The sister was directed to inform me as to the progress of the treatment, the inmates of the house were recommended to look upon the young girl as in no way an invalid, and the patient was told not to come and see me again for a month, thereby getting additional assurance from my statement that there was no serious trouble with her. In a little over three months she has become quite well, she walks, dances, and seems quite like the other girls in the school.

The second case belongs to a class much more difficult to deal with.

Miss, aged twenty-six, an intelligent, healthylooking, high-school taught Irish American, with a comfortable home in one of the suburbs, where she kept house for her father and sister. She did not know of any mental or nervous disorder or any socalled nervousness in any of the branches of her family. She has been told that at the age of six or seven years she had pleurisy, and when fourteen slow fever. Otherwise she has been quite well and strong, and the picture of physical health. She began to menstruate at the age of fourteen, and has from the beginning suffered from intense dysmenorrhoea. During the previous winter she had been up late and early, and her sisters thought that she had been overworking. She was not herself conscious of any weariness or feeling of effort. Her mind had been quite at rest. She had no anxiety, and had not lost flesh, and she was quite contented with her lot in life. She seemed to me exceptionally fortunate as regards the complicated circumstances combining to affect her general health. Last February she fell, striking her sacrum on the ice. The pain and discomfort from the blow were not great, so that she walked home and did not find it necessary to in any way diminish the labor of her daily life. For three weeks there was decided tenderness when lying on her back, and only slight pain at other times, which then disappeared. She noticed, however, that her daily work wearied her, and so she had walked out less than usual. Four weeks after the accident, in trying to walk a distance to which she had formerly been accustomed, she remarked a dull ache through the right thigh with decided weakness, and finally difficulty in walking. This symptom remained without abatement until August, when attempting to walk, the weakness of the leg rather increasing than diminishing, so that she then went to the sea-shore for a fortnight without benefit. Upon her return the leg began to ache in its whole length if used, so that she walked about only a little, and sat sewing much of the time. Then the arm began to ache and to feel weak. There was also about the same time a steady uncomfortable feeling in the head, always disagreeable, never severe.

She came to the out-patient department of the City Hospital September 19th, asking for the room for the treatment of nervous diseases. She was well formed, healthy looking. Her father had taken her to the horse-cars, and she found great difficulty in getting from Washington Street to the hospital, a distance of, perhaps, three hundred yards. The heart, lungs, and kidneys were ascertained to be healthy; the appetite was fair; bowels constipated; and there had been a slow but progressing loss of flesh, in all amounting to about five pounds. She slept poorly. There was a constant feeling as if the brain had been bruised, which was not much increased by mental effort, but any work requiring thought or planning produced a sense of general fatigue over the whole body. The emotional

state was much exalted. The patient could not sit long in the waiting-room without excessive fatigue and great increase in the pain affecting the extremities. She thought her mind was weakened, as she could not bear things at home with her customary equanimity. I could not find anything abnormal from an examination of the head, ears, or eyes. The ophthalmoscope was not used. The patient complained of a great ache, rather than pain, throughout the right arm and leg, and in the right side of the chest. The whole fore-arm sometimes felt as if encased in ice. A severe pain appeared at different times in different spots of the upper arm and thigh, and there was a feeling of numbness at the seat of the injury, sometimes very troublesome, oftener hardly noticeable. Between the shoulders, over a space ten inches in diameter, quite nearly symmetrical, and involving both sides, was an area of burning-heat sensation, varying in intensity under conditions for which I could not find any approach to a law. Sensation was slightly impaired pretty much throughout the right side, but there was at no time any marked anæsthesia. The arm could scarcely be used in any of the ordinary duties of life, and the leg was exhausted after quite moderate efforts. There had been a sense of muscular spasm without any visible movement as observed by the patient in both legs, much less in the left, but also in the right arm.

