284

COMMENTS ON CONTEMPORARY JOURNALS. Inebriety. In a useful and entertaining article contributed to a recent number of the New York Medical Record, its author, Dr. T. D. Crothers, discusses some obscure cases of inebriety. He regards this disease as more complex in its character than insanity, and complains that it has never received the careful and continuous study which it so fully deserves. Thorough examination, however, of the natural history of some cases, their progress being followed from stage to stage, will in his opinion furnish invaluable evidence both of physical causation and physical law, and the following example of a case in which the causation was clear and traceable, is well worthy of attention : " a strong, vigorous merchant, aged 30, with no A , heredity and temperate, suffered from a partial sunstroke. He remained greatly debilitated for two months in bed, then began to use spirits to excess, and was a continuous inebriate up to death, four years later. He made great exertions to recover by The the pledge and prayer, and failed and died of dementia. drink craving was clearly traced to the brain injury from sunstroke. No possible causation of vice could be traced to the first use of spirits, and the progress of the case was regular in spite of all means to check it." As an instance of apparently very obscure cases, which when sifted reveal an evident physical causation, Dr. Crothers quotes the subjoined history; the appended " remarks," serving to explain in a satisfactory manner, much of the obscurity : " The next case is a border-land one, full of mystery, but when carefully studied has clear outlines of an unmistakable ,was born of healthy parents and grew physical causation. B up a vigorous man, temperate and correct in all his habits. He At 31 was a prosperous mill owner and attentive to business. years of age he married, and his wife was killed on the wedding His grief was very profound; for two tour in an accident. months he was unable to do any business except to walk to the mill a few moments every day and direct some little matters. He took tonics under the direction of a physician, and complained generally of sleeplessness and poor appetite. A year after he began to frequent low places and use spirits over the bar and associate with bad company. Later he was intoxicated in public.

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285

Ihen he neglected his business, bought fast horses, and became

dishonest, doing many things that were foreign to his previous character. Gradually he sank from bad to worse, and finally

was sent to State prison for forgery. His property was gone, and he became a gambler and inebriate of a low type." Remarks.?" In this case the most prominent symptoms were low, vicious propensities seeking an outlet in bad society and drink. When the history was studied it was clear that the shock of the sudden death of his wife produced a psychical traumatism; some change in the normal functional action of the nerve centres, which became the starting point of a general moral and physical degeneration ; some loss of nerve force, manifest clearly in departures from health and changes of thought and action. The sudden shock of grief produced permanent His disposition changed; all his alterations of character. previous motives and ambitions in life vanished. He left the Church and began to lead a most irregular life, giving no reason except that he was discouraged. At times he seemed to manifest grief at his conduct and make an effort to recover, but soon relapsed. His brain retained, during the sober moments, an appearance of health in thought and action. He talked and reasoned clearly, and made efforts to recover; signed the pledge ; asked the prayers of the Church ; then, in the moment of greatest promise of success, fell precipitately into the lowest company and state of drinking. There was no reasoning or calculation in this ; the mind seemed at a certain point to be incapable of forming any views of the subject, and to act under a diseased impulse that was beyond control. The radical change of character and of motive, beginning at a certain point, leading rapidly to ruin, pointed to a physical cause uninfluenced by any moral state previous to this time." The influence of traumatism is one of which the conselittle as quences would seem not worthy of extended study ; and has been done hitherto in this field of observation, there can be no doubt that results already tend to show the success which of assisting further may attend its cultivation. As a means research, and to indicate the directions in which information relating to the laws of inebriety are to be studied, Dr. Crother formulates the following conclusions : First. All cases of inebriety should be studied carefully to ascertain not the heredity, but the possible history of

only

psychical or physical. As in epilepsy scars furnish clear indications of the chain of often may Fevers, and any disease or events which have pro-

traumatism, on the scalp causes.

either

foundly influenced the organism prominent factors in the history.

and

nervous

system

are

always

286

COMMENTS ON CONTEMPORARY JOURNALS.

Second. Inebriety is a central disease of the nervous ganglia, which may either follow a regular line of march down to chronicity or death, or to be attended with uncertain halts, long pauses, or rapid progress, from some unknown causes; but, whatever its course may be, always following a certain order and regularity, in the stages of degeneration, that is seen and may in many be predicted. Third. From a knowledge of the cases the varied means of treatment can be applied which will be most effectual in restoration. If the case is chronic and incurable such a study will point out the best means to limit and control its progress in the least harmful channels. Fourth. Inebriety and its problems must be studied by medical men above the superstitious theories of reformers and clergymen, before we shall have anj positive facts upon which to base accurate methods of treatment and cure. " Writing on Inebriety and how to deal with it," in the Journal of Inebriety, Dr. J. C. Jackson indicates four Quarterly stages of progress through which every person must pass in order to become a drunkard. These are : 1. Stimulation ; 2. Intoxication or blood-poisoning ; 3 Enervation or nervous prostration ; 4. Inebriety or drunkenness. This division is justified by resort to physiological data, and will probably not be objected to by those who stay to consider Dr. Jackson asserts that the reasoning on which it is founded. no man ever became a drunkard who was not in the habit or practice of simulation ; who has not, in other words, by habitual indulgence induced an unnatural and numerically increased pulsation, this being the effect of some cause operating in the nerve centres, and through them exciting the heart to increased

activity.

