cient treatment for syphilis in ordinary mercury and some of the arsenical preparations, and for that reason I feel that it is indefensible to use salvarsan in the manner in which it is used by some practitioners, imperiling the lives of our patients when we possess other therapeutic agents that can be employed with such excellent result. I have administered considerably over one thousand doses of the drug up to the present time, and thus far have not had a fatal result. A case was recently reported by a prominent New York man, whose patient died on the table while receiving an intravenous injection of salvarsan, and we have had three or four similar cases in Kansas City. I recently examined the brains of two patients who died following the intravenous injection of the drug. It is a question in my mind whether, in a disease like syphilis, for which we possess other efficient remedies, we have a right to imperil the lives of our patients by the employment of a method which can bring about such results. In my first one hundred cases I tried practically every form of administration that had been recommended, and now I use only the intramuscular route. In some instances, when the intravenous method was employed, the patient's lips became blue and there were other signs of collapse, although, fortunately, no serious complications ensued. Some of the symptoms and some of the results encountered in the intravenous administration of salvarsan will frighten even an experienced surgeon, and, considering the results that some men get, he has good cause to become frightened.

DR. H. P. COLLINGS: As Dr. Martin did not speak particularly of the technic of the administration of salvarsan in his paper, I would like to say a word or two regarding it. The instrument I use now is a little different from the one the doctor uses, and the apparatus is much simpler. It is the one, I believe, Dr. Fordyce now uses. It consists simply of a mixing tube, which is graduated in cubic centimeters both ways. It has a rubber cork and through this cork is a glass tube reaching to within about one inch of the bottom of the vessel or graduate, and another which reaches just through the cork about half an inch. The medicine is dissolved in the graduate, the rubber cork with its two glass tubes is fitted in and the whole is turned bottom side up; a soft rubber tube leading to the vein is kept attached to the short glass tube, and to this is clamped a small clamp so as to cut off the flow of the liquid until the proper time. The needle is introduced and the tube is then attached to the needle, and that is all there is to it. Neosalvarsan or 914, instead of 606, takes less water, about 150 c.c., is less irritating, and is supposed to be less dangerous, and no salt is necessary. When the solution is made with distilled water it is ready for intravenous injection and does not need the addition of soda solution.

DR. E. H. MARTIN (closing): I cannot agree with Dr. Sutton. If we all believed the same thing there would be no advancement, but I think Dr. Sutton exaggerates the dangers of the intravenous administration of salvarsan. Certainly a patient dying on the table must die from some fault in the administration and not from the drug administration when the drug is harmless in other cases.

Dr. Sutton spoke of a patient with myocarditis dying from an intravenous injection. I doubt this very much. I have never seen more than a ten millemeter rise in the blood pressure from eight ounces injected intravenously. I doubt

very much whether anybody has ever died directly from the effects of the intravenous use of salvarsan. Any man with myocarditis or with a weak heart is liable to die after drinking a cup of coffee or anything else. Such coincidences should not stand in the way of the absolutely perfect results obtained in most cases and beneficial effects in all cases from the administration of this drug.

I have given over 1100 intravenous doses; have given them in my office and allowed the patients to walk to their homes and to come back and report the next day. I have never had any unpleasantness. However there were several narrow escapes. One patient absolutely refused to take salvarsan when I was getting ready to give it to him. That night at the suppertable he had a stroke of paralysis. I asked him the next day, "What if I had given you salvarsan?" He replied that if I had done so no power would ever have convinced him that the "606" had not paralyzed him. Another patient went out to Mineral Wells, Texas, to stay a week before returning for salvarsan. She had been there only a few days when she had her first epileptic seizure. If she had been given salvarsan before going to Mineral Wells the drug would have been blamed. Personally, I do not think there is any danger whatever to be feared from the intravenous administration of salvarsan, if properly carried

out.

A PLEA FOR THE

EARLIER RECOGNITION OF CERTAIN NERVOUS AND MENTAL CONDITIONS.

The

E. P. BLEDSOE, M. D., Little Rock, Ark. Although this is the age of preventive medicine, and much is being said and written regarding the prevention of disease, the field of mental and nervous medicine is generally presumed to offer little either as a result of treatment or prophylaxis. reason for this erroneous presumption is due largely to the marked lack of interest in anything approaching the field of Neurology or Psychiatry-a condition brought about by our medical schools which only recently have recognized the importance of proper instruction in these two important branches of our profession.

