2. Repress the too often excitable or emotional disposition toward a quiet, steady control of self. Do not encourage any one to be a prodigy. Extreme brightness in some one way may mean an unbalance. It is not the enduring element.

3. A country life and an outdoor life for a child tend usually in the right direction. All seclusion and sedentary habits are to be avoided.

4. Educate the child freely, rationally, and plainly against the evils of dissipation, of alcoholism, and of all excesses. Alcoholism especially has a distinct tendency toward both physical and mental impairment. Of course, the parent is the natural educator of the child, and in proportion as the parent is unbalanced, erratic, unstable, hysterical, alcoholic, or of other mental defect, the tendency will be to perpetuate carelessly the defectiveness. To quote from J. Madison Taylor concerning imbeciles, "In a large proportion of cases the parents are themselves mentally incompetent. They are certainly rarely fit to grasp rightly the spirit of the inquiries." This is only to be met finally by the general culture of an enlightened public opinion, as before outlined.

5. Beside such causes as above considered, causes such as malnutrition, blood-changes, fevers, toxic elements, and ways of living are more vaguely acting causes calling for medical study and an education in physiology or physical life, as well as in the more and mental influences above.

Summarizing, then, we find that to those to whom most peculiarly belongs the name defective we have: 1. A gross form of mental feebleness can be produced by head-injuries or in later life by brainchanges like those of hemorrhage or abscess of the brain, and in senile life atheroma, atrophy, and general senile recession.

2. In very early life such causes as severe typhoid or scarlet fever can in a few cases produce permanent feebleness of mind, however, acting upon a predisposition.

3. Under heredity we may have (a) one or both parents insane, imbecile, epileptic, paralytic, eccentric, hysteric, choreic, or with other nervous or mental defects, or (b) one parent may be syphilitic, consumptive, alcoholic, or Brightic, and the nervous system thus impaired will show an impaired nervous system in the children of varying type, or developing into defects the form of, which seems largely a matter of seeming chance.

Under headings one and two our preventive ideas do not very thoroughly apply, but these do not make up a very high per cent. of our total cases. The third class is that to which we may apply our effective study. We advocate, first, legal measures controlling or preventing the marriage of the grossly defective ones; secondly, hygienic and general education which shall hinder the development of the predisposed traits and help people to avoid the

effects; and, thirdly, the education of the popular masses to sustain and support preventive measures as advocated.

In conclusion, concerning legal measures, just a note. It has been said that all men are "free and equal," but the fallacy of this is now quite well known. We are not free to do that which will interfere with other's freedom or well-being, and the marriage of epileptics certainly does just this to the offspring. I feel that by such measures we strike at the root of the evils, while by nursing and liberating the defectives we merely try to bend and direct and make healthy the branches and often perpetuate the defectiveness. I cannot think that by multiplying words or by rhetorical effects I can add to these plain statements, which I hope are honestly, if too bluntly, stated. I therefore leave the subject with you.

BIBLIOGRAPHY.

I. Shuttleworth and Beach: Causes of Idiocy and Imbecility. Dict. Psych. Med., vol. 1, p. 669.

2. Charles Mercier: Heredity. Dict. Psych. Med., vol. 1, p. 583.

3. Buckmill and Tuke: Causes of Insanity, Idiocy. Psych. Med., p. 54.

4. Arthur Mac Donald: Abnormal Man.

5. J. Madison Taylor: Some Causes of Mental Impairment in Children. Am. Med. and Surg. Bull., July 15, 1895.

6. J. Savory Pierce: Causes Conspiring to Produce Mental Enfeeblement in Children. Am. Med. and Surg. Bull., August 1, 1895.

7. W. O. Henry: Relation of Diseases, Crimes, and Vice. Journ. Am. Med. Assoc., March 22, 1895.

8. S. A. Work: Heredity and its Environments. Journ. Am. Med. Assoc., October 2, 1895. Woman's Med. Journ., Sept.

9. Jane Garver: Heredity.

1895.

10. Heredity as a Factor in Disease. (Editorial.) THE MEDICAL NEWS, April 13, 1895.

CLINICAL MEMORANDA. BELLADONNA-POISONING WITHOUT DILATATION OF THE PUPILS, CAUSED BY A BELLADONNA-PLASTER.1

BY DOUGLASS W. MONTGOMERY, M.D., PROFESSOR OF DISEASES OF THE SKIN, MEDICAL DEPARTMENT OF the UNIVERSITY OF CALIFORNIA; CONSULTING PHYSICIAN FOR DISEASES OF THE SKIN AND PATHOLOGY, GERMAN HOSPITAL.

