the technique of the operation, the treatment and results:

Irene M. of Baxter, Kansas, aged 11 years, visited me May 12, 1903, on account of a chronic dacryo-cystitis with the deformity of a saddle-back nose as is represented by side and front views. in photographs. The history as obtained from the father and by the family physicain, Dr. Vermillion, who accompanied her, was as follows:

"When a little girl of 6 years she was kicked by a horse in a runaway which caused the sunken broad flat nose. For some years pieces of dead bone escaped from the nose and ever since the injury the tears on both sides overflowed the cheeks. Of late, matter would escape from the inner corners of the eyes."

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Examination showed not only chronic dacryo-cystitis, but displaced and atrophied turbinates with partial destruction of the vomer with the depressed bridge of the nose as pictures I and II represent. I found some difficulty in passing the probe from the lachrymal sac into the nasal duct, as the latter was not only displaced and changed in its course, but partially occluded by the warped and displaced septum and turbinate. In this distorted condition it was very difficult to maintain a free drainage. To overcome these difficulties I crushed the vomer up in place and held it there by perforated hard rubber splints, one in each nostril and then to lift the saddle of the nose and straighten the lumen I resorted to paraffin injection. In making the injection, as is my custom, after rendering the parts thoroughly aseptic and with surgically clean hands and apparel, I first filled the syringe two-thirds full of paraffin and then the needle with hot water. I inserted the needle under the skin a little back of the tip of the nose, urged it along within the areolar tissue of the median line of the dorsum to within a quarter of an inch of the root of the nose, taking care not to go into the parenchyma, yet to keep entirely below the cutis vera and then I withdrew slightly the needle before injecting, so

was re

as to avoid invading any blood vessel, instructing my assistant to grasp the nose with both index fingers and make firm pressure so as to confine the injection to the dorsum or bridge of the nose. Then with a few turns of the screw, at the same time withdrawing the needle slightly, I injected about one drachm. As soon as I saw the nose begin to turn white and especially as the saddle stored to the desired height I stopped and removed the needle, I then placed collodion over the place of puncture and immediately applied ice cold plegets on either side of the nose, this to hasten the hardening of the mass. There was som hyper-redness which lasted for a few weeks, but then gradually passed away, Had this redness perisisted I should have resorted, as has been recommended by Dr. Mayo and others, to the X-ray treatment, which is said to distend the small blood vessels by hyperplasia of the connective tissues and so 're-establish normal circulation. The photos show the result as seen from profile and front view of the girl's face one week subsequent to the operation. Since the operation the epiphora and dacryo-cystitis have entirely subsided.

At

What Becomes of the Paraffin?—If the mass is of a melting temperature of 130F. or more, it becomes encysted, being too hard to admit of penetration, but if it is at a melting point of a lower degree, say 111F., it is then soft enough to admit of penetration and finally it is incorporated into the tissues. first it is invaded by leucocytes, which later on form lacunae and canaliculae a rudimentary lymphatic circulation and still later the whole mass is incorporated and finally replaced by animal tissue. Paraffin at first acts as a scaffolding, skeleton or framework for the building up of normal tissue. Later on, as has been demonstrated by microscopical examinations at different periods of time subsequent to injections, it is replaced by animal tissue. A process goes on similar to a petrifaction, particles of normal con

nective tissue taking the place of the paraffin. Therefore, I would not look for much, if any, contraction and shrinkage as we get in cicatrical tissues, the building up being more in the nature of a neoplasm similar to petrifaction.

Among the best articles I have read on the subject of paraffin injections are those of Dr. J. T. Campbell of Chicago, Harman Smith of New York and Gregory Cornell of Leadville, Col., from which I have taken some of the data of this article.

*WHAT SHALL BE DONE WITH THE
CRIMINAL INSANE?

JOHN PUNTON, M. D., Kansas City, Mo. Member American Psychological Association, American Neurological Association, Etc. What shall be done with the criminal insane is a problem that transcends in interest, importance and complexity all other medico-legal problems of the present period. Notwithstanding its practical significance and far-reaching influence to the welfare of the community, State and Nation, very little is being done by either the professions of law or medicine to arrive at a satisfactory solution of the question at issue.

Even today, with all the wealth of evidence to the contrary, the majesty of law declares that in a strictly legal sense there is no such thing as an insane criminal, and the lawyer, taking advantage of this technicality, exonerates his insane client from all responsibility of crime. Practical Practical clinical psychiatry, however, and medical experience teach us that insanity and responsibility are not incompatible, and that an individual may not only be insane, but also responsible for his criminal conduct. Hence there exists a serious conflict of authority between law and medicine, which, unfortunately, at the present time is being waged to a remarkable degree, and in which the ablest exponents of these two noble professions are busily engaged, the former pleading that insanity exon

Read before the Mississippi Valley Medical Association at Cincinnati, October 11, 1904. Reprinted from Lancet-Clinic, November 12, 1904.

erates crime, while the latter have ample evidence to prove that very few indeed of the insane are wholly irresponsible for their criminal conduct.

