This, in brief, is the plan of treatment which, in my opinion, should be given a high place in the therapeutics of trachoma. I will not occupy your time by reports of cases nor weary you with an extensive bibliography of the subject. As far as I am aware, Sattler was the first to call attention to the value of curettage in the treatment of trachoma; but for some time previous to the publication of his article I had been employing the operation devised by me and demonstrating its technique to my class of students at the New York Polyclinic. The method differs essentially from that of Sattler, who resorts to puncture of the follicles with a cataractneedle before the use of the curette. Davier, who has employed Sattler's method, lays less stress on the scraping than on the brushing and washing of the cul-de-sac with sublimate solution. Secondi recommends curettage followed by expression of the follicles with a special forceps. Peters advocates scraping the mucous membrane with a dull lancet. In fact, as far as I can learn, all those who have employed curettage have combined this procedure with scarifications, brushing, needling, expression, and other auxiliary measures, and no one has made use of curettage, pure and simple, as recommended in this article. It might be supposed that the removal of the conjunctival epithelium and deeper tissues with the sharp curette would be followed by extensive formation of cicatricial tissue; as a matter of practical experience this is not the case, the epithelium is almost completely regenerated, and the subconjunctival tissues assume a soft and pliable character except where scars had resulted from deeper-seated trachoma-fol licles. Indeed, this seems perfectly explicable when it is remembered that the curettage of granulation-tissue, and necessarily of more or less of the deeper structures, is constantly resorted to in other mucous surfaces of the body, with the result of a perfect restoration of the function of the affected membrane. In conclusion, I would emphasize the following advantages which curettage possesses over other methods advocated for the treatment of trachoma: 1. Its uncomplicated technique and the rapidity with which it can be performed. 2. Its comparative freedom from pain, enabling us to dispense with general anesthesia. 3. The minimum injury inflicted upon the conjunctival and subjacent tissues. 4. The absence of inflammatory reaction after operation, permitting the patient to follow his usual occupation without discomfort. This is an important point in its favor in comparison to other operative procedures which confine the patient to his room for several days. 5. The simplicity of after-treatment, which is of importance, in view of the fact that the majority of trachoma cases occur in the lower walks of life. 6. The radical character of the operation, recurrences being rarely observed. TETANY, WITH ILLUSTRATIVE CASE. BY GEORGE W. MILES, A.M., M.D., OF ONEIDA, N. Y. VERY little mention of the disease known as "Tetany" is found either in text-books of general medicine or in special works on nervous diseases. An interesting and exhaustive study of the subject has been published by Professor J. P. Crozer Griffith, of Philadelphia. Dr. Griffith expresses surprise at the scarcity of records of tetany to be found in American medical literature, and speaks of the disease as one of "rare occurrence in this country." A short time previous to the publication of Dr. Griffith's paper (December 11, 1894) I reported to the Madison County (N. Y.) Medical Society a sible that, in view of the conceded infrequency of case of tetany occurring in my practice. It is pos the disease, a brief consideration of the subject of tetany, in connection with the history of my own case, may be of interest. In a work published quite recently is found the following definition of "Tetany," "Tetanilla," or "Little Teta-nus”: “A functional disease of the nervo-muscular apparatus, characterized by the occurrence of paroxysmal tonic spasms that involve certain groups of muscles, and that in severe cases may extend to nearly all the voluntary muscles of the limbs and body." This definition gives little idea of the terrible intensity of suffering that marks the clinical history of tetany. The nerves that are concerned in the production of the contractions exhibit an immense increase of electrical and methe disease has led many observers to doubt the prochanical excitability. The functional character of priety of dividing it from other functional spasmodic disorders, or as to regarding the disease as a separate entity. The disease is observed more frequently by physicians in general practice than by those whose experience is limited to office and consultation practice. The weight of opinion seems to children. The influence of sex is not very decided. be that tetany occurs most frequently among Persons who have been exposed to cold or wet seem to be particularly liable to attacks of tetany. Stubborn constipation or any intestinal irritation is liable to provoke an attack. Dentition is said to be, likewise, a cause. Attacks occur also in confever. Constitutional causes favor its development. nection with other diseases, particularly typhoid 1 American Journal of the Medical Sciences, February, 1895. When a predisposition to tetany exists almost any irritation of the cutaneous or mucous surfaces may excite an attack of the disease. commissure and of the anterior horns of the cervi tion the healing process was rapid and the arm improved daily. About six weeks