probability there was a decided neurotic defect in the family. In their cases the weakness and instability of nerve cells, on which their mental disorder depended, was apparently in the hemispherical ganglia; in the girl it was probably in the nucleus of the pneumo-gastric nerve in the medulla oblongata. Here, then, in the descent from one generation to another there was transmutation from psychical derangement to spasm; morbid action had seemingly changed its locus from the surface of the brain to its base.

Some diseases of the nervous system are much more stable than others, and show less disposition to change in passing from one generation to the next. Thus though, as already indicated, in the great family of mental diseases substitution in descent is common, there are varieties in which the disorder in the parent is reproduced in almost the identical form in the offspring. This has not unfrequently been shown in the hereditary disposition to suicide, which, in instances on record, has been manifested in a marked form in three successive generations of the same family. The lower forms of mental defect do not seem readily to change in descent. Thus it is common for an imbecile mother to have an imbecile child or children. At present there is in the City Asylum an imbecile girl who is deaf and dumb, and sometimes slightly maniacal, whose mother was imbecile, and also under the writer's charge. The potency of the other parent, if free from defect, may, however, correct the evil disposition. This is illustrated by an elderly imbecile, likewise under care, who, when a girl, gave birth to an illegitimate male child. He is now grown up to manhood, and, though under the average of intelligence, is quite able to earn his livelihood. Monomania occurs occasionally in the descendants in much the same form as it showed itself in the parent. For example, a patient under my care for about twenty years, and now upward of seventy years old, cherishes the delusion that she has a mission to reform the churches, and writes numerous letters to the editors of newspapers and moderators of assemblies and synods on the subject, which never get beyond my waste-basket; otherwise she is a very active and intelligent woman. Her son is a sailor, about fifty years of age, and now and again writes to his mother. The letters are quite correct, except that he says that he too has a work to do, namely, to write a book about the heavens. This might be supposed to be an

instance of genius struggling under difficulties, but unfortunately his references to the subject leave little doubt that he labors under delusion of the same type as that of his mother, though somewhat different in form.

However, after full recognition of the fact that there are numerous cases of mental disease, especially in the forms to which I have referred, in which the reproduction in descent is very similar, if not quite identical, with the original type, the fact still remains true that metamorphosis in heredity is very common. In the production of this transmutation the influence of the other parent is often, no doubt, an important factor, and sometimes, as in the case mentioned, it seems sufficient to overcome the morbid dis position altogether.

Burrows and others have included apoplexy among the diseases which have interchangeable relations in descent. It can scarcely be questioned that apoplexy is hereditary, but its alleged property of transmutation with the neuroses is not so evident. These are essentially disorders of the nerve tissue itself, and are indicative of some weakness or peculiarity of its substance; it, on the other hand, is primarily a disease of the blood-vessels supplying the brain, so that they are respectively diseases of different tissues. There are, however, cases of apoplexy in which the first step in the morbid process is, through prolonged excitement or strain, enfeeblement and disorder of the structural elements of the brain, secondary to which there is degeneration of the walls of the blood-vessels. Such cases are probably allied to the neuroses in which there is instability of the cellular element in the central nervous system, inasmuch as a weak tissue will readily take on morbid action through excitement.

We

These may suffice as illustrations of substitution in the hereditary neuroses. now pass on to a consideration of this principle of mutation in the individual, confining our attention to the evidence of it in disorders of the nervous system. Heredity is here also by far the most potent factor in the formation of a constitution that is liable to a variety of neurotic disturbance. Bearing this in mind in regard to the whole group, I now proceed in reference to some of its members to remark that, just as we saw that asthma and insanity are substitutionary of each other in descent, so also they are in the individual. The following case is illustrative of this observation: A number of years ago a lady, about fifty years of

age, was under my care for acute mania. It was not the melancholic, gloomy, taciturn state which is usual in climacteric insanity, but a mischievous, somewhat happy excitement, with incoherence. Since her girlhood she had been a victim to asthma, the attacks being very severe, and occurring in paroxysms every few days. The mania lasted about six weeks, and during its continuance her breathing was easy and free from spasm. She herself had sufficient intelligence to observe this, and it was one of the points to which she referred in her morbid elation. The immunity was, however, but shortlived, for pari passu with the decline of the mental disease back came the asthma, and when she had fully recovered soundness of mind the paroxysmal distress of breathing was present in all its previous intensity.

