life. All in all, I believe that, judged simply mechanical objection to the employment of by its remoter effects, the operation of rapid electricity. Every sitting for the electrical dilatation is a dangerous one, and results often- treatment is prefaced by the use of the sound, er in subsequent harm than in lasting good. and followed necessarily by the introduction The surgical injury to the cervix is, in many of an electrode of some form. This is by a of these cases, more pronounced than the class of men who, in the main, have had no tears of the cervix which it is the intention to previous gynecological training or education remedy by Emmett's operation. In this case whatever. In such hands such methods can there is operation at each horn of the dilemma, only be harmful, and we are now reaping the and the results are often equally bad at both. fruits of their work in a class of pelvic operaSimple closure of the cervix in cases of pelvic tions not surpassed in the complications predisorder, almost certainly exacerbate the sented. Along with the sound may be placed symptoms. The necessary inflammatory ac- the curette in the same category. Dilatation, tion set up in the suture tract, is transferred with curetting of the uterus, have placed to along the lymphatic or venous channels to their credit a long series of major operations. the seat of the earlier inflammation, this is Another class of cases coming under this lighted up anew, and goes on in its develop-head are those in which there has been a long ment until a pelvic peritonitis is kindled or time during which intra-uterine applications rekindled, which at last entails a major opera- have been made. All the caustics in the catation. The minor gynecologist, as such, who logue have at one time or another been in has no regard for or appreciation of the rela- favor, as cure-alls, in intra-uterine therapeution of the commonly advocated general clos- tics. Nitric acid, chromic acid, nitrate of ure of perineal and cervical tears to major silver, and the rest. For a woman to have surgical complications, cannot but be a great undergone a routine treatment with this list, factor in the causation of the same. In Pep- and to have escaped pelvic inflammatory per's System of Medicine, vol. iv., there is on trouble, is little short of a miracle. A careful record a case in which the operator hoped to inquiry into many of these cases coming uncure a pelvic inflammation by the derivative der my care directly and indirectly, reveals effect of a perineal or cervical operation. the history that all sorts of minor procedures, Needless to say, pelvic operation was after- were tried, only to fail and apparently hasten. ward done. Such a cure is no less ridiculous the necessity for operation. than the so-called "faith" cure, and is certain ly more actively harmful. Insanity as a Symptom of Bright's Disease." ADDRESS IN MENTAL DISORDERS. Extract from the Proceedings of the Medical Society of the State of Pennsylvania, June 10, 1890. That the inconsiderate use of the uterine sound has been responsible for much inflammatory pelvic trouble, is scarcely to be disputed. This is not because the sound is of itself a dangerous instrument, but because it is put into the hands of every tyro, as an instrument of diagnosis. If used at all, it should be in the hands of those with whom its application, by reason of their skill, will be exceptional, not usual, and the rule should be, that in the hands of the non-expert it should be forbid- BY ALICE BENNETT, M. D., PH. D., OF NORden. The more expert and experienced the specialist, the more rarely will the instrument be required. My own rule is, that in cases in which it might at first seem indicated, a little In cases of Bright's disease with sudden inpatience and diligence will obviate the neces- vasion of melancholia, there is one feature so sity of employing it. The indiscriminate use constant that I have come to regard it as diagof the sound and electrode, is the most serious, nostic: it is the sense of impending danger, RISTOWN, PA. (Continued.) the overwhelming fear of some threatening In connection with gout, Bucknill and Tuke calamity, which inspires the one irresistible say: "Outside the walls of asylums cases are impulse to "get away" which dominates the frequently met with which are marked by un individual for the time, and under the influ- founded dread, especially on awaking in the ence of which he often jumps out of the near- morning, in which there is a gouty diathesis, est window. (See cases 55, 58, 47, and others.) and suspicion is aroused that there is a casTo prevent insanity by recognition and ual relation between the bodily condition and treatment of the conditions leading to it will the mental anguish. This suspicion is conbe our aim; frequently, however, so insidious firmed by the marked success of treatment is Bright's disease, and so unwilling are peo- founded upon this supposition." ple generally to appear to make much of their Schroeder Van der Kolk, under "Sympalittle ailments, which