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relation with a normal current of thought may resemble the erratic workings of disease, but there is no closer connection. An act is not to be judged of by itself, but its relations to the whole mind must be considered. In health connection can nearly always be traced between trains of thought and action, while in insanity the current is often broken, and processes arise and cease separately. The erroneous popular statement just mentioned may depend partly on a failure to define insanity properly and consider its nature. Most definitions given, indeed, do not make it clear, as they are descriptive or "accidental " definitions. An essential definition separates a phrase from all others, and limits its signification. Insanity is, primarily, unhealthiness ; secondarily, unhealthy mental action ; and by still further limitation, unhealthy mental action dependent on disease or imperfection of the brain. As we have no other word for it, insanity also means the disease itself, on which the manifestations depend. Much confusion arises from speaking of the functions of the brain as entities, or, not much better, as forces. It is only by a figure of speech that this is done. Instead of alluding to the mind, the intellect, the emotions, the memory, the will, etc., we ought to say that mental action, or cerebration, consists of perception, intellection, emotion, and resulting volition, with consciousness behind or above all. Perception commonly precedes emotion and intellection, but not always. Volition is not carried on alone, but with other functions, and hence there is no insanity of the will alone. Insanity is usually first shown in disordered perception and emotion, and intellection is interfered with later. The bad feeling and altered temper precede delusion and disorder of thought. The continuance and the degree of the alteration of these functions produced by disease are essentially different from the deviations observed in health, which are slight and transitory, and there is no common ground between them. – DR. FISHER said that this was a very large subject, and should be interesting. Many of the controversies between lawyers and experts on this subject would be done away with if it were not for the death penalty. In the cases read by Dr. Folsom most of the individuals were clearly irresponsible. It has often been said that as patients are amenable to discipline in asylums they should therefore be responsible to the laws, but such is not really the case, as the asylum exercises a sort of parental discipline, and does not hold patients fully responsible for their acts. The relation of epilepsy to insanity is well known, and yet epileptics and general paralytics are still occasionally sent to prison for acts of violence or theft, and imbecile boys to the reform school. But there is in these cases a chance to redress this wrong by appeal to the proper authority. Dr. Fisher stated that he was frequently called to examine persons guilty of homicide where insanity was alleged or suspected, in whom he found a susceptible state of the brain due to a blow on the head at some former period. Most of these had been under the influence of liquor at the time of the homicide, though not strictly insane, and not excusable on account of intoxication. Such patients are certainly irresponsible at the time. It is customary in some such cases for the court to allow a plea of murder in the second degree, and they are sent to state-prison for life. As a severe blow often produces epilepsy in after years, so a slight blow may produce an explosive or unstable condition of the brain, which shows itself in undue excitability and acts of violence.
JUNE 3, 1878. Post-Mortem Diagnosis of Certain Forms of Asphyxia. — DR. F. W. DRAPER read a paper on this subject, which will be published in full.
Small Ovarian Cyst mistaken for Fibroid. – DR. W. H. Baker related a case where a small adherent ovarian cyst was mistaken for fibroid. - Dr. E. G. CUTLER read the following account of the autopsy: On opening the abdomen there was found to be a limited adhesive peritonitis of recent date, involving the peritoneum from just below the umbilicus, the intestines and omentum being tied together quite firmly. There was found to have been old pelvic peritonitis and cellulitis, which bound the uterus, rectum, sigmoid flexure, and ascending colon, also the broad ligament of the left side, into a compact and immovable mass. The left ovary appeared normal. The left Fallopian tube, impervious at the uterus, was dilated to the size of three fingers, and filled with a thin, purulent fluid. It communicated with the sigmoid flexure by an opening about the size of the end of the thumb. Its inner surface was in a state of ulceration. The descending colon, sigmoid flexure, and rectum were filled with a thin, purulent fluid of a very bad odor. The mucous membrane was in a state of extreme ulceration, in some places reaching nearly to the submucous tissue. The right ovary was transformed into a closed sac the size of two fists. It was in immediate apposition to the uterus, and so placed that while in the pelvis it surrounded the latter posteriorly and laterally. The walls were thin and the inner surface presented several small calcareous plates and three or four ulcerating surfaces. The right Fallopian tube, also impervious at the uterus, was likewise dilated, and opened into the right ovarian sac. It was rather more dilated than its fellow. The sac and the tube contained a milky fluid, in which floated plates of cholesterine and granular fat, together with old and fresh pus. The old adhesions were so dense as to give the idea of a solid body, in palpating the right side, until somewhat loosened by incisions. The uterus was of normal length and appearance, except at the cervix, where its mucous membrane was injected aud discolored to just within the inter
HARRISON ON URINARY DISORDERS. The author of this volume, having the position of surgeon to the Liverpool Royal Infirmary, has enjoyed unusual opportunities of observing the surgical disorders of the genito-urinary system. At the same time be is by no means inattentive to contemporary medical literature, as is shown by his knowledge of the most recent American contributions to urinary surgery. His book is consequently interesting and instructive. The lectures are clear and concise in style, dealing with their subject matter in the plain, sensible, unpretentious manner which seems characteristic of English medical literature. In them we find no trace of the dogmatic, over-confident,“ swaggering ” tone which has seemed of late to be becoming somewhat the fashion in clinical teaching in this country. A certain modesty in the expression of individual opinion, of which the high
i Clinical Lectures on Stricture of the Urethra and other Disorders of the Urinary Organs. By REGINALD HARRISON. London: J. & A. Churchill. 1878. Pp. 193. Illastrated with Wood-Cuts and Lithographic Plates.
