under her control. From that time her recovery was steady and rapid, till she was well in mind and body.

Is any light thrown on the relations between rheumatism, chorea, and insanity, or on the connection between motor and psychical abnormality, by the case I have related? Was the rheumatism the true cause of the mental symptoms, of the chorea, or of both? Were these abnormal affections of motion and the perverted psychical manifestations the result of an identical and simultaneous lesion affecting both the motor and mental ganglia? Or was the one dependent on the other, secondary to it, or sympathetic with it? Is it not evident that in this case we have a distinct form of insanity, a form about which much may be ascertained by a careful study of its relation to, and its correlation with, the motor symptoms? It will be observed that nearly all the functions of the nervous system were here affected-the nutrition, heat production, motion, sensation, reflex action, the special senses, the memory, and the intellectual processes all at the same time, and they recovered their normal action

about the same time.

I think it cannot be doubted by anyone that the rheumatism was the true cause both of the chorea and the insanity in this case. All the symptoms-the coming on of the disease, the choreic movements, the paralysis of motor power, the deadening of reflex action of the legs, the hallucinations of sight, touch, and taste, the want of memory, the acute delirium with unconsciousness of anything going on around, succeeded by confusion of ideas, suspiciousness, and sluggishness of mind, the high temperature increased at night, the tendency to improvement in all the symptoms coincidently with the lowering of the temperature, and the slowness of the convalescence-all these things show that some lesion of the central nervous system existed. And when this is taken along with the fact that such a train of symptoms suddenly appeared in the course of an attack of rheumatism, that the symptoms of the articular rheumatism at once disappeared, while the fever did not do so, and that in this woman, when she was nearly well, rheumatic swelling of the knuckles of one hand appeared along with aggravated choreic movements, sleeplessness, and an increase of temperature, we have very strong data, not only to conclude that rheumatism was the cause of the nervous and mental symptoms, but that here we have a true and typical example of a rheumatic insanity, which must be classed by itself as a special form of mental disease-a true pathological entity.

As to how the nervous system was affected, may we not form a probable hypothesis? We know how rheumatic disease, whatever it is, affects the other tissues. We know also something of the kind of lesions of the spinal cord which are needed to produce paraplegia and the total absence of the power of the reflex action, even if we do not know fully the pathology of chorea or of insanity. In regard to the motor affection of the legs, we saw that at first there was violent choreic movement, which was succeeded by complete paralysis of motion, no power of reflex movement, and greatly diminished common sensibility. As the power of motion returned, which was in the course of a few days, there were hyperæsthesia and a sensation of heat. Does not this sequence of phenomena indicate a serious but transitory interference with the func

tions of the nerve-cells and fibres in the spinal cord, such as might be produced by slight rheumatic inflammation and infiltration of the connective tissue of the cord, causing pressure on the nerve elements? If the nerve-cells or fibres had been themselves attacked with any inflammatory affection, they would not have so soon regained their function. We know the rheumatic poison has a special tendency to affect the connective tissue. The rheumatic pains in the limbs are caused, we cannot doubt, largely by simple pressure on the small nerves. And if the cord was affected in this way, is it not probable that the same thing took place in the brain centres that minister to special sensation, and also in the mental portions of the organ? The raised temperature and the strongly acid urine remained the same, whether the rheumatic inflammation was in the joints or in the central nervous system. But when the inflammation had passed away, the effects were far longer visible in the delicate tissue of the nervous centres.

In this case the insanity might be described as a metastatic one, if such a term were strictly applicable to the effects of a poison in the blood whose effects are first seen in one set of tissues, and then in another set. The slight relapse, when the hand and the spinal cord were both affected at the same time, showed, however, that the effects of the toxic agent need not be absolutely limited to one sort of tissue. If we believe this theory, that of embolism falls to the ground, as an explanation of the chorea of rheumatism with or without mental symptoms. There was no ascertainable trace of a tendency to heart disease in the case. The effects of embolism could not have so soon passed away, even if it is conceivable that it could have been universal in all parts of the brain and cord.

It would seem that in such a lesion of the spinal cord as occurred in this case, the common sensibility was the last to be abolished and the first to come again; then the voluntary motor power returned, then the reflex action, and, last of all, the power of the nerves which preside over nutrition. That the sensory and motor functions should have been less interfered with than the reflex action is what might have been expected, when we consider that the greater number of the nerve-fibres ministering to the two former merely pass through the cord, while the nerve-cells forming the ganglia which subserve the latter function, lie in the cord itself. The cord was evidently more affected than the brain.

