retina, or a touch of the finger-tip. When we imagine each of the 2,000,000 private paths connected to each of the 500,000 common paths, or perhaps each connected to each through many and diverse routes, we arrive at some notion of the complexity of the vital keyboard.

These lectures are to be published in book form by Yale University.

400 Prospect Avenue.

[Written for the MEDICAL BRIEF.] Ophthalmia Neonatorum.

BY DAVID WEBSTER, M. D., Professor Emeritus of Ophthalmology in the New York Polyclinic; Surgeon Manhattan Eye and Ear Hospital; Consulting Ophthalmic Surgeon to the Hospital for Ruptured and Crippled; Consulting Physician to the Skin and Cancer Hospital; Fellow of the Academy of Medicine, American Medical Association, Etc., Etc., Etc. New York City.

Ophthalmia neonatorum is one of the forms of conjunctivitis which, without proper treatment, is moderately certain to destroy the eyesight. It makes its appearance within a few days of the birth of the infant, and is undoubtedly in nearly all instances due to gonorrheal infection.

At the Manhattan Eye and Ear Hospital, where a considerable number of these little patients are constantly under treatment, routine examinations of the conjunctival secretion are made, and gonococci are almost always found in large numbers, and the patients are never discharged until gonococci are no longer found in the secretions.

The symptoms of this disease are redness of the eyeball, swelling of the eyelids, often chemosis, and a very abundant purulent discharge.

Treated conscientiously and energetically, such a case will be nearly well in about two weeks.

The treatment consists in constant cleansing with a warm saturated solution of boric acid; as often as any secretion appears it should be washed away carefully, and this usually requires a repetition of the washing every fifteen or twenty minutes. Ice cloths should be applied as much as possible, but it is very difficult to keep them on the eyelids of these little patients, who are usually nerves, and are constantly moving their heads about, and removing the ice cloths.

Argyrol, anywhere from twenty-five to fifty per cent solution, should be dropped into the eye every two hours after cleansing. At least once a day the eyelids should be everted and the argyrol rubbed into the palpebral conjunctiva very thoroughly by means of cotton twisted about the end of a cotton holder. Where dropping the argyrol in in the ordinary way has failed in arresting the secretions, I have found it to be arrested in two or three days after applying it in this way— rubbing it in. The argyrol is superior to all other applications because, while thoroughly efficient as a bactericide, it produces no pain, smarting, burning or irritation whatever.

The chief danger in these cases is from ulceration of the cornea. An ulcer may be arrested at almost any stage, or, in spite of all treatment, it may go on to the destruction of the whole cornea. Ulcers, however, rarely appear in this disease if the case is treated early, and in the way I have indicated.

Quite a large proportion of our cases at the Manhattan Eye and Ear Hospital come to us after a week or more of neglect, and after the eye has either been destroyed or sloughing of the cornea or ulceration has already set in. In these cases, of course, the most we can expect is to save partial vision.

Very rarely, indeed, only one eye is affected. In such a case the other eye must be most carefully protected from the first, either by a bandage or by Buller's shield, if it can be kept on the eye of the little one.

As the disease is almost certain to be caught, if any of the secretion gets into the eyes of the nurse, or any other person, the greatest care should be taken to destroy all things that have been applied to the eye. The ice cloths and the cotton with which the eyes were wiped should be put into a newspaper cornucopia and conveyed to the furnace. The nurse should be exceedingly careful to wash her hands thoroughly after having used them about the eyes of the child so as not to commmunicate the disease to herself or anyone else. I have known more than one nurse to lose her sight through carelessness in taking care of children with ophthalmia neonatorum. 327 Madison Avenue.

BY EDWARD GEORGE YOUNGER, M. D., M. R. C. P., D. P. H.,

Senior Physician to the Finsbury Dispensary and Late Physician to the St. Pancras and Northern Dispensary. London, England.