est and most praiseworthy example is to be found in the writings of Sir James Paget, is noticeable in Mr. Harrison's book, and serves, we think, to strengthen rather than to weaken the impression made upon the reader.
Mr. Harrison's views on stricture of the urethra seem somewhat in advance of the opinions generally held in Europe. He is not one of those who think that the recognition and the treatment of stricture, as such, must be postponed until the stage of narrow or confirmed stricture, with manifest obstruction to the passage of urine, has been reached. He fully recognizes the significance of gleet as a sign of incipient contraction. “A gleet,” he says, “is to be regarded as indicative of the early formation of stricture. Nay, further, you will not do wrongly in regarding a gleet as the stage in the strictureforming process when, by your treatment, you can promise your patient to restore his urethra to its normal condition. When a stricture is once allowed to become cicatricial in its character you may palliate or adapt, but you can no more restore his urethra than you can by dissection or any other process remove a scar from his skin. You may moderate the inconveniences of a scar, but you cannot obliterate it. Let not, then, the curable stage of stricture pass by; at all events, let the onus of doing so rest with your patient, and not with yourself.” Elsewhere, speaking of the symptoms of stricture, he says: " The only outward sign may be a continuous, though slight, muco-purulent discharge. Such a discharge is usually most obvious in the morning, and is often sufficient to glue together the lips of the urethral orifice.”
With regard to the management of tight strictures, Mr. Harrison very wisely cautions his readers against the dangers attending the use of small-sized metallic instruments. He mentions a specimen which had come into his possession, showing that “in the hands of an experienced operator a number one metallic bougie had been made to leave the urethra in front of a hard stricture and to reënter it behind the stricture.” False passages not uncommonly result from the use of fine probe-pointed metallic instruments. We believe such to be dangerous, even in the most skillful hands. They are, moreover unnecessary, since flexible capillary bougies can always take their place with advantage.
Mr. Harrison is not averse to internal urethrotomy, and has himself invented an instrument for the performance of the operation. His urethrotome is provided with a slender, metallic, probe-like extremity "sufficiently small to pass into the narrowest strictures,” which has to be insinuated through and beyond the stricture before the cutting part of the instrument comes into play. When the advance of such an instrument is arrested, it must often be difficult to ascertain whether the obstacle is due to the grasp of the stricture around the bulkier, cutting portion of the instrument, or to the penetration of the probe-like point into the urethral wall. It seems to us to be a much safer and more efficacious plan to use as the avant coureur of the metallic shaft either the flexible conducting bougie of the French surgeons, or the long whalebone guide of Van Buren and Gouley. In cases of traumatic rupture of the urethra, Mr. Harrison advocates the performance of perineal section. In this he is at one with Professor Guyon, who advises an immediate resort to that operation in all such cases, even if a catheter can be introduced into the bladder.
With regard to the recognition of prostatic hypertrophy, Mr. Harrison very rightly lays stress chiefly upon the results of catheterism, saying nothing of the rectal examination. It is too little understood that the whole importance of this disorder lies in the disturbance of function which it entails. Unless interfering with the evacuation of the bladder, a large prostate causes no inconvenience and needs no treatment. We cannot quite accept, Mr. Harrison's explanation of the impediment to micturition which exists in cases of enlarged prostate, namely, “ that the outlet is above the water-level.” It is obvious that there can be no water-level in the bladder, unless air be contained in it as well as urine. The obstruction is due to the formation of a prostatic outgrowth, which occludes the outlet, acting either as a membranous valve or as a ball-valve. By means of this agency the urethra is plugged, in some cases permanently, in others only until the bladder becomes sufficiently distended to cause the lips of the outlet to be drawn apart.
