SOCIETY REPORTS.

BALTIMORE NEUROLGICAL

SOCIETY.

MEETING HELD MARCH 13, 1895.

The eleventh monthly meeting of the Baltimore Neurological Society was held. at the Catonsville Country Club, Wednesday evening, March 13. Fourteen members braved the storm and took part in the proceedings. The subject for general discussion was ALCOHOLISM AND ITS EFFECTS UPON NERVOUS AND MENTAL DISEASES.

Dr. E. N. Brush said that he regretted very much the absence of Dr. Berkley for he felt that after Dr. Berkley had talked of the pathology of alcoholism and Dr. Preston had given a statement of what neurologists observed in persons addicted to the inordinate use of alcohol, the ground would be so well taken that there would remain little for him to say. He believed that a description of the conditions observed clinically by neurologists were in many in stances very readily applicable to those observed by the medico-psychologists and certainly there was nothing different in the pathology of the nerve and cell changes, between those observed in diseases of the peripheral nerves, and the pathological effects which come under observation of those who deal mainly with the mental effects of alcoholism.

It was unnecessary, he believed, to enter upon the effects of alcohol upon the mental operations as observed either in ordinary intoxication or in delirium tremens in a discussion of this character. Aside from these we might next consider two varieties of those who use alcohol to their detriment; these are the inebriate and the dipsomaniac. The difference between these might be characterized as one of the resistance and the desire to resist. In the inebriate, before there had resulted those mental and moral changes which almost always, to a degree, follow the constant use of alcohol, there was commonly the ability to resist a temptation to drink without, however, the desire, while in the dipsomaniac there was the desire very com

monly to resist periodically giving away to temptation without the ability to self-control. The inebriate had commonly a low or deficient moral sense or sense of shame, while the dipsomaniac was usually wholly conscious of his unfortunate condition, but did not seem to possess the power to resist sufficiently developed to escape the unfortunate tendency which afflicted him. In the dipsomaniac there were commonly found other neurotic conditions and not infrequently a history of marked mental and nervous heredity. Cases were cited by the speaker which illustrated this point.

Aside from these cases, and inclusive of them, there were numerous instances observed by physicians both in institutions for the insane and out of them in which as the result of alcohol there seems to be a distinct loss of mental and moral tone. Individuals who previously were active mentally, careful and scrupulous in all the relations of life and neat in appearance and correct in behavior, became dull and forgetful, indifferent in matters of veracity, careless in dress and personal appearance. These cases form the advance guard, as it were, of the next class of cases in which there was more marked mental disturbance, a condition of actual confusion with more or less dementia, resembling in some respects the mental condition of extreme senility. These patients at times lose their senses of identity, they were unable to recognize where located, the passage of time made little impression upon them; they were unable to remember the time, day of the week or of the month, could not tell in the middle of the morning whether or not they had breakfast; would be able to talk with the visiting physician concerning their symptoms, but within a very few moments after he left forgot that he had made a visit. Sometimes these mental symptoms were ushered in by a convulsion and occasionally the course of the case was interrupted by a seizure resembling in many respects epileptiform attacks. Next in order to these cases would come those forms of insanity which more or less closely resemble ordinary attacks of melancholia and mania.

In the melancholic attack there were usually associated symptoms of marked hypochondriacal tendency, while the maniacal attacks were commonly of the delirious order. Another form of mental disturbance which had a more constant clinical picture was characterized by delusions of persecution, by hallucinations of hearing and occasionally of sight, and these cases were not only very difficult to manage, but were frequently dangerous by reason of their sudden and unprovoked assaults on persons whom they believed were persecuting them. These assaults were not commonly made upon members of their own family. Very commonly these patients had delusions regarding their wives, believing them unfaithful. There is another form of alcoholic mental disturbance resembling general paresis or progressive general paralysis of the insane, the pseudo-paresis of alcohol. The speaker related a case of this character, recently discharged recovered from the Sheppard Asylum, which upon admission in both the physical and mental symptoms resemble general paresis. There were unequal pupils, tremor of the extremities and of the lips and tongue, paretic speech and absence of reflexes. There were in this case no extravagant delusions, but on the contrary, as in true paresis, occasionally, the delusions were of a melancholic and hypochondriacal type. It is very difficult to say to what degree alcohol is responsible for attacks of mental disturbance in proportion to the entire number of cases of insanity in the community. Statistics upon this point vary exceedingly and depend somewhat upon the bias of the person who compiles the statistical tables. Moreover, there are associated with cases in which alcoholic excess plays a prominent role, conditions of disturbed health, family history, etc., which may cause the observer to lose sight of the alcoholic history. It is, moreover, often the case of chronic alcoholic insanity, with ideas of persecution and hallucinations, that the patient has been a secret drinker, going about his business in a regular and methodical way during the day time, but rarely retiring sober at night. This course, in