A case of insanity occurring in the practice of the general physician is almost certain to be the cause of much anxiety and worry to him unless he has had special training in the subject of mental diseases, which is rarely the case. The problems as to diagnosis, prognosis and treatment call urgently for prompt solution, and one of the greatest difficul

ties is to decide whether the case is one which can be treated at the patient's own home with a reasonable prospect of recovery for himself, and safety to those around him, or whether immediate removal to an asylum is necessary. Should the case occur in a large town, the advice of a skilled alienist can readily be obtained, but in remote country districts the whole burden of responsibility is thrown on the shoulders of the practitioner, and it is often a heavy one.

In the present short paper it is only possible to deal with those forms of insanity which are most likely to be met with in everyday practice, and to call urgently for treatment, and these my own experience has shown to be: mania, melancholia, delusional insanity or paranoia, general paralysis, puerperal insanity, and alcoholic insanity. Three-fourths of all cases admitted to asylums are examples of either mania or melancholia, and, indeed, almost every case of insanity can be assigned to either the maniacal or the melancholic type, and these have been spoken of as the pure or primary psychoses.

As in the course of this paper I shall have occasionally to refer to hallucinations, illusions and delusions, it is well here to differentiate between them, as they are often confused with one another.

Hallucinations are false perceptions of the senses-sight, hearing, taste, smell, or common sensation. They occur in many forms of insanity, but, on the other hand, a person may have hallucinations, and yet not necessarily be insane; he may recognize them as such.

Illusions are mistaken perceptions of the senses. The patient does actually see, hear, etc., something, but he mistakes it for something entirely different; he may, for example, see clouds in the sky and mistake them for armies fighting in the air.

If a patient believe in his hallucinations or illusions he is insane.

A delusion is a false belief in some fact which may have reference to the senses, as when a man thinks a rat is gnawing at his vitals, or it may be quite independent of these, as when he fancies he is a monarch, or the Messiah, or a great general, and so forth.

A person who has delusions is necessarily insane.

Almost all cases of insanity are preceded by a stage which is known as the period of emotional alteration. This may either be well-marked or very slight. The patient may have neglected his business, and his habits and temper may have altered; alternate periods of depression and excitement may have taken place; headache and insomnia are generally marked symptoms, and a general rule is that the greater the insomnia the more rapid is the progress towards undoubted insanity. If the physician be fortunately called in during this period of emotional excitement, an attack of insanity may often be warded off by judicious treatment of the insomnia by such drugs as trional, sulphonal, and chloralamid. Warm baths, also, with cold affusion to the head, will often procure refreshing sleep.

It will be advisable, I think, for me to give a short description of the symptoms of each of the forms of insanity I am about to deal with:

MANIA.

Acute, Sub-Acute or Hypomania, Chronic Mania.-Acute mania has a brief promonitory stage, generally unrecognized, but usually taking the form of restlessness and slight depression, after which there is a burst of violent excitement, with noisy incoherence, which may continue for days and nights together, the sense of muscular fatigue being altogether wanting. The tongue is furred, skin sweating and offensive, the bowels constipated, urine scanty and high-colored. The hair is harsh, and has lost its natural gloss. The habits are probably wet and dirty. The restless excitement may continue for days and nights together, the sense of muscular fatigue being altogether wanting.

The prognosis in early single attacks is good, but as the attacks multiply, it becomes less favorable, and the disease may end in chronic mania or dementia. There is in all cases a somewhat remote danger of the patient dying of maniacal exhaustion.

As regards treatment, this can only be carried out in an asylum, or a lunatic hospital, and the sooner the patient is removed the better for him and his friends.

The utmost the family physician can do is to endeavor, pending removal, to procure abatement of the noisy and constant excitement, and here chloral hydrastis is a useful drug, but in administering it we must always bear in mind that the tendency to death in acute mania is by asthenia. It is important, also, to remember that opium and its alkaloids are worse than useless in acute mania. Even if a strong hypodermic dose of morphine induce sleep for an hour or two, the patient invariably wakes unrefreshed, and in a more excited state than he was before its administration.

