reflex pupillary immobility to light, with retained mobility in accommodation, is of significance. It may affect one or both eyes.

Another symptom not mentioned in the books, I believe, after the study of about fifty cases, to be of the utmost importance,— anæsthesia of the ulnar nerve at the elbow. In only three cases out of the fifty have I found this nerve unaffected, and in two of these it was analgesic, and in the third there was very slight pain sensation.

The patient is easily made to believe that he is a musical wonder, and will try to imitate all musical efforts proposed, no matter how ridiculous.

A differentiation between the early stages of paresis and neurasthenia presents diagnostic difficulties. A number of symptoms are very much in common. Both show a preference for active, intelligent persons. Excesses play a part in the etiology of both. Neurasthenia may be the only symptom for a long time, later to develop a true paretic condition. It is a very suspicious symptom when a neurasthenic suddenly becomes euphoric or develops grandiose delusions.

Difficulty is also experienced in differentiating paresis from certain manifestations of chronic alcoholism (alcoholic pseudoparesis). Alcoholics seldom present a real reflex pupillary immobility. As a rule, after an extended period of abstinence the pupils react better in alcoholics.

Certain nervous conditions following accidents may also simulate progressive paresis, as they often present symptoms identical with those of certain types of paresis. However, if there is neither inequality nor reflex immobility of the pupils, nor progressive impairment of the intellectual faculties, the diagnosis "progressive paresis" is a very doubtful one.

To distinguish beginning paresis from diffuse syphilitic processes of the cortex is very difficult or even impossible. Having before us a disease whose diagnosis must give an absolutely unfavorable prognosis, the necessity of an early diagnosis is evident. Great mischief might be caused by men in high authority suffering from unrecognized general paresis. Only recently one of the legal fraternity stated to me that an offender against the law was sentenced to six years in the penitentiary by a paretic judge, when the prosecution would not have asked and could not have expected a

maximum penalty of more than six months in the workhouse. Not only might mischief be prevented, but loss of property and ruined reputation might be guarded against. Again, an early diagnosis will often enable us to secure absolute rest at once, the most important element in treatment, and possibly a remission with sufficient improvement to arrange all business affairs. As a rule, this rest cannot be had at home except under the most favorable circumstances.

As time passes these patients gradually grow worse. They may become very negligent as to their toilet and offer to take liberties with the ladies of their acquaintance or with the servants of the house. Some become angry on the slightest pretext and overlook gross infractions. Others become very egotistic and speak of themselves or their affairs incessantly. A lawyer under my care gave me numerous invitations to the club and handed me checks for fifty thousand dollars, one hundred thousand dollars, a million, and one check for a billion dollars.

Symptoms vary on different days, indeed on the same day. I have seen a patient rise in the morning very bright, but become towards evening dull, irritable, and flushed; or, vice versa, a patient may be bright in the evening and dull in the morning; in fact, I have seen a patient lapse from a comparatively normal condition to one of stupidity after a nap of an hour or two during the day.

Mickel describes a form of silent excitement which may take the place of mania, manifested by continually moving the limbs, pulling at the bedclothing, pushing at new objects, and resisting the necessary attentions of the nurse. The depressive form progresses more slowly than that in which the expansive delirium and the delusions are more marked. Megalomania of the French may be mistaken for paresis.

The sensibility of the skin is very much lessened in the advanced stages, particularly in the legs below the knees and in the feet. The cutaneous functions may be interfered with. There may be a dryness of the skin or increased, even excessive, diaphoresis at times, which may be confined to one side or otherwise localized. There is also marked impairment of vision, from degeneration and atrophy of the optic nerve. Amblyopia, amaurosis, or loss of color-sense may occur in the early stages.

Hæmatoma auris is peculiar to the advanced stages of this dis

ease.

This is more frequent in males than in females and attacks the left ear by preference. Remissions occur, which may last for some time and lead the attending physician to give a favorable prognosis. In such cases a dismissal from the hospital is of questionable expediency unless the patient be placed under the care of a faithful attendant, as he is unfit to withstand even the ordinary cares of life.

Treatment in the first place should be preventive. The ambition to reach the pinnacle of success and prominence in business and social life, especially when coupled with the different forms of vice, dissipation, and intemperance, often accompanied by venereal disease, causes such a tax and overstrain of the mental faculties that this may account for the disease. Or, as Krafft-Ebing more tritely puts the cause, " syphilization and civilization," with "syphilization," no doubt, in the ascendency. Or, as Hughes says, "The pace that kills is the pace that precipitates paresis." And this is especially true with those of great mental ability if unfortunate enough to contract specific disease. Those of the neuropathic type are prone to the other forms of nerve and brain trouble.

Very often these busy men think they know as much of the wants of the brain and nervous system as they do of business affairs. Hence they take their tours, their outings, their recreations, very often, however, with but little benefit, because of the lack of advice from their physician. Consultation with the family physician in conjunction with a neurologist is as necessary to the health of these men of affairs as consultation with an attorney is to the success of their business. Many times professional advice, if followed, would save the mind as well as the life. The recommendations of the family physician alone are not sufficient: he should also have the advice of a specialist.

Therapeutically, the patient should be given the benefit of the doubt in the way of specific treatment. Potassium iodide in doses increased to the limit of toleration is best in the majority of cases. As much as two hundred and fifty grains three times daily in some cases has done wonderfully well in the writer's experience.

Sometimes the mixed treatment is the one to adopt. Mercurial inunction may be necessary. The bromides, preferably sodium bromide, or in some cases bromide of lithium, actively given, with nerve tonics and a supporting diet, are very useful. Abstinence

from all alcoholics or stimulants of any kind is enjoined. Rest, especially mental rest, is absolutely necessary. The patient should get away from all business, even the ordinary cares of home. He should go to some quiet, healthful place. Even travel is to be advised against. Long, quiet sleep, oft repeated, is a valuable adjuvant to treatment. Bathing under the direction of a competent person, to increase the physiological metabolism., is essential. Turkish baths are beneficial in some cases, especially in those of alcoholic origin.

Persistent and methodical effort along this line will achieve satisfactory results in many cases and an occasional cure in others.

Surgery

OPERATIONS IN PRIVATE HOUSES.

A SPECIALLY PREPARED PRACTICAL PAPER.

BY E. STANMORE BISHOP, F.R.C.S. (Eng.),

Honorary Surgeon to the Ancoats Hospital.

THE late Lewis Carroll, in his really wonderful book “Through the Looking-Glass," makes Humpty Dumpty explain to Alice the meaning of what he calls a "portmanteau" word. It is, he says, "like a portmanteau; there are two meanings packed up into one word.”

In the literature of surgery we are constantly coming across what similarly I may call "portmanteau" sentences, only these contain not merely two, but many meanings. Take, for instance, the constantly recurring " My personal experience of such and such an operation is limited to fifty cases, with a mortality of four per cent." What a great deal is involved in such a phrase! To the surgeon it means at least half a dozen things; to the patient another half dozen, three or four of which are quite different; to the nurse, whose watchful care has contributed no little to the possibility of such a result, half a dozen others, some in common with the surgeon, some with the patient, some quite distinct and peculiar to herself.

Spoken of in this airy fashion an operation seems a small thing. In reality it is a matter which comprises many serious questions.

First, the surgeon must consider, is an operation required at all? next, is this the best operation for this particular patient? The mortality is four per cent. That sounds small, but to four patients it means death. Will this particular case survive? The knowledge of the general mortality percentage is useful, but in reality it tells us but little as to the prognosis in this particular case. Under