This thesis must be, at least, difficult to disprove, and equally that when the heart has been continuously subject to the influence of any stimulant, the point which marks the first step In the words of Dr. Jackson, to drunkenness has been reached. the patient is " a person living above his organic or constitutional power to live healthfully. If, then, he so excites himself that his organic forces are compelled habitually to act beyond their natural capacity, he has begun a course by which, if he continues in it, he must die, either by accident or disease, in spite of his constitutional ability to live, or he will die a drunkard." There is much to recommend the view expressed in this Paper, and especially in respect to the inescapable influence so

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287

exercised over the individual who once becomes thoroughly accustomed to the artificial exaltation induced by stimulants of whatever description. The confirmed drunkard, in effect, enters on a course of existence which necessitates his living beyond a natural rate, and the limits over which the force at his command will suffice to carry him must mainly depend on the individual characteristics which determine his powers of resistance. Once, however, the stage described as enervation has been reached possibilities of restoration must be few and far between; whence it occurs, t herefore, few instances of reclamation of drunkards can be recorded. Dr. Jackson thinks that a proportion of one in ten is a very liberal allowance. More than this are certainly not saved from the physical ruin which follows in the wake of inebriates.

Management

of

American Asylums.

Readers of reports presented by American asylum superintendents on the institutions under their care, must have been struck by the oftentimes incongruous assemblage of information and requests contained in these documents. Apparently, also, the same reflection has occurred to a home observer of the facts, for in a late number of the Journal of Nervous and Mental Disease, Dr. C. L. Dana has fully discussed the matter in an article on Asylum Reform. Judging from his strictures Dr. Dana does not hold a very exalted notion of the way in which the asylums are conducted, or of the scientific work done in connection with them. He concludes a " striking Paper thus : This absence of scientific work is not

always and entirely the superintendent's fault. Asylums are poorly equipped; in some States it is worth his position for an officer to ask the Legislature for a microscope or a laboratory. But when we find one report used in the expounding of phrenology, another in pleading eloquently for 20,000 raspberry bushes, another which seems infused solely with the warm hope that the Legislature will furnish a new boiler, another which happily informs us of the agricultural antagonism between Squashes and witch-grass, and a number of others which simply contain the praise of the Lord in a quarter of a column?and then the statistics,?when we read the not infrequent reports of It this kind, it is perhaps reasonable to enter a protest. that seems but fair to expect that the reports should show their authors are not only good superintendents but earnest and studious phvsicians. And such evidence I have not always found."

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288

Voluntary Drunkards

and

Dipsomaniacs.

The distinction to be drawn between

voluntary drunkards and dipsomaniacs is one which frequently causes a puzzling amount of indecision to even those most accustomed to consider the question. The following rational remarks on it from the Alienist and Neurologist will be read with interest: " The difference between voluntary drunkards and dipsomaniacs consists not only in the inherited neuropathic condition of the latter, but in prolonged vaso-motor disturbance, which often persists after a spree in the latter, whereas in the former the normal vaso-motor condition affecting the cerebral circulation and cell activity is soon regained, enabling the one to abandon drink, if he will, while the other is still irresolute and unstable. Cardiac gangliopathic states, too, are often persistent, in our experience of dipsomaniacs, so that an increased heart activity and more than naturally rapid pulse are second nature to these unfortunates. " Dipsomaniacs are accordingly not safe against repeated sprees, notwithstanding their promises of reform, for many months after the liquor of the last indulgence is entirely out of them, whereas the common drinking man, without the fatal heritage, who indulges from appetite alone, may be, if the incentive to self-restraint be strong. " It is therefore only folly to create and endow reformatory hospitals

for

dipsomaniacs

without

legal provision

for

prolonged

detention which cannot be evaded--not less than a year in all The links of the chain of heredity are cases, often longer. too generally strongly forged to be broken so easily as some

imagine.

" It is an organic slavery that the State undertakes to free these unfortunates from when it organises hospitals for inebriates, and it should take care of the slave till the master relinquishes his hold, and then guard the slave in his freedom ever after, even though the right of habeas corpus be permitted only such a conditional hold as will not re-enslave whom the State proposes to make free, that he may enjoy the benefits of true life, liberty, and the pursuit of happiness, and bless and care for those whom he may be bound in law to care for and support, but whom he does not, and cannot take care of and maintain in his pathological thraldom."

The In

a

restraint,

'

Non-restraint

Lunatic System

in

America.

number of the Lancet, the question of followed out in America, is thus remarked on

recent as

'

non:?

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289

" It is amazing, as well as amusing, to read in a recent number of the Boston Medical Journal an announcement to the effect

superintendent of an asylum numbering 800 (!) many violent and noisy, making them difficult to control,' has dared to adopt the non-restraint system. Of course it is only at one asylum that this temerity has been shown, and even there the doctor stands on his reserved right to restrain either by the usual devices or by the use of sedatives, if he thinks it necessary. By-and-by, if this sort of thing goes on, some one in connection with a public hospital will be making the public hair stand on end, and at the same time earning for himself eternal gratitude, by venturing to give the victim of a formidable operation chloroform! Happily, however, it is only in respect to the management of the insane America lags about forty years behind the rest of the world, and is now just beginning, in a very small and limited way, to perceive what other peoples have long recognised namely, that insanity is not either a ' visitation' or a crime, but simply a disease, which only needs to be treated on medical principles to be brought within the pale of human influences, when its victims will be found not less easily manageable than the sane." that the medical

inmates,

i

Intea-cranial Disease and Choked Disc.

