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ceived entirely wrong ideas in the beginning and supplemented them by his unguided experience. It is the cherished hope of many medical men that there will soon be in this country a good school of refraction, and not until this is established will the evil effects of eyestrain be abolished, for it is not sufficient merely to wear glasses. Exactly the right glasses are necessary, as the wrong glasses are frequently worse than none at all. This method has been tried on a small scale in one penal institution. With even the work attainable at the New York State Reformatory, the resident physician reports that deportment and efficiency have been enormously improved by fitting the boys with glasses.

For the sake of economy the lenses and mountings can be made in the prisons.

There is a tremendous demand for proper optical work in this country, and for a convict to understand the work of an optician thoroughly would give him a better chance of earning an honest living after his sentence expires.

2. DRUG HABITS.

A large proportion of all criminals are alcoholics and drug fiends. The present The present method of dealing with them is entirely inadequate. It consists merely in withholding the stimulants to which they have accustomed themselves, thus increasing their ugliness of temper. They can be cured of crime only by being cured of this craving.

In an epoch-making article in the Journal of the American Medical Association for September 25, 1909, Dr. Alexander Lambert gave the formula and method of use of C. B. Towns' mixture of belladonna, hyoscyamus, and prickly ash, which in three days really does eliminate permanently the craving for alcohol, morphine, and narcotics in 80 per cent. of the cases. I believe this method ought to be used in every penal institution on those who suffer from this craving. Would this not have been a sensible thing to do in the following case? I know a burglar, who has served

three sentences, the last being for seven years. He is a perfectly honest man when sober and only steals when drunk. Practically then he has served all his time for drunkenness. How much better for him and the state to remove this cause and add to the community a permanently honest man!

3. AS TO STOPPED-UP NOSES.

The medical profession is awaking to the fact that a large number of diseases are due to conditions in the nose as an underlying cause, and mouth-breathing as its consequence. From this come long-continued colds in the head, attacks of sore throat or tonsilitis, catarrhal deafness (which constitutes 95 per cent. of all deafness), irregular teeth caused by lateral pressure on them by the cheeks, giving mouth

breathing either by day or night, resultant

bad position and interlocking of the teeth, and a greater consequent deposit of tartar around their roots caused by the pockets thus formed for the retention of food particies, and the difficulty of cleaning them properly with the tooth-brush. This frequently goes on to formation of pus around the teeth, with their consequent decay and loss, and the flow of pus increases the frequency of sore throat and many digestive troubles. Many cases of appendicitis could be traced to this source of infection, and many surgeons now refuse to operate for this disease until the teeth have been put in a healthy condition.

Nasal disease is frequently an essential factor in the production of asthma and hay fever. Nasal obstruction results in mouthbreathing, with consequent lateral crowding of the teeth by the pressure of the cheeks, not counterbalanced as it is normally by the outward pressure of the tongue. This often makes it impossible for the lips to close over the teeth and mouth; breathing is continued even after the nasal obstruction is removed. Breathing through the mouth, the patient inhales the germs that have been spit in the street by consumptives and blown up in particles of dust. Tuberculosis of the lungs, of the

spine (hunchback), of the joints (as in hip disease), in most cases has as an underlying factor bad conditions in the nose. These nasal abnormalities, by producing attacks of bronchitis or by causing enlarged tonsils, present a favorable soil for the entrance of the germs of this disease. The so-called green sickness of young girls is nothing but unsuspected tuberculosis of the lungs or lymph glands.

The following case illustrates the connection between nasal stoppage, irregular teeth, and hip disease: Two years ago a boy of 10 was brought to me with pronounced nasal stoppage and irregular teeth, which gave him the appearance of the typical degenerate. His mother kept postponing an operation for the relief of this condition until he finally contracted hip disease. I am told that he must wear a brace for the next five years. Now, if that boy had belonged to poorer parents, the disease would probably have progressed until he was a cripple and he would subsequently have joined the ranks of beggars or incompetents who are always parasites on the working members of the community. Another example is a boy of 23 who has served two sentences in the House of Refuge, one in the Elmira Reformatory, and two years in Auburn Prison. Tuberculosis of the spine makes any prolonged physical exertion difficult, and this was due primarily to mouth-breathing. Dr. Orton informs me that 51 per cent. of defective boys entering the Rahway Reformatory suffer from serious nasal disease, and 33 per cent. of them have teeth which are so bad that they are a menace to their general health and efficiency. This is directly along the line of the results of the investigation conducted by the Russell Sage Foundation, which shows that children with defective teeth average worse in their studies than children with normal teeth. Lateral crowding of the teeth caused by nasal stoppage is one cause of what is known as impacted teeth, where a tooth comes in at right angles to an adjacent tooth. This is a cause of neurasthenia and insanity. Dr. W. S. Upson, of Cleveland, O.,

