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most noisy and disorderly, from the most profound prostration, and the most disgusting improprieties, to perfect restoration. It is in such cases as these that we find some consolation for the infinity of disasters, the numbers of incurables, from primitive defect or malformation which we so constantly meet with.

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'General paralysis is very amenable to the great law of hereditary transmission-every day furnishes us with proof of this. In families touched with insanity, epilepsy, and apoplexy at early ages, it is frequently the case that we meet with cases of general paralysis; at the same time, no alienation is so frequently due to accidental causes as this."

Two striking illustrations of the influence of sensual and sexual indulgences are given at length, concluding with these observations:

"Libertines and drunkards are frequent victims to general paralysis. Among the young women attacked by this cruel malady, a great proportion are prostitutes.

"The abuse of mercury for long periods appears to have produced insanitythe same may be said of opium, quinine, tobacco, and some other drugs."

Under the head of "Moral Causes," M. Trélat gives seven cases, one in a child from fright-one in a young girl, who witnessed the execution of members of her family-one in a young lady who accidentally saw a public execution-three from unkind treatment from husbands-and one from religious terror, induced by a severe confessor.

Pinel relates other cases: three young females were brought to the Salpêtrière very near together; the first had lost her reason, frightened by a spectre, made up by her companions; the second terrified by lightning; the third horrified by having been introduced by accident into a house of ill-fame.

M. Trélat, recognising the influence of all these classes of causes, yet supposes that in many of them there is the hereditary predisposition. He thus sums up his conclusions.

"There exists one great cause of alienation, primordial cause, cause of causes, hereditary transmission; it is a law. Nevertheless, this law can be modified by

alliances.

"There are families where all the children are affected, and again others where only part are so.

"There are cases even where the existence of this transmissible tendency, happily modified by matrimonial alliance, only seems to produce salutary effects, such as exalted intelligence, wit, and sometimes genius. We must receive these effects thankfully, when they appear, but not attempt to seek for them, in the present state of our knowledge of cause and effect; the experiment costs too dear occasionally. This great cause generally suffices of itself, and only needs favouring circumstances for its development.

"Far, very far below this, we have ranked all the other causes, physical and moral; the only method is to appreciate them correctly."

On Goître and Cretinism.

M. MOREL, in the Ann. Med. Psych., gives a letter from Mgr. Alexis Billet, Archbishop of Chambery, on the above-named subject, from which we extract a few observations, perhaps somewhat unconnected:

"

'Certainly it is laudable to take care of the moral and physical education of young cretins, so far as they are susceptible of it; but I believe that we must hope much more from prophylaxis than from therapeutics; for if a child be gravely affected with cretinism from its infancy, the cares of humanity may do much to alleviate its condition, but can scarcely hope for a cure."

The following statistics are given as illustrations of the simultaneity of the occurrence of cretinism and goître, and the proportions. In the diocese of Chambery there are 176,145 inhabitants. The cases are as follows:

Bovs.

Girls.

Total.

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In the diocese of Maurienne, 63,156 inhabitants :

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"I partake your opinion that the chief morbid agent concerned in the production of cretinism acts upon the cerebro-spinal system, and thus affects the whole organization of the individual; whilst to produce goître, when alone, it only produces hypertrophy of the thyroid gland. It is certain that out of those localities in which these diseases are endemic, sporadic cases of each are met with, goître much more numerous than cretinism. The latter, when sporadic, appears to be generally only a kind of idiocy, which does not present all the characteristics of the endemic affection."

Some interesting details are given in reference to the geological distribution of these maladies, and particularly in relation to iron, which does not appear to be a preservative, as the Archbishop at one time supposed; in one district where there are many iron mines, and but 1217 inhabitants, there are 299 afflicted thus. The chief habitat of these affections is the lias-the sulphate of lime, and clay. Those seem most free from them which are situated on the compact lime and chalk strata. There are few examples at an elevation greater than 1200 or 1400 metres.

"You attribute the diminution of these diseases in the locality of Nancy in great measure to alliances from healthy localities. In Maurienne, this means has been tried from time immemorial, but with very limited success; the general condition of the population has been scarcely at all ameliorated. Those young women who came to the district at eighteen or twenty years of age do not contract cretinism, but are liable to goitre; and their children are as liable to both as the rest of the population."

