person in the world, but you can't get out and fight for your living, well, what's that? I wouldn't want to sit in a chair-I have had about a million different selves. Dr. Last night when you came in you talked very well and then gradually grew confused. Pt. I don't remember anything-I am outside of myself—I am in myself. I feel inside-rather automatical—there is no sense of contrast of being tired or being refreshed, or the hundred of other contrasts that go to make up life-that's all it is-contrast-eating and sleeping and being tired and being restedhaving pleasure and having pain, and the keener the contrast the keener do you live. I have lost all relationship with people-they are not human. You see, it's that association and everything have gone, and what have you got? Suppose you go into a restaurant and eat and you have no ears or eyes, or anything, and are utterly out of relationship with everything. I cannot talk to you now rationally (pause). Dr. Did you have an unhappy home life? Pt. I have never known what-I don't know what it is to be unhappy because I have had to adapt myself—you can call it unhappiness, but I have never had happiness, so I don't know what unhappiness is. Any way, if you see how much pain is in life— ultimate analysis is probably pain any way, isn't it (laughing)? I want to hear you talk now a little, if you talk I will respond (smiling) to your talk (pause). Now, the usual terms, I don't grasp the meaning of terms, there's where feeling comes in—you feel the meaning of terms—you feel the richness and color (pause) in a sunset (pause). Dr. And you have lost that feeling of appreciation? Pt. There is no appreciation-there is no appreciation-no. Dr. What do you think the outcome of your state is? Pt. What the result of it is (pause)? I have forgotten what result means now-what the result of my state is (smiling) (pause). Dr. I mean, do you think you are going to get better or worse? Pt. I think I am gradually shriveling up-going back into childhood (pause); I am quite sure I cannot get better-I am (pause) (yawning drowsily)— no, I don't think it's possible.

For some time the mental condition of the patient varied; he was often dull and sluggish, his motor discharges correspondingly slow and deliberate. He was often silly and childish in bearing. For awhile, in his speech and gait, he simulated an intoxicated person, and always explained his condition as due to his abnormal metabolism which formed alcohol within his system.

The physical examination disclosed the following points of interest. The skin presents a condition of hyperæmic congestion and cyanosis, especially noticeable on the upper back and neck regions. Pressure of hands elicits the so-called X-ray appearance. Dermatographic reflex consists of an intense white, immediate pressure line, with no subsequent red line. Pupils examined in the dark show a somewhat diminished dilatation. With the torch the left pupil reacts about half a millimeter, the right about one and a half, and both very sluggishly. The right is irregular in outline. The accommodative reflex is also diminished in

Song the egr monés a vich pacent has been under observation Sere tall been consideratie prysement, with a gain of about 1 pounds n wg The most reaction, the moon si and the alcool-formation des he apply appeared. While there is ien tugines age and primccor spheres there is a THE BALIement du moran mend and narrowing of mental berino cd stere

Wale pandsheid mood he is not able to so clearly describe kis sobjective consciousness as before. In his daily routine he is careless and lovely in his personal appearance and in his room. His chief interest is his piano playing and in this be exhibits considerable skil He keeps much of the time to himself; is sometimes observed to sit and stare in one direction for a half hour, or even more; he has also shown recently unemotional or so-called irrelevant laughter, chiefly at night when alone in his room

The condition of the skin, pupils and reflexes remain the same as on admission

Fifty words, chosen with respect to patient's individual characteristics, were used to test the association. The average reaction time of two seconds was prompt, and did not disclose any complex of pathogenic import.

CASE II-Male, single, 27; a Russian-Jew, born of ignorant and illiterate parents. Nothing was discovered of importance in the family history. Patient was the oldest of seven children. He obtained a meager schooling and at an early age was set to work at a sewing machine. He was ambitious to become a lawyer and entered a night school. His lack of preliminary education proved a great obstacle and he failed to pass his final examinations. Three months before admission to the hospital he developed, without sufficient reason, an irritability and impulsivity toward his father, and on several occasions threatened to kill him. He is very reticent when questioned about his father, but patient evidently in some way blames him and his home surroundings for his present situation; in other directions as well, patient has also shown some delusions of paranoid and persecutory character. He was tested with 50 association words-the average time for the whole was 3.9 seconds. The reproduction to the word "father" clearly indicated that a complex had been struck. No reaction was obtained for 23 seconds, then the patient replied "home." He has shown some irritability and impulsiveness toward certain nurses, which, in connection with a frequently occurring refusal to eat, may indicate a hidden paranoid constellation. He walks slowly and holds his body in a strained and awkward position. In conversing he often breaks into a

broad smile without demonstrable reason. The disturbance in the somatopsychic sphere is most prominent and interesting. He spends much of the time on the bed, because when he stands the left side of his chest "jumps so." He repeatedly complains of his heart, fears it is going to stop, says it has no more ambition than he has. Complains of a great variety of paresthesias in surface areas, such as burning, warmth, electric touches, pains and numbness. These often are fleeting in duration, and very localized in extent. Cephalic pain and girdle sensation, he often mentions. He complains of a mental dullness, and that things feel strange to him, or that he cannot think at all and doesn't want to.