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Just as primitive life had its disadvantages and its diseases, so civilization has them also. Primitive man was not obliged to stand for hours in the same position, continually overusing the set of muscles which hold up the arch of the foot, nor was he obliged to walk on hard pavements, necessitating the use of shoes and the consequent wrongly directed pressure on the small bones of the feet. With the use of pavements and the consequent necessity for shoes, combined with the enormous specialization and division of labor which civilization brings, a great many of us are obliged to be on our feet continually. This is particularly true of the class of people whose poverty, ignorance, and lack of proper home training impel them into our penal institutions. This disease is particularly common among waiters, housemaids, clerks in stores, policemen, car conductors and motormen, and in fact every one who is on his feet the whole day long. It is like eyestrain, in that it arises from the necessity of using constantly a muscle or set of muscles which were never used in this way in primitive life and which therefore have not been fitted by natural

selection to stand this prolonged strain. The result is particularly common among the peddlers of the lower East Side of New York, giving them the peculiar walk which is comically depicted on the stage in imitating the East Side Jew. It should be pathetic instead of comic, for it is associated with the most excruciating pain and is due to the breaking down of the arch of the foot caused by long hours of standing in the street beside his cart. It is easily corrected and prevented by properly made shoes or steel arches inside of ordinary shoes, which can be manufactured in your institutions.

6. UTERINE TROUBLES IN WOMEN.

Just one word about the diseases peculiar to women. Before a woman begins a sentence in a penal institution she ought to be examined for any displacements of the womb and for gonorrhea. Nothing makes more laziness than the poisons produced in gonorrhea, and nothing produces more crime than laziness. All lacerations due to child birth ought to be repaired and all displacements of the uterus ought to be corrected. An example of this fell under my observation when I was in general practice, and shows how important the latter may be. Twelve years ago I was consulted by a girl of 19 with the following history. She was lazy, nauseated, headachy, had pains in the small of her back, and, to quote her adopted mother, "would cry if you crooked your finger at her." In addition to this she was so selfish that she never did anything for anybody except herself. After replacing a womb which had been pushed over backward by a sudden jolt when stepping off a street car, this girl became an industrious, helpful, unselfish woman.

7. DISEASES PECULIAR TO MEN. Most of the criminals I know have venereal diseases, and a routine examination of these ought to be made and appropriate treatment given. For example, most of them have chronic deep gonorrhea, which, as it gives no discharge is not recognized. A routine examination of the urine of con

victs ought to be made and, if cloudy, treatment instituted. It is very necessary, also, to make a routine examination for stricture, as undilated stricture is frequently the cause of chronic gout, and this often incapacitates people for work for long periods.

CONCLUSION.

There are almost as many exciting causes of disease as there are diseases themselves, but underneath them are a few great causes which can be grouped under two general heads faults of structure and faults of habit. That is, either the individual is built wrong somewhere, or else he is leading a wrong life. Sometimes causes from other. For example, the clergyman I bethese two groups act and react upon each fore told you of was suffering from a fault of structure in his eyes which caused his drunkenness. This habit was damaging his entire body, lessening his competence and so lowering his ability to provide properly for himself. Now, isn't it simpler and cheaper to do as Dr. Orton is doing in the New Jersey Reformatory with the cooperation of Dr. Frank Moore, namely, correcting all possible faults of structure and habit which lead to disease, rather than following the method of his predecessors, who spent hundreds of dollars on drugs which they distributed to the boys after they had become sick? With what help I can give him, Dr. Orton for the next year is going to pursue the following method: On the entrance of the boy into the reformatory he will give that boy proper glasses, if necessary. He will make a routine examination to relieve nasal stoppage, correct defective teeth, spine, joints, feet, and strictures of the urethra, and at the end of that year he will tell you what the results have been.

As matters stand now, men and women with physical defects come into our penal institutions and are compelled to work at occupations which they dislike because they cause some kind of physical discomfort. Just as prolonged near use of defective eyes increases their defects, so also does the prolonged strain on defective spines or

defective arches of the feet increase their defects. In other words, no matter how much we do in training these people morally, we actually turn them out of our institutions, in many instances with less physical ability than they came in with. Should we not turn these people out of our institutions in better physical condition, instead of discharging them in worse condition? And if we do so, will not many of them feel that their prison sentences were the best things which ever happened to them?

Won't some of you try the same method in your institutions? If you will I shall be glad to give my services and as much time as is necessary to the instruction of every physician whom you will send to me in New York. Won't you try it?

The Powellton, Broadway and
Ninety-seventh Street.

"SPES PHTHISICA."

BY THOMPSON FRAZER, M.S., M.D..

Asheville, N. C.

It is a difficult matter to change the trend of public opinion, especially when an opinion has been deep-rooted for centuries; old beliefs die hard. A statement containing a half-truth may by frequent repetition be converted into a dogma and accepted blindly by generations to come.

Such is the case in the attitude of the public toward the mental state of the tuberculous. By the world at large and by a considerable body of the medical fraternity he has been regarded as a hopeful, irresponsible being, who, without pains and without worries, looks upon his approaching death with serenity, for since the dawn of medicine "Spes phthisica" has been an axiom. It is the aim of this paper to show that not only is this cheerful frame of mind often lacking, but that the consumptive is, in addition, frequently subject to mental depression of a rather serious degree. Let us compare the writings of some of the tuberculosis specialists on this topic.

