have subordinate centers in the spinal cord is well established, and it seems probable that the degenerative changes in the sensory roots of the spinal nerves and the cord may in some cases involve these centers. The existence of heat centers in the brain is not yet beyond question, though the last observations the writer has found (24) seem to establish their existence in the higher warm-blooded animals.

In the 31 cases of the present study, when high temperatures occurred with evident meningeal irritation, while the range of temperature might be very large, the rhythm was much more. regular than in the cases apparently due to furor, minor physical ailments, external causes of discomfort, etc. The temperature in the first set of cases might range between 98° and 104°, as in the other cases, but had not the sudden onset, kept its general character for weeks and usually the temperature curve resembled the normal in spite of the wide range (Chart 5).

CONCLUSIONS.

The cases observed early in the disease showed no appreciable departure from normal in temperature. The curve was influenced by the time of day, ingestion of food, sleep and exercise as in healthy individuals.

When the disease had progressed further, anger, excitement, epileptiform and paralytic attacks, minor physical ailments, etc., produced effects on the temperature out of proportion to the causes, while some elevations of temperature unaccompanied by leucocytosis occurred for which no physical basis could be assigned. The inflammatory changes in the brain and spinal cord apparently are largely causative of the high temperatures occurring with leucocytosis.

On the whole, the general results of these observations confirm the opinions of Rottenbiller (16), except that the writer cannot fully accept his conclusions as to the diagnostic value of the temperature variations.

Sorokovekoff's conclusion that elevated temperatures in paresis are often due to excitation of the central nervous system would seem to be borne out by this study, but the demented state, while lower in average than the maniacal, gave no nearer approach to normal curves.

BIBLIOGRAPHY.

1. Benedict and Snell: Archiv für die gesammte Physiologie, 1901, Vol. LXXXVIII, p. 492; 1902, Vol. XC, pp. 33-72.

Benedict: Amer. Journ. of Physiol., 1904, Vol. XI, pp. 145-169.

2. Oberneir: "Der Hitzschlag" Bonn, 1867.

3. Jürgenson: Der Körperwarme des gesunden Menschen, Leipzig, 1873 4 Leibermeister and Hoffman: Handbuch d. Path. u. Therap. d. Feibers, Leipzig, 1875

5. Mosso: Vergleichende Phys. der haussäugethire, 1892.

6. Myers: (Quoted from Benedict.) Yale Med. Journ.

7. Mosso: Die Temperature des Gehirns, Leipzig, 1894.

8. Pembrey: Schäfer's Physiology, London, 1898.

9. Carter: Journ, Nerv. and Ment. Dis., Vol. XVII, p. 785, 1890.

10. Gibson: Journ. Med. Sci., 1905, Vol. CXXIX, p. 1049.

II. Bosanquet: "Annual Heat," Todd's Cyclopædia, Vol. II, p. 659. 12. Riva Rivista Sperimentale, 1879.

13. Riva: Arch. Soc. Freniatrica, 1883.

14. Croemer: Allg. Zeitschr. für Psych., Vol. XXXVI, Band 2, u. 3 Heft. 15. Wirsch: Centralblatt für Nervenheilkunde, Mar. 1, 1881. 16. Rottenbiller: Centralblatt für Nervenheilkunde, Jan. 1, 1889. 17. Savage: Quoted by Turner, Journ. Ment. Sci., Vol. XXXV, 18. Crichton Browne: Quoted by Turner, loc. cit. 19. Peterson and Langdon: Journ. Nerv. and Ment. Dis., Vol. XVIII, p. 750, 1893.

20. Parsons: Journ. Nerv. and Ment. Dis., 1895, Vol. XX, p. 407. 21. Sorokovekoff: Moniteur neurologique, Rus., 1904.

22. Diefendorf: Trans. Amer. Med. Psy. Assoc., 1903.

23. Noyes: Brit. Med. Journ., Vol. II, p. 551.

24. Ott: Jour. Nerv. and Ment. Dis., 1893, Vol. XVIII, p. 774

p. 347.

Ott and Scott: Jour. Exp. Med., 1907, Vol. IX, p. 61; Tangl. Pflüger's

THE VALUE OF STAFF CONFERENCES IN STATE

HOSPITALS.*

BY ELBERT M. SOMERS, M. D.,

First Assistant Physician, St. Lawrence State Hospital, Ogdensburg, N. Y. Staff conferences, essentially medical in character, have been in operation in the various State hospitals of New York State since the year 1905, as required by law.