In the physical examination the right pupil was more active than the left, and irregular in outline. The excursion of the left under torch-light was diminished. Accommodation reaction is also sluggish and restricted. All the deep tendon reflexes are increased. The extremities are usually cold and moist. There is a very slight grade of cyanosis. In the seven months the patient has been under observation there has been very slow, yet obvious, deterioration, consisting chiefly of affect dementia, an intellectual narrowing and a fixation of the somatopsychic complexes.

CASE III.-Male, 27, single. The only son of cultured and intelligent parents. After puberty he evidently showed marked psychopathic predisposition. He was admitted to the Sheppard and Enoch Pratt Hospital in May, 1908. His psychosis was said to have commenced several months previously. The principal feature was the occurrence of mental states characterized by marked disorientation and dissociation in the autopsychic sphere. There were active hallucinations, both visual and auditory. All varieties of delusions of reference paranoid in character were expressed. There were also prominent somatopsychic disturbances, which were, however, at all times present to a lesser extent. Such a phase as the above would last on the average several days to a week, when the auto- and allopsychic disturbance would clear entirely with the return of a good insight and appreciation of having been through some kind of a mental attack. As previously mentioned there would persist, when in his best condition, some somatopsychic disturbance which resembled a neurasthenic reaction. The patient often complained of paresthesias similar in quality to those shown by Case II.

Physical examination was negative except for pupillary anomalies, which were an irregular left pupil and a sluggish light reaction and diminished excursion. Similar attacks to the one described occurred at regular intervals during his stay at the hospital. Between attacks patient's general reaction to the casual observer was practically normal. He was discharged improved, and when heard from recently was able to do some work in the jewelry business, and was considered in good condition by his family. Evidently so far there has been but little deterioration, and if we are right in assuming that the process is a dementing one, the progress is evidently very slow.

CASE IV.-Male, single, 23. Admitted in July, 1905. The psychosis of this patient is strikingly like that of Case III. The attacks, however, have occurred at more regular intervals, and last a week or 10 days, to be followed by a fairly normal interim of about the same duration. The transition into the attack usually takes a few hours. This patient left the hospital in 1907, but has been seen at intervals since then. He shows a well-marked physical and mental deterioration. Formerly an expert stenographer, during his well periods he is still able to do a little work along this line, but the quality of his work has obviously degenerated.

The cyclic-nature of the disturbance in Cases III and IV seem to support the theory of the primary importance of the "X" or toxin of Jung, especially as no complex of pathogenic importance could be discovered in either case.

Cases II and III exhibit peculiar interest from the standpoint of differential diagnosis, inasmuch as a single examination during several phases might easily lead to a diagnosis of neurasthenia. The importance of a correct estimate of such cases is obvious.

THE APPLICATION OF IMMUNITY REACTION TO

THE CEREBRO-SPINAL FLUID.*

By J. W. MOORE, M. D.,

Assistant Physician, State Hospital, Central Islip, N. Y.

Time does not allow of a preliminary explanation and discussion of the various theories of immunity by which modern investigators have sought to explain the changes which occur in the serum of an animal which has been inoculated with some foreign cell or toxin.

Suffice it to say that the hypotheses of Ehrlich have so well withstood the assaults of critical experimentation that they have come to be tacitly accepted as, at least, a convenient working basis until chemistry in its rapid strides shall have come to our aid and simplified what are now merely to be expressed as properties possessed by a serum into definite colloid or proteid formulas. In the following paper the use of technical terms has been avoided so far as possible, but such as do occur are among those which were introduced by Ehrlich and are still in constant use.

One of the ingenious applications of an immunity reaction to diagnosis has been the so-called "complement-fixation test" introduced by Bordet and Gengou in 1901. The immune property of a serum, e. g., the immunity which a typhoid patient's serum acquires against the typhoid bacillus, by reason of which it agglutinates and destroys the bacilli in the Widal test, is known to consist of two parts. One part, called antibody, represents that peculiar property of the serum which makes it immune to that organism and to no other. This antibody is thermostabile, that is, it is not affected by heating the serum to 56 C. The other part, complement, is a constituent of all sera whether normal or immune. It is thermolabile and is driven off by heating to 56 C., but can be restored by simply adding a small quantity of fresh, unheated, normal serum from the same or from another suitable species. So, if we first heat the typhoid patient's serum and then add it to an extract made from a broth culture of typhoid bacilli, the organisms will not be destroyed, for the serum has been inacti

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