still good, but the power of deglutition is weak; he fills his mouth without swallowing, and the food gets imparted in the esophagus so as to compress the larynx, or else it gets into the latter and trachea, and chokes the unfortunate patient, who should never be allowed to eat alone.

A poor lunatic, in the last stage of the disease, was kept alive at Hanwell for thirteen months, on one of Mr. Arnott's admirable water beds, and without bed sores, which fact eulogizes the charity and care of his attendants. He was worn to a mere skeleton, but expressed himself by signs well and happy.

The special senses are not usually affected till toward the end; one patient had a glorious vision, and saw angels descending from heaven on ladders of gold, while another had an agonizing vision of his own wife, in the act of adultery.

It is an important fact in this disease, that mental and motor disorder are always coexistent.

In the last stage of the disease large sloughing bed sores form, in spite of the best care; and pneumonia and diarrhoea hasten the long ending disease. There is now, previously to the fatal conclusion, utter prostration of mind and body. The loss of memory is a frequent symptom. I have also noticed a tremulous motion of the lips, like a person about to break out in passionate weeping.

Dr. Nasse, of Siegburg, says, that out of 108 cases examined by him, in only three were no irregularity of the pupils, and which observation I consider important and pathognomonic, viz.: contraction of the pupils to pin points, succeeded by irregularity.

The ratio of liability to the general paralysis of the insane is, according to Dr. Sankey:

1 male lower class to 2 males higher class.

3 females lower class to 4 females higher class.

M. Calmeil says, the males are to females as 50 to 15.

The disease attacks generally men between 35 and 60, after which age it is very rare.

The causes seem to me to be the same as for other forms of mental disease. I am inclined to lay stress on sexual excess, marital or otherwise, as general paralysis is very frequently met with in cases of men, not very young, married to young wives.

Paralysis caused by alcoholism is not unlike general paralysis, but a difference lies in the distinct articulation in the former.

Treatment. This disease may well be placed among those styled opprobria medicorum; and still much may be done in the early stages. General paralysis of the insane, I am of opinion, is a disease of nutrition, good hygiene with good food, and not including the stimulus of brandy, which latter I consider most injurious. In the early stages, tincture of digitalis may be administered with benefit, in doses of ten to fifteen minims, in conjunction with morphia and opium. When epileptiform seizures occur, the bromide of potassium has been found useful, in doses of ten to twenty grains. The bichloride of mercury, in minute doses, I believe to be decidedly injurious; and although recommended by authorities on the subject, I have seen it fail in Dr. Conolly's experienced hands, he having prescribed it at the suggestion of the former authorities; the patient passes rapidly from the second to the third stages; from maniacal excitement to utter mental and physical prostration, and which the good and learned doctor attributed to the bichloride, and at which he was greatly distressed at prescribing, trusting to the experience of others. A strong solution of sulphate of zinc is a good application to bed sores.

Post Mortem.-In twelve brains examined at Hanwell, seven were softened, five were hardened; and softening or hardening of the brain seems to be unassociated with any modification of the patient's age or disorder.

In the seven cases where the brain was more or less softened, the age of the patients and the duration of the malady were as follows:

In the five cases where there was induration of the brain, the

ages of the patients and duration of the malady, were:

Life can be prolonged by great care still further, as exemplified in the case of a baronet, a man of great wealth, who was pronounced insane by a commission of lunacy, in 1854, and afflicted by general paralysis; he is still alive.

Dr. L. Meyer believes general paralysis to be chronic meningitis ; while M. Calmeil, who did so much for the accurate description of the disease, considers it an inflammation of the cortical portion of the brain, and quite lately Dr. Mershede has held the same opinion. Changes in the blood vessels of the cortical portion have been found, with degeneration of the white matter and atrophy of the nerve tubes. Drs. Joffe, Boyd and Westphal have called attention to the diseased condition of the spinal chord, and of the posterior columns only throughout their length, with atrophy of nerve tissue. Dr. Westphal considers the disease chronic myelitis.

Is general paralysis a distinct disease? The French say "Yes," the Germans, "No." A paraplegic affection of ten or twelve years' standing has been noticed before the mind becoming affected.

