attempt at its infraction.

Very few of us, if we were incarcerated as insane, would be careful enough of our conduct to keep ourselves from acting as though the allegation was true. It is easy, then, to perceive that the imprisonment of persons actually suffering from mental aberration has the worst influence. We should resort to it, therefore, only in cases of actual danger or necessity. If it is a reasonable thing to do otherwise, the patient should not be sent to a lunatic asylum. In fact, hospitals are not fit places for persons who can do better than go to them. The influence of one disordered individual upon another is very generally unwholesome. An hysterical person will induce hysteria upon others; chorea will run through a multitude; an epileptic will disseminate epilepsy; and mania or hallucination in the various forms will more or less incite sensitive patients to like abnormal manifestations. The displays of dancing mania during the Middle Ages are matters of history. Individuals engaged at their usual employments would abandon them when the troops of possessed persons came along the streets, and join the besotted multitude. Even armies of children forsook their homes and set out for the Holy Land to rescue it from the Turks. In more ancient periods, the individuals attending at the festivals of the Great Mother and the Slain God, were wont to become frantic and hallucinated. The very name of epilepsy was anciently "the holy disease," because it was so common at the religious processions and assemblies; and chorea received its designation from the choruses that used to dance infuriated around the altars of the gods.

We have the explanation of Dr. Benjamin W. Richardson, of London, perhaps one of the most accomplished of physiologists and intelligent psychologists, that every individual projects from him a nervous atmosphere which extends to a considerable distance in every direction. It is obvious, then, that in assemblages of excited persons, there will be a commingling of their nervous atmospheres, which will tend to intensify their excitement till exceedingly abnormal conditions are produced. The collecting of insane patients into large hospitals will, from a similar cause, operate powerfully to aggravate their several maladies, and even to render them incurable.

In regard to medical treatment, it should be carefully restorative. The chief physiological difficulty with the insane patient is the imperfect nourishing of his bodily organism. The functions

connected with nutrition are not duly performed. We have already noticed dyspepsia and consequent debility as operating to produce mental disorder. The intestinal system shares in the general derangement; its glands do not properly separate the disintegrated material from the blood, and the impaired peristaltic action results in accumulations of bile and urea, two most energetic agents to create disease. These conditions should be attended to when present.

It is of the greatest importance to promote sleep. This is the natural restorative of the body; and all the processes of nourish ment and secretion are then most active. Emanuel Swedenborg says that the soul is then released from its duty in the brain, and goes through the body repairing its waste and lesions, and restoring the normal condition. It is hardly necessary to add a deprecation of the use of narcotic drugs to produce sleep.

In short, insanity is a disorder of the volitional nature, attended by moral and physical disturbance. Whatever, therefore, impairs the force of the will does so much toward rendering the individual not a moral agent. The emotional department of our being is the chief seat of the mischief; and the impairment of vital energy the first physical departure. Then the blood fails to nourish the brain. and to remove waste material from it. That structure is accordingly atrophied and at the same time loaded with effete and morbid substance. The rational soul finds the machinery out of order, and incapacitated for normal function.

In contending with such a state of things we have a legion of devils to deal with. I would therefore have no moral, religious, or medical quackery in the matter. The medication should be simple, the purpose being to soothe irritation, promote functional activity, and produce normal sleep.

The aim of the true alienist is to restore the patient. The means to be employed shall always be recuperative. Every agency likely to create emotional disturbance should be kept out of the way. Administer no drug likely to react prejudicially; let there be no discourse that is of an exciting or depressing character; let repugnant individuals be kept out of the way; and let care be taken to obviate and prevent the rousing of the passions of hate, anger, jealousy, envy, hopelessness, or any inordinate emotion.

The patient should be kept busy at some employment in which

he takes deep interest; always stopping to rest at the very moment that he experiences a sense of fatigue. The Jesuits are said to have a rule that none shall keep longer than two hours at the same work. It is a most excellent one, and should be observed by every one. It would entirely obviate that condition which degenerates into monomania, and would be beneficial as a preventive to other forms of mental disorder. In the care of the insane, the hallucinated, hysterical, and hypochondriacal it would be invaluable.

If the insane person can be removed from the scenes where the trouble began or was aggravated and placed in the company of an individual of strong will, equable temper, kind disposition, watchful and discreet, who can exert all necessary authority without seeming to do so, much of the trouble of this character would be obviated, and generally he would recover. In Belgium there are cottages for the reception of such patients where they are secluded and their care is had with direct reference to recovery. Whether the method is all that can be desired I am not able to say; but it must be a vast improvement on hospitals.

