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hi 


—  THE 


Alienisti^  Neurologist; 

A    QUARTERLY    JOURNAL, 

OF 

SCIENTIFIC,    CLINICAL   AND    FORENSIC 

PSYCHIATRY    AND   NEUROLOGY. 


Intendeoi  especially  to  subserve  the  wants  of  the 
General  (Practitioner  of  Medicine. 


"Quantum  ego  quidem  video  motus  morbosi  fere  omnes  a  raotibns  iu  syste- 
mate  nervorum  ita  pendent,  ut  morbi  fere  omnes  qnodammodo  Nervosi  dici 
>ineant.  "—Cullen's    Nosology:    Book   11,  p.  181—Edinburg  Ed.  1780. 


VOLUME     I 


EDITED  BY 

C.     H.     HUGHES,     M.    D., 

And  an  associate  corp.s  of  collaborators. 


ST.  LOUIS: 

EV.  E.  CARRERAS,  STEAM  PRINTER.  PUBLISHER  AND  BINDKR. 
1880. 


PRESS     OF 

Ev.    E.    Carreras,   Steam   Printer,  Binder  and   Publisher, 
ST.   LOUIS. 


Contributors  to  Volume  I, 


Dr.  BEARD,  GEO.  M., 


Xew  York. 


Dr.  CHAPIN.  JXO.  B., 

Ovid,  X,  Y. 

Dr.  CUR  WEN,  JOHN. 

Harrisburg,  Penn. 

Dr.  DEAN,  D.  V., 

St.  Louis. 

Dr.  DICKINSON,  WM., 

St.  Louis. 

Dr.  EARLE,  PLINY, 

Northhampton,  Mass. 

Dr.  HAMILTON.  ALLAN  MgL., 
New  York 


Dr.  HENSKE,  A.  A., 


Dr.  HODGEN,  JOHN  T, 


Dr.  HUGHES,  C.  H., 


Dr.  KUHN,  DANIEL, 


St.  Louis. 


St.  Louis. 


St.  Louis 


St.  Louis. 


Dr.  KING,  WILLIS  P., 


Dr.  MARAGLIANO, 


Sedalla,  Mo. 


Genoa,  Italy. 


Dr.  MUDD,H.  H., 

St.  Louis. 

Dr.  MANN,  EDWARD  C, 

Fort  Washing-ton,  N.  Y. 

Dr.  NELSON,  E.  M. 

St.  Louis. 

Dr.  PORTER,  WM., 

St.  Louis. 

Dr.  RAY,  ISAAC, 

Philadelphia. 

Dr.  RUSSELL,  GURDON,  W., 

Hartford,  Conn. 

Dr.  RUSSELL,  IRA, 

Winchenden,  Mass. 

Dr.  SAUNDERS,  EDWARD  W. 

St.  Louis. 

Dr.  STEVENS,  C.  W.. 

St.  Louis. 

Dr.  STEPHENS,  GEO.  T., 

Albany.  N,  Y. 

Dr.  SEPPILLl,  GIUSEPPE, 

Italy. 

Dr.  STEARNS,  H.  P., 

Hartford,  Conn. 

Dr.  WORKMAN,  JOSEPH. 

Toronto.  Canada. 


Index  to  Volume  I. 


ORIGINAL  CONTRIBUTIONS 


Aphasiaand  Agraphia  with  ProfiTes- 
sive  Improvement 

Apparently  (>)n8cion8  Epileptic  Au- 
tomatism with  a  Sequel  of  Aphasia 

Aiilioiiia  from  Motor  Paralysis 

Atvdphy  of  the  »_  erebellum," 

Case  of  Hemiplegia  and  -aphasia    . 

Case  of  General  Paresis 

Cliuiciil  Inquiry  into  the  Diagnostic 
Significance  of  Absent  Patellar 
Tendon  Reflex 

Contributions  to  Cerebral  Localiza- 
tions  

Curability  of  Insanity  vs.  "Recov- 
eries from  Mental  Diseases." 

Experts  and  Expert  Testimonv 

Impending  Periodic  Mania. . . ." 

Improved  ^sthesiometer  and  some 
of  its  uses 

Insane  Diathesis 

Isolation  of  Persons  in  Hospitals  for 
the  Insane 

Medico-Legal  Aspect  of  Cerebral 
Localization  and  Aphasia 

Medico-Legal  Aspect  of  Cerebral 
Localization  and  Aphasia  (con- 
cluded)   

Morbid  Juvenile  Pyrophobia  caused 
by  Malarial  Toxhsemia 

Mysophobia-Melancholia  with  Filth 
Dread— Mania  Coutaminationis. . 

Kature  and  Treatment  of  Hysteria. . 

Notes  on  Keurafcthenia 


337  : 

46(i     j 


PAGE. 

Organizations  of  Hospitals  for  the 

Insane 509 

Pathological  Relation  of  Certain 
Ophthalmic   Phenomena  to  Tabes 

Dorsalis,  etc 178 

Post-Mortem  Notes  with  History  of 

Convulsions 343 

Propositions  of  the  Association  of 
Superintendents  of  American  Hos- 
pitals for  the  Insane 1  &  165 

Propositions  of  the  Association  of 
Medical  Superintendents  of  Amer- 
ican Hospitals  for  the  Insane 322 

Recoveries  from  Mental  Diseases. . .    131 
Reflex  Cardiac  Gangliopathy,  with 

Hereditary  Diathesis 211 

Relief  in  Important  Nervous  Dis- 
eases   following    Enucleation     of 

the  Eye  Ball, ns 

Salivation  in  the  Insane 203 

Sequences  of  Neurasthenia 18 

Studies  on  Cerebral  Thermometry. .      44 
Studies   on  Cerebral   Thermometry 

(concluded) 157 

Shorter  Clinical  Records 540 

Subsequent  History  of  Twenty-tive 
Persons  Reported  Recovered" from 

Insanity  in  1S43 65 

Syphilitic  Hypochondriasis 78 

Topical  Diagnosis  of  the  Disease  of 

the  Brain 271 

What  shall  be  done  with  the  In- 
ebriate?     285 


SELECTIONS. 


PAGK. 

Anatomical  society  proceedings. . .      24r.    : 

Anatomical  and   physiological    ex-  • 

cerps 357 

Bloody  sweat ,   case  of 242    | 

Clinical   neurology 360    I 

Clinical    and  necroscopic    illustra-  j 

tions  of  localized  brain  disease.   . 

Cerebral  tumor  -nithout  character- 
istic symptoms 

(-  erebrarand  neuro  therapeutics 

Choeric  convulsions  in  a  new  born 
child 

Contribution  to  the  pathological 
anatomy  of  chorea, 

Discussion  between  Westphal  and 
and  Nasse  on  the  present  status 
of  non-restraint  in  Germany 

Dr.  W  R.  Gowers  on  paralytic 
chorea 

Eflects  of  cephalic  electrization 
upon  the  vessels  cf  the  dura-maier 
and  of  the  pia-matei- 

Five  new  cases  of  pseudo-hyper- 
trophic  muscular  paralysis 116 

Four  new  cases  oi  alhetotis 238 

Idiosyrcrasies  of  constitution  and 
pathological  eflects  of  nturotic 
therapeutic   agents 2r8 

Illustrations  of  juvenile  insanity Us 


23.-. 


242 

2£9 


107 


PAGE. 

Impi-oved  iEsthesiometer 115 

La  MeniiDi  Carlo  Livi 227 

La  Menti  Di  Carlo  Livi  (concluded)    351 

Murder  by  a  somiambulist 115 

Meilical  congrets  at  Kh*  ims 54? 

Multiplicity  of  the  spinal  ganglia...    552 
New  facts  relative  to  the  study  of 

cerebral  localization 551 

New  and  important  discovery  con- 
cerning the  auditory  nerve 245 

New  symptom  and  diagnostic  proof 

of  facial  paralysis 247 

Phencmena  of  cei-vical  dislocation 
and  compression  in  an  executed 

criminal 372 

Proceedings  of  the  33d  annual  meet- 
ing of  the  a^8ociation  of  medical 
superintendents  of  American  hos- 
pitals for  ihe  insane 252 

Proceedings  of   the   New   England 

psychological  society 255 

Proceedings  cf  the  S4th  annual  meet- 
ing ol  the  asscciaticn  of  medical 
superintendents  of  American  hos- 
pitals lor  the  insane 376 

Physical  eflects  of  mental  impres- 
sion  ••••    252 

Prccetdings  ol  the  psycholoj^ical 
society  of  Berlin 219 


SELECTIONS— Continued. 


Physical  results  Irjm   mental   im- 
pVesslou.s 

PiMcewlings  of  the  medical  society 

of  the  hospitals,  Oct.  29th,  1879.... 
Proceediugs    of    the     academy    of 

sciences,   Pavis..  

PiMcec'diiifJTs    of  the    psycholosjical 

and  nc.irological  section  of  the 
^iittMiiational  Medical  Congress  at 

Amsterdam 

Psycho. motor  center  of  the  face. . . . 
Questions  and  answers  concernin;^ 

chloral 


PACK 

115 
112 
110 


PAGE. 

Results  of  autopsies  at  Danvers, 
Mu-8.,and  St  Ijouis,  Mo.,  hos- 
pitals for  the  insane 2")!t 

Rare  form  of  neurosis  .   -'42 

Society  of  Biology,  Oct.  25th,  1879. .  113 

Society  of  Biology 243 

Sop.iety  of  the  hospitals :..  248 

Teridoh  icllcx  phenomenon 373 

Traumatic  A)ihasia,  case  of  ..   .....  !!» 

Unilateral  convulsions  due  to  brain 

disease  .i.')2 

Wigan's  propositions  on  the  duality 

ofthe  mind  21(5 


EDITORIALS. 


Apologetic ... 

.<\ul>anel  prize 

American  Medical  Association 

Back  numbers  

Centralblatt  fur  nerrenheilkunde  — 
D  scussi.>n  on  aphasia 

Compliment  to  Dr.  E-   .VI.  Nelson.. 

Carl  Frederick  Flemming  Lockhart 
Clark  and  l>.  J.  C  )rrigan 

Curahility  of  insanity 

Careoftlie  insaue  and  their  legal 
coiitr.)! 

Cataphasia 

Colored  insane  asylums  of  North 
Carolina 

Chapel  and  amusement  hall  decora- 
tions  

C.  L.  Cherot 

Dr.  Ray's  bereavement 

Drs.  Beard  and  Bucke's  new  books 

Dr.L.  C.  Gray  and  the  tendon  re- 
flex ;  Explauation 

Drs.  Evarts,  Dewey,  Richardson, 
Fauntleroy " 

Dr.  Plinv  liarle 

Dr.  J    .<.  Jewell 

Dr.  II.  H.   Kane's  new  bonk 

\)v.  Relnr's  new  book 

Drs.  Dyce  Duckworth  and  Gout.... 

Dr.  Judson  B.  Andrews  

Dr.  Gundry 

Demise  of  Dr.  E.  B.  Hun  

Dr.  F.  E.  R)binson'8  chart  of  the 
cranial  nerves 

Dr.  Cnrwen's  series— Books,  pa- 
lmers and  hospital  reports  for  re- 
view   

Eflitorial  note  on  recoveries  from 
mental  <lisease  

Eirect-i..f  Tea 

Kurlou;;hing  the  insane 

II  )w  they  appear  abroad 

How  Ohio  wrongs  her  insane 

Hint  t  >  our  ho-^pital  friends 

Hospital  for  the  insane  at  Elgin.  III. 

Introductory .   


Addendum  to  the  article  on  hysteria 

Common  mind  troublen  

Care  of   the  insane  and  their  legal 

control 

Emotional   prodigality 

Emotional  Insanity 

General   Paresis.  ! 

Hypi>dormic  injections  of  moruhine, 

Its  history,  advantage)  and  dan- 


PAGE 

264 
2(54 
389 
561 


PAGE. 

In  memoriam— Dr    Eugene  Tyler...  124 

Insane  asylum  reform  in  New  York  20J 

In  msm.)riam— Dr.  NV'm    S.  t^hipley  2t>8 

Increasing  interest  in  Psychiatry..  5"i7 

Insane  hospital  Annexes." .". . .  ."iSS 

Instil ute  of  Heredity .">60 

Index  Medicus .560 

Large  number  oi  lunatics  in  Chicago 

and  Xew  York 391 

Loosening  of  the  tfeth  in  Ataxia....  ml 

Monument  to    Broci .560 

X-'W  Journals  2ti.5 

Nitrite  of  amyl  in  the  differential  di- 
agnosis of  cerebiial  Hyperaemia 
and  anaemia;  also,  as  a  thera- 
peutic agent  in  anaenua  and  im- 
becility    .5.56 

Xew  State  institution  for  the  insane 

at  Kankakee,  Ills .561 

Our  rece))tion 260 

Official  changes  and  new  appoint- 
ments   267 

Our    exchanges 386 

Oilicial  residence  in  a  State  hospital 

lor  the  insane :J90 

Our  exchanges— continued .5.55 

Prize  offered  by  the  American  Neu- 

r.dogical   .Society .560 

Pr  "positions  of  the  medical  super- 
intendents or  hospitals  for  the  in- 
sane   260 

Pathology  of  insanity  as  shown  at 

the  hospitals  for  the  insane 265 

Result  at  the  Dixmout  hospital 3S6 

Rights  of  the  insane .5.5s 

Reflex  Asthma     .560 

Safety  bedstead 2(i2 

Seppilli  on  cerebellar  atrophy .5.56 

Statue  to  Pinfel .5i;o 

Thirty-fiurth  annual  meeting  of  the 
association  ol  medical  superinten- 
dents of  hospitals  for  the  insane  .  264 
Two  homes  fir  the  nervous  and   in- 
sane   391 

To  our  friends :kA 


REVIEWS. 


gers 


L' Archives  dc  Xeurologie 

Man's  moral  nature 

Nervous  exhaustion -Neurasthenia 


PAGE 

.502 


562 
.562 


Nota  di  clinica  medica  

Naso  Pharyngeal  Catarrh  

Official  register  of  i)hysician8  and 

miclwi  ves  of  the  State  of  Illinois. . 

Physiology  vs.  philosophy 

Ruinbold's  hy;;iene  of  catarrh 

Sixth  annual  meetingof  the  Indiana, 

lllinoi)*,   and   Kentucky    tri-state 

medical  society 

Transactions  of  the  medical  associa- 

ti(m  of  the  state  of  Missouri 

Extracts  Irom  letters  and  answers 


THE 


Alienist  i  Neurologist, 


VOL.  L  JANUARY,  1880.  NO.  I. 


O  V  V vV vw.  tvV  C>  o  w\. Y  vV>  VV\ V  o  v\?> . 


Art.  I.— On  the  Propositions  of  the 
Association  of  Superintendents  of 
American  Hospitals  for  the   Insane. 


By  John  Curwen,  M.  D., 


SUPERINTENDENT    AND    PHYSICIAN    OF    THE     PENNSYLVANIA    STATE     LUNATIC 
HOSPITAL,    HARRISBURG,    PA. 


''  I  ""HE  Association  of  Medical  Superintendents  of  Amer- 
■*-  ican  Institutions  for  the  Insane  was  established  in 
1844,  with  the  object  of  advancing,  in  every  practicable 
manner,  the  best  interests  of  the  insane,  and  the  members 
are  "the  medical  superintendents  of  the  various  incorpor- 
ated, or  other  legallx'  constituted  institutions  for  the  insane, 
now  existing  on  this  continent,  or  which  ma\-  be  com- 
menced prior  to  the  next  meeting,  and  all  those  who  have, 
heretofore,  been  medical  superintendents  and  members  of 
this  Association,  or  who  may  be  hereafter  appointed  to 
those  stations."  It  is  the  oldest  medical  organization,  of  a 
national  character,  on  this  continent. 

This  Association  has,  at  different  times,  adopted  [propo- 
sitions  on   the    construction    and     organization    of    hospitals 


John  CuTwen, 


for  the  insane,  and  on  all  matters  bearing  on  the  welfare 
of  the  insane,  which  have  received  the  most  unqualified 
approval  of  those  best  capable  of  judging  in  Great  Britain, 
and  they  have  also  been  received  with  high  praise  in  France. 

These  propositions,  when  presented  as  the  report  of 
a  committee  appointed  to  draw  them  up,  have  alwa}-s  been 
most  rigidly  and  carefully  examined  and  discussed,  and 
after  such  examination  and  discussion  of  c\-cr\'  important 
word  in  ever)-  sentence,  the\'  have  been  unanimously 
adopted,  not,  as  some  would  say  and  have  said,  because 
they  were  proposed  by  the  more  prominent  members,  and 
the  others  did  not  care  to  discuss  them,  but  because  they 
received  the  cordial  endorsement  of  every  member  from 
the  fact  that  the}'  fully  and  clearly  expressed  the  senti- 
ments of  each  member,  and  "  may  be  regarded  as  the 
well  established  results  of  very  varied,  extensive  and  long 
continued  observation  in  nearly  every  section  of  the 
country  and  among  all  classes  of  patients."  The  first 
series  of  propositions  on  the  construction  of  hospitals 
for  the  insane  was  adopted  in  1851,  and  so  well  and 
so  carefully  were  they  matured  that  in  only  one  of  that 
number  has  any  change  been  made,  and  to  that  change 
attention  will  be  given  at  a  subsequent  time.  The 
second  series  was  adopted  in  1853,  and  relates  to  the 
organization  of  hospitals  for  the  insane.  To  these  propo- 
sitions special  attention  and  consideration  will  be  given 
in  this  and  subsequent  articles,  so  as  to  explain  them 
and  enforce  the  reasons  which  led  to  their  adoption ; 
to  convince  those  who  will  carefully  consider  the  points 
presented  that  "the  crude  theories  and  the  visionary 
suggestions  which  are  frequently  met  with"  need  the  sure 
foundation  of  experience  and  practical  observation  which 
can  most  certainly  and  unquestionably  be  found  in  these 
propositions. 

It  ma\'  be  stated,  also,  as  a  cardinal  principle,  from 
which  no  deviation  has  yet  been  made,  that  the  Associa- 
tion has  always  held  its  meetings  in  some  town  or  city 
where    a    hospital    for    the    insane  was  located,  so  that  the 


On  the  Propositions  of  the  Association.  3 

members  may  have  an  opportunity  of  examining  the 
pecuHarities  of  arrangement  and  management  in  detail, 
characteristic  of  the  institutions  in  different  sections  of 
the  countr\-,  and  be  thus  enabled  to  profit  by  what  has 
been    done    by    others    engaged    in    the    "noble    cause." 

I. — "  Ever}-  hospital  for  the  insane  should  be  in  the 
country,  not  within  less  than  two  miles  of  a  large  town, 
and    easily    accessible    at    all    seasons." 

Ever\'  one  will  admit  that  the  inmates  of  a  hospital 
should  be  placed  in  the  most  favorable  circumstances 
for  the  promotion  of  their  welfare,  and  that  their  sur- 
roundings should  be,  as  far  as  possible,  free  from  every 
source  of  annoyance,  or  whatever  might  tend  to  produce 
unpleasant  impressions,  and  these  can  best  be  attained 
in  the  countr\",  awa}-  from  the  bustle  and  confusion  of 
a  town  and  the  close  proximity  of  those  careless,  idle, 
vicious  and  thoughtless  people,  sometimes  found  in  towns, 
whose  conduct,  conversation,  general  character  and  habits 
would  certainly  not  have  a  very  beneficial  influence  on 
persons  of  disordered  minds,  filled  with  all  sorts  of 
vagaries  and  distempered  fancies,  but  would  rather  tend 
to    increase    and    strengthen    such    irregular    action. 

There  is,  unfortunately,  in  certain  classes,  a  morbid 
inclination  to  ridicule  the  peculiarities  of  manner,  conduct 
and  conversation  of  the  insane,  and  to  worry  and  irritate 
them  in  a  variety  of  ways,  and  that  would  most  surely 
be  done  by  the  idle  and  thoughtless;  and  a  very  prejudi- 
cial effect  would  thus  be  produced  on  the  insane,  should 
any  hospital  be  placed  so  near  a  town  as  to  enable  such 
persons  easily  to  visit  it,  or  to  meet  the  patients  when 
they  were  walking  for  exercise  and  recreation.  It  ma\- 
be  said  that  the  arrangements  of  a  hospital  should  be 
such  as  to  prevent  such  classes  having  access  in  an\- 
way  to  the  patients ;  but,  while  that  is  very  true  in 
theory,  it  is  often  found  very  difficult  to  regulate  in 
practice,  from  the  known  disposition  of  many  to  attempt 
to  do  that  which  is  forbidden  to  idlers,  simply  because  it 
is    forbidden ;     and    the    experience    of   ever}'    one     familiar 


John  Curwen, 


witli  the  management  of  a  liospital  teaches  tlie  extreme 
care  whicli  must  be  constantly  exercised,  even  when  a 
hospital  is  situated  at  some  distance  from  a  town,  to 
prevent  the  communication  of  improper  i)ersons  with  the 
patients.  Such  persons  seek  opportunities  to  convey  to 
the  patients  articles  thc\'  should  not  have,  and  with 
which  they  may  do  injury  to  themselves  or  to  others, 
and  also  to  tell  them  what  will  irritate  and  excite  or 
otherwise    injure    them. 

But  in  a  pleasant  position  in  the  country,  an  exten- 
sive landscape,  with  a  variety  of  natural  scener}-  of  iiill, 
cultivated  fields,  wood  and  water,  and  sufficient  of  the 
outward  moving  world  in  view,  but  not  in  close  contact, 
to  give  animation  to  the  scene,  a  greater  degree  of  fresh 
air  can  be  obtained,  greater  opportunities  for  exercise, 
unm  lested,  can  be  enjoyed,  with  extensive  and  beautifully 
ornamented  grounds  immediately  adjoining  the  buildings, 
to  attract  and  di\'ert  the  attention  at  all  times,  and,  also, 
a  good  farm  and  garden. 

Accessibility  at  all  seasons  is  ver)'  necessar\",  not  only 
for  the  convenience  of  those  who  are  required  to  bring 
patients  to  the  institution,  but  for  those  whose  business 
requires  them  to  visit  the  hospital  at  regular  periods,  and 
for  the  eas)-  procuring  of  those  supplies  of  every  kind 
which  enter  so  largely  into  the  daily  consumption  in  such 
institutions;  and  in  these  days  when  railroads  are  so 
ramified  into  ever)-  section  of  the  country,  it  is  not  very 
difficult  to  obtain,  near  the  centre  of  population  and  of 
railroad  facilities,  such  a  location  as  will  answer  nearl\',  if 
not  quite,  all  the  requirements  of  the  proposition. 

This  seems  the  proper  place  to  consider  a  proposition 
adopted  in  1866,  referring  to  this  subject  of  the  proper 
location  of  a  hospital. 

"The  large  states  should  be  divided  into  geographical 
districts,  of  such  size  that  a  hospital  situated  at,  or  near, 
the  centre  ol  the  district  will  be  practically  accessible  to 
all  the  people  living  within  its  i)oundaries,  and  a\ailable 
for  their  ben-ht   in   cases  of  mental  disordi  r." 


Cn  the  Propositions  of  the  Association.  5 

From  a  carefully  prepared  statement,  made  after  a 
thorough  examination  of  all  the  reports  of  the  different 
hospitals  in  this  countr\',  by  Dr.  Edward  Jarvis,  of 
Dorchester,  Massachusetts  (the  able  statistician  and 
pioneer  in  all  matters  of  the  kind,  on  the  subject  of 
insanity,  in  this  countr}'),  it  would  seem  to  be  established 
as  a  fact,  not  admitting  of  any  doubt  or  dispute,  that  the 
majority  of  all  the  patients  in  any  given  hospital  for  the 
insane,  come  from  the  section  of  country  most  contiguous 
to  the  institution,  the  facilities  of  travel  being  always  con- 
sidered. If  a  hospital  for  the  insane  be  located  as  near 
as  may  be,  having  regard  to  the  facilities  of  communication 
between  different  parts  of  the  district,  in  the  centre  of  the 
population,  great  expense  will  be  saved  in  the  conveyance 
to  and  removal  from  the  hospital  of  those  who  may  require 
its  accommodations,  and  this  item  of  traveling  expense  is 
a  very  serious  one  in  the  majority  of  cases ;  then  again 
the  risk  to  the  individual  from  the  fatigue,  the  excitement 
and  anno\'ances  attending  a  journe}-  of  any  length  in  a 
weak  and  depressed,  or  in  a  violentl}'  excited  condition, 
is  often  very  great  and  attended  with  considerable  danger 
to  life. 

The  friends  and  relatives  of  the  patients  in  any  hospital 
for  the  insane  often,  very  naturally,  desire  to  visit  them 
and  examine  into  their  condition,  more  particularly  when 
the  case  has  assumed  the  chronic  form,  and  the  expenses 
of  a  long  journey  often  press  heavily  on  their  means, 
especially  where  the  support  of  the  person  in  the  hospital 
has  to  be  defrayed,  in  whole  or  in  part,  from  the  amount 
they  derive  from  their  daily  labor.  The  same  reasoning 
will  also  appl\-  to  the  authorities  of  the  townships  or 
counties  who  are  necessarily  required  to  look  after  the 
welfare  of  those  entrusted  to  their  charge. 

Every  hospital  should  also  be  located  in  the  centre  of 
population  in  the  district,  because  the  most  thickly  settled 
sections  are  those  wherein  the  largest  number  of  insane 
will  be  found ;  and  in  those  parts,  also,  will  be  more 
readily  found  those  who  will  be  relied  on  for   the    various 


John  Cur  wen, 


occupations  and  employments  in  such  institutions ;  and 
there,  also,  can  be  had,  more  economicaly,  all  those  sup- 
plies of  different  kinds  which  are  required  in  the  domestic 
economy  of  the  institution,  and  the  communications 
between  different  sections  by  railroad,  will  also,  in  all 
probability,  be  more  complete  and   satisfactory. 

II — "  Xo  hospital  for  the  insane,  however  limited  its 
capacity,  should  have  less  than  fifty  acres  of  land,  devoted 
to  gardens  and  pleasure  grounds  for  its  patients ;  at  least 
one  hundred  acres  should  be  possessed  by  every  state 
hospital,  or  other  institution,  for  two  hundred  patients,  to 
which  number  these  propositions  appl)-,  unless  otherwise 
mentioned." 

The  reasons  for  requiring  a  given  amount  of  land  in 
connection  with  every  hospital  for  the  insane,  may  be 
briefly  stated  to  be  the  necessity  for  extensive  grounds 
for  exercise  and  recreation  immediatel}-  adjoining  the 
building,  a  large  garden  for  the  supply  and  cultivation  of 
all  the  vegetables  .required  in  an  institution  of  the  kind, 
so  that  they  shall  be  fresh  and  in  abundant  quantity  at 
all  times;  and  in  a  State  hospital,  a  large  farm  so  that  a 
large  stock  of  cows  may  be  kept  for  the  supply  of  fresh 
milk.  These  necessarily  require  that  a  large  amount  of 
hay,  grain  and  vegetables  be  provided  for  their  use  as 
well  as  for  the  other  stock  wliich  ma\-  be  required  to 
enable  the  operations  to  be  carried  on  A\ith  proper 
economy,  and  for  the  stock  cattle  whieli  main-  institu- 
tions, which  kill  their  own  beef,  find  it  necessar}-  aiul 
advantageous  to  feed. 

In  the  cultivation  of  the  farm  and  gartlen  an  opportu- 
nity will  be  given  for  the  employment  of  a  niunber  of  the 
patients  for  whom  such  occupation  is  required,  that  they 
may  have  some  regular  occupation  to  dixerl  their  minds 
and  improve  their  bodil}'  heakli,  and  prexent  tlicir  sinking 
it. to  a  dull  lethargic  condition,  or  wasting  the  energies 
which  should  be  given  to  active  exercise  in  mischievous 
destructiveness  of  various  kinds. 

Into     this     question     of   labor    b}'    the    insane    it    is    not 


On  the  Propositions  of  the  ,.4ssociation.  7 

intended  here  to  enter,  as  it  requires  a  more  extended 
consideration,  which  ma}-  be  given  at  another  time,  but 
onh'  to  indicate  the  fact  that  every  hospital  should  be 
full}-  provided  with  all  the  means  necessary  for  carrying 
into   effect  an\-  such  system  of  labor. 

III. — "  ^Nleans  should  be  provided  to  raise  ten  thousand 
gallons  of  water,  daily,  to  reserv^oirs  that  will  supply  the 
highest  parts  of  the  building." 

Where  practicable,  it  is  always  safest  and  best  to  have 
the  reservoirs  on  an  elevation  near  the  building,  or  within 
convenient  distance,  but  where  that  cannot  be  done  the 
tanks  should  be  made  of  boiler  iron,  placed  in  the  building 
above  all  the  occupied  portions,  so  as  readily  to  supply 
every  apartment  with  water,  and  so  arranged  that  any 
leakage  from  breaking  or  disorder  of  pipes  or  valves,  or 
the  condensation  on  the  tanks,  may  be  conveyed  away 
and  prevent  injury  to  the  ceilings  or  other  parts  of  the 
building. 

An  abundance  of  fresh  pure  water  is  an  absolute 
requisite  in  every  luxspital,  and  the  utmost  care  and 
attention  is  demanded  to  secure  such  a  supply  as  will 
prove  constant  at  all  seasons,  and  as  little  subject  as 
possible  to  variations  dependent  on  the  rainfall  in  any 
sections. 

The  experience  of  the  last  few  years  has  abundantly 
demonstrated  that  it  is  not  safe  to  rely  entirely  on  springs, 
however  inexhaustible  the}-  may  have  been  considered,  but 
recourse  should  be  had  to  a  large  stream  or  river,  so 
that,  while  the  fresh  supph^  may  be  had  from  one  part  of 
the  stream,  the  sewerage  of  the  institution  ma}-  be  carried 
into  the  same  stream  at  a  point  far  below  that  from  which 
the  fresh  supply  is  drawn. 

No  subject,  connected  with  the  location  of  a  hospital, 
has,  apparently,  received  so  little  consideration  as  the 
supply  of  water  and  the  disposal  of  the  sewerage,  and 
no  subject  is  attended  with  greater  sources  of  annoyance 
and  vexation  to  the  management,  and  risk  to  the  health 
and  lives  of  the  inmates. 


John  Curwen, 


No  good  can  be  attained  by  reference  to  special 
instances  where  these  matters  have  been  overlooked  in 
the  original  selection  of  a  locatit)n,  but  it  will  be  admitted 
by  all,  familiar  with  the  subject,  that  very  serious  anno\-- 
ances  have  been  suffered,  and  large  expenditures  of  money 
have  been  required  to  remedy  defects  which  could  ver\' 
easily  have  been  avoided  by  more  care,  attention  and 
forethought  in  the  original  selection.  Unfortunately  the 
evil  is  not  confined  to  the  selection  of  sites  for  hospitals 
for  the  insane,  but  will  be  found  in  a  ver\-  large  number 
of  buildings  intended  for  the  accomodation  of  different 
classes  and  conditions,  both  healthy  and  diseased. 

IV. — "No  hospital  for  the  insane  should  be  built  with- 
out the  plan  having  been  first  submitted  to  some  physician 
or  ph\-sicians  who  have  had  charge  of  a  similar  establish- 
ment, or  are  practically  acquainted  with  all  the  details  of 
their  arrangements,  and  received  his  or  their  full  appro- 
bation." 

The  principle  involved  in  this  proposition  is  founded  on 
the  general  experience  of  mankind,  that  those  who  have 
given  most  time,  thought  and  attention  to  any  given  matter 
are  best  qualified  to  give  advice  on  that  matter ;  or  that 
when  any  work  requires  special  skill  and  mechanical  or 
professional  knowledge,  the  persons  best  calculated  to  do 
or  direct  that  particular  work  most  satisfactorih',  will  be 
those  who  have  had  largest  and  longest  experience  in 
that  particular  branch.  But  we  are  told  b\-  official 
authority  that  it  is  not  worth  while  to  take  advice  from 
persons  familiar  with  the  details  of  the  construction  and 
arrangement  of  hospitals  for  the  insane,  because  their 
minds  will  be  biased  by  personal  interest  and  convenience. 

Do  those  who  seriously  put  forth  such  a  declaration 
consider  the  force  and  extent  of  their  own  declaration 
which  would  clearK'  debar  them  from  giving  advice  in 
any  case  falling  under  their  care  because  their  personal 
interest  in  that  case  would  surel)-  bias  their  judgment  ?  It 
will  be  claimed,  and  must  be  admitted,  that  where  this 
proposition  has  been  set  aside  and  institutions  built  without 


Oiv  the  Propositions  of  the  Association. 


such  counsel  and  advice,  the  result  has  proved  the  wisdom 
of  those  who  insisted  on  the  adoption  of  this    proposition. 

In  the  very  nature  of  things  it  must  be  so,  and  man- 
kind will  always  continue  to  act  on  this  principle  in  all 
important  matters,  in  defiance  of  every  plausible  pretext 
to  make  them  believe  the  contrary.  No  man,  nor  any 
set  of  men,  would  build  a  factory,  an  iron  furnace  or  any 
building  for  any  special  purpose,  without  fully  and  care- 
fully consulting  with  those  who  were  most  familiar  with 
the  special  character  of  the  work  to  be  done  in  that 
building;  nor  would  any  set  of  men  think  of  erecting  a 
hospital  for  the  ordinar}^  sick  without  first  examining  the 
plan  and  arrangements  of  the  best  institutions  of  the  kind 
to  be  found,  and  obtaining  in  the  construction  of  the 
plans  and  buildings  the  advice  of  those  most  familiar  with 
that  class  of  buildings. 

As  a  hospital  for  the  insane  is  different  from  an  ordi- 
nary hospital  in  the  greater  part  of  its  arrangements, 
designed  for  the  treatment  of  a  special  class  of  diseases 
and  therefore  requiring  special  adaptations  for  special 
purposes  in  the  different  portions  of  the  institution,  it  is 
but  reasonable  to  insist  that  those  who  have  been  most 
familiar  by  long  residence  and  observation  in  such  institu- 
tions, and  understanding  more  fully  what  will  be  most 
essentially  necessary  to  secure,  in  the  most  effective 
manner,  the  objects  of  the  institutions,  are  best  qualified 
to  give  advice  in  the  preparation  of  the  plans  and  to 
superintend  the  erection  of  such  buildings. 

Experience  has  proved,  and  will  continue  to  prove  to 
the  end  of  time,  that  where  the  plans  have  been  prepared 
and  the  buildings  erected  under  the  supervision  of  those 
most  familiar  with  the  details  of  construction  of  hospitals 
for  the  insane,  the  buildings  have  been  not  only  better 
constructed  and  arranged  for  the  purposes  of  their  erection 
.and  the  money  has  been  expended  more  judiciously  and 
economically,  and  with  a  higher  regard  to  the  interests  of 
those  by  whom  and  for  whom  the  hospital  has  been  built, 
than  where  the  contrary  plan  has  been  adopted. 


10  John  Ciirwen, 


The  statement  has  been  made,  time  and  again,  that 
the  superintendents  are  responsible  for  the  lavish  outlay 
which,  it  has  been  claimed,  has  been  made  in  many 
hospitals  for  the  insane  in  this  country.  That  some 
superintendents  may  have  erred  in  this  direction  may  not 
be  denied,  because  they  are  subject  to  errors  like  other 
men,  and  may  be  biased  in  favor  of  particular  plans  and 
persuaded  to  their  adoption  by  a  desire  to  conciliate  those 
with  whom  they  may  be  associated,  or  for  whom  they 
may  be  acting.  But  in  this,  as  in  many  other  things, 
they  have  been  made  to  bear  the  blame  of  what  strictly 
belonged  to  others  who  overruled  them. 

It  will  be  found,  on  careful  inquiry  and  examination, 
that  the  architect  employed  has  been  desirous  of  making 
an  elevation  which  would  reflect  special  credit  on  his 
taste  and  ability  to  prepare  such  plans,  and  that  the 
commissioners  for  building  have  been  biased  in  their 
judgment  by  the  persuasion  of  the  architect  and  of  the 
community  in  which  the  institution  has  been  located,  and 
have  consented,  in  order  to  gratify  the  desire  of  the 
people  of  that  section,  for  a  building  which  should  be  an 
ornament  to  their  locality,  to  the  erection  of  more  costly 
and  more  showy  buildings,  requiring  a  greater  degree  of 
ornamentation,  and,  consequently,  a  greater  expenditure 
of  money,  for  really  unnecessary  matters,  than  they  had 
intended. 

The  Association,  aware  of  this  tendency,  gave  expres- 
sion to  their  views  in  the  following  very  decided  terms : 
"  That  these  institutions,  especially  if  provided  at  the 
public  cost,  should  always  be  of  a  plain  but  substantial 
character;  and,  while  characterized  b}'  good  taste  and 
furnished  with  every^thing  essential  to  the  health  and 
comfort  and  successful  treatment  of  the  patients;  all 
extravagant  embellishments  and  every  unnecessary  expend- 
iture should  be  avoided." 

The  true  principle  is  clearK-  expressed  in  this  proposi- 
tion, that  the  building  should  be  in  accordance  with  good 
taste,    and    a    chaste    and    correct    taste    rejects    excessive 


On  the  Propositions  of  the  Association. 


embellishment,  and,  therefore,  all  undue  and,  consequently, 
unnecessary  ornamentation  should  be  avoided,  and  special 
care  and  thought  should  be  given  to  make  the  interior  of 
the  building,  which  is  to  be  occupied  by  the  patients,  in 
the  highest  degree  homelike  and  comfortable,  and  adorned 
with  everything  which  can  tend  to  give  pleasure  to  the 
eye,  diversion  to  the  mind  and  a  feeling  of  general  con- 
tentment and  satisfaction  to  the  individual. 

Everything  in  and  around  the  institution  should  min- 
ister to  the  grand  object  for  which  the  hospital  was  built 
— the  relief  and  restoration  of  those  placed  in  its  care — 
and  no  amount  of  money  ju-diciously  and  thoughtfully 
expended  for  such  purposes  can  ever  be  regarded  as 
excessive  or  misplaced. 

In  addition  to  this  it  should  always  be  borne  in  mind 
that,  in  all  buildings  erected  at  the  public  expense,  the 
money  is  drawn  from  the  people  by  taxation,  and  they 
have  a  clear  and  undoubted  right  to  insist  that  that 
money  shall  be  carefully  and  economically  spent  only  for 
the  purposes  for  which  it  was  appropriated,  and  not  to 
gratify  the  vanity  or  contribute  to  the  advantage  of  any 
particular  individuals ;  and  when  a  full  equivalent  is  ren- 
dered for  the  amount  appropriated,  it  will  be  found  that 
those  for  whom  it  was  spent  will  be  satisfied  with  the 
expenditure. 

V. — "  The  highest  number  that  can,  with  propriety,  be 
treated  in  one  building  is  two  hundred  and  fifty,  while 
two  hundred  is  a  preferable  maximum." 

It  is  believed  that  no  one  will  call  in  question  the 
truth  embodied  in  this  proposition,  that  the  best  results 
for  the  insane  themselves — and  their  interests  alone  are 
those  which  claim  paramount  importance  in  this  discussion 
— are  to  be  obtained  by  an  adherence  to  the  principle, 
that  a  small  number  can  best  receive  that  care  and  atten- 
tion which  will  most  surely  promote  their  restoration,  for 
the  very  plain  reason  that  the  physician  will  be  able,  more 
carefully,  to  study  out  their  special  ideas  and  peculiarities, 
and  the   bodily    conditions    which    may    have    influence    in 


John  Cuurwen, 


the  production  and  continuance  of  the  disorder,  and  thus 
be  more  fully  qualified  to  direct  the  varied  means  which 
may  be  most  influential  in  the  promotion  of  the  object 
sought  to  be  attained.  It  is  admitted  that  many  men 
claim  that  they  can  give  as  full  attention  to  a  much  larger 
number  as  they  really  require  ;  but,  without  any  intention 
of  disparaging  their  great  ability  and  attainments,  we 
make  free  to  say  that  they  do  not  do  it  by  personal 
attention  and  regular  visitation  each  day. 

Motives  of  expediency,  howev^er,  led  to  the  adoption, 
in  1866,  of  the  following  proposition,  which  received  a 
majority  vote,  just  at  the  close  of  the  sessions  of  that  year: 

"  The  enlargement  of  a  city,  county  or  state  institu- 
tion for  the  insane  which,  in  the  extent  and  character  of 
the  district  in  which  it  is  situated,  is  conveniently  acces- 
sible to  all  the  people  of  such  district,  may  be  properly 
carried,  as  required,  to  the  extent  of  accomodating  six 
hundred  patients,  embracing  the  usual  proportion  of  cura- 
ble and  incurable  insane  in  a  particular  community." 

The  reasons  urged  for  this  change  were,  that  legislative 
bodies  could  never  be  brought  to  the  point  of  agreeing  to 
the  erection  of  so  large  a  number  of  hospitals  as  would  be 
required  by  the  terms  of  the  original  resolution,  and  that 
some  concessions  must  be  made  to  their  views  in  order 
to  obtain  the  needed  accommodations  for  the  insane. 

Many  persons  consider  that  in  large  institutions,  w'ith 
the  number  at  its  maximum,  the  majority  of  the  patients 
must  necessarily  be  of  a  class  requiring  little  medical 
treatment,  and  that  the  care  of  these  can  be  transferred 
to  the  assistant  physicians,  and  that  the  superintendent 
should  only  be  required  to  give  his  special  attention  to 
that  class  of  recent  cases    requiring   special   medical    care. 

We  hold  it  to  be  the  bounden  duty  of  every  superin- 
tendent to  make  such  a  careful  daily  visit  to  all  those 
committed  to  his  charge,  that  he  shall  be  familiar  with 
their  mental  and  physical  condition,  and  his  practiced  eye 
will  enable  him  to  judge  what  changes,  if  any,  may  have 
taken  place  in    each    individual ;     and    he    will    be    able    to 


On  the  Propositions  of  the  dissociation.  13 

recognize  traits  and  symptoms  which  those  less  familiar 
with  the  insane  w^ould  overlook.  Not  only  justice  to  the 
insane  themselves,  but  to  those  by  whom  they  were  placed 
in  the  institution,  demand  that  such  special  personal  care 
be  given,  not  to  insist  on  the  obligation  which  rests  on 
every  medical  man  to  devote  the  best  energies  of  his 
mind  to  the  care  of  those  for  whom,  b}-  the  very  terms 
of  his  appointment,  he  is  made  special  guardian  and 
protector.  Such  a  duty  cannot  be  ignored,  and  should 
not  be  delegated,  but  performed  under  a  full  sense  of  all 
the  responsibility  involved. 

The  duties  of  the  superintendent  in  this  regard  are  thus 
expressed  in  another  proposition :  "  He  should  have  the 
ent  re  control  of  the  medical,  moral  and  dietetic  treatment 
of  the  patients ;  the  unreserved  power  of  appointment  and 
discharge  of  all  persons  engaged  in  their  care ;  and  should 
exercise  a  general  supei-vision  and  direction  of  every 
department  of  the  institution." 

To  the  full  scope  of  this  proposition  many  well-meaning 
persons  object,  and  insist  that  the  duties  of  the  superin- 
tendent should  be  confined  simply  and  exclusively  to  the 
medical  department,  and  that  the  business  arrangements 
should  be  conducted  by  a  steward  or  other  officer  who 
should  have  control  in  all  that  class  of  matters.  In  urging 
such  a  plan,  these  well-intentioned  people  overlook  some 
very  important  considerations. 

No  institution  can  be  successfully  managed  by  two 
persons.  There  must  be  one  authority  to  which  all  others 
must  be  obedient,  so  that  all  parts  shall  work  in  harmony 
and  aim  steadily  and  unvaringly  at  the  production  of  the 
best  results. 

This  practice  of  divided  authority  was  tried  in  the 
early  history  of  the  country,  when  the  management  of  the 
institutions  was  patterned  after  the  English  hospitals  ;  but 
it  has  been  gradually  abandoned,  and  even  in  Great 
Britain,  it  has  been  steadily  changing,  year  by  year,  so  as 
to  conform  to  the  plan  of  having  one  responsible  head,  to 
which  all  others  shall  be  amenable. 


14  John  Curwen, 


While  such  a  principle  might,  under  peculiar  circum- 
stances, be  made  to  answer  without  extraordinary  friction, 
in  a  general  hospital,  there  are  peculiarities  about  a 
hospital  for  the  insane  which  render  it  absolutely  essential 
to  the  proper  administration  of  all  its  parts,  that  one 
leading,  governing  mind  should  direct  the  whole  intricate 
mechanism. 

No  man,  who  can  lay  claim  to  any  correct  knowledge 
of  the  treatment  of  the  insane  in  these  days,  will  pretend 
to  say  that  the  medical  means  are  those  on  which  alone, 
or  principally,  he  relies  for  success  in  the  efforts  made  to 
restore  those  committed  to  his  charge,  or  to  give  the 
greatest  degree  of  mental  health  and  comfort  to  those 
who  may  not  be  looked  upon  as  likely  to  reach  that 
point.  It  is  admirably  expressed  in  the  proposition  quoted 
as  the  medical,  moral  and  dietetic  treatment.  It  must  be 
admitted  that,  as  all  mental  disorders  are  dependent  on, 
or  caused  by,  disordered  action  of  the  organ  through 
which  the  manifestations  of  mind  are  made  known  to  us  ; 
and  as  those  disordered  conditions  may  arise  from  diseased 
or  disordered  action  of  different  organs  of  the  body, 
acting  directly  or  sympathetically  on  the  brain  and 
nervous  system,  medical  means  must  be  resorted  to  calcu- 
lated to  remove  all  diseased  conditions  and  restore  the 
disordered  functions  to  their  normal,  healthy  action — and 
very  often  that  will  include  the  greater  part  of  the  treat- 
ment required. 

But  as  the  larger  part  of  the  disorders  are  often  trace- 
able to  defective  nutrition  in  some  of  its  many  forms,  the 
necessity  is  imperative  that  the  proper  food  should  be 
administered  in  conjunction  with  the  medical  means,  so  as 
to  bring  up  the  system  to  a  more  vigorous  and  healthy 
condition,  and  thus  place  it  in  the  most  advantageous 
position  to  throw  off  and  resist  all  unnatural  states. 

To  have  these  two  modes  of  treatment  work  together, 
satisfactorily  and  efficiently,  it  will  be  granted,  by  all 
reasonable  men,  that  they  should  be  entirely  controlled 
by  the  superintendent  and  physician  who  alone  is  capable 


On  the  Propositions  of  the  Association.  lo 


of  judging  what  is  best  calculated  for  the  benefit  of  his 
patients,  and  to  direct  what  kind  and  character  of  food 
is  best  suited  to  the  different  cases  which  come  under  his 
care,  and  for  whose  treatment  he  alone  is  held  responsible. 

But,  in  addition  to  these,  there  are  in  the  mind  certain 
desires,  affections,  passions  and  emotions  which  require  to 
be  acted  upon  by  repression  or  stimulation,  or  in  that 
way  which  will  be  most  conducive  to  the  ultimate  welfare 
and  relief  of  the  patient ;  and  in  the  moral  treatment  are 
included  all  those  appliances  which  may,  in  every  prac- 
ticable manner,  be  made  subservient  to  that   end. 

These  appliances  include  all  those  means  of  diversion, 
recreation  and  exercise  of  mind  and  body  which  may 
assist  in  changing  the  current  of  thought  from  an  unnat- 
ural to  a  natural  channel,  and  develop  more  healthy 
action  of  the  different  organs  of  the  body. 

Among  these  will  be  found  working  in  the  garden,  on 
the  farm  or  any  other  form  of  manual  labor  to  which  men 
have  been  accustomed,  and  which  may  be  most  suitable 
for  the  individual  in  the  condition  he  may  be  at  the  time, 
and  whatever  form  of  out-door  or  in-door  game,  or  amuse- 
ment, or  occupation  can  be  made  most  available. 

For  women,  all  the  infinite  diversity  of  occupation, 
from  the  lighest  form  of  fancy  work  in  all  its  varying 
grades,  to  more  active  duty  in  the  various  departments  of 
household  employm.ent;  and  for  both  classes,  music,  lect- 
ures, exhibitions  of  the  magic  lantern  with  the  almost 
endless  combination  of  views  of  scenerv^  and  objects  of 
interest,  of  every  kind,  which  may  now  be  had ;  together 
with  whatever  may  be  found  most  conducive  to  the  object 
to  be  attained,  and  most  in  conformity  with  the  habits, 
inclinations,  tastes  and  education  of  the  different  classes 
for  which  the  institution  was  designed. 

It  must  be  clear  to  every  thinking  man  that,  in  order 
to  the  proper  execution  of  all  these  different  forms  of 
treatment,  they  must  all  be  directed  by  one  mind,  which 
can  best  know  by  a  careful  study  of,  and  attention  to, 
the  peculiar  character  of  each  individual,  just  what  will  be 


16  John  Curwen, 


best  adapted  to  that  particular  case.  It  will  be  as  readily 
seen  that  where  these  different  modes  may  be  left  to  be 
executed  by  two  different  men,  there  will  be  the  strongest 
likelihood  of  a  difference  of  opinion  as  to  the  proper 
manner  in  which  the  plans  should  be  carried  out,  and  an 
equally  strong  probability  that  no  successful  plan  will  be 
put  in  full   operation. 

Experience  teaches  that  this  is  no  mere  fancy  sketch 
or  picture  of  the  imagination,  but  has  had  in  the  past, 
and  has  now  in  the  actual  present,  its  living  reality  in 
more  than  one  institution. 

But  it  is  asserted  by  the  advocates  of  this  theory,  that 
where  a  medical  man's  mind  is  occupied  with  the  oversight 
of  the  garden  and  the  farm,  he  can  not  give  proper 
attention  to  his  medical  duties.  Do  those  who  make  this 
assertion  consider  that  it  is  as  necessary  for  the  healthy 
action  of  every  medical  man's  mind  that  he  should  have  a 
diversity  of  mental  occupation,  as  that  he  should  have 
proper  nourishing  food  to  support  his  bodily  strength  ?  Is 
it  not  a  fact,  supported  by  the  amplest  evidence,  that 
every  man  who  confines  thoughts  and  attention  to  one 
thing  constantly,  becomes,  thereby,  a  man  of  only  one 
idea,  while  men  who  have  a  variety  of  duties  to  perform, 
mingle  in  the  world  of  thought  and  action,  and,  by  contact 
with  different  classes  of  men,  see  the  variety  of  ways  in 
which  things  are  done,  and  hear  the  wonderful  diversity 
of  views  which  men  entertain  and  the  peculiar  modes  of 
thought  and  expression  which  prevail,  become,  thereby, 
more  enlarged  in  their  ideas,  have  a  more  comprehensive 
grasp  and  are  better  able  to  understand  the  varying 
changes  of  thought  and  feeling  which  they  may  meet  in 
those  entrusted  to  their  charge,  and,  therefore,  much 
better  qualified  to  deal  with  the  almost  endless  variety  of 
disordered  mental  action  which  may  come  before  them  to 
be  properly  directed  and  led  along  into  more  healthy 
channels? 

Besides,  every  man  needs  a  certain  amount  of  physical 
exercise,  and  if  he  cannot  obtain  it    by    looking    after   the 


On  the  Propositions  of  the  Association.  17 

farm  and  garden,  and  various  other  out-door  matters,  he 
will  be  compelled  to  take  it  in  some  other  form  which 
may  draw  him  away  more  effectually  from  his  duties  at 
the  hospital. . 

Then,  also,  it  must  be  remembered  that,  by  the  very 
nature  of  his  position,  the  superintendent  of  a  hospital  for 
the  insane  is,  in  great  measure,  debarred  from  many  of 
those  social  enjoyments  and  recreations  which  other  med- 
ical men  can  enjoy;  and  that,  in  place  of  being  tied 
down  to  an  unvarying  routine  of  duties — such  as  these 
gentlemen  would  so  kindly  prescribe  for  him — he  is  enti- 
tled to  lead  that  kind  of  life  which  best  accords  with  his 
own  ideas  of  duty  to  the  hospital,  to  society  and  to  his 
own  family ;  to  enjoy  liberty  in  the  way  he  may  feel  most 
conducive  to  his  health  and  to  the  welfare  of  those  com- 
mitted to  his  charge,  and  to  engage  in  the  pursuit  of 
happiness  in  all  those  modes  which  may,  while  fulfilling 
strictly  and  conscientiously  the  duties  of  his  position, 
enable  him  to  realize  most  fully  that 

"  Not  enjoyment,  and  not  sorrow. 
Is  our  destined  end  or  way ; 
But  to  act  that  each  to-morrow, 
Find  us  farther  than  to-day." 


.^__^ 


Art.  II— The  Sequences  of  Neurasthenia, 


Bv  George  I\I.  Beard,  ]\I.  D. 

"VTEUR ASTHENIA  is  the  door  which  opens  into  quite 
-^  ^  a  large  number  of  diseases  of  the  nervous  system. 
It  does  not,  necessarily,  lead  to  any  of  these  ;  it  may 
never  go  beyond  itself;  but,  when  neglected  or  treated 
improperly,  it  may,  in  time,  advance  to  any  one  of  quite 
a  large  number  of  familiar  maladies  of  the  nervous  system. 
Some  of  these  maladies  arc  not  of  an  organic  or  struct- 
ural character;  they  are  functional — like  neurasthenia 
itself;  but  they  are,  oftentimes,  more  obstinate  than 
simple  neurasthenia — not  so  disposed  to  yield  to  manage- 
ment. Neurasthenia  may  go  on  for  years,  sometimes  for 
many  years,  before  it  reaches  any  of  these  diseases ;  but 
it  may  and  does  reach  them,  and  becomes,  in  fact,  one 
of  the  most  frequent  of  their  immediate  causes.  One  of 
the  most  familiar  sequences  of  neurasthenia  is  insanity 
itself;  especially,  in  the  form  known  as  melancholia.  Not 
a  few  of  the  cases  of  melancholia,  in  its  different  stages, 
that  enter  our  asylums  or  inebriate  homes,  have  passed 
through  a  long  stage  of  neurasthenia,  before  they  arrived 
at  the  condition  where  the  mind  is  really  and,  perhaps,  per- 
manently disturbed.  The  change  from  simple  neurasthenia 
to  melancholia  is  sometimes  gradual,  and  sometimes  quite 
sudden.  In  some  instances  there  may  be  a  ver)'  gradual 
decline,  from  a  nervous,  exhausted  state  to  the  most  serious 
.stage  of  mental  disorder.  Under  this  class  come  not  a 
few  women — house-wives  who   are   over-worked  ;    mothers, 


The  Seqwences  of  Keibr asthenia  19 

worn  by  repeated  child-bearing  and  prolonged  lactation, 
complicated,  perchance,  with  local  disorders,  such  as 
laceration,  enlargement  or  inflammation. 

HYSTERIA    AXO    HYSTERO-EPII.EPSY. 

It  is  onh'  a  minority  of  the  cases  of  h\-steria  and 
hystero-epilepsy  that  have  first  passed  through  the  stage 
of  neurasthenia.  Both  hysteria  and  hystero-epilepsy  may 
arise  in  persons  who  have  not  been  especially  nervously 
exhausted,  but  \\hose  mental  organization  is  weak  and 
ill-trained,  and  who,  consequently,  fall  into  the  symptoms 
of  these  disorders  through  needless  apprehension  or  worry, 
or,  perchance,  catch  them  through  psychical  contagion. 
Such  cases  of  hystero-epilepsy  as  Charcot  utilized  in  his 
experiments  in  the  Salpetriere  hospital,  Paris,  with  metals 
and  magnets,  are  not,  usually  or  always,  of  a  neuras- 
thenic type  ;  they  are  simply  weak-minded,  mentally 
untrained  girls  who  can  usually  be  affected  either  way. 
Hysteria  and  hystero-epilepsy  of  this  kind,  mental  epileps}% 
was  more  common  hundreds  of  years  ago,  before  neuras- 
thenia was  thought  of. 

GENERAL    NEURALGIA. 

One  of  the  results  of  neglected  neurasthenia  is  general 
neuralgia — by  which  I  mean  attacks  of  neuralgic  pains 
flying  about  in  difterent  parts  of  the  body,  in  distinction 
from  fixed  and  local  neuralgia — such,  for  example,  as 
sciatica  and  tic  douleureux,  which  may  occur  not  only  in 
the  neurasthenic,  but  in  persons  of  great  strength  and 
vigor,  and  who  are  not,  in  any  way,  anaemic  or  nervousl)- 
exhausted.  The  neuralgia  of  the  neurasthenic  is  more 
likely  to  take  the  phase  of  chronic  flying  pains  in  the 
lower  extremities ;  or  in  the  upper  extremities ;  or,  per- 
chance, in  the  stomach  or  bowels,  in  the  eye  or  in  the 
pelvic  regions. 

INEBRIETY. 

A  more  common,  indeed,  a  very  common,  and  an 
increasingly  common  sequence  of  neurasthenia  is  inebriety. 


Geo.  M-  Beard, 


Indeed,  the  main  cause  of  the  increase  and  frequency 
of  the  disease,  inebriety,  in  this  country  and  in  all  highly 
civilized  countries,  is  the  increasing  nervousness  of  the  age. 
When  a  man  becomes  prostrated  by  exposure  to  heat — 
what  is  called  heat-prostration — he  oftentimes  is  left  in  a 
neurasthenic  state.  A  few  moments'  exposure  of  this 
kind  may  be  the  source  of  neurasthenic  invalidism,  lasting, 
it  may  be,  for  months  or  years.  While  in  this  state,  an 
irresistible  desire  for  drinking  alcoholic  liquors  may  take 
possession,  and  very  suddenh',  indeed,  of  one  who  never 
before  had  the  least  inclination  for  drink,  and  without  any 
apparent  cause  he  may  become  an  inebriate ;  an  attack  of 
inebriety  may  come  on  as  suddenly  as  an  attack  of  neural- 
gia, or  insomnia,  or  hay  fever,  and,  like  these,  is  a  direct 
sequence  of  neurasthenia  excited  by  heat — by  exposure 
to  heat.  Neurasthenia  excited  by  any  other  cause,  may 
have,  and  does  have,  just  this  effect ;  though  not, 
usually,  with  such  suddenness  or  violence.  The  neuras- 
thenic state  developed,  as  it  is  so  often,  by  the  shock  of 
bereavement,  of  domestic  disappointments  and  griefs,  anxi- 
ety on  account  of  financial  troubles  and  worries,  may 
open  the  door  to  inebriety  ;  and,  so  to  speak,  push  the 
patient  in,  and  sometimes  shut  him  up  beyond  remedy. 
Phenomena  of  this  kind  occur  in  those  who  have  never 
been  accustomed  to  drinking — sometimes  in  those  who 
have  been  total  abstainers  all  their  lives — or  who,  at  least, 
have  never  been  excessive  drinkers.  Quite  a  large 
number  of  wealthy  citizens  of  this  country,  merchants, 
manufacturers,  speculators,  and,  in  a  few  instances,  profes- 
sional men,  who  have  acquired  their  means  b}'  constant 
friction,  and  great  and  excessive  drafts  on  the  nervous 
system,  have  sons  who  were  born  in  the  midst  of  this 
pressure  and  toil,  who  inherit  the  nervous  diathesis  and 
tendency  to  disease  of  the  nervous  system,  which  breaks 
out  in  the  form  of  inebriet}'. 

.MKCONISM    (oI'IO-MANIA). 

This  form  of  excess,    in    the    use    of  narcotics,  is  some- 


The  Sequences  of  Keiir asthenia. 


times  a  sequel  of  neurasthenia.  One  of  the  effects  of 
opium  is  to  relieve,  for  the  time,  the  depression — the  hope- 
lessness, worse  than  pain — from  which  neurasthenics  suffer. 
It  is,  therefore,  a  temptation  to  use  this  drug  ;  beginning, 
of  course,  with  small  doses  and  increasing  until  the  servant 
becomes  the  master — the  patient  a  slave.  In  some  cases 
there  is  an  alternation  of  opio-viaida  with  inebriety ; 
they  must  take  in  excess  one  of  those  two  poisons, 
alcohol  or  opium.  la  one  case  in  which  I  was  consulted, 
the  patient  stated,  positively,  that  it  was  impossible  for 
him  to  get  along  without  being  an  opium  eater  or  an 
inebriate  ;  that  it  made  little  difference  which  he  took,  whis- 
key or  opium,  either  one  or  the  other  was  sufficient  for  him. 
Not  all  cases  of  inebriety  or  opium  eating  have  a  neuras- 
thenic origin,  but  a  large  number  are  of  this  kind.  We  can 
make  a  differential  diagnosis  of  neurasthenic  inebriety  by 
the  symptoms  that  accompany  it.  Inebriates  of  this  kind, 
always,  or  almost  always,  have  other  evidences  of  exhaus- 
tion, such  as  insomnia,  headache,  nervousness,  irritability, 
neuralgia  and  the  like ;  and  inebriety  in  these  cases  is 
just  as  truh-  a  symptom  of  the  exhausted  state  as  the 
other  symptoms  accompanying  it,  and  ought  to  be  so 
regarded. 

Inebriety  and  opium  mania  of  this  kind  arc  to  be 
treated  like  the  other  s}-mptoms  of  neurasthenia,  that  is, 
by  strong  sedatives,  alternating  with  tonics  ;  and  there  are 
many  of  these  cases,  at  least  a  considerable  number,  that 
can  be  treated  outside  of  an  asylum — at  home — and  while 
pursuing  their  regular  business.  I  believe  in  inebriate 
asylums  just  as  I  believe  in  insane  asylums,  and  there  is 
no  antagonism  between  them.  There  are,  however,  a 
large  number  of  inebriates  that  can  be  successfully 
treated  outside  of  an  asylum,  just  as  there  are  some  cases 
of  melancholia  and  other  phases  of  insanity  of  a  mild 
type  that  can  be  treated  successfully  by  a  physician 
without  sending  them  to  any  institution,  whatever,  and, 
indeed,  more  successfully  than  in  any  institution ; 
just    so    there     are     cases    of    inebriates     and     of    opium 


Geo.  M-  Beard, 


eaters  that  can  be  treated  by  one  who  understands 
the  subject,  outside  of  an  asykim.  with  satisfactory 
results. 

One  wa}'  in  which  neurasthenia  induces  incbrict}'  is, 
that  it  causes,  sometimes,  a  great  and  incredible  tolerance 
of  alcohol ;  in  those  cases  they  can  bear  immense  doses 
without  feeling  any  effects,  good  or  bad — certainly  no  bad 
effects.  Some  of  these  cases  are  very  interesting  indeed  ; 
one  of  my  medical  patients  afflicted  at  one  time  with 
cerebrasthenia  (from  which  he  has  now  recovered),  at 
one  stage  of  the  disease,  when  he  was  at  the  very  worst, 
he  could  take  a  full  tumbler  of  whiskey  and  not  feel  any 
bad  effects,  although  he  was  not  used  to  drinking  when 
he  was  well.  One  of  my  hay  fever  patients  in  whom,  as 
is  sometimes  the  case,  the  attacks  were  preceded  by  a 
number  of  days  of  profound  exhaustion,  though  he  was  not 
accustomed  to  drink  at  all,  tells  me  that  in  one  of  those 
attacks  of  exhaustion,  alcoholic  liquor,  in  any  amount,  has 
no  effect  whatever. 

DISEASE    OF    THE    REPRODUCTIVE    ORGANS. 

Neurasthenia,  long  neglected  or  badly  treated,  and, 
sometimes,  in  the  early  or  acute  stages,  is  a  common 
excitant  of  functional  and,  sometimes,  of  structural  mala- 
dies of  the  reproductive  organs.  In  males,  irritabilit)'  of 
the  prostrate  gland  and  of  the  prostatic  urethra  ;  and  in 
females,  of  the  neck  of  the  cervix  and  of  the  ovaries  may 
be  a  direct  result  of  general  neurasthenia.  It  is  quite 
true  that  diseases  of  these  parts  are,  themselves,  excitants 
of  neurasthenia  ;  but,  none  the  less  is  it  true  that  neuras- 
thenia excites  disease  in  them.  There  is,  indeed,  a 
constant  action  and  inter-action  between  special  organs; 
between  themselves  and  between  special  organs  and  the 
nervous  system  in  general;  so  that,  in  individual  cases,  it 
may  be  quite  hard  to  tell  the  seat  of  the  primary  neurotic 
implication.  A  want  of  recognition  of  this  fact  is  the 
basis  of  an  enormous  quantity-  of  non-expert  reasoning  on 
this    subject,    among    specialists    and    general  practitioners. 


The  Seqwences  of  J^ eur asthenia.  23 

If  a  female  presents  herself  to  a  gynecologist  with 
evidences  of  inflammation  or  enlargement,  or  even  irrita- 
tion of  the  womb  or  ovaries,  and  has  associated  therewdth 
a  number  of  symptoms  of  neurasthenia  as  I  have  described 
them,  the  natural  inference  is  that  the  local  disease  is  the 
cause  of  the  general  disease — an  inference  sometimes 
justified  by  facts  and  sometimes  not ;  for  the  general 
neurasthenia  is  as  likely  to  be  the  exciting  cause  of  the 
local,  as  is  the  local  trouble  to  be  the  cause  of  the  general 
neurasthenia.  The  worst  failures  of  skilled  gynecologists 
of  our  time  are  just  with  this  class  of  cases;  and,  mainly, 
because  they  treat  them  locally,  without  treating  them 
generally  or  constitutionally  ;  or  if  they  do  treat  them 
constitutionally,  it  is  in  a  vague,  desultory,  half-hearted, 
incidental  and  doubtful  manner,  that,  in  therapeutics,  is 
always  sure  to  fail  of  its  purpose.  While  cases  of  this 
kind  need,  oftentimes,  careful  local  treatment,  yet  such 
local  treatment,  however  judiciously  and  patiently  carried 
out,  is  wasted,  unless  it  be  accompanied  by  an  equally 
patiently  carried  out  constitutional  treatment. 

Exclusive  dependence  upon  either  local  or  general 
treatment  is  non-expertness,  one-sidedness.  halfness  of 
therapeutics ;  for,  if  either  one  should  be  neglected,  it 
should  be,  in  some  cases  at  least,  the  local ;  or,  at  least, 
the  local  should  be  made  incidental  or  secondary  ;  and  it 
is  creditable  to  one  of  the  best  known  of  our  gynecolo- 
gists. Dr.  Goodell,  that  he  has  been  one  of  the  first,  in 
his  department,  to  recognize  this  fact,  and  to  illustrate  it 
by  interesting  cases  accompanied  with  just  and  verifiable 
philosophising  upon  this  subject.  Cases  of  this  kind  some- 
times go  around  from  one  g>mecologist  to  another,  seeking 
help  and  finding  none,  just  as  cases  of  neurasthenic  asthe- 
nopia go  around  from  one  occulist  to  another,  get- 
ting no  information  and  no  relief  beyond  this:  that 
"there  is  nothing  the  matter  with  them;"  which  is  equiva- 
lent to  saying,  that  the  ophalmoscope  can  reveal  nothing, 
and  what  the  ophalmoscope    cannot  reveal,  does  not  exist. 

My  own  habit    in    cases    of  this    kind    is,  to  obtain  the 


24  George  M.  Beard, 


co-operation  of  practical  gynecologists  and  oculists,  and 
I  have,  oftentimes,  thereby  secured  results  which  no  one 
department  alone  could  have  achieved. 

HAY    FEVER. 

One  very  interesting  sequel  of  neurasthenia  is  ha}' 
fever,  which,  philosophically  anal}-zed,  is  simpl\-  a  nervous 
idiosyncracy,  usually  against  some  one  or  many  external 
irritants,  of  which  pollen,  sunlight,  dust,  heat,  foul  air. 
smoke  and  various  fruits  and  flowers  are  the  most  familiar. 
But  these  external  irritants,  any  one  of  them,  or  all  com- 
bined, can  no  more  excite  hay  fever  than  they  can  excite 
small-pox  or  lepros}^  unless  they  strike  on  a  nervous 
system  predisposed ;  and  one  of  the  nicest  important, 
indeed  the  most  important  element  in  the  predisposition  is 
nervousness ;  though  not  always  going  on  to  neurasthenia. 

While  many  hay  fever  sufferers  are  apparently  well  and 
hardy,  yet  in  all  there  is  a  neurotic  element,  if  we  can 
trace  it,  and  in  a  large  number  of  instances  this  neurotic 
element  is  visible  in  many  ways — hay  fever  being  only 
one  of  many  symptoms,  and  not  alwa3-s,  by  any  means, 
the  most  serious.  This  ver}'  }'ear,  one  of  my  patients 
who  is  profoundly  neurasthenic,  has  made  an  addition  to 
his  catalogue  of  symptoms,  b}-  an  attack  of  the  later  form 
of  hay  fever.  In  countries  where  neurasthenia  is  rare, 
hay  fever  is  rare,  and  vice  versa ;  they  rise  and  fall 
together. 

writek'.s  cramp. 

Writer's  cramp  is  a  disease  which  is  characterized  by 
a  group  of  from  fifteen  to  twenty  symptoms ;  the  cramp 
being  one  of  the  group  only,  not  always  present  in  all 
the  classes. 

There  are  quite  a  number  of  types  of  this  disease.  In 
quite  a  number  of  cases  there  is  no  neurasthenia;  there 
is  not  even  a  marked  nervous  diatliesis.  There  is, 
only,  a  local  weakness  of  the  nerves  and  muscles  con- 
nected with   the  act  (if  u  riling ;    there  is,    also,    .i    form    of 


The  Sequences  of  Neurasthenia.  25 

this  disease  to  which  the  term  neurasthenic  writer's  cramp 
might  justly  be  appHed ;  and  this  form  occurs  in  persons 
who  are  of  a  nervous  constitution,  who  are  nervously 
exhausted,  and  who  descend  into  the  symptoms  of  writer's 
cramp  through  the  other  symptoms  of  the  neurasthenic 
state.  Patients  of  this  kind  find  that  in  writing  they  are 
troubled  with  pain,  aching,  heaviness,  fatigue,  tiredness 
of  the  arm,  or,  in  some  cases,  a  stiffness  that  suggests 
rheumatism — and  they  are  sometimes  so-  nervous  that  they 
cannot  write  at  all  continuously,  without  suffering  from  a 
nervousness    which,    without    pain     compels    them    to    stop. 

While  this  paper  is  in  process  of  preparation,  I  have 
received  a  letter  from  a  neurasthenic  patient,  the  hand- 
writing of  which  is  so  different  from  that  of  other  letters 
which  I  have  received  from  him,  that  I  did  not  recognize 
it.  In  this  letter  he  tells  me  that  quite  lately  he  has 
been  troubled  with  this  difificulty  of  writing ;  a  nervous 
symptom  of  which,  before,  he  knew  nothing,  although  he 
had  not  been  well  for  years.  The  letter  is  written  in 
better  style,  he  tells  me,  than  most  of  his  letters  of  late  ; 
yet  there  are  many  mistakes  in  it,  and  I  should  suppose 
it  came  from  a  regular  writer's  cramp  patient. 

It  is  a  satisfaction  that  writer's  cramp  of  this  variety 
(the  neurasthenic),  gives  way  to  treatment  more  readily 
than  any  other  form ;  the  diagnosis  is  far  more  hopeful, 
and  in  many  cases  they  get  well  themselves — which  is 
never  the  case  with  the  severe  form  of  writer's  cramp.  I 
have  seen  and  treated  quite  a  number  of  cases  of  neuras- 
thenic writer's  cramp  where  the  recovery  has  been 
absolute. 


That  morbid  state  of  the  nervous  sj^stem  which  we  call 
trance,  but  which  is  popularly  known  as  hypnotism, 
.somnambulism,  catalepsy,  all  being  special  varieties  of  the 
special  generic  condition  trance,  is  one  of  the  interesting, 
though,  perhaps,  not  frequent,  or  the  most  serious  of  the 
sequels  of  neurasthenia. 


George  M.  Beard, 


Neurasthenia  is  not,  by  any  means,  the  most  common 
of  the  exciting  causes  of  this  state.  In  the  middle  ages, 
an^ong  wild,  savage  and  semi-barbarous  races,  trance 
existed,  and  has  spread  a  mental  contagion,  even  among 
persons  who  have  great  strength  of  constitution,  or  at 
least,  who  have  but  verj^  little  of  the  nerve  element  in 
them. 

Trance  of  this  variety,  in  its  ps)'chical  form,  is  found 
to-day  among  certain  classes  of  the  people;  but  the  major- 
ity of  the  cases  of  trance,  among  our  better  classes,  are 
those  who  have  entered  that  state  through  the  doors  of 
neurasthenia.  Our  so-called  starving  girls,  with  their 
ecstacies  and  visions,  are  oftentimes  neurasthenic  for 
years,  before  they  develop  trance  phenomena. 

PARALYSIS      AND     ORGANIC      DISEASE      OF       THE      SPINAL      CORD. 

Temporary  paralysis  or,  at  least,  paralysis  that  are 
relievable  and  curable  by  treatment,  are  quite  common  in 
the  course  of  neurasthenia,  and  they  pass,  oftentimes,  by 
the  name  of  hysterical  paralysis,  which,  when  they  are 
accompanied  by  the  positive  symptoms  of  hysteria,  is 
entirely  correct.  But,  one  may  have  true  neurasthenic 
paralysis  without  any  symptoms  of  hysteria  proper  pre- 
ceding or  accompanying  it.  Paralysis  of  this  kind  may 
affect  the  larynx,  causing  aphonia,  or  the  neck  of  the 
bladder,  causing  retention  or  incontinence;  or  any  one  of 
the  upper  or  lower  extremities. 

Paralysis  of  this  kind  may  sometimes  go  away  as  soon 
as  they  come ;  and  sometimes  they  need  special  and 
prolonged  treatment.  But  they  differ  from  the  mechan- 
ical paralysis,  m  that  the\'  do  get  well,  and  get  well 
perfectly,  sometimes. 

The  belief  which  some  have  held,  which  some  hold 
now,  in  relation  to  which  many  of  the  best  physicians  of 
our  time  are  in  doubt  and  fear,  that  neurasthenic  symp- 
toms are  the  predecessor  of  severe  and  incurable  condi- 
tions of  the  spinal  cord,  such  as  ataxia,  muscular  atrophy, 
spinal  meningitis  and   the  like,  are  not  in  harmony  with  the 


The  Sequences  of  Neurasthenia 


facts,  and  will  be  held  by  no  one  who  unites  both  the 
power  and  the  opportunity  for  observing  large  numbers  of 
cases  through  many  years. 

Many  of  the  symptoms  of  neurasthenia  resemble  so 
nearly  the  symptoms  of  incipient,  and  even  the  final  symp- 
toms of  sclerosis,  that  to  distinguish  them  is  very  hard 
indeed;  and  }^et,  close  as  their  resemblance  is,  there  is, 
pathologically,  a  gulf,  wide  as  the  i\tlantic,  between  them. 
I  do  not  deny  that  in  occasional  instances,  neurasthenia 
neglected,  exasperated  by  bad  hygiene  or  by  bad  treat- 
ment, may  be  the  precursor  of  sclerosis,  or,  at  least,  of 
permanent,  fixed  congestion  of  the  cord  or  of  its 
membranes — just  as  it  is  the  possible  precursor  of  certain 
forms  of  insanity — but  it  is  not  the  rule  that  it  should  lead 
to  these  conditions,  any  more  than  it  is  the  rule  that  it 
should  lead  to  insanit}-.  Neurasthenia  has  symptoms 
enough  of  itself,  and  is  bad  enough  and  distressing 
enough,  without  adding  to  it  that  it  is  an  early  symptom 
of  structural  disease. 

CERTAIN    ST.VGES    OF    BRIGHT's    DISEASE. 

Neurasthenia  appears  in  some  cases,  to  prepare  the 
way  for  those  varied  congestions  and  inflam.mations  of  the 
kidneys,  to  which,  when  they  have  reached  a  certain 
stage,  the  vague  term,  Bright's  disease,  is  applied.  This 
term,  Bright's  disease,  is  the  one  doctors  use  to  include  a 
variety  of  morbid  conditions  of  the  kidney;  but  the 
generic  term,  congestion,  is,  without  doubt,  the  condition 
through  which  the  kidney  passes. 

Neurasthenia,  by  the  bad  nutrition  with  which  it  is 
connected,  would,  itself,  keep  the  circulation  in  a  state  of 
fluctuation  and  uncertainty,  and  prepare  the  way  for 
congestion  of  the  internal  organs ;  especially  on  exposure 
to  cold  after  over  exertion. 

•  •  These  congestions  may  be,  at  first,  of  a  temporary 
character  only,  and  may  disappear  as  suddenly  as  they 
came.  But  in  some  cases  they  become  chronic,  and  the 
kidneys  assume  a  state  where  an  examination  of  the  urine 


28  George  M.  Beard, 


shows  both  albumen  and  casts.  I  have  seen  quite  a 
number  of  cases  of  what  we  call  Bright's  disease  of  the 
kidney,  as  judged  by  the  presence  of  albumen  and  casts, 
that  seemed  to  have  followed  a  prolonged  neurasthenic 
condition. 

It  is  a  pleasing  and  most  interesting  fact  that  these 
neurasthenic  forms  of  kidney  disease  are  amendable  to  . 
proper  treatment.  A  number  of  cases  that  I  have 
treated  gave  all  the  symptoms  of  this  condition,  under  the 
microscope,  and  apparently  recovered ;  and  so  far  as  can 
be  seen,  the  recovery  is  permanent ;  and  it  appears,  also, 
to  be  the  direct  result  of  the  treatment  used,  and  not  a 
mere  coincidence. 

I  did  not  use,  for  these  cases,  the  internal  routine 
treatment  of  Bright's  disease — for  the  very  good  reason 
that  I  have  never  seen  any  very  good  results  from  it — 
and  many  of  the.se  cases  had  tried  it,  long  before  I  had 
seen  them. 

I  treated  them  by  general  faradization  and  galvaniza- 
tion, by  counter-irritation  over  the  kidneys,  persistently 
kept  up,  and  by  the  administration  of  vegetable  tonics — 
very  much,  indeed,  as  I  treat  the  neurasthenic  condition 
itself,  when  it  attacks  the  spinal  cord  or  the  biain. 

The  effect  of  this  treatment,  in  some  cases,  is  seen  in 
the  urine,  very  speedily,  after  the  treatment  is  begun. 

A  case  of  that  kind,  that  was  utterly  given  up,  I  lately 
treated  with  the  best  results;  if  this  patient  were  to  die 
of  the  disease  of  kidneys,  nevertheless,  the  improvement 
she  has  made  under  the  treatment  is  a  reality.  Even  in 
the  later  (the  incurable)  stages  of  Bright's  disease,  after 
dropsy  has  appeared,  I  have  seen  most  pleasant,  though 
perhaps,  not  so  thorough,  results  from  this  plan  of 
treatment. 

It  is  my  conviction,  from  the  study  of  quite  a  number 
of  these  cases,  and  a  careful  watch  over  them  after  the 
treatment  has  been  discontinued,  that  for  certain  forms  of 
Bright's  disease  with  albumen  and  casts  in  the  urine,  even 
in  considerable  quantity,  and   with  the  dcbilit)-  that  accom- 


The  Sequences  of  Jieurasthenia 


panics  such  conditions,  that  there  can  be  relief,  and,  so 
so  far  as  can  be  seen,  a  permanent  cure — not  by  the  old 
plan  of  treatment,  but  by  the  new — that  is  by  proper 
external  applications  in  the  neighborhood  of  the  kidneys, 
and  by  proper  sedatives  and  tonics  internalh'. 


Art.  Ill— ''A  Clinical  Inquiry  into  the 
Significance  of  Absent  Patellar  Ten- 
don Reflex.. 


Bv  C.  H.  Hughes,  M.  D., 


LATE  SUPERINTENDENT   AND    PHYSICIAN    OF    THE    MISSOURI   STATE    LUNATIC 

ASYLUM  AT  FULTON:   CONSULTING  PHYSICIAN  TOTHEMISERICORDIA 

ASYLUM    FOR     THE   INSANE   AND    NERVOUS,    AND     TO   THE 

FEMALE  HOSPITAL,   SAINT   LOUIS. 


IF  you  sharply  strike,  with  some  hard  substance,  the 
naked  skin  just  below  the  patella,  whether  anaesthe- 
tized or  not,  so  as  to  affect  the  quadriceps  extensor  femoris 
tendon,  between  the  knee  cap  and  its  point  of  insertion 
into  the  upper  end  of  the  tibia,  while  the  person's  leg 
hangs  loosely,  either  from  a  table,  from  across  the  leg  of 
the  operator,  or  from  across  his  own  opposite  knee,  a 
prompt,  marked  and  involuntar>'  upward  jerk  will  be  the 
usual  response.  Westphal,  Erb  and  others  say  the 
invariable  response.  So  invariable  do  they  and  others 
regard   it,  that  when  it  cannot    be    elicited    on   percussion, 

*Read  before  the  Missouri  State  Medical  Association,  June,  1879,  and  ordered  to 
be  published  iu  tlie  transactions. 


C.  E.  Hughes, 


they  claim  for  this  fact  a  distinctive  diagnostic  significance. 
It  is  never  present,  they  say,  in  progressive  locomotor 
ataxia  or  posterior  spinal  sclcivsis. 

In  Europe  the  majority  of  observers  have  ranged 
themselves  with  Westphal,  who,  more  restrictive  than 
Erb,  makes  it  the  diagnostic  sign,  par  excellence,  of 
locomotor  ataxia. 

Only  Gowers,  in  England,  and  in  this  country,  McLane, 
Hamilton,  Bannister,  Jewell,  Landon  Carter  Gray,  Beard 
and  myself,  have  ventured  to  question  the  infallibility  of 
this  so-called  pathognomionic  sign ;  and  I  believe  they 
constitute  the  majority  of  American  physicians  who  have 
written  upon  the  subject  At  least,  I  know  of  only  one 
other — Dr.  E.  C.   Seguin. 

That  the  absence  of  patellar  tendon  reflex  is  not 
incompatable  with  every  semblance  of  perfect  health,  may 
be  established  to  the  satisfaction  of  any  one  who  will,  by 
percussion,  diligently  examine  the  patellar  tendons  of  any 
considerable  number  of  healthy  persons,  in  the  manner 
prescribed  by  Westphal,  when  searching  for  his  indubi- 
table ( ? )  sign  of  locomotor  ataxia  ;  and  its  demonstrable  and 
admitted  absence,  occasionally,  in  perfectly  healthy  persons 
must  greatly  militate  against  the  sign  being  received  as 
certainly  and  unexceptionally  diagnostic.  That  Westphal 
must  recede  from  the  uncompromising  stand  he  has  taken, 
seems  certain,  in  view,  not  only  of  the  fact  that  it  is 
sometimes  physiologically  absent  (more  often,  perhaps, 
than  we  think,  though,  precisely  in  what  proportion  of 
cases,  no  one  has  yet  definitely  determined),  but  in  the 
face  of  accumulating  antagonistic  clinical  evidence  on  this 
side  of  the  Atlantic,  at  least. 

It  is  not  our  present  purpose  to  discuss  this  question 
/;/  extenso.  Any  person  sufficiently  interested  in  the 
subject  to  pursue  it  further,  will  find  an  accumulated 
literature  in  Europe  and  in  this  country,  since  the  subject 
was  first  brought  to  the  attention  of  the  profession, 
sufficiently  va.st  to  satisfy  the  most  diligent  student  of 
neurological  problems. 


Absent  Patellar  Tendon  Reflex. 


In  this  country,  McLane  Hamilton,  Boston  Medical 
and  Surgical  Journal,  Dec.  19th,  1878,  Bannister,  Journal 
of  Mental  and  Nervous  Diseases,  ibid,  Oct.  1878,  and 
Landon  Carter  Gray,  have  made  it  plain  that  the  sign 
looses    much    of  its    asserted  pathological  value. 

Dr.  Gray,  in  his  April,  1879,  paper,  repeats  in  substance 
and  more  at  length,  many  of  the  points  made  against  this 
sign  by  ourself  in  the  previous  February  number  of  the 
St.  Louis  Medical  and  Surgical  Journal. 

We  now  offer  for  your  consideration  a 

BRIEF      HISTORY      OF       SOME      CASES       IN       WHICH      WESTPHAL's 

TENDON     REFLEX     PHENOMENON    WAS    EITHER    ABSENT 

OR    EXAGGERATED. 

Case   i. — Dr.   W ,  married,  aged  53  years,  on  U. 

S.  A.  pension  list,  in  consequence  of  sunstroke,  hernia 
and  tibial  periostitis — the  latter  resulting  from  an  injury ; 
no  history  of  syphilis  admitted  or  demonstrable ;  "  was 
overcome  b\-  heat  and  taken  from  his  horse  in  a  state  of 
syncope,  June   5th,    1863." 

Diameter  of  pupils  not  materially  greater  or  less  in 
either  light  or  darkness  than  No.  i  of  Hutchinson's  pupil- 
ometer,  i.  l\,  than  two-thirds  of  a  line. 

Two  opthalmologists  found  substantially  as  follows : 
"  Pupils  habitually  contracted  and  scarceh'  dilating  in  a 
dark  room.  Symptoms  of  night  blindness  in  accordance 
with  the  myosis.  Color  perception  bad  for  both  red  and 
green,  but  no  impairment  of  visual  acuteness  in  either 
eye.  (Vision  measures,  12-16).  Retinal  vessels  and  gen- 
eral appearance  of  fundus  substantially  normal;"  while 
another  opthalmologist,  found  "a  small  white  ring  entirely 
surrounding  the  right  optic  nerve  entrance,  and  partly 
surrounding  the  left,  which  seems  to  indicate  approaching 
or  incipient  atophy  of  the  nerves ;"  all  concurring,  how- 
ever, in  regarding  the  symptoms,  noted  by  them,  as 
"pointing  rather  to  a  cerebral  than  local  origin  in  any 
change  in  the  eye  itself" 

This  gentleman  is  a  large  framed,  tall  man,  and  weighs 


C.  H.  Hughes, 


about  165  lbs,  av.,  his  complexion  is  florid,  pulse  is  now 
108  full,  and  habitually  above  the  normal  condition  in 
force  and  frequency,  the  tissues  are  well  nourished  and 
there  is  no  muscular  atrophy.  He  walks  unsteadily  in 
the  dark  and  totters  some  when  his  eyes  are  closed.  He 
feels  very  uncertain  about  the  position  of  his  feet  while 
descending  the  stairs  and  in  the  after  part  of  the  day. 
His  muscular  power  is  good.  He  can  force,  with  either 
hands,  the  needle  of  Mathieu's  dynamometer  round  to  80. 
Says  he  can  not  always  tell  when  the  bladder  or  rectum 
is  full,  or  whether  he  wants  to  urinate  or  defecate.  His 
urine  is  extruded  more  feebly  and  slowly  than  formerly, 
and  he  can  not,  at  times,  wholly  empty  the  bladder.  Has 
had  shooting  pains  in  the  lower  limbs,  complains  of  virtig- 
inous  sensations,  double  and  obscure  vision,  luminous  ap- 
pearances and  dark  spots  before,  the  eyes;  headache,  and 
noises  in  the  ears.  There  are  no  contractures,  but  slight 
bi-lateral  anaesthesia  in  the  lower  limbs. 

His  case  was  diagnosed  as  Meningitis  Vcjticalts 
by  several  excellent  diagnosticians,  besides  the  Army 
Board.  Among  those  who  so  diagnosticated  the  case, 
in  which  I  also  substantially  concurred,  were  two 
physicians  of  special  reputation  for  skill  in  recognizing 
diseases  of  the  nervous  system. 

None  of  the  medical  gentlemen  suggested  impending 
ataxia  but  myself. 

The  tendon  reflex  phenomenon  was  conspicuously 
absent  in  both  legs. 

This  patient  is  still  able  to  attend  to  the  practice  of 
his  profession. 

I  put  the  case  down,  by  courtesy,  as  doubtful,  because 
of  the  weight  of  opinion  being  so  largely  against  me.  If 
it  is  not  one  of  ataxia,  it  militates  against  Westphal's 
sign. 

C.\SE  2. — James  Minnix,  unmarried,  age  t,i.  Native 
of  Canada.  By  occupation  a  miner.  Was  formerly  a 
seaman,  sailing  from  New  York  to  Liverpool.  Admitted 
to  City  Hospital,  July  2nd,   1878. 


Absent  Patellar  Tendon  Reflex.  33 

In  Deadwood  City,  Black  Hills  country,  after  pro- 
longed exposure  to  inclement  weather,  he  sprained  his 
ankle,  and  at  the  same  time  noticed  want  of  sensation  in 
the  right  leg.  Formerly  had  momentary  jerking  pains  in 
the  knee,  which  he  thought  were  rheumatic.  Had  a 
chancre,  which  was  probably  syphilitic,  in  1870.  He  has 
now  a  rash  on  thighs  which  comes  and  goes.  Takes 
iodide  of  potassium. 

There  is  no  muscular  atrophy.  Loss  of  power  in  the 
legs  came  on  gradually.  He  can  not  stand  or  walk  in 
the  dark.  Sometimes  feels  like  there  was  nothing  under 
his  feet  when  standing,  and  cannot  tell  where  his  feet  are 
without  looking  at  them. 

Has  shooting  pains  from  middle  lumbar  region  down- 
ward, and  a  "  sort  of  sea-saw  pain,"  as  he  calls  it,  from 
back  to  thighs  "  drawing  like  a  cord."  Has  had  con- 
stricting pain  around  his  waist.  His  urine  dribbles  away 
from  him  frequently.  Will  go  to  the  water-closet  and 
fail  to  make  water,  but  on  returning  the  urine  will  come 
involuntarily  away.     This  man    used  to  drink  a  good  deal. 

His  eyes  were  not  examined  for  atrophy  of  optic 
nerve.  No  marked  inequality  of  pupils.  His  gait  is 
characteristically  ataxic,  and  he  buttons  his  pants 
clumsily. 

The  case  is,  undoubtedly,  one  of  locomotor  ataxia,  as 
it  has  been  pronounced  by  all  the  medical  men  connected 
with  the  city  hospital  who  have  examined  him. 

The  tendon  reflexion  can  not  be  elicited. 

Case  3. — Jas.  Noonan,  a  builder,  aged  34  years, 
single.  About  20  months  ago  first  noticed  that  he  trem- 
bled and  became  unsteady  in  his  limbs  while  walking  on 
scaffold  work,  and  was  soon  obliged  to  give  up  his  occu- 
pation through  fear  of  falling.  He  gradually  became  more 
and  more  unsteady  in  his  limbs,  stepping  more  and  more 
uncertain,  particularly  after  dark,  until  obliged  to  use 
crutches  in  order  to  get  around.  He  has  now  muscular 
power  in  limbs,  but  lacks  the  necessary  control  for  guid- 
ing his  steps.     His  heels    come    down    first  to  the  ground, 


34  C.  H.  Hughes, 


and  he  loses  his  balance  when  eyes  are  closed,  if  stand- 
ing. Says  his  arms  were  similarly  affected  for  a  short 
time.  Was  strong  and  healthy  up  to  date  of  the  pre- 
sent illness.  Had  gonorrhoea  twelve  years  ago,  which 
disappeared  in  three  weeks,  and  for  which  he  took  nothing 
but  Epsom  salts.  No  histor)-  of  syphilis,  and  has  been 
temperate  for  the  past  four  )'ears,  but  formerly  very 
intemperate.  He  attributes  his  disease  to  exposure  to 
cold  and  dampness  while  constructing  a  bridge.  No 
family  neurosis.     Tendon   reflex  absent. 

Case  4. — Wm.  Goff,  aged  42,  single,  laborer,  always 
healthy  until  lately.  Had  chills  and  fever  last  September, 
and  has  not  been  well  since.  On  the  17th  day  of  Jan- 
uary he  began  to  stagger.  Has  no  shooting  pains,  and 
the  floor  feels  natural  to  his  feet. 

Made  several  unsuccessful  efforts  before  he  could 
touch  the  point  of  his  nose  when  his  eyes  were  shut.  He 
can  not  stand  when  eyes  are  shut,  and  buttons  his  pants 
or  picks  up  a  pin  clumsily.  Eyes  not  examined  with 
opthalmoscope.  Has  plantar  anaesthesia,  and  no  tendon 
refle.x.     Does  not  complain  of  impaired  vision. 

I  am  inclined  to  regard  this  as  a  case  of  locomotor 
ataxia,  though  by  most  diagnosticians  it  would  probably 
be  considered  otherwise,  because  of  the  absence  of  the 
lightning  pains,  of  obscurity  of  vision  and  the  suddenness 
of  its  appearance.     Tendinous   reflexion  was  absent. 

Thus  far  the  clinical  testimony  has  been  rather  con- 
firmatory than  condemnatory  of  the  value  of  Westphal's 
sign.  We  come  now  to  record  some  cases  which  can  not 
be  doubted,  and  which,  therefore,  must  materially  modify 
the  claims  of  Westphal  as  to  the  certain  diagnostic  signfi- 
cance  of  absent  tendon  reflex. 

Case    5. — T.    J.    K ,    a    farmer,     aged    59   years, 

unmarried,  large-framed  and  tall,  weighs  about  181,  has  no 
sexual  appetite  and  no  muscular  atrophy.  Has  aphasia, 
to  the  extent  of  speaking  with  painful  slowness,  and  at 
times  forgetting  verj^  familiar  words,  such  as  the  name  of  the 
place  of  his  residence,  which  he   spells   out  or  pronounces 


Absent  Patellar  Tendon  Reflex.  35 


after  having  them  repeated  for  him.  Has  had  shooting 
pains  in  the  hmbs,  and  still  has  darting  pains  from  lumbar 
region.  Was  first  taken  sick  about  May  1st,  1867,  with  a 
dull  pain  in  the  region  of  the  heart,  followed  by  a  great 
cough,  after  riding  all  day  in  the  rain,  he  having  made  a 
practice  of  driving  from  the  city  to  his  farm,  a  distance  of 
ten  miles,  at  midnight,  during  the  preceding  summer.     Mr. 

K has    used    tobacco    excessively,  but    is   otherwise 

temperate. 

A  neuropathic  diathesis  pervades  his  family ;  a  brother 
having  died  of  brain  trouble  and  psychic  disturbance;  one 
living  brother  being  ataxic ;  one  sister  having  painful 
cerebral  and  psychic  disturbance,  with  hyperaemia  cerebri, 
which  nature  has  generally  relieved  by  epistaxis  ;  another 
sister  having  general  and  chronic  nervous  asthenia,  includ- 
ing the  cerebro  spinal  axis  and  the  sympathetic.  All  her 
vital  functions  have,  for  years,  been  performed  sluggishly, 
while  her  skin  is  shriveled  and  sallow.  Her  face  is  small 
and  she  is  likewise  small  of  stature.  The  rest  of  the 
family — one  sister  and  two  brothers — are  large-framed  and 
above  average  height. 

The  father  of  our  patient  died  at  60  years  of  age, 
after  being  two  years  paralyzed;  and  his  grandmother,  for 
twenty  years  before  her  death,  could  never  get  out  of  her 
chair,  by  reason  of  some  form  of  paralysis,  or  rheuma- 
tism and  paralysis  combined — the  family  say.  I  could 
not  get  the  precise  particulars  concerning  the  nature  of 
the  ancestral  affliction  from  medical  sources. 

The  ataxic  symptoms  were  first  manifested  in  1867. 
He  then  discovered  that  he  could  not  walk  well,  espe- 
cially in  the  dark,  and  that  he  had  a  tendency  to  fall — 
and  did  sometimes  fall  forwards  when  he  attempted  to 
wash  his  face.  He  can  not  stand  with  his  eyes  shut  and 
feet  together,  or  turn  round  with  the  latter  apart,  without 
•  assistance. 

He  has  had  the  not  infrequent  experience  of  ataxics 
in  regard  to  improvements  and  relapses,  concerning  the 
power    of    co-ordinating      his    locomotor    movements     and 


30  C.  H.  Hughes, 


balancing  himself,  having  for  a  few  days  during  the  past 
two  years  been  able,  sometimes,  to  stand  alone  with  his 
eyes  closed  when  knowingly  placed  in  very  close  prox- 
imity to  a  wall,  and  to  turn  around  without  grasping 
something  for  support  and  without  falling. 

He  has  always  been  an  early  riser,  as  farmers  usually 
are,  but  since  his  affliction  he  has  been  in  the  habit  of 
awaking  about  2  A.  M.  daily,  and  remaining  awake  for 
the  remainder  of  the  day,  except  during  an  after  dinner 
nap  of  a  quarter  or  half  an  hour.  His  vision  is  obscure 
and  there  is  some  optic  nerve  atrophy. 

He  can  not  dress  himself  without  assistance.  He  can 
not  readily  find  the  tip  of  his  nose  with  the  point  of  a 
finger  of  either  hand  when  his  eyes  are  shut,  and  can 
not  cross  his  legs  without  having  the  ball  of  the  foot  or 
toes  supported  by  my  hand.  He  lifts  his  foot  with  a 
jerk  and  brings  it  down  in  a  peculiar  manner,  and  shows 
a  tendency  to  pitch  forward  when  iie  walks.  He  has 
often  fallen  down  when  attempting  to  go  about  unassisted. 
He  never  ventures  out  at  night,  and  is  seldom  able  to 
rise  from  his  chair  without  putting  his  hands  on  his  knees, 
or  being  assisted  by  his  cane,   or  the  hand  of  a  friend. 

He  has  a  good  deal  of  anaesthesia,  especially  plantar. 
His  sensibility  to  temperature  is  somewhat  impaired,  and  his 
appreciation  of  weight  is  partly  gone.  The  ground  under 
his  feet  when  he  walks  does  not  now  feel  so  uncertain  as 
formerly. 

There  is  no  vesical  or  rectal  parah'sis.  He  is  some- 
times constipated  and  has  inconstant  shooting  pains  pro- 
ceeding toward  the  cervical  region.  He  has  had  no  head 
symptoms,  except  an  occasional  giddiness  when  constipated. 
(Since  this  was  written  he  has  had  more  vertigo  and  malarial 
poisoning.) 

When   I  first  examined     Mr.   K .   about    one   year 

ago,  his  pupils  were  very  small — not  more  than  half  a  line 
in  diameter,  in  good  daylight.  I  then  sent  him  to  an 
eminent  oculist  of  this  city,  Dr.  John  Green,  who  de- 
tected the   optic    nerve    atrophy.     The    pupils    are  now  a 


Absent  Patellar  Tendon  Refiejc. 


line  and  a  quarter  in  diameter  in  good  daylight.  Though 
formerly  a  fair  penman,  he  has  not  attempted,  since  his 
affliction,  to  write  a  letter,  but  contents  himself  with  slowly 
forming,  in  a  stilted  and  unnatural  manner,  his  signature. 
His  expression  is  anxious  and  peculiar,  but  I  can  not 
describe  it. 

Electro-muscular  contractility  is  increased,  and  the 
tendinous  reflexion  is  as  marked  as  I  ever  saw  it  in  a 
healthy  person. 

Other  physicians  have  pronounced  this  a  case  of  loco- 
motor ataxia  before  me,  among  them,  Dr.   C.  W.   Stevens. 

Case  6. — The    next  case  I  note   is   the  brother  of  Mr. 

K ,  who  is  younger,  but,  by    reason  of    intemperate 

habits,  looks  somewhat  older  than  his  brother  Thomas, 
just  described. 

In  this  case  the  ataxia  is  incipient,  and  characterized 
by  the  peculiar  pains  in  the  extremities,  plantar  anaesthe- 
sia and  feeble  tendinous  reflexion  on  percussion  below  the 
knee  cap;  but  no  more  feeble  than  I  have  seen  it  in 
several  healthy  persons,  and  not  so  tardy  as  I  have 
observed  it  in  some  of  the  latter. 

Case  7. — H.  M.    P ,    who    lives  with  case   5.  and 

usually  accompanies  him  to  my  office,  to  assist  him  in 
and  out  of  his  carriage,  is  a  married  man,  aged  39  years, 
and  a  brother-in-law  of   Mr.  K . 

He  had  abdominal  dropsy  and  anasarca  in  1856  and 
1857,  but  always  got  about.  He  has  had  no  sickness 
since,  except  an  occasional  cough  or  chill.  He  is  of 
medium  stature  and  rather  slight  build.  Hair  and  beard 
entirely  grey.  Never  had  syphilis  nor  indulged  exces- 
sively in  venery.  Has  spreed  some,  but  is  not  an  habitual 
drinker.  Has  never  done  much  hard  labor,  but  when 
occupied  has  been  mostly  engaged  in  clerking  or  selling 
goods.  He  makes  no  complaint  of  being  ill  in  any  way, 
•  and  I  can  discern  nothing  the  matter  with  him. 

He  has  no  tendinous  reflexion  of  quadriceps,  extensor 
tendon  or  tendon  patellae. 

Case  8.— H.   H.  M ,  aged    39  years,   married.     A 


C.  n.  Hughes, 


medical  friend.  In  every  way  healthy,  and  engaged  in 
the  active  practice  of  his  profession,  demonstrator  of 
anatomy  in  a  large  medical  college,  and  a  diligent  and 
laborious  worker.      Has  no  tendon  reflex  below  knee. 

Case  9. — Thos.  E.  Moss,  unmarried,  aged  23,  six 
weeks  ago  consulted  me  from  Jefferson  count}'. 

About  three  years  ago,  last  August,  he  had  his  skull 
fractured  at  the  left  parieto  temporal  junction.  Was  in 
bed,  in  consequence,  about  one  and  a  half  weeks.  Was 
never  unconscious.  Has  increased  pulse,  constant  head- 
ache and  musccB  volitantes.  Complains  of  frequently 
seeing  a  green  spot  before  his  eyes,  which  gradually 
widens  until  he  can  see  nothing  else  on  account  of  it. 
Ho  then  becomes  dizz)'  and  is  obliged  to  lay  down. 
This  used  to  appear  every  day  or  so  like  the  ague. 
Has  this  illusion  now,  whenever  he  has  a  chill.  He  is 
constipated  and  feels  sick  at  the  stomach  when  this  goes 
off. 

Tendinous  reflexion  below  the  knee  could  not  be 
elicited  after  the  repeated  trials.  Electro  muscular  contrac- 
tility in  legs,   normal. 

Case  10. — Joseph  Crary  came  under  treatment  January 
1 2th.  Left  pupil,  8;  right  pupil,  5;  eyes  otherwise  appear 
normal ;  atroph\-  of  both  optic  discs ;  totally  blind  ;  can 
not  perceive  when  the  electric  current  is  passed  or  inter- 
rupted across  the  optic  tract;  dull  pain  encircling  the  line 
of  the  occipito-parietal  junction,  and  settled  pain  in  back 
and  lower  part  of  the  cerebellum;  he  can  not  lie  with  the 
back  of  his  head  on  a  pillow.  He  first  felt  uncomfortable 
feelings  in  his  head  last  June.  Feels  like  he  was 
walking  in  the  sand  of  the  sea  shore,  or  in  the  soft  snow, 
sometimes.  The  carpet  feels  mushy  to  him,  as  though 
he  was  sinking  down  an  inch  or  so.  Stands  and  walks 
steadily,  however,  and  goes  about  familiar  places  unas- 
sisted. He  never  had  shooting  pains  in  his  limbs  ;  some- 
times a  pain  across  his  chest.  He  became  totall}-  blind 
one  year  ago,  while  on  his  way  to  Hot  Springs,  Ark. 
Lost    the    sight    of  the    left    eye  in  the  mines,  eight  years 


Absent  Patellar  Tendon  Reflex.  ^9 

ago ;  the  sight  faihng  gradually,  beginning  with  double 
vision.  His  right  eye  failed  him  quite  suddenly,  while 
w^orking  in  the  mines  at  Deadwood,  Black  Hills  country, 
after  riding  in  the  hot  sun  all  day,  about    June    28th,  last. 

He  is  anaesthetic  in  arms  and  legs  and  tongue.  There 
has  been  hyperaesthesia  cerebri ;  the  slightest  sounds,  as  the 
noise  of  boots  being  blacked,  or  the  playing  of  a  piano, 
having  been  quite  disagreeable  to  him.  This  has  now 
(May  loth)  passed  away,  and  he  walks  everywhere  about 
the  city  with  a  friend,  without  feeling  any  unusual  sensa- 
tions under   him. 

Repeated  trials  have  always  failed  to  elicit  any  tendon 
reflex   below  the  knee. 

From  these  clinical  demonstrations  we  conclude  that, 
while  absent  patellar  tendon  reflex  is  often  of  significance 
as  an  associated  symptom  of  present  locomotor  ataxia, 
and  may  even  serve,  when  unassociated,  to  excite  suspi- 
cion of  its  approach,  we  are  not  justified  in  regarding  it, 
when  it  is  the  only  phenomenon  observable,  as  a  certain 
sign ;  or  when  it  is  absent  and  the  other  symptoms  are 
present,  in  excluding  a  diagnosis  of  posterior  sclerosis. 
It  can  not  have  the  diagnostic  significance  claimed  for  it, 
when  it  may  be  observed  in  indubitably  healthy  states  of 
the  cord,  and  when  the  reverse  condition  of  exaggerated 
excitability  may  undoubtedly  be  found  in  cases  of  unques- 
tionable posterior  spinal  sclerosis. 


Art     IV.— Aphasia    and    Agraphia    with 
Progressive    Improvement. 


By  D.  v.  Dean,  M.  D., 

SUPERINTENDENT   OF   THE    SAINT    LOUIS  CITY    HOSPITAL. 

T^    K.   R ,    aged    fifty  years,  native  of  New    York, 

^-^  •  resident  of  St.  Louis,  single  (?),  comedian,  medium- 
sized  man  with  pretty  good  physique  and  well  formed 
head,  right-handed.  No  history  of  syphilis  obtainable, 
and  family  and  personal  history  otherwise  good — so  far  as 
can  l)e  learned  from  patient  or  his  acquaintance.  While 
acting  a  part  in  which  he  was  well  up,  at  the  Globe 
Theatre,  patient  suddenly  lost  all  command  of  speech, 
though  his  part  still  remained  clear.  A  few  da}'s  after- 
ward— Feb.  13,  1879 — he  was  brought  to  this  hospital. 
At  the  time  of  admission,  patient  appeared  to  be  in  fair 
health,  though  somewhat  anaemic.  No  hemiplegia,  right 
or  left.  What  at  first  might  be  taken,  while  his  features 
were  at  rest,  for  a  slight  paretic  condition  of  the  right 
oral  muscles,  appeared  to  be  an  acquired  peculiarity — 
patient  evidently  being  accustomed  to  assuming  dignified 
and  deliberate  attitudes,  and  sober,  if  not  thoughtful,  looks, 
during  tlic  intervals  of  speech,  even  when  he  attempted 
the  jocose.  His  tactile  sensibility  and  scnsibilit)'  to 
temperature,  and  his  sense  of  smell,  taste,  sight  and 
hearing  were  unimpaired.       The    half    dozen    words,    more 


Aphasia  and  Agraphia. 


or  less,  of  his  vocabulary,  he  articulated  without  awkward- 
ness and  distinctly.  His  gestures  were  usually  expressive ; 
his  dancing  somewhat  comic,  but  never  shambling.  No 
albuminuria,  no  heart-lesion,  no  atheromatous  feel  at  the 
radial  pulse.  Did  not  complain  of  pain  in  the  head,  and 
did  not  know  of  receiving  any  injurj^  of  the  head  from 
blows  or  in  other  ways.  Had  no  delusions.  He  could 
not  write ;  and  in  answer  to  almost  any  interrogation, 
he  would  reply:  "' Somebody  ;  yes,  si?';  here"  (gesturing 
toward  his  forehead)  "  gooei,  /rr;r,"  (toward  the  lower 
part  of  his  face  and  neck  vaguely,  and  shaking  his  head) 
" soxwQbody,  you  bet.''  While  he  did  not  seem  to  be 
ashamed  of  his  impairment,  like  some  aphasics,  he  appeared 
to  be  non-p!ussed,  and  not  simply  annoyed  and  vexed, 
like  one  who,  feeling,  without  success,  for  his  word,  can 
at  least  say,  "  pshaw  !  "  with  a  meaning  to  be  understood. 
Still,  he  would  strike  an  attitude,  as  if  that  furnished 
relief,  and  he  supposed  himself  made  clear  to  the  inquirer. 
If  asked  for  a  pen,  or  a  broom,  or  cup,  etc.,  he  would 
start  for  and  get  it  with  great  alacrity  and  ceremony, 
repeating  his  "  some^^cWr  "  and  the  like.  He  gained,  from 
day  to  day,  adding  to  his  repertoire  of  words,  "good 
7nan,  you,  you,  me,  this,  this "  (pointing  to  two  fingers, 
and  meaning  he  would  go  out  in  two  days)  ;  and,  by 
degrees,  he  came  to  write  his  own  name  and  mine  quite 
legibly.  At  his  own  request  he  was  discharged,  March 
24,    1879. 

May  20,  he  was  re-admitted,  and  he  remained  until 
June  3d.  During  this  sojourn  he  made  himself  familiar 
with  every  one  who  would  take  time  with  him,  and  when 
not  thus  occupied  or  with  work,  he  busied  himself  writing, 
on  slips  of  paper,  his  own  name  and  others,  with  business 
addresses,  etc.,  some  of  which  he  wrote  from  memory,  not 
having  them  before  him  to  copy — though,  after  once 
writing  a  name,  he  used  that  as  a  copy  or  improved  upon 
it — and  copying  two  or  three  notices.  Holding  up  four 
or  more  fingers  and  then  going  to  the  calender  to  shou' 
on  what  dav  of  the   week    the    fourth    or   other    day    from 


42  D.  V.  Dean, 


current  date  would  fall,  he  wuuUl  say :    "  Good  jnan !   this, 

this.'"    and    write,    "  McNann}'    and    R is  goinij  out 

next   Monday,   D.     K.     R .      Left    the    Millon    Jasper 

Company  in   Louisville     K.    Y.,    D.    V.    Dean,    H.   H.   Smit, 

Sam     Smit,    1).    K.     R ,"     etc.,    etc.       From    his    first 

admission  he  could  sing,  exceedingly  creditably,  several 
airs,  notably  the  Marseillaise,  which  he  carried  through 
with  a  single  syllable. 

To-day,  Nov.  23.  1879,  I  souglit  out  his  place  of 
employment  in  a  saloon,  and,  not  finding  him  in,  left  a 
note,  asking  him  to  call  and  see  me  at  the  hospital,  which 
he  did,  bringing  m)'  note.  He  brings  the  Grand  Opera 
House  hand-bill  for  Thanksgiving  week,  and  says :  "  Mary 
Anderson  very  fine,  sir,  finest  in  the  laud;  Hunchback 
very  fine,  sir ;  Meg  Merrides  (for  Merriles)  finest  in  the 
land."  Evadne  and  Tngomar  he  points  out  for  me  to 
read,  and  can  pronounce  after  me.  Remembering  my 
little  son,  he  pats  his  shoulder  and  sa\'s  to  the  child's 
mother:  "Finest  in  the  land,  sir."  He  is  as  sanguine  and 
anxious  about  his  speedy  recovery  as  he  was,  when  a 
patient,  about  being  well  enough  to  go  out  of  the  hospital 
in  two  or  three  days ;  and  every  now  and  then  he  says  : 
"  This  man,  Bedo  (Dr.  Bidaux)  says,  one,  two,  three 
weeks — I  hope  so,  anyicay."  Aphasia  he  pron()unces  after 
me  ;  and  my  explanation  ot  his  aihiicnt,  and  !i ow  he  ma}' 
improve,  and  that  he  may,  perhaps,  educate  a  right  speech 
centre,  etc.,  he  seems  not  only  full\'  to  understand,  but  to 
be  delighted  with,  as  it  appears  to  be  the  first  ray  of  real 
light  that  has  been  let  into  his  consciousness,  concerning 
his  condition  ;  and  he  seems  to  enjoy,  very  much,  the  idea 
of  left-handedness  and  right  speech  center,  etc.,  etc., 
patting  alternately  his  right  temple  and  left  arm,  and  left 
temple  and  right  arm,  saying,  antithetically:  "liere,  here ; 
here,  here."  His  vocabulary  is  }-et  very  limited;  his 
expressions  arc  incoherent,  except  such  as  he  has  practiced, 
and  they  come  in  much  too  often ;  but,  at  the  present 
rate,  he  bids  fair  to  go  on  to  such  a  measure  of  recovery, 
at  least,  as  will  enable  him  to  take  care    of  himself.       To- 


v4phasia  and  Agraphia.  43 


day  he  distrusted  his  ability  to  sing,  but  just  a  start  from 
the  piano  and  he  is  as  ready  with  the  Marseillaise  as  of 
old.      Says  he  has  never  had  syphilis. 

The  case  is  of  especial  interest  because  of  the  absence 
of  hemiplegia,  right  or  even  left,  from  the  beginning,  the 
absence  of  mental  aberration  also,  from  the  beginning — 
and,  therefore,  as  a  case  of  aphasia  and  agraphia,  pure 
and  simple — and  because  of  the  marked  and  continually 
progressive  improvement  in  ability  to  read  and  write;  and 
because  this  improvement,  taken  in  connection  with  the 
fact  that  the  patient  was  a  comic  actor,  suggests  the 
probability  that  the  opposite  speech  center  was  active  and 
is,  therefore,  more  susceptible  to  education  than  would 
ordinarily  be  the  case  in  a  man  of  his  age,  and  the  like- 
lihood of  a  useful  re-acquisition  of  speech  as  compared 
with  what  might  be  effected  from  the  left  center  after  so 
chronic  impairment. 

The  patient  promises  to  visit  me  from  time  to  time, 
that  I  may  be  advised   of  his  progress. 


Art.  V— "Studies  on  Cerebral  Thermom 
etry  in  the  Insane. 


By  Di's.  D.  JMaragliano  and  Z.  Scpelli. 


Translated  from  tlie  Italian   of  Kevista  Sperimeiitale  di  Frenotiia  e  di 
Medicina  Leijule. 


Bv  Joseph  Workman,  M.  D. 


LATE  SUPERINTENDENT  AND   PHYSICIAN   OF   THE   TORONTO,   CANADA,    ASYLUM 
FOR  THE  INSANE,  AND  PRESIDENT  OF  THE  TOKONTO  MEDICAL  SOCIETY. 


\  MOXG  the  modern  means  of  clinical  in\'estigation 
■^^  availed  of  for  better  appreciating  the  existence  and 
nature  of  diverse  morbid  processes,  examination  of  tem- 
perature is  certainly  one  of  the  most  valid  and  important, 
as  has  been  placed,  beyond  doubt,  by  the  labors  of 
Wundcrlich,  Lieberuicister  and  many  others.  But  until  the 
last  few  years  both  the  practical  and  the  clinical  observa- 
tions were  limited  to  the  study  of  the  general  temperature 
of  the  body  ordinarily  taken  in  the  axilla  or  rectum.  It 
is  only  recently,  whether  from  scientific  curiosity  or  for 
the  discovery  of  new  criteria  of  diagnosis,  that  the  study 
of  local    temperature    has    had  its  origin  and  development. 


•rhe  Kfciit  v:ilii«'  of  this  work  of  Drs.  Marasliiino  ,in(l  Seiielli,  aiul  (he  fact  that 
siinicipnt  prominence  has  not  eUewhere  been  given  it  in  this  coiintr>-,  is  our  juntilicaiioii 
f<ir  |>lacing  it  iiromincntlj  among  our  orig-nal  contril)Ution3— [Ko. 


Cerebral  Thermometry  45 

Thus  Coiity  has  studied  the  oscillations  which  the  palmar 
temperature  undergoes,  as  well  in  the  state  of  health  as 
in  that  of  disease,  and  he  has  reported  the  relations 
between  these  and  those  of  the  axillae.  More  recently, 
Pctej'  has  made  known  the  result  of  a  long  series  of 
researches  undertaken  by  him,  on  the  temperature  of  the 
thoracic  wall,  in  pleuritis  and  phthisis,  deducing  therefrom 
important  corollaries  for  the  diagnosis  of  these  maladies. 
In  this  relation,  the  studies  of  Duval,  Landrieiix,  Charteris, 
NegscJiaidcr  and  Concato,  and  those  most  recent  of  McAl- 
doiuie,  on  the  comparative  temperature  of  the  axillae  in 
pulmonary  affections. 

Other  observers  have  given  their  attention  to  the  tem- 
perature of  the  head.  First  among  these,  so  far  as  is 
knov\'n,  was  Albcrs,  of  Bonn,  who,  in  1 86 1,  with  this  view, 
completed  various  researches,  especially  among  the  insane. 
Next,  Lombard,  in  i86S,  studied  the  influence  which  active 
mental  exercise  induces  in  the  temperature  of  the  occipital 
region.  After  him,  Alvarenga,  studying  the  temperatures 
of  the  different  points  of  the  body  accessible  for  th  • 
application  of  the  thermometer,  occupied  himself  further 
in  that  of  the  head,  determining  its  general  mean. 

To  Broca,  however,  pertains  the  merit  of  first  having 
employed  on  the  head,  in  a  vigorous  and  rational  manner, 
thermometric  observations.  In  this  way  he  was  able  not 
only  to  establish  the  thermometric  means  of  the  heads  of 
the  sane,  and  the  variations  which,  through  functional  cere- 
bral activity,  they  undergo,  but  he  has  thus  succeeded  in 
furnishing  a  secure  criterion  for  the  diagnosis  of  cerebral 
embolism,  by  determining  that  part  of  the  brain,  which,  being 
deprived  of  sanguineous  irrigation,  gave  a  temperature  below 
that  of  the  other  regions.  This  fact  was  presently  confirmed 
in  three  cases  of  cerebral  embolism,  by  Professor  Marag- 
liano,  who  had  the  opportunity  of  observing  them. 

The  studies  of  cerebral  thermometry  undertaken  by 
P>roca,  were  repeated  on  a  large  scale  by  Gray,  of  Brook- 
lin,  who  did  not  limit  himself  merely  to  the  determination 
of  the  means,  in  the  sane.  but.     in  addition,  deduced  from 


46  Joseph  Workman, 


them  consequences,  which,  in  certain  cases,  might  be  of 
service  in  the  diagnosis  of  affections  of  the  brain.  Of  the 
results  at  which  these  different  authors  arrived,  in  their 
tliermomctric  observations,  we  shall  have  occasion  to  take 
special  notice  hereafter. 

Guided  by  these  researches,  and  yet  further  stimulated 
by  the  idea  that  to  mental  disorders  cerebral  alterations 
correspond,  and  more  especially  those  of  its  hydraulic 
system,  we  also  desired  to  undertake  a  series  of  observa- 
tions, availing  ourselves  of  the  rich  materials  presented  to 
us  in  the  lunatic  asylum  of  Rcggio,  with  the  view  of  learn- 
ing whether  the  various  forms  of  mental  alienation  present 
differences  in  the  cerebral  temperature,  alike  in  comparison 
of  the  indications  given  among  the  insane  and  the  sane. 
It  is,  indeed,  true  that  already  thermometric  observations 
have  been  executed  among  the  insane  by  Alters,  but  it 
appears  to  us  that  no  great  value  can  be  conceded  to 
these,  as  they  take  into  consideration  but  few  forms  of 
mental  alienation  (melancholia  and  dementia),  and,  besides, 
they  were  conducted  in  a  very  imperfect  way.  In  fact, 
both  as  regards  the  form  of  the  thermometer  employed, 
with  a  spherical  bulb,  and  the  points  of  application 
selected,  these  conditions  alone  sufficed  to  vitiate  the 
observations. 

In  our  researches  we  have  studied  to  place  ourselves 
in  better  and  identical  conditions,  from  which  the  results 
might  have  more  decisive  value.  For  this  purpose  we 
chose  the  summer  season,  as  that  in  which  the  calorific 
irradiation  of  the  body  is  less,  and  the  atmospheric  oscil- 
lations are  less  sensible.  Willi  the  same  view  we  have 
preferred  to  make  our  observations  between  the  hours  of 
noon  and  3  P.  M.,  taking  care  always  to  have  the  same 
surroundings.  Besides  this  we  always  took  the  precau- 
tion of  examining  the  patients  selected  some  hours  after 
meals. 

The  six  thermometers  used  by  us  are  of  small  dimen- 
sions, with  bulbs  little  and  elongated,  and  graduated  to 
the  centigrade  scale,  with  decimal  divisions.       Before  using 


Cerebral  Therjnonietry. 


them  their  exactitude  was  verified  by  comparison  with 
each  other,  and  with  a  standard  thermometer.  As  points 
of  appHcation  we  selected  the  same  as  were  indicated  by 
Broca,  that  is,  behind  the  external  orbital  epiphysis,  for 
the  frontal  region  ;  above  the  insertion  of  the  ear,  for  the 
temporal  region  ;  and  alongside  the  median  line,  for  the 
occipital  region.  The  thermometers,  for  better  isolation, 
were  covered  with  a  little  carded  cotton  wool,  and  were 
fi.xed  by  means  of  a  circular  bandage,  special  care  being 
taken  that  the  bulbs  were  not  pressed  against  the  surface 
of  the  cranium.  In  the  women  the  hairs  were  accurately 
divided,  so  that  the  elongated  bulb  of  the  thermometer 
might  come  into  close  contact  with  the  scalp.  The  dura- 
tion of  the  application  was  half  an  hour  for  each  patient. 
Application  was  made  in  the  axilla  and  the  rectum  in  im- 
mediate succession  to  those  on  the  head,  with  the  view  of 
avoiding  any  false  interpretation  of  the  latter;  because 
among  the  insane  a  febrile  state  may  sometimes  interpose, 
in  patients  examined,  and  the  augmented  temperature  of 
tlie  cranium  then  noted,  might  be  attributed  to  local 
influence,  whilst,  on  the  contrary,  it  was  but  a  manifesta- 
tion of  the  general  condition    of  the  system. 

We  have  deemed  it  necessary  to  explain  in  detail  the 
method  followed  by  us  in  our  observations,  in  order  that 
we  might  therein  have  a  guarantee  of  the  exactitude  of 
the  results  obtained,  and  that,  as  we  shall  say  further 
on,  this  explanation  might  furnish  a  reason  for  certain 
differences  which  we  were  obliged  to  note,  between  our 
results  and  those  of  Broca  and   Gray  in  the  same. 

As  subjects  of  examination,  we  selected  for  each  prin- 
cipal group  of  mental  diseases,  the  greatest  number  of 
typical  cases  we  were  able  to  collect,  as  those  most  dis- 
tant from  a  physiological  type,  distinguishing  further,  by 
the  states  of  depression  and  mental  weakness,  the  agitated 
patients  from  those  who  were  not  so.  The  total  number 
of  observations  made  by  us  was  115  ;  of  which  58  were 
on  men,  and  57  on  women.  In  some  cases  the  ther- 
mometric   examinations,   in  order  to  be   more  reliable,  were 


4S  Joseph  JVorkinafi, 


repeated.  From  all  th-e  figures  obtained,  which  would 
be  long  and  superfluous  here  to  report,  we  have  estab- 
lished for  each  form  and  for  each  region,  Dicans,  whicli 
we  present  in  the  three    following  tables. 

[Here  the  authors  introduce  three  tables,  which  tlic 
translator  refrains  from  reproducing,  believing  th.it  the 
summary  given  in  the  succeeding  paragraph  is  quite  suf- 
ficient.] 

The  evident  conclusion  is  that  the  mean  temperature 
of  the  head  reaches  its  maximum  in  furious  mania  {inaiiia 
conftirorc),  36.89;  and  in  a  progressively  decreasing  line,  in 
lypcinania  agitata,  36.81;  in  general  paresis  {paralisi 
progressiva),  36.63  ;  in  dementia  agitata,  36.45  ;  in  imbecility 
and  idiocy, -36.34 ;  in  mania,  without  fur\',  36.30;  in  simple 
lypemania,  36.17;  and  finally,  in  tranquil  dementia,  36.03. 
[Note  the  above  markings  are  from  the  centigrade  scale. 
The  easiest  way  of  turning  them  into  Fahrenheit,  is  to 
multiply  by  2 ;  deduct  one-tenth  the  product  and  then  add 
32".  Thus  36.89x2=73.78 — 1-10=66.40,  plus  32 -=98.40 
— pretty  near  the   normal^ 

This  same  order  is  found  exactly  maintained  through 
the  mean  of  the  entire  head  in  the  table  of  iK.'omen ;  in 
the  table  of  men  it  is  modified  somewhat,  as  tranquil 
dementia  in  them  appears  about  one-tenth  of  a  degree 
above  simple  lypemania. 

If,  now,  we  consider  the  complex  nieaii  of  the  separate 
regions,  frontal,  parietal  and  occipital,  we  shall  find  that 
the  various  forms  of  mental  alienation  hold,  in  relation  to 
it,  the  same  order  already  indicated  in  relation  to  the 
mean  of  the  entire  head,  with  this  sole  difference  that 
simple  mania  throughout  the  frontal  region  will  exceed  by 
only   four  one-hundreths  of  a  degree   imbecility   and  idiocy. 

Studying  then,  comparatively,  what  differences  the 
several  forms  of  alienation  present  in  regard  to  the  eleva- 
tions which  the  thermometric  scale  presents  in  the  three 
principal  regions  of  the  head,  it  results  that  the  lowest 
figures  are  constantly  furnished  by  the  occipital  lobes ; 
that  those  of  the  frontal  and    parietal    lobes    are    equal    in 


Cerebral  Thermoiyietry.  40 

dementia  agitata,  imbecility  and  idiocy;  that  the  tempera- 
ture of  the  frontal  regions  surpasses  that  of  the  parietal  in 
mania,  with  and  without  fury  in  simple  lypemania  and  in 
complex  dementia ;  whilst  in  progressive  paralysis  {paresis) 
and  lypemania  agitata,  the  temperature  of  the  parietal 
lobes  is  higher  than  that  of  the  frontal. 

As  regards  the  variations  of  temperature  of  the  three 
regions  of  each  half,  taken  in  their  ciiscviblc,  it  results 
that  with  exception  of  imbecility  and  idiocy,  in  which  it 
is  greater  on  the  right  side  by  about  one-tenth  of  a 
degree,  it  may  be  said  to  be  equal  in  all  the  other  forms. 
In  these,  indeed,  the  differences  between  the  two  sides 
are  so  trivial  (not,  at  the  most,  exceeding  the  four  one- 
hundreths  of  a  degree  in  simple  dementia),  that  we  do 
not  think  we  are  authorized  to  draw  from  them  any  serious 
well-founded  conclusions. 

It  is,  however,  to  be  observed  that  if  we  descend  more 
minutely  to  a  comparative  examination  between  the 
figures  furnished  by  the  two  sides  of  each  region,  we 
shall  no  longer  find  maintained  in  all  the  cases  that  equi- 
librium among  them,  which  the  fact  above  stated  might 
lead  us  to  suppose.  Instead  of  this  we  not  rarely  find, 
that  when  the  temperature  of  a  region  is  higher  than  that 
on  the  opposite  side,  the  temperatures  of  the  other  two 
regions,  or  that  of  only  one,  of  the  same  side,  or  of  the 
equivalent  one  of  the  opposite  side,  are  inferior  to  the 
first,  the  effect  of  which  would  be  an  equalizing  of  the 
mean  temperature  of  the  two  halves  of  the  head.  Thus 
it  is  seen  in  lypemania  agitata,  that  while  the  left  parietal 
region  is  superior  to  the  right  by  about  twenty  one-hun- 
dredths  of  a  degree,  the  other  two  regions,  frontal  and 
occipital,  taken  together,  are  on  the  contrary  inferior  b\' 
the  same  quantity  to  those  of  the  opposite  side.  Analo- 
gously, we  find  that,  in  dementia  agitata,  whilst  the  tem- 
perature of  each  side  of  the  frontal  region  remains  equal, 
that  of  the  left  parietal,  in  men,  exceeds  the  right  by  six 
one-hundredths  of  a  degree  (ii-ioo"  Fahr.),  whilst  the  in- 
verse fact  obtains  for  the  occipital  region;  in  women  the  right 


Joseph  IJ'orkmnn. 


parietal  and  the  left  occipital  regions  are  higher  than  the 
corresponding  parts  on  the  opposite  side  by  eight  one- 
hundredths  of  a  degree.  A  similar  fact,  although  not  in 
so  nett  a  manner,  is  verified  in  simple  mania  of  men, 
and  in  progressive  paralysis  and  simple  lypemania. 

We  have  said,  higher  up,  that  in  imbecility  and  idiocy 
the  mean  of  the  entire  right  half  stands  higher  than  that 
of  the  entire  left  half;  we  may  now  add  to  this,  that 
comparative  examination  of  the  corresponding  zones  of 
each  side,  as  well  in  men  as  in  women,  has  always 
shown  (with  exception  of  the  frontal  region  in  the  latter), 
a  difference  in  favor  of  the  right  side  ;  a  difference  which 
oscillates  between  0.06  and  0. 15. 

Without  desiring  to  be  too  hazardous,  and  to  draw 
from  these  records  any  corollaries  with  regard  to  the 
morbid  processes  which  underlie  insanit}-,  it  yet  appears 
to  us  that  they  harmonize  with  some  facts  alread\-  known, 
in  this  relation. 

We  have  pointed  out  that  the  most  elevated  mean 
temperature  of  the  cranium  was  obtained  in  lypemania 
agitata,  mania  furiosa,  or  progressive  paralysis.  Well 
then,  in  these  last  two  forms,  it  finds  its  region  in  that 
hyperremic  state,  which  has,  b}'  all  the  authors  who  have 
occupied  themselves  in  the  pathological  anatomy  of  the 
insane,  been  assigned  to  the  cortex  and  the  meninges, 
and  that  in  progressive  paralysis,  this  state  is  associated 
with   a  phlogosis  of  slow  process. 

As  regards  lypemania,  though  wishing  to  admit  with 
Voisifi,  FothcrgilL  and  others,  that  at  the  base  of  this  form 
there  may  be  an  anaemic  .state  of  the  brain,  it  is,  however, 
probable  that  in  the  variety  agitata,  there  may  exist, 
instead,  a  congestive  state,  as,  besides  our  results  and  the 
similarity  of  the  symptoms  which  are  exhibited  in  lypema- 
nia agitata  and  maniacal  excitement,  the  opthalmoscopic 
discoveries  made  by  Monti,  consi.sting  in  papillary  and 
peripapillary  hypenemia,  would  seem  to  demonstrate. 

Besides  the  consideration  of  this  hypentmic  element,  it 
is   natural  to  think  that   with  any  mensuration  of  the  tern- 


Cerebral  Thermometry . 


perature  of  the  head,  there  concurs,  also,  an  augmented 
functional  activity  of  the  brain,  through  the  greater  vivacity 
of  the  chemical  molecular  processes  which  it  induces  in 
the  nervous  elements.  We  know,  in  fact,  from  the  experi- 
mental studies  of  ScJiiff,  that  when  the  cerebral  organ 
exercises  its  functions,  it  gives  place  to  the  development 
of  heat.  And  it  is  also  known  that  the  blood  which 
comes  from  the  cerebral  sinuses  through  the  jugular  veins 
is  warmer  than  that  which  passes  to  the  brain  through  the 
carotid  artery,  especially  when  the  functions  of  the  brain 
are  excited.  That  a  state  of  mental  exaltation  influences 
the  amount  of  the  temperature  of  the  head,  has  been 
demonstrated  to  us  by  the  results  obtained  in  five  women, 
comparatively  examined  in  periods  of  agitation  and  perfect 
calm,  when,  as  shown  in  our  tables,  there  existed  a  notable 
difference  between  the  two  periods  ;  a  difference  oscillating 
between  a  minimum  of  0.58  and  a  maximum  of  i.ic. 
This  fact,  first  established  by  Alters,  has  been  confirmed 
by  Broca  and  Gray,  who  found  an  augmentation  of  tem- 
perature following  mental  labor. 

In  dementia  agitata  the  mean  temperature  of  the  whole 
head  gave  us  a  figure  some  tenths  of  a  degree  above  the 
normal  (of  the  head),  say  36.10  (96.98  F.).  In  imbecility, 
idiocy  and  simple  mania,  our  records  have  shown  figures 
a  little  above  the  normal  (0.26 — 0.20).  As  to  simple 
mania,  we  need  not  enlarge  on  the  consideration  as  to 
how  the  same  conditions  submitted  by  us  in  explanation 
of  the  augmented  temperature  in  mania  \\\\S\  fury,  but 
having  place  in  a  minor  degree  in  simple  mania,  should 
present  different  results  in  these  two  forms  of  insanity. 
It  is  not  so  easy  to  explain  the  results  obtained  in  imbe- 
cility and  idiocy,  unless  we  take  into  account  the  circum- 
stance that  several  of  the  patients  examined  by  us  had 
recently  been  in  an  excited  state,  which,  as  wc  have 
•observed  in  every  form  of  exaltation,  is  usually  attended 
with  increased  temperature  of  the  head. 

The  following  table  showing  the  ''differential  tempera- 
tures in  states  of  agitation    anei    ealin,''    is    here  presented. 


52 


Joseph  Workwnn, 


and  as  the  figures  may  be  of  interest  to  some  of  the 
readers  of  the  Alienist  and  Neurologist,  we  venture  to 
reproduce  them : 

TABLE  D. 

Differential  Temperature  in  states  of  Agitation  and  Calm. 
(IX  FIVE  FKMALE  LUNATICS.) 


Frontal  Region. 

Parietal  Region. 

Occipital  Reg'u. 

Half  of  Head. 

Mean   of 

tiiiire 

Left. 

Right. 

Left. 

Right. 

Left. 

Right. 

Left. 

Right. 

Head. 

i 

i 

II 

^1 

•-r  _. 

5?- 

11 

< 

|5 

'^1 

7,~' 

x'tc 

< 

ia 

II 
< 

I||s 

MP 
-^1 

11 

< 

li 

Cm    S 

a? '5; 

< 

11 

a:  ti. 

< 

7..  C. 

.37.3 

^3.6 

36.9 

.36.-5 

37.0 

36. .1 

.37.3 

36.6 

36.9 

36.2 

1 

.36.8  36.3 

1 

37.06 

.36.43 

37.00 

36.14 

37.03 

36.45 

Z.M. 

... 

».. 

.37.4 

36.1 

36.9 

36.0 

37.1 

36.1 

36.8 

3.->.8 

34.8 

35.6 

37.00 

35.96 

37.10 

35.93 

37.00 

&5.95 

s.  M. 

37.1 

36.2 

37.0 

36.3 

37.1 

36.2 

36.9 

37.1 

36.2 

37.1 

.36.0 

.37.10 

36.03 

.37.00 

.36.13 

37.00 

36. OS 

1 
I'.  V.  37.4 

.36.7 

.... 

36.5 

37.3 

36.8 

.37.1 

36.7 

37.3 

36..5 

37.1 

36.2 

37. .30 

36.46 

37.10 

36.46!.37.20 

.36.. 51! 

1 
(  .  \.  37.0 

.36.3 

37.1 

.36.2 

.37.3 

36.0 

.37.2 

36  0 

.37.1 

3.5.8 

r..„ 

3.5.8 

37.13 

3(!.03 

.37.10 

3f. 00  .37.11 

3<;.ni 

It  is  not  less  difficult  to  explain  the  results  furnished 
by  simple  lypemania,  as,  accepting  the  hypothesis  that 
this  form  is  connected  with  a  state  of  cerebral  anaemia,  it 
should  be  a  natural  consequence,  that  a  lower  tempera- 
ture than  that  obtained  by  us  would  be  presented.  Hav- 
ing, on  the  contrary,  found  a  temperature  almost  equal  to 
that  of  the  sane  person,  we  may  perhaps  assume  that  the 
mental  activity,  persistent  in  l}'pemania,  though  not  always 
exhibited,  may  give  origin  to  a  local  development  of  heat 
sufficient  to  raise  the  temperature  of  the  head  to  a  degree 
equal  to  the  normal.  In  confirmation  of  this  hypothesis, 
the  fact  may  be  stated,  that  whilst  the  temperature  of 
the  body,  taken  in  the  axilla,  gives  a  figure  a  little  below 
the  normal,  we  find  equal  to  the  normal,  or  but  a  little 
under  it,  that  of  the    head,    which    ought    to    be    inferior, 


Cr.rehral  Thermometry. 


since  between  the  two  localities  there  should  have  been 
maintained  that  relation  which  exists  in  physiological 
conditions. 

It  remains  now  to  us  to  consider  the  figures  furnished 
by  simple  dementia,  which  we  have  found  lower  than 
those  of  the  sane.  This  result  corresponds  to  the  fact 
of  the  trivial  or  no  activity  of  the  brain  in  these  patients, 
allied  in  its  turn  to  that  state  of  atrophy  of  the  cortical 
substance  which  i.s  the  ordinary  anatomical  discover}-  in 
dementia. 

We  deem  it  now  not  unprofitable  to  enquire  wherein 
our  results  differ  from  those  obtained  by  Broca  and  Gray. 
Broca,  experimenting  on  twelve  sane  persons  in  equal 
conditions,  obtained  as  .the  mean  temperature  of  the  right 
half  of  the  head,   33.90;  of  the   left    half,  a  little  above   34, 


and  of  the  whole  head, 


.82  ;   oscillating  between  a  max- 


imum of  34.85  and  a  minimum  of  32.80  ;  the  brain  being 
in  a  state  of  repose.  During  its  functional  activity  the 
two  halves  tend  to  equalize,  the  temperature  of  the  whole 
head  rising  about  half  a  degree.  In  the  different  lobes 
the  means  would,  according  to  Broca,  be  represented  by 
35.28  for  the  frontal ;  33.72  for  the  temporal,  and  32.92 
tor  the  occipital. 

Gray,  in  his  recent  rearches,  made  on  112  persons 
i ninety-two  students  and  ten  doctors,  of  different  ages, 
from  eighteen  to  fifty-one  years),  arrived  at  almost  identi- 
cal results,  which  are  represented  by  the  following  figures  : 


Frontal    Region. 

Parietal  Region. 

Occipital  Reg'n. 

Half  of  Head. 

Mean    of 
whole 

Left. 

Right. 

Left. 

Right. 

Left. 

Right. 

Left. 

Eight. 

head. 

34. &4 

34.28 

34.68 

34.21 

3:5.70 

33.30 

34.35 

33.84 

34.16 

Comparing  now  the  results  above  shown  by  Broca  and 
Gray,  with  those  presented  in  our  tables,  our  attention  is 
suddenly  struck  by  the  great  difference  existing  between 
them.  We,  in  fact,  have  found  that  our  means  of  the 
head    exceed    theirs    by    2.3     degrees;     and    further,    that 


54  Joseph  Workman, 


between  the  diliferent  lobes,  and  especially  between  the 
occipital  and  frontal,  there  is  not  so  marked  a  difference, 
as  is  indicated  by  Broca  (2.5),  but  of  only  a  few  tenths 
a  degree.  Surprised  at  this  difference,  which  appeared  to 
us  too  great,  we  have  desired,  in  order  to  give  greater 
value  to  our  results,  to  execute  a  series  of  observations 
on  persons  of  sound  minds,  observing  the  same  condi- 
tions already  indicated  for   those  of  unsound  minds. 

The  figures  thus  obtained  by  us  from  twenty  persons, 
almost  of  the  same  age  and  culture,  are  certainly  higher 
than  those  given  by  Broca  and  Gray,  as  will  be  seen  by 
the  following  table : 


Frontal  Region 

Parietal  Region. 

Occi|.itaI  Reg'n. 

Halfofllea.l. 

Mean    of 

■     1 
Left.      1    Right. 

Ltft.      1     Rijrht. 

Left.          Right. 

Left.      Right. 

hea.l 

36.-i0    j       36.15 

SiJ.lS 

.36.1.1 

.3(5.01     1      3.5.95 

36.13       36.08  j      36.10 

In  face  of  the  means  obtained  by  us  for  the  different 
lobes,  and  for  the  two  halves  of  the  whole  head  in  sane 
men,  the  question  naturally  arises,  to  what  causes  must 
we  ascribe  their  excess  over   those  of  Broca  and  Gray  ? 

We  certainly  can  not  believe  this  difference  due  to 
any  error  in  our  method.  The  objection  which  was  made 
to  Gray  by  Dr.  Shazu,  one  of  the  members  of  the  Ameri- 
can Neurological  Association,  with  respect  to  cerebral 
thermometry',  that  pressure  made  on  the  bulb  of  the 
instrument  might  cause  a  notable  elevation  of  the  mer- 
cury, could  not  happen  to  us,  for  the  following  reasons  : 
In  the  first  place  we  took  great  care  that  the  bulbs  should 
not  be  too  much  pressed  on  the  wall  of  the  cranium ; 
and  in  the  next  place,  in  order  to  dissipate  all  doubt,  we 
tried  to  ascertain  how  much  the  column  of  mercury  in 
our  thermometers  might  be  raised  by  a  strong  pressure  on 
the  bulbs.  With  this  view,  we  had  recourse  to  a  double 
experiment.  First,  we  held  the  bulb  between  the  tips  of  the 
thumb  and  the  index  finger,  watching  till  the  column  had 
reached  its  maxium,    and    then,     after    pressure    with    full 


Cerebral  Thermometry.  55 

force,  had  fallen  back  and  become  stationary.  The  high- 
est elevation  thus  obtained  by  us  was  three-tenths  of  a 
degree.  In  the  next  place,  we  applied  a  tight  bandage 
around  the  bulb,  and  drew  it  so  strongly  as  to  exert 
great  pressure.  We  thus  obtained  an  elevation  of  one  or 
two-tenths  of  a  degree.  These  two  experiments  appeared 
to  us  sufficient  to  remove  all  doubt  as  to  the  elevation  of 
figures  obtained  by  us  being  attributable  to  pressure  on 
the  bulbs  of  our  thermometers,  since  the  verified  differences 
from  Broca  and  Gray,  were  not  merely  a  few  tenths,  but 
whole  figures.  Nor  can  we  believe  that  we  are  blameable 
for  having  used  layers  of  albumenous  covering  of  the 
thermometers,  by  means  of  which  they  were  well  isolated. 
It  is  well  known  how  indispensable,  in  thermometric  ex- 
aminations, it  is  to  impede  the  radiation  of  heat,  especially 
when  working  on  peripheral  parts;  and  a  proof  of  this 
was  a  fact  observed  by  us,  that  thermometers  applied  to 
the  cranium  without  being  isolated,  showed  six  or  seven- 
tenths  less  elevation  then  when  coated  with  albumen. 
And  still  we  must  add,  that  our  figures,  even  without 
isolation  of  the  thermometers,  were  higher  than  those  of 
Broca  and   Gray. 

It  is  here  gratifying  to  us  to  observe  that  Alvarcnga, 
the  illustrious  clinic  of  Lisbon,  in  his  researches  on  gen- 
eral clinical  thermometers,  studying  the  temperature  of 
diverse  parts  of  the  body,  both  with  the  bulb  covered 
with  cotton  and  naked,  had  obtained  results  almost  equal 
to  ours.  He,  in  fact,  found  in  the  first  case  that  the 
mean  temperature  of  the  head  was  36.05  (maximum,  37.2; 
minimum,  35.2);  and  in  the  second,  35.74,  (maximum, 
36.04 ;  minimum,  34.06).  To  what  circumstances  then  are 
the  different  results  obtained  by  us  to  be  ascribed  ? 

We  venture  the  opinion  that  the  locality  and  the  sur- 
rounding temperature,  in  which  we  made  our  observa- 
tions, may  give  us  the  explanation.  Our  experiments  were 
made  in  the  warmest  months  (June,  July  and  August),  in 
Avhich  the  temperature,  in  the  hours  chosen  by  us,  oscilla- 
ted between  24  and    27    degrees  ==(65.2    and    70.6  Fahr.). 


oG  Joseph  jroT'kinfin, 


It  is  not,  therefore,  improbable,  that  this  elevation  of  tem- 
perature tended  to  diminish  the  irradiation  of  caloric,  and 
thereby  to  render  more  exact  the  temperature  of  the 
head.  IVufidirlich,  alluding  to  the  various  precautions  to 
be  taken  in  thermometric  practice,  observes  that  in  obser- 
tions  made  in  summer,  it  may  be  useful  to  take  account 
of  the  surrounding  temperature.  Now,  if  such  an  obser- 
vance is  of  value  in  axillary  and  rectal  thermometry,  it 
must  be  still  more  so  in  relation  to  that  on  the  head. 
And  that  this  circumstance  really  had  a  notable  influ- 
ence on  the  results,  was  demonstrated  to  us  by  some 
observations  made,  for  curiosity,  on  a  few  persons  in 
December  of  last  year,  which  gave  us  figures  very 
analogous  to  those  of  Broca  and  Gray.  We  have,  there- 
fore, been  led  to  believe  that  these  two  authors  carried 
out  their  researches  in  a  season  when  the  external  tem- 
perature was  low.  In  fact.  Gray  having  made  his  observa- 
tions after  the  communication  made  by  Broca,  on  30th  of 
August,  1877,  and  having  announced  them  to  the  American 
Neurological  Society,  on  June  30th,  1878,  it  is  verj^  prob- 
able that  he  had,  in  part,  made  them  in  the  winter,  and, 
without  doubt,  at  a  time  not  the  warmest  of  the  year. 
These  final  considerations  have  much  practical  importance ; 
and  that  they  lessen  the  value  of  his  researches,  basing 
conclusions  on  the  means,  obtained  by  him,  Gray  himself 
confirms,  as  on  some  occasions  he  found  a  variation  in  the 
temperature  of  the  entire  head,  over  or  under  normal,  of 
2'  and  2  1-2'  Fahrenheit  (i  and  i  1-4  cent.)  This  fact 
would  constitute  a  certain  criterion  for  admission  of  a 
morbid  alteration  in  the  encephalon.  Such  a  conclusion, 
though  in  general  admissible  in  the  sense  that  a  tempera- 
ture of  the  head,  much  above  the  normal,  always  indicates 
a  morbid  state  of  the  organ  contained,  cannot  be 
accepted,  when  the  mean  a  gixcn  by  Gray  are  taken  as  our 
point  of  departure,  since,  as  we  have  seen,  the  cerebral 
temperature  varying  according  to  that  of  the  surrounding 
air,  and  the  method  of  the  application  of  the  thermometer, 
we  should  frequently  be  led  to  believe,  as  from  the  figures 


Cerebral  Therm ortt etry ,  67 

obtained  by  us  in  sane  persons,  that   an    abnormal    condi- 
tion,   which    was    totally    absent,    actually    existed.       Ver}- 
different  is  the  case  when  it  is  sought  to  establish  a  great 
difference,  higher  or  lower,  in  one  of  the  regions  or  in  an 
entire  half  of  the  head,  as  then  the  value  ascribed  by  Gray, 
as  a  means  of  diagnosis   cannot,  at  the  least,  be  recognized. 
And,   as  relates  to  the   results  of  Gray,  it  is  not  superfluous 
to  note  another  particularity  in  which  they  differ  from  ours. 
He  states  that  he    has    found    the   temperature  of  the    left 
parietal  region,  in  the  mean,  higher  than  that  of  the  frontal 
region  of  the  same  side,  and  he    assigns    this    fact    to    the 
greater  functional  activit}'  of  the  third  frontal    convolution, 
which  he  holds  to  correspond,  more  or  less,  exactly  to  the 
point    of    application    of  the    thermometer    on  the  parietal 
region.       This    assertion    of  Gray,  besides  being    in  opposi- 
tion   to    the     records    of    Broca,    is    unsupported    by    our 
obser\^ations,    which    have    not    shown    to    us    the    predom- 
inance of  the  parietal  over    the    left    frontal    region,    either 
in     the     sane     or     the     insane,     with     the     exception     of 
l)'pemania      (8     cases)     and    of     progressive     paralysis     (7 
cases),    in    which    latter    both    the    parietal    regions    were 
higher   in    temperature    than    the    frontal,    but    the     right 
higher      than     the     left.        Furthermore     the     explanations 
given  by  him  do    not    appear    to     us    very    tenable,   since, 
having    selected    as    his    parietal    station    the    same  point 
as  that  used  by  Broca   and    ourselves,    near    the    insertion 
of  the  ear,  which  does    not  lie  over,  nor  in  full    proximit}' 
to,    the    third    left    frontal    convolution,     as    Gray   believes, 
but    over  the  tempora-sphenoidal  lobe,  as  a  just   valuation 
of  cranio-cerebral  topography  demonstrates. 

{To  be   Contimtcd.) 


Art.  VI.— Two  Cases  of  Enucleation  of 
the  Eyeball,  followed  by  Immediate 
Relief  in  Important  rsiervous  Dis- 
eases. 


Bv  Geo.  T.  Stevens,  M.  D.,  Albany.  N.  Y. 


CASE    I. — Enucleation  of  an   eyeball,  followed  hy  imtncdiate  and    marked 

reduction  of  the  amount  oj  urine  panaad,  in  a  case  of 

diabetes  iusijddus. 

/^X  the  17th  of  September,  1877,  Mr.  S.  brought  to  me 
hi.s  daughter,  whose  case  had  been  referred  to  me  b\- 
Dr.  Smythe,  of  Minaville,  N.  Y. 

A.,  the  patient,  was  a  bright  and  interesting  girl, 
thirteen  years  of  age,  who  had,  five  )-ears  previous  to  the 
visit  to  me,  thrust  the  sharp  point  of  a  scissors  into  the 
right  eyeball,  penetrating  the  sclera  and  the    ciliary    body. 

Intense  inflammation  followed  the  injury,  but  under  the 
care  of  the  family  physician,  she  at  length  recovered  from 
the  inflammation,  preserving  mainly  the  form  of  the  globe, 
but  with  entire  loss  of  sight  of  the  injured  eye. 

There  was,  at  the  time  of  her  visit  to  me,  opacit)'  of 
the  lens,  and  the  pupiliary  border  of  the  iris  was  adherent 
to  the  capsule  ;  a  prominent  scar  at  the  outer  border  of 
the   cornea,  marked  the  location  of  the  injury. 

The  eyeball  was  somewhat  enlarged,  and  tender  upon 
pressure,  especially  over  the  ciliary    region. 


Enucleation,  of  the  Eyeball.  59 


It  was  the  condition  of  the  uninjured  eye  which  had 
led  the  father  to  consult  me. 

This  eye  had,  for  several  weeks,  been  painful  and 
extremely  sensitive  to  light ;  conditions  causing  much 
solicitude  on  the  part  of  her  friends.  I  found  the  eye 
quite  sensitive  to  pressure,  with  well-marked  pericorneal 
injection,  and  learned  that  she  was  annoyed  by  subjective 
sensations  of  light. 

Opthalmoscopic  examination  revealed  nothing  more 
than  hyperaemia  of  the  deep  structures. 

I  had  no  hesitation  in  informing  the  father  that  the 
child  was  suffering  from  a  sympathetic  irritation  of  the 
eye,  and  that  it  might,  at  any  time,  pass  to  sympathetic 
inflammation,  which  would  be  likely  to  prove  fatal  to  the 
sight  of  the  eye.  I  advised  that  no  time  be  lost  in 
removing  the  injured  organ,  as  it  was  the  only  safe 
course. 

My  advice  was  accepted,  and  on  the  following  day  the 
girl  presented  herself,  accompanied  by  an  elder  sister, 
when,  under  the  influence  of  anaesthetics,  the  injured  eye 
was  removed. 

The  case  progressed  favorably,  so  far  as  the  wound  of 
the  op -ration  was  concerned,  and  after  a  few  days  she 
was  allowed  to  return  home,  the  pain  and  irritability  of 
the  remaining  eye  having  been  greatly  diminished,  although 
not  altogether  relieved,  as  there  remained  considerable 
supraorbital  neuralgia  of  the  side  from  which  the  eye  had 
been  removed,  and  a  less  degree  on  the  other.  On  this 
account  she  was  advised  to  return  after  a  few  days. 

It  was  nearly  a  month  after  the  operation  when  the 
patient  did  return,  this  time  accompanied  by  her  mother  ; 
and  it  was  at  this  interview  that  I  first  learned  the  facts, 
which  gave  to  the  case  unusual  interest. 

From  the  mother  I  learned  that  the  girl  had  always, 
until  the  time  of  the  injury  to  the  eye,  been  a  vigorous 
and  healthy  child,  never  having  suffered  from  an)-  form  ot 
nervous  troubles.  After  the  injury,  however,  and  up  to 
the  time  of  the  operation,  she    had    suftered    many   violent 


60  Gen,  T.  Stevens. 


paroxysms    of  pain    in    the   stomach,    each    of    which    had 
prostrated  her  with  severe  illness  for  several  days. 

These  attacks  the  mother  called  inflammation  of  the 
stomach,  but,  from  her  description,  I  regarded  them  as 
attacks  of  violent  neuralgia  of  the  stomach.  She  had 
also  suffered  greatly  from  headaches — so  much  so,  as 
seriously  to  interfi;re  with  her  attendance  at  school,  from 
which  she  had  been  detained  the  greater  part  of  the 
time  since  the  injury. 

But  the  fact  of  greatest  interest  was,  that  during  four 
years  past  she  had  suffered  from  a  severe  form  of  diabetes 
insipidus,  which  had  run  a  very  uniform  course  during  all 
those  years. 

She  had,  habitually,  voided  the  urine  very  frequently 
during  the  day,  and  it  had  been  the  custom  of  the  mother 
or  the  elder  sister  to  rouse  her,  from  her  bed,  several  times 
every  night  for  this  purpose,  and  it  had  been  usual  for 
her  to  fill  an  ordinary  chamber-vessel  nightly.  Notwith- 
standing all  these  precautions  and  the  great  discharge  into 
the  vessel,  no  night  passed  when  the  bed  was  not  repeat- 
edly wet,  the  fluid  sometimes  penetrating  the  mattresses 
and  flooding  the  floor  beneath. 

On  the  night  after  the  removal  of  the  eyeball,  the 
sister,  not  wishing  to  disturb  the  patient,  made  the  best 
preparations  she  could  for  the  protection  of  the  bed,  and 
carefully  watched  her  during  the  night.  To  her  surprise, 
no  urine  was  passed  until  the  patient  rose  in  the  morning, 
and,  to  the  greater  surprise  of  both  sister  and  mother, 
there  had  been  no  involuntary  discharge  of  urine  from  the 
time  of  the  operation  to  the  time  of  the  mother's  visit  to 
me,  a  month  afterward. 

The  amount  of  urine  passed  during  the  day  was 
greatly  reduced  in  quantity,  and  although  she  was  still 
under  the  necessity  or  leaving  her  bed  once,  or  even,  at 
times,  twice  during  a  night,  usually,  yet  many  nights 
passed  when  she  was  not  subjected  even  to  this  inconve- 
nience. 

For  several    months     I     watched    the     case    with  great 


Enucleation  of  the  Eyehall. 


interest,  and,  with  the  exception  of  a  sHght  relapse  on 
one  or  two  occasions,  when  she  had  been  exposed  to 
fatigue  and  cold  in  coming  to  Albany  and  returning,  I 
was  assured  that  there  had  been  no  return  of  the  invol- 
untary discharges.  Not  only  this,  but  the  headaches 
were  much  relieved  and  the  pains  in  the  stomach  had 
entirely  disappeared. 

As  there  still  remained  some  supraorbital  pain,  espe- 
cially over  the  orbit  from  which  the  eye  had  been  removed, 
and  as  there  was  still  an  abnormal  secretion  of  urine,  I 
had  the  patient  return  to  Albany  for  a  week  or  two, 
during  which  Faradism  was  practised,  the  current  being 
passed  from  the  supraorbital  region  to  the  temple.  Under 
this  treatment  she  was  so  nearly  well  of  both  troubles, 
that  I  allowed  her  to  return  home.* 

There  the  supraorbital  pain  and  the  dysuria  returned 
in  about  the  same  degree  as  before  the  treatment  with 
the  battery.  As  her  friends  wished  her  to  remain  at 
home,  various  medicines  were  prescribed,  with  a  view  of 
arresting  the  pain  over  the  brows  and  of  checking  the 
renal  secretion,  but  I  am  not  aware  that  any  medicine 
had  the  slightest  effect  upon  either.  About  two  months 
ago — or  about  eight  months  after  the  removal  of  the  eye 
— the  frontal  pain  was  again  almost  as  intense  as  before 
the  operation,  and  involuntary  discharges  of  urine  returned, 
although  in  a  degree  scarcely  to  be  compared  to  the 
original  condition.  I  now  insisted  upon  the  parents  pro- 
curing a  battery,  and  administering  the  induced  current 
as  before.  No  sooner  was  this  done  then  the  two  trou- 
blesome conditions  yielded,  although  neither  has  ever  been 
fully  and  completely  subdued. 

The  painful  spot  is  a  surface  nearly  an  inch  square, 
over  the  inner  angle  of  the  eyebrow  of  the  right  side.     A 


*  As  the  existence  of  the  abnormal  secretion  ot  urine  was  net  snspecteii  by  me  at 
the  time  of  the  removal  of  the  eyeball,  of  course  no  examination  of  the  chaiacter  of 
the  fluid,  nor  any  measurement  ol  the  amount  evcauated  ilaily,  was  m:i(le. 

That  the  amount  was  enormous  seems  beyond  question,  trom  the  testimony  of  the 
patient  and  her  Iriends.  Specimens  examined  after  the  operation  exhibited  a  specifle 
^•avity  of  about  1.010,  afaintly  acid  reaction,   and  abaeuce  of  sug:ir  or  albumen. 


62  Geo  T.  Stevens. 


corresponding  point,  with  pain  of  much  less  intensity,  is 
over  the  other  eyebrow.  The  first  is  ahvays  tender  to 
the  touch,  and  the  other,  generally.  There  is  no  apparent 
thickening  of  the  tissues  at  either  of  these  points. 

There  seems,  unquestionably,  to  be  neuritis  wliich  is 
relieved  by  Faradism  ;  which  docs  not  yield  to  any  medi- 
cine yet  administered. 

We  have  in  this  case  the  phenomenon  of  an  obstinate 
and  dangerous  disease  of  distant  organs,  having  for  its 
exciting  cause  an  injury  to  the  ciliary  body,  almost  en- 
tirel}'  relieved  by  the  removal  of  the  eye,  but  continued 
in  a  modified  degree,  b}^  a  neuritis  of  some  of  the  branches 
of  the  ophthalmic  nerve  acting  as  a  secondary  center  of 
irritation  ;  the  distant  disease  relenting  when  there  is  less 
manifestation  of  neuritis,  and  renewing  its  manifestations 
when   the  s\  inptoms  of  neuritis  are   active. 

CASE  If. — Enucleation  oj  an  eyeball,  f Mowed  by  immediate   recovery,  in  a 
case  of  epileptiform  disease,  associated  with  diabetes  insipidus 

In  the  following  case,  although  the  nervous  disturbances 
were  of  less  duration,  they  were  of  more  formidable 
character. 

The  patient,  Charley,  son  of  W.  D.,  was  brought  to  me 
March  iith,  1878.  He  was  five  years  of  age,  pale  and 
delicate,  and  the  subject  of  a  very  prominent  total  staphy - 
lomia  of  the  right  eye. 

I  learned  from  the  parents  that  when  the  child  was 
ten  days  old,  he  had  severe  inflammation  of  the  eyes,  that 
the  lids  were  swollen,  and  that  much  luirulent  matter  was 
discharged  ;  that  the  left  eye  at  length  recovered  from  the 
disease,  but  that  the  right  e}'e  soon  began  to  protrude, 
and  that  in  the  course  of  a  few  months  it  assumed,  sub- 
stantially, its  present   form. 

This  was  doubtless  a  histor)'  of  ophthahiiia  neona- 
torum. 

At  the  time  of  the  examination  the  right  eye  pre- 
sented more  of  the  form  of  an  irregular  cylinder  than  of 
a  globe,  and  projected,  considerabh-,  in  front  of  the  eye- 
lids, which  it  prevented  fiom    closing.        It  was  on  account 


Enucleation  of  the  Ei/eball.  63 

of  this  great  deformity  that  the  child  had  been  brought 
to  me. 

I  learned,  in  respect  to  the  general  condition  of  the 
child,  that  from  early  infancy  he  had  been  in  a  teeble 
and  irritable  state,  and  that  very  slight  causes,  such  as 
trifling  exposures,  errors  in  diet,  or  changes  of  the  air  had, 
habitually,  brought  on  some  form  of  illness. 

For  more  than  a  year  past  he  had  been  subject  to 
convulsions,  occurring  with  varying  frequency,  from  once 
in  two  or  three  days  to  once  in  a  month.  The  latter 
interval  having  occurred  once  only,  while  on  the  other 
hand,  he  had  sometimes  had  three  or  four  convulsions  in 
a  week.  The  paroxysms  were  characterized  by  uncon- 
sciousness, rigid  contractions  of  the  muscles  of  the  body, 
firm  closure  of  the  jaws  ,  and  foam  at  the  lips,  with  a 
gradual  return  to  consciousness,  followed  by  a  day  of 
lassitude. 

In  brief,  it  can  scarceh"  be  doubted  that  these  were 
epileptic  fits.  Beside  the  fits,  the  child  had  been,  dur- 
ing about  the  same  time,  the  subject  of  a  urinary  trou- 
ble, which,  without  entering  into  details  beyond  the  simple 
facts  that  the  frequency  of  voiding  urine  was  such  that 
the  child  always  wore  a  napkin,  and  that  the  quantity 
was  so  great  that  this  was  scarcely  a  protection,  may 
safely  be  called  diabetes  insipidus.  It  may  also  be 
stated  that  examination  of  a  single  specimen  showed 
neither  sugar,  albumen,   nor  casts. 

The  diseased  eye  was  enucleated  on  the  day  of 
the  first  examination,  and  I  saw  the  child  a  icw  days 
later,  after  which  he  was  taken  to  his  home.  I  saw 
nothing  more  of  him  until  July  3d  of  this  year,  nearly 
sixteen  months  after  the  operation,  when  the  mother 
called  with  the  child  to  consult  in  regard  to  the  use  of  an 
artificial  eye.  The  mother  informed  me,  that  the  urinary 
secretions  from  the  day  of  the  operation  had  been  per- 
fectly normal,  and  that  the  child  had  never,  since  the  eye 
was  removed,  suffered  a  convulsion  ;  that,  whereas,  he  had 
been  habitually  ill,  and  very  often  under  medical  care,  he 


Geo.  T.  Stevenn, 


had  since  the  operation  been  in  perfect  health.  The 
nWiust  and  healthy  appearance  of  the  child  fully  corrob- 
orated the  good  report    of  the  mother. 

In  each  of  the  cases  above  related,  we  have  an  in- 
stance of  very  marked  relief  from  formidable  nervous 
disturbances,  following  immediately  upon  the  removal  of 
eyes,  in  which  the  ciliary  body  was  involved  in  a  cicatrix, 
and  it  seems  logical  to  attribute,  in  each  case,  the  nervous 
disturbance  to  irritation  of  the  ciliary  nerves;  but  if  irri- 
tation from  injury  of  the  ciliar\-  nerves  is  competent  to 
produce  so  great  disturbance  of  the  functit^ns  of  distant 
organs,  as  appears  in  these  cases,  it  seems  an  entireh- 
justifiable  conclusion,  that  irritation  of  these  same  nerves 
from  any  cause  may  be  productive  of  neurotic  disturb- 
ances of  various  forms,  and  without  regard  to  distance  or 
immediate  nervous  communication  ;  and  it  would  also 
seem  reasonable  to  suppose,  that  we  may  expect  to  relieve 
these  neuroses,  when  a  relation  between  the  two  classes 
of  conditions  is  found  to  exist,  by  such  measures  as  would 
be  calculated  to  relieve  the  ciliary  irritation. 

During  the  past  five  years,  I  have,  at  various  times, 
endeavored  to  call  the  attention  of  the  medical  profession 
to  relations  between  difficulties  and  derangements  attend- 
ing the  performance  of  the  functions  of  the  ciliary  nerves 
and  a  great  variety  of  nervous  phenomena.  In  so  doing, 
I  have  hoped  to  convince  the  profession,  that  these  rela- 
tion^  are  of  far  greater  frequency  and  consequence  than 
have   been   hitherto  conceded. 

My  own  experience  in  a  considerable  number  and 
variety  of  obstinate  and  obscure  neuroses,  which,  after 
resi.sting  all  ordinary  treatment,  have  easily  and  quickl\- 
yielded  to  measures  directed  to  the  relief  or  assistance  of 
the  ciliary  nerves  in  the  performance  of  their  functions, 
has  led  me  to  the  belief,  that  these  cases  have  an  impor- 
tant bearing  upon   that  principle. 


Art.  VIL— Subsequent  History  of  Twen- 
ty-five Persons  Reported  Recovered 
from  Insanity  in  1843. 


Bv  Pliny  Earle,  A.  M.,  M.  D., 

SUPERINTENDENT   OF     THE     STATE     LUNATIC     HOSPITAL,     AT   NORTH  AM  PTON , 
MASSACHUSETTS 

TN  an  examination,  a  few  months  ago,  of  a  reprint,  in 
.  1863,  of  the  thitherto  pubhshed  reports  of  the  Ilhnois 
Hospital  for  the  Insane,  I  met  a  table,  copied  from  the 
report  of  the  Worcester  Lunatic  Hospital  for  1844,  ^"<^^ 
re-published  in  connection  with  a  memorial  by  Miss  Dix, 
for  the  purpose  of  showing  the  remarkable  advantage, 
pecuniarily,  of  the  treatment  of  insanity  in  its  early  stages. 
It  presents  two  columns,  or  series  of  cases,  twenty-five 
in  each.  Those  in  the  first  column  were  chronic  and 
incurable ;  those  in  the  second  were  recent  and  had  been 
discharged — all  of  them  "recovered" — from  the  said  hospital 
in  the  course  of  the  official  year    covered    by    the    report. 

The  official  year  at  that  time  ended  with  the  30th  of 
November,  and  not,  as    now,    with  the   30th   of  September. 

While  studying  the  table,  it  occurred  to  me  that  it 
would  be  interesting  to  know  the  history,  subsequent  to 
their  discharge,  of  the  twenty-five  persons  who  recovered 
after  so  short  a  period  of  treatment,  and  at  so  trifling  an 
expense.  Such  was  the  inception  of  this  article,  and  this 
the  cause  for  the  selection  of  the  table  of  1843,  in  pre- 
ference to  either  of  its  predecessors.  The  first  table  of 
the  kind  was  published,  if  I  mistake  not,  in  the  Worces- 
ter report  for    1837-38.        The    practice    was    continued  for 


66 


Pliny  Earle, 


a  series  of  years,  and  was  adopted  at  various  other  insti- 
tutions of  the  kind.  Indeed,  the  report  for  1843,  which 
contains  the  table,  gives  the  result  of  similar  tables  at  the 
State  hospitals  of  Maine,  Ohio  and  Virginia.  The  table 
is  hero  introduced,  in  order  th^t  the  reader  ma}-  obtain  a 
clear  understanding  of  the  subject. 

••Tabi-K  showing  the  Cotnparative  Expense  of  Supporting  Old  and  Recent 
Cases  of  insaniiy.  from  which  we  learn  the  Economy  of  placing  paiients 
in  Institutions  in  early  periods  of  disease. 


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Average  e.\|)C!i3(>  of  old  cases    .  -  - 

Whole  exiieoHi' iif  25  old  cases         .  -  . 

Averajfe  exjieiise  of  recent  cases         -  • 

Wliole  e.Nijense  of  25  recent  cases  till  recovered 


i2.ii;i;  20 

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1,4(51  30 


Tlie  results  of  tills  table  are  so  strikiiiiy,  and  show  so  cincliisively  the  imi)or- 
laiice  of  early  admission  to  the  iiLsane  lio8|)it;il9,  that  many  other  institutions  have 
instituted  the  !<ameiiii|ulry  with  similar  results.  (See  Report  of  the  Worcester 
r.unatic  Hospital  for  1843.)" 

The  report  gives  no  intimation  that  this  was  not  the 
first  attack  of  some  of  the  patients ;  it  contains  no  asser- 
tion that  the     twenty-five     recent    cases    were  pcniianently 


Reported  Recoveries  froT)%  Insanity 


cured;  neither  does  it  allude  to  the  probabilit}',  or  the 
possibility,  that  any  one  of  the  persons  might  again  become 
insane ;  hence  the  almost  inevitable  impression  left  upon 
the  mind  of  the  general  reader,  by  a  perusal  of  the  table, 
would  be,  that  the  twenty-five  persons  whose  insanity  was 
recent  had  never  before  been  insane ;  and  that  now,  on 
the  first  attack  of  that  disease,  they  were  returned  to 
their  homes  and  to  society  fully  and  permanently  restored 
to  mental  soundness.  Indeed,  the  force  of  the  table 
depends  upon  the  assumption  that  they  were  permanently 
cured.  Furthermore,  coupled  with  this  impression  would 
be  the  inference  that,  if  the  twenty-five  persons  whose 
disease  was  chronic  had  been  taken  to  a  hospital  in  the 
early  stages  of  their  mental  unsoundness,  they,  too,  would 
have  been  cured.  Then  follows  the  practical  deduction  ; 
If  you  send  your  insane  friend  early  to  the  hospital,  his 
cure  will  cost  but  $58.45  ;  if  you  neglect  such  early  action, 
his  support,  while  insane,  will  cost  at  least  $1,461.30.  This 
deduction  was,  apparently,  the  whole  ostensible  object  of 
the  table. 

Taking,  then,  these  twenty-five  persons,  so  happily,  so 
quickly,  and  so  cheaply  withal,  redeemed,  by  restoration, 
from  one  of  the  greatest  ills  that  flesh  is  heir  to,  let  us, 
while  learning  something  of  their  antecedent  history,  go 
forth  with  them  from  the  hospital,  and  follow  them  to  the 
present  time,  if  they  still  are  living,  or  through  their  sub- 
sequent life,  if  that    life  be  ended. 

THE    TWEXTV-FIVE    RECENT    CASES    RECOVERED. 

No.  1,622. — This  was  a  man,  and  this  was  his  second 
attack  of  insanity,  but  his  first  admission  to  the  hospital. 
He  was  discharged  recovered,  as  in  the  table.  May  i,  1843. 
Within  about  three  weeks  after  the  table  was  made,*  and 
on  the  20th  December,  1843,  he  was  again  committed  to 
the    hospital.       He    remained     a    little    more    than    three 

•  It  is  assiimed  thai  the  table  was  m  ule  oa  the  1st  of  December,  because  the  official 
year  ended  with  the  30th  of  November.  It  could  not  have  beeu  made  before  the  St^th 
of  Xoveiuber,  because  two  of  the  patients  represented  In  it  were  discharged  on  that 
day.      Eight  of  the  others  were  discharged  in  the  course  of  that  month. 


Pliny  Earle, 


months,  and  was    again     discharged   recovered,  ]\Iarch   25th, 

1844. 

He  afterwards  married,  and  it  is  believed  he  has  never 
been  insane  since  he  left  the  liospital.  He  was  well,  and 
living  with  his  fainil)-,  one  year  ago,  as  he  probably  is 
now.  This  information  comes  from  one  of  his  friends, 
who  visited  him  in    1878. 

No.  1,624. — A  woman.  This  was  her  second  attack 
of  insanity,  the  first  one  having  occurred  two  years  before 
her  admission  to  the  hospital.  The  case  is  recorded  as 
periodical  and  suicidal.  She  was  discharged  recovered,  as 
in  the  table,  June  21,  1843.  An  informant  writes  me, 
September,  1879 — "She  is  living,  and  is  apparent!)-  in 
good  health.  I  was  not  able  to  find  out  whether  she 
ever  became  insane   again  or  not." 

No.  1.625. — A  man.  This  was  his  second  admission 
into  the  hospital.  He  was  admitted  the  first  time  in  July, 
1840.  He  remained  less  than  two  months,  and  was 
discharged  recovered,  Sept.  17,  1840.  He  was  discharged 
recovered  the  second  time,  as  in  the  table,  Sept.  25,  843. 
He  was  admitted  the  third  time.  Jan.  8,  185 1,  and  nearly 
eight  months  afterwards,  on  the  29th  of  Aug.,  1851,  dis- 
charged recovered  for  the  third  time. 

His  father  and  a  son  were  insane.  On  his  third 
admission,  his  case  is  recorded  as  "periodical,  once  in 
about  four  or  five  years."  Hence  it  appears  that  there 
mu.st  have  been  one  attack  between  the  last  two  admis- 
sions to  the  hospital. 

Since  the  foregoing  was  written,  I  have  learned  that  he 
had  another  attack  in  1859,  vvliich  lasted  nearl\-  a  year. 
He  was  not  taken  to  a  hospital,  but  was  cared  for  at 
home.  After  recovery  he  remained  well  until  1872,  when 
he  died  of  cholera  morbus. 

His  wife  and  the  son  above  mentioned,  were  patients 
at  the  Worcester  Hospital,  and    the  former  died  there. 

No.  1.635. — -^  man.  Insanity  is  hereditar\-  in  his 
family.  He  was  discharged  recovered,  as  in  the  table. 
Oct.    II,    1843.        He  still  lives    and  is  in  business.     One  of 


Upporiecl  B e cover ed  fnmv  Insanity 


his  relatives  states  that  he  "has  not  been  insane  since  he 
left  the  Worcester  Hospital;"  and  that  he  "is  somewhat 
eccentric,  but  in   no  wise  insane." 

No.  1,642. — A  man.  The  case  is  recorded  as  heredi- 
tary and  suicidal.  Discharged  recovered,  as  in  the  table, 
June  21,  1843.  He  was  admitted  again  Xo\'.  19.  i844> 
and  discharged  recovered,  the  second  time,  Feb.  18,  1845. 
He  was  admitted  the  third  time,  July  14,  1856,  and  died 
within  less  than  thirty-six  hours  afterwards. 

On  his  last  admission,  it  is  recorded  that  a  sister  and 
a  brother  were  insane,  and  that  his  son  "hung  himself 
one  year    ago." 

No.  1,643. — -'^  woman.  Her  father  was  insane,  and 
she  had  had  tivo  previous  attacks  of  insanity,  "some 
twenty  years  ago,  in  two  successive  Springs."  After  a 
residence  of  a  little  more  than  three  months  in  the  hospital, 
she  was  discharged  recovered,  as  in  the  table,  July  i,  1843- 

Her  subsequent  history  is  related  to  me  in  dialogue 
form,  by  a  correspondent  who  received  it  in  conversation 
with  one  of  the  nearest  relatives  of  the  woman,  and  a 
member  of  her  family. 

Question. — "Was  she  cured   at  the  hospital?" 

Aimver. — "Oh,  no!  She  was  just  the  same  as  she 
had  previously  been;  very  despondent  most  of  the  time; 
and  she  was  constant!)-  watched, — not  that  we  feared  her 
doing  harm  to  others,   but  that  she  might  harm  herself." 

Q. — There  was  no  change,  after  her  going  to  the 
hospital,  in  her  condition  from  what  it  had  been  previ- 
ously?" 

A. — "Oh,  no.  She  continued  the  same  until  her 
death,  in    1854." 

Q. — What  was  the  cause   of  her  death?" 

A. — "She  was  run  over  by  the  cars.  Most  people 
thought  it  might  have  been  b}-  accident,  but  we  could 
'not  tell." 

No.  1,645. — -^  woman.  This  was  her  third  admission 
to  the  hospital,  and  she  was  admitted  four  times  after- 
wards.      Her  record  is,  as  follows  : — 


Pliny  Earle, 


First  admission,  Aug.  2,  1838;  discharged  recovered, 
Jan.    10,    1839. 

Second  admission,  April  26,  1840;  discharged  rrcc^e'^nv/, 
Nov.  6,   1840. 

Third  admission,  April  29,  1843;  discharged  recovered, 
as  in  the  table,  Nov.    i,   1843. 

Fourth  admission.  May  31,  1845;  discharged  recovered, 
June  23,    1846. 

Fifth  admission,  Jan  25,  1849;  discharged  recovered. 
May  8,   1851. 

Sixth  admission,  Nov.  6,  1855;  discharged  recovered. 
May    13,    1856. 

Seventh  admission,  Jan.  12,  1857;  died  at  the  hospital 
of  "old  age,"  April  22,    1857. 

It  is  recorded,  on  her  second  admission,  that  Ium- 
insanity  was  hereditary  and  periodical ;  and,  on  her  fifth 
admission,  that  two  of  her  brothers  and  one  sister  were 
insane. 

No.  1,649. — ^"^  man.  Admitted,  May  10,  1843;  dis- 
charged recovered,  as  in  the  table,  Nov.  17,  1843.  '^" 
informant  writes  that  he  is  now  living  and  well ;  and  that 
he  "has  shown  no  signs  of  his  previous  trouble  for  a 
number  of  yearsy  As  it  is  nearly  thirty-six  years  since 
he  left  the  hospital,  this  language  would  seem  to  impl\- 
that  he  has  shown  signs  of  the  disorder  since  the  time  of 
discharge. 

No.  1,650. — A  woman.  Admitted,  May  11,  1843; 
discharged  recovered,  as  in  the  table,  Sept.  12,  1843.  She  is 
still  living,  and  "has  never  shown  any  symptoms  of  insan- 
ity since  she  left  the  hospital." 

No.  1,658. — A  married  woman,  whose  mother  was 
insane.  She  was  admitted.  May  22,  1843,  and  discharged 
recovered,  as  in  the  table,  July  27,  1843.  I"  'ibout  two 
weeks  after  the  table  was  made,  and  on  the  13th  of 
December,  1843,  she  was  again  committed  to  the  hospital- 
She  was  discharged  recovered,  the  second  time,  March  15, 
1844. 

Since  she  left  the  hospital    she    has  had  two  attacks  of 


Reported  Recoveries frmjv  Insaniiy.  71 

insanity,  one  of  them  following  childbirth;  but  they  were 
not  severe  nor  of  long  duration,  and  she  was  not  taken 
to  a  hospital.  She  is  now  living  and  well,  the  mother  of 
twelve  children,  ten  of  whom  are  living. 

No.  1, 660. — rS.  woman.  She  had  one  previous  attack  of 
insanity;  and  in  the  table  on  page  twenty-three  of  the 
Worcester  report  for  1843,  her  case  is  recorded  as  period- 
ical. Her  mother  and  sister  were  insane.  She  was 
discharged  recovered,  as  in  the  table,  Aug.  23,  1843.  One 
of  her  nearest  relatives  states,  that  "after  her  discharge 
from  the  hospital,  in  1843,  she  remained  well  a  few 
months,  when  she  again  became  insane,  was  recommitted, 
and  again  discharged.  In  1846  she  was  again  placed  in 
a  hospital  and  again  discharged,  and  zvas  never  ivell  but  a 
fciv  montJis  at  a  time.  She  died  in  1849,  aged  about 
twenty-eight  years."  It  is  said  that  she  died  of  scrofula. 
Her  commitment  in  1846  was  to  the  Worcester  Hospital, 
from  which,  after  a  residence  of  thirty-seven  days,  she 
^\■as  discharged  recovered. 

No.  1,661. — A  young  woman,  whose  insanity  is  re- 
corded as  hereditary.  She  was  admitted,  May  24,  1843, 
and  discharged  recovered,  as  in  the  table,  Nov.  7,  1843. 
She  was  admitted  again  May  10,  1847,  and  discharged 
recovered,  the  second  time,  Sept.  30,  1847.  Admitted  the 
third  time,  Dec.  3,  1S49.  and  discharged  recovered,  the 
third  time,   March  20,    1850. 

I  am  informed  that  she  "  again  became  insane,  and 
w  cnt  to  the  hospital  in  New  Hampshire ;"  this  was  on  the 
14th  of  December,  1853.  She  was  removed  to  the 
McLean  Asylum.  Sept.  6,  1854,  "where  she  remained, 
insane,  until    her    death,    July    5,    1867.       Age,    44    years." 

No.  1,672. — A  man.  His  disease  is  recorded  as  period- 
ical, in  the  table  on'  page  24  of  the  Worcester  report  for 
1843.  He  was  admitted  June  10,  1843.  and  discharged 
recovered,  as  in  the  table,  Aug.  18,  1843.  He  is  now 
(1879)  in  the  almshouse  of  a  town,  the  officer  of 
which  writes  to  me,  as  follows  : — "  He  never  was  cured. 
He  is  a  foolish,  harmless  fellow.       He  was  taken  from  the 


Pit  ivy  Earle, 


hospital  (in  1843)  to  our  almshouse,  where  he  now  is,  in 
fair  health,  able  to  do  very  little  light  work ;  simple  and 
harmless  when  pleased,  but  ugly  when  crossed  very  much.  " 

No.  1,676. — A  woman.  This  was  her  ' tlvrd  attack  of 
insanity,  and  her  second  admission  to  the  hospital.  Ilcr 
first  admission  was  on  the  24th  of  Alay,  1842.  She  was 
discharged  iccovcnd,  July  4,  1842.  The  second  admission, 
as  in  the  table,  was  on  the  13th  of  June,  1843.  She  was 
dischargad  recovered,  Nov.  16,  1843.  I  am  informed  that 
she  "  remained  well,  after  her  return  from  the  hospital,  as 
long  as  she  lived,  which  was  not  many  years.  I  think 
she  died  about   1850." 

No.  1,688. — A  young  woman.  This  was  \\qx  fourtli 
admission  to  the  hospital.  Her  first  admission  was  on 
Aug.  20,  1836.  She  was  discharged  recovered,  Oct.  28, 
1836.  Her  second  admission  was  on  Jan.  19,  1839;  <^'-'^" 
charged  July  4,  1839.  Third  admission,  Aug.  7,  1840 ; 
discharged  recovered,  Nov.  25.  1840.  At  this  admission 
her  case  was  recorded  as  periodical.  Her  fourth  admis- 
sion was  on  June  30,  1843.  She  was  discharged,  as  in  the 
table,  recovered,  for  the  fourth  time,  Sept.  11,  1843.  On 
the  last  admission  it  is  stated  that  she  was  twenty-two 
years  of  age ;  consequently  she  could  have  been  but 
fifteen  at  the  time  of  her  first  admission.  After  her 
fourth  recovery  and  departure  from  the  hospital,  I  am 
informed  that  "  she  married,  went  West,  lived  with  her  hus- 
band some  years,  and   was  in  an  insane  asylum  out  there." 

Having  returned  to  Massachusetts,  she  was  admitteil 
into  the  Taunton  Lunatic  Hospital,  March  18,  1864,  and 
discharged  therefrom,  recovered,  Nov.  30,  1864.  She  was 
committed  to  the  Worcester  Hospital  for  the  fifth  time. 
Aug.  5,  1865,  and  nearl}'  two  years  afterwards,  on  the 
28th  of  June,  1867,  was  discharged  i:ot  improved.  She 
was  taken  directly  to  the  almshouse  of  the  town, 
which  supports  her,  and  there  she  still  remains.  "She 
works  in  the  family,  and  is  quiet,"  u  rites  \x\y  informant  ; 
"but  at  times  is  wild." 

No.    1,690. — A  young  woman.      Admitted,  July   5,  1843, 


Reported  Recoveries  from  Insanity. 


and  discharged  recovered,  as    in    the    table,    Oct.    21,    1843 

About  five  years  afterwards,  in  1848,  she  died  of  con- 
sumption, not  having  been  insane  after  she  left  the  hospital. 

No.  1,691. — A  woman.  Admitted  July  8,  1843,  and 
discharged  recovered,  as  in  the  table,  Oct.  16,  1843.  She 
died  on  the  second  anniversary  of  her  discharge,  Oct.  16, 
1875.  I  am  not  informed  whether  her  insanity  re-ap- 
peared.      Probably  it  did  not. 

No.  1,699. — A  man.  Admitted  July  20,  1843,  and 
discharged  recovered,  as  in  the  table,  Nov.  15,  1843.  Of 
his  subsequent  condition,  one  of  his  nearest  relatives  writes 
as  follows  : — "He  has  never  been  what  Vv"e  call  insane  sincp 
he  came  home ;  but  he  has  had  spells  of  nervous  excite- 
ment, when  he  would  not  sleep  well,  and  then  he  would 
be  full  of  his  talk,  and  very  nervous,  for  from  four  to  six 
weeks.  He  is  never  violent,  but  easily  excited  if  he  is 
opposed.  His  nervous  spells  are  generally  once  a  year, 
not  always,  and  then  in  cold  weather.  We  feel  anxious 
about  him,  fearing  he  may    be  insane." 

No.  1,705. — A  woman.  Admitted  July  25,  1843,  and 
discharged  recovered,  as  in  the  table,  Nov.  27,  1843 
She  was  admitted  the  second  time  July  5,  1848,  and 
discharged  recovered,  Dec.  5,  1848.  Admitted  the  third 
time  Dec.  27,  155 1,  and  discharged  recovered,  for  the 
the  third  time,  July  16,  1852.  On  the  19th  of  July,  1856, 
she  was  admitted  into  the  Taunton  Lunatic  Hospital, 
where  she  died  of  consumption  on  the  17th  of  October  of 
the  same  year. 

No.  1,706. — A  woman.  This  was  her  second  attack  of 
insanity,  the  first  having  occurred  in  1823.  She  was 
admitted  July  26,  1843,  and  discharged  recovered,  as  in 
the  table,  Sept.  26,  1843.  She  remained  sane  during  the 
rest  of  her  life,  and  died  Feb.   8,    1869,  aged  80  years. 

No.  1,709. — A  young  man.  Admitted  Aug.  7,  1843. 
The  record  on  admission  states  that  "he  has  had  previous 
attacks,"  and  that  "  he  has  a  brother  insane  now ;"  and 
in  the  table,  on  page  25  of  the  Worcester  report  for  1843, 
his  case  is  called  periodical.       He  was  discharged  recovered. 


Pliny  Earle, 


as  in  the  table,  Sept.  26,  1843.  Ten  days  afterwards, 
on  the  6th  of  October,  1843,  he  was  admitted  the  second 
time.  This  must  have  been  several  weeks  before  the  table 
was  finished,  because  the  official  year  did  "  not  end  until 
Nov.  30,  and  no  less  than  thirteen  of  the  other  patients 
referred  to  in  the  table  were  discharged  after  the  6th  of 
October. 

He  was  discharged  the  second  time,  improved,  Jan.  ii, 
1844.  The  records  of  this  admission  state  that  he 
"received  an  injury  on  the  head  many  years  since,  from 
which  he  never  entirely  recovered."  Although  discharged 
the  last  time  only  "  improved,"  he  afterwards  became  so 
well  that  he  married.  He  subsequently  left  New  England, 
and  died  somewhere  in  the  Middle  or  the  Southern 
States.  It  is  not  known  that  he  ever  had  another 
attack  of  insanity  after  he  left  the  hospital  ;  but  a  person 
who  knew  him  well  from  early  life,  while  he  remained  in 
New  England,  says  that  "he  was  alwa}'s  a  weak-minded 
man." 

No.  1,715. — -\  young  woman.  This  was  her  secoid 
admission  into  the  hospital  in  t8^j,  and  she  was  admitted 
three  times  afterwards ;  and,  on  this  admission,  the  case 
is  called  periodical,  in  the  table  on  page  25  of  the  report 
for  1843.  Her  record  is  as  follows:  First  admission, 
April  8,  1843;  discharged  improved,  June  12,  1843. 
Second  admission,  Aug.  16.  1853;  discharged  recovered, 
Nov.  28,  1843.  Third  admission,  Feb.  18,  1846;  dis- 
charged ircovered,  June  30,  1846.  Fourth  admission,  Nov. 
13,  1846;  discharged  recovered,  June  15,  1846.  Fifth 
Admission,  Oct.  19,  1847;  discharged  recovered,  July  12, 
1852. 

Her  last  term  of  residence  in  the  hospital,  as  will  be 
perceived,  was  more  than  four  years  and  eight  months- 
The  record  of  her  second  admission  says  that  she  "  has 
had  fits,"  and  that  her  "mind  (is)  not  sound  at  any  time." 
On  the  third  admission  it  is  recorded  that  the  case  is 
periodical,  and  that  "  for  three  weeks  past  (she)  has  had 
frequent  convulsive  fits  daily." 


Reported  Kecoveiies  from  Insanity  *  75 

The  case  is  as  interesting  as  it  is  remarkable.  Not- 
withstanding the  foregoing  history,  she  has  since  married, 
and  borne  two  children,  and  is  now  living  and  well. 

No.  1,716. — A  woman.  The  earliest  information  we 
have  of  her  is,  that  on  April  30,  1830,  at  the  age  of 
twenty-one  years,  she  was  admitted  in  the  McLean 
Asylum.  She  was  discharged  therefrom,  July  31,  1830, 
niitch  improved.  She  was  admitted  at  the  Worcester 
Hospital,  as  in  the  table,  Aug.  18,  1843.  The  records 
state  that  this  was  her  fourth  attack  of  insanity,  and  that 
each  attack  followed  childbirth.  She  was  discharged 
recovered,  Nov.   28,  1843. 

On  the  30th  of  April,  1849,  she  was  admitted  at  the 
Butler  Hospital,  Providence,  R.  I.,  where  she  remained 
more  than  seventeen  months.  She  was  removed  thence 
by  her  husband,  Oct.  8,  1850  ;  and  four  days  afterwards, 
on  the  1 2th  day  of  October,  1850,  she  was  admitted  the 
second  time  at  the  Worcester  Hospital.  The  records  of 
this  admission  contain  the  following  statements :  "Insane 
for  twent)'  years  ;  was  here  seven  years  ago ;  now  has  not 
worked  for  more  than  three  years."  She  died  at  the 
Worcester  Hospital,  of   consumption,   March  6,    185 1. 

No.  1,728. — A  woman.  Admitted,  Sept.  17,  843.  The 
records  state  that  she  had  had  "occasional  symptoms  of 
derangement  for  ten  years,"  and  that  the  disease  was 
hereditary.  She  was  discharged  recovered,  as  in  the  table, 
Nov.  23,  1843.  She  was  not  admitted  again;  but  I  have 
learned  through  her  relatives,  that  no  permanent  benefit 
was  derived  from  her  treatment  in  the  hospital.  Says  my 
informant :  "She  had  been  at  home  from  the  asylum  but 
very  few  days  before  she  was  as  bad  as  before  going." 
and  "her  mental  condition  remained  the  same  throughout 
life."        She  died  of  consumption,  Nov.  5,    1854. 

No.  1,737. — ^  woman.  Admitted,  Sept.  2^,  1843. 
Her  disease  is  recorded  as  hereditary,  and  she  had  a 
brother  in  the  Worcester  Hospital.  She  was  discharged, 
as  in  the  table,  recovered,  Nov.  22,    1843. 

She    is    still    living.        My    informant    writes    of   her    as 


Pliny  Earle, 


follows:  "She  was  and  is  a  Second-Advent  woman.  She 
believes  that  there  is  no  salvation  except  through  her 
creed,  and  in  so  far  is  a  monomaniac  in  religion ;  but  is 
right  in  all  other  respects,  and  is  in  excellent  health,  as 
she  has  been  always  since  her  discharge  from  the  hospital 
in    1843.'" 

And  so  we  come  to  the  end  of  the  table,  and,  essen- 
tially, to  the  end  of  the  force  of  it  as  an  argument. 
Time  and  history  sometimes  deal  rudely  with  the  most 
sanguine  hopes,  and  the  most  beautiful  devices  of  men. 
The  really  surprising  results  of  this  investigation  are 
suggestive  of  extended  comment,  but  they  must  be  dis- 
missed by  a  brief  reference  to  a  tew  points.     • 

1.  The  twenty-five  persons  were  discharged  recovered 
from  the  hospital  forty-eight  times,  contributing  forty-eight 
recoveries  to  the  statistics    of  insanity. 

2.  The  fi'/e  persons  who  died  in  the  hospitals  had  been 
discharged  recovered,  fifteen  times,  an  average  of  three 
recoveries  to  each   person. 

3.  Of  all  the  hitherto-published  representations  of  the 
curability  of  insanity,  the  most  unfavorable  is  that  of  the 
late  Dr.  Thurnam,  who  based  a  general  formula  upon  the 
actual  results  in  244  persons  (treated  at  the  York,  Eng- 
land,  Retreat),  whose  history  he  had  traced  until  death. 

"In  round  numbers,  then,"  says  he,  "of  ten  persons 
attacked  by  insanity,  five  recover,  and  five  die  sooner  or 
later  during  the  attack.  Of  the  five  who  recover,  not 
more  than  two  remain  well  during  the  rest  of  their  lives  ; 
the  other  three  sustain  subsequent  attacks,  during  which 
at  least  two  of  them  die." 

Let  us  compare  the  results  of  these  twenty-five  persons, 
recovered  at  the  Worcester  Hospital,  with  Dr.  Thurnam's 
formula.  According  to  the  latter  part  of  the  formula, 
two -fifths  of  the  persons  who  recover  should  never  have 
another  attack  ;  three-fifths  should  have  a  second  attack  ; 
and  two-thirds  of  that  three-fifths  should  die  insane. 
Therefore,  of  the  twenty-five   persons    recovered  : 

(n.\    Ten  should   never  have  a  second  attack. 


Reported  Recoveries  from  Insanity 


[b.)  Fifteen  should  have  a  second  attack,  and  perhaps 
more  ;   and 

(^.)  Of  these  fifteen,  ten  should  die  insane. 
But  we    find    that,    in    fact,    taking    the  twenty-five  per- 
sons at  the  time    of  their  first   recovery,    there    were,  under 
the  most  favorable   construction, 

(rt.)  Only  seven  who  did  not  have  a  second  attack;  and 
[b^  Eighteen  had  more  than  one  attack. 
(/■.)  As  so  many  are  still  living,  it  is  impossible  to  say 
what  will  be  the  final  result  in  regard  to  the  number  dying 
insane.  But  already  five  have  died  insane  at  the  hospi- 
tals, and  tiK.'o  have  died  insane  at  home,  making  a  total  of 
seven.  Two  others  are  at  almshouses,  both  having  for  a 
long  period  been  incurably  insane  (they  will  undoubtedly 
die  so),  and  one  has  died  at  home,  who  "was  never  well 
(sane)  but  a  few  months  at  a  time." 

It  is  no  exaggeration  of  the  unpleasant  aspect  of  these 
results  to  say  that  they  are  no  more  favorable  than  Dr. 
Thurnam's  formula  represents.  Their  near  approximation 
to  that  formula  is   somewhat  remarkable. 

4.  Can  our  statisticians,  philanthropists  and  statesmen 
longer  be  surprised  that  the  hospitals  do  not  put  a  stop 
to  the  increase  of  insanity  ? 

In  conclusion,  it  may  be  remarked,  that  the  table  it- 
self is  an  absurdity,  inasmuch  as  it  appears  to  be  based 
upon  the  assumption  that  the  twenty-five  "old"  cases, 
represented  in  the  left  hand  columns  of  it,  would  have 
been  cured  if  they  had  been  taken  to  the  hospital  in  the 
early  stages  of  the  disease.  There  is,  of  course,  no  evi- 
dence to  prove  that  even  one  of  them  would  have  recov- 
ered if  that  course  had  been  pursued.  In  the  language 
of  the  late  Sir  Coxe  :  "No  one  can  tell  what  would  have 
been  the  result  in  any  single  case,  if  it  had  been  in 
different  circumstances  from  those  in  which  it  was  actually 
placed."* 


•Luuacy  in  its  relation  to  the  State  (p.  33). 


Art.    VIII. — Syphilitic  Hypochondriasis. 


By  Allax  McLane  Hamilton,   M.  D. 


CONSULTING    NEUROLOGIST   TO  CITY    IDIOT    AND   INSANE   ASYLUMS;   VISITING 

PHYSICIAN    TO    HOSPITAL    FOR    EPILEPTICS   AND    PARALYTICS, 

NEW   YORK    CITY. 