Dr. Edward Gr. Loring contributes to the June number of York Medical Journal and Obstetrical Review an article on the nervous connection between intra-cranial disease and choked disc, the conclusions of which are: 1. That the vasomotor theory, as advanced by Benedikt, is not sufficient to explain either the mode of transmission of the morbid irritation within the head, or the resulting neuritis optica. 2. That the irritation is conveyed, not by the isolated fibres of the sympathetic system, as stated by Benedikt; but through the agency of 3. That choked disc or papillitis, in conthe trigeminus. nection with brain disease, is the expression of an irritation or compression of certain intra-cranial fibres of the fifth pair which preside over the blood supply of the disc and neighbouring parts, and also maintain the healthy processes of waste and repair of the tissues themselves. This being" so, he adds, the irritation" and same analogies and distinctions between " inflammation" can be made here as with sympathetic ophthalmia, so that here, as well as there, the irritation may exist as such for an indefinite time, or may so reduce the vitality and resisting power of the tissue of the disc and surrounding the New

290

COMMENTS ON CONTEMPORARY JOURNALS.

parts as to develop gradually, or explode suddenly, into an actual inflammation?that is, into a neuritis. The immediate and cause of this neuritis then be either an external exciting may one, such as exposure to cold or heat, over-exertion, either mental or physical, or, indeed, too much exposure to light, the effects of which, under the weakened condition of the organ, " may be looked upon as a traumatism "; or the exciting cause an internal be such as some irritation from the conone, may dition of the blood and circulating fluids, either chemical or mechanical, either local or general, which, insufficient in itself to produce any bad effect upon a normal disc, may yet be just sufficient to produce a condition of inflammation in a part that is weakened and irritable. Allocejiria.

Brain contains a communication from Dr. Ferrier on a case in his clinic which illustrates the condition named " allochiria," by Obersteiner. The distinguishing features of the disease are a perversion of sensibility and erroneous reference of sensory impressions to the corresponding part of the other side of the body. In Dr. Ferrier's case the patient was a man, twenty-nine years of age, admitted to King's College Hospital with history of severe cranial inj ury, causing prolonged unconsciousness, followed by motor disorder of a combined ataxic and liemiplegic character, together with the temporary remarkable perversion of sensory localisation. There was no ansesthesia, the slightest touch being readily perceived, but unhesitatingly referred to the corresponding point of the other side. In addition, the reflex actions were also transposed in sensation, thus offering a most curious combination of characters, on which speculation might be indulged to an indefinite extent. The following extracts from Dr. Ferrier's notes will be of interest in connection with the case. " On admission.?Patientis a healthy-looking, well-nourished of face peculiar, eyes having a fixed stare man. Expression ' and ' far look ; power of convergence apparently entirely gone. Cannot maintain equilibrium with the feet together, and staggers from side to side when walking, the legs having a tendency to cross one another. Left leg distinctly weaker than the right limb, the left hand than the right. Facial movement equal on both sides, but the tongue tends a little to

the

right.

"

Sensation.?Tactile sensibility is throughout normal as and quickness of response, but there is a most remarkable condition of allochiria, or localisation of impressions on the wrong side, as well as a similar reversal of reflex response

regards delicacy

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291

to tactile stimuli, affecting the legs from the groin downwards and also the tongue, inside of the mouth, and the nostrils. A touch on the right great toe was at once referred to the same spot on the left and vice versa, a similar condition extending on every point on both legs up to the groin. Above the groin impressions were correctly localised whichever side was touched. The conjunctiva} and both sides generally of the head and face were similarly and normally responsive to stimidi. But a feather or a spill of paper in one nostril immediately caused retraction of the head, and lachrymation, the patient at the same time rubbing the other nostril where the irritation was felt. The same kind of results were obtained on experimenting with the tongue and mucous membrane of the mouth, and this not only as regards mere tactile sensibility, but in respect also of taste. That the indications afforded by the patient might, without doubt, be accepted as reliable, he was securely blindfolded during the trials, his reference to the side on which he ex-

perienced

the sensation

being

more

than

ever

reversed, exactly

the opposite to that which was the seat of irritation. The most remarkable point, however, was undoubtedly brought out in Then, tickling the sole of connection with the reflex reaction. one foot, caused retraction of the other, the foot actually tickled remaining perfectly still; so also when one thigh was tickled on its inner side the other was at once flexed; and when the sole of one foot and the inside of the opposite thigh were simultaneously tickled, crossed reflex reaction of the foot and thigh occurred.

Light was normal, the pupils reacted to luminous stimuli in a regular manner, and the ophthalmoscope revealed nothing unusual. Except absence of convergence for near objects, the

ocular movements

were readily performed. Hearing was defective in the right ear ; patellar reaction was exaggerated especially on the left side. The patient complained greatly of headache, especially in the forehead and occiput, and when the latter region was percussed, the pain was intensified, or if not present at the moment,

at once excited. Under treatment improvement in all the symptoms took place, and after six months the man left the hospital, having recovered so far that the allochiria was no longer present, sensation being experienced and referred in a normal manner. The left leg, however, continued to be feebler than the right, The face had lost its and deafness persisted in the right ear. of and startled converging the eyes was power expression peculiar was

regained.

Dr. Ferrier abstains from

PART II.

VOL.

VIII.

speculating

NEW SERIES.

on

the

possible pathoX

COMMENTS ON

202

CONTEMPORARY JOURNALS.

of the signs observed in this interesting case, and contents himself with simply recording the symptoms

logical explanations and progress.

It is

quite possible

that

now

the appearances

have been so faithfully and graphically described, other observers may be fortunate enough to meet with similar instances of per-

sensibility, and add the results of their examination to already known. Until a further stock of information concerning this curious condition is found, it is probably best that attempts to unfold the mystery surrounding it should be

verted

what is

let alone.