At the meeting of the British Medical Association, in 1884, Dr. Norman read an interesting paper on Insanity Connected with Spasmodic Asthma, in which he detailed six cases which all showed a marked alternation of mental and pulmonary symptoms. In summarizing them he remarks: "In the first case we have chronic asthma vanishing when insanity comes on, and reappearing when the mental trouble becomes chronic. In the second, asthma cuts short and takes the place of an attack of insanity. In the third, perhaps the most remarkable and interesting of the series, habitual asthma disappearing, its place is rapidly taken by insanity, which again disappears immediately on the return of the asthma. the last change occurred the patient was under close observation in an asylum, so that there can be no doubt as to the sequence of events." In the fourth, fifth, and sixth cases the alternations of the two diseases were also present.

When

In his recently published work on Insanity, Dr. Savage relates two well-marked cases which were lately under his charge, and refers to two others that were still under treatment. The substitutionary features were similar to those already described.

The interchangeability of the different forms of neuralgia is well known. Thus, a lady was under my care for gastralgia, which had been troublesome for some years. In the earlier part of her life she had been a martyr to tic douloureux, which, however, had long ceased to give her any annoyance.

Neuralgia and insanity may alternate, or be transmitted the one into the other. In fact, what has already been stated respecting this and other neuroses in the passing

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from one generation to another is, at least with respect to some of them, true of the individual also. In the beginning of last year a female patient was under my care in the Infirmary, suffering from neuralgic pain in the arm; this being her chief ailment, though she had slight pains" elsewhere likewise. Two months previously she had been dismissed well mentally from the City Asylum, though at that time she also complained of pain in the arm. Her insanity had been of the melancholic type, with strong suicidal disposition. While it lasted there was no apparent ailment of the arm, and it was only when the mental disorder had passed away that the latter became evident. This case is certainly open to the doubt that the lunacy may have simply masked the pain in the extremity; but while admitting there is force in this objection, it is to be said that the impression left on my mind by all the facts of the case was that a metamorphosis of psychical into a sensory neurosis had occurred.

A protean disposition is characteristic of hysteria. Much attention has of late years been given to this disease, especially to its occasional striking sensory and motor manifestations, mainly owing to the writings and teaching of Charcot and his school. About seven years since a well-marked case of hystero-epilepsy with hemi-anesthesia was under the care of Dr. McCall Anderson, at the Western Infirmary, and the patient (S. R.), then a girl of eighteen, was shown at a meeting of the Medico-Chirurgical Society, when the bona fide character of the condition was fully established by a variety of tests which were applied in presence of the members. Since then she has been several times under my care in the City Lunatic Asylum, and as her case is a good illustration of substitution in disorder of the nervous system, I shall give an account of its leading features, summarized from a paper published by Dr. Anderson in the Lancet of July 12, 1879, and also from my own subsequent observation. It appears that her nervous illness began when she was fifteen years old, after an attack of typhus fever. At the commencement convulsion fits were the most prominent symptom of her neurotic disease, and the fits recurred about once a month, though when admitted into the Western Infirmary they were nearly of daily occurrence. She had then an almost constant pain in the left iliac region, and she stated that if she got a fright at any time the left leg and arm, especially the latter, became firmly contracted for a moment.

She had also amblyopia of the left eye, in so far as she had great difficulty in reading small print with that eye, and she was colorblind with respect to certain shades, which need not now be detailed. There was a slight powerlessness of the left side, but the most striking feature in the case was anesthesia of that side, together with loss of the sense of touch, temperature, and pain. The sense of taste on the left side of the tongue was likewise in abeyance. There was pain on deep pressure over the left ovary. The convulsions were general, affecting both sides of the body equally. Under metallotherapy, particularly when lead or gold was applied to the anesthetic side, sensation returned in a few minutes, but at the same time it usually disappeared from the side previously unaffected. A similar result followed the close approximation of a large magnet to the anesthetic arm and leg, but were simultaneously lost in the opposite extremities.

This girl left the Western Infirmary on April 5, 1879, being regarded at that time as nearly well. On the 20th October of the same year she was admitted into the City Asylum, suffering from acute mania.

This was chiefly manifested in excitement and violence, and a disposition to make dangerous assaults on her fellow-patients and the attendants during trifling quarrels, and sometimes on entirely imaginary provocation. She remained in the asylum till March 1, 1881, when she was dismissed well. During the earlier part of her residence she was subject to severe epileptoid seizures about once a week. Each attack was composed of many fits, sometimes forty or even more in the course of twelve hours, a condition corresponding to, but essentially different from the status epilepticus being established. She had also many attacks of mania in the form just described, and these lasted for three or four days. Even when what may be regarded as well, she was of a violent and vindictive temper. There was no recurrence of the anesthesia. This was carefully tested in the intervals of the attacks. During the paroxysms of convulsion, and in the brief intervals between them, sensation was in abeyance, at least there was no indication of its presence on pinching her limbs or pricking them with a needle. On four occasions since then she has been an inmate of the City Asylum for periods ranging from three to six months, once in Bothwell Asylum for some weeks, and once in Govan Asylum for two months. Mania and convulsions were the features of

all the seizures, but I am not aware that there has been any return of the anesthesia of the left side. I have questioned her repeatedly on the point, and her reply has always been in the negative, except once, when she said that there had been a slight relapse of the loss of feeling. In the summer of 1886, when she was last under my care, I carefully tested her powers of distinguishing colors. No defect was found in the right eye, but with the left one, when shown pink she named it white; blue she called black; yellow, white; scarlet, gray. She made no mistake with the color green.