It was not until all the other functions were restored that the trophic function was restored, and the patient gained in weight rapidly. The slough that formed over the buttock from the bruise, and the slow healing of the wound, showed how much it was affected at first. In regard to the special senses, sight was first affected, and then taste, and they were restored in inverse order. Of the purely psychical functions, memory and the power of voluntary attention were first affected, then the coherence and balance of the mental powers were upset, and lastly the whole of the mental operations were merged in the acute delirium and utter incoherence present. Curiously, in all the patients laboring under this disease that I have seen, there were suspicions of those about them, and entire scepticism as to what they were told about the most simple matters during convalescence. Yet there was never in either of them any tendency to mistake the identity of anyone about them, and one of the very

first mental acts they performed correctly was to take notice of persons about them, and know them again when they saw them. The healthy elasticity of mind and enjoyment of life, which is the most certain proof that the brain is performing all its functions normally, was the last to return, and corresponded to the restoration of function of the centres of nutrition, and the commencement of a rapid increase in weight of the whole body.

That was the first case of rheumatic insanity I ever met with, and it has been the best; but I have met with many cases of the same type since. One had an attack of chorea in youth, previously suffered from, though without rheumatic symptoms. I had one woman in whom the disease was very severe, and ended in complete paraplegia and death in a few months. I found the cord to have undergone a destructive inflammation and softening in all its columns pretty nearly throughout its entire length.

The treatment of such cases is just the treatment of acute rheumatism, with the nursing and care suitable for a bad delirious kind of mania in addition. The prognosis is favorable in most cases. On the whole, the disease is rare.

We may have a choreic insanity both in early youth-the common time for chorea-and in more advanced life without any acute rheumatic symptoms. The delirium is then, as Maudsley points out, of an incoordinated, jerky kind, like the muscular movements. Such a delirium

is apt to come in bursts, and to pass away quickly. In the cases of chronic chorea the mental affection is often depression at first, then mania with impulsive acts of violence or suicide, and then dementia in the end. Some of these cases are very sad from the sufferings-mental and physical -the patients undergo through their involuntary jactitations. I had man, J. G., who frequently had to be placed in a padded room to protect him from the bruisings he would otherwise have inflicted on himself. He at last literally wore himself out. One is justified in keeping such cases under the influence of chloral and the bromides to decrease their sufferings. Sleep in any form, and induced by any means, is to them a blessing, for it is the only time they are at rest and peace.

In many forms of insanity there are choreiform movements that cannot be called ideo-motor. I had a case of general paralysis, J. H., in which the patient's left hand was always engaged in a rhythmical rubbing of his trousers with his thumb and forefinger. I have now a case, J. J., of chronic delusional mania, in which the fingers of one hand are rubbed over the thumb of the other so constantly in a rhythmical way that the cutis of both hands is quite horny; and, like cases of ordinary chorea, if the patient is held still by muscular force, the subjective mental sensation is one of pain, which soon shows itself in outward acts. I had a case of chronic mania, J. K., a shoemaker, who, during all his waking hours, in church or at a dance, except when really shoemaking, went through the motor pantomime of pulling his threads through the leather. I have now a case of excited melancholia, J. L., a lady, who makes the most extraordinary choreiform faces and grimaces in a sort of automatic, unthinking way. She says it is a relief to her to do so. This sort of move

ment is common among the insane, and I look on it as being in many of them closely allied to chorea.

The treatment of all kinds of choreic insanity is, first, tonic and nutritive, and then anti-rheumatic. I have had one or two cases where arsenic worked wonders. I have had other cases where the bromides given as for epilepsy did good. Iron, too, and zinc, and the valerianates, are all good in some cases. Cold to the spine in certain cases temporarily stops the movements.

In the Middle Ages there used to be wonderful epidemics of St. Vitus's dance, with mental symptoms that were certainly morbid, affecting at the same time thousands of persons by a kind of morbid sympathy and imitation. Mankind seems less subject to these strange imitative, uncontrollable, mental-motor epidemics now than it was several hundreds of years ago.

GOUTY OR PODAGROUS INSANITY.