"T^OWSE,*  in  his  work  upon  nervous  syphilis,  has  <ronc 
^^^  so  far  as  to  make  the  following  statement :  "I  believe 
that  most  of  the  ailments  with  muscular  and  trophic  dis- 
turbances, as  megrim  and  other  conditions,  which  are,  in 
many  cases,  vaguely  termed  hysteria,  merely  indicate  an 
unstable  condition  of  the  sympathetic  nervous  system,  in 
persons  who  are  essentially  the  offspring  of  syphilized 
progenitors."  This  assertion,  which,  perhaps,  is  just  the 
least  bit  too  sweeping,  is,  however,  suggestive  of  how 
extensively  syphilis  may  enter  into  the  production  of 
certain  vague,  imperfectly-understood  neuroses,  which  so 
often  try  the  patience  of  practitioners  of  medicine. 

As  a  notable  instance  of  this  connection,  I  ma}-  speak 
of  a  form  of  hypochondriasis,  observed  in  male  subjects, 
especially  in  those  persons  who  are  well  developed,  robust 
and  apparently  in  good  general  health — so  far  as  external 

•Uiseuoe  ol  the  Brain  (p.  4j). 


Syphilitc  Hypochondriasis.  .       79 

appearances  are  concerned.  Cases  such  as  this,  are  of  the 
most  discouraging  kind  and  rarely  remain  with  one  med- 
ical man  for  any  length  of  time,  but  go  the  rounds  until 
they  finally  fall  into  the  hands  of  quacks.  In  such  pa- 
tients, the  history  of  syphilis  is,  by  no  means,  invariably 
clear  or  easily  made  out,  and,  occasionally,  it  is  necessary 
to  go  back  ten  or  fifteen  years  to  find  that  there  have 
been  initial  symptoms.  In  some  cases  the  patient's  posi- 
tion in  society,  and  his  circumstances,  may  be  such  as  to 
often  throw  the  medical  man  off  his  guard  in  hunting  out 
the  cause.  For  example,  I  may  allude  to  the  case  of  a 
well  known  clergyman,  recently  under  my  professional 
care,  who  gave  the  history  of  a  train  of  symptoms  which 
were  decidedly  incongrous  and  eccentric.  He  was  sup- 
posed to  be  suffering  from  the  effects  of  overwork,  though 
in  no  way  did  he  show  any  indications  of  prostration  or 
enfeeblement.  I  ascertained,  with  much  difficulty,  that  over 
twenty  years  before,  while  at  college  he  had  contracted  a 
chancre,  followed  by  secondary  symptoms,  so  slight,  how- 
ever, as  to  make  but  little  impression  upon  his  mind.  He 
rapidly  regained  health,  under  specific  treatment  alone, 
his  subjective  symptoms  disappearing  rapidly. 

As  Dowse  suggests  there  is,  in  some  cases  a  much 
more  remote  cause,  and,  doubtless,  hereditary  syphilis 
may  account  for  the  development  of  a  more  striking 
collection  of  disorderly  symptoms.  In  all  cases  of  hypo- 
chondriasis, or  male  hysteria,  it,  therefore,  befits  the 
medical  man  to  search  carefully  for  traces  of  syphilitic 
disease. 

The  indications  are  especially  strong  when  the  sec- 
ondary symptoms  have  been  unusually  light.  When  an 
apparently  strong  man  comes  to  us  with  a  history  of 
fugaceous  aches  and  pains,  inconstant  spasms  and  disor- 
dered subjective  sensations — notable  among  which  is 
subjective  cold — we  should  not  immediately  make  light 
of  his  troubles,  and  even  dismiss  him  for  change  of  air 
and  scene,  but,  empirically,  if  our  history  of  cause  is  not 
clear,  place  him  upon  proper  anti-syphilitic  remedies. 


so  Allan  McLane  Hamilton, 

I   may  illustrate  what  I  mean  by  the  following  case : 

/. — Syphilitic  infection  six  years  before ;  development  of 
irregular  nervous  symptoms;  mental  depression ;  tremor; 
inspiratory  spasni  ;  apprehension  of  danger ;  cold  hands 
and  feet ;    mercurial  treatmoit ;    cure. 

Mr.  L ,  an  actor,  twenty-three  years  old,  present- 
ing every  appearance  of  good  general  health.  Six  years 
before  had  a  primary  sore,  followed  in  a  few  weeks  by 
secondary  s)'mptoms,  sore  throat,  roseola,  very  slight 
alopecia,  &c.  Has  since  had  osteoscopic  pains,  iritis, 
and  eruptions,  but  there  has  been  no  headache,  however. 
The  chest  presents  several  copper  stains,  and  there  are 
cicatricial  depressions  at  various  parts  of  the  body.  Eight- 
teen  months  ago  he  became  alarmed  about  himself,  not 
because  there  was  anything  positively  the  matter  with  him, 
but  because  he  developed  a  vague  dread  that  he  was  about 
to  lose  his  mind.  He  disliked  to  be  left  alone,  and  said 
that  he  had  had  a  variety  of  subjective  feelings  of  an 
irregular  and  unsubstantial  character.  Among  these  were 
prrecordial  sinkings,  dysaesthesia  in  the  arms,  legs  and 
trunk.  A  few  months  after  the  beginning  of  the  ailments 
he  had  trembling,  which  was  pronounced  by  a  well  known 
neurologist  to  be  due  to  "Sclerosis,"  but  in  a  week  or 
two  after  leaving  Chicago  this  symptom  disappeared,  and 
has  never  returned.  Two  weeks  before  I  saw  him  he 
developed  a  peculiar  form  of  inspiratory^  spasm.  The 
features  of  the  paroxysms,  which  were  frequently  repeated, 
were  the  following  :  The  head  was  violently  thrown  back, 
the  nostrils  were  pinched  and  closed,  the  mouth  was 
opened,  and  short-labored  inspirational  efforts  were  made  : 
the  chest  walls  were  fixed,  the  abdominal  muscles 
were  convulsively  moved,  and  there  was  irregular  con- 
traction of  the  diaphragm.  His  face  became  livid  and 
anxious.  These  attacks  would  last  from  ten  to  fifteen 
seconds,  and  afterwards  there  were  occasional  short  seizures, 
characterized  by  one  or  two  forcible  inspirations  and  a 
choreic  twitchinu;    of  the    facial    muscles'.     Tiiese    forms    of 


Syphilitic  Hypochondriasis.  8i 

attack  occurred,  especially,  when  he  was  excited,  or  under 
observation. 

When  upon  the  Stage  he,  as  a  rule,  managed  to  control 
himself.  Anxious  to  witness  his  behavior  under  these 
circumstances,  I  accepted  his  invitation  to  go  to  the 
theatre  where  he  was  engaged.  Before  seeing  me  he 
showed  no  indication  ot  trouble,  but  as  soon  as  I  took  my 
seat,  and  when  he  noticed  me,  his  paroxysms  occurred  in 
a  way  to  seriously  interfere  with  his  acting.  I  left  my 
seat,  as  if  to  go  out  of  he  theatre,  and  when  I  did  so 
he  became  perfectly  quiet,  but  on  another  occasion  the 
attacks  were  repeated  as  before.  This  trouble  was  then 
entirely  hysterical,  as  it  always  occurred  when  his  mind 
was  especially  filled  with  his  complaint,  or  he  knew  he 
as  under  observation. 

In  a  few  weeks  these  attacks  subsided,  and  were 
supplanted  by  a  new  series  of  symptoms.  After  trying 
moral  treatment  without  avail,  he  was  placed  under 
specific  treatment  at  my  suggestion,  and  a  month  or  so 
ago  I  found  that  he  was  perfectly  well  and  happy,  and 
laughed  heartily  at  his  former  troubles. 

In  other  cases  I  have  witnessed  equally  striking  results 
of  specific  medication  in  such  forms  of  nervous  trouble, 
and  in  patients  who  had  resisted  all  form  of  general  and 
special  treatment,  I  found  a  course  of  mercurials  to 
promptly  put  an  end  to  the  hypochondriasis. 

I  have  been  unable  to  find  any  allusion  to  this  neurosis, 
but  my  friend,  Dr.  Keys,  tells  me  that  he  has  often 
observed  such  a  nervous  condition  as  a  late  feature  oi 
syphilis. 


Art.  IX.— "The  Curability  of  Insanity  vs. 
Recoveries  from  Mental  Disease. 


By  Pliny  Earle,  A.  M.,  i\I.  D., 

SUPERINTEMDENT     OF     THE    STATE     LUNATIC     HOSPITAL,     AT   NORTHAMPTOV, 
MASSACHUSETTS, 

UNDER  the  title  "  Recoveries  from  ^Mental  Disease," 
Dr.  Isaac  Ray  lias  recently  published  an  essay, 
suggested  by  what  has  been  written  upon  the  same 
subject  in  the  last  three  annual  reports  of  the  Northamp- 
ton Lunatic  Mospital,  and  in  a  pamphlet  entitled  "  The 
Curability  of  Insanity,"  which  was  read  before  the  New 
England  Psychological  Society,  in  December,    1876. 

In  regard  to  the  essay  as  a  whole,  it  is  submitted  that 
its  statement  and  general  representation  of  my  argument 
is  very  inaccurate.  At  the  opening  of  his  argument,  Dr. 
Ray  says  :  "  He  (Dr.  Earle)  finds,  as  a  general  fact,  that 
thirty  or  forty  years  ago,  the  proportion  of  recoveries,  or 
cures  as  they  are  sometimes  called,  was  much  larger  than 
it  has  been  of  late  years.  This  remarkable  difference,  Dr. 
Earle  attributes  to  two  sources  of  error  committed  b}' 
those  who  reported  the  large  proportion  of  recoveries." 
He  then  proceeds  to  .state  that  these  two  sources  of  error 
are,  in  general  terms,  first,  the  temperament  of  the  person 
reporting  the  recoveries  ;  and,  secondly,  the  duplicate  and, 
.sometimes,    multiplicate    recoveries    of    the    same    person. 


•This  mill  Article  VII  on  "The  Siibseqiieiit  History  of  Twenty-nve  Persons 
ICoporterl  Ki-covered  from  Insanity  in  1843,"  were  emljracfii  in  !i  imper  read  before 
llie  New  Englami  Pujchological  Society,  Dec.  16,  1879. 


Citrability  vs   Recoveries. 


whereby  the  recoveries  of  cases  are  made  to  appear  much 
larger  than  recoveries  of  persons. 

Now,  so  far  from  assuming  the  decreased  number  of 
recoveries  as  my  premises  or  proposition,  it  was  one  of 
the  objects  of  the  paper  to  prove  that  there  has  been  such 
a  decrease.  The  attempt  to  prove  it  is  not  made  until 
near  the  close  of  my  essay ;  and  the  fact  of  that  decrease 
is  made  the  seventh  and  last  deduction  from  the  whole 
discussion.  Furthermore,  strange  as  it  may  seem,  neither 
of  the  "  two  sources  of  error"  is  anywhere  alleged  to  be 
the  cause  of  that  reduction. 

After  having  considered  the  two  sources  of  error,  and 
arrived  at  the  conclusion  that  they  do  not  satisfactorih" 
account  for  the  reduction  in  the  number  of  cures,  Dr. 
Ray  says,  "As,  then,  neither  the  temperament  of  the 
physician,  nor  the  repeated  counting  of  periodical  cases, 
accounts  for  the  larger  proportion  of  recoveries,  in  the 
earlier  times,  we  must  look  for  the  explanation  in  another 
direction,  and  we  shall  find  it  in  various  agencies  that 
have  come  into  operation  in  later  times."  He  goes  on 
to  explain,  as  if  it  were  a  discovery  of  his  own,  that 
these  agencies  are,  in  short,  first,  the  admission  to  the 
hospitals  of  a  larger  proportion  of  incurables  ;  and,  second- 
ly, the  increased  incurabihty   of  the  disease. 

As  before  mentioned,  my  aim  was  to  demonstrate  that 
such  a  reduction  or  diminution  has  taken  place,  and  }iot 
to  show  the  causes  of  it.  And  yet  those  causes  are 
briefly  alluded  to,  on  p.  48  of  "The  Curability  of  Insanity," 
as  follows  :  "If  the  causes  of  the  general  reduction  of  the 
proportion  of  recoveries,  as  stated  under  the  seventh  head, 
be  sought,  some  of  them  will  be  found  in,  or  inferred 
from,  preceding  portions   of  this  discussion. 

"x-\mong  others  are,  first,  the  probable  fact  that,  as 
institutions  have  multiplied,  the  proportion  of  chronic  and 
I )t curable  cases  taken  to  them  has  increased;  and,  secondly, 
the  not  improbable  fact  that  insanity,  as  a  i.-hole,  is  really 
becoming  more  and  more  an  incurable  disease.  If  it  be  true, 
as    asserted    by  that    accomplished    scholar    and    profound 


94  Pliny  Earle, 


thinker,  Baron  Von  Fcuchterslcben — and  doubtless  no 
one  will  deny  its  truth — that  in  the  progress  of  the 
last  few  centuries,  as  civilization  has  advanced,  and  the 
habits  of  the  race  have  been,  consequently,  modified, 
disease  has  left  its  stronghold  in  the  blood  and  the  muscu- 
lar tissues,  and  at  length  seated  itself  in  the  nervous 
system,  it  follows,  perhaps,  as  a  necessary  consequence, 
that  by  a  continuation  of  the  cause  of  this  change,  the 
diseases  of  the  brain  and  nerves  viitst  become  more  and 
more  permanent."  .\nd  in  my  annual  report  for  1876- 
jj,  I  say:  ".\s  hospital  accommodations  have  increased, 
more  and  more  of  the  large  class  of  the  chronic  insane,  who 
formerly  remained  among  the  people,  are  tJiiis  removed  from 
their  homes"  to  the  hospitals ;  and  I  then  proceed  to 
quote  from  six  authorities,  showing  that  the  same  state 
of  things  is  found  in  Great  Britain. 

Thus,  when  Dr.  Ray  becomes  dissatisfied  with  the  two 
agencies  erroneously  assumed  by  him  to  be  those  to 
which  I  attributed  the  reduction  of  recoveries,  and  looks 
"for  the  explanation  in  another  direction,"  he  is  not 
obliged  to  look  beyond  the  writings  which  he  is  criticising ; 
and  four  or  five  pages  near  the  close  of  his  paper  are 
essentially  only  a  mere  elaboration  of  the  ideas  contained 
in  the  paragraph  just  quoted  from  those  writings. 

Not  only  have  I  not  alleged  the  "two  sources  of 
error"  as  causes  of  the  reduction  of  recoveries,  but  I 
never,  even  in  thought,  assufned  or  believed  them  to  be. 
to  any  considerable  extent.  The  reporting  of  multiple 
recoveries  certainly  cannot  be,  because  more  have  been 
reported  of  late  years  than  thirty  or  forty  years  ago. 
The  older  the  hospital,  the  larger  the  proportion  of  such 
recoveries.  In  regard  to  the  other  "source  of  error" — the 
diversity  of  temperament  of  the  different  reporters — it 
may  and  it  may  not  have  tended  to  reduce  the  number, 
as  a  whole,  although  tlicre  are  instances  in  which  it  has 
appeared  to  reduce  them,  which  are  more  striking  than 
any  in  which  they  appear  to  have  been  increased  by  it. 
The  only  stated  object  of  the  essay  on  "The  Curability  of 


Curability  vs.  Recoveries.  85 

Insanity"'  is,  to  ascertain  whether  the  popular  beUef  in  the 
Jreat  curability  of  insanity  is  justified  by  facts.  The 
general  scope  of  that  essay  is  asserted  (p.  4)  to  be  "a 
rez'iezi'  of  the  subject  of  the  curability  of  insanity."  This 
made  the  field  of  discussion  so  broad  that  the  influence 
of  temperament  was  legitimately  mentioned,  rather  as  a 
curious  phenomenon,  and  hence  a  matter  of  general  inter- 
est, than  as  one  of  the  agents  the  influence  of  which  has 
reduced  the  number  of  recoveries.  And  it  is  introduced, 
not  as  necessarily  either  a  diminisher  or  an  enlarger  of 
recoveries,  but  as  an  "influence  which  has  an  important 
effect  upon  the  proportionate  reported  restoration."  In 
one  instance  that  effect  may  be  to  reduce,  in  another  to 
increase.  And  I  perceive  no  reason  why  its  effect  was 
any  greater,  either  wa\',  thirty  or  forty  years  ago,  than  it 
is  now,  other  than  its  stimulation,  at  the  former  period, 
by  the  more  active  zeal  and  rivalry  among  the  superin- 
tendents of  the  hospitals.  So  far  it  undoubtedly  did  exert 
an  effect  of  increase,  at  that  time ;  and,  as  the  stimulation 
has  subsided'  by  the  less  active  rivalry,  the  effect  is  now 
towards  a  reduction. 

The  remarkable  instance  adduced  in  my  pamphlet,  in 
which  one  superintendent,  at  Worcester,  reported,  in  a 
period  of  three  years,  ninety-five  per  cent,  more  recoveries 
than  were  reported  b}'  his  successor  m  a  period  of  the 
same  duration ;  and  another  instance,  mentioned  in  the 
report  for  1877-78,  of  this  hospital,  in  which  one  superin- 
tendent of  the  McLean  Asylum,  during  a  period  of  seven 
years,  reported  one  hundred  and  twenty  per  cent,  more 
recoveries  than  did  his  successor  in  a  similar  period,  both 
occurred  within  the  last  fifteen  years. 

Even  Dr.  Ray,  himself,  not  only  acknowledges,  in  no 
less  than  three  different  places  in  his  essay,  that  this  dif- 
ference of  temperament  has  affected  the  statistics  of 
recoveries,  but  he  enters  into  a  somewhat  extended 
argument  to  prove  that  it  has,  and  that,  in  the  nature  of 
the  human  constitution,  it  cannot  be  otherwise.  Never- 
theless,   he    does    "question    whether    it    has    had    all    the 


86  Pliny  Earle, 


influence  attributed  to  it"  by  me,  inasmuch  as  I  "think 
it  has  sometimes  led  to  a  difference  in  the  number  of 
recoveries  as  reported,  amounting  to  twenty-five  per  cent." 
Here,  again.  Dr.  Ray  does  not  quite  accurately  represent 
the  author  whom  he  criticises.  I  did  not  write  "has 
sometimes  led  ;"  but  I  did  express  my  long  existing 
belief  that  "the  number  of  cases  reported  as  recovered 
inig-Jit  differ  at  least  twenty-five  per  cent.,  according  to 
the  man  who  might  act  as  judge  of  their  mental  condi- 
tion." But  that  is  unimportant;  the  error  of  representa- 
tion may  be  regarded  as  trivial.  I  still  retain  the  belief; 
and  for  the  benefit  of  persons  who  would  prefer  the 
concrete  to  the  abstract,  I  will  relate  an  anecdote. 
Within  the  last  three  months,  in  conversation  with  the 
superintendent  of  a  large  American  hospital — a  physician 
who  has  enjoyed  the  acquaintance  of  both  of  the  ex- 
superintendents  about  to  be  [mentioned — I  said,  "I  believe 
that  if,  when  Dr.  Ray  and  the  late  Dr.  Rockwell  (of  the 
Brattleboro'  a.sylum)  were  in  active  service,  it  could  have 
been  possible  for  both  of  them,  each  in  his  respective 
institution,  to  have  treated  the  same  patients,  and  to  have 
discharged  them  in  the  same  condition,  we  should  have 
had,  for  every  sevent}'-five  recoveries  reported  b\-  Dr. 
Ra}',  no  less  than  one  hundred  reported  by  Dr.  Rock' 
well,"  Here  is  a  difference,  not  alone  of  twenty-five,  but 
of  thirty-three  and  one-third  per  cent. ;  and  yet  the  super- 
intendent to  whom  I  spoke  immediately  over-endorsed  the 
(jpinion  with  the  remark :  "I  think  there  would  be  more 
difference  than  that."  Hence,  as  in  the  days  of  Moliere, 
there  were  feigots  and  fagots  ;  so,  now,  there  are  opinions 
and  opinions. 

The  general  misconception  and  misinterpretation  of  the 
writings  under  his  review  has  necessarily  vitiated  many  of 
the  minor  parts  of  Dr.  Ray's  argument  ;  and  more  than 
once  in  these  he  places  me  in  an  entirely  false  position. 
Thus,  for  example,  he  alludes  to  my  use  of  the  statistics 
of  the  Friend's  A.sylum,  at  Frankfort,  and  represents  me 
as  cnn)loying  them  for    the    purpose    of  accounting  for  tJie 


Ciirahility  vs.  Recoveries. 


dimumtion  in  the  number  of  recoveries,  in  the  course  of  the 
last  thirty  or  forty  years.  1  used  them  for  no  such 
thing.  I  used  them  for  the  purpose,  primarily,  of  show- 
ing that  (at  any  and  at  all  times),  in  consequence  of 
repeated  admissions  of  the  same  person,  the  percentage  of 
of  cases  that  recover  is  generally  larger  than  that  of 
persons  that  recover  ;  and,  secondh',  by  such  showing,  to 
illustrate  the  method  b)'  which  the  people  at  large  have 
received  the  impression  that  insanity  is  a  far  more 
curable  disease  than  it  really  is. 

]\Iy  argument,  when  using  the  Frankfort  statistics,  was 
intended  to  be,  briefly,  as  follows:  "The  people  have  been 
taught  to  believe  that  from  75  to  90  per  cent,  of  insane 
persons  can  be  cured.  The  Frankfort  statistics,  the  best 
we  have,  show  but  65.69  per  cent,  of  recoveries.  These 
recoveries  are  ot  ca^ts  not  of  persons.  Rejecting  the 
re-admissions,  we  find  that  the  recoveries  of  persons 
were  but  58. 35  per  cent.  But  these  v/ere  not  permanent 
recoveries.  So  many  of  the  recovered  persons  were 
re-admitted,  that  the  real  proportion  of  the  persons  who 
recovered  permanently  was  only  48.39  per  cent.  Hence, 
instead  of  having  ninety,  or  eighty,  or  even  seventy-five 
insane  persons  permanently  cured,  m  each  hundred  of  the 
acutely  insane,  these  statistics  show  that,  at  Frankfort, 
only  48  (48.39)  were  so  cured.  Some  persons  will  proba- 
bly think  that  to  be  a  pretty    important  difference. 

It  would  seem  that  Dr.  Ray  wrote  his  essay,  not  with 
my  pamphlet  or  my  reports  before  him,  but  rather  with  a 
very  imperfect  and  confused  memory  of  their  contents,  as 
derived  from  a  hasty  perusal  of  them  at  some  period  com- 
paratively remote.  He  makes  a  perfect  muddle  of  my 
argument,  and  throughout  his  essay  he  is  almost  constantly 
firing  at  a  target  of  his  own,  all  the  time  laboring  under 
the  delusion  and  all  the  time  leading  his  readers  to  believe 
that  he  is  firing  at  mine. 

It  would  occupy  too  much  time  and  space  to  follow 
the  Doctor  through  the  other  similar  mistakes  and  perver- 
sions in  his  essav.     There  are,  however,  some  other  things 


Pliny  Earle, 


that  may  be  noticed.  In  allusion  to  the  recoveries  at 
Frankford,  he  says:  "We  doubt  if  in  any  other  hospital 
the  discharges  have  been  at  the  rate  of  one  patient  recov- 
ered fifteen  times  ;  another,  thirteen  :  a  third,  nine ;  a  fourth, 
eight ;  and  a  fifth,  seven."  "  Nothing  easier,"  writes  Dr. 
Hack  Tuke,  "than  to  make  sweeping  statements  without 
proof."  It  is  no  less  ea.sy  to  make  a  statement  that  rests 
upon  a  doubt.  The  Doctor  was  evidently  in  a  doubting 
mood  when  his  paper  was  written.  Permit  me  to  dispel 
the  doubt  in,  at  least,  this  one   instance. 

The  total  of  recoveries  of  the  five  persons  at  Frankford 
is  fifty-tii'o . 

At  the  Hartford  Retreat,  five  persons  have  been  re- 
ported recovered,  as  follows  :  One,  fourteen  times  ;  another, 
thirteen;  a  third,  nine;  a  fourth,  nine;  and  a  fifth,  nine. 
Total  receveries  of  the  five  persons,  fifty-four. 

At  the  Bloomingdale  Asylum,  as  long  ago  as  the  year 
1845,  five  men  had  been  reported  as  recovered — one  of 
them,  seventeen  times ;  another,  thirteen  ;  a  third,  twelve  : 
a  fourth,  eleven ;  and  a  fifth,  ten.  Total  recoveries  of 
the  five,  sixty-three. 

At  the  same  institution,  at  the  same  time,  five  li.'ojnen 
had  been  reported  recovered — one,  twent}-  times  ;*  another, 
nineteen;  a  third,  seven;  a  fourth,  seven;  and  a  fifth,  six. 
Total  recoveries  of  the  five,  fifty-7ime. 

Taking  the  highest  five  of  both  of  these  sex-groups  of 
Bloomingdale  patients,  one  of  them  recovered  twent}- 
times  ;  another,  nineteen  ;  the  third,  seventeen  ;  the  fourth, 
thirteen ;  and  the  fifth,  twelve.  Total  recoveries  of  the 
five,  eighty-one. 

At  the  Worcester  Hospital,  five  men  have  been  dis- 
charged recovered, —  one  of  them,  fourteen  times;  another 
fourteen;  the  third,  twelve;  the  fourth,  nine;  and  the 
fifth,  nine.       Total  recoveries    of  the  five,  fifty-eight. 

At  the  same  institution  five  uomen  have  been  dis- 
charged    recovered, —  one     of     them,     twenty-two     times; 


•This  womnii  .itterwanls  increaactl  her  recoveries  to  forty-six,  or  only  six  less 
than  the  total  ol  the  five  persons  at  Frankford. 


Curability  vs   Recoveries.  80 

another,  sixteen  ;  the  third,  fifteen  ;  the  fourth,  fourteen ; 
and  the  fifth,  eleven.  Total  recoveries  of  the  five,  scvenir- 
eiglit. 

Uniting  these  two  sex-groups  of  Worcester  patients 
and  taking  the  highest  five  of  them,  one  recovered  twent}-- 
two  times;  another,  sixteen;  the  third,  fifteen;  the  fourth, 
fourteen  ;  and  the  fifth,  fourteen.  Total  recoveries  of  the 
five,  eighty-one. 

At  the  New  Hampshire  As}-lum,  at  Concord,  even 
among  the  twenty-seven  patients  discharged  recovered  in 
the  official  year  1878-79,  there  were  five,  the  number  of 
whose  recoveries  has  been,  one  of  them,  thirty-six  times ; 
another,  ten ;  the  third,  nine ;  the  fourth,  five  ;  and  the 
fifth,  three.  Total  recoveries  of  the  fi^•e,  sixty-three.  The 
number  of  recoveries  of  these  five  persons  is  larger,  by 
eleven,  than  that  of  the  five  at  Frankford ;  but  of  all  the 
patients  ever  treated  at  Concord,  the  highest  five  were  as 
follows  :  One  recovered  thirty-seven  times ;  another,  sixteen  ; 
the  third,  eleven ;  the  fourth,  ten ;  and  the  fifth,  ten. 
Total  recoveries  of  the  five,  eighty-four. 

In  every  one  of  the  instances  here  adduced,  the  "rate" 
of  recoveries  is  higher  than  that  of  the  Frankford  patients; 
and  in  that  of  either  the  Bloomingdale  Asylum  or  of  the 
Worcester  Hospital,  it  is  fifty-five  per  cent,  higher;  while 
in  that  of  the  Concord  Asylum,  it  is  sixty-one  per  cent, 
higher. 

Should  any  vestige  of  doubt  still  remain  upon  the 
Doctor's  mind,  perhaps  it  may  be  obliterated  by  the  fact 
that,  at  the  Concord  Asylum,  te7i  persons  have  recovered 
a  total  of  one  hundred  and  twenty  times,  or  an  average 
of  precisely  twelve  recoveries  to  each.  This  rate,  how- 
ever, is  not  quite  so  high  as  that  of  the  above-mentioned 
ten  patients  (five  men  and  five  women)  at  Bloomingdale 
or  as  of  the  ten  at  Worcester.  At  the  former,  the  ten 
patients  recovered  one  hundred  and  twenty-two  times; 
and  at  the  latter,  one  hundred  and  thirty-six  times;  an 
average  of  over  thirteen  recoveries  to  each  person. 

Again,  Dr.   Ray  writes  as  follows  :    "Dr.  Bell  had  good 


no  Plimj  Earle. 


reason  for  saying,  in  his  report  of  the  IVIcLean  Asylum 
for  1840,  'that  the  records  of  this  as}'lum  justify  the 
declaration  that  all  cases  certainly  recent — that  is,  whose 
origin  does  not,  either  directly  or  obscure!}-,  run  back 
more  than  a  }'car — recover    under  a  fair  trial'  " 

It  ma)'  be  assumed  that  Dr.  Bell  had  equally  good 
reason  for  sa\-ing,  as  he  did  say,  in  1857,  applying  his 
opinion  of  the  general  curabilit\'  or  incurability  of  insanity 
to  the  case  of  an  individual :  "I  have  come  to  the  conclu- 
sion, that  when  a  man  once  becomes  insane,  he  is  about 
used  up  for  this  world."  In  1840,  when  he  wrote  the 
extract  quoted  b)'  Dr.  Ray,  he  had  been  but  four  years 
in  the  specialty,  and  his  experience  was  comparatively 
small.  Seventeen  years  afterwards,  when  the  latter 
expression  of  his  opinion  was  given,  that  experience  was 
greatly  enlarged,  and  it  is  not  unlikely  that  he  had  had 
the  opportunity  to  learn,  in  the  later  history  of  the 
patients  who  recovered  in  the  earlier  years  of  his  resi- 
dence at  the  McLean  Asylum,  the  frequenc)^  and  often 
the  permanency,  of  subsequent  attacks,  such  as  the  reader 
may  learn  in  my  history  of  the  twenty-five  patients  dis- 
charged recovered  from  the  Worcester  Hospital  in  1843- 
Though  decided  in  his  opinions,  Dr.  Bell's  mind  was  open 
to  conviction  ;  and.  when  those  opinions  were  altered,  he 
liad  the    independence,    the    manliness,    to    acknowledge  it. 

In  regard  to  repeated  recoveries  of  the  same  person. 
Dr.  Ray  remarks:  "The  Dr.  (Earle)  himself  leaves  it  in 
doubt  whether  he  would  require  us  to  report  no  case  as 
recovered  which  has  been  so  reported  on  any  previous 
occasion.  lie  certainly  prescribes  no  rule  to  be  ob- 
served." Dr.  Ray  must  have  either  overlooked  or  forgotten 
the  first  paragraph  on  page  33  of  m\'  report  for  1877-78, 
from  which  the  subjoined   extract  is  taken  : 

"Nowhere  in  my  essa\'  is  it  asserted  that  the  calcula- 
tion of  recoveries  should  )iot  be  made  upon  cases.  I 
always  pursued  that  method,  and  I  do  not  sec  in  what 
way  it  can  be  avoided.  All  that  I  have  insi.sted  on  is, 
tliat  the  reports  of  recoveries  .shall  be  accompanied  by  aji 


Ciirahility  vs.  Recoveries. 


explanation,  by  which  the  reader  can  learn  \\hether  those 
recoveries  are  from  the  first  attack,  or  from  attacks  vary- 
ing from  the  second  to  the  thirtieth,  the  fortieth,  cr  the 
fiftieth;  whether,  if  you  report  ten  recoveries,  it  is  to  be 
understood  that  ten  different  persons  have  really  recov- 
ered, or  merely  that  one  person  has  recovered  from  ten 
successive  attacks.  The  inability  to  convey  this  informa- 
tion is  the  grand  fault  in  the  general  method  of  reporting, 
and  by  this  fault  public  opinon  has  been  grossly  misled." 

"Many  of  the  instances  of  repeated  recoveries  men- 
tioned by  Dr.  Earle,"  remarks  Dr.  Ray,  "were  periodical 
in  their  character.  These,  certainly,  were  not  recoveries, 
in  any  true  sense  of  the  term."  But,  in  most  instances 
— in  every  instance  but  one,  I  believe — they  were  reported 
as  recoveries,  and  hence  one  cause  of  the  prevailing  mis- 
apprehension in  the  public  mind  in  regard  to  the  curability 
of  insanity.  The  exceptional  instance  is  that  of  the  cases 
at  the  Pennsylvania  Hospital,  in  which  I  inferred  that  a 
patient  had  been  recovered  thirty-two  times,  from  the  fact 
that  he  is  reported  to  have  had  thirty-three  attacks.  But, 
in  allusion  to  those  cases.  Dr.  Ray  says  :  "We  learn  from 
Dr.  Kirkbride,  that  no  periodical  case  was  ever  discharged 
(at  the  Pennsylvania  Hospital)  as  recovered."  Referring 
to  page  37  of  Dr.  Kirkbride's  report  for  1878,  I  find  a 
table  "showing  the  number  of  the  attacks  in  7,867  cases," 
with  the  following  explanation  :  "This  table  shows,  that  of 
the  entire  number  admitted,  five  thousand,  six  hundred 
and  ninety-five  were  suffering  from  the  first  attack  ot 
insanity,  one  thousand,  two  hundred  and  fifty-nine  from  a 
second  attack,  four  hundred  and  twenty-one  from  a  third, 
and  so  on,  till  thirteen  were  laboring  under  a  nmth  attack 
when  received  into  the  institution.  All  these  ivere  distinct 
attacks  of  insanity,  and,  after  the  first,  had  been  developed 
subsequently  to  recoveries  from  a  previous  attack  or 
attacks  of  the  disease." 

According  to  this  explanation,  a  part  of  the  cases 
which,  in  "The  Curability  of  Insanity,"  are  taken  from  the 
report  for    1875    of  the    Pennsylvania    Hospital,    ivcrc,  as  I 


92  Pliny  Earle, 


inferred  them  to  be,  cases  that  had  recovered  from  each 
previous  attack.  In  the  ninety-four  persons  admitted  on 
the  fifth  attack,  and  the  one  hundred  and  seventy-two 
persons  on  the  fourth  attack,  the  disease  was  not  period- 
ical, but  every  patient  had  recovered  from  each  of  his 
previous  attacks.  The  one  hundred  and  seventy-two 
persons  admitted  on  the  fourth  attack  had,  consequently, 
previously  recovered  a  total  of  five  hundred  and  sixteen 
times,  making  the  number  of  previous  recoveries  three 
hundred  and  forty-tour  greater  than  the  number  of 
persons.  That  will  do  v&xy  well.  It  is  sufficient  to  illus- 
trate my  point,  that  the  reported  recoveries  largely  exceed 
the  number  of  persons  that  recover.  Or  if  it  be  not,  it 
may  now  be  supplemented  by  the  thirteen  persons  men- 
tioned by  Dr.  Kirkbride  in  the  above  explanation,  as 
"laboring  under  a  ninth  attack  when  received  into  the 
institution."  These  thirteen  persons  had  already  recov- 
ered eight  times  each — a  total  of  one  hundred  and  four 
recoveries. 

In  all  instances  where  the  person  has  had  ten  attacks 
or  more,  Dr.  Kirkbride  classes  the  case  as  periodical ;  and, 
according  to  Dr.  Ray,  not  one  of  these  cases  has  ever 
been  discharged  as  recovered  from  the  Pennsylvania 
Hospital.  But  in  all  instances  in  which  the  number  of 
attacks  has  been  less  than  ten,  the  case  is  not  periodical, 
and  the  patient  really  does  recover  from  each  successive 
attack ;  and,  of  course,  when  he  leaves  the  hospital,  is 
reported  as  recovered.  This  may  be  a  good  method  of 
classification,  but  the  propriety  of  its  universal  adoption  is 
doubtful.  It  might  lead  to  difficulty.  Not  every  physi- 
cian possesses  that  acuteness  of  mental  vision  by  which, 
when  a  patient  has  apparently  recovered  from  his  second, 
third,  fourth  or  fifth  attack,  he  can  determine  the  question 
whether  that  patient  is  going  to  have,  in  all,  only  nine 
attacks,  or  whether,  on  the  contrary,  he  will  have  ten. 
If  he  cannot  decide  that  point,  he  will  not  be  able  to 
classify  the  case  as  periodical  or  not  periodical;  and  if  he 
cannot  so  classify  him,  he  will  not  know  whether  to  report 


Curability  vs.  Recoveries. 


him  as  recovered  or  not  recovered!  This  would  be  greatly- 
embarrassing.  Again,  supposing  that,  by  a  mistake,  not 
unlikely  to  occur,  he  should  report  a  patient  as  recovered 
nine  times  in  succession,  and  the  patient  should  then  have 
a  tenth  attack.  Another  embarrassment,  from  which  there 
would  be  no  relief  but  by  lettmg  those  nine  recoveries 
(like  the  sick  man's  reconciliation  with  his  neighbor,  in  case 
the  sick  man  should  recover)  "  go  for  nothing,"  inasmuch 
as  that  tenth  attack  has  proved  that  they  were  not  recov- 
eries !  It  is  even  somewhat  singular  that,  of  the  no 
inconsiderable  number  of  periodical  cases  at  the  Pennsyl- 
vania Hospital,  not  one  of  them  has  had  less  than  ten 
attacks.  It  might  reasonably  be  supposed  that  there 
would  be,  at  least,  one  or  two  not  farther  advanced  than 
the  seventh  or  the  eighth  attack. 

In  allusion  to  my  remark,  that  "If  a  person  have  a 
thirty-third  attack  of  disease,  it  necessarily  follows  that  he 
had  previously  recovered  from  thirty-two  attacks,"  my 
reviewer  exclaims :  "This  is  a  tremendous  jump  at  a 
conclusion  based  on  the  vague  signification  of  a  single 
word."  I\Iy  impression  is,  that  if,  to  one  hundred  physi- 
cians, it  were  asserted  that  a  person  has  had  five  attacks 
of  insanity,  the  instant  inference  of  ninety  and  nine  of 
those  physicians  would  be,  that  the  person  had  recovered 
from  each  of  the  first  four  attacks.  The  hundredth,  and 
exceptional  man,  would  probably  be  Dr.  Ray.  But,  be 
this  as  it  ma)',  it  is  questionable  whether  the  two  contes- 
tants in  this  matter  are  quite  old  enough  yet  to  begin  to 
accuse  each  other  of  exalted  skill  in  gymnastics.  For 
one,  I  am  perfectly  willing  that  the  audience  shall  decide 
which  of  the  two  was  the  greater  leap,  mine,  in  drawing 
the  inference  as  expressed  in  the  above  quotation,  or  Dr. 
Ray's,  in  bounding  from  the  beginning  to  the  end  of  my 
essay,  and  mistaking  one  of  my  conclusions  for  my 
premises. 

In  all  that  I  have  written  upon  the  controverted  sub- 
ject under  consideration,  I  have  intended,  constantly,  to 
represent,    as    a    dominant    idea,    that    public    opinion   has 


94  Pliny  Earle, 


been  greatly  misled  by  the  method  of  reporting  recov- 
eries at  the  hospitals.  Dr.  Ray  comes  to  my  assistance 
in  the  pamphlet  before  me,  from  which  I  make  the  fol- 
lowing extract,  the  last  two  of  the  three  series  of  italics 
being  mine  : 

"It  may  well  be  doubted  whether  the  terms  recovered, 
improved,  much  improved,  have  been  of  any  use  not  more 
than  balanced  by  their  inevitable  tendency  to  mislead  the 
reader  respecting  the  curability  of  insanity.  But  the  public 
have  always  wished  to  know  particularly  what  the  hospi- 
tals were  doing,  and,  as  often  happens,  thought  that  the 
the  information  sought  for  was  to  be  found  in  a  parade 
of  vague  general  expressions^ 

Finally,  so  far  as  regards  Dr.  Ray's  essay,  it  is  main- 
tained and  submitted  that  not  one  of  the  seven  conclu- 
sions in  "The  Curability  of  Insanity,''  is  either  refuted,  or 
in  any  wise  weakened,  by  any  thing  in  the  ''Recoveries  from 
Mental  Disease." 

For  the  benefit  of  persons  who  may  not  have  seen  the 
essay  so  sorely  obfuscated  by  Dr.  Ray,  it  is  proposed  here 
to  insert  the  seven  conclusions  derived  from  its  argument, 
together  with  the  facts  and  methods  b\-  which  the  correct- 
ness of  those  conclusions  is  demonstrated  : 

I.  The  reported  recoveries  from  insanity  are  increased 
to  an  important  extent  by  repeated  recoveries  from  the 
periodical  or  recurrent  form  of  the  disease  in  the  same 
person. 

Many  proofs  of  this  are  given  in  the  pamphlet  entitled 
"  The  Curability  of  Insanity,"  but  here,  as  a  matter  of 
convenience,  we  will  take  the  cases  which  have  just  been 
adduced  for  the  purpose  of  relieving  Dr.  Ray  from  a  doubt. 
At  the  Frankford  Asylum,  5  persons  recovered  52  times. 
Hartford     Retreat.      5  "  "  54     " 

"  Bloomingdale  As\'l.,  10         "  "  122     " 

"  Worcester  Hospital,  10         "  "  136     " 

Concord   Asylum,      10         "  "  120     " 

Consequently,  the    40  persons  recovered  484  times. 


Curahility  vs  Recoveries.  95 

The  number  of  recoveries  is  more  than  twelve  times  as 
large  as  the  number  of  persons  that  recovered. 

2.  The  recoveries  oi  persons  are  much  less  numerous 
than  the  recoveries  of  patients  or  cases. 

Proved  by  the  same  statistics  as  conclusion  No.  i. 
The  number  of  persons  is  less  than  one-tz^'clfih  of  the 
.number  of  recoveries — each  recovery,  of  course,  representing 
a  patient  or  a  case. 

3.  From  the  number  of  reported  recoveries  of  cases 
or  ^ patients,  it  is  generally  impossible  to  ascertain  the 
number  of  persons  who  recovered. 

Proved,  likewise,  by  the  same  statistics.  The  484 
recoveries  were  published  merely  a^  recoveries,  without  any 
explanation.  Consequently,  no  reader  of  them  could  tell 
how  many  persons  furnished  those  recoveries.  The  natural 
inference  was  that  there  were  484,  whereas  there  were 
but  40. 

4.  The  number  of  reported  recoveries  is  influenced, 
sometimes  largely,  by  the  temperament  of  the  reporter , 
each  man  having  his  own  standard,  or  criterion,  of  insanit}'. 

This  conclusion  is  not  susceptible  of  absolute  proof, 
but  it  is  a  legitimate  inference  from  the  known  diversity 
of  organization,  temperament  and  mental  character  among 
men.  There  are,  however,  two  instances,  at  least,  in 
which  statistics  appear  to  warrant  the  conclusion. 

(<?.)  There  was  a  change  of  superintendents  at  the 
Worcester  Hospital  in  the  official  year  1871-72.  In  the 
three  next  preceding  official  years,  under  the  old  superin- 
tendent, the  reported  recoveries  were  equal  to  43.32  per 
cent,  of  the  admissions  ;  whereas,  in  the  three  next  suc- 
ceeding official  years,  under  the  new  superintendent,  the 
reported  recoveries  were  only  22.16  per  cent,  of  the  admis- 
sions. The  reported  proportion  of  recoveries  in  the  first 
three  years,  was  very  nearly  twice  as  large  as  in  the  last 
three  years.  There  is  no  conceivable  and  plausible  cause 
for  this  difference,  other  than  that  mentioned  in  the 
conclusion. 

(^.)     At  the  McLean  Asylum    there    was    a    change    of 


96  Plinij  Earle, 


superintendents  in  March,  1871.  During  the  n&x^t  preced- 
ing seven  years  (1864  to  1870  inclusive),  the  proportion  of 
reported  recoveries  equaled  44.19  per  cent,  of  the  admis- 
sions; but  in  the  succeeding  seven  years  (1871  to  1877 
inclusive),  that  proportion  was  only  19.94  per  cent.  The 
proportion  of  the  reported  recoveries  in  the  first  period, 
was  more  than  ticice  as  large  as  it  was  in  the  second 
period,  or  as  221   to   lOO. 

5.  The  large  proportion  of  recoveries  formerly  re- 
ported was  [a.)  often  based  upon  the  number  of  patients 
discharged,  instead  of  the  number  admitted;  and  {b^  gener- 
ally, upon  the  results  in  a  number  of  cases  to  small  t^ 
entitle  the  deduction  therefrom  of  a  general  formula  of 
scientific  truth ;  and  (r.)  those  proportions  were  evidently 
increased  by  that  zeal  and  (for  want  of  a  better  v.'ord) 
rivalry  which  frequently  characterize  the  earlier  periods 
of  a  great    philanthropic    enterprise. 

{a)  At  a  large  proportion  of  the  American  hospitals 
forty  years  ago,  the  ratio  of  recoveries  was  calculated  on 
the  number  of  patients  discharged. 

{b}j  The  most  widely  known  of  all  remarkable  percent- 
ages of  recoveries  of  cases  of  recent  insanity;  those  of  the 
Hartford  Retreat,  in  1827,  were  based  upon  only  twenty- 
three  cases,  of  which  twenty-two  recovered ;  and  one  of 
the  others,  that  of  the  Williamsburg,  Virginia,  Asylum,  in 
1842,  upon  only  thirteen   cases,  of  which  twelve  recovered. 

(^.)  There  are  various  evidences  of  the  existe  nee  of 
that  zeal  and  rivalry  in  the  earlier  history  of  the  hospi- 
tals, which  need  not  be    mentioned  here. 

6.  The  assumed  curability  of  insanity,  as  represented 
by  those  proportions,  has  not  only  not  been  sustained,  but 
has  been  practically  disproved  by  subsequent  and  more 
extensive  experience. 

The  assumption  was  that  from  75  to  90  per  cent,  of 
the  recent  cases  of  insanity  could  be  cured.  The  conclu- 
sion is  proved  by  many  statistics,  but  most  especialK'  by 
those  of  the  Frankford  A.sylum,  based  upon  the  treatment 
of  1,061   cases,  treated    in    the    course    of  about  thirty-nine 


Curability  vs.  Recoveries. 


years.  Only  65.69  per  cent,  of  these  cases  recovered. 
But  so  many  of  these  were  the  repeated  recoveries,  on 
re-admission,  of  the  same  persons,  that  the  percentage  of 
persons  who  recovered  was  only  58.35.  Many  of  these 
were  not  permanent  recoveries.  The  actual  proportion  of 
persons  who,  after  one  recovery  were  never  re-admitted, 
was  only  48.39  per  cent. 

7.  The  reported  proportion  of  recoveries  of  all  cases 
received  at  the  institutions  for  the  insane,  has  been  con- 
stantly diminishing  during  a  period  of  from  twenty  to 
fifty  years. 

This  conclusion  is  derived  solely  from  the  results  of 
the  table  on  page  45  of  the  pamphlet  on  "The  Curability 
of  Insanity."  In  that  table  it  is  shown  that,  at  twenty 
American  hospitals,  the  average  diminution  of  reported 
recoveries,  in  an  average  period  of  about  tuenty-five 
years,  was  from  46.08  to  34.26  per  cent,  of  the  admis- 
sions. So  that,  "for  every  hundred  that  recovered,  on  an 
average  of  twenty-five  years  ago,  only  a  fraction  over 
seventy-four  (74.34)    recover  now." 


SELECTIONS. 


The    International   Medical   Congress  at 
Amsterdam. 


Translated  by  E.  M.  Nelson,  M.  D.,  of  St.  Louis. 

WE  note  with  satisfaction  and  most  cordial  approba. 
tion  the  deserved  prominence  given  to  psychiatry 
by  the  International  Medical  Congress,  held  last  September, 
in  Amsterdam,  and  make  the  following  extracts  from  the 
report  of  the  proceedings  of  this  body  of  savants : 

"  M.  Van  x\ndel  made  a  communication  on  the  use  of 
Coercive  Measures  in  Mental  Maladies.     It  concluded  thus : 

1st,  The  rational  application  of  the  principles  of  non- 
restraint,  should  be  adopted  as  the  general  rule  in  the 
treatment  of  mental  maladies ;  2d,  insane  asylums  should 
be  constructed  in  view  of  these  principles,  and  their  med- 
ical and  administrative  service  organized  upon  the  same 
basis ;  3d,  principal  conditions — convenient  situation  of 
the  asylum ;  extent ;  sections  and  divisions  of  the  quarters 
appropriated  to  the  system  of  non-restraint.  The  physi- 
cian should  be  the  director-in-chicf  of  the  inner  service. 
Sufficient  number  of  male  and  female  overseers. 

M.  Van  Der  Swalme  treats  of  Mental  Alienation  as  a 
Motive  for  Divorce.     His  conclusions  are  the  following : 

The  reasons  which,  in  a  religious,  moral  or  practical 
point  of  view,  seem  to  plead  in  favor  of  mental  alienation 
as  a  ground  for  divorce,  are  not  sufficient.  In  a  medico- 
legal  point    of  view,    it    would    be    necessary   to   read,    in 


International  Medical  Congress  at  Amsterdam,         99 

place  of  mental  alienation,  mental  alienation  chronic,  incur- 
able and  with  loss  of  memory..  The  patients  of  this 
category  will  be  so  much  the  rarer  as  their  disease  often 
causes  early  death.  It  would  appear  dangerous  to  fix 
for  the  small  number  of  survivors  conditions  of  divorce, 
which,  although  carefully  determined,  could  easily  aggra- 
vate the  suffering  of  a  greater  number  of  unfortunates. 
It  results  from  these  facts  that  mental  alienation  does  not 
seem  to  constitute  a  ground  for  divorce  more  valid  than 
many  other  infirmities  and  diseases,  which  may  disturb 
conjugal  happiness. 

AI.  Van    der    Lith    discusses    the  question    whether    a 

classification    of  mental    maladies    is  necessary,    and    upon 

what  basis  it  should  be  established.  He  is  for  the  affirm- 
ative, and  sums  up  thus  : 

1st,  A  classification  of  mental  maladies  is  necessary,  as 
well  for  instruction,  study  and  treatment  of  the  insane,  as 
for  legal  medipine ;  2d,  the  difficulties  inherent  in  every 
classification  of  diseases,  have  caused  some  doubts  on 
this  subject,  difficulties  which,  for  mental  diseases,  become 
infinitely  more  serious  on  account  of  the  complicated, 
little  known  structure  of  the  affected  organs,  by  the  great 
diversity  of  their  functions,  which  rule  our  whole  exis- 
tence, by  the  individual  differences  of  disposition  and  of 
development,  and  by  the  great  number  and  the  great 
diversity  of  the  morbific  causes  ;  3d,  a  good  classification, 
above  all  clear  and  simple,  should  correspond  to  the 
end  for  which  it  is  destined  ;  for  study  and  instruction  it 
might,  perhaps,  be  other  than  for  treatment  of  the  insane 
or  for  legal  medicine ;  4th,  this  classification  may  have 
the  same  ground  as  that  of  other  diseases ;  it  should  have 
for  its  base,  in  the  first  place,  the  functional  troubles 
(symptomatic  classification) ;  in  the  second  place,  the 
the  causes  which  have  troubled  or  which  still  trouble  the 
normal  functions  ;  finally,  the  anatomical  lesions  on  which 
these  morbid  symptoms  depend  ;  5th,  it  is  useful  to  divide 
mental  maladies  into  some  well  marked  groups ;  but  it  is 
necessary  not  to  forget  that  transitions  and  complications 
may  modify  the  symptoms  of  the  disease. 

M.  Doukerloot  speaks  of  the  Etiology  and  of  the 
Treatment  of  Katatoiiy. 

1st,  It  is  useful  to  bring  together  under  the  name  of 
katatony,  a    certain    number   of   cases    which   present    as  a 


100  E.  M.  J^elsofi. 


principal  symptom  a  lack  of  power  to  act,  which  should 
be  attributed  to  a  derangement  in  the  part  of  the  brain 
which  presides  over  movements  ;  2d,  as  katatony  accom- 
panies or  complicates  often  difficult  nervous  diseases,  as 
catalepsy,  hysteria,  epilepsy  and  melancholia  with  stupor, 
it  is  impossible  to  make  a  special  etiology  of  it  or  to 
indicate  a  separate  treatment. 

On  motion  of  M.  Ramaer,  the  following  resolution  was 
adopted : 

"The  section  on  psychiatry  desire  to  express  their 
acknowledgments  to  the  committee  on  organization  of 
the  congress  for  having  added  it  to  the  other  sections, 
and  pray  the  congress  to  decide  in  general  meeting  that, 
in  future,  every  session  of  the  congress  shall  have  its 
section  of  psychiatr}'." 

M.  Billod  made  a  demonstration  of  an  instrument 
(mouth  of  silver)  tor  Forced  Alimentation  of  the  insane. 

M.  Ramaer  read  the  following  report  upon  the  Duties 
of  the  State  zuith  reference  to  the    Insane  : 

The  duties  of  the  State  with  reference  to  the  insane 
have  for  their  object,  on  the  one  hand,  the  protection  of 
those  patients  against  the  injurious  influences  of  social 
life ;  on  the  other  hand,  the  defence  of  society  against  the 
disturbing  effects  of  their  disease. 

As  to  the  protection  of  the  patients,  the  State  has 
only  to  deal  with  those  who  are  not  cared  for  by  their 
relatives  in  the  ascending  or  descending  line,  or  by  their 
brothers  or  sisters,  except  the  cases  where  these  relatives 
permit  on  their  part  illegal  acts,  contrary  to  the  terms  of 
common  right. 

Crimes  against  the  insane  ought  to  be  punished  more 
severely  than  the  same  acts  committed  against  people 
sound  of  mind. 

Every  msane  person  entrusted  to  the  care  of  other 
persons  than  his  near  relatives,  should  be  committed  to 
the  surveillance  of  the  State. 

It  is  by  a  special  law  that  the  surx^eillancc  of  the 
the  insane  by  tlie  State  should,  be  regulated. 

This  law  should  contain : 

The  prohibition  of  the  reception  of  insane  persons  into 
their  dwelling  without  the  permission  of  the  indicated 
authority. 


International  Medical  Congress  at  Amsterdam.       101 

The  conditions  to  which  one  must  submit  who  desires 
to  care  for  insane  persons. 

The  formalities  to  observ^e  for  admission  into  an  asylum. 

The  mode  of  surveillance    by  the  State. 

The  surveillance  of  the  State  should  be  maintained 
continually ;  it  can  be  exercised  in  different  manners. 
The  best  seems  to  be  that  which  intrusts  it  in  small 
countries  to  a  general  inspector,  chosen  among  the 
alienist  physicians  and  placed  in  direct  relation  with  the 
minister  to  whose  jurisdiction  the  service  of  the  insane 
belongs,  in  the  large  countries  to  inspectors,  each  of 
whom  will  have  oversight  over  the  insane  in  a  special  part 
of  the  country,  and  who,  for  that  part,  will  be  in  direct 
relation  wath  the  minister ;  in  the  interest  of  the  unity  of 
the  service,  these  inspectors  will  form,  under  the  presi- 
dency of  the  minister,  a  council,  which  will  assemble  as 
often  as  the  service  shall  demand. 

In  order  to  increase  the  oversight  of  the  insane  by 
the  State,  the  physicians  of  public  asylums  should  be 
named  by  the  State  and  be  subordinate  to  inspectors. 

Furthermore,  every  house  where  are  received  insane 
persons  outside  of  their  family,  should  be  visited  at  irreg- 
ular inten^als  by  the  chief  justice  of  the  place,  in  order 
to  assure  himself  that  persons  sound  in  mind  are  not 
detained  there 

It  is  a  part  of  the  duty  of  the  State  to  take  care  that 
all  the  insane,  who  cannot  be  cared  for  in  their  family, 
can  find  appropriate  treatment  in  a  public  asylum. 

It  is  not  only  the  persons  of  the  insane,  but  their 
property,  over  which  the  surveillance  of  the  State  should 
extend.  A  provisional  administrator  should  then  be 
appointed  for  every  insane  person,  who  is  not  incurable, 
from  the  moment  that  he  comes  under  the  surveillance  of 
the  State,  and  is  in  possession  of  any  property.  If  he 
is  found  to  be  incurable,  it  is  necessary  to  place  him 
under  guardianship. 

The  property  of  the  insane  should  not  be  taken  away, 
even  though  this  should  be  to  defray  the  expenses  of 
their  maintenance. 

The  insane,  whose  incomes  do  not  suffice  to  pay  for 
their  treatment  in  a  public  asylum,  should  be  admitted 
there  at  the  common  expense  either  of  the  State  or  of 
the  community,  and  according  to  circumstances,  in  whole 
or  in  part. 

In  the  last  place,  the    State    should    protect  the  insane 


T"'2  E  M.  Xelson, 


person  against  its  own  laws;  in  other  words,  the  State 
should  declare  the  impunity  of  the  insane  in  the  cases 
where  a  punishable  act  has  been  committed  by  him  under 
the  influence  of  his  malady,  which  does  not  miply  im- 
punity for  every  act  committed  by  an  insane  person. 

It  does  not  suffice  to  look  out  for  the  inte-rests  of  the 
insane  ;  it  is  necessary  also  to  defend  society  against  the 
harmful  acts  which  the  insane  could  commit  under  the 
influence  of  their  malady.  That  is  why  every  insane 
person  who  is  known  to  be  dangerous  ought,  for  public 
order,  for  the  safety  of  others  as  well  as  for  himself,  to 
be  confined  in  an  insane  asylum  ;  and  that  is  why  should 
be  given  to  public  officers  the  power  to  place  such  insane 
persons  in  a  place  of  safety,  and  why  those  should  be 
punished  who,  being  charged  with  the  care  of  these 
patients,  permit  them  to  escape  by  negligence  or  ill-will. 

]\I.  Seguin  read  an  essay  upon  "Psycho-physiological 
Education  of  the  Hand  of  an  Idiot." 

The  work  of  M.  E.  Seguin  is  one  of  those  little  out- 
lines full  of  materials,  which  would  have  sufficed  for  a 
v^olume.  But  if  a  volume  where  written  upon  this  sub- 
ject, would  one  read  it?  It  is  better,  then,  to  accept 
the  plan  than  to  criticise  it,  and  to  endeavor  to  appre- 
ciate the  brevity  of  which  the  author  gives  an  example. 
He  treats  of  an  infant  represented  by  four  portraits, 
whose  life  guarantees  the  authenticity  of  veritable  objects 
of  art  from  the  pencil  of  Mile.  Blanche  Maisonncuve,  well 
known  to  the  readers  of  the  "  Archives  de  Physiologie."' 
The  education  of  this  child,  directed  by  M.  Seguin,  has 
been  intrusted  to  Miss  E.  Nary  Nead  [E.  Mary  Mead  ?]. 
to  whose  zeal  and  solicitude  the  author  duly  renders 
homage. 

Like  the  preceding  works  of  M.  E.  Seguin,  that  of 
which  he  treats  rests  upon  the  principle  of  ""training''  of 
the  senses,  to  which  recourse  is  had  in  order  to  develop 
intellectual  faculties.  In  the  case  described,  the  hand  has 
been  taken  as  the  instrument  of  perception  and  of  execu- 
tion, and  is  shown  pa.ssing  by  a  physiological  gradation  of 
automatism  to  operations,  gradually  volitional  and  more 
rational ;    then  acting  upon  external  bodies  and  awaking  a 


InterndtioThcbl  Medical  Congress  at  Amsterdam.       l<^'3 

se  ries  of  ideas  by  the  aid  of  perceptions  of  form,  of  color 
of  consistence,  &c.  It  is  only  those  who  have  read  the 
preceding  works  of  the  author,  who  will  appreciate  all  the 
interest  of  this  curious  communication. 

M.  Ch.  Richet  made,  in  his  own  name  and  that  of  IM- 
Brissaud,  a  communication  upon  "  Hystero-epileptic  Con- 
tractions." 

M.  Petithau  proposed  to  the  section  on  psychiatry  to 
adopt  the  following  motion : 

"  There  is  occasion  to  make  a  law  against  alcoholism 
and  to  institute  temperance  asylums  to  treat  cases  of 
chronic  alcoholism  in  virtue  of  this  law." — Le  Progres 
Medical,  Oct.  4th,   1879. 

We  present  also  the  following  contribution  of  the  con- 
gress on  neurology  : 

"  Mr.  Guye  communicates  an  interesting!  work  upon 
the    '  Vertigo    of    Meniere.'        Here    are    his    conclusions : 

1st,  In  the  most  general  sense  of  the  word  one  can 
consider  as  Vertigo  of  Meniere,  all  cases  of  vertigo 
caused  by  abnormal  irritation  of  the  nervous  apparatus  of 
the  semi-circular  canals.  The  irritation  may  be  due  to 
an  exaggerated  normal  cause ;  intense  rotatory  movement 
of  the  head  or  of  the  whole  body ;  or  to  an  abnormal 
cause,  sudden  change  of  temperature,  most  frequently 
lowering,  variations  of  intra-tympanic  pressure,  circulator}- 
or  inflammatory  troubles ;  2d,  in  a  more  limited  sense, 
the  name  of  Meniere's  disease  is  applied  to  cases  where 
an  inflammatory  state,  either  of  the  semi-circular  canals 
themselves,  or  of  the  middle  ear  (tympanic  or  mastoid 
cavities)  is  the  cause  of  a  vertigo,  which  may  be  continu- 
ous, or  only  be  evoked  by  normal  movements  of  the 
head,  or  again  be  produced  only  in  the  form  of  paroxysms 
at  inter\'als  of  weeks  or  months  ;  3d,  cold  and  catarrh  of 
the  tympanic  cavity  play  a  great  role  in  the  etiology  of 
Meniere's  disease  ;  4th,  the  majority,  if  not  the  whole,  of 
the  cases  of  Meniere's  disease  are  of  secondary  nature,  that 
is  to  say,  they  are  caused  by  catarrh  or  inflammation  of 
the  tympanic  or  mastoid  cavity ;  5th,  in  typical  cases, 
the  vertigo  is  accompanied  or  preceded  by  sensations  of 
rotation,  which  follow  a  constant  order  ;  the  attack  com- 
mences   by    a  sensation  of  rotation  around  a  vertical  axis 


104  E.M.Kdson, 


and  always,  in  feeling,  on  the  diseased  side,  sometimes  with 
a  rotation  to  and  fro ;  then,"  in  severe  cases,  a  sensation 
of  rotation  around  a  frontal  axis  from  front  to  back ; 
afterwards  the  vertigo  becomes  general,  the  patient  falls, 
with  or  without  loss  of  consciousness ;  often  there  is 
vomiting.  In  certain  cases  the  attack  is  passed  in  ten 
to  thirty  minutes;  in  others,  the  vertigo  is  reproduced  by 
each  movement  of  the  head  during  one  or  two  days,  and 
the  patient  is  forced  to  remain  lying ;  6th,  in  some  cases 
the  sensations  of  rotation  are  produced  experimentally  by 
treatment  of  the  diseased  ear  (be  it  insufflation  of  air 
into  a  tympanic  cavity  which  is  the  seat  of  an  inflamma- 
tion, or  injection  of  Hquid  into  a  mastoid  cavity  after 
trephining  the  mastoid  apophysis).  In  these  cases  the 
sensation  of  rotation  has  always  taken  place  around  a 
vertical  axis  and  in  the  sensation  of  the  diseased  organ : 
/th,  in  certain  cases  the  attacks  are  accompanied  by  very 
strong  subjective  sensations  of  n9ise ;  in  others,  a  light 
humming  exists  constantly  without  exacerbation  in  the 
attacks ;  sometimes  these  sensations  of  noise  are  absolutely 
wanting;  8th,  in  cases  of  long  duration,  a  light  feeling  of 
vertigo  persists  in  the  free  intervals,  and  is  produced 
principally  by  the  first  movements  of  the  head  after  sleep. 
.Sometimes  the  patient  lias  the  sensation  of  falling,  either 
forwards  or  backwards.  Other  patients  are  forced  to 
hold  the  head  fixed  in  a  constant  direction,  because  each 
movement  in  the  plane  of  one  of  their  semi-circular 
canals,  gives  them  the  sensation  as  if  a  heavy  body  fol- 
lowed this  movement  in  their  head.  (In  a  very  well 
marked  case,  which  I  have  observed,  the  patient  held  his 
head  bent  forward  and  to  the  left,  and  so  prevented 
every  movement  of  rotation  in  the  plane  of  the  sagittal 
semi-circular  canal  of  the  left  side.  The  left  ear  was  the 
ear  affected).  9th,  besides  frequent  complications  with 
hysteria,  Meniere's  disease  often  produces  in  children  a 
state  like  chorea,  and  in  adults  clonic  contractions  of  the 
muscles  of  the  face  and  of  the  body,  which  may  disap- 
pear absolutely  by  local  treatment  of  the  middle  ear;  loth, 
Meniere's  disease  is  often  cured,  with  or  without  loss  of 
hearing;"  nth,  local  treatment  often  succeeds  in  cases 
which  are  not  too  inveterate;  12th,  in  internal  treatment, 
quinine,  recommended  by  M.  Charcot,  merits  most  confi- 
dence. It  often  has  the  effect  of  retarding  the  attacks 
during  its  use.  Quinine  has,  moreover,  sometimes  in 
patients    whose    middle    ear    is    affected,    the    paradoxical 


International  Medical  Congress  at  Jmsterdajn. 


effect  of  causing  to  disappear  the  humming  which  exists 
while  the  deafness  increases.  This  action  is  generally 
limited  to  the  duration  of  its  employment." 

M.  Meniere  does  not  think,  like  M.  Guye,  that  the 
majority  of  cases  of  Meniere's  disease  are  the  result  of 
catarrh  of  the  drum  or  of  the  mastoid  epiphysis.  On 
the  other  hand,  he  is  of  the  opinion,  with  M.  Delstauche, 
that  M.  Guye  generalizes  too  much,  in  calling  all  the 
cases  of  vertigo,  vertigo  of  Meniere.  Vertigo  is  only  one 
symptom,  while  Meniere  has  described  a  disease  in  which 
one  finds  other  concomitant  symptoms. — Le  Progres  Medi- 
cal, Oct.  4,    1879. 

Dr.  Damaschino  communicates  in  his  own  name  and 
in  the  name  of  M.  Henri  Roger,  a  paper  upon  the  Altera- 
tions of  the  Medulla  in  the  Spinal  Paralysis  of  Infancy 
and  in  Progressive  Muscular  Atrophy.  Among  the  dis-  , 
eases  of  the  nervous  system  which  are  observed  among 
infants,  there  is  one  whose  symptomatology  presents  special 
characteristics,  it  is  the  spinal  paralysis  of  infancy,  desig- 
nated otherwise  under  the  name  of  essential  paralysis  of 
infancy,  because  it  has  been  considered  as  belonging  to 
the  group  of  idiopathic  nervous  diseases. 

It  results,  from  a  certain  number  of  observations  col- 
lected by  Mm.  H.  Roger  and  Damaschino,  that  the  char- 
acteristic alteration  of  this  affection  is  a  lesion  of  the 
spinal  medulla,  of  which  atrophy  of  the  nerves  and  muscles 
is  the  consequence. 

M.  Damaschino  brings  to  the  support  of  this  proposi- 
tion histological  preparations  and  very  conclusive  observa- 
tions. In  three  of  these  observations  the  lesions  consist 
in  centers  of  inflammatory  softening,  which  are  seated  in 
the  anterior  cornua  of  gray  matter,  and  extend  into 
almost  all  the  depth  of  the  lumbar  medulla.  The  lesion 
is  more  marked  on  the  right ;  at  the  level  of  the  dorsal 
region,  there  are  no  distinct  foci,  but  granular  bodies  are 
found  accumulated  around  the  vessels ;  atrophy  of  the 
cells,  very  considerable  in  the  lumbar  region,  is  found 
equally  in  the  other  parts    of  the  medulla,  and  establish  a 


106  E  M.  Melson, 


constant  relation  with  the  dimension  of  the  foci  and  the 
variable  degree  of  the  vascular  lesions.  Atrophy  of 
the  white  antero-lateral  bands  was  very  distinct,  and  there 
was  at  this  level  an  abundant  accumulation  of  connective 
tissue  nuclei,  ver\-  pronounced  atrophy,  likewise,  of  the 
anterior  roots.  The  muscular  lesions  consist  especially, 
on  microscopic  examination,  in  the  diminution  in  volume 
of  tiie  primitive  fascicles. 

A  great  number  of  muscles  arc  the  seat  of  an  abun- 
dant deposit  of  fatty  cells  interposed  among  the  muscular 
elements. 

F"ollowing  the  communication  of  M.  Damaschino,  M- 
Bouchut  said  that  he  had  himself  performed  a  great  many 
autopses  in  cases  of  infantile  paralysis,  and  that  he  had 
not  observed  the  appearance  of  the  medulla,  signalized 
in  the  paper. 

M.  Damaschino  responded  that  if  he  had  not  found 
the  lesions  in  the  medulla,  which  he  himself  had  just 
described,  it  was  because  the  measures  adopted  were 
insufficient.  The  numerous  facts  which  he  has  observed 
with  M.  Roger,  and  the  histological  preparations  which  he 
places  before  the  eyes  of  the  members  of  the  congress, 
prove  to  a  demonstration  the  existence  of  these  lesions. 

Of  nervous  dyspepsias  and  their  treatment,  b}'  Prof. 
Scmmola  (of  Naples) : 

1st.  There  exist  dyspepsias  dependent  exclusivel}-  upon 
vices  of  gastric  innervation,  either  in  the  secretory  and 
chemical  phenomena,  or  in  the  mechanical  phenomena  of 
digestion. 

2d.  These  dyspepsias  are  in  relation  with  a  functional 
weakening  of  the  pneumogastric  and  of  the  sympathetic 
or  its  dependencies. 

3d.  The  most  prominent  symptoms  of  these  d)-spepsias 
are  a  great  intolerance  of  the  stomach  to  the  slightest  con- 
tact of  food,  with  epigastric  pain  and  gastralgia,  followed 
frequently  by  vomiting,  to  say  nothing  of  all  the  other 
symptoms  which  accompany  all  sorts    of  digestive  troubles. 

4th.  The  causes  which  constantly  produce  these  nerv- 
ous dyspepsias,  more  or  less  rebellious,  are  all  those  which 


International  Medical  Congress  at  Amsterdam.       107 

exhaust  the  nervous  system  in  general ;  but  especially, 
repeated  vexations,  violent  emotions  and  excess  of  coitus, 
especially  when  these  causes  have  acted  during  the  process 
of  digestion,  and  afterwards  without  respite. 

5th.  There  may  exist,  in  time,  in  these  cases  of  nerv- 
ous dyspepsias,  a  true  catarrh  of  the  stomach,  but  it  is 
alwa}^s  secondary  and  develops  in  consequence  of  three 
influences  : 

[a.)  The  same  vice  of  innervation  in  the  capillary  cir- 
culation of  the  stomach  (vaso-motor  paralysis). 

[b.)  The  prolonged  presence  of  aliments  which  digest 
veiy  slowly. 

[c.)  The  irritant  acl-Dn  of  all  the  products  of  defective 
digestion. 

6th.  Exaggeration  of  the  pathologico- anatomical  point 
of  view  and  of  tangible  local  lesions  has  caused  to  be  lost 
from  view  in  these  last  times,  the  great  value  of  nervous 
influences  upon  the  production  of  many  maladies. 

7th.  The  treatment  of  the  gastric  catarrh  does  not 
usually  succeed  in  these  dyspepsias  of  nervous  origin,  and 
it  amends,  almost  immediately,  the  most  prominent  troubles 
of  digestion. 

8th.  The  general  building  up  treatment  sometimes  suc- 
ceeds in  curing  also  troubles  of  stomach  innervation. 
(Hydrotherapie,  fresh  air,  &c.,  iron,  nuxvomica,  &c.) 

9th.  In  rebellious  cases  of  these  dyspepsias,  especially 
of  those  which  have  had  for  their  cause  excessive  coitus, 
prolonged  moral  causes,  the  only  means  of  succeeding 
surely  and  definitely,  is  the  employment  of  the  continued 
current  between  the  lateral  region  of  the  neck  and  the 
epigastrium.  The  duration  of  each  appUcation  should  be 
five  to  ten  minntes  each  time,  repeated,  at  least,  every 
'twelve  hours  methodically,  and  especially  in  the  hours 
which  immediately  precede  the  meals. — Airhiv.  Gen.  de 
Med.,  Oct.    1879. 


Of  the  Effects  of  Cephalic  Electrization  upon  the 
Vessels  of  the  Dura-Mater  and  of  the  Pia- 
Mater — By  Dr.   Ch.  Letouinian. 

"We  have  then  undertaken  to  determine  directly,  what 
is  the  eff"ect  upon  the  vessels  of  the  envelopes  of  the 
brain,  of  a  moderate  electrization,  practised  with  the  con- 
tinued current    through    the    integuments    and    the  cranial 


108  E.  M.  Xelson, 


wall,  nearly  in  the  ordinary  _  medical  conditions.  For  this 
it  was  sufficient  to  make  bare,  in  a  mammifer,  a  portion 
more  or  less  extensive  of  the  cerebral  membranes." 
Doctor  Laborde  assisted  him  in  the  experiment,  and  "in 
a  kitten  a  month  old,  in  which  the  cranial  wall  was  still 
very  thin,  and  was  quite  easy  to  cut,  a  considerable  por- 
tion of  cranium  has  been  cut  out  on  the  left  side.  The 
dura-mater  being  so  exposed  it  was  very  easy  to  see  with 
the  naked  eye,  and  still  better  with  a  magnifying  glass, 
the  arterial  and  venous  branches  which  ramify  upon  the 
surface.  We  proceeded  then  to  the  electrization,  mak- 
ing use  of  the  small  portable  pile  for  continuous  current, 
of  Mm.  Onimus  and  Brown.  This  pile  contains  eighteen 
elements,  and  we  took  care  by  the  aid  of  a  galvanometer 
introduced  into  the  circuit,  to  assure  ourselves  that  the 
passage  of  the  current  was  effected  regularly.  During 
all  the  duration  ot  the  experiment,  the  positive  pole  was 
placed  behind  the  right  ascending  ramus  of  the  inferior 
maxilla,  and  the  negative  pole  upon  the  anterior  cranial 
region  above  the  eyes. 

Ten  or  fifteen  seconds  after  the  closing  of  the  circuit, 
the  fine  arterial  branchings  of  the  dura-mater  became  less 
and  less  visible,  and,  a  little  later,  the  venous  branches 
themselves  became  pale.  At  each  interruption  ot  the 
current  the  anemia  increased  for  an  instant,  then  the 
vessels  resumed,  little  by  little,  a  little  larger  caliber. 

The  experiment,  repeated  a  number  of  times,  gave 
always  the  same  results,  determined  successively  by 
Doctors  Duval,  Laborde,  Condereau,  and  ourselves.  The 
dura-mater  of  the  right  side  having  been  denuded  in  its 
turn,  the  experiment  was  repeated,  which  on  this  side 
again  gave  the  same  results.  We  pursued  the  experi- 
ment cutting  out  on  the  left  side  a  portion  of  the  dura- 
mater.  The  pia-mater  being  thus  exposed,  and  its  vas- 
cular branches,  arterial  and  venous,  being  very  visible 
upon  the  gray  ground  of  the  cerebral  substance,  the  same 
observations  were  made  upon  it.  There,  also,  we  could 
obtain  at  will,  contraction  of  the  vessels. 

The  experiments,  which  we  have  just  related,  added  to 
facts  cited  in  the  commencement  of  this  paper,  put  it 
beyond  doubt  that  it  is  possible,  even  easy,  to  produce 
in  man  a  temporary  anemia  of  the  brain,  by  means  of 
suitable  electrization;  but  the  therapeutical  bearing  of  this 
fact  should  not  escape  the  physician.  For  this  temporary 
anemia  can,  without  the    least    inconvenience,    be  renewed 


Cephalic  Electrization. 


a  great  number  of  times  daily,  if  one  wishes;  and  our 
personal  experience  permits  us  to  affirm  that,  with  a  little 
persistence,  one  may  triumph  so  over  various  congestive 
states  of  the  brain,  manifesting  themselves  either  by  the 
simple  depression  of  the  intellectual  faculties  or  by  psy- 
chical disorders  of  varied  nature. 

In  support  of  the  preceding,  we  shall  cite  the  following 
fact,  chosen  among  many  others,  and  which  appears  to  us 
typical.  It  concerns  a  case  of  cerebral  congestion,  or, 
rather,  of  a  chronic  congestive  state  of  the  brain,  which 
has  yielded  to  electrization  repeated  persistently. 

The  patient,  the  abbe  C,  aged  fifty-five  years,  is  a 
corpulent,  full-blooded  person,  with  a  highly  colored  coun- 
tenance. When  he  applied  to  us  he  was  in  despair, 
because  he  suffered  several  times  a  week  from  persistent 
vertigo,  during  the  duration  of  which  he  could  not  take  a 
step  without  support,  and  from  which  he  was  relieved  only 
by  absolute  repose.  I\I.  C.  belonged  to  a  religious  com- 
munity whose  principal  object  is  teaching,  but  he  was 
obliged  to  renounce,  httle  by  little,  all  work.  It  had 
come  to  pass,  he  said,  that  he  could  scarcely  recite  his 
breviary  and  say  mass.  After  various  treatment,  there 
was  made  to  him,  at  the  end  of  five  months,  an  applica- 
tion of  fifteen  leeches,  with  so  little  effect  that  the  next 
day  he  had  a  severe  cerebral  congestion,  with  loss  of 
consciousness  and  instantaneous  fall.  This  serious  acci- 
dent occurred  several  times  afterwards,  and  was  ordinaril}- 
accompanied  by  violent  vomiting. 

To  modify  this  inveterate  organic  state  and  restore  a 
proper  tonic  contraction  to  vessels  habitually  dilated,  a 
treatment  of  long  duration  was  necessary.  During  five 
months  we  electrized  the  patient  three  times  a  week, 
placing  the  positive  pole  of  a  pile  with  continuous 
current  at  the  level  of  the  first  cervical  vertebra,  the 
negative  pole  at  the  level  of  the  superior  ganglion  of  one 
of  the  cervical  sympathetic  nerves.  The  number  of  ele- 
ments employed  varied  from  fifteen  to  twenty,  and  we 
took  care  to  interrupt  the  current  every  fifteen  seconds  ; 
for  experience  shows  that  vascular  contraction  is  produced 
especially  at  the  opening  and  closing  of  the  current. 
.  Each  seance  affected  an  immediate  amelioration  and 
longer  and  longer.  Soon  the  patient  was  able  to  resume 
his  occupation,  and  to  work,  at  first,  one  hour,  then  two 
hours,  then  four  and  five  hours  per  day.  At  the  same 
time  the  attacks  of  vertigo  became  more  and  more  rare 
and  brief.       At  the  end  of  five  months,  the  patient  ceased 


no  E.  M.  Jfelson, 


a  treatment  which  was  no  longer  necessary  ;    and  for  sev- 
eral months  the   alleviation  has  continued. 

This  fact  is  so  eloquent  that  it  appears  to  us  useless  to 
accompany  it  with  comments,  and  it  will  surely  suggest  to 
practicing  physicians,  therapeutic  applications  numerous 
and  various." — Gazette  Hebdovi.,  3  Oct. 


Sdaelen^j  of  Sciei\de.^. 

P.VRis,    October    20th,    1879. 

On  the  Power,  Rapidity  of  Action  and  the  Varieties 
OF  Certain  Inhibitory  Influences  of  the  Encepha- 
LON  UPON  Itself  or  upon  the  Spinal  Cord,  or  of 
this  last  Centre  upon  Itself  or  upon  the  En- 
CEPHALON. — Note  of  M.  Br ozvn-Se guard. 

I.  Inliibitory  influence  of  a  part  of  the  cncepJialon  upon 
another  part  of  this  centre  and  upon  the  spinal  cord. 

Galvanic  irritation  of  the  posterior  surface  of  the  sec- 
tion of  the  bulb  at  two  or  three  millimeters  above  the 
"  beak  of  the  calamus,"  and  of  the  spinal  cord  where  it 
gives  rise  to  the  first  two  pairs  of  nerves,  produces  no 
movement  of  the  limbs.  The  excitability  of  these  parts 
is  lost  suddenly  and  completely  in  the  most  of  the  cases 
where  this  lesion  is  made  in  dogs,  rabbits  and  "  cobayes." 
There  is  clearly  then,  as  numerous  experiments  have  shown 
me,  not  the  loss  of  excitability,  which  an  arrest  of  the 
circulation  may  cause,  but  the  effect  of  an  inhibitory 
influence  exercised  by  the  irritation,  which  section  pro- 
duces upon  the  bulb  and  upon  a  portion  of  the  cervical 
cord.  If  I  crush  the  encephalon  of  a  rabbit  or  a  "cobaye," 
I  obtain,  most  frequently  also,  a  very  clear  effect  of  inhibi- 
tion. The  anterior  limbs  have  no  (or  scarcely  any)  trace 
of  movements,  and  the  reflex  faculty  of  the  cervical 
enlargement  is  completely  lost.  An  inverse  condition 
e.xists  in  the  posterior  tract,  where  the  reflex  facult}'  lasts 
a  long  time  and  where  very  violent  and  prolonged  convul- 
sions take  place  immediately  after  the  crushing. 

//.     Influence  of  the  spinal  cord  upon  itself. 

Having  destroyed  a  portion  of  the  lumbar  cord  far 
from    the    origin    of  the    nerves    of   the    posterior  limbs,   I 


Academy  of  Sciences.  Ill 

have  most  frequently  determined  a  complete  absence  of 
the  convulsive  movements  in  those  limbs,  and  the  imme- 
diate loss  of  the  reflex  faculty  of  the  lumbo-sacral  enlarge- 
ment of  the  cord.  I  have  found  also  that  a  quite  pronounced 
paralysis  always  exists  in  one  of  the  arms  in  rabbits,  im- 
mediately after  transverse  section  of  a  lateral  half  of  the 
spinal  cord,  far  from  and  behind  the  origin  of  the  ner\'es 
of  the  arm.  This  paralysis  takes  place  on  the  side  of  the 
lesion  and  lasts  at  least  eight  to  ten  days.  M.  Vulpian 
has  already  seen  almost  the  same  thing  in  frogs. 

///.  Inhibitory  influence  exercised  by  the  spinal  cord  or 
the  sciatic  nerve  upon  the  encephalon,  of  the  opposite  side. 

The  section  of  a  sciatic  nerve,  or  of  a  lateral  half  of 
the  spinal  cord  in  the  dog,  the  rabbit,  and  the  "cobaye" 
produces  remarkable  effects.  There  is  immediately  after- 
wards a  diminution,  sometimes  even  the  loss  of  all  excita- 
bility by  galvanism  in  one  or  several  points  of  the 
encephalon,  of  the  side  opposite  to  that  of  the  lesion  of 
the  sciatic  or  of  the  cord.  In  the  rabbit,  the  diminution 
of  excitability  is  more  considerable,  and  especially  much 
more  extended  than  in  the  dog.  All  the  excito-motor  or 
sensitive  parts  show  a  notable  diminution  of  their  proper- 
ties. This  is  so  also  with  the  pretended  motor  centres, 
the  corpora  striata,  the  nates,  testes,  internal  capsule,  cere- 
bral peduncle,  mesocephalon,  the  bulb  and  the  part  of  the 
spinal  cord  where  the  first  two  pairs  of  nerves  arise. 

Conclusions. —  i.  Under  the  influence  of  a  local  irritation 
a  number  of  parts  of  the  encephalon  can  determine  the 
inhibition  of  excitability  to  galvanism  of  many_  other  parts 
of  this  nervous  center  or  of  the  spinal  cord,  either  on  the 
same  side  or  the  opposite  side.  2.  The  spinal  cord,  irri- 
tated at  certain  points,  can  determine  the  inhibition  of 
excito-motor  properties  of  other  parts  of  this  nervous  centre 
at  a  great  distance  before  or  behind  the  irritative  lesion. 
3.  The  sciatic  nerve  and  the  spinal  cord  can  determine, 
on  the  opposite  side  to  that  where  they  have  been  irritated 
by  a  section,  the  inhibition  of  excitability  to  galvanism  and 
other  properties  of  the  encephalon  in  all  its  parts,  includ- 
ing those  where  it  has  been  believed  that  psycho-motor 
centres  are    localized."— C^-^'//^'  Hebdomad,  Oct.    31,    1879. 


E.  M-  Kelaon, 


Alcdical  Society  of  tlie  Hospitals. 


Paris,  October  24th,  1879. 
]\I.  Debove  recalled  briefly  facts  already  published 
upon  the  relations  of  hemianeesthesia  with  hemiplegia,  and 
upon  their  cure  by  the  application  of  magnets.  In  all 
these  facts  it  is  only  a  question  of  hemianaesthesia  and  of 
the  influence  of  magnets  upon  the  return  of  sensibility. 
Xo  obser\-ers  make  mention  of  the  influence  of  magnets 
upon  motility,  and  M.  Debove  himself,  in  a  preceding 
communication,  has  not  thought  it  proper  to  enter  upon 
this  question  before  having  collected  other  facts  in  support 
of  that  which  he  had  established  at  first.  These  facts  he 
has  now  obtained  and  presents  to  the  Society.  In  all 
his  observations,  ]M.  Debove  has  determined  with  care  the 
condition  of  motility ;  it  is  within  bounds  to  assert  that 
the  influence  of  magnets  is  exerted  upon  hemiplegia  at 
the  same  time  and  to  the  same  extent  as  upon  hemian- 
aesthesia. The  author  repeats  with  details  the  observation 
communicated  previously  by  him  to  the  Society,  and  cites 
five  others,  of  which  three  may  be  summed  up  as  follows  : 

1st.  He  treated  a  man  having  had  several  returns  of 
epileptic  attacks,  who  had  fallen  on  the  public  street  and 
been  carried  into  the  ward  of  M.  Debove.  He  presented 
a  hemianaesthesia,  with  complete  hemiplegia.  One  appli- 
cation of  a  magnet  caused  to  disappear,  not  only  the 
hemianaesthesia,  but  also  the  hemiplegia.  The  patient 
left  the  hospital  the  next  day,  limping  a  little,  it  is  true, 
but  able  to  walk  without  support,  and  having  recovered 
all  the  strength    of  his  arm. 

2d.  A  patient  affected  with  hemiplegia  of  a  sj'philitic 
origin,  was  treated  by  iodide  of  potassium  in  the  service 
of  M.  Fournicr,  and  discharged,  cured,  after  several 
months  sojourn. 

A  month  ago  this  patient  awoke,  affected  on  the  left 
side  with  complete  hemiplegia  and  hemianaesthesia,  with 
loss  of  sight  on  the  affected  side.  Application  of  a 
magnet  upon  the  arm  for  an  hour  without  results ;  con- 
tinued application  of  a  magnet,  during  twenty-four  hours  ; 
the    symptoms    cease,    but    in    the    arm    alone  ;    the    same 


Medical  Society  of  the  Hospitals.  113 

application  for  twenty-four  hours  to  the  leg,  followed  by- 
recovery  limited  to  the  limb  touched  by  the  magnet ;  a 
third  application,  practised  this  time  upon  the  face,  re-es- 
tablished the  sight,  and   effected  a  complete  cure. 

3d.  He  treated  a  patient  of  M.  Proust ;  the  applica- 
tion of  a  magnet  had  caused  the  symptoms  to  disappear 
only  momentarily.  This  patient  entered  the  service  of 
M.  Debove,  with  hemiana^sthesia  and  hemiplegia.  An 
application  for  a  half  hour  gave,  as  with  M.  Proust,  only 
momentary  relief  A  continuous  application  for  twenty- 
four  hours  was  made  and  gave  complete  success. 

Besides,  M.  Debove  has  two  analogous  observations 
which  M.  Vigouroux  has  communicated  to  him ;  in  both 
cases  there  was  recovery. 

The  cases  observed  by  M.  Debove  are  very  dissimilar 
in  the  point  of  view  of  etiology  of  the  difficulties ;  in  one, 
cerebral  softening,  in  another,  saturnism,  syphilis ;  but  in 
all  we  find  a  common  character  of  capital  importance, 
which  binds  them  together  and  permits  to  range  them  in 
a  single  group — it  is  the  coincidence  of  hemiansesthenia 
and  hemiparesis.  Another  important  fact  which  results 
from  the  observations,  is  that  in  all  the  cases  where  these 
two  phenomena  co-exist,  they  are  inseparable  ;  one  disap- 
pears with  the  other;  when  one  re-appears,  the  other  is 
reproduced  to  the  same  degree  and  when  there  is  a 
transfer,  as  is  observed  in  hysteria,  the  transfer  always 
takes  place  with  both  at  the  same  time. 


Society  of  Siologv. 


October  25th,   1879. 

M.  Laborde  presented  two  animals  in  which  he  has 
sought  to  produce  artificial  cerebral  hemorrhages.  1st,  A 
cat,  which  offers  a  fine  example  of  movements,  en  manege, 
and  always  turns  to  the  left ;  2d,  A  dog,  hemiplegic  upon 
the  left  side  and  which  presents  a  corresponding  deviation 
to  the  right  of  the  head  and  eyes.  The  experimental 
lesion  is  seated,  probably,  in  the  right  paracentral  lobule. 
Hereafter  the  anatomical  specimens  will  be  brought  before 
the  Society,  which  shah  then  judge  also  the  relation  which 
exists  between  the  actual  symptoms  and  the  anatomical 
alterations  which  the  autopsy  shall  make    known. 


114  E.  M.  Kelson, 


M.  Francois  Fianck. — ^The  pneumogastric  nerve  at  the 
cervical  region  has  already  received  a  large  number  of  sensi- 
tive filaments  from  different  points  of  the  thorax  and 
abdomen.  The  excitation  of  the  central  end  of  the  nerve 
in  this  region,  produces  the  collective  effects  of  excitation 
of  these  different  centripal  filaments.  Also,  it  is  important 
to  study  separately  the  effects  of  the  excitation  of  each  of 
these  afferent  filaments  in  order  to  know  the  part  which 
belongs  to  them  in  the  results  of  the  excitation  of  the 
common  trunk.  One  can  commence  this  study  by  the 
excitation  of  the  sensitive  nerves  of  the  larynx,  of  the 
trachea  and  of  the  bronchi.  Excitation  of  the  central 
end  of  the  superior  laryngeal,  determines,  as  INT.  Bert  has 
indicated,  the  arrest  of  respiration  in  the  same  phase  where 
it  finds  it ;  it  determines,  also,  the  momentary  arrest  of 
the  heart.  By  reason  of  this  last  fact,  the  arterial  pres- 
sure is  lowered.  But  if,  by  a  preliminary  injection  of 
atropine,  the  heart  of  the  animal  is  removed  from  the 
reflex  influence  of  the  pneumogastric,  the  arterial  pressure, 
instead  of  lowering,  rises.  In  consequence,  the  superior  lar- 
}'ngcal  nerve  plays  the  role  of  moderator  nerve  in  relation 
to  the  heart,  and  of  vaso-constrictor  nerve  in  relation  to 
the  vessels ;  these  effects  are  produced  in  a  reflex  manner. 
The  sensitive  nerves  of  the  trachea  and  bronchi  rejoin 
the  pneumogastric  by  the  anastomosis  of  Galien.  Mm. 
Philipeaux  and  Vulpian  had  already  shown  that  the  sec- 
tion of  the  anastomosis  of  Galien  produces  degeneration 
of  a  certain  number  of  filaments  of  the  recurrent.  Direct 
experiments  show  that  these  degenerated  filaments  are 
sensitive  nerves  returning  to  the  superior  laryngeal  by  the 
anastomosis  of  Galien.  In  fact,  excitation  of  the  peri- 
pheric end  or  the  recurrent  nerve,  that  is  to  say,  of  the 
portion  of  the  nerve  which  reJ9ins  this  anastomosis,  deter- 
mines, aside  from  movements  of  the  larynx,  which  are 
here  out  of  consideration,  cardiac,  vascular  and  respiratory 
effects  analogous  to  those  of  centripetal  excitation  of  the 
superior  laryngeal.  Excitation  of  this  same  recurrent 
portion  fails  to  produce  this  effect,  if  the  anastomosis  of 
Galien  has  been  cut ;  excitation  of  its  central  end  also 
gives  negative  results,  which  shows  that  no  sensitive  fila- 
ment ascends,  following  it  directly,  to  the  pneumogastric. 
— Gazette  Ilcbdom.,  Oct.   31,    1879. 


Selections. 


Physical     Results     From     Mental     Impression. A 

healthy  girl,  aged  seventeen,  was  one  day  very  much 
frightened  by  a  floor  giving  way  beneath  her.  The  same 
night  she  began  to  complain  of  headache  and  chills,  and 
the  next  morning  felt  restless,  and  had  itching  of  the 
scalp.  During  the  following  days  she  steadily  improved, 
w^ith  the  exception  of  the  itching.  One  day,  while  combing 
her  hair,  she  noticed  that  it  came  out  in  great  quantities. 
Three  days  later  she  was  perfectly  bald  ;  and  in  two  more 
days  she  had  lost  every  hair  on  her  body.  Her  general 
health  was  good.  The  patient  remained  bald  and  was 
still  so  when  seen  two  years  after  by  the  reporter. — Hasp. 
Gazette,   1879. 

A  little  French  girl  was  so  greatly  frightened  during 
a  late  thunderstorm,  that  for  a  time  her  parents  feared  of 
her  recovery.  The  electric  fluid  passed  very  close  to  her, 
causing  a  sense  of  suffocation  and  a  fit  of  hiccoughs. 
Her  mother  took  her  to  the  Children's  Hospital,  in  Paris, 
for  advice.  At  the  operating  theatre,  on  seeing  the  med- 
ical man  standing  at  a  table,  covered  with  some  awful- 
looking  in.struments  and  surrounded  by  a  number  of 
assistants  in  white  aprons,  the  child  became  so  terrified 
that  she    forgot  her  hiccough,  and  was  thus    cured. — Ibid. 

Murder  by  a  Somnambulist. — The  British  Medical 
Journal,  of  July  20th,  1879,  gives  the  particulars  of  a 
somnambulist,  who  was  tried  last  year  for  the  offence 
of  throwing  his  son,  eight  years  old,  on  the  floor  with 
such  violence  as  to  cause  death.  The  jury  decided 
that  the  father  was  not  responsible  for  the  act,  because 
of  his  having  been,  at  the  time  of  its  commission,  in  a 
somnambulistic   state. 

AN  IMPROVED    .ESTHESIOMETER. 


Before  the  State  ^Medical  Association,  which  met  at 
Columbia,  Missouri,  last  June,  Dr.  C.  H.  Hughes  of  St. 
Louis,    described    the    improved    aesthesiometer,   one     side 


116 


Selections. 


of  which  is  illustrated  in  the  accompanying  cut.  Its 
distinguishing  features,  are  its  convenience,  compactness 
and  utility  in  the  hands  of  those  who  have  ot  become 
expert,  through  long  practice,  in  jESthesiometric  examina- 
tions. It  has  reversible  points,  blunt  and  sharp,  for  deter- 
mining both  an;tsthesia  and  analgesia,  and  on  one  side,  a 
register  of  the  principal  distance  points  of  normal  tactile 
sensibility.  The  sliding  point  can  be  fixed,  when  required, 
by  a  screw,  so  as  to  avoid  mistakes  in  tactile  mensuration. 
The  scale  is  both  English  and  decimal,  and  the  whole 
folds  up    like    a    pocket    knife. 


FIVE  NEW  CASES  OF   PSEUDO- 
HYPERTROPHIC MUSCU- 
LAR PARALYSIS. 


Selections.  117 


Last  May  Dr.  A.  J.  Steele,  of  this  city,  reported  to 
the  State  Medical  A  sociation,  of  Missouri,  a  typical 
case  of  this  affection  occurring  in  a  boy,  aged  1 1  years, 
referring,  at  the  same  time,  to  a  younger  brother  of  this 
boy  who  was  similarly  affected  ;  and  in  September  last 
Dr.  J.  P.  Kingsley  exhibited  before  the  St.  Louis  Medi- 
cal Society  two  sisters,  aged  respectively  thirteen  and 
ten    years,    having    this    disease    well    marked. 

Figs.  I  and  II  represent  two  views  of  Dr.  Steele's 
case,  and  fig.  Ill  shows  one  aspect  of  one  of  Dr. 
Kingsley's  cases. 

They  presented  the  usual  symptoms  of  this  interest- 
ing   affection. 

Dr.  Steele,  while  regarding  this  disease  as  neuropathic 
rather  than  myopathic  in  its  origin,  prefers  the  term 
pseiido-hypci  tropJiy  uuiscjilorum,  and  reasons  thus  in  support 
of  his  view : 

The  prominent  characteristic  of  this  affection  is  abnor- 
mal increase  in  size  of  certain  voluntary  muscles,  at- 
tended with  impairment  of  their  function,  as  a  rule 
commencing  with,  and  often  confined  to,  the  muscles  of 
the  lower  extremities.  It  is  quite  evident  that  an  irritation 
or  chronic  inflammation  of  the  muscular  substance  exists, 
following  and  accompanying  which  is  a  great  deposit  and 
accumulation  of  fat,  interstitial  and  even  interfibrillary, 
to  which  (increase  of  fat)  the  enlargement  of  the  affected 
muscle  is  due ;  and  thus  it  is  not  a  true  but  a  false 
(pseudo)  hypertrophy.  It  is  further  probable  that  a 
hyperplastic  development  of  the  connective  tissue  imme- 
diately precedes  the  deposit  of,  or  transformation  into,  fat. 
The  interfibriUary  deposit  of  fat  is  sometimes  so  great  as 
apparently  to  crowd  out  and  cause  an  absorption  of  the 
sarcous    element. 

In  the  stage  of  the  affection  when  the  muscular  fibrillae 
have  entirely  disappeared,  there  certainly  cannot  be  loss 
of  function  of  what  does  not  exist.  A  child  with  con- 
genital absence  of  the  muscles  of  the  leg  could  not  be  said 
to  have  paralysis  of  those  muscles.       If  the  sarcous  tissue 


1 18  Selections. 


is  present  and  there  is  inability  to  use  it,  then  it  is  para- 
lyzed ;  but  if  the  sarcous  tissue  is  absent  it  cannot  be 
paralyzed,  for  it  would  be  illogical  to  attribute  a  state  or 
condition  to  a  thing  that  did  not  exist.  And  thus  we 
object  to  titling  this  affection  "pseudo-hypertrophic  paral- 
ysis," but  prefer  rather  that  of  ''  pscndo-liypcrtrophy 
niusculoruniy 

Dr.  Steele's  case  weighs  58  pounds,  his  height  is  3  feet 
1 1  inches.  His  walk  on  even  ground  '\s,  slow  and 
labored,  with  a  waddling  or  rolling  gait,  hitching  the  limbs. 
The  feet  are  separated  in  walking  as  well  as  in  standing ; 
he  experiences  much  trouble  in  stepping  up.  cannot  do  so 
without  placing  his  hands  upon  his  thighs.  The  calves 
of  the  legs  are  enlarged,  prominent  and  hard  ;  the  left 
measures  11^,  right,  ii^  inches;  the  mid-thigh  meas- 
urements are  13.^  inches.  The  gluteal  muscles  are 
markedly  hypertrophied,  and  the  lumbar  and  scapular 
regions  likewise.  A  plumb  line,  let  fall  from  the  seventh 
cervical  vertebra,  passes  back  of  the  sacrum  about  two 
inches. 

Dr.  Kingley's  cases  are  quite  similar  in  respect  of  dif- 
ficulty of  movement  and  spinal  incurvation. 

CIRCUMFERENCE    OF    THE    LEGS    .VXD    THIGHS. 

Right  calf  of  elder  sister     -         -        \2\  inches. 

Left  "  "  -       -         -   12} 

Thighs  at  largest  part  -         -        14  " 

Right  calf  of  younger  sister  -         -    1I4 

Left  "  "       -  -         10:^ 

Right  thigh  at  largest  part  -  -    iif 

Left  "  "     -  -  11^" 

The  hypertrophy  of  the  calves  and  gluteal  muscles  is 
very  marked  in  Dr.  Kingley's  cases.  The  weakness  of  the 
muscles  of  the  thighs  is  so  great,  that  it  is  impossible  for 
the  elder  girl  to  place  one  leg  across  the  other  while  sit- 
ting in  a  chair,  without    seizing  it  with   the  hands. 

The  London  Lancet,  of  Oct.  25th,  contains  a  descrip- 
tion   of    a    case      reported     by      I\L     Dally    to    the     Paris 


Selections- 


iiy 


Therapeutical  Society,  Oct.  8th.  M.  Dally  is  reported  as 
having  said  :  "Only  thirteen  observations  of  this  disease  are 
recorded," — evidently  an    error. 

Traumatic  Aphasia. — In  the  Canada  Lancet  for  Decem- 
ber, Drs.  N.  R.  Colter  and  Stephen  Smith  report  a  case 
of  gradually  but  slowly  recovering  aphasia,  following 
speechless  traumatic  coma  and  convulsions.  The  injury 
was  a  semi-circular  wound  of  the  forehead,  the  lower  edge 
about  I  inch  above  the  left  superciliary  ridge,  the  outer 
edge  about  \  inch  from  the  temporal  ridge,  extending 
about   i^  inches. 

The  size  of  the  bone  was  nearly  half  that  of  a  INIex- 
ican  dollar.       At  least    \h  fld.  oz.  of  brain  was  lost. 

The  girl  understood  everything  said  to  her  readily,  but 
could  only  respond  with  "ga-ga-ga." 

In  the  same  Journal  is  reported  a  death,  b}*  heart 
paralysis,  from  the  inhalation  of  scarcely  an  ounce  of  sul- 
phuric ether,  given  before  the  extraction  of  a  tooth. 


EDITORIAL  DEPARTMENT. 


INTRODUCTORY. 


S)q£^|^0  GREAT  has  been  the  progress  in  Neurological  research 

W^^Sk'  ^'"^®    ^^^  gnat  CiiUen,  a  century    ago.  with    the  insph-a- 

Wi-'k^jk  tional  loresiglit  of    true  genius  and    a    discernment    above 

^_  ;?"'^that    of    his     cotemporai'ies.     asserted     the    now    clearly 

V^  -^s  ^'  ileiuonstrable    truth    that   "most    morbid    aftections    are   so 

*^li^*i..'    dependent  on   the  nervous  system,  as  in  a  manner,  to  entitle 

^  *  "-     them  to  be  called  nervous."  that  no  apology  seems  neees- 

I^'     ^''"    ^^^'  =^^^f^"^o-  ^^  tl"s  time,    one    more  to    the    number 

"^°     of  Psychological  and    Neurological  journals  extant.      The 

^M>       researches  of  tlie  last  few  years,  especially,  have  carried  us 

so  much    farther  than  before  into  the  Arcana  of  man's  subtle 

nervous  nature,  and  brought  to  light  so  many  morbid  processes  hitherto 

concealed  from   view,  that  more  adequate    media    than    now    exist  for 

diflusing  these  revelations  are  cert;iinly  required. 

A  hopeful  curiosity  now  stimulates  scientific  minds,  in  the 
ranks  of  medicine,  to  unexampled  eflorts,  and  these  efforts  are 
being  rewarded  by  grand  results.  Penetrating  research,  aided  by 
cunning  contrivances  of  man's  inventive  genius,  born  ot  the  quickened 
thought  of  the  age.  is  daily  -opening  up"  new  mines  of  truth,  and 
breaking  down  barriers  that,  hitherto,  have  stood  in  tlie  pathway  of 
progress.  Through  these  instrunientaliiies.  for  instance,  cerebral  local- 
ization, which,  until  a  lew  years  ago.  seemed  only  vague  conjectuic. 
has  become  a  realization,  so  that  the  expectation  is  not  extravagant  that 
tlie  next  decade  will  add  much  more,  to  our  knowledge  of  the  diseases 
of  the  brain  and  allied  nervous  system,  than  any  preceding  ten  years 
in  tlie  brilliant  history  of  medicjil  advance. 

But.  while  we  make  no  apology  for  our  apjiearing,  we  ask  for 
lenient  criticisms  on  our  appearance.  No  one  engaged  in  the  arduous 
practical  duties  of  every  day  professional  life.  can.  at  all  times,  faith- 
fully discharge  the  duties  of  such  avocation  and  not.  sometiiiies.  fail  to 
tullill  even  reasonable  expectations  in  the  conduct  of  a  medical  journ:iI. 
In  the  selection  of  the  cont-nts  ol  the  journal,  it  will  be  our  aim  to 
make  it  a  tiue  mirror  (as  announced  in  the  prospectus)  of  Clinical  and 
Practical  psychiatry  and  neurology,  to  subserve  the  wants,  especially,  of 
the  practising  physician.  With  thi^  end  in  view,  while  theoretical  dis- 
.u-sions  will  not  be  dis.  ounteiianced.  preference  will  be  g'weii  to  contri- 
butions of  a  practical  character. 

The  views  of  those  who,  fulfilling  the  injunction  of  the  great 
Esquirol,  liave  lived  with   the    insane,   and  by  long  personal  familiarity 


ERRATA. 

On  page  121.  Twenty-second  line.  tl>e  word 
•'o-reat"'  should  read  -just." 


Editorial.  121 


with  their  maladies  liave  learned  the  mopt  that,  thus  far,  is  knowable 
of  them,  will,  of  course,  be  more  favorably  regarded  respecting  the 
pathology  of  insanity,  and  the  proper  management  and  treatment  of  the 
the  insane,  than  mere  theoretical  notions  respecting  this  disorder  and 
the  disposal  ot  its  unfortunate  victims.  Remembering  ''how  much  less 
difficult  it  is  to  establish  systems  and  imagine  brilliant  hypotheses 
respecting  mental  alienation,  than  to  observe  the  insane,"  and  reach 
conclusions  concerning  them  through  the  slow,  but  more  certain  pro- 
cess of  experience. 

Such,  also,  will  be  our  attitude  toward  contributions  on  neurologi- 
cal subjects,  where  the  mind  is  not  specially  implicated.  Ripe  conclu- 
sions and  cautious  deductions  from  observation  will  be  preferred  to 
crude  conjecture. 

Chief  among  the  purposes  of  the  Alienist  and  Neurologist  will 
also  be,  to  garner  the  rich  stores  of  pathological  material  to  be  found 
near  home,  and  tender  it,  as  a  reciprocal  ofiering,  for  the  valuable 
contributions  so  freely  and  generou.'-ly  given  from  abroad. 

St.  Louis,  with  its  halt  a  million  of  souls,  its  large  and  numer  us 
hospitals,  efficient  medical  schools,  and  active  and  distinguished  medical 
workers,  must  soon  become  an  universally  acknowledged  medical  centre. 
It  will  be  our  endeavor,  by  all  proper  means,  to  hasten  the  day  of  her 
great  recognition  abroad. 

The  Alienist  and  Neurologist  will  seek  to  inculcate  the  idea  that 
psychiatry  and  neurology  should  not  be  divorced  from  the  main  body 
of  medicine.  It  will  regaid  these  departments  (as  set  forth  in  the 
prospectus)  rather  in  the  light  of  essential  parts  of  the  trunk,  than 
special  branches  of  general  medicine,  and  will  maintain  respecting  them  and 
that  "vast  chain  of  being,"  which,  in  health  and  disease,  constitutes  tlie 
human  organism,  that 

"All  are  but  parts  of  one  (great)  whole," 
Whose  life  the  blood  is, 
And  the  nerves  the  soul, 
a  fact  which,  if  we  may  be  permitted  a  little    of  that  license  of  expres- 
sion accorded  to  poets,  is  becoming  every  day    more  and  more  demon- 
strable. 

With  this  view  ot  the  relationship  of  psychiatry  and  neurology  to 
general  medicine,  the  journal  will  accept  the  aid  of  others  than  such  as 
may  have  won  distinction  alone  in  these  departments.  It  will  gather 
all  the  valurible  facts,  not  mal  appropos,  obtainable  from  distinguished 
sources  in  every  department  of  special  medicine.  Among  those  now 
aiding  the  journal  are  some  eminent  surgeons,  opthalmologists,  aurist-, 
laryngologists,  dermatologists  as  well  as  many  distinguished  alienists, 
neurologists  and  general  practitioners. 

Messages  of  co-operation  and  encouragement,  by  subscriptions  and 
and  otherwise,  have  come  to  us  from  all  points  of  the  compass.  So  uni- 
formly encouraging  liave  been  the  responses  fiom  all  with  whom  we  have 
directly  communicated,  that  we  need  no  further  assurance  that  the  kind 
of  Journal,  contemplated  in  our  prospectus,  is  demanded  by  the  necessi- 
ties of  the  times.      Had  we,  bowcAer,  to  conduct  it  unaided  we  should 


122  Editorial. 


disiiair  of  fulfilling  expectations,  but  with  the  substantial  co-operation 
promised,  we  enter  upon  the  discharge  of  our  part  of  the  work  with  a 
confidence  born  of  the  faith  we  repose  in  our  friends,  and  the  manifest 
onward  and  upward  de?tiiiy  of  psychological  and  neurological  medicine. 


The  Ckxtrai.bi.att  run  Nkrvkxheilkunde,  Psychiatric  und  Gerich- 
tliche  I'sychopathologie,  makes  the  following  reference  to  two  papers 
on  Aphasia,  read  before  the  St.  Louis  Medical  Society,  by  Drs.  C.  \V. 
Stevens  and  C.  11.  Hugiies,  which  we  translate  for  briet  correction  and 
remark : 

'•Dr.  Slevens  reported  a  case,  in  which  a  law  suit  was  instituted  con- 
cerning the  mental  capacity  of  a  man  to  dispose  of  his  property. 

An  architect  about  thirty  years  of  age,  a  very  skillful  and  respected 
man,  suffered  an  attack  of  apoplexy  in  the  street,  in  March,  1873.  After 
regaining  consciousness  it  was  found  that  he  was  hemiplegic  on  his 
right  side  and  completely  aphasic.  The  patient  remained  in  a  stupor 
for  some  time;  he  recognized  no  one;  he  did  not.  in  anyway,  make 
known  his  wis  ties,  not  even  his  natural  wants.  Very  gradually  his 
physical  condition  improved,  as  did  also  his  paralysis.  The  patient 
learned  to  make  himself  intelligible  by  means  of  signs,  but  always 
remained  aphasic ;  he  conveyed  the  impression  that  he  understood  what 
was  said  to  him.  With  the  aphasia  there  was  agraphia  ;  after  the  lapse 
of  tiuo  years,  he  learned  to  write  a  little,  again ;  thus  he  could  copy 
the  letters  of  the  alphabet,  and  he  learned  to  write  his  name,  but  he 
never  succeeded  in  writing  a  thought. 

Three  months  after  his  apoplectic  attack  he  was  induced  to  inter- 
est himselt  to  the  extent  of  $5,000  in  an  undertaking,  to  which  he 
had  assented  before  his  attack.  Some  of  his  relatives  questioned  his 
capability  to  dispose  of  his  property  and  a  law  suit  resulted,  in  which 
the  reporter  was  summoned  as  an  expert.  The  case  came  up  in 
187G.  and  again  in  the  spring  of  1878.  Two  of  the  experts  consid- 
ered him  oompos  mentis,  an  i  thought  he  ought  to  be  held  to  his 
agreement,  since  he  had  given  his  attention  to  the  transaction  before 
his  attack.  The  reporter  opposed  this  view,  and  denied  the  possi- 
bility of  the  patient  to  appreciate  such  a  step  three  months  after  the 
attack,  since  even  when  his  condition  was  best  alter  the  injury,  his 
changed  behavior  was  noticed  by  those  around  him.  I'he  patient  was 
indifierently  careless  and  childish — a  marked  contrast  to  his  former 
behavior. 

The   Court  declared  him  noii  compos. 

The  reporter  considers  the  ])athoU)gi(al  condition  to  have  been 
embolus  of  the  artery  of  the  Fossa  of  Sylvius,  since  tlie  patient  suf- 
fered from  valvular  disease. 

The  discussion  of  the  case  consisted  of  sonu;  remarks  of  the  op- 
posing expert.  Dr.  Hughes,  who  considered  the  patient  perfectly  well 
excepting  the  aphasia,  and  he  based  his  assertion  more  especially  upon 
theoretical  grounds;    he  said  that    only    one    hemisphere  was  involved, 


Editorial.  123 


its  functions  could  liave  been  performed  by  the  other  ;  the  part  invol- 
ved is  not  of  great  importance  so  tar  as  intellig'ence  is  concerned. 
for  its  seat  is  more  particularly  in  the  posterior  lobes,  which  were 
not  diseased;  besides  such  symptoms  as  delirium,  mania,  illusions  and 
hallucinations  were  not  observed. 

At  the  subsequent  meetin"-.  Dr.  Hughes  read  a  paper  on  aphasia 
and  its  medico-legal  signification,  in  which  he  made  a  critical  review 
of  the  different    (older)  authors." 

Dr.  Hughes'  views  respecting  this  interesting  case  and  analysis  ot 
all  the  alleged  insane  acts  of  the  man.  may  be  found,  in  extenso.  in 
the  January,  1869,  nuinber  of  the  American  Journal  of  In-^anity. 

This  aphasic  person  learned  to  write  his  own  name  legibly  with 
his  left  hand  loithin  four  months  from  the  time  when  he  was  first 
stricken,  and  four  months  after  his  attack,  signed  a  deed  of  trust  in 
fulfillment  of  a  promise  and  purpose  made  and  entertained  prior  to  his 
affliction    to  carry   out   predetermined   business  plans. 

Our  opinion  as  to  his  7ne7ital  competency  was  based  on  this  fact  and  on 
the  fact  that  all  his  actions,  to  our  mind,  were  explainable  in  accordance  with 
his  hemiplegia  and  aphasia,  as  well  as  on  theoretical  conceptions  as  to  the 
location  of  the  lesion.  An  aphasic,  paralyzed  on  one  side  of  his  face, 
and  one  half  of  his  body  w'onld  betraj'  a  changed  demeanor,  and  yet 
might  not  be  insane.  His  sanity  was  also  aduiitted  at  the  time  of  the 
suit — lie  admitted  that  he  was  then  mentally  recovered. 

The  man  was  not  ambidextrous.  His  signature  to  the  deed  of 
trust,  made  with  his  left  hand,  four  months  after  he  was  first  afflicted, 
being  then  not  different  from  the  following  specimen  which  he  made 
for  us  at  one  of  our  interviews,  a  short  time  before  the  suit.  At 
this  time  he  made  the  other  signatures,  also,  which  appear  below.  He 
realized  his  condition  of  disability  as  a  sane  man  would,  and  comported 
himself  accordingly,  never  attempting,  after  his  atflictic-n,  to  do  more 
than  finish  up  the  business  in  which  he  was  engaged  prior  to  it. 

He  designated  by  gesticulation  the  property  he  wished  to  encum- 
ber, as  well  as  that  he  wished  to  exclude  from  the  deed,  in  a  manner 
that  was  clearly  understood  by  those  about  him.  The  Notary  who 
took  his  acknowledgment,  and  the  witness  to  his  signature,  testified 
to  his  intelligent  understanding  of  the  deed  of  trust   he   signed . 

There  was  undoubted  mental  confusion  in  the  beginning  of  his 
attack,  but  he  made  the  not  unusual  rajiid  improvement,  as  shown 
by  his  so  soon  learning  to  sign  his  name  with  his  left  hand,  the 
very  thing  he,  at  that  time,  most  needed  to  learn,  for  he  had  unfin- 
ished business  to  be  completed  in  that  way.  Many  of  tlie  things  he 
did  seemed  to  proceed  from  insanity,  such  as  spitting  in  improper 
places  once  or  twice,  laughing  with  a  grimmace  and  foolishly,  which 
because  of  his  one-sided  facial  paralysis  he  could  not  help;  once  or 
twice  defecating  in  bed,  and  permitting  his  drawers  to  be  unbuttoned 
before  ladies  on  one  or  two  occasions,  during  the  first  weeks,  which  he 
likewise  could  not  avoid  because  of  his  paralytic  condition. 

None  of  the  acts  seemed  to  proceed  from  delusion  or  illusion,  hallu- 
cination   or    to   pass  into  habits  and   be    repeated    more  than    once  or 


124  Editorial. 


twice.  accon]!n<r  to  the  testimony  of  the  relatives  (interesteil  like  him 
in  the  snccess  of  his  snil)  or  to  persist  after  the  facial  paralysis  passed 
away.  NVe  regarded  the  man  at  the  time  of  signing-  the  deed  suffi- 
ciently competent  in  mind  to  appreciate  the  nature  and  quality  of 
that  act.     That  was    all  the  Court    asked. 

A  jury  (not  the  Court)  of   non-medical  men  thought  otherwise. 

Herewith  are  some  specimens  of  his  hand  -writing,  which  were 
given  at  the  time  the  case  was  reported  in  the  Journal  of  Insanity. 


In  reference  to  this  interesting  case,  while  we  think  we  (and  Dr. 
Bauduy,  wlio  coincided  Avith  us),  were  not  in  error  respecting  Bevin's 
mental  status,  we  make  no  claim  to  infallibility  of  judgment.  The 
majority  of  medical  men  testifying  in  the  case,  fortified  by  the  opinion  of 
Dr.  Stevens,  thought  differently  trom  us.  It  was  a  case  upon  which 
medical  men  might  be  expected  to  honestly  differ,  yet,  notwithstand- 
ing, we  have  reviewed  and  re-reviewed  all  the  facts  in  the  case— our 
opinion  is  unaltered. 

"RECOVKniES  PROM  Mbntal  DisKA.'iE,"  by  Dr.  Isaac  Ray,  and  the 
continuation  of  Dr.  Curwen's  paper  will  appear  in  the  next  issue. 

Several  books  for  review  and  notices  of  hospital  reports  are  unavoid- 
ably crowded  out. 


IN  MEMORIAM. 


Dr.  Jno.  Eugene  Tyler, — Notwithstanding  something  over  a  year 
has  elapsed  since  the  demise  of  this  great  and  good  physician,  whose  espe- 
cial province  it  was  to  "minister  to  minds  diseased,"  we  are  unwilling  that 
our  columns  should  contain  no  record  to  his  memory. 

At  the  request  of  the  New  England  Psychological  Society,  Dr.  J.  P. 
Bancroft,  of  Concord,  N.  H.,  prepared  a  lengthj-  and  fitting  memorial  trib- 
ute, from  which  we  make  the  following  extracts  (in  substance),  regretting 
that  we  can  not  give  more  space  to  the  memory  of  our  departed  friend  : 


Editorial.  125 


His  practice  and  consultations  were  confined  to  diseases  involving 
the  mind,  and  his  services  were  in  much  demand  in  his  own  city 
and  state,  and  in  New  England  an  l  New  York.  General  practition- 
ers cordially  welcomed  him,  extensively  sought  his  opinions  in  their 
practice,   and  held   them   in   high   esteem. 

As  a  superintendent  of  an  asylum  he  had  no  superior.  The  great- 
est diversity  of  qualifications  for  success  was  happily  blended  in  him. 
While  the  most  amiable  and  indulgent  of  men,  his  firmness  and 
decision   were   immovable. 

In  dealing  with  the  insane  personally,  he  could  not  be  surprised 
into  any  inconsiderate  haste  which  would  weaken  his  confidence.  His 
quick  perception  would  take  in  the  situation,  and  his  judgment  sug- 
gest at  once  the  best  thing  to  be  said  or  done  in  an  emergency.  The 
felicity  of  his  language  and  manners  among  the  insane,  in  response 
to  abnormal  manifestations,  was  remarkable.  A  single  word,  a  gesture, 
or  an  expression  of  the  countenance,  was  8ufl5cient  often  to  change 
the  whole  current  of  thought,  arouse  the  needed  emotion,  repress  the 
hurtful  one,  or  sent  a  ray  of  sunlight  into  the  darkened  chambers  of 
the  heart. 

He  was  quick  to  make  his  way  through  the  bewildering  and  often  con- 
flicting testimony  in  a  case  of  disputed  mental  integrity,  and  held  the  facts 
with  a  memory  of  singular  tenacity,  while  subjecting  them  to  exhaustive 
analysis.  With  untiring  patience,  every  item  was  considered  in  the  light 
of  the  whole  case.  In  two  of  the  highest  requisites  of  an  expert  worthy  of 
his  calling,  Dr.  Tyler  was  especially  conspicuous.  The  first  was,  the  rare 
powers  of  holding  clearly  before  the  mind  for  analysis  a  miscellaneous 
group  of  evidence.  The  second  was,  his  incorruptible  honesty  in  the  forma- 
tion and  use  of  his  opinions.  No  outside  influence  could  warp  his  judg- 
ment ;  no  temptation,  either  of  fear  or  favor,  could  seduce  him  into  the 
rendering  of  a  biased  opinion.  He  was  unable  to  entertain  the  thought  of 
being  secured  to  a  foregone  conclusion,  of  being  the  witness  of  a  side.  It  is 
not  inference,  but  knowledge,  with  the  writer,  that  there  was  not  power 
enough  in  money  to  tempt  him  to  labor  to  sustain  a  foreshadowed  opinion. 
With  him,  professional  opinions  were  sacred,  and  no  subject  of  traflSc.  The 
early  loss  of  such  a  man  is  a  public  calamity  at  any  time,  but  much  more  at 
a  time  when  this  virtue  is  not  a  universal  attribute  of  experts. 

At  the  time  of  his  death  the  President  and  P'ellows  of  Harvard  College 

^'■Resolved,  That  the  University  and  Community  haved  sufl"ered  a 
severe  loss  in  the  death  of  this  wise  physician,  accomplished  teacher 
and   upright   man." 

Dr.  Rat's  Berbavement. —  Our  readers  will  be  pained  to  learn 
of  this  eminent  alienist's  bereavement  by  the  death  of  his  son,  the  sad 
event  having  occurred  a  little  over  three  weeks  ag3.  This  is  a  crush- 
ing  blow  to  our  venerable  confrere,  for  his  son  was  an  active  and 
skillful  physician  in  the  prime  of  vigorous  manhood,  full  of  present 
usefulness  and   future   promise,    and  Dr.   Eay  was   much   devoted  to  him. 


0/ 


^ 


THE 


Alienist  i  Neurologist. 

VOL.  I.  APEIL,  1880.  ISO.  2. 


O  Y vavwtxX  C  o w\y  v\> vv\vo \\% . 


Art.  I. —Recoveries  from  Mental  Diseases. 


By  Isaac  Ray,  M.  D. 

Ty  ESPECTING  the  curability  of  insanity,  a  wide  differ- 
-^^  ence  of  opinion  has  always  existed,  and,  notwith- 
standing the  improvements  made  of  late  years  in  the 
care  and  treatment  of  the  insane,  this  difference  seems  to 
be  as  wide  as  ever.  It  might  be  supposed,  at  first  sight, 
that  the  establishment  of  hospitals  for  the  insane  would 
have  furnished  the  requisite  information,  but  the  onl}' 
effects  these  institutions  have  had  thus  far,  has  been  to 
give  us  a  keener  sense  of  our  ignorance  of  the  matter. 
A  new  phase  of  the  subject  has  been  presented  by  Dr. 
Earle,  Superintendent  of  the  Hospital  for  the  Insane  at 
Northampton,  in  his  recent  reports.      And    so  confident    is 

The  question  as  to  the  precise  proiiortioii  of  permanent  recoveries  from  men- 
tal disease  is  yet  undecided,  and  the  sulijoct  could  not  be  properly  discussed  iu 
our  pages  with  Dr.  Kay's  impcr  cjnitted.  We  accordinsrly  extract  it  from 
the  transactions  of  the'Colhre  ot'  I'livsiciaus,  of  Philadelphia,  and  give  it 
jilufe  in  (lur  iianos.  It  was  read  lieiin-f  that  body,  Mav  0th,  1879,  and  the 
Assnciatinii  ..IMii.crinlcndents,  at  their  nieetin.ir  at  Providence,  in  -Jnne,  1879,  and  is 
the  p.ipi'V  rclciT.il  ii>  bv  Dr.  Plinv  Earle.  in  the  Januarv  nnnilicr  of  lliis  Journal, 
in  his  article  entitled  :"  "The  Curability  of  Insanity  vs.  Recoveries  from  Mental 
Diseases." — Ed. 


132  Isaac  Ray, 


he  of  the  correctness  of  his  conckisions,  and  so  many  arc 
the  commendatory  notices. he  has  received,  both  at  home 
and  abroad,  that  they  are  entitled  to  a  careful  examination. 

In  his  last  as  in  his  two  next  preceding  reports,  Dr. 
Earle  has  examined  the  matter  of  recoveries  as  exhibited 
in  the  statistics  of  our  hospitals  for  the  insane,  and  has 
been  struck  by  some  things  so  different  from  what  might 
have  been  naturally  expected,  that  he  is  led  to  seek  for 
an  explanation.  He  finds,  as  a  general  fact,  that  thirty 
or  forty  years  ago,  the  proportion  of  recoveries,  or  cures 
as  they  are  sometimes  called,  was  much  larger  than  it  has 
been  of  late  years,  and  he  proceeds  to  explain  the  fact  in 
a  way  that  is  ingenious  if  not  satisfactor>'.  It  cannot  be 
denied  that  to  the  observer  of  our  own  day,  the  record  is 
somewhat  startling,  for  while  it  appears  that  once  almost 
every  patient  recently  attacked,  recovered,  our  statistics 
show  that  now,  taking  our  hospitals  together,  hardly  half 
of  them  have  been  so  fortunate.  This  remarkable  differ- 
ence Dr.  Earle  attributes  to  two  sources  of  error  committed 
by  those  who  reported  the  larger  proportion  of  recoveries. 
One  of  them  he  describes  as  "  the  special  characteristics  of 
the  person  reporting  them — his  temperament,  his  constitu- 
tional organization,  his  'psychological  individuality."  In 
another  place  he  says,  alluding  to  the  medical  officers  of 
hospitals  for  the  insane,  "  they  are  men  '  with  like  passions 
as  other  men.'  Self-interest,  in  some  instances,  and  ambi- 
tion in  perhaps  all — that  ambition,  at  least,  which  is 
manifest  in  the  desire  to  show  as  fair  a  record  and  as 
favorable  results  as  are  exhibited  by  colleagues  in  the 
specialty — have  probably  not  been  wholly  inoperative  in 
reporting  recoveries  from  insanity,  even  though  uncon- 
sciously to  the  person  producing  those  reports."  I  am 
not  disposed  to  deny  the  correctness  of  the  general 
principle  here  stated,  but  I  do  question  whether  it  has 
had  all  the  influence  which  is  here  attributed  to  it.  Dr. 
Earle  thinks  it  has  sometimes  led  to  a  difference  in  the 
number  of  recoveries  as  reported  amounting  to  25  per  cent. 

Again,   Dr.   Earle    sa)-s    that     "the    reported  recoveries 


Recoveries  from  Mental  Diseases.  1-53 

from  insanity-  are  increased  to  an  important  extent  by 
repeated  recoveries  from  the  periodical  or  recurrent  form 
of  the  disease  in  the  same  person;  and  consequently,  the 
recoveries  of  persons  are  much  less  numerous  than  the 
recoveries  of  patients  or  cases ;  and  consequently,  from  the 
number  of  reported  recoveries  of  cases  or  patients,  it  is 
generally  impossible  to  ascertain  the  number  of  persons 
who  recovered." 

Undoubtedly,  these  two  sources  of  error  have  helped 
to  swell  the  proportion  of  recoveries  as  shown  by  the 
statistics,  but  not  to  the  extent  supposed  by  Dr.  Earle, 
In  the  nature  of  the  case,  physicians  would  not  be  likely 
to  agree  in  their  reports  of  the  results  of  care  and  treat- 
ment in  every  particular  instance.  Very  often  the  mental 
condition  of  a  patient  cannot  be  accurately  discerned. 
One  may  see  traces  of  disease  where  to  another  the  cloud 
seems  to  have  entirely  dispersed.  Whether  a  certain 
patient  has  thoroughly  recovered,  or  only  reached  a  stage 
of  improvement  which  may  prove  to  be  only  a  remission 
in  the  severity  of  the  disease,  may  be  a  matter  of  opinion 
more  than  of  fact,  on  which  men  may  differ  without 
showing  any  lack  of  intelligence  or  honesty.  We  might 
appeal  to  Dr.  Earle  himself  to  say  whether  he  has  not 
sometimes  hesitated  to  put  upon  his  records  the  final 
decision  on  this  point.  Recovery  from  any  disease  is  the 
terminal  point  to  which  the  conservative  powers  conduct 
the  patient  by  steps  more  or  less  obvious,  more  or  less 
rapid.  One  stage  of  the  process  we  call  convalescence, 
but  nobody  thinks  of  indicating  the  precise  moment  when 
convalescence  passes  into  recovery.  But  the  patient  is 
discharged  before  every  doubt  is  removed,  and  the  result 
must  be  definitely  reported.  Here  comes  in  the  influence 
of  temperament,  of  education,  of  habits  of  thinking.  One 
man  is  well  aware  that  some  lingering  traces  of  disease 
remain ;  but  the  healing  process  is  going  on,  and  he 
believes  that  it  will  have  a  good,  successful  conclusion, 
that  it  is  only  a  matter  of  time — a  few  weeks  more  or  less 
— and    that,    whether    it    occurs    inside    or    outside    of  the 


1^'4  Isaac  Ray, 


hospital,  it  may  be  fairly  reported  as  among  the  results  of 
hospital  treatment.  Another  man,  differently  constituted, 
sees  the  same  case  under  a  different  light.  He  fears  that 
the  traces  of  disease  are  still  strong  enough  to  make  him 
apprehensive  of  a  relapse,  and  he  shrinks  from  calling 
that  a  recovery  which  may  prove,  to  his  discomfiture,  only 
a  temporary-  improvement.  The  original  fault  was  in 
undertaking  to  give  statistical  expression  to  an  order  of 
occurrences  largely  conjectural.  It  may  well  be  doubted, 
whether  the  terms  recovcj-ed,  improved,  much  ijnprovcd, 
have  been  of  any  use  not  more  than  balanced  by  their 
inevitable  tendency  to  mislead  the  reader  respecting  the 
curability  of  insanity.  But  the  public  have  always  wished 
to  know,  particularly,  what  the  hospitals  were  doing,  and, 
as  often  happens,  thought  the  information  sought  for  was 
to    be    found    in    a    parade    of  vague,  general  expressions. 

Now,  while  I  do  not  doubt  that  the  mental  constitu- 
tion indicated  by  Dr.  Earle  has  been  a  source  of  error, 
yet,  admitting  the  fact  as  he  states  it,  I  am  not  sure  that 
it  explains  this  difference  in  the  results  of  the  early  and 
latter  period  of  our  hospital  history.  He  gives  us  no 
reasons  to  believe  that  the  physicians  of  our  hospitals  are 
constituted  very  differently  from  those  of  an  earlier  period. 
The  world  is  not  now,  and  probably  never  will  be,  without 
a  class  of  men  of  the  Mark  Tapley  sort,  always  seeing 
things  through  a  rose-colored  medium,  and  prognosticating 
happy  results.  This  being  so,  we  are  obliged  to  look 
elsewhere  for  even  a  partial  explanation  ot  the  apparently 
greater  success  of  our  predecessors  in  the  treatment  of 
insanity. 

Nor  am  I  better  satisfied  with  the  other  factor  of  the 
problem,  assigned  by  Dr.  Earle  ;  and  that  too  for  a  similar 
reason,  even  if  there  were  no  other.  Without  denying 
the  fact  that  some  patients  have  been  discharged  as 
recovered  more  than  once,  wc  have  no  reason  to  suppose 
that  this  mode  of  reporting  results  has  been  changed  of 
late  years.  If  it  were  a  matter  of  mere  honesty,  we 
might  possibl)'  think    otherwise,    but    the    practice  in  ques- 


Recoveries  from  Mental  Disease.  135 

tion  springs  from  the  nature  of  the  case,  and  any  practi- 
cable change  can  be  only  one  of  degree.  The  matter  is 
burdened  with  difficulties,  and  the  Doctor  himself  leaves  it 
in  doubt  whether  he  would  require  us  to  report  no  case 
as  recovered  which  had  been  so  reported  on  any  previous 
occasion.  He  certainly  prescribes  no  rule  to  be  observed. 
In  the  case  of  a  person  who,  having  recovered,  to  all 
appearance,  from  a  first  attack,  and  having  showed  no  sign 
of  mental  disturbance  for  years,  becomes  insane  again, 
does  he  hold  that  that  person  never  recovered  really 
from  the  first  attack,  and  ought  not  to  have  been  so 
reported  ?  If,  however,  he  believes  that  it  was  a  genuine 
recovery,  why  may  he  not  believe  that  the  second  appar- 
ent recovery  was  not  equally  so,  inasmuch  as  the  evidence 
therefor  is  exactly  the  same — no  trace  of  disease  percep- 
tible for  years,  and  no  lack  of  the  usual  vigor  and  compe- 
tence ?  And  if  so,  where  is  he  to  stop  ?  Is  not  the 
same  evidence  just  as  valid  in  the  case  of  a  third,  fourth, 
fifth  attack  ?  If  no  person  is  to  be  reported  as  recovered 
who  has  a  subsequent  attack,  then  we  must  wait  till  he 
dies  before  we  can  certify  as  to  his  mental  condition 
when  -discharged,,  and  that  will  put  an  end  to  all  our 
statistics,  which,  probably,  would  be  the  better  course. 

I  have  never  supposed  that  the  term  recovery,  as 
applied  to  disease,  meant  necessarily  a  perfect  restoration 
of  the  affected  organ  to  its  normal  vigor  and  power  of 
endurance.  Even  after  the  most  satisfactory  recovery, 
there  is  left,  generally,  if  not  always,  a  susceptibility  to 
noxious  influences,  which  renders  the  person  far  more 
liable  to  disease  than  he  otherwise  would  have  been. 
Yet  we  do  not  hesitate  to  speak  of  recovery  from  inter- 
mittent fever,  for  instance,  though  quite  sure  that  it  will 
re-appear  on  a  renewal  of  the  exciting  causes.  In  our 
general  hospitals,  it  is  the  practice,  I  believe,  to  discharge 
patients  as  recovered,  without  any  reference  to  the 
possible  recurrence  of  the  disease.  Undoubtedly,  insanity 
is  more  likely  to  recur  than  many  other  diseases,  but  the 
difference  is  only  one  of   degree,    and,  therefore,  I  see  no 


Isaac  Ray, 


good  reason  for  a  different  rule  in  the  manner  of  report- 
ing results  of  treatment.  ]\Iany  of  the  instances  of 
repeated  recoveries  mentioned  b\-  Dr.  Earle,  were  periodi- 
cal in  their  character.  That  is,  the  pathological  condition 
was  continuous,  with  intervals  when  the  more  demonstra- 
tive symptoms  had  disappeared.  These,  certainly,  were 
not  recoveries,  in  any  true  sense  of  the  term,  but  between 
them  and  those  complete  restorations  which  are  followed 
by  years  of  uninterrupted  soundness,  there  is  a  class  in 
which  the  intervals  are  not  so  clearly  defined,  either  in 
length  or  in  freedom  from  abnormal  manifestations.  How 
to  designate  these  is  not  very  obvious,  and  men  may 
honestly  differ  in  their  conclusions. 

But  even  at  the  worst,  according  to  Dr.  Earle's  own 
showing,  this  vicious  mode  of  reporting  results  fails  to 
account  for  the  difference  in  question.  The  Doctor  illus- 
trates his  position  by  means  of  the  statistics  of  the 
Friend's  Asylum,  at  Frankford,  whereby  it  appears  that^ 
deducting  the  cases  of  attacks  subsequent  to  the  first, 
and  regarding  those  patients  only  as  "permanently  cured," 
who  never  suffered  a  second  time,  the  proportion  of  recov- 
eries in  recent  cases  is  reduced  from  58.35  per  cent,  to 
48.39  per  cent.  This  amounts  to  a  reduction  of  only 
about  17  per  cent,  of  the  larger  number,  which  is  far  less 
than  the  conditions  of  the  question  require.  And  this  is, 
probably,  an  extreme  case,  for  we  doubt  if  in  any  other 
hospital  the  discharges  have  been  at  the  rate  of  "one 
patient  recovered  fifteen  times ;  another,  thirteen  ;  a  third, 
nine;  a  fourth,  eight;  and  a  fifth,  seven."  True,  it  is 
stated  at  the  Pennsylvania  Hospital  for  the  Insane,  "one 
man  was  admitted  on  the  twenty-second  attack  and  one 
woman  on  the  thirty- third  ;  six  men  and  six  women  on 
the  tenth  attack  ;  ninety-four  persons  on  the  fifth  attack  ; 
and  one  hundred  and  seventy-two  on  the  fourth."  From 
anything  said,  it  does  not  appear  that  a  single  one  of 
these  persons  was  discharged  as  recovered  more  than  once. 
Dr.  Earle,  however,  infers  to  the  contrary,  because,  as  he 
says,  "if  a  person  have  a    thirty-third    attack  of  a  disease, 


Recoveries  from  Mental  Diseases. 


it  necessarily  follows  that  he  had  previously  recovered 
from  thirty-two  attacks."  This  is  a  tremendous  jump  at 
a  conclusion  based  on  the  vague  signification  of  a  single 
word.  We  learn  from  Dr.  Kirkbride  that  no  periodical 
case  was  ever  discharged  as  recovered.  In  his  last  Report 
he  explains  his  views  on  this  subject,  in  a  manner  emi- 
nently fair  and  reasonable. 

"When,*'  he  says,  "an  individual  sufterino;  from  insanity  is  relieved 
from  all  indications  of  mental  unsoundness,  returns  to  his  home  and 
family  without  any  developed  eccentricity,  resumes  his  ordinary  rela- 
tions with  society,  attends  to  his  business  with  his  usual  ability 
and  intelligence,  tor  a  year,  or  even  a  much  less  period,  we  have  no 
hesitation  in  recording  such  a  case  as  'cured,'  without  any  reference 
to  the  future,  about  which  we  can  know  nothing.  We  have  no 
power  to  insure  any  case,  or  to  say  that  there  may  never  be  another 
attack.  ^Ve  have  no  right  to  assert  that  a  combination  of  circum- 
stances like  that  which  produced  the  first,  may  not  cause  another; 
that  ilj-health,  and  commercial  revolutions,  and  family  sorrows,  and 
the  many  other  causes  that  may  have  originally  developed  the  dis- 
order, may  not  again  bring  on  a  return  of  the  same  symptoms,  just 
as  they  may  produce  them  in  one  who  has  never  had  an  attack  of 
the  kind.  live  thousand,  six  hundred  and  ninety-five  of  those  re- 
ceived here  never  hail  an  attack  before.  Whatever  induced  the  disease 
in  them,  certainly  may  induce  it  in  those  who  have  already  suffered 
from  the  same  malady,  for  we  cannot  expect  one  attack  of  insanity 
to  act  as  a  prophylactic,  and,  like  measles  or  small  pox,  to  give  im- 
munity for  the  future.  But  this  new  attack  is  no  evidence  that  the 
patient  was  not  cured  ot  the  previous  one.  It  the  patient  then  is 
svell,  in  tlie  sense  in  which  he  is  con-idered  well  from  an  attack  of 
typhoid  fever,  or  dysenterj',  or  rheumatism,  or  a  score  of  other  mala- 
dies, when  another  attack  is  developed,  it  is  as  much  a  new  case, 
and  the  recovery  is  a  cure  as  much  it  as  would  be  if  he  suffered 
from  any  other  form   of  illness,    and  it  ought    to  be  so  recorded.'' 

As  then  neither  the  temperament  of  the  physician  nor 
the  repeated  counting  of  periodical  cases,  accounts  tor 
the  larger  proportion  of  recoveries,  in  the  earlier  times, 
we  must  look  for  the  explanation  in  another  direction, 
and  we  shall  find  it  in  various  agencies  that  have  come 
into  operation  in  later  times. 

Fifty  years  ago,  when  State  hospitals  for  the  insane  be- 
gan to  be  established,  the  main  purpose  for  which  they  were 
to  be  ured  was  that  of  receiving  the  insane  inmates  of  the 
jails  and  almshouses,  whose  sad  condition  had  arrested  the 
public  attention.        It  was  not  long  before    the    benefit    of 


loS  Isaac  Ray^ 


hospital  treatment  became  so  obvious  that  it  began  to  be 
sought  for  other  classes  of  the  insane,  slowly  increasing  at 
first  with  the  slow  growth  of  confidence.  As  might  have 
been  expected,  the  earliest  of  these  was  that  of  the  violent 
and  dangerous  cases  that  could  not  be  restrained  by  any 
domestic  arrangements  consistent  with  comfort  or  decency. 
Even  for  the  care  of  such  it  required  a  little  more  than 
an  average  intelligence  and  freedom  from  prejudice  to  see 
in  the  hospital  one  of  the  improvements  of  the  age,  des- 
tined to  meet  a  fearful  exigency  in  the  human  condition. 
It  was  not  until  a  later  period  that  patients  of  a  different 
character — the  quiet,  the  desponding,  the  melancholic — 
resorted  to  the  hospital.  They  had  excited  no  fears,  and 
conformed  somewhat  to  the  domestic  requirements.  There 
was  no  pressing  necessity  for  their  removal  from  home, 
and  the  superior  fitness  of  the  hospital  for  the  care  of 
such  cases  was  seldom  recognized.  Now  we  all  know 
that  in  the  form  of  disease  first  mentioned,  we  have  the 
largest  proportion  of  recoveries. 

And  this  result  was  promoted,  unquestionably,  by  a 
circumstance  too  much  overlooked  in  these  discussions 
concerning  the  curability  of  insanity.  Fifty  years  ago  the 
country  furnished  a  larger  proportion  of  patients,  as  com- 
pared with  the  city,  than  it  ever  has  since.  Their  general 
health  was  not  appreciably  impaired,  they  had  spent  their 
days  working  in  the  open  air,  and  their  natural  forces  had 
not  been  w^eakened  by  sensual  indulgences.  They  were 
in  the  best  possible  condition  to  meet  the  inroad  of 
mental  disease.  During  this  period  a  remarkable  change 
has  been  going  on  in  the  distribution  of  our  population. 
It  is  estimated,  on  good  authority,  that  one-third  of  our 
population  live  in  cities  of  50,000  or  more.  Seventy-five 
years  ago  there  was  not  one  city  of  that  size,  and  fifty 
years  ago  there  were  not  more  than  ten.  This  great 
change  in  our  social  condition  has  been  accompanied  b}- 
a  steady  depreciation  of  the  conservative  powers  of  the 
constitution,  strongly  manifested  in  the  physical  condition 
of  the  patients  admitted   into  our  hospitals    for  the  insane. 


Recoveries  from  Mental  Disease.  ^39 

The  number  attributed  to  ///  health,  in  the  table  of  causes 
usually  given  in  the  annual  report,  has  been  steadily 
increasing. 

No  array  of  figures,  however,  can  convey  such  an  im- 
pression of  this  remarkable  difference  as  that  derived  from 
a  personal  observation  embracing  the  whole  period.  Dr. 
Bell  had  good  reason  for  saying,  in  his  Report  of  the 
McLean  Asylum  for  1840,  "that  the  records  of  this  asylum 
justify  the  declaration  that  all  cases  certainly  recent — that 
is,  whose  origin  does  not,  cither  directly  or  obscurely,  run 
back  more  than  a  year — recover  under  a  fair  trial."  In 
quoting  this  passage,  Dr.  Earle  admits,  to  use  his  own 
words,  that  "  no  abler  man,  intellectually,  and  no  more  con- 
scientious man,  morally,  has  been  engaged  in  the  specialty 
of  psychology"  in  this  country,  and  this  being  so,  we  are 
left  in  the  dark  how  to  explain  this  statement  of  Dr.  Bell, 
which  Dr.  Earle  must  regard  as  gross  exaggeration  of  the 
truth.  It  might  be  attributed,  perhaps,  to  the  influence 
of  a  sanguine  temperament  and  the  practice  of  curing  the 
same  person  more  than  once,  did  not  the  sequel,  as  given 
by  Dr.  Earle  himself,  suggest  a  very  different  reason.  It 
seems  that  in  after  years  Dr.  Bell  reported  a  much  smaller 
proportion  of  recoveries,  the  proportion  pretty  steadily 
diminishing  during  the  latter  fifteen  years  of  his  service. 
That  is  to  say,  as  the  community  became  more  and  more 
enhghtened  as  to  the  beneficient  purposes  of  the  asylum, 
it  was  more  and  more  resorted  to  by  patients  of  the  less 
violent  kind,  and  by  others  affected  by  those  incurable 
forms  of  the  disease,  whose  care  could  be  merely  custo- 
dial. And  this  leads  us  to  an  incident  in  the  history  of 
insanity  that  must  not  be  overlooked  in  our  estimates  of 
of  curability. 

About  forty  years  ago,  when  our  country  was  rising 
from  the  financial  depression  that  began  in  1836,  and  the 
means  of  intercommunication  had  been  greatly  increased 
by  railw-ays  and  ocean  steamers,  a  change  began  in  the 
social  habits  of  our  people,  as  just  intimated,  manifested 
in  a    distaste    for    the    quiet    pursuits    of   a  country    life,  in 


140  Isaac  Ray, 


surrendering  to  the  allurements  of  the  city,  and  plunging 
into  the  struggle  for  the  great  prizes  of  life.  The  vitiated 
atmosphere  of  crowded  streets  and  dwellings,  the  seductive 
appliances  of  ease  and  luxur\-,  the  mental  strain  required 
in  the  race  of  competition,  the  tumult  of  emotion  under 
the  frequent  alternations  in  fortune,  all  these  serve  to  lower 
the  conservative  forces  of  the  system  and  invite  the  inva- 
sion of  nervous  disease.  The  tables  of  mortality  tell  the 
stor\^  in  the  figures  assigned  to  apoplexy,  paralysis  and 
cerebral  congestions,  and  the  records  of  our  census  show 
it  in  the  steadily  increasing  amount  of  insanity  in  the  last 
semi-centennial  period.  Not  only  did  insanity  become 
more  frequent,  but  it  also  became  less  curable.  And  even 
new  forms  of  disease  appeared,  and  the  wards  of  our 
hospitals  were  pervaded  by  a  class  of  cases  utterly 
unknown  before.  But  little  more  than  thirty  years  have 
elapsed  since  that  remarkable  affection,  General  Paralysis, 
became  known  to  American  physicians,  and  there  is  no 
reason  to  suspect  that  it  had  been  previously  overlooked. 
Dr.  Bell,  who  first  obser\^ed  it  in  Europe  in  1845,  satisfied 
himself,  after  a  most  thorough  examination  of  the  case 
books  of  the  McLean  Asylum,  that  up  to  that  period  no 
instance  of  it  had  been  observed  in  that  institution, 
though  since  then  it  has  been    frequent  enough. 

And  we  have  now  other  cerebral  affections  which,  once 
seldom  seen  in  our  hospitals,  are  no  longer  an  extraordin- 
ary sight.  I  refer  to  those  cases  which  seem  to  be 
closely  affiliated  to  general  paralysis,  but  do  not  present 
.'^ome  of  its  characteristic  symptoms.  The  same  may  be 
said  of  another  affection,  passing  under  the  various  names 
of  Bell's  disease,  acute  delirium,  and  typho-mania,  which 
is  eminently  and  speedily  fatal.  In  these  forms  of  cere- 
bral disease  the  patient  is  insane,  certainly,  but  the 
insanity  is  only  an  incident  accompanying  a  deeper  and 
graver  affection,  and  they  of  course  swell  the  death 
record,  and  to  the  same  extent  lessen  the  proportion  of 
recoveries.  Now,  therefore,  in  considering  the  question  in 
dispute,  we  shall  leave  out  of  the  account  a  ver\-  important 


Recoveries  from  Mental  Disease.  141 

factor  if  we  overlook  this  change  in  the  pathological 
character  of  mental  disease. 

Before  leaving  the  subject,  I  take  the  opportunity  of 
saying  that  the  experience  of  our  hospitals,  as  given  in 
their  annual  reports,  is  a  fallacious  test  of  the  curability 
of  insanity.  Between  this  objective  result  and  the  facts 
on  which  it  seems  to  be  founded,  there  is  really  no  neces- 
sary relation.  If  we  had  a  right  to  believe  that  every 
patient  discharged  as  improved,  unimproved  or  stationary 
was  incurable,  then  we  might  take  the  construction  usually 
placed  on  the  record.  But  we  well  know  that  such  dis- 
charges indicate  not  the  incurability  of  the  disease  so 
much  as  the  impatience,  or  perversity,  or  straitened  means 
of  the  friends.  Nothing  can  be  further  from  the  truth 
than  the  idea  that  they  represent  the  results  of  a  fair 
trial  of  hospital  treatment.  It  i*s  not  at  all  unlikely  that 
under  such  a  trial  of  recent  cases,  at  least  twelve  or 
fifteen  per  cent,  would  be  added  to  the  number  of  recov- 
eries. In  order  to  approach  a  correct  estimate  of  the 
curability  of  insanity,  two  requisites  are  still  needed,  viz.  : 
that  every  case  should  have  a  fair  trial,  and  that  the  sub- 
sequent history  of  every  case  discharged  should  be  ascer- 
tained. Without  these,  and  we  are  not  very  likely  to  have 
them  in  our  day,  we  can  never  have  an  estimate  of  the 
curability  of  insanity  with  any  claim  to  scientific  accuracy. 

These  then,  I  believe,  are  the  points  which  I  have 
fairly  made,  viz. : 

I.  Those  qualities  of  temperament  which  lead  men  to 
unduly  magnify  their  achievements  are  as  common  at  one 
time  as  at  another. 

II.  The  practice  of  reporting  cases  instead  of  persons 
has  not  been  confined  to  any  particular  period,  and  there- 
fore while  it  may  vitiate  our  estimate  of  the  curability  of 
insanity,  it  cannot  make  the  proportion  of  recoveries  larger 
or  smaller  at  one  period  than  at  another. 

III.  Cases  marked  by  high  excitement  entered  our 
hospitals  in  a  larger  proportion  to  those  of  an  opposite 
character  fifty  years  ago,  than  they  do  now. 


142  Isaac  Bay. 


W .  Under  the  influence  of  highly  civilized  life,  the 
conservative  powers  of  the  constitution  have  somewhat 
depreciated,  and  to  that  extent  impaired  the  curability  of 
insanit}\ 

V.  During  the  last  fifty  \'cars,  cerebral  affections,  in 
which  insanity  is  onK'  an  incident,  have  been  steadily  in- 
creasing, and  thus  diminishing  the  proportion  of  recoveries. 


Art.    II. —The    Medico-Legal    Aspect    of 
Cerebral   Localization  and   Aphasia. 


By  C.   H.    HuGHKs.  M.  D. 

THE  beginning  of  the  present  century  witnessed  the 
first  attempt  at  the  cerebral  localization  of  phychi- 
cal  function.  In  1808,  the  renowned  Dr.  Gall  obtained 
a  glimpse  of  the  truth,  when  he  conjectured  that  the 
faculty  of  articulate  speech  in  man  resides  in  the  anterior 
lobes  of  the  cerebrum,  which,  at  the  outset  of  his  career, 
he  sought  to  confirm  by  careful  study  of  the  brain.  Had 
he  kept  on  in  the  method  of  investigation  with  which  he 
began,  his  system  of  craniology  had  not  fallen,  as  it  now 
is,  among  cautious,  scrutinizing  scientists,  into  neglect  and 
disrepute,  but  the  anatomical  and  clinical  confirmations 
which,  a  few  years  later  (1825)  rewarded  the  labors  of  the 
illustrious  Bouillaud,  and,  still  later  (1836- 1863)  the  more 
precise     demonstrations    of    the    elder     and    junior    Dax. 


Addre^-s  dcliveied  l»y  invitation  l)efori-  the  Soutlii-rn  Ulmoi.-i  Me<licjil  Association 
:it  Cairo,   Ills..   Jan.   2l8t.— [Ed.) 


Cerebral  Localization  and  Aphasia. 


had  been  his  reward,  and  the  laurelled  chaplets  which 
wreathe  their  names  and  that  of  Broca,  for  having  still 
more  circumscribed  and  defined  the  location  of  the  center 
for  the  co-ordination  of  speech  in  the  posterior  portion  of 
the  third  left  frontal  convolution,  had  now,  perhaps, 
adorned  the  brow  of  Gall  and  immortalized  his  name  as  a 
real  scientific  discoverer. 

Taking  up  the  correct  methods  of  research  abandoned 
by  the  founder  of  phrenology  (so-called),  Bouillaud, 
Aubertin,  Broca  and  the  Daxes  opened  the  way  by 
correct  demonstrative  methods  to  those  lucid  illustrations 
of  cerebral  localization,  which  are  now  causing  to  be 
centered  upon  the  labors  of  Ferrier  and  the  researches 
of  the  present  illustrious  chief  of  Salpetriere,  such  marked 
attention.  We  live  now  in  the  evolution  period  of  a 
true  phrenology,  or,  as  that  illustrious  predecessor  of 
Charcot — the  great  Trousseau — standing  in  the  glare  of 
the  grand  discover}-  of  Broca,  said:  "The  question  of 
cerebral  localization  has  entered  upon  a  new  phase." 
What  would  be  the  expression  of  Trousseau  to-day  in 
the  light  of  the  electric  excitability  of  the  brain  for 
which  we  are  so  much  indebted  to  Fritsch  and  Hitzig. 
and  in  the  light  of  the  localization  of  brain  function, 
as  maintained  and  demonstrated  by  Ferrier,  Jackson, 
Bartholow  and  their  many  eminent  co-laborers  and 
followers  ? 

"The  stone  which  the  builders  rejected  has  become 
the  head  of  the  corner."  The  method  which  Gall  aban- 
doned, taken  up  by  Ferrier  and  others,  aided  by  Fritsch's 
timely  discovery,  has  resulted  in  the  projection  of  a  true 
phrenological  edifice,  now  in  process  of  completion, 
gran'der  in  its  proportions  than  Gall  and  his  colleague 
Spurzheim  ever  dreamed  of.  Since  the  day  of  the 
founders  of  the  phrenological  idea,  the  centers  of  touch, 
and  taste  and  smell,  and  of  the  movement  of  the  limbs, 
face  and  other  portions  of  the  body  have  been  so  closely 
approximated,  as  to  leave  us  little  room  for  doubt  as  to 
their  precise  locality  m  the   brain. 


144  C.  n.  Hughes, 


So  rapidly  is  conjecture  giving  place  to  demonstrated 
fact  on  this  subject,  that  the  belief  expressed  by  Ecker,* 
"that  definite  portions  of  the  cerebral  cortex  subserve  defi- 
nite intellectual  processes,"  and  "that  there  is  a  possibility 
that  we  may  some  day  attain  to  a  complete  organology 
of  the  brain  surface,  a  science  of  the  localization  of  the 
cerebral  functions,"  is  in  the  way  of  more  speedy  fulfill- 
ment, than  the  author  of  these  words  probably  thought  at 
the  time  he  penned  them. 

So  far  as  our  present  subject  is  concerned  the  prophecy 
is  fulfilled.  It  is  a  demo7istrated  fact  that  the  locus  uiorbi 
of  true  clinical  aphasia,  simple  and  imcomplicated,  is  the 
posterior  portion  of  the  third,  left,  frontal  convolution,  so  that 
I  need  not,  therefore,  go  over  the  historic  battle  ground  of 
the  giants  before  the  Anthropological  Society,  of  Paris, 
where  Gratiolet,  Aubertin  and  Broca  crossed  lances,  the 
latter,  finally,  so  gracefully  surrendering,  that  he  conquered 
and  gave  to  the  convolution  of  the  speech  center  his 
immortal   name. 

Nor  need  I  present  the  long  array  of  clinical  demon- 
strations accumulated  in  medical  annals  since  Broca's 
victorious  defeat. 

The  locus  niorbi  of  aphasia  is  always  on  the  left  side 
of  the  brain  in  markedly  right  handed  persons,  while  in 
the  very  left  handed  it  may  be  oppositely  located,  and 
in  the  ambidextrous  it  is  possible,  perhaps,  to  have  disease 
of  either  side,  with  or  without  speech  defect.  This, 
though  conjectural  only  as    yet,  is  quite  plausible. 

The  fact  that  the  left  side  of  the  brain  is  the  almost 
universal  site  of  the  aphasic  lesion  has  been  fairly 
demonstrated  by  the  records.  In  1868,  E.  C.  Seguin 
collected,  and  subsequently  Hammond,  and  still  more 
recently  McLane  Hamilton,  have  added  up  all  the  cases, 
making  a  sum  total  of  635.  Of  these,  the  right  hemi.s- 

pherewas  morbidly  implicated  in  but  33  cases  (3.6  per  cent). 
The  aggregate  of  the  recorded  cases  is  now  much  greater. 
The  cause  of  aphasia  being  due,  nearly  always,  to  embol- 


*CunTolutions  of  Mun,   page; 


Cerebral  Locaiization  and  Jphasia.  Ho 

ism,  the  selection  of  the  left  side  for  the  lodgment  of  the 
clot  is  readily  explained  by  the  fact  that  the  necessarily 
obstructed  artery  on  this  side,  the  left  middle  cerebral, 
is  in  a  more   direct  line   from  the  heart  than   is  its  opposite. 

The  right  and  left  frontal  lobes  being  similar  in  struc- 
ture and  conformation,  it  is  more  than  probable  that  a 
power  of  vicarious  function  resides  in  these  regions  of  the 
brain,  which  sufficiently  accounts  for  the  few  exceptional 
cases  of  aphasia  with  right  sided  lesion,  without  looking 
to  Brown-Sequard's  reflex  phenomenon  or  Schroeder  Van 
der  Kolk  and  the  corpora  olivaria  for  an  explanation  of 
these  anomalous  cases,  and  for  the  occasional  recovery  of 
speech  where  the  left-sided  lesion  has  persisted.  Some- 
times in  these  cases  the  arterial  obstruction  is  removed ; 
at  others,  as  in  a  case  reported  by  Drs.  Batty  Tuke  and 
Frazier,  in  1872,  and  referred  to  by  Ferrier  (Functions  of 
the  Brain,  p.  279)  the  sound  side  does  the  work. 

"The  left  hemisphere,  like  the  right  side  of  the  body," 
as  Hughlings  Jackson  has  stated,  is,  probably,  "the  leading 
or  driving  side,"  and  there  exists  no  good  reason  why 
there  should  not  be  a  duplicate  speech  as  well  as  a 
duplicate  hand  and   foot  center,  etc. 

The  phenomenal  varieties  of  aphasia  are  so  numerous 
that  a  confusion  of  names,  each  adopted,  either  for  its 
more  comprehensive  or  restrictive  signification,  confronts 
and  confuses  the  student  who  seeks  to  master  its  protean 
verbal  varieties ;  from  the  alalia  of  Lordat  and  Jaccoud,  the 
aphemia  of  Broca,  the  aphasia  of  Trousseau  and  the  com- 
prehensive asemasia  of  McLane  Hamilton,  to  the  more 
restrictive  appellations  of    Ogle,   Romberg  and  Bastian. 

A  discussion  of  the  table  of  Jaccoud  and  such  restric- 
tive philological  coinages  as  asynesis,  laloplegia,  paralalie, 
agraphia,  echoalgia,  amesic  and  ataxic  aphasia,  etc. 
added  to  the  above  can  serve  no  useful  purpose,  that  I 
know  of,  before  a  Court,  though  in  forming  an  opinion  in 
a  given  case,  they    have    sometimes    to    be    considered. 

Among  the  phenomenal  varieties  of  aphasia  may  be 
found    every    conceivable    degree    of  failure    of  verbal  and 


146  C.  E.  Hughes, 


sign  expression,  from  the  not  uncommon  inability  to  recall 
a  familiar  and  oft  repeated  name,  as  was  the  case  with 
Messala  Corvinas,  whom,  Pliny  says,  forgot  his  own 
name  ;  the  occasional  substitution  of  wrong  words,  and 
the  common  forgetfulness  of  intoxication,  to  the  abso- 
lute inability  to  make  a  single  intelligible  sign  or  speech 
— the  complete  asemasia  of  Hamilton. 

Aphasic  displays  co-existing  with  unappreciable  mental 
impairment  are  very  common  in  the  records  of  medicine, 
and  if  they  were  all  collected,  they  would  make  a  volume 
that  would  read  stranger  than  fiction.  Trousseau,  Wins- 
low  and  other  writers  have  recorded  a  great  many  inter- 
esting examples. 

Some  patients  like  Guenier  and  Paquet,  described  by 
Trousseau,  can  only  write  or  speak  the  same  word  or 
two  in  answer  to  questions  ;  others,  like  Behiers',  Broca's 
and  Hughlings  Jackson's  patients,  can  only  sing,  and 
some  transpose  their  words,  sa\ing  "giiin,"  for  example, 
when    they    mean    mug. 

Dr.  Dean's  patient,  D.  K.  R.,  reported  in  the  Jan- 
uary number  of  the  Alienist  and  Neurologist,  could 
sing  the  Marseillaise  with  the  single  syllable  '7^,"  though 
he    could    scarcely    speak    a    word    of  this    national   hymn. 

A  marked  antilogy  of  speech  without  intending  that 
antithesis  of  meaning  which  the  words  imply,  often 
characterizes  the  utterances  of  these  cases,  as  when  they 
say :  "rise  dozuft,"  for  rise  up;  or,  with  reverent  meaning, 
irreverently  pray,  "(9//r  Father  lohich  art  in  hell;"  or  for  a 
friend!}'  salutation  say  :  "'stupid  fool!'  Scjme,  in  their 
words,  however,  more  nearh'  approximate  their  meaning, 
as  was  the  case  with  one  of  Dr.  Baudu}'s  patients  who 
asked  for  "^  cnp  of  coiv,"  meaning  a  cup  of  viilk;  or  a 
lady  patient  of  mine  who  would  say:  "comb''  {ox  hair  brush; 
while  some  employ  absolutely  meaningless  expressions, 
comprehensible  only  by  the  pantomine  with  which  they 
are  accompanied,  such  as  ''nin-nin"  or  "tan,"  the  latter 
having  become  historic  as  the  hospital  nick-name  of 
one    of   Broca's    celebrated    patients. 


Cerebral  Localization  and  Aphasia. 


The  chief  causes  of  aphasia  are  cerebral  emboHsm, 
thrombosis  or  softening,  atheromatous  degeneration,  syphi- 
hs,  apoplexy,  hyperaemia,  traumatism,  epilepsia,  catalepsia, 
insanity  and  hysteria,  as  well  as,  occasionally,  sclerosis 
or  atrophy  of  the  brain  and  certain  emotional  states,  and 
the  congenital  deficiencies  of  imbecility,  idiocy  and  some- 
times   of  deaf-mutism. 

Its  transitory  forms  are  the  epileptic,  the  h\'ster- 
ical,  the  hyperjemic,  the  reflex  or  sympathetic,  and  the 
emotional,  such  as  the  speechlessness  of  intense  passion 
or  fright. 

The  reflex  form  is,  probably,  dependent  upon  local- 
ized cerebral  hyperaemia,  active  or  passive,  induced  b}- 
the  reflected  uterine,  gastric  or  other  irritation,  etc. 
The  aphasia  of  catalepsia,  I  think,  is  a  morbid 
condition  of  the  center  for  articulate  speech,  as  well 
as  of  certain  centers  of  motion  in  the  brain ;  and 
persons  subject  to  nightmare,  often  find  themselves 
quite  aphasic  while  the  brain  is  in  a  tumult  of  semi-con- 
scious excitement  and  fear.  Sometimes  they  succeed  in 
making  a  monotonous  cry,  but  seldom,  in  saying  what 
they  wish  to  say. 

Though  true  uncomplicated  aphasia  is  now  recognized 
as  a  definite  symptomatic- manifestation  of  a  definitely  local- 
ized disease,  it  has  often  complications,  the  presence  of 
which,  together  with  their  causative  lesions  in  the  brain, 
give  the  subject  important,  and  sometimes  very  compli- 
cated, and  with  difficulty  ascertained,  medico-legal  sig- 
nificance. We  shall,  on  the  present  occasion,  look 
mainly  at  the  medico-legal  phases  of  this  interesting 
disease. 

In  aphasia  the  question  of  mental  competency  to  do 
certain  acts,  such  as  the  signing  of  powers  of  attorney, 
deeds  of  conveyance  and  other  important  papers,  may 
arise.  A  question  as  to  the  degree  of  accompanying 
mental  impairment  will  almost  invariably  be  raised  if 
acts  are  performed  b\'  these  patients,  involving  great 
pecuniary  interests,    or    questions    of  responsibilit}'  to  law. 


148  C.  n,  Hughes. 


for  aphasia  is  often  associated  with  such  a  degree  of 
brain  disease,  as  involves   the  mind  in  disordered  action. 

The  regions  round  about  Broca's  convolution  or  those 
extending  even  to  the  middle  and  posterior  hemispheres  or 
the  outward  conducting  paths  of  word  ideation  and  expres- 
sion may  be  so  involved  in  disease,  as  to  greatly  complicate 
the  subject. 

There  may  be  disease  in  the  medulla  oblongata  to 
interfere  with  verbal  expression  or  in  the  visual,  auditory, 
olfactory  or  tactile  centers,  interfering  with  the  proper 
perceptions  of  sight,  sound,  smell  or  feel  of  objects  or 
the  communications  between  these  centers,  or  any  one  of 
them  may,  by  disease,  be  cut  off  from  the  ideational  centers 
or  from  the  naming  center   of  the    cortex. 

These  possible  complications  have  all  to  be  taken  into 
consideration  in  forming  an  opinion  to  be  given  in  court 
on  a  question  of  aphasia,  for  we  are  then  to  estimate  the 
extent  of,  or  absence  of,  morbid  complications,  and  to 
determine  thereby,  if  we  can,  to  what  extent  the  mind 
may  be  conjointly    injured. 

Any  obstruction,  as  Hughlings  Jackson  has  shown,  to 
the  middle  cerebral  arter>%  would  likely  implicate  the 
corpus  striatum  of  the  same  side,  which  it  also  nourishes, 
and  cause  the  so  common  complication  of  opposite 
hemiplegia.  But  hemiplegia  is  the  least  complicating, 
from  a  medico-legal  point  of  view,  of  the  many  com- 
plications   of  this    subject. 

The  fact,  in  all  cases,  to  be  constanth-  borne  in  mind  is 
this,  viz. :  That  as  the  gray  matter  of  the  spinal  cord  ma}' 
convert  an  impression  transmitted  to  it  from  the  distal  ex- 
tremity of  an  afferent  nerve,  into  muscular  movement  with- 
out having  the  assistance  of  the  psycho-motor  centers  of  the 
brain,  so  may  an  internal  impression  made  on  the  speech  center 
zi'ithin  the  brain  itself,  be  converted  into  verbal  expression, 
without  necesarily  requiring  the  aid  of  that  high  degree 
of  cerebration  ivliicJi  constitutes,  in  individuals,  their  rational 
mentality.  With  an  impaired  power  of  word  ideation 
and  a  crippled  or   paralyzed    power    of   expression,   it  still 


Cerebral  Localization  and  .Aphasia  149 

is  possible  for  normal  mental  movement  to  go  on,  even  as 
it  is  possible  for  such  normal  physical  movements  in  the 
body,  as  constitute  true  physical  health,  to  continue  when 
limbs  are  destroyed  or  other  limited  parts  crippled  by 
accident  or  disease.  Nature  wonderfully  conserves  her 
powers  and  devises  wondrous  expedients  for  expressing 
them,  so  long  as  her  devices  are  only  damaged  and  not 
entirely   destroyed. 

The  soundness  of  the  judging  and  comparing  facul- 
ties is  not  necessarily  impaired  in  simple  aphasia.  The 
integrity  of  every  faculty  of  expression,  is  not  essential  to 
mental  competency.  In  fact,  nothing  has  contributed  more 
than  the  various  phenomena  of  aphasia,  co-existing  with  a 
sound  mind,  to    establish  this  fact. 

Let  us  take,  for  example,  the  patient,  Paquet,  already 
referred  to,  who  could  say  :  "coiisisi,''  and  after  a  few  days' 
effort,  learned  to  say  ''con-con,''  but  could  never  say  sisi, 
alone;  who  could  say  ''a'  easily,  but  could  never  say  pa; 
whose  principal  vocabulary  was  ''cousisi"  and  "sacon,  sacon,'' 
the  former  of  which  he  wrote  and  spoke,  when  asked  his 
name  as  well  as  in  answering  other  questions,  always 
showing  his  chagrin,  however,  at  his  mistake  ;  and  who, 
though  considerably  paralyzed  on  the  right  side,  could  write 
with  his  left  hand,  play  backgammon  and  dominoes  well, 
laughing  at  his  good  luck,  getting  fidgety  and  even  cheat- 
ing when  he  found  himself  losing. 

This  and  the  case  of  M.  X.,  related  to  Trousseau  by 
his  friend.  Dr.  Voyer,  of  Chartres,  who  always  ended  his 
syllables  with  "///","  as  inonutnentif,  montif,  bontif,  for  monn- 
mental,  monsieur,  bon  jour,  &c.;  besides  serving  to  show 
that  mentahty  consists  of  an  aggregate  of  functions,  some 
of  which  may  be  lost  or  impaired  without  the  necessary, 
consequent  or  co-existent  destruction  of  the  proper  and 
essential  attributes  of  rational  mentality,  appear  like  con- 
.  firmations  of  Ferrier's  experiments,  locating  the  center  for 
the  movements  of  the  lips  and  tongue  in    articulation. 

Though  aphasia  is  most  frequently  associated  in  its 
early    stage    with    hemiplegia    or    the    general    paralysis  of 


150  C.  n.  Hughes, 


the  insane,  or  with  dementia,  and  sometimes  with  other 
forms  of  insanity  and  ataxia  and  imbeciUty,  it  is  not  nec- 
essarily so  associated  and  must  be  differentiated  from 
these  conditions  of  mental  disorder.  The  question  of 
dementia  or  associated  mental  incompetency  is  one  to  be 
separately  considered  on  its  merits,  as  though  no  speech 
defect  existed,  and  Dr.  Ray  says,  Medical  Jurispudence  of 
Insanity,    p.    1 74  : 

"•Those  (cases)  in  wliich  the  faculty  of  language  is  affected, 
might,  by  the  careless  or  incompetent  observer,  be  mistaken  for 
insanity.  It  is  a  curious  though  well  established  fact,  ii, stances 
of  which  are  related  numerous  enough  to  fill  a  volume,  that 
the  faculty  of  language  or  the  power  of  representing  thoughts  by 
appropriate  articulate  or  wi'itten  signs,  may  be  utterly  or  partial- 
ly lost,  the  other  mental  powers  remaining  sound.'  On  the  same 
page.  Dr.  Ray  refers  to  the  case  reported  many  years  ago  by  Wm. 
Hood,  in  the  phrenological  transactions,  when  the  patient,  a  black- 
smith, lost  the  memory  of  all  words  except  yes  and  no,  while  he 
comiirehended  distinctly  whatever  was  said  to  him.  He  could  not 
read,  but  could  understand  what  was  said  to  him,  and  within  a  few 
days  went  to  his  shop  and  attended  to  his  workmen.  lie  improved 
somewhat  in  his  power  of  speech,  but  it  remained  greatly  impaired 
up  to  the  time  of  his  death,  three  years  afterwards.  Ray  refers  to 
a  coachman,  who,  after  a  fall  on  his  head,  could  never  say  any  word 
but  ont.  yet  his  mind  was  perfectly  sound  ;  and  to  the  celebrated 
Bruusonnet,  who.  after  entire  recovery  from  an  attack  of  apoplexy, 
could  never  utter  nor  write  the  names  of  persons  nor  things,  though 
other  parts  of  speech  were  at  his  command  in  abundance,  by 
which  he  could,  by  various  iutellectual  devices,  indicate  individuals, 
things  and  wants." 

Metaphysical  conceptions  as  to  the  nature  of  mind 
ought  not  to  be  allowed  to  bias  our  judgment,  respecting 
the  extent  to  which  aphasia  may  compromise  mentality  in 
any  particular  case.  The  great  Trousseau  fell  into  this 
error.  "The  intellect  of  an  aphasic  person,"  he  said,  "is 
forever  damaged,  just  as  the  motility  of  one-half  of  his 
body  is  impaired,  and  he  will  be  alwaj's  mentally  lame." 
This  view  of  the  classic  lecturer  on  clinical  medicine  given 
at  the  close  of  his  lecture  on  aphasia  and  immediately  fol- 
lowing a  reference  to  a  case  associated  with  hemiplegia, 
is  at  variance  with  the  later  teachings  of  the  most  eminent 
observers. 


Cerebral  Localization  and  Jphasia.  151 

McLane  Hamilton  says  : 
"The  aphasic,  of  course,  may  suffer  an  intellectual  impairment,  which 
lasts  a  short  time  after  the  attack.  This  is  not  necessarily  accom- 
panied by  a  loss  of  judgment.  It  is  more  a  condition  of  mental 
sluggishness  and  it  will  not  do  to  say  that  the  individual  is  incom- 
petent. It  7nust  he  remetnbered  that  aphasia  is  not  necessarily  associated 
with  such  siates'''* 

Bastian  says : 
"There  are  many  instances  on  record,  in  which,  though  the  aphasic 
condition  itself  has  been  most  complete,  the  mental  powers  of  the 
patients  have  been  well  preserved.f  *  *  *  These  cases  differ  very 
much  in  severity,  *  *  *  partly  owing  to  the  extent  and  situation 
of  the  brain  lesion,  aud  partly  to  the  period  of  the  disease  at  which 
the  patient  is  seen.  In  the  gravest  cases  of  this  kind,  the  amount 
of  general  mental  impairment  is  so  great,  that  the  patient's  inability 
to  speak  appears  only  as  one  form  of  mental  impairment.  Such 
severe  cases  are  almost  invariably  instances  of  recent  hemiplegia,  and 
the  patient  may  in  tlie  course  of  two,  three  or  more  weeks,  show  a 
ver}^  notable  improvement  in  some,  or  in  all,  respects.''^ 

Thus,  also,  says  Ferrier : 

"A  person  aphasic  from  destruction  of  his  speech  center  (as  we 
may  for  shortness  call  the  articulatory  motor  centers  of  the  left 
hemisphere),  still  remains  capable  of  appreciating  the  meaning  of 
words  uttered  in  his  hearing.  In  this  respect  he  does  not  (and  there 
is  no  reason  wliy  he  should)  differ  from  a  normal  individual.  Ills 
centers  of  sight,  hearing,  etc.,  being  unimpaired,  he  is  capable,  as 
before,  of  sight,  auditory,   tactile,  gnstatory  and  olfactory  ideation. 

The  difference  consists  in  tiie  fact,  that  in  the  aphasic  individual 
the  word  spoken,  though  it  calls  up  the  idea  of  meaning,  cannot  call 
up  the  word  itself,  actually  or  in  idea,  owing  to  the  word-execution 
and  word  ideation  being  destroyed.  The  appreciation  of  the  mean- 
ing of  spoken  words  is  readily  accounted  for  by  the  fact,  that  in  the 
process  of  edncation,  an  association  is  formed  directly  between  certain 
sounds  and  certain  objects  of  sense,  simultaneoasly  with,  if  not  ante- 
cedent to  the  formation  of  the  cohesive  association  between  these 
sounds,  and  certain  acts  of  articulation. 

The  cohesion  or  association  between  sound  and  meaning,  remains 
unimpaired  in  aphasia.  It  is  the  cohesion  between  sound  and  articu- 
lation which  is  broken  by  removal  of  the  motor  factor  of  the  organic 
nexus."§ 

This  was  well  illustrated  in  the  case  of  the  illustrious 
Professor  Lordat,  notwithstanding,  Trousseau,  who  inclined 
to  the  opinion  advanced  by  Condillac  and  Warburton  that 

•Nervous  Disease,  p.  177. 
tParalysis  from  Brain  Disease,   p.   198. 
tPar.alysis  from   Brain    Disease,    p.    19-2. 
§Kunction3  of  the   Biuiu,  pp.   -27.5  and  276. 


152  C.  H.  Bushes, 


words  are  indispensable  instruments  of  the  thought  process, 
beUeved  his  colleague  deceived  himself. 

Lordat  said  "H«'  ( oiild  think,  co-ordinate  a  lecture  or  rliangeits  arrange- 
ment in  liis  own  mind,  but  was  unable,  though  not  paralyzed,  to  express 
his  thoughts  in  speaking  or  writing  "1  thonglit,"'  says  he.  "of  the 
Christian  Doxology,  'Glo  j^  be  to  the  Father,  the  Son  and  the  Holy 
Gliost,'  and  I  was  unable  to  recollect  a  sing  e  word  of  it."" 

To  Trousseau  it  seemed  impossible  for  ideas  to  exist 
in  the  mind  without  words  to  express  them,  seemingly  for- 
getful of  the  fact,  that  very  young  children  and  learners  of 
foreign  languages  acquire  the  faculty  of  comprehension  in 
conversation  before  they  learn  how  to  express  themselves 
clearly. 

Trousseau  had  other  colleagues  and  quite  a  number  of 
patients  who,  in  their  own  persons,  illustrated  the  views  of 
Ray,  Hamilton,  Ferrier  and  Bastian.  Trousseau  really 
appears  inconsistent  or  has  not  made  himself  plain,  for  he 
admits  that  Lelong,  Broca's  second  case,  and  several 
others  that  he  relates,  were  not  impaired  in  their  intellects. 

Though,  to  do  Trousseau  justice,  it  must  be  recorded 
that  in  connection  with  the  above  criticism  of  Lordat,  he 
confesses  that  he  would  ";wt  presume  to  settle  definitely' 
this    "'jnost   intrieate  problejii    in  metaphysics^ 

The  very  common  fact  of  aphasics  being  able  to  copy 
words,  and  repeat  them  immediately  after  seeing  them 
written  or  hearing  them  pronounced,  shows  that  the  idea 
of  words  is  registered  in  the  mind.  They  often  recog- 
nize the  word  they  want  when  they  hear  it  pronounced, 
and  will  generally  show  by  their  manner  when  the  wrong 
word  is  suggested. 

Their  principal  defect  seems  to  be  an  inability  to  call 
into  proper  activity  the  requisite  co-ordinating  processes 
essential  to  the  proper  word  formation,  but  this  they 
often  succeed  in  doing  after  the  idea  has  been  formulated 
into  a  word  or  words  by  another.  This  is  especially  so 
with  such  cases  as  Bastian  classes  under  the  head  of 
amnesia,  which  he  calls — 

"A  kind  of  inco-ordinaiion  in  the  action  of  those  higher  cerebral  centers, 
whose   business   it   is     to     translate     thought     into    the    corresponding   acts. 


Cerebral  Localization  and  Aphasia.  ^5S 


There  is  ;in  irreofular  canying  out  in  fact  of  tliose  processes,  by  wliicli 
tlie  thouiiht  ot  the  patient  receives  that  physical  expression  which 
renders  it  intelligible  to  others.  The  individual  linows  what  he  wishes 
to  say,  but  there  is  a  defect  in  the  subsequent  molecular  actions  goino; 
on  in  his  higher  ner\e  centers  of  such  a  nature,  as  to  cause  hesitation  or 
delay  in  the  utterance  of  right  words  and.  what  is  more,  tlie  substitu- 
tion, occasionally,  of  entirely  wrong  words  or,  even,  of  a  meaningless 
set  of  sounds  in  the  place  of  those  he  wishes  to  utter. 

Although  such  a  patient  may  be  quite  unable  to  prevent  these  mis- 
takes or  failures,  he  usually  shows  by  his  manner  that  he  is  aware  of 
having  made  them,  and  yet  any  attempts  to  rectify^  the  errors  only 
seems  to  make  matters  worse.  This  defective  action  in  the  speech- 
centers  and  their  related  pnrts  is  very  comparable  with  what  occurs 
in  other  nerve  centers  in  loco-motor  ataxia.  In  this  disease  a  man  may 
have  an  adequate  knowledge  of  what  he  intends  to  do.  though  when  he 
attempts  to  move  his  legs  in  a  definite  direction,  he  jerks  them  about 
in  an  irregular  manner  or.  even,  moves  in  a  way  the  reverse  of  what  he 
iuten  ed.  In  each  case  we  have  to  do,  therefore,  not  so  much  with 
lack  of  power  as  with  involuntary  or  misdirected  power  *  *  *  and 
such  defects  in  oral  speech  otten  co-exist,  with  more  or  less  marked  dif- 
ficulties of  the  same  kind,  in  the  ti'anslation  of  thought  into  written 
speech,  that  is,  writing.  The  patient  is  then  "able  to  pei-form  the 
mechanical  act  very  well,  though  he  cannot  group  letters  correctly  into 
woids;  he  spells  altogether  wrongly  or,  even,  uses  words  which  have 
no  resemblance  to  those  he  wishes  to  employ*.'' 

Dr.  Ray  in  his  report  of  the  '"Parish  Will  case,"  attaches 
some  significance  to  the  fact  that  Mr.  Parish  could  not 
learn  to  put  the  letters  of  the  alphabet  together  so  as  to 
form  intelligible  \vords,  and  in  his  introductory  remarks, 
refers  to  the  fact  that  since  it  was  written,  the  prominent 
feature  of  the  disease,  aphasia,  has  been  greatly  investigated 
by  various  observers,  and  that  "these  investigations  have 
considerably  increased  our  knowledge  of  its  anatomical 
and  pathological  relations,"  though  they  have  not,  proba- 
bly, thrown  any  new  light  on  cases  like  this  one. 
Very  rational  cases  manifest  this  defect,  for  instance, 
Trousseau's  patient,  M.  X.,  who  could  neither  put 
together  loose  letters  of  the  alphabet  nor  write  with  his 
left  hand  ;  yet  this  patient,  as  Trousseau  confesses,  "was 
in  full  possession  of  his  intellect." 

McLane  Hamilton  proposes  this  as  a  test  of  an 
aphasic's  mental  integrity  : 

•Paralysis  fiom  Brain  Disease,  pp.  1SS-1&9. 


154  C.  H.  Hughes, 


"If  the  patient  be  insane,"'  lie  says,  '-he  will  not  ailniit  anj-  absurd- 
ities to  whicli  he  may  give  expression,  but  with  the  aphasie  the  case  is 
(Urtereiit.  for  lie  always  evinces  his  cliagrin  when  he  tiiids  that  he  has 
written  tlie  wrong  word  and  endeavors  to  correct  his  niistal<e.''* 

This  test  will  not  always  answer,  though  it  is  valuable 
where  agraphia  does  not  exist.  I  am  not  sure,  however, 
that  it  is  more  faultless  than  the  verbal  test,  which  is  by 
no  means  infallible,  as  even  Trousseau  concedes.  I  quote 
from  him  in  illustration  : 

"ilrs.  B had  never  been   iiaralyzed,  but  labored  under  a  very 

singular  disorder.  Whenever  a  visitor  entered  her  apartment  she  rose 
with  an  amiable  look  and,  pointing  to  a  chair,  exclaimed,  '*Pig,  animal, 
stupid  fool!"  -'Mrs.  B.  asks  you  to  take  a  chair,"  her  son-in-law  would 
then  put  in,  giving  this  interpretation  to  her  strange  expressions.  "In 
other  respects."  says  Trousseau,  "Mrs.  B.'s  acts  were  rational  and  her 
case  ditfeied  from  ordinary  aphasia,  in  that  she  did  not  seem  to  grow 
impatient  at  what  she  said  or  to  understand  tiie  meaning  of  the  insult- 
ing expressions  of  which  she  made  use." 

It  being  possible  for  disease  to  exist  between  the 
centers  for  the  perception  of  sound  and  the  speech  cen- 
ter, a  person  so  affected  might  not  understand  his  own 
words  or  the  words  of  others  spoken  to  him.  Such  a 
person  if  morbidly  affected,  also,  in  the  posterior  portion 
of  the  third  left  frontal  convolution,  even  while  giving 
utterance  to  an  incomprehensible  jargon,  might  have 
in  his  mind  correct  ideas  of  things  disccrnable  b)' 
the  eye  or  impressed  upon  the  mind  through  the  ear 
before  the  auditory  channel  had  become  affected.  He 
might  reason  well  within,  though  he  talked  without  like 
a  fool,  because  of  this  strange  affliction.  This  was 
probably  the  case  with  Madame  B.  Similar  cases 
have  been  recently  recorded  by  Dr.  Broadbent  and 
others. 

There  was  at  the  Infirmary  of  the  Salpetriere,  a  woman 
of  forty  years  of  age,  quite  hemiplegic,  and  who  could 
only  say:  "Madame  e'te  !"  "Mon  Dieu  !"  "Est  il  possible  ?"' 
•'Bon  jour,  Madame  !" 

Her  intelligence  was  perfectly  preserved.  Hamilton, 
referring  to  this  case,    which    Forbes    Winslow    and    others 

•Nervoub  Diseases,  p.  J77. 


Cerebral  Localization  and  Aphasia. 


have    quoted    from    Durand     Fardel,     quotes     Legroux    in 
explanation    as    follows : 

"It  is  to  be  supposed  in  tliese  cases  tint  tlie  patients  speak  without 
hearing  wiiat  thej'  say,  or  tliat  their  auditory  receptivity  is  unaljje  to 
reveal  the  imperfection  ot  their  speech." 

The  patient's  appreciation,  however,  of  the  aptness  of 
his  speech  or  gesture,  whether  he  has  spoken  rightly  or 
wrongly,  though  not  without  exception,  is  a  good  test  to 
be  added  to  other  evidences  of  mental  integrity  in  form- 
ing a  judgment  in  a  given  case.  Lelong,  one  of  Broca's 
historic  cases  possessed  it,  and  many  of  the  cases  collected 
and  recorded  before  and  since.  But  the  very  best  and 
only  satisfactory  test  of  sanity  in  aphasic  persons  consists 
in  ascertaining  the  manner  in  which  they  conduct  themselves 
with  reference  to  their  changed  surroundings.  The  range 
of  an  aphasic's  intellectual  operations  may  be,  and  often  is, 
limited  by  his  affliction.  But  if  he  properly  appreciates  the 
extent  of  his  affliction  and  changed  surroundings  and 
voluntarily  comports  himself  in  harmony  with  them,  he  is 
not  insane,  for  though  insanity  is  a  change  in  the  natural 
habits  of  thought,  feeling  or  action  of  the  individual  insult- 
ing from  disease  involving  the  bj'ain,  it  is  also  such  a 
mental  change  caused  by  cerebral  disease  as  places  him 
out  of  proper  harmony  zcith  his  natural  self  and  the  influ- 
ences which  act  upon  his  mind,  physical  or  othcrivise, 
wdthout  and  beyond  the  cerebral  seat  of  mental  individ- 
uality. 

To  Trousseau,  aphasia  seemed  to  be  always  a  failure  of 
the  memory  of  words,  whereas  it  is  usually  the  faculty  of 
symbolic  expression  that  is  lost  or  impaired,  and  an  incapa- 
bility of  verbal  co-ordination,  while,  abstractly  the  internal 
memory  of  words,  the  sounds  of  them  at  least  and  their 
association  with  registered  ideas,  either  remains  or  is  read- 
ily revived.  Thought,  as  Ferrier  observes,  may  be  carried  on 
without  language,  but  it  is  thought  in  particular,  restricted 
and  limited,  in  some  cases  no  doubt,  to  the  jrvival,  revol- 
ving, blending  and  combining  of  emotions,  sight,  sounds, 
touches,    tastes,     smells,     etc.,    impressed     upon  their  proper 


156  C.  H.  Bushes, 


centers  in  the  brain  through  such  neurotic  avenues  of 
ingress  thereto  as  may  have  retained  their  integrity. 

The  condition  of  aphasia  must  undoubtedly  be  a  source 
of  great  embarrassment  to  the  thought  process  of  most 
patients,  especially  in  the  beginning  of  the  seizure.  His 
situation  is  to  him  so  novel,  inexplicable  and,  often,  so 
alarming.  The  range  of  the  aphasic's  intellectual  opera- 
tions is  often  of  necessity  abridged  by  reason  of  his 
crippled  power  of  expression,  especially  if  the  aphasia  be 
complete — without  the  power  of  either  speaking  or  writing. 
Such  persons,  if  they  are  not  mentally  deranged,  display 
their  appreciation  of  their  condition  and  surroundings — 
their  good  sense  and  sanity — by  refraining  from  attempts 
at  conducting  themselves  beyond  their  powers  and  not  in 
accordance  with  their  changed  condition.  Though  they  can 
not  act  as  they  formerly  could,  they  still  act  in  harmony 
with  their  changed  condition  and  surroundings.  If  not  able 
to  carry  on  their  customary  business,  they  realise  the  fact 
and  act  accordingly.  Like  the  illustrious  Lordat,  who,  when 
stricken,  ver>-  sensibly  did  not  insist  on  lecturing  as  was 
his  wont — they  realize  their  affliction  and  reveal  this 
knowledge  of  themselves  by  acting  in  a  rational  manner 
though  they  cannot  speak. 

The  eminent  Dr.  Ray  in  discussing  the  "  Parish  Will 
Case"  (contributions  to  Mental  Patholog}-,  p.  328-9),  puts 
the  arginnentiim  ad  hoviinnin,  for  cases  of  long  standing, 
thus :  "Were  you  to  be  suddenly  deprived  of  the  power 
of  speaking  and  of  using  the  right  hand,  your  mind 
remaining  unaffected,  do  you  suppose  that  for  six  or 
seven  years  you  would  continue  as  incapable  of  making 
known  your  thoughts  as  Mr.  Parish  was  ?  There  certainly 
would  be  but  one  answer  to  that  question.  A  tolerable 
facility  of  writing  with  the  left  hand  could  be  obtained  by 
a  little  practice,  and,  in  the  meantime,  a  dictionar>',  block 
letters,  hyeroglyphics  and  maps  would  enable  him  to  con- 
convey  his  meaning  without  fear  of  mistake.  Ever)'  day 
would  also  witness  an  improvement  in  the  use  of  signs 
and    gestures. 


Cerebral  Localization  and  .Aphasia.  157 

In  every  actual  case  of  this  description  on  record  (i.  e., 
mere  loss  of  speech),  so  far  as  I  know  of,  the  integrity  of 
the  mind  was  shown  either  by  what  the  patient  did  or  by 
the  ideas  communicated  in  the  manner  here  mentioned." 
He  then  instances,  in  illustration,  the  blacksmith  already 
referred  to,  who  went  to  his  shop  and  gave  directions  to 
his  workmen;  the  tax  collector  who  "pursued  his  cus- 
tomary duties,"  and  "an  old  gentleman  who  enjoyed 
his  game  of  whist  as  much  as  ever,"  notwithstanding  they 
could  no  longer   speak. 

[To    be   coiitiiiiud.) 


Art.  III. — Studies  on  Cerebral  Thermom- 
etry in  the  Insane. 


CONCLUDED. 


'  I  ^'O  the  expositions  of  the  results  recorded  by  us  on 
-■-  cerebral  thermometry,  we  shall  add  a  few  brief  remarks 
on  the  general  temperature  of  the  body,  noted  in  divers 
forms  of  mental  disease,  in  the  axilla  and  the  rectum. 
As  may  be  seen  by  the  tables  presented  by  us,  it  results 
that  this  temperature,  as  does  that  for  the  brain,  attains 
its  highest  degree  in  lypemania  agitata  (37.32,  axillary — 
37.62,  rectal),  and  in  mania  furiosa  (37.21,  axillary — 37.62, 
rectal) ;  thence  progressively  descending,  in  progressive 
-paralysis  (37.30-37.40);  dementia  agitata  (36.09-37.34; 
mania  simple  (36.70-37.  lo) ;  imbecility  and  idiocy,  36.63- 
37.08) ;  lypemania  simple  and  dementia  complex  (36.56- 
36.96).       Comparing  these    results    with  those  obtained  by 


158  Joseph  lJ'o7^kinan, 

Cloiiston,  in  his  studies  on  the  temperature  of  the  body 
in  the  insane,  we  find  that  altliough  tlie  fi<^ures  of  the 
English  {ScotcJi)  observer,  are  all  lower  than  ours,  yet,  in 
the  mass,  they  accord  as  to  the  order  of  succession,  as  at 
the  head  stand  those  of  general  paralysis  ;  next  to  which 
are  those  of  mania,  then  melancholia,  and,  finally, 
dementia. 

Having  now  reached  the  end  of  our  work,  but  wish- 
ing, for  greater  clearness,  to  review  the  principal  facts 
herein  contained,  we  formulate    the    following  conclusions: 

1st.  Tlie  medium  temperature  of  the  sane  man  is, 
according  to  our  observations,  36.13  for  the  left  side  and 
36.08  for  the  right — 36.10  for  the  whole  head.  As  to  the 
diverse  regions  the  means  of  the  frontal  lobes  are  36-20 
tor  the  left  and  36.15  for  the  right;  of  the  parietal,  36.18 
for  the  left  and  36.15  for  the  right;  of  the  occipital, 
36.13  for  the  left  and  36.08  for  the  right. 

2d.  In  the  insane,  with  exception  of  simple  lypemania 
and  dementia,  the  mean  temperature  of  the  head  is  above 
the  normal. 

3d.  The  highest  degree  is  reached  by  mania  with  fur)' 
(36.89);  lypemania  agitata  comes  next  (36.81),  then  fol- 
low general  paralysis  (56,63)  ;  dementia  agitata  (36-45  ; 
imbecility  and  idiotism  (36.54)  ;  mania  without  fury  (35.30); 
simple  dementia    (36.03). 

4th.  In  all  the  forms  of  mental  disease  the  occipital 
lobes,  as  in  the  sane  man,  give  a  temperature  lower  than 
the  other  lobes ;  the  temperature  of  the  frontal  lobes, 
which  equals  that  of  the  parietal  in  dementia  agitata, 
imbecility  and  idiotism,  excels  it  in  mania,  simple  lype- 
mania and  simple  dementia,  whilst  in  general  paralysis  and 
lypemania  agitata  the  temperature  of  the  parietal  lobes  is 
higher  than  that  of  the   frontal. 

5th.  In  all  the  principal  groups  of  mental  diseases,  the 
mean  of  the  two  halves  of  the  head  is  almost  equal,  with 
the  exception  of  the  congenital  forms,  in  which  the  various 
regions  of  the  right  half,  present  figures  higher  than  those 
of  the  left  half 


Cerebral  Thermometry.  159 

6th.  The  residts  of  cerebral  thermometry,  placed  in 
accord  with  what  is  known  of  the  pathological  anatomy 
of  insanity,  confirm  the  fact,  that  in  general  paralysis, 
mania  and  divers  periods  of  exaltation,  which  are 
frequently  manifested  even  in  forms  of  depression  and 
mental  enfeeblement,  there  exists  a  state  of  hyperaemia  of 
the    brain. 

/th.  The  surrounding  temperature  has  a  notable  influ- 
ence on  the  results  of  cerebral  thermometr}^ 

8th.  The  general  temperature  of  the  body  in  the 
insane,  taken  in  the  axilla  or  in  the  rectum,  is  greater  in 
lypemania  agitata  and  mania  furiosa,  and  in  decreasing 
order  it  proceeds,  diminishing  in  general  paralysis,  demen- 
tia agitata,  mania  without  fury,  imbecility  and  idiocy, 
tranquil  dementia    and    simple    lypemania. 

Insane  Asylum  of  Reggio  Emilia,  20th  September,  1878. 

APPENDIX. 

