arise for further study such as neurological or other organic manifestations.

Relatively few patients are in such condition that they cannot be presented before the staff. Those that cannot are so because of some serious physical disorder or, rarely, because of extreme sensitiveness, such a state as we might readily infer in the case of a refined woman, depressed and fatigued upon entry.

The second presentation of the case is made only after the examiner has, as fully as possible, completed his examination. Six weeks are sufficiently long in which to gather and put in typewritten order what is obtained. For the sake of clearness a summary of the findings is submitted rather than the whole case in order to cover in succinct and comprehensive form the principal features of the case. The complete examination can, at any time, be referred to whenever more detail is required concerning some particular point.

It seems not wise to defer longer in hopes of adding anything materially helpful for diagnostic purposes, even if inaccessibility is the stumbling block. There will be a small percentage of cases that cannot be satisfactorily classified even at a more remote period, but enforced postponements for this reason should not deter energetic and painstaking efforts to come to early and fairly sound conclusions in those cases in which the symptoms are demonstrable.

It would add nothing to the value of a case of general paralysis to wait for positive evidences of memory faults before giving the disease a diagnostic name. The exhibition would be of more interest before this stage. The habit of waiting too long before making a diagnosis robs the case of its freshness and interest for others. The salient points become historical rather than clinical and the examiner substitutes convenience for expediency.

It is decidedly more interesting for the staff to witness retardation rather than to take another's word for it. A manic case is more instructive when he can be readily shown to be so. The mood, attitude and manner of the hallucinated person mean more when observed early. A case should be shown when it is worth while if clinical material is to be the means of sharpening our knowledge and rendering us more resourceful.

After the record is presented and the patient properly interviewed and dismissed, discussions are then in order. Herein rests much of the further value of a staff conference. The one who presented the case has been mindful of this when summarizing the record and arranging his diagnostic points. The contentions and arguments incident to such discussions should be pertinent and not allowed to become too miscellaneous or unprofitable.

In the main, the following questions are up for consideration, namely: What is your impression of the case? Do you agree in the conclusions that have been drawn? What features do you see that are unusual or that differ from those manifested in former cases of the same type? Have the therapeutic indications been met? What factors influence the prognosis?

In this way the case is not simply disposed of by merely giving it some diagnostic name. This characterization can be best reserved till the last. The more important consideration is whether we have understood the individual case, and of what use can it be in practical work.

A record of such a presentation should be made by the examiner covering the important features elicited from the patient and the opinions expressed by the various members of the staff. By this means, aid is given in the subsequent observation of the patient in whatever service he may be.

There are occasionally good reasons for again presenting the case to show some unusual mental or physical conditions that may have arisen or because of some obscurity regarding previous symptoms.

The final presentation of a patient is made when his discharge comes up for consideration. This usually takes but little time. particularly if the case has recovered. Under any conditions it is well to know as far as possible the exact mental attitude of those who are to leave our charge. A brief review of the main points of the case, together with the course of psychosis, is submitted, and the welfare of the patient, as well as the interests of the community from which he came, are determined by what is found. If the patient is well, some profit accrues from learning under what circumstances and by what method he was able to

readjust himself. What may constitute insight is a feature peculiar to each case.

Lastly, it seems advisable to set apart some portion of an hour during the week for the consideration of any autopsies that may have been held. The findings are considered in relation to the clinical notes. The extent of the continued observation and interest in the cases, which have been more or less disposed of, are hereby measured. The accuracy of the diagnosis of intercurrent physical disorders and of the terminal disease are here put to the test, and oversights become matters for explanation.

It is probable that in the past the necropsy has been put too much apart by itself, and has not been considered in close enough relationship to conditions found existing during life. Autopsy material manifestly belongs to the clinician. It is his case even after death and no autopsy should be conducted unless the examiner is there with the record of the case. Furthermore, the pathologist is thereby better guided in his immediate investigations.

In some such way, as briefly outlined, can the hour given to consultation be made profitable. It is this kind of schooling that will be likely to help the staff to keep pace with the present day requirements of practical psychiatry.

Matters of medical import are brought into better line with something definite in view, namely: Accuracy of observation, correction of wrong impressions and construction of permanent records, which contain more complete and orderly data for future help. In addition good opportunities exist for subjecting to practical test whatever may be found in general literature and mere book knowledge takes its proper level.

Daily conferences give the superintendent a greater personal knowledge of the general medical activity of his staff and he is in a better position to measure the value of each individual.

REVIEW OF INFECTIVE-EXHAUSTIVE PSYCHOSES WITH SPECIAL REFERENCE TO SUBDIVISION AND PROGNOSIS.*

BY SAMUEL W. HAMILTON, M. D.,1

Second Assistant Physician, Utica State Hospital, Utica, N. Y. In the New York State Hospital classification as projected by Dr. Adolf Meyer one of the divisions is called the infective-exhaustive group. It includes "autotoxic or infective or exhaustive psychoses not included in the group with a nervous disease or nervous complex or tangible brain disease; subdivided into (a) thyrogenous disorders, (b) uremic, eclamptic and demonstrated gastro-intestinal disorders, (c) febrile and postfebrile deliria, (d) exhaustive deliria and kindred psychoses." An allied group includes "those to all intents and purposes the same, but in which we cannot demonstrate such an etiology." Such cases have been in the past grouped in various ways by different writers. Let us review a few.

Ziehen describes acute hallucinatory paranoia which arises from exhaustion, intoxication, infection, trauma, hysteria and epilepsy, polyneuritis, puberty, climacteric, senility or the puerperium. Its diagnosis depends on proof of primary hallucinations which prevail throughout. Out of these develop delusions. Affect and association are only secondarily disturbed. With its varieties and subdivisions this would seem to include so many cases as to be of little help to us in any direction. For example there is the greatest possible range of prognosis. Moreover we find in cases otherwise similar that hallucinations were not prominent, and the existence of these can be determined only on recovery.

Krafft-Ebing object that this is not a paranoia and does not pass into a paranoia. He calls it primary hallucinatory insanity.

* Read at the sixty-fifth annual meeting of the American Medico-Psychological Association, Atlantic City, N. J., June 1-4, 1909.

'To Dr. Wm. Mabon, superintendent and medical director of Manhattan State Hospital, I am indebted for permission to use the hospital records; and to Dr. George H. Kirby, director of clinical psychiatry, for the impetus to this study and very many suggestions as to the form and content of this paper.