With the invited co-operation of Drs. N. EMMONS PAINE, Westboro, Mass., and CLARENCE BARTLETT, Philadelphia, Pa.

Subject for Discussion: Melancholia, its causes, means of prevention, and the best methods of cure.

REMARKS ON PHASES OF MENTAL DISORDER SEEN OUTSIDE OF THE ASYLUM.

BY CLARENCE BARTLETT, M. D.,

PHILADELPHIA, PA.

When the Chairman of your Bureau of Nervous and Mental Diseases invited me to prepare a paper on the Causes and Treatment of Melancholia, I felt obliged to decline the subject he assigned to me, for my experience with that lamentable disease is so small and his correspondingly large, that any remarks he might make concerning it would be of far greater value than anything I could present for your consideration. I chose instead to make a few remarks on certain phases of mental disorder seen outside the asylum. After thinking

*Annual meeting.

over the cases with which I had intended to illustrate this paper, I soon found that if I included in the following pages all that I would have liked to present, your patience and good nature would alike have been exhausted. I shall limit myself, therefore, to two phases of mental disorder with which it has been my lot to meet in neurological practice. These are, first, mental disorder in children, and, secondly, cases of insanity associated with delusions, said delusions having a positive existence as facts.

1. Mental Disorder in Children. In presenting the following cases for your consideration and discussion, I do so with the fear that some will disagree with me in my belief that some mental disorder was present in each case. Rather would they say that the patients were wrongly brought up, and that judicious punishment was the most efficacious therapeutic agent needed.

In November, 1886, Johnny F

æt. 3 years and 9 months,

was sent me for examination by Dr. Van Baun. For some time past the little fellow had been subject to violent paroxysms of rage, in which he would use language of the vilest sort. He would lie on the floor two or three hours at a time, screaming and kicking. Nothing that his parents could do for him would pacify him. He would ask for things which, when given him, he would refuse. In his periods of rage he often threw things at his mother. He frequently wet the bed at night. Even in the daytime he gave no warning of his desire for stool or micturition, but would perform these acts wherever it best suited him to do so. His pupils were very changeable, at one time being large and at another extremely contracted. The family history was of a remarkably neurotic character. He pulled at his privates a great deal, yet his father had never noticed the child actually masturbating. The child's prepauce was long and tight. There were glandulo-preputial adhesions. The penis was very irritable, an erection promptly appearing on my merely touching the organ. All possible means for the reformation of the child had been tried without avail. Punishment had been faithfully tried. By my advice Dr. Vau Baun circumcised the patient, after which he rapidly improved and was finally cured.

In the winter of 1886-87 there were admitted at different times to the Children's Homœopathic Hospital, of Philadelphia, two children, giving histories in many points similar. The first one was Emma N -, æt. 11 years. According to her mother's account she was subject to convulsions, which appeared nearly every day. These attacks were apparently of hysteroid character. Emma had been in

the hospital but a few days when the nurse discovered her to be a confirmed masturbator. She practiced her vile habit publicly in the wards. Nothing short of tying her hands could keep her from it. She gave frequent notice to the nurse that a "spell" was about to come on; but as she was "judiciously neglected" none came. Her disposition was anything but lovely. She did not hesitate to injure the other children on little or no provocation. She had been in the hospital for over a month without any of her "spells" when, early one morning, she was taken in convulsions. The spasmodic movements were confined to the left side of the body. They continued with short remissions for ten hours, after which the patient went into a stupid sleep, which lasted until the following morning. She was then as well as she was before the attack. In two weeks another convulsion came This was exactly like the first one. She was then removed to her parents' home, shortly after which she had another attack, in which she died.

on.

Herman æt. 10 years, was admitted with a history of epileptic seizure, said to have been produced by scarlatina. He was a bright little fellow, but was, nevertheless, of cruel disposition. Especially did he vent his ill feelings on the more crippled inmates of the institution. So far as the nurses could discover he did not masturbate. He was in the hospital more than a month before a convulsion appeared, and that convulsion was limited to the left half of the body. It lasted twelve hours, and was followed by stupor for eight hours longer, when he died. No post mortem examination was permitted.

