There is one thing they all agree upon that this group of symptoms indicates disease of some part or every part of the nervous system. The changes noted in the patient come on gradually. There is alternation of exaltation and depression in alternate waves lasting from one to three weeks each; a morbid watching of himself; exaggeration of his suffering and constant introspection; feeling neglected by others; intense belief in his own knowledge of his own condition and what is best for himself regardless of the experience of others; a disinclination to see a physician; the firm belief that he will recover; lack of desire for occupation; lack of ambition; nervousness in the presence of others. He has that tired feeling, or at least the absence of the feeling of conscious well-being. In nearly every case some delusion will be found referable to the region of the spine or chylopoietic system, or an unreasonable belief that there is existing some morbid condition of the body which no one can understand or explain. Society and the family relatives are of no interest to him. As one set of symptoms of an exaggerated or depressed condition of things disappears another takes its place. The appetite is poor, the skin is dry or excessively moist with lessened reaction after cold bathing. Sleep broken, and if the patient sleeps long enough in hours he is unrefreshed. He is oversensitive to noise and cannot endure even rhythmical sounds. He is nervous and restless and the little things that were formerly unnoticed are now very annoying and burdensome. Instead of appearing anemic, the patient is as often of full habit, ruddy color, and the number of blood corpuscles and the presence of hemoglobin normal, as demonstrated in a large number of cases I have examined. All this means that, from lack of elimination, the system reabsorbs from the blood its own ptomains and there occurs a form of autointoxication. Nervousness, weakness, insomnia, headache, neuralgia, vertigo, exaggeration and depression with local anesthesia and hyperesthesia over the spine (more frequently the latter) and elsewhere; this whole train of symptoms is born of a lack of physical nutrition, and there is not a symptom detailed in all this varied category, so-called neurasthenia, which does not belong to either hysteria, hypochondriasis or mild melancholia. True, neurasthenia may be a convenient term to molify the friends of the patient, but neurasthenia, as a distinct disease, in my opinion, does not exist. It is a popular term among the laity, and many a young woman has become a useless being in this world of action because she thinks she has neurasthenia or as later termed "amencanitis," the which name I utterly repudiate. It is a matter for consideration how much we physicians are to blame for encouraging this popular delusion and whether we may not some day on this very account he accused of nursing patients instead of placing a veto on this laity-born, selfperpetuating fad and letting firm-willed training school graduates do the nursing. I believe we are today on the verge of a revision of our nosological nomenclature, and that diseases should hereafter be classified in accordance with their essential producing causes. When this comes to pass the term "neurasthenia " will be dropped. We are not content with what knowledge we have gained secure or insecure, and while using it as best we may for the good of humanity we realize in all humility how much there is we cannot know yet cannot doubt. SHAKESPEARE asked, “Who can minister to a mind diseased?" I answer, "No one," but we can minister to the body and brain diseased, and that right well. Omitting the etiology of these conditions of the nervous system in reference to congenital physical defects, and the effect of the toxic matter of specific origin, I believe these abnormal states can be expressed in one word, malnutrition, and in turn that this condition of the body is due to the lack of equilibrium between elimination and repair. A continual procession of nonviable atoms is constantly penetrating living molecules, where they are themselves converted into living molecules by assimilation, that undiscoverable power of living matter. Each complex living molecule by varied processes of endosmosis, exosmosis and the chemical reactions with oxygen and other gases, is reduced to a dead or useless condition of matter, which then is eliminated to make way for the ingestion of othe new nutrient atoms. The systematic repetition of these processes is life and health. When we quit dying (eliminating) we cease to live. While in health, so far as consciousness registers these two processes are simultaneous, in a pathological state of the body to be treated we would place elimination preceding repair. In a sound balance there is a complete balance of this double process of nutrition. But when the equilibrium of these molecules of living matter is distributed in nerve, muscle or blood corpuscle we have a functional disorder which if continued eventuates in a pathological condition. To produce or aid in producing this double process and reestablish its balance is rational medical treatment. I would rather outline the treatment under elimination, food, environment. A systematic course of hydrotherapeutic treatment is essential to the best. elimination through the skin. This is obtained by the Turkish, electric, vapor, hot mineral, or fresh water baths (always with cold to the head) combined or alternated with wet hand, dry hand, alcohol or oil rub and faradization, all of which can be given by a trained nurse under direction of the physician at the patient's home if he will take the trouble, and the doctor give explicit instruction. The hot bath determines the blood to the surface by temporary inhibition of the vasomotor system