. Married.

Onset followed a dlfflcult first conflnement, during which there was
I'upture of tlie perloaeum whicb was unrepaired and upon which a
septic coudltiou developed, lasting about two months. During this
time there was manifested more or less mental disturbance which
cleared up as tbe physical condition Improved and no more mental
symptoms were shown until tbe second confinement, about three
years later. At this time she manifested more or less excitement,
with a tendency to violence towards her child and those about her,
and at times toward herself. Imagined that as her husband is a
carpenter she has the right to drive any person who may be in
any of the houses being built by him out of It and take posses-
sion herself. Patient Is negligent in regard to the care of herself
and family. Has persecutory ideas In regard to those about her.

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220

in regHi-d to the nwesBity of placing lierwelf under a doctor's care
or takliiK medicine, in regard to tbelr ability to live in houaea be-
yond tlaeir mean?, to tbe rightful iKisBeaslon of houses erected by
ber bushand, and lu regard to tbe reladoua of her husband toward
her. Later sbe olainiH tbiit threate were merely made to get even
for tbe supposed i>ersecution»i that she bud to undergo. Had no
In Bight Into ber condition.

(complete recovery ensued.

Two paternal aunts Insane.

Diagnosis : I'riniarily a sieptlc Intoxication dellrluni.

Female. Age 29. Married.

Onset about one week following ber marriage, nine months before
admission, with hallucinations espetlaltj at nigbt, to some extent
also of sight and smell. Later l>ecame irritable and susplclouB,
wltb delusions of Jealousy and infidelity. Insignificant Incidents
being interpreted as important. Followed her husband about.
Nailed up the doors and windows of her house. Became destruc-
tive. Imagined that ber brother was killed, tbat the police were
going to cut off ber head. Forced her husband to move freQuently.
Became violent toward those about ber. Became neglectful of ber
household duties and in personal care, filthy and profane. Re-
ports Indicate aypbllltic infection and excessive intemperance. Also
dissolute and immoral life. Facial e.xpi'esslou, attitude, actions
and conduct Indicate a low grade of mental, moral and Intellect-
ual development.

Mother said to have died of tuberculosis.

Diagnosis ■ \lcoliOlic insanltv upon a feeble-minded basis

I em lie 4ge 40 Single

Patient gives a history that about sK months ago she became Imbued
with tbe idea that her eni|lo\ers were giving her poison In order
to make her skk so that she would gi^e up some notes that sbe
bad igalnst them for monej borrowed from her Heard them
talk about It while in anotlier room '*he l>ecame depressed se
cluslie and suspicious Refused at times, to eat Latei sbe moved
to another town where the same londltlons developed Patient Is
German born Has no relatives or immediate friends General
health Is below p\i Outside of tbe emotional <<pbere nothing
(ould lie deteited ipirt from the Ideas of persecutorv content
] motton^lh she Is deiiressed listless mdlfferent to her surround
lugs and to her associates somewhat apathetic Actions and
movements coi respond to the content of her thought

Dugiiosis Paranoia

I emale \ge I'J Single

Onset four months before admlision with despondencj seflusive-
ne^s •Holding associates usuallj lefralned from talking at times
became profane and threatening Acted only by compulsion At
tempted suicide Patient reports that she be<.ame dissatisfied
ulth home and nent to another town to Ihe with a sister but
soon became Imrressed with the idea that she should be at borne
with her mother so that she wanted to go bonie and yet did not

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221

want to do so. This caused her to worry nbout it. About this time
sbe experienced n dlsnppointmeiit in her nfCectione, whlcb led
her to attempt suicide, giving no other definite reason tlian that
she wanted to die. She contlaually sits in one position. Facial
expression is staring. Answers questions slowly or not at all.
Thinks that she has lost her mind and that she has committed the
unpardonable sin, referring the latter to her attempt at suicide.
Emotionally is depressed and downcast ; actions and movements
corresponding to the content of her thought. Has a tubercular
diathesis, as Indicated by the enlarged cervical glands and several
old scars, the result of suppuration.

Diagnosis : Dementia hebephrenia.

['emale. Age 2!). Married.

When IG years of age the patient had an attack of what she calls
nervousness, lasting about two months. The following summer
another attack occurred for which she was sent to an insane hos-
pital, the report indicating a typical maniacal outbreali, from which
she also recovered. At the age of 21 she married. After the birth
of the third child a third attack occurred, In which she evidently
had hallucinations of sight, hearing and smell, delusions of altered
personality, psycho-motor activity and exaltation, with a tendency
to injure herself and others. Recovery also ensued. Present at-
tack also followed a confinement, with delusions of iwlsoning, of
having lost a child, with a desire to wander away, with alternat-
ing outhrenks of crying and laughing, with threats to kill herself,
her child and those alxiut her. Insight Is clear as to her previous
conditions, hut not as to her present condition. Recovery again
ensued.

Father and paternal grandmother insane. One sister tubercular.

Diagnosis ; Recurrent mania.

Female. Age 55. Married.

Patient was an Inmate of an Insane hospital at the age of 35, follow-
ing what the patient says was a severe chill, upon which ensued
unconsciousness fur several days After this she was excited, had
hallucinations of sight The whole illness lasting about four
months Three years later another attack occurred, following the
excitement incident to a Are burning down their house. This at-
tack lasted about nine months, when she was again discharged
as cured. A year later she was readmitted, but being found preg-
nant was discharged pending pregnancy, after which she was ad'
mitted with pronounced Ideas of persecution ; Imagined that her
children were against her. that the neighbors talked atmut her,
etc. Insight into her condition in regard to former attack was
clear, but not as to the present Memory seems to be impaired for
iMjth recent and remote events Intellectual sphere noticeably Im-
paired. Emotional sphere normal or dejiressed. Moral tone im-
paired as shown by her giving birth to an Iltegltlmate child and
later marrying a man of very dissolute and intemperate habits.

Physically there Is found a mitral systolic mnrmur.

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222

Mother and one slsler tubercular. One sister died of brain being
loo large. One sinter hns nervous trouble.

Diagnosis: Keiurrent luanlsi.

Female. Age -'IT. Married.

Onset of mentnl dlstucbituee followed tbe eighth pregnancy, but the
symptoms did not beooiue acute until after confinement, when she
became iudlfferenl to the family and household duties, overanslous
In regard to her cliiliireii. imagined that lier husband had poisoned
the children and had thrown them into the well ; that people were
trying to break Into tbe house, and would often be found gliding
about tbe house lookiug for the supposed intruder ; that the food
was poisoned, so refused to eat. This was followed by a depres-
sion in which ns a rule was well marked slowness of perception
aud comprehension, retardatlou In the association of Ideas and es-
presslou of them. Emotional sphere Is changeable, usually de-
pressed, but can be made lo laugh or cry almost at will. At times
somewhat excited. Memory for recent events markedly Impaired.
Manifests some confusion.

Physically there is general depression. Knee jerks activa

Diagnosis: Regarded as an acute confuslonal insanity. (Parturi-
ent)

Female. Age 58. Married.

Onset by nervousness, wanting to be in constant motion, calling for
her mother who has been dead for several years, dancing, shout-
ing, destroying furniture, breaking dishes, tearing clothes, becom-
ing violent, profane, obscene, threatening suicide and homicide.
Patient passed the climacterium two years before. Mistakes per-
sons of her surroundings. Is very talkative. Attention is v^
divertlble. Flow of thought accelerated. Emotionally exalted.
Easilf excited to acts of violence, to outbreaks of anger, of Joy,
etc. Imagines that she will become destitute, will be sent to tbe
workhouse, etc. Actions .and movements active and prompt

One maternal uucle insane. One sister nervous.

Diagnosis : Acute mania.

Female. Age i7. Married.

Onset a year prior to adiuiaslon by strange actions and peculiar
ways, by becoming very immoral In her talis and by threatening
violence to those about her. On examination was very suspicious.
Imagined that she was unjustly dealt with, that she was being
Imposed upon, aud that the family did not use her .rlglit Is very
talkative. Says that she sees her friends burning lu hell, etc.
Emotionally Is changeable and unstable. Manifests acceteratloa
in the flow of thought, in movements and actions. Has a feeling
of general well-being.

Physically there Is disturbed, Irregular menstruation.

Three brothers and one sister died of tuberculosis. Orandmotber
had a paraplegic attack. Mother Is hysterical. Two brothers and
one son Intemperate.

Diagnosis : Hyponiania of tlie climacterium.

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223

Female. Age 24. Married.

Onset b^an about 8lx weeks after confinement. ContlnnODBlr
talked and moved about. Imagined that Bhe wae going to die, tbat
someone was after her or after the babj'. Locked herself and
baby In a room and refased admission to anyone. Had halluclna-
■ tlona of sight, hearing and smell. Had delusions of a persecutory
content and to some extent of an esalted ebaracter, but transi-
tory and changeable. Is completely disoriented. Mistakes persons
and her surroundings. Interprets the falling of stars, the chirping
of birds, etc., as having special, signlflcance, at times of pleasant
content, at others of disagreeable content and of an apprehensive
nature. Attention is changeable and easily dlvertlble. Has no
insight into her condition. Memory noticeably impaired, for re-
cent events particularly. There Is noticeable confusion in the as-
sociation of Ideas, leading to incoherency and Irrelevancy. Flow
of thought Is considerably accelerated. There Is a feeling of geai-
eral physical well-being. Blood pressure, per Joneway, 125; pulse
rate, 90, In a sitting posture after the examination.

Diagnosis: Acute confuslonal In8anit.v. (Puerperal.)

Female. Age 40. Married. Negress.

First mental disturbance occurred about twelve years ago, due, she
says, to drinking whisky, and was manifested by exdtement. Is
now recovering from the fifth attack.- Attention Is somewhat dl-
vertlble. Emotions exalted. Plow Of thought, moderately accel-
erated. Is talkHtlve. Gives expression to Ideas having a perse-
cutory and religious content. Has some Insight Into her past con-
dition. Says that her actions In the present attack were the re-
sult of a feeling thnt arose within ber tbat impelled her to do
and say the things she did In order to make the world better and
not In response to anything seen or heard. Shortly before the
outbreak her consciousness becomes clouded ; the excitement de-
velops suddenly and Is followed by a varying degree of depression,
and there always remains more or less amnesia for the experiences
at the height of the attack. Blood pressure 130, pulse rate 110 in
the sitting posture after examination.

Mother died of tuberculosis. One daughter Insane.

Diagnosis : Recurrent mania.

Female. Age S3. Single.

Onset by restlessness, wandering about, imagining that some one
was going to kill her, refusing to take medicine, thinking that It
would poison her, talking excessively, usually about religious sub-
jects. Attention Is easily dlvertlble, yet makes an effort to con-
centrate her thought and to think. Repeats all questions asked.
Several seconds elapse before she Is able to answer. Answers
mostly correct, but always more or less combined with ideas hav-
ing no relation whatever. Speech Is slow and hesitating with a
pause between each word. Has no Insight Into her condition. Is
completely disoriented. Has emotional outbreaks of anger, during
which she is violent and destructive. Inflicting Injuries upon lier-

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224

self and others. At orhec tlnjes Is enslly tnclted to laughter. Gives

expression to Ideas or apprehensive and persecntory content.
Memory Is noticeably Impaired. Action and movements are re-
tarded corresponding to tlie retardation of Ideation.

One maternal uncle Intemperate. Mother tubercular. Patient gives
a history of venery and speclflc Infection.

Diagnosis : Manic, depressive Insanity.

Female. Age 50. Married.

Onset abont sis months before adinlsslou, with a manifestation of
general apnthy, llstleBsness, careiessnesH and Indifference In re-
gard to herself, her family and her Hurroiin dings, more or less
confusion, Incoherency, disorientation, chlidllhe response to all qiies-
tlons and actions to correspond.

Patient- Is well developed and well nourished. Perceives correctly.
Answers promptly. Shows n marked disinclination for any mental
effort. Answers all questions requiring any mental effort with the
simple answer, "I don't know." Manifests entire satisfaction and
contentment with her present circumstances and surroundings
Takes care of herself, hut Is not initiative. Her general tone o(
feeling is pleiisui-able. Memory apparently Impaired for both re-
cent and remote events. Physically facial expression Is flabby
and apathetic. Pupils unequal, the left pupil slightly larger than
the right ; la somewhat irregular In contour, responds Irregularly
to light, and the disks show pronounced choked disks, more so on
the right side. Speech Is hesltatlne and thick. Hands show tre-
mor. Writing Is tremulous nnd there Is elision of letters, although
when asked to spell the words does so correctly. Knee Jerks un-
equal, the right being active, the left difficult to elicit. Slight ten-
dency to Ithomberg's i)henomenon. Slight tendoachlllea response.

Diagnosis : Brain syphilis or general paresis.

Femtle Age ]i) Single

Onset two months before admission hv restle«!«ness constant wander
ing away from home attentlou and interest rapidly changing from
one thing to another Imagined that people were trying to poison
her [n the watei jjiven her to drink is talkative generally ex
alted at tlme-i violent At present maulfcf rather exalted emo
tlons somewhat changeful Talks rather rapidly Is inclined to
be jerk^ Is etiiily excited Is somewhat irrltabip Physically
three months after an acute febrile disen'-e diaguo>ied malaria
the patient began to manifest nervousness and fidgety movements
which have continued up to the present time Movements are
irr^nlar jerkv spasmodic mioUe priufliiallv the hands and feet
to a less extent the tnmk and face are only temporarily under
the control of the will are intreased by e'xcitement disappear
during sleep There is also a pulmonnrv systolic murmur slight
roughening of the mitril first sound and modente inaemla

Diagnosis Acute confuslonal msanltv (Choreic I

temile 4,;e il Married

Onset cUhteen months before admission Imagined that she heard
lolces coming from different directions telling her that she had

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been neglectful of her family duties. Imagined that she saw vie-
lons on tbe face of the clock, furniture, etc. Imagined that sbe
was being haunted by detectlres employed by the neighbors to steal
her property, that medicines given her were for the purpose of
putting her mind in the condition to deed away her property, that
her husband owes fines at different places and wants to go and
pay them, that she Is constantly receiving wireless telephone mes-
sages. Dreams over her past life and worries over Imaginary
misdemeanors. Is in constant fear of impending danger. Inter-
prets the puffing of escaping steam from an exhaust pipe as being
done to annoy her, that It makes Indecent proposals to her, that
It reveals her Innermost thoughts, that electricity Is a divine
power enabling the electrician to pry Into her thought. Emotion-
ally is very unstable, at one time very much exalted, at another
very much depressed, corresponding to the predominance of the
content of her thought. Manifests a tendency to Incoherency and
irrelevancy. Slight Impairment of memory. Patient's face asym-
metrical, the left side being the smaller.

Paternal grandmother suffered from senile dementia. One paternal
uncle feeble-minded. One sister Insane.

Diagnosis : Chronic hallucinatory paranoia.

female. Age 42. Married.

Onset sis months before admission, by neglecting family and house-
hold duties. Suspiciousness of friends. Talking foolishly, repeat-
lug the same story for hours. Imagined that she had committed
some crime for which there was no pardon ; that she had wronged
her friends. Would cry and weep for hours. At times became vio-
lent. Facial expression is anxious and apprehensive. Actions are
restless and agitated, wringing and rubbing her hands, constantly
moving about In her chair, turning around and looking furtively
about her continually moaning and lamenting, repeating "What
will I do? W hy did I leave?" "What is going to become of me?"
etc Attention la obtained with difficulty, retained only momen-
tarih and immediately returns to the subject of her ideas. The
flow (f thought and the association of Ideas are retarded. Ques-
tions requirins some effort of thinking are not answered at all or
by the expression I dou t know " Emotionally is depressed, agi-
tated and whining

Father and brothers intemperate One maternal aunt fiLsane.

Diagnosis Agitated melancholia

Female Age 21 Married

Onset sevenl months Iwfore admission. Became incoherent. Easily
In Ited to acts of violence Indulged in profanity and falsehood.
Imagined that everyone was talking about and trying to Injure her.
Patient is of a highly neurotic temperament. Was subject to night-
terrors and Somnambulism in childhood. B^an to practice onan-
ism about the age of 10, and has continued it more or less ever
since, even after her marriage, saying that she derived more
pleasure in that way than with her husband and was really driven
to do so to gratify her desires. Became run down physically and

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226

anempted suicide at the age of 20. Became Jealons of her bus-
band and believed him unfaithful. Regan to use alcohol freely,
and had an atuck of probable delirium tremens. Says that the
first mental dlsturbanceB were manifested Six fears ago by be-
coming greatly excited and alarmed at seeing a man with bis bead
cut off, after which she was haunted by phantoms, particu-
larly at night; who knocked upon the doors, whispered In ber
ears, etc. At present has hallucinations of all of the senses and
organs. Claims thiit her body Is Inhabited by another woman, In
imrt serpent, In iwirt a former attendant, who produces all of the
sensations that live at tbe basis of ber hallucinations, who fully
controls her. compels ber to do things against ber wish and will,
regulates and directs her thoughts, has converted her whole ali-
mentary canal Into a serpent, causes her to have Intense sexual
orgasnin, followed by great fatigue and exhaustion. Her emotional
Ideas arc somewhat expansive. Actions and movements do not
correspond to the content of her hallucinations and delusions.
Physically there exists considerable leucorrhoeal discharge and
niodernte prolapse of the uterus -producing some cystocele and rec-
tocele.

Mother Intemperate.

Diagnosis : Alcoholic hallucinatory paranoia.

Female. Age 35. Married.

Onset about two months before admission, by an attempt to kill her
brother-in-law. Since then she has given expression to a delu-
sional feur of being murdered, of neighbors stealing from her, and
of being poisoned, so refuses medicine. . Becomes violent. Thinks
that her children arc in the hospital, that she came to get them
and Is now being kept for some reason unknown to her. ThliAs
that she hears her children's voices and becomes somewhat agi-
tated. Is subject to extremely violent outbreaks upon the slight-
Diagnosis : Paranoia.

P'emale. Age 26. Married.

Onset about one year before admission, following typhoid fever.
Imagined herself an actress nud detective. Feared that she would
commit violence toward someone. Attempted suicide. Facial ex-
pression, action and attitude is one of depression. Is very secre-
tive. Feels that there Is nothing to live for, that she is not to
live, that she Is In the way, hence made the suicidal attempts.
Si>ee<-h Is low and monotonous, Shows loss of Interest. Is dis-
inclined to take anj- exercise, to l>estow any attention or to ob-
serve what is transpiring about her. Flow of thought is retarded.
There Is general physical depression and retardation.

One maternal aunt and one maternal cousin Insane.

Diagnosis: ICxhaustlve melancholia.

Female. Age 3G. Married.

Onset five months before, following some time after desertion by her
hnsband. Tore her clothing. Became violent and melancholic.
Einagined that every one was turned agfllu«t her, that she had

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come luto iiossesBiun of large sums of luouer and soltt furniture
aud clotbing for a mere trilte. Was very emotional, usually of
a depressive type. Says that she had St. Vitus daure at the age
of 15 and has been nervous ever since. Had four or five miscar-
riages, occurring about the seventh or eight month, only two going
full term. At present tbere is a feeling of general well-being and
egotism. Emotional instability and demeutia. Tremor of the
tongue and lips. Speech slow, tremulous and besitatlug. Knee
jerks absent. Marked Hhomberg pbenomenon. Plantar reflexes
exaggerated. Impaired perception of pain, of muscular sense.
Tremor of the hands. Writing tremulous with elision of letters.
Ataxia and inco-ordination of all voluntary movements. Gives a
history of abdominal girdle pains.

Two aunts were nervous. One sister had chorea.

Diagnosis : Tabo-pai'esis.

Female. Age 28. Single.

Onset over one year before admission, by becoming restless, hysteri-
cal, at times violent, threatenlug those about her. Imagined that
her friends at school were dying, that some calamity was to be-
fall her, that she was a good musician and composer. In child-
hood was subject to nlght-ten'ors and somuambulistic tendencies.
At school says that she escelled In linguistic hrauches, but that
other subjects were very difficult for her to learu. At the age of
18 to 19 she became reticent and unsociable, developed a violent
dislike for her mother, became imbued with the ideas regarding her
schoolmates already mentioned and which have continued ever
since. Sbe thinks that she is being punished for ber mother's
crimes, accuses her mother of having killed ber firstborn, of
giving birth to at least fifty chiidi-eu. Has hallucinations of hear-
ing. Uecognizes the voice whicb makes sneering remarks about
her, accompanies and watches her wherever she goes or whatever
she does, causes her face to be drawn to one side. It also causes
a burning sensation situated sometimes in the head, at other times
in the chest or abdomen. The effect of the voices is due to the
fact that they have killed. Saya that she can not imitate the
voices. Also speaks of visual hallucinations. Says that she has
always been the victim of persecution ; believes herself to be the
half-sister of Christ, that Christ was born by ber mother, etc.
Attention is often obtained with difficulty, due to the fact that It
adheres tenaciously to the idea uppermost in her mind. Is par-
tially disoriented. Emotionally is on the whole exalted and not
always In correspondence with the content of thought predomi-
nating.

Grandfather and father tubercular.

Diagnosis ; Paranoid dementia praecos.

Female. Age 23. Married.

Onset four months before admission, with all of the manifestations
of an acute mania. This was followed by a stage of depression,
in which the most prominent delusion was that she and all of her
friends were going to be killed. This passed Into a stage of pro-

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fouiHl <1<-meuliii, tlic imltt'iil boliiu' ii|ijiai'eiitly uiinble to answer the
simplest qiiemtlDiiK nr cull nbji^cts by their correct names, nor tell
tbetr use. Spends mutU of ber time trying to sing, at times a
complete verse of some familiar tune; usually, however, mnkes
lip the words as she soes along without any connection or asso-
ciation lietweeii them. Eats and sleeps well. Is filthy and inat-
teiitive to hernpir. At-tlons ami conduct that of a profound de-
Diagnosis :

Female. Age 36. Married.

Onset one j-ear before adralsaiou, coming on during pregnancy. Had
u similar attack two years previously, also wliile pregnant. Im-
agines titat she has been murdered several times and came bacli
to life again. Dislikes her best friends. Asks her husband to get
a revolver for her, so that she can use It. Answers some ques-
tions correi'tly. others she evades by asliing others. Others she
refuses to answer at all. After about ten minutes she becomes
obstinate and refuses to answer any question whatever. Seems
very suspicious, yet very good-natured over what Is being done,
laughing at and trying to ridicule it. Has periods of exaltation,
bnt as a rule is quiet. Si>eaks of some charges, but can not be
Induced to explaUi them ; also of bad administration, of blaming
others, of going to California when she leaves, of having revenge,
etc. Is very egotistical. Patient has a well marked mitral sys-
tolic murmur.

Father Insane.

Diagnosis : Chronic mania.

Female. Age 18. Married.

Onset about OJie month before admission. Itecame silent and morose
until conipulsion was attempted and then gave way to a convulsive
attack, hysterical In nature, crying and screaming; refused nour-
ishment; thought herself mistreated by her family; threatened
the life of herself and those about her.

Patient states that she has not l>een used justly for over twelve
years, but refers to nothing special, until she became pregnant
illegitimately, but later married the man who caused her to be lu
that condition. She claims that they endeavored to persuade her
to leave Mm. This falling they resorted to forcible means, which
led to the outbreak of violence. To this fact she also attributes
her moroseness and threatened suicide, feeling that death would
be preferable to the constant naming and tormenting. Patient
is of a very nervous teniperament and was committed to the in-
stitution in the absence of her husbaud. who was engaged at his
occupation at another locality, and it was during his al)sence that
she Is supimsed to have received the treatment complained of.

Paternal uncle, father and one brother Intemperate

Diagnosis ;

Female. Age 40. Married.

First attack of mental disturbance occurred eight years before the
present one. Three years later a second attack occurred. The

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preseut iittat/b be^ii abutit four niiiiithB beforo niluiiHSloii, by I't'st-
lessni'SK, destnictiveness. iiiitbiviiks of Tiolciue, liolug Injury to
herself iind thos^ about her.

Patient in exalted mentally and phyaituJly. Id talkative. Flow of
thought Is accelerated, witU a tendency to dlBconiiection aud irrel-
evancy. Is disoriented as to time. Attention is easily dlvertlble.
Ib unstable eaiotiouaUy; usually exalted. Content of thought aa
a whole Is iilcasurable. Feellug-tone tending to egotism. Mani-
fests som*; erotic inelhiatlons, some loss of control over the thoughts
and aetloHS. Is subject to Impulsive outbi-enks.

Father attemjited suicide. One brother liisahe.

Diagnosis: Recurrent mania.

Female. Age 38. Single.

Onset about one year before the date of examination by recl;leBe
manner of living. Imagined that she was very rich nud that her
husband was so, also, when they bad nothing at all. At present
there is marked mental enfeeblement, with pronounced delusions
of wealthy possessions, of a wealthy husband. Has some delusions
of a persecutory content, in that her committa! to the institu-
tion was the result of a plot. Manifests marked loss of memory.
General tone of feeling is that of well. being. Facial enpression Is
void and apathetic. Lips and tongue tremulous when attempting
to sijeak. Si)eech Is tremulous and hesitating with elision of let-
ters and sj-llables. Pupils unequal, the right being the lai^r.
Movements of the hands tremulous and Inco-ordinafe. The writing
tremulous, with elision of letters. Gait somewhat ataxic. Well
marked Khomberg's swaying. Patellar reflexes absent. Plantar
reflexes active.

Father intemperate. One brother died of meningitis. One sister
died of tuberculosis. Patient said to have had syphilis- ten years
ago.

Diagnosis: (^neral paresis. (Probably tabetic.)

Female. Age 35. Married.

Onset about three months before admission. Attributed to religious
excitement. Patient reports that she has ticen subject to fainting
spells for about ten years, usually coming before the menstrual
flow, sometimes between them, in most of which she loses con-
sciousness, at times biting her tongue and always feeling sore all
over after them. At the onset of the present disturbance slie had
several such attacks and when coming to heard voices telling her
tliat she had been thrown out of the kingdom of heaven as a
murderer because she had not prayed for her children to be
saved and now they could not be. Refused to eat [because some-
thing prevented her from doing so; a voice told her she should
not eat, gave her to understand that she would not starve, but
that she had to suffer as a judgment. Attempted suicide because
she was In so much misery. Saw handwriting on the wall, which
she could not read or understand, but It meant her doom. Her
body seems changed In that she has not the feeling In It that she
used to have ; always feels as If she were going to be murdered.

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Feels tbnt her mind is more like that of a child, etc. Tbere Is
generfli retardation and depresBion, iioth mentaliy and pliyslcally.

Diagnosis: Melniichnlln. Eplleiisy,

Female. Age 28. SIngie.

Onset ttve yeiirs before, by flightiiiess, melancbolla. at times tallclng
Incesaautly and Incoherently. Saw vUious of dead relatives, of
friends, of the Almighty, etc. Imagined that she was being per-
secuted because she refused to sacrifice her virtue, that attempts
are being made to poison her. Had outbrealcs of violence. Had
sjtells in which she would scream that she was dying, and would
call for the priest. The patient rei>orts that she haa always had
feelings of marked depression at the menstrual period, much pain
and considerable nervousness. Three years before admission she
underwent an operation for the removal of both ovaries. About
one year later she bad an attack of what she calls brain fever,
for wblch there Is complete amnesia on her part. Complains of
great worry and suffering caused by mistreatment on the iMrt of
her relatives wbere she made her home. Attributes the motive to
her knowledge of false transactions that had tieen made In their
business and to her refusal to sacrifice her virtue to blm. Has
some Insight Into her condition, in that she feels that there is
something wrong, as she calls it — "somewhat of an Inability to
control ber sensibility." Has hallucinations of vision. In which
she sees the devil, this having ■been suggested to her by a picture
she has of bim in her bedroom as he is represented in Faust Has
also received visits from the Lord. Aoditory hallucinations are
based ui>on the statements that she felt the presence of the Al-
mighty and guardian angels as the protectors of his children, by
an innate feeling in answer to her prayers, bearing the voice of
her dead father. Also lias hallucinations of taste, smell and gas-
tric sensations associated with the delusions of attempted poison-
ing. At times smells sulphur and brimstone in association with
the delusions of the devil. Her emotional sphere is unsteady and
chaugeable. in the i)erlods of her depression she screams at the
top of ber voice, says that there Is a great weight oppressing her,
has a feeling of choking and constriction about the neck, and
feels that she will smother, so screams to secure relief. Complains
of headache, cervical and dorso-lumbar puius and of a lump In her

Paternal mother, father, maternal mother and one brother died of
turberculosls. Patient Is of a highly nervous temperament.

Diagnosis : Hysterical insanity.

Female. Age 33. Married.

Onset occurred about the fourth month of lac-tation by a feeling
of depression. Imagined that slie had several bodily aliments,
that what was said to her was untrue, that she was suffering
from internal paralysis, that her heart was gone, that she was
sure to die, that those about her were unkind to her. Begged her
friends to accompany her through the darkness through which she
must pass. Neglected her family and household duties. Became
agitated at times. Attempted suicide. This was later firiiowed

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231

by a period at emotional exaltation with loquacity and acceleration
111 the flow of Ideas and In all movements. The patient reports
baying bad a spell of nervous prostration at the age of 18, follow-
ing an attact of la grippe, with an attack similar in nature to the
present

Father lutemperate. Patient has used alcohol tor years.

Diagnosis : Hypochondriacal melancholia. Recurrent mania.

Feniale. Age 32. Married.

Onset followed confinement about five months ago, evidently asso-
ciated with septic infection, and later pneumonia developed, after
which she became melancholic, restless and destructive. Imagined
that spirits were around her, that she had power to do anything
wltii the spirits, that as soon as she would get the word from
heaven she was to kill her children. Had an attacli recorded as
an acute mania following a previous confinement. On admission
was in a condition of wild maniacal excitement. Siuce then she
has had periods of depression, but no manifestations of maniacal
nature at all marked. Is somewhat seclusive and Indifferent to
her surroundings. Feels that her fellow-patients are jealous of
her and are her enemies. Has an Intense hatred for her husband.
Is somewhat indifferent in regard to her children. Emotions are
changeable and easily irritated. Right lobe of the thyroid is con-
siderably enlarged.

Diagnosis ;

Female. Age 60. Married.

Onset about one year before admission. Begun to think that some-
one was after her. That some one was going to drug or to kill
her. At times became agitated and violent. Armed herself to
protect herself from the supposed persecutors.

Patient is usually 'in a condition of mental depression, yet in a
state of strained attention and expectancy, due to the acuteness
of bearing, as evidenced by the alertness in hearing sounds and
carrying out movements of listening or making furtive glances
In the direction from whence the sounds come. Auditory hallu-
cinations are the predominating feature, and she interprets the
various sounds, such as the chirp of a bird, the whistle of an en-
gine, etc., as the voice of the Lord calling her by name and telling
her to come up, "You will be killed," etc., and pronouncing cer-
tain words, as "Kivelra," "chivarl," which means death or have
some similar meaning. Has some persecutory Ideas, in that they
are trying to deprive her of her property, hence her committal.
Has some exalted ideas of Self, in that her neighbors were Jealous
of her. Memory shows marked Impairment. Motor field is some-
what depressed, but at times becomes very much agitated, walk-
ing about, wringing her hands, moaning, etc., due to the feeling of
fear and apprehension. Facial expression and attitude one of ap-
prehension and expectancy.

Mother asthmatic. One brother died of brain fever. One brother
and one sister insane.

Diagnosis: Senile paranoia.

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Female. Age. 28. Single.

Ooset about two yeara before admission. Became very talkative,
profane and uncbaste. Subject to periods of violent excitement.
Imagined things that were not true, and at sucb times was ver;
quarrelsome, excited, talkative and noisy. Had delusions of re-
ligious content, such as the power of divine lieatlng, etc. In the
interval perception and conception seem to be about normal. An-
swers ordinary questions correctly, Kauge of knowledge seems
to be very limited. Actions and manners are childish. Emotionally
is very unstable and la easily influenced either pleasurably or other-
wise. Shows but little interest in ber surroundings. Seems to
exercise her power of observation, but little, It at all. Facial ex-
pression manifests apathy and a low grade of intellectuality.
There Is some stiffness In the movements of the lips. Some lordosis
of the spine In the lumbar region. Suffers mucb from beadache
and from dysmenorrboea. Thyroid giaud somewbat enlarged. Has
formed a strong attachment (or fellow-patient, who Is a pronounced
religious paranoiac.

Father committed suicide. Mother and two sisters died of turber-
culosis.

Diagnosis: Feeble-minded basis.

Female. Age 46. Married.

Onset about two weeks before admission. Was unable to collect
her thoughts, wandering from one to another. Wandered from one
form of work to another. Believed that she had doue things that
she bad not done. Talked oC events that never happened. Urinated
and defecated anywhere, aolllng herself without concern.

Patient comprehends correctly only the simpler questions, and often
only a part of these, giving only a silly laugh In answer to most
of tliem, indicatine; a profound dementia. Features and physical
condition generally are flabby. Facial expression vacant and
apathetic. Manifests very little interest In her surroundings. Is
non-obsen-aut. Sliows marked tremor of the lips, tongue and
facial nmscles when attempting to speak. Speech Is drawling,
hesitating, In a sluglng tone, with elision of letters, syllables,
words and parts of a sentence. Tremor ataxia and inco-ordi-
nntlon of the movements of the bands, more marked on the right
side, present when quiet otherwise; not Increased by volition, but
increased by excitement. Movements of the legs ataxic and inco-
ordinate, , rendering gait almost Impossible without assistance ;
knee Jerks and other tendon reflexes increaswl. Rhomberg's sway-
lug well marked. Perception of pain lessened and delayed. RIglit
pupil Irregular. Reaction of pupils sluggish. Involuntary urina-
tion and defecation. Copper-colored scars on the outer surfaces
of botli tibia. History of syphilis ten years aso.

Diagnosis : General paresis.

Female. Age 24. Married.

Onset four weeks before admission, following childbirth. B^au
two weeks after confinement. Conflnenjent was difficult, I«|-

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agined that Ood and augels were lomerslng nitli her that she
Lad a loathsome diseaie At times la quiet, at others Is nolsv

Patient answers I doiit know to all but the \eir simplest ques
tlons Can onlj call the simpler objecth and articles b> uame
Attention Is easllv diverted Is inattentive to herself and non
obseriont of her •"nrronndlng? Spits upon herself Chews her
lingers and her hair lier clothes and evervthlng that she gets
iDto her hands Frequently breaks out into ii Billy meanlngle^
laugh isajs that ■ihe feeli nell lias no Insight into her condl
tloii Memory apijarently wholly abolished Manifests prattitallj
no Intel leLtiiallty

One cousin insane

Diagnotis Dementia upon a feeble-minded basis

Female Age 37 Married

Onset one \ear before admission by inattention and indifference to
houflehoH duties and to family Imagined that people were trying
to get into her home would slip about the house at night look
Ing for them that her husband had poisoned their children and
thrown them Into a well that she nas going to be polapned and
refused to eat but when eoniinced that the food was not poisoufid
ate ravenousiv Was very talkative bat without reason or sense
These delusions later disappeared Patient reports that with the
last pregnanej she hecame weak and nertous her mind became
wealt and she lui<igi])ed the things mentioned aboie At present
manifests slight confusion of Ideas and mo\ementB and some Im
pairment of memorj

Father and two pntetnal unties intemperate Mother is an lll^iti
mate child One matimal half sister crippled and mentally weak

Diagnosis \cute confusional insanity

Female Age 20 Married

Onset began about two months after confinement Was restless
melanchoh Imagined that God told her to preach that she
inunt not Ihe with her husband that ^he must kill her babi
Since admission peilods of defression alternate with periods of
agitation In the former she sits about in a condition of apparent
stupor all mental and motor functions being in abeyance except
the emotional sphert whlcli is easily e\citcd to orjing In the
latter she screams attempts to do liolence to those about her
thinking that she Is going to be killed \^ hat eipresslons are tit
tered are more or less tinged n ith persecutory content She is
completely disoriented and more or less in a state of confusion

Great grandmother epileptii Mother Insane

Diagnosis 4.cute hallucinatory paranoia

Female 4ge 49 Single

Onset ten days btfore admission Betame morose Refused to eat
or talk Thought something was goiii.; to hippen f i her so
wanted to inn awa^ Inngiiied that she heard people talking to
her and held fonversatiou with them iier the telephone Talked
t > herself incoherently

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234

Pntient has a masculioe appeaniuce, a low tTpe of iDtelleetuallty.
CoDBlderable liair on the face, la Bueplcloue, seclUBWe and ap-
prehensive. Has ideas of marked persecutory content, in tbat
f el Ion-servants made sport of her, tried to slander ber and said
bad thiDicB ahout her, Also has some Ideas of exalted content. In
that her associates were envious of her. These two conditions
led her to change her position from time to time. Attention is
easily diverted. Talks Inaudlblr to herself. Seems to be entirely
occupied by the content of her own thoughts which, Judging from
her facial exprexelon, appear to he of a pleasing content. Is ^o-
tlstlcal, eelf-satlsfled, and emotionally esalted. Actions and con-
duct are childlike.

Father astlimatic. One brother tubercular.

Diagnosis : Paranoia.

Female. Age 33. Married.

Ouset about two months before admission, by a feeling tbat every-
tblcg was going wrong. Could not manage her work. Stopped
eating. Had apellB of crying. Would sit about with hands Folded
'without making any attempt to do anything. Imagined that she
was In the way; so wished to wander away; tbat the devil had
her. Did not want to live, so tried to commit suicide. Facial ex-
pression Is apathetic and depressed. Has had auditory hallucina-
tions, mostly of religious content, which seem to have given origin
to self-depreciatory and self -accusatory ideas In that she has
brought and will bring suffering to her family. Imagiues that
she is not fit to live, hence her suicidal attempts. Feels tbat she
la Incurable. Also gives expression to some Ideas of a persecutory
nature.

One maternal cousin and one brother insane.

Diagnosis : Acute melancholia.

Male. Age 50. Farmer. Married.

Onset about two years before admission, by becoming very much
worried. Thought tbat something dreadful was going to happen.
Could not concentrate his thought and energy upon his business.
Could not decide what was to be done. Aiipeared to be more or
less confused. Begged his wife to give him poison. Attempted
suicide.

Patient states that this condition really began about four years ago
by feeling depressed; could not remember. Thought he would
lose everything, that his mind was becoming affected, that he
was In the way, that he could not be cured. The feeling of tear
came over him lllte a wave from the head down and from the feet
u|), coming together about the pit of the stomach. Imperative
thoughts would arise from within himself, not In response to any-
thing external. These he could scarcely control. Emotionally he
Is irritable and unstable. Knee Jerks active. Blood pressure 150,
pulse rate 90 In sitting posture after esamlnation.

Diagnosis : Hypochondriacal melancholia.

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236

Male. Age 41. Fanner, Married.

Onset about six years before adiulssian, witb a pain In the bead,
Became uervous, irritable. Wanted to be constantly on the move.
Refused to talk. Memory failed. At times became confused and
oould not keep his business straight. Claimed that he lost money.
Imagined that others poisoned his stock and cheated lilm and
threatened his UCe ; also threatened him It he did not divorce his
wife.

Patient reports that h.e has severe pain In the left eye, in the head,
dlftuse pains in the arms and legs. Paresthesia of the hands and
arms, some difficulty In walking. Some dizziness on exertion.
Occasional difficulty In urination. At times polyuria. Tieft pnpll
greatly dilated and almost Immobile. Atropby of both optic disks.
Tremor of the tongne, lips and hands. Increased when attempting
to speak or to move the liands. Knee jerks absent. Tnco-ordlna-
tion of gait. Is subject to periods of amnesia. Is emotionally de-
pressed. Manifests mental and motor retardation.

One uncle, one aunt, and one cousin insane. Mother tubercular.

Patient was rendered unconscious by lightning about one year ago.
Gives an indeBnlte history of alcoholic Intemperance. I>enles s|>e-
dflc Inaction, but his wife had three successive miscarriages, which
were not produced artificially. Blood pressure 170 in the sitting
IKBture,

Diagnosis Tabo-iwresis

Mole Agp 30 Farmer Single

Onset a|)out fl^e month', before idmiision with dPluBlons of perse
tution in regard to the family of affection in regard to a neigh
boi B daughter wrltlnj; letters to her calling to i-ee her passing
back and forth before the hMise Yctlous aimless and confused

Patient traces the persetutlons back to the age of 21 it which time
there were endeavors to ruin his health Was given chloroform
when slewing which be recognized by the smell upon awakening
being administered from the outside of the house and causing a
heavy feeling In the chest Believes that he Is being Influenced
otherwise but Is not able to specify It all being done to ruin his
health Attention and thought are self centered causing retarda
tion in response to evtemal •"timull Facial expression assumes
) perplexed appearance frequentlv Movements and actions are
rather slow He is unable to explala his Ideas and seems to l>e
occupied looking for some e\planatlon Is somewhat egotistical
ind manifest's some erotic Inclinations

Both grandmothers two aunts two nncles one sister and the pa
tlent tubercular.

Diagnosis : Paranoia.

Male. Age fiO. Farmer, Married.

Onset ten to twelve years before, by nmstantly worrying about lit-
tle things; became melancholy. Had many delusions, such as
that he was going to lose all of his property, that he was going to
come to want, that his family would come to want, that every little
expense meant the breaking up of his iiome. Cried very easily.

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Became nervous. Muolfested loss of \vl]l-|)ower, excessive rellgioue
tendencieB ami some suicidnl tendeu<-les.

Patient Is well developed nnd well-|)rehiervpd. When admitted was
in s state of dejn-ession and UyiKK-liondrlaBls, gradually develop-
InK Into liiB present condition. Attention tends to follow the train
of thought, yet Is easily stoiii>ed. Is very talkative and Inclined
to Incohereney and Irreipvnncy. dealing with details. Manifests
marked acceleration In the flow of thought. Loss of control over
the einutlonn and actions. Emotions very changeable, suddenly
changing trum one extreme to another, and becoming very mncli
eicited when taHiing. Actions and movements accelerated, cor-
responding to the acceleration in the flow of thought. Memory
apparently unimpaired. Ideas exalted In regard to his own phys-
ical and mental powers. Has reilglous and spiritual condition,
with a strong tendency for the religious Ideas to predominate.
I.lps. tongue and hands very tremulous when excited.

History of Intemperance on Ihe maternal side. One sister insane.

Diagnosis: Mania. (Probably the early phase of general paresis.)

Male. Age 47. Married-
Onset about four months before admission. Delusions in regard to
his bnslHesa capacity, possessions and health. Had loss of mem-
mory. l<)ss of control over the emotions, loss of weight and de-
fect In 8i>eech.

Patient Is well devetoiied and well nourished. Attention rather eas-
ily diverted. Obsen'atlon rather loose. In that he overlooks de-
tails. Is exalted emotionally- Has some insight Into his condi-
tion. Manifests some impairment of memory, Judgment and intel-
ligence. Facial expression flabby. Marked tremor of the lips.
tongue and facial muscles on phonatlon. Speech tremulous with
elision of letters, syllables and words ; some stammering and
reduplication. Marked tremor of the hands and feet on move-
ment. Writing tremulous, with displacement of letters. Knee
Jerks absent. Slight Rhomberg's swaj-ing. Patient was lu a rail-
road accident at the age of 24, In which the right arm was cut
off, the inferior maxilla fractui'ed and otherwise severely injured.
Also had la grippe two years ago, when he became very nervoiis.

Oiagnosis: Heneral jmresls. (Possibly tabetic.)

Male. Age '2i, Painter.

Onset about one year before admission. Imagined that every one
wanted to do him brHllly harm. Broke windows. Threatened
people. Carried a rei'iilver and knife about with him. Cfflitin-
nally nnitters to himself.

Patient began drinking at the age of 10 and using tobacco as a
remedy for pIiii]>leB in the (ace, gradually increasing the consump-
tion to excess. Imagined that jieople were talking about him, and
Judged It from their actions; that he was being drugged in the
food and drink, as he always felt drowsy after taking It ; that
the family were against him becanst- he drank ; that the city ad-
mlnlsti'atlon were jiersecutlng him because of his influence, Re-

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237

sides the delusions of persecutory and exalted Ideas In regard to
himself, there Is also evidence of balluci nations, auditory, visual
and organic In origin. Mentality and action are somewhat re-
tarded. Attentiun Is to some extent occupied by his delusions.
Facial expression is one of suspicion, expectancy, apprehension
and uncertainty. Has seizures almost typically epileptic in char-
acter, but they seem to be somewhat Intentional, as there Is blink-
ing ot the eyes and partially retained consciousness. Cutaneous
sensation Is In general heightenecl, except in the ttands and wrists,
where It seems to be decreased or abolished. There Is some ap-
parent apathy, dullness of comprehension, general Indifference,
mental and motor sluggishness.

Diagnosis: Alcoholic pseudo-paranoia.

Male. Age 20. Single. No occupation.

Onset about six. years before, but only recently became intractable,
by manifestations of violence, destructlveness, profanity and se-
cluBiveness. The condition was attributed to masturbation. There
is pronounced mental depression and inertia, requiring a consid-
erable Interval before responding to any questions, however simple.
Intellectual sphere shows a very limited degree of knowledge.
Memory marked Impairment, hut It is very difficult to detennlne
whether due to retardation In tue association of ideas or due to
disinclination to inalte the effort or to actual loss. Emotionally Is
ii[)atlietic. At times manifests a silly, meaningless laugh. Sits In
11 stooi>ed iKeltion. Is fairly well developed. Somewhat anaemic, but
moderately nourished. Actions and movements are slow and retarded,
(orie&pondmg to the mental depression and retirdatlon riieie
are choreiform twltilnngs of thi muscles of the face shoulders
arms and iiaud*" A fine tremor of the lips and tongue somewhat
more marked on the left side Twltchinga are irr^ular increased
or decreased by lolition and disappear during sleep There Is
also a marked mitral sysbrtic munnur heard most distinctly In
the nipple line and propagitcd to the left The cardiac Ihipulse
is most marked In the nipple line Heart is enlarged ^Suicide
was attempted which the patient attributed to a sudden uncontrol
able impulse Patient had typhoid fe^er five jears ago which
nas followed by the twltchlnj, movements described

Diagnosis Hebephrenic dementia

aiale Age '3 Student Single

Onset about nine months ago following a febrile attaik probablj
typhoid fever Became nervous, depiessed Intr ispective and nor
lied Lost Intereit In his studle'i and hi'J surroundings Became
hypochondriac il and irritable later he becnme self actusatoij
excitable se hisl\e and dMatlsfletl lost <ontiol of himself whicb
resulted at times In outbreaks of violence and destiuctheneis De
(eloi)ed perse<utor\ delusions nnd made suitWal threats and at
temiit** The patient recovertd in a short time and appeared in
his ttonnti state except there nas a want of insight into his con
(litlon during the heiglit of his dlittirbance riiyslcally there Is

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23b

II rlgbt convergent strabismus. He was later dlecbarged as re-
covered, but w«H returned In a sbort time in a state of maniacal
picclteuiciit.

Oue iTousin iDsaiie.

Diagnosis : DeDiueiitIn praecox.

Male. Age 35. Clgnrmtiker. Single.

Onset about two months before a<imlsRlou. Imagined that bis cloth-
ing and food were infested wltli something that would kill him, that
there wei-e men In the waten)li>es, that hia friends were trying
to kill him, tbat he was Cull of India rubl>er dope administered
by enemies. Wanderenl aimlessly about the streets. Threatened
nets of violence.

Patient Is somewhat egotistical, self-sutisfled and loquacious. Mani-
fests some acceleration In the flow of thought and some emotional
exaltation.

Has used alcohol freely for 15 to 20 years. Had syphilis at the age
of 20.

Diagnosis : Alcoholic pseud o-paranoln.

Male. Age 47. Farmer. Married.

Onset about one week before admission, with delusions of persecu-
tion. Destructlveness. Acts of violence. Excitement, both motor
and mental. Movements and actions quick, snappy, with some over-
action. Is very loquacious. Has some Insight into his condition.
Flow of thought is accelerated. Motor and mental excitemeDt Is
due to the feeling tbat he must do something. Manifests general
tremor, l^eft pupl! irregular. Active knee Jerks.

Oiie brother asthmatic. One brother rheumatic. ■ One slater died In
Infancy, of spasms. Patient reports having bad an attack similar
to the present one fourteen yeai'S ago.

Diagnosis : Recurrent mania.

Male. Age 28. Mechanic. Single.

Onset about five months before admission, by secluding himself.
I.ocklng himself in his room. Refusing to recognize, eat with or
associate in any way with his family. Is very suspicious. Im-
agines that some oue enters his room and dopes him. Only eats
as a rule what he prepares himself, rind then In the raw state,
with the explanation that he is experimenting to flud out some-
thing. Carries firearms and other weapons of defense. Explains
his secluslveuess In that he felt that his family had no Interest
in him, misapprcciated and misunderstood him. His experiment
followed as n result of reading books on physical culture. Can
not ascertain what it Is that he wisbes to discover, but he still
adheres to It. Has no Insight Into his condition. Otherwise maul- ■
fests no marked disturbances.

Diagnosis: Paranoia. (Probably dementia praecox.)

Male. Age Gl. Blacksmith. Married.

Onset not given. Imagined that his head was full of cuts. Con-
veraation was rambling. Constantly talked to himself. Thou^t
some one had stolen his home. Actions at times became violent.

Patient Is well developed and well nourished. Is very talkative.

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239

Manifests a feeling of generni well-being. Is emotionally exalted.
Mow of tbougbt is accelerated. Is very witty. Slaulfegts loss of
control over bis emotions and actions. Knee Jerks absent.

Diagnosis : Hypomanla.

Male. Age 34. Farmer. Married.

Onset about a year before admission. Would bide bliuself, tbiuk'
Ing that some one was after bim. Tliought that he was being
cheated. Constantly roaming about and in motion. At times is
depressed and thinks tbnt lie will come to want. Threatens
suicide.

The patient manifests marked confusion and uncertainty. Gives
relevant and connected answers to questions, but rarely correct
ones. Does not seem to know whether he has lost everything, in-
cluding his family or not. There is general tremor. Exaggeration
of the knee jerke. Some hesitation of speech. Tremuloueiiess of
writing with elision of letters. Memory Is noticeably Impaired
for recent experiences. Impairment of judgment and Intellectual-
ity. General physicHl and mental depression and retardation.

Diagnosis : Ucnerat paresis.

Male. Age 42. Preacher. Married.