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This is a rare disease in forms sufficiently marked to come under specialist treatment, or to be regarded as technically mental disease; but mental phenomena due to gout are common enough, and have been described by all authors on the subject. Irritability, incapacity for mental exertion, and depression are the most common of these. Sydenham gives a good description of them in his classic work on gout. The body is not the only sufferer, and the dependent condition of the patient is not his worst misfortune. The mind suffers with the body, and which suffers most it is hard to say. So much do the mind and reason lose energy, as energy is lost by the body-so susceptible and vacillating is the temper-such a trouble is the patient to others as well as to himselfthat a fit of gout is a fit of bad temper." The above, no doubt, is the most common mental effect of gout, but it does not amount to mental disease. Deep melancholia is a common accompaniment of the gouty diathesis, especially about the climacteric and early part of the senile periods. I have had several cases of intense suicidal melancholia at this period of life in patients with a strong gouty heredity and gouty deposits, but who had not been subject to the regular acute attacks. I have one such case now, J. M., aged fifty-five, with a strongly gouty heredity and acquired syphilis, who was always more or less dyspeptic, and suffered from constipation. He always had marked psoriasis, and latterly gouty deposits on lobes of ears. Before he became affected in mind he fell off in flesh, his skin eruption disappeared, he became very costive, and a very dilated sigmoid flexure was found to exist. Sleeplessness and strong suicidal impulses, with delusions as to his trouble, were the chief characteristics of his depression, his reasoning power otherwise being good. Every kind of medical treatment-anti-gouty, anti-syphilitic, soporific, sedative, and tonic-was tried in vain. Nothing really seemed to do him good except feeding, with an excess of milk and eggs, sugar and fresh vegetables, given at first by the nose-tube, and living out in the fresh air. He got fat and his sleep returned in about nine months, the acute misery disappearing, and I am not without hope of a recovery of an incomplete kind. He gained two stone in weight under treatment—a great nutritive triumph

in such a subject. There are signs of slight degenerative tissue changes in him in the nerves or nervous centres, or both, evidenced by a partial paralysis of the ring and little fingers of the left hand, with wasting of the muscles. That of course I do not expect to disappear. Garrod describes "gouty mania" as a very acute delirious affection, occurring in some patients immediately after the cessation of the acute joint affections. Along with the mania there are heat of head and fever. In one such case which he describes, all the mental symptoms passed off when one toe became affected in the ordinary way. This kind of acute gouty insanity either terminates quickly in recovery, or runs on to congestion and inflammation of the membranes of the brain.

PHTHISICAL INSANITY.

An anæmic brain, from whatever cause, is always prone to disturbance of function. Lack of blood means imperfect nourishment. Where we have so vascular a tissue as the gray substance of the brain convolutions (almost half composed of capillaries), there the blood is needed in largest amount and richest quality if we are to have healthy and vigorous mentalization. Every one who has experienced any disease that has thinned and lessened the blood, has felt the difference in his mental power then as compared with health. The physiological effects of depriving the brain of part of its blood, or even of lowering the blood pressure down to a certain amount, are different in different cases to some extent. In this as in other ways in human beings, the strong and the weak hereditary qualities of a brain come out. One man merely has singing in his ears, a tendency to faintness, or a profound mental lassitude and paralysis of volition, amounting almost to torpor; those being probably the purely physiological mental results of a bloodless brain. Another man becomes intensely supersensitive and over-excitable, suffering torture from sounds and circumstances that in health would have been calmly borne; another cannot sleep; another has hallucinations of the senses; another takes convulsions, long before that amount of blood is lost that necessarily causes convulsions; and another becomes delirious, or is attacked with insanity. The same, or rather far greater differences of brain symptoms, result from the diseases and morbid conditions that cause or are specially accompanied by anæmia. The cachexiæ, the blood-poisonings, and the diseases of nutrition in which blood is not made in sufficient quantity, may all be attended with danger to some brain functions, though certain brains seem to have the innate trophic energy to nourish their tissues and perform their functions on less blood than others. In those predisposed by heredity to disturbance or enfeeblement of the mental functions, it is the mind that suffers in conditions of bloodlessness. We are entitled to assume that the convolutions of such brains have less than the normal trophic and functional energy. After death, in such cases, the whole brain, but more especially the convolutions of the anterior lobes and the vertex, are often found disproportionately anæmic as compared with the other organs of the body; and the brain is not only found anæmic, but manifestly wanting in normal consistence, in some cases atrophied to