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’the occurrence of the disease. This is actually so, for twoyears ago such a cold season occurred in Bengal, and duringit and the following early hot weather months an unusuallylarge number of sporadic kala-azar cases were admitted to Iboth the native and European hospitals of Calcutta, manymore than in the following year with a normal cold season. ’,Now this long spell of cold weather followed an earlycessation of the previous monsoon rains, for the withdrawalof the south-west monsoon is succeeded by a cold northbreeze, and it will be remembered that in my first lecture Ipointed out that the Assam epidemic arose as a consequenceof four out of five successive years of deficient rainfall in theearly " seventies," due to an early cessation of the monsooncurrent. I have not been able to get complete meteorologicaldata for the Rungpore district in the " seventies," but Ithose of Calcutta of that period show that during severalof the years of deficient rain the mean temperatures of theensuing cold season were below the average. Now, if a

single cold year had such a marked influence in increasingthe sporadic kala-azar in Calcutta, on account of the longerperiod which was favourable to the infection, it becomeseasy to understand how an unusual succession of suchseasons might have increased the number of cases, and sothe foci of infection, year by year, until the fever became sowidespread that the people began to leave their villages andthus carried the infection into areas at the foot of the Garohills and in the Goalpara subdivision, which had hithertobeen almost or quite free from it, and so started the spread-ing the disease in Assam in a people who were extremelysusceptible to it owing to not having previously suffered fromthe sporadic form. Such an origin of the Assam epidemic ofkala-azar is most in accordance with the known facts of itshistory, and also with the life-history of the parasite andmode of infection, which I shall deal with in my remaininglecture.

ABSTRACT OF

The Morison LecturesON

INSANITY, WITH SPECIAL REFERENCE TOPROGNOSIS,

Delivered before the Royal College of Physicians of Edinburghon Jan. 28th and 30th and Feb. 1st, 1907,

BY A. R. URQUHART, M.D. ABERD.,F.R.C.P. EDIN.,

PHYSICIAN-SUPERINTENDENT, JAMES MURRAY’S ROYAL ASYLUM,PERTH.

LECTURE L1Delivered on Jan. fJ8th.

IN no kind of disease is prognosis more doubtful than ininsanity. For long overshadowed by ignorance and supersti-tion, for long regarded as a mysterious calamity, for longobscured by confusing issues, it is only of late years that thefundamental truths have been disengaged from the fantasticphenomena which formerly dominated the attention of theobserver. The long-drawn melancholy, the violent excite-ment, the bizarre ideas, and the dangerous conduct of theinsane wholly occupied attention and precluded the study ofobscure and elusive bodily conditions. The tedious recital ofaberrant talk and morbid conduct long detained us withmere irrelevancies. It is unnecessary to discuss the historyof medical literature dealing with insanity, until thememorable publication of Schroeder van der Kolk’s lectureson Mental Diseases, which took shape about the middle oflast century. He arrived at the conclusion that muchinsanity is due to morbid conditions of the great intestine.In accordance with the medical ideas of his time hedescribed this class of cases as sympathetic insanity."While he clearly recognised the brain as the organ of mind,he believed that it is liable to disturbance in direct con-sequence of somatic conditions, influencing it in a secondarymanner. This conclusion was widely supported, and here inEdinburgh the influence of the body on the mind was

1 The lectures were illustrated by statistical tables, charts, andclinical observations.

definitely fixed and crystallised by Skae’s classification ofmental diseases.

It is almost impossible to gain any useful information fromold asylum records. In the earliest series the recorders notethe reception of a lunatic and briefly indicate that he wasfurious or fatuous, sometimes adding an account of heroicdoses of medicaments, blistering, and bleeding, and some-times an indication of removal by death or otherwise. Ata later period the cases are described as psychologicalcuriosities-how they arrived on foot or in a carriage, howthey displayed their morbid ideas, how they wrote, and howthey behaved. But withal the most chary record of physicaldisorders, the most elusive statements as to family or

