tion of uric acid, attributes certain forms of depression to this acid and explains the fact that melancholic states are more pronounced in the morning by the increased alkalinity of the blood at this time, with consequent greater solubility of uric acid. Krafft-Ebing* contents himself reports of Hagent and Raymond, jon. with with quoting the and ventures no opin Meynert makes no reference to Bright's disease direct, but speaks of the etiological effect of the various dyscrasias, tuberculosis, anæmia, chlorosis, marasmus, etc., in the genesis of melancholia. Dieulafoy, in a communication to the Societé Mediicale des Hopiteaux, mentions cases, and reports several in detail, assigning some influence to kidney lesions in the causation of insanity. Ollivier at the same time, however, stated that among 500 cases of insanity seen yearly by him, he noted no single instance of insanity due to Bright's disease. Gowers** states that Bright's disease may cause both atheroma and miliary aneurisms, and may thus induce either softening or hemorrhage, with consequent mental disturbance. Luige M. Petrone,tt in 1883, described an instance of maniacal exaltation with confusion and incoherence accompanying Bright's disease, and attributed the mental symptoms to uræmic poisoning. Dickinson‡‡ thinks that "prolonged mental disturbance, anxiety or grief," may cause granular disintegration of the kidneys. * Lehrbuch der Psychiatrie, Stuttgart, 1890. † Loc. Cit. Zeitschrift fur Psychiatrie, 39, page 4. § Vorlesungen uber Psychiatrie, Wien, 1890. || Quoted by Millard, "Bright's Disease," New York, 1892, page 186. Quoted by Millard, Loc. Cit. **"Diseases of the Brain," 1885, page 210. + Translated from Revista Sperimentale, by Joseph Workman, in ALIENIST AND NEUROLOGIST, Vol. IV., page 439. "Treatise on Albuminuria," 1881, page 165. Purdy also refers to the influence of mental disturbance in the causation of chronic interstitial nephritis, and Dr. Francesco Spallitaf writes upon the influence of the nervous system upon the renal functions, detailing numerous experiments upon animals, in the mair corroborating the statements of Kriemer, Morceau, Wittich and others, who have seen degenerations of the kidney cells follow disease or injury of the nerves supplied to this organ. Cases of co-existent Bright's disease and insanity have also been reported by Joffrey, Grainger Stewart, Haslund, Lecorche and others. In this country a number of cases of Bright's disease with insanity have been observed and recorded, and several very valuable articles have appeared, though here we find the same wide differences of opinion as to the significance of the co-existence of the two maladies. Dr. F. X. Dercum‡ gives in detail an instance of unilateral convulsions, and another of chorea occurring in uræmia; also reports "two cases of hemichorea associated with Bright's disease." Prof. William Osler,§ in 1888, reported three cases of mental disorder with uræmia, to the Philadelphia Neurological Society. Dr. L. Bremer || of St. Louis, records seven cases, assigning uræmia as a cause of the intellectual disorder. Gannett, in 1886, reported, in 68 autopsies upon insane patients, disease of the kidneys in 29, and in 20 autopsies by him at the McLean Asylum, disease of the kidneys was found in five.** Kellogg says: "Diseases of the kidneys are not * "Bright's Disease and Allied Affections of the Kidneys," 1886, page 142. †Translated from Il Pisani, by Joseph Workman, ALIENIST AND NEUROLOGIST, 1889, Vol. X., page 574. Journal of Nervous and Mental Diseases, August, 1887. § Journal of Nervous and Mental Diseases, Vol. XIV, page 771. Insanity from Bright's Disease," Journal of Nervous and Mental Diseases' June, 1888, Vol XIII., page 374. Report of Boston Lunatic Hospital, 1886. **Quoted by Tuttle, Loc. Cit. tt Article, "Insanity," Reference Hand-Book, Vol. IV., page 57. uncommon among the insane, but their pathological relations to the mental disorder are obscure." Edes,* before the American Neurological Association, in 1888, says: "It may be said with much confidence that insanity and delirium are not early or distinctive or common urotoxic symptoms." Blackburnt has recorded the post-mortem appearances of the kidneys in 263 cases of mental disease, finding distinct pathological changes in 43 instances, and "slight and unimportant" departures from the normal in 104 others. Christian, of the Eastern Michigan Asylum,‡ found 37 cases of Bright's disease among 2,600 admissions. He reports several cases in detail, dividing them into two classes, the "urotoxic" and the "vascular; " thinks the latter largely preponderate. He regards the mental symptoms accompanying Bright's disease as only rarely of distinctly urotoxic origin, but more commonly expressions of lowered nutrition, or of changes in the blood-vessels and brain. Dr. Alice Bennett, § calls attention to the extreme frequency of Bright's disease among