NATIONAL LIBRARY OF MEDICINE NLM ODSSfiEflq 5 SURGEON GENERAL'S OFFICE 1 i LIBRARY. mm>- ~^ Section,. No. iblQt(L,\ NLM005582845 A COMPENDIUM INSANITY. BY JOHN B. CHAPIN, M.D., LL.D., *> 6 ° PHYSICIAN-IN-CHIEF, PENNSYLVANIA HOSPITAL FOR THE INSANE; LATE PHYSICIAN- SUPERINTENDENT OF WILLARD STATE HOSPITAL, NEW YORK ; HONORARY MEMBER OF THE MEDICO-PSYCHOLOGICAL SOCIETY OF GREAT BRITAIN AND OF THE SOCIETY OF MENTAL MEDICINE, BELGIUM, ETC. illustraV^^racS OFFICE I hi 0% " ' PHILADELPHIA: W. B. SAUNDERS, 925 Walnut Street. 1898. W/Y] CU3C. ISIS COPYRKiHT, 10y8, By W. B. SAUNDERS. DORNAN. PRINTER PREFACE. It has been the purpose of the writer to compile in a condensed and concise form a compendium of diseases of the mind for the convenient use and aid of physicians and medical students. It is hoped that it may also prove helpful to members of the legal profession and to others who, in their relations to the insane and to those supposed to be insane, often desire to acquire some practical knowledge of insanity, presented in a form that may be understood by the non-professional reader. The author is under obligations to Dr. J. Mont- gomery Mosher for valuable aid in the preparation of the chapter on " Morbid Anatomy," for which he is especially fitted from his practical acquaintance with the subject, derived from his experience at home and abroad. Pennsylvania Hospital for the Insane, Philadelphia, March, 1898. CONTENTS. CHAPTER I. PAGE Introduction . . . . . . .17 CHAPTER II. Idiocy; Imbecility ...... 29 CHAPTER III. Insanity Defined ...... 32 CHAPTER IV. Definition of Terms ...... 36 CHAPTER V. Actions of the Insane ..... 44 CHAPTER VI. Classification; Nomenclature . . . -52 CHAPTER VII. Melancholia . . . . . . -59 Simple Melancholia without Delusions . . 59 Melancholia with Delusions and Agitation . 69 Melancholia with Delusions and Stupor . 75 CHAPTER VIII. Treatment and Management of Melancholia . 79 XVI CONTENTS. Mania . CHAPTER IX. PAGE IOI • 103 . 114 . 117 Recurrent 122 . 125 • 13° Subacute and Acute Mania Acute Delirious Mania . Puerperal Insanity . Chronic Mania; Paroxysmal Mania Mania . Paranoia; Monomania . Recurrent Insanities CHAPTER X. Treatment of Mania......*35 CHAPTER XI. Dementia . . • • • • • *47 CHAPTER XII. Paresis........l66 181 CHAPTER XIII. Epilepsy...... CHAPTER XIV. Abnormal Psychical States . . . .189 CHAPTER XV. Morbid Anatomy......193 CHAPTER XVI. Medical Certificates; Feigned Insanity . . 210 Index . 229 A COMPENDIUM OF INSANITY. CHAPTER I. INTRODUCTION. A knowledge of the mechanism of the human frame is necessary to the surgeon in the practice of his profession. The medical practitioner relies mainly upon his clinical ex- perience, and his acquaintance with physiology, pathology, and therapeutics. Both are aided by precise results such as may be obtained from the sciences of chemistry and bacteriology, the use of the microscope, and familiarity with all bodily functions in a state of health. The result of injuries and of disordered conditions of every kind, such as are appreciable by the senses, may be compared with normal standards that are known and recognized. By induction and deduction symptoms may come to aid in arriving at unerring conclusions. Those ab- normal conditions and manifestations usually embraced under the terms "insanity" and 2 i8 ■i COMPENDIUM OF INSANITY. "idiocy," or occurring as complications of bodily disease, are better studied and more intelligently understood when aided by some knowledge of the operations of the faculties of the mind in its normal action. The study of disordered mental manifestations is best ap- proached from the psychical side. The medical treatment and management require the appli- cation of principles such as govern the physi- cian in the ordinary course of his practice. To his knowledge of the principles and practice of his profession should be added a familiarity with the springs of human actions, tact, and the quality of intelligent sympathy for distress. Of matter one knows little except of its properties. As has been said of it that it has form, color, and density, so of the mind the definition may be accepted that it is that in man which thinks, perceives, feels, and acts. The intellectual faculties enable us to form judgments and conclusions ; the senses furnish perception, the emotions, the feelings ; and the will acts or executes. This is but an analysis of ordinary mental operations, or an attempt to classify the variable manifestations of mind. We can form no conception of that essence called the human mind. We know nothing of it except of its manifestations which m|fy be INTRODLCTION. 19 classified. It has been called a force—a psychic force—or a form of energy. Beyond is a veil that we cannot hope to penetrate. Self-con- sciousness alone furnishes sufficient evidence of the existence of mind, which is as good an indication of its reality as we can have of tan- gible matter. The brain is the seat of the mind, but of the bond between the material substance of the brain and the mind, and be- tween the mind and the soul, we know ab- solutely nothing. Neither the earlier mental philosophers nor modern psychologists have as yet attempted to furnish the measure of the qualities that make a sane mental organization. The so-called advances in psychology are as yet but interesting physical experiments, or minute analyses and descriptions of mental processes. Certainly, it should not be the reproach of science if it be not given to man, with his mundane qualities, to comprehend the mysteries of the Creator. By general agreement some of the opera- tions and manifestations of mind are called faculties. In a normal development certain mental properties co-operate to form what has been called the intellectual or reasoning faculty. This faculty includes perception, attention, A COMPENDIUM OF INSANITY. memory, and the power of comparison. Per- ception is that knowledge of a sensation of an external object transmitted by any one of the special senses. A sensation impressed upon the retina is transmitted to the sensorium, and we say the mind perceives or takes cognizance of the sensation. Thus through the avenues of all the senses the mind receives sensations and takes cognizance of external things, which are as imprints upon the sensitive plate of the photographer, ready for present and future use. As an aid to consciousness there is that quality which has been called attention, or the power of concentration, by means of which im- prints become fixed and ideas take definite form. It is largely acquired and developed by exercise and mental discipline. An overworked person will sometimes say the mind does not act, by which it may be understood that the ability to apply the faculty of attention and selection is in abeyance or is impaired. Having an intimate relation to the faculty of attention is that of memory, or the power to treasure and recall perceptions and sensations that have occurred, as occasion requires their use. Of all mental endowments, none conduce more to success than well-trained powers of at- tention and memory. Memory of early events INTRODUCTION. 21 is more vivid because the passions and emo- tions are more active at that period, but as life advances the interest in current events is not so intense. Even in middle life persons some- times have a fear that mental failure is ap- proaching because of their inability to recall at pleasure what they desire. The supposed fail- ure in these cases may be more apparent than real, and may arise from lack of precision in the power of attention, resulting from a multi- plication and diffuseness of mental operations. Comparison is the power of making a selection of those elements essential to the formation of a judgment or conclusion—the ability to select those impressions which memory can reproduce from the storehouse, and bring them to bear upon any question. The emotions constitute another division of the human faculties. Among them may be named self-love, fear, anger, and the affections. In the normal condition their possession is regarded as important to the preservation and propagation of the species and to man's happi- ness. In his lowest state he is controlled by passions similar to the brute creation, yet in his elevated state, through the influence of civiliza- tion, more convolutions have been added to his brain, and he has become more highly organized A COMPENDIUM OF INSANITY. and complex, with his passions more subdued and refined. It is true that the seed of some improved plants and delicious fruits may be propagated, and that they will reproduce their species, yet the product will be deteriorated and worthless. So we sometimes witness an arrested development or an unaccountable de- terioration of members of a family, and even of communities, to a savage state in which the lowest passions have sway. The emotions and passions in their several operations have much to do with the formation of character and the elevation of society. Under proper control and guidance they stimu- late men to cultivate good repute, to be zeal- ous in all reasonable desires, to seek the means of happiness, and to strengthen the in- stincts of self-preservation. Under the influ- ence of fear men are restrained from the com- mission of violent acts against public order. In periods of momentary dread, peril, and frenzy cowards have been known to commit acts of violence of a criminal nature while in states of which they have been seemingly un- conscious. The affections lead men to seek the sole possession of some object, tend to social order, and are the strongest incentives to the preservation of family life. The unbridled INTRODLCTION. 23 exercise of the emotions and passions has changed the course of nations, brought misery upon communities, and incited to crimes and calamities. A third division of the faculties of the human mind, for the purposes of this subject, is the will. While it has been doubted whether the will can be called an independent faculty— whether apart from the other faculties it has a separate existence and function, or would be manifested if there were no intellectual faculties or emotions—yet it manifests itself in actions, whether mental or physical, and in the execu- tion of conclusions formed from a comparison of ideas and conceptions. The mind is excited to action by ideas and sensations, and certain movements are set in operation to accom- plish a purpose. We speak of a man with a strong will as distinguished from one who is weak and vacillating; by which it is not to be understood that will differs essentially in differ- ent persons, but that from the storehouse of ideas an election is made from a larger range of the elements essential to clearer convictions, which one person will execute with more force and energy than another. The degree of will- power does much to constitute what in man is called character. A COMPENDIUM OF INSANITY. In the operations of the three divisions of the human mind, comprising the intellectual faculties, the emotions or feelings, and the will, there is an analogy to the functions of the afferent and efferent nerves of the excito-motor system. Sensations are conveyed to the sen- sorium, and an efferent force is exerted through the agency of the will. The higher afferent sensations—that which is observed of our en- vironment, those received through the medium of all the senses—are conveyed to the senso- rium and there compared with those previously received, while the conclusion and action are conveyed by the efferent part of the system. While it is unnecessary for the present pur- pose to do more than attempt to approximate classifications of mental manifestations, it may be stated that all the faculties so co-operate and are so intimately related that the mind is, in a sense, a unit. While motor centers have been located, ideational centers are not known and are only subjects of speculation. Men differ in respect to their moral and mental development, about the various rela- tions they hold to each other, and as to their political opinions and religious views. As there is no standard of religious belief, of po- litical doctrine, or views of social life, so there INTRODUCTION. 2$ is no recognized standard of complete mental development with which comparisons can be made. Every individual has an order of devel- opment peculiar to himself, influenced by his heredity, education, and environment, and comes to have qualities that distinguish him from his fellows. In a state of mental health thoughts and actions tend to flow through some channel, so far as each individual is concerned. This order becomes fixed and is characteristic of the individual. When this established order of thought, feeling, and action changes as the result of disease, there is a de- parture from the usual or normal standard of mental health. In this connection allusion should be made to certain physical characteristics of individuals and the relation that they seem to bear to mental peculiarities. In the early history of medicine the reciprocal influences that were supposed to exist between the body and the mind were noticed, and became the basis of a classification founded upon mental character- istics that seemed to accompany certain physi- cal developments. Although the division of certain qualities of mind and body into so- called temperaments—the sanguineous, lym- phatic, bilious, and nervous —may not be A COMPENDIUM OF INSANITY. strictly scientific, and may be the result partly of speculation, yet it is a recognition of the common observation that certain prominent mental qualities are usually found to be asso- ciated quite uniformly with physical constitu- tional development and conformations. As a rule they are inherited, and are transmitted from generation to generation in the same family until the vigor and force of the stock are dete- riorated and expended; or the stock is re-invig- orated by a cross and the introduction of new elements until the marked peculiarities are ob- literated. An insurmountable difficulty seems to arise in establishing an exact pathology, or in explaining by any theory of cell-changes those cases of eccentricity transmitted through successive generations with increasing inten- sity, culminating in insanity; or to explain those cases of sudden and intense psychic and emotional disturbances which are on the bor- der-line of insanity; or to furnish an explana- tion of those cases of gradual change of char- acter that result from indulgence in temper and passion ; or of those influences of natural scenery and environments which shape the mental development and modify the character of whole communities; or of physiognomonic ex- pressions that indicate in individuals and families INTRODUCTION 2J the approach of, and liability to, the neuroses; and, lastly, of transmitted hereditary predispo- sition to insanity which the changes incident to approaching adult age and the menopause ren- der active. It may be said of these cases and conditions that they bear the stigmata of physi- cal and mental degeneration. Mental and physical growth proceeds in ac- cordance with an order of development that belongs to the species, and which, while appli- cable to all alike, is subject to the dominating influence of heredity, human laws, social con- ditions, education, and religion. Under those various and varying conditions fixed and estab- lished qualities of mind, due to psychic forces operating along uniform lines or channels, come to mark and determine the characteristics of every individual. Each possesses similar in- tellectual faculties, sensuous functions, emo- tions, passions, and will-power, differing only in development, capacity, and degree. In a normal state there is consistency of development, har- mony, and individualism, with freedom to use the faculties of the mind to the measure of a ca- pacity bounded and defined by certain limits. In a disordered mental state the intellectual fac- ulties form erroneous judgments, sensations are at fault, the emotions and passions may be ex- 28 A COMPENDIUM OF INSANITY. cessive, perverted, weakened, or ungovernable, and the will-power in abeyance. The disor dered manifestations of these faculties give rise to the delusions, hallucinations, illusions, and incongruous actions of the insane. They con- stitute the symptoms of the conditions called insanity. A knowledge of the several faculties of the human mind in its normal state best fits the physician for approaching the study of its abnormal manifestations, whether connected with insanity or with closely-allied neuroses. To determine the existence of insanity, as there is no recognized standard of soundness with which a comparison can be made, the mental state when it is under consideration must be compared with what it was when in a normal condition, so far as that can be ascer- tained. From observation and experience a fair estimate may usually be made of those qualities of mind which together go to form for each person a distinct normal character and standard of development, as well as of any changes that may have occurred or of depart- ures from the usual standard. CHAPTER II. IDIOCY; IMBECILITY. Definition.—A person born without mental faculties or capacity is an idiot. Idiocy is a congenital condition due to arrested or abnor- mal development, prenatal conditions, disease, or accident. It is accompanied by physical defects, as short stature, deformity, irregular gait, or defective articulation. Many idiots show evidences of cerebral meningitis in in- fancy. An idiot does not become insane, though he may have psychical explosions, be- cause the mental faculties are not sufficiently developed to pass into a state of disorder or disease. He is one who requires the considera- tion of, and who is both by legal fiction and in fact, an infant throughout the whole life-period. The terms idiocy and imbecility are frequently used as synonyms, but by general agreement it is an aid to regard both as meaning a congenital defect, differing rather in degree, as might be expressed by the words partial and complete. The term imbecility has been applied with great A COMPENDIUM OF INSANITY. convenience to partial or arrested development which begins to show itself early in life and before the age of puberty. The child may be well formed and the mental faculties seem to be developing in a normal direction, but when he reaches a period when new and enlarged relations are usually established, and an ad- vance might be expected, he shows an inca- pacity to receive instruction, falls behind his fellows, has an ungovernable temper, is not amenable to discipline, is cruel to dumb and helpless animals, is devoid of affection, has no capacity for any business, and may have even criminal instincts from an apparent lack of all normal faculties. Though he may reach an adult age, yet it comes to appear that he has not advanced beyond the capacity of a child of six or eight years. Idiocy and imbecility, which imply deficiency of mind, are regarded as in- stances of congenital defect. They are not, however, to be confounded with or brought within the category of insanity, which is rather recognized as a disease or disorder of the mind. An imbecile may have an attack of insanity, depending on the degree of mental develop- ment. The several classes are treated and cared for in institutions that are quite unlike, although in a legal sense the insane, idiots, and PLATE I. 1 R ^ ^H wv -*£lS ■•-■-' 'i^fi 3 * .T rJ ^ I 3 Si _ t> ,^*i. ;" '/St 3 I. IMBECILK—MEDIIM (iRAIli:. 3. Idiot—Low Grade. 2. Imbecile—High Grade. 4. Idiot—Excitable. \ IDIOCY; IMBECILITY. 31 imbeciles are regarded as persons of unsound mind. A child may grow to manhood and then show an irregular development, as a strong will and vacillating judgment; a vigorous understanding and be destitute of affection, have peculiarities of dress and manner, a dis- position to walk in certain fixed directions, to touch persons and places in passing, to talk aloud when alone and gesticulate in periods of abstraction, or to assume unusual modes of dress and living. Channels of thought are formed which become habits' from frequent repetition. None of these peculiarities amount to insanity, but may be strictly in the line of a normal growth and development. They are the characteristics that normally belong to some individuals, and are regarded as eccentricities, but do not in themselves amount to a state of insanity, and need not have consideration here further than to place them properly as indi- cating a degree of degeneration inherited or acquired. CHAPTER III. INSANITY DEFINED. An attempt to formulate a definition of in- sanity may seem as futile as an effort to define a sane mind; yet writers have made the en- deavor, in order to limit the range of the sub- ject, to facilitate discussion by agreement about terms that have an understood meaning, and to aid medico-legal proceedings. Many re- frain from giving any definition, but announce a classification of forms of insanity, and fur- nish extended descriptions of each. Esquirol has defined insanity to be "^ cere- bral affection, ordinarily chronic, without fever, characterized by disorders of the sensibility, of the intelligence, and of the 7vill." Maudsley declares ''insanity to consist in a morbid derangement, generally chronic, of the supreme cerebral centers—the gray matter of the cerebral convolutions—giving rise to per- verted feeling, defective or erroneous ideatio7i, and discordant conduct, conjointly or separately, and more or less incapacitating the individual for his due social relations!' INSANITY DEFINED. 33 According to Conolly, " insanity is the impair- ment of any one or more of the faculties of the mind, accompanied with, or inducing, a defect in the comparing faculty!' Regis (1891), without pretending to give an accurate definition of insanity, observes that ''it is a special disease, is a form of alienation char- acterized by the accidental, unconscious, and more or less permanent disturbance of the reason!' Bucknill regards insanity as "a condition of the mind in which a false action of conception or judgment, a defective poiver of the will, or an un- controllable violence of the emotions and will, have separately and conjointly been produced by disease!' The courts are not disposed to accept pro- fessional definitions of insanity, but prefer to furnish an interpretation of the legal relations of the insane. Blackstone has said that "a lunatic, non compos mentis, is one who hath had understanding, but by disease, grief, or other accident hath lost the use of his reason!' Insanity may also be defined to be "that mental condition characterized by a prolonged change in the usual manner of thinking, acting, and feeling—the restilt of disease or mental defeneration!' The last definition is to be commended, as 3 A COMPENDIUM OF INSANITY. it is in accordance with medical requirements in the sense that it presupposes the existence of disease, and is readily comprehended by a court and jury. To establish the existence of insanity it is essential to determine that there has been a departure from the ordinary and usual way of thinking and acting—that it is a prolonged change, and that it is the result or accompani- ment of disease or mental degeneration. This definition, with its limitations, excludes from the category of insanity cases of sudden uncon- sciousness, as from injuries or shocks, delir- ium of fever, abuse of alcohol and drugs. Cases of this character are not to be certified for ad- mission to the hospitals for the insane, for deten- tion and treatment. The delirium of bodily dis- ease is purposely excluded from the definition. While an insane person may have delirium from toxic agencies, as a temporary accompani- ment of some physical disease—as, for instance, a fever—consisting mainly of hallucinations of the senses, of brief duration, the definition is intended to place the latter mental symptoms rather among the complications of bodily dis- ease. So also must be excluded those so-called popular delusions—as spiritualism and the INSANITY DEFINED. 35 belief in false religions—which are not due to the existence of disease. Persons addicted to the habitual use of alcoholic liquors or drugs are not included as coming within the scope of the definitions applicable to insanity and the insane. Such use is rather a habit than a dis- ease, and, though seclusion may prove bene- ficial, and prolonged indulgence may even result in insanity, cases of the opium-habit or alcohol-habit cannot be certified to be insane, nor legally detained in a hospital, as our lunacy- laws are usually construed. It is a frequently recurring question that the judges are called upon to meet, in the discharge of their duties, how far the term insanity shall be used to exonerate and excuse the acts of persons who habitually allow their passions to have unbridled sway, or those who indulge in theoretic vagaries until their conduct is a constant menace to human life and even the fabric of society. The definitions of insanity that have been fur- nished are not intended to include nor wholly to relieve from responsibility those who commit acts that accompany sudden explosions of an- ger, or those instances of social and fanatical speculation that render their promoters in- compatible with the safety of society and with public order. CHAPTER IV. DEFINITION OF TERMS. Delusion ; Hallucination ; Illusion. Delusions.—The insane, as a rule, act from motives very much the same as those that govern and influence the sane. They may show anger, resentment, and pleasure, but they are influenced and impelled to action by erroneous beliefs and ideas. The incorrect judgments of the insane are called delusions. A delusion is a false, perverted, and, in a medical sense, an abnormal belief As an illustration, a person may believe that he is full, or that his digestive functions will not act again, and per- sistently refuse to take food; that his head is enveloped in a shield, and to get rid of the encumbrance may beat his head against a wall; that he is the Almighty; that he is the oldest person in the world, having been well acquainted with Adam and Eve ; that he has great wealth, although surrounded by the ap- pearances of wretched poverty. Erroneous opinions of the sane are not to be confounded DEFINITION OF TERMS. 37 with delusions of the insane, as they are con- stantly and easily corrected by ordinary experi- ence and knowledge. No argument or per- suasion can, as a rule, correct the false beliefs of the insane. Delusions are almost univer- sally present in acute forms of insanity, and are easily recognized. When the disease develops slowly it is difficult to detect their nature, and they become apparent only by long and care- ful observation of the patient in all his varied relations to his occupation, to the community in which he lives, and to his family. Delusions of the insane are both objective and subjective. They are evolved from the external and internal sources of consciousness, as well as from an incongruous association of stored ideas. They are evolved from, and are symp- toms of, disorder of the intellectual and moral faculties. The existence of a single delusion that in itself may be harmless, if that delusion comprises the whole case, and does not ma- terially change the relations of the person to his various interests, is not a sufficient warrant for legal lunacy-proceedings or for advising admission to a hospital. If, however, there exists evidence of physical disease, together with delusions, or a delusion that dominates or controls the patient, then he is 38 A COMPENDIUM OF INSANITY. insane. If he commits a criminal act as the direct consequence of a delusion, in that case he is irresponsible in a legal sense. Out of this an attempt has been made by the legal profes- sion to recognize a distinction between what is called "medical" and "legal" insanity, which physicians are not disposed to accept, while admitting that there may be a modified degree of mental capacity and responsibility. Hallucinations are false perceptions. Or- dinarily, if an object is actually present, or any one of the special senses is excited, an afferent sensation is conveyed to the sensorium. If the mind takes cognizance of the sensation, the result is a perception. If there is an act of perception when no object is near, it is without foundation and is unreal or false. Halluci- nations are sensory symptoms of insanity as well as of delirium. The patient seems to hear voices of persons and see objects that are not present. Everything may be tinged a crimson color. Every pane of glass in a window may have a face in it, and the faces and forms of relatives long deceased may seem to appear. A person with hallucinations is noticed standing in one position in an abstracted manner, as one absorbed in deep contempla- tion, or gesticulating and conducting in an DEFINITION OF TERMS. 39 audible tone a conversation which to a spec- tator may seem somewhat one-sided. Another manifestation of sense-disturbance is the state- ment occasionally made by patients that some- one is reading their thoughts, and the patient claims that what he reads or what is passing through his mind is being repeated in an audi- ble voice. So annoying is this persecution through days and nights that sleep and repose are destroyed. The patient may attempt again and again to read, and is observed to lay aside the book and walk away. Men and women complain that wicked, obscene, and profane ex- pressions are constantly addressed to them, and they are persecuted—tormented to do terrible things by some unseen agency. It is common with the insane suffering from halluci- nations of hearing to assert that they have communication with spirits, that they are in connection with all parts of the world by tele- graphic wires, and that they receive messages by telephone to which they make replies. The senses of taste, smell, and feeling are all liable to perversion, but hallucinations of these senses are not as frequent as those of hearing and sight. The natural taste is changed so that food may seem to be compounded of dis- gusting substances, putrid or poisoned, and is 40 A COMPENDIUM OF INSANITY. persistently refused. One patient insisted that the room was filled with smoke and bad odors; another held a handkerchief to her face or waved it to dispel the imaginary vapor of chlo- roform which she said enveloped her. Individuals suffering from hallucinations of hearing may have a feeling that they are liter- ally pursued. Their peace of mind is destroyed, their judgment and self-control are gradually undermined, and delusions of persecutions come to be formed. Criminal acts are performed under the influence of hallucinations of hearing and sight; suicides and homicides have been committed under the influence of commands from a higher power; and assaults occur, in and out of hospitals, incited by imaginary and invisible agencies. The sense of feeling is dis- ordered, producing itching or uncomfortable sensations of heat and cold ; clothing is bur- densome, explaining the tendency to remove it and to denude the person. All of the senses may be involved in the same case. Individuals laboring under hallucinations by the influence of association often fix upon persons who are nearest to them as the authors of their persecu- tion. Mysterious assaults and even homicides are explainable sometimes on the hypothesis that they are committed under these circum- DEFINITION OF TERMS. 41 stances. The experienced observer comes to recognize a characteristic physiognomy of these cases—an appearance of abstraction and fixed attention—which affords a clue to the nature of the mental disorder. Visual and auditory hal- lucinations are uniformly present in delirium accompanying extreme physical exhaustion, dis- ease, and toxic conditions of the blood. The wandering, furtive movements of the eye, the seeming incoherent conversation — quite like that which may be heard at one end of a tele- phone line—are indications of hallucinations of both sight and hearing. The question will arise as to what extent auditory and visual hallucinations may exist before a physician is warranted in making a certificate of insanity. It is true that many suf- fer through the greater part of their lives from some disturbances of this nature which prove to be harmless. They seem to hear the sound of bells, hear reports, and see familiar faces. These are not the actions of a normal brain, yet they do not interfere with the usual busi- ness or other relations of a patient who recog- nizes the sensory disturbance and whose better judgment and self-control do not permit it to influence him. But if hallucinations exist to a degree to induce beliefs that have no better A COMPENDIUM OF INSANITY. foundation, and which influence the actions of the individual, then he is insane, although the mental disorder may be partial or general. Any explanation of hallucinations must be regarded as largely speculative. Why extreme nervous prostration, the exhaustion that follows alcoholic excess, indulgence in the opium-habit, or the presence in the circulation of toxic agencies should produce not only hallucinations but such hallucinations as are characteristic of the various causes that produce them, is beyond explanation. It may be said of all acute insani- ties, and of delirium attended with hallucina- tions, that there is a defective state of nutrition of the brain due to the quantity or quality of the blood circulating within it, or to some degree of cell-destruction. The phenomena of hallucina- tions are subjective: there is no object present to excite them. They are not instances of mis- taken identity, as they have an internal origin. It has been said that, like dreams, they are but reproductions of former actual sensations which memory recalls in incongruous, disorderly asso- ciation, as it is known that the blind and deaf are subject to them. They may occur only to those who have at one time possessed their senses, and subsequently lost the use of one or another; but the fact may have a bearing on DEFINITION OF TERMS. 43 the hypothesis that memory performs an un- conscious function in the reproduction of former sensations or images. Observers agree that hallucinations of hear- ing are more frequent than visual disturbances, although some have stated that in acute insanity the reverse is true. Hallucinations of hearing appearing early in the attack of insanity and persisting until the chronic stage, or appearing in a case that begins insidiously, are looked upon as a prognostic sign of unfavorable im- port. New habits of thought are formed in consequence, which become gradually changed into permanent channels that cannot be easily broken up. Illusions.—Another symptom of insanity is the occasional presence of a class of false beliefs closely allied to disordered sensations, and to which the term illusions has been applied. Illu- sions are the distortions of actual objects by the senses. The identity of persons and things is mistaken. A stranger may be addressed by the name of a familiar friend or as some dis- tinguished character, and things stationary and moving are converted in the mind of the. per- son into unreal objects. Hallucinations of the senses are subjective, while illusions have an objective origin. CHAPTER V. ACTIONS OF THE INSANE. In a normal mental state regular currents or channels of thought are formed. There also exists some law of association or relation of ideas, to be explained on the hypothesis of sug- gestion or otherwise, in accordance with which there appears to be some regular order of suc- cession. It may be said of delusions, halluci- nations, and illusions, that, usurping the places of other ideas, they also make new channels, and operate upon individuals so as to excite actions. While under control they do not per- ceptibly influence the conduct; but as a case progresses and becomes acute, the usual law of association of ideas is interrupted and discon- nected, and disassociated ideas and sentences appear with no more order than words selected at random from a dictionary. The mind seems to act, as it were, without co-ordination ; actions and words are often unintelligible and cannot be readily explained. It is sometimes possible to extricate the na- A CTIONS OF THE INSANE. 45 ture of the delusions and delusive ideas of the insane from their confused, apparently discon- nected mass of thoughts and actions, and obtain some explanation of their conduct. The acts of the insane when they are subjected to analy- sis often furnish a clue to the motives and delu- sions that exist in the mind of the patient, so that in the seeming disorder there will still ap- pear some semblance of order. The symptoms, habits, actions, and dress are to be carefully observed, so that some inference or conclusion may be reached. A patient presents himself with uncut and unkempt hair and beard, to- gether with other symptoms, and it may be elicited on examination that in the exaltation of mania he believes himself to be the Christ. An- other, charged with appropriating property not his own, asserts that he has taken only what was his own, and it subsequently appears that he was in an early stage of the disease known as paresis. Clothing is persistently stripped from the person, because it is burdensome, from a sensation of great heat, a condition of hyper- esthesia of the skin, or a hallucination of the sense of smell. A doctor stood day after day retaining his urine, lest its discharge might endanger the building and human life. Glass is broken and railroad trains are wrecked 46 A COMPENDIUM OF INSANITY. for the gratification afforded by the noise and crash. Indecent acts are perpetrated as the result of inordinate erotic propensities. The tendency to assume a strange and grotesque costume may exist for the purpose of attract- ing attention, and is one of the manifestations of an exaggerated self-conceit. The sudden disposition to enter upon a course of extrava- gance, to indulge in animal appetites, to make unusual purchases, may arise from delusions of wealth and expected riches, as an opposite habit of penurious living, abstinence from food, an unwillingness to procure necessary clothing, may come from a fear of loss of property and actual penury. Food is refused under a delusion that it is poisoned or medicated or that the functions of digestion are arrested. Food is often taken, on the other hand, in large quantities under a belief that each meal will be the last. A patient may plug his ears and avert the gaze to avoid annoyances from hallucinations. Changes in the expression of the face, in the manner of talking, gesticulating, and walking, are among the characteristics of insanity. The physiognomy is to a certain extent an index of the nature of prevalent thoughts and emotions while in a state of health; so delusions of fear ACTIONS OF THE INSANE. 47 as well, such as provoke to sadness, anger, and aggression, have their typical expression. The face may flush with anger or grow pale with emotion. On the other hand, as the mental functions are enfeebled in the course of con- tinued deterioration, the characteristics of a positive expression give place to dulness and the facial lines are obliterated. The expression of the eyes participates in the prevailing emo- tions and thoughts, and furnishes often some indication even of their nature and tendency. Emotional disturbances—as laughing immod- erately or weeping without sufficient cause, a disposition to exaggerate the import of trifling occurrences, indicating a weakness of judgment, alienation of the affections without apparent reason, impairment of the powers of attention and memory, introspection, brooding, erotic propensities—when they exist for a consider- able period of time and to an extent sufficient to influence the conduct and impair self-control, are among the symptoms of incipient insanity. An exaggeration of the usual and normal characteristics of an individual, without delu- sions or hallucinations, may constitute the only symptom of insanity. A person ordinarily moderately talkative may become even gar- rulous; one inclined to despondency may be 48 A COMPENDIUM OF INSANITY. depressed ; liberality may be replaced by reck- less extragavance; ungovernable passion may take the place of irritability. All may be marked departures from the ordinary charac- ter and habit. The delusions of the insane lead to the com- mission of suicidal and homicidal and other outrageous acts. Such crimes are among the earlier manifestations to attract attention, for the reason, commonly, that the case has not been intelligently or closely observed. A phy- sician of a hospital was assassinated by a patient who entertained a delusion that the doctor was the agent of conspirators employed to destroy life by the slow administration of drugs. He justified the act on the plea that he was impelled by motives of self-defence and self-preservation. Insanity is manifested by prolonged insomnia, refusal to take food, melancholy, stupor, agita- tion ; sometimes by an opposite condition char- acterized by excitement, exaltation of the emo- tions with great motor disturbance, harangues and talking in a loud tone ; also by the terminal stage of fixed delusions, failure of the mental faculties, and gradual decline of the vital powers. The actions of the insane when attentively observed may be ascribed to the existence of delusions or disorders of the intellectual powers, ACTIONS OF THE INSANE. 49 to hallucinations and illusions or disturbances of the sensory functions, to the abnormal ac- tivity of the emotions, or to exaggerations of the normal characteristics of the individual which amount solely to intense functional activity. The personal appearance, dress, and mode of living, the appearance of the apartments, may furnish some indication of the mental condition of the insane. A fulness of the vessels of the eyes may suggest the state of the circulation within the cranium. Contracted pupils and insensibility to light, or enlargement of one pupil as compared with its opposite, are due to paralysis of the circular fibers of the iris, and are symptoms observed in a large proportion of cases of paresis. Enlarged pupils are among the indications of exhaustion of nerve-force. A furtive, glancing, wandering expression of the eyes in a case of melancholia or mania is a warning of danger of suicidal, homicidal, or some kind of psychic explosion. The appear- ance of the skin shows the state of the general circulation. In conditions of nervous exhaus- tion associated with insanity the skin may be soft, relaxed, and moist; dry, hard, and shrunken in advanced stages of melancholia ; or, as in cases of mental hebetude and dementia, the 4 50 A COMPENDIUM OF INSANITY. extremities may be cold and livid—in either case an indication of impairment of the function of the vaso-motor system. If the patient is competent to express his feeling correctly, he may complain of pain in the head—a sense of fulness or of pressure which is sometimes definitely located at the vertex, in the frontal or occipital region, or along the course of the longitudinal sinus. It may quite as frequently be inferred that it exists by noticing that the patient manifests discom- fort by rubbing or pressing the head, causing the hair to be pushed back or upward or even rubbed off in patches by friction. The uneasi- ness and unrest of the melancholiac are mani- festations, of an emotional agitation which leads the patient to pick at the face or finger-nails, to walk to and fro, or to rub the hands and chin until the skin is abraded. The facial expression is regarded as an outward manifestation of mental activity or sluggishness, as well as even the nature of the dominating ideas. The mus- cles of the face of the insane may display the intensity of internal emotions, as in acute mani- acal excitement; sadness or melancholy, as in melancholia. There may be inco-ordination of muscular movements arising from an irregular, interrupted transmission of nervous force, as in ACTIONS OF THE INSANE. 51 paresis or spinal degeneration ; or the charac- teristic lines of the face may fade and be re- placed by a stolid and vacant expression. In response to a request for an examination the tongue maybe protruded suddenly and as the re- sultofan effort, and show in its fine fibrillar move- ments the evidence of interruption of nervous force along the motor tracts. The impairment of the functions of the lips and tongue in articu- lation furnishes an explanation of the change in speech that is recognized as one of the early characteristic symptoms of paresis, and bears a close resemblance to the thickness of the tongue commonly noticed in persons under the influ- ence of narcotic drugs or alcohol. In the early stage of insanity there is a diminution in the usual body-weight, and in eighty per cent, of the cases admitted to hospitals there is some evidence of impaired health; so that at this stage good health and the normal weight are exceptions to the rule of experience. Not only do the mental manifestations often plainly show the condition of the patient, but the physical signs of disease also furnish valuable clues in making a diagnosis. CHAPTER VI. CLASSIFICATION ; NOMENCLATURE. The actions, manner, and uniformly prevalent character of the mental manifestations, taken in connection with the physical condition of the patient, are the symptoms to guide in determin- ing the existence and form of insanity. There is no anatomic knowledge that can form the groundwork of a classification of insanity. Men- tal pathology is also partly a subject of specu- lation. The symptoms and actions which have been alluded to are the only tangible evidences of the existence of mental disorder in the ma- jority of cases, and by general assent they constitute the basis of every nomenclature in use. No universally accepted classification has yet been presented, and, as every writer on insanity is an authority to the extent only to which his views are in accord with uniform experience, there has been felt a freedom to indulge in speculation which is sometimes con- fusing. It is also to be noticed that, while authorities are disposed to be critical of the classification of others, they are none the less CLASSIFICATION; NOMENCLATURE. 