the doctor describes. Of course, a hospital cannot look after a man that is either very delirious or insane-delirium tremens, for instance, or anything of that nature-without having rooms specially prepared for the purpose. Every hospital should have certain rooms, with windows barricaded and arranged for taking care of these unfortunates. No doubt a great many of them are sent to the asylum and the primary cause of their trouble is overlooked and many of them might be cured much more speedily at one of the hospitals, where they could be looked after by a physician and treated as the case demanded. A patient in that condition must be constantly watched unless he is in a room prepared as I say, or else he may jump out of the window. You don't know what he may do, and as I say the hospitals are not prepared as they should be to take care of that class of cases.

DR. S. D. HOPKINS-I am very much interested in Dr. Work's excellent paper. About one month ago I had occasion to look up the subject of toxic causes of insanity, and was surprised to find so little written on this subject. All the cases which the doctor has reported are cases of melancholia, which form of insanity we would expect to find in cases of auto-intoxication. I wish to congratulate the doctor on his interesting paper, which is of value to all of us-particularly to the neurologist.

DR. JUDSON DALAND-I desire to congratulate Dr. Work in calling to the attention of this association a subject not only of great importance, but one that is peculiarly valuable, because a recognition of this cause is followed by the more or less prompt improvement and ultimate recovery of the patient. The entire subject of auto-intoxication is not yet thoroughly understood by the profession in its entirety, and it will require a great many years of study in organic chemistry before this accurate knowledge shall be acquired. There is very little doubt that in the intestines there is generated a large variety of poisons; a few of them known, but most of them unknown. These chemical poisons are quickly produced and as quickly resolved into other compounds, so one can readily understand why organic chemistry has not made more progress in this direction. That some of these poisons are intense in their influence is shown by the production of cases of pernicious anaemia, and that they produce a great influence over the nervous system is shown by Dr. Work's paper. Cases not quite sufficiently developed to deserve the term melancholia are very numerous. Many mild forms of autointoxication are classed under the general term of dyspepsia.

Auto-intoxication of internal organs is a condition that complicates not only many medical but also many surgical conditions. The mental anaemia of indicanuria and less frequently

of acetonuria in carying amounts is a sign or signal that a certain degree of auto-intoxication is present. That degree may be very small and may produce very slight symptoms, while in other cases a small amount of indican may exist and the poison formed in that particular case may be very intense, so that the symptoms are more marked; but the persistent presence of indicanuria I regard as an index of intoxication. That this is true, is evidenced by the fact that indican is only present when there exists in the body decomposing material. The number of places in the body where putrefactive processes are possible are few, and, therefore, it is easily recognized when not in the intestinal canal. Therefore, the clinical recognition of this class of cases is easy.

DR. ROBERT W. FISHER-1 did not know until this moment that I was expected to discuss this paper. Dr. Daland, in discussing this question, has gone over the subject much more extensively than I possibly could do. There is only one point in his discussion or statement that my experience does not bear out; that is, that the quantity of indican is an index of intoxication. Now, that would be a simple and very nice way if you could always rely on the quantity of indican to indicate the degree of intoxication.

DR. JUDSON DALAND-I would like to correct that statement. Slight indican is present with a slight amount of autointoxication, and vice versa.

You

DR. ROBERT W. FISHER-That is the one point. may have a large quantity of indican, yet have a very little intoxication. This question of auto-intoxication is interesting to me more especially in cases of neurasthenia, as in my limited experience, neurasthenia, every case, has been accompanied with auto-intoxication and always from the intestine. This is not according to a great many or a majority of the men who write on the subject. It may be simply because of my limited experience; but in every case I have found it. Judging from what the doctor has said, he considers that all the pernicious anaemias and secondary anaemias-a consid erable number of them are caused by auto-intoxication. If auto-intoxication would cause pernicious anemia, it would cer tainly account for all the symptoms that occur in neurasthenia.

DR. E. V. SILVER-Mr. President: I suppose most of us in our practice have seen cases where biliousness or intestinal indigestion has lasted a long while, and where the family seemed to think that the patient, generally the head of the family, was going insane. I remember lately, where a dose of calomel being given in a case of melancholia, all the symptoms gave way; just

that alone will almost prove that there is such a thing as autointoxication, or toxins giving rise to partial or entire insanity of various kinds. Pyaemia sometimes gives rise to insanity of one kind or another. If you study a case of biliousness, you will find you have there exactly the history and symptoms which seem to carry out this theory more than any other, and these are the same symptoms as pyaemic poisoning, or poisoning by auto-infec tion. I think just these few facts prove conclusively that there is such a thing as toxic insanity-an insanity simply coming from these gastro-intestinal troubles.

DR. HUBERT WORK-I simply desire to thank the members for the kindly attitude of the discussion, and do not care to add anything further.

DISCUSSION ON DRS. FLEMING'S AND GRANT'S PAPERS.

In the absence of Dr. H. D. Niles, of Salt Lake City, Utah, appointed to open the discussion of the papers of Drs. Grant* and Fleming, Dr. I. B. Perkins, of Denver, Colorado, introduced the discussion.