Onset about two months before admission. Thought that be had
a deformity of the bead. Complained of great pain in the bead,
of great weakness, etc. Says that his head feels as if split oiieu.
mashed and bound t<%ether ; head turned back and out, face
drawn out of shape, cut to pieces, bead and neck squeezed like a
bag of fruit to express the juice, one side of the neck turned to
the other side, breast turned so that one side feels like a lump In
the back, difficult for bim to breathe, has choking feelings, back-
bone comes forward, body feels tike a blanket flattened out and
doubled up and folded until about two Inches thick, etc. Has
pronounced ideas of infidelity on the part of Ills wife. Has numer-
ous ideas of persecutory conteiiL Has some exalted ideas of per-
sonal ability and attainments. Craves for and solicits sympathy.
Movements and actions at times correspond to the content of
thought, so that he goes through various grotesque movements to
secure relief from the imaginary ailments.

Father's parents and three aunts died of tuberculosis. Has two
brothers intemperate. Gives a history of so-called epileptic at-
tacks since the age of seven, but never manifested any while in
the hospital.

Diagnosis : Hypochondriasis.

Male. Age 49. Gardener. Married.

Onset about two weeks before fldmission. Became depressed, de-
spondent and attempted suicide. Had delusions of impending pov-
erty and consequent suffering. Manifested both physical and
mental depression and retardation.

Patient's head Is oval-shaped. Has a doubled talipes valgus and
planus. Complains of great pain iu the head and over the heart.
Of great muscular weakness. Has attempted suicide several times.

Dlaguosls :

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240

!»8. Male. Age 36. l-aborer. Married.

Ouset about five years before, foilowiug excCBSlve drinking. About
a year later tiad another attack, which the patient attributed to
the using o( paria green while taking care of potatoes.

Present condition developed somewhat gradually. Manifests pro-
nounced loquacity. Accelerated flow of thought. Has no insight
Into his condition. Is emotionally exalted. Has some Ideas of
persecution and exalted ideas o( his own capacity and ability.
Movements and actions are accelerated, corresponding to the ac-
celerated flow oC tlionght. Speaks of iMing afraid oC the horses,
as they might run over him; of being afraid to get on the
cars, as he might fall; of putting parls green on the potatoes, as
he might get poisoned, etc. Facial expression Is one of exaltation.
Lett pupil Is smaller than the right. Pronounced nystagmus, both
vertically and horizontally, and more marked on the left side.
Weakness of the left Internal rectus. Says the letters run to-
gether when reading. Movements of the hands tremulous, ataxic
and iuco-ordlnate. Writing tremulous, with a tendency to skip
letters. Knee jerks extremely exaggerated. Marked Ithomberg's
Bwayiug. Gait spastic, with a tendency to fail forward. Stiffness
of the ankle, knee and hip Joints. Apparently some analgesia In
the left 1^.

Diagnosis: Organic dementia. (Probably syphilitic.)
99. Male. Age 34. Clerk. Single.

Onset about five weeks before admission. Became depressed, mo-
rose, suspicious. Refused to talk. Had outbreaks of anger. Had
hallucinations of smell.

Patient is non-attentive to Iilmself, Non-observant. Sits motion-
less in the chair. Gazes vacantly on the floor before him. Does
not respond to questions. Does not manifest that he hears ex-
cept when told to do something, when he does what is requested.
if it suits him, and only the simpler acts after a prolonged inter-
val. Facial expression, when quiet, is vacant and apathetic, but
assumes one of auger when requested to do anything. Resents
active interference, but permits passive movements fairly well.
There is slight tremor of the tongue and of the hands. Exag-
gerated knee jerks. Some tendency to catatonia.

Paternal grandmother and one maternal aunt insane. Paternal
grandfather, father and patient intemperate. Patient has a chronic
otitis media on the left side.

Diagnosis: Alcoholic paranoia.
100. Male. Age 25. Parmer. Single.

Onset about two months before admission. Became depressed. Im-
agined that he was going to die. Wanted to lie in bed. Wanted
a guu to protect himself. Feels water falling upon him. Threat-
ens suicide.

Patient's attitude and actions correspond to the content of his ex-
|)ressed ideas, ilanifests retardation In his thinking and acting.
Depression in the emotional sphere. Has hypochondriacal Ideas

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241

In regiirtl to his bealth. Has do lusigbt luto tils coudltioii. Move-
meuts are maciilne-llke and antomatie. Void of Initiative.

Diagnosis: Hjpocljondriacal melancholln.

Male. Age iH. Business man. Married.

Onset about six months ago. Imagined tliat detectives wei'e after
falm, tliat ttie bank owed him a large amount of money. Talked
Incoherently. Tore his clothing. Attention U easily diverted. Im-
mediately forgets the subject of conversation. Is very changeable
and unstable emotionally. Very demonstrative, llanifests In-
creased mental and motor activity. Impairment of ideation, judg-
ment and nieniory. Has esalted ideas In regard to his wealth,
ability and attainments. Pliyslcally there Is tremor of the tongue
and tips. Speech is drawling, stammering, tremulous with incom-
pleteness of words and. sentences. Pupils are nonreactive to light.
Hands treuniious. Writing trGmuioua, witli elision of and redupli-
cation of letters and omission of words. Tendon phenomena are
exaggerated, left more so than the right. Slight Rhomberg's sway-
ing. General luco-ordlnatlon and uncertainty in movement.

Diagnosis : General paresis.

Male. Age 2G. Single.

Onset when about 15 years of age. Imagined himself an officer of
the law, as being wealthy, people owing him money. Wandered
about laughing and talking to himself. Masturbated,

Patient is egotistical. EnLotionally exalted. Shows limited intellect-
ual development. Conduct and actions of a child. Head dolio-
cepiiallc in shape. Kony framework of the body is small. Palatine
areh high and narrow. Asymmetry of the thorax. Bulging of
the pericardium. Retraction of the right side. A marked systolic
tricuspid murnmr propagated up and to the left. Cardiac dullness
Increased iioth to the right and left.

Diagnosis ; Imbecilic paranoia.

Male. Age 50. Married.

Onset about one month Iwfore admission. Became very talltatiye.
Imagined that he was the wisest man living, that all things were
in his power, etc. Attention Is easily diverted. Patient is very
talkative, move or less disconnected and irrelevant. Is disoriented
as to time and surroundings. Is changeable and unstable, emo-
tional, exaIta':ion predominating. Assumes very friendly atten-
tions. Mistakes persons of his surroundings as old friends. Flow
of thought is accelerated, leading to Incoherency. Says that he is
the strongest man living, that he can talk with God, that he has
enormous wealth, houses and barns built of and lulled with gold,
etc. Facial expression is animated. Cutaneous vessels congested.
Slight tremor of the hands. Tremnlousness of the writing. Gets
up and down stiffly, putting his hand to his back, and when asked
what was the matter, says that ia where lightning struck him yes-
terday. Manifests marked motor activity. Patient was the In-
mate of an Insane hospital from December to the following March
ten years ago.

Diagnosis : General paresis. Recurrent mania.

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Mule. Age 40. SAnmiiker. Married.

Ouset nbuut a jX'ar befur^ adiuiHHion. Z.ylag about. Refusing to
KUfk or to tall;. Liiughiiig to himBelf. KreakiDg the furniture.
Irritable, Net;lecled himself and his fumliy. ICoamed about at
uight. Atteutiuu is poorly sustained. le rt-holly nouobserTant and
ludlfferetit. Apathetic. Speaks when spoken to; otberwise not.
Answers promptly, but briefly, the simplest questions, as a rule
reluclutitly. Questions requiring any concentration of attention
are answered by sucb sentences as "l couldn't say." Patient is
completely disoricuted, more or less In a oouditloo of stupor meu-
tfllly nnd uiotorlally. Temporal arteries are tortuous. There Is
general tremor. Knee Jerks exaggeruted. Blood pressure In the
sitting posture 125.

Dill gnosis :

Male. Age 33. Teamster. Single.

Ouset about oue year before by talking flightiiy, rambling and In-
coherently. Imagined that his mind was leaving blin. Wanted to
break mirrors wiienover he saw one. Later had outbreaks of vio-
lence, attacking these about blm. Threatened suicide. Destroyed
articles about him. Imagined tbat he bad been In Jail seven years,
that he had nothing to eat for seven montbfi, nothing to drink for
sevei-al years. Visual halludiiatlous were prominent. Later there
develi4>cd complete disorteututiou and iirofound confusion in
tbougbt and action. Indltfereuce to hlmsplf and hia surroundings.
Talked In low, mumbling, indistinct tone, uot completely pro-
nouncing the words. Apathetic and somewhat stuporous. Occu-
slonnlly a meaningless grin passed over his face. Only answers
correctly the simplest questions. To other questions he always
says "I don't know." Consciousness somewhat clouded. Percei)-
tion, conception and flow of thought retarded.

Physically shows only moderate nourishment. (Jreat muscular pros-
tration. Sits In n iitouiied position, with mouth gaping, and the
saliva drihhliiig from the mouth. Hands tremulous. Writing
tremulous, the words being siielled incorrectly and incompletely.
Reflexes iioruial or decreased. Movements and actions slow and
retarded.

Father died of malignant disease. One brother died at the age of
17, attributed to dfnirette smoklna:. Patient used :ilcohol and to-
bacco to excess for twelve years.

Diagnosis: Stuporous ins-tnity.

Male. Age 67. Farmer. Married.

Onset two months before admission, by nervousness, sleeplessness.
Imagined that he was very stck. Complained of pain in the head,
that water was continually rnnnlng from his mouth. Became
emotionally unstable. At times garrulous. At times irritable and
subject to outbreaks of violence. Imagined that he was rich and
wanted to make large purchases. Thought people were against
htm and wanted to kill him. Later he developed pronounced Ideas
of persecution, of threats to kill him, of infidelity of his wife.
Talkativeness. Querulousness. Irritability. Meddlesomeness.

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Emotionally subject to Impulsive outbreaks. General tremulous-
ness. Slight in co-ordination of movement. Slight tendency to
Ithomberg's swaying.

Mother and sister died of tuberculosis. One brotber intemperate.
One brother committed suicide. Patient shows extensive arterio-
sclerosis, witU a blood pressure ot 200 in the sitting posture.

Diagnosis: Senile pnranoia (arterio-sclerotlc).

Male. Age 40. Laborer. Single.

Onset six j-ears before by attempting suicide. Often stops suddenly
and remains standing for a long time as if in a deep study. Re-
fused to work. Became Indifferent to himself and his surround-
ings. Irritable. Would breikk up and eat glass. Imagined that
he was sick. Had hallucinations of sight. Would talk to ttie
stove, calling It "Spirits of iron," and thought that It had some in-
fluence over him, etc. Is dull, stupid. Responds slowly as a rule,
but at times reacts promptly and smiles at a joke. Attention Is
secured wltli dltllculty. Has a false idea regarding himself and
his surroundings. Memory appears to be very much impaired.
Iklanlfests a change of peraonallty. More or less dementia. Phys-
ically the knee jerks are exaggerated. Apparent tenderness over
areas which are supposed to be the points of entrance of the spirits

Ohe aunt and one cousin tubercular.

Diagnosis

Male Age IS Single

Onset one neek before admission ^aid to ha^e followed eight days
before but the patient Is under treatment for syphilis and has
been indulging in \eneieal excesses for mouths Since admission
he is dull and stuporous Does not mo^e of his own accord The
saliva dribbles from his mouth Irine and faetes are passed In-
\oluntari1j In his clothing Mantfests no emotional expression,
Ansners onl} simple questions and then very sloitly and after
vigorous shaking and after a long Interval General seusorio-
niotoi and mental depression and retardation Respirations are
slow and sballon Pulse la slow and weak Skin i? f>ld clammy
and waxyllke Muscles soft and fla^b^ Palatine arch narrow
and high.

Diagnosis : Hebeplireutc dementia. Stuijorous insanity.

Female. Age Tifi. Widow.

Onset four years before, with delusions of having been bewitched,
of being persecuted. Worrying over Anancial affairs. Api)eared
confused to some extent Memorv noticeably impaired Emo-
tions leiy unstable usuallv depressLd Lnnble to recognize people
at times Repeats questions and answers and remembers nothing
about It Immediately iftemaid Snis that she feels unible to
mote vet her muscular power as ascertained by the strength of
the arms and legs is fairly good hut movements are somewhat
uncertain aud Inco-ordiuate Complains of pain dizziness and a
feeling of pressnii In tlie head is if it were going to burst Facial
expression rather relaxed and ajiathetlc even when whining it Is

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void of Diany of the wrinkles. Rliomberg'B swaying rather mttrked.
Kin;e Jerks active, the left more so than the right. Congestion of
the left optic dlec.

Fiitlier Inaane at the age of 83.

Diagnosis : Oi^anic psychoals.

Autopsy disclosed a sarecmia of the left <qitic thalamue.

(See autopsy report Ko. 99.)

Female. Age 49.

Ouset two weeks before adiuisslon, following the death oC a sister.

, Talked Int-essiintly and Incoherently. Had delusions of being In
heaven, of iKwsessiiig mines In South Africa. General psycho-
motor activity, typical oi acute mania. An ovariotomy was per-
formed prior to admission, but did not seem to have any effect
upon the mental condition. After admission the maniacal manifes-
tations in a couple of weeks gave place to those of depression and
stupor, which lasted several months. As the stupor passed off,
the physical manifestation of general paresis made their appear-
ance. Spastic gait. Exaggerated reflexes. Argyle- Robertson pu-
pils. General tremor. Ankleclonus. Later tremor and hesitancy
in siieech, most marked when excited. Writing tremulous, wavy,
skipping and reduplication of tetters and syllables. Memory im-
paired for recent events. Intellectual weakness became prominent.
Acquired a feelln;; of general well-being. Gradual decrease of
muscular strength. Emotionally very nnstahle, generally exalted.
Facial expression void of expression and somewhat relaxed. Later
gained some In weight. Still later convulsions developed, followed
by stupor, depi-esslon and whining eiuotlunalism. Physical mani-
festations became more marked. Course became rapidly pro-
gressive. General flabbiness. Altei-nating periods of depression
and excitation. Numerous transient iiaralytlc attacks. General

Blood examination : Haemoglobin, 8-5 per cent. Red blood cells,
4,500,000, White blood cells, 10,000. Polyuuclears, 50 per cent.
Lymphocytes, 20 per c«nt. Eosinopliiles, 3 per cent. Degenerate
leucocytes, 3 per cent

Diagnosis : General paresis.

<See autopsy reiKirt No. 110.)

Male. Age 53. Can'^uter. Married.

On admission imagined that lie was a traveling aaleaman for a large
wholesale house in a large city on a large salary, that a small
piece of glass was a valuable diamond : that he owned fast horses
having racing records and valued at from $10,000 to $25,000 apiece;
that he owned govcrniuetit bonds, and that he possessed an excel-
lent voice, etc. Siieut the most of his time singing and playing
cards. Was restless. Manifested an unsteady gait. General
tremor. Some speech defect. Later he improved considerably, and
at one time there appeared very Itttle disturbance in tbe mental
sphere, except that he manifested a feeling of general satisfaction
and well-beiiig. Some hesitatlou and uncei-talnty in manner.
Speech was slow and tremulous and slightly thick. Had Argyle-

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Kobertson pupils, with the right somewltat larger than the left.
Some slight general tremor. This condition lasted some months,
when he began to manifest more or less Irritability, had periods
of maniacal escitement, followed by more or less depression. Con-
vulsions developed, after which there was a rapid decline In all
of the mental and physical functions, leading to complete dementia
and physical marasmus.

Diagnosis : General paresis.

<See autopsy report No. 177.)

Male. Age 3!). Barber.

Admitted with niarited mental depression and was regarded as an
acute melancholia. Discharged as recovered in eight months. Re-
admitted the following month with delusions that he had suddenly
become wealthy, was worth mililoas of dollars, had large raining
interests out west and was preparing to visit the locality -to look
after them. Had a feeling of general well-being and happiness.
After a (ew months the delusions began to disappear, locomotion
began to be dliUcult, dementia began to be noticeable.

Physically there was facial asymmetry. Spinal deformity said to
have been due to spinal disease when a child. Fupiis unequal,
the left larger than the right, Argyle-Eobertson reaction. Move-
ments ataxic and unsteady. Lips and tongue tremulous. Speech
slow, thidi and tremulous. Tremor of the hands. Writing tremu-
lous, with elision of letters and some reduplication. Deeji reflexes
absent. Uhomberg's swaying prominent. <>alt ataxic. Later to-
tal blindness develo|)ed. Physical miniifes tut ions of tabes and gen-
eral paresis became more marked.

Diagnosis ; Tabo-paresis.

Female. Age 3fi. Married.

Onset throe weeks before admission, with meluntholia, restlessness,
sleeplessness, occasional outbreaks of maniacal excitement.
Thoaght her liead had l>een Injured by a blow. Was regarded us
a ease of acute coufusional insanity. Was dischai'ged in nine
mouths as recovered, but readmitted thi'ee months after in a con-
dition of complete mutism and stupor. Tills gave way to a cmi-
dition of general d^ressiou physlcailv and mentally. Emotional
instability usually depressed. Limitation of memory and intellect.
General pallor. Tremor of the lips, tongue and bauds. Inco-
ordination in speech and gait. Skipping of letters in writing.
Deep reflexes active. Superficial reflexes alrollshed. Pupils con-
tracted and unequal, tlie right lai^r than the left. Tremulousness
Inci'eased by volltioual movements. Partial dlsoreiitation and ap-
Itarently some Insigiit into her condition.

Diagnosis : General paresis.

Male. Age 53. Professor.

Onset with delusions of wealth, of ability to make money and to talk
to nnseeu spirits. Supposed canwc given as overwork. Mani-
fested some chant;eabillty in attention. Talkativeness. Incor-
rectness in many of iiis answers to cinestlons, the answer being
modified by the content of his ^ehislons. Emotional instability

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and exultation. Acceleration In the flow of tbougbt and In Idea-
tion. Exalted Ideas as to personal strength, abillt; and well-being.
Yet these were never beyond the realm of possiblllt;. HalluclnH-
tlons of sight and bearing in thut he saw and carried on a conver-
sation with the spirits of relatives, friends and even strainers,
the content of the subject tallied alwut was changeable.

Piiyslcally he had inrt;* winglilte ears, the right lamer than the left,
with proniiueiit Darwinian tHberciea. Pnpiilary reaction to llglit
alugglBb.
Diagnosis: Chronic mania.

Female. Age .tT. Mnrrled.

Well nourished. Attention somewNut divcrtlble. Komewbat dis-
oriented. Moderately observiint of bcr surroundings. Emotion-
ally unstable, usually exalted, fieuerni sense of well-being and
contenleduess. Noticeable dementia-
Facial expressiou when quiet vacant and rather apathetic. Tremor
of the tongue, lips and hands. Sjieech treniHlous, hesitating, and

- apparent Inability to And words to express lierself nuiess shown
the objects, when she Immediately recalls the word for the object.
Sense of pressure Imitalred. Sense of pain delayed. Pupils non-
reactive to light, unequal, the right dilated. Tendon reflexes ex-
aggerated. SuperDcial reflexes normal or abolished. Movements
treniuious, hesitating and ataxic. Marhed tremulousness of the
writing, with elision of letters.

Filter there developed paralysis of the external rectus, the inferior
rectus and the Inferior oblique on the left eye, and a marked ex-
aggcriition of the physical symptoms.

Diagnosis: t.!eueral iwiresls.

Male. Age IS.

Onset two and one-half years before admission. Mind wandering
n b tt! d wars. Cnntlnuaiiy wandering from one subject to

tb H outbreaks of anger. Strikes the family.

I ntl t aits 1 stooped position. Does not recognize anyone. Has
tb ale f motional basis lasting from a few minutes to half
n b esembling a maniacal furore, throwing the hands and

feet alwut hiding them about tiie chair, table or even a person
if thej are standing about, breaking the furniture If jxisslble, blinks
his eyes, grinds his teeth, resists all forms of movements active
or passive. Will not do anything requested of him. Cries, "Oh,
my God!" etc. Weeps apparently as If induced by a feeling of
fear. Actions and manners appear to be those of profound demen-
tlii. An oculist diagnosed brain-tumor.

Diagnosis :

Female. Age 38. Married.

Onset witii depression, seel u si vei less, melancholia, delusions that she
was pregnant, that she was hypnotized. Frequently practiced self-
abuse. At the time of admission she was extremely weak physic-
ally. Was irritable, excitable to anger e.aslly, sometimes followed
hy outbreaks of violence witliont evident cause. Believed that she
was pnriKiseiy annoyed. I>atei' she became quiet, cheerful and con.-

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tented. Anxloiia to get better. Attentive to herself, but emotlou-
ally uuBtftble ttDd escitable. Is rather tremulous, poorly nourlsheJ
mid ot a uervoua tempera raeut.

UiagDosiB : Melnuebolia upon a neurotic basis.

Female. Age 27. Married. One miscarriage.

On admission was dull and stupid. Mouth dry. Pupils contracted.
Had delusions that someone was tryli^ to do her bodily barm,
that she was on Are, that her husband was dead. Attempted to
jump out of the window because she beard Tolcea. After three
days the patient cleared up mentally aud appeared quite rational,
but was weak and exhausted physically. Complained of headache,
of throbbiug of the vertex and areas of spinal tenderness. Was
exceedingly irritable and nervous. Had some gastric disturbance.
Complained of pbotophobia, palpitation and praecordial distress.
Manifested some tremor of the upper extremities.

One paternal aunt Insane. Patient was delicate and nervous as a
child. At 19 became very Irritable, easily fatigued and troubled
with Insomnia. Was sent to the hospital shortly before admission
and was given morphia white there and appeared to be under its
Influence when admitted to the institution.

Diagnosis: Neurasthenic insanity?

Female. Age 47. Married.

Onset seven months before admission. On admission was non-atten-
tive and non-observant. Was completely disorientated. Manifested
emotional exaltation and Instability. General Intellectual Impair-
ment. Mental, motor and sensory retardation. General ^ense of
well-being. Facial expression is vacant and iipatbetic. General
emaciation. Pupils react sluggishly to ilght, are unequal. Paraly-
sis of the left external rectus of the eye. Some blindness. Speech
ataxic. Tendon and superflclal reflexes increased. Paralysis of
the sphincters, leading to involuntary evacuations. Ataxia of all
voluntary movements. A mitral systolic murmur. Several copper
colored seal's on the anterior and external surfaces of both legs.

Diagnosis: Brain syphilis.

Female. Age 84.

Was admitted as un acute mania. In August, 1877. Discharged as
recovered. Readmitted in 1884 as a chronic mania. Believes that
she is wrongly detained by what she calls the "Iron King" or
"Lal)oring people," mostly Democrats, who want to get her money.
Imagines that everyone is against her. Calls the attendants "Red
car attendants." Complains of various ills and much suffering.
Imagines that fellow-patients are common iieople, and does not
care to associate with them because of her envious and social
position. Thinks that she Is of Higli God," aud tliat it is wrong
for her to obey anyone else. All external objects have some bear-
ing of ill omen. Can not look into a paper without attaching some
significant references to herself. Associates the noise of the en-
gines with tlie red king. Manifests mental and emotional exalta-
tion. An arrogant demeanor, assuming anthoritativeness. Has no
Insight into her condition. Is fairly orientated. Has persecutory

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delnsloue, uuniotlved, peraisteut and well syatematlied. Has uu-
llmlted etiOtiBiii nn<i Ideas of gmudeur. Well lunrked halluclna-
llona of heorinj;. Drossps Ki'otesqiiely. Curries clipi>ings from tlie
papers In her ixx-ket and plays with tliem in a childish iiiaaner.
Thinhs that she is worth mllltons. Pupils are unequal, the left
being Hmall

Diagnosis: Chronic paranoia.

Male. Age 25, Painter.

Onset several months before udiulsslou. Queer actions. At times
violent, talking Incoherently. Had spells of maniacal fury against
bis father and asked hla mother and sisters to hold him. Imagined
that he was a great aitor. Was greatly emaciated. After a year
was dtschargei;! as recovered, but was readmitted after two years
with symptoms similar to the former attack, attributed to a love
affair. Imagined that lie was a great singer and playwright, that
he had splendid offers from theatrical companies, that he was
hypnotized, so could not remain at home, asd constantly wanted
to travel, demanding from his parents for this purpose money,
thinking that his parents were wealthy, that neighbors have hypno-
tized his mother and make her cough, that s|)lrlts converse with
him, etc. Manifests divertibility of attention. Talkativeness,
tending to Incohcrency and Irrelevancy. DllHculty in concentrat-
ing his thought and association of Ideas. Some Ideas of a perse-
cutory content, I^ter developed typical general paresis.

One maternal cousin Insane.

Diagnosis : General paresis.

Male. Age CI. Farmer. Married.

Onset four weeks before admission, following the attendance upon
spiritualistic meetings Imagined that be heard, talked with and
saw spiilts through doves etc

Patient is well deieloi)ed and «ell nourished Facial expression is
lacant and iokl Skin oily and flabby Movements aie uncer-
tain and tonfiised Wanders aimlessl3 and lestlessly about the
ward. Speech Is thick and tending to Indistinctness. Is appar-
ently unappreciative of bis surroundings. Does not appear to take
auy attention of his fellow-patient?. General loss of tone. States
that his hearing and sight Is poor, that his wife poisoned blm.
smoked him so as to make him go to sleep, that she Is untrue to
blm, that he has used considerable alcohol, that he can not think
and remember like formerly. Physical appearance la that of one
much older than he really is, and there Is marked dementia.

One cousin Insane.

Diagnosis : Itegarded as a senile dementia.

Female, Age 38,

Onset nine weeks before admission, by cursing and swearing upon
the slightest provocation. Believed herself to be a member of a
detective association, that she had at different times kept the town
from being dynamited, that she Is related to millionaires and to
people of influence, that she Is to marry a business man long since
dead. Becomes violent. Displays flrearms, Threeteni to destroy
the town, ate.

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249

Patient IB well developed and well nourished. Is rather talkative.
Emotlonatly excited and easily angered. Complains a great deal
of everything and everybody. Vows vengeance. Says that neigh-
bors bothered the family, tried to take her Curniture, leading her
to bum some of It and to sell other portions of it in order to pre-
vent them from getting It ; that they put poison In the well, as she
could see the green material that was put in. Attributes It to
jealousy. Imagines that she is a good singer; can command any
snlary asked ; that she has been a member of a detective associa-
tion (or over eleven years, the members of which are all foreign-
ers, men of power, Influence and Intelligence, Americans not bpiug
admitted, who rap on the window when she is required. Does
not aesoclnte with common people. LatQr her thoughts became
self -centered, and she was depressed and hj-pochondrlacal, losing
her former hallucinations. Physically she has an aortic systolic
murmur, with dilatation of the Inomlnate and the right carotid
artery.

Father Insane. Mother died of mammary carcinoma.

Diagnosis; Paranoia (hallucinatory) ,

Female. Age 61. Married. Colored.

Onset two months before admission. Melancholy. Intemperate.
Delusional. Wanders about the streets. After there was marked
confusion. She was unable to flud her room, llemory wiis
markedly impaired. Partial disorlentiatlon. Neither exaltation nor
depression. Limitation of the association of Ideas. Some Ideas of
persecutory content in reference to her family. Apparently marked
dementia. Physically there was some malformation of the ears,
some impairment of vision, decrease of tendon reflexes. Arcus
scDllls. Considerable nrterio-scierosis. Some oedema of the lower

Diagnosis Senile dementia (alcoholic dementia)

t em tie Age 35 Single Teacher

Onset tiio yeirs before admission with delusions of religious con
tent to some e\tent al«o of persecutoiy content \t the time of
examination she refused to walk closed her eyes flrtnly the lids
tonstantly blinking Befu'icd to open them when requested to do
MO and resisted any attempt to do so attlvcly Closed her mouth
flrmlj Threw her head bafk Would not lespond to any eutreati
or command Would not respond to an^ externa! stimuli exceft
pricking tht tip of the nose with a needle Ittsists pasaiie oi
active movemdits When told that she can not do certain mr\e
uients such as opening the eves mouth etc she does so lolun
tarllv after some interval and keeps them open long enough to
satisfy herself that she can do so As a rule maintains absolute
mutism with a facial expression of lesentfulness Will octasioii
ally talk to her friends or to herself Passes most (.f her time
sitting by herself or pushing the rubter abont the floor

One paternal relative Insane.

Piaguosls : Catatonic form of dementia praecos,

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250

Male. Age 40. Farmer.

Ooset tea years before b; a chau)^ in dtspoaltion. Two fears ago

he became talkative. Imuglned that he was uraking lai^ amoimts
of money. Made questionable tranBactloDS. Contracted nnaeces-
eaty debts. Worried over flnnnclal matters. Threatened suicide.
IB supposed to have burned his barns and to have secreted him-
self In a staed bear by wblle they were burning. Has maniacal
outbreaks, with a religions frenzy, iyecomlng confused and mani-
festing an apparent loss of memory. Realizes at times that be
has some mental dlstiirbnnce and attributes It to the feeling that
he can not control his mind. Says that be baa spells In which lie
becomes iinconstlous. Shows marked Impairment of memory and
intellect.

AfaterunI grandfather epllejitle. One aunt, two sisters and one
brother Insane.

Diagnosis: Recurrent mania. Epileptic insanity.

Male. Age 46.

Is subject to epileptic convulsions, which be attributed to being bit-
ten by a horse which had Iwen bitten by a dog and the dog by a
bog. Has delusions and illusions.

Is well developed and well nourished. Manifests marked psycho-
motor activity, eKaltatlon, loquacity, dlvertiblitty of attention, in-
coherence. Irrelevancy, accelerated flow of thought and Incoherency
In the association of ideas. Says that he was poisoned because
he would not vote republican, that he has had epileptic attacks
since three years of age, when he was bitten aa stated. Con-
vulsive attacks are typically epileptic and are almost always fol-
lowed by a period of acute maniacal excitement.

Diagnosis'. Epileptic Insanity.

Female. Age 23. Single.

Onset tour months before as an acute melancholia. Previous to that
she was Inclined to wander, being absent from home tor over six
years. Had delusions. Outbreaks of violence. Threatened sui-
cide and those about her. Since admission is reticent. Inclined
to seclnsiveness. Takes apparently no interest in her surround-
ings. Thinks herself superior to her fellow-patients, so does not
associate with them. Resents control and restraint by others. Is
Indolent. Lies on the couch most of the time. Makes but few
voluntary efforts. Actions and movements suggest importance and
bravado. Does up ber hair fantastically.

Is well develo])ed and well nourished. Generally has a vindictive
grin on her face. Answers questions relative to herself either
not at all or with "I don't know." Says that her parents abused
ber, that she can not claim them as her parents, that she does not
Intend to speak to them, that she has no father, wants to get them
away from home because she is as good as adopted by them, was
put out to work becanse they thought tbey could do away with
her, never had any frienils, does not want any, might as well com-
mit suicide as he butchered alive.

One brother Insane.

Diagnosis : Paranoid forin of denientia praecox.

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251

E'eiuale. Ago 30. Married.

Ouset eight \rwks beFor6 ndiuieslon, by Inteose uervousness. Loets
of interest Id lioine and surroondinga. Neglect of bouBehold dii'
ties. Several violent outbreaks, attempting to kill her husband
aud children. Imagined that she was being poisoned, so refused
food. Attaeli seemed to follow an attack of rheumatism. On ad-
mission she was greatly emaciated. Dull. Apathetic. Wandered
nbout continuously. Attention was easily direrted. Emotionally
usually depressed, but at times smiles and makes n witty remark.
Manifests complete disorientation. Answers questions as a rule
promptly. Manifests a feeling of apprehension and apparent dan-
ger. Memory apparently Impaired for both recent and remote
events. Movements and actions are somewhat negatived and
stereotyped. Beslsts all attempts at handling. Will, stand at the
door for hours, apparently due to hallucinations of hearing, in that
she hears voices of people to take her home. Becomes easily fa-
tigued Ijoth mentally and physically.

One cousin insane.

Diagnosis : Acute confuslonal Insanity.

Female. Age 41. Married.

Onset one month before admission, by becoming melancholy. Wan-
dered from home. Believed that she was going to build a town
for the abode of spirits. Had strong religious excitement.

Patient has had several periods of excitement, lasting from a few
days to weeks, characterized by physical and mental unrest, with
hallucinations of sight and hearing, delusions of a persecutory and
expansive nature tending to systeniutlzatlon. Excessive ^otism.
No insight into her condition or that of her fellow-patients. Slight-
ly increased ideation. Proud mental attitiide with histrionic ten-
dencies. Exalted emoticmal attitude tending to anger and arro-
gance. Was furloughed but returned within a short time, after
which she complained that she had been unjustly dealt with and
that a great disgrace had been brought upon herxelf and her fam-
ily. Said that she was able to hear and communicate with spirits,
at .times could see them; thought that a neighbor, au illiterate,
ignorant man, was hypnotized by her husband and induced to in-
stitute false proceedings against her, that she was not given a
fair trial, was not allowed to t>e present at the trial, was not given ,
a medical examination ; that her husband had sinister motives
when he flrst came to see her before they were married, fourteen
years ago. In that It was from aelQshness in himself and to take
her property rights. Is guarded and reticent. Actions and man-
ners coirespondiug to the content of her thought

One cousin insane. One brother partially paralyzed at the age of
57. One brother had nervous spells and took up Christian Science.

Diagnosis : Chronic paranoia.

Female. Age 37. Single.

Admitted with a psychosis of melancholia. Imagined that people
were trying to ruin her character. Inclined to wander away. Ite-
fused medicine. At times became violent and threatened thorn;
about her.

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Tatlent takes short, brisk sl^iis witli liciul thrown biK-k. HpH pressed
flrmty together. l(H>kiuK ctraicht fonviiril. sits upright In the chair,
legs tid(lu<-te<1 and Hiiiilj- presBert loKi'ther, face coiigested, pupils
dilated, seldom blinking, absolirtfly mute. Will obey some orders,
others not. Those earrled out are done promptly and Impulsively.
Sometimes carries out movements exactly contrary to those re-
(Iiieated. At first permits imsslve movements but later actively
resists them. Apparently payn no attention to ordlnnry stimuli,
but if inereased becomes violent In action. Sits In one position
for hours, becoming violent If disturbed. Rats and sleei* well,
but does nothing else voluntarily. Tendon reflexes inereased.

Diagnosis: Catatonic dementia praecox.

Female. Age 28.

Onset eighteen months before. Imagined that friends were her ene-
mies, that lipv bPothiT was ftlvlnK Iier medicine to deprive her of
her reason, etc.

Patient is moderately nourished. I'sually sits in the chair In a more
or less fixed position, assuming a fixed attitude, only moving when
ordered to do so, and then In a very hesitating and uncertain
manner. Eyes are iiartlnlly closed, continually bllnklns;. not look'
hig at anything but apparently into space. Head undergoes regu-
lar rhythmical simsinodic movements side to side and slightly
downwards about 1 to 2 cm. in extent. Arms are held before her
In a more or less flexed position from the shoulder down, with
the hands rather finnly clenched. Mouth puckered and protruding.
Nose drawn. Tendon refiexes very active. Manifests absolute
mutism and negativism. Responds to uo external stimuli except
commands to carry out certain movements and acts. Strongly
resists attempts to carry out passive movements, and after move-
ments are made slowly resumes the original position.

Diagnosis: Catatonic dementia praecox.

Male. Age 24.

Onset about one year before admission, with outbreaks of and acts
of violence following epileptic attacks. Epileptic attacks began
at the age of IS, following a railway robbery, and lasted two to
three days, and ha\e recurred at varying intervals-ever since
After admission they became lighter, recurred every two to three
weeks, their onset usually being Indicated a few minutes before
the outbreak by a peculiar feeling In the back of the left hand like
a soft brush, sometimes extending up to the elbow but never above
TIas had spells In which he says that he knew everything that was
going on but was unable to do or say anything. Facial expression
Is somewhat vacant and staring. Manifests deflfient Intellectual
Ity. At times said to have hallucinations and delusions after the
attacks. Mental disturbances are usually almost typical maniacal
outbreaks of furore and follow the convulsion.

Diagnosis : Epileptic Insanity.

Male. Age 56.

Is well developed and well nourished, but says that he feels physic-
ally weak. Muscular power seems to be about normal. Attention

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253

is I'iither easily divcrt*'rt. Flow i)f thoufil't somewhat a fee If rated,
lending to talkativeuess, Emotiouully is unstable mid cbaugeable.
usually exalted. Has extensive grandiose delusions In regard to
collie life, ability as a lawyer, as a commereial man, as a billiard
player, as to possessious, stocks, mines, diaiuouds, etc., of un-
limited extent. Also has some ideas of persecutory content and
of the relation of Iiis luotlier-lu-law to his wife. There appears
to be some limitation of meinory, more or less Impairment of judg-
ment and intellectuality.

Iteijorta one brother Intemperate. One brotiier still-born.

Diagnosis General paresis 1

I emaie 4ge So Ti icher bingle

Admitted lo a state of mamaoal esritpment said to baie followed an
epileptic onviilslon Had epileitU coniulsions siji years before
admlaslon altliougli the patient states that she has had unnatural
feelihgs since the age of 13 as If in strange places and amongst
strange peopJe filental disturbance dates batk at least six years,
and at first consisted of only a slight confusion following the
convuNlie seizures It giadually became more severe and finally
assumed a maniacal charactei The attacks nsually precede or
o(fur at the menstrual i>eriod are usually preceded by a feeling
of strant.enes'i and faintness while aftei the attacks there la al-
mtst alwajs maniacal excitement with at times hallutiuatlons of
heiring and the delusion that enemies are about There is gen-
eral retardation of mentality In all its forms during the lucid in-
ter\al Memory is impaired School Lnowledf,e is limited Facia!
evpreaeion is void Ejes prominent and staring Conduct and
actions that of mild dementia

Diagnosis bi»lleptlc insanity

t male ice 25 "liugle

Onset of epileptic attacks dates back four years prior to admission.
Are manlfestetl In three different distinct types. First, the grand mal
t.vpe, with three distinct phases. Second, the petit mal type. Tiilrd.
the psychical type, consisting of sudden maniacal outbreaks, tend-
ing to violence, until completely exhausted. The only aura ascer-
tainable Is a rushing of blood to the bead, lasting several minutes.
There is asymmetry of the facial outline. Inequality of the ears,
the right being larger and notched. Facial expresaion rather va-
cant. Left knee jerk less active than the right. Manifests re-
tardation of comprehension, conception. Bow ot thought and asso-
ciation o£ Ideas. Has no Insight into the mental condition of her
fellow-patients. Has a feeling of general well-being. Concentra-
tion of thought tenacious and tends to deal with details and
minutae. Has well marked ideas of reHglona and sexual content,
the latter being especially strong and at times overcoming her
Thinks that she Is under the control of spirits, tiarkcd dementia.

One uncle Insane

Diagnosis : Epileptic insanity.

(See autopsy report No. 100.)

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254

Male. Atie 54. Lawyer.

Ooset about six months tiefure, wltb delUBlous of wealtli, of pbfslcal
attributes, of profeselonal capabilities and of his wife's infldelit]'.

Is well developed and well nourished. Attention very divertible.
Miinifests marked mental and motor activity. Excessive loquacity,
teDdIng to Incoherence and disconnectedness. Emotional Instabil-
ity, readily changing with the content of bis thongtit. Accelera-
tion of the How of thought and In the association of ideas, tend-
ing to Incoherence and irrelevancy. Tongue Is tremulous. Speech
at times tlilck. Marked tremor of the lips and hands. Inco-
ordination in gait. Rhomberg's swnylug prominent. Left knee
Jerk Increased, the right de<:reused.

Diagnosis : (.ienernl jmresis.

Female. Age 41. Married,

is well developed and well nourished. Says tbat she Is nervous.
Was ill wltli a cold three weeks ; Iwwels are swollen and consti-
pated: bud nervous chills lasting about three hours at each time;
that her hust>and, who is only a barber. Is wealthy; that her rela-
tives are also and have willed everything to her, so tbat In time
she will be worth millions and mllllous; that she has 3,000 dollars
on deposit and Is making 15 dollars a week from one firm and 23
dollars a week from another firm copying, and could get more If
she wanted It. Facia! expression Is satisfied aud contented. Emo-
tions exalted. Is egotistical. Has no insight into her own condi-
tion or Into that of her fellow-patients. Tongue Is tremulous.
Speech is difficult. Some tremor of the hands. Writing large,
scrawling jiud sweeping. Knee jerks exaggerated. Manifests a
lack of decency In "ber conduct and manner. Has numerous hal-
lucinations.

Onset was firet shown by unreiisonable, unnecessary purchases, de-
struction of household materials, etc.. corelessness aud Inattention
to herself, her children and to her household duties. Patient had
typhoid fever at the age of '2'i and was delirious several weeks.

Diagnosis : (ieneral paresis.

Male. Age 43. Baker. MaiTled,

Was acting like a drunken man, but had been abstaining for montbs.
Became talkative. Kntertnlned strange and improbable schemes
tor making money, (iave a history of syphilis. Of unilateral
liarutysls of tlie face. Showed difference In pupils. Had delusions
of wealth. After admission the delusions of wealth became more
extensive. Said that he bad not worked for years, living upon
the interest of bis money and by the money obtained by playing
craps; tbat be bad millions, could not count It all, ending up with
owning the whole world. Attention readily divertible. Emotion-
ally unstable, usuolly exalted. Has no insight Into his own condi-
tion or Into that of his surroundings. Is completely disoriented.
Is talkative. Manifests a feeling of general well-being. Slight
tremor of tlie hands and tongue. Difficulty in speech. Tremu-
lousness In writing. Esaggeruted knee Jerks. Right ankle clonus.

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255

Slight Rhomberg's swaying- Inco-onJloatlon in gait. Gives a his-
tory of syphilis at the age of 23'.

Diagnosis : General paresis.

Female- Age 35- Married.

Admitted with a psychosis of eplle|jtlc mania, beginning about two
years before admission. Facial expression is somewhat vacant.
Manifests but little interest in her surroundings. Is apparently
well satisfied. Attention is rather divertible. Oomprehenston
dulled and sluggish. Insight as regards her own condition nega-
tive. Is disoriented as to time. Uallueluations of hearing. Mani-
fests moderate dementia- Sometimes has aura preceding the at-
tacks, either as forebodings, somewhat as a feeling of apprehen-
sion or as scotoma or scintillations*. Becomes very violent at the
time of the seizures. Tendou reflexes active. Superficial dimln-

Diagnosis: Epileptic insanity.

Female Afee 73 Married

Onset SIX months before admission becoming nervous excitable and
Irritable Conversation wandering and disconnected Tendencv
to suicide Facial expression Is one of distress Difficulty In con
centrating her thought on anything outside of herself Con
tlDuously complains that her stomach is full and can not bold
any more that food doe<i no good so refu'fes to eat General men
tal retardation and depression with tendency to agitation

Fhyslcally there is considerable emaciation General tremulousness
When standing the lower part of the abdomen protrudes the Intel
rectal space is wide the stomach and intestine >ccupy the lower
part of the abdomen the stomach <AheD distended has the center
of Its conca\e border a little to the left of the umbilicus The
right I Idney is quite movable Pttient was an inmate of tlie hos
pital at the age of 51

Diagnosis Recurrent melancholia

Female Age 29 Single

Patient Is depressied Ha"! outbreak of violence in nhlcb she threat
ens her own life and that of those about her Ponvulsions began
at the age of 13 at the onset of menstruation and have continued
ever since attacks are usually of the petit mal type otcasion
ally oC the grand mal type The latter are rare aud usually occui
at night only a fevi during the day In the course of a year Is
alvvavs awakened by thera when occurring at night The only
aura is a tlnt,llng beginning in the left hand later spreading to
the right and then over the whole body Sometimes there Is no
crnvulsion but instead an automatic movement varying in charac
ter sometimes twitching of the face or deviation of the eyes or
head After the attack there is almost always continuous per
sistent headache tor some davs The patient states that conscious
ness is retained until after the convulsive movements begin

Paternal grandfather insane. Patient is said to have fallen and
Injured her head at the age of one, which was followed by n

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256

IwralfBle of the left side. At preseot the left arm ts 2 cm. shorter
and otherwise smnller than the right, and the left hitnd and arm
are In a poeltion of fleslou.

Diagnosis: Epileptic Insanitr (urgiiaDlc basis).

Female. Age 32. Married.

Onset one year before admission, by becoming neglectful In her per-
sonal appearance and household duties. Poreetful and dull men-
tally. Inclined to leave home nlmlesHly. Six weeks before admis-
sion she became Irrational, talkative, and lost In her own home,
Incoherent and disconnected, manifested some acceleration In the
flow of thought and more or less profound dementia. Also a feel-
ing of general well-being.

Physically the pupils are dilated, the left more so than the right,
and react to light only and when very Intense. Tremor of the lips
and tongue. Speech hesitating, slurring, almost scanning and
singsong. Facial expression flaccid. Tremor of the hands. Writ-
ing tremulous, with elision and repetition of letters, nalt ataslc.
Sense of pressure and of pain delayed and diminished. Palatine
arch high.

Mother tubercular.

Diagnosis : General paresis.

Male \.ge 55 Former Married

Onset seien weeks liefore admission Melancholy Suicidal Abus-
ive to hia famili Imagines himself to be f hrM to be infallible
etc Had an attack of la grippe eight weeks before admission and
lost a great deal of sletp about the same time taking care of other
members of the family who were ill so that he betime run down
physlcallv emaciated and nervous Excitable and very irritable
with a tendency to violence Developed some ideas of a persecu
tory nature in that his wife would not agree with him in religious
matters and that the son wanted to run the farm Attention was
lomewhat self centered Emotions somew hat depressed Ten
dencv to complamlng Mental disturbance disappeaied as the
phjslcal condition improied and tomplefe re'oierv ensued

Father died of apoplexv at the age of 7'>

Diagno&ls Exhaustion Insanity fPiranold )

Female. Age 32. Married.

Onset one week before admission, by having spells of langhing, cry-
ing, ontbreaks of violence. Tbi-eatened to kill her children. Was
vulgar and profane. Jlnnlfestert confusion of consciousness. Par-
tial disorientation. Ideation quickened and incoherent. Atttention
flxed with diflieulty and easily diverted. Psycho-motor unrest.
Emotions changeable and imstable. Hallucinations of sight and
liearlng. Loss of insight into her condition. Delnslons of perse-
cutory content. Very talkative. Incoherent, disconnected and ir-
relevant. IndiCferent to her personal appearance and to her sur-
roundings. Exceedingly emaciated. Memory impaired. Facial
expression wan. Perception of pain decrensed.

Diagnosis: Acute mania.

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257

Female. Age 49. Married,
Onset one year before admission. Melancholy. Intemperate. At
times vicious and threatening the life of those about tier. Imagined
that Rverytwdy was trying to do her harm. Had pronounced de-
lusions of persecution being committed by ber relatives only to
get her out of the way. Had no insight into her condition. At
first had hallucinations of hearing, leading her to get up at night
and creep about the house with a gun, but later lost them. Facial
expression indicates excessive use of alcohol, although the patient
denies the use of it. Is emotionally depressed, but varies some
with the content of her thought. Memory in general Is noticeably
Impaired. Conduct and manner somewhat tinged with irritability
and resent fulness.

Diagnosis : Alcoholic pseudo-paranoia.

Female. Age 23. Married. ».

Onset from childbirth, but became worse two weeks before admis-
sion. Lost Interest lii household duties. Became indifferent to
herself and her surroundings. Wandered confusedly away from
honie. Talked incessantly, Incoherently and disconnectedly. Has
periods for the experiences of wiiich there seems to be complete
amnesia. Complained of a pain In the spine that would draw her
head back and Induced a feeling that she would lose her mind.
Had spells of dazzling before the eyes. Also a feeling that she
must go somewhere. Thei'e is a slight mitral murmur and a
slight prolapse of the uterus.

Diagnosis: Acute confuslonal Insanity.

Female. Age 30. Married.

Onset three years before admission. Quarrelsome. Emotional out-
breaks, EWstructiveness. Delusions. Threats of suicide. Has
-epileptic attacks, usually of the grand mal type, less frequently of
the petit mal type, occurring both during the day and at night,
noticeably connected with menstruation. Manifests quarrelsome-
ness. Memory Impaired. A dazed condition after the convulsions.
The epileptic convulsions began at the age of 9. Aura of a gen-
eral feeling of nervousness and hyper-acuteness of hearing are at
times present. Occasionally between the attacks has swimming
feelings. Says that she can sometimes abort an attack by rubbing
the hands together. Facial expression Is one of vacancy and de-
mentia.

Mother and one maternal aunt tubercular.

Diagnosis : Epileptic Insanity.

Male. Age 41. Farmer.

Onset two years before admission. Imagined that he was a detect-
ive, that he was working with the Almighty In a murder case,
and that he could communicate with the dead. Since admission
he has shown very little, apart from his grandiose and persecutory
delusions. Claims that his brother is perseci\f;lng him, that he
was arrested because they were prejudiced against him, that the
city wanted his money, that they feared that he would get the

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268

tK^t (if tln'iii. 'I'lioiiKht tliat he ivoiiM make a (tood detective, but
iH'ver liid anything along that line. Facial exjirpssion Is vhidlctire.
Ills tone lu speaking, his general (i>nduct and demeanor corre-
8|H>iid to the content of Mx thought.

One uncle insane.

DlaKnosia : Was repirtled u» a |<aranoiai'. The day following the
I'xamluatlon there ot'curred a violent maniacal outbreak which
lasted quite a loii^,' tluie and only jiPadually snbsided.

Male. Age 32. Barber.

Onset ten days before idiiiission bj showing >;reat affection for those
iboul him Whs nnable to earrj on a sustained coimrsation
Imat'ined tiiat lie v-as noun to (omc in puHaeislou of great wealth
and tliat money was growing on everything abnut bim Since
admission liis facial ex|ire«sioii has been one of apjttiv and va
oaocy I'avs do attention to himself to bin surroundings or to
external stimuli titans in<antlj before him Attention can not
be attratted Manifests no emotion exiept that an occasional
smile appears raomeutariH Hiwn ids fice Miitters inarticulate
Honnds to himself Itreti hi i out tlie hands as if grasping some-
thing Othtrwinc moiih onh what ltd or pushed and then are
punwwiti'i and automath Kiiee Jerks exaggerated 'flight ten
dency to anUe doiins NeMr (ariles out an initiative act «r utters
an audible word exteiit when |)laced at the table when he eats
heartily, but is poorly nourished.

Diagnosis; Stupoi-ous stage of some psycliosis, which?