Among the novelties noticeable in Mr. Harrison's book we find the description of pessary catheter” for the introduction of medicated cocoa-butter pessaries, or suppositories, within the bladder. The instrument seems well adapted to its purpose, and its use has, in its inventor's hands, been attended with happy results. “A grain of morphia,” he says, “ introduced into the bladder in this way and repeated twice in the twenty-four hours has, in several instances, completely and permanently relieved the most distressing symptoms of irritation.”
On the whole, Mr. Harrison's book will be found decidedly interesting to the American reader, though the branch of practice of which he treats is one in which American surgery is now taking rather a leading position.
THE STUDY OF HUMAN TESTIMONY, CONSIDERED WITH
REFERENCE TO “ METALLO-THERAPEUTICS.” 1 It is with much pleasure that we have read a series of papers by Dr. G. M. Beard, of New York, 2 bearing on the above-indicated and kindred subjects. It is time that thinking men should understand, not only in general, but in as strict detail as is possible, what are the principles according to which we should analyze and criticise the popular and scientific delusions which in one form or another are brought almost daily to our notice. It is not enough to adopt the attitude of “ skepticism," nor that of so-called “ fairness," nor even the “scientific” attitude, if by "scientific” we mean that which is determined by the study of the hitherto accredited sciences alone. For there is in almost every problem concerning popular delusions an element which has been as yet but little studied by scientific men, since its investigation, while belonging in part to both psychology and physiology, has been shunned by the representatives of each of those branches, as belonging more properly to the other.
1 Vide Journal, vol. xcvi., p. 656.
2 The Scientific Study of Human Testimony, in Popular Science Monthly for May, June, and July, 1878. A New Theory of Trance, in Chicago Journal of Nervous and Mental Diseases, 1877. How to Experiment on Living Human Beings, in Transactions of American Neurological Association, Chicago Journal for 1878.
This is the element of interaction between the involuntary or sub-conscious life and the conscious, voluntary life. In the acts of all of us the involuntary life plays by far the largest part, but in some persons, and preëminently the whole class of somnambulists, mesmerists, and hysterics, it plays a much larger part, even, than in the rest.
In consequence of the fact that these subjects have as yet been so little studied, there are but few experts in them; that is, there are but few persons who are able to see all sides of these problems without prejudice, and therefore to deal with them deductively, in the light of many kindred facts studied systematically; but few to the testimony of whose senses regarding them any great scientific value is to be attached. Broadly speaking, the testimony of the senses of non-experts is of little worth as a basis of exact reasoning. “Facts” are not facts unless we know also the persons by whom, and the circumstances under which, they were observed. The testimony of the man who saw " the sun turn black” would be very different, both as regards matter and significance, from that of one who described an eclipse.
Dr. Beard attempts to arrange and systematize the floating opinions of those most familiar with these matters, and lays down a number of definite rules with regard to human testimony, of which we quote the first :
I. “ The corner-stone of the reconstructed edifice of the principles of evidence must be the recognition of the necessity of the testimony only of experts, in all matters of science, and consequent absolute rejection of all testimony of non-experts, without reference to their number or the unanimity of their testimony."
What then constitutes an “expert” in any branch? In scientific terms he might be briefly defined as a person so familiar with the laws governing the occurrence of any series of phenomena as to be able to apply them deductively in special cases.1
Practically, we judge at least of the absence of expert ability if we find a witness, or experimenter, failing to provide sufficiently against recognized sources of error in an investigation. These sources of error, in cases of experimentation upon living human beings, Dr. Beard classes under six heads : 1. That arising from the intervention of the phenomena of involuntary life, both in the experimenter and the subject experimented on," . . . . embracing "all the interactions of mind and body that are below the plane of volition, or of consciousness, or of both. Without a knowledge of this side of physiology scientific experiments upon living human beings is impossible.” II. * Unconscious deception on the part of subject experimented on.” III. “Intentional deception, ditto." IV. “Unintentional collusion of third parties.” V. “ Intentional collusion, ditto." VI. “ Chance and coincidence."
It is evidently as important that some such scheme as this should be followed, not only in principle but in detail, as that the physicist should note down successively in his experiments the readings of the barometer, the thermometer, etc., without which his experiment might be absolutely valueless. In the metallo-therapeutic experiments, for example, especially considering Expertness being, of course, a question of degree, this rule has only a relative signifi