VOL. XIV. No. 15.

TERMS: $3.50 A YEAR.

REPORTS ON PROGRESS.

rotomy operations in general, the profession should be made to feel that it is acting under

AND NEUROTHERAPY.

BY C. H. HUGHES, M. D.

I. CASTRATION IN NERVOUS DISEASES.
II. INSANITY AND CRIME.

III. URETHAN, PARALDEHYDE AND CHLO

BAL IN THE NEUROSES AND PSYCHOSES.

IV. URETHAN AND PARALDEHYDE COM

PARED.

V. URETHAN HYPODERMICALLY EMPLOYED. VI. THE NEUROTIC SEQUENCY OF RAILROAD SHOCK.

VII. CLASSIFICATION OF MENTAL DISEASES. VIII. MECONEUROPATHIA.

CASTRATION IN NERVOUS DISEASES

is a smyposium of unusual interest at this time, and a most timely contribution by three writers. T. Spencer Wells leads, Alfred Hegar follows and Robert Battey concludes this interesting discussion which sets forth the views of these gentlemen and reveals the real progress in the direction of a rational therapeutic conservatism for this formidable remediable procedure which, while it has the power to remedy grave morbid conditions impressed upon the nervous system, it also cut off the possibility of posterity, healthy or diseased, to the castrated patient, and hence the wisdom of the language on the introductory paper of Spencer Wells' interesting article. "One is brought to see how indispensible strict ethical training is as the complement of technical education; how needed is a check upon the impulses of acquired or repeated manual dexterity; how, in reference to lapo.

decisions of its wisest and most vigilant leaders." And the following:

"In looking at the vast multitude of patients who come under professional notice with a medley of nervous or mental symptoms, so tantalizing by their refractoriness and their inexplicability, we can understand how it is that many hasty, impressionable practitioners exasperated by their fallibility, infatuated with novelty, enticed by example and eager for local notoriety, have yielded to temptation, have risked numberless abdominal sections in the hope that chance would favor them, and so have helped to prove how strong is the contagion of folly."

Spencer Wells, in the name of a sound and conservative gynecological neurology that would neither under-estimate or

over

value the relationship of the female generative organs to neural disease, we thank you

for this well-timed and truthful rebuke.

In the name of an honest, philanthropic and conservative psychiatry, which, while it seeks not to irreparably harm woman, would reject no curative procedure however radical, when absolutely demanded in her interest; in the name of that divine injunction "whatsoever ye would that others should do unto you, that do ye even so to them" and not more nor less we thank you for these bravely spoken words. It can never be said with your consent that "woman has no physiological rights that operative gynecology is bound to respect."

The following are the conclusions of the distinguished writer and surgeon:

1. That the operation of oophorectomy, or

the removal of normal ovaries, is one which

may be advised in some cases of uterine fibroids, and in uncontrollable uterine hem orrhages.

2. That it is to be resorted to in certain inalformations of the genital organs, deformities of the pelvis, and accidental obstructions of the vagina.

3. That the right to use it is very limited in cases of ovarian dysmenorrhea or neuralgia, and only when they have resisted all treatment, and life or reason is endangered.

4. That in nearly all cases of nervous excitement and madness it is inadmissible.

5. That it should never be done without the consent of a sane patient, to whom its consequences have been explained.

6. That the excision of morbid ovaries and appendages should be distinguished from oophorectomy, and ought not to be done without the authority of consultation, as in most other cases of abdominal section.