DR. I. B. PERKINS-In considering these papers, I do so entirely off-hand, having been asked to open the discussion since I came into the room, and I am not an off-hand speaker.

The cases which Dr. Fleming reported are, indeed, very interesting, from the fact of the two attacks having occurred in each case. It occurred to me in the report of the second attack in the first case, that this one might possibly have been a hemorrhage from the opening up of an artery at the place of the former hemorrhage, and might not have been a separate pregnancy. However, that was not verified by operation and it is impossible to say.

I had hoped the doctor would touch upon one part of the subject that he did not mention, and that is, the cause of ectopic pregnancy. I believe that in these cases of tubal pregnancy it is almost always possible to trace them to some attack previously, in which the tube becomes diseased and the ovule failing to reach the uterus, the spermatozoon reaches it in the tube and impregnation occurs there. That tubal pregnancy occurs frequently is coming to our attention more and more.

* Paper published in August issue, page 61. Paper published in September issue, page 134.

There are a number of cases of pelvic abscess which I believe originate from a ruptured tubal pregnancy and a great many cases are overlooked at the time of rupture. On first seeing a tubal abscess case, it is often possible, by going back over the his tory, to get the history of attacks of pain with slight collapse following. On operating these cases, while you get pus, it will fre quently be dark colored and contain some remnants of blood clots. These cases I believe to be tubal pregnancy. This condi tion is far from being rare. I have met with nine tubal preg. nancy cases in my own experience in 106 celiotomies operated during the last eighteen months.

Dr. Fleming mentioned that the pulse canot be depended on as a diagnostic point in these cases. This I have noticed my self. A rapid pulse is generally expected in all cases of hem orrhage, but I do not believe the pulse bears much relation to the condition. I call to mind two cases, one having a pulse of 60, the other 160, and the conditions were almost precisely the same in both cases.

Dr. Grant, I believe, has the right idea of the cause of uter ine carcinoma. I believe that injury is the primary cause of al most all, if not all, of these cases, and that lacerations are at the bottom of the most of them. I believe, also, where they occur in women who have not borne children, as they occasionally do, it may possibly be attributed to the use of a wire loop or other device for the purpose of preventing pregnancy or procur. ing an abortion. I believe that the injury comes in some way.

The great proportion of these cases occur in women who have borne children, and it is scarcely possible to find a woman who has borne one or more children who has not had at least a slight laceration of the cervix. The extent of the laceration will not always show externally, and it is frequently only by an internal examination of the cervical canal that it can be discerned. The os may look almost normal, and yet there be considerable laceration above.

I think in the case which Dr. Grant reported where trache lorrhaphy had been performed, the carcinoma was probably due to the denudations of the surfaces not having been deep enough to remove all of the cicatrix. I believe in cutting quite deep in performing the operation. When there are slight lacerations of the cervix with induration and excoriation, I believe it is by far safer to operate, especially if the patient is near the climacteric period. The prevention of laceration is the best way to lessen the occurrence of carcinoma of the cervix; and, by the way, the majority of cases of carsinoma of the uterus occur in the cervix. These lacerations of the cervix may sometimes be prevented by

giving the os plenty of time to dilate. After the patient has recovered from child-birth, say four or six weeks, never fail to make a vaginal examination, and if laceration exists to any extent, operate.

DR. E. S. WRIGHT-These gentlemen have essayed to deal with some very important subjects in gynaecology. I have had a comparatively limited experience in this matter. The first was disposed of in a manner that will not admit of much discussion, for we all agree on the virtues of operative procedures in these cases. Our science has made strides in this direction as much, perhaps, as in any line of medical work, and we now recognize many things heretofore not understood. Hematocele does not have the prominence in medical literature it formely occupied, as we recognize many cases of so-called hemetocele are ruptured extra-uterine pregnancies.

So far as the second paper is concerned, I accept the teachings and agree with the spirit of Dr. Grant's conclusions, although I must confess they are not entirely clear and satisfactory to me. Why it is that a traumatism of the cervical mucous membrane should be accredited as a cause of cancerous growths, I do not fully understand, and think there is room for some other explanation for an exciting cause in these cases. Why some women have cancerous growths following this supposed cause, and others subjected to the same influences escape, suggests this cause as not a factor operating continuously in the same direction. I am inclined to believe that the ulceration and conse quent irritation may partly explain this condition as well as lacerations. I do not believe that lacerations of the cervix necessarily predispose to cancerous growths. This is the only point to me not entirely satisfactory, and I simply wish to express a skepticism 1 entertain about the usual explanation made, and suggest the possibility that a beter one can be found.

DR. C. K. FLEMING-I haven't much to add in closing the discussion. In answer to Dr. Perkins, I will state that I do not know the cause of the tubal pregnancies in these two cases, although I presume they were due to previous tubal disease, although, as stated, no history of previous disease could be elicited.

In regard to Dr. Wright's suggestion, I believe it is conceded by all that the great majority of pelvic hematoceles are due to ruptured tubal pregnancy or tubal abortion.

DR. W. W. GRANT-I notice Dr. Perkins agrees with me, or I with him, when he asserts that the diminished number of cases of cancer of the cervix are due to the operation of trachelorrhophy. I consider this an absolute illustration of the argu