insane patients, reports sixty cases at length, and regards uræmic poisoning as one of the most frequent causes of insanity. Recently, in response to inquiry, she writes me that "probably onehalf" of the patients she now has under treatment at the Norristown Asylum, suffer from Bright's disease in some form. Tuttle, of the McLean Asylum, reports the presence of albumin and casts in the urine of 55 of 200 female patients examined; reports five cases at length, and thinks that chronic nephritis may occasionally be a cause of insanity; but assigns to "long-continued "Relation of Renal Diseases to Diseases of the Nervous System," Journal of Nervous and Mental Diseases, Vol XIII., page 566. † Report of Government Hospital, 1888. "Chronic Bright's Disease in it Relati on to Ir sanity," Journal of American Medical Association, March 23d, 1889. § ALIENIST AND NEUROLOGIST, Vol. XI., page 566, October, 1890. || Kidney Disease and Insanity, American Journal of Insanity, April, 1892. anxiety" a prominent place in the causation of kidney diseases" albumin hyaline, granular, epithelial and blood casts in the urine, with oedema in some cases," being, he thinks, not infrequent results of mental distress. Both Tuttle and Bennett especially emphasize the fact that the mental symptoms of uræmia are prone to assume the form of melancholia. Millard,* in the last edition of his "Bright's Disease," discusses the subject of insanity as a symptom, but inclines to the belief that uræmic poisoning plays a very unimportant part in the production of mental disease. He says: "In a very large experience in the observation of cases of Bright's disease I have not as yet met with one where I could attribute what alienists regard as insanity to any affection of the kidneys." He says, however, in a preceding paragraph: "Retention of excrementitious matter, urea, etc., which should be expelled by the kidneys, may produce numerous disturbances of the mind, the nervous system and the morale," and further explains that he "would not, however, be considered as regarding as true insanity the numerous mental disturbances, as moroseness, diminution of mental power, transient delirium, which might occur in the course of the disease." Dr. Milton D. Norris, of the Maryland State Hospital, has recently reported three cases of insanity with Bright's disease, and is inclined to assign some causative influence to the kidney lesion. Wise, of the St. Lawrence State Hospital, speaking of the arterial disease and brain degeneration and senility, recognized as a sequela of chronic Bright's disease, says: "The manifestations of insanity in these cases appear to indicate lowered nutritive conditions, and cannot well be confounded with the uræmic insanity of Bright's disease, which, in my opinion, is seldom * Bright's Disease," New York, 1892, page 186. t Report of Maryland Hospital for the Insane," 1892. "Bodily Diseases and Senility" Trans. New York State Medical Association, 1891. met with in hospitals for the insane, if anywhere." The views and opinions quoted above are many and various. Most of the text-books in psychology make no mention of the subject, or comment on the infrequency of Bright's disease among the insane; all of the more recent writers dissent from this view, and look upon kidney disease as a very common complication; some regard their co-existence. as accidental; some think anxiety, worry and mental disorder, precede and cause the kidney trouble; others recognize in the existing intellectual disorder the psychic symptoms of uræmic poisoning. Most of them say it is only the chronic forms of Bright's which are commonly found, and almost all agree that melancholia or some form of mental pain and distress is the most common psychic expression of kidney disease. Mann, in his "Psychological Medicine,"* deplores the fact that the physicians of asylums have not been able thus far to give the profession the result of their observations upon the urine of the insane, which is so much to be desired; and it is still evident that this subject, an important one, all will admit, is not receiving the attention it deserves. About a year ago a circular letter of inquiry addressed to the superintendents of many of the insane hospitals in the United States, brought me replies from about forty institutions of all classes, and revealed the fact that at not more than a half-dozen insane hospitals in the United States was any attention being paid to the subject in hand, examination of the urine of even recent admissions being very generally neglected. The opinions as to the frequency of kidney lesions among the insane, the influence of such lesions upon mental character, the form such mental disturbance usually assumes, etc., expressed by the gentlemen who were kind enough to reply to my inquiries, varied widely, and were in many cases, owing to failure to recognize any cases which might exist, of little value. |