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as malarial, scarlet, and typhoid fever. Illusions, hallucinations, delusions of identity and great anxiety are the early mental manifestations. Pleasurable delusions or ideas of grandeur often develop. Most of these cases recover rapidly, continuing rarely inore than a few weeks. In some cases, however, a more chronic course is observed, and there is a markeď stupidity and confusion of ideas throughout the illness. Malarial fever is sometimes accompanied by mental disturbances with lucid intervals corresponding to the period between the attacks.

Case III.—Mrs. B. came under my care a few months ago, during her convalescence from typhoid fever. I was told the fever had been of four weeks' duration and she was making a good recovery, when she developed delusions and illusions. At times they were terrifying in character; again she was abnormally gay and happy. Insomnia was a very obstinate symptom. The disturbed periods continued only for four weeks, and in three months recovery was practically complete, except that her memory was weakened, but this was ultimately restored to normal strength.

Several cases of shorter duration have come under my observation, complicating or following measles and pneumonia, when the mental disturbance was less trying, resembling a condition of melancholy and weak-mindedness, or slight excitement, the chief anxiety with the family being that the patient might drift into dementia or chronic insanity. Whether engaged in general practice or doing the work of an alienist and neurologist, we are all constantly meeting this line of cases and it is well to have the ideas presented here in mind, thus making our diagnosis and plans for action clearer, and perhaps saving many patients from drifting into chronic organic mental diseases; also, preventing patients from being committed to institutions for the insane, when a few weeks of skilful patient treatment at home, or in a general hospital, might restore them physically and mentally to normal health.

BIBLIOGRAPHY.

Wagner, February, 1903, Klinische Wochenschrift.
F. Mott, from London Lancet, 1901.
Macpherson, London Lancet, nervous diseases.
Franz Glenard, Le Progres Medical, March, 1902.
Savage, On insanity.
Gowers, Nervous diseases.
Peterson: Peterson & Church, Nervous and mental diseases.

429-431 UNIVERSITY BLOCK.

DISCUSSION. Dr. E. H. HOWARD, Rochester: Permit me to utter a word relative to this very interesting and important paper, merely to accentuate its importance. At a recent meeting of the American Association of Superintendents of Hospitals for the care of the insane a whole day was given up to the consideration of the first portion of this paper-namely, toxins as causative factors in insanity. We were edified and instructed by a series of papers from various parts of the United States and Canada, widely separated sections, where studies and efforts were made in this relation, and were told a great deal about test meals, the effect of hydrochloric acid on the stomach, and of a group of cases where there was an excess of this element. A great deal of time was taken by the physiologists and students in the chemical laboratories in the hospitals, in trying to understand these cases.

Dr. Hill, of Baltimore, in discussion, said: "A general practitioner hasn't time for all this test meal business. hasn't the apparatus or the inclination, and I find I get on well by a little experimentation. When a patient comes into my office with these mental symptoms, I look upon it as probably a case of this character, and prescribe bicarbonate of soda, directing him to come back in three days. If the patient is not better, showing a marked degree of improvement, then I prescribe hydrochloric acid and find the cause of the trouble." Dr. Hill even made a little sport of the doctors who exploited their laboratory work with the test meals.

As to that portion of the paper, it is very well, indeed, to be reminded that we must be alert to this possibility, because it must make a difference sometimes in the care of the infectious disease. I wish to express my appreciation of the excellent paper, and incidentally, without attempting to discuss the president's address, I may add that his remarks about disinclination to send patients to hospitals for the insane meets the hearty approval of the hospital superintendents. It is a great surprise to many of us that so many patients are sent so hastily to hospitals for the insane.

Dr. F. S. CREGO, Buffalo: I desire to add a word concerning the advisability of keeping these patients at home. I am a strong advocate of keeping patients with mental disease at home, and also I think the profession at large should learn something about insanity. In my course of lectures at the University of Buffalo every year I try to teach the students a few preliminary and primary ideas of insanity, but, as a rule, they do not like to attend lectures on this subject.

We have had struggles with almost every class to get them to attend, and now we put a few questions into the examination papers with the object of compelling attendance, but they seem to learn but very little. They do not study the subject enough to judge of a case, and yet they will sign a paper of commitment. not for the actual money but for the relief, as they suppose, of the patient. I am of the opinion that 50 per cent. of the patients sent to the state hospitals are cases that should not go there. Indeed, if the truth were really known, there is a large number of patients sent to state hospitals every year that are not insane, but are cases of typhoid or toxemic delirium.

Not long ago I was called to testify in the southern part of the state in a murder trial, in the course of which one of my students testified on the other side. When asked what his experience was, he said he had heard Professor Crego's lectures and also been to New York. He said he knew all I knew and all the New York men knew. After he left the witness box I asked him how many of my lectures he attended, happening to remember he was marked for not attending. He attended two lectures and I think one clinic which comprised his instruction on the subject of his testimony.

Dr. R. G. Cook, Rochester: The president's address and Dr. Stephenson's paper both emphasise the need of a pavilion for the care of mental and nervous cases. We have been working for one in Rochester a good while, thus far without success, but we must not despair. Dr. Stephenson's paper is interesting, instructive, and valuable, and in only one point would I disagree with him—namely, in regard to the recognition of toxins in recent years. We are apt to think that it is only the modern writers that have recognised these conditions. Now, as a matter of fact, in the old days when physicians believed in humeral pathology, they described clinical conditions, which correspond exactly to some conditions which we recognise now; one, for instance, is lithemia. Recently in looking over a book on insanity written by Dr. Pritchard, in 1835, I discovered that he gave an exact description of the lithemic condition as one of the exciting causes of insanity, and the treatment was not very different from that which we now use.

