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the infection and may subside when the disease granted, the possibility of the stimulation of conbecomes fully developed. It is apparently due to sciousness must depend upon the degree of excitthe sudden invasion of the body with bacterial ability possessed by the cells and, since ability to toxins. Under this same head also come states clearly recognize our surroundings depends upon of delirium which do not run parallel to the fever the arousing of a normal degree of activity in and may be present even when the temperature the various brain pathways, it is also obvious is but little raised or has fallen to normal or that any interference with the normal functioning below. Such are seen, for instance, in the course of these pathways must necessarily lead to a disof influenza, chorea and rheumatism. In some of turbance in our grasp of the surroundings. the especially severe cases of this group there One of the most prominent features of the is an actual deposition of bacteria in the brain. infective-exhaustive reactions is such a failure to The effects seem to be due to the bacterial toxins fully, or correctly, grasp the situations in which rather than to autotoxins and hence they are the patient may happen to be placed. Consciouscalled infection as opposed to fever deliria. Many ness is, as it is said, clouded and the objects and of this type represent very severe infections and happenings around are more or less misunderhence the prognosis as to life is always serious. stood because incompletely perceived. The conThey tend, however, when not fatal, to be of short sequence is that the behavior and conduct of the duration corresponding with the persistence of patient (which is all that we can observe) seems the toxins plus the time which the damaged brain more or less incongruous and inappropriate to tissue requires for recovery.

the actual circumstances. The third group of acute confusion is not very Where there is over-excitability of tissue this clearly defined from the last but includes a clouding is accompanied by confusion and gennumber of severe intoxications appearing after eral restlessness. If on the other hand lowering infection, especially with typhoid, acute rheum- of function is more marked the tendency is to a atism and the puerperium and also in connection quieter but at the same time more incoherent with severe exhausting conditions. Death may state well seen in the so-called “muttering deliroccur, but it is not so frequent as in the last. ium” of severe typhoid states. When not fatal the condition generally lasts for But in addition to these misinterpretations or some time, being given by Kraepelin as from two illusions, and consequent disorientation, there is to six months.

often present a condition of hyperexcitability of The fourth group again is not very well dif- the cells of the lowest brain levels, that is to say ferentiated from the last as it appears following those of the sensory regions of the cortex, with infection or other exhausting factor. The pic- the consequence that stimulations which in health ture is one of general reduction of psychic activ would be insufficient to give rise to sensations ity with easy fatigue, and this usually lasts for may now suffice. There will thus be aroused some months and may be permanent.

sensations which do not correspond with any In order to understand the manifestations of stimulus of the environment—so-called hallucinathese intoxications it is essential to think of the tions. These tend to add to the confusion and function of nerve tissue. This, in addition to the apparent disorder of conduct and speech. maintenance of its own nutrition, consists of ex- These features of clouding of consciousness citability and the conduction of such states of with more or less disorientation, illusion and halexcitement. It must also be remembered that lucination are quite intelligible upon the disconsciousness is the brain cells in action. Inter- order of function due to the poisoning of the ference with function can take place only in two cerebral cells. But it may be difficult to underdirections, increase or diminution. In a general stand why they take the particular forms which way it may be said that lesser degrees of damage we observe clinically. It is easy to see why there to a cell give rise to increased excitability while may be a hallucination of vision, but why does more severe injury results in diminution and it take a special form such as that of the devil, finally loss of excitability. This is perhaps not a particular face or what not? One can underuniversally true, as there may be some toxins stand that objects or happenings in the surroundwhich produce lowering of function without the ings may be misinterpreted. But it is not so initial excitation. It can readily be understood, obvious why the interpretation made should have however, that in states of generalized intoxica- some one particular form and this error be retion there is a liability to the occurrence of a peated over and over again in the same form. simultaneous combination between irritative and The explanation of these facts depends upon paralytic phenomena especially during the earlier many factors and it is possible here only to indistages which may later give place to a general cate briefly certain important points. Firtly, it and marked lowering of function in which excit must be remembered that the direction of one's ability is more or less completely in abeyance. thoughts is to some extent dependent upon one's

We have defined consciousness as the brain mood. When we “feel good” it is difficult to cells in action and it is obvious that, if this be see the dark side of things. When depressed we

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find it hard to see the “silver lining” to the cloud. ness of his remarks and actions to the situation The mood is largely dependent upon the harmon- as the patient grasps it. Since he may be sufferious activity of the various bodily organs. In ing from illustion and hallucination it is obvious states of generalized intoxication there is neces- that this may differ largely from the situation sarily more or less severe dysharmony and conse- as the examiner sees it. quently the mood is generally one of depression. To illustrate what is implied by these last reHence one particular trend is at once given to marks suppose that one gathers from the pathe thoughts aroused by any sense perception. tient's remarks that the sounds in the street are There are especially liable to be aroused those misinterpreted as the voices of her children. One thoughts which fit in with the mood of depres- then observes the conduct and contextual resion and the patient's erroneous perceptions marks with the view of determining whether therefore tend to be unpleasant.