As a result, we might say that the field of nervous and mental disease is far behind other branches of medicine, as regards either early or accurate diagnosis. Unfortunately, it is only by the early recognition of many nervous and mental conditions that we may hope to accomplish results either curative or prophylactic, while in others, lack of early diagnosis often leads to incurable disesae.

There is no field of medicine of which this statement is more true than that of mental disease, and yet how seldom are the earlier symptoms recognized.

The possibilities of preventive principles to mental medicine and by mental medicine

-I do not refer to insanity alone, but to all disorders of the mental process, however slight are just beginning to dawn on the medical profession at large. We are beginning to realize that certain individuals are being born into the world poorly equipped to bear the "slings and arrows of outrageous fortune." Such an individual may have difficulty in adjusting himself to his environment, so to speak, and in that effort may develop certain mental peculiarities, which are as much symptoms of disease as the rash in scarlet fever or a Kerning's sign. Allow these danger signals to go unheeded, with the comforting assurance to the parent that the child is just a little nervous and will outgrow it all," and we have a splendid nucleus for the development of a neurosis or psychosis in later life.

How many times have we all been asked, "Doctor, why is my child nervous?" and have replied with some glittering generality of heredity or environment, when a careful examination of the child's mental processes would reveal the fact that he was struggling against an unsurmountable obstacle-that of a retarded mental development.

This leads me to speak of a subject of vast economic importance-that of the recognition and special instruction of mentally defective children in our public schools.

The work of Binet and Simon has put a method into our hands by which we are able to accurately diagnose and classify all mental defectives. It is in this class of children, not necessarily imbeciles or Morons, but the child just a little below the normal standard, that the potentialities of nervous and mental disease lurk. Place this child in classes with children with minds up to the normal standard, and he soon becomes discouraged and falls behind-the pace is too fast for his slower mental processes and he cannot adjust himself to his environment. As a result, he becomes nervous and irritable, develops violent fits of temper followed by depressed states, and is often sent from the school with the reputation of being an incorrigible, to finally land in an institution as a care and expense to the state.

The same child, when carefully tested by the Binet-Simon scale and given proper instruction for his mental age, will often develop mentally and physically into a useful citizen.

The initiative in this work is in the hands of the physician for laymen are slow to recognize its importance. Much needed laws for the medical inspection of our schools should be urged in the state legis

latures, and steps should be taken to provide for the care and instruction of all defective children.

We are all ready to admit that this is the age of the strenuous, and that many individuals fall by the wayside in the struggle for existence. It is this class whose disorders are dependent upon purely psychological factors who are most apt to develop into troublesome neurotics, or even if unrecognized, into some type of psycosis.

As Dr. Wm. A. White in his excellent little monograph on "Mental Mechanisms" says: "The individual at some point or other comes into conflict with the conditions about him, in which he must live and to which he must adapt himself if he is to proceed in life with anything like efficiency and he fails to make the necessary adjustment. He is unable for example to reach a condition of emotional calm after the loss of a dear friend or relative, or after a disappointment in love; he cannot get on his feet again after being ruined by a trusted employee; he is placed in a position of too great complexity for a limited mental equipment, and cannot produce results that are up to reasonable expectations.

At these periods of conflict, failure is not infrequently expressed by the development of a psycosis. Failures of this sort, the inability of the individual to square up with the events of every-day life, upon analysis are found to depend largely upon faulty and erroneous viewpoints-upon vicious habits of thought, upon narrow and inadequate ideals, false notions and ambitions, in short upon a biased mental attitude toward the world of things and events.

It is the importance of the early recognition of conditions and types, such as these, to which I wish to direct your attention to. Instead of passing such cases by with a cursory examination and a tonic for their "nerves," let us inquire more closely into their mental processes, their mental processes, their habits of thought and ideals of life. The investigations of Jung and the psycho-analytic school have shown the value of psycho analysis as a diagnostic measure, and often the mere revelation of some psychic trauma, unrecognized by the patient gives us sufficient insight into the case and enables us to stamp out an incipient psychosis.