personal history-in brief, it was the study of mind apartfrom body-the psychological content. Having arrived atthe conclusion that there is no pathology of insanity com-ment on somatic conditions was, of course, superfluous.The blood of the insane is the derni(jr ori of the modern

investigator. Dr. Lauder Lindsay, so long ago as 1854,published a series of observations on the histology of theblood of the insane, which he had made in the CrichtonRoyal Institution. He did not claim that his researcheselucidated the morbid conditions of mind, or its organ, thebrain ; but rather illustrated the laws of pathology, thenatural relations of healthy and morbid states of mind andbody, and more particularly the reaction of physical diseaseson mental phenomena. The r6sume’ was presented under 14headings, the fourth being to the effect that a leuoocytbasmiccondition frequently exists. As examples of this, cases ofgeneral paralysis, acute mania, and melancholia are cited.Unfortunately, Dr. Lindsay concluded that there was noconnexion between the state of the blood and the mentalcondition, but that it bore a relation to the physical disorder,debilitated conditions of the system, and general vitiation ofthe blood.

’

Thirty years elapsed before another systematic investiga-tion of the blood of the insane was undertaken, when Dr.S. R. Macphail in 1884 won the medal of the Medico-Psychological Association. By that time the haemocytometerand the hsemoglobinometer had been invented and with theseinstruments of precision further advance was recorded. In

general paralysis Dr. Macphail recorded an increase in therelative proportion of white to red corpuscles, coincidentwith the progress of the disease ; he failed to find any greatinfluence on the proportion of white to red corpuscles inmaniacal attacks, while in a series of recent admissions theproportion was increased. Most important is his conclusionthat there is a close connexion between gain in weight, im-provement in the quality of the blood, and mental recovery.

I Another prize essay on the same subject was the work ofDr. Johnson Smyth in 1890. He inferred that the relative

proportions of white to red corpuscles were so variable as tobe of little importance. In many instances, however, herecorded an excess of leucocytes and stated that the blood ofthe insane is in a pathological condition.

Quite recently the position has been still further developedby the researches and conclusions of yesterday. Within thelast few months Dr. L. C. Bruce has published his records ofclinical investigations. Much of his book is concerned withobservations on the blood of the insane, and specially on theleucocytosis which he has shown to be of definite importancein diagnosis and prognosis. What was dimly discerned byDr. Lauder Lindsay half a century ago is made clear byDr. Bruce to day, and especially the important conclusionthat the morbid state of the blood is a dominating factorin the evolution of mental diseases. Sufficient has been saidto indicate the growth of medical opinion relevant to in-sanity as an affair of medicine. Similar references might bemade to other somatic conditions the true nature of whichis only now intelligible and explicable. I have referred toSchroeder van der Kolk as one of the first to appreciate thetoxic nature of insanity. He said: "It is evident that thebrain, as the organ through which the higher intellectualpowers are immediately manifested, must especially suffer ininsanity. We should, however, be much in error in seekingthe proper source and cause of the disease always in thebrain, for the. influence which many organs exercise uponthe brain is evident enough." The Hippocratic doctrinethat insanity is caused by disease had been obliterated by thesuperstition of the Middle Ages. The brain, as the organof mind, infinitely complex in its own proper connexions,is at present the subject of study relative to its relationswith all pathological somatic conditions. Thus the sym-pathetic insanity of van der Kolk is regarded as a toxic

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:affection, not always and inevitably caused by the directcontinuity of nervous elements, but rather by a poisonedblood-supply and the newer view is the wider. The contri-

butory causes of insanity are to be sought in heredity, indefect and decay of organisation, in the disordered workingof the somatic mechanism, and specially in the toxic ele-ments which may be formed by that disordered mechanismor introduced from without, which again brings the mani-festations of cerebral disorder into line with other patho-logical somatic conditions and leaves the mystery of madnesson a par with the mystery of rheumatism. For the positionis that we have to deal with a constitutional disease, pro-foundly affecting metabolism, mainly originating in heredi-tary defect, and issuing in a liability to repeated attacks of’insanity of a cyclical nature, quite different from thosemaladies which, like small-pox, appear to confer a futureimmunity.From the medical point of view mind is not a separate

