one from the study of another—as, for example, the liver, kidneys and heart, often related links in one morbid process-nevertheless each has its definite function, interference with which is followed by equally definite consequences.

By "Bright's disease" we no longer understand a morbid process affecting the kidneys only, but whether we consent to accept the kidney lesion as a part of a general" arterio-capillary-fibrosis" (after Gull and Sutton), or with Dr. A. V. Meigs, look upon it as a localized expression of a general "endarteritis," the fact is undisputed that at some stage in the train of morbid processes, covered by the monumental name "Bright's disease," lesions of the kidney do exist; their function is interfered with; to a greater or less extent they fail to separate certain waste products from the blood, which, being retained and circulated through the body, produce toxic effects which we have been accustomed to group under the general term "uræmia," or "uræmia poisoning."

I must pass by, as not essential to my purpose, any consideration of the various theories concerning the nature of these nitrogenous waste products, and confine myself to some observations upon their effects, which my experience has led me to believe are more varied and farreaching than has generally been supposed.

There has been a general impression abroad that diseases of the kidney are not common among the insane, founded upon statements to that effect in most of the text-books and perpetuated by the very general absence of systematic and careful observations in this direction. Griesinger, in his work on insanity, says: "Anomalies in the urinary secretion may be much more frequent, i. e., among the insane, than is generally supposed. Unfortunately any reliable researches upon this subject are still wanting."

My attention was first arrested by the clinical observation of the very · constant coincident of some form of mental pain or distress, i. e., melancholia, with the physical signs in the urine of disturbed kidney action; this is not invariably, but the rule. We have cases of undoubted mania associated with a uræmic condition, and, on the other hand, cases of melancholia without it; as for example, in some conditions of grave heart lesions with general debility, and some transitory cases associated with disturbed liver action with the uric-acid formation.

(A. Haig, in an article in the London Practitioner, vol. xl, No. 5, on "Mental Depressions and the Excretion of Uric Acid," speaks of the demoralizing influence of uric acid upon the nerve centers, and explains the well-known fact that states of mental depression are intensified in the morning, by the increased alkalinity of the blood at that time, and consequent greater solubility of uric acid. We know that our melancholia patients are worse, and that suicidal impulses are to be specially guarded against in the early morning.)

Briefly formulated, my experience has led me to believe.

1. That, contrary to generally received opinion, affections of the kidney are very common among the insane.

2. That "uræmic poisoning" is one of the most frequent causes of insanity.

3. That while the mental manifestations may be as varied as there are different centers subjected to irritation by these unknown poisons, the most prominent and constant symptom is some form of mental pain, which may range from simple depression, through all degrees and varieties of delusions of persecutions, self-condemnation and apprehension, with or without hallucinations, or up to a condition characterized by a frenzy of fear, with extraordinary motor excitement, and rapid physical prostration, the "grave-delirium " or "typho-mania" of some authors,

4. That the motor centers are specially liable to affection, as evidenced by the restlessness and incessant activity of many cases, less frequently by convulsions and convulsive twitchings: occasionally by choreic movements; occasionally by cataleptoidal states.

Undoubtedly there is much more of "Bright's disease" in the community than appears on any record book, the interstitial form often running a very long course, frequently unrecognized. Persons subject to "bilious attacks" and "sick-headaches;" to obscure neuralgias; to crawling sensations (often described to me "like the flowing of water" over the part affected) in the head and especially in the back of the neck; people who are "tired all the time," who have sleepless nights or occasional night-terrors; who have unexplained attacks of sudden weakness, or periods of low spirits without cause; who show an unnatural irritability, or a gradual change of character or disposition; those who are subject to gout, rheumatism, chorea, skin eruptions, to itchings of the surface of the body, either local or general-all these may well be suspected of dangerous tendencies.

