general contour of the head, and even features, has been closely studied by Virchow, Griesinger, and others.

It can be readily conceived how the shape of the cranium would be modified by one or other suture becoming ossified out of proper order. For example, if there were premature ossification of the whole of the sutures, the cranium would simply remain small but symmetrical; if the sutures of the apex were ossified prematurely, the head would remain small at the apex, and would increase only at the base; if the suture at the base were first fixed, the cranium would be contracted at the base, and expand only above. Thus various forms of cranium would result. The chief varieties found among idiots are shown in these plates which I exhibit from M. Morel's work, before quoted.

With the malformations of the cranial cavity, alterations not only result in the general contour of the head, but of course in the features also. Thus, if the base of the cranium ossified slowly, the brain would find there an important means of compensation, and an expansion of the base would result; and this would give the features, by displacement, the peculiar type of the Aztec while the closing of the sutures of the base prematurely would produce the opposite form in the features, or the physiognomy of the cretin; the sphenoid bone, at the point of junction with the basilar, forming a smaller angle than normal, the hollow of the base would be shortened and the sphenoid tilted, as it were, toward the occipital region; the bridge of the nose would be thus retracted and rendered broader, the orbits separated, the eyes sunken, the cheek bones prominent. These two principal types of feature have been rendered familiar by the public exhibition of certain dwarfs.

The cretin proper has a round head, and it is somewhat large in relation to the size of his body. His neck is short; in cases there is goître. The expression and the form of the features are those of a child; the eyes are usually wide apart; the cheek bones high; the nose without bridge, and small or snubbed; the mouth large; the teeth irregular, and the dentition is usually delayed to a late period; the belly is large; the limbs large at the joints, and ill-formed: if puberty be developed at all, it is late; but in the worst cases the cretin is sterile.

LECTURE VII.

Argument. Cases in which the motor functions are principally involvedEpilepsy and general paresis-Forms of epileptic insanity-Epileptic imbecility Epileptic mania-Epilepsia larvalis-Stages of general paresis— Phenomena of the second stage.

TO-DAY I am about to enter upon a different class of affections. In the previous lectures, with the exception of the subject of idiocy, we have been wholly occupied with one species of disease in its various phases. I have traced the characters of the chief variations which that disease takes at different epochs, and under different circumstances; but there is nothing, so far as I can discover, to warrant us in considering that these variations constitute distinct species of disease. There are, in fact, like variations in every known form of disease; take, for example, a case of pneumonia, in this disease we have different phenomena, which are peculiar to each stage of the affection. Pneumonia, like insanity, may also terminate at the first, second, or third of its artificial stages; it may continue and pass into a state of chronic disease, leaving certain troublesome symptoms behind; and, lastly, after it has actually ceased as pneumonia, there may be left as a consequence of it, certain structural changes which may inconvenience the individual for the rest of his life. Now, though we should not, perhaps, still call it a case of pneumonia, in this last condition, yet we should acknowledge an unity of cause for all the phenomena exhibited throughout the case. We should certainly attribute the symptoms to one species of discase only.

The class of cases which I am about to speak of to-day, are totally distinct from those hitherto mentioned; that is, there is every reason to believe that they are developed from a perfectly different origin and source; such, at least, appears to my mind the most correct view to take of them. But I shall lay before you the arguments which lead me to this conclusion.

In mental disease, whether the symptoms are chiefly melancholic or maniacal, I told you that the motor functions were usually in some way involved. In some cases, there is a statuelike immobility; in others, even convulsions. In the group of cases which we are now about to consider, a disturbance of the motor faculties is the predominating feature of the morbid phenomena.

These affections exhibit also some mental aberration, some unsoundness of mind, or they would not be included in my specialty. The affections, in which this state of the motor faculties is met with, are epileptic insanity, and general paresis, or general incomplete paralysis.

Epileptics are met with in public lunatic asylums in three chief varieties. 1. There are patients who are unable to take care of themselves; or cases in a state of mental imbecility. 2. There are cases attended with maniacal insanity. 3. And certain cases which have been called epilepsia larvalis.

Your Professor of Medicine has brought before you the first description of case. You have, also, in your Professor of Clinical Medicine, one of our ablest authors on the subject, of whose teachings you have, doubtless, availed yourselves. In Dr. Reynold's work on 'Epilepsy,' you will have learned the phenomena of the ordinary epileptic attack.

