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tions that have to do with love. Take for example fetichism. Normal love," according to Ludwig Brunn, "is a symphony of tones of all kind — results from various stimuli. Fetichism appreciates the tone of but a single instrument and results from but one stimulus." The fetichist is a man with one predominant sense. Fetich ism may be a predominant note in normal sexual desire, in inverted desire, in auto-erotism of the Narcissus type, or may be an expression of algophily.
In the chivalric love of the middle ages this fetichism appears. The "favors" given by fair ones were both "tokens of remembrance" and sexual excitants of satisfaction. The suggestive places in which many of these were carried furnish ample evidence of the latter function. Many, of the present day, wear these tokens with a high sense of chivalry and all unconscious of the powerful sexual element in the symbolism; but that element nevertheless is present and dominant. These "favors" stand as the shadow indicating the substance; but to the fetichist they are the substance. We may term this reversal abnormal but it is not more lustful than love itself. Love is normally a fetichism according to Tarde: "We are a long time before we fall in love with a woman," he remarks. "We must wait to see the detail which strikes and delights us, and causes us to overlook what displeases us. Only in normal love the details are many and always changing. Constancy in love is rarely anything else but a voyage around the
beloved person; a voyage of exploration and ever new discoveries. The most faithful lover does not love the same woman in the same way for two days in succession."
And so we find in erotic symbolism
extreme development of forces present and active in normal sexual selection, which latter has evolved from "the simple search for physical sexual means of satisfying protoplasmic hunger." Out of this basic desire. arise all that is fairest and most tender in our human relations: ideas of beauty; maternal affection and the desire to please and serve those we love. The romance and chivalry and sacrifice of centuries are grouped about this primal law-this call of cell to cell. And out of this romantic love, with restrained egotism, crop the perversions of the saddist, the masochist and other sexual psychopaths.
There can be no plea for toleration of these abnormals, for before any consideration of them as individuals must be placed the right of society to be protected from obscene exhibitions; and of youth to be safeguarded from pernicious influences. But it would be well for the medical profession at large and the legal profession also to have a clearer conception of the origin of these perversions, of the imperativeness of many of them, and of the fact that these perverts are quite distinct from the degraded and degrading debauchees and sensualists, who because of failing sexual powers or a depraved moral sense, offend with perverse acts public morality and personal modesty.
Brief Notes on Vasomotor Ataxia.
By SOLOMON SOLIS COHEN, M.D., Philadelphia. Professor of Clinical Medicine in Jefferson Medical College. Vasomotor ataxia is a term introduced into medical literature by the writer, and first published in a lecture delivered at the Philadelphia Polyclinic in 1892. It had been used by him, however, for some six years previous to this time in his lectures and clinical demonstrations, the first case thus diagnosticated having been observed in 1885. This case was reported, with others, in a communication to the Pan-American Medical Congress at Washington 2 in September, 1893, and a further communication was made to the Association of American Physicians 3 in 1902. Hans Herz published a monograph on the subject under the title, "Zur Lehre von den Neurosen des peripheren Kreislaufsapparates (Ueber Vasomotorische Ataxie)," Berlin und Wien, 1902. Citations from the author's paper of 1893, and various allusions to the subject have since found their way into many journal articles and text-books; among the latter, Monro's brilliant treatise on "Raynaud's Disease" (Glasgow, 1899), Cassirer's encyclopedic study of "Vasomotor-trophic neuroses and Osler's article on "Vasomotor Disorders" recently published.
Cases belonging to the group established by the writer have also been reported in Germany under the head of
1 Phila. Polyclinic, June, 1892.
2 American Journ. Med. Sci., Feb., 1894. 3 Trans. Asso. Amer. Phys., 1902, p. 654 seq. 4 Vasomotorische-tropische neurosen, Berlin, 1901.
Modern Medicine, Vol. VI, page 626.
"exudative diathesis "; in France as examples of the "angioneurotic diathesis "; and in England as types of "vascular incoördination," and "vascular crises."
It seems, however, to be as yet unfamiliar to the general medical public. The most elaborate account published by the author is to be found in his communication on the subject of "Viscereal Angioneuroses" to the Association of American Physicians in 1909, and those especially interested are referred to that article.
The present paper, communicated at the request of the Editor of the MEDICAL REVIEW OF REVIEWS, is intended merely to summarize the main facts.