would be such valuable thetic Insanity," records two cases of insanity indicators if revealed, that we know nothing accompanying vesical catarrh, of which one of the state of affairs until some catastrophe recovered; in the other an affection of the has taken place. Even then it is worth much kidneys supervened, and the patient died." to be able to say why it has occurred, and even in unpromising cases gratifying results sometimes follow prompt treatment in the lines indicated, but prognosis must always be guarded. Sankey found adhesion of the capsule of the kidney in one-half his cases post-mortem, and, "in a large number, other evidences of disease, as atrophy of the cortex, fatty degeneration, waxy disease, etc." This author does not seem to have made any study of the kid I think that I can serve you best by presenting some clinical notes of cases with com-neys during life. The presence of kidney ments; but before going on to speak of my own experience, I will ask you to look at the literature of the subject. Books on diseases of the kidney say almost nothing of the effects of retained nitrogenous waste products upon the nervous system, except convulsions and coma, generally preceding death. From all the works on insanity accessible to me, I have gathered everything bearing on this subject that I could find. * changes post-mortem he regards as "evidence that the blood has been impure" (emphasized by him as the first step in the production of "ordinary insanity," as quoted above); nevertheless, he concludes by saying: "I do not consider the true pathology of insanity to have any necessary relation to kidney disease." Gowers calls attention to organic changes (as apoplexy), which may ensue from atheroma of the arteries in advanced Bright's disease. Griesinger says: * "Bright's disease to which any etiological relation to insanity could be attributed is very rare indeed." One would much like the complete clinical record of a case like his No. 12, of which the following is a condensed abstract: "Delirium oc From Buckmill and Tuke: "The kidneys are remarkably free from disease in all forms of insanity. We have met with three cases of Bright's disease among the insane, and we have found the experience of others of a similar nature." They quote, with evident surprise, Howden, who had admitted twelve curring in second pregnancy, formication and cases of albuminuria in three years, and who, in 235 post-mortem examinations, had found kidney disease in 86. They admit two genuine cases of "insanity coexistent with the waxy form of Bright's disease," mentioned by Dr. Wright, in the "Report of the Royal Edinburgh Asylum," for 1871, and speak also of a similar case recorded by Dr. Wilkes in the Journal of Mental Science, for 1869. Psychological Medicine. smarting over whole surface, a general sense of ill-being, sleeplessness, ringing in ears, vertigo, pulse hard, slight cardiac hypertrophy, recovered, and relapsed in the following year." Or his No. 8: "Man, hepatitis in the beginning, variable temper, pain in lumbar reregion, burning in urethra and bladder, at times had gravel, died in a few months." Blandford speaks of a variety of melancholia "usually ascribed to dyspepsia or dis * Clinical Lectures on Mental Diseases, London, 1883 order of the stomach and liver." He has also noticed that "melancholia-often comes on, as a precursor of death, at the close of other diseases." In Clouston's very interesting work I find more bearing upon this subject than in any other I have read, although I cannot always agree with this author in his interpretation of facts. For example, his two cases of diabetic insanity, which have been extensively quoted in other text books. In Case No. 2, a man, who died after melancholia of two years' duration, with delusions of persecution, the diagnosis rested entirely upon one examination of the urine made near the close of life; no symptom had led to the suspicion of diabetes, and there was no post-mortem examination. That some amount of sugar in the urine is frequently associated with chronic Bright's 8. Suicidal and homicidal melancholia. These divisions are convenient, but it is needless to say that (excluding “organic,” which seems to me out of place here) they are descriptive of mental states, rather than varieties of disease; often transitory, passing one into the other in the same case. Etiologically, I would consider them all as one, including also stuporous melancholia, which Clouston considers under the separate general head "stupor." Of the "motor" and "epileptiform" varieties, he remarks that they are "specially liable to skin irritations, itchings, boils," etc. disease is well known; and I have twice met The treatment that this author has found the condition noted in my Case 6, where, of most value in melancholia is, to me, signifishortly before death, sugar appeared in large cant: milk is his "sheet-anchor;" farinaceous quantities in the urine, from which it had pre- and fatty foods; an abundance of fresh air; viously been absent. baths, and