Female. Age 48. Widow.

Admitted in 1SS4 as an acute melanchoUc. Discliarged in 1885. Re-
admitted in I'JOi with a mental disturbance beginning one weelc
before, by melancholia, depression, loss of interest in herself, her
home and lier surrountlings. Refused to associate or tailf with
anyone. Extremely Rusplclons. Imagined that someone was going
to harm her. Had si>elis of e.vciteuent followed by inoroseness
and secUislveiioss. Kefused food. Said that she was to die and
would not live long.

I'atient is greatly emaciated and extremely nervons. Manifests
nmrbed de[)reRRion and rctai'dation mentally, ^ome clouding of
consciousness and confusion. Some Inipairment of memory. At-
tention is centeretl n|)on herself ajiiKirently and is attracted with
great dilliculty. ]''uiotioually de|>ressed, but at times t>ecomes
much agitated mentally anil motorially. ApiH'ars to observe what
is transpiring about her. Facial expi'ession is anxious, sad, de-
jected and somewhat apprelieiisivc. Refuses to answer most qnea-
tions, either saying nothing at all or "Don't aalt me." Responds
slowly to external stimuli, to iiei'ceptioii of heat and cold, etc.
Lnter develoix-d a profound 8tu]KU'.

Mother insane. Patient used »)piuiu five yeiirs. Has I'een passing
tbrougli the ('1ima<-terium tlie last few years,

Dingnosis : Involution Insnnity.

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269

Female Age 40 Manled

Oiibtt six weeks before admiBsiou

Pntleut ts considerably emaciated 1 licrt Is general biouzuig of
the &klii Nodular eiiltrgemeut of the right lobe of the thyroid
({laud Slight protrusion of the eveballs Weak rapid pulse Tem
peiatiire 01) b ]< Mnulfests almost •.omptetp disorientation At
teiition aelf-tentered attracted with diifitulty and can be held
only momentarily bmotionul attitude is depressed gloom} and
agitated Talking inieeiiintiv using audi expressions as I want
to go home What do you want with me etp Does not seem
to comprehend what is beint, sjld oi doiie I^acial evpreesion Is
one of apprehpiiaion \11 actions and nioiements are uncertain
and p.eem to be (ontrollpd bi the fetlmg of apprehension and are
more or less agitated Is very suipiclous Makes freciiient fur
tive glances alwnt the room Geiieial attitude is one of expett
anty and of Impending danger

Diat,nosis Agitated melantholli

Female A^e 71 Widow

Patient has just retorered from an attack of manmal excitement
ind manifests \eiv little disturbance apart from some phvskal
ind mental exaltation '^he liab Just passed through the Qfth
attack of a similar natuie the first attack having followed her
first tonflnemput which she alludes to as nervous prostiatlou
and as having occurred off and on ever since There is onlj par
tial Insight into her exiwrimces during the attack

One niece insdnt One child died in con\uJ«ions One cbild hai
spinal disease lea\ing it with small hands

Diagnosis Recurrent mama

Female Age 49 Mariled Was \n inmate from March to Novem
her twenty two ^eais aj,o

Onset three months before admissi >u folloning the birth jf a full
grown still born child

Patient Is hjalerlcal garrulous capricious Ilecognizes no one Is
completely disoriented Mistakes persons of her surroundings
Attention is chtngeable and easily diverted Is cintlnually talk
tng incoherentiv irrelevantly and disconnectedly Marked accel
eration in the flow of thought \ssoclatlon of ideas disconnected
ind irrelevant Hallucinations of all of tiie senses Delusions
variible transitory and varvm? in content Lmotlons are un
stable but not changing with the content of her thoughts Usually
exalted Irritable Excitable Impulsive lends to verbigera
tlon and echolalla Manifests intense motor excitement

Is poorly nourished hazard and fatigued looking

Diagnosis Aucte mania

Male Age 32 Single

Patient fell from a horse at the flj,e of lo and received an Injury
to the head Three years aftei he hid the first convulsive seizure
■it the i^e of 2S he received an injurs to Ills back which Incapaci
tated hiin fci several months after which the convulsive seizures
occurred more frequentiv At the present time he has three to

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four a day. Tbe only aura ast-ertaluitble are a teeliiig of dlKziuesu
and a ruslilut; of blood to the head.

Onset of mental distiirbaiioe began about a year before admiealon.
Tbe patient Is morally degenerate and Intemperate. Facial ex-
pression one of degeneracy and dullness aud has a low degree of
intellectuality. Patient has fixatloD of the lower three dorsal
vertebrae, some degree of lordosis and prominence of tbe' cor-
reBponding spinous processes.

One uncle and father intemperate. Cue brother and two sisters
tubercular.

Diagnosis : Epileptic Insanity.

Male. Age 32. Single.

Onset one and one-halt years before admission, by writing manu-
scripts and ofteriug them for sate. Imagined that he was paying
his father for his keep, yet he does not live at home. Is stub-
born and seclusive. Will not work. Talks continuously of bis
grand future as an author, of his special acquirements. Is very
optimistic. Has used opium.

Patient is well developed and well nourished. Facial expression is
one oC suspicion. Is very talkative. Has some Ideas of hypo-
chondriacal content. Some of persecutory content in r^ard to
himself and his writings. Some of grandiose content In regard to
the same. Looks upon himself as a Luther. An advance agent
trying to get above his environment. Wanted to stand before the
puliiic as an originator and gain their confidence. Has written
several plays most extensively in German, making use of favorite
axioms as subjects. Was importuned to accept tbe secretaryship
for tbe governor, but thought it wiis no good politically, so he
announced his candidacy for governor, especially in his writings.
He Icnew there were competitors in the field, that his manuscripts
were obstructed and confiscated, that insanity proceedings were a
political dodge, that he had entered a requisition against them,
had instituted a suit for $25,000 damages with which be would
make a successful run for governor, etc. The patient's actions
and manner are quiet, rather good-natured and do not correspond
with tbe content of his ideas of persecution, but are rather child-
ishly ^otistlcai in regard to his grandiose ideas.
'Diagnosis: Paranoid dementia praecox.

Female. Age 32. Marrieti.

Onset about one month before admission. Imagined that everyone
was against her. Had oiitbreaks of violence and destmctiveness.
Became vulgar and profane. Since admission the patient stands at
the door for hours thinking that she will get out. Is very reticent,
suspicious and seclusive. Refuses to answer guestlons. When she
talks her expressions are tinged with persecutory content. Has
no insight into her ovra condition or Into that of her fellow*
patients. Is rather vindictive and unapproachable in her manner
and conduct. Emotionally inclined to be irritable and depressed.

Diagnosis : Paranoid.

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261

Female. Age 33. Married.

Onset four months before admission as an acute mania with delu-
sions of persecution. Imagined the iife of herself and child to be
in danger. Was very easiiy excited. Improved some. Was fur-
lougbed, t)ul: had to be readmitted. At the second admission again
manifested intense motor excltemenf and deatruetiveiiess, with
mental exaltation resembliug typlcallj' acute mania. After a cou-
ple of weelts tbls was followed by a period of depression. This
later gave way to her present condition, in which she is non-atteut-
Ive and non-observant. Perception and comprehension dulled. At-
tention easily diverted. Memory greatly Impaired for both recent
and remote events, forgetting immediately what is said to her.
Consciousness seems to be clouded. Emotions unstable, tending to
be childishly exalted. Talkative, which is disconnected and inco-
liei'ent. Facial expression is vacant and tlaccid. Loss of the nat-
ural folds, more so on the right side. Tremor of the lips and
tongue. Speech defective. Drawling at the mouth. Volitional
tremor of the hands. Writing tremulous, scrawling and unintel-
ligible. I'upils unequal, the loft dilated more than the right.
Argyle-Kobertson pupil. Tendon reflexes exa^erated. Gait mark-
edly ataxic. Sensation perception noticeably Impaired,

Diagnosis : Gieneral paresis.

Female. Age 30.

Onset two to three years before by talking to herself. Imagined
that the doctors wereafter her and wanted to cut her up. Had
outbreaks of violence and destructiveness. Led the life of a pros-
titute. Was flithy, lntemi>erate, used cocaine and cigarettes. Re-
covered as the effects of the drugs wore off.

Diagnosis: Intoxication insanity upon a i)sycliopathlc constitution.

Female, Age 59. Married,

Onset six weeks before admission, with many delusions and halluci-
nations. Imagined that she was being poisoned by her family.
Threatened suicide and the lives of those about her.

Patient Is non-attentive to her person and her wants. Partially
disoriented. Irrelevant In answering questions. Mistakes persons
of her surroundings. Imagines dual personages. Has hallucina-
tions of hearing. Delusions of a persecutory content by Danville
Co. Sent to the present place by several ways, one by dissolution
of the family and the other (which could not be ascertained).
Manifests marked confusion of ideas. Speaks of ventriloquism,
mesmerism, etc. Resists and resents actively any interference or
the close approach of any one. Refused food for a long time.
Physically has a mitral systolic murmur.

Diagnosis : Hallucinatory paranoia.

Male. Age 50,

Onset one year previous to admission. Threatened suicide and the
lives of those about him. Imagined that he was choking.

Is well developed and well nourished. Manifests slight general
mental weakness. General feeling of well-being. Some oedema of

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lower limbs. Geuernl eiilargcmeut of the lympbatic glands. Oc-
casional fecllug of crniniilnK of tlio iuiihcIcb of the legH. Soiue tre-
mor In writing. Weukiiess In the leics. iH-glntilug tbree years be-
fore admission, leading to well ninrketl paresis. ' Gait Is spastic,
with stitfuess of the Joints, dragging of the feet, with scraping of
the Inner side over the metatarso-phalangeal Joints of the great
toes. Steps short and r^ular. Knees partially crossed when put
forward. Knee jorlis exaggerated, the left more so than the right.
Well marked ankle clonus, most marked on the left side. Super*
flclal reflexes, slight or absent. Welt marked Bablnski reflex.
Slight Ithomberg's swaying. Slight enlargement of the jirostate,
leading to frequency of micturition at nlRlit- History of gonor-
rhea and syphilis.

Diagnosis : I'rluiary lateral sclerosis and dementia.

Male. Age 31. tiroccry clerk.

Was a periodical drinker. Pour months ago he ceased drinking and
soon afterward l>^aH to be forgetful. Two months ago he be-
gan to bare dlzsy spells followed by an Inclination to sleep, but
was conscious of his surroundings during the 8i>ells.

la well developed and well, nourished. Face is espresslouleSB and
void of Intelligence. Is more or less drowsy. Is slightly deaf In
the left ear. Marked tremor of the lips, tongue and hands. Speech
thick and hesitating, with elision of letters and words. Gait is
uncertain, spastic and inco-ordinate. Movements In general inco-
ordinate. Knee jerks excessively exaggerated, the right more so
than the left. Ankle clonus, more marked in tbe right foot. Bab-
inskl's reaction on the right side. Rhomberg's swaying moderately
marked. Pronounced dementia. Rtaln syphilis was diagnosed.
A few days after the examination the patient became somnolent.
not moving unless disturbed, right side became paralyzed, and
there devrfoped stertorous breathing, loss of superficial reflexes,
impairment of swallowing, paralyls of the right external rectus of
the eye, and later convulsions, with death.

Diagnosis: Brain sypbllis. Tbronibo^iiB of the left middle cerebral

Female. Age 33. Married.

Onset two years before admission, by becoming neglectful of her
clothing and her personnl appearance, Jealous of her husband and
thought him untrue, Inclined to outbreaks of violence, and to
make suicidal and homicidal attempts.

Patient well educated. Attention dlvertlble. Comprehension, prompt
but correct. Some talkativeness. Some acceleration In the flow
of thought with a temleney to flight of Ideas. Association of
Ideas very active. Movements and actions correspond to the ac-
celerated flow of thought and flight of ideas. Content of thought
tends to be persecutory and makes frequent furtive glances from
side to side.

One uncle eccentric. Father intemperate. Mother and one brother
tubercular.

Diagnosis : Chronic mania.

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263

Female. Age 25. Domestie. Sli^e.

OoBet six weeks before admission, with ballncinatlons of eight and
hearing, dolusionB of a religious content, leadlDg lier to drown her
Illegitimate child of the age of two, in obdelence to so-called com-
mands from God,

Patient is well developed and well Dourlshed. Has Bome ideas of a
persecutory content dating back to childhood, but moRt prominent
after the birth of her iUegitimate child two years before. Asso-
ciated with these are also some of a self -depreciatory character
for backsliding from a religious standard which she originally
held. About sis weelcs before admission ahe became imbued wltb
religious ideas of a grandiose content and had hallucinations of
eight and hearing, in seeing angels and hearing the voice of God
telling her that as she had sinned in giving birth to an Illegitimate
child she must atone for it by killing the child. She tells of plead-
ing for the life of the child, offering her own as a substitute, but
it was unacceptable. After deciding that ehe must kill it, the
first order was to strike it In the head with an nJte, but, appear-
ing too terrible, she piead further and was told to burn it This
again appearecl too horrible, and after more pleading and praying,
she was told to drown it, which she carried out. After having
done so she felt some relief, but was not happy, as she telt that
she had to suffer some more trouble. Wbat the latter was she
would not tell, saying that no person could understand It, as it was
a secret between her and God. She manifests satisfaction at hav-
ing done it, meets every argument with the statement that the
Lord commanded and she was compelled to do It Later she de-
veloped some Ideas of a grandiose religious nature, in that the
Lord had a mission for her to perform, thnt she was to become
a saint, that the Lord required of her to tell others of their sins
which she did more or less, even about the wards, etc. She also
has had periods of psychomotor restlessness and agitation, at times
depressive in content, at others eialted. Has no insight into her
condition or into that of her fellow-patients.

Diagnosis; £>ementia praecox. (Religious paranoia.)

Male. Age 50.

Onset with melancholia, obscenity, destructiveness, and threats
against the lives of those about him, attempting to burn his child.
imagining that people were trying to poison him, complained for
some time of gastric disturbances. Bight months before admis-
sion the patient began to complain of numbness and pricking sen-
sations in the hands and extendiug to the wrists. A little later
the feet were also involved, gradually extending up to the knees.
There was also a feeling of coldness to the patient, but to otiiers
they appeared quite normal. Gradually there developed a feeling
of unsteadiness In the movements in the arms and legs. Cramps
in the mnscles of tlie thigh. Gait rather ataxic, steps regular, the
right toe frequently dragging, feet placed flatly upon the floor.
Tremor of the tongue manifested In the speecli. Knee Jerks ex-
aggerated, more so on (he right side. A well develoi>ed Babinskl

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reaction. Tremor and lD<»ordlDatlon In tbe hands, rendering the
writing practically Impossible and wboll; unintelligible. Muscular
power weak. Patient h&s a high, narrow palatine arcb. Tborax
1b long and narrow. Tbe left side more excursive ttmn the rlgbt
and alBO more resonant. Expiration prolonged on tbe rlgbt Bide,
wltb dullncEs in tbe apex, increased tactile fremitus aad fine rales
poaterlorly. (General enlargement of the lymphatic glands. Men-
tjilly is irritable; taas no insight Into bis condition and shows
mariied dementia.

One sister tubercular. Patient bad gonorrhoea at tbe age of 20.
Diagnosis ; Combined posterior and lateral sclerosis wltb dementia.

Male. Age 16.

Onset six months before admission b; singing, praying, crying,
laughing, trying to bite bimsoif aad others. Thought the bouse
was falling in, tbe horses were running away, all kinds of animals
were after bini. At times was violent and destructive, at others
dull and apathetic.

Patient Is said to have had brain fever when a child. Had an at-
tack of measles, nnd after three weeks' sickness, tbe right arm
began to Jerk, the back to bend in, to step ^igh with tbe left foot
and Inter to drag it and then to Jerk it. Also extended to the right
side. Is unable to stand. Ijegs bend forward and In. Can hobble
along with assistiiiK'e, walking on the, toes, left foot dragging
slightly. Movements are Jerky and Inco-ordinate, tbe left more
BO than the right. When sitting the left arm Is rotated Inward.
palm looking out, arm and hand fully extended. Left leg Hexed
on the thigh and tbe thigh on tbe abdomen. Is unable to straight-
en it Tolitloiially, but by overcoming a moderate amount of re-
sistance It can readily be done, but only remains so temporatliy,
as spasmodic Jerklngs cau«ie it to again resume Its former posi-
tion. Muscles of the left arm similarly affected. Ocular, lingual
and facial muscles are not involved. Sensfltion Is difficult to de-
termine because of hypersenstltiveuess and Intense nervousness.
Marked atrophy of tbe left leg. Plantar reflexes exaggerated.
Ankle clonus on the left side. Knee-jerks decreased, more so on
tbe left side. Patient is very nervous, irritable and excitable;
fairly quiet during the morning hours, but becomes restless and
complaining the latter part of the day.

One uncle alcoholic. One cousin epileptic.

Diagnosis ; Acute myelitis.

Male. Age 28. Blacksmith.

Onset about three months before admission. Incoherent in talk ana
action. Imagined that people were after him and were trying to
make him lose his job, etc.

Patient sits about, manifesting no interest in himself or in bis sur-
roundings, facial expi'ession Is vacant. Movements are listless.
Answers questions slowly and in a low tone. Speecb is thick
and slightly tremulous, flight tremor of tbe bands. Knee Jerks
exaggerated. Is secluslve. Refuses to associate with the family.

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Is subject to outbreaks of violence. Has hallucinations of hearing,
persecutory in content. Later the patient developed stereotyped
movements and attitudes, with a tendency to. absolute mutism and
negativism. Still later became profoundly demented. Patient in-
temperate and auicidal.

Mother said to have died of paresis at the age of 60.

Diagnosis : Hebephrenic dementia.

Male. Age 42. Eugineer. Married.

Onset four weeks before admission. Would uot swallow his food.
Did not thinli that he was at home. B^s to be taken home. Be-
I'omes excited and tries to escape. Is confused, emotional, liico-
hereut and Irrelevant.

I'atlent is well developed and well nourished. Is iuattentive and
non-observant. Facial expression flabby, the right more ao. Sits
In the chair apparently contented. Talces no luterest Id his sur-
roundings. Is completely disoriented. Has no insight into his
own condition or Into that of his surrouudlugs. Memory mark-
edly Impaired. Profound dementia. Tremor of the tongue and
lips. Speech thick, drawly, with elision of letters, syllables and
words. Spits frequeutly and allows the saliva to dribble out of his
mouth. Tremor of the hands. Writing tremulous, with elision of
letters. Movements in general inco-ordinate and ataxic. Legs
appear weak, so that gait is waddliug, both of which are In-
creased by exercise. Feet drag, apparently due to an inability to
lift them. Knee-jerks excessively exaggerated. Ankle clonus.
Slarked Rhomberg swaying. Marked Babinskl reaction. All more
marked on the left side. Paresis and dementia were rapidly pro-
gressive, flnally involving the organic nmsculature and proving
fatal. History of syphilis was absolutely denied, but autopsy dis-
closed two large gumma, one Involving the left frontal lobe at its
anterior Inferior part and the other the lower part of the right
Rolandic area. A smaller mass was also found in the left optic
thalamus.

Diagnosis: Organic dementia. (Brain syphilis.)

(See autopsy report No. 116.)

Female. Age 22, Single.

Onset one year tiefore admission. Melancholy, Did not recognize
her friends. Imagined herself superior to her surroundings. (3ot-
ers her head when approached. Is nervous.

Patient always was reticent. Inclined to Isolate hei-seif. Eccentric
in manner and action. Attitude and manner are those of self-
importance. Is indifferent to her surroundings. lias no insight
into her own condition or into that of her fellow-patients. Dis-
torts facts relating to herself, to her family, to her surroundlnga
and to her own manner of thinking. Says that she does not feel
rery well, but will not siie<-ify anything in particular.

Father intemperate.

Diagnosis : Hetieplirenic dementia.

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MBle. Age 19. Sli^le.

Onset oue week bcfori! ttiluiisBion. iDcoherent and dlBconneeted.
Iniagined tbat be was a horee-traioer, that people were about tats
boiue to ikDDoy btm, etc.

Patient Is well developed. Attention fe easily diverted. Re^onds
promptly to external stimuli or not at all. Answers to questions
are at times correct and relevant, at others Incoherent, Irrelevant
and disconnected. Flow of thought Is accelerated. Flight of
Ideas, with some Incohereucy. Emotional attitude is pleasurable,
often smiling to himself. Frequently makes some jocular remark
In regard to the questions or to the answers. Makes rapid glances
from one person to another. Speech Is low and mumbling. At
times manifests tremor of the lips when talking. Sometimes
shows some hesitation In response to orders or requests. Holds
l^B stiffly when examined. Writing scrawly and unintelligible.
Attempts to read consist of disconnected, incoherent sentences.
Promptly names the letters but not the words.

Was an inveterate cigarette smoker.

Diagnosis: Hebephrenic dementia.

Male. Age 19. Single.

Onset with talltatlveness. Gbangefulness of facial expression. Re-
fusal to eat or take medicine. Physically active. Suicidal ten-
dencies eleveu weeks before admission. Complained of pain In tbe
head. Imagined that he could preach, that he could practice law,
auctioneer, etc. Emotionally is cheerful. Has ideas of pronounced
persecutory content in regard to his aunt, with whom he made his
home. Othei-wise nothing could be elicited.

Grandfather and father tubercular. Mother insane. One brother
tubercular.

Diagnosis : Hebephrenic dementia.

Female. Age 4ij. Married.

Onset three months befoi* admission by talking and acting pecu-
liarly. Imagined that people were trying to rob and punish her.
Became vicious, profane, obscene and violent.

Patient is intemperate and has used alcohol eight years. Is Illiterate
and uneducated. Has moved frequently, apparently to escape
rental, and to some extent the bases of some persecutory ideas.
Facial expression Is that of a chronic alcoholic. Shows marked
tremor of the tongue, lips and bands, increased when trying to
talk or move her hands. Knee jerks exaggerated.

Mother and one child died of convulsions.

Diagnosis: Chronic pseudo-paranoia. (Alcoholic.)

Female. Age 28. Single.

Has had epilepsy ten years. Onset of mental disturbance was three
weeks before admission. Visual hallucinations, bugs, Insects, etc
Admitted In a state of dullness and stupidity. Occasionally becomes
transitorily excited owing to hallucinations inducing constant dread
and fear. Consciousness is considerably clouded. Almost impos-
sible to attract her attention. Resisted passive movements. As
the stupor passed off there was complete disorientation. Impaired

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267

memory. Confusion. Mistaking of persons and of her surround-
ings. Want of insight into ber condition. Nervousness. Irrltubll-
Ity. Einotlouallsm. Refusal to answer qoeatlons. More or less
constant psychomotor activity and agitatlou. Refusal to oliey
orders. A complete cessation of the epileptic seizures.

Diagnosis i Epileptic dazed-condition.

Male. Age 27. Artist. Single.

Onset, three months before admission. Delusion that he was being
hjpiiotlzed, that he was being persecuted, that he could look Into
other people's eyes and read their thoiiglits. Manifested some
erotic tendencies. Imagined that be possessed some electric pow-
ers. Inclined to outbursts of violence.

Patient Is talkative. Exceedingly sociable. R\a)ted, tending to iu-
coherency and disconnectedness in movements and action. Flow
of thought accelerated. Association of ideas t<-nding to incoher-
ency. TalliS about telepathy, telegraphy, affinity, mind and thought
reading, evil persons, etc. Underlines and scores bis writing.
Emotionally Is exalted, irritable, changeable, aud excitable. Has
Ideas of persecutory content in regard to his father, to Tam-
many hall, etc. Ideas of grandiose content in regard to hia ability
as an artist, to telepathic powers, to his ability to read and see
in other's eyes what are tbelr thoughts, etc. Has no Insight into
his condition. Shows partial disorientation. Seems to have hal-
lucinations, but does not specify. Says that lie was sent here by
propulsion, due to tivo laws, first, the law of telegraphy, which is
the es-^ieuce of i>eople who can do certain things, and secondly, the
law of gravitation, etc. Is reported as having a strong hereditary
history.

I>lagnosls : Dementia jiraeoox,

B>male. Age 30. Married,

Onset eighteen months before admission. Hatred against her hus-
band, family and friends. Quarrelsome. Combative. Profane.
Suspicious of every move and action. Seclusive. Esalted In her
ideas. C^impialning of pain In the head and spine. Tends to In-
terpret wrongly and exaggerate trivial Incidents, Is quite Irritable
Frequently makes the statement that she would be able to get
along if she were left alone.

Patient underwent |>rogreB8ive mental deterioration, leading to pro-
nounced dementia, with a dlHapi>ea ranee of the Ideas of persecu-
tory content Became rather neshy Sui>]ect to frequent im-
pulsive outbreaks of violence and deatructiveiiess, of meaningless,
silly laughter, with display of mannerism and other stereotyped
movements. no<lding of the bead, tivitching of the face, winking of
the eyes, etc.

Diagnosis : Dementia praecox.

Male. Age 44.

Admitted In a state of Intense psychomotor activity. Loquacious-'
ness. Restlessness. Disorientation as to time. Attention easily
diverted. Very eniothmal, usually corre«i)onding to the content
of his thought. Elgotlstlcal and grandiose. Some ideas of perse*

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cutloD Htid Injustice. Accelernted flow of thought, tending to
flight of Ideas.

Physlcall.v large; projecting enrs. Speech thicit and tending to
elision of letters jind words. Some tremor of the tongne, lips and
hands. Writing scruwiy. Knee Jerks absent. Some optic atrophy.

Diagnosis : General paresis.

Female. A^e 44.

Admitted the second time. Onset eight months before admission.
Was lu a state of physical and mental depression and retardation,
with a feeling of constant fear that her husband would Kill her.
There Is delay and retardation in perception and comprehension,
with some tendency to agitation at times. Previous attack said
to be one of depression also.

One paternal uncle Insane. Mother tubercular.

Diagnosis; Recurrent melancholia.

Male. Age 23, Parmer.

Onset four uiontha before admission. Imagined that a letter that
he wrote to a girl friend, arowing his love and proposing to her.
has marred all hope of future happiness, which led him to attempt
suicide. Is usually seclusive. Has outbursts of violence and pro-
fanity.

Patient Is In constant movement. Continuously talks to himself and
to others of bis imaginary troubles. Has ideas decidedly self-
accusatory and Belf-depreciatory. Emotionally is unstable, usually
depressed. Attention is easily diverted ; can not be sustained for
any length of time on any one subject except his delusions. De-
gree of intellectuality seems to be limited.

Father suicidal. One sister and one brother died of brain fever.
Patient had convulsions as a child and again at the age of l.j.

Diagnosis: Dementia praecox.

Male. Age 4C. Laborer.

Onset eight months before admission. Imagined that be was hypno-
tized, that people wanted to poison him. that he could talk with
people at a distance, that he is under the influence of a woman at
a distance, that be hears voices calling him vulgar names, that
he has spots upon bis body pushing on his brain, etc. These are
said to have followed a debauch and he thinks that someone put
something into his drink at the time and judges so from the feel-
ing that came over him. Imagined that food was poisoned, so re-
fused to eat, and judged so from the peculiar smell while in the
Jail. Also that the water had a peculiar taste, that he was put
in jail for talking hypnotism. Heard voices asking him about Im-
moral resorts and of people in them calling him vulgar names.
These voices were at times those of men, at times those of women.
Imagined that people followed him about which led him to move
frequently to avoid them, etc.

Patient manifested a great deal of suspldon during the examination.
Manifests some Impairment of memoi'y and some dementia. Knee
Jerks absent.

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GrandTatber, paternal uncle and cousin insane, Fntlier intemperate.
I'atient intemperate.

DiaguoBis : Alcoholic pseudo-paranoia.

Female. Age 35, Itlarrlei],

Onset one year l^efore admission. Imagined that someone was pur-
suing her to burn her, that her huBband is against her and causes
spells to come over her. Is melancholy. Has outbursts of vio-
lence against her surroundings.

Patient is emotionally exalted. Easily excited. Has ideas of per-
secutory content in regard to her husband, her mother and the
Catholics. Has hallucinations of sight, taste and of somatic sen-
sations. Is yiodictlve In her talii and her actions. Manifests some
erotic tendencies. Knee jerks exaggerated.

Alother Insane.

Diagnosis : Hallucinatory paranoia.

Female. Age 33.

Onset a few weeks before admission. Imagined that she saw ol)-
jects, heard mysterious sounds, voices calling her. Said to have
been hard of hearing and to have been partially paralyzed. Mani-
fests mental dullness. Retardation in speech and thought. Emo-
tional iuBtability, Delay in response to sensory and to painful
stimuli. Is inattentive and non-observant. Indifferent lu regard
to herself and to lier surroundings. Is completely disoriented. Hos
ideas of persecutory content. Shows moderate dementia. Facial
espressfon Is vacant. Has intense optic neuritis. A coarse tremor
of the lips. Speech is thick and dlfflcult. The right patellar and
plantar reflexes are more active than the left. No evidence of
paralysis.

Diagnosis: Organic dementia. (Brain syphilis.)

Female. Age 25. Married.

Onset two months before admission. Irritable. Ii3xcitable. Violent.
Forgetful. Imagined that friends were trying to Injure her.

Patient's attitude ip one of indifference. Has no concern in r^ard
to the future. Is emotionally unstable and excitable. Inclined to
be exalted and rather hysterical. Has some Ideas of persecutory
and also of grandiose content in that she was not allowed to
leave the Institution because she was too good a cook and also
that they were afraid that she would tell upon them. Knee jerks
are active.

Mother tubercular. Patient nsed tobacco, whisky, beer and chloral.
Had three successive miscarriages.

Diagnosis i Alcoholic paranoia.

Female. Age 36, Married.

Patient Is very nervous and suspicious. Imagines that she will be
poisoned, that people are talking about her and wilt do her harm.
Has hallucinations of hearing, Js completely disoriented. Is
more or less confused. Tills passed away, leaving the patient with
a complete amnesia for three weeks at the height of the illness.
She became oriented, (ialned Insight Into her condition except as
alwve. Remained very suspicious. Irritable and excitable. Lost

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nil of the lie 111 silo IIS mid hull uci nations. Complained of eplnal ten-
<leriieSB. raticiit liiid ii slnillar nttnck about six years ago, last-
ing about one week.

Father and several brothers intemperate.

Diagnosis: Acute hallucinatory paranoia.
• Female. Age 35. Married.

Was an inmate tliree years before the present odmlsslon.and at that
time was incoherent in thought and action. Imagined that she
was In commnRlcatliin with God. Manifested rather intense psy-
chomotor activity. Was emotionally eJiftlted. Inclined to suicide
and homicide. At present the patient Is emotionally exalted. Has
exalted graiKlloKc ideas In retjard to herself. Was attending
spiritualistic meetings nt wlitcii she became excited; removed her
clothing under the Idea that as that wiis the way she came into
the world, the r^rd intendeil that siie should live that way. Says
tliat she has- to do what God tells her to do, that she is chosen by
Him and called to preach, etc. Is very talkative. Has well marked
grandiose Ideas of religious content, and If doubt be expressed
III regard to her Ideas she begins to weep, etc. Attention Is diver-
tlble. Manifests some acceleration In the flow of thought and
some flight of Ideas.

Parents were alcoholic. One sister intemperate. One child tuber-
cular. One child hud convulsions.

Diagnosis ; Hallucinatory imranoia, (Iteligious.)

Male. Age 40. Pharmacist. Married.

Onset Ave months before admission. Imagined tliat a mob was
after him, thut he heard i>eople talking about him. Has some ap-
prehension. Tliinks that every i>erson that he meets and is talk-
ing refei-s to him. Accused his wife of deafness because she did
not hear the things that tie did. Kan out of his house and from
place to place, moved from place to place, to escape the Imaginary
mob. Later he became exalted and egotistical, in that some of
his personal make of remedies which he iilaccd on the market were
in such demand that the other dealers were compelled to buy
them. Claimed that the mob belonged to the druggists' associa-
tion and were after him because he would not join them. Has
hallucinations of sight and taste, in that he saw and tasted poison
In the food. Divorced his flrst wife because of suspected infidelity.

Fatiier inteinjieratc. Patient intemjierate and used cocaine.

Diagnosis : Alcoholic pscu do-pa ranola. (Apparently completely re-
covcre*!.)

Male. Age 24. (!»r|M'nter. Single.

Admitted three mcuiths before in a stah^ of Incoherency, Inteusj
IMychomotor ivstlessness. At times violent. Imagined that lie
vms a speculator. Secluslve. Refused to talk to or recognize the
people or his HiirroundiiiKs. At times he is stuporous. At others
he Is also liomlcldal. In the depres-sed stages he r^eats the ques-
tions asited. S|Miiks of allowing his breath flow from his body for
the benefit <if the |iatlents, of his body being tramped upon, of
doing things in n'sponse to thpuglits put hito his bead by an un-

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271

seen power over which he has no control, and which gives him
no rest uotil he carries out what it requests. Has some Ideas of a
peraetutory (-■oiiteiit.

One matemiil uut-le ecceuti'lu. Mother tubercular. One sister insane.
His father reports that he began to have ideas of delusional con-
tent at the age of 10.

Diagnosis : Dementia praecox. (Paranoia.)

E'emale. Age 40. Married.

Onset sis nioiitlts befove admission by making unnatural noises.
Thinking that the police were watching lier, that others Were try-
ing to do her harm. Talking excessively to herself. Cursing,
swearing; was fllthy. Up at all hours of the night. Using her
living room for a water closet. Carried a revolver and threatened
the lives of those about her.

Patient Is dull and depressed. Irritable, excitable and quarrel some.
Has well marked Ideas of iiersecutory content. Regards her com-
mittal as spite work. Is emaciated and sallow. Complains of de-
ranged digestion and of neuralgic pains.

Father and one sister tubercular. Patient has used morphia over
twenty years.

Diagnosis ; Intoxication liisnulty.

Male. Age 28. Barber.

Onset nineteen months before admission by acting strangely. Im-
agined that the police and detectiies were after him. Walked the
streets at night. Talks continually when under the Influence of
cocaine. Siwccli is incoherent. Dreaded to be left alone. Was
fnrloughed. but had to be recommitted in a short time. On ad-
mission he was nervous. Irritable, excitable, iu a state of rather
Intense psychomotor restlessness. Attention is divertlble, tending
to flight of ideas and liicoherency. Emotionally unstable. Im-
agined that people were after him, were watching him because
they thought he was insane, and to prevent him from harming
himself. After a few days he became quiet and apparently lucid,
and remained so while In the hospital.

Two maternal uncles and father intemi)erate. One maternal cousin
epileptic. One cousin Insane. Patient Intemperate since the age
of 21. Has used opium three years, cocaine three months.

Diagnosis: intoxication Insanity upon a dcKeueratlve basis.

Male, Age R2. Butcher.

Onset ten months before, foUowins a stroet-car accident, manifest-
ing loss of memory, hallucinations. Imagined that he had a large
amount of money coming to him and did not need to work. Ac-
cused his friends of having it. Resented opposition. Becomes
abusive and violent. Wandereil away from home. Passed urine
an fa s u bed Fa al expression void and vacant and apathetic,
fa s a tl bifo him. In non-talkative and non-sociable,
I itabi V t E it Actively resents Interference. Compre-
h si imi I ed in that he freqnently gives the same answer to
dlff ent 1 ti Answers' are not always relevant and are al-

ways dis nnected and mote or less Incoherent. Alludes to Im-

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aginary possessious and to the uon-ue<.-eH8lty ot work. Attention
is attracted with difficulty and readily returns to his own delu-
sions. Prououni-ed dementia. Pupils react sluggishly to Uglit and
accommodation. Are uuegual, the left being the larger. Tremor
of the lips, tongue aud hands. Speech thick, partly English and
partly German. Writing tremulous. Tendon reSexes exaggerated,
more so on the left side. Marked Kbomberg'a swaying.

Diagnosis: Orgauic dementia. (Possibly general paresis.)

Female. Age 28. Married. Had three children In four years.

Onset three months before admission, by rambling talk and (oollsh
actions. Imagined that her husband was tiylng to get a divorce,
that lie had married another woman, that people were stealing
from her, etc.

Patient is Incoherent In thought and action. Completely disoriented.
Emotionally unstable and changeable. Has slight insight into ber
condition. Inclined to be self -depreciatory and self -accusatory.
Imagined persons transfigured of her surroundings Into the per-
son of her husband who had forsaken her. Facial expression
rather weak. Underwent rapid antl progressive dementia.

Diagnosis : Acute confusloual insanity.

Female, Age 34. Married.

Onset three or four days after confinement, becoming inattentive
to herself and family, restless, sleepless and melancholy. During
the examination she sits quietly in the chair, bonds )□ almost con-
stant motion, frequently placing them In the mouth. Mumbles
iuaudibly to herself. Rarely replies to questions, and when she
does it Is in monosyllables and limited to a few words, wbicb are
repeated, regardless as to the question, but are prompt. Carries
out movements requested quickly and promptly, tending to repeat
them vfhen they are not too complicated. Gaze is wandering and
fleeting. Wi'iting consists only of scratches of the peu. In talking
makes use of words that have a rhyming sound. Underwent com-
plete recovery and had almost complete amnesia for the greater
period of tbe mental disturbance.

One cousin and one aunt insane. This is the sixth attack that the
patient has had of a similar character.

Diagnosis : Recurrent manic-depressive insanity.

Female. Age Sa. Single.

Onset two months befoi'e admission. Talking Incoherently. Be-
came suspicious, obstinate and immodest. Imagined that she was
the daughter of the President, that she possessed supernatural
power, that the room was filled with singing birds. Onaet followed
the prolonged daily application to the practice of music. Becoming
indifferent, indisposed and lost interest In her surroundings. More
or less depre^ed. Later a period of intense excitement followed,
with hallucinations of liearing and sight and Ideas of grandiose
content Imagined that she was President Roosevelt's wife, that
she received commands from God, that she possessed supernatural
powers. After admission she manifested considerable psychomotor
restlessness, wandering about the ward, disarranging tbe furniture.

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Emotionally was elated, as a rule, except when Irritated, when she
would become violent. Manifested accelerated flow of thought and
fligbt of Ideas, leading to Incoherency and to more or less confu-
sion. Complete disorientation. Talking continually to herself,
mumbling Incoherently and disconnectedly. Attention very diyert-
Ible, Teudency to grimacing, meanlngtei^s laughter and staring.
Some tendency to negativism and Impulsiveness. Responses are
either carried out promptly or after some intentional delay. After
several months this condition for the greater part gave way to
a series of well systematized delusions of persecution, bns»t upon
hallucinations of sight and hearing, and also bad delusions of a
religious content, hearing voices of spirits, who were the agencies
of God. Says that she has been ordained a character similar to
the Virgin Mary. Voices tell her that she must undergo physical
and mental torture of an iuvislble nature, and as a reward she
was to become the Eve of some planet. Christ Is to become Adam,
There is to be a new blbie, a new creation, founded according to
her dictates. Interprets many characters of the bible as having
refereucp to herself. Is very egotistical. Is unable to adapt her-
self to her surroundings. Considers herself superior to her fellow-
patients. Imagines that abe is h^notlzed, that her body Is pos-
sessed of the spirit of a dead child whose photograph she took and
which makes her act foolish and childish, etc.

Grandmother insane. Mother highly neurotic and eccentric.

Diagnosis : Hallucinatory jmranola.

Female, Ase 43. Married.

Onset Ave months before, claiming to have prophetic visions, carrying
stones which she said Indicated prophecies, becoming enamored
of practical strangers, writing love-letters dally, annoying busi-
ness men aud publishing companies in regard to a book that she
wishes to have published ; claims that she Is commissioned by God
to do a great work in her publications. Sees visions and hears
voices telling her to do those things. Traces back lier visions for
over four years, appearing to her flrst as an open book, suspended
from the celling of her room, beautifully lllumiiiated. Below It
was a little child telling her what to do. etc. Is talkative. Has
well marked and well systematized and well motived delusions of
persecutory content. Implicating the whole of her surroundings.
Becomes excitable and subjec't to outbreaks of violence. Actions
aud conduct correspond to the C'ontcnf of her thought to some ex-
tent. Emotionally is somewhat elated.

Diagnosis: Hallucinatory paranoia,

Male. Age fiO. Blacksmith,

Onset six years before admission. Was committed to prison three
years before. Began with a sudden attack of hemiplegia Involving
only the arm and leg. No sensory disturbances on that side, but
a sensation of sticking pains on the right side. Sometimes loss of
force In expelling the urine at times ; Incontinence of urine. Con-
siderable dizziness. Later there develo|)ed rather severe pains In
the right leg, extending up to the abdomen. Slight tremor of the

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bands. Exaggerated knee jerks. Ankle clonus. Well marked
Bablnskl and Rhumberg i>lieiiomenti. Gait stilt; feels uncertain
and spongj; dnigs the toes on tbe Inner side and touches the floor
first when putting tbe feet down. DrawlUK n pencil Rcrosa tbe
BoIe feelB like a kidfe cutting. Sense of deep pressure and palu
Impaired; moderate niUBCiiiar weakness in tbe legs. Legs tire
easily. IjOss of sexual power. Some demeutia.

Diagnosis : Combined sclerosis and dementia,

Male. Age 49. Farmer.

Onset eight montbs before adniisslou. Wandered from home, es-
I>e('lally at night. Imagined tbat he was dying, that be was kill-
ing some one. Talke<l liicoberently and disconnectedly. Became
violent toward his surroundings. Facial expression Is one of con-
fusion. Has pronounced ideas of persecutory content, in tbat they
want to kill him at home, that they were working bim to death,
that his nervousness was due to the overwork. Has slight insight
into his condition. Manifests 8(nne delay in comprehending and
answering queBtions. Emotional elation. Impaired memory.
Tremor of tbe lips and tongue. S|)ee(-h dillicult, particularly witb
words containing "r," with elision of letters and syllables. Hands
tremulous. Jerky and inco-ordlnate. Knee Jerks absent. Plantar
reflexes exaggerated. Marked Uhoniberg's swaying. Muscular
power lessened in tlie legs.

Father and two brothers intemiierate.

Diagnosis : (Jenerni paresis.

Female. Age 21. Married.

Onset three months before admission, with depression and anxiety.
Change of disposition. Lack of interest tn her surroundings. Lack
of alTection for her family. Tendency to Impulsive outbreaks of
violence and to suicide. This was followed by a condition of
emotional exaltation. Slight insight into her condition. Subject
to sudden changes of depression and exaltiition. Loss of memory
fur recent events. Ideas of well-marked persecutory content, in
that her husband's people wanted to kill her, that they have pro-
cured medicine secretly and compel her to take It. Is suspicious.
Actions and manner not corresponding to the content of her perse-
cutory ideas. Patient bad hip disease.

Father lntem|jerate and suicidal. One sister in a sanitarinm.

Diagnosis : Paranoid dementia praecox.

Male. Age 40. Laborer.

Onset two weeiiS before admission, becoming nei'voiis and moody.
Would lose his way. Memory at times a blank. Discharged in
nine months as recovered. Readmitted in eight months. Said
to have had a mild attack of paralysis, limited to tbe left arm,
passing off in a few days. Manifests no particular interest in
his surroundings. Face is exiiresslonless. Features flabby. Gazes
into vacancy. Is slightly deaf, having been so for many years.
Pays attention to and understands what la said, hut immediately
forgets the subject. Has no insight into hla condition. Memory

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Impaired for both recent and remote events. - Emotionally rather
satisfled and happy, Couduct and manner childish. Pupils react
slui^lshly. Tremor o£ the lliis and tongue, the latter being jerky.
Sjieech tremulons, slow, Blurring and difficult, with elision of let-
ters and syllables. Left arm markedly tremulous and ataxic.
Writing fairly good. Knee Jerks exaggerated. Slight Rhomberg's
swaying. Gait iueo-ordlnate. Sensory condition difficult to deter-
mine because of the profound dementia.

Diagnosis : Oeneral paresis.

Male. Age 4C. Salesman.

Onset one weeli before admission, by a change ill appearance and
conversation. Incoherent. Imagined that he was going to be a
millionaire. Wanted to make laree purchases, etc. Is very talka-
tive. Has exalted ideas in regard to wealth, strength, ability,
etc. Is emotionally exalted. Egotistical. Has a-Ceeling of gen-
eral well-belug. Complains of pain In the limbs and side. Ex-
aggerated plantnr and knee jerk reflexes. Beginning speech de-
fect

One brother had tabes. I'atlent had gonorrhea and probably syphilis
at the age of 18.

Diagnosis : General paresis

Male. Age 35 Druggist

Onset about thlee years befoie a Imlsslon bv walking about at night
Irritability Quarrelsome yot apologetle Had a maniital attack
one year later Later there developed forgetfulnesa Megalomania
relative to wealth and to petionallty Loss of control o\er th«
passions. Collapse Fever and delirium This was followed b\
ideas of persecution of exalted personality Want of Insight Into
his condition Defective memorv 4.ateieogno'<is Gradual pro
gresslve dementia Pupils unequal and react slugglshlj to light
Flattening of the nasolabial folds \olte monotonous and tend
ing to word and sound association Moderate tachycardia and
arhytiimla Diminished unequal knee jerks Right wrist diop

Patient was in eight months child of nenous temperament intern
])erate.

Diagnosis; Kefearded as a general paretic

Female. Age 26 Single

Onset five to Six years before admission bj outbursts of passion
Melancholy Despondent Seclusive \t times outbreaks of vio-
lence, praying and swearing in the same bnath So fir as ascer
tainable these peiiods \arled in length and intensity with a com
parative lucid lntei\a1 between Later ideas of maiked peise
ciitory content developed with suspkloiisness nnd refusal to eat
with the famllj leading to ilolent outbreaks against her surround
Ings. Kepjrted as haling hid (horta at the age of 12

Diagnosis : Hebephrenic dementia

Female. Age 38 Single

Onset six months befire admission Irritable seclusive and feus
pidous. Iin icnicd li i-^lf the lidim of a conspiraiv the snbjei t

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of persecution, that the devil was In the telephone, that an evil
influence waa working against her, that she was haunted by aplrlte,
that those nljout eierted an evil influence upon her, etc.

Patient aaya that she has felt adverse Influences acting upon her for
the last twenty-one years, in that she was not allowed to follow
what she thought was right, that she has not always been treated
aa she treated others, that the treatment of her was a form of
mental malpractice, such people belonging to servants, etc., and
had an evil Influence by brute force. Spoke of others meddling
In her affairs, of reetralulng her free will, of not understanding
her, etc. Has exalted ideas in regard to herseit. Is extremely
suspicious and often makes furtive glances toward anyone moving
or making a noise. Is somewhat restless motorially. Attributes
hidden meanings to ordinary incidents.

One paternal aunt Insane.

Diagnosis : Paranoia.

Female. Age 32. Single.

Onset seven months before admission as a religious mania. Says
that she has inspirations directly from God, that she is going to
marry Christ, that she is going to be the Virgin Mary and give
birth to Jesus. Calls pictures in the magazines her dead father
and brothera, claiming that they have risen again. Went to bed
and fasted a week. Took three cold baths dally, after which she
stood before the window nude, claiming that it was the will of
God. Became enamored of a minister, later heard hla voice talk-
ing in content erotic and religious, often hearing it upon retire-
ment. Its content then being of endearment and afCection. Also
saw hlin and smelled a distinctive odor of him. Had some ideas
of persecutory content. In that she had opposition in the choir
which she led, and also In the office where she worked, from others
envious of her and wanting her position. Had hallucinations of
sight, hearing and general sensation, the latter being of hypnotic
and electric nature. Has no insight into her condition. Emotions
changeful, usually cheerful. Feels irresistibly imi)elled to do and
say things of a religious nature. Patient is of a nervous tem-
perament. Has an enlarged thyroid gland. Is decidedly prog-
nathic.

Mother tubercular. Several members of the family have enlarged
thyroid glands.

Diagnosis : Hallucinatory paranoia. (Religlooa. ) The patient later
recovered and was discharged as such.

Mate. Age 38. Married.

Onset two weeks before admission, by talkativeness. Delusions of
wealth. Periods of depression and exaltation alternating. More
or less confusion. Assumes a stooped posture when sitting in the
chair. Has a fixed attitude. Is stuporous. Non-observant. Al-
lows the saliva to dribble from his mouth when in the depressed
state. Answers to questions are irrelevant, disconnected, mostly
monosy I labile, tending to rhyming, alliteration and repetition. Bom
72,000,000 years ago. Always was married. Has 5,000 children,

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etc. Completely disoriented. Ueneral incohereocy In thought and
action. Manner and action depend upon his mental status.
Diagnosis :

Male. Age 35. Farmer.

Onset fltteeu years before. ThlnliH that everybody is trying to beat
him out of what he has, that women are after hlin, that people
are trying to poiaon him, that poison Is thrown upon him in the
air, and claps his hands over his mouth to prevent himself from In-
haling It, etc. Hidts in bis bedclothes. Threatens those about
him. First manifestations followed a love affair, liecoming erotic,
suspicious, and acquired a feeling of decided persecutory content,
which has continued to the present time.

Diagnosis : Paranoid dementia praecox.

Male. Age 49. Groceryman.

Onset two weeks t»efore admission. Imagined that someone was
after blm, that someone wanted to do bim barm, and that he had
been poisoned. Leaves home at night and sleeps away from home
to escape the supposed danger. Carries a gun to defend himself.
Has Ideas of infidelity in r^ard to his wife, in that bis mind has
been affected by drugs put Into the coffee by his wife. This is
also associated with auditory and visual hallucinations, in that
while going down the streets with his wife he felt something
squirting upon hie face. Misinterprets every remark and action
of his wife. While in the Institution received a letter from his
w4fe, but refused to open It or to touch It. Refused to sign bis
name, and when ordered to write his name writes another name
entirely different.

Is well developed and well nourished. Emotions are stable but col-
ored by the content of hla delusions. Is very suspicious. Dates
bacic his ideas of delusional content fully four years. Has tbem
well systematlsed and motived, his actions and manners being
wholly dependent upon the content of bis delusional ideas.

Diagnosis : Chronic paranoia.

Female. Age 45. Married.

Onset many years ago. Complained of being watched, slandered.
threatened with danger and harm. Has been considered eccentric
for over fifteen years, but more so the last Ave years. Is very
suspicious. Misiutei-prets the actions and conduct of others as
having reference to herself. Says that she can read the espreasion
of people's faces who are slandering her. Is very talltatlve in re-
gard to her ideas of persecution. Is being persecuted. Her char-
acter slandered. Is being talked about, followed, her house is
being peeped into, etc. Has been forced to move from place to
place. People want to get her property, to prevent her fi'om
getting married. Have interfered with her getting married to
a number of prominent men, to whom she has proposed, all due
to spite work and Jealousy. Has exalted ideas in regard to herself,
so will not associate with ordinary people. Has hallucinations of
sight and hearing. Is somewhat egotistical. Is estremely sus-
picious, and in her ideas of persecution involves all with whom she

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coine« In coDtaet. Delustone are w«ll eyetematlEed and motived
and entirely control her tbougbt and action.