Vasomotor ataxia is not a disease, but a condition; it is dependent upon an aberration an aberration (apathy or erethism) of the autonomic (sympathetic) nervous system. It is usually congenital, commonly hereditary, but in a small number of cases appears to be acquired in sequel to disease, privation, fatigue or shock. It is often observed in persons with very mild or very rapid tuberculosis; in persons recovered from tuberculosis; and in immune members of tuberculous families. Its detailed etiology, however, is as yet obscure. In persons who exhibit it, various and varying disorders, syndrome groups, affections, perhaps maladies, arise under the incidence
• Transactions Ass'n of Amer. Physicians, 1909, and New York Medical Journ., Feb. 19, Feb. 26, March 5, 1910.
of different exciting and determining dative and purpuric eruptions of various kinds, pseudo-angina pectoris, angina abdominalis, cardiac palpitation, tachycardia, vascular throbbings, epileptiform seizures, syncope, recurrent vertigo, transient hemianopsia or even complete blindness, intermittent swellings in and about the joints, chilblains, and a host, of irregular inconstant and perplexing disorders. In its less developed forms it often passes unnoticed; but it is just in these that its recognition is of the highest importance to the future welfare of the individual. Enlargement of the thyroid gland and derangement of the balance of internal secretions is a frequent accompaniment of the condition - hence a recent erroneous tendency to consider it a manifestation of "hyperthyroidism." This is putting the cart before the horse.
causes. As the fundamental and persistent factor (the other factors being adventitious, and often transient) its recognition and the realization of its significance is necessary to the understanding of the case and the preventive management of the patient; as well as to the immediate treatment of the special syndrome group or crisis.
The varying susceptibilities of different individuals, and of the same individual at different times, to the same influences, has long been a matter of everyday observation. We call it, whether exhibited in relation to the exciting causes of disease or to the action of foods or drugs, "individual liability," "predisposition," "idiosyncrasy "- terms which in themselves are simply confessions of ignorance. For every so-called idiosyncrasy there must be a constitutional or temperamental basis, expressed both functionally and structurally-physically and chemically.
Thro comparison of the phenomena, special and general, exhibited by a group of persons presenting similar or identical idiosyncrasies, we take a step toward the recognition of the basic conditions.
There is exhibited by many persons an idiosyncrasy of the circulatory mechanism, which, in its extreme degrees, manifests itself in the form of well recognized and persistent symptom complexes - such as Graves's syndrome and Raynaud's syndrome; in its minor degrees gives rise to manifestations of great variety of detail and severity, and usually paroxysmal in type — including migraine, hay-fever, certain forms of asthma, circumscript (angioneurotic) edemas, gastric, renal and other visceral crises, serous discharges, hemorrhages, exu
In the class of persons under consideration, constituting a distinct variety, and approximately one-twentieth, in number, of the human species, there is a relatively imperfect power of adjustment of the circulatory mechanisms to internal and environmental changes. In these individuals the cardiovascular equilibrium is disturbed by influences that in persons belonging to the other nineteen-twentieths of the species have no such effect, and greatly disturbed by influ ences that normally have but slight effect; while restoration of the physiologic balance is slow and imperfect. Their symptoms are exaggerations, sometimes caricatures, of the physiologic and pathologic reactions of the average man.
For a brief designation of this condition the self-explanatory name of vasomotor ataxia has seemed appropriate. Ataxia autonomia might be more comprehensive, since it is not the
cardio-vascular system only that is affected, but the entire autonomic nervous system. The vascular manifestations, however, are the most persistent and most obvious. Hence the original designation has been retained. Neither angiospasm nor angioparesis would be strictly correct because both excessive vascular dilation and excessive vascular constriction may be either spastic or paretic-or even, in not a few cases, both spastic and paretic -as dilator or constrictor nerves, or both, are affected. Moreover, even in the extreme and opposite types of vasomotor ataxia, the phenomena, while always more or less paroxysmal, are neither exclusively those of dilatation nor exclusively those of constriction; but both abnormal dilatation and abnormal constriction are usually present in varying degrees in the same patient.
Three types of reaction may therefore be separated: (A) chiefly constrictive; (B) chiefly dilative; (C) chiefly mixed.
The manifestations may be local, diffuse or general. They may affect any tissue, region or organ; frequently many regions simultaneously. simultaneously. In their production three factors are at work: (1) the constitutional liability (2) an excitant (3) a (local) de(3) a (local) determinant. The liability is one and constant; the excitants and determinants are various and inconstant; the resultant symptoms are therefore multiform. When excitants and determinants recur periodically, the attacks are likewise periodic; when these factors manifest irregularly, the attacks are irregular.
