instructed in every kind of industry, to be treated each and every one for epilepsy, and to be offered a home in a sort of village life, where they will no longer have the feeling of social ostracism, or be debarred from the privileges of intellectual and moral development enjoyed by the rest of mankind. The out-of-door life in a farming community has already had wonderful results, which may be learned from the annual reports of the colony. It will suffice to say here that the average reduction in frequency of attacks among all the patients has been fully fifty per cent., and that the mental and moral regeneration of the beneficiaries has been truly remarkable. What the effect of such change of environment must be as a prophylactic against psychic degeneration and insanity can not be estimated. We may now briefly touch upon the medicinal and surgical treatment of epilepsy. The old drugs-borax, nitrate of silver, belladonna, and the bromids-have their uses. One is valuable in one case and not in the other; and each patient, where the disease is idiopathic, and no etiological indication exists for the preferment of an especial agent, must be experimented upon with one drug after another for two or three months at a time, until a satisfactory remedy is discovered. Upon the whole, the bromids are most effective as a general antispasmodic for all cases. While the bromids are, perhaps, the most useful remedy we can employ as an antispasmodic in many cases of epilepsy, their exhibition in every case is not advisable. With a considerable number of patients the bromids are entirely ineffectual; with no small number, too, very serious symptoms, such as acute bromism, increase of seizures, and even insanity, supervene upon their use. In many of the cases where actual good is done by the bromids in reducing the frequency and severity of the attacks, the concomitant symptoms are such that it becomes questionable whether the remedy be not, after all, worse than the disease. The writer makes it a practice, therefore, to exhibit the bromids with caution, and never to employ them until the series of less harmful, but often quite as efficacious, remedies for epilepsy have been tried in vain. There are some new drugs and remedial methods that have come into vogue of late which are worthy of attention. In the first place, there is simulo, a South American plant of the hyssop family, the tincture of which is given in doses of one to two or three drams three times daily. After an experience in many cases for several years, I would say of simulo that it deserves trial in most cases; that it is perfectly harmless, which can not be said of the bromids, borax, belladonna, and some other drugs; that in a few cases it has been extremely beneficial in my hands, and that in most cases it has no effect at all. Simulo combined with small doses of bromid acts very well. The so-called opium-bromid treatment of Flechsig is of value for many patients, especially in old and obstinate cases where all other agents have proved ineffectual. This treatment consists of the administration of opium for some six weeks, beginning with one-half to one grain three times daily, and increasing gradually until ten to fifteen grains a day are taken, when the use of opium is suddenly stopped, and bromids in large and grad ually reduced doses are given (thirty grains four times daily, to begin with). I had used in certain cases of epilepsy for some years codein with considerable success, but this combination of the opiate with bromids is still more satisfactory. Adonis vernalis conjoined with the bromids, as recently suggested by Bechterew, is an efficient method of treatment, from which, in several instances, I have had gratifying results. Digitalis, which has properties similar to Adonis vernalis, was formerly frequently given in epilepsy, but the new combination seems to be much more efficacious. There are a few cases of epilepsy in which careful investigation indicates self-intoxication as a factor. In these an excess of ethereal sulphates (indican) in the urine, together with periodical or constant attacks of gaseous diarrhea, are almost positive manifestations of putrefactive or fermentative changes taking place in the alimentary tract. It is remarkable how much benefit may be obtained in such patients by the regulation of the diet (milk and its modifications, koumiss, matzoon, somal, rare or raw beef, eggs, green vegetables, and special breadstuffs, like Zweiback, Huntley & Palmer's breakfast biscuits, and Voebt's biscotte de legumine), by the frequent drinking of hot water and the occasional flushing out of the large intestine by hot water, and by the use of certain intestinal antiseptics, given two hours after eating, with plenty of water (beta-naphtol or salol, gr. v). The remarkable effect of the thyroid extract upon general nutrition would naturally suggest the advisability of its administration