The  publication  of  this  article  which  was  communi- 
cated by  one  of  us  to  the  medical  congress  at  Pisa,  in 
the  session  of  28th  September,  of  the  medical  section, 
has  been  unavoidably  retarded  to  the  present  time,  from 
typographic  reasons,  and  we  have  profited  by  this  delay 
to  repeat  some  experiments  in  cerebral  thermometry  on 
the  insane,  in  a  position  different  from  that  in  which  our 
previous  observations  were  made.  It  is  superfluous  to 
add  that  the  method  used  by  us  in  this  new  series  of 
obsei"vations  was  the  same  as  we  have  already  described. 
Well  then,  with  an  external  temperature  of  9"  to  10'  cent. 
(48.2  to  50  Fahr.),  we  have  found,  whether  in  forms  of 
exaltation  or  depression,  means  lower  by  0.7'  to  1.2'  cent, 
than  those  obtained  in  our  first  series.  This  minor  eleva- 
tion in  the  figures  obtained  was  verified,  not  only  in  the 
general  means,  but  also  in  the  examination  of  single  cases, 
.  and  it  was  greater  in  states  of  depression  than  in  those 
of  mental  over-excitement.  This  tends  to  confirm  the  hypo- 
thesis announced  by  us,  that  the  temperature  of  the 
surroundinsr  air  is  not  without    influence  on  the    results    of 


160  Joseph    WorhmaTi, 


cerebral  thermometry,  and  that  it  is  necessary  to  take  this 
into  account,  not  only  when  we  would  determine  the 
comparative  temperature  of  single  symmetrical  regions 
contiguous,  but  also  that  of  the  whole  head. 

In  order  to  render  our  labors  more  complete,  we  desire 
here  to  add  a  brief  notice  in  relation  to  cerebral  tempera- 
ture,   communicated    after    the    compilation    of  our  paper. 

Professor  E.  Maragliano  read  to  the  medical  congress 
at  Pisa  (26th  September),  the  result  of  a  series  of  experi- 
ments made  by  him  in  his  School  of  General  Pathology, 
in  Genoa.  He  first,  by  means  of  experimental  investiga- 
tions, sought  to  eliminate  whatever  doubt  might  arise  as 
regards  the  capacity  of  the  cranial  walls  to  transmit 
promptly  in  thermometers  placed  on  the  exterior,  the  inter- 
nal oscillations  of  temperature.  With  this  view  he  applied 
thermometers  to  the  exterior  of  different  cranial  envelop- 
ments, which  were  filled  with  water,  at  various  tempera- 
tures, and  he  was  able  to  see  that  the  thermometers  on 
the  outside  rapidly  followed  the  oscillations  shown  by 
those  placed  inside. 

He  next  studied  the  ph}'siological  and  pathological 
temperature,  and  that  present  during  chloralic  sleep.  The 
conclusions  which  he  drew  from  these  researches  were 
the  following  : 

1st.  The  thermometers  applied  to  the  cranial  integu- 
ments   faithfully    follow    the    thermal    internal    oscillations. 

2d.  The  cerebral  temperature  revealed  in  this  manner 
in  physiological  conditions  is  shown  more  elevated  on  the 
left  than  on  the  right  side,  especially  by  thermometers 
placed   near  the  frontal  region. 

3d.  The  degree  of  temperature  varies  according  to 
age  and  sex. 

4th.  In  the  same  individual  there  arc  presented  in  the 
course  of  a  day,  from  time  to  time,  elevations  or  depres- 
sions which  do  not  exceed  half  a  degree. 

5th.  The  cerebral  temperature  may  have  relations  to 
pathology,  but  relatively  to  the  conditions  existing  between 
the  two  sides,  or  between  points  on  the  same  side. 


Cerebral  Thermometry.  161 

6th.  To  have  absolute  value,  elevations  or  depressions, 
at  least  one  degree  above  the  physiological  mean,  are 
called  for. 

7th.  In  cerebral  embolism  there  is  a  diminution  in  the 
lobe  irrigated  by  the  plugged  vessel,  from  which  may  be 
deduced  an   important    diagnostic  criterion. 

8th.  During  the  chloralic  sleep  there  is  a  constant 
diminution  of  the  cerebral  temperature. 

The  importance  and  utility  of  cerebral  thermometry  in 
mental  diseases  has  been  placed  beyond  doubt  by  Voisin, 
who,  besides  availing  of  this  means  of  examination  as  an 
element  of  diagnosis,  has  found  in  it  also  a  criterion  for 
suitable  treatment,  so  that  he  matches  the  value  of  ther- 
mometric  explorations  of  the  head  in  the  insane  with  that 
of  stethescopic  examination  in  diseases  of  the  chest.  The 
results  obtained  by  this  illustrious  alienist  were  first  com- 
municated to  the  International  Congress  of  Mental  Medicine, 
at  Paris,  last  August,  but  they  were  not  known  to  us 
except  through  the  lectures  given  by  him  in  the  Salpc- 
triere,  and  by  so  much  of  them  as  was  reported  in  his 
latest  treatise  on  ''Paralysic    Gencrale    of  the    Insaiid' 

He,  having  first  made  some  researches  on  individuals 
of  sound  minds,  found  that  the  temperature  of  different 
parts  of  the  cranium  varied  in  a  certain  measure  in  these, 
as  appears  from  the    following  figures  : 

Frontal  _  _  -  -  from  31  to  34 
Bregma  -  -  -  -  -  "  33  to  35 
Occiput         -         -         -         -  "       34  to  35.5 

Mastoid  region-  -  -  -  "  31  to  34 
Temporal  region  -         -         -  "       34  to  35.5 

The  maximum  figure  of  the  cranium  never  exceeded 
36^  (96.8  F.),  even  when  the  brain  was  in  a  state  of 
functional  activity,  and  with  diminution  of  this,  the  cere- 
bral temperature  descended  concurrently  to  a  lower 
figure.  As  regards  the  insane,  Voisin  has  established,  as 
we  have  done,  a  cranial  hypera^mia  in  general  paralysis 
and  in  ah  the  cases  of  insanity  with  maniacal  delirium, 
also    in    lypemania,    which    is    accompanied    by    a    chronic 


162  Joseph  Workman, 


congestion  of  the  encephalon.     This  hypenemia  sometimes 
pervades  the   whole    head ;"    at    other    times,  it  is    partial ; 
not     rarely    cerebral     thermometry     gives     a    temperature 
above    that    of  the     axilla,     whether     this    be     normal     or 
febrile.     Thus,    Voisin    reports  having  observed    in  patients 
affected  with    the    congestive    insanity   of  general  paralysis, 
but    without    fever,    the    following  temperatures : 

Bregmatic     ------  38 

Post-auricular  ------     37.8 

Temporal     ------  38 

Occipital  -         -         -         -         -         -     41 

A  cerebral  temperature  above  the  normal  maximum, 
according  to  this  author,  always  appears  to  signalise  a 
a  hyperaemic  or  phlogistic  state  of  the  brain,  demanding 
the  application  of  revulsives  and  depletives  to  the  head, 
and  especially  over  the  regions  which  are  chiefly  the  seat 
ot  the  hyperaemia.  In  support  of  this  fact,  he  relates  in 
his  w^ork  on  general  paralysis,  various  observations  on  such 
treatment,  adopted  after  the  indications  of  cerebral  ther- 
mometry, and  which  sufficed  to  lower  the  temperature  of 
the  head  and  diminish  the  delirium  and  the  other  morbid 
phenomena. 

As  an  element  of  diagnosis  of  the  seat  of  cerebral 
lesions,  the  thermometry  of  the  head  has  given  further 
results,  besides  those  of  embolism  already  mentioned,  in 
two  cases  of  cerebral  tumors.  The  case  described  by 
Gray,  in  his  article  on  cerebral  thermometr>%  was  that  of 
a  woman,  aged  34,  in  which  a  pupillary  stasis,  paroxysms 
of  pain  in  the  temporal  and  superciliary  regions,  nausea, 
vomiting,  ptosis  and  paralysis  of  the  ocular  muscles,  had 
led  the  physician  to  form  the  diagnosis  of  inter-cranial 
tumors,  situate  at  the  base  of  the  brain.  Gray  having  the 
opportunity  of  observing  it,  applied  the  thermometer  on 
various  regions  of  the  head,  and  obtained  the  following 
results : 

Frontal  region,  left,     -     35.97;  right     -     36.85 
Parietal       "  "    -     -  35.00;       "    -     -  37.63 

Occipital     "  "       -      35.97;        "       -     38.05 


Cerebral  Thermometry. 


Resting  on  these  data,  he  was  able  to  conclude  that 
the  lesion  must  be  extended  from  the  base  of  the  Sylvian 
fissure  backwards  along  the  right  occipital  lobe.  The 
autopsy  showed  the  existence  of  a  gliomatous  tumor,  sit- 
uate between  the  horizontal  or  posterior  branch  of  the 
Sylvian  fissure,  and  the  parallel  one  of  the  right  side, 
whilst  the  entire  occipital  lobe  was  converted  into  a 
colloid  mass,  extremely  vascular.  The  meninges  were 
unaltered. 

The  other  case,  communicated  to  the  Philadelphia 
Pathological  Society  by  Dr.  Mills,  on  14th  November, 
was  that  of  a  man,  aged  36,  in  which  the  principal  symp- 
toms were  intense  headache,  vomiting,  mental  enfeeblement, 
hallucinations,  but  without  delirium,  no  disturbance  of  the 
speech,  slight  paralysis  of  the  left  arm,  weakness  in  the 
lower  limbs,  deviation  of  the  head  to  the  right,  nystagmos, 
blunted  sensibility,  diminution  of  vision  and  of  olfac- 
tion, dilated  pupils  and  pupillary  stasis.  The  cerebral 
temperature  taken  for  seven  days  preceding  death,  gave  as 
tnean,  the  following  figures  ; 

Frontal  median  region,     -         -         _         35-83 

"         left  "     -         -         -         -     34.83 

Parietal     "  ••  _         _         _         34.66 

Occipital  median     "     -         -         -         -     35.27 

Frontal  right  "  -         -         -         35-00 

Parietal     "  "     _         _         _         _     54.83 

Leaving    out    of   account    the    high  temperature  of  the 

middle  occipital   region,  due,  as  Mills    has  pruperly  noted, 

to  the  position    of  the    head    of  the    patient    favoring   the 

accumulation  of  blood  in  the  sinuses,  it    is    seen  that    the 

frontal    median    region    gave    the  highest  figures,  and  that 

both  the  right    frontal    and    parietal    were    a    little    above 

those  of  the  left.     These  notes  of  the  clinical  observations 

found  explanation  in  the  anatomical  lesions  discovered    in 

.  the  autopsy,  which  showed  the  existence  of  a  large  tumor 

in    correspondence    with    the    right    frontal  lobe,  which  had 

destroyed     the     anterior     half    of    the     first     and    second 

frontal    convolutions,    part    of    the     corpus    callossum     and 


164  Joseph  Workman. 


of  the  gyrus  fornicatus,  saving,  however,  the  third 
frontal  convolution.  The  whole  brain  was  somewhat 
congested.  This  case,  according  to  Mills  and  contrary 
to  what  Broca  has  found  in  cerebral  embolism,  shows 
that  the  temperature  of  the  head  is  found  to  be  aug- 
mented in  connection  with  tumors  of  the  encephalon. 
The  most  recent  study  of  cerebral  thermometry  is 
that  communicated  by  the  illustrious  physiologist,  Paolo 
Bert,  to  the  Society  of  Biology,  on  the  i8th  January 
of  this  year.  He  made  his  experiments  on  himself, 
using,  not  thermometers,  but  thermo-electric  elements  of 
great  sensibility,  limiting  them  for  an  hour  to  the 
frontal  region  solely.  The  result  of  his  observations 
was,  that  every  time  the  temperature  was  not  equal  on 
both  sides,  that  of  the  left  was  always  the  higher, 
which  was  further  verified  by  the  fact  that  the  tem- 
perature on  such  occasions  was  increased  by  mental 
activity.  Bert  intends  to  follow  up  his  studies  with  the 
view  of  testing  the  theory  of  localization,  by  exploring 
the  temperature  of  the  points  which  correspond  to  the 
various  regions  of  the  brain,  regarded  as  the  seats  of 
diverse    functions. — Reggio   Emilia,     1st    March,    1879. 


Art.  IV.— On  the  Propositions  of  the 
Association  of  Superintendents  of 
American   Hospitals  for   the  Insane. 


By  John    Curwen,    M.    D., 

SUPERINTENDENT   AND    PHYSIC'AN     OF    THE    PENNSYLVANIA    STATE  LUNATIC 
HOSPITAL,   HARRISBURG,    PA. 

THE  principles  which  underiie  the  arrangement  and 
construction  of  a  hospital  for  the  insane  are  founded 
on  the  dictates  of  sound,  rational  common  sense,  and  the 
results  of  experience  obtained  by  residence  in  such  build- 
ings, and  derived  from  the  careful  study  of  the  require- 
ments of  the  peculiar  class  of  persons  for  which  they  are 
to  be  constructed,  and  whose  comfort  and  treatment  are 
alone  to  be  considered  in  such  construction.  The  most 
important  of  these  principles  may  be  stated  to  be  such  a 
plan  as  will  facilitate  to  the  greatest  degree,  and  render 
practicable  at  all  times,  the  readiest  and  most  thorough 
supervision  of  every  department  by  the  officers,  careful 
selection  of  the  best  material  for  the  construction,  and  the 
most  unwearied  attention  to  the  proper  arrangement  of 
the  different  kinds  of  that  material  in  the  various  parts  of 
the  building,  that  everything  may  not  only  be  of  the  best 
quality,  but  put  together  in  the  best  manner  calculated  to 
secure  the  purpose  designed;  the  most  systematic  adapta- 
tion of  every  part  to  the  wants  and  requirements  of  those 
who  are  to  occupy  the  wards ;  ease  and  economy  of 
administration;  and  ready  and  prompt  distribution  of  heat, 
food  and  other  articles  constantly  required,  and  special 
care  that  every  part  of  the  building  shall  have  abundance 
of  light  and   air. 


John  Curwen, 


While  the  greatest  latitude  may  be  allowed,  in  what 
may  be  termed  the  architectural  arrangements,  the  plan 
which  has  been  found  to  combine,  in  the  greatest  degree, 
all  the  points  above  enumerated  is  the  lineal  plan,  in 
which  each  wing  shall  be  opened  to  the  full  light  at  both 
ends,  and  the  different  wings  shall  be  continued  in  the 
same  line  as  that  nearest  the  center,  but  falling  back  so 
far  as  to  leave  the  second  open  at  both  ends,  and  so  on 
through  all  the  wings,  in  contradistinction  to  that  plan 
which  would  place  the  second  wing  at. right  angles  to  the 
first,  and  so  make  the  whole  surround  an  included  square. 
This  plan  was  first  fully  elaborated  and  explained  by  Dr. 
Thos.  S.  Kirkbride,  for  so  many  years  the  able  and  ac- 
complished superintendent  and  physician  of  the  Pennsyl- 
vania Hospital  for  the  insane,  in  Philadelphia,  and  has  been 
adopted  in  the  majority  of  hospitals  for  the  insane  erected 
within  the  last  thirty  years.  While  adhering  strictly  to 
this  principle  of  construction  many  changes  in  interior 
detail  and  arrangement  have  been  made  by  different  per- 
sons, but  these  changes  do  not  in  any  manner  affect  the 
original  idea. 

VI. — "All  such  buildings  should  be  constructed  of  stone 
or  brick,  have  slate  or  metallic  roofs,  and,  as  far  as  pos- 
sible, be  made  secure  from   accidents  by  fire." 

Circumstances  connected  with  the  locality  of  the  build- 
ing will  often  determine  the  fact  of  the  use  of  stone  or 
brick  in  the  construction,  but  when  stone  is  used  it  is 
always  best  and,  in  the  end,  most  economical,  to  line  the 
outer  wall  with  brick  with  an  air  space  of  about  three 
inches  between  the  brick   and  the  stone. 

The  brick  should  be  well  joined  with  or  "tied  into" 
the  stone,  at  short  distances,  so  as  to  make  the  brick 
secure  and  firm,  and  the  space  thus  left  between  the  walls 
will  not  only  render  the  walls  more  dry  and  prevent  the 
penetration  of  moisture,  after  a  long  continued  driving 
storm,  as  is  often  seen  in  solid  stone  walls,  but  will  also 
have  the  effect  of  making  the  building  warmer  in  winter 
and  colder  in  summer,  from  the  fact  that  neither  heat  nor 


On  the  Propositions  of  the  Association.  167 

cold    can    penetrate     beyond     the    layer  of   air    confined 
between    the  walls. 

The  same  effect  could  also  be  obtained  in  the  con- 
struction of  brick  walls  in  a  similar  manner  and  thus  avoid 
what  is  so  often  required,  the  furring  off  or  nailing  strips 
of  wood  to  the  walls  on  which  the  lath  is  nailed.  Lath 
and  plaster  partitions  are  always  objectionable  in  parts  of 
a  hospital  occupied  by  patients,  from  the  ease  with  which 
they  may  be  broken,  and  also  from  the  fact  that  they 
furnish  a  more  ready  receptacle  for  rats,  mice  and  vermin 
of  various  kinds.  The  wood  used  in  furring  off  walls, 
and  lath  and  plaster  partitions  are  also  objectionable  from 
the  fact  that  fire  is  easily  started  in  them,  and  when  so 
started  is  extremely  difficult  to  trace  or  to  extinguish. 
The  objection  to  metal  roofs  in  this  climate  arises  from 
the  injurious  effects  caused  by  the  alternate  expansion  and 
contraction  of  heat  and  cold,  the  thermometer  often  fall- 
ing twenty  or  more  degrees  in  the  course  of  a  few  hours  ; 
and  in  certain  metals  the  constant  tendency  to  rust, 
requires  the  frequent  use  of  paint  to  preserve  them  from 
the  corroding  influence  of  heat  and  moisture. 

Sufficient  care  is  not  generally  exercised  in  preparing 
the  sheathing  of  the  roof  on  which  the  metal  roof  is  to 
be  laid,  or  for  the  slate. 

The  best  plan  is  carefully  to  plane  and  plough  and 
groove  the  boards,  and  have  them  laid  as  carefully  as  a 
floor.  Slate,  when  properly  laid  on  a  roof,  thus  carefully 
prepared,  furnishes  the  best  material  for  roofing  in  a 
climate  subject  to  so  many  changes  in  temperature. 

The  cornices  of  the  roof  should  be  made  of  the  best 
galvanized  iron  and  carefully  backed  up  with  brick. 

The  surest  plan  to  avoid  accidents  by  fire  will  be  to 
have  the  whole  interior  constructed  with  brick  partition 
walls,  the  floors  made  of  brick  arches  between  iron  beams, 
.  and  this  arrangement  carried  through  every  part  to  and 
including  the  ceiling  of  the  upper  story  directly  under  the 
roof,  and  the  main  division  walls  of  brick  carried  up  to 
the  roof 


168  John  Curwen, 


This  practically  renders  the  building  fire  proof,  as  the 
only  part  in  any  hall  which  could  burn  would  be  the 
floor,  and  if  that  is  well  laid,  of  good  and  thoroughly  sea- 
soned lumber,  there  will  be  the  smallest  chance  for  the  fire 
to  spread  from  one  room  to  another.  Every  room  is  in 
effect  a  brick  box. 

But  where  this  cannot  be  done,  and  in  institutions 
already  built,  the  best  plan  will  be  to  introduce  pipe  con- 
nected with  the  tanks  in  the  attic,  or  from  an  outside 
reservoir  on  high  ground,  into  each  ward,  and  have  sufficient 
hose  to  carry  the  water  to  every  part  of  the  ward,  and 
fire-plugs  outside  with  hose  of  large  size.  An  additional 
means  of  security,  when  the  institution  is  heated  by  steam, 
will  be  to  carry  pipes  into  the  attic  of  the  center  and  differ- 
ent wings  from  the  boiler,  so  that  by  opening  a  few  valves, 
the  whole  attic  could  be  filled  with  steam,  in  case  a  fire 
should  break  out,  and  it  is  well  known  that  no  better  fire 
extinguisher  can  be  found  than  an  abundance  of  steam. 

VII. — "Every  hospital  having  provision  for  two  hundred 
or  more  patients  should  have  in  it,  at  least,  eight  distinct 
wards  for  each  se.x,  making  sixteen  classes  in  the  entire 
establishment." 

While  this  proposition  says  "at  least  eight  distinct 
wards  for  each  sex,"  it  impHes  that  a  larger  number  would 
be  advisable,  and,  as  a  general  rule,  it  could  and  should 
be  arranged  so  that  a  more  thorough  classification  could 
be  obtained  in  a  larger  number  of  wards. 

This,  in  many  cases,  is  very  necessary  for  the  comfort 
of  patients  and  the  greater  success  in  treatment,  so  that 
those  patients  who  were  annoying  to  others  and  particularly 
to  convalescent  patients,  may  be  removed  from  the  wards 
for  that  class,  and  placed  among  those  who  could  not  be 
so  much  injured  by  their  conduct  or  their  manner  of  talk- 
ing. It  is  well  known  to  every  superintendent,  that  there 
always  is  a  certain  class,  generally  quiet  and  free  from 
excitement,  and  who  can  behave  themselves  very  well, 
but  who  take  special  delight  in  retailing  the  most 
outrageous    stories    to    all    who    come    within    their   reach, 


On  the  Propositions  of  the  Association.  169 

particularly  to  recent  and  convalescent  patients ;  and,  the 
impression  thus  produced  on  this  class  of  patients  is  often 
very  injurious  and  calculated  to  retard  their  restoration,  if 
it  does  not  throw  them  into  a  state  of  excitement  or  lead 
to  more  serious  results. 

The  arrangements  for  classification  should  be  such  that 
all  this  class  could  be  separated  entirely  from  convalescents, 
and  placed  where  they  could  have  only  those  of  a  similar 
inclination  with  themselves  to  associate  with,  and  less 
incentive  therefore,  to  exercise  their  mischievous  propen- 
sity. The  subject  is  more  fully  stated  in  a  proposition 
adopted  in   1866,  which  reads  thus  : 

"The  facilities  for  classification  or  ward  separation 
possessed  by  each  institution,  should  equal  the  require- 
ments of  the  different  conditions  of  the  several  classes 
received  by  such  institutions,  whether  those  different  con- 
ditions are  mental  or  physical  in  their  character." 

VIII. — "Each  ward  should  have  in  it  a  parlor,  a  corri- 
dor, single  lodging  rooms  for  patients,  an  associated 
dormitory  communicating  with  a  chamber  for  two  atten- 
dants, a  clothes  room,  a  bath-room,  a  water-closet,  a 
dining  room,  a  dumb  waiter  and  a  speaking  tube,  leading 
to  the    kitchen,    or     other    central    part    of  the    building." 

The  parlor  should  be  so  placed  as  to  command  the 
most  pleasant  outlook  to  be  obtained,  and  should  be  of 
ample  size  so  as  to  afford  room  for  a  piano,  library,  sofa 
and  the  other  necessary  furniture ;  and  have  as  much  light 
from  windows  as  possible ;  and  the  whole  front  might 
easily  be  made  to  resemble  a  bay  window  by  projecting 
the  wall  so  far,  in  advance  of  the  other  walls,  as  to  allow 
a  window  to  be  placed  in  the  connecting  wall  on  each 
side. 

Everything  about  this  parlor  should  be  made  bright 
and  attractive  by  pictures  and  other  ornaments,  so  as  to 
induce  the  patients  to  spend  as  much  time  in  it  as  pos- 
sible ;  though  when  bay-windows  are  placed  in  a  ward, 
they  seem  to  be  places  of  greater  attraction. 

The  corridors  should  be  made  at  least  twelve  feet  wide 


170  John  Curiven, 


and  twelve  feet  high  in  the  cciHng  and  "no  chamber  for 
the  use  of  a  single  patient  should  ever  be  less  than  eight 
by  ten  feet,  nor  should  the  ceiling  of  any  story  occupied 
by  patients  be  less  than  twelve  feet  in  height." 

Where  the  wing  immediately  adjoining  the  center 
connects  with  it,  a  space  of  at  least  ten  feet  should  be 
arranged  with  w^indows  open  on  each  side  from  floor  to 
ceiling,  so  as  to  give  abundance  of  light  and  air  at  that 
point,  and  these  windows,  like  all  the  windows  in  the 
wards,  should  be  protected  with  some  ornamental  form  of 
guard  to  prevent  intrusion  by  outsiders,  and  to  prevent 
also  the  escape  of  the   patients. 

The  omission  of  this  open  space  makes  that  end  of 
the  hall  dark,  and  at  that  point,  also,  the  air  will  be  very 
apt  to  be  impure  from  the  inability  to  obtain  a  free 
circulation. 

It  must  be  very  distinctly  kept  in  mind  that  every  part 
of  a  hospital  for  the  insane,  occupied  by  patients,  should 
be  as  bright  and  cheerful  and  have  as  much  sunlight  as 
it  is  possible  to  obtain  by  means  of  windows  and  open- 
ings at  the  ends  of  the  hall.  No  hall  can  be  made  too 
bright  and  cheerful  at  all  times;  and  even  when  the  warm 
rays  of  the  sun  in  summer  require  to  be  excluded,  that 
can  be  done  without  interfering  in  any  way  with  the 
cheerfulness  and  brightness  of  the  wards. 

The  advantages  of  this  abundance  of  light  are  two- 
fold :  In  the  first  place,  as  a  matter  of  health,  and,  then, 
as  tending  to  promote  greater  cheerishness  in  all  within  the 
range  of  its  influence  ;  for  it  is  a  matter  of  common  obser- 
vation, that  persons  obliged  to  be  in  dark  rooms  become 
dull  and  depressed,  while  they  are  at  the  same  time  more 
blanched  and  unhealthy  in    appearance  and  in  fact. 

It  has  been  objected  to  rooms  on  both  sides  of  the 
hall  that  the  effect  will  be  to  make  the  halls,  if  long,  dark 
and  gloomy,  but  if  they  have  large  windows  from  floor  to 
ceiling  at  each  end,  with  a  large  bay-window  on  each 
side  in  tlie  center,  no  unpleasant  gloom  or  darkness 
will  be    observed  ;    and    the    bay-windows  will  give   a   very 


On  the  Propositions  of  the  -Association.  171 

pleasant  sitting  room  which  will  be  occupied  nearly  all 
the  time  by  the  patients,  and  will  be  a  place  where  flowers, 
birds  and  other  objects  of  interest  may  be  kept.  In  the 
arrangement  of  the  rooms  in  a  ward,  great  care  should  be 
taken  to  have  the  door  and  window  opposite,  so  that  the 
bed  may  be  placed  to  one  side  and  out  of  the  line  of 
any  drafts,  which  would  be  occasioned  by  opening  the 
door  and  window. 

Every  room  should  be  provided  with  a  flue  for  the 
admission  of  warm  air,  and  also  one  for  the  removal  of 
foul  air,  so  arranged,  that  no  unpleasant  draft  from  the 
w^arm  air  shall  strike  the  person  who  may  occupy  the 
room  ;  and,  where  a  system  of  forced  ventilation  is  used, 
this  may  readily  be  effected  by  having  the  warm  air 
admitted  above  the  level  of  the  person's  head,  and  the 
foul  air  removed  at  a  lower  point ;  but  unless  a  strong 
power  is  used  to  keep  up  the  circulation,  this  arrangement 
will  not  answer  satisfactorily  in  practice,  whatever  excel- 
lencies may  be  claimed  for  it  in  theory. 

The  question  of  the  particular  arrangement,  of  the 
window  of  the  room  must  be  left  to  the  prevalent  idea  in 
any  particular  section. 

There  are  really  three  different  forms  of  window ;  one 
where  both  sashes  are  of  iron  and  the  upper  is  made  to 
balance  the  lower,  and  when  the  lower  is  raised  about 
five  inches,  the  upper  is  lowered  the  same  distance, 
by  an  arrangement  of  connecting  chains  and  pulleys  ; 
another,  where  the  upper  sash  is  of  cast  iron  and  station- 
ary, and  the  lower  sash,  hung  with  cords  and  weights, 
raises  the  whole  distance,  and  a  guard  of  an  ornamental 
character  protects  the  space  opposite  the  lower  sash  so 
that  the  patient  cannot  fall  out  or  jump  out ;  and,  the 
third  form  is  where  both  sashes  are  of  wood  and  hung  by 
ropes  and  weights  so  as  to  move  up  and  down,  and  the 
space  outside  is  covered  with  a  guard,  either  plain  or 
ornamental. 

The  idea  has  been  strenuously  advanced  by  some  that 
all  guards  to  the  windows    and    locks    to  the  doors  should 


172  John  Cur-wen, 


be  dispensed  with,  which  we  beheve  to  be  most  erroneous, 
and  one  of  those  extreme  "measures  which  will  cure  itself 
by  the  verj'  state  which  it  will  induce,  of  remissness  on 
the  part  of  those  in  charge  of  the  wards  and  of  acci- 
dents and  injuries  to  the  patients.  It  is  going  from  the 
extreme  of  care  to  the  extreme  of  carelessness,  and  avoid- 
ing that  which  has  always  been  found  the  safest,  the  mean 
between  the  two  extremes.  If  the  insane  be  irresponsi- 
ble, as  will  be  generally  admitted,  the  effort  to  give  them 
full  liberty  to  go  and  come  as  they  please,  places  them  in 
a  position  attended  with  risk  to  themselves  and  to  others ; 
to  themselves,  because  it  places  them  in  a  position  to  be 
subjected  to  influences  and  temptations  which  will  have  a 
decidedly  injurious  influence,  and  to  others  by  the  risk  to 
life,  person  and  property  at  the  caprice,  ill-will  or  the 
delusions  of  an  irresponsible  party,  and  it  is  neither  right 
nor  just  to  expose  the  innocent  and  unsuspecting  mem- 
bers of  any  community  to  any  such  risks. 

It  has  been  the  fashion  with  many  to  insist  on  large 
associated  dormitories,  but  we  believe  this  to  be  contrary 
to  the  desire  and  habits  of  our  people,  who  all  insist  on 
having  a  room  to  themselves.  It  is  true  that  a  hospital 
can  be  constructed  more  cheaply  when  the  majority  of 
the  patients  can  be  placed  in  associated  dormitories,  but 
there  are  many  other  things  besides  cheapness  to  be  con- 
sidered in  the  construction  of  a  hospital  for  the  insane, 
and  chief  among  these  are  the  comfort  and  welfare  of  the 
patients. 

We  have  no  sympathy,  whatever,  with  that  wretched 
sentiment,  born  of  parsimony  and  disregard  of  the  feelings 
and  rights  of  others,  which  insists  that  the  comfort,  the 
welfare,  the  happiness  and  the  restoration  of  th.e  insane, 
of  any  class,  are  to  be  weighed  in  the  balance  with  a  few- 
hundred  dollars.  The  State  is  bound,  in  honor  and  duty, 
to  make  the  very  best  provision  for  all  its  wards,  and  the 
more  helpless  and  dependent,  the  greater  care  should  be 
exercised  in  provision  for  them  ;  and  while  proper  economy 
should    always    be    exercised     in    the    disbursement    of    all 


On  the  Propositions  of  the  Association.  1~3 


money,  both  in  public  and  private  undertakings  of  any- 
kind,  and  every  dollar  should  be  strictly  accounted  for,  no 
State  nor  any  private  corporation  or  association  can  afford 
to  do  wrong,  for  wrong  in  every  form  is  wasteful  expen- 
diture, nor  are  any  so  poor  that  they  cannot  afford  to 
provide  for  those  who  may  be  committed  to  their  care,  in 
that  manner  which  will  best  promote  the  welfare  of  the 
insane  in  every  way  in  their  power.  That  cannot  be 
done  when  the  individual  is  placed  in  a  position  which 
injures  his  self-respect  or  is  entirely  at  variance  with  all 
his  previous  habits  and  education.  Men  and  women 
insist  on  some  accommodation  which  will  give  them  a 
degree  of  privacy,  which  cannot  be  obtained  by  being 
obliged  to  be  in  a  large  dormitory,  and  it  will  not  do  to 
say  that  because  they  are  insane  their  feeHngs  are  not  to 
be  considered. 

The  effort  in  these  days  seems  to  be  to  lower  the 
standard  of  self-respect  and  make  people  feel  their  depen- 
dency ;  but  true  humanity  teaches  that  men,  born  in  the 
image  of  God,  should  be  trained  to  a  proper  regard  for 
their  high  destiny,  and  that  true  charity  consists  in  the 
dispensation  of  its  gifts,  in  such  a  manner  as  to  instill 
higher  aims  and  more  ennobling  sentiments,  and  to  lead 
all,  of  every  class  and  condition,  to  seek  that  which  will 
give  true  comfort  in  better  and  more  enduring  provision, 
for  themselves  and  all  within  the  sphere  of  their  influence. 

The  principle  which  should  govern  in  all  cases  is  : 
"Whatsoever  ye  would  that  men  should  do  to  you,  do  ye 
even  so  to  them ;"  and  regard  must  also  be  had  to  the 
consideration  which  sooner  or  later  comes  home  to  every 
one  in  some  form,  that  he  or  his  may  at  some  time  require 
some  such  accommodation  as  a  hospital  for  the  insane 
affords,  and  he  must  consider  how  the  plan  of  such  asso- 
ciation would  suit  his  own  case,  or  whether  he  would  like 
•some  member  of  his  family  placed  in  such  a  position  as 
has  been  indicated.  Unfortunately  this  principle  has  too 
limited  an  application  in  governing  bodies,  and,  particu- 
larly where  the  expenditure    of  money  in  public  buildings 


174  John  Curwen. 


is  involved,  but  that  is  no  reason  why  it  should  continue 
to  prevail,  but,  on  the  contrary,  every  dictate  of  justice 
and  humanity  demands  that  the  sooner  men  in  every  rela- 
tion of  life  do,  as  they  would  be  done  by,  the  better  will 
mankind  be. 

There  is  still  another  consideration  directly  bearing  on 
the  patients  themselves,  that  the  proper  degree  of  sleep 
at  night,  and  that  calm  state  which  should  precede  and 
is  necessary  to  sound  sleep,  cannot  be  had  in  nervous  and 
restless  patients  in  a  room  where  a  number  sleep,  for  the 
reason  that  among  that  number,  particularly,  if  it  exceed 
six,  there  will  always  be  one  or  more  who  are  restless 
and  uneasy  and  are  apt  to  be  up  and  about  the  room,  to 
the  annoyance  of  others  and  interference  with  their  sleep  ; 
and  unless  the  room  is  very  well  ventilated,  the  breath 
and  other  effluvia  arising  from  a  number  of  persons,  soon 
vitiates  the  air  so  as  to  render  it  unpleasant  and  unhealthy. 

The  argument  in  favor  of  dormitories,  that  those  inclined 
to  suicide  may  be  placed  in  them  with  greater  safety  and 
less  probability  of  an  attempt  on  their  part  to  effect  their 
purpose,  has  only  a  very  limited  application,  and  really, 
as  a  rule,  does  not    effect  the  object. 

The  only  preventive  of  suicide  is  careful  and  constant 
watchfulness  by  day  and  by  night. 

Every  room  of  the  kind  should  have  a  strong  wire 
frame  in  the  upper  half  of  the  door,  so  as  to  answer  the 
double  purpose  of  easy  inspection  and  more  efficient  ven- 
tilation. 

It  is  well  known  that  associated  dormitories  are  not 
used  until  it  becomes  a  matter  of  necessity,  and  the  fewer 
of  them,  and  the  more  limited  the  number  they  can  accom- 
modate, the  better  for  the  patients  themselves. 

Where  a  dormitory  of  large  size  is  used,  the  necessity 
of  a  chamber  for  two  attendants  communicating  with  it  is 
requisite,  in  order  that  they  may  better  minister  to  the 
patients  in  it,  and  prevent  any  disturbance,  though,  as  a 
rule,  if  the  attendants  have  attended  to  their  duties  dur- 
ing the   day,    they    generally    sleep    so    soundly,    and    they 


On  the  Proposifions  of  the  .Association.  1"5 

should  have  their  full  sleep  for  the  proper  performance  of 
their  daily  duties,  that  they  hear  very  little  that  may 
occur  during  the  night,  unless  of  a  very  unusual  charac- 
ter, and  the  real  dependence  must  be  on  the  activity  and 
efficiency  of  the  night  watch,  which  in  cases  of  special 
emergency  would  be  increased  for  the  time. 

More  thought  and  attention  should  be  given  to  the 
room  designed  for  the  clothing  of  the  patients  in  each 
ward  than  has  usually  been  the  case.  It  should  be  of 
ample  size,  well  lighted  and  well  ventilated,  and  placed  in 
close  proximity  to  the  bath  room,  and  should  be  conve- 
niently arranged  with  closets  and  boxes  in  which  the 
clothing  can  be  neatly  folded  and  arranged,  with  hooks 
for  hanging  up  coats  and  various  other  articles  ;  which  are 
better  hung  up  than  folded  and  laid  away.  In  addition 
to  this  there  should  be  ample  arrangements  for  the  sheets 
and  other  bed  clothing,  with  a  convenient  place  in  which 
hats  and  shoes  may  be  placed  by  the  men,  instead  of 
being  allowed  to  lie  promiscuously  about  the  ward  to  the 
annoyance  of  all  careful  people,  and  the  inevitable  loss  to 
those  who  wear  them. 

The  bath-room  should  be  conveniently  arranged  with 
an  ample  supply  of  hot  and  cold  water,  and  should  also 
be  kept  at  a  warm  temperature  in  the  coldest  weather  so 
that  the  most  delicate  may  suffer  no  injury  before  enter- 
ing or  after  leaving  a  bath.  In  immediate  connection 
with  the  bath-room  should  be  a  wash  room  with  station- 
ary basins  and  an  ample  supply  of  water,  to  which  the 
patients  can  have  ready   access  at  all  times. 

The  arrangements  of  water  closets  are  generally  on  too 
limited  a  scale,  and  it  is  best  to  place  in  every  ward  at 
least  two  hoppers,  so  that  there  may  not  be  any  excuse 
for  careless  habits  on  the  part  of  the  patients,  by  inability 
to  obtain  the  needed  accommodation. 

While  such  improvements  have  been  made,  and  are 
still  making,  in  the  arrangement  for  these  conveniences,  it 
is  not  requisite  that  any  special  plan  should  be  insisted 
on  further  than  that    "all    water    closets    should,    as  far  as 


176  John  Curwen, 


possible,  be  made  of  indestructible  material,  be  simple  in 
their  arrangements  and  have  a  strong  downward  ventila- 
tion connected  with  them,"  and,  also,  that  "the  floors 
should  be  made  of  material  that  will  not  absorb  moisture." 

The  dining  room  should  be  of  such  size  as  to  give 
comfortable  sitting  room  for  all  who  may  occupy  the 
ward,  should  be  bright  and  airy,  and  should  have  con- 
nected with  it,  a  neat  china  closet,  where  all  the  articles 
used  on  the  tables  can  be  kept  in  neat  order ;  and  in  it  a 
sink  with  hot  and  cold  water  attached,  in  which  the 
plates,  dishes  and  all  articles  used  on  the  table  can  be 
washed. 

The  dumb-waiter  should  be  conveniently  located  in 
connection  with  the  dinning  room,  and  the  apparatus  for 
hoisting  it  should  be  such  as  to  involve  the  least  labor 
and  trouble,  and  easy  communication  afforded  with  the 
kitchen  by  means  of  a  speaking  tube  or.  as  may  now  be 
very  satisfactorily  arranged,  by  telephone. 

IX. — "No  apartment  should  ever  be  provided  for  the 
confinement  of  patients,  or  as  their  lodging  rooms,  which 
are  not  entirely  above  ground." 

The  requirement  of  this  proposition  would  appear  super- 
fluous, but  it  seems  needful  in  these  days  when  the  effect 
is  made  to  cheapen  things  to  the  very  lowest  point,  and 
endeavor  to  make  provision  for  a  certain  class  of  the  insane 
in  a  manner,  which  is  not  in  strict  accordance  with  that 
proper  regard  for  their  comfort  and  welfare  which  their 
position  imperatively  demands,  and  also  to  place,  so  far  as 
words  and  a  protest  can  do  it,  a  barrier  to  any  further 
efforts  in  that  direction. 

X. — "No  class  of  rooms  should  ever  be  constructed 
without  some  kind  of  window  in  each,  communicating 
directly  with  the  external  atmosphere,"  and  this,  for  the 
reason  before  stated,  that  every  patient  should  have  the 
benefit  of  sunlight  to  as  great  a  degree  as  possible,  and  a 
better  opportunity  can  be  afforded  for  the  freest  admission 
of  fresh  air,  which  in  many  rooms  is  absolutely  requisite  to 
insure  cleanliness. 


On  the  Propositions  of  the  Association.  177 

The  eleventh  proposition  has  been  already  consid- 
ered in  connection  with  the  size  of  the  rooms  to  be  used 
for    patients. 

XII. — "The  floors  of  the  patients'  apartments  should 
always  be  of  wood."  It  would  seem  scarcely  necessary 
to  insist  on  this  requirement,  but  as  stone  and  brick  floors 
have  been  used  in  the  past,  and  are  exceptionally  cold  and 
uncomfortable,  particularly  for  that  class  who  would  be 
most  probably  compelled  to  occupy  such  rooms ;  there 
might  be  those  who  would  consider  it  a  good  thing  to  do,  to 
return  to  such  a  state  of  aflairs  in  the  future,  on  the  ground 
that  wooden  floors  would  rot  out  by  frequent  scrubbing, 
and  it  would  be  economy  to  prevent  such  expenditure. 

Wooden  floors  may  be  rendered  nearly,  if  not  quite, 
impervious  to  all  fluids  by  an  application  of  boiled  oil, 
applied  hot,  so  as  to  saturate  the  floor,  and  having  this 
repeated  every  few  months. 

XIII. — "The  stairways  should  always  be  of  iron,  stone 
or  other  indestructible  material,  ample  in  size  and  number, 
and  easy  of  access  to  afford  convenient  egress  in  case  of 
accident  from  fire."  Every  ward  should  have,  at  least, 
two  stairways,  one  at  each  end,  leading  directly  to  the 
ground,  both  front  and  rear,  so  that,  by  opening  the  doors 
the  patients  could  readily  be  taken  out  to  the  ground 
around  the  building.  The  stairways  must  be  of  iron,  stone 
or  slate,  and  walled  into  a  brick  wall  on  each  side,  so  that 
they  shall  be  virtually  fire-proof  from  top  to  bottom — all  the 
landings  being  of  the  same  material  as  the  stairs. 

Circumstances  peculiar  to  the  location  of  the  hospital 
will  probably  determine  the  character  of  the  material  to  be 
used,  as  in  some  localities  one  of  the  articles  named  may 
be  obtained  at  a  more  reasonable  price  than  others. 
Slate  forms  really  the  neatest  and  pleasantest  stairway  to 
travel  over,  as  it  is  less  noisy  when  trodden  on,  and 
experience  has  shown  that  it  wears  very  little  by  constant 
treading  over  it. 

Unless  care  is  taken  to  have  the  iron  slightly  rough- 
ened on  the  top  of  the  step,*  it  will  in  time  become  smooth 


John  Curwen< 


and  slippery,  and  the  same  may  be  said  of  certain  kinds  of 
stone — but  it  does  not  hold  good  in  slate.  In  these  days 
when  so  mnch  is  said  about  fire-escapes  from  public 
buildings,  it  is  wisest  and  best  to  construct  the  stairway 
in  such  a  manner  as  to  be  virtually  a  fire-escape  from  all 
the  wards.  This  can  readily  be  done  in  the  manner  indi- 
cated above,  and  then  should  a  fire  unfortunately  take 
place,  the  inmates  can  all  readily  be  removed  by  the  mode 
of  egress  to  which  they  have  been  accustomed. 

Any  fixture  outside,  such  as  is  usually  constructed,  is 
worse  than  useless,  for  very  few  patients  would  venture  on 
them,  and  they  would  be  very  likely  to  be  used  by  mis- 
chievous persons,  for  the  purpose  of  annoying  the  patients. 

For  females  such  outside  fixtures  would  be  utterly 
impracticable  ;  whereas,  a  stairway  constructed  of  either  of 
the  materials  named,  and  well  built  into  a  brick  wall, 
would  be  perfectly  safe  and  secure,  and  very  easily  avail- 
able at  all  times,  and  free  from  every  objection  which 
could  be  urged  against  outside  fixtures. 


Art.  v.— Pathological  Relation  of  Cer- 
tain Ophthalmic  Phenomena  to 
Tabes  Dorsalis  (Locomotor  Ataxia, 
Posterior  Spinal  Sclerosis,  &c.) 


By  Wm.  Dickinson,  M.  D.,  of  St.  Louis. 

JOHN  S.,  57  years  of  age,  a  watchman  on  board  of  river 
steamboat,  came  under  my  observation  and  treat- 
ment, March,  4th,  1874,  for  rapidly  progressing  amblyopia. 
He  gave  his  history  as  follows  :  Weight,  about  200  lbs.  ; 
robust  health — uninterrupted  during  his  entire  life  ;  never 
suffered  from  previous    affection    of   his  eyes  or  head,  not 


Certain  Oph.  Phen.  in  Cerehro- Spinal  Sclerosis.      179 

even  from  presbyopic  symptoms ;  vision  unimpaired  until 
last  Christmas,  and  able  to  read  the  daily  papers.  For 
the  purpose  of  obviating  increasing  dim  ess  of  vision, 
which  at  that  time  he  had  first  observed,  he  endeavored  to 
select  a  pair  of  glasses,  but  these  rendered  him  no  aid, 
and  he  expressed  to  his  wife  apprehensions  of  becoming 
blind.  During  his  adult  life,  he  has  used  much  tobacco 
by  chewing,  rarely  by  smoking,  and  very  sparingly  has 
indulged  in  alcoholic  liquors.  He  attributes  his  failure 
of  vision  to  the  unvoidable  exposure  in  the  performance  of 
his  ordinary  duties.  In  December,  1872,  he  had  a  fall, 
receiving  an  injury  on  left  hypochondriac  region,  the 
effects  of  which,  however,  seemed  to  be  but  temporary. 
On  Thanksgiving  day,  1873,  he  accidently  fell  into  the 
river  at  Cairo,  but  from  this  accident,  also,  he  was  not 
conscious  of  suffering  any  ill  effects.  With  his  left  eye 
he  can,  at  twelve  inches  distance,  distinguish  only  large 
letters.  No.  L.  Snellen,  and  with  the  right,  those  of  No. 
C,  or  those  twice  as  large. 

O.  S. — Dioptric  media  all  in  normal  condition  ;  details 
of  the  fundus  distinctly  perceived;  papilla  exhibits  marked 
optic-nerve  atrophy  and  a  brownish  gray  color  ;  its  peri- 
phery was  irregular,  but  presented  no  atrophy  of  the 
choroid. 

Diagnosis. — Grave  central  disease  suspected,  but  its 
character  not  sufficiently  declared  by  distinctive  symptoms. 

Under  general  derivative  treatment  vision  steadily  and 
greatly  improved,  so  as  to  be  able,  on  April  8th,  to  dis- 
cern most  of  No.  6,  at  twelve  inches.  But  my  record  of 
the  loth  states,  vision  rapidly  declining.  On  this  day,  he 
first  complains  of  numbness  of  the  left  hand,  especially  of 
the  fingers.  Galvanism  was  used  with  temporar}'-  benefit, 
from  nucha  and  over  the  cervical  sympathetic  to  the 
closed  lids.  April  25th — vision  in  right  eye  totally  lost, 
but  with  left  he  still  perceives  No.  XXX.  He  now  des- 
cribes a  sensation  throughout  the  entire  surface  of  the 
fingers,  similar  to  that  of  accumulation  of  dirt  under  the 
nails.       Treatment  with  different  agents  continued  through 


180  Wm.  Dickinson, 


the  month  of  May.  On  the  30th,  he  stated  the  middle 
finger  of  right  hand  was  "for  some  time  stiff.  Strychnia 
employed,  hypodermically,  without  avail.  June  7th. — For 
the  first  time  he  complains  of  numbness  of  right  side,  of 
lower  extremities  and  in  back,  together  with  a  sense  of 
constriction  around  waist,  as  of  a  tight  belt.  Vision  in 
left  eye  now  rapidly  declined,  and  in  spite  of  all  effort 
the  impairment  soon  reached  such  a  degree,  that  he  could 
not  see  sufficiently  to  walk  about  alone.  In  rapid  suc- 
cession, now,  other  symptoms  appeared.  Loss  of  co-or- 
dinating power  in  lower  extremities  verj'  observable  ;  can 
not  stand  erect  without  assistance;  he  staggers  and  reels 
when  attempting  to  walk.  He  describes  a  sense  of 
enlargement  of  left  chest,  as  if  from  a  foreign  body  within; 
to  the  eye,  that  side  appears  more  prominent  but  it 
measures  actually  less  than  the  other.  Ataxic  symptoms, 
also,  appear  in  the  arms,  hands  and  fingers ;  he  dresses 
himself  with  difficulty  in  consequence.  He  experiences 
much  delay  in  the  act  of  micturition.  His  urine  contains 
no  albumen,  but  many  crystals  of  oxalate  of  lime.  Sexual 
function  almost  annihilated.  19th. — Rigidity  of  muscles 
of  the  leg  and  still  progressive ;  gait  more  unsteady ; 
psychic  faculties  much  hightened,  especially  in  re- 
gard to  sentiments,  .sheading  tears  from  trivial  causes 
or,  even,  without  cause,  but  still  retaining  power  of 
judgment  and  of  will.  2 1st — After  application  of  gal- 
vanism (galvanic  current),  he  could  discern  objects  which 
were  near.  Complains  of  legs  being  stiff;  extensors  of 
fingers  in  a  state  approaching  tonic  contraction  ;  attempts 
to  flex  them  occasion  pain.  Without  material  change, 
with  appetite  good,  he  continued  till  July  loth,  when  ho 
was  seized  with  a  paroxysm  of  sensation  of  "smothering," 
accompanied  by  a  sense  of  an  oppressive  weight  in 
lumbar  region,  and  great  general  debility,  and  in  connec- 
tion therewith,  he  has  an  irresistible  impulse  to  stand 
erect,  for  the  purpose  of  better  resisting  the  tendency  of 
"dragging  down."  No  well  pronounced  pain  experi- 
enced, but  a  vague  sense  of  great    discomfort    in  the    left 


Certain  OjjTi.  Phetv   in  Cerebro-Spinal  Sclerosis.      ^81 

hypochondrium  ;  face  flushed,  vessels  of  conjunctiva  con- 
gested and  eyes  suffused.  This  assemblage  of  symptoms 
were  all  dispelled  by  the  administration  of  a  small  quan- 
tity of  whisky.  At  this  date,  all  perception- of  light  totally 
annihilated.  Numbness  of  left  side  continues,  and  now 
in  both  hands,  but  to  a  greater  degree  in  the  left.  On 
the  1 2th,  without  obvious  cause,  another  paroxysm, 
similar  to  that  of  the  loth,  occurred,  which  continued  from 
noon  till  night.  i8th. — Numbness  has  extended  over  the 
entire  trunk  and  extremities,  but  the  other  symptoms  are 
diminished  in  intensity.  Now,  when  attempting  to  walk, 
he  describes  a  sensation  in  the  soles  of  his  feet  as  if 
pressing  upon  a  coil  of  cord  or  of  wire.  Galvanism  seemed 
to  dilute  the  intense  darkness  experienced,  and  enabled 
him,  for  a  short  time,  to  discern  the  reflexion  of  light 
from  the  surface  of  a  gold  watch.  He  complains  of  gen- 
eral debility  and  of  disturbed  sleep.  31st. — Perception  of 
light  totally  extinguished ;  the  arteries  and  veins  of  optic 
disc  are  greatly  diminished  in  size,  and  gray  atrophy  is 
well  pronounced.  The  gustatory  sense  is  obtunded  and 
perverted ;  he  perceives  a  salt  taste  in  his  mouth,  and 
requires  an  unusual  quantity  of  sugar  in  his  coffee  to 
render  it  palatable.  He  is,  also,  less  dispondent ;  has 
regained  the  proper  use  of  his  fingers,  and  the  grasp  is 
much  increased  in  power ;  but  the  sense  of  constriction 
about  his  body  still  persists,  extending  from  the  lumbar 
region  to  left  hypochondrium  and  hip.  Without  essential 
change  he  continued  in  the  condition  described  tor  several 
weeks,  until  he  was  removed  to  the  immediate  care  of  his 
friends  in  the  East,  from  whom,  five  years  later,  came  the 
report  that  he  was  still  living,  and  that  his  condition  had 
undergone  no  essential  change. 

The  case  detailed  above  presents  a  symptom  picture, 
approximating  the  typical  form  of  Tabes  Dorsalis — the 
designation  used  in  its  widest  and  generic  signification,  as 
nearly  as  generally  falls  under  our  observation,  and  though 
lacking  some  of  its  most  characteristic  features,  it  possesses 
others  that  are  peculiar,  well-marked  and  distinctive.      The 


182  W^ryv.  Dickinson, 


discrepancies  existing  in  this  case  and  in  others,  which 
have  come  under  my  treatment,  have  induced  a  preference 
for  the  classification  of  symptoms  made  by  Remak,  a 
score  of  years  since.  He  distinguishes  different  forms  of 
the  disease  according  to  its  apparent  seat,  but  the  pathol- 
ogy by  him  attached  to  each  must,  in  the  light  of  more 
recent  investigations,  be  somewhat  modified.  His  classi- 
fication, containing  a  larger  number  of  subdivisions, 
possesses  the  excellence  of  greater  system,  as  well  as 
greater  perspicuity  and  intelligibility  of  description,  and 
is  as  follows,  viz. : 

I.  Tabes  Basalis — Usually  commences  with  deranged 
action  of  the  muscles  of  the  eye,  and  disorders  of  vision  ; 
anaesthesia  and  paresis  of  the  hands  ensue  at  a  later  date. 
2.  Tabes  Cetvicalis — Characterized  by  eccentric  pains,  small 
immovable  pupils  and  the  long  duration  of  the  motor 
disorders.  3.  Tabes  Dorsalis — The  power  of  walking  and 
the  functions  of  the  genital  and  urinary  organs  and  of  the 
rectum  are  more  evidently  impaired,  and  the  eccentric 
pains  are  very  severe.  4.  Tabes  Lnmbo-Dorsalis — Pain 
or  pressure  over  the  spinous  processes.  This  symptom 
occurs  only  in  this  form,  and  is  a  favorable  prognostic 
sign,  as  indicating  a  still  existing  myelitis.  5.  Tabes 
Lumbalis — Is  sometimes  an  independent  affection  ;  some- 
times united  with  a  uni-lateral  lumbo-sacral  neuritis. 
6.  Tabes  Cerebelli — Is  very  rare,  and  characterized  by  ex- 
treme unsteadiness    of  gait    and,  sometimes,  by  amblyopia. 

All  vital  phenomena  proceed,  primarily,  from  and  are 
controlled  by  the  autocracy  of  the  central  nervous  sys- 
tem— cerebro-spinal.  For  the  achievment  of  any  specific 
vital  action,  continuity  of  nervous  tissue,  constituting  a 
conducting  nerve  path  between  center  and  organ,  muscle, 
skin,  &c.,  is  essential.  This  implies  the  arrangement  of 
granules  of  nerve  substance  into  rows  or  fibrils.  By  this 
fibrillation  is  forshadowed  the  great  fundamental  law  by 
which  in  the  realm  of  nervous  phenomena.  Nature  works. 
The  law  of  isolated  conduction,  is  clearly  enunciated  in  the 
determination  of  tiic  simplest  muscular  effort,   as  well  as  in 


Certain  Oph.  Phen.  in  Cerebro- Spinal  Sclerosis.      183 

the  production  of  that  which  is  the  resultant  of  the  united 
action  of  the  most  complex.  This  coronal,  intrinsic  pro- 
position, it  is  important  to  bear  in  mind,  in  our  attempts  to 
account  for  the  progress  of  disease  up  or  down  along  the 
great  nervous  highway,  when  once  commenced  in  any  one 
part  and  announced  by  characteristic  symptoms. 

In  this,  as  in  a  large  number  of  other  diseases,  without 
doing  violence  to  any  theory  or  fact,  we  must  premise 
the  existence  of  a  constitutional  predisposition,  and  in 
rare  instances,  heredity;  if  not,  all  persons  subjected  to 
the  same  influences,  c.  g.,  atmospheric  vicissitudes,  habits 
ot  life,  specific  infection,  accident,  &c.,  would  be  affected 
in  the  self  same  manner. 

Again,  observation  confirms  the  assertion  that  symp- 
toms referable  in  their  causal  relations  to  different 
sections  of  the  cerebro -spinal  system,  do  not  observe 
definite  and  regular  periods  in  the  time  or  order  of  their 
occurrence.  In  some  instances  the  disease,  with  remark- 
able regularity,  traverses  this  vast  system  from  above 
downward,  from  basal  to  lumbar  regions,  giving  evidence 
of  its  remorseless  presence  by  characteristic  phenomena, 
at  each  successive  portion.  It  may,  again,  commence  in 
the  lumbar  region  and  with  like  regularity  and  phenom- 
ena proceed  upward  through  the  medulla  oblongata  to 
the  thalami  optici  and  optic  apparatus,  running  riot  and 
strewing  ruin  in  its  progress ;  or  the  symptoms  of  any  two 
contiguous  or  separate  regions,  simultaneously  affected, 
may  co-exist,  the  intermediate  portions  remaining  intact, 
or,  as  yet,  not  sufficiently  affected  to  project  the  legiti- 
mate consequences  upon  the  peripheral  nerves  arising 
therefrom.  Rarely  or  never  does  it  simultaneously  invade 
the  entire  domain  and  develop  pari  passu  throughout  its 
entire  length,  though  it  cannot  be  maintained  that  such 
an  occurrence  is  inconsistent  with  its  pathology. 

Now,  how  stands  the  case  with  the  classification 
adopted  ?  The  symptoms  first  experienced  belong  to  the 
Basal  group.  Amblyopia  was  the  first  symptom  observed  ; 
from  no  one  of    the    numerous    inflammatory    affections  of 


184  IFni.  Dickinson, 


the  eye  had  he  ever  suffered,  nor  from  any  disease  of  the 
brain  ;  he  had  no  syphiHtic  history,  was  debihtated  by 
no  cachexia,  but  was  a  man  of  robust  frame  and  in  the 
habitual  enjoyment  of  perfect  health.  The  lancinating 
pains  usually  attacking,  capriciously,  different  parts  of  the 
body,  and  among  the  first  symptoms  of  invasion  were  here 
entirely  absent.  Some  pain  he  experienced,  but  it  was 
in  no  degree  characteristic.  The  fall  which  he  had  in 
1872,  probably,  has  no  causal  relation  to  this  attack  ;  but 
that  of  November,  1873,  into  the  river,  we  regard  as  the 
pouit  d'appui,  the  proximate  efficient  cause  of  the  disease, 
through  sudden  arrest  of  cutaneous  perspiration  and  other 
inevitable  consequences  to  the  nervous  system,  though  not 
at  the  time  appreciated.  At  that  very  moment,  also,  the 
optic  nerve,  from  the  habitual  use  of  tobacco,  may  have 
suffered  trophic  disturbances,  which  were  rapidly  aggra- 
vated by  the  accident  referred  to,  in  its  own  specific 
manner.  While  the  continued  exposure,  incident  to  the 
pursuit  of  his  avocation,  still  farther  and  energetically  pro- 
moted the  progress  of  the  degenerative  process  com- 
menced. 

The  Cervical  portion  seems  to  have  escaped  involvement 
during  the  early  history  of  the  case.  Since  he  manifested 
no  disturbance  of  the  muscles  of  the  eye  ;  no  diplopia  or 
strabismus,  convergent  or  divergent ;  no  ptosis ;  nor  at  any 
time  was  this  portion  of  the  cord  to  any  considerable 
degree  affected,  though  later  in  the  progress  of  the  dis- 
ease there  was  developed  in  the  upper  extremities  formi- 
cation, numbness  of  the  fingers  and  diminished  power  of 
grasp.  Meanwhile  the  disease  descends  to  the  Dorsal 
region.  Now  is  experienced  numbness  in  the  trunk  and 
commencing  inco-ordination  of  muscular  movements  in  the 
lower  extremities,  with  aggravation  of  the  symptoms 
already  enumerated,  belonging  to  the  basal  and  cervical 
groups.  This  was  evinced  by  progressive  amblyopia  and 
tonic  contraction  of  the  extensors  of  the  fingers ;  and 
anomalous  symptoms  about  the  thorax,  now  supervened, 
also,    impairment    of    the     functions    of    the     urinary    and 


Certain  Cph.  Then,  in  Cerebro- Spinal  Sclerosis.      185 

genital  organs;  delay  in  commencing  the  act  of  micturi- 
tion and  failure  of  sexual  power,  no  congress  having  been 
indulged  in  for  several  months,  with  the  still  farther 
downward  progress  of  the  disease  to  the  Lumbo-Dorsalis 
region.  In  addition  to  the  category  of  symptoms  already 
detailed,  there  ensued  increased  inco-ordination  of  muscu- 
lar movements  of  the  extremities,  and  sensation  of  a  tight 
girdle  around  the  waist.  The  disease  having  reached  the 
lumbar  region,  psychic  disturbances  begin  to  manifest 
themselves,  and  super-added  to  the  symptom-picture  we 
have  abnormal  sensibility  of  the  soles  of  the  feet  with 
other  manifestations  of  perverted  sensibility,  besides,  great 
muscular  debility  and  increasing  helplessness.  No  symp- 
toms characteristic  of  the  cerebellar  complication  arose, 
unless  the  seat  of  co-ordination  of  muscular  movement,  as 
maintained  by  some,  is  to  be  referred  to  this  organ.  The 
cervical  sympathetic  and  the  trigeminus  seem  not  to  have 
entirely  escaped  complication,  evinced  by  flushing  of  the 
face  and  conjunctival  congestion,  and,  also,  by  perversion 
of  the  gustatory  sense,  in  which  the  glossopharyngeal 
doubtless  participated. 

One  of  the  salient  features,  in  the  history  of  this  case, 
is  the  distinct  origin  or  earlier  maturity  of  the  disease  in 
in  the  basal  section,  and  the  singular  regularity  of  its 
advance  downwards  through  the  great  central  nervous 
highway,  announcing  its  constant  and  irresistable  progress, 
with  corresponding  precision  by  characteristic  phenomena. 
The  law  of  progression  of  disease  is  generally  in  the 
direction  of  the  function  of  the  part,  from  center  to 
periphery,  except  in  those  which  arise  from  a  constitu- 
tional diathesis  or  dyscrasia.  The  manifestations  of  this 
law  are  often  reversed.  There  is,  therefore,  no  anatom- 
ical heresy  in  the  hypothesis  that  this  disease  may  com- 
mence in  the  posterior  columns  and  posterior  roots  of  the 
.  spinal  cord ;  the  lumbar,  by  preference  ;  since  in  this  por- 
tion it  possesses  larger  dimensions  and  a  great  predomin- 
ance of  gray  substance ;  and,  that  its  extension  is  upwards 
towards    the    brain,    giving    rise    to    characteristic  signs  in 


Wm.  Dickinson, 


the  various  portions  of  the  body,  which  have  their  nervous 
centers  successively  in  that  of  the  lumbo-dorsahs,  dorsahs- 
ascendens,  cervicaHs  and  basahs — from  the  latter  of  which 
eye  symptoms  are  determined ;  or  it  may  commence  in 
some  one  of  the  mediate  sections  and  proceed  in  both 
directions.  It  is  often  possible  to  determine,  with  almost 
hair-breadth  precision,  the  height  in  the  cord  to  which 
the  disease,  if  considerable,  has  reached. 

It  is  but  a  coarse  and  meagre  description  (though  for 
general  purposes  ample),  that  systematic  treatises  on  anat- 
omy present  of  the  sources  of  origin  of  the  optic  nerve, 
viz.  :  from  the  corpora-quadrigenima,  thalami  optici,  tuber- 
cula  geniculata,  &c.  These,  in  fact,  are  but  mediate 
ganglia  through  which  pass  certain  fibres  of  the  optic 
tract  to  the  hemispheres  and  cerebral  convolutions,  or, 
according  to  some,  are  but  ganglia  into  which  these  fibres 
penetrate,  and  from  which  others,  of  similar  function,  pro- 
ceed, receiving  the  luminous  impressions  borne  thither  by 
the  former,  and  conducting  them  to  their  distal  destination 
in  the  cortex  cerebri,  where  perception  of  light  takes 
place.  Respecting  the  relation  of  the  optic  apparatus  to 
the  brain  oa  the  cerebral  convolutions,  Griesinger  expresses 
himself  thus,  viz:  "The  optic  nerve  and  its  roots  are  in 
the  human  species  relatively  small,  but  the  expansion  of  the 
nerve  within  the  brain  assumes  an  extraordinary  develop- 
ment. A  fan-torm  expansion  can  be  distinguished  within 
the  hemispheres  passing  from  the  optic  tract  to  the  summit 
of  the  posterior  lobes  ;  other  such  radiations  pass  forward 
in  all  the  anterior  convolutions,  the  high  development  of 
which  is  characteristic  of  the  human  brain.  This  expansion 
is  not  to  be  considered  throughout,  as  a  simple  continua- 
tion of  the  fibres  of  the  optic  nerve  itself,  but  rather  as 
the  multiplication  of  these  or  of  the  addition  of  a  new 
system  of  fibres  of  the  optic  nerves.  The  high  develop- 
ment of  the  expansion  of  the  optic  nerve  appears  to  con- 
stitute an  essential  characteristic  of  the  human  brain,  and 
also  that  of  the  higher  apes,  and  to  represent  an  apparatus 
adapted  to  some  of  the  most  important  mental  functions." 


Certain  Oph.  Phen,  in  Cerebro- Spinal  Sclerosis. 


187 


In  works  treating  of  the  diseases  of  the  eye  the  asso- 
ciation of  amaurosis  (in  its  generic  signification)  with 
tabes,  obtains  a  recognition  far  incommensurate  with  its 
importance.  The  omission  of  it  altogether  on  the  part  of 
Mackenzie,  is  venial,  on  account  of  the  time  and  the 
accepted  pathology  of  his  day ;  but  the  same  indulgent 
judgment  cannot  be  extended  to  Walton,  who,  in  his 
voluminous  and,  in  most  respects,  excellent  work,  has 
totally  ignored  its  existence  ;  though  Romberg  had  nearly  a 
quarter  of  a  century  earlier  given  a  clear  and  extended 
description  of  the  two  affections  and  their  relations. 
Stelwag,  in  his  classic  work,  devotes  but  two  brief  para- 
graphs to  the  subject,  and,  apparently,  intentionally  refrains 
from  committing  himself  to  an  opinion  as  to  the  causal 
relations  of  the  two  affections,  diverse  in  mode  of  manifes- 
tation and  remote  in  situation,  but  grants  the  existence  of 
a  special  amaurosis,  and  describes  the  atrophic  process  as 
generally  advancing  from  the  optic  thalamus  to  the  optic 
tract,  its  commissure  and  the  nerves.  Wells  evinces  his 
greater  appreciation  by  extending  his  observations  over 
less  than  half  a  page  ;  while  Schweigger,  making  no  dis- 
tinct mention  of  the  disease  under  consideration,  simply 
alludes  to  the  condition  of  gray  atrophy  presented,  and 
quotes  from  Virchow :  "The  mottled  gray  atrophy  of  the 
opticus  appears  to  be  connected,  especially,  with  the 
mottled  atrophy  of  the  spinal  cord,  and,  under  the  circum- 
stances, amaurosis  is  associated  with  paralysis  and 
anaesthesia  of  the  extremities." 

Trousseau  and  Isnard  regarded  tabes,  essentially,  as  a 
neurosis,  and  the  anatomical  changes  as  merely  secondary 
results;  but  pathologists  of  the  present  day  are  quite 
agreed  as  to  the  essential  nature  of  the  change,  which 
constitutes  the  disease,  viz. :  That  it  consists  in  a  gray 
degeneration  of  the  posterior  roots  and  posterior  columns 
of  the  spinal  cord  ;  that  it  is  developed  simultaneously  or 
successively  at  various  points  in  the  central  nervous  sys- 
tem, especially  predisposed  thereto;  that  it  extends  also 
laterally    affecting    the     lateral     columns;     the    extension 


Tr'/^2/.  Dickinson, 


laterally  may  explain  the  later  more  severe  distubances  of 
sensibility,  the  disturbances  of  co-ordination,  the  motor- 
paresis  and  paralysis,  the  vesical  and  sexual  weakness. 

It  is  not  demonstrable,  though  highly  probable,  that 
the  initial  stage  of  this  affection  is  a  chronic  inflammator}' 
process,  and  represents,  consequently,  one  form  of  chronic 
myelitis,  sclerosis,  leading  to  gray  degeneration,  being  the 
result;  "and  in  proportion  as  the  atrophy  progresses' and 
the  ner\'es  in  certain  directions  perish,  we  find  cunei-form 
segments  in  which  the  substance,  up  to  that  time  white, 
becomes  from  without  inwards  grey,  there  being,  appar- 
ently, a  production  of  grey  matter." — VircJum. 

The  disease  develops,  in  respect  to  time  and  location, 
very  variably,  but,  generally,  manifests  precedence  in 
the  lumbar  cord,  and  extending  transversely  and  longitu- 
dinally, it  lessens  in  extent  and  degree  as  we  ascend, 
extending  throughout  the  entire  extent  of  the  cord  into 
the  optic  thalamus.  In  cases  in  which  amaurosis  has 
supervened,  the  entire  optic  nerve  apparatus  has  been 
found  presenting  degenerative  changes,  analogous  to  those 
found  in  the  spinal  cord.  The  optic  nerves  are  often  the 
first  and  most  intensely  attacked,  the  metamorphosis  dimin- 
ishing as  we  approach  the  corpora  geniculata.  It  begins, 
as  in  the  cord,  at  the  periphery  of  the  trunk  of  the  nerve 
and  involves  its  more  central  fibres  last.  It  is  preceded 
by  a  manifest  optic  neuritis  of  the  ascending  form.  McLane 
Hamilton  entertains  opinions  diametrically  opposite,  assert- 
ing that  "the  change  begins  at  the  point  of  origin  of  the 
nerves  and  progresses  towards  the  distal  end."  Though 
it  may  be  impossible,  in  the  present  stage  of  histological 
knowledge,  to  find  any  anatomically  demonstrable  contin- 
uity of  gray  degeneration  between  the  optic  nerves  and 
the  posterior  columns  of  the  cord,  yet,  it  is  not  a  ground- 
less assumption  to  assert  that  such  a  continuity  virtually 
exists.  If  this  be  granted,  then  extension  of  degenera- 
tive changes  from  foci  in  one  or  more  of  the  sections 
premised  to  other  sections  contiguous,  is  in  entire  harmony 
with  other  pathological    processes.       Prodromal    symptoms 


Certain  Oplv.  Phen,  in  C erebro- Spinal  Sclerosis.    ^89 

varied  in  character  and  gravity  are  presented  during 
variable  periods,  extending  through  intervals  of  months  or 
even  years,  before  that,  by  the  successive  supervention  of 
positive  and  characteristic  symptoms,  the  physiognomy  of 
the  actual  disease  is  portrayed  with  sufficient  distinctness 
for  recognition.  Graefe  has  observed  a  case  in  which  the 
disease,  having  commenced  in  the  basal  region,  atrophy  of 
the  optic  nerve  occurred  several  years  before  the  first 
symptoms  of  the  spinal  disease  were  manifested.  In  the 
case  of  our  patient  the  disease,  unsuspected  and  unde- 
clared, in  the  seclusion  of  the  same  region  of  the  cere- 
brum, must  have  existed  from  a  period,  long  anterior  to 
December,  1873,  and  had  been  insidiously  making  pro- 
gress in  local  development,  if  not  in  extension,  also ;  or, 
if  initiated  by  the  occurrence  on  that  day  and  b}-  the 
accident  alleged,  it  must  have  matured  with  surprising  and 
exceptional  rapidity,  for  in  March,  when  first  examined, 
gray  atrophy  was  not  only  demonstrable,  but  was  far 
advanced — a  period  of  less  than  four  months  from  the  date 
of  its  invasion.  At  the  date  last  referred  to,  there  was 
not  the  least  sign  present,  objective  or  subjective,  other 
than  amblyopia,  to  indicate  the  grave  significance  of  this 
symptom,  or,  of  its  ante-current  relation  to  the  spinal  com- 
plications, which  so  speedily  and  in  such  rapid  succession 
followed,  in  which  all  the  cranial  nerves,  except  the  first, 
third,  fourth,  sixth  and  the  last,  were  to  a  greater  or  less 
degree  involved. 


Art.  VL— Apparently  Conscious  Epilep- 
tic Automatism  with  a  Sequel  of 
Aphasia. 


In  the  practice  of  Drs.  C.  W.  Stevens  and  C.  H.  Hughes. 

''  I  ^HE  medico-legal  importance  which  might,  under 
-■-  certain  circumstances,  be  attached  to  cases  answering 
the  description  of  the  above  caption,  constitutes  a  sufficient 
justification  for  giving  place  to  a  completed  description 
of  a  case  reported  for  the  Avzt'  Vor/c  Medical  Record  last 
August. 

It  differs  from  the  somewhat  similar  cases  reported  by 
Hughlings  Jackson,  in  the  absence  of  the  marked,  though 
momentary,  lapse  of  consciousness  which  characterized  the 
latter,  and  we  think  no  precisely  similar  case  is  recorded 
by  Eccheverria  or  Abercrombie.  The  occurrence  of  this 
somewhat  phenomenal  case  recalls  to  mind  the  position 
assumed  by  Biegel,  ten  or  more  years  ago,  accompanying 
a  report  of  some  cases  to  the  London  Lancet,  that  uncon- 
sciousness is  not  an  uiivarying  characteristic  of  epilepsia,  a 
position  which,  we  think,  as  our  observations  of  epileptic 
and  especially  of  epileptoid  disease,  increase  and  become 
more   precise,    will  be  fully  sustained. 

The  medico-legal  significance  of  this  case  appears  in 
the  fact,  co-existing  with  undoubted  epileptic  disease  (often 
nocturnal),  that  there  was  scarcely  a  perceptible  departure 
from  the  indivuiuats  normal  self  in  his  deportment,  in  the 
vnappreciahle   lapse    of  cotiscioiisness,    tJic   absence  of  double 


Conscious  Epileptic  Automatisin.  191 

consciousness,  of  exalted  mental  activity,  hallucination,  illu- 
sion or  confusion  of  mind,  some  of  which  phenomena  accom- 
pany ordinary  somnambuHsm,  and  any  of  which  may  pre- 
cede, follow  or  supplement  an  epileptic  seizure.  Its 
undoubted  connection  with  epilepsia,  an  attack  of  which, 
during  sleep,  may  have  preceded  the  somnambulistic 
display  about  to  be  recorded,  reveals  the  true  cause. 

In  the  fall  of  1867,  Dr.  M.  got  up  after  midnight, 
dressed  himself,  walked  a  quarter  of  a  mile,  to  a  certain 
place  on  his  farm,  to  look  at  his  stock.  After  he  had 
been  there  a  while,  seemingly  to  him  a  very  short  time, 
he  came  to  a  realization  of  the  fact  that  it  was  not  the 
proper  time  for  him  to  be  at  such  a  place  ;  although  con- 
scious of  every  step  he  took  to  get  there.  He  went  back 
to  his  house,  undressed  himself  and  again  retired  to    bed. 

He  was  conscious  of  all  that  he  did  from  the  time  of 
rising  to  dress  himself,  but  did  not  realize  the  incongruity 
of  his  position  and  that  he  ought  then  to  have  been  in 
bed.  In  1875  he  again  did  about  the  same  thing,  getting 
up  and  dressing  himself,  putting  on  his  boots,  clothing, 
cravat,  collar  and  hat,  and  taking  his  watch  from  under  his 
pillow  and  looking  at  the  time — every  act  being  remembered 
in  the  order  in  which  it  was  done.  He  this  time  walked 
out  into  the  street.  When  he  fully  came  to  a  realiza- 
tion of  the  fact  that  he  ought  to  have  been  in  bed,  he 
was  standing  by  a  fence  looking  over  into  a  vacant  lot. 
He  knew  he  had  come  to  the  lot,  but  not  that  he  ought 
not  to  have  been  there  at  that  hour  of  the  night,  until 
after  a  time,  it  occurred  to  his  mind  that  he  ought  to 
have  remained  in  bed,  whither  he  immediately  returned. 
The  patient  had  had  many  real  epileptic  seizures  for  months 
preceding  these  somnambulistic  displays,  his  paroxysms 
having  been  so  violent  and  so  alarmed  his  second  wife,  to 
whom  he  had  lately  been  married,  that  she  parted 
from   him. 

This  patient  was  put  on  treatment  (bromide  of  calcium, 
lacto-phosphate  of  calcium  and  ergot),  last  winter,  with 
the  result  of  a  complete    arrest    of   his    paroxysms  except 


192  C.  W.  Stevens  and  C.  B.  Hughes, 

the  following,  whicJi  we    give    in    the  patient's  own  words, 

he  being  himself  a  physician : 

"Drs.  C.  W.  Stevens  and  C.  H.  Hughes,  St.  Louis. 

Gentlemen: — I  will  give  you  a  short  statement  of  my 
condition  since  I  wrote  you  last.  On  May  i/th,  I  was 
asked  a  question  by  a  friend  and  I  knew  and  understood 
perfectly  what  I  was  asked,  but  on  trying  to  answer  the 
question,  I  was  unable  to  do  so.  I  continued  to  talk  for 
about  twenty  minutes,  attempting  to  explain,  what  I  was 
trying  to  say.  Finally,  I  walked  half  a  block,  took  a 
drink  of  water,  went  to  my  office  and  felt  all  right.  The 
next  time  I  saw  the  man  to  whom  I  tried  to  explain  the 
question  he  had  asked  me,  I  obtained  all  the  information 
I  could  as  regards  my  actions  at  the  time  alluded  to.  He 
asked  me  a  great  many  things,  to  find  out  if  I  knew  what 
I  had  said,  and  I  remembered  nearly  all.  The  night  of 
the  17th  inst.  I  had  an  attack  which  was  as  hard  as  they 
used  to  be.  These  are  all  of  the  appearances  of  epilepsia 
that  I    have    had,    since  I  wrote   to  you  six  months  ago." 

It  will  be  observed  that  this  was  not  the  usual  post 
epileptic,  but  an  ante  epileptic    display. 

The  possible  medico-legal  importance  of  this  case,  in 
view  of  its  undoubted  association  with  epilepsia,  is 
obvious.  But  suppose  the  connection  with  epilepsia  had 
not  been  so  apparent,  what  would  have  been  the  results 
had  some  act  been  done  by  this  same  patient,  during  his 
apparently  conscious  somnambulism,  involving  him  in  a 
pecuniary  obligation  ?  Suppose  he  had  signed  a  deed  or 
done  an  act  making  him  liable  in  law  ? 

The  gentleman  has  had  no  repetitions  of  these 
attacks  up  to  this  date.  The  Protean  forms  of  epileptoid 
display  incite  to  cautious  thought.  They  have  not  in 
all  their  possible  manifestations   been  yet  recorded. 


Art.  VII.— Case  of  Hemiplegia  and  Apha- 
sia ending  in  Recovery. 


By  A.  A.  Hexske,  A.  M.,  M.  D. 

1\ /TRS.  M.,  aged  63  years,  Irish,  and  married,  consulted 
-^^-^  me  for  the  first  time  Sept.  1st,  1879.  She  was 
then  complaining  of  a  severe  and  continuous  headache, 
and  of  a  slight  numbness  of  her  whole  right  side.  She, 
also,  saw  dark  spots  before  her  eyes,  and  had  a  great 
and  continuous  inclination  to  sleep.  There  were  no  signs 
of  gastric  disturbance.  The  pulse  was  regular,  70 
per  minute,  and  of  an  atheromatous  feel.  Patient  had 
suffered  of  inflammatory  rheumatism  eight  years  ago,  and 
had  returns  of  it  about  four  and  two  years  ago.  A  physical 
examination  of  the  heart  revealed  considerable  enlargement 
and  extensive  valvular  lesions.  The  patient  appeared  to 
be  well  nourished  and  inclined  to  obesity.  I  prescribed 
saline  purgations  and  bromide  of  sodium  in  large  doses. 
The  described  symptoms  disappeared  until  Sept.  6th,  when 
they  returned  and  were  more  severe. 

Patient  now,  also,  complained  of  tinnitus  aurium  and 
nausea.  She  had  become  forgetful  and  incoherent.  The 
movements  of  the  tongue  were  embarrassed  and  the 
speech  somewhat  confused.  Telling  her  story  she  con- 
tinually wept.  Asked  why  she  wept,  she  said  she  did  not 
know.  The  pulse  was  retarded  (65  per  minute) ;  the 
heart's  action  irregular.  At  first,  the  face  w^as  pale  and 
ghastly ;  afterwards,    became    flushed.       Saline    purgations 


194  J.  A.  Eenske, 


and  bromide  of  sodium  were  again  resorted  to,  also,  a  fly- 
blister  was  applied  to  the  nape  of  the  neck.  Sept.  loth, 
the  patient  said  that  she  felt  well,  and  had,  also,  slept 
well.       The  bromide  of   sodium    was    continued  at  nights. 

The  morning,  Sept.  14th,  our  patient  was  found  lying 
in  bed  in  a  comatose  condition.  The  right  pupil 
was  contracted,  the  left  a  little  more  dilated  ;  neither 
reacted  to  the  light.  The  face  was  flushed  and 
puffed  up  with  each  expiration ;  the  breathing  was  slow 
and  heavy  ;  pulse  48  per  minute  ;  the  temperature  of  the 
axilla  96^  F.  There  was  complete  inability  to  swallow. 
The  reflex  excitability  was  entirely  abolished  on  the  right 
side ;  lessened,  but  not  entirely  abolished,  on  the  left  side. 
To  an  injection  per  anum,  containing  a  few  drops  of 
croton-oil,  the  bowels  responded  freely. 

Sept.  15. — Patient  was  able  to  svv^allow  liquids.  The 
face  was  swollen,  flushed  and  a  little  distorted,  being 
drawn  to  the  left  side.  The  pupils  were  still  contracted 
and  did  not  respond  to  the  light ;  but  she  could  open  and 
shut  her  eyelids.  Pulse,  65  per  minute  ;  temperature, 
102=   F. 

Sept.  1 6th. — Patient's  condition  about  the  same  as  the 
day  before.        Pulse,  70  per  minute;  temperature,    103^   F. 

Sept.  17th. — Patient  appeared  to  be  conscious.  The 
reflex  excitability  of  the  right  side  still  abolished ;  that  of 
the  left  side  nearly  normal  ;  patient  would  moan  if  the 
skin  of  the  left  side  were  pinched.  Pulse,  75  per  minute ; 
temperature,  lOi  1-2^  F.  Iodide  of  potassium,  60  grains 
every  six  hours,  was  prescribed. 

Sept.  1 8th. — Patient  appeared  to  be  quite  conscious; 
could  protrude  her  tongue  which  deviated  to  the  right 
side  ;  could  open  and  shut  both  eyes,  pupils  normal  and 
responding  to  the  light.  Pulse,  80  per  minute  ;  tempera- 
ture, 99  1-2'  F.  The  iodide  of  potassium  continued  in  the 
same  doses. 

Sept.  19th. — Considerable  improvement.  Pulse,  80  per 
minute;  temperature,  98'  F.  Patient  took  food  freely.  She 
had  voluntary  and  normal  discharges  from  the  bladder  and 


ffemiplegia  and  .Aphasia.  195 

bowels.  The  hemiplegia  was  well  defined,  being  confined 
to  the  right  side.  The  patient  could  move  the  limbs  of 
the  left  side  freely.  The  sensibility  of  the  right  side 
had  returned,  but  was  lessened ;  the  limbs  of  that 
side  were  rigid,  considerably  contracted  and  slightly 
swollen.  The  distortion  of  her  face  was  hardly  notice- 
able, except  when  asked  to  protrude  her  tongue  or  when 
she  tried  to  produce  a  sound.  She  was  completely 
aphasic.  The  only  sound  she  could  produce  was  a  deep 
moan.  When  questioned,  she  appeared  to  understand 
very  well,  and  tears  flowed  from  her  eyes.  The  iodide 
of  potassmm  was  continued    in  the  same  doses. 

Sept.  20th. — A  rash  had  broken  out  all  over  her  body, 
and  there  were  other  symptoms  of  iodism.  The  iodide  of 
potassium  was  discontinued  and  the  patient  remained  with- 
out medicinal  treatment. 

Sept.  28th. — The  iodism  had  disappeared,  and  the 
general  condition  of  the    patient    the    same  as  Sept.    19th. 

October  15th. — In  regard  to  the  hemiplegia  there  was 
no  change  for  the  better,  but  there  w^as  considerable 
improvement  in  the  aphasic  condition.  She  could  say,  "Yes, 
O  yes,  sister"  (calling  every  one  sister),  and  "tae"  for  tea. 
If  asked  questions,  she  began  to  weep.  She,  apparently, 
appreciated  the  meaning  of  words  and  sentences,  uttered 
in  her  hearing,  very  well ;  she,  also,  comprehended  the 
condition  in  which  she  was.  She  shook  her  head  as  a 
negation  and  nodded  as  an  affirmation.  The  distortion  of 
her  face  was  hardly  visible,  even,  when  speaking ;  the 
tongue  did  not  diviate  when  protruded.  There  was  no 
irregular  contraction  of  the  muscles  of  mastication.  The 
few  words  spoken  were  plainly  pronounced.  The  aphasia 
was  entirely  amnesic. 

Nov.  1st. — Aphasia  about  the  same.  Paralysis  slightly 
improved,  the  sensibility  nearly  normal. 

Dec.  1st. — Paralysis  so  far  improved  that  she  could 
slightly  move  the  limbs  and  stand  without  support. 
Aphasia  the  same. 

Dec.  15th. — Patient's  vocabulary  considerably  increased. 


196  A.  A.  Henske. 


she  used  "yes"  and  "no"  correctly.  Paralysis  much 
improved. 

Jan.  1st. — Patient  could  walk  without  support,  but  was 
not  able  to    use  her  arm.       Aphasia,  also,  much  improved. 

Jan.  15th. — The  aphasia  had  nearly  disappeared.  The 
patient  .spoke  correctly,  but  slower  than  before  the  attack. 
The  mental  condition  appeared  to  be  normal,  although 
the  patient  was  more  irritable  and.  fretful  than  she  used  to 
be,  shedding  tears  profusely  at  the  least  circumstance 
causing  annoyance  to  her.  She  had  perfect  motion  of 
her  right  leg,  can  walk  without  difficulty,  but  could  not 
use  the  right  arm  as  freely  as  formerly. 

Feb.    15th Patient's    arm    still    slightly  paralyzed,  but 

she  can  use  it. 

The  case  just  narrated  is  chiefly  interesting  in  the  fact 
that  although  seen  when  the  premonitory  symptoms  of 
cerebral  apoplexy  could  be  recognized,  and  the  usually 
recommended  measures  were  resorted  to,  only  temporary 
relief,  perhaps  postponement,  of  the  excessive  haemorrhage 
was  gained.  Further,  although  after  the  haemorrhage 
took  place,  no  drugs,  except  the  iodide  of  potassium,  for 
four  days  were  prescribed,  nor  electricity  or  other 
measures  made  use  of,  gradual  recovery  from  the  imme- 
diate effect  as  well  as  from  the  remaining  hemiplegia  and 
aphasia  followed. 


Art.  VIII.— Aphonia  from   Motor  Paral- 
ysis. 


A    CLINICAL    STUDY. 


By  Wm.  Porter,  A.  M.,  M.  D.,  of  St  Louis. 

TT  is  well  understood  by  most  physicians  that  aphonia  is 
-■-  but  a  symptom  which  may  pertain  to  different  laryngeal 
conditions.  It  is  certain,  however,  that  in  many  instances 
the  precise  nature  of  these  conditions  is  overlooked,  and 
thus  a  simple  cause,  undiscovered,  may  give  rise  to  con- 
tinued discomfort,  if  nothing  worse.  A  laryngoscopic  ex- 
amination, while  important  in  every  case  of  loss  of  voice, 
does  not  always  solve  the  question  of  diagnosis,  for  often 
all  that  is  seen  must  be  still  further  relegated,  ere  the 
definite  cause  is  reached. 

This  is  especially  true  in  aphonia  resulting  from  the 
paralysis  of  the  motor  nerves  of  the  larynx.  When  such 
diseases  as  phthisis,  syphiHs  and  cancer  invade  the  larynx, 
inspection  may  discover,  at  once,  the  cause  of  well-marked 
objective  as  well  as  subjective  symptoms.  In  paresis  of 
the  laryngeal  muscles  as  elsewhere,  the  cause  of  the  im- 
pairment may  not  be,  seldom  is  seen,  and  is  often  seated 
in  a  remote  part  of  the  organism.  There  is  no  more 
interesting  illustration,  of  cause  and  effect,  than  the  apho- 
nia of  a  neurosis,  general  or  limited. 

In  the  clinical  study  of  laryngeal  paresis,  the  cases 
may  be  somewhat  naturally  arranged  as    due    to  : 

I.     Lesion  of  the  nerve  centers, 

II.     Peripheral  disease. 


198  Tl^m.  Porter, 


III.  Disease  of,  or  pressure  upon,  the  trunk  of  the  motor 
nerve. 

IV.  Reflex  irritation.* 

I.  In  aphonia  from  paralysis  resulting  from  central  lesion, 
the  cause  is,  generally,  readily  distinguished  on  account  of 
evidence  aside  from  that  furnished  by  the  larynx.  Thus 
Mackenzie'^  describes  a  case  of  immobility  of  the  "  right 
vocal  cord  with  other  symptoms  of  diseased  innervation — 
all  confined  to  the  right  side."  The  motor  loss  may  be 
upon  one  side,  or  both,  dependant  upon  the  amount  and 
site  of  the  central  disease  In  most  instances  the  rootlets 
of  the  spinal  accessory  nerves  are  involved. 

A  year  ago  I  examined  Dr.  ,  a    practitioner   from 

an  adjoining  State,  who,  with  a  history  of  s)-philis,  con- 
tracted 12  years  ago,  presented  evidence  of  the  later 
effects  of  the  disease.  Among  these  were  gummata  of 
the  right  tibia,  and  clavicle  and  of  the  frontal  bone.  He 
had  also  symptoms  ot  disturbance  of  the  medula  oblongata, 
among  which  was  paralysis  of  the  adducter  of  the  right 
v^ocal  cord  with  consequent  aphonia.  There  was  no  other 
laryngeal  lesion.  Accepting  the  opinion  offered  that  there 
was  a  localized  disease  of  specific  character  at  the  base  of 
the  brain,  he  began  anti-syphilitic  treatment  with  great 
earnestness,  giving  close  attention,  also,  to  improving  his 
physical  condition  by  good  food,  regular  exercise,  etc. 
No  local  meditation  was  used  in  the  larynx,  yet,  within  six 
months  he  had  regained  some  power  of  phonation.  From 
this  time,  his  voice  became  stronger,  and  his  general  health 
being  improved;  he  has  this  winter  resumed  the  practice 
of  his  profession. 

x\s  a  rule,  however,  these  cases  do  badly ;  indeed  from 
the  very  nature  and  seat  of  the  disease  we  expect  an 
unfavorable  termination.  Before  leaving  this  part  of  our 
subject,  it  may  be  remarked,  that  the  change  of  voice 
sometimes  noted  in  the  insane  is,  probably,  frequently  due 
to  pathological  processes  in  the  brain,  and  is  not  always 
the  result  of  the  dulusions  or  the  constant  vociferation  of 
mental  alienation  as  some  have  supposed,  but  rather  a  co- 

(1)  others  have  classified  the  laryngeal  paresis  according  to  the  muscles  aflected. 
The  above  arrangement  is  more  appropriate  in  these  columns. 

(2)  Hoarseness  and  Loss  of  Voice,  p.  29. 


Aphonia  from  Motor  Paralysis. 


existing  condition,  though  proceeding  from  the  same 
morbid  cause. 

II.  A  much  more  pleasing  group,  so  far  as  prognosis 
is  concerned,  is  that  in  which  the  paresis  is  peripheral. 
This  condition  is  always  bilateral — the  result  of  such 
direct  laryngeal  injury  as  often  follows  catarrhal  laryngitis, 
or  in  rare  cases  of  diphtheria,  or  still  more  rarely  succeed- 
ing the  inhalation  of  irritating  vapors.  I  have  been 
fortunate  in  meeting  with  the  following  remarkable  instance 
of  this  class  : 

Mr.  H ,  aged  30,  in  general  good  health,  was  ex- 
amined on  account  of  aphonia  of  long  standing.  His 
history  was  that  eleven  and  a-half  years  before,  while  in 
the  army,  he  had  taken  a  "severe  cold;"  that  he  suddenly- 
lost  his  voice,  and  had  continued  voiceless.  He  was  dis- 
charged from  service  and  had  been  living  at  home  ever 
since.  His  habits  were  good  and  he  showed  no  evidence 
of  organic  disease  ;  his  physique  was  unexceptionally  fine. 
He  had  abandoned  all  thought  of  recovery  of  his  lost 
function  ;  but  indignant  at  the  suggestion  of  an  acquaintance 
that  his  condition  was  the  result  of  syphilis,  he  desired 
laryngoscopic  testimony  to  assist  in  refuting  this  assertion, 
as  he  had  since  married  and  was  a  father. 

After  a  careful  examination  I  found  not  only  no 
organic  lesion  apparent,  but  also  little  failure  of  motion. 
When  he  attempted  phonation,  the  vocal  cords  approached 
the  median  line,  yet  leaving  a  narrow  space  between  them, 
sufficient  for  the  column  of  air  to  pass  through  without 
producing  vibration.  In  other  words,  the  larynx  was 
normal  in  every  respect,  except  a  very  slight  bilateral 
paralysis  of  the  adductors,  just  enough  to  produce  aphonia. 
The  immediate  result  of  this  examination  was  satisfactory, 
it  proved  a  good  moral  character — so  far  as  his  throat 
was    concerned — and    gave    promise    of   a  return  of  voice. 

Faradization  was  applied  directly  to  the  cords,  with 
the  pleasing  effect  of  completely  restoring  the  voice  in  two 
days.  During  the  first  day  there  was  feeble  vocalization, 
which  became  perfect  on  the  subsequent  day.  On  account 
of  the  long  continuance  of  the  aphonia  and  the  short  time 
of  treatment,  it  was  not  supposed  the  change  was  perma- 
nent ;  but  since  then — five  years  ago — his  voice  has 
been  faultless,  and  there  was  no  further  treatment  of 
any    kind.       Had    there    been    complete    paralysis    of    the 


200  Wm.  Porter, 


affected  muscles,  in  this  length  of  time,  doubtless,  there 
would  have  been  atrophy  of  both  muscles  and  cords ;  as 
it  was,  the  movement  was  all  but  complete,  and  the  nutri- 
tion of  the  parts  unaltered. 

In  some  respects  this  is  a  unique  case,  and  yet,  in  others, 
a  typical  one.  Here,  as  often,  there  was  slight  peripheral 
paralysis — the  sequel  to  the  laryngeal  inflammation  of  his 
camp  life — the  nerve  impulse  was  not  sufficiently  evolved, 
and  the  muscles  did  not  act  with  normal  power.  The 
result  shows  that  this  was  an  exceedingly  simple  case,  and 
in  cause,  condition  and  indication  for  treatment  there  are 
many  that  resemble  it.  As  a  rule,  these  cases  of  periph- 
eral paralysis  yield    readily. 

III.  Aphonia  may  also  result  from  pressure  along  the 
course  of  the  motor  nerves  of  the  larynx,  notably,  of  the  re- 
current laryngeal  of  either  side.  In  such  cases  there  is,  also, 
paralysis  of  the  adductor  muscles  of  one  side — rarely  of 
both.  Though  most  of  these  are  due  to  a  grave  condi- 
dition.  as  aneurism  or  maUgnant  disease,  and  sometimes  to 
pulmonary  consolidation,  yet,  now  and  then  an  exception 
occurs. 

Mrs.  D ,  aged  25,  of  strumous  habit  but    fairly    well 

nourished,  lost  her  voice  a  year  previously  to  applying  for 
treatment.  An  examination  showed  paralysis  of  the 
adductor  of  the  right  cord.  There  was  an  enlarged 
lympathic  gland  lying  in  the  carotid  triangle  in  the  course 
of  the  recurrent  nerve.  It  was  concluded  that  this  was 
the  cause  of  the  aphonia,  especially,  as  the  enlargement 
of  the  gland  was  co-incident  with  the  occurrence  of  the 
aphonia.  Vessication  over  the  gland  was  employed,  and 
finally  a  few  drops  of  acetic  acid  were  injected  by  the 
hypodermic  syringe,  into  the  substance  of  the  neoplasm, 
at  intervals  of  three  days  for  a  fortnight,  when  soften- 
ing took  place  and  resolution  followed.  When  the 
pressure  was  thus  removed  from  the  motor  nerve,  the 
voice  returned,  at  first  weak  and  unreliable,  but  grad- 
ually   improved   and    soon    became    perfect. 

A  similar  case,  so  far  as  the  laryngeal  conditions 
were  concerned,  was  that  of  a  child,  six  years  old, 
under  the  author's  care,  at  the  London  hospital  in  1874. 
It   was    admitted    with     far  advanced    marasmus,     and    had 


Jphnnia  from  Motor  Paralysis.  201 

been  aphonic  for  two  months.  An  imperfect  view  of 
the  glottis  was  obtained,  but  enough  to  see  that  there 
was  unilateral  paralysis  of  the  adductor  muscles  of  the 
right  side.  The  patient  soon  died,  and  at  the  autopsy 
a  small  and  very  hard  gland  was  found  completely  sur- 
rounding   and    compressing    the    right    recurrent   nerve. 

I  have  met  with  one  case  of  aphonia  caused  by  a 
goitre,  which  evidently  interfered  with  the  motor  supply 
of  the  larynx,  and  was  only  relieved  when  the  goitre 
was   reduced    by   the    injection   of  iodine. 

But  it  is  needless  to  multiply  examples  of  this  kind 
The  plain  inference  from  those  already  cited  is,  that 
aphonia  may  occur  as  a  result  of  pressure  upon  the  recur- 
rent laryngeal  nerve,  and  the  indication  for  treatment 
in    such    cases    is  the    removal    of  the    interference. 

IV.  Not  infrequently  loss  of  voice  is  the  result  of  reflex 
irritation.  Many  of  the  cases  of  so-called  "hysterical" 
aphonia  are  caused  by  an  undue  excitement  of  the  sympa- 
thetic, through  disease  affecting  some  of  its  branches.  It 
is  a  matter  of  both  interest  and  importance  to  note  the 
intimate  relation  existing  between  the  sympatethic  system 
and  the  pneumogastric  nerve.  Through  irritation  of  the 
former,  we  sometimes  find  the  latter  so  influenced,  that 
the  cardiac  rythm  is  altered  or  spasmodic  contraction  of 
the  bronchial  tubes  induced,^  or  from  the  same  cause  the 
function  of  the  recurrent  nerve  may  be  so  impaired  as  to 
produce  paralysis  of  the  laryngeal  muscles.  Cases  of  this 
kind  occur  in  the  practice  of  most  physicians,  and  when 
recognized  are  generally  susceptible  of  relief.  Oftentimes 
the  aphonia  disappears  without  direct  treatment  when 
the  distant  cause  is  modified  or  removed.  Many  of  the 
pretended  miraculous  restorations  of  the  voice  have  been 
due,  simply,  to  the  return  of  the  normal  condition  of  some 
part  of  the  organism  in  which  was  the  disturbing  element 
— perhaps  unnoticed. 

I  am  willing  to  go  further  than  this  and  state  my 
belief,  that  there  are  few  cases  in  which  aphonia  is  simply 
due  to  an  emotional  exaggeration  rather  than  to  a  definite, 

(a)  ^ee  report  of  author's  cases.    New  York  Med.  Rec,  Oct.  11th,  1«79. 


202  IFm.  Porter, 


though  often  remote  morbid  cause.  Dr.  Englemann*  has 
described  the  hystero-neuroses  of  the  larynx  as  occurring  in 
a  mild  form  "  in  young  girls,  but  at  times  it  becomes  a 
source  of  great  annoyance.  Examination  will  in  such  cases 
reveal  a  healthy  larynx,  but,  generally,  flexion  or  stenosis 
and    painful     dysmenorrhea,    sometimes     uterine     catarrh." 

The  objection  has  been  urged,  that  reflex  irritation 
would  stimulate  muscular  fibres  to  contract,  which  in  the 
larynx  would  produce  approximation  of  the  cords  and 
consequent  dyspnoea.  Even  upon  this  theory  we  would 
expect  the  same  phenomena,  for  opposed  to  the  powerful 
abductor  muscles  of  both  sides,  we  have  but  a  single 
true  adductor,  the  arytenoideus  proprius  and  the  crico- 
arytenoidei  laterales  which  act  obliquely.  More  probably, 
however,    the    paralysis    is    due    to    over    stimulation. 

It  is  needless  to  here  detail  cases  of  aphonia  from 
reflected  cause.  The  writings  of  Fordyce  Barker,^  Mayer," 
Holden,'  Hegar,*  Hughlings-Jackson,^  Brown-Sequard,  the 
essay*  already  quoted  and  many  others,  teem  with 
illustrations  of  perverted  functions  of  different  organs 
from  distant  irritation,  while  accomplished  laryngoscop- 
ists  have  added  to  the  testimony.  Though  we  may  not 
as  yet  understand  how  an  impression  from  a  deflected 
uterus  or  diseased  overy,  may  reach  the  larynx  and 
interfere  with   its    function,  yet    the  fact  remains. 

These  cases  are  cited,  not  as  showing  special  skill  in 
treatment,  but  as  instances  of  the  amenability  of  some 
forms  of  aphonia  to  measures  addressed  to  the  cause. 
In  conclusion,  the  thought  may  be  repeated — it  is  not 
enough  that  the  laryngoscopist  discover  that  in  any  case 
the  aphonia  is  due  to  paralysis  of  one  or  more  of  the  laryn- 
geal muscles ;  it  is  only  when  the  cause  of  the  motor 
impairment  is  found,  that  he  can  expect  to  institute 
means  to  a  successful  termination. 

(4)  The  ny8tero-X(>nr<«8e8.    Gynec«lr)prical  Traiis!ictii)ns,  1878 

(5)  .Journal  of  the  liyiiecological  Society  of  Boston,  May,  1872. 

(6)  JJeitr.  Z.  Gt'burtsh.  ii.  Gyn.,  iii.  3.  Sitzungs— BericlUe. 

(7)  New  York  MchI.  .Jour.,  Aug.,  1877. 

(8)  Wiener  Mert.   Presse,  1877,  Nos.  14—17. 

(9)  London  Hospital  lieports. 


Art.  IX.— Salivation  in  the  Insane. 


By  Dr.  REINHARD,  Kcenigslutter. 


Translated  from  ihe    "Ce^itral-Blatt  fiir  Nervenheilkunde,    Psychiatrie    mid 
Gerichtliche  Psj/chopathologie.''' 


By  Edward  W.  Saunders,  M.  D.,  of  St.  Louis. 

T  have  been  unable  to  find  in  medical  literature  more  than 
-*-  a  passing  mention  of  this  subject;  generally,  it  has  only 
been  noticed  as  a  symptom  of  little  importance  in  the  history 
of  a  case ;  and  yet,  every  one  who  has  had  much  experience 
with  insane  patients,  will  allow  that  salivation  is  not  at  all 
uncommon  amongst  them.  Often,  salivation  is  found  to 
exist  in  five  or  six  per  cent,  of  the  inmates  of  an  asylum ; 
still  it  would  be  erroneous  to  view  them  all  alike.  It 
would  be  better  to  classify  them  into  three  groups,  ar- 
ranged according  to  their  etiology,  leaving  out  of  the 
question,  of  course,  all  those  cases  in  which  salivation  is 
caused  by  a  mouth  or  throat  affection,  or  by  the  use  of 
mercury. 

In  the  first  group  is  classed  ver}^  idiotic  patients,  with 
weakness  approaching  to  paralysis,  and  paralytics ;  in  the 
second,  patients  with  a  mania  for  self-destruction  by  poison 
and  obstinate  (violent)  refusal  of  food  ;  in  the  third,  which 
is  the  largest,  patients  with  primary  and  secondary  mental 
alienation,  in  whom  there  is  a  condition  of  irritation  in 
the  domain  of  the  sympathetic,  seemingly  always  having 
its  origin  in  the  genital  apparatus. 


204  Edivard  W.  Saunders, 

In  all  the  salivation  may  be  of  any  intensit)-,  but  it  is 
always,  both  for  the  attendants  and  the  patient,  an  unpleas- 
ant and  often  a  very  troublesome  symptom,  that  in  many 
cases    has    a    directly    pernicious    effect  upon  the    system. 

If  now  we  examine  more  closely  into  the  first  group 
of  cases,  we  see  at  once  in  their  general  condition  the 
cause  and  the  explanation  of  this  symptom. 

Here  we  have  insane  patients  whose  mental  and  phys- 
ical condition  is  very  low ;  in  whom  the  functions  of 
vegetative  as  well  as  of  animal  life  have  been  impaired  ; 
they  are  patients  in  the  lowest  condition  of  cretinism,  or 
last  stage  of  idiocy  with  paralysis,  or  rather  of  the  general 
paralysis  of  the  insane.  In  them  we  see  various  manifes- 
tations of  the  imperfect  discharge  of  the  functions,  having 
the  character  of  paralysis — for  instance  the  livid  hue  and 
coldness  of  the  extremeties  ;  the  small,  mono-erotic,  slow 
pulse.  We  cannot  be  mistaken,  then,  if  we  attribute  the 
salivation  in  these  cases  to  the  vaso-motor  paralysis  which 
manifestly  exists,  aided  by  the  co-existent  hydremia. 
We  see  a  confirmation  of  this  view  in  the  fact  that  some 
of  these,  patients,  on  account  of  weakness  or  paralysis  of 
the  muscles  of  the  lower  part  of  the  face,  especially  of  the 
labial  muscles,  breathe  all  the  time  through  the  mouth, 
thus  causing  dryness  of  the  mucous  aiembrane  of  the 
mouth,  which  in  turn,  excites  the  salivary  glands  to  abnor- 
mal activity.  We  see  an  analogous  phenomenon  often 
in  people  w^ho  are  not  insane,  but  who,  during  sleep, 
breathe  through  the  open  mouth.  An  additional  cause 
is  to  be  found  in  the  habit  that  many  of  this  class  of 
patients  have  of  putting  irritating  or  hard  substances  in 
the  mouth,  and  sucking  or  chewing  them.  From  what 
has  been  said,  w^e  would  expect  to  find  that  the  saliva  of 
this  class  of  patients  is  thin  and  water>%  which  is  also  a 
fact.  To  what  extent  this  loss  of  saliva  is  detrimental  to 
the  system,  cannot  be  proved,  but  it  is  a  factor  that 
should  not  be  forgotten  in  giving  the  prognosis  as  to  the 
length  of  life.  Of  course  there  can  be  no  rational 
treatment    of    these    cases    of    salivation. 


Salivation  in  the  Insane. 


205 


[The  excessive  salivary  secretion  of  such  of  these  patients  as  eat,  iudiflerently 
plaster,  paper  or  bitsof  clothin-,  may  be  materially  restaiuerl  bv  adroitly  supplvin- 
them,  as  we  have  sometimes  done,  with  small  pieces  of  alum,  astringent  woods" and 
vege  tal lie  extracts  to  masticate  adlibi.'um.  A  diet  of  persimmons  between  meals 
would  not  be  contra-indicated,  though  we  never  tried  the  latter. 

Syringing  of  the  buccal  mucous  lining  with  a  solution  of  plumbi  acetas, 
has  proved  beneficial  in  some  of  these  cases,  where  the  psychical  condition  was  not 
such  as  to  contra-indicate  the  necessary  manipulation,  namely:  where  pre-existing 
delusions  were  not  aggravated,  or  new  ones  excited,  by  this  attempt  at  local 
treatment  —Kd.] 

In  the  second  group   the    cause    of   the    salivation  is    a 
totally  different  one.       Here  there  is  a  condition  of   irrita- 
tion of  psychical  or  cerebral  origin,    a    process  that  might 
be  classed,  generally,    amongst    the    "  conscious    reflexes." 
These  patients  imagine  constantly  that  they  are   forced  to 
take    bad-tasting,    injurious    or  even    poisonous  compounds 
— they  taste  these  properties    plainly    and  are  then   unable 
to  get  rid  of  the  taste  ;    and  now  the  same  thing  happens 
in    them  that  occurs  in    many   healthy  persons  when    they 
think    of    some    abominably-tasting  medicine,  or,    perhaps, 
dream    of   biting    into    a  green  persimmon  (schlehen) — the 
saliva    flows    freely    and    they    must  spit  it  out  constantly. 
Besides,    the    flow    of   saliva  is  increased  by  the  efforts  of 
the  patients  to  get  rid  of  the  remains  of  the  poison  to  be 
found    between    their    teeth,    in    the  cavities  of  their  teeth 
and    the    buccal    cavity,    or    else  of  the  illusory  bad  taste. 
In  their  fruitless    endeavors    they    keep  the  tongue  moving 
about    in    every    direction    in    the    mouth,  pick  their  teeth 
and  search  all  the  corners  of  the  mouth  energetically  with 
their    fingers.       In  this  way  the  mucous  membrane    of  the 
mouth  becomes,  finally,  very  much  irritated.       At  first  the 
saliva,  in    this    class    of  patients,    is    thin    and    watery  and 
seems  to  be  chiefly  secreted  under  the  influence  of  chorda 
tympani    nerve  irritation  (chorda-speichel),   at  least    I  have 
never   been    able    to    find    many    gelatinous    masses    in    it. 
However,    this    watery    character    is  gradually  lost,  as    the 
mucous  membrane  of  the  mouth  becomes  more  and  more 
irritated,  owing  to  the  fact  that    its  epithelium  and  that  of 
the    ducts    of    the    mucous    glands    is    mingled    in    greater 
quantity  with  the  saliva.    The  secretion  then  becomes  white 
and    turbid  and  much   thicker.      This   is  more   pronounced, 


206  Edward  W.  Saunders, 

as  the  catarrh  of  the  buccal  and  pharangeal  mucous  mem- 
brane becomes  more  intense — an  invariable  consequence 
of  obstinate  resistance  to  food.  When  these  concomitant 
affections  are  very  severe,  the  saliva  often  becomes  puru- 
lent— creamy — without  diminishing  in   quantity. 

The  amount  of  expectoration  from  many  of  these 
patients  is  truly  astonishing.  I  have  seen  some  who 
expectorated  to  the  amount  i4  to  2  liters  in  twenty-four 
hours.  If  to  this  amount  is  added  the  quantity  of  saliva 
that  was  swallowed  with  the  food  and  during  the  short 
time  that  they  slept,  we  have  a  quantity  treble  the  normal 
amount.  It  is  worthy  of  note  that  in  many  of  these 
patients,  although  their  minds  are  becoming  continuously 
more  and  more  imbecile  with  the  decline  of  the  disease 
and  the  diminution  of  the  illusions  as  to  poisoning,  still  the 
abnormal  flow  of  saliva  does  not  diminish  so  rapidly,  but 
sometimes  remains  nearly  the  same  from  habit. 

In  the  patients  of  this  group  the  injurious  effects  of 
salivation  upon  the  whole  system  are  most  readily  seen 
and  are  easily  explained.  The  digestive  function  already 
seriously  impaired  by  the  want  of  nourishment,  the  little 
that  is  taken  having  to  be  forcibly  introduced,  must  cer- 
tainly suffer  still  more  from  the  want  of  the  assistance  of  the 
saliva,  which  plays  an  eminent  part  in  the  chemistry  of  diges- 
tion. This  effect  could  be  renewed  no  doubt,  by  giving  the 
patients  only  such  food  as  can  be  digested  without  the  aid 
of  the  saliva.  By  this  means,  however,  as  much  would  be 
lost  in  one  way  as  could  be  gained  in  the  other,  if  we  take  a 
larger  view  of  the  subject ;  for  if  the  patient  were  fed 
upon  exclusively  nitrogenous  diet,  the  hydraemia  already 
existing,  owing  to  the  salivation,  would  be  still  further 
aggravated  by  the  increa.sed  loss  of  water  from  the  kidneys. 

Accordingly  to  this  class  of  patients  suffering  from 
salivation  and  obstinately  refusing  nourishment,  it  is  best 
to  give  food  containing  as  much  fat  as  possible,  avoiding 
the  am)-lacea;.  These  indications  arc  best  fulfilled  by 
using  unskimmed  milk,  sweet  or  sour,  and,  indeed,  this 
article  of  diet  cannot  be  praised  too  warmly.      Of   course 


Salivation  in  the  Insane.  207 

this  regimen  is  great!}'  assisted  by  frequently  giving  the 
patients  water  to  drink.  In  order  to  hinder,  or  at  least 
limit,  the  production  of  bacteria  and  consequent  fermenta- 
tion in  th.Q' prum^  vice,  chlorate  of  potash  should  be  given 
internally,  in  addition  to  the  local  treatment  of  the  mouth 
and  pharynx,  with  a  salycilic  acid  solution,  used  very 
frequently.  The  chlorate  of  potash  is  given  in  his  milk 
or  in  drinking  water.  In  addition,  it  would  be  advisable 
to  treat  the  mucous  membrane  of  the  mouth  by  the 
topical  application  of  mild  astringents,  such  as  Decoct, 
cort.  quercus,  or  a  weak  solution  of  tannin.  In  many 
cases  this  treatment  succeeds  in  reducing  the  flow  of 
saliva.  Subcutaneous  injections  of  morphine  may  be  used, 
symptomatically,  in  order  to  combat  the  mental,  or  rather, 
cerebral  irritation,  which  is  the  prime  cause  of  the  refusal 
of  food  and  the  salivation.  To  be  effectual,  the  dose  must 
not  be  too  small,  and  it  is  advantageous  to  combine  a 
small  quantity  of  atropine  with  the  morphine.  I  must, 
however,  confess  that  in  the  majority  of  these  cases  I  have 
had  no  lasting  good  effects  from  morphine,  and  the 
patients  soon  begin  to  bear  it  badly. 

I  will  now  describe  the  third  group  of  cases  of  saliva- 
tion of  the  insane.  I  have  already  said  that  this  is  the 
largest  group,  and  in  it  by  far  the  greatest  number  of 
cases  are  females.  Whilst  in  the  cases  belonging  to  the 
first  two  groups  the  saliva  is  more  or  less  watery  in  char- 
acter, in  these  cases  we  find  it,  generally,  thick  and  glairy 
— the  quantity,  too,  is  never  so  great  as  it  is  in  some 
cases  belonging  to  the  second  group.  Still,  even  in  these 
cases  under  consideration,  the  quantity  of  saliva,  is,  at 
times,  not  inconsiderable.  It  is  at  first  as  clear  as  water, 
but  after  the  affection  has  lasted  for  some  time,  it  becomes 
white  and  turbid,  from  the  presence  of  glandular  elements 
in  larger  proportion.  Upon  more  careful  examination  the 
secretion  is  found  to  contain  an  abundance  of  gelatinous 
masses,  which  accounts  for  its  tenacious  character.  In 
a  word,  we  find  in  these  cases  a  considerable  increase, 
both    relative    and    absolute,    of  the  so-called  sympathetic 


2f^8  Edivard  ^]\  Saiinrlers, 


saliva  (saliva  secreted  uader  the  influence  of  the  sympa- 
thetic). This  points  to  a  condition  of  irritation  in  the 
domain  of  the  cervical  sympathetic,  and  the  next  question 
is  whether  these  patients  do  not  present  other  symptoms, 
having  a  similar  origin.  Such  is  the  case,  for  almost 
without  exception,  the  pupils  are  found  to  be  dilated  and 
re-acting  very  sluggishly  to  the  light.  The  amount  of 
dilation,  too,  is  in  proportion  to  the  severity  of  the  saliva- 
tion. When  the  latter  becomes  periodically  worse,  as 
often  happens  in  these  cases,. the  mydriasis  also  increases 
in  the  majority  of  them;  in  addition  there  are  signs  of  irri- 
tation of  the  cardiac  sympathetic,  and  the  pulse  becomes 
somewhat    smaller    and    harder.  Examining      into     the 

source  and  cause  of  this,  sometimes  more,  sometimes 
less,  intense  and  extensive  irritation  of  the  sympathetic, 
we  obtain  the  same  results  in  every  case.  Patients  of 
this  class  invariably  suffer  from  irritation  of  the  genital 
organs — the  majority  of  them  are  masturbators.  In 
the  few  male  patients  that  belong  to  this  class,  this  is 
the  only  apparent  cause  for  the  irritative  condition  of 
the  sympathetic  nervous  system.  In  proportion  to  the  ex- 
tent to  which  they  indulge  in  this  vice  at  different  times, 
do  they  manifest  these  disorders,  especially  saUvation, 
in  the  domain  of  the  sympathetic,  to  a  varying  degree. 
The  same  is  true  of  the  female  patients.  In  them 
however,  besides  the  central  genital  irritation  that  is 
superinduced,  leading  to  the  practice  of  masturbation, 
there  is  peripheral  irritation  in  the  genital  system, 
dependent  partly  upon  physiological  processes  in  these 
organs,  and  partly  on  pathological  changes.  In  reference 
to  the  form  of  these  causes  (physiological  processes)  V. 
Krafft-Ebing,  in  his  work  "  Investigation  upon  the  Insan- 
ity of  the  Menstrual  Epoch  (Archiv.  fur  Psychiatric,  Bd. 
VIII.  Heft,  i)  in  several  places  mentions  the  occurrence 
of  salivation  at  the  menstrual  period,  without  giving  any 
opinion  as  to  how  this  symptom  is  to  be  explained.  I 
can  confirm  his  observations  on  this  point  from  my  own 
experience.         So    far    as    my  observations   extend,    these 


Salivaiion  in  the  Ijisane.  209 

women  are  generally  masturbators.  In  those  who  are 
masturbators,  there  is  usually  some  degree  of  salivation 
in  the  intermenstrual  periods.  Undoubtedly,  then,  at  the 
time  of  menstruation  both  symptoms  become  much  worse. 
Only  in  exceptional  cases  does  it  happen  that  the  saliva- 
tion comes  on  for  the  first  time  with  the  catamenial 
flow,  not  preceded  by  masturbation.  Moreover,  I  found 
that  when  menstruation  was  the  exciting  cause  of 
the  salivation,  or  aggravated  it,  if  already  present,  there 
was  always  at  the  same  time  more  or  less  excitement 
existing,  frequently  in  the  form  of  nymphomania.  In 
these  cases  the  explanation  of  the  whole  train  of 
symptons  is  probably  as  follows:  The  growth  of  the 
Graafian  follicle  and  its  bursting,  in  conjunction  with  the 
greater  turgescense  of  the  internal  organs  of  generation 
brings  about  in  the  sympathetic  system,  a  more  intense 
and  widespread  state  of  irritation  than  normal.  Certainly 
we  must  presuppose  an  unstable  nervous  system,  and  this  in 
practice  is  found  to  be  almost  invariably  the  case, 
since  those  wiio  are  affected  in  this  manner  are  generally 
individuals  possessing  a  strong  predisposition  to  nervous 
and  mental  disorders.  In  reference  to  the  remainder  of 
the  female  patients  belonging  to  this  class,  we  find  that 
they  are  nearly  all  cases  of  perpueral  insanity,  or  of 
insanity  from  lactation,  in  which  there  are  recognizable 
pathological  changes  in  the  genital  apparatus.  Here 
there  can,  generally,  be  found  erosions  at  the  external  os, 
a  moderate  degree  of  hyperthrophy  and  flexion  of  the  cer- 
vix, evidences  of  sub-acute  or  chronic  metritis,  or  else 
catarrh  of  a  portion  or,  of  the  whole,  of  the  vaginal  mucous 
membrane.  In  these  patients  the  irritation  thus  produced 
becomes  often  so  intense  that  they  are  continually  man- 
ipulating with  their  genital  organs.  They  often  He 
in  an  ecstatic  state,  with  a  smile  of  supreme  happiness 
upon  their  faces,  and  reciting  obscene  verses.  The 
pupils  are  very  widely  dilated,  the  eyes  brilliant,  the 
pulse  rapid  and  hard,  the  face  somewhat  pale,  while  sali- 
vation   is    present    in    proportion  to  the  intensity  of  these 


210  Edivard  W.  Saunders, 

symptoms.  With  reference  to  the  prognostic  value  of 
salivation  in  these  cases,  it  is  a  less  unfavorable  symptom 
in  cases  belonging  to  the  third  class  than  it  is  in  those 
of  the  second  ;  since  in  the  former  the  appetite  and  diges- 
tion are  generally  unimpaired,  and  only  occasionly  do  they 
refuse  food  for  a  short  time 

However,  even  in  them,  severe  salivation  must,  in  the 
course  of  time,  exercise  an  unfavorable  influence  upon 
digestion,  assimilation  and  tissue  metamorphosis.  The  bad 
effects  will  be  more  lasting  in  proportion  to  the  extent  to 
which  the  other  debilitating  influences  are  at  work,  whether 
masturbation  or  pathological  changes  in  the  genital  organs 
or  both.  In  this  class  of  cases  of  salivation,  we  can 
accomplish  most  by  treatment.  Besides  watching  these 
patients  and  giving  them  something  to  do  to  prevent  them, 
or  rather  hinder  them,  as  much  as  possible  from  mastur- 
bating, we  can  also  successfully  use  drugs  to  control  the 
irritation  of  central  or  peripheral  origin,  existing  in  the 
genital  organs,  and,  secondarily,  in  the  domain  of  the 
sympathetic.  Morphine,  with  or  without  the  addition  of 
atropine,  used  subcutaneously,  has  a  happy  effect  in  many 
cases,  especially  in  those  in  whom  the  irritation  seems  to 
be  entirely  of  central  origin.  In  many  cases  in  which  the 
salivation  was  dependent  upon  menstrual  excitement,  or  else 
was  aggravated  by  it,  bromide  of  potassium,  in  large  doses, 
as  high  as  6.00  grammes  (one  and  a  half  drachms),  per  diem, 
was  of  great  use.  In  addition,  I  have  tried  the  subcutaneous 
employment  of  camphor,  and  have  sometimes  had  good  re- 
sults from  it,  while  hypodermic  morphine  in  these  cases 
nearly  always  failed  to  effect  any  good  result.  I  have  used 
both  these  drugs,  especially  the  former,  in  the  salivation  of 
the  puerperal  insane,  and  of  the  insane  from  lactation. 
At  the  same  time,  in  these  cases,  which  rarely  fail  to  show 
morbid  changes  in  the  genital  apparatus,  a  rational  local 
treatment  accomplishes  the  greatest  good.  In  reference 
to  vaginal  injections,  I  give  the  decided  preference  over  all 
others  to  a  2  %  solution  (9  grains  to  the  fluid  ounce)  of 
carbolic  acid.      Under  this  treatment,  the    salivation    soon 


Salivation  in  the  Insane.  211 


begins  to  improve.  I  cannot  close  this  article  without  say- 
ing that  these  three  types  of  salivation  in  the  insane  are  not 
always  separatable  in  practice,  since,  in  a  few  cases,  it 
happens  that  to  the  causes  at  work  in  the  first  and  third 
classes,  those  mentioned  in  the  second  may  be  added  fur 
a  time.  I  have  never  seen  any  other  modifications  of 
these  types.  The  possibility  mentioned,  is  very  excep- 
tionable in  cases  belonging  to  the  first  class. 


Art.    X.— Reflex    Cardiac    Gangliopathy 
with  Hereditary  Diathesis. 


By  C.  H.  Hughes,  M.  D. 

l^OTWITHSTANDING  the  great  advance  that  has 
-^  ^  been  made  in  the  direction  of  a  just  recognition  of 
the  ganglionic  maladies,  since  Edward  John  Tilt,  in 
the  midst  of  an  excellent  contribution  to  the  pathology  of 
the  ganglionic  nervous  system  (Change  of  Life,  3d  ed.,  p. 
129,  anno  1870),  reproached  the  Profession  for  looking  upon 
the  latter,  "in  a  pathological  point  of  view,  as  a  ten-a 
incognita,  and  neglecting  its  diseases,  or  very  incompletely 
considering  them,  in  systematic  works  on  pathology,  and 
scarcely  better  treating  them  in  works  on  nervous  dis- 
eases," and  notwithstanding  the  later  appearance  of  Milner 
Fothergill's  invaluable  treatise  on  the  "Neurosal  and 
Reflex  Disorders  of  the  Heart,"  added  to  Tilt's  own 
inestimable  book,  and  some  of  the  still  more  recent 
very  sensible  utterances  of  Austin  Flint,  Jr.,  in  this 
country,    on  cardiac  diseases,    have  greatly  atoned    for  the 


212  C.  R.  Hughes, 


sins  of  omission  charged  on  the  Profession  in  the 
above  quotation,  the  ganghbnic  disorders  of  the  heart  are 
not  yet  so  generally  recognized  as  to  render  further 
clinical  confirmations  of  them  unnecessary. 

It,  doubtless,  yet  seems  to  many,  as  it  did  to  Dr. 
Tilt,  quite  "incomprehensible  that  so  much  vital  force  for 
good  or  evil,"  as  both  physiological  and  pathological 
testimony  confirm,  "should  be  centralized  in  those  little 
irregular  lumps  of  nervous  matter,  and  in  sundry  tangled 
skeins  of  nervxs,  the  geography  of  which,  like  the  polar 
regions,  is  differently  mapped  out  by  successive  observers," 
but  while  it  seems  incomprehensible  to  this  careful  clinical 
observer,  his  experience  has  taught  him,  as  it  has  others, 
as  well  as  the  physiologist,  that  "these  knots  of  nervous 
matter  and  these  tangled  skeins  of  nerves  no  less  cer- 
tainly control  the  blood  vessels,  and  are  indissolubly 
connected  with  the  supreme  power  which  guides  the 
processes  of  healthy  or  diseased  nutrition,"  and  preside 
over  certain  deranged  organic  movements  v.hich  are  called 
functional  disorders. 

It  would  be  interesting,  though  not  as  we  conceive 
profitable,  to  here  discuss  the  manner  in  which  the  three 
cardiac  ganglia — of  Remak,  Bidder  and  Ludwig — are 
affected,  and  to  trace  their  s\-mpathetic  connections, 
but  as  the  purpose  of  this  paper  is  only  clinical  and 
its  object  brevity,  we  relegate  this  problem  to  the 
reader. 

A  professional  man,  twice  married,  aged  forty-five 
years — but  looks  younger — one  of  twin  brothers,  and  of  a 
family  of  eleven  children  ;  has  alwa}'s  been  strictly  tem- 
perate ;  habituated  to  no  narcotic  or  stimulant,  save  coffee, 
and  to  this  not  immoderately.  Except  an  attack  of  dysen- 
tery and  jaundice,  of  short  duration,  about  sixteen  years 
ago,  and  an  occasional  malarial  chill  since  then,  his  general 
health  has  been  very  good.  He  is  a  little  above  medium 
stature,  well  built,  of  good  weight  and  healthy  appearance, 
eats  heartily,  sleeps  well  and  abundantly  and  feels  well  gen- 
erally,   except    some  dizziness  at  times,  and  an  occasional 


Refl,ex  Cardiac  Gangliopa,thy.  213 

nightmare.  Has  had  no  dyspepsia.  Has  one  living 
epileptic  child.  His  wife,  the  child's  mother,  died  of 
cancer. 

His  father  lived  to  the  age  of  80  years,  and  died  of 
senile  decline  ;  though  he  had  paralysis  agitans  for  twenty 
years  preceding  his  death.  His  mother  died  at  ninety 
years  of  age,  without  appreciable  disease.  He  never 
knew  of  either  of  his  parents  having  had  a  physician, 
though  his  father  s  pulse   used  to  intermit. 

This  gentleman  had  a  brother  whose  pulse  intermitted 
from  ehildhood,  who  died  at  the  age  of  twenty-two. 
His  twin  brother's  pulse  became  intermittent  in  con- 
sequence of  drinking  tea,  but  took  to  behaving  properly  on 
the  abandonment  of  the  beverage.  A  sister,  now  at  the  age 
of  sixty-eight  years,  has  had  paralysis  agitans.  Another 
sister,  aged  52,  and  a  brother,  aged  40,  are  quite  healthy. 
His  twin  brother  is  very  "  nervous  and  fearful."  He 
always  used  to  feel  that  he  would  be  grabbed  by  a  dog; 
and  on  driving  down  a  hill  would  fear  that  the  breeching 
would  break  or  that  the  team  would  upset  or  go  over  a 
precipice.  For  several  years  the  patient  has  had 
a    gradually    increasing    hydrocele    of    the    right    testicle. 

About  the  first  of  last  July  he  felt  some  headache, 
and  was,  in  consequence,  led  to  examine  his  pulse,  when 
he  discovered  an  intermission  of  the  second  and  sixteenth 
beat.  About  the  middle  of  July  he  consulted  me,  when 
I  also  detected  irregularty,  every  eighth  beat  omitting. 
No  sphygmographic  trace  was  taken.  Pulse  beats  and 
heart  beats  synchronous.  He  never  could  detect 
any  irregularity  of  pulse  till  this  month.  He  thinks 
mental  strain,  may  have  been  a  factor  in  causing 
the  resultant  irregularity,  but  his  easy  temperament  and 
satisfied  manner  of  taking  hfe  seem  to  contradict  this 
hypothesis. 

Possibly,  also,  the  contemplation  of  matrimony,  which 
he  was  at  that  time  considering,  may  have  been  another 
factor,  but  I  am  inclined  to  think  that  the  exciting  cause 
of  the  cardiac    disturbance    proceeded    mainly  from    below 


214  C.  H.  Bughes, 


upwards,  rather  than  from  above  downwards,  and  was  due 
to  irritation  of  one  or  both  testicles — the  result  of  distension 
of  the   right    vaginal  tunic  and  pressure    on    the    testicles. 

The  gentleman  was  married  in  August.  His  heart 
troubled  him  a  great  deal  in  his  bridal  tour ;  but  it  is 
now,  Jan.  26th,  quite  regular,  though  more  frequent  and 
excitable  than  normal.  His  headache  has  greatly  dimin- 
ished. To-day  his  pulse,  on  first  examination,  after  a 
moderately  brisk  walk,  was  96  ;■  on  applying  the  sphygmo- 
phone,  an  instrument  that  was  new  to  him,  his  pulse 
immediately,  thereafter,  increased    ten  beats  per  minute. 

The  gentlemen  says  he  was,  from  the  death  of  his  last 
wife  to  his  recent  marriage,  a  continent  man.  It 
is  not  improbable  that  his  improvement  is,  in  a  great 
measure,  due  to  the  regular  natural  depletion  of 
the  testicles  and  seminal  vesicles,  and  to  the  diminution 
of  scrotal  distension  and  pressure  on  the  testicles. 
But  whether  we  consider  the  irritation  as  having  trav- 
ersed the  sympathetic  chain  and  chord  to  the  cardiac 
ganglia,  from  the  t( sticks  or  from  the  brain,  or  both,  the 
exciting  cause  of  the  heart  disorder  was  reflex. 

This  case  was  referred  to  our  friend,  Dr.  Wm.  Porter, 
whose  proficiency  and  interest  in  the  exploration  of  cardiac 
phenomena,  at  once  suggested  him  as  the  proper  person 
to  conjointly  examine  it.  The  result  of  hi^  examination, 
therefore,  shall  herewith  supplement  our  description,  and 
dispense  with  further  detail  by  us.  The  conviction  that 
there  existed  no  structural  heart  lesion,  was  communicated 
to  Dr.  Porter,  at  the  time  the  case  was  sent  to  him. 
"ST.  LOUIS,  Sept.  27th,   1879. 

Dear  Doctor  :     At  your  request    I  examined  Dr. 

a  month  since.  There  was  no  direct  evidence  of  cardiac 
lesion,  though  the  functional  disturbance  was  marked. 
Pulse  no — including  time  for  a  missed  beat  once  in  eight 
— and  compressible.  The  intermission  and  frequency 
were  not  influenced  by  gentle  exercise  or  position.  The 
transverse  line  of  cardiac  dullness  was  2  i-O  inches.  First 
sound  of  the  heart,  short,  abrupt  and  indistinct,  not  dull 
and  heavy,  as  is  usual  in  hypertrophy;  second  sound, 
well  defined  and  somewhat  heii^htened.       Neither  a  naimic 


Reflex  Cardiac  Gangliopathy.  215 

nor  valvular  murmur.  Respiration,  20 — and  normal. 
There  was  a  trace  of  albumen  in  the  urine  and  scales  of 
bladder  epithelium,  but  no  renal  casts  were  found. 

To-day  I  again    saw    Dr. on    his    return  from  a 

short  vacation.  Pulse,  84,  and  almost  normal  in  charac- 
ter, except  an  intermission,  once  in  about  twenty  beats. 
When  the  patient's  attention  is  suddenly  directed  to  the 
cardiac  movement,  the  intermissions  are  more  frequent 
and  the  heart's  action  more  rapid. 

Respectfully. 
To  Dr.  Chas.  H.  Hughes.  Wm.'  Porter." 

When  we-  consider  how  almost  omni-present  is  that 
ganglionic  chain  which  we  call  the  sympathetic  nervous 
system,  and  how  intimate  are  its  connections  with  the 
spinal  cord  and  brain,  and  in  what  close  rapport  by  these 
media  of  communication,  are  placed  the  ganglionic  cen- 
ters of  the  heart  with  those  of  the  cerebrum,  as  well  as 
of  the  generative  apparatus,  it  is  not  at  all  strange  that 
reflex  cardiac  disease  should  be  extremely  common,  as,  in 
fact,  we  find  it  to  be,  and  manifest  in  the  greatest  variety 
of  number  and  rj'thm  of  the  heart's  beats.  Influences 
from  above  downward — mental  causes,  such  as  excessive 
emotions,  inducing  palpitations  and  syncope,  have  been 
recognized  from  time  immemorial,  and  the  gastric  and 
abdominal  reflexes,  as  in  dyspepsia,  are  nothing  new  in 
neural  pathology. 

The  reflex  gangliopathic  disorders  of  the  heart,  too, 
connected  with  ovarian  irritation  in  women  of  neurotic 
temperaments,  confront  us  every  day  ;  and  so  commonly 
is  cardiac  irritation  associated  with  genital  excitation,  that 
Tilt's  experience  confirms  the  accuracy  of  Schmideman.  who 
has  paid  so  much  attention  to  nervous  affections.  The 
latter  says,  "  so  often  as  a  young  man  consults  me  for 
cardialgia,    I  suspect  onanism." — (P.    140,  op.  cit.) 

We  should  not  like  to  make  so  strong  an  assertion, 
nevertheless,  we  have  now  under  observation  a  monorchid, 
seventeen  years  old,  whose  left  testicle  can  be  felt  with 
the  finger  quite  low  down  in  the  inguinal  canal ;  whose 
heart  is  at  times  quite  irregular  and  always  abnormally 
rapid  in    its    beats.      The    case    above     detailed    may    be 


216  C.  H.  Hiidhes. 


regarded  as  the  analogue  in  the  male  of  those  reflex 
cardiac  neuroses,  which,  in  the  opposite  sex,  begin  in  a 
wave  of  morbid  irritation,  starting  in  an  ovary  and  going 
on  to  the  heart.  The  cardiac  difficulty  would,  probably, 
entirely  disappear  for  the  present,  on  the  evacuation  of  the 
fluid  from  the  distended  scrotum,  as  we  have  advised, 
since  it  sustains  the  relationship  to  the  disorder  of  exciting 
cause. 


SELECTIONS 


Thtj  Propositions  of  Dr.  Arthur  Ladbroke 
Wigan  on  the  Duality  of  the    Mind. 


TN  1844,  Dr.  Arthur  Ladbroke  Wigan  put  forth  and,  in 
^  a  very  ingenious  manner,  attempted  to  prove  the 
following  propositions  which,  in  view  of  the  present 
progress  of  cerebral  localization  and  the  acknowledged 
vicarious  action  of  the  cerebral  hemispheres,  are  quite 
interesting  reading,  and  we  reproduce  them,  as  the  book  is 
out  of  print. 

1.  'I'liat  each  cerebrum  is  a  distinct  and  perfect  wliole.  as  an  organ  of 
thought. 

2.  That  a  separate  and  distinct  process  of  lliinking  or  ratiocination 
may  be  carried  on  in  each  cerebrum  simultaneouslj'. 

3.  That  each  cerebrum  is  Ciipfible  of  a  distinct  and  separate  volition, 
and  that  these  ;ire  very  often  opposing  volitions. 

4.  That,  in  the  healthy  brain,  one  of  the  corebra  is  almost  always 
superior  in  power  to  the  other,  and  capable  of  exercising  lontrol  over  the 
volitions  of  its  fellow,  and  of  preventing  them  from  passing  into  acts,  or 
from  being  manifested  to  others. 

5.  That  when  one  of  these  cerebra  becomes  the  subject  of  limctional 
disorder,  or  of  positive  change  of  structure,  of  such  a  kind  as  to  vitiate 
mind  or  induce  insanity,  tlie  healthy  organ  can  still,  up  to  a  certain  point, 
con.rol  the  morbid  volitions  of  its  fellow. 


On  the  Duality  of  the  Mind.  217 

6.  That  this  point  depends  partly  on  the  extent  of  the  disease  or  dis- 
order, and  partly  on  the  degree  of  cnltivation  of  the  general  brain  in  the 
art  of  self-government. 

7.  That  when  the  disease  or  disorder  of  one  cerebrum  becomes  snfFi- 
ently  aggravated  to  defy  the  control  of  the  other,  the  case  is  then  one  of 
the  commonest  forms  of  mental  derangement  or  insanity  ;  and  Ihat  a  lesser 
degree  of  discrepancy  between  the  functions  of  the  two  cerebra  constitutes 
the  state  of  conscious  delusion. 

8.  'i  hat  in  the  insane,  it  is  almost  always  possible  to  trace  the  inter- 
mixture of  two  synchronous  trains  of  thought,  and  that  it  is  the  irregularly 
alternate  utterance  of  portions  of  these  two  tialns  of  thought  which 
constitute  incoherence. 

9.  That  of  the  two  distinct  simultaneous  trains  of  thought,  one  may 
be  rational  and  the  other  irrational,  or  both  may  be  irrational ;  but  that,  in 
either  case,  the  efl'ect  is  the  same,  to  deprive  the  discourse  of  coherence  oi' 
congruity. 

Even  in  furious  mania,  this  double  process  may  be  generally  per- 
ceived ;  often  it  takes  the  form  of  a  colloquy  between  the  diseased  mind  and 
the  healthy  one,  and  sometimes,  even,  resembles  the  steady  continuous 
argument  or  narrative  of  a  sane  man,  more  or  less  frequently  intenupt(d 
by  a  madman  ;  but  persevering  wich  tenacity  of  purpose  in  the  endeavour 
to  overpower  the  intruder. 

10.  'J  hat  when  both  cerebra  are  the  subjects  of  disease,  which  is  not 
of  remittent  periodicity,  there  are  no  lucid  intervals,  no  attempt  at  self- 
control,  and  no  means  of  promoting  the  cure ;  and  that  a  spontaneous  cure 
is  rarely  to  be  expected  in  such  cases. 

11.  That,  however,  where  such  mental  derangement  depends  on 
inflammation,  fever,  gout,  impoverished  or  diseased  blood,  or  manifest  bodily 
disease,  it  may  often  be  euied  by  curing  the  malady  which  gave  rise  to  it. 

12.  That  incases  of  insanity,  not  depending  on  structural  injury,  in 
which  the  patients  retain  the  partial  use  of  reason  (from  one  of  the  cerebra 
remaining  healthy  or  only  slightly  affected),  the  onlj'  mode  in  which  the 
medical  art  can  promote  the  cure  beyond  the  means  alluded  to  is  by  pre- 
senting motives  of  encouragement  to  the  sound  brain  to  exercise  and 
strengthen  its  control  over  the  unsound  brain. 

13.  That  the  power  of  the  higher  organs  of  the  intellect  to  coerce  the 
mere  instincts  and  propensities,  as  well  as  the  power  of  one  cerebrum  to 
control  the  volitions  of  the  other,  may  be  indefinitely  increased  by  exercise 
and  moral  cultivation ;  may  be  partially  or  wholly  lost  by  desuetude  or 
neglect;  or,  from  I'epraved  habits  and  criminal  indulgence  in  childhood, 
a  general  vicious  education  in  a  polluted  moral  atmosphere,  may  never  have 
been  acquired. 

14.  That  one  cerebrum  may  be  entirely  destroyed  by  disease,  cancer, 
softening,  atrophy  or  absorption;  may  be  annihilated,  and  in  its  place  a 
yawning  chasm;  j'ct  the  mind  remain  complete  and  capable  of  exercising 
its  functions  in  the  same  manner  and  to  the  same  extent  that  one  eye  is 
capable  of  exercising  the  faculty  of  vision  when  its  fellow  is  injured  or 
destroyed;  although  there  are  some  exercises  of  the  brain,  as  of  the  eye 
which  are  better  performed  with  two  organs  than  one.     In  the  case  of 


218  Jrthur  Ladbroke  Wi§an, 

vision,  tlio  piuver  of  luoMsiiring  distances,  fcr  example,  and  inlliccase  of 
tlic  brain,  tlie  power  of  conceul rating  the  thoughts  u])un  subject,  deep  eon- 
sideration.  Iiard  study;  but  in  this  latter  case,  it  is  difficult  to  decioe  how 
tar  the  diuiinished  power  depends  on  diminution  of  general  vigor  from 
tonnidable  and  necessarily  fatal  disease. 

\'>.  That  a  lesion  or  injury  of  both  cerebra  is  incompatable  with  such 
an  exercise  of  the  intellectual  functions,  as  the  common  sense  of  mankind 
would  designate  sound  mind. 

16.  Thar  from  the  apparent  division  of  each  cerebrum  into  three  lobes 
it  is  a  natural  and  reasonable  presiunption  that  the  three  portions  have 
distinct  offices,  and  highly  probable  that  the  three  gieat  divisions  of  the 
mental  functions  laid  down  by  phrenologists,  are  founded  in  nature.; 
whether  these  distinctions  correspond  with  the  natural  divisionsis  a  different 
question,  but  the  fact  of  different  portions  of  the  brain  executing  different 
functions,  is  too  well  established  to  admit  ot  denial  from  any  pliysiologist. 

17.  That  it  is  an  error  to  suppose  the  two  sides  of  the  cranium  to  be 
always  alike;  that  on  the  contrary,  it  is  rarely  found  that  the  two  halves  of 
the  exterior  surface  exactly  correspond;  that  indeed,  in  the  insane,  there  is 
often  a  notable  difference — still  more  frequent  in  idiots,  and  especially  in 
congenital  idiots. 

18.  Tliat  the  object  and  effect  of  a  well-managed  educarion  are  to 
establish  and  confirm  the  power  of  concentrating  the  energies  of  both 
brains  on  the  same  subject  at  the  same  time;  that  is,  to  make  both  cerebra 
carry  on  the  same  train  of  thought  together,  as  the  object  of  moral  discipline 
is  to  strengthen  the  power  of  self-control;  not  mereh' the  power  of  both 
intellectual  organs  to  govern  the  animal  propensities  and  passions,  but  the 
intell.  ctual  antagonism  of  the  two  brains,  each  (so  to  speak)  a  sentinel  and 
security  lor  the  other  while  both  are  healthy;  and  the  healthy  one  to  correct 
and  control  the  erroneous  judgments  of  its  fellow  when  disordered. 

19.  That  it  is  the  exetrcise  of  this  power  of  compelling  the  combined 
attention  of  both  brains  to  the  same  object,  till  it  becomes  easy  and  habit- 
ual, that  constitutes  the  great  superiority  of  the  disciplined  scholar  over  the 
self-educated  man;  the  latter  may  perhaps  possess  a  greater  stock  of  useful 
knowledge,  but  set  him  to  study  a  new  subject,  and  he  is  soon  outstripped 
by  the  other,  who  has  acquired  the  very  difficult  accomplishment  of 
thinking  of  only  one  thing  at  a  time;  that  is,  of  concentrating  the  action  of 
both  brains  on  the  same  subject. 

20.  That  every  man  is,  in  his  own  person,  conscious  of  two  volitions, 
and  very  often  conllicting  volitions,  quite  distinct  from  the  government  of 
the  passions  by  the  intellect;  a  con.sciousness  so  universal,  that  it  enters 
into  all  figurative  language  on  the  moral  feelings  and  sentiments,  has  been 
enlisted  into  the  service  of  every  religion,  and  forms  the  basis  of  some  of 
them,  as  the  Manichicaa. 


PROCEEDINGS    OF   THE    PSYCHOLOGICAL    SOCI- 
ETY,  BERLi:^. —  Tra;is/atcd  by  Edward  IV.  Saunders. 


Dr.  LacJir — Mechanical  Restraint ;  Gastrozvitz — Treatment 
of  Dread  and  Certain  Contra-indications  of  Chloral ; 
Folk  and  Gock — Digitalis  in  Excitement. 

^  I  ""HE  president,  Dr.  Laehr,  thanked  the  members  for 
-*•  their  congratulations  sent  him  on  the  occasion  of 
the  celebration  of  the  25th  anniversary  of  the  asylum, 
and  referred,  feelingly,  to  the  sudden  death  of  Koppe. 
The  members,  at  his  request,  rose  from  their  seats,  in 
honor  of  the  deceased. 

Dr.  Laehr  then  delivered  an  address  on  the  question  : 
"  Is  mechanical  restraint  allowable  to  physicians  in  the 
treatment  of  the  insane;  and  if  so,  to  what  extent?"  As 
follows  : 

Three  years  ago,  at  our  23d  meeting,  a  similar  theme 
was  discussed.  We  were  at  that  time  assailed  severeh-, 
owing  to  a  misapprehension,  and  to  the  fact  that  the  time 
had  not  yet  come  for  a  calm  consideration  of  the  subject. 
Our  expression  of  what  was  then  the  prevailing  sentiment, 
can  be  found  in  the  very  wording  of  the  subject  which 
was  under  discussion  :  "Cannot  humanity,  when  carried  too 
far,  be  of  disadvantage  in  the  treatment  of  the  patients?  " 
In  the  debate  also  this  circumstance  appeared  to  have 
exercised  considerable  influence.  Perhaps  this,  too,  is  an 
unfavorable  time  for  a  discussion,  but,  at  any  rate, 
during  the  last  }'ear  or  two,  the  views  upon  the  question 
have  become   clearer. 

Even  in  England,  where  an  original  opinion,  which 
runs  counter  to  the  received  doctrines,  makes  slower 
headway     than    here,     there    have      been     several     voices 


220 .  Edward  W.  Saunders, 

raised  against  tlie  hitherto  received  opinion,  as  we  learn 
from  the  hrocJiure  of  Davics:  In  America,  the  debates 
on  this  subject  last  year  were  very  animated.  The 
Association  of  South-West  Germany  has  this  subject  for 
discussion  at  its  next  meeting.  In  the  meeting  in  V^ienna, 
on  the  occasion  of  the  25th  anniversary  of  the  asylum 
there,  the  extraordinary  method  was  adopted  of  putting 
the  question  to  the  vote,  and  also  the  German  society,  of 
Alienists  has  taken  this  subject  for  discussion  at  its  next 
meeting  in  the  Autumn.  There  are  then  sufficient  reasons 
why  our  society  should  express  itself  with  regard  to  this 
subject,  and  thereby  render  the  discussion  in  our  general 
meeting  more  productive  of  good  results.  It  appears  to 
me,  for  instance,  that  amongst  us  in  Germany  the  opinions 
are  not  so  radically  at  variance,  that  an  agreement  is 
prevented  only  by  false  assumptions,  and  if  this  be  the 
case,  an  understanding  could  easily  be  reached.  •  I  will 
discuss  the  question  whether  restraint  is  allowable  or  not, 
in  the  treatment  of  the  insane.  In  the  treatment  of  other 
classes  of  patients,  restraint  is  employed  without  a  second 
thought,  and  in  many  text-books,  on  surgery  for  instance, 
astonishment  is  expressed  that  we  should  make  such  ado 
about  employing  it.  We  force  a  child  to  take  its  medi- 
cine, when  it  is  in  need  of  it  and  refuses  it ;  we  do  not 
hesitate  to  plunge  a  typhoid  fever  patient  into  a  cold 
bath,  when  his  temperature  rises  above  40^  C,  even 
though  he  makes  resistance  ;  and  many  surgeons  have  no 
scruples  about  ordering  a  patient  to  be  held  and  bound 
in  order  to  operate  upon  him.  Taking  a  patient  to  an 
asylum  is  putting  a  restraint  upon  him,  and  is  done 
generally  against  his  will,  often  b)-  the  use  of  force.  We 
recommend,  for  scientific  reason,  that  a  patient  should 
not  be  gotten  into  an  asylum  by^  the  use  of  deception, 
but  if  need  be,  by  force.  We  give  him,  within  the  asylum, 
the  greatest  amount  of  liberty  consistent  with  the 
good  government  of  the  institution,  and  give  him  that 
plan  of  treatment  which  has  been  found  to  be  the  best 
for  him.  We  carefully  guard  him  against  all  causes  of 
excitement  while  he  is  in  the  acute  stage, — isolate  him, 
even  against  his  will.  When  he  has  become  more  sober, 
we  begin  often  with  psychological  treatment,  in  addition 
to  dietetic  treatment.  We  attempt  to  induce  the  patient 
to  do  certain  things,  and  to  abstain  from  doing  certain 
other  things.  The  majority  of  patients,  when  within  the 
asylum,   comply     of    their    own     accord  ;    in    the    case     of 


Proceedings  of  the  Psychological  Society,  Berlin.       221 

those  who  refuse  to  obey,  the  methods  of  influencing 
them  are  very  various,  and  are  determined,  not  only  by 
the  nature  of  their  disease,  but  also  by  the  means  that 
are  at  our  disposal.  Sometimes  a  gentle  word,  some- 
times a  stern  command  has  the  desired  effect ;  in  one 
case,  the  j^romise  of  something  to  eat,  in  another,  the 
prospect  of  obtaining  a  request.  Many  patients,  though 
of  mature  age,  are  just  like  children  in  this  respect.  We 
call  this  method  "  moral  restraint,"  the  same  that  we 
employ  in  ordinary  relations  of  life,  whenever  the  duty  is 
imposed  upon  us  of  governing  some  one,  and  it  is  the 
duty  of  the  physician  to  induce  the  patient  to  carry  out 
his  regulations.  There  are  cases  in  which  this  moral 
restraint  is  not  sufficient.  Under  these  circumstances, 
in  private  practice,  the  physician  gives  up  the  case,  when 
the  patient  will  not  follow  his  directions,  and  the  family 
will  not  force  him  to  do  so.  In  an  institution  we  cannot 
do  this,  since  there  it  is  our  duty  not  only  to  give  direc- 
tions, but  also,  in  the  interest  of  the  State  or  of  the  friends 
of  the  patients,  to  see  that  they  are  carried  out.  At 
this  point  the  opinions  of  medical  men  become  divided. 
Moral  restraint  is  approved  of  by  all,  but  many  are 
unwilling  to  resort  to  mechanical  restraint.  The  latter 
is,  undoubtedly,  a  two-edged  sword,  and  is  capable,  when 
not  employed  in  the  right  place  in  proper  manner,  of 
doing  harm,  by  embittering  the  patient,  while  possibly, 
it  may  even  fail  to  bring  him  into  submission.  However, 
the  greater  the  experience,  skill  and  self-possession  of  the 
ph}-sician,  and  the  better  the  means  of  help  at  his  com- 
mand, personal  and  mechanical,  as  well  as  that  afforded  by 
the  construction  of  the  building,  the  less  will  be  the 
danger  of  his  making  a  mistake,  and  the  sooner  he  will 
discover  it,  if  he  is  so  unfortunate  as  to  make  one.  Every 
one  has  observed  that  there  are  cases,  which,  when  left 
to  themselves,  get  continually  worse,  while  if  their  conduct 
is  controlled  before  it  is  too  late,  they  become  more 
rational,  and  if  curable  at  all,  make  a  good  recovery,  or 
if  incurable,  their  existence  becomes  at  least  a  bearable 
one.  Often  the  exercise  of  force  on  a  single  occasion 
only  will  be  sufficient  in  inducing  a  patient  thereafter 
to  bate  himself,  to  go  out  into  the  fresh  air  to  take  his 
meals,  or  to  be  cleanh'  in  his  habits.  He  sees  his  power- 
lessness,  and  makes  no  more  resistance.  Often  he  is 
glad  that  force  has  been  used  upon  him,  and  that  he  is 
now  able  to  eat,  to  bathe,  to  walk  out,  and  to  be  cleanlv. 


222  Edward  W.  Saunders, 


There  are  some  who  would  gladly  obey,  and  long  for 
some  one  else  to  supply  tlie  defect  in  their  power  of 
will.  A  recent  example  will  illustrate  this  point.  Frau  E. 
came  to  us  recently  from  an  asylum,  in  which  every  patient 
is  allowed,  on  principle,  the  greatest  amount  of  freedom 
possible.  She  had  been  a  torment  to  her  attendants, 
through  her  discontent  and  her  wailing.  As  this  had 
lasted  for  several  months,  the  superintendent  concluded 
to  recommend  the  friends  of  the  patient  to  transfer  her 
to  another  asylum,  either  from  pity  towards  his  nurses, 
or  that  he  was  principled  against  the  emplojment  of 
force.  In  her  new  quarters,  the  patient  proved  also  a 
scourge  to  her  attendants.  After  observing  her  for  some 
time,  and  finding  that  she  kept  up  her  lamentations  only 
from  a  force  of  habit,  while  she  was  perfectly  able  to 
stop  it,  if  she  would,  I  explained  to  her,  that  she  could 
not  remain  in  the  ward  reserved  for  quiet  patients,  unless 
she  would  behave  herself,  but  that  I  would  put  her  in 
another  ward,  where  ^he  could  disturb  no  one.  Evidently, 
she  did  not  believe  that  I  was  in  earnest,  and  kept  on 
as  before.  I  then  had  her  brought  into  an  observation 
ward  by  several  female  attendants,  who  succeeded  in 
doing  so  without  any  trouble.  In  a  few  hours  she  became 
much  quieter,  and  wished  to  return.  Since  she  complied 
with  the  conditions  that  I  had  made,  I  granted  her  wish. 
This  had  to  be  repeated  several  times,  but  the  intervals 
of  quiet  became  progressively  longer,  and  now  she  is 
convalescent;  declared  to  be  perfectly  well  by  her  friends, 
after  repeated  visits,  and  she  is,  moreover,  as  well  as  her 
friends  ;  very  thankful  for  the  restraint  that  was  put  upon 
her,  as  such  patients  generally  are.  I  need  not  add  that 
such  mechanical  restraint  should  be  employed  only  by 
order  of  a  physician,  and  should  be  carried  out  by 
reliable  attendants,  under  his  personal  supervision,  if  it  is 
to  effect  any  good  result.  This  condition,  however,  is 
not  different  from  that  which  is  required  in  all  medical 
treatment.  If  now,  it  is  granted,  that  mechanical  restraint 
is  admissible  in  the  treatment  of  certain  forms  of  insanity, 
always,  of  course,  by  direction  under  the  supervision  of  a 
physician  ;  that,  in  fact,  no  asylum  can  get  along  without 
it,  that,  in  reality,  the  conveying  of  a  patient  to  a  room, 
against  his  will,  is  employing  restraint,  granting  this,  it 
appears  to  me,  that  relativily,  but  small  importance  is 
attached  to  the  question,  whether  this  restraint  shall 
be  applied  by  the  hands  of   attendants,  or  by    mechanical 


Procserlin^s  of  the  Psychological  Society,  Berlin. 


inventions.  The  only  question  is,  to  attain  the  object 
desired,  whilst,  at  the  same  time,  the  patient  is  treated 
with  the  greatest  possible  consideration.  That  a  safety, 
or,  as  many  others  term  it,  a  restraint  jacket,  can  be 
dispensed  with,  is  proven  by  the  experience  of  many 
asylums  ;  and  it  is  a  fact,  that  in  other  asylums,  in  which 
non-restraint  has  not  been  adopted,  frorii  principle,  it  is 
seldom  used,  not  a  single  time,  perhaps,  during  a  number 
of  years.  In  my  institution  we  have  not  used  it  for 
years.  There  are  also,  other  mechanical  appliances,  and 
at  one  time,  I  recommended  the  wet  sheet  for  some 
classes  of  patients.  This  can  be  used  as  an  adjunct  to 
the  jacket.  In  fact,  I  know  of  no  one  in  Germany 
who  upholds  the  principle  of  absolute  non-restraint. 
Even  those  who  wish  to  abolish  restraint,  acknowledge  that 
circumstances  may  arise  that  would  justify  its  employment. 
I  know  of  no  one,  either  who  is  fond  of  employing  it  or 
would  have  it  used  in  certain  forms  of  insanity.  To  what 
extent  it  may  be  considered  necessary  in  practice,  will 
depend  upon  the  ability,  the  tact,  the  experience,  and 
the  means  at  command  of  the  physician.  He  must  have 
the  choice  of  the  method  which  will  be  most  humane  to 
the  patient,  and  at  the  same  time  accomplish  the  purpose 
of  curing  him.  An  abuse  of  this  power  is  condemned,  of 
course,  but  this  objection  can  be  made  against  any  potent 
therapeutic  means.  It  has  been  said  that  the  question 
of  non-restraint  does  not  hinge  upon  the  jacket  now 
and  then,  but  that  the  word  expresses  a  s}-stem,  in  which 
a  new  spirit  of  humanity,  and  therefore,  perfection  in  the 
medical  treatment  of  the  insane  has  been  introduced.  I 
cannot  subscribe  to  this,  since  all  the  means  which  have 
been  introduced  to  take  the  place  of  mechanical  restraint, 
were  in  use  before  ConoUy's  time,  and  like  all  other 
innovations,  they  were  slowly  improved  upon,  and  even 
now,  have  not  reached  perfection.  I  must  lay  the  more 
stress  upon  this,  because  my  career  began  just  at  the 
time  when  Conolly's  labors  became  known  in  Germany. 
His  system  of  non-restraint  was  not  a  new  departure  in 
the  treatment  of  the  insane.  It  was  rather  a  consequence 
of  the  new  impulse,  which  was  given  at  the  time  when 
the  treatment  of  the  insane  fell  into  the  hands  of 
physicians,  when  they  began  to  live  with  them,  to  be  in 
daily  intercourse  with  them,  to  observe  their  diseases, 
and  to  see  how  they  ought  to  be  attended.  This  was  the 
period   A\hen  medicine  ceased  to  be  a   school  of  philosophy, 


224  Edward  TT'.  Saunders, 


and  became  a  school,  of  science.  Since  that  time  our 
department  of  therapeutics,  like  many  other,  has  been 
slowly,  but  steadily  developing,  and  in  Germany  it 
would  be  rather  difficult  to  classify  the  asylums  according 
to  the  question  of  non-restraint.  The  public  itself,  for 
whom  the  asylums  exist,  reposes  confidence  in  them 
according  to  the  standing  of  the  physicians  in  charge, 
and  to  their  means  at  their  command,  irrespective  of 
the  question  whether  they  use  restraint  or  not,  where 
they    may    consider  it    advisable. 

The  speaker  then  left  it  to  the  society  to  decide 
whether  the  question  should  be  further  discussed.  In 
consideration  of  the  importance  of  the  question,  Ideler, 
Gastrowitz,  Zinn,  and  Schaefer,  as  alternate,  were  elected 
to  further  investigate  the  subject,  and  report  at  the  next 
meeting. 

Gastrowitz :  "  Some  observations  upon  the  treatment 
of   conditions    of   dread." 

In  the  introduction  to  this  address,  the  speaker  called 
especial  attention  to  the  difficulty  of  forming  a  correct 
judgment  in  the  use  of  therapeutic  agents.  He  thought 
it  would  be  better  to  limit  our  efforts  at  attaining  a  cure, 
based  upon  a  certain  theory  of  the  manifestations  of  the 
disease.  Starting  from  the  better-known  attendant  symp- 
toms of  the  (state  of  dread)  fright ;  he  analyzed  the  differ- 
ent modes  of  manifestation  of  the  various,  principal 
comlitions  of  dread,  which  he  stated  could  be  best 
explained  upon  the  theory  of  a  diminution  of  tone  in  the 
medulla  oblongata,  which  want  of  tone  could  be  brought 
about  cither  b)-  central  or  peripheral  causes.  He  spoke  of 
the  drugs  hitherto  in  general  use,  and  first  of  all,  the 
narcotics — opium,  morphine  and  chloral.  The  first  two  he 
considered  to  be  so  useful,  because  they  improve  the  tone, 
and  therefore  acted'  not  only  as  narcotics,  but  as  tonics. 
Still  there  were  many  cases  in  which  opium  and  its  deriv- 
atives only  restrained  the  dread,  as  the  dam  in  the  run- 
ning stream,  to  let  it  break  forth  with  greater  violence 
afterwards.  A  small  number  of  patients  who  become 
worse  under  the  use    of   the    same    medicines,    since  after 


Proceedings  of  the  Psychological  Society,  Berlin.        225 


long-continued  administration,  the  symptoms  of  chronic 
intoxication  appeared,  and  the  novel  sensations  they 
experience  arouse  the  dread  anew.  It  would  be  desira- 
ble if  the  unqualified  advocates  of  subcutaneous  morphine 
would  tell  us  their  bad  results  also.  In  addition  to  the 
well-known  contra-indications  against  chloral,  the  speaker 
added  the  following:  I.  Extensive  adhesions  between 
the  pulmonary  and  parietal  pleurae,  discernible  in  persus- 
sion.  2.  A  certain  incapability  of  the  nervous  system 
to  be  influenced  by  the  drug,  shown  b}'  the  absence  of 
the  symptom  first  described  by  himself,  of  contraction  of 
the  pupils.  Such  patients  have  moderately  wide  pupils  ; 
they  get  no  relief  at  all,  or  only  a  short  sleep,  from  ordi- 
nary doses  of  the  drug — 3  to  4  grammes.  If  the  adminis- 
tration of  the  drug  is  pushed  farther,  they  become  suddenly 
cyanotic,  and  there  is  failure  of  the  heart's  action,  and 
with  these  symptoms  death  might  supervene,  as  he  had 
actually  seen  in  the  practice  of  other  physicians. 

The  intensified  action  of  chloral,  when  small  doses  of 
morphine  are  given  with  it,  is  to  be  attributed  to  the 
effect  of  the  morphine  in  diminishing  the  secretions — a 
fact  proven  by  Moreau,  in  the  case  of  the  intestinal 
secretions,  and  by  CI.  Bernard  in  the  case  of  the  secre- 
tion of  the  sublingual  glands.  In  this  way  the  chloral  is 
forced  to  remain  for  a  longer  time  in  the  body,  and  its 
action  more  or  less  intensified.  Tlureforc,  large  doses  of 
morpJiine  a)id  cldoral  should  )iot  be  give?!  at  once,  as  is 
often  done,  for  in  this  way  fatal  results  may  ensue.  It  is 
best,  as  advised  by  the  speaker,  ten  years  ago,  to  combine 
^— I  gramme  of  chloral  with  minimum  doses  of  morphine, 
and  administer  this  under  careful  observation  for  some 
time,  but  not  for  a  period  extending  over  weeks.  Codein 
has  the  same  effect  as  opium.  Often,  subcutaneous  mor- 
phine, strange  to  say,  does  not  have  the  same  happy 
effect  as  codein  or  opium  in  much  smaller  doses,  adminis- 
tered by  the  mouth,  and  here  a  change  is  of  advantage. 
Digitalis  he  has  found  useless,  though  administered  for  a 
long    time    in    medium    doses.       It     is     remerkable    that    in 


Edward  W.  Saunders, 


conditions  of  dread,  commencing  with  an  accelarated  pulse, 
it  never  once  reduced  its  frequency,  that  is,  it  failed  to 
display  its  physiological  effect.  Bromide  of  potassium,  as 
is  well  known,  is  serviceable  in  cases  in  which  sexual 
excitement  is  a  cause  of  the  trouble  ;  the  combination  of  it 
with  extr.  cannabis  indicae,  as  recommended  by  Clouston, 
he  has  not  found  of  any  advantage,  owing,  possibly,  to 
the  bad  quality  of  the  latter  preparation.  In  two  cases  of 
emphysema,  and  in  one  of  emphysema,  complicated  with 
a  vitiinn  cordis,  he  obtained  striking  results  with  iodide  of 
potassium,  as  advised  by  Lee.  He  used  a  solution  of  the 
strength  of  10:200 — at  first,  with  a  little  morphine  added, 
aftenvards.  without  the  morphine.  The  dose  was  a  table- 
spoonful,  in  sweetened  water,  two  or  three  times  a  day. 
It  is  well  to  give  it  well  diluted,  as  otherwise  a  repug- 
nance for  it,  with  loss  of  appetite  is  easily  produced- 
The  speaker  ended  by  referring  to  the  cold-water  treat- 
ment, which  he  had  not  employed  often,  but  from  what 
experience  he  had  had  with  it,  he  was  inclined  to  think 
that  during  convalescence  it  ranked  first  amongst  the 
therapeutic    agencies. 

Folk  related  a  case  that  had  come  under  his  obser\'ation, 
in  which,  after  the  administration  of  digitalis,  the  patient 
became  quiet,  although  the  pulse  remained  as  frequent  as 
before.  Gock  said:  "In  Eberswald  a  number  of  observations 
have  been  made  upon  the  effect  of  digitalis  in  conditions 
of  excitement.  Only  those  cases  which  were  attended 
by  an  increase  of  the  temperature  and  of  the  pulse 
rate,  without  a  local  affection  to  account  for  it,  were 
benefitted  by  this  agent." — Dr.  Schaefer,  Allgeinei7ie  Zcit- 
schrift  fur  Psychiatric,  36  Bund,  5  Heft,  Berlin,  March 
15,    1879. 


La  Menti  di  Carlo  Livi. 


Pel  Dottori,  E.  Morselli  e  A.   Tanibiirini . 


The  Memory  of  Carlo  Livi  by  Doctors  E.  Morselli  and  A.  Taraburiiii. 


Translated  by  Joseph  Workman,  M.  D.,  Toronto,  Canada. 

THE  January  number  of  the  Revista  Sperirnentale  di 
Freniatria  e  di  Mcdicina  Legale  gives  the  conclusion 
of  a  compressed  and  eulogistic  biography  of  the  illustrious 
alienist,  whose  name  adorns  the  heading  of  our  present 
article.  We  have  read,  with  warm  gratification,  this 
affectionate  tribute  of  two  sorrowing  pupils  to  the  mem- 
ory of  their  venerated  master,  and  we  cannot  but  regret  that 
our  available  space  precludes  the  reproduction  in  our  own 
pages  of  the  whole  memoir,  for  we  cannot  doubt  that  it 
would  be  read  by  every  member  of  the  American  specialty 
of  alienism,  with  fraternal  interest,  and  not  without  profitable 
and  encouraging  instruction. 

Carlo  Livi,  in  that  unsuccessful  struggle  for  liberty  and 
national  independence,  through  which  his  oppressed  coun- 
try was  doomed  to  pass  in  the  memorable  year  of  1848, 
fearlessly  entered  the  patriotic  ranks  of  the  revolutionists, 
as  a  common  soldier.  This  spartan  band,  "on  the  29th 
day  of  May  fought  with  a  valor  worthy  of  their  ancient 
fathers,  but  in  vain,  at  Curtatone  and  Montanara ; 
they  were  in  numbers  scarcely  five  thousand,  badly  armed, 
badly    fed,  badly  commanded,  and  they    were  vanquished. 


228  Joseph  Workman. 


decimated  by  thirty-five  .  thousand  Austrians  with  fifty 
pieces  of  artillery.  They  struggled  desperately  through 
eleven  hours,  resisting  the  persevering  renewals  of  attack 
by  the  enenny,  who  slaughtered  many,  and  made  few 
prisoners." 

Such  was  the  youthful  experience  of  Carlo  Livi,  but 
he  lived  to  see  his  country  rescued  from  the  iron  grasp  of 
the  tyrants,  and  to  become  himself  one  of  her  most  illus- 
trious benefactors. 

We  must,  however,  take  up  the  story  of  his  useful  life 
at  an  advanced  period,  after  he  had  accomplished  many 
valuable  and  much  needed  reforms  in  several  of  the  Italian 
asylums  for  the  insane  ;  we  now  introduce  the  reader  to  the 
words  of  his  eulogists,  in  the  following  translation,  from  the 
glowing  Italian  into  our  own  inadequately  representative 
tongue : 

"But  if  such  were  the  material  benefits  which  the 
asylum  of  Reggio  derived  from  the  brief  direction  of  Livi, 
greater,  and  perhaps  better  known,  were  the  moral.  In 
fact,  through  the  exclusive  actions  of  our  venerated  mas- 
ter, that  institution  became  an  important  scientific  center 
of  psychiatric  studies,  for  which,  beyond  the  vast  clinical 
material  furnished  by  a  large  number  of  curable  cases,  the 
administration  spared  no  expense  necessary  to  endow  it 
with  all  the  means  required  for  the  experimental  progress  of 
our  science.  On  the  arrival  of  Livi,  the  asylum  became 
the  seat  of  a  psychiatric  clinique  of  the  neighboring  Uni- 
versity of  Modena,  and  the  sagacity  of  the  Director 
sufficed  to  obtain  from  the  administration,  the  institution 
of  practical  positions  for  those  young  physicians  who 
desired  to  dedicate  themselves  to  psychiatry.  At  the 
same  time,  Livi,  aided  by  the  Hon.  President  of  the 
asylum,  the  Deputy  Fornaciari,  requested  and  the  minister 
of  public  instruction  assented,  that  the  graduates  \\ho  had 
come  out  successful  in  the  competition  for  governmental 
posts  in  the  interior,  and  who  wished  to  devote  themselves 
to  psychiatric  .studies,  should  be  sent  to  the  asylum  to 
perfectionate  themselves  in  the  study  of  mental  medicine. 
By  this  means  the  Hospice,  the  first  of  all  in  Italy, 
was  raised  to  a  comparative  eminence  among  the  princi- 
pal scientific  institutions,  and  the  primary  universities  of 
the  Kingdom,  and  it  remains  the  onK'  example  in  cultivated 


La  Menti  di  Carlo  Livi.  229 


Europe  of  a  theoretico-practical  school  of  psychiatry.  For 
the  better  instruction,  afterwards,  of  his  pupils,  Livi  omitted 
nothing,  and  first  of  all  be  established  a  rich  library  of 
many  select  books,  relating  to  the  specialty,  as  well  as  of 
Italian  and  foreign  periodicals  :  he  undertook  an  important 
series  of  observations  on  the  relations  between  epileptic 
and  maniacal  paroxysms,  and  the  meteorological  changes 
of  the  atmosphere  ;  he  instituted  a  pathological  museum 
with  a  numerous  collection  of  crania,  and  preparations 
related  to  the  normal,  and  the  morbid  anatomy  of  the 
nervous  system ;  he  donated  to  the  asylum  a  labora- 
tory for  observations,  provided  with  instruments,  the  best 
adapted  for  somatic  examination  of  the  msane ;  finalh', 
in  order  to  compare  the  new  times  wdth  the  old — the 
present  of  psychiatry  w4th  the  past — he  collected  the 
frightful  apparatus  used  when,  in  the  treatment  of  the 
insane,  force  held  the  place  of  reason,  and  he  made  of 
them  a  strange  museum  of  mixed  antiquities,  where  so 
much,  alas!  maybe  learned,  that  it  would  be  for  the 
decency  of  medicine,  and  the  honor  of  humanity,  that  all 
should  be  consigned  to  eternal  oblivion. 

In  the  meantime  Livi  was  preparing,  in  his  mind,  a 
new  project,  for  the  execution  of  which  Italian  science 
ought  to  be  ever  grateful.  The  medicine  of  alienism  had 
already  in  Italy  an  excellent  organ  in  the  Archivio  delle 
Malattic  Nervose  e  Mentali,  which,  for  almost  a  quarter  of  a 
century  remained  the  only  proof  of  scientific  activity 
among  Italian  alienists ;  but  it  appeared  to  Livi,  that  to 
that  activity  a  second  field  of  exercise  might  be  given, 
as  the  number  of  the  schools  had  increased,  and  that  of 
the  cultivators  of  the  new  science  appeared  sufficient!}- 
augmented.  On  the  other  hand,  there  was,  in  Italian 
medical  literature  a  void,  rather  shameful,  which  should 
be  filled ;  legal  medicine  stood  in  need  of  a  journal  all  its 
own,  which  might  save  medical  legists  from  the  necessit)' 
of  begging  space  in  other  scientific  periodicals,  and  might 
impart  to  the  forum,  that  authority  which  is  necessary  for 
its  ample  and  practical  perfectionment.  Livi  was  thus  led 
to  the  founding  of  the  Revista  Speiimentale  di  Freniatria 
e  di  Mcdicina  Legale,  in  which  he  purposed  to  apph'  to 
the  study  of  psychical  observations  and  to  that  of  medico- 
forensic  problems,  that  logical  method  learned  by  him  in 
the  traditions  of  the  Tuscan  school;  that  is  to  say,  the 
method  of  the  divine  Galileo,  the  great  Redi,  and  the 
illustrious  Biiffalini.      The  harmony  between    two  sciences 


230  Joseph  Workman, 


Avhich  have  so  man}'  points  in  common,  their  subjection 
to  a  sole  objective  and  experimental  method,  the  neces- 
sity for  a  community  of  cognitions  and  understandings, 
between  physicians  and  jurist-experts,  and  finally,  the 
reasons  for  the  publication  of  this  new  periodical  were 
expressed  with  eloquence,  life  and  efficacy,  in  a  preface 
which  is  certainly  one  of  the  finest  productions  that  ever 
went  forth  from  his  splendid  genius.  Under  such  auspices 
the  journal  was  hailed  at  its  appearance  with  lively 
demonstrations  of  sympathy,  and  from  the  first  it  showed 
that  it  had  in  itself  the  elements  of  an  independent 
existence,  and  of  it  future  development.  Certainly,  it 
was  to  the  name  and  to  the  authorit}"  of  Carlo  Livi, 
that  it  owed  the  validity  and  robustness  of  which  it  has  al- 
ways given  proof;  but  that  the  Rcvista  has  met  the  wants  of 
Italian  science,  has  been  clearly  shown  by  the  encourage- 
ments, praises,  counsels  and  collaborations  of  such  eminent 
men  as  Carrara,  Manciiii,  ScJiiff,  Holtzcndorff,  Kraft-Ehing, 
Brierrc  dt  Boisiiiont,  UlUrsperger  and  Brusa.  Of  contempor- 
ary origin  with  the  Rcvista  was  the  Gazetta  del  Frcnocomig  di 
Rcggio;  rendered  so  attractive  by  its  homeliness,  conjoined 
with  its  brightness,  its  freshness  of  style  and  elegance  of 
diction,  and  that  ingenuous  vivacity,  with  which  the  mas- 
ter pen,  and  the  lively  affection  of  Livi  described  so  many 
good  and  pleasing  things,  and  the  persons  and  facts 
that  gave  lustre  to  the  little  world  oiXviS,  hospice.  Of  that 
golden  Gazetta,  it  may  well  be  said,  that  the  beauteous 
mind  of  the  ph\'sician,  and  the  finely  analytic  spirit  of 
the  man  of  good  heart,  were  conspicuous  on  every  page, 
whilst  an  air  of  inimitable  delicacy  and  profundity  of 
knowledge,  was  shed  forth  from  its  every  line. 

From  such  valuable  labors,  it  might  be  expected  that 
his  fame  would  augment  both  within  and  beyond  Italy; 
and  such  was  the  fact.  From  all  parts  new  honors  and 
new  demonstrations  of  esteem  flowed  in  to  him,  alike 
from  the  Government,  the  alienistic  administration  and, 
finally,  from  his  specialistic  confreres.  As  his  writings 
were  sought  after  by  psychiatrists  and  medical  jurists, 
these  enquirers  were  continually,  both  at  home  and  abroad, 
in  quest  of  his  views  of  diseases,  on  practical  psychiatry, 
and  medico-forensic  judgments.  In  the  midst  of  so 
great  and  so  various  engagements,  he  still  found  time 
for  his  asylum  duties,  for  the  school,  and  for  the  Revista 
and  the  Gazetta,  and  over  and  above,  for  his  original 
productions.       At  the   Congress  in  Imola,  so  great  was  the 


La  Menti  di  Carlo  Livi.  231 


veneration  of  his  colleagues,  that  in  the  first  meeting  he 
was,  by  acclamation,  elected  vice-president,  although,  from 
important  impeding  engagements,  he  was  not  yet  present ; 
and,  still  more,  the  Congress,  which  was  forthwith  to 
discuss  the  subject  of  transfusion  of  blood  in  the  cure  of 
insanity,  adjourned  the  discussion  because  he  was  absent, 
who,  "first,  in  Italy,  had  carried  into  operation"  this  potent 
modifier  of  diseased  organism.  Having  subsequently 
arrived,  he  read  his  important  memoir  on  ''Lypemania  Stu- 
pida  Ciirata  Colla  Trasfiisiouc  del  Sangue^'  exposing  that 
classic  case  treated  by  him  in  the  asylum  of  Reggio, 
probably  the  only  one  on  record,  with  safe  and  precise 
result;  he  also  presented  his  project  ''Villa  di  Sahitc'  for 
the  wealthy  insane ;  and  proposed  for  the  consideration 
of  the  next  Congress  of  alienists,  the  presentation  of  a 
theme    on  ''Asylum  Agricultural  Colonies!' 

In  the  school  of  which  he  was  the  master,  his  profound 
knowledge,  and  that  vigor,  so  distinctly  Italian,  with  which 
his  lectures  were  adorned,  will  not  be  forgotten.  He  did 
not,  however,  trust  himself  to  casual  improvisations,  nor 
did  he  seek  to  capture  the  attention  of  his  hearers,  by 
addressing  himself  to  their  imagination  rather  than  to  their 
reason  ;  on  the  contrary,  with  the  modesty  and  sincerity 
which  distingnish  great  minds,  he  followed  the  laudible 
custom  of  putting  on  paper,  his  principal  ideas,  adding 
to  them  accessory  and  pertinent  observations,  during  the 
course  of  delivery.  This  habit  of  Livi  proceeded  in  a 
great  measure  from  his  high  respect  for  form,  and  he  held 
to  it  in  both  the  investment  and  the  substance  of  his 
thoughts,  regarding  the  Italian  language,  when  its  powers 
are  understood,  as  adequate  to  the  expression  of  the 
nicest  modifications  of  thought,  as  well  as  of  the  experi- 
mental sciences.  His  language,  free  from  distortion  and 
pedantry,  was  simple  and  pure,  and  his  ideas,  thus  clothed, 
acquired  such  a  clearness  and  freshness,  as  to  show  to 
the  life,  all  the  serenity  of  his  intellect,  and  to  render 
partakers  of  it,  almost  unconsciously,  all  his  hearers ;  and 
thus  it  was  that  their  attention  was  held  captive  by  a 
two-fold  power,  and  that  his  instructions  proved  so  profit- 
able. We  know  not  how  otherwise  to  account  for  the 
fact,  that  he,  although  not  gifted  with  that  adapted  talent 
required  for  inprinting  on  science  imperishable  foot  prints 
by  original  discoveries  or  grand  doctrinary  systems,  yet 
had  the  merit  of  enamoring  so  many  youths  with  his 
beloved    science,     and    of     initiating     a    fruitful    practical 


232  Joseph  IForkman, 


and  scientific  movement,  which  must  commend  his  name 
to  posterity  better  than  that  of  many  superior  to  him  in  the 
novelty  of  their  researches,  and  the  individuahty  of  their 
conceptions.  It  is  the  fact,  that  Italian  psychiatry,  to 
him  at  last  was  indebted  for  its  organization,  its  ameliora- 
tion, and  we  may  say,  for  its  whole  moral  reconstruction, 
and  a  great  part  also  of  the  material  requirements  of 
insane  asylums.  The  asylum  of  Siena,  as  we  have  seen, 
owed  to  him  almost  everything ;  St.  Lazaro  of  Reggio 
had,  by  his  advice,  first  Za?ii,  and  three  and  a  half  years 
afterwards,  himself,  as  superintendent  ;  St.  Croce  di 
Macerata  was  enlarged  by  one  of  his  pupils,  and  was  re- 
made (in  discipline)  on  the  ideas  and  instructions  of 
Livi ;  in  the  provincial  asylum  of  Voghera,  next,  nothing 
was  undertaken  that  did  not  emanate  from  the  counsels 
and  opinions  of  our  master ;  finally,  it  is  to  be  recorded 
that  although  very  many  reforms  in  the  great  asylum  of 
Aversa  originated  in  the  natural  genius  and  happy  dispos- 
ition of  Dr.  Gaspare  Virgilio,  yet  not  a  few  were  b)^ 
this  last  friend  and  admirer  of  Livi,  derived  from  the 
asylum  of  Reggio.  From  all  this  it  must  be  apparent 
how  great  was  the  diffusion  of  the  ideas  of  our  master, 
and  how  great  has  been  the  good  effected  by  him,  for 
the  insane  of  Italy. 

As  regards  the  doctrinal  part  of  science,  whether  the 
school  founded  by  Livi  has  advanced  Italian  psychiatry, 
or  seeds  capable  of  germinating  to  useful  fruit  were  sown 
by  his  instructions,  it  pertains  not  to  us,  his  loving  pupils, 
to  speak;  yet  we  well  might  say,  that  the  teachings  of 
Livi  are  conspicuous  for  their  most  happy  eclectic  charac- 
ter, for  their  safe  direction,  and,  as  we  may  well  say, 
for  their  Galilean  exactitude.  His  school  was  really  of 
such  a  character  as  to  become  the  cradle  of  experimental, 
resting  on  logical  method  ;  it  was  not  scientifically  exclu- 
sive but  placing  above  all  authority,  experience  and 
observation,  as  "the  sole,  faithful  and  secure  interpreters 
of  nature,"  it  nevertheless  did  not  disdain  those  sympa- 
thetic conceptions  and  rational  doctrmes,  without  which 
the  vast  complex  of  the  humanly  knowable  would  run  on 
in  isolated  rivulets  unconscious  of  their  real  affinities,  not 
only  those  most  distant,  but  even  the  nearest ;  and  hence 
must  result  general  sterility.  Exclusivism  was  in  the 
estimation  of  Livi  a  defect ;  his  potent  genius  carried  him 
to  the  comprehension  of  vast  speculative  doctrines,  as  well 
as  to  minute,    and    sometimes,    (permit    us    the    word,)    to 


La  Menti  di  Carlo  Livi.  233 

emasculate,  analysis  of  specialization.  In  medicine,  as 
in  science,  he  has  himself  told  us,  there  must  be  specula- 
tors, divided  into  two  classes  :  "  the  first  is  of  those,  who, 
of  powerful  synthetic  genius,  but  also  learned  and  expert 
in  the  science  of  facts,  understand  how  to  rise  from  these 
to  certain  laws  governing  them  ;  which  laws,  if  they  do 
not  express  the  ultimate  reason  of  ideal  knowledge,  are 
yet,  to  him  who  duly  values  them,  the  ladder  of  ascent 
to  that  eminence."  To  this  class  Livi  belonged,  and 
certainly  not  to  the  other,  composed  of  daring  and  strong 
speculators,  who  are  richer  in  imagination  than  in  intellect, 
and  draw  their  inspirations  to  philosophise  on  nature,  not 
from  nature  herself,  but  from  their  own  brains.  Livi,  in 
short,  followed  in  the  steps  of  his  master,  Pticcinotti,  who, 
although  not  indulging  in  any  other  than  the  experimental 
philosophy,  yet  did  not  ignore  the  deductive  method. 
If  there  is  any  part  of  medical  science,  in  which  this 
eclecticism  of  method  is  useful  and  necessary,  it  is 
certainly  psychiatry,  whether  in  the  symptomatology  of 
insanity,  or  in  its  medico-forensic  applications. 

As  to  the  observance  and  the  diagnosis  of  mental 
maladies,  Livi,  educated  in  thfe  school  of  Buffalini,  did 
not  avail  himself  of  any  single  criterion,  it  being  impossi- 
ble, in  his  opinion,  to  define  any  form,  whatever,  of 
insanity,  basing  our  decision  on  an  isolated  and  exclusive 
series  of  phenomena,  and  conveniently  overlooking  all 
others.  Thus,  not  merely  from  physio-pathological  study 
of  the  patient,  but  still  farther  from  the  rational  valuation 
of  all  the  symptoms,  and  an  anamnestic  exigesis,  he  drew 
the  basis  of  those  admirable  expert  judgments,  which  may 
serve  as  the  applications  of  scientific  data  in  particular 
cases  of  forensic  psychiatry. 

In  the  life  and  genius  of  Livi,  yet  another  aspect 
would  merit  analysis  and  comment ;  and  that  is,  his 
position  as  a  medical  expert  in  the  tribunals,  and  a  psy- 
chological obser\''er  in  his  relations  to  that  most  harmful 
of  human  aberrations — crime.  On  another  occasion  we 
shall  speak  of  his  influence  on  the  doctrinal  evolution  of 
forensic  cerebralism,  to  which  he  contributed  by  labors, 
highly  applauded  abroad,  and  by  publications  of  numerous 
important  cases.  Accepting  the  onerous  duty  of  reporting 
-on  the  doubtful  mental  state  of  delinquents,  or  of  the 
criminal  insane  (an  undertaking  often  very  difficult  and 
always  very  weighty),  Livi  had  a  most  elevated  concep- 
tion of  the  responsibility  resting  upon  him  in  the  presence 


234  Joseph  Workman, 


of  justice  and  of  science,  and  of  solving  to  the  very 
bottom,  the  problem  of  imputability ;  therefore,  he  never 
tired  in  investigating,  in  the  most  acute  and  profound 
manner,  all  the  phenomena  of  the  mind  led  astray  by 
insanity  or  by  passion.  Expertly  cognizant  of  the  human 
heart,  he  possessed  a  singular  keenness  of  perception  in 
his  psychological  examinations,  and  an  exquisite  analytic 
faculty  in  his  interpretation  of  the  less  prominent  symp- 
toms of  mental  alterations.  Taught  by  long  habit,  he 
discovered  in  the  insane,  better  than  in  the  sane,  certain 
lurking  places  of  the  soul,  and  it  was  his  daily  study  of 
the  psychical  anomalies  which  led  him  to  contend  with 
so  much  ardor,  and,  for  psychological  reasons,  for  the 
abolition  of  capital  punishment ;  not  indeed  that,  as  might 
be  with  others,  his  long  residence  among  the  insane,  and 
his  knowledge  of  their  morbid  impulses,  had  rendered  him 
prone  to  justify  too  often  criminal  acts  ;  on  the  contrary, 
if  there  was  any  forensic  cerebralism  in  which  he  excelled, 
it  was  in  his  most  sagacious  detection  of  all  simulations, 
however  artfully  exhibited.  Profound,  secret  and  impene- 
trable did  he  regard  the  masterhood  of  the  intellectual 
functions,  and,  hence,  so  much  the  more  in  his  observa- 
tions of  cases  of  forensic  psychology,  did  he  exercise  his 
searching  powers,  testing  the  entire  organism  of  the 
accused,  and  bit  by  bit  exploring  the  whole  psychical 
mechanism  which  he  had  before  him ;  in  such  arduous 
and  patient  investigations  he  was  unsurpassable.  In  his 
view,  it  is  required  of  medicine  not  alone  to  heal  and 
cure  the  infirm  man,  but  in  her  application  to  juridical 
science,  she  must  protect  and  defend  him  in  his  rights ; 
therefore,  two  sacred  duties  are  to  be  obeyed  by  the 
medical  legist — that  of  the  scientist  and  that  of  the  citi- 
zen. Of  this  profound  conviction  and  sincere  sentiment 
of  responsibility.  Carlo  Livi  became  the  victim  at  the 
yet  green  age  of  54  years.  It  was  the  year  1877,  and 
never,  perhaps,  had  brighter  days  shone  on  his  life  ;  glory, 
famiK',  affections,  position,  esteem  and  universal  respect, 
all  smiled  on  him,  and  the  rigid  and  powerful  force  of  his 
intellect  and  his  vigorous  constitution,  seemed  to  promise 
to  him  other  rewards,  more  ample  and  well  merited,  of 
his  hard  labors.  But  in  the  May  of  that  year  he  was 
summoned  to  Livorno,  as  an  expert,  in  a  very  important 
case.       Whether    it    was    that    the    organic    fibre,    though 

\^To  be   Contiiiiud.] 


Selections.  235 


CLINICAL    AND    NECROSCOPIC    ILLUSTRATIONS 
OF  LOCALIZED  BRAIN  DISEASE. 

Tumor  of  the  Pons  Varolii. — Last  year,  Dr.  Hirsch- 
berg  reported  in  the  Berliner  Medizinhch  PsycJiolgiscJi 
Gesellschaft,  the  case  of  a  child  three  years  old,  presenting 
paralysis  of  the  left  oculo-motor,  paresis  of  the  right 
oculo-motor  of  the  right  facial,  and  slight  paresis  of  the 
right  and  lower  extremities,  visual  disturbances,  bilateral 
choked  papillae. 

He  diagnosed  a  tubercular  neoplasm,  mainly  implicat- 
ing the  left  half  of  the  pons  Varolii.  After  five  months 
there  were  contractures  of  both  right  extremeties  with 
coreiac  movements,  both  oculo-motors  were  paralyzed, 
the  left  especially,  with  bilateral  atrophy  of  the  optic 
nerve. 

There  was  no  disturbance  of  the  sensorium.  The 
autopsy  showed  a  yellow,  hard  tubercle,  the  size  of  a 
walnut,  in  the  left  half  of  the  corpora  quadrigemini, 
extending  over  to  the  pons  Varolii. 

A  Suggestive  Case  of  Hemiplegia  and  Aphasia  with 
Autopsy — Dr.  A.  A.  Henske,  physician  to  the  hospital  of 
the  Little  Sisters  of  the  Poor,  of  this  city,  reported  to  the 
St.  Louis  Medical  and  Surgical  Journal,  for  November,  1879, 
the  case  of  an  Irish  railroad  laborer,  who  had  been 
struck  on  the  left  side  of  the  head  by  an  iron  bar,  causing 
unconsciousness  for  several  days.  On  the  return  of 
consciousness,  complete  motor  and  partial  sensory  paral- 
ysis, wdth  aphasia,  were  revealed.  When  the 
patient  first  came  under  Dr.  H's  observation,  Sept.,  'yj, 
the  only  word  he  could  utter  was  "?2^,"  which  he  used 
both  for  affirmation  and  negation.  His  intellect  seemed 
clear,  and  he  made  himself  understood  by  nodding  or 
shaking  the  head  and  by  gesticulating  with  his  left  hand 
His  facial  expression  was  intelligent  and  impressive 
When  asked  his  age,  and  an  incorrect  number  of  years 
were  named,  he  said  ''no"  accompanied  by  a  negative 
turning  of  the  head;  but  when  the  correct  number  of  years 
were  mentioned,  he  responded  ''no^'  with  an  affirmative  nod. 

Within  the  last  two  years  his  vocabulary  increased 
considerably.  He  learned  to  say:  ''yes,  water,  milk,  God 
damn,  left  him  alone  (meaning,  let  him  alone),  etc." 

The  paralysis,  however,  gradually  increased ;  the  patient 
grew  apathetic  and  imbecile,  had  nocturnal  epileptic  par- 
oxysms, with  loud  screaming  spells ;  defecated  involuntarily ; 


Selections. 


had  extensive  bedsores  ;  and,  on  the  9th  of  October,  1879, 
he  became  comatose,  and  on  the  next  day  he  died.  His 
age  was  59  years. 

He  had  no  rheumatism  or  organic  heart  disease. 

The  autopsy  revealed  softening  of  part  of  the  middle 
and  posterior  portion  (second  and  third  convolutions)  of 
the  left  anterior  lobe  and  of  the  anterior  portion  of  the 
left  middle  lobe  of  the  brain.  The  convolutions  of  the 
Island  of  Riel  were  destroyed,  and  the  left  corpus  stria- 
tum was  also  affected.  The  softened  brain  substance  had 
the  appearance  of  a  thick,  yellowish,  creamy  liquid. 
Other  parts  of  the  brain  appeared  normal.  There  was  no 
fracture  nor  depression  of  the  skull,  but  the  scalp  over 
the   affected  region  was  cicatrized. 

[We  saw  this  patient  several  weeks  before  his  demise, 
and  noticed  the  improvement  in    his  vocabulary. 

In  fact,  the  man  had  learned  to  speak  before  the  fatal 
change,  much  better  than  would  be  inferred  from  Dr. 
Henske's  brief  description,  and  much  better  than  can  pos- 
sibly be  explainable,  in  view  of  the  fatal  sequel  and  the 
destructive  cerebral  changes  in  the  brain  which  undoubt- 
edly led  to  it,  without  assuming  the  gradual  education  of 
the  opposite  speech  center  to  the  performance  of  a 
vicarious  function  in  the  co-ordination  of  verbal  express 
sion.  We  then  carried  on  quite  a  satisfactory  conversation 
with  this  patient,  in  which  he  gave  his  name,  named 
several  things  he  liked  to  eat,  and  some  that  he  disliked  ; 
told  how  long  he  had  been  in  the  hospital,  where  he  was 
born,  and  with  some  verbal  assistance  and  prompting  from 
us,  gave  something  of  his  life's  history  besides. — Ed.] 

Soft  Gliom.v  of  the  Pons  and  Cerebellum — In  the 
practice  of  Dr.  Voorhies,  and  reported  with 
other  cases  of  cerebral  disease  by  Dr.  J.  H.  Mackenzie, 
in  the  Cincinnati  Lancet  and  Clime  of  Feb.  14th,  occurred 
an  interesting  case  of  the  above  disease,  the  essential 
facts  of  which  we  here  transcribe.  The  patient  was  a 
boy  aged  eight  years,  who,  when  finst  seen  by  Dr. 
Voorhies,  had  pain  in  the  back  of  his  head,  ptosis  of  the 
left  eyelid,  unsteady  gait,  mouth  drawn  to  the  left  side 
and  vomited  after  eating.  His  pulse  and  bowels  were 
regular,  and  his  appetite  was  good.  There  was  no  anaes- 
thesia on  the  side  of  the  face.  Head  inclined  to  the  left  side. 
Sitting  near  his  mother,  he  suddenly  fell  into  her  lap, 
and  when  helped  up,  he  trembled  greatly  and  could  not 
stand.       Vomiting    and    evacuation  of  the  bowels  followed, 


Selections.  23V 


after  which  he  rallied.  Three  days  subsequently,  a  sim- 
ilar attack  occurred,  from  which  he  again  rallied,  but 
was  clumsy  in  his  movements,  without  appreciable  intellect- 
ual impairment.  At  school  he  had  darting  pains  in  his 
head,  often  vomiting  without  apparent  cause,  and  grasped 
things  with  difficulty  with  his  left  hand.  A  week  later, 
the  symptoms  were  somewhat  aggravated  pulse,  80  ptosis ; 
of  7-ight  eye,  none  in  left.  Three  weeks  after  Dr.  V.  first 
saw  him,  his  condition  was  much  worse. 

His  countenance  had  a  silly  expression,  and  his  mental 
capacity  appeared  like  that  of  a  boy  three  or  four  years 
old.  He      was    garrulous,     and    his     articulation       was 

thick  and  drawling,  but  he  seemed  to  understand  anything 
that  was  said  to  him.       He  was  playful  and  cheerful. 