Fatber died of paresis. One sister and one child ot tuberculo^.

Diaenosis : Paranoia.

Female. Age 26. Single.

Onset two montlis before admission. Thought her parents did not
like ber, so became violent and threatened suicide. Imagined that
her relatives were mean to her, so would not let tbem come into
her room. Felt de|>reiised becnuee she was not as smart as others,
(lid not gel nioug as well, could not trust anyone, that she bad
physical and nervous ailments and could not get well.

Patient is of a very nervous temperament. Facial expression one
of depressioii. Emotions very chanfceabie, usually depressed.
Slanlfests eome mental and motor retardation and depression.
Some dlttlciiltF In oont.'entratlng her thought or ot associating Ideas
outside of herself. Knee Jerhs exaggerated.

Mother Insane.

DIuguosIa : H.vwterkul Insanity.

Male. Age 32. Laborer.

Onset a few days before admission. Expression vacant and listless.
Attention easily diverted, yet he manifests slowness and retarda-
tion in perception, comprehension and association of ideas. Con-
siderable confusion in bla acting and thinking. Marked Impair-
ment of memory. Has anchylosis of the right shoulder. Slight
unsteadiness ot tlie eyes up and outward. Lips and tongue tremu-
lous. Speech tremulous, with elision and Incomplete pronuncia-
tion. Tremor of the hands. Writing tremulous, with attempts
at flourishing. Exonerated knee Jerks and tendency to ankle
clonus, taost marked on the left side. Exaggerated plantar re-
flexes. Babinski most marked on the left side. Gait spastic.
Hazy optic disks.

Grand uncle insane. Grandfather and fonr aunts. tubercular. One
cousin had convulsions. Mother liysterlcal. Father intemperate.
Patient intemperate, dissolute morally. Was shot in the right
shoulder thi'ee years before In a drunken spree.

Diagnosis: General paresis or brain syphilis.

Female. Age 36. Married.

Onset five years before by Indifference. Wanting to move from
place to place. Burning her household goods. Imagined her body
impaired by an oiieratlon. Renounced religion. Kefused to allow
her children to go to school. Became untidy. Talked incoherently
and disconnectedly. Had no insight Into her condition. Had the
Idea that the policemen were associating with her through her
mind. Had ideas of persecutory content. Hallucinations of hear-
ing and sight. Is somewhat ^otistlcal. Complains of many ail-
ments of the genital organs and lungs. Onset followed shortly
after the operation.

Father died ot malignant disease. Three sisters tubercular.

Diagnosis :

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Female. Age 20. Single,

Onset ten weeks before admissiou, and admitteil as an agitated melan-
cholia. DlBcbarged aa recovered in eight moiitbM. Keadmltted in
three years, beginning with loss of interest In herself and her sur-
roundings. Sitting about the house all the day. Will not speali
unless spoken to. Is slow to respond, and often responds with an
afflrmatlve answer when a negative Is required. Manifests marked
retardation in action and thought. Volition Impaired. Reads
fluently. Figures correctly. Hesitates somewhat In obeying or-
ders as if undecided. Apparently makes efforts and finally does
so promptly. Is rather exalted and smiles with satisfaction after
succeeding in carrying out an act requested. Is observant. Move-
inenta and gait slow. Pupils dilated. Facial expression rather
vacant, except when spoken to, when she flushes up or smiles while
trying to give expression to her thoughts. Lips quiver several
seconds before answering, face assumes a smile until the answer
is given, when it agalu resumes Its vacant emotional impassi-
bility. Appears to be somewhat apprehensive. Knee jerks exag-
gerated. Writing full and free.

Diagnosis: Manic depressive insanity. (Had numerous maniacal
outbreaks from time to time afterwards.}

Female. Age 34. Single.

Onset two months l>efore admission, with talkativeness. Shouting
disconnectedly and Incoherently. Imagined that neighbors were
writing and talking about her' aud trying to wrong her. Was
hysterica!. On admissiou was in a state of typical acute mania.
Required feeding. Had delusions of persecution, iiolsoniiig, mur-
der, etc. This was followed by total amnesia for the experiences
during the height of the disease. Disorientation. General feeling
one of exaltation. Emotions changeful. This again was followed
by a period of depression, with a feeling of fear and apprehension.
Delusions of persecution. These iieriods of exaltation and de-
pression alternated for some time, when they finally gave place
to well-deflned ideas of persecution, which governed her general
feeling, tone, thinking and acting.

One paternal uncle insane. Mother died of paralysis. One brother
intemperate.

Diagnosis : Secondary paranoia.

Male. Age 18. I.aborer. Single.

Onset four years before by uervouaness, excitability and emotional-
Ism, linaglned that he was never going to be over 13 years of
age, that people were talking about and making fun of him, etc.
Attention is easily distracted. Is Inclined to be intraspective.
Mutters a great deal to himself. Repeatedly stretches out his
right hand as if taking hold of something, sometimes reaching
down to the floor. Frequently taps on the floor with his left foot.
Facial expression vacant. Emotions unstable. Memory impaired.
Intellectuality limited. Skips words aud syllables when reading.
Frequently turns bis bead to one side with a furtive glance. Head

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Is (lollocephallc. Eyes are close together. Ears peculiar sliai)e
and asymmetrical. Palatine arch blgh. Knee Jerks exaggerated.
Diagnosis : Hebephrenic dementia, upon a reeble-mlnded baBis.

Female. Age 28. Married.

OiixeC two moDths before admission. Follovlog the death of a sla-
ter she became Imbued with the idea that her sister was buried
alive, based upon the fact that at her death she liad tahen hold
of her hand and In letting it go It fell limp. Later there developed
a fear and anxiety, causing at times mental and motor unrest.
This was followed by the development oC hallucinations of sight
and hearing of religious content. Some Ideas of persecutory con-
tent In that alie was surrounded by Catholics, who were continually
annoying her. Was afraid that they would steal her child, and
threatened to cut Its throat rather than allow that to occur.
Imagined that it would be best if herself, husband and child were
dead. Has some self -accusatory Ideas, in having allowed her
sister to be buried alive. N^lects her personal appearance and
duties. Manifests some confusion and uncertainty. Retardation
In comprehension, association of ideas, mental and physical activity
and movements.

Father Intemperate. Mother died of tuberculosis. Patient's young-
est child Is between eight and nine months old.

Diagnosis : Acute confusional insanity.

Female Age 24 Married

Onset alwut one \ear before admlis'slon Folliwed what was called
an attack of neiioui. prostration Had choreiform movements
Audltoiy hallucinations of religious content in that she heard God
tell her that she hart done wrong that she had ommittwl an
unpardonable sin that she must fast to atone for it to refused to
eat Li>ou this developed a morbid fear of death '*he beiame
agitated destructive and subject to ouflreaks of violence

Patient is poorly nourished anaemic appears weik and exhausted
Manifests spasmodic movement* of the face arms and sometimes
of the legs and trunk which are irregular Jerky and Inco-ordlnate
increased by etcitement lessened bv \olltlon and disappear during
sleep Patients attention Is rather absorbed in her own th ughts
Seems 1 1 have partial in&lght Into her condition Is emotionally
depress) d Manifests slowness In comprehension association ot
Ideas fliw of thought and some impairment cf memory and in
tellectnnlitv Patient has a ^erv wide hrllge of the nose yet eves
are close together

Paternal grandfather and father had a similar disease Two ma
temal aunts died of tuberculosis Three brothers and the one child
of the oldest are very nervous constitutionally

Diagnosis; Choreic Insanity (Huntington's).

Female. Agp 17. Single.

Onset about one year before admission. Imagined that she was be-
ing imposed upon and persecuted. Had auditory hallucinations,
mostly of unfriendly content, some also In the form of commands.
la nervous, irritable and quarrelsome. Either secludes heraelf or

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wanders awaj from home. Is very susceptible to Buggegtlon.
Frequently manifeatB a spasmodic barking congh, which is gen-
erally induced when attention is attracted toward her. Occa-
sionally manifests Inco-ordinate, arhythralcal movements of the
hands and feet.

Patient Is well developed and well nourished. Attention Is easily
dlvertlble and rather difficult to concentrate. Mauifests loss of
will power. Emotional instability. Motor restlessness in the form
of fldgetluess. A childish conduct and manner. Has insight only
as regards lier nervousness. Regards her position indifferently.
Shows intellectual deficiency and backwardness. Assumes great
intimacy with strangers, etc.

Paternal grandfather insane. Maternal grandfather tulwvcular. One
halt-brother died at the age of four with conrulelons.

Diagnosis : Paranoia dementia praecox upon a mentally feeble basis.

Female. Age 21. Single.

Onset about six months before, fallowing an attack of apiiendicltis.
She has been regarded as eccentric tor at least two years. Had .
auditory hallucinations. Exalted Ideas of self. Became proud.
Suspicious. Acquired ideas of persecutory content. Occasionally
hallucinations of smell, in that people were blowing gases upon her
and would hold her nose. Also halluclnatlous of sight and some
of general sensation, all mostly of disagreeable content.

Patient Is sparely built, rather poorly nourished and anaemic. At-
tention Is readily attracted, but easily diverted. Often responds
to questions evasively. At times there Is a definite Interval be-
fore an answer is given, In which the facial expression is one of
esaltatlou, at other times one of depression. There are hallucina-
tions of all the senses, mostly auditory, the content usually agree-
able but at times not so. Manif^ts some tendency to Incoherency,
(llghtlness of ideas, some sound assoelntlon. Slight Insight, as she
considers herself nervous. Emotionally exalted. Movements and

. actions correspond to the conteut of her ideas and are self-Im-
portant and rather haughty. Has a strong suicidal tendency.

Grandmother and aunt asthmatic. Father moody. Mother hyster-
ical. One brother eccentric.

Diagnosis : Acute confusional Insanity.

Male 4ge 3t) Molder Married

Onset two years before admission with convulsion and delirium
followed bv talkativeness destructlveness and outbreaks of vio
leni'e running away from home sukldal attempts

latient H well developed and well utunshed Has considerable In
Bl;^ht into his londltion In that he sayi that be becomes insane
after eath coui-uliion Has a feeling of general well being men
tally and phjsically Is emotionally exalted loquaciius Maul
fests some acceleration m the flow >f thought Has grandkse
Ideas In regard to future plans and prospects Has no conception
if ^era<.lt\ Movemeuts and actiins correspond to the accelerated
flow of thought and exalted id( is Physically there are ouvul
slons of the grand mal tvre with numbness of the left side as

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282

an aura recurring at Irregular Intervals. Complaine of beadache
and morning vomiting. Shows weakness of tbe left Internal rectus
o( the eye. Slight tendency to n>-staginu9 In the left eye when
looking to tlie left. Pupils are dilated and respond slowly to light
and to a limited extent. Vision lu the right field of the left eye
Is i«ntraeted. Atrophy in both disks, more so in the left. Slight
tremor of the hands. Absent knee Jerk. Rhoraberg's swaying
Iiroiuinent. ttlood pressure 175 In the sitting posture. Pulse
slightly Irregular, 100.

Father Inteniiiernte. Patient Intemperate. Had lues at iige of 18.

DiHKnosiH: Organic dementia. (Brain sy|ihllis.) Incipient paresis.

Femiile. Age Xt. Single.

Onset two years ago by talkativeness. Inclination to run away.
Imagined that the family were against her, and In couKequence
had outbreaks of violence. She stntes that at the age of 20, fol-
lowing an attack of la grippe, she had a s|)ell of nervousness and
hns had several similar attacks since. They frequently b^u with
the feeling of a lump coming up in the throat, giving rise to a
feeling of suffocation and strangulation, dizziness uud apparent
unconsciousness. Yet she says that she kuows what Is transpiring.
The attacks resemble true epilepsy, except In the after-convulsive
Mfage there is qnivering of the eyelids. She manifests laii of
(itncentvation. Rnfeeblement of volition. Moderate dlvertiblllty
of attention. JAtas of self-control. Great emotional Instability.
luipulHiveness. Has some Insight Into her condition. Patient was
of a very nervoiis temperament. Tmlei'went an oiieration of
oi'ariotomy for her nervous trouble four years ago, b<it no result.

Orandmother, grandfather and one annt died of paralysis. One
matei-ual uncle lutcmiierate.

Dlagmwls: Hj'stei'o-eiilleiJsy.

Female. Age 27.

Ouset about one year ago by attempting to take charge of a church
service, saying that she was called u))on t<) do so by God. Is very
susijicions. Thinks that jieo|>le are all opposed to lier. Negligent
as r^ards lier iwraona! appearau<-e an<l hev surroundings.

Patient is well developed aud well nourished. Is reticent, querulent
and suspicions, which often leads her to ask anestlons as to what
Is meant by certain words, etc., and when In doubt says that she
can not answer it until she has had time to think It over, or often
answers in a jocose manner, while at the same time a frown passes
over her face, interprets the actions and motives of others as
having i-eference to hei-sclf. Has iierlwls of Intense religious ex-
citement. Auditory hallucinatlous ai'e prominent and seem to be
at the basis of the delusions and also control her maimer and act-
ing. Has HO Insight into her own condition or into that of her
fellow-iMitlents, Is emotioimlly exalted, aomeivhat irritable. Ego-
tistical. Patient was considered odd iis a child. Thought herself
better than other chlldivn. Since the age of 13 has been at various
cmplo.vnieuts, cliaiiEing freijuently liecause of the idea that she
was being unjustly dealt with.

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Odb cousin iiisaue. One brother tubercular. One sieter afithmatlc.

Diagnosis ; I'arauold denieDtia praecox.

Female. Age 22. Married.

Onset Ave montlis before, by hearing voices, talking to herself, hav-
ing delusions of pcraecution and of defamation of character. Emo-
tionally depressed. Suicidally Inclined.

Patient was hypochondriacal for several years. Suffered a great
deal wltb headache aud neuralgia. Used bromides continually for
a year. First began to Imagine that the uelgbbors were talking
about her, and caused her husband 1o move from place to place
to get away from It. Also ImagEned tliat peo|)le were following
her to harm her. Became ajiprehensive and at times agitated;
at other times reticent, dejected and almost stuporous. Indifferent
(o herself and her surroundings. After some months she suddenly
appeared to clear up and had an almost complete amnesia for the
exiierlences during the time of the mental disturbance.

Father Insane. Mother tubercular.

Diagnosis : Hallucinatory paranoia.

Female. Age 60. Married.

Onset about six years ago by restlessness, irritability and quarrel-
someness. Outbursts of anger and violence. Delusions of perse-
cution, of infldelity on the part of her husband, etc.

Patient is well develoiM-d and well nourished. Is talicative. Deals
with details. Has ideas of jiersecutory content, dating back for
some years, and Involve her husband and daughter. Also ideas
of Infidelity of her husband. Patient has cousiderable athero-
matous degeneration of the arteries. Some cardiac arhythmla.
Blood pressure 140 in tiie sitting posture.

One sister Insane, One sister iiurt one maternal aunt tubercular.

Diagnosis; Senile paranoia.

Female. Age 20. Married.

Onset about two months before admission, following the death of a
brother. Became deijressed, apprehensive, dejected, suspicious.
Manifested loss of iuterest, loss of activity, neglect of herself and
family. Accused herself of being the cause of her brother's death.
Wandered about at night. Suicidally Inclined. After a time this
was followed by a phase of acute. Intense ixsychomotor activity.
This again was followed by a phase of depression and stupor.
This again by a phase of excitement and agitation. This gradually
subsided, giving pln(« to more or less confusion and disorientation
and almost total amnesia for the experlen<'es during the acute
phases.

One maternal uncle Intemperate, who has one child epileptic. One
cousin and one aunt tubercular. One brother insane. One sister
has fainting st)ells.

Diagnosis : Maulc depressive lusanity.

Female. Age S-'i. Married.

Onset about two weeks before admission. Imagined that she was
being executed, that bombs were being thrown at her, and that she
was being otherwise abused. Wandered aimlessly about. Co-

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284

hablteil ludlBcrlminatelj' with the oiiposite sex. Had sudden out-
breaks of violence and Intense exciteiiient. At the time of admis-
sion she was (luiet, but in a few days she suddenly broke out Into
an acute typical manlaeal state, lasting about a week, after which
she agalu became quiet, but was euepiclouH and api>rehenslve. Had
Ideas of prominent iiersecutory content and evidence o( auditory
hallucinations. The patient Is as a rule emotionally exalted. Has
occasional spells of apparent unconsciousness, out of which she
iirou»«s lis from a sleep. The field of vision U considerably con-
tracted. EeaponBe to the prick of a plii la decreased but modified
by the control ot the will. Has no Insight Into her condition or
into that of her fellow-patients.

One aunt died of tuberculosis, and also had n sod die of convulsions.

Dlngnosis : Hystero-epileptlc Insanity,

Female. Age 26. Married.

Onset three months before admission and about two weeks after her
marriage. Became depressed, melancholy. Imagined that she had
committed an unpardonable sin by marrying her husband, whom
she did not love in the proper wny ; that the Lord had forsaken
her, that lie had taken away her feelings, that she was doomed
to eternal puuiBhmeut, that her family would suffer and come to
waiit because of her. Became careless in her personal appearance
and more or less agitated. Attempted suicide.

Patient is of a highly nervous temperament. Quidi and active.
Thought is largely limited to the subject of her delusions. At
times becomes intensely agitated, moaning, praying, wringing her
hands and in almost continual movement. Facial expression one
of mental pain and apprehension ; yet the patient Is rather easily
diverted from her delusions, and at such times her attention is
closely concentrated upon what Is being said and done. Interrupts
discussions. Becomes somewhat jovial. Discusses other topics In-
telligently and becomes somewhat egotistical. Emotionally exalted
and talkative. Manifests an accelerated flow of thought, movement
an action corresponding to the exaltation.

One aunt died of tuberculosis.

Diagnosis: (Rome phase of a complex psychosis.)

Female. Age 31. Married.

Onset about one month before admission, by choreiform movements,
followed In a few days by Incoherency, sleeplessness, talkativeness,
sinking and laughing. Did not recognize her relatives. Inattentive
to herself and to her household duties. Inclined to wander about.
Imagined that the food was poisoned, that people did not want her
about, etc.

Patient is slim built and poorly nourished. Facia! expression is one
of exhaustion, depression and ntijirehenslon. Attention Is easily
diverted, excejit from a feeling of apprehension and the desire to
return home. Comprehension is confused. Association of Ideas Is
Incoherent, Irrelevant and disconnected. Tendency to psychomotor
agitation. Almost complete loss of insight. Emotionally depressed,
tending to agitation. Speech tremulous. Movement of the lips

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ami tongue slightly jerky. UovemeotB of the hHnd» and fingers
when taking hold of au object oue of ftexion, pronation and ten-
dency to cross. General motor restlessneHS, tending to retardation
and delay In compreheaslon, in association of ideas and In move-
ments. Some rcBlatance to passive movements.

One materaal uncle suicided. Two first cousins insane. One sister
teeble-nilrdcd.

Diagnosis : Acute confuslonal Insanity.

Female. Age 22. Married. Youngest child two months.

Onset nine days after confinement, by an acute maniacal outbreak.
Excitement and Incoherency in speech and action. Excessive psy-
chomotor activity. Outbursts of violence. Complete disorienta-
tion. Visual hallucinations. Delusions of Impending danger. At
present tbe patient Is almost normal, return to normal having
taken place rather suddenly. There is almost total amnesia for
the acute period of illness of over four weeks' duration. Patient
had an attack of what she calls nervous prostration at the age of
17 and again at tbe age of 21.

Patber intemperate. Mother tubercular.

Di g I B t I

F m 1 Ag _o M id

O t tw weel b f dmu i by dd h mi id 1 tb k
i whi h 1» w tdt kilh whom hiid B ma

g bl Im 1 d th t peoi.1 w p rs i g h At tlm b
ra t lid d d 11 Abo t m tb ft S m t th

ptitbegtl ttih n Banid

d p essed l-psel des tdbe f self t y

d self-d lit id Tl gilt h w bel g p 1 d

h Id t t it f sed t t n t ed i id

P tl t t w 11 d 1 ped d mod t ly I I ed Att ti

m t b t k ip by tb ght wbi h b III t p es
C mp hdwiti id Ibt pod yilyp-

p tly eti 1 i (, 1 ed m t 1 ff 1 1 sso i t id At

tim d t seem t d t d A w 1 I

t 1 t d Em ti t bl lly d p essed d

p th ti M m f t p i t hildlirtb w II

t i ed b t th i t t 1 m if wl t b t pi ed i
C mpl t di I t ti I n ight t I I 1 ssl 1

ly p th ti rhj i I ttlt 1 d tl h w ios f t

M t besitati g 1 ggi h d d 1 d Lips f eq t)y

m wh t yl g t f m 1 t w igh ft f

f t f thi 111 g M t 1 ff rt ccel t th p ! e- t K ee
j k b t H m if t y id i th t h

t 1 gs t Id lies t wh bild whi h Les h wl ked

O m t 1 1 r" Pti F th i t mpe t M th d 1

t ligi f ti

Diagnosis: Acute confusional insanity. (Puerperal.)

Female, Age 29. Married.

Onset six weeks before admission, by depression. At times was ex-
citable. At others dull. Imagined that sbe had spoken 111 of a

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frieiiil thill sill hull Uonp HroiiK in jolnlnjj a ihiirtb that a mob
was after her ro kill her that Rhe hml been cmsed etc

PatiPDt in poi)rli lumrlHlied auaeiiiit Mta iu a stooiiml [Mwltion
tjebrons plpiati'd l;oielipn<I nrhikled Attentioo obtained with
<lini<u]t] Is c|ukkH lu^'t aguln ajiiiaieiitlj nlisorbed in her ouii
thouKlits CompreheiiHlou sinu iiid retnrdtd Ausners \ery slow
1} often re<|uirln;{ rei>etition of <]tieHtlouH tud sometimes Rhaiiiii,^'
The effort of thluklng seems to <auw fatigue Often says that
she does not know *et when urged eventually gives the <"orre<t
answer i low of tliou.'ht retarded ( ont< nt of tlmiiEht ueea
tive In that she has done wront; his told an unlrnfh to her hus-
band hm liruiiictit a (Uft upon hemelf her husband her ftmlly
and frieiiibi All luust suffer for nluit she his done Has no
hope Does not deserve to live Knous that she will go to hell
and deseries to Jrlonds laugh at hir Siivs that she was told
by God of the ourse His seen and heaid the devil Facial ex
pression ai)[>rehensl\ e and ofttn mikeb quiik movements as if ex
[>ectlDg harm as If due to auditors hallndiiatlons

I ather msanc

Diagnosis 8tui«)rous melandiolln

Pemile Age SI Mairled

Onset two months before adinibslon with headache restlcesneas out
breaks of lioltnie Think? that [leople are agalUHt her are going
to harm her ete Facial expression one of uncertainty and con
fusion Is vtr> apprehensive and suspltlous \eiv unstable emo-
tionally and usnallj dtpressed \nawers questions \erj slowly
often Irrelevantly Appears to associate Ideas with difficulty The
left side of the fai-e is sraalltr than the right Left palpebral fls
sure narrower than the right Manifests tienior of the lips and
tongue bei'onilng more mirke<l when excited Knee Jerks eTag
gerated After toi months was veir excitable and emotional Had
periods of e\(iteni<nt follow p<i bi i^riods of catatonic depression
Gave exjiression to ideas of a per-,eiutory content variable and
changeable Ideas of Impending dinger leading to motor aglta
tion

Diagnosis

Female \ge '17 Married

Patient hogiiii to use moriihia four vears before admission but not
continuously until later Mental dlsturbinces consisted mostly
of hallucinations diieflv auditorv In heiiring voices that repeated
her thoughts w hk h uttered abush e thri ats and objectionable
vvords etc In tooting of hornB Refused food beciuse voices
told her that it v\ is poisoned Thnw shoes out of the house be-
cause the voices told her to do so Has tactile hilincinations
In that she is (ontinuiillv Ivliig upon u bed of electric wires Im
iRlned that iieople <oiiId fee her through the walls and wanted to
take ft photo:!! mill of hu to show the effects of morphia Emo
tioniil feeling w is one of depression nt times more or less agl
tntcd Fasih luuoved and Irritnted bv tmlai affairs Attention
concentinttd with some dlffitulty Intro-'-|>ectivc Easily fatigued

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C(nii|)lalns of iieraistent (Kvipital headache, slight gastric dlaturb-
luice, cardiac i>alpitntion and iiraeuordlal fear. Teudon reflexes

One maternal cousin had chorea.

Diagnosis; Toxic Insanity. (Paranoia hallucinatory,!

Female. Age 28. Married.

Patient had diphtheria about one year ago, followlug which she
became nervous. Later she became depressed. Indifferent to her-
self and her surroundings. Suicidally inclined. Husband became
siclt. She had to worh; bard, Wnrlt became a drudgery. Became
discouraged. Had sevpre headache. Felt that Nbe wonld not get
better. Thought she was ?oUig to lose her mind. Preferred death
to an Insane hospital, so atteiupted suicide. Has considerable in-
sight Into her condition. Manifests retardation and depression tyitb
mentally and iihysically. (xeneral apathy Negative tone of feel-
ing. Is in a ]>oor state of nutrition Knee Jerks exaggerated.

(Jrandmothei' tubercular. Mother and one sister nervous.

Diagnosis : f iyiKK-hondriacal nielanchoiia

Female. Age 31. Married. \ luugest child six mouths of age.

Onset about two weeks before idmission aud three months after con-
conflnement, with a mental dl<«turbance of acute mania, gradually
liassing into dementia. Attention can not be concentrated nor
sustained only momentarily ( ompnheniion is limited to the sim-
plest questions and only gives correct answers to such. Memory
entirely lost. Does not remember from one moment to another.
Can point out the letters of the alphabet when named. Can rec-
ognize and t,i»e tlie names of ordinarj objects shown 4dd and sub
tract smipie problems but not multiply or di> Ide Indulges in
senseless meaniuRless laughter Moienitnts and aj-tions are more
or khs iniiiulsive and moti*eless I*- fniil^ neli nouiished

I ither and one sister Insane One sister fcelile minded One brothei
deformed

DiaUioBis Dementia heleihienlca

Eemale ^e 26 Mjiried loungest (hild six months of afee

Onset three weks tiefore admiB.sion Began running from one looni
to another turning everything uiialde Sown and disarranging every
tiling Incoherent in thought and action Intense psvchoraotoi
activity lasting abtut file days followed by a period of deprea
sion nud confusion both phisically and mentalh

I at lent is iiak and pc rlv nourished Manifehls apathj iiid depres
sioH ( oncenti ition < t thought api»eavs to cause fatigue Has
difficulty in reinemhei nife Has had to work hard and has giien
birth to three chlldnii in as ininj years Is apparentiv of poor
Intellectuality

tather mother and hrothei Intemiteiate

Diagnosis Manic depressl-\e insaniti uiirn a p \chfpathic lasls

temale Age IS Single

Onset shortly after an llleglfimnt( blith In eiuotloinl e\citabl!ity
Outbreak of lioleme Chmglng disposition Feaiful of her closest
ft lends Irofano bukidalh inclined

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Patleot Is ot a highly nervoue constitution. Extremely emotional,
chnnging suddenly from Intense excitement to profound weeping.
Is very Irritable. Excitable. Subject to outbreaks ot violence.
Very talkative. Fl<)w of tbought accelerated. Corresponding ac-
celeration In actions. At times BOme mightiness of ideas. Profound-
ly hysterical.

Father and several paternal uncles intemperate. Mother highly
nervous, becoming ahout the age of 40, also following a confine-
ment. Later the father also became Insane.

Diagnosis: Hysterical Insanity.

Female. Age 29. Married. Youngest child seven months old.

Onset three weeks before admission. Began to talk of dying. Im-
agined that someone was going to bnrn her, or going to kill her.
Tried to kill her baby. Attempted suicide. Became excited and
said that she was ordered by God to leave home and to live at
other places, etc.

Patient Is poorly nourished, anaemic. Has had several miscarriages.
Attention is fairly well concentrated. Answers questions relevantly
and connectedly, but as soon as answered her thoughts seem to be
centered upon her own Ideas. Is suspicious. Asks whom we are
looking tor and if her husband sent us. Imagines that her hus-
band has divorced her, JudgUig so from what she has heard. Says
that she was committed by mistake.

One sister Is a mute. One sister had chorea at the age of men-
struation.

Diagnosis: Acute confuaional insanity, (Lactation.)

Female. Age 28. Married. Negress.

Onset about two weeks before admission, following a few weeks
after confinement, by outbreaks of Intense maniacal excitement
and psychomotor restlessness.

Patient was very much emaciated and exhausted. Attention can
be gained and held only momentarily. Answers questions promptly,
but Irrelevantly and disconnectedly. Very talkative. Manifests
a rapid flight of ideas. Is loud and boisterous. Tends to rhym-
ing of words. Refers to hallucinations of hearing. Has numerous
delusional ideas transitory and fleeting, some of grandiose content.
Emotions exalted mostly and unstable. Content of thought char-
aeterlned by confusion and Incoherency. Movements and actions
accelerated, corresponding to the accelerated flow of thought.

Mother died of puerperal mania.

Diagnosis : Pueri>eral mania.

Female. Age 32. Married.

Onset about three months before admission. Began to Imagine that
everyone hated her, that she had sinned against God. that he had
placed a curse upon her. laments and bewails her loss of soul
and respect of friends. Becomes dei)reBsed, Indifferent and sui-
cidal.

Patient is well develojicd and well nourished. For some time be-
fore the acute outbreak she had been overenthuslastic In religious
matters, during which she had professed conversion. Two days

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after she bad tbe acute outbreak. The acute phase gave place
to partial insight. Emotional instability. Many [deas ot negative
feeling tone in regard to actions, thoughts and church services.
Complains of pain in the head and back.

Grandmother Insane.

Diagnosis :

Female. Age 46, Married.

Onset six months before admission, by Intense nervousness, rehears-
ing of her conversations. Loquacity. Fl^btlneas of Ideas. De-
lusions of a religious character. Palpitation of the heart. The
patient underwent an operation for removal of the carcinoma of
the uterus about six weeks before admission, after which the men-
tal disturbances became much worse. She became more Irritable,
Incolierent and had outbreaks of violence.

Is well developed and fairly well nourished. Attention is rather
divertible. Is loquacious. Manifests accelerated flow of tbonght,
some flightiness of Ideas. Has almost complete Insight Into her
condition. Is emotionally unstable, usually exalted. Movements
and actions entirely correspond to the accelerated flow of thought.
Is subject to periods of Intense maniacal excitement, with numer-
ous hallucinations and changeable delusions. Says that at the
age of 40 she began to notice that her memory was not as-good as
formerly, that she could not concentrate her thoughts as well.
Suffered considerably with headache and palpitation of the heart.
Passed Into a condition of chronic mania and later^ recovered so
as to be able to be sent home.

Maternal uncles intemperate. Mother and one sister died of nervous
prostration. Father and brother of n very nervous constitution.
Patient Is of a very nervous teni]ierruneiit.

Diagnosis : Mania.

Female. Age 44. Married,

Onset a few weeks before admission, imagined that people were
about the house, that they were Jumping off the roof. Would get
out of t)ed and watch at the window. Laugh to herself without
any reason. Says that the Democratic party has wires attached
to the honse and are trying to make Democrats of her husband,
son and herself. That there is an infernal machine attached to
It, etc. That neighbors throw carbolic acid into her back yard.
as she smells It. That they are talking about her family, etc.

Is well developed and well nourished. Emotionally rather excitable
and Irritable. Has hallucinations of sight, hearing and smell.
Delusions of persecution rather well founded, systematliieil and
motived. General feeling tone Is negative. Is somewhat ^o-
tistlcal. Movements and actions prompt and influenced by the con-
tent of her thinking. Son SMit to the prison.

Diagnosis: Hallucinatory paranoia.

Female. Age 46. Married.

Onset about one week before admission, by a sudden outbreak of
acute maniacal excitement, preceded by a period of depression
of about four weeks' duration.

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290

Patient Is well develo|ied and fairly nourished. KaniCeats talkative-
ness, ncceteruted flow of thought, emotional exaltation. Feeling
tone on the whole la positive. Has only partial insight into her
condition. Gives expression to ideas of persecutory content, but
het movements and actions do not correspond, and they are also
superficial and changing. Periods ot excitement alternate with
periods of depression, each lasting from one to several days.

Mother had some mental dieturbauce. One child had spinal trouble.
Patient had some mental disturbance, following a miscarriage at
the age of twenty-two, lasting several weeks.

Diagnosis : Uecurrent mania.

Female. Age 37. Married.

Onset about eight months before admission. Incoherent In talk
and action. Imagined that i^eople were after her, that she had
no friends. Wanted to run away from home. Would crawl about
the house on her abdomen. Did not rec<^:nlze her children, Tbreat-
eued suicide.

Patient is poorly nourished. Manifests retardation In thought and
action. Has do Insight Into her condition. Memory visibly im-
paired. Some confusion and uncertainty. Apprehension of np-
proachlng danger. Hallucinations of common sensation in that
she feels as if something were crawling over her body. Has ideas
of persecution, fairly motived and fairly systematized.

Pulse Is Irregular uud the arteries sclerotic

Diagnosis

1 emale \^e lb Single

Onset a few day^ before admission by an outbreak of maniacal ex
tltemtnt ind motor restlessntss

Is well dtveloiKd iiid well nourished \eiv talkative Manifests
tousiderable Itiglit of ideas ;ind a ccierited flow of thought l^
excitable ^eii emotional Bgotlstkal Ilns no ii sight Into hei
onu condition ol Into that of her fellow patients lias ideas ot
grandiose content

One maternal c uain and ne brjthei insane Father <.f a neriout.
tempeiament Mother died of tubenulo&H Patient hud two slmi
lar attacks within the last five year<)

Diagnosis I ecurreut mania

Femait Age 3' 'Married

Onset a few weeks before admission folkwlng an Illness of six
weeks dtiratl u left home when the weather was extiemely
cold wall in ,i a distuitc of tnuitj iniles Was depressed Inco
hereiit Emotioi il Irritloujl li different and negleftful In re-
gard to heiselt and hf r household duties Tiitd to birn the bouse

Patient Is spirely built ind poorly nourished Attention Is fairly
sustained Itesponds very slowlv Manifests marked dullness
and slowness in comprehension I ii s iioie ind she apparently
makes tht, atteuiit t> answer but <ai not bid the words When
aiiccessEiil the answers are m (el uid leleiant but speech Is

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291

stuttering and stammpvliig. Repeats some of the words and
phrtises. Memory Is uotlcenbly iiupiiii'ed. Fiiclal exiiression is one
of satisfaction when eucceedlDK and of disaiipohititieut when fail-
ing;. MoTcDienta end actions are also retarded in correspondence
to the retardation of thinking. Manifests confusion and Inde-
cision. Says tliat It is due to ber brain being tangled so that she
can not think. Manifests loss of tone, strength and energy. Urine
contains albumen and excess of Indican.

Diagnosis : Manic-depressive insanity.

Female. Age 42. Single.

Onset about four months before admission. Followed the death of
her father, by becoming sad, dejected aud appreliensive. Ima^ned
that all of her friends had turned against her, that she had com-
mitted some great wrong, that people were trying to poison her,
so refused food and medicine, becoming greatly emaciated.

Patient w^s well developed and well nourished. Is subject to periods
of depression In which it Is difficult to divert her attention from
the thoughts that seem to hold It, At other times she becomes
Intensely excited and agitated, to the extent of requiring restraint.
Has considerable insight into her condition. Has a few ideas of
hypochondriacal content. Refuses to give any explanation or to
discuss the delusions which she formerly held. Pbyslcally tbere
Is enlargement of the thjTold gland. Some prominence of the
eyeballs, the right side mote than the left. Incomplete convergence
of the movements of the eyes. Some tremor of the hands.

One paternal aunt insane.

Diagnosis : Paranoia?

Female. Age 28. Married.

Onset about eighteen months before admission, by a sudden suicidal
attempt. This was preceded by a period of depression in which
she was inclined to worry and be despondent. After the attempt
of suicide she began to imagine that her family were against her.
that they were wanting to dispose of her, that she was better than
they, that she occupied a higher social position and a vast fortune.
Had frequent hallucinations of hearing, especially at night, with a
content of negative feeling tone. Following this there were periods
of depression and exaltation, alteniating and varying In Intensity
and duration.

Patient Is well developed but poorly nourished. Attention is readily
divertible. (Jomprehends clearly. Is very talkative. Oives con-
nected relevant answers to questions, bnt immediately becomes in-
coherent and Irrelevant. Has no Insight into her condition. Some
flight of ideas, with incoherency and disconnectedness. Emotional
depression and apprehension. Ideas of negative feeling tone, per-
secutory in content. Association of ideas impaired. Facial ex-
pression Is one of confusion. Some general tremor. Confusion
and indecision of movemeut-s and actions. Motor restlessness and
excitement.

Diagnosis : Manic-depressive Insanity.

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Female. Age ISO. Married.

Onset about one v/eek before adiulaslon, with iDcoberency au<I irrele-
vancy In thought and actios. lUglit of Ideaa, talkativeness, inclina-
tion to wander about and imagining physical allmente.

Patient is well developed and well nourished. Attention in regard
to the condition relatine to herself is well sastalned. Ib exceed-
ingly talkative, denllng with details. Klnnifcsta accelerated flow
of thought and flight of ideas, eialted feeling tone. Content of
thought as a rule exalted, yet refers at times to wrongful treat-
ment and to being made the victim of a plot for the purpose ot
making an interesting case of her or for the purpose of experiment-
ing. Has no Insight into her condition. Is emotionally exalted.
Has exalted Ideas in regard to her ability and capability. Shows
some general arterlo-sclerosis. Some cardiac Irregularity. Bi-
lateral cataract. Dimness of vision. Hlood pressure 180 while
Bitting.

Father intemperate. Mother tubercular.

Diagnosis : Jilanla.

Female. Age SO. Married.

Onset about two months before admission. In tbe third month of
lactation, becoming nervous, irritable, emotional, obscene in man-
ner and action. At times very much excited. Began to feel that
she was being mistreated.

Patient Is well developed but poorly nourished. Is of a very nervous
temperament. Has ideas of persecutory content in regard to re-
ligious affairs. Says that she Is Innocent and must suffer. Has
Ideas of conjugal Infelicity, of attempts to poison her. Has hal-
lucinations of hearing, and less so of sight and taste. Patient re-
ported hysterical. Manifested some mental disturbance following
an attack of measles and also following a previous confinement.

Two cousins Insane. One cousin tubercular. Father snld to have
died of nervous prostration. One sister very nervous.

Diagnosis : Hallucinatory paranoia.

Female. Age S9. Single.

Onset nearly fifteen years ago, but only recently became pronounced.
Restless. Excited. Had haliuclnations of hearing. Imagined that
she was going to die, that harm would befall ber. so would lock
the doors and hide herself, that she had done wrong, that she must
marry, and that she must do whatever came Into her mind.

Patient has been subject to periods of depression since the age of
32 and at times also of self-depreciation and self-accusation, which
led her to spend considerable time Iti religious matters, eventually
Christian Science. She had a severe Illness at the age of 3,
wblcb was followed by weakness and paralysis of botb arms,
tbe right more so than the left; and also the left \eg. She can
not raise, pronate or aupinate the right arm except when lying
upon bet lap. Can open and close the hand, rotate It slightly.
Can not extend or flex the wrist or elbow. Can not abduct but
can adduc't. or move forward or backward. There la marked
atrophy of the muscles involved, also of the muscles of the upper

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arm and sboiilder od the left side, where the movements are also
Impaired, but to a much more limited degree. There Is alfio arrest
of development of the left 1^ and involvement of most of its
muscles. Knee jerks are Increased on the left side.

One aunt tubercular.

Dlagnosla ; Agitated melancholia.

Female. Age 27. Single.

Onset abont Bve months before admission, following a disappoint-
ment In a love affair, by making false accusations, teliing gross
lies, using obsceue htnguage, overzealous in religious matters, sing-
ing and praying Ions and frequently. Imagined that someone was
murdering her brothers. Feared she would be robbed. Had out-
breaks of violence, liifllctlog injuries upon herself.

I^tient Is tall, slim and moderately nourished. Head and face are
very small. Has au enlarged thyroid gland. Intellectuality is be-
low the average. Has some insight into her own condition, but
not into that of her (el low-patients. Manifests a lack of modesty.
Frequently interrupts. Is egotistical. Refers indirectly to ideas
o( persecutory content. General feeling tone is negative.

Grandmother and mother had enlarged thyroid glands. Grandfather
intemperate.

Diagnosis ; Dementia praecon upon a feeble-minded basis.

Female. Age 18. Single.

Onset three weeks before admission, by restlessness, singing, con-
stant Incoherent talking, emotional excitement. Imagined that
she saw stars and large gatherings of people. Had religious de-
lusions.

I'atlent Is well developed and well nourished. Anaemic. Assumes
a listless attitude. Manifests lack of interest, of attention and
observation, delay in answering questions, appearing to be occu-
pied in trying to comprehend what has been said and formulating
an answer, or In predominating self-centered ideas. Seems to be
somewhat confused. The only outward manifestation is an occa-
sional frown or wrinkling of the brow. Only answers simple ques-
tions. To others she says "I don't know." Realizes that there
is something wrong and does not want to be the way she is but
cannot find out what is the matter. Refers to vague Ideas of
religious matters of grandiose content as having been Imagined.
Could not understand certain passages in the Bible, so asked others
about them for explanation. Memory Impaired, apparently due to '
the confusion. Emotionally Is either apathetic or exalted, depend-
ing upon the content of her thought. Fi-equently puts the hands
to her foi-ehead as if in pain. Shows general lassitude. Extremi-
ties cold.

Diagnosis: Hebephrenic dementia.

Male. Age 34. Laborer.

Ouset about one month before admission, by jumping at im^lnary
Insects and animals. Believed that he was making beer and
whisky. Took off bis clothes in public. Threw water on himself.
Talked incoherently.

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Patient is well developed and well nourished. la rery talkative,
going into detnils. Emotionally tends to depression. Has no In-
sight Into his condition. Attributes his artlons to the treatment
he received. Has well-marked ha 11 uel nations of sight, bearing and
general sensation. Has some delusions of persecution. Manifests
some confusion. Patient is intemperate, had syphilis eight years
ago, shows marlied tremor of the hands, some of the tongne and
lips. Writing is tremulous.

Father and three brothers Intemperate.

Diagnosis Alcoholk Insanity

Male \ge 34 Laborer feliu,le

Onset one year before admission Melancholy Restless Sle^lesa
Intemperate Imagined that snueone was after him Reported
as ha\liig had a onvulsion followed b? unLonsclonsness for twen
tv four hours and this by maniacal estltement

Patient Is well developed and well nourished In October 1W3 he
began to suffer with headache niostlj frontal and \\orse at night
Also weakness loss of appetite prae^ordlal pains dyspnoea and
dizzy spells Had a spell of nnconsclouiness lasting eight hours
Similar attacks have occurred at Irregular Intervals atnavs feel
ing badly afterwards After admission to the hospital the bead
aches disappeared but he has oiiasional epileptic attacks averag
Ing about one per month and usually occur at night following
which he Is alu^lsh Irritable and excitable Beyond a mild de
mentis nothing more is manifested

Father died of Bright s disease Mother of asthma Patient began
drinking ibout the age of IS and has been more or less addicted
to the use of alcohol ever since Ilrlne contains a small quantity
of sugar which varies firm time to time

Diagnosis Epileptic insanitv

Male Age 31 Machinist Mariied

Onset three months before admlbsion Imagined that he had lost his
right of suffrage that he bid glass and iron in his body that his
fandly and friends are against him and trying to injure him that
medicine ivill kill him and that he is <iupFeme ruler rhreatens
to kill wife md family Attempted suicide Iried to operate upon
his testicles

Patient is well developed and well nourished Has marked delusions
of porsoi uti in slightly so of impending dai^jer of Iron and glass
m his body Has hallu initios :>f tai>te and visceral sensations
In that lie tastes the iron and feels if in liis abdomen Has partial
Insight into the condition of the fellow patienti Manifests some
af parent dementia

Mother and maternal grandmotbei insane Patient Intemperate

Diifcnosis Paranoid dementia pratfox

Male Age 52 1 aimer Married

Onset about three months before admission by extreme nervoumjesa
Has maniftsted eiitreiiie Jealousy of his wife for years Exag
gerates inslt,nificnnt incidents Burns articles belonging to his
wife school books of the chlldrpn Is subject to outbreaks of vio-
lence

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Patient is well developed. SHm build. Moderately nourlebed. Dates
back bis ideas of persecution at least ten yeai-s. Imagines tliat
tlioee coucerned In bis persecutory ideas are "queer" aud some-
what "feeble-minded." lias no insight into his condition. Patient
bad malaria and grip before admission some time. I^Ias extensife
atterio-Bcierosis. High biood pressure. Enlarged heart. A mitral
systolic murmur. Oedema of the tegs. Albumen in the urine, 2
l>er cent., and extensive granular taets.
. Some Insanity on tlie paternal side. Brothers intemperate. One
daughter bad spinal irritation. One daughter is high-tempered.

Diagnosis : Paranoia.

Male. Age 30. Lsiljoter. Single.

Onset three weelts l)efore admission, by an attempt at self-destruc-
tion. Is seciuslve. Imagined that everyone was plotting to kill
him, etc.

Patient is well nourished. Head is very narrow. Sides are slanting
and come to a point near the sagittal suture, which is very promi-
nent. His movements are slow and slu^lsh, somewhat retarded.
He manifests weli-marked mental retardation, requiring frequent
repetition of what is said to him before be responds, it being diffi-
cult to determine whether he Is afraid to answer or can not formu-
late what he desires to say. At times he fails to answer or to giTO
any evidence that he hears or comprehends what is said. Can
elicit no explanation or comment as to the cause of the attempted
suicide. Knee JerlM are barely elicited. Biood pressure is low.

Diagnosis : Dementia praecox.

Male. Age 28. Barber. Single.

Onset two months before admission, beeoming nervous, restless.
Could not work. Wandered away from home. Imagined that the
family did not want him at home. Felt that life was not worth
living. Attempted suicide. Had .^iwciflc and ear disease.

Patient is well developed and well nourished. Is listless, apathetic
and somewhat stuporous. Takes almost no Interest In his associa-
tions or in his surroundings. Pays but little attention to what is
being said or done. Spits frequently, due, he says, to the nervous-
ness. Is inclined to be seciuslve. At times is more stuporous than
others. Feels Giloomy and depressed all of the time. Memory
seems to be impaired for both recent and remote events. Realizes
that there is something the matter, saying that he can not think.
Gives expression to some ideas of persecutory content. Hallucina-
tions of hearing. Ko insight into the condition of his fellow-pa-
tients. Patient Is Intemperate. Had syphilis five years ago. Tends
to resent Interference and Is stubborn.

Diagnosis : Brain syphilis.

Male. Age 54. Chinaman. Married.

Onset three' weeks before admission, by acting strangely, by not eat-
ing nor steeping, by muttering to himself. Imagined that someone
was going to kill him, that someone had stolen his sons, who live
III China. rnoB and asks for protection.

Patient is well deveiojied and well nourished. Appears to he en-
tirely occupied by Intraspective ideas. Tallfiiig to himself. Fre-

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queutly lau^lilng to himself. Some teudency to motor restlessoess.
Attention can be diverted only momentarily and with dlflSculty.
Appears to be confused and apprehensive. Recently siirfered fluau-
dal losses and ttie death of his mother.

Diagnosis :

Male. Age 45, Fbyslclau. ' Married.

Onset twelve weeks before admission. Was Connd on the top of hie
house looking for a man. Imagined tbul someone was after his
wife, dnugbter and blmself. Was nervous, restless. Had halluci-
nations. At times became violent. Used opium and cocaine.

Patient is well developed. Sallow featund. Began to use opium
about four years ago, and somewhat lattr cocaine. Developed de-
lusions of persecution, having a deQnitv; basis, well formed and
well systematized, motived and InQuendng his actions. The basis
appeai-s to be mostly of hnlluci:>atory origin, those of hearing and
sight. Also has delusions of jealousy. Says that he is the victim
of circumstani.'es and a conspiracy.

Diagnosis : Toxic iosanity.

Male. Age 22. Farmer.

Onset a couple of mouths before admission, by odd conduct. Best-
lessness. Sleeplessness. Wanted to roam about Imagined that
his family were against him, that his associates had drugged and
doped him, that people mistreated him. Complains of headache.
Had outbreaks of violence. Tbreatened suicide and homicide.

Patient is of medium build and in a poor state of nutrition. Had
some facial asymmetry. The left optic disk appears congested. Said
that following a drink of whisky that had been given blm was the
cause of the headache.. Vomiting followed. Saw objects doubly
and apiieared to be at a great distance, but when he attempted
to take bold of them tbey would come cli;sor togetber. Could not
remember. Would be overcome by blaukness, but would imme-
diately regain consciousness. Is emotional and depressed. Mani-
fests apparent dementia. Has some Insight into his condition.

One sister insane. Patient iuteigperate.

Diagnosis : Dementia praecox.

Male. Age 48. Farmer. Married.

Onset thirty days before admission, followiug the death of bis wife.
Became sleepless, melancholy, Incoherent in thought and action.
Imagined that he was ruined, that he was going to starve and
freeze, that lie was all broken up. Threatened suicide.

Patient is well developed and moderately nourished. Emotionally
unstable, usually depressed. Is apprehensive and fearful. At
times becomes agitated. Rubs his bands and pulls his whiskers
continually when talking. Is easily excited. Complains some of
his treatment at home, bnt it can scarcely be called persecutory.
Has a feeling of impending poverty and ruin, etc. Has partial in-
sight into his condition. Attention can be sustained only witli
difficulty apart from the subject of his delusions, and his whol*
niiinner of acting; and thinking Is colored by the content of his
delusions.

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297

Maternal grandfather and one matei'Dal uncle Insane. One sister
and one halC-brother have nervous trouble.

Diagnosis : Agitated melancbolia.

Male. Age 44. Farmer. Married.