these are in keeping with such observation. Again, in every individual, some trends of The fate of the cells which have suffered from thought are much more habitual than others. such intoxications is obviously an important This means that those nerve pathways, the activ- point in determining the question as to whether ity of which they are, even in health, are more recovery of the previous mental capacity will easily stimulated than others. This will give occur. One is quite accustomed to give assurrise to the tendency to misinterpret in the direc- ance that these people will fully recover provided tion of frequent experience and will explain the life is preserved and fortunately this is generally frequent occurrence of so-called “occupation de- true. But it must be remembered that if the damlirium" in which the patient seems, by his re- age to the cell is sufficiently severe the cell will marks and movements, to be following up his die and disintegrate. Nerve cells differ from all Lisual avocation.

other cells in the fact that each has a different In states of general excitement with failure connection to make from every other. They do to understand the surroundings as the result of not all do exactly the same work as do all liver clouding together with depressed mood resulting or kidney cells because they have different anafrom the general bodily upset and a confused tomical connections. Hence the loss of nerve cells mass of sensations due to hyperexcitability one means complete loss of certain possibilities of can then readily understand that the reaction of transfer of energy and consequently lessened the patient will be colored by fear and anxiety mental efficiency. and that his words and behavior will indicate You are all familiar with the fact that after the most terrible and awful misinterpretations a severe infectious disease, such as a bad attack which he is capable of imagining. In other words of typhoid, patients may remain permanently less the particular form which the hallucinations, active and efficient and more dull and lethargic illusions and the consequent delusions take will than before. Such permanently enfeebled states depend upon the individual experiences and inter- are rarely of sufficient severity to call for more ests of the patient. Just as the anxious mother than surprised comments by friends, but occawhen her son fails to return home at the expected sionally it happens that the loss is more severe hour pictures as having happened all the things as seems to be the case in a patient I have had she most dreads, the particular dreads being de- on my wards in the State Hospital. Such cases pendent upon her personal experience as to what are included under the title of enfeeblement from might happen, so the patient, confused and be- infection used by Kraepelin and mentioned above. wildered by a host of unusual sense experiences Rarely being severe, they require but passing (illusions and hallucinations), interprets them in mention and consideration when dealing with the light of his own personal fears.

severe and prolonged delirium. In this connecThe importance of this point lies in the light tion do not forget that severely damaged cells which it throws upon the fact that in these infect- may eventually recover even after several months ive states the actual manifestations, the words and that, therefore, rest and hope should be perseand acts which we observe, depend more upon vered with. the individuality of the patient than they do upon Having thus very cursorily considered the the particular infection from which he is suffer- nature and manifestions of these infective-exing. No two cases of delirium are alike as re- haustive psychoses we may turn to the question gards the particular illusions and consequent de- of the indications for treatment. lusions which occur. The recognition of the na- It was pointed out that the state of dysharture of the disorder from which the patient is mony and disordered metabolism in the body, suffering must therefore depend upon the de- due to the infection, resulted in a state of emotection of the basis of disturbance in excitability tional depression. This mood when added to the of brain cells with clouding of consciousness. illusions and hallucinations resulting from local The manner in which one does this is by attempt- damage to the brain cells gave rise to a still more ing to determine how much the individual is able active disorder in mood. This again as Pawlow, to grasp of his surroundings and the appropriate- Cannon and others have shown means still fur


ther interruption of bodily metabolism and there than persons in more asthenic conditions. Hyosthus exists a vicious circle which must militate cine may be used with caution and is often of seriously against the patient's chances of recov- value, but I believe it should not, in these condiery. All such active emotional states imply fur- tions, be combined with morphine. Chloral in ther a big expenditure of energy as well as a small doses is not a cardiac depressant, but large difficulty in digesting and absorbing food. Hence doses should be avoided. I will not bore you the indications for treatment (apart from those with an enumeration of the many such drugs belonging specifically to the treatment of the in- available, but will conclude with the earnest fection which are not changed by the existence recommendation to attend carefully to water, of the psychosis) are fairly clear and may be food and quiet surroundings before deciding to grouped under two main headings, nutrition and employ them. sedation. Of these the former is by far the more important.

