research that the ganglion-cells in the anterior cornua of the spinal cord and the motor nuclei of the medulla are really of two kinds-motor and trophic.

The progressive muscular atrophy may be due to lesion of trophic cells secondarily involved, as Friedreich suggests, by preceding trophic changes in the peripheric branches and in the trunks and roots of the nerves. Where the paralysis is unattended with muscular atrophy, a circumstance of some rarity, we may suppose the lesion to be in the motor cells only, and to have originated there. In this way opposing views may be reconciled.

Professor Kussmaul, from his own observations and those recorded by others, states that this form of paralysis is seldom met with under thirty years of age, that the frequency of its occurrence increases with the number of years. Sex seems to have some influence in its etiology, inasmuch as it is far more frequently met with in males than in females. Heredity cannot be traced, nor can social position be said to exert any control, since it is met with in all grades of society. It is, however, occasionally associated with syphilis, and when this is the case it offers the best prospect of recovery, as in a case published by Dr. Silver. It is usually slow in its progress and insidious in its onset; Dr. Wilks has, however, recorded an instance where its onset appeared to be sudden. Dr. Dowse also records four cases associated with peripheral paralysis, in which the attack was sudden.

With reference to the relationship subsisting between bulbar paralysis and progressive muscular atrophy, Kussmaul points out that the two are often intimately associated, either at the commencement or at the close. The spinal cord becoming implicated, exhibits the same changes in the motor columns as are found in the medulla oblongata. As to the condition of the muscles, there is, he adds, no essential dissimilarity between progressive muscular atrophy and progressive bulbar paralysis. Atrophied and simply paralysed muscles, alone or in groups, may be found side by side. Hayem, for example, reported the case of a man suffering from progressive muscular atrophy, in whom paralysis of the diaphragm was shown to exist. Later on, Duchenne himself found in the same patient the serratus magnus, sterno-cleido-mastoid, and the scaleni paralysed. The autopsy found all these muscles attenuated in correspondence with the general emaciation, but in other respects normal. The resemblance is also striking between these two affections, as regards their steady progress usually to a fatal termination, the shorter duration of bulbar paralysis being due, doubtless, to the physiological

1 P. 35.

importance of the parts in which it is seated. The myopathic origin of either, Kussmaul attributes to misconception arising out of macroscopic observation, whereby the coarser changes have been dwelt upon to the exclusion of the minuter or microscopic lesions. This author goes on to observe—

"When a man like Lockhart Clarke, so remarkably conversant with the histological and pathological anatomy of the spinal cord asserts that in not less than eight cases of muscular atrophy, several of which presented the particular type of the progressive disease, he found the most unequivocal lesions of the grey substance of the spinal cord, and its nerve-roots in the form of a degenerative atrophy. But not only in England, also in France and Germany, with every year there is an increase in the number of minute investigations, which place beyond a doubt the fact of a causal connection between wasting of muscle and atrophy of the grey substance of the spinal cord, particularly of the large cells of the anterior cornua. ... Charcot has good reason for assigning almost dogmatical importance to the fact, that in these atrophies the region of the altered portion of the grey matter of the spinal marrow corresponds with the points of exit of the motor nerve-roots which supply the atrophied muscles with nerve-twigs; W. Müller also states that the number of muscles in a state of degeneration keeps pace in an approximate degree with the atrophy of the anterior ganglionic cells" (p. 36).

As an additional argument for the central origin, or against the myopathic origin of progressive muscular atrophy, Kussmaul adds:

"In conclusion, the investigations of Vulpian and Dickinson show that the loss of large masses of muscles, by amputation of entire limbs, never induces a degenerative atrophy of the ganglion-cells, but only, very slowly, a simple atrophy, moderate in amount, of the corresponding portions of the spinal cord; at all events, no adequate diminution of the ganglion-cells attends the loss of the muscles."

To the inference conveyed in the preceding paragraph, and especially to its last clause, we venture to demur, declining to accept it as affording the proof it is supposed to convey. We have beside us at this moment a well-prepared transparent section from the lumbar region of the spinal cord of a subject upon whom amputation of one of the lower limbs had been performed several years previously. In this example the large anterior cells of the amputated side differ so obviously from those of the other, that from these appearances alone it was possible to say on which side the amputation had been performed. The nerve-cells of the anterior horn on this side of the cord have lost their distinctness of outline; they are many of them shrunken, and, instead of presenting clearness, exhibit the

semi-opacity of granular or pigmentary degeneration; they have not taken the carmine dye, as seen in the normal cells of the opposite side, and in many their processes have disappeared.

Kussmaul, moreover, urges that the changes which, up to the present time, have been demonstrated in the spinal cord from progressive muscular atrophy, are manifold," and have nothing specific about them-nothing which belongs only to this disease." He enumerates the various forms of softening and degeneration that have been described by Clarke, Charcot, and other pathologists, and shows that these have been equally found in tetanus, chorea, and other affections. This is doubtless true, as also that they may be regarded as different forms or phases of myelitis. The connection or association, however, is not so close between these pathological discoveries after death, and the clinical phenomena during life; and Kussmaul admits, in a subsequent sentence, that "to clear up the obscurity there is need of still further exact clinical anatomical investigations, and still more so of physiological experiments" (p. 41).