The excitants are, for the most part, temperature and cold more than heat fatigue, emotion (espe cially shock, anger, grief, fright and
fear), reflex irritation, and toxic or irritative agents formed in the organism7 or introduced from without; sometimes doubtless the products of infection.8
The local determinants may be direct or reflex. Among them are position, gravity, pressure, (which may be very slight), anatomical peculiarities, local irritation, the presence of indigestible food, eyestrain, overexertion, selective drug or toxin action.
Whether perversions of metabolism and derangements of internal secretions are to be classed only with exciting factors or are concerned in production of the fundamental liability or whether, as seems more probable, there is a "vicious cycle," which extends beyond individuals into generations the facts yet at hand are insufficient to determine. Doubtless in some cases there is a specific, and usually hereditary, anaphylaxis.
As already stated, the condition is usually congenital; in most cases inherited. Similar but not identical liabilities are exhibited by many members of a family, and this is frequently to be traced through many generations. Certain races, Russian Jews and Irish Celts in particular, are especially prone to the development of these symptoms; but they are to be found in all
7 In chronic nephritis and in chronic tuberculosis certain symptoms, especially the eyesigns (exophthalmos, retraction of lids, etc.). are not infrequent. In the former case the nephritis may, at times, be a sequel to longcontinued vascular disturbances; in other instances the patients do not belong in the present category. The relation with tuberculosis is more fundamental, but it cannot be discussed here.
8 Infections of certain types may give rise in normal persons to symptoms of the same order, but these cases are out of the present category; just as the normal results of severe cold, severe shock, and the like, are excluded. The essence of vasomotor ataxia is the disproportion of effect to cause.
races and nations. In the minority of instances vasomotor ataxia may be acquired as a sequel to disease, privation, anxiety, shock, or prolonged fatigue.
The most striking and easily recognized phenomena are those exhibited by the heart and by the cutaneous vessels (arterioles, capillaries and venules). Analogy early indicated that similar occurrences were frequent in the vessels of glands and viscera, and this has since been confirmed by anatomical studies, both post-mortem, and, thru the opportunity afforded by surgical operations, during life; angioneurotic edema and angioneurotic congestion of various portions of the gastro-enteric tract having been demonstrated. Congestions, edemas, acute varices have been seen, likewise in the conjunctivæ, retina, nose, lips, mouth, tongue, pharynx, oesophagus, rectum, larynx, and trachea; and they may occur in the bronchi, the appendix, the gall ducts, the pancreatic ducts, the ureters, the neck of the bladder, etc. Realization of this fact clears up many a perplexing case. Certain symptoms are only to be explained by disturbance of cerebral circulation; and as indicative of the reality of such disturbances may be taken Hansell's observations upon the eye-grounds of a number of the writer's patients.
THE DIAGNOSIS is in the main a diagnosis of the patient, rather than of the particular collocation of symptoms constituting a special attack. For For while some patients present consistent attacks of the same type, e.g., migraine, asthma, urticaria, hay-fever, cyclic vomiting, others present from time to time attacks of varying type; H. F. Hansell, Ophthalmic Record, xix, p. 199; p. 306. Trans. Amer. Ophthal. Soc'y, 1910, p. 526.
and even those who exhibit recurrence of consistent paroxysms may, in the intervals, have various other kinds of seizures. Thus the same patient may show at one time hives; at another "dead finger"; at another acute indigestion, with colic and pyrosis; at another vertigo or asthma; at another membranous enteritis. Or eczema may alternate with purpura in the intervals between crises of vomiting or of polyuria. In one case, partial loss of vision in another, complete loss of vision was the initial symptom; but the recurrent crises were of angioneurotic edema, affecting especially the lips, tongue or larynx. The variety, if not infinite, is at least indeterminable. Sometimes there is an abrupt transition in the type of attacks. Thus one patient had serous diarrhoea, with colic, annually from his sixth or seventh to his nineteenth year, when hay-fever was apparently substituted. substituted. Another patient suffered from paroxysmal tic instead of pseudoangina pectoris. Patients who have had frequent migraine in early life may have, in later life, infrequent headaches, gastro-enteric crises or asthma, instead. Most women develop some vasomotor disturbance during the climacteric, but in those belonging to the class under discussion the symptoms are exaggerated and often bizarre. In one patient, asthma of frequent occurrence took the place of hay-fever that had appeared every August for 19 years. In another woman, following oophrectomy, hemicrania, recurring biweekly, was substituted for menstrual sick headache. Menstrual derangements are common. Sometimes, both in children and in adults, organic affections or acute inflammations are mimicked by vascular crises; and patients have thus been mistakenly operated