REACTION OF THE SEMI-CIRCULAR It is impossible and unnecessary for me to CANAL TO STIMULI AND DIAGgo into details on these points, but a few features

NOSTIC SIGNIFICANCE* may be emphasized. First a large supply of

J. B. POTTS, M. D., Omaha, Neb. water, of which the body holds no reserve sup

The announcement of your secretary was, ply, is essential. If necessary, this must be given

that the meeting was to be along the lines of by rectum, hypodermically or even intrvenously.

medicine in the present war. As a member of Secondly, since digestion is always markedly in

the examining unit for aviation service in Omaha, terfered with, the food must be in readily assim

it occurred to me that the profession might be ilable form and easily combustible. For this pur

interested in the special tests that are required for pose may be mentioned especially the sugars

this service. This was emphasized some days such as glucose, which can, if necessary, be ad

later by the irrelevant question of one of our inministered hypodermically, and well diluted alco

ternists. This man while unusually well posted hol. Under this same category also comes the

and having a working knowledge of the caloric question of alkali. Depletion of the alkali-re

and turning tests, flew wide of the mark when serve of the body and even definite acidosis

inquiring as to the tests necessary for aviators;

in (meaning thereby, of course, not an actual acid

his idea being that the tests were intended to ity of the blood, but only a diminished alkalinity)

hty determine a man's ability to stand being turned are quite frequent and the addition of alkali in

round and round with the swooping and slidany prolonged state of this kind is of importance.

ing that might be experienced in driving aeroThe question of sedatives must be weighed

planes. Also the ability to remain cool under by careful consideration of the probable dura

unusual conditions and stimuli. This all is very tion and the damage which is apparently result

erroneous as will be made plain as the paper ing from the excitement. Do not rush to drugs

proceeds. which are also toxins and may add to the diffi

The principal interest lies in those tests which culties with which the body has to contend. Sim

are directed to the semi-circular canals. Howple quiet and the avoidance of stimulating sights

ever, previous to testing these, the hearing and and sounds with adequate water and food will often suffice. In addition, if conditions are suit

*Read before the Medical Society of the Missouri Val

ley at Lincoln, Neb., Sept. 21, 1917. able, hydrotherapy in the form of baths or packs will often act like magic in securing sufficient rest. Only where such measures fail or where

LOYALTY AND SERVICE they are impossible of application should resort be had to drugs.

• Doctor, have you offered your services to your In thinking of drugs for such purpose do not forget that the stimulation of a lagging heart may result in sufficient improvement in general metabolism to have a general sedative effect. For this purpose we may employ the more powerful but more transient stimulants such as ammonia and camphor (strychnin is a nerve poison and not a cardiac tonic) or those of the digitalis group which produce a milder though more prolonged members are in service. We need new members to effect. Finally, in any case, when the dangers of

fill up the ranks. If you do not receive a program, excessive activity lead to the decision to use some

Fraternally, sedative drug, careful attention must be paid to


Medical Society of the Missouri Valley. its effect upon, and the condition of, the heart.

Subscribe to the Fourth Liberty Loan and help Remember that such patients are usually much hurry the final decision. more susceptible to the toxic effects of morphine

country? Service is the supreme test of loyalty. and true patriotism should inspire every man to do his duty in time of his country's need. Surgeon General Gorgas needs more doctors, and he needs them now. The increasing activities on the western front will intensify the demand for medical men. Now is the golden opportunity for you to serve your own country. And what a glorious thing to be able to say later on that you took an active part in a grand victory! Perhaps you are disqualified for active service: if so, there is ample opportunity for service in the "Home Guard." Come to Omaha September 19th, and hear these matters discussed. Bring a friend with you. Many of our

write me at once.

vision must be ascertained to be normal in both mally, touching the examiner's fingers. The eyes and both ears. No deviation from this rule same test is performed, turning the candidate to is allowed. In addition to this, the eye muscles the left. The last test consists in having the must be carefully examined, and only a slight candidate place his knees together, the palm of deviation from the normal balance is allowable. the left hand over the knees and the right fist on The eyes then should be rotated in every direc- the back of the left hand, forehead on fist. He tion, and nystagmus if any should be noted. is now turned four to five times to the right Static tests are made by having the candi

slowly, and then asked to sit upright. On ac

slow date stand with his heels together, hands to the

count of the stimulation of the vertical canal, he side and eyes closed. He is then commanded to

normally should fall to the right. walk across the floor for several paces, halt and Incidentally, while making these tests, we then back to his original position. He is then have also tested many of the principal nerve seated in a chair and tried on the pointing tests. tracts of the cerebellum and cerembrum. Thus This is done by closing the fist tightly with the the tests are of great importance to the otologist, exception of the forefinger. This the candidate neurologist, and profession in general. As any places on the forefinger of the examiner's hand, intra-cranial growth or pressure, if it interferes which has been closed in the same way, and with any nerve tract that is concerned with any then with the eyes closed, the hand is raised of the tests, the reaction naturally is not normal. to the height of the shoulder and brought down Up to date our knowledge is not sufficient nor on the examiner's finger. In a normal person the facts sufficiently correlated for the otologists this, is accomplished without difficulty. Should to definitely state that this tumor, cyst or other there be some question as to this reaction, other obstruction, exists at a certain point. However, pointing tests may be carried out, as from below we are warranted in saying that certain tests give up and horizontally. Pointing tests may also certain reactions which indicate and interference be done with the foot, using the great toe as the with the nerve transit at a probable location. pointer, but this is not done in aviation work but