7. That in nymphomania and mental diseases, it is, to say the least, unjustifiable. After these conclusions, Spencer Wells thus discourses:

"Professional reputation is a sacred trust. To maintain it is with us a personal obliga. tion, and our individual responsibility is now greater than ever. People pay little heed to presidents and rectors. The village doctor represents the profession to them, and each in his little circle is high priest and chancellor. By his skill and conduct the whole faculty is judged. He is like one of the fragments in a mosaic. If he is unsound, goes wrong, fails in fidelity to the lex non scripta of his class, he falls from his place, leaves a blot which all can see, and the whole composition is marred. In the exercise of his profession, each member is so independent, while all are so linked together in honor and duty, that, as sentinels, we have a mutual interest in keeping watch and ward over each other's loyalty, and sounding an alarm in case of default. Of late, the laparotomy epidemic has called for one of these challenges. It has roused a feeling not of jealousy, but of suspicion and concern for professional honor. When men in clubs be When men in clubs be gin to jeer at gynecological, domiciliary fus

siness, and husbands are furious at the ru mors of mysterious diseases, unknown to Sydenham and Cullen, being rife among their daughters there must be something wrong. It is time to look into the matter. If we hold the mirror up to nature, only changing the sex of the actors, the spectacle is not flattering. Fancy the reflected picture of a coterie of the Marthas of the profession in conclave, promulgating the doctrine that most of the unmanageable maladies of men were to be traced to some morbid change in their genitals, founding societies for the discussion of them and hospitals for the cure of them, one of them sitting in her consultation chair, with her little stove by her side and her irons all hot, searing every man as he passed before her; another gravely proposing to bring on the millenium by snuffing out the reproductive powers of all fools, lunatics and criminals; a third getting up and declaring that she found at least seven or eight of every ten men in her wards with some condition of his appendages which would prove to be incurable without surgical treatment, and a bevy of the younger disciples crowding around the confabulatory table with oblations of soupplatefuls of the said appendages. "Should we not in our shame see ourselves as others see us?"

*

Prof. Hegar holds that castration is indicated in a psychosis evoked or maintained by pathological alteration of the sexual organs, and in a neurosis originating from the same source, as soon as this imperils life or hinders all occupation and all enjoyment of life. The indication is also present when that disease represents only one causal factor in the genesis of the affection, without the removal of which a cure is not to be thought of. The remaining causes of suffering must be in this case accessible to treatment. Other milder methods of treatment must have been tried previously without success, or, as in the case of many small tumors of the ovaries and tubes, must from the outset give no promise of success. Castration must actually affect the cause which occasions or keeps up nervous irritation. The operation will thus be

of use when a degenerated or dislocated ovary represents the irritative focus, or as soon as a greatly swollen and retroflexed uterus presses on the sexual plexus and the organ is brought into a state of atrophy. Castration promises success when the bleeding and anemia occasioned by a fibroma play an important part in the maintenance of a psychosis, so that a cure does not appear possible without getting rid of that evil; but castra tion is absolutely no universal remedy for any neurosis originating from a genital organ disorder, or kept up by the same. The cessation of ovulation will avail nothing if the irrita tion starts from the nerves which are com. pressed in a shrunken cicatrix of the broad ligament, or elsewhere in a cicatrix of the pelvic connective tissue.

Dr. Battey performs castration for the re lief of three classes of mental and nervous disorders, oophoro-mania, oophoro-epilepsy, and oophoralgia. He uses the terms oophoromania and epilepsy instead of hystero-mania and hystero-epilepsy, because clinical experience teaches him that these disorders are de pendent upon a nervous irritation proceeding from the ovaries and not from the uterus. He finds the disorders existing (a) in cases in which he recognizes organic disease of the ovaries, and is not able to recognize any organic disease of the uterus; (b) in cases of uterine as well as ovarian disease, when the diseased ovaries are removed, the nervous disturbance disappears, notwithstanding the fact that a displaced or diseased uterus may remain. In his experience the time required for the disappearance of nervous disorders, after removal of the ovaries, has been quite variable. In general, epileptiform manifestations have ceased at once. Some of the cases have required for a time the tranquillizing effects of the bromides to ward off threatening symptoms, whilst others have needed nothing. His cases of mania have all been quite chronic, and the improvement has been slow. In oophoralgia, in a few instances, the cure has been immediate and permanent. In the majority it has been slow and gradual; and in others nothing

has been gained for even two years after the operation. In a few the long established opium habit has proved a complete bar to recovery.