Habit. "

" are so accustomed to employ the term habit in a sense that is seemingly justifiable, that a few sensible remarks on it by Dr. William A. Hammond, in the American Journal of Stimulants and Narcotics, are quite worthy of being reproduced. Dr. Hammond concludes that "when a living being performs an act under the operation of certain impressions which are received, there is a tendency towards the performance of a similar acf if like influences are brought to bear upon the organism. " This disposition to repetition is not limited to physical acts ; it prevails in regard to almost every function of the body and mind, and forms often an important element in the promotion of disease. " Habit, therefore, is periodicity, and may be defined as the disposition which the organism acquires from the frequent performance of certain acts to repeat these acts till some more force intervenes. powerful " Again, it is well known that the impressions, or consequences which result from the action of certain agents, become less marked if the operation of the cause be repeated. Thus the system becomes habituated to the action of alcohol, opium, chloral, and many other substances, so that while a small quantity will, in the first instance, produce the characteristic result, the dose must gradually be made larger or be more frequently repeated in order to be followed by a corresponding effect. " The influence of habit over the ordinary operations of the economy is plainly seen. The sensations of hunger and thirst are experienced at stated periods of the day, because by frequently eating or drinking at those times the system, as it were, expects a repetition, and hence the appropriate sensation is experienced. The votary of opium or chloral is subject to the same law, and invariably feels the want of the customary sedative if its ingestion be delayed for even a short time. " The oft-repeated impression has left its traces each time until at last it assumes a local habitation and becomes per-

We

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COMMENTS ON CONTEMPORARY JOURNALS.

manently

fixed in the

brain,

not to be lost unless

through

some

powerful influence acting in a similar manner to the first. " Besides this, the various organs of the body also become habituated to the effects of stimulants and sedatives, such as alcohol, tobacco, opium, chloral, and the like, and are the seat more

of various

painful sensations if the supply be cut off. Relative to the propriety of stopping habits which are injurious to the body or mind, there can be no doubt. To do so, often involves the causation of much tempurary suffering, but the object to be ultimately gained is of far greater importance, and is well worth ail the pain and anguish that may have to be endured." "

Insanity

in

the

United States.

late number of the Journal of Mental and Nervous Dana gives the following statistics respecting the insane population of the United States of America. There were, in 1880, in round numbers, 8!),000 (to 96,000) insane, which gives a ratio of 1-570 (1*520) of the population. The census ratio in 1860 was 1*1,310; in 1870, 1*1,100; in 1875, 1*953. The population increased in the decade 1870 to 1880 about 26 per cent., while the insane population has apparently increased over 100 per cent. As regards the distribution of insanity and its increase, the proportion of insane is greatest in New England, where the ratio is 1 to 357. Here, however, the rate of increase is becoming slower. In proportionate number of insane, after the New England and Pacific States, come the Middle States (1 to 446), then the Western (1 to 570), and then the Southern (1 to 780). In 1881, 74 State and 14 large private asylums, with a capacity approximately for 31,900, but holding 39,145. At a very low estimate, In

a

Diseases Dr. C. L.

American asylums are overcrowded to the extent of patients, while there are about 50,000 who are not in asylums at all. The amount of capital invested in these

therefore, 10,000 anv

institutions is ?8,000,000, an average cost of over ?100,000. It takes about ?1,600,000 a year to maintain them, or ?16,400 for each institution, not including interest. Adding interest the total annual expenditure for the care of the insane amounts to ?2,400,000. The annual cost per patient has been variously estimated at from ?33 to ?63. Guiteau's Brain.

the execution of the late President Garfield's careful examination of the criminal's brain was made,

Following

assassin

a

X

'I

294 and the

COMMENTS ON CONTEMPORARY JOURNALS.

subjoined report

New York Dana.

was

Medical Record

presented on by Drs, W. J.

the subject to the Morton and C. L.

Pieces of brain from the left frontal lobe, the right central a piece of the spinal cord just below the medulla were obtained about five hours after death, and three and a half after the opening of the cranium. These pieces were placed in seventy per cent, alcohol for twenty-four hours, then in absolute alcohol until sufficiently hard to cut. Over one hundred sections were made and stained in various fluids, chiefly in Bismarck brown, carmine, and hematoxylin. Sections were also stained in osmic acid, analine blue, Lugol's solution, vesuvin, &c. Other sections were soaked in ether, and in concentrated acetic acid. These various methods were employed chiefly in order to determine positively the nature of certain peculiar bodies seen under the microscope. They were quite numerous, but were mostly in the white matter. They were generally round in shape, but sometimes appeared in agglutinated masses. They inch were somewhat translucent, and measured from yJ-g- to in diameter. Some, perhaps, were smaller. They had the appearance of not being incorporated in the brain-tissue itself. They stained with Bismarck brown, vesuvin, and gave a rosered colour with analine blue?this being usually considered a But they were not stained reliable test for amyloid matter.

convolution, the cerebellum, and

with iodine, even after soaking sections twenty-four hours in water to remove the alcohol. They were not dissolved by soakan hour in ether, and half sections they were not stained by ing

osmic acid. Hence, they were apparently not fat. They were not dissolved in, but were brought out strongly by soaking sections in strong acetic acid, a substance which dissolves colloid matter. These bodies were found in sections from the frontal lobes, central convolutions, and spinal cord. We saw none in the

cerebellum;

but

only

a

few sections

were

made of this

part.

regard them as post-mortem products. One of the writers lias sections from the spinal cord of a man who died from tetaCertain writers on nus which show apparently similar bodies. cerebral pathology have described similar bodies as being " proteinaceous" and as either post-mortem or the result of chronic brain disease. The analine reaction was very striking, and might perhaps justify an opinion that they are amyloid bodies, though they gave no iodine reaction. The writers observed occasional thickened blood-vessels in the cortex. No other change of interest was noted. The perivascular spaces, the cells, the nuclei, all presented no abnormaliWe

COMMENTS OX

ties which

we

CONTEMPORARY JOURNALS.

could detect.

pigmentation. The large convolutions (one of which and

were normal in

There were no aneurisms, and no motor-cells from the right central was

small)

were

abundantly present,

appearance.