For some months this patient has been in Gartnavel Asylum. She continues subject to convulsive seizures, and is regarded by the officials as one of the most dangerous patients in the institution.

In relation to her case I remark that there is evidence of more than one transference of morbid action within the brain in the course of her malady. The convulsive seizures pointed to the motor centers as their special seat. The mania probably implied that the hemispherical ganglia generally were involved. At the time she was shown to the Medico Chirurgical Society, except the very slight motor weakness, only sensory symptoms were present, and we infer that while in that stage of her illness the sensory ganglia or centers were almost exclusively affected. The substitutionary character of the disease was strikingly demonstrated by the transference of the sensory defect from one side of the body to the other, the disorder having, so to speak, jumped from the sensorium in one hemisphere of the brain to the sensorium in the other hemisphere.

Our knowledge of the intimate mutual relations of the different parts of the nervous system is not yet sufficiently advanced to enable us to speculate to much advantage on the pathology of this substitutionary action. Where there is a materies morbi, as in gout, a determination to the joints (whatever way that may be effected), and the deposition of the urate of soda in and around them, seems satisfactorily to account for the disappearance of discomfort from the internal organs; for we may reasonably think that the irritating matter has been withdrawn from them to the articulations. When the phenomena to be accounted are such as epilepsy or apoplexy, following the healing of old ulcers, we may suppose that morbid action has somehow been diverted from the region of the sore, which has come to act as a kind of safety-valve to the brain. The alternative of asthma or neuralgia and

insanity are not inexplicable by our present knowledge. The same remark is applicable to the mutations of heredity, though we can imagine that in the building of the nervous tissue there has been a defect in one or more parts, and the organ thus imperfectly developed will readily fall into disordered action. As already indicated, the influence of the other parent naturally occurs as a feasible explanation of the change in the seat or nature of the histological defect.

The principle of substitution is suggestive in relation to treatment. It underlies the different modes of counter-irritation, such as blisters, setons, issues, and the actual cautery. By their means we establish an artificial disease in a safe part, usually the integument, and often thereby succeed in partially or completely withdrawing abnormal vital force or action from some internal organ, where it is destroying tissue, to the surface of the body. There it may safely expend itself in various ways; for example, in the formation of a blister, if a vesicating agent has been used, or in throwing off a slough, should an issue have been formed, and in the after-process of restoring the integument to its normal condition. — Dr. Alexander Robertson, Edinburgh Med. Journal.

THE ETIOLOGY AND CLASSIFICATION OF THE ANEMIA OF PUBERTY.-A large number of girls suffer during puberty from a condition of ill health characterized by a very constant train of symptoms, and to which the names anemia and chlorosis are applied. Although the disease is so common, its symptoms so plain, and the treatment, as a rule, so successful, the etiology is by no means well established, various theories being put forth by different writers.

Trou-seau considered it a neurosis, the blood changes being secondary. Niemeyer appears to consider it as a result of premature sexual activity. He writes: "According to my observation, obstinate chlorosis attacks all young girls, without exception, in whom the menses have appeared in the twelfth or thirteenth year, before the development of the breasts and pubes." Mitchell Bruce says the origin of the disease lies in a peculiar condition of the blood and blood-vessels, which is believed to be congenital and perhaps hereditary. Aitken considers chlorosis as one of the "functional diseases of the female organs of generation in the unimpregnated state." Sir Andrew Clark considers "feculent retention and its consequences" as the cause. Sée looks

upon the inability of the organism to meet the demands made upon it by the simultaneous advent of menstruation and of rapid growth of the tissues as the cause.

A great many predisposing and exciting causes have been described by various authors; most of these seem to be not so much causes as merely coincident with the time of life at which the disease begins, but, generally speaking, all things are causes which lessen metabolism and the power of • the system to meet the demands made upon it, such, for instance, as want of exercise, improper food, and vitiated air, and the variety of the disease caused will depend greatly upon the force and direction of these causes.