Three  weeks  after  Dr.  Voorhies  first  saw  him.  Dr. 
Mackenzie  reports,  that  : 

The  special  senses  were  not  impaired,  and  f^eneral  sensibility  of 
limbs  seemed  normal.  Ej'es  moved  equally,  the  pupils  were  normal, 
no  strabismus.  Xo  absolute  paralysis  anywhere.  The  movements  of  the 
limbs  were  quite  feeble,  particularly  the  left  hand.  He  could  neither 
walk  nor  stand,  and  his  head  seemed  too  heavy  for  the  muscles  supporting 
it.  Ophthalmoscopic  examination  of  the  fundus  of  the  eyes  showed 
nothing  abnormal,  heart  sounds  were  healthy,  pulse  80,  with  fair  force, 
and  temperature  normal. 

He  finally  became  quite  helpless  and  remained  in  bed,  amusing  himself 
with  his  toys.  His  appetite  was  good  but  he  did  not  sleep  well ;  intelli- 
gence was  about  as  before.  Memory  good,  articulation  indistinct ;  left  hand 
helpless.  Some  power  in  left  foot ;  strabismus  in  right  eye ;  left  pupil 
dilated;  ptosis  of  right  eyelid  ;  on  right  side  of  face  some  anaesthesia;  lies 
most  of  the  time  on  left  side;  suffers  pain  ia  the  back  of  head  to  the  right 
of  median  line ;  pulse  72,  irregular  and  slower  ;  temperature  in  right 
axilla  98.4°  sudamina  over  breast  and  abdomen.  For  the  last  week  of  his 
life  he  had  complete  anaesthesia  on  the  right  side  of  his  face  and  left  arm. 
Kept  his  right  foot  in  motion  most  of  the  time.  Until  within  two  days  of 
death  his  appetite  continued  good  ;  his  intellect  and  memory  about  as 
before.  Two  days  before  death  his  pulse  increased  in  frequency  to  120, 
his  right  foot  was  in  constant  motion,  articulation  became  so  imperfect 
that  he  could  not  be  understood,  though  he  seemed  to  understand.  He 
died  on    the  10th  of  February. 

Dr.  Voorhies  removed  the  brain  and  found  disease  of  the  pons  Varolii, 
which  pare,  together  with  the  medulla  oblongata,  he  sent  to  Dr.  Alacken- 
zie.    The  rest  of  the  brain  was  quite  normal. 

The  right  side  of  the  pons  Varolii  was  much  larger  than  the  other  and 
very  soft,  so  that  it  flattened  out  from  its  own  weight.  The  mass  was  dif- 
fluent and  white.  The  softening  involved  the  whole  of  the  right  side  of  the 
cerebrum  to  the  medulla  oblongata,  and  extended  along  the  middle 
peduncle  for  some  distance  into  the  right  hemisijhere  of  the  cerebellum. 


Selections. 


The  fifth  nerve  could  uot  be  tiaced  into  tlie  mass  any  distance.  The 
arteries  of  the  membranes  ^vere  not  diseased. 

Microscopical  examination  disclosed  round  and  o\a\  cells  embedded  in 
a  ofranular  stroma.  Few  of  them  were  distinctly  nucleated  ;  most  of  them 
contained  granular  contents,  'ihe  round  cells  averaged  1-3000  of  an 
inch  in  diameter,  the  oval  cells  1-lOCO  of  an  inch  in  their  long  diameter. 
The  growth  was  by  no  means  deficient  in  vessels,  and  the  vessel-walls 
were  in  many  places  clearly  implicated  in  the  morbid  process,  containing 
distinct  oval  cells. 

This  was  a  case  of  soft  glioma  of  the  pons  Varolii  and  cerebellum.  The 
case  is  interesting,  from  the  comparative  rarity  of  this  form  of  glioma,  and 
its  uncommon  seat.  The  symptoms  were  somewhat  distinctive,  the 
unsteadiness  of  gait,  persistant  vomiting  (although  that  is  not 
an  infrequent  symptom  of  tumors  situated  elsewhere)  and  the  anaesthesia 
of  the  right  side  of  the  face  all  rather  pointed  to  the  pons  and  cerebellum 
A  curious  feature,  in  the  historj',  is  the  changenbleness  ol  some  of  the 
symptoms  :  when  first  seen  there  was  ptosis  of  the  left  eve.  then  of  the 
right  eye.  In  January  there  was  no  ptosis  at  all :  and  the  same  variability 
was  observed  in  regard  to  the  strabismus. 

[A  case  similar  to  the  above  appears  in  a  recent  number  of  Brain. 
the  Xew  English  Journal  of  Neurology. — Ed.] 


FOUR  NEW  CASES  OF  ATHETOSIS.— .5j'  A.  Brousse. 

The  first  two  cases  were  cases  of  so-called  hemi- 
athetosis.  In  both,  cerebral  atrophy  of  childhood,  hemi- 
plegia of  left  side,  and  hemiathetosis  of  left  hand  were 
present ;  the  second  was  subject  to  epileptiform  attacks. 
They  were  distinguished  from  post-hemiplegic  chorea, 
essentially,  only  by  the  slowness  of  the  inv^oluntary 
movements,  and  the  restriction  of  these  movements  to 
the  hand  and  foot.  In  the  third  case,  one  of  double 
athetosis — which,  according  to  Oulmont,  alone  deserves  the 
name — cerebral  atrophy  and  idiocy  were  noted.  All  four 
extremities  participated  in  the  movements.  In  the  fourth 
and  last  case,  the  face  and  neck  also  exhibited  the 
characteristic  movements,  which  alternated  with  contrac- 
tion of  the  knees  and  joints  of  the  feet. 

The  author  came  to  the  following  conclusions: 

I.  Athetosis  is  a  symptom  that  may  present  itself 
clinically  quite  differently. 

II.  Whether  single  or  double-sided  it  shows  great 
likeness  to  chorea,  of  which  it  may  be  considered  a  variety. 
(See  Bournevillc,  Charcot,  v.  Fetzcr  II.  Abth.  IV.  Theil. 
Reporter.) 

III.  Transitions  between  typical  athetosis  and  chorea 
are  seen. 


Selections. 


IV.  Athetosis  occurs  in  more  or  less  completely  differ- 
ent forms.     Three  principal  forms   may  be  distinguised  : 

I. —  Typical  Form.  Involuntary  movements  persisting 
during  rest.  2. — Incomplete  complicated  form.  Involun- 
tary movements  only  at  intervals,  or  simultaneously  with  vol- 
untary movements.  3. — Mixed  or  transition  foim.  With 
the  movements  of  the  extremities  are  associated  movements 
of  the  face,  neck,  and  even  other  parts  of  the  body. 
(Compare  with  this  exposition  the  report  of  Dehn,  in 
Centralblatt,  Nro.   22,  1879,   Reporter.) 

V.  There  exists  an,  as  yet,  unexplained  relation 
between  cerebral  athrophy  and  athetosis.  Goldstein. 
Aachen. — (Extracted  from  Montpellier  Medical,  1879,  and 
translated  into  German  in  Centralblatt  fuer  Nervenheilhmde, 
Psychiatric  und  Gerichtliche  Psrchopathologie.) — Dean. 


CONTRIBUTION  TO  THE  PATHOLOGICAL  ANAT- 
OMY OF  CHOREA.— 57  DR.  C.  EISENLOHR,  of 
Hamburg. —  Translated  by  Dr.  D.    V.  Dean. 

During  my  service  in  a  general  charity  hospital,  I  had 
an  opportunity  to  make  a  necropsy  in  a  case  of  chorea 
in  which  the  central  nervous  system — specifically  the 
spinal  cord — furnished  a  positive  lesion.  The  case  was 
that  of  a  fourteen-year-old  girl,  whose  chorea,  according 
to  the  positive  accounts  of  her  mother,  was  congenital. 
The  child  had,  from  birth,  exhibited  characteristic  choreic 
movements  of  the  muscles  of  the  face  and  head,  and  had 
learned  only  lately  to  walk,  and  imperfectly,  but  was  of 
passably  good  physical  and  mental  development.  During 
a  prolonged  stay  in  the  hospital  during  '75  and  f6,  the 
intensity  of  the  choreic  movements  was  much  mitigated, 
and  locomotion  and  speech  were  considerably  improved. 
The  abnormal  movements  of  the  extremities  in  no  way 
differed  from  those  of  ordinary  chorea  minor,  and  the 
grimacing  of  the  face  continued.  No  paralysis.  The 
heart  was  normal  and  the  pulse  always  regular.  In  the 
year  1877,  during  a  long  residence  of  the  patient  at  home 
under  unfavorable  circumstances,  she  had  marked  exacer- 
bations of  the  choreic  movements  of  the  upper  extremities, 
and,  at  the  same  time,  strong  contractions  of  the  lower 
extremities  set  in.  There  were  adduction  of  the  thighs 
and  flexion  of  the  legs,  so  that  the  knees  were  drawn 
together  with  great  force,  pressing  against  each  other, 
and  walking  or  standing  was  absolutely  impossible.     Passive 


240  D.  V.  Dean. 


resolution  of  the  contractions  caused  considerable  pain. 
In  the  Fall  of  1877,  while  patient  was  suffering  from 
remittent  fever,  ulcerous  pneumonia  set  in,  running  a 
quick  course  and  followed  by  breaking  down  and  by- 
intestinal  tuberculosis ;  and,  in  the  course  of  a  few 
months,  she  succumbed.  On  section,  the  brain  presented, 
macroscopically,  nothing  abnormal.  In  the  cord,  after 
artificial  hardening,  a  sclerotic  fleck  was  found  in  the 
right  lateral  column  of  the  cervncal  portion,  having  its 
greatest  area  at  the  level  of  the  third  cervical  nerve. 
Here  the  right  postero-lateral  column  was  visibly  slimmer 
than  the  left.  In  a  carmine  preparation,  the  part  imme- 
diately bordering  upon  the  base  and  the  lateral  border  of 
the  posterior  cornu,  extending  nearly  to  the  middle 
of  the  lateral  column,  was  intensely  colored,  the  anterior 
half  of  the  column  remaining  quite  free.  The  external 
boundary  of  the  degenerated  part  was  not  very  sharp, 
but  ran  out  in  numerous  processes  along  the  radiations  of 
the  pia.  The  processes  that  lay  mostly  along  side  the 
posterior  roots,  bending  outward,  seemed  to  pass  into 
them.  The  posterior  roots  and  posterior  cornu,  with  the 
rest  of  the  transverse  section  of  the  cord,  were  entirely 
normal.  The  changed  part  was  characterized,  histologi- 
cally, by  a  marked  thickening  of  the  neuroglia  network 
with  narrowing  of  the  meshes,  nearly  complete  disappearance 
of  the  medullary  sheaths  and  axis-cylinders — which  in 
only  isolated  cases  were  visible  in  the  sclerotic  tissue — and 
by  great  development  of  Deiter's  cells.  The  vascular 
walls  did  not  appear  to  be  changed,  and  there  were  no 
corpora  amylacea  or  granular  cells.  Upward  as  well  as 
downward  from  the  third  cervical  nerve,  the  degeneration 
rapidly  decreased.  At  the  level  of  the  fourth  cervical 
nerve,  in  the  postero-lateral  column,  there  appeared,  also, 
a  triangular  fleck,  which  was  separated  from  the  posterior 
cornu  by  the  intact  processus  reticularis.  The  nerve 
fibres  were  almost  entirely  wanting  in  this  spot.  In  the 
region  of  the  fifth  and  of  the  sixth  cervical  nerve,  the 
sclerotic  portion  turned  somewhat  more  toward  the 
periphery,  and  contained  only  a  few  nerve  fibres  in  the 
transverse  section,  and,  at  the  eighth  cervical,  there  was  not 
a  trace  of  the  degenerated  part  left.  The  changes  ceased 
entirely  at  the  first  cervical  nerve.  Passing  on  to  the 
medulla  oblongata  there  was  nothing  abnormal  observable, 
and  the'  oblongata  itself,  as  also  the  pons, — especially, 
the  pyramids  and  the  longitudinal  fibres  of  the  pons, — was 


Selections.  241 


entirely  normal.  In  the  dorsal  and  lumbar  portion,  no 
change,  whatever,  could  be  seen.  The  trunk  of  the 
right  nervus  ischiaticus  was  examined  in  transverse 
sections,  and  nothing  peculiar  found.  It  is  apparent 
enough,  from  the  foregoing  description,  that  the  change 
in  the  cord  was  a  true  sclerosis,  and  did  not  belong  to 
the  category  of  connective-tissue  proliferation  described 
by  Ellis,  and  so  thoroughly  corroborated  by  Fr.  Schultze 
(D.  Arch.  f.  Klin  Med.  XX.  Bd.). 

As  regards  the  connection  between  the  anatomical 
changes  found,  and  the  phenonema  of  the  chorea  during 
life,  it  IS  to  be  remarked,  that  the  former  can,  in  no  way, 
be  considered  a  sufficient  cause  for  the  latter.  To  be 
sure,  the  alteration  in  the  cord  is,  by  no  means,  without 
significance  in  the  chorea  existing  from  birth,  but  it  belongs 
to  a  series  of  grosser  anatomical  lesions,  whose  connection 
with  the  especially  characteristic  spasms  is  not  plain, 
either  as  to  their  histological  nature,  or  as  to  their  locality. 
I  am  strongly  inclined  to  think  the  changes  in  the  cord 
are  congenital,  the  residue  of  a  foetal  inflammatory  process, 
though  I  can  furnish  no  positive  proof  of  the  fact.  How- 
ever, I  may  cite  a  strikingly  analagous  case  of  Fr. 
Schultze's,  of  a  sclerotic  focus  found  in  the  left  lateral 
column  of  the  upper  cervical  portion  of  the  cord,  in  a 
child,  twenty  months  old,  that  had  suffered  an  attack  of 
tetanus,  with  spasms  of  the  glottis,  which  change  Schultze 
looked  upon  as  congenital  (6V;//r«/<^/a//,  1878,  Nro.  8).  And 
Kahler  and  Pick  have  reported  a  similar  case  of  a  scle- 
rotic fleck  in  the  left  lateral  column  of  the  upper  cervical 
portion  of  the  cord  in  a  syphilitic  child  (Prag.  V.  J.  S.  Y. 
142.  Band  1879).  I'^  another  place  (ibid.  Nro.  VII,  S. 
25),  they  express  the  opinion,  based  on  two  cases,  that  in 
severe  cases  of  chorea  the  white  substance  of  the  cord 
shows  decided  changes  of  the  nerve  fibres.  As  may  be 
seen,  this  agrees  with  what  I   found. 

I  add  a  remark,  pertaining  to  the  patholygy  of  chorea, 
concerning  the  arrhythmia  of  the  pulse,  in  connection 
with  this  disease,  as  reported  by  some  authors,  since  this 
anomaly  is  not  confirmed  by  some  recent  observers,  and  is 
thought  by  them  to  be  a  very  rare  occurrence  (v.  Ziems- 
sen.  Chorea,  in  s.  Handbuch  XII.  2,  S.  415).  As  against 
some  twenty  cases,  under  my  observation,  that  were  not 
complicated  with  heart  affections,  I  had  opportunity  in 
three  cases  to  observe  an  exquisite  irregularity  of  the 
pulse  for    a    considerable    period    of  time,    this    irregularity 


242  Selections. 


ceasing  with  the  recovery  from  the  chorea.  That  this 
arrhythmia  cannot  be  ascribed  wholly  and  solely  to  the 
disturbance  of  circulation  caused  by  the  spasmodic 
muscular  contraction,  is  shown  by  the  circumstance,  that 
in  other  cases  of  more  intense  character,  this  irregularity 
did  not  exist.  Accordingly,  chorea  of  the  heart  is  not 
so  exceedingly  rare. —  Centralblatt  fuer  Nervcnheilknnde 
Psychiatrie  und  Gerichtliche  Psychopathologie,  Hamburg, 
Dec.  22,   1879. 


Case  of  Bloody  Sweat. — At  the  last  meeting  of  the 
King  William  County  Medical  Association,  Dr.  R.  G. 
Hill  reported  an  interesting  case  of  "bloody  sweat,"  the 
subject  being  a  boy  four  years  of  age,  suffering  from 
malarial  fever.  During  each  sweating  stage,  blood  oozed 
from  the  face  and  neck.  Febrifuges,  followed  by  quinine, 
afforded  rehef;  but  two  months  later  he  was  taken  with 
hemorrhage  from  the  alimentary  canal,  accompanied  with 
both  vomiting  and  purging  of  blood,  from  which  he  died. 
No  autopsy  was  made. —  Va.  Med.  Montldy. 


A    RARE  FORM    OF    NEUROSIS. 

In  the  transactions  of  the  Psychical  Society  at  their 
meeting  in  Berlin,  March  15,  1879,  Boettcher  relates  the 
following  :  A  middle-aged  man  got  a  fall  upon  the  back 
of  his  head,  which,  however,  did  not  cause  him  to  lose 
consciousness.  Immediately  after  the  accident,  his  voice 
acquired  a  falsetto  tone,  but  it  could  be  brought  back  to 
its  natural  pitch  by  making  pressure  upon  the  spot  on  the 
occiput  on  which  he  fell.  Nothing  abnormal  could  be 
discovered  by  lar>'ngoscopic  examination.  The  gentlemen 
present  declared  that  it  was  impossible  to  give  a  definite 
opinion  as  to  the  anatomical  cause  of  the  phenomenon  in 
this  case.  Dr.  Sander  advised  that  continuous  pressure 
be  made  upon  the  injured  spot. — [Allgcmeinc  Zcitschrift  fucr 
Psychiatrie,  Band   36,   Heft  5.) — Saunders. 


Choleric  Convulsions  in  New-Bokn  Child. — Dr.  Coles 
reported  the  following  case:  I  have  a  case  of  a  child 
who  had  chorea  of  the  muscles  of  the  forearm  and  hand, 
and  was  so  affected  at  the  time  of  birth.  I  am  satisfied 
that  this  condition  of  the  hand  is  in  some  way  related  to 


ERRATA. 


On  Page  242  read  '' Choreic"'  for  -Choleric.'-  and  on  Page  258  add 
the  words,  ''Aoents  of  l^eurotic." 


Selections.  243 


that  class  of  deformities  which  we  meet  with  in  talipes 
varus.  (This  child  has  talipes  varus  in  one  foot.)  When 
it  is  asleep  its  hands  are  perfectly  natural,  but  if  you 
wake  it  up  and  touch  the  hand,  it  immediately  assumes 
this  position  (the  doctor  illustrated  the  position),  and  its 
fingers  become  twisted — evidently  a  choreaic  spasm  of  the 
fingers.  The  hands  are  affected  alternately.  The  child 
is  about  three  weeks  old. — Procedings  of  the  St.  Louis 
Obstetrical   and    Gynecological  Society,  Jan.  i^tJi,  1880. 

Cerebral  and  Ocular  Disorders  in  the  Inebriated. 
This  form  of  disease  of  the  eye  appears  as  a  sequel  to 
cerebral  congestion  after  exposure  to  cold,  especially 
among  drunkards. 

An  intoxicated  person  exhibited  grave  cerebral  symp- 
toms after  prolonged  exposure  to  excessive  cold;  he 
remained  forty-eight  hours  unconscious,  and  when  the 
meningeal  symptoms  disappeared,  an  incomplete  paralysis 
of  the  third  pair  was  noted.  —  [Gazette  Hebdoni.)  — 
St.  Louis    Courier  of  Medicine. 


Sodiety  of  Siology. 


Section  of  the  Posterior  Columns  of  the  Spinal  Cord. — 
M.  Laborde  Concludes  that  their  Functions  are 
U^K^ow^.—  Translatid  by  E.  M.  Nelson,  M.  D. 
M.  Laborde  remarked  that  young  cats,  still  nursed 
by  their  mothers,  are  wonderfully  adapted  to  experi- 
ments upon  the  spinal  column ;  the  spinal  column 
may  be  opened  to  a  considerable  extent  without  their 
seeming  very  much  affected.  In  an  animal,  in  these 
conditions,  M.  Laborde  has  been  able  to  divide  the 
posterior  columns,  and  afterward,  enough  time  passed  to 
make  sure  that  the  section  affected  only  these  cords  and 
that  the  rest  of  the  cord  was  intact.  The  cat  never 
presented  any  trouble,  either  of  sensibility  or  motility. 
A  slight  degree  of  ataxia  of  movement  followed  the 
operation  and  rapidly  disappeared.  The  animal  is  still 
living  to-day,  eight  months  after  the  experiment.  The 
functions  of  the  posterior  cords  are  then  still  unknown. 
At  a  subsequent  meeting,  M.  Laborde  called  to  mind  the  fact 
that  he  has  already  shown  to  the  Society,  a  cat,  in  which 
he  cut  the  posterior  cords  of  the  spinal  cord  ten  months  ago. 


M4  E.  M.  jYelson. 


and  in  which  sensibility  never  has  been  altered  ;  a  second 
animal,  in  which  section  of  the  grey  axis,  added  to  that  of  the 
posterior  cords  has  produced  ajicesthesia  of  the  lower  limbs. 
He  presents,  to-day,  a  "cobaye"  paraplegic  after  section 
of  the  antero  lateral  cords,  but  whose  lower  limbs  have 
preserved  their  sensibility  intact.  M.  Laborde  insists  upon 
the  clearness  of  the  results  of  this  triple  experimentation, 
the  operative  details  of  which  have  been  watched  with  the 
most    scrupulous    care. 

Atrophy  of  Papilla  of  the  Optic  Nerve  Following 
Traumatism. — M.  Galesowski,  Nov.  29th,  1879. — Papillary 
atrophy  may  be  consecutive  to  a  traumatism,  and  simulate 
the  atropliy  zuhich  accompanies  progressive  locomotor  ataxia. 
Sometimes  this  atrophy  succeeds  injuries  of  the  cranium, 
which  have  set  up  meningitis  and  optic  neuritis,  sometimes 
it  results  from  the  presence  of  foreign  bodies  in  the  orbit ; 
finally,  in  a  third  series  of  cases,  it  supervenes  long  after 
the  injury.  In  these  cases,  the  loss  of  sight  has  been 
immediate,  and  yet,  the  lesions  revealed  by  the  opthalmo- 
scope,  have  only  appeared  later.  We  may  explain  this 
course  of  affection  by  supposing  that  the  optic  nerve  has 
been  bruised  or  torn  at  the  level  of  the  optic  foramen,  by 
fracture  of  the  top  of  the  orbit.  At  this  point,  the  central 
artery  of  the  retina  has  not  yet  penetrated  into  the  nerve. 
There  is  then  no  reason  why  the  circulation  of  the  fundus 
of  the  eye  should  be  immediately  disturbed,  and  atrophy 
develops  gradually  in  the  nerve  separated  from  the  nerve 
centers.  In  some  cases,  after  two  or  three  years,  papillary 
atrophy  takes  place  on  the  opposite  side,  consecutively  to 
the  atrophy  of  traumatic  origin  of  one  papilla. 

M.  Magnan  asked  if  in  these  cases  of  bilateral  atrophy, 
the  hereditary  antecedents  of  the  patients  observed,  had 
been  carefully  investigated,  and  ^I.  Laborde  cites  the 
case  of  a  man,  in  whom  atrophy  of  the  two  papillae  has 
been  consecutive  to  an  injury  of  the  eye,  but  whose  sister 
has  presented  the  same  lesions  without  our  being  able  to 
attribute  them  to  any  exterior  cause.  M.  Hallopeau 
observed  that  the  ocular  troubles  sometimes  precede  by 
ten  or  twenty  years  the  other  symptoms  of  ata.xia.  The 
facts  cited  by  M.  Galezowski  have  importance  with  refer- 
ence to  the  etiological  value  of  traumatism,  only  if  the 
subjects  are  followed  during  a  long  time ;  as,  otherwise, 
the  traumatism  may  be  the  cause  of  an  ataxia  com- 
mencing with  the  papillary  troubles ;  finally,  if  the 
opinions     of    M.    Galezowski     are    correct,    the    pearl-like 


Society  of  Biology.  245 


atrophy  of  the  papilla  loses  its  diagnostic  value  in  locomotor 
ataxia. 

A  New  and  Important  Discovery  Concerning  the 
Auditory  Nerve. — The  Sense  of  Space. — By  M.  Duval. 
— At  the  Feb.  2ist  session,  says  Le  Progres  Medicalc,  M. 
Mathias  Duval  presented  to  the  society  an  important 
anatomical  fact,  which  he  believes  that  he  has  discovered 
in  the  course  of  his  researches  upon  the  origins  of  the 
cranial  nerves.  It  relates  to  the  origin  of  the  auditory 
nerve  ;  according  to  M.  Duval,  the  auditory  nerve  has  two 
quite  distinct  roots,  the  posterior  one  proceeding  from  a 
nucleus,  described  by  all  authors,  the  other,  anterior, 
proceeding  from  a  nucleus  for  motor  fibres.  Some  fibres 
of  the  anterior  root  turn  back  into  the  cerebellum.  Now, 
we  know  that  the  cerebellum  is  the  center  for  the  co- 
ordination of  movements. 

In  associating  this  anatomical  fact  with  the  physiologi- 
cal researches  of  M.  de  Cyon,  upon  the  sense  of  space, 
and  with  some  pathological  facts,  tending  to  prove  that 
vertigo  has  for  a  cause,  a  lesion  of  the  semi-circular 
canals,  M.  Duval  concludes  that  the  anterior  root  of  the 
auditory  nerve  forms  the  ner-oe  of  space,  of  which  the 
semi-circular  canals  are  the  peripheric  organs. — Gazette  Heb- 
domedaire,   Nov.  21st,  Dec.  §th  and  ijth. 


Si|atoir)ical    Society 


Absence  of  Characteristic  Symptoms  of  Tumor. — Cere- 
bral Tumor. — Right  Hemiplegia. — Aphasia. 

On  January'  13th.  1879,  entered  at  La  Pitie,  ward 
St.  Athanase,  No.  34,  service  of  M.  Gallard,  a  locksmith 
named  Pierson,  aged  57  years,  in  whom  was  no  syphilitic 
or  alcoholic  antecedents,  and  who  says  he  has  always  been 
well.  Three  or  four  days  ago  only,  he  perceived  that  he 
could  not  move  as  easily  as  usual  the  fingers  of  his  right 
hand  ;  then  he  noticed  that  the  leg  on  that  side  could  no 
more  sustain  him  as  previously. 

When  he  entered  the  hospital  there  was  determined  a  right 
hemiplegia,  much  more  marked  in  the  upper  extremity  than 
in  the  lower.  The  patient  can  still  walk  alone.  Right 
facial  hemiplegia  ;  no  trouble  of  speech  ;  no  contractions  ; 
sensibility  is  a  little  diminished  on  the  right  side. 

Patient  says  that  he  has  had  no  headache  ;  that  he  has 


:^46  F.  M.  Aelson. 


never  vomited,  nor  has.  he  ever  had  any  loss  of  conscious- 
ness which  might  be  Hkened  to  epileptiform  attacks.  There 
is  no  trouble  of  vision,  nor  deviation  of  one  of  the  ocular 
globes,  nor  inequality  of  the  pupils.  Nothing  in  the  or- 
gans of  the  abdomen.       Nothing  at  the  heart. 

In  presence  of  this  right  hemiplegia,  coming  on  gradually, 
we  thought  that  we  had  to  deal  with  a  cerebral  softening. 
The  absence  of  every  other  s}-mptom  excluded  the  idea  of 
a  cerebral  tumor. 

During  the  week  following  his  admission  the  paralytic 
symptoms  increased  little  by  little.  The  leg  grew  so  weak 
that  he  could  not  get  up  from  the  bed.  But  at  the  end 
of  two  weeks  arose  a  new  symptom,  aphasia. 

The  patient  commenced  by  stammering,  then  lost  com- 
pletely the  use  of  speech.  The  appearance  of  this  new 
symptom  seemed  to  confirm  the  diagnosis  of  softening.  He 
only  grew  weaker  from  that  moment.  At  the  end  of  about 
a  month,  contracture  appeared  in  the  right  arm.  The  fore- 
arm was  flexed  and  pronated ;  a  little  later  there  was  also 
a  contracture  of  the  low'er  limb.  Sensibility  was  almost 
wholly  lost  on  the  right  side.  The  patient  died  March 
14th  without  having  had  either  vomiting  or  epileptiform 
convulsions.  There  was  the  commencement  of  a  bedsore 
on  the  sacrum. 

Autopsy.  The  meninges  were  found  a  little  injected ; 
the  right  cerebral  hemisphere  is  sound.  The  left  hemis- 
phere is  a  little  prominent  at  the  level  of  the  fissure  of 
Roland.  In  this  region  the  cerebral  substance  is  yellow 
and  softened,  but  on  palpation  it  is  also  found  that  it 
covers  a  hard  tumor. 

In  fact,  after  removing  a  layer  of  cerebral  substance 
about  I- 10  inch  thick,  a  tumor  is  reached  of  about  the 
size  of  an  orange,  a  little  elongated,  following  the  axis  of 
the  fissure  of  Roland.  It  is,  as  it  were,  covered  with  the 
softened  cerebral  substance  which,  furthermore,  does  not 
adhere  to  it.  It  is  located  just  exactly  before  the  ascend- 
ing parietal  convolution  as  it  turns  backward,  flattening  out. 

In  front  it  reaches  to  the  termination  of  the  three  frontal 
convolutions  upon  the  ascending  frontal.  It  is  this  last  which, 
wndencd,  pressed  back,  and  thinned,  covers  the  timior. 

Above,  this  last  extends  even  to  the  superior  border  of 
the  hemi.sphere.  Below,  it  touches  the  foot  of  the  third 
frontal  convolution.  It  is  evidently  to  the  pressure  exer- 
cised by  the  tumor  upon  the  convolution  of  Broca  that  the 
aphasia    should    be    ascribed,    the    cerebral    substance  not 


Society  of  Biology,  247 


being  softened  at  that  point.  This  observation  is  interest- 
ing from  the  point  of  view  of  difficulty  of  diagnosis.  The  ab- 
sence of  the  ordinary'  signs  of  cerebral  tumors,  the  existence 
of  right  hemiplegia  associated  witli  aphasia,  all  concurred  in 
fact  to  make  us  believe  in  the  existence  of  a  softening. — 
Lc  Progres  JMcdical,  Nov.,    1879. 

A  New  Symptom  and  Differential  Diagnostic  Proof  of 
Divers  Forms  of  Facial  Paralysis. —  Translated  frovi 
the  Gazette  des  Hospitanx.  by  S.  Pollak,  M.  D, 

The  modifications  in  the  secretion  of  sweat  by  alteration 
of  the  nervous  system,  central  or  peripheric,  have  hitherto 
been  objects  of  only  fragmentary  and  accessory  studies. 
The  works  referring  to  this  subject  are  very  poor — mere 
statements,  and  without  physiological  analysis. 

This  lacuna  is  due  to  different  causes,  and  especially  to 
the  prevalent  opinion  that  the  sudorific  function  is  only  a  phe- 
nomenon of  filtration,  depending  necessarih-  and  absolutely 
on  cutaneous  circulation. 

The  existence  of  secreo-sudorific  nerves  has  been  theo- 
retically admitted  by  many  physiologists,  among  whom,  M. 
Vulpian,  in  his  lectures  on  the  vaso-motor  apparatus.  But 
it  has  been  recently  established,  experimentally,  by  Goltz, 
Luchsinger,  Ostroumow,  Vulpian,  Adam  Kiewicz,  Nawrocki, 
etc.. 

Pilocarpine  constitutes  a  precious  diaphoretic  agent, 
which  M.  Strauss  compares,  in  a  certain  measure,  to  the 
action  of  electricity  upon  muscles  and  motor  nerves. 

He  thinks  the  time  has  come,  to  study  methodically,  in 
divers  diseases  of  the  nervous  system,  as  in  hemiplegia, 
paralysis,  etc.,  the  modification  in  sudorific  secretion,  by 
means  of  pilocorpine. 

The  sudoriprarous  glands  must  be  interrogated,  just  as  the 
muscles  and  nerves  are  explored  by  electricity.  The  semi- 
ology and  physiology  of  diaphoresis  will  be  much  advanced 
by  it. 

In  support  of  his  views  M.  Strauss  communicates  the 
results  of  his  experiments  upon  the  modification  of  the  sweat 
brought  about  in  facial  paralysis. 

His  researches  are:  ist,  in  facial  paralysis  of  cerebral 
origin  (hemorrhage,  softening,  etc.)     2d,  of  peripheric  origin. 

In  facial  paralysis  of  cerebral  origin,  there  is  no  ap- 
preciable difference  between  the  sudation  of  the  paralysed 
and  the  healthy  half  of  the  face,  neither  in  the  moment 
of  breaking  out,  duration,  nor  quantity. 

Just  as  the    electric  exploration  of   nerves    and  muscles 


2-48  E.  M.  .Yd son. 


shows  no  difference  between  the  healty  and  paralyzed  side> 
"  sudorale  reaction,"  by  means  of  pilocarpine,  is  the  same 
on  both  sides. 

M.  Strauss  had.  unfortunately,  no  opportunity  to  experi- 
ment upon  cases  of  peripheric  facial  paralysis  of  the  "  nii/d 
form,  i.  e.  with  integrity  of  faradic  and  galvanic  reaction  of 
paralysed  muscles.  He  hopes  soon  to  be  able  to  fill  the 
hiatus.  Theoretically,  he  thinks,  that  the  sodurale  function 
will  be  as  on  the  healthy  side. 

But  he  has  been  able  to  study  fine  cases  of  facial  pa- 
ralysis of  the  ''grave''  form,  with  loss  of  faradic  contracti- 
lity, exaggeration  of  galvanic  contractility  of  muscles, 
or  loss  of  both  modes  of  contractility  at  the  same  time. 
A  great  many  experiments  with  subcutaneous  injections  of 
pilocarpine  were  made,  and  in  all  (except  in  a  case  of  facial 
paralysis,  in  consequence  of  otitis  interna,  where  the  re- 
sults were  not  clearly  defined,)  a  retardation  of  several 
minutes  in  the  breaking  out  of  the  sweat  of  the  paralyzed 
side,  was  seen. 

But  after  that  time,  perspiration  was  about  the  same, 
quantitatively,  on  both  sides.  It  would  even  appear  more 
abundant  and  last  longer  on  the  paralyzed  side.  But  the 
most  significant  and  constant  symptom  is  the  retardation 
of  suciation   of  the  paralyzed   side. 

M.  Strauss  compares  this  fact,  with  electro  muscular 
phenomenon  observed,  at  the  same  time. 

He  thinks  that  there  is  a  "  reaction  "  of  degenerescence 
of  motor  nerves  and  muscles,  as  seen  by  Baierlacher,  Erb, 
Vulpian,  Onimus,  etc.  He  thence  concludes,  that  in  a 
physiologico-pathological  view,  there  is  one  more  link,  be- 
tween the  nervo  muscular  and  nervo  glandular  system. 

As  to  the  signs  furnished  by  ptyalism,  on  administra- 
tion of  pilocarpine,  the  results  are  less  clear. 

In  either  form  of  facial  paralysis  saliva  is  seen  to  flow 
from  both  sides.  Nevertheless,  in  several  cases  of  ''grave'' 
facial  paralysis  (with  probable  participation  of  the  corda  tym- 
pani)  the  patient  invariably  declared  that  the  saliva  com- 
menced to  flow  from  the  healthy  side. 

Society  of  tl|c  H-oi^fitals. 

P.\RJS,   February  28th,    1880. 
Hysteria. —  Vaso-Motor  Troubles. — M.  Dujardin-Beaumetz 
presented  to  the  Medical  Society  of  the  Hospitals  of  Paris 
a  woman   in  whom  the  slightest  touch  of  the  skin  quickly 


Society  nf  the  Eospitals.  249 

provokes  the  appearance  of  wheals  Hke  those  of  urti- 
caria. The  marks  which  are  traced  with  the  finger 
upon  the  skin  become  elevated,  and  their  elevation  per- 
sists for  four  or  five  hours.  The  temperature  at  these 
points  is  higher  than  in  the  neighboring  parts.  M.  Vul- 
pian  has  seen  an  analogous  fact  in  a  non-hysterical  man, 
M.  Dujardin-Beaumetz  observed  the  production  of  these 
cutaneous  elevations  at  the  points  where  a  magnet  was 
applied  or  punctures  were  made  in  another  hysterical 
subject.  At  the  end  oi  a  certain  time  these  elevations 
spread  and  present  then  distinctly  the  character  of  patch- 
es   of   urticaria. 

In  the  discussion  of  the  subject  M.  Strauss  recalled 
that  in  a  German  work,  published  in  1878,  in  the 
Centralblatt  and  entitled  "  Vaso-Motor  Troubles  of  the 
Skin "  are  found  related  a  number  of  cases  of  urticaria, 
provoked   in    the    same    manner. 

M.  Besnier  remarked  that  the  influence  of  friction 
upon  the  appearance  of  urticaria  is  easy  to  note  in  a 
good  number  of  patients.  That  which  is  peculiar  in  the 
patient  of  M.  Dujardin-Beaumetz,  is  the  co-incidence  of 
this   with    hysteria. 

M.  Constantin  Paul  has  ascertained  in  one  patient,  a 
sort  of  balancing,  or  alternation  between  the  "  nettle " 
eruptions  and  intense  hepatic  pains.  It  might  be  sup- 
posed that  there  were  produced  on  the  part  of  the  liver 
vaso-motor  troubles,  similar  to  those  of  the  external  in- 
tegument.— Le  Progres  Med.,  Feb.  28th,   1880. 


CEREBRAL  AND  NEURO-THERAPEUTICS. 

The  Therapeutical  Effects  and  Dosage  of  Electri- 
city.—5jf/  Geo.  M.  Beard,  M.  D. 

Dr.  Geo.  M.  Beard,  in  a  paper  read  before  the  Ameri- 
can Neurological  Association,  June  9th,  1879,  and  published 
in  the  JownaL  of  Nervous  and  Mental  Diseases,  thus  reca- 
pitulates   his    views    on    this    practical    subject: 

I.  The  therapeutical  effects  of  electricity — stimulant, 
sedative  and  tonic — can  be  obtained  by  either  pole,  and 
by  any  direction  of  the  current,  ascending,  decending, 
diagonal  or  reversed,  the  practical  difference  being  of 
degree  rather  than  of  kind.  This  is  true  even  in  electro- 
lysis. On  the  whole  the  positive  is  the  more  calming, 
the  negative  the  more  irritating. 


250  Geo.  M,  Beard, 


2.  Individual  exceptions,  as  seen  in  the  pathological 
reactions  of  some  forms  of  paralysis,  and  in  certain 
temperaments  and  phases  of  disease,  do  not  disprove 
this  rule.     These  exceptions  are  to  be  respected  in  practice. 

3.  The  dosage  of  electricity  is  a  complex  resultant  of 
(i)  the  strength  of  the  current;  (2)  the  length  of  the 
application ;  (3)  the  quality  of  the  application  (size  of 
the  electrodes,  etc.);  (4)  the  method  of  application  (general, 
central,  or  local) ;  (5)  the  position  of  the  poles ;  and  (6) 
the  temperament  of  the  patient. 

4.  Attempts  to  prescribe  electricity  mathematically, 
by  the  deflection  of  the  needle  of  the  galvanometer, 
or  by  the  resistance  of  the  rheostat,  are  unscientific  and 
illusory.  Water  rheostats  are,  however,  a  practical 
convenience,  because  they  enable  us  to  avoid  sudden 
interruptions,  and  to  gradually  increase  or  diminish  the 
current. 

5.  The  therapeutical  effects  of  electricity  are  very 
considerably,  though  not  entirely,  of  a  reflex  character. 
This  is  true  not  only  of  general  or  central,  but  of  many 
local  applications.  Hence,  in  part,  the  mistake  of  carry- 
ing the  laws  of  electro-tonus  into  electro-therapeutics. 

6.  The  range  of  dosage  of  electricity  is  very  wide, 
both  in  regard  of  strength  and  length  of  application. 
Although  the  sensitiveness  of  the  patient  is  the  best 
guide,  yet  in  some  cases  currents  that  can  scarcely  be 
felt,  and  applications  of  but  a  moment's  duration,  are 
required  ;  while  in  other  cases,  quite  painful  currents,  or 
applications  prolonged   for  hours,  may  be  useful. 

The  New  Ax/ESTHetic-Bromide  of  Ethyl,  or  hydro- 
bromic  ether,  first  employed  by  Dr.  Lawrence  Turnbull, 
is  a  colorless  liquid  with  a  specific  gravity,  a  little  greater 
than  that  of  water.  Its  vapor  is  not  inflammable.  Its 
anaesthetic  action  is  rapid,  and  recovery  is  speedy  after 
its  administration.  The  cerebral  anaemia  and  fatal  sycope 
of  chloroform  do  not  characterize  its  action.  Nausea 
and  vomiting  are  less  frequent  than  from  other  anaesthetics, 
respiration  is  but  little  influenced,  and  general  excitement 
and  the  tendency  to  struggle  occur  less  frequently. 

.\nccsthesia  is  usually  affected  in  two  or  three  minutes. 
The  pupils  dilate  with  anaesthesia  and  contract  with  return 
of  consciousness. 

"The  most  rapid  production  of  complete  insensibility" 
in  the  experience  of  Dr.  R.  J.  Lewis  {Phil.  Med.  Times) 
from    whom    the    above    and    following    facts    are    gleaned. 


Cerebral  and  Xeivro- Therapeutics.  251 

was  in  one  minute,  in  the  case  of  a  girl  eight  years  old  ; 
the  longest,  four  minutes. 

The  quantity  consumed  has  varied  from  one  drachm, 
in  a  case  of  iridictomy,  to  eleven  drachms,  in  a  forty- 
minute  amputation  of  the  fore-arm. 

Its  use  is  recommended  with  the  ordinary  anaesthetic 
precautions. 

M.  Arloing's  Conclusions  Concerning  Chloral. — That 
it  decomposes  into  chloroform  and  alkaline  formiates  in 
the  blood. 

Its    anaesthesic  effects  are  due  to  chloroform. 

The  alkalines  formiate  mechanically,  assist  in  bringing 
about  anaesthesia  by  promoting  the  rapidity  of  the  cir- 
culation, and  thereby  the  impregnation  of  the  nervous  ele- 
ments by  the  drug. 

Ergot  vs.  Alcohol. — Dr.  Thomas  W.  Poole,  who  lately 
astonished  the  medical  world  with  some  starthngly  heterodox, 
but  very  plausibly  sustained  teachings  on  physiological  the- 
rapeutics, discourses,  in  the  Canada  Lancet,  on  ergot  vs. 
brandy  in  uterine  hemorrhage,  maintaining  that  the  two 
being  physiologically  antagonistic — the  one  contracting  and 
the  other  dilating  the  arterioles — should  not  be  conjointly 
administered.  He  thinks  the  general  inefficacy  of  tincture 
of  ergot    is    due    to    its    alcohol. 

Nitrite  of  Strychnia  Hypodermia  for  the  Cure  of 
Optic  Atrophy. — Dr.  David  Webster,  Trans-American 
Optlial.  Soc.  i8yg,  reports  a  case  of  apparent  atroph}'  of  the 
left  optic  nerve  (the  right  was  totally  blind),  in  which  re- 
covery followed  the  hypodermic  use  of  one-eightieth  of  a 
grain  of  nitrite  of  strjxhnia,  continued  for  two  weeks. 

With  the  left  eye,  when  first  examined,  the  patient 
could  only  distinctly  discern  objects  so  as  to  count  them 
at  twelve  inches  distant.  There  was  pupillary  dilation  with 
two-thirds  n\stagmus  and  great  nictitation.  After  the 
first  day  the  latter  symptoms  disappeared,  and  vision 
power  rose  to  20-40,  and  after  14  days  to  20-20.  There 
was  no  change  in  the  papilla. 

Charles  Napier's  Therapeutics  for  Dipomania  con- 
sist of  a  farinaceous  food,  boiled  and  seasoned  with  butter 
or  olive  oil. 

Dr.  Dupuy  concludes,  concerning  Kava-Kava,  that  it  is 
sialagogue,  specially  stimulating  to  the  central  nervous  sys- 
tem, diuretic,  blennostatic,  anti-catarrhal  (uro-genital,)  and 
prevents  painful  micturation  and  priapism. 


252  Cerebral  and  .N'euro- Therapeutics. 

The  anti-catarrlial  action  seems  to  be  due  to  the  resin, 
and  the  diuretic  effects  to  a  neutral,  crystaHzable  principle 
called  kavaine,  and  perhaps  also  to  an  alkaloid  not  yet  dis- 
covered, whose  presence  would  explain  more  satisfactorily 
the  phenomena  excited  in  the  central  nervous  s}stem,  as 
well  as  the  alterations  in  the  circulation  and  secretions  of 
the  uro-genital  apparatus. 

Physical  Effect  of  Mental  Impression. — Dr.  Richard 
Maurice  Bucke,  Medical  Superintendent  of  the  Asylum  for 
the  Insane,  at  London,  Ontario  Province,  Canada,  in  his 
recent  very  thoughtful  book,  which  receives  further  notice 
in  our  pages,  gives  (on  page  164,)  this  example,  of  the  effects 
of  sympathetic  mental  impression  :  "I  once  attended  a  lady 
who  died  under  peculiarly  painful  circumstances.  A  few 
minutes  after  her  death  I  met  her  husband  in  another 
room.     He  had  been  summoned  on  account  of  her  critical 

condition.       He    said    "how  is ?"      I  said  "It  is  all 

over."  He  said  "dead?"  These  were  the  only  words 
spoken  by  either  of  us.  His  face  showed  very  little  sign 
of  emotion.  The  moment  he  spoke,  or  even,  I  think,  be- 
fore he  spoke  the  word  "  dead"  I  felt  an  intense  vibration 
or  thrill  of  grief  sweep  through  my  body.  Instantly  the 
tears  literally  poured  from  my  eyes.  All  this  during  the 
moment  while  I  stood  looking  at  him.  Almost  at  the 
same  instant  tears  ran  from  his  eyes  in  a  stream,  a?id  di- 
rectly aftenvards  blood  poured  from  his  nostrils.  This  man, 
who  was  about  twenty-five  years  old,  and  in  excellent 
health,  died  in  about  three  months  after  this  of  a  broken 
heart." 


The  Thirty-Third  Annual  Meeting  of  the  Association 
OF  Medical  Superintendents  of  American  Hospitals 
for  the  Insane. 

At  the  meeting  last  year,  at  Providence,  47  members 
were  representing  institutions  in  the  American  States  and 
Canadian   Provinces. 

Dr.  C.  H.  Nichols,  of  Bloomingdalc,  resigned  the  chair, 
and  Drs.  Clement  A.  Walker,  of  Boston,  and  Callender,  of 
Nashville,  were  elected,  respectively,  President  and  Vice- 
President.  This  old  and  distinguished  body  of  medical  men 
was  entertained  by  the  profession  and  citizens  of  Provi- 
dence in  a  manner  characteristic  of  the  hospitality  of  her 
people  and  of  the  resi)ect  in  which  this  honorable  Associa- 


Association  of  Medical  Superintend ents.  i^o3 

tion  of   our    professional  brethern    is     held    wherever  it    is 
known. 

Dr.  Ray  read  the  paper  on  "the  curability  of  the 
insane,  vide  ante,  and  an  interesting  discussion  followed, 
which  is  reported  in  full  in  the  Journal  of  Insanity,  a 
repetition  of  which  would  be  stale  to  our  readers,  since 
most  of  them  take  that  excellent  psychiatric  journal. 

Dr.  Kirkbride  thought  the  paper  would  do  much  good 
in  the  profession  ;  Dr.  Steves,  that  formerly  insanity  was 
considered  a  remarkably  incurable  disease,  while  recently 
it  had  been  regarded  as  curable  as  ordinary  physical 
diseases. 

Dr.  Nichols  said  an  improvememt  had  been  made  in 
the  treatment  of  insanity  during  the  last  thirty-five  years — a 
larger  proportion  of  a  given  type  were  now  cured.  To 
relapses  of  insanity  he  applied  the  same  reasoning  as  to 
recurrences  of  other   diseases. 

Drs.  Godding,  Browne  and  Kempster  concurred  with 
Dr.  Ray.  Dr.  Harlow  said  the  type  of  insanity  had 
somewhat  changed.  To  test  recovery-  the  patient  should 
be  tried  among  his  friends,  and  remain  rational  at  least 
one  year  before    being    pronounced  cured. 

Dr.  Morse  saw  no  reason  why  one  year  should  be 
the    limit   period    of  cure. 

The  apparent  increase  in  the  number  of  incurable 
cases  and  decreased  proportion  of  recoveries  was  due, 
in  Ohio,  to  the  fact  that  all  the  insane  were  the  wards 
of   the    State. 

Dr.  Camden  thought  that  though  many  cases  discharged 
as  cured,  relapsed;  many  cases  discharged  as  only  improved, 
recovered  at  home.  In  Dr.  Butler's  large  experience, 
though  recovered  cases  relapsed,  more  cases  discharged 
as  much  improved,  continued  to  improve,  and  were 
reported  as  permanent  cures  by  the  patient  and  his  friends. 
Dr.  Shultz  remarked,  that  the  present  hospital  populations 
were    less     curable    now    than    formerly. 

Dr.  C'ark  thought  the  term  "cured"  should  be 
accepted  in  its  relative  sense.  Drs.  Chenault,  May, 
Bancroft,  Callender,  Strong  and  Ray  further  discussed 
the    paper. 

Dr.  Shew  gave,  in  a  paper,  his  impressions  received 
during  a  visit  to  the  Insane  Colony  at  Gheel,  Belgium, 
in  1878,  which  were  in  accord  with  the  views  of  most 
psychiatric  physicians  who  have  visited  that  unique 
colony.       In    the    discussion    which    followed   Dr.   Bancroft 


254  Thirty -Third  Annual  Meeting. 


said,  it  was  all   narrowed    down  to  a    question    of  expense. 

The  asylums  of  to-day  furnish  the  best  known  sj^stem 
for  the  care  of  the  chronic  and  pauper  insane  ;  Dr. 
Kenipster,  that  the  cost  of  caring  for  the  chronic  insane 
in  his  asylum  has  been  greater  than  the  care  of  the 
acute.  Dr.  Nichols  said  the  chronic  poor  insane  can 
be  comfortably  and  properly  cared  for  at  less  cost 
than  the  acute  and  active  cases,  especially  under  the 
same  superintendence — that  the  plan  recommended  by 
the  Association  in  1866,  and  now  being  carried  into 
effect,  is  the    only    practicable    one. 

Dr.  Kirkbride  thought  that  ever\'  State  was  able  to 
provide  hospitals  for  the  proper  accommodation  of  all  of 
its  insane.  Drs.  Ray,  Stearns,  Draper,  Clark,  Strew  and 
Lathrop  also  remarked  on  the  paper,  mainh-  in  concurrence 
of  its    views. 

Dr.  Draper's  paper  on  the  "Responsibility  of  the  Insane 
while  in  Confinement  in  Hospitals,"  excited  an  interesting 
discussion,  the  general  sentiment  being  that  while  before 
courts  the  line  of  demarkation  between  responsibility  and 
irresponsibility  could  not  well  be  drawn,  the  insane,  under 
the  peculiar  surroundings  and  restraints  of  well  conducted 
asylum  life,  do  possess  a  modified  degree  of  responsibility. 

Hon.  Amos  C.  Barstow,  in  an  eloquent  speech  of  vvel- 
come,  complimented  the  Association  on  its  work  of  science 
and  philantrophy.  A  concluding  reference  to  Dr.  Ray,  called 
forth  from  this  eminent  aliepist  some  well  chosen  remarks 
in  review  of  the  history  of  Butler  Hospital,  of  which  he 
was  the  first  Superintendent,  and  some  justly  complimen- 
tary allusions  to  the  present  capable  and  accomplished 
Superintendent,  Dr.  Amos  W.  Sawyer. 

President  Walker  responded  to  the  speech  of  welcome 
in  behalf  of  the  Association.  Dr.  Clark  spoke  in  behalf 
of  the  Canadian  members,  and  in  behalf  of  the  citizens 
remarks  were  made  by  Governor  Van  Zandt,  Chief  Justice 
Durfee ;  Professor  Chase,  Pres't  State  Board  of  Charities ; 
Alderman  Toby,  Rev.  Dr.  Robinson  and  Prof.  Dinan,  of 
Brown    University. 

The  remainder  of  the  session  was  accupied  with  the 
subject  of  cerebral  traumatism,  introduced  by  Dr.  Cur- 
wen's  paper  on  a  case  of  suicidal  pistol  shot,  with  post 
mortem  details ;  the  discussion  of  subjects  germane  to  Dr. 
Echeverria's  paper,  translated  by  Dr.  Curwen  from  the 
Annalcs  Midico  Psyckologiqiics,  and  some  clinical  cases 
with    necropsies,    reported    by     Drs.    Kirkbride     and    Hess, 


Jssoctation  vf  Mpdical  Superintendents.  255 


from  the  Pennsylvania  Hospital  for  the  Insane,  which  led  to 
extended    discussion. 

Dr.  Reed — some  interesting  experiments  in  establish- 
ing communication  with  the  several  parts  of  an  institu- 
tion   by    means    of  gas    pipe. 

Drs.  Noyes,  of  ]\Iichigan,  Channing  and  Russell,  of 
Massachusetts,  McLane,  Hamilton  and  other  eminent  medi- 
cal   gentlemen    were    introduced    during    the    session. 

After  the  presentation  and  discussion  of  some  inter- 
esting microscopic  preparations,  by  Dr.  Walter  Kempster, 
from  the  spinal  cord,  an  excursion  on  the  bay  and  an 
-expression  of  thanks  for  the  many  kindnesses  and  cour- 
tesies shown  them  during  their  session.  The  Association 
adjourned  to  meet  at  Philadelphia  on  the  tw^enty-fifth  of 
May,  proximo. 

¥l\e  ]\QW  lii)g]iit\el  'P^S^dl\olo^ical  ^odiety. 

Dec.   15  th,   1879. 

The  society  met  at  the  Worcester  Hospital,  tlie  Pre- 
sident in  the  chair.  Present:  Drs.  Harlow,  Bancroft, 
Draper,  Earle,  Shew,  Stearns,  Park,  Fisher,  Geo.  Brown, 
Lathrop,    Ira    Russell    and    Quinby. 

The  records  of  the  last  meeting  were  read.  In  mov- 
ing their  approval,  Dr.  Earle  wished  especially  to  com- 
mend the  change  made,  at  the  last  meeting,  in  the  by- 
laws regarding  associate  members.  He  had  always  felt 
uncomfortable  at  the  position  of  these  members  of  the 
society  and  was  glad  now  to  admit  them  to  full  asso- 
ciation. At  the  opening  of  the  National  Association,  he 
had  assisted  in  passing  one  vote,  for  which  he  had  al- 
ways been  sorry.  It  was  a  mistake  not  to  admit  the 
Superintendents    of  the    Idiotic   Schools. 

Dr.  George  Brown  remarked  that  he  was  not  thin- 
skinned  and  had  always  enjoyed  the  meetings  of  the 
National  Society.  He  knew,  however,  that  there  was 
some  feeling  among  his  associates  on  account  of  the 
vote  spoken  of  by  Dr.  Earle,  and  that,  growing  out  of 
this,  much  had  been  said  and  written  for  which  he,  at  least, 
was  exceedingly  sorry.  Wlien  elected  to  this  society  as  an 
•  associate  member  he  was  glad  to  accept  and  now  had 
to    thank   the    society    for   conferring   full    membership. 

Dr.  Bancroft  was  glad  to  feel  that  the  associate  mem- 
bers   were    now    placed    upon    an    equal    basis    with    the 


266  Mew  England  P.fychoTn^i'cal  Society, 

other  members  of  the  society.  Out  of  the  action  of  the 
National  Association  had  grown,  he  had  no  doubt,  much 
ill-feehng,  and  no  Httle  writing,  which  he  beUeved  could 
do    no    good   to  either   party. 

Dr.  H.  W.  Buel,  of  Litchfield,  Conn.,  and  Dr.  VV.  B.  Hal- 
lock,  of  Cromwell,  Conn.,  were  elected  members  of  the 
society. 

Dr.  Earle  thought  it  well  to  delay,  for  the  present, 
the  election  of  honorary  members,  as  societies  often  made 
a  mistake  by  being  in  too  great  haste  in  this  matter. 
He  hoped,  however,  that  Hack  Tuke  would,  at  some- 
time, be  elected  an  honorary  member  of  this  society, 
since  he  regarded  him  as  the  only  man  in  the  specialty, 
in  England,  who  understood  and  appreciated  what  was 
being    done    by    us    in    America. 

On  proceeding  to  the  election  of  officers  for  the  fol- 
lowing year,  Dr.  Earle  wished  to  say,  that  at  the  be- 
ginning of  the  society  it  was  thought  that  its  meetings 
would  be  as  much  of  a  social  as  of  a  scientific  charac- 
ter, and  for  this  reason  but  little  attention  was  given  to 
the  subject  of  the  election  of  officers.  He  now  felt  that 
it  was  time  for  the  society  to  take  action  upon  this  point 
for  the  future.  As  Dr.  Walker  holds  the  presidency  of  the 
National  Association,  it  may  become  a  question  with  the 
society  whether  it  be  proper  that  he  should  be  elected  to 
the  same  position  in  this  society  and  thus  hold  the  two 
highest  offices  in  the  specialty  at  the  same  time. 

Dr.  Bancroft  had  hardly  thought  of  the  matter,  and,  if 
it  had  not  been  brought  up,  should  have  deposited  his  bal- 
lot according  to  custom.  There  might,  possibly,  be  argu- 
ments for  a  contrary  course. 

Dr.  Stearns  did  not  know  how  weighty  reasons  there 
might  be  for  departing  from  the  usual  custom,  but.  unless 
there  were  such,  he  feared  that  any  action  of  this  kind,  at 
the  present  time,  might  be  regarded  as  a  slight  by  the  Bos- 
ton members  of  the  society. 

Dr.  Fisher  wished  to  disclaim  any  feeling  on  the  part 
of  the  Boston  members,  and  would  suggest  two  ways  out 
of  the  matter :  to  re-elect  the  present  President,  or  elect  a 
new   President  and  retain  Dr.  Walker  as  Vice-President. 

Dr.  Shew  thought  the  old  custom  should  be  followed, 
unless  for  better  reasons  than  those  already  given. 

Dr.  Geo.  Brown  felt  that  electing  Dr.  Walker,  President, 
would  serve  to  fuse  the  interests  of  the  two  societies. 

Dr.   Draper  was   not    present  at  the  second  meeting  of 


Kew  England  Psychological  Society, 


the  society,  and  was  sorry  to  hear  that  a  new  President 
was  elected,  at  that  time.  He  should  like  to  see  this  ro- 
tation abolished.  The  society  then  proceeded  to  ballot 
and  elected  the  following  officers  : 

Dr.  Clement  A.  Walker,  President;  Dr.  A.  M.  Shew, 
Vice-President ;     Dr.   H.   M.  Quinby,   Sec'y  and  Treasurer. 

On  motion  of  Dr.  Shew,  seconded  by  Dr.  Fisher,  the 
following  committee  was  appointed  to  consider  the  subject 
of  the  election  of  officers  and  report  at  the  next  meeting: 
Drs.   Shew,  Bancroft  and  Geo.  Brown. 

Voted  that  the  next  meeting  be  held  ]\Iar.  9th,  1880, 
at  2  p.  M.,   at    the    Bay    State    House. 

Dr.  Park  then  read  a  paper  on  the  "Recoveries  from 
Insanity."  basing  his  remarks  upon  a  series  of  tables 
compiled  from  the  records  of  the  Worcester  Lunatic 
Hospital,  from  its  opening  to  the  present  time,  and 
giving  the  results  of  this  compilation  for  the  first  seven 
years.  According  to  the  reports  of  these  earlier  years, 
from  82  to  90  per  cent,  of  recent  cases  recovered,  but 
in  following  the  history  of  these  cases,  as  it  appears 
in  the  subsequent  records  of  the  institution,  this  percentage 
is    reduced    Irom    1-3    to    1-2. 

Dr.  Earle  remarked  that  Dr.  Park  was  working  in 
the  right  direction.  We  all  wish  to  know  what  the 
curability  of  the  disease  is.  The  public  have  been 
mislead  in  this  matter  and  much  unnecessary  expense 
in  the  treatment  of  insanity  has  resulted.  It  is  a 
debt  which  we,  as  superintendents  of  the  hospitals,  owe 
to    the    public  to    now    show  them  the  truth. 

They  should  understand  that  this  burden  is  upon 
them,  and  they  can  then  take  measure  to  meet  it. 
The  whole  subject  of  statistics  must  be  revised,  before 
any  proper  deductions  can  be  made  therefrom.  This 
association  must  take  a  stand  on  new  ground  if  it  is  to 
have    the   influence    which    it   should    have. 

In  reply  to  a  question  by  Dr.  Shew,  Dr.  Earle  said 
that  it  was  a  fact  that  a  larger  portion  of  acute  cases 
came  to  the  hospitals  formerly  than  now. 

Dr.  Stearns'  attention  was  drawn  to  this  subject 
while  making  up  his  first  report  as  Superintendant  of  the 
Hartford  Retreat.  He  then  found  that  he  should  make 
a  very  poor  showing  in  comparison  with  his  predecessors, 
and  was  thus  led  to  remark  upon  the  steady  decrease 
in  the  rate  of  recovery  during  the  latter  years  of  the 
Retreat's  existence.      He  hoped  Dr.  Park  would  follow  up 


268  iN'ew  England  Psychological  Society, 

these  statistics,  and  trace  each  case  as  far  as  possible. 

Dr.  Earle  then  read  a  paper  entitled  "Studies  Relative 
to  the  Curability  of  Insanity,"  in  which  he  traced  the 
history',  subsequent  to  their  discharge,  for  twenty-five 
persons  reported  as  recovered  at  the  Worcester  Lunatic 
Hospital  in   1843. 

Dr.  Shew  expressed  much  interest  in  the  paper  of  Dr. 
Earle,  and  thought  it  would  be  instructive  to  follow  out 
these  statistics  in  regard  to  the  number  discharged 
improved,  who  really  recover  after  leaving  the  hospital. 
He  had  done  this  in  thirty-three  cases  thus  reported,  at 
Middletown,  last  year,  and  found  that  nine  had  recovered. 

Dr.  Stearns  regarded  the  tracing  of  those  twenty-five 
cases  as  one  of  the  most  important  steps  taken  in 
the  specialty,  but  he  thought  something  should  be  said  to 
counteract  the  vast  effect  such  a  showing  would  have 
upon  the  public. 

He  moved  that  Dr.  Earle  be  requested  to  publish  his 
paper. 

The  society  then  adjourned. 

H.   M.   OuiNBY,   Scc'y  and  Treas. 


IDIOSVXXRACIES  OF  CONSTITUTION  AND  PATH- 
OLOGICAL EFFECTS  OF  NEUROTIC 
THERAPEUTIC. 


Death  C.\USED  BY  Electricity. — On  January  17th,  Mr 
Bruno,  the  euphoneum  player  in  the  orchestra  of  HoJ' 
theatre,  Aston,  a  suburb  of  Birmingham,  died  in  forty  min- 
utes after  catching  hold  of  the  wires  connecting  the  bat- 
ter>''  and  stage  lights,  the  premises  being  lighted  by  electricity. 
Sciefitijic  American  Abridged. 

Chloral  Erythe>l\. — I\I.  ^Martinet  discussing  erythema, 
which  sometimes  appears,  especially  after  eating  or  the  use 
of  alcoholic  liquors,  finds  that  it  occurs  only  in  certain  in- 
dividuals predisposed  to  its  influence,  that  it  is  accompanied 
by  palpitation  dyspnoea,  often  severe,  but  that  there  is  fre- 
quently no  fever  and  the  duration  is  often  brief  Witkow- 
ski,  in  the  Deutsch  Med.  IVochenscIuift,  makes  the  practical 
point  that  those  in  whom  the  chloral  rash  appears  after 
the  ingestion  of  30  to  90  grs.  are  most  liable  to  the  fatal 
accidents  that  sometimes  follow  the  use  of  the  drug. — Chi- 
cago Med.   Gazette  Abridged. 


Selections.  259 


Iodoform  Narcosis. — Dr.  Oberlander  reports  two  cases 
which  .confirm  the  experiments  of  Binz  on  the  narcotic 
action  of  iodoform.  A  syphihtic  woman  had  taken  twenty- 
four  grammes  of  the  drug,  in  pills  of  one  centigramme,  in 
eighty  days.  Suddenly  she  was  seized  with  weakness,  ver- 
tigo, and  diplopia,  and  fell,  after  two  days,  into  a  profound 
sleep,  which,  after  thirty-six  hours,  was  followed  by  ner- 
vous exaltation,  severe  cephalalgia,  delirium,  and  disordered 
speech.  Then  followed  a  period  of  weakness  and  stag- 
gering ;  then  the  cephalalgia,  vertigo  and  diplopia  re-ap- 
peared. All  this  lasted  two  weeks.  In  the  second  case 
the  syphilitic  woman  was  aged  69,  and  presented  symp- 
toms of  poisoning  in  seven  days  after  having  taken  about 
five  grammes.  The  sleep  continued  five  days,  and  was  fol- 
lowed for  several  weeks  by  a  sensation  of  debility  and  verti- 
go.—(Z^//  /  prakt.  Med.,  i8yg.)—N.  V.  Med.  Journal. 


At  thk  Dan  vers,  Mass..  State  Lunatic  Hospital,  since  Dr.  J.  J.  Putnam 
beo;an  his  labors  there  as  pathologist,  six  naked-eve  autopsies  have  been 
made.    Tlie  principal  raoibid  appearances  found  were: 

1.  Obliteration  of  the  internal  cartoid  artery,  with  necrosis  of  a  large 
amount  of  brain  tissue. 

2.  Diffused  inflammation  of  the  membranes  and  surface  of  the  brain  ; 
atrophy  of  convolutions ;  emphysema  of  the  lungs. 

3.  Large  fibroid  tumor  of  the  uterus. 

4.  Hypertrophy  of  the  heart ;  oedema  of  the  lungs. 

5.  Signs  of  old  pelvic  diseases,  causing  great  dilatation  of  both  Fallo- 
pian tubes. 

6.  In  this  case  no  notable  morbid  change  was  discovered. 

Of  the  autopsies  made  during  the  year  1879,  at  tlie  St.  Louis  Insane 
Asylum,  one  showed  cerebral  hemon-hage  with  lateral  convulsions ;  one 
of  cerebellar  abcess  with  muscular  inco-ordination ;  another,  a  tumor  of  the 
corpus  stnatum  with  paralysis  of  limbs  of  the  opposite  side  and  aphasia  and 
dysphagia.  The  fifth  case  illustrates  the  manner  in  which  delusions  may 
arise  from  disease  of  some  organ  from  the  brain.  This  patient  had  the  delu- 
sion that  his  enemies  were  continually  screwing  his  stomach  in  a  vise,  and 
the  post  mortem  investigation  disclosed  the  fact  that  that  organ  was  the  seat 
of  extensive  cancerous  disease. 

One  case  is  mentioned  on  account  of  the  unusual  size  of  the  brain,  its 
weight  being  63f  ounces. 


EDITORIAL   DEPARTMENT. 


Our  RECEniox  hj  tlie  xMedical  Press,  whose  acquaintance  we  have 
solicited,  has  been  most  orjatifying.  liuleed.  so  unifoinily  con  plinientaiy 
have  been  the  notices  by  all  the  exchan<^es  received,  that  possibly  the  very 
manifest  di.sposition  to  appiove  our  purposes  and  not  to  early  place  dis- 
couraofincr  obstacles  in  our  way.  may  haA'e  lead  our  friends  to  lightly  list 
our  imperfections  or  to  entirely  overlook  them.  We  are  conscious  of 
deficiencie.?— who  is  not?— and,  a/jro/jos  to  the  subject,  we  may  be  permit- 
ted to  s.iy  that  candid  criticism,  couched  in  courteous  terms  and  coming 
from  worthy  sources,  ought  not  to  be  shuimed  by  the  medical  journalist. 
"The  wounds  of  a  friend  are  faithful.*'  ana  adverse  critici.'-ms  Irom  frienc'ly 
sources  may  be  no  less  protitable  than  encouraging  compliments. 

The  nearest  approach  to  criticism  comes  from  two  of  our  Chicago 
coteraporaries  (whose  good  ojnnions  we  heartily  reciprocate  and  hope  to 
retain),  in  the  shape  of  an  exception  to  that  portion  of  our  January  edito- 
rial, wherein  we  express  our  preference  for  the  conclusions  of  practical 
experience  respecting  the  pathology  ol  insanity  and  the  proper  manage- 
ment and  treatment  of  the  insane,  over  mere  theoretical  notions  resrect- 
ingthem.  We  have  thoughtfully  noted  the  exceptions  of  these  estimable 
journals,  and  are  still  unpersuaded  of  error.  ^Totwithstnnding  the 
anomalous  views  implied  or  directly  expressed  in  these  and  other  quarters 
of  late,  to  the  effect  that  those  who  have  become  most  familiar  by  personal 
intercourse  with  the  insane,  in  the  capacity  of  physicians,  know  least  about 
them,  we  must  continue  to  hold  the  opposite  opinion  until  confronted  by 
more  cogent  convictions  to  the  contrary.  With  a  di?i)osition  to  be  as 
complaisant  as  may  be  compatible  with  our  conception  of  the  truth,  we 
must  continue  to  hold  that  our  views  are  in  accord  with  the  universal 
sentiment  of  mankind,  namely,  that  those  who,  by  actual  observation  and 
practical  study,  know  most  about  a  subject  are  best  qualified  to  judge  and 
express  the  soundest  opinions  thereon;  the  proper  methods  of  caring  for 
and  treating  the  insane,  constituting  no  exception  to  the  rule. 

The  Puoi'OsiTio.vs  of  the  Medical  Supkrintendexts  of  ITosi'ital-* 
fortueIxsaxe — Insane  .AsYi.uM  Refoh.m  in  New  York.  Etc.— NVe  ob- 
serve with  regret  the  unjust  efforts  that  hive  been  and  are  still  being  made, 
in  certain  quarters,  to  disparage  Ampricau  psychiatry,  and  the  undoubtedly 
good  and  meritorious  work  done  in  this  field  of  medical  labor  by  the  alienists 
of  this  country.  The  course  pursued  in  Xew  York,  especially,  under  the 
specious  plea  ot  "insane  a.sylum  reform,"  appears  to  us  to  have  been 
extremely  reprehensible  and  unprofessional.  Aside  from  its  detrimental 
effect  on  the  welfare  of  the  insane  through  the  unwarrantable  popular 
distrust — always  smouldering  among  the  uninformed — ^\hicll  this  agitation 
has  sought  and  seeks  to  fan  into  a  resistless  flame  of  popidar  indignation 


Editorial.  261 


t1ire(.'ted  towards  the  hospitals  forthe  uisanein  that  State,  the  whole  move- 
ment is  unprofessional.  There  is  no  warrant  in  the  code  of  ethics  for  the 
arraif,nmient  before  the  popilace  bj'  one  set  of  physicians,  ot  another  body 
of  tiie  same  profession  in  acknowledged  honorable  lellowship,  as 
incompetent,  retrogressive  and  barbarous,  ana  calling  to  their  assistance 
in  such  an  unprofessional  crusade,  such  political  stump-speakers  and 
clerical  rhetoricians  and  other  citizens  as  joined  in  petitioning  the 
legislature  and  the  Cooper  Institute  harrangues  ot  1878. 

It  is  no  wonder  that  tliat  movement  ignonilniously  failed.  Real  reform 
in  methods  of  hospital  practice  ought  not  to  be,  and  cannot  be.  promoted 
by  such  proeeckires.  The  politicians  and  clergymen  who  joined  in 
that  nssault  upon  the  liospitals  for  the  insane  of  New  York,  would  be 
equally  as  ready  to  liiud  a  worthless  nostrum  as  they  were  to  damage  the 
good  reputations  of  our  professional  brethren  in  that  State.  Such  methods 
oi  seeking  to  bring  public  odium  and  contumely  on  our  medical  brethren 
are,  as  the  iV^ew  York  JowrwaHias  rightly  chaiacterized  them,  "ill  advistd, 
unwise  and  harmful."  Tliey  evince  a  reckless  disregard  of  the  welfare  of 
the  insane  and  of  our  profession. 

If  medicine  in  this  countr.y  has  gathered  no  laurels  in  psychiatry,  as 
has  been  sought  to  be  impressed  upon  the  public  mind  of  New  York,  it 
hasgatiiered  none  in  any  department  of  medicine.  We  have  been  accustomed 
to  point  to  the  modern  liospitals  for  the  insane  ms  monuments  commem- 
orative of  the  humane  mission  of  scientific  medicine.  To  call  upon  the  public 
to  assist  in  demolishing  our  own  handiwork,  or  to  ask  them  to  join  in 
denunciation  of  thi  se  of  our  representative  bretliren  in  charge  of  these 
institutions,  is  a  kind  of  self  degradation  which  we  can  not  countenance. 
Public  sensational  assnults  made  by  medical  men,  in  which  the  populace  nre 
invited  to  join,  cannot  redound  to  the  honor  or  glory  of  our  common 
profession,  and  to  seek  to  instill  distrust  and  prejudice  towards  one  of  the 
oldest,  most  dignified,  conservative,  respectable,  earnest  and  representative 
bi)dies  of  our  medical  men  by  intiammatory  appeals  to  popular  sympathy 
and  prejudice,  with  the  rhetorical  artifices  of  demagoguery,  must  lead,  either 
to  the  conclusion  on  the  part  of  the  people  that  medicine  has  not  done 
much  good  generally,  and  that  the  insane  had  better  be  relegated  to  the 
old  non-medical  '"Keeper,"  or,  that  pi  ysicians  as  a  class,  are  a  very 
inferior  and  inetticient  body  of  men,  or  that  one  portion  of  the  profession  is 
actually  ignorant  of  what  the  other  has  done,  or  that  niedical  men  may 
know  something  of  practical  neurology  and  yet  understand  little  of  clinical 
psychiatry  and  the  best  methods  of  treating  and  providing  for  the  insane. 

The  Medical  Superintendents  of  American  hospitals  for  the  in.-ane, 
with  few  exceptions,  are  representative  men  and  an  honor  to  our  connnon 
profession.  They  belong,  with  us,  to  a  common  fraternal  fiunily— they 
are  our  brethren  and  equals, — the  peers  geneially,  of  those  who  assail  them, 
and  we  have  no  sympathy  with  such  assaults.  As  our  compeers,  in  a 
noble  and  reputed  honorable  calling  they  aie  entitled  to  honorable  treat- 
ment— the  same  courteous  and  protessional  consideration  before  the 
public — respecting  their  views  of  hospital  management,  and  the  treatment 
of  their  patients,  that  would  be  accorded  by  any  other  considerable  body 


262  Editorial. 


of  reputable  imdical  Dicn.  interested  in  the  nianagnnent  of  any  otlier 
hospitals,  or  en<r:'<,^ed  in  the  pursuit  of  any  other  .-pecial  department  of 
medicine.  We  care  not  how  much  of  honest  and  efficient  surveillance  the 
hospitals  for  the  insane  shall  liave  (they  should  have  enough  to  prevent 
their  corridors  Irom  becoming  public  thoroughfares  for  curiosity  seekeis 
and  seniiatioii  mongers),  nor  hov  many  organizations  are  tormeil  for  tlie 
protection  and  amelioration  of  the  condition  of  the  insane  in  alms  houses 
and  penal  institutions  (there  is  room  in  the  latter,  lor  the  (Xerci.-e  of  a 
large  and  vigilant  philanthropy);  nordowe  now  propose  to  discuss  the 
relative  merits  of  the  English  over  the  Caiiidian  smd  New  York  jilaus  of 
having  a  half  dozen  or  more  commissioners  instead  of  one  asylum  in.«pector : 
nor  the  propriety  of  having  dual  governors  or  consulting  physicians  for 
asylums  for  the  insane ;  nor  the  many  other  propositions,  practicable  and 
impracticable,  novel  or  old,  lately  made,  concerning  these  institutions.  Otir 
purpose  now  is  to  record  our  condemnation  of  such  methods  of  discussing 
medical  subjects  as  lead  one  portion  of  the  public  to  bele\e  that  our  breth- 
ren, engaged  in  the  practice  of  psychiatry,  have  been  so  derelict,  inefllcieni 
and  retr<  gressive  that  great  reforms  are  needed,  while^from  others  of  the 
laity,  come  such  reproof  and  rebuke  as  is  contained  in  tlie  report  of  the 
Xew  York  Legislative  Committee  on  "public  health  relative  to  lunatic 
asylums,"  the  pith  of  which  is  in  the  followingextract:— "This  attack,  by 
medical  men.  on  the  scientific  work  of  a  btate  institution  evinces  an 
ignorance  and  a  spirit  ot  recklessness  unworthy  of  a  great  and  liberal 
profession,  and  shoidd  be  condemned  by  all  who  have  the  interest  of  science 
and  humanity  at  heart." 

We  make  this  protest  simply  on  principal,  for  we  are  confident  that  the 
body  of  our  brethren,  now  assailed,  will,  out  of  this  agitation,  rise  higher 
than  ever  before  in  public  and  professional  esteem:  their  wise  and 
experience-proven  propositions,  respecting  the  insane,  will,  through  it. 
become  better  known  and  they  need  only  to  be  well  understood  to  be 
appreciated;  and  to  them,  as  they  are  being  presented  in  our  pages,  we 
in\ite  the  considerate  attention  of  the  profession. 

The  Safety  Beadstead— Thisis  the  ordinary,  full  length  and  width  hos- 
pital bedstead,  constructed  of  wood  and  so  altered  as  to  ex.ictly  resen.ble  a 
child's  crib,  having  high  banister  sides  and  high  open  balustered  detached 
top,  which,  when  necessary,  may  be  attached,  closed  down  and  fastened. 
A  few  of  these  bedsteads  may  be  found  in  some  of  the  best  conducted 
hospitals  for  the  insane  in  this  country,  and  one  or  more  ol  them  would  be 
a  valuable  addition  to  any  hospital  that  receives  and  treats  deliriimi  tremens, 
puerperal  mania,  etc.  They  can  or  ought  only  to  be  locked  or  imlocked 
with  tiie  ph3'sician"s  key.  a  key  w  hich  generally  is.  and  always  should  be.  of 
different  construction  from  that  of  the  nurses'  or  attendants'.  In  certain 
Ciises  and  under  certain  circumstances,  familiar  to  all  who  have  had  exten.sive 
medical  care  of  the  insiane,  tliis  bedstead  is  a  means  of  restraint  and  safety 
far  more  protective  and  humane  to  patients  than  the  hands  of  attendants. 
It  never  gets  tired,  sleepy  or  incautious,  nor  fearful,  rough  or  brutal:  nor 
returns  word  for  word :  nor  blow  for  l»low ;  nor  looks  defiance ;  nor  makes 
grimaces;  nor  threateningly  gesticulates;  nor  utters  imprecations,  real  or 


Editorial.  263 


imaginary,  to  the  patient.  AVere  we  to  become  afflicted  with  any  one  of  those 
forms  of  insanity  for  wliich,  by  skilful  alienist  physicians,  it  is  employed 
we  feel  that  we  should  infinitely  prefer  to  be  safely  placed  to  sleep  in  so. 
humane  a  contnvance,  and  removed  from  the  presence  of  imaginary 
tormentors  than  to  be  intrusted  to  the  constant  restraint  of  human  hands. 
Amono-  tiiose  who  most  require  it  at  times  are  tlie  persistently  homicidal 
and  suicidal,  who  constantly  and  cunningly  plan  to  escape  the  attendant's 
vigilance;  patients  who  constantly  keep  in  motion  or  stand  stock  still  like 
a  statue,  never  wanting  to  lie  down  or  sleep,  or  such  as  would  continually 
strip  themselves  and  expose  their  nude  persons. 

Xocturnal  epileptics  likewise  and  certain  infirm  patients  should,  for 
obvious  reasons,  sleep  in  such  a  bed  rather  than  on  the  fioor. 

This  bedstead  is  just  as  essential  in  certain  other  cases  and  not 
more  objectionable  than  the  stomach  pump  and  forced  alimentation. 

With  an  exceptionally  good  corps  of  attendants,  nearly  all  forms  of 
mechanical  restraint  maybe  largely  dispensed  with,  as  is  now  demonstrable 
in  our  hospitals  for  the  insane,  but  where  mechanical  restraint  can  be  done 
away  with,  it  is  not  always  the  wisest  moral  management  of  certain 
patients  not  to  use  it,  for  the  reason  that  some  patients  prefer  to  be  thus 
restrained  to  being  personally  controlled.  For  medical  men  to  create, 
through  the  columns  of  the  secular  press  or  elsewhere  beyond  the 
pale  of  legitimate  professional  discussion,  a  popular  prejudice  against 
this  bedstead  as  it  is  used  in  our  best  hospitals  for  the  insane,  and  espe- 
cially against  a  particular  institution,  among  a  dozen  or  more  that  have  it, 
by  calling  it  the  Utica  crib,  and  designating  it  as  a  barbarous  appliance,  is 
as  unjust  and  unprofessional  as  it  would  be  to  thus  enveigh  against  the 
forcible  feeding  of  the  insane,  the  involuntary  medication  of  children;  the 
inhumanity  of  the  cold  batli  in  certain  forms  and  degrees  of  fever;  or 
against  ana:\sthesia;  or.  Sayre's  plaster  jacket;  or  any  of  the  more  formidable 
appliances  of  surgery.  These  are  methods  of  restraint  employed  by 
science  against  disease,  yet  it  would  not  be  difficult  for  infiuential  medical 
men,  fluent  and  rhetorical  of  speech  and  pen,  to  so  bias  the  public  mind 
against  them.  as.  perhaps  for  a  time,  to  bring  into  disrepute,  those  who 
might  persist  in  employing  them. 

If  the  safety  bedstead  were  ever  so  unlike  the  cribs  in  wliich,  in  innocent 
infancy,  we  were  wont,  in  security,  to  fall  asleep  to  a  mother's  lullaby — 
even  it  were  the  barbarous  and  inhumane  contrivance  it  has  been  ijictured 
to  be— as  barbarous  looking  even  as  the  boiled  oil  process,  by  which 
bleeding  stumps  were  staunched  before  Ambrose  Pare  taught  the  profes- 
sion a  better  lesson  in  haemostatics,  there  is  a  way  to  secure  amendments 
of  objectionable  methods  of  practice  in  hospitals  lor  the  insane  witliout 
invoking  indignation  upon  a  large  and  reputable  portion  of  our  brethren 
in  the  profession,  and  seeking  to  cast  upon  them  the  unjust  odium  of 
greater  inhumanity  llian  the  rest  of  mankind,  and  less  than  average  med- 
ical ability.  It  required  no  vis  a  tergo  of  popular  clamor  to  promote  the 
humanitarian  advances  of  Pinel  and  Tuke  or  Connolly. 

The  profession  knows  and  the  world  concedes,  that  medicine  has  been 
especially  the  friend  of  the  insane;  that,  under  the  care  of  pliys'cians,  the 
condition  of  these  unfortunates  has  steadily  improved  from  that  raemora- 


Editorial. 


ble  day  that  iiuniortali/.ecl  the  humanity  of  medicine  in  the  dungeon  cell? 
of  Bicetre  totliis — until  now",  outside  of  the  alms  houses  and  penitentiaries, 
there  are  no  more  tm-nkeys  ami  Bedlams,  for  these  children  of  misfortune. 
Ameri«in  alienists  have  done  their  share  in  promotuvg"  thi;*  refonu,  an<l 
we  cannot  be  silent  and  see  them  traduced. 

We  are  oi)posed  to  having'  the  medical  or  surgical  appliances  of  an>' 
kind  of  hospital  disi>;iragliigly  discussed  bef)re  non-medical  tril)ut)als. 
or  prescribed  by  legislative  enactment.  We  would  not  even  thus  discuss 
or  prosciilx*  the  brutal  looking  actual  cautery,  or  thus  either  proscribe  or 
prescrit)e  the  aspiration  of  tiie  liver  for  melaiicholla.  Let  us  not,  in  these 
matters,  disregard  professional  proinlety, 

ArBAXEi^  Prize — We  learn  from  Le  Proves  Medical  that  the  Medico- 
Psy(;hoiogical  IS-ociety  will  award  in  1881.  the  Aubanel  prize  of  3,000  franc? 
to  the  author  of  the  best  work  upon  a  subject  of  mental  and  neiTOus 
pathologj%  The  manusciipts  are  to  be  presented  before  January  1st,  1881  r 
to  the  General  Secretary.  M.  le  Dr.  Moter,^  IGl  Rue  de  Cliaronne,  Paris  . 
France,  and  bear  a  motto  to  be  reproduced  upon  a  sealed  envelope,  contain- 
ing the  name  of  the  author. 

The  Effects  of  Tea. — Dr.  Geo.  ^I.  Beard,  in  his  new  book,  endorse^: 
Dr.  Dana's  conclusions  in  preference  to  Dr.  Morton  on  this  subject.  There 
IS  n  jewel  of  truth  down  deep  m  the  well  here,  whicli  we  would  like  to  see 
brought  fully  to  the  surface. 

Apologetic— We  find  ourselves  again  compelled  by  miscalculation 
of  space  at  our  disposal  to  omit  che  notices  of  several  books,  and  to  exclude 
some  most  excellent  selections.  Among  the  former  are  Dr.  Geo.  M.  Beard'g 
new  book  on  "Nervous  Exhaustion,"and  Dr.  Richard  Maurice  Bucke's  book 
on  "Man's  Moral  Nature,"  both  of  which  we  conuuend  to  our  readers. 

The  older  writers  sought  to  unify  diseases.  Dr.  Beard  goes  a  long 
way  in  this  direction,  so  fin*  as  the  earlier  stages  of  many  disi-ases  are  con- 
cerned. The  psychical  evidence  of  disease  comes  in  for  a  good  share  of  Dr. 
Beard's  attention. 

In  Dr.  Bucke's  book  the  advocates  of  moral  insanity  will  lind  comfoit 
and  new  arguments. 

We  had  also  prepared,  but  must  omit,  a  Icngrhj'  nnd  somewliat  spe- 
cific notit-e  of  the  individual  exiellences  of  our  many  exchanges. 

The  new  joiu-nals— Chicago  3Iedical  Gazettt\  Kansas  Medical  Index, 
Indiana  ]\Iedical  Rei)orter,  New  Jerscsy  Count ly  Practitioner,  Louisville 
]\rcdic;d  Herald,  New  York  Anatomical  and  Albany  Medical  Annals,  the 
Philadclpliia  Medical  News  and  Library,  and  Youngstown  (Ohio)  "Traus- 
actioi\s"— all  present  good  appearances  jind  have  made  u])<)n  us  a  goodim- 
pression.    We  shall  speak  of  them  again. 

The  Thiutv-Fouktii  Annual  Meeting  of  hie  Association  of  Med- 
ical Sl'vekintendents  of  American  In-stitchons  for  the  Insane,  will 
be  held  at  the  Continental  Hotel,  in  the  city  of  Philadelphia,  Penn.,  com- 
mencing at  10  A.  M.,  on  Tuesday,  May  2r)th,  1880. 

iZcso^ueci,  that  the  Secretary,  when  giving  notice  of  the  tinu'  and  place 
of  the  next  meeting,  be  requested  to  urge  on  the  menil)ers  the  imporcance 


Editorial.  265 


of  prompt  attention  at  tlie  organization,  and  of  remaining  with  the  Asso- 
ciation till  the  close  of  the  session. 

By  standing- resolution,  the  Trustees  of  the  several  institutions  are  in- 
cited to  attend  the  meetings  of  the  Association. 

When  an  Assistant  Physician  represents  an  institution,  a  notice  stating 
the  fiict  should  be  sent  to  the  Secretary. 

The  Pathology  of  Insanity  as  Shown  at  the  Hospitals  for  the 
Insane. — 'I'o  those  ^si^eeially  int-erested  in  the  care  and  treatment  of 
tlie  insan<?  nothing  is  of  •••renter  interest  than  tlie  advancement  made 
within  the  past  few  years  in  om-  Ivnowledge  of  the  pathology  of  dis- 
eases of  the  brain  and  nervous  system.  To  the  intelligent  laborei-s 
In  this  field  we  are  indebted,  in  a  large  measure,  for  the  elevation  of 
■obscure  nervous  affections  and  mental  derangements  from  the  region 
of  superstition  and  charlatanism  to  their  legitimate  place  in  medical 
science,  alongside  other  diseases  which  are  amenable  to  proper  ti-eat- 
luent. 

Post-mortem  examinations  of  those  who  have  died,  with  well  as- 
eertained  mental  disturbances,  will  do  more  towards  making  medical 
practice  in  these  diseases  scientific  and  successful,  than  any  number  of 
l)hysiological  experiments  alone. 

The  last  annual  report  of  the  State  Lunatic  Asylum  at  Utica,  X. 
Y.,  gives  an  account  of  some  of  the  pathological  work  done 
■during  the  past  year  in  that  excellent  institution.  Most  of  our  readers 
are  a\\are  that  for  yeai-s  past  Dr.  Gray  has  given  much  attention  to 
the  pathology  of  the  brain,  and  has  made  valuable  contributions  to 
the  literature  of  the  subject.  For  some  time  past  Mr.  Theodore  Deecke. 
an  ac-complished  mici-oscopist,  has  had  charge  of  the  pathological  de- 
l)artment  in  this  institution,  and  has  done  work  of  great  practical 
value. 

In  this  report  the  histories  of  nine  typical  cases  of  insanity  are 
given,  and  annexed  to  each  is  the  autopsy  and  a  full  account  of  the 
microscopical  appearances  of  the  various  tissues.  This  gives  us  the 
best  possible  opportunity  of  getting  at  a  glance  the  part  played  by 
certain  alterations  in  the  brain,  the  blood  vessels,  and  the  blood  it- 
self, in  connection  with  insanity. 

There  are  two  cases  each  of  acute  mania,  sub-acute  mania,  melan- 
cholia and  dementia,  and  one  case  of  general  paresis. 

One  striking  thing  in  the  history  of  these  cases  is  that,  apparent- 
ly similar  causes  do  not  operate  to  produce  the  same  form  of  men- 
tal disturbance.  Here  we  liave  two  cases  of  syphilis  in  which  charac- 
teristic lesions  are  found  in  tlie  brain,  and  yet  one  man  had  melancholia, 
the  extreme  of  mental  depression ;  the  other  general  paresis,  Avith  its 
characteristic  mental  exaltation. 

Again,  one  case  of  sub-acute  mania  is  seen  as  a  result  of  phthisis, 
and  is  slow  in  its  advent  and  progress;  another  case  of  sub-acute 
mania  in  an  apparently  well  pei-son  comes  on  suddenly,  has  paroxysms 
of  great  excitement,  runs  a  rapid  course  and  is  caused  by  great  men- 
tal shock  and  the  consequent  disturbance  of  circulation,  in  a  person 
alreadv   weakened  bv  overwork. 


266  Editorial. 


And  yet.  from  the  patholoonical  view  of  these  cjises,  we  get  one 
veiy  constant  factor  in  the  production  of  insanity,  namely :  an  altera- 
tion of  the  walls  of  the  blood  vessels  in  the  hrain.  In  seven  of  these 
cases,  embracinjr  all  the  general  forms  of  insanity,  tliere  were  foun<l 
sufficient  changes  in  the  arteries  of  the  brain  to  mark  their  departure 
from  health  and  to  explain  many  of  the  pathological  changes  in  the 
brain  substance. 

The  importance  of  these  changes  .«eems  to  be  fidly  appreciated  in 
the  examinations  made  at  Utica.  for  in  the  preceding  year,  out  of 
the  eighteen  autopsies,  fully  reported  in  all  but  one  instance,  the  ar- 
teries of  the  brain  were  found  so  altered  as  to  materially  intei-fere 
with  the  nutrition  of  the  nerve  tissue,  and  in  many  instances  to  cause  death. 

It  is  probaldy  true  that  tlie  importance  of  these  vascular  changes 
has  not  been  generally  appreciated,  because  autopsies  upon  the  insane 
have  not  been  made  with  sufficient  completeness  in  all  instances.  At 
Utica  lumdreds  of  consecutive  microscopical  sections  of  the  same  brain 
are  made  with  an  end  in  view  of  obtaining  a  knowledge  of  the  minutest 
changes  in  blood  vessels,  as  well  as  of  the  relations  between  the  vessels 
and  alterations  of  brain  tissue. 

Another  marked  feature  in  these  post  mortem  cases  is  the  very 
■painstaking  examinations  of  the  blood  of  those  having  died  insane. 
This  is  a  new  feature  in  pathological  investigations  in  this  class  of 
cases,  and  for  only  three  years  past  has  been  done  at  Utica.  The  ex- 
aminations are  both  microscopical  and  chemical.  The  number  of  white 
and  red  coiijuscles  was  determined  for  a  given  square  of  a  microme- 
ter, and  their  relative  projections  ascertained.  Tlie  record  in  each  case 
is  the  average  taken  from  six  examinations.  The  amount  of  li.-emo- 
globin  was  determined  in  each  cjise  by  spectrosc<ipic  analysis  after 
Preyer's  method. 

The  report  shows  that  in  a  majority  of  cases  the  number  of  blood 
corpuscles  was  sensibly  diminished  a&  compared  with  healthy  blood. 
The  same  fact  was  noticed  regarding  the  percentage  of  hiemoglobin. 
Xo  general  conclusions  conoM-ning  tlie  fluctuation  of  tliese  essential 
constituents  of  the  blood  is  made,  but  we  shall  look  forward  with  in- 
terest to  future  developments  in  this  field,  as  it  is  one  which  pro- 
mises important  results. 

The  changes  in  the  nerve  tissue  were  noted  especially  with  refei- 
ence  to  their  lowdity.  both  as  to  the  special  convolution  involved,  ami 
to  the  layers  of  the  cortex.  The  general  conclusion  from  all  these  in- 
vestigations is.  that  in  all  cases  of  insanity,  some  portion  of  the  gray 
cortex  of  the  brain   undeigoes  i)athological  change. 

The  Cincinnati  Lancet  and  Clinic  which  does  not  entertain  a  very  ex- 
alted opinion  of  St.  Louis  go-ahead-acliveness.  nevertheless  pays  a  justly 
liigh  comiiliment  to  Dr.  Nelson,  the  new  editor  in  chief  of  the  St.  Louin 
Courier  of  Medicine  whicli  we  are  gratified  to  see. 


Editorial.  267 


CoxcERNixG  Dr.  L.  C.  Gkay  and  theTkxdkxRkflex. — In  our  article 
on  Tenden  Reflex  (Jan.  number)  occurs  this  passage:  "  Dr.  Gray  in  liis 
April,  1879,  paper  reports,  in  substance  and  more  at  length  many  of  the 
points  made  against  tliis  sign  by  oiirself  in  the  previous  Feb.  number  of  the 
St.  Louis  Medical,  and  Surgical  Journal.''''  A  note  from  Dr.  Gray  states 
the  above  "is  considered  to  contain  an  imputation  upon  him.  amounting 
to  a  charge  of  plagiarism,"  and  explaining  that  had  he  known  of  our  article 
he  would  have  given  us  proper  credit,  &c. 

We  most  cheerfully  state  that  no  such  imputation  was  intended,  and  we 
have  no  doubt  but  Dr.  Gray  would,  as  he  states,  have  mentioned  our  contri- 
bution had  he  known  of  its  previous  existence. 


OFFICIAL  CHANGES   AND  NEW  APPOINTMENTS. 

Dr.  Orpheus  Everts,  for  eleven  years  Superintendent  of  the  Indiana 
Hospital  for  the  Insane,  at  Indianapolis,  succeeds  Dr.  Ohipley,  lately 
deceased,  as  Superintendant  of  the  "  Cincinnati  Sanitarium." 

This  is  a  most  Judicious  selection,  and  can  not  fail  to  be  promotive  of 
the  continued  usefulness  and  prosperity  of  this  well-known  private  hospi- 
tal for  the  insane. 

Dr.  R.  S.  Dewey,  the  new  Superintendent  and  Physician  of  the  new 
Hospital  for  the  Insane,  at  Kankakee,  Ills.— the  Eastern  Illinois  Lunatic 
Hospital— ought,  from  his  antecedents,  to  make  a  good  medical  and  execu- 
tive chief  of  that  institution. 

He  served  for  many  years  as  the  flrst  assistant  physician  under  that 
efficient  Superintendent  Physician  of  the  Hospital  for  the  Insane,  at  Elgin, 
Dr.  E.  A.  Kilbourne. 

Dr.  Dewey  has  also  contributed  some  thouglitful  papers  to  the  medical 
press,  on  subjects  connected  with  the  welfare  of  the  insane 

We  congratulate  the  Trustees  of  the  hospital  at  Kankakee  on  having 
chosen  its  medical  head  independently  of  political  considerations. 

Dr.  D.  D.Richardson— The  Commissioners  foi  the  new  State  Hospital 
for  the  Insane  at  Warren,  Penn.,  have  made  a  most  commendable  selection 
of  a  Medical  Superintendent,  in  the  person  of  Dr.  D.  D.  Richardson, 
for  the  last  twelve  years  the  medical  chief  of  the  insane  department  of  the 
Philadelphia  hospital.    This  is  a  well-deserved  promotion. 

Dr.  a.  M.  Fauntleroy,  recently  elected  Superintendent  of  the 
Western  (Va.)  Lunatic  Asylum  at  Staunton,  is  well  and  favorably  known 
to  the  profession  of  Virginia  and  other  States— having  been  the  contributor 
of  many  valuable  articles  to  medical  literature.  He  was  the  physician  to 
the  Blind,  Deaf  and  Dumb  Institution,  at  Staunton.  In  1871  he  was  elected 
President  of  the  Medical  Society  of  Virginia,  and  has  since  been  elected  an 
Honorary  Fellow  of  that  body.  The  Va.  Med.  Monthly  says,  his  election 
meets  with  the  cordial  approval  of  the  profession  and  citizens  of  Virginia. 


Editorial. 


Dr.  Fauntleroy  has  been  so  loiitf  connected  witli  the  management  of 
the  institution  at  Staunton  tliat  he  can  not  have  failed  to  acquire  a  hirg«^ 
fund  of  that  kind  of  practical  experience  which  so  greatly  assists  in  the 
successful  diagnosis  ai.d  management  of  the  mahulies— mental  or  other- 
wise— of  the  insane. 


IN  MEMORIAM. 


Dr.  Wm.  8.  Cliipley.  who  died  at  College  Hill,  Ohio.  Feb.  11th. 
18S0.  of  dilation  and  valvular  insufficiency  of  the  heart,  was  born  in 
Lexington.  Ky..  October  ISth,  1810.  He  was  a  student  in  the  office  of 
the  distinguished  Dr.  Benj.  Dudley,  and  received  the  degree  of  Doctor 
of  Medicine  from  the  Transylvania  Universitj*.  1S3I.  He  located  soon 
after  at  Columbus,  Georgia,  where  he  remained  for  ten  years.  Return- 
ing to  Lexington,  Ky.,  he  devoted  himself  to  his  profession ;  and  as  a 
general  practitioner,  a  teacher  of  medical  science  in  the  Transylvania 
School,  and  Medical  Superintendent  of  the  Eastern  Limatic  Asylum  of 
Kentucky,  at  Lexington,  the  oldest  and  for  a  long  time  the  largest  in- 
stitution of  the  kind  west  of  the  mountains,  he  achieved  a  reputation 
worthy  of  his  calling,  which  grew  wider  and  better  with  hii- 
years.  On  retiring  from  the  Superintendency  of  the  State 
Asylum,  Dr.  Chipley  opened  a  pnvate  asylum  for  the  treatment 
of  mental  disorders,  in  Lexington,  tiut  was  soon  afterwards  burned 
out,  with  great  loss  to  himself  pecuniarily,  as  tlie  insurance  company 
which  earned  a  lisk  on  his  building  and  furniture  failed  before  adjust- 
ment of  the  losses  could  be  made. 

In  the  course  of  events  Dr.  C  hipley  was  restored  to  the  Superinten- 
dency of  the  State  Asylum  at  Lexington,  only,  however,  to  be  displaced 
again  l)y  political  influences,  a  few  weeks  afterwards. 

For  the  last  live  years  Dr.  Chipley  had  charge  of  the  '"Cincinnati 
Sanitarium."  where  he  died— and  altliongh  well  advanced  in  years — 
bereft  of  his  wife  and  removed  from  liis  children  and  life-time  associations. 
he  brought  to  his  new  field  of  labor,  reputation,  skill  and  habits  of  industry 
which  soon  placed  the  '•Sanitarium"  upon  a  basis  of  usefulness,  whidi 
alone  was  required  to  ensure  success. 

Professionally,  he  had  laid  broad  foundations  in  general  principles  of 
science,  and  remained  a  student  to  the  last,  as  the  well  selected  and  well 
marked  books  in  his  private  ofiice  bear  testimony.  His  mind  was  com- 
pact and  comprehen>ive,  rather  than  tlifluse  and  speculative.  He  was  not 
inclined  to  adopt  new  tlieories  and  remedies  without  careful  consideration. 
Consei-vative  without  timidity,  he  was  rational  rather  than  ideal,  in  senti- 
juent  as  well  as  in  science. 

Dr.  Chipley  leaves  four  children,  all  grown. — and  his  aged  motl)er. 
whose  home  had  been  with  him — and  who  was  to  have  celebrated  iier 
ninety-first  birthday  on  the  day  of  her  son's  death.  Dr.  Chipley's  father 
was  a  minister  of  the  Gospel — long  and  familiarly  known  at  Lexington 
as  "Father  Chipley."  O.  E. 


Editorial.  269 


The  Death  of  Carl  Fkiepuich  FLE.AnrixG. — The  AUgemeine  ZeitsehHft 
fuer  Psychiatrie  und  Psychich-Gerichtliche  Mediein,  conies  to  us  with  a  metno- 
lial  pao-e,  clothed  in  mourning-,  to  the  memory  of  its  senior  editor,  Carl 
Friedrich  Flemmino-.  He  was  born  Dec.  ^rth.  1779,  at  Juesterbock,  and 
died  at  Weisbaden,  Jan.  27th.  of  the  present  year,  and  was  buried  at 
ycliwerin.  in  Mecklenburo-,  Feb.  3d. 

His  surviving-  colhiborators  thus  spealc  of  him  : 

••As  a  true  Icnight  in  the  arena  of  intellectual  combat,  he  has.  through- 
out a  long-  life,  fought  victoriously  for  his  profession.  He  built  the  tirst 
hospital  for  the  insane  in  Germany ;  aided  in  the  founding  of  this  Journal; 
was  one  of  the  founders  of  the  Association  of  German  Physicians  for  the 
Insane.  As  president  of  this  association,  he  directed  and  presided  over  its 
destiny  for  many  years.  His  scientific  and  practical  experiences  are  record- 
ed in  numerous  publications.  By  his  long  and  active  life,  the  versatility  of 
his  acquirements,  his  untiring  capability  for  work,  and  his  ceaseless  aspira- 
tions after  progress,  and  his  co-operation  in  so  many  ways.  he.  more  prom- 
inently than  any  other,  aided  in  the  construction  and  recognition  ot  German 
psychiatry  as  a  specialty.  With  him  the  hist  pioneer  of  German  alienism 
lias  been  lowered  into  the  grave." 

LocKHART  Clark  anb  D.  J.  Corrigax.— The  recent  death  of  these  two 
great  men  is  a  severe  loss  to  medicine  in  Great  Britain.  It  is  to  us  a  source 
of  regret  that  we  cannot  honor  their  memories  with  the  space  their  past 
distinguished  services  to  the  profession  deserve. 

The  latter  was  born  in  Dublin,  in  1802,  and  was  the  last  survivor  of  that 
immoital  phalanx  of  Irishmen,  Maish,  Stokee  and  Graves,  whose  memories 
will  live  so  long  as  the  heart  of  mankind,  whose  diseases  they  contributed 
so  much  to  elucidate,  shall  continue  to  beat. 

Tlie  former,  born  in  1812,  has  contributed  more,  perhaps,  than  any 
other  Englishman,  toward  the  enlightenment  of  his  countrymen,  upon  the, 
physiology  and  pathology  of  tlie  nervous  system.  Every  modern  English 
alienist  of  note  lias  paid  just  tribute  to  his  genius  and  researches. 

The  pages  of  Maudsiey  and  Blandford,  especially,  bear  record  of  his 
valuable  labors  in  cerebral  histology. 


-1^ 


THE 


Alienist  i  Neurologist, 


VOL.  I.  JULY,  1880.  :so.  3. 


O vvtt'vwivV  C o w\yv\> vv\.'vo \\% , 


Art.  I.— Topical   Diagnosis  of  Disease  of 
the  Brain. 


'Topische   Diagnostic  der   Gehirn-Kranhheiten."' — Von  Dr.    Noih?iaffel, 
Berlin.  1879. 


Seppilli — Workman  . 


TN  this  recently  published  work,  Nothnagel  has  been 
able  to  form  a  treasury  of  all  those  cases,  scattered  in 
medical  literature,  of  cerebral  diseases  well  defined  in 
their  seat,  and  well  observed  in  their  clinical  manifestations, 
and  thus  to  establish  the  symptomatology  according  to 
the  diverse  regions  of  the  brain,  and  to  declare  from  them, 
most  useful  precepts  for  diagnosis  of  their  seat.  He  does 
not  at  all  enter  into  physiological  questions,  because, 
as  he  well  observes,  the  diagnosis  of  the  seat  of  cerebral 
lesions    ought    to    be    founded    solely    on    experience  and 

Not  having  in  liaud,  the  above  treatise,  we  have  to  acknowledge  onr  indebtedness 
to  Dr.  Seppilli,  one  of  the  editors  of  the  Revista  Sperimentale,  for  this  very  interesting 
.summary  of  its  most  important  contents,  clothed  in  the  attractive  garb  of  his  own 
pure  and  lovelv  Italian.  We  do  not,  however,  reproduce  the  whole  of  Dr.  Seppilli's 
review,  which  would  be  too  lengthy  for  the  available  pages  of  the  Alienist  and 
Xeurologist,  but  content  ourselves  with  the  presentation  of  its  most  instructive 
passages. — Ed. 


272  Sepilli—  Workman. 


observations  at  the  bedside  of  the  patients,  or  on  the 
anatomical  table.  In  the  introduction  to  the  work,  he 
indicates  the  method  which  he  has  followed,  in  order  to 
reach  conclusions  of  some  value  in  relation  to  topographic 
diagnosis,  and  before  all,  to  demonstrate  how  it  is  that 
from  the  rich  assemblage  of  cerebral  lesions  connected  with 
diseased  foci,  in  which  the  morbid  process  has  a  chronic 
course,  or  is  stationary  or  quite  circumscribed,  and  (not 
causing  compression,  or  provoking  disturbance  in  the 
circulation,  or  a  phlogistic  state),  does  not,  in  any  way, 
influence  the  surrounding  parts.  Hence,  the  author  takes 
no  account  of  cases  of  acute  encephalitis,  but,  instead, 
of  these,  of  those  in  which  the  inflammatory  phenomena 
have  disappeared,  leaving,  however,  foci  of  stationary- 
softening,  or  of  old  and  encapsulated  abcesses.  The  best 
material  for  local  diagnosis  is  given  by  hemorrhagic  foci, 
and  by  softening,  but  in  this  selection  we  should  proceed 
with  much  caution,  since  it  is  not  infrequent  to  observe 
that  conclusions  are  drawn  from  foci-extensive,  multiple, 
or  too  recent.  According  to  Nothnagel,  we  ought  to  wait, 
at  least,  for  a  period  of  from  six  to  eight  weeks  after  the 
outset,  before  referring  the  observed  phenomena,  to  a 
morbid  focus.  Cerebral  tumors  very  frequently  lead  to 
diagnostic  errors  with  respect  to  location.  If,  however, 
these  are  considered  with  much  prudence,  they  may 
sometimes  have  special  interest  in  the  diagnosis  of  seat, 
since  they  are  associated  with  a  series  of  important 
phenomena  characterized  by  excitement." 

[The  reviewer — then  proceeds  to  quote  at  some 
length,  observations  on  cases  detailed  by  the  author, 
which  we  must  pass  over, — that  we  may  reach  their 
analysis,  as  presented  nearer  the  conclusion.] 

Analysis  of  the  Observations. 

The  author,  after  having  collected  the  clinical  observa- 
tions of  cortical  lesions,  according  to  their  seats,  proceeds 
to  study,  in  the  complex  way,  in  what  manner  and  in 
what  cases    the  several  functions  of  motion,  sense,  etc.,  are 


Regional  Brain  Disease.  273 

altered.  He,  however,  takes  special  account  of  those  cases 
in  which  the  lesions  embrace  only  the  gray  substance,  and 
the  medullary  substance  lying  immediately  under  it. 

I.     DisUirbaiice  of  Motility. 

From  analysis  of  the  cortical  lesions  pertaining  to  the 
frontal,  temporal,  occipital  and  parietal  convolutions,  and 
those  of  the  insula,  it  results  that,  with  exception  of  the 
central  convolittions  of  the  paracentral  lobule,  all  the  other 
regions  of  the  cortex  may  be  diseased  without  paralysis  of 
^notion  being  produced.  In  some  rare  cases,  in  which  the 
last  named  convolutions  have  been  observed,  an  accurate 
examination  shows,  most  usually,  that  the  central  convolu- 
tions have  shared,  either  directly  or  indirectly,  in  the 
morbid  process ;  and  though  the  same  cannot  be  said  of 
some  few  cases  (4  and  6),  it  yet  seems  more  logical  to 
ascribe  the  discrepancy  to  some  oversight  in  the  autopsy, 
or  to  some  complication,  than  to  oppose  so  small  a 
number  of  cases  to  the  results  declared  from  a  large 
number  of  significant  observations.  On  the  other  hand, 
lesions  of  movement  are  manifested  when  a  morbid  process 
has  its  seat  in  the  anterior  and  posterior  central  convolutions, 
and  in  the  paracentral  lobide.  This  is  demonstrated  in 
those  cases  in  which  the  lesion  is  so  often  exclusively 
limited  to  the  central  convolutions,  and  when  it  follows 
secondary  atrophy  in  the  motor  zone,  consequent  on  the 
amputation  or  loss  of  an  extremity.  There  are,  however, 
some  cases  which  seem  opposed  to  the  fact  here  stated, 
but  when  accurately  analyzed  they  are  not  so ;  the  author 
demonstrates  this  examination  of  a  case  observed  by 
himself,  and  that  by  Samt,  as  well  as  others,  in  which 
neoplasms  were  described,  which,  from  their  nature,  were 
unaccompanied  by  grave  functional  disturbances,  or  by 
any  whatever ;  also  the  cases  recorded  by  Lusanne  and 
Lemoigne,  in  support  of  their  theory,  that  motor  function 
is  unrelated  to  the  cortex.  Therefore,  from  a  diagnostic 
point  of  view,  he  establishes  the  following  corollary : — 
"  Whe)i  in  any  case  the  disorders  of  motion  may  be,  or  ought 
to  be,   attributed  to  a  cortical  affection,    this  is  found  in   the 


274  Seppilli—  Workman. 

central  convolutions  and  the  paracoitral  lobule  alone,  or  at 
the  same  time  in  other  parts. 

As  regards  the  depth  to  which  a  cortical  lesion  should 
reach  in  order  to  produce  disorders  of  motion,  it  can  only 
be  established  that  these  arise  even  when  the  morbid 
process  is  quite  superficial,  or  has  hardly  compromised 
more  than  a  little  of  the  cortex  of  the  central  convolutions. 
It  is  then  of  great  physiological  consequence,  that  in 
superficial  lesions,  which  have  reached  no  depth  towards 
the  centrum  ovale,  paralysis  of  motion  has  not  only 
existed  from  the  outset,  but  may  persist  permanently. 

The  author  then  proceeds  to  consider  under  what  form 
disorders  of  motility,  depending  on  a  cortical  lesion,  may 
be  manifested,  {a) — Paralysis  of  Motion. — This  is  presented 
under  the  form  of  hemiplegia  total,  equal  to  that  depending 
on  a  diseased  focus  in  the  corpus  striatum,  and  in  such  a 
case,  it  is  impossible  to  make  exact  diagnosis  of  the  seat, 
(this  fact  w^as  established  also  by  Maragliano,  vide  this 
Revista,  Anno  iv.  Fasc.  iv.),  most  frequently,  paralysis, 
from  cortical  lesions,  affect  single  cerebral  nerves,  or  a 
single  extremity,  or  both  extremities,  without  participation 
by  the  cerebral  nerves.  The  French  authors  call  these 
monoplegias  and  dissociate  hemiplegias  (stuckweise  hemi- 
plegie).  Up  to  the  present  time,  the  following  forms 
have  been  mentioned:  ist,  isolate  ptosis;  2d,  facial 
paralysis ;  3d,  hypoglossal  paralysis ;  4th,  paralysis  of  one 
extremity,  and  most  frequently  of  the  superior;  5th, 
paralysis  of  two  extremities,  without  that  of  a  cerebral 
nerve ;  6th,  paralysis  of  an  arm,  with  that  of  a  cerebral 
nerve,  most  frequently  the  facial  (paralysis  of  this  ner\'e, 
and  of  the  inferior  limbs  has  not  yet  been  noted) ;  7th, 
paralysis  only  limited,  or  extending  to  the  nerve  ramifica- 
tions of  an  extremity. 

From  the  assemblage  of  cases  of  monoplegia,  studied 
by  the  author,  it  results  that  in  paralysis  of  the  facial 
and  hypoglossal,  the  lesion  falls  on  the  inferior  third  of  the 
central  convolution,  respective  to  the  fissui-e  of  Rolando;  in 
paralysis  of  a  superior  limb,  the  middle  third  is  affected,  and 


Regional  Brain  Disease.  275 

especially  that  of  the  ascending  frontal;  in  paralysis  of  a 
leg,  or  of  this  and  an  arm,  the  superior  third  is  affected. 
The  paracentral  lobe  seems  to  be  solely  in  relation  with  the 
limbs.  The  author  shows  that  monoplegias  and  dissociate 
hemiplegias  do  not,  of  themselves,  suffice  for  the  diagnosis 
of  a  cortical  lesion,  as  he  has  observed,  that  also  in  hem- 
orrhages, or  in  softening  of  the  pons,  though  in  very  rare 
cases,  we  may  find  a  paralysis  hmited  only  to  one  ex- 
tremity without  the  participation  of  cerebral  nerves.  The 
same  may  happen  from  lesions  of  the  cerebral  peduncle, 
or  of  the  internal  capsule  and  the  centrum  ovale.  On 
the  other  side,  then,  if  it  is  considered  that  the  above 
named  forms  of  paralysis  are  frequent  in  cortical  lesions, 
and  very  rare  in  those  of  other  parts  of  the  brain,  we 
may,  in  a  given  case  of  monoplegia  [of  cerebral  origin),  re- 
gard it  with  great  probability  as  of  cortical  positioji. 

In  the  monoplegic  form,  in  the  circumstances  accom- 
panying it,  and  the  mode  of  its  development,  what 
relations  exist  which  may  serve  as  a  point  of  departure 
for  a  precise  diagnosis  ?  First  of  all,  we  are  to  consider 
that  isolate  ptosis,  without  other  symptoms,  and  the 
paralysis  of  a  single  extremity,  have,  up  to  this  time,  at 
least,  been  met  with  only  in  cortical  lesions  (the  latter, 
perhaps,  oxAy  in  cases  of  central  foci).  Further,  paralysis 
of  the  facial,  which  proceeds  isolated  in  basilary  affections 
of  the  pons  and  the  corpora  striata,  is  extended  to  all  its 
branches,  whilst  that  depending  on  cortical  paralysis, 
according  to  the  author's  observations,  is  generally  cir- 
cumscribed to  the  interior  portion  of  the  facial.  These 
are,  however,  cases  of  cortical  lesions  with  complete  facial 
paralysis  (  Hitzig,  Samt ).  Hence,  it  results,  that  the 
dissociate  form  of  simple  paralysis,  in  cortical  monoplegias, 
offers  great  diagnostic  probability,  but  not  absolute 
security. 

The  slow  and  unforeseen  development  of  monoplegia, 
with  or  without  loss  of  consciousness,  does  not,  in  a 
majority  of  cases,  constitute  a  differential  character,  since 
both  these  possibilities  are  met  with,  resulting  from  lesions. 


Sepilli—  Workman. 


situate  in  different  localities.  But  the  concomitant  phen- 
onema  frequently  offer  a  point  of  departure  for  different 
diagnosis.  And  thus,  if  with  a  paralysis  of  motion  of  one 
or  both  of  the  extremities,  there  are  associated  vaso-motor 
and  sensitive  disturbances,  it  may  be  admitted,  with  great 
probability,  or  almost  with  security,  that  the  focus  of 
disease  has  not  its  seat  in  the  cortex.  On  the  other 
hand,  if  with  isolate  facial  paralysis,  there  is  found  aphasia, 
of  contemporary  origin,  we  should  search  for  the  seat  of 
the  focus,  not  in  the  corpus  striatum  or  in  the  pons,  but 
in  the  cortex.  For  the  diagnosis  of  a  cortical  monoplegia, 
the  most  important  signs  are  given  by  the  phenomena  of 
excitation  of  motion,  which  precede,  follow  and  accompany 
the  paralytic  phenomena. 

From  these  considerations,  the  author  concluded,  that 
the  form  of  a  monoplegia  and  its  mode  of  development  are 
almost  never  secure  signs  for  the  admission  of  either  its 
cortical  or  its  non-cortical  origin,  zvhilst,  hoivever,  this  deci- 
sion may  be  deduced  from  certain  phenomena  ivhich  some- 
times accompany  monoplegias. 

{b).  Motor  Phenomena — Excitement.  These  are  divided 
by  the  author  into  two  groups,  as  follows  : 

ist.  Secondary  Contractures. — These  are  absolutely  an- 
alogous to  those  which  are  developed  in  subsequence  to 
certain  foci  in  the  centrum  ovale,  in  the  internal  capsule, 
in  the  cerebral  peduncle  and  in  the  pons.  They  do  not 
possess  the  least  value  as  diagnostics  for  cortical  lesons. 
2nd.  Convrdsions  ;  in  part  chronic,  and  in  part  tonic,  ivhich 
arise  in  an  acccssional  manner,  and  are  limited  to  one-half 
of  the  body,  or  to  a  certain  nerve  ramification  {epilepsia 
partialis  et  7inilateralis) — The  relation  of  these  localized 
convulsions  with  the  paralysis  of  motion  varies  in  an  ex- 
traordinary manner.  Thus,  in  cases  of  softening  and  of 
hemorrhage  at  one  time,  the  convulsions  precede  the 
paralysis,  at  another,  they  follow  it  some  hours  after,  or 
even  some  weeks  or  months. 

In  neoplasms,  the  localized  convulsions  very  frequently 


Regional  Brain  Disease.  277 

precede  the  paralysis  which  is  developed  more  tardily. 
In  the  majority  of  the  cases,  the  convulsions  are  of  the 
chronic  nature ;  frequently  there  are  also  tonic  contrac- 
tions, which  either  constitute  the  entire  paroxysm,  or 
precede  the  chronic.  The  convulsive  phenomena  compre- 
hend almost  all  the  paralyzed  parts ;  as  a  general  rule, 
they  are  not  always  limited  to  these.  It  is  characteristic 
of  these  convulsions,  to  commence,  ordinarily,  in  the  same 
group  of  muscles.  Consciousness,  in  most  of  these  cases, 
remaining  intact. 

ji'd.  Epileptic  Attack. — The  convulsions  extend  to  both 
sides  of  the  body,  but  they  differ  from  those  of  the  classic 
common  epilepsy.  In  epilepsy  of  cortical  origin,  the  com- 
mencement of  an  access  is  most  frequently  represented  by 
phenomena  of  excitement  of  motion,  which  are  in  some  cases, 
extensive.  In  certain  patients,  the  paroxysm  commences 
constantly  in  the  facial  muscles,  or  in  those  of  the  neck, 
or  of  one  extremity.  This  mode  of  comportment  is  so 
typical,  that  even  when  paralysis  of  motion  does  not  exist,  as 
in  some  cases  of  tumor  of  the  convexity,  it  ought  always 
to  lead  to  the  suspicion  of  cortical  epilepsy.  The  more 
extensive  is  the  convulsion,  the  more  frequent  is  the 
loss  of  consciousness.  The  history  of  cases  teaches, 
that  in  hemorrhagic  foci,  different  from  those  of  neo- 
plasms, epilepsy,  general  or  local  in  its  repetitions,  is 
usually  presented  with  the  same  characters.  In  the 
majority  of  cases,  from  the  incubation  of  the  disease 
to  the  bursting  out  of  the  first  epileptic  attack,  a  con- 
siderable interval  of  time  elapses  (rarely  less  than  six 
weeks). 

The  author  next  enters  on  the  study  of  the  diagnostic 
significance  of  the  phenomena  above  stated,  and  formulates 
the  two  following  conclusions  : 

"The  partial  convulsions,  which  result  in  sequence  to 
a  hemorrhage  or  a  softening,  may  be  taken  as  indicating, 
with  probability,  but  not  with  certainty,  a  cortical  lesion- 
On  the  contrary,  it  having,  up  to  the  present  time,  been 
observed,   that   only    in    morbid    processes    of    the    cortex. 


278  Seppilli—  Workman. 


parts  already  paralyzed  present  later  partial  convulsions, 
there  is  reason,  in  similar  circumstances,  to  make  diagnosis 
of  a    cortical    affection." 

"The  general  epileptiform  attacks,  which  are  manifested 
under  the  above  type,  and  are  developed  in  the  tardy 
course  of  an  epileptiform  hemiplegia,  dissociate  or  total, 
may  be  considered  as  one  of  the  most  important  and 
reliable  signs  of  a  morbid  process  localized  in  the  central 
convolutions." 

11.     Disturbances  of  the  liluscnlai'  Sense. 

"In  cortical  lesions,  very  rarely  have  symptoms  been 
described  which  may  or  ought  to  be  ascribed  to  a 
disorder  of  the  muscular  sense.  The  reason  of  this 
consists  in  the  frequent  omission  of  research  exclusively 
directed    to    such    disturbances. 

The  case  of  Wetter,  and  another  of  Kahlcr  (sense 
of  prickling  or  stinging  in  all  the  right  half  of  the 
body  ;  no  disturbance  of  cuta-nervous  sensibility,  nor  any 
paralysis ;  ataxy  of  the  right  arm ;  a  caseous  tumor  in 
the  cortex  of  the  posterior  part  of  the  left  frontal  and 
the  left  parietal  lobe),  demonstrate  that  lesion  of  the 
inusc7ilar  sense  may  exist  as  a  unique  symptom,  zvithoiit 
paralysis  of  motion,  and  zvithont  aitaneoiis  ancesthesia. 
In  all  the  cases  it  has  been  observed  that  the  patient  had 
no  idea  of  the  position  or  the  locality  of  the  affected 
extremity. 

The  clinical  observations  are  too  few  and  dubious  to 
permit  us  to  establish  to  what  part  of  the  hemispheres 
the  symptom  pertains.  In  some  cases,  the  lesion  was  in 
the  parietal  lobe;  in  others,  a  lesion  of  the  central  convo- 
lutions was  added.  For  the  present,  there  is  datum, 
perhaps,  for  concluding  that  the  cortical  regions,  ivhose 
lesions  determine,  on  the  one  side,  paralysis  of  motion,  on 
the  other,  disturbances  of  the  muscular  senses,  are  in  close 
relations,  but  are  not  identical.  Further  observations 
may  show  whether  the  central  terminal  apparatus  of  the 
muscular  sense,  shall  be  found  on  the  anterior  part  of  the 
parietal  lobe. 


Regional  Brain  Disease.  279 

III.  Dishirbanccs  of  the  Cutaneous  Sensibility. 
The  author  cites  briefly  some  observations  on  cutaneous 
anaesthesia,  associated  with  other  morbid  phenomena,  in 
which  a  lesion  of  the  parietal  lobes  is  met  with  constantly. 
On  the  other  hand,  in  a  large  series  of  cases  of  lesions 
limited  to  the  central  convolutions,  hemi-anaesthesia  was 
never  met  with. 

The  researches  of  Meynert  have  made  it  presumable, 
that  in  the  lesions  of  the  occiputal  lobes,  anaesthesia  may 
be  manifested  ;  but  such  a  supposition  has  not,  in  reality, 
found  support  in  the  assemblage  of  morbid  cases  collected, 
because,  in  those  cases  in  which  a  real  anaesthesia  existed, 
other  regions  were  injured,  and  anaesthesia  and  other 
disturbances  of  sensibility  were  absolutely  wanting  in  lesions 
of  the  occipital  lobes. 

Hutchinson  believes  that  lesions  of  the  sphenoidal 
lobes  give  place  to  alterations  of  sensibility  ;  but,  accord- 
ing to  the  author,  nothing  positive  in  this  regard  exists. 
The  same  may  be  said  of  the  opinion  of  Ferrier,  as  to 
lesions  of  the  hippocampus,  in  connection  with  disturbances 
of  sensibility. 

Nothnagel  states,  that  it  is  not  yet  possible  to  estab- 
lish a  connection  between  the  disorders  of  cutaneous 
sensibility  and  cortical  lesions. 

From  the    clinical    cases  we  may  be  inclined  to  admit, 

as  relatively  quite  possible,  that    the  parietal   convolutions 

ought  to  be  considered  in  the  first  line  of  the  disturbances 

of   sensibility.      Nevertheless,  it    ought  to  be    added,  that, 

for  the    present    no    case    of   cortical    lesion    is    known,  in 

which    a    permanent    anaesthesia    has    been  noted,  without 

involving  the    medullary  substance  through  a  considerable 

extent.     It    follows,  that,  for  diagnosis    of   cortical   lesions, 

disturbances  of  cutaneous  sensibility  have  no  value. 

IV.     Disturbances    of  the    Visual  Faculty. 

These  may  be  divided  into    two    groups.      To  the  first 

•  appertains    hemi-anopsia.      The  visual    faculty  of  the  nasal 

retinal    section    of   the    eye,    opposite    to    the  seat    of  the 

focus  of  the  brain  disease,  and  that  of  the  temporal  section 


280  Seppilli— Workman. 


of  the  homonimous  eye,  are  injured.  Heml-anopsia  may 
be  lasting,  and  may  pass  as  a  symptom  of  decadence. 

To  the  second  group  there  belongs  a  special  form  of 
visual  disturbances,  first  described  by  Furstner,  and  after- 
wards by  Reinhard.  It  is  observed  only  in  the  eye 
opposite  the  cerebral  focus  (which  is  unilateral).  We 
do  not  here  treat  of  an  ordinary  ambliopia,  nor  of  a 
simple  weakening  of  the  visual  power,  but  of  a  disturbance 
of  the  sense  of  colors  and  forms,  and  a  loss  or  diminution 
of  perception  of  depth  (profondita?  space).  In  very  slight 
cases  the  optic  nerve  receives  and  conducts  the  visual 
impression  in  the  normal  manner,  and  the  patient  can 
indicate,  with  exactness,  the  retinal  images,  but  he  judges 
erroneously  of  their  relations  in  space,  and  confounds  the 
lines  and  letters  when  he  writes  and  reads,  etc.  To  this 
there  is  accidently  added  a  mistaking  of  colors;  at  such 
times,  the  patient  sees  everything  as  if  through  a  gray 
veil,  and  badly  distinguishes  objects;  in  some  cases  blind- 
ness exists. 

The  clinical  cases  which  serve  as  illustrations  of  these 
two  groups  of  visual  disorders  are  but  few.  Among  those 
of  the  first  group,  there  does  not  exist  even  one  of  a 
lesion  limited  to  the  cerebral  surface ;  the  medullaty  sub- 
stance is  akvays  involved  tJiroitgh  a  considerable  extcnsio)i 
(Pooley,  Hirschberg,  Wernicke,  Baumgarten),  The  author 
believes  that  in  the  case  of  Huguenin,  the  morbid  phen- 
omena were  due  not  to  the  cortical  lesion  alone,  but  in 
part — especially  the  hemi-ana^sthesia — to  that  of  the 
medullary  striatum.  Thus,  too,  in  the  cases  of  Furstner, 
which  belong  to  the  second  group,  the  lesion  of  one  was 
limited  to  the  occipital  lobe,  and  in  the  others  it  extended 
further.  All  the  clinical  cases  of  visual  disturbances  with 
lesion  of  the  hemispheres  (excepting  the  case  of  Huguenin) 
had  this  fact  in  common,  that  they  presented  lesion  of 
the  occipital  lobes,  which,  indeed,  in  two  cases,  were 
found  the  only  parts  affected. 

//  may  therefore  be  concluded  that  visual  disturbances 
(comprehending  both  groups)  depend  on  alterations   in  this 


Regional  Brain  Disease.  281 

region.  This  will  be  confirmed  by  the  following  observa- 
tions of  Huguenin,  ist,  on  the  brain  of  a  person  of  50 
years,  blind  in  the  left  eye.  On  the  left  side  were  found 
modifications  of  the  optic,  atrophy  of  the  pjdvinar,  of  the 
anterior  and  posterior  quadra-gemini,  and  of  the  external 
corpus  geniculatum  ;  further,  there  was  a  notable  diminu- 
tion of  the  convolution  of  the  occipital  lobes,  which  was 
more  marked  on  the  right  than  on  the  left  side.  2d,  in 
a  woman  who  during  many  years,  had  very  little  sight  in 
both  eyes ;  pronounced  atrophy  of  the  cortex  was  found 
in  the  convolution  of  both  sides. 

Visual  disturbances  have,  however,  been  reported  by 
Furstncr  and  RetJihard,  without  any  lesion  in  the  occipital 
lobes.  For  the  present,  it  is  not  possible  to  explain  these 
differences.  As  worthy  of  consideration,  in  further  observ- 
ances the  following  points  may  stand  as  merely  recorded  : 
Unilateral  lesions,  with  a  focus  in  the  cerebral  cortex,  and 
in  the  corresponding  medullary  stratus,  if  they  are  the 
principal  condition  of  the  visual  disturbances,  have  up  to 
the  present  always  been  followed  by  hemi-anopsia,  and 
not  by  unilateral  visual  disturbances,  but  with  these,  when 
they  have  been  dependent  on  cortical  disease,  diffused 
and  extensive  lesions,  usually  in  both  hemispheres,  have 
been  associated.  In  pronounced  hemi-anopsia  (excepting 
the  case  of  Huguenin),  the  occipital  region,  either  alone 
or    associatad    with  other    parts,    has  been  found    affected. 

What  diagnostic  value,  in  relation  to  cortical  lesions, 
have  visual  disturbances? 

It  is  certain  that  neither  in  hemi-anopsia,  nor  in 
ambliopia  and  unilateral  amaurosis,  can  they  alone,  suffice 
to  establish  the  precise  seat  of  a  morbid  focus,  since 
hemi-anopsia  may  depend  also  on  lesions  of  the  optic 
thalamus,  and  visual  disturbances  on  lesions  of  the 
posterior  part  of  the  internal  capsule.  However,  certain 
visual  disturbances,  together  with  other  clinical  phenomena 
may,  in  a  concrete  case,  establish  with  more  or  less  prob- 
ability, a  lesion  of  the  cortex,  or  of  other  parts  of  the 
brain.       The  author    then    remarks  as  follows  :       A    hemi- 


Seppilli  -Workman. 


anopsia,  which  arises  as  a  unique  and  unexi)ectcd  symp- 
tom, and,  perhaps,  after  an  apoplectiform  attack,  even  when 
opthahnoscopic  examination  is  negative,  may  be  referred 
to  a  cortical  lesion,  and  hence  to  the  probable  existence 
of  a  focus  in  the  occipital  lobes.  If  in  addition  other 
phenomena  present,  as  hemi-anaesthesia,  hemiplegia,  aphasia, 
the  interpretation  is  not  then  secure,  as  from  observation, 
made,  it  is  necessary  to  admit  a  greater  extension  of  the 
morbid  process,  and  in  certain  circumstances,  no  cortical 
lesion  whatever  may  be  present.  Unilateral  visual  disturb- 
ances may  be  held  to  depend  on  cortical  lesion,  when 
along  with  negative  opthahnoscopic  report,  symptoms  of  a 
diffuse  cortical  lesion  are  observed  without  phenomena 
indicating  a  focus ;  they  may  be  referred  to  a  morbid 
focus  situate  more  deeply  {internal  capsule),  if  with  them 
there  is  present  a  notable  hemi-paralysis  of  the  cutaneous 
sensibility,  and  of  other  nerves  of  sense.  What  portion  of 
the  cortex  should  be  regarded  as  affected  in  the  first  case 
we,  as  yet  have  not  data  to  establish. 

V.     Disturbances  of  the   Auditory   Faculty. 

There  is  an  interesting  special  form  of  auditory  dis- 
turbances, which  Wernicke  first  put  into  relation  with  a 
given  lesion  of  the  cortex  ;  he  called  it  sensorial  aphasia. 
Kussmaul  gave  it  the  name  of  7vord  deafness  (Taubheit). 
The  patients  hear  well,  distinguish  noises,  and  the  single 
words  of  those  who  speak.  The  acoustic  nerve,  therefore, 
receives  and  conducts  the  sonorous  sensations,  which  reach 
consciousness ;  yet  they  do  not  comprehend  what  is  said 
to  them,  and  they  reply  non-pertinently ;  they  do  not 
perform  the  acts  requested,  or  they  perform  quite  different 
ones,  and  thus  they  appear  to  be  deaf,  or  demented ;  but 
by  attentive  observance  we  may  be  persuaded  of  the 
contrary.      Aphasic  phenomena  are  also  noted. 

What  part  of  the  cortex  is  the  seat  of  lesion  in  this 
form  of  auditory  disturbance?  Wernicke  holds  that  we  are 
here  concerned  with  a  lesion  of  the  temporal  lobe,  and 
more  especially  with  the  T'.  Nothnagel  finds  nothing  to 
the  contrary.     The  relations  of  the  acoustic  nerve  with  the 


Regional  Brain,  Disease.  283 

temporal  lobe,  have  .been  demonstrated  by  Hugucnin,  from 
a  recent  case,  in  which  deafness  had  existed  in  connection 
with  atrophy  of  the  T'. 

But  cases  of  disease  of  the  temporal  lobes  exist  with 
out  deafness.  Kahlcr  and  Pick  have  sought  to  give  an 
explanation  of  this  fact.  They  have  established  that  deaf- 
ness exists  in  the  lesions  of  the  left  side,  and  is  wanting 
in  those  of  the  right  side.  The  same  relation  would 
here  be  constructed  as  for  ataxic  aphasia ;  the  acoustic, 
verbal  images  would  also  be  accumulated  in  a  predominant 
manner  in  the  left  hemisphere.  The  author  observes  that 
some  of  the  above  cases  should  be  left  out  of  considera- 
tion, as  from  the  description  of  them  no  certainty  results 
of  an  affection  of  the  T',  whilst  in  other  cases,  the 
fact  is  not  met  with,  or  it  exists  only  in  an  insignificant 
manner. 

Several  cases  of  lesion  of  the  entire  left  hemisphere 
and  hence  of  the  T',  have  been  known,  without  deaf- 
ness. They  are,  however,  old  cases,  for  explanation  of 
which  Kahler  and  Pick  have  recourse  to  the  vicarious  action 
of  other  parts.  Finally,  from  a  diagnostic  point  of  view, 
the  author  sums  up  in  the  following  manner :  Wlien  a 
symptomatic  representatio7i  of  zvord  deafness  is  presented,  it 
may  be  held  as  very  probable  that  some  morbid  process, 
exists  in  the  left  T' . 

VI.     Disorders  of  Language. 

Examination  of  the  rich  material  related  to  aphasia 
leads  the  author  to  hold,  as  beyond  discussion,  the  great 
and  real  importance  which  the  posterior  extremity  of 
the  F^"  (3rd  fronttal, — and  almost  always  of  the  left, 
though  exceptionally  of  the  right  side),  has  in  language. 
Disorders  of  speech  are  also  met  with,  from  lesions  of 
the  temporal  lobe,  and  more  especially  of  the  T^  of  the 
left,  and  through  these,  of  the  white  medullary  substance 
in  the  vicinity  of  the  F",  or  of  the  left  insula  alone. 
In  the  greater  part  of  the  cases  of  foci  in  the  parietal 
lobes,    these    disorders    have    not    been    met    with,    and    in 


284  Seppilli—  Workman. 


the  few  cases  in  which  they  have  been  present,  there 
is  reason  to  doubt  whether  they  should  not  be  put  in 
relation  with  parts  overlooked  in  the  examination,  rather 
than  with  lesion  of  the  parietal  convolutions,  Kussmaiil 
asserts  that  he  has  not  succeeded  in  finding  observations, 
sufficient  and  exact,  in  which  the  lesions  of  the  occipital 
lobes    had    provoked    true    aphasic  disorders. 

Is  it  possible  to  refer  the  diverse  forms  of  disphasia 
and  aphasia  to  given  lesions  of  the  cortex?  Wernicke  has 
located  motorial  aphasia  in  the  F-\  and  sensorial  in  the 
T'.  Kussmaul  has  found,  ist,  that  in  cases  of  true  ataxic 
aphasia,  or  of  aphasia  from  ataxia  and  amnesia  com- 
bined, there  is  found,  almost  without  exception,  a  lesion 
of  the  anterior  region  of  the  cortex,  either  alone  or 
along  with  that  of  the  posterior  part ;  2nd,  in  true  aphasia 
from  amnesia,  at  one  time  the  anterior  region  only  is 
affected,  or  at  another  the  posterior.  Nothnagel  adds,  that 
the  region  of  Broca,  the  posterior  third  of  the  F-^  the 
great  importance,  which  is  past  denial,  in  the  motila 
co-ordination  of  words ;  and  after  examination  of  several 
cases  he  lays  it  down,  that  in  isolated  lesions  of  the  region 
of  Broca,  ataxic  aphasia  is  almost  nevei  ivanting,  or  there  is 
at  least  a  mixed  form  of  aphasia  from  ataxia  and  amnesia. 
But  the  relation  of  ataxic  aphasia  with  destruction  of  the  F  ^ 
cannot  be  held  as  exclusive,  since  there  are  cases  (apparently 
quite  exceptionable),  in  which  ataxic  aphasia  has  been 
met  with,  with  lesion  in  other  parts  (the  insula,  temporal 
and  parietal  convolutions). 

It  is  not  possible,  from  existing  clinical  facts  to  draw 
conclusions  regarding  the  cortical  localization  of  aphasia 
from  amnesia.  The  same  fact  obtains  as  to  agraphia  and 
ataxia. 

VII.     Disturbances,     Trophic  and   Wiso- Motor. 

The  author  here  expends  but  few  words,  and  con- 
cludes that  these  disturbance  have  not  up  to  the  present 
any  significance  for  the  topographic  diagnosis  of  cortical 
lesions. 


Regional  Brain  Disease.  285 


VIII.     Psychical  Disturbances. 

The  author  here  limits  himself  to  the  observation,  that 
it  is  to-day  absolutely  impossible  to  resolve  the  question 
whether  the  disorders  of  the  intellect,  which  in  general 
depend  on  that  of  the  cortex,  have  any  given  location, 
or  are  on  the  contrary,  a  confederate  solidarity. 


Art.  II.— \Arhat  Shall  be   Done  with  the 
Inebriate?* 


By  GuRDON  W.  Russell,  M.  D.,  of  Hartford,  Conn. 

TN  considering  this  question,  practically,  we  may  regard 
^  the  habitual  drunkard  and  the  inebriate  as  one  and 
the  same,  for  though  some  have  made  a  distinction,  yet 
for  our  purpose,  it  is  a  refinement  of  nosology,  of  no  more 
real  use  than  is  much  of  the  nosology  in  medicine  divid- 
ing and  subdividing  the  symptoms  of  a  disease,  which 
should  be  general  and  characteristic  as  a  whole,  and 
which  is  to  be  subjected  in  the  main  to  the  same  general 
treatment.  This  subject  was  so  thoroughly  discussed  at 
our  last  meeting,  that  there  is  not  much  remaining  unsaid, 
and  I  must  be  excused,  therefore,  if  my  remarks  are  mainly 
to  the  question,  "What  shall  we  do  with  the  inebriate  ?" 

Drunkenness,  or  the  excessive  use  of  alcoholic  liquors,  is 
so  extensive,  seizing  upon  so  many  persons,  that  from  its 
very  frequency,  it  becomes  hard  to  deal  with.  When  we 
consider  the  number  who  are  the  subjects  of  alcohol, 
and  the  number  who  are  afflicted  with  poverty,  and 
those    naturally  dependent  on  them,  the  saying  is,  not  far 

•Read  before  the  New  EngUmd  Psychological  Society,  Sept.  13,  1879. 


Gurdon  TV.  Russell. 


from  correct,  that  it  takes  one-half  of  the  world  to 
properly  care  for  the  other ;  and  so  a  government  must  be 
very  paternal,  indeed,  which  undertakes  to  provide  for 
all  of  them,  upon  all  infractions  of  law  or  of  morals.  There 
must  be  a  certain  limit  to  the  care  or  oversight  exercised 
by  any  government ;  for,  if  its  energies  or  duties  are 
engrossed  by  petty  interferences  or  directions,  then  the 
great  objects  and  duties  of  government  are  apt  to  be  lost 
sight  of,  and  its  strength  and  influence  frittered  away  upon 
minor  details,  and  such  a  course  acts  injuriously  upon  the 
people,  also  takmg  away  the  robustness  and  independence 
from  the  individual,  learning  him  to  depend  less  upon  him- 
self and  more  upon  a  few. 

So  the  law  declares  certain  acts  to  be  crimes,  but  it 
does  not  interfere  with  every  wrong  doing,  nor  can  it 
remedy  the  numerous  cases  of  cruelties  in  families,  of 
abuses  of  parents  and  children,  of  petty  quarrels  and  an- 
noyances among  neighbors,  unless  there  are  of  a  gross  and 
aggravated  character,  and  are  publicly  brought  to  its 
notice.  These,  in  their  effect  upon  men,  are  often  much 
more  serious  in  their  nature  and  injurious  in  their  results 
than  many  of  the  offences  which  it  does  seize  upon  and 
attempt  to  adjudicate. 

But  drunkenness  is  a  crime  ;  it  is  so  considered  in  the 
law,  and  divine  declaration  has  said  that :  "No  drunkard 
shall  inherit  the  Kingdom  of  Heaven." 

It  is,  therefore,  a  subject  of  so  much  importance  that 
we  cannot  escape  from  it  ;  nor  do  I  feel  that  I  can  grapple 
satisfactorily  with  the  question :  "What  shall  we  do  with 
the  Inebriate?" 

He  who  answers,  that  with  no  alcohol  there  would  be 
no  inebriation,  summarily  disposes  of  this  matter;  but 
then  other  questions  might  arise,  whether  upon  the  whole, 
considered  in  its  whole  breadth,  both  in  relation  to  its 
use  by  man,  and  its  use  in  the  manufactures  and  arts, 
the  world  is  not  better  by  its  discovery ;  and  also 
whether  all,  or  even  a  majority  of  those  who  now  abuse 
it  would,    in  its  absence,    be   good   citizens,  perfectly  moral 


What  Shall  he  Bone  with  the  Inebriate.  287 

in  their  character,  free  from  all  evil  passions,  and  wicked 
conduct — in  a  word,  perfect  patterns  of  the  upright  man. 
That  certain  of  them  would  be  better,  and  that  a  ma- 
jority even  would  be  better,  I  have  no  doubt.  But  a 
large  number  are  defective  by  nature,  and  by  this  I  mean, 
that  their  mental  and  physical  characteristics,  even  at 
the  time  of  their  generation,  and  added  to  during  the 
period  of  pregnancy,  and  further  increased  by  their  sur- 
roundings after  birth,  are  so  bad,  that  they  fall  into  evil 
habits  easily,  have  no  very  deep  sense  of  the  sins  which 
they  commit,  and  are  rather  surprised,  than  otherwise,  that 
society  ever  feels  bound  to  interfere  with  their  conduct. 
Now,  exactly  where  this  doctrine  will  lead,  I  shall  not 
speculate  upon,  for  enough  has  been  written  upon  it, 
but  if  investigators  and  close  observers  knew  this  to  be 
true,  then  the  whole  responsibility  does  not  fall  upon 
the  inferior  resultant  or  debased  nature  or  understanding, 
but   would   rest,  in   part,    upon  some   of  the    progenitors. 

This  view  should  lead  us,  therefore,  to  be  lenient  in 
our  judgment,  and  endeavor  to  overcome  a  part  of  the 
evil  by  moral  means ;  leaving  the  law  to  deal  with  those 
subjects  found  to  be  incorrigible,  and  some  do  seem  to 
be    perfectly    incorrigible,  headstrong,    sensual,    devilish. 

"Not  all  the  blood,  of  all  the  Howards, 
Can  ennoble  knaves  to  cowards. " 

They  are  amenable  to  neither  entreaty  or  command ; 
the  strong  hand  of  the  law  only  can  control,  whilst  it 
does   not    reform    them. 

As  the  law  regards  drunkenness  as  a  crime,  it  will 
be  well  to  consider  why  the  law  should  not,  in  all 
cases,  be  enforced ;  whether  with  the  common  drunkard 
or  the  occasional  drunkard,  or  whether  it  occurs  in  the 
lowest  or  highest  classes  of  society.  If  all  cases  were 
punished,  then  the  magistracy  would  be  necessarily  increas- 
ed, and  a  large  part  of  society  would  be  under  punishment ; 
the  moral  influence  of  this,  of  course,  is  bad,  and,  so  wisely, 
the  law  takes  no  cognizance  of  cases  not  brought  to  its 
notice ;    one    may    get   drunk   in    his   own  room,    day    after 


288  Ourdon  TV.  Russell. 


day,  yet,  if  he  does  not  seriousl)'  injure  himself  or 
squander  his  property,  and  is  not  Hkely  to  become  a 
tax  upon  the  community ;  is  not  noisy,  so  as  to  disturb 
his  neighbors,  and  does  no  personal  violence  to  another, 
the  chances  are  that  he  is  persistently  let  alone. 
The  paternal  government  does  not  interfere  with  him  as 
long   as  he   interferes  with    no    one    else. 

This  may  be  the  best  course ;  some  will  consider  it  the 
most  judicious,  but  we  should  not  forget  that  what  the 
man  has  done  is  a  crime,  so  pronounced  by  the  law,  yet 
ignored  by  the  law,  leaving  its  enactments  to  be  broken 
without  punishment,  and  so  lessening  the  terms  as  other 
enactments,  and,  perhaps,  encouraging  the  transgressor  in 
further  and  more  serious  crimes.  Now,  no  one  becomes 
bad  all  at  once,  and  possibly,  if  the  law  had  been  en- 
forced at  its  first  transgression,  then  all  the  future  life  of 
the  transgressor  might  have  been  fair. 

That  such  would  be  the  case  in  some  instances,  I 
have  no  doubt.  The  accidents  of  time  and  associations 
may  induce  the  first  drunkenness,  without  any  such  intentions 
on  the  part  of  the  man,  and  when  brought  before  the 
law,  he  recognizes,  at  once,  if  there  is  any  virtue  in  him, 
the  perilous  position  he  is  in,  and  cries  out  in  the  bitter- 
ness of  his  sorrow,  "My  God !  what  will  become  of  me  ? 
this  must  be  stopped ! "  And  the  chances  are  that  it  is 
stopped  ;  it  is  his  first,  and  only  experience.  I  recall  the 
case  of  a  young  man,  who,  after  a  military  parade,  rode 
about  the  streets  with  prostitutes,  drinking  at  saloons 
until  all  were  drunk ;  who  was  arrested  by  the  police 
and  arraigned  before  the  justice.  The  shock  was  so 
great  to  his  moral  sense,  that  he  never  sinned  again. 
Yet,  if  his  case  had  been  ignored  by  the  law,  or  his 
conduct  only  gently  reprimanded  by  a  friend,  the  chances 
are  that  this  drunkenness,  of  an  accident,  would  have 
degenerated  into  the  drunkenness  of  a  habit.  I  think 
there  are  like  operations  in  other  crimes,  when  the  crimi- 
nal, to  his  great  astonishment,  finds  himself  a  victim  of  the 
law,  and  the  inmate  of  a  jail.     The  crime  was,   in  no  way, 


What  Shall  be  Done  with  the  Inebriate.  289 

premeditated,  and  was  the  result  of  associations — in  a 
word,  was  an  accident.  He  realizes  his  condition,  and 
resolves  never  again  to  be  called  a  criminal.  If  he  is  in 
earnest,  and  has  in  him  the  elements  of  a  man,  he  guides 
his  way  carefully  eve  •  afterwards.  His  being  inveighed 
with  his  crime,  was  not  unlike  the  way  of  the  one  who 
was  inveighed  into  drunkenness.  Had  it  been  overlooked, 
and  the  sinfulness  of  it  not  been  made  apparent,  then, 
perhaps,  he  would  have  drifted  into  other  and  greater 
crimes.  It  is  the  persistency  in  drunkenness  and  other 
crimes,  that  makes  them  so  difficult  to  be  remedied.  The 
moral  nature,  like  the  physical  structure,  soon  adapts 
itself  to  its  surroundings.  The  man  becomes  a  drunkard, 
easily;  he  also  becomes  a  thief,  easily;  he  becomes 
untruthful,  easily.  I  know  that  many  fall  into  these 
ways  easily,  for,  as  I  have  explained,  it  is  their  nature  ; 
but  not  a  few  are  the  result  of  no  deliberate  intent,  only 
of  time  and  places  and  associations.  Few  women  lapse 
from  virtue,  deliberately ;  it  is  usually  the  result  of  accident ; 
but  persistance  in  prostitution,  from  any  cause,  gives  little 
chance  of  reformation,  and  much  less  in  those,  when  from 
moral  debasement,  their  occupation  is  regarded  as  a  trade — 
as  legitimate  as  any  other.  A  young  girl,  who  seemed 
to  be  intelligent,  and  was  working  in  a  book-binding 
establishment,  told  her  physician  that  she  might  as  well  be 
in  a  house  of  ill-fame  as  to  be  there,  required  to  work 
all  day.  Now,  with  such  a  mental  organization,  no  one 
is  to  be  reformed  as  a  drunkard  or  a  thief,  or  a  strumpet ; 
for  drunkenness  is  not  regarded  as  a  very  bad  thing,  nor 
theft  as  a  crime,  and  fornication  as  just  a  matter  between 
two  persons  only.  It  is  in  this  persistency  that  we  find  our 
greatest  obstacle  to  reformation,  and  to  this,  I  shall  soon 
further  refer.  A  London  police-officer  once  said  that  he 
would  walk  from  Sands  road  to  John  O'Greats  house,  to 
see  a    professional    burglar   who    had    fully    reformed. 

Thus  much  has  been  written,  not  because  I  believe 
that  every  first  transgression  should  be  met  with  the  pen- 
alties of  the   law,    but    that    it    should    be    in    some    way 


'290  Gurdon  W.  Russell. 


noticed,  and,  if  possible,  checked.  All  crime  or  vice  grows 
by  what  it  feeds  on,  and  it  grows  very  quickly,  and  is 
not  easily  eradicated.  "Whatsoever  a  man  soweth,  that 
shall  he  reap." 

I  may  add  in  this  connection  the  opinions  of  Sir  Wm. 
Gull,  who  "advocated  punishing  a  mere  drunkard,  and  do- 
ing it  early.  He  would  publish  the  name  of  a  man  found 
drunk,  and  if  found  a  second  or  more  times,  he  would 
put  the  number  of  times  opposite  his  name,  for  public 
reprobation,  although  quite  aware  that  society  would  not 
at  present  agree  with  him  in  this."  In  the  early  days  of 
New  England,  drunkenness  was  quite  common,  and  the 
punishment  was  frequent;  besides  being  fined,  the  criminal 
was  sometimes  whipped,  and  at  others  put  in  the  stocks, 
but  a  certain  number  continued  to  get  drunk,  and  were 
frequently  punished.  A  few  were,  undoubtedly,  deterred 
from  sinning  again  by  the  first  punishment,  but  soon  this 
became  too  often  an  old  story,  considered  of  no  special 
account  and  really  of  no  benefit  so  far  as  reformation  was 
concerned,  and  in  that  respect  corresponds  very  well  with 
the  punishment  now  accorded  to  common  drunkards 
ever)'where.  After  a  certain  time  the  man  becomes  reck- 
less, or  his  nature  is  so  blunted,  that  he  looses  his  self 
respect, — becomes  a  liar,  lazy,  feeble,  and  too  often  des- 
titude.  He  feels  no  degradation  in  imprisonment,  and 
is  so  lost  to  all  sense  of  honor,  that  he  is  really  of 
little  use  in  the  world.  If  it  were  not  for  the  sake  of 
those  dependent  upon  him,  we  should  very  likely  say 
that  he  is  as  worthless  as  a  dead  man.  And,  yet, 
right  here  comes  in  the  question,  "What  shall  we  do  with 
the  Inebriate ;"  for  he  is  one  of  us,  and  must  be  provided 
for.  If  he  has  arrived  at  that  point,  where  he  is  wasting 
his  property,  or  has  wholly  wasted  it,  is  a  source  of  anx- 
iety and  fear  to  his  friends,  and  is  constantly  becoming 
a  tax  upon  society,  why  then  he  is  a  useless  fellow, 
and  society  has  a  right  to  try  to  make  a  better  man 
of  him.  It  has  been  exerting  this  right,  perhaps,  for 
years,    but   to     no    avail;    imprisonment    has    followed    im- 


What  Shall  be  Done  with  the  Inebriate.  291 

prisonment,  but  he  is  a  drunkard  still.  The  short  sen- 
tences which  have  been  imposed,  have  allowed  him  to 
recuperate,  and  he  comes  out  of  prison  in  better  health 
than  when  he  went  in,  with  no  idea  of  reformation  in 
his  mind,  or  if  he  does  entertain  it,  only  very  feebly, 
with  as  much  power  as  he  possesses  perhaps,  but  usu- 
ally only  to  relapse  upon  the  first  temptation.  I  know 
some  of  these  men  to  say  that  they  do  not  like  the  taste 
of  liquor,  and  that  it  is  very  disagreeable  to  them. 
This  is  doubtless  true,  sometimes,  for  there  are  men 
who  are  seized  with  a  sudden  frenzy  for  alcohol.  These 
are  usually  periodical  drinkers,  who  will  remain  temper- 
ate for  weeks  or  months,  and  then  suddenly,  without 
any  warning  to  those  around  them,  feeling  an  irresistable 
desire  for  alcohol,  start  off  upon  some  specious  plea, 
and  are  soon  drinking  all  the  stimulants  they  can 
procure. 

But,  to  most  of  them,  I  question  if  the  taste  is  dis- 
agreeable at  first ;  it  becomes  disagreeable  no  doubt,  after  a 
week's  debauch,  when  the  stomach  retains  neither  alcohol  or 
anything  else.  Then  the  poor  victim  is  in  a  miserable  con- 
dition ;  he  cannot  stop  drinking  if  he  wishes  ;  his  mental  pow- 
er, for  resistance,  is  at  the  lowest ;  he  may  be  as  ugly,  as 
cruel,  as  obstinate,  perhaps,  as  ever;  all  the  bad  elements 
of  his  nature  are  as  active  as  ever,  or  even  more  so, 
for  his  restraining  power  is  gone ;  the  balance-wheel  of 
the  machinery  is  deranged  and  it  drives  on  in  its  un- 
governed  motion,  until  arrested  by  a  superior  hand.  A 
dear  friend,  gentle,  unselfish,  generous  to  a  fault,  had, 
in  early  and  middle  life,  been  subject  to  periodical 
drinking.  Through  the  influence  of  friends,  and  the 
great  mercy  of  God,  he  had  been  able  to  restrain  himself 
for  years,  but  as  advancing  age,  and  imaginary  pecuniary 
troubles  came  upon  him,  he  occasionally  indulged  in  excesses. 
Like  many  others,  he  thought  they  were  concealed 
from  the  public,  though  he  openly  entered  nearly  every 
saloon  on  the  street,  and  like  some  of  them,  deserted 
alone,    he    would    continue  in  his  debauch    until    some  one 


292  Gurdon  W.  Russell. 

ordered  him  to  stop.  He  seemed  to  have  no  power, 
and  did  have  no  power  to  stop  of  himself,  and  so 
day  after  day  his  drinking  continued.  Repeatedly,  I 
have  said  to  him,  "Now,  this  must  be  stopped,"  and  the 
gentle  replies  were :  "Well,  if  you  say  so,  I  will  stop," 
and  he  did,  and  there  was  no  transgression  again — 
until  the  next  time,  a  period  of  four  or  six  months 
afterwards,  perhaps.  Sometimes,  when  I  knew  of  his 
excesses,  I  kept  away  for  days,  to  assertain  if  he  would  not 
stop  of  his  own  will,  but  never ;  though  he  always  did 
when  a   firm   voice    commanded    him. 

Now  I  do  not  wish  to  regard  this  case  of  my  friend 
as  one  typical  of  all  drunkards,  or  of  all  inebriates,  if 
that  term  suits  anyone  better;  but  it  is  typical  of  a 
class  of  them.  Nervous,  sensitive,  refined,  generous  and 
intelligent  ;  a  perfect  gentleman  in  his  dress  and  manner  ; 
sympathetic,  delicate  and  obliging,  there  was  a  restless- 
ness and  indecision  about  him,  a  disposition  for  excite- 
ment, and  disinclination  for  the  daily  processes  of  ac- 
tive life,  that  showed  how  deeply  he  was  excited  by  all 
the  sensitive  parts  of  his  organization,  and  how  little  he 
was  controlled  by  the  solid  reasoning  faculties  of  his 
mind ;  and  I  do  say,  that  he  was  typical  of  the  class 
of  impassioned,  impulsive,  periodical  inebriates,  whose 
cases   are    most    interesting  as    objects    of  study. 

And,  now,  right  here  arises  the  point,  as  to  the  actual 
disease  in  this  case,  either  of  the  brain  or  of  any  other 
organ.  Aside  from  the  time  when  in  an  actual  debauch, 
or  the  short  time  succeeding  it,  his  mind  was  as  ac- 
tive as  ever;  neither  in  his  enunciation  or  actions,  did 
he  show  that  it  was  at  all  disturbed.  He  regretted  his 
numerous  falls,  and  was  thoroughly  ashamed,  and  again 
and  again  resolved,  that  by  divine  aid,  there  should  be 
no  recurrence.  It  is  difficult  to  conceive  of  any  struct- 
ural change  in  the  brain  in  such  a  case,  though  it 
might  follow,  and  doubtless  does  follow  after  a  while, 
in  the  periodical,  as  it  usually  follows  in  the  common 
drunkard.     There    was    functual  disturbance,  doubtless,  and 


What  Shall  be  Done  with  the  Inebriate.  293 

this  is  probably  true  in  most  of  these  cases.  These 
people  bear  disappointment  poorly,  great  good  fortune  or 
great  calamities  affect  them  alike ;  a  little  excitement 
throws  them  off  their  balance,  and  they  fly  to  the 
stimulant  to  raise  their  spirits  if  depressed  ;  to  raise  them 
still  higher,  if  already  exalted.  It  matters  but  little  what 
the  exciting  cause  may  be,  some  irritation  in  business 
or  disturbance  in  domestic  affairs,  or  prolonged  idleness, 
are  equally  efficient.  I  have  repeatedly  seen  it  to  occur 
upon  trivial  or  grave  occasions  ;  a  quarrel  about  a  trifle 
excites  the  anger;  a  birth  in  the  family,  excites  a  joy, 
a  death  assures  the  grief,  and  the  common  result  is  a 
resort  to  alcohol. 

These  men  are  not  hereditary  drunkards,  but  they 
are  born  with  certain  tendencies,  which  we  call  heredi- 
tary, and  which  are  developed  under  certain  conditions. 
There  is  not  unfrequently  a  strumous  element,  or  a 
syphilitic  one,  or  some  constitutional  taint  existing,  in 
the  parents,  or  great  mental  disturbance  at  the  time  of 
or  shortly  before  the  generation,  or  decided  ill- health 
on  the  part  of  the  mother  during  pregnancy ;  a  neu- 
raesthenic  condition  which  forbids  the  expectation  of  a 
healthy  child ;  so  rheumatic  diseases,  and  consumptions, 
and  apoplexies  and  intemperance  are  readily  developed,  and 
it  is  curious  how  far  back  these  peculiarities  may  be 
traced,  often  through  several  generations.  These  families, 
however,  like  the  notably  intemperate  ones,  are  pretty 
sure  to  die  out  soon,  or  if  any  one  member  survives 
to  a  ripe  old  age,  it  is  due,  doubtless,  to  some  strug- 
gling spermatozoon  who  has  come  down  from  former  ages, 
and  escaped  contamination  in  his  generations  of  trans- 
mission. He  stands  out  a  living  and  lasting  example  of 
some  stout  old  fellow  of  a  century  or  centuries  ago ; 
and  his  extraordinary  vitality,  his  red  hair  possibly,  or 
some  peculiarity  of  features,  are  only  matters  of  tra- 
dition   in    his    family. 

I  have  repeatedly  requested  these  men  to  come  to 
me,    or     to     apply    to     some     friend,     as     soon     as     their 


294  Gurdon  W.  Russell. 

urgent  desire  for  stimulants  was  upon  them,  and  although 
they  promise  well,  yet  I  have  never  known  of  one  who 
complied  with  it;  and  further,  I  have  never  known  of 
one  who  has  said  that  he  would  not  do  it,  but  in 
a-half-ashamcd  way  would  offer  some  pretended  excuse 
for  not  keeping  his  promise ;  but  likely  it  was  like  this 
that  he  felt  the  need  of  something,  and  thought  he 
would  just  take  a  glass  of  beer  and  stop  there ;  he  did 
not  intend  to  take  anything  more,  only  the  one  glass. 
Fool  that  he  was,  he  could  not  stop  ;  he  had  not  the 
force  to  do  it,  if  he  was  disposed,  and  I  doubt  if  often 
they  are  much  disposed.  Having  commenced,  there  is  but 
one  course,  to  keep  on,  until  consciousness  is  drowned  in 
insensibility,  or  until  he  is  arrested  in  his  debauch.  He 
is  now,  I  believe,  in  a  majority  of  cases  powerless  to 
stop  of  himself;  having  fired  the  train  of  powder,  it 
burns  itself  out,    unless  tramped  upon    and    scattered. 

I  say  that  this  is  the  course  in  a  majority  of  the  cases, 
yet,  I  once  found  a  young  man,  who,  periodically  drank 
to  the  greatest  excess,  who  limited  himself  to  a  debauch 
of  sixty  days.  When  called  to  see  him,  on  one  occasion, 
he  said:  "This  is  my  last  day,  you  need  not  give  me 
any  medicine,  doctor,  I  shall  stop  now."  "I  don't  believe 
it,"  I  replied.  "Yes  I  can;  on  my  last  tear  I  had  a 
grand  old  bum,  and  I  kept  at  it  for  sixty  days,  and 
then  stopped  and  came  out  all  right,  and  I  can  now. "  "  But 
why  did  you  not  stop  before?"  "Oh,  I  was  on  a  tear,  and 
wanted  to  have  it  out ;  this  is  my  last  day,  and  I 
shall  drink  no  more," — and  he  did  not.  There  were 
intervals  of  months  between  these  turns,  and  then  he 
was  sober,  quiet,  industrious  and  gave  no  anxiety  to  his 
friends.  His  father  said  that  he  was  the  smartest  of  his 
sons;  was  quick  at  figures,  and  could  do  more  business 
than  any  of  them.  But  he  was  course,  sensual,  with 
no  realization  of  his  conduct ;  he  made  no  regrets, 
expressed  no  sor.ow.  He  had  been  at  Binghampton 
once,  where  he  remained  one  day,  and  in  an  insane 
asylum    once    or     twice,     where    he     remained     not    much 


What  Shall  be  Done  with  the  Inebriate.  295 

longer.  Good  advice  and  counsel,  he  assented  to, 
but  it,  apparently,  made  no  impression  upon  him ;  he 
talked  lightly  of  his  excesses ;  appeared  pleased  in 
recounting  his  vulgarity  and  brutality,  and  in  no 
way  showed  any  shame  for  what  he  had  done.  His 
education  was  fair,  his  intelligence  good,  was  fond  ol 
reading,  but  was  more  fond  of  attending  to  his  horse; 
lounging  about  the  stable,  and  talking  to  the  laborers. 
He  was  affectionate  to  his  wife  and  children  ;  the  darling 
of  his  mother,  who  secretly  supplied  him  with  money; 
the  darling  of  his  father,  when  sober ;  the  curse  of  his 
life,  when  drunk.  Feared,  coaxed,  petted  and  blamed, 
with  no  high  moral  sense  about  him,  but  unrestrained, 
and  filled  with  low  ideas,  how  could  he  ever  be  anything 
from  himself.  With  one  parent  supporting  him.  and 
the  other  alternately  encouraging  and  blaming  him, 
how  could  such  divided  counsels  ever  bring  about 
anything  but  misery,  even  if  the  mental  organization 
was  healthy.  His  father  was  active,  industrious ;  one 
of  the  most  laborious  of  men,  working  seven  days 
out  of  seven,  taking  no  recreation  whatever, — wholly 
absorbed  in  making  money ;  one  of  his  sons  was  feeble- 
minded ;  another,  amiable,  gentlemanly,  attending  to 
business  quietly,  and  a  good  citizen,  probably  come  down 
from  a  spermatozoon  of  previous  ages.  His  mother  was 
quiet,  unpretending,  rheumatic  and  somewhat  peculiar; 
one  or  more  of  her  brothers  were  also  peculiar,  visionary, 
unstable.  The  boy  came  naturally  by  all  that  pertained  to 
him;  all  that  was  bad  in  him  had  fallen  into  good  ground 
for  growth  ;  whatever  of  good  was  in  him,  had  received 
but  little  of  encouragement,  and  had  taken  care  of  itself. 
Now  this  case  I  have  dwelt  upon  somewhat,  because 
it  is  one  in  which  there  may  be  differing  views.  I  can 
see  here  no  evidence  of  a  brain  diseased,  and  in  truth, 
no  evidence  of  insanity.  There  is  moral  perversity  which  is 
very  plain,  and  existing  at  all  times,  and  at  the  period  of 
the  debauch,  perhaps  a  certain  amount  of  functual  brain 
disturbance,  but  this  must  be  small,  when    the  man  limits 


Gurdon  W.  Russell. 


his  debauch  to  sixty  days,  and  conchidcs  it  at  the  time 
appointed.  He  stops  then,  wiUingly,  but  no  inducements 
will  lead  him  to  stop  before.  About  forty  years  of  age 
and,  physically,  very  strong,  he  is  able  to  endure  yet  a 
great  deal  of  abuse  of  himself,  and,  probably,  will  continue 
it  as  long  as  he  lives. 

There  is  no  use  in  spending  much  time  with  such  a 
person  as  this.  Reason  has  no  influence  with  him  ;  shame 
has  no  abidement  in  him ;  his  animal  gratification  is  su- 
preme ;  all  his  ideas  and  tastes  are  low ;  though  ordinarily 
well-informed  and  well-behaved,  when  temperate,  yet  he 
is  "sensual-devilish,"  when  drunk.  What  shall  be  done 
with  him? 

Possibly,  something  might  have  been  accomplished  at 
the  outset  of  his  dissipation.  He  should  have  been  told 
that  drunkenness  was  a  crime  against  the  laws  of  God  and 
man,  and  then  publicly  flogged.  Probably  it  w^ould  have 
done  the  most  good,  in  this  case,  to  have  flogged  him 
first,  and  then  to  have  given  him  the  advice,  for  if  there 
is  anything  which  fellows  like  him  fear,  it  is  punishment 
upon  the  back,  which  hurts ;  which  comes  quickly  and 
unexpectedly,  and  which  hurts  him  where  he  is  most 
sensitive,  not  mentally,  but  bodily  ;  if  this  did  not  restrain 
him,  then  he  should  be  confined,  and  made  to  labor, 
receiving  such  moral  instructions  as  suited  his  case ;  and 
to  effect  much  good,  the  period  of  confinement  should 
not  be  short.  Not  much  can  be  made  out  of  him,  and 
he  does  not  require  a  great  amount  of  sympathy  to  be 
wasted  upon  him. 

In  the  case  of  my  friend,  previously  mentioned,  flog- 
ging would  have  killed  him  outright.  His  fine  sensibili- 
ties would  have  been  mortified  beyond  expression;  his 
honor  and  dignity  would  have  been  wounded  in  their 
most  sensitive  part.  His  shame  for  being  drunk  was 
great  enough,  but  he  could  never  have  lifted  his  head  af- 
ter this,  and  he  would  have  terminated  his  life  with  his 
own  hands.  Though  his  religious  sentiments  were  strong, 
and  he  was  earnest  in  his  prayers  for  strength  to  be  kept 


What  Shall  be  Done  with  the  Inebriate.  297 

from  temptation,  yet  I  think  a  public  flogging  would  have 
killed  him.  It  would  have  done  nothing  in  effecting  a  re- 
formation ;  it  would  have  led  him  to  overlook  the  crime, 
in  the  punishment  which  he  thought  still  greater.  What 
could  have  been  done  with  him?  Proper  restraint,  suitable 
occupation,  the  presence  of  a  friend,  always  near  to  en- 
courage and  admonish,  and  that  friend,  perhaps,  a  wife.  But 
it  is  a  lottery,  with  the  chances  against  him,  and  most 
men  are  like  him.  The  increased  responsibilities,  and  some- 
times perplexities,  weigh  hard  upon  all  such  nervous,  im- 
pulsive, sensitive  beings.  If  the  woman  was  wise  and  pa- 
tient above  most  women,  then  there  would  be  a  rea'^onable 
probability  of  success  in  reformation,  or  such  a  partial  re- 
formation as  would  make  life  tolerably  pleasant  to  both  of 
them.  With  one  of  a  different  character,  he  would  soon 
be  completely  ruined.  What  he  needs,  and  all  like  him 
need,  is  the  restraining  influence  of  a  mind,  stronger  and 
more  judicious  than  their  own,  whether  this  be  of  wife  or 
friend. 

What  is  the  pathological  condition  of  this  man?  There 
is  no  indication  of  any  disease  of  the  brain.  I  mean  by 
this,  that  there  is  no  reason  to  suppose  that  there  is  any 
structural  lesion  of  this  organ,  produced  by  his  use  of 
alcoholic  stimulants,  for  his  use  of  them  is  short  and  at 
unfrequent  intervals.  There  is  in  all  probability  some 
functional  disturbance,  similar  to  what  has  already  been 
mentioned,  and  back  of  this,  and  dominating  it,  is  the 
mental  condition  coeval  with  his  origin,  controlled  and 
modified,  perhaps,  increased  and  intensified  just  as  likely, 
by  the  circumstances  of  education  and  association.  His 
mind  is  clear,  active,  intelligent,  when  not  under  the  in- 
fluence of  stimulants ;  he  transacts  his  business  with  dis- 
cretion, his  judgment  is  unimpaired  ;  he  is  not  insane  ;  it 
is  a  perverted  use  of  the  term  to  call  him  so.  His  recovery 
is  rapid ;  it  is  as  frequent  as  the  attack  ;  unless  he  dies 
by  accident,  or  by  some  sudden  complications.  If,  however, 
this  evil  course  is  persisted  in  for  many  years,  then  the 
foundation  is  laid  for  organic  changes,  which  may  be  fatal. 


Gurdon  W.  Russell. 


Very  unlike  this  man,  but  similar  to  the  one    just  pre- 
viously mentioned,  is  a  class  of  young  men,  with  little,  or 
with      much     education,     of     uncontrolled     appetites     and 
possessive  of  wealth ;    these    are  usually,    but    not    always, 
idlers,    selfish    and    sensual,    with    little  regard    for  others; 
with  no  respect  for    age   or  friends,    and    possessing    very 
little  of  moral  sense;  their  aim  is  to  "enjoy  life,"   as    they 
phrase  it,    and   this   enjoyment   consists  in   spending  money 
freely,  in  drinking  and  riotous  living,  in  habits  of  idleness  and 
wontoness.    These  become  hard  and  continuous  drinkers,  and, 
fortunately,  die  early.     Fortunes  are  destroyed,  the  hearts  of 
parents  and  friends    are    broken,    anguish    overwhelms    all 
connected  with  them  ;  their  life  is  one  of  wretchedness  and 
misery.       If  reproached,  they    are    indignant;    if  it    is  told 
them,  after  repeated    disgrace,    that    they    are    not     to    be 
trusted,  as  their  promises  have  always    been  broken,    then 
they  talk  of  their  affronted    honor.         Why,    there    is    not 
enongh    of    honor     in    a  regiment    of  them  to    supply    an 
honest  man  for  one  day ;  they  are  not  to  be  trusted  ;  they 
are  deceptive  beyond  measure ;  they  are  wholly  unreliable. 
This  is  the  class  that  oftenest  get  into  our  insane  hospitals, 
and  are  the    quickest  in    getting    out ;    one    of   them    will 
demoralize  a  whole  ward  in  forty-eight  hours.     So  curious 
is  their  sense  of  honor,    that    they  prefer  to  be  sent  to    a 
hospital     for    the    insane,    rather    than    to    a    hospital    for 
inebriates.         They    show    wonderful    perception    here,     in 
considering  what    is    regarded    as    a    crime,    as    being    less 
disgraceful  than    a    calamity.        Nothing,    at  Binghampton, 
some  years  since,  gave  me    more    pain,  than    to  see  there 
a  large  number    of  these  fellows,  sauntering  idly  about  the 
halls,    with    hands    in     their     pockets,     restless,    unea.sy ; 
recounting   to    one    another,  with    evident    pleasure,    their 
dissolute  lives,  with  a  make-believe  of  good  behavior,  and 
waiting    impatiently  for  the  three  months  to  expire,  when 
as  one  said,  "the  old  man  will    come   down,    and    we    will 
go  to  Europe,  and  have  a  good  time." 

All  sympafliy  is  thrown  away  upon  tlicsc  fellows.   They 
need  and  will  listen  to  good  advice,  but  all  of  them  cannot 


What  Shall  be  Do/ie  with  the  Inebriate.  299 

appreciate  it;  and  the}-  need  also  the  restraining  influence 
of  labor,  and  of  a  strong  hand.  But  excessive  drinking 
and  excessive  venery  soon  makes  an  end  of  them  ;  a  few 
only  are  permanently  reformed. 

These  men  are  not  insane ;  their  mental  power  is 
weak  for  good,  but  very  strong  for  evil ;  their  moral  per- 
versity is  great ;  it  is  true,  certainly,  of  them,  that  the\- 
are  as  "prone  to  evil  as  the    sparks  to  fly  upward." 

The  common  drunkard  is  a  difficult  subject  to  deal 
with  ;  the  persistent  use  of  alcohol  has  led  to  unhealthy 
changes  in  the  bram,  in  the  digestive  organs  and  the  kid- 
neys ;  the  whole  nervous  system  is  in  a  diseased  state. 
His  intemperance  may  have  so  effected  the  brain,  that  he 
never  afterwards  fully  recovers  his  mental  powers,  even  if 
he  lays  aside  his  stimulants;  the  unnatural  congestion  of 
the  cerebral  vessels  causes  certain  structural  changes  in 
this  organ,  which  cannot  but  effect  its  power.  When, 
from  disease  of  any  kind,  we  find  the  brain  unusually  firm, 
or  unusually  soft,  we  think  we  have  the  evidences  of  disease 
unmistakable.  When  we  find  these  evidences  in  persons 
habitually  intemperate,  then  it  is  fair  to  suppose  that  al- 
cohol has  been  the  primary  cause.  In  one  instance,  I 
found  the  brain  almost  as  firm  as  if  it  had  been  macer- 
ated in  alcohol;  the  stomach  was  in  a  perfectly  healthy 
condition,  no  erosions,  no  inflammations — his  excesses  for 
many  years  had  not  troubled  his  digestive  organs ;  his 
mental  powers  were  weak,  however ;  his  ambition  was 
destroyed,  and  he  was  content  to  perferm  the  offices  of 
a  menial;  but  he  was  not  an  insane  drunkard,  nor  was  he 
demented  as  we  speak  of  senile  dementia,  but  there  was 
a  diminution  of  active  mental  force,  which  settled  him 
down  in  life  into  a  very  circumscribed  area.  The  chances 
of  reforming  such  a  man  are  small  indeed,  and  usually  he 
is  not  worth  much  when  he  is  reformed.  No  organ,  and 
especially  so  delicate  a  one  as  the  brain,  can  be  subjected 
for  years  to  such  harsh  treatment  as  the  drunkard  gives 
it,  and  not  show  evidence  of  disease  ;  if  the  scalpel  does 
not    reveal    it,  and      it     often    does     not,    we  may      hope 


300  Gurclon  W.  Russell. 

that  the  microscope  will  yet  effect  sometliing  in  this 
direction.  But  whether  the  pathological  condition  is  ever 
more  clearly  revealed  or  not,  yet  we  may  judge  from 
psychological  manifestations,  that  some  change  has  cer- 
tainly taken  place,  and  perhaps,  if  the  exact  change  was 
known,  we  should  be  no  better  prepared  to  treat  it.  It  is 
here,  as  sometimes  elsewhere,  that  the  careful  study  of  the 
rational  symptoms,  will  afford  all  useful  suggestions  for 
treatment.  I  would  be  one  of  the  last  to  undervalue  the 
study  of  pathology,  which  should  be  the  base  of  thera- 
peutics, but  the  minute  investigation  into  the  diseased 
structure,  does  not  always  produce  the  most  useful  prac- 
titioner. It  may  be  fairly  questioned,  whether  some  of 
the  older  physicians,  who  made  a  careful  study  of  symp- 
toms, did  not  do  as  much  in  effecting  a  removal  of  disease 
as  the  minutest  etiologist,  who  is  proud  of  his  precision. 
If  I  might  venture  to  suggest,  in  your  presence,  who 
know  so  much  better  than  myself,  I  would  say  that  it  is 
a  question  whether  a  violent  case  of  insanity,  though  it 
recovers,  yet  always  recovers  fully,  completely,  so  that 
the  patient  is  himself  again,  as  he  was  before  the  attack. 
I  can  understand  that  this  may  be  the  case,  if  the  mental 
disturbance  is  functional,  due  to  some  derangement  of 
the  digestive  organs,  for  instance  ;  but  if  it  is  due  to 
excessive  brain  action,  as  sudden  grief,  or  intense  appli- 
cation to  business,  tlicn  there  is  a  chance  that  the  brain 
has  received  a  shock  or  undergone  a  change,  which  permits 
of  a  recovery,  indeed,  but  a  recovery  which  leaves  it 
short  of  its  original  power.  That  this  does  not  always 
occur,  only  proves  that  the  cerebral  disease  was  compar- 
atively slight.  The  fact,  that  insanity  is  generally  incur- 
able, if  it  continues  for  some  length  of  time,  would"  indicate 
that  the  brain  is  exceedingly  sensitive  to  injurious  impres- 
sions. The  recoveries  which  have  taken  place  in  cases  of 
insanity  of  long  standing,  are  truly  wonderful,  and  are  of 
themselves  worthy  of  careful  study;  one  or  two  about 
which  Dr.  Butler  has  .spoken  to  me,  when  the  insanity  had 
lasted  nearl}'  twenty  }-ears,   I  think,  were  quite  remarkable, 


What  Shall  he  Done  with  the  Inebriate.  301 

but  even  here  he  doubted,  if  all  the  faculties  were  in 
perfection  again ;  there  was  still  something  singular  about 
these  persons,  he  said. 

Every  case  of  habitual  drunkenness  is  not  a  case  of 
dipsomania,  and  this  it  is  well  to  bear  in  mind.  Some 
men  drink  steadily,  day  after  day,  and  drink  to  excess, 
without  becoming,  daily,  absolutely  drunk;  they  may 
approach  pretty  near  this  point,  and  occasionally  become 
dead  drunk,  that  is  insensible ;  it  is  fair  to  term  these 
men  as  drunkards.  Not  always  is  there  with  them,  that 
raging  thirst  for  alcohol,  which  cannot  be  resisted.  They 
drink  as  a  matter  of  habit,  and  if  opportunity  is  not 
afforded  for  their  accustomed  stimulant  for  a  day  or  so, 
W'hilst  they  suffer  from  a  general  uneasiness,  as  an}-  one 
may,  whose  habits  are  interrupted,  yet  they  are  not 
raging,  uncontrollable,  upon  the  border  of  mania  a  potu. 
Their  moral  strength  seems  to  keep  down  the  emotional 
nature  which  some  have,  and  carries  them  on  safely  for 
a  short  time.  These  men  are  phlegmatic,  not  easily 
excited,  not  led  away  by  passion  or  nervous  excitement 
at  any  time  ;  the  very  fact,  that  they  are  so  passive,  has 
enabled  them  to  resist  the  destructive  poison  of  alcohol. 
There  is  not  fire  enough  in  them  to  be  kindled  by  a 
stimulant  which  would  overturn  a  dozen  of  more  nervous 
men ;  for,  from  their  very  nature,  as  well  as  from  long 
habit,  it  has  required  large  doses  to  arouse  them.  A 
friend,  in  the  company  of  Daniel  Webster,  found  him  to 
be  a  very  dull  companion,  and  remarked,  that  he  was 
much  disappointed  in  him.  "Wait  until  he  has  taken  a  few- 
more  glasses  of  brandy,"  was  the  reply,  "and  thea  judge;" 
and  he  afterwards  thought  differently.  Silas  Wright,  one 
among  the  great  men  of  this  nation,  was  another,  and  so 
phlegmatic  and  unimpressible  was  he,  that,  while  the 
stimulant  doubtless  gave  increased  mental  activity,  yet  it 
affected  but  little,  or  at  all,  his  general  conduct.  So 
that  what  Mr.  Clay  said  of  him,  "His  brain  is  never  drunk," 
was  not  far  from  the  truth.  Probably,  in  both  of  these 
celebrated    men,  there  were    to    be     found,    some    of    the 


302  Gurdon  W.  Russell. 


pathological  changes  which  are  to  be  found  in  the  brains 
of  habitual  and  excessive  drinkers.  But  they  were 
dipsomaniacs  in  no  true  sense  of  the  word  ;  they  liked  the 
stimulant,  and  were  incommoded  by  its  absence,  but 
they  had  none  of  ths  frenzy  of  the  dipsomaniac;  they 
could  have  been  shut  up  in  a  prison  or  confined  in  any 
hospital,  and  could  only  have  suffered  the  uneasiness  of 
interruption  of  the  habit.  It  is  doubtful  if  delirium  tremens 
would  have  been  developed  in  either  instance.  When 
set  at  liberty  again,  both  would  probably  have  returned  to 
their  former  ways,  but  more  moderately,  and,  perhaps 
never  to  the  previous  excesses.  It  may  be,  however, 
that  in  both,  the  use  of  stimulants  had  so  changed  the 
brain  structure  that  in  their  latter  days  they  were  led  to 
consider  as  serious  and  grevious  injuries,  those  disap- 
pointments which  would  have  been  more  lightly  regarded 
in  earlier  days. 

How,  unlike  these  men,  is  the  conduct  of  the  true  dipso- 
maniac. If  he  drinks  steadily,  he  drinks  excessively,  and 
is  soon  hopelessly  drunk ;  it  is  done  with  passion,  with 
fury;  he  will  not  be  controlled  ;  all  interference  is  resented, 
all  advice  is  disregarded;  his  reason  is  beyond  his 
control.  If  brandy  is  kept  from  him  he  will  drink 
alcohol  itself,  or  cologne,  or  bay  rum,  or  spirits  of 
camphor,  anything,  in  fact,  which  is  within  his  reach;  his 
one  desire  is  to  obtain  some  fluid  which  contains  alcohol ; 
he  will  even  drain  the  bottles  containing  anatomical 
preparations ;  nothing  comes  amiss  which  he  fancies  will 
gratify  his  thirst.  This  man  is  diseased,  he  was  not 
diseased  when  he  first  commenced  to  drink,  but  the 
continuous  use  of  stimulants  has  developed  in  him  a 
disease,  which  is  fairly  no  less  a  disease  than  that  of 
many  other  monomaniacs.  The  disposition  to  its  devel- 
opment was  apt ;  perhaps  it  was  hereditary,  perhaps  it 
was  a  nature,  sensitive  to  every  emotion,  which  yielded  to 
every  impression ;  a  will  which  was  feeble,  and  always 
surrendered  to  any  attack,  however  slight. 

While  the  excessive  use  of  alcoholic    stimulants  is  the 


What  Shall  be  Done  with  the  Inebriate.  303 

cause  of  a  large  percentage  of  the  cases  of  insanity,  yet 
it  must  be  remembered  that  insanity  is  one  of  the  causes 
of  drunkenness.  When  a  man  begins  to  indulge  in 
stimulants  who  has  always  been  temperate,  and  orderly  in 
his  conduct,  then  it  may  be  well  to  carefully  investigate 
his  case ;  possibly  other  symptoms  of  insanity  may  be 
found,  besides  his  drunkenness,  which  will  appear  as  only 
one  of  the  evidences  of  a  mind  disordered.  This  idea 
is  no  new  one,  but  is  mentioned  as  a  well-established 
fact,  of  which  all  of  you  may  have  cognizance.  Why 
should  he  not  resort  to  stimulants,  just  as  the  insane 
do  other  unreasonable  things  ?  The  popular  feeling  that 
one  who  becomes  a  drunkard  and  is  pronounced  insane, 
is  insane  because  of  his  drunkenness,  is  not  always  true, 
and  it  is  well  for  us  to  bear  this  in  mind.  We  can 
afford  to  be  discriminating  and  charitable  in  some  of  these 
cases,  though  they  are  far  in  the  minority.  The  dispo- 
sition to  charge  the  most  of  crime  upon  the  use  of 
alcohol,  is  no  more  justifiable,  than  to  attribute  the  most 
of  insanity  to  the  same  agent.  If  there  was  no  alcohol 
in  existence,  there  would  still  be  crime  in  abundance* 
Men  would  kill,  and  steal  and  falsify ;  crimes  against 
persons  and  against  property  would  still  be  frequent,  as  long 
as  anger  and  hate  and  covetousness  are  allowed  to  prevail. 
It  is  easy  to  dispose  of  the  insane  drunkard  ;  he  is  an 
insane  man,  and  requires  the  treatment  of  other  insane 
persons.  While  the  excessive  use  of  intoxicants  was  the 
cause  of  his  insanity,  yet  he  needs  not  to  be  separated 
from  other  insane  on  account  of  this  cause  ;  it  would  be 
idle  to  strictly  classify  as  to  causes  of  derangement.  So 
the  Insane  Hospital  becomes  the  place  for  these  men; 
the  prospect  of  cure,  when  the  cause  is  from  chronic 
alcoholism,  may  be  very  small,  indeed,  but  they  need  the 
protecting  care  of  society,  nevertheless.  Dr.  Fisher  has 
written  so  well  upon  this  part  of  the  subject,  that  I  need 
say  nothing  further.  But  what  can  be  done  with  the 
large  class  of  drunkards,  who  are  not  insane,  in  the  true 
and    generally    accepted    sense  of  the  word  ? 


304  Gurdon  W.Russell. 


If  drunkenness  is  a  crime,  or  a  vice,  or  a  disease,  and 
the  victim  does  not  or  cannot  control  himself,  is  wasteful 
of  his  property,  is  injurious  to  himself  or  others,  then  he 
should  be  placed  under  control,  and  be  subjected  to  such 
treatment  as  promises  to  be  for  his  benefit.  If  this  is 
fully  recognized,  and  becomes  well  established,  then  the 
plan  is  easily  worked  out,  and  almost  establishes  itself. 
When  the  four  and  six-bottle  men  were  common,  and  it 
was  considered  a  ver}'  proper  thing  to  be  tumbled  i.nder 
the  table  after  dinner,  then  it  would  have  been  impossible 
to  have  interfered  with  the  drunkard  in  the  manner 
proposed.  While  the  gentleman  might  have  acknowledged 
that  it  was  a  very  proper  thing  to  send  the  laborer,  found 
drunk,  to  the  work-house  or  the  jail,  yet  he  was  not 
willing  to  acknowledge  the  application  of  the  law  to 
himself  or  to  any  like  him.  Happily,  the  coarseness  and 
vulgarity  and  brutality,  even  of  the  higher  class  of  a  former 
age  have  passed  away,  and  there  has  come  in  an  improve- 
ment of  manners,  if  not  of  morals,  but  probably  of  morals 
also.  So  that,  as  society  is  now  constituted  and  regulated, 
the  time  is  more  propitious  than  before  for  effective  dealing 
with  this  subject.  It  is  well  to  remember,  however,  that 
no  legislation,  which  does  not  receive  the  sanction  of 
public  opinion,  is  satisfactorily  carried  out.  It  is  a  great 
mistake  to  legislate  far  in  advance  of  it,  for  it  effects 
nothing,  and  tends  to   bring  the  law  itself  into  disgrace. 

Probably,  public  opinion  now  sanctions  the  efforts 
which  have  been  made  towards  restraining  the  drunkard. 
After  much  discussion  and  much  hesitation,  men  have 
come  to  acknowledge  that  something  more  must  be  done 
for  them,  than  merely  imposing  a  small  fine,  or  commit- 
ting them  to  jail.  Whether  they  accept  the  theory, 
that  drunkenness  is  a  disease  or  not,  is  another  question ; 
the  probability  is  that  they  regard  it  more  as  a  vice,  or 
disposition  of  the  drunkard  himself,  than  as  originating 
from  any  disease.  But  the  public  is  disposed  to  listen 
to  the  discussion  which  is  now  going  on,  and  to  view 
favorably  the  proposed  efforts  for  reform.     It  only  remains. 


What  Shall  be  Done  with  the  Inebriate.  SOo 

therefore,  for  educated  men,  who  look  deeply  into  these 
matters,  and  all  others  effecting  the  social  body,  to  study, 
carefully  and  dispassionately,  all  the  problems  which  are 
proposed,  and  not  allow  themselves  to  be  lead  astray  by 
fanciful  ideas  or  impracticable  schemes. 

So  if  you  say  that  every  one,  who  becomes  drunk  or 
drinks  to  excess,  is  insane,  and  must  be  subjected  to 
confinement,  you  state  a  proposition  which  is  opposed 
by  the  common  sense  of  mankind,  and  is  wholly  impracti- 
cable in  its  execution. 

But,  if  the  views  which  have  been  held  in  this  paper 
are  accepted,  why,  then  some  may  be  subjected  to  pun- 
ishment, more  committed  to  work-houses,  or  asylums 
especially  for  the  inebriate,  and  some  let  alone,  as  they 
now  are,  and  probably  always  will  be. 

If  then,  the  inebriate  is  committed  to  a  work-house, 
or  a  special  asylum,  these  institutions  should  have  full 
control  of  him,  just  as  much  as  the  prison-keeper  has  over 
his  prisoners,  or  as  the  superintendent  of  a  hospital  for 
the  insane  has  over  his  patients.  Without  this,  control 
is  a  farce,  and  treatment  worse  than  useless ;  it  amounts, 
in  fact,  only  to  such  detention  and  such  treatment  as  the 
inebriate  himself  is  willing  to  submit  to  or  affirms.  When 
an  insane  person  is  taken  to  an  Insane  Hospital,  it  is 
for  the  purpose  of  improvement,  of  using  the  means  which 
experience  has  found  useful  in  such  cases ;  if  restraint  is 
one  of  them,  then  that  is  yielded  to,  and  the  patient 
submits  his  own  will,  or  is  supposed  to,  to  that  of  one  who 
knows  more  than  he  does  himself.  It  would  strike  the 
common  mind,  even,  as  absolute  folly,  to  allow  such  a 
one,  whose  insanity  had  been  manifested  in  violence,  his 
full  liberty  of  action,  else  why  was  he  restrained  at  all ; 
with  his  liberty,  he  is  liable  to  continue  in  just  such  prac- 
tices, as  before  his  removal  to  a  hospital,  and  so,  what 
benefit  is  to  accrue  from  it,  or  what  benefit  is  to  accrue 
in  any  case  where  this  license  is  allowed  ? 

If  then,  from  any  account,  whether  from   actual  disease 
or  infirmity  of  will,  it    is  thought  best  to  restrain  the  ine- 


Gurdon  W.  Russell. 


briatc,  it  should  be  done  so  effectually,  that  he  is  prevented 
from  any  further  access  to  intoxicating  liquors;  having 
been  brought  into  difficulty  through  the  use  of  alcohol, 
he  must  let  alcohol  alone,  absolutely,  totally ;  all  oppor- 
tunities for  obtaining  it  must  be  shut  off,  for  one  indulgence 
may  destroy  the  effect  of  months  or  even  years  of  treatment. 
It  may  seem  hard  to  many,  that  so  severe  a  confinement 
and  guardianship  as  this  should  be  exacted,  but  I  am 
satisfied  that  there  are  many  whose  reforms  will  never 
be  effected  without  it  ;  and,  in  truth,  there  are  too  many 
whose  reforms  will  never  be  effected  with  it.  But  for 
those  desirous  and  anxious  for  reformation,  it  is  believed 
that  this  will  avail  much. 

Men  regard  places  of  confinement  with  different  ideas  ; 
a  prison  is  more  disgraceful  than  a  jail ;  a  jail  more  dis- 
graceful than  a  work-house,  and  an  inebriate  asylum  less 
objectionable  than  an  Insane  Hospital.  If  it  is  decided 
that  the  inebriate  should  not  be  admitted  to  the  latter, 
then  one  of  those  already  mentioned  must  be  resorted  to, 
so  that  he  must  go  either  by  force  or  willingly  to  one  of 
them,  that  is  if  he  goes  to  any  public  institution.  I  know 
that  in  some  places  he  has  been  sent  to  an  alms-house,  as 
if  poverty  was  not  affliction  enough  without  being  obliged 
to  herd  with  criminals.  If  he  is  sent  to  prison  or  to  jail, 
whether  for  drunkenness  or  some  other  crime  committed 
while  drunk,  then  he  undergoes  the  punishment  which  the 
law  inflicts,  but  gets  no  benefit  from  efforts  for  reformation. 
The  infractor  of  the  law  is  punished,  and  if  he  happens  to 
be  a  drunkard,  he  is  punished  again  and  again ;  he  is 
fined,  perhaps,  and  "  sent  up,"  as  the  phrase  is,  no  way 
disgraced  by  his  short  term  of  punishment,  and  in  no  way 
bettered  by  it.  unless  it  be  by  a  partial  and  temporar>' 
return  to  health,  which  gives  him  a  longer  lease  of  life 
and  fits  him  for  repeated  indulgences. 

It  would  seem  then,  that  there  were  left  for  us  two 
resources  for  these  men,  the  work-house  and  the  hospital 
for  inebriates.  They  might  well  accommodate  all  persons 
guilty  of  simple  inebriet)-,  whether  continuous  or  paroxys- 


What  Shall  be  Done  with  the  Inebriate.  307 

mal  whether  they  were  committed  by  law,  or  entered  volun- 
tarily;  as  few  would  go  to  a  work-house  of  their  own  accord, 
there  would  be  left  for  them  the  hospital  for  inebriates, 
and  this  also  would  almost  necessarily  include  those  who 
were  able  to  pay  for  their  treatment. 

The  work-house  then  should  be  specially  designed  for 
the  inebriate  committed  by  law,  and  who  would  find  no 
other  place  for  reformation. 

The  inebriate  hospital  should  be  designed  for  those 
who  have  not  committed  great  crimes,  who  can  make 
proper  compensation,  who  recognize  their  condition  and 
are  desirous  of  reformation,  or  whose  friends  desire  it  for 
them.  This  latter  is  to  a  certain  extent  exclusive,  and 
so  cannot  ask  any  great  amount  of  aid  from  the  State,  for 
it  would  be  an  unjust  principle  for  the  State  to  aid  one 
class  of  citizens  and  not  all.  So  that  to  private  benevolence 
must  be  left  the  establishment  of  hospitals,  looking  to  its 
own  income  for  its  means  of  support. 

