this girl, however, and it is my experience that in active motor hysteria hypnotism is more difficult to effect than in the hysterical anesthetic cases. An anemic boy with habit chorea of the shoulders, head and face, was cured on three distinct occasions in a month to six weeks. Immediately he began his inordinate cigarette smoking the choreoform movements appeared. This case teaches the lesson, that excess of tobacco may excite inco-ordinate movements in the susceptible, and in my experience nervons patients bear tobacco illy. The Epilepsy. In conjunction with Dr. Wharton Sinkler we have reported† long remissions and one or two apparent cures of this terrible disease. following cases not recorded there are worthy of note: M. P., Italian, aet. 33, had from ten to twenty attacks of petitmal daily. Was first seen November, 1896. He was put on sodii bromidi gr. x, t. d., and iost sight of. A report from him recently shows that he continued the medicine for a year, and for the past six months has had no attacks. A girl, aet. 20, having had infrequent (one in two months) attacks of grandunal for two years, has now stopped six months, while a boy, aet. 7, with weekly attacks for one year, has had no evidence of any epilepsy since circumcision for a tight phymosis, four months ago. General Neuritis.-A case of multiple neuritis simulating Landry's paralysis, etc., in a man aet. 59 years, just escaped death at the time, and from a total paralysis, by the use of massage, electricity and movements is able to walk about, although he has little use of finer finger movements. The instance of a multiple neuritis following an infected vaccination escar in a girl aet. 16, seen in 1896, is today entirely recovered by persistence in the above outline. Post-diphtheria and alcoholic neurites while the most common varieties of multiple neurites, are yet the better singularly in prognosis. The apparently idiopathic cases, as in the man's case mentioned, are severer and less apt to recover. Lead palsy also recovers easily. Local Neuritis.-As a trauma may produce this, the prognosis is good in most cases if the wound has not been a needle prick or other jagged injury to nerve terminations. In the latter an ascending neuritis is very apt to develop and persist in spite of rest, counter-irritation, etc. Where the nerve is completely severed by a clean cut at its trunk, results of suture are excellent. I reported three such cases in Medicine for August, 1897. Compression of nerves and right arm monoplegia is shown in a total motor and sensory paralysis of the right forearm of a lad 15 years of age, who had the arm mashed in a roller in a mill, fracturing the humerus, radius and ulna. This was one and one-half years ago, Dr. C. H. Frazer, by operation, relieved callous pressure, and by persistent massage and electricity, on October 30th motion was fast recovering. Exophthalmi Goitre.-Grave's disease is not of the bad prognosis often assumed if taken in time. Two cases occurring incipiently in growing girls, were stayed by cutting down the school hook, and especially the climbing +"A Study in Epilepsy," Pennsylvania Medical Journal, September, 1897. +Journal of Nervous and Mental Diseases, March, 1894. of stairs at a high school in one instance, and a private boarding seminary in the other instance. The use of tr. strophanthus in small doses occasionally, care as to quietude at the menstrual epochs, have been measures looked to in these two cases. R. G., female, aet. 20, a bad case of exophthalmi goitre, with all the typical cardinal symptoms, and who had been under prolonged treatment, the use of thyroid extract being among the drugs used, has been greatly benefited by the use of galvanism to the cervical sympathetic and to the apex of the heart, thus slowing the cardiac beat perceptibly by stimulation of the vagi nerves, the negative pole being placed below. This treatment was begun a yoar ago, and kept up from once to twice a week, From chronic invalidism the girl is now able to work as a clerk in a store, and has gained fifteen pounds in weight. Anemic Neurasthenia is a recurrent condition, generally occurring in young girls of the working class. These cases recover after thorough hygienic instruction, a restriction of sweets, a milk diet largely, a stomachic tonic and carbonate or lactate of iron. R. Z., aet. 17 years, first came under our care in December, 1895, with secondary neurasthenia, and a blood count of 3,200,000 s. 1. c. and H. 35 per cent. She has recovered four separate times and to full blood value, and with better family living promises now to be well. Another case, seen October 13, 1896, of a seamstress, aet. 24 years, had developed a most persistent simple anemia, changing her habitat to girlhood farm life has made her well in six months, in which time the blood count went from r. b. c. 3,500,000 and H. 24 per cent to normal; and also gained twelve pounds. On March 25, 1897, she was in good health. This man also had a transient