A. C. ABBOTT, M.D., of Philadelphia.
LEWIS H. ADLER, JR., M.D., of Philadelphia.
HARRISON ALLEN, M.D., of Philadelphia.
OSCAR H. ALLIS, M.D., of Philadelphia.
HERMAN B. ALLYN, M.D., of Philadelphia.
JAMES M. ANDERS, M.D., of Philadelphia.
ALBERT S. ASHMEAD, M.D., of New York.
SAMUEL AYRES, M.D., of Pittsburg.

L. BOLTON BANGS, M.D., of New York.
WM. S. BARKER, M.D., of St. Louis, Mo.
ROBERTS BARTHOLOW, M.D., of Philadelphia.
SAMUEL BELL, M.D., of Detroit.

E. OLIVER BELT, M.D., of Washington, D. C.
D. BENJAMIN, M.D., of Camden, N. H.
HERMANN M. BIGGS, M.D., of New York.
JOHN S. BILLINGS, M.D., Surgeon U. S. Army.
BERNARD E. BRODHURST, F.R.C.S., of Manchester,
Eng.

MRS. CHARLOTTE B. BROWN, M.D., of San Francisco, Cal.

PAUL R. BROWN, U. S. Army.

CHARLES H. BURNETT, M.D., of Philadelphia.
CHARLES W. BURR, M.D., of Philadelphia.
HERBERT L. BURRELL, M.D., of Boston, Mass.
J. S. CAIN, M.D., of Nashville, Tenn.

J. ABBOTT CANTRELL, M.D., of Philadelphia.
JAMES STRATTON CARPENTER, M.D., of Pottsville,

Pa.

R. J. CHRISTIE, SR., M.D., of Quincy, Ill.
T. M. L. CHRYSTIE, M.D., of New York.
R. CLEARY, A.M., M.D., of Rio Janeiro, Brazil.
J. SOLIS-COHEN, M.D., of Philadelphia.
SOLOMON SOLIS-COHEN, M.D., of Philadelphia.
W. M. L. COPLIN, M.D., of Philadelphia.
ANDREW F. CURRIER, M.D., of New York.
S. G. DABNEY, M.D., of Louisville, Ky.
ALEXANDER DALLAS, M.D., of New York.

J. HERBERT DAREY, A. M., M.D., of Granger, Minn.
EDWARD P. DAVIS, M.D., of Philadelphia.
JOHN B. DEAVER, M.D., of Philadelphia.
H. C. DEMBITZ, M.D., of Louisville, Ky.

JOHN L. DICKEY, M.D., of Wheeling, W. Va.
JOSEPH EASTMAN, M.D., of Indianapolis.
Jos. EICHBERG, M.D., of Cincinnati.
E. C. ELLETT, M.D., of Philadelphia.
FRANK R. ENGLAND, M.D., of Montreal.
AUGUSTUS A. ESHNER, M.D., of Philadelphia.
J. T. ESKRIDGE, M.D., of Denver, Col.
CHARLES PERRY FISHER, of Philadelphia.
EDWARD D. FISHER, M.D., of New York.
F. FORCHEIMER, M.D., of Cincinnati.
WILLIAM H. FORD, M.D., of Philadelphia.
A. H. FRASER, M.D., of Harper, Kansas.
CARL FRESE, M.D., of Philadelphia.
HENRY D. FRY, M.D., of Washington, D. C.
V. P. GIBNEY, M.D., of New York.
ARTHUR J. GILLETTE, M.D., of St. Paul, Minn.
WILLIAM GOODELL, M.D., of Philadelphia.
GEORGE M. GOULD, M.D., of Philadelphia.
EDWIN E. GRAHAM, M.D., of Philadelphia.
N. F. GRAHAM, M.D., of Washington, D. C.
W. M. GREENLEE, A.M., M.D., of Lebanon, Ohio.
J. P. CROZER GRIFFITH, M.D., of Philadelphia.
B. E. HADRA, M.D., of Chicago, Ill.