entity, nor can we think of mental disorders as entities.The mind, normal or abnormal, is but one or rather oneseries of vital manifestations, part and parcel of the indi-vidual. The brain is the organ of mind but it is entirelydependent upon somatic agencies for nutrition, repair, rest,regeneration, and removal of noxious products-in short, forthe normal manifestations of mind. These are elementarypropositions which are constantly overshadowed by pre-possessions which hinder us as the smoke of the conflagrationobscures the origin of the fire. The psychic disorder isgeneralised, the somatic disorder is generalised, both areconstitutional. Very rarely is insanity a local disease.Rather is it a generalised mental reduction, characterised bya loss of the finer feelings, and inability to adapt, a loss ofxestraint on motor manifestations ; and the depth and con-tinuance of this reduction, the severity and pathologicalimportance of the organic concomitants are the measure ofprognosis. All insanity is defect-at least, a degradation offunction if not a degradation of structure. Insanity is aunity, not a fortuitous collection of kaleidoscopic symptomseach requiring a proper name. Still, one may convenientlypeak of melancholia, mania, and dementia, meaning de-pression, excitement, and enfeeblement, and it is also per-missible to use the term circular insanity and delusionalinsanity as denoting a pronounced mixed, alternating form,-and a systematised delusional condition, neither of which is

,distinctly mania, melancholia, or dementia. In fact, thissimple classification is founded upon symptoms in terms of’time.

It is evident, however, that as our knowledge progresseswe are enabled to screen off from the total numbers ofinsane persons certain persons affected by definite pathological forms. I shall therefore, following Sankey, further,di,vide the cases under review into cases of ordinary insanity-of obscure causation and cases of definite pathological’causation. On the one hand, while I regard the patho-logical forms as of little moment in respect of prognosisunder present conditions, as fixed, irrecoverable, and alreadydoomed ; on the other hand, I regard ordinary insanity asuncertain, curable, and now even hopeful. It may be that

general paralysis is to be lifted out of the category of

.reproach, that it will be fought and conquered, as hasbeen suggested by Dr. W. Ford Robertson. Dr. Bruce has

lately shown that, disregarding the mental concomitants,there is evidence of the toxic nature of insanity. Thisevidence is of such a nature as to be appreciable by themethods of the clinic and the laboratory, to be checked orcorroborated by the observers. It is not a theory of disease,but the direct outcome of a long, laborious, and skilfulinvestigation into the facts of disease, honest and unpre-judiced. His work opers up new vistas and affords newhopes. He has, finally, brought insanity into the categoryof other somatic diseases and established a parallel con-

dition, long surmised end discovered with difficulty, longobscured, and at length c istinguished by none other than themethod of Zadig.

Briefly, it would appear that the time has already come whenthe conclusions formulated by Dr. Ford Robertson last yearin reference to general paralysis, the failure of the organismto protect itself against bacterial invasion, may be extendedto forms of ordinary insanity which hitherto have evadedthe skill of the pathologist. Whether it is consequent on ametabolic toxaemia or on a bacterial invasion, insanity mustnow be regarded as a condition of disease which demands nospecial pathology and therefore no exceptional treatment.The numbers under consideration are 419 men and 390

women, being a total of 809 persons, admitted from 1880to 1904 inclusive. Any study of insanity must beginwith a consideration of heredity, the earliest conditions

affecting the organism. The percentage of those with a here-ditary history of insanity may be stated as 45, while the inclu-sion of the whole neuropathic heredity increases that numberto 72. It is a narrow view of the heredity of insanity whichdoes not include the occurrence of the graver neuroses, wantof mental balance, eccentricity, alcoholism, and paralysis.These manifestations in one generation so frequently issue inpronounced insanity in the succeeding generation that thenature of the incidence is obvious. We have to deal with acondition which has certain hereditary relations owing to adefect of organisation and comparable with arterio-sclerosis,gout, or other diseases of obscure causation It is not thecrude heredity of yesterday but a failure in development or aweakening of somatic defences apparent in early life, in theperiod of development, in the stress of maturity, or in thedecay of old age. And I believe that the more marked the

