1914-20 that a certain crystalline product of anomalous thyroid glands was able to determine convulsive crises. This body was of protein nature, formed octahedral crystals, and contained in its molecule some phenol derivative. In 1916 Parhon found these

crystals in the thyroid of an epileptic during life.

Studies by Buscaino, Parhon and Stocker have shown that these crystals occur in about 70 per cent of epileptics. A large number of non-epileptics have since been investigated and less than 15

per cent of these controls showed the crystals. The total number of epileptics examined was 62 and of controls 326. In addition to the authors who obtained the positive results others collaborated on the controls and the latter comprise Isenschmidt who examined 106 and Clerc with 83. The manner of examination does not appear and it also seems as if symptomatic cases were included with idiopathic. Apparently the thyroids were examined both post mortem and after operation and the crystals were revealed in sections of thyroid properly stained. The enlargement of the microscopic examination is not stated but was presumably not very high. Other facts which implicate the thyroid are epileptic convulsions in myxedema and cretinism (Browning, Hertoghe, Levi-Rothschild and Rapp). Epileptic progenitors have myxedematous children (Hertoghe) and goitrous and Basedow parents epileptic children (Browning, Jeandelize, Samaja, and Parhon). Goitre is not rare in epilepsy and has been seen by Jeandelize, Schultze, Bastin, Mosse; Basedow and epilepsy are frequently associated as recorded by Parhon, Kurella, Ballet, Benedikt, Raymond, Delasiauve, Euziere, Margarot and others.

Study of the distribution in Italy of goitre and epilepsy is instructive. Sormanni and also Morselli have noted the frequency of epilepsy in the maritime counties and recently Consiglio has corroborated this. It is in these coastal communities that the thyroid seems stimulated. Maranon states of the Spanish coast that the hyperthyroid predominates there. However, there are certain exceptions where the inland situation is no preventive. Not only goitre but cretinism flourishes in Lombardy away from the sea, while epilepsy is also more frequent. The abnormal secretion of the thyroid may be a factor in both affections. Special complex protein bodies have been found in the blood of the epileptic by Ceni, Trevisanello, Held, Lumiere, Pagniez, Mouzon and Turpin, Antheaume and Trepsat and Weichbrodt. Schlect has noted that eosinophilia is common and may be due to parenteral disintegration of abnormal protein. The author finds that in the inter-paroxysmal

period about a third of the epileptics show eosinophilia. Frequency of this find without any exact figures has also been claimed by a series of investigators, only Roncoroni coming to the opposite conclusion. Popovici attempted to throw light on epilepsy through Abderhalden's reaction. He tested blood serum against thyroid and found that in the epileptic the phenomenon was much more intense and more frequently positive.

Several investigators have studied epilepsy from the angle of an anaphylactic phenomenon, comparing it with experimental anaphylaxis, serum sickness, etc., the attempt being made also to study anaphylaxis on both the epileptic and non-epileptic. Buscaino gives the record of many animal experiments of his own over several years interval.

The evidence of the similarity of genuine epilepsy to anaphylaxis is worked out in animal experiment in great detail and need not be summed up here; but Buscaino assumes that the sensitizing protein originates in the thyroid and suggests the term "dysthyroid anaphylaxis." The chief authority on the anaphylactic nature of genuine epilepsy is Ceni, who was at work on the hemic origin of the latter in 1899 before anaphylaxis had been discovered. His work is entirely on rabbits and guinea pigs and may be passed over. Lumiere, Pagniez, Mouzon and Turpin and others have worked along the same line and have found that when the serum of epileptics is injected into the heart of the guinea pig it perishes of convulsions. The animal, however, may be immunized against this result. In mankind Widal, Abrami and Brissaud produced crises in a genuine epileptic by injecting him with his own blood serum. This effect was constantly obtained. Attempts to treat epilepsy on the principle of antianaphylaxis go back to Ceni. Numerous others, chiefly Italian, have applied his methods and in a material of 54 cases positive results have been obtained in 26. This must not be confused with the non-specific protein treatment for it consists in the use of a vaccine obtained from epileptic blood. Held introduced a serum prepared from rabbits and has seen 70 per cent of favorable response in 400 epileptics although apparently no cures. Buscaino mentions several instances of the use of non-specific protein but hardly scratches this large subject and we find no allusion, for example, to crotalin. The favorable action of luminal has been ascribed by Santenoise and Tinel and by Strauss to its power of disintegrating the offending protein substance in the blood and not to any obtunding of the reflex arc, etc.

