Our so-called mental diseases are simply groups of symptoms." This is logic and common sense; it is also physiology, and it is difficult to follow this This is the fundamental thought which I author when, in his chapter on pathology, he want to emphasize. Insanity is a symptom, reviews the organs most concerned in a pure or group of symptoms; not always, not in the and equable blood supply, as follows: "Hearts majority of cases, at least in its beginnings, a are frequently morbid, but we are not to consymptom of integral disease of the organ nect these with the outbreak of insanity." whose perverted action it is, but of faulty con- "In the pathology of commencing insanity ditions external to it. Whatever the initial the kidneys play a very unimportant part." step leading to disordered brain action (I am I believe the liver has little to do with the speaking now of "ordinary insanity" in the pathological condition of a patient who has sense used by Sankey, excluding that which recently become insane," etc. is organic or developmental), the remote effects are similar; whether beginning as mania or melancholia, it ends sooner or later (i. e., if the morbid process be not checked), in dementia, that is, the limited function of a more or less impaired brain tissue. To the general disturbance in the process of nutrition as yet practitioner alone, in the great majority of unknown to science." Sankey separates cases, comes the opportunity to study insanity what he calls "ordinary insanity from paresis, in its inception, and to investigate the per- epilepsy, organic and developmental insanity. verted bodily functions which determine the Speaking of the etiology of "ordinary insannutritive changes leading to disordered brain ity," he says: "The disease consists in a moraction, when only preventive measures may bid state of the blood, or of the processes conoften be attended with gratifying results. cerned in nutrition." When we consider the marvellously delicate structure of the brain, whose susceptibility to every impression is, in fact, its function, is it not self-evident that any defect in the nutritive processes upon which its integrity depends, any deterioration in the quality of the blood or in the manner of its supply, will be liable to influence its action? And this, by a majority of the writers on mental diseases, is conceded in theory, if denied in practice. Schroder von der Kolk says: * Griesinger says: "Many cases that terminate fatally in the acute stage present pretty much the appearance of the normal brain; often enough to lead to the conclusion that the symptoms during life were due to some His résumé of the morbid anatomy in insanity is at once so comprehensive and so concise, and bears so directly upon our subject, that I make no apology for quoting it: "During the earlier period of the disease (Sankey regards mania and melancholia as only differing manifestations of one morbid process), the symptoms are due to an alteration in the blood, in its quality and in its amount; there is some congestion with interstitial deposit of serum and of protein compounds; then atrophy of the brain substance and hypertrophy of the vessels. At first the symptoms are due to the circulation of impure blood; they next are due to excessive supply; then they evidence the imperfect function of an altered cerebral tissue." Among the causative forces acting on the brain, the first place must be given to the blood." Blandford says: † "Could we comprehend the blood supply of the brain, beyond all manner of dispute, we should go far toward explaining most of the phenomena of brain function and of brain disorder." And again: "The life and functions of the highest cerebral centres are disordered by interruption in their natural nutrition; if there is a defect- by peripheral disease in some other part of an impoverished blood, or a blood poisoned by deleterious ingredients, the effects must be visible in the functions of the brain." Coulston says of melancholia: "It is a constitutional disorder of the brain developed out of hereditary tendency and excited into action the body." Accepting then the self-evident fact, which, morever, has the support of the high authorities named, that "ordinary in * The Pathology and Therapeutics of Mental Diseases. sanity" in its first stage depends upon some † Insanity and is Treatment, Edinburgh, 1884. * Lectures on Mental Disease, London, 1884. 66 defect in the quality, or the mode of supply, direction. Griesinger, in his work on Inor both, of the blood, we can hope to get some sanity, says: "Anomalies in the urinary selight upon the causes of insanity only by cretion may be much more frequent," i. e., studying the organs which have to do with among the insane, than is generally supblood production, purification and supply. posed. Unfortunately any reliable researches In this vast field, where so many avenues of upon this important subject are still wanting." inquiry open, I shall attempt no more than to My attention was first arrested by the clinmake some suggestions along one path in ical observation of the very constant coinciwhich my own clinical experience has hap-dence of some form of mental pain or distress, pened to lead me. i. e., melancholia, with the physical signs in It is understood, of course, that no organ, the urine of