after admission into the asylum; and I have re

tables.

BY J. WORKMAN, M.D., PRESIDENT

Continued.

I

I have examined carefully over 130 reports of U. States and Canadian asylums for the last 3 years. In more than one-half this number I have found that paresis is either totally unmentioned. or but very exceptionally noted in the obituary I believe it is a recognized fact that in the Southern, and the farthest Western States, the disease is unknown; or at least it has been unnoticed. A year or two ago a very intelligent superintendent of a Southern asylum stated at the annual meeting that he had never met with a case of paresis in his institution, and several others made similar statements. To an English superintendent, who numbers his paretics by the score, and shows a paretic death proportion of 1 in 3, or 4, this fact could not fail to appear marvellous; but even in Philadelphia, only 18 years ago, I was shown in the Insane department of Blocksley Alms House, which then lodged over 1,000 pauper lunatics, one case of reputed paresis-the only one said to be in the house ;—and it was not one at all-or at all events it was not like any I had seen: for the only symptom adduced in support of the diagnosis, was one I had never met with in the Tor nto Asylum-and that was, intense and constant pain in the head. Never yet have I met with a Paretic who would say he had pain in the head, nor indeed, in the vast majority, any pain, whatever, in any part. I do not say that this exemption from head-pain is an invariable fact, in the earliest st ge of this disease: it has, however, as far as I can recall, been the rule in all cases

of the disease.

As illustrative of the great disparity between the numbers of male and female paretics, in the largest city in America, I present the following figures from the reports for 1876 and 1877, of two large asylums, representing the lower classes of the insane of the city of New York.

Ward's Island, 1876,-male asylum 44 deaths of Paretics, in a total of 131 deaths, or 1 in 3; 1877, do. 55, in a total of 126, or 7 in 16.

1876, Blackwell's Island-Female Asylum, 2 deaths, in a total of 97, or 1 in 481⁄2; 1877, do. 2 deaths, in a total of 98, or 1 in 49.

These figures astonish even me, for in the first place the New York city male mortality from paresis, comes fully up to the highest English paretic rate, and in the next place, the female rate is far below that of either the English asylums, or any others from which I have had reports showing the comparative mortality of male and female paretics. But the reports of the Ward's Island asylum are from the pen of our talented fellow-countryman, Dr. A. E. MacDonald, whose veracity and correctness of diagnosis, I regard as thoroughly reliable. I do not venture to say so much for the other reports, as I am not personally acquainted with the author. I am disposed to believe that the female returns of Blackwell's Island asylum are quite erroneous, and that the under-rating has arisen from the dis-similarity of the mental symptoms in the two sexes. I also believe that the paresis of females is of much longer average duration than that of males, and may therefore be ranked as mere dementia. Why a New York city asylum should show a lower proportion than an English asylum, I fail to understand.

In striking contrast with the preceding reports, is that for the year 1876, of a third New York city asylum at Flatbush, where, in a total under treatment, in the year, of 1080, (459 males and 621 females), only 4 deaths from paresis are given in a total of 62 deaths. Distinction of sex is not given. I must observe, however, that 7 deaths are ascribed to apoplexy, 7 to exhaustion of chronic mania, and 3 to mollitics cerebri. I question if two-thirds of these were not paresis.

I find from the records of the New York State Lunatic Asylum at Utica, which are perfectly

3

reliable, that in 29 years, from 1849 to 1877, inclusive, 267 deaths resulted from paresis, of which 250 were of men, and only 17 of women, being in the proportion of nearly 16 men to 1 woman.

I need not trespass on your patience with any further citation of figures, illustrative of the fact that paresis is paramountly a disease of the male sex; nor need I press upon your attention the concomitant fact, that an asylum, lodging any consider able number of these cases, must exhibit a higher death rate than others containing none, or only a a few such cases. Figures are of little value dissociated from the facts from which they are derived. From a recent inspection of my friend, Dr. Clark's resident paretics, I venture to predict that his future death tables will show higher figures than did that of last year, when he had only 4 from paresis whereas in 1874, I had 14. It would be very gratifying to find that decrease in the supply of new cases has begun to take place, but since this paper was written, Dr. Clark has had 3 deaths of paretics.

It is now time that I should offer a few ob ervations on the leading characteristic symytoms of this formidable disease.. Although very ample, if not indeed confusingly prolix, details are presented in all our late writers on insanity, it is a fact of which you all are cognizant, that to the general practitioner of medicine, opportunities of observing paresis in the living subject are of comparatively rare occurrence. The 40 counties of Ontario do not average one case each, annually, or, at least, they do not contribute this quota to our 4 asylums. I believe the total number admitted into the Kingston asylum, since its opening 23 years ago, would not exceed a dozen. The number admitted at London has not been great. The Hamilton Asylum has received none. Toronto has come in for the lion's share, and it has had to bear the bulk of the opprobrium of failure to cure, and of consequent augmented mortality. Now, taking the entire number of medical practitioners in our Province at 1500, and putting the number of annually occurring cases at 30, we have one case presented for every 50 practitioners; but considering that the majority of cases are furnished by the cities and larger towns, it may not be an exaggeration to say, that very many physicians in the rural districts may pass their whole lives without meeting with a single case; and coming down nearer home,

and supposing that our own city sends into the asylum one-fifth or one-sixth of all the cases of insanity admitted, and that it sends in a like propor. tion of paretics, we should have, yearly, for the 100 doctors of Toronto, 2, or at most, 3 paretics for observance, which in the course of 40 years, would come to about one case for every doctor. But then, bearing in mind that doctors emancipate themselves from these cases with all becoming, or possible celerity, it must be evident, that unless they follow up their coses by frequent visitation, in the asylum, (which, I am very sorry to confess, they too seldom do), they deny themselves the advantage of valuable clinical observation. very sure that my worthy successor would derive no less gratification from such visits by his professional brethren, than I did, or perhaps, I may more truly say, than I would have done.

Writers on insanity have generally assigned to the disease three different stages, but here, just as in many other morbid progressions, it is found that we cannot draw any clear line of demarcation between the stages; for they sometimes run into each other under such interchanging shadings, as to render their identification very difficult. We may this week find a paretic in such a condition of both body and mind, as to tempt us to the conclusion that his case is far advanced in the second stage, and yet in the succeeding week, he may have, apparently, retrograded, and may present only the symptoms of the first stage, and even these only in a moderate degree.

It has been usual to speak of the first stage as that of incubation; of the second, as that of full development, or pronounced maniacal disorder; and of the third as that of established dementia, with unequivocal subversion of both bodily and mental competency.

Now, as to the first stage. It is my belief that nothing can be more difficult than the fixing of its inception. It is true, indeed, that when once the destined paretic has begun to exhibit palpable extravagancies of thought or conduct, and to appear under a totally transformed character, few of his more reflecting, intimate acquaintances can fail to see that reason no longer holds her sway, and that the dire alternative of substituting extrinsic control for frenzied anarchy, must soon be submitted to by his weeping friends.

It has been questioned by some writers, whether