(b) Spare all periosteum possible. (c) Avoid curet, or use cautiously. (d) Purify the wound by the strictest antiseptic methods. After treatment: (a) Maintain aseptic conditions. (b) Avoid too frequent and rough dressings. (c) Treat as a fracture, by immobilisation in a fracturebox. (d) Carefully shape the parts, as bone tissue develops, by bandages or adhesive straps. (e) Protect the young bone by means of plaster-of-Paris. (f) Abstain from use of the limb until the new bone is capable of sustaining the weight of the body. (g) Look after general health. 407 EAST GRACE STREET. R Toxemia and Infections as Causes of Insanity.' BY FRANK STEPHENSON, M. D., Syracuse, N. Y. EGARDING the etiology of insanity, it is of comparatively recent date that particular attention has been directed toward the effect upon the brain of toxins developed by fermentation and putrefaction in the gastrointestinal tract,-faulty metabolism, and from the poisons in the blood developing from acute infections. According to Peterson "these toxin producing bacteria may be the chief agents whose influence acts upon the cortical cells and nerve fibers of the brain." It is not strange that the blood charged with these toxins should carry agents to the brain, which cause a disturbance of its functions, as we know the blood is the source of all the brain's nutrition and the channel for exit of its waste material. In brain disorders, even without any history having been given of disturbed digestion, on investigation we find evidences of extensive digestive and fermentative changes shown by urinary analysis; that is, diminished or increased specific gravity, abnormal color, a lack of proper ratio between the specific gravity and the amount of urea eliminated; the presence of indican, zanthins, urates, phosphates, oxalates, and other products. Wagner, in the Klinische Wochenschrift, February, 1903, reports several mental cases in which indican and acetonuria were in excess, and that some of these cases, characterised by severe depression left 1. Read at the 37th annual meeting of the Medical Association of Central New York, held at Rochester, N. Y., September 20, 1904. his clinic cured after three days of thorough eliminative and antifermentative treatment. The correction of these errors is also the first step in producing sleep, and in quieting the various nervous and mental manifestations in both borderline and classified insanities. We also prepare the system for making more and better blood, thus controlling not only the toxemia but the anemia. which is sure to develop and be a stubborn factor in all of these patients. F. Mott (London Lancet, Avgust, 1901,) says, "the new neurology does not involve merely an acceptance of the neuron theory, but a recognition of the fact that every cell possesses a biochemical sensitiveness to its lymph environment, termed chemotaxis; the alteration of the environment causing, in many cases, the presence of some form of poison." And the essential cause of a class of diseases of the nervous system, which includes functional disorders and primary degenerations, is the failure of the neuron to carry on the processes of assimilation and dissimilation, which are essential for the well-being of every cell." We believe, also, that poisons circulating in the blood act as contributory, predisposing or exciting causes, in persons with a neuropathic or psychopathic heredity, and in persons who have subjected their nervous systems to excessive functional activity. Toxins may either be introduced into the body from without or they may be produced within,-exogenetic or endogenetic. In either case, however, it is the toxic state of the blood or lymph which causes the morbid nervous phenomena, but the symptoms which arise depend upon conditions of either increased excitability or depressed excitability of the nervous elements which are selected by the poison. Franz Glenard (Le Progrés Medical, March, 1902,) says, "there is undoubtedly an enteroptosic neurosis, a hepatic neurasthenia and a hepatic agoraphobia which require for treatment regulation of the diet, and laxatives, instead of bromides, hydrotherapy and tonics. In every neurosis or psychosis the digestive apparatus should be explored, including the liver, intestine, stomach, kidney and spleen, as to their size, consistency, sensitiveness, location, relation and degree of fixity." Macpherson, at the Stirling insane asylum, says he submits all such patients to lavage of the stomach, laxatives, intestinal antisepsis and strict diet. He reports the case of a young man of sedentary habits, who was attacked with neurasthenic anxiety and digestive cachexia with vomiting, and was so ill it was feared he would die. He recognised nobody and talked as if insane, but after purgation and. vomiting excessively he became rational, slept well, and the next. morning was in his usual health. All of my acute or incipient cases of mental disease, I have treated along these lines for some years. Many of these patients are able to come to the office where lavage can be given, and taught them or members of the family if a nurse is not in charge. Frequent prolonged hot baths act as a most excellent sedative and favor climination, which is so beneficial to these patients. I insist upon their drinking eight glasses of water daily, hot or cold. and insist upon their taking much exercise in the open air if strong enough to do so, and if the urinary analysis, blood tests, general symptoms and condition seem to require it, I place many upon the following prescriptions: Tan albumen in 15 gr. doses after meals. These arrest fermentation and overcome putrefactive changes. Dilute hydrochloric or phosphoric acid also produces good results in some of these cases, but the following seem to me the most satisfactory: The diet must be regulated, and I usually eliminate potatoes, as the starch in potatoes oxidises so rapidly, and use rice or macaroni instead. An excellent daily diet is: Two eggs, one-half to one pound of meat, one quart of milk, seven ounces of bread. Let me illustrate by a case or two. Case I.