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anatomical and functional state, and as a result of these lesions they are no longer able to perform all their functions; or, 2d, the secretory organs are at first unaltered but the quantity of work which is to be done, the quantity of toxins which must be eliminated is increased during gestation. Many authors agree with the first proposition, i. e., M. Riviere, who holds that the blood of the puerperal woman is hydræmic; that the heart is hypertrophied; that the nervous system is more irritable; that the liver is altered; that the functions of the lungs are hindered by the elevated position of the diaphragm and by the hydræmia; that there are digestive troubles and finally that the kidneys are affected and that from their incapacity to accomplish the surplus work which is imposed upon them by the insufficiency of the other organs named. But Schroeder, Teblin, Reine and the author have demonstrated that the blood does not become hydræmic in the puerperal woman; M. Schmorl and Lohlein have demonstrated that during pregnancy the dimensions of the heart are not changed. As for the changes in the liver, which Riviere mentions, they were not as a rule demonstrated during pregnancy. In normal pregnancy we find only more or less cyanosis or dyspnea indicative of respiratory trouble. There only remain then the functions of the intestines and of the nervous system which are often altered. But these are seen in nonpregnant women and moreover are never a cause of eclampsia. It is probable that during pregnancy the kidneys, normal before pregnancy, do not become diseased by any other cause than the toxicity of the blood and once the lesion is established (nephritis gravidarum) the toxicity is still increased. If the eclampsia really is due to inability of the secretory organs to perform their normal functions, the writer asks why it is that eclampsia is not more frequently observed in debilitated women, and why should the convulsions cease upon the death or birth of the child when the maternal organs are still diseased and incapable of eliminating all the toxines ? One must admit that there is an increased toxicity due to the elimination of the products of combustion in the fætus where the nutritive changes are greatest. This is proved by the greater temperature of the fætus and by the fact that the greatest number of cases occur at a period when the growth of the fætus is most rapid. The toxic products then are eliminated either through the placenta or by absorption from the liquor amnii and must increase the work of the maternal organs. This toxæmia causes a parenchymatous degeneration of the secretory organs and as a result the toxæmia is increased. This toxæmia also produces the same lesions in the fætus where the toxic condition of the blood is found to be greater than that of the mother-another proof of the fætal origin of eclampsia. This theory explains why eclampsia is so frequent in twin pregnancies and why the symptoms so often cease after the death of the fætus without the mother being delivered. When eclampsia occurs after the birth of a child, although the mother is relieved of the source of the toxines, the lesions of the maternal organs still remain and cause an insufficient elimination of toxines and a consequent augmentation gives rise to the eclampsia. The living child of an eclamptic woman usually shows symptoms of intoxication although it often passes by unobserved.

PSYCHIATRY

Edited by G. Alder Blumer, M. D. A Degenerative Form of Syphilitic Insanity.-G. A. Welsh (Journal of Mental Science, April, 1899) reports conclusions arrived at after the observation of sixteen cases of syphilitic insanity. This malady is a degenerative condition of the nervous system, primarily attacking the nerve cells. It closely resembles general paralysis in its clinical manifestations. The progress, however, shows that in some cases the disease is curable; in others, which do not permit of cure, alleviation, in the form of remissions, can be obtained by antisyphilitic treatment. The cases which progress follow closely the progressive degeneration known as general paralysis. The writer discusses the probable effect of the syphilitic poison upon the nerve cells, and believes that there are two stages of development; the first a slow degeneration, and the second, an active change. The resulting symptoms are distinctive. The disease is one which admits definition, and may be defined as a disorder of the nervous system, characterized by mental symptoms with motor accompaniments. In every case there are motor accompaniments, and the diagnosis cannot be made without them. The mental condition is exaltation with excitement, and might well be called syphilitic mania. The premonitory stage is short in duration, and in the writer's cases has varied from 10 to 21 days. It is marked by a change in manner, irritability, eccentric acts, restlessness and insomnia. It varies greatly in the intensity of its manifestation, and in cases is so slight that it passes without attracting attention. The stage of invasion is acute, and is characterized by mental exaltation with delusions of grandeur, and in some cases, in addition, with delusions of suspicion and persecution. Some authorities claim a distinction between the grandiose delusions of syphilitic disease and those of general paralysis, but the writer's cases did not permit this differentiation. The other symptoms of special note are sleeplessness, mental enfeeblement, variability and alternation of the mental condition and the occurrence of remissions. Great importance is placed upon the motor signs. These are principally local or general paresis, paretic incoordination, as a rule limited to the lower extremities, absence or diminution of the knee and other tendon reflexes, muscular tremors, and defective articulation of speech, and congestive attacks.

The points of diagnosis are the acuteness of the attack, the degree of mental enfeeblement, the variability of the mental condition, the character of the motor phenomena, with the absence of sensory phenomena anda pupillary changes, and the deciding test of vigorous antisyphilitic treatment. The prognosis is grave as the outcome is doubtful, and depending upon the results of antisyphilitic treatment.