after the vaccination, on the morning of November 14th, I was The occurrence of an attack is usually preceded asked to see the child, the parents being much by certain premonitory symptoms, as dizziness, de- alarmed about her. At this time the sloughing surface upon the arm was rather an insignificant termination of blood to the head, humming noises one. The general symptoms, however, were severe in the ears, and disturbance of vision. When the and so closely simulated tetanus as to be startling, attack is matured, the force of the paroxysms is ex- to say the least. There were tonic spasms of the pended upon certain groups of muscles, the flexors arms and legs, succeeded by the same condition in being affected more frequently than the extensors. the muscles of the neck and back, and likewise in Neuralgic pains and soreness are complained of, the abdominal muscles. In the latter, particularly, headache, dizziness, and other cerebral symptoms The muscles of the neck remained for the most part the rigidity was so great as to elicit cries of pain. of sensory disorder. The increased and inordinate in a state of tonic contraction, so that any moveexcitability of the motor nerves is further indicated ment of the head was rendered quite impossible. by their behavior under the influence of mechanical | The rigidity of any of the muscles was so great that stimulation, a slight tap upon the nerve-trunk being passive movements were impossible. The muscular sufficient to arouse a paroxysm. The duration of a groups of the forearm, the upper arm, and the legs were involved. The facial muscles were affected, paroxysm may vary from a few minutes to many and the grimaces and contortions resulting served hours, or even two or three days. The disease might be confounded with tetanus, but is lacking cular spasms were bilateral. The tips of the fingers more thoroughly to alarm the friends. The musin the rapidly increasing severity of the phenomena and thumbs were drawn together into a conical of that terrible disease. Although a few examina- shape. Some of the toes were flexed and bent tions post mortem have been made in tetany there laterally under the other toes. The upper arms is little known of the pathology of the disease. were drawn against the sides of the thorax and the One observer claims to have found a periarteritis forearm strongly flexed. There did not seem to and a periphlebitis of the blood vessels of the white be any involvement of the muscles of the diaphragm or bladder, as reported in some cases. These paroxysms lasted only a few moments at a time, but continued intermittently for three or four days, and in the beginning at least the phenomena of tetanus were closely counterfeited. Opisthotonos occurred frequently during the first day. Several authorities, while speaking of the startling resemblance which tetany bears to genuine tetanus, mention as distinguishing the diagnosis that trismus occurs in the outset in tetanus, and is not apt to be or is not often found in tetany. In this case this diagnostic aid was not given me, as the initial spasm of the masseters was a prominent feature of the case. jaws were so firmly set together that the handle of a spoon could not be inserted flatwise. Any attempt to stir the child in bed was immediately followed by a tense and extremely rigid condition of the entire muscular system. The increased mechanical excitability, which is a well-marked symptom of tetany, was very prominent in this case. The slightest sound, even speaking the patient's name or extending the hand toward her or touching the surface was sufficient to produce a paroxysm. These spasms continued, as I have said, for three or four days at irregular intervals. The patient slept very little for all of that time during the day or night, a light sleep of fifteen or twenty minutes being followed by her awakening with screams and new paroxysms and pain in the contracted muscles. The pain complained of was sometimes in the jaws, sometimes in the left arm, sometimes in the abdominal muscles. Following each spasm the entire surface of the body was bathed in perspiration. While in the beginning the spasms occurred several times in the space of an hour, the intervals of relaxation became gradually lengthened, and much cal portions of the spinal cord. Others have found nothing of the kind, but, in the place of pathological facts, have built up an ingenious theory that the attacks of tetany are due to an irritable condition of the gray matter of the medulla and spinal cord, and that this irritable condition is due to sympathetic disturbances, causing irregularities in the vascular innervation of the blood vessels of the spinal cord. This, however, does not appear to be a very lucid explanation of the attacks. The disease is seldom fatal, but sometimes persists for a considerable period of time. In these lingering cases a certain degree of muscular contracture and weakness is often evident after the cessation of spasmodic attacks. The disease has a distinct symptomatology, and this will be best illustrated by the narration of the case before mentioned. In October, 1894, Florence S., a girl, aged seven years, was brought to me with the request that she be vaccinated. I performed the minor operation in the ordinary way, and in the usual site upon the left arm. About ten days later severe inflammatory symptoms supervened upon the full development of the pock, caused by undue traumatism, the child having injured the arm and destroyed the original vesicle by scratching or rubbing it during