time, resulting in mental break-down while the physician in charge of the case does not have any intimation of the real history of the patient's life.

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Dr. Brush then referred to some statistics from English asylums for ten years, 1878 to 1887 inclusive, which showed that alcohol was the cause attributed in 191 per cent. of the men admitted to the asylums of Great Britain for that period and in 7 per cent. of the women or in 13 for both. In New York State, from 1888 to 1893 inclusive, 12,207 cases were admitted, in 10 per cent. of whom alcohol was assigned as the cause of insanity. The statistics of the asylums of Pennsylvania show about the same percentage of cases in which alcohol was assigned as the cause as in New York. In the opinion of the speaker, this percentage was below the actual number. Dr. Brush referred to an article which he had just seen on the day of the meeting, by Dr. Bond, pathologist and assistant medical officer of the London County Asylum, Banstead, in the British Medical Journal of March 2, 1895, in which Dr. Bond attempted to show by the much larger percentage of cases of renal disease found in the autopsies in the asylums of London than in the general hospitals drawing patients from the same district that the percentage of cases in whom insanity was in a measure traceable to alcohol was much higher than represented in the statistical tables. Dr. Bond, in conclusion, stated his opinion that at least more than twice the number than at present enumerated in statistical tables owed their entrance to the asylums of London partly at least to alcohol. Dr. Bond's statistics were drawn from the asylums at Hanwell, Conley Hatch, Banstead and Cane Hill. Dr. Brush did not quote these statistics with a view of endorsing them, but as affording some interesting and suggestive facts.

Dr. George H. Rohé expressed the opinion that too much influence is generally attributed to the abuse of alcoholic stimulants as a factor in the causation of insanity. The personal equation of the observer who finds 12 to 15 per cent. of insanity to depend upon

alcoholism should be known. There is always a strong desire to find a cause for the insanity and intemperance is such an elastic term that it can be stretched to cover very widely divergent conditions. Much depends upon the point of view of those who make the statistics. Doubtless also the social stratum from which the patients come makes a difference. Thus while it is probable that in institutions like Bay View and pauper asylums generally, the percentage of alcoholic insanity is large, in hospitals drawing their population from a better class of persons it will likely be found smaller. In the admissions to the Maryland Hospital for the Insane, the cases where the insanity could be directly attributed to the abuse of alcohol is very small, under five per cent.

He was particularly interested in two groups of cases of alcoholic insanity to which Dr. Brush had called attention. First, those simulating general paresis. In these the symptoms so closely resemble those of that fatal disease that a mistake in diagnosis, and consequently of prognosis, is easily made. In his experience, the prognosis in these cases is fairly favorable. The other group is that in which there are delusions of want of conjugal fidelity. This symptom is so often present that von Krafft-Ebing has called especial attention to it as a characteristic manifestation of alcoholic insanity.