In  both,  however,  the  same  principles  of  government 
and  reformation  should  be  established,  and,  what  I  now 
say,  may  be  considered  of  general  application. 

When  men  undertake  to  accomplish  any  object,  they 
set  about  it  in  a  certain  way,  and  the  reasons  and  methods 
are  supposed  to  be  necessary.  The  soldier,  when  he  enters 
the  army,  does  it  with  the  full  knowledge  of  what  it  is  for, 
and  submits  his  will  to  the  will  of  another;  the  boy  enters 
a  school  for  the  purpose  of  obtaining  instruction,  and 
applies  himself  to  his  books,  following  the  command  of  his 
teachers;  he  is  there  for  an  object,  and  it  is  not  lost  sight 
of;  he  is  not  in  school  merely  to  pass  a  certain  number 
of  hours  in  idleness,  and  then  allowed  to  go  out  into 
the  world  as  ignorant  as  when  he  entered  it,  but  he  is 
instructed,  and  is  told  why  he  is  instructed,  that  he  is  in 
school  for  this  very  purpose,  and  must  improve  his 
opportunities,  and,  very  likely  is  admonished,  in  no  gentle 
way,  if  he  does  not  improve  them.  What  would  be 
thought  of  a  teacher,  who  so  neglected  his  duties,  that  he 
furnished  amusements  only  for  his  scholars,  and  neglected 


308  Gurdon  W.  Russell. 


their  studies  for  fear  of  putting  upon  them  something 
distasteful  ?  And  so  I  might  go  on,  showing  how  that 
any  one,  who  undertakes  anything,  goes  about  it  in  an 
appointed  way,  gives  his  energies  to  it,  submits  himself 
to  the  will  of  another,  if  necessary,  works  out  his  task, 
and  does  it  often  laboriously,  perseveringly,  if  he  ex- 
pects to  succeed.  Just  so  much  as  he  is  inferior  in 
mental  or  physical  ability,  just  so  much  the  more  is  he 
dependent  upon  c  thers,  and  must  be  guided  by  them. 
Whether  as  an  artisan  or  a  day  laborer,  he  does  not  lay 
out  his  work  for  himself,  and  say  that  he  will  execute  it 
so  and  so,  but  he  follows  the  commands  and  designs 
of  his  superiors,  and  he  is  willing  to  do  it,  for  thus  he 
accomplishes  the  very  object  of  his  work. 

Of  course  you  perceive  my  design  in  dwelling  upon 
this  point,  for  I  wish  to  show  how  necessary  it  is  that 
certain  principles  should  be  well  established,  and  well 
understood  and  acquiesced  in ;  that  certain  methods  of 
treatment,  thought  to  be  necessary  in  the  treatment  of 
inebriety,  should  be  carried  out,  even  if  they  did  not  meet 
the  full  approval  of  the  inebriate,  or  were  not  consid- 
ered necessary  by  him.  And  so  there  should  be  no 
ignoring  of  their  inebriety,  or  the  cause  for  which  they 
entered  the  hospital.  With  judicious  firmness,  they  should 
be  told  of  their  weakness,  and  the  way  pointed  out  by 
which  they  might  return  to  society  again.  As  this  can 
be  fully  understood,  why  should  it  not  be  done  ?  The 
delicacy  which  is  used  in  our  intercourse  with  insane 
persons,  need  not  be  practiced  here. 

Some  of  the  inebriates  will  acquiesce  in  this,  and  say 
that  this  course  is  all  very  proper  for  Jones,  or  Brown,  or 
Smith,  but  is  not  necessary  for  them ;  that  they  only 
require  the  detention  of  a  few  days,  when  they  will  be  all 
right  again,  and  they  will  become  drunk  no  more ;  that 
their  mind  is  strong,  and  capable  of  resisting  any  tempta- 
tion; that  there  need  be  no  fears  of  their  drinking  again, 
for  the\'  do  not  want,  and  have  a  dislike  for  the  very  taste 
of    alcohol.       If   these  remarks  had  not    been  often    made 


What  Shall  be  Done  with  the  Inebriate.  309 


before,  we  should  have  more  confidence  in  them ;  the 
truth  is,  these  men  need  the  counsel  and  guidance  of  a 
wiser  and  more  stable  mind  than  their  own,  and  they 
especially  need  the  discipline  which  comes  from  restraint 
and  the  judicious  use  of  labor. 

Perhaps  nothing  is  better  for  them  than  systematic 
labor;  its  effect  in  strengthening  the  body,  in  building  up 
and  renovating  a  feeble,  or  weakened  nervous  system, 
renders  it  one  of  the  most  useful  of  remedial  measures. 
And  this  is  just  the  way  to  put  it,  that  labor  is  a  remedial 
measure,  which  must  be  accepted  and  acquiesced  in  by  all 
inebriates,  inmates  of  hospitals  or  work-houses.  Like  other 
remedial  measures,  it  holds  its  place  with  therapeutical 
agencies,  with  amusements,  attention  to  diet,  and  general 
conduct  and  proper  advice.  It  is  not  the  least  of  them; 
in  my  opinion,  it  is  the  chief  of  them,  and  suited  espe- 
cially to  their  erratic,  impulsive  and  often  ill  directed  lives. 
Stability,  fixedness  of  purpose,  in  a  word,  a  stronger 
power  of  their  own  will  for  good,  is  what  is  especially 
needed.  Some  of  them  will  get  it  for  the  first  time  under 
such  a  system. 

I  have  said  enough  already  to  show  that  I  have  no 
confidence  in  a  short  period  of  treatment;  how  much  can 
be  done  by  a  long  course,  is  as  yet  a  problem,  not  full}- 
v/orked  out,  but  promising  much,  and  I  would  like  to 
impress  you,  gentlemen,  with  earnestness  and  as  much 
confidence  as  I  have  myself,  that  it  is  in  this  liirection, 
that  it  is  to  the  remedial  influence  of  labor,  and  long 
continued  restraint,  that  we  are  to  look  for  successful 
treatment  of  the  inebriate.  Various  amusements  are 
proper,  yes,  are  absolutely  necessary ;  but  more  than 
amusements  are  wanting;  these  men  perceive  this  very 
thing  themselves,  and  feel  the  need  of  something  more 
profitable.  Why,  the  very  insane  perceive  this,  also,  and 
mere  amusements  are  not  always  satisfactory  to  them ; 
and  doubtless  more  occupation  in  labor  may  be  found  of 
greater  benefit  to  them,  than  was  ever  supposed. 

If  it  were  possible  for    the  inebriate  to    enjoy  some  of 


310  Gurdon  W.  Russell. 

the  profits  of  his  labor,  it  would  be  well.  Some  system 
miglit  be  devised  by  which  this  could  be  accomplished, 
but  I  have  no  great  faith  that  any  prison  or  hospital  can 
be  made  a  very  profitable  manufactory ;  prisons  in  general 
have  not  been  successful  in  this  respect,  and  with  inebri- 
ates, the  enforced  and  lengthened  hours  of  labor  could 
not  be  exacted ;  labor  and  amusements,  instruction,  and 
various  methods  of  passing  the  time,  agreeably  and  profit- 
ably,   should  all  be  employed. 

Now  some  may  say  that  with  enforced  labor  we  should 
never  receive  any  patients,  voluntarily,  or  any  whose 
fortunes  were  abundant.  But,  if  labor  is  a  remedial  agent, 
is  especially  necessary  in  these  cases,  and  is  considered  so 
very  generally,  why  then  the  inebriate  must  be  very 
unreasonable,  and  so  mu.st  his  friends,  who  refuse  to 
adopt  it  as  a  way  out  of  his  difificulties.  A  firm  decision 
on  our  part,  if  we  so  regard  it,  will  carry  confidence  and, 
ultimately,  respect.  Though  the  one,  who  is  willing  to  pay 
largely  for  his  treatment  may  object  to  this,  yet,  it  should 
be  required  of  all,  according  to  their  ability.  To  take 
away  this,  is  to  take  away  one  of  our  best  remedies;  it  is 
requiring  us  to  make  bricks  without  straw,  when  it  is 
difficult  enough  to  make  them  with  it. 

In  a  work-house  it  would  be  especially  desirable  that 
a  portion  of  the  proceeds  of  labor  should  be  given  to 
the  inebriate.  Very  often  the  only  means  of  support  of 
the  family  is  taken  away,  when  the  father,  or  the  husband, 
is  shut  up.  Though  he  may  be  drunk  and  neglect  his 
work  for  half  of  his  time,  yet  he  contributes  to  their 
support,  and,  perhaps,  supports  them  wholly.  To  bring 
them  upon  the  town  by  his  incarceration,  especially  if 
it  was  for  a  long  time,  would  be  hard  for  the  family, 
and  prejudice  the  public  against  any  such  scheme  which 
proposed  to  increase  its  burdens.  It  might  be  found, 
however,  that  the  repeated  arrests  of  the  common  drunk- 
ard, with  the  expenses  of  convictions  and  detention  in 
prison,  under  the  system  of  short  sentences,  would 
amount    to    more,   in  the  aggregate,    than    would  the    cost 


What  Shall  be  Done  with  the  Inebriate.  311 

of  the  support  of  the  family.  But  men  do  not  under- 
stand, or  do  not  wish  to  understand,  that  a  sum  which 
is  indirectly  saved,  can  possibly  be  larger,  than  one  which 
is  directly    paid  out. 

I  ought  to  allude  to  another  agency  in  reforming  the 
inebriate,  and  that  is  the  influence  of  association  and 
co-operation.  To  this  was  due,  in  part,  the  success  of 
the  Washingtonian  Movement,  a  few  years  ago,  and  is 
now  found  so  successful  in  some  reformations.  Their 
weekly  gatherings  led  to  the  binding  together  of  men  in 
the  same  cause ;  naturally  emotional,  this  gave  them 
something  to  do,  to  think  about,  to  act  in.  As  no  long 
time  elapsed  between  these  meetings,  so  the  dangerous 
periods  were  sheeted  over,  and,  perhaps,  safely  passed. 
Each  one  knew  that  if  he  was  absent,  his  case  would  be 
enquired  into — he  himself  be  sought  out.  Even  with 
these  men  came  relapses,  with  all  their  mutual  guardian- 
ship and  sympathies.  If  they  met  but  once  a  month,  or 
once  in  six  months,  the  chances  are  that  they  would 
recur  much  oftener. 

It  is  now  well  known  that  short  terms  of  imprisonment 
have  no  effect  in  reforming  the  criminal ;  on  the  contrary, 
they  tend  to  confirm  him  in  his  course.  All  that  the 
drunkard  gets,  by  his  detention,  is  a  better  state  of  health 
for  a  short  time  only  ;  he  is  in  no  way  reformed,  as  he  is 
imprisoned  again  and  again,  so  he  becomes  more  and 
more  confirmed  in  his  habit,  and  generally  continues  in  it, 
until  death  comes  to  his  relief.  A  detention  of  a  year 
to  three  years  may  appear  to  be  too  long,  and  to  many 
to  be  too  severe,  for  "  only  getting  drunk,"  as  may  be 
said,  but  it  is  not  too  long  if  it  is  necessary  for  his  cure, 
and  probably  it  is  necessary  often  times.  When  it  is  not, 
then  the  inebriate  may  be  permitted  to  go  out,  and  remain 
unconnected  with  the  asylum,  only  so  far  that  he  should 
report  to  it  at  certain  times.  He  may  be  allowed  his 
liberty  and  attend  to  his  ordinary  business,  if  he  does 
not  abuse  his  privilege.  But  he  should  understand,  that 
if  he  commences  to  drink  again,  he  will  be    arrested    and 


812  Gurdon  W.  Russell. 

brought  back,  to  undergo  further  detention.  Such  was 
the  "Crofton"  Prison  System,  which  having  been  found  to 
work  well  with  the  convict,  may  be  applied  to  the  inebriate 
also.  The  strong  arm  of  the  law  should  reach  out  and 
apprehend  these  men,  if  they  escape,  or  violate  their 
"  ticket  of  leave." 

I  apprehend  that  too  much  stress  has  been  laid  upon 
the  want  of  will  power  in  inebriates,  and  that,  thereby 
the  public  have  not  always  formally  regarded  the  opinions 
of  physicians  in  this  matter.  I  fully  acknowledge,  that  the 
will  is  often  feeble,  and  that  after  the  man  has  com- 
menced his  drinking,  it  is  very  difficult,  if  not  impossible, 
for  many  of  them  to  stop.  I  have  previously  said  enough 
about  this,  and  will  now  only  state  that  the  extent  of  it 
is  somewhat  exaggerated,  and  will  mention  this  case  in 
illustration :  A  man  in  middle  life,  whose  mother  died 
young,  with  consumption,  and  a  brother  also,  with  the  same 
disease,  commenced  drinking  when  in  college ;  this  he  had 
followed  pretty  steadily,often  excessively,  though  occasionally 
with  some  months  of  intervals.  His  tastes  were  decidedly 
literary,  and  he  was  able,  with  his  pen,  to  earn  a  fair  liveli- 
hood. Brilliant,  witty,  learned,  his  conversation  was  pleasing 
and  instructive,  and  he  was  as  companionable  a  man  as 
one  would  often  find.  After  a  long  while  he  was  at 
Binghampton,  where  he  was  perfectly  correct  in  his  habits  ; 
in  a  week  his  health  was  good,  and  he  followed  his 
occupation  as  a  writer,  remaining  mostly  in  his  room, 
but  allowed  full  liberty,  upon  his  promise  not  to  abuse  it ; 
there  is  no  reason  to  suppose  that  he  ever  abused  it,  al- 
though he  was  there  more  than  once.  To  show  how 
much  he  could  control  himself  while  an  inmate  of  that 
institution,  he  told  me  that  there  being  an  important 
public  meeting  in  Albany,  he  obtained  permission  from 
the  Superintendent  to  attend  it,  provided  he  would 
promise  to  abstain  from  stimulants  during  his  absence. 
He  left  Binghampton  on  a  cold,  unpleasant  day  in  winter, 
and  arrived  in  Albany  at  night.  He  went  to  his  hotel, 
chilled    by    his    long  ride,    knowing    no    one  ;    he  was  cold, 


What  Shall  be  Done  with  the  Inebriate.  313 

a  stranger  and  every  way  uncomfortable ;  on  any 
other  occasion  he  would  have  drank  a  glass  of  whisky 
at  once,  or  a  dozen  of  them,  but  now  he  hesitated,  and 
this  was  the  way  the  subject  lay  in  his  mind.  "  I  want 
the  whisky,  I  feel  that  it  will  do  me  good ;  a  hot 
tod  will  warm  me  up,  and  put  me  all  right;  just  one, 
and  there  I  will  stop;  no  one  will  know  it,  and  I  shall  be 
better  for  it.  But  shall  I  stop  when  I  have  drank  once, 
can  I  ?  The  Doctor  will  certaintly  know  it  when  I 
return,  and  then  there  will  be  no  further  liberty  for 
me  ;  it  will  grieve  him  I  know,  to  think  I  have  broken 
my  promise,  and  that  he  can  put  no  further  confidence 
in  me,  I  will  not  drink  at  all ;"  and  he  did  not ;  it  was 
a  great  struggle,  he  said,  but  he  was  successful. 

Now  why  did  he  not  drink,  as  he  had  hundreds  of 
times  before  ?  He  gave  the  true  reasons ;  the  fear  that  he 
could  not  be  content  with  one  glass,  and  then  there 
would  come  an  awful  period  of  debauch  ;  the  fear  that  he 
would  be  restrained  in  his  liberty,  being  subjected  to  a 
longer  detention,  and  the  regret  that  he  had  abused  the 
confidence  reposed  in  him.  It  was  certainly  an  unlooked 
for  triumph  on  his  part,  and  one  cannot  help  asking  if  he 
could  so  govern  himself  in  this  instance,  why  could  he 
not  do  so  in  many  others.  I  cannot  answer  it  satisfac- 
torily, but  it  has  cautioned  me  not  to  allow  too  much  for 
this  claimed  "feeble  will  power."  .  His  will  was  feeble 
enough,  if  he  drank  but  once;  he  knew  his  weakness  and 
in  this  instance,  refrained.  His  periodical  excesses  were, 
and  are  now  great,  and  in  endeavoring  to  learn  the  excit- 
ing causes,  I  have  found  that  general  ill-health,  perplexi- 
ties in  business,  a  want  of  occupation,  anything,  in  fact, 
which  disturbed  him,  was  ver>'  sure  to  lead  to  a  debauch. 
When  at  Binghampton,  he  studied  this  subject  of  inebri- 
ety quite  closely,  and  he  was  capable  of  doing  it ;  one  of 
his  results  he  told  me  was  this  :  "You  cannot  make  much 
out  of  these  fellows,  Doctor,  if  they  do  not  wish  to 
reform."  It  occurred  to  me  that  there  was  a  great  truth 
here,  and  that  joined  to  the  wish,  there  must  be  added  a  con- 


314  Gurdon  W.  Russell. 

siderable  length  of  time,  and  a  great  amount  of  patience. 
This  paper  is  already  too  long,  and  yet  there  are  more 
points  which  might  have  been  developed,  but  with  the 
essay  read  at  the  previous  meeting,  the  ground  has  been  pretty 
well  covered.  I  will  only  say  that  a  law  in  Connecticut, 
which  gave  asylums  full  authority  to  hold  inebriates, 
was  found  to  be  defective  in  this  :  that  it  authorized  no 
one  to  apprehend  fugitives,  and  officers  hesitated  to  act 
under  it.  At  the  last  session  of  the  legislature,  an  addi- 
tional act  was  passed,  remedying  this  defect,  and  now  it 
is  believed'  to  be  as  perfect  as  it  can  be  made.  With 
authority  to  apprehend  inebriates  who  have  escaped,  and 
to  hold  them  from  a  few  months  to  three  years,  sub- 
ject of  Course,  to  the  right  of  habeas  corpus,  which  all 
enjoy,  there  is  much  to  expect,  that  considerable  may 
be  affected  in  reforming  them.  It  becomes  us  all  to 
study  this  subject  of  inebriety  dispassionately,  and  to 
bring  to  its  investigation  all  the  knowledge  and  candor, 
and  earnest  desire  for  truth,  that  we  should  bring  to 
any    subject    in    psychology. 


Art.    III.— The    Medico-Legal   Aspect  of 
Cerebral  Localization  and  Aphasia. 


By  C.  H.  Hughes,  M.  D. 


COXCLUDED 


'  I  ""HE  hysterical,  the  choreic,  the  cataleptic,  the  emo- 
-*-  tional,  the  h}-pera;mic  and  reflex  forms  of  speech 
failure  have  neither  distinct  clinical  significance,  nor  are 
they  often  likely  to  have  medico-legal  importance,  separate 
from  the  diseases  with  which  they  may  be  associated.  They 
need  not,  therefore,  be  considered  here,  and  we  mention 
them  mainly  to  exclude  them,  as  we  likewise  do  the 
speechlessness  of  nightmare.  Marc'  and  others,  however, 
have  noted  the  temporary  impairment  of  the  mental  facul- 
ties in  chorea,  and  the  defect  in  the  speech  power  in  this 
disorder,  is,  probably,  as  much  dependent  on  the  cerebral 
disorder  implicating  the  speech  center  along  with  other 
portions  of  the  cortex,  as  on  disturbance  of  the  motor  area 
for  the  organs  of  articulation.  There  are  circumstances,  too, 
under  which  aphasia  occurring  in  the  course  of  cerebral 
hyperaemia,  might  have  corroborative  significance  in  a  ques- 
tion of  doubtful  sanity,  but  if  we  were  to  discuss  all  these 
possibilities,  we  should  transcend  the  limit  of  the  evening. 
We  may  say,  however,  in  order  not  to  be  understood  as  under- 
rating the  matter,  that  such  a  degree  of  general  cerebral 
congestion,  if  persistent  for  any  length  of  time,  as  would 
paralyze  the  speech  co-ordinating  power,  would  probably 
also  simultaneously  impair  the  higher  psychical  faculties. 

The  occasional  aphasia  of  drunkenness  has  never  been 
pathologically  defined  with  sufficient  distinctness.  It  is 
often,  no  doubt,  a  sort  of  incomplete  and  transitor}^  glosso- 
labial    paralysis,     like    the    other    forms  of   inco-ordination 

The  regional  "iiygram  aufi  reniarkson  cerebral  localization,  are  omitted,  tlie  latter 
being  covered  by  the  excellent  epitome  of  Nothn-xgel,  Vide  Art.  I.— Ed. 


316  C.  H.  Hughes. 


seen  in  inebriates,  or  the  peculiar  and  more  permanent 
defects  of  speech  displayed  by  general  paralytics.  This 
latter  form  of  speech  defect,  also,  need  not  be  considered 
apart  from  the  graver  disease  with  which  it  is  associated, 
and  which  has  other  characteristic  signs.  Nor  need  we 
note  any  of  the  glosso-plegias    causing  speech  defect. 

The  momentary  speechlessness,  sometimes  occurring  in 
persons  overcome  by  fright  or  profound  surprise,  at  being 
the  unwilling  or  unexpected  witnesses  of  some  horrible 
tragedy,  might  possibly  have  to  be  considered  where  an  inno- 
cent person  is  indicted  as  particcps  crmiinis  from  the  fact  of 
his  being  present,  and  uttering  no  protest  or  cry  of  alarm  ; 
but,  in  such  cases,  the  proper  explanation,  I  believe,  has 
always  been,  and  is  still  likely  to  be,  made  and  received  ; 
so  well  understood  is  the  fact,  by  the  common  mind,  that 
intense  fear  may  for  a  time,  paralyze  the  power  of  speech, 
as  well  as   of  motion. 

I  saw,  recently,  an  account  of  a  man  who  could 
neither  read  nor  write,  having  been  imprisoned  for  forgery. 
An  aphasic  person  might  sign  as  well  as  speak  a  name 
not  his  own,  and  yet  mean  it  for  himself,  though  I  have 
never  seen  such  a  phenomenon.  I  have,  nevertheless,  seen 
enough  of  these  singular  cases  to  eradicate  from  my 
mind  much  former  scepticism  on  the  subject,  respecting 
the  almost  infinite  possibilities  of  distorted  or  preverted 
expression  to  be  found  in  these  cases.  But  aphasics,  who 
can  write  any  name  at  all,  are  generally  capable  of  making 
their  own  proper  signatures,  though,  it  must  not  be  for- 
gotten, that  these  persons  do  sometimes  forget  even  their 
own  name,  as  well  as  how  to  write  it,  and  it  is  a  reasonable 
conjecture,  that  their  mental  conception  of  their  cognomen, 
probably,  no  more  closely  approximates  the  real  thing  in 
some  instances,  than  the  cross  or  other  marks  they  make 
to  represent  it.  These  things  are  very  singular,  and  seem 
to  militate  against  the  idea  of  the  unity  of  all  the  facul- 
ties of  the  mind  into  one  entirety. 

In  the  asylum  at  Fulton,  I  had  a  patient,  who,  in 
several    years — all  the  time    I     knew    him — I    never  heard 


Cerebral  Localization  and  Aphasia. 


speak  a  single  word.  He  had,  many  years  before  he 
became  insane,  received  an  injury  to  the  parietal  bone, 
near  the  sagito-lambdoidal  sutural  junction  on  the  right 
side,  causing  depression  and  fracture  of  the  inner  and 
outer  tables  of  the  skull. 

After  I  had  loosened  two  buttons  of  bone,  with  the 
trephine,  and,  at  the  moment  of  elevating  them,  he 
exclaimed:  "Oh!  it  hurts!"  He  had  lived,  all  the  time 
I  knew  him,  like  a  mere  automaton ;  going  forward,  if 
started  by  a  gentle  push  from  behind,  and  not  halting  in 
his  walk  until  he  had  gone  the  whole  length  of  the  asylum 
corridor,  125  feet,  and  come  in  contact  with  the  semi-circu- 
lar wire  window-guard,  where  the  flowers  were  kept,  at 
the  end  of  the  hall.  If  turned  about  here,  and  started 
back  in  like  manner,  he  would  go  on  as  before,  stopping 
only  at  the  opposite  window-guard.  Since  the  operation, 
he  has  continued  to  speak  well  and  freely,  and  is  much 
less  automatic  in  his  movements,  but  remains  quite  insane, 
though  he  now  lives  at  his  home.  This  is  not  true 
aphasia,  but  it  was  a  phase  of  insanity,  which  might  be 
called  aphasic.  The  cranial  injury  in  this  instance,  it 
will  be  observed,  was  quite  remote  from  the  speech  center. 

This  man  also  had  symptoms  that  simulated  catalepsy. 
He  would  stay  wherever  he  was  placed,  and  maintain  his 
limbs  in  the  position    we  would  put  them. 

Where  the  insanity  is  placed  beyond  doubt,  as  it  was 
in  this  instance,  the  significance  of  any  co-existent  aphasia, 
real  or  apparent,  is  likely  to  be  overshadowed  by  the 
graver  cerebral  disease,  but  there  are  cases  where  the 
perversion  or  impairment  of  the  speaking  power,  especially 
if  associated  with  motor  paralysis  of  certain  facial  muscles, 
gives  the  patient  the  semblance  of  being  insane.  This 
complicates  the  subject  of  aphasia  in  its  forensic  aspects. 
In  some  forms  of  insanity  there  is  often  an  indisposition, 
a  disinclination  to  speak,  especially  in  silent  melancholia 
unaccompanied  with  any  paralysis  of  the  motor  tract 
or  the  speech  center,  and  a  real  aphasia  may  co-exist 
with  undoubted  mental  aberration.     This  may  also  sometimes 


318  C.  H.  Hughes. 


complicate,  the  subject,  and  only  discriminating  clinical 
observation  of  both  sane  and  insane  aphasics,  will  enable 
us  to  form  a  correct  judgment.  To  form  right  conclusions 
upon  which  to  base  opinions  that  shall  prove  satisfactory 
to  ourselves,  and  intelligible  to  courts  and  juries,  we  must 
become  practically  familiar  with  the  habitual  expression  of 
the  mind  diseased,  as  well  as  the  mind  rational  and  unclouded. 

We  must  make  companions  of  and  gain,  so  far  as  we 
can,  the  familiar  confidence  of  the  insane  as  well  as  the 
sane.  We  must  see  the  former,  as  we  every  day  may 
see  the  latter,  face  to  face,  and  divested  of  every  psychical 
mask.  We  must  learn  to  interpret  mental  action  through 
the  obstinate  silence  which  some  maniacs  display,  as  well 
as  through  the  vague  and  violent  expressions,  fantastic  dress 
or  indifference  to  dress,  and  appearance  of  others. 

Long  range  conjectures,  as  to  what  ought  to  consti- 
tute insanity,  but  which  clinical  demonstrations  disperse, 
as  the  wakefulness  of  the  morning  drives  away  the  dreams 
of  the  night,  and  comparison  of  real  cases  submitted  to  our 
judgment  with  ideal  standards,  will  mislead  us,  and  the 
blind  expert  thus  misleading  the  blind  judge  and  jury, 
they  all  fall  into  the  ditch  together. 

The  physician  can  no  more  ignore  or  disparage  clinical 
psychiatry  in  the  study  of  psychical  problems,  whether 
for  solution  at  the  bedside  or  on  the  witness  stand,  than 
he  can  dispense  with  clinical  research,  in  fitting  him  for 
understanding  other  diseases. 

If,  "in  the  gestures,  movements,  looks  and  general 
aspect  of  the  insane  person,  in  his  proposals,  actions  and 
shades  of  conduct,  which  are  inperceptible  to  others,  the 
physician  often  derives  his  first  thought,  respecting  the 
treatment  which  is  suited  to  each  patient  committed  to  his 
care,"  how  much  more  important  it  is  that  we  should  either 
"live  with  the  insane,"  or  often  visit  them,  in  order  to  safely 
determine,  whether  actions  readily  attributed  by  the 
non-professional  to  insanity,  are  actually  the  offspring  of 
mental  disease  or  of  a  non-psychical,  and,  purely  local 
cerebral  affection,  such  as  that  of  aphasia. 


Cerebral  Localization  and  Aphasia.  319 

Aphasia,  dissociated  from  mental  impairment,  is  much 
more  frequent  than  that  connected  with  insanity,  so  that 
in  a  case  of  suspected  mental  disease,  the  burden  of 
proof  would  fall  on  those  who  might  maintain  the  co-exist- 
ence of  mental  aberration,  and  the  legal  presumption  would 
be,  in  such  a  case,  in  favor  of  sanity. 

In  1862,  a  cabin-boy,  sleeping  in  the  texas  of  a  Missis- 
sippi steamer — on  which  I  was  at  the  time — while  the 
boat  was  rounding  out  into  the  stream  from  Mound  City, 
was  struck  in  the  left  temple  by  a  glancing  minnie-ball, 
fired  from  the  shore  by  Guerrillas.  He  was  insensible 
for  a  while,  and  when  he  recovered  consciousness  could 
not  speak,  until  after  the  depressed  bone  was  raised. 
He  recovered  completely,  both  from  the  aphasia  and 
concussion,  and  in  a  few  weeks  was  again  waiting  on  the 
cabin  table.       This  is  simple  traumatic  aphasia. 

I  saw,  during  the  past  year,  three  cases  of  aphasia, 
one  of  them  uncomplicated  with  paralysis,  two  of  whom 
are  living;  the  other  had  cerebral  softening,  quite  general 
in  the  left  hemisphere,  and  died  paralytic.  His  aphasia, 
though  not  really  very  marked  when  I  saw  him,  actually 
improved  towards  the  close  of  his  life.  His  right  hemis- 
phere took  on  a  vicarious  function.  The  post  mortem 
revealed  a  healthy  third  frontal  convolution  on  the  right 
side,  while  the  corresponding  left  side  was  completely 
disorganized. 

This  patient  was  in  the  Old  Men's  Hospital,  in  charge 
of  the  Little  Sisters  of  the  Poor,  and  I  am  indebted  to 
Dr.  Henske,  the  visiting  surgeon,  for  having  called  me  to 
see  him.  (An  abstract  of  the  case  appeared  in  the  April 
number).  The  man  learned  to  say  a  great  many  words 
correctly,  after  failing  once  or  several  times,  in  his  attempts 
to  speak  them,  so  that  it  was  undoubtedly  an  instance 
of  successful  education  of  the  vicarious  function  of  the 
opposite  speech  center.  His  ability  to  speak,  and  his 
improved  fluency  of  speech,  notwithstanding  the  destruction 
of  the  whole  of  the  left  frontal  lobe,  can  not  be  explaina- 
ble on  any  other  hypothesis.     Of  the  two  other  cases,  one 


320  C.  H.  Bushes. 


was  an  intelligent  patient,  though  somewhat  mentally  con- 
fused in  the  begining,  of  Dr.  Dean's,  at  the  City  Hospital, 
(which  was  reported  in  the  January  number  of  this  journal). 

His  chief  expression  for  a  long  time  was  "  somebody, 
somebody,  somebody,"  with  which,  and  a  copious  gestic- 
ulation (he  was  an  actor,)  he  had  for  awhile  to  indicate 
all  his  wants.  He  soon  greatly  improved,  enlarged  his 
vocabulary  of  words,-  and  learned  to  write,  though  he  is 
not  yet  entirely  well.  The  other  case  I  saw  with  Dr. 
Newman,  at  St.  Luke's.  The  disease  was  associated  with 
syphilitic  hemiplegia;  the  man's  oral  vocabulary  was  and 
still  is  very  limited  and  imperfect ;  though  there  being  no 
agraphia,  he  expresses  himself  with  pen  or  pencil  moder- 
ately Aveil. 

When  hemiplegia  exists,  it  adds  to  the  gravity  of  the 
case ;  It  indicates  that  the  cerebral  lesion  for  a  time,  at 
least,  extends  beyond  the  convolution  of  Broca,  and  we 
have  then,  if  we  can,  to  define  its  further  limits.  Espe- 
cially, have  we  then  to  determine  to  what  extent  the 
intellectual  centers  of  the  cortex  are  involved.  This  will 
have  to  be  done,  largely,  by  interrogation  of  the  psychical 
symptoms.  If,  through  the  impaired  communicating 
power,  we  are  yet  enabled  to  discern  the  undoubted 
existence  of  hallucinations,  delusions,  or  marked  illusions, 
or  if  coma  exists,   our    task  is  not  ver>'  difficult. 

With  the  power  of  normal  mental  expression  destroyed 
or  weakened  by  disease,  the  precise  mental  status  of  an 
aphasic  may  be  wrongly  interpreted,  especially  if  there  be 
associated  paralysis  of  the  nerves  distributed  to  the  face, 
so  as  to  cause  alteration  in  natural  expression.  This  was 
so  in  the  case  of  Wm.  T.  Beven,  a  case  which  I  consider 
entitled  to  be    classed  among  the  causes  cclcbrcs. 

The  particular  forms  of  insanity  with  v.hich  real 
aphasia  is  most  likely  to  be  associated,  that  are  apt  to 
have  any  medico-legal  importance,  are  the  insanity  of 
old  age — senile  insanity  as  it  is  called — and  the  general 
paralysis  of  the  insane. 

When  aphasia  occurs  in  the  prime  of  life,  it  is  not  so  likely 


Cerebral  Localization  and  Aphasia.  321 

to  be  fatal  to  either  mentality  or  life.  Beyond  the  prime,  it 
is  often  associated  with  degenerative  changes  in  the  arteries, 
which  admit  of  rupture  and  extravasation  of  blood.  The 
destructive. lesion  in  the  latter  case  being  more  extensive 
than  in  the  former,  and  more  likely  to  more  generally 
implicate  the  cortex.  The  young  often  recover  from 
aphasia ;  the  very  aged  seldom,  if  ever.  Some  famous 
cases  in  old  men  have  engaged  the  attention  of 
courts  in  this  country,  in  which  the  testimony  of 
reputable  medical  men  has  been  obtained  on  either 
side,  such,  for  example,  as  the  celebrated  Parish 
Will  Case,  where  four  or  five  well-known  physicians  testi- 
fied on  one  side,  and  the  eminent  Drs.  I.  Ray,  Pliny 
Earle^  and  Bell  on  the  other  (the  latter  three  being  skillful 
experts) ;  and  the  more  recent  case  of  David  B.  Lawler, 
where  Drs.  Comegys  and  Bartholow,  of  Cincinnati,  held 
opposite  opinions  as  to  the  testators  mental  capacity.' 

The  most  important  and  recent  medico-legal  case,  I  now 
recall,  is  that  of  Wm.  T.  Beven,  reported  in  the  American 
Journal  of  Insanity,  for  January,  1879,  already  referred  to, 
where  reputable  medical  men  again  differed,  as  to  the 
mental  status  of  the  individual. 

In  this  instance  the  man  was  the  defendant  in  a  suit 
brought  for  the  recovery  of  money  on  a  deed  of  trusty 
signed  by  himself,  when  he  was  aphasic,and  so  hemiplegia 
on  his  right  side,  that  he  had  to  make  his  signature  with 
the     left  hand. 

So  that  these  cases,  whether,  we  will  that  they  should 
or  should  not,  do  get  before  the  Courts,  and  doctors  will  be 
called  upon  to  aid  in  deciding  them,  and  they  will, 
probably,  continue  to  differ  concerning  them,  as  they 
have  done  heretofore,  according  to  the  range  of  their 
observations,  but  we  should  endeavor  to  so  understand 
them,  that  we  may  more  often  agree. 

1.  Contributions  to  Mental  Pathology.     By  I.  Ray,  1S73,  page  .314. 
Vide  .Som<^  Medical  Qnestions  of  the  Lawler  Will  Case.    By  Roberts  Buitholow, 
Journal  of  Psychological  Medicine,  Vol.  IV.  Xo.  3. 


Art.  IV.— On  the  Propositions  of  the 
Association  of  Medical  Superinten- 
dents of  American  Hospitals  for  the 
Insane. 


By  John  Curwen,  M.  D., 

SUPERINTENDENT   ANO   PHYSICIAN    OF    THE    PENNSYLVANIA    STATE    LUNa.iC 
HOSPITAL,    HARRISBURG,    PA. 

XIV. — "A  large  hospital  should  consist  of  a  main 
central  building,  with  wings." 

This  means,  as  a  matter  of  course,  that  the  whole 
should  be  so  joined  together,  that  the  communication 
between  the  different  parts  shall  be  under  the  same  roof, 
and  not  that  the  buildings  shall  be  separated  one  from 
the  other  by  a  conside  able  intervening  space,  even  if 
the  different  buildings  should  be  connected  by  covered 
ways.  There  is  no  advantage  claimed  for  separate  build- 
ings, which  cannot  be  better  and  more  pleasantly  obtained, 
and  with  greater  economy  in  construction  by  having  all 
the  wards  in  direct  connection,  one  with  the  other ;  and 
there  are  advantages  attending  this  latter  arrangement 
which  can  never  be  obtained  in  the  other. 

The  patients  in  one  ward  constitute  a  distinct  family, 
and,  as  before  stated,  the  classification  should  be  such  as 
to  make  this  family  as  homogeneous  as  possible,  and  there 
need  be  no  more  communication,  and  in  reality,  there  is 
no  more  between  one  ward  and  another,  than  between 
one  house  and  another  adjoining  in  the  same  street. 

Various  reasons  have  been  assigned  for  the  separation 
of  the  buildings,  but  they  all  resolve  themselves  into  one  ; 
the  fancy  of  their  advocates,  that  such  would  be  better 
for  the  insane  themselves.  The  experiment  was  tried  by 
Dr.  Kirkbride  more  than  thirty  years  ago,  under  the  most 
favorable  circumstance,  and  with  every  desire  and  effort  to 
make  it  a  success,  and  it  was  a  failure,  as  evinced  by  the 
fact  that,   from  the    result  of  that  trial,    he  is    opposed    to 


On  the  Propositions  of  the  Association.  323 

cottages  and  other  separate  buildings.  After  a  residence 
of  thirty-six  years  among  the  insane,  the  writer  has  not 
yet  been  able  to  find  among  them  advocates  for  any  such 
separation,  but,  on  the  contrary,  they  much  prefer  being 
in  a  building,  where  all  the  wards  can  be  most  readily 
reached  by  the  officers,  with  whom  they  feel  that  they 
can  thus  obtain  more  ready  and  more  frequent  communi- 
cation. 

The  great  outcry  against  hospitals  for  the  insane  arises 
from  "the  alleged  abuses  so  frequently  practiced  on  the 
patients."  It  must  be  readily  acknowledged,  by  every 
reflecting  mind,  that  such  abuses  can  be  more  readily 
practiced  when  the  patients  are  in  separate  buildings, 
which  the  officers  cannot  reach  without  being  seen  by 
some  one  ;  and  attendants,  who  would  be  likely  to  abuse 
patients,  would  be  on  the  watch  constantly  for  the  officers, 
and  could  always  find  one  or  more  patients  who  would 
keep  a  careful  lookout  for  the  approach  of  the  officers. 
Besides  the  greater  extent  of  distance  to  be  traveled  by 
the  officers  in  such  separate  buildings,  the  constant  change 
in  winter  from  warm  to  cold,  and  cold  to  warm,  would  not 
be  very  beneficial  to  the  health  of  the  officers  or  the 
inmates ;  and  even  the  most  strenuous  advocates  of  the 
separation  of  the  buildings  would  scarcely  feel  inclined,  on 
a  dark  and  stormy  night,  particularly  if  it  was  very  cold 
and  snowing,  to  go  to  visit  a  sick  patient  in  the  most 
remote  building,  just  before  going  to  bed,  or,  as  some 
gentleman  would  advocate,  once  or  twice  between  bed 
time  and  day  light. 

But  when  the  wards  are  all  under  the  same  roof 
with  an  equable  temperature  in  all,  the  officers  can  go 
in  slippers  and  dressing  gown  to  any  part  unheralded  and 
unannounced,  and  learn  by  such  unexpected  visits,  just  how 
things  are  and  what  the  condition  of  any  patient  may  be, 
without  any  risk  to  their  own  health ;  and,  certainly,  it 
would  not  be  very  conducive  to  the  health  of  the  more 
delicate  and  feeble  of  the  inmates  to  be  obliged  to  pass 
through    these    constant    and    frequent    changes,  from    heat 


324  John  CuTwen. 


to  cold,  whenever  they  wished  to  attend  the  entertain- 
ments and  rehgious  services  which  should  be  held  in  the 
evening  for   their   amusement    and    instruction. 

XV. — "  The  main  central  building  should  contain  the 
officers  receiving  rooms  for  company  and  apartments,  en- 
tirely private,  for  the  superintending  physician  and  family, 
in  case  that  officer  resides  in  the  hospital  building." 

The  main  central  building  should  have  a  neat  hand- 
some front,  calculated  to  convey  a  pleasing  and  cheerful 
impression  to  all  who  may  see  it,  but  at  the  same  time 
should  be  free  from  that  gaudy  ornamentation,  in  which 
a  certain  class  of  architects,  at  the  present  day,  seem  to 
take    especial   delight. 

In  this  central  building  should  be  arranged  all  the 
offices  for  the  transaction  of  the  business  of  the  Insti- 
tution. 

The  office  of  the  superintendent  and  physician  should 
be  located  in  the  most  convenient  place,  near  the  main 
entrance,  so  that  those  who  may  call  to  see  him  may 
not  be  required  to  go  to  any  distance ;  and,  the  office 
should  be  so  arranged  as  to  have  two  parts,  one  of 
which  can  be  used  for  more  strictly  private  work,  so 
that  he  may,  when  required,  be  free  from  interruption; 
and  in  one  of  the  rooms  they  should  be  a  large  fire- 
proof safe,  in  which  all  the  medical  records  and  books  and 
papers  pertaining  to  the  medical  affairs  of  the  Institu- 
tion should  be  kept.  These  rooms  should  be  connected, 
by  a  private  stairway,  with  the  apartments  of  the 
superintendent  above.  The  ordinary  business  office 
should  be  in  such  proximity  that  persons  could  readily 
pass  from  one  to  the  other  without  disadvantage  or 
inconvenience,  and  so  as  to  allow,  also,  of  ready  com- 
munication between  the  superintendent  and  the  officer 
who  may  have  charge  of  the  business  operations  of  the 
hospital. 

Not  far  from  these  should  be  the  rooms  for  the 
reception  of  visitors,  and  in  which  the  patients,  as  a 
rule,    may    see    their    friends;    though,  in    cases   of  severe 


On  the  Propositions  of  the  Association.  325 

sickness,  or  great  excitement,  rooms  should  be  provided 
in  the  wards  where  the  friends  may  see  the  patients 
without  interfering  with  the  other  patients.  Adjoining 
these  rooms,  should  be  a  wash-room  and  water-closet,  for 
the  convenience  of  visitors  and  others  who  may  come 
from  a  distance. 

In  the  rear  of  the  first  story  should  be  all  the  store- 
rooms, required  for  the  different  articles  needed  for  the 
use  of  the  Institution,  and  also  the  kitchen  and  all  the 
rooms  required  for  the  various  things  to  be  used  in  that 
department,  with  a  dining-room  for  those  employed  in 
the  various  domestic  and  out-door  arrangements  of  the 
Institution.  A  room  should  also  be  arranged,  connected 
with  the  kitchen,  for  the  preparation  of  all  vegetables 
and  other  articles  to  be  cooked,  so  that  the  kitchen  may, 
at  all  times,  be  free  from  such   dirt. 

It  would  be  well,  also,  to  have  the  bakery  arranged 
convenient  to  the  kitchen,  with  the  rooms  required  for 
the  storage  of  flour,  and  of  the  bread,  after  it  is  baked,- 
and  from  which  it  can  be  distributed  to  the  different 
dining-rooms. 

In  the  cellar,  under  the  kitchen,  should  also  be 
provided  rooms,  thoroughly  ventilated,  and  cut  off  from 
all  communications  with  other  parts  of  the  house,  for  the 
storage  of  fish,  vinegar,  molasses,  etc.,  with  convenient 
means  of  taking  them  in,  when  brought  to  the  hospital, 
with  as  little  labor  as  possible. 

A  convenient  mode  of  effecting  all  these  arrangements, 
without  unduly  increasing  the  size  of  the  central  building, 
will  be  to  place  the  kitchen  and  all  the  other  rooms 
mentioned,  in  a  one-story  building,  and  a  vestibule 
between  the  rooms  in  the  center,  and  the  kitchen,  open 
at  each  side,  with  large  windows  from  the  floor  to  the 
ceiling,  to  prevent  the  odors  from  the  kitchen  spreading 
over  the  center,  and  all  the  chimneys  may  be  carried 
up  in  the  rear  walls  of  the  center,  and,  if  needed,  be 
used  also  for  ventilating  purposes. 

Apartments,    strictly     private,    should     be    provided    for 


326  John  Curwen. 


the  superintendent  and  his  family,  in  the  second  story ; 
and  in  the  rear  of  the  same  floor  should  be  the  main 
apothecary -shop  of  the  hospital,  with  a  room  for  a  medi- 
cal library,  and  the  usual  investigations  now  required 
to  be  conducted  in  the  determination  of  diseased 
conditions  and  microscopic  investigations ;  with  a  room, 
also,  for  the  storage  of  the  larger  and  heavier  articles 
for   medical   use. 

The  rooms  for  the  assistant  physicians  should  be 
immediately  adjoining  these  rooms,  so  that  they  may  be 
convenient   at   all   times. 

The  rooms  for  the  steward  and  matron  could  also 
be  arranged  on  this  floor ;  though  it  is  an  excellent 
arrangement  to  have  an  officer  on  each  floor  of  the 
Institution. 

In  the  third  story  front,  will  be  arranged  rooms  for 
the  accommodation  of  the  Trustees  and  others,  whose 
business  may  require  them  to  visit  the  hospital.  In 
the  rear  should  be  the  chapel  for  the  religious  services, 
and  in  the  fourth  story  front,  could  be  arranged  the 
amusement  hall,  where  all  the  entertainments  for  the 
patients  could  be  held  without  any  alteration  or  inter- 
ference with  the  arrangement  of  the  chapel.  It  must 
be  understood,  that  the  detail  of  all  arrangements  in  the 
main  central  building  must  be  in  accordance  with  the 
extent  of  the  hospital  and  the  requirements  of  its  parti- 
cular locality,  but  abundant  rooms  should  be  provided 
for  all  the  officers  usually  required,  so  that  while  their 
apartments  are  strictly  private,  they  may  not  be  far 
from  their  regular  work,  and  may  be  convenient  when 
required  out  of  regular  office  hours. 

The  great  error  committed  in  the  erection  of  the 
majority  of  hospitals  for  the  insane  consists  in  not  making 
ample  arrangements  for  the  domestic  operations  of  the 
institution  in  the  way  of  store-rooms  and  other  conveni- 
ences of  that  kind,  and  also  in  the  proper  provision  of 
abundant  accommodation  for  those  employed  in  the 
domestic  operations  of   the  hospital,  so  that  they  may  not 


On  the  Propositions  of  the  Association.  327 

be  required  to  go  far  from  their  work,  and,  particularly, 
should  not  be  required  to  mount  many  flights  of  stairs. 
Part  of  this  latter  accommodation  could  readily  be  ob- 
tained in  the  construction  of  the  building  in  which  the 
boilers  for  heating  the  hospital,  the  laundry  and  other 
similar  matters  are  placed,  and  this  building  can  be  so 
connected  by  an  underground  archway,  that  females  can 
pass  to  and  from  without  exposure  in  any  kind  of 
weather  or  at  any  hours.  Of  course,  all  these  are  matters 
of  great  moment  in  the  domestic  economy  of  the  hospital, 
and  it  should  be  carefully  kept  in  mind,  that  the  health 
and  comfort,  of  all  those  employed  in  the  different  depart- 
ments of  the  hospital,  is  absolutely  necessary  to  the 
proper,  economical  working  of  the  establishment. 

XVI. — "The  wings  should  be  so  arranged  that  if  rooms 
are  placed  on  both  sides  of  a  corridor,  the  corridors 
should  be  furnished  at  both  ends  with  moveable  glazed 
sashes,    for   the    free    admission    of  both    light    and    air." 

The  main  points  of  this  proposition  have  been  dis- 
cussed, when  speaking  of  the  arrangement  of  the  rooms 
and  corridors,  in  the  remarks  on  a  previous  proposition, 
but  it  may  be  well  to  state,  that  economy  of  con- 
struction and  greater  compactness  of  arrangement  can 
be  had  by  placing  the  rooms  on  both  sides  of  the 
corridor,  and  providing  for  the  bright  and  cheerful  appear- 
ance of  the  ward,  as  before  stated,  by  the  movable 
glazed  sashes  at  both  ends,  and  large  bay-windows  on 
both   sides    in   the    center    of  the    corridor. 

XVII. — "The  lighting  should  be  by  gas,  on  account 
of  its    convenience,    cleanliness,    safety  and   economy." 

Within  the  last  few  years,  a  number  of  different 
methods  for  making  gas  for  lighting  buildings,  have 
been  before  the  public,  each  claiming  certain  merits 
and  advantages  over  others,  previously  in  use,  on  the 
score  of  economy  and  better  light ;  but,  after  trial, 
the  majority  have  been  found  to  have  certain  defects, 
which  interfered  seriously  with  the  proper  provision  of 
light,     in    ways     differing    in    different     arrangements,    but 


328  John  Cur  wen. 


calculated  to  cause  annoyance  and  difficult)-.  The  plan, 
which  has  been  found  most  free  from  trouble,  in  every 
\\a\-,  is  the  manufacture  from  bituminous  coal;  and,  while 
it  may  be,  in  some  cases,  rather  more  expensive,  there 
are  no  drawbacks,  such  as  has  been  found  in  most  of 
the  other  modes,  and  there  is  a  certainty  and  reliability 
at  all  seasons,  which  have  not  been  found  to  attend 
the    majority   of    the   plans   heretofore    devised. 

The  reasons  for  the  use  of  gas,  In  preference  of  any 
other  mode  of  lighting,  are  given  so  concisely  in  the 
proposition,  that  it  is  not  worth  while  to  enlarge  on 
them. 

XVIII. — "The  apartments  for  washing  clothing,  etc., 
should  be  detached  from  the  hospital  building"  (in 
connection    with   proposition). 

XXII. — "  The  boilers,  for  generating  steam  and  warm- 
ing the  building,  should  be  in  a  detached  structure, 
connected  with  which  may  be  the  engine  for  pumping 
water,  driving  the  washing  apparatus,  and  other  machin- 
ery." 

A  building,  erected  about  one  hundred  feet  in  the 
rear  of  the  main  central  building,  can  readily  be  con- 
structed so  as  to  accommodate,  not  only  all  that  may 
be  included  in  the  above  proposition,  but  much  more 
equally    essential. 

In  the  basement  may  be  the  boilers  for  generating 
steam  for  heating  the  hospital,  with  ample  storage  room 
for  all  the  coal  needed  during  the  year ;  a  room  for  the 
storage  of  pipe  and  other  fixtures  so  needful  in  an  insti- 
tution heated  by  steam ;  a  blacksmith  shop  with  all  the 
machinery  needed  for  cutting  pipe  etc.;  the  engine  for 
driving  all  the  machinery  of  the  laundry,  of  the  carpenter 
shop,  etc.  etc.;  the  fans  and  engines  for  the  forced  venti- 
lation of  the  institution  ;  a  room  for  making  soap  and  for 
washing  the  worst  class  of  clothing,  and  mortuary  room, 
properly  fitted  up,  with  whatever  may  be  needed  in  that 
department. 

In  the  second  story,  on  one  side,   may  be  the  laundry. 


On  the  Propositions  of  the  Association.  329 

proper,  the  ironing-room,  the  drying-room  with  a  strong 
forced  ventilation  of  hot  air,  and  with  all  the  fixtures  and 
machinery  so  needful  in  this  department ;  a  room  for 
assorting  and  mending  all  the  clothing,  so  arranged  that 
the  person  in  charge  can  have  a  proper  supervision  of  the 
whole  range  of  rooms ;  and  on  the  other  side,  a  carpenter 
shop,  with  rooms  in  this  and  the  story  above  for  the 
men  employed  in  the  different  out-door  operations. 

In  the  story  over  the  laundry  department  should  be  the 
rooms  for  all  the  women  employed  in  that  department 
and  in  the  kitchen,  with  wash-room,  etc.  This  building 
should,  of  course,  be  connected  with  the  main  central 
building  by  an  underground  archway,  so  that  the  women 
can  pass  to  and  fro  at  all  seasons  without  exposure  ;  and 
the  part  for  the  women  should  be  so  arranged  as  to  be 
entirely  separated  from  that  for  the  use  of  the  men.  Over 
the  carpenter  shop  should  be  a  large  room  for  furniture 
in  which  it  can  be  made,  repaired,  varnished;  and  another, 
adjoining,  in  which  it  can  be  stored ;  and  in  close 
proximity,  to  these  rooms,  can  be  a  large  room  for 
making  and  repairing  mattresses.  The  main  chimney  for 
the  boilers  will  be,  of  course,  in  this  building,  and  should 
be  so  arranged  as  to  be  an  efficient  aid  in  the  process 
of  ventilation,  and  this  may  be  done  by  having  a  large 
cast-iron  pipe  in  the  center,  through  which  the  gases  and 
smokes  shall  ascend,  and  a  space  between  that  and  the 
brick  work  into  which  pipes  from  different  parts  of  the 
hospital  can  be  brought.  In  very  many  cases  it  will  be 
found  most  advantageous  to  have  the  pumps  for  the 
supply  of  water  placed  near  the  stream  from  which  the 
supply  will  be  obtained,  and  then  the  apparatus  for  making 
the  gas  can  be  placed  in  some  part  of  the  same  building, 
so  that  the  same  men  can  attend  to  both  the  supply  of 
water  and  gas. 

It  is  a  matter  worthy  of  serious  consideration,  when 
the  supply  of  water  is  taken  from  a  stream  or  river, 
whether  it  is  not  wisest  and  best,  in  every  point  of 
view,    to    sink    the  well,    from    which    the    water     may    be 


330  John  Curwen. 


pumped,  at  some  distance  from  the  stream,  and  tunnel 
towards  it,  so  that  the  water  may  be  filtered  by  per- 
colation through  the  sand  and  gravel,  before  it  is  pumped 
into    the    tanks  or    reservoirs. 

It  may  entail  a  slight  additional  expense  in  the 
first  construction,  but  will  be  of  immense  service  after- 
ward, in  keeping  the  water,  at  all  times,  clear  and  free 
from    any    matter   likely    to    be  thrown    into     the    stream. 

XIX. — "The  draining  should  be  under  ground,  and 
all  the  inlets  to  the  sewers  should  be  properly  secured, 
to    prevent  offensive  emanations." 

The  sewers  should  be  carefully  laid  in  the  best 
quality  of  hard  brick,  with  the  best  kind  of  hydraulic 
cement,  should  be  oval  in  form,  with  the  point  of  the 
oval  downward,  so  as  more  readily  to  be  kept  clean 
by  the  constant  stream  of  water  passing  through  them ! 
should  be  not  less  than  three  feet  in  their  long  diameter, 
and  have  ventilating  openings  at  different  points  in  their 
course,  so  constructed,  that  they  could  be  entered,  if 
required  to  be  examined  and  repaired ;  and  the  outlet,  if 
possible,  should  be  under  the  water  of  the  stream  into 
which  the  sewer  empties. 

All  the  pipes  leading  from  the  different  parts  of  the 
building  and  laundry  into  the  sewer,  should  be  of  iron, 
carefully  examined  in  the  interior  before  the}'  are  put  in 
for  any  irregularities  and  projections,  which  might  act  as 
impediments  to  articles  passing  through  them,  and  all  the 
pipe,  thus  laid,  should  have  such  a  descent  in  its  course,  as 
to  free  itself  readily  from  all  matters  which  might  other- 
wise accumulate  in  them,  and  the  pipes  should  also  be  as 
free  as  possible  from  bends  and  short  curves.  No  part 
of  the  brick  sewer  should  be  laid  within  any  part  of  the 
building,  and  when  the  necessity  does  not  exist,  for 
catching  the  rain-water  in  cisterns  for  domestic  use,  all 
the  water  falling  on  the  buildings  might  be  conveyed  into 
the  sewer,  the  inlets  from  the  pavement  being  prop'erly 
secured  by  traps,  while  the  pipes  from  the  roof  might  be 
left  open,  to  act  as  ventilators  to   the  sewer. 


On  the  Propositions  of  the  Association.  S31 

The  question  of  the  successful  utilization  of  sewage 
is  yet  undecided,  and,  although  in  many  places  it  seems 
to  have  received  a  satisfactory  solution,  the  methods 
used  are  so  diverse,  that  time  must  be  given  to  decide 
which  will  ultimately  be  the  best  and  most  satisfactory, 
as  to  cost  and  freedom  from  unpleasant  effects  in  the 
production  of  various  diseases,  which  have,  heretofore,  been 
attributed  to  the  free  use  of  the  sewage  on  the  lands  about 
the  buildings.  During  many  months  of  the  year,  owing  to 
the  coldness  of  the  weather,  no  use  could  be  made  of  the 
material,  and  there  would  be  required  large  tanks  for 
its  storage,  and  this  might  become  very  inconvenient  and 
troublesome. 

XX. — "All  hospitals  should  be  warmed  by  passing  an 
abundance  of  pure  fresh  air,  from  the  external  atmosphere, 
over  pipes  or  plates  containing  steam  under  low  pressure, 
or  hot  water,  the  temperature  of  which  does  not  exceed 
212"  F.,  and  placed  in  the  basement  or  cellar  of  the 
building  to  be  heated." 

The  section  of  country,  in  which  the  hospital  may 
be  located,  will  determine  the  amount  of  heat  which  it 
will  be  necessary  to  secure  for  the  maintenance  of  the 
proper  temperature  during  the  winter  season.  In  those 
sections  where  the  changes  are  not  great,  and  where  a 
moderate  amount  of  heat  only  will  be  required,  heating 
by  hot  water  has  been  thought  by  some  to  be  sufficient, 
but  in  those  sections  where  the  range  of  temperature 
is  very  low  for  days  at  a  time,  where  the  winters  are 
long  and  severe,  and  where  high  winds  prevail  for  any 
length  of  time  in  cold  weather,  steam  will  be  found,  by 
far,  the  most  efficient  means  of  maintaining  that  degree 
of  temperature  in  the  coldest  weather,  which  will  best 
conduce  to  the  health  and  comfort  of  the  inmates.  With- 
out entering  into  a  statement  of  the  arguments  for  the 
two  different  systems  of  heating  (which  our  space  will  not 
permit),  it  may  suffice  to  say  that  as  steam  is  now  used 
to  a  certain  extent  for  a  variety  of  operations  about 
the  hospital  ;  it  will  be    found    most  convenient    in     ever}- 


John  Curicen. 


way,  to  extend  the  system,  and  use  steam  for  all  purposes, 
as  it  is  more  manageable,  is  more  quickly  applied,  and  at 
all  times  more  efficient  in  its  action,  and  on  the  whole, 
more  economical. 

Where  forced  ventilation  by  fans  (as  will  be  mentioned 
hereafter)  is  used,  a  greater  amount  of  heat  will  be  needed, 
for  the  reason  that  the  constant  change  of  air,  by  such 
means,  requires  that  the  degree  of  heat  be  steadily  main- 
tained, and  as  the  current  of  air  is  constantly  changing, 
unless  a  good  degree  of  heat  is  preserved,  the  proper  and 
pleasant  temperature  will  not  be  reached,  and  feeble  and 
delicate  patients  will  suffer. 

Cast-iron  radiators,  of  which  there  are  several  forms, 
are  preferable  to  wrought-iron  pipe  for  heating,  as  the 
cast-iron  retains  the  heat  longer;  a  larger  amount  of  steam 
can  be  introduced  into  them,  and  the  condensation  of  the 
steam  is  not  so  rapid,  and  the  amount  of  radiating 
surface,  for  a  given  area,  is  more  compact. 

In  the  arrangement  of  these  radiators,  special  care 
should  be  taken  that  the  amount  of  radiating  surface 
is  properly  calculated  to  the  contents  of  the  room  to  be 
heated,  and  that  it  should  be  ample  for  the  coldest  weather ; 
and  the  radiators  should  be  completely  surrounded  on  the 
top  and  sides  with  tin  to  prevent  the  diffusion  of  the  heat 
into  the  air  chambers  and  oblige  it  to  pass  into  the  room, 
and  the  bottom  should  have  in  it  a  sliding  door  to 
graduate  the  amount  of  fresh  air  admitted  in  accordance 
with  the  external  temperture.  It  is  not  safe  to  have  less 
than  one  foot  of  radiating  surface  to  every  seventy-five 
feet  of  air  to  be  heated,  for  then  it  will  not  be  necessary 
to  carry  so  high  a  degree  of  steam  at  the  boiler,  and 
provision  will  be  thus  made  for  the  severest  cold,  without 
any  undue  forcing  of  the  apparatus  which  it  is  always 
desirable  to  avoid. 

One  point  of  great  practical  importance  should  be  looked 
after,  to  arrange  the  pipes  conducting  the  steam  to  the 
radiators  in  such  a  manner,  that  a  pipe  from  the  boiler 
should  carry  the  steam    separately    to  each  section  of  the 


On  tlve  Propositions  of  the  Association.  338 

building.  Where  the  steam  is  carried  in  one  main  pipe 
to  all  the  sections,  the  life  of  the  steam  seems  to  be  taken 
out  of  it  in  great  measure  before  it  reaches  the  extreme 
wings,  and  the  degree  of  heat  needed  in  those  wards,  is 
often,  in  the  severest  weather,  not  fully  obtained ;  but 
where  a  separate  pipe  carries  the  steam  to  each  particu- 
lar section,  it  can  be  done  in  a  smaller  pipe,  and  the  force 
of  the  steam  can  be  more  readily  maintained  at  all  times. 
By  this  means,  also,  any  ward  can  be  heated  without  the 
necessity  of  heating  the  whole  building,  as  occasions  will 
often  arise,  where  it  may  be  requisite  to  have  certain 
wards  heated,  and  not  the  whole  house.  It  is  also  more 
economical  to  maintain  a  regular  steady  heat  during  the 
night,  as  well  as  the  day,  m  cold  weather,  so  that  the 
radiators  may  not  become  chilled,  and  the  pipes  cooled, 
which  carry  the  steam  to  them,  while  the  rooms  do  not 
become  cool  and  the  patients  exposed  to  the  risk  of  taking 
cold  by  any  sudden  and  severe  change,  which  may  occur 
during  the  latter  part  of  the  night. 

XXI. — "A  complete  system  of  forced  ventilation  in  con- 
nection with  the  heating  is  indispensable,  to  give  purity  to 
the  air  of  a  hospital  for  the  insane,  and  no  expense  that 
is  required  to  effect  this  object,  thoroughly,  can  be  deemed 
either  misplaced  or  injudicious." 

In  order  to  maintain  efficient  ventilation,  it  is  abso- 
lutely necessary  that  an  abundant  supply  of  fresh  air,  from 
a  point  above  the  building,  sufficiently  elevated  to  be  free 
from  all  contaminating  influences  of  every  kind,  should 
be  driven  into  the  different  rooms.  It  has  been  consid- 
ered by  some,  that  if  efficient  means  of  withdrawing  the 
foul  air  from  the  rooms  is  provided,  the  problem  of  ven- 
tilation is  solved,  but  this  leaves  the  air  to  be  drawn  from 
the  cellars  and  the  parts  around  the  building,  where  it  is 
liable  to  be  affected  by  a  variety  of  deleterious  influences ; 
and  when  cold  weather  comes,  every  external  opening 
will  be  closed,  and  the  strong  probability  is  that  vitiated 
air  will  be  drawn  into  the  rooms  from  unexpected  sources. 
But  when  the  fans  are    placed  in  a  separate  building  with 


334  John  Curwen. 


towers  over  them,  raised  considerably  above  the  roof  of 
the  building,  the  air  can  be  obtained  free  from  every 
probable  contamination,  and  thus  driven  pure,  steadily  and 
regularly  into  every  room.  The  best  plan  is  to  have  one 
fan  for  each  department  of  the  building,  male  and  female, 
situated  at  some  central  point  in  the  rear  of  the  main 
building,  so  that  by  a  proper  arrangement  of  tunnels, 
ever>-  part  of  the  central  building  and  wings,  can  be  fully 
supplied  with  all  the  air  which  they  may  need.  These 
fans  should  be  at  least  twelve  feet  in  diameter,  and  each 
fan  should  have  an  engine  attached  to  its  shaft,  so  that 
it  may  be  run  without  any  interference  with  the  other 
machiner}-,  or  any  likelihood  of  stoppage  from  other 
causes,  which  might  arise  by  connection  with  a  series  of 
belts  and  puUies  used  for  other  work.  These  fans  should 
be  kept  in  motion  both  day  and  night,  at  a  regular  rate, 
calculated  to  force  into  every  part  of  the  institution,  such 
a  supply  of  fresh  air,  as  will  change  that  of  the  rooms 
every  minute. 

Some  think  that  if  the  fans  are  run  during  the  day  it 
will  answer  the  purpose,  but  a  little  reflection  will  show, 
that  with  the  whole  house  closed  and  every  means  of 
ingress  of  air  cut  off,  and  where  the  number  of  inmates  is 
large  and  the  wards  reasonably  or  quite  full,  the  air  will 
be  much  more  quickly  contaminated  at  night,  and  on  that 
account  a  steady  supply  of  fresh  air  should  be  driven  in 
so  as  to  displace  the  foul  air  likely  to  accumulate.  By 
this  means  the  inmates  will  breathe  a  purer,  fresher  air 
when  they  really  most  need  it,  and  be  less  exposed  to 
to  any  danger  arising  from  vitiated  air,  the  source  of  so 
much  ill  health,  and  the  origin  of  so  many  troublesome 
diseases. 

We  speak  what  we  do  know,  when  we  affirm  that  the 
freedom  from  zymotic  diseases  enjoyed  by  many  institutions 
for  the  insane,  must  be  attributed  to  the  regular  and  steady 
supply  of  fresh  air  which  has  been  driven  into  the  rooms 
by  the  constant  action  of  the  fans,  and  in  the  over  crowded 
condition  of  many  hospitals    this    degree    of   health    could 


Cn  the  Propositions  of  the  Association.  335 

never  have  been  maintained,  but  by  the  continued  action 
of  the  fans  through  the  whole  twenty-four  hours. 

Another  matter  which  will  be  found  of  importance, 
will  be  placing  a  number  of  radiators  over  each  fan  so 
that  the  air  in  sev^ere  winter  weather  may  be  moderated 
before  it  passes  into  the  air  shalts,  and  over  the  radiators  in 
the  air-chambers,  thus  preventing  the  freezing  of  so 
many  pipes,  the  risk  to  those  whose  duty  calls  them 
into  those  parts  from  the  great  change  from  the  heat 
of  the  air-chambers  to  the  low  temperature  of  the  air  shafts, 
and  the  greater  ease  of  maintaining  an  equable  tempera- 
ture. Then  at  certain  seasons  when  it  is  necessary  to 
moderate  the  temperature  in  the  morning,  or  in  the  evening, 
or  during  a  cold  or  wet  period  of  weather,  the  requisite 
amount  of  heat  could  be  obtained  in  this  way,  without 
the  labor  and  expense  of  generating  steam  in  the  boilers 
for  heating  the  hospital. 

XXII. — "The  boilers  for  generating  steam  for  warming 
the  building  should  be  in  a  detached  structure,  connected 
with  which  may  be  the  engine  for  pumping  water,  driving 
the  washing  apparatus  and  other  machiner>'." 

By  this  arrangement  all  risk  from  accident  of  any 
kind  to  the  boilers  will  be  removed  from  the  building 
in  which  the  officers  and  patients  reside ;  the  dust  and 
dirt  from  handling  the  coal  and  ashes  will  be  kept  from 
th  main  building,  and  all  unpleasant  effuvia  from  the 
laundrj'  and  other  rooms  connected  with  it,  will  be 
prevented  from  reaching  the  wards,  and  also  all  the 
noise  and  confusion  so  incident  to  that  character  of  work 
and  from  the  machiner}\ 

XXIII. — "All  water-closets  should,  as  far  as  possible, 
be  made  of  indestructible  materials,  be  simple  in  their 
arrangements  and  have  a  strong  downward  ventilation 
connected   with    them." 

Xo  part  of  a  hospital  for  the  insane  is  more  difficult 
to  keep  pure  and  free  from  offensive  emanations,  and  on 
this  account  the  floors  should  be  of  large  slate  tile,  well 
laid  in  cement  so  as  to  be  firm  and  solid,  and  all  parts  of 


John  Curiuen. 


the  apparatus  in  these  rooms  should  be  of  iron,  lined  with 
porcelain,  and   well   painted    on    the    outside. 

Two  plans  have  been  used  to  obtain  an  effective 
downward  ventilation.  One  consists  in  connecting  all  the 
downward  pipes  from  the  closets  with  a  pipe  which 
passes  to  the  main  chimney  stack  of  the  boilers,  for 
heating  the  hospital  and  for  the  machinery,  and  having 
this  stack  arranged  with  a  large  iron  pipe  in  the  center, 
through  which  all  the  smoke  and  gases  shall  pass  up, 
while  into  the  space  between  this  iron  pipe  and  the 
brick  work  of  the  chimney,  all  the  pipes  from  the  water- 
closets  shall  be  carried  so  that  a  current  of  air  will 
be  created  upward  in  the  chimney  drawn  from  the  water- 
closets.  To  make  this  thoroughly  effective,  the  pipes 
should  be  carried  as  directly  as  possible,  so  as  to  avoid  all 
bends   and   turns. 

The  other  plan  will  be  to  exhaust  the  air  from  the 
pipes  by  means  of  a  fan  or  blower,  and  thus  create  a 
strong  downward  current  and  prevent  all  unpleasant  effuvia 
rising  into  the  room,  and  also  take  from  the  room  any 
odors  which  might  come  from  other  sources. 

The  efficiency  of  this  will  depend  on  the  strength  and 
rapidity  of  the  blower,  and  the  care  taken  to  keep  it 
steadily  and  regularly  in  action ;  and  where  it  has  been 
tried,  it  has  given  entire  satisfaction. 

Both  plans  must  be  provided  with  a  trap  between  the 
main  sewer  and  the  point  at  which  the  air  is  taken  from 
the  pipes  of  the  closets. 

In  addition  to  this  ventilation  an  abundant  supply  of 
water  should  be  provided,  which  shall  flush  the  hoppers 
and  pipes  freely  and  regularly,  and  thus  add  to  the 
efificiency  of  the  ventilation. 

The  vital  importance  attached  to  the  subject  of  heating 
and  ventilation  may  be  inferred  from  the  following  resolu- 
tions, adopted  in  1848,  before  the  proposition  under  con- 
sideration were  formulated : 

Rksolvkd,  Tliat  it  is  tlie  deliberate  conviction  of  tliis  Association, 
that  an  abundance  of  pure  air,  at  a  proper   temperature,  is  an  essential 


On  the  Propositions  of  the  Association.  337 


element  in  the  treatment  of  the  sick,  especially  in  hospitals;  and 
whether  for  those  afflicted  with  ordinary  disease,  or  for  the  insane,  and 
that  no  expense  that  isi  required  to  eftect  this  object,  thoroughly,  can 
be  deemed  either  misplaced  or  injudicious. 

Resolved.  That  the  experiments  recently  made  in  various  institu- 
tions in  this  country  and  elsewhere,  prove  to  the  satisfaction  of  the 
members  of  this  Association,  that  the  best  means  of  supplying  warmth 
in  winter,  at  present  known  to  them,  consists  in  parsing  fresh  air  from 
the  external  atmosphere  over  pipes  or  plates  containing  steam  under 
low  pressure,  or  hot  water,  the  temperature  of  which  at  the  boiler,  does 
not  exceed  212o  F..  and  placed  in  large  air-chambers  in  the  basement  or 
cellar  of  the  building  to  be  heated. 

Eesolvkd,  That  a  complete  system  of  forced  ventilation,  connected 
with  such  a  mode  of  heating,  is  indespensable  in  every  institution  devoted 
to  these  purposes,  and  where  all  possible  benefits  are  sought  to  be 
derived  from  its  arran<rements. 


Art.    v.  — An    Improved  ./Esthesiometer 
and  Some  of  its  Uses.-' 


By  C.  H.  Hughes,  M.  D. 

TF  two  points  of  a  pair  of  compasses,  blunted  or 
-^  guarded  with  small  bulbs  of  rubber  or  cork  be  simultane- 
ously applied  to  any  portion  of  the  body  on  the  same 
longitudinal  line,  they  can  only  be  perceived  as  two  dis- 
tinct points,  provided  the  skin  remains  immovable,  when 
they  are  a  certain  distance  apart.  The  distance  at  which 
the  two  points  of  contact  with  the  skin  are  recognizable, 
varies  in  the  healthy  individual,  at  different  parts  of  the 
body  and  at  the  same  parts  of  the  body  in  the  same 
person,  in  diseased  conditions  of  the  nervous  system. 

•This  paper  was  intended  to  accompany  the  instrument  described  in  the  January 
number  of  this  Journal,  but  was  crowded  out  by  other  matter.  We  give  it  place  now 
to  satisfy  a  number  of  the  subscribers  who  have  asked  for  information,  by  letter, 
concerning  our  new  instrument.  An  explanation  of  the  abbreviations  for  the  distance 
points  of  the  KSthesiometer,  there  illustrated  and  described,  is  aj^pended. 


338  C.  U  .Hudhes. 


This  'fact  gives  diagnostic  value  to  the  employment  of 
the  aisthesiometer. 

In  liypcmstlicsia  or  abnorm.il  exaltation  of  sensibility  in 
a  part,  the  two  blunt  points  are  distinguishable  when 
much  nearer  together  than  they  could  be  perceived  by 
the  individual  when  in  health ;  while  in  a/icssthesia,  the 
points  are  distinctly  felt  when  placed  at  a  much  greater 
distance  from  each  other  on  the  skin. 

Loss  of  sensibility  may  even  be  so  great  that  the  two 
points  can  not  be  separately  recognized  if  applied  on  the 
same  longitudinal  line,  at  any  distance  apart,  and  sensi- 
bility to  touch  may  be  so  exalted  that  the  points  can 
scarcely  be  so  closely  approximated  as  not  to  be  distinctly 
felt  as  two. 

In  determining  normal  algesia,  hyperalgesia  and  anal- 
gesia, the  reversible  sharp  points  will  likewise  be  of 
service. 

In  estimating  possible  liypcrcestlicsia,  some  allowance 
must  be  made,  in  certain  instances,  for  greater  natural 
delicacy  of  skin  in  certain  individuals,  in  certain  active 
mental  temperaments,  and  in  persons  whose  occupations 
require  and  lead  to  a  high  state  of  cultivation  of  the 
sense  of  touch ;  the  tactile  sense  being  greatly  increased 
in  the  fingers  of  the  blind,  who  learn  to  so  appreciate 
distance,  by  touch,  as  to  construct  the  finest  fabrics,  play 
the  most  delicate  instruments,  thread  needles  with  their 
tongues,  and,  it  is  said,  to  even  distinguish  colors  through 
variations  in  their  grain,  though  an  old  and  eminent  super- 
intendent of  the  blind  told  me  he  doubted  this,  while  he 
knew  it  to  be  a  fact,  that  some  of  his  pupils  could  readily 
distinguish  proximity  to  solid  objects,  without  touching 
them. 

"The  Bengalese  spinning  women  can  distinguish  the 
threads  of  the  cocoon  with  a  tactile  sensibility  which  is 
almost  incredible ;"  while  in  armless  persons,  the  toes 
have  been  taught  to  rival  the  fingers  in  power  of  tactile 
appreciation. 

The    tactile    perceptive     power     is     also     modified     in 


An  Improved  ^^sthesiomeier. 


certain  mental  states,  as  in  profound  melancholia,  and  in 
some  forms  of  insanity,  being  often  lessened  in  the 
depressed  and  chronic  stages  of  mental  disease,  and  in 
some  cases  of  violent  recent  general  mania,  as  well  as 
heightened  in  some  of  the  acute  forms  of  this  disease. 

Cutaneous  ensibility,  as  is  well  known,  is  likewise  often 
modified  or  suspended  in  hysteria,  catalepsia,  ecstacy, 
preceding  and  during  the  epileptic  paroxysm,  as  well  as 
in  affections  of  the  spinal  cord,  and  under  the  use  of  cer- 
tain drugs,  as  strychnia  and  atropia,  the  former  increasing 
and  the  latter  diminishing  it. 

When  employing  the  ^esthesiometer  for  diagnostic  pur- 
poses, we  should  be  assured  that  these  medicines,  as  well  as 
alcohol,  opium,  chloral,  bromide  of  potas-ium  and  other 
obtending  agents,  are  not  present  in  the  system  in  any 
considerable  quantity,  to  retard  cutaneous  sensibility  and 
vitiate  our  conclusions. 

When  the  morbid  change  in  the  nerve  function  exists 
in  one  limb  only,  or  on  one  side  of  the  body,  as  in 
hemi-anaesthesia,  it  is  best  always  to  compare  the  sound 
with  the  unsound  part. 

Successful  jesthesiometrical  mensuration  requires  that 
the  patient  should  have  no  definite  idea  of  the  num- 
ber of  points  you  are  going  to  apply,  or  how  many  you 
expect  him  to  feel.  Some  tact  is,  therefore,  required  to 
avoid  the  influence  of  imagination  and  expectant  atten- 
tion, and  the  exercise  of  the  guessing  f  iculty  on  the  part 
of  the  patient. 

It  is  always  best  in  the  beginning  to  apply  but  one  point, 
and  afterwards  to  let  the  patient  see  that  he  has  answered 
correctly,  and  afterwards  to  proceed  with  the  examination 
to  its  close,  without  letting  him  know  whether  or  not  his 
replies  are  accurate.  Though  some  little  tact  in  manip- 
ulation is  requisite,  in  order  to  elicit  from  the  patient 
more  than  mere  guesses,  as  to  the  number  of  points  he 
■feels,  there  is  not  really  so  much  difficulty  experienced 
here  as  novices  realize,  in  employing  the  microscope  and 
other  instruments. 


340  C.  E.  Bushes. 


It  would  be  a  grave  error,  if  \vc  should  mistake  a 
patient's  mere  guess  of  two  points,  when  only  one  is 
applied,  or  of  three,  when  only  two  are  brought  in  con- 
tact with  the  skin,  for  a  real  abnormal  sensation  of  that 
kind. 

Where  this  latter  perversion  of  contactile  discrimination 
has  really  been  found,  there  has  co-existed  cerebral  "inflamma- 
tion or  congestion,  sometimes  the  result  of  an  intra-cranial 
tumor  at  the  base  of  the  brain,  and  especially  in  one  of 
the  cerebral  peduncles,  or  in  one  of  the  lateral  halves  of 
the  annular  protuberance.  The  sites  of  this  phenomenon 
are  the  face,  neck  and  hand ; "  but  most  commonly  the 
face.  As  McLain  Hamilton  observes :  "there  seems  to  be, 
in  some  individuals,  a  discouraging  stupidity  which  prompts 
them,  in  answer  to  the  question  'how  many  points  do  you 
feel  ?'  to  oftentimes  reply  'three,'  when  they  know  that 
the  instrument  has  but  two    points." 

I  witnessed  this  lately  in  a  blind  man,  who  began  by 
guessing  "three"  and  "two,"  without  regard  to  the  number 
of  points  he  actually  felt,  when  there  was  nothing  the 
matter  with  his  nerves.  He  had  probably  gleaned  from 
my  conversation,  in  his  hearing,  with  Dr.  McVVorkman,  the 
Superintendent  of  the  Blind  Asylum,  that  an  individual's 
sensations  were  very  deceptive  as  to  the  number  of  points 
applied  to  certain  parts,  and  endeavored  to  make  up  in 
guessing  what  he  lacked  in  power  of  tactile  perception. 
After  being  told  he  was  only  guessing,  his  answers  became 
more  satisfactory. 

In  the  use  of  the  aesthesiometer,  we  must  keep  constantly 
in  mind  the  fact,  that  what  is  normal  to  one  part  is 
not  always  normal  to  another.  For  instance,  in  the  partial 
anaesthesia  of  alcoholism,  or  that  associated  with  commenc- 
ing disease,  or  partial  section  of  the  posterior  portion 
of  the  peduncular  expansion,  or  in  disease  of  the  tactile 
center  of  Ferrier,  it  is  not  necessary  that  the  points  should 
not  be  discriminated  at  all,  but  that  they  should  not  be 
felt  at  a  distance  apart,  at  which  they  can  be  readily 
appreciated  on  the    opposite  side ;    and,  in    chronic    spinal 


^fv  Improved  Msthesiometer.  341 

meningitis,  where  the  sensibiHty  is  so  greatly  increased,  the 
points  need  not  be  discriminated  in  the  middle  of  the  arm, 
thigh,  or  back,  at  the  distance  of  only  a  line  or  two  apart, 
to  indicate  the  disease,  but  if  they  are  felt  an  inch,  or  an 
inch  and  a-half  apart,  that  would  be  sufficient. 

The  best  instrument,  now  in  common  use,  is  that  of 
Sieveking,  the  original  inventer.  All  the  others,  however, 
except  Carroll's,  being  preferred  by  different  neurologists, 
because  of  their  being  more  compact  and  requiring  less 
room  in  the  pocket-case. 

An  examination  and  comparison  will  show  wherein  the 
one  I  hav^e  devised  differs  from  its  predecessors,  and  its 
advantages,  both  for  convenience  and  utility.* 

The  objection  which  has  been  urged  against  instru- 
ments, constructed  on  the  principle  of  dividers,  does  not 
hold,  in  either  my  own  or  Sieveking's,  for,  in  both,  one 
of  the  points  is  stationar}^  while  a  screw  secures  the 
sliding  point  from  dropping  down  unobserved,  towards  the 
other,  after  removal  from   contact  with    the  patient's    skin. 

To  Brown  Sequard,  more  than  to  any  other  physician, 
belongs  the  credit  of  having  utilized  this  instrument  in 
diagnosis,  while  to  Weber  the  credit  is  due,  of  giving  us 
the  best  approximative  normal  distance  record  for  the 
the  points  in  different  localities  of  the  body  surface. 

Weber  found  the  spot  for  the  nicest  discrimination  to 
be,  as  this  instrument  shows,  the  tip  of  the  tongue.  He 
gives  it  as  .0433  of  an  inch,  a  minute »  decimal  fraction 
less  than  half  a  line.  The  finger-tips  and  the  tip  and 
volar  side  of  the  thumb,  as  might  be  suspected  from  their 
tactile  dexterity,  come  next  in  order  of  discriminating 
power. 

The  lips  come  next,  their  red  surface  being  more 
sensitive  than  the  lighter  parts.  Next  comes  the  great 
toe,  on  its  volar  aspect ;  then  the  eyelids,  the  skin  over 
the  cheeks  and  the  lower  part  of  the  forehead. 

A  wide  range  of  sensibility    exists    on    the    dorsum    of 

•For  cut  see  January  number  of  this  Journal .  The  instriiment  is  manufac- 
tured by  Aloe  tS;  Herusteiu,  of  St.  Louis. 


>42  C.  B.  Hughes. 


the  hand  and  foot,  from  two  and  a-third  to  seven  lines  for 
the  former,  and  from  six  to  almost  thirteen  lines  for  the 
latter. 

The  hands  and  feet  are  more  sensitive  than  the  fore- 
arms and  legs,  and  the  forearms  and  legs  are  less  sensitive 
than  the  middle  of  the  fleshy  part  of  the  thighs  and  the 
middle  of  the  back;  the  elbow  and  knee  joints  are  more 
sensitive  than  the  segment  of  the  limbs  they  connect ;  the 
face  and  occiput  are  more  sensitive  than  the  top  of  the 
head,  and  the  abdominal  than  the  dorsal  surface  of  the 
body.  The  foreskin,  the  soles  of  the  feet  and  axilla, 
notwithstanding  their  special  sensibility,  are  far  below  the 
lips  and  the  tips  of  the  nose  and  fingers  in  perceptive 
power  as  to  distance. 

These  are  Weber's  results,  and  they  have  been  accepted 
as  quite  correct,  and  generally  adopted  as  the  standard 
of  comparison,  which  may  be  found  in  many  books  on 
practice.  His  table  may  be  consulted  with  profit  by  any 
one  wishing  to  use  this  instrument. 

Explanations    of   abbreviations    on    the    aisthesiometer, 
described,  and    illustrated    in  the    Januar}'    number  of  this 
journal. 
Mid.,  1 
Neck,    I 

Bali'    \  "^''^  ^^^  '•'^^  middle  ol"  the  neck,  arm,  back,  leg  and  thigh. 
Leg,      I 
Thig..  J 

CeT\  V.  ( ^^^^  ^'^^  lumbar  and  cervical  vertebral  r.-gions. 
Sitr. — Is  for  Sternum. 

F^.  Z).  Sac. "(  Are  for  the  dorsum   of  the  foot,    the  sacrum  and  the  accro- 

Ace.  jmial  region. 

Pat.— Is  for  the  patella. 

Ver.,  NL— Are  for  the  vertex,  and  for  the  neck  under  the  lower  Jaw. 

Oee. — For  occiput,  lower  part. 

L.  For.— Lower  forehead. 

D.  II.  Afe^c— Dorsum  of  the  hand  and  metacarpal  region. 

Zyg.—Zv'^oma. 

G.  to;P,n.  c*.— Great  toe,  palm  of  hand,  cheek. 

Nose^  }  ^^^^""^  ^^  t^^  ^''•'■'^  linger,  and  tip  of  the  nose. 

e^l  P.  }^*^^^  surface  of  lips,  and  palmar  aspect  of  second  tinger. 
F.  71— Fingertip. 
71  71— Tongue  tip. 


Art.  VI.  —  Post-Mortem  Notes  with  His- 
tory of  Convulsions. 


By  Henry  H.  Mudd,  M.  D., 

PROF.  OF  ANATOMY,  ST.  LOUIS  MEDICAL  COLLEGE. 

"1\ yfRS.  S.,  aged  35  years,  mulatto,  has  been  an  active, 
-^^■^  intelligent  woman,  serving  for  the  last  two  years  as 
cashier  in  a  large  barber-shop  in  our  city.  She  has  had 
occasional  epileptic  seizures,  at  the  menstrual  epoch.  In 
August,  1879,  she  had  slight  hemorrhage,  supposed  to 
come  from  the  lungs. 

Health  about  as  usual  during  the  early  winter  of 
1879-80,  but  during  the  latter  part  of  winter  had  severe 
pains  in  the  right  shoulder,  in  both  hands  and  wrists,  with 
wandering  pains  over  body  and  extremities,  supposed 
to  be  rheumatic,  but  without  any  swelling  of  parts  involved. 

About  the  ist  of  March,  1880,  she  commenced  com- 
plaining of  pains  in  her  head,  and  after  sudden  move- 
ments, when  the  pain  was  severe,  she  would  place  her 
hand  to  the  side  of  her  head — near  the  ear.  This  com- 
plaint became  more  constant  during  the  latter  part  of 
April,  when  she  became  more  irritable  than  was  her  habit, 
but  less  talkative,  and  rather  dull  and  sleepy.  Her  com- 
panions noticed  that  she  was  reluctant  to  use  her  hands 
as  usual,  and  complained  of  being  weak. 

On  or  about  the  nth  of  May,  while  at  work  in  the 
office,  she  became  dizzy  and  felt  numbness  of  right  side 
of  body,  became  semi-conscious,  but  after  resting  was 
able  to  get  home,  when  I  saw  her  for  the  first  time,  with 
reference  to  her  present  condition.  I  found  her  somewhat 
nervous  with  anxious  expression,  and  complaining  of  pain 
in  the  back  of  her  head.  I  was  called  again  to  see  her 
on  the  17th  of  May,  after  she  had  been  taken  home, 
having  suffered  another  attack  while  at  work.  She  was 
again  suffering  severely  with  the  back  of  her  head ;  was 
pale,    somewhat    confused,    but    with    no  fever;    her  pulse 


>44  Henry  H.  Mivdd. 


was  about  80.  I  saw  the  patient  again  Friday,  May  21, 
soon  after  a  severe  convulsion  ;  from  this  time  to  death, 
convulsions  continued  at  varying  intervals;  when  severe, 
they  involved  all  the  extremities  and  the  face;  when  less, 
violent,  only  the  right  side  was  convulsed.  She  became 
unconscious,  and  noticed  nothing  after  the  evening  of  the 
2ist;  reclined  on  leftside  and  moved,  at  intervals  between 
the  spasms,  the  right  arm  and  leg,  but  did  not  use  the  left; 
face  was  turned  to  left ;  eyes  half  open — pupil  very  small ; 
breathing  was  impeded  by  mucous  which  collected  in 
the  throat,  but  was  regular  and  easy  when  freed  of  this 
impediment.  Temperature  hitherto  normal,  began  slowly 
to  increase,  and  on  the  evening  of  May  23d,  reached  the 
highest  point  observed,  103  1-2 ;  pulse  at  this  time  was 
140.  Patient  died  at  2  a.  m.  the  24th  of  May;  post-mor- 
tem at  4  p.  m.,  same  day. 

Calvarium  removed  ;  dura-mater  normal,  except  a  mass 
resembling  a  pachionian  body  had  perforated  the  mem- 
brane an  inch  to  the  right  of  the  longitudinal  sinus.  The 
dura-mater  was  firmly  adherent  along  the  left  side  of  the 
longitudinal  fissure  to  the  arachnoid  by  pachionian 
granules.  Beneath  the  arachnoid,  and  extending  over  the 
superior  and  inferior  parietal  lobes,  the  angular  gyrus,  the 
superior  tcmper-sphenoidal  and  first  occipital  convolotions, 
there  was  a  very  thin  layer  of  venous  colored  extravasated 
blood  on  left  side,  with  well-marked  clods,  1-8  of  an  inch 
thick,  in  or  about  the  upper  posterior  extremity  of  the 
inter-parietal  fissure.  There  was  also  effusion  under  the 
arachnoid,  over  part  of  same  region,  on  the  right  side,  but 
it  was  not  so  well  marked  and  more  limited  in  area. 

A  slight  opalescence  was  observed  along  the  vessels 
on  the  base  of  the  brain,  and  more  serum  was  found  in 
the  arachnoid  than  usual. 

The  fissure  of  sylvius,  on  the  under  surface  of  the 
brain  did  not  correspond  with  the  depression  which  rests 
on  posterior  border  of  the  lesser  wing  of  the  sphenoid,  but 
was  found  presenting  well  down  toward  the  middle  of  the 
anterior  extremity  of  the  middle  lobe. 


Post-Mortem  JVotes-  345 


Sections  were  freely  made  through  the  substance  of 
the  cortex,  through  the  cerebellum,  the  basal  ganglia, 
the  pons  and  the  medulla,  but  nothing  abnormal  was 
observed  by  those  present,  viz :  Drs.  Hodgen,  Hughes, 
Black  and  myself,  as  well  as  a  number  of  students.  The 
only  perceptible  lesion  here  found,  was  in  the  effusion 
under  the  arachnoid  and  over  the  lateral  posterior  surface 
of  the  brain.  There  was  an  entire  absence  of  inflamma- 
tory lesion  about  this  effusion. 

Seppilli,  as  translated  by  Workman,  present  number  of 
the  Alienist  and  Neurologist,  in  his  review  of  Nothna- 
gel's  observations  on  "Topical  Diagnosis  of  Disease  of  the 
Brain,"  says,  "In  epilepsy  of  cortical  origin,  the  commence- 
ment of  an  access  is  most  frequently  represented  by 
phenomena  of  excitement  of  motion,  which  are  in  some 
cases  extensive.  In  certain  patients  the  paroxysm 
commences  constantly  in  the  facial  muscles,  or  in  those  of 
the  neck,  or  of  one  extremity.  *  *  *  * 

The  partial  convulsions  which  result  in  sequence  to 
a  hemorrhage  or  a  softening,  may  be  taken  as  indicating 
with  probability,  but  not  with  certainty,  a  cortical  lesion." 


Art.  VII. — Case  of  Morbid  Juvenile 
Pyrophobia  caused  by  Malarial 
Toxhaemia. 


Reported  by  Willis  P.  King,  M.  D.,  of  Sedalia,  Mo. 

IX/T  Is  a  ten-year-old,  pale,  fair  haired  boy,  of  good 
"^  -■-•  intelligence,  learns  his  lessons  well,  and  has  always 
appeared  to  have  pretty  good  general  health.  There  is 
no  history  of  insanity,  epilepsy,  apoplexy,  dipsomania 
or  paralysis  in  his  ancestry. 

His  father,  however,  is  a  very  nervous  man ;  always 
extremely  agitated  and  alarmed  when  any  of  the  family  are 
sick,  and  constantly  fearing  wind  and  rain-storms,  and  when 


346  ]mUs  P.  Kin^. 


the  latter  come,  he  confidently  expects  the  house  to  be 
blown  down  or  some  other  calamity  to  happen.  He  faints  at 
sight  of  blood  or  on  suffering  pain.  The  mother  is  just  the 
contrary.  During  the  summer  and  autumn  of  1879,  M.  had 
a  tertian  ague,  regularly  recurring  for  a  period  of  two  or 
three  months.  A  Homoepathic  ph}'sician  treated  him  un- 
successfully. 

On  the  27th  of  September,  1879,  his  mother  consulted 
me  about  her  boy.  She  stated  that  he  had  become  so 
morbidly  fearful  of  fire,  that  the}'  could  scarcely  have  a 
fire  in  the  house,  even  for  cooking  purposes.  On  visiting 
him,  I  found  his  body  considerably  wasted  from  the  pro- 
longed ague.  His  face  was  very  pale  and  puffy.  His 
pulse  constantly  over  one  hundred,  and  his  temperature 
above  normal,  the  former  being  most  accelerated,  and  the 
latter  exalted  in  the  afternoon.  He  ate  but  little,  and 
slept  fitfully.  He  was  up  and  dressed,  and  generally 
"about  the  house,"  before  the  rest  of  the  family,  but 
spent  a  goodly  portion  of  his  time  reclining  on  a  sofa. 
All  of  his  thoughts  seemed  to  be  taken  up  with  the  sub- 
ject of  fire.  He  stated  to  me  that  he  knew  the  town 
would  be  burned  down ;  the  flues  of  all  the  houses  were 
out  of  repair;  the  houses  were  nearly  all  of  wood,  and  the 
people  didn't  seem  to  have  any  sense  of  their  danger." 
His  mother  stated  that  when  the  bell  of  the  City  Hall 
rang  the  hours  of  nine,  twelve  and  six,  he  would  run  out 
in  great  agitation,  exclaiming  that  there  was  a  fire,  and 
would  scan  the  horizon  in  all  directions  for  the  object  of 
his  fears.  He  went  repeatedly  during  the  day  from  room 
to  room,  and  inspected  the  stoves  and  the  flues  about  the 
house.  He  went  to  bed  at  night  protesting  against  the 
building  of  fires,  and  in  the  morning,  when  the  cook 
began  the  preparations  for  breakfast,  at  the  first  noise  of 
poker  or  shovel,  he  would  bound  out  of  bed  (when  at  his 
worst,  not  taking  time  to  put  on  his  pants)  and  would 
hurry  down  to  the  kitchen  and  would  try  to  prevent  the 
cook  from  making  the  fire.  He  had  to  be  literally  guarded 
by  his  mother  during  tlie  preparation  of  the  meal,  and  as 


Case  of  Morbid,  Juvenile  Pyrophohia.  347 

soon  as  this  was  done,  the  fire  had  to  be  extinguished  to 
allay  his  fears.  He  would  deliberately  extinguish  the  fire  in 
the  sitting  room  against  his  mother's  orders.  In  one  instance 
on  a  cool  morning,  when  there  was  more  fire  than  usual, 
he  procured  a  bucket  of  water,  and  in  spite  of  the  exer- 
tions of  his  mother  to  prevent  him,  he  succeeded  in 
opening  the  stove  with  his  foot — plunging  his  boot  into 
the  fire  to  keep  the  stove  door  open — and  dashed  the 
water  into  and  over  the  stove  and  carpet. 

These  contests  were  of  daily  occurrence.  Threats 
of  punishment  would  not  deter  him.  Although  very 
irritable,  he  conversed  intelligently  on  all  subjects  except 
fire.  Upon  this  subject  he  seemed  utterly  incapable  of 
reasoning  correctly.  I  discovered  no  evidence  of  epilepsia 
or  epileptoid — day  time  or  nocturnal.  The  sole  exciting 
cause  of  all  this  pyrophobia  seemed  to  be  cerebral 
hypera^mia,  dependent  upon  malarial  toxhsemia.  Upon 
consultation  with  eminent  authority,  he  was  put  upon  five- 
grain  doses  of  quinine,  three  or  four  times  a  day;  the 
bromides  of  sodium  and  calcium  with  the  syr.  calc.  lacto- 
phos  before  meals.  Ether  was  poured  upon  the  crown 
of  his  head,  and  allowed  to  evaporate,  several  times  a 
day.  Under  this  treatment  he  improved  steadily,  after 
about  the  first  week.  Within  six  weeks  he  was  apparently 
well,  so  far  as  the  pyrophobia  was  concerned,  but  he  was 
kept  upon  the  treatment  for  some  months,  in  order  to 
prevent  a  relapse. 


SELECTIO  NS. 


Illustrations  of  Juvenile  Insanity.* — By  Isaac  N.  Kcrlin, 
M.  D. — The  establishment  of  institutions  for  children  of 
defective  mind,  in  many  of  our  American  States,  is  bringing 
to  our  knowledge  facts  and  statistics  on  this  important 
subject,  which  prove  that  juvenile  affective  insanity  is  more 
common  than  has  been  hitherto  stated ;  indeed,  it  is  not 
improbable  that  lesser  degrees  of  this  disorder  have  been 
been  allowed  to  go  unrecognized,  being,  as  they  so 
generally  are,  the  temporary  consequences  of  sympathetic 
disturbances,  or  the  sequelae  of  acute  diseases,  removed 
w^hen  the  cause  is  dismissed  or  outgrown. 

Cast  I. — Be>sie  was  three  years  old  when  brouglit  to  my  Jiotice.  It  is 
said  that  one  year  before  she  had  a  fall  which  injured  her  spine,  followed 
by  fever  ami  convulsions;  on  her  recovery  from  tliese  symptoms,  she  was 
found  witli  vacant,  starinof  eyes ;  her  feet  turned  inward,  and  her  <rait  was 
totterinj^;  she  ran  wildly  from  thing  to  thing,  and  seemed  to  have  but 
momentary  enjoyment  in  each ;  she  knew  not  when  danger  was  near. 
Before  her  ilhiess  she  had  begun  to  talk,  knew  her  parents  and  called  them 
by  name ;  after  it  she  not  only  lost  their  names,  but  was  wanting,  in  great 
measure,  in  that  natural  affection  which  before  had  endeared  them  to  lier. 
Her  destructiveness  was  very  marked,  her  habits  became  lllthy.  and  her 
tastes  strangely  perverted.  She  was  placed  in  an  institution;  it  did  not 
pain  her  to  see  her  mother  leave ;  she  was  at  home  in  a  strange  place, 
.at  home  with  anybody.  She  ran  among  the  other  children,  without 
interest  in  any  of  tliem.  She  amused  herself  with  what  came  within  reach, 
and  injured  or  destroyed  everything  that  amu>;ed  her.  Seven  months  after 
her  admission  her  condition  is  thus  described:  Her  eyes  are  not  now  staring 
and  vacant,  her  feet  are  not  now  unsteady,  but  as  she  prances  through  our 
apartments  and  grounds  she  carries,  in  her  sure  and  steady  step,  the  glad 
tidings  of  approaching  recovery ;  she  is  not  now  wild  with  the  aimless 
capers  of  imbecility ;  her  enjoyments  are  natural,  and  her  affections  are  full 
and  spontaneous.  At  a  recent  visit  of  her  father,  he  was  recognized  by  her 
before  he  had  yet  seen  her,  and  his  ear  caught  the  sound  of  "Papa  I  papal" 
before  he  saw  from  whence  it  came.  She  had  been  wi^^ely,  painfully  taken 
from  her  home,  though  onlj'  three  years  old.  very  soon  after  her  calamity, 
and  had  been  placed  under  circumstances  favorable  to  her  recovery .  The 
result  proves  the  self-sacrificing  good  sense  of  her  parents,  who,  having 
the  welfare  of  their  rhild  alone  at  heart,  listened  not  to  the  false  notions  of 

•Extracted  from  the  l*ro(  Heilinjti-  of  the  Association  of  MeiUc.ul  Oflicers  ot 
American  Institutions  for  Idiotic  und  FetMe-.Minded  Persons. 


Selections.  349 


popular  affection,  which  inculcate  indulgence  at  home  as  the  pity  for  early 
misfortune,  hut  took  the  best  and  the  earliest  means  to  restore  the  lost 
one. 

Case  II. — Tom  McK.,  aged  twelve,  when  first  brought  to  our  knowledge, 
was  described  as  an  incorrigible  boy,  who  had  been  passed  from  one  county 
home  to  another,  through  a  juvenile  reformatory,  and,  at  last,  to  prevent 
his  own  self-destruction,  because  of  his  propensity  to  climb  the  rods  and 
water-spouts  of  the  refuge,  and  to  ramble  dangerously  over  its  roofings,  he 
was  locked  in  a  secure  room.  Excepting  his  under  stature,  nervous  manner, 
and  glittering  eyes,  there  was  nothing  in  the  aspect  of  the  pale-faced  boy  to 
suggest  any  unlikeness  to  normal  boyhood;  indeed, his  aptness  in  language 
both  usual  and  profane,  would  suggest  precocity.  A  study  of  his  case 
under  tieatment,  will  discover  no  inability  to  acquire  knowledge  ;  lie  is 
but  little  more  backward  in  his  studies  than  would  be  any  neglected  boy ; 
he  is  full  of  mischief  and  deceit;  the  usual  indifierence  of  a  bad  boy  to 
punishment  is  morbidly  increased  in  his  case;  and  there  is  moral  hebetude 
dnd  a  causeless  willfulness  that  have  taken  the  place  of  the  fretfulness, 
kickings,  and  bitiugs  of  his  earlit-r  childhood. 

Result  of  Treatment. — The  blind  propensity  to  climb  lightning-rods 
seemed  to  have  been  extinguished  on  the  first  day  of  our  intercourse,  when 
he  was  gravely  requested  to  climb  a  rod  fastened  to  a  stack  one  hundred 
and  eight  feet  high  and  straighten  the  point,  which  had  been  injured  in  a 
storm.  The  little  fellow  seemed  to  measure  the  difficulties,  and  to 
compute  the  impossibility,  but  he  did  not  guess  the  purpose  of  his 
physician;  he  shamefacedly  turned  away  from  the  chimney,  evidently 
discomfited,  and  from  that  day  he  has  had  the  freedom  of  the  grounds, 
without  showing  nny  unusual  disposition  to  clamber.  The  restlessness  of 
the  eye,  and  its  strange  glitter,  are  no  longer  noticeable,  and  by  the 
appliancesof  our  means  of  teaching  in  the  school,  and  the  agreeable,  but 
constant,  occupation  and  exercise  found  out  of  school,  the  boy  is  certainly 
getting  well.  If  any  doubt  existed  as  to  his  title  to  insanity,  the  diagno- 
sis seemed  complete  when,  a  few  days  since,  the  writer  discovered  Tom's 
mother  in  the  insane  department  of  a  county  home,  one  of  the  saddest  of 
dements,  and  learned  that  the  father  had  always  been  an  unsteady,  wild  and 
\iolent  man.  seriously  addicted  to  liquor.  The  boy's  conception,  birth  and 
childhood,  nay,  his  whole  history  was  laid  in  physical  disorder,  fright  and 
disoluteness.     There  are  no  otlier  children. 

Case  ///.—Annie  W.,  a  pretty  little  child  of  seven  years,  was  brought 
to  me  two  years  ago,  she  was  slightly  under  stature  for  her  age,  had  a 
peculiarly  delicate  and  waxen  skin,  and  a  brilliant,  unsettled  black  eye ; 
the  toes,  turned  in  slightly,  and  in  walking  she  bore  the  most  of  her 
weight  on  the  outer  side  of  the  right  foot ;  the  tongue,  in  protruding, 
diverged  from  the  median  line  to  the  left  somewhat.  These  indications 
could  only  be  read  by  the  physician ;  any  causal  observer  would  not 
surmise  tliat  the  pretty,  petite  girl  could  be  a  subject  for  an  Institution  for 
feeble-minded  childi"en,  and  would  be  slow  to  believe  the  mother,  who 
flushed  with  exasperation  while  telling  her  trials,  and  betraying  her  own 
unfitness  to  nurse  and  rear  such  a  babe.  When  brought  to  us  she  was 
described  as    obstinate    to    the    last    degree,    and    she  proved    so;    as 


350  Isaac  A".  Kerlin. 


el:imberiii<r  o\er  slieds  ami  oiit-buildings,  if  allowed  any  freedom;  as 
niiinintr  into  danjjer  %vitliout  any  appreliensloii  or  attention;  but  worse 
than  all  she  repeated  tlie  livelong  ilay.  ringing  in  monotonous  changes  tlie 
the  solitary  idea  of 'inarble  steps/'  Marble  steps  formed  the  substantive 
of  almost  every  sentence. — "Can  ray  mother  have  marble  steps?"  "Has 
that  man  marble  steps?''  "Anne  wants  marble  steps."— wherever  meeting 
with  her  motiicr.  whenever  sitting  in  her  hij),  wiien  l)eing  rocked  in  her 
cradle  or  put  in  her  bed,  this  monotone  of  marl)le  steps  was  poured  into 
her  mother's  ears,  until  tiie  woman  was  wild  with  this  honor,  and  tlie 
chihl  had  become  to  her  an  object  of  avei-sion. 

This  strange  child  was  brought  to  our  Institution,  and  I  have  only  to 
add  that  to-day  there  are  no  marks  ui)on  her.  and  no  impulses  betraying 
any  other  than  the  reaction  of  child-life  to  its  best  impressions.  The 
child  is  healed,  to  all  appearances. 

Now  family  history  helps  us  to  the  comprehension  ofsuch  a  case  as  this. 
Annie's.father  died  of  softening  of  the  brain,  at  thirty-tlve.  after  a  life  of 
excesses,  leaving  two  babes  Iniried— one  of  cholera  infantum  and  one  of 
convulsions — and  two  living  children. — Anne,  alreadj^  described,  and  a 
little  girl  of  live  years  of  age.  who  is  dwarfed,  and,  as  the  motiier  feared, 
"growing  like  Anne."  A  sou  of  the  mother's  sister,  aged  twenty,  is  in  an 
insane  asylum,  and  is  said  "never  to  have  been  all  right"  So  that  as  far  as 
the  family  history  of  this  little  girl  is  made  up,  her  own  blight  is  suggested 
in  a  poor  inheritance. 

Catt  IV. — M.  P..  act.  thirteen;  reasoning  exact  in  all  particulars;  pos- 
sessing a  copious  vocabulary  and  most  retentive  memory;  but  in  natural 
.•itfcichment  to  friend,  sister,  or  mother  entirely  wanting;  oblivious  to  all 
rules  of  order  and  discipline,  delighting  only  in  antagonisms;  all  methous 
of  conciliation,  restraint,  or  punishment  which  an  intelligent,  excellent 
mother  could  devise  have  failed,  and  under  sheer  exhaustion  of  all  home 
eft'orts  she  has  been  committed  to  our  care. 

Since  her  admission  she  has  unceasingly  womed  to  be  whipped.  It 
has  been  the  subject  of  the  most  complacent  reflection  that  "soiie  of  the-e 
days  I  expect  the  matron  will  whip  me.''  She  has  diligently  inquired  into 
the  special  character  of  our  whippings,  whether  thev'  leave  marks,  wliether 
they  draw  blood,  and  eagerly  imagining  the  delights  of  a  flogging.  She 
claps  her  hands  with  anticipation,  exclaiming.  "Oh,  I  shall  be  so  happy  if 
they  will  only  give  me  a  good  wliippingi'' 

All  the  small  deprivations  wliich  would  atflict  another  child  are  lost 
on  lier  in  the  ineflalde  joy  of  punishment,  and  she  is  daily  and  hoiuly 
•  ircumventingr  all  rules,  misbehaving  in  all  conceivable  ways,  irritating, 
annoying  and  disturbing,  until  her  wishes  for  sufl'ering  shall  be  gratifled. 

Conchtsions: — ist.  The  affective  insanity  of  children  is 
manifested  in  paroxysmal  passion,  destructiveness,  and 
incorrigibility,   in  emotional  storms  and  fantastic  willfulness. 

2d.  Delusions  rarely  exist,  for  these  doubtless  depend 
on  a  prior  organization  of  definite  ideas,  which  being 
more  or  less  limited  in  the  child's  mind,  the  extent  of 
delusion  is  likely  to  be  also  limited. 


Selections.  351 


in  those  uncertain  cases  which 
border  on  normal  childhood,  as  in  Case  IV.,  consists 
in  the  unlikeness  of  the  patient  in  general  behavior 
to  the  usual  standard  of  childhood.  Headache,  coated 
tongue,  and  sick  stomach  are  frequent,  as  also  irregularity 
of  the  heart's  action  and  low  vital  temperature ;  a  singu- 
lar lustre  of  the  eyes  was  noticeable  in  all  the  cases  above 
enumerated. 

To  diagnose  between  idiocy  and  juvenile  insanity  is 
not  so  difficult;  the  latter  condition  is  excitable,  erratic, 
intractable,  intense ;  speech,  sight,  and  hearing  are  gen- 
erally all  perfect,  which  is  an  exceptional  fact  in  idiocy 
and  imbecility  ;  the  moral  nature  is  usually  perverted  to 
the  last  degree  in  the  insane  child ;  while  the  idiot  and 
enfant  arriere  are  trustful,  kind  and  loving ;  the  insane 
child  is  suspicious,  secretive,  and  violent  in  its  likes  and 
dislikes.  We  should  not  omit  from  our  investigation  a 
careful  inquiry  into  the  antecedents  of  the  child ;  family 
history  may  throw  much  light  upon  doubtful  features, 
aiding  not  only  in  our  diagnosis,  but  in  the  prognosis  and 
treatment. 

[One  interesting  case  and  its  treatment  are  omitted  for 
want  of  space,  and  for  like  reason  are  many  valuable 
reflections  of  Dr.  Kerlin's  paper. — Ed.] 


La  Menti  di  Carlo  Livi. 


Translated  by  Joseph  Workman,  M.  D.,  Toronto,  Canada. 

Whether  it  was  that  the  organic  fibre,  though  robust, 
had  felt  the  injury  of  the  feverish  activity  of  the 
last  three  years,  or  that  in  the  exercise  of  his  present 
duties  he  had,  sohcitious  even  to  the  utmost  scruple,  sur- 
passed the  wonted  tension  of  his  cerebral  powders,  he 
became  extraordinarily  fatigued  and  tired  in  that  trial. 
On  the  30th,  at  the  close  of  the  debate,  after  a  tiresome 
and  annoying  discussion,  he  was  prostrated  under  vertigo, 
and  symptoms  of  ischaemia  presented,  followed  by  conges- 
tion of  the  brain  ;  on  the  night  following,  with  all  its 
gravity  and  terrors,  cerebral   apoplexy    occurred.       In    the 


352  Joseph  Workman. 


days  following,  successive  alternations  of  better  and  worse 
took  place,  but  despite  of  every  care  and  of  all  the  affec- 
tions and  hopes  of  those  around  him — children,  friends, 
fellow-citizens — Carlo  Livi  ceased  to  live  on  the  night  of 
the  4th  of  June,   1877. 

The  demonstrations  of  sympathy  and  esteem  which, 
during  the  few  days  of  his  illness,  reached  his  family  from 
every  part  of  Italy,  and  the  solicitude  of  the  city  of 
Livorno  for  the  health  and  the  relief  of  the  illustrious  sick 
one,  showed  how  painful  was  the  fear  of  his  unexpected 
loss.  But  when  the  sorrowful  announcement  left  no 
longer  any  hope,  the  grief  and  lamentations  were  universal. 
In  that  bereavement,  his  family  and  his  intimate  friends 
had  the  comfort,  that  not  one  scientist,  juris-expert  or  ali- 
enist was  unmoved.  The  honors  rendered  him  were  truly 
touching;  municipal  officers,  moral  societies,  public  author- 
ities, friends,  citizens  and  colleagues,  all  rivaled  in  rendering 
still  more  solemn  the  mournful  occasion,  and  in  following 
his  remains  to  their  last  resting  place.  Among  the  scien- 
tific institutions  represented  in  the  noble  demonstration,  we 
may  record  the  universities  of  Modena,  Siena,  Pisa, 
Bologna,  Pavia,  Padova,  Roma,  Torino,  and  the  Superior 
Institute  of  Florence.  By  request  of  the  municipality  of 
Reggio,  inspired,  no  doubt,  by  the  generous  counsels  of 
the  Deputy  Fornaciari,  for  many  years  his  friend,  not  to 
say  brother,  the  body  of  Carlo  Livi  was  sent  from  Livorno 
to  Reggio,  and  accompanied  by  two  escorts  of  his  dear 
patients,  and  the  entire  body  of  the  citizens,  it  w^as  buried 
in  the  suburban  cemetery  of  S.  Maurizio,  near  the  tomb 
of  his  Giuseppina,  who  was  taken  from  her  loving  husband 
and  children  four  years  before.  There,  at  a  little  distance 
from  the  Hospice,  rendered  sacred  by  his  name,  was 
closed  the  mortal  horizon  of  that  laborious  and  splendid 
person  ;  and  if  it  is  true  that  thought  is  a  perpetual  undu- 
lation of  atoms,  it  is  certain  that  on  the  visitation  of  his 
grave,  by  so  many  unhappy  ones,  to  whom  the  paternal 
heart  of  Livi  restored  mental  light,  a  piteous  groan  will 
be  uttered  over  his  venerated  ashes. 

Carlo  Livi  had  a  body  equal  to  his  mind  ;  both  were 
beautiful  and  strong.  He  was  tall,  his  complexion  was 
white  and  rosy,  his  hair  rich  and  already  gray,  marking  a 
pleasant  contrast  with  the  youthful  freshness  of  his  face. 
He  had  brown  and  lively  eyes,  but  of  an  expression  so 
benevolent  and  sincere,  that  he  appeared  always  smiling. 
His  voice  was  sweet  and  almost    always    low,    but    in    the 


La  Menii  di  Carlo  Livi.  353 


emotions  of  his  mind  it  could  always  reach  the  hearts  of 
his  auditors  and  move  their  affections ;  in  rare  moments 
of  displeasure  it  assumed  a  certain  tremor,  which  modified, 
without  altering  it,  and  thus  all  the  more  commanded 
respect  and  deference.  It  was  remarkable  that  with  his 
profound  knowledge  of  our  language,  and  his  exquisite 
elegance  of  form,  he  yet  commenced  his  discourses  in 
public  with  such  slowness,  that  he  sometimes  appeared 
embarrassed  or  timid,  whilst  he  was  only  pondering ;  but 
after  a  brief  period,  his  words  flowed  forth  limpid  and 
abundant,  pure  and  plain  in  phraseology,  and  inimitably 
new  in  ideas. 

He  thought  highly  of  himself,  not  from  pride  but 
from  dignity,  and  from  his  whole  person  there  breathed 
that  serenity  of  mind  which  only  a  just  consciousness  of 
its  own  value  imparts.  He  had  a  noble  carriage,  sometimes 
even  majestic,  when  he  treated  of  grave  matters  ;  never- 
theless this  seriousness  of  aspect,  instead  of  repelling 
others,  drew  them  to  him  ;  so  great  were  the  courtesy  of 
his  demeamor,  and  the  benevolence  of  his  physiognomy  ; 
and  great  as  these  were  towards  his  equals  and  inferiors, 
they  were  yet  greater  towards  the  afflicted  ones  entrusted 
to  his  care.  He  thus  possessed  in  a  high  degree  that 
natural  gift  which  the  physicians  of  mental  infirmities 
ought  to  have,  whether  bestowed  by  nature  or  acquired 
by  education ;  such  were  Ideler  and  Pisani,  of  whom  it 
may  be  said,  that  they  affected  all  their  marvellous 
cures  of  the  insane,  by  means  of  the  attractiveness  and 
the  profound  respect  which  they  evinced  towards  each 
individual. 

He  was  most  affectionate  in  his  own  family,  to  whom  he 
devoted  all  the  spare  moments  that  his  numerous  occupa- 
tions left  him.  If  in  his  last  hours  a  thought  flitted 
through  his  stricken  mind,  it  assuredly  was  upon  the  dear 
children  whom  he  had  wished  to  see,  and  now  unhappily 
could  not,  placed  in  honorable  and  secure  positions. 

He  loved,  in  an  especial  manner,  young  persons,  to 
whom  he  was  rather  a  father  than  a  master  ;  but  from  the 
reserve  of  his  mind,  he  but  rarely  gave  himself  over  to 
excessive  intimacy  ;  thus  he  was  sparing  in  his  friendships, 
but  he  cultivated  social  relations  with  sincerity  and 
delicacy,  in  which  he  differed  from  those  who,  in  order  to 
rise  to  fame,  do  not  hesitate  to  grasp  at  it  by  ever\' 
available  artifice.  Instead  of  this,  he  went  around  loftily, 
and  he  was  content  with  the   captivation  of  the   minds    of 


354  Joseph  Worhman. 


his  patients,  who  respected  him  in  hfe,  and  now  speak  of 
him  dead,  with  fihal  tenderness.  He  had  no  enemies, 
which  must  be  ascribed  more  to  his  merit  than  to  fortune  ; 
for  if  any  one  caused  him  displeasure,  he  took  care  to 
conceal  from  the  eyes  of  strangers,  resentment  proper  to 
his  dignity,  and  even  when  opportunity  offered  he  would 
not  retnrn  offences. 

He  had  an  enthusiasm  for  all  that  is  true,  lovely  and 
noble,  and  with  such  a  sentiment  he  governed  himself 
most  loyally  in  every  eventuality.  Cultivated  and  wise — 
but  not  in  that  culture  and  wisdom  which  go  around  dis- 
playing themselves  in  public — he  possessed  a  most  exquis- 
ite senje,  of  art ;  Tuscan  as  he  was  in  his  entire  disposi- 
tion and  genius,  in  this  he  was  superlativ^ely  Tuscan  ;  and 
the  proof  of  this  remains  in  all  done  and  directed  by  him 
in  the  asylums  of  Siena  and  Reggio. 

In  practical  obser\'ations  as  w-ell  as  in  his  scientific 
speculations,  his  mind  laid  hold  preferentially  of  the  ele- 
vated side,  or,  so  to  speak,  the  resthetic.  He  abhorred, 
wherever  he  found  them,  niggardliness  and  littleness  ;  not 
that  he  was  by  nature  adapted  to  daring  attempts  and 
originality  of  genius,  but  he  possessed,  in  the  highest 
degree,  that  faculty  of  assimilating  and  elaborating  the 
discoveries  of  others,  which  assumes,  sometimes,  the  aspect 
and  importance  of  an  original  creation,  He  was  tardy  in 
taking  a  resolution,  but  tenacious  in  maintaining  it,  not 
with  obstinacy  or  haughtiness,  but  by  the  action  of  that 
close  consideration  and  prudence  which  he  bestowed  on 
every  thing.  His  firmness  of  character  was  evinced  with 
augmented  force,  in  relation  to  political  and  scientific 
questions,  but,  however  tender  he  was  as  to  the  privileges 
of  his  own  opinions,  he  never  manifested  intolerance 
towards  those  of  others.  When  in  any  discussion  he 
failed  to  persuade,  rather  than  to  protract  a  useless  argu- 
ment, he  preferred  to  close  it  by  his  silence,  for  it  seemed 
to  him  more  consistent  with  dignity  to  conserve  esteem 
towards  a  cleaver  adversary,  than  to  gain  a  reluctant  and, 
perhaps,  unstable  porselyte. 

In  his  political  opinions  (as  to-day  we  are  free  to 
speak  on  politics),  he  ever  held  the  same  views  as  he  did 
at  the  age  of  35  years,  when  he  fought  for  his  country  at 
Curtatone  ;  he  was  liberal  from  conviction,  from  intol- 
erance, and  moderate  without  pusillanimity. 

It  may,  perhaps,  by  some  be  cast  as  a  reproof  on 
Livi,    that     in    his    philosophic     and    religious    opinions    he 


La  Menti  di  Carlo  Livi.  o55 


tardily  reached  that  point  which  some  others  are,  to-day, 
wont  to  arrive  at  more  speedily  and,  we  may  say,  much 
more  easily.  This  is  quite  true  ;  for  between  that  Livi 
who  wrote  the  exordium  of  the  work  ''Coutro  la  pena  di 
viortr  (Siena,  1862),  and  the  Livi  who  gave  the  stupendous 
discourse  ''Del  JMctodo  Spcrimentalc  in  Freniatria  e  in  Mcdi- 
cina  Legale'  (Reggio,  1875),  some  may  have  observed  in 
the  two  productions  a  notable  difference.  But  if  we  duly 
consider  the  times  in  which  the  mind  of  Livi  was  devel- 
oped, the  education  he  received,  and  the  magnanimous 
race  to  which  he  belonged,  inclined  to  the  culture  of 
poetry  and  art,  and  if  we  take  into  account  the  peculiar 
bent  of  his  genius,  we  shall  not  marvel  either  at  his  trans- 
formation or  the  manner  or  time  in  which  it  was  effected. 
On  the  contrary,  we  should  rather  rejoice  that  the  change 
was  made,  and  that  it  was  so  made  as  to  demonstrate  the 
truth  of  the  maxim  written  by  himself:  "There  is,  in  the 
defects  of  great  minds,  a  something  that  is  useful — almost 
good — when  applied  to  our  own  instruction."  And  the 
instruction  we  may  derive  from  the  case  of  Livi  is  that 
when  a  mind,  nurtured  by  invigorating  studies  and  a 
moral  individuality  so  excellent  as  was  that  of  Livi,  after 
a  long  journey  under  the  cloudy  horizon  of  metaphysics, 
reposes  confidingly  in  the  certainty  of  modern  science,  it 
has  reached  a  stage  which  assures  its  future  stability. 

Livi,  perhaps,  felt  all  the  bitterness  of  this  inward 
conflict,  and  all  the  more  acutely  must  he  have  felt  it, 
because  of  the  long  and  gloomy  phases  which  crossed 
his  mind,  now,  from  its  virility,  less  ductile  than  in  early 
years.  But  his  intellect  was  not  of  that  order  which  rests 
satisfied  with  first  proofs,  or  becomes  discomfited  by  the 
first  difficulties  of  doubt.  His  medical  education,  based 
on  the  experimental  method,  which,  to  use  the  words  of 
Buffalini,  admits  only  "cognitions  of  facts,"  led  him  onward 
to  scrutinize,  in  their  innermost,  the  reasons  of  new  ideas, 
and  in  the  scrutinizing  and  weighing  of  these  he  arrived 
at  those  convictions,  in  search  of  which  he  had  so  long 
been  engaged.  Thus  was  he  at  last  conquered  by 
modern  philosophy,  which  is  really  more  benefited  by 
such  conquests  than  by  the  discovery  of  new  truths,  inas- 
much as  they  facilitate  the  journey  to  that  goal,  where, 
after  infinite  efforts  amid  the  distrusts  of  the  vulgar,  the 
grand  problem  is  to  be  solved,  which  is,  in  the  words  of 
Livi  himself,  ''the  unfolding  of  the  mechanism  of  human 
reason!' — Macerata,  8th  October,    1879. 


SoG  Joseph  Workman. 


We  hardly  dare  venture  the  anticipation  that  all  the 
readers  of  the  Alienist  and  Neurologist  will  find  in  the 
abstract  from  the  memoir  of  Carlo  Livi,  which  we  have 
above  presented,  the  same  interest  and  gratification  which 
the  translator  has  realized  in  the  perusal  of  the  entire 
article.  Our  deep  regret  is  that  the  elegiac  tribute  of 
Livi's  two  loving  disciples  cannot  be  presented,  uncurtailed, 
in  the  pages  of  this  Journal,  for  we  feel  assured  that  there 
is  not,  on  all  this  Continent,  a  single  medical  superintend- 
ent or  officer  of  our  insane  institutions  who  will  fail  to 
recognize  in  the  character  and  practical  life  of  Livi,  a 
perfect  embodiment  of  all  those  mental  and  moral  quali- 
ties which  are  recognized  as  indispensable  endowments  in 
every  competent  psychiatric  practitioner.  We  trust  this 
expression  of  our  appreciation  of  the  article  will  be  kindly 
accepted  by  the  reader,  as  our  justification  for  the  devo- 
tion of  so  much  space  to  its  insertion. 

We  must  not,  however,  close  our  remarks  without 
taking  exception  to  an  assertion  made  by  Livi's  eulo- 
gists. It  is  found  in  the  following  words :  "He  had  no 
enemies."  Now,  of  all  the  inscriptions  which  may  ever 
be  found  on  the  tombstone  of  any  medical  superintendent 
of  an  insane  asylum,  this  is  the  very  ver>'  worst  we  could 
desire  to  read,  even  on  that  of  our  "direst  foe."  That 
any  man — nay,  that  even  an  angel — shall  faithfully,  fear- 
lessly and  luimancly  discharge  the  incumbent  duties  of  an 
asylum  superintendent  for  any  number  of  years,  or  even 
of  months,  and  escape  the  making  of  enemies,  is  (and  we 
speak  from  dear-bought  experience)  one  of  the  most  flag- 
rant absurdities  within  the  reach  of  our  conceptive  powers. 
If  we  could  believe  that  Livi  never  made  enemies,  yea, 
bitter  and  unrelenting  ones,  then  should  we  conclnde  that 
his  eulogists  had  better  have  concealed  the  fact;  at  all 
events,  we  ourselves  trust  that  no  such  violation  of  truth 
will  ever  find  a  place  in  our  obituary  announcement,  for 
it  would  be  an  enormous  falsehood  ;  and  though  de  mortuis 
nil  nisi  bonum  is  a  very  charitable  maxim,  yet  as  nothing 
is  good  which  is  not  true,  we  desire  no  better  monumental 
record  than  that  we  made  scores  of  enemies,  among  knaves 
and  hypocrites,  and  friends  only  among  the  honest  and 
truthful. 

[  Concludcd7\ 


Selections. 


ANATOMICAL  AND  PHYSIOLOGICAL  EXCERPTS. 


The  Physiology  of  the  Optic  Area  of  the  Cortex 
OF  the  Brain. — Prcpf.  Monk. — The  author  commences 
by  referring  to  the  results  of  his  first  experiments,  in 
1877-8,  to  determine  the  situation  and  extent  of  the  optic 
area,  which  was  found  to  extend  over  the  whole  posterior 
lobe,  including  the  side  of  the  gyrus  medialis  which  lies 
next  the  falx.  Extirpation  of  several  of  these  portions 
produced  in  the  animal  experimented  upon,  only  psychical 
blindness  (seelenblind)  that  is,  the  animal  had  no  recollec- 
tion of  the  appearances  of  objects  previously  seen ;  its 
recollection  of  previous  visual  impressions  was  lost.  When 
the  whole  portion  was  extirpated,  the  animal  became  in 
addition  retina  blind  ?  rindenblind  that  is,  visual  impression 
was  lost  in  particular  portions  of  the  retina,  and  recovery, 
which  in  the  first  case  was  rapid,  was  here  slow  and  incom- 
plete. The  object  of  his  present  experiments  was  to  deter- 
mine in  the  first  place  whether,  by  extirpation  of  the  cortex 
of  o)ie  posterior  lobe,  the  connection  of  each  hemisphere 
with  both  retinae  could  be  demonstrated,  and  thereby 
whether  a  physiological  demonstration  upon  the  dog,  of 
the  incomplete  decussation  of  the  optic  nerves,  shown  to 
exist  by  Gudden's  anatomical  researches,  might  not  be  given. 

One  optic  area  was  totally  extirpated,  the  whole 
posterior  portion  of  the  hemisphere,  and  the  cortex  of 
the  gyrus  medialis,  looking  toward  the  falx  being 
included.  Seven  dogs  in  whom  the  cortex  was  cut  away 
to  the  depth  of  3  Mm.  over  the  area  named,  were  kept 
alive  for  thirteen  weeks.  In  all  of  them  it  was  discov- 
ered that  the  extreme  outer  portion  of  the  retina  does  not 
belong  to  the  optic  area  of  the  opposite  side,  and  that 
just  as  much  of  the  left  retina  belongs  to  the  optic  area 
of  the  left  side,  as  there  is  of  the  right  retina,  which 
is  not  supplied  from  this  area.  Each  retina,  therefore,  is 
chiefly  connected  with  the  optic  area  of  the  opposite  side, and 
only  to  a  small  extent  in  its  extreme  outer  portion,  with 
the  optic  area  of  the  same  side.  The  second  object  in 
view  was  to  determine,  on  one  hand,  the  relative  position 
of  the  sensitive  layer  of  the  retina;  on  the  other,  that  of 
the  perceptive  cortical  layer. 

Accordingly,  we  see  that  systematically  conducted 
partial  extirpations  of  the  optic  area  have  proved  that  the 
extreme  outer    portion    of    each  retina    is  connected    with 


358  Selections. 


the  extreme  outer  portion  of  the  optic  area  of  the  same 
side.  The  much  larger  remaining  portion  of  the  retina 
belongs  to  the  much  larger  remaining  portion  of  the 
opposite  optic  area.  The  retina  may  be  imagined  to  be 
projected  upon  the  optic  area  in  such  a  manner  that  the 
lateral  border  of  that  portion  of  the  retina  supplied  from  the 
opposite  side  corresponds  to  the  lateral  border  of  that 
portion  of  the  optic  area  that  supplies  the  inner  border 
of  the  retina  to  the  median  border  of  the  optic  area,  the 
superior  border  of  the  retina  to  the  superior  border  of 
the  optic  area,  and  the  inferior  border  of  the  retina  to 
posterior  border  of  the  optic  area.  Diagrams  are  given 
to  illustrate  this  very  interesting  discovery,  which  makes 
an  important  addition  to  our  knowledge  of  the  semi-de- 
cussation  of  the  optic  nerves  in  the  optic  chiasm  in  the 
higher  mammaha.  It  teaches  us  also,  that  in  the  optic 
chiasm  all  the  fibres  of  the  optic  nerve  are  transposed. 
Thus  it  comes  to  pass  that  the  fibres,  when  they  have 
passed  through  the  chiasm,  have  reversed  their  relative 
)ositions. — Dr.  Nieder,  Bochum,  Ibid. — Saunders. 

Lucas'  Experimental  Investigations  Concerning  The 
Arterial  Circulation  in  the  Brain. — The  author  used 
for  the  purposes  of  injection,  an  alcoholic  solution 
of  fine  sealing  wax  (sometimes  also  a  solution  of  asphalt 
in  benzine).  The  results  confirmed  the  statements  of 
Duret  in  most  points,  except  that  he  always  succeeded 
when  the  injection  had  been  well  done,  in  finding 
wery  considerable  anastomoses  between  the  arteries  within 
the  pia  mater.  Besides  a  network  of  anastomoses  between 
the  smallest  arteries,  he  could  often  see  relatively  large 
vessels,  with  a  lumen  of  more  than  one-fourth  mm.  diam- 
eter, directly  communicating  with  each  other. — Dr.  Ober- 
stcincr,  Vifuna. — Abstracted  from  Revieiu  Department  of>.  . 
jOentralblatt  fiier  Ncrvenheilktinde ,  &c.,  Nov.  ist,  i8jg.  Jll.y^l^^ 

The  Relations  of  the  Developmental  Brain  to  the 
Cr.a.niu.m. —  Ch.  Fere.  Our  author  undertook  to  investi- 
gate the  topographical  relations  of  the  cerebral  convul- 
sions to  the  subsequent  sutures  of  the  cranium,  in  the 
foetus  and  in  the  child.  He  limited  his  attention  to  the 
Sulcus  Fossa  Sylvii.  He  has  established  the  following 
facts  in  the  foetus,  as  in  later  life,  the  Sulcus  Rolandoi, 
as  soon  as  it  becomes  perceptible,  is  found  to  be  in  its 
whole  length  behind  the  satura  coronalis. 

The  Fossa  Sylvii  in  the  foetus  is  situated  quite  high 
up.  and  sinks,  as  the  brain  becomes  more  fully  developed. 


Selections.  359 


gradually  downward.  On  the  other  hand,  the  Fissura 
parieto-occipitalis  is  found  in  the  developmental  stage, 
proportionately  very  far  in  front  of  the  Sutura  lamb- 
doidalis.  From  these  two  facts  he  concludes  that  in  the 
foetus  and  in  the  child,  the  occipito-temporal  region  is 
more  largely  developed  at  the  expense  of  the  parietal  lobe. 

In  grown  persons  the  relations  between  the  convo- 
lutions and  the  cranial  sutures  remain  the  same  at  differ- 
ent ages. — Dr.  Obersteiner,  Vienna. — ibid. 

Form  of  the  Corpus  Striatum. — Dr.  John  C.  Dalton 
concludes  an  able  contribution  on  Cerebral  Anatomy  m 
No.  I,  Vol.  2,  of  the  Annals  of  the  New  York  Anatomi- 
cal and  Surgical  Society,  with  the  italicized  statement, 
that  "this  important  ganglion,  situated  in  the  interior  and 
at  the  base  of  the  brain,  has  the  same  annular  form 
which  is  reflected  externally  in  the  general  configuration 
of  the  hemisphere,"  and  he  makes  it  appear  quite 
"evident  that  the  fissure  of  Rolando  is  not  really  in  inter- 
ruption to  the  general  run  of  the  convolutions." 

The  force  of  the  paper  commends  it,  the  author  and 
the  "Annals,"  to  every  student  of  the  brain. 

Excitability  of  the  Depressor-Nerve  before  and 
AFTER  Pricking  the  Floor  of  the  Fourth  Ventricle. — 
At  the  close  of  a  paper  upon  this  subject  before  the 
Paris  Anatomical  Society  last  year,  M.  Laffont  presented 
the  following  conclusions  as  the  result  of  his  experiments  : 

A.  There  exist  in  the  bulb  below  the  short  diagonal  of 
the  floor  of  the  fourth  ventricle,  two  symmetrical  vaso- 
dilator centers  for  the  liver  and  intra-abdominal  organs. 
These  two  centers  are  separately  excitable. 

B.  The  action  of  the  pricking  of  the  floor  of  the  fourth 
ventricle,  that  is  to  say,  of  these  centers,  is  double  : 

1st.  Local  irritation,  producing  an  over-activity  of  the 
circulation  of  the  abdominal  viscera. 

2d.  Alteration  due  to  the  consecutive  paralysis  of  the 
altered  center  which  is  no  longer  excitable,  either  directly 
(by  a  new  pricking)  nor  by  reflex  action  (excitation  of 
the  central  end  of  the  depressor  nerve  of  the  same  side.) 

C.  After  excitation  and  consecutive  paralysis  of  one 
of  the  two  intra-bulbar  vaso-dilator  centers,  the  over-activ- 
ity of  the  circulation  of  the  abdominal  viscera  may  again 
be  produced  either  directly  (pricking  at  the  intact  center), 
or  by  reflex  action  (excitation  of  the  central  end  of  the 
depressor-nerve  of  the  sound  side). — Le  Frogres  Medical, 
April  3d,    1880. 


Selections. 


CLINICAL  NEUROLOGY. 


Amyotrophic  Lateral  Sclerosis. — M.  Charcot,  Hos- 
pital Salpctricrc. —  Translated  by  Dr.  E.  M.  Nelson,  St. 
Louis. — We  may  say,  in  a  general  way,  that  cer- 
tain paralyses  show  themselves  principally  by  the  rigidity 
or  spasmodic  contraction  of  muscular  masses ;  while  others 
are  marked  by  the  absence  of  this  symptom,  or  even  by 
an  opposite  condition,  flaccidity  of  the  members.  This 
two-fold  division,  summary  as  it  is,  suffices  to  show  the 
practical  interest  which  attaches  to  the  symptom  of  con- 
tracture. 

For  several  years,  observers  have  shown  the  import- 
ance of  different  phenomena  which  may  be  designated 
under  the  generic  name  of  tendon-reflexes.  The  minute 
examination  which  has  been  made,  may  some  day  throw 
great  light  upon  the  patho'ogical  conditions  which  favor 
the  appearance  of  contractures.  These  reflexes,  when 
they  do  not  exceed  a  certain  degree,  belong  to  normal 
conditions.  But  when  they  shuw  themselves  manifestly 
exalted,  they  constitute  a  morbid  symptom  of  real  import- 
ance, both  from  a  purely  clinical  point  of  view  and  form 
the  point  of  view  of  physiological  theory. 

Now,  in  the  actual  state  of  our  physiological  knowl- 
edge, permanent  spasmodic  contraction  of  the  muscles, 
passes  with  just  title  for  a  strange  inexplicable  phenom- 
enon, or,  it  may  be  paradoxical  in  some  sort. 

Moreover,  numerous  researches  recently  undertaken  in 
France  and  abroad,  tend  to  show  that  the  exaltation  of 
tendon-refle.x  and  contracture  are  allied  facts,  equivalents 
as  it  were,  or  at  least  belonging  to  the  same  series  ;  that 
the  physiological  interpretation  which  belongs  to  one, 
belongs  equally  to  the  other;  of  such  a  nature,  therefore, 
that  permanent  spasmodic  contracture  will  be  found  to  be 
despoiled  of  its  paradoxical  character. 

Here  is  the  case  to  which  Mr.  Charcot  calls  attention  ; 
it  is  most  valuable  from  the  point  of  view  of  the  thesis, 
which  he  proposes  to  develop  : 

It  is  the  case  of  a  woman,  aged  forty-seven  years. 
She  is  confined  to  bed,  and  appeared  absolutely  immobile 
— inert.  However,  .her  intelligence  is  perfect,  and,  although, 
she  can  no  more  make  herself  understood,  she  renders  a 
very  good  account  of  her  condition.  We  decide,  at  first 
sight,  that  this  woman  is    paral)v.ed    in  all  her  limbs,  that 


Selections. 


the  head  holds  itself  no  more  in  its  normal  position,  and 
that  it  turns  sometimes  to  the  right,  and  sometimes  to  the 
left,  without  power  to  be  replaced  voluntarily.  We  should 
suppose  then,  that  this  unfortunate  is  affected  with 
a  total  flaccid  paralysis.  But  it  is  far  from  being  the 
truth.  Moreover,  a  more  minute  examination  is  indis- 
p  .nsable  to  render  account  of  the  relative  condition  of 
the  different  parts  of  the  body. 

In  that  which  concerns  the  lower  limbs,  we  perceive, 
in  fact,  that  they  have  an  attitude  quite  pecuhar ;  the  feet 
are  extended,  the  knees  are  fixed — the  one  to  the  other;  the 
two  legs  appear  rigid.  Nevertheless  we  can  flex  them 
and  do  not  encounter  a  very  great  resistence.  Some- 
times this  resistance  is  more  considerable  than  in  ordinary 
conditions ;  it  suffices,  in  order  to  show  this,  to  provoke 
this  passive  flexion  successively  in  this  patient  and  in  a 
healthy  person ;  we  show  then  that  the  stiffness  truly 
exist,  or,  in  other  terms,  that  the  flaccidity  of  the  limb  is 
replaced  by  that  which  has  been  called  the  flexibilitas 
cerea.  If  we  percuss  with  a  Skoda's  hammer  the  patellar 
tendon,  immediately  the  limb  starts,  and  even  at  times 
remains  animated  for  some  time  with  rapid  movements  of 
spinal  epilepsy.  Finally,  these  two  limbs  are  emaciated, 
not  atrophied,  and  what  we  observe  upon  one  may  be 
observed  upon  the  other.  As  to  sensibility  it  is  every- 
where intact ;  the  patient  presents  in  this  regard  no  morbid 
troubles,  and  we  may  aflirm,  that  aside  from  exceptional 
circumstances,  she  will  never  present  them. 

As  to  the  functions  of  the  bladder  and  rectum  there 
is  nothing  further  abnormal  to  signalize ;  so  that  if 
we  confine  ourselves  to  the  start  of  the  lower  limbs,  in 
making  an  abstract  of  the  morbid  characters  which  will 
be  questioned  directly,  we  should  notice  in  this  patient 
only  symptoms    of  spasmodic    paraplegia. 

But  the  upper  extremities  present  also  peculiar  charac- 
ters, and  at  first  their  attitude  is  most  remarkable.  They 
are  semi-flexed  upon  the  chest,  insupination,  the  hands 
turned  forward,  the  fingers  drawn  up.  Furthermore,  these 
limbs  are  extremely  emaciated,  and  in  appearance,  flaccid, 
so  that  to  consider  them  separately  we  might  believe  our- 
selves in  the  presence  of  a  case  of  progressive  muscular 
atrophy.  It  is  not  so,  however,  and  here  again  we  are 
dealing  with  a  spasmodic  paralysis.  In  fact,  if  we  exam- 
ine closely  what  remains  of  the  muscular  masses  of  the 
arm  and  forearm,  we  distinguish  in  certain  points  a  cutaneous 


362  Selections. 


trembling  corresponding  to  the  spontaneous  and  passing 
fibrillar  contractions;  furthermore,  the  forced  flexion  of 
these  members  determine  the  same  sensation  of  resistance 
as  in  the  lower  limbs  ;  finally  percussion  of  the  tendon  of 
the  triceps  determines  a  reflex  manifestly  exaggerated ; 
and  if,  instead  of  provoking  the  reflex  action  of  this 
muscle,  we  strike  lightly  the  anterior  face  of  the  forearm 
at  the  different  points,  which  correspond  to  the  flexor 
tendons  of  the  fingers,  the  "claw"  becomes  more  pro- 
nounced under  the  influence  of  each  of  these  shocks,  a 
most  important  characteristic,  since  the  tendon  reflex  of 
the  tendons  of  the  fingers  is  little  pronounced  or  even 
wanting  most  generally  in  the  normal  state.  It  is  necessary 
to  note  likewise  the  fact  that  the  two  upper  extremities 
are  affected  symmetrically  and  that  sensibility  is  preserved 
intact. 

If  now  we  analyze  the  details  which  the  attitude  of 
the  head,  and  the  expression  of  the  face  present,  here  is 
what  we  may  observe  :  The  neck  is  powerless  to 
support  the  head  ;  the  chin  rests  against  the  sternum,  and 
if  the  patient  is  turned  a  little  backward,  the  head  is 
carried  down  by  its  weight,  and  the  anterior  muscles  are 
absolutely  incapable  of  restoring  it  to  its  usual  position. 
As  to  the  face,  it  presents  a  physiognomy  which  may  be 
characterized  in  one  word  :  labio-glosso-laryngeal  paralysis. 
But  here  we  have  to  do  with  a  labio-glosso-laryngeal 
paralysis,  a  little  different  from  that  which  Duchenne  has 
described,  and  the  peculiar  mask  which  results  from  it 
often  permits  us  to  recognize,  at  first  sight,  this  kind  of 
disease.  Wrinkles  in  great  number,  furrows  deeply 
creased,  and  specially  the  nasolabial  furrows,  as  also  those 
of  the  frontal  region,  the  great  open  eyes,  as  if  the  lids 
had  difficulty  to  close,  impress  a  truly  specific  stamp  on 
this  face,  which,  by  its  "crying-child"  aspect,  is  easily 
differentiated  from  the  inert  mask  of  the  paralysis  of 
Duchenne. 

The  patient  cannot  articulate  a  single  word  ;  she  emits 
a  monotonous  nasal  sound,  at  each  instant  interrupted  by  a 
movement  of  painful  deglutition.  She  can,  however,  make 
her  tongue  protrude  slightly,  small  and  trembling  between 
the  dental  arches,  feebly  separated.  But  she  cannot  whistle, 
blow,  or  even  swallow,  without  choking  consequently,  and 
allows  the  saliva  to  flow  continually  from  the  half-closed 
mouth. 

The    history    of   the    patient    allows    us    to    sieze    the 


Selections. 


conditions  of  the  strange  combination  of  all  these 
phenomena  in  some  sort  incompatible. 

The  first  symptoms  appeared  two  and  a-half  years 
ago, — piercing  pains  in  the  loins  and  thighs.  Then  she 
commenced  to  feel  weak  in  her  legs,  walking  with  difficulty, 
"as  if  she  had  a  bullet  under  each  foot."  Three  months  later, 
paralysis  of  the  upper  extremities  appeared,  characterized 
by  loss  of  motor  power,  with  fibrillar  contractions  and 
stiffness.  Towards  the  sixth  month  the  difficulty  of 
speech  appeared.  Little  by  little  the  symptoms  became 
aggravated,  and,  after  ten  months,  she  became  absolutely 
powerless.  M.  Huchard  treated  her  at  the  Hospital 
Laennec,  and  was  able  immediately  to  give  the  diagnosis 
of  amyotrophic  lateral  sclerosis.  It  was  only  after  eighteen 
months  that  this  woman  was  admitted  to  La  Salpetriere, 
and  then,  for  the  first  time,  some  troubles  in  deglutition 
appeared,  as  also  transitory  dyspnoeic  difficulties  (April, 
1879).  Up  to  that  date,  which  can  be  considered  as 
the  apogee  of  the  spasmodic  period,  all  the  symptoms 
of  reflex  excitability  had  only  increased.  But  from 
then,  and  in  proportion  as  the  muscular  atrophy  compli- 
cation was  more  accentuated,  they  diminished  progressively, 
at  first  in  the  upper,  then  in  the  lower  limbs  ;  and  so  it 
is  that  to-ilay  the  patient  presents  only  a  trace  of  spas- 
modic symptoms,  with  which  she  had  been  previously 
affected  to  so  high  a  degree.  Another  case  is  detailed,  of 
almost  identical  character,  except  that  the  patient,  a  man 
thirty-five  years  old,  was  first  affected  a  year  ago,  and 
that  the  course  of  the  disease  has  been  somewhat  more 
rapid  in  his  case  than  in  that  of  the  woman.  The  prog- 
nosis in  both  cases  is  death,  after  a  brief  delay — Le 
Progres  Medical,  Jan.  8,  1880. 

Probable  Association  of  Ataxy  and  General  Paral- 
ysis.— In  one  of  his  last  clinical  lessons,  Dr.  M.  Raynaud 
has  presented  two  cases  of  locomotor  ataxy  presenting 
some  quite  curious  anomalies. 

The  first  was  a  typical  case  of  progressive  locomotor 
ataxy.  The  first  anomaly  present  is  the  preservation  of 
the  sense  of  heat ;  but  the  most  curious  and  most  unac- 
customed fact  is  the  difficulty  of  speech  with  which  this 
patient  is  affected,  notwithstanding  the  absence  of  ataxy 
of  the  tongue. 

There  is  not  in  this  patient,  paralysis  of  the  tongue, 
nor  of  the  orbicularis  muscle  of  the  lips,  nor  of  the  larynx. 
There  is  no  flow  of  saliva  from  the  mouth,    none  of   that 


364  Selections. 

hebetude  of  countenance  so  characteristic    of  labio-glosso- 
laryngeal  paralysis. 

The  rythmic  movements  of  sclerosis  en  plaques  are 
wanting,  as  well  as  the  tremblings,  so  characteristic.  We 
do  not  find  here  the  contractures  of  the  advanced  period 
of  the  disease. 

In  general  paralysis  difficulty  of  speech  is  usually 
associated  with  very  marked  psychic  phenomena.  Now 
here  the  intellect  remains  perfect.  Furthermore,  there  is 
no  trembling  of  the  hands,  no  inequality  of  the  pupils. 
All  that  can  be  said  is  that  a  phenomenon  of  general 
paralysis  is  superposed  upon  a  clearly  marked    ataxy. 

M.  M.  Raynaud  is  brought  to  think,  ist,  that  there  is 
the  beginning  of  a  general  progressive  paralysis.  2nd, 
that  the  anomalous  phenomena  are  purely  bulbar,  and 
then  it  is  necessary  to  admit  that  the  lesion  has  made 
a  jump,  causing  a  lesion  of  the  roots  of  the  glosso- 
pharyngeal   nerves    or    of  the    restiform    bodies. 

In  the  second  ataxic  there  were  hemorrhages  asso- 
ciated with  very  slightly  adv/anced  lesions  of  the  lungs, 
and  preceding  the  appearance  of  the  ataxic  phenomena. 
— Gazette  des  Hospetaiix,  April  24,  1880. — Nelson. 

Cerebral  Syphilis. — At  the  Societe  Medicale  des 
Hopitaux,  March  12,  1880,  M.  Fournier  presented  a 
specimen  from  a  patient  who  had  been  treated  repeatedly 
in  his  wards  for  various  manifestations  of  syphilis.  She 
had  been  treated  each  time  for  a  couple  of  weeks,  and 
then  left  without  doing  anything  further.  This  time 
she  presented  an  extensive  syphilis  of  the  back,  of 
ulcerative  character,  a  clavicular  periostosis,  a  frontal 
gummy  periostosis  on  the  left  side ;  she  complained, 
moreover,  of  headache,  of  diffused  pains  of  the  head,  but 
especially  referred  to  the  side  opposite  the  frontal  perios- 
tosis, and  of  some  slight  vertigo.  Under  the  influence  of 
treatment,  this  condition  improved  some  little,  when  she 
was  taken  intercurrently  with  a  hemorrhage  variola,  to 
which  she  succumbed  in  a  few  days. 

At  the  autopsy  there  were  found  no  more  traces  of 
the  gummy  periostosis,  but  there  were  found  evidences  of 
cerebral  syphilis  which  were  quite  unexpected.  There 
were,  in  the  first  place,  deep  erosions  of  the  anterior  part 
upon  the  right,  lesions  which  have  been  described  by 
Virchow,  under  the  name  of  dry  caries.  The  dura-mater 
was  adherent  and  presented,  upon  its  external  face, 
characteristic    gummatous     indications.       The    membranes 


Selections.  365 


were  thickened  and  presented  all  the  characteristics  of  a 
gummatous  meningitis.  There  was  a  perfect  blending  of 
the  meninges  and  cerebral  substance,  and  finally,  a 
considerable  thickening  of  the  cranium. 

This  autopsy  shows,  then,  that  cerebral  syphilis  may 
produce  grave  lesions  without  evidencing  it  by  symp- 
toms of  any  importance.  A  second  conclusion  is  that 
in  cerebral  syphilis,  aside  from  the  specific  lesions, 
there  exist  lesions  of  ordinary  character,  common  lesions, 
which  are  most  grave,  and  which  escape  treatment. 
Now,  specific  treatment  is  of  no  avail  against  these 
common  lesions ;  mercury  and  iodide  of  potassium  can 
serve  nothing  in  such  cases,  and  the  patients  die  of 
these    ordinary    lesions. 

Cerebro-Spinal  Syphilis. — In  considering  an  obser- 
vation on  this  subject  by  M.  du  Cazal,  M.  Fournier  said : 
"This  observation  shows  once  more  that  phenomena 
most  serious  ma}-  be  produced  in  consequence  of  a 
syphilis  in  appearance  most  benign  and  insignificant. 
It  is  an  almost  constant  fact  that  the  mildest  cases  of 
syphilis  come  out  later  in  the  direst  effects.  In  the 
greatest  number  of  cases  of  centro-spinal  syphilis,  if  the 
antecedents  are  interrogated,  almost  nothing  is  found. 
Patients  affected  with  syphilis  of  the  spinal  cord  or  of 
the  brain,  commence  with  a  chancre  of  no  gravity  or  a 
very  light  eruption.  This  is  not  the  law,  but  it  is  the 
usual  case.  I  have  always  noted  a  singular  contrast 
between  the  apparent  benignity  of  certain  cases  of 
syphilis    and   the    gravity   of  the    later    manifestations. 

It  is  true  that  the  most  benign  cases  of  syphilis  in 
appearance,  are  those  which  are  least  thoroughly  treated. 
We  may  not  affirm  it ;  but  there  is  room  to  admit  a 
possible  relation  between  the  two  things  :  the  insufficiency 
of  treatment   and    the    gravity  of  the  ultimate    phenomena. 

However  this  be,  the  mildness  of  a  commencement  of 
a  case  of  S3^philis  should  be  far  from  inspiring  any  security 
as  to  future  manifestations. 

Another  interesting  point  occurs  in  the  communication 
of  M.  Cazal,  namely :  that  in  syphilis,  the  type  of  the 
paralysis  is  never  pure.  To  hemiplegia  or  to  paraplegia, 
are  almost  always  added  paralysis  of  the  special  senses. 
It  is  so,  that  at  the  same  time  with  a  paraplegia  is 
determined,  for  example,  a  paralysis  of  the  third  pair,  of 
the  facial  or  of  the  recurrent.  This  singular  association 
of  paralysis,  whose  points  of  departure  may  be  far  removed 


Selections. 


from  each  other,  is  hardly  observed  except  in  s)-phiHs. — 
Gazette  dcs  Hopitaux,   March  23,  1880. — Nelson. 

An  Atrophied  Cerebellum — The  patient,  a  female  32 
years  of  age,  during  convalescence  from  a  severe  attack 
of  typhus  fever,  manifested  the  following  symptoms  :  tremor, 
with  uncertainty  of  movements,  unsteadiness  of  gait,  diffi- 
culty in  speaking,  and  pain  in  the  cervical  region ;  at  the 
same  time  a  diminution  of  the  mental  faculties,  with  hallucin- 
ations, were  observed.  A  careful  examination,  about  six 
weeks  before  death,  revealed  functional  irregularity  of  all 
the  muscles,  clonic  contractions  of  the  facial  muscles, 
especially  on  the  right  side,  rotation  of  the  balls,  alternate 
opening  and  closing  of  the  mouth,  and  retraction  of  the 
tongue.  There  was  rigidity  of  the  muscles  of  the  neck 
and  partly  also  of  the  pectoral  muscles  ;  contraction  of  the 
arms,  particularly  of  the  right  one  ;  ataxic  movements  of 
the  bracial  muscles  were  always  observed.  The  lower 
extremities  were  semi-flexed,  and  similar  movements  were 
noticed  in  them.  With  the  exception  of  considerable 
hyperaesthesia  and  pain  in  the  occipital  region,  there  \vere 
no  marked  abnormalities  of  sensibility. 

On  post-mortem,  the  cerebellum  (56  grm.)  was  found 
very  much,  but  systematically,  atrophied  ;  its  general  outline, 
however,  was  normal.  The  convolutions,  as  also  the 
nucleus  dentatus  appeared  atrophied. 

A  microscopical  examination  showed  considerable 
atrophy  of  the  cortical  substance;  the  individual  lobules 
are  peculiarly  irregular  and  distorted.  On  the  surface  of 
the  cortical  layer  of  the  cerebellum,  there  appears  a  ridge 
of  oval  cells  which  send  processes  towards  the  deeper 
layers;  the  cells  of  Purkinge.are  either  entirely  absent,  or 
else  small  round  cellular  bodies  without  distinct  nuclei 
and  processes  take  their  place.  The  granular  layer  is 
remarkably  narrow;  in  the  medullary  layer,  which,  like  the 
whole  cortical  layer  of  the  cerebellum,  consists  for  the 
most  part  of  a  net-work  of  fibres  of  connective  tissue, 
there  are  but  few  nerve  fibres. 

Analogous  changes,  but  less  marked,  were  observed  in 
the  vermiform  body  process. 

The  cells  of  the  nucleus  dentatus  appeared  smaller 
and   fewer  in  number  than  normally. 

The  author  traces  the  whole  process  to  a  gradual  irri- 
tat  on  proceeding  from  the  meninges,  which  may  have 
been  caused  by  he  typhus  fever.  The  vocal  paralysis 
must  be  placed  on  an  equal    footing  with  the  disturbance 


Selections.  367 


of  function  observed  in  the  entire  muscular  system. — Z. 
Seppelli. — Revista  Spcrbnentale  di  Freniatria,  etc.,  vol.  V., 
number  4,    1880. 

The  Choroidal  Pigment  in  the  Insane. — In  the  insane, 
especially  in  those  forms  of  insanity  of  an  intermitting 
character,  or  in  those  which  depend  upon  a  pellagrous 
cachexia,  the  fundus  of  the  eye  is  unchanged,  in  conse- 
quence of  a  more  or  less  defined  depigmentation  of  the 
choroid  and  paleness  and  cloudiness  of  the  retina,  although 
a  similar  condition  of  affairs  may  exist  in  the  healthy  eye, 
yet  they  do  not  reach  that  degree. 

The  simultaneous  occurrence  of  these  intro-occular  phe- 
nomena with  certain  pathological  conditions  of  the  brain, 
which  are  calculated  to  favor  the  production  of  active  or 
passive  hyperaenia  of  the  choroidal  vessels,  makes  it  appear 
highly  probable,  that  such  disturbances  in  the  circulation 
are  the  main  cause  of  the  morbid  changes  in  the  fundus 
above    referred  to. —  C.   Riva — Ibid. — Liitz. 

The  Mechanism  of  Anaesthetic  Death. — On  the 
mechanism  of  death  by  anaesthetics,  M.  Arloing  con- 
cludes that  in  the  first  phase  of  anaesthesia,  the  attention 
should  be  directed  at  times  to  the  heart  and  respiration, 
as  well  with  ether  as  with  chloroform.  In  the  second  phase 
we  should  watch  the  heart,  and  with  redoubled  vigilance 
if  we  use  chloroform,  because  it  is  at  that  period  that  we 
are  likely  to  see  apoplexy  occur,  especially  with  that 
agent.  In  the  third  case  we  should  watch  the  respira- 
tion   with    care. 

Cardiac  Phenomena  Under  Electric  Excitation. — 
Mm.  Dustro  and  Morat  are  studying  the  action  of  con- 
tinuous currents  and  of  very  frequent  induced  currents 
upon  the  apex  of  the  heart.  It  results  from  their  study 
that,  if  the  apex  of  the  heart  is  excited  apart  from  the 
rest  of  the  organ,  there  is  observed  at  first  a  contraction 
on  closing  the  circuit ;  then  if  the  strength  of  the  current 
is  increased,  a  contraction  at  the  opening  and  one  at  the 
closing ;  then  a  regular  rhythm,  with  successive  pulsa- 
tions   and    finally  tetanization. 

M.  Marey,  does  not  admit  the  explanation  which 
]\Im.  Dustro  and  Morat  have  given  of  the  phenomena 
of  the  pulsation  of  the  apex  of  the  heart  under  the 
influence  of  a  continued  current.  According  to  him,  the 
intermission  is  due  to  this,  that  at  a  certain  moment 
the    heart    become     refractory    to    the   excitation :    at    this 


Selections. 


moment,  the  continuous  current  acts  no  more,  the  heart 
obeys  it  no  more,  and  so  forth.  Then  the  continued 
action  of  the  current  results  in  producing  an  intermittent 
response  of  the  muscle. 

Sweat  Phenomena,  Atropine  and  Pilocarpine. — The 
excitation  of  the  peripheric  and  of  the  sciatic  brings 
about  an  abundant  secretion  of  sweat  in  the  cat.  Cl-Bernard 
claimed,  with  Dupuy  and  AUfort,  that,  in  the  horse  it  was 
the  section  of  the  sympathetic  which  eftected  the  increased 
secretion.  Mm.  Vulpian  and  Raynaud  thought  that  such  a 
seeming  di-cord  could  not  exist  between  the  two  animals. 
They  have  repeated  the  experiments  of  Dupuy,  and  they 
have  seen  that  the  excito-sudoral  nerve  fibres  destined  for 
the  skin  of  the  face  proceed,  either  from  the  sympathetic 
nervous  filaments  which  accompany  the  vertebral  artery  in 
its  ascending  tract  across  the  transverse  apophyses  of  the 
cerebral  vertebrae,  and  by  the  intervention  of  these  fila- 
ments from  the  superior  thoracic  ganglion  ;  or  from  the 
parts  of  the  s}'mpathetic  which  arise  from  the  medulla 
oblongata  and  pons  Varolii.  These  excito-sudoral  fibres 
take  their  places  in  the  different  cutaneous  nerves  ;  they 
are,  perhaps,  numerous  in  the  cutaneous  filets  of  the 
trigeminal  nerves. 

M.  Straus  communicates  a  number  of  experiments 
upon  local  sweating,  obtained  by  means  of  hypodermic 
injections  of  pilocarpine.  1st — If  you  inject  pilocarpine 
under  the  skin,  you  obtain  around  the  injection  a  circle 
of  little  drops  of  sweat.  If  the  dose  is  moderate,  all 
remains  there,  and  the  sweat  does  not  become  general. 
2d — If,  upon  a  subject  in  free  perspiration,  you  make  an 
injection  of  atropine,  you  see  the  sweat  arrested  first  in 
the  points  where  the  injection  was  made.  3d,  If,  before 
making  the  injection  of  pilocarpine,  you  produce  upon 
the  skin  an  intense  refrigeration,  you  have  no  more 
phenomena  of  local  sweating. 

M.  Prevost,  presents  a  note  upon  the  physiological 
effects  of  brom-hydrate  of  coniine.  This  substance  paral- 
ysis motor  nerves,  and  the  pneumo-gastric  and  excites 
secretion,  it  passes  off  in  the  urine.  It  controls  the  action  of 
the  secretory  nerves,but  does  not  modify  muscular  contraction 

Marey's  New  Instrument,  the  Polygraph,  permits  the 
registration  at  the  same  time,  of  the  pulse,  the  respiration 
and  the  movement  of  the  heart.  It  contains  all  the 
instruments  necessary  for  myographic  researches.  It  can 
be  carried  in  the  hand. 


Selections.  369 


Cerebral  Thermo:metry. — Before  the  Paris  Academy 
of  Medicine,  Dec.  30th,  1879,  M.  Broca  made  the  following 
remarks  upon  local  cerebral  temperatures :  Finally,  in 
cerebral  affections,  in  aphasia  and  the  paralysis  which  may 
be  caused  either  by  an  embolus  in  the  Sylvian  artery  or 
by  an  acute  or  chronic  encephalitis  of  the  cerebral  region 
which  surrounds  that  artery,  the  employment  of  a  ther- 
mometer permits  a  diagnosis  which  the  indentity  of  the 
symptoms  would  render  otherwise  almost  impossible.  In 
fact,  in  case  of  embolus  of  the  sylvian  artery,  the 
temperature  which  is  found  lowered  in  the  temporal 
region,  is  found,  on  the  contrary,  quite  notably  increased 
at  the  frontal  region,  and  sometimes  even  also  a  little  at 
the  occipital  region.  This  depends  upon  the  fact,  that 
the  re-establishment  of  the  circulation  in  the  region  which 
ceases  to  be  supplied  by  the  Sylvian  artery  takes  place, 
principally,  by  the  anastomoses  of  this  artery  with  the 
vessels  which  nourish  the  anterior  part  of  the  frontal  lobe, 
and,  in  proportion,  much  less  by  the  posterior  anastom- 
oses   of  the  sylvian. 

In  the  cerebral  softening  by  encephalitis,  we  observe 
nothing  analogous.  If  the  encephalitis  is  acute,  the 
temperature  is  notably  increased  in  all  the  part  affected ; 
if  the  encephalitis  is  chronic,  the  differences  are  less 
appreciable,  but  always  of  the  same  kind. 

Encephalitis  is  not  susceptible  generally  of  being 
treated  by  surgical  means.  There  is,  however,  one  case 
where  the  surgeon  may  be  called  upon  to  interfere,  and 
with  great  advantage  :  it  is  when  following  a  depression 
of  the  cranium,  some  bony  fragments,  irritating  the 
cerebral  substance,  produces  sometimes  long  after  the 
injury,  such  accidents  as  symptomatic  epilepsy,  etc.  If 
then  the  trephine  is  applied,  the  epilepsy  ceases  once  the 
cause  has  been  removed.  In  such  a  case  we  find  that 
the  temperature  is  elevated  at  the  point  where  it  is  best 
to  apply  the  trephine.  ^, 

M.  Broca  used  an  ordinary  thermometer  in  making 
these  researches,  covering  over  the  bulb  with  a  sort  of 
hood  and  waiting  till  the  column  became  stationary. — 
Gazette  des  Hopitaux,  Jan.   3d,   1880. — Nelson. 

The  Muscular  Tonicity  of  Tabetics. — Mm.  Debove 
and  Boudet,  of  Paris,  have  undertaken  at  the  hospital  of 
Bicetre,  a  series  of  researches  upon  the  muscular  tonicity 
of  tabetics,  researches  of  which  we  give  here,  briefly,  the 
results  :     The  muscular  tonicity  of   tabetics    is    profoundly 


370  Selections. 


affected.  M.  Tschirjew  has  maintained  that  it  is  dimin- 
ished. The)'  have  found  it  preserved  in  a  number  of 
muscles  and  were  especially  struck  by  its  inequality  in 
the  different  muscular  groups  of  the  same  limb.  They 
recognized  the  difference  by  palpation,  auscultation  and 
the  study  of  the  muscular  twitching.  In  most  ataxics 
they  determined  by  the  touch  that  the  muscles  of  the 
same  limb  presented  an  unequal  consistence,  which,  it 
would  appear,  should  be  attributed  to  a  diminution  of 
tonicity  of  certain  of  them.  In  examining  these  same 
muscles  by  means  of  a  myophone,  invented  by  one  of 
them,  they  have  been  able  to  catch  great  variations 
in  the  tonalit}-,  and  especially  in  the  intensity  of  the 
muscular  bruit.  Now  the  muscular  bruit  being  due  to 
the  tonus,  they  conclude  that  this  last  was  very  unequal 
in  ataxics. 

With  the  aid  of  registering  apparatus,  they  have 
recognized  that  the  lost  time  varies  from  one  muscular 
group  to  another,  and  that  these  variations  are  more  pro- 
nounced than  in  a  physiological  state. 

The  different  researches  have  forced  them  to  admit, 
in  ataxics,  a  very  great  inequality  of  muscular  tonicity  as 
the  cause  of  the  inco-ordination  of  the  movements.  They 
intend  to  offer,  in  a  further  paper,  their  researches  in  all 
their  details,  and  to  show,  that  they  can  make  under- 
stood the  moter  inco-ordination  of  subjects  affected  with 
sclerosis  of  the  posterior  cords. — Lc  Progrcs  Medical,  Feb. 
26,  1880. — Meeting  of  February  75  a>id  21,  1880,  Society  of 
Biology. — Nelson. 

Questions  and  Answers  Concerning  Chloral. — Dr. 
H.  H.  Kane,  191  W.  Tenth  Street,  New  York  City,  spe- 
cially requests  members  of  the  profession  with  any  experi- 
ence, whatever,  in  the  use  of  the  Hydrate  of  Chloral  to 
answer  the  following  questions,  and  give  any  information 
they  may  possess  with  reference  to  the  literature  of  the 
subject : 

1.  What  is  your  usual  commencing  dose? 

2.  What  i.s  the  largest  amount  you  have  administered  at  one  dose,  and  the 

largest  amount  in  twenty-four  hours. 
;!.  In  what  diseases  have  you  used  it  (by  the  mouth,  rectum,  or  hypoder- 
matically).  and  with  what  results? 

4.  Have  you  known  it  to  affect  the  sight? 

5.  Have  you  ever  seen  cutaneous  eruptions  produced  by  it? 

G.  Do  you  Icnow  of  any  instances  where  deatii  resulted  from  or  was  attri- 
buted to  its  ise?  If  so,  please  give  full   particulars  as  to  disease  for 


Selections.  371 


which  given;  condition  of  pulse,  pupils,  respiration  and  temperature^ 
^manner  of  death;  condition  of  heart,  lungs  and  kidneys;    general 
condition,  age.   temperament,   employment,    etc.,  etc.,  etc.    If  an 
autopsy  was  lield.  please  state  the  condition  there  found. 
7.  Have  you  seen  any  peculiar  manifestations  from  chloral — as  tetanus, 

convulsions,  or  delirium  ? 
S  Do  you  know  of  any  cases  of  tiie  chloral-habit?  If  so,  please  state  the 
amount  used,  the  disease  for  which  the  drug  was  originally  admin- 
istered, the  person's  temperament,  and  the  present  condition  of  the 
patient. 
Physicians  are  earnestly  requested  to  answer  the  above 
questions,    in  order  that  the  resulting  statistics  may  be  as 
valuable  as  possible.     All  communications    will    be  consid- 
ered    strictly    confidential,    the    writer's    name    not    being 
used  when  a  request    to  that  effect  is    made. 

To  which  wc  answer  for  ourselves  as  follows  ; 

1.  Twenty-five  grains    in    ordinary  sleeplessness ;    40  grains  more    fre- 

quently, in  the  persistent  insomnia  of  melancholia,  or  where  ence- 
phalic pain  or  marked  eccentric  nei^vous  irritation  are  associated  with 
the  sleeplessness  ;  25  grains  in  the  fitful  somnolency  of  some  of  the 
fevers,  where  delirium  exists.  In  these  latter  cases  associated 
with  potassium  bromide  40  grains,  largely  diluted  Avith  water. 

2.  Sixty  grains  to  a  sane  person;   80  to  a  maniac  with  high  excitement. 

Two  of  such  doses,  with  never  less  than  a  twelve  hour's  interval 
between  them. 
:^.  Epilepsia,  during  the  paroxysm,  acute  mania,  delerium  tremens.  In 
infantile  convulsions,  by  mouth  and  rectum ;  very  frequently  by  the 
rectum  in  these  cases.  In  delirium  tremens,  and  in  mania  and  epilep- 
sia, have  given  one  hundred  grains  per  rectum  in  beef  tea,  with  good 
results — sixty  grains,  however,  have  often  sufliced  in  this  way.  For 
the  convulsions  of  children,  from  ten  to  thirty  grains  ^er  a^ii,  accord- 
ing to  age,  not  repeating,  unless  the  first  enema  has  come  prema- 
turely away;  have  never  used  it  hypodermically.  I  consider  it 
too  irritating  an  agent,  to  be  used  in  this  way.  Have  employed  it 
externally  as  an  anodyne  counter-imtant  in  intercostal  neuralgia, 
etc.,  etc. 

4.  Have  never  known  it  to   permanently    effect  the    sight.    Have    had 

hysterical  cases,  complain  after  the  abortive  treatment  of  a  paroxysm 
by  this  agent,  of  dimness  and  perversion  of  vision.  I  have  known 
its  use  to  be  followed  by  headache  even  after  a  single  dose,  causing 
long  sleep,  sometimes  ;  but  most  usually  the  headache  resulted  from 
the  interruption  of  the  induced  sleep. 

5.  Yes,  especially  in  inebriates,    and    when  given  with    egg-nog,  as  I 

used  to  often  give  it. 
.0.  Several    cases— not    less    than    five— of    sudden  death,    apparently 
from  heart  paralysis  in  persons  who  had  become  chloral  habituates, 
and  had  become  accustomed  to  take  the  drug  ad  libitum.    They 
were  under  no  physician's  treatment  at  the  time. 


372  Selections. 


7.  Once  a  teraporaiy    trismus,  often  delirium    from    small  doses —  5  to 

10  grains— at  hotn-  iiitei-vals,  so  that  I  no  longer  give  it  in  this  maimer. 

8.  Yes.     For    opium  ^or    alcoholic    intemperence     or    after    debauches. 

Sanguine  nervous,  or  nervous  temperament.     I  can  recall  five  of 

these  patients  wlio  are  now  dead.     One  of  the  patients  had  used  as 

much     as   SO    gra.    of   morph.    sulph.,    hypodermically,    and  died 

suddenly,  though  general  dropsy  preceded  her  death  some  weelvs. 

I   have    seen    much   miseliief  done  by  the  constant    and  persistant 

saturation  of  the  blood— with  chloral.  If  a  patient  has  taken  chloral  in  live 

to  ten  grain  doses,  every  hour  or  two,  in  a  case  of  high  cerebral  excitement. 

for  ten  or  more  honrs,  and  lias  not  been  sent  to  sleep    for  an  interval  of 

several  hours  by  this  plan,  I  wonld  consider  it  dangerous  to  give  a  full  dose 

of  forty  to  fifty  or  sixty  grains  before  an  elapsed  interval  of  from  eight  to 

twelve  hours  for  elimination  of  the  previous  ineftectual  doses  which  have 

poisoned  the  blood  and  irritated  and  exhausted,  rather  than  tranquilized 

and  recuperated  the  cerebral  centres,   whereas  a  single  dose  of  forty  to 

sixty  grains,  according  to  the  intensity  of  the  excitement,  may  be  given 

with  impunity  when  there  has  been  no  previous  abortive  action  of  the 

drug. 

Phenomena  of  Cervical  Dislocation  and  Compres- 
sion IN  an  Executed  Criminal. — Dr.  Geo.  L.  Porter,  in 
his  report  to  the  Bridgeport  (Conn.,)  Medical  Society,  June 
9th,  on*the  case  of  Hoyt,  the  parracide,  who  was  hanged 
there  on  the   13th  of  May,  says: 

The  left  lateral  and  the  anterior  ligaments  of  the  third 
and  latter  cervical  vertebra  were  ruptured,  and  a  small 
portion  of  the  anterior  superior  surface  of  the  body  of 
the  latter  vertebra  was  broken  off,  causing  compression 
without  rupture  of  the  spinal  cord. 

There  was  no  contraction  of  the  muscles,  nor  any 
general  convulsions.  Immediately  upon  the  fall,  a  tremor 
went  down  the  body,  there  was  a  quivering  of  the  legs, 
a  slight  shaking  of  the  foot,  and  then  the  body,  without 
any  self-motion,  swung  passively  in  the  breeze. 

Immediately  the  pulse  of  the  left  wrist  was  felt  and 
counted  by  Dr.  Lander;  the  time  was  noticed  by  Dr. 
Wilson,  and  the  results  tabulated  by  the  other  Medical 
men.  The  trap  fell  at  40  minutes  and  30  seconds  after 
II  o'clock.      Immediately  the  following  numbers  were  taken  : 

Minutes 1st      -Jiul      M      4th      5th  Gth      to      10th 

PnlBp'hP^t«l    ■■'^      ^-'^         ^^        *>■*       iJ7    Too  rai.i.l  to  count  and  somo- 

iriuhe  ue<iifej  times  imperceptible. 

Dr.  Lander  then  took  the  right  wrist  and  found  the 
pulse  beat  there  as  follows : 

Minutes.  10th  11th  121  li  12:30 

Beat".  52  22  21  .Sioppeil  beating. 


SeleeHnns. 


At  the  end  of  20  minutes,  there  was  no  heart  sound 
recognizable  on  auscultation. 

The  pupils  of  both  eyes  were  dilated.  In  the  right 
eye,  under  the  opthalmoscope  the  cornea  was  ruptured  in 
its  outer  coat  in  a  horizontal  direction,  nearly  across ;  the 
anterior  capsule  was  lacerated ;  the  whole  fundus  was 
pale  ;  the  arteries  were  pale  and  the  veins  nearly  empty 
of  blood.  In  the  left  eye  the  cornea  was  intact ;  the 
anterior  capsule  was  lacerated  ;  the  fundus  pale,  and  the 
arteries  and  veins  emptied  of  blood. 

The  features  were  peaceful  and  composed.  The  knot 
had  tightened  just  behind  the  left  ear.  Thirty-four  and 
a-half  minutes  after  the  fall  the  body  was  quickly  removed 
and  electricity  applied  with  the  result  of  muscular  con- 
tractions everywhere  except  at  the  heart. 

The  Tendox-Reflex  Phenomenon. — In  order  to  ascer- 
tain what  are  the  variations  in  this  phenomenon,  under 
normal  and  abnormal  conditions,  Dr.  W.  R.  Gowers, 
Assistant  Professor  of  Clininal  Medicine  in  University 
College,  London,  assisted  by  Mr.  A.  E.  Broster,  resident 
medical  officer  at  the  National  Hospital  for  the  Paralyzed 
and  Epileptic,  examined  300  individuals,  of  whom  150 
were  suffering  from  no  known  paralytic  condition  of  the 
lower  extremities.  Of  these  some  were,  as  far  as  was 
known,  in  perfectly  normal  health,  but  the  majority  were 
the  subjects  of  simple  epilepsy.  Of  the  whole  300  cases 
the  movement  was  entirely  absent  on  this  mode  of  testing, 
on  both  sides,  in  seventeen.  The  observations  were  care- 
fully made. 

"Four  of  the  seventeen  were  suffering  from  undoubted 
locomotor  ataxy  ;  a  fifth  had  atrophy  of  the  optic  nerves, 
and  commencing  ataxy  was  suspected.  Of  the  remaining 
twelve,  two  were  under  treatment  for  paraplegic  weakness 
of  legs,  but  presented  no  indication  of  ataxy.  These 
were : 

(i.)  A  man,  set.   52. 

(2.)  A  man,  aet.  45  ;  with  some  weakness  of  the  legs, 
especially  in  the  flexors,  which  had  apparently  been  left 
by  an  attack  of  spinal  meningitis.  Sensation  of  the  leg 
was  normal. 

The  remaining  ten  patients  were  as  follows  : 

I.)  A  woman,  set.  58,  who  had  had  an  attack  of  right 
hemiplegia,  but  had  recovered  so  as  to  be  able  to  walk 
five  miles.  The  patellar  reflex  was  absent  on  both  sides 
'  (as  in  all  the  cases  now  under  consideration). 


374  Selections. 


(2.)  A  man,  net.  58,  suffering  from  some  mental  disturb- 
ance and  slight  weakness,  deafness,  and  considerable 
auditory-nerve  vertigo. 

(3.)  A  man,  a:t.  36,  suffering  from  tumor  cerebri,  not 
syphilitic,  of  whicn  he  afterwards  died.  When  tested  he 
was  suffering,':  from  slight  weakness  in  the  right  arm,  but 
was  able  to  walk  a  long  distance. 

(4.)  A  girl,  net.  ii,  suffering  from  chorea;  a  good  walker. 

(5.)  A  man,  net.  19,  suffering  from  epilepsy,  whose  legs 
were  curved  from  old  rickets,  and  who  was  not  able  to 
walk  more  than  a  mile. 

(6.)  A  man,  net.  30,  suffering  from  epilepsy  and  con- 
siderable cardiac  disease ;  able  to  walk  about  two  miles. 

The  remaining  four  cases  were  all  young  epileptics. 

(7.)  A  boy,  net.  7  ;  a  bad  walker. 

(8.)  A  girl,  net.    19;  a  bad  walker. 

(9.)  A  girl,  net.  22 ;  walking  power  not  good — about  a 
mile. 

(10.)  A  girl,  net.   20;  walking  power  not  good. 

Whenever  the  reflex  was  apparently  absent  it  was 
tested  repeatedly  with  great  care,  without  the  intervention 
of  the  clothes  or  with  only  a  single  garment. 

It  would  thus  appear  that  the  knee  reflex  cannot 
be  obtained,  at  least  with  the  hand,  in  about  four  per 
cent,  of  patients  suffering  from  disease  of  the  nervous 
system  who  present  no  symptom  of  locomotor  ataxy,  and 
that  in  many  of  these,  from  sex  and  age,  the  possibility 
of  commencing  ataxy  can  be  certainly  excluded ;  but 
that,  in  most  of  them,  the  loss  is  associated  with  defective 
power    of  continued    exertion   with    the    legs. 

In  at  least  half  the  cases  of  nervous  disease  in  which 
the  knee  reflex  cannot  be  obtained  ivith  the  hand,  the 
patient  is  not  suffering  from  locomotor  ataxy.  To  those 
who  have  followed  recent  discussion  on  this  subject  this 
statement  will  appear  surprising.  Hitherto  apparently, 
the  sj'mptom  has  rarely  been  searched  for  except  in 
ataxics  or  in  few  persons  in  normal  condition  for  the 
sake  of  comparison. 


"Sinoe  tliis  pap^-  was  read,  Dr  Herjrer  lias  i)ul»lisli(Hl  {'  Centralbl.  fuer 
NervenkeiLkundCy  No.  4.  187M)  tlie  results  of  tlic^  ('.xaiiiiiiation  of  l4()i» 
lipaltliy  individual.  He  found  that  no  rellcx  could  bo  obtained  by  any 
nicthoil  of  examination  in  22.  (H-  1:.")0  per  cent.  in  comparing;  tliis  re- 
sult with  those  which  I  have  obtained,  it  must  be  remembered  that 
luorft  of  the  persons  tested  bj'  me  were  sutlerin<;  from  some  aflection  of 
the  nervous  system. 


Selections.  375 


Twenty-sev^en  cases  of  hemiplegia  from  cerebral  disease 
were  examined.  They  were  of  various  duration  and 
degree  of  recovery :  most  attended  as  out  patients  and  so 
were  able  to  walk.  The  reflex  was  equal  in  the  two  legs 
in  13  of  the  cases,  and  it  was  unequal  in  14.  In  the 
latter,  without  an  exception,  the  excess  of  movement  was 
on  the  paralyzed  side.  The  occurrence  of  this  excess 
seems  to  bear  no  necessary  relation  to  the  development 
of  the  ankle  clonus,  which  is  often  present  in  old  hemi- 
plegics.  This  ankle  clonus  was  marked  in  several  of  the 
cases  in  which  the  knee  reflex  was  equal  on  the  two  sides, 
and  it  was  absent  in  several  cases  in  which  the  excess  of 
movement  on  the  paralyzed  side  was  very  large. 

In  order  to  estimate  the  average  degree  of  movement, 
apart  from  any  weakness  of  the  legs,  the  range  of  move- 
ment (of  one  foot)  which  could  be  excited  by  such  a  tap 
as  usually  develops  the  maximum  effect,  has  been  compared 
in  one  hundred  epileptics  whose  walking  power  was 
reasonably  good.  The  amount  of  movement  was  estimated 
by  the  eye,  checked  by  an  occasional  measurement. 
Of  the  100,  T)"/  were  women  and  63  were  men.  The 
results  are  shown  in  the  following;  table  : 


in  inches. 

Men . 

\V 

'omen. 

Total 

e.<icii  degree. 

h 

3 

1 

... 

4 

1 

22 

6 

28 

2 

19 

18 

27 

3 

14 

11 

25 

4 

3 

1 

4 

5 

2 

— 

... 

2 

It  appears  from  this  that  in  90  per  cent,  of  individuals 
possessnig  good  walking  power,  the  range  of  movement 
is  between  i  and  3  inches.  The  mean  of  the  whole  is 
just  2  inches,  and  about  as  many  present  a  slight  excess 
above  the  average  movement,  as  present  a  deficiency. 
The  reflex  was  entirely  absent  in  no  patient  with  good 
walking  power,  although  in  4  it  was  slight,  not  more  than 
half  an  inch.  In  only  6  did  it  exceed  3  inches. — 
Gozvers 

To  Successfully  Reunite  Severed  Nerves. — Dr. 
Backowicki  concludes,  after  a  hundred  experiments,  on 
the  sciatic,  vagus  and  hypoglossal,  with  catgut,  silk  and 
silver  wire,  that  they  should  be  sutured  with  catgut  within 
twenty-four  hours  after  section,  and  through  the  neuri- 
lemma only.  He  attributes  the  failure  of  Eulenberg  and 
others  to  get  successful  results,  to  ligating  through  the 
nen'e  substance. 


3'6  Thirty- Fourth  Annual  Meeting. 

PROCEEDINGS  OF  THE  THIRTY-FOURTH  ANNUAL 

MEETING  OF  THE  ASSOCIATION  OF  MEDICAL 

SUPERINTENDENTS  OF   AMERICAN 

HOSPITALS  FOR  THE  INSANE. 


The  Thirty-Fourth  Annual  Meeting  of  the  Association  was  called  to 
order  at  11  a.  m.,  May  25th,  1870.  in  Parlor  C,  of  Continental  Hotel,  in  the 
City  of  Philadelphia,  by  tlie  President,  Dr.  Clement  A.  Walker.  The 
minutes  of  the  last  meeting  were  read.  The  following  members  were 
present  during  the  sessions  of  the  Association: 

J.  K.  Baudcy,  M.  D.,  St.  Vincent's  Institution  for  the  Insane,  St.  Louis,  Mo. 

D.   F.  BocGHTOs,  M.  D.,  State  Hospital  for  the  Insane,  Mendota,  Wis. 

J.  P.  Brow.v,  M.  D.,  State  Lunatic  Hospital,  Taunton,  Mass. 

Peter  Bkyce,  M.  D.,  Alabama  Insane  Hospital,  Tuscaloosa,  Ala. 

R.  M.  Bdcke,  M.  D.,  Asylum  for  the  Insane,  London,  Ont. 

D.  R.  BuBRBLL,  M.  D.,  BrighamHall,  Canandaigna,  N.  Y. 

H.  A.  BcJTTOLPH,  M.  D.,  State  Asyhim  for  the  Insane,  at  Morristown,  Morris 
Plains,  N.  J. 

John  H.  Callendkb,  M.  D.,  Tennessee  Hospital  for  the  Insane,  XashviUe, 
Tennessee. 

T.  B.  Camdek,  M.  D.,  West  Virginia  Hospital  for  the  Insane,  Weston,  W.  Va. 

John  B.  Chapin",  M.  D.,  Willard  Asylum  for  the  Insane,  Willard,  N.  Y. 

Daniel  Clauk,  M.  D.,  Asylum  for  the  Insane,  Toronto,  Canada. 

H.  F.  Carriel,  M.  D.,  Hospital  for  the  Insane,  Jacksonville,  111. 

JoH.v  CuRWEN,  M.D.,Peuna.  State  Lunatic  Hospital,  Harrisburg,  Penna. 

Thko.  Dimon.  M.  D.,  Asylum  for  Insane  Criminals,  Aul)urn,  X.  Y. 

B.  D.  Eastman,  M.  D.,  Topeka  Insane  .Vsylum,  Topeka,  Kas. 
Orphkus  Everts,  M.  D.,  Cincinnati  Sanitarium,  College  Hill,  O. 

F.  T.  Filler,  .M.  I).,  Assistant  Physician  Insane   Asylum,  Raleigh,  N.  C. 

W.  W.  Godding,  M.  D.,  Gov't  Hospital  for  the  Insane,  Washington,  D.  C. 

John  P.  Gray,  M.  I).,  State  Lunatic  Asylum,  Utica,  X.  Y. 

Richard  Gundry,  M.  D.,  Maryland  Hospital  forthe  Insane,  Cantonsville,  Md. 

John  C.  Hall,  M.  I).,  Friends'  Asyliim  for  the  Insane,  Fr.inkford,  Philadel- 
phia, Penna. 

Henry  M.  Hcrd,  M.  D.,  Eastern  Michigan  Asylum,  Pontiac,  Mich 

Walter  Kkmpstkr,  M.  D  ,  Northern  Hospital  for  the  Insane,  Winnebago, 
Wisconsin. 

Thomas  S.  Kirkrride,  M.  D.,  Penna.  Hospital  forthe  Insane,  Phila.,  Penna. 

A.  E.  Macdon'ald.  M.  D.,  City  Lunatic  Asylum,  Want's  Island,  Xew  York. 

C.  F.  MacDonald,  M.  I).,  Binghampton  Asylum  for  the  Insane,  Binghamp- 
ton,  X.  Y. 

S.  B,  McGlumphv,  M.  D.,  Dakota  Hospital  for  the  Insane,  Yankton,  Dakota 
Territory. 

C.  S.May,  M    D.  ,  Dauvers  Lunatic  Hospital,  Dan  vers,  Mass. 
W.  G.  Metcalf,  M.  D.  ,  Asylum  for  the  Insane,  Kingston,  Ont. 

C.  A.  Miller,  M    D.,  Longview  Asylum,  Carthage,  Ohio. 

D.  a.  Morse,  M.  D.,  Dayton  Asylum  for  the  Insane,  Dayton,  Ohio. 
Charles  H.  Xichols.  M.  I)  ,BI<)omingdale  Asylum  for  the  Insane,  X.  Y.  City. 
Geo.  C.  Palmer,  M    D.,  Michigan  Asylum  for  the  Insane,  Kalamazoo,  Mich. 
T.  O.  Powell,  M.  D.  ,  Georgia  Insane  Asylum,  Milledgeville,   Ga. 

Isaac  Ray,  M.  D.,  Philadelphia,  Pa. 

Joseph  A.  Reed,  M.  D.,  Western  Penna.  Hospital  for  the  Insane, Dixmont,  Pa. 

D.  D.  Richardson,  M.  D.,  State  Hospital  for  the  Insane,  Warren,  Penna. 


Association  of  Medical  Superintendents.  377 


Joseph  G.  Rogers,  M,  D.,  Indiana  Hospital  for  the  Insane,  Indianapolis,  Ind. 
John  W.  Sawykk,  M.  D.,  Butler  Hospital,  Providence,  R.  I. 
S.  S.  ScHULTZ,  M.  D.,  state  Hospital  for  the  Insane,  Danville,  Penna. 
G.  A.  Shurtlkff,  M.  D.,  Asylum  for  the  Insane,  Stockton,  Cal. 
James  T  Stkeves,  M.  D.,  Provincial  Lunatic  Asylum,  St.  John,  N.  B. 
J.  Strong,  M.  D.  ,  Cleveland  Asylum  for  I  he  Insane,  Cleveland,  O. 
J.  D   Thomson^,  M.  D.,  Mount  Hope  Retreat,  Baltimore.  Md. 
Clement  A.  Walker,  M.  D.,  Boston  Lunatic  Hospital,  Boston,  Mass. 
John  W.  Ward,  M.  D.,  N.  J    State  Lunatic  Asylum,  Trenton,  N.  J. 
H.  Wardxkr,  M   D.,  Southern  Hospital  for  the  Insane,  Anna,  Ills. 
J   H.  WoRTHiNGTON,  M.  D. ,  Baltimore ,  Md. 

John  S.  Woodside,  Assistant  Physician,  Kings  County  Lunatic  Asylum, 
Flatbush,  N.  Y 

Also : — 

Alfred  T.  Livingston,  M.  D.,  Philadelphia,  Penna. 

I.N.  Kerlin,  M.  D.,Supt.  of  the  Institution  for  Feeble-Minded  Children, 
Media,  Penna. 

Gardner  A.  CHURCHHtLL,  Trustee  of  the  Lunatic  Hospital,  Dtinvers,  Mass. 

Geo.  W  Jones,  Trustee  of  the  Willard  Asylum  for  the  Insane,  Willard,  N.  Y. 

Traill  Green,  M.  D.,  Trustee  of  the  Penna.  State  Lunatic  Hospital,  Harris- 
burg,  Pa. 

Wm.  Corson,  Commissioner  of  the  State  Hospital  for  the  Insane,  Warren,  Pa. 

John  C.  Allen  and  Henry  HAi>fKS,  Managers  of  the  Friends'  Asylum  for  the 
Insane,  Frankford,  Philadelphia,  Penna. 

The  President  announced  as  the  Committee  on  Business— Drs. 
Kirkbride,  Ray  and  Curwen. 

On  motion  of  Dr.  Gray,  it  was 

Resolved,  That  the  members  of  the  Medical  Profession  of  Philadelphia 
be  invited  to  attend  the  meetings  of  the  Association. 

The  Secretary  read  letters  from  Drs.  Harlow,  Stearns  and  Reynolds, 
expressing  their  regret  in  being  unable  to  attend  this  meeting ;  also  from 
Miss  Dix,  expressing  liindest  regards  to  the  members;  also  an  invitation 
from  Dr.  I.  N.  Kerlin,  of  the  Institution  for  Feeble-Minded  Children,  at 
Media,  to  visit  and  spend  a  day  at  that  institution,  which  was  referred  to 
the  Committee  on  Business.  The  Secretary  also  stated  that  Dr.  Kirlibride 
had  received  an  invitation  from  Prest.  Allen,  of  Girard  College,  to  visit 
that  Institution ;  also,  that  it  was  probable  that  an  invitation  would  be 
received  to  visit  tlie  new  hospital  at  Norrlstown. 

On  motion  of  Dr.  Curwen,  Dr.  I.  X.  Kerlin  was  invited  to  take  a  seat 
with  the  Association. 

On  motion  of  Dr.  Nichols,  a  recess  of  twenty  minutes  was  taken  to 
enable  the  Committee  on  Busiu'^ss  to  arrange  the  business  of  the  Association 

On  re  assembling,  the  President  announced  the  following  committees  : 

Committee  on  Resolutions— Drs.  Nichols,  Bucke  and  Bryce. 

On  Time  and  Place  of  Next  Meeting— Drs.  Clark,  Kempster  and 
Shurtleff. 

To  Audit  the  Treasiu-er's  Accounts— Drs.  Gundry,  Eastman  and  May. 

The  Committee  on  business  made  the  following  report,  which  was 
unanimously  adopted : 

Continue  tiiis  ses.sion  to  1  p.  m.  ;  meet  at  4  p.  m. 


378  Thirty-Fourth  Jntiual  Meeting, 


Wednesday— l.v.WG  the  hotel  at  9.30  a.  m.  for  tlie  departinent  of  males 
of  the  Pennsylvania  Hospital  for  the  Insane :  iiold  a  meetiny^  there  at  10.30 
A.  M. ;  adjourn  at  12  .m..  to  vi>it  tlie  wards.  Dine  at  2  v.  m.  Leave  at  4  r. 
M.,  for  tile  department  for  females;  hold  a  meeting  there  at  5  p.  m.,  and 
leave  tlie  Hospital  at  9.30  v.  m.  for  the  hotel. 

Thursday. — Meet  at  10  a.  m.  for  husiness;  adjourn  at  1  p.  M.  Vi<it 
Girard  College  at  4  p.  m. 

Friday. — Meet  at  10  A.  M.  for  business;  adjoiu-n  at  12  m.  Leave  west 
Philadelphia  at  2.30  v.  M.,  by  special  train  for  Friends"  Asylum  at  Frank- 
ford;  return  in  the  evening. 

Saturday.— 'He^i  at  10  a.  ji.  for  business. 

The  Treasurer  then  laid  before  the  Association  his  accounls,  which 
were,  on  motion,  referred  to  the  Auditing  Committee. 

Dr.  Steeves  then  read  the  memorial  of  Dr.  John  Waddell.  which 
was.  on  motion,  directed  to  be  entered  on  the  minutes  of  the  Asso- 
ciation, 

The  committee  appointed  to  prepare  a  memorial  record  of  the  death 
of  the  late  Dr.  Jolin  Waddell,  of  Canada,  a  member  of  this  association, 
presented  the  following: 

John  AVaddell,  whose  father  was  a  native  of  Sholts.  Scotland,  was  born 
in  Truro,  Nova  Scotia  on  March  17tli,  1810.  He  was  the  youngest  sou  of 
the  Reverend  John  Waddell.  an  eminent  Presbyterian  .clergyman,  and 
broiherofthe  late  James  U'addell.  also  a  distinguished  member  of  the 
Presbyterian  Churcli.  The  early  part  of  his  education  was  received  at  tlie 
Grammar  School  in  Tnu-o;  sut)sequeiitly  he  attended  the  Picton  Academy, 
where  he  spent  seAcral  years  completing  a  full  eourse  of  lilieral  cidtuie. 
At  the  end  of  this  period  he  engaged  in  bu.siness,  continuing  for  one  year; 
but.  tiudiiig  this  enterprise  uncongenial,  it  wys  abandoned.  In  the  year  1834 
he  commenced  thestuily  of  medicine  in  his  niitive  place,  under  the  precep- 
torship  of  Dr.  Lyna.  '  He  next  proceeded  to  Glasgow,  continuing  his 
medical  studies  there ;  and  on  the  ISth  of  October.  1839.  he  received  his 
diploma  from  the  Royal  College  of  Surgeons,  London.  After  obtaining 
his  degree  the  Doctor  attended  medical  lectures  in  Paris,  during  the  winter 
of  1839  and  1840.  In  the  summer  of  1840  he  returned  to  Truro.  Nova  Scotia, 
and  entered  on  the  practice  ofhis  chosen  profession.  Dnriig  the  following 
nine  years  he  was  engao^ed  in  general  practice,  and.  being  eminently 
successful,  he  extended  his  name  and  fame  tar  bevond  the  immediate 
.sphere  of  his  labors.  In  1849.  Dr.  VVaddell  was  appointed  the  Medic:d 
Superintendent  of  the  Provincial  Lunatic  Asylum,  at  St.  John.  Xew 
Brunswick,  and  in  December,  of  that  year,  heeiitered  upon  the  duties  con- 
nected therewith.  In  the  management  of  this  Institution  the  Doctor  found 
a  sphere  congenial  to  his  order  of  mind,  and  he  soon  won  a  i<])utation 
more  than  i)rovin<ial.  In  a  pre-eminent  degree  he  possessed  the  inialities 
of  mind  and  heart  to  ensure  success  in  his  chosen  tield.  His  administn.tive 
ability  was  of  a  high  order;  he  was  prudent,  practical  and  econoniic.il  in 
Ills  management,  and  adverse  to  the  use  of  too  delinitelv  written  rules, 
preferring  a  freipient  resort  to  him.<e!f  as  the  source  of  "authority  in  the 
house  which  h<^  controlled.  His  tine  ;)ersowe/.  irentlenianly  hearing  suave, 
manners  and  cheerful  disposition  gained  for  him,  at  once",  the  confidence 
and  esteem  of  his  associates,  and  the  public  as  well. 