Onset about one year before, by Incoherency in speech, lack in the
sense of propriety, becoming intoxicated, having delusions of
wealth and of persecution.

tatient is well developed and well nourished. Has a feeling of gen-
eral well-being and exaltation. Is emotionally exalted. Has de-
lusions of unlimited wealth, of personal ability, of power and ac-
quirements, etc. Attention Is easily diverted. Memory impaired.
Impairment of reason, judgment, moral tone and Insight into his
condition.

Facial expression Is rather void and espressioulesa. Tremor of the
lips and tongue. Dlfliculty in speech. Tremor of the hands. Writ-
ing defect. Unequal pupils, the left being the larger. Loss of
knee jerks. Increased plantar reflexes. Marked Rhomberg's sway-
ing. Marked ataxia of movement and gait. I'atient had Hypbllls
at the age of 20. l>ater rheumatic-like pains In the muscles and
stomach.

Qrondfother intemperate and father Insane.

Diagnosis : Tabo-paresls.

Male. Age 57. Farmer. Single.

Onset about one year liefoi'e admission. Followed overheating In
the sun, resulting in involuntary evacuations of urine and faeces,
high temperature. Became loud, talkative, profane. Had out-
breaks of violence against his surroundlngx. Manifested general
mental and physical depression. Mad delusions in regard to pos-

Patient well developed and well nourished. Feeling tone generally
exalted. Emotions unstable, usually exalted and easily excited to
anger or laughter. Talkative at times, manifesting alight tremor
of the lips and tongue, with slight hesitation in speech. Accelera-
tion in the flow of thought, with a tendency to flight of ideas and
Incoherency. Attention dlvertible. Has no insight into his own
condition or Into that of his fellow-patients. Has rather pro-
nounced ideas of persecution, with some degree of reasoning. Is
egotistical. Actions and movements exalted and accelerated, corre-
sponding to the accelerated flow of thought, leading at times to
outbreaks of anger and violence.

One brother said to be tubercular. Patient has well-marked arterio-
sclerosis.

Diagnosis ; Hypomania.

Male. Age 33. Merchant. Married.

Onset about nine mouths before admission, by turning against his
family. Wanting to go away, but to no definite place. Could not
be controlled. Imagined that he was drugged. Refuses to take
mt'diclue. Was unable to concentrate his mind or to manage his
business. Manifested loss of memory. Had exaggerated ideas of
wealth. Secreted knives and rocks about him.

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Patient of alim build hut fnlriy weli nourished. Very n
perament. LoquaciouB, with acceierated flow of thouglit and
flight of ideas ieadiifg to iucoherency. Manifests a haughty, self-
important demeanor, an overestiraafion of aeif, hia actions and
movements corresponding. Has a teeilng of general weil-being.
No Insight. Total amnesia for a period of about six weets of
the acute stage. Mild persecutory Ideas, which are not sys-
tematized. Some tremor of the ilps and face when talking. De-
creased knee Jerka. Attention readily dlvertible. Emotionally
exalted. Patient bad ayplillis at the age of 20.

Ail of the family are of a nervous temperament. One sister had
nervous prostration.

Diagnosis ; General paresis.

Male Age 54 Farmer Married

Onset two years before while being sworn foi a jury In a murder
trial at whiih he was not accepted and then Imagined it was
because he had done some great wrong Was restless sleepless
and wandered ibout Would not talk Imagined that someone
was after him and ran away Wmted to see the Judge At
tempted suicide

Patient Is sparelj built Shows facial nod aural asymmetry Facial
expression Is anxious and ai>t-''^bensive Movements and actions
aie slow and retarded and show loss of tone How of thought
and associatlcn of Ideas are retarded Imagines that he gave
answers to questions that he should uA ha\e given that he beard
the word bloody and tLought It refeiiwl to him upon which
he has engrafted the delusion of impending harm Has only par
tial Insight into his condition I<i emotionally unstable Looks
restlessly about him ( ontiiiually tul>s bis hands Patient has
rather extensive arterio-sclerc«is and a mitral murmur

Mat«ruai fathei not bright One maternal coualn auicidal One
brother intcmijeiate One birther tubercular

Diagnosis Agitated mel incholia

Male Age 31 Laborer Married

Onset nine months before admission by foolish talking and acting
cursing shearing outbreaks of anger and violence Imagined that
someone was lyln^ in wait to kill him that t>eople nere In the
(ellar that the house was full of electricity that people were
Hhooting at him and that be nis being smotheied

latlent is well developed and well nourished Manifests some re
tnrdatlon In com[>rehenslon and in the flow of thought Emotions
as 1 rule are Indifferent at times exalted and excited Actions
and movements as a rule indifferent and listless Facial expres
sion apathetic and listless Memory a| parently much impaired
piobnbly due to the Indifference and to the lad of mental energy
more than to actual 1 iss or torgetfuliiess Has some vague de
lusDis tf persitiition and Infldtlity Patient is Intemperate In
the us of alcihol and tobacco

U inaterinl uncle feebleminded Mother liysterical One sister
physically deformed

Diagnosis: Alcoholic paranoia.

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209

Male Age 54 ( nrpenter Married

Onset one month before admission Moody Melancholy Irritable
Intempemte Imagined that something was pressing upon his
skull that he was itraing his mind that he would Injure himself
tr others Wandered about (.i-mpliined of headache

Patient is well nourished Shows fatial and ranial asymmetry
Some limitation In the field ofi'iaion in the right eye Urine con
tains albumose and oxalatci Admits intemperance but claims
total amnesia for the mental disturban<es Patient has had sev
eral injuries

One maternal uncle Intemperate

Diagnosis Alcoholic insanity

Male Age 35 Farmer Married

Onset not given Imagined that a mol was after him that the
state militia w<»s waiting for him Threatened to liiil himself
and wift Alleged plfts against him Was \ery suspitiouB Tin
conditicn followed the wounding and killing n man in self defense
which caused him to brood and grow despondent Was discharged
in six months ItecommKted ftiir years after as l>elng melancholy
Secreting blutself Threatening his wife and son Cutting the
telephone wires etc

Patient le powerfully built Is susi itioua seeretHe and irritable
I acial expression one of resentfulnes? and obstinacy Has de-
lusions that he was doped by poison being put into his food which
made his mind floudy Could not understand things or get the
connection between them Has delusions of persecution and In
fidellti Has no insight into his itrnditlou Patient hal gonor
rhoea at the age it 20 Is intemperate Has glycosuria Blood
pressure 175 m a sitting pcsture

Father intemperate Mother tubercular

Diagnosis: Alcoholic pseudo-paranoia.

Male. Age 43. Laborer. Married.

Onset two weeiiS before admission, by a pain In the head, by leaving
his bed at night and running to the country nude. Imagined that
some one liad burned his wife and child and would burn him.
Became maniacal and excited

Patient la slim, moderately nourished. Head very small posteriorly.
Bars large and winglllte. Had gonorrhoea at 18. Is Intemperate
at times. Has had several pulmonary haemorrhages. Says that
he was drunk when arrested prior to admission.

Diagnosis : Acute alcotiolism.

Male. Age 34. Pattern maker. Married.

Onset five weeks before admission. Talked to himself. Treasured
and played with the children's playlhinga. Imagined that he was
wealthy, had killed burglars, and owned considerable property.
Had hallucinations.

Patient is small. Pale. Has an infantile featured face, yet is wrin-
tieil and apijears senile. Face is small, narrow and pointed.
I'ai-iai expression is apathetic and indlfEerent. Manifests general
tremulousness, most marlced In the lips, tongue, hands and feet.
Speech is tremulous, hesitating, with elision and reduplication of

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300

letters and syllables, and at times words. Writing shows similar

, defects. Knee Jerk Is absent on tbe right Bide, exa^eroted on
the left. Plantar reflexes are Increased. Shows marked demen-
tia. Memory defect pronounced both for recent and remote events.
Emotions unstable, tending to exaltation. Manifests a feeling of
general well-being. Has well-marked delusions of wealth, and
slight of persecution. Patfent had syphilis at the age of 20. Well-
marked optic neuritis.

Diagnosis : General paresis.

Male. Age 37. Miner. Married.

Onset one year before admission, by talking at random, by asking
foolish questions and giving foolish answers. Tncoherency In talk
and action. Melancholy and whining. Subject to attacks of un-
consciousness but no convulsive seizures and followed by a para-
lytic condition of the left arm, passing off in twenty-four hours
imagined that his friends were conspiring against him and threaten
to kill him.

Patient is well developed and well nourished. Facial expression is
apathetic and confused. Has alight insight into his condition.
Is partially oriented. Manifests memory and intellectual defects.
Rather well-marked dementia. General tremor of the lips, tongue,
hands and feet. Speech hesitating, tremulous and stumbling.
Writing is tremulous. Tremor of the left band more than the
right, and Is increased by volitional movement, the left shaking
rather violently while trying to write with the right. Knee Jerits
increased, the left more than the right. Plantar reflexes de-
creased. Movements and gait inco-ordlnate. Had gonorrhoea at
18, Wife had three successive miscarriages. Had an injury to
the back of the neck about one year before admissioh. Blood ves-
sels are thickened.

Diagnosis : Brain syphilis.

Male. Age 35. Walter. Single.

Onset one year before admission. Imagined that his friends were
against him, that detectives were after him. Was restless, sleep-
less and noisy. Wandered away from home. Played marbles and
other simple games with small boys. Was Immoral. Used cocaine.

Patient is well nourished, Atttention easily diverted. Talkative.
Flow of thought accelerated. Flight of ideas. Irrelevancy and
incohereucy. Almost complete disorientation. Many delusions,
mostly exalted, transient and fleeting. Some acceleration In move-
ments and actions.

Grandmother and one uncle Insane.

Diagnosis i Toslc Insanity. (Cocaine.)

Male. Age 31. Brakeman. Single. *

Onset ton days before admission. Irrational in talk. Sleepless.
Melancholy. Morose. Has some delusions of persecution. At
times becomes violent and destructive. Works constantly at mak-
ing what he imagines are mechanical contrivances out of Strings.

Patient is well duveioiied and well nourished. Facial expression
apathetic and confused, Atttention poorly sustained. At times

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301

. retardation lo the flow of thought and In the association of Ideas.
Complete disorientation. Mistakes the personality of others.
MenjOTT defective. Tendency to irrelevancy and incoherency.
Very little Insight Into hlq condition. Delusions of persecntory
content nnmotlved. Is suspicious and apprehensive. Tremor of
the lips and tongue. Difficulty and hesitation of speech. Tremor
of the hands. Defect in writing. Impaired vision. Contraction
of the field of vision, more on the left side. Optic atrophy, more
marked on the right side. Ataxia in the movements of the feet.
Depression over the left parietal bone, the result of an operation
performed for an injury received three months Ijefore in a railroad
accident. Patient had syphilis at 22, gonorrhoea at 24. Acts In
youth necessitated his being sent to the house of correction sev-
eral times.

Father and two brothers insane.

Diagnosis : General paresis,

Male. Age 37. Miner. Married.

Onset two years before admission, by pain In the head. Confused
In what be attempted to do. Loss of memory. Having spasms.
Preaching and praying. Imagined that his watch was full of
diamonds. Had an injury to the head. Later was operated on
to relieve the pain, but was ineffectual.

Patient is well developed and well nourished. Attention is some-
wttat divertlble. Is talkative. Speech somewhat tremulous, hesi-
tating and lalling. Has no Insight Into bis condition. Is egotiatical.
Emotionally exalted- Manifests a feeling of general well-being,
ncceleration iu the flow of thought. Grandiose delusions of wealth,
of personal ability and power. Hands tremulous, well shown 'In
the writing. Knee jerks exaggerated slightly. Right pupil non-
reactive to light. Atrophy of the optic nerves, more marked in
the right eye. There is a depression and overlying scar over the
riglit temporal region about 5 cm, in diameter and posterior to the
external angular process of the frontal bone and inferior to the
inferior temporal ridge, the result of an operation. Patient is
subject to convulsive seizures, not involving the legs and followed
by drowsiness.

Diagnosis : Traumatic general paresis.

^fale. Age 50, Farmer. Married.

Onset one year before admission, by tendency to concentrate his
thoughts upon his stomach trouble. Complained of pain in the
head and hack. Nervousness. Insomnia. At times t)ecame ex-
citable, claiming that he was losing his mind. Threatened suicide.
Had a feeling that be must strike some one.

Patient is poorly nourished. Began to have jialn In the head, back
and neck. Complained of stomucb trouble three years ago, which
was almost continuous, and be finally felt that he would not get
better, that he and his family would come to want. Grew de-
spondent and hypochondriacal. Emotions markedly depressed.
Acquired ideas of self -depreciation. Killed his wife and three
cliildren and attempted suicide under the Idea that such was the

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only way by which his fniully could be prevented from coming
to want. After admission Improved some mentally and physically,
hot after about six months succeeded Id committing suicide.

Diagnosis : UjiKH'hondrlacal melancholia.

(See autopsy report No. 189.)

Klale. Age 22. Cabinet maker. Single.

Onset about one year before admission, by strange actions. At-
tempted suicide. Had outbreaks of anger and violence. Imagined
that he owned his uncle's proi>erty and had owned It for thirty
years, and so need not work.

Patient is well nourished. There Is facial asymmetry. Is a Dane
by birth and can not understand or speak English very well. Says
that a year ago he was not feeling well, so sent away for some,
medicine, and thinking that if a ijnmll dose did some good a larger
dftse would do more good, took an overdose, hence tlie basis of
suicide. Admits that he grew angry because they refused to as-
sist htm in regard to some imlou papers. There is present a
spasmodic Jerking of the heqd, more marked on the left side, quick,
short, chin down and head back, under voluntary control, ex-
aggerated by eicltement or when attention is directed to It,

Diagnosis :

Female. Age 31). Married twenty years.

First admission at 20, followed a change of residence. C<»uld not
eat nor sleep. Would neither talte medicine nor do what was
asked of her. Was not satisfied with anything done for her. She
said the world was on fire. Every one was going to be burned up.
Has delusions of fear and of imaginary enemies, continually talk-
ing Incoherently and disconnectedly. Has spells of excitement,
running about the house, screaming, pulling her hair, etc. Fol-
lowed by periods of depression, in which she remains mute and
stares into vacancy, refuses food. Threatens suicide and threatens
violence to those about her. Was discharged as recovered four
months after admission. Readmitted ten' years later.

Emaciated and anaemic ; disoriented as to time, clouded and con-
fused in consciousness; no clear Insight into her condition; knows
there is something the matter, can not tell wtiat Has delusions
of Impending barm with persecutory coloring. Says if she has
sinned the fault does not lie within herself. Is fearful, suspicious
uud somewhat confused. Responses, mentally and volltionally,
are slow and delayed, but coherent and relevant. Emotional at-
titude is changeful, with a mild degree of hebetude noticeable,
slight tendency to mutism, some difficulty in arriving at a de-
cision. Patellar and plantar reflexes active. General tremor, af-
fecting chiefly the hand and tongue. Slight static and motor inco-
ordination. Slight disturbance of tiie color vision as regards yel-
low and green. Slight venous stasis of the lower limbs, feet cold
and slightly oedomatous, gait Inelastic. Facial expression down-
fast, rather anxious. Thinking and acting requires visible effort
and seem to cause fatigue. Blood pressure in right arm in sitting
posture 115 mm. ; pulse rate 80 after examination.

Diagnosis : Regarded as manic-depressive.

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303

Female. Age 37. Married ten years. One child.

Onset followed taking part actively in religions services. Became
greatly worried about her spiritual welfare; became agitated,
wandered ahont the streets. Said the last days wonid see signs
and wonders of tlje end of the world. Became extremely sensi-
tive to praise and criticism. Has auditory and visunl hallucina-
tions. Would loot into books and say she saw pictures where
there were none. Would butt her bead against anything solid
in order to fry to kill herself. Has been subject to hysterical at-
tacks of excitement. Takes no notice of ber surroundings. Does
not appear to understand what is being said and done. Only the
simpler questions are answered relevantly, and the simpler orders
carried out; otherwise is coufused and uncertain. Tendency to
mutism and negativism. Condition ot memory is difficult to as-
<«rtain. Is apprehensive. Says that she ought to be burned for
her sine.

Physically annemlc. Apparently prostrated. Tongue tremnlous.
Reflexes exaggerated. Movements slow and tremulous. Blood
pressure, 105. Pulse rate 85 In a sitting posture. Temperature
09° to 100° F.

Mother insane

Diagnosis

Female Age 43 Married

Onset foil med a fire In the house within a week with great psychical
and some mctor restlessness Incohetenoy and irrelevancy in oon-
lersatlon mostly of reltgtous content Think'i that it Is ber duty
to preach and wants to do so continually General exaltation Is
noticeable la disoriented as to time place and persons Has de-
lusions of persecutorv and religious nature Hallucinations of
hearing Emotions unstable exaltation being the prevailing mood.
Memory impaired for both recent and temote events Attention
is eai-llj diverted Vt-sodatlon of ideas is changeable and the
flow of thought is accelerated ultb a tendency to attempted wit
and endeavor to make remnrks lmpres.iie No Insight into her
condition Loss of control oier her thinking and acting the latter
tending to be impuKlve

Phjsicalir i« well develoiied and well UDiirished Bellexes decreased.
Popular} reattijn sluggish irregular and uneiual Biglit iris
more pigmented than the left Some tremor of the tongue and
hands Slight nmllllng and ludistmctne«s of the mitral systolic
murmurs Irregularity of the menstrual fiinLtlons

Mother died of asthma Father it lung trouble Both oier 70

Diagnosis Mania

Male. Age 54. Machine hand. Married.

Onset eight weeks before admis'Suui. limigined that a neighbor had
lllliit relritloiiK with his wife and daushter. Was exti-eniely Jeal-
iiiiH of Ills wife. Had haltucinallonw of hearing, sight and smell.
Feared tlint jiolson would be administered to hlni. UestlesJi.
Sleepless. Subject to outbreaks of violence. Threatened suicide.

I'fltleiit Is well developed and well nourished. Is Irritable, emotional
and excitable. Has pronounced delusions of persecution and of

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lujnstice. Has no Insight into his condition. Began by having
hallucinations of hearing, In that he heard the people at the fac-
tory talk, and also heard noises which led him to go home to ex-
amine If things were all right and would fled It so. The delusions
of persecution and infidelity are mostly based upon the hallnclna-
tlons of hearing and smell. Also baa delusions of sight and or-
ganic sensation, the latter forming the basis for the delusion of
being poisoned. Has a feeling of fear and apprehension. Knee
jerks exaggerated. Arcus senilis becoming marked.

Diagnosis: Hallucinatory paranoia, (Chronic, possibly praesenile.)

Male. Age 50. Farmer. Married.

Onset four weeks before admission, by wandering about aimlessly,
by threatening his family, by starting off to his work and forget-
ting about It. Imagined that his wife was untrue to him. Was
insanely Jealous of his wife. Could hear strange noises and see
strange sights. Had outbreaks of violence.

Patient well developed and moderately nourished. Had pronounced
Ideas of his wife's Infidelity. Well-marked delusions of persecu-
tion, well motived and well systematized. Had hallucinations of
hearing and sight. The following Is a copy of a letter he wished
the doctor to sign, whom he accused of Illicit relations with bis

wife: "This certifies that Mr. has paid me in full up to

date for doctoring, swearing lies and getting others to swear the
same and sending him to the asylum." The patient eloped to an-
other state. Later returned. Had to be recommitted.

One paternal cousin insane. One aunt tubercular. Father died of
apoplexy. Three children tubercular.

Diagnosis : Chronic hallucinatory paranoia.

Male. Age 27. Walter. Married. Negro.

Onset several weeks before admission, by acting strangely, refusing
to talk or recognize his friends. Subject to outbreaks of violence.
During the last four or five years has manifested a wicked dis-
position. Within the last six weeks has had epileptic convulsions.

Patient Is well developed and moderately nourished. Manifests re-
tardation in comprehension and response. Answers very slowly.
Appears to be In a state of confusion. Is completely disoriented.
Emotions are listless and apathetic. Memory In general is uncer-
tain. Shows marked speech defect. Knee jerks are exaggerated.
Ankle clonus. Plantar reflexes decreased. Had syphilis at the
age of 20, Complained much of headache during the last year.

Diagnosis : Brain syphilis.

Male. Age 61. Farmer. Married.

Onset one year before admission, with a psychosis reported as de-
mentia, supposed to be due to a bullet In the brain. Is restless,
sleepless, violent and intemperate. Discharged In seven months.
Readmitted in (our years, tben became violent aud delnsional.

Patient Is well developed and well nourished. Has very little educa-
tion. Claims to have a bullet In the brain, received In the war
over forty years ago, which affects his hearing, sight, taste and
smell on that side, and that he has not had a full nlghfs sleep

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305

for over twenty-five years. Has Lad every bone In his body
broken, etc. Is very loquacious. Emotionally exalted. Manifests
acceleration In the flow of thought and flight of ideas. Is ego-
tistical. Motor restlessness and activity. Loss of control. Nu-
merous changeable delusions and hallucinations which have no
motive and exercise very little influence upon bis acting and think-
ing.

Father and one brother tubercular.

Diagnosis: Recurrent mania.

Male. Age 47. Railroad conductor. Single.

Onset several months before admission. Imagined that he was mar-
ried, that he had killed many women, that be was a millionaire.
Was Bleeyless, restless. Had difficulty In speech. Loss of Itnee
jerks. In co-ordination of movements. Tendency to outbreaks of
violence.

Patient Is well developed and moderately nourished. Attention
easily diverted. Emotionally exalted and excitable. Very talka-
tive tending to Incoherency and Irrelevancy. Manifests accelerated
flow of thought and flight of Ideas. Has no insight into bis con-
dition. Is completely disoriented. Mistakes persous and sur-
roundings. Pronounced dementia. Pupils nou-reactive to light.
Tremor of the lips, cheeks and tongue, speech tremulous and
typically paretic. Knee Jerks exaggerated. Achilles reflex ac-tive,
with tendency to ankle clonus. Slight tendency to Rhomberg'.*
swaying. Some motor restlessness. Pronounced grandiose de-
lusions as to wealth, ability as a conductor, umpire in a state
baseball league for 20,000, has billions upon billions of money,
knew the Bible by heart, killed 30,000 negroes, will kt!l thousands
more, etc. Patient was In a wi-eck twelve years before. Also said
to have had syphilis.

M ternil aunt Insane ,

Dlagnnsls General paresis

Male Age 30 Farmer Married

Oniet about three ^ears before jdmisslon Melancholy Refusing
t eat at the table with anyone Imag ued tbnt some one was
toing to harm him Assa Ited fa uiiy Carr el flrearm*: and shot
at the neighbors

Patent s well de elo| -d and well nourished In agines that people
talk about h m Has delus ona of persecution and spite w r it be-
cause he drank Denies the rej ort of the co umitmeut record

1 ather one brother some uncles and cousins Inte u crate One
mitenal aunt, father mother aud one 'i ""ter tub r lar One
slst r bas i ervo s spells

Diagnosis . Alcoholic pwjudo paranoia.

Male. Age IS. Clerk. Single.

Onset three months before admission. Restless. Talkative. Had
outbursts of violence and anger. Made threats against the family
and himself. Had delusions in regard to his business. Imagined
himself a Jew and that he must convert the whole world to the
Jewish religion.

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306

Patient Is only fairly well nourished. Tnlkatlve. Active and ex-
alted. No iuelght Into Ills condition. Manltests Impaired Judg-
ment and reason, States that It wan difficult for him to learn at
school. Could not remain at work for any length of time at any
one place. Was subject to night terrors. Thought that he was a
Jew from what he heard voices telling him; these also told him
that his father was not his real father, that his father owned
extensive possessions, and by a process of square root he was to
fall heir to unlimited wealth. Imagined that he had been an
jictor, that his companions were always trying to get on the good
side of him, etc.

Ooe aunt, one paternal cousin and one brother melancholic.

Diagnosis: Hebephrenic dementia.

Female. Age 35. Married.

Onset two and one-half months before admission, by strauge actions,
crying, outbreaks of violence. Imagined that some one was after
her, that she had enemies. Feared that she would harm her chil-

Patlent Is well developed and well nourished. Said that about one
year l>efore admission she became restless and sleepieus. B^an
taking alcohol to produce quiet and gradually leading to excess.
Manifests considerable amnesia for the acute phase of the mental
disturbance. At times melancholic. At others agitated and moan-
ing, wringing the hands and wanting to go home. More or less
general enfeeblement of all the mental faculties. Physically there
Is a history of pconounced intempfivance and considerable arterio-
sclerosis

Diagnosis Akohollr insanity

(emale Ai,e -<i Married

Onset three to four weeks before adralssi )n by an outbreak of
maniacHl excitement and violence Crying sluglu^, swearing
etc Seeing blood on the nilN Imiglued that someone was
shooting her that the house wis on Are ett

Patient is well de\eloped and well nourished shortly after ad
mi'.ilon eiHlei tit (tnvulsions de^elojud which have contiuued
e\er since General muscular tone le flibby facial expression
somenhnt apatlietic lendeiitv to stupuous state* at times at
others whining depressloD at otheis ImbetlllL elation Speeth
dltflcnlt and retarded Writing tremulous lirge tending, to flour
Ishlng \ oluntarv moi emciits sluggish devoid of energy and
tonicity slow and retarded Sensory stimuli are slowly perceived
\ttention divertible Only answers simple questions correctly
and then slowly The more tompll(ate<l are ansnered the quicker
with the answer I don t know FUv. of thought retarded
Memory markedly Impaired Emotions unstable childish laugh
ter predominating Marked Improvement followed an tl syphilitic
treatment

Diagnosis: Organic dementia. (Syiihllls of the brain.)

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307

Female. Age 37. Married.

Onset three moutbs before admission. Imagined (hat she had com-
mitted some crime and was going to tie arrested Cor it Heard
men talking and planning to do her Injury. Is suspicious. Hides
all papers and labels. ThlDks that she is beiug persecuted, that
some persons are trying to make her sit and lie In certain posi-
tions. Refuses at times to ent. Is nervous, sleepless and easily
excited. Threatens suicide.

Patient Is well developed and moderately nourished. Only aDswers
simple questions, saying "I don't know" to the more complicated
oues. Seems to realize tliat something Is the matter, but does
not know what it is. Paclal expression Is rather apathetic, but
at times somewhat exalted. Talks to herself, Resists active or
passive movement and often refuses to carry out ordered move-
ments, becoming agitated when pressed to do so. Is auspicious,
apprehensii-e, disoriented and apparently confused. Makes quick,
furtive movements of strained auditory attention as if in response
to what she hears.

Two maternal uncles tubercular.

Diagnosis : Acute hallucinatory paranoia.

Female. Age 32. Married.

Onset six months before admission. Imagined that the U. S. au-
thorities were after her, were keeping ber out of work, were per-
secuting her, that she was to get a large amount of money, and
that people were trying to rob her, eta

I'atient Is well developed. Is very talliatlve. Dates back her trouble
over two years lu attempts to scandalize her by her employers
and fellow- workers, making Improper proposals, insulting remarks
and actions by men, etc. This led her to frequently change her
place of occupation. Is out of harmony with her surroundings.
Imagines that persons whom she accuses are conducting a legal
process to procure damages and expects to get a large amount
of money by this means. Emotions are unstable and do not cor-
respond to the content of her delusions. Patient of a highly nerv-
ous constitution.

Father and several brothers intemperate. Motber tubercular.

Diagnosis : Paranoia.

Female. Age 45. Married.

Onset iibout nine mouths before admission. Melancholy. Restless.
Nervous. Talkative. Easily excited. Pears poverty and ruin
to herself and family, that her husband can not care for her,
that her son will not give her tlie attention that she should have.
Threatens suicide.

Patient is well deveioi>ed, but poorly nourished. Is obstinate. Re-
sists Interference. Becomes violent Is suspicious and apprehen-
sive. Refuses to answe questions except as it suits her. Moves
uneasily about. Makes quick, turtive glances out of the windows,
frequent references to Injustice, impending danger and harm. Says
thiit there Is notliing to live for, everything twlng lost. Doctors

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belDg qnackB, etc. Fncinl expression 1b siisplclouR. apprebeneive,
frowning and vJclous. At times becomes agitated.

Diagnosis : Hallucinatory {laranola.

Female. Age 41. Married.

Onset two mouths Iwfore admission, by depression, loea of flesh.
Imagined that neighbors had connected electric wires to ber bouse,
that everyone was talking about her, slandering her, etc.

Patient is well dcveloiied and moderately nourished. She states
tbat about two years before sbe suffered from some disturbance of
vision, became dissatisfied with her surroundings, made frequent
cbanges, her neighbors became Jealous of Iter because she would not
associate with tbem, consequently they circulated stories about ber.
Heard phonographic voices of i)eoi>le sbe recogulzed. Imagined
that they came into her house at night when she slept and doped
ber with chloroform and opium, as she smelled It ; they put poison
In her food, as she tasted It; they reflected lights upon her. as
she saw It; acted upon her with electricity, as she felt it from
the hips down ; and heard voices at the windows at night. Tbinks
tliat ber husband acts differently than formerly, t)elng influenced
by others. Facial expression Is somewhat flabby. Manifests tre-
mor in speech, wltb a tendency to slow, distinct pronunciation.
Falls In the test phrases. - Tremor of the lips and angles of
mouth. Left pupil contracts Irregularly. Bight knee Jerks more
active than the left. Complains some of muscular weakness.
Slight oedema of the lower limbs.

Used morphia over ten years.

Diagnosis: Morphinism. (Incipient paresis.)

Female. Age 28. Single.

Onset about five years before admission. D^ressed. Melancholy.
Quarrelsome. Imagined that she was being persecuted ; that the
family were against her. Feared poison, which led her to eat
alone and only food prepared by herself. Threatened suicide.

Patient well developed and moderately nourished. Apart from the
delusions and want of insight there does not seem to be much
disturbance otherwise. Expression and action are Influenced and
controlled by the content of her thoughts and give a negative col-
oring to her general feeling tone.

One maternal cousin Insane. One paternal uncle epileptic.

Diagnosis : Chronic paranoia.

Female. Age 25. Married.

Onset five months before admission, by peculiar actions, singing,
talking incoherently.

Patient well developed, poorly nourished and anaemic. Manifests
fl defiant, self-important air. Answers questions sharply, curtly
and defiantly. Assunies an attitude of defiance and suspicious-
ness. Minds her own business and wants other people to mind
theirs ulso. Has Ideas of marked persecutory content. Does not
associate with others, as she does not consider them of ber sta-
tiou. Only lives where she does because finances compel ber to
do so. Has no intimate friends because she trusts no one, etc.

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Emotions are unstable anil correspond to the uoatent of ber
thought. Patient of a highly nervous constitution.

Diagnosis : Paranoia.

Female Age dO S ngle Negress

Onset abrut six wee s before adra aslon Mslted the pastor askiug
foolish question*) about the bible ( alls | eople o er the te ephone
and askt the same tl ugs Ret ises to let her father w rk Is
restless and talk tl e I naglucs that sbe is ele trifled that a
medium Is golDji, to eleitro ute her that si e has the key to King
Solomon B temi le that p rlta ate try ng to m rder 1 er ef Haa
hallu inations of h ar ng

Patient is wel leve oped and ell nourishes! Ai ude** to some
somati disturb n ■es n reference to e ectrle t H s s me insight
Into tbe past b t ot Into the present Be Iglo ^ ideas are sti
prominent Ideas of per&eiutory content api are tl subsiding

Ditgn:>sis Paranoid dementia praeiox

Female Age 2) Mnrrel (hid tea months of age

Onset about t o onths b fore adm ss n by suddenly becomi g
talkati e orjing rest e s and seep ss In ag ned that someone
or s mething vas go ug to 1 arm her her husband and babv that
they ould be k led Calls upon ber b sband to protect her At
times l>e omes viole t At tl e tl ne f adn lesion there was com
plete dlsorientat on na t of Insight clouding of co sclousuess
retardat on n compreheus on and flo v of thu ght Impairment
of memorj Later mpro enient gradually s pervened but there
was total an s a from the t me of onset of the disturbance un
til after adn isslon

Diagnosis Acute co fuslonal Insanltv

Fe nale Age 06 Married

Onset aboo one vear before by be nig abusive thro vl g rocks
at passersl)} tear ng up the carpets looking for bugs Imagined
that bI e as nder a mesmeric si ell that sbe on d reid mes
sages off le litres passiig the house that ne ghbors annoy her
that they t! ro v ele Irl ity uj n her Mu tera and ta ks to her
self rhre tens her own life and that of others

Patent la veil de e oped and well nourlshe! Dates her tronble
back o er tWo y ars re ing n essiges fr m the chirping of
birds the t cki g of t! e xrk the noise of the rad ator the p f
flag of the e glne et some of agr eab e content Others telling
her to be are to ha\e | atlence etc Some of rel g ous content
Has 1 ron lue t aud torv an 1 10 nitlc I a c natloi s Well marked
Ideas of persecutory ntent Mlsi t rprets what she perceives as
having direct referen e to herself Is ery eg tfstical soiplc o a
appreheni ve and antagonistic

One aiater t bereular &o k 1 el h s fe lldren and himself

D agnos a Ha cinatory paranoia

Femile 4ge 55 Married

O set abo t cissl t wefks bef re admlssl Tnagines th t she had

spcclfi trouble ff tli g t e reituu Bet n e elan holl rest
less ard sleep ess Itef sel to eat or drinl. saying that she co d

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not swallow. Became iiegllgeut of berself and family. StrODglj
suicidal.

Patient well developed aud moderately nourished. Says that she
Is not as she used to be, but Is Dot iueane. Is apathetic, seclu-
Bive aud Indifferent. Itetalns the hypochondriacal Ideas.

F«ther and one brother lusaue. Husband was shot by her brother.

Diagnosis : Hypochondriacal melancholia.

t'emaie. Age 33. Married.

Onset Qve mouths before admission. Talked irrationatly. Was fear-
fnl of impending harm. Imagined that her lungs were gone, that
her other oi^ans were decayed. At times became violent and pro-
fane. Is BuspiciouB, 'J'breatened suicide.

Patient well developed and well nourished. Dates the present trou-
ble back two months, in that she was kicked down stairs by an
unseen woman ; was put into a trance lasting four days. Has
ideas of a persecutory content, some of grandiose content, some
of Jealousy. Persecutory Ideas are systematized and motived. Has
hallucinations of sight, taste and general sensation. Is apprehen-
sive and suspicious. Emotions are changeable corresponding to
the content of her thought. Hints at self-destruction. Actions
and movements are to a great extent governed by the content of
thought. Patient had an attack of nervous prostration some
years at,'o. Is said to always have been reticent, self-willed and
thought herself superior to her surroundings.

Mother's family tubercular.

Diagnosis : Hallucinatory paranoia.

Female. Age 29. Married, Youngest child Ave months old.

Onset two months before adAiission following a severe fright sliortly
before confinement, by becoming melancholic, restless, sleepless
and suicidal. Imagined every one talking about her and that she
was being influenced by electricity.

Patient well developed, but only moderately nourished. Has de-
lusions of persecutory content, of having been poisoned, of vis-
ceral derangements, of snakes being thrown into her bed. Has
hallucinations of hearing, tasting and common sensation. No
motiving or systematlzation of the delusions. Is snspiclous and
apprehensive.

Si other insane.

Diagnosis : Haliuncinatory paranoia.

Female. Age 40. Single,

Onset three mouths before admission. Became absent-minded. Paid
no attention to anything about her. Constantly disarranged
things. Dissatisfied with everything. Had periods of d^resslon
followed by periods of excitement. At times in a partial cata-
leptic condition. Was obstinate. Refused to talk. Said that she
was Impelled to do things by voices that she beard. Secreted
things of no significance. Bat only when told.

Patient well developed but poorly nourished. Tall and slim build.
For some months after admlssloD there was absolute mutism tend-
ing to stereotype and catatonia. After this passed away there

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was retardation in thought and action fl»w of thought and asso-
ciation of Ideas all movements and actions being carried out un
der considerable tension and stiffness causing some inco-ordina
tion saying that they were induced by the voices which she hears
within her the content of them being usually of iKisitive feeling
tone Facial expression Is one of blankness Memory seems to be
Impaired

Mother insane

DiaguoHls Haltuilnatorv iNirauoia

iemale Age 70 Married

Onset seieral year>t before admission Restless Sleepless "serv
ous Excitable t^uicidal and homicidal

Patient well de\eloi)ed but pooriv nourished Undergoes spasmodic
jerky movements affecting all parts of the body Are involuntary
Increased bj excitement Affect speech AfCect all actUe and
passive movements Gait silastic and Incoordinate These move
uienls began about eight years before Involve the arras and head
more than the lower limbs In addition there is a fine tremor on
voluntary morement Rather extensive dementia ESitensive
arterlo-scieroslB and atheroma Valvular disease of the heart
\rcus senilis Impaired vision

Grandmother mother and two slsttrs had a similar affection in old
age Mother and one brother tubercular

Diagnosis Huntingdon e chorea n ith dementia

Female Age 50 Married

Onset sin months before admission by carelessness in her household
duties tilthlness Erratk ideas In regard to doing things eating
and drinking Also In her relations toward child bu9t>and neigh
bors and ihurih Writing disconnected letters Wandering about
the streets etc

I'atient is of a lery nervous constitution loolts much older than
she ii Has always been eccentric Traces her peculiar ideas
back to the time of the birth of her first child Gives various ex
planations for all hei actioufc Ihluita that She has been mlsuu
derstood Did not come tt^ether with the iieople She wanted
to accomplish a certain object but could not explain as the idea
seemed to be rather vague e»en In "her own mind Has no insight
into her o\in condition or into that of her fellow patients Is
very egotlstital

History of tuberculosis on the maternal side One maternal uncle
lud lunt dtaf niutis Mother ecrentrlc One brother and one
sister Insane

Diagnosis IMiranoia upon a psycfqjathic constitution

Female \ge 55 'iingle

Onset three weeks liefore admission Imagined that she heard men
breaking Into th< housL heard messages over the ttlephone
Wanted people arrested for inmginarj wrongs Thought someone
do|Md her when asleep Had outbrealis of violence and anj.er

I'atient well developed and well nourished Has prominent hallud
nations of hearing taste, smell general and sexual feelings, thoae

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312

of smell being particularly prominent and referring to ttie eesual
orgaii8 arousing sexual organiems. Is drugged at ulgbt, cauelng
Iter head to wlilii the pljlow. lias Ideas oC persecution, of seif-
impui'tance, being apparently baaed upon the ha Hue I nations. Is
very talkative yet evasive in her answers. Secluslve and sus-
picious.

Diagnosis ; Hallucinatory paranoia.

Female. Age 31. Mtirried.

Onset about two weeks before admission, tloldlug her hands and
arms above her liead almost continuously. Singing. Praying.
Saying that the witches were after her, that she was bewitched,
tliat the witches beat her, pound her flesh, stamp ou the floor ;
that the neighbors have control over her. Moving about con-
tinuously, making peculiar ntovemeuts and gestures.

Patient is poorly nourished. Onset followed a miscarriage, com-
plicated with severe haemorrhage, lias some insight Into her
condition. Mas a feeling of burning in the flesh somewhat like
electricity, which lualies her reel and stagger at times. At the
time of admission there was considerable depression which grad-
ually disappeared as the physical condition improved giving place
to a mild degree of hypoiuanlacal exaltation, eventually passing
to normal. Paternal grandfather had senile dementia. Father in-
temperate. Mother had lieart trouble. One brother intemperate
One sister had mental disturbance following puerperal septi-
caemia. One Sister had enlarged thyroid gland. Patient either
aborted or miscarried with the last three pregnancies. Also has
bilateral enlargement of the thyroid gland.

Diagnosis Acute confusional insanity

I tmaie Age 59 Married.

Onset not known On admission was taitiatlve abusive proCane
destructhe and Inclined to nander awaj

Ptdent Is well deieloped ind well nourished Has prominent de-
lusions of persecutory tontent with a definite bails well mart>ed
sj '.tenmtization and motiving Some general hallndnatku^ No
insight into her cfndltlon i,motionaliy exalted Feeling of gen
t-ral well being and satisfaction Egotistical In regard to personal
ability ind accomplishments shrendness Is rither talkative
rone rathei vindictive 1 atlent has had three mlstarrlages Was
in Inmate of \n Ins me hospital three years before

Maternal heredity of lntemperan<-e Mother and one lialf brother
tubercular

Diagnosis Chronic paranoia

female Age 49 Married

Onset two years befoie iidmlsslon with a feelint of tear of impend-
ing harm Imagined that she had enemies Had Ideas of perse-
cutory content Hallucinations of hearing the voices tantalizing
her etc Hallucinations of seeing persons cf her community etc.
■\Iumbles tud laufehs to hei'self Lses piofiiu and obscene lan-
;,ua>,e Makes foolish motion'. Threatens the lives oC the neigh-

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Patient well developed and well nourished. Snys that she beard
the people whisper and curse her, talk about her because she would
not visit them, would shoot beaus at her and blister her skin, saw
cayenne pepper on the doorstep, etc. These delusions are traced
back over five years. Is very secretive and suspicious. Has no
Insight Into her condition. Patleut has a discharging sinus In
the left side of the epigastrium which b^an as a boil many years
ago, its margins are considerably indurated and It is apparently
situated In the niuscnlar walls. Patient has just passed the
climacterium.

Mother and two sisters of a neurotic constitution. Tko sisters
tubercular.

niagnosls: Halluciiiatorv imrauoia. (Climacteric.)

Female \g( 23 *iingle

Onset sl\ weeks before admission Morose D<ires>!ed frr se\(iil
week'5 then btiime wild and extlteil I inching and talkin,; m
coherently Imagined that someme was ;,olng to kill her ran
info the street" shoiitins murler r«ndly exposed the body Had
outbreaks of violtnce On admission the patient was noisy e\
(ited Irntional luioherent nith well maiked psycliomotor m
tiiiti Imirnement gnduallv took pla e and fsr several mouths
she seemed noimal Then then was complaint of impaired vision
lieada(he restlessneHS and somt igltatlon Imaj-lncd tbat she
had swallowed a pin tbat her sj«tem was full of mlneials thit
she had committed iDdeccnt acts disgracing herself the Institii
tlon etc Had ideas of self depretiatli n with no insight Into her
condition eittit to admit that she was Insane W is more or leas
agitated Imai^ined that the hammeiin^ of wiikmen about the
building was for the puriose of building a dail pH e t> put her
into It that o\ery me In the ward wis against her and thInkH
bidh other etc Knee Jerl s letni HI xwl i ressuie 1 m lulse
fast

One lunt insane

Uiagnosls i Circular insanity.

Female. Age 45. Married.

Onset two months before admission. Imagined that people weri'
angry at her, made fun of her, were trying to harm her. Had out-
breaks of violence In which she shouted, clapped her hands, walked
the floor, threatened her own life and that of those about her. On
ailiiiission was restless, sleepless, Incoherent, Irrational. Feared
harm. Had Ideas of i>eraecution. of self- depreciation Halluclna-
tloas of hearing.

Patient well developed and tiesby. Onset followed the sudden death
of ber husband who had come home dnink and bad driven her
out, during which she expressed the wish that he would die. As
a result u|ios this was engrafted the idea that his death had been
brought about by this wish. Imagined that people were coming
toward ber to kill her. Interpreted the remarks of strangers as
having that slgiilflcaiKf Facial e.vpresaion Is downcast and de-
{iressed. Movements and actions are languid and slow. Moans

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and bewails ber Inipendlag deatb. Is emotionally ai;ltated and
depressed.

Fatber committed suicide.

DlagnoBls : Agitated melancholia.

Female. Age 27. Married.

Onset a week before admission by strange actions, Incoberent talk.
Imagined tbat someone was going to poison ber, tbat the charm of
God lay next to her heart. Took off her clothes. Drove people
from ber taoutte. Could not keep still. Screamed at night. Had
outbreaks oC violence and excitement.

Patient well developed and well nourished. Has a low type of in-
tellectual appearance. Is very emotional, usually depressed,
Laugbs and cries easily. Imagined tbat she is being poisoned and
is going to die, that she can not be saved, that she is pregnant,
that she was conceived by the Holy Ghost, that the Catholics
and Jews were trying to get ber, that she Is an Illegitimate child.
that her mother never treated her justly and would never talk to
her of her early life, etc. Memory la noticeably Impaired,

One great uncle insane. Patient was Immoral, dissolute and intem-
perate before marriage.

Diagnosis : Paranoid dementia praecox.

Female. Age 36, Married.

Onset nine years ago. Talking Incoherently. Crying and singing
alternately. Imagined that everyone was agiiinst ber, aud that
they are plotting against ber, etc. Had outbreaks of anger and
violence.

Patient is of a very nervous temperament. Well developed. Has al-
ways had feelings of depression and melancholy at the time of
the menstrual periods. Onset of the present trouble followed con-
finement. Emotions unstable, usually exalted. Very excitable, be-
ing subject to outbreaks of excitement, followed by a period of
depression. Has Ideas of well marked persecutory content.

Patient has had seven confinements in eleven years, wltb nervous
spell after each one. Oldest cblld bad convulsions beginlng at
the age of 2^! years aiid is feeble-minded. One child is near-
sighted aud another is croas-eyed.'

Diagnosis : Hccnrrent mania.

Female Age 30 Married

Onsit ubout two months before admission bj talking irrational!}
and Rtlug like a drunken woman Imiglued tbat her husband
and familj had turned against ber Began preathtn, and praying
upon the streets liefused to eat Attempted suUlde

Patient well developed and fairly nourished Hhi almost complete
insight Into her condition Dates the onset of her disturbance
to the death of her mother about fl\e months before admission
Ijecoming dqtressed melantholy ett because ber mother had told
her that she had negletted her Bible so began to gne more time
aud att nticn to b(i de^otims felt that she bad not been doing
«hat was right noiiled l>ecHiise her hn^buid diank some and
mlwtreated lier and hud i'cpre>is<d a «lsh (hat she woul 1 die

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3J5

B^an to feel that her husband and ftiiitlly were ogaiusf her, con-
sequently there was notliing for her to live, so attempted suicide.
Had always felt that her husband's relatives did not care for h*>r,
and had so ludueuced him as to make htm act strange); towards
her, floally leading him to place her In the institution to get her
out of the way.

Ooe maternal cousin had chorea. Some maternal UDcles and father
Intemperate.

Diagnosis :

Female. Age 32. Married, Negress.

Onset unknown. Imagined that i>eople were envious of her and an-
noyed her, that the spirit of dead persons tormented her day aod
night and were going to do her harm.

Patient fairly developed, only moderately nourished. At times re-
sents Interference and is obstinate. When left to herself appears
depressed and downcast. Mas ideas of well marked persecutory
content, dating bat* over three years, leading her to go from place
to place to escape it. Thinks herself the victim of envy. Has
hallucinations of sight, hearing and general sensation referring
in content to eats, dogs, etc. Is talkative. Emotionally is some-
what exalted. Is subject to outbreaks of excitement and violence.
Some tremor of the tongue and hands. Cannot repeat test phrases
correctly. Knee Jerks exaggerated. Tendency to ankle clonus
aud to Rhotnberg's swaying. Patient intemperate. Refers to an
attack of mental disturbance ten years ago.

One maternal cousin epUeptic.

Diagnosis Aii-ohollc hallucinatory paianola

Femile Age 38 Single

Onset about se\en years before gi\lug up her work as a teacher be-
cause of imaginary moral unhtuess Varied hei religious opin
ions Became greatly eittlted when opposed Had outbreaks of
violence Was irritable and emotional I nable to pursue ine
line of conduct or thought for anv length of time

Patient well developed and well nourished At times la dictatorial
and unreasonable in her demands and requests Says that as
she sees things now nlie made a mistake In the way that she did
things leading to the mental disturbanc-es Was right in her mo-
tives but adopted the wrong methods Was not correctly under
stood lii^erythlng would have resulted satisfactorily If she had
been allowed to have her own way Makes vague references to
the objects that she wished to attain Has some ideas of a perse
cutory content others of personal sujieriority Manifests Impair
ment of Judgment and reason Is entotlonally exalted and rather
Irritable Has no Insight Into her own condition Has been fur
loughed sc\i.ia] times but can not a commodate herself to her
surroundings

One paternal un le and one slstei Insane One sister and niece
scrofulous.

Diagnosis : Paranoia.

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Female. Age 27. Single.

Ouset by becoming Biillen and abusive to those about her, by onf-
brenke of auj-er and violeace. At timps boisterous, vulgar and in-
decent. . Talking ramljllug and slily.

Patient well developed and well nourished. Tracee her disturbance
back to the age of 16. in that her mother thought less of her than
the other ohlldreu, did not teach her as she should have done.
gave her no attention. Influenced the neighbors so that they never
came to see her. and did not treat her right. But says that she
did not cnre, as they were not good enough for her to associate
with, so would not go to tlie same church aa they did. Brothers
did not love her and would not let her love them. Neighbors
were always laughing at and elurrlnc her. Attributes the whole
trouble to a school girl who took away her sweetheart and Influ-
enced her mother and brothers. lias no Insight Into her condition.
Has hullncinations of sight and hearing. Has exalted Ideas In
regard to lierself. When furlougUed is subject to outbreaks of
anger and violence.

One paternal cousin and uncle epllejitlc. One paternal cousin Insane.
Mother has nervous spells. One brother tubercular.

Diagnosis : Paranoia-
Female. Age 29. Married.

Onset alKiut two and one-half months before admission, following
the death of a child. Depressed. Melancholy. Neglectful In re-
gard to her personal appearance and her household duties. Would
walk the floor constautly, moan and groan. Imagined that the
child was still living. Threatened suicide.

Patient well developed and moderately nourished. Had no insight
into her condition. Gradually Improved until apparently recov-
ered, except n slight depression and a tendency to meddle in the
affairs of others and of the ward. She states that at the age of
13 she had an attack of what she calls nervous prostration. An-
other two years before the present one following the death of her
mother, which lasted about two months.

Diagnosis : Reciirreut melancholia.

Female. Age 35. Married.

Onset one mouth before admission, with spells of laughing. Im-
agined that persons doped her and wanted to have tbem prose-
cuted. That her friends were her enemies. That she was In com-
nmtilcatlou with people that she had never seen aud are dead.
That she was n medium, etc.

Patient well develoi>ed and well nourished. Dates her trouble back
over six years, b^lnning with Infidelity, neglect and persecution
by her husband aud neighbors. Describes In detail the doings of
the conspiracy* leading to her committal. Has an exalted Idea
of self. Is egotistical. Suspicions. Denies the statements of the
commitment record, attributing them to the methods adopted by
those In the conspiracy against her. Improved somewhat and was
discharged, but was recommitted in a short time.