I shall conclude with some interesting remarks by Drs. Poincaré and Henry Bonnet, to be found in the "Annales Medico-Psychologiques," tome xii., 1868, to the effect that in general paralysis of the insane the cells of the whole chain of the sympathetic is covered with a brown pigment; and, although this is noticed also in other forms of mental disease, it is not so constant and less marked in the latter, and there is, besides, in general paralysis, a substitution of cellular tissue and adipose cells for the nerve cells. in the cervical and thoracic ganglia.

Although these researches would seem to be in the proper direction, and most interesting with regard to throwing light on a still obscure disease, it is the opinion of the writer of this essay that the actual pathological conditions have not yet been found.

London, December, 1879.

SOME THOUGHTS ON THE GENERAL DUTIES AND QUALIFICATIONS OF THE GYNECOLOGIST.

BY H. G. NEWTON, M. D.

I.

No nerve specialist, in any department of medicine, can ever attain to that high degree of excellence to which the noblest minds in the profession aspire, for reasons which will be apparent when we examine the subject matter involved in this proposition.

As in ethics, no one can be accounted a perfectly good person who only abstains from some overt crime, such as murder, theft, adultery or slander, while neglecting many of the more weighty matters of the law-justice, judgment, mercy and charity. So, in medical science, the ideal practitioner is the one alone who possesses that versatility of talent, and makes that indefatigable effort, which impels him not to neglect anything that will be of any advantage in the case entrusted to his care.

Never should there be occasion for the vanishing shade of some suffering or departed fellow being to gaze reproachfully at night, on his sleepless couch, with a sad countenance, that would almost seem to say, "One thing thou lackest." It should be a matter of professional conscience, not that we should seek to be able to do the best that can be done for the patient on our part, but that we should firmly insist that the best should be done that can be done on the part of the patient and his or her friends.

How much is involved in these two points! They open the gate to a pathway, rugged and steep, over many a mountain and through many a dark labyrinth, but not, at the same time, destitute of beauty and attraction; while even its most obscure passages are illumined by the bright scintillations of those medical stars who have toiled on before, and none the less by that of those who are comrades in the march.

In this, and perhaps in some subsequent papers, I propose to indicate some of the points in which many of us come short of the requisite and desirable qualifications and conditions, which would so greatly conduce to our usefulness, as specialists, in the department of gynecology.

II.

One is a disposition to ignore the causes which have induced, or may still be producing or aggravating, a morbid condition, or rather a supineness, which leads to a laxity of effort in the vigilant search for the many influences which have brought about the variation from a normal condition. This is a point which it is very important not to neglect, however hard it may be to make the desired discovery. Many of the causes of disease, so infinite in variety, do not appear at first glance, are not apparent to the superficial observer. Even a diligent search by the medical detective may, for a very long time, reveal "nothing but clues." But so very important is the etiology of disease, that no practice can be other than empirical without a tolerably full knowledge of all herein involved.

In other language, where this is ignored or neglected, we are experimenting on each patient, which we have no right to do. It is not doing as we should wish to be done by. One of the greatest blunders which I have ever known, and which resulted in the death of a very estimable young lady, and created a profound sensation in the whole community, was in consequence of an attempt to perform an operation on the uterus, without first ascertaining the cause of the dysmenorrhoe which the operation was intended to

cure.

I hope that no one whom I now address will ever attempt to perform Sims' operation, without first, by introducing the sound, satisfying himself of the small calibre of the uterine neck, and thus have some reason to believe that the cause of the excruciating pain may thereby be removed.

I not long since learned from a young lady, who had been afflicted for some years with congestion, ulceration and displacement of the uterus, and, like one of old, "had suffered many things from many physicians," only to find herself growing no better, and becoming greatly depressed in spirits, that neither of the eminent practitioners who had attended her could assign any cause for the existence of such a morbid condition in so chaste a young person. When I pointed out that the cause was undoubtedly the wearing of corsets and other criminal manner of dress, she seemed surprised, and asked, "Do you suppose that dressing in a manner common to