I need not say that numberless cases of slow kidney trouble live long and fairly comfortable lives without showing any mental disturbance, and that many others run a rapid course to death without such complication. We must assume, in some cases, a toxic impression of overwhelming power, but, doubtless, some brains are predisposed, by inheritance or otherwise, to an easy overthrow of the mental balance. This seemed plain in many of my cases. In such a one, given a chronic nephritis, or even without it, insanity may be induced by anything that increases the burden thrown upon the kidney, diminishes its working force, or interferes with other excretions. Such causes are: improper diet; long-continued constipation; sudden exposure to cold; pregnancy, or any unusual interference with the circulation; overwork of body or mind and especially worry; intercurrent disease or anything that depresses the system and lessens its power of resistance. The influenza epidemic in the beginning of the present year sent us a number of cases of melancholia which belong in this catagory. (See cases

LVI, LVII and LIX.) A factor which cannot be left out of account in these cases in the heart; whether a coincident or a resultant change, we know that, with diseased kidneys, we are apt to have abnormal hearts, and it is an interesting question, to what degree mental disturbance may be aided by some modification in the supply of blood to the brain, due to normal heart action.*

Dr. Landon Carter Gray, of New York, read a very interesting and suggestive paper before the American Neurological Association in 1889, on "Three Diagnostic Signs of Melancholia," with notes of sixteen cases illustrating the association of mental depression, insomnia and post-cervical ache, which he has found so constant in his practice. Dr. Gray says: "The simple forms of melancholia are often extremely difficult to diagnosticate, especially in the early stage, as the reasoning powers, the memory, and the perceptions are then often seemingly unimpaired or not more affected than is possible from a myriad unimportant causes. Patients suffering from this mental disease too frequently figure as neurashthenics to be confidently treated as such, until some determined and frightful suicidal, or homicido-suicidal, attempt throws startling light upon the true nature of the malady. These, too, are the cases of unaccountable suicide which puzzle friends, and competing newspaper reporters account for so satisfactorily and sensationally upon some theory of rejected love or high-flown sentimentalism. Any certain diagnostic symptoms in this class of cases should be, for these reasons, of value * * So firmly have I come to rely upon the association of this symptomatic triad" (i. e., mental depression, insomnia, and post-cervical ache), "that I have lately made a diagnosis in two cases by means of it. The first patient was a gentleman who came to me complaining of a distress in the back of the head and neck which at times was painful. I learned from him that the onset dated back to six years ago, when, as he said, he had been run down and depressed. I then told him that I would outline to him his symptoms at that time, and I proceeded to tell him that he had been very much depressed, had not been able to sleep, had thought of committing suicide, had been slightly confused in mind, and had remained in this condition for several months. He was amazed, and asked me if I was a mind reader, finally admitting that he had passed through just such an attack of melancholia, which he had concealed from everybody, because he was then living in Burmah in the employ of the English government, and was afraid that he would lose his position if thought insane."

I fully concur in all that Dr. Gray has so well said in this paper; but, in going a step farther and investigating the causes of insomnia and post-cervical ache, both among the most common symptom of "uræmic"

* In the address of Mental Disorders, for 1884, the writer gave an analysis of 500 cases of insanity, 20 per cent. of which had some heart affection.

blood-poisoning, we shall find additional aids to diagnosis, and safeguards against catastrophes like those mentioned.

In case of Bright's disease with sudden invasion of melancholia, there is one feature so constant that I have come to regard it as diagnostic: it is the sense of impending danger, the overwhelming fear of some threatening calamity, which inspires the one [irresistible impulse to "get away" which dominates the individual for the time, and under the influence of which he often jumps out of the nearest window. (See cases LV, LVIII, XLVII and others.)

To prevent insanity by recognition and treatment of the conditions. leading to it will be our aim; frequently, however, so insidious is Bright's disease, and so unwilling are people generally to appear to make much of their little ailments, which would be such valuable indicators if revealed, that we know nothing of the state of affairs until some catastrophe has taken place. Even then it is worth much to be able to say why it has occurred, and even in unpromising cases gratifying results sometimes follow prompt treatment in the lines indicated, but prognosis must always be guarded.