Diagnosis : Paranoia.

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Female. Age 38, Married.

Onset about tbree weeks before admission, by attempting to hariu
berself and otbers, by being downcast and gloomy, at other times
excited and agitated. Walking the floor and talking constantly.
Imagined Impending harm and danget. Since admlsRion baB been
more or less agitated; continuously moans and worries. Im-
agines tbat sUe has committed a Bin (or which she will not be for-
given. The greater part of the time she Is dull, reticent and se-
cluslve. Has well marlied Ideas of self-accusation and self-de-
preclatlou. Sits In a stooped position. Moans. Wrings her hands.
Facial expression Is one of anguish and depression. Attention
can be withdrawn from her delusional ideas only with the greatest
dilBculty and then only momentarily. Marked retardation in re-
sponse to questions and In her movements. Emotionally depreseied
and agitated. Delusions appear to be based upon hallucinations
o( sight, hearing and common sensation. When asked to write,
does so iMJckwarda, saying that it Is the only way that she can
do so.

Diagnosis: Agitated melancholia.

Male. Age 27. Single. Farmer.

Onset one year before admission, following the accidental killing of
his sister. IndifTerent to his surroundings. Dull and despondent,
followed by outbursts of auger and violence. Wandering about a
great deal at night. Extremely suspicious. Eavesdropping con-
siderably and refusing to eat.

Patient poorly nourished. Complains of great weakness. Move-
ments tremulous and without euei^y. Facial expression one of
depression and fatigue. Emotionally depressed. Manifests re-
tardation mentally and physically. Some delusions of persecu-
tion. Urine contains granular and hyaline casts and albumen.

One uncle insane.

Diagnosis :

Female. Age 32. Married.

Onset about one year before admission, by neglecting her children
and household duties, by becoming forgetful and uncertain in
speech with incoherency, confused in ber actions, subject to periods
of sadness or liysterical excitement. Complained of headache,
backache and a choking sensation. Easily excited. Tremor of
the tongue. Staggering gait. Exaggerated knee Jerks. Voiding
urine involuntarily.

Patient Is rather fleshy, features are flabby, natural folds of the
face are obliterated, manifests marked tremor of the lips and
tongae. speech is diflicult, slurring and stumbling, leaves out
syllables and words; others are pronounced lucmnpletely ; hands
■are tremulous, fingers are hypereitended and adapted with diffi-
culty, movements are inco-ordinate and ataxic, writing is unin-
telligible consisting of mere scratches. Knee jerks are exagger-
ated, the left more so than the right. Achilles and plantar reflexes
are more active on the left side, muscular power is only fair ; tires
easily; gait is dragging, shuffling, Inco-ordinate and ataxic; Khom-

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318

iKTg'B pLeiMimeiiou Is flight, cesentlou of pain elowly purcelvod
aud markedly decreaBtMl, cerebro-BpiBal fluid is ext'essive, spurted
on inserting the nppdlf. in alkaiine in reufttoii, rednii'S Fehliug's
solution promptly, forais Hue pheiiyltiydrnzlu irystals, contains no
cellular constituents. Manifests pronounced dementia and In-
dlFFereuce as regards herself or her surroundlugs.

One uncle, two aunts and one sister tubercular.

Dlaguosla : General iiareais.

Female. Age 47. Single.

Onset about six months before, by peculiar action on the street,
peculiar manner of dress and conversation, talking Incoherently,
imagines that t)eople are after tier, are going to kill her, is t>elng
followed from place to place. The night before admission she'
sjient crawling about on her hands and feet iu a nearby corn
field. Is worse at each menstrual period.

Patient is sparely built, Is of a nervous temperament; says that she
has tried to be original all her life; was led to do so by tbe tiooks
that she read ; that she dressed and acted according to her own
ideas of originality and according to her financial and social cir-
cumstances. Says she sijent the night in a com field because
she was told to do so by a voice within her and impelled by feel.
ing of fear. Has eiculted ideas in regard to her present ability,
her probable accomplishments in tbe future and ber success in
the past. Patient is very talkative, somewhat auspicious, lias
baliucinatlous of bearing of disagreeable content, telling her to
use language \f'hich is very vulgar ; speaks of electrical influence
which Blie can throw off from any part of her body; of others
trying to influence her ; has no insight Into her condition ; is par-
tially disoriented ; is subject to periods of moderate excitement
and psychomotor restlessness ; is irrelevant in conversation ; ac-
tions, conduct aud movements are influenced and modified by the
content of her thoughts.

Diagnosis: Chronic hallucinatory paranoia.

Male. Age 53. Married. Conductor.

Onset one aud one-haif years before admission, by wanting to place
red crosses in all of the railroad stations, to provide a silk cur-
tain model train, by having outbreaks of violence, talkative and
easily excited, tieing suspicious. Is said to have had a sunstroke
two years previously, followed by delirium and signs of dementia.
but improved and resumed work for several mouths, when he had
another attack of nervous excitement and delusions. Recovery
again apparently took place lasting atwut eight months, when he
was taken with a hemlplegic attack with distinct signs of demen-
tia.

Patient well develoijed and well nourished. Marked tremor of the
lips and tongue. Speech tremulous. Rather a coarse tremor of
the hands lessened by volition. Itight hand fiexed and pronated.
Is unable to suplnate. Movements are Inco-ordlnate and ataxic.
The same is true of the movements of the legs, but more marked.

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319

E>eep reflexes increased Bablnskis reaction well marked Optic
atrophy distioct Marked dementia lud emotional iDstabllity

Diagnosis Organic dementia

Male Age 40 Married Merchant

Onset eifc,ht mtnths before admission by iniestlug in real estate
of no \ilue by spending money lavishlv Imagined himself
wealths Restlessness Talkative I nusually gay and Jolly
Hallucinations of sight

Patient well developed and well nourished Has no Insight Into
his condition Is emotionally exalted Loss of control in his
actions and feelings l^salted Idea'A in regard to his business
ability and capacity General feeling tone Is <ne of well being
Some delusions of perseeutlra Pupils non reactive to light Some
tenlency to strabiomus in the right eye Knee jerks exaggerated
Some history cf Intemperance

Diagnosis <.ener)l paresis

Female Age 37 Married

Onset two years before admission by trying to commit suicide
Imagined that some one was tr\lng to get her child that harm
nould befall herself ir fainitj that some one had hvpnotic In
flupuce over her Mumbled to herself Tjooked frightened Shrank
in terror from strangers Also from the slightest sounds Fell
down frequently as if from heart trouble Had hallucinations of
sight and hearing

Patient poorly nourished Appears w eak Facial eKpre«slon one
of feai and apprehension Delusions of perserution and Impend
Ing danger Haltuc [nations of sight hearing and geneial sensa
Hon Partiallj disoriented At times i-itated Emotionally de
pressed and appears to be wholly engr< ssed with her delusion' of
impending barm Retardation in thought and a tion Ten \cais
ago was operated upon for fistula in ano and fclnce then has used
morphia Has been in several sanitaria during the last three

Diagnosis Toxic Insanity (Mirphlnism )
Female \ge 32 Married lountest child eleven months old
Onset four weeks before admission by change of character strange
actions Imagined that it was wrong to eat Talked IncoherentU
Despondent at times at others maniacal Has outbreaks of anger
and liolence Neglects her famlh Is quarrelsome and irritable
Sleepless at night Patient states that she has had several mis
carriages Was conflued to the Insine hospital four years ag>
follow Ing a confinement AA as depressed Would not talk eit
or work Thought her husband committed her to get rid of her
because she was stubborn and contrary Recovered and was dis
charged after four mouths This time tMngs began to go wrong
She began to neglect her work Thought that the devil would
get her (hildren Henri spirits talking to her Is tshamed to
look i>eople in the fa e Iicl uisp she thiul s that It is wrong (an
not think >ntinuoush be ausi she forgets There Is facial as(in

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metry, the left Bide belDg the smaller. Chin la very pointed. In-
tellectual expression of a tow tyx»e.
Dlaguoaie: Recurrent melancholia.

Female. Age 28. Married.

Onset tbree we«ks ago. being about three and one-half montlis after
a premature birth, with an Intense maniacal eicltement.

Patient is irrelevant and incoherent in thought and action. Talks
to herself a great deal lu disconnected senteoces, Intermixing Ger-
man and English. Requires restraint to prevent her from injuring
herself and others and from destroying her clothing. Ib easily
Incited to outbursts of anger and violence. Partially oriented as
to time, not at all as to place and surroundings. Attention Is
easily diverted. Can elicit uo information as regards her previous
history or heredity. Has no iosigbt into her condition. Mani-
feets marked acceleration In the flow of thought and In the asso-
ciation of ideas. Also in her actions and movements. Is vulgar,
has lost all sense of modesty and shame. Is uucleanly. Indiffer-
ence as to herself and her surroundings.

Diagnosis : Acute delirious mania.

Female. Age 34. Married.

Had a miscarriage. Was found to be pregnant on admission, so was
dlschai^ed until offer confinement. She did very well until about
one month before confinement, when she became restless and
nervous. Was in a sanitarium until after confinement, and after
several weeks she became talkative. Had trouble with her brother-
in-law. Threatened her mother. Had pronounced Ideas of perse-
cution. Had outbreaks of violence.

At present patient is poorly nourished. Nervous. Excitable. Talka-
tive. Einotionaliy somewhat exalted. Manifests slight psycho-
mittiir activity and restlessness. Is slightly incoherent and irrele-
vant. Has no insight Into her condition. Has well-marked Ideas
of persecution. Attention Is changeable and easily dlvertibie.
iiJmotionttlly unstable. Patient worries about the child.

Father intemperate. Mother's family extremely nervous.

Diagnosis :

Female. Age -ST. Married.

Onset twelve years before admission with an attack of acute mani-
acal excitement based up<Mi hysteria. Has had several attacks
since then.

I'atieiit well developed and well nourished. Very talkative. Emo-
tionally exalted. Marked acceleration In the flow of thought and
In actions and movements. Attention readily dlvertible. Subject
to outbreaks of anger and violence. Marked Ideas of persecution.
Becomes abusive and profane. At times is morose, despondent
and Irritable. Manifests erotic tendencies. Has no Insight into
her own condition or Into that of her surroundings.

One maternal cousin idiotic. One brother Insane. One sister in-
temiM?riitc. Mother extremely

DingnoBls: Uecitrrent mania.

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321

Female. Age 23. Stogie.

Onset by a feeling oC depression, headacbe and backache. At-
tributed to failure of menstruation. Spells of depression were
associated with crying, incoherency and disconuectedoess In talk-
ing. Had some apprehension and delusions of a persecutory na-
ture. Imagined tliat her father was the perecm of another man
who had committed murder. These spells oC depression were fol-
lowed by periods of exaltation, singing at the top of her voice,
talking excessively, and more or less tinged with obscenity and
profanity. Increased flow of thought and flight of ideas. Later
these were followed by a feeling of general well-being and con-
tentment. Physically no disturbance apart from irregularity of
menstruation.

Two paternal uncles intemperate. One maternal cousin intemper-
ate. One half-sister and one maternal aunt Imbecilic. One ma-
ternal cousin and one sister have nervous spells, probably hyster-
ical. Patient has similar spells. Patient underwent complete re-
covery.

Diagnosis : Mania.

Female. Age 22. Single.

Onset by delusions of impending death, loss of soul, etc. Tendency
to self-destruction. Peraistent worrying and crying. Ideas self-
accusatory in content, of having committed the unpardonable sin.
Language profane. Conduct immoral. Delay in perception and
conception. Only partial insight. Emotionally usually depressed,
ci-ying and some motor unrest, giving expression to anxious
thoughts and feelings of self-depreciation and also of religious
content. Reflexes exaggerated. Delusions of having committed
the unpardonable sin, of having joined the church when not lit,
of not being flt to live, of being despised by the family and friends,
with actions corresponding to the content of the thought. Ten-
dency to suicide.

Diagnosis : Agitated melancholia.

Female. Age 32. Married.

Onset after childbirth. Ideas of persecution in that her husband
and family were against her. Became indifferent to home and
surroundings. Carried the furniture out of the house. Allowed
her hair to become densely matted together and refused to allow
anyone to comb It out. . Threatened to take the life of herself and
child. Perception and conception at the time of the examination
were apparently normal, but there Is a history of visual, facial
and auditory hallucinations. Delusions of impending harm, of
persecution, of conjugal infelicity and of somatic disturbances.
To some extent she still thinks that they were real, althougii ad-
mitting that they were most distinct during sleeping periods.
Has no Insight toto her condition. Emotions somewhat depressed.
Attitude, conversation and facial expression also depressed. For
some weeks there was absolute mutism, with some stupor, which
she now explains by saying that she thought that she had some

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tlirunt ti luble iiid b} not talking it would hasten tbe ''ure nnd
moreo^ei n<uld not require htr to answer the many foolish que^
tlona that were asked Refused to eat because &he was not
hungry Did not attend to herself or to her housework beiause
she w\t too ill (r not strong enough Frequently complained of
a sense of bei\luess in her throat "uhlch tlireatened to close up

DlignoRis Melancholia

female Age 28 Married

Onset followed a difficult ftr-*t contlnement dunug whiih there was
laceration of the perlnaeum allowed to go unrepaired followed
by septic infection Ibis listed about t\^o month'! during nhkh
there was manlfCBted more or less mental dliturbancf Thih
cleared up a*? the i bysical conditions improved and no more raent il
diatnrbances were shonn untii tbe birth of the second child about
three vear-i latir Manifested more or less estitement with j
tendency to violence toward her child and toward her surround
ings and toward herself Imagined that as ber husband was a
carpenter ihe hid the right to drive out intone that was in the
houses built by hiui and take possession of tliem herself Is
negligent in the care of heiself and famllj Has ideas of perse-
cution in reference to ber surroundings In regard to placing her
self under a doctor s care or of tal Ing medicine Ilnd delu&lous
in regard to her ability and right of possession in regard to the
advisability if Ihlig m houses beyond her means and nKi of
the relations of tier husbau 1 to her Claims that the threats
were made merely to get e>en for the supjiosed persecutions that
she had to undergo (omilete reco\cry ensued

Tivo paternal aunts nisane

Diagnosis 1 ecuirtnt halliuinatoiy ]>Branoia

l emale Age 29 Married

Onset about one week following' her marriage nine mouths befoie
admission with hallucination', especially at night to some extent
also of sight and smell ijatpi became lirltable and suspicious
with delusions of jealousy and infidelity InsigniBcant incidents
were interpreted as being of the greatest imjiortance Followed
her husband ab uf nailed np the windows and doors Became
destructive Iinagineii that hei brother was killed that the polite
were going to cut off her head Betume violent to those about her
Oompelled bir liusbai d to mo*e frcqumtly Was neglectful of
household duties and of bei i>ersonal tppeorance Was filthy and
(irotane facial e\|irepslon ittltnde conduit and actims indi
(ate a low grade of moul and intelleitual development Reports
indicate ayphllltlc Infection and Intemperance Is dissolute and
immoral

Afotiier siid to have died of tnberdilosis

Dl'»;aiosis Alcoholic Insanity upon a teeble minded basis

Female Age 40 Single

Patient gives a history that sr uie time i„o about si\. months slie
became Imbued with tin hU i thit her employers were giiing hei
some poison to ni it < bir sick so that she would give up some

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Uutps tlint shf 1ml utiilnst them fur miiiip inoim of lii i s tiiat
tim liflrt lurrnweii Ihoustlit -ilie liianl thi*ni talk iilHmt [t wluii
ebe A IS ill 111 idjoiiiiiig room lliis (iiuHed hti to bi^toiiie de
)>resstd stHliiBiic anil 8u<:i)Iliouh At times refused to eat Later
slip luoicd to iiuotlier to«ii where the ^aine conditions arose
Tiic rHtleiit is (.PFiiiaii Ijorn Hns no reiatlvee or immediate
trleuds In tliese parts (.eiieriii health Is below par Oiitside of
tin ennitloniil f.phei'e nothing iiartlmlar touUl tw discovered apart
from the ililuslons of imtm' iitur^ (onteiit tinotlonnll; she is
deprestKd iistlfS'- liidllferent to hei surioniidlnit'< and associates
aud souK^flint apithetit Aitionti lorrenpoitd to the emotiunal

Diagnosis . I'araiiola

Female. Afte 10. Single.

(ti!set four iiioiUhs ago, with di'SiHindeiicy, sefliisivfiiess, avoiding
asHot-lutex. iiiiit talking except at times. be<'aiue iirofaue and
thrc.itciiliij;. Attemiiti'ii NuU-ide Atfs and eats only by compul-
sion t'outlunally sits in one position. Facial exjiression staring.
Answers iiiieBtimis slowly or not at all. ImagliieB that she hns
lost h< r iiilnil, that site has committed the nujMirdonuble sin. Sb6
jeiKirts that she became dlssatisfletl with home, went to another
town to Ih'e witb a sister, but w>on became (^utrolled with the
Idea thiit she should be at home with her mother, ijhe wanted
to go and yet did not want t<) go, which caused her to woi-ry.
While there esiHTienied a dlsaiiiMilutmeut In a love affair and
attempted suicide, giving no definite reason other than that she
wauti'd to die. KxplalnH the unpardonable sin as referring to the
attempt at suicide. Emotionally is downcast and depressed.
Actions and movements corres^ioud to the emotional content. Has
enlarged lervical glands and several old scars indicative of old
suppuratUe involement

Diagnosis ; Dementia praei^ox.

Female. Age 29. Married.

Wlien It! years old the patient had an attadt of what she calls
uei'vous prostration, lasting about two months. The following
snuuiicL' another attack sui)en'ened, for which she was sent to
the insane hosiiltal, the report indicating a typical maniacal out-
break, from which she also apimt'ently recovered. Was married
at the age of 21, and one month after the birth of the third child
a third attaik iK-cnm-d. Ueporta having had hallucinations of
sight, hearing and smell. AIno had delusions of altered person-
ality, with psychomotor restlessness and activity, and a tendency
to Injnrc herself and otliers. Present attack again followed a
<-ontinenicnt. with delusions of piilHoning, of having lost a child
Had deslw to wander away. Had outbreaks of langhter and cry-
ing alternating Tlireiitened to kill her ehlltl, her huxband and
those about her. Insight Is clear as to former conditions, but
not as to the present. \t the time of examinatloti. i-ecovery had
almost ensued.

Father and paternal grandmother insane.

D;n.:tio.'--is : Itecurrent niiinia.

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E'emalc. Age 55. Married.

Patleot was an inmate of an insane bospltal at the age of 35, fol-
lowing what she saya was a severe chill and later uncouscloHsoess
for Beveral days, after which she was excited, Lad hallucinations
of eight, the whole illness lasting atioiit four months. Three years
later another attack developed Incident to a fire burning down
the house, from wiilch she was confined nine months. Readmitted
a year later, but being found pregnant was discharged pending
confinement, after which she was admitted with pronounced ideas
of persecution, children were against her, the neighbors talked
about her, etc. Insight is clear as to former attacks, but not
as to the present one. Intellectual sphere noticeably impaired.
Memory Impaired for both recent and remote events. Emotional
sphere norma! or depressed. Moral tone Impaired, as shown by
the fact that she gave birth to an illegitimate child and later
married a man of dissolute habits. Physicai examination revealed
a mitral systolic murmur.

Mother and one sister died of tuberculosis. One sister died because
the brain was too large. One sister nervous.

Diagnosis : Recurrent mania.

Female. Age 37. Married.

Onset followed the eighth pregnancy, but symptoms did not become
acute until the confinement. Inattention to family and household
duties with more or less indifference. Apparent overauxlety In
regard to the children. Imagined that her husband had poisoned
the children, had tbrown them into the well, that people were try-
ing to get into the house, consequently would be found gliding
about tlie bouse looking for the supposed Intruders; that the^food
was poisoned, so refused to eat. This was followed by depression,
In which as a rule tliere was slowness in perception and compre-
hension, retardation in the association of ideas and expressions.
Emotional sphere was changeable, usually depressed, but at times
could be made to laugh or cry almost immediately. At times was
excited.

Diagnosis :

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RESUME OP THE MORE IMPORTANT CLINICAL FEA-
TURES ASCERTAINED FROM TUB CASES PRESENT-
ED AT THE STAFF MEETINGS.

Diagnosis :
Race — Male. Female.

Negi-o

138

199

Age—

Male.

Femal

40 to 50

... 3t

Occupation of mules

so far as ascertainable :

Druggist

Physician . . .

Laborer

Kallroading

Lawyer

Barber

Teaser

Miner

Preaclier ....

Machinist

Student

Carpenter

ArtUt

Painter

Molder

Clerk

Butcher

Salesman

Policeman ...

Blacksmith

Fireman

Merchant

Baker

Walter

Cigar maker ..

FAMILY HISTORY.

Intemperance

Insanity

Tuberculosis

Nervous constitution ...

Epilepsy

Suicide

Iloinlclde

Weak-mindedness

Pai'esis

Malignant disease

Chorea

1'hyrold gland disease ..

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326
I'EitsoNAL iiisixmr.

Male.

Intemperance 33

Spetific aisease 23

Neurotic coDstltiitlon 9

EpU^>sy 8

Heart dlaease S

Imbeellic 1

Tobacco pxceBE 3

Morphia 2

Cocaine 4

Gonorrhoea 5

Tuberculosis 1

Menstrual disorders

Nervousness 3

Injury 7

Couvulsions a

Sunstroke 2

Chorea 1

Tliyrold gland dlaease

Acute Infet-tloua disease 3

DELUSIONS MANIFESTED.

Male.

Persecution 74

Impending harm ^ 32

Plots estating 28

I'eople talking about them 10

Grandiose 47

Poison 11

Hyiiochoudriacal 10

Fear o( being Itilled fi

Altered personality 12

Hypnotic influence 4

Poverty li

Biecti'l<-al Influence 3

Spirit possession 4

lufldelity 11

Jealousy 8

nelislon 8

Negation 2

Having committPd some serious crime 3

Self -accusatory 4

Self -depreciatory 7

Unpardonable sin

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327

HALLUCINATIONS.

Male.

Sight 23

Hearing 30

Smell 7

Taste 6

General aenBatlon 9

Organic sensation 5

GENERAL DISTURBANCES.

Male.

Sexual 16

WoiTy over business 14

Poor nutrition 16

Hysteria

Hystero-epilepsy 1

Headache 15

Weakness 9

During pregnancy

After confinement

Suicidal, ._. 32

Homicidal . . , 15

Inclination to wander 32

PSYCHICAL DISTURBANCES.

Male.

Loss of interest 57

Loss of memory 63

Secluslveness 14

Secretlveness 8

Confusion 22

Apprehension 22

Apathy 27

Emotional depression 40

Emotional exaltation 47

Emotional agitation 6

Mental retardation 31

Mental aceeleratloii 38

Flight of Ideas 37

Stupor IT

Talkativeness 60

Refusal to talk 4

Mutism 7

Irrelevancy 44

Incoherency 49

Disorientation 21

DIvertlblllty of attention 45

Verbigeration 1

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328

PHYSICAL DISTURBANCES— Continued.
Negativism 3

Stereotopy 6

Catatonia 5

Amnesia for the acute stage 4

Imperative concepts 2

Agoraptiobia 1

Irritability 45

Excitability 67

Violent outbreaks 71

Huspiclousneas 34

Egotism 40

Feeling of well-being 33

No insight H7

Partial insight 13

PHYSICAI-. DISTURBANCES.

Male.

Facial expression depressed 28

Facial expression exalted 31

Facial expression flabby 9

Facial asymmetry 3

Pupils uneijual 14

Argyle- Robertson pupil 10

Ocular muscle paralysis 4

Retinal and disk cliangee 14

Muscular tremors 43

Speech defect 40

Speech typically paretic 21

Writing defective 33

Writing typically ijaretic 19

Knee Jerks exa^erated 34

Knee Jerlts decreased 12

Knee Jerks unequal 8

Ankle clonus 10

Superficial rellexes increased 7

SuperBcial reflexes decreased 10

Muscular weakness 14

Paraesthesia 13

Rhomberg's reoction 19

Babinski's reaction 5

Inco-ordi nation of movements 23

Ataxia in movements 23

Spasticity in movements 4

Intense anaemia 4

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CLASSIPIOATION OF THE PSYCHOSES PROVISIONALLY BASED

UPON 'X'HIO CLINICAL MANIFESTATIONS AND EXAMINATION.

Total. Male. Female.

Acute melancholia 5 5

Chronic melancbolla 2 2

Kecurreut melancbolia 4 4

Agitated melancholia 10 2 8

Ilypochoudriacal melancholia 10 7 3

Acute mania 15 4 11

Chronic mania 8 4 4

Recurrent mania 15 4 11

Epilpetic Insanity 12 6 6

Acute confuslonal Insanity 21 2 19

Circular insanity 1 1

Toilc insanity 8 3 . 6

Hysterical insanity 5 5

Manlc-depresalve insanity 10 2 8

General paresis 34 26 8

Tabo-paresis 5 3 2

Acute hallucinatory paranoia 6 3 3

Chronic hallucinatory paranoia 28 7 21

Simple paranoia 33 11 22

Senile dementia 2 1 1

Organic dementia 18 13 5

Dementia praecox (Hebephrenic) 16 9 7

Dementia praecox (Catatonic) 2 2

Dementia praecox (Paranoid) 18 9 7

Stuporous insanity 7 5 2

Unclagsifled 44 17 27

Respectfully mibmitted,

CHARLES F. NEU, M. D.,

Pathologist.

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„ Google

MEDICAL PAPERS.

The following papers, by Charles P. Neu, M. D., the ones
referred to in the beginning of the Summary, were presented to the
Marion County Stedieal Society.

Page.

The Relation of the Peripheral Nerves to the C«ntral Nervous System, . , . 332

Tumors of the Brain; Their Etiology and Patholc^ical Effects 340

Acute Hiemorrhagic Pancreatitis 348

Report of Three Cases of Cerebro-Spinal Meningitis of Pneumococcal Origin , 353

Case of Rupture of the Aorta, plus Hemorrhage into the Pericardium. . . . 357

Report of Two Cases of Brain Tumor 360

Report of a Caise of Death by Coma in Which There Was Found Extensive

Tuberculosis of the Lungs and Intestines 366

Report of Eight Cases of Brain Tumor, With Comments 368

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THE RELATION OF THE PERIPHERAL NERVES TO THE
CENTRAL NERVOUS SYSTEM.

In placing this subject before you, it is not with the intention
of presenting anything new or original : more a grouping of facts
so far as seems to be recognized by modern authorities. The time
being limited, more than a synopsis can scarcely be given r

The peripheral nerves represent all those multiple channels by
which external agencies exercise an influence upon the great Cen-
tral Nervous System — and through it upon the body as a whole, or
upon some individual organ, or part of an organ, or upon one or
more of the physiological processes going on within the body.
That they do exert an influence is clearly manifested by the effects
following prolonged irritation of any sensory area or pathway on
the one hand, or upon a motor area or pathway on the other, but
it seems very probable that they exert a i;ar greater influence in pro-
ducing and maintaining an alteration in structure and function
than is attributed to them, Iti no branch of medical science is
there more diversity of opinion amongst authorities than upon the
nervous system, and probably no part of the animal economy pre-
sents such a complex and intricate relationship as the nervous sys-
tem itself, and because of this, probably less is known of the exact
relationship of the different parts of the nervous system to each
other than of any other system in the body.

By peripheral nerves are meant: those nerves by which the
central nervous system is connected with the other parts or organs
of ihe body and with the external world. They can be classifled
into two great groups, first those conveying impulses into the cen-
tral nervous system — or afferent in fun(rtion, and those conveying
impulses away from it or in an efferent direction. By the former
the central nervous system is acted upon by external influences or
agencies, by the latter it influences the other functions of the or-
ganism. As von Lenhossek ingenuously puts it, "The former care
for the import, the latter for the export relations, while the central
nervous system itself looks after the home conditions."

While the relationship of the peripheral nerves to the central
system is relatively simple compared to the relations of the various
parts of the central mass itself to each other, yet even these present
many features which as yet have not been placed upon a satis-
factory basis. It is not the intention to' take into consideration
the many foriris of peripheral end organs of both sets of fibres, noi-
their relationship with their immediate surrounding, nor of the

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□erves themselvea except as they are connected with the central sys-
tem. Leaving out of consideration for the present those nerves
concerned in the special sense of smelling, seeing and hearing, we
find that all the others enter the cerebro-spinal axis by one of two
portals of entrance, forming an anterior and posterior root. It is
generally admitted that with the exception of a very few fibres
which enter the anterior from the posterior root and vice versa,
the anterior root fibres convey impulses away from the central sys-
tem, are efferent in the function of conduction, and have their
origin from cells within the central nervous system; while those
of the posterior root convey impulses to the central system, are af-
ferent in function, and have their origin from cells situated in the
spinal ganglia external to the central nervous system. As the re-
lations of the anterior root fibres to the central system are perhaps
better understood, and are placed upon a simpler basis than the
posterior roots, let me direct your attention to these first :

As previously stated the anterior root fibres have their origin
from cells within the central nervous system. The great majority
being situated in the grey matter of the anterior horn of the spinal
cord or its representative in the higher parts of the cerebro-spinal
axis, always lying ventral or ventro-lat«ral to the central canal, and
with the exception of the fourth cranial nerve, all have their exit
from the ventral or ventro-lateral surface. As the grouping of
these cells is not placed upon an uniform basis no attempt will be
made to discuss this part of the subject, but for the purpose of il-
lustration will use the following diagram in which the cells are ar-
ranged into an anterior, median, posterior-median, lateral, posterio-
lateral and central group. With but few exceptions all the an-
terior root fibres have their origin from these or similar groups of
cells.

Regarding the dendritic processes of these, they may be ar-
ranged into three groups, 1st, those passing toward the ventral
commissure decussating with those from the opposite side ; second,
those passing toward the dorsal horn ending chiefly about the cells
of that part ; third, those passing in a lateral direction entering the
lateral columns or terminating in a plexiform arrangement beneath
the piamatcr. The axis cylinder processes, non-medulated at first,
give off collaterals from non-medulated portions which turn back-
wards and terminate according to some authorities around the cell
bodies within the gray matter, according to others they come into
contact with the sensory terminals of the dorsal root fibres, thus

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334

giving origin to the pussiliility of a reflex pathway without passing
thri)iijrh the cell body of the anterior horn cells.

While this description of the anterior root fil)rc8 applies more
particularly to the spinal cord, the same conditions hold true as we
pass to the higher parts of the cerebru-spinal axis. As the spinal
cord merges into the medulla, and the central canal expands into
the cavity of the fourth ventricle, certain alterations of these rela-
tions are produced, one of which is the rutting oflt of a portion of
the anterior horn by the decussating fibres of the crossed pyramidal
tract, leaving the pyramidal tract of the medulla to enter the lat^
eral column of the opposite side of the spinal cord. As a result of
this some of the cells represented in the anterior horn of the spinal
cord are displaced dorsally and laterally, while the remainder re-
tain their relative position to the upper continuatiou of the central
canal; from the latter group of cells which extend as a more or
leas continuous column from the lower end of the medulla below,
to the Ant. Corp. Quad, above, we find the fibres of the 12, 6, 4
and 3 cranial nerves taking their origin, the twelfth nerve fibres
arising from those cells situated between the lower and upper ex-
tremities of the medulla, the sixth nerve fibres from those cells sit-
uated in the pons, the fourth nerve fibres from those cells situated
beneath the posterior Corp. Quad, and the third nerve fibres from
those cells situated beneath the anterior Corp. Quad. The group
of cells representing that portion of the anterior horn of the spinal
cord that has been cut off by the decussation of the fibres of the
crossed pyramidal tract, and which have been carried dorsally and
laterally, first by the pyramidal tract of the medulla, and second
by the olivary body, but still occupying a position mesial and ven-
tral to the gelatinous substance of Rolando, extending from the
lower to the upper part of the medulla, and now called the nucleus
ambiguous, gives origin to the efferent fibres of the accessory por-
tion of the spinal accessory, of the vagus and of the glosso-pharyn-
geal in the order mentioned from below upwards. In the pons the
continuation of the same group of cells gives origin to the efferent
fibres of the facial nerve, and above the pons to near the level of
the anterior corpora quad, to the efferent fibres of the fifth nerve.

With the exception of the fourth and seventh nerves,' the fibres
of all the cranial nerves pass ventrally and laterally and make their
exit from the ventro-lateral groove in the medulla, or from the side
of the pons corresponding to the groove. The fibres of the fourth
nerve run laterally l)eneath the floor of the canal of Sylvius, curve

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around its lateral margin to the dorsal surface, then run inward
and crossing the middle line decussate with the fihres of the op-
posite side nnd make their exit from the dorso-lateral surface of the
cerebral peduncles. The fibres of the facial nerve run mesially and
dorsaily, winding around the nucleus of the sixth nerve, first be-
tween this nucleus and the middle line, then between the nucleus
and the floor of the fourth avontriele, then run ventrally and later-
ally, passing between its nucleus of origin and the gelatinous sub-
stance of Eolando, making its exit from the ventro- lateral groove
of the medulla. From all these nuclei of origin of the cranial effer-
ent nerve fibres, other branches are given off, whether dendritic or
axis cylinder is not known definitely, which take a course similar
to the dendritic processes of the cells in the anterior horn of the
spinal cord. Some crossing to the opposite side terminating in the
opposite nucleus, or entering a lonffitndinal bundle of fibres lying
beneath the mesial group of cells, forming the so-called posterior
longitudinal bundle, in which fibres run both in an ascending and a
descending direction. Others enter a similar bundle on the same
side, while still others terminate in the general mass of gray
matter.

With regard to the fibres of the posterior roots it has been
definitely proved thai they have their origin in the cells of the pos-
terior spinal ganglia, or their representatives situated outside the
central nervous system. Whether the fibres running from the cells
to the 'gray matter of the eerehro-spinal axis represent the axis
cylinder or dentritic process, is as yet a subject of discussion. Be
that as it may. all agree that they carry impulses in an afferent
direction, i. e.. away from the cell intii the central gray matter.
The central prolongations ()f the posterior roots enter the spinal
t-: rd as two bundles of fibres, a small lateral and a large mesial
bundle, the lateral bundle enters the cerebro-spinal axis immedi-
ately anterior to the tip of the posterior horn, where the fibres di-
vide into ascending and descending branches forming the column
of Tiissauer. The mesial bundle enters between the posterior horn
and the posterior median fissure, its fibres also dividing into ascend-
ing and descending branches forming the column of Burdach and
Goll. While the majority of fibres thus bifurcate, some enter the
gray matter directly. The descending branches of both bundles
only descend downward for a few segments, each fibre giving off
collaterals to the adjoining gray matter where the fibre itself also
terminates. The ascending branches of Lissauer's Column run

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centrally for a variable distance, also (tiving off collaterals which
enter the gray matter, whilst some terminate iu the gelatinous sub-
stance of Rolando where the terminal itself also ends. The ascend-
ing fibres of the column of Burdaeh and GoU form an uninter-
rupted tract running centrally until they reach the medulla where
they terminate in the gray matter of the Cuneate and Gracile
nuclei respectively. While probably the majority of fibres of these
two columns take this unbroken course, some, however, enter the
gray matter of the various segments along their course, as do the
collaterals that are given off by the fibres of both columns. A few
fibres are supposed to pass even beyond the medulla, some terminat-
ing in the cerebellum and some in the gray matter of the pons, and
even as far up as the optic Thalamus.

As to the distribution of the fibres after entering the gray mat-
ter, some fibres have been shown to terminate in the region of the
vesicular column of Clark, a collection of cells situated in the pos-
terior horn at its junction with the posterior gray commissure.
Other fibres run forwards and terminate about the cells of the an-
terior bom of the same side. Others cross to the opposite side of
the gray matter of the anterior and posterior horn, while the re-
mainder are scattered through the body of the gray matter itself.
Thus it will be seen that each posterior i-oot forms a more or less
direct connection, not only with the anterior horn cells or fibres of
the same and of the opposite side of its own segment, but also ad-
joining segments, both above and below its segment of entrance,
and in the case of the long fibres of the column of GoU and Bur-
daeh, fibres entering in the lowest extremity of the cord make more
or less connections by means of their collateral branches, with each
segment throughout the entire length of the cord.

In the distribution of the cranial nerves carrying impulses in an
afferent direction we have to consider not only those concerned in
the sensory functions proper, but also those concerned with the
special sense functions. Leaving the latter class out of considera-
tion for the present, there yet remain the sensory portions of the
eleventh, tenth, ninth, seventh and fifth nerves. Each of these
have ganglia from which they take their origin, similar to the pos-
terior spinal ganglia. Their central distribution is modified owing
to the rearrangement of the various constituents of the cerebro-
spinal axis represented in the spinal cord and to the appearance of
new structures. The afferent fibres enter the eerebro-spinal axis at
the same place that the efferent fibre? make their exit. They also

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337

resemble the spinal nerves in dividing into ascending and descend-
ing branches, and giving off collaterals.

The afferent fibres of the accessory vagus, vagus, and gloaso-phar-
yngeat and facial (intermediate of "Wrisberg) all terminate abouttwo
columns of cells extending from the lower of the medulla to the
junction with the pons. In the lower part of the medulla, situated
almost directly behind the hypoglossal nucleus, dorsal to the central
canal. The other slightly dorsal and lateral to the former. In the
upper part of the medulla, owing to the expansion of the central
canal into the cavity of the fourth ventricle, both columns are car-
ried laterally and come to lie ventral to the floor of the venticle.
In the former group of cells the majority of fibres of the accessory
vagus and vagus terminate, while in the latter the greater part of
the glosso-pharyngeal and intermediate of Wrisberg terminate.
While the afferent fibres of the glosso-pharyngeal convey ordinary
sensory impulses, some of its fibres, as well as those of the nerve of
Wrisberg, carry . impulses of the special sense of taste. The af-
ferent fibres of the fifth form a definite tract beside the gelationous
substance of Rolando between it and the Restiform body and ex-
tend downwards as low as the midcervical region, and upward as
far as the Ant. Corp. Quad. The collateral and terminal branchy
of this nerve all appear to terminate in the gelatinous substance of
Rolando. Thus it is capable of influencing either directly or in-
directly all the efferent fibres of the upper extremity of the cere-
bro-spinal axis from the third nerve down to the midcervical re-
gion at least.

When we come to consider those afferent fibres concerned in
conveying the special impulses of the sense of hearing, seeing, smel-
ling, and tasting, we meet with a somewhat different problem,
especially those of sight and smell. With regard to the auditory
nerve, it is known to consist of two distinct groups of fibres, having
a separate origin, possessing separate functions, and for the greater
part have a separate termination in the cerebro-spinal axis. These
two divisions are the vestibular and cochlear.

The vestibular fibres have their origin from the vestibular
ganglia, those of the cochlear nerve from the spiral ganglia, both
of which are situated in the internal ear and are somewhat an-
alogous to the posterior spinal ganglion. After entering the cere-
bro-spinal axis at the ventro-lateral groove, the fibres of the ves-
tibular nerve divide into ascending and descending branches, both
of which give off collaterals, and terminate in at least five distinct

[22—18438]

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groups of cells. One group situated beneath the floor of the fourth
ventricle just lateral to the nucleus of Iht; hypoglossal nerve, and
called the chief nucleus. Another gr;,up of cells situated a little
laterally to the chief nucleus called Deiter's nucleus. A third
group of fibres end in the cuneate nucleus lying just lateral to
Deiter's nucleus. A fourth group of cells lying beside the lateral
wall of the fourth ventricle called the superior or Beehterew's
nucleus. While the fifth consists of a number of fibres which enter
the restiform body and terminate with it in the nucleus of the
middle lobe of the cerebellum of the same and the opposite sides.

The fibres of the Cochlear division of the auditory nerve ter-
minate for the greater part in a group of cells lying ventral and
dorsal to the restiform body forming the ventral and dor.ml ac-
cessory auditory nuclei. Some of its fibres terminatt^ in the su-
perior olive of the same and the opposite side, while others wind
around the restiform body, run mesially beneath the flo!>r of the
fourth ventricle forming the striae acusticae, eroai the median line
and terminate in the opposite gray matter.

As regards the i>eripheral nerves concerned in the s]>ecial sense
of sight, authorities really differ as to which are the peripheral
neurons. All admit that the cell bodies are situated in the retinae.
One class of investigators look upon the outer nuclear layer. A
second class look upon the inner nuclear layer, while a third class
apply the term to the ganglionic layer as the representative of the
posterior spinal ganglion neuron. As the object of this paper is to
point out the relation of the central nervous system to the various
channels by which impulses enter and leave it, reference will only
be made to those neurons connecting the retina with the cerebro-
spinal axis, namely, to the ganglionic layer. The central branches
of these go to make up the optic nerve and the greater part of the
optic tract. When the fibres of the optic nerve reach the optic
commissure some of the fibres cross to enter the optic tract of the
opposite side, and with those fibres of the opposite tract which have
not crossed terminate in the gray matter of the posterior portion of
the optic thalamus. External Geniculate Body, and the Anterior
Corpora Quadrigemina.

The peripheral nerves concerned in the special sense of smell
have their origin in the Schneiderian membrane of the nose, their
central ends terminating in the gray matter of the olfactory bulbs.
Here again the liberty is taken to apply the remarks to the nerves
entering the eerebro-spinal axis, directly, and allude to the ol-
factory tract whose fibres arise in the cells of the olfactory bulb.

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terminate partly in the same side, and partly in the opposite side of
the cerebral hemisphere in the anterior portion of the temporo-
sphenoidal lobes and to some extent in the anterior portion of the
corpus striatum. Those crossing to the opposite aide do so by the
anterior white commissure. "While other connections are given:
these seem to be the most important.

Thus it will be seen that after leaving out of consideration the
peripheral neurons of the Olfactory and the Optie nerves, all the
others can be arranged into two great groups. The " individual
members of each group bear a close resemblance tfl each other in
their origin and in their connection with the central nervous sys-
tem. This connection serves to indicate the different pathways
that may be taken in the production of a. reflex act, and also serves
to explain to some extent, certain phenomena regarding reflex man-
ifestations that have been observed clinically, and that have been
demonstrated experimentally on some of the lower animals, where
it has been Bh::wn that stimulation of th» central end of a divided
posterior root will involve first the efferent root cells of the seg-
ment of entrance, primarily on the same side, secondarily on the
opposite side; and by increasing the intensity of the stimulus, the
involvement of the adjoining segments takes place until the whole
efferent mechanism is thrown into aetitin. This fact should ever re-
■ mind those engaged in clinical investijrations that an abnormal
sensory or motor phenomenon may not be due to an implication of
the immediate sensory or motor nerve concerned hut may be pro-
duced by the involvement of some other group of neurons. As an
illustration one has only to mention pain in the knee joint, in hip,
cr saero-iliae joint disease ; earache or spasm of the ocular muscles
from a carious tooth ; epileptic convulsions from irritation of per-
ipheral nerves such as occurs in eyestrain, nasal affections, gastric
disturbances or adherent prepuce.

Keeping in view these anatomical relations, and remembering
the physiological functions of these two great channels of entrance
to and exit from the reservoir of the whole nervous system, the lat-
ter channels exercising a motor, a secretory and a trophic function
upon all the tissues and elements that enter into the construction of
the living organism, the former conveying impulses which inform
the central controlling and rngulating mechanism of the condition
these tissues are in, of their relation to CHch other, and to the out-
side world, one is able to determine alti^rations of these relation by
the alterations of their physiological functions and consequent clini-
cal manifestioiis. The clinical manifestations will depend upon

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whether the pathological process be an irritative or a destructive
lesion, and* whether it iDVolves the anterior root neuron, or the pos-
terior root neuron or both. If the anterior root neurons only are af-
fected, there results disturbance of muscular action, of secretory
and of trophic conditions. This is clearly demonstrated in the
condition of anterior poliomyelitis, the sensory phenomena being
but little if at all affected in the majority of cases. If on the
other hand the posterior neuron only be affected, there follow vari-
ous disturbances of the sensory phenomena, while the functions of
the anterior neuron are unaffected except as the result secondarily
of the influence of the modified impulses reaching them from the
afferent pathway. These eharacters are fairly well illustrated in
the condition of locomotor ataxia. Therefore these anatomical
and physiological relations form a basis, by means of which a more
or leaa tangible explanation can be formulated for most if not all of
the clinical manifestations met with in pathological conditions in-
volving this part of the nervous system.

TUMORS OF THE BRAIN— THEIR ETIOLOGY AND PATHO-
LOGICAL EFFECTS.
By tumors of the brain is meant any morbid growth within the

cranial cavity, whether cystic or solid.

Almost every known form of new growth may occur but tile
great majority, probably 95 per cent, are either tubercular, syphi-
litic, sarcomatous, carcinomatous or cystic. Excluding syphilis
about 50 per cent, are tubercular, and 35 per cent, are gliomatous
or sarcomatous, the sarcoma being rather more frequent than the
glioma. Parasitic and carcinomatous growths occur with about
equal frequency, constituting between 5 and 10 per cent. Thus it
will be seen that tubercular, sarcomatous and gliomatous growths
constitute at least 80 per cent, of nonsyphilitic growths, while in-
cluding syphilis they constitute at least 90 per cent, of all intra-
cranial tumors met with clinically. It is not the intention to in-
clude hemorrhage and abscess formation, although their occurrence
produces effects similar to other morbid growths, only differing in
their origin, mode of development, progress and termination.

They may arise from the brain itself, from the membranes
which surround it, or from the bony walls that enclose it. Be-
tween 40 and 50 per cent, occur in the cerebral hemispheres, from
25 to 30 per cent, in the cerebellum, 8 to 10 per cent, in the pons,
5 to 7 per cent, in the central ganglia, 5 per cent, in the medulla, 3

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per cent, in the emra cerebri and the Corp. Quad. Ineludiag all
ages, from 30 to 35 per cent, occur in the cerebellum, pons and
medulla, being more frequent in these situations in children than
in adults, forming at least 50 per cont. of all intracranial growths
in children, while in adults they form only about 30 per cent.

In childhood the order of frequency as regards situation is as
follows: Cerebellum, pons, centrum ovale, central ganglia, lateral
ventricles, cerebral cortex, base, medulla and fourth veutricle. In
adults it is the cerebral cortex, cerebellnm, centrum ovale, pons,
central ganglia, medulla, corpora quadripemina and crura.

iNo age is exempt. A case has been reported in a child 4 weeks
old, by Steffen, and cases are reported occurring in individuals
liver 70 years of age, but they are rather rare at the two extremes
of life. According to statistics given by Gowers, one-third of all
intracranial growths occur before the age of 20, two-flfths between
20 and 40 years, one>fifth between 40 and 50 years, and one-fifth
after 60 years ; or, in other words, 18.5 per cent, occur during the
first ten years ; 14 per cent, between 10 and 20 years ; 20 per cent.
between 20 and 30 years; 18.5 per cent, between 30 and 40 years;
14 per cent, between 40 and 50 years; and 15 per cent, after 50
years of age. Excluding tuberculosis, 20 per cent, occur before 20
years, 50 per cent, between 20 and 40, 25 per cent.'between 40 and
60, and 5 per cent, after CO years of age. Age seems to exercise a
certain influence in the form of tumor that occurs and the site
from which it arises. In children and early youth tubercular and
cystic growths predominate, while glioma and sarcoma are com-
paratively frequent. In young and middle adult life glioma, sar-
coma and syphilitic growths are the forms usually found, and in
old age carcinoma usually occur.

b\om 75 to 80 per cent, of all tnbercular growths occur in
childhood, and 50 per cent, before the age of 10, 75 per cent, before
the age of 20. About 70 per cent, of glioma occur in active adult
life, that is between 20 and 50 years of age ; probably 20 per cent,
occurring before the age of 20, and 10 per cent, after the age of
50. Sarcoma occur in about the same frequency as glioma, if there
is any difference they are relatively more frequent during the ac-
tive period of life.

Cystic growths are most common between 10 and 30 years of
age, being rare under 10 or over 30. Carcinoma usually occur in
old age. Some cases are reported as occurring in childhood, but it
is probable that some of those reported iis carcinoma really belong
to the sarcomatous group of modern authorities.

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Syphilis, since it almost always follows the acquired form of the
disease, rarely if ever the inherited, occurs mtratly during active
adult life. As the time of infection so frequently occurs between
15 and 25 years of age, and the growth when it appears usually
makes its api)earanee from 5 to 12 years after the primary infec-
tion, it explains to some extent their occurrence during the active
period of life.

As regards other forms they are rare, and rarely if ever occur
before the age of 20.

It has already been pointed out that tubercular growths are the
most common form of intracranial tumors, especially in childhood,
in which they constitute at least 50 per cent, of all forms found.
They are nearly always secondary to tubercular disease elsewhere,
being carried there either by the blood vessels or the lymphatics.
If by the blood vessels the brain substance is likely to be affected ;
if by the lymphatics, the meninges are more likely involved. It is
maintained by some that the tubercular growth always springs
from the membranes; others claim that they originate within the
brain substance and have no connection with the meninges. Their
growth is said to begin in the lymphatic sheaths of the blood ves-
sels, which accounts for the tendency in vascular occlusion, the ab-
sence of blond vessels within the mass, and the tendency to de-
generation and necrosis.

In appearance they are firm, roundetl masses, non-vascular or
nearly so, with a yellowish white to cheesy aspect on section, vary-
ing in consistency, having small areas of softening, the periphery
being softer than the center and grayish-l ranslueent in color. They
vary in size from a pea to a turkey egg. The adjoining brain sub-
stance is usually softened, due to inflammatory changes, and consti-
tutes the danger zone when operating, in that its removal creates
too much havoc, while to leave it in invites speedy recurrence and
reinfection. The growth may become surrounded with a fibrous
capsule or become infiltrated with calcareous deposit, and then by
pressure eau.se atrophy of the adjoining tissue, it rarely becoming
infiltrated by the tubercular growth. They vary in number, being
multiple in at least 50 per cent, of cases. Instead of a circum-
scribed growth, there may be mere meningeal thickening, producing
effects similar to those of a tumor. This latter ccmdition usually
affects the base involving the optic commissure, the pons, and the
medulla.

Syphilitic growths are nearly always the result of the acquired
disease, usually occurring from 5 to 12 years after the primary in-

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fection, but may occur within a few months or not for 20 years
They occur more frequently than autopsy records show, since one
often meets with a condition manifesting ail the symptoms of brain-
tumor which disappear with specifie treatment. According to
Bramwell they constitute the most common form' of the intracranial
growths in adults between 25 and 50 years of age. They are near-
ly always found near the surface of the brain, situated on the con-
vex surface in or adjacent to Eolandic area, at the base, or in the
pons, rarely in the cerebellum, and are connected with the men-
inges.