53 disposed to venture upon attempts in the same line. A nomenclature may be of great aid in scientific research if it conveys a meaning in which all engaged in similar investigations ac- quiesce. If, however, it does not stand for the results of extended observation and general experience, it is misleading to the student and even erroneous, often representing rather the aspirations of science, stilted with terms derived from the dictionaries of dead languages. The terms most commonly used by alienists convey a meaning quite as well understood, and have a more rational application than those applied to ordinary bodily diseases by the gen- eral practitioner. The names applied to mental disorders must be understood to denote only the presence, for the time being, of prominent symptoms, and are not to be considered as recognizing distinct diseases or entities. Pinel recognized four forms of insanity—viz.: Mania, Melancholia, Dementia, and Idiocy. Esquirol, his pupil, adopted five forms, introducing the term mono- mania, and making a distinction between idiocy and dementia. Out of these divisions as a basis have since been evolved other classifications. The Medico-Psychological Association of Great Britain has adopted the following divisions, A COMPENDIUM OF INSANITY. which are in general use in the preparation of the statistical tables of the asylums of that country : i. Congenital or infantile mental deficiency ; {a) With epilepsy; (b) Without epilepsy ; 2. Epilepsy (acquired); 3. General paralysis of the insane (paresis); 4. Mania—recent, chronic, recurrent, a potu, puerperal, senile ; 5. Melancholia—recent, recurrent, puerperal, senile ; 6. Dementia — primary, secondary, senile, organic ; 7. Delusional insanity; 8. Moral insanity. An attempt was made in 1886 by American alienists to bring about some uniformity of classification and statistics by the adoption of the foregoing varieties, with the exception of the form "moral insanity," and the addition of "toxic insanity." At the Congress of Men- tal Medicine in Antwerp, in 1885, an attempt was made with the same object; and at the Paris Congress of 1889 a classification was adopted which is both comprehensive and in strict accord with experience ; 1. Mania (comprising acute delirious mania); CLASSIFICATION; NOMENCLATURE. 55 2. Melancholia; 3. Periodic insanity ; 4. Progressive systematic insanity; 5. Dementia ; 6. Organic and senile dementia; 7. General paralysis ; 8. Insane neurosis (hysteria, epilepsy, hypo- chondriasis, etc.) ; 9. Toxic insanity; 10. Moral and impulsive insanity ; 11. Idiocy. All of the classifications attempted have as their basis the division first announced by Pinel. A division or classification may also be made based on the supposed causes or etiology oi insanity. The first may include all of those cases that arise from a predisposition to insan- ity that is transmitted by "inheritance—the traits that descend with increasing intensity in family lines ; unequal' development of faculties that appears during adolescence ; eccentricities that pass beyond the border-line that lies between mental soundness and unsoundness; cases due to exaggeration of personal characteristics which are the basis and genesis of delusions ; those resulting from degenerations following endarteritis, atheroma, syphilis, tumors, menin- gitis, and the trophic changes attending old age. 56 A COMPENDIUM OF INSANITY. A second division may comprise those cases of insanity resulting from neurasthenia, deficiency in the quantity and quality of the blood sent to the brain, disordered functions of bodily organs, malarial cachexia and fevers, exhausting ex- cesses, toxic agencies, traumatism, shock, etc. A classification of insanity according to the supposed causes is helpful not only for the purposes of diagnosis but for prognosis and treatment. The first division embraces mainly those cases that develop gradually, that have their origin in some constitutional deterioration or physical degeneration, and, it may be added, that generally do not recover. The second class is intended to include the cases that originate from those functional disturbances that attend ill-health of some kind, which un- der favorable conditions make a good recovery. While the physical conditions of the two classes may differ, and have even a different origin, the mental symptoms are similar; that is to say, the melancholia or mania arising from any of the causes named in either class will have simi- lar features. A nomenclature may be confusing, mislead- ing, and even a hinderance to comparison of results and of progress. It is desirable for these reasons, in the present state of our CLA SSIFICA TION ; NO A TENCL A TURE. knowledge, to avoid a multiplication of new terms, which, while they may serve to show the presence of prominent or controlling delu- sions and characteristics, do not indicate for that reason alone distinct forms of disease. For all the purposes of the general practitioner a simple classification, with a few subdivisions, which contemplates the arrangement of groups of cases having similar characteristic types and mental symptoms under one of the commonly used terms—melancholia, mania, dementia, and paresis—answers every ordinary requirement, and is also in accord with and based upon recognized psychic manifestations of the human mind in its normal state. The time has not yet arrived when a classification can be based on the pathologic conditions of the insane, because too little is known. Observation, ex- perience, and the results of treatment lead to the conclusion that all insanities have an origin in physical changes in the nervous mass, men- tal and physical degenerations, or in a defi- ciency of those nutritive processes that sustain the functions of the nervous centers. "It may be right to assume that morbid phenomena are invariably associated with organic change, but this organic change is not always of a nature to persist after death." "Cases of so-called 5 8 A COMPENDIUM OF INSANITY. functional disturbance or disease are instances of the interruption, suspension, or impairment of vital force, in which the pathologic state exists during life, but disappears when life is extinct, and leaves no trace behind." CHAPTER VII. MELANCHOLIA. («) Simple Melancholia Without Delusions. Melancholia is a form of insanity character- ized by prolonged and profound mental depres- sion. Many persons are at times conscious ol some depression of spirits, which may be a reaction after a period of excitement and ex- haustion, which passes away after a temporary duration. Such instances are examples of psychic disturbances that arise from unexplain- able functional states of the brain, or they may be dependent upon toxic or other agencies in the circulation that affect the nutrition of the nervous centers or pervert mental functions. As they are corrected the gloom and weight of depression are lifted and disappear. It is proper to make a distinction, and in many cases to draw a line of demarcation, between melancholia and hypochondria. The melancholiac and the hypochondriac experience depression and are sad and gloomy; but one may be insane, and the other does not come 60 A COMPENDIUM OF INSANITY. within the category. The depression of the melancholiac is mainly mental, and relates to subjects having a relation to the mind of the pa- tient, while that of hypochondria relates mainly to supposed bodily conditions. The hypochon- driac may be worried about his head—he may say it is " numb ;" that he is destitute of feel- ing ; he looks at his face, his tongue, and his body, and seems to see evidences of disease ; and, while in fact his general health is below its normal standard, he exaggerates every ab- normal sensation. He carefully watches his excretions. Every strange feeling, as palpita- tion of the heart, indigestion, is a symptom of disease of the heart and stomach. Every organ may thus have its turn. Actual symptoms of functional disorder indicate to the sufferer organic changes. The physician is constantly changed, and the patient is a victim of quacks who impose upon him by a promise of relief by nostrums and excessive medication. The will- power is weakened, and the patient is listless, vacillating, and passive, until he is disposed to surrender to the dominating influence of a stronger character than his own. So long as the hypochondriac is not seriously affected in his relation to his business or his family affairs, and is not influenced and changed by actual MELANCHOLIA. 61 delusions, he cannot be considered insane. Hypochondria may, however, progress to mel- ancholia. Sensory disturbances, hallucinations, and delusions may develop and change and influence the ordinary actions of the patient. At this stage the patient may be pronounced insane, and in some of the nomenclatures the term hypochondriacal melancholia has been used to designate this class of cases. Depression, sadness, or gloom may be an early stage of an attack of mania or other form of mental disorder, or may follow an acute mania, or attend the pre-natal and puerperal state, the physical debility of fever, influenza, or other physical ailment that affects the nervous system. It is a stage too often overlooked in the study of a case. Profound depression may be a premonitory symptom of some form of mental disease, in the same sense that a chill, languor, and debility are often the precursory symptoms of physical disease. Cases that throughout present a history of prolonged de- pression may be classified under the term simple melancholia without delusion. It is rather an exception to the rule of ex- perience that a case of insanity is fully devel- oped without a preceding stage of depression. It may be of brief or prolonged duration—of a 62 A COMPENDIUM OF INSANITY. few days or several months. When a case is presented for examination or treatment, it is usual to find that the friends of the patient date the beginning of the attack to some outbreak or unusual acts of the patient. As a rule which is established by uniform experience in the largest proportion of cases, insanity is not a disease of sudden development, but has an incipient, formative, and prodromal stage. In all of the cases referred to in the second divi- sion of the classification made on page 56 in a preceding chapter, which is intended to in- clude those cases that have an origin in the functional disturbances that attend ill-health, as well as the majority of the patients placed in the first division, a prodromal stage may on careful inquiry and examination be clearly developed. It will appear that the patient has perhaps a neurotic heredity, and unstable mental and physical organization, either acquired or inher- ited ; that there have been worries attending the household, business affairs, or school studies; bodily sickness or frequent child- bearing may have occurred. From some one of these experiences of human existence, singly or together, there has been produced a great tension or strain. These are only relative terms, so that what one person may seem to MELANCHOLIA. 63 bear without appreciable injury will be followed in another by ill-health, insomnia, loss of appe- tite, derangement of digestion, and disturbance of all the bodily functions. The blood on which the nutrition of the nervous mass de- pends is generally impoverished, and the circu- lation is imperfectly performed from a lack of nervous stimulus. While the bodily condition gradually approaches a state of invalidism, some marked mental changes are noticeable. The patient may become irritable, easily annoyed by trifling circumstances, forsake his accustomed haunts and friends ; the usual occu- pation is burdensome; he complains of a weary, tired feeling, and, as a matter of fact, is tired and exhausted with slight mental or physical exertion. The gait is slow, the manner is lan- guid, and the patient has a worn, exhausted appearance. He may complain of headache, a sense of pressure located at some definite por- tion of the head, indigestion, vomiting, or mental confusion. Without rational or positive evidence of any organic disease, a stage of invalidism exists which may have been developing for months or years, consisting wholly of functional disorders. A clergyman who had suffered from many of the symptoms named above during the in- A COMPENDIUM OF INSANITY. cipiency of his disease aptly likened his condi- tion to that of an engine in perfect order, but in which the means to generate the force to move it were lacking. The term neurasthenia has been given to those conditions of "nervous weak- ness often accompanied by perverted nervous disorders" (Billings). Its meaning is synony- mous with the terms "nervous prostration" and "nervous exhaustion," in more common use. In 1868, Van Deusen published an essay on "A Form of Nervous Prostration (Neuras- thenia) Culminating in Insanity." Beard in 1869, and Cowles in 1889, in his admirable memoir on "The Mechanism of Insanity," and others, have discussed the relation of neuras- thenia to nervous diseases and the production of insanity. The views announced by these writers have been confirmed by extended ob- servations of other observers. Nerve-strain may thus come from the whole range of those causes that operate upon either the mental or the physical system in such a manner as to ex- haust strength, or vital force, more rapidly than recuperation takes place, so that the term nervous exhaustion is also properly used. Various disorders of the nervous system are among the manifestations of neurasthenia, as neuralgia affecting several parts of the nervous, MELANCHOLIA. 65 system ; headache ; vertigo ; chorea ; disorders of the circulation; palpitation of the heart; heart-weakness; angina; disorders of the digestive system, as dyspepsia; prolonged vomiting simulating gastric irritation; func- tional disorders of the liver and kidneys, from which may come failure to eliminate excremen- titious matter ; or a change in the chemistry of digestion. The relation of neurasthenia to many bodily diseases may yet be found to be more intimate than is now recognized. As a factor in the production of insanity, neurasthe- nia must be considered the most important. The largest proportion of hospital admissions received in an acute stage have a history of neurasthenia. It is fitly called the "soil" out of which insanity develops. It is too often the formative stage, or incipiency, of insanity. If with the prominent symptoms of nervous ex- haustion there is depression of spirits together with a decided loss of weight, if there is emo- tional disturbance, it may be considered that the patient has received a serious warning. Symptoms of Simple Melancholia.— The patient is observed to be sad and dejected. There is a sense of depression that cannot be explained, a vague fear of some impending trouble, an unaccountable gloom that over- 5 66 A COMPENDIUM OF INSANITY. shadows every relation the patient may hold to his various interests. While he seems to have an appreciation of his condition, he cannot throw off the gloom that oppresses him. He loses his interest in his business, secludes him- self from his friends and family, reviews his past life, reproaches himself for his past mis- takes and shortcomings, and indulges in retro- spection and forebodings. Life seems to him undesirable and unendurable. The simplest daily transactions are burdensome. The most trivial occurrences are' distorted to the detri- ment of the patient. The slightest exactions or exertions, as rising, dressing, exercise, and taking food, are avoided. The gait is slow, the gaze is downcast, obstacles that seem impossi- ble to remove are made to every suggestion for mental or bodily effort. Everything is opposed, nothing is proposed, and the patient desires to be left alone. If the history and temperament of the patient are known, many of these manifestations may be recognized as exaggerations of his normal characteristics. The conversation is deliberate and coherent, and the patient can, and often will, furnish a connected history of his own case. Thus far the emotions and feelings are principally affected, but the judgment may not be impaired MELANCHOLIA. 67 to such an extent that clearly-defined delusions are formed. On a physical examination of a mild case of melancholia the facial expression is one of sadness and misery. The face may be pale and sallow. The eye has lost its accustomed ex- pression. The appetite is not good, and food is taken sparingly. There is no fever—the temperature may even be subnormal. The tongue is pale or flabby and coated. The bowels are constipated, the urine is scanty and high-colored, the skin is dry and harsh, and the pulse is slow and soft. The pupils, are quite susceptible, and perhaps are more than nor- mally dilated. The patient is, and has been for a long time, probably, insomnious. The blood may show an excess of uric acid ; the hemo- globin may be from twenty to forty per cent. below normal, and the blood-corpuscles one million or even two millions below the average of five millions per cubic millimeter. In women the function of menstruation is usually sus- pended. A decline in weight has probably been going on for several months, attracting little attention, and may amount to a loss of twenty, thirty, or forty pounds below the aver- age ; so that it should always be a subject of serious concern if mental depression is accom- 68 A COMPENDIUM OF INSANITY. panied with decided loss of body-weight. The patient may complain of dull pain or a sense of fulness and pressure at the vertex or in the frontal or occipital region—a symptom arising from the stasis of the cerebral circulation, or fulness of the sinuses. The physical condition of the patient is usually below the average or normal standard. It may be noticed that not an organ of the body is performing its function in a normal manner. The case has all the aggravated symptoms of neurasthenia, or nervous exhaustion, but there is superadded a melancholy more or less profound. It is usual to discover that there has been some strain from mental or physical overwork, such as comes from constant and prolonged application without change or rest; from ex- haustion attending the puerperal-state ; or there is physical and nervous exhaustion from ill- health, sexual or other excesses, or the alcohol- or opium-habit. For all purposes of diagnosis, treatment, and management, it is a safe course to assume that from some cause, even if not apparent, there has been defective or altered nutrition of the brain or of some portion of it, or that damage has been done to its cellular organization. An attack of simple melancholia may run a MELANCHOLIA. 69 course of several months without other mental disturbance than the presence of depressing ideas. The emotions are principally affected, but the intellectual faculties may not be in- volved to such an extent that clearly-defined delusions appear. The danger to be guarded against from the commencement and through- out the attack is suicide. The danger of such a tragic end at this stage may be even en- hanced from the fact that the intellectual facul- ties are still intact, and a disposition to end a condition that seems intolerable is more likely to be executed than at a later stage, when the patient is likely to be more carefully guarded and the will-power is more or less impaired. [6) Melancholia with Delusions and Agitation. The symptoms which have been described as characterizing simple melancholia, if recovery does not take place, continue in a more intensi- fied form in the further evolution of the dis- ease. The intellectual faculties become in- volved, and clearly-defined delusions are formed. Sense-disturbances, as hallucinations and illu- sions, appear, of a character to excite appre- hension in the mind of the patient. The depression also becomes more profound. In- somnia, restlessness, and motor excitement, A COMPENDIUM OF INSANITY. amounting to an agitation of the . whole system, are all symptoms which may be looked for, resulting mainly from the nature of the delusions, which reach and undermine the very instincts of self-preservation.' Throughout the attack there is an active suicidal tendency to contend with, requiring on the part of the physician and nurses the most vigilant and constant watchfulness. It is difficult or impos- sible to gain or hold the attention of the patient or to engage him in conversation about ordinary affairs. He is engrossed with his delu- sions. He may charge himself with the com- mission of great crimes and sins, for which he is to suffer and to be punished here and here- after for endless ages, and he even seems to see his tormentors and their means of torture. He alleges that he has committed the unpar- donable sin—sinned against the Holy Ghost— and has other delusions concerning his religious state. He may state that he and his family are bankrupt. While he is suicidal he may also be homicidal, under a conviction that greater suffering is awaiting himself and family, from which death would be a happy release, or under the influence of a delusion he may resort to some form of self-mutilation. A woman at- tempted to drown her grandchildren and kill MELANCHOLIA. 71 her daughter. She announced her intention to kill herself, and declared that they would all go together to heaven. The urine is retained, and attempts are made to restrain the action of the bowels. The patient wrings his hands and may moan and groan aloud, imploring mercy. He picks at his face and nails, rubs and scratches his hands, and denudes portions of the scalp by rubbing and pulling out single hairs. He shows an inability to keep quiet, moves about in a rhythmical manner or to and fro, gets into bed and out of it, and stands at night. The patient may throw off his clothing because it is burden- some, or on account of imaginary odors attach- ing to it, or because of hyperesthesia of the skin. The patient may refuse food because of a belief that he is Satiated, that all digestive operations are arrested, or that he has no money with which food may be purchased, or because of halluci- nations concerning the food, which to him may look like blood, or have a putrid odor and a loath- some taste. There is in some cases a degree of restlessness amounting to constant, uncontrol- lable motion or agitation—symptoms that have suggested the terminal affix used in connection with this form of melancholia. So incessant is the motor disturbance, so intense is the mental confusion, and so completely does the self-con- 72 A COMPENDIUM OF INSANITY. trol seem to be suspended, that the term frenzy has been applied to the temporary paroxysms of excitement which sometimes supervene. To that condition of mental agony characterized by moaning and groaning, with or without self- accusations, the term psychalgia, or mind-pain, has been aptly suggested by Clouston. 1 he patient may say, "I am in such dreadful agony it cannot be endured," yet a careful examina- tion will fail to locate the seat of alleged pain or any possible source of bodily pain. In this con- dition of mind patients have made, and are in constant danger of, assaults upon them- selves. The facial expression is some indication of the controlling thoughts ordinarily, and espe- cially is this true of melancholia. The lines of the face lose their mobility ; the eyes betray suspicion, apprehension, and fear; the face has a shrunken expression, and may have a sallow or congested appearance. The extrem- ities are cold, the bowels are torpid, and all of the secretions and functions seem to be im- perfectly performed. It is common to notice that the patient rubs his head and pushes the hair back from the forehead ; that he presses his hands upon the forehead, or rubs his face until it is abraded in spots ; and that he pinches MELANCHOLIA. 73 the palms of the hands until they have a hard, calloused appearance. It is not to be inferred that all of the symp- toms named will appear in every case of melan- cholia. The extraordinary range and character of the delusions and disturbances—always de- pressing in character—have been mentioned, but a sufficient number of them do appear to determine the form of disease, and occasionally every one of them can be seen in a single case. The mental pathology of the delusions of melancholia is a subject of speculation. To de- scribe its evolution and its manifestations does not wholly explain its nature. The instinctive dreads incident to childhood, some of which are transmitted in families for generations, form the groundwork of many of the delusions of the insane. The traditions concerning demo- niac possession, obsession, and the beliefs of early ages that insanity was not a disease, but was due to demons and evil spirits, finds its expression at the present day in the delusions of melancholiacs. Yet it is not uncommon for the expansive insanity nomenclature of our day to recognize every fear of the melancholiac which has some prominent place in his mind as a distinct form of disease. Even the term " religious melancholia" has been given a A COMPENDIUM OF INSANITY. place ! One hundred years have passed since insanity began to be recognized as a disease, and not as a demoniacal possession, yet it is unquestionably true that this and other popular delusions have still an underlying force, and form the groundwork of many delusions of the insane. They will probably continue to do so for many generations to come. Why neurasthenia or nervous exhaustion, or nervous and physical degeneration, should in one case be a cause of melancholia with de- pressing ideas, and in another exalted ideas and exhilaration, is in the present state of knowledge beyond human ken. Duration and Prognosis.—The average duration of an attack of simple melancholia, passing into the stage of agitation, followed by recovery, varies from nine to twelve months. Such a result is to be accepted as satisfactory. If with the delusions there are observed in the progress of the case signs of dementia or men- tal failure, hallucinations, fixed delusions, with increasing indifference to surrounding objects, and greater difficulty in holding the attention, the prognosis is unfavorable. If the patient, on the other hand, shows some abatement of the motor disturbance, as of the degree of moaning and groaning ; if an interest is manifested in the MELANCHOLIA. 75 environments, shown by a more erect position, gazing at surrounding objects, perhaps making some inquiries ; and if a perceptible gain in weight is noticed from time to time, the prog- nosis becomes favorable. (c) Melancholia with Delusions and Stupor. A patient may pass from the condition of sim- ple melancholia into a more aggravated form of the same disease, characterized by an appearance of stupor. The stuporous condition is mainly due to the domination of delusions and to a par- tial or complete suspension of will-power, which may amount to a cataleptoid state. When a patient is presented for examination suffering from stuporous melancholia, there is usually a long history of invalidism or of progressive de- pression, with a comparatively sudden transition to a stuporous condition. It is not to be un- derstood that a patient necessarily passes first through an attack of melancholia with agita- tion before entering upon the stage under consideration, as both forms of disease appear to continue along the lines of their respective development till the end is reached in recovery or in terminal dementia. When a patient is pre- sented for observation suffering from stuporous melancholia, the appearance will be in striking 76 A COMPENDIUM OF INSANITY. contrast with the other forms of this disease. There will be offered a history of physical ill- health, insomnia, and worry, or possibly of some profound moral shock. The prodromal stage is not usually prolonged. The more aggra- vated mental symptoms may appear at an early stage. The patient is disposed to be absolutely silent, and the only response to questions may be monosyllabic. The eyes have a fixed and down- cast appearance or are entirely closed. The facial muscles are immobile. The countenance is pale or sallow, and has a smooth, oleaginous appearance. A fixed and rigid position is main- tained, and whether sitting or standing there is a reluctance to any change, accompanied often by actual resistance. There is an unwill- ingness to rise from the bed, to dress, or to undress. Food is not desired, or absolutely re- fused, and only administered by placing liquids in the mouth, or often by overcoming the re- sistance of the patient by the use of force. The bodily functions are performed uncon- sciously or are in a state of apparent sus- pense. Saliva is retained in the mouth, giving rise to an offensive odor. The tongue when examined seems flabby, enlarged, and shows indentations produced by pressure of the teeth. The pulse is not accelerated, and the MELANCHOLIA. 77 temperature is normal or subnormal. There is an apparent indifference to surroundings, to heat or cold or bodily comforts. Every effort to arouse the patient is without avail. There is an appearance of stupidity and stupor; but, as a matter of fact, the mind of the patient is intently engrossed with delusions which are of centric origin or wholly subjective. The intense will-power necessary to maintain fixed posi- tions for long periods, the resistance offered to all changes proposed, the expression of the eyes, all indicate that the mind is intently absorbed in some controlling delusion. This condition might be confounded with the stupid state that characterizes mental enfeeblement or dementia, but the history of the case will usually furnish the right clue. It is important, however, to the proper treatment that a distinction be made. A person may pass rapidly into the stuporous stage of melancholia, but dementia, as will ap- pear, is the usual terminal stage of several forms of mental disease of long standing. Pa- tients have stated on recovery that while in this state they believed they were fragile, like glass, and would go to pieces if jarred or moved ; that they were transformed into another state of existence, and could subsist without food; that the world had come to an end, and all 78 A COMPENDIUM OF INSANITY. human operations were suspended. The patient believes he is incapable of making any exertion to extricate himself from some terrible fate awaiting him—conditions showing the power exerted by dominating delusions. An experience with some dreadful dream fur- nishes the nearest approach to what may be conceived to be the mental state of these wretched persons. The nature of the delu- sions of a stuporous melancholiac are usually unknown, and their consequent actions so un- certain that it is never safe to act upon any pre- sumption. Some outbreak of violence directed against the patient himself, his attendants, or surrounding objects may occur at an unex- pected time, so that it is not wholly safe to leave a patient unattended. CHAPTER VIII. TREATMENT AND MAN AGEMENT OF MELANCHOLIA. As the study of the mental symptoms of in- sanity in any of its forms is best approached from the psychical side, so the treatment of all recoverable cases is to be directed toward cor- recting and overcoming the physical conditions on which it usually depends, or to influencing the patient by means of environment, the impres- sions of which are conveyed to the sensorium through the senses. In the classification of causes of insanity various forms of ill-health appear as the most frequent in hospital reports. The term "general ill-health" was used and commonly assigned as a cause in hospital reports fifty years ago. In recent years the tendency of medical thought has been to ascribe to a nervous origin a much larger range of so-called bodily ailments than for- merly, and allusion has already been made in these pages to the relation of neurasthenia as a cause to a number of diseases as well as to insanity. Ninety per cent, of the admissions 80 A COMPENDIUM OF INS A Nil Y. to the hospitals present the condition and ap- pearance of some form of bodily ill-health. Seventy per cent, of the fresh cases admitted have a history of neurasthenia or nervous ex- haustion, or of the nervous weakness which may come from the whole range of causes that ope- rate upon both the mental and physical organ- ism to exhaust vital force more rapidly than recuperation can be maintained. In melancholia in its various forms the physi- cian is called upon to treat a patient whose physical condition is probably much impaired; one who in the several stages of the disease is likely to be perverse and to resist, and who may or may not co-operate with any remedial measure that is proposed. He will probably object to the administration of food, and needs at every stage to be carefully guarded lest he commit suicide or do some violent act. It should at once be understood that there is no specific or known medicine that alone will cure insanity. The plain indications for medical treatment are to improve and sustain the gen- eral health by a course of generous living, to stimulate digestion and assimilation of food, and to improve the quality of the blood by the administration of tonics and the judicious use of hypnotics to produce sleep. As the change TREA TMENT OF MELA NCHOLIA. 81 and deterioration of the bodily health have been going on for many weeks or months, it should be plainly understood by the friends of the patient and by the physician that recovery, if such a result is to be reached, can hardly be expected under favorable circumstances within several months, and that during the whole of this period the patient may require medical ad- vice, personal attendance, and direction as to the best environments. One of the first questions to decide will be : Shall the patient be treated at home or else- where ? Shall he travel, or be sent to a hos- pital ? If the case is one of simple melancholia without delusions, and if the patient has such an appreciation of his condition that he is willing to follow advice and co-operate with the course of treatment proposed, he can be treated at home, if that is preferred. If possessed of am- ple means, a change of residence with a suitable companion should be urged as soon as improve- ment begins and is assured, so that the patient may be surrounded by such new environments as may prove a diversion as well as a stimulant. It is not to be understood from such a sugges- tion that continuous, wearisome journeying is to be advised, but restful changes, as in new places. It should be borne in mind that the 6 A COMPENDIUM OF INSANITY. fatigue and worry attending travel and sight- seeing may only increase the melancholy and insomnia, as well as excite new apprehensions. There are often business perplexities and wor- ries that center about a home, with which a patient is so identified that they cannot be wholly laid aside, so that any attempt at treat- ment there with a prospect of success is futile. In such a case change is the first step. Change may be one means of supplanting depressing thoughts and ideas. If the financial circum- stances do not permit travel, change, or proper medical and other attendance, and if the patient will not co-operate with the physician or act in accordance with advice, then he may properly be certified to be a suitable person for admis- sion to a hospital, in order that he may receive treatment that is essential to recovery. Too often travel, changes, social diversions, and novelties are mistaken experiments, undertaken at a serious risk of the expenditure of the little physical strength that is still held in reserve, as well as of the money savings of years. It may be here observed that while advice to travel is easily given as a solution of a perplexity as to what is really the best thing to do, it is often a most serious error to commit. To leave a comfortable home while the outlook is doubtful TREATMENT OF MELANCHOLIA. 83 as to whether the patient will improve or grow worse in the future, or when it is doubtful whether improvement has actually begun, is often to remove a patient from his customary medical and other attendance, with grave un- certainty whether in the midst of journeying the patient will be overtaken with some serious out- break or complication. If, however, an improve- ment in a case has actually begun, and the pa- tient is co-operative, no embarrassment from a medical standpoint need arise as to the course to pursue. The treatment must have a psychic as well as a physical basis. Influences that have acted upon the patient injuriously must be removed, and the physician should have such an influence over the patient and such a professional stand- ing that he will be implicitly obeyed. It is oftener the case that home, with all its surroundings and the presence of the family, is rather a source of annoyance and anxiety than a comfort. The daily surroundings, occupation, companionship, diversions, are a part of the psychic treatment. As the condition of the patient may be largely due to nervous exhaustion, it will naturally follow that mental rest and freedom from irri- tation and its causes must be an important ele- ment of the psychic treatment. A COMPENDIUM OF INSANITY. It is important to learn early in the case the normal weight of the patient, and to cause it to be taken from time to time. The information thus afforded may furnish a clue as to the course and probable results of the treatment. The state of the blood, the urine, and the digestive organs should be carefully examined. The latter are usually deranged and constipated to such a degree as to seriously interfere with a desire for food, and to retard its assimilation. The patient and nurse may state that evacuations of the bowels occur regularly, when the adminis- tration of an alterative cathartic followed by mild saline medicines will usually furnish abun- dant evidences of accumulations of fecal matter. From inattention, indifference, and the exist- ence of delusions in relation to the usual bodily habits, the urine and contents of the bowels are voided irregularly or restrained. In hospital practice, and in private practice, when it is not quite clear what the previous treatment has been, it is the more judicious course to suspend for a brief period all medication, that the physi- cian may observe the manifestations of the dis- ease uncomplicated by the effects of drugs. Then a course of alimentation and medication may be commenced intelligently, as it is not un- usual that the constipation and even the mental TREATMENT OF MELANCHOLIA, condition have both been affected by the ad- ministration of hypnotic drugs. Whether the desire for food does or does not exist, the patient should take as much as can be di- gested. It is not necessary to wait until the tongue is free from the accumulation of vitiated secretions. Under the influence of an improve- ment of the nutrition and a liberal administra- tion of food the tongue will often become clean and improvement begin. There is usually a decided loss of weight in melancholia, amounting to twenty-five or thirty pounds, or even more. Although food may have been taken sparingly, the waste of tissue has gone on more rapidly than reparation has taken place. The desire for food does not ex- ist, and it is refused partly for this reason, but more frequently on account of delusions con- cerning it. There may be a deliberate purpose to end life by abstaining from food ; there may exist a delusion that normal bodily functions have ceased ; or the patient may have suspicions that the food is poisoned, and that it is not what it is alleged to be. One patient, after recovery, stated that he had refused certain articles of food because all ordinary processes of the di- gestive organs were changed, and that under the new order of things articles taken into the 86 A COMPENDIUM OF INSANITY. system would be actually absorbed and no ex- crementitious matter would remain. The character and regularity of the evacua- tions should be a constant guide as to the quantity of food to be administered. The quantity of food taken ought to be sufficient not only to make good the current waste, which may go on rapidly, but, in addition, to restore the loss that has taken place. It is very impor- tant that the nurse keep a record for the guid- ance of the physician of all the articles of food taken every twenty-four hours. If solid food that requires mastication is refused, milk, animal broths, and fruits may be given. The insane make less objection to milk than other articles of food, and, if given with some regularity, it will liberally supplement the usual meals. Eggs broken in the presence of the patient, fruit with the skin unbroken, will often be taken when prepared food will be rejected because of delu- sions concerning it. The nurse may, however, report that food is taken sparingly or that it is refused. It is not advisable to resort to force or mechanical means at once in order to introduce food into the stom- ach if the patient is not feeble, but to present it regularly and insist that it be taken. It is also a good plan to leave some articles of food within TREATMENT OF MELANCHOLIA. 87 reach of the patient, as he may be tempted to partake of it when not observed. Although the patient may neither converse nor respond to in- quiries, and may look upon the physician and nurse with silent suspicion, it is important at every opportunity that the medical attendant reassure the patient that the food is free from drugs or medicine, urge the importance of proper sustenance, and patiently explain the necessity and wisdom of all the various meas- ures adopted for the patient's restoration. In the midst of the agitation, and even in the stu- porous stage of melancholia, it is important to explain to the patient that his troubles and wor- ries have no foundation in fact, but are due to some disordered action of his mind. This may be reiterated again and again. It constantly occurs that some assuring word, a sympathetic look or manner frequently repeated, will find an encouraging lodgement in the patient's mind that will inspire hope. After two or three days' total abstention from food, if the strength visi- bly fails, it should then be administered, not- withstanding the resistance of the patient. A change of nurses in hospital practice will some- times accomplish the result desired without force, as one person may have more tact than another, and delusions sometimes attach to one A COMPENDIUM OF INSANITY. person and not to another. A woman nurse will often induce one of the opposite sex to take food when others fail. Some patients will swallow liquid food if placed in the mouth, utter- ing a mild protest, while others require the introduction of a tube through the mouth ; or a nasal tube may be used as a last resort. Per- haps, on a second trial, a display of the feeding- apparatus, with the preparations and presence of the assistants, may be sufficient to overcome the opposition of the patients. Some patients, after being fed for some time with a tube, ac- quire considerable expertness in evacuating the contents of the stomach by voluntary effort. Forced alimentation may be necessary during several weeks or months, and in one case was continued three years. It is not advisable to withhold the adminis- tration of food until the system is supposed to be prepared for it, but to begin at once and continue it freely. As an illustration of what is meant by liberal feeding, it may be stated that a female patient weighing eighty-one pounds and suffering from melancholia, whose mind and body were in a constant state of agitation, and who would moan aloud and wring her hands, yet was willing to take food whenever presented. She took daily six tumblers of TREATMENT OF MELANCHOLIA. 