INTERNAL EXAMINATION. Cranium.-Antero-posterior diameter, seven and onefourth inches; transverse, five and three-fourths. Skull of the usual thickness, shape somewhat asymmetrical, the left side being the larger; sutures were all distinct. Dura mater showed slight adhesion to the bone. [No injury to the skull was observed at the post-mortem]. Brain-Weight of left hemisphere, twenty and onehalf ounces; right, nineteen ounces; cerebellum, pons and medulla, five and three-fourth ounces; total, forty-five and one-fourth ounces. The pia mater showed slight opacity over the convexity. Arteries at the base were small and irregular in size and contours, but not distinctly diseased. On the right side the posterior communicating artery was unusually large and furnished the main blood. supply to the posterior cerebral region of the hemisphere; the posterior cerebral artery was very small before it joined the former vessel. The ventricles were dilated; the endyma granulated. Brain flabby and collapsed with its own weight as the fluid escaped from the ventricles. The tissue was soft and oedematous; the perivascular spaces were greatly enlarged, and curved vessels could be seen lying within them. The membranes were not unusually adherent to the cortex. Spinal cord normal to the naked eye. Thorax.-Weight of right lung, twenty-four and threefourths ounces; left lung, eighteen and three-fourths ounces. The left lung showed slight emphysema of anterior margins; the right lung contained a large gangrenous cavity in the upper lobe, and the bronchi were filled with muco-purulent secretion. There were no signs of tuberculosis in either lung, Heart.-Weight eight and three-fourths ounces. Valves of right side normal; slight chronic thickening of left valves; fibrous change at summits of the muscular papillæ, and some thickening of the chordæ tendinæ. The lining of the aorta was somewhat corrugated by early atheromatous change, and a large ante-mortem clot had formed in the arch and greatly obstructed the vessel. Spleen.-Weight, three and three-fourths ounces. The organ contained two recent hemorrhagic infarctions. Kidneys.-Weight of left four and one-fourth ounces; right, five and one-fourth ounces. Capsules not adherent; general appearances normal; left contained several recent infarctions. Bladder normal. Liver.-Weight forty-eight ounces. The tissue seemed normal. Nothing abnormal was discovered in the other BRIGHT'S DISEASE AND INSANITY. By E. D. BONDURANT, M. D., Assistant Superintendent of the Alabama Insane Hospital at Tuskaloosa. As early as 1838, Ellis, discussing the physical causes of mental disorder, wrote:* "Dropsy is another disease which my own experience would not lead me to assign as a cause of insanity. That dropsical affections have existed to a considerabie extent amongst the patients both at Wakefield and at Hanwell I cannot deny; but they have usually occurred amongst those who have long been previously insane, and have generally been the symptoms of a gradual breaking up of the constitution, rather than the cause of the disease." The subject of kidney disorders was little understood or studied in Ellis' day, and the "dropsy" was a very comprehensive malady. It is not amiss to surmise, however, that a fair proportion of the dropsy which prevailed "to a considerable extent" among his patients was due to renal disease. The mental symptoms of uræmia were first described by Addison, in Guy's Hospital Reports, 1839. Since this time the occurrence of dropsies and kidney disorders in connection with insanity is occasionally noted. by writers. Sutherland found "kidneys congested and larger than natural in 70 out of 167 cases, and 27 in which the kidneys were granular, mottled and marbled;" and Sankey, speaking of post-mortem examinations upon insane patients, makes the remark that "the cases of which I have notes are in a large proportion those of general paresis, in which disease the affection of the kidneys is less frequently met with than in other cases. In about one half of the cases to which I can refer, the * "Treatise on the Nature, Symptoms, Causes and Treatment of Insanity." London, 1838, page 101. "Lectures on Mental Disease," 1866, page 206. kidneys exhibited distinct changes in the parenchyma, as purulent collections, small cysts, atrophy of the entire organ and atrophy of the cortical layer.' No one apparently attached much importance to the occurrence of Bright's disease among the insane, or assigned it any place as a causative agent until Hagen* in 1869, reported several cases, and suggested a possible connection between the two maladies; following this by a second and more complete exposition of the subject, with report of numerous cases taken from his own experience and collated from other sources. Wilks, in 1869, reported one case, and in 1874, three cases of Bright's disease, with marked psychic disturbance, and asked if uræmic intoxication might not be the cause of the mental disorder; and has recently again. referred to the cerebral disturbance which sometimes occurs as a symptom of bodily diseases, among them. Bright's disease of the kidneys. Wright, of the Royal Edinburg Asylum, in his report for 1871, recorded two instances of insanity co-existent with the waxy form of Bright's disease. Howden,|| of the Montrose Asylum, in an analysis of 235 autopsies upon insane patients, found fatty degeneration of the kidneys in 55 cases, and cysts of the kidney in 31, and reports that during three years twelve patients were admitted into his asylum with albuminuria. Jolly, of Berlin, in 1873, and Schulz, of Bremen, in 1876, recorded of co-existent Bright's disease and insanity, and Friedreich has reported several such. Brieger** describes a case of uræmic convulsions, followed by mental disturbance of brief duration, ending in amnesic aphasia, with final complete recovery. * Zeitschrift fur Psychiatrie, 38. † Schmidt's Jahrbuch, 1880 Journal of Mental Science, July, 1874, Vol. XX., page 243. § "Dictionary of Psychological Medicine," Vol. I., page 366. Article, "Delir ium " Quoted by Bucknill and Tuke, "Manual of Psychological Medicine," London, 1879, page 595. Allgemeine Pathologie, page 402. ** Klinische Beobachtungen, Charite Annalen, 1882, page 237. Blandford, in his text-book* says: "In the pathology of commencing insanity they (the kidneys) play a very unimportant part, and even after death, they are not often found diseased. Acute renal disease, with albuminuria and dropsy, is decidedly rare among the insane." Bucknil and Tukef make the statement: "The kidneys are remarkably free from disease in all the forms of insanity, and the changes which give rise to albuminous. urine are especially rare in them. We have only met with three instances of decided Bright's disease among the insane, and upon inquiry in other asylums we have found that the experience of others has been of a similar nature." Griesinger remarks: "Bright's disease, to which any etiological relation to insanity could be attributed, is very rare in the insane." Clouston devotes a page of his works to the "Insanity of Bright's Disease," describing forms of delirious mania with dread and extreme restlessness; has seen "several cases" and quotes Grainger Stewart in corroboration. Savage|| reports a case, and in his book¶ refers to "domestic trouble as a cause, and says that under its influence, "the pulse becomes hard, the tension being high," and that this "may pass into Bright's disease or insanity." T. Clifford Allbutt** assigns to mental anxiety and prolonged distress a high, if not the chief place, in the causation of certain forms of kidney lesion; reports thirty-six cases of nephritis, in twenty-four of which some mental distress or care, or both, were shown in history. A. Haig,tt writing in the London Fractitioner, on the connection between mental depression and the "Insanity and its Treatment," 1887, page 79. t Manual of Psychological Medicine," London, 1879, page 594. excre + "Memal Pathology and Therapeutics." Trans. Robinson and Rutherford, 1882, page 135. 1877. § Mental Diseases," 1884, page 414. Journal of Mental Science, Vol. XXVI., page 245. "Insanity and Allied Neuroses," 1884, page 44. **"Mental Anxiety as a Cause of Granular Kidney," British Medical Journal, tt London Practitioner, Vol. XLI., No. 5. |