Yet, with it all, I would fall back upon the words of Macbeth's physician: "Herein the patient must minister to himself." It is our place to help, not to do for them. In the New Testament faith seems to have been required even for what we denominate miracles. I am not disposed to agitate religious questions or dogmas, nor to ignore the religious element in our nature. But faith as I understand it is more than mere assent and passive receiving of an idea or statement. It is an active quality of purpose and resolve. The patient whether a lunatic, or the object of some other malady, must participate in the active volition of his own recovery. He should be treated like a responsible human being, and so far as in us lies be made conscious that he is such. While we are aware that a morbid egotism or self-consciousness lies at the bottom of his trouble, we should seek to rouse him to a vivid sense of selfrespect. If he imagines himself suffering from some fancied ailment, or that he is the victim of conspiracy or persecution, or that he is in the presence of some fancied personage, let him be quietly shown that he is in error. The next phantasy after this one will be less fixed. The like course may be pursued with the next, and all succeeding ones. Self-respect will be gradually attained, and, with the improvement of bodily health, the derangement will pass

away. As the mind recovers its equilibrium, the emotions will come under subordination to the will, the abnormal phantasms will cease or will be intelligently recognized as objective images of mental conceits, and the individual thus set free from his terrible infirmity will return to the society of his fellows redeemed and made whole. ALEX. WILDER, M.D.

CHOREA AND ITS TREATMENT.

PARADOXICALLY our greatest success in the management of chorea would be in its prevention. If the silly idle stories of elders told to children, and the unnecessary and pernicious threats resorted to terrorize children into obedience and subjection were unknown, we would find fewer unstable brains and expectant nervous systems awaiting but a slight exciting cause to start them in the gamut of functional nervous disorders. Chorea may be due to certain local or constitutional predispositions in many instances, but in many it is directly traceable to some immediate exciting cause or to where some sudden and profound impression of an emotional nature has put into disorder an imperfect nervous system. In my clinic where most of the children are from the poorer classes, chorea is one of the commonest nervous affections, and in a majority of my cases a cause can be traced, e. g., being locked alone in rooms all day while the parents are at work; children being left in the charge of older children who worry, annoy or even terrorize them being deprived of food for misdemeanors-and this most potent factor and frequent mode of punishment, the placing of children in the cellars or dark closets where vermin or rats may possibly be present or suggested. In other words; if at any time in the early development of a child it has been thoroughly frightened and the memory of that fright remains, "a nervous predisposition has been induced and always renders that child liable to nervous disorders whenever the external stimulus is sufficient to arouse this unstable nervous system. Close observation of the various forms of chorea makes one believe that it is a brain-disorder, probably of the cerebral cortex, or produced within the influence of the internal capsule (the place of gathering of all the motor fibres from the cortex just before forming the crus cerebri and pons) and its surroun

dings. Morbid anatomy has been mostly negative, though recently Elischer reported a case where he found softening in the motor cortex; Jackson, Fox and others, cases of softening in and about the corpus striatum; Gray and Tuckwell, cases of disease in the anterior and middle convolutions. The older observations of various conditions of the brain and spinal cord cannot be considered in the light of our present knowledge. Many theories have been warmly advanced and upheld but the great advances made in cerebral physiology in the past decade have left most of them far behind.

Nothnagel urged that chorea was a disease of the medulla and experimentally he proved a spot in the fourth ventricle-known as "Nothnagel's Convulsive," where irritation was always followed by convulsive movements. Nothnagel's theory is a fascinating one, for it is well known that at certain times, certain parts of the medulla oblongata, including the vaso-motor centre, acquires the power of periodically producing vascular changes which lead to explosive or convulsive discharges in the motor nerve - centres, Hughlings Jackson, since followed by Ferrier, Gavers and others, claimed that the disordered movements were caused by "discharges" or explosions in the cerebral cortex, and that all special forms like chorea, facial tic and what may be termed localized convulsive movements are dependent upon interruption in conduction through either the motor cells or the motor conducting strands. As these movements seem to be mostly "direct," it is probable that they are produced without any material agency of the spinal cord. In fact the agency of the spinal cord has been much exaggerated in these disorders, which are not dependent upon "reflex" conditions.

In certain clinical cases observed, where the movements are unilateral or involved certain special muscular groups, the diagnosis can be made easily, and the localization in such cases would be in the cerebral cortex (motor convolutions), pyramidal tract or basal ganglia of the opposite hemisphere. The relation between chorea and rheumatism and cardiac disorders has long been considered an important one; and many clinicians still advocate the embolic origin of chorea. True, autopsies in a limited number of cases (Dickinson, Wilkes) have demonstrated the embolism in the distribution of the middle cerebral artery. The theory is one that is most plausible, for it so readily explains why the disordered incoordinated movements of face, tongue, arms and legs are caused by