89 milk, six eggs, malt and cod-liver oil, in addi- tion to three regular meals. Another patient took ten tumblers of milk and twelve eggs daily, in addition to three meals. The gain in weight is also remarkable in some cases. One patient weighed 62 pounds on entering the hospital, and was discharged at the end of six months weighing 126 pounds. Another increased in weight from 91 pounds to 127 pounds. The gain in weight, when, fortu- nately, it takes place, is one of the gratifying incidents of the progress of a case. It is an indication that improvement and activity of nutrition and assimilation have begun, and as this improvement progresses there is the rea- sonable hope and expectation that a corre- sponding change will take place in the nervous system. If this improvement does not take place the prospects of the case are not so fa- vorable. Great stress is purposely laid upon the importance of promoting and stimulating nutrition. To this end special attention is to be given to the condition of the alimentary canal, and to whatever will supplement nutri- tion. The essential object in all recoverable cases is the restoration of the bodily health to its best normal state. In addition to the psychic and dietetic man- 90 A COMPENDIUM OF INSANITY. agement of melancholia and other forms of in- sanity, the medical treatment has an important part. It may suffice to state generally that this should be such as the judicious physician might prescribe in his ordinary practice when he en- counters corresponding conditions. Primarily it should be so directed as to improve the quality of the blood, promote nutrition of the nervous system and the normal action of all bodily functions, and secure rest and sleep. Iron in some form, Fowler's solution of arsenic, qui- nine with strychnine or fluid extract of nux vomica are among the useful tonics. The fol- lowing familiar combination is one that experi- ence has proved very useful, and with variations, if found necessary, may be taken for a long time. Each dose may contain : Strychninae Sulphat., Ferri Sulphat., . Acid Sulph. Dilut. Magnes. Sulphat., Syrup. Simp. Elix. Aromat., " ij. "1 iv. gr. v. 1L xv. q. s. ad fl. dr. j. Pain in the head and a sense of fulness or pressure are commonly present and complained of when an intelligent answer to questions can be elicited. Its existence may be inferred from the manner and actions of the patient, as rub- bing the head, pressing the hands upon the TREATMENT OF MELANCHOLIA. 91 forehead, or pushing the hand through the hair. It may be suspected, also, if the hair is abraded, or is noticed to be pushed back from the fore- head. These symptoms are accounted for on the hypothesis that there is a congestion of the venous currents. Cold, livid, and edematous extremities, observed particularly when the patient is disposed to maintain a standing posi- tion, plainly show the general sluggish state of the circulation. All of these conditions are relieved, or may be entirely removed in the early part of the attack by fluid extract of ergot combined with nitrate of strychnine. Massage may be directed to supplement the medical treatment, if the patient will submit to it. In general experience the patient objects and resists it. It is an interference with the personality which is usually resented, or it may be a source of delusive ideas, and should then be discontinued. The physiology of sleep and the abnormal condition called insomnia are involved in ob- scurity. It may be said of sleep that it is a suspension of the will, and that the usual mental operations are in a state of temporary abeyance. Sleep or repose is so essential to the refreshment of the whole nervous mass that we cannot expect to restore a patient who Q2 A COMPENDIUM OF INSANITY. suffers from persistent insomnia without an effort to cure it. Such co-operative measures as riding, walking, massage—if the patient will not object—or a hot bath at bedtime, followed by a warm nutritious drink, as milk, may prove to be efficient helps. The temptation exists to resort at once to hypnotics and narcotics, and as the effects of moderate doses may not con- tinue to have the desired result, to increase the frequency and quantity of the dose. The phys- iologic condition of sleep is so unsettled, the therapeutic action of medicines in producing it so uncertain and unknown, and the insomnious symptoms so persistent, that embarrassment arises in the selection at once of a hypnotic that is satisfactory in every case. A trial of several medicines may be deemed necessary, and all may fail. In turn sodium bromide, cannabis indica, chloral, hyoscine hydrobromate, sulfonal, trional, hyoscyamine, hyoscyamus, paraldehyde, opium and its preparations and salts, and many other so-called hypnotics have been used with good results, and again they have been misused and their use abused. It may be said of opium that it is uniformly the most reliable narcotic in the materia medica; but in many of the hospitals for the insane a dose of it is rarely administered for purely hypnotic purposes. It TREATMENT OF MELANCHOLIA. may be said of the other hypnotics, that they have been used, but have been laid aside as ineffectual. The principal object to attain is the promotion of nutrition and the elimina- tion from the circulation of all toxic agencies. The use of several of these agents disturbs the nutrition, increases the torpor of the bowels, produces mental hebetude, and causes toxemia. While opium and its alkaloids will produce sleep and repose, the after-effects often add a new complication to embarrass the management of a case, so that the unsatisfactory results are not balanced by its exceptional good effects. Occasionally, however, when the mental dis- tress is so acute and intense that by analogy it has been called a mind-pain, with a tendency to exhaustion, such as suffering may produce, when the pupils are normal or dilated, the pulse and skin soft and relaxed, and no sign of capillary congestion appears, small doses of vinegar of opium or morphine sulphate may produce comparative comfort and relief. It may be said of opium and its alkaloids, the bromides, chloral, and the hypnotics named, that their continued and excessive use is too often followed by unpleasant after-effects. As the several forms of insanity extend over weeks and months, great care must be exercised in 94 A COMPENDIUM OF INSANITY. the prolonged use of drugs in this class. Among the new hypnotics less objection lies against hyoscine hydrobromate and sulfonal. Hyoscine is especially indicated in the insomnia of all forms of insanity attended with much motor disturbance, over which it exercises a marked control. The first dose may be one two-hundredth of a grain. If the pupils are not decidedly dilated nor the heart's action affected, the second dose may be one one- hundred-and-twentieth of a grain, and the dose may be even increased to one-sixtieth of a grain. It is good practice to administer one dose in twenty-four hours, and that at night. It would not be good practice to give more than two doses at intervals of less than twelve hours. The drug has the advantage in admin- istration that it is tasteless, and that it can be administered in very small doses hypodermati- cally. Dryness of the throat and languor are complained of as after-effects, but they are not to be offset against the refreshment that comes from sleep, rest, and repose. Hyoscine in con- nection with nitrate of strychnine (gr. 732) has a favorable action upon the restlessness and in- somnia of the alcohol-habit and opium-habit. Some of the uncertainty of action of hyoscine has been owing, doubtless, to its tendency to de- TREA TMENT OF MELANCHOLIA. 95 terioration and to the imperfection of its manu- facture. Sulfonal has thus far proved to be a valuable hypnotic. It is best administered in warm milk, and its effects, on account of the slowness of its absorption, may be perceived in the course of an hour. The dose may be fifteen grains, or it may be increased to twenty- five grains. Some observers claim to have noticed unpleasant after-effects, but the con- sensus is that both hyoscine and sulfonal are valuable additions to the materia medica, and must remain such until displaced by something better. The value of trional is yet to be deter- mined by further experience. The abuse of hypnotic drugs deserves a notice here, as well as a warning. The pro- longed administration of hypnotic drugs in fre- quently repeated doses has the effect of super- adding to the existing mental disorder a new pathologic state, characterized by acute and general sense-disturbance, as delirium accom- panied by delusions and hallucinations. The physical symptoms of what may be considered the effects of excessive narcotic drug-adminis- tration are not always easy of recognition at first view. A study of eighteen of these cases showed quite uniformly subacute delirium with hallucinations and diminished mental reflexes, 96 A COMPENDIUM OF INSANITY. a feebly acting heart, a flabby, somewhat en- larged tongue covered with a pasty coat, a tumid abdomen, pupils slightly dilated and sluggish, and the countenance pale, expressionless, and in some cases covered with an eruption due to the bromides. It has repeatedly occurred that the hebetude, the speech-disturbance, and the diminished mental and physical reflexes have been mistaken for advanced stages of paresis or organic disease. The fact may be stated of these cases that on admission to a hospital improvement began when the hypnotic drugs were stopped and the patient felt the effects of nutritious food. The indirect effect of ex- cessive hypnotic drugging is to add a toxic agent to retard or even endanger mental re- covery. Life itself has been placed in jeopardy in consequence of partial paralysis or impaired performance of the functions of vital centres, by this injudicious practice. As might be inferred, the tendencies of hos- pital practice are to place less dependence upon drugs and the greatest reliance upon nutritious food, to remove known causes of ill-health, and to promote the normal perform- ance of the bodily functions. The function of menstruation is usually sus- pended in melancholia, as it is in other forms TREA TMENT OF MELANCHOLIA. gj of acute insanity. The stoppage is one of the incidents or symptoms of the exhausted state of the nervous and physical systems. The fact excites in the minds of the friends of the patient, and sometimes also of the physician, an apprehension that it is the cause of the dis- ease rather than one of the effects. It is often a subject of special treatment by the physician, and sometimes even surgical interference is suggested. There need be no special concern about the suspension of this function, as ex- perience shows it will be resumed with an im- provement of the general health; and when the resumption does take place, it may be regarded as one of the favorable signs that may presage further changes toward recovery. Throughout the whole course of melancholia, assuming that the patient's strength will per- mit, it is better to insist that he rise from his bed daily, that he dress in the usual manner, go out of doors to walk or ride for exercise, receive massage if he will co-operate (which is not often the case when the disease is devel- oped), and that he take the accustomed meals with the family or patients of the ward. It often occurs that a patient will partake of food at a table in company with others, taking chances with them that the food is not poisoned. 7 A COMPENDIUM OF INSANITY. The patient is thus diverted and kept somewhat in accord with his usual daily routine habit of living when well, which it is important to adhere to systematically and persistently. The importance of early and appropriate treatment in all cases of mental disease is uni- versally conceded. The prospects of recovery will very much depend upon what is done during the first three months. It has fre- quently been urged that a patient with simple melancholia be sent at once to a hospital, but for personal and family reasons this may not always be practicable. If the diagnosis is clear, if the patient, though suffering from a mild melancholia, or a form of mental disease of another character—as the rule is of wide appli- cation—is still tractable and will accept advice, although not willing to go to a hospital, and if he has abundant means to carry out whatever medi- cal treatment may be directed, it may be proper to make a trial elsewhere. The majority of the insane are not able to incur the expense inci- dent to change of residence and prolonged professional and personal attendance, and must resort promptly to a hospital to give them the best chance for restoration. It is the well- known experience of all hospitals that the largest proportion of their recoveries come TREATMENT OF MELANCHOLIA. 99 from the indigent class, who are necessarily admitted in the early stages of insanity. With the subsidence of the active symptoms of melancholia, and when a marked improvement of physical health has fairly begun, it then be- comes most important to break up morbid ideas before they become fixed. At this stage it is sometimes observed that the mental condition is stationary. The tendency of thoughts and mental processes to flow in certain established channels in a normal state is well understood and must here be considered. It is important to prevent the delusions which have existed throughout the active stage of the disease from becoming fixed as the result of habit. Delu- sions may become fixed by indulgence in ab- normal channels of thought. It is essential to divert the mind of the patient into new channels by a change of environment, which alone often serves as a sufficient corrective. In ordinary experience a new thought or idea will displace and supplant another, and the same rule will apply here. In every form of melancholia the patient has an appearance of reserve, or may be wholly irresponsive even to a degree of apparent stupor. From the appearance of the patient, and such delusions and feelings as have been or are manifested, it is safe to conclude that 100 A COMPENDIUM OF INSANITY. depressing ideas, fears, and apprehensions con- tinue to occupy, the mind, to the exclusion of other thoughts. In the management of the case it is important that the medical attendant and nurse frequently reassure the patient of his security and safety from any supposed impend- ing trouble, that he is not to be harmed, and that his fears and worries arise from delusions which accompany sickness. While the patient may listen in a listless and apparently indiffer- ent manner, yet this should not be a reason for refraining from encouraging words. It is of frequent occurrence that after recovery it has been stated by the patient that some words used, some change of location, or a trifling circumstance, marked the beginning of improve- ment. Melancholia may terminate in recovery in from six months to one year. It may termi- nate fatally from gradual exhaustion in a few months. It may also terminate in a chronic stage, in which the patient may live an average period of fifteen years. During this period the delusions may be less concentrated and have a wider range, hallucinations, usually an unfavor- able prognostic sign, may appear, self-control become impaired, maniacal outbreaks occur, and mental degeneration proceed until the terminal stage—dementia—is at last reached. PLATE 11. i. Simple Melancholia. 2. Melancholia with Agitation. CHAPTER IX. MANIA. Under the term mania may be grouped a large number of mental manifestations quite the opposite of those described as belonging to melancholia. Mania is a condition characterized by an abnormal exaltation and activity of the mental functions—the intellectual faculties, the emotions, and the will—and may show itself by irrational talking and acting, by delusions, illu- sions, and hallucinations, and by unusual muscu- lar activity or movements. Here again a com- parison of the condition of the individual in the disordered state in which he is found with what it was prior to the attack is necessary. It is important to learn the history of the patient in respect to his intelligence, his everyday life in relation to his accustomed occupations and to his family, his normal and usual manner of act- ing, and to learn whether any heredity or ec- centricity-history exists. As it is difficult to find two persons who think and act exactly alike, so it is equally difficult to find two cases 102 A COMPENDIUM OF INSANITY. of the same form of insanity that are precisely similar. There are complex combinations of ideas, and complications of mental faculties and psychic forces to deal with in every case. While it is an easy matter, and quite the rule, to find one case of uncomplicated fever or pneumonia very much like every other case, in dealing with the form of disease now under consideration it would be most difficult to find one case in all respects the counterpart of an- other. Yet, without regard to the dissimilarity that exists in normal mental development, the activity of the emotions or the imagination, the brightness or the stupidity of different individuals, there is a sufficient similarity in the symptoms that are observed to make a subdivision of all cases of so-called mania into subacute mania, acute mania, chronic mania, and recurrent mania. These terms have reference mainly to degree, intensity, duration, and frequency. The number of so-called "manias" that have been actually described and named—usually from some prom- inent characteristic or persistent delusion—ex- ceeds sixty. To present the refinements of nomenclature adopted by various writers upon insanity, no one of which is universally accepted, would consume more space than has been al- lotted to this subject, would not be helpful, and MANIA. 103 would only result in confusion. The given classification will sufficiently aid an intelligent comprehension and study of any case that may ordinarily occur, and will answer the present purpose. In subacute and acute mania there is usually a history of physical or mental over- work and protracted mental application with- out repose, resulting in strain; also, reverses or successes in business, profound moral shock, resulting from loss of property or kindred, and from disappointments, th^exhaustion attending the puerperal condition, and alcoholic or sexual excess—all" of which operate directly or indi- rectly to impair the normal standard of health, to cause loss of sleep, and to produce a func- tional irritability of the brain. It is so unusual to meet with a case of mania in the acute stage that is not preceded by some symptoms of depression that the rule may be stated that this form of mental disease does not occur instantaneously as a transition from a nor- mal state of physical health. As was stated of melancholia, there is here also a prodromal stage. A careful inquiry will reveal some dis- turbance of the physical health, or that a moral shock has been received, producing a profound depression upon a person possessed of a neu- 104 A COMPENDIUM OF INSANITY. rotic temperament or heredity. The patient may show a disposition to devote his whole thought to some matter that concerns his per- sonality or welfare, to seclude himself, and to dwell upon religious subjects, perhaps studying the Bible more than usual. Business matters may not be wholly laid aside, but as other sub- jects engross a great deal of attention the usual occupations are neglected, or are a constant source of perplexity. In the case of a woman, her personality or concerns engross her thoughts, and she may give herself up to emo- tional disturbance, as fits of weeping, laughing, and demonstrations of extravagant conduct of an hysterical character. It will be noticed that there is a loss of appe- tite, that food is taken irregularly, and that the body-weight is diminished. Complaint may be made of insomnia, and that the small amount of sleep is disturbed and broken by dreadful dreams. There is an ill-defined sense of ap- prehension that something is to happen. There may be functional disturbance of the circula- tion, pain or discomfort in the head, flushing of the face, or vertigo. There may be unusual demonstrations of irritability or anger, outra- geous conduct of some kind, or manifestations of erotic propensities. In women the function MANIA. ios of menstruation is usually suspended. While the physical and psychical symptoms of an in- cipient stage of mania may furnish a warning to an experienced observer, they are usually regarded as insignificant in proportion to the conditions they foreshadow, so that they may wholly escape serious attention. The symptoms which have been named form the history of the incipient stage of a large pro- portion of cases of subacute and acute mania. The patient who may be suffering from them is seriously threatened with an attack of insanity, although, if he will co-operate with the meas- ures the physician may propose, a further de- velopment of the disease may be arrested. The question will arise whether the patient should at once be sent away from his home for treat- ment. The decision should depend upon a willingness to submit absolutely to such ra- tional treatment and advice as the physician may direct, until sufficient time has elapsed to determine whether improvement is to take place, or whether other more serious symp- toms are to appear. If the threatening symp- toms abate, it would then be advisable that some change of environment and absolute rest from business should be enjoined, and that all such measures as will promote sleep and the 106 A COMPENDIUM OF INSANITY. complete restoration of physical health should be systematically followed. A companion pos- sessed of common-sense, firmness, and mild- ness, with a course of tonics and generous living, may often be most helpful at this stage. After a period of incubation, which may last from one to three months, marked changes may appear, and in the progress of the case the patient enters upon an advanced stage of the disease, during which the symptoms of maniacal disturbance are pronounced, or prove to be of the most aggravated character. Singly or to- gether the emotions, the intellectual faculties, and the will are exalted beyond the normal activity. On an analysis of the mental symp- toms, they may not be found to be due to de- lusions and hallucinations, but rather are limited •to an exaggeration of the emotional and intel- lectual faculties. The disordered manifestations result from morbid functional activity, all of which may subside gradually, followed by par- tial hebetude and recovery. If the case advances to an acute stage, ac- companied with delusions and hallucinations, emotional disturbances, consisting of immod- erate laughing mingled with tears, exhilaration, anger, affection, lewdness, frenzy, and revenge, will in turn appear. The patient becomes MANIA. 107 garrulous in the extreme. Ideas originate with such rapidity that the conversation ap- pears to be a disconnected confusion of words, which are uttered so rapidly and with such effort that they come forth as if propelled by some inward force. If the attention can be attracted, the answers to questions are often non-responsive; not for the reason that they are not wholly comprehended by the patient, but because, with the rapid discharge of ideas, he attaches but little weight to what he deems an intrusion in comparison with the importance of his own incessant, disconnected, rambling jar- gon. The conversation of both men and women may be carried on with a voice pitched to a high key, and with dramatic enunciation. Such is the conceit and egotism, that this may be one form the patient takes to attract attention by the noise he can make, or as a manifestation of his self-importance. The nature of the conversation is often obscene, profane, or trifling, directed promiscuously toward those who- are near, or carried on when entirely alone. The feelings of modesty and decency which belong to men and women seem to be impaired, and self- respect is gone. The conduct of many patients of this class is exceedingly trying and vexatious to those about them and to the nurse in charge. 108 A COMPENDIUM OF INSANITY. They cause a variety of mischief, provoke as- saults, and make attacks upon others; they rend their garments and destroy furniture with ap- parent joy. Their habits are often dirty; they even smear their persons and the walls of their rooms at night with dirt, urine, and excre- ment. There is a propensity to make a noise, as by the destruction of glass or whatever can be damaged or moved about—sometimes to dem- onstrate their strength or to attract attention. They resist efforts made to control them, and be- come exceedingly violent. As the majority have a confused recollection of what has occurred, they are too likely to misconstrue the efforts of friends and attendants to control them into acts of actual abuse, which come to form the ground- work of nearly all of the complaints of ill-treat- ment. There is always much motor disturbance in acute mania. All the muscles appear to be in a state of activity. The patient may even dance or leap ; or he may try his strength, which is usually much overestimated by others, in vari- ous ways. The patient is disposed to add force and emphasis to his harangues by demonstra- tive gestures with the hands, feet, and body, keeping time continuously to rhythmic sen- tences. While these muscular demonstrations MANIA. 109 and the loud tones of the patient seem quite formidable, and offer a strong temptation to attendants to overcome them by force and the use of mechanical restraint, yet it is pos- sible to avoid much or all of this by judicious care, tact, and as little interference as may be consistent with safety in respect to non- essential things. If the physical condition is good, there is no objection to the noise or the muscular activity of the patient, and, if he really enjoys it, even to taking him out in a carriage or for a prolonged walk, in order that he may expend in a harmless way some of the superabundant force. The expression of the face and eyes and the rapid move- ment of the muscles show the variety and intensity of the inward emotions and the nature of the delusive ideas. The eye is more than usually bright and expressive, the pupils— rarely dilated—are natural in size, or slightly contracted; the face is flushed, or may have a pallor according to the nature of the control- ling delusions or of the prevailing emotions. There is usually an absence of fever, the tem- perature rarely rising above ioo° if no physical complication exists. The intellectual faculties are seriously disturbed from the outset. The egotism and vanity of these persons HO A COMPENDIUM OF INSANITY. stand out prominently. The patient is loqua- cious, perhaps talks about everyday matters; but running through the thoughts and conduct are an egotistical exaltation and exaggeration of manner, and a self-assurance and aggressive- ness that are wholly unnatural. If there is to be a further development of more active symptoms, which is altogether prob- able, the delusive ideas are less distinct and systematized. On the principle of association, ideas present themselves in quick and rapid succession. Small incidental circumstances sug- gest new combinations, until the rapid flow of words seems to be a disconnected mass. Yet if the operations of the mind, acting in this rapid manner, can be closely observed, it will be found that the faculty of memory—always in these cases sharpened in a wonderful man- ner—is largely engaged in contributing to the apparent mental confusion by recalling ideas suggested by surrounding circumstances. Many of the delusions seem to be the outcome of the association of dissimilar ideas, and have but an evanescent, transitory existence. The delusive ideas—we can hardly consider them as having a clearly defined existence in the mind of the patient—produce but a momentary impression, and are supplanted by others, so that the pa- MANIA. Ill tient, who at one moment may be irascible and rebellious, may at the next be amiable and readily disposed to do what may be requested. One. important lesson from these mental indi- cations in the management of these cases is to abstain from undue, unnecessary, irritating in- terference, and to let the patient intelligently alone. Some of the turbulence and violence of acute mania, like other mental disturbances, seem to be in the nature of successive explo- sions of uncontrolled psychic force. Those manifestations, consisting of loud harangues, with disconnected words, uttered with great muscular energy, or some sudden and impul- sive violence, are explainable on the hypothesis that the powers of inhibition,or the governing, counteracting faculties and forces, are abso- lutely suspended or are in abeyance. Convul- sive muscular movements are but a momentary suspension of the co-ordinating functions. So, many of the psychic mental phenomena are to be explained on the supposition that counter- acting, co-ordinating, controlling forces are sus- pended, the governing function being in a state of temporary suspense. Hallucinations and illusions of the senses are usually present in acute mania — more fre- quently those of the senses of sight, hearing, A COMPENDIUM OF INSANITY. and taste. Rarely all of the senses are abnor- mally affected, although such cases sometimes occur. The patient may successively be dom- inated by each in turn. He hears voices, to which he responds in audible words. He seems to see in the persons about him the forms of former friends or of distinguished personages. The food is rejected because the taste of medi- cine or of some disgusting substance is per- ceived. The air that is breathed is loaded with suffocating gases, and a sense of formication and intolerable heat is associated with the surface. Hallucinations, as has been stated, are largely subjective or centric, while illusions are usu- ally objective, eccentric, or have an external suggestive source. As a prognostic indication or sign in acute mania, a valuable intimation may be derived from the prominent sensory disturbances present. If these are connected with the objects surrounding the patient and in the nature of illusions—that is, are sensory distortions of actual existing objects—then the prognosis continues more favorable than when the sensory disturbances are wholly of a hal- lucinatory character, or have an inward, centric, subjective origin. There are other abnormalities that belong to MANIA. "3 this disease, as prolonged insomnia, insensi- bility to heat and cold, indifference to pain or fatigue, perversion of taste, increase of sexual propensities, and suppression of menstruation. The latter symptom, as has been stated of mel- ancholia, is always of much concern to the friends of the patient, and sometimes to the family physician. But it is of no special sig- nificance, as the function is resumed with the restoration of health. It is rather an accom- paniment of physical exhaustion than a cause of the insanity. The usual rule is that an attack of acute mania runs a course of from three to six months, followed by a short or long period of mental and physical depression and inactivity. The prognosis is usually favorable if no serious meningeal complication occurs. The degree of excitement and turbulence is not to be regarded as an unfavorable element in our conclusions as to the result, as it is often but a manifestation of excessive functional activity. It is most important that the process of re- covery, when it begins, be not interrupted, and that a relapse be avoided. Relapses are gen- erally unfavorable. If the process of restora- tion is interrupted, as from the imprudent inter- ference of friends, or from some disturbance of 8 A COMPENDIUM OF INSANITY. the processes of nutrition, or some unknown cause, the patient's mental condition may re- main stationary. His peculiarities may then assume the phase of strong eccentricities, which remain, with some mental weakness, like unsat- isfactory results, such as deformities after an attempt to treat a fracture, predisposing the patient to recurrent attacks. Acute Delirious Mania. — Another and more serious form of mania, differing from the invasion of acute mania by reason of the sud- denness of the attack, the delirium that is pres- ent from the onset, and the imminent danger to life, deserves a brief notice, although of rare occurrence. There are few premonitory symp- toms. The disease has been called acute de- lirious mania, acute delirium, and mania transi- toria. There is mania with active delirium. The patient may have been prostrated by sudden news or by some event that has produced a pro- found moral shock. There may have been ex- haustion following a season of social dissipation, an active participation in a political campaign, at- tendance upon meetings that have deeply moved the emotions, or profound mental application and effort. The patient may have been noticed to be nervous, restless, and fidgety for a few days or a day, unable to obtain sleep, moving about MANIA. "5 in an aimless way, quite busy, but accomplishing nothing. The facial expression and eyes betray deep inward mental activity. With a few pre- monitory symptoms, the delirium appears sud- denly. It is active and profound from the onset. The patient talks rapidly and incoherently in a low muttering tone. The attention cannot be aroused, and there is unconsciousness of all surroundings, although the condition is not exactly like that of coma. The patient is too deeply absorbed in his delusions and hallucina- tions to pay any attention to place, persons, or things about him. The manner, anxious physi- ognomy, and disconnected utterances indicate that the patient is under the influence of delu- sions that excite fear, terror, and apprehension. There is prolonged insomnia. There is often a quick transition in a day or two after the attack to a state of quiet and repose, and ap- parently a return of reason. But this is followed by a return of the maniacal excitement and de- lirium. There are remissions of the psychic and physical symptoms. With the paroxysms there is great motor activity, the patient showing a dis- position to roll upon the bed or floor, or to move about with a gyratory motion. Fever is present, the temperature rising above ioo°. During the exacerbations the pulse rises quickly up to 120 Il6 A COMPENDIUM OF INSANITY. or even 140. The tongue is heavily coated, and soon becomes dry, and the urine scanty. The skin is cool and soft. The delusions and hallucinations are depressing and wholly cen- tric or subjective, and have no connection with the environments of the patient. The prognosis is unfavorable, and the chances are that the patient will die within ten days of the attack. If he survive two weeks the probabilities of life and mental recovery are fair. A few hours of sleep and the ingestion of nourishment are most encouraging indications. In view of the prob- able termination of the case in a short time, if the patient has a comfortable home it is not advisable to urge removal to a hospital when a journey must be made to reach it, as a crisis will soon be reached. The disease is one of exhaustion, and, when death occurs, aside from engorgement of the vessels, probably nothing is to be found to explain the result. The dis- ease is rapid in its progress, terminating in death or recovery, and frequently excites in- terest from the character and social position of its victims. The diagnosis oi acute delirious mania is materially aided by noting the fact of exacerba- tions of the pulse and temperature, the pro- PLATE III. i. Melancholia with Stupor. 2. Acute Mania. MANIA. 117 found delirium in connection with maniacal manifestations, and marked remissions of phys- ical and mental symptoms. The mental pathology is an acute neuras- thenia, or the acute culmination of nervous exhaustion, with a tendency to a collapse of vital force. The temperature and pulse-range, together with the acute delirium and active hallucinatory disturbances, suggest a strong conviction that this disease is closely related to and dependent upon morbid changes of the constituents of the blood, or the existence of septic conditions of a grave form. Puerperal Insanity.—The insanity of pregnant and parturient women should be noticed in this connection. Women become insane both before and after confinement, and the term "puerperal insanity" has been applied to this class of cases, because the disease has a relation to the puerperal state. The disease may appear in a few days or several weeks after confinement, or during lactation. The form, for convenience, may be called puerperal melancholia, puerperal mania, mania with delu- sions, simple depression or excitement, accord- ing to the degree or prominence of symptoms. The insanity of gestation, or prenatal insanity, Il8 A COMPENDIUM OF INSANITY. usually takes the form of depression. It is due to the worry, strain, and physical exhaustion that in some cases accompany gestation. Post-partum insanity is usually maniacal in form and complicated with delirium. It is more frequently due specially to sepsis. The obser- vations at the Pennsylvania Hospital for the Insane, if they are confirmed by general expe- rience, would go far to strengthen this opinion. Since the introduction of stricter antiseptic measures in obstetrical practice the number of cases of puerperal insanity has decidedly de- creased. For a period of ten years preceding the year 1897, twenty cases of acute puerperal insanity were admitted. For a corresponding period preceding 1877, ninety-nine cases were received. The opinion is entertained that if in every obstetric case a rigid exclusion of every source of septic infection should be observed there would be a further reduction of the num- ber of cases of puerperal insanity. If practi- cable to obtain, the temperature and pulse changes will greatly assist the formation of a correct diagnosis in all these cases, and will prove most suggestive as to the proper treat- ment if septic conditions are thus shown. The mental symptoms that characterize mel- ancholia or mania, as they have been described, MANIA. II9 are not essentially different in these cases, ex- cept that the onset is rapid, and may be either mild or severe. The rapidity with which some symptoms appear may be partly owing to the sudden change that takes place in the patient's condition at the delivery of the child. Slight emotional disturbances, as weeping or laughing, sometimes called hysterical manifestations, pet- ulance, irritability, worry about the newborn child, are not infrequent immediately after con- finement ; but these conditions soon pass away with rest, returning sleep, food, and quiet, and may be managed at home. If these manifes- tations are prolonged, characteristic symptoms, such as have been described as belonging to the acute stage of mania, will appear. They are usually of the most aggravated character. The language and actions are inconsistent and at variance with the established character of the patient. The words may be profane, obscene, and uttered in a loud voice. The suspicions relating to persons and food are in- tense, and necessitate tact and patience in the management, and frequent changes of attend- ants. The agitation, jactitation, and general motor disturbance are very marked, and con- tribute to the exhaustion of strength and vital force. If the temperature and pulse do not rise, A COMPENDIUM OF INSANITY. if there is no complication, if the delusions and hallucinations are associated with the persons and things actually surrounding the patient, and if she will take food and procures sleep, then the prognosis is favorable, and no unrea- sonable anxiety need be felt about the result. On the other hand, if there is a temperature ranging from ioo° to 1040, and the pulse over 100, with a rising and variable tendency, there is sufficient reason to suspect sepsis. To the maniacal condition there may be superadded a mental condition in the nature of delirium, confusion, and symptoms of meningitis. The attention of the patient cannot be aroused, the sensory disturbance is active, distressing, and exhausting. The tissue-waste is so rapid that emaciation goes on faster than the loss can be made good by liberal administration of nutri- tious food. The tongue may be coated and inclined to dry. While the threatening symp- toms last the patient's condition is to be con- sidered critical in the extreme. If it is decided that the patient has passed the incipient stages and that she is likely to con- tinue insane for several weeks, if the strength is good and the home cannot conveniently or for any reason be converted into a hospital, removal to a hospital should be effected without MANIA. 121 delay. It is a common hospital experience to receive acute puerperal cases which have been transported long distances in a feeble condition at great risk to life. There should be no haste to undertake a journey if the patient is ex- hausted, as it is far better to convert the house into a hospital for two or three weeks, when a critical stage may have passed. The attend- ing physician and the nurses must meet the emergencies until the strength of the patient will permit removal. As a rule, removal to and treatment in a hospital furnish the best guarantee against suicide, accidents, or any other calamity, as well as the best assurance of recovery. The probabilities are that the largest proportion will recover in from three to five months. If sepsis exists, it is a serious complication while it lasts. The tendency to suicide, to the infliction of self-injuries and mutilation, or to some act of violence to the newborn child, are all indica- tions of extreme perversions of natural instincts in these cases, and should be borne in mind and guarded against. The precautionary meas- ures should comprise constant observation, the removal from the room of all instruments that can be used as weapons, the security of the windows so that they cannot be opened beyond 122 A COMTENDIUM OF INSANITY. a few inches, and the care of keys and the bath- rooms. It is the wisest course to make the patient absolutely safe at all times. The recognition of melancholy or other alterations of the usual manner that attend the prenatal stage, and the diagnosis of puerperal mania and the insanity that accompanies the period of lactation, as well as the septic con- ditions that so often complicate this form of disease, are important to the proper treatment and care of the patient. The melancholy of prenatal insanity, and the subacute mania which may follow, as well as the acute maniacal stage which succeeds to delivery and lactation, may be mainly due to exhaustion of nervous force. They may also be incident to gestation, to the delivery of the child with accompanying hemor- rhage, to the additional drain from lactation, or to septic causes which supervene. Chronic Mania; Paroxysmal Mania ; Recurrent Mania.—The active symptoms of acute mania may subside and leave the mental faculties permanently damaged. The disease then assumes a chronic form. In all cases complicated with meningitis some oro-anic change may have occurred, involving the capil- lary circulation, and affecting the nutrition and blood-supply of the brain. The term "chronic" PLATE IV. i. Chronic Delusional Insanity. 2. Chronic Mania. MANIA. 123 has reference to time, and in hospital-reports is understood to imply a duration of insanity beyond one year. Chronic insanity is not necessarily incurable. After the acute consti- tutional and mental symptoms subside, if re- covery does not take place, the patient may yet resume to a degree an orderly habit of living, but does not return to his usual, or to any useful, occupation. The patient may show peculiarities and some mental weakness. He may laugh or talk aloud when alone, have no capacity or desire for self-support, be irritable, impatient, or fault-finding, and seclude himself from the society of his family and friends. It cannot be said of these patients that they have lucid intervals, but the remission of the active symptoms is so marked that they may often be discharged from a hospital when the habits of orderly living have been established. The periods of remission can hardly be called lucid intervals, for delusive ideas and decided insta- bility and vacillation remain. Many such cases in and out of hospitals may, in the fur- ther course of their lives, have paroxysms with a recurrence of all the active symptoms of their disease, such as require hospital care, so that at no period can they be pronounced men- tally well. The term paroxysmal mania has 124 A COMPENDIUM OF INSANITY. been applied to designate appropriately this form of mental disease. The tendency of chronic mania is toward continued deterioration and mental degenera- tion. A case of chronic mania presents during the life of the patient varying degrees of mental impairment, so that in every hospital will be found a number who have passed through the acute stage and are hopelessly wrecked and damaged as to their mental organization. They are often continuously noisy, turbulent, destructive of clothing and property, dirty and filthy in their habits, discharging their excre- ment in their clothes or in their beds. All traces of decent and orderly behavior, and the facial expression which may have characterized the patient in his normal condition, seem to be obliterated. They need the care of attendants to bathe and dress them in the morning, to place food before them during the day, to con- trol their outbreaks of violence and their dan- gerous propensities, and to undress and place them in bed at night, where they pass so many sleepless nights that the night attendants can never report them as asleep. The care of these cases is incessant, and may extend through months and years. In all of these cases the hallucinations and MANIA. 125 illusions, which are prominent and dominating, have become fixed, and out of them have grown an infinite variety of delusive ideas and confused beliefs. The natural emotions and feelings are blunted or obliterated. They have as a class, however, a certain resemblance in respect to their disordered judgments, their manner and habits, their disconnected, incohe- rent conversations, their changed and perverted feelings, and the tendency to gradual mental failure and enfeeblement, sufficient to classify them under one general head. The Germans have used the term Secundare Verrucktheit to indicate chronic mania with mental confusion, and for the disconnected ideas and delusions following an acute attack. Paranoia ; Monomania.