C. A. HAMAN, M.D., of Philadelphia.
WILLIAM D. HAMILTON, A.M., M.D., of Columbus,
Ohio.

WILLIAM A. HAMMOND, M.D., of Washington, D.C.
T. A. HARRIS, M.D., of Parkersburg, W. Va.
F. C. HEATH, A.M., M.D., of Lafayette, Ind.
FREDERICK P. HENRY, M.D., of Philadelphia.
E. P. HERSHEY, M.D., of Denver, Col.
BARTON COOKE HIRST, M.D., of Philadelphia.
F. HORTON, M.D., of New Castle, Wyoming.
DR. HOVENT, of Brussels.

L. HUFFAKER, M.D., of Daisy, Tenn.
E. P. HURD, M.D., of Newburyport, Mass.
WOODS HUTCHINSON, M.D., of Des Moines, Iowa.
H. ILLOWAY, M.D., of Cincinnati.

HENRY D. INGRAHAM, M.D., of Buffalo, N. Y.
A. B. ISHAM, M.D., of Cincinnati.

EDWARD JACKSON, M.D., of Philadelphia.

E. G. JANEWAY, M.D., of New York.

H. L. JENCKES, M.D., of Hazel Green, Wis.
ROBERT W. JOHNSON, M.D., of Baltimore.
ALLEN A. JONES, M.D., of Buffalo, N. Y.
W. D. JONES, M.D., of Rising City, Neb.
E. KELL, M.D., of New York.

G. W. KEMPER, M.D., of Muncy, Ind.
S. RUSH KETCHAM, M.D., of Philadelphia.
EDWARD L. KEYES, M.D., of New York.

WILLIAM CLINTON SHEEHY, M. D., of New Bedford,
Mass.

GEORGE ERETY SHOEMAKER, M.D., of Philadelphia.
MANNING SIMONS, M.D., of South Carolina.
WHARTON SINKLER, M.D., of Philadelphia.
HENRY SKINNER, M.D., of Philadelphia.

R. M. SLAUGHTER, M.D., of Virginia.
RICHARD SLEE, M.D., of Brooklyn, N. Y.
STEPHEN SMITH, M. D., of New York.

field, Ill.

H. A. LAFLEUR, M.D., of Baltimore.
ERNEST LAPLACE, M.D., of Philadelphia.
JOSEPH LEIDY, M.D., of Philadelphia.
JAMES J. LEVICK, M.D., of Philadelphia.
A. A. LEVINGS, of Appleton, Wis.
WILLIAM M. LEWIS, M.D., of Greensburg, Ky.
ALFRED L. LOOMIS, M.D., of New York.
G. FRANK LYDSTON, M.D, of Chicago, Ill.
M. MAGELSON, M.D., of Fergus Falls, Minn.
G. BETTON MASSEY, M.D., of Philadelphia.
PETER MCCAHEY, M.D., of Philadelphia.
D. J. MILTON MILLER, M.D., of Philadelphia.
MORRIS B. MILLER, M.D., of Philadelphia.
W. H. F. MILLER, M.D., of Clifton Forge, Va.
JAS. MITCHELL, M.D., of Madison, W. Va.
ROBERT B. MORISON, M.D., of Baltimore.
CHARLES P. NOBLE, M.D., of Philadelphia.
FRANK P. NORBURY, M.D., of Jacksonville, Ill.
ROSWELL PARK, A. M., M.D., of Buffalo, N. Y.
W. THORNTON PARKER, M.D., of Salem, Mass.
BRUCE PEDEN, M.D., of Bloomfield, Ark.
WILLIAM PEPPER, M.D., of Philadelphia.
A. M. PHELPS, M.D., of New York.
C. R. PONTIUS, M.D., of Fremont, O.
MILES J. PORTER, M.D., of Fort Wayne, Ind.
WILLIAM HENRY PORTER, M.D., of New York.
D. W. PRENTISS, M.D., of Washington, D. C.
JOSEPH PRICE, M. D., of Philadelphia.
W. B. PRITCHARD, M.D., of New York.
AMAND N. RAVOLD, M.D., of St. Louis.
THADDEUS E. REAMY, M.D., of Cincinnati, O.
JOHN RIDLON. M.D., of New York.