parental defect the earlier will the failure of the neworganism be manifested exactly in conformity with the vitalstatistics of gout. We are so accustomed to think ofsomatic stigmata and congenital idiocy as inborn defectsthat it is easy to misinterpret the true nature of thesefailures. So far as I can see, the defect is of the sameintrinsic nature, whether the mental disorder be manifested inearly idiocy or delayed senility. There is no adequate reasonto deny the existence of pre-natal toxin, assuming thattoxins are effective in the production of cerebral disturbanceand later insanity. By the hereditary nature of insanity Itherefore mean the inborn defect which is manifested undercertain conditions in the existence of the organism. Not,crudely, that fatuous and furious persons are so conceived, -but that their defect of organisation is such as renders themliable to fatuous or furious manifestations throughout thecourse of their existence when subjected to certain morbidinfluences.

Heredity works out in two directions-for better or worse.We hear so much of the latter that the former is neglectedor but partially recognised. Glib talk about the extinctionof families and the eradication of undesirables must bebalanced by the reasoned knowledge of natural processes.On the one hand, we can discern the ruin and decay offamilies in spite of the constant effort of nature at re-

construction and rehabilitation ; on the other hand, by theprepotency of new blood and a more favourable environmentthere is a reversal of the process, a rehabilitation just asimportant and just as certain. Of course, this cannotbe demonstrated by the statistics of asylums, andthe official mind. " subdued to what it works in," isobsessed by the calamities and the degradation of humannature. It is just here that our statistical informationgenerally fails, for the records of special hospitals must bereplaced by the statistics of the general population taken atrandom, and deeply I regret that work of this importance isleft to a few enthusiasts instead of being undertaken by themedical profession as a whole in furtherance of biologicaland sociological knowledge. This method of research doesnot apply merely to insanity but to all those constitutionaldisorders, to all those departures from the normal which areof the greatest national importance. Until a collectiveinvestigation of the kind is completed and analysed it is vainto attempt any final prognostic in heredity. If vital historiesof families, with medical details of their normal andabnormal members, could be extracted from clinical recordsand reluctant memories to the number of some thousands, theinchoate condition of our opinions in reference to hereditywould be reduced to order and some degree of precision.

It has been my practice so far as possible to constructgraphic charts of each family under observation, and thesehave been submitted to Mr. David Heron, whose importantstudy of the " Relation of Fertility in Man to Social Status

"

gained a wide and appreciative audience last year. Mr.Heron has kindly constructed a chart which shows theincidence of insanity in regard to individuals, one memberof each family at least having been insane. It would appearthat the incidence bears heaviest upon the eldest members ofthe families in fraternity, and that there is a fairly constantdiminution of frequency as the families increase in size. I

.

am not aware that this calculation has been made previously-in fact, the methods of applied mathematics and the workingout of problems of probabilities in relation to biology are asyet in an early stage of development. The important bio-metric system advocated and instituted by Professor Karl

11 2

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Pearson will greatly enlarge our knowledge and correct ourprepossessions, if the desirable data are forthcoming. Weonly require a collection of accurate facts in sufficientnumbers to correct the margin of error.

SOME OBSERVATIONS ON UTERINEFIBROIDS :

BASED ON A SERIES OF 150 CONSECUTIVE CASES TREATEDBY ABDOMINAL OPERATION.1

BY ARTHUR E. GILES, M.D., B.Sc. LOND., F.R.C.S.EDIN.,

SURGEON TO THE CHELSEA HOSPITAL FOR WOMEN; GYNÆCOLOGIST TOTHE TOTTENHAM HOSPITAL.