In his cases which have had two years or more to test them, seven have been cases of oophoro-mania, of them one was cured, and four improved; nine were cases of oophoroepilepsy, all cured; twenty were cases of oophoralgia, and thirteen were cured and three improved.

Dr. Battey in the course of his interesting article notes the fact that the removal of the ovaries has been occasionally followed by acute mania. In his own cases, relapses have occurred after three or six months. His cases of oophoro-epilepsy gave the most satisfactory results.

Dr. Battey quotes Byford, Reamy, Mann, (of Buffalo), Sutton, Howard, of (Baltimore), H. P. C. and Robt. T. Wilson, Addis Emmet and Gaillard Thomas' experience as mainly in favor of the operation under due precautions, and giving the unfavorable results of Baer, and recording the unsuccessful as well as successful record of Goodell, concludes as follows: "Castration of the female for nervous diseases has a brilliant future before it, and yet in this, as in other conditions, it is now being greatly abused by resort to it in entirely inappropriate and unnecessary cases."

Hegar further presents the following conservative considerations:

"Castration has had the same fate as many other curative measures; it was at the outset received with enthusiasm, was announced as the arcanum for all possible evils, and has finally in many quarters been completely rejected, when it did not, of course, completely fulfil the previously cherished expectations. The greatest part of the defective results has doubtless depended on the false position of the indication. All operations which are undertaken without the presence of a disease or anomaly in the sexual system are, according to the present standpoint of our knowledge, unjustifiable. The mere presence, however, of a pathological change in the genital system,

as has commonly been held, is not sufficient, and a strict proof of the causative connection between that change and the nervous disorder has to be demanded.

INSANITY AND Crime.

Dr. Richard J. Kinkead in the October number of The American Journal of the Medical Sciences discusses at length the relation of crime to insanity, and controverts the views expressed by Lord Bramwell in a late number of The Nineteenth Century and presenting the generally accepted advanced views of alienists on the duty of courts to the victim of insanity and the insane man's rights.

Dr. Kinkead believes that madmen who have committed criminal offences should be sent to an asylum. If an insane man commits homicide, he should be confined in an asylum for life; the protection of society demands this, not only to guard against a repetition of the act by the lunatic himself, but to prevent simulation of insanity by the sane. Imprisonment for life with lunatics would be to the sane far greater punishment than penal servitude to many, even worse than death. For less offences he should be confined in an asylum till cured. To punish a man for having a disease, or for the acts which his dis ease compels him to do, is unjust.

To remove a madman to a place where his disease will be properly treated, and where he cannot injure others, is just, politic, and humane. Penal discipline is injurious to the insane; lunatics cannot be kept in prison; not only because it is detrimental to them, but because their presence is subversive of discipline, and a constant danger to the other prisoners and to the officers. Whether a man is mad or not can be decided only by those who have experience of insanity-that is, by experts.

subtleties, they have not studied physiology or pathology, nor acquired experience of the insane; just as no amount of book learning alone will enable a physician to deal with sickness, or a surgeon to operate; so no mere mental philosophy or legal training will enable a lawyer to grapple with the paradoxes of insanity. If lawyers were obliged to spend six months in an asylum studying mental diseases, they too would be quite as anxious as doctors are that the law should be changed, and would be just as convinced that it is wrong, as Lord Bramwell is that it is right. Nor would they fall into the error of consid ering madness not a disease of the body; for whether we look upon mind as the product of the brain or merely working through it, it is disease, functional or organic, of the organ, which is either its origin or instrument that constitutes madness.

URETHAN, PARALDEHYDE AND CHLORAL IN THE NEUROSES AND PSYCHOSES.