While  Dr.  Waddill  w;is  urbane,  generous  and  forciving.  yet  he  pos- 
ses.eeil  jrreat  tirnine>s  of  character,  when  ojipo.'cd  in  his  cheri.efied  views  or 
plans:  his  ojiix-nent  found  -a  foeman  worthv  of  his  steel."  Dr.  Waddell 
continued  Suiierintendent  of  the  Asylum  at  St.  John,  from  December,  1849, 


Associalion  of  Medical  Superintendents.  379 


to  the  first  of  May,  1875,  a  period  exten(]in«r  upwards  of  26  years,  and 
during-  all  that  time  he  labored  with  gi  eat  assiduity  and  with  marked 
success  in  the  Uiedical  treatment  of  the  patients,  the  general  management 
of  the  house,  and  in  all  that  pertained  to  the  prosperity  of  the  institution; 
for  the  best  part  of  his  life  was  devoted  to  a  noble  purpose,  caring  foi-  the 
helpless  and  insane,  going  in  and  out  among  them  at  all  hours  of  the  daj^ 
and  night  ministering  to  their  diseased  bodies  and  minds— performing  the 
office  of  a  faithful  ph5'sician.  Early  in  the  history  of  this  Association.  Dr. 
Waddcll  liecame  an  active  member,' taking  a  deep  interest  in  its  work,  and 
earnestly  jdoHioting  its  welfare.  His  agreeable,  social  qualities,  varied 
information  and  practical  good  sense,  made  him  a  great  lavorite  among 
the  members  of  the  Association.  On  the  doctors  retiring  from  the  S uper- 
intendency  of  the  Asylum,  he  again  took  up  his  residence  at  'Jruro,  his 
birth-place,  where  he  himself  and  his  friends  hoped  that  he  might  enjoy 
many  years  of  quiet  and  peace  after  his  arduous  life  duties  had  been  so 
well  performed.  But  this  hope  was  not  realized:  the  good  doctor  had 
almost  finished  his  course ;  he  had  well  nigh  fallen  before  his  armor  was 
removed.  The  watching,  the  anxiety,  too  long  coi  tinned  without  sufii- 
cient  aid.  had  so  wrought  upon  his  physical  system  and  mind,  that  a 
nervous  affection  fastened  upon  him,  to  which  he  soon  succumbed.  On 
Thursday,  the  29th  of  August,  1S78,  our  friend,  a  christian  gentleman, 
passed  away  peacefully  to  his  rest  and  his  reward. 

James  S.  Steeves, 
Calvin  S.  May. 

Tlie  Secretary  read  a  telegram  from  Dr.  C.  H.  Hughes  conveying  good 
wishes  and  prosperity  to  the  members,  and  regretting  his  inability  to 
attend  this  meeting. 

Dr.  May  introduced  to  the  Association.  Mr.  Gardner  A.  Churchhill. 
Trustee  of  the  Danvers  ( M  ass.)  Hospital  for  the  Insane.and  Dr.  J.  B.  ( "hapin 
also  introduced  Mr.  Geo.  W.  Jones,  Trustee  of  the  Willard  Asjlum  for  the 
Insane,  Willard,  >l.  Y. 

On  motion  of  Dr.  Gray,  the  Association  adjourned  to  4  p.  m. 

The  Association  was  called  to  order  by  the  President,  at  4.30  p.  M.  Dr. 
Bryce  then  read  the  memorial  of  Dr.  Thos.  F.  Green,  prepared  at  the 
request  of  the  Association,  which  was,  on  motion,  directed  to  be  entered 
on  the  minutes: 

Dr.  Thomas  F.  Gieen  was  born  in  Beaufoit.  S.  C.  on  the  25th  of  Dec, 
1S04.  He  died  in  Midway,  Ga..  on  the  the  13th  of  February.  1879.  of 
•apoplexy,  while  superintendent  of  the  Georgia  Lunatic  Asylum.  His 
parents  were  of  the  best  class  of  Irish  people.  His  father,  a  warm- 
iieai-ted,  highh -educated,  enthusiastic  young  Irish  patriot,  joined  in  the 
ill-fated  I  ebellion  ofl79S.  and  was  forced  to  flee  the  country.  His  wife, 
who  was  a  Fitzgerald,  a  lady  of  noble  blood,  came  with  him  to  America. 
He  had  no  fortune  save  his  talents,  no  friends  save  those  whom  he  won 
by  his  virtues  ;  he  began  to  teach,  and  as  a  teacher,  came  to  Beaufort.  S. 
C.  [lere  his  oldest  son,  Thomas  Fitzgerald,  was  born.  He  removed  to 
bavannah,  Georgia,  where  he  taught  a  high  school,  and  then  was  elected 
a  professor  in  Athens,  in  the  Georgia  University.  He  afterwards  removed 
to  Milledgeville.  the  Capital  of  Georgia,  and  here  the  son  was  educated. 
He  was  past  his  majority  when  he  studied  medicine  and  began  to  practice. 
He  located  in  Milledgeville  and  was  doing  well  as  a  physician,  when  the 
current  of  his  life  was  changed,  and  turned  into  a  direction,  which  was  to 
.be  full  of  blessings  to  his  race. 

A  northern  philanthrophist,  who  was  interested  in  the  welfare  of  the 
insane,  visited  Milledgeville  to  suggest  and  advocate  the  establishment  of 
an  asylum  for  them.    He  called  a  meeting  of  a  few  gentlemen  of  broad 


3S0  Thirty- Fourth  Annual  Meeting, 


views  aud  generous  hearts,  and  laid  his  plans  before  them.  The  warm 
heart  of  Dr.  Thomas  F.  Green  became  much  interested  in  the  great  ques- 
tion presented,  and  he  gave  it  close  attention.  He  was  connected  with 
the  first  eftbrt  made  to  secure  thegi-ant  from  the  legislature. 

In  1846.  lie  succeeded  Dr.  Cooper  as  Superintendent  of  the  asylum. 
He  continued  in  the  office  for  thirty-three  years.  It  was  very  small  when 
he  took  hold  of  it.  It  became  a  grand  institution  ;  one  of  the  largest  in 
the  Southern  States,  when  he  was  called  by  death  from  it. 

Dr.  Green,  in  person,  was  sliort,  stout,  of  broad,  grand,  humane 
countenance;  in  his  youth  handsome,  and  in  his  old  age  venerable.  He 
was  full  of  life,  cheerful,  merry,  courteous,  considerate.  He  was  a  sincere 
christian;  in  his  home  life,  a  model;  one  of  the  most  benevolent  and 
unselfish  of  men.  He  was  devoted  to  the  institution— he  literally  lived 
for  the  Jisylum.  He  thought  of  it — talked  of  it  all  the  time.  His  success  in 
the  management  of  it  was  marvellous,  and  the  blessed  results  of  his  work 
can  not  be  told  in  time.  He  Avas  a  deh'ghtful  companion,  a  true  and 
symi)atlii/liig  fri-nd.  a  man  whom  all  loved,  and  one  worthy  of  all  the 
honor  heapi'il  upon  him.  The  moral  grandeur  of  his  character  was  best 
illustrated  by  the  interest  he  manifested  in  the  unfortunate. 

Dr.  Gundry,  from  the  committee  to  audit  the  Treasurer's  accounts, 
reported  the  accounts  correct.  The  receipts,  $287.88 ;  the  expenditures, 
§172.65.  and  the  amount  on  hand  S115.24;and  they  also  recommend  an 
assessment  of  five  dollars  on  each  member  for  this  year. 

On  motion,  the  Association  adjourned. 


Wednesday,  May  26,  1880. 

The  Association  was  called  to  order  at  the  department  for  males  of 
the  Pennsylvania  Hospital  for  the  Insane,  by  the  President  at  11  a.  m.  Dr. 
Curwen  introduced  to  the  .\ssociation,  Dr.  Traill  Green,  Trustee  of  the 
Pennsylvania  State  l.unatic  Hospital,  and  Dr.  W'm.  Coison,  Commissioner 
of  the  State  Hospital  for  the  Insane,  Warren,  Penna.,  who  were  invited 
to  take  seats  with  the  Association. 

On  the  nomination  of  Dr.  Kirkbride,  Dr.  Daniel  Hack  Tuke,  of  London, 
was  unanimously  elected  as  honoraiy  member  of  the  Association. 

Dr.  C.  F.  Mac  Donald  then  read  to  the  Association  the  report  of  a  case 
of  Feigned  Epilepsy,  the  discusion  of  which  was,  at  the  hour  of  adjourn- 
ment, postponed  until  tiie  afternon  session. 

After  passing  through  the  wards  of  tlie  Department  for  Males,  and 
partaking  of  the  bountiful  collation  provided,  and  then,  at  4  r.  m.  passing 
through  the  wards  of  the  Department  for  Females,  the  Association  was 
called  to  order  at  5.30  p.  m.  by  the  President. 

The  President  read  a  letter  from  Dr.  Jos.  AVorkman,  expressing  his 
continued  interest  in  the  Association,  and  his  regret  at  his  inability  by 
rea.son  of  advancing  years,  to  attend  this  meeting;  also  a  letter  from  Dr. 

E.  Mead,  regretting  his  inability  to  be  i)resent  with  the  Association  at  this 
time. 

The  Association  resumed  tlie  discussion  of  tlie  paper  read  bv  Dr.  C. 

F.  MacDonald. 

Dr.  Puiy  read  a  paper  on  the  increase  of  "Mental  Disorders." 


Association  of  Medical  Superintendents,  381 


On  motion,  the  Association  adjourned  to  10  a.  m.  Thursday,  After  the 
adjournment,  the  members  witnessed  the  calisthenic  exercises,  and  after 
some  time  spent  in  social  entertainment,  returned  to  the  hotel. 


Thursday,  May  27,  1880. 

The  Association  was  called  to  order  at  10.30  a.  m.  by  the  President. 

Miss  Dix  was  present  and  was  introduced  to  the  members. 

The  Secretary  read  invitations  from  tlie  President  of  the  Board  of 
Trustees  of  the  State  Hospital  for  the  Insane,  at  Xorristown,  to  visit  that 
hospital ;  from  the  Librarian  of  the  Library  Company,  of  Pliiladelphia.  to 
visit  the  building  of  that  company,  and  from  the  Trustees  of  the  Women's 
Medical  College,  which  were  referred  to  the  Committee  on  Business. 

A  communication  was  also  received  from  tlie  Committee  of  Arrange- 
ments of  the  American  Medical  Association  to  attend  the  meeting  of  the 
Association  in  Xew  York,  and  also  an  invitation  to  attend  the  reception  at 
the  Academy  of  Music,  which  were,  on  motion,  accei)ted. 

The  first  business  in  order  being  the  discussion  of  the  paper  read  by 
Dr.  Ray.    On  motion  it  was,  at  the  request  of  Dr  Ray,  laid  on  the  table. 

Dr.  John  B.  Chapin  read  a  paper  on  "Experts  and  Expert  Testimonj'." 

Dr.  Kempster  offered  the  following : 

Resolved,  That  a  committee  be  appointed  to  report  by  resolution,  or 
otherwise,  to  the  next  meeting,  a  method  which  shall  express  the  views 
of  this  Association  as  to  the  best  manner  of  proceedure  in  procuring 
experts  in  medico-legal  questions  of  insanity,  and  what  qualifications  in 
our  opinion  constitute  an  expert. 

On  motion,  the  resolution  was  divided,  and  the  question  being  put  on 
the  first  clause,  that  clause  was,  on  a  division,  voted  down  (14  in  favor, 
22  against),  and  the  resolution  was,  therefore,  not  adopted. 

Dr.  Gundry  then  read  a  paper  on  "The  Insanity  of  Critical  Periods 
of  Life;'"  the  discussion  of  which  was  postponed  for  the  present. 

On  motion,  the  Association  adjourned  to  8  p.  m. 

The  members  spent  the  afternoon  in  visiting  and  inspecting  the 
admirable  arrangements  of  Girard  College,  under  the  conduct  of  President 
Allen,  and  Vice-President  Arey,  and  returned  to  the  hotel  early  in  the 
evening. 

A  few  of  the  members  met  at  8  p.  m.,  but,  on  account  of  the  ditficulty 
of  obtaining  a  full  meeting,  by  reason  of  the  unusual  heat,  a  motion  was 
made  and  adopted  to  adjourn  to  10  a.  m.  of  Friday. 


Friday,  May  28,  1880. 
The  Association  was  called  to  order  at  10  a.  m.  by  the  President, 
Dr.    Everts  announced  to  the  Association  the  death  of  Dr.    \Y.  S. 
Chipley,  and,  on  motion,  a  committee  was  directed  to  be  appointed  to 


382  Thirty  Fourth  Annual  Meeting, 


prepare  a  memorial,  to  be  presented  to  the  next  meeting  of  the  Association. 
The  President  appointpd  Dr.  Everts  the  committee. 

The  President  annonnc-ed  the  death  of  Dr.  K,  F.  Baldwin,  of  Vn-gini:i. 
and.  on  motion.  Dr.  Black,  of  William^buro:,  «'a.s  appointed  to  prepare  u 
memorial. 

Dr.  Gimdry  reported  to  the  Assooiotion,  the  death  of  Dr.  O,  M.  Lanji- 
don.  Dr.  Jo*.  I'.  Webb  and  Dr.L.  R.  Landfear. 

On  motion,  the  Presi(h-nt  was  authorize  1  to  appoint  a  committee  to 
prepare  a  memorial  for  each  of  these  deceased  members.  The  President 
appointed  Dr.  Gundry  to  prepare  the  memorials  of  Dr.  Langdon  and  Dr. 
Landfear  and  Dr.  Miller  to  prepare  the  memorial  of  Dr.  Webb. 

The  Association  resumed  the  discussion  of  the  paper  read  b\'  Dr. 
Gundiy,  and  after  the  conclusion  of  the  discu-sion.  Dr.  Hurd  read  a  paper 
on  "Recent  Judicial  Decisions  on  lasmity,  in  Michigan,"  which,  alter 
discussion,  wa.s  laid  on  the  table. 

On  motion  of  Dr.  Kempster  it  was 

Resolved,  That  the  Committee  on  Business  he  appointed  at  the  close  of 
ea  di  an:uial  meeting  to  prepare  the  business  and  ascertain  the  papers  to  be 
read,  and  notify'  the  Secretary'  at  least  two  months  before  tiie  meeting,  so 
that  the  members  may  be  inform;*d  of  what  will  be  read  at  tlie  meeting  : 
an  I  that  the  Secretary  in  sending  the  n  )tices  of  the  m'^eting,  shall  state  what 
papers  will  b.i  read,  and  that  the  members  who  prepar.'  papers  shall  bring 
them  with  them,  to  be  ready  to  read  at  tlie  call  of  the  Secretary. 

On  motion,  the  Association  adjourned  to  S  v.  m. 

The  members  spent  the  afternoon  in  visiting  an  1  inspecting  the  excel- 
lent arrangements  of  tlie  Friends'  Asylum  for  the  Insane,  under  tlie  con- 
duct of  Dr.  John  (J  Hall. 

The  Association  was  called  to  order  at  8.30  v.   m.  by  tlie  President. 

Dr.  Hall  introduced  to  the  Association,  John  C.  .Vllen  and  Ili-my  Haines, 
managers  of  the  Friend's  Asylum  for  the  Insane. 

The  CommitSe  on  the  Time  and  Place  of  the  Next  Meeting  made  tlie 
following  report,  which  was  unanimously  adopted  : 

The  Committee  to  whom  was  referred  the  (lueslion  of  determining 
the  place  and  time  of  the  n.-xi  meeting  of  the  .Association,  respectfully 
suggest  the  City  of  Toronto  as  the  place,  and  the  second  Tues  lay  of  June 
1S81,  as  tlie  time  for  the  next  aiiiiual  meeting  of  the  Association." 

DAN'tKL   Cl.AKK.  1 

\Naltkk  Kkmi'stek,    V  Committee. 
G.  A.  Shlkti.eff,       J 

The  President  appointed  on  the  Committee  on  Business,  Drs.  Kemp- 
ster, Clark,  Workman  Curwen  and  Callender. 

Dr.  Bryce.  from  the  Committee  on  Resolutions,  presented  the  follow- 
ing report  wliich  was  unanimously  adopted  : 

The  Thirty-Fourth  Annual  Meeting  of  the  Associati  )n  of  MeHical 
Stiperintendents  of  American  Institutions  for  the  Insane,  and  the  ^ixth 
held  in  Philailelpliia  (the  orijjinal  biith-plaee  of  the  Association),  being 
about  to  close,  its  members  in  attendan<;e  this  year  desire  to  express  ho'li 
their  exalted  sense  of  the  abounding  presence  in  this  great  city  of  Broi  heriy 
love,  of  those  institutions  and  material  conditions  which   contribute   in  a 


Association  of  Medical  Sicperiivtendents. 


special  degree  to  the  general  intelligence, social  order,  health  and  rational 
happiness'of  its  favored  citizens,  and  their  srnitefnl  a  >preciation  of  the 
attentions  ;ind  hospitalities,  which  have  been  bestowed  upon  them  during 
this  meeting,  with  generous  and  unsparing  hands. 

To  tlieir  very  distinguished  and  beloved  assosiate  and  friend  Dr. 
Thomas  S.  Kirkbride,  and  to  his  able  and  faithtulassistants.  Ur.  S.  Preston 
Jones  and  Wm.  J'.  Moon,  and  their  associates,  and  to  the  Managers  of  the 
Pennsylvania  Hospital  for  the  In-;ane ;  we  again  return  our  hearty 
acknowledgments  for  the  pl'-asure  and  profit  we  have  derived  from  an 
inspection  of  the  admirable  provisions,  both  in  material  arrangements  and 
administration,  which  this,  the  oldest  organization  for  the  care  of  the 
insane  in  this  western  world,  continues  to  present  for  the  comfort  and 
remedial  treatment  of  its  afflicted  inmates,  and  for  their  cordial  and 
abundant  attentions  to  our  comfort  and  refreshment  daring  the  day  so 
agreeably  spent  at  that  institution.  Though  this  department  of  the  Penn- 
sylvania Hospital  is  the  oldest  provision  in  the  country,  by  about  a  quarter 
of  a  century,  for  the  humane  and  remedial  treatment  of  the  insane,  tlie 
earnestly  progressive  am)  philantroohic  spirit  with  which,  under  its 
present  "head,  it  has  always  been  administered,  keeps  it  steadily  in  the 
ranks  of  the  newest  and  best  of  American  institutions  of  this  class. 

Kevering  the  srood  Providence  under  which  Dr.  Kirkbride  his  meas- 
urably recovered  fi-ora  a  severe  and  protracted  sickness,  we  trust  that  his 
life  of  usefulness  and  honor  may  yet  be  prolonged  through  many  years. 

In  this  connection  we  wish  to  express  to  Mr.  Wm  Biddle.  President 
of  the  Board  of  Managers  of  the  Penn.  Hospital  for  the  Insane,  and  Messrs. 
Samuel  Mason.  Benjamin  H.  Shoemaker,  T.  Wistar  Brown,  Joseph  C. 
Turnpeimy  and  Henry  Haines,  members  of  the  Board,  our  high  a|)precia- 
tion  of  their  devotion  of  the  entire  day,  of  our  visit  to  that  institution,  to 
our  entertainment. 

To  Dr.  John  C.  Hall  and  the  Managers  of  the  Friends'  Asylum  for  the 
Insane,  situtated  at  Frankford.  in  this  city,  we  are  much  indeltted  for  the 
pleasant  afternoon  they  aiforded  us  the  privilege  of  spending  at  that 
excellent  institution.  VVe  found  it  to  be  steadily  advancing  in  the  extent 
and  character  of  its  accommodations,  to  l)e  in  shining  cleanliness  and  order 
as  usual,  and  to  present  evidences  of  the  very  kind  and  beneficial  care, 
which  we  believe  its  patients  have  never  failed  to  receive  in  all  its  long 
history. 

We  return  our  thanks  to  Wm.  H.  Allen,  LL.  D.,  Pi-esident,  and  Mr. 
Henry  VV.  Arcy,  Vice-President  of  Girard  College,  for  personally  conduct- 
ing the  members  of  the  Association  through  the  buildings  and  apartments 
of  that  unique  andadmirabiy  managed  institution,  where  nearly  a  thousand 
fatherless  boys  are  receiving  a  liberal  business  education,  and  a  sound 
moral  training,  which  are  shown  by  the  prominence  of  its  graduates,  in 
many  of  the  useful  walks  of  life.  'Two  of  its  graduates  are  now  in  the 
Congress  of  the  United  States. 

We  have  again  liad  the  pleasure  of  the  society  arid  counsel  of  our 
illustrious  and  venerable  associate.  Dr.  Isaac  Ray,  who,  thouarh  long  retired 
from  the  active  duties  of  his  profession,  does  "not  manifest  the  slightest 
abatement  of  his  interest  in  the  specialty  of  mental  medicine,  which  he  has 
so  long  and  so  conspicuously  illustrated  and  adorned. 

We  are  glad  again  to  be  able  to  record  the  pleasure  we  have  had  in  the 
course  of  this  annual  meeting,  of  paying  our  respectful  duty  to  Miss  D.  L. 
Dix,  whose  labor  and  name  underlie  the  benevolent  work  in  which  many 
of  us  are  engaged. 

For  invitations  from  Hon.  John  F.  Hartranft,  President  of  the  Board 
of  Managers  to  visit  the  buildings  of  the  hospital  at  Norristown,  which 
ai'e  about  to  be  opened  for  the  care  of  the  insane  of  the  southeastern 
counties  of  Penna.;  from  Dr.  1.  N.  Kerlin.  Superintendent,  and  the  Trustees 
of  the  Institution  for  Feeble-Minded  Children,  at  Media,  Penna.;  from  the 
Faculty  and  Trustees  of  the  Women's  Medical  College,  of  Philadelphia,  and 


384  Association  of  Medical  Superintendents. 


from  the  Library  Company,  of  Philadelphia,  to  visit  their  respective 
institutions,  which  we  regret  that  we  were  no'  able  to  accept  from  lack  of 
time;  we  wish  to  express  our  appreciation  and  thanks. 

We  wish  to  commend  the  gentlemanly  bearing  of  the  reporters  for  the 
newspapers  of  Philailephia.  vvlio  have  been  present  during  the  sessions  of 
the  Association  this  year,  and  to  thank  them  for  the  fullness  and  general 
accuracy  of  their  rrpoits  of  our  proceedings 

To  Messrs.  J.  E.  ivingsley  &  Co..  Proprietors  of  the  Continental  Hotel, 
we  return  our  thanks  for  t!ie  courtesies  we  have  received  at  the  hands  of 
themselves  and  their  clerks  and  servants,  during  the  week  wf  have  spent 
in  their  excellent  hostelry  ;  and  for  the  use  of  a  quiet,  convenient  room,  in 
which  to  hold  our  sessions. 

On  motion  of  Dr.  Curwen  it  was 

Reaolved,  That  the  Association  now  adjourn  to  meet  in  Toronto, 
Ontario,  on  the  second  Tuesday  of  June,  1881. 

JOHN  CURWEN, 

Secretary. 


EDITORIAL  DEPARTMENT. 


The  Curability  of  Insanity. — Among  the  questions  yet  sub-judice 
in  psychiatry  is  that  of  the  precise  ratio  of  permanent  cures  which  takes 
place  among  the  insane.  That  insanity,  under  judicious  medical  manage- 
ment, if  begun  in  its  earlv  stages,  is  as  curable  as  most  of  the  otiier  grave 
maladies,   has  been  satisfactorily  attested  by  all   experienced   alienists. 

The  records  of  the  hospitals  for  the  insane  make  quite  as  good  an 
exhibit  in  the  matter  of  cures,  to  the  credit  of  our  science  and  art.  as  the 
records  of  other  hospitals,  and  they  have  been  prepared  and  presented  to 
the  profession  at  large,  and  to  the  public  in  precisely  the  same  way, 
namely  :  whenever  the  patient  has,  to  the  best  of  the  chief  physician's 
diagnostic  discernment,  appeared  to  be  recovered,  he  has  generally  been  so 
pronounced  and  recorded,  that  is  where  the  form  of  the  disease  has  not 
been  known  to  be  recurrent. 

There  is,  however,  the  exception  in  favor  of  the  hospitals  for  the 
insane,  that  convalescents  are  longer  retained  in  them  than  in  general 
hospitals,  after  convalesence  appears,  in  order  to  more  securely  and 
permanently  establish  and  be  assured  of  their  restoration,  if  unwisely, 
the  persistent  importunities  of  friends  do  not  procure  the  patient's 
premature  removal  to  his  home,  contrary  to  the  wiser  counsel  of  the 
physician  and  to  his  true  interest,  as  not  unfrequently  happens,  result- 
ing in  the  patient's  relapse  on  again  coming  within  the  influence  of  the 
exciting  cause  or  causes  at  home,  which,  in  the  first  instance,  precipitated 
the  patient's  overthrow. 

Thus,  by  re-exposure  to  the  causes  which  excite  them,  the  insanites, 
like  other  diseases,  recur. 


Editorial. 


It  has  even  been  found  that  in  some  organizations,  insanity  is  as  tena- 
cious and  as  repeatedly  recurrent,  as  the  oft-returning  manifestations  ot 
syphilis,  scrofula  or  intermittent  fever,  and  that  it  constitutes  in  this  regard, 
no  exception  to  the  rule  applicable  to  all  disease,  save  certain  contagious 
affections,  the  exanthemata,  especially,  which,  tiirough  some  permanent, 
but  occult  change,  caused  by  one  attack  in  the  impressibility  of  the 
nervous  system,  seem  to  secure  immunity  against  a  recurrence. 

The  general  hospitals  of  the  United  States  and  their  medical  staffs 
have  never  been  arraigned  that  we  know  of,  either  by  medical  societies 
or  public  outcry  for  reform,  for  misleading  professional  or  public  opinion 
by  recording  as  recovered  such  cases,  as.  to  all  appearance*,  are  well  when 
they  go  from  the  hospitals,  notwithstanding  the  majority  of  the  patients 
that  go  out  of  a  general  hospital  certified  as  cured,  are  likely  to  be  again 
similirlyjitflicted,  soma  of  them  again  SiwA  again  in  the  course  of  their 
lives,  that  is,  if  thzy  are  skillfully  treated,  as  they  generally  are  in  this 
country. 

All  hospitals'— for  the  sane  as  well  as  for  the  insane — that  have  been 
for  any  considerable  length  of  time  in  operation,  if  the  methods  of  treat- 
ment pursued  are  efficient,  must  show,  in  the  course  of  time,  repeated 
recoveries  of  the  s.ime  person  from  the  same  disease,  i.  e.  more  cases 
must  recover  than  persons,  for  it  is  ths  nature  (with  the  exception  noted 
above)  of  disease  to  recur. 

It  would  be  a  sorry  day  for  the  Profession  of  Medicine  and  for  afflicted 
humanity,  if  the  time  should  ever  come  when  we  could  not  cure  repeated 
recurrences  of  the  same  disease  in  the  same  person. 

Dr.  Pliny  Earle,  the  Superinten  lent  and  Physician  of  the  Southampton 
(Mass.)  Lunatic  Hospital,  an  accomplished  practical  alienist  of  great 
experience,  has  undertaken  the  labor  of  ascertaining  precisely  the  exact 
proportion  of  permanent  recoveries  that  have  taken  place  in  the  Hospitals 
for  the  Insane  of  the  United  States,  during  the  latter  half  of  the  present 
century. 

These  results  have  appeared  in  two  papers,  contributed  to  the  January 
number  of  this  Journal,  and  in  less  completed  form,  in  the  >forthampton 
reports.  Dr.  Earle  found  that  of  all  the  recoveries  reported  at  the  Frank- 
ford  Institution  for  the  Insane,  near  Philadelphia,  48.39  per  cent,  remained 
permanently  cured,  while  the  remainder  of  them  had  recurrences  of  their 
disease  once  and  oftener  during  the  course  of  their  lives. 

In  looking  over  this  interesting  subject.  Dr.  Earle  finds  it  recorded 
at  the  Frankford  Asylum  that  five  persons  had  recovered  52  times ;  5  at  the 
Hartfort  Retreat,  54  times ;  10  at  the  Bloomingdale  Asylum,  122  times ;  and 
the  same  number  at  the  Worcester  Hospital  and  Concord  Asylum,  respect- 
ively, 136  and  120  times  in  the  com-se  of  their  lives. 

These  patients  lived  to  quite  an  advanced  age  notwithstanding  their 
affliction,  and  is  quite  an  instructive  showing  in  favor  of  the  skillful,  restorative 
and  conservative  tnethods  (so  far  as  prolonged  vitality  is  concerned)  of  these 
institutions. 

That  a  malady  so  persistent  in  its  tendencies  to  recur,  outside  of  an  hos- 
pital as  to  re-appear  484  times,  in  only  40  different  persons,  can  be   so   often 


Editorial. 


cured  is  an  overwhelming  and  irrefutable  argument  in  favor  of  the  present 
asylum  methods ;  and  shows  that  these  ijtstituticns  are  capable  of  doing 
almost  everything,  except  of  making  over  anew  an  hereditary  neuropathic 
organization  surcharged  with  the  insane  diathesis. 

When  we  consider  the  o^ravity  of  insanity,  and  reflect  that  under 
the  most  rigid  and  merciless  handling  of  the  statistics  of  its  curability  ever 
made  (a  method  to  which  objection  has  been  made  by  high  authority),  it  is 
still  shown  that  about  one-half  of  all  the  persons  who  liave  been  treated  in 
our  hospitals  for  the  insyne.  duriiigthe  last  loity  years,  have  recovered,  a 
large  part  of  them  never  to  relapse,  while  the  recurrent  cases  have  recovered 
again  and  again;  we  have  just  reason  to  be  proud  of  A\hat  the  profession 
of  medicine  has  done  for  the  insane,  notwithstanding  the  sad  tact  daily 
confronts  us  that  many  of  these  unfortunates,  like  the  hopeless  victims  of 
hereditary  cancer  or  phthisis,  because  they  cannot  be  born  aghin.  and  of 
other  and  better  endowed  ancestry,  are  fated  to  ultimate  dt  struction. 
despite  our  best  efforts  to  lescue  them.  When  mediiine  shall  teach 
typhoid  -Siwa  phthisis  not  to  recur  and  tabes  not  to  persist,  or  surgery  shall 
train  cancer,  whin  once  cut  out,  to  never  ccmeback  again,  then,  possibly, 
might  the  profession,  oveilooking  the  utility  of  cur  hospitals  for  the 
insane  in  vast  amelioration  and  mitigation  of  e\ils  which  they  can  not  yet 
wholly  eradicate,  acquiesce  in  and  sustain  assaults  made  on  these  estimable 
institutions  for  the  lack  of  perpetuity  in  all  of  their  rtporttd  recoveries. 
Till  then,  what  cannot  be  cured  must  be  endured. 

Eesults  at  the  Dixmount  Hospital.— Since  the  opening  of  the 
Western  Penn.  Hospital  lor  the  Insane,  at  Dixniount,  in  1856,  three 
thousand,  nine  hundred  and  eleven  patients  have  been  under  treatment,  and 
of  this  number,  one  thousand,  two  hundred  and  eight  have  been  restored, 
or  rather,  more  than  thirty-three  per  cent.  IS'ine  hundred  and  thii1y-eight 
have  been  disch:lrged  in  an  improved  condition,  some  of  whom  recovered 
entirely  in  a  short  time  after  their  discharge ;  added  to  this,  says  Dr.  Beed. 
the  Superintendent,  the  partial  relief  aflbrdcd  to  many  who  were  removed 
before  a  cure  was  established,  the  improved  physical  health  that  leads  to 
recovery,  the  comforts  enjoyed  by  the  inctn-able  who  remain  with  us,  the 
protection  secured  for  them  from  the  annoyances  and  abuse  of  inconsiderate 
people,  and  the  relief  afforded  to  the  patient's  friends  by  the  removal  from 
their  midst  of  an  oft-times  dangerous  and  disturbing  member  of  the 
family  circle,  must  be  considered  in  making  an  estimate  of  what  may  be 
or  has  been  accomplished  by  the  Institution. 

Olr  Exchanges.— It  is  not  possible,  in  a  single  issue  to  reciprocate 
the  many  kind  notices  bestowed  upon  us  by  the  medical  press,  or  to 
point  out  the  special  commendable  feature  of  each  of  our  cotemporaries. 

We  have  already  tacitly  indicated  by  the  copious  extracts,  which  we 
have  made  for  our  pages,  the  high  esteem  in  which  we  hold  some  of  them  : 
we  shall  yet  utilize  others  equally  deserving  for  the  pleasure  and  profit  of 
our  readei-s.  Among  the  former  are  those  well  known  Foreign  journals. 
LeProgres  Medical;  Gazette  des  Hopitaux  ;  Gazette  Ilebdominaire;  Der 
Centralblatt  fuer  Nervenheilkunde,  Psychiatria  und  Gerichtliche  Psycho- 
pathologia;    Allegemeine   Zietschrift   fuer  Psychiatric  und  Gerichtliche 


Editorial. 


Medicine;  K.  K.  Geiselschaft  der  Artz,  and  Revista  Speriraentale  di 
Freniatria  e  di  Medicina  Legale.  We  have  in  a  similar  manner  indicated 
our  appreciation  of  many  of  our  domestic  exchanges.  In  our  April  num- 
ber appeared  a  valuable  abbreviated  contribution  to  cerebral  pathology 
from  the  original  department  of  that  excellent  weekly  journal,  the  "Cin- 
cinnati Lancet  and  Clinic,"  a  journal  which  deserves  hearty  commenda- 
tion for  the  real  appreciation  it  displays,  of  the  due  importance  to  the  gen- 
eral practitioner  of  psychological  and  neurological  medicine.  In  the  same 
category  we  place  the  ISTevv  York  Medical  Record,  the  Philadelphia  Medical 
and  Surgical  Reporter,  the  New  York  Journal,  and  the  American  Practi- 
tioner. The  latter  has  recently  contained  Dr.  Dan'l  H.  Kitchens''  contri- 
butions to  the  practical  study  of  insanity,  and  the  Cincinnati  Medical 
News  likewise  finds  room  for  the  clinical  lectures  of  Dr.  E.  A.  McDonald 
on  the  same  subject.  Both  are  gentlemen  who  are  entitled.to  be  heard,  for 
they  teach  by  authority  of  experience.  The  North  Carolina  Medical 
Journal  gives  its  I'eaders  the  benefit  of  Prof.  Balls'  lectures  on  the 
diagnosis  of  insanity,  and  always  contains,  like  the  preceeding,  much 
matter  of  interest  and  value  upon  neurological  and  general  medical 
subjects. 

Before  us  lies  that  old  and  reliable,  the  American  Journal  of  Insanity, 
whose  venerable  pages  have  contained  and  still  contain,  more  wealth  of 
scientific  truth  on  the  subject  of  clinical  and  forensic  psychiatry,  than 
seems  to  be  known   to  some  of  our  editorial  brethren. 

The  difficulty  in  regard  to  a  notice  of  our  home  exchanges,  consists  in 
the  multiplicity  of  their  individual  merits  and  the  insufficiency  of  space  in 
which  to  note  them. 

If  any  one  of  our  readers  takes  but  one  journal,  we  commend  to  him 
our  list  of  exchanges,  and  advise  him  to  add  at  least  a  half  dozen  more,  for 
in.  this  rapid  age,  no  man's  library  of  periodical  medical  literature  is  com- 
plete with  less.  Aside  from  our  two  home  journals,  the  St.  Louis  Courier 
of  Medicine  and  St.  Louis  Medical  and  Surgical  journal,  which  we  pre- 
sume every  neighborhood  physician  takes,  there  are  the  special  quarterlies 
and  the  journals  that  are  issued  at  the  other  great  medical  centers,  which 
likewise  can  not  well  be  disi^ensed  with. 

The  annals  of  the  Anatomical  and  Surgical  Society,  published  in 
Brooklj  n,  and  the  English  Journal  of  Physiology,  we  class  among  the 
indispensable. 

Before  us  are  the  three  Chicago  medical  journals — a  little  too  near 
St.  Louis  to  shine  with  uneclipsed  brilliancy,  but  nevertheless,  very  bright 
journals,  all  of  them ;  the  Medical  Examiner,  with  Browers'  contributions 
on  psj'chological  subjects;  the  Medical  Gazette,  a  spicy  journal  of  opin- 
ions on  every  subject,  not  so  accurate,  however,  or  well  matured  when  dis- 
cussing asylum  reform  ;  and  the  journal  of  Nervous  and  Mental  Disease, 
whose  pages  display  great  industry  and  ability  on  neurological  subjects, 
in  strange  contract  with  its  impractical  notions  regarding  clinical  psychiatry 
and  the  proper  management  of  the  insane.  There  are  psychological  as 
well  as  neurologicul  truths  which  lie  at  the  bottom  of  the  well  of  clinical 
experience.    Nevertheless,  because  we  do  not  find  psychiatriatic   geme 


388  Editorial. 


wliere  we  might  wish  to  see  them,  constitutes  no  reason  why  we  should 
ili-parage  neurological  Jewels 

The  Medical  News  and  Abstract  is  before  us  in  a  new  and  handsome 
dress,  its  tout  ensemble  much  more  attractive  and  valuable  than  formerly. 
Its  older  and  larger  and  better  companion,  the  American  Journal  of  the 
Medical  Sciences,  still  sustains  its  well  earned  reputation  as  one  of  the 
substantial  and  invaluable  American  medical  quarterlies. 

In  the  Sanitarian  we  have  read  the  "old  doctor's"  story  with  pleasure, 
and  looked  over  its  memi.  Peace  to  the  author  of  the  former  and  health  to 
the  latter.  The  intellectual  menu  of  former  numbers  has  been  more  pala- 
table to  our  mental  taste,  than  the  March  spread  ;  but  bills  of  fare  varj'  in 
the  best  conducted  journals  as  they  do  in  the  best  regulated  families. 

Before  us  lies  also  the  Detroit  Lancet,  with  its  rich  table  of  contents, 
chief  among  them  being  Dr.  Isaac  Ott's  valuable  contribution,  on  the 
decussation  of  the  motor  fibres  in  the  medulla  oblongata,  and  the  Virginia 
Me<lical  Monthly  which  continues  to  sustain  its  established  reputation  as  a 
fir<r  class  medical  periodical. 

The  Toledo  Medical  and  Surgical  Journal,  the  Indiana  Medical  and 
Surgical  Reporter,  the  Medical  Annals  of  Albany,  New  York ;  the  Louisville 
Medical  Herald,  the  Louisville  Medical  News,  the  Country  Practitioner  and 
the  Kansas  Medical  Index  come  also  to  our  sanctum,  though  some  of  them 
not  so  often  as  we  would  like  to  see  them.  The  five  latter  are  young 
medicos  and  will  f-ill  into  more  regular  habits,  doubtless,  as  they  grow 
older.  These  are  all  journals  of  ftiir  promise  and  we  wish  them  hearty 
success. 

The  Obstetric  Gazette,  it  gives  us  pleasure  to  note,  gives  due  promin- 
ence to  the  meritorious  discus^^ions  of  our  own  obstetrical  society,  and  we 
spvially  commend  it  to  our  medical  home  circle  on  that  account.  It 
CO  lid  not  select  good  material  for  its  pages  from  a  better  source. 

On  our  table  still  lie  the  three  excellent  Canadian  Journals,  the  Medi- 
cal and  Surgical,  the  Journal  of  Medical  Science,  and  the  Lancet;  the 
fornipr.  with  an  unaccredited  extract  from  Dr.  Beard's  article  on  the 
".Sequences  of  Neurasthenia,"  which  appeared  in  our  January  number : 
the  latter  with  an  excellent  editorial  on  "Cerebral  Syphilis;"  and  the 
second  named  containing  a  good  two-page  selection  fron  the  St.  Louis 
Courier,  by  Dr.  Willis  P.  King,  of  Sedalia,  Mo. 

The  Youngstown,  Ohio.  "  Pran.sactions"  presents  a  good  appearance, 
and  the  .Maryland  Mi-dical  Journal  likewise. 

One  of  the  numbers  of  the  Journal  of  Inebriety,  b?fore  us,  contains 
practical  illustrations  of  Cerebral  Trance  by  Dr.  Crothers,  and  an  abstract 
ot  an  excellent  paper  on  the  Medico-legal  Relations  of  Insane  Drunkards, 
by  Dr.  T.  W.  Fisher,  of  Boston.  We  wish  the  journal  long  life  and  pros- 
perity, and  should  be  pleased  to  see  in  its  pages  more  illustrations  of  the 
clinical  and  definite  pathological  features  of  inebriety. 

Here  we  close,  and  doubtless  you  wish  we  had  concluded  sooner.  On 
our  table  still  lie  the  Quarterly  Epitome  of  Braithwaite's  Retrospect,  and 
Ralph  Walshe's  Retrospect,  the  Archives  of  Dermotology,  Chronica 
Medico  Quirurgica  de  la  Habana,  El  Medico  y  Cirujano  Centro-Ameri- 
cano,  and  Scientific  American,  and  many  others,  to  note  which,  would  too 


Editorial. 


greatly  lengthen  this  already  too  lengthy  notice.    In  another  number 
we  shall  continue  the  subject. 

The  American  Medical  Association. — The  Thirty-First  Annual 
Meeting  of  this  representative  medical  body  in  New  York,  on  the  first, 
second,  third  and  fourth  days  of  June,  was  the  largest,  as  well  as  one  of 
the  most  interesting  in  the  histoiy  of  its  existence.  The  New  York  Med- 
ical Record,  \\  ith  characteristic  enterprise,  issued  a  daily  record  of  the 
work  of  the  Association,  and  in  its  issue  of  the  fifth  instant,  contains  a 
complete  summary  of  the  work  of  the  whole  session,  filling  the  whole 
issue  of  that  date  ;  and  since  the  medical  man  of  one  journal  like  the  man 
of  but  one  book  has  disappeared,  we  therefore  make  but  brief  mention  of 
this  meeting. 

The  neurological  contributions  were  quite  numerous  and  indicative  of 
the  present  tendency  of  medical  thought.  They  tend  to  show  how  largely 
practical  medicine  is  made  up  of  clinical  neurology. 

Dr.  A.  D.  Rockwell,  of  New  York,  read  a  paper  on  the  "Electrical 
Treatment  of  Exopthalmic  Goitre ;"  Dr.  V.  P.  Gibney,  one  on  the  "Treat- 
ment of  Sciatica  by  the  same  agent;"  Dr.  J.  J.  Caldwell,  of  Baltimore,  one 
on  the  "Study  of  Special  Nerve  Centers ;"  Dr.  Richard  C.  Brandeis,  of 
New  York,  one  on  the  "Probable  Cause  of  Some  Forms  of  Globus  11}  s- 
terius;"  Dr.  David  Hunt,  of  Boston,  one  on  the  "Variability  of  the  Hum.iu 
Eye;"  Dr.  Turnbull,  of  Philadelphia,  one  on  "Hydrobromic  Ether;"  Dr. 
Sequin  on  the  "Training  of  an  Idiotic  Eye ;"  Dr.  M.  A.  Fallen,  of  New 
York,  read  a  paper  on  the  "True  Import  of  Oophorectomy,  or  spaying 
for  reflex  disease,  more  particularly  in  epilepsy,  hystero-epilepsy.  or  cate- 
lepsy;"  Dr.  Geo.  M.  Beard,  of  New  York,  read  a  paper  or,  "Phiraopis 
as  a  Cause  of  Nervous  Symptoms,  and  gave  the  results  of  operative  tr<  at- 
ment  in  several  of  his  cases,"  and  Dr.  S.  D.  Risley,  of  Philadelphia,  detaileil 
two  eases  of  "Inspissated  Cerumen,"  one  of  which  gave  symptoms  of  men- 
ingeal compression,  the  other,  symptoms  of  locomotor  ataxy. 

Dr.  John  T.  Hodgen,  of  St.  Louis,  read  a  paper  on  "  Section  of  the 
Infra-Orbital  and  Inferior  Dental  Nerve,"  for  neuralgia. 

The  address  of  Dr.  W.  T.  Briggs,  of  Nashville,  president  of  the  surgical 
section,  was  on  "Preventive  Trephining." 

The  section  on  medical  jurisprudence,  psychology.  State  medicine 
and  public  hygiene  was  mainly  occupied  with  the  discussion  of  subjects 
presented  by  the  State  Medical  Boards. 

An  abstract  of  a  paper  on  Microscopical  Sections  from  Cases  of  Disease 
of  the  Brain  and  Spinal  Cord."  was  read  by  Drs.  Chas.  R.  Mills  and  Carl 
Seller,  of  Philadelphia;  and  Dr.  Chas.  W".  Pasre.  of  Hartford,  Conn.,  read  a 
paper  on  the  "Moral  Treatment  of  the  insane;"  Dr.  J.  V.  Quinby,  of 
Jersey  City,  read  a  paper  on  the  "Criminal  Use  of  Chloroform ; "  Dr.  J.  H. 
Lathrop,  "Some  Thoughts  Regarding  Almshouses;"  Dr.  AntiseU,  o^" 
Washington,  on  "Suspicions  of  Poisining;  "  and  Dr.  W.  F.  Thony,  of  New 
York,  on  "Humane  Societies,"  when,  at  the  close  of  the  session.  Dr.  A.  N. 
Bell  proposed  that  the  State  medicine  men  capture  the  section,  which  seem 
to  have  been  acquiesced  in  by  the  few  remaining  at  the  close,  as  an  aflSrm- 
ative  report  was  transmitted  to  the  general  session,  and,  heretofore,  the 
section  is  to  be  known  by  the  name  of  State  Medicine. 


Editorial. 


Look  Affer  the'  ALMskcKJSE  I jfskNE.— We  should  come  sliort  of  our 
duty,  says  Pliny  Earle,  if.  on  the  present  occasion,  we  should  fail  to  call 
atttention  to  an  apparently  gross  inconsistency  in  tlie  prevailing  method 
of  conducting  the  enterprise  of  benevolent  oversight  of  the  insane.  In 
some  of  the  States  where  the  government  of  the  commonwealth  assumes 
a  superNisory  authoritj'  over  all  the  institutions  specially  devoted  to  the 
insane,  whether  those  institutions  be  coi-porate,  private,  or  the  propertj' 
of  the  State,  there  is  an  utter  failure  even  to  recognize  county,  city  and 
township  almshouses,  in  which  large  numbers  of  the  insane  are  sup- 
ported. The  Argus-eyed  watchfulness  over  the  hospitals  is  offset  by  a 
mole-eyed  disregard  of  a  class  of  establishments  which,  to  .say  the  least, 
have  not  heretofore  proved  themselves  especially  worthy  of  contidence. 
The  apparently  exalted  sympathy  of  the  people,  which  surrounds  the 
lunatic  as  with  a  protective  atmosphere  so  long  as  he  is  in  an  institution 
fortified  with  safeguards  against  evil  practices,  deserts  him  the  moment 
he  enters  the  almshouse,  in  which  those  safesTuards  are  comparatively 
few.  As  before  intimated,  the  tiict  betrays  a  most  niarv'ellous  incon- 
sistency, and  would  seem  to  throw  a  seiious  shadow  of  doubt  upon 
the  sincerity  of  that  sympathy  w'hich,  in  various  ways,  blazons  itself 
before  the  people  whenever  the  public  hospiUils  are  in  question.    , 

Ax  Official  Residence  in  a  State  Lunatic  Asylum  for  the  Insane, 
would  materially  improve  the  judgment  of  some  of  our  cotemporaries— 
the  Journal  of  Mental  and  INTervous  Diseases,  for  instance — to  such  an 
extent,  at  least,  tbat  the  latter  journal  would  not  expect  to  tind  the  Supei- 
intendent's  reports  mirrors  of  the  medical  views  or  scientitic  work  of  the 
medical  staffs. 

Such  a  residence  w'ould  soon  reveal  the  obstacles  in  the  way  of  getting 
professional  matters  before  the  public,  because  of  the  frequent  opposition 
of  Boards  of  Management  and  Legislatures  to  incurring  the  expense  ot 
publication  and  the  opposition  of  friends  of  patients. 

With  some  Supeiintendents,  too,  who  are  not  opposed,  it  is  a  question 
of  piopriety  as  to  whether  asjdum  reports  to  the  legislature  are  the  proper 
media  for  clinical,  therapeutic  and  post-mortem  details. 

The  ditiiculty.  in  so  many  instances,  of  securing  consent  of  friends  also 
to />08^-moriems  in  State  Asylums — their  inmates  being  generally  of  the 
middle  class,  and  not  friendless  paupers— would  be  apparent  to  these 
gentlemen,  had  they  looked  at  the  matter  from  the  inside  instead  of  the 
outside  of  a  hospital  for  the  insane.  State  Asylums  for  the  Insane  are 
different  in  this  respect  from  metropolitan  general  hospitals.  Tbey  are 
much  more  closely  watclied.  Go  in  and  look  out,  gentlemen,  and  you 
will  change  your  editorial  tone  towards  these  institutions. 

Dr.  Pliny  Earle,  the  eminent  New  England  Alienist,  paid  us  a  brief 
visit  last  May.  We  are  pleased  to  see  that  he  bears  the  weight  of  years 
•well,  and  hope  he  may  long  contituie  to  serve  the  people  of  the  Bay  State 
in  his  present  sphere  of  labor  at  Northampton. 

We  also  acknowledge  a  more  recent  visit  from  Dr.  J.  S.  Jewell,  one  of 
the  accomplislied  editors  of  the  Chicago  Journal  of  Nervous  and  Mental 
Diseases,  and  regret  that  we  were  not  at  home  to  receive  him. 


Editorial.  391 


The  Care  of  the  Insane  and  Their  Legal  Control — Bj^  John 
Charles  Bucknill,  F.  R.  S.,  London — will  receive  the  notice  that  such  a 
work  and  such  an  author  deserve,  in  our  next  issue.  The  book  is  a  plea 
and  demand  for  larger  liberty  for  the  insane.  The  author  insists  that  "  in 
the  development  of  a  system  of  domestic  treatment  lies  the  greater 
promise  of  the  largest  possible  amelioration  of  tlie  unhappy  lot  of  those 
afflicted  with  mental  diseases." 

Dr.  H.  H.  Kane's  new  book  on  "Morphia  Hypodermically "  was 
handed  over  to  another  party  for  review,  and  the  reviewer  of  the  book  has 
not  been  heard  from.  A  cursory  examination  of  tlie  volume  has  given 
a  favorable  impression  of  it.  The  author  has  collected  a  vast  fund  of 
information  on  this  subject  that  cannot  be  found  elsewhere. 

Dr.  Chas.  T.  Eeber's  interesting  little  book  on  'Taresis  of  the  Sym- 
pathetic Centres,"  or  the  so-called  Malaria,  etc.,  will  set  the  reader  to  think- 
ing. It  has  come  to  hand  too  late  for  review  in  this  number ;  but  the  hun- 
dred pages  before  us  contain  five  hundred  pages  of  thought. 

Those  w^ho  live  in  malarious  districts  and  are  subject  to  "chills"  should 
get  it  and  read  it.  It  will  serve  to  warm  their  ideational  centers  into 
increased  activity.    Geo.  S.  Rumbold  &Co.,  publishers,  St.  Louis. 

Two  Homes  for  thk.  Nervous  and  Ins ine.- -There  are  seasons 
and  circumstances  fjimiliar  to  all  practical  alienists,  when  the  judicious 
management  of  the  insane  requires  their  removal,  not  only  from  home, 
but  from  the  vicinity  of  home.  At  this  hot  season,  especially,  many 
cases  may  be  profited  by  being  sent  to  a  cooler  latitude.  On  our 
advertising  pages  may  be  found  the  names,  localities  and  special 
features  of  two  reputable  institutions,  for  the  treatment  of  a  limited 
number  of  the  insane  of  the  private  class.  They  are  both  in  good  hands. 
We  most  cheerfully  commend  them. 

How  They  Appear  Abroad. — A  British  correspondent  says:  — 

"I  receive  scores  of  pamphlets  from  Ameilcan  physicians  on  special 
subjects,  which  1  am  almost  ashamed  to  see  on  my  table— so  grossly  ofteusive 
to  respectable  scholars  are  they.  I  imagine  this  pamphleteering  system  is 
but  an  advertising  dodge.  I  think  it  ought  to  be  snufled  out.  I  am 
always  pleased  to  meet  with  a  brochure  containing  something  new  and 
instructive,  but  I  detest  all  strutting  in  stolen  clothes." 

This  is  blunt,  but  incisive.  Just  like  Johnny  Bull,  but  we  can  assure 
the  mouographists  that  it  comes  from  a  big-hearted  and  most  kindly 
disposed  Englishman. 

What  a  Large  Number  of  Lunatics  there  must  be  in  Chicago  and 
New  York  ! 

Hear  the  Chicago  Medical  Gazette  : 

'■''There  are  physicia?is  in  this  city  and  in  New  Fork  who  see  every  year 
more  fresh  cases  of  insanity  than  are  seen  by  the  average  asylum  Superinte^id- 
ent  in  the  same  period.,  whose  knowledge  of  the  pathology  of  insanity — which 
is  not  largely  contributed   to   from    our   asylums — is  incomparably   superior. 

We  were  under  the  impression  that  the  majority  of  all  cases  of  insanity, 
-as  they  are  found  in  those  cities  and  the  States  in  which  they  are  located, 
generally  found  their  way  quite  speedily  into  the  State  Asylums,  and  soon 
fell  under  the  eye  of  the  Medical  Superintendents. 


392  Editorial. 


It  may  do  in  politics  to  try  to  convince  llie  people  that  the  "outs" 
know  more  than  the  '"ins,"  but  in  regard  to  clinical  hospital  matters,  such 
opinions  are  not  liJvcly  to  prove  convincing  to  the  medical  mind  of  average 
logical  discernment.  The  chiefs  of  our  hospitals  for  the  insane  aie  at 
present  in  the  best  position  to  observe  and  know  more  of  the  insane,  in 
all  stages  of  their  malady,  tlian  tliose  outside;  and  we  believe,  as  a  rule, 
that  they   do — symptomatology,  treatuK  nt  and  pathology  included. 

The  Gazette's  opinions  are  not  so  sound,  though  equally  as  pronounced 
on  psychical,  as  on  other  subjects. 

This  may  be  due  to  the  fact,  that  when  the  editorial  stall"  approaches 
tlie  unfamiliar  matters  in  practical  psychiatiy,  alter  wrestling  with  other 
subjects  it  handles  better,  it  beconus  scmewl  at  certbnisthenic  or  neu- 
r.-vstlienic  as  it  were,  or  possibly  to  its  close  proxiniitj%  to  another  cotem- 
porary  of  much  sounder  notions  in  neurology  than  in  psychiatry. 

We  think  there  is  loomfor  'nform  in  psycl.ialry'*  upon  the  lake 
shore,  and  we  hope  the  hot  wf  atl  er  m:iy  ij<  t  ."-o  depress  tl  eir  nerve-tcne 
as  to  prevent  it.    Again,  ibidem: — 

'■Indeed,  if  it  were  desired  to  learn  about  the  cases  and  the  treatment 
in  many  asylums,  our  own  past  experience  would  lead  us  to  apply  to  the 
assistant  physician  rather  than  to  the  official  head  of  the  institution.'' 

Do  not  the  assistants  generally  become,  in  time,  superintendents? 
Please  search  the  records,  and  give  us  another  opinion. 

Cataphasia — Dr.  Tienzi,  of  Genoa,  applies  this  term  to  an  aflection  of 
speech  characterized  l)y  frequent,  successive  and  unavoidable  repetitions 
of  the  same  words  or  phrases,  either  spontaneously  uttered  or  in  response 
to  a  question,  as,  for  instance,  fourteen  yea7-s.fouTteen  yea7-s,  fourteen  years. 
continuing  to  repeat  five  or  six  times  when  asked  how  long  he  has  been 
ill.  or  he  may  answer  appropriately  and  correctly,  but  repeat  in  the  same 
manner.  In  these  cases  the  neuropatliic  diathesis  was  usually  found  to 
exist  either  through  hereditarj-  descent  from  nerve  degenerate  or  inebriate 
ancestry  or  acquired  nerA^ous  asthenia. 

This  is  not  entirelj^  a  new  phenomenon.  We  know  a  patient  who,  in 
answer  to  almost  any  question,  when  in  certain  states  of  mental  abstraction, 
would  answer.  -'Fes,  I  love  God:  Fes.  Hove  OodJ  Fes,  I  love  G'dT  She 
was  not  generally  regarded  as  insane,  but  we  should  now  so  consider  her. 
Cataphasia  is  not  singular  among  the  insane. 

The  Colored  Ixsaxe  Asylum,  of  Xorth  Carolina,  is  located  two  miles 
West  ofGoldsboro.  Dr.  W,  H  Moore,  of  Goldsl)oro,  has  been  electeil 
as  Superintendent.  This  is  the  third  institution  of  the  kind  in  the  United 
States. 

.Maxv  ok  ouk  Sci$s.:-i{iukk.s  being  at  the  head  of  hospitals,  having  need 
of  Chapel  and  Anuisemeut-IIall  decorations,  we  take  pleasure  in  referring 
them  to  Messrs.  Xoxon  &  Toomey,  Scenic  Artists,  of  tliis  city,  who  go  out 
of  the  city  in  sunnncr  to  do  decoration  work. 


REVIEW  DEPARTMENT. 


Man's  Moral  Nature.*— This  book  comes  from  the  north  side  of  the 
Great  Lakes,  but  it  is  from  the  pen  of  a  man  who  must  have  been  born  and 
raised  on  our  side,  or  who,  at  least,  has  spent  some  portion  of  his  life  on  a 
soil  more  congenial  to  the  evolution  and  prosperous  growth  of  adventur- 
ous thought  and  free  speculation,  than  we  have  been  accustomed  to  regard 
that  "-quelques  arpents  des  neiges,"'   which  our  forefathers  were  wont  to 
speak  of  as  the  ne  plus  ultra  ot  possible  civilization.     Dr.  Bucke  is  assur- 
edly a  big-hearted  anl    bold-headed  fellow,   who,  like  Mark   Antony, 
'•speaks  riglit  on."  telling  us,  if  not  "that  wliich  we  ourselves  do  know,"' 
certainly  chat  which  he  himself  doth  feel.    He  is,  too,  one  of  the  most 
sympathetic  of  rational  bipeds, — a  child  of  that  lovelj^   family  from  among 
whom  Sterne  drew  forth  his  Eugeiiius,  who  drew  aside  the  curtain  of 
"Yoric'v  a:id  my  unole  Toby,"  who,  in  a  dismal  rainy  night,  despite  his 
chronic  wound  in  the  groin,  made  his  way  to  the  side  of  the  death-bed  of 
the  Le  Fevre.     NVe  really  love,  not  only  Dr.  Bucke,   but  all  buckish  men, 
especially  when  they  bear  their  antlers  nobly  up,  and  beckon  to  their  timid 
followers    not    to    f;xlter    where    they    lead     the     way.      We    can    not 
for  the    life    of  us,    (though    for    the     mere    sport    of    the    thing    we 
might.)  cull  out  of  Dr.   Bucke's  remarkable  book,  a  few,  perhaps  a  dozen 
or  so,  passages,  which,  to  a  more  cynical  pen  than    ours,  might  offer 
tempting  target  circles  for  bulls-eye  rifle  practice.    But  this   would  be 
cruel  sport,  and  we  abhor  all  su;h,  more  especially  as  a  now-and-again 
sober  retrospection  of  our  own  scriptorial  inadvertencies  whispers  in  our 
ear,  to  be  lenient  in  our  criticism  of  the  effusions  of  our  fellow  adventures . 
If,  however,  we  could  but  attain  to  that  wise  discrimination  which  Dr. 
Bucke  has  so  adventurously  established  between  the  domain  of  the    intel- 
lectual and  the  moral  faculties  of  man  (but  especially  of  the  man  and  the 
woman),  we  might  more  justly  appreciate  his  theory.      Di-.  B.  regards  the 
moral  constitution  of  woman,  as  necessarily  superior  to  that  of  the  coarser 
sex,  because  of  the  ample  extension  in  her  of  the  domain   of  the   great 
sympathetic,  and  he,  as  in  duty  bound,  assigns  to  the  uterine  and  mammary 
regions,  the  honors  of  the  local  habitation  ot  her  virtuous  supremacy.   This 
we  must  confess,  puzzles  us,  almost  painfully,  for  what  are  we  to  conclude 
as  to  the  moral  nature  of  feminine  rats,  cats,  dogs  and  swine,  whose   pro- 
creative  and  lactative  apparatus,  so  far  surpass  in  extent  that  of  woman. 
If  woman's  moral  nature  is  superior  to  that  of  man,  because  her  organiza- 
tion affords  to  moral  excellency  a  wider  and  richer  field  for    its  develop- 
ment and  culture,  then  must  there  be  latent  in  her  quadrupedal  cousins  a 
vast  amount  of  uucredited  amiability.    Woman,  Dr.  Bucke  assures  us,  is 
no  match  for  mm  in  hating  \  this  is  a  new  article  in  the  logic  of  f;icts, 

*  Richard  Maurice  Bucke,  Medical  Superiutendent  of  the  Asylum  for  the  Insane, 
London,  Ontario,  Canada.  Published  by  Putnam  &  Sons,  New  York.  Willing  & 
Williamson,  Toronto. 


394  Review, 


which  we  should  be  pleased  to  see  illustrated  ])y  either  living  or  dead 
specimens;  for  if  it  be  true,  historians,  dramatists,  and  writers  (even 
female)  of  fiction,  have  hugely  misunderstood  and  monstrously  misrepre- 
sented her.  One  of  them  having  even  said  that  '•ilell  iiatli  no  tiend  like 
woman  (scorned).'" 

If,  however.  Dr.  Bucke  fail  to  come  to  the  rescue,  and  elevate  the 
moral  nature  of  our  mothers,  sisters  and  lovely  cousins,  from  their  appar- 
ent moral  inferiority,  to  other  competitors  in  the  sympathetic  nerve  king- 
dom, and  shall  thus  leave  us  the  conclusion  that  the  paternity  of  his 
thought  is  to  be  assigned  to  his  chivalrous  wish,  let  no  one  say  that  we 
therefore  undervalue  the  merits  of  his  book.  We  have  ourselves  read  it 
with  nuich  gratification,  and.  we  trust,  not  without  profit ;  for  notwith- 
standing a  few  straggling  indiscretions  of  heterodox  deviation  from  cur- 
rent theology,  it  presents  to  the  intelligent  and  unbigoted  reader,  much 
that  is  both  interesting  and  instructive ;  and  we  earnestly  hope,  that  at 
some  future  day,  when  a  few  half  score  years  have  given  time  to  the  author 
to  ruminate,  revise,  amplify,  or,  ifso  it  may  appear  judicious  to  his  matured 
wisdom,  to  curtail  the  contents,  he  will  favora  more  intelligent  and  appre- 
ciative generation  with  a  second  edition,  ileantime,  we  unhesitatingly 
say,  that  any  one  who  can  read  his  book,  and  fail  to  find  in  it  abundant 
indications  of  both  original  and  scrutinous  thinking,  must  either  have  in 
his  mora i  ^milMre  little  of -'the  milk  of  human  kindness,"  or  little  of  the 
tenderness  of  generous  criticism. 

'•Xeuvous  Exhaustion — Neurasthenia."* — This  book,  the  author 
states,  is  '-the  result  of  the  experience  of  his  entire  professional  life."  on  the 
subject.  The  English  speaking  portion  of  the  medical  profession  have 
been  made  quite  familiar  Avith  the  most  of  the  book's  contents,  through 
the  medium  of  the  leading  periodicals  of  this  countiy  and  England ; 
a  part  of  one  of  the  best  chapters,  namely :  "  The  Sequences  of 
Neurasthenia,"  having  been  printed  in  our  Januaiy  number.  The  book  is 
probably  the  forerunner  of  many  other  treatise  ~  on  this  subject,  from  the 
same  and  other  sources. 

In  fact,  the  author  himself  announces  his  intention  to  continue  the 
subject,  promising  a  book  on  "American  Nervousness." 

Neurasthenia  has  occupied  medical  minds  more,  we  think,  than 
might  be  infeired  from  the  reading  of  the  book  before  us,  and  is  evidently 
destined  to  receive,  as  it  yet  undoubtedly  demands,  much  more  of  profes- 
ional  thought.  Besides  the  German  writeis,  Dr.  Dowse,  on  the  othei- 
si<le  of  the  oc^ean,  has  begun  to  speak  for  Great  Britain,  and  Drs.  Jewell, 
Mitchell  and  others  have  spoken  on  this  side;  but  a  Scorch  physician 
wrote  quite  intelligibly  on  this  subject  more  than  a  century  ago.  while  one 
American  physician  has  preceded  Dr.  Beard ;  nevertheless,  no  one  here- 
tofore has  made  so  much  of  the  subject  as  the  present  author.  To  him 
is  due  the  credit,  by  the  pertinacity  and  i^ersistency  with  which  he  lias 
clung  to  his  subject,  of  re-awakening  medical  thought  upon  a  disease  of 
more  significance  than  has  been  attributed  to  it. 

•Apractiral  treatise,  by  Geo.  M.  Beard,  A.M.  M.B..  Fellow  of  the  New  York 
Academy  of  Science,  Vice-President  of  tlie  American  Academy  of  Medicine,  etc. 
\Vm.  Wood  &  Comijany,  New  York,  rublisliers. 


Reviews.  395 


Till-  Chapter  on  "Morbid  Fears,"  is  eitlier  too  specific  with  a  multipli- 
cation of  terms,  or  too  meagre;  for  to  specify  the  numberless  fears  which 
beset  the  nerve  exhausted— if  an  attempt  were  made  to  enumerate  them 
all — would  till  a  moderate  sized  volume. 

There  are  the  monopliobics.  the  deutophobies.  and  so  on,  to  the  poly- 
phobic,  Avlio  have  all  conceivable  fears. 

The  author  is  demonstrably  in  error  in  asserting  that  the  morbitl  fears 
of  the  insane  ai'e  never  recognized  as  such  by  the  latter,  though  such 
recognition  is  exceptional.  The  insane  not  only  have  delusions  of  dread, 
but  they  sometimes  also  have  morbid  fears,  in  which  they  do  not  constantly 
believe,  and  out  of  which,  for  a  time  at  least,  they  may  be  reasoned  just  as 
neurasthenics  can  be. 

The  subject  of  morbid  fears,  as  one  of  the  psychical  evidences  of 
physical  disease  is  an  interesting  one,  and  the  exact  differentiation  of  the 
pathological  from  the  physiological  is  not  always  easy,  the  true  criteron 
being  (and  this  Dr.  Beard  does  not  mention),  as  in  determining  the 
existence,  or  non-existence  of  a  more  pronounced  mental  aberration,  the 
comparison  of  the  individual,  with  his  former  and  natural  self,  sinc-e 
healthy  men,  and  animals  too.  often  have  many  of  the  fears  described  by 
Dr.  Beard  as  morbid— tlie  fear  of  lightning  and  of  storms  for  example. 

These  and  the  other  fears  described  by  Dr.  Beard,  however,  when 
found  in  persons  unaccustomed  to  them,  are  certainly  of  significance 
They  may  indicate  only  cerebrasthenia,  as  Dr.  Beard  says,  or  they  may 
accompany  simple  cerebral  hyperaemia,  or  foreshadow  or  accompany, 
insanity  or  organic  brain  disease.  Some  of  the  insane  do,  at  times, 
discredit  tlieir  illusions,  hallucinations,  and  sometimes  even  their  delusions, 
especially  in  the  beginning  of  their  insanity,  and  as  they  approach  convales- 
cence. 

The  purport  of  Dr.  Beard's  views  on  this  subject  seems  to  be  as 
follows : 

Fear  is  normal,  physiological.  The  difference  between  fear  in  health 
and  fear  in  disease  is  oi  degree  rather  than  of.  kind:,  but  healthy  fears  pass 
mto  morbid  fears  by  insensible  gradations. 

Dr.  Beard  admits  that  the  insane  have  many  morbid  fears,  but  he 
would  associate  theirs  always  with  delusio7is  and  hallucinations. 

The  morbid  fears.  Dr.  Beard  discusses,  are  not  accompanied  by 
delusions  or  hallucinations.  The  subjects  of  these  morbid  fears  know 
that  their  fears  are  absurd  and  groundless,  but  they  cannot  control  them. 
The  classification  of  morbid  fears,  which  Dr.  Beard  proposes,  is  as  follows : 

First.  Autrophobia — fear  of  lightning.  This  was  first  described 
by  him,  though  long  known  to  exist  a  number  of  years  ago  ;  among  the 
accompanying  symptoms,  ascribed  by  Dr.  Beard,  are :  headache,  numb- 
ness, pain  in  the  back  of  the  head,  nausea,  vomiting,  diarrhoea,  and,  in 
some  cases,  convulsions. 

Second.  Topophobia— a  generic  term,  proposed  by  Dr.  Beard,  for 
fear  of  places.  Under  this  general  term  come  two  special  forms  of  fear  of 
places. 

Agoraphobia— fear  of  open  places  on  squares,  described  by  Westphal ; 
by  Rosenthal,  as  Platzangst,  and  by  Benedict,  Platzschwindle. 


396  Reviews 


Claustrophobia— fear  of  close,  narrow  places,  described  by  Prof.  Ball 
of  Paris. 

There  are  many  very  interestino^  cases  of  morbid  fear  that  cannot  come 
under  either  fear  of  open  places  or  fear  of  close  places  ;  but  properly  come 
under  the  generic  term,  topopiiobia,  fear  of  places. 

Dr.  Beard  describes  two  remarkable  cases,  illustrative  of  this. 
Third.     Antropophobia— fear    of  society;    this    phase  also  has    its 
opposite, — Monophobia — fear  of  being  alone. 

Fourth.  Pantophobia — fear  ot  everything;  any  responsibilities  or 
changes. 

Fifth.  Pathophobia — fear  of  disease  or  hypochondriasis,  conunonly 
called. 

Sixth.     Mysopliobia — fear   of   contamination  or  detilement. 
The  priority  of  designation  of  this  form  of  fear  he  ascribes  to  Dr. 
Hammond. 

This,  too,  is  a  form  of  fear  not  rare  among  the  insane,  and  quite 
common  among  healthy  persons.  It  is  alsj  undoubtedly  present  in 
morbid  mental  states,  short  of  pronounced  insanity.  We  have  seen 
illustrations  of  all  of  these  forms  among  the  insane. 

The  general  conclusions  in  regard  to  these  varieties  of  morbid  fear  are : 
1st.    That  they  indicate  functional,  rarely  organic  disease. 
2d.    That  they  rarely  exist  alone,  but  in  connections  with  other  neu- 
rasthenic symptoms,  as  vertigo,  oxaluria,  or  insomnia  and  al)normal  per- 
spiration. 

3d.    Morbid  fears  may  come  on  suddenly,  almost  instantaneously. 
4th.    They  are  fre(iueutly,  though  not  necessarily,  associated  with 
disorders  of  the  reproductive  system  in  both  sexes. 

'Ah.  These  fears  are  very  apt  to  take  an  opposite  phase,  as  is  shown 
in  the  above  analysis. 

6th.  The  treatment  is  the  treatment  of  neurasthenia  in  general. 
As  we  have  already  intimated,  it  would  be  an  almost  endless  task  to 
specify  all  the  morbid  fears  of  the  neurasthenic,  and  we  think  Dr.  Beard  is 
too  specific.  Their  name  is  legion,  from  the  fear  of  one's  own  voir;e  or 
certain  sounds,  or  the  screech  of  a  locomotive  whistle,  to  that  of  a  clap 
of  thunder,  of  being  poisoned,  or  of  traveling  in  certain  vehicles.  Timidity 
not  natural  to  the  individual.,  is  the  most  characteristic  sign  of  neurasthenia 
the  number  of  fears  and  sensations  which  one  encounters  in  the  victims 
of  neurasthenia,  are  its  morbid  accompaniments  and  sequences,  and  to 
this  is  ultimately  added  groundless  suspicions,  where  insanity  is  not  far  oft". 
The  difterential  diagnosis  of  morbid  from  physiological  fears  is  not 
sufficiently  dwelt  upon  by  the  author.  The  antecedent  history  should  be 
inqiured  into,  in  these  cases.  Superstitious  temperaments  and  early 
education  ought  also  to  be  considered.  Former  experience  likewise .  For 
instance,  if  one  had  ever  narrowly  escaped  or  experienced  a  strgke  of 
lightning,  a  railroad  accident  or  a  shipwreck.  I  have  known  a  hale  old 
man,  who  could  never  be  induced  to  board  a  railroad  train  ;  who  never  had  a 
sleepless  night.and  who  never  missed  a  meal  in  sixty  years,  afraid  to  travel  by 
rail ;  while  a  cerebrasthenic  and  neurasthenic  lawyer  visits  me  from  a  neigh- 
boring state,  who  never  dares  to  come  unaccompanied  by  his  wife  or  son. 


Reviews. 


This  patient  has  cocaydynia  along  with  other  marked  symptoms,  and 
illustrates  and  confirms  one  of  Dr.  Beard's  rather  remarkable  but  true  state- 
ments, namely:  that  many  of  these  patients  can  work  all  day  with  muscle  and 
brain,  but  in  the  presence  of  their  special  fears  they  are  a?  infimts.  (p.  40.) 

We  never  saw  one  of  these  patients  who  felt  it  to  be  ''an  infliction  to 
see  a  physician"  as  Dr.  B.  asserts,  p.  36,  though  we  hav(?  seen  them  life- 
bm'dened,  disappointed  and  weary  of  life,  because  of  the  little  satisfaction 
they  had  received  from  treatment,  have  gone  from  physician  to  phj'sician, 
and  been  told  by  one  of  them  that  only  their  imagination  was  at  fault. 

The  causes  of  neurasthenia,  the  author  states, '-receive  no  considera- 
tion"' for  the  reason  "that  the  work  is  designed  to  be  exclusively  practi- 
cal."' This  «e  can  not  regard  as  a  good  reason  for  excluding  causes,  since 
their  correct  ascertainment  is  so  essential  to  the  prescribing  of  a  proper 
course  of  treatment. 

The  author  regards  neurasthenia  as  an  American  disease,  and  speaks 
of  it  as  having  been  first  made  of  special  consequence  in  this  country,  but 
he  nowhere  alludes  to  a  very  valuable  and  quite  exhaustive  contribution 
to  the  subject — one  of  the  pioneer  contributions,  in  fact — by  that  accom- 
plished physician.  Dr.  E.  H.  Van  Deusen,  whose  paper  may  be  found  in 
the  American  Journal  of  Insanity,  for  April,  1869,  having  previously 
appeared  in  the  form  of  a  supplement  to  the  annual  report  of  the  Mich- 
Asylum  for  the  Insane  forli>67-GS.  Dr.  Van  Deusen  introduces  his  article 
by  saying :  ••Observations  have  led  us  to  think  that  there  is  a  disorder  of 
the  nervous  system,  the  essential  character  of  which  is  well  expressed  by 
the  terms  given  above— (Nervous  Prostration — Neurasthenia)— and  so 
uniform  in  development  and  progress,  that  it  may,  with  propriety,  be 
regarded  as  a  distinct  disease. 

The  authors  idea  of  the  extent  of  neurasthenia  may  be  gleaned  from 
the  following:  '"When  neurasthenia  lays  its  hands  on  a  man.  it  is  liable  to 
leave  its  impress  on  every  organ  and  function  of  the  body,  from  the  crown 
to  the  toe;  there  is  no  fibre  that  is  safe  from  the  attack." 

This  is  most  true.  The  neurasthenic,  before  his  malady  is  done,  is 
liable  to  be  ''sick  all  over." 

He  distinguishes  it  from  organic  or  structural  nervous  disease,  by  the 
usually  fixed  and  stable  character  of  the  symi^toms  of  the  former  ^'while 
very  many  of  the  syniptoma  of  neurasthenia  and  allied  nervous  states  are 
fleeting.  7netastatic  and  transient." 

The  author  discusses  the  relation  betwen  neur.nstlienia  and  the  genital 
organs,  and  wisely  takes  the  middle  ground  between  those  who  assert  that 
these  organs  have  all.  and  those  who  say  that  they  have  nothing  to  do  with 
nervous,  exhaustion.  In  this  connection,  he  pays  a  just  compliment  to  that 
clear-headed  and  close-observing  gynecologist.  Dr.  Wm.Gooddell.  of  Phil- 
adelphia. 

For  diflerential  diagnostic  purposes.  Dr.  Beard  utilizes  and  points 
out  the  significant  fact,  that,  while  in  exceptional  instances  of  organic 
disease — as,  for  example,  spasmodic  spinal  paralysis  and  amiotrophic  lateral 
•sclerosis— "refiex  activity  of  a  certain  kind  may  be  increased,  yet.  as  a  law, 
the  reverse  appears.  The  absence  of  the  tendon  refiex,  in  the  majority  of 
cases  of  ataxy,  is  an  extreme  illustration  of  the  tendency  of  organic 
disease  to  deminish  refiex  irritability."     [p.  95.] 


Reviews. 


The  chapters  on  the  treatment  of  hj'giene  of  nervous  exhaustion  are 
valuable  to  the  general  practitioner. 

These  two  chapters,  more  than  any  others,  evince  the  ranjje  of  Dr. 
Beard's  observation  and  careful  study  of  an  interesting  morbid  state  of  the 
system  and  its  treatment,  which  cannot  be  ignored  by  the  general  practi- 
tioner, who  has  reasonable  aspirations  in  the  direction  of  an  intelligent 
comprehension  of  thQ  maladies  of  many  of  his  patients  and  their  successful 
management. 

The  author's  remarks  on  the  treatment  and  dosage  of  remedies,  in 
general,  and  on  electincity  in  particular  are,  in  the  main,  quite  judicious, 
but  we  have  not  space  to  indicate  his  views. 

We  should  have  been  pleased  to  have  dwelt  upon  the  really  helpful 
etlbrt.  made  by  the  author,  at  ditferential  diagnosis  between  neurasthenia 
and  an;emia,  and  between  the  former  and  hysteria,  and  the  distinction  he 
makes  between  the  disease,  under  consideration  and  certain  manifestations 
of  syphilis  and  other  affections.  But  lack  of  space  forbids,  and  the  only 
alternation  for  the  reader  is  to  get  the  book  and  read  it.  It  will  keep  the 
general  practitioner  to  a  hopeful  view  of  his  cases,  Avhich,  without  its  aid, 
he  would  be  likely  to  unfavorably  prognosticate.  Dr.  Beard  has,  more 
tlian  any  other  writer  of  the  day,  contributed  to  establish  the  ftict  that  grave 
appearances  of  local  disease  may  exist  without,  in  fact,  having  a  local 
organic  habitation,  or  requiring  a  name  dissevered  from  the  general 
nervous  sj'stem. 

E.MOTioxAL  Prodigality.* — This  is  an  odd  subject  for  an  address 
before  a  body  of  dentists,  nevertheless  it  was  well  received  by  our  odon- 
tological  brethren,  and  contains  some  valuable  suggestions,  well  known  to 
psyciiologists,  respecting  the  influence  of  emotional  excess  over  processes 
of  physical  development. 

Possibly,  Dr.  Taylor  may  have  overpainted  his  picture,  yet  it  is  an 
encouraging  sign  of  the  progress  of  the  daj'  to  see  men  whose  tields  of 
research  have  hitherto  been  far  from  psychology,  thus  turning  tlieir  atten- 
tion to  the  influence  of  the  mind  and  nervous  system  over  the  physical 
processes  of  repair. 

The  purpose  of  his  paper  is  especially  to  show  the  "deleterious  effects 
of  early  and  excessive  mental  activity  on  special  organs  as  well  as  to  the 
frame  as  a  whole." 

General  Paresis. — A  paper  read  before  the  Worcester  Xorth  District 
Medical  Society  by  Ira  Russell,  M.  D.,  Winchendon,  Mass.,  last  year,  has 
the  merit  or  brevity  wiiile  it  teaches  sound  doctrine.  Dr.  Russell  makes 
reference  to  the  experience  and  introduces  the  testimony  of  the  lamented 
Dr.  Compton,  of  Mississippi,  who  had  large  experience  amonj^  the  insane 
in  the  Southern  States,  and  wdio  informed  the  author  that  he  had  never 
seen  or  known  of  a  case  of  general  paresis  among  tlie  negroes. 

The  author  thinks  that  heredity  has  but  little  influence  as  a  producing 
cause  in  this  form  of  insanity,  and  that  lewdness  ha-  been  overestimated  as 
a  cause,  for  the  reason  that  nearly  all  paretics,  during  the  course  of  the 


•By  Fayette  Taylor,  M.   D.— Read  before  the  New  York  Odontological    Society, 
March  18.  1879. 


Reviews. 


disease,  manifest  erotic  desires,  which  he  considers  symptoms  due  to  the 
disease  rather  tlian  the  cause  of  it. 

It  is  a  notable  ftict,  says  Dr.  W.,  ''that  the  early  writers.  Esquirol  and 
Calmeil  are  in  accord  with  the  more  modern  observers,  namely,  that  the 
disease  is  essentially  a  chronic  inflammation  of  the  membranes  and  corter 
of  the  frontal  part  of  the  brain.  At  the  last  meeting  of  the  Amerienn 
Medical  Association,  at  Buffalo,  Dr.  Kempster,  of  Oshkosh,  Wisconsin, 
read  a  long  and  able  paper  upon  '-General  Paresis,"  giving  the  morbid 
appearances  observed  in  thirty-five  autopsies  of  patients  dying  from  it. 
Dr.  J.  Crichton  Browne,  of  the  West  Riding  Asylum,  England,  has  given 
a  great  deal  of  attention  to  the  pathology  of  this  disease,  and  his  observa- 
tions agree  with  those  of  Dr.  Kempster.  The  constant  lesion  found  has 
been  a  thickening  of  the  pia-mater,  and  adhesions  of  the  same  in  spots  to 
the  apices  of  the  convolutions  of  tlie  anterior  lobes  of  the  cerebrum  ;  so 
that  wlien  the  brain  has  been  hardened  in  a  solution  of  nitric  acid,  one  part 
of  the  acid  to  eight  parts  of  water,  the  pia-mater  will  show  the  points  of 
adhesion.  The  adhesions  are  on  the  summits  of  the  convolutions,  which 
are  flattened  and  hardened.    They  never  extend  into  the  sulci. 

The  cortex  shows  signs  of  inflammation,  and  sometimes  there  is  a 
fatty  degeneration  of  the  deeper  portions.  Both  Drs.  Kempster  and 
Browne  have  been  impressed  by  the  evidence  aft'irded  by  the  post-mortem 
examinations  of  the  truth  of  the  localizations  of  the  functions  of  the  brain, 
as  taught  by  Ferrier  an  I  others.  The  disease  commences  in  the  anterior 
and  parietal  portions  of  the  cerebrum,  and  progresses  from  before  back- 
ward, and  many  of  the  psychical  and  motor  symptoms  seem  to  correspond 
with  the  supposed  mental  motor  centres  as  tliese  centres  become  affected 
by  the  progress  of  the  disease. 

The  author  regards  the  disease,  in  common  with  almost  universal 
experience  thus  far  recorded,  as  always  fatal,  and  thinks  but  little  can  be 
said  about  treatment.  I^  othing  has  been  discovered  that  seems  to  exert 
any  controlling  power  in  arresting  this  disease.  It  is  not  usu  illy  recog- 
nized until  it  has  existed  for  a  considerable  time,  and  when  it  has  passed 
the  curable  stage,  if  there  is  such  a  stage ;  but  much  can  be  done  to 
mitigate  the  symptoms  as  they  appear.  The  patient  should  be  allowed  all 
the  freedom  compatible  with  safety  to  himself  and  others;  his  surroundings 
should  be  as  pleasant  as  it  is  possible  to  make  them;  his  diet  should  be 
nutritious;  and,  if  necessary  to  procure  sleep,  anodynes  should  be 
administered,  consisting  of  chloral  hydrate,  hyoscyamus  and  meconate  of 
morphia,  in  combination.  The  calabar  bean,  or  some  of  its  preparations 
may  be  used  to  control  excitement,  especially  of  the  erotic  kind. 

Emotional  Insanity.*— This  paper  is  written  in  the  author's  usual 
attractive  and  happy  style.  The  following  paragraph,  all.we  regret  to  say, 
that  we  have  room  for.  is  a  summing  up  of  the  diagnostic  evidences,  as  the 
authors  sees  them,  of  emotional  insanity: 

Emotional  insanity  is  therefore  known  to  exist  by  the  history  of  the  case, 
' the  existence   of  heriditary  predisposition,    the  presence  of  some  of  the  well 

*BvJ.  K  B.auduy,  M.  D.,  Professor  of  Nervous  and  Meutal  Diseases  in  the 
Missouri  MedicalCollege  and  Pliysician  toSt.  Vincent's  Institution  for  the  Insane. 


400  Reviews. 


known  conditions  of  causation,  the  change  of  character,  the  cessation  of  social 
h%rmony  with  surroundings^  the  corroborative  circuynstances,  the  impaired 
judgment  of  relations,  the  measuring  of  the  perversion  according  to  an  indi- 
vidual standird,  and  that  governed  by  the  common  sense  or  the  general  consent 
of  mankind,  the  m,otiveless  assaults  upon  relatives  and  intimate  friends,  the 
existence  of  some  of  the  physical  symptoms  of  insanity ;  in  other  words,  our 
diagnosis  is  to  be  based  upon  all  the  above  mentioned  states,  the  etiological  con- 
ditions, the  sequence  of  symptoms,  and  the  geiieral  course  of  the  affection.  *  * 
As  in  insanity,  the  feelings  are  first  affected,  it  is  through  them  that  we  must 
study  all  collateral  phenomena.'"' 

The  author  is  not  a  believer  in  moral  insanity,  as  defined  by  Ray  and 
others,  '"without  appreciable  intellectual  impairment."  yet  we  cannot  see 
how  anyone  can  gainsay  the  existence  of  this  form  of  mental  derangement, 
in  view  of  the  fact,  that  almost  all  insanity  usually  begins  in  the  derange- 
ment of  the  aifective  faculties,  the  emotions,  propensities  or  passions,  in 
short,  the  feelings,  as  stated  above. 

•'Common  Mind  Troubles  and  the  Secrets  of  a  Clear  Head." — 
By  J.  Mortimer  Granville,  M.  D.,F.R.,S.C.,  etc,  is  a  short,  practical,valuable 
English  book,  edited  by  an  American  physician,  who  states  that  the  author 
"has  devoted  more  attention  than  most  physicians  engaged  in  the  specialty 
of  treating  deranged  intellect,  to  the  earliest  and  faintest  symptoms  of  this 
terrible  malady." 

The  author  asks  the  scientific  reader  "to  remember  that  these  essays 
were  not  written  for  those  who  have  professionally  investigated  the 
phenomena  of  which  they  treat,"  yet  they  will  bear  examination  by  the 
expert  in  the  study  of  the  precursory  phenomena  of  possible  mental 
aberration. 

The  author's  '"sole  purpose  has  been  to  seize  on  a  few  salient  difficulties 
and  grapple  ^vlth  them  in  the  interests  of  self-help,''''  and  he  has  accomplished 
his  purpose  well.  The  key-note  of  his  theme  is  the  presumption  that  there 
is  often — if  not  generally— a  stage  of  conscious  embarrassment  preceding 
mental  derangement  or  mind  weakness,  and  while  this  condition  exists 
there  is  hope  in  the  power  of  repair  and  self-recovery,  which  exists  in  the 
mind  not  less  than  in  the  body."  This  is  true,  and  the  book  -will  be  of 
service,  not  only  to  the  lay  reader,  but  to  the  physician  who  has  not  the 
time  to  read  in  extenso  the  larger  and  more  technical  works  on  the  subject. 
It  is  a  good  book  to  place  in  the  hands  of  certain  iieurastlienic  patients, 
after  convalescence,  or  when  advising  a  leave  of  absence  from  business,  and 
after  starting  them  on  a  tour.  It  is  published  by  D.  G.  Brinton,  117  S. 
7th  St.,  Philadelphia. 


Sook^,  ^or\o^rkpl\^,  ^t6.  f{edeived. 


The  Care  of  the  Insane  and  then-  Legal  Control.     By  Jno.  Charles 

Bucknill,  M.  D..  F.  R.  S.    London :  Macmillen  &  Co..  1880. Paresis 

of  the  Sympathetic  Centers  from  Over-Excitation  by  High  Solar  Heat,  etc. 
The  So-Called  Malaria,  its  Etiology,  Pathogenesis,  Pathology  and  Treat- 
ment.   By  Chas.  T.  Reber,  M.  D.    St.  Louis :  Rumbold  &  Co. The 

Hypodermic  Use  of  Morphine.    By  Dr.  H.  H.  Kane,  New  York. 

Sopra  un  Casa  di  Atrofiia  del  Cervelletto  del  Giuseppe  Seppilli.  Reprint 
from  Revista  Sperimentale  di  Freniatria  e  di  Medicinia  Legale.    Anno  V. 

Faciculo  IV. Physiology  vs.  Philosophy :  A  Short  Study,    by  H.  P. 

Stearns,  A.  M.,  M.  D.,  Hartford,  Conn.   Reprinted  from  theNevi'  Englander 

for  July,  1880. The  Structures  of  the  Vessels  of  the  Nervous  Centers 

in  Health,  and  their  Changes  in  Disease.  Parts  1, 2, 3  and  4.  By  Theodore 
Deecke,  Special  Pathologist,  New  York  State  Lunatic  Asylum,  Utica. 
From  the  American  Journal  of  Insanity  for  July,  1877,  and  January,  1879. 

Urea  and  Phosphoric  Acid  in  the  Urine  in  Anaemia.     By  Theodore 

Deecke.    From  the  American  Journal  of  Insanity  for  July,  1879. The 

Problems  of  Insanity.  A  Paper  read  before  tlie  N.  Y.  Medico-Legal 
Society,  March  3d,  1S80.  By  George  M.  Beard,  A.  M.,  M.  D.,  Member  of 
the  N.  Y.  Medico-Legal  Society ;  Reprint  from  the  Physician  and  Bulletin 
of  the  Medico-Legal  Society. 

Moral  Insanity.  A  Paper  read  before  the  Clinton  County 
Medical  Society,  and  reported  to  the  Michigan  State  Medical  Society  at  its 
Annual  Meeting,  June  11th,  1879.  By  Simon  Herres,  M.D.,  of  Westphalia, 
Mich.      Reprint  from  the  Transactions  of  the  Michigan  State  Medical 

Society. The  Brain  in  Health  and  Disease.    By  Edward  C.  Mann, 

M.  D. An  Essay  on  the  Lawyer  and  the  Law  as  a  Profession.    By 

George  A.  Ritter,  St.  Louis. Legal  Relations  of  Insane  Patients.    By 

Foster  Pratt,  M.  D.,  Lansing,  1878. General  Paralysis  of  the  Insane. 

By  I.  D.  Thomson,  M.  D.,  Assistant  Physician,  Mt.  Hope  Retreat  for  the 
Insane,  Baltimore,  1878. The  Hystero-Neuroses.  With  especial  refer- 
ence to  the  Menstrual  Hystero-Neurosis  of  the  Stomach.    By  George  J. 

Englemann,  M.  D.,  St.  Louis,  1878. Metaphysics.    By  Samuel  Spahr 

Laws,  M.  D.,  LL.  D.,  Professor  of  Metaphysics  in  the  University  of  the 
State  of  Mo.,  Columbia.  Mo.,  1879. Buildings  for  Insane  Crim- 
inals.   By  Walter  Channing,  M.  D.,    Boston,    1879. A    Rare   Case 

of  Peri -Neuritis.      By  F.  F.  Dickman,  M.  D.,  Fort  Scott,  Kas.,  1880. 

Insane  Drunkards.     By  Theodore  W.  Fisher,  M.  D.  (Harv.),  Boston,  1879. 

The  Relations  of  Insanity  to  Modern  Civilization.    Hartford,  Conn.. 

1879. Heredity,  Worry  and  Intemperance,  as  Causes  of  Insanity.    By 

Daniel  Clark,  M.  D  ,  Medical  Superintendent  of  Asylum  for  the  Insane, 

Toronto;  Ex-President  of  the  Medical  Council.     Toronto,  1880. 

Diseases  of  the  Maxillary  Sinus.     By  Edward  Borck,  M.  D.,  Member  of  the 


402  Books  and  Monographs  Received. 


St.  Louis  Medical  Societj',  etc  ,   St.  Louis,  April,  ISSO. Functional 

He.irt  Tioul)le.s.   B\-  Charles  Kelsey,  M.  D.,  1879. The  Mind,  and  How 

to  Treserve  It.    By  Peter  Bryce,  M.  D..  Medical  Superintendent  of'  the 

Alabama  Insane  Hospital,  etc.    1880. A  Plea  for  Cold   Climates  In 

the  Treatment  of  Pulmonary  Consumption.  Minnesota  as  a  Health-Resort, 
By  Talbot  Jones,  M.  D.,  St.  Paul.  Minn.,  1879. Dipsomania.  As  Dis- 
tinguished from  Ordinary  Di-unkenness.  By  I.  D.  Thomson,  Junior. 
Physician  to  the  Mt.  Hope  Eetreat  Baltimore.  Reprint  trom  Transactions 
of  Medical  and  Chirurgical  Faculty  of  Maryland.  1879. 

The  Cinchona  Cure  for  Intemperance.  By  Chas.  Warrington  Earle- 
M.D..  Professor  of  Diseases  of  Children,  Women's  Medical  College,  and 
Physician  to  the  AYashington  Home.  Chicago.     From  the  (,  hicago  Medical 

Journal  and  Examiner.  February,  1880. On  Division  of  the  Sphincter 

ani  Muecle  as  a  Therapeutic  Measure.  By  Charles  B.  Kelsey.  M.  D., 
Surgeon  totheEastSide  Infirmary  for  Dieasesof  the  Rectum,  Xew  York. 
Reprint  from  the  New  York  Medical  Journal.  June,  1880.  D.  Applcton  & 
Co.,  1,  3  and  5  Bond  Sti-eet. A  Glance  at  In-anity.  and  the  Manage- 
ment of  the  Insane  in  the  American  States.     By  Pliny  Earle,  M.  D.,  1879. 

Rupture  of  the   Uterus.     By  G.  M.  B.  Manglis,  M.  1)..  1880. 

Researches  on  Hearing  Through  the  Medium  of  the  Teeth  and  Cranial 
Bones.     By  Chas.  Herman  Thomas,  M.  D.    Revised  and  reprinted   from 

the  Philadelphia  Medical  Times.  Februaiy  28,  1880. The  Perimetric 

Dimension  System;  A  General  System  of  Measurement  for  L'rethral, 
Uterine,  Rectaland  other  Instruments :  and  an  Adaptable  Metric  Gauge. 
By  Chas.  Herman  Thomas,  M.  D..  Fellow  of  the  College  of  Physicians 
etc.,  Philadelphia,  Penn. 

Annual  Report  of  the  Trustees  and  Superintendent  ofthe  State  Lunatic 

Hospital  of  Pennsylvania.      Harrisburg.  1878. Twenty-fifth  Annual 

Report  of  the  Board  of  Trustees  and  Officers  of  the  Cleveland  Asylum  for 

the  Insane.      1879. Report  of  the  Medical    Superintendent  of  the 

Provincial  Lunatic  Asylum.      St.  John,  X.  B.,  1879. 

First  Annual  Report  of  the  Trustees  of  the  Binghampton  Asylum  for 

the  In.?ane,  Binghampton.  X.  Y..  for  the  year  1879. Report  of  the  Medi- 

Superintendent  of  the  Asylum  for  the  Insane,  Toronto,  for  the  year  ending 

September  30th.  1879. Cromwell  Hall,  for  Mental  and  Nervous  Diseases, 

Cromwell  Conn.    Annual  Circular  for  1880.    W.  B.  Hallock,  M.  D. 

Fourth  Annual  Report  of  the  Managers  and  Officers  ofthe  State  Asylum 

for  the  Insane.     Morristown,  N.  J.,  October  31st,  1879. Report  ofthe 

Western  Kentucky  Lunatic  A.syluin.  Hopkinsville.  Ky..  1879. Repoi-t> 

of  the  Trustees  and  Resident  Officers  of  the  Maine    Insane   Hospital 

Augusta,  1879, Report  of  Brigham  Hall,  Canandaigua.  N.  Y.,  1879. 

Report  of  the  Asylum  for  the  Insane,  London,  Out.,  for  1879.     By  R.  M. 

Bucke.  M.  D.,  Superintendent. The  109th  Annual  Report  of  the  New 

-•  York  Hospital  and  Bloomingdale  Asylum,  for  1879. Transactions  ofthe 

Michigan  State  Medical  Society,  for  the  year    1879.     Lansing. Tenth 

Annual  Reiiort  of  the  Willard  Asylum  for  the  Insane,  for  the  year  1878. 

Albany. Fourteenth  Report  ofthe  Connecticut  Hospital,  18.80. Sixth 

Annual  Report  of  the  Cincinnati  Sanitarium,  1879. Fourth   Biennial 

Report  of  the  Iowa  Hospital  for  the  Insane,  at  Independence,  for  the  fiscal 


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years  of  1879  and  ISSO.    Des  Moines. Twenty-sixth  Annual  Eeport  of 

the  .State  Lunatic  Hospital  at  Taunton,  for  the  year  endino- September  ciOth, 
Boston,  1880. Annual  Eeport  of  the  Pennsylvania  State  Lunatic  Hos- 
pital.   Harrisburg. Sixty-second  Annual  Report  of  the  Asylum  for  the 

Relief  of  Persons  Deprived  of  the  Use  of  Their  Reason.    Philadelphia. 

1879. Report  of  Burn-Brae,  a  Private  Hospital  for  Nervous  and  Mental 

Diseases,  Clifton  Heights.  Delaware  Co..  Penn. Twenty-second  Annual 

Report  of  the  Xova  Scotia  Hospital  for  the  Insane,  for  year  1879.     Halifax 

X.  S..  1880. Reports  of  the  Directors  and  Superintendent  of  the  Insane 

Asylum  of  California,  at  Stockton.  1880. Annual  Report  of  the  Western 

Pennsylvania  Hospital  for  the  Insane,  at  Dixmont,   1879. Thirteenth 

Report  of  the  Connecticut  Hospital  for  the  Insane.  1879. — ^Annual  Report 

of  the  Asylum  for  the   Insane,   Kingston.  Ontario,  1880. Sixty-third 

Annual  Repnit  of  the  Asylum  for  the  Relief  of  Persons  Deprived  of  the 

L'se  of  Their  Reason.     Philadelphia,  1880. Twentieth  Annual  Report 

of  the  Wisconsin  State  Hospital  for  the  Insane  for  the  fiscal  year  ending- 
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Retreat  for  the  Insane,  at  Hartford,  Conn..  April.  1880. Report  of  the 

North  Carolina  Insane  Asylum,  for  the  year  ending  December  31st,  1879. 

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chester, 1879. Thirty-seventh  Annual  Report  of  the  Mt.   Hope  Retreat' 

for  the  year  1879.    By  Wm.  H.  Stokes,  M.  D.    Baltimore,  1880. Annual 

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Public  Charities  for  the  Pro\ince  of  Ontario,  for  the  year  ending  September 

30th,  1S79.    Toronto.  1880. Report  of  Dr.  F.  Norton  Manning.  Inspector 

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Committee  on  Public  Health  relative  to  Lunatic  Asylums.  Transmitted 
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u 


) 


THE 


Alienist  j  Neurologist. 

VOL.T  "OCTOBEE,  188(X  NO.  4. 


OvWvwaV  Cjo^\vvV)vv\*vows. 


Art.  I.— Atrophy  of  the  Cerebellum. 


By  Dr.  Giuseppe  Seppilli,  Reggio  Emillia.     Translated  by 
Joseph  Workman,  M.  D.,  Toronto,  Canada. 

WE  are  indebted  to  the  politeness  of  the  author  for 
a  reprint  of  his  most  interesting  article,  on  the  above 
subject,  from  that  most  valuable  periodical,  "La  Revista 
Sperimentale  di  Frcniatria  e  Medicina  Legale^'  in  Reggio 
EmilHa,  Italy,  1879,  Ease.  IV.  We  cannot  better,  perhaps, 
exhibit  our  high  appreciation  of  this  contribution  of  Dr. 
Seppilli  to  cerebral  pathology,  than  by  introducing  it  to 
our  readers  in  our  own  language. 

Dr.  Seppilli  prefaces  his  article  with  the  following 
brief  explanation: 

Though  neoplastic  productions,  inflammatory  processes, 
and  foci  of  softening  are  found  with  some  frequency  in 
the  cerebellum,  an  atrophic  process  is,  on  the  other  hand, 
a  truly  rare  anatomical  condition.  In  searching  the  med- 
ical literature  relating  to  the  diseases  which  have  their 
seat  in  this    organ,    we    have  been  able    to  collect  only  a 


406  Joseph  Workman. 


very  small  number  of  cases,  in  which  atrophy  has  obtained 
record.  It  is  superfluous  here  to  remark  the  greater 
importance,  which,  in  a  functional  view,  should  be  accorded 
to  atrophy,  in  comparison  with  other  morbid  alterations 
to  which  the  cerebellum  is  ordinarily  subject.  No  small 
proportion  of  the  controversies  which  still  prevail,  respect- 
ing the  functions  of  this  organ,  depend  on  the  fact,  that 
with  the  view  to  establish  them,  there  seems  to  have  been 
a  determination  to  study  and  bring  into  association,  the 
results  of  affections  widely  different,  without  taking  account 
of  either  their  nature,  or  their  course,  and  even  less  of 
their  actual  seat,  in  consequence  of  which,  cases  of  alter- 
ations proper  and  limited  to  the  cerebellar  mass,  have 
been  confounded  with  others  in  which  the  lesions  were 
diffused  in  the  neighboring  nervous  organs,  or  were  solely 
confined  to  these,  and  acted  indirectly  on  the  cerebellum. 
The  functional  importance  of  the  cerebellum,  however, 
comes  into  clearer  light  in  cases  of  pure  atroph)-,  total 
or  partial,  without  any  complication,  as  then  we  are  in 
a  better  position  for  recognizing  and  establishing  the 
physio-pathological  nexus  of  the  appreciable  clinical 
phenomena  by  which  they  have  been  accompanied. 

It  is  simply  as  a  contribution  to  atrophy  of  the  cere- 
bclbim  that  we  relate  the  following  observations,  but 
without  desiring  to  omit  recording  similar  cases  already 
noted,  from  comparative  examination  of  which,  facts  may 
be  deduced   which   seem  to  us  of  great  importance  : 

History  of  the  Case. — M.  A.,  aged  32,  daughter  of 
sane  and  robust  parents,  naturally  docile,  but  with  intellect 
slow,  and  poorly  developed  ;  of  weak  and  h-mpathic 
constitution;  ver)-  subject  rn  infancy  to  gastro-euteric 
disorder,  w^hich  caused  a  very  notable  general  anaemia. 
The  menses  first  appeared  at  the  age  of  20,  and  were 
preceded  and  accompanied  by  intense  j)ains  in  the 
abdomen,  and  were  afterwards  always  irregular  and 
trivial  in  quantity.  Sometimes  they  were  suspended,  and 
lucorrhea  supervened.  At  the  age  of  18  she  had  pleuro- 
pneumonia  on    the    left    side,  but,    having    recovered,    she 


Atrophy  of  the  Cerebellum.  407 

enjoyed  good  health  until  her  28th  year,  when  she  fell  ill 
of  a  grave  typhus,  which  lasted  four  weeks,  and  was 
followed  by  a  long  and  difficult  convalescence,  because 
of  intercurrent  intestinal  catarrh.  Her  father,  in  reply  to 
our  enquiries,  stated  that  in  her  convalescence  from  the 
fever,  a  general  tremor  with  disorder  of  all  her  move- 
ments was  developed,  and,  in  consequence,  she  became 
unable  to  hold  anything  with  security  or  precision,  or  of 
sewing,  dressing  herself,  or  putting  on  her  stockings,  etc.  ; 
she  tottered  in  walking,  as  a  drunken  person  ;  sometimes 
she  stammered,  and  at  other  times  pronounced  her  words 
well.  It  is  to  be  noted  that  the  tremor  occurred  only 
when  she  wished  to  execute  some  movements,  and  it  did 
not  appear  during  sleep.  At  this  time  the  mental 
faculties,  which,  before  the  fever,  were  but  little  developed, 
but  yet  orderly,  became  somewhat  disturbed ;  incoherence 
of  ideas  was  observed,  also  a  ready  tendency  to  weep  or 
laugh,  and  visual  and  acoustic  hallucinations  occurred,  in 
consequence  of  which  she  believed  she  saw  dangerous 
animals,  and  heard  persons  continually  calling  to  her. 
This  state  of  things  did  not  undergo  any  marked  modifi- 
cations. The  movements  continued  disordered,  though 
varying  in  intensity.  When  she  became  a  little  tranquil 
she  often  complained  of  a  fixed  pain  in  the  neck.  She  did 
not  become  subject  to  convulsions  or  paralysis,  nor  did 
she  ever  manifest  any  erotic  tendency.  The  psychical 
faculties  became  much  more  enfeebled  and  were  never 
restored.  In  the  past  year  the  mental  disturbances 
underwent  a  transient  exacerbation,  and  during  the  present 
year  they  have  presented  as  new  and  strong  aggravation. 
Since  the  end  of  May  she  has  lost  sleep  and  appetite, 
and  has  manifested  delirious  and  more  disordered  ideas 
than  before ;  she  has  had  visual  hallucinations,  and  has 
attempted  to  leap  out  of  a  window.  Co-incidently  with 
these  occurrences,  a  genenal  absence  of  nutrition  has  been 
noted,  caused  chiefly  by  her  destitution,  which  has  con- 
strained her  to  reside  in  a  damp  house,  with  little  light  or 
air,  and  to  live  on  scanty  and  bad  diet.      Because  of  such 


^^^  Joseph  Workman- 


disorders  of  her  psychical  and  vegetative  Hfe,  she  was,  at 
the  request  of  her  medical  adviser  and  her  parents,  received 
into  our  asylum  on  the  30th  of  May  of  the  current  year 
-1879. 

Examination  and  Course  of  the  Disease. — When  we 

saw  M ,  she  presented  a  notable  emaciation ;    the  skin 

was  soft  and  yellow,  there  was  little  adipose  tissue,  the  mus- 
cles were  soft,  her  gait  was  uncertain,  and  she  was  very 
liable  to  fall.  Her  physiognomy  was  contracted,  her  eyes 
showed  extraordinary  mobility,  different  groups  of  mus- 
cles, more  especially  those  of  the  upper  extremities  and 
the  hand,  were  subject  to  continuous  and  inordinate  move- 
ments. She  manifested  delirious  disconnected  ideas,  her 
speech  was  tremulous,  and  she  was  incapable  of  giving 
the  least  attention.  As  she  was  troubled  with  catarrhal 
enteritis.  She  was  placed  in  bed  on  the  2nd  of  June,  and 
so  remained  till  her  death,  on  the   17th  of  same  month. 

In  order  to  avoid  useless  and  annoying  repetitions, 
we  shall  present  in  a  synthetic  mode  the  phenomena 
which  we  had  the  opportunity  of  observing  during  the 
time  she  was  under  our  care,  distinguishing  them  into 
those  which  belong  to  relational  life,  and  psychical  and 
vegetative  life. 

Functions  of  Relation.  Mobility. — All  the  mus- 
cles of  the  body  were  disordered  in  their  functions. 
Clonic  contractions  were  observed  on  both  sides  of  the 
face,  but  most  on  the  right ;  also  rotation  of  the  eye-balls, 
alternate  depression  and  raising  of  the  lower  jaw,  retrac- 
tion of  the  tongue,  which  was  arched,  with  the  point 
drawn  back  and  downward.  The  muscles  of  the  neck 
were  rigid  and  contracted,  as  were  also  those  of  the 
thorax,  which  was  but  little  dilated.  The  arms  were 
flexed  and  contracted,  the  right  much  more  than  the  left, 
and  she  had  very  great  difficulty  in  extending  them; 
they  continually  presented  ataxic  movements,  and  were 
carried  with  great  rapidity,  now  forward,  then  sidcwise, 
and  again  backwards ;  the  fingers  were  especially  thus 
affected,  and  were  contorted  in  a  most  varied  and  strange 


Atrophy  of  the  Cerebellum.  409 

manner.  This  ataxia  in  the  movements  of  the  superior 
members  was  most  conspicuous  when  anything  was  placed 
in  her  hands  (as  a  bottle,  or  a  key),  that  she  might  raise 
it  to  her  mouth.  An  intense  tremor  and  strong  jerkings 
would  at  such  times  take  place,  the  arms  would  be  thrown 
out  hither  and  thither,  whilst  the  hands  grasped  with 
stronger  force  the  object  held  by  them.  The  lower  limbs 
presented  semi-flexion,  with  slight  contracture,  and  from 
time  to  time  there  were  some  isolated  contractions  of  the 
muscles  of  the  calf  of  the  leg.  The  phenomena  above 
described  were  constant,  but  they  varied  much  in  their 
intensity.  They  were  exacerbated  whenever  we  approached 
the  patient's  bed  and  practiced  the  necessary  examina- 
tions, or  when  the  ps}'chical  exaltation  became  very 
strong.  On  the  contrar\',  when  she  was  calm  and  tran- 
quil, or  fell  as  into  a  state  of  semi-stupor,  the  inco-ordi- 
nation  of  the  movements  became  slight,  and  was  limited, 
for  the  most  part,  to  the  arms  alone  ;  during  sleep  it  was 
completely  absent.  The  grave  condition  of  the  patient 
prevented  our  examination  of  the  process  of  deambula- 
tion;  we  can  merely  state  that  when  the  ataxy  of  the 
muscles  became  intense  and  general,  she  could  not  sit  up 
in  bed,  in  consequence  of  the  contractions  of  the  muscles 
of  the  vertebral  column. 

Sensibility. — The  general  sensibility  was  always  found 
exquisite  ;  the  dolorific  and  reflex  were  much  exaggerated 
in  the  periods  of  excitement ;  even  a  slight  puncture  of  a 
pin  on  the  face,  the  limbs  or  the  trunk  was  then  suffi- 
cient to  provoke  a  prompt  and  most  vivid  reaction ; 
tickling  the  soles  of  the  feet  caused  rapid  retraction  of 
the  limbs ;  by  giving  light  and  dry  blows,  with  a  percussion 
hammer,  on  the  rotular  ligament,  whilst  holding  the  Hmb 
semi-flexed,  extension  (the  reflex  of  Westphal)  was  instantly 
produced  with  great  energy.  Nothing  remarkable  was 
observed  in  the  organs  of  sense.  The  pupils  were  equal, 
small  and  little  sensible.  OptJialmic  examination  showed 
the    papillae  rosy-colored,  and  the  retinal    vessels    distinct.. 

PsYCHic.VL  FuNXTioxs. — Periods  of  excitement  alternated 


•ilO  Joseph  Workman. 

with  others  of  cahn.  During  those  of  excitement  it 
was  impossible  to  get  hold  of  the  patient's  attention 
so  as  to  learn  her  sufferings ;  she  manifested  a  few- 
ideas  without  any  connection,  and  it  was  very  difficult  to 
apprehend  them,  chiefly  because  the  inco-ordinate  move- 
ments of  the  lingual  and  facial  muscles  rendered  the 
speech  tremulous,  and  the  articulation  of  sounds  confused  ; 
but  the  shrunken  physiognomy,  the  anxious  state,  which 
increased  when  anyone  approached  her,  and  the  vain 
attempts  made  by  her  to  get  away,  were  proofs  that  she 
was  suffering  very  painful  sensorial  disorder.  The  state 
of  calm  which  followed  that  of  excitement,  was  some- 
times presented,  under  the  form  of  semi-stupor,  during 
which  she  remained  mute  and  motionless,  or  again  with 
a  certain  degree  of  ordinate  intelligence,  through  which 
she  gave  attention  to  questions,  and,  if  so  requested,  she 
put  out  her  tongue  and  made  movements  of  her  limbs, 
but  as  has  already  been  said,  uncertainty  and  inco-ordi- 
nation  were  observable.  She  complained  of  diffused 
headache  and  pain  in  the  belly.  In  her  calm  periods 
she  sometimes  pronounced  words  well,  but,  at  other  times, 
she  had  great  difficulty,  and  stuttered.  She  seemed  to 
have  only  a  very  confused  recollection  of  the  period 
in  which  she  had  been  in  any  degree  agitated.  The 
affective  sentiments  were  w^ell  developed,  and.  among 
these,  that  of  religion,  predominated.  She  never  showed 
any  tendency  towards  masturbation ;  she  was  quite 
modest,  as  was  shown  by  her  efforts  to  prevent  personal 
examination. 

Functions  of  Vegetative  Life. — As  has  before  been 
said,  M.  was,  at  the  time  of  her  admission,  ill  under 
catarrhal  enteritis.  To  this  was  added,  in  a  few  days 
after,  a  pulmonitic  process,  acutely  developed  in  the  inferior 
lobe  of  the  right  lung,  and  this  much  aggravated  her 
condition.  It  was  not  accompanied  by  expectoration, 
but  by  great  frequency  of  the  respiration  (30  to  40!, 
and  of  the  circulation  (90  to  120),  and  by  a  fever  which 
oscilated    between    38"    and  39.5°     C. ;     and    rose    to    40. S" 


Atrohpy  of  the  Cerehpllum.  411 


shortly  before  death,  which  took  place  on  the  morning 
of  the  i/th  of  June.  The  examination  of  the  urine 
gave    negative    results. 

Autopsy. — Body  much  emaciated ;  skin  soft  and  pale, 
with  very  little  fat ;  muscles  small  and  tender ;  the  arms 
contracted  and  bent  over  the  breast  at  right  angles ; 
the  lower  limbs  slightly  flexed ;  a  bed-sore  over  the 
sacrum.  Head. — Skull  light,  symmetrical,  with  the 
vascular  furrows  shallow ;  sutures  incompletely  ossified ; 
diploe  scarce  and  pale.  The  Cranium  has  normal  thick- 
ness; a  circumference  of  520  mm.  (about  20  and  1-2 
inches);  antero-posterior  diameter  ;68  mm.;  biparietal,  145 
mm.  The  several  fossae  of  the  base  are  symmetrical, 
and  their  measures  normal ;  dura-mater  slightly  adherent 
along  the  sides  of  the  longitudinal  fissure,  with  a  soft 
coagulum  in  the  superior  longitudinal  sinus.  Much  serum 
is  contained  in  the  sub-arachnoid  spaces  of  the  vault  and 
the  base,  and  especially  in  the  posterior  fossa.  The  veins 
of  the  pia-jnater  diYC  turgid;  the  capillaries,  on  the  contrary, 
are  almost  quite  empty.  The  circle  of  JVillis  contains  a 
small  quantity  of  blood.  On  removal  of  the  brain,  the 
cerebellum  is  found  to  be  entirely  concealed  by  the  occipi- 
tal lobes,  so  much  is  it  reduced  in  size.  The  cerebral 
lieuiisplicrcs  weigh  1,080  grammes;  the  pia-uiater  is  easily 
separated  from  the  surface,  on  which  small  open  mouths 
of  vessels  remain.  The  convolutions  are  well  developed, 
liscid  and  uniform  on  the  surface ;  the  gray  substance 
is  very  pale ;  the  white  substance  presents  here  and 
there  some  red  points.  Nothing  notable  in  the  ganglia 
of  the  base.  The  lateral  ventricles  are  of  normal  size, 
and  contain  a  few  drops  of  serum.  The  consistence 
of  the  cerebrum  is  normal.  The  cerebellum  is  notably 
diminished  in  its  lateral  hemispheres,  and  it  is  hardened, 
but  less  so  in  its  median  lobe ;  it  weighs  56  grammes. 
The  two  hemispheres  being  examined,  externally,  are 
seen  to  be  equal  in  volume,  and  perfectly  symmetrical. 
The  pia-mater,  which  is  notably  thickened,  but  easily 
detached,  being  removed,  each  hemisphere  of  the  cerebel- 


412  Joseph  Workman. 

lum,  as  well  on  the  under  as  on  the  upper  surface,  is  seen 
to  be  normally  divided  in  its  principal  parts.  The  lateral 
lobes  are  constituted  of  normal  convolutions,  disposed 
horizontally  equal  to  each  other,  divided  by  shallow  sulci, 
and  are  thin  to  such  a  degree,  that  many  of  them  have 
not  a  thickness  of  2  mm.  The  median  lobe,  or  vermes, 
is  not  much  diminished,  in  comparison  of  the  two 
hemispheres,  and  the  lamellae  of  which  it  is  composed 
have  a  parallel  course  and  a  thickness  nearly  normal. 

In  making  vertical  and  horizontal  sections  of  the  cere- 
bellum, great  resistance  was  found,  and  it  was  seen  that 
the  gray  substance  was  reduced  in  all  the  convolutions 
to  a  very  thin  stratum,  almost  uniform  and  of  a  pale 
color.  The  nucleus  dcntatus  was  also  much  thinned. 
The  fasciculi  of  the  white  substance,  which  penetrate  each 
convolution,  were  very  contracted.  The  two  halves 
of  the  po7is,  of  the  medulla  oblongata,  and  of  the 
peduncles  of  the  cerebellum  are  of  equal  volume,  and  do 
not  seem  at  all  diminished  ;  they  weigh  together  26  grs. ; 
on  section  they  have  a  normal  aspect.  Examination  of 
the  spinal  cord  also  gave  a  negative  result. 

The  Chest. — The  lungs  are  adherent  to  the  ribs  by 
old,  strong  attachments.  The  left  lung  and  the  superior 
lobe  of  the  right,  have  a  bright  rose  color,  they  crepitate, 
and  on  section  they  give  issue  to  an  abundance  of  sero- 
sanguinolent  fluid,  mixed  with  small  bubbles.  The  lower 
right  lobe  is  in  a  state  of  red  hepatization.  The  Jicart  is 
of  normal  size,  the  valves  sound,  the  muscular  fibres  of 
a  pale  yellow,  small  atheromatous  patches  are  on  the 
origin  of  tiie  corta. 

The  Abdo.men.  —  Nothing  remarkable  in  the  liver, 
spleen  or  kidneys.  The  mucous  coat  of  the  small  intes- 
tine hypercTemic,  and  the  follicles  a  little  enlarged. 

Microscopic  Examinations. — After  hardening  the  brain 
in  a  solution  of  bichromate  of  potass  (2°),  we  made 
preparations  of  it,  by  laceration  and  sections  in  different 
directions.  Ever>'  part  of  the  lateral  lobes  offer  to  lacer- 
ation   a    great    resistance,    which    is,    however,     greater  on 


Atrophy  of  the  Cerebellinn.  413 

the  superficial  than  in  the  central  parts.  The  small  pieces 
of  cerebellum  examined  under  the  microscope,  in  place 
of  presenting,  as  in  the  normal  organ,  borders  slightly- 
dentate  and  fibrillar,  show  on  the  contrary,  through  a 
certain  extent  on  their  outside,  a  quantity  of  thin  fibrillae, 
long,  shining  and  rigid,  which  intersect  each  other  in 
various  ways,  constituting  a  sort  of  net  with  very  small 
meshes.  Many  of  these  fibrillae  are  separated  by  small 
bodies  of  oblong  or  rounded  form,  with  round  nuclei, 
containing  many  granules,  which  are  easily  recognized 
as  connective  elements.  It  is  to  be  noted  that  these  are 
sufficiently  isolated  on  the  external  border  of  the  convolutions . 
By  lacerating  and  coloring  with  a  solution  of  carmine  and 
borax,  it  is  found  that  in  the  gray  substance  of  the 
greater  part  of  the  convolutions,  we  do  not  succeed  in 
seeing  the  cells  of  Purkinje,  which  in  a  normal  cere- 
bellum are  so  easily  brought  into  view  and  isolated. 
In  other  convolutions,  however,  by  laceration,  a  few  of 
the  cells  of  Purkinje  were  isolated ;  but  these,  instead 
of  having  a  thick  globose  body,  with  regular  borders, 
were  reduced  in  size  below  the  normal  half,  wrinkled  on 
their  borders,  crushed  on  the  sides  and  granulous  ;  some 
of  them  presented  a  small  nucleus  and  nucleolus,  but 
others  none  at  all.  Only  in  a  very  few  cells,  did  we 
meet  with  a  cylinder  axis,  in  a  very  limited  tract ;  the 
protoplasmic  prolongations  were  slender — very  fragile  and 
granulous.  Laceration  of  the  vermes  was  less  difficult 
than  that  of  the  lateral  lobes,  and  in  it  we  succeeded  in 
isolating  a  distinct  quantity  of  the  cells  of  Purkinje,  of 
which  the  conformation  was  sufficiently  regular,  the  size 
a  little  under  normal,  and  the  contents  very  granular;  the 
nuclei  and  nucleoli  were  rather  indistinct.  Making  sec- 
tions in  different  parts  of  the  cerebellar  convolutions,  the 
first  fact  that  struck  us,  was  the  very  great  diminution  of 
their  different  strata,  and  more  especially  that  of  the  gray 
and  granulous  stratum.  From  numerous  comparative 
measurements  taken  by  the  ocular  micrometer,  it  could 
be  established,  generally,   that  the  thickness  of  the  different 


414  Joseph  Workman. 


strata  examined  stood  to  that  of  the  normal  as  i  to  4 
for  the  lateral  lobes,  and  as  3  to  4  for  the  median  lobe. 
For  the  most  part  the  single  convolutions  had  not,  as  in 
normal  cases,  an  oval  or  rounded  form,  and  equality  in 
size,  but  were,  on  the  contrary,  contracted  in  every  sense, 
as  if  crushed,  unequal,  and  divided  from  one  another  by 
narrow  sulci  of  little  depth.  In  thin  and  complete  sec- 
tions of  the  convolutions,  complex  alterations  of  their 
intimate  texture  were  clearly  observed.  In  fact,  in  pro- 
ceeding from  the  exterior  to  the  interior,  we  distinguished 
in  the  outermost  stratum  of  the  cortex,  a  thick,  shining 
border,  constituted  of  bodies  of  oval  form,  granulous,  and 
at  a  little  distance  from  each  other,  with  numerous  robust 
prolongations.  Some  of  these  had  a  horizontal  direction, 
others  described  a  decided  curve,  took  a  vertical  direc- 
tion, and  having  united  in  small  fasciculi,  traversed  the 
gray  matter  as  rays,  and  were  continued  into  the  gran- 
ulous stratum.  These  fibrillas  fascicles  intersected,  leaving 
inter-spaces  of  various  sizes  of  lozenge  form,  and  filled 
with  a  granulous  detritus.  Here  and  there,  as  in  ordinary 
cases,  but  in  smaller  quantity  and  size,  there  were  found 
round  nuclei,  surrounded  by  a  thin  stratum  of  protoplasm. 
As  regards  the  stratum  of  the  cells  of  Piirkinjc,  which 
divide  the  gray  or  nuclear  stratum  from  the  granular  or 
rugose  one,  in  the  greater  part  of  the  lateral  convolutions 
it  was  altogether  wanting,  and  was  substituted  by  an 
areolar  texture  analogous  to  that  before  described.  In 
some  other  convolutions,  however,  the  atrophy  of  these 
gangliar  cells  was  not  so  complete  as  to  determine  their 
total  disappearance  ;  but  on  the  other  hand,  in  place  of 
these  there  were  seen,  as  in  preparations  by  dilaceration, 
some  small  bodies,  oval  or  fusiform,  of  a  granulous  aspect, 
with  an  indistinct  nucleus,  or  without  an\-  nucleus,  dis- 
posed in  a  single  series,  distant  from  each  other,  and 
having  their  greater  diameter  from  0.003  to  0.005  "''"''. 
(Oc.  2,  Ob.  6,  Werick) — parallel  in  direction,  or  perpen- 
dicular to  the  surface  of  the  cerebellum.  Neither  the 
peripheral    prolongations     nor    the    central    one    could    be 


Atrophy  of  the  Cerebellum.  416 

distinguished.  The  rugose  stratum  was  much  diminished, 
in  some  parts  to  such  a  degree  that  its  thickness  was 
not  greater  than  0.002  (Oc.  2,  Ob.  6,  Werick).  It  was 
constituted  of  fasciculi  of  fibrillai,  which,  by  intersecting, 
formed  meslies  in  which  were  found  the  so-called  gran- 
ules, which,  however,  were  neither  so  abundant  nor  so 
dense  as  in  normal  cases.  These  granules  had  a  diameter 
of  0.002  to  0.003,  3-rid  were  constituted  of  a  large  nucleus 
surrounded  by  a  scanty  protoplasm;  by  isolating  them,  a 
few  thin  granulous  prolongations  might  be  seen.  The 
medullary  stratum  also  had  a  finely  reticulated  aspect;  a 
granulous  and  shining  detritus  occupied  the  interstices. 
By  the  method  of  black  coloration  of  Golgi,  numerous 
archniform  cells,  provided  with  many  robust  prolonga- 
tions were  discovered.  Only  a  few  thin  nervous  fibres 
were  observed.  The  gray  stratum  constituting  the  nuclejis 
dentatus,  was  also  much  diminished,  its  nervous  cells  were 
smaller  and  scarcer  than  normal,  with  rather  irregular 
outlines,  granulous  contents  and  indistinct  nuclei.  Sec- 
tions made  on  the  median  lobe,  brought  into  view  the 
same  alterations  as  were  noted  in  the  lateral  lobes,  but 
in  a  much  lower  degree.  In  fact,  the  gray  stratum 
did  not  present  that  fibrous  aspect  so  distinctly  as 
it  was  met  with  in  the  gray  stratum  of  the  lateral 
lobes ;  it  had  a  very  regular  border,  and  contained 
nuclei  in  moderate  quantity.  The  cells  of  Piirkinje  were 
well  distinguished,  but  not  numerous,  consequently  the 
distance  between  them  was  much  greater  than  nor- 
mal. The  most  of  them  had  a  rather  small  body,  a  little 
wrinkled,  contents  very  granulous,  nucleus  and  nucleolus 
little  visible.  The  axial  and  central  prolongation  was  not 
seen;  the  peripheral  prolongations  were  followed  for  a 
certain  distance  in  the  nuclear  stratum,  and  were  very 
slender  and  granular.  The  stratum  of  granules  was  of 
moderate  thickness ;  but  the  granules  were  not  very 
abundant,  nor  near  to  each  other,  therefore,  they  left  inter- 
stices which  were  occupied  by  a  fibrous  texture  and  a 
finely     granular    detritus.       The     walls    of    the    meningeal 


416  Joseph  Workman. 


vessels  were  thickened,  and  had  thick  shining  borders 
consisting  of  a  series  of  fibrilUe,  with  many  large  nuclei 
interspersed,  of  an  o\m1  or  round  form.  This  appearance 
was  chiefly  conspicuous  in  the  vessels  which  cross  the 
gray  stratum  from  the  meninges.  The  perivascular  lym- 
phatic space  was  completely  wanting.  By  isolating  the 
vessels  of  the  cerebellum,  it  was  seen,  more  especially  in 
those  of  the  gray  stratum,  that  numerous  slender  prolon- 
gations proceeded  from  their  outer  coat. 

Considerations — It  is  still  a  question  among  histolo- 
gists,  whether  on  the  surface  of  the  cerebellum  there  exists 
a  liviiting  or  fiindmnental  membrane,  analagous  to  that  of 
the  retina.  Bergmann  was  the  first  to  describe  it  under 
the  form  of  an  annexed  membrane,  from  which  many 
radiate  fibres,  with  large  base,  come  away  and  proceed  in 
a  perpendicular  direction  across  the  molecular  substance. 
Schnlse,  Henle,  Merkel  and  Oberstciiur  also  admit  the 
existence  of  a  limiting  membrane,  excepting  that  while  the 
first  and  the  last  named  of  these  authors,  in  accord  with 
Bergmann,  regard  it  as  the  most  internal  stratum  of  the 
pia-mater,  whilst  the  others  hold  it  to  be  independent  and 
finely  striated  as  the  basal  membrane.  For  the  most 
part,  the  limiting  membrane  is  not  applied  directly  to  the 
cerebellum,  but  between  the  two  there  may  be  found  a 
space  of  lympathic  character,  traversed  b}-  fibres,  and 
containing  numerous  h^mpathic  corpuscles  [Hcnlc,  Markcl, 
Obersteincr).  Golgi,  on  the  contrar\',  does  not  hesitate 
to  mantain  that,  on  the  convolutions  of  the  cerebellum, 
there  exists  not  an  investing  membrane,  but  that  on  the 
contrar}',  there  is,  in  immediate  contact  with  the  cerebellar 
parenchyma,  a  simple  stratum  of  connective  cells,  from  which 
numerous  direct  prolongations  proceed  horizontally  and 
vertically.  Our  own  anatomical  research  fails  to  confirm, 
fully,  the  assertion  of  Golgi.  In  fact,  from  examination  of 
very  many  of  the  atrophied  convolutions,  at  no  point  were 
we  able  to  discover  a  space  which  di\ided  the  substance  of 
the  cerebellum  from  a  membrane  situated  on  its  surface.  If 
this  space  really  existed,  it  should  have  been  very  evident  in 


Atrophy  of  the  Cerebellum.  417 


our  case,  because  of  the  accumulation  of  lymph-corpuscles 
which  were  there  met  with,  caused  by  the  great  difficulty 
with  which,  beyond  doubt,  the  circulation  of  the  cerebellum 
was  accomplished,  in  presence  of  the  co-arctation  of  the 
texture.  But,  on  the  other  hand,  we  were  able  to  recog- 
nize, on  the  surface  of  the  convolutions,  an  undulate 
shining  line,  formed  of  slender,  long  fibres,  in  connection 
with  cellular  bodies,  constituted  by  a  round  nucleus,  with 
granulous  protoplasm,  and,  in  consequence,  these  bodies 
maintianed  the  general  type  which  is  wont  to  be  observed 
in  the  connective  cells  of  the  nervous  system.  We  also 
saw  the  greater  part  of  these  fibrillae,  reunited  in  bundles, 
crossing,  vertically,  the  gray  stratum  ;  this  was  rendered 
more  conspicuous  from  their  great  quantity,  which  was 
very  far  above  the  normal.  This  radiate  disposition  of 
the  connective  fibres,  which  proceed  from  the  outermost 
stratum  of  the  cortex  of  the  cerebellum,  has  been 
described  more  particularly  by  Obersteincr  and  Golgi, 
according  to  whom  the  radiate  fibres,  intersecting  with 
those  which  proceed  from  the  connective  cells,  situated  in 
the  deepest  part  of  the  gray  stratum,  form  the  web 
sustaining  the  above  named  stratum.  We  may  also  add, 
that  Golgi  has  described,  in  the  rugose  and  medullary 
stratum,  an  interstitial  web,  constituted  of  connective  cells 
furnished  with  numerous,  long,  fine  and  unramified  pro- 
longations. 

As  has  been  said,  the  examination  of  the  rugose 
stratum  has  enabled  us  to  see  some  round  bodies,  with 
a  little  protoplasm  and  a  few  prolongations.  These 
corresponded  exactly  to  the  so-called  gramtlcs,  described 
by  histologists,  on  which  there  is  doubt  whether  they  are, 
for  the  most  part,  of  connective  or  nervous  nature.  If  we 
consider  that,  in  our  case,  such  elements,  different  from 
ordinary,  were  scarce  in  quantity  to  such  a  degree  as 
to  become  very  distinct  from  one  another,  and  to  form  a 
very  thin  stratum,  and  that,  concurrently  with  their  defi- 
ciency, there  existed,  also,  an  atrophy  of  the  gangliar  cells 
of  Purki)ije,  and,  conjunctly,    a    hyperplasia    of    interstitial 


418  Joseph  Workman. 


connective,  recognizable  from  the  fibrou'^  and  reticulated 
aspect  of  the  cerebellum,  we  may  be  induced  to  regard 
the  granules  as  very  probably  of  nervous  nature,  since,  if 
they  were  connective  elements,  they  should  have  been 
present,  not  in  smaller,  but  in  larger,  or  at  least,  in  equal 
quantity  to  the  normal. 

Having  premised  these  brief  histological  considerations, 
suggested  by  the  examination  of  the  cerebellum  studied 
by  us,  we  stop  now  to  study  the  nature  of  the  morbid 
process  which  had  its  seat  in  the  organ. 

The  profound  modifications  which  the  cerebellum  of 
M.  presented  to  us,  readily  cause  us  to  hold  that  they 
were  due  to  a  morbid  process  of  atrophy,  with  sclerosis 
of  the  organ  limited  chiefly  to  the  lateral  lobes.  This 
was  shown  by  the  small  size,  the  induration,  the  weight 
(56  gr.),  less  than  half  the  normal,  the  complete  want  of 
the  nerve  cells  of  Purkinje  in  some  convolutions,  whilst, 
in  others  they  were  present,  but  were  atrophied,  and  con- 
sequently had  a  much  diminished  body,  irregular  borders, 
granulous  contents,  nucleus  and  nucleolus  little  or  not  at 
all  distinct ;  few  and  slendor  protoplasmic  prolongations, 
and,  finally,  an  abundance  of  connective  tissue,  which 
occupied  diverse  strata  of  the  cerebellum,  and  was  consti- 
tuted, in  great  part,  of  bundles  of  robust  fibres.  Well, 
now,  the  first  requirement  presented  is  to  know  to  what 
causes  the  atrophy  and  the  sclerosis  of  the  organs  ought 
to  be  ascribed. 

Pathological  anatomy  teaches  us  that  defective  devel- 
opment of  the  endo-cranial  organs  is  either  congenital 
or  acquired,  and  in  the  latter  case  it  may  happen  in 
infancy,  or  even  when  the  brain  is  already  developed. 
The  causes  which  more  especially  develop  it  are  disor- 
ders of  nutrition  during  intrauterine  life  ;  a  precocious 
solidification  or  ossification  of  the  sutures ;  an  abnormal 
development  of  the  bones  of  the  cranium  ;  external  hydro- 
cephalus during  infantile  life,  or  finally  inflammatory  pro- 
cesses, which,  by  direct  or  indirect  course,  induce  the 
destruction  of  the  nerve  elements ;   neoplasms  which  com- 


Atrophy  of  the  Cerebellum.  419 

press  and  destro\'  the  parts  in  which  they  are  developed, 
as  we  have  had  occasion  to  observe  in  adult  life.  Accord- 
ing as  such  agencies  act  over  the  whole  of  the  brain,  or 
on  only  a  part  of  it,  they  give  place  to  a  total,  or  a  par- 
tial atrophy  of  the  organ.  Coming,  then,  to  our  case,  we 
do  not  believe  that  the  diminution  of  the  cerebellum 
should  be  considered  as  congenital,  for  in  that  case  the 
fossjE  of  the  occipital  bone,  which  have  the  most  strict 
relation  with  the  nutrition  of  the  cerebellum  would,  with- 
out doubt,  have  presented  some  appreciable  modification. 
Instead  of  this,  we  observed  that  these  fossae  had  a 
capacity  and  thickness  quite  equal  to  the  normal,  were 
symmetrical,  and  did  not  present  neoplastic  products. 
The  symmetry  of  the  whole  cranium,  the  normal  direc- 
tion, and  the  incomplete  ossification  of  the  sutures,  the 
regular  development  of  the  cerebrum,  and  more  than  any 
other  fact,  the  external  conformation  of  the  cerebellum, 
which  did  not  deviate  much  from  normal,  are  so  many 
facts,  which,  taken  together,  render  still  more  difficult  the 
hypothesis  of  a  congenital  atrophy  of  the  cerebellum,  in 
which  there  would  most  likely  be  associated  some  devi- 
ation of  form  and  volume  at  some  point  in  the  skull,  or 
in  the  hemispheres  of  the  cerebrum. 

The  same  reasons  have  equal  value  for  excluding  the 
belief  that  the  atrophy  of  the  cerebellum  took  place  in 
the  early  period  of  extra-uterine  life,  in  which  the  cra- 
nium, and  the  organs  contained  in  it,  proceeded  in  devel- 
opment. We  are  thus  obliged  to  admit  that  the  change 
took  place  when  the  cerebellum  had  already  attained  its 
complete  and  definite  develoi^ment.  Now,  if  we  bear  in 
mind  that  in  the  cerebellum  we  found  a  diffused  thick- 
ening of  the  pia-mater,  and  sclerosis  of  the  vessels  of  the 
neuroglia,  it  does  not  seem  illogical  to  refer  the  genesis 
of  the  whole  morbid  process  to  a  lesion  of  irritative 
nature  developing  slowly  and  primitively  in  the  meninges, 
and  afterwards  diffused  into  the  vessels  and  the  connec- 
tive tissue  of  the  cerebellum.  The  immediate  consequence 
of  this    fact    should    be    a    lesion    of   the    nutrition  of  the 


-120  Joseph  Worlcniarv, 


nerve  cells  and  their  degeneration  and  death.  We  have 
in  fact  seen  that  where  there  was  larger  and  more  con- 
spicuous lesion  of  the  vessels  and  the  cerebellar  connec- 
tive, there,  too,  there,  was  an  absence  more  or  less  com- 
plete of  the  nervous  cells  (in  the  lateral  lobes).  These 
were,  on  the  contrary,  clearly  conserved  where  the  char- 
acter of  the  sclerosis  was  lighter    (in  the  median  lobe). 

It  will  now  remain  to  decide  in  what  epoch  the  dis- 
ease of  the  cerebellum  in  ?»I was  developed.     Nothing 

precise  can  be  established  in  this  relation,  since  the  organ 
is  one  of  those  parts  of  the  nervous  system,  in  which 
more  easily  than  in  others,  certain  lesions,  especially  if 
slow  in  progress,  proceed  for  some  time  hidden.  Be  it 
as  it  may,  if  we  consider  that  the  disorders  of  motility, 
which,  as  we  shall  say  presently,  are  due  to  lesions  of 
the  cerebellum,  were  presented  for  the  first  time  after  a 
grave  typhus,  and  that  thereafter  they  continued  to  mani- 
fest themselves,  it  is  probable  that  during  the  typhus  the 
morbid  process  was  developed  which  had  as  its  comple- 
tion the  atrophy  of  the  organ.  So  far  as  has  come  to 
our  knowledge,  cases  of  lesion  of  the  cerebellum  coinci- 
dent with  typhus,  have  not  been  described  ;  it  is  mcrel\- 
known  that  with  this  disease  grave  cerebral  disorders  are 
often  associated,  which,  without  doubt,  are  due  to  profouml 
alterations  in  the  encephalic  mass. 

In  medical  literature,  cases  of  congenital  atrophy  of 
the  cerebellum,  partial  or  total,  are  not  wanting.  LalU- 
nicnt  has  described  a  case  in  which  the  left  lobe  was 
reduced  to  the  size  of  a  nut.  The  corpus  striatum  and 
the  corpus  olivare  were  atrophic  on  the  right  side,  whilst 
the  left  hemisphere  of  the  cerebrum,  and  the  right  of  the 
cerebellum  were  increased  in  volume.  Vcnielli  in  an 
imbecile  epileptic,  besides  other  remarkable  anomalies,  in 
the  posterior  parts  of  the  cranium,  met  with  an  atrophy 
of  the  two  lateral  lobes  of  the  cerebellum,  which  were 
comparable  in  size  to  that  of  the  tonsils  ;  the  median  lobe 
was  sufficiently  developed.  Between  the  arachnoid,  which 
had  become  much  thickened    and    resisting,  and    the  pia- 


viirophyoftheCerehellum.  421 

mater  of  the  inferior  surface,  there  was  found  a  kind  of 
sac,  larger  than  a  hen's  egg,  full  of  limpid  serum.  The 
author  believes  that,  in  this  case,  he  had  a  congenital 
partial  hydrocephalus,  with  atrophy  of  the  cerebellum. 
Otto  has  described  a  case  of  general  hyperostosis  of  the 
occipital  bone,  with  diminution  of  the  posterior  fossae  of 
the  cranium,  to  which  the  cerebellum  extraordinarily 
decreased  in  size  in  both  hemispheres,  corresponded; 
the  gyri  did  not  run  in  a  parallel  course,  but  perpendicular 
to  their  posterior  border.  He  regards  the  occipital 
hyperostosis  as  depending,  not  on  an  inflammatory  process, 
but  on  the  abnormal  deviation  during  fottal  life,  in  the 
primitive  development  of  the  bone,  and  hence  arose  the 
contraction  of  the  endocranial  space  corresponding,  which 
had  prevented  the  complete  development  of  the  cere- 
bellum. 

In  the  famous  case  of  Comb  cite,  it  is  doubtful  whether 
the  total  atrophy  of  the  cerebellum  was  congenital,  or  as 
Cruveilher  holds  probable,  who  reports  it  in  his  classic 
treatise  on  "  Pathological  Anatomy,"  the  organ  had  been 
previously  existing  and  a  gradual  successive  atrophy  had 
afterwards  taken  place. 

Obersteincr  has  reported  a  case  of  partial  atrophy  of 
the  right  hemisphere  of  the  cerebellum,  which  seems  to 
have  been  of  acquired  nature,  and  to  have  resulted  from 
an  ancient  inflammatory  process.  In  addition  to  a 
considerable  development  of  the  connective,  he  found 
degeneration  of  the  cells  of  Purklnje.  In  the  parts  nearest 
to  the  atrophic  region,  the  cells  were  diminished  in  size, 
and  deformed  ;  their  prolongations  were  broken,  wrinkled 
and  more  slender  than  in  the  normal  state.  In  some  of 
them  the  nucleus  appeared  under  the  form  of  a  shining 
oval  body ;  in  others,  in  which  the  process  was  more 
advanced,  it  was  indistinct  or  had  disappeared.  At 
certain  points,  in  place  of  gangliar  cells,  which  had  been 
observed,  a  lacuna  existed.  Around  the  diminished  cells 
of  Piirkinjc,  Obersteiner  has  noted  a  netting  formed  of  fine 
connective  tissue,  which   indicated  the  limits    of  the    form 


422  Joseph  Workmnn 


and  size  of  the  intact  cells ;  the  smaller  were  the  cells, 
the  wider  was  their  distance  from  the  net ;  and  when 
the  cells  completely  disappeared,  the  net  merely  enclosed 
the  space  where  they  had  existed. 

In  other  cases  of  atrophy  of  the    cerebellum,    nothing 
has  been  said  with    precision    respecting    its    genesis,    but 
they    are    interesting    from    an  anatomical    point    of    view. 
Miyficrt    made      microscopic      examination     in     a    notable 
case    of  atrophy  of  the  pons,     and    of    the     right  cerebel- 
lar   hemisphere,    and    he    found    atrophy    of    the    nervous 
elements    of    the  cortex,  man}-  connective  elements,    amy- 
loid    corpuscles,    and    a    degeneration    of    the    transverse 
fibres  which  go  from  the  mesocephalon   to    the  cerebellum  ; 
but  those  longitudinal  fibres,  which  were  carried  from  the 
cerebral    paduncles     into    the     bulb,    traversing    the    pons, 
were  intact.        The  atrophy  of  the  cerebellum,  which    was 
reduced  to  one-third    its    weight,    with    loss    of   the    ner\'e 
elements  and  an  increase  of  the  connective,  was  met  with, 
by  Clapton,  in  a  woman  of  33  years,  who  died  of  pleurisy. 
The  case  of  Pierret,  of  atrophy  of  the    pons,  the  bulb  and 
the  cerebellum  is  important.     The  atrophy  affected  specially 
the  gray  cortical  substance,  which  adhered  to  the  menin- 
ges,  and  was  transformed  into    a    species  of   fibroid    web. 
Under  the   microscope,  there  were  noted   disappearance  of 
the     large     nervous     cells,     and     sclerosis    of     the    white 
sub.stance ;    the     nuclei     denlati    were  normal ;    there    was 
a!mo-st  complete  atrophy  of  the  fibres  of  the  olivary  bulbs, 
and    of    the    transverse    of   the    pons,    in    consequence    of 
connective    neoformation.        The    atrophy    of   the    nervous 
elements  of  the  cerebellum,  with   sclerosis  of   the  connect- 
ive, had  been    noted    already,    first    by    the    distinguished 
observers,  Fiedler  and   Bcrgniaini,  in  a  man    of    72     years. 
and  by  Dugiiet  in    a    woman  of   62,  an    epileptic  ;    also  in 
another  woman  of  39.       In    the    first  two    of   these    cases 
the  cerebellum  was  less  than  the  normal  by  almo.st  one-half 
To  these   cases  of  atrophy  of   the  cerebellum,  we  ought 
to  add  \et,  that  described  by   Fischer,  in  which  the  maxi- 
mum length,  breadth  and  thickness  were   3  cm.   in  the  left 


Atrophy  of  the  CerebelluTn.  428 

hemisphere,  and  respectively  3.8,  4.5.  and  4.  in  the  right  ; 
and  that  of  Hiippcrt,  in  which  the  cerebellum,  the  pons 
and  the  bulb  were  reduced  much  in  size,  and  increased 
in  consistence. 

From  the  cases  described,  it  may  be  established  as 
the  general  fact,  that  atrophy  of  the  cerebellum  may  occupy 
both  hemispheres,  or  only  one,  and  that  it  is  character- 
ized by  sclerosis  of  the  organ,  from  hyperplasia  of  the 
interstitial  connective,  and  diminution  of  the  nervous  ele- 
ments in  quantity  and  volume.  We  would  call  attention 
also  to  the  circumstance  that,  in  many  cases,  diminution  of 
the  pons  has  been  observed,  and  in  some  of  the  bulb  also. 
This  fact  finds  explanation  in  the  anatomical  arrangement 
of  the  commissural  fibres,  which  are  carried  on  the  pons 
from  each  hemisphere  of  the  cerebellum,  across  the 
median  cerebellar  peduncles,  and  in  that  of  the  other 
fibres  which,  proceeding  from  the  cerebellum,  go  across 
the  corpora  restiformia,  to  form,  in  the  medulla  oblongata, 
the  rich  and  complex  system  of  arciform  fibres  {Mey- 
ncrt). 

In  consequence  of  this,  it  is  easy  to  admit  that,  as  in 
atrophy  and  sclerosis  of  certain  parts  of  the  cerebrum, 
from  a  process  of  secondary  descending  degeneration, 
there  succeeds  a  sclerosis  of  the  medullary  fasces  which 
proceed  from  it,  so,  on  the  other  hand,  it  should  happen 
in  all  the  nervous  fibres  which  are  found  related  to  the 
cerebellum,  when  this  organ  has,  for  a  long  time,  been  the 
subject  of  advancing  atrophy  and  sclerosis. 

As  relates  to  the  opinion  upheld  by  Meynert,  and 
rejected  by  others,  that,  between  the  cerebrum  and  the 
cerebellum,  there  exists  a  system  of  cross  fibres,  by 
means  of  which  a  hemisphere  of  the  one  is  connected 
with  an  opposite  one  of  the  other,  it  does  not  seem  to 
us  that,  in  the  cases  reported,  there  have  been  found 
facts  very  sufficient,  either  for  its  support,  or  for  its  denial. 
We,  however,  limit  ourselves  to ,  the  observation,  that,  in 
some  cases,  in  which  the  atrophy  was  bilateral,  but  greater 
in    one  hemisphere    than    in    the    other    {Otto,   Fisher),    we 


424  Joseph  Workman. 


do  not  find  mention  made  of  :i  difTcrcncc  between  the 
two  hemispheres,   in  volume. 

Taking  now  in  review  tlie  jjrincipal  facts  resulting 
from  the  clinical  examination  of  our  case,  they  are 
embraced  in  lesions  of  niotio/i,  under  the  form  of  inco-or- 
dination  of  all  the  movements  of  the  face,  the  trunk  and 
the  limbs;  in  lesions  of  sense  characterized  by  a  hyper- 
aesthesia,  general  and  transitory,  of  the  brain  ;  and  finalh' 
lesions  ps\'chical,  which  consis  ed  in  a  ver}-  limited  devel- 
opment o'i  the  intelligence,  to  which  were  added  at  a 
later  period  ideational  and  sensorial  disorders,  which, 
becoming  exacerbated,  rendered  necessary  the  confine- 
ment of  the  patient  in  our  asylum. 

As  legards  the  lesions  of  motion,  our  case  offers  much 
analogy  to  some  of  those  in  which  almost  the  same  ana- 
tomical alterations  were  met  with.  The  patient  of  Fiedler 
was  uncertain  in  his  movements;  he  fell  frequently,  and 
always  backward,  and,  in  walking,  ho  searched  to  lay  hold 
of  such  objects  as  he  found.  The  patient  of  Pierret 
walked  badly  from  infancy,  and  fell  readil}^  ;  afterward  she 
became,  from  time  to  time,  subject  to  general  tremor, 
and  had  an  irresistible  tendency  to  bend  to  the  right. 
Hi4ppe7't,  in  his  case,  met  with  movements  of  the  limbs, 
of  choreiform  character;  impossibilit)'  of  holding  the 
trunk  in  a  vertical  position,  tendency  to  fall  forward  or 
backwards,  without  ability  to  rise  again.  Disorders  of 
co-ordination,  and  uncertainty  in  the  movements,  were 
met  with  by  Meynevt,  Diignet,    Clapton  and  Pierret. 

These  clinical  observations  run  in  conformity  with  the 
doctrine  su.stained  by  the  majority  of  physiologists,  that, 
in  the  cerebellum,  the  co-ordination  of  the  different  mus- 
cular adaptments  necessary  to  maintain  the  equilibrium 
and  harmony  of  the  movements  of  the  whole  bod)',  or  of 
any  part  of  it,  has  its  origin.  hVom  the  beautiful  experi- 
ments of  Ferrier,  it  results  that  the  cerebellum  may  be 
considered  as  an  assemblage  of  centers,  of  which  those  of 
the  lateral  lobes  co-ordinate  the  lateral  and  rotary-  postu- 
lations,   whilst  those  of   the- median   lobe   serve  to    co-ordi- 


Atrophy  of  the  Cerebellum.  425 

nate  the  movements  forward  or  backward  of  the  body. 
Hence,  a  lesion  of  these  centers,  disturbing  their  func- 
tional synergy,  ought  necessarily  to  give  origin  to  loss  of 
harmony  in  the  actions  of  diverse  groups  of  muscles. 

As  to  the  further  consideration,  that  the  cerebellum 
must  exercise  a  considerable  influence  on  the  normal 
co-ordination  of  movements,  this  fact  is  demonstrated  also 
by  its  relation  with  the  multifold  fibres,  which  bring  the 
different  parts  of  the  body  into  relation  with  the  great 
nervous  centers.  In  fact,  b\'  means  of  the  restiform 
bodies,  and  more  especially  of  the  cuneiform  cords,  many 
fibres  of  the  spinal  marrow  are  carried  towards  the  corti- 
cal stratum  of  the  cerebellum ;  the  same  is  observed  as 
concerns  the  median  cerebellar  peduncles,  which  are  con- 
stituted in  part  of  fibres,  proceeding  from  the  cerebral 
peduncles.  By  means  of  the  latter,  an  anatomical  con- 
nection becomes  established  also  between  the  cerebrum 
and  the  cerebellum ;  and  this  is  rendered  yet  greater  b}' 
another  order  of  fibres,  which,  departing  from  the  corona 
radiata,  and  passing  under  the  posterior  portion  of  the 
thalamus  opticus  and  the  tubercula  quadra-gemini,  pro- 
ceed, after  crossing,  to  form  the  superior  cerebellar  pedun- 
cles (Ahyncrt). 

The  studies  of  Golgi  on  the  "Minute  Anatomy  of  the 
Human  Cerebellum,"  also  merit  special  mention.  This  dis- 
tinguished histologist  had  observed  a  direct  continuation 
of  the  nervous  fibres  of  the  medullary  substance  of  the 
cerebellum,  with  the  a.xial  prolongations  of  the  small  and 
large  gangliar  cells,  situated  in  the  external  or  molecular 
stratum. 

From  such  anatomical  results,  the  cerebellum  may  be 
considered  as  a  great  center,  in  which  the  peripheral 
impression,  carried  in  by  means  of  the  restiform  tracts 
and  the  inferior  peduncles,  of  those  movements  which 
have  their  origin  in  the  cerebrum,  are  transformed  into  an 
impulse  regulating  or  co-ordinating  the  diverse  musclar 
combinations  indispensable  to  the  maintenance  of  the 
equilibrium  of  the  bod\%    and    are    afterwards    transmitted 


426  Joseph  Workman 


to  tlic  spinal    nervous    apparatus    and  its  ramifications,    by 
means  of  the  median  cerebellar  peduncles. 

But,  with  this  opinion,  how  are  those  cases  to  be 
reconciled,  in  which,  while  an  atrophy  of  the  cerebellum 
was  present,  yet  inco-ordination  in  the  movements  was 
absent  ?  Thus,  the  little  patient  of  Combette  presented 
only  a  great  feebleness  of  the  legs ;  in  the  case  of  Ver- 
delli  the  movements  were  never  observed  to  be  inco-or- 
dinate ;  in  that  of  Otto,  considerable  muscular  power  was 
observed,  and  the  movements  were  safe  and  harmonious, 
but  had  an  impulsive  character.  No  lesion  of  movement 
existed  in  the  case  of  Lallonent.  We  hold  that,  in  such 
cases,  which  seem  contradictory  to  the  doctrine  that 
regards  the  cerebellum  as  an  organ  co-ordinatory  of 
movement,  divers  facts  should  be  examined,  and,  before 
all,  the  intimate  alterations  of  the  texture  of  the  organ. 
In  the  case  of  Otto,  certainly,  the  want  of-  lesion  of 
motional  co-ordination  is  easily  explained,  when  it  is  con 
sidered  that,  although  the  cerebellum  was  rudimentary,  it 
was  normally  organized,  and  hence  capable  of  functioning. 
"The  diverse  cortical  strata  were  distinct  and  well  formed, 
and  their  several  elements,  and  more  especially  the  gan- 
gliac  cells,  were  perfectly  normal.  The  nervous  fibres  of 
the  medullar}-  substance  had,  in  every  relation,  the  habit- 
ual aspect ;  there  were  no  alterations  of  the  connective  of 
the  vessels."  But  further  account  is  to  be  taken  of  the 
degree  of  disorganizing  lesion,  for  if  this  is  limited  to  one 
portion  of  the  cerebellum,  nothing  is  opposed  to  the 
admission  that  the  part  remaining  free  may  augment  the 
proper  activity,  invigorating  thus  the  function  of  the 
organ  which  might  be  debilitated  elsewhere.  The  case  of 
Lallfinvnt  affords  proof  of  this.  There  was,  in  truth,  an 
atrophy  of  the  left  hemisphere  of  the  cerebellum,  but,  at 
the  same  time,  there  existed  a  hypertrophy  of  the  other. 
It  should  be  remembered  that  Nath)iagcl,  resting  his 
decision  on  a  great  number  of  cases  of  disease  of  the 
cerebellum,  had  established  the  fact,  that  only  to  direct  or 
indirect  lesions  of  the  vermes  do    disturbances  of    co-ordi- 


Atrophy  of  the  Cerebellum.  427 


nation    stand    related  ;     therefore,    the    vermes    having,    in 
the    case    of    Lalltinoit,   remained    intact,    and    in    that    of 
Otto    ahnost  normal,    the     manifestation    of    alterations    in 
motion  must  have  been    impeded.     Lastly,    we    may    con- 
sider that  the  cerebral    hemispheres    themselves,    may,    in 
certain    cases,     compensate    the   diminished    or    abolished 
faculty  of  co-ordination  of  the  cerebellum  by  a  species  of 
x'oluntary    and     conscient     force,     by    which    it    becomes 
capable    of  reproducing  by    degrees,    and    in    harmonious 
method,     all    the    combinations    of    muscular    groups,    on 
which     the    equilibrium     of    the    body    depends     [Ferrier). 
Thus,    it    may    be    held,    that    to    favor    the    perfect  equili- 
brium  of    the    movements    in    a    few     cases     of    cerebellar 
atrophy,    the    action    of    certain     centers     has     concurred, 
which    together    constitute   the     so-called     excitable     zone 
of  the    cortex.     These    centers   which,  as  has  been  demon- 
strated   by    physiology  and  clinical  observance,  give   place 
to    well     determined     movements    of    various    groups     of 
muscles,     by    augmenting    the    proper    functional    energy, 
may    become   capable    of    co-ordinating    movements,   even 
without    the    combined    action    of    the    cerebellum.      It    is 
probable     then    that    this     compensation,    on    the     part     of 
the    cerebrum,    occurs    more     readily    the     earlier    the    age 
in    which    the    atroph}-     of    the     cerebellum     takes     place, 
because,   perhaps,    at    such    time,    the    intact    parts  have    a 
larger   field     for    nutrition,    growth    and    development,   and 
for    becoming  substitutive    of  those  with    which    they    are 
in    close    relation,     and     which     have    lost,     more    or    less, 
their    functional    activity.     This    may  find  a  certain  support 
in    the    fact,    that    those     cases    of    atrophy    of    the    cere- 
bellum, in  which  no  mention  is    made    of   disordered  co-or- 
dination,   were     congenital.       But,    in    our    case,    in   which 
the    atrophy    of  the    cerebellum  happened   long  after  birth, 
the    conditions     favorable    to    the    supply    to    the    deficient 
functionality    of  the     cerebellum,    would    be     wanting,     in 
consequence    of  which    the    inco-ordination   of  the    move- 
ments  could    neither    cease    nor    diminish    in    intensity. 
In  some  of  the  cases  cited  by  us,    of   atrophy    of   the 


428  Joseph  Workman. 


cerebellum,  epileptiform  convulsions  were  noted  {Combettc, 
Dugitet,  Vt-rdelli,  Pierrct).  It  is,  however,  difficult  to 
decide  whether  the}'  were  due  to  lesions  of  the  cerebel- 
lum, or.  as  appears  to  us  more  probable,  to  the  diffusion  of 
the  morbid  process  to  the  pons  and  the  medulla  oblongata, 
which,  according  to  some  physiologists,  have  so  great  a 
part  in  the  pathogenesis  of  the  epileptic  access. 

As  has  been  seen  in  the  history  of  our  case,  there 
were  observed  disorders  of  speech,  under  the  form  of 
stammering  and  the  impossibility  of  good  articulation  of 
sounds.  These  were,  however,  transitory,  they  appeared  onl)- 
in  some  periods  of  excitement ;  at  other  times,  in  which 
she  was  calm,  she  was  sufficiently  intelligent,  and  informed 
us  she  had  been  unable  to  speak  because  of  the  impos- 
sibility of  moving  the  tongue  as  she  wished.  At  other 
times,  on  the  contrary,  .whether  she  continued  calm,  or 
fell  into  excitement,  the  speech  was  quite  articulate.  The 
disturbances  of  the  speech,  mentioned  by  us,  seemed 
rather  to  proceed  from  defect  of  co-ordination  of  the 
nervous  apparatus,  destined  to  verbal  transmission,  than 
to  disorder  of  ideation,  since  the  patient,  during  her  calm 
periods,  manifested  discreetly  ordinate  ideas,  however 
limited  they  were,  but,  at  the  same  time,  spoke  stammer- 
ingly,  and  with  such  irregularity  as  frequently  to  render 
it  difficult  to  understand  her.  As  then  the  movements 
of  the  tongue  and  lips  were  not  at  all  paralyzed  (  ?  )  but 
only  very  inco-ordinate,  it  is  legitimate  to  suppose  that 
this  disorder,  like  th  it  in  the  limbs,  depended  on  defective 
functional  co-ordination  of  the  various  parts  of  the 
nervous  center,  destined  to  associate  properly  the  complex 
muscular  apparatus,  which  serves  for  the  extrinsication  ui 
thought  and  the  formation  of  speech.  Applying,  however, 
the  classification  proposed  by  Prof.  Tamburini,  for  the 
diverse  forms  of  aphasia,  we  should  say  that  in  our  case 
we  had  an  aphasia  from  disordinatc  trans)nissioii,  and 
more  exactly  of  that  variety  which  he  denominates ///f^y/^^- 
ata.xia  (glosso-ataxia  of  Jaccoiid).  But  more  than  the 
clinical  analysis  does  the   pathological  alteration,  found   by 


Atrophy  of  the  Cerebellum.  429 

us,  in  the  cerebellum  authorize  admission  of  the  above 
named  form  of  aphasia,  as  this  corresponds,  by  its  seat, 
to  that  which  constitutes  the  ordinary  record  of  phono- 
ataxia.  In  fact,  from  the  case-histories  collected  by 
Prof.  Tamburini,  with  the  view  of  bringing  into  prominence 
the  different  lesions  which  correspond  to  the  various  forms 
of  aphasia,  it  results  that,  in  cases  of  phonoataxia,  the 
lesion  occupies,  prevalently,  the  pons  and  the  medulla 
oblorigata  (and  more  especially,  the  olivary  prominences 
of  the  latter),  and  the  cerebellum ;  from  which  it  may 
be  inferred  that  all  these  parts  are  engaged  in  the  trans- 
mission of  words  and  the  articulation  of  sounds,  and 
thus  constitute  a  connecting  path  between  the  organ 
of  ideation   and     that    of  sensation. 

It  is  true  that,  in  wishing  to  bring  into  relation, 
the  disorders  of  speech  with  cerebellar  alterations,  it  is 
difficult  to  reconcile  the  permanence  of  the  one  with 
the  transience  of  the  other,  unless,  at  least,  we  should 
have  recourse  to  the  hypothesis  of  a  functional  instability 
of  the  co-ordinating  centers  of  language,  through  which 
these,  in  certain  periods,  shall  respond  in  a  synchronous 
manner  to  the  voluntary  impulse,  producing  thus  the 
associate  movements  of  the  muscles  of  the  vocal  organs ; 
and  in  others,  in  which  this  synchronism  fails,  the 
muscles  may  enter  into  action  at  different  moments, 
and  the  articulation  of  sounds  may  then  become  irregular 
and  indistinct.  It  is  interesting  to  bear  in  mind  that,  in 
almost  all  the  cases  of  atrophy  of  the  cerebellum  and  the 
bulb,  disturbances  of  the  speech  have  been  noted, 
under  the  form  of  difficulty  in  the  pronounciation  of 
words  and  the  articulation  of  sounds,  a  fact  which 
tends  to  confirm  what  has  been  pointed  out  and  admit- 
ted by  all  pathologists,  to-wit :  that  in  the  cerebello- 
bulbar  regions  the  centers  destined  to  verbal  transmission 
are   placed. 

The  integrity    of  the    cutaneous    and    reflex   sensibility 

noted    in    M ,    corresponds  to  what  has    been    observed 

by  Luys  in  cases  of  cerebellar  disease,  and  to  the  experiments 


430  Joseph  Workman. 


made  on  animals  by  Broivn-Seqiiard,  Vulpian  and  Ferrier, 
who  have  found  the  sensibUity  of  the  skin  intact,  even 
after  considerable  lesions  of  the  cerebellum.  This 
accordance  of  clinical  with  experimental  facts  may 
stand  as  proof  that  the  nervous  fibres  which  proceed 
from  the  entire  cutaneous  envelope,  do  not  go  to  the 
cerebellum,  since,  if  they  did,  we  could  not  understand 
how  atrophy,  or  destruction  of  the  organ,  could  occur 
without  alteration  of  the  cutaneous  sensibility.  Liisajma, 
on  the  contrary,  holds  that,  in  such  cases,  there  exists 
only  a  lesion  of  the  imiscular  sense,  that  through  which 
we  have  the  idea  of  the  intensity  of  the  muscular  contraction 
necessary  to  overcome  resistences,  and  by  which  the  position 
of  our  body  is  recognized,  and,  it  is  understood,  that  we 
thus  have  the  power  of  maintaining  it  in  equilibrium,  both  in 
standing  and  locomotion.  Whether  such  a  theor}^  may  find 
place  in  our  case  or  not,  we  cannot  say,  since  the 
state  of  the  patient  prevented  us  from  practicing  all  those 
minute  inquiries  that  are  requisite  for  determining,  with 
exactitude,  the  existence  and  the  degree  of  the  muscular 
sense.  We  may  not,  however,  be  indisposed  to  admit 
that,  as  in  degeneration  of  the  posterior  cords,  from 
which  ataxia  of  movements  arises,  the  muscular  sense 
may  be  found  abolished,  and  yet  the  cutaneous  remain 
intact  ;  the  like  condition  may  be  found  in  lesions  of  the 
cerebellum,  into  which  many  fibres  of  these  cords  are 
continued  by  means  of  the  corpora  restiformia.  In  this 
relation,  the  case  already  mentioned  by  Huppert,  seems 
to  us  to  be  very  instructive ;  it  was  that  of  a  man  of 
24  years,  a  victim  to  choreiform  ataxic  movements. 
There  were  no  disturbances  of  sensibility,  nor  any  of 
the  reflex  action ;  muscular  force  was  not  diminished, 
but  the  patient  could  not  appreciate  the  exact  position 
of  the  limbs,  and  of  the  vertebral  columns,  in  the  act 
of  executing  any  movement.  In  consequence  of  this, 
Huppert  holds  that  the  cerebellum  regulates  and  co-ordinates 
the  voluntary  movements  by  means  of  impressions 
resulting    from    muscular    contractions.       As    remains,   this 


Atrophy  of  the  Cerebellum.  43 J 

opinion  does  not  at  all  weaken  that  advanced  by  us, 
which  is,  that,  through  a  conscient  voluntary  force  co- 
operating with  education,  it  may  be  possible  to  regulate 
all  the  muscular  adaptments,  which,  primarily  organized 
in  the  cerebellum,  become  automatically  accomplished 
in  associate  method,  after  having  been  disordered 
by  lesion  of  the  organ,  and  so  much  the  more  probable 
is  this,  when  we  recollect  that,  in  order  to  maintain 
well  the  equilibrium  of  the  body,  there  concur,  as 
co-ordinatory  means,  not  only  the  impressions  proceeding 
from  the  muscular  apparatus,  but  also  the  cutaneous 
sensations,  and   those    of  sight    and  hearing. 

As  regards  those  transient  phenomena  of  hyperaes- 
thesia  which  appeared  in  our  case,  we  do  not  believe 
that  we  should  take  them  into  consideration  since  they 
were  noticed  only  in  those  periods  of  high  psychical 
excitement,  in  which,  as  has  been  stated,  the  function 
of  the  sensorial  apparatus  was  so  exaggerated,  as.  upon 
the  slightest  stimulation,  to  give  back  the  most  vivid 
and  prompt  reaction.  Much  rather  would  we  claim 
attention  to  the  fact  of  occipital  pain,  of  which,  as  has 
been  stated  in  the  history  of  the  case,  the  patient  often 
complained  in  the  period  which  followed  the  typhus. 
This  symptom,  which,  in  hardly  any  of  the  cases  of 
atrophy  of  the  cerebellum  has  been  mentioned,  has,  in 
our  case,  a  certain  value,  both  as  regards  its  seat,  and 
the  time  at  which  it  was  presented,  since  it  may  sup- 
port  the    hypothesis    emitted    by    us,  that  in  M there 

was  initiated,  during  the  typhus,  a  morbid  process  in 
the   cerebellum,    which    terminated    in   final    atrophy. 

The  tardy  and  limited  development  of  the  intelligetice 
has  been  noted  in  several  cases  of  atrophy  of  the  cere- 
bellum [Combette,  Fiedler,  Verdelli,  Otto).  We  do  not, 
however,  believe  that  between  the  two  facts  there  was 
the  relation  of  cause  and  effect,  for  any  such  supposition 
would  stand  in  open  contradiction  to  whatever  has  been 
demonstrated  by  comparative  anatomy,  physiology  and 
pathology ;    and    this  is,  that  the    psychical    faculties  have 


432  Joseph   Workman. 


their  exclusive  seat  in  the  cerebral  hemispheres.  To  the 
modifications  of  these  alone,  ought  we  to  have  recourse, 
for  explanation  of  the  trivial  mental  development  in  the 
cases  mentioned ;  nor  does  the  fact  that  they  have  not 
been  observed  on  the  table  of  the  anatomist,  constitute  a 
valid  reason  for  denying  them,  for  frequently  so  delicate 
are  the  morbid  processes  which  have  their  seat  in  the 
nervous  system,  that  they  escape  our  means  of  detection. 
In  the  case  described  by  us,  of  atrophy  of  the  cerebellum, 
better  than  in  any  other,  every  relation  of  causality 
between  it  and  the  defective  intelligence  may  be  excluded. 
In  fact,  this  condition  was  manifest    from    the    infancy 

of  M ;  that  is,  at  a  time  in  which  the  cerebellum  had 

very  probably  attained  its  normal  development.  If,  on 
the  other  hand,  we  take  into  account  the  poor  nourish- 
ment she  received  from  her  birth  onward,  her  feeble  con- 
stitution, and  her  very  limited  education,  we  need  not 
marvel  that  the  brain  felt  the  injurious  influence,  and  being 
poorly  nourished,  it  did  not  present  in  its  elements  all 
those  conditions  of  structure,  chemical  composition  and 
organization    which    constitute    the    fundamental    bases    of 

normal    intellectual    development.      In     M ,    therefore, 

there  was  verified  from  her  childhood  a  limitation  of  the 
sphere  of  the  psychical  phenomena,  though  these  were 
not  discovered  from  the  first.  But,  with  the  occurrence 
of  typhus,  at  the  age  of  28,  real  mental  disorders  began 
to  manifest  themselves,  dependent,  perhaps,  on  infection 
of  the  blood,  which  must  have  very  profoundly  altered 
the  nutrition  of  the  brain,  which  was  already  predisposed 
to  disease.  Neither  did  the  mental  disorders  ever  pass 
away;  to  which  misfortune,  without  doubt,  the  absolute 
impossibility  in  which  she  found  herself  of  procuring  those 
means  which  might  have  improved  and  restored  her  feeble 
and  ill-fed  organism,  must  have  not  a  little  contributed. 
Instead  of  this  improvement,  the  psychical  disturbances 
went  on,  subject  to  periods  of  exacerbation,  associated 
with  sensorial  disorders,  and  its  condition  reached  such  a 


Atrophy  of  the  Cerebellum.  433 


point  in  May    of  this    year,    as    to    render    necessary    the 
confinement  of  the  patient  in  our  insane    asylum. 

After  the  observations  offered  on  the  principal  mor- 
bid phenomena  of  our  clinical  case,  we  may  be  permitted 
to  add  a  few  words  on  the  theory  of  Gall,  according  to 
whom  the  cerebellum  is  the  seat  of  the  erotic  sense  and 
the  sexual  appetite.  Many  illustrious  scientists  have 
already  demonstrated  the  erroneousness  of  this  doctrine, 
on  experimental  and  pathological  data,  and  have  entirely 
denied  it.  To  us  it  suffices  to  remember  how  contrary  to 
this  assigned  localization  was  the  case  of  Combette,  in 
which  nymphomania  was  noted,  and  that  of  Otto,  in 
which  there  was  an  immoderate  venereal  appetite,  that 
rendered  the  patient  onanistic  and  pederastic.  On  the 
other  hand,  recent  psychological  studies,  founded  not 
upon  vain  metaphysical  doctrines,  but  on  objective  method, 
contradict,  in  an  absolute  manner,  the  doctrine  of  Gall; 
by  these  we  have  been  led  to  admit  that  the  sexual 
appetite,  like  all  the  other  instincts,  has  its  seat  in  the 
cerebrum,  and  that  it  represents  merely  a  demand  pro- 
duced in  the  cerebral  centers  for  satisfying  a  sensation, 
in  sequence  to  impressions,  which,  having  traversed  the 
centripetal  nervous  fibres,  proceed  to  the  genital  organs. 
Onanism,  which  is  but  one  of  the  forms  in  which  exag- 
gerated sexual  instinct  manifests  itself,  may  be  of  either 
peripheral  or  central  origin,  according  as  the  morbid  irri- 
tation has  its  seat  in  the  nervous  fibres  which  ramify  on 
the  genitals,  or  in  those  regions  of  the  brain  which  cor- 
respond to  them.  Now,  it  appears  according  to  the  late 
researches  of  Ferrier,  that  the  visual  sensations  have  their 
seat  in  the  occipital  lobes  (of  the  cerebrum);  and  those 
which  proceed  from  the  genital  organs,  and  are  at  the 
basis  of  the  sexual  appetite,  being  of  a  tactile  nature, 
will  be  found  located  in  a  center,  probably  situated  in  the 
occipito  temporal,  or  the  temporo-sphenoidal  convolutions, 
which  have  a  close  relation  with  the  region  of  the  hippo- 
campus, which  has  been  considered  by  that  eminent 
physiologist  as  the  center  of  the    tactile    sensations.     This 


434  Joseph  Workman. 


localization  of  the  sexual  appetite,  admitted  by  Fcrrier 
as  an  hypothesis,  waits  for  further  research  for  its  con- 
firmation. The  opinion  of  Hitzig  seems  to  us  sufficiently 
just,  that  friction  of  the  genitals  does  not  always  indicate 
an  excessive  development  of  the  sexual  appetite,  since  it 
is  practiced  more  especially  by  individuals  in  a  state  of 
pronounced  dementia,  who,  in  all  probability,  do  not  know 
what  they  are  doing,  nor  experience  any  erotic  feeling. 

Desiring  now  to  resume  the  principal  considerations 
which  proceed  from  the  study  of  our  case,  and  of  other 
cases  analagous,    it  may    be   established    that : 

1st.  The  microscopic  alterations,  which,  in  general, 
characterize  atrophy  of  the  cerebellum  are :  enormous 
development  of  the  interstitial  connective  and  atrophy 
of  the  cells  of  Piirkinje.  These  either  disappear  totally, 
or  are  presented  small  in  volume,  irregular  in  outline, 
with  granulous  contents ;  nuclei  and  nucleoli  little  or  not 
at  all  distinguishable,  and  scarce  and  slendor  prolongations. 
The  nervous  fibres  are  also  diminished  in  quantity  and 
size. 

2d.  The  principal  morbid  phenomena,  that  accom- 
panies atrophy  of  the  cerebellum,  is  inco-ordination  of  the 
movements;  but  this  is  not  a  constant  phenomenon,  since, 
in  some  cases,  it  is  wanting. 

3d.  The  latency  of  ataxia  in  atrophy  of  the  cerebellum, 
may  be  explained  either  by  the  normal  structure  of  the 
organ,  notwithstanding  its  diminution,  or  by  the  augmented 
functional  activity  of  those  parts  of  the  cerebellum  free 
from  the  atrophic  process,  or  by  the  integrity  of  the 
vermes,  or,  lastly,  by  a  conscient,  voluntary  and  newly 
aroused  force,  by  which  the  cerebrum  supplements  the 
co-ordinating  activity  of  the  cerebellum. 

4th.  Disorders  of  the  cutaneous  sensibility  are  not 
presented  in  atrophy  of  the  cerebellum. 

5th.  The  localization  of  venereal  appetite  in  the 
cerebellum  is  erroneous. 

In  addition  to  the  considerations  which  the  explanation 
of  our  case  has  suggested,  it  may  not  be  superfluous,   basing 


Atrophy  of  the  C erebellum.  435 

our  views  upon  it,  and  on  so  much  as  has  been  observed  by- 
others  in  atrophy  of  the  cerebellum  that  we  add  a  brief  obser- 
vation on  the  principal  facts,  which  may  sometimes  prove 
useful  in  the  differentiation  of  this  affection  from  other 
diseases  which  have  their  seat  in  the  cerebellum  or  else- 
where. Among  these,  a  chief  position  is  occupied  by 
neoplastic  processes,  which,  with  a  certain  frequency,  are 
developed  in  the  cerebellum.  Indicative  of  these,  two 
phenomena  of  no  small  value  are  presented,  which  are 
wanted  in  atrophy  ;  these  are  pain,  located  most  commonly 
in  the  occiput,  and  continuous  or  intermitting  vomiting. 
There  are  other  secondary  phenomena,  as  disturbances 
in  the  circulation,  and  respiration,  lesions  of  some  of  the 
nerves  of  the  cranium,  due  to  relations  more  or  less 
extensive,  assumed  by  the  neoplasm  of  the  cerebellum 
with  adjacent  parts.  In  some  of  these  cases,  however, 
it  is  found  that  the  symptomatology  of  the  cerebellar 
tumor  corresponds  so  exactly  to  that  of  simple  atrophy, 
that  differentiation  becomes  impossible.  We  should,  in 
such  circumstances,  always  bear  in  mind  that  atrophy  of 
the  cerebellum  is  an  extreme  rarity  [Hitaig). 

It  may  be  less  difficult  to  avoid  confounding  atrophy 
of  the  cerebellum  with  locomotor  ataxy,  though  sometimes 
identical  disturbances  of  movements  are  presented,  as  loss 
of  the  faculty  of  association  and  co-ordination.  In  atrophy, 
however,  the  terrible  neuralgic  pains,  the  hypersesthesia 
of  the  neck  of  the  bladder,  the  stomach  pains  which  are 
observed  in  the  first  stage,  besides  the  diminution  of  the 
various  sorts  of  sensibility,  and  especially  the  loss  of  the 
tendon  reflex  [We stphal,  Erb,  Rosenthal),  y^hlch  is  observed 
in  the  more  advanced  periods  of  tabes  dorsalis,  are 
absent.  In  the  latter  disease,  the  optic  nerve  is  generally- 
affected  with  gray  degeneration,  causing  ambliopia  and 
amaurosis,  and  paralyses  are  presented  in  the  districts  of 
some  of  the  cerebral  nerves,  among  which  those  of  the 
eye  are  included.  Finally,  in  ataxy,  embarrassment  of 
the  speech  is  very  rare  [Charcot,  Rosenthal [yy).  We  may 
here  recollect  that,  in    our    case,  the    examination    of  the 


436  Joseph  Workman. 


ocular  fundus  gave  a  negative  result ;  vision  was  distinct, 
and  the  tendon  reflex  persisted,  since  the  slightest  blow 
on  the  patellar  tendon,  whilst  the  limb  was  semi  flexed 
and  relaxed,  caused  prompt  and  energetic   extension. 

Bulbar  paralysis  presents,  in  its  symptoms  and  rapid 
course,  a  picture  altogether  different  from  that  of  atrophy 
of  the  cerebellum.  The  characteristics  are  distinct, — as 
the  paralytic  disturbances  in  the  field  of  the  hypoglossus, 
the  facial,  the  vagus,  the  glosso-pharingeal,  by  which 
deglutition,  speech  and  the  functions  of  the  heart  and 
lungs  are  profoundly  altered.  In  general,  disorders  of 
co-ordination  in  the  movements  of  the  body  are  not 
observed,  but  rather  paralytic  phenomena. 

Lastly,  we  may  observe  that  the  tremor,  which  accom- 
panies all  the  voluntary  movements,  the  intense  head 
pain,  the  vertigo,  the  muscular  spasms,  the  visual  and 
mental  disturbances,  are  readily  met  with  in  diffuse  cerebro- 
spifial  sclerosis,  which,  in  certain  cases,  presents  in  common 
with  atrophy  of  the  cerebellum,  defectively  co-ordinate 
movements  and  disorders  of  the  speech. 


We  have  deemed  it  more  just  to  the  author,  and  more 
gratifying  to  our  readers,  to  reproduce  the  whole  of  Dr. 
Seppilli's  article,  than  to  present  selected  abstracts,  which, 
detached  from  their  context,  might  but  imperfectly  rep- 
resent the  interesting  case  described  by  him,  and  the 
very  important  conclusions  educed  by  him  from  it.  We 
cannot,  perhaps,  better  manifest  our  appreciation  of  this 
contribution  of  our  Italian  confrere  to  the  histology  and 
pathology  of  cerebellar  disease,  than  by  expressing  the 
hope  that  it  will  be  read  by  the  subscribers  to  the 
"Alienist  and  Neurologist"  with  the  same  instruction 
and  pleasure  as  we  have  found  in  its  translation  from 
the  grand  and  lovely  language  of  the  Roman  penin- 
sula into  our  own  less  glowing,  though  not  less  powerful 
Anglo-American    dialect. 

We  have  no  preten.sions  to  that  critical  competence 
which    should    be    possessed    by    one    qualified    to    pass    a 


Atrophy  of  the  Cerehellum.  437 

just  judgment  on  any  article  coming  from  the  pen  of  so 
erudite  and  careful  a  writer  as  Dr.  Seppilli  has,  in 
this    valuable    brochure,    shown    himself  to    be. 

We,  therefore,  with  full  confidence  in  the  generosity 
and  the  scientific  acumen  of  his  trans-atlantic  brethren, 
leave  his  little  work  to  be  judged  of  on  its  own  merits, 
but  with  the  hope  that  it  will  be  read  and  pondered 
over  with  that  sedulous  attention  to  which,  as  we  believe, 
it    is    amply   entitled. 


Art.  II.— Notes  on  Neurasthenia.'^ 


From  an  AUenLfs  Standpoint,  intended,  mainly,  to  introduce  the  views  of  a 
Pioneer  American    Writer. 


By  C.  H.  Hughes,  M.  D,. 

FORMER     MEDICAL     SUPERINTENDENT    OF     THE     MISSOURI     STATE    LUNATIC 

ASYLUM,    CONSULTING     PHYSICIAN     TO     THE     MISERICORDIA 

ASYLUM   FOR  THE  INSANE,   AND    TO  THE  FEMALE 

HOSPITAL,   ST.   LOUIS. 

'Hp^'O  the  neurologist  neurasthenia  is  not  novel,  and 
-*•  alienist  physicians  have  long  been  familiar  with  it. 
Its  frequent  sequence  is  insanity ;  its  principal  and 
most  characteristic  symptoms  are  psychical,  for  its  pres- 
ence is  often  first  revealed  in  cerebrasthenia  and  it  often 
likewise  end  5,  if  unarrested  by  favoring  circumstances  or 
timely  treatment,  in  brain  exhaustion. 

The  general  practitioner,  as  well  as  the  neurologist 
and  alienist,  have  often  encountered  it  and  treated  it 
under  the  form  of  general  debility,  hysteria  or  chronic  mala- 
rial poisoning.  From  time  immemorial  it  has  been  more  or 
less  clearly  discerned ;  even  Hippocrates  treated  it,  and 
the  other  old  English  writers  saw  it,  though  darkly,  as 
through  a  glass. 

*  Having  askeil  the  President  of  a  Medical  Society  ttiat  hail  solicited  an  address 
from  us,  what  subject  would  please  th.' Society  best,  lie  said  "Neurasthenia,"  but 
tne  Committee  had  already  announced  for  us  another  subject.  This  is  the  beginning 
of  an  effort  to  piease  that  "friend  and  Society. 


438  C.  B.  Bushes. 


The-  term  is  an  older  one  than  tlie  science  of  neurol- 
ogy. More  than  a  quarter  of  a  century  ago  Dunglison's 
dictionary  gave  its  derivation  from  Vivpov,  a  nerve,  and 
acrdevsia,  debility,  with  a  Latin  synonym  of  dcbilitas  nervosa. 
This  is  the  true  signification, — debility  of  the  nervous  sys- 
tem, nervous  exhaustion,  with  this  qualification  that  the 
disease,  neurasthenia,  as  contra-distinguished  from  physio- 
logical nerve  exhaustion,  or  the  coincident  nervous  debility 
of  other  diseases,  is,  essentially,  a  chronic  and  slowly  cul- 
minating exhaustion  of  the  nervous  system  not  necessarily 
or  demonstrably,  due  to  recognizable  precedent  changes  in 
the  blood,  but  inherent  in  the  cerebro-spinal  or  sympa- 
thetic nervous  systems,  or  in  both,  but  more  especially, 
and  I  believe  generally  primarily,  appearing  in  the  latter. 
Neurasthenia  is  then  a  chronic  disease  of  the  nervous 
system,  caused  by  long  continued  overaction  and  strain 
of  this  system  in  one  or  all  of  its  parts,  unaccompanied 
with  adequate  nerve  nutrition  and  nerve  rest.  It  is  the 
stammering  outcry  of  the  brain  and  nerves  for  needed 
repair — the  unstable  expression  of  the  dis-equilibrium  of 
repair  and  waste  in  the  nervous  organism. 

While  it  is  essentially  slow  in  its  formative  stages,  it 
often  displays  itself  in  an  apparently  sudden  break-down  ; 
breaking  out  like  a  long  smothered  flame,  or  like  a  river, 
long  retained  by  a  dam,  until  a  sudden  flood  breaks 
through  the  restraining  embankment  and  reveals  its  inher- 
ent weakness. 

Neurasthenia  is  mainly  a  disease  of  adult  life,  and  is 
mostly  seen  in  the  male  at  that  period  when  prose  sup- 
plants the  poetry  of  existence,  and  the  real  labor  of  life 
and  its  trials  supplement  the  recreations  and  exhubcrent 
enjoyments  of  youth ;  when  the  fancies  of  dawning  manhood 
are  dissipated  by  the  stern  realities  of  existence.  The 
period  when  work  is  hardest,  cares  and  sorrows  are 
most  numerous,  and  the  tests  of  our  inherent  strength  of 
organism  are  greatest.  Real  neurasthenia  seldom,  if  ever, 
appears  to  man  or  woman  before  puberty;  but  to  women, 
after  repeated   child    bearings,    and    lengthened    lactations. 


iN'ntes  on  iN'eur asthenia.  439 

domestic  infilicities  and  bereavements,  it  is  no  stranger. 
This  neitrasthenia  jiiatronis  is  even  more  familiar  to 
the  neurologist  and  general  practitioner  than  viCDuistiipral 
nerve  cxhajistion,  or  the  exhaustion  of  conjugal  onanism  of 
Goodell — the  sexual  neurasthenia  of  Beard. 

When  the  strain  of  the  passions  and  vices,  superadded 
to  the  struggle  for  existence,  or  ambition  for  success,  in  the 
race  of  life  are  greatest,  is  when  the  nervous  system  of  man 
breaks  down,  and  neurasthenia  and  its  attendant  train  of 
neuropathic  and  other  (and  organic)  lesions  appear. 

Dr.  Geo.  M.  Beard,  of  New  York,  has  recently  given 
new  emphasis  to  the  study  of  this  interesting  subject, 
though  his  enthusiasm  has  led  him  into  too  indiscriminate 
a  symptomatology,  and  into  a  too  voluminous  and  need- 
less symptomatic  nosology. 

To  an  American  superintendent  and  physician  of  a  hos- 
pital for  the  insane,  is  due  the  credit  of  having  first,  in  this 
country,  clearly  pointed  out  and  differentiated  neurasthenia 
from  other  diseases.  The  name  of  that  physician  is  Dr.  E.  H. 
Van  Deusen,  of  Kalamazoo,  Michigan.  In  a  supplement  to 
the  bienniel  report,  of  the  Michigan  Asylum  for  the  Insane, 
for  1867-8,  under  the  caption  of  ''Observations  on  a  Form 
of  Nervous  exhaustion  {Neurasthenia^  Culminating  in  Insan- 
ity^' he  wrote  as  follows:  Our  observations  have  led  us  to 
think  that  there  is  a  disorder  of  the  nervous  system,  the 
essential  character  of  zvhich  is  well  expressed  by  the  term 
given  above,  and  so  uniform  in  development  and  progress  that 
it  may,  with  propriety,  be  regarded  as  a  distinct  form  of  dis- 
ease." In  this  instance,  as  in  many  others,  the  medical 
superintendents  of  the  hospitals  for  the  insane,  in  this 
country,  have  anticipated  the  profession  outside  of  them  in 
important  contributions  to  clinical  medicine. 

This  excellent  paper  of  Dr.  Van  Deusen  reappeared 
also,  at  a  later  date  in  the  American  Journal  of  Insanity, 
in  April,  1869,  a  little  in  advance  of  Dr.  Beard's  first  pub- 
lished paper  on  the  subject,  so  that  Dr.  Beard  will,  at  least, 
have  to  share  the  honors  of  pioneer  work  in  this  field  on 
this  side  of  the  Atlantic,  with  the   asylum   superintendent,  if 


440  C.  R.  Hughes. 


he  does  not  accord  to  him  absolute  priority.  While 
American  alienists  will  discover  nothing  to  them  especially 
novel  in  Dr.  Van  Deusen's  contribution,  the  paper  will 
prove  to  the  general  practitioner,  an  excellent  companion 
to  Dr.  Beard's  new  book,  as  it  will  enable  the  latter  to 
discern  the  approach  of  insanity  in  some  of  their  patients 
and  to  put  a  timely  stop  to  its  progress.  Dr.  Van 
Deusen   says : 

''Among  the  Causes  (of  Xeurasilienia),  excessive  mental  labor, 
especially  wlien  conjoined  with  anxietj-  and  deticient  nourishment,  ranks 
tii-st.  it  is  also  traceable  to  depressing  emotions,  grief,  domestic  trouble, 
piolonged  anxiety  and  pecuniary  embarrassment; hemorrhage  and  debili- 
tating diseases,  following  or  coincident  with  depressing  mental  inlluences 
and  sleeplessness.  Prolonged  exposure  in  a  malarial  region  under  certain 
circumstances  may  also  induce  it. 

Its  Leading  Symttoms  are  general  malaise,  impaired  nutrition  and 
assimilation;  muscular  atonicity.  changing  the  expression  of  the  counte- 
nance; uterine  displacements,  with  consequent  results,  and  neuralgias  of 
debility,  cerebral  anjemia,  with  accompanj'iug  tendency  to  hypera'Sthesia. 
irritability,  mental  depression,  impaired  intellection,  melancholia  and 
mania.  In  cases  terminating  fatalh  ,  death  ensues  from  exhaustion,  or 
from  coma,  with  extensive  sub-arachnoid  effusion. 

Malaria.— If  an  individual  exposed  to  malaria  is  in  robust  or  usual  good 
health,  and  the  exposure  be  recent,  we  may  have  the  ordinary  phenomena  of 
intermittent  fever,  .is  generally  met  within  all  malarial  districts.  If  the 
reverse  be  the  case,  and  the  resistive  power  of  the  individual  be  less,  the 
result  is  often  a  series  of  neur.ilgic  affections  and  disabilities,  of  frequent 
occurrence  in  the  experience  of  every  practitioner  of  medicine ;  but  occa- 
sionally, when  the  struggle  is  prolonged  and  under  circumstances  of  a  pecu- 
liarly depressing  character,  the  nervous  system  is  weakened  and  its  func- 
tions Ijecome  disordered,  the  secretions  are  more  or  less  deranged,  diges- 
tion is  enfeebled,  tlie  patient  becomes  irritable  and  depressed,  and  serious 
intellectual  rlisturl)ance  ensues.  Thus  may  malaria  develop  the  morbid 
condition  now  under  consideration. 

Physicians  i)ractising  in  malarial  districts  are  familiar  with  the 
multiform  nervous  phenomena,  occurring  as  a  consequence  of  exposure 
to  the  malarial  poison,  so  frequently  met  with  in  certain  localities. 
They  are  constantly  meeting  with  neuralgic  and  morbid  mental  man- 
ifestations, sometimes  carried  even  to  the  point  of  maniacal  excite- 
ment, all  solely  attributable  to  the  effects  of  this  strange  poison.  They 
find  no  difficulty  in  detecting  their  nature  and  cause,  and  applying suit.ible 
remedies.  Many  of  our  physicians,  also,  are  perfectly  familiar  with  the 
particular  ailment  now  under  consideration,  and  have  readily  recognized 
the  points  of  differential  diagnosis. 

Otheu  Cai-ses.— In  by  far  the  larger  i)roi>orti()n  of  cases,  however.which 
have  been  presented  fur  treatment  in  this  institution,  malaria  can  have  had 


Jfotes  on  Neurasthenia.  441 


no  influence,  either  recent  or  remote,  in  the  causation  of  the  disease.  In 
most  of  them  there  had  been  a  coincidence  of  depressing  influences,  under 
which  even  the  most  robust  and  healthy  organizations  have  finally  yielded. 

The  exhaustion  consequent  upon  protracted  attendacce  at  a  sick  bed, 
with  loss  of  sleep  and  irregular  meals,  solicitude  as  to  the  final  issue,  and, 
in  case  of  a  fatal  termination,  the  shock  of  the  bereavement,  is  a  cause.  It 
has  occurred,  too.  in  the  persons  of  those  occupying  positions  of  great 
responsibility,  the  duties  of  which  were  of  a  nature  to  make  heavy  demands 
upon  the  nervous  energies  of  the  individual,  and  at  the  same  time  deprive 
him  of  the  large  amount  of  sleep  rendered  requisite  by  the  exhausting 
labors  of  the  position. 

The  early  married  life  of  the  wives  of  some  of  our  smaller  farmers 
seems  especially  calculated  to  predispose  to  this  condition.  Transferred 
to  an  isolated  farm-house,  very  frequently  from  a  home  in  which  she  had 
enjoyed  a  requisite  measure  of  social  and  intellectual  recreation,  she  is 
subjected  to  a  daily  routine  of  very  monotonous  household  labor.  Her 
new  Aowe.  if  it  deserves  tbe  name,  is,  by  a  strict  utilitarianism,  deprived 
of  everything  which  can  suggest  a  pleasant  thought:  not  a  flower  blooms 
in  the  garden ;  books  she  has,  perhaps,  but  no  time  to  read  them.  Remote 
from  neighbors,  as  in  sparsely  settled  districts,  for  weeks  together,  she 
fees  only  her  husband  and  the  generally  uneducated  man  who  shares  his 
toil. 

The  urgency  of  farm  work  necessitates  hurried,  unsocial  meals,  and 
as  night  closes  in,  wearied  with  his  exertions,  the  farmer  is  often  accus- 
tomed to  seek  his  bed  at  an  early  hour,  leaving  his  wife  to  pass  the  long 
and  lonely  evening  with  her  needle.  Whilst  tlie  disposal  of  his  crops, 
and  the  constant  changes  in  the  character  of  farm  labor  aflbrd  her  husband 
sufficient  variety  and  recreation,  her  daih'  life,  and  especially  if  she  have 
also  the  unaided  care  of  one  or  two  ailing  little  children,  is  exhausting  and 
depressing  to  a  degree  of  which  but  few  are  likely  to  form  any  correct 
conception.  From  this  class  come  many  applications  for  the  admission  of 
female  patients. 

The  Hot-House  Educational  System  of  the  present  day,  and  the 
rash,  restless,  speculative  character  of  many  of  our  business  enterprises, 
as  well  as  professional  engagements,  are  also  strongly  predisposing  in 
their  influence  to  debilitating  forms  of  nervous  disorder. 

