DR. MOORE.-I see your point, but can not answer.

DR. JOHN F. CONWAY, of Kings County.-I have frequently observed the phenomenon noted by Dr. Moore. I have been impressed by the fact, but I always attributed the exaltation of function to the diffusible stimulation of the ether; because, in those cases which I can recall, there was entire freedom from pain. On that account, I attributed the reaction of the patient to the stimulant action of the ether.

DR. W. F. GARDINER, of Kings County.-As house surgeon to Saint Mary's Hospital, in cases of operation, I have often had occasion to remark the improved condition after the administration of the ether. I have but very little doubt that the credit thereof was due to the stimulation of the medicinal agent in question.

DR. ELY VAN DE WARKER, of Onondaga County.-In reference to the question of shock, my experience comes from the peculiar chill that follows a direct impress upon the uterus, as, for instance, in the matter of an intra-uterine injection. A most acute pain is invariably followed by shock, and a shock which, to my mind, is due exclusively to the pain. You have every one of the characteristic phenomena of the shock. Now, the next after that is the chill, which, to my mind, is simply a beginning reaction, and then we encounter the high temperature, which, being an ephemeral fever of short duration, does not need any treatment.

In order to explain the phenomena, I assume that nerve action is due to movement of nervous particles, nervous atoms. We have an arrest of action as the first result of shock. A second effect is chill, and the further swing of the pendulum from that reaction is the fever. I have seen that occur very often in instances of pelvic disturbance, which we are constantly liable to explain by septic poisoning; yet this last can safely be excluded. It satisfies me that shock consists largely of a nervous element, and then, assuming an arrest of nerve movement due to the shock, the reaction follows as a natural consequence.

DR. CHARLES W. BROWN, of Chemung County.-It has occurred to my mind, in regard to the theory of the sudden fall of temperature, that it is due to the arrest of that which produces heat, namely, life; it is a partial arrest of life. The digestion and assimilation, etc., go to produce animal heat. The sudden arrest of this must produce so much depression of the tempera

ture. I do not at all subscribe to Dr. Van de Warker's theory, that shock is largely due to pain. In railroad cases I do not know of one where severe pain was complained of; especially where the injury was severe. My observation is that pain does not begin until the reaction is thoroughly established. Where there is no pain, there is no complaint, and usually no dread.

DR. F. H. HAMILTON, of New York County.-I fear that my friend Dr. Moore has misapprehended my meaning. It was only in those cases in which there were no primary evidences of shock did I assume that initiatory inflammation was not in the matter itself, but in the overlying tissues.

REPORT OF A CASE OF INSANITY FOLLOWING GUNSHOT INJURY TO THE HEAD; CEREBRAL CYST; ASPIRATION; RECOVERY.

By CARLOS F. MAODONALD, M. D., of Cayuga County.

Read November 17, 1885.

HAVING Consulted such files of leading journals and standard works on mental and nervous diseases, surgery, etc., as were readily accessible, without finding a case closely resembling the one about to be described, I do not feel wholly unwarranted in claiming your attention to its brief recital. I think you will agree with me that it is unique, on account of its intrinsic interest, and I hope, also, that it will prove a clinical contribution to the study of the localization of brain functions.

Darwin Dingman, convict, aged twenty-seven years, native of New York State, married, a farmer by occupation, and of intemperate habits, was admitted to the State Asylum for Insane Criminals, from the New York State Reformatory, on June 6, 1885, upon the certificate of Dr. H. D. Wey, physician to the Reformatory. The commitment stated that Dingman was convicted, in Delaware County, of assault in the first degree, and sentenced on February 27, 1883, to the State Reformatory for a maximum term of ten years; that on a former occasion he had been confined in jail at Cooperstown for sixty days, on a charge of intoxication; that he was addicted to liquor and tobacco, and probably to self-abuse; that he had been employed in prison as a general laborer and stonecutter; that his present bodily condition was good; that he had a depression of the external table of the frontal bone, said to have been caused by a pistol ball, three or four years ago; that so far as known he had not been insane before conviction; that at the time of his conviction he was a "crank," of unknown heredity,

but not regarded as insane; that his habits as to sleep and food were irregular; that he had been confined in a cell since the present outbreak of violence began, four days previously; that the form of his insanity was chronic mania, and that the cause was possibly a bullet wound in the frontal region.