especially Turkish baths, of which he says: "I have seen many chronic, incurable cases of melancholia improved by a course of Turkish baths.” His Case No. I was a "woman, aged 59, agitated melancholia; toward the end, sleepy all the time; urine never very copious; ordinary treatment of diabetes of no avail." In our own country there have been some special contributions: In 203 autopsies at the Government Hospital for the Insane at Washington, D. C., about one-sixth of the kidneys "presented alterations sufficient to constitute disease." Clouston recognizes a "variety of mental derangement, half delirium and half mania, which results from uræmic poisoning, which he names the "insanity of Bright's disease." "Usually occurring in chronic cases with contracted kidneys, where there has been enlargement of the heart and a tendency to dropsy for some time," and he gives one illus-delphia Neurological Society, in 1888, three cases of insanity associated with "Bright's disease:" trative case. He has also noticed in such cases "mania of a delirious character, with extreme restlessness, with remissions, attended with great prostration" (the equivalent of the "grave delirium" of some authors, of which I shall want to speak again.) I was especially interested in Dr. Clouston's studies of melancholia, which is the one form of insanity I so constantly find associated with defective kidneys. He considers it under eight heads, as follows: I. 2. Simple melancholia. Hypochondriacal melancholia. * Mental Pathology and Therapeuries. Prof. William Osler reported to the Phila Case I. Man, aged forty-two, known to be the subject of "Bright's disease;" after three or four days of violent mania, died in a comatose condition. Case 2. Man, the subject of interstitial nephritis, admitted to the University Hospital in a semi-stuporous condition; had previously been maniacal, and had delusions of persecution; committed suicide by jumping from an upper window. Case 3. A man, with chronic "Bright's disease," who for a time refused food, under the influence of delusions of persecutions; afterward improved. Dr. L. Bremer, of St. Louis, in a paper read before the State Medical Society of Missouri, in April, 1888, details seven cases that have come under his observation: the second. In this my experience is widely at variance with Dr. Christian's.) could it be said that the mental manifestations were not dependent upon, or modified to some extent by, the renal disease." Of these cases he makes two divisions: 1, the "uro-toxic;" Case I. Unmarried woman, thirty-eight; 2, the "vascular." I give condensed abstracts rheumatism and chorea at fourteen; albumin- of his five cases illustrating the first class, uria, following fall into cold water, of four which he considers much less common than years' duration; a second exposure followed by scanty secretion of urine, insomnia, irritability, mania of two days' duration, followed by melancholia with self-condemnatory delusions; attempted suicide on the ninth day, resulting in excessive hemorrhage, followed by sleep and rapid recovery. The urine contained albumin, hyaline and epithelial casts, pus, and blood-corpuscles, disappearing with complete restoration to health. Case 1. Woman thirty-four; convulsions, followed by insanity, at a miscarriage three years before. A second attack, also puerperal, two years later. Third and last attack, also puerperal; "grave dyspeptic disorders and failing vision" in interim. Mostly "confused and restless; a low muttering delirium. Died semi-comatose, in the third month of attack. Urine contained albumin, waxy casts, and debris. No autopsy. Case 2. Case 2. Man, a drinker; acute rheumatism, with fever, tremors, spastic state of mus cles, delirious insanity marked by intense restlessness and vivid hallucinations; urine con- aches, frequent vomiting, eczema, etc., was A year of dyspeptic troubles, headtained enormous amount of albumin, hyaline followed successively, by delusions of susand blood casts, which almost disappeared picion, hallucinations of sight and hearing, during a remission of three weeks, when mind low delirium, and, near the close, intense exwas clear, and again increased with a relapse citability of the motor centres, with spasms of which ended in coma and death eight weeks all the voluntary muscles. Albumin, hyaline, from the inception of the disease. No post- and granular casts in the urine. four months. No autopsy. mortem examination. Case 3. Woman forty-eight; injury to head in childhood; puerperal mania at thirtyfour; six years later, rheumatism with intense insomnia, preceded a melancholia of several months' duration. Last attack followed prolonged exposure in a railroad accident; active delirium, with menacing hallucinations, coma, death one month from beginning of the attack. Albumin, epithelial and hyaline casts in urine. Case 4 Woman, fifty-five; sciatica for ten years; an exceptionally severe attack, followed by mental confusion, quickly passing into coma and death. Urine contained epithelial and blood