The distribution of the disease bears this out. It is not confined to any class, but is more often met with in large towns than in the country, and is much more common among girls who sit at their work than among others. When it does occur among servants, defective drainage is often an exciting cause. In Dublin the disease is very common; yet in Huddersfield, where the great majority of the girls work from an early age in mills, it does not seem to be common, as, on looking over the notes of more than six hundred cases treated there consecutively, I find only three examples of the disease, and one of these girls is specially noted as having a "sitting job" in a mill. The chief differences between the girls in Yorkshire towns and those in Dublin are, that the former are better fed and have more exercise both at their work and after it.

But, although these causes are generally met with, sometimes they are absent, and the disease occurs in girls of good physique, living in country air, warmly clad, and well fed.

In Sir Andrew Clark's paper the graphic description of the patients only dealt with one variety of the disease-that generally termed chlorosis; but other well-marked varieties of the anemia of puberty are met with. I would venture to propose the fol-. lowing classification:

1. Fat anemia, where there is a wellmarked deposit of adipose tissue.

2. Anemia of overgrowth, where there has been well-marked general increase of growth without much deposit of fat.

3. Anemia of general malnutrition.

The first and second and the second and third may overlap, but never the first and third. In the first variety the symptoms of anemia generally follow the deposit of fat

The

in the tissues; in the second they follow the rapid growth; in the third they generally follow the appearance of the menses. second and third (those in which there is no deposit of fat) are liable to be complicated by tubercular disease.

In spite of the great weight of Sir Andrew Clark's experience I can not look upon constipation as even an important cause of this anemia. Constipation and anemia are often associated, but very often the constipation is not greater than would be expected from the general sluggishness of the functions, and is similar in significance to the copious pale urine, of low specific gravity and deficient in urates, so generally associated with this anemia. That the constipation is accompanied not only by torpidity, but also by loss of power, is shown by the failure of belladonna and nux vomica to relieve it.

Another argument against constipation being the cause of the disease is, that cure often follows the use of iron in the form of Griffith's mixture or Blaud's pills, without any purgatives being administered.

Habitual constipation is a common complaint, and as long as the bowels are evacuated regularly, uncomfortable symptoms seldom arise, no matter what the interval between the motions. There seems no reason why constipation should at one age and in one sex cause this characteristic train of symptoms, and produce none of these symptoms at other times.

In some curious cases the constipation is persistent through life, but is not accompanied by any definite symptoms except at puberty and the menopause, at both of which periods there is palpitation, with shortness of breath on exertion. In the one case at present under observation there has been obstinate constipation, as a rule not more than one motion in nine days; the patient is now forty, and it is only quite lately that the palpitation and shortness of breath have appeared.

With regard to the occurrence of the menses, my experience is very different from that of Niemeyer. Early develop ment and not premature menstruation seems the rule. Often the anemia sets in without any appearance of the menses, but in many of the cases there has been a slight appearance for from one to three or four months, and then either a total cessation or an occasional slight appearance for a month or two, and then several months without any.

Generally speaking, I have found that in

the anemia of general malnutrition the menses may be absent, scanty, or, in rare cases, normal. In the anemia of overgrowth there is an attempt at establishment of menses without development of the breasts, etc.; and the beginning of fatty anemia is coincident with the development of the breasts, etc.

In the fatty anemia there is certainly an hereditary acquired causation. It is very common to find several sisters affected. In one family I have noted four, in another three, and in several two so affected. In these cases I have often found that the mother has been married early in life, and I have learned to look upon this as an important factor. In one family of good means, and living in the country, the mother was eighteen years of age at the birth of her first child. She has had five sons and three daughters; all the sons have been very strong, but the daughters, although when young strong and of healthy color, have all passed through well-marked fatty anemia. In another case the mother never suffered from anemia; her first child, a daughter, was born when she was only seventeen; the child is now rapidly getting stout, has no appearance of the menses, and is, in fact, passing into fatty anemia.

Another very interesting point in this variety of anemia is, that if any strong call in a particular direction is made upon the system it will be able to meet it; thus, there is generally marked shortness of breath and palpitation on going upstairs, and but little while walking not too rapidly on level ground, yet domestic servants so anemic as hardly to be able to walk on level ground, will sometimes be able to carry heavy weights upstairs. This I have never observed in the other forms of anemia.

A most important contribution to the etiology of the disease has been made by Beneké, who has shown that the annual increase in the heart and blood-vessels in girls up to puberty is eight per cent per annum, while during the establishment of menstruation it is eighty to one hundred per cent, so that if puberty is established in a single year, an extra growth of from seventy to ninety per cent weight in addition to ordinary growth is entailed, and at the end of puberty the lungs have arrived at the fullest development, and the excretion of carbonic-acid gas has reached its highest. There is no such rapid change in the male.

Professor Bowditch says that, up to eleven or twelve boys are, on the average, taller