I think I might say without fear of successful contradiction, that there are many psychoses dependent upon mental causes, which if recognized in time, are preventable.

This is doubly true in cases of recurrent psychosis and one of the strongest argu

ments in favor of the intelligent after-care of the Insane. Here we are dealing with individuals whose whole metal equilibrium has undergone a powerful shock. Often these patients are discharged from the discharged from the hospitals apparently normal, but, when called upon to meet the conditions of the every-day struggle of life, their mental processes are too weakened to stand the strain of the sudden change of environment. Recognition of this fact has led to a system of after-care of this class of patients, which has given excellent results, and which should become a part of the institutional care of the insane in every state.

In

In this brief paper, I have merely touched on a few phases of this question. stances might be multiplied time and again, and the answer would always be the same. What is the remedy? The answer is, Education. First of all of the physician himself.

We must begin to realize that nervousness" is only a symptom of some underlying pathological condition, often physical it is true, but more often mental, and in either case, usually preventable. The physician must learn to recognize not only physical but mental symptoms in his patients and, having recognized them, it is only a step to the removal of the cause.

Then, the individual himself must be educated, and it is upon the physician that this burden must necessarily fall. Many cases are mere individual problems, which may call for a detailed study of character and a process of re-education along certain lines, while others may assume vast sociologic and economic importance, such as the question of defective children.

Last and most important of all, the public must be educated to realize the fact that it is by the neglect of such problems as child labor, state care of epileptics, etc., that our asylums are filled with insane and our jails with criminals. Much of this might be prevented for many cases have their incipiency in childhood, often under the eyes of the school teacher and the family physician. Finally, it is the physician on whom both the public and individual must depend for the solution of these great problems.

DISCUSSION.

DR. S. GROVER BURNETT: Dr. Bledsoe has called attention to the fundamentals of psychiatric eugenics in the formative epoch. He refutes the old "beautiful diagnosis and bad prognosis" in neurologic and psychiatric work. It is not true today. It was only true in the past for the simple reason that no diagnosis was made until irreparable damage had been done. Any one can make a diagnosis after the condition is fully established.

The inability of the child to adjust itself to its

A

surroundings is emphasized by Dr. Bledsoe. something that is born in that child, a minus developmental compensation, that does not meet the standard of educational requirements, or the environmental requirements of the day. A common teaching training curriculum today is fixed as a standard. This standard is based on the past achievements of strong, healthy children of superior mental endowment. From the highly endowed educational possibility to the inferior grades of educational possibilities all are urged to acquire the mental memories, lifting the same mental loads in the same way to make the same gradings to meet this fixed requirment. Physiologically and psychologically this is an impossibility in the biological frailties. The overstrain and overstress can do violence to the fundamental structures essential to mental acquirements, causing, possibly, a disassociated chemistry of the primitive elements. Accordingly these children fall behind instead of being educated, trained and graded according to their own developmental possibilities. Here it would seem possible for attempted educational refinement to plant the seed of evolutional decay, namely, dementia prècox. Dementia precox belongs to the juvenile epoch. The recognition of its symptoms later is to acknowledge the presence of a terminal pathology resulting from the unseen_initial chemical structural twists which Dr. Bledsoe would have us recognize early and retwist to the normal trend, fortifying the physiological weakness with educated physiological resistance. How many of these children can be saved by instituting an early educational prophylaxis, before an atomic and a chemic and later an anatomic and pathologic retrogression has displaced the primitive upbuilding, developmental process? That question is embodied deep down in Dr. Bledsoe's paper.

Dr. Cotton's demonstration before the recent Psychological Association enlightened us on the present status of the histopathology of the brain cortex in mental disease. He showed the value

and limitations of Nissl's method and the newer and the additional findings by the Charlach R. method, illustrating the heretofore overlooked fatty degeneration of the neuro-fibriles in dementia precox with the gradual change from a functional disturbance to an organic condition. This reminds us first of a functionationally disturbed developmental process to be followed in time, if the disturbance remains uncorrected, by a retrogressive blight of that function with the final terminal pathologic changes.