glysonuria, which was perplexing. A case of cardiac neurasthenia simulating petitmal in a traveling man, seen July 8, 1898, is now well under tonics and change of scene. Many more cases of essential neurasthenia recover from by proper "rest" and "semi-rest" treatment. Where it is not a terminal case, and is slow in response to treatment, or if symptoms point, of course have a gynecological examination and treatment, if a palpable genital lesion is found. In this way only can we hope for surer results and less patchwork in neurasthenia. Be careful to exclude the "born fools" from neurasthenic category. A case of melancholia, seen May 7, 1897, presented a bad one to deal with. After a "rest" treatment of six weeks, Dr. B. C. Hirst repaired the pelvic floor, cervix and did Alexander's operation for retroverted uterus. This woman had had local uterine treatment for years to no avail. The combined neural and surgical treatment has effected a cure in this case. Mental Disease require a good deal of experience in before one learns to find the "something" that leads to safe prognosis. Hebephremia, or insanity of adolescence, is bad in proportion as heredity is a factor. Look careful to the emunctories in the treatment of mental depression. Thyroid See Neurasthenia; Its Co-relation to the Physiology and Pathology of the Female Generative Organs."— with H. D. Breyea, M. D., Memphis Lancet, September, 1898. extract may aid metabolism. Most cases of simple melancholia have 75 per cent chance of recovery, especially if an asthenic system coexists and no organic disease is found. The exhaustive stuporous melancholias, resultant from terminal neurasthenias, as in L. McC., female, aet. 28, who is such a one now in "Kirkbrides," and seems hopeless. She has constantly to be fed, and yet withal will occasionally smile at a careful questioner. The mental habit in such a case must sooner or later establish degeneration. A case of starvation and religious mania in Mrs. G. D., aet. 33, was committed to Norristown Asylum, April 30, 1898, and removed July 8, 1898, cured of her violent insanity and bodily health was restored. High culture and insanity are the worse cases. This is illustrated in the case of apparently mild delusional insanity in a girl aet. 24, who speaks five languages fluently, but is not improving. Many more useful illustrations of "prognosis of the case" might be cited, but the above abbreviated examples may give you some practical ideas so much desired in our first cases. Discussion of the paper will be desired by the writer, in order that all may amplify more the points presented. Especially, too, is it desired to counteract the tendency of doctors and lay persons of prognosing nervous maladies with but little accuracy. With the better expression of Vierhordt in the fourth edition of " Medical Diagnosis," the writer wishes to emphasize, that "science has not revealed in any organ of the human body any anatomical structure so fine and complicated as exists in the different parts of the nervous system. No where else can be found tissues which differ so entirely and which are so clearly distinguishable clinically as here." To the purely scientific, satisfaction of making a correct diagnosis, in many cases, add the most important practical element, the discovery of means to cure. For although hitherto some of the diseases of the nervous system, have been little accessible to treatment, nevertheless there are many in which exerything-life, ability to earn a living, and a general well-being of the patient-depends upon correct treatment. We must learn to recognize with a clear vision those offering favorable prognosis under satisfactory methods adopted. With one of our guild, Holmes, we say, "How blest is he who knows no meaner strife له F. Savary Peane M. LO 1407 Locust street. G The Causes of Insanity. BY PHILIP ZENNER, A. M., M. D., CINCINNATI, Lecturer on Diseases of the Nervous System in the Medical College of Ohio. Read before the Miami Valley Medical Society, November 1st, 1898. ENTLEMEN: The subject upon which I have been asked to read today is, indeed, an old one, but yet so important that it may not be without profit to present it for your consideration. Insanity is supposed to be, essentially, a disease of civilization. To what extent it has occurred, and occurs, among primitive peoples cannot be determined with any accuracy; certainly far less than with us. Statistics seem to prove its rapid increase in our own day. But such observations are largely delusive, for they are based chiefly on the number of inmates in public and private asylums, and this increase in number is due to the multiplication of asylums, the greater readiness to resort to the same-which brings many insane out of hiding-and the prolongation of life through better treatment, which increases the number of old people, and, thereby, the sum total of the insane. It is still possible, as is generally believed, that there is an actual increase in insanity, for some