—Another class of cases has a proper place under the head of chronic insanity, as the disease in these cases endures for more than a year, or during the life of the patient. There does not appear to be a marked, or even a perceptible, acute stage. There is a history of mental and moral degen- eration, with a gradual, insidious change in the character, affections, passions; and fixed and clearly-defined delusions are developed, which influence the life of the patient. The term paranoia, a Greek word signifying derange- 126 A COMPENDIUM OF INSANITY. ment, or madness, has been applied to this form of mental disease. The term is good enough if there is a general agreement about its meaning and application. To designate this form of insanity the Germans have applied the term "primare" verriicktheit. In these cases there is usually an inherited predisposition to insanity, or an unstable men- tal diathesis, which forms the groundwork out of which the subsequent disorder develops. The patients may be the offspring of neurotic or intemperate parents. They are eccentric, indolent, reserved, suspicious, conceited, and vain. They array themselves in queer-looking clothing and strut about in public places with a pompous manner to attract attention. Their whole thoughts and lives show a strong self- consciousness, and their egotism is intense. As such a case progresses, erroneous ideas take the shape of fixed beliefs or delusions that influence and change the life of the person. The individual places a high estimate upon his powers and capabilities, and gradually comes to assume that he has some exalted mission to perform for the world. He may consider him- self a self-constituted reformer, and may resort even to acts of violence. Some of these per- sons come to believe that they are important MANIA. 127 individuals, generals, kings, queens, and in some way have a personal relation to the rest of mankind. Delusions founded upon an over- estimate of the individual and his assumed re- lations are systematized and occupy the mind for a time, to the exclusion of all other thoughts. One man conceives the idea that he is commis- sioned to save the world, and begins to preach. Soon he may believe himself divinely inspired, and then perhaps that he is himself the Messiah. Another conceives that he is a military person- age, a general of high grade, a Grant, or a Napoleon—the titles expanding to reach his imaginary greatness. Crimes, acts of violence, and suicides are committed by such disordered persons possessing a strong will-power, under the influence of fixed delusions, as of persecu- tion or conspiracy. The majority, however, are orderly, commit no breach of the peace, and are contented in the quiet enjoyment of their place of abode and their supposed greatness. From the fact of the manifestations of uni- form and fixed delusions continuing for a long period in the class of cases under consideration, there existed at one time a tendency to found a nomenclature and a theory of insanity, based on the hypothesis that the human mind was made up of separate and independent faculties I28 A COMPENDIUM OF INSANITY. or ideational centers. When one was affected a name was devised, suggested by the promi- nent or fixed idea, or, as was suggested by the French, the person might be affected with in- sanity of one ideational center and sane in respect to all others. The supposed affection was called a "monomania." As the impulses and ideas originating in the human mind are numerous, the number of monomanias might become very large, if admitted without any limi- tation as to meaning or use. This term has a professional as well as popular recognition, from long usage, but no scientific foundation which can rest on the wider and more extended medical experience of the present day, as no ideational centers have been discovered. It is alluded to, so that if the terms are met with, or are used, there may be an intelligent com- prehension of their actual significance and application and the class of cases to which they have been applied. Thus, writers have referred to homicidal mania, suicidal mania, kleptomania, dipsomania, theomania, etc., and these terms have been thought to serve a convenient purpose. It is to be understood, however, that the names used are only in- tended to indicate the existence and promi- nence of strong, so-called propensities and MANIA. l2g ideas which the patient cannot or does not re- sist, by reason of impulses or actual delusions. On a careful examination of these cases it can usually be ascertained that the acts which these so-called monomaniacs commit grow out of the existence of some delusion, or result from ha- bitual indulgence in unrestrained passions and vicious habits. For a time the patient seems to be dominated, perhaps, by a single prominent delusion or idea; but other mental disturbances show themselves in due time, and gradually, if the patient lives long enough, there is a general delusional condition. The stage of fixed ideas, of systematized delusions, is supplanted by a more advanced state of deterioration, so that in look- ing over the whole case at the end, while there have been periods in it when the patient had one or more strong, impelling, controlling de- lusions, which some might dignify with a special name, yet, as a fact, there has been a steady but gradual mental degeneration from the onset of the disease. A woman was called a "pyromaniac" because she made repeated attempts to set fire to the hospital in which she was detained. It subse- quently appeared that she believed the fire would be a signal for her release. A French- man in New York entertained a delusion that 9 130 A COMPENDIUM OF INSANITY. he had inherited a fortune of several millions, yet he continued about his usual work. One day, while walking on Broadway, he suddenly drew a compass and thrust at every one near him, wounding three seriously and one fatally. Dr. Spitzka reported on examination that the man alleged that he heard from every side the cry: "There goes the man who is going to take all the money out of the land—kill him," and that he had drawn the weapon and used it in self-defense. So it might be possible to find that criminal and other acts committed by in- sane persons said to have irresistible impulses are the outcome of delusions or hallucinations of long-continued mental disease. Recurrent Insanities.—It is the frequent experience of all hospitals for the insane to receive for treatment a patient who has a record of several admissions. The terms recurrent insanity and periodic insanity have both been used in this connection. The latter miaht con- vey the impression that the insanity appeared at stated periods, or that there was an element of regularity in the occurrence of the attacks, which is not generally correct. The term re- current insanity is therefore preferred, as there is no known law of periodicity that governs these attacks. The form of insanity may be mania PLATE V. i. Chronic Mania : Homicide. 2. Chronic Mania with Fixed Delusions : Homicide. 3. Habitual Criminal and Convict: Chronic Mania. 4. Habitual Criminal and Convict: Chronic Mania. PLATE VI. i. Paranoia. 2. Composite Portrait of Eight Cases of Paresis [by Dr. Noyes.] MANIA. 131 or melancholia; or the characteristic symptoms of both forms may occur in the same case. It is a recurrent psychosis of a variable type. In some cases the evolution does not proceed beyond the stage of depression. The larger proportion of cases of recurrent insanity are instances of acute disorder of the mental facul- ties. During the intervals between the at- tacks, the patient seems to recover his normal mental state, and resumes his ordinary occu- pation. The intervals are of brief or of long duration. They may be months or they may be years. The interval between attacks may also be brief and scarcely appreciable. If the patient is noticed to be exhilarated, talkative, attracting attention by busy ways and unusual activity about small things, making useless purchases, incurring debts, etc., it may be assumed that another attack is about to take place. There may be an explosion of acute maniacal excitement, which will be followed by melancholy, hebetude, and seclusion, with indolence and inertia. After a brief remission a similar series of symptoms may reappear. The term circular insanity (folie circulaire) has been conveniently used to further distinguish this class of recurrent insanities. They are instances of recurrent insanity with A COMPENDIUM OF INSANITY. brief and diminishing remissions, and not cases of a distinct form of mental disease. Recurrent insanity does not ordinarily arise from the same causes that are mainly instru- mental in producing the several insanities which are said to be acquired, such as neuras- thenia, general ill-health, malaria, the puerperal condition, and organic brain degeneration. The majority of cases have a neurotic heredity, or a constitutional predisposition to insanity, derived from the mental degeneration of ancestors or the intemperance and vices of parents. These persons show in their manner, actions, and ap- pearance marks of the psychic stigmata which have been inherited. They are eccentric, er- ratic, unstable, unbalanced, even while in their normal condition. They may even be bright and cultured, and in their best condition they are distinguished examples of original genius. There are numerous instances of those coming within the latter class whose minds have been clouded by frequent attacks of recurrent mania or melancholia. The period of pubescence, the menopause in women, shocks, ill-arranged marriages, the sad and even joyous experiences of life are critical periods, and may be exciting causes of insanity. The alternating conditions of the human mind MANIA. 133 and organization, and the mysterious periodicity which is noticed in all nature, may be an un- known factor in some of these cases. The actions in recurrent insanity are not unlike those described as characterizing mania, or melancholia, in its various manifestations. The incipient stage, however, is of brief dura- tion, and the active symptoms appear rapidly. It does not seem possible to abort the attack, which runs a self-limited course of several months. Recovery, when it begins, is rapid, and even sudden. A relapse need not be looked for until a fresh recurrence takes place, the patient in the interval seeming to be quite restored to his usual health. Patients are brought to hospitals for treatment as many as eight or ten times. As the attacks multiply in number or frequency it becomes apparent to the friends and to the physician that mental impairment begins, and recovery after each new attack takes place, more slowly. The mental symptoms are such as belong to increased or intense activity of the faculties of the mind, rather than those that accompany organic brain changes. Prominent or fixed delusions are not always present, notwith- standing the intense mental activity. Some of these cases, when the type of disease is melan- 134 A COMPENDIUM OF INSANITY. cholia, pass rapidly into stuporous states with controlling delusions, or they are impulsive, homicidal, or suicidal. While the cause of a recurrence is sometimes clear, it repeatedly happens that patients who remain in a hospital during the periods of re- mission, living while there a quiet and unevent- ful life, seem quite as likely to have a paroxysm as at their own homes, without any apparent cause for its return. Patients suffering from the several forms of mania are proper cases for hospital treatment and care. Their own safety and the protection of society alike require that the power of legal detention in places authorized by law for the reception of the insane shall be invoked. CHAPTER X. TREATMENT OF MANIA. The general therapeutic principles that are laid down for the guidance of the physician in the treatment of functional disorders and rec- ognized pathologic conditions in general prac- tice, so far as they have an application to mental cases, are of equal force here. The treatment of mania is both moral and therapeutic. The moral treatment embraces all that concerns the environment, the personal attendants, the room or ward, the discipline—for the insane are amen- able to discipline, which does not of course im- ply punishment. The quarters of the patient should be prepared by removal of all furniture not absolutely required ; all articles that might be used as weapons should be secured, and an attendant procured, if the patient is in private care. If the occupation and pursuits have been such as to produce great strain ; if a serious impair- ment of the physical health exists that deterio- rates the quality of the blood ; if the mental 136 A COMPENDIUM OF INSANITY. faculties have been too actively exercised at a period of life when the physical organization was in process of development; if mental operations, formerly easily performed, are now attended with difficulty and confusion of ideas; if the usual business or occupation is neglected;. if there are depression of spirits, melancholy, and a tendency to introspection and self-re- proach ; if the whole manner of the patient has changed so as to be in marked contrast with the previous character; if there is restlessness, irri- tability ; if the manner is hurried and vacillat- ing ; if the manner and usual habit are accentu- ated, the time has arrived when a warning has been received that must not be allowed to pass unheeded. A departure from the normal state such as we have indicated has its origin usu- ally in strain, overwork, neglect, or violation of wholesome rules of living, and impaired bodily health. The bodily health and weight may not appear to be materially impaired, but some change of nutrition or pathological condition of the brain has occurred. If at this early stage the patient is willing to receive advice and co- operate with measures directed by a medical attendant, a resort to a hospital may not be necessary. But if the patient is not disposed to co-operate with the treatment proposed, on TREATMENT OF MANIA, 137 account of perverseness, lack of will-power, mental enfeeblement, or vacillation; if delu- sions are present or a tendency to do violent or dangerous acts, then the strong will and judg- ment of some other person must be substituted for that of the patient. Removal from home, where the patient has been accustomed to con- trol or has not been disposed to submit to con- trol by others, is fully justified, in order that a proper course of treatment may be carried out, even if it involve the preparation of certificates for his legal detention in a hospital. At this stage, as in other mental cases, argument and persuasion are of no avail. Instead of convinc- ing the patient by either method, suspicions are likely to be aroused, or the patient adheres to his own convictions with greater tenacity. If the case progresses to a stage in which the patient is unmanageable and the symptoms are more active, the friends of the patient must be resigned to the fact that the disease will run a course from three to six months under the most favorable circumstances, during the whole of which time he will require medical advice, watchful nursing, and supervision by day and by night. It must be borne in mind that the phys- ical condition of the patient is usually below the normal standard ; that he is insomnious ; 138 A COMPENDIUM OF INSANITY. that a constant tissue-waste is going on; that the bodily functions are disordered; that the brain is anemic or hyperemic, the quality of the blood deficient in its normal constituents, and the nervous system in a state of irritability. The patient needs plenty of food, which may be given freely at the usual time for daily meals and at other times. It is hardly probable that he will get too much. He needs sleep, fresh air, and, if there is no fever and the strength permits, plenty of exercise out of doors. It is a good rule to allow the patient to move about under reasonable restrictions, to avoid unneces- sary, irritating interference, or non-essential antagonisms of any kind, and, so far as prac- ticable, to insist that he conform to his usual habits as to rising, dressing, taking of food, bathing, walking out of doors, exercise, and removal of clothing at night. If the habits of the patient are destructive, the bedstead and all movable furniture may be removed, as* the broken pieces may be used to destroy property or as weapons. The mattress may be protected by a covering of strong, painted canvas, and laid upon the floor. If clothing is persistently destroyed and the pa- tient denudes himself, a suit of canvas or twilled moleskin cloth may be prepared for men. For TREA TMENT OF MANIA. \ 39 women a combination or union suit of twilled goods, composed of waist and pantaloons, but- toned or laced behind, over which a skirt may be worn, will be found useful in an extreme case. If force is to be used at any time, it is the more prudent course to employ plenty of assistance, so that a serious struggle be avoided. If it appears that a struggle is likely to occur in placing a patient in a bath-tub, it is the better course to substitute a sponge bath. Much of the nervous irritability noticed in all of these cases, it should be remembered, is due to an altered or defective state of the nutrition, and tonics and iron should be administered for a long period. If the state of the circulation or of the heart is such as to require support, stimulants, digitalis, and strychnine should be given. In the treatment of mania, especially if signs of delirium be present (as well as in all forms of acute insanities), the first attention should be given to the state of the bowels and kidneys. As a rule, there is constipation, and the urine is scanty and ammoniacal. Until the intestines are freely evacuated nutrition will not fairly begin. For this purpose a dose, or doses, of calomel will often prove effectual. The reten- tion of fecal matter to a degree that is most 140 A COMPENDIUM OF INSANITY. offensive from neglect and inattention, and excessive uric acid, may be among the toxic agencies that are sufficient to account for the superadded delirium. The insomnious condition of all maniacal patients is one of the most embarrassing symp- toms to overcome. It is persistent for weeks and months, but need not in itself create alarm, for the endurance of these persons is aston- ishing, and, as a matter of actual experience, death does not often take place from this cause, even in acute mania. The insomnia of the in- sane is due to nervous irritability, to the strong excitement of the feelings from delusions and hallucinations, and a motor disturbance that is only "a form of propulsion of nervous activity at the periphery." Functional activity of the brain causes an excessive flow of blood to the brain, which is not removed by the veins in states of nervous exhaustion, and stasis and engorgement result. Sleep is, therefore, pro- moted by medicines as well as other measures that tend to reduce the functional activity of the brain and excessive motor disturbance. Of all the narcotics, opium is the most certain and powerful, but its administration is not, on the whole,, satisfactory in mental cases. The con- stipation that results renders opiates very ob- TREA TMENT OF MANIA. 141 jectionable; but the greatest objection to their use is the capillary congestion that follows the narcotism, and which is likely to be one of the conditions to be met and counteracted in the critical states of acute cerebral disease. The after-effects of preparations of opium are so unsatisfactory that their use is not to be recom- mended in the case of acute mania, or in one of insomnia with the delirium of fever, or from the excessive use of alcohol. Sulfonal alone, or sodium bromide and tinc- ture of hyoscyamus, in combination, will often produce sleep, and chloral may be occasionally added. This combination is thought by some to be attended with average good results for a short time; but there is objection to the effects of chloral and the bromides when used con- tinuously for a long period. If the vessels ap- pear to be full, if the face is flushed and turgid, the fluid extract of ergot may be administered to the extent of 30 or 40 minims three or four times daily. Hyoscyamin and hyoscin hy- drobromate exercise a marked influence in controlling excessive motor activity and in in- ducing sleep in cases of mania. The second is a most powerful drug, and when used it is safer to commence with a dose of one two-hundredth of a grain, which may be repeated once in twenty- A COMPENDIUM OF INSANITY. four hours, carefully observing the effect. The dose may be increased to one one-hundred- and-twentieth or one-sixtieth of a grain. In the treatment of insomnia from alcoholic ex- cess, hyoscin in doses of one one-hundred-and- twentieth of a grain is a useful hypnotic. In increasing the dose we should be guided by the state of the pupil (which dilates under the action of hyoscin), by the degree of muscular relaxation that the drug produces, and by the action of the heart. If the effect of hyoscin is to produce sleep and quiet, there is no objec- tion to its use for a considerable period, but its prolonged use may cause retention of urine. The dryness of the mouth and throat that at- tends the use of hyoscin is a discomfort, but of small consequence in comparison with the good results that are often obtained. The effect of hyoscin in controlling excessive motor activity is one of the excellent results obtained from the use of this drug in conserving the strength and reducing tissue-waste. Sulfonal, one of the new hypnotics, will un- doubtedly have a place until a better is ob- tained, as it produces sleep in 80 per cent, of administrations without constitutional disturb- ance or serious after-effects. Sulfonal may be given in doses of from 15 to 20 grains. As it TREA TMENT OF MANIA. 143 is insoluble, it may be best administered in suspension in a tumbler of warm milk. It is slow in its effects. Trional has produced very satisfactory hypnotic effects in doses of gr. xv. '• All medicine should, as a rule, be adminis- tered to the insane in a liquid form. If given in pills the chances are that the patient will not swallow it. Noisy and sleepless patients are known to sleep better if they have abundance of outdoor exercise and fresh air. In the insomnious condition of acute mania with delirium, puerperal mania, and, it may be added, in the delirium of fever and other dis- eases, the danger to life seems to proceed from exhaustion of the vital force and paralysis of the vasomotor system. In all of these conditions the indications of danger are suffusion of the eyes, dry tongue, rapid pulse, fever, partial suppression of urine, contracted pupil, and lividity of the face and extremities, together with a complication of delirium of subjective or centric origin. All of these symptoms are evi- dences of capillary congestion, paralysis, and sepsis. Unless this tendency can be promptly averted, a fatal collapse will assuredly ensue. In this crisis a hot pack may be directed, and is often followed by a decided improvement, tiding the patient over a critical stage of his 144 A COMPENDIUM OF INSANITY. disease. This pack may be administered by placing two beds side by side, or by placing the patient on a sofa and preparing a bed with a rubber sheet, upon which is placed a blanket. Two double sheets are to be placed in water at or a little above the temperature of the body, folded and thoroughly soaked. The water is then to be wrung from the sheets, which are quickly spread upon the blanket on the bed, and the patient placed upon the sheet. The blanket and sheets are to be folded loosely, but securely about the patient, in which he may remain two or three hours, after which the whole body may be rubbed dry, avoiding un- necessary exposure. This treatment, followed by food and an hypnotic, will often be attended with several hours of refreshing sleep, a dis- charge of urine, with a decided improvement of all symptoms. The French resort to a method for obtaining the same result by placing the patient in a hot bath for several hours. The patient may be placed in a tub with water at 950, with a cover so arranged as to allow the head to appear above the tub and receive cold applications. The action of prolonged warmth applied to the whole body is to dilate the capil- lary vessels, relieve the strain upon the cerebral TREATMENT OF MANIA. 145 vessels, and improve generally "the state of the circulation. Two cases of acute mania are very briefly presented for the purpose of illustrating the efficacy of medicines and liberal administration of food in the treatment of recoverable mania: Case I.—The patient was a young woman, by occupa- tion a teacher, who had a history of overwork, loss of weight, and nervous exhaustion. She was noisy, insomni- ous, and in constant agitation. Her weight on admission was seventy-six pounds; blood-count 3,350,000 per cmm.; the hemoglobin estimation 60 per cent. She was dis- charged well in fourteen weeks, her weight being one hun- dred and nine pounds, the blood-count 4,450,000 cmm.; the hemoglobin estimation 69 per cent. The treatment consisted of tonics, ferric sulphate with strychnine, sulfo- nal at night, with most liberal and systematic administra- tion of food. Case II. has a special interest on account of the cause and the efficacy of the specific treatment. A married woman suffering with acute mania was noisy, dirty in her habits, rubbed excrement on her person and in her hair, denuded herself, destroyed clothing and hospital property. She had tubercular syphilides on the legs, arms, and back. Treatment consisted of mercuric chlorid, potassium iodid, syrup of ferric iodid, and tonics. The improvement was rapid, so that the maniacal symptoms abated in four weeks, and the patient was discharged well in four months. In the general management and treatment of mania in the acute stage, the indications throughout are to sustain the strength of the 10 146 A COMPENDIUM OF INSANITY. patient and repair the waste that goes on rap- idly, rather than to place the chief reliance upon medication. In this, as well as in all forms of insanity, the greater advantage of hospital treat- ment lies in the systematic and persistent ap- plication of all measures and the administration of all medicines directed by the physicians. In the hospital treatment and care of the chronic insane the regularity of the daily life of the patient tends to establish orderly habits of liv- ing, to the development of self-control, and the abatement of paroxysms of excitement. A chronic case of insanity may acquire habits of industry which divert the mind from introspec- tion, from the influence of delusions and hallu- cinations. New paths of thought become fixed, which in turn supplant suspicious and delusive ideas, the patient gains self-control, and may often be discharged from the hospital to reside among his friends. CHAPTER XI. DEMENTIA. It has been stated that the two opposite conditions—mental depression and mental ac- tivity with general exaltation, described as mel- ancholia and mania, with its several subdivisions —may have a terminal stage in mental enfeeble- ment, which is called dementia. Dementia is an enfeeblement of the mental faculties. Men- tal enfeeblement peculiar to childhood, from arrested development, congenital idiocy, or im- becility, is not included under this term. There are varying degrees of the abatement of vigor of the judgment or understanding, impairment of the will-power, and of subsidence of the mani- festations of the normal feelings and affections, showing degrees of deterioration, even to com- plete obliteration of all power to form thought, to act, or to show any feeling. In brief, in complete dementia the mind is damaged or destroyed. Dementia may also occur as the result of organic disease of the brain, of cere- bral hemorrhage, of embolism, or of changes 148 A COMPENDIUM OF INSANITY. in the cerebral circulation, such as may result from endarteritis that may interfere with the nutrition of the brain ; it may be due to the pres- ence of tumors, syphilitic gummatous growths and degenerations, or to alcoholic excesses; it may be a sequence of disease, as malarial ca- chexia and typhoid fever; and it may follow the trophic changes incident to old age. The more frequent form of dementia met with in hospitals is that which follows as a terminal and consequential stage of melancholia and mania. Dementia may be either primary or secondary, partial or complete—terms indi- cating order of development and the degree of impairment. Dementia appears sometimes, but rarely, as a primary condition. Under such circum- stances it may be the result of sudden shock, physical or moral, or of excesses, either sexual or alcoholic. There is no preceding stage of excitement, and, while the symptoms are quite like those of secondary dementia, to make a differential diagnosis for the purpose of treat- ment it is necessary to study the history of the case carefully, as the one condition offers more hope of recovery than the other. If the patient has passed through an attack of illness, as fever, or has been exhausted by close and long appli- DEMENTIA. 149 cation to business or brain-work of any kind, or has been profoundly impressed by some moral shock, such as may occur from domestic affliction, sudden disappointment, or injury of the head, as from a fall, the mental functions are inactive and feebly performed. The patient undergoes a change, may become apathetic, lack decision, be indifferent to his surround- ings, laugh when alone, show little interest in his family, appear to be confused, be unable to collect his thoughts or to write a letter (which may be noticeable by the number of omitted words and sudden breaks in sentences which are left incomplete), and talk slowly, while the memory of recent dates and events is indis- tinct and evanescent. The mental condition is that of hebetude not due to organic brain- changes, but is dependent upon a suspension or abeyance of mental function. In a state of partial dementia a person may sometimes be able in part to carry himself fairly well, in accord- ance with the degree of impairment, performing many habitual acts in an automatic way, but show an incapacity to originate. The physical condition is also impaired, the circulation is sluggish, the extremities are cool, soft, and moist, with a tendency to lividity. The face is pale, or may change color quickly, with or A COMPENDIUM OF INSANITY. without apparent cause, due undoubtedly to fleeting emotional impressions. The pupils are dilated, the usual facial expression is lost, and the patient wears a vacant, staring look. If the patient does not pass beyond this stage it is hardly probable that he will enter a hospital for treatment if he has ample means and a home. If in moderate circumstances the chances of recovery are best in a hospital; and in either case a certificate may properly be made, if nec- essary. It must here be remembered that the patient is seriously threatened. Rest, the gentle diversion that change of air and scene will fur- nish, tonics, iron and arsenic, electricity and mas- sage, with generous diet, afford the best hope of recovery. In all these cases improvement may be expected if the physical health can be sus- tained and a new order of nutrition stimulated and established. Primary dementia and mental enfeeblement may result from injuries to the head, as from blows or falls. Under these circumstances the brain is jarred, and, in addition to the concus- sion, its nutrition is seriously disturbed. In a hospital case the patient had concussion from a fall, striking the head upon the street pave- ment. The pupils were dilated, the pulse was slow and soft, the temperature subnormal; the DEMENTIA. 151 mental operations were sluggish and apathetic ; the consciousness and memory were impaired, and the patient was indifferent to movements of the bowels. There was inco-ordination of the muscles of the legs. The mental state was that of hebetude and dementia. Recovery ensued in three months under the use of tonics—strych- nine, electricity, and attention to the alimentary canal. In another case, a colonel at the head of his regiment received a wound in the left frontal region from a spent ball, which pene- trated the external table, but did not injure the internal table. After a slow convalescence he recovered his usual strength, but was noticed to be irritable and passionate; he lacked judg- ment, was vacillating, and incompetent to per- form his duties. After the lapse of seven years he was in a state of complete dementia, and eventually died in a convulsion. A post-mor- tem examination disclosed a cyst filled with straw-colored fluid at a point corresponding to the point of injury, together with extensive pachymeningitis, with effusion. In a third case, an iron-worker fell from a truss of a roof of a station-building, sustaining a fracture of the skull. After recovery from the immediate effects of the injury there were inequality of the pupils, double vision, inco-ordination of A COMPENDIUM OF INSANITY. gait, headache, extreme hebetude, and halluci- nations of hearing. Recovery followed pro- longed use of mercuric chlorid and potassium iodid. The three cases best illustrate the direct and remote results of injuries to the head, and also, as in the last case, the importance of di- recting the treatment of the early stage on the assumption of the existence of an acute or subacute meningitis with its attending results. Primary dementia may appear with such manifestations as to resemble melancholia with stupor, from which it should be distinguished. In primary dementia the mind is impaired and weakened. Delusions are absent, as the de- ment does not formulate any fixed idea. He is passive and indifferent. He is not suicidal, and takes food when it is offered. The pulse is slow, and the patient is not insomnious. Men- talization is feebly performed. It seems in a state of suspension. On the other hand, the stuporous condition of melancholia is due to the existence of controlling delusions, so that, while the patient seems in a state of stupor, the mind really is intensely active. The melan- choliac is suicidal and resists being moved, as well as walking and taking food. In dementia the mental reflexes are blunted and inactive, while in melancholia they are active and per- DEMENTIA. 153 sistent. The study of the prodromal or in- cipient stages of the two forms of disease may be an aid in arriving at a differential diagnosis. The prognosis in these cases is usually favor- able. It may be important to distinguish idiocy from dementia. When a question arises it should be remembered that while idiocy and imbecility are usually recognized in childhood, dementia appears later in life and in a person who has presented palpable mental develop- ment. The idiot has, as a rule, some marks of physical defect; there may be some malforma- tion or irregular development of the cranium ; the arch of the mouth may be high and narrow; the vision may be defective; the physiognomy has a prematurely old expression ; the fingers may be short, and there is unsteadiness of gait from inco-ordination ; or there may be some lack of symmetry in the development. The dement shows rather physical weakness than physical defect. In accordance with the degree of dementia, the mind receives only transitory impressions which may leave no trace. They come and go, so that the memory neither re- calls events that are past nor notices present occurrences. The face of a familiar friend may elicit a momentary sign of recognition, but the A COMPENDIUM OF INSANITY. impression is a fleeting one and is forgotten. Life may seem to be but an animal existence, destitute of emotions, the pleasure of the society of kindred, and all interest in former concerns is ended, the patient standing or sitting in a state of passive indifference to all environments. Senile Dementia.—As the mental faculties of infancy are weak from lack of development, so in old age they have failed from prolonged use, from degeneration of the cerebral vessels, and trophic changes in the cerebral mass. Here the enfeeblement — characterized usually by the term senile dementia—seems to be a primary change, although in a small proportion of cases it is ushered in by a state of subacute delirium and insomnia. The patient seems confused, forgets his way, or, thinking he is not in his own home, attempts to wander, and may show resistance if opposition is interposed. Loss of memory is one of the earliest symptoms of de- mentia of mental failure due to old age. Lack of attention must not be confounded with ab- sent-mindedness and inability to recall names, dates, and events, which is quite common even in middle life by persons much engrossed in business affairs, who pay little heed to matters not exactly in their line. Memory does not alone fail, but there is a general failure of all DEMENTIA. 155 the mental powers, together with loss of physi- cal vigor, and the state called " second child- hood," or senility, appears. The vacillation, loss of will-power, and erotic propensities, which senile dements so often exhibit, render them an easy prey to designing persons who bring about marriages, or procure the execution of papers that often give rise to vexatious litiga- tion, or wills are changed and codicils added which are subsequently disputed. Persons who have well-marked symptoms of senile dementia at sixty-five, or subsequently, do not recover their reason, and their friends should be so ad- vised. Senile dementia rarely occurs prior to the age of sixty. If subacute mania or delirium seems to precede the failure, the friends of the patient will often consult the family physician about the necessity of taking the patient to a hospital. While this alternative must some- times be adopted, this stage will probably be of brief duration, and will be followed by a pas- sive and manageable condition. The nervous system seems susceptible to the deteriorating influences and changes produced by syphilis, and primary dementia may be one of the sequences of syphilis. According to Savage, idiocy and moral perversion may be due to inherited syphilis. Acute and recur- 156 A COMPENDIUM OF INSANITY. rent insanity, with optic neuritis, impairment of sight, ptosis, and strabismus, may all follow con- stitutional syphilis. Syphilis may be a cause of melancholia and acute mania; also of epilepsy, locomotor ataxia, hemiplegia, and amaurosis. It is associated with the history of 80 per cent. of cases of paresis. As there are no symptoms, and none of the forms of nervous and mental disease already mentioned that belong exclu- sively to syphilis, it is important to get as much history and as many clues as possible in any given case that may lead even to an inferential diagnosis of the existence of syphilis, that may be suggestive of a course of treatment. Primary dementia, or profound hebetude, with a history of syphilis, may simulate paresis. If the history, for any reason, leaves the physi- cian in doubt as to the cause or form, an anti- syphilitic course of treatment is fairly warranted. Recovery sometimes is equally surprising and rapid. A hospital case recovered from a state of apparent complete dementia after fourteen weeks' treatment with mercuric chlorid and potassium iodid, taking 70 grains of the latter three times daily. Primary dementia may follow the exhaustion attending prolonged physical and mental strain, such as may attend military campaigns, home- DEMENTIA. 157 sickness, deprivation of food, and the vicissi- tudes of war. After the late war thousands who had been prisoners, or who had passed through the terrible experiences of the field, were left as mental wrecks. No one who reviews a pro- cession of the survivors of the war can fail to discern in their fixed and immovable faces, often their prematurely old look and loss of physical vigor, the disastrous effects of the severe ordeal upon their nervous organizations—a disability not perhaps to be exactly estimated, and con- clude that it is appreciable and equivalent to the added wear and tear of from ten to fifteen years of life in the case of each one. Dementia may follow melancholia and the various forms of mania, epilepsy, and, as we shall see, paresis or general paralysis of the insane, as a secondary or terminal stage. It is, as has been observed, "the goal of all insani- ties." After a prolonged period of depression or exaltation there ensues a stage of quiet and repose. The violence and force of the shock of the disease has expended itself, and the brain has been damaged. Nutrition may have re- commenced and gone on actively, with in- creased body-weight, but there is no mental improvement. The patient has lost his vigor, and has settled into a passive, indifferent state. A COMPENDIUM OF INSANITY. Memory is weakened, the natural affections are blunted, the powers of attention and concen- tration are gone. There is an indifference to personal appearance and dress; ideas are eva- nescent, although some of them—perhaps a rem- nant of the active stage—remain, and excite but a momentary emotion. There are no fixed and prominent delusions; the face wears a placid, smooth, expressionless look, for the facial mus- cles have lost their characteristic responsive action. The man is in no respect what he was before his sickness, and is like a ship after a storm, having form and motion, but without a pilot or rudder to guide. A patient partially demented may remain in a stationary condition during the remainder of his life. He may have some capacity to re- ceive impressions, but he has no capacity to formulate ideas. A near relative, a judicious attendant, or a hospital organization, furnishing the will-power that has been lost, may be able to keep the patient up to his highest attainable standard, and this may be all that can be done for him. Yet, despite all that may be at- tempted, the dement has a tendency to de- teriorate physically and mentally, and may sink to the lowest state of animal existence. The functions of animal life are performed, the food DEMENTIA. 159 is received into the stomach and digested, but the psychic storms are ended, and there is no recognition of days, dates, or kindred. The contents of the bowels and the urine are dis- charged in the clothing or in the bed, and saliva flows from the mouth. The countenance has lost the natural expression, the extremities are cold, livid, and perhaps edematous from the feeble state of the circulation, and the down- ward tendency is progressive until death occurs. The prognosis of primary dementia following physical or moral shock, fevers, or arising from functional conditions, is not unfavorable. If dementia has appeared suddenly the prognosis is more favorable. A fair proportion of cases will recover. In secondary dementia, when there is reason to believe that some damage to the brain has been done, or some organic change has occurred, the prognosis is unfavor- able. This opinion is always strengthened if the bodily weight has increased without any corresponding mental improvement. Another class of mental cases bears such a close resemblance to primary dementia that they may be easily mistaken and confounded with that disease. The prominent symptoms are the suspension of mental activities and the will- power, and the appearance of a state of hebe- 160 A COMPENDIUM OF INSANITY. tude, such as may be observed in advanced and pronounced cases of dementia. These symp- toms are not, however, the terminal stage of a preceding acute attack. The disease is com- monly observed in the young at or near the age of adolescence. In women it may appear near a menstrual period. It may also make its appearance in states of nervous and physical prostration that follow fevers, malarial poison- ing, or exhaustion from excesses of any kind. The tendency to a recurrence of the state of mental confusion, with some appearance of periodicity, is one of the notable things to be observed—the patient quickly passing into a stuporous condition. The resemblance to de- mentia consists in the apparent mental inac- tivity, which, on a closer examination, is rather a suspension or abeyance of the mental func- tions that connect the patient with his environ- ments. The patient may as quickly return to consciousness after a period of partial stupor, lasting for a week or several weeks. These cases assume a trance-state, and sometimes show cataleptoid tendencies. They are to be distinguished from dementia after a careful ex- amination of the history of the case; by the ab- sence of an acute stage; the absence of mental and physical symptoms that would indicate an DEMENTIA. 161 organic change; the recurrence of stuporous conditions, followed by remissions and a return of rational conduct and conversation, and a physiognomy and expression indicating much more intensity of mental action than appears in dementia. On emerging from the mental con- dition which has been alluded to as indicating rather a suspension than the loss of mental fac- ulties—a trance-state which might imply rather an abeyance of the will-power than its destruc- tion—it has been the experience of patients to converse rationally, to remember, and even make statements of the prominent ideas that occupied the mind during the disordered func- tional state, even to state many things that actually occurred, and their utter helplessness. From the statements made and the appearance of the patient, important suggestions are de- rived for treatment and prognosis, which is usually favorable. The thoughts seem to be centered upon some one prominent topic. They are likened to a vagary of a distressing character, such as may be remembered of a dream-state. The physical symptoms are such as may be observed in states of exhaustion and depression of the vital forces, such as accompany anemia. The face is pale, the temperature is inclined to u 162 A COMPENDIUM OF INSANITY. be subnormal, the skin cool and relaxed, the pupils dilated. The position of the patient is bowed and inclined forward, the hands may rest upon the knees; there is no response or attention to questions. The tongue is enlarged and has a pasty coating. Saliva is retained; food is swallowed if placed in the mouth in liquid form, but no heed is given to any of the discharges. The patient is absolutely passive. While these cases simulate dementia, they are to be differentiated from that disease. They are cases of subacute delirium with mental confusion, often associated with the conditions of anemia and various as well as complicated nervous phenomena. Treatment.