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Protocol: Body of a female of medium height and slight frame. Emaciation extreme. Post-mortem rigidity present and lividity over dependent portions of the trunk. Large decubitus chronicus over sacrum. Eyes directed forward. Pupils, 4 millimeters in diameter; circular and equal. Facial features symmetrical. Extremities are of equal size on the two sides.

Head Section: The tables of the calvarium are thickened at the expense of the diploe. The dura is diffusely thickened and firmly attached to the overlying skull cap, but not to the pia-arachnoid. Brain weighs 1050 grams with membranes. Arachnoidal and perivascular spaces are dilated by straw colored fluid. Blood vessels over the brain surface are engorged with a dark colored blood. Over the tips of the frontal lobes some slight extravasation is present. The pia is diffusely thickened, this being particularly noticeable along the course of the blood vessels. On removing the pia-arachnoid from the underlying convolutions, the cortical surface presents a dull appearance instead of a normal, smooth, glistening one. The upper portions of the Rolandic areas, superior convolutions of the parietal lobes and tips of the frontal lobes have lost their normal plumpness. Some of these gyri are quite narrow and a trifle retracted; others are not so badly affected. The surface appearance of the remaining portion of the brain shows no marked departure from the normal. The cut surface after a vertical section of the brain, presents a thin cortex, some medullary shrinkage, dilated ventricles and numerous little red weeping points, the sites of the cut, engorged blood vessels.

Macroscopic appearance of the cerebellum, pons, medulla and spinal cord is negative.

The gross changes found in the other organs of the body were not sufficiently interesting to justify a detailed description here.

Sections for microscopic study were taken from the brain, cord, lungs, heart, aorta, liver, spleen, kidneys, suprarenal glands, cervix and ovaries. The stains used for the tissues were Nissl's, Marchi's, Weigert-Pal's, Van Gieson's and eosin-hæmatoxylin.

The microscopic findings of the general tissues were as follows: The left lung showed an acute tuberculous process involving all three lobes. The right lung was negative except for a small pneumonic area situated in the lower portion of the upper lobe. The muscle cells of the heart were shrunken and the nuclei appeared to be quite numerous on account of the cells being small and the connective tissue proliferated. The coronary arteries were thickened; this thickening being more evident in the intima and adventitia. The specimen of the aorta showed a marked diffuse proliferation of the endothelial cells. The liver showed considerable hyperplasis of the connective tissue, also numerous fat droplets in its parenchyma cells. The specimen taken from the spleen revealed a definite chronic interstitial and perisplenitis. The trabeculæ were more numerous and larger than normal, and the splenic pulp diminished in quantity and contained numerous little collections of blood pigment. The kidneys showed no acute changes, but the fibrous tissue was markedly increased;

some of the epithelial cells lining the tubules were granular and others had separated entirely from the basement membrane. Hyalin casts could be seen in the tubules. The arteries of the kidneys were thickened; this thickening being most marked in the intima. The suprarenal glands and ovaries were negative. The specimen of the cervix showed round cell infiltration and some hyperplasia.

Microscopic changes found in the nervous system:

On examining the cortex stained by eosin and hæmatoxylin with the two-thirds objective, the most striking features observed were the thinness of the cortex, the unusual thickness of the first layer, the dilated state of the perivascular spaces, the great number of small, round, intensely stained nuclei, and the apparent proliferation of the small blood vessels, including the capillaries. The entire vascular system of the cortex and subcortical layer was markedly engorged and in the latter some extravasation of the cellular elements of the blood could be seen. Looking around the margin of the specimen just beneath the pia and in a few instances extending down into the cortical tissue, numerous little spherical bodies, a trifle larger than a leucocyte, palely stained and without well-defined nuclei, could be seen with the low objective. The one-sixth objective revealed considerable cell proliferation in the walls of the capillaries and arteries, with definite minute hemorrhages in the subcortical layer. The spherical bodies previously mentioned were found to be myelin globules and the numerous small, deeply stained nuclei seen with the low objective were thought to be the nuclei of the proliferated glia cells.

The nerve cells of the cortex as well as those of the cord (Nissl's stain) showed chromatolysis, shrinkage, granular degeneration, and in some instances, complete disintegration. In the cortex the greatest damage done seemed to be in the third layer, motor area, but the same condition was present in the other layers of the cortex as well as the other areas of the brain, to a less extent. Fat droplets were found in those cells which were partially degenerated; also scattered around between the cellular elements little black bodies could be seen which had taken on the osmic acid stain. Specimens from the various portions of the spinal cord, stained by the Weigert-Pal method, showed a diffuse fiber degeneration; the anterior and lateral columns suffering most. The fiber destruction in the cord was not in any place sufficient to entirely destroy its functioning power. The posterior columns were found to be in practically a normal state, possibly on account of having their seat of origin outside of the cord.

The above clinical and laboratory notes have been presented in as brief a form as practicable, therefore deductions are unnecessary. However, attention is called to a few particularly interesting features of this special case, such as the great number of relatives affected, the violent choreic movements, and the rapid mental reduction; also the extreme atrophy of the entire brain and the decided proliferation of the glia tissue elements.