I ONCE ran across the following case of belladonnapoisoning, which had not the usual prominent symptom of dilatation of the pupils, and this peculiarity, together with some other circumstances of the case, put me so on the ragged edge of doubt for a few hours that the lively impression of the incident will probably never leave me.

On April 2, 1891, about 10 o'clock in the evening, I was called to see a patient who had consulted me several times before on account of rheumatic pains, cramps, and various minor ailments.

He was a large, fleshy man, aged sixty-seven years,

1 Read before the San Francisco County Medical Society, December 10, 1895.

ounces of urine a day, excluding that passed at stool, but he always perspired very freely, which would account for the somewhat diminished quantity. Bright's disease without albuminuria does occur, and the heart-lesion, the diminished quantity of urine, and the patient's habits made me watchful in this regard. There was no urinous odor on his breath, however, and the general symptoms did not tally with those of a case of uræmic delirium.

As I said before, I was called in to see him on this particular evening, and I found him with a flushed face and his tongue so hard and dry that it felt as it sometimes does in extreme cases of diabetes. There were constant attempts to swallow, and he had a quickened and rather stormy pulse and increased respirations. His speech was rather thick on account of the dryness of the tongue and mouth, and he was a little "rattled" in his ideas, but rational enough to give an account of himself. He said he had felt this coming on just before dinner, and he attributed it to some whiskey and quinine which he had taken at a bar during the afternoon. It happened that just at that time this way of taking whiskey was the fashionable "tonic " in the down-town drinking-resorts, and was drunk by a large number of people who wished to be in that particular "swim." I knew of and had seen the erythema sometimes caused by quinine, and also knew that whiskey thickened the tongue and jangled the ideas out of tune, but neither of these drugs nor their combination seemed to fit the symptoms in the present case. Atropine- or belladonna-poisoning ran through my mind, but this idea was dismissed because the pupils were not dilated, and they did not dilate during the entire trouble. Furthermore the whiskey and quinine were taken at a bar, not in a drug-store, so that there was little chance of a mistake in dispensing, and he said he had not taken any other drug during the afternoon, and of this fact he was positive.

Although he had every appearance of having a very high fever, yet his temperature was normal; but then febrile affections do occur without a thermal rise. I went over his chest carefully to exclude pneumonia, nor could I find anything else to account for his condition. All this was not very satisfactory, but the facts as I saw them were: A man puffing away at a fairly high rate, with a stormy, accelerated pulse, a dry, hard, furred tongue, a dry, reddened, but not hot skin, a flushed face, constant efforts to swallow, no rise of temperature, and no dilatation of the pupils.

Having determined to await further developments, I left him, promising to be back early the next day.

I was called again at 2 o'clock in the morning, those who were watching him becoming very much alarmed. He was now frankly delirious, although the delirium was not of a dangerous character. He was very restless, picking at the bed-clothes, constantly attempting to get out of bed, and mumbling incoherently and rapidly about a gold-mine in which he was interested. He had evidently grown a great deal worse during the few hours I had been absent. He was not suffering from diabetes, for there was no sugar in his urine, and there had been none in any of the examinations that had previously been made of it. Nor had I ever found any

While sitting on a chair watching the patient and thinking what in the world could be the matter with him, it suddenly occurred to me that I had told him to put a belladonna-plaster over one of the numerous pains and aches he used to complain of. I almost automatically walked across the room and felt under his shirt, finding an immense belladonna plaster twenty inches long and six inches broad over the left side of the chest. This was quickly pulled off, the skin well washed, and a hypodermic of morphine given.

He soon recovered and was able to go about his ordinary business in a few days.

He gave the following account of how it all happened: He had worn smaller pieces of belladonnaplaster over the left side of the chest for quite a long time, and had frequently suffered from dizziness and a dry, uncomfortable feeling in the throat. The dizziness was supposed to be owing to functional derangement of the liver, and the dryness in the throat to a pharyngitis. The afternoon of the evening on which he was taken ill he went to a drug-store and asked for a good, big piece of plaster. They said they had some in just fresh, and they cut off as large a piece as he wanted. Having secured the plaster he went to the baths and took a piping-hot soak, and applied the plaster to the actively perspiring, freshly washed skin. Before dinner his mouth was already disagreeably dry and his throat constricted, but he did not heed it much. The other symptoms followed as they are related.