disturbed kidney action; this is or system of organs, acts independently; that not invariable, but the rule. We have cases there can be no absolute separation of the of undoubted mania associated with a uræmic study of one from the study of another-as, condition, and, on the other hand, cases of for example, the liver, kidneys and heart, often melancholia without it; as for example, in related links in one morbid process-never- some conditions of grave heart lesions with theless each has its definite function, inter- general debility, and some transitory cases asference with which is followed by equally sociated with disturbed liver action with the definite consequences. uric-acid formation. By "Bright's disease" we no longer under- [A. Haig, in an article in the London Pracstand a morbid process affecting the kidneys titioner, vol. xli., No. 5, on "Mental Depresonly, but whether we consent to accept the sion and the Excretion of Uric Acid," speaks kidney lesion as a part of a general "arterio- of the demoralizing influence of uric acid. capillary-fibrosis" (after Gull and Sutton), or upon the nerve centres and explains the wellwith Dr. A. V. Meigs, look upon it as a local-known fact, that states of mental depression ized expression of a general "endarteritis;" are intensified in the morning, by the increasthe fact is undisputed that at some stage in the train of morbid processes, covered by the monumental name "Bright's Disease," lesions of the kidney do exist; their function is interfered with; to a greater or less extent they fail to separate certain waste products from the blood, which being retained and circulated through the body produce toxic effects which I. That, contrary to generally received we have been accustomed to group under the opinion, affections of the kidney are very comgeneral term "uræmia," or "uræmic pois-mon among the insane. oning." ed alkalinity of the blood at that time, and consequent greater solubility of uric acid. We know that our melancholic patients are worse and that suicidal impulses are to be specially guarded against in the early morning.] Briefly formulated, my experience has led me to believe: 2. That "uræmic poisoning" is one of the most frequent causes of insanity. I must pass by, as not essential to my purpose, any consideration of the various theories 3. That while the mental manifestations concerning the nature of these nitrogenous waste products, and confine myself to some observations upon their effects, which my experience has led me to believe are more varied and far-reaching than has generally been supposed. may be as varied as there are different centres subjected to irritation by these unknown poisons, the most prominent and constant symptom is some form of mental pain, which may range from simple depression, through all degrees and varieties of delusions of persecuThere has been a general impression abroad tion, self-condemnation and apprehension, that diseases of the kidney are not common with or without hallucinations, up to a conamong the insane, founded upon statements dition characterized by a frenzy of fear, with to that effect in most of the text-books, and extraordinary motor excitement, and rapid. perpetuated by the very general absence of physical prostration, the "grave-delirium" or systematic and careful observations in this "typho-mania" of some authors. 4. That the motor centers are specially ber of cases of melancholia which belong in liable to affection, as evidenced by the rest- this category. (See Cases 56, 57 and 59.) A lessness and incessant activity of many cases, factor which cannot be left out of account in less frequently by convlsions and convulsive these cases, is the heart; whether a coincitwitchings; occasionally by choreic move- dent or resultant change, we know that, with movements; occasionally by cataleptoidal diseased kidneys, we are apt to have abnormal hearts, and it is an interesting question, states. Undoubtedly there is much. more of to what degree mental disturbance may be "Bright's Disease" in the community than aided by some modification in the supply of appears on any record book, the interstitial blood to the brain, due to normal heart form often running a very long course, fre- action.* quently unrecognized. Persons subject to Dr. Landon Garter Gray, of New York, read "bilious attacks" and "sick-headaches"; to a very interesting and suggestive paper beobscure neuralgias; to crawling sensations fore the American Neurological Association, (often described to me "like the flowing of in 1889, on "Three Diagnostic Signs of Melwater" over the part affected) in the head and ancholia," with notes of sixteen cases illusespecially in the back of the neck; people trating the association of mental depression, who are "tired all the time," who have sleep- insomnia, and post-cervical ache, which he less nights, or occasional night terrors; who have unexplained attacks of sudden weakness, or periods of low spirits without cause; who show an unnatural irritability, or a gradual change of character or disposition; those who are subject to gout, rheumatism, chorea, skin eruptions, to itchings of the surface of the body, either local or general-all these may well be suspected of dangerous tendencies. nature of the malady. There, too, are the has found so constant in his