perience, is possibly so indefinite, nevertheless, that its introduction would be of doubtful utility. It strikes me that with more distinct limitations than the Doctor has placed upon it, it may be useful; and yet it is a question whether it is not already covered by some such term as acute dementia or stuporous insanity-that form which we naturally get from auto-toxic processes and which consequently leads to and necessitates special methods of treatment distinct from those employed in exaltation or depression. I can recall several cases following severe attacks of typhoid fever, other cases following sudden shock, of that general type of cases which, I would think, answer very well to the Doctor's general description of confusional insanity, and which have undoubtedly a different pathological condition at their base from that which is usually found in cases of exaltation or depression. In so far as this describes such a type and assists us in fixing a distinction in the pathological basis from those of general exaltation or general depression, it is of unquestionable advantage

to us.

I think the doctor's delineation was an admirable one and that the paper will be of advantage to us in the way I have mentioned, and yet, as Dr. Mills has said, it is a question whether it is of advantage to introduce these refinements.

Dr. WORCESTER: I only wish to make my meaning clear and then let the matter stand or fall on its own merits. I must take exception to what Dr. Mills has said that delusion is the fundamental thing in melancholia. I think it must have fallen to the lot of many of us to meet with cases of melancholia in which there was no definite delusion, only a vague feeling of general distress, in which the delusions developed subsequently, if at all, to this. The subject matter of the delusions in melancholia is something which varies very much with the circumstances and the previous habits of thought of the patient. But, letting that matter drop, the point which I especially wish to call to the attention of the Association is the fact that, in my own experience at least, there have been a good many cases which ordinarily would be classed as mania at a certain period, which have not presented that symptom at all during a pretty long course of treatment while under my observation, or in which that symptom has been very transitory. I have, for instance, two cases in mind of middle aged women who were under my treatment at the time I left the Arkansas State Lunatic

Asylum. Both were quite violently excited at the time of coming under treatment, although without any appearance of elation. Both in a short time became quiet. Both appeared confused during a number of weeks (as long as they remained under my observation); one was apprehensive, she imagined we were all going to be burned and had other vague delusions of apprehension. The other would not talk at all but usually would wander aimlessly about the ward, evidently in a state of perfect bewilderment. Now, in this condition, under the ordinary classification, the cases might, perhaps, be classed as cases of acute dementia, but they had previously shown symptoms of active excitement. I have had other cases in which melancholic symptoms were at one time a prominent feature of the cases, maniacal symptoms at another and symptoms of quiet bewilderment at still another, but the symptom of mental confusion ran through the whole. Now when we have a symptom or group of symptoms which is transient and another which persists throughout the whole course of the disease, the disorder can more properly, if we are going to adopt the classification based upon symptoms, be named in accordance with the symptom which is persistent than the one which is transient.

FREQUENT DISORDER OF PNEUMOGASTRIC FUNC

TIONS IN INSANITY.

BY T. H. KELLOGG, M. D.,

Medical Superintendent Willard State Hospital, Willard, N. Y.

It would not be within the appropriate limits of this article, even on this semi-centennial occasion, to mention to my hearers by way of preface the anatomical and physiological researches which have within the last fifty years so vastly increased our knowledge of the functions of the pneumogastric nerve.

Suffice it to affirm that this knowledge, taken in connection with pathological facts, is now such as to account for certain symptoms not infrequently present in cases of insanity.

An attempt will be made, therefore, within the brief scope of this paper, to offer some scientific rationale for certain clinical phenomena familiar to observers of mental disease, and consisting chiefly of functional disorders of organs within the region of distribution of the pneumogastric nerve.

A momentary review of the anatomical facts of the subject is first in order.

The deep origin of the vagus or pneumogastric nerve is in a tract of gray matter beneath the lower and outer half of the floor of the fourth ventricle; its surface origin is by eight or ten filaments emerging from between the restiform and olivary body and uniting to form the trunk of the nerve which, springing from the medulla between the glossopharyngeal above and the spinal accessory below, passes out of the cranium through the jugular foramen and down the neck in the sheath of the carotid vessels into the thorax and to the upper part of the abdomen.

During this extensive course from above downward it gives off branches to the pharynx, larynx, trachea, esophagus, heart, bronchi, lungs, stomach, spleen, liver and intestines. Its functions are in the main motor and sensory, and, to avoid repetition, it is stated broadly at once that most of its motor fibers are to be traced ultimately to spinal accessory sources.