Belladonna, or its alkaloid atropia, is used so much in medicine, and the drug acts so energetically on human beings, that cases of poisoning by it cannot be said to be rare. Poisoning by the application of a plaster is, however, undoubtedly not a frequent occurrence, but its possibility ought to be borne in mind.1 This case was peculiar in that there was no dilatation of the pupils, an event so rare that its absence would justify entirely overlooking the fact that it was a case of

1 Pye-Smith mentions a case of belladonna-poisoning under the care of Mr. Hilton, "caused by the application of a large belladonna-plaster in a woman, who must, one supposes, have been more than commonly susceptible." (Diseases of the Skin, by Pye-Smith, p. 180.)

In one case 100 milligrammes (about 1% grains) of atropine caused death by being absorbed through a vesicated surface. (Lehrbuch d. Intoxikationen, von Dr. Rudolf Kobert, Seite 606.)

Crocker mentions the case of a man who wore a belladonnaplaster for a week and then took two seven-drop doses of the tincture, causing his hands and feet to become swollen, red, and tense. (Diseases of the Skin, by H. Radcliffe Crocker, M.D., p. 327.)

Ernest F. Maddox has also reported a case of poisoning by a belladonna-plaster (Amer. Journ. Med. Sciences, vol. cvi. p. 572). The pupils were no more dilated than is frequently the case in myopia.

BY CHARLES R. WEED, M.D.,

LARYNGOLOGIST AND RHINOLOGIST TO ST. ELIZABETH'S HOSPITAL, UTICA, N. Y.; MEMBER OF THE ONEIDA COUNTY MEDICAL SOCIETY, ETC.

SEPTEMBER 14, 1894, Mrs. H., seventy-five years of age, was sent by Drs. Quin and Bergess, of this city, as a case of epithelioma, which, on examining carefully, I confirmed. The characteristic "concentric globes or epithelial nests" presenting in microscopic section, I at once proceeded to clean the ulcerated and broken-down surface carefully and thoroughly, and though advising curettage, it was decidedly objected to by the patient. The seat of the disease was on the right nasal ala near the junction of the cartilage with the right bone of the nose, and extending in its course to within one-fourth of an inch of the internal canthus of the right eye. As destructive action had advanced under the scab which covered it I proceeded to use trichloracetic acid, being particular to cauterize thoroughly every portion of the cancerous mass, first using a 10 per cent. solution of cocaine to relieve the pain. I then gave my patient a solution of zinc chloride, ten grains to the ounce, with directions to keep the surface wet with the same and to see me the following day. The disease was of three years' standing, the woman emaciated, poorly nourished, and full of "Irish obstinacy," so much so that she would not take any internal medicines, and other doctors had prescribed ointments, etc., galore-of course, unavailingly.

This case at the sixth visit began to show slight improvement. The slough from the acid was removed and effort made to induce granulation. For months it was "up and down," and when after healing twothirds of the sore pearly nodules would appear in the upper portion and have to be destroyed, necessitating more patience and care. I continued my treatment of

1 It must not be forgotten that this was a case of chronic poisoning, for the patient had worn belladonna-plasters, although not such large ones, for a very long time, and Sabatini (quoted by Kobert) draws attention to the fact that the drug, after a time, ceases to act on the salivary glands, the heart, the intestine, and last of all on the pupil. (Lehrbuch d. Intoxikationen, von Rudolf Kobert, Seite 610.)

Dr. L. Lewin draws attention to the fact that there can be belladonna-poisoning with only moderately dilated pupils. (Nebenwirkungen d. Arzneimittel, p. 221.)

2 Mentioned by Prof. H. C. Wood in his lecture on belladonna. (The Boston Medical and Surgical Journal, July 13, 1893.)

Infection through Books -At a recent meeting of the Société de Biologie, DU CAZAL and CATOIN (Münchener medicin. Wochenschrift, 1896, No. 1, p. 22) detailed the results of an investigation to determine whether books were capable of transmitting contagious diseases. The streptococcus, the pneumococcus, the diphtheriabacilli, the tubercle-bacillus, and the typhoid-bacillus were thus studied. Animals inoculated with cultures prepared from books contaminated with the products of the various conditions in which the organisms named were found developed the given affection. It is thus necessary to practise disinfection of books that have been used or in any way contaminated by persons suffering with infectious diseases.