"You appear to indulge the hope of causing these sad affections to disappear entirely by ameliorating the hygienic conditions. It is almost the sole point on which I differ from you. I grant the propriety, by every possible means, of attempting this by draining, &c.; the effect must be good, but will not be complete, because it can only affect the secondary causes. Perhaps more may be hoped from the establishment of cisterns for pure water, and the use of iodized salts, &c. You consider these hereditary maladies. I believe them to be

transmissible to the first, perhaps to the second generation. But it appears to me that if an affected family goes into a perfectly healthy district, after the second generation there ordinarily remains no trace whatever of the malady; whilst, if a healthy family comes into an affected district, the children already born are liable to goître, and those born afterwards are liable to both diseases, like the others."

"I have always thought, and think still, that children are born cretins, but become goîtrous. Cretinism attacks the fatal life; it would be prudent to send pregnant women to a healthy district."

In conlusion:

"I think with you that goître and cretinism have a common origin; that we must seek the principal cause in the geological constitution of the soil under the surface, not above it; that this may exercise its baneful influence in uniting itself to the water, the air, and even to the natural productions used for food; that the unhealthy condition of the dwellings and the other objectionable hygienic conditions are only secondary causes, which favour the development of the diseases. It is very desirable to attempt the rectification of these conditions as far as possible, but especially to direct the principles of prophylaxis against those first causes which seem to be most potent-healthy alliances, the establishment of cisterns, and the use of iodized salts."

Other communications appear to have passed between Dr. Morel and the Archbishop on this important subject, which we have not had the opportunity of seeing.

Alternating Mania and Melancholy cured by Quinine.
By H. LEGRAND DU SAULLE.

MADAME M., ætat. thirty-four, small stature, lymphatic temperament, habitual good health, sweet and affectionate character, with simple and modest tastes, is received January 25, 1852, under care, a prey to the most profound melancholy, apparently arising from religious influences. There is no hereditary tendency discoverable. Her paleness is almost cadaveric; her weakness intense. For three days she has refused nourishment; she has heard a voice saying, "Fast, and thou shalt be pardoned." She was induced to eat, but retained for some days this extreme depression. On the night of the 29th she began to talk incoherently, to sing, laugh, and shout, and to disturb or break everything near her; exhibiting every symptom of acute delirium. Thus in the evening she was melancholic, possessed with religious feelings; in the morning, she was maniacal, shouting and swearing. Treated by prolonged baths, cold affusion to the head, and morphia. Feb. 4. The violence has given way to a consciousness of illness and weakness-gradually subsiding until

Feb. 6, when the entry is "Perfect calmness-reason sound, demeanour cheerful. The catamenia have appeared during the night.

Feb. 16. Up to this time the patient has appeared well: but now the symptoms of melancholy reappear; she hears the last trumpet, and is doomed to eternal perdition. From the 17th to the 21st, the melancholy is as profound as on her first entrance, and with the same general tendencies. From the 22nd to 28th, there are again the symptoms of acute mania, as violent as before. On March 2nd, calm

ness is re-established. The sulphate of quinine is prescribed and taken in increasing doses till the 10th of April; on the 16th of March there is a very slight attack of excitement; after that all goes on well, menstruation is regular and natural, the health is restored, and the patient is discharged on the 31st of May, apparently perfectly well. This is a very graphic instance of the Folie à double forme, noticed by M. Baillarger in an interesting communication on the subject to the Academy.

Mania and Delirium-Treatment in several cases.