When occurring in the substance of the brain they are prob-
ably connected with a process of pia mater, as their invasion is
usually along vascular sheaths. They vary in size from a hazel to
a chestnut, are regular in shape and not uniform in consistency.
They occur in two forms, one as a juicy, grayish red, jelly-like vas-
cular mass, infiltrating the adjoining tissues, the other as a yellow-
ish, quite firm, non-infiltrating growth, pr^enting irregulai; areas
of infiltration, with more or less fibroid induration and sometimes
calcification. At times the central portion undergoes liquefaction,
having a straw-colored, watery appearance. The surrounding
brain ti^ue is often the seat of more or less inflammatory changes
and the overlying membranes are often inflamed and thickened.

The presence of the fibrous tissue and the irregular areas of
caseation serve to distinguish the syphilitic from the tubercular
growths.

Sarcomatous growths are second in order of frequency of inter-
cranial tumors. They may arise from the brain substance, the
meninges or the bony walls. They usually originate in the cerebral
cortex, the cerebellum or the basal ganglia. They are usually
single and primary, rarely secondary, but the melanotic variety
only is multiple. They vary in size, the larger forms reaching 2 to
4 inches in diameter. These usually invade the convex surface,
while the smaller forms usually involve the membranes at the base.
They vary in consistency and may be either soft or hard; the
former are usually single, vascular, at times spongy, and have their
origin in the brain substance, while the latter form small, firm,
rounded growths, n on -infiltrating. They have not the infiltrating
characters of the glioma, but have rather a well defined limit, and
are surrounded by a zone of softened brain tissue.

The glioma are said to arise from the neuroglia, since they only
occur in the central nervous system and so closely resemble that
tissue, but their cells diflEer somewhat from the normal neuroglial

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cells in that there are rarely any stellate cells present, being nearly
always delicate, their outlines scarcely rouogiiinable, sometimes only
the nucleus being visible. They are usually primary, but may be
secondary glioma of the retinae. Fifty per cent, occur in the cere-
brum, 25 per cent, in the cerebellum, the remainder distributed
elsewhere. In children they involve the cerebellum and pons in 66
per cent, of eases. In adults the cerebral cortex is the seat in 33
per cent, of cases. Then follows the centrum ovale, the basal
ganglia, the lateral ventricles, the cerebellum, and the fourth ven-
tricle in the order of frequency.

Of all forms of intracranial growths the glioma have the great-
est tendency to infiltrate the adjoining tissues, making it practical-
ly impossible to t«ll where the new growth ends or the normal tis-
sue begins. They are very vascular and the blood vessels are
poorly supported, thus predisposing to rupture and hemorrhages,
but the hemorrhage rarely escapes beyond the limits of the growth.
They form gray or reddish gray masses, being very slightly if at
all paler than the normal cortex, and of about the same consistency,
making it almost impossible to distinguish it from the normal cor-
tex upon expcBure by these characteristics, only the yellowish, lus-
treless appearance of the exposed cortex, the increased cerebral
pres.sure, and the absence of pulsation indicate the presence of a
growth. They tend to undergo softening, forming a somewhat
cystic mass containing the debris of the broken down cells and
often more or less blood, due to rupture of the unsupported blood
vessels. The adjoining brain tissue is rarely softened and rarely
infiltrated by hemorrhage. Adhesions to the meninges are also
rare. The growth is single in 90 per cent, of eases. They never
involve the meninges primarily, and never produce secondary
growths. They vary in size from a hickory nut to the largest form
of intracranial tumors found. When the cortex which is the seat
of a gliomatous growth is exposed after death, it appears swollen,
but usually retains the normal cdlitour of the convolutions.

Carcinoma are usually secondary to carcinoma elsewhere in the
body. They seldom occur in children, mostly in adults over 50.
They commonly arise from the dura, but are also found in the basal
ganglia where they are relatively more frequent than other forms
of tumors. They are usually single and form rather vascular, soft,
infiltrating growths and grow rapidly. The surrounding brain
tissue is softened and infiltrated.

Cystic conditions are frequently connected with the arachnoid

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and are more frequent probably in the choroid plexus of the lateral
veatrieles.

Occasionally one appears on the surface adherent to the arach-
noid, appearing as a reddish pulpy fluctuating swelling, usually
small, but may be so extensive as to envelop the whole hemis-
phere. This form most frequently follows blows or injuries to the
head. These forms are generally associated with a debilitated con-
dition of the blood or nervous system. Another form occurs in
connection with some of the solid growths, particularly glioma, as
a result of a degenerating process, or h'^morrhage within its sub-
stance ; a few are developmental in origin.

As regards other forms of new growths they are rare and do not
differ in any way from similar growths occurring elsewhere in the
body.

In attempting to outline the pathological effects produced by a
growth within the cranial cavity, one must look upon it as prac-
tically a closed one. Enclosed by an imyielding inelastic wall and
lined by a dense fibrous membrane, rather richly supplied with
sensory nerves and from which partitions are given off which subdi-
vide the cavity into several smaller ones. Between the layers of
the membrane which lines this cavity and forms these partitions are
the vascular channels which transmit the blood from the venous
radicles of the brain substance to the portals of exit. The walls of
these vascular channels are wholly devoid of any muscular or other
contractile tissue which might contract upon and assist in forcing
the blood onward ; as a consequence the circulation through them
is wholly dependent upon the difference in pressure of the blood
in the venous radicles which empty into them and that in the vas-
cular channels in which they themselves empty.

This cavity has a definite capacity which is taken up by the
brain and its membranes with the contained blood and lymph cir-
culating through them ; any alteration in the content is due to an
increase or decrease in the quantity of blood or lymph present.
Nature has made some provision by the connection between it and
the spinal canal whereby it can accommodate itself to certain varia-
tions which may be termed the physiological limits. Any addition
therefore to its normal content must necessarily increase the pres-
sure within the cavity. This increased pressure may exert either
an irritative or destructive action or may act as an irritant at one
part and as a destructive agent at another. Not only is there this
general effect, but the pressure of the new material must be looked

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upon aa a foreign element and as such exerts a local action which
may also be of an irritative or destructive character. The effects
produced by any new growth will be modified by the situation,
size, and rapidity of growth, by its effect upon adjacent structures,
and by the complications that may arise.

The growth may effect the brain substance itself or the blood
vessels, and so the vascular supply of a definite part ; or the lym-
phatic channels, and so the circulation of the cerebrospinal fluid ;
or the nerves which ent«r and leave the cranial cavity, or the mem-
branes which line it or the bony wall that encloses it.

There is always an increase in the intracranial pressure due to
the development of the new growth, and to the interference with
the outflow of blood, or the increased secretion of the cerebrospinal
fluid. Even though the growth exerts a destructive action the new
material formed always occupies more space than that destroyed.
The pressure effects are greatest upon those structures nearest to
the seat of the growth and is in proportion to the resistance to be
overcome. If the new ^owth be situated above the tentorium, the
subtentorial pressure is not much affected until late, when more or
less gener^ oedema becomes manifest. Subtentorial growths affect
the general pressure more by obstructing the circulation through
the veins of Galen and increasing the quantitj^ of cerebrospinal
fluid within the ventricles. The cerebrospinal fluid is chiefly se-
creted by the choroid plexus of the lateral ventricles, from where
it passes through the foramina of Munroe into the third ventricle, .
then through the canal of Sylvius into the fourth ventricle and
thence into the central canal of the spinal cord and subaraehnoid-
ean space. Any obstruction along these channels must lead to ac-
cumulation within the lateral ventricles causing distention, dila-
tion, and the condition of internal hydrocephalus. Whether this
distention of the lateral ventricles is due to an increased secretion
of fluid, to a normal secretion, but obstruction to the outflow, or to
obstruction to the circulation of blood through the veins of Galen
has not as yet been conclusively proved. According to Gowers it
is not probable that obstruction to the veins of Galen alone would
cause internal hydrocephalus, so the increased secretion of or the
obstruction to the outflow of the cerebrospinal fluid must be the
catise. Probably all these factors have n causative influence.

The local effects will vary:

First. With the function of the part affected.

Second. With the manner in which it is affected,

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Tliird. With the degrw of <'(nii]>ciisJitioii (ir substitutiiin of
function by some other part for the part <lestro.ved.

Fourth. With the rapidity of the process.

The adjacent structures are destroyed partly by pressure, and
partly by the growth of morbid tissue elements. Noninfiltrating
growths act by compression producing a zone of softening and
atrophy. Infiltrating growths grow between, envelop and destroy
the normal nerve elements.

The irritative effects are both local and general, and are due
partly to the pressure effects, partly to the vascular disturbance,
partly to the influence of the new cell i'ormation, and partly to the
circulation or morbid products formed in and absorbed from the
growth itself as a result of the metabolic process going on within.
The irritative effects are manifested by a temporary increase of
function of the part or parts affected, not only of the brain sub-
stance but the meninges, particularly the pia mater. The men-
inges are more liable to inflammatory changes than is the brain sub-
stance. Sometimes there is evidence of meningeal inflammation at
a dista?ice from and having no connection with the growth itself,
the cause of which can not be shown. These inflammatory condi-
tions are more liable and more frequent in tumors of a diathetic
basis such as tubereulosis and syphilis. The tubercular inflamma-
tion is usually acute and general and is often the immediate
cause of death. The syphilitic is local and chronic, leading to ex-
tensive thickening and matting of the inflammatory products with
the new growth.

The irritative effects are most prominent when the growth is
situated in or near the cortex, at the base or subtentorially, and are
the cause of many of the most eharaeteristie symptoms of brain
tumor.

The destruction of tissue is an almost invariable result of a new
growth occurring from the infiltrating character of the growth,
from the softening due to pressure, and from the interference with
the blood supply. The destruction of any part is manifested by
lessened or abolished function. De.struction of the cortex of one
part may be compensated by the cornisponding area of the op-
posite side taking on iUi function, but tho destruction of conducting
fibres is never fully compensated.

As a result of the increasi-d general pressure there is produced
general flattening of the surface of th^i convolutions with narrow-
ing of the fissures and sulci.

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348

The pressure exerted upon the bony walls often causes atrophy
and thinning, which may be local, corresponding to the seat of the
growth, usually, however, involving the roof and the sides. This
atrophy will occur whether the growth be situated upon the sur-
face or within the brain substance. The condition is found only
when the tumor is large, and when there is internal hydrocephalus,
and seems to be the result of the intracranial pressure. At times
the inner surface of the bones is roughened, due to the unequal
erosion, and occasionally leads to perforation.

ACUTE HAEMORRHAGIC I'ANCREATITIS.

The ease was a patient of Dr. Stockton, to whom I am indebted for the follow-
ing clinical report.

The patient was 55 years of age, admitted to the institution t«n
years ago, having delusions of persecution, hallucinations of sight
and hearing, was restless, sleepless, dull and melancholy. Little
is known regarding her life and condition previous to admission,
but from what could be gathered from herself and the commitment
papers, the indications are a dissolute, immoral life and addiction
to morphine. From the time of her admission until the onset of
her illness her physical health was good except for a moderate con-
stipation, which necessitated the use of a purgative from time to
time.

Mentally there were no marked alterations, but she manifested
some retardation of thought, with occasional periods of irritability
and quarrelsomeness, with obscene and ijn moral talk.

Upon arising the morning of March 14, 1904, she complained of
feeling ill and suffered with nausea and vomiting, but was up and
about until 11 a. m., when she began complaining of great pain and
distress in the region of the stomach, aggravated when lying on the
back, and more or less tenderness on examination. The severity of
the pain was such that an opiate was necessary to relieve it.

At 6 p. m. the temperature was 102. G, pulse 130, with but little
alteration in the local or general condition. Vomiting still con-
tinued, the vomited matter being quite bile stained. The pain was
duU and aching, probably due to the opiate. The following morn-
ing there was considerable tympanitis, rigidity and tenderness most
marked in the epigastric region and general jaundice. Vomiting
had somewhat lessened ; the pain was stilt dull and boring in char-
acter. While attempting to get out of bed about 11 a. m. she sud-
denly became semiconscious, and died in a very short time.

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The autopsy report was as follows : Performed 3% houra af tijr
death. The body is that of an adult female, white, apparent age,
55. Weiftht, 145 pounds. Height, 5 feet 5 iuehes. Well devel-
oped, well nourished, rather fleshy, slightly jaundiced, post mortem
rigidity in neek, hands and feet. Post mortem lividity slight pos-
teriorly. Abdomen prominent, tense, tympanitic, liver dulness
very indefinite.

On opening the abdominal cavity the omentum and the intestine
protruded, the intestines were considerably distended with gas.
The omentum and peritoneum were of a pink to a light red color,
and a thin dark red odorless fluid ran out of the incision. About
350 ec. was diffused throughout the peritoneal cavity. The appen-
dix 6 cm. long, lying to the inner side of the caecum and curled be-
hind the lower end of the ileum and weis normal. The pyloric half
of the stomach, the duodenum and the transverse colon were
pushed forward by a dark red, rather soft mass lying posteriorly to
them and apparently involving the whole of the pancreas. Scat-
tered throughout the omentum, mesentery and wall of the stomach
and intestine were numerous small white nodules, varying in size
from a pinhead to a split pea, rathnr soft, white on section, and
were most abundant in the neighborhood of the pancreas. All the
structures in the immediate surroundings of the pancreas were mar-
kedly swollen and oedematous and infiltrated with a fluid similar
to that lying free in the peritoneal cavity, the infiltration and
oedema extending into the retro-peritoneal tissues, surrounding
both kidneys and down into the post-caeeal region on the right side,
giving the whole a softened, boggy and a dark red color. The mass
consisted of coagulated blood diffused through the whole of the
pancreas except a small portion of the head and tail. The source
of the bleeding could not be found.

The mucous membrane of the stomach and intestine were swol-
len, oedematous and pale in color.

The liver was of a yellowish red color, softened, lobules indis-
tinct.

The gallbladder contained about 22 cc. dark reddish-brown bile,
and quite a number of small brown-colored calculi.

The bile duets are patent, no thickening of their walls, the
biliary and pancreatic duct opened by separate orifices into the
duodenum. The spleen is slightly softened, the spleenic artery and
vein filled with coagulated blood.

The kidneys have several small cysts and were markedly con-
gested.

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The idaddcr contaiiied a few c*;. slightly albuiuiiums urine, no
sugar.

Apart from the abdominal condition there was some fatty de-
generation of the heart, marked atheromatous condition of the
aorta, with some calcareous deposition, bilateral chronic pleuritic
adhesions, cicatricial contraction of the lower lobe of the right
lung. Excess of eerebro-spinal fluid, considerable subarachnoidean
exudate, marked atheromatous condition of the arteries at the base
of the brain.

Incomplete as the clinical report is. yet it indicates some of the
most prominent symptoms that should lead one to suspect an acute
involvement of the pancreas. The onset of this condition is usually
sudden, but may be preceded by epigastric uneasiness for a day or
two. It occurs more frc()uently in adult males and Heshy people.
It usually begins with abdominal pain, inten«'. more or less diffuse
and persistent, with paroxysmal exacerbations, increased by move-
ment, associated with well marked tenderness above the umbilicus,
by distension of the superior abdominal region and by vomiting.
Nausea and vomiting are early symptoms, increase in severity, no
relief follows the aet. The vomit consists first of food remnants,
later of bile and blood in various stages of degeneratioU.

Collapse soon follows. The abdomen usually distends and is
tender. The bowels are as a rule constipated. Rarely there is
diarrhoea. Slight jaundice is usually present and increases the
longer the patient lives. The mass may be palpable, but usually
the distension and tenderness are so great as to render it very diffi-
■ cult if not impossible except under anaesthesia.

Severe attacks are usually fatal in twenty-fisur hours. Where
less acute, a gangrenous condition often is produced and proves
fatal in from two to five days from absorption of the virulent toxic
material.

M'^here the condition is still less acute it may lead to ulcer for-
mation or become subacute, chronic in mild forms, to resolute re-
covery. The haemorrhage may precede or take place during the
inflammatory proces.s. If it precedes the intlammation the bleeding
is usually within and without the glandular substance, and usually
runs an extremely acute course. If it arises during the inflam-
matory process the bleeding is less profuse and runs a less acute
course.

The diagnosis is difficult, as there are several diseases which
manifest a similar group of symptoms and occur more frequently,
the principal ones being :

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1. Acute ptomaine poisoiiiug.

2. Perforation of a gastric or duixieiial ulcer,

3. Gangrenous appendicitis.

4. Phlegmonous eholecystitis.

5. Acute intestinal obstruction.

Judging from the important part taken in the digestive process
by the pancreatic secretion discharged inbD the duodenum and in
the processes of metabolism by the internal secretion that is given
off by the pancreas to the blood or lymph or both, one would ex-
pect that the clinical manifestations of a diseased condition would
be so characteristic that a diagnosis would be comparatively easy,
but there are several reasons why such is not the case.

1. Because the pancreas is rarely involved in a pathological
process without other organs also being involved, particularly the
biliary ducts, the stomach and duodenum.

2. Because every function performed by the pancreas can be
performed to some extent by some other organ in the body except
the glycogenic function.

3. Because the greater portion of the gland may be destroyed
and yet the remaining portion may apparently be able to carry on
the normal function of the entire gland.

But while these conditions may give rise to very conflicting and
perplexing combinations of symptoms, yet there are some pro-
nounced features manifested which should lead one to suspect a
diseased condition of that special organ.

Fitz has laid down a rule that when a previously healthy person
or sufferer from indigestional attacks is suddenly seized with
violent pains in the epigastrium, followed by vomiting and collapse,
and in the course of twonty-four'hours by a eireumicribed epigas-
tric swelling, tympanitic and resistant, with slight rise of tempera-
ture, one should suspect aeute pancreatitis.

In a lecture delivered before the B. C S. E., Mr. P. J. Cam-
midge stated that there were present in the urine certain products
which were almost if not quite pathognomic of acute pancreatitis.
The method of examination to prove their presence or absence is as
follows:

To 10 cc. filtered urine is added 1 cc. strong HCL, gently boil
for 10 minutes in a sand bath.

A mixture of 5 cc, filtered urine and 5 cc. distilled water is
then added and the whole cooh'd in running water. The excess of
acid is then neutralized by slowly adding 4 gms. Pb. carbonate.
The whole is again tiltpred. the flask rinsed with 5 cc. water, to this

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are now added 2 gms. Sodium acetate and .75 phenilhydrazin hy-
drochlorate and boiled for 3 or 4 hours on the sand bath. It is
then poured in a test tube and allowed to cool undisturbed, when a

floculent precipitate forms which consists of rosettes of golden
yellow crystals.

The presence of sugar or albumen must be previously gotten rid
of, as they interfere with the process and the results. As some-
what similar results are obtained in patients suflEering from cer-
tain diseases in which active tissue changes are going on a differ-
entiating test is applied which consists in taking 20 ec. of filtered
urine and adding 10 ee. of saturated aqueous solution of mercuric
chloride, and filtering. To 10 cc. of the filtrate add 1 cc. of strong
HCl, and boil as in the former process. It is then diluted with
5 cc. of the former filtrate and 10 ee. of distilled water, cooled and
treated as in the former instance.

The practical results of these examinations of the urine by these
two methods Gammidge summarized as follows : If no crystals are
obtained by either method the pancreas is not at fault and the ex-
planation of the symptoms must be sought elsewhere. If crystals
are obtained by the first and not by the second method, active in-
flammation of the pancreas is present and surgical interference is
generally indicated.

In acute inflammation the. crystals are fine and dissolve in a 33
per cent, solution of H2SO4 in about 30 sec.

In chronic inflammation the crystals are coarser and dissolve in
1 to 2 minutes.

If crystals are obtained by both methods there may exist :
*1. Malignant disease of the pancreas.

2. Chronic disease of the pancreas.

3. Nonpancreatic disease.

In malignant disease the crystals are very coarse, require from
3 to 5 minutes to di^olve and operation is contra-indicated.

In chronic inflammation the crystals are smaller and dissolve in
from 1 to 2 minutes.

In nonpancreatic disease the crystals dissolve in 1 minute.

Thus it seems that the size of the crystals and their solubility
are directly dependent upon the aeutiioss of the inflammatory
process.

As regards treatment, the pathological condition indicates that
practicallj' only one line of treatment could be beneficial and that
is evacuation of the septic material, arrest of the hemorrhage and
free drainage by surgical methods. Even though the mortality

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353

following operation in the acute stage is very high (36 out of
59 eases operated upon proved fatal), yet when we consider the
fact that the disease almost invariably ends fatally if not treated
surgically, an operation is strongly indicated.

REPORT OP THREE CASES OF CEREBRO-SPINAL MENIN-
GITIS OP PNEUMOCOCCAL ORIGIN.

Case 1. Patient of Dr. Todd, to whom I am indebted for the
clinical report.

Female. Age 56. Admitted January, 1889, with a psychosis of
acute mania, beginning five weeb.s prior to admission. No report
given of her physical or inental condition prior to this.

During the stay in the hospital the mental condition gradually
assumed a type of chronic mania, with the development of de-
mentia. The physical state was comparatively good until March
16, 1905, in the afternoon of which there was manifested general
lassitude and tendency to lie down, and at night was reported sick
at the stomach, with some rise of temperature and acceleration of
pulse.

Physical examination of the attending physician on March 17
revealed nothing beyond an indistinct systolic murmur at the apex,
temperature 103, and pulse 130.

March 18 patient vomited several times, otherwise much in the
same condition.

ivrarch 19. Attendant in charge reported deviation of the eyes
to the left, and a slight sanguino-purulent discharge from the left
ear, but the physician failed to discover any evidence of either on
examination. Patient died in the early morning of the 20th. Au-
topsy was made six hours after death, with following rraults :

Body well developed and fairly well nourished; general ap-
pearance of a septie condition.

Pericardial sac contained about 50 cc. of transparent serous
fluid, the right side oi the heart was slightly dilated, slight fibroid
thickening of the margins of the mitral valves. Heart muscle
somewhat softer and paler in color than normal, moderate sclerosis .
of the aorta, most marked about the orifices of the coronary
arteries.

Left pleural cavity cntained 100 cc. of fluid similiar to that in
the pericardium. There was slight hypostasis of both lungs on
■ posterior surface of lower lobes. A cicatricial sear on the under
surface of the left lower lobe near the apex,

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The ab<loiiiiiiaI organs were iu a conditimi of so-called cloudy
-swelling.

'I'hcre were moderate firm adhesions of the dura to the skull.

thickening of the dura, its iDner surface covered with a yellowish
inirulent exudate. The subdural fluid was somewhat increased,
turbid, yellowish, purulent with fibrinous shreds. The arachtio-pia
tnater was diffusely thickened and :)paf|ue. Tlierc was extensive
subarachnoidean exudate— yellowish, purulent and fibrinous. The
brain substance apparently swollen and somewhat oedematous.

Blood vessels deeply injected.

A simi'ar condition was found involving the spinal cord and
its meninges, but rather less intense.

I:^jiiears made Emm the fluid obtained by spinal puncture, and
from the exudate on the surface of the brain showed pure forms
cf pneuinoeocci. Cultures were made on bouillon and glycerin
agar, and pure growths of the same organism obtained. Spinal
injection into a dog of a 24-hours' glycerin agar culture produced
a typical meningitis, causing death on the third day, and from the
eerebro-spinal exudate the same organism was again obtained in
pure form.

The portal of infection of this case could not be found, inas-
mu;-h as there was no visible alteration in the openings into the
cranial cavity.

Case 2. Patient of J)r. ISahr.

Female. Age 50. Admitted SeptiMiiber 24, 18!)0, with a psy-
chosis of recurrent mania, this being her third admission.

During the stay in the hospital the physical health wai^ good
until about January 15, 191)5. Mentally there was gradual demen-
tia with occasional maniacal outbreaks.

About January 15, 1905, she was taken ill, and on examination
it was found that there was consolidation of the right lung, accom-
panied by high temperature, great depression, and exhaustion, and
was thought to be tubercular. The symptoms decreased in inten-
sity and severity but persisted until JIarch 11, 1905, when there
was a sudden rise of temperature, rapid, laborious breathing, pro-
nounced dyspnoea, short hacking cough, and extreme depression.

Examination revealed consolidation cf the upper lobe of the
right lung and diminished respiratory sounds of the lower lobe
with compensatory liyperesonancc of the left side.

Patient died .March 2'J. 1905.

Autopsy was made 10 hours after with following results:

Body well developed but poorly nourished, slight oedema of

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the liiwpr extn^mitif's. Heart muscle was soft, flabby, and pale in
eolor, slight selerotie patches in the aorta, mist marked about the
coronary orifices.

Slight oedema of the left lung. The right pleural cavity was
obliterated by diffuse adhesioos easily broken down. Over the
lower lobe was a dense yellowish purulent exudate, somewhat ad-
herent to both surfaces of the pleura, nearly 1 cm. in thickness.

The right lung weighed 1190 gra. and was solid throughout, the
upper lobe being somewhat softer than the lower, and in the apex
was seniifluctuating. On section the lower and middle lobes were
in a condition of mixed red and grey hepatization. The upper
lobe was of a dirty, clayey-gray color, semisolid consistency, almost
fluid near the apex, and emitted some odor.

The abdominal organs were in a condition of cloudy swelling.

The brain and spinal cord presented a condition almost iden-
tical with the former case. Smears and cultures made from the
cerebro-spinal fluid and exudate and from the pleural exudate
and different parts of the lung presented pure forms of the pneu-
mococcus. None were obtained from the blood contained in the
heart, nor were any tubercle bacilli fouud in the right apex.

Case 3. Also a patient of Dr. Bahr.

Female. Age 43. Admitted January 23, 1905, with a psychosis
of acute meianehoUa.

She had complained a good deal of indigestion and constipation
for a year. The mental symptoms began about six months prior to
admission.

March 19 the patient was taken with excruciating pain over
the liver, and to the right of the median line in the epigastrium,
followed by acute gastric disturbances. Abdominal tenderness was
more or less diffuse, though most marked over the liver and just
to the right side of epigastrium. Examination of the urine showed
the presence of bile, although jaundice did not develop until a week
or tf-n days later.

Physical examinatitm March 26 revealed general jaundice, ex-
treme prostration, septic appearance, no rigors. Temperature
varying from 101° F. to 104° F., rigid abdominal walls, more so
over right roctus, general tenderness most marked over the hepatic
region.

Patient died March 30.

Autopsy was held 5 hours after with following results:

Body well developed but considerably emaciated, intense
general jaundice with slight wdema of the lower extremities.

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Outer surface of the pericardium on the left side, where in
contact with the left pleura, was deeply injected and had a red-
dened, granular appearance. A moderate quantity of epiear-
dial fat.

Heart muscle soft, and rather pale in color. Slight art«rior-
sclerosia of the aorta, most marked about the coronary orifices and
in the upper portion of the arch.

There were fibrinous adhesions at the lower portion of the left
lung, considerable fibrinous exudate, loosely attached to the lung,
the surface of which on removal was deep red in color, roi^h
and granular in appearance. The underlying limg substance to a
depth of 1 em. was dark red in color, less crepitant than remainder
of the lung, and exuded an abundant bloody exudate on pressure.

The right lung consisted of only two lobes, the upper lobe was
solid throughout except a small portion of the upper and anterior
margin, there were a number of firm fibrous bands on the anterior
surface of the upper lobe, also a general fibrinous plastic adhesion
of the whole pleural surfaces. The apex of the lower lobe was in
a similar condition. The remainder of the lower lobe was covered
with a thick, yellowish, fibrinous exudate similar to that on the left
side, but more extensive. The exudate was rather more adherent.
The underlying lung substance was similar to that on the left side,
while the remainder of the lung substance was somewhat oedema-
tous and congested. On section the solid portion was in a condition
of red hepatization, with beginning gray. The bronchial
mucosa on both sides, and the lower portion of the trachea, were
deeply injected, red and swollen, and covered with a viscid, san-
guinous, mucoid secretion. In the right apex was a calcareous nod-
ule about 1.5 cm, in diameter.

The gall bladder contained 5 small, irregular calculi, one of
which was in the cystic duct about one-third of the way down the
canal, the cut surface of the liver had a diffuse cloudy appear-
ance, swelling ot many of the lobules. The papilla of Vater was
very prominent, and the lumen of the common bile duct within the
substance of the pancreas was narrowed, owing to the firm carti-
laginous consistency of the pancreas itself.

The spleen was large, swollen and softer than normal.

The kidneys presented the eharacteristii^ of an acute nephritis.

The brain and spinal cord again presented characters identical
with those of eases 1 and 2.

Smears and cultures from the pleural exudates, the pneumonic
lung and the cerebro-spinal fluid and exudates all contained the

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pneumoeoeei in pure condition. Smears and cultures from the
gall bladder contents showed pure bacilli eoli communis infec-
tion.

Tour attention is particularly directed:

1. To the intense and extensive involvement of the meninges
of the brain and cord.

2. To the absence of any clinical manifestations pointing to
this involvement, such as are usually found in inflammatory af-
fections of the meninges.

3. To the absence of pulmonary involvement in the first case
and its presence in the other two.

4. To the probability that the meninges are involved in the
infectious process associated with pneumonia in a far greater num-
ber of eases than clinical records show.

5. To the advisability of making lumbar puncture, at least
in suspicious cases, not only for the purpose of diagnosis, but
more as a factor upon which to base a prognosis, and also open a
channel along which therapeutic investigation may be directed.

CASE OP RUPTURE OF THE AORTA, HAEMORRHAGE
INTO THE PERICARDIUM.

C. M. Age 52. Single. Parmer. Weight, 170 pounds. "Was
admitted to the Central Indiana Hospital for the Insane Pebruary
16, 1900. For two years he has threatened those about him and
destroyed his own property. Believed that neighbors wanted to
kill him. He is easily angered. Incoherent in conversation.
Drinks to excess. Noisy, melancholy, very destructive, homicidal,
and suicidal. Exposed himself to inclement weather. Had rheu-
matism, with other kindred diseases. Discharged gun in public
places. Threatened lives of people. Thinks some one is on the
constant hunt for him. Temperature normal. Pulae, 102. Res-
piration normal. Pain in right knee and back of neck. Discharged
May 21, 1901. Recommitted September 20, 1901. Very talkative,
very abusive in conversation and actions. Is inclined to wander.
Is uncontrollable. Threatens to do injury to any one he meets.
At time of second admission left ankle was bruised. Prom Sep-
tember, 1901, to November, 1905, he bad several mild attacks of
muscular rheumatism, otherwise was free from illness. December
22, 1905, he had an attack of angina pectoris. Severe pain in
left chest and arm of short duration. He had a second similar
attack on January 5, 1906, severe, and from which he rallied

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slowly. He was confined to the bed until January 11, 1906, when
he dressed himself, walked about the ward. On the morning of
January 12, 19U6, he arranged his bed, did light work from 7 :30
- a. m. to 9 a. m. No lifting or straining. During the morning he
walked about the ward and at 11:45 a. m. walked to the dining
hall, a distance of three hundred and fifty feet. When in the act
of sitting he became faint, sliding lo the floor, partially supported
by an attendant. Life was extinct in three minutes or less.

The autopsy report is as follows :

The body is that of a wcU-developed, well-nourished man, 180
em. in height, 175 pounds in weight. P. M. rigidity absent. Hair
gray, eyes blue, pupils uniform, equal and regular, ears cyanosed,
teeth raueh decayed.

Head^Cireumferenee, 57.5 em. Biauricular, 38.7 cm. Oc-
cipito-nasal, 35.5 em. Antero-posterior, 18.5 cm. Biparietal, 15 cm.
There are extensive, firm dural adhesions throughout and the dura
is thickened. There is excess of subdural fluid. The arachno-pia
is diffusely opaque. The arteries at the base are extensively thick-
ened. The right vertebral is twice the size of the left. The right
post-cerebral is very small. The right post-communicating is rather
large and arises from the internal carotid; apparently takes the
place of the posterior cerebral.

Brain — Weight is 1,450 grams. There is slight dilatation of the
ventricles.

Thorax — The pericardium bulges and is completely filled with
serum and hlood-coagulum, the latter forming a layer about 2 cm.
thick, surrounding the heart. The heart is enlarged, and firmly
contracted. The arteries on the surface are tortuous and thick-
ened. Between tlie pulmonary artery and the left auricle ante-
riorly is a dark red area about 2 cm. in diameter infiltrated with
blood, and in the center is an irregular opening about 7 nun. in
diameter, with ragged margins, leading into the aorta just above
the left coronary orifice. Both cavities of the heart are empty.
The endocardium is smooth throughout. The body and margins
of the mitral and aortic valves are thickened and sclerotic. The
chordae tendinae of the mitral cusps are thickened and apparently
shortened. The margins of the aortic cusps are fenestrated. Heart
with the attached vessels weighs 600 grams. Its muscles are rather
firm, pale in color and the right ventricle has yellowish streaks
extending inward from the surface. The aorta is moderately scle-
rotic, most marked about the coronary orifices and in the convexity
of the arch. The fir.^t portion is considerably dilated and thiaoed.

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The remaining portions less so. Beginning at the left coronary
orifice is a ragged tear extending along the coronary artery a dis-
tance of about 5 mm. laterally and slightly toward the heart about '
2 em. in both directions, upward and slightly obliquely toward the
left about 5 cm., then quite obliquely about 3 cm., the margin of
the main tear being separated about 1 to 2.5 cm. The arterio-
sclerosis extends throughout the whole arterial system. There are
a few band-like fibrous adhesions over the anterior surface of the
right upper lobe of the lung. The left lung weighs 330 grams.
the right 375 grams; they are crepitant throughout with some
dilatation of the marginal lobules. There is some hyperplasia of the
bronchial glands. The remaining thoracic and cervical struetufes
are normal.

Abdomen — Spleen, liver, and pancreas show more or less
sclerosis. The alimentary canal apparently normal. Some hyper-
plasia of the mesenteric glands. The kidneys are large, weighing
280 and 270 grams for the right and left respectively; are firmly
adherent to the perirenal fat, are firm on section, deep red in color,
granular in appearance, show no striation, contain many small
cysts more numerous at the cortico-medullary junction, varying
in size from 2 to 10 mm. in diameter, and also contain a large
quantity of fatty tissue in the pelves.

This ease illustrates the necessity and advisability of attaching
greater importance and significance to anginal pains, especially
when connected with arterio-sclerosis. It is a danger signal and
should not be considered insignificant nor lightly treated. It de-
mands an accurate and thorough examination as to existing condi-
tions and the adoption of means which have in view the removal of
those conditions producing the pain where this is possible, or where
it i.s not possible, the staying of the process that is going on and
the lessening of its influence upon the organism. The case also
illustrates one mode of death attributed in many of these casijs
to heart failure. Rupture of the aorta as a cause of death is not
so very infrequent and always takes place in a diseased vessel wall
unless of traumatic origin. Aneurysmal pouching of the aorta be-
hind one or other of the aortic cusps is rather frequent and serves
to explain the tendency to rupture when subjected to a sudden in-
crease of intravascular pressure. One of the interesting features
of this ease is the extensiveness of the rupture, occurring appar-
ently spontaneously, that is without having undergone anything,
so far as known, that would tend to produce a sudden increase of
blood-pressure.

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REPORT OF TWO CASES OP BRAIN TUMOR.

The following case ia considered of sufficient interest to report :

First. Because of the extreme rarity of this form of tumor.

Second. Because of the extreme size to which it grew.

Third. Because it offers a typical illustration of nearly all, if
not all, of the effects of a slowly-developing intracranial growth.

Fourth. Because of the clinical manifestations shown.

The clinical report, submitted by Dr. MacDonald, who had
chaise of the patient at this institution, is as follows :

H. B. Age 36 years. A patient in the Central Indiana Hos-
pital for Insane. The hospital records show him to have first been
admitted October, 1898, and discharged in September, 1902, as
"improved." The present admission was December 30, 1904. The
history obtainable was incomplete and entirely lacking in many
important features.

The parents are living and in fair li^alth; a maternal uncle
was epileptic, one cousin insane. Remaining family history un-
known.

There is no account of severe illness or injury in the patient's
early childhood, but at the age of 16 he developed major epilepsy,
whieh was attributed to a sun-strolse, and about 10 years later it
was noticed that the left eyeball was becoming abnormally promi-
nent, but observation is faulty as to the date of the first appear-
ance of this condition, and it does not seem to have been consid-
ered of importance. Pour years later, i. e., eight years ago, it was
first discovered that a right hemiplegia had developed.

Upon admission the patient was found to have frequent severe
epileptic seizures without discoverable aurea and without focal
prodromata. The mental state is one of arrested development.
He is found to be quite amiable during the intervals, but is quite
irritable before his convulsions, and is apt to have outbreaks of
fury following them.

The physical examination is as follows; The patient is a man
of medium height and unusually powerful muscular development.
The cranium is apparently symmetrical except that just behind the
left external orbital process is an abnormal prominence of the
skull.

This is not abrui)t in outline, is smooth, rises 1 cm., above the
surrounding skull level, and is about 10 em, antero-posteriorly, by
5 cm. in the vertical dimension.- The percussion note over this
prominence is quite flat, and the finger receives an impression of

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greatly increased resistance. It is apparently not sensitive lo
pressure. The eyes are promioeDt, the left showiDg an extreme
degree of protrusion which is said to have increased in degree very
gradually over several years. The pupils are unequally dilated,
the left being the larger, and they react slowly to light. There are
no palsies of the external ocular muscles. Ophthalmoscopic exami-
nation shows a rather extreme degree of optic atrophy. The mouth
is drawn slightly to the left.

The mental state prevents a satisfactory examination of the
tongue and palate. Speech is confined to some half dozen words.
There is partially recovered right hemiplegia with some contrac-
ture of hand and foot. Both knee jerks are constantly exagger-
ated, the right more so. There is right ankle clonus and Bahin-
sbi's toe phenomenon is present on the right side. Cutaneous sen-
sation could not be studied.

Operation was advised, although it was felt that the damage
wrought through the long years was irreparable, but the relatives
would not consent to this.

On December 19, 1905, by a fall during a convulsion, the pa-
tient sustained a fracture of the right mandible. Shock was ex-
treme and three days later serial convulsions appeared, soon pass-
ing into epileptic status and fatal pneumonia.

AUTOPSY REPORT,

The body is that of an adult male. Age 37, Height 168 cm.
Weight 160 pounds. Well-nourished, post-mortem rigidity well-
marked. There is a linear scar, recently healed, over the right in-
ferior maxilla, beginning 2 cm. to the right of the median line,
extending up and backward, parallel with the lower margin, and
about 1 cm. above it, for a distance of 4 cm. Hair is black. Eyes
gray; left pupil 8 mm., right 4 mm. in diameter; otherwise both
are uniform and regular. The nose and ears are normal. Tongue
furred, teeth much decayed.

Head — The general formation is asymmetrical, due to a consid-
erable bulging of the left eyeball, and of the whole left frontal emi-
nential area. The head is distinctly hrachycephalic in type; cir-
cumference, 61.3 cm. Biauricular, 38.2 cm. Occipito- nasal, 38,8
cm, in diameter. Scalp is 5 mm, thick, and bleeds very little.
Bone-thickness is very irregular, and unequal, thinned at one place
while thickened at another, thinning being particularly marked in
the outer portion of the left frontal, and upper portion of left

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parietal, the squamuus portion of the left temporal and in the
bones forming the floor of the left anterior and middle fossae,
forming a mere shell, readily breaking with the slightest pressure.
There is atrophy of the petrous portion of the left temporal bone,
of the left side of the body of the sphenoid, of the anterior and
posterior elinoid processes, and of the sphenoidal ridge, thus en-
larging the capacity of both fossae, and by depression of the floor,
the two fossae being practically continuous with each other. The
thinning is much loss marked on the right side. The thickening
is i»articularly marked on each side of the groove for the middle
meningeal artery, and to some extent along the sutures. At the
lower and anterior part of the left squamous, just above the floor
of the middle fossa, there are two cone-like projections protrud-
ing about one cm. into the cranial cavity, their bases gradually
spreading, becoming continuous with each other at their adjoin-
ing surfaces.

There are moderate dural adhesions most marked on the left
side. The dura is somewhat thinned on the left side and anteriorly.
No subdural or subarchnoidean fluid. Growing from the inner
surface of the vertical portion of the hit frontal bone toward ita
outer part, and attached by a base about 6-3 em. is a hard, whit-
ish, irregular, nodular, cartilaginous growth, with scattered areas
of slight calcareous infiltration, its weight 575 gm., its size 16-12-9
cm., extending inward and backward. On its external surface are
two depressions corresponding to the two bony prominences on the
inner surface of the squamous portion of the left temporal bone.
The growth extends into and displaces the external portion of the
frontal, the anterior portion of the parietal and the greater part
of the temporo-sphenoidal lobes on the left side. There is a second
smaller growth, 3-2-,'5 cm. in size, springing from the inner sur-
face of the squamous portion, which is similar in appearance and
structure to the former growth, and is attached by a narrow pedi-
cle -like base.

There is a fracture of the right inferior maxilla just about at
the point of junction of the horizontal with the vertical portion,
running obliquely back, in and upward. There is a moderate
amount of callous surrounding the frjictiire which is easily broken
down.

The brain weight is 1,68(1 grms. There is complete displace-
ment, with atrophy of the frontal lube except a layer averaging
about 2 cm. in thickness on its mesial and inferior surface, also of
the outer and inferior portion of the parietal lobe, and the whole

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of Ihc central three-fifths of the temporosphenoidal lobes ou the
left side. The left corpus striatum and optic thalmus are also
displaced inwards and downwards and are decreased in size.

The 1st, 3rd, 4th, 5th, 6th, 7th and Sth cranial nerves on the
left side are small, grayish, and atrophic. The optic nerves, optic
commissure and tracts are similarly affected, the left more so than
the right. There is extensive dilation of tlie right lateral and of
the third ventricle. The spinal cord is apparently smaller than
normally.

Thorax — There is slight fatty infiltration of the right ventricle
of the heart. Slight arterio-selerosis of the aorta, most marked
■ about the coronary orifices, and involving the coronary vessels
slightly. There are extensive, diffuse, fibrous, batid-like adhesions
in both pleural cavities with an acute fibrinous exudate over the
base of the lower right lobe. The lower lobe and base of the upper
lobe of the right lung are solid throughout and in a condition of
mixed red and gray hepatization. There is slight hypostasis of tht^
l)osterior and lower portion of the lower left lobe. The thyroid
gland is moderately enlarged with tendency to cystic forjnation.
There is some hyperplasia of the bronchial glands and some conges-
tion of the bronchial mucosa. The remaining thoracic and cervi-
cal structures are apparently normal.

Abdomen — Apart from the kidneys, the abdominal viscera d;»
not show any gross changes pathologically- The kidneys are in a
condition of chronic parenchymatous nephritis. The right renal
pelvis is dilated and pouch-like, the mucosa thickened and covered
with a somewhat yellowish exudate, and the cavity contains a mul-
berry-like calculus 1.5 cm. in diameter. The right ureter is slightly
dilated.

Microscopically, the growth consists of practically normal hya-
line cartilage throughout.

The renal calculus is somewhat stratified, and chemically cuii-
sists mainly of phosphates, but there are also oxalate, some xan-
thine, and some organic constituents present.

Osseous deposits in the dura, or small osseous projections from
the inner surface of the skull arc not infrequent, but the develop-
ment of definite tumor, benign in character, is a rare condition,
especially chondroma. Gowers, in speaking of benign brain-tumor..!,
does not even mention this form (Gower.s, .Mental and Nervous Dis.,
Vol. II, 1893 Ed.). Mills refers to them ns having been observed
iti the brain, usually springing from the base of the cranium in
the form of flattened nmsscs, arising cither from the bi>nes or

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364

from the dura, aud lying like plates upon the brain (Mills, The
Nervous System and Its Dis., 1898 Ed.). Starr, in speaking of
benign brain-tumors as a group, also refers to their extreme rarity,
and while meationing other forms, does not meution chondroma.
The same may be said of mostly all, if not all, writers upon the
subject of intraeranial-growths.

We have not been able to find any report of a brain-tumor of
any kind of the size of this one. Mills reports a sarcoma 2^^ in.
by SYz in. in size, and weighing 5 oz. Other writers, as Gowers,
Bramwell, Loomis, Bartholow, Hartshome, etc., refer to growths
of the size of oranges, a closed fist, etc., so that it is evident that
this intracranial tumor is one of extraordinary large size. It ig
difficult to imagine how it would be possible for an intracranial
growth to reach the size of this one, and yet be compatible with
the continuance of life. The fact that it affected primarily one of
the so-called silent areas, that it was of benign character, and that
it evidently was extremely slow in development, is, of course,
quite apparent, but even those factors are probably not the only
ones to be taken into consideration.

The effects which an intracranial growth may produce are as
variable as the conditions producing them. There may be no mani-
festations whatever of the existence of one, or there may be a
symptom-complex involving all the anatomical structures, aud
physiological functions of the cranium aud its contents. We have
here a pronounced enlargement of the cranial cavity to a capacity
capable of holding a brain weighing 1,680 grams, a new formation
weighing 575 grams, the dura, and blood that escaped when the
vessels were severed, so was not collected and weighed, the total
amounting to at least 2,300 grams. This enlargement was the re-
sult of at least two factors, expansion and atrophy from pressure
which in numerous places led to marked thinning of the bones.
But with this there was also a compensatory thickening of other
parts. In addition there are all those conditions mentioned in the
report of the autopsy.

Judging from the clinical report, one may safely assume that
the growth was present at the time of the first so-called epileptic
seizure. To what extent it had developed at that time, or to what
degree it had involved the brain substance, is impossible to say.
One can only surmise. It is possible, of course, that the epileptic
seizures were primary, and the development of the tumor a sec-
ondary phenomenon, which may have been the result, directly or
indirectly, of those seizures, or conditions producing them, or it

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365

may have had no connection whatever with them at first. The
probabilities, however, are that the growth waa the direct cause of
the epileptoid symptom-complex. The arrest of the development
of the mental faculties, with gradual and progressive deterioration
and destruction of those that had developed, was probably depend-
ent upon not only the direct action of the growth itself upon the
left hemisphere, but also the indirect action in its effect upon the
intracranial pressure, the interference with or modification of the
circulation of the blood and cerebro-spinal fluid, and so of the proc-
esses of metabolism in the brain substance itself. The complete
hemiplegia that occurred after 14 years' duration of the epileptoid
seizures was probably due to the gradually developing direct pres-
sure upon the cortical motor area anil its connections, wholly de-
stroying the functioning power of that part. If this be so, and
the appearance of the structure of the hemisphere at the autopsy
certainly warrants such a supposition, then one most presume that
the partial recovery of the paralysis that ensued was due to the
corresponding area of the opposite side taking on the function to
the extent from which the paralysis recovered.

The case also is illustrative of a group whose clinical manifesta-
tions are very similar to and not always difterentiable from those
constituting the symptom-complex of true, idiopathic epilepsy. In
the latter no visible, maeroseopical alterations are found. In the
former there is present some pathological condition, such as a
tumor, a haemorrhage, an area of softeoing, an inflammatory con-
dition, vascular disease, or other conditions, as a direct and excit-
ing cause. It does seem that there shtiuld be some means whereby
an epileptoid symptom-complex could be differentiated from that
of a true, idiopathic epilepsy, At present, however, we must con-
fess to an inability to do so, since on the one hand one often meets
with cases which, during life, are regarded as idiopathic epilepsy,
and the autopsy reveals the presence of some gross organic lesion,
while on the other hand, one also meets with cases regarded as
epileptoid, due to some gross lesion, and iire operated upon as such,
hut operation and autopsy fail to discover the existence of any
visible gross lesion. In this ea.se one is led to ask the question, was
it not possible to diagnose the presence of a tumor at an earlier
stage of its growth, at a time when operative procedures might
have been carried out, and have remi-dicd the condition that ex-
isted? Even though there may have been nothing in the epilep-
toid seizures themselves to indicate or suggest an organic lesion.
should not the bulging of the frontal area, of the orbit, and of

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366

the eyeball, which began to be noticed (irst about 10 years after
the onset of the seizures, along with the mental impairment, have
led one to suspect the existence of some such condition, and in ad-
dition, it can scarcely be doubted that an examiaation of the eyes
would have revealed disk changes, and the occurrence of hemi-
plegia some few years later would have been against the epileptic
seizures being idiopathic and in favor of an organic lesion.
For other case see autopsy report No. 179.

REPORT OF A CASE OF DEATH BY COMA IN WHICH
THERE "WAS FOUND EXTENSIVE TUBERCULOSIS OF
THE LUNGS AND INTESTINES.

Mr. B. W. S. was an attendant at the hospital for one month
previous to death. On the afternoon preceding his death he was in
the city, attended the theater during the evening, returning to the
hospital about 11 :15 p. m. Before retiring he sat beside a radiator,
and upon being asked if he were ill he replied "No," but that his
feet were cold and that he felt chilled and had some ringing in the
right ear with slight pain. At midnight he retired. At 4:30 a. m.
his room-mate regarded his breathing ass unusual and spoke to
him, but received no answer. This was n'peated several times, but
getting no response, he arose and shook him, and failing by this
he called the physician.

The doctor found him comatose, pupils contracted, pulse rapid.
Cheyne-Stokes respiration. Fearing that some narcotic might
possibly have been taken, the stomach pump was used, and the
contents evacuated, after which cardiac stimulants were adminis-
tered, but the coma gradually increased until death supervened
at 9 a. m.

Examination of the stomach-content disclosed lio narcotics.

Patient is reported as having gone west for his health three
years previously, due to pulmonary trouble. At several times he
is said to have had fluid removed from thi> left pleural cavity while
there. Later he returned east much improved.

About two weeks prior to his death he contracted what ap-
peared to he a slight cold with some cmighing, for which he was
given a bottle of medicine, afl«r whiith no further complaint was"
heard.

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AUTOPSY REPORT.

Body is that of a young adult malt', of slim build, about 27
years of age. Height, 178 em. Weight, 165 pounds. Fairly nour-
ished. Rigor mortis is not present.

Hair black. Eyes gray. Leff pupil 7 mm., right 5 mm. Some
bluisb discoloration subconjunetivally in the lower portion of the
right eye. Some cyanosis of the left ear. Nose and mouth nega-
tive. Finger and toenails eyanosed. Body generally appears
blanched. Left testicle smaller than the right. Some haemor-
rhagiii extravasation subeutaneously in the left side of the scrotum.
Tattoo marks on the anterior surface of the right forearm.