A Proof An

295

of

Localisation

in

Practice.

case tending to illustrate the doctrine of communicated to the June number of the Archives of Medicine, by Dr. Wm. S. Cheeseman. The patient was a woman, aged 42, with no history of injury or syphilis, but she had long been subject to headache. In January last she began to lose power over her right hand and arm, and on February 18th completely lost the use of both hand and arm, but continued to perform her domestic duties. On February 21st she attended a prayer meeting, and was there seized with a convulsion. On recovering consciousness she was hemiplegic on the right side. February 22nd she was admitted into hospital with right hemiplegia and dysphasia, though the mental faculties seemed unimpaired. Her condition so far improved that the paralysis of the lower limb became paresis, while that of the face disappeared. More or less contraction of hand and arm supervened, and she gradually became duller, had involuntary evacuations, vomited considerably, had several convulsions, and finally died in coma on April 11th, 1882. No ophthalmoscopic examination was made. Autopsy two and a half hours after death. Nothing abnormal in organs of chest or abdomen?skull, meninges and surface of brain as usual. After removing the brain a bulging was noted at the top of the left ascending frontal convolution, the ascending parietal convolution being pushed backward to make

interesting

localisation,

room

is

To the touch this was very soft. A longitudinal it exposed a rounded mass as large as an English reddish brown in colour, soft and friable, the cortex

for it.

section

through

walnut,

it being swollen and gelatinous. The section also revealed in the white substance beneath, and behind the mass a second of the same size, its lower border nearly reaching the These were separated by a roof of the left lateral ventricle. substance. The right white narrow of compromised partition hemisphere was normal. A microscopic examination of the specimens showed, in the opinion of Prof. W. Welsh, that it consisted of nerve-cell gliomata.

covering

Stammering.

Professor Delver gives the following rules for the observance of stammerers, in the Cincinnati Lancet and Clinic.

296

COMMENTS ON CONTEMPORARY JOURNALS.

1. Serious and persevering practice, until it becomes a settled habit. 2. Before speaking to take a full and quiet breath and to renew the respiration according to the sense of the phrase, and never to speak when the air is exhausted. 3. Put into practice the observations made relative to the movements of the lips and tongue. 4. Preserve a good syllabation. This is easily hidden by the intonations and inflexions of the voice. 5. Speak with assurance, watch over the emission of words, exercise full control, and the more embarrassed seek the more to

speak slowly, coolly, and deliberately. 6. Inspiration, syllabation, and tranquillity include everything, and they are equally indispensable. 7. Take advantage of all opportunities to speak slowly, particularly when in the presence of family or friends. Electro-Therapeutics. Dr. Julius Port severely condemns the ignorance which concludes that no special education or capacity is necessary to enable a skilful application of electricity to be made for therapeutic purposes, and, in an article contributed to the Detroit Lancet, he thus writes on the subject:? that it requires no brains to of electro-therapeutics. Any idiot, or mere infant, can hold two sponges to the body while a current is passing; and if that were all of electricity in medi-

"The prevailing impression apply electricity is the curse

cine, the science

of that department would be very largely moonshine. A dose of opium or quinine any fool can give or take, but to know when to use these drugs, how to use them, when not to use them, requires oftentimes our best skill and judgment. To know the diagnosis and pathology of subtle and obscure diseases ; what form of application each disease requires ; to know when to use localised faradisation ; when localised galvanisation ; when general faradisation; when central galvanisation ; when electrolysis, and when galvano-cautery; and how and when to combine two or more of these methods ; and how to change them to vary with changes in the condition of the patient; how to modify the strength and current according to the wants of the case?all this knowledge only comes from hard study and long experience. When we consider that there are many forms of electricity, each adapted to particular cases, and that each one of these requires long and faithful study to master details, we can, in a measure, appreciate the magnitude of the science As a rule, a patient never receives any of electro-therapeutics.

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permanent benefit from the application of electricity, except when applied by a competent electro-therapeutist. Left to the public, this branch of science would pass out of memory. Left to the charlatan, it would do more injury than could be remedied by a host of reputable physicians. A physician who speaks lightly of electricity only shows Lis ignorance, and lends his assistance to force this valuable agent into the realm of

quackery. "

than convinced that it requires quite as much experience, and quite as good judgment to become an accomplished electro-therapeutist, as it does to become an accomplished surgeon and physician. Electricity in the hands of an incompetent person is a dangerous remedy; in competent hands it is a powerful agent for good. Indiscriminately used it falls into bad repute: if the cases are carefully selected, and the remedy used in an intelligent manner, we may reasonably expect good results. It is somewhat humiliating to be obliged to acknowledge that very few physicians give the therapeutics of electricity any attention. Magnetism, galvaniI

am more

skill and

If asked to define principles, they reply in so vague explain something and unsatisfactory a manner that the inquirer is satisfied at As phyonce that they are treading on unknown territory. the if we wish to benefit it becomes our sicians, public, duty to thoroughly investigate and understand the nature of any remedy which is entitled to consideration. It behoves us to inquire into any plan of treatment which promises to benefit a sick When we meet with visionary people, demoralised on person.

sation, and faradisation or

are

alike to them.

of its

medical topics, who know, in their own minds, more of medicines and the physiological effects of remedies than a studious, well-informed physician could expect to acquire in a lifelong experience; when we meet with knowing people, who are sceptical as to remedies and physicians, who, to use a hackneyed expression, are crank on theories which have no foundation in who are practically a neighbourhood nuisance and dangerto be at large; if they are allowed to peddle their crackbrain views in the community, it is enough to disgust any man. Such people exist in every community, and it becomes the first duty of the physician to warn the public, and, lest it be deceived

fact, ous

and suffer from the meddlesome misrepresentations of these beings, to give them a wide berth. No person would be such a fool as to attempt to run a locomotive without properly understanding the machinery and the power which drives it; but every day we meet with people who assume to know more of the human mechanism than a medical man who has devoted his life to the study. In the first instance they would expect to

298

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be blown up, and thus end their brilliant career; in the second case, if their meddlesome interference causes the death of a

patient, they can lay the blame on the doctor, and this bright particular neighbourhood adviser would be spared to keep up his or her devilish perturbations. These things are not imaginary, they are constantly before us; and if, as physicians, we can be the means of warning the public against, some of these impostors, medical and social, whom we meet almost every day, our

work will be well done." Tabes Dorsalis

and

Patellar Reflex.