The pneumogastric both inhibits and accelerates circulation and respiration and has also vasomotor and trophic influences. The

anatomical division of this whole topic is as simple as any, and the subject will be presented therefore in the order of the original distribution of the pneumogastric branches from above downward, beginning with the disorders of its pharyngeal functions as witnessed in cases of insanity.

The pharyngeal branch of the pneumogastric nerve supplies the principal motor fibres to the muscles and constrictors of the pharynx, and to loss of the motor influences which it conveys is due the paralysis of the pharynx both partial and complete, found in certain forms of insanity.

In dementia paralytica some or all of the muscles and constrictors above mentioned may be paralyzed, and the degree of difficulty in swallowing varies accordingly, and the pathology in these instances is doubtless degeneration of the pneumogastric and spinal accessory nuclei. A like pathology of nuclear changes also holds good for the dysphagia of certain cases of insanity complicated with locomotor ataxia or with bulbar paralysis, but in dementia syphilitica the paralysis of the pharynx may be due to syphilitic growths involving the roots of origin of the pneumogastric and upper roots of the spinal accessory nerve. In certain forms of organic dementia with central brain lesions and hemorrhage, softening, or pressure of medulla, or pons pharyngeal paralysis may also be present.

There is also loss of function of the pharyngeal and of other branches of the pneumogastric nerve in typhomania and other forms, with acute encephalitic and meningeal inflammations, and also in cases with effusions of fluid exerting pressure in the fourth ventricle. The pathological diagnosis in these cases is important and they often require artificial feeding, and the dysphagia may be mistaken for voluntary rejection of food.

The changes in respiration and in cardiac rhythm in the above cases will be referred to later. They are to be regarded as further evidences of pneumogastric lesions, like the failure of action of the soft palate in instances with nasal intonation, and passage of food into the posterior nares in deglutition, as the palate muscles are in part innervated through the pharyngeal branches of the pneumogastric.

There are other cases presenting minor degrees of paresis of pharyngeal muscles and varieties of dysphagia, due doubtless to vagal disorder of some kind, but not traceable to organic central lesions, like those first mentioned.

R

Spasm of the pharynx is a manifestation of functional pneumogastric disorder not uncommon among the insane. It may take the form of globus hystericus, or attend hypochondriacal cases with persistent delusions of inability to swallow, or it may constitute the motor aura of epileptic insanity.

It may render artificial feeding very difficult, and in one case under observation it was an absolute impediment to the use of the ordinary nasal tube for the purpose of alimentation.

It may possibly furnish some reasonable basis of explanation of a symptom encountered occasionally in hypochondriacal patients who are unable to swallow in the presence of others, as in a case mentioned by Gowers. In this same class of patients delusions of foreign bodies in the throat are due to paræsthesia of the pharynx.

There are numerous and interesting affections of the larynx in insanity, due to disordered functions of the pneumogastric nerve or of one or both of its laryngeal branches. The superior laryngeal nerve gives sensation to the larynx above the vocal chords, supplies the cricothyroid muscle, conveys inhibitory impressions to the respiratory center, and causes glottic closure and arrest of the diaphram in deglutition.

To heightened irritability of this nerve in hysterical and hypochondriacal insanity are due reflex and paroxysmal cough and persistent laryngeal hyperæsthesia. The latter affection is so pronounced that an attempt at forced alimentation in one of these will provoke violent cough, or vomiting, or inhibition of respiration, carried often to a most alarming degree.

Paræsthesia in the region of distribution of this nerve also accounts for the familiar delusions of hypochondriacal cases with imaginary foreign particles in their larynx.

There is also anæsthesia of the larynx in several forms of insanity, and in general paresis it is often complete before paralysis of the pharyngeal constrictors begins, and to it is to be attributed the deglutition pneumonia of the early stages of paresis.

The fact that cough, as an objective sign of pulmonary affections, is often absent in insanity may in some cases be explained on the ground of suspension of the sensory innervation of the superior laryngeal nerve and of impressions from the different fibers of other vagal branches.

The inferior or recurrent laryngeal nerve furnishes motor innervation to all the muscles of the larynx except the cricothyroid.