—As dementia may be primary and secondary, so it may be partial and com- plete. The physician should direct the treat- ment of primary dementia to the removal of any causes that have contributed to the disease. Primary dementia is a rare affection. In some cases the causes are ascertained, and in others they are conjectural. The diseas.e may be caused by an occupation. Workers in lead and those exposed to fumes of mercury and arsenic have suffered from primary dementia. Persons exposed to marsh malaria, and prisoners of war, have alike suffered from this disease. It DEMENTIA. 163 follows physical diseases, as fevers, syphilis, endarteritis, and organic changes in the brain. In the majority of these cases appropriate medi- cines, calculated to improve the physical condi- tion, and good nursing, contribute to improve- ment or recovery. In secondary dementia, or dementia following chronic melancholia and chronic mania, an incurable damage has been done, and organic brain changes and degenera- tions have occurred. In the early stage of an acute mania there may have been a meningitis with exudations, and the succeeding trophic changes may have taken place in the brain. Endarteritis and other changes in the intra- cranial system may occur, which remain perma- nently. As the tendency in all cases is toward de- terioration and continued mental degradation, persistent efforts should be maintained to an- tagonize the drift in these directions. System- atic and persistent efforts should be made to conform to some ordinary and usual rules of living, as to rising, ablutions, dress, taking food, exercise, and occupation. In a hospital service baths, changes of bedding, clothing, and venti- lation for purposes of cleanliness and sanitation require constant attention. In the management of dements, as they are indifferent or negligent, 164 A COMPENDIUM OF INSANITY. and cannot make their wants known, attention is necessary to their dress, food, and habits, in order to promote their comfort. It is the duty of the attending physician to study the needs and the helpless condition of the patient in order that intelligent directions may be given to the nurses. Habits of cleanliness may be formed by tak- ing these persons to a water-closet with some regularity during the day and at bedtime. Many of the hospitals where large numbers of dements and bedridden patients are congre- gated provide for a distinct night service in in- firmary wards for the care of these cases. The improvement that takes place in the habits and comfort of patients assigned to special care in infirmary wards in charge of a night service, as well as the relief and comfort which are afforded to other patients who are cleanly, is well known by actual trial. The irritability and discomfort these patients manifest often arise from inattention to their personal condition and to their extreme debility. The comfort of the insane of this, as well as other classes, is promoted by attention to their simplest wants, by such medical treatment as will improve the physical conditon, by tonics and a generous dietary. Sedentary habits, with the DEMENTIA. I65 consequences that ensue, should be broken. As many cannot or do not masticate food, it should be cut into small pieces or given in liquid form to avoid accident. Cases that have the appearance of primary dementia arising from shock, profound moral impression, bodily sickness, cachexia from fever, etc., are properly treated with generous diet, wine, iron, arsenic, and massage, for prolonged periods. CHAPTER XII. PARESIS. Paresis is a form of insanity in which there is mental disorder of several types, accompanied with progressive muscular paralysis. The terms that have been applied to this disease in medi- cal literature are "general paralysis of the in- sane," "paretic dementia," and "paresis," all of which are synonymous, or are so intended and understood. The last has equal significance from its derivation, and is short. It is a disease of the brain and spinal cord, characterized usu- ally by maniacal disturbances in the early stage, with enlarged and grand ideas of wealth, power, and greatness, followed by mental failure and dementia, defective articulation, gradual pro- gressive paralysis of the muscular system, with occasional epileptiform convulsive seizures. For convenience the disease may be divided into three stages: i. A prodromal stage, or period of incuba- tion. 2. A stage of decided maniacal activity, or dementia, with symptoms of paralysis. PARESIS. 167 3. A stage of profound mental enfeeblement, with physical helplessness. Although it has been usual to refer to a prodromal or incipient stage of general paral- ysis, the symptoms that may be called char- acteristic, or those that indicate the coming disease, are not definitely determined in the initial stage. It is a stage that precedes the outbreak, or that period in its progress when a convulsive seizure may have occurred, or when the friends of the patient or the public authori- ties interpose to control or restrain the liberty of the patient, lest he commit some outrageous act. Then, for the first time, probably, the case comes to the knowledge of a physician, and the acquaintances of the patient will recall peculiarities in his conduct covering a con- siderable period of time. It may appear on inquiry that there has been a period of depress- ion or hypochondria, that the patient has been extravagant beyond his income, that he became intemperate and licentious, unmindful of mari- tal relations, negligent in respect to business, and sleepless; he may have complained of headache, dyspepsia, general loss of vigor, and loss of memory of recent events. The indi- vidual has undergone some change, and is an object of solicitude to his friends. He !68 A COMPENDIUM OF INSANITY. may have been noticed to be abstracted, as if absorbed in deep contemplation, and to be reserved or taciturn. There is no apparent constitutional disturbance, the appetite is rav- enous, the sexual propensities are strong, and the patient seems to lead a contented, ab- stracted life. How long these symptoms may have lasted is usually a matter of uncer- tainty. They appear in some cases to have existed for several weeks or months. Not one of these symptoms can be regarded as pathognomonic of general paralysis, but taken together, when occurring in an individual of thirty-five or forty-five, who has enjoyed excep- tionally good health, who has the reputation of living what is called a "fast" life, they are threatening and alarming premonitions. The mental symptoms that belong to the initial stage are sufficient to excite an apprehension of some impending and serious disease. The second stage furnishes unequivocal signs of the existence of this fatal disease. The pa- tient's manner now undergoes a marked change. Whatever may have been the previous mental symptoms, his sleep is short and broken ; he rises early; he is restless, moving about from one place to another, but really accomplishing nothing. If he. has been depressed or despond^ PARESIS. 169 ent, his manner is changed; he is exhilarated, the voice is elevated, and the manner more self-assertive. There is a disposition to make purchases of useless articles and property, with- out any regard to the extent of the obligations incurred. There are ideas of great wealth, of investments that will return great profits, of enormous business projects, of great physical strength and prowess, and food is taken raven- ously and in large quantities. If the physician at this stage inquire of the patient as to the state of his health, he will almost invariably answer "first-rate"—that he never was better. If close attention is given to the articulation, the existence of some hesitation or peculiarity may be detected. There is a slight thickening of the speech, caused by an inco-ordination or paralysis of the muscles of the tongue and lips. If at this stage of the case, exalted, expansive delusions of wealth, power, or strength are ob- served, though the patient's condition does not reach a maniacal stage, but is one of general comfort, indifference, and good feeling, the cause of which the observer does not succeed in draw- ing out, and if, in addition, there is noticed a hesitation of speech, the kind of articulation so much like the thick talk of a person under the influence of alcohol, there need be no doubt as A COMPENDIUM OF INSANITY. to the diagnosis. The motor disturbance of the tongue may be obscured at first by the activity of the maniacal symptoms; but the peculiar pronunciation of words containing several syl- lables with consonants will sooner or later be- come quite marked. This is the first sign of a beginning of general and progressive paral- ysis. The patient seems to stumble over words or enunciates them with an omission, perhaps, of one or two syllables. There is a propulsion given to the word with an evident effort of the facial and labial muscles. The tongue appears to be protruded with a similar effort, as if there was a gathering of strength, followed by a sudden movement. Part of the effort is due to a mental incapacity to compre- hend the question at first. When the tongue is protruded fibrillar movements will be noticed to be quite active and distinct, giving to it a tremulous appearance. The altered speech seems to be the first indication of approaching paresis, although there is another physical symptom that may also appear quite early, and should be looked for—an inequality of the pupils, or unequal dilation, or the opposite—a contraction to pin-head size. The experienced observer may discover in the exalted and grandiose delusions the men- PARESIS. 171 tal symptoms of paresis, yet a conservative Judgment and diagnosis will be better fortified by awaiting the manifestations of characteristic physical evidences furnished by the altered ar- ticulation and inequalities and changes of the pupils, when it is of great importance that con- clusions should be correct. If the patient is physically broken down at the onset, and of a mild disposition, there may not be any extraordinary maniacal de- velopment, and he may pass through this stage quietly, pleased with his good health, his imaginary riches, and his supposed comfort- able surroundings. These are, however, the exceptional cases. The general activity and exaltation, the amount of imaginary business to be transacted, and the general exagger- ation of the ego, the personal individuality of the patient, lead to an enormous amount of letter-writing. In hospitals, in addition to the stationery that may be issued, newspaper mar- gins and book leaves are appropriated to write upon. The handwriting here throws some light upon the diagnosis of the case. The hand- writing is altered and bears evidence of inco- ordination in the wavy lines ; the spelling of words is incomplete from the omission of let- ters and syllables, and whole words or sentences A COMPENDIUM OF INSANITY. are broken, run together, or omitted. The substance of the letters shows the mental con- dition ; they may contain orders, notes of hand, or checks for fabulous amounts. Now and then a person who is actually rich is seized with paretic dementia, and enters upon new and enlarged schemes, which are the actual growth of disease, and may seriously compromise an estate or a trust before the real condition is understood. Men who have been accustomed to manage their own affairs will not brook con- trol and advice, and if opposed are violent and dangerous. As a matter of actual experience, these paretics are so full of business, so good- natured with their vast possessions, that they are easily managed or diverted, even in their excitement. They rarely commit violent or criminal acts as a result of their delusions, although, if opposed, as, for instance, in at- tempting to leave their homes or in attempts to travel about the country, they will persist in their efforts, even to a forcible resistance of all control. Although they may boast of their great strength, that they are trained athletes, and delight in displaying their muscles, their strength is expended in a single effort, which leaves them exhausted. PARESIS. 173 The nationality seems to influence somewhat the nature of the delusions of the paretic. In Continental countries, where the possession of political power and aristocratic titles seems to be the ideal and aim of earthly existence, a paretic is an emperor, a king, a duke, or a lord. In America, where money and all that it will command seem to count for more than political honor, he is richer than those who count their riches by millions, is about to build great railroads, which he will equip with gilded palace cars. He may say he is the oldest person in the world, knew Adam and Eve very well, cre- ated and even owns the world. The paretic is a very destructive person in a hospital during the maniacal stage of the disease, destroying his clothing, denuding his person, twisting the torn threads into rolls and ropes, filling his pockets with scraps and rubbish which he treasures as diamonds. During the second, or maniacal and delusional stage, hallucinations of the senses are seldom observed, and can hardly be said to exist. The memory is impaired, the appetite is ravenous, there is no fever, the pulse is normal, and the bodily functions are fairly well performed. The expression of the face undergoes a change. It 174 A COMPENDIUM OF INSANITY. becomes smooth and rounded as the facial muscles lose their play, and the physiognomy has a puffy, bloated look. Disturbances of the cerebral circulation are frequently observed throughout the disease. The partial paralysis of the vasomotor system results in hyperemia of the brain. The face is flushed and turgid, and convulsive seizures may take place during the second and last stages of the disease. The convulsive seizures are epi- leptiform and apoplectiform, and characterized by unconsciousness and convulsive muscular movements. The convulsions of general paral- ysis have some peculiarities to distinguish them. They are oftener confined to the upper extremi- ties, affecting one side of the face or an arm or a leg, and are followed after a return of con- sciousness by a convulsive twitching of the facial muscles or an arm, which may continue for a period of one or more days ; or there may be a succession of these seizures. The convulsive movements may be unilateral, clonic, or tonic. If the convulsion is severe and at- tended with a rise of temperature, death may take place from cerebral effusion at any stage. The presence of a convulsive seizure during the early stage is a very strong diagnostic symptom in any case that is not otherwise clear. PARESIS. 175 The maniacal symptoms of the second stage usually soon subside, and the patient may as- sume a quiet, natural manner, and be regarded by his friends as improved. There may be a remission or complete abatement of the active symptoms, and the patient may even be dis- charged from a hospital to reside at home. The remission may continue a few weeks or months, to be broken by a convulsive seizure, followed by decided mental failure. If no re- mission occurs the mental failure and paralysis proceed and constitute the third stage. In the future progress of the disease the character- istics of dementia appear. The comfortable, indifferent appearance and manner are pre- served through all stages. Memory fails. Im- pressions are evanescent; a visit from a relative is forgotten when ended, and all the conditions of mental enfeeblement that have been men- tioned as characterizing advancing dementia are present. The paralysis gradually becomes general if life is prolonged. The gait is stag- gering or ataxic; articulation becomes indis- tinct; solid food cannot be masticated, and only liquid food should be offered. If the patient does not die during a convulsive seizure, he gradually becomes helpless and bedridden, and is a pitiable object. It is not unusual in this \j6 A COMPENDIUM OF INSANITY. stage, after the patient is confined to bed, that extensive bed-sores and sloughs appear, not- withstanding every precaution and care that may be taken. At every stage of paresis the patient may have a convulsive seizure, which may be followed by others in succession. While a convulsion, or a series of attacks of this nature may occur, and the patient returns to his usual condition, yet, for prognostic purposes, the temperature should be frequently taken. If the temperature is noticed to rise to 1040, with an upward tendency, the case may then terminate fatally in a very brief period. The subdivision of the stages of paresis is based upon the prominent mental and physical manifestations, rather than upon any established or known variation in the supposed pathologic conditions. The maniacal manifestations are not always observed, as we have seen that a patient may pass through the second stage without them, but it is the usual experience that they do occur. Neither do remissions always appear, but they are often observed, and the question may then arise whether the patient is to be regarded as recovered and may be again restored to the control of his business. If the patient has had a history of obscure ner- vous and mental disease, has passed through a PARESIS. 177 brief or prolonged subacute maniacal stage, with an altered and changed articulation, and perhaps an apoplectiform seizure, an opinion must be expressed that the remission is only a respite, and that further unfavorable changes will inevitably appear sooner or later. The several stages of paresis are comprised in a period of two years in seventy five out of every one hundred cases. It is the general experience that every case terminates fatally, and no treatment seems to avert or much delay the inevitable result. It is observed that women suffering from paresis live longer than men, and rarely manifest the maniacal symp- toms noticed in the opposite sex. The causes of general paralysis have been the subject of most careful inquiry. The largest proportion of cases occur in the male sex. It was formerly supposed that women were ex- empt, but this has been shown to be in- correct. The disease is believed to be not in- herited, but acquired. The history of the large majority of cases is one of intemperance, licen- tiousness, sexual excess, syphilis, or some ner- vous exhaustion incident to excessive applica- tion to business, or the great strain attending reverses. Fifty per cent, of the males admitted to the Pennsylvania Hospital for the Insane 1? i;8 A COMPENDIUM OF INSANITY. have had a history of syphilis, and, of eight women, six had a history that furnished the strongest presumption of the existence of syph- ilis. It has been remarked by several careful observers that they have never known a well- bred lady to be affected with general paralysis. It is always a delicate question to determine the existence of sexual excess, and it is usually a matter of conjecture. On the other hand, as has been stated, paresis is a disease known to occur most frequently among the people more advanced in civilization. It is most frequent in the Anglo-Saxon race. Neither can we accept the allegation that business activity is an im- portant factor, as the Hebrew race, always en- grossed in business affairs, shows an exemption from the disease next to the negro. (Savage.) So, of syphilis as an element in the causation, how far its existence is a coincidence, and to what extent it is a cause, is yet to be regarded as unsettled. Of 20,000 cases of syphilis, it is reported (Lewin) that one per cent, became insane, but not a single case of general paral- ysis was observed. Others, however, insist that paresis is but one of the several manifestations of brain-degeneration from syphilis. While, therefore, the cause of general paralysis is still unsettled, the fact remains that the largest pro- PARESIS. 179 portion of its victims have led a life marked by some kind of excess, and a large percentage are known to have had syphilis, and whose brains on post-mortem examination show the peculiar changes produced by that disease in the nervous tissue and in the vessels. Of the treatment of a disease that all experi- ence goes to show progresses by gradual but certain steps to a fatal termination, but little can be suggested with a probability of averting the inevitable end. In hospital practice an at- tempt is made to ameliorate and cut short the paroxysms of maniacal excitement by medi- cines, one of the best of which is hyoscin. The action of digitalis is sometimes attended with excellent results. Chloral may aid in averting a recurrence of convulsive seizures, and in promoting sleep. If there is reason to suspect a syphilitic complication, mercuric chlorid and potassium iodid will often bring about a subsidence of acute symptoms and establish a remission. With the loss of muscular power, if life is prolonged, a time arrives when the patient will be confined to bed, and will require attention to the bowels and bladder, and much care to pre- vent bed-sores. With every attention, it fre- quently happens that gangrenous sloughs form 180 A COMPENDIUM OF INSANITY. rapidly from pressure as well as from trophic changes. It is important that the patient be kept dry, and the pressure upon sensitive parts be relieved by padding. An application of alcohol, alum, and solution of tannic acid has a tendency to harden the skin. Remembering the gluttonous habits of a paretic, and the gen- eral muscular impairment and paralysis that exist in the later stages of the disease, danger of suffocation from the lodgement of solid food may be averted by dividing it into small pieces or administering it in liquid form. The prognosis of paresis is unfavorable for recovery. The delusions, propensities, general disturbance, and disposition to squander money are so pronounced that the wiser course is to place the patient in a hospital rather than to attempt the care at home. CHAPTER XIII. EPILEPSY. The mental disorders that result from epi- lepsy deserve a brief notice. An epileptic seizure is characterized by sudden unconscious- ness, convulsive muscular movements, a slight cry or moan, pallor of the face at the onset, followed by a flushed, turgid appearance of the countenance, frothing at the mouth, labored respiration, with deep inspirations, and sleep which is more or less prolonged. The seizures return from time to time, but not in accordance with any known rule. It is usual to describe two forms of epileptic seizures: (i) One showing the graver symptoms described, and called by some epilepsia gravior; by the French, grand mal. The symptoms above alluded to seem to comprise a complete attack. (2) The seizure may be characterized by temporary, even momentary, unconscious- ness, by pallor, and a slight convulsive twitch- ing of the eyes and mouth. This incomplete form has been named epilepsia mitior, a milder 182 A COMPENDIUM OF INSANITY. form of epilepsy; also by the French, petit mal. The attack may be so mild that the individual may pause while walking or engaged in con- versation, a slight twitching of the muscles of the face and pallor appear, and at once resume where the interruption occurred. In one view a convulsion is simply a sudden interruption of those normally acting and con- stantly existing co-ordinating functions of mus- cles, of those restraining factors that are called inhibitory. The intensity of contractile power that a muscle will show depends upon the de- gree of force emitted from the nervous centers. If there can be a conception of a high tension of psychic force, with such a sudden discharge or explosion as will disturb or destroy all bal- ances or restraining powers, then there can be some appreciation of those irregular movements of the muscles that make up a convulsion. But the convulsive movements are not the whole of. the case. There is, in addition, a state of un- consciousness, resulting in part from a disturb- ance of the circulation within the cranium. The convulsive seizure may be preceded or followed by mental changes; and these, when present, consist in irritability, hebetude, dulness, or rest- lessness, unusual mental and motor activity, passionate outbreaks, even to maniacal out- EPILEPSY. 183 bursts of fury. This changed condition of the patient may exist from one to two or three days before, or subsequent to, the seizure.' The con- vulsive action of the muscles is only one of the manifestations of epilepsy, as epilepsy may ex- ist without actual muscular convulsion. There may be unconsciousness of a momentary dura- tion, so brief that a person engaged in writing, or in his usual occupation, may suspend and resume it without changing his position. There may also be a brief frenzy, continuing from a few moments to several hours without convul- sion, or of such a slight nature that a friend will only notice a change in the countenence and a stare of the eyes. These peculiarities are in the nature of a discharge of a psychic force and temporary suspension of will-power, of which we know nothing except through its manifestations. To this condition, generally rec- ognized, the term "mental epilepsy" has been applied. An epileptic paroxysm is often pre- ceded by some sensory disturbance or sensa- tion called an "aura," and which is uniformly of the same kind. An epileptic may pass many years without perceptible mental change, but the usual ex- perience is that he is observed to gradually become irritable and passionate, and that the 184 A COMPENDIUM OF INSANITY. mental vigor abates. Some of the most terri- ble crimes recorded in the criminal annals of the insane have been perpetrated by epileptics. " The maniacal fury of these patients is of the wildest and blindest kind, which nothing can tame, the individual acting automatically, as it were, and in a state of unconsciousness." The mind of the epileptic is left after a fit in a mor- bidly irritable condition, in which the slightest provocation will derange it entirely. The ten- dency is toward enfeeblement, and the epileptic may eventually pass into a low, stupid state of dementia. Many of these persons go through life without visible mental impairment. Men- tal failure seems to depend on the frequency of the attacks and the degree of cerebral con- gestion that accompanies the seizures. Epileptics have committed acts of incendia- rism, homicides, and petty crimes, of which they retained no exact memory or consciousness. In some of these cases a confused recollection of some terrible struggle or mental oppression remains, in which hallucinations and illusions of sight and hearing have played an important part. In these cases, when criminal acts are committed, the courts usually hold that an epileptic during the interval between the seiz- ures is not necessarily in a disordered mental EPILEPSY. I85 condition, and the question of legal responsibil- ity for acts committed during this intermission is submitted to a jury. It is, of course, true that during the progress of a case in which the seizures occur at long intervals little or no im- pairment may be observed; but when it is shown that a criminal has epilepsy, and the well-ascer- tained deteriorations and changes that attend epilepsy—such as irritability, uncontrollable passion, dementia—are demonstrated to the court by a medical expert, or if the criminal act is committed at about the usual time of the oc- currence of a convulsion, too great caution can- not be exercised about pressing a conviction in these cases. In those cases in which an act was perpetrated in close connection with a convulsion, there should be little doubt about the irresponsibility. During and immediately succeeding the fit the epileptic is in an uncon- scious condition, unable to exercise self-control, having no recollection of what has transpired, and is legally irresponsible. Epileptics rarely die in a convulsion, and of the two forms, the milder form, or petit mal, is believed to exercise a more decidedly deterio- rating influence upon the mental faculties than the other form. In a doubtful case, in which the mental conditions and changes peculiar 186 A COMPENDIUM OF INSANITY. to epilepsy appear from time to time, such as intermittent, periodic manifestations of delirium, maniacal outbreaks of a transitory nature, dulness, stupidity, and hebetude in the morning, reasonable suspicions may be aroused that a convulsion has occurred, but had not been observed. It would be advisable in such a case that the patient be watched at night, as seizures are always more frequent at this time, and sometimes only nocturnal attacks oc- cur. The tongue should be examined to ascer- tain whether it bears any mark of the teeth, and the bed, to learn whether an involuntary dis- charge of urine occurs during the night. The status epilepticus is a prolonged uncon- sciousness and semi-comatose condition accom- panying a quick succession of seizures. If there is a marked rise of temperature a fatal termina- tion may be expected from cerebral effusion or from exhaustion of vital force. It not unusually occurs that an adolescent is brought to the physician with a history of con- vulsive attacks closely resembling epileptic seizures, but it is not often that the physician is able to observe the patient in one of these attacks, which may have occurred intermittingly for a year. It is important to make a thorough physical examination of a young child who has EPILEPSY. 187 no neurotic heredity, and who has had no fall nor received any cerebral injury or shock, and in whom epileptic or epileptiform seizures are said to occur from time to time. Quite uniformly there will be found a disordered digestion, in- dicated by a tongue heavily coated with a pasty fur, and a distended, protuberant belly, reso- nant on percussion. Invariably there has been a ravenous, gluttonous appetite, the patient living largely upon starchy foods. A number of these cases have been relieved and cured by a change of food and the adoption of a new dietary, restricting the starchy foods, the ad- ministration of a tonic, a laxative, with a few grains of sodium bromid and fluid extract of ergot at night. It seems important to break up what seems to be a tendency to a recurrence of convulsive seizures at an early age before the epileptic habit becomes established, and to determine how far they may result from reflex irritation, due to some error of diet or digestion, or both, which may be removed. Recovery from epilepsy rarely occurs as a result of medical treatment. The number and frequency of fits may be decidedly reduced by the administration of potassium or sodium bromid alone, or combined with fluid extract 188 A COMPENDIUM OF INSANITY. of ergot and strychnin. This must be accepted as the best result now attainable from medical measures. The effect of the prolonged use of the bromids is understood, yet the improved condition and comfort of the patient from their use is considered as a sufficient warrant for their indefinite administration. If the seizures recur with frequency, chloral with strychnine may be administered by the mouth, or by enema, with good results. CHAPTER XIV. ABNORMAL PSYCHICAL STATES. There are disordered mental states which may arise either from traumatic or moral shock, or from obscure nervous disease, in which there appears to be a suspension of conscious cere- bration or of the function of some one or more of the faculties of the mind, as the will and memory. There is some exercise of will-power, but in an automatic way, of which the individual has no conscious recollection. As illustrations of these conditions, it may be reported that an officer was thrown from his horse, receiving a concussion and shock, but remounted in an au- tomatic way, spurred the animal to jump fences and cross ditches, made a proper salute to all sentries, threw himself on his cot in an ex- hausted condition, and on the following day had no recollection of what had occurred after the injury. A young man, while under the in- fluence of a sudden and profound moral shock, was tried for the commission of a homicide by striking a blow, of which he testified he had no A COMPENDIUM OF INSANITY. recollection. In another case, a person in a railroad accident was said to have performed heroic service for the relief of others, and of which he was afterward wholly unconscious. Instances of persons who lie in a cataleptoid state, in ecstatic or lethargic conditions, or a "trance," or who wander away and suddenly recover consciousness, are examples of the abeyance of the will-power, the suspension of the faculty of memory, hallucinations of the senses, or of a prolongation of the so-called dream-state. A student devoted himself assiduously to his studies, complained of inability to apply himself to his work and to retain what he heard or read. He suffered from headache and a sense of ful- ness about the head. He was pale, had an anxious, careworn expression, and moved about in a restless, weary, aimless manner. Sud- denly, without any known cause, he disappeared from his college, and appears to have proceeded from Philadelphia to New York, which city he had never visited. How he travelled, how he subsisted, or where he lodged he was unable to state when found by his friends, ten days after his disappearance. Recovering a degree of consciousness, he addressed an envelope to his father, placing upon it his own name, and ABNORMAL PSYCHICAL STATES. I9I gave a number in White Street, New York. He had an apprehension that he would lapse again into unconsciousness, and that he was not equal to composing a letter to explain his situation. When found his shoes and dress were worn, and his pockets contained paper bags with crackers and cake. The housekeeper who gave him a room stated that he never con- versed, but answered questions "yes," or "no." In the following year there was a similar dis- appearance, which lasted thirty-three days, the person going from Pennsylvania to New York, where it subsequently appeared he had no set- tled place of lodging. The second disappear- ance was preceded by restlessness and a cessa- tion of all occupation and ability to apply his attention to his studies. After remaining at home for a year, symptoms of a third journey again appearing, he was placed under custodial care, when he was found affected with an ob- scure psychosis. With every appearance of frankness in reply to questions, and with no known cause for concealment, there is a loss of memory of what transpired during his wander- ings, and the detail of the journeys is a blank. Some of the conditions to which only an allu- sion is made in this chapter are, in the opinion of some observers, among the varied manifes- A COMPENDIUM OF INSANITY. tations of hysteria or the prolonged symptoms that attend the epileptic state. Persons thus afflicted cannot be classed under any one of the forms of insanity. They are in a state of unconsciousness, and criminal acts committed in either one of these conditions must be care- fully analyzed and examined to fix the degree of mental unsoundness and responsibility, though they cannot be classed as insane. It is characteristic of these cases that they have a history of nervous exhaustion. It is a story of neurasthenia in another key. There is a visible loss of mental and physical force; the bodily condition is below the normal stand- ard ; the face is pale ; the pupils are dilated. The prognosis is generally to be regarded as favorable to recovery, and that under an im- proved dietary, tonics, and a complete change of environments, improvement will begin. CHAPTER XV. MORBID ANATOMY. Although we are far from a definite patho- logic basis of insanity, the great advances in the histology of the brain during the last half cen- tury, and more especially in the last decade, justify the hope that much now involved in obscurity may be sifted and analyzed to some practical result. The earlier investigations of cerebral localization, anticipating centers of intellect, emotion, volition, and other mental faculties, have yielded to a more generous ap- preciation of the principles of brain-structure and brain-action, placing, on the one side, the so-called "motor" and " sensory" areas upon the higher level of "psycho-motor" and "psy- cho-sensory" function, and, on the other, admit- ting the participation of the mind in all activities of the cortex, whatever their site. It is worthy of note, however, that cellular changes in the cortex in cases of mental disorder are most marked in the so-called motor region. Dr. Batty Tuke relates his experience to be that in 13 194 A COMPENDIUM OF INSANITY. patients who " had succumbed earliest after the incidence of insanity, none of the cells of the anterior two-thirds of the frontal convolutions and of the posterior occipital gyri were as deeply implicated as those of the Rolandic area."1 In this area are found the greatest number and most marked grouping of the " ganglionic " cells, " the organs through whose instrumen- tality cerebral action is manifested," and in the changes and structure of these "psychic" cells must be sought the explanation of the mental symptoms of disease. Conforming to the uni- versal law that the most complicated machin- ery is adjustable to the finest movements, their mechanism constitutes a most delicately organ- ized system, responding quickly and easily to irregularities in tissue metabolism. According to Bevan Lewis,2 each cell is surrounded by a looped capillary plexus, from which its nourish- ment is derived, the whole lying in a pericellular sac, an ampullar dilatation of the perivascular lymph-canal. In the perivascular structures are Deiters' "spider-cells," at first thought to be connective-tissue elements, but afterward assigned,! by Bevan Lewis, a place in the 1 Morrison: Lectures on Insanity, 1894. 2 Text-Book of Mental Diseases. MORBID ANATOMY. 195 "lymph-connective system." It was supposed by Bevan Lewis, in his earlier studies, that Deiters' cells, in view of their probable func- tion, might be assumed to be scavenger cells; but more recent observations have led to the expression of other views, which accept the phagocytic action of the leucocytes, as well in the brain as in other structures of the organ- ism. Several investigators have noticed that this phagocytic action is exerted upon the gan- glion cells themselves. The relations of these two bodies have been recently explained by an analysis of the conditions found in sections not distorted by the process of hardening. In the pericellular spaces cells have been noted lying near the degenerated cerebral cells. The latter have presented upon the surface nearest these invading cells a semilunar gap, as if a piece had been bitten out. The impression given by this very striking appearance is that the nerve- cells have been the object of attack by the leuco- cytes.1 The integrity of the minute mechanism thus briefly outlined depends upon the prompt sup- ply of nutrition and removal of the effete prod- 1 John Turner: " Some Appearances Indicating Phagocytosis Ob- served in the Brains of the Insane." Journal of Mental Science, January, 1897. 196 A COMPENDIUM OF INSANITY. ucts of cellular activity. The former fails in blood-stasis; the latter follows the accumulation of detritus and leucocytes, either from excessive action of the cell itself or from extrinsic causes of obstruction of drainage. This view seemed plausible from the change in the so-called spider- cells during active morbid processes in the brain, and its errors may be attributed to the lack of knowledge of the normal conditions of these cells. The rble of the spider-cells was assumed from their connections and from their hyper- trophy and proliferation in morbid processes. In the normal brain they are insignificant, but in pathological states they are greatly enlarged, and numerous processes become visible. Some of these processes approach or surround the ganglionic cortical cells, and the new system thus made apparent is completed by a connec- tion with the cerebral vascular elements. They seem to have a more important function than simply binding, like guy ropes, the whole of the other tissues, though such binding cells must be necessary, and their hypertrophy ap- pears to cause a disturbance of the other struc- tures of the brain.1 Attempts to associate naked-eye lesions with particular mental symp- 1 See Clouston. MORBID ANATOMY. 197 toms will be futile until the relations between the former and the cellular deviations shall have been revealed, a result partially attained in the assumption of general paralysis as a distinct pathologic entity. Granular and pigmentary degeneration and vacuolation are the important organic changes in the cortical cells. Granular degeneration, first described by Major1 (whose accurate de- scription has not been improved), is character- ized by a swollen and deformed contour of the cell, with dislocation of the nucleus toward its border, giving a " hooded " appearance. Pigmentary degeneration, as shown by the fresh methods of Lewis, results in an irregu- larly outlined cell, enclosing in one of its parts " a small collection of golden-yellow pigment, through which a number of dark, amorphous, minute granules are scattered. It appears to be surrounded on all sides by protoplasm, but is quite distinct from the latter." The steps of the process are thus summarized by Bevan Lewis :2 Period of Over-activity.—(1) Swelling of cell, with increase of pigment. Dark staining of protoplasm, nucleus, and branches. 1 West-Riding Asylum Reports. 2 Op. cit. I98 A COMPENDIUM OF INSANITY. (2) Advancing degeneration ; cell more globose ; protoplasm retracting; sclerotic investment of cell and cincture formed. Period of Diminished Activity.—Nucleus eccen- tric, deformed, fatter, with narrow encir- cling zone of protoplasm. Processes few; these, as well as cell-protoplasm, faintly stained. Period of Absorption. — Fatty transformation and decoloration of cell. Atrophy, with shrinking or rupture into a heap of gran- ules. Vacuolation follows the escape from the cell of the oil-globules of fatty degeneration by ab- sorption or manipulation. The cavities thus formed are limited and intact, and vary in num- ber, as many as eighteen having been detected in one cell. The nucleus is individually suscep- tible to the same process. Granular degenera- tion is an accompaniment. Morbid processes outside the cell consist in aggregations of leucocytes, development of spider-cells, and proliferation and contraction of connective tissue, with increase of its nuclei. Colloid degeneration and miliary sclerosis, probably due to degeneration of medullated nerves, occur in the white matter, occasionally invading the cortex in the course of nerve-fibers. MORBID ANATOMY. 199 The following comprise the commoner naked- eye appearances in those dying insane. The Skull may be asymmetric or deformed, even in cases beyond the suspicion of idiocy. The bones may be thickened, attenuated, or increased in density. Greater or less degrees of thickening may accompany chronic inflam- matory processes, resulting in increased depth of the normal depressions of the interior, the proliferation of bone not infrequently convert- ing the grooves for the meningeal vessels into closed canals. Roughening is occasionally ob- served, but exostoses and spiculae are rare, Bucknill and Tuke1 reporting only three in- stances in four hundred examinations. In- creased density may reach actual eburnation. Attenuation, with diaphanous areas, especially in the Pacchionian region, occurs most fre- quently in the aged. The Dura Mater.—Severe frontal headache and neuralgia have been ascribed by Duret to compression of the nerve-filaments of the dura, arising from its inelastic nature when subjected to inflammation. Abnormal adhesion to the bone, so strong as to prevent removal of the calvaria without incision, is not uncommon. 1 Manual of Psychological Medicine. 200 A COMPENDIUM OF INSANITY. Attachments to other structures are more rare, and usually exist only through the medium of the Pacchionian bodies. A subdural false membrane, from inflammation or hemorrhage (pachymeningitis, hematoma of the dura), vary- ing from a soft, gelatinous, yellowish or reddish- yellow mass, to a tough fibrous tissue, is found in all forms of advanced insanity, most fre- quently in general paralysis. "Rusty stain- ing" of the inner surface, osseous plates in its laminae, are occasionally developed. Psammo- mata, single or multiple, grow upon the inner surface, and encroach upon the brain, excavated to receive them. They generally appear insig- nificant. "Cauliflower-like excrescences" from the outer surface were noted by Clouston1 in 1872. They accompanied tumors, and were regarded as hernia cerebri, resulting from pres- sure. An identical condition, complicating a large tumor compressing both frontal lobes, is recorded in the American fournal of Insanity for October, 1892. The Pia=arachnoid.