dilating the capillaries withdrawing the blood from the deeper tissues, causing perspiration and at the same time temporary increase of nutrition of the skin. Rubbing is skin massage. Faradization is a skin stimulant. I do not speak now of the induced current with TRIPIER apparatus which effects the muscles and deeper tissues. For the kidneys I direct a glass of mild alkaline water on rising, at 11 A. M., and 4 and 9 P. M., and use ozonate lithia, a pint or quart daily, if the solids are in excess. Saline laxatives with an occasional tablet triturate of one grain of calomel are given as needed. Alternation of rest and exercise is prescribed definitely. Passive and resistive manual movements are directed and those of mechanical appliances also, where available. Walking, horseback riding, cycling or the gymnasium practice after anthropometric examinations are prescribed, and when the patient is too weak to be out of bed, the induced current and massage are employed, the patient taking one treatment of each daily properly graduated in addition to some form of hydrotherapeutic measures. For stimulation of the nerve centres a hot fomentation of the entire spine, or the alternation of the fomentation and ice to this entire region produces admirable results. Cold head bath with heat to stomach, liver and extremities reduces cere bral congestion and determines the blood to the central organs when advisable. Wholesome nutritious food should be taken at regular intervals every six hours (during night, if awake) in large quantities, with or without an appetite. Appetite, I believe to be largely a mental condition. Stimulating broths, but not food nor milk, 'should be given between the intervals of eating. The stomach of even a sick person should have some rest. If there is difficulty of digestion, the stomach contents should be examined, and the lacking digestant should be supplied. The patient's environment should be pleasant, agreeable and often unhomelike. He should be mentally occupied and make some effort to forget himself by thinking of something else, and taking an interest in others. The removal from responsibility, change of occupation (not idleness, though no set heavy tasks), living away from scenes where the association of ideas will bring a return of the morbid thoughts are essential aids to recovery. With the daily oversight, care and direction of the physician, and the above indications intelligently carried out, the great majority of this class of patients, both chronic and acute, will recover, and many men and women be saved from a life of insanity in the present and in the next generation. REPORT OF A CASE OF DOUBLE PYOSALPINX.* BY JAY L. McLAREN, M. D., SAGINAW, MICHIGAN. [PUBLISHED IN The Physician and Surgeon EXCLUSIVELY] IT affords me pleasure to report an interesting case of double pyosalpinx upon which I operated a short time ago, and I hope that the points connected with it may be of some benefit to physicians in handling similar cases, which, I am quite positive, are more numerous in our midst than are generally recognized. The case is that of a young married woman who has one child three years of age. There is nothing unusual in the history of this patient up to October 5 last, when, not menstruating at her regular time, and suspecting a possible pregnancy, she introduced a soft catheter into the uterus. This instrument had been in the house for some time, and had previously served a similar purpose for another. A few days later she commenced flowing, apparently normal, and experienced no trouble until about a week afterward, when she began to have an uncomfortable feeling in her left side. At this time my services were sought, and, making a digital examination at my office, I discovered an enlargement of the left tube corresponding in size to my little finger. It was not sensitive unless subjected to considerable pressure. There had been no chill and only fever to cause an elevation of one-half degree of temperature; pulse about seventy-five. It was after the examination that I learned what had been done by the patient. The husband was informed of her condition, and likewise of the possible necessity for an operation. The patient was advised to refrain from lifting or straining, to keep the bowels open by salines, and to report in two or three days, or sooner if any marked change occurred. Three days later I saw her again at my office, and her general appearance was slightly changed, a more sallow complexion presenting. The pulse and temperature were a trifle higher, and the appetite had failed. The same uncomfortable feeling continued in her side, and examination revealed increase in the size of the tube. The patient was informed that an operation was necessary, *Read before the SAGINAW COUNTY MEDICAL SOCIETY. and two days later I asked DOCTOR B. B. ROWE to see her with me. the enlargement, but was somewhat uncertain regarding its nature. time the tube had increased to the size of one's thumb. He found At this The following morning I found a rapid development in size, and determined to operate at once. As the patient was averse to entering a hospital, I sent a nurse to the house to prepare for an operation in the afternoon. In anticipation of this emergency the patient had been put in suitable condition. On October 19, assisted by DocTORS ROWE, BECKWITH, WRIGHT and OSTROM, I dilated and curetted the uterus and made application of a ninety per cent. carbolic acid solution to the interior. An opening was then made posterior to the cervix through the culdesac and an effort made to extract the tube, but fearing the advent of a rupture this method was abandoned and the abdomen opened. The tube was lifted from the pelvis and ligated close to the uterus, without any difficulty or loss of pus. In pursuance of