sleep. The inflammation was readily relieved by an anodyne and astringent lotion. A considerable wound resulted, however, and there was sloughing of the skin over a space as large as a silver halfdollar. After subsidence of the inflammatory ac The CONCEPTIONS AS A SYMP. TOM OF NEURASTHENIA. BY THEODORE DILLER, M.D., PHYSICIAN TO NEUROLOGICAL DEPARTMENT OF PITTSBURG FREE DISPENSARY; VISITING PHYSICIAN TO ST. FRANCIS' HOSPITAL, PITTSBURG. relief was obtained, though some stiffness of the IMPERATIVE muscles remained after three or four weeks. After the second day the relaxation of the jaws for a portion of the time was sufficient so that a tube could be inserted between the teeth, and in this manner it was necessary to introduce nourishment. This method of feeding was followed for about two weeks, as for that entire period the masseter muscles were never entirely relaxed except occasionally during sleep. The bowels were greatly constipated. The pulse during the height of the attack remained at about 140 at night and 120 in the morning. There was very little rise in temperature, at least not to exceed a degree. I learned that for a couple of weeks preceding the complete attack nervous symptoms had been noticed by the parents, slight rigidity of the muscles, disturbances of vision, etc. The result of this case was complete Convalescence was considerably pro longed. While the condition in this case at first sight was, as I have said, quite startling, and the simulation of true tetanus was great, still the complete recovery (a circumstance not within my experience in tetanus), a consideration of the latent period which had existed, the prominence of the mechanical excitability, the complete relaxation of all the muscles during the intervals of the attack, all of this leads me to the belief that the disease was not the graver The idea of an hysterical element in the case was not lost sight of, but all symptoms and the entire history seem to admit of classifying this case with those of tetany already reported. one. How much, if anything, the vaccination or the wound following had to do with the symptoms which existed I do not know. I imagine that these matters were neither directly nor entirely causative. In the minds of the frightened parents, however, the vaccination was the only thing prominent, and the night-calls, the extra work, and the unnecessary trouble that was made me for three or four days were such as almost to make me wish that the immortal Jenner had never been born. I know that the child is of a general neurotic temperament; she was of a constipated habit; she had been exposed to the cold and wet; she had at the time an extremely sore mouth, the result of digestive disturbances. Each of these things and many others are believed to have been causes of special cases of tetany. I have no doubt that some or all of them entered into the etiology of this case, and it is possible that the irritation of the cutaneous surface by vaccination may have likewise been a factor. THE CHAUTAUQUA COUNTY MEDICAL SOCIETY will hold its semi-annual meeting at the Sherman House, Jamestown, N. Y., on January 14, 1896. An attractive programme has been arranged, and a cordial invitation of attendance is extended to the profession of Chautauqua and adjacent counties. UNDER the term imperative conceptions have been described a great variety of morbid impulses and fears which thrust themselves into consciousness. They may arise in a great variety of mental states or be present as an isolated symptom. They are always to be regarded as a symptom, never as a disease. The term imperative conception is somewhat misleading in that the command it implies is by no means always obeyed. Morbid impulses may frequently and for many years arise in an individual, and yet always be successfully resisted. Probably in all of us impulses, fears, or doubts arise suddenly in consciousness as isolated thoughts or emotions, and which may be apparently totally disconnected with the mental state immediately preceding their appearance. For instance, many of us, I presume, have been seized with the desire to count the windows or doors in passing along a street, or in walking to avoid carefully the cracks in a pavement or to touch fence-posts. Looking from a great height the idea occurs to most persons to precipitate themselves below. The sight of a fragile piece of china or glassware suggests the idea that it could be readily crushed. A helpless child or a feeble invalid suggests how easily each could be killed. Certain words or phrases, lines of poetry or bars of music, may thrust themselves into consciousness at odd times. These simpler forms of imperative conceptions cannot, of course, be considered abnormal in view of the fact that they probably occur in some shape to all persons. In normal individuals they never result in action contrary to volition. In their exaggerated form, whether seen alone or in conjunction with some neurosis or psychosis, they constitute a serious symptom, and may be the dominant feature of a grave form of insanity. Between the extremes there are all gradations; and to say when an imperative conception ceases to be physiological or within the bounds of health would be as difficult as to say where sanity ends and insanity begins. Many morbid impulses and fears have received special names. The impulse to steal has been called kleptomania; to set fire to property, pyromania ; the fear of open places, agoraphobia; the fear of narrow places, claustrophobia; the fear of dirt, mysophobia; the fear