great causes seem to be acquiring a greater influence; for instance, cities grow more rapidly, factory life becomes more prevalent, the struggle for life is getting fiercer, syphilis more widespread, etc. There is no doubt that some mental disorders, notably paresis, have increased within recent years. At the same time there is a growth of other influences that tend to lessen disease; improved hygiene, better food, clothing, dwellings, etc.; also greater security, as well as the feeling of security, as regards epidemics, war, famine and the like. Insanity is found at all periods of life. To a certain extent the etiology is characteristic of the period. The mental disease of childhood is rather that of mental arrest, varying from slight imbecility to profound idiocy. Its basis is usually structural disease from inherited or other congenital conditions, or the accidents or diseases of birth and infancy. The insanity of puberty and the climacterium occurs mostly in predisposed subjects, that predisposition being most commonly an hereditary taint. The mental disorders of old age, like those of childhood, have usually a structural basis; in this instance disease of blood vessels, or changes in the brain. In adult life, the age most prone to mental disease, the latter is chiefly due to extrinsic conditions, alcohol, syphilis, and the excesses and trials of life. Both sexes are about equally attacked, though there is some difference as to the most effective causes in each. The changes of puberty and the climacterium are more frequently disastrous to the female than the male. The former has also to contend with pregnancy, parturition, and lactation, as well as, ofttimes, a life with little aim and purpose. In the male we find more commonly alcohol, tobacco, syphilis, sexual excesses and abuses, while he must usually bear the brunt of the struggle for existence. Heredity. When we come to special causes, we must place at the head of the list heredity. It is so difficult to elicit facts as regards hereditary taint, on account of the desire to conceal them, or ignorance, on the part of the family or patient, that there have been great discrepancies in statistics on the subject, The proportion of the insane who have an hereditary taint has been estimated all the way from 10 to 20 per cent. We will probably not go far amiss if we put it between 30 and 40 per cent. The disease may appear in the same form in parent and offspring; in fact the resemblance may be so great that even the same ideas and delusions reappear. A striking instance of this order is the frequent occurrence of suicide in a family, the separate acts often at a distance in time and space, and apparently independent of each other. More frequently the disease is not unlike in different generations. For instance, epilepsy in the parent is followed by brain disease in another form in the offspring. In the same way different forms of insanity, alcoholism, epilepsy and other nervous diseases, tuberculosis, etc., become related to one another. Morel formulated a law of progressive degeneracy, according to which light nervous or mental troubles in the first generation are followed by gradually more profound mental disease in the second and third generations, and, finally, by idiocy and stérility in the fourth. But such a typical history is rarely found. Usually there are changes for better or worse from one generation to another, according to an admixture of healthy blood or other favorable conditions come in on the one hand, or alcohol, crime, or other unfavorable conditions come in on the other. The manner of transmission of disease varies also. The hereditary taint may consist of actual disease, or merely a predisposition to it. In the first instance structural changes may or may not be detected. But there is, at least, some pathological state of the nervous system, manifested from infancy by peculiarities of character and the like. Such a condition is usually the foundation of certain forms of insanity, notably paranoia and moral insanity. The predisposition to disease probably consists of an inherent weakness in the organism, a lessened power of resistance, which renders it a prey to disease where a normal nervous system would escape. Doubtless many individuals with such heredity pass through life unscarred, because they have never been subjected to specially injurious influences. Again, this class is often attacked by mental disease at puberty, the climacterium, in childbed, after infectious and other diseases, and succumb the more easily in mature years to alcohol, syphilis, psychic disturbances, excesses, etc. The likelihood of transmission of disease is greater if both, than if only one, parent is affected, and greater when the disease occurs in the parent, than when only found in more distant ancestry. The likelihood of transmission depends also, on how deeply rooted is the disease in the parent's system. An acute attack of mania or melancholia in an otherwise normal |