"The perfectly typical classical cases of progressive muscular atrophy have, indeed, this character of the pure, nutritional myopathia, and they almost tempt one to regard the degree and extent of the muscular degeneration as a gauge of the force and extension of the same affection in the ganglia. But this formula is open to the objection that in many cases the paralysis and muscular atrophy are not proportional to each other... We have, therefore, a contradiction before us; on the one hand numerous anatomical accounts are in favour of a nutritional dependence of the muscles upon those ganglion-cells; on the other, the wasting of the ganglion-cells is not in direct proportion to that of the muscles."

The doubt here expressed may be partially explicable upon the view of this affection taken by Friedreich. The degeneration and atrophy of nerve-cells may, it is suggested by BrownSéquard, be due to irritation; this irritation may become augmented into inflammatory action invading the nutritional cells, involving their rapid wasting and extension to the motor cells; hence the paralysis of parts supplied by either the bulbar or spinal nerves. Thus it may fairly be inferred that here, as in many other difficult and disputed points, the truth may lie midway. It is quite possible that these paralytic forms of atrophy may sometimes be of a peripheral origin, and sometimes have their primary seat in the nervous centres. The question that remains to be determined is, Which is the more frequent occurrence? We doubt not that the accumulating facts of pathological anatomy direct our attention to the latter.

Another inference that may be drawn from the study of these

affections is, that their separation as distinct maladies constitutes one of those additions to our nomenclature of disease that is at present wanting in definite attributes-that they present rather the features of dependent or associated phases of the same pathological condition.

V.-Lunacy in the United States.1

COMPARATIVE mental pathology is, as yet, an unexplored, even an untrodden field of inquiry. Comparative psychology may, ultimately, in the hands of Herbert Spencer, be worked and welded into a shapely and serviceable scientific instrument, but few and isolated and unimportant attempts have been made to compare or contrast the deviation from healthy mental action in different races or in the same race under different circumstances and influences. Content with the observation of similarity in the origin, symptoms, and issue of morbid affections in different countries and communities, and with the adoption of the same names, medical philosophers have refrained from all efforts to determine whether the diseases thus designated are identical in nature, origin, and course, with those with which they have been accustomed to examine or to treat. The vastness of the undertaking and the paucity of the materials accessible may have justified this abstention. It has been recorded that the children of many semi-savage tribes, such as those of the inhabitants of the Sandwich Islands, display a precocity in such faculties as acquire or apply a knowledge of external objects, and, what is less extraordinary, in the muscular pursuits and pastimes of their parents, which is unknown among civilised or cultured peoples, even under the influence of training and education. This prematurity, however, never ascends into higher grades of intelligence, and the possessors continue to be incapable of all abstract notions and reasoning. Similar acuteness and aptitude have been noticed in the pro

11. Les Alienées aux Etats-Unis, Legislation et Assistance. Par FOVILLE, 1873. 2. American Journal of Insanity from 1844-1876.

3. Annual Reports of American Asylums for the Insane from 1840 to 1876. 4. Transactions of American Association of Medical Superintendents from 1844 to 1876.

5. Ray's Synopsis of the Laws of the several States of the Union respecting the Confinement of the Insane (Appendix, American Edition of Insanity and its Treatment. By Dr. BLANDFORD, 1871).

6. Report relating to the Management of the Insane in Great Britain. By Dr. WILBUR, 1876.

7. Report of the Commission in Lunacy, Massachussetts, 1874.

Mind,' No. 1, 1876.

geny of the criminals sent to our penal colonies, and in that of respectable emigrants to new and foreign lands, and even in the capabilities of well-fed, well-clothed, well-lodged children, when associated with the waifs and strays, the weak starvelings of the poor and unfortunate. Such conditions may depend upon physiological causes upon which it would be foreign to our present purpose to enter. But, what is more germane to this investigation is that no, or very, scanty evidence exists of the prevalence of any of the forms of insanity among many aboriginal nations, untouched and untainted by civilisation, although exposed to the hardships, privations, and sources of degeneracy inseparable from a nomadic and precarious mode of life. Catlin and other travellers affirm that idiocy and deafmutism have not been traced among the North American Indians, even where the form of the skull has been artificially interfered with, or have, at least, escaped observation. This immunity, granting that it is real, has been explained in two ways-either, by supposing, on the faith of early explorers, that feeble and deformed infants were destroyed as burdens to the tribe, or that mature lunatics were destroyed, as is known to be the case in Australia; or, by holding that the standard of mental capacity is generally so low, and the call upon the higher faculties so limited that the harmless imbecile is regarded as an inoffensive member, if not a brave. Upon what appears the unexceptional authority of Dr. Lillybridge, of Virginia, appointed by his Government to superintend the removal of the Cherokee Indians in 1827-8-9, and who saw and examined about 20,000 Indians, particularly in reference to their diseases; who affirms that he never even saw or heard of a case of mental derangement among them. Dr. Butler, again, for twenty-five years a missionary among the same races, states emphatically that, although he had seen delirium as a concomitant of other diseases, he had never met with a case of decided alienation. He quotes an intelligent chief of eighty years of age who fully corroborated this statement. It is presumable that paroxysms of mania and of depression may have been accepted by these simple hunters and warriors as manifestations of patriotism, courage, tolerance of suffering, or, on the other hand, as the shadow of the great Spirit, and that individuals who would have been deprived of their civil rights and subjected to medical manipulation in the light of civilisation, may have secured admiration, wonder, even worship, as heroes, martyrs, saints. It is certain, further, that many moral perversions and many violations of laws recognised elsewhere, such as cunning, theft, treachery, ferocity, may have appeared to be the normal characteristics of the peoples to whose persecution and