of crowds, anthropophobia; fear of fears, phobophobia. The French, especially Morel, have described 1 Paper read before the Pittsburg Academy of Medicine, December 23, 1895. us. and isolated two forms of obsessions, which have | For instance, the impulse to touch fence-posts been named délire du toucher and folie du doute. might be obeyed, without exciting comment, by a Fear of contamination and doubts are, of course, person passing along a quiet country road and present within the limits of health. Many individ- successfully resisted without great effort, when uals are hypercritical as to cleanliness, or unduly under other circumstances these actions would exfear disease, or contagion. Doubts arise in all of cite astonishment or subject him to ridicule. On The uncertainty as to whether a letter posted the other hand, if he acted on the impulse, being was sealed or had a stamp affixed to it; whether the unable to resist it, while walking with friends in gas has been turned out, or the door locked, or the city streets, the impulse would be distinctly abnorheat regulated, has haunted most of us. I know a mal. It might be present in the absence of any bank officer who, in receiving money, often counts other abnormal manifestation of the mind. We it over two or three times oftener than would ap- must admit with Hack Tuke and Mercier,' I bepear to be demanded by a reasonable caution. These lieve, as in the example given, that there are disdoubts may assume such exaggerated forms as to eases of the mind other than insanity; in other constitute a true insanity, the folie du doute of the words, to say that an individual has some abnorFrench. The difference between the minor forms mality of his mind is not equivalent to saying that of doubt and the grave forms going to constitute he is insane. folie du doute is, as has been emphasized by Hack Tuke and Hughlings Jackson,' one of degree only. I recall a patient who was constantly pestered with doubts of all descriptions. If she was eating, she felt she ought not to be doing so; if sitting, she ought to be standing or walking; if knitting, idle; if in bed, out of it, etc., ad infinitum. She could never be addressed without expressing doubts, which were to her a real source of distress. She was, in short, a case of folie du doute. There can now be little doubt that certain crimes are due to sudden impulses which arise in the minds of persons who are not ordinarily regarded as insane, and which the subjects are wholly unable to resist. Impulses to suicide, or to make assaults, or do deeds of violence, or commit crimes, arise in many persons, and yet do not result in action-are not obeyed because they are put in subjection, so to speak, by the inhibitory forces of the mind. When an impulse to commit crime arises and the inhibition to check it is insufficient, the crime is committed. This is the philosophy of the suicidal and homicidal impulse. "Pinel and Esquirol at first doubted the existence of pure insane impulse apart from intellectual flaw or delusion, and many authorities of repute have since their day considered the doctrine a dangerous as well as a fallacious one; yet eventually Pinel and Esquirol asserted the existence of this terrible malady and painted its distinctive features in no uncertain colors." Bevan Lewis, from whom I quote these words, and Maudsley, are both firm believers in irresponsible, impulsive crime. 2 The simpler forms of impulses, doubts, and fears cannot, as I have said, be regarded as abnormal. In certain individuals, however, they may be so strong or persistent as to be distinctly morbid. 1 "Summer and Autumn," Brain, 1895. 2 Text-book of Mental Diseases, p. 178. 3 From the fact that these morbid impulses, fears, and doubts are so frequently seen in those undoubtedly insane, and especially in the degenerative types of insanity, such as paranoia, it seems likely, as suggested by Savage, that most frequently in those cases where imperative conceptions appear as an isolated symptom they are the outgrowth of a neuropathic soil; they are marks of degeneracy. They may be in abeyance for years and brought to the surface by shock or disease, lowering vital tone, probably by lessening the inhibitory powers, and in other ways interfering with the association of centres in what Hughlings Jackson calls the upper range. "The man who to-day is conscious of and smiles at an imperative idea gravely believes it tomorrow and labors under a systematized delusion.' With this brief survey of the subject of imperative conceptions in general, I propose to ask your attention to them as a symptom of neurasthenia. Certain insanities, such as melancholia, mania, paranoia, and paralytic dementia, may develop upon a neurasthenic basis, as has been so well shown by Kirchhoff. Neurasthenia may have been an early stage of insanity, or the mental symptoms may have been developed pari passu with the neurasthenic ones; but in either case it is of prime importance to recognize the neurasthenic condition. From the exhaustion, starvation, and poisoning of nerve-centres, which I take to be the basis of neurasthenia, arise many mental symptoms. These have been ably discussed by Cowles. In individuals in whom there is a slight or latent tendency to imperative conceptions it is reasonable to suppose that they might become prominent upon the super 1 "Summer and Autumn," Brain, 1895, p. 328. 