The existence of patellar reflexes in patients affected with locomotor ataxy is of such rare occurrence that any authenticated instance is well worthy of notice and preservation in our records. A case of the kind is mentioned in the New York Medical Record, as having been observed by Dr. James Leslie, of Hamilton, Canada, in a shoemaker, aged forty-five years. The symptoms of inco-ordination without loss of muscular There were no lightning-like pains, power were well marked. at the knee was very distinct, and the tendon-reflex however, The patient had not had syphilis. He received the most benefit from daily forcible flexion of the thighs upon the abdomen. Electrical Batus, The misuse of electricity by quacks, who subvert its employment in baths to purposes of pecuniary gain, and without any desire to make it of scientific utility, has been frequently complained of by those who have been convinced of the real thera-

peutic efficacy of electric applications in cases of disease. The question appears to have excited a good deal of attention recently in American medical circles, and the editor of the New York Record avers that from the testimony given it cannot be doubted that the electrical bath deserves a place in therapeutics, and that it should not be relegated so entirely to charlatans

There are a number of prosperous as heretofore. in New York who live in fine style upon the profits of electrical baths alone, using them largely in rheumatic and

quacks

diseases. The administration of electricity by baths is not difficult. An ordinary bath-tub has often been used. It is better, how ever, that the tub be of some non-conducting material like wood. A double-cell faradic battery will furnish quite enough electricity. The electrodes should be large, made of metal or carbon, and should dip several inches into the water. The patient lies in the tub so that neither electrode touches him,

nervous

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The current is passed generally from one shoulder to the opposite foot. It may, however, be localised. The general effect of the current can be strengthened by adding salt, soda, or an acid to the water. The baths are generally given for from ten to twenty minutes, and repeated alternate days. The claim for the electrical bath is that it is the best way to apply general faradisation. It is certain that by the influence of the warm water the skin is made a better conductor. It is well known that the dry skin opposes immense resistance to electrical currents, and that it is largely by virtue of its pores that electricity passes through to a sensible extent. The warm bath moistens the skin, dilates its ducts, stimulating at the same time the cutaneous vessels and glands. The conditions are thus favourable for the so-called catalytic actions of the electrical current. The objection occasionally made that water is a poor corductor, and hence not suitable for electrical action, is quite trivial. The resistance of pure water as compared with that of mercury is about 120,000,000 to 1 ; that of salt water, however, is better by only five or ten millions, and the resistance of In salt water is nearly the same as that of the moist tissues. other words, water is a vastly better conductor than the skin under ordinary conditions. There is no reason a priori, therefore, why the electrical bath should not be useful, and we have referred to the matter at some length because it is quite possible for the general practitioner to prescribe and use it as well as the specialist. Its real value, however, has of course to be tested by clinical

experience. Very many practitioners have used it successfully in mercurial and alcoholic tremor, acute and chronic rheumatism, obstinate sciatica, neurasthenia, &c. Weisflog has used local electrical baths in rheumatism with good results.

What is needed, however, is further careful clinical records, whicli shall tell the failures as well as successes from this treatment. The former, we fear, as in electro-therapeutics generally, will not he

rare.

Alcohol

and

Disease.

At the last meeting of the British Medical Association, Dr. Norman Kerr communicated a valuably suggestive paper on the public medicine aspect of the alcohol question, in which he endeavoured to trace the amount of sickness and death caused alcohol. Some diseases, he said, were caused by alcohol

by

alone,

as

delirium tremens,

acute and chronic.

and alcohol poisoning, from other causes, some-

dipsomania,

Some, which

arose

300 times

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caused

alcohol

by

directly,

as

alcoholic

phthisis,

gout, and paraplegia. Alcohol might also be a main contributory factor, as in fatal frostbite and sunstroke after drinking.

proportion of sickness and death from alcohol had been shown in the Government returns of the Indian army for 1849. The mortality of the temperate was double and that of the

The

that of the total abstainers. The ab11*1 per 1,000; the temperate 23*1 ; and the intemperate 44*5. The admissions of the abstainers were only 10*7 per 1,000 less than those of the temperate, showing that the diseases of the former took a milder form. Insurance companies were so satisfied of the superior healthfulness of the abstinent, that one had paid the abstainers insured 23 per cent, additional bonus, and another offered an extra bonus of 20 per cent. The influence of alcohol on the death-rate was well illustrated in the Registrar-General's report for 1880, from which it could be seen that in every class except one the mortality had steadily diminished ; but in Class III. the mortality had as steadily increased. In this class the principal increase had been in deaths from diseases of the brain and nervous system, of the organs of circulation, of the respiratory organs, of the liver, and of the kidneys. These were precisely the organs most apt to be seriously affected by indulgence in alcohol. Di. Kerr had estimated the annual deaths from personal intemperance in the United Kingdom at 40,500. Others made it larger. The indirect fatality by violence,

intemperate quadruple

staining deaths

were

disease, poverty, &c., arising would

from the

intemperance

of

others,

probably raise the number to 120,000 or 200,000. For the cure of dipsomania, total abstinence was indispensable. Heredity was the chief predisposing cause. The marked increase in the variety and consumption of unintoxicating beverages was an aspect of the question which called for the consideration of students of public health, as an increased use of non-intoxicants was a favourable omen of the future improved sobriety and consequent health of the community. Alcoholic Epilepsy.