Sub-Acute or Hypomania differs from acute merely in degree, as its name implies. In its very mildest form, little may be observable beyond some excitement, usually of an hilarious character, with restlessness and diminished power of application. The more pronounced forms approach more nearly to the type of acute mania, though stopping short of the noisy excitement and dirty habits.

The mild form is often transient, and may get well without any treatment at all. It is, however, likely to recur, and should it do so it will be probably in a more accentuated form. In this mild variety, treatment without removal to an asylum may be tried with a reasonable expectation of success. Rest, change of air and occupation, with the bromides, especially the ferrous bromide, in five-grain doseswill be useful. It is desirable to avoid both narcotics and alcoholic stimulants, as in these cases a craving is easily established.

In the more pronounced form of hypomania, asylum treatment is the best. Recovery in a few weeks, or possibly months, will most probably take place, though a very few cases drift into chronicity.

Chronic Mania is rarely seen in private practice, its victims usually being already inmates of asylums. The symptoms vary greatly. The delusions may be many or few. Some of these patients are docile and work fairly well under supervision, but they are nearly all liable to outbreaks of maniacal excitement at irregular intervals, home treatment being, therefore, out of the question. More or less brain degeneration is always present, and the prognosis is most unfavorable.

MELANCHOLIA.

Simple Melancholia, Melancholia with Delusions, Agitated Melancholia, Stuporous Melancholia, or Melancholia Attonita, Chronic Melancholia.-Some of the above will need merely a passing notice, as in them home treatment is quite impossible.

Simple Melancholia.-This in its mildest form amounts merely to depression of spirits, with gloomy and desponding thoughts, forebodings of evil, and a general pessimistic view of life, but without any irrationality. It has been said that those who have suffered from a bad attack of "the blues" have had an experience of a mild form of simple melancholia. In the more severe form all the symptoms become accentuated, the patient becomes hopeless and despairing; he sleeps badly, and awakens from his broken rest in deep despondency.

It is in this stage that promptings to suicide are likely to manifest themselves, and here it is important to remember that a melancholiac's symptoms are, as a rule, most pronounced in the morning, and are likely to ameliorate as the day wears on, so that if a melancholy patient destroys himself, the deed is almost always done in the morning hours. In early simple melancholia, the great question arises as to where ordinary depression of spirits ends, and true melancholia begins. It is important also to ascertain, if possible, whether any suicidal impulse is present, but leading questions on this subject must be carefully avoided.

The prognosis in simple melancholia is generally good, though improvement is slower than in corresponding cases of mania. Most recoveries take place within twelve months, and improvement in the general health, with increasing appetite, is usually of good augury. Some cases, however, become chronic.

It is these cases of simple melancholia which are most likely to do well outside an asylum. The very mild ones, like those of mild hypomania, will often recover without any treatment beyond a rest from work, a change of air, and an occasional mild hypnotic (chloralamid for chronic). In the more marked cases, if home treatment be decided upon, the patient should be in sufficiently good circumstances to afford a change of air and

scene, and two trained attendants, for, on account of the tendency to suicide, he must never be left alone, especially in the morning hours, for the reason mentioned above. The principal objects of treatment, after constant supervision, are to obtain sleep, to give adequate and even abundant nourishment, and to relieve the usual constipation.

In all cases of melancholia, solid food, if the patient will take it, is much more beneficial than the most nutritious slop diet. Obstinate refusal of food will often disappear after a few days' complete rest in bed. Should forcible feeding become necessary, or should the promptings to suicide be very marked, asylum treatment is indicated. In the insomnia of melancholia, in great contradistinction to that of mania, some of the preparations of opium and morphia are valuable; they do not seem to aggravate the constipation, and the drug habit does not seem to get formed in these cases. The Turkish bath is a useful adjunct. Some very good results have lately been obtained from the high-frequency current. The constipation must be treated on general lines, but no medicine should ever be administered surreptitiously, i. e., mixed with the food or drink.