You will have learned that, in a certain proportion of epileptics, the memory and the mental powers generally become affected, the proportion is, however, according to Dr. Reynolds, but small. I quote the following conclusions from his book: he says that

"1. Epilepsy does not necessarily involve any mental change. "2. That considerable intellectual impairment exists in some cases; but that it is the exception not the rule.

"3. That women suffer more frequently and more severely than men.

4. That the commonest failure is loss of memory, and that this, if regarded in all degrees, is more frequent than integrity of that faculty.

"5. That apprehension is more often found preserved than injured.

"6. That ulterior mental changes are rare.

"7. That depression of spirits and timidity are common in

the male sex, but not in the female; that excitability of temper is found in both."

Dr. Reynolds found that the memory was normal, or affected only immediately after the fits, in 43 per cent. of his cases, and more or less defective in 56 per cent., but only to a great degree in one sixth of the whole. Apprehension was normal in 62 per cent.; defective in 37 per cent.

It is not my intention, however, to enter into the question of epilepsy. The epileptic who has become imbecile, and is, therefore, passed into the lunatic asylum, because he is not able to take care of himself, has become already incurable so far as his epilepsy is concerned. His mental imbecility requires only the same treatment as imbecility from other causes, and of that I shall speak hereafter.

The second description of true epilepsy which is met with in asylums is that in which the disease involves the intellectual faculties.

The pathology of epilepsy according to authors has its starting point in the medulla oblongata, which has been demonstrated by the researches of Schroeder Van der Kolk, BrownSéquard, Kussmaal, and Tennel, &c. The two essential phenomena of epilepsy are loss of consciousness and convulsions, and these being the condition or state produced, and the medulla oblongata, the organ through which they are produced, the question arises, what is the immediate operating cause? Dr. Reynolds argues that loss of consciousness is a simple negative condition, and that the convulsion is due to irritation at the medulla or upper part of the spinal axis, and is a modification of a normal function, and not the effect of a structural change, since the organ shows a complete structural integrity in the interval between the fits.

He considers, therefore, that the convulsion is a simple excess of a normal action.

"The nature of the morbid change is," he writes, "an exaggeration in degree of the functional activity of the medulla oblongata and upper part of the spinal axis;" and he considers that augmented activity in the nutritive processes is the prime and essential fact in epilepsy.

The seizure or excess of action, however, he believes may be brought on by lesions of the adjacent nervous, or other tissues.

In the cases of epileptic mania, however, there appears to me to be an extension of this morbid activity to the rest of the cerebral organs, and a certain persistence of it in those parts presiding over the motility; for not only is the patient convulsed, but for a period anterior or subsequent to the fit, there is generally exhibited great restlessness and irritability of the motor faculties.

The cases which become maniacal are not numerous, and are mostly of old date, as far as the epileptic symptoms are concerned. A patient, for example, who has been subject to epilepsy for several years, becomes affected with maniacal symptoms on the approach of each seizure. Most of the patients who came under my care at Hanwell in this condition, were admitted in a state of great debility, and some of them were greatly emaciated. One poor woman had been submitted to a long course of some epileptic nostrum, and had wasted rapidly under its use; another was taken with maniacal symptoms after parturition. In nearly every case the maniacal attacks ceased when the patient regained her strength. Out of 1000 patients in the Asylum, the number of epileptics under treatment was about 45, of whom five or six were subject to maniacal paroxysms on the occurrence of the fits. The violence of these patients exceeds the violence of any other kind of lunatic. Their fury is blind; without provocation or warning, they will rush at the nearest bystander, and tear, bite, or attack with any implement or weapon they can seize. During the time I was at Hanwell, an epileptic male patient, while in the fields digging, was seized with his paroxysm, and rushed blindly upon an inoffensive patient near, and cut him down with the blade of the spade, inflicting frightful injury, and killing him on the spot. The epileptic, in some cases, gives no warning, except by a slight alteration in colour, and some indisposition for a day or two previous to the attack, the act of violence itself is sudden. When the convulsion has followed, and which may be repeated four or five times for several days, the patient will pass into a drowsy state for a period, and then will return to a state of tranquillity or the irritability and violence may occur after the accession of convulsion. It has never occurred to me to have a patient with maniacal symptoms who did not improve in respect to the