—The aptitude of the pia for disposing of rapidly varying quantities of blood, the circulatory dependencies of the manner of dying, and the facility of gravitation Journal of Mental Science. MORBID ANATOMY. 201 after death, inject problems into the determina- tion of cerebral congestion not easily solved. Prolonged hyperemia, or low grade, chronic in- flammation, during which a habit of accommo- dation of large quantities of blood has been acquired by the vessels, is indicated by thick- ening, opalescence, and the extravasation of serum, resulting in "water-logging" of the membrane and increase of the sub-pial fluid. Limitation of the latter to circumscribed areas, especially within the adhesions of general paral- ysis, is not unusual, thus scattering over the surface, generally near the vertex, "lakelets" of serum, of analogous origin, with which are cysts of the choroid plexuses. To severe de- grees of inflammation are attributable minute hemorrhages, sanguineous effusions, and de- posits of hematoidin near the vessels and their bifurcations. Miliary tubercles in the mem- branes and agglutinations of the latter with the cortex (except in general paralysis), are more appropriately lesions of physical disease than of the occasionally accompanying insanity. The Vessels,—The significance of anoma- lous arterial distribution is rather physiologic than pathologic. Calcification has not been more frequently found among the insane than among those dying without marked mental A COMPENDIUM OF INSANITY. symptoms ; at any rate, other than the intel- lectual failure of old age. Atheroma other than the preliminary stage of calcareous de- generation may be of syphilitic or of idiopathic origin. The shades of distinction are not clear; both show general distribution, are attended with thickening, and present the same liabilities of obliteration or rupture. The tendency of gummatous deposits to encircle the vessels, producing band-like constrictions, with proxi- mal distention of the weakened walls in marked cases, produces a characteristic series of alter- nate contraction and dilatation resembling the outlines of a peanut. The development of at- tenuated sacs from these fusiform aneurisms follows the constant pressure of the blood-cur- rent. In one such case a series of consecutive aneurisms reached its culmination in size at the union of the internal carotids and middle cere- brals, presenting two large marble-like excres- cences, one of which ruptured, flooding the base and causing instant death. Chronic endarteritis,1 whether idiopathic or secondary to chronic nephritis, has not received the recognition demanded by its importance or frequency. The cerebral form is distinctly an- 1 Transactions of the College of Physicians of Philadelphia, i88g. MORBID ANATOMY. 203 tagonistic to the proper nutrition of the brain. For its determination calcareous deposits are not essential. The vessels are tortuous and rubber-like, and on section of the cerebral mass the smaller arterioles yield unwillingly to the knife and protrude from gaping canals as twisted and tough shreds. Hypertrophy and dilatation, or valvular disease of the heart, often with distinctly accentuated aortic second sound, firm radial vessels, various paresthesias or local palsies, apoplectiform or epileptiform at- tacks, mental failure, and the general aspect of premature senility, indicate before death the nature of the pathologic process. The Brain.—The average weight of 77 brains examined in one of our State hospitals for the insane was 42^ ounces ; of 43 male brains, the average weight was 48 ounces ; of 34 female brains, 37 ounces. The largest male brain weighed 56^ ounces, the smallest 37 ounces. Both of these were from cases of general paralysis. The largest female brain, from a case of organic dementia, weighed 48 ounces; the smallest, from a case of senile de- mentia, 32 ounces. Thurnam's1 results showed the average weight of 1030 English, Scotch, and 1 Journal of Mental Science, 1866. A COMPENDIUM OF INSANITY. German brains to be 47.7 ounces; the average weight of 257 brains of male patients in the Wilts Asylum, 46.2 ounces, and of 213 women, 41 ounces. In 853 examinations at the West-Riding Asylum, Bevan Lewis1 found "increased con- sistence or average firmness " in 390 cases, the remainder being "softened, either as the result of disease or of post-mortem change." The conditions resulting in diminished consistence were senile atrophy, general -paralysis, and or- ganic degenerations, following disease of the arteries. General softening is sometimes ob- served in cases of acute insanity on removal of the membranes, the pressure of manipulation disfiguring the surface, and the hemispheres fall- ing apart from rupture of the callosal fibres. Post-mortem congestion,2 apart from the passive hypostatic distention of the veins, in- dicates inflammation. The cortex in inflam- matory processes often presents more or less circumscribed and clearly defined pinkish areas. On section, the centrum ovale is studded with numerous scarlet puncta vasculosa, from which the blood freely oozes. 1 Op. cit. 2 Gowers: Manual of Diseases of the Nervous System, 2d ed., vol. ii. p. 377. MORBID ANATOMY. 205 Atrophy would be the classic condition of the brain in advanced dementia, and it not infre- quently exists, though excessive weights are found in terminal stages. In atrophy the con- volutions are shrunken and thin, the fissures gaping and shallow, and the ventricles enlarged. In hypertrophy the summits of the gyri are flat- tened against the skull and the sulci are ob- scured. A typical configuration of the convo- lutions has little place in insanity. Sclerosis with contraction of one or both hippocampi is a common occurrence in epilepsy. So-called organic dementia follows the great destruction of brain-tissue involved in tumors and hemorrhages, the latter probably occurring proportionately more frequently among the in- sane than in the community at large. Old hemorrhagic cysts, occasionally not suspected, are revealed at the post-mortem. Absorption of large portions of the cerebrum, placing the sub-pial region in direct contiguity with the ven- tricle, has been described as porencephaly by Kundrat, and an analogous condition, hydrops ex vacuo, is equally rare. The absorption of one entire occipital lobe, following an acute illness in a girl of fifteen, is recorded in the medical reports of the St. Lawrence State Hospital for 1894. 206 A COMPENDIUM OF INSANITY. GENERAL PARALYSIS OF THE INSANE. The essential pathologic process of general paralysis is acute or chronic meningo-encepha- litis, or periencephalitis, whose important results are morbid adhesion of the pia mater to the cortex and atrophy of the brain. Both condi- tions are almost constant, Mickle1 having de- termined the former in 92 per cent, of his cases, while absence of the latter is attributable to examination during the initial stage of engorge- ment. Variations in the lesions indicate differ- ences in degree rather than in character of the morbid process. The skull is generally thickened, either dense or rarefied, and may present irregularities of the inner surface. The dura is thickened, tough, abnormally adherent, and frequently lined by hemorrhagic membrane. On incision, an increased quantity of clean or bloody serum escapes, sometimes aggregating ten fluid- ounces. The Pacchionian granulations are en- larged and form adhesions between the dura and the pia that do not otherwise exist. The pia is thickened and injected, and its free sur- face is irregularly tumefied from localized accu- 1 General Paralysis of the Insane, 2d ed. MORBID ANA TOMY. 207 * mulations of serum. Adhesions of contiguous folds in the great fissures frequently lead to a coalescence of lobes. The arachnoid is dense, occasionally studded with minute granulations, and presents streaks of opacity along the ves- sels. Across the interpeduncular space it is hypertrophied into a tough, glistening curtain. Removal of the pia discloses the characteristic cortico-meningeal adhesions, the membrane being glued to the cortex "like a glove that had dried into an open sore." Portions of the gray matter, scattered and more or less punc- tate, are torn away, leaving pinkish, eroded patches, and resulting in the irregular surface graphically described as the "moth-eaten cor- tex." The adhesions are almost invariably limited to the summits of the gyri, and are most abundant in the motor areas, the superior frontal and temporal regions, and the orbital lobes. The blood-vessels are irregularly distended, distorted, and thickened; those of the choroid plexuses are intermingled with serous cysts of varying size and number. The brain is soft- ened and shrunken, the convolutions atrophied, the fissures patulous, the white centrum ovale beset with numerous bleeding points. The ventricles are enlarged, full of serum, and the lining ependyma granular. 208 A COMPENDIUM OF INSANITY. The microscopic appearances indicate in- volvement of all tissues in the degenerative in- flammation. The following observations were made from one section prepared by the fresh method of Bevan Lewis from a case of general paralysis of several years' standing: there were numerous irregular and ampullated arterioles, with superabundance of adventitial nuclei; the large pyramidal cells were swollen and " glo- bose," and presented invariably a large extent of pigmentary degeneration ; deeply stained spider-cells were numerous, especially near the summit, where was seen an intricate fibrillar network of clearly-defined and elongated cell- processes. Crowded closely about the edges of the gray matter, and less abundantly scat- tered through it, was a host of colloid bodies. The following imperfectly summarizes the events of the morbid process : diapedesis, de- position of hematoidin, transudation of serum and leucocytes ; stasis, distention, obstruction, aneurism, rupture ; nuclear proliferation of the adventitia ; excess of spider-cells and processes with susceptibility to stain; degeneration of nerve-cells from change in consistence to a broken-down residue, recognizable only as a faintly pigmented patch. Participation of the spinal cord results from MORBID ANATOMY. 209 extension of meningeal inflammation or nervous degeneration. Multiple sclerosis is occasionally found with general paralysis—locomotor ataxy frequently. The association of locomotor ataxy with organic cerebral disease and with morbid processes in the peripheral nerves leads Hirt1 to remove it from the catalogue of systemic spinal diseases to a place among diseases of the general nervous system. Although we are far from a definite patho- logic basis of insanity, the great advances in the histology of the brain during the last half century, and more especially in the last decade, justify the hope.that much now involved in ob- scurity may be sifted and analyzed to some practical result. A host of laboratory workers, following the suggestions of Golgi, His, Kolli- ker, van Gehuchten, Nissl, and other pioneers, have elaborated methods of technique, but to Nissl has been attributed the statement that the anatomy of the nerve-cell must be sharply defined before we may hope that a satisfactory pathology will be evolved. 1 The Diseases of the Nervous System. 14 CHAPTER XVI. MEDICAL CERTIFICATES; FEIGNED INSANITY. Medical Certificates. — In the several States some provision exists for the legal detention and treatment of the insane in hos- pitals. In every proceeding for this purpose the opinion of physicians is the initial step, as from the nature of their profession they are expected to be able to decide the existence of insanity and direct the medical and moral treatment of the insane. The opinion of the physician is usually rendered orally under oath, or in the form of a sworn certificate. The State lunacy laws generally define the qualifications of physicians who are competent to make cer- tificates of insanity. It is the duty of an ex- aminer in lunacy to be familiar with the laws relating to the admission and detention of the insane in hospitals, in order that he may per- form intelligently the service they impose, with- out undue risk to himself, and with a due sense of his obligation to all the interests concerned. " If the examiner is a physician of good repute, MEDICAL CERTIFICATES. 211 if the examination and the certificate (or oral statement) are made in good faith, and as pre- scribed by the statute; if he possesses the req- uisite knowledge and skill to enable him to judge of the mental condition of the patient under examination, and if the examination be made with the usual professional care and at- tention—such a certificate (or oral statement) meets every requirement of the law, and if error is committed therein, and if, unfortunately, by reason thereof, a person of sound mind is com- mitted to an asylum or hospital for the insane, the medical examiner will be relieved of respon- sibility and of liability in damages for unjust restraint of liberty."1 The insane may be divided into two classes : One class is made up of recent and probably curable case's, with many of the characteristics belonging to sick persons in general hospitals. Insanity may be due to obvious derangement of physical functions, on the correction of which recovery takes place. The patient needs medi- cal treatment, nursing, and such restrictions as can only be furnished in a hospital. Another class comprises the insane with fixed delusions of gradual development and long standing, but 1 T. W. Barlow, Esq., Commissioner of Lunacy, Pennsylvania. A COMPENDIUM OF INSANITY. without obvious bodily ill-health. They may be dangerous to themselves and to the commu- nity in which they live, or incapable of caring for themselves. They are not likely to recover under any treatment, but require suitable cus- todial care. The hospitals and institutions for the insane become, therefore, places for their medical treatment, as well as their care and custody. The State has created hospitals for the care of the insane of the indigent class, and has legalized other institutions for the insane for the express purpose of furnishing the means for their treatment and recovery. It is the public policy to encourage prompt and early treatment of all curable cases rather than to surround the admission of such cases to the hospitals by obstacles, delays, and vexatious perils to those engaged in the process of com- mitment. A certificate of insanity is but an opinion of the medical examiner committed to paper ac- cording to the forms prescribed by the State or by its authority. A certificate of insanity has not, and cannot from its nature have, any inherent force, although it is an essential pre- liminary proceeding to admission to a hospital; yet, when completed, it is a sufficient warrant for detention. The physician does not, and MEDICAL CERTIFICATES. 213 cannot, commit an insane person to a hospital by making a certificate of insanity—he has but expressed an opinion that insanity exists. The completed medical certificate establishes the status of the insane person. The medical certificate alone is usually not a warrant authorizing detention, and should not be con- sidered complete until it has received the signature of a near relative, or some person requesting the admission, and until the jurat of a judge or magistrate is affixed.1 The forms of admission vary in the several States, but the general principle seems to be first to establish, by medical testimony, the ex- istence of insanity to the satisfaction of a judge or magistrate, who may then issue the order for removal and detention in a hospital, or sig- nify his approval or knowledge of a medical certificate. As admission to the hospital depends wholly upon the actual existence of insanity, it can only be determined by a personal examina- tion made by physicians separately. It is the duty of each physician to make a careful per- sonal examination. It will not answer to come to a conclusion based upon verbal statements 1 Pennsylvania Insanity Laws, 214 A COMPENDIUM OF INSANITY. of other parties alone, or on the opinion of the co-examiner. Having made an examination, as contemplated by the law, and executed a certificate, the physician is exempt from the consequences of his act, provided he is not in collusion with others engaged in a conspiracy with a criminal intent, for he has discharged a responsibility and duty clearly imposed upon him by the statutes. The examiner is first to determine whether the patient is insane. As insanity is a pro- longed departure from the usual and estab- lished manner of acting and thinking, resulting from disease, in proceeding to make an exami- nation the examining physician should endeavor to ascertain what is the normal mental and physical state of the person he is called to ex- amine ; whether any departure from the usual mental and physical health has occurred, and its nature; when and under what circum- stances the change took place ; whether there is any family heredity or neurotic diathesis, any constitutional organization predisposing to in- sanity, or whether there have been previous attacks. It is important to note the state of the physical health; the expression of the face as to the probable existence of dominating de- lusions or ideas ; the state of the pulse; the MEDICAL CERTIFICATES. 215 appearance of the face and eyes, as they may show the state of the circulation ; the pupils, whether unequal, dilated, or contracting nor- mally under the influence of light, and whether the expression of the eye is unusually bright, furtive, or suspicious; the temperature-record, if it is accessible; the state of the tongue or lips, to ascertain whether there are any irregu- lar muscular tremors ; the state of the reflexes and muscular tension; the character of the speech—whether thick, slow, or distinct, and whether words abounding in consonants are clearly pronounced ; whether there is an inco- ordination of muscular contractions and move- ments ; whether the person moves about in a restless, uncontrollable way; whether there has been a loss of weight; whether the person takes his usual food in sufficient quantity with the family and in his accustomed manner; when and why he ceased his usual vocation ; whether the person sleeps or is insomnious; whether he remains in bed during the night, or rises and walks about; whether there has been a tend- ency to an exalted manner or enlarged and extravagant ideas, to talk in a loud tone and emphatic manner that may be unusual; whether there is a propensity to unaccustomed indulg- ence in excess of any kind ; whether there is a 2i6 A COMPENDIUM OF INSANITY. tendency to depression and melancholy without apparent cause ; whether answers to questions are rational and responsive, or evasive and monosyllabic, and whether there is a hesitation in conversation due to evasion, dulness of com- prehension, or stupor. The personal appear- ance and attire and the room occupied by the person to be examined should be carefully scrutinized. Bearing in mind the definitions of insanity, it should be established that the men- tal disorder is a prolonged one and not of a transitory character, nor due to the delirium that accompanies some bodily disease, as a fever. In the course of the examination the ex- aminer may learn of the existence of actual delusions or hallucinations of the senses from positive declarations, or their existence may be inferred from the answers given and the man- ner of the person examined. The existence of mental disease may be clearly apparent at once, but in doubtful cases a second or a third visit may be necessary. The examination by the physician should in all cases be thorough, and it is advisable, for his own protection and for that of all concerned, that a record or minute of the case be preserved for future reference. If the examiner concludes that the patient is insane, then he should determine whether or MEDICAL CERTIFICATES. 217 not he should be placed in a hospital for treat- ment and detention. If the person examined is, in the judgment of the examiner, insane, be- fore the certificate is prepared the physician should determine whether "the disease is of a character which requires that the person should be placed in a hospital or other establishment where the insane are detained for care and treatment." How shall he determine this point, which is an important element to the further or essen- tial feature of the proceeding ? The examina- tion of the patient may or may not furnish a clue, but the physician may by means of his professional judgment, from the history of the case, and from conversation with the relatives, conclude as to what is, on the whole, best or necessary. If the patient is in a comfortable home, has no delusions about the place, the environments, or relatives, is willing to take medicine or food, and all can be done there for his safety that a hospital with its staff can do for his care and treatment, the physician may hesitate and not feel warranted in signing a certificate. If, on the other hand, the patient is noisy and refuses to yield to advice, has delusions about his home, friends, food, and medicine, if there are well-grounded fears of 2i8 A COMPENDIUM OF INSANITY. suicide, homicide, or escape, or if the relatives and estate are not able to furnish all that is essential for the care and treatment, then the physician is justified, and it is his clear duty, to sign a certificate for admission of the patient to a hospital, "in order that he may receive the care and treatment" that are necessary, which he cannot receive otherwise, and which can only be furnished by a hospital. If the physi- cian is familiar with insanity, and is able to make a diagnosis of the form and tendency of the dis- ease, it is not necessary or advisable to wait and delay until a violent paroxysm has actually occurred, with the danger that permanent dam- age may be done to the brain, or, in another case, until the patient has passed into a con- firmed melancholy or dementia. The authority given to physicians to certify to the insanity of lunatics who are dangerous on account of delusions, but who are not suffer- ing from an acute form of insanity, is likewise conveyed by the statute. The physician should proceed to make a careful personal examina- tion of the individual alleged to be insane, as in other cases, and determine whether insanity exists, and whether the disease is of a character that requires that the person should be placed in a hospital where the insane are legally de- MEDICAL CERTIFICATES. 219 tained for care and treatment. The physician is to determine, from his examination, whether the person is insane, rather than that he is simply dangerous, which may be regarded as a term vague and general, and not wholly within the province of the physician, although such a con- dition may attend the existence of insanity.1 The physician may be called to examine a person charged with crime or one convicted of crime and under sentence, and to express an opinion as to the existence of insanity. In some of these cases a conclusion is easily reached. There is also a perplexing border-land in which there is a shadowy line of demarcation between insanity, congenital obliquities, and criminal instincts, about which confusion, doubts, and honest differences of opinion will and do arise. Here the physician has no other course open to him than to ascertain as far as practicable what was the normal state of the criminal—his usual mental and physical health prior to the commission of the crime, and the time when it is alleged that a change of manner, thinking, and acting occurred, and compare the normal state with his condition at the time of the com- mission of the crime. The physician should 1 Dr. J. B. Chapin : Report of Penna. Com. of Lunacy, i88g. A COMPENDIUM OF INSANITY. proceed in his own way to come to a conclu- sion, by pursuing a course of examination as for the preparation of a certificate of insanity, and to feel assured that the symptoms that are disclosed have appeared in an order that con- forms to general experience. Feigned Insanity.—The physician must bear in mind, in many of these cases, the possibility of the existence of a motive to conceal, to prevaricate, and to feign the ex- istence of insanity. The ordinary experience is that individuals do not feign insanity for the purpose of gaining admission to hospitals or to be declared insane. If they exhibit any senti- ment at all in the matter, ordinarily they seek to make the most favorable impression upon the mind of the examiner. Criminals who feign insanity usually affect some of the extreme manifestations of the disease. Suddenly, with- out any prodromal symptoms, the criminal may become destructive, violent, noisy, or dirty, or may sit silently, with his head bowed, may neg- lect his personal habits, allow the saliva to drool from his mouth, and refuse food. The experience of the physician teaches that mania is not developed without precursory symptoms, and that dementia is the terminal, and rarely the primary stage of long-standing mental dis- FEIGNED INSANITY. 221 ease. These cases have suddenly, and with- out any incipient stage, presented symptoms that could only have resulted from insanity of several months' or even years' duration. It is as incongruous as if a typhoid could be said to have begun with the last stage of the fever, which is contrary to universal professional ob- servation. The attempt to successfully feign a semblance of insanity for a long time usually results in failure. As these, feigners find it convenient to omit the usual precursory symp- toms, they almost invariably end their sham- ming suddenly from sheer physical incapacity to carry on the deception longer, or the motive for its continuance no longer exists. Both the history of the beginning and the end of at- tempted frauds of this character furnish evi- dence for its detection, so that it is important that such persons be placed where opportuni- ties exist for prolonged observation. It may be said to be the rule of experience and obser- vation that insanity is not of sudden origin, its gradual development actually extending over periods of weeks and months. Neither does it begin and end with a criminal act as its sole manifestation. The criminal act, when com- mitted by an insane person, is but one of sev- eral symptoms of his disease, or a legitimate A COMPENDIUM OF INSANITY. sequence of it that may be traced to a delusion. So, it may be said, that single, isolated, dis- connected expressions are not, in themselves, symptoms of insanity. What is common, nor- mal, and usual in one person may in another be unusual, abnormal, and only to be accounted for on the hypothesis of insanity. The indi- vidual must be compared with himself, as no fixed standard of sanity is recognized. The examiner must consider whether the whole group of symptoms amount to insanity, in com- ing to a conclusion in the preparation of a cer- tificate of insanity, as well as in the examination of criminal cases. It may be assumed that four-fifths of all per- sons feigning insanity will simulate dementia. Some of these malingerers in the course of their varied experience have seen cases of dementia, and this form of simulation does not require the intensity of action ordinarily witnessed in mania. The history of all these pretenders is usually quite uniform in one respect—that the simulation commences suddenly; that the man- ifestations are of an extreme character and always much overdone at the wrong period. The same rule that prevails in the observation of ordinary physical disease holds good here, so that the examiner has the right to expect some FEIGNED INSANITY. 223 approach to a regular order of development. The physician does not look for a consolidated lung at the outset of pneumonia, nor a typhoid eruption on the first day of the fever, and when he observes these symptoms he correctly as- sumes that a previous stage has passed. So, if a person is reported within a few hours to have refused to talk, who bows his head, allows the saliva to drool from the mouth, smears his room or cell with his excrement, rends his gar- ments, refuses to talk or reply to questions; or if he makes a reply that is not responsive, or he utters a continued low mumbling of unintelli- gible words, there is presented a series of mani- festations that belong to an advanced stage of dementia which, as a matter of actual experi- ence, may be looked upon as a terminal stage appearing after a lapse of months or even years of previous insanity, and which could not de- velop possibly in a few days or hours. As a rule, and with rare exceptions, all forms of insanity have a prodromal stage like other dis- eases. Observing, therefore, carefully the mani- festations and their exact history, bearing in mind under what circumstances dementia may appear and that all diseases have certain fixed laws of rise, progress, and decline, the physician can hardly fail to arrive at a correct conclusion 224 A COMPENDIUM OF INSANITY. that the simulating dement is a fraud. If a suf- ficient time be also allowed for observation, it will soon appear that the simulator of mania has not sufficient physical strength or will-power to go through a paroxysm of more than a few days at the utmost, when the pretence will be- come transparent. There may be less difficulty in reaching a conclusion when the criminal act is clearly the result and consequence of a delusion, and in those cases of mental degeneration in which the inhibitory powers have been obliterated by general disorder, or in which they are in abey- ance from defective development. Criminal acts are also committed by persons who are partially insane—that is, they have delusions and delusive ideas, have an insane ancestry, and are known to be erratic, but the acts them- selves have no direct connection with the men- tal disorder. They know the difference between right and wrong, yet upon slight provocation, smarting under a fancied injury, with delibera- tion, avowing their intention, commit a homi- cide or other grave offence. There exist all the elements of responsibility that belong to ordinary crime. Such cases are of acknowl- edged embarrassment to courts and juries. The physician must here express the opinion that FEIGNED INSANITY. 225 partial insanity exists, and may properly assume that it is only a question of time when in its progress it will become general, content to leave the question of degree of criminal respon- sibility for the court and jury to determine. It is also of primary importance in any medico-legal investigation to determine the fact of the existence of insanity according to some principle or rule of experience, rather than to contend about the exact form of the disease or to indulge in pyschological theorizing. Differ- ences in regard to the nomenclature of insanity will prevail, and no universal agreement can be expected—a fact that is commented upon as an exhibition of uncertainty in regard to a subject from its nature obscure and complex. It is not an unusual practice in our courts, where the issue is the question of insanity, to extract from medical witnesses or experts a name or form of insanity that exists. If there is a disagreement among the witnesses in this respect, or if ob- scure terms of a technical character are em- ployed, there may result confusion and grave doubts in the minds of the court and jury as to the certainty and precision of science. It is a wiser course for medical men to avoid the use of unfamiliar and scientific terms and to adhere to a simple nomenclature in the present state 15 226 A COMPENDIUM OF INSANITY. of knowledge and until a better agreement is reached as to terms and definitions. There is often an effort to establish the exist- ence of insanity in a doubtful or questionable case by aggregating together a number of epi- sodes or events trivial in themselves in the life of a person, and assume that they prove the existence of insanity. The medical witness is confronted with the incidents in court, or may be obliged in the course of an examination of a person charged with a crime to form some opinion as to their import. Here he must con- clude that while the trifling incidents are per- haps such as may appear in well-recognized cases of insanity, they are insignificant in them- selves to prove that it actually exists, unless delusions are present to account for the actions. The insane act from motives, as do the sane, and both classes perform similar actions. In all medico-legal inquiries it is important that the medical witness, acting as an expert, endeavor to form some estimate of the normal character- istics of the person whose condition is under in- vestigation, and ascertain whether any marked change has occurred as a result of disease or mental degeneration, and whether in its prog- ress and continuity it is in accord with the rule of experience. To show the presence of in- FEIGNED INSANITY. 227 sanity to a degree to exempt from responsibility and consciousness, the mental change should be shown to exist to a degree to alter the usual habit of thinking and acting, otherwise little in- cidents and episodes, scattered over a lifetime, are of small significance. The medical witness may also be asked whether writers on insanity are authorities, and to this question an affirma- tive answer may usually be given, but with a qualification and reservation that no authorities exist in medical literature in the sense that the legal profession accept the opinions and dog- mas of the higher courts. The views of medi- cal writers are accepted only as they are in conformity to the general experience of the profession. INDEX. Abnormal psychical states, 189 Actions of the insane, 44 Adhesions, dural, 199 Admission to institutions for the in- sane, 213 Alcohol, habitual use of, not insanity, 35 Alcoholism, 142 Amaurosis and syphilis, 156 American alienists, classification of insanity, 51 Aneurisms, 202 Anomalous arterial distribution, 201 Antisepsis in obstetric practice, 118 Apoplectiform seizures in paresis, 174 Appetite in paresis, 168 Arsenic in melancholia, 90 Arterial distribution, anomalous, 201 Articulation in paresis, 169, 175 Atheroma, 202 Atrophy of brain, 205 Attention, faculty of, 19 Aura, 183 Beard on neurasthenia, 64 Bed sores in paresis, 176 treatment of, 180 Billings, definition of neurasthenia, 64 Blackstone, definition of insanity, 33 Blood in melancholia, 67 Bloodvessels, 201 Body, influences existing between mind and, 25 Bowels in melancholia, 67, 72 Brain, 203 atrophy of, 205 congestion of, 204 I Brain, hemorrhages into, 205 hypertrophy of, 205 sclerosis of, 205 softening of, 204 tumors of, 205 weight of, 203 Bromides in mania, 141 in melancholia, 92 Bucknill and Tuke, 199 definition of insanity, 33 Calcification of arteries, 201 Calomel in mania, 139 Cannabis Indica in melancholia, 92 Cataleptoid state, 190 tendencies, 160 Causes of paresis, 177 Cellular changes in the cortex, 193 Cerebral, 205. (See Brain.) effusion in paresis, 174 Certificate of insanity, 212 Certificates, medical, 210 Characteristics, exaggeration of nor- mal, in insanity, 47 Chloral in epilepsy, 188 in mania, 141 in melancholia, 92 in paresis, 179 Choroid plexuses, 201 Circular insanity, 131 Circulation in dementia, 149 Classification of insanity, 52 based upon causes. 55 Clouston, Dr., 72, 196, 200 Colloid bodies, 208 degeneration, 198 Commitment, conditions justifying, 217 Confusion, mental, 162 Congestion of brain, 204 230 INDEX. Congress of Mental Medicine, classi- fication of insanity, 54 Conolly, definition of insanity, 33 Constipation in mania, 139 Convulsions, 182 Convulsive attacks resembling epi- lepsy, 186 seizures in paresis, 174 Cortex, cellular changes in, 193 Cowles, on neurasthenia, 64 Crimes among the earlier manifesta- tions of insanity, 48 and epilepsy, 184 in paranoia, 127 Criminal acts influenced by delu- sions, 224 lunatics, 219 Curability of chronic insanity, 123 Dangerous lunatics, 218 Degeneration, granular and pigmen- tary, 197 Deiters' cells, 194 Delirium, acute, 114 not insanity. 34 subacute, 162 Delusions, definition of, 36 in acute delirious mania, 116 in dementia, 152 in mania, no in melancholia, 69 in paranoia, 126 in paresis, 169 in recurrent insanity, 133 in stupor, 77 melancholia with, 75 objective, 37 popular, not insanity, 34 present in insanity, 37 subjective, 37 systematized, 129 Dementia, 147 cases resembling, 159 causes of, 147 contrasted with stupor, 77 differential diagnosis from idiocy J53 from melancholia with stupor 152 in paresis, 175 management of, 163 organic, 147 paretic, 166. (See also Paresis.) Dementia, partial, 149 primary, 148 from injury, 150 prognosis of primary, 159 secondary, 157 senile, 154 tendency of, 158 terminal, 157 treatment of, 162 Demoniacal possession. 73 Diagnosis of acute delirious mania, 116 Digitalis in paresis, 179 Dipsomania, 128 Dream-state, 190 Drugs, habitual use of, not insanity, 35 Dura mater, 199 Duration of paresis, 177 Duret, 199 Eccentricities, 31 Ecstatic conditions, 190 Emotions, 21 disturbances of, 47 in melancholia, 69 Endarteritis, chronic, 202 Epilepsia gravior, 181 mitior, 181 Epilepsy, 181 and crimes, 184 caused by syphilis, 156 Epileptic seizures. 181 Epileptiform seizures in paresis, 174 Ergot in epilepsy, 188 in melancholia, 91 Erotic propensities in senile demen- tia, 155 Esquirol, classification of insanity, 53 Esquirol's definition of insanity, 32 Examination to determine insanity, 214 Exercise in melancholia, 92 Expansive delusions in paresis, 169 Experts, medical, 225 Eyes in stupor, 76 FACE, change in expression of, 46 expression of, in insanity, 50 in melancholia, 72 in paresis, 173 INDEX. 231 Face, expression of, in stupor, 76 Faculties of mind, 19 " Fast " living and paresis, 1 68 Feeling, hallucinations of, 39 Feigned insanity, 210, 220 Fixed ideas, 129 Folie circulaire, 131 Food in melancholia, 86 refusal of, 46 in melancholia, 71, 85 in stupor, 76 Forcible feeding in melancholia, 88 Frenzy, 72 Gait in paresis, 175 Ganglionic cells, 194 General paralysis of the insane, 166. (See also Paresis.) Gestation, insanity of, 117 Grand mal, 181 Gummatous endarteritis, 202 Hematoma of the dura, 200 Hallucinations, definition of, 38 explanation of, 42 in acute delirious mania, 116 in chronic mania, 124 in epilepsy, 184 in mania, in in melancholia, 69 indications of, 38 justifying certificate of insanity, 41 of feeling, 39 of hearing, 38, 40, 43 of sight, 38, 40, 43 of smell, 39 of taste 39 Handwriting in paresis, 171 Head, pain in, in insanity, 50 Hearing, hallucinations of, 38, 40,43 Hemiplegia and syphilis, 156 Hemorrhages into the brain, 205 Hernise cerebri, 200 Hirt. 209 Home, removal from, in mania, 137 treatment of melancholia, 81 Homicidal acts due to delusions, 48 Homicide and epilepsy, 184 in melancholia. 70 Hospital, indications for commit- ment to, in mania, 136 treatment, advantages of, 146 Hot bath in mania, 144 Hot pack in mania, 143 Hydrops ex vacuo, 205 Hyoscin hydrobromate, indications for use of, 94 in melancholia, 92 in mania, 141 in paresis, 179 Hyoscyamin in mania, 141 in melancholia, 92 Hyoscyamus in mania, 141 in melancholia, 92 Hypertrophy of brain, 205 Hypnotics, 92 abuse of, 92, 95 after-effects of, 93 symptoms of prolonged adminis- tration of, 95 Hypochondria, characteristics of, 60 distinction from melancholia, 59 Hypochondriacal melancholia, 61 Hysteria, 192 Idiocy, characteristics of, 30 definition of, 29 differential diagnosis from demen- tia, 153 due to syphilis, 155 Idiot does not become insane, 30 Illusions, definition of, 43 in chronic mania, 125 in epilepsy, 184 in mania, in in melancholia, 69 Imbecile may have an attack of insanity, 30 Imbecility, characteristics of, 30 definition of, 29 Incendiarism and epilepsy, 184 Infirmaries for dementia, 164 Injuries to head, 150 Insane, actions of, 44 classes of. 211 Insanity defined, 32 et seq. | determination of, 28, 214 feigned, 210 partial, 225 to establish existence of, 34 Insomnia in mania, 140 in melancholia, 67, 69 Intellect in melancholia, 69 Intemperance and paresis, 177 Iron in mania, 139 in melancholia, 90 232 INDEX. Jurat of magistrate, 213 Kleptomania, 128 Lethargic conditions, 190 Lewin, 178 Lewis, Bevan, 194, 195. 197, 208 Locomotor ataxia, 209 caused by syphilis, 156 Lucid intervals, 123 Major, Dr., 197 Mania, 101 acute, 103 caused by syphilis, 156 delirious, 114 duration of, 113 illustrative cases, 145 chronic, 122 symptoms of, 124 commitment to hospital, 134 depression an early stage, 61 habits in, 108 homicidal, 128 incubation of, 106 management of, 138 of acute and subacute, 105 paroxysmal, 122, 123 puerperal, 117 recurrent, 122 subacute, 103 subdivision of, 102 suicidal, 128 symptoms of, 106 transitoria, 114 treatment of, 135 Massage in dementia, 165 in melancholia, 91 Maudsley, definition of insanity, 32 Medical certificates, 210 Medico Psychological Association of Great Britain, classification of insanity, 53 Melancholia, 59 alimentation in, 84 caused by syphilis, 156 characteristics of, 59 distinction from hypochondria, 59 duration of, 74 forcible feeding in, 88 hypochondriacal, 61 loss of weight in, 85 Melancholia, medical treatment of, 90 medication in, 84 physical examination in, 67 [ prognosis of, 74 puerperal, 117 simple, symptoms of, 65 ' without delusions, 59, 61 terminations of, 100 i travel in treatment of, 81 treatment and management of, 79 treatment at home of, 81 [ with delusions and agitation, 69 and stupor, 75 with stupor, differential diagnosis from primary dementia, 152 Memory, faculty of, 19 in paresis, 175 Menstruation in acute mania, 113 in mania, 104 in melancholia, 67, 96 Mental changes in convulsive attacks, 182 deterioration in epilepsy, 185 epilepsy, 183 states, disordered, 189 Mercuric chlorid in paresis, 179 Mickle, 206 Miliary sclerosis, 198 tubercles, 201 Mind, faculties of, 19 influences existing between body and,25 operations of, 24 Monomania, 125, 128 Moral perversion due to syphilis, 155 Morbid anatomy, 193 Multiple sclerosis, 209 Muscular disturbance in mania, 108 movements in insanity, 50 Narcotics, 92 Nationality, influence of, upon de- lusions of paresis, 173 Nervous exhaustion and paresis, 177 Neurasthenia, definition of, 64 manifestations of, 64 the formative stage of insanity, 65 Nocturnal epileptic seizures, 186 Nomenclature of insanity, 52 Nux vomica in melancholia, 90 INDEX. 233 Opium in mania, 140 in melancholia, 92 Opium-habit, not insanity, 35 Origin of insanities, 57 Pacchionian bodies, 200 Pachymeningitis, 200 Pain in melancholia, 68 in the head, in insanity, 50 Paraldehyde in melancholia, 92 Paranoia, 125 symptoms of, 126 Paresis, 166. (See also General Paralysis.) and syphilis, 156 causes of, 177 morbid anatomy of, 206 prodromata of, 167 prognosis of, 180 stages of, 166 treatment of, 179 Paretic dementia, 166. (See also Paresis.) Partial insanity, 225 Pathology, mental, of acute delirious mania, 117 of melancholia, 73 Periodic insanity, 130 Personal appearance of the insane, 49 Petit mal, 182 Phagocytosis, 195 Physical evidences of paresis, 171 signs in insanity, 51 Physicians, qualifications of, as ex- aminers in lunacy, 210 Pia-arachnoid, 200 Pinel, classification of insanity, 53 Porencephaly, 205 Post-partum insanity, 118 Potassium bromid in epilepsy, 187 iodid in paresis, 179 Prenatal insanity, 117 Prodromal stage of insanity, 62 Prognosis in acute delirious mania, 116 of chronic mania, 124 of paresis, 180 of puerperal insanity, 121 Psammomata, 200 Psychalgia, 72 " Psychic" cells, 194 Psychical states, abnormal, 189 Puerperal insanity, 117 management of, 120 symptoms of, 119 Pulse in acute delirious mania, 115 in melancholia, 67 in paresis, 173 in puerperal insanity, 120 in stupor, 76 Pupils in dementia, 150 in insanity, 49 in melancholia, 67 Pyromania, 129 Quinine in melancholia, 90 Recovery from epilepsy, 187 Recurrent insanities, 130 insanity, causes of, 132 symptoms of, 133 Refusal of food, 46 Regis, definition of insanity, 33 Religions, belief in false, not in- sanity, 35 " melancholia," 73 Remissions in paresis, 175 Responsibility in epilepsy, 185 Right and wrong, 224 Rolandic area, 194 Savage, Dr., 155,178 Sclerosis of brain, 205 Self-mutilation in melancholia, 71 Senile dementia, 154 Sepsis in mania, 143 Sexual excess and paresis, 177 propensities in paresis, 168 Shock, 189 Sight, hallucinations of, 38, 40, 43 Skin in insanity, 49 in melancholia, 67 Skull, 199 Sleep in paresis, 168 Smell, hallucinations of, 39 Sodium bromid in epilepsy, 187 Softening of brain, 204 Speech in paresis, 169 Spiritualism not insanity, 34 Spitzka, Dr., 130 Stage of insanity, neurasthenia the formative, 65 prodromal, 62 234 INDEX. Status epilepticus, 186 Strychnin in epilepsy, 188 in melancholia, 90, 91 Stupor, characteristics of, 76 contrasted with dementia, 77 melancholia with, 75 partial, 160 violence in, 78 Suicidal acts due to delusions, 48 tendency in puerperal insanity, 121 Suicide in melancholia, 69, 70 Sulfonal in mania, 141, 142 in melancholia, 92 Syphilis and paresis, 177 causing dementia, 155 Syphilitic endarteritis, 202 TASTE, hallucinations of, 39 Temperature in acute delirious mania, 115 in melancholia, 67 in paresis, 173, 176 in puerperal insanity, 120 in stupor, 77 Terminations of melancholia, 100 Theomania, 128 Thurnam, 203 Tongue in acute delirious mania, 116 in melancholia, 67 in stupor, 76 Tonic, formula for, 90 Tonics in dementia, 165 in mania, 139 Trance, 190 Trance-state, 160 Treatment, early, importance of, 98 indications for medical, 80 of bed-sores, 180 of dementia, 162 of mania, 135 of melancholia, 79 of paresis, 179 Trional, 95 in melancholia, 92 Tuke, Dr. Batty, 193 Tuke and Bucknill, 199 Tumors of brain, 205 Unconsciousness, 192 in epilepsy, 182 sudden, not insanity, 34 Uric acid, 67 in mania, 140 Urine in mania, 139 in melancholia, 67 Vacuolation, 198 Van Deusen, Essay on Neurasthenia, 64 Vasomotor changes in paresis, 174 Verriicktheit, primare, 126 secundare, 125 Weight in melancholia, 67, 85 of brain, 203 Will, 23 STANDARD Medical and Surgical Works PUBLISHED by W. B. SAUNDERS, 925 Walnut Street, Philadelphia, Pa. ♦American Text-Book of Applied Thera- peutics ................4 ♦American Text-Book of Dis. of Children . 