PSYCHIATRY.

BY WILLIAM M. EDWARDS, M. D., KALAMAZOO, MICHIGAN.

MEDICAL SUPERINTENDENT OF THE MICHIGAN ASYLUM FOR THE INSANE.

THE INCREASE AND PREVENTION OF INSANITY. DOCTOR G. ALDER BLUMER, in the Presidential address to the American Medico-Psychological Association at Washington, District of Columbia, 1903 (American Journal of Insanity, July, 1903), discusses interestingly among others the subjects of the increase and prevention of insanity. He says that a study of Sanborn's figures no ionger leaves it doubtful that the insane are increasing in New England beyond the natural increase of population. In Maine at a conservative estimate the annual increase of insane persons is at the rate of two per cent a year while the total population has not shown a gain of twelve per cent in thirty years. He concludes that in the entire population of New England there is one insane person in every three hundred seven inhabitants. Census enumeration, whether of federal or state direction, is notoriously untrustworthy in this matter of the insane, otherwise the proof of disproportionate increase or a decrease might be established beyond peradventure.

He further says that the fact that in New England and New York the ratio of insane to the general population is as one to three hundred is sufficiently impressive to raise the query whether we are doing all in our power to prevent its occurrence and for himself unhesitatingly answers in the negative. He believes the prevention of insanity lies most largely in curtailing the production of insane persons and is encouraged that the principle that prevention is the chief end of all medicine is gaining ground among the laity in its application to the subject of insanity and marriage. Many otherwise reasonable people imagine that there is initiated some mystic process, phychic or physical, that makes for sanity when marriage of whatsoever sort is consummated and it is a common enough delusion that if insanity develops after marriage child bearing will cure the psychosis. Men and women do not realize how much insanity is multiplied in the land by natural increase by birth. He quotes Wilcox that heredity and drink are the two overwhelmingly important causes of insanity and says the tendency in degenerate families is to rear a larger number of children than in those of average intelligence. It appears that while nature tends to check increase in the case of gross bodily infirmity, it is otherwise where only the higher faculties are involved in the degenerative process. And in these days when presidents of republics and universities an emperors are exhorting to marriage and singing paens to frequentative maternity, it is well that they ponder these things.

Doctor Blumer thinks that the prevention of marriage and the production of offspring by legal prohibition in persons with distinct family history of insanity or alcoholism will do most to prevent the increase

of insanity. In commenting upon Doctor Wilcox's advocacy of the prohibition of such marriages, the permanent detention of persons after 2 third admission to an asylum and the granting of divorce from the unfortunate victims of incurable insanity or continued drunkenness, he says that harsh as such measures may seem to some and shocking as they may be to the religious sentiment of others, it is well for all of us to reflect that the making a human life is as serious a matter as the taking one. He refers to recent enactment of a Connecticut statute forbidding marriage between known defectives under heavy penalties and the introduction of similar bills in the legislatures of other states. If such bills fail to pass because public opinion may not yet be ripe for them, they at least serve the useful purpose when introduced of calling attention to the evils with which it is their purpose to deal.

NEUROLOGY.

BY DAVID INGLIS, M. D., DETROIT, MICHIGAN.

PROFESSOR OF NERVOUS AND MENTAL DIseases in THE DETROIT COLLEGE OF MEDICINE,

IMMEDIATE SUTURE OF INJURED NERVES.

THIS is a subject which naturally interests every general practician and surgeon. Judging by the number of cases treated at neurologic clinics, its importance is often overlooked.