for experimental purposes in some of the nervous diseases which we are accustomed to look upon as due to nutritional disturbances in the nervous system. With this idea in view, I have employed it in a good many cases of epilepsy, in a number with very good effect. Especially noteworthy was mental improvement in several cases of epilepsy with apparently considerable dementia. It is worthy of more extended trial. Aside from the remedies for the epilepsy just described, we need occasionally to employ certain other drugs for particular conditions, such as status epilepticus, maniacal outbreaks, pronounced melancholic states of terror, etc. In status epilepticus rectal injections of chloral, gr. xx, with an ounce of starch-water, repeated at intervals of two or three hours if needed, give the most satisfaction. In great ideomotor excitement we should use hyoscin, hyoscyamin, or duboisin hypodermatically, in doses of to of a grain. In anxious melancholic conditions morphin hypodermatically is, perhaps, the best alleviating agent to exhibit. The question of trephining must naturally come up in certain cases of epileptic psychoses where trauma to the head is evidently the cause of the epilepsy and psychic degeneration. The following points are to be taken into consideration as a guide in this matter : 1. In the very small number of cases having injury to the head as a cause the epileptic habit is so strong, and the changes in the brain are usually so old and deep-seated, that an operation, as a rule, does not cure, and seldom permanently diminishes the frequency of the attacks. 2. Of miscellaneous traumatic cases, where a surgical procedure seems justifiable and is undertaken, a cure of the epilepsy may be reasonably expected in, perhaps, four out of every hundred cases operated upon. 3. The removal of a cicatrix from the cortex, supposed to be the epileptogenic nidus, will naturally be followed by the formation of a new cicatrix in the surgical wound-the creation, therefore, of a new epileptogenic center. 4. The more recent the injury, the greater will be the promise of lasting benefit. 5. In cases of traumatic epilepsy with marked epileptic psychoses (recurrent attacks of rage, fury, violence, destructiveness, etc.) trephining would be justifiable as a possible means of diminishing the severity, danger, and frequency of the maniacal attacks, even though the epilepsy itself or the psychic degeneration might not be improved. CHAPTER X. DEMENTIA. Secondary; Senile; Primary. Definition." Dementia" is a term employed to designate simply a general enfeeblement of all the mental faculties. It is often used improperly by the laity as synonymous with insanity. But in medicine it signifies only a general weakening of a mind once normal. Hence it is not applied to congenital mental weakness. The term "idiocy," with its various degrees, includes all of these congenital psychic defects. There are innumerable gradations comprised in dementia, from the merest dullness to profound deficiency or complete loss of all the intellectual faculties. Such enfeeblement of the mind may be the result of serious cerebral diseases or disorders, such as epilepsy, alcoholism, syphilis, etc., when the dementia is qualified as epileptic, alcoholic, syphilitic dementia, etc. It is often a sequel to acute insanities, like mania and melancholia, and to chronic psychoses, like circular insanity and paranoia, and hence the distinctive term secondary dementia applied to such examples. It takes the chief part in the syndrome of paresis, so that that disorder is often entitled "paralytic dementia." Progressive mental enfeeblement not infrequently accompanies senile involution and organic changes in the brain incident to that epoch of life; hence the well-known disorder called senile dementia. Finally, there is a form of mental disease characterized in the main from the very beginning by extraordinary psychie enfeeblement, and this malady is classified as an acute or primary dementia. Under the heading of dementia we shall now consider separately the more important forms of dementia just described-viz., secondary dementia, senile dementia, and primary dementia. SECONDARY DEMENTIA. Secondary dements make up by far the greater number of the patients accumulated in our large asylums. Every year the number is augmented by the increment of new cases which enter upon this terminal and incurable condition. It has been estimated that some two-thirds of the patients in asylums belong to this category. Symptomatology.