practice. Dr. Gray says: "The simple forms of melancholia are often extremely difficult to prognosticate, especially in the early stage, as the reasoning powers, the memory, and the perceptions are then often seemingly unimpaired or not more affected than is possible from a myriad unimportant causes. Patients suffering from this mental disease too frequently I need not say that numberless cases of figure as neurasthenics to be confidently slow kidney trouble live long and fairly, com- treated as such, until some determined and fortable lives without showing any mental frightful suicidal, or homicido-suicidal, atdisturbance, and that many others run a rapid tempt throws startling light upon the true course to death without such complication. We must assume, in some cases, a toxic im- cases of unaccountable suicide which puzzle pression of overwhelming power, but, doubt- friends, and competing newspaper reports acless, some brains are predisposed, by inheri- count for so satisfactorily and sensationally tance or otherwise, to an easy overthrow of upon some theory of rejected love or highthe mental balance. This seemed plain in flown sentimentalism. Any certain diagnosmany of my cases. In such a one, given a tic symptoms in this class of cases should be, chronic nephritis, or even without it, insanity for these reasons, of value. .. So firmly may be induced by anything that increases have I come to rely upon the association of the burden thrown upon the kidney, dimin- this symptomatic triad" [i. e., mental depresishes its working force, or interferes with sion, insomnia, and post-cervical ache], "that other excretions. Such causes are: Im- I have lately made a diagnosis in two cases proper diet, long-continued constipation, sud- by means of it. The first patient was a genden exposure to cold, pregnancy, or any un- tleman who came to me complaining of a disusual interference with the circulation; over-tress in the back of the head and neck, which work of body or mind, and especially worry; at times was painful. I learned from him that intercurrent disease, or anything that de- the onset dated back to six years ago, when, presses the system and lessens its power of resistance. The influenza epidemic in the beginning of the present year sent us a num In the Address in ental Disorders, for 1884, the writer gave an analy is of 500 cases of insanity, 20 per cent. of which had some heart affection If not as he said, he had been run down and de- leges, and little is to be found in text-books. pressed. I then told him that I would out- Yet every village has its numerous sufferers line to him his symptoms at that time, and I who ought to be under treatment. proceeded to tell him that he had been taken in charge by the family physician-if very much depressed, had not been able to turned away with an indifference born of igsleep, had thought of committing suicide, had norance, or with a remark that "the subject been slightly confused in mind, and had re- is too nasty for discussion"-such cases pass mained in this condition for several months. on into impotency and its untold misery, or He was amazed, and asked me if I was a mind worse; fall into the hands of the advertising reader, finally admitting that he had passed sharks. Of this Milton "On Gonorrhoea and through just such an attack of melancholia, Spermatorrhoea;" Wm. Wood & Co., N. Y., which he had concealed from everybody, because he was then living in Burmah in the employ of the English government, and was afraid that he would lose his position if thought insane." I fully concur in all that Dr. Gray has so well said in this paper; but, in going a step farther and investigating the causes of insomnia and post-cervical ache, both among the most common symptoms of "uræmic" blood poisoning, we shall find additional aids to diagnosis and safeguards against catastrophes like those mentioned. (Continued in November No.) Treatment of Spermatorrhoe. Read by title at the Missouri Valley Medical BY EMORY LANPHEAR, M. D., OF KANSAS 1887, page 305, says: "That the disease is a mere phantom, the offspring of a morbid fancy, to be discouraged as much as may be, has done and is still continuing to do an amount of harm, which it is scarcely an exaggeration to speak of as incalculable; and the mischief is all the greater because this opinion is upheld by men who justly enjoy the confi-. dence of the profession. But its ill effects are not restricted to the misery it inflicts upon the patient. Ingenuity could hardly devise a more efficient stimulus to charlatanism of the worst kind; for it is but natural and inevitable that a man who finds his case rejected or misunderstood by the physician he consults, will turn to those who so loudly proclaim their readiness and ability to help him." To remedy this, in some measure, is the object of this paper. As a broad rule, it may be said that nocturnal emissions occurring more often than once in two weeks are debilitating; indicate a pathological condition, and demand treatment. And discharges of semen taking place during the day-a very uncommon occurrence-are always of serious import. In such cases the SURGEON TO EAST SIDE DISPENSARY-ORTHOPÆDIC SUR- patient also complains that he cannot stand GEON UNIVERSITY MEDICAL COLLEGE OF KANSAS rare. fatigue well, that he cannot concentrate the mind continuously or carry out a fixed train of thought, and there are present such proCases of true spermatorrhoea must be very found trophic disturbances as to cause exAs usually employed by authors the treme wasting, the skin becoming of a leaden term spermatorrhoea covers only instances hue or yellow; the eyes encircled with blue. where the semen dribbles away insensibly from rings, etc., as described by Trousseau.