An Analysis of Eighty Cases of Lithotrity.-At the recent French Congress of Surgery, ALBARRAN (Ann. d. Malad. d. Org. Gen. Urin., 1895, No. 12, p. 1079) presented a statistical analysis of 80 cases of lithotrity. Seventy-six were in males, 4 in females (1 in a girl of ten years). Of the calculi, 46 were phosphatic, 29 uric acid, 4 urophosphatic, and I oxalic. Of the patients, 20 were older than seventy years, and 7 had reached or passed seventy-eight years. The oldest was eighty-four years, and presented aortic insufficiency; the operation was performed without anesthesia, and the calculus removed weighed 400 grains. The largest stone crushed

2.5 ounces.

In two-thirds of the cases the bladder was

infected, and in many the prostate was enlarged; in several pyonephritis existed. In 8 cases the operation was performed without anesthesia, sometimes because of facility of performance and small size of the stone, and at other times because of contraindications to anæsthesia. Recovery ensued in all cases but one, in which death resulted from anæmia.

The Renal Changes of Diphtheria.-REICHE (Centralbl. für innere Medicin, 1895, No. 50, p. 1209) reports the results of a study of the kidneys in 85 fatal cases of diphtheria observed prior to the antitoxin-period. Thirtyeight of the cases had been in males and 47 in females. Fifty-two were under five years of age, 23 between six and ten years. In 22 death took place between the 2d and 5th days, in 36 between the 6th and 10th days, in 27 between the 11th and 24th days. Tracheotomy had been performed in 58. Forty-seven presented lobular pneumonia of varying extent. In many cases the trachea and bronchi were involved in the diphtheritic process; in 14 the gastric mucous membrane, in 8 portions of the œsophagus, and in 1 a portion of the ileum.

The kidneys presented no constant or characteristic naked-eye appearance. Microscopically, changes in

paralysis of the muscles supplied by the two inferior branches of the facial nerves, involving especially the orbicularis oris; those supplied by the upper branches were normal. The hypoglossus was paretic on both sides. Respiration was free, but phonation was impaired. The extremities were rigid, but the electric reactions were preserved. The cutaneous reflexes were generally increased, and the tendinous reflexes also, especially in the lower extremities. The feet occupied a position of equinovarus. The little one could stand erect if supported, but it was unable to walk. Urine was passed incontinently.

Successful Total Extirpation of a Gravid and Myomatous Uterus.-CAMERON (British Medical Journal, No. 1823, p. 1414) has reported the case of a woman, thirty-six years old, in the fifth month of her first pregnancy, whose abdomen was greatly distended. Eight years ing in the left iliac region, about the size of a hen's egg, previously the patient had noticed by accident a swellwhich for a month or two increased in size slightly, then ceased growing and remained stationary till she became pregnant. The legs and thighs were œdematous, and some dyspnoea existed. There was no diffi

were visible. Those in the parenchyma were the most pronounced and assumed two main types. In all there was cloudy swelling of the epithelium and later fatty degeneration. A smaller number of cases presented coagulation-necrosis. In 44 cases inflammatory proliferation of the interstitial connective tissue was found. In all instances the changes were most pronounced in the cortex. The Malpighian bodies constantly presented alterations, though of varying degree. All of these changes are attributed to the action of the toxins generated at the seat of the diphtheritic process, and thence absorbed

into the circulation. The liver was affected in a similar way, but in a much smaller number of cases and in slighter degree; the pancreas only exceptionally. No relation, however, could be established between the character and extent of the diphtheritic process and the secondary changes in the abdominal viscera.

Pseudo-bulbar Paralysis in a Child Three Years Old.-At a recent meeting of the Society of Pediatrists of Moscow, KYSSELE (Presse Médicale, 1896, No. 3) reported the case of a girl apparently normal at birth except for pronounced flexion of the fingers and toes. It was at once observed, however, that the infant suckled with difficulty, and later that it failed to protrude its tongue. At the age of about a year, following an acute illness lasting three months and diagnosticated as typhoid fever, the child presented a condition of weakness, with difficulty in deglutition. It had never spoken. On examination, at the age of three years, the child protruded its tongue with difficulty. There was copious salivation and a disagreeable odor exhaled from the mouth. The bony skeleton and the musculature were well enough developed. There was no evidence of rhachitis, although the state of the nutrition was below par. The mucous membranes presented a normal tint. The gums were swollen and hyperæmic, and bled readily. No lesion of the viscera could be discovered. The sternum was deeply depressed with each inspiration. Hearing and Hearing and vision were normal. There existed simple nonatrophic