-The cardinal symptoms are defect of memory, deficient ideation, and feebleness of judgment. There is no longer any logical coördination in the flow of thought. The speech is incoherent when there are any ideas at all to seek expression. Some patients chatter a great deal with no coherence or meaning, the only connection of one word or phrase with another being similarity of sound. Other patients are absolutely silent. Hallucinations are often present, more particularly at the period of transition from the antecedent psychosis to the terminal dementia. Delusions may also exist, but they are vestiges of the delusions of the primary insanity carried over into the secondary condition. The feebleness of mind is shown especially in the state of the emotions, which have a child-like simplicity of expression. These patients laugh boisterously over nothing, weep about trifles, and are easily enraged without sufficient motive. Naturally, all of the higher concepts are lost, especially those of esthetic and ethical character. The habits become depraved and loathsome in extreme cases. Masturbation, destructiveness of clothing, besmearing of the person with and eating of filth are frequent manifestations in the lowest degrees of dementia. The patients become robust and fat. They lose all expression, save some single, automatic, fatuous smile, angry frown, furtive look, or aspect of misery, which may linger as a legacy from the previous psychosis. They swallow anything they can get hold of; they collect pebbles, pieces of paper, string, glass,-in fact, all sorts of rubbish,— which they either pocket or use for personal ornament. Many show a proclivity to automatic movements, analogous to those observed in idiocy, such as anteroposterior or lateral oscillations of the body. Occasionally these movements are more complicated, taking the form of grimaces; gesticulations with the fingers, hands, and arms; running to and fro, running in a circle, whirling round on the heel, etc. A considerable loss of sensibility to pain is generally noticeable in secondary dements. Hematoma auris is common among them. It is customary to classify secondary dementia into two groups, bespeaking contrasting syndromes-viz., apathetic and agitated dementia. Patients with apathetic dementia are expressionless, never speak, crouch or lie about the floor or in corners in the most negligent attitudes, and cover their heads with their clothing. Patients with agitated dementia are the restless ones just alluded to, and such cases as show a tendency to accesses of excitement. These outbreaks are doubtless aroused by processes going on within the organism, since they occur without any external exciting cause. Secondary dementia may be regarded as a presentment of the mind in ruins. The storm has swept by with its havoc and devastation. After its fury has been spent, a certain amount of placidity remains. In the midst of this calm we note the wreck that has been wrought. Some of the old architectural details stand out, so that we may still recognize what manner of mind it was. There are residua, too, of the destructive agent that was at work, traces that indicate the character of the brain-storm when it was at its height. The foregoing are the main outlines of secondary dementia, but, as intimated before, there are innumerable gradations of mental enfeeblement in these cases. A large part of the work done in and about asylums is performed by secondary dements in whom the intellectual decay is not extreme. Course and Prognosis.-The course of secondary dementia is chronic. Usually, there is no progressive increase of mental enfeeblement, rather a pause after a time, when the mind reaches a certain plane of deterioration. Here the process becomes stationary. The patient leads his mindless, vegetative existence for years and years, sometimes to a good old age, because in the asylum he lives a life of perfect regularity as to food, sleep, and exercise, and is snugly protected from the vicissitudes of weather and of the daily struggle in the outer world. These patients never recover. Actual tissue-alterations were made by the psychosis which swept through their brains. Pathological Anatomy.-Thickening of the vascular walls, distention of the perivascular spaces, destruction of ganglion-cells and cortical association fibers, and some narrowing of the cortex-these are the main postmortem findings. SENILE DEMENTIA. This is a progressive mental enfeeblement at the period of senile involution, dependent upon organic changes in the brain: therefore, a chronic organic psychosis. cases. Etiology. Heredity has been noted in some fifty per cent. of the Males and females suffer about equally. The disorder rarely appears before the sixtieth year. Mental stress and physical illness, together with the senile involution, are the chief etiological factors. In most of the cases arteriosclerosis takes part in the causation of the disease, inducing, as it does, general malnutrition of the brain, as well as frequent local degenerations of small or large extent. Symptomatology.-The earliest symptom is failure of memory. The most recent memories disappear first in a sort of chronological order. After a time the patient fails to recognize any of his surroundings or any of the people about him. He converses with those near |