In such a case as this healthy occupation and diversion for the mind are of the first importance, so that isolation and the rest cure were not to be thought of. A feeling of introspection and self-consciousness was particularly to be avoided, so that a hospital was distinctly contra-indicated on account of the danger of establishing a chronic invalidism. I saw no reason for removal from home except for convenience of treatment, and that could not be afforded, and yet the home was not a favorable place for the care of a sick person. I doubted whether massage would be of use, and my experience of other similar cases led me to question whether it might not do harm. At all events it was not procurable.

She was directed to walk only as much as was necessary to get to the hospital three times a week, her father driving her to the horse-cars; to use the arm only a couple of minutes at a time, at long intervals, and then for no fine movements. She was not to read or do anything involving mental effort except in a general way to direct her sister about the management of the house. She was to be taken out of herself as much as possible. From week to week she was allowed to gradually increase the amount of physical and mental work as she found she could bear it, and I soon ascertained that she was better those days when she came to the hospital than when she remained quietly at home. The faradic brush was used over the arm of a strength just beyond what could be comfortably borne for a month. At the end of a month's time all the most disagreeable symptoms in the arm had disappeared, and in a month more it was quite well except that it had still to be used carefully. The leg remained stationary, or, if anything, getting worse for a month, while the arm was improving, so that the patient was directed to apply the faradic brush to the whole length of the leg, since which time improvement has begun. With malt, cod-liver oil, and hypophosphite of lime four times a day the general condition improved, there was a slight but continuous gain in

flesh, the sleeplessness disappeared, and in a month and a half the uncomfortable feeling about the head had gone, to return only for a short time at considerable intervals. I dare say that the daily cold affusions to the back helped to improve the general condition, and had something to do with the rapid subsidence of the dyspnoea, panting breath, sensation of constriction about the chest, tightness about the heart, and parasthesias. As soon as the head began to feel well iron was given, at first in very small doses, and later the acid phosphates and arsenic. The constipation has been regulated by diet and mild laxatives.

At the present time the mental state has returned to the normal. The arm is quite well but not fully strong, the head does not cause any trouble or uneasiness, the abnormal sensations have gone except the pain in the thigh, although that has improved, and the strength of the leg is constantly mending. I confidently expect a full cure within three to six months. But the element of time seems to me extremely important in these cases, and I think that careful treatment should be insisted upon for at least six months after apparent recovery, to enable the system to entirely regain its tone. I know of no way in which the physician can form an opinion as to the extent of the damage done by injuries to the back and head except by reserving his prognosis for quite a time in order to see which set of symptoms appears. There probably will be a difference of opinion among equally qualified men with large opportunities for observation, as to the extent to which rest should form an important part of the immediate treatment of even seemingly trivial accidents causing a physical shock to the brain or the spine. Doubtless evil results happen less often than others. But serious trouble comes not seldom, and incurable, almost life-long, suffering is not uncommon in cases where there will always be at least a doubt whether sufficient care in the beginning might not have averted a tragedy. Whether in the first of these two cases the severe pain necessitated the rest which saved the young girl from the development of more serious disorder, and whether, in the second, the mildness of the initial symptoms encouraged the activity which prevented a speedy cure are questions of interest to the physician, and of importance to the patient. My own experience leads me to treat all similar cases with great caution from the beginning.

THE USE OF TOBACCO BY BOYS.1

BY EDWARD O. OTIS, M. D. (HARV.)

ONE might deem an apology almost necessary for adverting again to the trite subject of the use of tobacco, a subject which has been discussed almost from time immemorial, and of which so much true and false has been said. Still it is a fact that tobacco-using among boys is common, and, further, most medical men, I think, will admit that the use of tobacco by boys, either moderately or immoderately, is injurious. So long, then, as this is the state of things it may not be amiss to raise one's voice from time to time against the abuse. Although not much that is new upon the

1 Read before the Section for Clinical Medicine, Pathology, and Hygiene of the Suffolk District Medical Society, December 12,

1883.

matter may be presented, every agitation against an evil does something towards eradicating it.