The essayist correctly accuses us of studying symptoms postponed till an irreparable condition has become fixed; till the gradual change from the functional disturbance to what amounts to a pathologic change has been established. As in the highly sensitized cortex of the child that has a proverbial "worm spasm,' a "teething spasm." This hypersensitization, unabated, initiates an abnormally irritable, therefore, an overly responsive cortex to the ordinary ingoing impulse messages from the exterior. At first the disturbance is functional and the "worm spasm" was the danger signal, heeded or unheeded. The spasm recurring between 5 and 8 years of age is the alarm of a condition, meaning more than a disturbed function. Recurring again between 10 and 15 years of age means the unprotected hypersensitized cell, always irritable, therefore stressed, has developed a changed and fixed molecular and chemic morbidity with a probable neuroglia proliferation around the cell, making the child an epileptic for all time. This does not

President, Frank C. Neff, M. D.

Vice-President, Halsey M. Lyle, M. D.

Censor, C. B. Francisco, M. D. Secretary, Paul V. Woolley, M.D.

STERILITY OF WOMEN.*

H. C. CROWELL, M. D., Kansas City, Mo.

In gynecological practice one of the most common conditions or complaints which the physician meets is sterility. By this statement we would not presume to say that a larger number desire children than do not, for we are disposed to think it the reverse, a larger number being desirous of escaping the burdens of child-bearing, at least for a certain number of years, or until a more convenient time shall arrive, when, in other words, they are ready to give up society and its exactions. During this period of delay often develops the condition which renders them sterile at the time when they become reconciled to bearing children. In general terms, however, it has been claimed that a woman must remain childless three years, exercising no hindrance to pregnancy, before she can be said to be sterile. This period of time, however, is not essential to establish well founded reasons for failure to fecundate. While this condition is so very common, and treatment results in futility and not fertility in such a large per cent of cases, it nevertheless deserves not to be ignored but to be given even greater thought and attention than is customary. It is easy and, I judge the practice, of most men, to turn such cases off with some unmeaning excuse, such practice is is encouraged by the fact that it has always existed and always will, that, occasionally, a woman will come into her own and get pregnant though no treatment has been instituted. In my own experience I have known a case to go sixteen years barren and then be gratified with offspring, when all hope had departed.

While the profession is well agreed upon the almost universal cause resting in some form of gonorrheal infection (70 per cent at least), of these cases, yet it is well known that so many other conditions figure as etiological factors that it may well be considered a result of protean origin, requiring the greatest diagnostic discrimination in order that intelligent conception may be entertained or effective treatment instituted. As we have previously indicated, so intractable to ordinary considera.

tion has this condition seemed, that only a rather general treatment has been employed, and that treatment may be summed up by a dilatation and curettement, with little regard being paid to its real indications, sometimes, however, resulting in apparent benefit as we have seen in some even who have simply waited.

We would not assume that in some cases the proper treatment may not be to curette, but we would take occasion to emphasize the fact that curettement not infrequently may be the beginning of trouble that makes apparent sterility positive. The curette is not the innocent instrument it is held to be. The work done by it, intrauterine, is so imperfect and uncertain, that resulting infection, quite enough, we are sure, may result to travel out through the tubes interfering with the delicate fimbriae and causing a closure of the distal end, precluding the entrance of the ovum into the tube, or in adhesions that distort and defeat. Moreover it has been demonstrated that a thorough curettement with a sharp curette may so thoroughly remove the endometrium that it is regenerated in but an embryonic form not well calculated to fix the fecundating ovum. We must, then, in the inception, expect for physiological results to obtain, that the communication from vulva to ovary must be untrammelled by disease or mechanical interference. Gonorrhea, as we have said, is the most common cause of conditions deleterious, if not absolutely abrogating all possibility of pregnancy.

Among the resulting conditions that might be mentioned in passing are perioophoritis, oftentimes symptomless and yet effective, resulting from a mild form of peritonitis following a so-called latent gonorrhea. Such cases may fully recover by expectant treatment, if very mild. True, the minuteness of the Fallopian tube and the downward movement of the ciliary epithelium serve, in a measure, to safeguard the entrance of gonococci; nevertheless, they do find their way to the pelvic cavity and set up inflammations of the fimbriated end of the tube and the ovary. It is quite common to find this, class of cases to have had but one child, if any. In such cases it is often possible to elicit the history