the majority of writers on the subject, of a melancholic form. Gintrac thus describes it:

"The cerebro-spinal symptoms consist of an alteration of the sensibility of the motility and of the intelligence. They are vertigo, pain, or rather a feeling of heat, along the spine, slight losses of consciousness, apathy, a great indisposition to muscular exercise or any sort of work. These symptoms gradually become more distinctly marked, the debility is more intense, the gait is staggering, the lower extremities become the seat of numbness, and of weakness which sometimes terminates in paralysis. At other times the pellagrous individuals are subject to tremors, and to a degree of ataxia which renders their movements very uncertain and peculiar. They have, besides, hallucinations of sight and of hearing, they remain obstinately silent; and preserve an immovable attitude. They have a slowness of speech, an incoherence of ideas, a sad delirium, a fixed idea of despair, and a degree of melancholia sometimes reaching to stupidity. In a word, they afford the sad spectacle of mental alienation, extending through all degrees, from simple hebetude to mania and monomania, and which often leads to suicide.

Strambio, observing that the subjects of pellagrous insanity generally committed suicide by drowning, suggested the name of hydromania for this form of mental derangement. The intense heat of the skin excites not only directly to immersion in water, but also gives rise to delusions of fire, both in this world and in the next, and the miserable victims plunge into the water to extinguish at the same time the real and the imaginary fire.

Gintrac adds that, in travelling through the districts in which pellagra exists, he has been informed that every year many pellagrous maniacs or melancholics are found drowned in the ponds.

Baillarger finds in the phenomena of pellagrous insanity so many similitudes to general paralysis, that he insists on the existence of a striking analogy between the two diseases. These, however, are mostly as regards the somatic symptomsthe troubles of speech, the advancing paralysis.

Lombroso regards the emotional impressionability of the subjects of pellagrous insanity as one of the most prominent characteristics of the disease. The slightest untoward event is sufficient to produce a degree of emotional disturbance

altogether out of proportion to the exciting cause. Thus, a woman missing mass is thrown into a condition of despair, because she thinks she is in consequence doomed to eternal damnation. A man becomes acutely maniacal because a friend to whom he has lent a pistol will not return it; and a woman becomes similarly affected because her husband, who is a fisherman, is a few minutes late in coming home. Sometimes the patients remain obstinately mute for long periods; refusal of food is common, as are various hallucinations. Derangements of speech are also met with. Hydromania is among the most characteristic symptoms: some crave water for the cooling and refreshing influence which it has on the skin, others simply desire to see it. One patient told Dr. Lombroso that nothing in the world gave him so much pleasure as the sight of water. Occasionally some patients have a strong dislike for water.

It appears to me, therefore, that pellagrous insanity should be regarded as a distinct pathological entity, the pathognomonic features of which are mental derangement, generally of the character of melancholia in some one of its forms, or of acute mania, and accompanied by the somatic phenomena of derangements of sensibility and motility, not unlike, in some respects, those which exist in general paralysis.

The prognosis of the affection is bad. Remissions may occur, but the symptoms are almost certain to return with increased violence.

d-CHOREIC INSANITY, ETC.

Chorea is quite often accompanied by mental derangement of a peculiar kind. Reference is not made to the various epidemics of so-called chorea, which in former times appeared in various parts of the civilized world, nor to those other forms of disorderly movements which are more or less contagious or epidemic in character, and which sometimes accompany great religious excitement. Some of them have been considered under the head of epidemic insanity. But by choreic insanity is to be understood solely the aberration of mind which is an accompaniment or a result of chorea, and which is due to the same cause which produces the convulsive disorder.

The first to study the subject systematically was Marcé,

and little has been added to our knowledge of the subject since the publication of his monograph over twenty years ago.'

Marcé distinguishes four categories of phenomena connected with the mind which may exist in conjunction with chorea-troubles of the emotions; of the memory and intellectual faculties generally; of the perceptions; and then maniacal delirium. The first three are, I think, observed with more or less completeness in all cases of chorea. In some instances they are slight, and may consist merely of defects of memory and weakness of the intellect in other respects; but in others there are great emotional disturbance and almost constant hallucinations of sight. Without dwelling on these symptoms to any great extent, it may be well to call attention to them in a few words before proceeding to consider the more pronounced type constituting choreic insanity.