A YOUNG girl, ætat. 19, brought to the Salpétrière, March 18, 1855; with all the signs of acute mania, shouting, threatening, incoherence and sleeplessness. She was menstruating. About a grain of opium was given at once, and repeated with increase till three grains were taken at one dose. Sickness supervened, causing a suspension of the remedy, but it was again given, and continued till the 20th of April, when the symptoms having in great measure subsided, the dose was gradually diminished. In the beginning of May the agitation returned, and the dose was again augmented to four grains at night. Again there was a marked amendment, and again a reduction of the opium. At the end of May, menstruation occurred so very profusely as to require perfect repose, and to reduce the strength extremely; and the agitation and violence became so marked as to require the straitwaistcoat. The delirium was complete-the opium was again increased, but calmness was not restored till June 15th. From the 10th, iron and quinine were given, always containing the opium. Menstruation again appeared on the 20th, not so violent as before; and there were some indications of excitement, but not strong. These measures continued, resulted in complete restoration in July. It is necessary to add, that during the treatment, she had taken purgative medicines a few times, and a few baths. Opium appears to me to be indicated in all cases of mania, but especially in those which result from, or are attended by, extreme feebleness; it is in such cases far preferable to prolonged baths, which are attended then with real danger. I have seen a young man recently, attacked with acute mania, subsequent to rheumatism and spare diet, treated by 5 grain doses of opium for fifteen days, and completely relieved.

The German and English physicians employ narcotics in the treatment of mental affections much more frequently than we in France; and M. Michéa has rendered us a real service in recalling attention to this mode of treatment. For two years I have resorted to it frequently; and if I have not in all cases seen rapid results from it, I have never, even in the most unfavourable, seen the duration of the cases increased. I have employed opium also to calm the maniacal paroxysms of the paralytic, with the same effects as in simple mania.-(BAILLARGER.) Another case, interesting from the results of sedative treatment, is related by M. Forget, of Strasbourg. A young, delicate, nervous lady is seized on the 4th Nov., 1854, after a chill, with headache,

depression, febrile symptoms, anorexia, furred tongue, and constipation. The exhibition of a bottle of "Seidlitz water" was followed by great prostration, fever, with nocturnal exacerbation, and subdelirium. About the fifteenth day, it takes the form of furious and prolonged mania. Æther had no power in calming this state, and M. Forget having no faith in other antispasmodics, including musk, prescribed a quarter of a grain of opium every quarter of an hour. At the end of two hours, the delirium still persisting, more opium was given, making altogether 3 grains in three hours. The excitement abated, and calm sleep followed. The pulse was regular, respiration gentle, the skin moist. The details need not be followed-on the twenty-fifth day convalescence was declared.-(FORGET.)

On the treatment of the peculiar and rapid form of mania called acute delirium (délire aigu), some remarks of Dr. Jensen, of Copenhagen, are important:

"We must not forget that this is a central hyperæmia, the course of which is that of the idiopathic mental alienation. We must carefully avoid general bleeding, which experience shows to be dangerous, unless in active congestion. Bleeding must only be employed to reduce the force of the circulation, to lessen pressure on the brain, or to check convulsion. It must also be remembered that in passive hyperemia, whatever tends to slacken the general circulation, tends in so far to increase the venous stasis. On the same account, we must be chary of local depletion.

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The methodical employment of cold gives more satisfactory results. It is the best mode of producing the necessary reaction, and of re-establishing the contractility of the capillaries. It calms the patient, relieves headache, and prevents the return of the paroxysms of agitation. The first effect is paleness of the skin, falling of temperature, diminution of the force and frequency of the pulse, and of the agitation: the patient seems to come out of a dream. Afterwards the usual phenomena of reaction. The longer the irritation is continued, the colder the water, the weaker the patient, by so much is the reaction longer in appearing, but also stronger in proportion. The water should be 14° or 16° (Reaumur? or Cent. ?), and its application be continued from two minutes at the beginning to ten at last. If it be only to the head, it may be applied for an hour whilst the body is in a hot bath. The most prompt reaction is obtained by irrigation over the body, which is to be wiped dry, and wrapped in warm linen. It may be repeated many times a day.

"After the immediate danger is passed tonics must be used, especially quinine; sometimes, where irritation still continues, opium may be combined with the quinine. It is an important point not to forget to empty the bladder. "It is customary, on recovery, to put a seton in the neck."

Medico-Legal Cases.

DR. DELASIAUVE extracts from a Spanish paper the following interesting case of fratricide and attempted suicide, the subject of which was acquitted as not at the time responsible.

Arsanz, æt. twenty-six, had been a soldier, always of good conduct; his health seemed tolerable; he was subject every spring to epistaxis, also to talking in his sleep. The spring of 1854 passed without epistaxis, and from that time, particularly during the night, he was

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