casts, and pus corpuscles. Dr. Bremer's cases 5, 6 and 7, are somewhat complicated, and I pass over them here. Dr. E. A. Christian, of the East Michigan Asylum reports 37 out of 2,600 cases of insanity admitted to that hospital, "in which the appearance of grave disturbances of nutrition had been coincident with albumin and tube-casts in the urine; in only about a dozen * Journal of America. Medical Association, March, 1889. Death in ritable for eighteen months. Case 4. Male, forty-five; sequence of symptoms as follows: Peculiar and forgetful; confused; hypochondriacal; suspicious; religious delusions. Died, semi-comatose, in four months. No autopsy. Albumin and casts in our early apoplexies. I want to say, also, in actively insane, with extreme restlessness and passing, that the relation between paresis and increasing bodily depression. On admission "Bright's disease seems to me to require fur- showed most intense motor excitement, which ther investigation; we know that many cases was almost incessant for one week. This was of paresis are associated with kidney disease, followed by a week of great physical prostraand I have seen cases, beginning as melan- tion in bed, ending in death on the fourteenth cholia with uræmia, pass into a condition day, three weeks from the beginning of the similar to, if not identical with, paresis. attack. At times, during the last week, mind was quite clear. A few days before death a double pneumonia developed which hastened the fatal issue. Urine contained albunin and hyaline casts on admission. Autopsy showed the large mottled kidneys of chronic, diffuse First group.-Cases (12) rapidly fatal (twelve nephritis. Heart flabby, hypertrophied, and days to three months.) I am persuaded that dilated. Liver enlarged. Lungs, red hepato this class belong many of the cases various-tization, except at apices. The cases which I present are all taken from the records of the Department for Women of the Norristown Hospital for the Insane. They are divided into clinical groups, and are condensed as much as possible. aortic insufficiency. Kidneys normal size, cortex thin and very fatty; one hemorrhagic infarct size of marble. Liver "nutmeg" on section. ly designated as "typho-mania,” “grave de- Case 2. , aged 22, American, married, lirium," etc., by different writers. Nothing mother of three healthy children; paternal more distressing, nothing more hopeless of uncle insane; showed slight peculiarities for even amelioration, can come either to the preceding year; apt to complain of "pain general practitioner or the specialist. Their across back," but was not considered sick uncharacteristic features are intense motor ex- til ten days before admission, when violent incitement, with rapid physical prostration, a sanity developed suddenly, during the night; condition graphically described by Spitzka, as was kept in bed by mechanical measures, and follows: "Insomnia and inability to think, was brought to the hospital bound to a increased irritability, and a sense of impend- stretcher a distance of sixty miles. On admising misfortune precede the outbreak, which sion she was in a semi-comatose condition; is often so sudden as to suggest the fulminat-action of heart extremely feeble; urine loaded ing type of typhus, or of epidemic meningitis. with granular and waxy casts and blood discs. There is wild, aggressive delirium-a pan- She lived six days in this condition. Autphobia-the patient jumps out of the window, opsy-Heart, organized clots in all cavities; beats the plaster from the walls, eats bedding, and clutches at his attendant with the frenzy of despair; may sing, whistle, yell, and tear off clothing continuously for days. One patient kept plunging his head against the ceil-, aged twenty-nine, single, of ing until beaten to a jelly. Another rubbed Irish parentage, good family history. Rehis thumb against his teeth until it hung by a ported good health up to three weeks before thread." Dr. Spitzka concludes, since "all admission, when she became melancholy, with the pathological changes of the brain noted the delusion that the neighbors were defampost-mortem are only collateral results of dis- ing her character; persistently suicidal. On turbed circulation, and throw no direct light admission urine contained albumin, hyaline on the essential pathology of 'grave delir- and granular casts; action of heart feeble. ium,'" that we must infer the "formation of a Death occurred after thirty-three days (in toxic agent in the nerve-centres themselves." eighth week of attack), during which she was Case 1. aged forty-two, American, the subject of intense motor excitement with married but deserted by husband; general agonizing apprehensions. Once repeated raphealth said to have been poor during her mar- idly for hours, in most piercing screams, “O ried life; had been “ a little unlike herself" God! where is my brother?" Fed with tube. for the preceding five or six months. One No autopsy. week before admission to the hospital became Case 4. Case 3. aged thirty-nine, of German |