A break of continuity, in bone or blood-vessel, so obviously demands attention that it is practically never overlooked. The same injury sometimes causes either an immediate break or, more often, a bruising of the nerves, at the site of injury, but the injury to the nerve does not compel immediate attention as does a fracture or hemorrhage. Again, crushing injuries which do not cause either fracture or hemorrhage, often injure nerves seriously; the same is true of lacerated wounds. All of these injuries often show their ill effect some time after the injury, for it very generally happens that enough fibres remain uninjured, so that the defect which follows, is not a total paralysis of either motion or sensation; hence has originated the unfortunate practice of waiting for time to cure the damage when close observation would show that degeneration of the injured nerve is steadily progressing. Even in incised wounds of nerves there seems to be a reluctance, on the part of some physicians, to proceed to immediate suture, yet the indications all are in favor of the most prompt action. In cleaning up a lacerated wound, involving any considerable nerve, it would seem even more important to suture the nerve than to secure union of less important structures, such as muscle substance.

There is much reason to believe that bad lacerations, caused by dog. bites, would not lead to severe reflex neuroses, were careful examination of the wound and immediate suture of injured nerves more commonly done. It is not sufficient, in such case, to simply secure disinfection. It is not solely a question of possible hydrophobia. In view of these facts

the discussion of the subject at a recent meeting of the New York Neurological Society (Journal of Nervous and Mental Disease) is of value:

Doctor Russel A. Hibbs presented a boy of fifteen years who had come to the Orthopedic Hospital on October 6, 1902, with a history of having fallen upon a knife seven weeks previously and injured the leg. On October 9 he was operated upon, and on exposing the site of the injury, it was found that the popliteal nerve had been divided. It was accordingly sutured, with a practically perfect result. While the voluntary power in the muscles supplied by this nerve was lost, there was still some sensation, which was apparently accounted for by the fact that a few fibers of the nerve remained intact. The limb was kept slightly flexed for six weeks after the operation.

Doctor M. Allen Starr thought surgeons as a rule did not recognize the great importance of suturing nerves at the time of such injuries, for it was not uncommon for persons so afflicted to seek relief a considerable time after the injury. There could be no question that a divided nerve would not unite spontaneously in the majority of cases, and it was equally certain that by nerve suture a good result was usually secured. He had seen one or two interesting cases in which nerve suture had been essayed in children in whom the brachial plexus had been injured at birth. Four successful cases of this kind had been recently reported. The operation consisted in laying bare the brachial plexus, finding what nerves were torn, and uniting them.

Doctor William M. Leszynsky said that in injuries of the hand special care should be taken to determine whether or not the nerves had been injured. He had recently seen a case in which the divided tendon had been sutured and the divided ulnar nerve had been entirely overAs a result, a neuritis of this nerve had developed before he saw the case. Although rather late, an operation had been advised in the belief that even late operations were often successful.

Doctor Fisher said that he had had under observation for some time

a facial paralysis that dated from childhood, the patient being a woman of thirty. After a while a faradic response from the facial muscles was obtained; hence he thought one could hardly place a time limit after which nerve suture would afford but little prospect of benefit.

Doctor Hibbs said that in his case the original wound had been treated at a hospital, but the nerve injury had not been noticed.

THERAPEUTICS.

BY DELOS LEONARD PARKER, PH. B., M. D., DETROIT, MICHIGAN.

LECTURER ON MATERIA MEDICA IN THE DETROIT COLLEGE OF MEDICINE.

SUMMER COMPLAINTS OF CHILDREN.

SAMUEL A. VISANSKA, M. D. (Therapeutic Gazette, July, 1903) considers summer complaints of children under the three heads, gastroenteritis, enterocolitis, and colitis. Of the causes that produce these conditions he eliminates the one commonly considered by the laity as

the most frequent and effective of all, namely, teething. He says: "To my mind teething has absolutely nothing to do with diarrhea, and every modern text-book on pediatrics will agree with me." He calls attention to the fact that children teethe in winter, and asks how many cases of winter diarrhea the physician is called upon to treat.

As true causes of summer complaint he mentions heat, low power of resistance, bad ventilation, overcrowding, improper diet, too much diet.