The introduction and adoption of newer methods of clinical study, shortly before this period, clearly emphasized the need of more uniform and concerted action on the part of hospital staffs with reference to the study of the mental and physical condition of those admitted for care and treatment.

Previously, some of the hospitals had, for some time, held more or less regular meetings, but they were pre-eminently for administrative purposes.

Staff meetings, fortunately for all concerned, have now become medical clearing houses, and have been of value in proportion to the interest manifested by the individuals taking part in the work. Cases have become common property and experience consequently widened.

The former methods, whereby, largely through heresy, or on account of unusual interest, only a few came before the staff, have been corrected as far as possible.

There are obvious reasons why the entire staff should share in the results of every examination that has been made by another. Clinical work is better for having been scrutinized and passed upon in a formal way rather than casually brought to notice.

The facts of the history, the mental and physical findings and the patient are presented. All are considered with the view of giving full value to the diagnostic points.

The impressions thus made are less likely to lose their force or fail to be of help in the study and observation of future cases. It is not to be forgotten that purely physical questions should receive their share of attention in relation to psychoses.

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

Criticism under the proper conditions is also a valuable feature in bringing out points of interest that may have been overlooked. The best policy, as to the treatment of a case, is known to all. The impression gained by the patient, that the entire staff is interested in his behalf, aids materially in gaining the good will and confidence of the subject. The various services in institutions become less individualized and apart. They are rather made to contribute whatever may be of medical interest to the general fund, and those in charge draw their experiences from sources broader than formerly, for each member of the staff is continually assigned new cases for study and presentation.

A properly organized staff conference is a step forward in hos pital organization, and when it is fully inaugurated there seems to be no good excuse for substituting the time thus spent for other methods of instruction.

Uniform methods of examination with definite times set apart for the mutual consideration, as far as possible, of medical questions, cannot be considered as impracticable, either because too much time may be required or because of fear that other matters of routine will be neglected. The arguments against this procedure can best be made only after a fair trial.

It is probably true that no State hospital staff is so busy that it cannot set apart some portion of time for conference upon strictly medical matters.

The sole object of this paper is to briefly point out some of the elements of value in staff conferences, based upon the assumption that all obstacles for their prosecution have been successfully removed. Therefore, one's description will be largely from personal experience in a hospital where daily conferences are the rule.

In organizing the medical program for such meetings, it should be the duty of the one in charge of the clinical department to assign cases to other members of the staff as soon as they are admitted, and so arrange the work that it be as equally divided as possible. This duty rather naturally falls to the first assistant physician, as he usually has general oversight of the recent admissions and of all clinical matters generally.

In institutions where the annual admissions are not over 400, and the ratio of physicians to the general population is about one

to 170, all the cases can, upon entry, be fully examined and presented a sufficient number of times before their discharge if daily conferences are held. Many of the larger hospitals of this State, however, have admission services so active that even daily conferences could not properly dispose of all the cases. The practical advantages gained by the presentation of as many cases as possible, nevertheless, holds good.

In the selection of cases to be presented, enough material should be provided to completely occupy at least one hour.

It has been found feasible to present all cases under three different conditions. First, within five days after admission. Second, when the case is completely worked up, usually within six weeks. Third, before discharge.

The advantages of the first presentation are of some importance. In New York State there is a statutory regulation that requires the superintendents of hospitals to see all patients within five days after admission, and thereby this requirement is conveniently observed, as the superintendent is naturally the presiding officer during the clinical hour.

At this period, more attention is paid to the points of history than to making a diagnosis, and in addition, to primarily determine whether the patient is a proper subject for detention in the institution. Therefore, the attendant, whose trained duty it was to obtain from the relatives or otherwise as full a history as possible before bringing the patient to the hospital, is also required to be present before the staff in order that the errors of history may be corrected, doubtful points inquired into and fuller descriptions of certain events obtained.1 In this way, there is often gained additional information of value, the mental level of the relatives and home conditions are better understood, and the history, when recorded, is in better form.

This method of scrutiny of the attendant's report has its obvious advantages and tends to make him more accurate in his inquiries.

Those hospitals, which draw their patients from large rural

1The New York State hospitals send, upon notification, trained attendants to the homes of patients, for whom admission has been sought, to convey such patients to the hospital.