BORDERLAND CASES OF INSANITY AND THE

VOLUNTARY PATIENT.*

BY ALBERT WARREN FERRIS, A. M., M. D., NEW YORK,
President of the New York State Commission in Lunacy.

Rarely does a physician experience as great satisfaction as that which attends the recovery of an insane patient. If skilfully adjusted occupation and diversion, special individual study and care, and personal suggestion result in the emergence of the patient, the medical attendant has received his highest recompense. Scarcely less valuable than his services are those of the physician who lifts to a higher plane the chronic case and makes the most for an irrecoverable patient of the remnant of life's enjoyment that is left him.

While relief from distress and cure of disease are generally considered by the thoughtless to be the whole duty of the physician, these do not in reality compass it; for prevention is the greater duty as it is the crowning achievement. Humanitarian, sanitarian, psychologist, and publicist the capable physician must be, and his arena is the world.

Over the entrance to the surgical amphitheatre of St. Come, Paris, are inscribed the words: " Ad cædes hominum prisca amphi theatra patebant, ut discant longum vivere nostra patent." That is, "The amphitheatres of old were open for the slaughter of men, ours that they may learn to prolong life." Not only to prolong life does the modern Esculapian enter the arena, not only to give successful battle to disease, but also to indicate undermining agencies, to avoid and remove causes of disease, and even to baffle heredity. This the psychiater of to-day accepts as his function and office.

We are led by habit of superficial thought, and by the subtle appeal of the artist to our emotional instincts, to accept the historic

* Read at the sixty-fifth annual meeting of the American Medico-Psychological Association, Atlantic City, N. J., June 1-4, 1909.

statement that the picture of Pinel, striking off the shackles from the wrists and ankles of lunatics at Bicêtre, represents the earliest acceptance and practical result of the truth that penal repression of the insane is not necessary treatment, but is mere brutality. His moral intrepidity undoubtedly stimulated and encouraged the world, and paved the way for the conviction and action of Tuke, Hill, and Conolly in England, of Everts in Holland, and of Rush in the United States. But the fact is that in 1751, when Philippe Pinel was but six years old, the Pennsylvania Hospital in Philadelphia was founded largely because of the statement in the first clause of the petition for its charter. The petition, written by the hand of Benjamin Franklin, in its first paragraph

"Humbly showeth

That with the Numbers of People, the number of Lunaticks or Persons Distemper'd in Mind and depriv'd of their natural Faculties, hath greatly encreased in this Province."

The hospital was established in large part "for the care and treatment of Lunaticks," and thus early was the truth recognized that the insane are ill and deserve, as well as profit by, treatment. The petition sets forth in its third paragraph:

"That few or none of them are so sensible of their Condition as to submit voluntarily to the Treatment their respective Cases require, and therefore continue in the same deplorable State during their Lives."

Here is an ancient record of the conviction of the desirability of voluntary application and of the benefits of early treatment. Statistics regarding the insane population in the State of New York confront us with two most grave and significant facts:

First. The total number of cases of insanity admitted during the last fiscal year was 6681, against an average of 5539 for five preceding years, thus furnishing us with a net increase of 1246, against an average net increase of 766, for the five preceding years.

Second. While the annual death rate in the State hospitals for the insane is 8 per cent of their population, 40 per cent of all the deaths occur during the first year after admission, and 15.6 per cent of the new cases die during their first year of residence in the hospitals.

The first fact necessitates immediate and energetic action to limit the production of insanity by instruction of the public throughout the whole State concerning the precipitating factors in the causation, emphasizing the avoidable causes, and uncovering to the youth and the adult the actual agencies that can be controlled, and the actual measures that can be taken to preserve mental integrity. Such action will consist in plain and forcible presentation of the subject of syphilis and its results; the subject of the use of alcoholic beverages in so-called "moderation," as well as in excess; and the subject of drugs, such as morphine, cocaine, and chloral.

The fact of our net increase of 61 per cent more than in previous years suggests not only the necessity for education of the people, but also the emphatic desirability of placing the insane under earlier treatment. But much more forcibly is this necessity stated in the fact of the early death of 15.6 per cent of our newly admitted. Many of these are suffering from infection-exhaustion psychoses, a few are aged or bedridden patients. Many have suffered so long that their psychoses are deeply fixed, and they are in a condition of dread, antagonism, confusion, or enfeeblement, which interferes with immediate examination, and constitutes a barrier to early access to the personality. If brought more promptly into reception wards they would, in many instances, never have progressed so far, and their recovery would have dated from an earlier period.

The early case, the borderland case, must be put under treatment. The question arises, What is a borderland case? Meyer, with characteristic practicality, answers: "Any case that can be benefited by hospital treatment; " that is, any case in which symptoms of commencing mental trouble have been noticed, and which should have a psychiatrist's care. Within the area of the borderland we must include psychasthenia, with its impulsions, obsessions, doubts, phobias, anguish, agitation, and delirium of touch; and for practical purposes we must also include all psychoses in their incipiency; we must include psychopathic exaltation and psychopathic depression; constitutional inferiority; disorders in the train of thought, disorders of volition, of the emotions, of memory, of attention, and of personality, whenever such disorders are more than transient. It seems trivial to say it (yet this

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