Another point about the care of these cases to be borne in mind is in regard to prognosis. These patients recover from their individual attacks, but a person that becomes delirious or sinks into a condition of stupor from a comparatively mild toxemia, is one who is always in danger of becoming insane from very slight exciting causes. This was strongly emphasised in a case I happened to meet in my college days. A young man who was either very moody or very jolly, one or two glasses of beer or ale would make one of the merriest persons in college. We did 110t think there was anything the, matter with him at the time, but he has spent over half the time since graduation in a hospital for the insane. This goes to show that individuals who show mental symptoms from a mild toxemia must be watched carefully when under our general care for mental. symptoms on very slight exciting cause.

Dr. B. C. LOVELAND, Syracuse: In the first place, under the question of toxemia which causes mental disturbances, permit me to say there are two certain classes. In one class will be included those of intestinal origin; in the other class are cases which result from infectious fevers and the like. Another point is that in the mind of the general practitioner the idea of insanity as a disease has not taken hold. It is mysterious, it is beyond the conception of those who look for a real pathology or causation, hence it is impossible for a large number of physicians to grasp the truth in regard to mental observations.

It has been impossible, due to the lack of facilities, for the average practitioner and particularly for the student in many of our smaller colleges, to have an opportunity of studying the course of mental disease. The keeping of patients at home has been advocated today, which is a very valuable way of affording an opportunity to study the course of the disease. I believe it is desirable to keep patients who are not dangerous to themselves or others, or who can be well handled, at home as long as possible, giving them the best treatment that can be administered there, with the hope and expectation that it will be more efficacious than treatment at hospitals. The necessity, already referred to, for a detention ward or pavilion in every city of considerable size, should receive the serious consideration of every medical man. When such are established the profession can get such a knowledge of these cases as will be of use to it.

Dr. J. HENRY Dowd, Buffalo: I was interested in Dr. Stephenson's paper, for one reason among others, that we do not know the day when these patients may reach the dangerous stage described. What I would like to know is, how can we tell just before they reach the turning point? In my work on the urethra and bladder, I have mentioned that it is as important to test for indican in the urine as for albumin, and I will say now, it is a good deal more important to test for indicanuria. A young woman was sent to my office to have an examination of the urine made, the diagnosis being optic neuritis. The examination was made especially for albumin, but there was none, though I found indicanuria. She had no symptoms of indicanuria or intestinal fermentation. She was put upon salicylate of soda in large doses. Another patient was a young woman, married about three years, but had never been pregnant. Her husband asked me to examine her urine, and upon doing so I found marked indicanuria. I administered salicylate of soda and nux vomica. The husband consulted me in about three weeks, saying his wife did not menstruate. I asked him to bring a specimen of urine in about three weeks more, which he did, and after an analysis of it I pronounced her pregnant. She was confined about eight months afterward. Both patients presented mental disturbance.

Dr. W. J. HERRIMAN, Rochester: I have been very much interested in what has been said on this subject, and I wish particularly to emphasise Dr. Crego's remarks about the general practitioner's need of more knowledge on the subject of insanity, but, also, I think it is time for a word of warning lest errors be made in keeping dangerous patients at home. Dr. Crego tells us that 50 per cent of the cases sent to state hospitals should not be sent there; while Dr. Howard tells us the superintendents of the state hospitals are surprised at the number of patients who are sent to those institutions that might have been kept at home. I agree fully with these gentlemen, that when a case is known (if it is possible to know such a thing) to be harmless to himself or to others, and there is a fair prospect that such a patient may be treated successfully at home, the case should be treated at home by all means; but I do believe that if more cases of a dangerous nature were sent to a hospital for care promptly, a great many lives, especially of women and children, would be saved that are sacrificed to the delusions of an insane person. How frequently we read in the newspapers of a woman who has killed her children, and, perhaps, herself; that for some time she has been acting strangely, and was supposed to be deranged but harmless. That woman should have been isolated in a proper hospital. She was not a case for calomel and hydrochloric acid. Such are cases for restraint, and I drop this little word of caution: don't wait too long with the cases of a suicidal or homicidal tendency, or they may commit crimes.

Dr. E. B. POTTER, Rochester: I agree with Dr. Herriman in what he just said, and I am of the opinion that the general practitioner is apt to err on the wrong side in sending cases to the hospital. Dr. Howard and myself have worked together for twenty years, and we have always been careful with our statistics. I know of but two or three cases having been sent to us in that time which were not insane, easily demonstrable as such, and they were cases that were benefited by coming to us. The idea of a detention hospital is growing. We are working toward it steadily. It is proof that we are working toward it that so much time is spent in this meeting this morning discussing this topic. A few years ago the subject of insanity would not have taken up much time. This morning it has been interestingly discussed, which shows that Dr. Crego's lectures are doing good, and all centers of learning are now adding to their courses something on this topic, which is growing in importance. I know that the idea that insanity is a disease and not devilishness is becoming understood in the profession and by the people, showing that they are being educated on this subject. Half of the people who come to us now know that they are brought to the hospital for treatment. They come to us for treatment as they would for a broken leg or a tumor. They come because they are sick and need treatment.

A member!: There is one advantage in the hospital treatment which is superior to treatment in the home; that is the

1. This visitor was unknown to the chair and was not announced when he discussed the paper.-C.A, G., Secretary.

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