Dr. John Morris said: My experience in alcoholic insanity has been chiefly among the depraved and criminal classes. This experience has been gained as a Commissioner in Lunacy. More than thirty per cent. of the criminals in our prisons and in the various asylums and almshouses of our State suffering from insanity owe their condition (leaving out the law of inheritance) to the excessive use of alcoholic drinks. There is a form of acute insanity not fully recognized by writers on jurisprudence or by courts of law in which men and women become thieves and kleptomaniacs. There is a total loss of memory in these cases and crimes are committed of which there is no recollection when reason is restored. Cocaine

and morphia more particularly bring about this condition. The courts hold that excessive indulgence in alcoholic stimulants only aggravates a crime when committed under their influence. This, in my judgment, is bad reasoning and not founded on experience and observation. Of course, if a man, as occasionally happens,, prepares to commit a crime, to obtain "Dutch courage," as it is vulgarly termed, his offense is doubly serious and should, if possible, receive double punishment. Cases of this kind are not frequent, but the class of cases which I have termed acute alcoholic insanity are very numerous and must have come under the observation of every medical man in general practice. It must be understood that I do not include cases of delirium tremens in this classification, for men suffering from this trouble do not, as a rule, commit crime. Of course they are insane, but this insanity, whilst of an acute character, lasts for many days. The symptoms, in the case I first described, in which crime is committed in a condition of apparent unconsciousness, do not last more than a day or two at the furthest. As a State expert in the criminal courts during the past thirty years I have had several criminals acquitted on the ground that the offence was committed whilst suffering from insanity due to the use of narcotics. Two notable cases come to my mind at this moment. In the first, a lady, the wife of a physician and daughter of a gentleman with whom I had served in the Legislature more than forty years ago, was indicted for stealing books from a physician's offices. These thefts were committed for the purpose of procuring opium which she had taken immoderately for years. She was acquitted on the ground of insanity and was placed in Mount Hope Asylum, where she remained more than a year and when released was apparently cured. The second was that of a young man indicted for stealing jewelry. When I visited him at the City Jail he was violently insane. He refused to take food and was unable to sleep for four or five days and nights. His condition was such as we observe in delirium tremens.

As he was not a drinker I was puzzled at first to account for the suddenness and violence of the attack, but, on consulting his family and investigating his history I found that he was a confirmed opium fiend and that he spent all the money he could procure in "hitting the pipe,' "as it is classically termed, and that his delirium was entirely due to the abrupt deprivation of the narcotic. Cocaine is the only drug the effects of which are more dangerous and more slavish than the inhalation of the fumes of opium. The young man was acquitted by the jury after hearing my statement. It would be well if this subject were more thoroughly studied by medical men who have the care of criminals.

Dr. Henry M. Hurd said that his experience in connection with institutions. for the insane led him to think that the figures which had been detailed respecting the number of cases in British asylums, where mental disease was due to alcoholic indulgence, were correct. It may be remembered that the opinion of alienists upon this subject has been very divergent. Some years since the Secretary of the Brewers' Association sent letters of inquiry to all institutions for the insane in the United States to ascertain what proportion of insane patients, in the judgment of the medical officers of these institutions, owed their insanity to alcoholism. The replies which were received differed widely and ranged from 5 per cent. in the lowest to 90 per cent. in the highest. The speaker had occasion to examine carefully the statistics of the Michigan institutions and found the percentage of insanity unmistakably due to alcoholic indulgence was between 10 and 15 per

cent.

Drs. Preston, H. M. Thomas and Osler also spoke.

There being no further business before the Society, they were invited by Drs. Rohé, R. F. Gundry and S. J. Fort to enjoy an additional discussion of the palatability of roasted oysters with trimmings as prepared by the celebrated chef of the Country Club, and every man did his duty.

The next meeting will be held at the

Sheppard Asylum, by invitation of Dr. Brush. Subject for discussion, “Disturbances of Speech."

SAMUEL J. FORT, M. D.,

Secretary.

MEDICAL PROGRESS.

RELIEVING A CROWDED PROFESSION. At this season of the year, says the Medical World, when the annual new recruits to the army of physicians are going forth to take their places in the already well-filled ranks, it may be appropriate to consider how we may practically deal with the problem of overcrowding. The struggle for existence is becoming closer and closer, when, with vast untouched natural resources, and with new inventions daily multiplying our power of creating wealth, we should be able to live even more easily every year. As a proof of the fact that it is our artificial conditions and not nature's limitation that makes the struggle severe, it has been demonstrated that any one of our six largest States is capable of sustaining in comfort and plenty the entire present population of the United States.

