Abstracts and Extracts.

La mort suite de ponction lombaire. Par DRS. MINET et LAVOIX. L'Echo Médical du Nord, Année 13, p. 193, 25 Avril, 1909.

The authors have collected 24 cases from the literature in which death has accompanied lumbar puncture or followed it at intervals varying from one hour to 12 days. Various authors are quoted who give various reasons for such accidents, these being discussed, and in conclusion it is stated that "the pathogenic mechanism of the fatal accidents consecutive to lumbar puncture is truly multiple and it is not always in the same way that the subtraction of cerebrospinal fluid leads to a fatal termination: sometimes it is due to vasomotor phenomena resulting in a hemorrhage (this being the only exact fact which we know); at other times the fall of the cerebellum on the bulb may be a cause of sudden death; at other times, and these are the most numerous cases, we have grounds to believe, without proof to the contrary, that there occurs a bulbar shock. In reality, in most instances, the pathologic physiology of these accidents is obscure. We may discuss these proposed explanations and express our preference for one or another, but we may not decide in favor of any one."

The article is concluded with directions for performing lumbar puncture so that chances of death occurring are minimized, these having been formulated by Sicard, particularly for cases of cerebral neoplasm.

1. Refuse to puncture any patient known to have cerebral tumor, in whom the functional disturbances, cephalalgia, nausea, and vertigo are noticeably exaggerated by horizontal decubitus.

2. Putting this even more strongly, the authors say: Refuse lumbar puncture to any patient known to have cerebral neoplasm, in whom the functional troubles are not very marked, where they yield to palliative therapeutics. Neither practice it on any patient where these troubles, not yielding to any symptomatic treatment, make life intolerable for the patient. 3. Before performing lumbar puncture allow the patient to rest in bed for 24 hours.

4. For each lumbar puncture, operate in lateral decubitus with the head not elevated.

5. After having made lumbar puncture allow the patient to remain in bed, in dorsal decubitus, the head not elevated, for 24 hours.

6. Do not abstract more than 4 or 8 ccm. of fluid, and without aspirating. 7. Use a fine needle, from .8 to 10 mm., to reduce to a minimum the meningeal opening.

In cases of cerebral neoplasm the following should apply most strictly: 1. Before puncture, rest in bed for 24 hours, the head not elevated. 2. Do not puncture except in lateral decubitus, the head slightly lowered, in a sort of Trendelenberg position, which may be easily obtained by supports slid under the front feet of the bed.

3. After puncture keep this position with head slightly lowered for 12 or 24 hours; then a horizontal position in bed for 24 hours, the head not elevated. W. R. D.

La colesterina nel liquido cefalorachidiano del paralitici, e sua partecipazione alla reazione di Wassermann. Del DOTT. GIACOMO PIGHINI. Reforma Medica, Anno XXV.

Recently in another paper, after showing that cholesterin, as in an emulsion of nervous tissue, had the property of impeding the hemolysis of lecithin and of the specific serums, the author expressed the hypothesis that the cerebrospinal fluid of paretics and the extract of the liver of syphilitic fœtuses-richest in those elements known in the Wassermann reaction as antigen and antibody-might contain cholesterin. The present study is to confirm this view and was made on a number of insane patients, including 10 paretics. Another research showed that cholesterin was found in the alcoholic extract of liver of a syphilitic fœtus in greater quantity than in that of a normal fœtus.

It is known that the serum of normal blood contains a trace of cholesterin. The cerebrospinal fluid does not normally contain cholesterin. The method used is then given in detail, following which is a table giving a very brief description of each case and the results of the tests upon the cerebrospinal fluid and serum; these results are also summed up for each group of cases and after some discussion concludes as follows:

Cholesterin may be found as a pathologic constituent of the cerebrospinal fluid of paretics, and of severe cases of dementia præcox and of epilepsy; it may be found also in abnormal quantities in the serum of paretics and severe cases of epilepsy.

It seems probable that the active substance in the alcoholic extract of the cerebrospinal fluid and of the serum used in the Wassermann test may be cholesterin.

W. R. D.

Book Reviews.

Sixteenth Annual Report of the State Charities Aid Association to the State Commission in Lunacy. Nov. 1, 1908. (New York City: United Charities Building, 105 E. 22d St.)

All persons interested in the better care of the insane will find many helpful suggestions in the annual reports of the New York State Charities Aid Association. From the report before us we learn that the total number of insane persons treated in State hospitals and licensed private asylums has increased by 1414 during the year, the largest annual increase in the history of the State. During the previous ten years the average annual increase has been 741 persons. No explanation is given of this unusual increment and we are left to infer that it may have been connected with exceptional conditions incident to the recent financial and industrial crisis. In the consideration of the question of the amount of land required for a State hospital for the insane the following excellent suggestions are made:

"We may properly inquire, not simply what is the minimum amount of land required, but also what are the larger advantages which may result both to the hospitals and to the community in a more generous conception of the possibilities of usefuless of these State farms. The State is spending large sums of money in schools of agriculture; why not treat these State hospital farms as a part of such schools, as it were, or as extensions of them, making a practical connection in various parts of the State with the farming community?"