Head — -Brain and cord apparently noi-mal.

Thorax — The external surface of the pericardium adherent to
the pleura on both sides. The pericardial cavity contains 30 cc.
of transparent straw-colored serous fluid. Heart is somewhat di-
lated, both sides are relaxed, surface veirn^ are distended, and there
is a moderate amount of epieardial fat mostly in the interventri-
cular and auriculo- ventricular grooves. Both cavities are filled
with blood, the right side somewhat distended. Valves, endo-
cardium and muscle appear normal. W(iight, 250 grms. The left
pleural cavity is completely obliterated by firm dense adhesions
throughout. Also the right except for a small area surrounding
the upper portion of the upper lobe. "Weight, left 545 grras. ;
right 700 grms. Pleura thickened. Extensive subpleural blackish
pigmentary infiltration. Lungs rather firm, very irregular dimin-
ished crepitation. Has the same blackish pigmentation through-
out its substance. Lobes firmly adherent to each other. Of a
somewhat shotty nodular feel. Marked increase of fibrous ti^ue.
Sojne localized areas deeper in color arxl show a tendency to break-
ing down. Bronchial mucosa deeply injected. Bronchial glands
enlarged and deeply pigmented. Other thoracic viscera appar-
ently normal.

Abdomen — Firm fibrous adhesions of the omentiim to the an-
terior abdominal wall, particularly overlying the pelvis and also
surrounding the liver and spleen. The pelvic peritoneum is
deeply injected and contains many fibrinous band-like adhesions.

Spleen — Weight, 320 grms. Capsule thicltencd with many
fibrous shreds by which it is attached to the surrounding struc-
tures. Rather soft. Bleeds freely when cut. Parenchyma bulges
beyond the capsule. Dark red in (^olor. Easily lacerated. Mal-
pighian bodies not visible.

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Liver — Weight, 1,740 grma. Diffuse baudlike adhesions to the
diaphragm. Capsule thick and shreddy, ■ Bleeds cousiderably when
cut. Dull red color. Lobular outline poorly marked. Gall bladder
and ducts apparently normal.

Pancreas and adrenals negative.

Kidneys — Weight, left 150 grms, right 145 grms. Apparaitly
normal. Bladder contains 400 ce. amber colored urine. No albu-
men, no sugar, no narcotic reaction.

Left testicle atrophied.

Stomach contains a eoffee-eolored fluid, more or less viscid and
mucoid.

.Small intestines, duodenum and first portion of the jejunum
somewhat dilated with contents similar to that of the stomach.
The lower six feet of the ileum contains numerous ulcers, varying
in size and shape, generally situated opposite the mesenteric at-
tachment, tend to run longitudinally, surface irregular and nodu-
lar, grayish in color, margins thickened and nodular, periphery
injected, showing on the peritoneal surface as deeply reddish areas
and granular with more or less inflammatory exudate sticking the
adjoining surfaces together. Moderate enlargement of the mesen-
teric glands and of the retro- peritoneal glands in the neighborhood
of the pancreas.

This case is reported to call attention ;

1. To the peculiar mode of death.

2. To the few symptoms complained of in connection with such
extensive pathological changes.

3. To ascertain, if possible, a plausible explanation for the
peculiar and rather sudden manner of death.

BEPOKT OF EIGHT CASES OF BRAIN TUMOR, WITH
COMMENTS.

Case 1. Female. Age 43, Affected with general tuberculosis.
She had suffered with neuralgia for some time, in addition to the
tubercular affection of the lungs and intestines. The respirations
were from 30 to 40 per minute, the pulse from 85 to 100. Speech
was slow and difficult. There was a gradual onset of coma, in-
creasing in degree until death supervenird.

The autopsy disclosed a diffuse nodular involvement of the
meninges, most marked at the base, and a small nedule, about 5
mm, from the median line, and the same distance from the ven-
tral surface.

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Caae 2. Male. Age 57. Machinist by occupation. Began in
March, 1901, to complaiu of duluess of hearing, numbness of the
left aide of the forehead and scalp tending to become painful,
headache at the left side, and back of the head, which was relieved
by lying upon the right side. Also difi^inesa in the dark, upon
rising from a chair, or stooping over, everything becoming black.
Tliese conditions were continuous, graduiilly increasing in intensity
and severity. In March, 1902, it was diacovered that he masti-
cated his food wholly on the right side, owing, as he said, to his
not feeling it when on the left side. In May, examination showed
that the pupils reacted normally to light and accommodation. No
optic atrophy. Pulse 64. Arteries somewhat thickened. Urine
normal. In August, diplopia and dimness of vision were mani-
fested. By October there was entire blindness, and double optic
neuritis. The deep reflexes were increased, Babinaki's aign was
present, also ankle clonus. Cheyne-Stokes respiration, projectile
vomiting, attacks of syncope, convulsions and death in coma in
January, 1903.

Autopsy disclosed an oval, elongated, moderately firm, reddish-
white tumor, 5 by 2^4 cm. in size, springing from the left mid-
cerebellar peduncle, on its posterior and superior border, extend-
ing forward to the tip of the petrous portion of the temporal bone,
Ijing beside the pons and left cms, pressing against and causing
absorption of the bone around the internal auditory meatus.

Case 3. Female, Age 50. Admitted to the hospital in May,

1904, with manifestations of restlessness, sleeplessness, melancholia,
seclusion and delusions of apprehensive harm and injury. There
was a history of blindness for 32 years following a sickness, the
nature of which could not be ascertained. While being brought to
the hospital she was thrown from the carriage and severely shaken
up, but no definite injuries were found upon examination at the
time of admission, and the patient merely complained of feeling
sore all over. Eight hours after admission she suddenly expired.

Autopsy disclosed a small oval-shaped, reddish-gray mass, about
3 by 1 cm. in size, involving the middle lobe to the cerebellum,
and extending into the right lateral lobe to the outer margin of the
dendate nucleus. The left oeeij)ital lobe was smaller than the right
and its convolutions somewhat smaller. Both optic tracts and
nerves were small, gray and atrophic.

Case 4. Male. Age 30. Admitted to the hospital in January,

1905, with a psychosis beginning a week previously, consisting of
sleeplessness, restlessness, and at times \'iolent outbreaks, disorient-

[24—18438]

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370

atioii. failure to rccoftnize people, talking incoherently and irra-
tiunally, very (iiin-h cxeited and apparently suflEering great pain.
On examination it was found that the sixth, seventh and eighth
rii;s on the left side were fractured in the anttsrior axillary line,
and that there was aome fluid in the pleural eavity. Death en-
sued within twenty-four hours after admission. All that could
be learned of his health previous to admission was that about two
• years bufore he had consulted an oceulist for disturbance of vision,
who informed him that there was sojiie diseased condition in the
brain. There was also a history of severe gastric disturbances.

Autopsy disclosed a reddish-gray mass occupying the posterior
and upper part of the right parietal lobe, lying anterior to the
jiarieto-occipital fissure, extending forwards 6 em., laterally about
the same distance, while on the mesial surface it extended down to
the calloso-marginal fissure.

Case 5, Female. Age 50. Admitteii with a psychosis of acute
melancholia, associated with delusions of a persecutory nature.
Father died at the age of 8^1 of some brain trouble, supposed to be
insanity. , Patient had typhoid fever at 10 years of age, rectal
trouble 5 years ago, for which she underwent some surgical opera-
tion, and to which she attributes her present condition, and from
which she dates her trouble. Also ri^poi-ts middle ear trouble for
the last 5 years. There was marked deteriorati<m of memory, repe-
tition of questions and answers, inability fo recognize those about
her, emotionalism mostly depressive in character, confusion in
thoughts and ideas, complaining of a feeling of fulness and great
pressure in the head, amounting at tim^s to great pain, inability to
concentrate her mental powers, dizziness, indistinctness of vision
and great mental distress. There was jiresent marked tremor of
the hands, a staggering gait, bilateral weakness of voluntary
muscles, exaggerated knee-jerks, slight ti^ndeney to Babinski reac-
tion, slight manifestation of Bhomberg's phenomenon, and some
muscular weakness. All of these phenomena were more marked on
the right side. There was no involvement of the sphincters, no
museular atriiphy, and no sensory disturbances ascertainable. The
blood and urinary examinations were negative. There was some
cloudiness of the optie disks. The course was progressive. Stupor
supervened, developing into eoma and death.

Aiitopsy disclosed an oval-shaped, rather firm mass, irregular in
outline, noncapsulated, involving' the leEt optic thalamus, present-
ing an ulcerated surface on the floor of the left lat<!ral ventricle
over an area 3 by 1^^ cm.

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371 -

Case 6. Ma!p. Age 42. Occupation, engineer. Admitted to
the hospital with the history that 4 weeks previously he had come
home from work at the usual time for supper, but acting in a con-
fused manner, and when asked by his wife as to the cause, replied
"Durned if I know." lie masticated his food, but would not swal-
low it; would sit and watch his wife, and at times begin to cry. A
physician was called, who attributed the condition to acute dia-
betes. After two weeks' treatment a specialist on nervous dis-
eases was consulted, who pronounced the condition one due to cere-
bral softening. So far as could be learnc-d, his family history was
negative. The patient was said to have bad typhoid fever when 11
years ot age, acute inflammatory rheumatism at 25 years of age,
another attack of rheumatism in 190^1. He was married and had
one child, quite healthy. He drank some, rarely to excess, and not
at all regularly. There was no history of specific infection obtain-
able. Examination revealed a man well developed and well nour-
ished, with facial features flabby and expressionless, the right side
more pronounced than the left. There was constant dribbling of
saliva, with frequent partially successful attempts at spitting.
Speech was slow, thick and slurring, with frequent elision of let-
ters, syllables, and, at tim^, words. The writing was very tremu-
lous, with reduplication of letters, and at times elision of them.
The gait was waddling, with dragging of the feet, beeomini; more
pronounced with exercise, until it would become almost impossible
for him to continue. When eating the food would collect between
the teeth and gums, without any attempt being made to remove it.
The voluntary part of the act of swallowing seemed to be impos-
sible, as be could not get the food back in the pharynx. Sight,
hearing, taste and smell seemed to be unimpaired, but there Mas
intense redness of both optic disks. Tactile, temperature, nnd
muscular sense could not be determined because of the prolVmnd
dementia. The tongue and hands were moderately tremulou^;. the
knee-jerks were highly exaggerated, ankle clonus was present, as
were Babinski's, and Rhomberg's phenomena. The superficial re-
flexes were also active. The prick of a pin brought a quick re-
sponse reflexly. All the phenrnnena were more pronounced on the
right side. There was no nmseular atrophy, but the movements
were ineo-ordinate and ataxic. The blood and urinary examiiiH-
tions were negative. Spinal fluid obtained by lumbar puncture
gave a negative result bacteriological I. v. The course was rapidly
progressive, terminating fatally 68 days from the tirst definite
manifestations.

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372

The autopsy disclosed a brain weighing 1,880 grms., the dura
adherent over the left frontal lobe, the surface of the convolutions
flattened, an entire absence of cerebro-spinal fluid, a firm nodular
mass, irregular in outline, about 3 cm. in diameter, situated over
the anterior, external, and inferior surfaces of the left frontal
lobe. A second mass, similar in appearance, size, and character,
situated over the lower part of the ascending frontal, the ascend-
ing, and inferior parietal convolutions on the right side. A third
mass in the substance of the left optic thalamus, several cm. in di-
ameter.

Case 7. Male. Negro. Age 50. Admitted October, 190S.
Family history negative, except that mother died at an advanced
age with some form of paralysis.

Personal history : Patient is said never to have been sick until
the present illness. History of alcohol and syphilis is uncertain
but probable. About 9 months previous to admission he is said to
have changed somewhat and there is a rather indefinite account
of increased psychomotor activity with delusions about money
matters. At this time he frequently became confused, wandering
away from home, especially at night. About 5 months after the
onset of this condition, while at work he suddenly lost the power of
speech and soon after failed to recognize the use of knife or fork
at the table, taking both in one hand. Mastication and swallowing
taking place normally, when food was placed in his mouth. He
next became violent toward his sister, with whom he lived. Be-
came very tremulous in both hands and feet and swayed when
walking. There was no report of pain in the head, vomiting, con-
vulsions, or apoplectic attacks.

Examination on admission revealed the following : The mental
condition was one of complete fatuity, with some apprehension,
and much resistance to examination. General nutrition fairly
good. Facial expression mask-like. Pupils unequal, the right
being the smaller. Both react only slightly to light. No ocular
palsies. Test for aeeominodation impossible. Optic atrophy
marked. There was a fine tremor of the lips and tongue. Vocal
sounds were possible, but no articulate speech. Mastication, deglu-
tition normal. Gait markedly spastic. Inco-ordination of both
upper and lower extremities with very pronounced coarse tremor.
The left knee-jerk slightly exaggerated, the right normal, if any
change decreased. No Babinski, Kernig, or Rhombei^ phenomena
present. Incontinence of urine and faeces, slight oedema of the
lower extremities. Resistance and rigidity rendered abdominal ex-

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aminatioii impossible, and examiaatiOD of the thorax difficult, but
tubereulosia of the left side was diagnosed.

Adult, Male. Negro. Extremely emaciated; small subcon-
junctival haemorrhagie extravasation in the right eye; extensive
bed sore over the sacrum.

Head — Boues hard and heavy, grooving for the meningeal ves-
sels moderately deep, depressions for the pacchionian bodies fairly
deep, several osteophytic protuberances on the inner surface of the
frontal bones on each side of the superior longitudinal sinus, ex-
cess of subdural fluid, moderate increase of subarachnoideau fluid,
which over the anterior surface of the right frontal lobe is accumu-
lated into a cystic formation pressing upon and causing atrophy
of the convolutions. Dura thickened and covered on its inner sur-
face with a fibrinous membrane -I ike exudate, most marked on the
.■ight side, and somewhat adherent. In the anterior part of the
falx cerebri there is a calcareous plate 3 cm. antero- posteriorly and
.2-.25 cm. in thickness. The arachno-pia is extensively thickened
and diffusely opaque, most marked over the frontal and upper
part of the parietal lobes.

Brain — Weight, 1,040 grms. Basal vessels extensively thick-
ened. The right frontal lobe is smaller than the left. On the
under and outer surface of the right hemisphere, midway between
the extremities of the teniporo-sphenoidal and occipital lobes is a
quadrangular area dark mottled red in color, lying immediately
over the collateral fissure, 3.5 cm. antero-posteriorly, and extending
over the lateral surface 1 cm., and 2 em. mesially on the under sur-
face, semisolid in consistency. On section is seen to extend into
the brain substance 1 to 2 cm., its margins merging with the brain
substance itself. Moderate dilatation of the ventricles and granu-
lation of the ependyma throughout. The spinal cord appears
small.

Thorax — Bilateral chronic pleuritic apical fibrous, band-like ad-
hesions. Bilateral lobar pneumonia, involving almost the entire
lower lobes and the adjoining portion of the upper apical cicatriza-
tion and calcification. In the body of the lower left lobe is an
area about the size of an orange semifliictuating in consistency,
consisting of a dogeneratcd semifluid gruraous material. Some
marginal lobular emphysema, congestion of the bronchial mucosa,
hyperplasia of the bronchial glands. Extensive general arterio-
sclerosis and moderate atheroma.

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374

Abdomen — Enlargement of the mesenteric glands and a mod-
erate degree of chronic diffuse nephritis.

Case 8. Male. Age 36. Admitted to the insane hospital Octo-
ber, 1898. Dischai^ed improved September, 1902. Readmitted
December, 19M.

Family history — Parents living and in fair health. A maternal
uncle insane, one cousin epileptic. Remaining history unknown.

Personal history — Facts obtainable from the family were very
meagre. No account of severe illness or injury in childhood. The
epileptic condition came on at the age of 16. The ex^jphthalmos at
age of about 26, but observation as to the latter point is faulty and
it does not seem to have been considered important. The right
hemiplegia came on at age of about 28.

Upon admission the patient was found to have frequent severe
epileptic seizures with discoverable aurac and without focal prod-
romata. The mental state is one of arrested development. He is
found to be quite amiable during his interval, but is quite irritable
before his convulsions, and is apt to have outbreaks of fury follow-
ing them.

The convulsions are of the major type of extreme severity,
and not beginning with any discoverable aurae.

The physical examination is as follows: The patient is a man
of medium height and unusually powerful muscular development.
The cranium is apparently symmetrical, except that just behind the
left external orbital process is an abnormal prominence of the skull.
This is not abrupt in outline, is smooth, rises 1 cm. above the sur-
rounding skull level, and is about 10 cm. antero-posteriorly by 5
cm. in the vertical dimension. The percus-sion note over this prom-
inence is quite flat, and the finger receives an impression of greatly
increased resistance. It is apparently not sensitive to pressure.
The eyes are prominent, the left showing an extreme degree of pro-
trusion which is said to have increased in degree very gradually
over several years. The pupils are unequally dilated, the left
being the larger, and they react slowly to light. There are no
palsies of the external ocular muscles. Opthalmosaopie examina-
tion shows a rather extreme degree of optic atrophy. The mouth
is drawn slightly to the left. The mental state prevents a satis-
factory examination of the tongue and palate. Speech is confined
to some half dozen words. There is partially recovered right hemi-
plegia, with some contracture of hand and foot. Roth knee-jerks
are constantly exaggerated, the right more so. There is right ankle

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375

I'lonus and Babinski's toe phenomenon is present on the right side.
Cutaneous sensation eould not be studied.

On December VJ. 1905, by a fall during a convulsion, the pa-
tient sustained a fracture of the right mandible. Shock was ex-
treme and three days later serial convulsions appeared, soon passing
into epileptic status and fatal pneumonia.

The body is that of an adult male. Age, 37. Height, 168 em.
Weight, 160 pounds. Well-nourished. Post-mortem rigidity well
marked. There is a linear sear, recently healed, over the right in-
ferior maxilla, beginning 2 cm. to the right of the median line, ex-
tending up and backward, parallel with the lower margin, and
about 1 cm. above it, for a distance of 4 em. Hair is black, eyes
gray, left pupil 8 mm., right 4 mm. in diameter ; otherwise both are
uniform and regular. The nose and cars are normal. Tongue
furred, teeth much decayed.

Head — The general formation is asymmetrical, due to a consid-
erable bulging of the left eye-ball, and of the whole left frontal
eminential area. The head is distinctly braehyeephalic in type, cir-
cumference 61.3 cm. Biauricular 38.2 cm., occipito-n^al 38.8 cm.
in diameter. Scalp is 5 mm. thick, and bleei^ very little. Bone-
thickness is very irregular, and unequal, thinned at one place, while
thickened at another, thinning being particularly marked in-the
outer portion of the left, and upper portion of left parietal, the
squamous portion of the left temporal and in the bones forming
the floor of the left anterior and middle fossae, forming a mere
shell, readily breaking with the slightest pressure. There is atro-
phy of the petrous portion of the left temporal bone, of the left
side of the body of the sphenoid, of the anterior and i)osterior eli-
noid proe^s^, and of the sphenoidal ridge, thus enlarging the ca-
pacity of both fossae, and by depressioii of the floor, the two fossae
being practically continuous with each other. The thinning is
much less marked on the right side. The thickening is particular-
ly marked on each side of the groove for the middle meningeal ar-
tery, and to some extent along the sutures. At the lower and an-
terior part of the left squamous, just above the floor of the middle
fossa, there are two cone-like projections protruding about one em.
into the cranial cavity, their bases gradually spreading, becoming
continuous with each other at their adjoining surfaces.

There arc moderate dural adhesions most marked on the left

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side. The dura is somewhat thiooed on the left side and anterior-
ly. No subdural or subarachnoidean fluid. Growing from the
ianer surface of the vertical portion of the left frontal bone toward
ita outer part, and attached by a base about 6-3 cm. is a hard,
whitish, irregular, nodular, cartilaginous growth, with scattered
areas of slight calcareous infiltration, its weight 575 gm., ite size 16-
12-9 em., extending inward and backward. On its external surface
are two depressions corresponding to the two bony prominences on
the inner surface of the squamous portion of the left temporal
bgne. The growth extends into and displaces the external portion
of the frontal, the anterior portion of the parietal and the greater
part of the temporo-sphenoidal lobes on the left side. There is a
second smaller growth, 3-2-.5 cm. in size, springing from the inner
surface of the squamous portion, which is similar in appearance
and structure to the former growth, and is attached by a narrow
pedicle-like base.

There is a fracture of the right inferior maxilla just about at
the point of junction of the horizontal with the vertical portion,
running obliquely back, in, and upward. There is a moderate
amount of callous surrounding the fracture which is easily broken
down.

The brain weight is 1,680 gms. There is complete displacement
with atrophy of the frontal lobe except a layer averaging about
2 ctn- in thickness on its mesial and inferior surface, also of the
outer and inferior portion of the parietal lobe, and the whole of the
central three-fifths of the temporo-sphenoidal lobes on the left side.
The left corpus striatum and optic thalmu^ are also displaced in-
wards and downwards and are decreased in size.

The first, third, fourth, fifth, sixth, seventh and eighth cranial
nerves on the left side are small, grayish, and atrophic. The optic
nerves, optic commissure and tracts are similarly affected, the left
more so than the right. There is extensive dilation of the right
lateral, and of the third ventricle. Tbe spinal cord is apparently
smaller than normally.

Thorax — There is slight, fatty infiltration of the right ventricle
of the heart. Slight arterio-sclerosis of tlie aorta, most marked
about the coronary orifices, and involving the coronary vessels
slightly. There are extensive, diffuse, fibrous, band-like adhesions
in both pleural cavities with an acute fibrinous exudate over the
base of the lower right lobe. The lower lobe and base of the upper
lobe of the right lung are solid throughout and in a condition of

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mixed red and gray hepatization. There is slight hypostasis of the
posterior and lower portion of the lower left lobe. The thyroid
gland is moderately enlarged with tendency to cystic formation.
Tliere is some hyperplasia of the bronchial glands and some con-
gestion of the bronchial mucosa. The remaining thoracic and cer-
vical structures are apparently normal.

Abdomen — Apart from the kidneys the abdominal viscera do
not show any gross changes pathologically. The kidneys are in a
condition of chronic parenchymatous nephritis. The right renal
pelvis is dilated and pouch-like, the mucosa thickened and covered
with a somewhat yellowish exudate, and the cavity contains a mul-
berry-tike calculus 1.5 cm. in diameter. The right ureter is slight-
ly dilated.

SlicrosopicaUy the growth consists of practically normal hyaline
cartilage throughout.

The renal calcuhis is somewhat stratified and chemically eon-
sisls mainly of phosphates, but there arc also oxalates, some xan-
thine, and some organic constituents present.

Microscopically case 1 was tubercular, cases 2 and 3 were glio-
aarcomata, case 4 was an angiosarcoma, case 5 was a mixed celled
sarcoma, case 6 was syphilitic, case 7 was glioma with foci of
haemorrhage, ease 8 was chondroma.

It is to be regretted that more complete clinical reports have not
been submitted with these eases, but incomplete as they are a
summary of the clinical manif&stations reported shows the presence
of the great majority of those usually present in cases of brain-
tumor.

Irregular expansion of the cranial bi>nes, irregular thinning and
thickening, absorption and erosion of the same in at least 1 ease, in-
creased resistance on percussion in 1 case, attacks of facial neural-
gia in 2 eases, headache in 2 cases, feelinr^ of fullness and pressure
in 1 ease, dizziness in 2, syncope in 1, great mental distress in 1,
disturbance of vision in 5, of the pupils in 2, optic disk and retinal
changes in 4, exophthalmos in 1, disturbances of speech in 4, of
hearing in 1, sensory disturbances in 3, tremors in 3, paretie condi-
tions in 4, hemiplegia in 1, the knee-jerks exaggerated in 3, de-
creased in 2, ankle-clonus present in 3, Tiabinski's phenomenon in
4, Rhomberg's phenomenon in 3, difficulty in swallowing in 1, dis-
turbance of respiration in 1, gastric disturbance in 2, glycosuria in

1, incontinence of urine and faeces in 1, convulsions in 2, coma in

2, mental disturbances in (5, are amongst those given.

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It will be noticed that the great majority of them belong to
those tisually described as general symptoms of brain-tumor, while
there are verj- few of a localizing significance.

Another point of practical significance is the great variability
in symptoms manifested. For all practical purposes they can be
arranged under two groups.

1. Those which occur independent of the position of the tumor,
or general.

2. Those directly dependent upon the interference with the
fun(;tion of some local area, or focal.

Of the general manifestations some stand out prominently, aiid
are rather characteristic, while others are vague and indefinite, but
no one manifestation is pathognomonic of brain-tumor. In most
cases the general manifestations precede the focal and are the first
to require attention. They appear to depend upon :

1. The rapidity of the growth.

2. The vascularity of the growth.

3. The pathological characters of the tumor.

The manifestations vary in intensity according to:

1. The activity of the pathological process.

2. The condition of the blood supply of the brain.

3. The size, location and character of the growth.

4. The age of the patient.

5. The indirect effects of the growth.

Headache is one of the most constant, most distressing and
earliest of symptoms. Putnam and Jacoby give it as present in 74
per cent, of cases. Mills and Loyd in !>5 per cent. Eskridge in 100
per cent, Gowers as being rarely absent. It is usually more or less
continuous, with paroxysmal exacerbations. It varies in character,
and its intensity is increased by anything that tends to increase
cerebral congestion. It may be general or local. General pain is
probably due to the increased intracranial pressure pressing upon
the meninges, as trephining often affords relief, but one may have
a very small tumor and but little increase in intracranial pressure,
yet the pain be intense ; or there may be a lai^e growth, and great
increase of pressure, yet very little pain. Local pain is usually
due to meningeal irritation. The locality of the pain is not always
over the seat of the growth, for a cerebellar tumor is often associ-
ated with frontal headache, and cerebral involvement with oceipitu!
pain, or the pathological process may be on (me side of the brain,
and tilt' pain on the opposite side of the head. Usually when the
growth is on the surface of the brain, the pain corresponds to the

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379

seat of the growth, when it is in the white substance the pain is
often frontal, when subtenti>rial it is occipital, and when the
growth is unilateral the pain is on that side. When the pathti-
logical proems is syphilitic in nature the pain is worse at night.
In other forms it is usually worse when awake. The pain is usu-
ally less in children, due, probably, to the greater elasticity of the
skull. There may be an intermission of the pain, especially after
th« administration of iodides, or it may last weeks or months, or
until dementia destroys the power of its perception. While it is
almost useless to speculate as to its causation, yet it is usually at-
tributed to one or all of the following factors:

1. Increased intracranial pressure.

2. Stretching of the membranes,

3. Effusion into the ventricles.

4. Variations in the cerebral circulation.

5. Direct involvement of the meninges.

Associated with headache there is often marked tenderness on
percussion, this being more common when the growth is situated
just beneath the bone, involving the meninges, or in the super-
ficial brain substance, and is a valuable indication when not due
to sensitive nerve trunks.

At times there is also flatness on )>c'rcussion, but this is not
always present, even when the growth is superficial.

Optic 'neuritis occurs in about 80 pei' cent, of cases regardless
of the seat, nature, or origin of the growth. It is most frequent
when the growth is subtentorial, least so when in the meninges or
centrum ovale. It is not a very early symptom unless the growth
ia cerebellar or basal, usually not appearing before 3 months after
the onset of symptoms. It is usually a transient event in the
course of brain-tumor, as the latter condition may exist for years
without affecting the disk, and then suddenly develop acutely,
reach an intense degree within a few days or weeks, run its course
rapidly, and pa^ on to atr()pliy. The condition is usually bilateral,
appearing first in one eye, conse^iuently showing more involvement
of one eye than the other. Rarely the condition is unilateral, and
when so, indicates that the lesion is anterior to the chiasm. The
neuritis may exist to a marked degree without impairing vision,
and when impairment is shown, it will be found that the neuritis is
fully developed in those cases. This is particularly true when the
inflammatory process is moderate, vision often failing more during
the subsidence than the active stage of the process. Sudden loss of

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vision is most common in. children, probably because the gradual
loss is not noticed by them. Central vi3i<in may be normal, and the
field of vision for light and bright obj(?cts but little impaired until
atrophy sets in. The course of the neuritis usually coincides with
the symptoms, and probably indicates the progress of the disease.
If the neuritis be acute, and the tumor not influenced by treat-
ment, it usually goes on to atrophy. If the morbid process can be
influenced by treatment, the neuritis may subside, and normal
vision be restored, and this may be the first indication that im-
provement is taking place. The cause of the neuritis is a disputed
question. Extension of the pathological, irritative process to the
optic tracts and nerves, distension of the sheath of the optic nerve,
and lymphatics of the papilla, meningitis involving the nerve, and
increase of intracranial pressure have been alluded to as causative
factors. Optic atrophy when present is the result of a previous
neuritis, and according to Gowers is never reached until after
many months.

General convulsions occur in about 33 per cent, of cases. They
are particularly liable to occur as an early symptom in childhood,
and also may be the first manifestatian in adults. They usually
occur at long intervals, and indicate :

1. A rapid progress of the growth, or

2. Effusion into the ventricles, or

3. Haemorrhage within the tumor, or

4. Secondary involvement of the meninges.

They are epileptiform in character, but are rarely associated with
epileptic automatism, or destructive mania. They vary in intensity
from the petit mal to the grand mal type, but are usually severe,
SQ much so, that at times death supervenes during one. They may
be preceded by aura when involving the special centres, or may be-
gin as a local spasm, but these conditions have no special signifi-
cance as a localizing factor.

Vomiting is present in about 50 per cent, of eases. It occurs
without apparent cause, and may or may not be accompanied by
nausea, or bear any relation to the taking of food. It occurs most
frequently when the growth is cerebellar or basal. It is more com-
mon in children than adults. It is most frequent in the early
morning, and when making attempts to move the head, and is often
associated with headache and vertigo.

Vertigo may be a most constant symptom. It is usually inde-
pendent of the act of vomiting, but may be associated with it.

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381

Things about the patient seem to be in motion, and at times the
patient also. It occurs at intervals, and may be excited by change
of position, with increase of blood pressure, or in the acme of
cephalalgic exacerbations. It is rarely intense, except the growth
lie in the posterior fossa, and is variable in duration. Mendall, of
Berlin, states, that true vertigo is always associated with disturbed
musculature of the eyes, and is due to imperfect blood supply to
the nuclei of the nerves supplying the muscles.

Mental changes are almost a constant manifestation. They may
be slight, merely a mild impairment of mental vigor, but their
progress is marked by apathy and failure of memory, change of
disposition, irritability, loss of self-control, loss of interest, loss of
memory, delirious attacks, drowsiness, semi-conseious states, coma
and death. In a few cases there may be maniacal excitement or
melancholia or hallucinations and delusions. The cause is sup-
posed to be due to the increased intracranial pressure, and com-
pression of the brain.

Insomnia is usually due to the headache, and is more prominent
in adults with a syphilitic history, due, it is said, to disturbance of
the cerebral circulation, or, to the intensity of the general symp-
toms. Occasionally there is somnolence instead of insomnia, and
may be recurrent in character, lasting several days at a time.

Syncope occurs in a few cases, especially those involving the
posterior fossa. In rare cases there is a distinct apoplexy due to a
haemorrhage within the growth.

The pulse is usually slow and irregular, supposed to be due to
the increased intracranial pressure, and is regarded as an indica-
tion of such condition. It becomes very rapid toward the ter-
mination of the disease.

Respiration is often irregular, and of the Gheyne-Stokes char-
acter. It may become embarrassed by a growth in any part of the
brain, due to the intracranial pressure, or to the direct involve-
ment of the nerves of respiration, or their nuclei. The tempera-
ture may be normal, subnormal, or increased, especially if there be
any inflammatory changes.

lienai disturbances are as a rule associated with the increased
intracranial pressure. There may be polnria, or grycosuria, due to
pressure upon, or irritation of the nuclei of the vagus nerves.

Nutrition is not much affected in sarcoma, but often is in
syphilis, and emaciation is frequent in tuberculosis and carcinoma.

The deep reflexes are often increased on both sides, even when
the growth is unilateral. Usually, however, they are greater on the

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382

side of the lesion. The exceptions to this are, when tlie tumor is
situated in the pons, or medulla, when Ihey are often absent. The
superficial reflexes are variable and bear no definite relation to the
deep, as they may be lessened or increased on the side of exag-
gerated reflexes.

The sphincters are usually not much affected unless there is
great mental disturbances, profound stupor, or coma.

The focal manifestations depend upon the situation of the
growth, and may be produced, either directly from irritation or
destruction of the part, or indirectly fr<*m interference with the
blc{)d supply. Tumors usually cause both. A slow growing, non-
infiltrating growth may occur in any situation without producing
symptoms until of large size. A single tumor rarely produces a
large number of focal symptoms, and these are always unilateral
unless it lie on or near the median line.

A predominance of the mental disturhsnces as an early manifes-
tation points to an involvement of the frontal lobe. In tumors
elsewhere they are usually a late manifestation, when the intra-
cranial pressure becomes great. Disturbances of the power of bal-
ancing, and staggering have been noticed, but are not constant, and
are supposed to be due to involvement of the frontocerebellar fibres.
The ataxic movements differ from those of cerebellar ataxia :

1. In being often associated with symptoms of general paresis,

2. In there often being localized tenderness over the frontal
region,

3. In optie neuritis developing late in the disease,

4. In the mental symptoms being early in the disease,

5. In smell often being affected.

The vomiting is leas constant, the headache less agonizing, and
the choked disk not so frequent as when the growth is located else-
where in the brain. It is impossible to li'll from the mental symp-
ttnris which hemisphere is affected. Decided change of character,
of disposition, mental apathy, and tendency to si)mnoIence must be
i-egarded as local manifestations- of f rontial lobe involvement.

Convulsive seizures, paresis, or paralysis of certain movements
l)reeodcd or followed by numbness and tingling in the part affected,
muscular inco-ordination, disturbance of muscular sense, point to
an involvement of Uie sensorio-motor area. If these disturbances
are limited to the movements of the face, and phonation, it indi-
cates a probable involvement of the brsi in -substance surrounding
the lower part of the fissure of Rolando; if they are limited to the

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upper extremity, it points to the middle third of the fissure, and if
the lower extremities are involved, it suggests an involvement of
the upper part of the fissure. The spasms may be limited to one
part, or assume the characters of a Jacksonian seizure. They are
fairly uniform, and form the most reliable information for localiz-
ing purposes. They are usually followed by temporary paralysis
which becomes more pronounced as the tumor enlarges, while at the
same time the convulsions become more frequent and severe. If
the irritation be intense the local spasms may become general, may
be associated with loss of consciousness, and terminate in general
convulsions; yet a general convulsion beginning suddenly, with
loss of consciousness, without local spasms, is said not to be indica-
tive of an involvement of the motor area, "When a tumor pro-
duces mere compression of the motor area there are no spasms as a
rule, but a progressive paralysis.

Local sensory phenomena may precede, or take the place of a
spasm, and to a certain extent have the same localizing value, so
that where the paralysis is associated with ataxia, marked inco-ordi-
nation, disturbance of muscular sense, and anaesthesia, it points to
an involvement of the posterior portion of the sensorio-motor area.
Contracture, fine tremors, movements becoming coarse and jerky,
choreoid or athetoid may result from tumors involving the motor
area, but have little localizing value.

Disturbance of muscular sense is said to point to an involvement -
of the supramarginal convolution.

Word ■ blindness to an involvement of the angular gyrus.

Homonymous hemianopsia, paraesthe&ia, and partial anaes-
thesia, to an involvement of the deep white matter of the parietal
lobe.

Disturbances of sight point to an involvement of the occipital
lobe, bilateral homonymous hemianopsia resulting from an in-
volvement of the euneate convolution.

Disturbances of the sense of hearing point to the temporosphe-
noidal convolutions 1 and 2. ,

Disturbances of the senses of taste and smell point to the apex
of the uncinate gyrus.

A special form of sensory aphasia is often present in tumors in-
volving the temper (sphenoidal lobe characterized by an inability to
recall the name of the object seen, or to recognize the name heard,
and is said to be due to an invasion of the association iibres be-
tween the areas in which are located the memory of sight and
sound-

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Hemiplegia, brtmiaaaesthesia, incliidiag those of special senses,
and hemianopsia, point to a lesion involving the internal capsule.
Gowers says that hemianaesthesia, including those of special sense,
is one of the rarest effects of brain-tumor, and is absolutely un-
known from this cause, unless associated with some loss of power.

The assuming of forced positions, in co-ordination, and awkward-
ness in making movements, loss of inhibitory control over the emo-
tions, disturbance in the recognition of the limbs, indicate an in-
volvement of the optie thalamus.

A sta^ering drunken man's gait, nystagmus, paresis or paraly-
sis of some of the ocular muscles, with the general manifestations
of brain-tumor, point to an involvement of the corpora quadrige-
mina. The ataxia differs from that due to cerebellar disease, in
that the ophthalmoplegia precedes these conditions.

Hemiplegia with crossed third nerve paralysis without special
sense involvement or hemianopsia points to a lesion of the erus
cerebri.

Hemiplegia involving the body and face on one side, and the
third, fifth and sixth nerves on the opposite side, su^ests a lesion
of the upper half of the pons. If in addition to the third, fourth
and sixth nerves the facial be involved on the side opposite to that
of the body, the lesion is in the lower half of the pons. " In most
all pontine lesions the loss of the tendon reflexes are quite com-
mon.

Hemilplegia, hemianaesthesia with symptoms of involvement of
the ninth, tenth, eleventh and twelfth cranial nerves, involving ar-
ticulation, phonation, degluition, heart, and respiration, projectile
vomiting, polyuria, glycosuria, and local vasomotor disturbances
indicate a lesion of the medulla.

Early and severe headache, exc&ssive vomiting, and intense
choked disk, staggering gait, with tendency to fall in certain direc-
tions, and ataxia, point to cerebellar involvement. The manifesta-
tions appear earlier in the course of the disease in tumors of the
cerebellum than elsev/here, because of the rigid tentorium. If the
lateral lobe only be involved there may be no symptoms. The
ataxia associated with cerebellar disease is characterized by a stag-
gering, reeling gait, with the feet widely separated, the steps of ir-
regular length, and position, swaying of the body like a drunkard,
accompanied by a sense of vertigo which disappears on lying down.

Since these manifestations of brain-tumors, are so variable and
numerous, the question of diagnosis is rendered difficult according-
ly. So closely do functional diseases of the brain simulate those of

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organic lesion, that very few of these aymptoma when taken by
themselves can be positively asserted to be due to an organic dis-
ease. The following conditions are given as indicating the ex-
istence of an organic lesion :

1. Marked muscular atrophy in the distal part of a paralyzed
limb of cerebral origin with tiexor contracture, and increased deep
reflexes.

2. Wasting of the muscles of the face with reaction of degener-
ation not due to an extracranial lesion.

3. Most cases of crossed paralysis.

4. Most eases of pronounced trophic disturbances of cerebral
origin to one or both eyes.

5. More than transient hemianopsia.

6. More than transient sensory aphasia.

Having decided that the manifestations are due to an organic
lesion, it becomes necessary to ascertain the nature of the onset of
the manifestations, whether sudden, acute or chronic.

If the onset is sudden one must dilferentiate between haemor-
rhage, embolism, thrombosis and brain-tumor, for a brain-tumor
may be latent and sudden symptoms arise in the form of sudden
paralysis, stupor, deepening coma, and stt^rtorous breathing, and in
the absence of optic disk changes, and of a history, it is impossible
to diagnose from those conditions.

Haemorrhage alone never eausts optic neuritis. An apoplexy
with persistence, and increase of symptoms, appearance of head-
ache, convulsions, and optic neuritis, indicates a tumor, probably
glioma, with haemorrhage into it.

A sudden onset of symptoms, without any premonition associ-
ated with an organic lesion of the heart, and convulsive seizures is
indicative of an embolus.

Gradual onset, with the presence of premonitory symptoms, and
a history of spyhilis, or alcohol would indicate thrombosis.

If the onset be acute, practically only acute meningitis need be
considered. This begins, as a rule, more acutely, runs a more
rapid course, involves one or more cranial nerves, manifi^ts bilater-
al symptoms, is attended with greater febrile disturbances, and
less swelling of the optic disk. A tubercular affection, either as a
nodule or a diffuse meningitis, may be dormant until some exciting
cause, such as a blow, or mental excitement lights it up, and then is
liable to manifest symptoms of both tumor and meningitis. The
longer the duration after one month, the more liable it is to be a
[25—18438]

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tumor, aithou^h tubercular meningitis may run a course of six to
eight mouths, Optic neuritis, followed by primary optie atrophy,
is common in prolonged meningitis, while choked disk followed by
secondary optic atrophy is common in tumor.

If the course be a chronic one, and there are manifestations of
tumor, it may be mistaken for :

1. Aneurism.

2. Chronic meningitis.

3. Chronic cerebritis.

4. Chronic hydrocephalus.

5. Brain abscess.

6. Brain syphilis.

7. General paresis.

8. Uraemia.

9. Sclerosis.

10. Chronic anaemia.

11. Epilepsy and other epileptoid conditions.

The only diagnostic sign of aneurism is the aneurismal bruit in
the skull.

Chronic cerebritis is rare, but when present can not be diag-
nosed from brain-tumor when the latter is not accompanied by
focal symptoms.

Chronic hydrocephalus is characterized by being slower in de-
velopment, having fewer symptoms of irritation, having bilateral
manifestations, flexor spasms, or spastic paralysis, affecting the
legs more than the arms, ineo-ordination of the hand movements,
and no local spasms. One must not lose sight of the fact that this
condition may be the result of a brain-tumor, and not the primary
affection. The fluid may displace the medulla, pons, or crura and
manifest cranial nerve involvement by' stretching so that it is often
possible to diagnose only by noting the development of the
symptoms.

Chronic meningitis is rare except the result of alcohol, syphilis,
or tubercle. A history of alcohol, slighter headache, impaired
memory, mental dulness, delirium, and primary optic atrophy
would justify one in making a diagnosis of alcoholic meningitis.
In tubercular meningitis, the headache is more severe and continu-
ous, there is more marked sensitivenras to light, sound, and touch,
the optic neuritis is less frequent, less intense and less rapid; tiiere
are tubercles on the choroid, and there may be a gradual subsiding
of symptoms, but it must be remembered that there may be a local-

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ized meningitis resembling tumor, or a meningitis about the tumor,
in which case diagnosis is practically impossible.

The symptoms of brain abscess are practically those of brain-
tumor, often differing, however, in their origin, mode of develop-
ment, progress and termination. The presence of a cause, head-
ache not so severe, and less paroxysmal, mental change more sud-
den, and less constant, less swelling of tie optic disk, less impair-
ment of sight, faster onset of local symptoms, and shorter dura-
tion, and situated in the frontal, occipital, or temporo-sphenoidal
lobes, are strongly indicative of abscess. This condition may be-
come latent and later recur with fatal termination.

Persistent headache, paroxysmal in character, slight failure of
memory, unwonted slowness of speech, general lassitude, apathy
and indifference, lack of will for mental exertion, aimless wander-
ing, restless nocturnal automatism, somnolence, momentary giddi-
ness, and vertigo in a syphilitic patient are alarming symptoms.
Epileptiform convulsions following a history of intense protracted
headache, should excite a suspicion of syphilis (Pepper-Fournier),
Epileptic attacks with hemiplegia or monoplegia, incomplete but
progressive, when not due to alcohol or uraemia, in a subject over
30 years of age, are due to syphilis in 90 per cent, of cases. Brain
syphilis may develop within three months, but is usually a late
manifestation.

Bilateral, jerky inco-ordination, absence of choked disk, absence
of vomiting, and seanny speech are suggestive of diffuse sclerosis.

The general appearance, high pulse tension, cardiac hyper-
trophy, albumin and casts in the urine, albuminuric retinitis, and
less swelling of the optic disk, are characteristic of uraemia. So
closely do uraemic symptoms resemble those of brain-tumor at
times, that BramweU makes the statement that one should never
make a diagnosis of brain-tumor without first excluding uraemia.

General paresis manifests a gradual dementia rather thMi dul-
ness, complicated by:

1. Stupid delusions sometimes grandiose.

2. Motor symptoms, at first ataxic, later paretic.

3. Pupillary alterations or defects.

4. General tremors causing speech and writing defects.

5. Diffuse sensory disturbances.

6. Supervention of a mania or melancholia.

In the early stage one usually meets with pupillary changes,
tremor of the tongue, facial muscles and hands leading to speech

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and writing defects, mental alterations tending to eccentricity and
vagueness, with paroxysmal exacerbations lasting several days or
longer. If to these symptoms are added delusions of grandiose, ab-
sence of headache, vomiting and optic neuritis, the diagnosis of
paresis is pretty certain.

The clinical manifestations of brain-tumor are very similar to
and not always differentiable from those constituting the symptom-
complex of true idiopathic epilepsy. It does seem' that there
should be some means whereby an epileptoid symptom-complex
could be differentiated from that of a true epilepsy. Thus far,
however, an inability to do so at times must be admitted since on
the one hand one often meets with cases which, during life, are re-
garded as true epilepsy and after death autopsy reveals the pres-
ence of some organic lesion, while on the other hand one also meets
with cases regarded as epileptoid dne to some gross lesion and oper-
ated upon as such, but operation and later autopsy fails to disclose
the existence of such.

The diagnosis of epilepsy from the convulsions of organic brain
disease presents many aspects and is of great importance. If the
convulsions are general and unattended by any other symptoms the
diagnosis is impossible (Loomis & Thompson) ; epileptoid cases
having every indication of genuine epilepsy on careful examination
often show vestiges of old plegias, e. g. unilateral excess of reflex,
traces of paresis, slight retardation of growth, a certain amount
of rigidity, etc. Organic epilepsy tends to exhibit a unilateral
character in its spasms.

. Slistakes between epilepsy and brain-tumor are most likely to
occur in slow-growing tumor in or near the central convolutions;
convulsions almost always begin locally, but localization does not
prove it. Presence of other symptoms are the most important in-
dications. In the absence of these the etiological factors must be
considered, e. g. a history of epileptic inheritance or of syphilis.
Epilepsy is probable :

1. If con^Tilsions existing alone are first on the one side, and
then on the other.

2. By the length of time they exist as the only symptom.

Intense persistent headache, permanent hemiplegic weakness,
paralysis of cranial nerves, vomiting without eaUse, vertigo, dizzi-
ness, slow pulse, bilateral optic neuritis, mental disturbance last-
ing from one to two years, and convulsions are very strongly in-
dicative of tumor. Convulsions of organic brain disease are:

)v Google

1. Generally unilateral when slight, bilateral when severe.

2. Show a tendency to extend, becoming wholly general.

3. Induce a secondary state closely resembling that of epilepsy,
leading to the oeeurreuee of both minor and major attacks.

In attempting to arrive at a diagnosis one has to determine the
presence, location, and variety of the tumor, and to do this, one
must consider on the one hand, the whole genera! symptom-com-
plex, and the other hand, the local manifestations in the order of
their appearance, method of development and extension.

The course of brain-tumor is usually gradual and progressive,
with an increase in the number and intensity of the symptoms.
The average duration is about 15 montlis, unless carried off by some
intercurrent disease. Death is usually in coma, or convulsions, and
in a few cases they die suddenly with all the manifestations of an
acute intracranial vascular lesion.

The treatment, with the exception of those of syphilitic origin,
is practically surgical where this is possible. Those of syphilitic
origin usually respond to ant i -syphilitic measures. Even in those
that are not luetic, however, the administration of iodides often
produces a temporary amelioration of symptoms, and is apt to lead
one astray at times, in arriving at a cimelusion that the condition
has a syphilitic basis. "Where no benefit is derived following the ad-
ministration of anti-syphilitic treatment for a p'eriod of three
months, a luetic basis may be excluded, and further treatment
along that line is useless.

)v Google

PATHOLOGICAL DEPARTMENT.

This building was erected in 1895 and equipped in 1896. It ia
two stories high, constructed over stone foundation, and built of
bricli and stone. It contains nineteen working rooms, with toilet
rooms, etc.

The first floor contains the following rooms :

General reception, reception for relatives, viewing, mortuary,
dissecting, furnace, supply, chemical laboratory, anatomical and
pathological museum, lecture room. The latter has a seating ca-
pacity for 160 persons.

The second floor has the following rooms:

Pathologists' study (private), records, photography and acces-
sory, models, charts, diagrams, etc., library and conference, micro-
scopical laboratory, bacteriological laboratory, pathologists' re-
search (private).

This department was built with a view of furnishing the med-
ical staff with every facility for the study of their cases and to
enable them to thoroughly examine all specimens.

All the facilities for clinical study are extended to the physi-
cians and medical students of the State.

)v Google

THE NEW HOSPITAL FOR SICK INSANE.

This Hospital consists of five distinct buildings, all of which are
connected by corridors. The administration building forms the
central feature and is directly connected with the Department for
Men and the Department for Women; it contains the reception
room for visitors, the various offices, supply rooms and lavatories
on the first floor, and the sleeping rooms for the clinical assistants
on the second floor.

The Department for Men and the Department for Women, to
the right and left of the administration building, contain the
surgical wards on the first floor and the medical wards on the
second floor.

Each ward consists of a day sitting-room, adjacent to the large
dormitory, and of ten separate bed-rooms, also of a nurses' day-
room, clothing-room, linen and supply rooms, lavatory and bath-
rooms for patients, and lavatory and bathrooms for the attend-
ants. ^11 bathrooms and lavatories throughout are in separate
buildings, independeht of the wards.

The operating department is on the first floor, in direct com-
munication with the men's and women's surgical ward. It con-
sists of an operating room, rooms for general diagnosis, anaes-
thetizing, instruments, etc.

The rooms for serilizing, for drugs, supplies, bandages, etc.,
are near at hand.

The building is also provided with bathrooms and lavatories,
for the operator and for the nurses or attendants.

Directly connected with the Department for Men and the De-
partment for Women, in the rear of the entire group of buildings
are the general dining-rooms, storage rooms, sculleries, dishrooms,
linen room and the kitchen. This connection is by means of cor-
ridors amply provided with cross ventilation. Under this arrange-
ment the odors from this department can not permeate the wards.

On the second floor of this building are the sleeping rooms for
the attendants. A basement of eight feet in the clear extends
under the entire group of buildings. The construction, in all of its
details and the selection of the materials throughout were well
considered. AH outer and inner walls rest upon a concrete foun-

)v Google

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