9 *An American Text-Book of Diseases ot the Eye, Ear, Nose, and Throat......31 *An American Text-Book of Genito-Uri- nary and Skin Diseases........31 ♦American Text-Book of Gynecology ... 8 ♦American Text-Book of Obstetrics ... 5 ♦American Text-Book of Physiology ... 3 ♦American Text-Book of Practice .... 6 ♦American Text-Book of Surgery ... 7 Anders' Theory and Practice of Medicine . 31 Ashton's Obstetrics...........28 Atlas of Skin Diseases..........12 Ball's Bacteriology...........28 Bastin's Laboratory Exercises in Botany . 22 Beck's Surgical Asepsis........26 Boisliniere's Obstetric Accidents, Emer- gencies, and Operations........23 Brockway's Physics...........28 Burr's Nervous Diseases.........26 Butler's Materia Medica and Therapeutics 29 Cerna's Notes on the Newer Remedies . . 18 Chapman's Medical Jurisprudence .... 26 Church and Peterson's Nervous and Men- tal Diseases..............31 Clarkson's Histology....."...,. 14 Cohen and Eshner's Diagnosis......28 Corwin's Diagnosis of the Thorax .... 29 Cragin's Gynaecology..........28 Crookshank's Text-Book of Bacteriology . 13 DaCosta's Manual of Surgery......26 De Schweinitz's Diseases of the Eye ... 15 Dorland's Obstetrics ..........26 Frothingham's Bacteriological Guide ... 16 Garrigues' Diseases of Women . . ... 20 Gleason's Diseases of the Ear......28 ♦Gould and Pyle's Anomalies and Curi- osities of Medicine..........30 Griffin's Materia Medica and Therapeutics 26 Griffith's Care of the Baby........24 Gross's Autobiography.........10 Hampton's Nursing...........23 Hare's Physiology...........28 Hart's Diet in Sickness and in Health . . 22 Haynes' Manual of Anatomy......26 Heisler's Embryology..........31 Hirst's Obstetrics...........31 Hyde's Syphilis and Venereal Diseases . . 26 Jackson and Gleason's Diseases of the Eye, Nose, and Throat...........28 Jewett's Outlines of Obstetrics......21 Keating's Pronouncing Dictionary .... 10 Keating's Life Insurance.........23 Keen's Operation Blanks........22 Kyle's Diseases of Nose and Throat ... 26 Laine's Temperature Charts.......18 PAGE Lockwood's Practice of Medicine .... 26 Long's Syllabus of Gynecology.....20 Macdonald's Surgical Diagnosis and Treat- ment .................31 McFarland's Pathogenic Bacteria .... 16 Mallory and Wright's Pathological Tech- nique .................31 Martin's Surgery............28 Martin's Minor Surgery, Bandaging, and Venereal Diseases...........28 Meigs' Feeding in Early Infancy.....16 Moore's Orthopedic Surgery.......31 Morris' Materia Medica and Therapeutics 28 Morris' Practice of Medicine......28 Morten's Nurses' Dictionary.......24 Nancrede's Anatomy and Dissection ... 17 Nancrede's Anatomy..........28 Norris' Syllabus of Obstetrical Lectures . 21 Penrose's Gynecology..........31 Powell's Diseases of Children......28 Pye's Elementary Bandaging and Surgical Dressing...............29 Raymond's Physiology.........26 Rowland's Clinical Skiagraphy.....14 Saundby's Renal and Urinary Diseases . . 29 ♦Saunders' American Year-Book of Medi- cine and Surgery...........32 Saunders' Pocket Medical Formulary . . 19 Saunders' Pocket Medical Lexicon .... 32 Saunders' New Aid Series of Manuals . 25, 26 Saunders' Series of Question Compends 27, 28 Sayre's Practice of Pharmacy......28 Semple's Pathology and Morbid Anatomy 28 Semple's Legal Medicine, Toxicology, and Hygiene...............28 Senn's Genito-Urinary Tuberculosis ... 31 Senn's Tumors.............11 Senn's Syllabus of Lectures on Surgery . . 21 Shaw's Nervous Diseases and Insanity . . 28 Starr's Diet-Lists for Children......24 Stelwagon's Diseases of the Skin.....28 Stengel's Manual of Pathology......26 Stevens' Materia Medica and Therapeutics 18 Stevens' Practice of Medicine......17 Stewart's Manual of Physiology.....21 Stewart and Lawrance's Medical Elec- tricity ................28 Stoney's Practical Points in Nursing ... 13 Sutton and Giles' Diseases of Women . . 26 Thomas's Diet-List and Sick-Room Dietary24 Thornton's Dose-Book and Manual of Pre- scription-Writing ...........26 Van Valzah and Nisbet's Diseases of the Stomach...............31 Vierordt and Stuart's Medical Diagnosis . 12 Warren's Surgical Pathology......11 Wolff's Chemistry............28 Wolff's Examination of Urine......28 The works indicated thus (*) are sold by subscription (not by booksellers), usually through travelling solicitors, but they can be obtained direct from the office of publication (charges of shipment prepaid) by remitting the quoted prices. Full descriptive circulars of such works will be sent to any address upon application. All the other books advertised in this catalogue are commonly for sale by booksellers in all parts of the United States; but any book will be sent by the publisher to any address (post-paid) on receipt of the price herein given. ^ GENERAL INFORMATION. One Price. One price absolutely without deviation. No discounts allowed, regardless of the number of books purchased at one time. Prices on all works have been fixed extremely low, with the view to selling them strictly net and for cash. Orders. An order accompanied by remittance will receive prompt attention, books being sent to any address in the United States, by mail or express, all charges prepaid. We prefer to send books by express when possible, and if sent C. O. D. we pay all charges for returning the money. Small orders of three dollars or less must invariably be accompanied by remit- tance. 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In every instance the latest revised edition is sent. In ordering, be careful to state the style of binding desired— Cloth, Sheep, or Half-Morocco. A complete descriptive circular, giving table of contents, etc. of any book sold by subscription only, will be sent free on application. CATALOGUE OF MEDICAL WORKS. 3 For Sale by Subscription. AN AMERICAN TEXT-BOOK OF PHYSIOLOGY. Edited by William H. Howell, Ph.D., M. D., Professor of Physiology in the Johns Hopkins University, Baltimore, Md. One handsome octavo volume of 1052 pages, fully illustrated. Prices: Cloth, $6.00 net; Sheep or Half- Morocco, $7.00 net. This work is the most notable attempt yet made in America to combine in nne volume the entire subject of Human Physiology by well-known teachers who have given especial study to that part of the subject upon which they write. The completed work represents the present status of the science of Physiology, particularly from the standpoint of the student of medicine and of the medical practitioner. The collaboration of several teachers in the preparation of an elementary text- book of physiology is unusual, the almost invariable rule heretofore having been for a single author to write the entire book. One of the advantages to be derived from this collaboration method is that the more limited literature necessary for consultation by each author has enabled him to base his elementary account upon a comprehensive knowledge of the subject assigned to him; another, and perhaps the most important, advantage is that the student gains the point of view of a number of teachers. In a measure he reaps the same benefit as would be obtained by following courses of instruction under different teachers. The different standpoints assumed, and the differences in emphasis laid upon the various lines of procedure, chemical, physical, and anatomical, should give the student a better insight into the methods of the science as it exists to-day. The work will also be found useful to many medical practitioners who may wish to keep in touch with the development of modern physiology. The main divisions of the subject-matter are as follows: General Physiology of Muscle and Nerve — Secretion — Chemistry of Digestion and Nutrition— Movements of the Alimentary Canal, Bladder, and Ureter—Blood and Lymph —Circulation—Respiration—Animal Heat—Central Nervous System—Special Senses — Special Muscular Mechanisms — Reproduction — Chemistry of the Animal Body. CONTRIBUTORS: HENRY P. BOWDITCH, M. D., Professor of Physiology, Harvard Medi- cal School. JOHN G. CURTIS, M. D., Professor of Physiology, Columbia Uni- versity, N. Y. (College of Physicians and Surgeons). HENRY H. DONALDSON, Ph.D., Head-Professor of Neurology, Univer- sity of Chicago. W. H. HOWELL, Ph. D., M. D., Professor of Physiology, Johns Hopkins University. FREDERIC S. LEE, Ph. D., Adjunct Professor of Physiology, Colum- bia University, N. Y. (College of Physicians and Surgeons). WARREN P. LOMBARD, M. D., Professor of Physiology, University of Michigan. GRAHAM LUSK, Ph. D., Professor of Physiology, Yale Medical School. W. T. PORTER, M.D., Assistant Professor of Physiology, Har- vard Medical School. EDWARD T. REICHERT, M.D., Professor of Physiology, University of Pennsylvania. HENRY SEW ALL, Ph.D., M. D.. Professor of Physiology, Medical Depart ment, University of Denver. 4 W. B. SAUNDERS For Sale by Subscription. AN AMERICAN TEXT-BOOK OF APPLIED THERAPEU- TICS. For the Use of Practitioners and Students. Edited by James C. Wilson, M. D., Professor'of the Practice of Medicine and of Clinical Medicine in the Jefferson Medical College. One handsome octavo volume of 1326 pages. Illustrated. Prices: Cloth, #7.00 net; Sheep or Half-Morocco, $8.00 net. The arrangement of this volume has been based, so far as possible, upon modern pathologic doctrines, beginning with the intoxications, and following with infections, diseases due to internal parasites, diseases of undetermined origin, and finally the disorders of the several bodily systems—digestive, re- spiratory, circulatory, renal, nervous, and cutaneous. It was thought proper to include also a consideration of the disorders of pregnancy. The list of contributors comprises the names of many who have acquired dis- tinction as practitioners and teachers of practice, of clinical medicine, and of the specialties. CONTRIBUTORS: Dr. I. E. Atkinson, Baltimore, Md. Sanger Brown, Chicago, 111. John B. Chapin, Philadelphia, Pa. William C. Dabney, Charlottesville, Va. John Chalmers DaCosta, Philada., Pa. I. N. Danforth, Chicago, 111. John L. Dawson, Jr., Charleston, S. C. F. X. Dercum, Philadelphia, Pa. George Dock, Ann Arbor, Mich. Robert T. Edes, Jamaica Plain. Mass. Augustus A. Eshner, Philadelphia, Pa. J. T. Eskridge, Denver, Col. F. Forchheimer, Cincinnati, O. Carl Frese, Philadelphia, Pa. Edwin E. Graham, Philadelphia, Pa. John Guiteras, Philadelphia, Pa. Frederick P. Henry, Philadelphia, Pa. Guy Hinsdale, Philadelphia, Pa. Orville Horwitz, Philadelphia, Pa. W. W. Johnston, Washington, D. C. Ernest Laplace, Philadelphia, Pa. A. Laveran, Pans, France. Dr. James Hendrie Lloyd, Philadelphia, Pa. John Noland Mackenzie, Baltimore, Md. J. W. McLaughlin, Austin, Texas. A. Lawrence Mason, Boston, Mass. Charles K. Mills, Philadelphia, Pa. John K. Mitchell, Philadelphia, Pa. W. P. Northrup. New York City. William Osier, Baltimore, Md. Frederick A. Packard, Philadelphia, Pa. Theophilus Parvin, Philadelphia, Pa. Beaven Rake, London, England. E. O. Shakespeare, Philadelphia, Pa. Wharton Sinkler, Philadelphia. Pa. Louis Starr, Philadelphia, Pa. Henry W. Stelwagon, Philadelphia, Pa. James Stewart, Montreal, Canada. Charles G. Stockton, Buffalo, N. Y. James Tyson, Philadelphia, Pa. Victor C. Vaughan, Ann Arbor, Mich. James T. Whittaker, Cincinnati, O. J. C. Wilson, Philadelphia, Pa. The articles, with two exceptions, are the contributions of American writers. Written from the standpoint of the practitioner, the aim of the work is to facili- tate the application of knowledge to the prevention, the cure, and the allevia- tion of disease. The endeavor throughout has been to conform to the title of the book—Applied Therapeutics—to indicate the course of treatment to be pursued at the bedside, rather than to name a list of drugs that have been used at one time or another. While the scientific superiority and the practical desirability of the metric system of weights and measures is admitted, it has not been deemed best to discard entirely the older system of figures, so that both sets have been given where occasion demanded. CATALOGUE OF MEDICAL WORKS. 5 For Sale by Subscription. AN AMERICAN TEXT-BOOK OF OBSTETRICS. Edited by Richard C. Norris, M. D.; Art Editor, Robert L. Dickinson, M. D. One handsome octavo volume of over 1000 pages, with nearly 900 colored and half-tone illustrations. Prices: Cloth, $7.00; Sheep or Half-Morocco, $8.00. The advent of each successive volume of the series of the American Text- Books has been signalized by the most flattering comment from both the Press and the Profession. The high consideration received by these text-books, and their attainment to an authoritative position in current medical literature, have been matters of deep international interest, which finds its fullest expression in the demand for these publications from all parts of the civilized world. In the preparation of the " American Text-Book of Obstetrics " the editor has called to his aid proficient collaborators whose professional prominence entitles them to recognition, and whose disquisitions exemplify Practical Obstetrics. While these writers were each assigned special themes for dis- cussion, the correlation of the subject-matter is, nevertheless, such as ensures logical connection in treatment, the deductions of which thoroughly represent the latest advances in the science, and which elucidate the best modern methods of procedure. The more conspicuous feature of the treatise is its wealth of illustrative matter. The production of the illustrations had been in progress for several years, under the personal supervision of Robert L. Dickinson, M. D., to whose artistic judgment and professional experience is due the most sumptuously illustrated work of the period. By means of the photographic art, combined with the skill of the artist and draughtsman, conventional illustration is super- seded by rational methods of delineation. Furthermore, the volume is a revelation as to the possibilities that may be reached in mechanical execution, through the unsparing hand of its publisher. CONTRIBUTORS: Dr. James C. Cameron. Edward P. Davis. Robert L. Dickinson. Charles Warrington Earle. James H. Etheridge. Henry J. Garrigues. Barton Cooke Hirst. Charles Jewett. Dr. Howard A. Kelly. Richard C Norris. Chauncey D. Palmer. Theophilus Parvin. George A. Piersol. Edward Reynolds. Henry Schwarz. " At first glance we are overwhelmed by the magnitude of this work in several respects, viz. : First, by the size of the volume, then by the array of eminent teachers in this depart- ment who have taken part in its production, then by the profuseness and character of the illustrations, and last, but not least, the conciseness and clearness with which the text is ren- dered This is an entirely new composition, embodying the highest knowledge of the art as it stands to-day by authors who occupy the front rank in their specialty, and there are many of them. We cannot turn over these pages without being struck by the superb illustrations which adorn so many of them. We are confident that this most practical work will find instant appreciation by practitioners as well as students."—New York Medical Times. Permit me to say that your American Text-Book of Obstetrics is the most magnificent medical work that 1 have ever seen. I congratulate you and thank you for this superb work which alone is sufficient to place you first in the ranks of medical publishers. With profound respect I am sincerely yours, Alex. J. C. Skene. 6 W. B. SAUNDERS' For Sale by Subscription. AN AMERICAN TEXT-BOOK ON THE THEORY AND PRACTICE OF MEDICINE. By American Teachers. Edited by William Pepper, M. D., LL.D., Provost and Professor of the Theory and Practice of Medicine and of Clinical Medicine in the University of Pennsylvania. Complete in two handsome royal-octavo volumes of about iooo pages each, with illustrations to elucidate the text wherever necessary. Price per Volume : Cloth, $5.00 net; Sheep or Half-Morocco, #6.00 net. VOLUME I. CONTAINS: Hygiene.—Fevers (Ephemeral, Simple Con- tinued, Typhus, Typhoid, Epidemic Cerebro- spinal Meningitis, and Relapsing).—Scarla- tina, Measles, Rotheln, Variola, Varioloid, V >ccinia,Varicella, Mumps,Whooping-cough, Anthrax, Hydrophobia, Trichinosis, Actino- mycosis, Glanders, and Tetanus.—Tubercu- losis, Scrofula, Syphilis, Diphtheria, Erysipe- las, Malaria, Cholera, and Yellow Fever.— Nervous, Muscular, and Mental Diseases etc. VOLUME II. CONTAINS: Urine (Chemistry and Microscopy).—Kid- ney and Lungs.—Air-passages (Larynx and Bronchi) and Pleura.—Pharynx, CEsophagus, Stomach and Intestines (including Intestinal Parasites), Heart, Aorta, Arteries and Veins. — Peritoneum, Liver,and Pancreas.—Diathet- ic Diseases (Rheumatism, Rheumatoid Ar- thritis, Gout, Lithaemia, and Diabetes.) — Blood and Spleen.—Inflammation, Embolism, Thrombosis, Fever, and Bacteriology. The articles are not written as though addressed to students in lectures, but are exhaustive descriptions of diseases, with the newest facts as regards Causa- tion, Symptomatology, Diagnosis, Prognosis, and Treatment, including a large number of approved formula;. The recent advances made in the study of the bacterial origin of various diseases are fully described, as well as the bearing of the knowledge so gained upon prevention and cure. The subjects of Bacteriology as a whole and of Immunity are fully considered in a separate section. Methods of diagnosis are given the most minute and careful attention, thus enabling the reader to learn the very latest methods of investigation without consulting works specially devoted to the subject. CONTRIBUTORS: Dr. J. S. Billings, Philadelphia. Francis Delafield, New York. Reginald H. Fitz, Boston. James W. Holland, Philadelphia. Henry M. Lyman, Chicago. William Osier, Baltimore. Dr. William Pepper, Philadelphia. W. Oilman Thompson, New York. W. H. Welch, Baltimore. James T. Whittaker, Cincinnati. James C. Wilson, Philadelphia. Horatio C. Wood, Philadelphia. "We reviewed the first volume of this work, and said: * It is undoubtedly one of the best text-books on the practice of medicine which we possess.' A consideration of the second *.nd last volume leads us to modify that verdict and to say that the completed work is, in our opinion, the best of its kind it has ever been our fortune 10 see. It is complete, thorough, accurate, and clear. It is well written, well arranged, well printed, well illustrated, and well bound. It is a model of what the modern text-book should be."—New York Medical Journal. " A library upon modern medical art. The work must promote the wider diffusion of sound knowledge."—American Lancet. " A trusty counsellor for the practitioner or senior student, on which he may implicitly rely."—Edinburgh Medical Journal. CATALOGUE OF MEDICAL WORKS. J For Sale by Subscription. AN AMERICAN TEXT-BOOK OF SURGERY. Edited by Wil- liam W. Keen, M.D., LL.D., and J. William White, M. D., Ph. D. Forming one handsome royal-octavo volume of 1250 pages (iox 7 inches), with 500 wood-cuts in text, and 37 colored and half-tone plates, many of them engraved from original photographs and drawings furnished by the authors. Prices : Cloth, $7.00 net; Sheep or Half-Morocco, #8.00 net. SECOND EDITION, REVISED AND ENLARGED, With a Section devoted to "The Use of the Rbntgen Rays in Surgery." The want of a text-book which could be used by the practitioner and at the same time be recommended to the medical student has been deeply felt, espe- cially by teachers of surgery; hence, when it was suggested to a number of these that it would be well to unite in preparing a text-book of this description, great unanimity of opinion was found to exist, and the gentlemen below named gladly consented to join in its production. While there is no distinctive Amer- ican Surgery, yet America has contributed very largely to the progress of modern surgery, and among the foremost of those who have aided in developing this art and science will be found the authors of the present volume. All of tbem are teachers of surgery in leading medical schools and hospitals in the United States and Canada. Especial prominence has been given to Surgical Bacteriology, a feature which is believed to be unique in a surgical text-book in the English language. Asep- sis and Antisepsis have received particular attention. The text is brought well up to date in such important branches as cerebral, spinal, intestinal, and pelvic surgery, the most important and newest operations in these departments being described and illustrated. The text of the entire book has been submitted to all the authors for their mutual criticism and revision—an idea in book-making that is entirely new and original. The book as a whole, therefore, expresses on all the important sur- gical topics of the day the consensus of opinion of the eminent surgeons who have joined in its preparation. One of the most attractive features of the book is its illustrations. Very many of them are original and faithful reproductions of photographs taken directly from patients or from specimens. CONTRIBUTORS: Dr. Charles H. Burnett, Philadelphia. Phineas S. Conner, Cincinnati. Frederic S. Dennis, New York. William W. Keen, Philadelphia. Charles B. Nancrede, Ann Arbor, Mich. Roswell Park, Buffalo, N. Y. Lewis S. Pilcher, New York. Dr. Nicholas Senn, Chicago. Francis J. Shepherd. Montreal, Canada. Lewis A. Stimson, New York. William Thomson, Philadelphia. J. Collins Warren, Boston. J. William White, Philadelphia. " If this text-book is a fair reflex of the present position of American surgery, we must admit it is of a very high order of merit, and that English surgeons will have to look very carefully to their laurels if they are to preserve a position in the van of surgical practice."— London Lancet. 8 W. B. SAUNDERS' For Sale by Subscription, AN AMERICAN TEXT-BOOK OF GYNECOLOGY, MEDICAL AND SURGICAL, for the use of Students and Practitioners. Edited by J. M. Baldy, M. D. Forming a handsome royal-octavo volume, with 360 illustrations in text and 37 colored and half-tone plates. Prices: Cloth, $6.00 net; Sheep or Hall-Morocco, #7.00 net. In this volume all anatomical descriptions, excepting those essential to a clear understanding of the text, have been omitted, the illustrations being largely de- pended upon to elucidate the anatomy of the parts. This work, which is thoroughly practical in its teachings, is intended, as its title implies, to be a working text-book for physicians and students. A clear line of treatment has been laid down in every case, and although no attempt has been made to dis- cuss mooted points, still the most important of these have been noted and ex- plained. The operations recommended are fully illustrated, so that the reader, having a picture of the procedure described in the text under his eye, cannot fail to grasp the idea. All extraneous matter and discussions have been carefully excluded, the attempt being made to allow no unnecessary details to cumber the text. The subject-matter is brought up to date at every point, and the work is as nearly as possible the combined opinions of the ten specialists who figure as the authors. The work is well illustrated throughout with wood-cuts, half-tone and colored plates, mostly selected from the authors' private collections. CONTRIBUTORS: Dr. Henry T. Byford. John M. Baldy. Edwin Cragin. i. H. Etheridge. William Goodell. Dr. Howard A. Kelly. Florian Krug. E. E. Montgomery. William R. Pryor. George M. Tuttle. " The most notable contribution to gynecological literature since 1887, .... and the most complete exponent of gynecology which we have. No subject seems to have been neglected, .... and the gynecologist and surgeon, and the general practitioner who has any desire to practise diseases of women, will find it of practical value. In the matter of illustrations and plates the book surpasses anything we have seen."—Bos/on Medical and Surgical Journal. " A valuable addition to the literature of Gynecology. The writers are progressive aggressive, and earnest in their convictions."—Medical News, Philadelphia. "A thoroughly modern text-book, and gives reliable and well-tempered advice and in- struction. —Edinburgh. Medical Journal. " The harmony of its conclusions and the homogeneity of its style give it an individuality which suggests a single rather than a multiple authorship."—Annals of Surgery. " It must command attention and respect as a worthy representation of our advanced clinical teaching. —American Journal of Medical Sciences. CATALOGUE OF MEDICAL WORKS. For Sale by Subscription. AN AMERICAN TEXT-BOOK OF THE DISEASES OF CHIL- DREN. By American Teachers. Edited by Louis Starr, M. D., assisted by Thompson S. Westcott, M. D. In one handsome royal-8vo volume of 1190 pages, profusely illustrated with woodcuts, half-tone and colored plates. Net Prices: Cloth, $7.00; Sheep or Half-Morocco, #8.00. The plan of this work embraces a series of original articles written by some sixty well-known paediatrists, representing collectively the teachings of the most prominent medical schools and colleges of America. The work is intended to be a practical book, suitable for constant and handy reference by the practi- tioner and the advanced student. One decided innovation is the large number of authors, nearly every article being contributed by a specialist in the lino on which he writes. This, while entailing considerable labor upon the editors, has resulted in the publication of a work thoroughly new and abreast of the times. Especial attention has been given to the latest accepted teachings upon the etiology, symptoms, pathology, diagnosis, and treatment of the disorders of chil- dren, with the introduction of many special formulae and therapeutic procedures. Special chapters embrace at unusual length the Diseases of the Eye, Ear, Nose and Throat, and the Skin ; while the introductory chapters cover fully the important subjects of Diet, Hygiene, Exercise, Bathing, and the Chemistry of Food. Tracheotomy, Intubation, Circumcision, and such minor surgical pro- cedures coming within the province of the medical practitioner are carefully considered. CONTRIBUTORS: Dr. S. S. Adams, Washington. John Ashhurst, Jr., Philadelphia. A. D. Blackader, Montreal, Canada. Dillon Brown, New York. Edward M. Buckingham, Boston. Charles W. Burr, Philadelphia. W. E. Casselberry, Chicago. Henry Dwight Chapin, New York. W. S. Christopher, Chicago. Archibald Church, Chicago Floyd M. Crandall, New York. Andrew F. Currier, New York. Roland G. Curtin, Philadelphia J. M. DaCosta, Philadelphia. I. N. Danforth, Chicago. Edward P. Davis, Philadelphia. John B. Deaver, Philadelphia. G. E. de Schweinitz, Philadelphia. John Doming, New York. Charles Warrington Earle, Chicago. Wm. A. Edwards, San Diego, Cal. F. Forchheimer, Cincinnati. J. Henry Fruitnight, New York. Landon Carter Gray, New York. I. P. Crozer Griffith, Philadelphia. W. A. Hardaway. St. Louis. M. P Hatfield, Chicago. Barton Cooke Hirst, Philadelphia. H. Illoway, Cincinnati. Henry Jackson, Boston. Charles G. Jennings, Detroit, Henry Koplik. New York. Dr. Thomas S. Latimer, Baltimore. Albert R. Leeds, Hoboken, N. J. J. Hendrie Lloyd, Philadelphia. George Roe Lockwood, New York. Henry M. Lyman, Chicago. Francis T. Miles, Baltimore. Charles K. Mills, Philadelphia. John H. Musser, Philadelphia. Thomas R. Neilson, Philadelphia. W. P. Northrup, New York. William Osier, Baltimore. Frederick A. Packard, Philadelphia. William Pepper, Philadelphia. Frederick Peterson, New York. W. T. Plant, Syracuse, New York. William M. Powell, Atlantic City. B. Alexander Randall, Philadelphia. Edward O. Shakespeare, Philadelphia F. C. Shattuck, Boston. J. Lewis Smith, New York. Louis Starr, Philadelphia. M. Allen Starr, New York. J. Madison Taylor, Philadelphia. Charles W. Townsend, Boston. James Tyson, Philadelphia. W. S. Thayer, Baltimore. Victor C. Vaughan, Ann Arbor, Mich Thompson S. Westcott, Philadelphia. Henry R. Wharton, Philadelphia. J. William White, Philadelphia. J. C. Wilson, Philadelphia. 10 W. B. SAUNDERS' A NEW PRONOUNCING DICTIONARY OF MEDICINE, with Phonetic Pronunciation, Accentuation, Etymology, etc. By John M. Keating, M. D., LL.D., Fellow of the College of Physicians of Phila- delphia; Vice-President of the American Psediatric Society; Ex-President of the Association of Life Insurance Medical Directors; Editor " Cyclo- paedia of the Diseases of Children," etc.; and Henry Hamilton, author of "A New Translation of Virgil's vEneid into English Rhyme;" co- author of "Saunders' Medical Lexicon," etc.; with the Collaboration of J. Chalmers DaCosta, M. D., and Frederick A. Packard, M. D. With an Appendix containing important Tables of Bacilli, Micrococci, Leucomaines, Ptomaines, Drugs and Materials used in Antiseptic Sur- gery, Poisons and their Antidotes, Weights and Measures, Thermometric Scales, New Official and Unofficial Drugs, etc. One very attractive volume of over 800 pages. Second Revised Edition. Prices : Cloth, $5.00 net; Sheep or Half-Morocco, $6.00 net; with Denison's Patent Ready-Refer- ence Index; without patent index, Cloth, $4.00 net; Sheep or Half- Morocco, $5.00 net. PROFESSIONAL, OPINIONS. " I am much pleased with Keating's Dictionary, and shall take pleasure in recommending it to my classes." Henry M. Lyman, M. D., Professor of Principles and Practice of Medicine, Rush Medical College, Chicago, III. " I am convinced that it will be a very valuable adjunct to my study-table, convenient in size and sufficiently full for ordinary use." C. A. Linuslky, M. D., Professor of Theory and Practice of Medicine, Medical Dept. Yale University: Secretary Connecticut State Board of Health, New Haven, Conn, AUTOBIOGRAPHY OF SAMUEL D. GROSS, M.D., Emeritus Pro- fessor of Surgery in the Jefferson Medical College of Philadelphia, with Reminiscences of His Times and Contemporaries. Edited by his sons, Samuel W. Gross, M. D., LL.D., late Professor of Principles of Surgery and of Clinical Surgery in the Jefferson Medical College, and A. Haller Gross, A. M., of the Philadelphia Bar. Preceded by a Memoir of Dr. Gross, by the late Austin Flint, M. D., LL.D. In two handsome volumes, each containing over 400 pages, demy 8vo, extra cloth, gilt tops, with fine Frontispiece engraved on steel. Price per Volume, $2.50 net. This autobiography, which was continued by the late eminent surgeon until within three months of his death, contains a full and accurate history of his early struggles, trials, and subsequent successes, told in a singularly interesting and charming manner, and embraces short and graphic pen-portraits of many of the most distinguished men—surgeons, physicians, divines, lawyers, states- men, scientists, etc.—with whom he was brought in contact in America and in Europe ; the whole forming a retrospect of more than three-quarters of a century. __________CATALOGUE OF MEDICAL WORKS. II SURGICAL PATHOLOGY AND THERAPEUTICS. By John Collins Warren, M. D., LL.D., Professor of Surgery, Medical Depart- ment Harvard University; Surgeon to the Massachusetts General Hospital, etc. A handsome octavo volume of 832 pages, with 136 relief and litho- graphic illustrations, 33 of which are printed in colors, and all of which were drawn by William J. Kaula from original specimens. Prices: Cloth, $6.00 net; Half-Morocco, $7.00 net. " The volume is for the bedside, the amphitheatre, and the ward. It deals with things not as we see them through the microscope alone, but as the prac- titioner sees their effect in his patients; not only as they appear in and affect culture-media, but also as they influence the human body; and, following up the demonstrations of the nature of diseases, the author points out their logical treatment." (New York Medical Journal). " It is the handsomest specimen of book-making * * * that has ever been issued from the American medical press" (American Journal of the Medical Sciences, Philadelphia). "Without Exception, the Illustrations are the Best ever Seen in a Work of this Kind. "A most striking and very excellent feature of this book is its illustrations. Without ex- ception, from the point of accuracy and artistic merit, they are the best ever seen in a work of this kind. * * * Many of those representing microscopic pictures are so perfect in their coloring and detail as almost to give the beholder the impression that he is looking down the barrel of a microscope at a well-mounted section."—Annals of Surgery, Philadelphia. PATHOLOGY AND SURGICAL TREATMENT OF TUMORS. By N. Senn, M. D., Ph. D., LL. D., Professor of Practice of Surgery and of Clinical Surgery, Rush Medical College; Professor of Surgery, Chicago Polyclinic; Attending Surgeon to Presbyterian Hospital; Surgeon-in-Chief, St. Joseph's Hospital, Chicago. One volume of 710 pages, with 515 engravings, including full-page colored plates. Prices: Cloth, $6.00 net; Half-Morocco, #7.00 net. Books specially devoted to this subject are few, and in our text-books and systems of surgery this part of surgical pathology is usually condensed to a de- gree incompatible with its scientific and clinical importance. The author spent many years in collecting the material for this work, and has taken great pains to present it in a manner that should prove useful as a text-book for the student, a work of reference for the busy practitioner, and a reliable, safe guide for the surgeon. The more difficult operations are fully described and illustrated. More than one hundred of the illustrations are original, while the remainder were selected from books and medical journals not readily accessible. *' The most exhaustive of any recent book in English on this subject. It is well illus- trated, and will doubtless remain as the principal monograph on the subject in our language for some years. The book is handsomely illustrated and printed.....and the author has given a notable and lasting contribution to surgery."—Journal of American Medical Asso- ciation, Chicago. 12 W. B. SAUNDERS MEDICAL DIAGNOSIS. By Pr. Oswald Vierordt, Professor of Medicine at the University of Heidelberg. Translated, with additions, from the Second Enlarged German Edition, with the author's permission, by Francis H. Stuart, A. M., M. D. Third and Revised Edition. In one handsome royal-octavo volume of 700 pages, 178 fine wood-cuts in text, many of which are in colors. Prices: Cloth, $4.00 net; Sheep or Half-Morocco, #5.00 net. In this work, as in no other hitherto published, are given full and accurate explanations of the phenomena observed at the bedside. It is distinctly a clin- ical work by a master teacher, characterized by thoroughness, fulness, and accu- racy. It is a mine of information upon the points that are so often passed over without explanation. Especial attention has been given to the germ-theory as a factor in the origin of disease. This valuable work is now published in German, English, Russian, and Italian. The issue of a third American edition within two years indicates the favor with which it has been received by the profession. THE PICTORIAL ATLAS OF SKIN DISEASES AND SYPHI- LITIC AFFECTIONS. (American Edition.) Translation from the French. Edited by J. J. Pringle, M. B., F. R. C. P., Assistant Phy- sician to, and Physician to the department for Diseases of the Skin at, the Middlesex Hospital, London. Photo-lithochromes from the famous models of dermatological and syphilitic cases in the Museum of the Saint-Louis Hospital, Paris, with explanatory wood-cuts and letter-press. In 12 Parts, at $3.00 per Part. Parts 1 to 8 now ready. "The plates are beautifully executed."—Jonathan Hutchinson, M. D. (London Hospital). "The plates in this Atlas are remarkably accurate and artistic reproductions of typical examples of skin disease. The work will be of great value to the practitioner and student." —William Anderson, M. D. (St. Thomas Hospital). *' If thesucceeding parts of this Atlas are to be similar to Part 1, now before us, we have no hesitation in cordially recommending it to the favorable notice of our readers as one of the finest dermatological atlases with which we are acquainted."— Glasgow Medical Journal, Aug., 1895. " Of all the atlases of skin diseases which have been published in recent years, the present one promises to be of greatest interest and value, especially from the standpoint of the general practitioner."—American Medico-Surgical Bulletin, Feb. 22, 1896. "The introduction of explanatory wood-cuts in the text is a novel and most important feature which greatly furthers the easier understanding of the excellent plates, than which nothing, we venture to say, has been seen better in point of correctness, beauty, and general merit."—New York Medical Journal, Feb. 15, 1896. "An interesting feature of the Atlas is the descriptive text, which is written for each picture by the physician who treated the case or at whose instigation the models have been made We predict for this truly beautiful work a large circulation in all parts of the medical world where the names St. Louis and Baretta have preceded it."—Medical Record, N Y Feb 1 1896. . • 1 CATALOGUE OF MEDICAL WORKS. 13 PRACTICAL POINTS IN NURSING. For Nurses in Private Practice. By Emily A. M. Stoney, Graduate of the Training-School for Nurses, Lawrence, Mass.; Superintendent of the Training-School for Nurses, Carney Hospital, South Boston, Mass. 456 pages, handsomely illustrated with 73 engravings in the text, and 9 colored and half-tone plates. Cloth. Price, #1-75 net- SECOND EDITION, THOROUGHLY REVISED. In this volume the author explains, in popular language and in the shortest possible form, the entire range of private nursing as distinguished from hospital nursing, and the nurse is instructed how best to meet the various emergencies of medical and surgical cases when distant from medical or surgical aid or when thrown on her own resources. An especially valuable feature of the work will be found in the directions to the nurse how to improvise everything ordinarily needed in the sick-room, where the embarrassment of the nurse, owing to the want of proper appliances, is fre- quently extreme. The work has been logically divided into the following sections: I. The Nurse : her responsibilities, qualifications, equipment, etc. II. The Sick-Room: its selection, preparation, and management. III. The Patient: duties of the nurse in medical, surgical, obstetric, and gyne- cologic cases. IV. Nursing in Accidents and Emergencies. V. Nursing in Special Medical Cases. VI. Nursing of the New-born and Sick Children. VII. Physiology and Descriptive Anatomy. The Appendix contains much information in compact form that will be found of great value to the nurse, including Rules for Feeding the Sick; Recipes for Invalid Foods and Beverages; Tables of Weights and Measures; Table for Computing the Date of Labor; List of Abbreviations; Dose-List; and a full and complete Glossary of Medical Terms and Nursing Treatment. " This is a well-written, eminently practical volume, which covers the entire range of private nursing as distinguished from hospital nursing, and instructs the nurse how best to meet the various emergencies which may arise and how to prepare everything ordinarily needed in the illness of her patient."—American Journal of Obstetrics and Diseases of Women and Children, Aug., 1896. A TEXT-BOOK OF BACTERIOLOGY, including the Etiology and Prevention of Infective Diseases and an account of Yeasts and Moulds, Haematozoa, and Psorosperms. By Edgar M. Crookshank, M. B., Pro- fessor of Comparative Pathology and Bacteriology, King's College, London. A handsome octavo volume of 700 pages, with 273 engravings in the text, and 22 original and colored plates. Price, $6.50 net. This book, though nominally a Fourth Edition of Professor Crookshank's " Manual of Bacteriology," is practically a new work, the old one having been reconstructed, greatly enlarged, revised throughout, and largely rewritten, forming a text-book for the Bacteriological Laboratory, for Medical Officers of Health, and for Veterinary Inspectors. '4 W. B. SAUNDERS A TEXT-BOOK OF HISTOLOGY, DESCRIPTIVE AND PRAC- TICAL. For the Use of Students. By Arthur Clarkson, M. B., C. M., Edin., formerly Demonstrator of Physiology in the Owen's College, Manchester; late Demonstrator of Physiology in the Yorkshire College, Leeds. Large 8vo, 554 pages, with 22 engravings in the text, and 174 beautifully colored original illustrations. Price, strongly bound in Cloth, $6.00 net. The purpose of the writer in this work has been to furnish the student of His- tology, in one volume, with both the descriptive and the practical part of the science. The first two chapters are devoted to the consideration of the general methods of Histology; subsequently, in each chapter, the structure of the tissue or organ is first systematically described, the student is then taken tutorially over the specimens illustrating it, and, finally, an appendix affords a short note of the methods of preparation. "We would most cordially recommend it to all students of histology."—Dublin Medical Journal. "It is pleasant to give unqualified praise to the colored illustrations ; . . . the standard is high, and many of them are not only extremely beautiful, but very clear and demonstra- tive. . . . The plan of the book is excellent."—Liverpool Medical Journal. ARCHIVES OF CLINICAL SKIAGRAPHY. By Sydney Rowland, B. A., Camb. A series of collotype illustrations, with descriptive text, illustrating the applications of the New Photography to Medicine and Sur- gery. Price, per Part, $ 1.00. Parts I. to V. now ready. The object of this publication is to put on record in permanent form some of the most striking applications of the new photography to (he needs of Medicine and Surgery. The progress of this new art has been so rapid that, although Prof. Rontgen's discovery is only a thing of yesterday, it has already taken its place among the approved and accepted aids to diagnosis. WATER AND WATER SUPPLIES. By John C. Thresh, D. Sc, M. B., D. P. H., Lecturer on Public Health, King's College, London ; Editor of the "Journal of State Medicine," etc. i2mo, 438 pages, illus- trated. Handsomely bound in Cloth, with gold side and back stamps. Price, $2.25 net. This work will furnish any one interested in public health the information requisite for forming an opinion as to whether any supply or proposed supply is sufficiently wholesome and abundant, and whether the cost can be considered reasonable. The work does not pretend to be a treatise on Engineering, yet it contains sufficient detail to enable any one who has studied it to consider intelligently any scheme which may be submitted for supplying a community with water. CATALOGUE OF MEDICAL WORKS. 15 DISEASES OF THE EYE. A Hand-Book of Ophthalmic Prac- tice. By G. E. de Schweinitz, M. D., Professor of Ophthalmology in the Jefferson Medical College, Philadelphia, etc. A handsome royal- octavo volume of 679 pages, with 256 fine illustrations, many of which are original, and 2 chromo-lithographic plates. Prices: Cloth, #4.00 net; Sheep or Half-Morocco, $5.00 net. The object of this work is to present to the student, and to the practitioner who is beginning work in the fields of ophthalmology, a plain description of the optical defects and diseases of the eye. To this end special attention has been paid to the clinical side of the question; and the method of examination, the symptomatology leading to a diagnosis, and the treatment of the various ocular defects have been brought into prominence. SECOND EDITION, REVISED AND GREATLY ENLARGED. The entire book has been thoroughly revised. In addition to this general revision, special paragraphs on the following new matter have been introduced : Filamentous Keratitis, Blood-staining of the Cornea, Essential Phthisis Bulbi, Foreign Bodies in the Lens, Circinate Retinitis, Symmetrical Changes at the Macula Lutea in Infancy, Hyaline Bodies in the Papilla, Monocular Diplopia, Subconjunctival Injections of Germicides, Infiltration-Ansesthesia, and Steriliza- tion of Collyria. Brief mention of Ophthalmia Nodosa, Electric Ophthalmia, and Angioid Streaks in the Retina also finds place. An Appendix has been added, containing a full description of the method of determining the corneal astigmatism with the ophthalmometer of Javal and Schiotz, and the rotations of the eyes with the tropometer of Stevens. The chapter on Operations has been enlarged and rewritten. " A clearly written, comprehensive manual. . . . One which we can commend to students as a reliable text-book, written with an evident knowledge of the wants of those entering upon the study of this special branch of medical science."— British Medical Journal. " The work is characterized by a lucidity of expression which leaves the reader in no doubt as to the meaning of the language employed. . . . We know of no work in which these diseases are dealt with more satisfactorily, and indications for treatment more clearly given, and in harmony with the practice of the most advanced ophthalmologists."—Mari- time Medical News. " It is hardly too much to say that for the student and practitioner beginning the study of Ophthalmology, it is the best single volume at present published."