toward the dicrotic or monocrotic type, being never tricrotic in uncomplicated cases. It becomes more characteristic as the mental condition degenerates, and assumes its typical form in the most profound state of dementia. The following traces which I obtained from patients in this Asylum, will serve to demonstrate the pulse curves so found in the different forms of insanity.

Fig. 6. Melancholia. Female, aged 38 years.

Fig, 7. Melancholia. Female, aged 28 years.

Fig. 8. Melancholia. Male, aged 48 years.

Fig. 9. Melancholia. Male, aged 51 years.

Fig. 10. Acute mania. Male, aged 40 years.

Fig. 11. Acute mania. Male, aged 28 years.

Fig. 12. Sub-acute mania. Male, aged 26 years.

Fig. 13. Paroxysmal mania. Female, aged 30 years.
Subsequently died of apoplexy.

Fig. 14. Periodic mania. Male, aged 51 years. Taken while he was recovering from an attack.

Fig. 16. Chronic mania. Male, aged 60 years.

Fig. 23. Dementia. Aged 34 years.

Fig. 24. Dementia. Aged 40 years.

An analysis of the above traces shows two points of difference between them and the normal type: 1st, a loss of tricrotism with a marked tendency to the dicrotic and monocrotic form, and 2d, a flat top in place of the acute angle found in health and febrile diseases. The first of these changes we have already found to exist in cases of fever when the temperature of the body is elevated, but among the insane there is no increase of temperature, and we may therefore consider a dicrotic pulse unaccompanied by an abnormal rise of temperature as one of the physical phenomena of insanity.

The second deviation from the normal standard is still more characteristic of psychical disorder. This peculiar pulse curve with a flat summit has been described by Marey, and attributed by him to a pathological condition of the arterial walls, whereby their elasticity was diminished and an impediment offered to the free flow of blood. Now in the examples of this form of pulse which he figures in his work upon the circulation of the blood, Marey states that his patients were inmates of the Bicêtre and Salpêtrière, which asylums contain for the most part insane, demented and paralytic persons. Consequently, we are as fully justified in considering the alteration of the pulse curve due to the condition of the nervous system, as we are in attributing it to a pathological state of the walls of the arteries.

Moreover, I am fortunately able to furnish pulse traces of two patients who have fallen under my observation, in which Marey's results are directly contradicted.

Fig. 25, represents the pulse of a patient aged 60 years, who presented upon physical examination all the characteristic symptoms of structural change in the heart and arteries. Angina pectoris, dyspnoea, and a condition of the radial arteries which communicated to the finger, a sensation as if they were firm, inelastic cords, were symptoms which I frequently had occasion to observe,

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Fig. 25. Male, aged 60 years.

and yet the trace has an acute apex, and is distinctly

tricrotic.

Fig. 26, on the other hand, is the pulse of a patient who was hemiplegic, and presented symptoms of mental derangement resulting from an apoplectic attack, and in whom neither auscultation or palpation revealed any

Fig. 26.

abnormal condition of the heart or arteries, and yet we find a flat-topped monocrotic pulse curve.*

* NOTE.-I do not intend to be understood as denying that an atheromatous condition of the arteries may not be accompanied by a pulse which gives a trace similar to that seen in fig. 26, but I think that in these cases the same defective nutrition which causes the change in the walls of the blood-vessels may also interfere with the proper reparation of nerve tissue, and thus influence the form of the pulse. In fact, a diseased condition of the nutrient vessels of the brain is one of the most frequently observed facts in cases of paralysis and mental disorders, and it may be that the alteration

If we examine the traces represented in figs. 12, 15, 17 and 22, we find the well marked senile pulse of Marey, while the age of the patient contraindicates atheromatous degeneration, and we are therefore compelled to seek some other explanation of the phenomenon, the key to which, I think, can only be found in the sympathetic nervous system.

The disordered condition of the ganglionic system in the insane, is evidenced by such marked symptoms that it would be indeed surprising if we did not find a pathological condition of the pulse. The sluggish circulation through the peripheral capillaries is rendered evident by the passive congestion of the hands and feet, and the white line bordering the edge of the lip, observed both in melancholia and mania, and attains its maximum when the patient relapses into the most profound dementia; the frequent attacks of local hyperæmia, which in some cases are sufficiently intense to result in rupture of the vessels, and to produce that remarkable appearance known as hematoma auris, can only be attributed to the disordered action of the sympathetic system, while the altered condition of all the secretions, both cutaneous and intestinal, must be referred to the same agency. Again, the defective nutrition of the insane is but the index of some unknown cause, influencing the functions of organic life through the medium of the sympathetic ganglia.

Comparatively recent investigations of physiologists have demonstrated that the centres of the great sympathetic are situated in the crura cerebri, and pass downward along the central axis of the cord. From these centres fibres radiate toward the periphery of the body

of the nervous tissue is due to the disease of the vessels, and that the pathological pulse is therefore the result of the combination of two elements, which are related to one another as cause and effect.