routine practice the right tube was then examined, and to my surprise I also found this one enlarged, adherent to the ovary, and both bound by adhesions to the pelvis. In separating them from their bed a small leakage of pus took place. This tube was ligated close to the uterus and removed. The abdomen was thoroughly irrigated with sterilized water, allowing it to pass through the vaginal opening as well as the abdominal. The vaginal opening was packed with iodoform gauze and the abdomen closed in the ordinary manner. The patient made a good recovery, having scarcely any pain and never more fever than two degrees. The points of greatest interest in this case are the absence of pain, chill, or of any fever to speak of before the operation, and the slow but gradual increase in the size of the tube until it approximated the size of a small sausage. I believe the majority of these cases are not diagnosed as such, but as pelvic abscesses, after leakage and peritonitis has occurred. In November, 1894, I opened an immense pelvic abscess following a pyosalpinx I had diagnosed a week previously, the family delaying an early operation on the advice of another physician. In July, 1893, I operated upon a similar case, which, judging from the history, resulted from the same cause. In neither of these cases was there any pain to speak of before the leakage. From the above cases one would conclude that the early symptoms are not in proportion to the gravity of the condition, and that consequently pyosalpinx is often overlooked until alarming symptoms ensue. TRANSACTIONS. DETROIT MEDICAL AND LIBRARY ASSOCIATION. STATED MEETING, NOVEMBER 11, 1895. THE PRESIDENT, ERNEST T. TAPPEY, M. D., IN THE CHAIR. DISCUSSION OF PAPERS. DOCTOR W. F. STRANGWAYS, of Flint, Michigan, read a paper entitled "Hay Fever: A Successful Treatment Founded on a New Theory." (See page 1.) DR. SHURLY: I am greatly interested in the doctor's paper, and particularly with the innovations that it contains. I trust that he may be able to demonstrate that this very puzzling and annoying disease can be traced to such an origin. A great deal of the confusion attendant upon the disease called hay fever seems to me to come from the fact that we do not clearly know the physiological function of the turbinated bodies. It has been demonstrated that the nervous influence of the sphenopalatine ganglion preponderates over this region. There may be certain anatomical differences between individuals in these cases which may account for certain peculiarities that exist. It has been clinically proven that there is a very strong neurotic element in hay fever, because we find that it attacks only certain kinds of individuals. The Russians tell us that it is very rare in Russia, and when it does occur it is among the class of people who live in warm houses all the time. There are a great many instances of the disease to pass over without comment; instances of attacks of hay fever being brought on through mental impressions. You are all acquainted with the fact that many people will have an attack of hay fever if they ride behind horses, others if they ride on a street car, others if they go into the stable, et cetera, which shows that animal emanations may also be responsible for an attack of hay fever. I will cite the case given by DOCTOR JOHN MACKENZIE, which many of you, perhaps, know of, where a friend of his, who had suffered with hay fever for a great many years at a particular time, was subjected to experiment. He thought that she would be a good person to experiment upon with regard to psychic influences. He therefore obtained a fine wax rose. She was invited (just before the hay fever season, perhaps two weeks) to visit his house, and while there he requested her to step into his office, saying "Here is a beautiful rose; I want you to smell of it." "Oh my! you will bring on my hay fever." "But your hay fever does not come on until the 21st of September, and it is not nearly that time yet;" so she smelled of the rose, which brought on the sneezing characteristic of the disease, profuse watery discharge from the nose, the eyes became suffused with tears, and all the phenomena of hay fever were present. He afterward showed her that the rose was only wax. She felt a little dubious about it for a time. That is an illustration on record, by a man whose observations are always very conservative and correct, showing that there is a strong psychic influence in the etiology. It is not claimed, as I understand, that such individuals to be neurotic must have had antecedents who were insane or epileptic. As I understand it, the neurotic tendency is something that can be acquired just the same as any other predisposition can be acquired. The neurotic effect may be localized or general; in other words, such a person may have the neurotic disturbance expressed in one locality or another, in the nose or elsewhere, and until we know what is the nerve supply of the part I do not see how we can positively say that the cause in any given case is of local or general origin. Now, in regard to the treatment. Some people are relieved by going to certain districts. Some patients of mine have been relieved as soon as they get upon Lake Saint Clair. I have had patients severely attacked while attending to business down town in the lower part of the city, who, on going to their residence in the northern part of the city, would be relieved. With regard to the fact of there being, generally, inflammation of the nasal passages, I agree with the doctor, that there is none, but that there is vasomotor paresis. The blood-vessels get filled up; they lose their contractility, and we might have a permanent lesion. Many of the cases of hay fever are not due to deformity of the nasal cavities or to neoplasms. The doctor's |