2 See paper by writer on "Imperative Conceptions in Para- 5 Handbook of Insanity, pp. 327 et seq. vention of the underlying conditions which pro- | fears in a well-established case of neurasthenia is duce neurasthenia. Indeed, in certain individuals seen in the following case: where the conditions favor it, a morbid impulse or fear may appear suddenly and be the dominant feature in neurasthenia, as, for example, in this case: M. C., a well-built, tall man, aged thirty-six years, an engineer, of good habits, was referred to me by Dr. J. D. Shull, of Derry, in June, 1892. Mr. C. had in the previous February been prostrated by a A hard-working, robust-looking, professional severe attack of influenza, following which he had man, aged twenty-nine years, was sent to me by suffered up to the time I saw him from marked Dr. W. F. Robeson last spring. Six weeks before, neurasthenic symptoms, such as mental depression, while sitting in the first balcony at the theatre, he insomnia, dull occipital headache, general muscular experienced suddenly a strong impulse to precipi- weakness, vertigo, flushings, tingling, muscular tate himself below. In great fear and agony he twitching, and constipation. After these symptoms left the theatre lest he should act upon the impulse. had become established he began to suffer shortly The next day he felt strongly impelled to break all before I saw him with morbid fears. Although long the china upon the table. After this he was seized accustomed to his work he began to dread a wreck with many imperative conceptions, and his life was of his train. This feeling, he explained to me was, one of great distress to him, as he feared he was he knew very well, altogether groundless. Yet this going insane. Examination revealed a long train fear came to him frequently and suddenly, causing of neurasthenic symptoms: headache, morning-tire, him the most acute distress. It often caused him to loss of endurance, irritability, insomnia, etc. He turn pale and perspire, and on several occasions he had worked very hard, frequently over-taxing him- called on the fireman to relieve him temporarily, self, mentally and physically, since boyhood, and feeling unfit to be at his post. He debated with while he suffered from some of these neurasthenic himself whether it was not his duty to resign his symptoms prior to the appearance of the sudden position, and asked my counsel in the matter. impulse and fear which came to him in the theatre, yet they were not marked, and he had almost wholly ignored them, and had in nowise drawn less on his nervous force in the prosecution of his work; but with the advent of these imperative conceptions his other neurasthenic symptoms became marked, and it was not difficult to discover them when I first saw him, and hence to recognize the morbid impulses and fears as belonging to them. The case is an illustration of how the onset of neurasthenia may be apparently sudden. In some cases, where the output of nervous energy is greater than the ordinary process of recuperation, there is apparently some compensatory action for a time, just as we see in valvular heart-disease; but a time comes when compensation cannot keep pace with the extra demands, and the break may be, as in valvular heart-disease, sudden and alarming. Firm assurances as to the absence of organic diseases and the harmlessness of these imperative conceptions, if the will-power were brought to bear, coupled with a semi-rest treatment, hydrotherapy, faradism, tonics, and occasional hypnotics, brought about in the course of six months a restoration to health. Several relapses, however, occurred, and for a time the patient was frequently seized with imperative conceptions of one sort or other; but with the assurances he had received they caused him much less fear. The most persistent of these impulses was to cast himself from a great height. For a time he feared to cross a river bridge lest he should give way to the impulse to jump over, or in crossing he would, at times, avoid the foot-path and walk in the wagon-track. An instance showing the appearance of morbid A plan of treatment similar to that pursued in the first case was instituted, and after several months he reported himself as restored to health. The development of these morbid fears in a man suffering from a severe train of neurasthenic symp. toms and their disappearance together with his other symptoms, leave, I think, little doubt that they resulted from the underlying condition of his nervous centres which had produced the other neurasthenic symptoms and of which they were only a part. In all cases presenting the symptom of imperative conceptions it is highly important to make a careful search for neurasthenia and to determine, if possible, whether they be not an expression of this condition. The prognosis of imperative conceptions is best when they result from the neurasthenic state. Speaking of them in a general way Savage1 expresses the belief that they are incurable if they have existed more than a year, and he allowed only slight hope when they are acute or associated with any special cause or period of life. The experience taught by the two cases cited, however, would strongly indicate that the prognosis is good when they are associated with such a "special cause" as the neurasthenic condition. Probably the prognosis is as gloomy as painted by Savage when the isolated symptom is observed in a neuropathic subject. Scant reference to the relationship between imperative conceptions and the neurasthenic states is made in works on medicine or neurology. In some of the more recent text-books on nervous diseases, however, as, for instance, in that edited by Dr. 1 Op. cit. |