Now, I believe that while the mental symptoms in each of the three cases above described were not of such a nature as to merit the name of insanity, they were yet actual parts in the disease from which the patients were suffering. In the first case they were the result of genito-urinary irritation; and in the second and third, they were concomitants of organic disease of the brain. Masturbation may also have been an etiological factor in the first case as it was also in the second. The subject of masturbation in very young children is not without interest, and is, I fear, of greater practical importance than we are aware. That younger children than Johnny F- —, whose case I just described, will engage in the practice, there is abundant evidence. The most remarkable case of the kind I ever saw was that of a child but little over two years of age. He was admitted to the Children's Hospital. The nurses looked upon him as a model of good behavior until it was discovered that he amused himself by practicing

onanism. Dr. Van Lennep, the surgeon of the hospital, then circumcised him; but that accomplished but little.

A case of purely mental trouble in a child was that of Harry P————, æt. 12 years, whom I saw with Dr. Pemberton Dudley. He had been ailing three months. His trouble was an over-conscientiousness, he being in constant fear that he would do wrong, or that each act he performed was a misdeed. This one idea preyed on him constantly. He also lost the power, at times, of selecting words with which to express his ideas. At such times he would exhibit his impatience at his infirmity by well-defined choreiform movements. In all other respects he was perfectly healthy. Dr. Dudley had had the boy watched carefully in order to discover whether or not masturbation was practiced. The result was negative. The general appearance of the little fellow was, moreover, against the existence of such a habit. Glandulo-preputial adhesions were found on examinations of his penis. These were broken up by Dr. Dudley. The parents were directed to keep him from school and from his books when at home, and encourage him to play out doors as much as possible. Recovery followed in a short time. A remedy was prescribed, but my note-book containing the account of this case has been mislaid, so that I cannot give you the name of the remedy, an important omission.

Public interest in the question of insanity in children has recently been awakened by the case of the Wilson child, who made several attempts to burn the Hospital for Crippled Children on Lexington Ave., New York. A case of very similar character came under my observation in November last. Dr. W. H. A. Litz asked me to see Maggie F æt. 18 years, to determine as to her sanity. I examined the patient at a large reformatory institution, in which she had been placed by her father. The girl's appearance and manners were those of a child twelve years of age. In my interview with her she gave no evidence of anything wrong, except the tardy development above referred to. She confessed having fired the dormitory in the institution in which she then was, besides having been the active agent in two fires at her father's house and one at a school which she had been attending. She gave no reason for her strange behavior. Her father stated that on several occasions she had run away from his house to that of an uncle, where she would stay two or three days; then, becoming dissatisfied, she would return home. As an etiological factor in this case, it may be stated that her mother, while carrying her, was intoxicated most of the time.

2. Insanity with delusions, these delusions having an actual existence

as physical conditions.

To illustrate this class of cases I shall æt. 48 years. She had a

mention but one case, that of Mrs. history of chronic lung trouble of years' standing. On a windy day of last March, she called on the physician who resided in the neighboring house to have him examine her chest. At his request, she did not wear her corsets. Her mental condition was then perfect. Shortly after this she became possessed of the idea that she had phthisis (which she really did have), and that death was near. She moaned constantly day and night. She walked the floor, wringing her hands and bemoaning her fate. Her only topic for conversation was the condition of her lungs and her imprudence at visiting the physician next door without wearing some extra clothing to compensate for the corsets she left off. To this cause she attributed her whole trouble. She declared herself perfectly well up to this time, and that she had no cough before she caught cold from going without corsets. Her mental state grew worse and worse. She gave those with whom she came in contact no peace whatever. At one of my visits, in order to let me carry on a conversation with her husband undisturbed, she voluntarily went to the window, put her head out and kept up her moans. When her mental disorder had lasted six months she was sent to an asylum. After she had been there two or three weeks, her delusions respecting her pulmonary condition disappeared, and she then declared her lungs perfectly sound. In their stead, she has developed maniacal attacks. These, after four months' residence at the asylum, still continue. Her pulmonary trouble is now more serious than before, and yet gives her no concern whatever.

In closing this paper, let me express the hope that the discussion will elicit from the physicians present further information concerning mental disorders in children. The subject is an interesting one, and one, too, about which we can learn much.