I think that I can serve you best by presenting some clinical notes of cases with comments; but before going on to speak of my own experience. I will ask you to look at the literature of the subject.

Books on the diseases of the kidney say almost nothing of the effects of retained nitrogenous waste products upon the nervous system, except convulsions and coma, generally preceding death.

From all the works on insanity accessible to me I have gathered everything bearing on this subject that I could find.

From Bucknill and Tuke:* "The kidneys are remarkably free from disease in all forms of insanity. We have met with three cases of Bright's disease among the insane, and we have found the experience of others of a similar nature." They quote with evident surprise, Howden, who had admitted twelve cases of albuminuria in three years and who, in 235 post-mortem examinations, had found kidney disease in 86.

They admit two genuine cases of "insanity coexistent with the waxy form of Bright's disease," mentioned by Dr. Wright, in the Report of the Royal Edinburgh Asylum, for 1871, and speak also of a similar case recorded by Dr. Wilkes in the Journal of Mental Science, for 1869.

In connection with gout, Bucknill and Tuke say: "Outside the walls of asylums cases are frequently met with which are marked by unfounded dread, especially on awaking in the morning, in which there is a gouty diathesis, and suspicion is aroused that there is a casual relation between the bodily condition and the mental anguish. This suspicion is confirmed by the marked success of treatment founded upon this supposition."

Schroeder V. Der Kolk, under "Sympathetic Insanity," "records two * Psychological Medicine.

cases of insanity accompanying vesical catarrh, of which one recovered; in the other an affection of the kidneys supervened, and the patient died." Sankey found adhesion of the capsule of the kidney in one-half his cases post-mortem, and, "in a large number, other evidences of disease, as atrophy of the cortex, fatty degeneration, waxy disease, etc." This author does not seem to have made any study of the kidneys during life. The presence of kidney changes post-mortem he regards as "evidence that the blood has been impure" (emphasized by him as the first step in the production of "ordinary insanity," as quoted above) nevertheless he concludes by saying: "I do not consider the true pathology of insanity to have any necessary relation to kidney disease."

Gowers calls attention to organic changes (as apoplexy) which may ensue from antheroma of the arteries in advanced Bright's disease.

Griesinger says: "Bright's disease to which any etiological relation to insanity could be attributed is very rare indeed." One would much like the complete clinical record of a case like his No. 12, of which the following is a condensed abstract: "Delirum occurring in second pregnancy; formification and smarting over whole surface; a general sense of ill-being; sleeplessness; ringing in ears; vertigo; pulse hard; slight cardiac hypertrophy; recovered and relapsed in the following year."

Or his No. 8: "Man; hepatitis in the beginning; variable temper; pain in lumber region; burning in urethra and bladder; at times had gravel; died in a few months."

Blandford speaks of a variety of melancholia "usually ascribed to dyspepsia or disorder of the stomach and liver." He has also noticed that "melancholia often comes on, as a precursor of death, at the close of other diseases."

In Clouston's very interesting work I find more bearing upon this subject than in any other that I have read, although I cannot always agree with this author in his interpretation of facts. For example, his two cases of diabetic insanity, which have been extensively quoted in other text-books. In case No. 2, a man, who died after melancholia of two years' duration, with delusions of persecution, the diagnosis rested entirely upon one examination of the urine, made near the close of life; no symptom had led to the suspicion of diabetes, and there was no postmortem examination.

That some amount of sugar in the urine is frequently associated with chronic Bright's disease is well known; and I have twice met the conditions noted in my case VI, where, shortly before death, sugar appeared in large quantities in the urine, from which it had previously been absent. His case No. 1, was a "woman, aged fifty-nine; agitated melancholia; toward the end, sleepy all the time; urine never very copious; ordinary treatment of diabetes of no avail."

*Mental Pathology and Therapeutics.

†Clinical Lecture on Mental Diseases. London, 1883.