Lungs and heart presented no abnormality. Milk could be expressed from the breasts. The abdomen was greatly distended, presenting the appearance of pregnancy at term. It measured thirty-seven inches in circumference at the level of the umbilicus. On palpation, a large, smooth, round, hard swelling was found in the left side of the abdomen, crossing the middle side, from which, however, it was separated by a sulcus. line and being continuous with a swelling on the right The swelling on the right side was elastic in consistence, but two or three hard, rounded nodules could be dis

tinctly made out on its anterior surface. Over it the

uterine souffle could be heard, but the foetal heartsounds could not be recognized. On vaginal examination the whole cavity of the pelvis was found to be filled with a hard mass, impacted in it and continuous with the tumor above. The uterus appeared to be very much drawn up. Cœliotomy was undertaken, and when the abdomen was opened a large, irregular tumor was encountered, the left portion consisting of an interstitial myoma, the right of the distended uterus. In addition, implanted upon the upper and posterior uterine walls, were several subserous myomata, varying in size from a walnut to an orange. Through an incision in the anterior wall of the uterus a five months' fœtus was removed, which was perfectly formed and had evidently been dead only a short time. The placenta was well developed and was easily detached. An elastic ligature was passed around the uterus and tumors as close as possible to the cervix and secured. The uterus and tumors were cut away and the uterine and ovarian arteries were ligated. The ovaries and tubes were also removed. The tumor blocking up the pelvis was with some difficulty freed from adhesions, drawn up, and enucleated. The peritoneum was stitched round and round with catgut ligatures to the mucous membrane of the vagina. These ligatures were then drawn down into the vaginal canal and the abdominal wound was closed with silkworm-gut sutures. The patient made a good recovery, being dismissed perfectly well in the seventh week after the operation.

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IN THE MATTER OF IDIOTS.

THE State Commission in Lunacy of New York have so construed the amended Constitution that a class of inmates of the State Hospitals for the Insane are liable to be left without proper care and supervision. The Constitution provides that there shall be "a State Commission in Lunacy, which shall visit and inspect all institutions used for the care and treatment of the insane (not including institutions for epileptics or idiots)." The Lunacy Commission construes this exemption of institutions from its visitation and inspection to mean that the idiots at present in the State hospitals must be removed, and accordingly a circular has been issued by the Commission to the superintendents, "In the matter of Idiots," directing them to notify friends and county authorities that they must forthwith remove those idiots for whose care the latter are responsible. The superintendents are now engaged in informing the county officials of the names of idiots in their hospitals who must be removed under this order of the Commissioners. moval of idiots from the State hospitals means that they are to be returned again to the poor-houses from which they were, for the most part, so recently

This re

105

transferred under the provisions of the State Care Act.

The result of this action of the Commission has created great excitement in many counties, owing to the disturbances which these so-called "idiots" create in the poor-houses, and the entire want of adequate facilities for their proper care. In Kings County the Charities Commission has flatly refused to receive these "idiots" unless the Superintendent of the State hospital certifies that in each case the person is not insane. The Commissioners have taken that position under the instructions of the State Board of Charities, which has supervision of the poor-houses of the State. Meantime, this most helpless and pitiable class of dependents, for which the vaunted State Care Act was believed to have done so much, by removing them from the poorhouses, have no legal status in the State or county institutions. The insane idiots of New York are like the bat in the fable, which the beasts would not receive because he was a bird, and the birds because he was a beast.

The position taken by the Lunacy Commission seems hardly tenable in view of all the facts. The new Constitution simply prohibits that body from visiting and inspecting institutions for idiots. It in nowise forbids the reception and retention of persons duly adjudged insane in the State hospitals, though they may be otherwise classed as idiots. On the contrary, the law prohibits all other institutions from receiving and retaining them in custody except the State hospitals and institutions licensed by the Lunacy Commission for the care and treatment of the insane.

A fair construction of the Constitution and the lunacy laws would seem to lead to two conclusions: (1) that the Commission cannot officially visit and inspect institutions for idiots, and (2) that the State hospitals must receive for care and treatment all persons taken to them with duly prepared papers adjudging them insane. Nor are these two legal requirements incompatible, for while the Lunacy Commission is prohibited from visiting and inspecting poor-houses, the insane of the poor-houses must be removed to the State hospitals. So it has followed, under the operations of the State Care Act, that among the insane persons found in the poorhouses were some who are now called "idiots." They were transferred to the State hospitals as insane, and were by them duly received, registered, and held in custody. The fact that subsequently