Quarterly Journal of Inebriety, the term According not clinically correct. is Many of these epilepsy cases are only moderate alcoholics, and the epileptic symptoms cannot be attributed to this drug. The alcohol merely explodes a degeneracy which comes from other causes. Cerebral traumatism in its widest sense often produces inebriety, which takes on epileptic symptoms. Often epilepsy is ushered in by excess in the use of alcohol. Here epilepsy is the disease, and the drink-craving only a symptom. To t)e alcoholic epilepsy to the

alcoholic

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from excessive use of alcoholism is the chronic stage of inebriety. The disease is inebriety with epileptic symptoms. Some cases of inebriety exhibit epileptic symptoms with every toxic effect of alcohol. Others never develop these The epileptic symptoms through many years of excess. symptoms are due to other conditions than that produced by alcohol. Alcoholic epilepsy is only the name of a condition of inebriety, and not the name of a distinct disease. case

alcohol.

must be shown to spring The condition known

Insanity

of

directly

as

Inebriety.

Writing under this head in the Quarterly Journal of Inebriety, Dr. W. Nasse quotes two very interesting cases under treatment in the asylum over which he has charge. The symptoms recognised in them, and in fifty other cases admitted during a period of two years, and arising from abuse of alcohol, are classed by Dr. Nasse, after Marcell, as hallucinations and delirious conceptions, totally ignoring all regard for the physical and moral welfare of themselves and others. No special incoherence of ideas is noticed, memory and power of concentration seem natural, also the will appears strong. A mania for suicide, accompanied with jealousy, and occasionally febrile conditions, Insomnia is are the most prominent symptoms in these cases. often present, also delirium of agitation, more or less intermittent. This form of insanity resembles Lipomania, described by Calmoil. Not unfrequently hallucinations of a painful character precede the suicidal mania; fear, restlessness, anxiety, jealousy, hatred against their best friends and surroundings, are often the prominent prodromic signs. Later, when the disease has reached its chronic state, distortions of the muscles of the face and tongue, amesthesia of the extremities, disturbances of the digestion, are common. Such are some of In the most significant symptoms of this form of inebriety. one hundred and sixty cases admitted in the hospital at Sigiburn during two years, there were The almost exclusive cause

fifty

cases

of this form of

insanity.

alcohol. The following cases this form of disease better than any was

given as illustrating description of symptoms :? are

CASE I.

H. F., age 44, farmer. No hereditary predisposition to Of medium intelligence; proud, self-conceited in Started in business manner, and always healthy and rugged. and failed a few years after; then was obliged to work hard to support his family. About this time he began to drink sud-

disease.

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to great excess, and later drank less, and continued for six years to alternate between short periods of excessive drinking, with long intervals of moderate indulgence. Never had delirium tremens. After an attack of severe drinking he was prostrated in bed with a low form of fever, which continued many days. Began then to have suspicions that his wife was plotting

denly

Heard noises at night, such as voices, threats, to die; had suicidal manias, muscular tremblings, and sleeplessness. This continued for some months His without change, then he was brought to an asylum. was as follows : thin in arteries face red, appearance person, rigid, pupil of the right eye larger than the left, left part of the face flabby, shivering of the facial muscles when talking, pushes the tongue straight out, and complains of heaviness in the forehead, also interrupted sleep. Protests against staying in the asylum, says he is not sick, complains of persecution, which he dates back to his youth, hears voices which threaten him, saying that he is to be shot, that the ball is already on its way, hears his wife's voice at the door telling him that he must die, acknowledging that his hearing is more acute in bed. His wife shouts to him through the ke)7hole that he is a horse, and immediately he is made miserable by equine odours. He hears other voices calling him a dog, and begs the nurse to open the window so that he can get rid of the canine odour. He hears the voice of Grod, and has the taste of the Host in his mouth. From these and other voices he knows

to kill him.

slanders; wanted

what is

going

on, and what will

happen

in the future.

All his

friends and relatives have conspired against him, and daily persecute him in every way. He is constantly seeking methods to take his own life, and escape from these afflictions. Generally he is elated and egotistical, also quite happy at times. Keeps himself separate from others. During the thirteen months' residence in the asylum he steadily improved in physical health, but the old delusions remained. He was at length discharged as incurable. CASE

II.

A baker, age 45. Both parents insane in youth and early manhood ; was very irritable and unpleasant in his manners, of average intelligence and industry. Married, and has nine children. He is very poor. Drank suddenly and to great excess for several weeks, ending in an acute attack of delirium tremens. He did not recover from this for a long time. He then complained of persecution, sleeplessness, hears voices threatening him, wishes to escape by taking his life. Left part of his face

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flabby, has a shivering of the facial muscles, sleeps badly, is elated and extremely irritable, and suspicious of every one. Would write kind letters to his wife in the moments of his greatest suspicion. Delirium of grandeur would alternate with those of persecution. After a few months' residence in the asylum these symptoms disappeared ; his health became better, A year later he was readmitted to the so he was discharged. incurable. Some of the points of difference chronic as a asylum between these cases (which are noted as Lipomanias and delirium tremens) may be noted thus :?In delirium tremens the hallucination is mostly of the eyes, in the other it is of the ear. The feeling and condition of the organs are changed in Lipomania, and sensations of heat and burning are present. The sense of smell i^ affected, and the taste also. Many symptoms of paralysis, which are commonly seen in alcoholism, may be present, such as shaking of the lips, tongue, and facial muscles, difficulty in talking, formication, also anaesthesia, motor disturbances, and obscure psychical symptoms. These symptoms are more or less unequally distributed through, and are rarely seen in cases of delirium tremens. Inequality of the pupils is also prominent. Suicidal mania is always present. Cardiac Symptoms