While it is true that we do not need more doctors, yet we always need better ones. Hence, those who keep themselves so constantly prepared by daily study, careful observation and occasional post-graduate courses, that the recent graduates cannot be better informed than they are in the latest advances of the science, will be able to hold and extend their practice.

Yet, on account of improvements in sanitary regulations and preventive medicine, and the rapidly extending popular knowledge of personal hygiene, the need of medical services is becoming less and less all the time. Hence, as the total amount of practice is thus diminishing and the number of physicians is increasing, there must be some who will find it difficult to obtain a living by the practice. To meet that difficulty we offer the following suggestions:

Insist that all public positions involving medical and sanitary service-coro

ners, superintendents of public institutions where medical knowledge is desirable, members of boards of health, sanitary inspectors and commissions be filled by practical physicians. This gains for the public better service and. relieves professional competition.

When a physician of education, character and ability presents himself for public legislative or executive office, the entire profession of the community, imitating the custom of our brethren of the legal profession, should cast aside all personal jealousy and unite in aiding to elect him. This, again, eases professional competition and secures a valuable public servant at the same time. Our law-making bodies are composed almost entirely of lawyers and bankers. Doc

tors come in touch on all sides with the people, of all grades and classes, and hence know their ideas and their needs. They naturally love justice and equity, and their scientific training well fits them for faithful public service. We need a great many of them in the various departments of legislative and executive service.

In many localities physicians may profitably engage in cultivating medicinal plants. This is at once a congenial, healthful scientific calling. Many of our native American medicinal plants are almost in danger of becoming extinct; while many that are obtained from foreign lands at great expense could be successfully cultivated here.

In many localities it would prove highly profitable to one who has an inclination for it to make especial study and become a thorough chemist, microscopist or bacteriologist, both for industrial purposes and for diagnosis in consultations. Every county could support such a specialist. In fact, a well-educated physician is prepared to engage with promise in one of the many scientific pursuits, should he not find the practice of medicine satisfactory, or even as a profitable recreation.

Lastly, we should all use our influence to dissuade as many as possible of the young men who seem inclined to plunge without due consideration into an ex

aal unprofitable medical course.

TREATMENT OF OVARIAN AND TUBAL DISEASES. Dr. A. Lapthorn Smith, in an article on the treatment of diseases of the Fallopian tubes and ovaries in the Canadian Medical Review, speaks of the frequency of these troubles as shown by Dr. John Whitridge Williams of Baltimore. He gives his experience, relates cases and draws the following conclusions :

1. We are never justified in removing tubes and ovaries simply for ovarian pain or neuralgia which can surely be cured by electricity and tonic treatment.

2. We are not justified in removing tubes and ovaries for active or passive congestion which can be easily cured by antiphlogistics and local depletion.

3. We are not justified in removing appendages for inflammation when it has not extended to the pelvic perito

neum.

4. We are not justified in removing even chronically inflamed tubes and ovaries until we have first given a thorough trial (six to twelve weeks) of the ordinary measures of local or general treatment.

5. We should not hesitate to remove chronically inflamed appendages when six to eight weeks' systematic treatment fails to relieve the patient so that she can enjoy life and fulfil her duty to her husband, and if not with pleasure at least without pain.

6. We should not hesitate to remove appendages so diseased as to set up recurrent attacks of inflammation of the pelvic peritoneum by leakage or continuity of infection.

7. We should not hesitate to remove a tube or ovary large enough to fill Douglas' cul-de-sac, no matter what the nature of the enlargement, a simple cyst, a tubal pregnancy or pus tube. As long as it remains it is a source of danger and sometimes of suffering, and when the inevitable time comes when its removal is imperative, the operation will be the more difficult and dangerous the longer it is delayed.

8. The removal of both tubes and both ovaries should not be done when only one tube and one ovary is diseased. It is worth while leaving even the half