-Mr. L. G., aged 52, German; occupation, engineer: family history negative. For the past ten years, at irregular intervals, he has had attacks of depression preceded by loss of appetite, indigestion, constipation, diminished elimination of urine, coated tongue, foul breath and vertigo, and later insomnia; also irritability, so pronounced that his family could hardly endure his presence in the home, these very severe attacks of depression were accompanied by weeping. He lost from 20 to 30 pounds of flesh; felt cold and weak. The temperature averaged 98°, pulse, 58; urine scanty, deep colored and 1030 specific gravity. Urea, 1⁄2 per cent.; indican, marked. Uric acid crystals and calcium oxalates in great number. This is the usual history of his attacks with some slight variation in symptom. The treatment given him is already outlined elsewhere in this paper, and has restored the patient to normal health when suffering from his various. relapses. Case II.-W. W. C., aged 11. Family history, negative; had passed through some of the diseases of childhood without sequelæ. He was brought to me with the following history: great fear at night and if left alone during the day; marked irritability and depression; over sensitive and felt that none of his family loved him; cried frequently and was greatly depressed. He was discovered walking toward an incoming train on the railroad track, and in explanation said he "was going to let the train kill him, he felt so badly." This undoubtedly was a case of melancholia induced by toxemia. I found on inquiry and examination, a quick pulse, heavily coated tongue, fetid breath, choreic manifestation of the facial muscles, throat and nose; constipation, and the urine loaded with the uric acid; indican, oxalates, high specific gravity and low urea; no albumin or sugar. Purgatives, eliminatives, digestives and antifermentatives with frequent baths, controlled this attack in a few weeks, and in over four years there has been no return, as his diet and habits are carefully observed by his family. Many of these cases are of a few days duration and easily controlled, but where we have chronic toxemia from faulty elimination and digestion, the condition is often most trying. We recall the irritating influences in the nervous system of carbonic acid gas, uremia, and diabetes, and many mental disturbances are reported, giving these influences as their probable exciting causes. Among the toxic insanities we also include alcoholism, which, by the way, is the most frequently met with by a large per cent. ; also morphinism, cocainism, metal poisoning, and occasionally he suffers from excessive cigarette smoking. Savage says, "Alcohol acts directly upon the brain as a poison; it acts indirectly upon the brain by impairing nutrition and interfering with the depuration of the blood." We have observed that large single doses of stimulants may act almost like a shock and render the person taking them powerless, or in some cases suddenly maniacal. In chronic drinkers the whole nutrition of the body suffers. There is a progressive loss of mental power which resembles in many particulars progressive paralysis of the insane. Repeated attacks of delirium tremens shock the nervous system severely, often developing acute mania or dementia. The detrimental influence of alcohol is greatly increased, if there be strong neurotic inheritance. The pathological changes in subjects addicted to alcohol, according to Gowers, may be looked upon as hardening or sclerosis of the nerve tissues, so that conduction of impressions is retarded and the impressions themselves are imperfectly received and slowly organised. Statistics give chronic alcoholism as the most frequent cause of criminal insanity, and it is a factor producing great aggravation of the symptoms or manifestations observed in the various insanities, either functional or organic. Polyneuritis, tremors, epilepsy, and hysterical manifestations are. often observed with or preceding alcoholic insanity. The prognosis in acute alcoholic insanity is good, except that we usually have a neuropathic basis which accounts for the frequent relapses. Plumbism and other metal and drug poisonings, producing nervous and mental disturbances, are observed and written of at some length. Those of the first class, plumbism, present a great deal of motor disturbance; the drop wrist, incoördination, painful neuritis and cachexia, with mental changes, suggesting paretic dementia. It is stated that the irritation and degeneration of the cell fibers, arteriosclerosis and gliosis of syphilis, may be due to toxins created by specific microorganisms. Of the acute infectious diseases, causing or preceding mental disease or psychoses, la grippe, typhoid fever, malaria, pneumonia, acute rheumatism, and neuritis doubtless head the list. In private practice, and in all of our large institutions for the insane, we very frequently find la grippe given as the first cause of insanity. Mental symptoms often develop acutely with general grippe symptoms; again the mental disturbance may be delayed for weeks and develop apparently from a condition of chronic toxemia infection or exhaustion. In other cases I have seen, the mental collapse had been preceded by grippe, and then rheumatism or pneumonia. These are trying cases of long duration and fill one with anxiety. Some such cases under my care have had apparently normal intervals, but on recovery the entire period seems to be a blank or filled with confusion, delusions and morbid fears. Their minds often remain weak for a long period after all mental distress has disappeared; they are easily fatigued, weep and have a tendency to sleep a great deal, showing but slow recovery from their exhaustion and autointoxication. Recently a case of cervico-brachial neuritis with most persistent mental derangement and accompanied by general inflammatory rheumatism came under my care; the mental symptoms continuing for weeks after all fever and pain had ceased. I am surprised at finding so little written on the subject in medical books and journals, for the condition is quite frequently met with and has been a source of great anxiety to many physicians who feared the mental disturbance would become a chronic condition. The term, post febrile insanity is given to disorders which complicate the crisis or convalescent period of acute fevers, |