Cornet,1 discussing the "Physical Condition of the Tuberculous," says: "The changes which the mind undergoes in pulmonary tuberculosis are worthy of greater attention than they ordinarily receive." The intellect, he says, shows a somewhat diminished endurance, but (excepting for a tendency on the part of the sufferer to become introspective) is otherwise normal. The emotional state, however, varies greatly. At the beginning there is often "depression, hypochondria, or absolute helplessness," this frequently giving way, as the disease progresses, to optimism of the most intense sort. Often rapid changes of mood are encountered, according to Cornet, periods of hopefulness alternating with periods of great despondency. There is sometimes encountered a state of the mind which he calls "levity of spirits rather than good nature." Lack of will-power is common; the patient is easily irritated and shows little self-control. The picture which Cornet draws for us is that of a mild "neurasthenia."

Dr. Maurice Letulle2 shows us the minds of the consumptive in a more unfavorable light. He takes up first the intellect, and says that in the beginning there is often an increased activity of the mind, a "functional excitement" of the intellect. But brainwork soon becomes laborious and intellectual efforts are made only by fits and starts. Soon a general "lassitude of the intelligence" dominates the picture and a veritable neurasthenia develops. The power of attention is lost and prolonged mental effort becomes impossible; memory remains faithful, but is seldom utilized excepting in connection with himself and his condition; complete indifference to all things save those which affect him directly is very characteristic.

The moral nature likewise undergoes great deterioration, says Letulle. Some, it is true, accept with fortitude the knowledge of the seriousness of their condition

1 Cornet, Tuberculosis; Nothnagel's Practice.

2 Maurice Letulle, "Psychology of the Consump tive," Journal of Tuberculosis, Jan., 1901.

and remain brave to the end; but the greater number become moody, irritable, and selfish, while moral obliquities already present become exaggerated. "Sadness is the rule in tuberculosis"-sadness and selfishness, for egoist, the consumptive is, to the core; and egoist he will be, even though he recover, to the end of his life. The consumptive undergoes a real "shrivelling of the soul." The desire to exist which has become the sole aim of the invalid results in a sharpening of the normal instinct of self-preservation, so that he not only accepts, but demands as his right, all sacrifices that family and friends may make for him.

According to Minor the mental condition of the tuberculous varies greatly, a large number being normal; he quotes Wolff as saying that a morbid state of the mind is more apt to be the cause than a result of tuberculosis. Early in the disease there is apt to be excitability and irritability, due, perhaps, to toxins or to the knowledge that plans and ambitions will have to be given up or altered; in the course of time, however, a mental adjustment to the changed conditions takes place and the patient becomes more resigned and cheerful. In some patients there is persistent mental depression, and Minor finds this more common in those who do not live in special houses for the treatment of tuberculosis. He thinks that neurasthenia is especially common in Jews. He says that "spes phthisica" sometimes occurs in advanced cases, but that it is not as common as we formerly thought.

In comparing the views held by the writers above quoted, although we note differences of opinion as to the incidence and the degree of mental depression, we may safely say that the experience of all is that it is relatively common and that the "consumptive's hope," of which we heard so much in the past, is not of much importance and is apt to be confined to the more advanced cases.

To what is the psychical unrest of tu

Minor, in Kleb's Tuberculosis.

berculosis due? Is it to be attributed directly to the morbid process, or is it the result of conditions, such as the changed mode of living, with which the "cure" is associated? The former theory has its advocates, who attribute the neurasthenic symptoms to the toxins of the disease, but the most usual explanation is that the mental symptoms are chiefly the result of the patient's being suddenly obliged to give up his occupation and to abandon projected plans. A psychical revolt takes place, dissatisfaction and unhappiness occur and persist until he has learned to live his life on another plane, to fit himself into a new groove.

Environment is a factor of considerable importance; surroundings influence us all, but the consumptive without occupation becomes affected more readily by them. If at home, the well-meaning attentions of friends and of family may be a source of discomfort, and the invalid's comparison between his state of health and that of his friends does not affect him favorably. The attempt will be made to keep up to some extent with business and social interests, much to the detriment of the patient, who then loses heart because his progress is so slow. Nor is the environment always satisfactory at the resorts to which he is sent. If he attempts to take the cure at a boarding-house, where he is regarded as a pariah and is not allowed his reclining chair on the porch, the results will naturally not be satisfactory. Much more can be accomplished if the patient is put in a house in which only the tuberculous are received; they are there for a common purpose, a community of interest develops, and mental depression does not prevail to the same

extent.

Enforced idleness is a great mental strain. on the patient. It is not so many years since the tuberculous were sent west with the instructions to "rough it," to stay outdoors, and to take all the exercise possible. This method of treatment having been tried and found wanting, was superseded by the "rest treatment." Rest, in

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