Pagniez and Lieutaud discovered that merely eating chocolate

small

would produce a convulsion in an epileptic while at the same time the blood showed Widal's hemoclastic shock. This case certainly was purely anaphylactic. By administering to this man very quantities of chocolate he became habituated to the substance and showed neither the seizures nor blood phenomenon. In regard to the action of luminal on the blood it is said to suppress the Widal hemoclastic reaction. Various operations have been performed on the endocrines and sympathetic with more or less positive results. In theory thyroidectomy ought to cure the disease and is said to do away with anaphylactic sensibility. As thyroidectomy would deprive the organism of a valuable secretion it is evident that partial removal would have to be the practice. Parhon practised hemithyroidectomy in two epileptics but the results do not seem to have been satisfactory. Crile seems to have removed one suprarenal and three-quarters of the thyroid besides dividing the cervical sympathetic in 11 epileptics, but while there was improvement it does not seem to have been decisive. There is no allusion to the large literature of reduction of the suprarenals from German sources.

Asthma and migraine are both regarded as largely anaphylactic and the two are often found associated in family histories. There are also numerous points of contact between these two conditions and epilepsy. The same blood states as eosinophilia and the hemoclastic shock occur. Recently the protein therapy has been efficacious in treating migraine. Buscaino seeks to show in support of his thyroid theory that injury to the head, tumors of the brain, etc., cause but a small amount of genuine epilepsy which is therefore not a cerebropathic disease save in the Jacksonian form. His physical substratum of epilepsy is primarily the result of dysthyroidism and his degenerative or inferiority anomalies throughout the body appear to be only associated with dysthyroidism.

CONCLUSION

From the foregoing data it is relatively obvious that there exists no constant physical substrate for the epileptic constitution. That is, no essential alteration is shown that is not seen in an equal number of other individuals who are, perhaps, biologically inferior either as a result of their inheritance or because of the continued activity of their disease phenomena. Just what part is due to the latter and what proportion may be ascribed to the fundamental constitutional inheritance are matters which anthropological data as yet offer no line of demarcation. If one wished to take a broader psychoanalytic view, one might say that organic anomalies pave

the way to inferiority of mechanism; or that many of the defects present are, at least so far as functioning is concerned, somatic manifestations of narcistic defect colligative of those known to exist in the psychic constitution of epileptic narcism. However, these general conclusions are but suggestive rather than conclusive in the sense of our being able to determine the exact relationship which constitution has to the narcistic neuroses, if we may be permitted to call essential epilepsy an instance of that type.

SUGGESTIONS REGARDING DUTIES OF MEDICAL

INSPECTORS*

BY GEORGE W. MILLS, M. D.,

MEDICAL INSPECTOR, DEPARTMENT OF MENTAL HYGIENE

I have felt for some time that the Commission, the hospitals and the patients were not getting the maximum benefit from the visits of the medical inspectors and as many changes in the law and the rules will be made in connection with the organization of the Mental Hygiene Department I thought the time opportune to present these views and was asked to do so today that they might be discussed by the Conference.

The provision in the Insanity Law which specifies that the inspector shall see all patients admitted and remaining since his last visit is the pivotal point. No doubt at one time this provision served a useful purpose but I question if it does now and if it is necessary. During the last two fiscal years we have seen nearly 18,000 admissions in the civil State hospitals, and practically all of our available time is spent in examining these cases. This is especially true at the large hospitals in the Metropolitan district. We call it examining them; in reality it can be only a perfunctory passing in review. Very little can be done except to ask the routine questions as to complaints, etc., if we are to make the prescribed four visits a year. It is tedious to all concerned and I believe unprofitable. Since the inspection department was created much of the suspicion in the minds of the general public has disappeared and the standard of care, degree of special attention and methods of parole have improved remarkably.

Of over 8,000 admissions seen last year, 34, or approximately 0.4 per cent, made complaints of ill treatment but investigation did not elicit any foundation therefor in a single instance. Fifteen special investigations were made in response to written or verbal accusations of illegal detention or wrong treatment. No case of improper detention was found and only in one case was the complaint of ill treatment substantiated. In this case the facts were known to the hospital superintendent, the guilty attendants had been dismissed and the district attorney consulted. During the year 17 of the new admissions were found to be non-psychotic but in every instance this had been realized by the hospital physicians and appropriate steps for their removal taken.

*Read at Quarterly Conference at Brooklyn State Hospital, December 16, 1925.