I propose to leave out entirely any discussion of the effects of tobacco, injurious or otherwise, upon adults, and refer only to its use by boys.

My attention was especially directed to this subject while in practice at Exeter, N. H., where I met with many of the students of the Phillips Exeter Academy, and noted the effect of tobacco upon them. I became still more interested by reading through the kindness of the late principal, Dr. A. C. Perkins large number of letters sent by parents, teachers, and others in response to a circular letter of the principal asking their opinion regarding the use of tobacco by boys in the school. To the circular and letters I shall refer later on.

a

As to the exact percentage of boys who use tobacco there do not seem to be any very accurate statistics. At the academy above referred to I should say that at least one half of the students used it. The statement was made some time ago, I believe in a secular paper, that seventy-five per cent. of school-boys over twelve or thirteen years old smoke cigarettes. I am inclined to believe that this is too high. At the Boston Latin School, of those in the upper classes from fourteen to eighteen years of age, the head master stated last year that probably about half used tobacco to some extent. The principal of another school stated that since his connection with it the number of smokers had nearly doubled. This is enough to show that the evil prevails extensively, and gives good reason for serious apprehension.

Whatever injurious effects the excessive and constant use of the drug may have upon adults, these are more marked and intensified in the case of the youthful user of tobacco; and, moreover, the youth are more inclined to its use to excess, for theirs is an age of immoderation. For example, a young student, from fifteen to seventeen years of age, I should think, told me he was smoking about a bunch of cigarettes a day, and although promised a trip to Europe if he would abandon the habit, said he did not think he could do it even for that prize. It is a time of rapid change, physically and mentally, with them; there is a constant development going on, and although I am not aware that any careful series of observations have been made, still I am sure that the general observation of all is to the effect that tobacco interferes with and retards the proper symmetrical development both of mind and body. Of course there are exceptionally robust and strong boys who, although they use tobacco, mature into sturdy men with good minds, but it is in spite of the tobacco. The especial deleterious effects of tobacco upon the young are pretty well known from all the discussion and much exaggeration that has been rife about them. I will briefly mention some of them.

There is the so-called "tobacco heart," an irregular, irritable heart. Dr. Gihon, in his report on the United States Naval Academy, says, "The annual examination of cadets reveals a large number of irritable hearts among the boys who had no such trouble when they entered the school." This was before tobacco was prohibited at that institution.

Another effect is defective muscular coördination, as shown in the tremulousness of the hand in manipulating a pencil or pen, and inability to draw a perfectly straight line. The professor of drawing at the Naval Academy said that he could invariably recognize a

user of tobacco from this inability. I myself observed the same thing in the case of a young man who smoked continually.

Besides impeding mental growth it is an obstacle to mental application and effort. It is said to produce progressive deterioration of the intellect, and to impair its integrity. At the instance of Napoleon III. a commission was appointed to examine the young men in the government training schools of France as to the effect of tobacco upon them. The students were divided into two classes, the smokers and non-smokers. The former were found so inferior, physically, mentally, and morally, that the use of tobacco was prohibited in all the schools under governmental supervision. In the École Polytechnique it was found that the non-smokers took the highest rank in every grade, and that the smokers continually lost grade.

The principal of a boy's school near Boston stated that the habit of smoking was more prevalent in the lower classes than in the upper, the reason being that the smokers were usually the poorest scholars, and were gradually weeded out as the class advanced in the school. In one of the letters above referred to the writer says: "If a successful salesman to whom I was paying a high salary should begin the use of tobacco, I should feel that about fifteen per cent. of his vitality or ability was taken from his usefulness, and hence should be taken from his salary."