—Medical News. " The latest and one of the best books on Ophthalmology. The book is thoroughly up to date, and is certainly a work which not only commends itself to the student, but is a ready reference for the busy practitioner."— International Medical Review. PROFESSIONAL OPINIONS. "A work that will meet the requirements not only of the specialist, but of the general practitioner in a rare degree. I am satisfied that unusual success awaits it." William Pepper, M. D. Provost and Professor of Theory and Practice of Medicine and Clinical Medicine in the University of Pennsylvania. " Contains in concise and reliable form the accepted views of Ophthalmic Science." William Thomson, M. D., Professor of Ophthalmology, Jefferson Medical College, Philadelphia, Ta. i6 W. B. SAUNDERS TEXT-BOOK UPON THE PATHOGENIC BACTERIA. Spe- cially written for Students of Medicine. By Joseph McFarlam), M. D., Professor of Pathology and Bacteriology in the Medico-Chirurgica College of Philadelphia, etc. 359 pages, finely illustrated. Price, C o , #2.50 net. The book presents a concise account of the technical procedures necessary in the study of Bacteriology. It describes the life-history of pathogenic bacteria, ana the pathological lesions following invasion. , , The work is intended to be a text-book for the medical student and lor the practitioner who has had no recent laboratory training in this department ot medi- cal science. The instructions given as to needed apparatus, cultures, stainrngs, microscopic examinations, etc., are ample for the student's needs, and will attord to the physician much information that will interest and profit him relative to a subject which modern science shows to go far in explaining the etiology of many diseased conditions. The illustrations have been gathered from standard sources, and comprise the best and most complete aggregation extant. " It is excellently adapted for the medical students and practitioners for whom it is avowedly written. . . . The descriptions given are accurate and readable, and the book should prove useful to those for whom it is written.—London Lancet, Aug. 29, 1896. " The author has succeded admirably in presenting the essential details of bacteriological technics, together with a judiciously chosen summary of our present knowledge of pathogenic bacteria. . . . The work, we think, should have a wide circulation among English-speaking students of medicine."—N. Y. Medical Journal, April 4, 1896. " The book will be found of considerable use by medical men who have not had a special bacteriological training, and who desire to understand this important branch of medical science."—Edinburgh Medical Journal, July, 1896. LABORATORY GUIDE FOR THE BACTERIOLOGIST. By Langdon Frothingham, M. D. V., Assistant in Bacteriology and Veteri- nary Science, Sheffield Scientific School, Yale University. Illustrated. Price, Cloth, 75 cents. The technical methods involved in bacteria-culture, methods of staining, and microscopical study are fully described and arranged as simply and concisely as possible. The book is especially intended for use in laboratory work " It is a convenient and useful little work, and will more than repay the outlay necessary for its purchase in the saving of time which would otherwise be consumed in looking up the various points of technique so clearly and concisely laid down in its pages."—American Med.- Surg. Bulletin. FEEDING IN EARLY INFANCY. By Arthur V. Meigs, M. D. Bound in limp cloth, flush edges. Price, 25 cents net. Synopsis : Analyses of Milk—Importance of the Subject of Feeding in Early Infancy—Proportion of Casein and Sugar in Human Milk—Time to Begin Arti- ficial Feeding of Infants—Amount of Food to be Administered at Each Feed- ing—Intervals between Feedings—Increase in Amount of Food at Different Periods of Infant Development—Unsuitableness of Condensed Milk as a Sub- stitute for Mother's Milk—Objections to Sterilization or "Pasteurization'' of Milk—Advances made in the Method of Artificial Feeding of Infants. CATALOGUE OF MEDICAL WORKS. 17 ESSENTIALS OF ANATOMY AND MANUAL OF PRACTI- CAL DISSECTION, containing " Hints on Dissection " By Charles B. Nancrede, M. D., Professor of Surgery and Clinical Surgery in the University of Michigan, Ann Arbor; Corresponding Member of the Royal Academy of Medicine, Rome, Italy; late Surgeon Jefferson Medical Col- lege, etc. Fourth and revised edition. Post 8vo, over 500 pages, with handsome full-page lithographic plates in colors, and over 200 illustrations. Price : Extra Cloth or Oilcloth for the dissection-room, $2.00 net. Neither pains nor expense has been spared to make this work the most ex- haustive yet concise Student's Manual of Anatomy and Dissection ever pub- lished, either in America or in Europe. The colored plates are designed to aid the student in dissecting the muscles, arteries, veins, and nerves. The wood-cuts have all been specially drawn and engraved, and an Appendix added containing 60 illustrations representing the structure of the entire human skeleton, the whole being based on the eleventh edition of Gray's Anatomy. " The plates are of more than ordinary excellence, and are of especial value to students in their work in the dissecting-room."—Journal of American Medical Association. " Should be in the hands of every medical student."—Cleveland Medical Gazette. " A concise and judicious work."—Buffalo Medical and Surgical Journal. A MANUAL OF PRACTICE OF MEDICINE. By A. A. Stevens, A. M., M. D., Instructor of Physical Diagnosis in the University of Penn- sylvania, and Demonstrator of Pathology in the Woman's Medical College of Philadelphia. Specially intended for students preparing for graduation and hospital examinations, and includes the following sections: General Diseases, Diseases of the Digestive Organs, Diseases of the Respiratory System, Diseases of the Circulatory System, Diseases of the Nervous Sys- tem, Diseases of the Blood, Diseases of the Kidneys, and Diseases of the Skin. Each section is prefaced by a chapter on General Symptomatology. Post 8vo, 512 pages. Numerous illustrations and selected formulas. Price, $2.50. FOURTH EDITION, REVISED AND ENLARGED. Contributions to the science of medicine have poured in so rapidly during the last quarter of a century that it is well-nigh impossible for the student, with the limited time at his disposal, to master elaborate treatises or to cull from them that knowledge which is absolutely essential. From an extended experience in teaching, the author has been enabled, by classification, to group allied symp- toms and by the judicious elimination of theories and redundant explanations to bring within a comparatively small compass a complete outline of the prac- tice of medicine. 18 W. B. SAUNDERS MANUAL OF MATERIA MEDICA AND THERAPEUTICS. By A. A. Stevens, A. M., M. D., Instructor of Physical Diagnosis in the University of Pennsylvania, and Demonstrator of Pathology in the Woman's Medical College of Philadelphia. 445 pages. Price, Cloth, #2.25. SECOND EDITION, REVISED. This wholly new volume, which is based on the last edition of the Pharma- copoeia, comprehends the following sections: Physiologkal Action of Drugs; Drugs; Remedial Measures other than Drugs; Applied Therapeutics; Incom- patibility in Prescriptions; Table of Doses; Index of Drugs; and Index of Diseases; the treatment being elucidated by more than two hundred formulae. " The author is to be congratulated upon having presented the medical student with as accurate a manual of therapeutics as it is possible to prepare."— Therapeutic Gazette. " Far superior to most of its class ; in fact, it is very good. Moreover, the book is reliable and accurate."—New York Medical Journal. " The author has faithfully presented modern therapeutics in a comprehensive work, . . and it will be found a reliable guide."— University Medical Magazine. NOTES ON THE NEWER REMEDIES: their Therapeutic Ap plications and Modes of Administration. By David Cerna, M. D., Ph. D., Demonstrator of and Lecturer on Experimental Therapeutics in the University of Pennsylvania. Post-octavo, 253 pages. Price, #1.25. SECOND EDITION, RE-WRITTEN AND GREATLY ENLARGED. The work takes up in alphabetical order all the newer remedies, giving their physical properties, solubility, therapeutic applications, administration, and chemical formula. It thus forms a very valuable addition to the various works on therapeutics now in existence. , Chemists are so multiplying compounds, that, if each compound is to be thor- oughly studied, investigations must be carried far enough to determine the prac- tical importance of the new agents. " Especially valuable because of its completeness, its accuracy, its systematic consider- ation of the properties and therapy of many remedies of which doctors generally know but little, expressed in a brief yet terse manner."—Chicago Clinical Review. TEMPERATURE CHART. Prepared by D. T. Laine, M. D. Size 8x 13^ inches. Price, per pad of 25 charts, 50 cents. A conveniently arranged chart for recording Temperature, with columns for daily amounts of Urinary and Fecal Excretions, Food, Remarks, etc. On the back of each chart is given in full the method of Brand in the treatment of Typhoid Fever. CATALOGUE OF MEDICAL WORKS. 19 SAUNDERS' POCKET MEDICAL LEXICON; or, Dictionary of Terms and Words used in Medicine and Surgery. By John M. Keating, M. D., editor of " Cyclopaedia of Diseases of Children," etc.; author of the " New Pronouncing Dictionary of Medicine;" and Henr\ Hamilton, author of " A New Translation of Virgil's .Eneid into Eng- lish Verse;" co-author of a " New Pionoundng Dictionary of Medicine.'' A new and revised edition. 32mo, 282 pages. Prices: Cloth, 75 cents; Leather Tucks, #1.00. This new and comprehensive work of reference is the outcome of a demand for a more modern handbook of its class than those at present on the market, which, dating as they do from 1855 to 1884, are of but trifling use to the student by their not containing the hundreds of new words now used in current litera- Lure, especially those relating to Electricity and Bacteriology. • " ^m,?rk,ably accurate in terminology, accentuation, and definition."—Journal of Amer- ican Medical Association. J " Brief, yet complete .... it contains the very latest nomenclature in even the newest departments of medicine."—New York Medical Record. SAUNDERS' POCKET MEDICAL FORMULARY. By William M. Powell, M. D., Attending Physician to the Mercer House for Invalid Women at Atlantic City. Containing 1750 Formula?, selected from several hundred of the best-known authorities. Forming a handsome and con- venient pocket companion of nearly 300 printed pages, with blank leaves for Additions; with an Appendix containing Posological Table, Formula? and Doses for Hypodermatic Medication, Poisons and their Antidotes, Diameters of the Pemale Pelvis and Fcetal Head, Obstetrical Table, Diet List for Various Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive Fevers, Weights and Measures, etc. Third edition, revised and greatly enlarged. Handsomely bound in morocco, with side index, wallet, and flap. Price, #1.75 net. A concise, clear, and correct record of the many hundreds of famous formulae which are found scattered through the works of the most eminent physicians and surgeons of the world. The work is helpful to the student and practitioner alike, as through it they become acquainted with numerous formulae which are not found in text-books, but have been collected from among the rising genera- tion of the profession, college professors, and hospital physicians and surgeons. " This little book, that can be conveniently carried in the pocket, contains an immense amount of material. It is very useful, and as the name of the author of each prescription is given is unusually reliable."—New York Medical Record. " Designed to be of immense help to the general practitioner in the exercise of his daily calling."—Boston Medical and Surgical Journal. 20 W. B. SAUNDERS' DISEASES OF WOMEN. By Henry J. Garrigues, A. M., M. D., Professor of Gynecology and Obstetrics in the New York School of Clinical Medicine; Gynecologist to St. Mark's Hospital and to the German Dis- pensary, New York City. In one handsome octavo volume of 728 pages, illustrated by 335 engravings and colored plates. Prices : Cloth, $4.00 net; Sheep or Half Morocco, $5.00 net. A practical work on gynecology for the use of students and practitioners, written in a terse and concise manner. The importance of a thorough know- ledge of the anatomy of the female pelvic organs has been fully recognized by the author, and considerable space has been devoted to the subject. The chap- ters on Operations and on Treatment are thoroughly modern, and are based upon the large hospital and private practice of the author. The text is eluci- dated by a large number of illustrations and colored plates, many of them being original, and forming a complete atlas for studying embryology and the anatomy of the female genitalia, besides exemplifying, whenever needed, morbid condi- tions, instruments, apparatus, and operations. Second Edition, Thoroughly Revised. The first edition of this work met with a most appreciative reception by the medical press and profession both in this country and abroad, and was adopted as a text-book or recommended as a book of reference by nearly one hundred colleges in the United States and Canada. The author has availed himself of the opportunity afforded by this revision to embody the latest approved advances in the treatment employed in this important branch of Medicine. He has also more extensively expressed his own opinion on the comparative value of the different methods of treatment employed. "One of the best text-books for students and practitioners which has been published in the English language; it is condensed, clear, and comprehensive. The profound learning and great clinical experience of the distinguished author find expression in this book in a most attractive and instructive form. Young practitioners, to whom experienced consultants may not be available, will find in this book invaluable counsel and help." Thad. A. Reamy, M. D., LL.D., Professor of Clinical Gynecology, Medical College of Ohio: Gynecologist to the Good Samaritan and Cincinnati Hospitals. A SYLLABUS OF GYNECOLOGY, arranged in conformity with "An American Text-Book of Gynecology." By J. W. Long, M. D., Professor of Diseases of Women and Children, Medical College of Vir- ginia, etc. Price, Cloth (interleaved), $1.00 net. Based upon the teaching and methods laid down in the larger work, this will not only be useful as a supplementary volume, but to those who do not already possess the text-book it will also have an independent value as an aid to the practitioner in gynecological work, and to the student as a guide in the lecture- room, as the subject is presented in a manner at once systematic, clear, succinct, and practical. CATALOGUE OF MEDICAL WORKS. 21 A MANUAL OF PHYSIOLOGY, with Practical Exercises. For Students and Practitioners. By G. N. Stewart, M. A., M. D., D. Sc, lately Examiner in Physiology, University of Aberdeen, and of the New Museums, Cambridge University; Professor of Physiology in the Western Reserve University, Cleveland, Ohio. Handsome octavo volume of 800 pages, with 278 illustrations in the text, and 5 colored plates. Price, Cloth, $3.50 net. " It will make its way by sheer force of merit, and amply deserves to do so. It is one of the very best English text-books on the subject."—London Lancet. " Of the many text-books of physiology published, we do not know of one that so nearly comes up to the ideal as does Professor Stewart's volume."—British Medical Journal. ESSENTIALS OF PHYSICAL DIAGNOSIS OF THE THORAX. By Arthur M. Corwin, A. M., M. D., Demonstrator of Physical Diagno- sis in the Rush Medical College, Chicago; Attending Physician to the Central Free Dispensary, Department of Rhinology, Laryngology, and Diseases of the Chest. 200 pages. Illustrated. Cloth, flexible covers. Price, $1.25 net. SYLLABUS OF OBSTETRICAL LECTURES in the Medical Department, University of Pennsylvania. By Richard C. Norris, A. M., M. D., Lecturer on Clinical and Operative Obstetrics, University of Pennsylvania. Third edition, thoroughly revised and enlarged. Crown 8vo. Price, Cloth, interleaved for notes, $2.00 net. " This work is so far superior to others on the same subject that we take pleasure in call- ing attention briefly to its excellent features. It covers the subject thoroughly, and will prove invaluable both to the student and the practitioner. The author has introduced a number of valuable hints which would only occur to one who was himself an experienced teacher of obstetrics. The subject-matter is clear, forcible, and modern. We are especially pleased with the portion devoted to the practical duties of the accoucheur, care of the child, etc. The paragraphs on antiseptics are admirable; there is no doubtful tone in the direc- tions given. No details are regarded as unimportant; no minor matters omitted. We ven- ture to say that even the old practitioner will find useful hints in this direction which he can- not afford to despise."—New York Medical Record. A SYLLABUS OF LECTURES ON THE PRACTICE OF SUR- GERY, arranged in conformity with " An American Text-Book of Surgery." By N. Senn, M. D., Ph. D., Professor of Surgery in Rush Medical College, Chicago, and in the Chicago Polyclinic. Price, $2.00. This, the latest work of its eminent author, himself one of the contributors to " An American Text-Book of Surgery," will prove of exceptional value to the advanced student who has adopted that work as his text-book. It is not only the syllabus of an unrivalled course of surgical practice, but it is also an epitome of or supplement to the larger work. " The author has evidently spared no pains in making his Syllabus thoroughly comprehen- sive, and har. added new matter and alluded to the most recent authors and operations. Full references are also given to all requisite details of surgical anatomy and pathology."—British Medical Journal, London. 22 IV. B. SAUNDERS' AN OPERATION BLANK, with Lists of Instruments, etc. re- quired in Various Operations. Prepared by W. W. Keen, M. D., LL.D., Professor of Principles of Surgery in the Jefferson Medical Col- lege, Philadelphia. Price per Pad, containing Blanks for fifty operations, 50 cents net. SECOND EDITION, REVISED FORM. A convenient blank, suitable for all operations, giving complete instructions regarding necessary preparation of patient, etc., with a full list of dressings ana medicines to be employed. On the back of each blank is a list of instruments used—viz. general instru- ments, etc., required for all operations; and special instruments for surgery of the brain and spine, mouth and throat, abdomen, rectum, male and female genito-urinary organs, the bones, etc. The whole forming a neat pad, arranged for hanging on the wall of a sur- geon's office or in the hospital operating-room. " Will serve a useful purpose for the surgeon in reminding him of the details of prepa- ration for the patient and the room as well as for the instruments, dressings, and antiseptics needed "—New York Medical Record " Covers about all that can be needed in any operation."—American Lancet. " The plan is a capital one."—Boston Medical and Surgical Journal. LABORATORY EXERCISES IN BOTANY. By Edson S. Bastin, M. A., Professor of Materia Medica and Botany in the Philadelphia Col- lege of Pharmacy. Octavo volume of 536 pages, 87 full-page plates. Price, Cloth, $2.50. This work is intended for the beginner and the advanced student, and it fully covers the structure of flowering plants, roots, ordinary stems, rhizomes, tubers, bulbs, leaves, flowers, fruits, and seeds. Particular attention is given to the gross and microscopical structure of plants, and to those used in medicine. Illustra- tions have freely been used to elucidate the text, and a complete index to facil- itate reference has been added. " There is no work like it in the pharmaceutical or botanical literature of this country, and we predict for it a wide circulation."—American Journal of Pharmacy. DIET IN SICKNESS AND IN HEALTH. By Mrs. Ernest Hart, formerly Student of the Faculty of Medicine of Paris and of the London School of Medicine for Women; with an Introduction by Sir Henry Thompson, F. R. C. S., M. D., London. 220 pages; illustrated. Price, Cloth, $1.50. Useful to those who have to nurse, feed, and prescribe for the sick. In each case the accepted causation of the disease and the reasons for the special diet prescribed are briefly described. Medical men will find the dietaries and recipes practically useful, and likely to save them trouble in directing the dietetic treatment of patients. CATALOGUE OF MEDICAL WORKS. 2$ HOW TO EXAMINE FOR LIFE INSURANCE. By John M. Keating, M. D., Fellow of the College of Physicians and Surgeons of Philadelphia; Vice-President of the American Psediatric Society; Ex- President of the Association of Life Insurance Medical Directors. Royal 8vo, 211 pages, with two large half-tone illustrations, and a plate prepared by Dr. McClellan from special dissections; also, numerous cuts to elucidate the text. Second edition. Price, Cloth, $2.00 net. " This is by far the most useful book which has yet appeared on insurance examination, a subject of growing interest and importance. Not the least valuable portion of the volume is Part II., which consists of instructions issued to their examining physicians by twenty-four representative companies of this country. As the proofs of these instructions were corrected by the directors of the companies, they form the latest instructions obtainable. If for these alone, the book should be at the right hand of every physician interested in this special branch of medical science."—The Medical News, Philadelphia. NURSING: ITS PRINCIPLES AND PRACTICE. By Isabel Adams Hampton, Graduate of the New York Training School for Nurses attached to Belle vue Hospital; Superintendent of Nurses and Principal of the Training School for Nurses, Johns Hopkins Hospital, Baltimore, Md.; late Superintendent of Nurses, Illinois Training School for Nurses, Chicago, 111. In one very handsome i2mo volume of 484 pages, profusely illustrated. Price, Cloth, $2.00 net. This original work on the important subject of nursing is at once comprehensive and systematic. It is written in a clear, accurate, and readable style, suitable alike to the student and the lay reader. Such a work has long been a desidera- tum with those entrusted with the management of hospitals and the instruction of nurses in training-schools. It is also of especial value to -the graduated nurse who desires to acquire a practical working knowledge of the care of the sick and the hygiene of the sick-room. OBSTETRIC ACCIDENTS, EMERGENCIES, AND OPERA- TIONS. By L. Ch. Boisliniere, M. D., late Emeritus Professor of Obstetrics in the St. Louis Medical College. 381 pages, handsomely illus- trated. Price, $2.00 net. " For the use of the practitioner who, when away from home, has not the opportunity of consulting a library or of calling a friend in consultation. He then, being thrown upon his own resources, will find this book of benefit in guiding and assisting him in emergencies." INFANT'S WEIGHT CHART. Designed by J. P. Crozer Griffith, M. D., Clinical Professor of Diseases of Children in the University of Penn- sylvania. 25 charts in each pad. Price per pad, 50 cents net. A convenient blank for keeping a record of the child's weight during the first two years of life. Printed on each chart is a curve representing the average weight of a healthy infant, so that any deviation from the normal can readily be detected. 24 W. B. SAUNDERS THE CARE OF THE BABY. By J. P. Crozer Griffith, M. D., Clinical Professor of Diseases of Children, University of Pennsylvania; Physician to the Children's Hospital, Philadelphia, etc. 392 pages, with 67 illustrations in the text, and 5 plates. i2mo. Price, #1.50. A reliable guide not only for mothers, but also for medical students and practitioners whose opportunities for observing children have been limited. " The whole book is characterized by rare good sense, and is evidently written by a mas- ter hand. It can be read with benefit not only by mothers, but by medical students and by any practitioners who have not had large opportunities for observing children."—American Jjurnal of Obstetrics. THE NURSE'S DICTIONARY of Medical Terms and Nursing Treatment, containing Definitions of the Principal Medical and Nursing Terms, Abbreviations, and Physiological Names, and Descriptions of the Instruments, Drugs, Diseases, Accidents, Treatments, Operations, Foods, Appliances, etc. encountered in the ward or in the sick-room. Compiled for the use of nurses. By Honnor Morten, author of " How to Become a Nurse," "Sketches of Hospital Life," etc. i6mo, 140 pages. Price, Cloth, $1.00. This little volume is intended for use merely as a small reference-book which can be consulted at the bedside or in the ward. It gives sufficient explanation to the nurse to enable her to comprehend a case until she has leisure to look up larger and fuller works on the subject. DIET LISTS AND SICK-ROOM DIETARY. By Jerome B. Thomas, M. D., Visiting Physician to the Home for Friendless Women and Children and to the Newsboys' Home; Assistant Visiting Physician to the Kings County Hospital; Assistant Bacteriologist, Brooklyn Health Department. Price, Cloth, $1.50 (Send for specimen List.) One hundred and sixty detachable (perforated) diet lists for Albuminuria, Ansemia and Debility, Constipation, Diabetes, Diarrhoea, Dyspepsia, Fevers, Gout or Uric-Acid Diathesis, Obesity, and Tuberculosis. Also forty detachable sheets of Sick-Room Dietary, containing full instructions for preparation of easily-digested foods necessary for invalids. Each list is numbered only, the disease for which it is to be used in no case being mentioned, an index key being reserved for the physician's private use. DIETS FOR INFANTS AND CHILDREN IN HEALTH AND IN DISEASE. By Louis Starr, M. D., Editor of " An American Text-Book of the Diseases of Children." 230 blanks (pocket-book size), perforated and neatly bound in flexible morocco. Price, $1.25 net. The first series of blanks are prepared for the first seven months of infant life; each blank indicates the ingredients, but not the quantities, of the food, the latter directions being left for the physician. After the seventh month, modifications being less necessary, the diet lists are printed in full. Formula iox trie preparation of diluents and foods are appended. Practical, Exhaustive, Authoritative. SAUNDERS' NEW AID SERIES OF MANUALS FOR Students and Practitioners. Mr. Saunders is pleased to announce as now ready his NEW AID SERIES OF MANUALS for Students and Practitioners. As pub- lisher of the Standard Series of Question Compends, and through intimate relations with leading members of the medical profession, Mr. Saunders has been enabled to study progressively the essential desiderata in practical " self- helps " for students and physicians. This study has manifested that, while the published " Question Compends" earn the highest appreciation of students, whom they serve in reviewing their studies preparatory to examination, there is special need of thoroughly reliable handbooks on the leading branches of Medicine and Surgery, each subject being compactly and authoritatively written, and exhaustive in detail, without the introduction of cases and foreign subject-matter which so largely expand ordinary text-books. The Saunders Aid Series will not merely be condensations from present literature, but will be ably written by well-known authors and practitioners, most of them being teachers in representative American Colleges. This new series, therefore, will form an admirable collection of advanced lectures, which will be invaluable aids to students in reading and in comprehending the contents of " recommended" works. Each Manual will further be distinguished by the beauty of the new type; by the quality of the paper and printing; by the copious use of illustrations; by the attractive binding in cloth; and by their extremely low prices. 25 SAUNDERS' NEW AID SERIES OF MANUALS. VOLUMES PUBLISHED. PHYSIOLOGY. By Joseph Howard Raymond, A. M , M. D., Professor of Physiology and Hygiene and Lecturer on Gynecology in the Long Island College Hospital, etc. Price, $1.25 net. SURGERY, General and Operative. By John Chalmers DaCosta, M. D„ Demonstrator of Surgery, Jefferson Medical College, Philadelphia, etc. Double number. Price, $2.50 net. DOSE-BOOK AND MANUAL OF PRESCRIPTION-WRITING. By E. Q. Thornton, M. D., Demonstrator of Therapeutics, Jefferson Medical College, Philadelphia. Price, $1.25 net. MEDICAL JURISPRUDENCE. By Henry C. Chapman, M. D., Pro- fessor of Institutes of Medicine and Medical Jurisprudence in the Jeffer- son Medical College of Philadelphia, etc Price, $1.50 net. SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and to the German Poliklinik; Instructor in Surgery, New York Post-Graduate Medical School, etc. Price, $1.25 net. MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct Professor of Anatomy and Demonstrator of Anatomy, Medical Department of the New York University, etc. (Double number.) Price, $2.50 net. SYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M. D., Professor of Skin and Venereal Diseases, and Frank H. Montgomery, M. D., Lecturer on Dermatology and Genito- urinary Diseases, in Rush Medical College, Chicago. (Double number.) Price, $2.50 net. PRACTICE OF MEDICINE. By George Roe Lockwood, M. D., Professor of Practice in the Woman's Medical College of the New York Infirmary, etc. (Double number.) Price, $2.50 net. OBSTETRICS. By W. A. Newman Dorland, M. D., Asst. Demonstrator of Obstetrics, University of Pennsylvania; Chief of Gynecological Dispen- sary, Pennsylvania Hospital. (Double number.) Price, $2.50 net. DISEASES OF WOMEN. By J. Bland Sutton, F. R. C. S., Assistant Surgeon to the Middlesex Hospital, and Surgeon to the Chelsea Hospital for Women, London; and Arthur E. Giles, M. D., B. Sc. Lond., F. R. C. S. Edin., Assistant Surgeon to the Chelsea Hospital for Women, London. 436 pages, handsomely illustrated. (Double number.) Price, $2.50 net. VOLUMES IN PREPARATION. NERVOUS DISEASES. By Charles W. Burr, M. D., Clinical Pro- fessor of Nervous Diseases, Medico-Chirurgical College, Philadelphia, etc. NOSE AND THROAT. By D. Braden KYLii, M. D., Chief Laryngolo- gist to St. Agnes' Hospital, Philadelphia; Instructor in Clinical Microscopy and Assistant Demonstrator of Pathology in Jefferson Medical College. V* There will be published in the same series, at short intervals, carefully prepared works on various subjects, by prominent specialists. SAUNDERS' QUESTION COMPENDS. Arranged in Question and Answer Form. THE LATEST, MOST COMPLETE, and BEST ILLUSTRATED SERIES OF COMPENDS EVER ISSUED. Now the Standard Authorities in Medical Literature WITH Students and Practitioners in every City of the United States and Canada. THE REASON WHY. They are the advance guard of " Student's Helps "—that DO help ; they are the leaders in their special line, well and authoritatively written by able men, who, as teachers in the large colleges, know exactly what is wanted by a student preparing for his examinations. The judgment exercised in the selection of authors is fully demonstrated by their professional elevation. Chosen from the ranks of Demonstrators, Quiz-masters, and Assistants, most of them have be- come Professors and Lecturers in their respective colleges. Each book is of convenient size (5x7 inches), containing on an average 250 pages, profusely illustrated, and elegantly printed in clear, readable type, on fine paper. The entire series, numbering twenty-four subjects, has been kept thoroughly revised and enlarged when necessary, many of them being in their fourth and fifth editions. TO SUM UP. Although there are numerous other Quizzes, Manuals, Aids, etc. in the mar- ket, none of them approach the " Blue Series of Question Compends;" and the claim is made for the following points of excellence: 1. Professional distinction and reputation of authors. 2. Conciseness, clearness, and soundness of treatment. 3. Size of type and quality of paper and binding. «,; Any of these Compends will he mailed on receipt of price (see over for List . SAUNDERS' QUESTION-COMPEND SERIES, Price, Cloth, $1.00 per copy, except when otherwise noted. I. ESSENTIALS OF PHYSIOLOGY. 4th edition. Illustrated. Re- vised and enlarged by H. A. Hare, M. D (Price, #1.00 net.) 2. ESSENTIALS OF SURGERY. 6th edition, with an Appendix on Antiseptic Surgery. 90 illustrations. By Edward Martin, M. D. 3. ESSENTIALS OF ANATOMY. 5th edition, with an Appendix. 180 illustrations. By Charles B. Nancrede, M. D. 4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. 4th edition, revised, with an Appendix. By Law- rence Wolff, M. D. 5. ESSENTIALS OF OBSTETRICS. 4th edition, revised and en- larged. 75 illustrations. By W. Easterly Ashton, M. D. 6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. 7th thousand. 46 illustrations. By C. E. Armand Semple, M. D. 7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRESCRIPTION-WRITING. 4th edition. By Henry Morris, M. D. 8, 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, M. D. An Appendix on Urine Examination. Illustrated. By Lawrence Wolff, M. D. 3d edition, enlarged by some 300 Es- sential Formulae, selected from eminent authorities, by Wm. M. Powell, M. D. (Double number, price $2.00.) 10. ESSENTIALS OF GYNECOLOGY. 4th edition, revised. With 62 illustrations. By Edwin B. Cragin, M. D. 11. ESSENTIALS OF DISEASES OF THE SKIN. 3d edition, re- vised and enlarged. 71 letter-press cuts and 15 half-tone illustrations. By Henry W. Stelwagon, M. D. (Price, $1.00 net.) 12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL DISEASES. 2d edition, revised and enlarged. 78 illustrations. By Edward Martin, M. D. 13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 130 illustrations. By C. E. Armand Semple, M. D. 14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. 124 illustrations. 2d edition, revised. By Edward Jackson, M. D., and E. Baldwin Gleason, M. D. 15. ESSENTIALS OF DISEASES OF CHILDREN. Second edi- tion. By William H. Powell, M. D. 16. ESSENTIALS OF EXAMINATION OF URINE. Colored " Vogel Scale," and numerous illustrations. By Lawrence Wolff, M. D. (Price, 75 cents.) 17. ESSENTIALS OF DIAGNOSIS. By S. Solis-Cohen, M. D., and A. A. Eshner, M. D. 55 illustrations, some in colors. (Price, $1.50 net.) 18. ESSENTIALS OF PRACTICE OF PHARMACY. By L. E. Sayre. 2d edition, revised. 20. ESSENTIALS OF BACTERIOLOGY. 3d edition. 82 illustra- tions. By M. V. Ball, M. D. 21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. 48 illustrations. 3d edition, revised. By John C. Shaw, M. D. 22. ESSENTIALS OF MEDICAL PHYSICS. 155 illustrations. 2d edition, revised. By Fred J. Brockway, M. D. (Price, $i.oo'net.) 23. ESSENTIALS OF MEDICAL ELECTRICITY. 65 illustrations. By David D. Stewart, M. D., and Edward S. Lawrance, M D 24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Glea- son. M. D. 114 illustrations. Second edition, revised and enlarged. RECENT PUBLICATIONS PENROSE'S DISEASES OF WOMEN A Text-Book of Diseases of Women. By Charles B. Penrose, M.D., Ph.D., Professor of Gynecology in the University of Pennsylvania ; Surgeon to the Gynecean Hospital, Philadelphia. Octavo volume of 529 pages, handsomely illustrated. Cloth, $3.50 net. " I shall value very highly the copy of Penrose's " Diseases of Women " received. I have already recommended it to my class as the best book."—Howard A. Kelly, Professorof Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Md. SENN'S GENITOURINARY TUBERCULOSIS Tuberculosis of the Genito=Urinary Organs, Male and Female. By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of Surgery and of Clinical Surgery, Rush Medical College, Chicago. Handsome octavo volume of 320 pages, illustrated. Cloth, $3.00 net. SUTTON AND GILES' DISEASES OF WOMEN Diseases of Women. By J. Bland Sutton, F.R.C.S., Assistant Surgeon to Middle- sex Hospital, and Surgeon to Chelsea Hospital, London ; and Arthur E. Giles, M.D., B.Sc. Loud., F R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, London. 4.36 pages, handsomely illustrated. Cloth, $2.50 net. BUTLER'S MATERIA MEDICA, THERAPEUTICS, AND PHAR= MACOLOGY A Text=Book of Materia Medica, Therapeutics, and Pharmacology. By George F. Butler, Ph.G., M.D., Professor of Materia Medica and of Clinical Medicine in the College of Physicians and Surgeons, Chicago; Professor of Materia Medica and Therapeutics, Northwestern University, Woman's Medical School, etc. Octavo, 858 pages, illustrated. Cloth, $4.00 net; Sheep, $5.00 net. SAUNDBY'S RENAL AND URINARY DISEASES Lectures on Renal and Urinary Diseases. By Robert Saundby, M.D. Edin., Fellow of the Royal College of Physicians, London, and of the Royal Medico-Chirur- gical Society; Physician to the General Hospital; Consulting Physician to the Eye Hospital and to the Hospital for Diseases of Women ; Professor of Medicine in Mason College, Birmingham, etc. Octavo volume of 434 pages, with numerous illustrations and 4 colored plates. Cloth, $2.50 net. PYE'S BANDAGING Elementary Bandaging and Surgical Dressing, with Directions Concerning the Immediate Treatment of Cases of Emergency. For the Use of Dressers and Nurses. By Walter Pye, F.R.C.S., Late Surgeon to St. Mary's Hospital, London. Small i2mo, with over 80 illustrations. Cloth, flexible covers. Price, 75 cents net. MALLORY AND WRIGHT'S PATHOLOGICAL TECHNIQUE Pathological Technique. By Frank B. Mallory, A.M., M.D., Assistant Professor of Pathologv, Harvard University Medical School ; and James H. Wright, A.M., M.D., Instructor in Pathology, Harvard University Medical School. Octavo volume of 396 pages, handsomely illustrated. Cloth, $2.50 net. " I have been looking forward to the publication of this book, and I am glad to say that I find it to be a most useful laboratory and post-mortem guide, full of practical infor- mation, and well up to date."—William H. Welch, Professor of Pathology, Johns Hopkins University, Baltimore, Md. ANDERS' PRACTICE OF MEDICINE A Text=Book of the Practice of Medicine. By James M. Anders, M.D., Ph.D., LL D Professor of the Practice of Medicine and of Clinical Medicine, Medico- Chirurgical College, Philadelphia. In one handsome octavo volume of 1287 pages, fully illustrated. Cloth, I5.50 net; Sheep or Half Morocco, $6.50 net. JUST ISSUED. SOLD BY SUBSCRIPTION. ANOMALIES AND CURIOSITIES OF MEDICINE. BY GEORGE M. GOULD, M. D., and WALTER L. PYLE, M. D. Several years of exhaustive research have been spent by the authors in the great medical libraries of the United States and Europe in collecting the material for this work. JTedical literature of all ages and all languages has been carefully searched, as a glance at the Bibliographic Index will show. The facts, which will be of extreme value to the author and lecturer, have been arranged and annotated, and full reference footnotes given, indicating whence they have been obtained. In view of the persistent and dominant interest in the anomalous and curious, a thorough and systematic collection of this kind (the first of which the authors have knowledge) must have its own peculiar sphere of usefulness. As a complete and authoritative Book of Reference it will be of value not only to members of the medical profession, but to all persons interested in general scientific, sociologic, and medico-legal topics; in fact, the general inter- est of the subject and the dearth of any complete work upon it make this volume one of the most important literary innovations of the day. An especially valuable feature of the book consists of the Indexing. Besides a complete and comprehensive General Index, containing numerous cross-references to the subjects discussed, and the names of the authors of the more important reports, there is a convenient Bibliographic Index and a Table of Contents. The plan has been adopted of printing the topical headings in bold3 face type, the reader being thereby enabled to tell at a glance the subject- matter of any particular paragraph or page. Illustrations have been freely employed throughout the work, there being 165 relief cuts and 130 half-tones in the text, and 12 colored and half-tone full- page plates—a total of over 320 separate figures. The careful rendering of the text and references, the wealth of illustrations, the mechanical skill represented in the typography, the printing, and the bind- ing, combine to make this book one of the most attractive medical publications ever issued. Handsome Imperial Octavo Volume of 968 Pages. PRICES: Cloth, $6.00 net; Half Morocco, $7.00 net 30 JUST ISSUED AN AMERICAN TEXT=BOOK OF GENITOURINARY AND SKIN DISEASES Edited by L. Bolton Bangs, M.D., Late Professor of Genito-Urinary and Venereal Diseases, New York Post-Graduate Medical School and Hospital; and William A. Hardaway, M.D., Professor of Diseases of the Skin, Missouri Medical College. Octavo volume of over 1200 pages, with 300 illustrations in the text, and 20 full-page colored plates. Prices : Cloth, $7.00 net; Sheep or Half Morocco, $8.00 net. MOORE'S ORTHOPEDIC SURGERY A Manual of Orthopedic Surgery. By James E. Moore, M.D., Professor of Ortho- pedics and Adjunct Professor of Clinical Surgery, University of Minnesota, College of Medicine and Surgery. 8vo, 356 pages, handsomely illustrated. Cloth, $2.50 net. MACDONALD'S SURGICAL DIAGNOSIS AND TREATMENT Surgical Diagnosis and Treatment. By J. W. Macdonald, M.D. Edin., L.R.C.S. Edin., Professor of the Practice of Surgery and of Clinical Surgery in Hamline Uni- versity; Visiting Surgeon to St. Barnabas' Hospital, Minneapolis, etc. Octavo volume of 800 pages, handsomely illustrated. Cloth, $5.00 net; Half Morocco, $6x0 net. CHAPIN ON INSANITY A Compendium of Insanity. By John B. Chapin, M.D., LL.D., Physician-in-Chief, Pennsylvania Hospital for the Insane; late Physician-Superintendent of the Willard State Hospital, New York, etc. i2mo., 234 pages, illustrated. KEEN ON THE SURGERY OF TYPHOID FEVER The Surgical Complications and Sequels of Typhoid Fever. By Wm. W. Keen, M.D., LL.D., Professor of the Principles of Surgery and of Clinical Surgery, Jeffer- son Medical College, Philada. Octavo volume of 400 pages. Cloth, $3.00 net. VAN VALZAH AND NISBET'S DISEASES OF THE STOMACH Diseases of the Stomach. By William W. van Valzah, M.D., Professor of General Medicine and Diseases of the Digestive System and the Blood, New York Polyclinic ; and J. Douglas N'isbet, M.D., Adjunct Professor of General Medicine and Diseases of the Digestive System and the Blood, New York Polyclinic. Octavo volume of 700 pages, illustrated. Cloth, $3.50 net. IN PREPARATION AN AMERICAN TEXT=BOOK OF DISEASES OF THE EYE, EAR, NOSE, AND THROAT Edited by G. E. de Schweinitz, M.D., Professor of Ophthalmology in the Jefferson Medical College; and B. Alexander Randall, M.D., Professor of Diseases of the Ear in the University of Pennsylvania and in the Philadelphia Polyclinic. CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES Nervous and Mental Diseases. By Archibald Church, M.D., Professor of Mental Diseases and Medical Jurisprudence, Northwestern University Medical School, Chicago; and Frederick Peterson, M.D., Clinical Professor of Mental Diseases, Woman's Medical College, New York, etc. KYLE ON THE NOSE AND THROAT Diseases of the Nose and Throat. By D. Braden Kyle, M.D., Clinical Professor of Laryngology and Rhinology, Jefferson Medical College, Philadelphia; Consulting Laryngologist, Rhinologist, and Otologist, St. Agnes' Hospital, etc. STENGEL'S PATHOLOGY A Manual of Pathology. By Alfred Stengel, M D., Physician to the Philadel- phia Hospital; Professor of Clinical Medicine in the Woman's Medical College; Physician to the Children's Hospital, etc. HIRST'S OBSTETRICS A Text=Book of Obstetrics. By Barton Cooke Hirst, M.D., Professor of Ob- stetrics, University of Pennsylvania. HEISLER'S EMBRYOLOGY A Text-Book of Embryology. By John C Heisler, M.D., Professor of Anatomy, Medico-Chirurgical College, Philadelphia. 31 NOW READY, VOLUMES FOR 1896,1897,1898. & s^tt:£t:d:e:r,s' AMERICAN YEAR-BOOK OF MEDICINE and SURGERY. Edited by GEORGE M. GOULD, A.M., M.D. Assisted by Eminent American Specialists and Teachers. » -----'----- ^ Notwithstanding the rapid multiplication of medical and surgical works, © still these publications fail to meet fully the requirements of the general physician, ^ inasmuch as he feels the need of something more than mere text-books of well- 's known principles of medical science. Mr. Saunders has long been impressed if with this fact, which is confirmed by the unanimity of expression from the pro- 8 fession at large, as indicated by advices from his large corps of canvassers. fe. This deficiency would best be met by current journalistic literature, but most tg practitioners have scant access to this almost unlimited source of information, S and the busy practiser has but little time to search out in periodicals the many g interesting cases whose study would doubtless be of inestimable value in his a practice. Therefore, a work which places before the physician in convenient ^ form an epitomization of this literature by persons competent to pronounce upon 8 *i § The Value of a Discovery or of a Method of Treatment a 5 » cannot but command his highest appreciation. It is this critical and judicial § 4» function that will be assumed by the Editorial staff of the " American Year- 's Book of Medicine and Surgery."