The Alienist and Neurologist in its editorial columns, for July discusses these hypnotics: It is plain that the place of chloral as a hypnotic has not yet been perfectly filled. Its power in high states of cerebral excitement over urethan and paryldehyde, at least in safe doses, is still paramount, but both urethan and paraldehyde are most excellent alternates, permitting the perfect elimination of chloral after long use from the blood, and allowing the therapeutically besieged psychi cal centers to partly recuperate from the pow erful hold of chloral, while the physician may yet retain sufficient hold upon the aberrant cortex cells, by these alternate hypnotics, to maintain quasi physiological cerebral repose.

The doses of urethan given by Otto and Koenig seem to us needlessly large, but certain chronic forms and stages of insanity and idiocy require larger doses than the less exhausted and impaired cortex sensibility to narcotic impression of other forms and of the non-insane.

use of doses as large as from one to two and a half drachms, especially if not largely diluted.

Urethan, in our experience, has proven a most acceptable and efficient hypnotic, in fifteen-grain doses, given after the patient has retired to bed and after he has during the day taken a drachm or two of bromide of ammonium.

It is the most agreeable to the taste of all the hypnotics. In our hands it has proven highly valuable in the insomnia of melancholia and all morbid psychical states accompanied with sleeplessness and not associated with high maniacal excitement. In the latter condition we have not sufficiently often substituted it for chloral and hyosciamin to fully decide upon its merits. We have learned enough of it, however, from practical observation, to esteem it worthy of a valuable place in neurotherapy and give it a favorite place in many conditions in our own therapeutic armamentic train.

and which are so common in the course of cerebral affections, and have also noted good. effects in the convulsive neuroses, and in particular in the epileptic crises and multiple manifestations of hysteria, (Kéraval et Nerkam, Action hypnotique et sedative de la paraldehyde dans les differentes formes d'alienation mentale, Soc. Medico-Psychol., Mai, 1884; Nerkam, These de Paris, 1884), to which he adds that even in many cases of morphiomania he has been able to replace the morphine injections to which the patients were habituated, by paraldehyde, in the dose of three or four grammes (45 to 60 grs.) a day.

Chloral is superior to paraldehyde, in the fact that the latter drug sooner loses its effect on patients than the former.

His observations do not bear out the view. He has seen patients who for months have always obtained the same effects from the same doses, and cites, in illustration, the case of a Mexican affected with chronic icterus,

Dujardin-Beaumetz, in a late article in the Therapeutic Gazette very favorably compares paraldehyde with chloral for internal use. lle thinks it less irritating to stomach and pharynx than chloral. (He probably never gave it largely diluted in a viscid vehicle). It is not a cardiac poison, he says, is less anodyne. He thinks it a better antidote to strychnia than chloral, and though he concedes its inferiority to chloral or morphia in painful affections, he considers it better in "nervous insomnias, and especially in those produced by the abuse of alcohol, paralde- | hyde is much superior to chloral, and I have many times seen, in my hospital service, the great benefit which may be derived from paraldehyde in the disorders arising from inebriety."

And in the various forms of mental alienation he quotes Dr. Kéraval and Dr. Nerkam, who, in France, have made the greatest number of trials with it in maniacal diseases, who show that paraldehyde is an excellent hypnotic in certain forms of insomnia with restlessness,

habit of relying on a three gramme dose of paraldehyde to get his sleep at night, and who never has been obliged to increase the dose; and it was the only agent which he found capable of safely combating the tormenting it ching which deprived him of sleep, all other hypnotics having failed in consequence of determining ill effects on the part of the liver or stomach. I think, then, that paraldehyde does not lose its remedial power as soon as has been represented, and among the hypnotics it is one of those that may be the longest continued with the least inconvenience.

It remains to be seen whether, after it shall have been as long tried and as much used as chloral, the superiority asserted for paraldehyde over chloral by this writer and clinician will be maintained. Until further and more convincing testimony, we shall still adhere to our old therapeutic friend in combatting the somnolent and convulsive neuroses.

Paraldehyde has also been given hypodermically and by enema. The hypodermic injections, however, have proven so painful as