Dr. Wey further stated that he based his opinion as to the patient's insanity upon the following grounds: "That on the morning of June 2d he was discovered in an excited state, pulse quickened, skin dry, tongue pasty and covered by a whitish fur; he refused to answer questions, stared sullenly at those who approached him, and occasionally muttered 'go away and don't tantalize me.' He resisted being examined, and it was necessary to use force to bring him out of his cell and place him where he could be studied. For the last four days he has been under my observation, and during that time he has refused to answer questions or communicate in any way. He has been emotional, and upon being talked to or chided would lose self-control and cry. His manner and actions would indicate he was suffering from a delusion which he has thus far concealed.

"For a number of weeks past his cell-mate has noticed that he has surrounded all his actions with an air of mystery, and that he has been irritable and uncertain in his temper. At work he has been quick to fly into a passion, resenting with sullenness and displeasure any directions given him as how to perform his work. Ever since his admission to the Reformatory, in March, 1883, he has, at intervals of two or three months or longer, been subject to attacks of irritability, which were regarded as outbursts of an ungoverned temper rather than as proceeding from mental disease and organic brain trouble, the result of the former injury to his head, the mark of which is to be found in the frontal region beneath the hair.

"Recalling his action and manner in the past, and connecting them with his present condition, I am inclined to believe there has been mental disturbance, varying at times in intensity, for several weeks past, or even for months."

On admission to the asylum, about 11 A. M., the patient was in a state of violent maniacal excitement, with marked bodily agitation, so much so that it was impossible to satisfactorily make the usual physical examination of the chest-organs. When spoken to

he would not reply, but would shake his head violently, strike the top of his head with his hands, and thrusting his fingers into his hair would frantically pull it as if to relieve himself from the great distress which he evidently suffered. He was immediately sent to the ward, given a warm bath, placed in bed, and kept under special observation for the purpose of determining his exact condition uninfluenced by drugs. At noon he refused food, the sight of it seemed to excite an exacerbation of the violence, as also did any attempt to examine his head. His face presented a livid, dusky hue, and his hands were cold and clammy; pulse, 116 and quite feeble; temperature, 100°; respiration, 40; pupils dilated, tongue milky in appearance, broad, flabby, and edges indented by teeth. So far as could be determined by careful examination, there was no paralysis, anæsthesia, or disturbance of the special senses.

An examination of the head revealed a nearly circular depression of the skull, about half an inch in diameter and about a fourth of an inch deep at the center, and corresponding to which, in the scalp, was the point of crossing of a crucial scar. The skull lesion was located, as nearly as could be determined by external measurement, over the right first frontal gyrus, at a point corresponding to the junction of its anterior and middle third, being about one inch and three eighths from the margin of the hairy scalp, and about three eighths of an inch to the right of the median line. The least pressure upon the point of depression seemed to produce intense pain, and would throw him into violent bodily agitation. During the afternoon he remained substantially in the same condition as above described; at 6 P. M. he again refused solid food, but took, voluntarily, a pint of egg-nog, containing mag. sulph. one half ounce, and potass. bromid. grains 40. He continued restless and sleepless throughout the night, drinking water with avidity several times; also had one movement of the bowels, and passed a moderate quantity of urine, which had a specific gravity of 1035, but contained neither casts, albumen, nor sugar. On the following morning he seemed worse, shaking his head and striking it violently with his hands, or upon the floor; and wildly clutching his hair with his fingers; requiring the constant presence of an attendant to prevent him from inflicting self-injury. About 7 A. M. he drank a cup of coffee and some water, but refused to eat or speak, and frequently smacked his lips and moaned. His pupils