Dr. 0.

or

Sturges {Brain, July 1881)

Chorea. summarises the several

factors of the heart symptoms thus:?1. In the course of the chorea of childhood the heart's action is apt to become irregular or uneven, and its first sound to be followed by apex-murmur, which is variable in pitch, influenced by posture, seldom audible in the axilla or at the angle of the scapula, and which disappears along with or shortly after the chorea, the heart and the circula2. This liability on the part of the tion suffering no injury. heart to what, from its signs, would seem to be a functional disturbance, is independent of the violence or method of the but upon the age of the patient, the younger

dependent

chorea,

children being most, and the elder least, liable ; while beyond childhood there is little, if any, liability of the kind. 3. These heart signs of chorea?acute rheumatism being excluded?give

rise,

as

a

general rule,

to

no

symptoms

whatever

affecting

the

health comfort of the child. They make no apparent difference to the prospects of recovery, or to the structural integrity of the heart. Nevertheless, choreic children having this murmur and happening to die either with, or shortly after recovery from the chorea, very commonly exhibit a beading of recent lymph on the mitral valves. Such, he says, are the chief statements which statistics seem to warrant. To these he adds another. or

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which, so far as he knows, has never been statistically recorded, but which no one will gainsay. It is, indeed, the most constant of all the heart symptoms of chorea, and met with at a later age than the rest. He refers to the acceleration of the heart and

pulse. Ligature of the Vertebral Arteries for Epilepsy. The treatment of epilepsy

by means of ligaturing

the vertebral

arteries, introduced by Dr. William Alexander, of Liverpool,

has been followed up by its author in numerous cases since the first publication of his papers on the subject. In a late number of Brain he gives the history of all the patients who could be

found

after recovery from the submitted at his hands ; and several additional instances are recorded. Eespecting the utility of the operation, Dr. Alexander remarks that in twenty-one cases referred to in his paper, three have been quite well for nearly a year. Nine others have been free from fits, and for such a space of time that it may be said a cure has resulted or is likely to result; and eight have improved in so many respects, or are improving so steadily, that the operation would be justifiable were no better results ever obtained. The case of one patient, who died in a fit two months after his discharge

subsequently

operation

to which

leaving his they had been to

care

from

hospital, is regarded as an accident such as occasionally in all epileptic establishments. The state of his kidneys was so surprising as to lead Dr. Alexander to examine the urine in all cases before operating. He adds that the diminution of the fits after operation makes him doubt if the renal disease had any influence on their production. Dr. Alexander then cont now think that ligature of the external arteries tinues, ought to take its place as a recognised operation for the cure of epilepsy, when other means, such as the removal of peripheral causes of irritation, and the soothing of irritated nerve-centres have failed. by drugs The surgical difficulties of the operation can easily be overcome by practice. My method of operation does not involve any important structures. The danger to the patient's occurs

"

"

life is very small; and should the operation fail to relieve the is in no respect worse off than before. No instance of any deformity or disability on the part of the patient has, as yet, been noticed by me, or reported to me by

fits, the patient

anyone.

" To afford reasonable hopes of success the epilepsy must not be allowed to become too chronic. It should, therefore, be performed as soon as it becomes evident that drugs have no

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curative effect, but that they only diminish the fits by temporarily paralysing the nerve-centres. In some of the very chronic cases improvement has resulted, and I am not yet prepared to say how far that improvement may progress, or how far it may

yet retrogress. "

Before performing the operation, every external irritating should be, as far as possible, removed. This cannot always be done. Nor is it necessary, provided it be not done, that its nature or severity is the sole cause of the epilepsy. When the sensibility of the epileptic nerve centre or centres is reduced, that cause will have no more effect in producing fits than it has in any other healthy, non-epileptic individual. " Where the exciting causes of epilepsy are cerebral, and are accompanied by or alternating with uncontrollable anger or maniacal excitement, the effects of operation are not so apparent or so permanent. In two cases in which imperfect success was attained, the cause to which it was due was probably cerebral excitement; and the same cause is apprehended to cause

The exciting a similar want of success in another case. in those instances are so powerful and so uncontrollable that the stimulation of the epileptic centres soon restores the

produce causes

the principle that ubi stimulus ibi flux" of chronic epilepsy the operation mitigates the disease, and may, Dr. Alexander thinks, ultimately cure the fits. In one case where power was restored to a paralysed arm, the effect upon the cord must have been decided, and was unmistakable. Inspecting the explanation to be given of the effect of the operation, Dr. Alexander maintains a cautious reserve. He suggests that the epileptic centres may be rendered hypersensitive through some powerful shock. The circulation is in blood

supply,

In old

many

shown

on

cases

cases

restored to the

by only

one

fit

or

a

normal, and series of fits.

is the attacks in

hyper-excitability In other

cases

but only produces epileptic consequence of peripheral excitement caused by worms, gastric or sexual disturbances, or of the cerebral irritation produced by anger. That we can influence for good the nutrition of the medulla, and of the upper, or even of the lower spinal cord, by ligature of the vertebral centres, Dr. Alexander has incontestably proved. Latterly, also, he has ligatured both arteries in all The risk, he cases, that the greatest possible effect may ensue. declares, is no greater, but experience has demonstrated that the

hyper-sensibility exists,

effect is both

greater

and

more

permanent.