Among  the  earlier  symptoms  is  an  impaired  appetite,  and  perhaps  slight 
loss  of  flesh,  but  with  a  degree  of  mental  and  physical  languor  singularly 
disproportionate  to  the  other  symptoms  and  circumstances  of  the  (?ase. 

The  KiDXEYS,  Urea  and  Urixe. — The  careful  observer,  having  his 
attention  directed  to  the  imperfect  assimilation  due  to  the  loss  of  nerve 
tone,  will  often  detect  a  marked  excess  of  urea.  To  the  same  deranged 
functional  action  of  the  kidneys  may  be  traced  the  strange  drowsiness 
occasionally  observed.  In  a  patient  treated  here  in  1860,  in  whom  this 
somewhat  unusual  drowsiness  was  well  marked,  it  was  found  that  the 
urine  nearly  semi-solidifled  on  the  addition  of  nitric  acid.  As  a  general 
rule,  however,  the  urine  in  these  cases  is  paler  than  in  health,  and  is 
secreted  in  larger  qttantities. 

Muscular  Atonicity. — A  succeeding  symptom  is  marked  muscular 


•142  C.  B.  Bushes. 


atonicity,  inanifost  in  the  position  and  gait,  and  whicli  often  singularly 
I'lianges  tlie  expression  of  the  patient,  more  particularly  of  tlie  mouth  and  the 
lower  portions  of  the  face,  and  especially  so  in  females.  Thus  the  approx- 
imation to  a  more  natural  ex|)ression  marks  the  pro<n-ess  towanls  restor- 
ation. To  the  same  muscular  atonicity  is  attributable  the  frequent  occurring 
uterine  displacenients.and  the  distressing  train  of  accompanying  symptoms. 

IlYrKUKSTHEsiA. — Irritability  and  hyperiesthesia,  increasing  propor- 
tionally with  the  increasing  nervous  prostration,  we  have  next  a  new  series 
of  morbid  manifestations — the  neuralgias  on  the  one  hand,  or  disordered 
intellection  on  the  other — developed  in  accordance  with  tlie  direction  of 
the  morbid  action.  With  these  nein-algias  we  have,  in  this  connection, 
very  little  to  do.  and  will  dismiss  them  for  the  present,  with  a  few  remarks 
relative  to  the  difference  existing  between  them  and  similar  neuralgic 
developments  in  certain  fomrs  of  malarial  disease. 

Difference  BETWEKX  Malauial  and  Neukasthenic  Neuralgia. — 
As  a  general  rule  in  the  malarial  neuralgias,  when  once  located,  thei*e. 
need  be  little  apprehension  of  further  complication  or  transfer  to  any 
other  portion  of  the  nervous  system,  but  not  so  in  the  neurasthenic.  In 
these  we  have  the  premonitory  symptoms  before  alluded  to,  and  even,  as 
previously  remarked,  if  the,  direction  of  the  morbid  action  for  the  time  being 
deoelop  a  simple  neuralgia^  judicious  treatment  alone  can  arrest  the  tendency 
to  tnental  complication.  The  recognition,  therefore,  of  this  form  of  nerv- 
ous disorder,  the  presentation  of  a  few  hints  as  to  the  agency  most  likely  to 
arrest  this  tendency,  and  the  course  of  treatment  we  have  found  most  efHea- 
cioiis  in  the  menUil  alienation  accompanying  it,  is  the  object  of  this  paper. 

As  to  the  term  neurasthenia,  it  is  an  old  term,  taken  from  the  medical 
vocabulary,  and  used  simply  because  it  seemed  more  nearly  than  any  other  to 
express  the  character  of  the  disorder,  arid  more  definite,  perhaps,  than  the 
usual  term  "  nervous  prostration.  " 

Secondary  Hvper-Emias. — Secondary  to  the  earlier  symptoms  of  irri- 
tability and  the  depression  of  the  vital  power  already  mentioned,  is  a 
marked  tendency  to  hypei"cmia.  The  earlier  morbid  conditions  having 
failed  to  attract  attention,  it  is  not  strange  that  observers  have  occasionally 
r(!garded  one  of  these  located  b3'per?emias  or  congestions  as  the/o»s  malo- 
rum  itself. 

Cerehral  An.kmia  and  Hyper.emia. — In  the  case  of  all  patients  who 
have  suffered  from  nervous  prostration  for  any  length  of  time,  cerebral 
an.'emia  may  be  anticipated,  and  when,  coincident  with  irritability,  it  exists 
as  a  second.ary  result,  or,  in  consequence  of  impaired  digestion  and  assim- 
ilation, cerebral  hypertemia,  with  its  distressing  train  of  symptoms,  is  very 
readily  induced,  by  any  cause  calculated  to  quicken  the  circulation.  Hence 
tlie  iniporumce  of  great  caution  in  protecting  the  p.aticnt  from  influences 
likely  to  produce  this. 

To  this  circumstance  is  due  the  fact  that  neurasthenic  patients  seldom 
tolenite  the  use  of  alcoholic  stimulants.  A  single  teaspoonful  will  often 
produce  llusliing  of  the  face,  burning  heat  of  the  eyt-litls  and  distress  in 
the  head.  Mentiil  emotions,  ill-timed  interviews  with  friends,  and  the 
injudicious  act<  and  remarks  of  an  attendant  may  also  speedily  induce  an 
unpleasant  hypenemia. 


Xotes  on  J^eurasthenia,  443 


Psychical  Symptoms. — It  is  a  well  recognized  fact  in  mental  path- 
ology, that  in  the  asthenic  the  earliest  marked  morbid  psycliical  symptom 
is  distrust.  It  is  true  that  this  is  usually  preceded  by  irritability  and 
other  modifications  of  temper  and  disposition — grave  symptoms  always— 
which  slionid  promptly  receive  the  attention  ])oth  of  physicians  and 
friends,  but,  as  before  remarked,  the  first  clearly  marked  morbid  sentiment 
is  distrust.  If  the  sufferer  be  an  individual  of  deep  religious  feelings,  to 
whom  there  is  but  the  one  only,  great  and  vital  interest,  there  is  distrust 
of  God's  promises,  morbid  views  of  personal  relations  to  the  church,  and 
to  society— in  fine,  wliat  is  improperly  termed  "religious  melancholy." 
If  the  acquisition  of  gain  and  the  possession  of  broad  acres  have  been  the 
great  object  of  life,  there  are  torturing  appreliensions  of  poverty ;  the 
poor-house  stares  the  patient  in  the  face,  and  pauperism  is  his  inevitable 
fate.  Title  deeds  are  filled  with  flaws,  his  notes  are  foi-geries,  and  even 
gold  and  silver  to  him  are  worthless.  If  the  conjugal  relations  have  been 
peculiarly  close  anti  tender,  there  are  the  tortuies  of  jealousy.  In  a  few 
exceptional  cases  the  morbid  feeling  has  been  general. 

If,  at  any  time  during  this  stage,  there  occurs  a  sudden  and  entire 
change  in  sentiment;  if  hope  takes  the  place  of  dispair,  and  the  jealousy 
and  suspicion  be  suddenly  supplanted  by  the  opposite  sentiments,  it  almost 
invariably  betokens  still  greater  prostration,  and  but  a  trifle  more  will  then 
be  required  to  develop  mania. 

As  before  observed,  in  the  earlier  stages,  through  deficient  innervation 
there  is  derangement  and  suppression  of  secretion,  and.  as  would  naturally 
be  expected,  very  uniformly  in  female  patients,  menstrual  suppression. 
If,  through  a  misapprehension  of  the  character  of  this  suppression, 
active  emmenagogues  and  uterine  excitants  be  resorted  to.  with  a  view  of 
forcing  the  organ  to  a  resumption  of  its  function,  the  attempts  will  not 
only  fail,  but  will  induceuterineand  vaginal  hyperasthesia.  create  delusions 
of  a  most  unpleasant  character,  and  sometimes  develop  an  almost  uncon- 
trollable furor  uterinus.  So,  also,  when  dyspepsia  is  the  prominent 
symptom,  an  analagous  course  of  treatment  will  frequently  cause  great 
local  distress,  and  often  develops  delusions  of  apprehensions  of  personal 
danger  from  poison,  with  a  disposition  to  refuse  food  under  ttie  influence 
thereof.  Uterine  displacement,  with  leucorrheal  discharge,  is  very 
commonly  present,  and,  at  some  stage,  is  apt  to  be  the  most  prominent 
difficulty  under  which  the  patient  labors.  Through  muscular  atonicity  the 
organ  sinks  and  finally  rests  upon  the  vaginal  walls,  the  pressure  producing 
congestion,  ulceration  and  discharge.  En  several  cases  admitted  here,  the 
condition  of  the  patient  from  this  cause  had  become  one  of  great  miseiy; 
still  in  no  single  instance  has  it  become  necessary  to  resort  to  any  local  treat- 
tnent  whatever.,  and  in  no  case  has  there  been  a  failure  to  give  the  patie7it  entire 
and  permanent  relief  by  remedies  addressed  to  the  constitutional  condition  solely. 

Headachks  are  not  a  prominent  or  frequent  symptom,  except  as  an 
accompaniment  of  cerebral  hyperaemia,  and  sometimes,  perhaps,  when  it 
occurs  in  association  with  uterine  irritability. 

Sleeplessness  is  a  common  and,  at  certain  stages,  a  most  distressing 
symptom.  As  previously  observed,  drowsiness  sometimes  occurs  as  a 
consequence  of  disordered  renal  function ;  it  may  likewise  depend  upon 


444  C.  B.  Hughes. 


venou-  cerebral  hypencmia.  Healtliy,  refreshinor  sleep  is.  of  course,  not 
to  be  expected  under  such  circumstance.*.  As  the  debility  increases,  the 
morbiil  irritability  andactivity  increase  therewith,  and  maniacal  excitement 
soon  follows. 

A  few  patient-,  espocially  in  the  earlier  histoiy  of  the  attack,  suffer  from 
wakefulness  only  duriiifrthe  earlier  hours  of  the  nipht.  When,  throu<^h  the 
composure  induced  by  quiet  and  the  recumbent  position,  the  circulation  is 
equalized  and  the  cerebral  hyperaemia relieved,  a  few  hours  of  healthful  and 
natural  rest  is  enjoyed.  To  this  is  due  the  frequent  statements  of  these 
patients  that  they  sleep  much  better  towards  morning  than  at  any  other  time. 

PnoFUSE.  Satikating  Perspiration  is  anotlier  frequent,  and  to  the 
patient,  very  annoying  and  distressing  symptom.  Its  occurrence  usually 
accompanies  extreme;  nervous  prostration,  and  very  dearly  indicates  the 
character  of  the  remedial  agency  to  be  employed.  It  may  occur  at  any 
hour  of  the  day,  and  it  may.  or  may  not,  be  preceded  by  shiverings  ;  more 
commonly,  however,  the  patient  falls  into  a  profound  sleep  after  a  few  hours 
of  restless  tossing,  and.  on  awakening  from  his  brief  rest,  finds  himself 
bathed  in  perspiration,  his  clothing,  and  sometimes  a  portion  of  the 
mattress  and  pillow,  saturated. 

At  a  still  later  stage,  when  the  exhaustion  is  verj*  profound,  copious, 
oft-recurring  mucous  stools  frequently  occur.  They  are  sometimes  of  a 
very  offensive  and  nearly  putrid  odor,  a  circumstance  supposed  to  be  due 
to  the  acknowledged  tendency  to  spontaneous  decomposition,  which 
accompanies  low  vital  power.  So,  also,  the  urine  is  often  found  of  very 
disagreeable  odor,  and  probably  from  a  similar  cause.  The  breath  is 
sometimes  so  fetid  as  to  suggest  mercurial  sore  mouth ;  indeed,  the  room 
occupied  by  a  patient  in  this  stage  of  the  disease,  unless  it  be  thoroughly 
ventilated,  is  pervaded  by  a  peculiarly  characteristic  and  unpleasant  odor. 

Modified  Hkart  Sodnds. — In  two  cases  ascites  existed,  and  was  at 
first  a  puzzling  symptom.  The  sounds  of  the  heart  being  modified,  in  a 
measure,  by  the  impaired  character  of  the  blood  driven  through  it,  a 
fjardiac  complication  might  be  suspected  by  an  experienced  auscultator. 
The  condition  disappeared  as  the  patient  improved ;  and  where  it  thus 
exists,  it  is  probably  to  be  relieved  only  by  restoring  the  tone  of  the 
system,  and  thus  constricting  anil  rendering  firmer  and  closer  the  coats  of 
the  weakened  and  relaxed  vessels. 

Elasticity  of  ihe  Skix. — When  a  portion  of  the  skin  in  taken  up  and 
pinched  into  a  fold,  it  very  slowly  returns  to  its  position.  By  comparing 
this  want  of  natural  elasticity  from  time  to  time,  a  tolerably  correct 
opinion  can  be  formed  of  the  progress  towards  restoration. 

MuRuiD  Sknsatioxs. — Through  deranged  innervation,  and  cutaneous 
hyperasthesia  dependent  thereon,  patients  sometimes  experience  very 
strange  sensations.  In  the  case  of  a  lady  imder  our  care,  no  amount  of 
atmospheric  heat,  and  no  application  of  clothing,  could  change  in  the 
least  these  morbid  sensations.  v\'arm  as  the  room  could  be  made,  and 
wrappecl  up  in  blankets  and  shawls,  she  still  complained  of  cold. 

In  our  experience,  after  convalescence  commenced  there  has  been  no 
tendency  to  relapse.  The  improvement,  both  mental  and  physical,  lias 
been  pari  passu,  and  in  no  case  iias  there  been  a  return  of  the  disease. 


Motes  on  Neurasthenia.  445 

Here  Dr.  Van  Deusen  asserts  that  excessive  venery  and 
masturbation  do  not  cause  this  disorder;  and  here  follows 
reference  to  some  cases  caused  by  over  exertion  and 
underfeeding.       Dr.  Van  Deusen  then  proceeds  : 

Importance  of  Its  Early  Recognitiox — We  cannot  but  regard  the 
early  rcco^rwt^ion  of  this  condition  as  of  special  importance,  convinced  that 
properly  directed  treatment  will,  in  the  larger  proportion  of  cases,  stay  its 
progress.  In  the  analagous  affections  of  malarial  origin,  a  few  months  delay 
is  not  of  vital  moment,  and  a  change  of  i-esidence,  to  a  mountainous  region 
or  a  seaside  district,  is  often  sufficient  in  itself  to  effect  restoration.  In  the 
neurasthenic,  the  morbid  tendency  is  ^tvon^lj  progressive.  If,  in  the  early 
neuralgic  stages,  a  course  of  medical  treatment,  analagous  with  that 
employed  in  malarial  neuralgias,  be  instituted, with  proper  general  hygienic 
measures,  a  cure  may  be  anticipated.  Sciatica  is  by  far  the  most  frequent 
form  of  neuralgia  accompanying  neurasthenia.  The  blisters,  counter-irri- 
tants and  purgatives,  so  efficacious  in  the  sthenic  form  of  the  disease,  are  of 
no  service— on  the  contrary,  usually  aggravate  the  symptoms.  Relief  from 
intense  pain,  to  secure  sleep  and  preserve  the  strength  of  the  patient,  may 
be  procured  by  the  hypodermic  use  of  the  acetate  of  morphia,  which  will 
generally  be  found  successful.  This,  with  a  carefully  conducted  course  of 
nerve  tonics,  has,  in  the  cases  coming  un  ler  our  observation,  uniformly 
restored  the  patient  to  his  previous  health. 

Mkntal  Dei'Ressiox  axd  Insomnia. — Where,  however,  there  is 
present  instead  of  the  neiu-algic  pains,  depression  of  spirits,  irritability  and 
disturbed  sleep,  there  is  evidenced  a  location  or  direction  of  the  morbid 
action,  wliich  should  create  the  liveliest  apprehension  and  induce  prompt 
treatment.  Proper  hygienic  and  medical  agencies,  with  relief  from 
previous  cares  and  anxieties,  and  change  of  scene  and  occupation,  Avill,  we 
think,  in  the  larger  proportion  of  cases,  preserve  the  patient  from  confirmed 
melancholia  or  mania.  These  are  the  only  forms  of  mental  alienation,  in 
our  experience,  associated  with  neurasthenia. 

When  this  paper  was  written,  the  author  had  not  seen 
a  single  case  of  hypochondriasis,  or,  as  Dr.  Beard  terms  it, 
pathophobia.  Yet  pathophobia  is  not  uncommon,  while 
it  is  not  the  most  common  form  of  dread  or  fear  that 
torments  these  persons.       Dr.  Van  Deusen  proceeds  : 

In  the  organization  of  those  portions  of  the  nervons  system  designed 
more  especially  for  the  performance  of  the  mental  functions,  or  intellection, 
there  is  found  a  far  more  liberal  supply  of  blood  vessels  than  elsewhere. 
This  shows  an  anticipation  of  more  rapid  tissual  destruction  here,  and  at 
the  same  time  provides  a  medium  of  nutritional  repair  and  renewal,  properly 
proportioned  to  the  extreme  requirements  of  this  portion  of  the  organization. 
Through  this  medium,  the  remedial  and  preventive  efibrts  must  mainly 
act.  Whatsoever  agency  therefore,  or  hygienic  influence  can  be  made  to 
improve  nutrition  and  enrich  the  blood,  will  be  curative,  and  will  act  in 
the  right  direction.  ****** 


446  C.  H.  HiL^hes. 


The  several  organs  again  receiving  a  liealtliy  nerve  influence,  resume 
the  proper  discharge  of  their  respective  functions.  Assimilation  is  rendered 
perfect,  digestion  becomes  vigorous,  the  muscles  are  toned,  the  liver 
kitlncys  and  skin  perform  aright  their  important  duties,  the  brain  function 
also  is  licaUtifully  and  naturally  performed,  and  the  work  of  restoration  is 
complete. 

The  Doctor  recognized  neurasthenia,  then,  as  we  see 
it  now,  on  the  increase,  and  fixed  for  it  no  specific  structural 
change. 

It  nuist  be  borne  in  mind  that  we  have  not  failed  to  recognize  the  facts 
that  loss  of  nervous  power,  does  much  more  largely  than  heretofore, 
characterize  many  of  the  disorders  now  presented  for  treatment.  Cases  of 
well-marked  asthenic  mania  and  melancholia  are  also  frequently  received 
and  easily  enough  recognized.  The  intellectual  disturbance,  in  the  cases 
under  consideration,  is  not  sympathetic  with  physical  derangement,  nor 
due,  either  to  the  sluggish  action  of  eliminating  organs,  or  to  the  circula- 
tion of  impoverished  blood,  hut  seems  to  be  purely  a  functional  derange- 
ment, sti  ictly  identical  in  character  with  the  neuralgia,lhe  muscular  atonicity 
and  the  oilier  evidences  of  deficient  innervation  preceding  it;  the  brain 
as  under  other  murbid  agencies,  being  slow  to  yield  to  disturiung  influences. 

Thk  Mokal  Trkatment  is  the  same  as  that  adopted  in  corresponding 
forms  of  mental  alienation  from  any  other  cause,  and  is  conducted  on  the 
same  general  principles. 

Exercise  axd  Recreatiox. — Frequent  and  long-continued  gentle 
exercise  in  the  open  air  is  of  gi'eat  service  in  relieving  the  morbid  irrita- 
bility. It  should  never  be  carried  to  the  point  of  fatigue.  Its  quieting 
influence  Is  well  shown  in  the  effect  of  a  slow,  lounging  walk  about  the 
grounds  by  this  class  of  patients.  An  individual  lal)oring  under  a  consid- 
erable measure  of  maniacal  excitement  becomes  calm  and  composed, 
while  the  same  exercise  in  a  corresponding  state  of  sthenic  maniacal 
excitement  would  still  more  disturb. 

In  the  earlier  stages,  recreative  occujyation  is  a  term  expressing  the 
exact  requirements  of  the  patient  in  this  direction.  Physical  exercise  and 
occupation,  to  be  of  any  special  service  must  be  recreative  and  of  a  char- 
acter to  engage  the  thoughts  of  the  individual  healthfully  It  should 
secure  the  satisfaction  of  some  usefid  object  or  i)urpose  fully  attained.  If 
it  does  not  fully  occupy  and  engage  the  attention,  it  must  constantly 
remind  the  patient  of  his  invalidism,  and  thus  fail  entirely  in  securing  the 
object  suggesting  it. 

Travel  not  Liki;i,v  to  Henekit. — As  a  relief  for  the  depression, 
traveling  is  very  likely  to  be  suggested,  but  is  very  seldom  beneficial.  The 
different  stages  of  a  journey  cannot  be  so  arranged  as  to  secm-e  regularity  in 
sleep  and  in  taking  meals.  The  mode  of  jireparing  the  food  and  its  character 
cannot  be  made  to  meet  the  requirements  of  the  ca.S(!.  Ideas  and  thoughts 
are  presented  and  suggested  so  rapidly  as  to  cause  great  weariness,  and  it 
is  not  at  all  unfrequent  to  meet  with  instances,  in  which  a  patient  leaving 
home  suffering  from  depression  simply,  returns  more  deeply  melancholic, 
or  even  maniacal. 


Jfotes  on  Neurasthenia.  447 

The  form  of  mania  in  its  more  general  features,  does  not  differ  decid- 
edly from  asthenic  mania,  at  the  same  time  it  is  of  the  utmost  importance 
to  distinguish  between  the  two.  The  usual  treatment  of  acute  mania  with 
great  prostration,  by  hyoscyamus.  or  by  hyoscyamus.  moi-pliia  and  cam- 
phor, brandy  and  the  prolonged  hot  bath,  is  inadmissible  in  cases  of  neu- 
rasthenic mania,  death  usually  ensuing  from  coma,  and  sometimes,  with 
great  rapidity.  The  use  of  tart.  ant.  et  pot.,  which  so  pleasantly  arouses 
secretion  in  sthenic  mania,  and  thus  renders  efficient  the  anodynes  indi- 
cated, is  here  of  no  service  and  does  positive  harm. 

Sponge-baths,  while  the  patient  is  lying  in  well- warmed  blankets, 
with  brisk  and  prolonged  spirit  frictions,  is  very  soothing  in  its  effects, 
insomuch  that  patients  have  fallen  asleep  during  the  process,  as  in  the  hot 
bath  in  sthenic  mania.  While  this  is  being  administered,  a  few  spoonsful 
of  beef-tea  at  occiisional  intervals,  or  a  little  wine  in  extreme  cases,  may 
be  necessary.  When  an  equality  of  temperature  between  the  head  and 
the  extremities  is  established,  and  the  sldn  has  become  warm,  moist  and 
natural,  small  quantities  of  wine,  or  a  teaspoonful  of  brandy,  prepared  -nith 
milk  and  egg,  should  be  cautiouslj*  administered  in  small  quantities,  at 
stated  intervals. 

When  there  is  great  imtability  of  the  stomach— a  very  common 
symptom — a  teaspoonful  or  two  of  champagne,  or  of  water  charged  with 
carbonic  acid,  may  be  given  with  advantage  tlirough  a  syphon,  with 
sinapisms  to  the  epigastrium.  When  there  is  reason  to  suspect  hyperte- 
mia  of  the  stomach,  the  tendency  to  vomiting  continuing  with  pain  on 
pressure,  ice  cream  and  nutritious  gelatines  should  be  the  principal  diet. 

In  treating  the  melancholia  of  this  class  of  patients,  morphia,  of  suck 
7narked  service  in  other  forms  of  menial  depression,  is  inadmissible. 

QuixiNE,  in  the  experience  of  this  Institution,  ranks  lir.-t  as  a  nerve 
tonic.  The  cases  in  which  it  is  not  tolerated  are  very  rare.  Though 
accustomed,  except  in  extreme  cases,  to  defer  its  administration  until  atten- 
tion has  been  given  to  the  secretions,  it  is  not  necessary  or  advisable  to 
await  the  cleaning  of  the  tongue.  Indeed,  in  many  cases  alteratives  have 
but  little  influence  in  this  du-ection  until  the  use  of  the  quinine  has  sufii- 
ciently  toned  the  nervous  system  to  secure  their  proper  application  and 
eftect.  It  appears  to  be  contra-indicated  only  where  there  exists  a  very 
marked  tendency  to  cerebral  hyper;^mia.  and  then  only  at  particular  stages 
of  treatment.  It  is  usually  given  in  single  grain  doses,  reiidei-ed  soluble 
by  five  or  ten  drops  of  dilute  phosphoric  acid,  repeated  four  times  daily. 

Arsexic  has.  in  very  many  instances,  proved  itself  a  rnist  efficient 
remedy.  It  has  been  especially  beneficial  in  cases  marked  by  considerable 
irritability,  with  emaciation,  and  the  ill-conditioned  skin  occasionally 
met  with.  Under  its  use  in  this  class  of  patients,  the  skin  soon  becomes 
smooth  am)  fau-,  fiesh  is  gained  rapidly,  and  the  irritability  propoitionally 
de(-reases.  The  instances,  however,  in  which  it  disturbs  the  stomach, 
and  is  intolerable,  are  not  few  ;  and  when  this  intolerance  really  exists,  it 
is  manifested  towards  even  the  smallest  doses.  It  is  generally  well  adapted 
to  cases  in  which  quinine  is.  for  any  reason,  conti-a-iudicated.  At  the  same 
time,  as  an  antiseptic,  it  probably  arrests  the  rapid  tendency  to  tissu.al  dis- 
organization characterizing  this  form  of  disorder,  and  it  is  our  opinion. 


44.S  C.  H.  Hu^hps. 


that  in  tlie  earlier  stages  it  will  be  found  of  great  service.  It  may  be 
ranked  as  a  nerve  nutrient. 

Strychnine  is  most  sei-viceable  in  casesacoomianicd  ])y  intestinal  tor- 
pidity and  rauseular  atonicity.  It  has  been  prescribed,  also  the  ext.  nuc. 
voni.  in  combination  with  the  vegetable  bitter  extracts  and  taraxacum. 
As  an  ellicient  laxative  in  these  cases — and  often  unaided— its  action  is 
decided.  *  *  *  In  the  dyspepsia  of  the  neurasthenic  it  has 
always  acted  well.  ***** 

Iron  and  its  various  preparations,  we  have  come  to  regard,  as  of  but 
little  positive  service  in  the  earlier  treatment  of  the  severer  cases  presented; 
it  seems  to  be  of  much  service,  only  after  there  has  been  secured  some 
measure  of  nerve  force;  and  that  form  should  be  used,  which,  by  actual 
trial  is  found  best  suited  to  the  particular  case  under  treatment.  When 
the  malaise,  restlessness  and  irritability  is  persistent,  a  very  efficient  for- 
mula is  the  one  introduced  many  years  ago,  and  known  as  the  Mist.  Conii 
et  Feiri.  We  can  easily  understand  the  stl'ong  preference  expressed  foi" 
it  by  the  older  practitioners.  It  is  not  at  all  unpleasant  to  the  taste,  and 
is  aluiost  invariably  tolerable.  ***** 

From  phosphorus,  though  considered  an  efficient  renovator  of  nerve 
tissue  and  nene  power,  the  author  states  that  he  had  not  obtained  such 
satisfactory  results  as  to  lead  to  its  very  frequent  administration,  though 
he  concedes  its  possible  value  in  the  earlier  stages  of  this  disorder  and  in 
combination  with  iron,  in  cases  of  female  chlorosis,  when  blood  impover- 
ishme  nt  is  due  to  impaired  assimilation  from  defective  innervation. 

While  skillful  pharmaceutists  have  recently  placed  in  the  hands  of  the 
profession  many  attractive  preparations,  the  constituents  of  which 
w  ould  seem  to  adapt  them  almost  perfectly  to  the  precise  requirements  of 
this  class  of  patients;  in  treatment  at  this  Institution,  Dr.  Y.  found  more 
satisfactory  results  from  extempore  prescriptions.  ''Careful  daily  obser- 
vation at  the  bedside"  he  says,  "will  detect  many  slight  variations  in  symp- 
toms, indicating  (  orresponding  modifications  of  prescription.  The  combi- 
nation of  remedies  used,  are  presented  in  the  histories  of  the  cases  prepared 
to  illustrate  tiiis  subject."  These  cases,  with  the  statistical  tables  covering 
the  Doctors' experience  in  this  form  of  di.>-order,  were  given  in  in  full  a 
subsequent  report. 

Such  was  neurasthenia  as  it  appeared  to  an  American 
Superintendent  of  a  Hospital  for  the  Insane  thirteen 
years  ago,  and  it  appeared  then  to  him  not  materially 
different,  in  many  respects,  from  what  it  appears  to  those 
who  write  upon  it  now.  Some  of  its  features,  however, 
are  different  in  its  earliest  incipiency  in  some  persons. 
Some  of  them  have  since  been  painted  by  other  American 
writers,  others  still  remain  to  be  described.  The  fur- 
ther delineation  shall,  at  another  time,  engage  our  atten- 
tion.    The    timidity    and    consequent    states  of  indecision 


Jiotes  on  Neurasthenia.  449 

and  fear,  which  precede  the  more  advanced  distinct  sus- 
picion and  delusions  of  dread  of  the  neurasthenic  insane 
are  yet  to  be  noted  as  well  as  some  forms  of  undoubted 
nerve  exhaustion,  in  which  special  morbid  fears  of  any  kind 
are  not  symptoms. 


Art.     Til— The  Isolation    of  Persons    in 
Hospitals  for  the  Insane.^ 


By  Dr.  Isaac  Ray. 

WHEN  a  man  loses  his  reason,  it  becomes  necessary 
that  the  reason  of  others,  in  a  greater  or  less 
degree,  shall  supply  its  place.  To  that  extent,  the 
movements  of  the  person  thus  afflicted  are  subject  to  the 
control  of  others,  and  his  property  is  taken  from  his 
management  and  disposal.  Humanity  demands  this ; 
the  peace  and  safety  of  society  demand  it,  and  the  ultimate 
good  of  all  parties  is  promoted  by  it.  Thus,  of  necessity, 
one  of  the  hardest  penalties  of  the  criminal  law  is  visited 
upon  men  who  have  not  only  committed  no  crime,  but 
are  themselves  the  victims  of  as  sad  a  calamity  as  any 
in  the  long  catalogue  of  human  ills.  The  manner  in 
which  this  consequence  is  determined,  however,  differs 
very  much  in  the  two  cases.  In  the  one,  it  follows  a 
judicial  investigation,  conducted  according  to  the  strictest 
forms  of  legal  procedure,  with  all  the  safeguards  and 
indulgences  which,  in  the  progress  of  humanity,  have 
come  to  be  regarded  as  unquestionable  rights ;  while  in 
the    other,    in    most    instances,    it    is    determined    by    the 

[This  paper  not  having  appeared  before,  th.-it  Ave  know  of,  in  the  pages  of  any 
medical  periodical,  we  deem  it  especially  entitled  to  a  place  in  our  columns,  as  the 
niamred  views  of  America's  most  distingnished  alienistnpou  a  subject  now  attracting 
much  attention,  and  especially  since  the  recent  publicatiou  in  London,  of  the 
eminent  Dr.  Bucknill's  book  on  "The  C:ire  of  the  Insane,"  a  subject  destined  to 
engage  still  ra>'re  of  medical  and  public  thought.— Ed.] 

•Readbefore  the  Philadelphia  Social  Science  Association,  October23d,  1S79. 


460  Isaac  Ray. 


arbitrar\-  will  of  individuals  proceeding  under  none  of  the 
ordinar}'  formalities  of  law,  and  guided  by  none  of  its 
principles. 

The  inquiries  which  this  first  view  of  this  subject 
suggests  are  deeply  interesting,  because  the  idea  now 
prevails  that  the  legislature  should  prescribe  under  what 
circumstances  this  interference  with  the  inalienable  rights 
of  men,  on  the  ground  of  insanity,  is  to  be  allowed  ;  to 
whom  this  privilege  of  interference  is  to  be  entrusted  ;  by 
what  safeguards,  against  abuse,  this  trust  is  to  be  protected  ; 
by  what  solemnities  this  deprivation  of  liberty  and  pro- 
perty is  to  be  accompanied  and  recorded.  Precisely  what 
legislation  the  exigencies  of  the  case  require,  is  one  of 
the  much  vexed  problems  in  social  science.  To  solve  it 
satisfactorily  to  all  is  simply  impossible,  because  much  of 
its  difficulty  proceeds  from  the  circumstance  that  well 
established  facts  and  incontrovertible  reasoning  are 
deprived  of  their  legitimate  force  by  the  influence  of 
passion,  prejudice  and  temperament. 

In  the  first  place,  let  us  understand  the  requirements 
made  necessary  by  the  nature  of  the  disease,  the  social 
and  domestic  relations  of  the  patient,  and  those  attentions 
that  are  instinctively  prompted  by  the  ties  of  blood  and 
friendship.  In  the  next  place,  we  are  to  see  how  these 
requirements  are  provided  for  by  law. 

Beginning,  then,  with  first  principles,  let  it  be  obsen-ed 
that,  in  the  more  sudden  and  violent  forms  of  insanity, 
the  patient  is  necessarily  placed  under  unceasing  surveil- 
lance, his  wishes  are  disregarded,  medicine  and  food 
may  be  forced  upon  him,  and  his  limbs  subjected  to 
restraint.  And  yet  all  this — because  necessary  to  the 
patient's  welfare — is  justified  by  the  common  sense  and 
the  common  feelings  of  mankind.  No  outrage  is  supposed 
to  be  committed,  no  right  is  trampled  on,  no  apprehension 
of  abuse  is  excited.  On  the  contrary,  the  friends  are 
regarded  as  under  a  moral  obligation  to  interfere,  as  far 
as  the  circumstances  require,  and  substitute  their  will  for 
the  will  of  the  patient.       So,  too,  nobody   would  question 


Isolation  of  the  Insane.  451 

the  right  of  a  man  to  confine  his  wife  in  his  own  house, 
were  she  bent  on  self-destruction,  or  disposed  to  injure 
her  children.  The  same  position  would  be  rightfully  held 
by  the  wife  towards  the  husband,  by  the  parent  towards 
the  child,  by  the  child  towards  the  parent.  No  one 
would  question  the  propriety  of  such  a  measure.  To 
abstain  from  it,  in  fact,  would  be  justly  regarded  as  a 
most  reprehensible  neglect  of  duty.  Now,  it  is  not  very 
obvious  how,  in  the  subsequent  stages  of  the  disease,  this 
obligation  can  be  lessened,  or  any  different  one  created. 
Does  there  necessarily  occur  a  period  when  society  is 
bound  to  assume,  in  any  degree,  a  charge  for  which  the 
friends  are  no  longer  fitted  ?  Neither  does  it  appear  how 
this  right  can  become  a  wrong,  by  making  the  place  of 
confinement  some  other  than  one's  own  home.  If,  in  the 
progress  of  knowledge  and  philantrophy,  institutions  have 
become  established  expressly  for  the  care  of  the  insane, 
in  which  they  are  supposed  to  be  more  successfully  treated 
than  they  can  be  at  home,  it  would  seem  as  if  the  natural 
right  in  question  would  be  all  the  more  heartily  recognized 
by  making  choice  of  them  for  this  purpose.  This  right 
has  been  distinctly  recognized  and  established  in  this 
commonwealth  by  an  act  of  General  Assembly,  passed  in 
1869.  The  act  declares  that  insane  persons  may  be 
placed  in  a  hospital  for  the  insane  by  their  legal  guar- 
dians, or  by  their  relatives  or  friends,  if  they  have  no 
guardians;  but  it  also  provides  that  the  measure  must  be 
sanctioned  by  two  physicians  who  shall  certify,  under  oath, 
that  the  person  is  insane,  and  a  fit  subject  for  hospital 
treatment.  The  act  does  not  require,  but  the  hospitals 
do,  for  their  own  protection,  that  the  application  shall  be 
made  in  writing  by  some  person,  either  a  member  of  the 
family,  or  some  responsible  friend. 

The  question  now  before  us  is,  whether  upon  a  broad 
consideration  of  the  various  forms  of  insanity,  of  our  social 
habits,  of  the  liability  to  mistake,  of  the  sacredness  of 
private  grief,  and  the  requirements  of  justice,  anything 
more    than    this    is    necessary.     The    inquiry    will    take    a 


452  Isaac  Ray. 


two-fold  direction,  because  we  must  consider  not  only  the 
amount  of  abuse  which  any  proposed  restriction  is  intended 
to  prevent,  but  also  the  amount  of  mischief  which  it  may 
itself  occasion,  when  not  really  required.  If  we  dismiss 
all  thought  of  the  latter  result,  we  shall  have  little  hesita- 
tion in  adopting  any  restriction  for  which  some  plausible 
reason  may  be  given. 

It  is  not  denied  that,  for  the  most  part,  the  medical 
certificate  fulfills  every  requisite  purpose.  It  is  not  denied 
that  exceptional  cases  are,  at  the  most,  exceedingly  few, 
and  there  seems,  at  first  sight,  a  peculiar  fitness  in  a 
measure  which  secures  the  performance  of  a  painful  duty 
without  adding  to  the  motives  for  delay,  and  shields  the 
friends  from  all  unnecessary  exposure  of  domestic  afflic- 
tion. It  is  in  accordance  with  our  national  habits  and 
customs,  and  especially  with  the  right  of  persons — nowhere 
so  extensively  recognized  as  among  us — to  manage  their 
own  private  affairs  in  their  own  way.  But,  it  is  alleged, 
the  physician  may  be  biased  by  his  relations  to  the 
party  or  his  family ;  he  may  be  deceived  by  false  repre- 
sentations, or  be  honestly  mistaken  in  his  opinion.  The 
friends,  too,  who  make  the  application  may,  for  fear  or  a 
worse  motive,  be  too  ready  to  confound  caprice,  or  oddity, 
or  passion,  with  insanity,  and  thus  favor  isolation  when 
not  strictly  necessary.  The  liberty  of  any  person  in  the 
community,  it  is  said,  is  at  the  mercy  of  one  or  two 
doctors  who  may  be  induced  by  one  motive  or  another, 
to  sign  a  certificate  of  insanity.  Such  is  not  an  uncom- 
mon style  of  argument,  and  it  sometimes  makes  an 
impression  even  on  men  whose  culture  might  be  supposed 
to  place  them  beyond  its  reach.  Hence,  a  prevalent  idea 
that  here  is  a  frequent  opportunity  for  flagrant  abuses 
which  should  be  met  by  stringent  legislation.  By  some, 
it  is  proposed  to  make  the  isolation  of  the  insane,  in 
every  case,  the  result  of  a  legal  procedure  in  the  nature 
of  an  inquisition,  to  be  conducted  either  by  the  municipal 
authorities,  or  some  magistrate,  or  a  board  of  commis- 
sioners appointed    for   this    purpose.     Now,    in    regard    to 


Isolation  of  the  Insane.  453 

these  two  courses,  it  is  not  very  obvious,  at  first  blush 
that  either  the  possible  abuses  charged  upon  the  former, 
or  the  advantages  claimed  for  the  latter,  are  so  great  as 
to  set  the  question  at  rest.  If  there  is  to  be  an  inquisi- 
tion who  is  so  competent  to  make  it  as  a  physician?  If  he, 
has  been  acquainted  with  the  person,  as  is  very  likely,  he 
has  materials  for  forming  his  opinion,  which  no  one  else, 
may  have.  If,  on  the  contrary,  he  is  a  stranger,  he  is 
of  course,  as  far  beyond  the  influence  of  prepossessions 
and  biases  as  any  functionary  whom  the  lavv-  might  desig- 
nate for  the  purpose,  while  his  decision  would  be  attended 
with  this  advantage,  that  no  unnecessary  trouble  or  publicity 
is  given  to  a  domestic  affliction,  in  the  case  of  those  of 
whose  mental  disease  there  can  be  no  doubt  whatever. 
To  argue  against  the  use  of  a  thing  from  its  possible 
abuse  has  always  been  regarded  as  very  poor  logic.  It 
may  be  that  the  liberty  of  any  person  in  the  community 
is  at  the  physician's  mercy,  and  so  is  the  life  of  every 
person  who  calls  in  a  physician  when  he  is  ill;  but  who 
hesitates  to  employ  a  physician  from  the  fear  that  he  may 
be  bribed  by  wicked  relatives  to  poison  him?  In  signing 
a  certificate  of  insanity,  a  physician  performs  a  professional 
service  in  which  he  is  amenable  to  his  own  sense  of  right 
and  wrong  and  responsible  to  the  laws  of  his  country.' 
Under  what  stronger  obligations  and  sanctions  can  any 
one  act  ? 

Under  stress  of  these  objections  to  the  medical  cer- 
tificate, it  has  been  proposed  to  have  the  measure  super- 
vised and  sanctioned  by  some  executive  or  judicial  officer 
of  the  state  or  county.  In  Scotland,  the  sheriff  is  entrusted 
with  this  duty  ;  and  the  Legislature  of  Massachusetts,  last 
winter,  provided  that  no  one  should  be  placed  in  a  hospital 
for  the  insane  without  the  knowledge  and  .consent  of  a 
judge  of  a  law  court.  It  is  not  supposed  that  these  func- 
tionaries are  going  into  an  exhaustive  investigation  of  every 
case,  because  other  duties  would  not  permit  it,  so  that 
it  becomes  a  mere  matter  of  form. 

Whatever  course  be    adopted,    no    one    thinks    of   dis- 


454  Isaac  Ray- 


pensingwith  the  medical  certificate.  But  its  value  cannot 
long  remain,  unless  physicians,  in  the  performance  of  this 
professional  duty  are  better  protected  than  they  now  are- 
Indeed,  leading  physicians  in  this  community,  to  avoid  the 
peril  of  a  suit  at  law,  have  concluded  to  sign  no  more 
certificates  of  insanity. 

Nothing  evinces  this  distrust  of  any  and  all  the  known 
means  resorted  to  for  the  purpose  of  preventing  abuses, 
than  the  fact  that  in  one  State — Illinois — a  trial  by  jury 
is  provided  for  deciding  the  fact  of  insanity,  in  every  case 
that  offers  for  admission  into  a  hospital  for  the  insane. 

To  remove  a  person  from  his  own  home  at  the  very 
moment  when  he  seems  most  in  need  of  the  care  and 
attentions  of  his  friends,  and  place  him  in  the  hands  of 
strangers,  is  always  a  painful  duty,  to  be  reluctantly  and 
hesitatingly  performed.  The  advice  of  physicians,  the 
remonstrances  of  friends,  the  failing  strength  of  nurses  and 
attendants,  the  increasing  illness  of  the  patient,  are  often 
disregarded,  while  the  voice  of  affection  pleads  for  a  longer 
trial.  To  be  obliged,  under  such  circumstances,  to  call  in 
a  stranger  to  witness  the  private  grief,  or,  worse  still,  a 
band  of  strangers,  as  jurors,  with  a  following  of  news- 
paper reporters,  and  hear  those  revelations  of  trouble  and 
trial  and  sore  calamity,  which  the  coarsest  sense  of  delicacy 
would  keep  within  the  bosom  of  the  family,  would  serve 
as  an  additional  excuse  for  delaying  so  disagreeable  a 
measure.  The  sensitiveness  on  this  point  is  so  strong  and 
so  natural,  that  it  is  entitled  to  respect.  The  effect  on 
the  patient  himself,  provided  he  is  conscious  of  what  is 
going  on,  and  especially  if,  as  is  frequently  the  case,  his 
mind  is  full  of  apprehensions  and  suspicion,  is  highly 
objectionable.  Fresh  excitement  is  furnished  to  that 
dread  of  impending  evil,  or  bitter  hostility,  or  some  other 
morbid  emotion,  which  may  have  possession  of  the  mind, 
and  thus  bad  impressions  are  made,  not  to  be  soon  effaced. 
But,  admitting  these  objections  to  the  use  of  any 
other  restriction  than  the  medical  certificate  to  be  conclu- 
sive, still,  it  is  contended,  it  is  not  improbable  that  persons 


Isolaiion  of  the  Insane.  455 

may  be  held  in  confinement,  who  either  never  were  insane, 
or  are  detained  unnecessarily  long  after  their  recovery. 
Many  firmly  believe  that  in  every  hospital  for  the  insane 
may  be  found  persons,  who  are  simply  victims  of 
outrageous  wrong,  torn  from  their  customary  sources  of 
enjoyment,  and  subjected  to  associations  well  calculated  to 
craze  the  strongest  intellect.  To  those  who  are  practically 
acquainted  with  insanity,  it  is  easy  to  see  how  an  impres- 
sion, so  utterly  destitute  of  foundation,  has  gained  such 
currency  in  the  world.  With  a  large  part  of  mankind, 
insanity  implies  noise,  turbulence,  confusion  and  incoherence 
of  thought,  folly  and  delusion.  The  more  quiet  and 
undemonstrative  forms  of  the  disease  are  utterly  ignored, 
because  not  discernable  to  a  superficial  or  unpracticed 
observation.  The  coolness,  coherency  and  good  sense 
which  often  mark  the  conversation  of  the  insane,  and 
the  correctness  of  their  conduct,  are  supposed  to  preclude 
the  existence  of  any  mental  disorder  whatever.  And 
even  when  some  questionable  traits  are  too  prominent  to 
be  ignored,  they  are  attributed  to  the  common  infirmities 
of  our  nature  rather  than  to  mental  disease.  The  insane 
are  not  conscious  of  their  insanity,  and  by  ignoring 
altogether  some  facts,  explaining  some  in  a  manner  to 
suit  themselves,  and  charging  others  with  wrong-doing, 
they  easily  convince  the  incautious  inquirer  of  their  own 
mental  soundness,  as  well  as  the  dishonesty  and  malice 
of  their  friends.  A  story  plausibly  told  is  presumptively 
true ;  and  in  the  case  before  us,  nobody  troubles  himself 
to  hear  the  other  side,  unless  it  may  be,  probably,  with 
a  mind  already  made  up.  Considering  the  number  of 
the  insane  who  have  been  discharged  from  hospitals 
uncured,  and,  of  course,  with  all  their  feelings  of  hostility 
towards  those  who  have  been  instrumental  in  promoting 
their  isolation  unchanged,  it  is  not  strange  that  the 
impression  in  question  should  prevail  extensively.  Indeed, 
it  would  be  more  strange    if   it    did    not  prevail. 

Again,    it    is    alleged    that,    in    every    hospital    for    the 
insane,  there    are   many  who,    though    technically    insane, 


456  Isaac  Ray. 


arc  not  proper  subjects  for  confinement,  neither  their  own 
welfare  nor  the  good  of  society  requiring  it,  and  that 
some  outside  party  should  pass  upon  the  propriety  of 
their  detention.  Here,  too,  we  see  the  influence  of 
those  false  notions  respecting  the  nature  of  insanity  just 
mentioned.  A  complete  and  correct  account  of  such  cases 
would  show,  with  scarcely  an  exception,  that,  instead  of 
being  unjustly  dealth  with,  they  have  been  humanely  placed 
where  they  enjoy  as  much  of  comfort,  and  suffer  as  little  of 
discomfort,  as  their  own  mental  condition  will  permit.  Some 
of  them,  for  instance,  may  pass  for  patterns  of  propriety  and 
injured  innocence,  suffering  bitterly  from  the  abuse  of  those 
to  whom  they  had  a  right  to  look  for  kindness  and 
protection,  while,  in  fact,  they  were  completely  destroying 
the  peace  and  comfort  of  home  by  their  jealousies  and 
suspicions,  tlieir  bursts  of  passion,  their  irregular  ways, 
their  disregard  of  domestic  proprieties,  their  unhesitating 
mendacity,  and  even  by  scenes  of  violence.  There  is 
another  class  whose  manifestations  of  disease  are  not  ver\' 
demonstrative,  or  are  such  as  might  pass  for  eccentricity  or 
strong  peculiarity.  They  talk  sensibly,  behave  correctly, 
and  may  make  themselves  somewhat  useful.  The  stranger 
sees  nothing  of  an  abnormal  character,  unless  it  may 
be  a  proclivity  to  exaggeration,  and  excessive  self  confi- 
dence, and  an  indescribable  hurry  and  restlessness  of 
movement.  At  home,  they  were  careless  of  the  little, 
perhaps  of  the  greater,  proprieties  of  life,  were  up  late  at 
night,  went  out  regardless  of  weather,  and,  though  never 
violent  or  mischievious,  were  prone  to  get  into  trouble, 
and  were  a  source  of  much  anxiety  to  their  friends. 

Persons  belonging  to  one  or  another  of  these  various 
classes  easily  enlist  the  sympathies  of  those  whose 
acquaintance  they  happen  to  make.  They  come  to  be 
regarded  as  victims  of  domestic  cruelty,  and  the  popular 
wrath  is  kindled  by  charges  against  faithless  husbands,  or 
unfeeling  wives,  or  heartless  children.  The  utmost  rigors 
of  legislation  are  invoked  to  deliver  them  from  durance, 
and  to  punish   those  who,  under    the    guise    of    humanity. 


Isolation  of  the  Insane.  457 

thus  perpetrate  a  great  wrong.  Now,  all  these  persons, 
probably,  have  proved  by  actual  trial,  prolonged,  perhaps, 
for  years,  and  repeated  again  and  again  under  different 
forms,  to  be  very  unfit  inmates  of  a  private  family, 
especially  when  made  up,  in  part,  of  children  and  women 
of  a  nervous  temperament.  To  turn  them  adrift  upon  the 
world,  where  they  find  no  welcome  in  those  domestic 
circles,  whose  peace  and  comfort  they  have  persistently 
marred,  and  roam  about  from  one  boarding  house  to 
another,  in  a  round  of  perpetual  worriment,  would  be  no 
kindness  to  them,  but  rather  the  severest  kind  of 
cruelty.  If  they  have  no  home  of  their  own,  and  no 
claim  for  one  upon  relations  or  acquaintances,  where  can 
they  better  find  the  protection  and  care  which  they  need 
than  in  a  hospital  for  the  insane? 

In  the  firm  belief,  however,  that,  after  all,  much  wrong 
is  actually  committed  by  depriving  of  their  liberty 
persons  who  are  but  little  if  at  all  insane,  many  discreet 
and  intelligent  men  are  of  the  opinion  that  a  supervising 
power  should  be  lodged  somewhere  for  the  purpose  of 
correcting  mistakes,  preventing  abuses  and  doing  justice 
generally  in  this  matter  of  confinement.  They  would 
have  a  special  permanent  commission,  whose  duty  it 
should  be  to  investigate  every  case  of  doubtful  insanity  in 
the  hospitals,  or  of  alleged  unfitness  for  hospital  treat- 
ment, and  to  discharge  or  advise  the  discharge  of,  the 
patient,  if  they  think  proper.  And,  in  other  respects,  the 
interest  of  the  insane  might  be  confided  to  their  over- 
sight. The  favorite  remedy  just  now  for  all  the  ills  of 
hospital  confinement  seems  to  be  a  roving  commission, 
with  plenary  powers  to  visit  all  persons  wherever  confined 
on  the  ground  of  insanity,  and  to  discharge,  or  cause  to 
be  discharged,  all  such  as  they  may  deem  not  insane. 

The  arrangement  looks  well  and  it  is  not  strange  that 
it  should  have  found  favor  with  some  intelligent  men. 
Considered,  however,  under  the  light  of  practical  experi- 
ence, and  our  knowledge  of  the  ways  and  habits  of  men, 
it  appears  to  be  calculated  to    do    immense  harm,    in    the 


458  Isaac  Ray. 


attempt  to  prevent  an  evil  confessedly  small.  Such  a 
commission  would  be  led  to  its  decisions  ,  by  no  fixed 
principles  of  law  or  science.  Indeed,  it  is  regarded,  prob- 
ably, as  the  principal  merit  of  this  provision,  that  it  would 
be  governed  solely  by  an  enlightened  sense  of  honesty, 
justice  and  fair  dealing.  This  might  be  a  merit  were  the 
questions  to  be  decided  such  as  could  be  readily  under- 
stood and  appreciated  by  ordinar\-  men.  But  here  are 
professional  points  to  be  considered,  which,  even  with  the 
best  intentions,  cannot  be  decided  correctly  without  the 
knowledge  of  an  expert.  A  disposition  to  do  what  is 
right  is  but  a  poor  qualification  for  a  scientific  inquiry. 
It  may  even  be  a  dangerous  one.  What  cares  a  man  for 
the  scientific  bearings  of  a  question,  who  looks  only  at  its 
moral  aspects,  and  is  sure  that  he  cannot  be  misled  by 
his  own  honest  intentions?  In  the  class  of  cases  where 
the  interference  of  the  commission  would  be  most  expected, 
there  are  always  facts  on  the  true  significance  of  which 
the  question  of  sanity  or  insanity  must  turn.  If,  in  any 
given  case  the  conclusions  of  the  commission  coincide 
with  those  of  the  officers  of  the  hospital,  the  fact  may 
inspire  fresh  confidence  in  the  latter,  and,  to  that  extent, 
be  of  some  service.  But  if,  on  the  contrary,  they  differ, 
it  is  not  easy  to  see  why  the  decision  of  the  commission, 
not  one  of  whom  may  have  had  any  practical  acquaint- 
ance with  insanity,  can  be  more  reliable  than  that  of  the 
officers  whose  field  of  observation  may  have  embraced 
thousands  of  cases.  How  they  are  to  proceed,  by  what 
course  of  inquiry  they  are  to  reach  their  object,  is  not 
very  apparent.  They  visit  a  hospital  containing  three 
hundred  patients,  and  make  known  to  them  their  official 
character  and  the  purpose  of  their  visit.  The  patients 
are  invited  to  tell  them  their  grievances,  with  the  assur- 
ance that  if  any  among  them  are  not  insane,  they  shall 
be  discharged  forthwith.  It  is  not  overstating  the  matter 
to  say  that  from  fifty  to  a  hundred  would  declare  that 
they  are  wrongfully  detained,  and  nothing  in  their  con- 
duct   or    conversation     might    belie    the     truth     of     their 


Isloation  of  the  Insane.  459 

declarations.  If  they  entertain  delusions,  no  clue  is 
furnished  whereby  they  can  be  reached  ;  if  they  are  dis- 
posed to  mischief,  no  opportunity  is  afforded  by  the 
occasion  to  display  the  propensity ;  no  provocation  leads 
them  to  relax  the  self-control  which  many  of  the  insane 
possess  in  a  remarkable  degree.  In  this  dilemma  what  is 
to  be  done?  The  testimony  of  the  officers  and  directors 
is  excluded  by  the  conditions  of  the  case,  they  being,  it 
is  supposed,  interested  parties.  The  minutest  inquiries  of 
the  patients  themselves  fail  to  bring  out  anything  but  the 
same  uniform  tale  of  wrong  and  outrage  on  the  part  of 
fathers  or  children,  husbands  or  wives,  guardians  and 
relations,  who,  to  conceal  their  ow^n  iniquities,  take  this 
means  of  consigning  their  victims  to  a  sort  of  living  death. 
There  is  obviously  but  one  course  left,  if  they  would  dis- 
charge their  official  duty  so  as  to  procure  any  satisfactory 
results.  They  must  summon  the  friends  and  all  who  have 
been  anyways  connected  with  the  patient,  to  appear  and 
show  cause  why  he  should  be  confined  ;  and,  in  order  to 
secure  an  impartial  hearing  on  both  sides,  public  notice 
should  be  given,  inviting  all  who  have  any  knowledge  of 
the  case,  to  attend  the  inquisition  and  give  their  testi- 
mony. The  hearing  of  each  particular  case  would  occupy 
not  less  than  two  days.  Supposing  twenty-five  per  cent, 
of  the  three  hundred  cases  in  the  hospital  to  claim  an 
inquisition,  which  would  be  a  low  estimate,  the  commision 
would  be  employed  in  one  hospital  alone,  one  hundred 
and  fifty  days.  At  this  rate,  the  hospitals  in  Pennsylvania, 
containing  about  twenty-six  hundred  patients,  would  require 
thirteen-hundred  days.  True,  the  commission  might  be 
large  enough  to  work  by  sub-committees,  which  would 
shorten  the  time,  and,  perhaps,  diminish  the  expense  ;  for, 
of  course,  they  must  be  paid,  as  well  as  the  people  who 
are  summoned.  And  by  the  time  they  have  gone  the 
rounds  of  the  hospital,  the  new  comers,  who  have  been 
steadily  accumulating,  will  equally  require  their  attention. 
If  this  simple  statement  of  the  proceedings  carries  with  it 
an    air    of   the  ludicrous,    the  fact  does  not  proceed  from 


460  ^ Isaac  Ray. 


an\-  false  coloring  of  tlic  incidents  themselves.  They  are 
given  precisely  as  they  must  occur,  if  the  commissioners 
are  determined  to  satisfy  themselves  by  reliable  evidence, 
whether  any  person  is  detained  in  the  hospitals  of  this 
commonwealth,  who  is  not  really  insane.  To  hurry  through 
a  hospital  once  or  twice  a  >'ear,  listen  half  an  hour  to  a 
few  of  the  large  number  who  claim  their  attention,  and, 
on  the  strength  of  that  conversation,  decide  to  recommend 
the  discharge  or  farther  detention  of  the  patient, — this 
would  not  be  to  meet  the  requirements  of  their  office.  A 
thorough  judicial  investigation,  be  it  long  or  short,  cheap 
or  costly,  in  every  doubtful  or  disputed  case,  is  what  the 
popular  sentiment  concerned  in  the  matter,  if  it  means 
anything  beyond  a  windy  sensation,  implicitly  demands. 
If  this  involves  a  practical  absurdity,  it  ought  to  convince 
us  that  the  present  method  is,  with  such  a  provision  of 
law  as  I  shall  presently  mention,  under  all  circumstances 
best  calculated  to  prevent  abuses.  The  officers  and  trus- 
tees of  our  hospitals  have  no  interest  in  retaining  patients 
not  insane.  Whether  kept  or  discharged,  their  compensa- 
tion remains  the  same.  In  fact,  however,  in  doubtful 
cases,  their  natural  tendency  is  to  discharge  the  patient, 
in  order  to  avoid  the  odium  and  annoyance  which  they 
occasion.  Nothing  but  a  strong  sense  of  duty,  supported 
by  the  most  satisfactory  reasons,  will  induce  them  to 
retain  a  charge  which  brings  them  into  the  most  unpleas- 
ant relations  to  others. 

Thus  far  I  have  gone  on  the  supposition  that  there  are 
actual  abuses,  however  people  may  differ  as  to  their 
extent.  But  the  evidence  in  favor  of  the  fact  is  far 
from  reliable.  The  diseased  impressions  of  the  patients 
themselves,  and  the  clamors  of  their  self-constituted 
friends  are  not  evidence ;  and  yet  upon  these,  chiefly, 
the  current  belief  is  founded.  The  observations  of  those 
who  have  had  the  most  abundant  opportunities  to  learn 
the  real  facts  in  the  case,  tell  a  very  different  story.  I 
have  never  met  with  a  patient  in  any  hospital  for  the 
insane,  who,  I   had    good  reason    to    suppose,  finally,    had 


Isolation  of  the  Insane.  461 

never  been  insane,  but  had  been  committed  under  the  pre- 
tence of  insanity,  in  order  to  accompHsh  some  iniquitous 
purpose  ;  and  my  observation  embraces  about  three  thou- 
sand persons,  mostly  under  my  own  charge.  I  have  been  told 
by  other  gentlemen,  who  have  had  charge  of  hospitals  for 
the  insane,  that  their  experience  has  been  much  like  mine. 
In  two  instances  that  came  under  my  care,  I  had  strong 
suspicions  that  there  was  no  real  insanity  in  the  case.  I 
thought  that  an  irritability  of  temper,  caused  by  bodily 
disease  might  have  been  provoked  into  violence  by  relatives 
who  had  some  selfish  purpose  to  serve  by  keeping  the 
patient  away  from  his  home  and  customary  pursuits.  The 
sequel  shows  that  my  suspicions  were  groundless,  and  that  the 
removal  from  home,  and  the  scenes  and  persons  that  were 
connected  with  unpleasant  associations,  only  kept  in  abey- 
ance for  a  time  the  manifestation  of  a  disease  which  had 
been  obvious  enough  at  home  and  serious  enough  to 
require  the  restraint  of  a  hospital.  In  England  there  has 
existed  for  more  than  forty  years,  a  Board  of  Commis- 
sioners of  Lunacy,  as  they  are  called,  appointed  by  the 
Crown  for  the  purpose  of  visiting  all  the  hospitals  for  the 
insane,  public  and  private,  with  this  very  object  in  view 
among  others — of  detecting  the  much  alleged  abuse  of 
confining  people  who  were  never  insane.  I  have  been  a 
diligent  reader  of  their  annual  reports,  in  which  their 
transactions  are  minutely  described,  and  I  have  not  found 
that  they  have  advised  the  discharge  of  a  single  individual 
on  this  ground ;  and,  certainly,  the  manner  in  which  their 
official  duties  have  been  discharged,  has  indicated  no 
undue  leniency  towards  the  officers  and  directors  of  these 
institutions.  The  Earl  of  Shaftesbury,  who  was  for  many 
years  a  member  of  this  commission,  and  who  has  been 
deeply  interested  in  insanity  and  institutions  for  the  insane, 
once  declared  in  Parliament,  that  he  had  never  known  an 
instance  of  a  sane  person  being  held  in  confinement  on  the 
pretence  of  insanity,  and  this  is  in  England,  where,  of  all 
countries  in  the  world,  the  abuse  in  question  is  supposed 
to  be  most  frequent.  This  testimony  would  seem  to  be 
conclusive  that  it  has  no  real  existence,  and  that  the  safe- 
guards already  provided  have  been  sufficient  for  the  purpose. 
But,  admitting  all  this,  it  is  contended  that,  considering 
the  public  sensitiveness  on  this  subject,  it  is  necessary',  in 
order  to  secure  the  popular  confidence  in  the  management 
of  our  hospitals,  that  there  should  be  a  supervisory  power 
appointed  by,  and  responsible  directly  to,  the  government. 
If,  as  has  already  been  shown,  such  a  power  is  entirely 
inefficient    for    any    practical    purpose,    then    it    nmst    be 


462  Isaac  Ray. 


desired  only  as  a  sort  of  tub  thrown  out  to  amuse  the 
whale.  The  tone  of  feeling  in  England,  after  a  trial  of 
more  than  forty  years,  shows  conclusively  that  it  would 
not  even  have  this  effect.  There,  although  the  commis- 
sion has  been  watchful  and  suspicious  to  the  last  degree, 
the  whale  refuses  to  be  amused.  This  must  be  apparent 
to  any  one  much  conversant  with  newspapers,  magazines 
and  books  of  the  day.  It  is  notorious  that  any  body  can 
obtain  the  ear  of  the  public,  who  can  tell  a  tale  of  false 
imprisonment,  however  improbable ;  and,  on  evidence  that 
would  not  be  listened  to  in  a  court  of  justice,  the  news- 
paper press  is  swift  to  pour  out  the  vials  of  its  wrath  on 
the  supposed  offender.  The  horrors  of  the  madhouse  have 
become  a  favorite  element  in  the  plot  of  sensational  novels. 
There  is  no  reason  to  suppose  that  the  result  would 
be  otherwise  in  this  country.  A  sentiment  like  that  in 
question  cannot  be  effected  by  facts  or  arguments.  The 
testimony  of  the  wisest  commission  would  avail  nothing 
against  the  statements  of  a  disordered  mind,  still  manifest- 
ing some  degree  of  coherence  and  plausibility.  We  may 
as  well,  therefore,  take  things  as  they  are — satisfied  that 
the  present  safeguards  are  all  that  could  be  reasonably 
expected,  and  also  that  some  popular  distrust  is  one  of  the 
unavoidable  results  of  all  correct  hospital  management. 

There  is  another  view  of  the  subject  that  ought  not  to 
be  overlooked  in  considering  the  expedience  of  restrictive 
measures.  All  persons  engaged  in  that  specialty  of  the 
medical  profession  which  is  concerned  with  the  treatment 
of  insanity,  tell  us  that  the  greatest  difficulty  they  have 
to  contend  with  is  the  reluctance  of  friends  to  bring  the 
patient  in  the  earliest  stage,  and  the  impatience  which 
leads  to  a  premature  removal.  Under  the  operation  of 
these  feelings,  the  number  of  recoveries  are  unquestionably 
lessened,  and  it  cannot  be  doubted  that  they  will  be  still 
farther  lessened  by  the  proposed  restrictions.  Their  eftect 
on  the  first  mentioned  feeling  has  been  already  alluded  to, 
while  their  operation  in  England  furnishes  abundant  testi- 
mony as  to  their  effect  in  causing  premature  removals. 
During  that  period  of  the  disease,  when  the  patient  is 
coming  to  himself  and,  outwardly,  seems  free  from  all 
irrational  thoughts  and  ways,  great  care  is  necessary,  in 
order  to  conduct  the  process  of  restoration  to  a  complete 
recovery,  that  he  does  use  his  renewed  powers  too  much 
or  too  soon — that  he  does  not  resume  too  soon  the 
control  of  his  own  movements,  nor  mingle  too  soon  in 
the  scenes  and  associations  of  ordinary  life.  The  patient 
himself,  however,  may  see  no  necessity  for  much  caution. 


Isolation  of  the  Insane.  463 

He  never  felt  better  in  his  life,  to  use  his  own  expression, 
and  he  sees  no  propriety  in  being  detained  any  longer. 
In  this  impatient,  fretful  frame  of  mind,  he  pours  his  com- 
plaints into  the  ears  of  the  commissioners,  who,  observing 
no  manifestations  of  insanity,  and  unable  to  understand  the 
reasons  which  influence  the  physician  (because  they  are 
purely  a  matter  of  professional  experience)  and  readily 
induced  to  advise  his  removal. 

The  mischievious  effects  of  the  restrictive  measures  now 
used  in  England,  are  strikingly  manifested  in  another 
class  of  cases,  by  no  means  a  small  one.  The  more  active 
and  obvious  signs  of  disease  have  disappeared,  the  patient 
is  quiet,  orderly,  and  behaves  like  other  people,  and  his 
remarks  are  shrewd  and  sensible,  indicating  neither  delu- 
sion nor  extravagence.  But  there  is  something  in  the 
air,  manner,  tone  and  way  of  the  patient,  imperceptible 
to  the  ordinary  observer,  but  real  enough  to  the  expert, 
signifying  that  disease  has  not  entirely  vanished,  but  is 
only  kept  in  abeyance, — that  freedom  from  restraint  and 
the  necessity  of  self-control,  with  opportunity  to  gratify  a 
morbid  impulse,  would  soon  be  followed  by  acts  of  mis- 
chief or  violence.  He  knows,  however,  that  his  appre- 
hensions will  not  be  appreciated  by  the  Commissioners, 
and  that  a  delay  of  the  patient's  discharge  might,  probably, 
be  followed  by  an  action  for  false  imprisonment,  ending 
in  a  verdict  of  heavy  damages.  To  obviate  such  a  result 
he  discharges  his  patient,  with  fearful  forbodings  that  are 
too  often  realized.  In  England,  some  fifteen  years  since, 
a  man  was  admitted  into  a  private  asylum,  who  had  made, 
at  least,  two  homicidal  attempts.  After  a  few  months' 
stay,  he  was  so  far  improved  that  no  trace  of  disease 
was  obvious  on  a  casual  inspection.  His  physician  strongly 
suspected  that  the  disease  was  only  masked,  not  removed, 
but  he  feared  to  detain  him  longer,  on  the  ground  that 
could  not  be  appreciated  by  ordinary  observers.  So  he 
discharged  him,  but  his  apprehensions  were  so  keen,  that 
he  sent  him  home  in  charge  of  an  attendant,  with  injunc- 
tions to  the  family  to  exercise  unceasing  vigilance  over 
his  movements,  but  it  was  not  long  before  he  committed 
an  atrocious  homicide,  without  the  slightest  provocation. 
The  case  is  a  fair  specimen  of  what  may  be  expected 
where  a  physician  in  charge  of  an  establisment  for  the 
insane  is  hampered  in  the  exercise  of  his  duty  by  con- 
siderations that  ought  to  have  no  influence  whatever  on 
his  professional  conduct.  To  meet  this  contingency  of 
persons  being  kept  in  hospitals  when  no  longer  insane, 
the  act  of  1869  contained  he  following  provision: 


Isaac  Ray. 


"On  a  written  statement,  properly  sworn  to  or  affinned.  beinif  ad- 
dressed by  some  respectable  person  to  any  law  jiidjre,  that  a  certain  person 
then  confined  in  a  hospital  for  the  insane  is  not  insane,  and  is  thus  unjustly 
deprived  of  his  liberty,  the  jud<re  shall  issue  a  writ  of  habeas  corpus,  coin- 
niandinjf  that  tlie  said  alle<(ed  lunatic  be  brouj^ht  before  him  for  a  public 
h<arin<r,  wiu're  the  question  of  his  or  her  alle<;ed  lunacy  may  be  diter- 
mined.  and  where  the  onus  of  proving  thea]le<^ed  lunatic  lo  be  insane  shall 
rest  upon  such  persons  as  are  restralnin<r  ium  or  herof  his  or  her  liberty." 

The  bill  passed  through  its  first  stages  with  the  same 
provision  in  this  case  as  in  that  of  persons  committed  to  a 
hospital,  viz.:  a  commission  composed  of  three  members,  and 
this  was  chosen  in  order  to  avoid  the  publicity,  exposure, 
trouble  and  excitement  incident  to  a  public  trial  in  court, 
and  the  cause  of  incalculable  mischief  to  the  patient.  It 
was  thought,  however,  by  some  persons  who  had  the  power 
of  giving  their  opinions  the  force  of  law,  that  the  offence  of 
keeping  a  person  in  confinement  after  his  recovery,  should 
be  dealt  with  in  the  swiftest,  sharpest  manner  known  to  the 
law.  And  so,  at  the  request  of  any  one  calling  himself 
a  respectable  person,  any  judge  in  this  city  is  obliged  to 
transfer  any  victim  of  suffering  from  the  rest  and  seclusion 
of  an  asylum  to  the  repulsive  scenes  of  the  old  Quarter  Ses- 
sions court  room,  and  deal  with  him  as  if  he  were  a  criminal 
on  trial  for  this  offence.  To  obtain  anything  like  an  adequate 
idea  of  this  gross  impropriety,  we  must  put  the  case  to  our- 
selves, and  conceive  the  subject  of  it  to  be  a  wife,  or  mother, 
or  daugher  or  sister. 

The  fallacy  so  prevalent  in  most  communities,  that  insan- 
ity is  always  something  superficial,  and  obvious  to  the  casual 
observer,  and  never  obscure  and  revealed  by  traits  that  are 
significant  only  to  the  expert,  is  singularly  foolish,  and  as 
mischievous  as  it  is  foolish.  Some  idea  of  its  prevalence 
may  be  obtained  from  the  frequency  with  which  it  is  intim- 
ated, in  every  grade  of  society,  that  the  man  who  for  many 
years  has  spent  his  days  and  nights  surrounded  by  the 
insane,  is  less  qualified  to  give  an  opionion  as  to  the  exist- 
ence of  insanity  in  a  given  case,  than  those  whose  knowledge 
of  the  disease  is  confined  to  a  few  general  impressions 
respecting  it.  The  abundance  of  his  experience  and  the 
thoroughness  of  his  studies  are  regarded  as  the  very  things 
that  render  his  opinions  unreliable,  although,  in  accordance 
with  all  analogy,  it  might  be  supposed  that  they  would 
enable  him  to  see  insanity  where  others,  without  such  oppor- 
tunities, cannot  see  it.  A  surgeon's  large  experience  is  not 
supposed  to  render  all  the  more  incapable  of  detecting  a 
fracture  or  a  dislocation  which  is  unsuspected  by  other  men. 
And  he  is  no  more  able  to  give  a  reason  for  his  belief,  that 
would  be  any  reason  at  all  to  others,  than  an  expert  in  insan- 
ity sometimes  is,  for  his  belief  that  a  certain  person  is  insane. 


Isolation  of  the  Insane,  465 

In  fact,  it  is  just  the  most  dangerous  cases  in  which  the 
insanity  is  oftentimes  the  most  obscure,  BelHngham  who 
killed  Mr.  Percival,  McNaughton,  who  killed  the  Secre- 
tary of  Sir  Robert  Peel,  and  many  others,  manifested  no 
insanity  before  the  commission  of  their  bloody  deeds. 
They  talked  and  acted  and  seemed  very  much  like  other 
men,  and  so,  no  doubt,  they  have  seemed  to  a  board  of  com- 
missioners in  lunacy.  And  yet,  I  apprehend  that  an  expert 
would  have  been  satisfied,  after  a  little  observation,  that 
the  two  just  mentioned  were  unquestionably  insane.  To 
this  notion,  respecting  the  competence  of  experts  in  insan- 
ity, the  legislature  of  Massachusetts,  at  its  last  sessions,  gave  a 
remarkable  expression,  by  enacting  that  no  superintendent  of 
a  hospital  for  the  insane  should  give  a  certificate  of  insanity. 

There  is  a  class  of  insane  for  whose  isolation  a  certificate  of  insanity 
alone  is  not  sufficient.  Persons  become"  insane  who  have  no  family  or 
friends,  or.  havin^f  family  and  friends,  they  are  unwilling:  to  authorize  their 
conlinenient.  The  patient  nuiy  still  be  at  large,  engaged,  apparently,  in 
his  usual  pursuits,  etc.,  and  with  large  social  and  business  relations.  For 
various  reasons  no  one  is  willing  to  assume  the  responsibility  of  ordering 
his  arrest  nad  depriving  him  of  his  liberty.  His  wife  or  child  fears  to 
enf.'ounter  his  displeasure,  his  partner  in  busiuesss  is  deterred  from  inter- 
fering one  way  or  the  other,  lest  he  may  be  suspected  of  sinister  designs, 
and  others,  perhaps,  are  not  aware  of  the  urgency  of  the  case.  And  even  If 
one  should  feel  willing  to  interfere,  the  patient's  social  or  busines  relations 
would  seem  to  require  some  formal  adjudication,  in  order  to  satisfy  other 
parties  of  the  necessity  of  a  measure  followed  by  such  important  conse- 
quences. It  may  lead  to  the  dissolution  of  a  business  connection,  or  the 
avoidance  of  a  contract,  it  may  enable  him  to  escape  a  suit  at  law,  or  suspend 
execution  of  a  judgment.  The  propriety  of  the  measure  is  still  more 
apparent  when  the  presence  of  the  disease  is  not  perfectly  obvious  and  the 
patient  is  likely,  when  the  opportunity  oilers,  to  make  use  of  every  legal 
means  in  his  power  to  annoy  and  injure  all  who  took  any  pait  in  procur- 
ing his  isolation.  Under  such  circumstances  it  is  peculiarly  fit  that  the 
person  should  be  comnutted  by  some  process  of  law,  whereby  the  f;imily 
is  spared  the  performance  of  a  painfid  duty,  and  the  public  sentiment  is 
satisfied.    Accordingly,  in  act  of  1869  we  have  the  following  provision  : 

"Insane  persons  may  be  placed  in  a  hospital  bj^  the  order  of  any 
court  or  law  judge,  after  "the  following  course  of  proceedings,  viz.:  On 
statement  in  writing  of  any  respectable  person,  that  a  certain  person  is 
insane,  and  that  the  welfaie  of  himself  or  of  others  requires  his  restraint, 
it  shall  be  the  duty  ofthe  judge  to  appoint  immediately  a  commission  who 
shall  inquire  into  and  report  upon  the  fiicts  ofthe  case.  This  commis- 
sion shall  be  composed  of  three  persont-.  one  of  whom  at  least  shall  be 
a  physician,  and  another  a  lawyer ;  in  their  inquisition  they  shall  hear  such 
evidence  as  may  be  offered  touching  the  merits  of  the  case,  as  well  as  the 
statements  ofthe  party  complained  of,  or  of  his  eoiuisel ;  if  in  their  opinion,  it 
is  a  Suitable  case  for  confinement,  the  judge  shall  issue  his  warrant  for  such 
disposition  of  the  insane  person  as  will  secui-e  the  object  of  the  measure." 

These,  then,  are  the  only  requirements  necessary  to  provide  for  the 
proper  isolation  of  the  insane,  and  if  the  law  is  honestly  and  dispassion- 
ately administered,  we  believe  that  the  right  of  all  parties  will  be  secured. 


Art.   IV.— The  Insane  Diathesis.* 


By  H.  P.  Stearns.  M.  D.,  Hartford.  Conn. 

SUPERlNTENOtNT     AND     PHYSICIAN      OF     7HE     RETREAT     FOR     THE     INSANE, 
HARTFORD,    CONN 

THE  ideal  hu-man  system  would  be  one  in  perfection  ; 
that  is,  it  would  be  one  so  constituted  as  to  discharge 
all  of  its  natural  functions  perfectly.  Its  capacities  would, 
however,  be  limited  as  they  now  are,  though  not  to  the 
same  extent.  Digestion  of  such  articles  of  food  as  the 
system  requires  would  be  perfect,  though  this  might  not 
be  true  as  to  many  other  articles  which  are  appropriate 
for  food  for  other  animals.  Sight  and  hearing  would  be 
perfect,  but  only  within  certain  ranges  and  distances; 
memory  would  be  perfect  in  reference  to  everything  com- 
prehended and  understood.  The  limitations  would  be 
dependent  upon  the  inherent  nature  of  the  organism,  in  its 
relation  to  its  environment.  What  is  stated  above  would 
be  true  of  the  functions  of  all  inherent  faculties  of  the 
human  system,  both  physical  and  psychical. 

The  actual  human  system  tends,  in  a  greater  or  less 
degree,  towards  this  ideal  one.  It  possesses  all  the  fac- 
ulties, both  physical  and  psychical,  but  they  are  tainted 
with  imperfections  which  vary  from  the  highest  state  of 
health  attainable  down  to  some  assumed  standard,  below 
which  we  say  diseased  or  pathological  conditions  exist. 
It  will,  however,  be  observed,  and  hereafter  more  definitely 
appear,  that  this  border-land  is  merely  one  of  assumption. 
Imperfection,  which  means  disease,  exists  in  every  one.  It 
matters  not  whether  we  put  it  in  the  form  used  in  the 
old  catechism:  "In  Adam's  fall,  we  sinned  all,"  or  whether 
we    commence    on   the    Darwinian    theory    and    work    up. 

•Read  »)ef»re  the  Connecticut  S  ate  Medical  Society.  J880. 


The  Insane  Diathesis.  467 

The  point  reached  is  the  same  on  either  road.  In  the 
latter  case  we  are  actually  far  from  the  ideal  standard, 
while  in  the  former  we  are  not  yet  wholly  diseased. 

But  the  actual  condition  is  one  of  changing  stability, 
even  with  the  most  robust.  It  is  not,  however,  my  pur- 
pose to  discuss  this  point,  except  so  far  as  pertains  to 
the  psychical  element,  and  I  therefore  do  not  refer  to 
illustrations  of  its  truth  among  the  purely  physical  func- 
tions. 

We  do  not  know  certainly  upon  what  conditions  of 
the  brain  sound,  healthy  mentality  depends ;  we  cannot 
lift  the  veil  and  look  in  upon  cerebration ;  we  cannot 
hear  its  vibratory  movements;  but  there  can  be  no  doubt 
that  certain  prerequisite  conditions  are  necessary.  For 
instance,  there  must  be  a  requisite  amount  of  blood 
passing  through  the  blood-vessels  of  the  brain;  there  must 
be  such  a  condition  of  these  blood-vessels  in  arrangement 
of  distribution,  and  character  of  their  coats,  as  to  favor 
free  exosmosis  and  endosmosis  in  all  portions  of  the  cere- 
bral hemispheres.  The  nerve  cells  of  the  brain  must 
possess  at  least  a  certain  standard  of  both  delicacy  and 
strength  in  their  constitution,  and  the  same  is  true  of 
both  the  connective  tissue  and  the  whole  of  the  sensory 
portion  of  the  nervous  system.  These  conditions  given, 
with  possibly  others  the  nature  of  which  we  do  not  fully 
understand,  and  we  may,  with  reason,  expect  that  those 
manifestations  of  mind  which  we  term  normal  will  be 
present. 

But  I  desire  especially  to  call  attention  to  the  fact, 
that  even  in  what  are  termed  normal  mental  manifesta- 
tions there  exists  a  very  broad  diversity  of  character 
While  some  apprehend  anything  a  little  abstruse  with 
great  difficulty,  or  fail  to  do  so  at  all,  others  understand 
it  with  a  readiness  which  we  are  accustomed  to  call 
intuition.  While  many  occurrences  seem  merely  to  impinge 
upon  and  glance  off  the  minds  of  some  persons  never  to 
be  remembered  again,  they  pass  from  the  minds  of  others 
only  after  long  years,   or  remain  through  life. 


4fiS  Henry  P.  Stearns. 


Some  persons  always  look  upon  and  judge  of  occur- 
rences and  events  in  an  unusual  way.  They  are  odd  or 
singular  in  their  mental  constitution,  and  are  accustomed 
to  do  odd  and  out-of-the-way  things,  just  as  naturally  as 
others  would  do  the  same  things  in  such  a  manner  as  to 
attract  no  attention.  Some  persons  hear,  see,  taste,  touch 
and  smell  so  much  more  quickly  and  delicately  than 
others,  that  we  must  conclude  there  exists  a  radical  differ- 
ence in  the  perfection  of  the  organization  of  the  nerve 
cells  of  these  various  organs  of  special  sense. 

Again,  there  are  periods  during  which  all  persons  see, 
hear,  touch,  taste  and  smell  with  much  greater  readiness 
and  delicacy  than  at  other  times,  even  in  a  state  of 
so-called  health.  Musical  sounds  are  much  more  delicate 
and  pleasing;  harsh  and  rough  sounds  are  more  harsh  and 
rough ;  certain  articles  of  food  produce  a  keener  sense  of 
relish,  and  colors  a  greater  sense  of  pleasure  ;  all  of  which 
would  indicate  temporary  changes  in  the  condition  or 
function  of  the  nerve  element  composing  these  special 
organs  of  sense. 

The  same  is  true  to  even  a  larger  extent  of  the  emo- 
tional nature.  Persons  are  placed  in  certain  states  of  the 
nervous  system  with  sensations,  objects,  and  persons, 
which  afford  them  no  pleasure  at  other  times;  they  are 
displeased  and  pained,  while  in  other  conditions,  with 
sentiments  which  would  at  other  times  produce  no  such 
effects.  They  sometimes  feel  that  the  world  and  its  pos- 
sessions and  pleasures  are  so  great  and  grand  that  they 
can  never  leave  them,  and  the  thought  of  doing  so  causes 
the  keenest  anguish,  while  in  another  state  all  these 
pleasures  and  possessions  appear  as  empty  and  valueless 
as  a  bubble  of  air,  while  the  thought  of  leaving  them, 
and  throwing  off  the  burdens  and  cares  of  life,  which  are 
usually  so  much  annoyed,  seems  almost  pleasurable. 

Again,  persons  have  periods  of  being  irritable,  restless, 
nervous  ;  they  cannot  bear  much ;  little  incidents  which,  in 
other  conditions  of  the  nervmis  s)stem  they  would  think 
little   or  nothing  of,  turn  them    into    a    passion    of    excite- 


The  Insane  Diathesis.  469 

ment,  which  can  hardly  be  controlled  for  the  time  being. 
In  other  states  they  may  long  to  weep,  or  to  be  in  solitude 
where  they  can  neither  see  nor  hear  anything ;  or  they 
may  shout,  and  laugh,  and  talk,  while  thoughts  come 
coursing  through  the  brain  so  fast  that  words  fail  to 
express  them.  The  same  changes  occur  among  the 
impulses;  these  are  at  times  almost  irresistible.  Nearly 
every  one,  while  standing  on  a  high  cliff  or  house-top, 
has  had  an  impulse  to  jump  off  or  push  his  friend  off, 
reckless  of  all  consequences,  or  while  on  a  bridge  or  in  a 
boat,  to  jump  mto  the  water. 

In  the  usual  conditions  of  the  nervous  system  persons 
love  their  children  and  relatives,  and  are  ready  to  do  and 
suffer  and,  at  times  even  to  die  for  them,  if  need  be, 
while,  at  other  times,  all  these  sentiments  fade  away,  so 
that  they  are  unconscious  of  them,  and  even  the  opposite 
sentiment  of  disHke  or  hatred  takes  their  places. 

Periods  of  mental  lethargy  come  over  most  persons  at 
times,  so  that  they  care  neither  to  talk  nor  engage  in 
any  of  their  usual  intellectual  or  physical  pursuits ;  and 
such  stimuH  as  are  usually  sufficient  to  rouse  to  action 
the  brain,  appear  to  have  very  little  effect.  Persons  say 
and  feel  that  there  is  a  state  of  only  partial  brain  activity. 
At  other  times  the  brain  acts  with  the  greatest  freedom  ; 
occurrences  which  took  place  long  years  before,  and 
which,  perhaps  have  not  been  thought  of  since,  come 
back  with  all  the  freshness  of  yesterday.  Thoughts  come 
rapidly — more  so  than  words  to  express  them.  Keen 
flashes  of  wit,  bright  scintillations  of  thought,  forms  of 
expression  of  unusual  felicity  pour  forth  spontaneously, 
while  the  mind  apprehends  and  retains  many  kinds  of 
knowledge  with  the  greatest  readiness.  Similar  variations 
take  place  in  reference  to  courage  and  its  opposite,  timid- 
ity, truthfulness  and  suspicion,  and,  in  fact,  the  whole 
range  of  mental  endowments. 

Now  all  this  grand  play  of  diverse  emotions  and 
conditions  in  the  psychical  functions  takes  place  in  a 
state  of  health;   still  there  can  be  no  doubt  that  it  comes 


470  Henry  P.  Stearns. 


from  changes  produced  in  some  manner  in  the  varied  and 
dehcate  structure  of  the  brain.  It  may  come  from  the 
changes  which  are  constantly  taking  place  in  the  blood, 
in  the  processes  of  reception  and  elimination,  or  from  those 
delicate  chemical  operations  which  must  be  forever  going 
on  in  the  nerve  elements  of  the  brain  hemispheres,  affect- 
ing their  recipient  and  sensitive  capacities,  or  it  may  be 
from  other  unknown  causes. 

Now  we  have  only  to  suppose  a  person  with  a  nervous 
system,  so  constituted  that  these  conditions,  which  I  have 
described  as  temporarily  occurring  with  most  persons,  are 
permanent,  though  in  a  latent  state,  and  we  have  that 
peculiar  organization  which  is  termed  the  Insane  Diathesis. 
That  is,  we  have  a  nervous  system,  so  illy  adjusted  with 
its  environment  that,  when  brought  in  contact  with  its 
exciting  influences,  there  occur  abnormal  instead  of 
normal  results,  and  these  become  more  or  less  continuous 
instead  of  evanescent.  The  husband  hates  his  wife,  and 
the  wife  her  husband  ;  the  parent  his  child,  and  the  child 
his  parent.  We  have  the  person  whose  daily  condition 
is  such  that  he  feels  no  pleasure  and  experiences  no 
satisfaction  in  life,  but  hates  it,  and  longs  tfo  throw  off  its 
burdens  and  care,  and  leaves  no  effort  untried  to 
accomplish  it;  while  another  is  so  filled  with  joyous 
emotions,  his  brain  is  so  excited  in  functional  activity- 
that  he  can  neither  eat  nor  sleep,  but  ideas  flow  forth  in 
one  constant  stream  of  words — words  ;  bright  visions  appear 
on  every  side,  and  his  life  is  worth  a  thousand  worlds. 
Or  we  may  have  any  other  of  the  ten  thousand  perverted 
mental  activities  which  attend  the  "  mind  diseased." 
•'And  he,  ...  (a  short  tale  to  make) 

Fell  into  a  sadness;  then  into  a  fast; 

Tlience  into  a  watch;  thence  into  a  weakness; 

Thence  into  a  lightness;  and  by  this  declination 

Into  the  madness  whereon  now  he  raves, 

And  all  we  mourn  for." 

I     have    thus    endeavored  to    trace     out    in    a    hurried 
manner  and  explain  what  is  meant  by  the  insane  diathesis, 


The  Insane  Diathesis,  471 

and  how  it  borders  upon  healthy  conditions.  In  the  above 
view  there  does  not  appear  to  be  any  well-defined,  sharply- 
bounded  line  between  what  is  termed  normal  and 
abnormal  mental  activity.  The  one  insensibly  merges 
into  the  other,  while  both  depend  upon  the  condition  of 
the  brain  for  the  time  being.  When  the  brain  is  in 
what  is  determined  a  healthy,  normal  condition,  then  we 
have  healthy  mind,  and  vice  versa.  When  it  may  vary 
ever  so  little  from  this  state,  either  by  inheritance  or 
acquirement,  then  we  have,  for  the  time  being  abnormal 
mind.  Thousands  are  born  into  the  world  with  brains  so 
constructed,  and  thousands  more  attain  to  such  conditions 
by  the  friction  of  life  and  abuse  of  its  conditions  and 
enjoyment. 

I  wish  now  to  trace  out  briefly  some  of  the  influences 
in  operation  in  modern  life,  more  especially  in  the  educa- 
tion of  the  young,  and  their  habits  of  life,  which  tend  to 
render  the  functional  activity  of  the  brain  unstable  and 
liable  to   abnormal  manifestations. 

The  higher  conception  of  an  education  would  embrace 
the  idea  of  its  being  sy?nmetrical,  that  is,  that  the  psychical 
and  the  physical  should  be  in  harmony.  The  system 
should  be  considered  and  treated  as  a  whole.  The  brain 
should  not  be  stimulated  or  cultivated  at  the  expense  of  the 
body,  nor  should  it  be  neglected  while  the  latter  is  devel- 
oped. If  both  are  in  harmony,  then  both,  and  especially 
the  brain,  will  be  in  the  best  condition  to  withstand  the 
strain  and  wear  and  tear  of  after  life.  But  who  thinks 
now  of  educating  or  developing  the  body  of  a  child  as  a 
part  of  education?  This,  in  the  vast  majority  of  cases, 
is  left  to  take  care  of  itself,  while  all  thought  of  education 
centers  upon  mind.  At  five  or  six  years  of  age,  and 
while,  for  some  years,  the  system  must  be  in  the  formative, 
growing  period  of  its  existence,  the  child  is  confined  five 
hours  a  day  on  a  hard  seat  or  chair  in  a  room  often  illy 
ventilated  and  irregularly  heated.  During  the  larger 
portion  of  this  time,  he  or  she  is  expected  to  have  the 
mind    occupied     in     study     or    recitation,    which    is     quite 


472  Henry  P.  Stearns. 


equivalent  to  study.  In  addition  to  this,  after  the  child 
arrives  at  the  age  of  twelve  or  fourteen  years,  tasks  of 
such  extent  are  imposed  that  it  becomes  necessary  to 
study  from  one  to  two  hours  during  the  evening.  I  think 
that  most  persons  with  much  experience  in  intellectual 
occupations  will  agree  with  me  in  saying  that  six  hours 
a  day  is  quite  enough  for  an  adult  mind  to  be  occupied, 
with  advantage,  in  study.  I  think  it  will  be  found  that 
our  most  successful  clergymen  and  lawyers  and  litterateurs, 
though  at  times  a  more  protracted  period  of  effort  may 
be  necessary,  yet,  as  a  rule,  do  not  spend  a  longer  time 
in  intellectual  effort.  Yet,  in  the  education  of  our  little 
ones,  we  find  that  both  teachers  and  parents,  in  their 
blind  ambition  to  hurry  them  forward,  conspire  together 
in  imposing  tasks  of  such  a  character  as  to  require 
longer  hours  than  we  know  to  be  wise  for  the  adult 
brain. 

I  believe,  however,  that  the  largest  mischief  does  not 
come  from  the  length  of  time  occupied  in  confinement 
and  study,  great  as  this  may  be.  A  still  larger  defect  in 
the  system  lies  in  the  multipUcity  of  the  subjects  studied, 
and  the  lack  of  sufficient  individuality  in  its  administra- 
tion. In  our  graded  schools,  pupils  are  parceled  out 
in  numbers  ranging  from  forty  to  sixty  in  number  in 
one  room,  and  put  under  the  charge  of  one  teacher.  I 
venture  to  say  that  no  one  teacher  can  do  even  half 
justice  to  any  such  number  of  children.  The  whole 
system  is  purely  a  mechanical  one ;  all  must  come  in, 
go  out,  rise  up  and  sit  down,  study  and  recite,  together. 
There  is  no  room  or  time  for  individuality  in  any 
department  of  study.  Each  one  goes  on  with  the 
whole  or  he  drops  out  and  back,  while  the  half 
exhausted  teacher  has  no  time  or  opportunity  to  bestow 
the  little  aid  which  would  often  be  of  much  value. 
His  task  is  to  know  that  in  some  way  or  other  the  pupil 
seems  to  know  the  lesson,  and  if  he  does  not  he  must 
work  until  he  does,  or  drop  back.  Now  doubtless  one 
or  two  out  of  every  five  of  these   fifty  or  sixty  can    press 


The  Insane  Diathesis.  473 

on  with  ease  and  health  through  all  the  studies  which  all 
are  expected  to  master,  but  for  the  other  three  or  four 
out  of  the  five  there  exists  a  large  tendency  toward  con- 
fusion and  imperfect  knowledge,  rather  than  vigor  and 
strength  of  brain. 

In  this  respect  I  believe  the  education  of  fifty  years 
ago  was  better  than  that  of  to-day.  The  teacher  had  a 
less  number  of  scholars,  while  a  few  subjects  were 
thoroughly  mastered.  A  few  books  only  were  read,  but 
what  was  studied  and  read  was  generally  more  thoroughly 
studied  and  understood.  There  were  fewer  confused  and 
half-understood  lessons  and  theories,  and  as  the  mind 
became  older  it  went  out  for  larger  fields  and  broader 
pastures  of  knowledge.  They  doubtless  did  not  have 
much  information  as  to  the  movements  of  the  heavenly 
bodies,  or  of  the  names  of  insignificant  towns,  hamlets,  or 
rivers  on  the  eastern  or  western  coast  of  Africa.  They 
might  not  be  able  to  define  the  boundaries  of  Kamtschatka, 
nor  give  the  pluperfect  of  a  large  number  of  irregular 
verbs ;  but,  on  the  other  hand,  their  brains  were  clear 
and  vigorous,  and  possessed  a  recipient  capacity.  They 
were  not  crammed  and  confused  by  dim  memories  of  a 
vast  multitude  of  names  or  facts,  which  could  by  no 
possibility  have  any  important  bearing  on  their  future 
lives  or  fortunes.  Knowledge  to  be  of  much  practical 
value  in  life  must  be  clear  and  definite  in  the  mind  of  its 
possessor.  When  half  mastered,  it  tends  rather  to  weaken 
and  confuse  than  strengthen  and  invigorate ;  and  there- 
fore, during  the  earlier  periods  of  life,  study  in  our  schools 
should  be  confined  to  a  comparatively  few  subjects.  Please 
bear  in  mind  that  the  grand  object  in  education,  physio- 
logically considered,  is  to  render  the  brain  strong,  vigor- 
ous, and  stable,  and  as  little  liable  to  instability  and 
uncertain  and  irregular  action  as  possible.  Any  course  of 
training,  therefore,  during  this  early  formative  period  of 
life,  which  tends  to  crowd  the  mind  or  stimulate  it  to 
over-activity,  must  tend  to  after  weakness  and  instability. 

This  leads  me  to  protest  against  the  modern  tendency 


Eenry  P.  Stearns. 


to  continually  increase  the  requirements  for  entering  and 
continuing  in  our  graded  schools  and  colleges  ;  while  the 
number  of  studies  is  increased  the  time  for  their  acquisi- 
tion must  remain  unchanged,  and  each  scholar  is  hurried 
on  through  or  dropped  by  the  way.  To  avoid  the  latter 
result  too  great  and  too  protracted  effort  is  necessary  on 
the  part  of  many  children,  while  in  some  cases  the  results 
are  manifested  in  a  state  of  mental  confusion  and  uncer- 
tainty, and  a  nervous,  hysterical  condition. 

I  have  in  mind,  at  this  writing,  a  case  which  will 
illustrate  my  point.  It  was  that  of  a  young  lady  of  ordi- 
nary mental  endowments,  whose  parents  usually  brought 
her  to  me  for  advice  as  often  as  every  two  or  three 
weeks,  because  she  was  nervous  and  suffered  with  frequent 
and  protracted  headaches,  especially  near  her  monthly 
periods.  Inquiry  elicited  the  fact  that  she  was  obliged 
to  study  during  the  evening  until  ten  or  eleven  o'clock  to 
accomplish  the  tasks  which  were  assigned  to  her  class, 
and  it  was  thought  by  the  parents  that  this  practice  was 
all  right ;  that  it  evinced  faithfulness  and  ambition  on  the 
part  of  the  young  lady,  which  was  undoubtedly  true  ;  and 
it  was  with  great  difficulty  that  I  could  convince  her 
or  her  parents  that  her  condition  was  due  to  the  con- 
stant violation  of  the  laws  of  health  ;  that  her  brain  and 
whole  nervous  system  required  longer  periods  of  repose 
and  quiet  at  her  age  than  it  would  be  likely  to  need 
later ;  that  the  future  of  her  whole  life,  as  a  member 
of  society,  might,  and  must,  in  a  large  degree  depend,  not 
on  the  grade  of  the  marks  she  might  receive  in  her  daily 
recitations,  but  largely  on  the  nervous  and  physical  strength 
she  might  be  able  to  build  up  before  she  should  become 
twenty-one  years  of  age.  This  young  lady  was  of  a 
healthy  parentage  and  inherited  a  good  physique,  and 
with  proper  habits  of  life  and  study  would  have  had 
excellent  health.  As  it  was,  her  system  will  not  for 
years,  if  ever,  recover  from  the  effects  of  her  habits  of 
excessive   hours  of  study. 

The    name    of  another   patient   occurs   to    me,  a  young 


The  Insane  Diathesis.  475 

man  of  good  parentage  and  apparently  inheriting  a  good 
constitution.  He  was  ambitious  in  study,  and  his  par- 
ents allowed  him  to  do  all  he  might  choose  to.  He 
entered  college,  standing  among  the  best  scholars  of  his 
class,  but,  before  the  end  of  his  first  year,  began  to 
be  troubled  with  noises  in  his  head  and  confusion  of 
mind.  He  was  removed  from  college,  and  remained  out 
till  the  end  of  the  year,  but  partially  kept  up  his  studies 
at  home.  He  entered  the  sophomore  year,  but  was 
obliged  to  leave  earlier  in  the  year  than  before.  He 
tried  the  junior  year  with  a  like  result,  and  from  this 
time  began  to  show  more  decided  indications  of  mental 
impairment.  He  traveled  both  in  this  country  and  in 
Europe ;  he  consulted  the  most  eminent  physicians,  but 
all  to  no  purpose  ;  the  mischief  had  been  too  effectually 
accomplished.  The  delicate  tissue  of  the  brain  had  been 
over-strained,  and  so  impaired  that  when  his  parents 
awoke  to  its  importance  it  was  too  late  to  repair  the  mis- 
chief. 

Multitudes  of  similar  cases  could  be  cited  if  it  was 
necessary.  Another  young  man,  barely  graduated,  stand- 
ing in  the  front  rank  in  his  class,  and  then  for  years 
was  able  to  do  but  little  study,  and  spent  his  time  in 
vain  search  for  that  health  which  by  judicious  habits  in 
study   he   would    never   have   lost. 

I  desire,  however,  not  only  to  emphasize  the  effects 
of  study  so  far  as  they  may  manifest  themselves  on  the 
individuals  themselves,  but  the  effects  which  they  are 
certain  to  transmit  to  their  posterity.  The  brain  may, 
and  does  in  many  cases,  so  far  recover  that  it  may 
fairly  do  the  work,  or  a  work  in  life,  but  it  has  attained 
a  bias — a  twist,  which  will  be  sure  to  manifest  itself  in 
the  next  generation  in  something  more  than  a  twist ; 
it  will  be  an  insane  diathesis — a  brain  constituted  in  so 
unstable  a  manner  that  the  friction  of  ordinary  life  will 
upset    it,    ending    in   insanity. 

I  have  often  thought  that  teachers  are  only  partially 
to    blame    as    they    are    countenanced    and    encouraged  by 


Henry  P.  Stearns. 


the  parents  in  this  .injudicious  course  of  mental  stimu- 
lation in  early  life.  Perhaps  the  very  freedom  of  our 
educational  and  governmental  institutions  also  helps  it 
on;  every  child  is  taught  that  all  the  prizes  of  life  are 
within  his  grasp,  if  he  v.'ill  only  make  the  requisite  effort 
while  every  parent  longs  to  see  his  child  higher  up  in 
the  social  scale  than  he  himself  is.  These  conditions 
not  unfrequently  serve  to  stimulate  those  especially  ambi- 
tious to  over-exertion,  while  again,  there  is  less  of  the 
controlling  element,  both  in  home  and  social  life,  than 
exists  under  most  other  forms  of  government.  Educa- 
tion should  embrace  the  learning  of  self-control,  and 
self-denial  even,  for  individual  or  the  general  good,  and 
when  this  element  is  lost  sight  of,  and  the  child  is  per- 
mitted to  grow  up  having  his  own  way  in  most  things, 
and  his  every  wish  gratified,  he  has  a  large  disadvantage 
when  brought  into  contact  with  the  friction  of  adult  life. 
It  has  happened  in  my  professional  experience  that  I 
have  seen  not  a  few  young  men  and  women  hopelessly 
stranded  in  life,  whose  early  education  had  been  one  of 
extreme  indulgence.  They  had  never  been  controlled  in 
home  life,  and  when  projected  against  the  rough  experi- 
ences of  actual  life  were  brought  up  with  a  round  turn, 
or  with  no  turn  at  all.  The  shocks  were  too  much 
for  them ;  the)-  could  not  bend,  and  therefore  broke. 
Obedience  to  law,  whether  it  be  parental,  social,  or  civil, 
is  one  of  the  corner-stones,  in  fact  the  fundamental  element, 
in  an\'  efficient  and  worthy  system  of  education.  While 
I  would  not  go  back  to  the  strict  s}'stem  of  a  hundred 
years  ago,  wherein  all  individualitx'  was  lost,  and  ever}'- 
thing  was  made  to  yield  to  the  law  element  in  society, 
yet  I  fear  that,  in  the  recoil  from  that  system,  we  have 
been  and  still  are  in  great  danger  of  going  too  far  in  the 
other  direction.  Freedom  of  individual  action  and  thought 
is  m  danger  of  degenerating  into  mere  license,  so  that  in 
too  many  quarters  respect  for  parental,  school,  and  civil 
authority  is  among  the  }'oung  considered  as  an  indication 
of  weakness  and   indecision. 


The  Insane  Biathesis.  477 

Still,  it  is  but  just  to  say  that  we  in  America  are  not 
the  only  ones  who  need  to  plead  guilty  in  reference  to 
over  stimulation  and  faulty  education.  An  English  physi- 
cian, in  referring  to  this  subject,  lays  similar  accusations 
against  teachers  and  parents  in  that  country.  He  says, 
"The  master  of  a  private  school  informs  me  that  he  has 
proof  of  the  ill  effects  of  over-work,  in  the  fact  of  boys 
being  withdrawn  from  the  keen  competition  of  a  public 
school  career,  which  was  proving  injurious  to  their  health 
and  sent  to  him,  that  they  might,  in  the  less  ambitious 
atmosphere  of  a  private  school,  pick  up  health  and 
strength  again.  He  refers  to  instances  of  boys  who  had 
been  crammed  and  much  pressed  in  order  that  they  might 
enter  a  certain  form,  or  gain  a  desired  exhibition,  having 
reached  the  goal  successfully  and  then  stagnated."  He 
further  says,  "Too  many  hours  daily  study  and  the  knowl- 
edge of  an  approaching  examination,  when  the  system  is 
developing  and  requiring  an  abundance  of  good  air  and 
exercise,  easily  accounts  for  pale  and  worn  looks,  frequent 
headache,  disturbed  sleep,  nightmare,  and  nervous  fears* 
When  the  career  of  such  students  does  not  end  in  grad- 
uating in  a  lunatic  asylum,  they  lose  for  years,  possibly 
always,  the  elasticity  and  buoyancy  of  spirits  essential  to 
robust  mental  health.  A  strong  constitution  may  be 
sacrificed  to  supposed  educational  necessities." 

The  above  statements  were  made  as  showing  a  ten- 
dency, on  the  part  of  prevalent  modes  of  education  in 
England,  to  produce  in  its  subjects  either  insanity  or  a 
tendency  toward  it.  I  here  introduce  them  as  showing 
how  strongly  such  an  influence  is  developed,  which  may, 
and  in  most  cases  does,  fall  short  of  actual  disease,  but 
which  is  of  such  a  nature  that  it  w411  tend  to  develop  the 
insane  diathesis  in  the  next  generation.  Parents  transmit 
required  tendencies  towards  disease  as  well  as,  and  indeed 
I  think  much  more  frequently  than  disease  itself. 

I  must  beg,  however,  not  to  be  misunderstood.  I  think 
I  value  the  importance  of  an  education  for  the  development 
and    discipline    of   the    brain    as    profoundly    as    any  one. 


478  Benry  P.  Stearns. 


Indeed,  I  believe  the  lack  of  brain  discipline,  for  those 
who  are  to  compete  in  the  struggle  of  life  in  the  midst 
of  such  a  civilization  as  that  of  to-day,  is  one  of  the 
greatest  misfortunes ;  but  I  do  desire  to  protest  with  all 
emphasis  against  this  indiscriminate  system  of  cramming, 
towards  which  the  English-speaking  people  appear  to  be 
so  rapidly  tending.  It  tends  to  defeat  one  of  the  most 
important  ends  to  be  gained.  Instead  of  rendering  the 
brain  stronger  and  more  capable  of  vigorous  work  in  life, 
and  transmitting  to  another  generation  a  sound,  healthy 
mentality,  there  exists  a  probability  that  there  will  be 
transmitted,  in  too  many  cases,  a  tendency  to  unstable 
and  irregular  action  which  will  have  a  final  ending  in 
insanity.  I  wish  to  plead  earnestly  for  a  larger  degree 
of  individuality  in  our  system  of  education,  even  if  it  be 
at  the  expense  of  some  diminution  in  other  respects.  Let 
there  be  fewer  subjects  studied,  and  let  what  is  studied 
be  more  thoroughly  mastered.  Have  fewer  half-under- 
stood porblems  and  half-remembered  lessons,  and  I  believe 
we  shall  have  stronger  intellects  and  more  stable  brains 
in   after  life. 

There  are  certain  other  conditions  which  I  think  have 
an  important  influence  toward  increasing  instability  of 
brain  action,  to  which  I   wish  briefly  to  refer. 

And  first,  the  great  change  which  has  occurred  during 
the  period  of  the  last  generation  (the  much-glorified 
period  of  the  telegraph  and  railroads),  in  the  habits  and 
customs  of  living  among  the  older  civilizations.  Immensely 
fewer  people  till  the  soil  and  follow  out-door  occupations 
for  a  livlihood  than  thirt\--fi\'e  years  ago,  and  the  improved 
agricultural  machinery  is  tending  constantly  to  make  this 
number  still  smaller.  Larger  numbers  are  congregated 
in  factories  and  mills,  and  are  engaged  in  mechanical 
occupations,  counting-houses,  mercantile,  and  in-door  lives. 
Instead  of  being  in  the  open  air,  every  moment  breathing 
in  its  purity  and  freshness,  they  are,  for  twenty  or  more 
hours  out  of  the  twenty-four,  cither  in  the  close  or 
vitiated  atmosphere  of  the   factor)-  or    counting-house,  or, 


The  Insane  Diathesis.  479 

what  is  not  unfrequently  worse,  the  illy-ventilated  sleep- 
ing-room or  parlor.  In  the  one  case  the  blood  is  purified 
and  nourished  by  the  influence  of  a  large  supply  of  pure 
oxygen  which  it  bears  to  every  portion  of  the  system 
and  especially  the  brain,  while  in  the  other  it  is  only 
partially  decarbonated  and  bears  a  taint  during  its  whole 
round  of  circulation.  Thousands  and  tens  of  thousands 
who,  thirty-five  years  ago,  in  England,  France,  Switzerland, 
and  this  country,  lived  largely  out  of  doors,  whose  cheeks 
were  fanned  with  the  fresh  breeze  from  "early  morn  till 
dewy  eve,"  to-day  are  immured  in  the  dense  atmosphere 
of  cities  and  factories. 

Again,  there  has,  within  the  same  period  of  time, 
come  a  large  change  over  the  human  system  itself,  attri- 
butable in  a  measure,  probably,  to  the  above  causes. 
There  has  been  a  change  in  the  relative  prominence  of 
the  circulatory  and  nervous  system  in  reference  to  disease, 
so  that  those  which  affect  the  former  system  to-day 
demand  and  receive  a  largely  different  mode  of  treatment 
from  that  used  forty  years  ago ;  the  heroic  system  of 
those  days  so  freel}'  resorted  to  would  not  be  so  well 
borne  to-day.  The  force  or  tendency  of  disease  seems  to 
be  carried  over  (if  I  may  so  speak)  into  the  nervous 
system,  so  that  there  is  a  much  larger  tendency  toward 
disease  of  this  system  than  before,  while  the  keen  compe- 
titions, the  intense  mental  activities  which  pervade  all  the 
avocations  of  modern  life,  tend  to  still  further  increase  it. 
These  results — there  can  but  result,  on  the  whole,  a  much 
less  robust  and  vigorous  system,  and  also  much  less  robust 
and  vigorous  families  of  children.  While  the  number  is 
largely  diminished,  those  who  are  so  fortunate,  or  unfor- 
tunate, as  to  complete  the  journey,  arrive  in  the  world  to 
meet,  it  is  to  be  feared,  in  many  cases,  with  a  cold  recep- 
tion, and  bear  in  their  nervous  systems  a  weakness  which 
clings  to  them  through  the  journey  of  life. 

Further,  with  such  changed  conditions,  more  especially 
among  the  English-speaking  people  of  to-day,  I  can  but 
believe  that  the  effects  of  alcohol  and  tobacco,  especially 


480  Henry  P.  Stearns. 


the  former,  are  much  more  injurious  upon  the  nervous 
system  than  they  would  be  under  the  former  modes  and 
avocations  of  former  Hfe.  I  have  not  time,  or  incHnation 
if  I  had  time,  to  descant  upon  the  effects  of  alcohol 
upon  the  general  system,  but  I  desire  to  call  attention 
to  the  fact  that  its  primary  effect  is  that  of  one  of  the 
active  stimulents,  both  to  the  circulatory  and  nervous 
systems,  and  as  such,  when  long  and  continuously  used, 
must  have  a  demoralizing  effect  upon  these  systems. 
While  probably  there  is  much  less  alcohol  used  among 
the  more  intelligent  classes  to-day  than  there  was  fifty 
years  ago,  we  must  bear  in  mind,  first,  that  society  to- 
day is  reaping  the  harvest  of  its  use  fifty  years  ago  in 
the  form  of  a  nervous  system  inclined  to  disease ;  and, 
second,  that  there  is  an  increased  use  of  it  among  the 
young,  especially  in  all  our  large  towns  and  cities.  Let 
anyone  pass  through  the  principal  streets  and  drinking 
saloons  of  any  of  our  large  towns  or  cities  during  an 
evening,  from  eight  to  eleven  o'clock,  and  I  think  he 
will  be  astonished,  unless  already  familiar  with  the  state 
of  the  case,  at  the  number  of  young  men  and  boys  from 
the  age  of  sixteen  years  up  to  that  of  twenty-four  he 
will  find  engaged  in  drinking  beer  or  wines,  and  envel- 
oped in  the  fumes  of  tobacco.  Perhaps  it  is  not  wise  to 
be  extreme  in  our  views  in  reference  to  the  use  of 
these  articles.  They  may  doubtless  be  used  with  moder- 
ation by  adult  persons,  for  long  periods  without  serious 
results  in  the  way  of  actual  disease,  but,  when  used  from 
the  age  of  twelve  to  twenty-two,  and  when  the  whole 
energy  of  its  system  should  be  occupied  in  its  growth,  I 
believe,  from  a  somewhat  extended  observation,  that  their 
effect  is  immensely  disastrous,  and  largely  attends  to 
create  nervous  diathesis  in  after  life.  An  alternate 
stimulation  and  depression,  while  it  must  be  unfavorable 
in  its  effects  at  any  time  of  life,  yet  upon  the  young  is 
vastly  greater.  We  observe  its  effects  upon  the  young 
of  our  domestic  animals,  and  exercise  the  grearest  care 
that    they    be    not    over-fed,    over-driven    or    over-worked. 


The  Insane  Diathesis.  481 

while  their  systems  are  undeveloped  and  in  the  growing 
period.  Where  one  is  looking  for  the  best  growth  or 
the  highest  speed  or  strength  attainable,  if  judicious,  he 
will  exercise  the  largest  care  and  vigilence  lest  his 
animal  should  be  over-stimulated  by  food  or  work,  and 
never  permit  its  full  strength  to  be  tested  until  the 
system  is  developed  and  firmly  knit  together.  How  can 
an  opposite  course  in  reference  to  either  education  or 
habits  of  life,  food  or  drink,  have  any  less  serious  effect 
upon  the  vastly  more  delicate  tissues  of  the  brains  of 
young  men  and  women?  Besides,  I  beheve  the  effects 
of  alcohol  upon  the  system  are  less  injurious  when  the 
subject  spends  the  larger  portion  of  every  day  in  the 
open  air,  and  is  engaged  in  the  exercises  of  out-door 
occupations.  It  becomes  sooner  eliminated  from  the 
'system,  and  acts  as  a  less  efficient    stimulus. 

If  the  above  views  in  reference  to  education,  the 
changes  which  have  come  over  the  habits  and  modes  of 
modern  living,  and  the  effects  of  stimulents  upon  the 
young  especially,  be  true,  then  it  appears  that  there  is  a 
vtcntal,  as  well  as  a  physical  hygiene,  and  that  similar 
laws  may  hold  good  in  reference  to  both.  Within  a  few 
}^ears  we  have  made  wonderful  advances  in  our  knowledge 
of  the  latter,  and,  by  an  investigation  of  the  former,  it 
will  appear  that  no  more  surely  does  typhoid  or  diphtheria, 
and  kindred  disease,  follow  in  the  track  of  neglect  in 
reference  to  their  causation,  than  does  the  insane  diathesis 
follow  from  neglect  to  observe  and  avoid  its  causes. 
There  is,  however,  this  cause :  In  the  one  case,  effects 
are  soon  seen  and  in  many  cases  easily  traced  to  their 
cause,  while,  in  the  other,  they  only  appear  after  a  long 
time,  and  not  unfrequently  pass  over  into  the  next  gener- 
ation before  appearance.  Persons  rarely  become  insane 
at  once.  The  operative  causes  are  long  in  incubating ; 
they  are  generally  insidious  in  their  operation,  so  that 
months,  if  not  years,  may  pass  before  the  nervous  system 
actually  gives  way  in  insanity.  Hence,  the  uncertainty 
and,  oftentimes,  mystery  connected    with  the    etiology    of 


4i82  Henry  P.  Stearns. 


individual  cases;  we  mark  down  long  lists  of  exciting 
causes  of  insanity,  and  are  too  prone  to  forget  that  the 
real  causes  lie  far  back  of  these.  These  exciting  causes 
may  be  equally  operative  in  a  dozen  cases,  and  yet 
produce  insanity  in  one  only  ;  and  in  that  one  because 
that  sometime  in  the  past  the  treatment  of  his  nervous 
system,  or  that  of  his  parents,  has  violated  the  laws  of 
its  health. 

1  trust  I  may  be  pardoned  if  I  venture  to  suggest  that 
we  have  given  undue  importance  to  the  former  class  of 
causes,  and  too  little  to  the  latter.  Thousands  may 
suffer  from  these  exciting  causes,  and  never  become  insane, 
because  the  potentiality  for  the  disease  does  not  exist  in 
the  form  of  a  nervous  system  rendered  unstable  in  its 
constitution  either  by  inheritance  or  acquirement. 

Finally,  I  venture  to  suggest  the  importance  of  our 
responsibility  in  reference  to  the  public  health,  7ncntal  as 
well  as  physical.  While  we  have  been  active  and  vigilent 
in  reference  to  the  latter,  and  have  won  large  victories, 
I  greatly  fear  we  have  too  much  neglected  the  former. 
It  is  the  general  practitioner,  rather  than  the  specialist, 
who  comes  more  often  into  contact  with  these  insidious 
and  generally  unsuspected  causes,  so  silently,  and  yet 
surely,  operating  to  ruin  the  nervous  system.  He  it  is 
who  must  plead  for  wise  and  judicious  courses  of  educa- 
tion and  development  of  the  young.  He,  more  author- 
atively  than  any  one  else,  can  point  to  the  outcome  of 
stimulation  and  excess  of  all  kinds  upon  the  nervous  system 
in  its  formative  period.  He,  more  than  others,  must 
realize  the  unwisdom  of  delay  until  the  mischief  is  done 
and  disease  has  manifested  itself.  Insanity  is  rightly 
regarded  as  one  of  the  greatest  of  calamities,  in  whatever 
light  it  may  be  viewed,  so  that  no  field  of  medicine 
offers  a  larger  reward  for  every  success  which  may  be 
attained  in  it  than  the  one  under  consideration.  To  the 
general  practitioner  this  field  lies  open  for  occupancy,  and 
on  him  rests  the  responsibility  of  its  development. 


Art.  v.— Contribution  to  Cerebral  LocaL 
izations. 


By  Prof.  A.   TAMBURINI. 


Translated  by  Joseph  Workman,  M.  D.,  Toronto. 

Hemiplcgic  epilepsy,  ivith  left  Jiemi-atrophy  and  aphasia. 
Atrophy  of  the  right  hemisphere ;  atropliy  and  sclerosis 
of  the  ascending  frontal  and  parietal  convolutions,  and 
of  the  third  frontal,  the  optic  thalamus,  tJie  corn:; 
animonis,  &c. 

History  of  the  Case. — Paola  Veronesi,  aged  45,  a 
pauper,  entered  the  insane  asylum  of  Reggio,  on  13th  of 
May,  1874,  being  affected  with  imbecility  and  epileptic 
fits,  frequently  followed  by  furious  delirium,  in  one  of 
which  accesses  he  had  killed  a  poor  idiot  with  a  knife. 
Very  little  information  was  given  in  the  medical  history 
sent  in  with  him.  The  epilepsy  dated  from  infancy  ; 
atrophy  and  paralysis  of  the  upper  and  the  lower  limbs 
resulted,  which  we  shall  presently  describe.  The  parox- 
ysms of  post-epileptic  furious  delirium  had  been  of  only 
two  years  duration.  As  to  hereditary  conditions,  it  was 
merely  ascertained  that  his  mother  and  her  brother  had 
been  of  rather  impetuous  character.  Veronesi  himself  had 
always  led  a  miserable  and  depraved  life. 

During  all  the  time  he  had  lived  in  the  asylum,  he 
showed  ordinary  docility,  he  was  tranquil,  and  strict  in 
attending  to  some  occupations,  so  far  as  his  limited  intel- 
ligence and  his  hemiplegia  permitted  ;  but  in  proximity  to 
his  fits,  and  sometimes  also  unconnected  with  them,  he 
became  irritable,  strange,  intolerant  and  violent,  especially 
towards  children.  The  fits  appeared  with  variable  fre- 
quency, as  will  be  indicated  by  the  following  tabular 
statement,  which  shows  the  number    of  epileptic    accesses 


4S4 


Tamhurini—  Workman. 


and  vertig'ics,  to  which  Veroiiesi  was  subjected  from 
October,  1874,  the  time  of  liis  entrance,  to  that  of  his 
death,  April    18,    1879: 


]874 

187.5 

1870 

j8 

-7 

1878 

1879 

MONTHS. 

A. 

V. 

A. 

V. 

A 

V 

A. 

V 

A. 

8 

V. 

3 

A 
4 

V 
1 

Janiinrv. .. 

1 

Febrii:irv  . 

5 

4 

1 

1 

March..... 

2 

5 

2 

8 

April 

.. 

4 

4 

May 

■2 

T, 

June  ...... 

.. 

4 

1 

6 

1 

July 

6 

1 

4 

August    ... 

6 

7 

5 

.. 

September 

1 

9 

3 

4 

7 

October  . . . 

10 

2 

.") 

1 

1 

November. 

4 

4 

3 

December. 

■1 

3 

14 

•■ 

4 

.. 

11 

♦• 

47 

13 

6S 

31 

13 

•2  ! 

From  the  above  figures  it  is  seen  that  the  complete  or 
incomplete  accesses  of  epilepsy  proceeded  gradually  aug- 
menting, e.-pecially  in  the  years  1877  and  1878.  In  the 
first  months  of  1879,  they  were  in  notable  numbers.  The 
points  in  April,  1879,  indicate  accesses  so  frequent  in  the 
days  preceding  his  death,  as  to  be  uncountable. 

The  accesses  were  always  preceded  by  a  sense  of 
aura,  and  by  clojiic  movements,  which  began  in  the  fingers 
of  the  paralyzed  and  atrophied  arms  ;  most  generally  tJie 
convulsive  access  ivas  limited  to  the  left  arm,  or  was  extended 
to  the  face  and  to  the  lower  limb  of  the  same  side ; 
sometimes  they  became  general  over  the  entire  body. 
After  the  access  he  remained  most  usually  in  a  state  of 
mental  stupor  and  depression ;  but  sometimes  he  was 
seized  with  a  maniacal  delirium,  during  which  he  became 
dangerous,  but  this  state  was  generally  of  short  duration. 

Objective  E.xamin.vtion. — This  was  practiced  very 
often,  the  patient  having  served  as  a  subject  of  conference 
for  the  psychiatric  clinique,  and  anthopologic  studies  on 
the  imbecile  ;  the  data  which  I  now  produce  were  taken 
from  repeated  observations  made  by  Doctors  Maragliano 
and  Boiivecchiato. 

A.NTHROPOMETRV. — Cranium  rather  narrow  ;  the  occipital 


Cerebral  Locnlizntions.  485 

region  very  flat,  especially  on  the  right  side;  the  right 
parietal  eminence  less  than  the  left.  The  following  are 
the  measures  given  by  the  cranium  : 

Anterio-posterior  diameter,     mm.      172=6  3-4  in. 
Biparietal  "  maxim.   "        150=6  " 

Biparietal  "  mimim.   "        110=42-5   " 

Anterior-posterior  curve,  "        308^12        " 

Bi-auricular  "  "        282=11         " 

Circumference,  "       525=21         " 

Cephalic  index,  "  "^7^=1  1-2   " 

Sum  of  curves,  "      1115=44 

Distance  from   chin  to  occiput,  "        215^8  " 

Distance     from     chin     to     meatus- 

auditorii,  mm.      135  =  5  ^"3  i^i- 

Bi-zigomatic  diameter,  "        134=5  1-3    " 

These  measurements  show  a  bracehicephalic  head  and 
a  small  skull,  if  not  in  relation  to  the  patient's  height, 
which  was  1.60  m,  certainly  to  the  skeleton  development, 
which  was  notable. 

Face. — The  physiognomy  was  remarkable ;  the  dis- 
tance between  the  zygomatic  bones,  the  narrowness  of 
the  forehead,  and  the  cocked-out  ears,  gave  the  creature 
something  of  a  bestial  aspect.  The  left  side  of  the  face 
was  flatter  than  the  right;  the  left  nostril  was  contracted. 
The  naso-labial  sulcus,  and  the  frontal  wrinkles  were  less 
pronounced  on  the  left;  the  angle  of  the  mouth  was 
somewhat  drawn  up  on  the  right,  especially  in  speaking. 
The  Truxk — The  left  shoulder  less  developed  than 
the  right ;  the  acromion  nearer  to  the  median  line  ; 
the  clavicle  smaller  and  shorter  than  the  right.  The  left 
half  of  thorax  much  narrower  than  the  right,  consequently 
the  curvature  of  the  ribs  more  abrupt,  and  the  scapula 
was  drawn  towards  the  sternum.  The  lower  part  of  the 
sternum  bends  inward.  The  whole  of  the  muscles  on  the 
left  less  in  volume  than  on  the  right.  Adipose  tissue 
equal  on  both  sides. 

The  Upper  Limbs.^ — The  left  compared  with  the  right, 
is  much  atrophied,  and  is  held  in  permanent  forced  flexion  ; 


Tamhiorini—  Workman. 


the  upper  arm  closely  pressing  the  thorax ;  the  fore-arm 
flexed  almost  at  a  right  angle  on  the  upper ;  the  hand 
flexed  at  an  acute  angle  on  the  fore-arm,  and  bent  on 
the  ulnar  margin  ;  the  fingers  are,  on  the  contrary,  forci- 
bly extended,  and  the  index  and  middle  ones  so  much 
so  as  to  appear  luxated. 

The    comparative    measures    of  the    two    arms    are    as 
follows  : 


RIGHT. 

mm. 

LEFT, 
mm 

ABOUT. 
Inches. 

Greatest  circumf.  of  upper  arm , 

"               "              foi-P-arm,.. 

carpal  region, 

3»5 
2(i0 
170 
33.5 
•225 
190 
170 

210 
ICO 
130 
29.5 
220 
170 
63 

12. 
10. '25 

6.75 
13. 

9. 

7.00 

4.40 

8.5 
6.40 
5. -20 
12. 
8.75 
6.80 
2.75 

' '         lore-arm  .     ... 

"         palm 

The  Lower  Limbs. — The  muscular  masses  on  the  left 
are  somewhat  atrophied,  but  much  less  so  than  in  the 
upper  limb. 


Greatest  circumf.  of  femoral  region 

"  "  crural  "       

I  "  "  lower  extre.  of  lea 

I    Length  of  femur 

I  "  log 

S'  loot 


RIGHT. 

LEFT. 

mm. 

mm. 

480 

430 

3.50 

280 

310 

2<'0 

360 

350 

375 

.370 

250 

245 

From  these  measures  it  is  seen  that  the  femoral  region 
is  singularly  short,  in  comparison  with  the  leg,  on  both 
sides. 

Psychical  Function's. — Ideation  very  limited ;  memory 
fragmentary;  sentiments  little  developed,  but  instincts 
strong.  He  is  usually  taciturn,  readily  irritated,  espe- 
cially by  boys,  whom  he  is  prompt  to  strike.  He  attends 
to  the  rough  work  of  cleaning  his  section.  Language  is 
very  defective  ;  he  strives  to  utter  words,  and  precedes 
them  with  inarticulate  sounds,  and  contractions  and  oscilla- 
tory movements  of  the  muscles  of  the  face,  and  especially 
of  the  lips,  with  a  drawing  of  the  angle  of  the  mouth  to 
the     right.        Having     commenced    the    pronouncing    of   a 


Cerehral  Localizations.  ^387 

word,  he  often  halts  at  the  first  syllable,  or  repeats  it, 
or  stops  in  the  middle  of  the  word,  stammering  on  the 
last  syllable.  No  sound  is  neatly  uttered,  but  always  in 
a  uniform  and  incomplete  manner,  and  the  timbre  of  the 
voice  is  hoarse  and  guttural. 

FuNXTiONS  OF  Relation. — Sensibility  is  sufficiently 
normal ;  the  tactile,  the  dolorific  and  the  thermal  do  not 
differ  on  the  two  sides  ;  the  electric  was  slightly  less  on 
the  left.  The  other  senses,  normal;  but  taste  rather 
obtuse.  Motility  normal  in  the  pupils  and  the  right  half 
of  the  body;  paresis  on  the  left  of  the  face,  and  almost 
complete  paralysis  of  the  left  upper  limb,  which  is  only 
capable  of  slight  brachial  adduction.  The  lower  left  limb 
is  only  paretic ;  in  walking  it  straggles,  and  the  foot  is 
but  little  raised  from  the  floor.  The  electric  muscular 
contractility  is  greater  on  the  right  in  the  upper  limbs, 
but  equal  in  both  the  lower. 

The  Vegetative  Functions  are  normally  performed. 
On  the  1 6th  of  April,  1879,  he  had  many  epileptic  fits, 
which  were  repeated  with  great  frequency  on  the  17th, 
and  became  general.  In  the  intervals  between  fits  he 
was  comatose.  For  some  days  before  he  complained  of 
severe  head-pain  on  the  right,  and  of  intense  pain  in  the 
inner  ear  of  same  side ;  he  also  complained  of  malaise 
and  want  of  appetite ;  he  was  listless  and  duller  than 
usual.  In  an  epileptic  seizure,  which  lasted  about  an 
hour,     he  ceased  to  live    on  the   i8th  of  April. 

Autopsy. — The  illustrious  professor  Taruffi,  of  Bologna, 
was  present,  and  took  full  notes,  of  which  we  give  a 
resume  : 

The  Cranium. — The  bony  case,  very  heavy  and  thick ; 
the  diplos,  ossified  ;  the  longitudinal  suture  turned  towards 
the  right,  so  that  the  right  half  of  the  cranium  was 
smaller  than  the  left. 

Cerebrum. — The  skull  being  removed,  we  soon  discov- 
ered that  the  right  hemisphere  was  much  less  than  the 
left;  in  fact,  when  taken  at  the  external  auditory  openings, 
the  transverse  arc  of  the  hemispheres  showed    a    curve  of 


Tamhurini—  Workman. 


170  mm.,  of  which  95  belonged  to  the  left  and  75  to  the 
right  hemisphere;  the  total  circumference  of  the  two 
hemispheres,  with  the  dura-mater  left  on,  was  mm.  410, 
of  which  there  belonged  to  the  left,  mm.  225,  and  to  the 
right,  mm.   185. 

The  dura-mater  was  .strongly  adherent  to  the  hemis- 
pheres ;  more  on  the  right  than  on  the  left ;  when  removed, 
the  smallness  of  the  right  hemisphere  became  more  evident, 
and  the  surface  of  the  right,  over  large  portions,  was  seen 
covered  with  tracts  of  patches  of  sub-arachnoid  exudate 
of  greenish  yellow  color,  which,  to  the  naked  eye,  and 
under  the  microscope,  were  evidently  purulent.  These 
patches  were  large  and  numerous  on  the  frontal  lobe, 
especially  in  correspondence  with  the  fissure  of  Sy/vius, 
which  was  completely    covered    and  infiltrated  \\ith  them. 

On  the  /f/t  hemisphere  there  were  some  exudative 
cells,  but  of  less  number  and  smaller  size.  All  the 
vessels  of  the  pia-mater,  both  arterial  and  venous,  were 
much  injected;  this  membrane  was  readily  detached  from 
the  cortex,  but,  in  consequence  of  its  decreased  consist- 
ence, it  came  off  in  shreds  The  consistence  of  the 
hemispheres  was,  on  the  whole,  greater  than  normal, 
especially  on  the  right. 

The  Left  Hemisphere. — The  conformation  and  devel- 
opment was  normal  in  all  parts. 

The  Right  Hemisphere. — The  convolutions  of  the 
right  frontal  lobe,  on  the  convexity,  were  sufficiently 
developed,  though  rather  less  than  on  the  left.  On  the 
contrary  the  ascending  parietal  convolution  was  notabl}' 
atrophied,  especialh^  on  its  exterior.  In  fact  in  its  most 
internal  part,  where  it  was  yet  visible,  it  was  much  dimin- 
ished, and  somewhat  indurated ;  at  6  cm.  from  the 
median  line  it  was  very  thin,  ribbon  formed,  so  that  it 
was  necessary  to  turn  aside  the  ascending  frontal  from 
the  parietal  in  order  to  observe  it,  and  it  was  hardened 
to  cartalaginous  consistence,  as  far  as  its  embouchure  in 
the  fissure  of  Sylvius. 


Cerebral  Localizations.  489 


Here  are  the  measures  of  breadths  of  ascending  parietals 
in  the  two  hemispheres  : 


LEFT.         RIGHT. 

mm.       1        mm. 

16 
1-2 
1. 

0 

Meiliaii  part, 

External  extremity, 

4 
2 

From  these  figures  the  notable  degree  of  atrophy  of 
the  ascending  parietal  on  the  right  side  is  brought  into 
bold  relief,  as  well  as  the  progressive  thinning  from  within 
outwards. 

The  ascending  frontal  was  sufficiently  well  developed 
in  correspondence  with  ist  F.  and  2d  F.,  but  in  its 
external  extremity,  or  its  correspondence  with  the  origin 
of  the  3d  F.,  it  disappeared  from  the  surface  of  the 
hemisphere,  and  we  had  to  turn  aside  the  foot  of  the  3d 
F.  in  order  to  recognize  it  beneath  (atrophied  and  hard- 
ened), as  the  external  part  of  the  convolution  (asc.  F.) ;  it 
was  then  also  seen  that  a  portion  of  the  foot  of  the  3d 
F.  was  equally  atrophied  and  hardened.  We  also  found 
that  the  foot  of  the  2d  parietal  participated,  though  in  but 
a  small  part,  in  the  atrophy  and    sclerosis. 

All  these  atrophied  and  sclerosed  part.s — the  foot  of 
the  3d  F.,  the  external  extreme  of  asc.  F.,  of  the  asc. 
P.  and  the  foot  of  the  second  F.,  constituted  the  margin, 
respectively,  anterior,  superior  and  posterior,  or  more 
exactly  to  speak,  a  sort  of  cartilaginous  enfolder,  of 
a  cavity  which  represented  what  remained  of  the  fissure  of 
Sylvius.  Drawing  aside  the  margins  sitting  on  this 
enfolder,  we  discovered  a  cavity  of  the  size  of  a  pigeon's 
^gg.  o^it  of  which,  together  with  the  arachnoid  and  pia- 
mater,  a  large  quantit)'  of  purulent  exudate,  which  filled 
it,  v.'as  removed;  in  the  bottom  of  this  cavity,  which  was 
no  other  than  the  fossa  of  Sylz'ins,  we  did  not  discover 
any  trace  of  the  convolutions  of  the  insula  (of  Reil).  The 
walls  were  constituted  of  a  uniform  tissue,  of  reddish 
gray  color,  arborated  here  and  there  with  arterial  branch- 
lets,     and    covered    at     parts    wath     patches    of    purulent 


490  Tamhurini—  Workman. 


exudate.  Tlie  frst  temporal  convolution,  which  formed 
the  inferior  margin  of  the  cavity  was,  in  its  most  posterior 
part,  thinned  and  of  increased  consistence.  On  widening 
the  great  longitudinal  fissure,  we  discovered,  on  the 
anterior  internal  parts  of  the  hemispheres  that  the  convohi- 
tion  of  the  corpus  callosum  of  the  right  presented,  in  its 
anterior  part,  a  projection  which  pressed  on  the  corre.s- 
ponding  part  of  die  left,  where  there  was  an  excavation 
in  which  it  had  been  embedded. 

On  the  base  of  the  cerebrum  we  noted  that  the  purulent 
exudation  extended  over  the  whole  of  the  right  temporal 
lobe  and  the  chiasm  of  the  optic  nerves,  also  between  the 
margins  of  the  longitudinal  fissure,  which  adhered  by  exudate 
bridles,  and  even  back  to  the  covermg  of  the  cerebellum. 
The  consistence  of  the  right  hemisphere  was  increased 
on  the  base,  but  especially  in  correspondence  with  the 
point  of  the  spheno-temporal  lobe,  and  precisely  at  the 
point  of  the  internal  temporal  convolution,  or  convolution  of 
the  hippocampus,  where  it  was  as  of  woody  hardness.  On 
vertical  section  of  this  region  the  sclerosis  was  most  mani- 
fest, so  that,  in  cutting,  the  texture  creaked  ;  it  was 
traversed  by  thin  strata,  hard  and  alternating,  of  white 
reddish  gray  substance,  as  far  as  the  cornu  ammonis,  the 
walls  of  which  were  strongly  atrophied. 

The  Thalami  Optici  and  Corpora  Striata. — On 
opening  the  lateral  ventricles,  the  right  optic  thalavnis  w-as 
found  much  diminished  and  hardened,  as  the  following 
comparative  measures  show  : 


1    LEFT. 
I       mm. 

RIGHT, 
mm. 

Greatest  longitudinal  dianieter 

1         40 

21 

...J            5.S 

The  corpora  striata  were,  however,  of  nearly  equal 
dimensions  on  both  sides,  there  being  a  difference  of 
only  4  mm.  less  in  the  transverse  maximum  diameter  of 
the  right. 


Cerebral  Localizniions.  491 

exudate.  The  fiyst  tejtiporal  convolution,  which  formed 
the  inferior  margin  of  the  cavity  was,  in  its  most  posterior 
part,  thinned  and  of  increased  consistence.  On  widening 
the  great  longitudinal  fissure,  we  discovered  on  the 
anterior  internal  parts  of  the  hemispheres  that  the  convolu- 
tion of  the  corpus  callosum  of  the  right  presented,  in  its 
anterior  part,  a  projection  which  pressed  on  the  corres- 
ponding part  of  che  left,  where  there  was  an  excavation 
in  which  it  had  been  embedded. 

On  the  base  of  the  cerebrum  we  noted  that  the  purulent 
exudation  extended  over  the  whole  of  the  right  temporal 
lobe  and  the  chiasm  of  the  optic  nerves,  also  between  the 
margins  of  the  longitudinal  fissure,  which  adhered  by  exudate 
bridles,  and  even  back  to  the  covernig  of  the  cerebellum. 
The  consistence  of  the  right  hemisphere  was  increased 
on  the  base,  but  especially  in  correspondence  with  the 
point  of  the  spheno-teuiporal  lobe,  and  precisely  at  the 
point  of  the  internal  temporal  convolution,  or  convolution  of 
the  hippocampus,  where  it  was  as  of  woody  hardness.  On 
vertical  section  of  this  region  the  sclerosis  was  most  mani- 
fest, so  that,  in  cutting,  the  texture  creaked  ;  it  was 
traversed  by  thin  strata,  hard  and  alternating,  of  white 
reddish  gray  substance  as  far  as  the  cornu  ammonis,  the 
walls  of  which  were  strongly  atrophied. 

The  Thalami  Optici  and  Corpora  Striata. — On 
opening  the  lateral  ventricles,  the  right  optic  thalamus  was 
found  much  diminished  and  hardened,  as  the  following 
comparative  measures  show : 


Greatest  longitudinal  diameter. 
Greatest  transverse  diameter... 


LEFT 
mm. 


RIGHT, 
mm. 


The  corpora  striata  were,  however,  of  nearly  equal 
dimensions  on  both  sides,  there  being  a  difference  of 
only  four  mm.  less  in  the  transverse  maximum  diameter  of 
the  right. 


492 


Tamhurini—  Workm  an. 


The    following  are  the  dimensions  and  the    weights    of 
the  two  hemispheres : 


RIGHT.         LKFT. 
ram.  mm. 


Greatest  loiiftitu'linal  diamefer. 
Greatest  transverse  diameter... 


Weight  ofhemisi)here8. 


1(>3 

in-> 

grms. 
510 


Weight  of  mesocp))haIon. 
Weight  of  cerebrum 


The  last  figure  is  noteworthy,  as  it  shows  us  the 
small  development  of  the  cerebrum  in  an  individual  who 
was  imbecile  from  birth. 

Mesocephalon, — The  j'ig/i^  cerebral  peduncle  was  very- 
much  smaller  than  the  left,  and  much  firmer  in  consistence ; 
its  transverse  section  gave  a  surface  only  half  of  that  of 
the  left.  The  right  half  of  the  pons  was  much  less  than 
the  left,  and  the  same  maybe  said  of  the  right  bigeminal 
eminences.  On  the  other  hand,  in  the  medulla  oblon- 
gata, below  the  pyramids,  the  left  half  appears  very  small 
and  of  diminished  consistence,  as  became  very  evident 
in  cutting  the  bulb  across.  The  hemispheres  of  the  cere- 
bellum presented  no  difference  in  size. 

The  Medulla  Spinalis — The  vertebral  canal  being 
opened,  the  vessels  of  the  dura-mater  were  found  much 
injected  in  all  its  extent,  and  in  the  dorsal  region  it  was 
covered  with  a  purulent  exudate.  This  membrane  being 
cut  into,  there  was  found  in  the  cervical  region  a  strong 
vascular  injection,  and,  in  all  the  rest  of  the  medulla,  an 
abundant  fibrinous  exudate,  which  masked  all  the  vessels 
of  the  pia-mater.  The  consistence  of  the  medulla  was 
notably  diminished  from  the  cervical  region  to  the  eighth 
dorsal  vertebra,  but,  on  the  contrary,  it  was  augmented 
in  the  lumbar  region.  On  the  arachnoid,  plates  of  ossifi- 
cation were  observed,  one  of  which  was  of  distinct  volume, 
in  the    superior    lumbar  region.        Beneath  the    arachnoid 


Cerebral  Localizations.  493 

there  was  an  abundant  purulent  exudate  along  the  cervico- 
dorsal  region,  and  there  was  some  rare,  scaly  exudate 
in  the  lumbar  region.  By  careful  transverse  section  we 
ascertained  that  softening  of  the  two  upper  thirds  of  the 
medulla  existed ;  atrophy  of  the  left  half  was  very  con- 
spicuous, especially  in  the  cervico-dorsal  region. 

The  Thorax — Lungs,  slightly  hypostatic.  The  bronchi, 
hyperaemic.  Heart,  hypertrophied ;  atheromic  patches  on 
the  aortic  wall,  and  on  bits  of  the  tricuspid  valves. 

Abdomex. — Liver,  congested;  its  size  and  consistence, 
normal.  Spleen,  rather  voluminous  and  firm.  Kidneys, 
of  normal  size;  their  glomerule  and  pyrimidal  substance, 
injected.       Nothing  abnormal  in  the  gastro-intestinal  tract. 

Microscopic  Examination. — The  histologic  examination 
of  the  sclerosed  parts  (the  atrophied  convolutions,  the 
cornu  ammonis,  the  optic  thalamus),  made  by  Prof.  Foa, 
showed  in  all  these  parts  a  notable  augmentation  of  inter- 
stitial connective  tissue ;  in  parts  of  the  sclerosed  convolutions 
surrounding  the  fissure  of  Sylvius,  numerous  amyloid 
corpuscles  were  observed,  and  a  great  accumulation  of 
white  globules,  especially  around  the  blood  vessels  and 
the  gangliar  cells,  which  showed  only  much  pigmentation. 
In  the  medulla  spinalis  connective  sclerosis  of  the  anterior 
horn,  and  very  evident  hemi-atrophy  of  the  left  half  of 
the  medulla,  were  observed,  especially  in  the  cervico- 
dorsal  region. 

REFLECTIONS. 

The  case  we  now  have  described,  presents  itself  so  clearly  eloquent 
from  the  point  of  view  of  cerebral  localization,  as  to  require  but  few  words 
to  give  prominence  to  its  high  importance.  We  shall  therefore  make  only 
a  brief  survey  of  the  several  points  of  chief  interest,  and  of  the  questions 
on  v.'hich  some  liglit  may  be  thrown. 

First.  Atrophy  of  oxe  Hemisphere. — The  fact  most  conspicuous 
was  the  atrophy  of  the  whole  Hght  cerebral  hemisphere,  which  was  continued 
into  the  cerebral  peduncle,  the  pons,  and  the  anterior  pyramid  of  the  same 
side,  and  passed  thence,  after  crossing,  into  the  opposite  half  of  the  medulla 
spinalis.  This  fact  brought  into  rapport  with  the  atrophy  and  the  paraly- 
sis from  infancy  of  all  the  left  side  of  the  body,  proves  once  more  the 
dependence  of  the  trophic  and  the  motor  functions,  not  only  on  the  medulla 
spinalis  and  the  mesocephalon,  but  also  on  the  cerebral  hemispheres  them- 


494  Tamburini—  Workman. 


selves;  and  it  proves  the  erossi II oj,  lately  brought  into  doubt  by  Brown- 
Seywarti.  of  tliese  functions,  and  hence,  of  the  conducting  fibres  from  tlie 
cerebrum  to  tlie  parts  innervated;  finally,  it  shows  the  importance  of  the 
study  of  peripheral  lesions,  for  recognition  of  the  pathological  state  of  the 
brain  in  persons  of  infirm  mind.  As  we  have  already  noted,  the  low 
weight  of  the  encephnlon  in  this  case  (g.  930)  was  very  significant  when 
dealino  with  an  individual  who  had  been  imbecile  from  birth,  and  whose 
cranium,  though  not  volumnious.  yet  did  not  indicate  from  its  exterior,  a 
weigiit  and  volume  of  contents  so  small;  the  circumference  of  the  hemis- 
pheres was  only  410  mm.,  whilst  that  ot  the  cranium  was  5"25 — the 
difference  being  ascribable  to  the  remarkable  thickness  of  the  skull. 

Second.  Lesioxs  of  the  Motor  Zone. — The  importance  of  the 
case  was  furnished  by  tlie  S|)ecial  localizaiion  ol  the  lesion  in  the  cerebrum 
placed  in  rapport  with  the  special  localization  of  the  paralysis  and  the 
atrophy,  and  with  the  other  prominent  functional  lesions.  These  were 
tlie  convolutions  which  in  the  diseased  hemisphere,  were  found  atrophied 
and  sclerosed  in  a  remarkable  manner,  tlie  ascending  parieial,  especially  in 
itsouter  two-thirds,  the  ascending  frontal,  in  its  external  third,  and  the  foot 
oi  x\\^  third  frontal.  Confronting,  then,  a  notable  lesion  of  movements — 
paralysis  and  epilepsy  in  the  limbs,  especially  the  upper — we  find  an  exten- 
sive lesion  corresponding  to  the  cortical  motor  zone.  Assuming  from  the 
numerous  experimental  and  clinical  labors  relating  to  the  subject,  within 
the  last  few  years,  especially  by  Feri-ier,  Charcot  and  Pit7-es,  hy  Maragliano. 
DeBoyer  and  by  myself,  in  collaboration  with  Prof.  Luciani.  the  special 
motor-function  of  the  several  parts  which  were  especially  lesed  in  this  case. 
it  may  now  be  given  as  facts  established,  that : 

(a)  The  ascending  parietal  is  found  in  rapport,  in  its  innermost  and 
superior  part  with  the  motility  of  both  the  (upper  and  lower)  limbs;  in  its 
7niddle.  with  that  of  the  fore  arm  and  hand,  and  in  its  external  or  inferior 
part  with  the  facial  muscles. 

(6)  ThQ  ascending  frontal  in  its  most  exter?ial  or  inferior  part,  where  the 
third  frontal  has  its  origin,  iii  found  in  rapport  with  those  movements  of 
the  lips  and  the  tongue,  which  are  destined  to  the  pronunciation  of  words, 
a  function  which  is  also  shared  in  by  the  most  proximate  portion  of  the 
third  frontal  itself. 

Now,  we  maj'  see  in  this  case  a  perfect  parallelism  between  the  inten- 
sity of  the  lesion  of  movements  and  the  gravity  of  the  lesion  in  the  motor 
zone;  as.  whilst  the  most  grave  anatomical  lesion  occupied  the  external 
two-thirds  of  the  ascending  parietal,  where  is  found  the  center  for  the 
movements  of  the  fore-arm  and  hand,  exactly  in  the  upper  limb  was  seen 
the  most  grave  lesion  of  movements,  in  the  form  of  paralysis  and  conti-ac- 
ture.  It  must  also  be  noted  that  in  this  limb,  whose  cortical  center  was 
most  profoundly  lesed.  the  epileptic  accesses  usually  commenced,  in  the 
form  of  aura  and  oscillatory  movements  of  the  fingers,  and  the  convulsive 
movements  were  most  usually  limited  to  the  left  superior  limb  and  the  left 
side  of  the  face;  though  sometimes  they  extended  to  the  lower  limb  and 
pervaded  the  trunk.  The  paralysis  of  the  face,  whose  center  for.movement 
is  found  in  the  inferior  extremity  of  the  ascending  parietal,  was  also  an 
important  fact.    This  c:isc  splendidly  confirms  the  diagnostic  criterion 


Cerebrnl  Localizaiior);^.  495 


brought  into  liglit  by  Hughlings  Jackson,  and  experimeiitally  verified  by 
ourself,  to-wit,  tliat  from  tlie  region  of  the  body  where  tiie  convulsive 
moveraements  commence,  which  open  the  epileptic  access,  we  may,  with 
security,  diagnosticate  the  cortical  center  primitively  and  principally  Used, 
which  is  that  con-esponding  to  the  group  of  muscles  earliest,  and  some- 
times uniquely  brought  into  action. 

We  could  cite  a  numei'ous  series  of  clinical  cases  analog'ous  to  ours,  in 
which  the  accord  between  tlie  cortical  lesion  and  the  peripheral  and  func- 
tional, proves  the  exactness  of  the  localization  ;  but  we  shall  limit  ourselves 
to  comparison  of  our  case  with  one  very  similar,  of  spasmodic,  infantilci 
cerebral  liemiplegia,  published  by  Bonrneville,  in  wliich  the  paralysis, 
atrophy  and  convulsions  pi-evailed  in  the  left  lower  limb,  and  the  first 
manifestation  of  convulsive  movements  was  initiated  in  the  left  fool ; 
here  the  focus  of  destruction  specially  occupied  the  upper  part  of  the 
ascending  parietal  and  frontal,  where  the  existence  of  the  psycho-motor 
centei's  for  the  lower  limbs  has  been  demonstrated  ;  whilst  In  our  case,  in 
which  the  lesion  was  more  grave,  and  the  epilepsy  connnenced  in  the 
upper  limb,  the  atrophy  had  seized  the  two  interior  thirds  of  the  parietal, 
where  the  center  for  that  limb  is  found.  It  is  difficult  to  find  a  more  exact 
proof  of  the  similarity  of  these  two  cases,  through  the  exactitude  of  the 
topographic  limitation  in  the  human  brain  of  the  psyche-motor  centers 
of  the  limbs. 

Third.  Lesion  of  the  Center  of  Sph ecu. —We  do  not  believe  that 
we  need  to  spend  many  words  in  demonstrating  the  connection  of  the 
lesion  of  the  most  inferior  i^art  of  the  ascending  frontal  convolution,  and  of 
tiie  foot  of  the  third  frontal,  with  tlie  lesion  of  language,  wliich  was  very 
conspicuous  in  Veronesi.  The  theory  of  Broca,  so  famous  and  so  much 
discussed,  which,  since  1862,  bus  located  the  seat  of  language  in  the  third 
frontal  convolution,  could  not  find  a  more  splendid  confirmation  than  the 
recent  experimental  researches,  which  have  shown  that  actually  in  this 
part  the  motor  centers  for  the  muscles  of  the  lips  and  the  tongue  have 
their  seat,  that  Is  to  say.  for  the  muscles  principally  destined  for  the  pro- 
nunciation of  words;  so  that  on  such  researches  and  a  numerous  collection 
of  clinical  cases,  I  have  been  able  in  another  work  (Physiology  and 
Pathology  of  Language,  Rivista,  1876)  to  establish  the  fact,  that  in  the 
cortical  centers  named,  the  transformation  of  ideas  and  verbal  images  into 
motor  impulse  towards  the  muscles  destined  for  their  extrinsication,  takes 
place.  And  now  at  length,  after  so  many  collected  clinical  cases  and 
repeated  experimental  researches,  this  may  be  asserted  to  be  one  of  the 
points  of  cerebral  localizations  on  which  no  further  question  can  arise.  In 
the  case  of  Veronesi,  the  alteration  of  speech  was  very  palpable  ;  arrest  in 
the  beginning  and  in  the  middle  of  words  ;  in  every  tract  of  discourse, 
deficiency  of  impulse,  or  difficulty  in  its  conduction,  became  evident.  It 
was,  thei'efore.  a  case  of  verbal  paralysis,  in  which  /the  relative  cortical 
localization  of  the  lesion  found  clear  confirmation.  Tw^o  circumstances, 
however,  merit  in  this  case  some  consideration:  q.  s.,  the  seat  of  the  lesion 
on  the  right ;  and  the  destruction  of  the  island. 

The  monolaterality  of  the  center  of  language,  which  has,  by  Broca, 
and  many  others,  been  located  in  the  left  hemisphere  alone,  winlst  it 


Tamhurini—  Workman . 


conflicts,  as  I  have  elsewliere  shown,  with  tlie  law  of  bilateral  symmetrj'' 
wliicli  <,'overns  the  devolopnient  of  innervation  in  the  series  of  the  verte- 
hrata,  is  then  essentially  contradicted  by  the  facts  which  show  that  cases 
of  lesion  of  the  ri<?ht  hemisphere  productive  of  aphasia  are  met  witli 
onh'  in  the  proportion  of  one  to  four,  in  comparison  with  the  left :  so  that 
the  ditference  is  reduced  to  a  simple  inonolateral  prevalence,  which  is 
explaineil  as  has  been  elsewhere  (Ri vista,  1872)  amply  shown  by 
the  law  of  the  functional  pre-eminence  of  the  left  hemisphere.  The  case  of 
Veronesi  is.  therefore,  a  fresh  confirmation  of  the  fact,  that  lesions  of  the 
center  of  language,  in  the  right  side,  also  are  capahle  of  producing  aphasia. 

Must  the  absence  of  the  convolutions  of  the  island  on  the  rights  met 
with  in  "Veronesi.  be  also  put  into  connection  with  the  alteration  of  lan- 
guage ? 

The  idea  sustained  by  Meynert.  and  next  supported  by  WcTnicke,  that 
the  island  of  Reil  is  the  center  of  language,  has.  by  us,  under  the  author- 
ity of  anatomical,  clinical  and  athroi)ologie  facts,  been  placed  in  a  portion 
which,  in  conformity  to  the  facts,  befits  it ;  that  is  to  say,  demonstrating 
that  the  convolutions  of  the  ishmd  are  the  path  ot  transmission  of 
motor  impulse  awakened  in  the  cortical  centers  of  language,  in  the  lenti- 
culo  striate  region,  from  which  they  are  transmitted  to  the  apparatus  of 
execution.  Hence,  a  destruction,  so  striking,  of  the  island,  in  continuation 
of  the  lesions  which  occupied  the  motor  convolutions  of  the  phonetic 
muscles,  cannot  be  regai'ded  as  a  matter  of  indifference,  in  relation  to  the 
alteration  of  speech,  which  was  observed  in  our  patient.  But  here  the 
question  arises  :  "\Vas  the  absence  of  the  island  on  the  right  a  congenital 
or  an  acquired  fact?"  If  acquired,  did  it  date  back  to  the  remote  epoch  of 
the  other  lesions  already  studied,  or  was  it  the  efiect  of  a  suppurative 
lepto-meningitis  of  certainly  recent  occurrence,  which  was  shown  in  the 
cerebrum  and  the  medulla  spinalis,  and  which  appeared  to  liave  been 
very  intense  in  the  right  fissure  of  Sylvius?  In  truth,  considering  that  all 
the  otliei-  lesions,  wliich  undoubtedly  were  of  ancient  date,  consisted  in 
atrophy  from  sclerosis  of  the  connective,  whilst  in  the  cavity  of  Sylvius 
there  were  evident  signs  of  softening  and  destruction;  and  that  in  the 
interior  of  the  cavity  there  was  deposited,  in  great  abundance,  a  sub-arach- 
noid purulent  exudate,  and  that  some  patches  of  suppuration  were  seen 
adhering  to  the  walls  of  the  cavity,  even  after  removal  of  the  meninges, 
we  might  be  induced  to  believe  that  there  had  existed  a  recent  destructive 
process,  in  rapport  with  the  suppurative  process.  But.  on  the  other  hand, 
if  we  reflect  on  the  morbid  phenomena  presented  by  Veronesi  in  the  last 
days  of  his  life,  and  suppose  that  these  may  be  placed  in  relation  with  the 
above  process— for  example:  the  right  cephalalgia,  the  right  auricula- 
temporal  ])ain.  the  malaise,  the  stupor,  etc. — we  should  admit  as  of  too 
short  duration  such  a  process,  to  be  adequate  to  produce  a  destructive 
work  of  such  a  sort;  and,  furthermore,  so  rapid  a  destruction  of  parts 
destined  to  the  function  of  language  ought  to  have  given  a  prompt  and 
palpable  alteration  of  that  function,  which,  on  the  contraiy,  was  not  the 
ca^e.  It  is  then  more  logical  to  admit  that  the  convolutions  of  the  island 
had  been  affected  by  the  same  process  of  atrophy,  to  which  the  convolu- 
tions of  the  fissure  of  Sylvius  had  fallen  a  prey,    a  process  whose  morbid 


Cerebral  Localizations.  497 


results  would  be  represented  by  the  elevated  sclerotic  modules  in  the 
Sylvian  cavit}',  where  the  convolutions  of  the  island  ought  to  have  been 
found;  but,  as  the  recent  supperative  process  was  found  to  have  been  very 
copious  and  intense  in  the  interior  of  this  cavity,  the  destruction  may  thus 
have  been  pi'oduced  of  tliose  parts  whose  texture  and  function  were  so 
profoundly  altered. 

Fourth.  Lesion  of  the  Opnc  Thalamus. — Another  important  fact 
was  the  atrophy  and  sclerosis  of  the  right  optic  thalamus.  It  is  well  known 
how  great  a  difterence  of  opinion  still  continues  with  regard  to  the 
function  of  this  great  basilar  ganglion.  Luys,  on  the  basis  of  anatomi- 
cal research,  makes  it  a  center  of  pure  sensibility,  sub-divided 
into  four  special  centers ;  the  anterior,  olfactive ;  the  middle,  optic ;  the 
posterior,  acoustic:,  and  the  central  deputed  to  general  sensibility.  Ferrier, 
who  had.  in  sequence  to  itsdcstruction.experimetally  produced  anjesthesia 
of  the  opposite  side,  held  it  as  a  center  of  conveyance,  or  an  interrupting 
ganglion  of  the  sensitive  fibres,  through  which  might  pass  all  the  fibres  of 
the  sensory  nerves  which  have  their  origin  beneath  the  cerebral  peduncles. 
Fournier  also  admits,  as  the  result  of  experimental  reseaiches.  that  all  the 
sensoi-y  fibres  go  to  terminate  in  the  optic  thalamus,  where  he  would 
locate  animal  perception — an  opinion  which  Duret  and  Carville  approach, 
as  well  as  Cricliton  Brown,  who,  resting  on  clinical  facts,  regards  it  as  the 
center  of  general  sensibility.  ISTothnagel,  in  a  series  of  experiments, 
executed  in  the  method  of  intersticial  injections,  hns  not  found,  in  sequence 
to  destruction  of  the  optic  thalamus,  lesion  of  sensibility,  nor  of  voluntary 
motility.  Laflorgue,  basing  on  clinical  observation,  excludes  the  relation 
of  hemi-anfBsthesia  of  cerebral  origin  with  lesions  of  the  optic  thalamus, 
attributing  them,  instead,  alwaj'S  to  lesion  of  the  posterior  part  of  the 
internal  capsule.  Meynert,  resting  on  anatomical  researches,  admits  that 
in  the  optic  thalarai,  the  sensory  impressions  coming  from  the  periphery 
are  transformed  into  movements,  so  that  the  thalami  would  be  automatic 
centers  of  reflex-unconscious  movements,  and  would  also  stand  in  some 
relation  with  voluntary  movements.  Floureus.  Longet,  and  more  recently 
Schiff,  basing  on  experimental  researches,  have  attributed  functions 
decidedly  motor,  to  the  thalami,  and  Lusanna  and  Lemoigue  in  their  more 
recent  experimental  hibors  on  the  physiology  of  the  nervous  centers,  have 
concluded  that  the  optic  thalamus,  with  its  median  fascicules,  is  the  center 
for  movements  of  the  arm  and  hand  of  the  opposite  side,  an  idea  which 
might  be  supported  by  some  clinical  observations,  and  especially  by  one 
very  conclusive  of  Rusconi. 

Now,  far  from  pretending  to  give  to  the  case  illustrated  by  us  a  deci- 
sive value,  in  a  question  so  controverted,  it  is  yet  certain  that  it  would 
come  in  support  of  the  last  opinion.  In  our  case  there  was  a  very  mani- 
fest lesion  of  motion,  which  resided  specially  in  the  superior  limb ;  but 
there  was  not  any  lesion  of  sensibility  (however  accurately  examined), 
either  in  that  limb,  or  in  all  the  left  side,  nor  was  there  any  appreciable 
lesion  of  the  other  senses;  and  yet  the  right  optic  thalamus  was  in  a  state 
of  marked  atrophy  and  sclerosis,  which  was  in  extension  of  the  atrophy 
and  sclerosis  of  the  motor-convolutions.  This  jDrocess  of  atrophy,  which 
commenced  in  the  cortex  of  the  hemisphere,  was  continued  lower  and 


498 


Tamhurini —  Workman. 


lower,  down  to  the  pediintle,  then  to  the  protui'berance,  and  passin*^  from 
the  other  sideot  tlie  medulla  spinalis,  it  gave  source  to  the  atrophy  of  the 
limbs  of  the  left  side,  especially  to  that  of  the  upper  one,  which  was  much 
atrophied  and  paralyzed,  thus  serving  to  represent  a  species  of  anatomical 
pathway  of  motor  conduction  nicely  delineated  by  the  morbid  work;  this 
process,  in  traversing  the  gi'eat  cerebal  ganglia,  left  the  corpus  straitum 
untouched,  and  it  presented  a  verj-  slight  diflerence  of  volume,  but  it  seized 
and  gravely  attacked  tlie  thalamus  opticus  The  conclusion  might  natur- 
ally follow  Liiiit  the  motor-lii)res  whicii  reach  the  limbs  of  the  opposite 
side,  especially  the  upper,  pass  through  the  thalamus,  whether  it  be  that  it 
presents  the  sole  pathway  for  them,  or  may  be  a  true  becondary  motor 
center  subordinate  to  the  psycho-motor  centers  of  the  cortex. 

Fifth.  Sclekosis  of  the  Cornu  Ammoxis. — Another  important 
point  for  consider.ition  in  our  case  is  the  sclerosis  ot  the  cornu  ammonis. 
Tlie  existence  (if  this  lesion  in  epilepsy  was  tiist  demonstrated  by  French 
neurologists.  CazauvielUi  and  IJouchet  were  the  tirst  who.  in  1 825,  reported 
having,  in  eighteen  autopsies  of  epileptics,  found  hardening  of  one  or  both 
of  the  cornua  ammonis  nine  times.  Foville  mentined  this  alieitition  as  one 
of  the  most  trequent  iu  epilepsy  Bouchet  reports  having  found  it  anew 
twelve  times  in  forty-three  autopsies.  I.elut  and  Delasiauve  record 
analogous  facts.  Meynert  afterwards  called  attention  to  it,  in  describing 
twenty  cases  of  atrophy  and  sclerosis  ot  the  cornu  ammonis  iu  epileptics. 
iJollcr  found  it  in  four  cases,  and  Snell,  in  three  cases,  in  one  hundred  autop- 
sies of  epileptics  Hemkes,  in  thirty-four  epileptics,  met  with  six  cases 
of  hardening  and  atrophy  of  one  or  both  of  the  cornua.  Finally  Plleger, 
within  the  last  few  months  has  reported  having  in  forty-three  autopsies  of 
eiiileptics,  met  with  twenty-five  cases  of  sclerosis  and  atrophy  of  the  part. 
Cliarcot,  also,  in  his  lectiires  on  diseases  of  the  nervous  system,  records 
a  case  of  hystero-epilepsy,  in  which  (besides  softening  of  the  convolutions 
about  the  fissure  of  Sylvius)  bilateral  sclerosis  of  the  cornu  was  presented. 
BoiU-neville,  in  tliirty-four  autopsies  of  ei)ileptics,  made  from  18C6  to  1874 
in  the  service  of  Charcot  and  Delasiauve,  found  the  cornu  ammonis  hard- 
ened five  times. 

Calculating  from  llie  figures  above  cited  the  proportion  of  cases  iu 
which  the  lesion  w;i-s  met  with,  in  comparison  with  those  in  which  the 
record  in  this  relation  was  negative,  and  excluding  the  cases  of  Meynert 
and  UoUer,  who  did  not  give  the  comparative  data,  we  have : 


POSITIVE. 

XKGATIVK. 

TOTAL. 

9 
12 

3 

0 
25 

6 

9 
.'U 
i»7 
2tt 
18 
29 

IS 
100 

34 
43 
34 

Snell                              

lleiiiked                                     

Bourneville  

60 

212 

272 

That  is  to  say,  we  have  the  proportion  of  22  per  cent  of  positive  cases. 

But  now,  what  relation  exists  between  this  lesion  and  epilepsy?   And 

in  the  cases  in  which  it  was  present,  should  the  genesis  of  the  epilepsy  be 


Cerebral  Localizations.  499 


attributed  to  it?  What  relation  has  the  cornii  aiiimonis  to  the  motor- 
functions  ? 

If  we  examine  the  histology  of  this  region,  facts  are  found  which  may 
be--pe  ik  some  relation  between  it  and  the  motor  functions.  The  researcties 
of  Meynert  have  shown  that  the  unique  cellular  elements  existing  in  the 
cornu  ammonis  are  the  grand  pyramidal  cells  which  he.  because  of  this 
exclusivity,  proposes  to  call  the  ammonic  cells,  and  hence  he  holds  the 
formation  of  the  cornu  ammonis  to  be  a  cortical  stratum,  generally  of 
grand  pyramidal  cells, — a  structure  which  is  therefore  analagous  to  that 
of  all  the  central  nervous  regions,  which  are  undoubtedly  motor  (the 
anterior  horns  of  the  medulla  spinalis;  the  convolutions  of  the  motor 
zone. — Uuguenin).  But  physiological  results  do  not  as  yet  support  the 
induction.  In  fact,  the  researches  of  Nothnagel,  repeated  more  recently 
by  Hemkes,  have  demonstrated  that  destructive  and  irritative  lesions 
(by  injections  of  chromic  acid,  or  by  puncture)  of  the  cornu  ammonis, 
do  not  produce  any  lesion  of  motion.  Furthermore,  the  classic  experi- 
ments of  Kussmaul  and  Tenner,  on  "Epilepsy,"  have  shown  that.  In 
animals  in  which  epileptic  convulsions  have  been  experimentally,  induced, 
the  ablation  of  the  cornu  ammonis  caused  no  modification,  either  in 
the  production  or  in  the  intensity  of  the  general  convulsions.  It  is  well 
known,  on  the  other  hand,  that  the  researches  of  Ft-rrier,  on  the  sensory 
centers,  have  led  him  to  admit  in  the  subiculumof  the  cornu  ammonis.  the 
seatof  taste  and  smell,  because  excitement  of  it  produces  movements  of 
the  nostril  and  the  head,  and  its  destruction,  merely  produces  loss  of 
smell  on  the  same  side,  and  of  taste  on  the  opposite  side,  whilst  bilateral 
lesion  causes  the  total  loss  of  both  senses. 

Phj^siologlcal  researches  do  not  then  support  a  causal  relation 
between  lesion  of  the  cornu  ammonis  and  epilepsy.  And  yet  Benedickt, 
holding  the  epileptic  access  to  be  essentially  produced  by  circulatory 
disorders  of  the  brain,  regards  (but  only  by  way  of  induction,  and  without 
the  support  of  experimental  researches)  the  cornu  ammonis  as  a  vaso- 
motor center,  from  which  the  disorders  of  the  cir^julation  of  the  brain, 
productive  of  the  epileptic  access,  take  their  stai-t. 

Meynert,  however,  although  he  held  that  lesion  of  the  cornu  ammonis 
was  much  more  frequent  in  epilepsy  than  ulteri<jr  researches  have  demon- 
strated, did  not  attribute  to  it  any  signification  other  than  that  of  a  lesion 
consecutive  to  epilepsy,  which  might,  instead,  have  its  cause  in  some  part 
far  from  the  brain ;  and  in  this  idea  he  has  been  followed  by  Hemkes, 
Rosenthal,  Pfleger,  and  the  majority  of  those  who  have  engaged  in  the 
discussion. 

Verily,  if,  outside  of  the  experimental  facts,  above  related,  we  reflect 
on  the  comparative  inconstency  of  this  lesion  in  epilepsy  (among  tlie 
many  autopsies  of  epileptics  made  by  us.  this,  which  we  have  described, 
is  the  first  case  in  which  we  have  met  this  lesion),  and  on  the  fact  that  it 
pertains  not  exclusively,  to  epilepsy  since  Pfleger  found  it  evident  in  a 
paralytic  dement,  and  in  a  hysteric  case,  whilst  he  met  with  adhesion  of  the 
anterior  wall  of  the  cornu  ammonis,  with  the  opposed  ventricular  wall  in 
two  cases  of  paralysis,  and  seven  of  senile  marasmus,  one  might  be  led  to 
regard,  as  probable,  the  opinion  of  Meynert. 


500  Tamhurini—  Workman. 


But  Avhat  as  to  sclerosis  of  the  cornu  amraonis  in  consequence  of 
epilepsy?  Heuikes  and  Pfleger  have  realizeJ.  and  our  case  is  a  confirma- 
tion of  the  fact,  that  this  lesion  is  found  only  in  cases  in  wliich  the 
epilepsy  has  been  of  long  standing,  and  in  which  tlie  accesses  have  been 
complete,  intense  and  frequent.  Besides,  cases  not  appertaining  to 
epilepsy,  in  which  Pfleger  has  met  with  lesion  of  the  cornu  animonis. 
offered  in  their  symptomatology,  central  circulatory  disturbances  calcu- 
lated to  recall  those  observed  in  epileptic  accesses;  as,  in  the  brains  of 
ei)ileptics,  in  which  he  had  found  hardening  of  the  cornu  ammonis.  he 
had  in  this  region  frequently  seen  changes  of  color  and  consistence, 
extending  also  to  surrounding  parts.  From  all  these  facts.  Hemkes  and 
Plleger  have  been  led  to  admit  that  sclerosis  and  atrophy  of  the  cornu 
ammonis  represent  one  of  the  local  effects  of  a  partial  process  of  enceph- 
alitis, which  may  find  their  explanation  in  circulatory  disturbances  that 
are  verified  in  the  brain  during  and  after  the  epileptic  access;  whose  loca- 
tion in  the  cornu  ammonis  would  be  through  a  special  disposition  in  it 
of  tlie  blood  vessels 

In  our  case,  the  process  of  encephalitis,  with  atrophic  sclerosis,  was 
very  distinct  in  all  the  hemisphere,  and  more  especially  intense  in  certain 
points,  and  it  was  evident  that  the  lesion  of  the  cornu  ammonis  represented 
only  one  of  the  diverse  foci  of  localization  of  the  morbid  process. 

Sixth.  Pathogenesis.— The  causal  dependence  of  epilepsy  on  sclerosis 
of  the  cornu  an.imonis,  not  then  being  in  an  actual  state  of  sustainable 
science,  the  qtiestion  now  remains :  To  which  of  so  many  lesed  motor  paths 
should  the  epilepsy  in  our  case  be  ascribed?  The  fact  that  the  most  grave 
lesion  was  found  in  the  cortical  motor  zone,  and  the  other  parts  noted, 
that  the  epileptic  accesses  in  the  fingers  and  in  the  arm.  whose  center  was 
most  profoundly  lesed  in  the  ascending  parietal,  might  give  to  this  case  the 
value  of  a  reconfirmation  of  the  theory  proposed  by  Luciani.to  wit:  that 
lesion,  direct  or  indirect  of  the  cortical  motor  zone,  is  always  the  essential 
moving  agency  of  the  epileptic  process. 

Among  the  many  questions  to  which  the  study  of  this  case  might  yet 
give  placf.the  following  is  an  important  one:  \\\  the  process  of  atrophy 
of  the  motor-paths,  which  began  in  the  cortical  motor-zone  and  passed  to 
the  muscles  of  the  opposite  side,  what  line  of  progression  did  the  morbid 
process  pursue?  For  the  elucidation  of  this  point  we  are  totally  in  want 
of  all  historical  data,  as  to  the  mode  in  which,  in  infancy,  the  diverse  mor- 
bid phenomena  of  epilepsy  and  paralysis  were  presented  Nevertheless, 
considering  that  the  highest  degree  of  lesion  was  met  with  in  the  cortical 
zone,  and  precisely  in  the  regions  corresponding  to  the  cortical  territory 
of  the  Sylvian  artery;  also,  that  from  the  muscles  innervated  by  the  part 
most  lesed  in  this  zone,  the  access  commenced;  that  permanent  contracture 
of  the  limbs  is  always  connected  with  consecutive  sclerosis  of  the  lateral 
cords  ((Jharcot)  and  reflectinir.  finally,  on  the  general  advancement  of  spas- 
modic infantile  cerebral  paralysis,  we  may  hold  it  as  very  probable  that  the 
central  i)rimitive  lesion  had  produced  the  epilepsy  and  paralysis,  and  that 
the  entire  continued  process  of  atrophy  advancing  along  the  motor  paths, 
represented  only  the  effect  of  the  process  of  degeneration  of  all  the  lines 
of  conduction  of  motor-impulse,  which  could  not  be  sent  forward  by  the 


Cerebral  Localizations.  501 

the  lesed  center.  And  pertinent  to  this  view,  Charcot  and  Issarties  have 
demonstrated  that  the  development  of  secondary  degeneration  in  hemi- 
plegia and  hemi-epilepsia,  is  always  connected  with  primitive  alteration 
of  the  motor  zone,  and  especially  of  the  ascending  frontal  and  parietal 
convolutions,  whilst  lesions  of  the  occipital  convolutions  and  of  the  ante- 
rior part  of  the  frontal  lobe,  are  never  followed  by  secondary  degener- 
ations. 

Finally,  a  recorded  fiict  of  some  importance  has  been  presented  in  the 
microscopic  observance  of  the  amount  of  white  globules  around  the  vessels 
and  the  gangliar  cells  in  the  parts  of  the  sclerosed  convolutions  most 
proximate  to  the  fissure  of  Sylvius.  This  accumulation  was  evidently  in 
rapport  with  the  greater  intensity,  in  that  region,  of  the  inflammatory  pro- 
cess and  the  suppurative  exit  which  caused  death. 


Art.  VI. — A  Case  of  General  Paresis. 


By  Ira  Russell,  M.  D.,  Wichendon  Highlands,  Mass. 

A  B.,  aged  59,  a  man  of  sanguine,  nervous  temper- 
-^  ^*  ament,  active  business  habits,  who,  from  small 
beginnings,  had  accumulated  an  immense  fortune,  estimated 
at  ten  or  twelve  millions  dollars,  came  under  my  care 
in  July,  1877.  He  had  been  under  treatment  in  a 
private  asylum  the  previous  fourteen  months.  From 
physicians  whose  care  he  had  been  under,  and  from 
Drs.  Tyler  and  Walker,  of  Boston,  and  Choate,  of  New 
York,  and  from  his  family,  I  learned  the  following  partic- 
ulars in  regard  to  his  personal  habits  before  the  access 
of  the  disease  and  after  he  was  taken  sick  :  For  years 
he  had  devoted  himself  unsparingly  to  his  business,  early 
and  late — was  very  irregular  about  eating  and  sleeping. 
He  engaged  actively  in  politics — run  for  office — sometimes 
successful,  soinetimes  defeated.  Some  two  or  three  years 
previous  to  his  coming  under  my  care,  his  friends  noticed 
that    he    had    attacks    of  unconsciousness,  lasting  only    for 


502  Ira  Rwssell. 


a  few  seconds,  or  long  enough  to  interrupt  his  conversa- 
tion, but  would  immediately  continue  what  he  was  saying 
as  though  nothing  had  happened.  He  became  irritable  in 
his  temper  imperious  in  his  manner,  and  fault-finding 
with  his  associates.  His  appetite  was  poor,  and  he  slept  but 
little.  In  the  spring  of  1876,  after  engaging  in  an  import- 
ant and  long  continued  business  transaction,  going  without 
sleep  and  eating  but  little,  he  had  an  attack  of  acute 
mania  and  became  so  violent  as  to  necessitate  his  removal  to 
a  private  asylum,  where  he  remained  fourteen  months. 
The  acute  symptoms  soon  passed  off,  leaving  him  with 
feelings  of  discontent  and  great  dislike  to  all  restraint. 
Previous  to  the  acute  attacks,  Dr.  Walker  had  diagnos- 
ticated his  disease  as  general  paresis.  Having  been 
placed  under  guardianship,  he  was  removed  to  Wichendon, 
and  placed  under  my  care.  I  employed  three  intelligent 
gentlemen  as  attendants,  two  of  whom  were  with  him 
constantly.  He  was  allowed  all  possible  freedom,  and, 
as  far  as  possible,  all  signs  of  confinement  and  restraint 
were  removed.  He  played  billiards,  croquet,  bowled, 
went  riding,  boating,  to  concerts,  fishing  and  parties,  and 
everything  was  done  to  make  his  time  pass  pleasantly. 
When  he  first  came  under  my  care,  although  very  active, 
walking  and  running  with  great  agility,  he  had  the  hitch 
and  shuffle  in  his  gait  peculiar  to  general  paresis.  His 
appetite  was  good,  his  sleep  irregular  and  disturbed.  He 
had  illusions  of  sight,  saw  vermin  on  his  clothes.  He 
was  easily  excited,  irritable  and  passionate,  crafty  and 
cunning.  His  memory  was  defective.  He  had  notions 
of  self-importance  and  his  great  ability,  but  not  in 
relation  to  wealth,  so  common  in  this  disease,  and  of 
which  he  possessed  so  much.  He  had  slight  epileptiform 
attacks,  after  which  his  speech  would  be  affected  and 
his  gait  less  secure.  During  this  time,  when  his  friends 
called  upon  him,  he  would  appear  quite  sane  and  talk 
quite  rationally  upon  matters  that  happened  years  before. 
His  letters  were  a  medley  of  sanity,  insanity  and  vulgarity; 
his  hand  writing  was  bad.       During    the    first    six  months 


Case  of  General  Paresis.  503 

he  was  with  me,  the  change    in    his  symptoms  was  shght. 

In  February  his  epileptiform  attacks  were  more  frequent 
and  severe ;  his  gait  was  more  unsteady,  frequently  faUing 
down  ;  his  mind  was  less  active,  his  memor)^  very  much  im- 
paired. In  May  he  was  unable  to  walk  or  feed  himself;  lost 
all  control  of  the  sphinctors  and  died  July  3d,  com- 
pletely demented.  July  5th,  an  autopsy  was  made  by 
Dr.  Moses  G.  Parker,  and  the  morbid  appearances  were 
carefully  noted  by  myself  and  Dr.  Theo.  W.  Fisher,  of 
Boston.  The  scalp  was  rather  thick  and  anaemic.  On 
removing  the  calvarium,  the  bones  were  quite  thin  and 
the  marks  of  vessels  were  deeply  impressed  upon  the 
inner  tables.  The  diplce  congested.  Dura-mater  not 
very  adherent.  There  was  a  general  and  marked 
cloudiness  of  arachnoid  over  frontal  parietal  and  temporo- 
sphenoidal  lobes.  The  brain  weighed  53  ounces;  the 
cerebrum,  46  1-2,  the  cerebellum  and  oblongata,  6  1-2. 
Five  ounces  of  bloody  cerum  flowed  from  the  cranial 
cavities.  Sub-arachnoid  effusion,  moderate;  small  vessels 
distinctly  traced.  There  was  shrinking  and  flattening 
of  the  convolutions  of  the  anterior  lobes.  The  effusion 
and  opacity  were  limited  to  the  frontal  and  parietal  lobes. 
The  other  organs  of  the  body  were  examined  and 
found  healthy,  except  the  heart,  which  was  enlarged  and 
fatty. 

The  brain  was  put  in  alcohol  and  taken  to  Boston 
by  Dr.  Fisher,  for  further  examination,  who  makes  the 
following  report,  together  with  a  report  by  Dr.  S.  G. 
Webber: 

*  *          *  In  the  afternoon  of   July    5th,    it    was 

examined  superficially  with  the  assistance  of  Dr.  Webber. 
The  alcohol  had  somewhat  obscured  the  appearances 
above  described ;  we  found,  however,  a  moderate  amount 
of  wasting  over  both  frontal  and  parietal  lobes.  On  the 
7'ight  opacity  extended  backwards  to  the  perpendicular 
fissure,  following  it  downwards  and  forwards  to  fissure  of 
Sylvius,  which  it  followed  to  the  base  of  the  brain.  Opacity, 
greatest    over    fissure    of  Sylvius,    lower    part    of  fissure  of 


504  Ira  Russell. 


Rolando  and  vertical  frontal  fissure,  over  anterior  portions 
of  first  and  second  frontal  convolutions  and  along  the 
medial  border  of  hemisphere.  We  found  on  the  left,  opacity 
a  little  posterior  to  that  on  the  right,  but  rather  less 
marked  in  degree.  It  was  greatest  in  the  before  mentioned 
localities,  which  correspond  for  the  most  part  to  the 
course  of  the  larger  vessels  as  well  as  sulci.  The  veins 
were  full,  but  not  excessively  injected.  At  the  base 
we  found  opacity  marked  along  the  fissure  of  Sylvius, 
processus  iincinatus  and  gyrus  hippocampus  at  anterior 
extremity ;  also,  along  olfactory  bulbs  and  over  the  first 
and  second  frontal  convolutions.  Occipital  lobe  and 
external  portion  of  temporal  lobe  free  from  opacity.  No 
marked  atrophy  at  the  base.  This  applies  to  both  sides 
alike. 

We  found  and  located  seventeen  small  extravasations 
(see  diagrams)  :  (i)  On  the  rigJit,  at  the  base  for  one- 
eighth  of  an  inch  on  each  side  of  third  temporal  fissure, 
and  extending  two  inches  in  length,  was  a  spot  of  blood 
under  the  pia-mater.  (2)  About  the  middle  of  the  second 
temporal  convolution,  a  spot  three-quarters  inch  in  diam- 
eter. (3)  In  same  convolution,  a  little  anterior  to  last,  a 
spot  three-quarters  by  one-quarter  inch  bordering  on 
first  temporal  fissure.  (4)  At  lower  portion  of  ascending 
frontal,  a  small  spot  one-quarter  inch  in  diameter.  (5) 
About  the  center  of  the  second  frontal  convolutions  a 
small  stain.  (6,  7,  8,  9)  At  extreme  anterior  portion  of 
the  first  frontal,  four  small  spots.  (10)  Posterior  to  ascend- 
ing parietal  at  median  fissure,  a  spot  three-quarters  by  one- 
half  inch.  No  spots  on  left  s'xdo.  at  base.  (11,  12,  13, 
14,)  At  anterior  extremity  of  frontal  lobe,  involving  first, 
second  and  third  frontal  convolutions,  a  row  of  four 
small  spots.  (15)  A  large  spot  three-quarters  by  one 
inch,  on  both  sides  the  fissure  of  Rolando  at  its  lower 
part.  (16)  At  anterior  part  of  temporal  lobe,  bordering 
on  the  fissure  of  Sylvius  opposite  its  bifurcation,  a  small 
spot.  (17)  On  gyrus  fornicatus  an  inch  behind  the 
corpus    callosum,    a    small    spot. 


A  Case  of  General  Paresis. 


J 


Dr.  Webber  removed  some  portions  for  microscopical 
examination,  his  report  of  which  is  enclosed.  The  brain 
was  then  immersed  in  nitric  acid,  one  part ;  water,  nine 
parts,  and  allowed  to  remain  four  weeks.  August  3d,  it 
was  removed  and  carefully  stripped  of  its  toughened 
membrane,  which  separated  easily,  coming  out  from  the 
sulci  and  leaving  a  clear  yellow  surface  of  the  hardness 
of  new  cheese.  At  various  points  could  be  seen,  by 
careful  inspection,  shallow  erosions  with  ragged  edges, 
where  a  very  thin  film  of  the  cortex  had  been  removed 
with  the  membranes.  They  were  all  on  or  near  the 
summit  of  a  convolution.  Some  were  so  faint  as  to  be  doubt- 
ful, but  we  made  out  and  located  twenty-five  or  twenty-six 
as  shown  on  a  sketch  of  the  convolutions,  as  observed 
in  this  case.  These  are  quite  irregular,  and  differ  much 
from  a  typical  diagram ;  most  of  the  convolutions  can 
be  made  out  however.  There  were  no  adhesions  at  the 
base,  nor  so  low  down  at  the  sides  as  not  to  be  included 
in  a  single  view  from  above.  On  the  right  they  follow 
the  median  fissure  along  its  anterior  two-thirds.  The 
largest  are  at  the  upper  part  of  the  ascending  parietal 
and  frontal  convolutions,  and  along  the  first  frontal  to 
its  anterior  extremity.  On  the  left  they  follow  the  fissure 
of  Rolando  on  both  sides,  a  large  one  being  seen  at  the 
head  of  the  ascending  frontal ;  another  at  middle  of 
ascending  parietal ;  then  in  lower  parietal  lobule ;  five 
or  six  lower  down  in  ascending  frontal,  and  one  each  in 
first    and    second    frontal. 

At  the  second  examination  the  extravasations  had 
disappeared  ;  but  it  will  be  seen  that  they  do  not  corres- 
pond to  the  adhesions,  and  with  the  exception  of  4,  5 
and  15,  are  outside  the  motor  region  of  Ferrier.  These 
correspond  to  Ferrier's 'numbers,  No.  9  and  10,  lips  and 
tongue;  No.  12,  lateral  motions  of  head  and  eyes,  eleva- 
tion of  eyelids,  and  dilatation  of  pupils,  and  No.  7  and 
8  and  A,  elevation  and  depression  of  angle  of  mouth 
and    motions    of   hand   and    wrist,  respectively. 


506  Ira  Russell. 


The  erosions  on  the  Uft  correspond:  i,  to  Ferrier's 
No.  2,  3  and  4,  complex  motions  of  ar^ns  and  legs ;  2, 
to  No.  6,  biceps,  i.  c,  supination  and  flexion  of  forearm; 
3,  to  No.  7  and  8,  el.  and  dep.  ang.  of  mouth ;  4,  to 
a,  b,  c,  hand  and  wrist ;  5,  to  No.  13,  the  center  of  vision; 
6,  to  No.  12,  lat.  motion  of  head  and  eyes,  elev.  of 
lids  and  dil.  of  pupils.  On  the  right  they  correspond,  7 
and  8,  to  No.  2,  3  and  4,  arms  and  legs ;  9,  to  No.  5, 
arm  and  hand;  10,  to  No.  12,  see  above;  11,  to  a,  b, 
c,  hand  and  wrist.  Ferrier's  centers  are  all  accounted 
for  except  No.  i,  leg  and  foot;  No.  9,  10  and  ii,  where 
there    was    an   extravasation ;  and    No.  14,  hearing. 

Having  thus  placed  the  facts  before  you,  I  leave  you 
to  draw  your  own  inferences.  I  am  in  some  doubt 
whether  the  extravasations  were  not  post-mortem,  due 
to  accidents  in  removal  of  brain.  There  was  no  gross 
lesion  in  the  interior  of  brain,  to  account  for  death,  and 
if,  as  I  hear,  there  was  a  fatty  heart,  death  after  con- 
vulsions   would  not    be  remarkable. 

Very    respectfully. 
To  Dr.  Ira  Russell,  Thos.  W.  Fisher. 

Winchendon. 


Boston,  August  7th,   1878. 
Dear  Dr  : 

Dr.  Fisher  asked  me  to  examine  the  brain  microscopi- 
cally. I  found  around  many  of  the  blood  vessels,  granular 
blood  pigment.  I  found  that  many  of  the  nerve  cells 
were  strongly  pigmented,  and  that  many  contained  fat 
granules  without  pigment.  These  changes  were  rather 
more  marked  in  the  anterior  portion  of  the  frontal  lobes 
than  in  the  motor  region.  The  convolutions  about  the 
central  extremity  of  the  fissure  of  Rolando  contained 
amyloid  corpuscles;  the  large  cells  in  these  convolutions 
were  strongly  pigmented. 

Under  the  pia-mater,  in  several  spots,  especially  where 
there    was  most    opacity,    were    collections    of  leucocytes. 


EROSIONS 


left  right 

Posterior 


a  Fissure  of  Rolando 


EXTRAVASATIONS 


LEFT 


CO    G5 


RIGHT 


LEFT 


ANTERIOR 


A  Case  of  General  Paresis.  507 


My  method  was  to  take  small  pieces  out  of  various 
regions,  or  to  make  slight  incisions  and  take  small  sections 
out  of  the  cortex ;  these  were  teased  apart  and  the  cells 
thus  examined.  As  it  was  desired  to  examine  the  adhe- 
sions, I  could  not  take  any  portion  to  harden. 

Yours  Truly, 

S.  G.  Webber. 


Remarks  : — I  am  under  great  obligations  to  Dr.  Fisher 
for  his  careful  and  thorough  examination  and  report  of 
the  morbid  condition  of  the  brain.  The  lesions  observed 
correspond  very  nearly  with  those  observed  by  J.  Crichton 
Browne  in  the  cases  of  general  paresis,  reported  by  him 
in  vol.  VI.  of  "West  Riding  Lunatic  Asylum  Medical 
Reports  ;"  viz. :  "The  uniformity  of  inflammation  of  the 
membranes  of  the  anterior  lobes  of  the  brain,  and  adhe- 
sions of  the  same  in  spots  to  the  apices  of  the  convolutions, 
the  cortex  beneath  being  more  or  less  affected.  Dr. 
Browne  and  others  express  the  opinion  that  the  lesions 
found  and  the  symptoms  manifested  during  the  progress 
of  the  disease  verify  the  localization  of  function  as  taught 
by  Ferrier." 

I  give  the  order  in  which  the  psychical  and  motor 
symptoms  appeared  in  the  above  case  : 

Psvchical. — First. — The  first  abnormal  symptoms  noticed 
by  the  family  of  A.  B.  were  general  restlessness  ;  intense 
application  to  business  ;  irritability  of  temper  ;  change  of 
disposition,  and  less  regard  for  the  proprieties  and  mor- 
alities of  life. 

Second. — Extravagant  ideas  and  desires,  with  self-exal- 
tation. 

Third. — He  had  an  attack  of  acute  mania  after  a 
prolonged,  harrassing  and  important  business  transaction 
— recovering  from  it. 

Fourth. — He  had  impairment  of  memory,  especially  of 
recent  events,  and  forgetfulness  of  persons  and  names. 


508  Ira  Russell. 


Fifth — Extreme  willfulness  and  unwillingness  to  be 
controlled,  and  general  discontent,  with  occasional  attacks 
of  maniacal  excitement. 

Sixth. — Hallucinations  of  the  senses  of  sight  and 
hearing. 

Seventh. — Good  nature,  mental  weakness,  dementia, 
coma  and  death. 

Motor  Syuiptouis. — First. — An  excited  manner  of  walk- 
ing. 

Second. — A  pleased  expression  to  the  countenance, 
caused  by  the  contraction  of  the  occipito-frontalis  muscle. 

Third. — A  fibrillar  motion  of  the  tongue ;  irregularity 
in  the  pupils  of  the  eye;  a  tremulous  movement  of 
the  chin  and  lips. 

Fourth. — Loss  of  co-ordinating  power  of  the  hands 
(as  shown  by  hand-writing),  and  a  hitch  or  shuffle  in  his 
gait. 

Fifth. — Alteration    in   the  voice. 

Sixth. — And  lastly,  a  general  paralysis  of  the  arms, 
legs'^  and  sphincters. 


Art.  VII.— The  Organization  of  Hospitals 
for  the  Insane. 


The  Propositions  of  the  Association  of  Medical  Superintendents  of  American 
Hospitals  for  the  Insane. — Continued. 


By  John  Curwen,  M.  D.,  Harrisburg,  Penn. 

TN  institutions  of  a  corporate  character,  either  pubHc  or 
-*•  private,  it  has  always  been  found  proper  and  expedient 
to  delegate  certain  power  and  authority  for  the  general 
direction  of  the  affairs  of  the  institution  to  a  given  number 
of  individuals,  under  the  general  name  of  trustees,  man- 
agers, directors,  or  similar  titles  indicating  the  nature  of 
the  duties  which  they  are  expected  to  perform.  These 
duties  are  generally  of  a  mixed  character,  requiring  the 
oversight  of  the  financial  affairs  and  the  appointment  of 
certain  executive  officers  to  whom  are  committed  the 
immediate  direction  of  certain  classes  of  duties. 

In  institutions  of  a  more  directly  charitable  character, 
it  is  incumbent  on  them  to  see  that  the  special  design  of 
the  institution  is  fully  carried  out  in  accordance  with  the 
specific  objects  of  its  creation ;  and  in  all  institutions  for 
the  care  of  the  insane,  the  primary  duty  is  to  insist  that 
the  medical,  moral  and  hygienic,  treatment  which  has  been 
found  by  experience  most  in  accordance  with  the  greatest 
relief,  comfort  and  restoration  of  the  patients,  be  carried 
out  in  the  most  thorough  manner,  regardless  of  all  con- 
siderations, except  the  welfare    of  the    insane  themselves. 

What  then  should  be  the  character  of  those  to  whom 
such  a  high  trust  should  be  committed? 

This  question  seems  very  fully  answered  by  the  follow- 
ing propositions  of  the  Association  : 

1st.— The  general  controlling  power  should  be  vested  in  a  board  of 
trustees  or  managers ;  if  of  a  State  institution,  selected  in  such  a  manner  as 


610  John  Curwin. 


will  be  likely,  most  effectually,  to  protect  it  from  all  intlnences  connected 
with  politii-al  lueasiires  or  political  chan«res ;  if  of  a  piivate  corporation, 
by  those  properly  authorized  to  vote. 

2d.— Tlie  board  of  trustees  should  not  exceed  twelve  in  number,  and 
be  composed  of  individuals  possesiiig  the  public  contidence,  distiiijfuished 
for  llbendlty,  intellifjence  and  active  benevolence,  above  all  political 
Inllueiice,  and  able  and  willing  faithfully  to  attend  to  the  duties  of  their 
station.  Their  tenure  of  office  should  be  so  arranged  that,  where  changes 
are  deemed  desirable,  the  terms  of  not  more  than  one-third  of  the  whole 
number  should  expire  in  one  year. 

Nothing,  at  first  sight,  appears  more  desirable  in  all 
such  institutions  than  to  keep  them  free  from  all  political 
management  or  control,  and  yet  events  within  the  last 
few  years  have  shown  most  conclusivel}'  that  in  certain 
sections  of  the  country  this  principle  has  been  entirely 
disregarded  ;  and  the  officers,  from  the  lowest  to  the 
highest,  have  been  selected  with  special  reference  to  their 
political  relations  to  the  party  which  chanced  to  be  in 
power,  and,  should  a  change  of  administration  in  the  State 
take  place,  every  officer  must  be  displaced  to  make 
room  for.  and  reward,  those  of  the  party  which  was  at 
the  time  in  the  ascendant,  demanded,  as  the  phrase  is. 
"by  the  exigencies  of  party." 

Any  party  which  cannot  recommend  itself  to  the  sound 
sense  of  the  community  by  any  other  course  than  by 
dragging  institutions  for  the  insane  and  the  defective 
classes  generally,  into  the  slough  of  politics,  ought  to 
cease  to  exist  or  have  any  control  in  public  affairs. 

That  this  whole  proceeding  is  essentially  and  radically 
wrong  is  admitted  even  by  those  who  practice  it,  in  the 
excuses  which  they  make  to  justify  it;  but  no  justification 
can  ever  be  made  for  that  which  is  fundamentally  wrong, 
and,  in  its  tendency,  injurious  to  the  best  interests  of  those 
who  are  the  wards  of  the  State,  and,  therefore,  fully 
entitled  to  the  best  which  the  State  can  give  them. 
No  man  need  to  be  told  that  it  is  impossible  for  an 
institution  for  the  insane  to  be  managed  for  the  greatest 
welfare  of  its  inmates  when  its  officere  are  displaced 
with  every  turn  of  the  political  wheel.  It  requires  time 
and  careful  study  for  a  man  to  understand  all  the  varieties 


Organization  of  Hospitals  for  the  Insane.  511 

of  mental  disorder  in  any  institution,  before  he  can  be 
said  to  be  qualified  to  give  proper  direction  to  the  treat- 
ment ;  and  to  be  displaced  just  when  he  has  gained  such 
information  is  a  flagrant  wrong  done  to  the  insane  them- 
selves, unless  the  principle  is  avowed,  which,  in  these 
latter  times,  seems  in  some  quarters  to  have  obtained 
official  sanction,  that  the  more  experience  a  man  has  the 
less  he  is  qualified  to  minister  to  the  treatment  of  the 
insane. 