I. A

WHEN discussing such a subject as uterine fibroids thegreatest risk that one runs is that of becoming too discursive, fbecause there are so many aspects of the subject that are ffull of interest and importance. In order to minimise this risk I propose to confine my remarks to a few points, asexemplified by cases that have come under my own obser-vation, and upon whom I have had occasion to perform anabdominal operation. The text or basis of my paper is there-fore a consecutive series of the first 150 cases so treatedspread over a period of 11 years.The points that I wish to consider are the following :

1. The age-incidence of fibroids. 2. The relation between between fibroids and sterility. 3. Indications for operation as based <

upon (a) the symptoms produced ; and (b) the complications i

to which fibroids are liable. 4. Methods of operation inrelation to varieties of fibroids. ’

1. THE AGE-INCIDENCE OF FIBROIDS.An examination of the ages of the patients at the time of

operation gives the following results :-

These figures are in harmony with the general view thatfibroids are almost unknown under 20 years and rare under30 years ; they are met with not infrequently between theages of 30 and 40 years, and between 40 and 50 yearsthey are relatively common. It must be noted that these

figures do not express the age of onset of fibroids,because many of the patients had been the subjectsof these tumours for years before they were operatedupon ; nor do they represent the relative ages of all

patients suffering from fibroids ; their more precisesignificance is the age at which the fibroids in my cases

gave rise to such troubles as called for operation. Thereason that the numbers rapidly diminish after the age of50 years and drop almost suddenly after 60 years is thatby this time the majority of patients have been operated uponnowadays, whilst some have died from the complications offibroids, and some have been enabled, by the absence of com-plications or serious symptoms, or by putting up with a lifeof semi-invalidism, to retain their tumours undisturbed bythe surgeon’s knife. The youngest patient on this list wasNo. 11; she was 23 years old, and operation was necessitatedby profuse haemorrhage- The two oldest patients, Nos. 31and 42, were aged 63 years, the one a single woman and theother a widow ; both required operation on account of

A paper read before the West Kent Medico-Chirurgical Society,Nov. 2nd, 1906.

pressure symptoms, amounting, in the case of the latter, to.partial intestinal obstruction.

I have examined my cases to see if there be any relationbetween the age of patients and the characters of theirtumours and the results are set forth in the followingtable :-

* Conditions allowing of myomectomy instead of hysterectomy.

We cannot lay great stress on this table because thenumbers are too small, but it appears evident that the age-of patients does not materially influence the character ofthe tumours, except in the matter of degenerative changes,which are strikingly absent before the age of 40 years.This, of course, is what we should expect from the life-history of fibroids.

2. THE RELATION BETWEEN FIBROIDS AND STERILITY.It has long been known that there is a close association

between sterility or arrested fertility and fibroids, and itoccurred to me that it would be a matter of interest toendeavour to ascertain the precise nature of that association..It may be said briefly that the relation appears to be notbetween fibroids and sterility-i e., incapacity to conceive-but between fibroids and the absence of pregnancy, whether-the patient has had the opportunity of conceiving or not.I shall first state the facts at our disposal, derived from amanalysis of these cases, and then make some rather specu--lative observations by way of inference. Of the 150 patientsoperated upon, 56 were single women and 94 were married.Of the 94 married women, 34 had never been pregnant and60 had borne children. Thus the total number who had notbeen pregnant was 90. and our first deduction is that in 60 percent. of cases of fibroids the patient has not been pregnant.The length ot time that the nulliparas had been married

was as follows, the time being not stated in my notes in11 cases :-

When we investigate the cases of women who had bornechildren we obtain some interesting and striking results. Inthe next table I have drawn up a list showing the number ofpregnancies that each patient had had and the number ofyears that had elapsed since the last pregnancy. In my notesthe data concerning the number of pregnancies are wantingin three cases, and the length of time since the last confine-ment in six cases.

Omitting the last three cases on the list, where the numberof pregnancies was not known, 57 patients had had betweenthem 172 pregnancies, giving an average of three pregnanciesto each patient. Of these 172 no fewer than 38 hadterminated in miscarriages. On glancing at the list one isstruck by the relatively large number of patients who hadhad only one or two pregnancies-namely, 27 out of 57.Our second deduction is that among marrrried 7vonten fibroids-are associated with diminished ferrtility - But perhaps themost notable feature about this list is the long time, in themajority of cases, that had elapsed since the last pregnancy.Data are wanting on this poi it in six out of the 60 cases-and of the remaining 54 three were pregnant when first seen ;