It is said to impair the memory. In another one of these letters, the writer somewhat graphically relates the effect of tobacco upon his memory, as follows: "I commenced the use of tobacco when thirteen years old, both smoking and chewing. I went to school but could not study, had no ambition at all to learn anything, and it was almost as well not to learn, since I could hardly remember anything from one school to the next. . . . The most lasting injury is the fact that tobacco ruined my memory, which does not come back to me, although I have not used tobacco for fifteen years." Another writer says that there is a young man in his factory twenty-one years old, powerfully built, and weighing one hundred and eighty pounds, brought up on a farm, who uses tobacco. Years ago he noticed a loss of memory, and a diminution of vitality generally. It is a well-known fact that tobacco may cause defective vision. Dr. Gihon in the report above referred to says: "I have myself several times rejected candidates for admission into the academy on account of defective vision, who confessed to the premature use of tobacco, one of those from the age of seven." I have noticed that the mechanical irritation of the smoke, especially from cigarettes, which bring it so near the eyes, will produce and keep up catarrhal trouble. I have a suspicion that tobacco used as the boy is emerging from boyhood into manhood causes an undue irritation and excitability of the sexual system, prompting to abuse and excesses.

Then there is the irritation of the mucous membrane of the mouth and throat, impairment of digestion, sometimes, an habitual sense of uneasiness, palpitation, hypochondriasis.

With regard to cigarette smoking by boys, I will refer to two paragraphs from an editorial on the use of tobacco in the Boston Medical and Surgical Journal for November 23, 1882: "The number of young men who smoke cigarettes is almost startling. It is not only students but even school-boys in their teens who vigorously and openly indulge in this dangerous habit."

And again: "The dangers, then, which are incident to cigarette smoking are, first, the early age at which it is taken up; second, the liability to excess; and third, the bad custom of inhaling the smoke. These are dangers superadded to those attendant on the ordinary use of tobacco, and should be carefully considered by all medical men."

Dr. Witter, of Grand Rapids, Wis., in a paper in the Report of the State Board of Health of Wisconsin for 1881, among the conclusions which he deduces from a large number of letters written on the subject by physicians of the State, says: "That beginning the use of tobacco in early life cannot be too strongly condemned as producing most pernicious effects upon the constitution of the young, and as impairing greatly, if not wholly destroying, the chances of success as students and scholars."

The evil effects, then, of tobacco upon boys which can be said to have been fairly proved by observation, are:

First. An interference with and impairment of the general development, physically and mentally. Probably it does this by retarding progressive cell change. and impairing nutrition. In an adult the development is attained, consequently he can smoke with impunity so far as this effect is concerned, when the boy only does it with injury.

Second. The tobacco heart. This likewise happens to the adult, but is, I should think, more likely to happen to the youth, and with graver result, because his is such an unstable age physically. For this same reason the other injurious effects are more liable to be intensified in the youth.

Third. Defective muscular coördination. I have but little proof to show that this condition is more than temporary, continuing only while the tobacco is used.

Fourth. It reduces the intellectual power of the boy. It does this either by opposing mental application and effort, or else by producing deterioration of the intellect, probably both to a greater or less extent.

Fifth. It impairs the memory. What proof I have adduced seems to show that this is a permanent injury. Sixth. It may cause defective vision, and also irritation, more or less chronic, to the external parts of the eye.

Seventh. It may unduly excite the sexual system and lead on to excesses. I have no positive proof of this, but my observation among boys rather points to it.

Eighth. Irritation of the mucous membranes of the mouth and throat, more especially in case of cigarette smoking.

Ninth. It may impair digestion, and produce other derangements, such as habitual uneasiness, hypochondriasis, and so on.

One cannot reason as to the effect of tobacco upon boys from its effect or lack of effect upon the mature man. The conditions are different. It would be quite as reasonable to say that, because to a sick man a certain drug is administered with good effect, the same drug may be administered to a well man with no evil effect.

If what I have said is true or approximately true, it would seem eminently wise to do what we can to keep tobacco from boys. It is a pity to allow them unwittingly to do that which may prevent their highest development physically, mentally, and morally. It is the physician's duty to expose the danger and warn parents and teachers. The latter must use their influ