Canada, and the bone scraped. An X-ray examination showed nearly the whole ring metacarpal invaded by some kind of destructive process, but there was no evidence that the disease had invaded any other bones.

The whole finger with its metacarpal bone was removed. Prompt healing occurred, without a drop of pus. The little finger closed up snugly to the middle finger, and the deformity was scarcely noticeable unless one stopped to count the fingers. Pathological examination of the diseased bone showed the affection to be tubercular.

Web

4. A Case of Congenital Deformity of the Fingers. Fingers. A Supernumerary Finger. Angular Lateral Curvature of the Ring Finger.

This case, an infant of five months, was referred to me by Dr. J. S. Devereaux, of Marblehead. The right hand had the middle and ring fingers webbed to within a quarter of an inch of the ends. The portion representing the ring finger was disproportionately large and thick, and had two nails which were fused, but showed cleavage at their free margin. The ring finger of the left hand was laterally bent to nearly a right angle, and rested across the palmar surface of the ring finger. X-ray exposure showed a most surprising state of matters in the right hand. In the webbed portion there

were three fingers instead of two; that is, the part included in the web, which was supposed to be an unusually thick and strong ring finger, had within it the bony structures of two fingers. These two sets of phalanges were situated closely to each other, and the two first were fused through about two thirds their length.

The middle metacarpal was forked, presenting two articular heads, one for the middle finger, the other apparently for a part of the double ring finger.

OPERATION.

The middle finger was separated from the double ring finger by the Didot method, and the curved left ring finger straightened by an osteotomy. Perfect healing occurred without suppuration.

There is always some danger that web fingers may contract after separation or that they may grow together again. Many ingenious contrivances have been recommended looking to more perfect results. It seems to me that skin grafting by the Thiersch method may offer a better solution than the flap method of Didot. In this case already one of the fingers is beginning to show indication of contraction, and may later require skin grafting.

STATES OF MENTAL EXALTATION.

BY HENRY J. KLOPP, M.D.

[Read before the Worcester County Homœopathic Medical Society.]

Under this head are to be included the conditions of mental derangement which manifest "continued hilarity, excitement, and increased mental function in any special direction" (Stearns). It is not to be limited as simply ex- . pressing delusions of grandeur, of increased wealth, power, and importance, or a sense of well-being. Instead, exaltation is to be considered synonymous with "excitement" or "increased mental activity" that include mania and allied conditions.

It is a well-established fact that both depression and ex

citement may and often do exist without any morbid basis, and while the brain is in a condition of health. In the first place, it will be necessary to remember that every individual can be considered in this respect to be a law unto himself, although limited by the constitution of his central nervous system. Remembering this fact, it will be necessary to establish a basis to work from, and to do this I shall take for my standard the best, and which to my mind appears to be the clearest, definition of insanity; namely, “A prolonged departure from the individual's normal standard of thinking, feeling, and acting."

In intoxication from liquor we usually find a varying degree of exaltation; but as a rule the exaltation does not become a prolonged departure unless, as we shall learn later, it develops into a form of alcoholic insanity. We may have exaltation developing in consequence of fever and other conditions, but more frequently it is only a temporary departure.

There exists at times in every person a wide departure, either in direction of depression or exaltation. A degree and a continuance of excitement which might rightly be regarded as abnormal in one person would not necessarily be so regarded in another. The ever-varying conditions of the physical system have a large influence upon the brain, not only in respect to the amount of its function, but also in respect to its quality and its facility of action.

I shall lay stress upon the characteristics and the mental and physical accompaniments of this condition in the different forms of insanity, so that it may be a help rather than a hindrance in diagnosis. At the same time I wish to impress this fact, that mental exaltation is common to a majority of different classes of insanity, and that a condition of mental exaltation in a patient does not necessarily indicate that the case is one of the several forms tending to recovery, or, in other words "not tending to dementia"; instead, it may be simply symptomatic of a case "tending to dementia."

In endeavoring to study some one form of mental derangement, we should proceed to differentiate the clinical forms.

upon the basis of the underlying pathological processes. Although yet far from being able to demonstrate the underlying path, always remember that we must include what we can observe of the cause, symptoms, course, and outcome of the disease. In this way we will be enabled to determine whether a case belongs to the "functional psychoses," those "not tending to dementia," or whether it belongs to the "dementing psychoses," or those "tending to dementia." 1 We are able to do this in general paralysis. Here we can take into account the principles of general pathology, studying the cause, pathology, symptoms, course, and termination of the disease, and thus understand it in its entirety.

Taking into consideration, in the first place, the pathological cause of mental exaltation upon the basis of the neuron theory, we find the inhibitory centres are the first to become affected; "there is very marked lowering of the resistance of the cortical neurons, beginning in the higher (ideational) centres."2 All the symptoms point to heightened activity and lowered resistance of the neuron groups." MacPherson says: "In mental exaltation the implication of consciousness is more extensive and more profound than in mental depression. The lowered resistance and consequent heightened activity of neurons of the higher centres, which are concerned in the process of conscious attention, are so pronounced that attention cannot be fixed for any given time upon any one idea or sensation or group of ideas. Consequently, the lower centres, freed from inhibition, become hyperæsthetic and hyperkinetic. The absence of the feeling of normal fatigue, after great and prolonged exertion, which is so remarkable a feature of acute mania, is entirely owing to the fact that conscious attention, which is alone capable of feeling exhaustion, is in this state in abeyance. The unconscious mind does not become tired." 3

In order to be able to make a diagnosis, and determine whether mental exaltation belongs to the recoverable "functional psychoses or to the "dementing psychoses," it will

1 Cowles, Progress in the Clinical Study of Psychiatry, 1899.

2 MacPherson, Mental Affections, 1899.

3 MacPherson, Mental Affections, 1899.

be necessary to study the mental and physical symptoms under the various forms. Under the first head we have mania, with its various sub-divisions.

Simple or sub-acute mania is the first degree of mania. Intellectually all the faculties manifest marked mental exaltation, which shows itself in a general tone of self-satisfaction. The ever-stimulated imagination leads the individual to devise various schemes and projects, partaking of the nature of business plans, political and social schemes, as well as literary and scientific ideas. The character of the ideas are extremely variable, being based chiefly upon fortune, pride, and ambition. They remain, as a rule, coherent, and manifest no distinct delusions. The memory is in a condition of hyperexcitation. They remember dates, names, and figures with great accuracy, and may recite long passages. The maniacal excitement is nearly always accompanied by bodily activity. The personal character of the individual is changed; the moral nature usually becomes perverted during the attack. They are ungrateful, unjust, untruthful, and cruel. They may plunge into venereal and alcoholic excesses, and before insanity is recognized by their friends they undergo serious financial and social losses.

The general excitement of the cerebral functions attains its greatest height in acute mania, also known as typical mania. In this form we have great mental exaltation, combined with intellectual disturbance, sensory disorders, and extreme motor restlessness. In the large majority of cases the condition of maniacal excitement is preceded by a phase of depression. The depression preceding acute mania may be so brief as to be hardly noticed, or it may take several days or weeks before full development.

Acute mania may, however, commence as simple mania and then pass into the acute form. When the general malaise passes away, it is followed by a feeling of well-being and exalted ideas. As the intellectual excitement progresses the patient is less able to fix his attention upon any one subject. His ideas become more numerous, until in many cases the symptom of incoherence of speech presents itself;