He further says: "All cases of enterocolitis are not true cholera infantum, and Rotch has placed this disease (cholera infantum) where it belongs, under specific infectious diseases caused by a specific organism and characterized by acute gastroenteric disturbance with intense choleriform symptoms." Cholera infantum is a rare disease and care should be taken not to confuse it with other conditions presenting similar symptoms.

In the treatment of gastroenteritis four things are demanded: (1) To assist the effort which nature is making to free the stomach and intestine from the poison which is in them; (2) to restore the surface circulation; (3) to supply water to the tissues; (4) to support the strength until the disease has run its course.

Under all circumstances milk, whether from mother, wet-nurse or bottle, should be interdicted. In carrying out the treatment outlined above, the stomach should be washed out with warm normal saline solution and then three to five grains of calomel placed on the tongue. If vomiting continues the irrigation should be repeated. Next the bowels should be irrigated with warm water and Castile soap, to be followed by an injection of cool water containing tannic acid, thirty grains to the pint. The child should be allowed to suck from a bottle sterilized icecold water containing a few drops of brandy. If vomiting and diarrhea continues, morphin and atropin should be given in doses of one onehundredth grain of the former and one eight-hundredth grain of the atter for child one year old.

For signs of collapse hot pack should be employed. For weakness of heart minute doses of strychnin, digitalis and nitroglycerin may be indicated. When the condition of the child begins to improve, a little sterile food should be given. The child should be kept outdoors as much as possible.

In enterocolitis the above treatment should be reinforced by rectal injections containing a few minims of laudanum.

In colitis the tenesmus and bloody stools are best treated by regulation of the diet and the following given by the stomach.

This to be followed by bismuth given freely. When possible change

of air should be secured.

DIABETES AND A DIET CONTAINING POTATOES.

THE Journal de Médecine et de Chirurgie Pratiques, September 10, 1903, in a leading article, reviews a publication of Doctor Mossé of Toulouse, on the subject mentioned above.

In a previous work Doctor Mossé had advanced the idea that potato is an aliment not only permissible but even useful in diabetes, and one capable of being substituted for bread in sufficient proportion to maintain the proper standard of alimentary ration; that is to say in the ratio of two and one-half to three of potatoes, weighed before cooking, to one of bread.

In his latest work Doctor Mossé has declared that the substitution was well supported in almost all the cases in which it was made, notwithstanding the generally accepted ideas in opposition to the use of feculents by diabetics.

The daily ration of potatoes prescribed in place of bread was from one to one and a half kilograms (two to three pounds). This diet was followed by a rapid diminution of the thirst, and the glycosuria, and an improvement in the patient's general condition. These good results were secured in gouty patients, presenting the disease in light, medium and severe forms, as well as in others suffering from a nervous cr undetermined form of diabetes. In all cases in which it occurred. return to a bread diet destroyed the improvement that had been gained.

Doctor Mossé explains the beneficial effects of potato-containing diet in diabetes by saying that water is six times more abundant in potatoes than in bread, a fact that accounts in some measure for the diminution of thirst, and sensation of dryness in the mouth. Also that by the carbonate of potassium, which develops in the system when potatoes are ingested, the acid dyscrasia is lessened, and on this account the cells of the body are placed in an improved physiologic condition. This, he thinks, facilitates the manifestations of vital cellular activity with an increase of glycolytic energy.

Doctor Mossé insists that the regime he recommends is not a treatment of the disease itself. It simply prevents or lessens the disturbances dependent on morbid supply of sugar in the blood; but it docs not cure the disturbed nutrition which characterizes the diabetic; it lessens the effects by diminishing in an indirect manner the acid dyscrasia of the blood and other fluids of the body; it is, in a word, only a treatment of the syndrome.

The best results from the treatment were met with in so-called arthritic subjects. In other forms of the disease, however, good was accomplished.

In whatever form of the disease the remedy is used it is necessary to watch closely the effect on the organism. Frequent and regular examinations of the urine are called for here. As to the amount of potato to be given it is best to increase the quantity gradually from a small initial dose and let the effect decide this point.