L. T RIESMEYER, M.D., of St. Louis, Mo.
HENRY A. RILEY, ESQ., of New York.
JOHN B. ROBERTS, M.D., of Philadelphia.
JOHN RODMAN, M.D., of Abilene, Texas.
GEORGE G. Ross, M D., of Philadelphia.
JULIUS L. SALINGER, M D., of Philadelphia.
AMOS SAWYER, M.D., of Hillsboro, Ill.
REGINALD H. SAYRE, M.D., of New York.
G. E. DE SCHWEINITZ, M.D., of Philadelphia.
HENRY SEWELL, M.D., Ph.D., of Denver, Col.
CASPER W. SHARPLES, M.D., of Seattle, Wash.
EDWIN B SHAW, M.D., of Osage City, Kans is.

B. C.

J. W. SNOWBALL, M.D., of Plainfield, N J.
A. O. SQUIER, M.D., of Springfield, Mass.
ALFRED STENGEL, M.D., of Philadelphia.
C. S. STEWART, M.D, of Amite City, Louisiana.
DAVID D. STEWART, M.D., of Philadelphia.
JOHN S. STEWART, M.D., of Philadelphia.
LOUIS A. STIMSON, M.D., of New York.
CHARLES G. STOCKTON, M.D., of Buffalo, N. Y.
GEORGE A. STUART, M.D., of Wahu, China.
J. E. SUMMERS, JR., M.D., of Omaha, Neb.
CHARLES SZADEK, M.D., of Kieff, Russia.
HENRY LING TAYLOR, M.D., of New York.
J. MADISON TAYLOR, M. D., of Philadelphia.
ROBERT W. TAYLOR, M.D., of New York.
W. H. THOMSON, M.D., of New York.
PAUL THORNDIKE, M.D., of Boston.
H. TOULMIN, M.D., of Baltimore.
F. J. TOWER, M.D., of Milwaukee.

W. R. TOWNSEND, A.M., M.D., of New York.
LAURENCE TURNBULL, M.D., Ph. G., of Philadelphia.
JAMES A. TURNER, M.D., of Little's Mills, N. C.
J. HILGARD TYNDALE, M.D., of New York.
JAMES TYSON, M.D., of Philadelphia.
FRANCIS UBER, M.D., of New York.
WELLER VANHOOK, A. B., M.D., of Chicago.
EUGENE WASDIN, M.D., of Charleston, S. C.
W. H. WASHBURN, M.D., of Milwaukee, Wis.
T. H. WEAGLY, M.D., of Marion, Pa.
EDWARD A. WELCH, M.D., of Pottstown, Pa.
WILLIAM H. WELCH, M.D., of Baltimore.
MARIE B. WERNER, M.D., of Philadelphia.
GEORGE D. WESTON, M.D., of Fort Payne, Ala.
ROYAL WHITMAN, M.D, of New York.
W. J. WILBERT, Ph.G., of Philadelphia.
BURT G. WILDER, M.D., of Ithaca, N. Y.
DEFOREST WILLARD, M. D., Ph.D., of Philadelphia.
J. W. WILLIAMS, A.M., M.D, of Paterson, N. J.
A. W. WILMARTH, M.D., of Elwyn, Pa.
WM. E. WIRT, M.D., of Cleveland, Ohio.

G. A. WRIGHT, B.A., M.B. Oxon., F. R.C.S., of
Manchester, Eng.

H. V. WURDEMANN, M.D, of Milwaukee, Wis.
JAMES K. YOUNG, M. D., of Philadelphia.

VOL. LIX.

ORIGINAL ARTICLES.