The following, in line with this suggestion, is also quoted approvingly from a visitor to one of the State hospitals:

"What, for instance, is there to prevent the Farm Department [of the St. Lawrence State Hospital] from giving an object lesson to the farmers of this section of the State in modern scientific cultivation of crops, and why should not the live stock on the farm be of the best type? Would it not be a wise policy to breed the best type of cattle and horses and hogs and offer yearly by public sale, the overplus to the farmers of the State? There can be no question but that such a policy would result in better financial returns, to say nothing of the benefits to be derived by those who pay for the support of the hospital. It has always seemed to me that a State institution should embrace all the opportunities at its command to radiate instruction and usefulness, and while a hospital for the insane is primarily for the care of those unfortunates who are its inmates, yet, when it can at the same time act as an instructor in any of the great industries of the State, surely it misses the higher calling when it fails to do so."

The training of nurses and attendants still demands much thought and attention, and the outlook is not encouraging. Every effort which has been made thus far to raise the educational requirements of State hospital training schools seems to have decreased the number of those who applied for entrance. There has been no marked increase in the number of pupils in these training schools for some years, and, as a result, the very large proportion of those who are in charge of patients are neither pupil nor graduate nurses. In the annual report of the State Charities Aid Association for 1907 the percentage of pupils and graduates in the State service for the thirteen State hospitals was but 37.4 per cent. This deplorable state of affairs would seem to call for a radical remedy and yet it is difficult to indicate what should be done. It would seem wise to establish a preparatory course based on the experience of training schools for nurses in general hospitals and to insist that all persons entrusted with the care of patients be required to take this course prior to employment. It is evident that greater use should be made of women nurses in men's wards, and that many, and perhaps the majority, of men nurses should be relegated to a position analagous to that of an orderly in a general hospital, being subordinate to women nurses and under their direction. It is encouraging to perceive a movement to place training schools in State hospitals under trained superintendents of nurses of large experience and of recognized ability. It is to be hoped that the Lunacy Commission will give increased attention to the importance of securing well-trained and competent persons to take care of the insane. The old era of the "asylum attendant" is passing, and the "hospital nurse" should replace him.

The chapter on Occupation and Entertainment" deserves careful attention. The suggestion that a well-qualified person travel about from hospital to hospital to give instruction in useful handicrafts to beautify the hospitals and to furnish instruction in what may afterwards prove a remunerative occupation for discharged patients is an excellent one.

We regret to note that little progress has been made in the attempt to give better care to the alleged insane pending commitment in view of the fact that in 1907 17 per cent of the patients admitted to State hospitals were received from jails, lockups and police stations. Dr. W. L. Russell made a report to the Conference of Superintendents of State Hospitals which showed that in many instances "the patients were given no special consideration, and were found in unsanitary, uncomfortable, sometimes filthy and vermin-infested cells, not infrequently in company with persons accused of crime, notwithstanding that this is specifically forbidden by law. In one instance the patient was found in the same room with a person accused of being implicated in a murder and developed a delusion that she herself was accused of the crime. In another a patient received a scalp wound by being struck with a pitcher by a prisoner. In still another the report stated that a woman patient was found in a basement cell, without windows, dark and damp, with no toilet facilities and separated only by a slat door from the quarters of a drunken man. Other reports showed

that the patients were cared for by prisoners, or were in a common room with drunkards and tramps. Under such circumstances no attempt at medical care and nursing could be expected, and sometimes the most ordinary needs of the patients were neglected. At a jail in one of the larger cities, a woman was found by the nurse in a cell in which she could scarcely sit up, it was so small. 'Three walls were padded with some course material and the fourth, the front, was a grated door. There was no water section or available toilet facilities. The patient was entirely naked and was extremely filthy and dirty.' The village lockups in which the patients were found were sometimes apart from other buildings and little used. The patients in them were sometimes left alone for long periods, and a suicidal attempt and a fire started were among the occurrences reported. Reports of insufficient food, clothing and bedding, of cold, and of inattention to medical treatment and nursing are among those received. In one instance it was stated that the food was bread and water. One man was far advanced in tuberculosis and delirious. Another was very sick, without fire or sufficient clothing, and died two days after reaching the hospital. An epileptic was drenched with a bucket of water whenever he had a fit.

The worst feature of all in the case of the insane women confined in jails and lockups is the lack of provision for attendance by persons of their own sex. In a large number of instances, the reports indicated that they were left entirely to the care of men. The impropriety and danger of this to both the patients and their custodians can scarcely be exaggerated and accusations of sexual assaults by police officers or jail keepers have been made by some of the women. In this way innocent persons may be exposed to false accusations from which they might have no opportunity to defend themselves. In one instance the nurse found an insane woman entirely nude in her cell, and the only person to attend to her was a man who handed her food in at each meal. The detention of women without attendance by persons of their own sex is, to say the least, indecent, and one wonders why it is permitted even in the case of those accused of crime." The only remedy would seem to be a State law governing the matter of the detention of alleged insane persons prior to admission and applicable to every part of the State. Where institutions for the insane are easily accessible or where general hospitals exist patients should be admitted to these institutions under emergency certificates. Jails and lockups ought to be absolutely forbidden to insane persons.

Space will not permit a consideration of the important work undertaken in the after-care of patients. It is gratifying to observe how rapidly agencies for this care are increasing in connection with many institutions for the insane. The excellent work done by the forty-one legally appointed visitors to the State hospitals is most interestingly told in their reports under the headings of their respective hospitals. No better method could have been devised to interest public-spirited and philanthropic persons in the institutions in their neighborhoods.