The Epileptic Impulse to Wander. (Poriomania.) – JUL. Donath in the Arch f. Psychiatrie, xxxii, 2, discusses a form of mental epilepsy, which he calls der epileptische Wandertriebe, or poriomania. Loss of consciousness is not necessary to epilepsy. In Jacksonian epilepsy, which is a rudiment of general epilepsy, consciousness may be entirely retained, and in various manifestations of general epilepsy numerous psychical equivalents are now recognized in which disturbance of consciousness and amnesia are pushed more and more to the background and finally disappear, so that although disturbance of consciousness is a frequent and important symptom, it is not an essential sign of the epileptic attack, and need not be present for the differentiation of epilepsy. The epileptic attack may consequently be defined as every form and every source of morbid irritation of the cortex which begins suddenly, returns periodically, runs a typical course and quickly ceases. The presence or absence of consciousness with or without amnesia depends entirely upon the intensity and extent of the cortical irritation. The writer describes fully three cases whose wanderings during the epileptic seizure covered a great extent of territory. The impulse to wander is the form of psychical equivalent and may often be preceeded for twenty-four hours by various bodily and mental disturbances. These are attended by an uncomfortable and restless feeling which may lead to thoughts of or attempts at suicide, but yield to contentment and relief when the wandering begins. Donath consequently regards poriomania as a psychical equivalent of special kind which differs from the usual, in that perversion of consciousness either is wanting entirely or being transient and insignificant attracts very little attention.

Epilepsy Terminating in General Paralysis.—WATTENBERG (Archiv f. Psych. u. Nervenkrankh., Vol. 32, Part 3) describes a case of genuine epilepsy terminating in general paralysis. The occurrence of epileptiform seizures and similar attacks is well known in general paralysis, and the literature shows a few cases in which a strong suggestion of epilepsy has been given by preceding symptoms, but with a liberal interpretation of the phenomena of general paralysis and the recognition of a longer duration of the disease than the limit of two years which was formerly accepted, these occurrences may be taken as the prodromal manifestations. The author's case showed pure epileptic seizures at the age of eight, which increased in intensity until his admission to a hospital in a state of epileptic status at the age of thirty-three. Four years later he was again admitted into a general hospital with the diagnosis of "Psychopathia epileptica,” two years later again, and this time was transferred to a hospital for the insane. Here he developed expansive ideas and other mental and physical symptoms characteristeric of general paralysis, of which he died. Trauma, alcoholism and syphilis were positively excluded. The case is the first of its kind on record, and justifies the following conclusions derived by the author:

1. It is shown that genuine epilepsy, to this time regarded as an independent, well-defined psycho-neurosis, may precede general paralysis, and may terminate in the latter.

2. It is also demonstrated that general paralysis is not necessarily due to lues. but may develop entirely independently of venereal disease.

3. It is finally made evident that similar appearances both clinically andı pathologically may be present in genuine epilepsy as well as in genera paralysis, and that these in susceptible individuals may be due to certain endogenous toxines.

ALBANY

MEDICAL ANNALS

Original communications

EDUCATION AND THE PROFESSION OF

MEDICINE.*

By PRESIDENT ANDREW V. V. RAYMOND

of Union College.

I appreciate the courtesy of the invitation which brings me before you this afternoon and am grateful for an opportunity to speak to such a representative company of physicians upon a subject which is already of interest to you because vitally connected with the future of your profession. I feel, however, like claiming at the outset your indulgence if I seem to show lack of knowledge, or at best lack of appreciation of certain practical conditions which appeal strongly to you, and modify your views upon the general subject, for you must understand that I am not a physician, and therefore naturally speak from the academic rather than the professional side. At the same time you will admit that the question before us cannot be settled without due consideration being given to the side which I represent. I shall try, however, to avoid any extreme positions and look at the question as far as possible from all sides.

The terms of the subject before us have been chosen deliberately as indicating two more or less distinct interests or aims. On the one hand education, as we shall use the word, stands for what is known as liberal culture, and, on the

Address delivered to the Medical Society of the State of New York, January 31, 1900. a

other hand "the Profession of Medicine" stands for technical knowledge and skill, and incidentally a means of livelihood. In making the latter interest only incidental I feel that I express your own thought, for it is the glory of your profession to put the service of humanity first, but even you cannot ignore the fact that if one would serve he must live; so that the question of getting a living is of some importance in connection with the practice of medicine. Indeed it is that more than anything else that just now complicates the relation between education and the profession of medicine; for while all admit that the profession demands the most thorough and liberal preliminary training, that training requires under present conditions so many years of study that the average young man cannot hope to become self-supporting as physician until past the first vigor of youth. How far is this inevitable, and how far is it the result of false ideals and faulty methods of instruction ? These questions define the range of the present discussion.

We cannot, however, discuss these questions intelligently without coming to some agreement as to the aim of education. If it is simply to make physicians and lawyers and engineers and financiers, then it will be claimed by many that the specific purpose fixes its own limitations upon the course of studies and the time that may be spent profitably in pursuing that course. It is this conception of education that finds expression in the demand for early specialization, a demand so apparently reasonable that few stop to think of all that it involves. Without pausing now to show the essential weakness, even if we assume that the theory of education is right, we ask, “Is this theory right? Is it the great aim of education to give ability in any profession or calling ?” This is fundamental, and I do not hesitate to answer emphatically, "No," because a man is more than a machine fitted to do a certain kind of work. He has interests and responsibilities, capacities and sympathies, wholly separated from his professional calling, and it is the mission of education to develop his whole nature, unfolding the powers that give the widest range to life. No one will claim that purely technical instruction does this. Of necessity it limits his knowledge and cultivates but a part of his being, thereby excluding him from much of the world that

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