GASTRO-INTESTINALAND HEPATIC DISORDERS,

ESPECIALLY CHRONIC GASTRO-INTESTINAL CATARRH, IN RELATION TO THE ETIOLOGY OF SOME CASES OF INSANITY.1

BY SAMUEL AYRES, M.D.,

PROFESSOR OF NERVOUS AND MENTAL DISEASES IN THE WESTERN
PENNSYLVANIA MEDICAL COLLEGE, PITTSBURG, PA.

I THINK it is generally admitted by those who have given the subject much thought that in many cases the usually assigned causes of insanity are unsatisfactory and insufficient. Relatives or friends are generally ready with an explanation, particularly when this fits in with some preconceived idea of their own, as, for example, those much-abused causesreligious excitement, disappointment and overwork; but to the student of psychology these are too often inapplicable, if not incorrect. He feels that much is wanting to account for the phenomena witnessed, and that many links in the chain of etiology are missing; but it is not always easy to find these missing links; indeed, the subject is one beset with difficulties. On this matter of exact etiology, both the text-books and asylum reports leave much unsupplied. The list of causes is long enough, but we cannot help feeling that they are too general, and do not meet the requirements of scientific precision.

In connection with the obscure causes of some cases of insanity, it is the purpose of this paper to examine briefly into certain morbid states of the gastro-intestinal tract, of the liver, and of deficient excretion, which seem in the writer's judgment not uncommon but perhaps often unrecognized causes of mental derangement, and especially of melancholia.

In a general way, disturbances of the nervous system arising from derangement of the digestive organs have been recognized from remotest antiquity. It would be superfluous to more than refer to the well-founded connection between dyspepsia and despondency; between so called biliousness and "the blues," or between prolonged constipation and mental dulness, drowsiness or headache. The derivation of the words melancholia and hypochondriasis sufficiently indicates that the old Grecians were acute observers and believed in such relation

1 Being the Address in Mental Disorders delivered at the annual meeting of the Pennsylvania State Medical Society at Reading, Pa., June, 1891.

No. I.

ship. This association is so quaintly described by that inimitable writer, Sydney Smith, that I shall crave your indulgence for a few moments while I include a short quotation.' He says:

66

Happiness is not impossible without health, but it is of very difficult attainment. I do not mean by health merely an absence of dangerous complaints, but that the body should be in perfect tune, full of vigor and alacrity. The longer I live the more I am convinced that the apothecary is of more importance than Seneca, and that half the unhappiness in the world proceeds from ing in the wrong place, from a vexed duodenum, or an little stoppages, from a duct choked up, from food pressagitated pylorus. The deception as practised upon human creatures is curious and entertaining. My friend sups late, he eats some strong soup, then a lobster, then some tart, and he dilutes these esculent varieties with wine. The next day I call upon him. He is going to sell his house in London and retire into the country. He is alarmed for his oldest daughter's health. His expenses are hourly increasing, and nothing but a timely retreat can save him from ruin. All this is the lobster, and when over-excited nature has had time to manage this testaceous encumbrance, the daughter recovers, the finances are in good order, and every rural idea effectually excluded from the mind. In the same manner old friendships are destroyed by toasted cheese, and hard salted meat has led to suicide. Unpleasant feelings of the body produce corresponding sensations in the mind, and a great scene of wretchedness is sketched out by a morsel of indigestible and misguided food. Of such infinite consequence to happiness is it to study the body."

Of course, this is known to everybody, but a more striking picture could not be presented of the effects of disordered states of the digestive organs on the mind.

To make the subject before us better understood, let us divide it into three parts. In the first, we shall consider the morbid states of the gastroenteric canal and the liver and also other conditions favoring the accumulation and generation of nent cause of the mental disturbance in question. those toxic agents which we believe to be a promiIn the second, the absorption of these toxines and their effect on the brain and nervous system generally will claim our attention; and in the third we shall consider the partial retention or retarded elinnnation of various poisons from the economy and their further cumulative effect upon the brain and excretory organs.

Addressing ourselves to the first part, it is our opinion that chronic gastric and intestinal catarrh, with chronic indigestion in the stomach and intes

1 Quoted from Brunton: Disorders of Digestion, p. 45.