The modifications of states of feeling which accompany chorea are in general well marked. The patient is irritable, impressionable, laughs in a silly way over circumstances not in the least risible, or sheds tears over events which are of the most inconsequential character. The tendency to deceive is developed to a surprising degree, and patients who have ordinarily been remarkable for their truth-telling quality and freedom from subterfuge and fraud, will lie with and without reason, and resort to altogether unnecessary tricks and cheats, actuated apparently by no other motive than a kind of automatic spirit of falsehood. It is possible that in some cases the stories that are concocted by choreic children have their origin in delusions which are mistaken by them for actual

Occurrences.

So far as the intellect is concerned, the principal aberrations are perceived as regards the memory and the power of concentrating the attention. Nothing seems to make any permanent impression on the understanding, though, as we have seen, the emotions are affected readily enough. Learning lessons at school becomes an impossibility. The child can neither apply itself nor retain the little it may acquire. These phenomena indicate a condition of mental weakness approaching dementia, and, indeed, the state of mind induced is in some cases as well-marked dementia as is ever seen.

"De l'état mental dans la chorée," "Mémoires de l'académie impériale de médecine," t. xxiv, 1860, p. 1; also, "Traité pratique de maladies mentales," Paris, 1862, p. 576.

In some very severe cases of chorea the mental manifestations are very profound, and a state of stupor is induced, during which the patient is more or less insensible to what is going on around him.

Indeed, it is almost invariably the case that the mental aberration is in direct relation with the somatic symptoms. When these latter are at their height the disturbance of mind is always greatest, and, when they are diminished in violence, the mind tends to the resumption of its normal condition.

Marcé states that it is not rare to meet with hallucinations in chorea. Except in cases of fully developed choreic insanity, few cases of the kind have come under my observation, and these, all except one, related to the sense of sight. In this respect my experience is in accordance with that of Marcé, who states that he has never seen the sense of taste or of smell involved, and only one case in which the hearing, and three in which the touch were affected. Hallucinations in chorea are, as he states, more frequent between the ages of fourteen and twenty-four years than at other times. In very young patients they are never seen. Of forty patients examined by Marcé, eleven had hallucinations of sight. Of the very many cases of chorea which have been under my observation and treatment in hospital and private practice, thirteen only exhibited sensorial aberration unaccompanied by the manifestations of acute mania.

As Marcé has pointed out, the peculiarity of choreic hallucinations is, that they are not present during the state of wakefulness or when the eyes are open, but only appear in that period between sleeping and waking, which occurs when the patient is going to sleep or when he is about awaking. The moment he shuts his eyes in the process of going to sleep, they occur; and again they may-but not with the same degree of frequency-make their appearance just as he is about to open his eyes on awaking. Marcé had one case in which hallucinations appeared during the day whenever the patient shut his eyes.

The images are of all kinds-friends, relations, demons, angels, all kinds of deformed persons, giants, dwarfs, and every variety of animals. Sometimes when some person has been vividly brought before the mind, the image of that person appears as a hallucination, and persists for a long time.

Occasionally the hallucinations appear before there are

any convulsive movements; in other cases they occur only when the paroxysms are most intense.

Of fully developed choreic insanity, only five cases have come under my observation. Three of these are referred to in another place,' and two have occurred in my experience during the past two years. It may make its appearance at any time during the course of the disease, and sometimes, as in one of my cases, before there are any convulsive moveIn most cases, however, it does not supervene till after the tenth day. So far as my observation extends, the essential points of difference between it and the ordinary form of acute mania are the occurrence of the hallucinations only at the time of going to sleep or awaking, and the existence of a peculiar species of incoherence characterized by the utterance of isolated words, which have no relation whatever to each other. Marcé alludes to this symptom. It appears to be due to the excessive rapidity with which hallucinations, illusions, and delusions succeed each other - a rapidity which is never in my experience equalled in acute mania of the usual type.

Thus, in a young lady of seventeen, who came to me from a neighboring city, mental derangement had supervened on the sixth day after the occurrence of choreic movements. These had gone on rapidly from the very beginning, augmenting in violence every hour till they involved her head, arms, legs, and trunk. On the sixth day she became violently excited in consequence of hallucinations of sight, which effectually prevented her sleeping. The moment she closed her eyes, old men and women, with black imps, appeared to be dancing round her, and pointing their fingers at her in derision. She could hear them laugh, as they capered around her in all possible combinations of dancing figures. After a night, during which she was entirely without sleep, delusions ensued, and her maniacal disturbance was still greater. Then she began to talk, but in such a way that no one could understand what she said. It seemed, as her mother said, as though she had taken a thousand pieces of paper with words on them, and, after shaking them all together, was naming them off one by one.

On the tenth day of the attack, I saw her at her hotel in 1 "A Treatise on the Diseases of the Nervous System," seventh edition, New York, 1881, p. 732.