-Lecthe urethra. I have never seen such a patient. tures on Clinical Medicine, 1870. Vol. iii., Seminal emissions are exceedingly common, page 455. But such marked results are not but constitute what is commonly known as common; they certainly never are met in the spermatorrhoea, and nearly always demand earlier stages of the affection. treatment. Few physicians have learned how Under ordinary circumstances, the patient to treat these cases-nothing is taught at col- consults the doctor, and gives a history rather If the disease has gone on until the paralytic form of impotency is reached (where both desire for intercourse and power of erec suggestive of "malaria," or "indigestion." thirty-five, and the emissions have continued He does not usually at once declare the na- for many years, and with frequence, and when ture of his trouble, and in some instances he there is marked dyspepsia and constitutional does not know. Complaint is made of a gen- disturbance, the outlook is not good, though eral lassitude, sometimes amounting to in- a favorable result may after a long time be seability to work, sometimes there is palpitation cured in most cases. and breathlessness after any severe exertion. Erichson (Science and Art of Surgery, 1872, Pain in the back is often a disagreeable and vol iii., page 788) says: "Under any form of obstinate symptom. Constipation is usually treatment these cases will be slow, and longpresent, and it is uncommon to find a case in continued perseverance in the use of remedies, which dyspepsia is not present. The distur- local and constitutional, is imperatively nebances of digestion are accompanied by such cessary." perversions as pain after meals, tenderness of the epigastrium, a sensation of fullness and flatulence after meals; eructations, heartburn and stomach acidity. There may be bad tion are abolished) the prognosis is gloomy, memory, headache (especially occipital) neu- but by no means hopeless, if proper treatment ralgias; sleeplessness, or disturbed sleep, and be adopted. But suitable measures must be other nervous phenomena. Inquiry elicits the employed or the patient will continue to go fact that there are seminal emissions, varying on miserable, despondent, and sometimes they in frequency from one every ten or twelve become melancholic, sexual perverts, or even days, to two or three each night. Examina- sexual dements, though these results are extion of the genitals may show nothing; or the tremely rare. penis may be cold, and the testicles hyperæsAfter a thorough confidence between pathetic. If a sound be introduced, in most tient and physician has been established-best cases there will be found a hyperæsthesia of secured by a careful examination, patient listhe deep urethra, and sometimes a stricture tening to minor details and other evidences. of large calibre near the meatus. Impotency that a genuine interest is taken in the case— has resulted in a considerable per centage of the terms of treatment must be arranged. all cases coming under the notice of the physician. The cause of the trouble is almost invariably masturbation, or excessive venery, which amounts to the same thing. There must, first of all, be a distinct understanding that nothing will be done unless the patient will continue under treatment for many months if necessary, and obey the docAs to prognosis, if the subject has already tor's orders to the letter. The payment of a quit his pernicious habit, if impotency have good fee, as of $50 or $100 in advance, assists not occurred, if there still be occasional erec- very greatly in gaining the faithful adherence tions. and if the patient awakens at the emis- of the patient and in hastening a favorable sions, the probabilities of cure are good, termination. Then the first prescription may though it may take many weeks of patient work to accomplish it. be given. A request for something to check the discharges at once is usually made. There The prognosis is always good if the bad con- is nothing, to my knowledge, that will do this. dition be attended to early-in fact the dis- without harm. In long-continued, general ordered state very often spontaneously disap- and local treatment, is the only true relief. pears before the age of twenty-five, under fa- Complications must first be removed. For vorable circumstances. If the emissions have the dyspepsia, a mixture of pepsine, pulverbeen very frequent for a period of two or three ized charcoal, glycerine and water, answers years, and the systemic effects are marked, admirably; and if there be much nervousthe case may prove very troublesome. Often ness bromide of sodium may be added with as great difficulty is experienced in effecting a advantage. When there is nervousness, sleepcure as if the trouble had existed for a decade. lessness, irritability or despondency, with a When the patient has reached the age of coated tongue, constipation and turbid urine, |