The practical result of these two opposite opinions necessarily favors radical extremes, hence the gulf betwixt them grows wider and more extensive as civilization advances, besides offering a most favorable opportunity for the successful plea of insanity as a defense. for crime and much consequent miscarriage of justice.

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In order that one may fully realize the truth of this assertion, he has simply to acquaint himself with some of the more recent rulings and decisions of the ablest judges of the various courts of this country, as well as England. By So doing he will soon discover that the reputed failure of the medical experts in courts of law are not the only persons subject to censure for their apparent ignorance or unsatisfactory evidence. The lawyers, and even the supreme judes themselves, often fail to agree, and also enjoy honest differences of opinion, quite as many and varied, relative to insanity and its relations to crime, as physicians themselves, while the general public look on in surprise and disgust at the clashing interests of each.

In view, therefore, of the legal and medical misunderstanding which now exists, and the consequent misleading of public sentiment (for it must be remembered that our jurors belong, as a rule, to the laity and are selected irrespective of their knowledge of law or medicine), it would seem eminently fitting if the votaries of these two noble professions could confer with each other in such a manner as to definitely formulate certain practical practical conclusions in keeping with the more correct and advanced state of knowledge regarding insanity and its relation to crime which could be used as a criterion in courts of law to govern its true medico-legal aspects.

That this idea may by some be thought impossible is certain, on the ground that

each case is a law unto itself, and therefore should be judged solely upon its own merits. This, no doubt, in a certain sense is true, but if this is generally accepted as the only logical argument, as it now is, without any specified limitations, it at once leaves the entire field of legal technicality open to invasion, with its consequent endless litigation. Moreover, in its skillful manipulation it often sweeps aside the entire medical aspect of the case, and the fate of the prisoner, even when his guilt is admitted, is sometimes decided solely upon the legal merits, which, as before remarked, is often full of error and grossly unjust.

The numerous legal subterfuges that are now put forward to screen criminals on the plea of insanity has brought much shame and disgrace on both the legal and medical professions, besides being the responsible agent for the great increase of lynching in America.

Every physician whose duty necessarily brings him in contact with the medico-legal complications of insanity fully realizes the great necessity that now exists for practical reforms in our present methods of dealing with the criminal insane.

As preliminary to these needed reforms, the writer has already solicited the co-operation of the members of the American Psychological Association in a communication entitled "Ahe the Insane Responsible for Criminal Conduct?" and read at their recent meeting at St. Louis, Mo. In this they are urged to interest themselves in the formulation of certain definite conclusions relative to the mental responsibility of the insane, as well as to specifically define the mental conditions which ought to exonerate a criminal from punishment.

After a spirited discussion, in which many of the leading American alienists and neurologsts took part, Dr. F. W. Langdon, of Cincinnati, stated he was fully convinced that the subject had not received the attention from the medical profession that it richly deserved, and moved that a committee be appointed

with a view of drafting a set of resolutions embodying the conclusions of the society regarding the relation of insanity to crime, and, upon their adoption, be properly presented to the American legal profession for similar acton. The moton, being put, was carried unanimously and a committee duly appointed, with instructions to report at their next annual meeting. Whether ustified or not, it is my belief that much of the confusion which now prevails relative to medico-legal problems in courts of law are largely due to the apparent indifference manifested by our specialized medical organizations to furnish the general medical profession with definite specific knowledge concerning the problems whch they alone are the only recognized capable exponents. Hence in every community where insanity becomes a plea for crime and the question of the mental responsibility of the accused is referred to the members of the local medical profession, it is very distressing to find the wide difference of opinion that prevails at times between apparently equally competent medical witnesses. If, however, these specialized medical organizations have any function distinctly their own, it would seem to be the right to decide medical questions which strictly pertain to their own specialty. For instance, we find the organization known as the Congress of American Physicians and Surgeons, composed of no less than sixteen distinct specialized societies, each having their own specialized field of work and recognized as the ablest exponents in these respective medical departments in America. It is only logical to assume that any question pertaining to either of these particular specialties could with more propriety be referred to them for judicious advice and wise disposition than to any other class of men. It was the application of this principle, therefore, that led me to select the American Psychological Association, composed as it is of the leading alienists and neurologists of America, as the legitimate organization to appeal for help relatve to the solution of these most