The  phrase  in  the  proposition,  "above  all  political 
influence,"  means  that  they  should  be  men  so  imbued 
with  a  sense  of  duty,  so  highly  "distinguished  for  liberality, 
intelligence  and  active  benevolence"  that  they  will  be  far 
removed  from  all  political  motives  to  influence  their  man- 
agement, and  will  have  an  eye  single  to  the  best  interests 
of  the  insane,  and  that   alone. 

It  is  unquestionably  true  that  such  men  do  not  push 
themselves  forward  for  such  places;  but  that  is  no  reason 
why  the  appointing  power  should  not  seek  them  out  and 
give  them,  in  all  cases,  the  preference,  to  those  who  seek 
the  position  for  some  fancied  advantage  in  one  way  or 
other  which  they  think  it   may  give  them. 

That  man  is  of  the  class  required,  and  very  much 
needed  too,  who,  though  for  years  connected  with  the 
management  of  large  hospitals,  would  never  consent  even 
to  take  a  dose  of  medicine,  if  he  required  it,  without 
paying  for  it  at  once. 

They  should  also  be  men  "possessing  the  public  confi- 
dence," to  inspire  the  minds  of  the  community  with  the 
conviction  that  they  will  administer  the  trust  committed 
to  them  in  a  high-toned  and  honorable  manner,  free  from 
all  private  piques  and  resentments,  with  no  desire  to 
serve  personal  ends  or  purposes,  and  possessing  that 
amount  of  leisure,  or,  if  engaged  in  business,  willing  to 
take  that  amount  of  time,  which  will  fully  enable  them, 
and  that  degree  of  philanthrophy  which  will  qualify  them 
"faithfully  to  attend  to  the  duties  of  their  station."     They 


512  John  Curwen. 

should  also  be  selected  from  as  extensive  a  section  of  the 
country,  for  which  the  hospital  is  designed,  as  can  be 
done,  so  as  to  give  a  full  representation  to  every  part, 
and  not  have  them  confined  to  the  immediate  neighborhood 
of  the  institution. 

In  some  States  the  law  requires  "that  no  two  members 
of  the  aforesaid  board  of  trustees,  or  directors,  of  said 
institutions  shall  be  residents  of  the  same  county,  nor 
shall  more  than  one  trustee  or  director  aforesaid  reside  in 
the  county  where  said  institutions  shall  be  respectively 
located." 

The  official  explanation  of  that  clause  is,  that  they 
shall  not  be  able  to  influence  the  patronage  or  purchases 
of  the  institution  to  their  own  advantage,  or  to  that  of 
their  friends ;  and,  in  many  States,  the  law  expressly 
forbids  any  trustee  or  director  to  have  any  interest, 
directly  or  indirectly,  in  any  purchases  made  for  the 
institution,  or  furnishing  any  articles  of  any  kind. 

The  number  appointed  to  the  charge  of  any  institution 
will,  of  course,  vary  in  different  sections,  but  it  seems 
desirable  that  it  should  reach  that  number  which  will 
most  fully  represent  the  whole  section  in  which  the 
institution  may  be  located  (not  exceeding  twelve),  and 
not  throw  too  much  labor  on  a  few  men  who  may  be 
willing  to  perform  their  duty  most  fully  and  most 
patiently,  and  in  a  manner  to  give  entire  satisfaction  to 
the  community  they  are  called  upon  to  represent ;  and 
when  changes  are  by  the  terms  of  their  appointment,  or 
from  any  other  cause,  required,  so  far  as  possible,  the 
same  men,  or  men  of  the  same  high  tone  of  character, 
should  be  appointed  so  that  familiarity  with  the  duty  may 
enable  them  to  perform  those  duties  with  the  greater 
facility  and  advantage  to  the  institution  and  to  the 
community. 

They  should  also  be  men  of  steadiness  of  aim  and 
purposes,  not  inclined  to  fall  in  with  all  the  crotchets  and 
fancies  of  the  would-be  reformers  and  philanthropists,  who 
care  more  for  the    success    of    some     favorite    scheme    or 


Organization  of  Hospitals  for  the  Insane.  513 

project  than  for  the  welfare  of  the  insane,  and  who  lack 
in  the  composition  of  their  own  character  that  ingredient 
of  charity,  "which  thinketh  no  evil,"  which  they  are  so 
anxious  should  be  infused  into  the  character  of  all  con- 
nected with   the  care  of  the  insane. 

What  is  rriost  needed  at  this  time  is  calm,  cool 
judgment,  sober  reason,  and  a  steady  adherence  to  just 
and  correct  principles,  which  have  been  established  by 
extended  experience,  and  found  by  the  most  careful  and 
rigid  observation  to  be'  what  is  most  needed  in  the  man- 
agement of  all  our  hospitals  for  the  insane. 
"A  little  learning  is  a  dangerous  thing. 
Drink  deep  or  touch  not  the  (Pinelian)  spring." 

If  all  men  appointed  to  offices  of  trust  and  management 
in  institutions  for  the  insane  were  animated  with  the 
indomitable  spirit,  calm  faith,  cool  courage  and  steady 
perseverance  in  high  aims  and  noble  purposes  of  Philip 
Pinel,  the  community  would  never  have  cause  to  complain 
of  the  management  of  any  institution  for  the  insane  in 
this  or-  any  other  land. 

3d.— The  board  of  trus^tees  should  appoint  the  physician,  and  on  his 
nomination,  and  not  otherwise,  the  assistant  physician,  steward  and 
matron.  They  should,  as  a  board  or  by  committee,  visit  and  examine 
every  part  of  the  institution  at  frequent  stated  Intervals,  not  less  than 
semi-monthly,  and  at  such  other  times  as  they  may  deem  expedient,  and 
exercise  so  careful  a  supervision  over  the  expenditures  and  general 
operations  of  the  hospital,  as  to  give  to  the  community  a  proper  degree  of 
confidence  in  the  correctness  of  its  management. 

The  reasons  will  be  given  in  full  for  the  manner  of 
appointment  of  the  physicians,  and  those  subordinate  to 
him,  when  the  next  proposition  claims  consideration,  as  it 
is  desirable  to  confine  the  present  discussion  to  the  char- 
acter and  duties  of  trustees. 

No  duty  of  a  trustee  of  a  State  hospital  for  the  insane 
is  more  neglected  than  that  which  requires  them  "as  a 
board  or  by  committee  to  visit  and  examine  every  part 
of  the  institution,  at  frequent  stated  intervals,  not  less 
than  semi-monthly,  and  at  such  other  times  as  they  may 
deem  expedient,"  for  in  this  way  only  can  they  become 
properly     and    thoroughly    acquainted    with    the    interior 


614  John  Ciirwin. 

management  of  the  institution.  No  better  rule  can  bo 
adopted  than  that  regularly  and  systematically  carried 
out  by  the  trustees  of  many  incorporated  institutions  of 
visiting  the  wards  of  the  hospital  regularly  every  week, 
and  seeing  and  knowing  the  actual  condition  of  every 
patient ;  and  by  the  knowledge  thus  obtained,  they  will  be 
able  to  say  that  all  the  inmates  are  properly  cared  for, 
and,  also,  properly  inmates  of  the  hospital,  and  not,  as  is 
so  frequently  alleged,  kept  there  to  gratify  the  personal 
animosities  of  friends  and  relatives. 

(It  may  not  be  amiss,  in  this  connection,  to  call  attention 
to  a  remark  made  in  an  address  of  Lord  Shaftsbury,  Chair- 
man of  the  English  Commissioners  in  Lunacy  for  nearly  forty 
years,  that  the  parliamentary  committee  appointed  in  1879. 
to  examine  into  the  condition  of  the  insane  in  England,  after 
repeated  meetings  extending  over  many  months,  and  the 
examination  of  every  one  who  expressed  a  desire  to  appear 
before  them  and  of  many  who  did  not  Avish  to  appear, 
found  that  of  188,714  insane  in  the  different  institutions 
for  the  insane  in  England,  not  one  had  been  wrongly  or 
unjustly  confined).  By  such  knowledge  also  the  trustees 
are  better  able  to  give  advice  and  counsel  to  those  in 
charge  of  the  hospital,  which  will  aid  them  in  the  execu- 
tion of  their  duties,  and  assist  them  in  the  various  trials 
and  perplexities  of  their  position,  and  not  rely  on  the 
reports  made  by  subordinates  in  the  institution,  who  too 
often  color  what  they  say  in  such  a  way  as  to  place  the 
superintendent  in  a  false  position,  by  endeavoring  to  excite 
prejudice  against  him. 

By  such  visits,  and  careful  examination  also,  they  arc 
much  better  prepared  to  exercise  "so  careful  a  supervision 
over  the  expenditures  and  general  operations  of  the 
hospital,"  as  to  show  and  be  convinced  that  such  expen- 
ditures are  just  and  needful.  Many  expenditures  which, 
at  the  first  view,  seem  unnecessary  are  found,  when 
carefully  examined,  to  be  not  only  correct  and  proper, 
but  greatly  to  conduce  to  the  welfare  of  the  patients ; 
and  the    sanction    of  such    expenditures    by    the    trustees 


Organization  of  Hospitals  for  the  Insane.  515 

removes  what  might  otherwise  be    an    unju.'^    assertion  or 
reflection  on  the  superintendent. 

No  superintendent  will  ever  feel  inclined  to  complain 
of  any  criticism  on  his  management,  dictated  by  a  full 
knowledge  of  all  the  facts  derived  from  full  and  careful 
investigations ;  but  everyone  will,  with  justice,  complain 
when  those  criticisms  are  founded  on  information  derived 
from  subordinates,  who  have  no  just  perception  of  their 
own  duties,  and  who  perform  what  they  think  are  their 
duties  in  a  careless  and  indifferent  manner,  and  are 
roused  to  resentment  by  the  enforcement  of  the  rules 
requiring  them  to  attend  to  their  duties  in  a  more  correct 
and  satisfactory  manner,  and  whose  misrepresentations  are 
in  proportion  to  the  extent  in  which  they  have  failed  to 
comply  with  what  was  required  of  them. 

It  is  not  too  strong  a  .statement  to  make,  that  every 
trustee  will  better  perform  his  duty  to  all  connected  with 
the  institution,  if  he  will  consider  clearly  how  he  would 
like  to  be  treated  if  he  was  in  the  position  of  those 
whose  conduct  he  may  be  disposed  to  criticize  or  con- 
demn. 

"The  uiembei's  of  a  hoard  of  trustee*.  i)erfoiniino:tlieir  duties  properly, 
are  always  al)le  to  exeroise  a  most  important  influence  on  the  j)rosperity  of 
any  institution,  and  on  the  welfare  of  its  inmates  ;  and  they  may  also  by 
injudicious  measures,  or  a  want  of  ii.terest  in  its  affairs  produce  eflfecfs  of 
an  entirely  dilforent  character.  While  uflvin^:  the  strictesi  attention  to  their 
own  appropriate  functions,  they  should  most  carefully  avoid  any  interfer- 
ence with  what  is  dele.irated  to  otiiers.  or  meddlinof  with  the  direction  of 
details  for  which  others  are  responsible.  EspecinlJy  sliould  they  avoid 
any  personal  interest  in  subordinates  that  miofht  lead  tliem  to  a  course 
that  would  weaken  the  authority  of  the  principid  of  the  institution.  It 
would,  indeed,  be  a  safe  principle  to  adopt,  that  there  should  be  no  ties  of  a 
personal  or  pecuniary  character,  between  a  member  of  the  board  of 
trustees  and  those  who  are  emjdoyed  in  any  of  the  departments  of  an 
institution,  which  could,  at  any  time,  prevent  an  unbiased  judgment 
ill  a  case  of  dithculty  Under  no  circumstances  should  a  trustee  so  far 
foro'et  the  proprieties  of  his  station  as  to  resort  to  subordinates  for  infor- 
mation that  should  come  from  the  principal— or  to  circulate  unfavorable 
reports  in  reiiard  to  the  institution  without  first  havino:  informed  this 
oflScer  of  their  existence  ana  tendency,  and  learned  from  him  tlie  truth  or 
falsehood,  as  well  as  the  reasons  which  may  have  induced  acts,  which, 
altliough  correct  in  themselves,  miuht,  without  proper  explanation,  be 
readily  so  misunderstood  as  to  do  great  injustice  to  innocent  parties. 


610  John  Curwin. 


••Hoard  of  trustees  wliilst  exercising  the  strktest,  honorable  scrutiny 
of  tlicir  (.fHcers  shoiihl  be  pr<  pjired  on  every  proper  occ:ision  to  give 
them  a  steadfast  support  in  the  perlorniance  of  tlieir  arduous  and  respon- 
sil>le  duties.  Tiiey  can  tiius  add  e>peeially  to  their  power  of  doing  good. 
It  is  a  great  eiicourageu)ent  to  tliose  who  are  engaged  in  \\\\<  Toratifm,  to 
tind  their  etforis  properly  appreciated  by  tliose.  to  whom  they  are  directly 
n-sponsible.  and  who  ought  to  be  most  familiar  with  their  modes  of  man- 
agement and  the  beneficial  results  of  their  lKbois.'"—A'i;-A6rirfe,  1854. 

The  following  extract  is  given  from  a  paper  read  by 
that  highly  accomplished  and  distinguished  alienist,  Dr. 
Isaac  Ray,  before  the  Association,  in  1873,  and  published, 
at  its  request,  for  circulation  among  the  members  : 

'•The  Good  Director  hath  accepttd  his  office,  not  solely  as  a  token  of 
honoi',  or  of  kindness,  or  to  be  an  ornamental  appendage  to  a  list  of  other 
names,  but  as  a  field  lor  active,  intelligent,  nselul  work  in  the  service  of 
humanity.  He  t:ikeih  its  duties  upon  him,  determined  to  discharge  them 
to  the  best  of  Ins  ability,  and  to  allow  no  llimsy  excuse  to  turn  him  from 
their  regidar  performance.  He  is  deeplj-  interested  in  the  welfare  of  the 
unfortunates,  for  \\  hose  comfort  he  hath  made  himself  in  sonje  measure 
responsible,  and  is  distressed  by  none  of  those  delicate  sensibilities  which 
are  oflended  by  the  si-iht  ol  misery.  While  he  patiently  listeneth  10  their 
complaints,  he  loimtth  no  judgement  i.nd  maktth  no  promise  until 
enlightened  by  farther  inquiry  ;  becaui^e  he  is  .>-uie  tlieie  is  a  reason  for 
whatever  is  alleged  in  spite  of  appearances,  and  he  is  bound  to  know  what 
it  is.  However  reasonable  the  patient  may  appear,  he  never  forgetteth 
that  circumstances  may  render  compliance  with  his  requests,  prejudicial 
to  his  best  good.  His  protestations  that  he  was  never  insane,  but  only  the 
victim  of  malevolence;  or  that  he  is  ill-used  by  attendants  and  doctors, 
and  subjected  to  all  manner  of  hardship,  disturbeth  not  the  even  balance 
of  the  Good  Director^  judgment  and  Jeelings.  He  declinelli  to  cairy 
messages  to  or  from  the  patients,  as  well  as  invitations  to  this  or  that 
person  to  visit  them.  He  maketh  no  pronuses,  hastily  or  inciiutiously, 
but  when  once  made  he  faithfidly  performs  them.  His  stated  visits  are  never 
omitted  except  for  the  most  imperative  reasons.  He  would  sooner  allow 
his  note  in  bank  to  go  to  protest  than  to  let  such  an  omission  appear 
on  the  records  of  the  hospital.  He  confineth  not  the  visits  to  stated 
periods,  but  maketh  many  intormally  and  without  notice.  In  this  manner 
he  seeth  the  hospital  in  various  aspects,  and  extendeth  hi.-«  knowledge  of  its 
operations.  He  thus  learns  to  distinguislM\  hat  is  accidental  and  tempor- 
ary from  that  wiiicii  is  habitual  and  systematic.  He  seeth.  in  some 
degree,  how  its  lesults  are  obtained,  as  well  as  the  spirit  which  guides  and 
governs  its  movements.  In  this  way  he  learns  to  api)reciate  justly  the 
laborsof  the  officers,  the  difficulties  they  are  under  anil  the  trials  tiiey 
sustain.  He  thus  learns  also  how  far  their  shortcomings  proceed  from 
incompetence,  and  how  far  they  may  beattributed  to  the  peculiar  natuie  of 
their  duties.  He  enteiiaineth  a  higher  notion  of  his  office  than  to  sti)  jiose 
that  its  sole  object  is  the  discovery  of  faults  or  occasions  of  criticism,  and 


Organization  of  Hospitals  for  the  Insane. 


so  his  visits  are  not  made  in  the  spirit  of  a  detective  on  tlie  track  of  an  old 
offender,  but  rather  of  an  earnest  and  judiciou*  friend  prepared  to  discrim- 
inate wisely,  and  to  commend  and  encourage  wliatever  is  indicative  of  ze;il, 
industry  and  intelligence,  high  aims  and  study  progress.  He  esteenietli  it 
a  privilege  and  a  blessing  to  aid.  by  all  the  means  in  his  power,  in  tiiis 
signal  service  of  humanity,  and  yieldeth  no  grudging  support  to  the 
superintendent  in  his  plans  of  improvement.  He  regurdeth  it  as  no  part 
of  his  duty  to  interfere  with  any  work  tliat  properly  belongs  to  the 
superintendent,  well  knowing  that  such  interference  is  sure  to  create  ill 
feelings,  to  impair  respon.-ibility  and  frustrate  the  ol)jecr  sought  for. 

When  the  public  is  alarmed  by  stories  of  wrong  doing,  he  is  ready  to 
say  on  the  strength  of  his  own  personal  knowledge,  that  such  stories  are 
without  any  other  foundation  than  that  of  a  distorted  reason  or  depraved 
imagination.  And  so  when  the  wrath  of  men  is  kindled,  and  the  public 
clamor  is  linid,  he  is  never  led  by  lack  of  knowledge  or  of  honesty  to  cast 
off  all  responsibility,  and  make  a  scape-goat  of  the  superintendent.  He 
restetli  on  the  conviction  that  the  latter  is  right,  and  waiteth  serenely  for 
the  better  judgment  of  the  future.  Much  as  he  is  attached  to  the  hospital, 
he  never  persuadeth  himself  that  it  is  exempt  from  deficiencies,  and,  in  all 
things,  worthy  of  imitation.  On  the  contrary,  he  believeth  that  no  work 
of  mortal  hand  or  head  is  beyond  tlie  reach  of  improvement,  and,  so  think- 
ing, he  visiteth  other  e^tablishments,  in  the  hope  of  finding  something 
that  may  be  profitably  adopted  at  home.  All  nil  admirari  feeling  is  left 
behind,  and  whatever  meets  his  notice  is  viewed  in  a  teachable  disposition." 


Art.   VIII.— Experts  and    Expert    Testi- 
mony." 


By  John  B.  Chapin,  M.  D., 

SUPERINTENDENT    AND   PHrSiClAN     OF     WILLARD   ASYLUM    FOR   THE     INSANE, 
WIlLARD,    N.  Y. 

IN  presenting  the  subject  which  forms  the  title  of  this 
paper,  it  is  not  the  intention  to  attempt  to  clear  away 
the  difficulties  which  are  conceded  to  surround  it.  It  is 
the  purpose  to  offer,  for  your  consideration,  some  propo- 
sitions which  may  promote  discussion,  and  an  interchange 
of  views,  which  will,  in  the  end,  solve  the  recurring 
problem,  viz :  The  conditions  which  are  essential  to 
enable  a  witness,  called  into  court  in    the    capacity  of  an 

•Head  before  the  Association  of  Medical  Superintendents  of  American  As.vlunis 
for  the  Insane,  May,  1880. 


518  John  B.  Chopin. 

expert,  to  appear  in  such  a  manner  that  his  independent 
judgment  may  be  secured,  and  that  it  may  be  presented 
free  from  bias  or  the  suspicion  of  its  existence. 

The  practice  of  the  courts  is  to  admit  the  testimony 
of  a  class  of  witnesses  who  are  not  supposed  to  have 
personal  knowledge  of  any  facts  or  circumstances  bearing 
upon  a  pending  case,  but,  on  the  assumption  that  they 
are  able  from  their  special  training  and  experience  to 
apply  scientific  tests  and  present  to  the  court  and  jury 
the  import  and  value  of  such  evidence  as  may  appear, 
which  laymen  could  not  be  expected  to  comprehend  and 
properly  estimate.  The  expert  witness  may  be  said  to 
be  tolerated  by  the  courtesy,  and  usages  of  the  practice, 
of  the  courts.  He  cannot  have  any  other  standing.  That 
he  can  be  compelled  to  furnish  any  testimony  against  his 
inclination  is  not  clearly  established.  He  has  nothing  to 
offer  but  his  opinions  or  scientific  deductions,  which  may, 
or  may  not,  in  the  estimation  of  the  court  and  jury,  have 
an  appreciable  value. 

According  to  the  statutes  and  common  law,  a  person 
of  unsound  mind  is  not  in  a  fit  state  for  punishment,  to 
enter  upon  his  defense,  or,  responsible  for  his  acts.  The 
opinion  the  medical  expert  offers  has  reference  to  the 
quality  and  quantity  of  mind  at  the  time  of  the  commis- 
sion of  a  crime,  or  when  some  transaction  took  place 
about  which  a  question  may  arise.  The  opinion  which  is 
presented  can  hardly  be  said  to  have  been  formed  from 
a  circumstantial  knowledge  of  the  occurrence,  or,  as  the 
result,  in  all  cases,  of  a  personal  examination. 

The  true  mental  condition  of  the  party  involved  is  a 
question  of  fact,  like  other  facts  pertaining  to  the  guilt  or 
innocence  of  a  person  charged  with  crime,  to  be  deter- 
mined by  the  verdict  of  a  jury.  This  method  must  stand 
until  some  other  process  of  adjudication  shall  be  accepted. 
To  this  tribunal  the  medical  witness  offers  his  opinion, 
not  as  he  may  have  formed  it  from  the  whole  of  the 
evidence  adduced,  but,  upon  an  assumed,  or  a  hypothet- 
ical case  embracing  as  much  of  it,  and  omitting  as  much, 


Experts  and  Expert  Testimony.  519 

as  may  serve  the  purpose  of  the  examiner.  Courts  are 
not  disposed  to  remit  to  other  tribunals  the  determination 
of  issues  of  fact,  for  there  "would  be  nothing  left  for 
the  jury  to  determine."  So  carefully  guarded  do  the 
courts  seek  to  preserve  the  sacred  province  of  the  jury, 
that  the  medical  expert,  in  cases  where  the  issue  is  the 
mental  condition  of  the  party  involved,  is  only  permitted 
to  express  an  opinion  upon  a  hypothetical  question,  or 
an  assumed  case. 

In  the  language  of  a  learned  judge  : 

"A  question  of  this  chaiacter  to  be  admissible  must  always  be  an 
hypotlietical  one,  based  either  upon  the  truth  of  all  the  evidence  given  in 
the  case,  or  upon  an  hypothesis  specially  framed  of  certain  facts  assumed 
to  be  proven  for  the  purpose  of  the  inquiry,  {juch  a  question  leaves  it  for 
the  jury  to  decide  in  the  tirst  ease  whether  the  evidence  in  whole  or  in 
part  is  true  or  not,  and  in  the  second  case  whether  the  particular  facts 
assumed  are  or  are  not  proved."* 

Assuming  this  dictum  to  be  the  settled  practice  in 
conducting  judical  inquiries  of  this  nature,  hypothetical 
questions  to  be  propounded  to  medical  witnesses  are 
prepared  by  council  representing  opposite  theories  of  the 
case,  and  calculated  to  elicit  replies  entirely  different. 
Counsel  confer  beforehand  with  medical  men,  summoned 
in  the  interests  of  their  clients,  in  the  preparation  of  the 
questions.  By  a  process  of  ingenious  aggregation,  or 
elimination  of  symptoms,  answers,  favorable  to  either  view 
of  the  case,  are  elicited,  or  such  a  congregation  of 
circumstances  presented  so  deficient  in  essentials,  that  the 
witness  is  unable  to  express  any  opinion. 

While  the  courts  are  disposed  to  insist  that  the  basis 
of  the  hypothetical  question  shall  embrace  conditions  that 
have  been  developed  in  the  course  of  the  investigation, 
there  is  a  radical  defect  permitted  in  their  formation  in 
this  respect,  that  the  hypothesis  does  not  embody  all  the 
medical  history,  neither  is  the  medical  witness  allowed  to 
frame  a  case  which  will  embrace  a  complete  history  of 
it.     The  witness  is  present  to  answer    questions,    and    not, 

•tarpeiiterrs.  Blake,  '2d  Laiising,  New  York. 


5-0  John  B.  Chapin. 


as  he  may  be  informed,  to  deliver  a  disquisition  on  medi- 
cal science. 

The  hypothesis  which  is  presented  contains  just  so 
much  of  the  case  as  will  elicit  an  answer  or  opinion 
favorable  to  the  party  in  whose  interest  it  is  framed.  The 
courts  do  not  insist  that  it  embrace  more,  but  that  wliat  it 
does  contain  shall  have  appeared  in  evidence  in  the  course 
of  the  trial.  The  answer  to  the  question  comes,  some- 
times, with  the  automatism  of  a  machine.  We  have 
known  the  medical  witness,  impatient  at  the  tedium  of  a 
protracted  trial,  request  that  he  might  record  his  "aye" 
and  "nay"  in  response  to  the  hypothetical  questions  as 
they  may  appear,  and  that  he  be  allowed  to  depart.  If 
the  questions  are  skillfully  framed  the  experts  usually 
agree  in  their  replies,  otherwise  they  appear  ranged  on 
opposite  sides  offering  opinions  that  are  contradictory. 
The  spectacle  is  presented  of  the  uncertainty  of  medical 
judgment  and  science,  as  well  as  of  men,  who  ought 
with  like  premises  to  reach  conclusions  precisely  similar, 
expressing  opinions  in   conflict  with  each  other. 

It  is  not  a  matter  of  surprise  that  courts  have  announcetl 
from  the  bench  that  medical  men  might  be  better 
employed  at  home,  in  attendance  upon  their  patients,  and, 
that  doctors  are  respectable  men  in  their  way, 

••\Vho  are  called  to  administer  to  our  ailments,  but  we  are  not  bound 
to  believe  their  opinions  unless  they  are  comi)atil)le  with  sound  sense; 
•  loctors  give  opinions  which  are  merely  speculative.  They  have  their 
theories  and  speculations.  You  (gentleiuen  of  the  jury)  are  not  bound  to 
believe  the  opinion  of  a  doctor  unless  it  comports  vkith  your  common 
sense." 

It  is  undoubtedly  true  that  many  cases  are  presented 
for  judicial  investigation  which  are  beyond  the  domain  of 
actual  determination — subjects  of  mere  opinion,  uncertainty 
and  speculation,  to  be  determined  only  by  results.  Juries, 
on  the  other  hand,  have  furnished  too  many  unfortunate 
instances  of  the  extreme  assertion  of  their  prerogative  in 
cases,  within  the  knowledge,  doubtless,  of  many  here 
present,  where  they  have  ignored  the  expression  of 
professional     opinions,    which     were      founded     on    actual 


Experts  and  Expert  Testimony.  521 

experience,  and  should  be  received  with  all  the  weight 
to  be  attached  to  the  testimony  of  facts  bearing  upon 
the  case. 

How  opinions  that  are  merely  speculative  and  theoret- 
ical are  to  be  discriminated  from  those  formed  from  actual 
professional  experience  it  may  not  be  easy  to  determine. 
It  must  be  admitted  that  a  real  difficulty  arises  at  this 
point.  Possibly  a  recognition  of  this  difficulty  may  have 
induced  the  judge,  whose  language  we  have  quoted,  to 
advise  the  jury,  in  the  dilemma  and  amidst  the  conflict 
of  professional  opinion  in  the  mazes  of  which  he  found 
himself  involved,  to  adhere  to  and  exercise  their  common 
sense. 

We  have  alluded  to  the  fact  that  the  practice  of  the 
courts  is  to  admit  a  class  of  witnesses  known  as  experts, 
and  that  the  physicians  of  asylums,  and  others  who 
have  relations  with  the  insane,  are  in  a  position  rendering 
them  liable  to  be  called  to  give  testimony  in  certain  cases. 
They  are  also  subjected  to  a  hne  of  examination,  which, 
while  established  by  the  usages  of  the  courts,  is  not  in 
harmony  with  the  course  of  inquiry  recognized  by  medical 
men  and  believed  by  them  to  be  the  method  best  calculated 
to  reach  a  correct  opinion.  They  are  not  always  willing 
witnesses.  Sometimes  they  attend  on  request,  and,  again 
they  are  present  in  obedience  to  the  commands  of  the 
court. 

Such  briefly  being  the  practice,  it  remains  to  consider 
some  of  the  results,  one  of  which  may  be  stated  to  be  a 
growing  distrust  of  the  value,  and,  we  may  say,  the 
honesty,  of  expert  testimony.  Want  of  confidence  exists 
not  only  towards  medical  experts,  but  towards  experts  in 
sciences  reputed  to  be  exact.  It  is  only  necessary  to 
point  to  some  recent  trials  to  assert  that  the  want  of 
confidence  and  distrust  are  confined  not  wholly  to  judges 
and  jurors,  but,  to  a  certain  extent,  prevade  the  com- 
munity. This  sentiment  has  its  origin  in  various  causes, 
among  which  may  be   mentioned : 

]st.    The  fact  that  medical  experts  are  usually  summoned  by  counsel, 


622  John  B.  Chapin. 


and  not  by  the  court,  in  the  interest  of  tlieir  side  or  clients,  and  their 
supposed  liability  to  have  a  bias  arise  in  the  progre-s  of  tlie  case — a 
pos?ible  risk  th  it  their  feeliui^s  and  sympathies  m  ly  l>ecoine  enlisted  in 
behalf  of  tlie  side  on  which  tiiey  are  called. 

2d.  The  arrangement  which  is  sometimes  made  for  the  payment  of 
money,  or  a  retaining  fee  to  medical  expeits  for  their  services,  by  counsel 
in  whose  interests  they  are  summoned,  the  amount  of  which  is  not  fixed 
by  law,  and  which  may  possibly  be  contingent  upon  the  issue  ot  tlie  case. 

3d.  The  form  of  submission  of  the  hypothetical  question,  which  is 
permitted  to  contain  a  portion,  and  not  the  whole,  of  wiiat  a  physician 
may  deem  essential  to  the  formation  of  a  satisfactory  opinion,  or  so  luucli 
as  may  be  necessary  to  bring  an  answer  favorable  to  the  Interests  of 
one  or  the  other  parties,  and, 

4th.  The  general  prejudice  which  exists  in  the  popular  mind  against 
the  interposition  of  the  plea  of  insanity  in  criminal  cases. 

There  may  be  a  difficulty  about  the  adoption  of  any 
new  rule  for  the  selection  of  witnesses  other  than  the 
one  in  force.  It  cannot  become  a  question  but  that  under 
the  present  practice  counsel  have  a  right  to  summon  such, 
and  so  many  witnesses  as  may  be  admissable,  or  that  a 
person  charged  with  crime  may  avail  himself  of  any  proper 
line  of  defence  at  any  stage  of  the  trial,  and  for  this 
purpose  call  witnesses.  There  is  no  doubt,  however,  that 
the  results  which  we  have  pointed  out,  are  in  great  part 
to  be  attributed  to  the  existing  practice.  As  a  profes- 
sion, we  have  the  right  to  protest,  and  to  ask  that  a 
mode  of  procedure  calculated  in  its  operation  to  bring 
discredit  upon  the  profession,  be  changed.  To  effect  a 
change,  legislation  must  be  invoked  to  alter  the  practice 
so  that  the  law  confer  upon  judges  alone  the  power  to 
supoena  experts  in  such  cases  where  their  opinions  would 
seem  to  be  desirable.  There  can  be  no  doubt  the  power 
thus  conferred  would  be  exercised  wisely  and  result  in 
elevating  the  standing  and  character  of  expert  testimony, 
and,  what  is  more  important,  restore  to  experts  that  inde- 
pendence of  judgment  and  respect  for  their  opinions  we 
do  not  believe  they  enjoy  under  the  present  system.  No 
suspicion  of  bias  could  then  properly  attach  to  them. 
They  would  then  assume  their  appropriate  and  originally- 
intended  relation  to  the  court,  that  of  amicus  curice. 

It  has  been  urged,  as  a  defence    of  the    present,    that 


Experts  and  Expert  Testimony.  523 

each  party  in  interest  is  entitled  to  have  as  full  an 
exposition  of  expert  knowledge  as  can  be  brought  forward 
to  serve  the  respective  interests — that,  in  other  words — 
medical  experts  should  be  permitted  to  say  as  much  as 
possible  in  behalf  of  the  cause  in  which  they  are  engaged, 
and  as  little  as  possible  as  may  serve  the  opposite  party. 
The  course  is  hardly  admissible,  as  it  ignores  the  true 
position  of  the  expert  and  converts  him  into  that  of 
a  quasi  counsel. 

The  physician,  by  actual  study  and  experience, 
acquires  knowledge  and  matured  judgment,  which  is 
peculiarly  his  own  property  and  capital,  the  independent 
use  and  enjoyment  of  which  ought  to  be  as  fully  assured 
to  him  as  if  the  avails  of  his  life-work  were  invested  in 
goods  and  land.  His  goods  and  land  cannot  be  taken 
from  him  without  his  consent  or  some  process  of  law,  and 
his  proprietary  right  to  his  professional  experience  ought 
to  be  as  sacredly  guarded  and  secured  to  him. 

If  the  knowledge  and  experience  of  the  expert  is  a 
necessity,  and  if  the  principles  laid  down  above  are 
correct,  he  should  unquestionably  be  paid  for  the  service 
he  renders.  Ought  the  compensation  to  be  the  subject  of  a 
private  bargain  between  the  expert  and  parties  interested 
in  his  testimony,  or  be  fixed  in  a  manner  authorized  and 
provided  by  law  ?  Certainly,  whatever  plan  will  elevate 
the  expert  witness  above  all  suspicion  of  bias,  and  conduce 
to  his  independence  would  seem  the  more  desirable  one 
— indeed,  the  best.  The  witness  appears  before  the  court 
and  jury  to  submit  his  opinion  on  a  hypothesis,  the  elements 
of  which  are  made  up  from  evidence  already  adduced. 
He  is  not  a  juror,  but  a  quasi  juror.  Extreme  caution  is 
taken  that  jurors  themselves  shall  have  no  pecuniary 
relations  with  parties  interested  in  the  result  of  the  trial, 
and  penalties  are  imposed  for  the  violation  of  a  rule 
intended  to  preserve  the  purity  of  the  jury-box.  It  would, 
therefore,  seem  to  be  the  proper  and  obvious  course  to 
authorize  and  direct  the  court  in  all  cases  where  experts 
appear,  to  fix    and    determine   their   compensation,    in    its 


524  John  B.  Chapin. 


discretion,  and,  if  deemed  necessary  to  go  further, 
prohibit,  by  positive  enactment,  the  reception  of  any  gift 
or  compensation  for  expert  services  directly  from  parties 
interested. 

The  composition  of  the  hypothetical  question,  and  the 
time  of  its  submission,  have  been  alluded  to  as  causes 
tending  to  bring  discredit  upon  expert  testimony.  They 
are  believed  to  exert  a  decided  influence  in  that  direction. 
The  expert  testimony  is  introduced  at  successive  stages 
of  a  trial,  and,  if  the  question  is  so  framed  as  to  include, 
generally,  what  has  been  produced  in  evidence  to  a 
certain  period  of  the  trial,  it  necessarily  embraces  but  a 
portion  of  the  whole  case.  The  consequence  is,  that, 
at  one  stage  of  the  trial,  a  hypothesis  will  admit 
of  one  answer  by  an  expert,  and,  at  a  subsequent 
stage,  another  hypothesis  framed  from  additional  evidence 
warrants  another,  and  exactly  opposite  answer.  There  is 
presented  an  apparent  conflict  of  professional  opinion 
between  "two  trained  bands  of  witnesses  in  battle  array 
against  each  other,"  with  the  possible  and  probable  result 
of  lowering,  in  the  estimation  of  the  court  and  jury,  the 
value  of  the  whole  expert  testimony.  We  know  of  no 
remedy  for  this  except  it  may  be  found  by  changing  the 
rule,  and  permitting  experts  to  express  an  opinion  on  a 
hypothetical  question  which  embraces,  in  the  judgment  of 
the  medical  expert,  all  the  points  bearing  on  the  question 
of  insanity,  where  this  is  involved.  A  medical  opinion 
formed  after  hearing  one  side  of  a  case,  is  deserving  of  no 
more  respect,  and  has  no  more  value,  than  a  verdict  of  a 
jury  formed  in  a  similar  manner,  or  the  opinion  of  a  high 
court  of  appeal,  the  judges  of  which  are,  in  a  sense^ 
experts  in  law,  rendered  after  argument  on  one  side  only. 

The  frequency  with  which  expert  testimony  has  been 
introduced  in  judicial  proceedings  leads  to  the  conclusion 
that  it  is  destined  in  the  future  to  bear  a  still  more 
important  part.  The  influence  which  it  will  exert  upon 
the  issues  of   trials,    and    the    respect    in    which  it  will  be 


Experts  and  Expert  Testimony.  525 

held,  will  depend  greatly  upon  the  independence  of  the 
witness,  and  his  absolute  freedom  from  circumstances 
calculated  to  produce  a  bias  or  even  the  suspicion  of  its 
existence.  Whatever  may  conduce  to  these  results,  "to 
the  elevation  of  the  standard  and  character  of  the  medical 
expert,"  it  should  be  our  highest  duty  to  promote.  Notwith- 
standing the  respect  we  may  have  for  the  usages  and 
established  traditions  of  the  law;  however  willingly  the 
medical  witness  may  feel  disposed  to  assume  grave  respon- 
sibilities which  are  imposed,  and  not  coveted,  we  still 
believe  the  right  of  respectful  protest  should  be  vigorously 
exercised  against  practices  which  tend  so  frequently  to 
depreciate  the  estimation  in  which  he  and  his  opinions 
ought  to  be  held. 


Art.  IX  —Impending  Periodic  Mania. 


By  C.   H.  Hughes,  M.  D. 

THE  rapid  increase  in  the  number  of  recognized  cases 
of  insanity  and  the  over-crowded  condition  of  our 
hospitals  for  the  insane,  devolves  upon  the  medical  pro- 
fession the  imperative  duty  of  early  discerning,  and  so 
far  as  may  be  practicable,  repressing  this  disorder  in  its 
initial  stages.  To  this  end  brief  records  of  these  cases 
and  their  management  from  authentic  sources,  ought  to 
be  welcomed  and  read  by  the  family  practitioner  who 
must  become,  to  no  inconsiderable  a  degree,  the  psycho- 
logical physician  of  the  near  future,  since  successful 
psychiatry  embraces  nearly  the  whole  domain  of  medicine. 
Case.— In  November,  1876,  S.  K.,  age  14  years,  was 
sent  to  me  by  Drs.  Gordon  and  McKenzie,  of  Chester, 
Ills.  The  father  of  the  youth  related  that,  at  from  four 
to  seven  years  of  age,  the  child  was  excessively  nervous. 
He  would  become  tremulous,  agitated  and  frightened  at 
night,  when  disturbed  by  any  one  touching  hnn,  even  by 
cold    air,    and    seemed    to    waken    at    the    tmie.     In    the 


526  C.  H.  Hughes. 


morning  he  would  remember  nothing,  but  would  not  be 
so  quiet  on  such  days,  as  after  nights  when  not  so  dis- 
turbed. These  were  night  terrors.  He  was  at  this  age 
different  from  the  rest  of  his  brothers  and  sisters — three 
in  all — being  more  excitable  and  passionate  at  times.  At 
seven  years  of  age  he  was  treated  by  Dr.  Frazier,  of  St. 
Louis,  for  worms,  and  improved,  but  did  not  get  entirely 
well.  Has  had  chills  and  fever  several  times  in  his  life. 
Lives  on  low  lands  on  the  Mississippi  river. 

He  has  now  periods  lasting  a  week  of  extreme  quiet, 
with  marked  and  obstinate  indisposition,  but  not 
viability  to  talk  or  move.  He  can  be  induced  by  author- 
ative  parental  command,  to  both  walk  and  talk.  Has 
remained  in  bed  all  day,  and  would  do  so  most  of  the 
time,  during  this  stage  of  inertia,  if  permitted  to.  He  is 
never  unconscious  at  these  times.  These  periods  are 
followed  by  and  alternated  with  a  marked  hyper-activity, 
in  which  he  is  excessively  voluble  and  active.  He  com- 
mits no  very  flagrant  impropriety  at  these  times  of  reaction 
either  of  speech  or  of  conduct,  but  is  a  great  tease  and 
mischief-maker. 

In  his  quiet  state  he  is  constipated,  sleepless  (for  sev- 
eral nights  in  succession)  and  refuses  food,  saying  he  does 
not  want  it,  but  eats  a  little  when  urged  to  do  so  by  his 
father.  His  answers  to  questions  at  this  time  are  gener- 
ally correct  and  suitable  to  his  age  and  the  subject,  but 
he  is  really  indifferent  as  to  whether  they  please  or 
displease,  and  responds  to  questions  only  when  persistently 
pressed  for  answer.  When  he  emerges  from  these  quiet 
and  passive  stages,  he  remembers  and  will  discuss  what 
he  has  seen  and  done  in  them.  He  displays  no  marked 
shame-facedness  nor  disposition  to  be  away  from  others 
observation,  on  the  contrary,  he  does  not  want  to  go  out 
of  the  house  alone  at  these  quiet  times,  and  an  indefina- 
ble, though  not  exaggerated  fear  comes  over  him — "phobo- 
phobia." 

At  our  first  days  interview  he  wanted  to  return  home 
because  he  felt  afraid  of  the  crowds  in  the  city — Anthro- 
phobia. 

His  memory  is  good  for  names  and  dates,  and  facts 
and  faces,  present  and  remote ;  and,  his  perceptive  powers 
are  active. 

He  has  not  been  to  the  city  for  seven  years,  yet  he 
manifests  but  little  interest  in  scenes  that  are  novel,  and 
ought  to  interest  him.     He  took    no    notice  of  a    passing 


Impending  Periodic  Mania.  527 

band,  though  naturally  fond  of  music,  explaining,  when 
asked  to  notice  it  that,  "it  bothered  his  head."  The  most 
attractive  places  of  the  city,  though  he  would  notice 
what  was  pointed  out  to  him,  elicited  but  little  evidence 
of  interest  on  his  part.  Surrounding  influences  cause  no 
evidence  either  of  psychical  pain  or  pleasure  ;  his  emotional 
nature  being  passive  and  abeyant. 

He  is  not  of  much  trouble  when  out  of  doors,  but  teases 
and  annoys  the  other  children  at  home  when  in  his  stage 
of  exaltation.  He  has  never  had  chorea,  epilepsy,  hydro- 
cephalus or  somnambulistic  displays,  but  is  dizzy  at  times, 
though  never  unconscious,  in  the  quiet  stage  of  his 
malady. 

At  a  subsequent  visit  to  the  city  he  took  more  interest 
in  an  aviary  of  rare  birds  than  in  anything  else. 

His  head  measures  twenty-two  inches  in  its  greatest  occi- 
pito-frontal  circumference  and  is  symmetrically  proportioned. 
On  first  examination  his  height  was  5  feet  4  inches. 
In  two  months  after  he  measured  5  feet  5  1-2  inches  in 
height.  His  muscular  development  is  good  for  a  boy  of 
his  age.  No  marked  variation  was  shown  in  the  cerebral 
temperature  during  the  quiet  stage,  and  we  had  no  oppor- 
tunity to  compare  the  head  heat  of  one  stage  with  that 
of  the  other,  since  the  treatment  has  caused  him  to  gradu- 
ally emerge  from  the  quiet  periods,  which  are  growing  less 
frequent  and  prolonged,  into  one  continuous  state  of 
natural  and  ordinary  and  not  exhuberant  and  hilarious, 
mental  activity.  The  ssthesiometer  revealed  no  abnor- 
mal peripheral  sensibility,  but  there  was  a  delayed  per- 
ception of  peripheral  nerve  impressions.  His  pulse  was 
seventy-five  in  the  quiet  stage,  his  tongue  coated  yellow 
and  white.     He  confesses  to  masterbation. 

His  brother  and  sisters  are  said  to  be  health}- ;  his 
father  has  had  asthma,  is  sallow,  somewhat  deaf,  and 
otherwise  impaired  in  phyisque  by  working  in  tobacco, 
and  living  in  a  malarious  country  ;  his  mother  is  described 
by  the  husband  as  healthy. 

The  boy's  maternal  grandfather  died  of  apoplexy,  at 
85  ;  his  grandmother,  at  68 — disease  not  ascertained.  His 
paternal  grandfather  died  of  epidemic  spinal  meningitis, 
aged  72;  his  p.  g.  m.,  at  55  years.  Among  the 
collateral  branches  of  the  mothers'  family  one  of  the 
ancestors  died,  at  65  years  of  cancer  of  liver;  one  of  same 
disease,  at  75  years;  one  of  erysipelas,  at  65;  one  of  old 
age,  at  96 ;  one  of  heart  disease,  at  62 ;  one  of  dropsy,  at 


528  C.  B.  Euahes. 


45  ;  one  of  asthma  and  general  debility,  at  65.  Malarial 
fever  carried  off  several  others.  The  ancestral  mortality 
on  the  fathers  side  could  not  be  further  ascertained. 

Tre.\tment. — At  the  beginning  we  kept  him  under 
observation  two  weeks,  and  gave  three  ten  grain  doses  of 
quinine  and  three  ten  drop  doses  of  Fowlers'  solution, 
daily  for  four  days  ;  an  active  mercurial  cathartic — Hyd. 
Chi.  mit.  gr.  x;  pulv.  Jalapae  gr.  x;  Ol.  Tiglii  gt.  tj. — 
daily  for  two  days.  Cephalic  electrization  five  minutes 
daily ;  forty  grains  Kali  brom.  at  bed  time ;  a  copious 
sulphuric  ether-lotion  daily  to  the  head,  to  make  a  pro- 
found impression. 

This  initial  treatment  was  supplemented  by  a  continu- 
ous one  of  thirty  grain  doses  of  the  Potassium-bromide 
forty  minims  of  fluid  extract  of  Ergot,  and  five  minims  liq. 
potass,  ars.  ^er  in  die,  assisted  by  a  brisk  cathartic 
and  three  ten-grain  doses  of  quinine  one  day  in  each 
week;  the  patient  to  visit  the  city  as  often  as  once 
in  six  weeks  and  remain  a  week  under  observation,  at 
which  times  we  always  gave  him  daily  cephalic  electriza- 
tions. After  the  accomplishment  of  bromism,  a  combin- 
tion  of  calcium  bromide  in  five-grain  doses,  the  syrup  of 
the  lacto-phosphate  of  calcium  in  half-drachm  doses, 
and  the  Fowler's  solution,  were  employed  three  times  daily. 
A  single  thirty-grain  dose  of  Chloral  hydrat,  largely 
diluted,  was  given  nightly  when  required  to  induce  sleep. 

Some  minute  details  of  treatment,  indicated  for  special 
intercurrent  symptoms,  need  no  be  here  mentioned. 

The  case,  though  not  entirely  well  has  progressed 
quite  favorably,  and  promises,  if  judiciously  managed,  to 
escape  the  graver  stage  of  an  evidently  impending  serious 
mental  malady.  The  boy's  change  of  manner  is  less 
noticeable,  the  excitable  stages  have  disappeared,  and  the 
periods  of  quiet  are  much  less  marked,  so  that  he  is  even 
somewhat  companionable  at  these  times,  and  more  resem- 
ble his  former  natural  self,  which  is  the  true  criterion  of 
improvement. 

The  causative  factors  in  this  case  appear  to  be  malaria 


Impendin,^  Periodic  Mania,  529 

and  masturbation,  and,  possibly,  a  too  rapid  growth.  The 
ancestral  element  cannot  be  satisfactorily  made  out. 

There  being  no  antipathies  to  those  about  him  neces- 
sitating a  change  in  his  surrounciings,  no  inclination  to 
violence  towards  himself  or  others,  or  resistence  to  medical 
treatment,  no  causative  influence  other  than  physical,  and 
the  case  seeming  as  yet  to  require  only  medical  treatment, 
we  shall  continue  our  efforts  towards  the  boy's  restoration 
at  home,  advising  the  continuance  of  periodical  visits  to 
the  city,  and  if  he  is  not  speedily  cured  we  shall,  in 
addition,  recommend  a  change  of  residence  to  a  more 
salubrious  locality. 

[Other  cases  intended  to  have  been  here  reported, 
are  deferred  to  a  subsequent  issue  for  want  of  space.] 


Art.      X. Mysophobia. Melancholia 

with   Filth  Dread.  —  Mania  Contam- 
inationis. 


By  Ira  Russell,  M.  D.,  Wichendon,  Mass. 

TN  November,  1877,  the  late  lamented  Dr.  John  E. 
-*-  Tyler,  of  Boston,  sent  me  a  patient  for  treatment  in 
my  family  home.  From  Dr.  Tyler,  and  the  friend  who 
came  with  the  patient,  I  learned  the  following  particulars 
of  his  life,  and  the  manner  in  which  his  disease  com- 
menced. The  patient  was  a  large  portly  gentleman, 
unmarried,  aged  forty-seven,  of  fine  personal  appearance 
and  cultivated  manners,  a  graduate  of  Harvard  College 
and  of  the  Harvard  Medical  School.  Being  a  man  of 
wealth,  he  never  engaged  actively  in  the  practice  of  his 
profession.  He  visited  medical  schools  and  hospitals 
abroad,  and  traveled  extensively  in  Europe,  Egypt  and 
Palestine.  He  was  of  a  cheerful,  happy  disposition, 
upright    and  conscientious;    his    ready    wit,    learning,    and 


530  Ira  Russell. 


intelligent  conversation  rendering  him  a  great  favorite  in 
the  cultivated  circles  in  which  he  moved.  I  lis  father,  a 
well-to-do  merchant ;  a  brother,  an  eminent  law}-er ;  and 
a  sister  committed  suicide,  A  few  months  prior  to  his 
coming  under  my  care,  a  brother  had  died  suddenly  in 
his  arms,  which  made  a  profound  impression  upon  his 
nervous  system.  He,  in  consequence,  became  melan- 
cholic, slept  badly,  was  noted  for  indecision,  imagined 
his  hands  were  dirty,  and  began  constantly  washing 
them.  When  he  came  under  my  care,  although  very 
courteous  and  gentlemanly  in  his  manners,  he  was 
much  depressed,  and  complained  of  a  bad  feeling  in 
his  head.  He  was  fearful  that  everything  he  touched 
would  contaminate  and  soil  his  hands ;  the  chair,  the 
door-knob,  in  fact,  everything  that  came  in  his  way  he 
carefully  avoided  touching  with  his  hands.  When 
reasoned  with  in  regard  to  his  morbid  notions,  he 
would  admit  their  unreality,  but  could  not  resist  the 
impulse  to  wash  his  hands  whenever  they  had  come 
in  contact  with  anything.  I  provided  him  with  an 
attendant,  a  medical  student,  who  is  now  an  assistant 
physician  in  the  N.  H.  Insane  Asylum,  who  was  con- 
stantly with  him  and  carefully  watched  and  noted  his 
symptoms.  He  had  a  routine  which  he  regularly 
observed  and  for  several  weeks  did  not  vary  from  it. 
Usually  he  would  begin  his  preparations  to  retire 
about  ten  o'clock  in  the  evening,  and  it  would  be  two 
o'clock  in  the  morning  before  he  would  be  fairly  in 
bed.  Before  he  would  begin  to  undress,  his  attendant 
must  fill  the  wash  bowl  with  water,  as  he  dared 
not  touch  the  stop-cock  with  his  hands ;  then  the  water 
must  be  let  off,  the  bowl  washed  and  filled  again  for 
three  times,  then  he  would  wash  his  hands  three  times,  the 
bowl  being  filled  anew  each  time.  Then  after  the  removal 
of  each  garment  he  must  wash,  finall)'  he  would  wash 
his  face,  rinse  his  mouth,  each,  three  times,  say  his 
prayers  and  retire,  consuming  three  or  four  hours,  and 
using  twenty    or  more  towels.       In    the  morning  he   went 


iN'ature  and  Treatment  of  Hysteria.  531 

through  a  similar  process,  taking  two  or  three  hours 
to  dress.  Before  and  after  each  meal  he  would  wash 
three  times.  During  the  day  he  walked  or  rode  with 
his  attendant,  played  billiards,  bowled,  and  frequently 
went  to  dancing  parties  in  the  evening.  At  such 
places  no  one  would  suspect  that  anything  was  the 
matter  with  him,  Ke  was  fond  of  music  and  enjoyed 
playing  on  the  flute,  while  some  one  played  on  the 
piano.     On    Sunday   he  went  to    church. 

After  several  months  he  began  to  improve,  and  the 
following  summer  was  nearly  well.  At  this  time,  his 
friends  insisted  on  taking  him  away,  in  opposition  to 
my  judgment,  and  the  opinion  of  Drs.  Hodges  and 
Walker,  of  Boston,  who  saw  him  in  consultation  with 
me,  as  they  feared  a  return  to  his  home  would  bring 
on  a  relapse.  Still  his  friends  insisted  and  took  him 
away.  In  two  or  three  weeks  after  his  return  home, 
all  his  morbid  fancies  returned  very  much  intensified, 
and  with  so  much  mental  excitement  that  his  friends 
became  alarmed  and  put  him  in  the  insane  asylum. 

Not  meeting  with  the  improvement  his  friends  expected, 
I  was  importuned  to  take  him  again,  which  I  did, 
and  found  him  much  worse  than  when  he  first  came 
to  me.  He  was  unwilling  to  admit  that  the  ideas  of 
filth  were  groundless.  But,  after  a  few  weeks  of  treat- 
ment, he  began  to  improve,  and  in  three  months  was 
so  much  improved  that  he  went  to  New  York  and 
Washington  with  his  attendant,  spending  several  months. 
But,  on  his  return  home,  he  immediately  had  a  relapse 
and  came  under  my  care,  and  staid  with  me  until 
he  fully  recovered.  Without  stopping  at  his  home,  he 
sailed  for  Europe,  and  thus  far  has  had  no  return  of 
his  disease. 

Treatment. — When  he  first  came  under  my  care,  and 
after  each  relapse,  he  was  very  much  troubled  with 
insomnia,  requiring  large  doses  of  hipnotics  to  procure 
sleep.  For  that  purpose  I  gave  .him  monobromide  of 
camphor,    bromide    potass.,    chloral   hydrate,    mecona   feet 


632  Ira  Russell. 

morphia,  belladonna,  hyoscyamus,  each  alone  or  variously- 
combined.  I  gave  him  also  Esquirol's  Red  Mixture — 
strychnine,  quinine,  and  syr.  of  hypophosphites  of  iron, 
lime  and  soda.  At  first  it  was  a  question  with  me 
how  much  I  should  restrain,  or  whether  I  should 
permit    him    to    gratify    his    morbid    desire    to    wash. 

After  mature  deliberation  I  decided  to  grant  him 
perfect  freedom  to  wash  as  often  and  to  use  as  many 
towels  as  he  chose.  At  the  same  time  I  endeavored  to 
show  him  the  absurdity  of  his  whims,  and  appealed  to 
him  as  an  educated  physician  to  use  his  own  reason 
and  judgment  and  to  consider  how  he  would  regard 
similar  symptoms  in  another  person.  Finally,  at  first, 
and  after  each  relapse,  I  persuaded  him  to  make  an  effort 
to  lessen  the  number  of  washes  each  day,  and  as  he 
did  so  he  gradually  gained  the  power  of  self-control, 
and  was   much  pleased  with   the    results    of  his   efforts. 

While  in  the  asylum  he  was  restricted  to  a  certain 
number  of  washes  and  towels  a  day,  but  he  told  me 
that  the  restriction  only  aggravated  his  morbid  desire 
to   wash   and    made   him   almost   frantic. 

From  the  first,  I  regarded  the  case  as  a  pecuhar 
form    of  melancholy. 

Like  other  forms  of  that  disease,  the  mind  had 
fastened  upon  one  thing  or  subject,  while  rational  upon 
all  others.  Thus  it  is  with  melancholia,  some  fancy 
that  they  have  committed  the  unpardonable  sin;  some 
that  they  are  poor,  and  refuse  to  eat ;  some  that  they 
have  committed  a  criminal  act;  and  yet,  on  a  great 
variety    of  subjects,    will   reason    and   act   rationally. 

The  above  case,  to  my  mind,  teaches  this  lesson: 
That  an  insane  person  may  be  cured  and  remain  cured, 
provided  he  is  not  subjected  to  the  causes  or  conditions 
that  produced  the  attack,  but  may  have  a  relapse  or 
recurrence  of  the  disease  when  exposed  to  the  causes 
that  produced  the  first  attack.  Many  insane  patients 
are  sent  to  an  insane  asylum,  and,  to  all  appearances, 
are   cured.      They    are    discharged  and   subjected   to  the 


Mysophobia— Melancholia  with  Filth  Dread.  533 

same  moral  and  physical  causes  that  first  produced  the 
disease,  and  a  relapse  follows,  while,  under  other  con- 
ditions and  surroundings  there  would  be  no  return  of 
the    disease. 

The  symptoms  of  physical  defilement,  associated 
with  melancholia  is  a  less  frequent  occurrence  than  that 
of  moral  defilement.  Hammond  has  applied  the  term 
mysophobia  to  a  symptomatic  expression  of  disease  not 
necessarily  associated  with  insanity.  In  a  paper  read 
before  the  New  York  Neurological  Society,  in  April,  1879, 
and  published  in  the  "Neurological  Contributions,"  of 
that  year,  he  reported  two  cases,  and  referred  to  eight 
others  that  had  come  under  his  observation. 


Art.  XI— The  Nature  and  Treatment  of 
Hysteria. 


By  Dr.  Edward  C.  Manx, 

SUPERINTENDENT     OF     SUNNYSIDE     MEDICAL      RETREAT      FOR      MENTAL      AND 

NERVOUS   DISEASES,    FORT   WASHINGTON,    NEW   YORK   CITY. 

MEMBER   OF   N.    Y.    NEUROLOGICAL   SOCIETY,    N.    Y. 

MEDICO-LEGAL  SOCIETY,    ETC. 

ANYTHING  that  weakens  a  woman  generally  may —  by 
altering  the  relation  of  the  several  nervous  functions — 
bring  about  the  condition  of  nervous  disturbance,  known  as 
hysteria.  Our  women  are  the  more  readily  becoming  hyster- 
ical by  reason  of  the  absence  of  a  physique  and  stability 
of  nerve  tissue  capable  of  meeting  successfully  the  demands 
that  our  climate  and  civilization  make  upon  them.  The 
vital  temperament  is  deficient  in  the  American  woman 
and  the  nervous  temperament  is  too  predominant  and  too 
active  ;  so  much  so  as  to  require  an  undue  proportion  of 
the  nutrition  of  the  body.  If  we  are  to  avoid  an  aggra- 
vated type  of  hysteria  in  the  girls  of  the  rising  generation, 
we  must,  by  great  and  continual  attention  to  the  subjects 
of  diet,  fresh  air,  sleep  and  tranquility  of  life  of  the  young 


534  Edward  C.  Mann. 

of  the  present  generation,  endeavor  to  produce    a    better 
type  of  physical  development  and  mental  stamina.     What 
is  especially    needed    is    a    greater  harmony  between   the 
physical  and  mental  organization.     We  need,    among    our 
American    women,    a    better    developed    physical    system, 
more  evenly  balanced    in    all  its  parts    or    organs,    with  a 
greater  harmony  in  the  performance  of  all  their  functions. 
The  principal  characteristics  of  hysteria    consist    in  an 
exaggeration  of  involuntary  motility  and    a    diminution  of 
the  power  of  the  will.     The  voluntary  movements  are  not 
properly     executed,      while    the     reflex,    sensational     and 
emotional  movements  are  abnormally  active.      The  will   is 
determined  by  the  ideas,    feelings   and  fancies.      There  is 
a     malnutrition      of    the     nervous     system,      so     distinct, 
that     the     higher    functions     are     impaired.       The    lower 
functions     exhibit     increased    activity,    while    the     higher 
functions  exhibit  diminished  power.     Hysteria  is  pre-emin- 
ently   a    disease    of  females,  and  is    induced    by    want    of 
occupation,  real  or  fancied  morbid  states  of  the  reproduc- 
tive organs,  conflicting    emotions,    disappointed  affections, 
late  hours  and  unhealthy  and    perverted    manner    of   life. 
It  is  sometimes  met  with  in    males    as  the  result  of  over- 
mental     work,     worry     and     excitement,     or      dissipation. 
Hysteria  appearing  in  women  generally  comes  on,  for  the 
first  time,  between   the  age  of  commencing  puberty    and 
twenty-five   years.     It   may,    however,    come    on    at    any 
time    during    the    life    of   the    individual.       Of    the    cases 
admitted    here    for     treatment,    I    have    traced    emotional 
disturbance  as  the  principal    cause    in    the    production    of 
the  hysteria,  and  the  majority  of  the  cases  admitted  here 
have  been   young    unmarried    women.      I  have  found  the 
ovaries  involved  more  often    also    than    the    uterus.      The 
evidence  of  this  may  be  found  in  the   fact  that    they    are 
painful  upon  pressure.     The  mental  condition  of  a  woman 
affected  with  hysteria  is  somewhat  peculiar.     The  patient, 
when    the    hysterical    feelings    come    upon    her,    does    not 
feel  disposed  to  make  the  slightest    effort  to    resist   them, 
and  yields  U>  her  emotions,  whatever  they    may  be.     She 


Kature  and  Treatment  of  Hysteria.  535 

will  laugh  or  cry  on  the  slightest  provocation,  and  is  very 
nervous  and  excitable.  She  cares  nothing  for  her  duties 
and  seemingly  takes  pleasure  in  exaggerating  all  her 
slight  discomforts  and  annoyances,  and  by  her  suspicious 
exacting  and  unreasonable  behavior  makes  life  generally 
uncomfortable  to  those  about  her.  She  indignantly  resents 
all  attempts  and  efforts  for  her  comfort  and  cure,  and 
discards  all  advice  from  her  best  friends,  but  will  eagerly 
listen  to  the  counsel  of  the  many  friends  who  come  in  to  pity, 
sympathize  and  condole  with  her.  She  will  say  that  for  her 
to  do  certain  things  is  absolutely  impossible,  but  under  the 
stimulus  of  strong  desires  or  wishes,  will,  if  unobserved, 
do  precisely  the  things  declared  to  be  impossible.  I  have 
repeatedly  known  hysterical  women  to  undergo  severe 
fatigue  and  even  privation  under  the  influence  of  a  dominating 
idea,  that  a  healthy  person  would  find  most  arduous  and 
difficult  of  accomplishment,  and,  upon  my  next  visit,  the 
same  patient  would  declare  that  the  slightest  effort  to 
move  her  limbs  was  excruciatingly  painful.  I  have  also 
had  patients  declare  that  they  were  suffering  the  most 
frightful  neuralgia,  and  exactly  simulate  a  neuralgic  attack 
of  great  severity,  although  the  placid  countenance  and 
expression  of  the  mouth  was  a  convincing  proof  to  the 
contrary.  As  a  rule,  I  have  observed  no  marked  distur- 
bance of  the  menstrual  functions,  although  my  patients 
generally  give  a  very  undue  prominence  to  them  when 
stating  their  cases  to  me.  I  have  also  failed  to  see  that 
hysteria  in  women  could  be  traced  to  sexual  excesses. 

One  of  the  earliest  symptoms  of  hysteria  is  a  condi- 
tion of  hyperaesthesia  or  exalted  sensibility.  All  the 
senses  seem  to  be  preternaturally  acute — hearing,  sight,  smell 
and  taste.  Patients  also  complain  of  pain,  which  they 
locate  on  the  top  of  the  head,  in  the  mammary  region, 
the  hypogastric  or  sacral  region,  or  in  the  various  joints. 
It  is  a  noticeable  fact  that,  although  a  slight  touch  on  the 
joints  is  much  complained  of,  that  pretty,  active,  passive 
motion  will  be  borne  without  discomfort.  Hysterical 
anaesthesia  I  have  also  found  existing  in  the  some  instances. 


536  Edward  C.  Mann. 


As  regards  the  muscular  system,  we  may  find  an  increase 
of  involuntary  muscular  activity,  and  a  diminution  of  the 
voluntary  movements.  We  find  at  times,  in  hospital 
patients,  partial  paralysis  of  the  various  limbs.  Thus,  the 
leg  or  the  arm  will  appear  to  be  paralyzed,  or  the  patient 
will  feign  paraplegia,  and  she  generally  watches  very 
carefully  the  effect  of  her  performance  upon  the  bystanders. 
Such  a  patient  will  tumble  down  and  recover  herself  as  a 
paraplegic  patient  could  not  do.  The  nutrition  of  the 
affected  limbs  does  not  become  impaired,  as  it  does  in 
actual  paralysis,  and,  as  a  rule,  there  is  unimpaired  elec- 
tric sensiblity  and  contractility.  We  may  find  indefinite 
disturbances  in  all  parts  of  the  body.  The  general  health 
may  be  good,  and  the  body  very  well  nourished,  or  there 
may  be  a  condition  of  ill  health  and  general  delicacy. 
The  disturbances  of  digestion  are  generally  traceable  to 
a  foolish  diet  and  excess  of  stimulants.  This  excess  of 
stimulants  not  unfrequently,  in  cases  coming  under  my  care, 
has  gradually  led  to  dipsomania,  which  exists  at  the  time 
of  admission,  and  requires  to  be  combated  and  cured. 
The  indulgence  in  opium,  especially  in  the  form  of 
morphia,  I  have  also  seen  several  times  complicating 
the  state  of  hysteria.  In  the  hysterical  convulsions  which 
occur  there  is  no  sudden  loss  of  consciousness.  The 
patient  will  inform  her  nurse  or  whoever  is  near  that  she 
"is  going  to  have  a  fit,"  and  a  general  theatrical  effect 
follows.  There  is  no  distortion  of  the  features  as 
in  epilepsy,  neither  is  there  dilatation  of  the  pupil. 
The  eyelids  quiver,  and  the  patient  sees  and  often 
watches  the  effect  of  her  "fit"  upon  her  friends  or  attend- 
ant. There  may  be  foaming,  but  the  tongue  is  not  bitten 
unless  purposely  to  deceive  her  physician,  as  I  knew  one 
patient  to  do.  The  patient  often  utters  a  loud  scream  as 
she  falls,  but  she  is  very  careful  to  fall  so  as  not  to  hurt 
herself.  The  presence  of  the  hysterical  aura,  commencing 
often  in  the  iliac  region,  spreading  to  the  epigastrium, 
causing  nausea  or  vomiting  to  the  chest,  causing  palpita- 
tion of  the  heart ;  to  the  throat,  giving  rise  to  the  globus 


Katiire  and  Treatment  of  Hysteria,  537 

hystericus,  and  finally  to  the  head,  where  it  induces  noises 
in  the  head  ;  dimness  of  vision  and  clavus,  generally  pre- 
cede the  hysterical  convulsion  and  serve  to  distinguish 
between  it  and  the  epileptic  convulsion.  The  larynx  and 
air  passages  may  be  involved  to  the  extent  of  aphonia 
and  dyspnoea.  Very  often  there  is  a  loud,  barking  cough, 
which  has  a  very  characteristic  sound.  The  urinary 
organs  may  be  affected,  and  we  may  find  either  retention 
of  urine,  or  a  large  secretion  of  pale,  limpid  urine.  As 
regards  the  reproductive  system  I  have  found,  as  I  have 
remarked,  that  many  hysterical  women  are  quite  free  from 
menstrual  disorders.  We  may,  however,  find  amenorrhoea, 
dysmenorrhcea,  menorrhagia  and  other  menstrual  troubles. 
Treatment  : — The  treatment  of  aggravated  hysteria  is 
almost  impossible  in  the  home  of  the  patient,  and  in  the 
midst  of  the  usual  surroundings,  as  the  moral  and  bodily 
constitution  rapidly  deteriorates  under  the  influence  of 
the  pity,  sympathy  and  over-attention  which  hysterical 
patients  live  for,  and  which  they  are  constantly  laying 
plans  to  attract  from  their  friends.  There  is  no  radical 
cure  for  hysteria,  but  judicious  firmness  of  management, 
combined  with  kindness  and  friendliness  of  manner  on  the 
part  of  the  physician.  This  is  much  more  easily  accom- 
plished by  a  change  of  scene  and  surroundings.  In 
addition  to  improving  the  general  health  and  bringing  up 
the  general  nervous  tone,  regulating  the  menstrual  func- 
tion, relieving  anaemia  and  constipation  and  local  symptoms 
of  hysteria,  the  patient  should  be  made  to  take  an 
interest  and  pleasure  in  some  occupation,  intellectual 
recitation  or  study.  We  must  endeavor  to  remove  the 
mental  or  emotional  cause  of  the  disease,  and  particular  atten- 
tion must  be  paid  to  diet,  rest,  exercise  and  recreation.  The 
class  of  patients  who  are  sent  here  by  their  friends  are 
women,  who,  from  their  social  position  and  surroundings, 
have  really  no  object  in  life  to  occupy  them  but  to  amuse 
themselves.  They  have,  as  a  rule,  been  spoiled  and 
petted  since  childhood,  and  as  their  nervous  system  is 
developed  far  in  excess  of  their  physique,  they  become, 
as  they  grow  up,  capricious  and  hysterical.  Their  imag- 
inary ailments  are  undoubtedly  the  cause  of  much  distress 
to  them,  for  to  a  person  with  highly  strung  nerves  a 
slight  pain  seems  a  severe  pain,  and  discomfort  is  magni- 
fied into  pain.      One  of  my  last  cases,  who  had  an  income 


638  Edward  C.  Mann. 

of  six  thousand  dollars  a  year  and  was  unmarried, 
would  have  been,  as  a  physician  who  was  also  here  as  a 
patient  remarked  :  "a  splendid  woman  if  she  was  married 
and  had  to  live  on  twenty-five  hundred  dollars  a  year." 
It  is  certainly  true,  that  nothing  to  do  and  nothing  to 
profitably  occupy  the  mind  with,  are  strong  provocations 
of  hj'steria  in  a  person  predisposed  to  it.  Occ^asionally, 
hysteria  assumes  a  grave  form  and  becomes  hysterical 
insanity.  Such  a  case  in  the  person  of  a  young  lady  24 
years  of  age  was  referred  here  by  Dr.  Wm.  A.  Hammond, 
about  two  years  ago. 

Upon  her  admission  she  was  acutely  maniacal,  with  no 
appreciation  of  her  condition  or  surroundings.  She  was  a 
girl  who  had  a  highly  sensitive  nervous  organization,  and 
who,  being  a  Catholic,  had  attended  all  the  Lenten 
services,  and,  after  attending  the  general  confession,  had 
arrived  at  a  state  of  emotional  frenzy  which  passed  into 
hysterical  insanity.  She  was  entirely  incoherent,  with 
delusions  relating  to  religious  subjects,  and  also  relating 
to  persons.  The  physical  condition  was  very  fair.  She 
was  given  a  warm  bath,  followed  by  one  fluid  drachm  of 
Fothergill's  hydro-bromide  acid.  This  was  followed  in 
two  hours  by  a  four-grain  capsule  of  mono-bromide  of 
camphor,  and  the  patient  slept  well.  For  a  week  after 
admission,  rest  in  a  darkened  room,  with  mono-bronide  of 
camphor  /.  /.  d.,  and  Fothergill's  sol.,  following  the  use  of 
the  prolonged  warm  bath,  was  employed.  At  the  end  of 
that  time,  the  delusion  had  disappeared  ;  the  mania  had 
subsided  and  the  patient  made  her  appearance  in  the 
family  circle.  Electricity,  in  the  form  of  central  galvan- 
ization, was  applied  daily.  Daily  exercise  was  insisted 
upon,  and  due  remedial  treatment  continued,  and  in  a 
short  time  a  perfect  recovery  took  place.  The  lady  has 
since  married  and  has  enjoyed  perfect  health  up  to  the 
present  time. 

Hysterical  patients  require  to  be  watched,  attended  to 
and  unconsciously  guided  away  from  self  and  into  new 
grooves  of  thought,  feeling  and  action,  at  once  interesting 
to  the  mind,  while  not  fatiguing  to  the  body,  and  this  can 


Mature  and  Treatment  of  Hysteria.  539 

be  done,  not  by  harshness  or  dicipHne,  but  by  kindness, 
firmness  and  wise  regard  to  the  feelings  of  the  patient. 
We  must  supply  some  purpose  or  motive  in  life,  which 
can  easily  be  done  by  studying  patients'  characters,  thus 
stimulating  them  to  make  co-operative  endeavors  for  their 
own  care,  unknown  to  themselves.  All  this  requires 
strong  will  and  great  patience  on  the  part  of  the  physi- 
cian, but  success  is  certain  if  such  treatment  be  persevered 
in,  and  is  not  interfered  with  by  over  anxious  friends  or 
relatives.  With  regard  to  the  medicinal  treatment  to  be 
pursued,  I  have  used  with  benefit,  mono-bromide  of 
camphor,  two-grain  pill  /.  i.  d.,  Fothergill's  solution  of 
hydrobromic  acid,  the  chloro-phosphite  of  arsenic  (Routh's 
formula),  the  bromide  of  hthium  and  the  constant  current 
of  electricity,  which  la-t,  if  properly  applied,  is  of  the 
greatest  value. 

Niemeyer  says  : 

"Tliereis  no  doubt  but  that  the  moi-bid  excitement  of  the  motor  nerves 
wiiicli  gives  rise  to  liysterlcal  spasms,  proceeds  from  the  spinal  marrow 
and  medulla  oblongata." 

And  this  morbid  excitement  is,  in  my  experience,  very 
markedly  relieved  by  the  employment  of  the  constant 
current  in  the  manner  I  have  spoken  of.  It  is  certainly 
one  of  the  most  effectual  nervines,  and  affords  radical  re- 
lief in  most  cases,  instead  of  the  merely  palative  effects 
obtained  from  many  drugs.  The  psychical  treatment  is, 
however,  of  primary  importance.  By  the  use  of  the 
galvanic  or  constant  current  of  electricity,  we  modify  the 
circulation  and  nutrition  of  the  whole  body,  and  from  my 
experience  with  it  I  am  more  and  more  satisfied,  as  Nie- 
meyer says  :  that 

'"In  the  constant  current  we  have  a  means,  more  powerful  than  any  other, 
of  modifying  the  nutritive  conditions  of  parts  that  are  deeply  situated." 

When  hysteria  is  caused  by  uterine  disease  or  by 
anomalies  of  menstruation,  the  original  cause  must,  of 
course,  be  removed,  if  possible,  by  appropriate  treatment. 
In  several  cases  I  have  discovered  the  existence  of  dys- 
menorrhea, which  I  have  entirely  cured    by  the    Fl.    ext. 


540  Edward  C.  Mann. 

of  Viburnum  prunifolium  in  one  fluid  drachm     doses.     This, 
in  some  cases,  is  a  very  valuable  remedy. 

In  cases  where  the  hysterical  state  seems  to  depend 
upon  chronic  uterine  disease  in  married  women,  there  is 
a  condition  of  malnutrition  and  passive  congestion,  and, 
to  improve  the  uterine  tissues  and  to  excite  reflex  action, 
so  that  the  nerves  accompanying  the  distended  vessels 
will  cause  contraction,  and  thus  restore  the  natural  tonicity, 
I  direct  the  prolonged  application,  by  the  nurse,  of  hot 
water  vaginal  injections,  with  local  application  of  electircity 
as  an  adjuvant.  By  this  means  we  are  generally  success- 
ful in  combating  the  state  of  chronic  inflammation  that 
exists  in  such   cases. 


Art.  XII. — Shorter  Clinical  Records. 


Arsenic  Hypodermically  in  Traumatic  Tetanus. 
T^R.  JNO.  T.  HODGEN,  of  this  city,  contributes  the 
^-^  following  notes  of  a  case  of  comminuted  fracture  of  the 
femur  (upper  third),  and  of  the  os  calcis,  with  intercur- 
rent tetanus,  successfully  treated  by  hypodermic  injections 
of  arsenic ;  the  patient  subsequently  dying  of  septicaemia : 

Charles  Dauber,  age  34  years,  robust  and  healthy, 
fell,  Sept.  14th,  from  a  ladder  forty  feet,  and  alighted  on 
a  projecting  point  of  stone,  cutting  the  skin  and  dense 
tissue  of  the  foot,  and  producing  the  fractures  named  in 
the  caption.  Dr.  Hodgen  saw  the  patient  just  recovering 
from  shock,  at  4  a.  m. — Dr.  Shore  in  attendance — 
enlarged  the  wound  in  the  sole,  removed  such  fragments 
as  could  be  easily  detached,  made  extension  of  the  thigh, 
and  employed  such  other  essential  measures  including 
carbolic  acid  dressings,  arrangement  for  proper  drainage, 
etc.,  as  would  suggest  themselves  to  a  surgeon  of  Dr. 
Hodgcn's  well-known  ability,  but  needless  hero  to  mention, 
and  which  we  therefore  omit. 

On    the    29th    of  September,  trismus  and  opisthotonos 


Shorter  CUnical  Records.  641 

appeared.  Dr.  Shore  gave  the  patient  some  morphine 
during  the  night.  On  the  30th,  Dr.  Hodgen,  for  the  reHef 
of  the  persistent  tetanic  rigidity,  injected  at  12:30  p.  m. 
ten  drops  of  Fowler's  solution  of  arsenic,  ordering  also 
30  grains  of  chloral  every  hour  if  patient  was  not  asleep. 
At  4  p.  M.  the  patient  was  much  more  comfortable 
though  still  rigid.     He  had  taken   120  grains  of  chloral. 

Ten  drops  more  of  the  arsenic  solution  were  then  given 
and  the  chloral  discontinued.  At  8  p.  m.  another  ten- 
drop  dose  of  the  arsenic  was  given  hypodermically.  At  12 
and  8  a.  m.,  Dr.  Shore  repeated  the  arsenic,  and  at 
12  M.  the  patient  was  quite  free  from  rigidity,  rational 
and  talkative.  At  4  p.  m.  another  hypodermic  injection 
was  given.  At  8  p.  m.  another  tetanic  spasm  occurred, 
when  Dr.  Shore  repeated  the  hypodermic  dose.  At  10 
A.  M.,  Oct.  2d,  the  arsenic  was  again  repeated  and  the 
patient  was  free  from  rigidity.  Vomiting  took  place 
at  4  p.  M.      Arsenic  was  given  at   10  p.  m. 

Aug.  3d,  8  A.  M. — Patient  had  a  good  night,  takes 
food   freely  and  has  no  rigidity. 

To-day,  however,  the  thigh  is  distended  with  fluid  and 
tympanitic  on  percussion,  and  the  patient  is  restless  and 
inclined  to  delirium.  On  the  4th  of  Oct.  decided  symptoms 
of  septicaemia  set  in,  and  the  patient  died  Oct.  5th, 
at  2  p.   M. 

Remarking  on  this  case,  Dr.  Hodgen  says  :  "The  effect 
of  arsenic  was  most  marked,  the  symptoms  being  decidedly 
improved  after  the  second  dose.  For  many  years  I  have 
used  arsenic  in  treatment  of  tetanus,  but  never  hypoder- 
mically. Dr.  Barnes,  of  this  city,  first  called  my  atten- 
tion to  it  as  a  valuable  remedy  in  this  affection.  Its 
hypodermic  use  was  first    practiced  and  recommended  by 

Dr.  ,  of  Boston." 

A  Case  of  Cerebral  Traumatism.— 5y  Dr.  DanH  Kuhn. 

Mrs.  F.  received,  April  14th,  1880,  at  four  o'clock  in  the 
evening,  a  shot  from  a  small  pistol.  When  I  saw  her,  twenty 
minutes  after  the  accident,  she  was  conscious,  but  vomiting. 
The  ball  entered  just  above  and  in  front  of  the  right  ear,  at 
the  termination  of  the  helix,  and  passed  downward,  back- 
ward and  inward.  The  probe  followed  the  track  until 
opposite  the  auditory  canal,  having  entered  the  bone,  blood 
flowed  from  the  ear,  showing  that  this  canal  had  been 
injured,   and  immediately  after  probing,  the  patient  had    a 


542  Hodgen—Kiihn—Mudd. 


severe  convulsion,  in  wliich  she  turned  to  the  left  side  ;  the 
face  was  drawn  to  the  left  side.  The  convulsion  lasted  about 
ten  minutes,  after  which  the  patient  went  into  a  deep 
stupor  with  sturterous  breathing ;  the  stupor  continued  one 
hour  at  this  time.  She  had  another  convulsion  similar  to 
the  first,  with  turning  to  the  left  side,  and  followed  also 
by  stupor.  About  the  time  of  her  recovery  from  this 
stupor,  three  hours  after  the  accident,  Dr.  Hodgen  saw 
her,  she  was  then  restless — sick  at  stomach — and  inclined 
the  head  to  left  side.  During  the  night  heavily  complained, 
when  awake,  of  dizziness  in  the  head,  and  asked  frequently 
that  something  should  be  given  her  to  relieve  it.  The 
dizziness  was  much  intensified  when  she  turned  to  the 
left  side,  or  allowed  the  head  to  rest  on  the  left  side; 
had  darting  pains  through  the  right  ear.  She  remained 
very  much  in  the  above  condition,  except  the  vomiting 
and  convulsions,  until  the  i6th,  when  she  complained  of 
a  constant  hammering  up-stairs ;  when  told  that  there 
was  no  hammering  up  stairs,  she  referred  it  to  her  head  ; 
was  much  disturbed  by  it,  and  asked  her  attendants  to 
listen  that  they  might  hear  it  also.  Lightness  of  head 
and  nausea  continued.     Has  had  no  more  convulsions. 

April  i6. — The  nausea  is  less,  the  dizziness  less,  but  is 
increased  when  she  turns  to  the  left  side,  and  she  cannot 
get  up  because  of  the  dizziness. 

April  20th. — The  noise  in  the  head  has  ceased  ;  the 
hearing  is  almost  perfect.  When  she  walks  there  is  a 
constant  tendency  to  turn  to  the  left ;  the  gait  is  very 
unsteady. 

April  23d. — Patient  is  improving  rapidly  in  every 
respect. 

On  the  loth  of  May,  I  called  to  inquire  about  her, 
and  found  her  quite  recovered,  and  she  so  continues  to 
this  day. 

Clinical  Illustration  of  Cerebral  Localization.*— %  H.  H.  Mudd. 
M.  Z>.,  St.  Louis. 

William  Ford,  colored,  aged  32,  and  healthy,  was 
struck  with  a  stone  on  the  left  side  of  the  head  about 
one  and  three-quarter  inches  to  the  left  of  the  sagittal 
suture,  in  a  vertical  line  drawn  three-quarters  of  an  inch 
in  front  of  the  parietal  eminence.  The  blow  produced  a 
scalp  wound  but  did    not  render  the  patient  unconscious, 

•noin>r  part  ol' a  paper  on  "Cerebral  Locilization,"  re:nl  before  the  Missouri 
State  Medical  Afisocialion,  May  IHtli,  18.S(t,at   Cartlia;;e,  Mo.— Kd. 


Shorter  Clinical  Records.  543 

and  he  continued  at  work  as  teamster  for  four  or  five 
days,  when  headache  and  dizziness  compelled  rest. 

I  saw  the  patient  at  6  p.  m.,  Oct,  27,  seventeen  days 
after  the  injury,  and  found  the  scalp  wound  healed  ;  no 
thickening  or  cedema  about  it,  but  slightly  sensitive. 
There  was  very  little,  if  any,  irregularity  detected  in  the 
bone  by  firm  pressure.  He  was  at  this  time  suffering 
with  epileptic  convulsions,  which  commenced  on  the  night 
of  Oct.  24,  by  irregular  jerking  of  the  right  hand.  He 
next  observed  the  same  involuntary  jerking  in  the  right 
leg.  The  first  general  convulsion  occurred  at  12  m., 
the  27th  inst.  The  convulsion  involved  only  the  right 
side  at  first,  but  finally  included  convulsive  action  of  all 
parts.  He  was  entirely  rational  between  attacks,  but 
lucid  intervals  became  shorter,  and  convulsions  more 
prolonged  and  severe. 

I  gave  bromide  of  potash  gr.  xl.  at  a  dose,  and  the 
convulsions  became  less  frequent  and  severe  during  the 
early  part  of  the  night,  but  the  next  morning,  notwith- 
standing continuance  of  use  of  bromide,  they  became  more 
severe. 

At  9:30  A.  M.,  the  28th  inst.,  I  trephined  at  site  of 
cicatrix  in  scalp,  and  found,  upon  denuding  the  bone, 
that  there  was  a  line  of  fracture  about  three-eighths  of  an 
inch  long,  showing  a  slight  depression,  possibly  one-eighth 
of  an  inch.  I  found  the  inner  plate  very  slightly  depressed, 
and  the  bone  at  the  site  of  injury  congested  and  somewhat 
softened;  dura  mater  not  injured,  but  seemed  to  be  tense. 
As  anaesthesia  passed  off,  the  twitching  in  the  right  arm  and 
leg  reappeared,  but,  at  4  p.  m.  the  same  day,  all  convulsive 
twitching  disappeared.  Nov.  28. — Wound  healed  ;  feels  well, 
and  has  not  had  convulsion  or  headache  since  operation. 
April  27,  '80. — The  wound  afterwards  inflamed  and  suppur- 
ated, and  he  had  epileptic  spasms,  which  were  relieved  when 
the  pus  was  freely  evacuated.  Since  it  permanently 
healed  he  has  at  intervals,  varying  from  three  weeks  to 
four  months,  had  an  epileptic  seizure.  It  is  possible,  I 
think,  that  these  have  been  produced  by  thickening 
about  the  wound,  in  consequence  of  continued  suppuration. 

This  case  presents  some  interesting  features.  The 
convulsions  supervened  on  the  seventeenth  day  after  i  jury, 
and  were  preceded  by  twitchings  of  the  arm  and  hand, 
which  commenced  on  the  fourteenth  day  after  injury.  Sub- 
sequent to  the  first  twitching  of  the  arm    and    hand,    but 


544  Bod^en—Kuhn—Mudd. 

prior  to  the  development  of  general  convulsions,  no 
evidence  of  compression,  no  tangible  evidence  of  inflam- 
matory action  was  present,  no  marked  depression ;  the 
line  of  fracture  could  not  be  determined  through  the 
natural  scalp ;  inner  plate  of  cranium  did  not  press  upon 
or  injure  the  cerebrum;  the  dura  mater  was  not  broken 
or  inflamed,  but  was  irritated  by  the  focus  of  irritation 
in  the  bone,  which  was  unnaturally  vascular  and  somewhat 
softened. 

The  muscles  involved  in  the  spasm  indicated  the  site 
of  the  lesion,  and  the  removal  of  this  point  of  irritation 
relieved  the  epileptic  spasms. 


EXTRACTS  FROM    LETTERS    AND  ANSWERS  TO 
SAME. 


Workman. —  Vicarious  Function  of  the  Cerebrum  with  the  CereieUum. 
Bkam.. — The  Rilatlun  of  Broini<sin  and  Epilepsy  to  the  Possibility  of  Rape. 


I  have  for  several  years  had  under  observance  a  case  on  which  I  think 
it  (J?ei)]>illi"s  article  on  "Atrophy  Etc./'  vile  ante — Ed.)  throws  some  li^ht 
—that  of  a  boy.  now  about  12  years  old.  He  is  tlie  youngest  and  only  sur- 
viving of  tive  children— tlie  four  preceding  having  all  died  in  early  infancy  of 
souie  Ijrain  .iffection.  For  the  first  four  or  live  yeai-s  of  liis  life  he  appeared 
to  be  quite  defective  in  standing  or  walking  power,  and  crept  around 
on  all  fours,  pretty  nimbly.  liniiUy,  througii  improvement  of  muscular 
development  and  tone,  assiduously  and  earnestly  seconded  by  a  discreet 
motlicr,  he  began  to  assume  an  erect  position,  but  balancing  power  was 
very  tletective,  and  he  had  to  keep  himself  up  by  leaning  on  or  holding  to 
surrounding  objects.  As  his  strength  increased  he  was  able  to  walk  or 
run  fast,  right  onward,  but  when  he  halted  he  wabbled,  or  fell,  or  had  to 
sit  down.  This  defect  still  continues,  but  in  a  far  loss  degree.  He  is  almost 
entirely  speechless,  but  quite  acute  in  hearing.  At  first  he  could  say  good 
dog  but  not  <log  alone.  lie  can  now  say  Jack,  Joe.  and  a  few  other  mono- 
syl'  ibic  words.  He  perfectly  understands  every  word  spoken  to  him  by 
his  )arents.  and  perhaps  by  others  also,  as  is  clearly  shown  by  his  obedi- 
ence to  all  instructions.  He  is  very  affectionate,  and  verj^  truthful,  for  he 
shows  that  he  believes  all  he  is  told,  and  cannot  understand  a  joke  which 
involves  anything  of  fiction  or  dissimulation.  His  general  health  is  good, 
and  \\U  appetite  normal.  His  head  is  small,  forehead  receding,  but  high, 
occipital  development  small.     It  is  pretty  evident  that  his  muteness  is  not 


Questions  and  Answers,  545 


tlie  result  of  perceptive  or  conceptive  incapacity.  1  am  therefore  inclined 
to  ascribe  it  to  a  missing  link  in  tlie  connection  between  ideation,  or 
thought  action,  and  the  apparati's  of  speech.  qucBre?—Has  there  been  a 
congenital  atrophy,  or  but  a  rudimental  develoi)ment  of  the  Co-ebellum, 
which  as  he  has  advanced  in  growth  and  strength,  has  been  \icariously 
supplemented,  as  Seppilli  has  suggested,  by  the  cerebrum?  The  problem 
is  one  of  great  interest,  and  I  would  very  much  like  to  have  your  criticism 
on  the  case. 


Hepi.y  :— As  the  hemispheres  of  the  cerebellum  like  those  of  the 
cerebrum  are  in  a  measure  vicarious  in  function,  and  as  it  seems  demon- 
strable that  the  convolutions  are  likewise,  the  suggestion  of  Seppilli  is  not 
at  all  unieasonable  or  rhe  fact  improbable.  Nature  is  ever  conservative 
of  function,  and  often  cures  by  substitution,  what  she  cannot  remedy  by 
restitution.  Vicarious  function  set  in  action  under  the  stress  of  gradually 
invading  disease,  is  probably  destined  to  explain  some  of  the  yet  unsolved 
problems  in  cerebral  pathology,  for  which  the  supposition  of  existent 
anatomical  abnormalties,  like  the  absence  of  decussation,  has  been 
invoked. — Ed. 


Office  o?  Drs.  Burts,  Beall  &  Feild,  Physiciaxs  and  Surgeons 
4S  Main  Strket,  Fort  \N  orth,  Texas.  Dear  Dr. :— If  a  party, 
who  is  the  subject  of  epilepsy  and  who  had  been  subjected  to  large 
doses  of  bromide  potas  for  years,  is  accused  of  attempt  to  rape,  what 
inference  might  be  drawn  as  to  his  guilt  considering  his  illness  and 
treatment?  There  is  pretty  strong  evidence  that  a  party  so  circumstanced 
as  to  illness  and  treatment  was  mistaken  for  the  real  guilty  one. 

Do  scientists  now  hold  to  a  state  of  insanity,  preceding,  during  or 
after  a  seizure  of  epilepsy  that  renders  one  irresponsible  for  criminal 
intention?  With  respect,  &g., 

E.  J.  BEALL,  M.  D. 


Reply  :— The  continuous  regular  use  of  bromide  of  potassium  in 
lai-ge  doses  for  years,  might  justify  a  reasonable  doubt  as  to  the  persistence 
of  such  a  degree  of  sexual  passion,  as  would  be  likely  to  lead  even  a 
strong  animal  nature  to  attempt  a  rape  for  the  purpose  of  sexual  gratifica- 
tion. The  conclusion  would  be  more  reasonable  that  such  a  person  as 
is  here  described,  even  if  taken  apparently  in  the  act,  was  attempting 
l)lind  and  aimless  violence,  rather  than  rape  proper.  There  may  be  in 
epileptics,  anti,  post  or  supplemental  paroxysms  of  maniacal  automa- 
tism, in  which  acts  apparently  volitional  but  actually  without  free  and 
voluntarily  directing-will  are  performed,  and  tiiese  acts  maj-  be  violent  or 
incendiary,  or  otherwise  destructive  and  criminal  as  well  as  harmless. — Ed. 


-^f:v3El£EC'FI0N?.v3J£^ 


DISCUSSION    BETWEEN     WESTPHAL    AND    NASSE     ON    THE 

PIJESENT    STATUS    OF    THE    QUESTION    OF 

NON-RESTRAINT   IN    GERMANY.* 


Translated  by  Dk.  E.  W.  Sauxders,  M.  D. 

The  President.  Weitphal,  said :  As  rhi«  was  an  eminently  pi-aclical 
question,  he  wished  to  have  it  discussed  by  a  body  of  practical  men.  and 
he  expected  that  more  would  be  done  in  this  way,  than  could  be 
accom|)lisht'd  by  collectin;;  statistical  material. 

Forty  j^ears  have  pa>^■ed  since  Conolly's  reform  be<;aii,  and  still  the 
question  has  not  been  definitely  settled.  However,  those  who  know  with 
what  ditfleulties  any  practical  reform  has  to  contend  will  under.«;tand  this. 
He  would  tou  ;h  upon  only  one  point  in  reference  to  the  causes  which  led 
to  the  opposition  ao:ainst  Conolly's  reform — a  dark  pag-e  in  the  history  of 
practical  psychiatry.  The  motive  of  Conolly's  efforts  was  humanity,  for 
the  tre  itmeiit  of  the  insane  at  that  time  was  deplorable  in  the  extreme— in 
the  interestsofAwmamiy  he  demanded  the  abolition  of  mechanical  restraint. 

Now.  there  were  many  alienists  in  Germany  as  humanely  disposed  as 
ConoUy.  who  could  not  yet  coincide  with  liLs  views.  It  was  natural  that 
they  should  incur  the  suspicion  of  a  want  of  humanity,  and  this  unjust 
injputation  embittered  them.  According  to  a  psycholosical  law,  they, 
finding  that  tliey  were  unjustly  treated  by  their  opponents,  made  in 
return,  captious  opposition  to  them  and  tiieir  principles.  It  appeared  as  if 
the  advo(uites  of  non-restraint  had  at  the  same  time  become  the  sole 
champions  of  lunuane  treatment.  This  is  to  be  deplored,  and,  at  the 
present  day,  in  Germany  at  least,  the  question  is  simply  as  to  what  is  the 
best  means  to  be  adopted  in  the  treatment  of  certain  classes  of  patients. 
an<l  it  should  be  dicussed  upon  its  merits  alone. 

We  must  not  forget  that  the  mechanical  restraint  of  the  insane  was 
a  measure  introduced  by  the  laity  and  not  by  the  profession.  When 
medical  science  first  turned  its  attention  to  the  insane,  it  found  them  fast 
bound,— bound  l)y  the  laity  for  the  purpose  of  self-protection.  Medical 
science  had  shown  more  and  more  that  restraint  was  unnecessary,  and 
that  it  was  also  injurious.  The  speaker  would  not  feel  himself  called 
upon  to  reply  to  any  one  who  would  now  claim  that  it  w;u<5  salutary  in  its 
effects  upon  the  patients. 

The  question  may  now  be  stated  as  follows : 

1.  Is  it  possible  to  bring  the  treatment  of  the  insane  to  that  sttite  of 
development,  when  all  mechanical  restraint  may  be  dispensed  with  ? 

2.  Is  the  dispensing  with  all  mechanicjil  restraint  advantageous  to 
Before  the  Society  of  Uerman  Alieuistn,  held  in  Heidelberg,  .Sept.  16  and  17, 


Selections.  547 


the  treatment  of  the  insane,  or,  are  there  such  disadvantages  inseparably 
connected  with  it,  that  it  would  be  better  not  to  introduce  it? 

The  question  can  be  decided  only  by  the  test  of  experience,  and  he, 
the  speaker,  did  it  not  seem  too  arrogant,  would  deny  to  any  one  the  right 
to  express  an  opinion,  unless  lie  had  made  an  honest  and  energetic  attempt 
to  do  away  with  restraint  in  his  practice. 

It  is  hard  to  tight  against  prejudice,  indolence,  ill-will,  in  those  who 
ought  to  be  our  helper;  far  harder  is  it,  however,  to  tight  against  one's 
own  false  conceptions  and  timiility.  Another  condition  that  he  would 
make  is,  the  experiment  should  be  made  strictly  in  the  spirit  of  ConoUy's 
work.  What  a  farce,  for  instance,  was  that  which  Hofrath  Stienmei  was 
guilty  of,  when  he  published  the  results  of  his  trial  of  the  Conolly 
System,  the  particulars  of  which  he  had  learned  from  a  non-raedical  otticer 
of  an  English  asylum  1 

The  speaker  was  astonished,  that  Laehr  should  have  referred  to  this 
article  in  his  attai-k  upon  the  non-restraint  system.  The  publications  of 
recent  dale  upon  the  subject  are  rather  scanty.  In  1868,  Stoiy,  in  Halle 
(Tyrol),  said  tiiat  he  considered  that  the  possibility  of  dispensing  with 
mechanical  restraint  in  the  treatment  of  the  insane  had  been  proven  by 
his  experience,  but  that  the  question  wliether  the  general  introduction 
and  practice  of  the  system'  of  non-restraint  is  desirable  or  possible,  he 
rau>t  leave  to  the  future  to  decide.  As  champions  of  the  system  in  Ger- 
many we  find  L.  Myer,  Griesinger,  Gudden,  Cramer  (and  the  speaker  him- 
self), while  others  have  adopted  the  system,  though  they  have  not 
published  their  results.  The  speaker  then  gave  a  partial  list  of  the 
general  asylums  in  which  perfect  non-restraint  had  been  adopted,  to- wit : 
those  at  Hamburg,  Gottingen,  Berlin  (Charite)  Halle,  Marburg,  Heidelberg 
Eberswalde,  Keppenheim,  Weriieck,  Munich  and  Alt-Scherbitz,  besides 
all  the  asylums  of  Switzerland.  Wherever  non-restraint  has  been  carried 
out,  there  his  never  afterwards  a  doubt  been  entertained  of  its  advantages. 
If  he  might  be  so  bold  as  to  speak  of  his  own  experience,  he  would  say, 
that  having  served  as  assistant  in  the  Charite  under  the  old  system,  and 
then  under  the  new,  to  which  he  had  become  converted,  he  would  now 
never  again  employ  mechanical  restraint — he  knew  no  indication  for  the 
application  of  the  jacket.  The  diflference  in  the  results  obtained  under  the 
two  systems  was  simply  enormous.  The  only  exception  allowed  too  by 
Conolly.  to  be  made,  was  in  the  case  of  surgical  patients,  but  even  here, 
one  must  use  mechanical  restraint  only  after  due  consideration. 

The  change  in  sentiment  on  this  subject  that  has  taken  place  in 
Germany  might  be  expressed  as  follows :  Formerly  the  rule  was,  that 
noisy,  troublesome,  etc.  patients  should  be  put  under  mechanical  restraint. 
Latterly,  there  has  been  a  growing  tendency  to  limit  the  application  of 
mechanical  means  as  much  as  possible,  so  that  now  the  rule  is  exactly 
reversed,  and  it  is  taken  for  granted  that  noisy,  troublesome,  etc.  patients 
should  not  be  restrained  by  mechanical  means  from  using  their  limbs 
freely,  unless  in  exceptional  cases.  Opinions  are  still  divided  as  to  whether 
it  is  best  to  dispense  with  mechanical  restraint  altogether  (except  in 
surgical  cases),  or  to  reserve  its  employment  still  for  certain  classes  of 
cases.    Those  who  have  in  practice  done  away  with  restraint  altogether, 


548  Selections. 


believe  that  neither  necessity  nor  advantage  justify  tlie  partial  retention 
of  restraint,  and  that  it  is  better  in  every  respe<  t  to  dispense  with  it 
altogether.  Tlie  speaker  declared  that  it  was  an  undisputed  fact  that 
Conoily  and  his  followers  exercised  a  real  and  determining  influence  in 
bringing  about  tliis  change  of  oi)inion  ;  this  should  be  generally  advuowl- 
edged.  He  himself  felt  contidtnt  that  judging  from  its  progress  in  the 
past,  the  complete  non-restraint  system  would  be  adopt(d  in  the  future. 
Of  course,  the  necessary  conditions  must  first  be  fulfilled,  the  most 
important  of  which  is  that  the  asylums  should  not  be  overcrowded,  and 
that  the  patient  should  be  under  constant  medical  supervision. 

Nasse  agreed  with  Westphal  in  the  main,  although  he  objected  to  the 
dignifying  of  non-restraint  to  the  position  of  a  "system."  Betbre  Conolly's 
time,  humanity  had  been  introduced  into  the  treatment  of  the  insane — the 
distinguishing  feature  of  his  system  was  the  abolition  of  all  mechanical 
bodily  restraint — the  abolition  of  all  mechanical  re.-traint  is.  of  course, 
out  of  the  question.  Formerly,  mechanical  restraint  was  the  kind  chiefly 
employed,  and  it  is  undeuiable  that  its  abuse  had  become  very  great, 
a  gainst  which,  naturally,  there  came  a  reaction,  and.  it  is  well  known,  that 
to  this  reaction  we  owe  manj'  and  great  improvements  in  the  treatment  of 
t  he  insane.  However,  the  unqualified  adoption  of  non-restraint  seems  to 
be  fraught  with  danger,  and  especially  in  England,  where,  through  the 
i  nterference  of  the  laity,  the  liberty  of  physicians  has  been  infringed  upon, 
and  the  bad  results  are  already  apparent.  It  is  to  be  feared  that  lack  of 
energy  in  treatment  has  resulted,  and  then  non-restraint  jiroves  to  be 
onlj'  a  name. — Allgetneine  Zeitschi-ift  fuer  Psychiatric,  36  £d.,  6  Heft. 
iTo  be  continued  in  January  Nutnber.'] 


THE  MEDICAL  CONGRESS  AT  EUEIMS. 


The  French  Association  for  the  Advancement  of  Science  held,  during 
the  month  of  August,  at  the  above  named  place,  an  important  live  day's 
session,  in  the  interest  of  n>edical  advancement  We  nuike.  from  le  Gazette 
des  Hopiieaux.  the  following  interesting  extracts: 

PuHi'iKA  OF  Emoiioxal  OiMOi.N.— M.  Landowsky  gave  the  history  of 
such  a  case  in  the  person  of  a  ynmig  Ijoy  of  previous  good  health  and 
strong  constitution.  The  eruptions  appeared  in  diflerent  regions  of  tlie 
surface  of  the  body.  The  gums  were  scorbutic,  and  there  was  also  a'dema  of 
the  genital  parts,  wliicli  presented  some  sphacelated  point.*.  The  patient 
suflered,  at  the  same  time,  from  a  very  sliarp  pain,  extending  from  the 
epigastrium  to  the  umbillicus.  According  to  Or  Quiiiquad,  tliis  young 
boy  having  got  between  two  veliicles,but  witliont  being  at  all  hurt  or  com- 
pressed, was  frightened  and  syncope  ensued.  His  puiijura  must  have 
lieen  the  result  of  the  lesion  ol  the  dorso-abdominal  plexus.  M.  Constan- 
tine  Paul  discussed  the 


Selections.  549 


Treatmext  of  Tremblings  by  Galvanic  Baths.  His  expei'iments 
<^ave  excellent  result?  in  nearly  all  the  cases,  amelioration  in  some,  cure  in 
others,  notably  in  the  tremblings  from  spinal  irritation,  alcoholism  and 
mercurial  poisoning.  On  the  contrary,  in  locomotor  ataxia  the  galvanic 
bath  is  without  a  particle  of  effect.  He  discriminates  between  the  galvanic 
and  the  electric  bath.  The  former  is  a  bath  of  water  in  which  the 
patient  is  placed,  and  constantly  traverse!  by  interrupted  currents  in  an 
ascending  direction.  The  baths  should  be  repeated  every  two  days  and 
have  a  duration  of  half  an  hour.  M.  Urausart,  of  Soma!  n,  cited  some  very 
curious  observations  on  the  pathological 

Sympathy  Between  the  Eyk  and  Ear.— The  first  relates  to  a 
coppersmith,  drunkard,  who,  having  become  blind  in  one  eye, 
subsequently  in  both,  by  splinters  of  iron  pen-^trating  the  ocular  globe, 
also  became  successively  deaf  in  the  one  and  botli  ears,  after  the 
occurrence  of  each  successive  accident.  The  secoad  observation  is  of  a 
child  whose  deafness  of  the  right  ear  also  followed  the  traumatic  loss  of 
the  eye  of  the  correspuniling  side.  In  the  third  observation,  two  young 
patients,  in  whom  the  ocular  troubles,  accompanied  by  deafness,  were 
happily  modified  by  treatment.  The  hearing  improved  pari  passu  with  the 
recovery  of  the  sight. 

The  author  thinks  there  are  pathological  relations  of  reflex  nature 
between  the  organ  of  sight  and  hearing  through  the  medium  of  the 
tri-geminus.  He  thinks,  also,  that  these  influences  are  the  more  easily 
impressed  if  the  patient  be  under  the  influence  of  a  general  diathesis,  such 
as  scrofula,  syphilis,  alcoholism,  etc. 

A  Case  of  Syphilitic  Locomotor  Ataxia  with  the  results  of  the 
autopsie  was  communicated  by  M.  Estorc,  of  Montpelier,  The  principle 
lesion  was  an  extensive  congestion  of  the  raehidian  meninges  with 
thickening  and  adherence  of  the  pia  mater  to  the  nervous  substance,  a 
peculiar  transparency,  together  with  a  gray  coloration  of  the  posterior 
columns,  a  softening  of  the  cortical  substance  of  the  brain  and  its  adherence 
to  the  meninges.    M.  Charpentiere  presented  a  memoir  on 

The  Sexse  of  Light  and  of  Colors  — These  two  senses,  he  said, 
are  distinct.  If  white  color  is  formed  physically  by  mixture  of  different 
colors  it  is  physiologically  different.  The  sensation  of  white  is  simple, 
while  the  notion  of  color  is  the  result  of  a  different  and  more  complex 
function.    The  following  is  the  explanation : 

1.  White  is  not  a  compound  color  because  it  acts  on  the  retina  like 
other  colors.  These  latter  have  a  restricted  visual  area  varying  with  the 
nature  and  intensity  of  each.  White  has  a  visual  area  which  is  constant 
and  most  extensive. 

2.  The  sensibility  of  the  retina  to  white  light  is  the  same  for  all  parts 
of  the  visual  area.  The  retina  is  less  and  less  sensitive  to  colors  as  the 
point  of  fixation  becomes  distant— LaraioZ^  and  Charpentiere. 

3.  Pathological  cases  are  known  in  which  the  sense  of  color  is  totally 
abolished  (total  achromatopsie),  whilst  the  luminous  sensibility  (sensi- 
bility to  light)  still  persists.      The  author  has  observed  in  the  clinic  of 


6)0  Selections. 


M.  I.nndolt,  m  I'.-ne  of  hiemiophi.  wliich  only  existetl  in  regaril  to  the  per- 
ception of  colors 

4.  A  colonel  liiflit.  own  iaonochrora;itic,  which  is  iiui'le  to  increase 
only  in  intensity  from  zero,  comniences  to  produce  a  simple  luminous 
sensation  with  a  certain  very  feeble  intensity.  It  is  only  when  that  in- 
tensity is  more  considerable  that  there  is  a  sensation  of  specific  color. 

Li«^ht  tlien  acts  in  two  ways  upon  the  org^an  of  sight:  1st.  On 
luminous  sensibility  ;  ■2d,  chromatic  sensibility.  It  is  thus  that  the  action 
of  a  liji-ht  upon  tlie  luminous  sensibility  can  be  increased,  the  chromatic 
sense  remaining  tlie  same. 

It  sutHces  for  this  to  c;uise  the  eye  to  remain  fifteen  to  twenty  minutes 
in  obscurity.  The  luminous  sensibility  is  then  hightened,  whilst  the 
chromatic  has  not  changed.  On  emerging  from  obscurity,  there  is 
added  to  all  color  sensations,  a  sensation  of  white  whicli  imparts  to  the 
purest  colors  a  washed  or  whitish  tint.  Finally  the  addition  of  a  certain 
quantity  of  white  light,  even  strong  to  a  simple  color,  does  not  change 
the  sensibility  of  the  eye  for  that  color. 

Spasm  of  thk  Glottis  of  Hysteric  Origin.— From  an  observation 
of  grave  spasm  in  a  hysterical  patient,  which  almost  necessitated 
tracheotomy,  after  reading  a  paper  on  laryngeal  spasm  of  hysterical 
origin  simulating  a  true  narrowing  of  the  trachea,  M,  Gougueidieim 
concludes :  Nervous  aphonia  accompanies  spasm  as  well  as  paralysis 
of  the  glottis.  When  the  spasm  is  light,  it  may  pass  unobserved,  and 
then  the  vocal  troubles  are  the  predominating  symptoms  of  the  laryngeal 
aftection.  Laryngoscopical  exa  nination  is  then  the  only  means  of  ascer- 
taining if  the  aphonia  is  symptomatic  of  a  spasm  or  muscular  paresis. 
The  grave  spasm  of  the  glottis  in  the  liysterical  is  often  as  dangerous 
as  infantile  spasms.  It  is  a  complication  very  rarely  observed.  It  can  cause 
death  or  at  least  necessitate  tracheotomy.  Tliis  last  resort  may  be  taken 
in  subjects  whose  antecedents  are  unknown,  and  in  whom  the  spasm  may 
simulate  a  laryngo-stenosis  of  organic  nature.  The  application 
of  revulsives  to  the  anterior  part  of  the  neck  or  even  the  preparations 
for  tracheotomy  may  cause  cessation  of  the  attack.  An  accident  of 
tliis  kind  must  alwajs  be  thought  of  in  case  of  a  woman  whose  history 
is  unknown,  and  before  practising  the  operation,  urgency  demands  a  laryn- 
go.scopic  operation  should  be  made.  M  Blondeau  would  advise  chloroform 
inhalation  to  muscular  relaxation. 

"The  ri;-<olutive  Treatment  of  Fihro-Myxomata  by  Subcutaneous 
Ergotine  Injections"  by  Courty.oi  Mont|)elier;  •■The  Alterations  of  the  Blood 
in  Disease,''^  b}'  Dr.  Quinquad;  *^' Dropsies  and  Renal  Accidents  in  the  Con- 
valescent from  Variola."  by  Letidet,  of  Rouen;  "Rebellious  Epi.staxis 
Cotmected  with  Cirriio.si-;  of  the  Liver," — successfully  treated  by  a  large 
blister  to  the  Iwepatic  region — reported  by  Gamier;  and  many  other 
matters,  were  presented  in  a  practical  and  profitable  manner.  Had 
we  more  room  at  our  dispo.^al  we  should  cheerfully  give  space  to  the 
interesting  communication  of  MM.  Dujardin,  Beaumetz  and  Audige, 
on  "The  Toxic  Power  ot  the  Alcohols,"  and  that  of  M.  Plonquet  on 
"Individual    and    Hereditary    Alcoholism,"  as     well   as   the    instructive 


Selections.  551 


paper  of  Liincereau  on  "The  Habits.  Localization  and  Evolution  of 
Hereditaiy  Phthisis"  and  JSI.  Diunontpelier's  account  of  his  refrigerating 
inetliods,  antl  Scholtz's  Xew  Uptlialmonieter. 


NEW    FACTS    RELATIVE    TO     THE    STUDY    OF    CEREBKAL 
LOCALIZATION.— %  A.  Pitres. 


I  had  occasion  to  observe  at  Bordeaux,  in  the  course  of  the  year  which 
has  just  passed,  a  number  of  cases  of  limited  cerebral  lesions. 

The  piinciple  of  cerebral  localization  is  not  yet  universally  accepted. 
It  encounters,  it  is  true,  only  a  small  number  of  ardent  opposers.  but  many 
physicians  receive  it  only  with  reserve,  hesitation  or  defiance.  It  is  tittiug 
then  to  multiply  still  the  proofs  and  to  accumulate  facts  in  order  that  we 
may  finally  constitute  a  ma))  of  observations  sufficient  to  convince  the 
hesitating  and  persuade  the  incredulous. 

Obs.  I.  Softening  of  the  inferior  parietal  lobule  and  spheniodal  convo- 
lutions— Absence  of  hemiplegia. 

Piot,  aged  59  years  entered  the  hospital  for  Incurables  (service  of  Dr. 
M.  C.  Solles)  in  1S60.  He  was  effected,  at  his  entrence.  with  a  double 
cataract,  which  was  afterward  successfully  operated  upon.  Duiing  his 
abode  in  the  hospital,  he  presented  the  symptoms  of  progressive  muscular 
atrophy,  but  never  had  hemiplegia ;  he  was  able  to  walk  to  the  last  day  of 
his  life.  Sensation  was  unimpaired  in  the  extremities  on  both  sides. 
Death  took  place  in  December,  1876,  from  spontaneous  gangrene  of  the 
right  lower  extremity. 

The  autopsy  disclosed  an  old  lesion  of  the  brain,  which  nothing  in  the 
clinical  history  of  the  patient  would  have  caused  us  to  suspect.  Upon 
tlie  right  hemisphere  was  found  a  cortical  softening  of  about  five  centi- 
meters in  diameter,  with  a  yellowish  irregular  base  occupying  all  the 
inferior  pai'ictal  lobe  from  its  foot  to  the  origin  of  the  occipital  convolu- 
tions and  extending  to  the  posterior  third  of  the  first  and  second 
splienoidal  convolutions.  The  base  of  the  softened  patch  was  separated 
from  the  sphenoidal  corner  of  the  lateral  ventricle  by  a  thickness  of  three 
millimeters  of  healthy  white  tissue.  The  rest  of  the  hemisphere  was 
normal.  The  protuberance,  bulb,  spinal  cord,  presented  neither  asymetry 
nor  band  of  secondary  degeneration.  On  sections  of  the  cord  made  after 
hardening,  and  microscopic  examination,  the  two  lateral  columns  appeared 
perfectly  healthy. 

Oba.  II.    Abscess  of  the  occipital  lobe — Absence  of  hemiplegia. 

In  the  course  of  the  month  of  March,  1878,  I  was  called  to  take  the 
place  of  Dr.  M.  C.  Montalis.  in  his  service  at  the  Hospital  Saint  Andre. 
.\mong  the  patients  whom  I  had  to  treat,  there  was  a  phthisical  one  who 
died  from  tlie  advance  of  pulmonary  lesions,  without  having  presented 
any  disturbance  of  motility.    Sensation  was  not  investigated. 

At  the  autopsy  there  was  found  in  the  right  occipital  lobe  an  abscess 
of  the  volume  of  a  large  hazel-nut,  surrounded  with  a  pyogenic  membrane 


552  Selections. 


two  milliiueters  tliick.  TIih  absces?;  li;ul  destroyed  almost  all  liie  wliite 
fibres  of  the  occipital  lobe,  and  extended  to  the  immediate  vicinity  of  the 
posterior  horn  of  tlie  lateral  ventricle.  The  spinal  cord  was  not 
examined. — Le  Progres  Med.,  Aug.  7. — Nelson,  St.  Louis. — {To  be  continued.) 

The  Psycho-Motok  Centkr  of  thk  Face. — M.  Ballet,  interne  des 
hopitaux,  Salpetriere,  communicates  to  Le  Progres  Medicate,  of  September 
ISh,  the  anti  iind  post-mortem  liistory  of  a  laundry-woman,  aged  71  years, 
illustrating  the  fact  acquired  since  tlie  publicarian  of  tiie  memoir  of  MM. 
Cliarcot  and  Pitres  (in  1877),  "that  tlie  cortical  center  which  presides  over 
the  movements  ot  the  face,  or,  to  speak  more  exactly,  the  movements 
of  tlie  muscles  controlled  by  the  inferior  facial,  reside  in  the  inferior  third 
of  the  ascending  parietal  and  frontal  convolutions."  The  case  reported 
is  precisely,  in  fact,  very  clearly  a  primitive  paralysis,  limited  to  the 
domain  of  the  inferior  facial  with  a  circumscribed  lesion  of  the  inferior 
part  of  the  ascending  frontal.  The  patient  died  on  the  6tli  of  August,  and 
the  autopsy  was  made  twenty-four  hours  after  death.  The  arteries  of  the 
b:ise  of  the  brain  were  slightly  atheromatous. 

An  inspection  of  the  external  face  of  the  right  hemisphere  revealed  a 
focus  of  cortical  hemorrhage  about  the  size  of  a  walnut.  It  contained  a 
clot,  recently  exuded,  of  red  blood  which  weighed  about  five  grammes; 
occupied  the  lower  part  of  the  ascending  frontal  convolution  and  was 
confined  to  the  base  of  the  fissure  of  Sylvius. 

On  making  repeated  sections,  it  was  found  that  the  hemorrhage  had 
destroyed  the  inferior  frontal,  and  encroached  upon  the  corresponding 
parietal  fasciculi  without  penetrating  deeply  enough  to  reach  the  central 
gray  nuclei. 

MuLTiPUCiTY  OF  THE  Spixal  Ganglia. — Dr.  Leo  Davida,  of  Pesth, 
reports  in  the  Lancet  for  August,  that  he  has  found  in  a  man  twenty-three 
years  of  age,  the  first,  second,  third  and  fourth  lumbar  ganglia  double  on 
the  lefD  side,  but  on  the  right  only  the  third  and  fourth.  In  most,  the 
giuglia  were  quite  separate,  in  some  they  were  connected  by  a  gray  com- 
missure. The  largest  was  three  millimeters  in  diameter  The  posterior 
root,  two  millimeters  above  the  ganglion,  divided  into  two.  one  for  each 
ganglion.  There  was  a  difference  in  tiie  size  of  the  roots  corres|)onding  to 
the  size  of  the  ganglia.  lu  a  man  forty-five  years  old,  on  the  left  side,  the 
first  four  lumbar  ganglia  were  double,  and  tiie  fifth  was  treble.  On  the 
riirht  side,  the  first  two  were  double  and  the  last  three  treble  ;  one  of  the 
sacral  ganglia  was  also  double.  In  some  instances  the  three  ganglia  were 
quite  separate,  in  others  they  were  united  by  gray  commissures.  In  a 
man  thirty-two  years  of  age,  the  third,  fourth  and  fifth  lumbar  ganglia 
were  double  on  the  left  side,  the  second,  third,  fourth  and  fifth  on  the 
right.  These  were  the  only  bodies  examined,  and  this  condition  was  found 
in  all. 

Unilateral  Convulsions  due  to  Brain  Disease.— Dr  Brown- 
Sequard's  conclusions,  British  Med.  Journal,  August  28th,  1880. — 1.  They 
can  be  caused  by  a  lesion  in  almost  any  part  of  the  brain.  2.  By  any  kind 
of  lesion.    3.  They  can  be  associated  with  anj'  other  symptom  of  brain 


Selections.  553 


difepase.  or  may  be  for  a  time  or  until  death,  the  only  symptom  existiijg* 
4.  They  can  appear  at  once  in  all  parts  of  one  ?ide  of  the  body,  or  begin  in 
any  muscle  or  oroup  of  muscles.  5.  They  can  pass  into  general  convul- 
sions or  follow  them.  6.  Tliey  usually  last  longer  than  general  convulsions 
due  to  brain  disease,  and  still  longer  tlian  genuine  idiopathic  epileptic 
convulsions.  7.  They  often  appear  witiiout  loss  of  consciousness,  either 
at  their  beginning  or  at  any  time  of  an  attack.  8.  'J'hey  can  take  place 
either  on  the  side  of  the  brain  lesion  which  causes  them,  or  on  the  opposite 
side,  tlie  cross  convulsions  being  more  frequent  than  the  direct  ones.  &• 
The  right  Ihnbs  are  attacked  more  frequently  than  the  left,  in  cases  of  cross 
convulsions,  and  al>o  wiien  unilateial  convulsions  appear  in  cases  of 
lesion  in  tlie  the  two  ceiebrnl  or  cerebellar  hemispheres.  10.  In  the  same 
individual  and  from  a  single  lesion,  unilateral  convulsions  can  appear  at 
tir-ston  the  side  of  the  hsion  and  then  on  the  opposite  sid*^,  or  vice  versa. 
11.  These  convulsions  can  appear  on  the  side  of  hemiplegia  or  on  the 
opposite  side,  the  paralysis  in  either  case  being  a  cross  one;  but  they  can 
also  be  direct  -when  the  paralysis  is  also  direct  and  cross  while  the  paraly- 
sis is  direct.  12.  Lirect  unilateraL  convulsions  are  inore  fi-eqiienily  produced 
than  cross  ones  by  lesion  of  the  great  cerebral  ganglia,  the  crura  cerebri,  the 
cerebellum,  the  pons  Varolii,  the  medulla  oblongata ;  while,  on  the  contrary, 
cross  convulsions  aretnuch  more  frequent  than  direct  ones  caused  by  lesions  of 
the  centrum  ovale  or  the  convolutions.  13.  In  animals,  as  he  had  found, 
an  irritation  of  the  base  of  the  brain  and  even  of  the  motor  part  of  the 
crura,  the  pons,  and  the  medulla  (the  anterior  pyramid)  generally  produces 
muscular  contractions  on  the  corresp(  ndirg  side;  while  irritation  of  the 
so-called  motor  centers,  or  of  the  fibres  uniting  these  parts  with  the 
cerebral  ganglia,  usually  produces  mov<ments  on  the  opposite  side,  so  that 
the  same  general  eflects  are  generated  in  animals  as  in  man.  14.  Jack- 
sonian  convulsions  (either  when  exc•lusi^ely  and  persistently  unilateral  or 
only  temporarily  so)  can  appear  on  the  side  of  the  lesion,  or  from  lesion  in 
parts  of  the  brain  considered  .-s  not  belonging  to  the  motor  appsiratu.-*.  15) 
The  study  of  U7iilateral  convulsions  brings  forth  a  large  number  of  facts 
altogether  in  opposition  to  the  views  now  held  about  cerebral  localization.  16. 
The  diagnostic  significance  of  unilateral  convulsions  is  often  considerable, 
owing  to  the  association  of  this  symptom  wiih  other  cerebral  morbid 
manifestations.     [Over  500  cases  were  analyzed] 

Dr.  W.  E.  Gowers  on  Paralytic  Chorea.— Tliree  symptoms  might 
ordinarily  he  rec(-gnized  in  chorea:  spontaneous  movencnt,  incc-ordina- 
lion  of  voluntary  movement,  and  muscular  weakness.  These  were  not 
always  proportioned.  Any  one  of  them  might  so  predominate  as  to  give 
u  special  character  to  the  case.  In  the  form  now  considered,  muscular 
weakness  predominated,  and  appeared,  at  first  sight,  to  be  the  only 
symptom.  A  series  of  illustrative  cases  %\ere  narrated.  The  aim  was 
always  the  part  aflected,  and  the  muscular  weakness,  which  alone  was 
noticed  by  the  friends,  and  sometimes  by  the  medical  attendant,  might  be 
very  great  and  real.  In  some  cases,  however,  the  natural  weakness  might 
.beless  than  the  loss  of  use  would  suggest.  There  was  no  weakness  of  face, 
tongue  or  leg.  Close  observation  would,  after  a  time,  usually  detect  a 
slight  occasional  choreiform  tAvitch,  but  this  might  be  quite  absent.    There 


654  Selections. 


luijilit  be  marked  twit'cliing  in  the  other  urm  which  was  not  weak.  The 
affeotion  ini<>:ht  pass  off  without  more  conspicuous  spasm.  Sometimes 
clioreiform  movements  become  more  marked  as  power  increased.  The 
course  of  this  form  was  often  teilioiis,  but  did  not  pass  into  severe  general 
chorea.  In  his  experience,  whenever  a  child  between  the  ages  of  seven  and 
flfteen,  presented  gradual  loss  of  power  in  one  arm,  without  affection  of 
face,  tongue  or  leg,  the  disease  was  always  cliorea,  even  although  chorei- 
form movements  might  not  be  observed. — British  Med.  Journal,  Proceed- 
ings Brit.  Med.  Ass'n. 


-^icEDITei^I^IivDEP^I^TjaENT.*- 


To  OrK  FuiKNDs:— This  number  completes  the  first  volume.  Ifetn>- 
spectlon  brings  to  mind  many  delinquencies,  and  the  familiar  confession  in 
the  ei)is(0]);d  ritual:  "We  have  left  undone  the  things  we  ought  to  have 
done,  and  done  those  things  we  ought  not  to  have  done."  A  confession  we 
commend  to  such  of  our  exchanges  as  may  discover  some  of  tiie  motes 
which  may  have  obstructed  our  mental  visual  apparatus,  while  failing  to 
discern  the  beams  in  their  own.  We  shall  not  endeavor  to  point  out  the 
beams  which  we  have  seen  during  the  past  year  in  others  eyes  if  they  do 
not  attempt  to  make  beams  out  of  our  motes,  and  "So  mote  it  be." 
Nevertheless,  we  have  made  an  honest  effort  to  faithfully  execute  our 
l)urpose  to  present  to  the  profession  such  matters  in  "scientific,  clinical 
and  forensic  psychiatry  and  neurology  as  would  especially  answer  the 
wants  of  the  general  practitioner  of  medicine.  The  hearty  encourage- 
ment and  generous  reception  given  us  from  the  inception  of  our  enterprise 
to  tlie  present  time,  confirm  our  faith  in  the  necessity  of  and  demand  for 
the  continued  existence  of  such  a  Journal  as  ours,  and  accordingly  we 
shall  continue  to  visit  our  subscribers  during  another  year  in  much  the 
same  lineaments  and  In  habiliments  quite  similar  to  those  which  nuoke 
up  otir  present  dress. 

Doubtless  the  attempt  whicli  we  have  made  to  introduce  into,  and 
amalgamate  practical  psychiatry  and  neurology  with  sreneral  medicine  may 
seem  chimerical,  and  our  .Joitknal  may  seem  novel,  but  if  you  continue 
to  take  it.  the  novelty  will  wear  off,  the  strange  face  become  familiar, 
the  merely  tolerated  visitor  will  become  a  welcome  guest,  and  finallj'  we 
hope,  a  permanent  member  of  your  family  of  medical  periodicals. 

Since  our  purpose  lias  been  to  present  mainly  clinical  psycliiatry  and 
neurology  in  their  scientific  and  forensic  asi)ect&,  we  have  endeavored  to 
guard  our  pages  against  becoming  overburdened  with  neurological  ana- 
tomy and  physiology,  while  at  the  same  we  have  not  omitted  terse  mention 
of  real  progress  in  this  ilepartment  of  neurological  research,  so  f;ir  as  our 
paramount  purpose  and  limited  space  woidd  permit.  For  further  light  our 
intelligent  readers  have  the  Journal  of  Physiology  and  the  Anatomical 
Annals. 


Editorial.  556 


The  luedical  editor  who  would  in  this  day  of  active  research,  endeavor 
to  make  his  pages  even  a  complete  epitome  of  the  advance  in  the  various 
foundation  branches  of  clinical  medicine  would  have  to  conduct  a  monthly 
quarto  encyclopjedia. 

\Ve  hope  in  the  next  four  quarters  to  double  the  number  of  our  sub- 
scribers and  to  be  enabled  thereby  to  make  material  improvements  in  our 
Journal. 

Our  patrons  and  those  who  think  of  becomino:  such,  will  please  bear  in 
mind  that  the  Alienist  and  Neurologist  is  conducted  on  business  princi- 
ples, and  lives  in  accordance  with  business  laws,  and  will  be  what  its  friends, 
by  pecuniary  and  other  assistance,  determine  to  make  it.  "  The  stream 
cannot  rise  above  its  source."  We  cordially  thank  the  friends  who  have 
helped  us  and  hope  they  may  call  others  to  our  aid. 

Our  Exchanges,  Continued.— Before  us  lies  that  old  French 
medical  periodical,  now  in  its  flfty-first  year  and  still  enjoying  the 
confidence  of  French  physician?,  Le  Journal  de  Medicine  et  de 
Chirargie  Pratiques  a  L'usage  des  Medicine  Practiciens.  founded  by 
Lucas  Championiere,  the  accomplished  editor-in-chief,  whose  contribu- 
tions to  "'Anticeptic  Surgery,"  to  the  study  of  "Traumatic  Fever"  and 
other  previous  works,  together  with  his  contribution  to  the  "Historical 
and  Clinical  Study  of  Trephining  of  the  Cranium  as  Governed  by  Cerebral 
Localization,"  have  so  greatly  enriched  the  medical  literature  of  France. 
Its  pages  bear  evidence  of  its  cosmopolitan  character,  and  show  that  even 
the  reputable  journals  of  St.  Louis  do  not  escape  the  editor's  eye  and 
scissors.  The  I^yon  Medical,  now  in  the  twelfth  year  of  its  existence,  is 
on  our  table,  presenting  a  good  list  of  contents. — [Among  the  Jan.  selec- 
tions of  the  A.  and  N.,  we  shall  give  from  it  one  interesting  translation.] 

A  new  candidate  for  the  support  of  the  profession  in  Franoe  has 
just  appeared  in  the  wide  and  ever  widening  field  of  psychiatry  and 
neurology,  bearing  the  name  of  L'Archives  de  Neurologie,  under  the 
direction  of  the  illustrious  Charcot,  and  to  be  editorially  conducted  by  the 
well-known  editor,  Bourneville.  The  associate  stafl"  embraces  also  some 
of  the  best  known  names  in  neurology  in  France  and  in  this  country. 

The  old  and  valuable  Italia  Medica,  of  Genoa,  under  the  direction 
and  collaboratorial  management  of  Maragliano,  Ageno,  Albertoni,  Gas- 
parini  and  others  equally  eminent,  comes  to  us  in  weeklj'  numbers,  and 
never  fails  to  contain  such  contributions  of  merit  as  the  world-wide  fame 
of  its  many  contributors  would  lead  us  to  seek  in  its  valuable  columns. 

LaPresse  Medicale,  Beige,  is  one  of  the  less  pretentious  of  our  foreign 
exchanges,  yet,  under  the  able  direction  of  M.  Magolez,  its  pages  are 
always  interesting. 

We  turn  now  to  note  two  new  domestic  journals,  and  for  the  present 
must  conclude.  The  College  and  Clinical  Record  is  a  monthly  journal, 
conducted  by  Drs.  Richard  J.  Dunglison  and  Frank  Woodbury,  especially 
in  the  iuterests  of  the  graduates  and  students  of  Jefferson  Medical  College, 
and  though  not  especially  interesting  thi-oughout  its  pages  to  the  profes- 
sion generally,  it  always  contains  something  of  interest  and  value  to  every 
physician.  It  is  sufficient  commendation  of  the  number  before  us  to  say 
it  contains  one  of  Prof.  Bartholows'  lectures. 


55G  E  diiorial. 


The  St.  Joseph  Medical  and  Surgical  Ef  porter  is  a  monthly  journal, 
devoted  to  the  interests  of  Western  Medicine,  conducled  by  Dr.  J.  P. 
Chesney.  It  has  a  good  deal  of  value  in  its  pages  for  its  size  and  price, 
and  is  conducted  by  a  gentleman  who  possesses  the  editorial  ability  to 
successfully  manage  it. 

The  Editorial  Pen  is  fluent  and  its  scissors sAo?-;).  Its  contributions  are 
good  andselections  well  made,  especially  those  taken  fr«m  tlic  Ai.iKNisTA>n 
Nki-koi-ogist.  Thcprofession  of  the  section  in  which  it  is  published  ou^lit 
to  give  it  a  hearty  support  and  unstinted  sustenance.  The  kind  of  mc  dical 
journal  the  profession  of  any  section  sustains,  tells  what  sort  of  physi- 
cians that  part  of  the  countiy  contains. 

In  our  last  issue  we  inadvertently  included  the  Louisville  Medical 
News,  one  of  the  best  of  our  weekly  exchanges  'among  the  younger 
medical  journals.  The  ''News"  is  now  in  its  ttnih  year,  and  the  wisdom 
displayed  in  its  editoiial  msinagcmfnt  is  such  as  its  age  :.nd  experience, 
and  the  fame  and  good  repute  of  its  edite  rs  would  lead  us  to  expect. 
Although  the  Journal  is  weekly,  it  is  s^7-07?<?/2/ lepresenlative  of  n.tdical 
opinion  in  the  South  and  West. 

Skppilli  ox  Cerebellar  Atrophy.— To  fonn  a  correct  judgment 
of  Seppilli's  able  clinical  contribution  to  the  subject  of  "Atrophy  of  the 
the  Cerebellum."  the  article  must  be  read  entire,  hence  we  have  ojven  it 
without  .abridgement.  A  bright  and  glorious  future  seems  in  waiting  for 
the  men  of  re-born  Italy.  The  recent  productions  of  Livi,  ^^eppilli.  Marag- 
liano,  Tamburini.  Morselli  and  others  of  that  sunny  dime,  show  that  1  er 
medical  writers  are  no  superlicial  skimmers,  and  while  they  dive  far 
down  into  the  depths  of  their  subjects,  they  never  weaiy  these  who  follow 
them  with  obscure  or  tiresome  verbiage  In  saying  this  much  for  the 
language  of  the  Italian  medical  writers,  we  mean  no  disparagement  to 
our  own  mono-syllabic  English,  which,  though  possibly  less  musical  than 
the  Italian,  eclipses  in  brevity  and  concentrated  expressive  foree,  all  the 
continental  tongues. 

Nitrite  ok  Amyl.—Difkerkxtial  Diagnosis  of  cerebral  hypua?- 
mia  and  aijcniia.— Although  it  is  not  difliddt  to  distinguish  marked  Ibims 
of  tliese  opposite  c«  rebial  states,  yet  there  are  instances  where  they 
someiimes  present,  even  to  tlie  neurologist,  so  many  negative  evidences 
that  any  additional  sign  that  may  aid  in  clearing  away  the  doubt  is  an 
actual  gain  in  our  means  of  diagnosis.  This  sign  we  have  found  in  the 
action  of  nitrite  of  amyl  inhalations  In  the  minimum  doses.  In  the  maik- 
edly  anajmic,  a  single  five-drop  inhalation  eloes  not  produce  cephalalgia,  or 
any  considerable  amount  of  head  uneasiness  or  sufliisicn  of  the  lace,  while 
in  the'  decieledly  hyijerstmic  the  s<  nse  of  fullness  e)f  the  head,  anei  even  of 
cephalic  pain,  is  often  exaggerated  and  very  persistent  even  after  one 
inlialation,  the  f:;ce  also  flushing  more  readily  and  extensively. 

As  A  TiiERArEUTic  agent  in  anaemia  and  ind)ecility. — The  known 
property  of  this  agent  in  cjuickening  the  cerebral  e-irculation  inductMl  us 
to  employ  it  by  inhalation  in  the  treatment  e)f  cerebral  and  spinal  aiiicmia 
and  in  tlie  management  of  some  imbecile  patients.    One  little  patient  with 

ind   weakened   power 


Editorial.  557 


of  ('ontrol  over  the  lower  limbs,  is  now  evidently  being  benefited  by  it 
conjoined  with  electricity  and  internal  treatment.  Two  of  our  chronic 
apliasics  are  also  on  trial  with  it,  conjoined  with  other  medication,  with 
a  view  of  diminishing  the  area  of  possible  arterial  obstruction  within  the 
brain. 

The  Loosening  of  the  Teeth  in  Ataxia.— The  New  York  Medical 
Record  makes  a  note  from  Le  Courier  Medical,  of  March  Gth,  of  the  fall- 
ing out  of  the  teeth,  observed  by  M.  Vallin.  MM.  Luys  and  Lereboulet  in 
several  cases  uf  locomotor  ataxia,  not  preceded  by  pain  or  caries,  a  phe- 
nomena due  to  a  bony  rarefiction  of  the  alveolar  border— a  trophic  alter- 
ation not  hitherto  described,  but  which  deserves  careful  study,  as  it  may 
be  an  early  sj'mptom  of  the  general  disease.  Two  ataxics  now  under 
our  own  observation  present  this  feature,  some  of  the  teeth  being  so  loose 
that  they  were  merely  lifted  out  with  the  forceps;  one  patient  realizing  no 
pain  at  all,  and  the  other  scarcely  any  on  remo\al  of  the  teeth.  It  would 
be   well  to  look  carefully  into  the  mouths  of  all  our  suspected  ataxics. 

The  Increasing  Interest  in  Psychl\try. — It  is  an  encouraging 
sign  to  note  the  increasing  interest  in  the  profession  at  large  in  psychiatric 
problems,  notwithstanding  the  crude  notions  occasionally  expressed,  and 
the  facility  with  which  the  Gordian  knot,  which  has  so  long  remained  tied 
to  the  most  experienced  alienists  respecting  the  disposition  and  treatment  of 
some  of  the  varied  forms  of  mental  alienition,  is  sometimes  theoretically 
severed.  We  welcome  the  discussion  of  this  subject,  or  rather  the  many 
subjects  of  insanity,  for  when  discussion  increases,  attention  and  interest 
ai'e  enlisted,  and  these  are  the  beginnings  of  knowledge. 

How  Ohio  Wrongs  Her  Insane. — No  State  in  the  Union  has  made 
more  ample  provision  for  the  comfortable  care  of  its  insane  than  the 
"Buckeye"  State.  Her  many  magnificent  hospitals  for  tliese  unfortunates, 
complete  in  all  their  internal  arrangements,  magnificent  in  proportion 
and  even  extravagantly  lavished  in  architectural  design,  staiul  up  as  beau- 
tiful and  enduring  monuments  of  the  good  intentions,  grand  and  noble 
philanthropy  of  a  great  and  glorious  commonwealth,  but  with  these  good 
intentions  and  commendable  philantliropy,  the  politicians  of  that  state 
have  played  sad  havoc.  Rotation  in  office  for  her  Insane  Hospital  Officers 
and  Boards  of  Trustees  with  evei-y  change  n  the  political  sentiments  of 
her  people,  and  the  pitiably  small  salaries  for  the  highest  kind  of  medical 
service,  fixed  by  "Retrenchment  and  Reform''  politicians,  have  done  and 
must  continue  to  do  the  unfortunate  insane  of  that  State  great  wrong,  and 
we  hope  tiie  profession  of  Oliio  will  fight  this  wrong  until  the  unfortunate 
wards  of  that  State,  who  cannot  do  battle  for  themselves,  shall  receive 
tlieir  rights  in  more  permanent  medical  administration  for  the 
hospitals  for  the  insane.  We  hope  to  s  e  no  more  changes  in  asylum 
administration  in  that  State  for  political  causes.  The  medical  charities  of 
a  commonwealth  are  not  legitimate  spoils  of  political  triumpli  and  public 
sentiment  in  every  State  should  be  so  moulded  by  the  medical  profession, 
that  no  party  would  have  the  temerity  to  claim  them  as  the  reward  of 
political  victory. 

What  is  true  of  Ohio,  is  true  of  some  other  Western  States.    The 


558  Editorial. 


Eastern  States  have  ;renerally  gotten  over  this  folly.  NVe  should  like,  in 
this  connection,  to  have  made  room  for  some  extracts  from  President 
Murphy's  vigorous  protest  against  this  outrageous  custom  before  the 
O  hio  State  Medical  Society,  but  space  forbids. 

Iksank  Hospital  A^^^;xFs.— Every  friend  of  the  insane  who  has 
taken  the  trouble  to  accurately  acquaint  him?elf  with  the  provision  made 
for  the  care  and  treatment  of  these  unfortunates  in  many  of  the  American 
States,  must  fee!  a  glowing  pride  as  lie  contemplates  tlie  living  evidences 
of  the  magnanimous  philanthroi)y  and  thoughtful  care  for  the  most  pita- 
ble  and  helpless  of  God's  creatures,  as  dis-pbyed  in  these  State  institutions 
Tlieir  home-like  and  cheerful  interior  arrangements,  with  facilities  of  many 
family  groupings,  their  attractive  surroundings,  ample  pleas-ure  walks, 
drives,  farm,  garden,  dairy,  libraries,  amusements,  workshops,  etc.,  in 
short  all  the  appurtenances  essential  to  a  life  of  industry,  recreation  or 
diversion,  for  such  as  can  enjoy  them,  greatly  compensate  for  the  neces- 
sary withdrawal  of  the  patient  from  the  social  life  and  liberty  of  home, 
pending  the  medical  treatment  and  mcdilied  liberty  essential  to  his  wel- 
fare. But  as  the  aim  of  all  experienced  American  Alienists  who  truly 
appreciate  the  varied  requirements  of  the  many  diflerent  forms  of  insanity, 
is  to  accord  to  patients  all  the  liberty  compatable  with  their  mental  con- 
dition, so  that  they  may  not  greatly  feel  their  deprivation  of  liberty,  we 
should  like  to  see  some  of  our  States  try  the  experiment  of  provid- 
ing hospital  annexes  quite  disconnected  from  the  main  building,  even 
removed  many  miles,  to  which  some  convalescents  who,  having  reached  a 
certain  stationary  stage  in  their  progress  towards  recovery,  might  be  sent 
with  the  hope  of  giving  a  new  impulse  towards  their  restoration.  There  are 
in  everj'  large  hospital  some  of  these  patients,  as  there  are  likewise  always 
some  mild  forms  of  chronic  cases,  the  remains  of  whose  insanity,  like  the 
physical  limp  that  sometimes  outlasts  a  sprain,  is  so  slight  that  these 
patients  make  good  companions  for  any  company  away  from  home  and 
the  circumstances  which  first  engendered  their  disease.  Such  an  arrange- 
ment legalized  by  the  State  would  enable  superintendents  to  more  safely 
and  extensively  cany  out,  with  less  risk,  the  practice  of  furloughing 
patients  now  more  or  less  in  vogue  at  many  institutions. 

For  beginning  the  experiment.  States  might  make  it  lawful  for  medical 
superintendents  to  assign  carefully  selected  cases  to  some  of  the  private 
homes  conducted  by  medical  men,  permitting  the  friends  to  pay  for  main- 
tenance in  the  case  of  private  patients,  and  in  the  case  of  county  charges, 
the  State  providing  for  their  si.pport. 

This  would  encourage  and  develop  a  disposition  on  the  part  of  medi- 
cal men  to  treat  the  insane,  such  as  might  be  so  treated  outside  of  asylums, 
and  thus  more  greatly  familiarize  the  general  profession  and  the  public 
with  a  subject  concerning  which  too  much  ignorance  exists,  namely:  the 
proper  management  of  exceptional  forms  of  insanity. 

Thk  Eights  of  the  Insane.— When,  by  reason  of  disease,  an  individ- 
ual departs  from  that  natural  manner  of  thought,  feeling  or  acting,  which 
in  his  normal  mental  state  he  voluntarily  preferred  and  which  gave  him 
bis   rational  individuality  and  no  longer  governs  his  actions  as  he  was 


EditoriaL  559 


wont  to  <lo,  and  as  he  would  do  again  were  his  reason  restored  to  him,  it 
is  the  duty  of  the  State  or  of  the  patient's  friends,  in  consideration  for  what 
the  State  has  received  from  that  individual  in  his  best  estate,  to  assume 
such  a  guidance  of  that  person's  conduct  as  may  as  certainly  and  speedily 
as  possible  protect  him.  not  only  against  inflicting  physical  but  mental 
injury  to  himself  as  well  as  others.  It  is  a  mistake  to  assume  that  the 
insane  have  no  rights  which  the  sane  are  bonnd  to  respect,  and  that  the 
sole  purpose  of  State  provision  for  the  care  and  treatment  of  the  insane  is 
to  protect  society  only  against  the  lunatic.  The  mentally  raained,  whose 
disordered  minds  guided  by.iUseaseand  not  reason  are  in  danger  of  psychi- 
cal suicide,  are  as  much  entitled  to  protection  from  impending  mental 
death,  as  they  are  to  be  restrained  from  self  physical  violence  or  destruc- 
tion. 

FunLOUGHiNG  THE  Insane. — The  recognized  necessity  of  depleting 
the  large  State  hospitals  for  the  insane,  as  well  as  the  well-known  precau- 
tions essential  to  guard  against  premature  discharges,  and  the  consequent 
endangering  of  relapses,  and  the  apparent  necessity  in  some  instances, 
wheie  the  mental  ^tateof  the  patient  seems  to  reach  a  certain  point  in  the 
direction  of  convalescence  and  then  to  become  stationary,  has  lead  to  the 
practice  in  this  country  and  England  of  furloughing  certain  cases,  i.  c, 
giving  them  only  a  conditional  discharge,  so  that  if  they  relapse  or  do  not 
improve,  they  may  be  restored  to  the  asylum  without  the  formality  of  a 
recomraitmenr.  The  Inspector  General  of  the  insane  in  France  recently 
favored  the  adoption  of  a  similar  system. 

It  would  be  a  wise  improvement,  we  think,  in  certain  instances,  when 
friends  or  the  patient's  estate  will  meet  the  expense,  to  temporarily 
discharge  such  case  to  reside  for  a  while  in  some  of  the  private  homes  for 
the  insane  and  nervous,  like  '"Bellevue"  "Burn  Brae,"  "The  Highlands,"  or 
"Sunnyside." 

A  Hint  to  our  Hospitai-  Friends.*— "An  urgent  and  imperative 
duty  is  imposed  upon  those  who  have  special  opporrunities  of  studying 
and  investigating  nervous  diseases.  It  is  pre-singly  incumbent  upon  them 
to  improve  their  opportunities.  It  behooves  them  to  add  some  quota  to 
our  knowledge  of  the  physiology  and  pathology  of  the  nervous  system. 

To  few  is  it  given  to  penetrate  mysteries  or  flash  forth  discoveries, 
but  to  many  is  permitted  to  prepare  the  way  for  such  enlightenment. 
Every  fact  faithfully  observed,  every  experiment  judiciously  perfoiTned,  is 
a  step  gained  on  the  path  of  progress.  It  is  upon  asylum  officers  that-the 
obligation  to  watch  and  interrogate  nei-vous  diseases  most  heavily  fiills, 
for  their  opportunities  of  doing  so  are  peculiarly  great  and  excellent.  Our 
lunatic  hospitals  are  stored  with  only  too  vast  an  accumulation  of  patho- 
logical material,  while  their  organization  affords  unusual  facilities  for 
observation  and  research.  The  public  are  entitled  to  look  to  them  and  their 
medical  officers  for  no  small  subsides  to  scientific  medicine  and  for  practical 
aid  in  stemming  the  great  and  growing  tide  of  insanity,  and  allied  diseases 
that  overwhelms  so  many  valuable  lives." 

•.J.  Crichton  Browne  preface  to  West  Riding  Asylum  Reports,  1875. 


•560  Editorial. 


Institctk  of  Hkredity. — A  movement  of  va-t  and  inestimable 
si<rnilic-ance  and  importance  is  being  inauj^urated  by  Mr.  Lorin;^:  Moody, 
of  Boston,  wbich  indicates  tbat  tlie  public  mind  is  beirinniiijj  to  give 
thouirlit  to  a  subject  wiiicb  greatly  concerns  the  future  welfare  of  the 
human  family,  and  seelving  to  avert  the  not  impossible  calamity  (unless 
intolligeut  effort  is  made  to  avert  it  through  prevention  of  hereditary 
traiismif^sion).  of  f  imilj'^  degeneration,  race  deterioration  and  ultimate 
extinction.  We  wisli  tiiis  important  movement  the  aid  it  merits  from  all 
thoughtful  and  philantrophic  people. 

MoNUMEXT  TO  Broca  — The  commissioners  appointed  by  the  An- 
thropological Society  of  Paris,  to  obtain  subscriptions  for  the  erection  of 
a  monument  to  the  memory  of  this  illustrious  medical  savant,  will  receive 
donations  througli  the  treasurer  of  the  society,  M.  Leguay,  No.  3  Rue  de 
la  Sainte-Chapelle,  Paris. 

While  it  is  gratifying  to  see  the  memory  of  one  so  illustrious  thus 
publicly  perpetuated,  it  is  still  more  gratifying  to  know  that  M.  Broca  has 
erected  for  himself  a  more  enduring  monument  tlian  inscribed  brass 
or  m  irble  column.  Monument  or  no  monument,  upon  Broca's  name  will 
be  centered  a  share  of  the  world's  praise,  so  long  as  tlie  speech  centers  of 
mankind  do  not  become  too  aphasic  to  applaud  the  worthy  achievements 
of  the  great. 

Statute  to  Pinkl. — The  Municipal  Council  of  Paris  having,  on  the 
recommendation  of  M.  Dubois,  autliorized  the  Medico-Psychological 
Society  to  erect,  in  the  Place  de  la  Salpeiriere,  a  statue  to  this  illustrious 
reformer,  subscriptions  have  been  opened  tliere  by  this  society  for  this 
purpose. 

The  Index  Mkdicus. — The  worth  of  this  valuable  periodical  index 
of  medical  literature  to  every  student  of  medicine  and  enlightened 
physician  is  so  great,  that  we  hope  to  hear  in  ISSl  of  its  being  suc- 
cessfully and  permanently  established  on  a  paying  basis.  It  is  so  important 
an  aid  to  the  medical  journals,  that  they  alone  ought  to  support  it,  and  we 
are  prepared  to  join  with  any  fifty  journals  in  contributing  the  subscrip- 
tion price  for  an  extra  copy  additional  to  the  exchange  copy ,  if  the 
publi--hers  are  not  now  making  the  enterprise  pay. 

The  American  Neurological  Society  oifers  $500  for  the  best  essay 
upon  the  "  Functions  of  the  Optic  Thalamus."  Tlie  comiuittee  to  re- 
ceive and  decide  upon  the  merits  of  the  essays  are  Drs.  Miles,  of 
Baltimore;  Squires,  of  New  York;  Jewell,  of  Chicago.  The  essays  are 
to  be  sent  in  before  the  meeting  of  tlie  society  in  1SS2. 

Heflex  Asiiima. — Drs.  Wm.  Barrett,  of  this  city,  and  J.  W.  Collins 
of  Colorado  Springs,  Col.,  have  recently  had,  each,  a  case  of  Asthma  in 
women,  in  whom  relief  followed  surgical  treatment  of  the  uterus. 

Dr.  Dvce  Duckworth,  of  Edinburgh,  in  "Brain,"  for  April,  very 
plausibly  assigns  gout  a  place  among  the  diathetic  neuroses. 

Dr.  Judson  B.  Andrews,  a  gentleman  of  extensive  experience  as 
Senior    Assistant  Physician  of  the  New  York  State  Lunatic    Asjlum, 


Editorial.  561 


Utica.  and  Associate  Kditorof  the  Americiin  Journal  of  Insanity,  of  wide 
culture  and  raie  administrative  ability.  h;is  been  cliosen  to  organize  and 
put  in  successful  operation  the  New  State  Hospital  forthe  Insane,  located  at 
Buifalo.  X.  Y.  We  unite  in  the  sentiment  so  generally  expressed,  through- 
out that  ii^tate.  of  approval  of  this  excellent  selection.  The  Buffalo  Asylum, 
under  his  management,  will  assume  a  leading  position  among  the  institu- 
tions for  the  care  of  tlie  insane  in  this  country.  'J  he  Buffalo  Medical  College 
has.  in  its  announcement,  nrtified  the  profession  of  tlie  addition  to  its 
curriculum  of  a  course  of  lectures  on  nervous  diseases,  by  Dr.  Andrews. 
Tliis  is  an  important  and  valuable  addition  to  its  lecture  course.  Dr. 
Andrews  is  the  right  man  in  the  right  place. 

Dr.  Gundry.— We  congratulate  the  College  of  Physicians  and 
Surgeons,  of  Baltimore,  Maryland,  on  the  accession  of  Dr.Bichard  Gundry, 
Superintendent  and  Physician,  to  the  Maryland  Hospital  for  the  Insane,  to 
its  staff  of  lecturers.  Dr.  Gundry  will  lecture  on  'Insanity,''  a  field  of 
usefulness,  for  which  his  long  experience  in  clinical  psychiatry  peculiarly 
fits  him. 

Df-aiise  of  Dr.  E.  R.  Hun.— In  the  death  of  Dr.  Him,  the  Albany 
Medical  School  has  lost  a  valuable  member  of  its  faculty ;  clinical  psychi- 
atiy,  an  able  teacher;  society,  a  useful  member.  Dr.  Hun  was  but  thirty- 
six  years  old  when  he  died,  but  in  his  life-time  he  did  some  good 
professional  work  Mhich  will  live  after  him.  He  was  once  on  the  Medical 
Staff  of  tlie  New  York  State  Lunatic  Asylum. 

The  Hospital  for  the  Insane,  at  Elgin.  Ills.,  lias  recently  added  to  its 
medical  staff  a  sp(  cial  pathologist. 

In  this  connection  \\e  may  mention  that  theCliief-Physician  of  another 
Western  hospital  for  the  insane,  recently  inquired  if  we  could  recommend 
a  young  medical  man  with  a  fondness  for  miscroscopy  for  the  position  of 
Assistant  Physician.  We  are  pleased  to  chronical  facts  like  these  in  refer- 
ence to  the  younger  institutions  of  the  West. 

The  New  State  Ixstitltion  for  the  Insane,  at  Kankakee.  Ills.,  is 
making  trial  of  two  large  cottages.  Dr.  Kilbourue,  of  Elgin,  has  two  small 
ones  which  he  thinks  will  answer  well  for  a  certain  limited  numlier 
of  Ills  patients. 

Dr.  F.  E.  Eobinson's  Charts  of  the  Cranial  Nerves,  arterial 
.system  and  topographical,  are  excellent,  cheap  (65  cents  a  set  by  mail.)  and 
convenient  in  size.  Every  student  should  have  them  in  his  study  room. 
Address  :  No.  303  Ninth  street.  Brooklyn,  N.  Y. 

C.  L.  Cherot.  1624  Chestnut  street.  St.  Louis,  is  an  excellent  Cupper 
and  Leecher,  whom  Ave  commend  to  the  profession. 

Back  Numbers.— One  dollai- will  be  paid  tor  every  copy  of  number 
one  of  this  jouinal  sent  to  this  office. 


^Id^EYIEW-fDEP^l^'FMENT;!^ 


"The  Cake  of  the  IxdAXE  and  Theik  Legal  Control.''* — A  bree/e 
is  refreshing,  even  a  storm  luay  be  enjoyed,  but  this  book  sweeps  tliroiig-b 
nearly  all  the  present  territory  of  British  "asylunidom"  like  a  cyclone. 

The  opinion  is  broadly  stated  that  '-no  change  of  the  law  can  he 
satisfactory  which  does  not  contemplate  the  eventual  abolition  of  all 
proprietary  lunatic  asylums.'"  (p.  130).  The  autlior,  "sows  tiie  wind."  with 
no  timid  hand,  and  fe;u-s  not  the  reaping  of  tlie  whirlwind.  In  fact,  he  sows 
the  Whirlwind  also.  He  would  "roll  back  all  (iieece  and  besom  wide  the 
plain''  with  such  a  tornado  of  official  and  public  indignation  as  would 
leave  standing  in  its  pathway  no  present  English  proprietary  asylun), 
save  only  "such  as  may  survive  under  some  other  name,  for  persons  of 
damaged  mind,  as  »oZMni!arj(  retreats." 

For  these  establishments  the  author  proposes  to  substitute  "the 
system  of  State  asylums  genera!  throughout  the  United  States,  and 
universal  in  Holland,''  "provided  by  the  State  and  managed  by  Boards  of 
Governors,"  pp.  130  and  131.  The  authors  recent  visit  to  this  country, 
and  pretty  general  inspection  of  our  admiralty  managed  State  hospitals 
"  such  as  have  been  put  to  the  test  of  trial  and  already  exist  in  successful 
practice,"  seem  to  have  made  upon  liim  a  very  favorable  impression,  but 
he  gives  no  evidence  anywhere  in  his  book  of  familiarity  with  our  estima- 
ble piivate  American  homes,  for  the  wealthy  insane  and  nervous. 

The  autlior's  "  fullest  and  latest  experience  has  convinced  him  that  the 
curative  effects  of  asylums  have  been  vastly  overrated,  and  that  tliose  of 
isolated  treatment  in  domestic  care  have  been  greatly  under  valued."  He 
thinks  the  "  care  and  treatment  of  the  quiet  and  harmless  cases  of  insanity 
by  the  open  medical  profession  in  domestic  life,  in  single,  double  or  treble 
cases  ought  to  be  encouraged  by  the  law  and  not  discouraged  as  it  is  at 
present"  in  Great  Britain.  By  domestic  treatment,  he  does  not  mean  the 
patients'  own  home.  Undoubtedly  the  treatment  of  many  cases  on  the 
domestic  plan,  where  jiecuuiary  resources  are  ample,  is  quite  feasable  if 
the  cases  are  judiciously  chosen  and  treated  by  medical  men  of  special 
skill  and  experience,  but  to  treat  them  on  the  voluntary  plan  is  not  so 
practical,  for  the  majority  of  even  the  quite  and  harmless  insane.  Patients, 
if  compelled  to  choose  between  the  enforced  residence  in  a  large  State 
hospital  and  domestic  treatment,  or  that  of  a  private  asylum  away  from 
home,  might  be  induced  to  prefer  and  accept  the  latter,  as  the  only  alter- 
native left  them,  just  us  chrome habiiuea  of  the  hospital. after  being  used  to 
legal  restraint,  will,  if  put  ontheii  good  behavior  and  furloughed.  go  home 
and  in  many  instances. conduct  themselves  with  sufficient  propriety,  though 
in  the  beginning  of  their  madness  and  before  the  State  had  demonstrated 
its  power  and  determination  to  restrain  their  erratic  conduct  within 
ceruin  limits,  they  were  not  so  tractable. 


Reviews.  563 


We  do  not  see  the  logic  either  of  limiting  the  domestic  plan  to  the 
treatment  of  single,  double  or  treble  cases  only,  or  of  making  the 
domestic  plan  voluntary  with  the  patient,  and  the  state  plan  compul- 
sory. If  three  may  be  thus  treated,  why  not  a  larger  number  in 
one  household  ?  The  best  public,  corporate  and  private  hospitals  and 
homes  for  the  insane  have  facilities  of  family  groupings  of  from  eight  to 
twenty  or  more.  The  more  the  better,  if  they  can  be  congenially  associated. 
Some  patients  do  best  alone,  some  fare  badly  thus,  some  improve  in  small 
group*  and  some  in  crowds,  and  some  do  best  by  often  changing  them 
from  solitude  to  company  and  back  again  according  to  the  varying  aspects 
of  their  mental  aberration.  Some  patients  are  damaged  by  coming  in 
conbict  with  other  insane,  and  some  are  benefited  by  obseiving  and 
reflecting  upon  the  insanity  of  others.  Associations  and  surroundings 
for  the  insane  should  be  modified  according  as  they  tend  to  excite  or 
suppress  antipathies  or  delusions.  Thus  the  proposition  of  the  best 
disposition  of  the  insane  widens  as  cases  multiply.  Psychiatry  is  the 
broadest  field  of  medicine,  and  the  treatment  of  insanity  and  the  manage- 
ment of  the  insane,  with  all  of  its  difiiculties  and  embarrassments,  must 
sooner  or  later  occupy,  as  they  are  now  more  than  ever  engaging,  general 
medical  attention. 

The  author  refers  to  asylum-made  lunatics,  from  the  error  of  too  long 
detention  in  the  proprietary  establishments,  but  nowhere  notes  the  greater 
evil  of  the  home-made  insane,  whose  minds  are  ruined  hy  the  often  tardy 
and  vacillating  course  of  friend?,  and  eflbrts  too  long  made  to  effect  conceal- 
ment and  cure  at  home,  or  to  the  confirmed  insanites  from  premature 
removal  from  hospital  restraint  and  treatment. 

The  chapter  on  commitment  contains  the  following  preliminary  con- 
cession— "If  asylums  were  really  hospitiils,  insanity  a  brief  disease  and  no 
continuous  restraint  of  personal  liberty  required  in  its  treatment,  it  is  not 
obvious  that  commitment  papers  would  be  at  all  needful."  Then  why 
not  make  all  the  English  asylums  really  hospitals,  and  provide  adequately 
for  abbreviating  the  disease  and  the  necessary  restraints,  by  lawful  encour- 
agement of  early  and  prompt  commitments,  and  lawfully  enjoining  the 
"non-restraint"  our  Briti>^h  cousins  are  constantly  talking  about. 

All  community  life  of  sane  persons,  even,  is  a  regulated  liberty,  in 
"which  the  individual  must  conform  to  the  prescribed  usages  of  society  and 
practice  some  self-restraint,  and  if  a  sane  individual  falls  sick  the  modi- 
fication of  his  liberty  which  his  disease  imposes,  is  not  essentially  different 
in  degree  from  that  which  mental  disease  most  often  requires.  Hospital 
life  for  the  sane  as  well  as  the  insane  is  rather  a  regulated  than  suppressed 
liberty. 

He  thinks  the  English  Legislature  in  its  laws  respecting  the  commit- 
ment of  insane  persons  "for  ways  that  are  strange,"  equal  those  of  the 
'' Heathen  Chinee,"  which  even  Johny  Bull  knows  "are  peculiar."  He 
denounces  the  law  which  requires  the  separate,  instead  of  conjoint  exam- 
ination of  insane  persons  by  certifying  physicians  as  "a  strange  embodi- 
ment of  jealousy  and  distrust,"  and  unwisely  at  variance  with  the  custom 
in  all  other  diseases. 

He  disapproves  of  the  mere  certificate  of  insanity  without  the  medical 


664  "Reviews. 


man's  assio-ning  his  reason?  and  the  failure  to  discriminate  between  the 
unsoundness  of  mind  associated  with  cono-enital  deficiency,  the  enfeehJe- 
ment  of  disease  or  natural  decay  and  the  homicidal  or  suicidal  lunatic,  or 
the  raving  maniac,  in  these  certificates— the  same  certificate  for  I  he  asylum 
the  hospital,  and  the  home,  the  lunatic,  imbecile  and  infirm  of  mind— he 
condemns,  and  we  think  very  justly. 

The  whole  chapter  on  certificates  is  suggestive  reading,  yet  the  state- 
ment made  on  pages  20  and  27  that  -'  no  person  of  unsound  mind,  may  by 
common  law  be  rightfully  placed  in  an  asylum,  if  it  can  be  proved  that  he 
is  perfectly  managable,  safe  and  harmless."  in  the  enjoyment  of  his  liberty 
is  moot;ible.  The  ins.-me  man  is  a  changed  man.  He  is  not  his  natural- 
self.  Not  to  treat  his  malady  or  regulate  his  conduct  for  his  welfiire 
because  he  may  not  be  hanuless  toothers,does  not  confortn  to  the  common 
sense  idea  of  justice  to  the  insane.  While  tlie  sane  mjin  is  entitled  to  life 
liberty  and  the  voluntaiy  pursuit  of  happiness  in  his  own  way.  provided 
lie  harms  no  one  else  in  its  pursuit,  the  insane  man.  in  his  afHiction.  is 
entitled  to  such  a  degree  of  restraint  and  modified  liberty  as  his  malady 
requires,  in  order  to  bring  about,  if  possible,  a  speedy  restoration  of  his 
natural  capacity  to  enjoy  life,  liberty  and  happiness,  in  a  rational  manner 
One  of  the  rights  of  the  insane  is  to  have  his  liberty  regulated  in  his  ovin 
in^eres^  if  by  so  doing  a  chance  is  afforded  for  mental  restoration.  No 
community  has  any  more  right  to  let  a  curable  insane  person  pursue  his 
own  morbid  inclinations  to  his  own  hurt  and  mental  ruin,  even  though  he 
be  ha|)py  in  his  destructive  course,  and  harm  no  one  but  himself  than  to 
permit  a  delirium  tremens  patient  to  w  alk  out  of  an  upper  window  in  enjoy- 
ment of  his  liberty,  under  the  delusion  that  be  is  going  to  fly  to  heaven. 
The  case  is  different  with  harmless  and  hopeless  or  chronic  maniacs,  where, 
while  the  ineradicable  n;f  ntal  scar  of  a  spent  disease  still  remains,  enough 
of  rationality  persists  to  (n:lle  the  individual  to  apprtciate  and  enjoy 
liberty.  To  the  latter,  hospitals  for  the  insane  should  be  closed,  except 
as  voluntary  resorts. 

In  the  best  regulated  civil  governments  the  natural  liberty  of  the  citizen 
is  abridged  by  law,  lie  is  compelled  to  yield  up  certain  rights— yet  he  is 
allowed  the  largest  possible  liberty  compatible  \\itl)  tiie  individual  and 
collective  welfare.  So  it  should  be  with  the  insane.  He  should  have  the 
largest  i)0ssible  liberty  compatible  with  his  welfare,  and  should  be 
deprived  only  of  so  much  as  is  necessan-  for  his  own  welfare  or  protection 
from  the  ravages  of  his  disease,  or  for  the  welfare  or  protection  of  society 

We  hold  it  to  be  the  duty  of  the  State  to  do  for  the  insane  man  in  his 
affliction  as  he  would  wish  to  be  done  by  were  he  sane  enough  and  well 
enough  in  mind  to  determine  what  would  be  best  for  him.  "To  be  pro- 
nouced  insane  by  physicians,  by  a  judge  or  jury  does  not  mean  "itnp7-ison- 
nunt  for  months,  for  years,  or  for  life ;"  or  to  put  it  in  another  way,  "that 
there  is  a  disease  which  reduces  its  victims  to  a  level  with  persons  accused 
of  crime  and  exposes  them  to  loss  of  liberty  and  happiness.''  In  the  same 
sense  that  a  criminal's  liberty  and  happiness  are  taken  fonu  him,  this  is  not 
true.  The  restraint  of  the  insane  is  in  no  sense  penal,  though  it  does  unjustly 
on  some  States  expose  the  wealthy  to  loss  of  property  by  requiring  them 


Reviews.  565 


to  pay  for  support  in  the  very  institution  their  taxes  have  contributed  to 
build  and  sustain. 

In  the  properly  organized  State  hospitals  for  the  insane  of  this 
country,  such  as  Dr.  Bucknill  wishes  to  introduce  into  Great  Britain  in 
lieu  of  the  English  proprietary  asylums,  liberty  is  regulated  according  to 
the  extent  and  nature  of  the  disease,  just  as  in  general  liospitals,  the 
liberty  of  the  patient  is  controlled.  The  man  with  a  bullet  wound  in  his 
brain,  an  attack  of  typhoid,  a  sunstroke,  or  a  fever,  may  b«»  taken  to  the 
hospital  and  restrained  of  his  liberty,  and  no  one  thinks  of  suggesting  that 
he  is  reduced  to  the  level  of  a  criminal  in  consequence.  When  in  the  battle 
of  life  a  citizen  is  mentally  wounded,  it  is  just  as  much  the  duty  of  the 
State  to  take  proper  care  of  that  injured  mind  as  it  is  incumbent  on  the 
same  power  to  care  for  its  soldiery  when  they  fall  before  the  foe,  and 
in  the  one  instance  as  in  the  other,  no  expense  or  means  should  be  spared 
which  promises  to  promote  the  comfort  and  restoration  of  the  stricken 
one.    No  cry  of  economy  should  stand  in  the  w'ay  of  duty  ! 

While  we  do  not  subscribe  to  all  the  \iews  of  Dr.  Bucknill,  and  while 
we  know  there  is  another  side  to  many  of  the  questions  mooted  in  this 
book,  held  by  Lord  Shaftesbin-y.  the  Journal  of  Psychological  Medi- 
cine and  by  others  equally  eminent  and  capable  in  Great  Britain, 
we  do  not  hesitate  to  say  that  it  is  a  vigorous  attack  by  a  strong  arm 
upon  the  proprietary  institutions  for  the  treatment  of  the  insane  in  Great 
Britain.  Respecting  such  establishments  of  this  kind  as  are  conducted  by 
non-professional  men  as  purely  business  ventures  upon  the  principle  of 
gain,  alone,  and  without  the  higher  sentiments  of  professional  pride  and 
aspiration  after  progress  in  psychiatry,  which  characterizes  the  true 
physician  in  rapport  with  his  profession,  we  do  not  hesitate  to  join  our 
condemnation  with  that  of  Dr.  BucknilFs,  but  the  indiscriminate  attack 
upon  all  the  proprietary  establishments  of  the  Island,  because  they  are  con 
ducted  on  the  principle  of  gain  is  not  logically  tenable.  The  principle 
of  gain  is  a  universal  and  underlying  principle  of  human  conduct 
and  is  not  vicious  peme.  It  has  the  sanction,  even,  of  Holy  Writ.  Take 
aw'ay  the  principle  of  gain  and  the  wheels  of  human  progress  woidd  well 
nigh  stand  still.  Mighty  things  for  the  good  of  the  race  have  been 
done  through,  pursuit  and  by  the  aid  of,  the  "mighty  dollar."'  The 
same  argument  that  Dr.  B.  uses  against  the  proprietary  establish- 
ments for  the  insane  of  Great  Britain  would  cast  suspicion  upon 
all  the  physicians  and  pharmacies  of  T^ondon,  and  destroy  confidence 
between  man  and  man  in  all  matters  of  trade  The  book  Avill  probably  do 
much  good  to  the  cause  of  the  insane  by  attracting  additional  public 
attention  to  this  class,  and  awakening  new  interest  in  them  and  their 
treatment  thus  leading  to  the  correction  of  abuses  where  they  may  exist, 
and  securing  rights  where  they  may  have  been  invaded. 

Such  proprietary  establishments  as  are  not  what  they  ought  to  be 
will  probably  either  go  out  of  existence  or  rise  to  a  higher  plane  of  use- 
fulness. Mere  boarding-house  places  of  confinement  for  the  insane  ought 
to  go  out  of  existence  everywhere.  The  denial  of  freedom  to  the  lunatic  on 
the  sole  ground  of  lunacy  independently  of  hopes  of  recovery  or  con- 
siderations of  personal  or  public  safety,  ought  not  to  be  allowed  anywhere. 


666  Reviews. 


and  something  more  than  the  mere  fact  of  insanity  should  be  alledg(  d  to 
justify  commitments. 

But  in  Dr.  Biicknill's  book  we  discover  no  valid  argument  against 
properly  conducted  private  enterprises  for  the  wealthy  insnre.  who  wish 
to  avoid  tlie  public  liospitalp,  and  go  where  tlie  highest  skill  in  psychiatry 
may  be  secured,  as  it  may  be  secured  in  the  treatment  of  other  diseases,  on 
the  principle  of  gain  to  the  physician  who  will  and  is  qualified  to  give  his 
services  in  this  direction.  In  this  country  wliere  the  tenure  of  office  of 
tlie  State  hospital  superintendent  is.  from  political  and  oiher  riciows  con- 
:5iderations,  made  so  unceitain,  no  better  field  of  usefulness  is  left  to  the 
ex-suporintendent  then  to  give  the  benefits  of  his  experience  to  the 
paying  class  of  the  insane  public,  in  a  private  way. 

This  is  about  the  only  compensation  of  the  vicious  principle  of  rotation 
in  oflice,  for  political  reasons  unhappily  in  vogue  in  some  sections  of  this 
country,  viz. :  tliat  it  better  fits  some  of  the  professioo  tlian  before,  for 
treating  the  insane  in  private  homes  and  hospitals. 

Physiology  vs.  Philosophy.*— The  author  essays  a  comparison  of 
some  of  the  more  important  claims  of  science  and  philosophy,  in  helping 
to  elucidate  the  still  apparently  unsettled  probhm  of  life  and  mind  in  their 
relation  to  body,  pointing  out  the  contrasts  and  agreements  of  the  two, 
and  the  reader  is  reminded  that  in  the  ages  gone  by  some  of  the  grandest 
discoveries  ever  made  by  means  of  which  science  has  been  built  up  step  by 
step  and  the  relation  of  our  world  to  the  universe  besides,  made  known, 
'^^  have  come  to  us  through  the  door  of  philosophy,  while  science  was  in 
the  cradle  of  its  infancy."  'J  he  doctor  thinks  the  assistance  of  philosophy 
in  helping  to  elucidate  some  of  the  yet  unsolved  problems  of  life  ought 
not  to  be  ignored,  and  are  in  darger  of  being  overlooked  as  something 
unreal  and  impracticable. 

The  attitude  of  physiology  is  set  forth  as  viewing  man  as  "an  animal 
only'*  with  "no  duality  of  his  nature.'*  a  "unit— entire,"  and  different  from 
other  animals  in  degree  only,  beginning  with  '•'Protoplasm  as  the  basis  of 
all  forms  of  living  matter,  and  Protozoa  as  the  beginning  of  animated 
stiucture.  Fromthise  lumogeneous.  unindividualized  masses  in  which 
are  neither  cells,  bkod-vesscls.  nor  nerves,  without  stomach,  nor  lungs; 
but  sensible  to  external  stimuli,^''  she  passes  up  to  those  having  the  rndi- 
nient  of  a  nervous  sysiera,  viz.:  fibres  connected  with  a  cell  to  a  complexity 
of  fibres  and  cells,  until  brains  with  only  white  matter  are  reached,  and  next, 
to  such  as  have  the  nidimentary  cen  bral  Ik  misi)heres  with  their  tliin  layer 
of  gray  matter  near  the  optic  lobes  as  in  fi>hes;  then  the  bird,  with  a  little 
more  gray  matter,  thm  the  nijinimalia  up  to  tlie  monkey  and  man,  with 
their  greatly  increased  areas  of  graj'  cerebral  substance. 

This  gradual  increase  of  the  cerebral  gray  is  physiologj'*s  account  of 
the  gradual  ascent  of  man  from  the  rudimentary  forms  of  life  and  the 
proof  that  man  and  tlie  animals  below  him  in  intelligence,  difl'er  only  in 
degree  and  not  in  nature. 

It  certainly  furnishes  a  physical  explanatory  basis  of  the  many  resem- 

•A  ehoit  stuily  by  Dr.  H.  P.  Steams,  Sti)  erinteiident  and  Pliysician  of  the 
Retreat  for  tlie  Insane  of  Harlfonl,  Conn.  Read  before  tlie  N.  E.  Psychological 
Society,  May  9,  1880. 


Reviews,  567 


blances  of  m.an  to  the  members  of  the  animal  kingdom  below  him,  though 
the  author  does  not  note  this. 

The  autlior  does  not  dispute  the  claim  of  physiology,  that  in  propor- 
poition  ns  the  cerebral  cortex  is  increased  in  volume  and  texture  in  like 
proportion  is  intelligence  increased,  the  bird,  in  this  respect,  excelling  the 
fish,  the  lower  forms  of  the  mammalia,  the  bird,  and  the  higher  mammals, 
the  lower." 

But  physiology  goes  no  fei  ther,  while  philosophy,  conceding  all  the 
advances  made  by  physiology,  takes  a  secure  step  higher  and  beyond  the 
reach  of  physiology  pure  a»d  simple. 

The  author  has  fau-ly  stated  the  attitude  of  physiology  towards  mind. 
So  far  as  the  latter  can  enable  us  to  see. there  exists  no  mind  independent  of 
matter  ;  no  function  without  precedent  bodily  form.  The  limitations  thus 
imposed  in  the  nature  of  things  on  the  researches  of  physiology  demon- 
strate tiie  need  of  its  hand  maiden — philosophy. 

There  is  a  philosophy' of  mental  as  there  is  a  physiology  of  cerebral 
life  This  we  take  to  be  tiie  drift  of  the  author's  able  effort,  which  to 
portray,  more  clearly  in  the  author's  own  words,  we  regi-et  that  we  have 
not  more  space. 

This  essay  of  Dr.  Steam's  is  entertaining  and  instructive  reading 
throughout. 

L'Arciiivfs  DE  Neurologie,  a  quarterly  review  of  nervous  and  mental 
diseases,  published  under  the  direction  of  J.  M.  Charcot,  with  the  assist- 
ance of  MM.  Amidon.  Ballet,  Bitot,  Bouchereau,  Brissaud,  Brouardel, 
Cotard,  Debove,Duret,Duval,  Fere,  Ferrier,  Gombault,  Joffroy,  Landouzy, 
Magnan,  Neumann,  D'olier,  Pierret,  Pitres,  Raymond,  Regnard,  Richer, 
Seguin,  pere  ti  Jils;  Talamon,  Teinturier,  Thulie,  Troisier,  Vigouroux, 
Voisiu.      Editor  in  chief,  Bourneville ;  Secretary,  H.  CI.  DeBoyer. 

This  first  number  of  a  new  journal  devoted  to  diseases  of  the  nervous 
system  is  full  of  choice  and  interesting  material.  The  introduction  sets 
forth  the  casus  essendi  of  the  journal,  alluding  to  the  remarkable  progress 
atti.iued  in  ihe  anatomy  and  physiology  of  the  nervous  system,  and  the 
great  variety  and  number  of  observations  made  in  the  field  of  neuropa- 
th ology.  He  notes  the  fact  that  for  a  long  time  the  vaiious  papers  upon 
these  subject  have  been  scattert  d  through  the  journals  on  general  medicine 
While  in  other  countries,  there  have  for  some  time  been  journals, 
devoted  specially  to  this  department  of  medical  investigation  and  practice, 
among  which  M.  Charcot  specifies  the  Alienist  and  Neurologist,  there 
has  heretofore  been  no  such  journal  in  France  except  the  Annals  Medieo- 
Psyehologigues,  which  is  devoted  especially  to  mental  diseases,  and  it  is  for 
the  purpose  of  supplying  this  want  that  the  Archives  of  Neurology  has 
been  established. 

He  maintains  the  importance  and  the  necessity  of  specialism,  but 
cautions  the  specialist  not  to  loose  sight  of  the  totality  of  the  symptoms, 
which  show  the  condition  of  the  whole  economy. 

Under  the  heading  of  Anatomy,  we  find  an  article  by  MM.  Debove  and 
Gombault,  "On  the  Decussation  of  Sensitive  Fibres  of  ihe  Bulb,"  one  byM. 
Debove  "On  the  Method  of  Making  Preparations  of  the  Cord."'  Under  ex- 
perimental pathological  anatomy  there  is  an  elaborate  paper  byM.  Gom- 


568  Reviews. 


baiilt,  ''A  Contribution  to  the  Anatomical  Study  of  Subacute  and  Clironic 
Parenchyemetpus  Neuritis."  This  is  illustrated  with  two  admirably- 
executed  litho<rrapliic  plates.  The  department  of  patholofry  is  represented, 
by  a  paper  entitled  "Researches  upon  the  Motor  Incordination  of  Ataxic 
Patients,"  by  MM.  Debove  and  Boudet  of  Paris.  In  tlie  Mental  Clinic, 
E.  Macruan  writes  "On  the  Co-existence  of  several  Deleriuras  of  different 
Nature  in  the  same  Insane  Patient."  M.  Bourneville  supplies  ''A  contribu- 
tion to  the  Study  of  Idiocy,"'  whicli  is  to  be  the  first  of  a  series,  and  is., 
illustrated  with  two  lithoofraphic  plates  of  the  brains  of  two  subjects. 

M.  Debove  contributes  to  the  dei)artment  of  Therapeutics,  a  note 
upon  two  cases  of  hemiple^a  of  motion  and  sensation,  cured  by  applica- 
tion of  magnets.  Dr.  H.  C.  DeBoyer,  has  a  "Critical  Review"  of  the  subject 
of  cephalic  thermometry. 

The  last  fifty  pages  of  the  Archives  is  occupied  with  selections  from 
other  journals,  under  the  headings  "Review  of  Anatomy','  "Review  of 
Physiology,  etc,"  and  notes  and  reviews  of  books. 

Under  such  auspices  as  attend  the  inauguration  of  the  Archives  its 
success  is  fully  assured,  and  we  anticipate  finding  its  numbers  filled  with 
abundance  of  material  of  the  highest  value,  quite  equal  to  that  which 
renders  the  first  number  so  attractive  and  interesting. 

Rumbold's  Hygienk  of  Catarrh*  is  a  book  of  sanitary  precepts 
for  the  guidance  of  the  victims  of  this  obstinate  and  almost  universal 
malady,  given  as  the  result  of  the  author's  long  experience  of  tlii.s  annoy- 
ing and  mischief-breeding  affection.  Placed  in  the  hands  of  the  patients 
of  the  country  practitioner,  it  will  supplement  and  save  much  talk.  The 
city  doctor  usually  sends  .^uch  cases  to  the  specialist,  who  is  better 
prepared  than  he  is,  with  suitable  appliances  to  take  this  enemy  of  health, 
happine.ss  and  comfort  '■'by  the  throat,''''  While  acknowledging  our  indebt- 
edness to  the  author  for  this  interesting  little  work,  we  must  record  our 
exceptions  to  the  author's  injunction  to  his  patients,  against  frequent 
change  of  their  underclothing,  and  note  what  appears  inconsistent  advice, 
in  advising  patients  to  eat  such  food  as  is  agreeable  to  them,  while  prohib- 
in<r  cnndy  and  cakes  to  children.  Also  to  lus  views  in  regard  to  the  influence 
of  fretfuUness  and  anger  on  the  restorative  progress  of  nasal  catarrh. 

We  see  iio  logical  ditFerent-e  between  moderate  quantities  of  uncolored 
candy  and  light  cakes  at  proper  times  of  the  day,  and  buckwheat  cakes  and 
syrup,  which  are  never  or  ought  never  to  be  refused  to  children  in  due 
season.  The  book  before  us  is  the  first  part  of  a  complete  prospective 
treatise  on  the  subject  by  the  same  author. 

NOTA  Di  Clinica  MEDiCA.f— Z)e^  Professors  Edouardo  Maragliano, 
Oenoa.—\Ye  beg  to  express  our  warm  thanks  to  the  di.stingui.<hed  author  of 
the  above  valuable  brochure,  for  his  polite  transmission  of  a  copy  ot  his 
valuable  practical  observations  on  several   higlily  interesting  forujs  of 

•Hygienic  and  Sanitive  Measures  for  Chronic  Catarrhal  Inflammation  of  the 
Nose,  Throat  and  Ears.  By  Thos.  F.  Kumbold,  M.  D.  Cloth;  pages,  174.  1880. 
St.  LouIb:    Geo.  O.  Rnmbold  &Co. 

tNotPB  of  clinical  medicine,  by  Professor  Edward  Maragliano,  Professor  of 
Pathology,  in  Genua. 


Reviews.  '         569 


disease,  which  he  has  treated  of  with  much  ability,  and  with  that 
precision  of  detail,  wliicli  is  so  chiiracteristic  of  the  present  cultivators 
of  medical  science  in  the  glorious  old  classic  peninsula. 

Professor  M.'s  first  article  is  "Essential  Congenital  Tremor,''  which  is 
illustrated  by  microscopical  tracings,  taken  over  the  muscles  of  the  fore- 
.arm  and  leg.  The  subject  of  the  disorder  was  a  man  who  had  reached  the 
age  of  50,  and  had  been  effected  with  the  muscular  oscillations  from  his 
birth  ;  he  ultimately  became  incapable  of  performing  any  sort  of  work 
Prof.  M.  clearly  diagnoses  the  disease  as  quite  distinct  from  paralysis 
agitans,  disseminate  sclerosis  ov  toxic  t? emor.  and  he  states  that  it  is  the 
.first  case  of  congenital  tremor  that  has  been  placed  on  record. 

Prof.  M.'S  second  article  relates  to  a  case  of  ''EydrocBmic  (Edema''' 
which  he  a*-ciibes  to  poverty,  hunger  and  vagrancy.  He  treated  it 
.rationally  with  plenty  of  good  food  and  preparations  of  iron,  and  though 
several  serious  complications  had  arisen,  he  had  the  pleasure  of  discharging 
the  patient  cured  in  seven  weeks  from  entrance,  with  an  addition  of  4  kilo- 
grams to  his  weight. 

An  important  subject  treated  of  by  Prof.  M.  is  ""Nitrite  of  Amy  I  in 
Epilepsy,'''  to  which  40  pages  are  devoted,  largely  covered  with  tabular 
records,  arranged  in  periods  of  10  days,  showing  the  number  of  fits  nightly 
and  daily,  and  their  character,  as  strong  or  mild,  also  the  number  of  inhal- 
ations administered,  and  the  quantities  used.  We  imagine  the  latter  may 
be  regarded  by  most  of  our  readers  as  critically  liberal.  Prof.  M.  says  he 
began  experimentally  with  2,  3,  5,  6  and  8  drops,  and  being  convinced  of 
the  efScacy  of  large  doses,  he  resolutely  raised  them  from  10  to  40  drops, 
and  never  obsen^ed  any  bad  result.  He  sometimes  extended  the  periods 
of  inhalation  to  15  minutes,  or  even  to  25.  The  conclusion  which  he 
draws  fi'om  his  large  surface  of  figures  is  not  very  encouraging  to  the 
believers  in  the  curative  power  of  nitrite  of  amyl  in  epilepsy  ;  he  says  the 
action  "was  not  persistent,"  and,  ''at  the  most,  it  lasted  only  for  ten  days, 
after  being  suspended  ;''  but  he  thinks  the  results  obtained  by  him  should 
encourage  us  to  give  it  a  full  trial. 

W  e  much  regret  that  owing  to  the  lateness  of  aiTival  of  Prof.  M.'s 
favour,  we  are  unable  to  devote  to  it  that  extent  of  space  which  we  would 
very  gladly  award  to  it.  We  may,  however,  in  our  next  issue,  present  to 
our  readers,  some  textual  extracts,  translated  into  our  own  language. 

Thk  Hypodermic  Injection  of  Morphine— Its  History,  Advan- 
tages AND  Dangers. — (Based  on  the  experience  of  S60  physicians),  hy  H.  H' 
Kane,  M.  D. — N.  Y. — The  author  has  given  us  a  carefully  prepared  work  on 
a  subject  of  interest  to  every  physician.  It  is  no  easy  task  to  supply  the 
profession  with  an  interesting  and  instructive  thesis  on  a  subject,  the  practi- 
cal bearing  of  which  every  one  has  been  dilligently  studying  for  a  number 
of  yefirs.  This  makes  Dr.  Kane's  work  all  the  more  meritorious.  He  has 
compiled  the  experience  of  360  physicians, — supplying  a  clinical  record, 
which  no  other  treatise  on  this  subject  gives. 

After  devoting  a  short  chapter  to  the  history  of  the  discovery,  the 
intruments  and  advantages  of  the  method,  he  passes  to  the  second  chapter, 
and  1  elate*  therein  the  difterence  of  experience  found  among  physicians  in 


670  Reviews. 


the  matter  of  abscess  and  inflammation  following  the  puncture  of  the 
hypodermic  needle,  the  different  solutions  used,  and  of  the  danger  of 
transmitting  sj'philis  and  c^ircinoma. 

Chapter  III.  treats  of  the  dose  of  the  medicine — Idiosyncraey,  narcot- 
ism, eliininiation  of  morphine  by  tlie kidneys,  and  experiments  on  the  lower 
animals,  tending  to  show  that  deficient  or  aboHshed  renal  function,  may 
lead  to  unusually  forcible  action  of  morphine.  In  chapter  IV.,  the  author 
inquires  into  certain  alarming  symptoms  following  immediately  upon  the 
injection,  subcutaneously,  of  moderate  doses  of  morphine. 

In  chapter  V.,  thirty-six  deaths  from  subcutaneous  injection  are  re- 
ported, many  of  them  iu  subjects  of  intemperate  habits. 

Chapter  VI.  discusses  the  "Treatment  of  Opium  Narcosis."  In  chap- 
ter VIII.,  "The  Advantage  in  Using  the  Sulphate  of  Atropia  with  the 
Sulphate  of  Morphia  for  the  purpose  of  Subcutaneous  Injection"  is  consid- 
ered. In  ciiapter  IX.,  is  discussed  ''The  Morphia  Habit,  Its  Danger, 
Peculiarities  and  Treatment."  This  is,  perhaps,  the  most  interesting 
chapter  of  tlie  work. 

The  Book  will  well  repay  the  reader's  perusal.  "We  regret  that  we 
have  not  the  space  at  command  to  give  it  the  extended  and  critical  notice 
its  merits  desei-ve,  and  which  had  been  prepared  for  us.  While  dissenting 
from  some  of  its  conclusions,  on  the  whole  we  commend  it.  It  is  decidedly 
the  most  inquisitive  and  satisfactory  book  on  the  subject  now  before  the 
American  public. 

Naso  Pharyngeal  Catarrh,  by  Dr.  Martin  F.  Coomes,  of  Louisville, 
Kentucky,  iihould  supplement  Ifumbold's  Hygiene,  in  the  hands  of  the 
country  physician,  as  it  outlines  the  treatment  pursued  by  the  author, 
and  is  accompanied  with  numerous  illustrations  of  the  instruments  and 
appliances  necessary  in  the  treatment  of  this  alfcction.  The  book  is  simple 
and  eleraentiry.  plain  and  practical,  and  well  suited  as  a  reference  book  for 
the  physician  who  desires  to  know  how  to  treat  this  disease  The  author 
is  a  professor  of  physiology',  ophthalomology  and  otology,  in  the  Kentucky 
Scliooi  of  Medicine,  member  of  his  State  and  the  National  Medical  Asso- 
ciation, and  surgeon  to  several  local  medical  institutions.  Bradley  and 
Gilbert,  of  Louisville,  are  the  publisliers ;  1S80.      The  book  has  168  p.ages. 

Thk  Transaction  of  the  Medical  Association  of  the  State  of  Mi>8ouri, 
held  at  Carthage,  May  18,  19  and  20.  1880,  are  presented  in  1(^  pages, 
bound  in  cloth  and  neatly  gotten  up.  The  address  of  the  president.  Dr.  J. 
M.  Maughs,  on  "Medical  Ultraisms"  is  interesting,  and  quite  characteristic* 
The  essays  and  reports  are  interesting,  but  as  a  whole,  hardly  up  to  the 
standard  of  the  preceding  year  for  progressive  character.  The  report  of 
Prof.  Mudd,  on  "Lithotomy  and  Lithotrity''and  his  contribution  to  "Cere- 
bral Locjdization"' being  probably  the  best  of  the  papers  presented.  None  of 
the  contributions,  however,  are  discreditable  to  their  authors  or  the 
association,  though  some  of  them  are  not  so  far  removed  from  mediocrity 
as  we  should  like,  for  the  medical  glory  of  the  btate,  to  have  seen. 
Dr.  C.  A.  Todd,  discusses  "The  Dry  Method  of  Treating  Discharges  from 
the  Ear;"  Dr.  TefTt,  ">tiasmata ;"  Dr.  Allen,  "The  Ilelation  of  Mind  to 
Matter ;"  Dr.  Alleyne,  "The  progress  of  Medicine ;"  Dr.  Laws,  "Medical 
Education;'"  Dr.  Engleman,  "The  Accorapaning  Dangers  of  lutra-uterine 


Reviews.  571 


Manipulations  and  Operations,"  while  Drs.  Lutz,  Halley,  Steele  and  John- 
son, present,  respectively  cases  of  "Cyst  of  the  Broad  Ligament,  Lapar- 
otomy and  Recovery,"  "Resection  of  the  Infra-Orbital  Nerve  and  Spheno 
Palatine  Ganglion,"  "Deformity  of  the  Wrist  successfully  relieved,"  and 
"Complete  Outward  Dislocation  of  the  Radius  and  Ulna." 

We  have  not  room  for  other  matters  of  interest  brought  before  the 
body.  The  proceedings  are  of  sufficient  value  to  every  physician,  not  a 
member  of  the  Association,  to  justify  the  pecuniary  outlay  necessary  to 
procm-ethem.  We  join  our  regrets  with  those  of  the  Publication  Com- 
mittee that  the  imperfect  stenographuj  reports  of  the  discussions  should 
have  occasioned  the  omission  of  the  remarks,  in  whole  or  in  part,  of  some 
of  the  members. 

We  think  the  Association  would  do  wisely  to  contract  its  proceedings 
next  year  to  some  one  who  would  also  give  them  to  the  profession  thi-ough 
some  medical  jounnil,  as  well  as  in  separate  form.  Such  a  course  would 
make  the  work  of  the  Association  better  known  throughout  the  State, 
increase  its  usefulness,  membership  and  prosperitj'  and  help  the  journals. 
While  no  journal  siiould  have  a  monopoly  of  the  proceedings,  turn  about 
would  be  but  fair  play,  and  sooner  or  later  every  reputable  medical 
monthly  or  semi-monthly  throughout  the  State,  old  or  young,  large  or 
small  (bids  being  tlie  same),  should  have  its  turn.  Such  a  course  could 
not  fail  to  be  promotive  of  a  more  vigorous  vitality  in  the  representative 
medical  body  of  the  State. 

"Official  Kegistee  of  Phjsicians  and  Midwives  to  whom  certificates  have 
been  issued  by  the  Illinois  State  Board  of  He:ilth,  under  the  Act  of  May  '29th,  1877; 
and  of  Physicians  and  Midwives  who  have  registered  in  the  County  Clerk's  office, 
under  the  Act  of  May  25th,  1877,  and  who  claim  to  have  practiced  in  Illinois  ten 
years  prior  to  July  1st,  1877,  but  to  whom  no  certificates  have  been  issued.  Paper; 
pages  286.    1880.     Springfield,  Ills." 

We  acknowledge  the  receipt  of  the  above,  and  upon  examination  find 
it  the  most  complete  record  of  the  kind  we  have  seen.  It  is  invaluable  to 
all  who  have  use  for  a  complete  registry  of  the  physicians  of  that  state. 

Thk  Sixth  Annual  Mketixg  of  the  Indiana,  Illinois  and  Kentucky 
Tri-State  Medical  Society  will  be  held  at  Masonic  Temple,  Louisville,  Ky., 
©n  Tuesday,  Wednesday,  Thursday  and  Friday,  9th,  10th,  llthaud  12th  of 
November.  1880,  and  promises  to  be  unusually  interesting  Many  eminent 
men  will  be  there,  and  a  good  ariay  of  valuable  papers  are  announced. 

Addendum  to  the  Article  on  Hysteria  by  Dr.  E.  C.  Mann. —  In 
conclusion  I  w'ould  say,  study  the  uterus  and  ovaries,  and  see  that  ex- 
isting disease,  if  there  be  any,  is  remedied.  Examine  the  eyes  if  you 
find  head  symptoms  in  cases  of  hysteria  and  neuraestiienia.  and  I  ^vould 
place  the  utmost  stress  on  the  systematic  treatment  by  rest,  seclusion 
from  society,  full  feeding,  massage  and  electricity.  This  treatment  if 
carefully  carried  out  by  trained  nurses,  \\ill  restore  many  women  to 
health  who  are  entirely  discouraged  by  the  tiulures  of  their  phj'sicians  to 
cure  tliem,  and  many  of  whom  are  on  the  border-land  of  insanity.  [Omit^ 
ted  from  the  context.] 

The  Index  to  Vol.  I.  will  be  transmitted  with  the  January  number. 


«  B  «  <w)       «^  ^^ 


UMIM   1  ;y    l9/b 


P  Alienist  and  neurologist 

Med 
A 
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