Melancholia with Delusions. In these cases, hallucinations of hearing are very common, and next in order come those of sight, smell and taste. Those of smell are of grave import, and generally point to incurable insanity, very likely of alcoholic origin. These patients often think their souls are lost, and that they have committed the unpardonable sin. They very commonly recover, but their progress is slow, and may extend, with relapses, even over a few years. Occasionally the disease becomes chronic. Asylum treatment is imperative.

Agitated Melancholia is commonest in women. The patient is never still for one moment, but paces the room, or sits rocking her body to and fro, sobbing and moaning. She may tear her hair, or pick her skin into sores. Hallucinations are not, as a rule, present, but the delusions are numerous and distressing. She may think she has brought ruin on all her friends; that her soul is lost, and so forth. It is a curious fact that these pa

tients, in spite of their despair, are not, as a rule, actively suicidal, and they often take their food well. A large number get well eventually, but improvement is slow. Here, again, asylum treatment is the only course to pursue.

Stuporous Melancholia or Melancholia Attonita.-These patients will sit for hours in one position, plunged in melancholy, and seeming to take no notice of their surroundings, but they will almost certainly attempt suicide if they get a chance. They sleep badly, and are unwilling to take food. A great many of them gravitate towards a condition of dementia. They can only be managed in an asylum.

Chronic Melancholia.-This, like chronic mania, is rarely met with in general practice. It is usually a result of one of the acuter forms. These cases are unsuited for home treatment, for although remissions are common, relapses are equally so, and, during the latter, suicidal impulses are often very marked. The tendency is always towards incurable weak-mindedness.

Delusional Insanity or Paranoia.-This is a chronic disease characterized by fixed delusions, and unaccompanied by any failure of the reasoning faculties. These fixed delusions are generally of a disagreeable nature. The patient often thinks that strangers can read his thoughts, and they make gestures to him on the streets. Another common delusion is that paragraphs in the papers refer to him. Hallucinations of hearing, taste and smell are common. Soon he becomes indignant and resentful, and he is then prone to assault some passerby as the author of the annoyances. Later on, delusions of grandeur commonly develop, and all his irascibility tends to be swallowed up by his conceit as weak-mindedness becomes more marked. The prognosis is bad, but these patients often live to a great age.

It has been said that all paranoics are potential homicides, and that for this reason an asylum is the only place for them. There is much truth in this, but there is another side to the question. The power of self-control in some of these patients is very great, and I have latterly taken this very much into calculation when the question of placing them in an asylum has

been under consideration. However, I find the dangerous proclivities vary much with the patient's natural temperament, whether irascible and hasty, or gentle and patient. The person of the former temperament will assuredly seek to revenge himself on his persecutors, and, perhaps, commit a murderous assault on some inoffensive person, while one of the latter may content himself with tearful and piteous protests to his friends.

I have now under my observation two cases of paranoia of the latter type, both men, and both are at present at large and following their employment after a fashion. One of them has hallucinations of smell, delusions that people are spreading reports that he has had syphilis, and an erroneous idea that his rectum is obstructed. The other thinks he is pointed at in the streets, watched in all his movements, and that there is a conspiracy against him. They are both timid, patient men, and, in my opinion, most unlikely at present to act on their delusions, but rather to take them "lying down." They will, no doubt, come to an asylum sooner or later, as every paranoic must, but as each is able to earn a small living, and as neither of them shows at present any signs of violence, I think I am justified in taking the risk.

General Paralysis.-This terrible and fatal malady usually makes its appearance between the ages of thirty-five and fifty. It is much commoner in men than in women. Many of its early symptoms are physical rather than psychical, such as hesitation and slurring of speech, fibrillary tremors of lips, tongue and facial muscles, pupillary changes, enfeebled gait, and slight attacks of "faintness." These may be accompanied or followed by a silly kind of elation of spirits, forgetfulness, drowsiness, neglect of business, and, later, by the well-known myalomania, with delusions of wealth and grandeur, when the patient will squander money on useless articles. He may, sooner or later, find his way to a police court in consequence of some absurd act of indecent exposure, or some senseless theft.

Soon the attacks of "faintness" develop into epileptiform seizures known as congestive attacks. Remissions of all the symptoms very often take place, and may