For the classification and investigation necesis valued in some pathological conditions. The

sary to bring this important work begun by candidate is now placed in a chair for turning,

Berani, to a reasonable working basis, we are with the head slightly forward so as to bring

indebted to Dr. Jones of Philadelphia, now Major the outer angle of the eyes on a level with the

Jones of the U. S. Army, in charge of the examexternal auditory meatus. This is necessary in

ining for the aviation branch of the service. I order to bring the horizontal canal perfectly in

am indebted to Major Jones and Dr. Lewis, fora horizontal plane. If this is not done you will

merly of Dubuque, Iowa, now Captain Lewis, in get a mixed horizontal rotary nystagmus as

charge of the aviation unit of the Aviation Corps there is some stimulation of the vertical canals

at Omaha, for most of my knowledge on this also. With the eyes closed, the candidate is now

subject. turned to the right ten times in twenty seconds with the head still bent forward; the eyes are

567 Brandeis Bldg. opened and the candidate is required to look at some object distant, if possible fifty to one hun Based on the mortality statistics of the allied dred feet. In a normal case, true horizontal armies, a soldier's chances are as follows: nystagmus will be present with the pull to the

Twenty-nine chances of coming home to one right and with a jerk or quick component to the left. Normal reaction for this turning test is

chance of being killed. twenty-six seconds. The same test is now per Forty-nine chances of recovering from formed turning the candidate in the opposite di- wounds to one chance of dying from them. rection. In the same position the candidate is One chance in 500 of losing a limb. turned rapidly to the left ten times in ten sec

Will live five years longer because of physical onds, with the eyes closed and with the head

training, is freer from disease in the army than still in position. He is now required to do the in civil life, and has better medical care at the pointing tests. Owing to the stimulation of the

front than at home. vestibular apparatus, altho the chair has been stopped, the sensation of the patient is that he is

In other wars from 10 to 15 men died from still turning. This is perfectly natural and is disease to 1 from bullets; in this war 1 man dies the result of all our previous training. The only from disease to every 10 from bullets. thing we have to go by with the eyes shut is the For those of our fighting men who do not sensation we receive from our vestibular appa- escape scatheless, the government under the solratus. Hence the candidate feels that he is turn- dier and sailor insurance law gives protection to ing to the right to compensate for this he points the wounded and their dependents and to the to the left. This pointing is continued until the families and dependents of those who make the reaction has stopped and the patient points nor- supreme sacrifice for their country.

The Monthly Song Sermon

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The Fourth Liberty Loan—The campaign for the Fourth Liberty Loan will begin September 28 and close October 19. The result of the loan will be watched with keen interest in Europe, not only by our associates in the war against the

Teutonic powers but by our enemies. It will be “HOW FAR?”

regarded by them as a measure of the American DR. G. HENRI BOGART, Shelbyville, Ills.

people's support of the war. The Germans know Her red eyes streamed hot tears

full well the tremendous weight and significance For blackest bitterness, despair,

of popular support of the war, of the people at Had followed gray, grave shades of fears

home backing up the army in the field. As the That left their grewsome loads of care

loan succeeds our enemies will sorrow; as it falls For her to bear,

short they will rejoice. Every dollar subscribed These, she had kept With vigiled prayer

will help and encourage the American soldiers While others slept.

and hurt and depress the enemies of America. She sought to leap the bar

The loan will be a test of the loyalty and willingThat answers "Why the war?”

ness of the people of the United States to make Her heart swelled pent with nation's wails

sacrifices compared with the willingness of our Then when her eyes were dry, Her tears all wept away,

soldiers to do their part. There must be and will There was no answered “Why"

be no failure by the people to measure up to the There was no longer day.

courage and devotion of our men in Europe. Tears last till night,

Many of them have given up their lives; shall we Fears flee the light, Who wrestles with All Wisdom, fails.

at home withhold our money? Shall we spare

our dollars while they spare not their very lives. There are the many well meaning souls who If it weren't that most of us desire luxuries, ask why the Omnipotent shall allow the world- it would be impossible to keep a factory open wide war with all its baleful blur of inhuman- more than four days a week ity, who pray or who question the efficacy of prayer, who claim “Gott mit uns,” or the “Lord Most people in the country, despite the fact is with us” as though their petty puny finite had that we are at war, are making more money than been able to grasp the secrets of the Infinite. ever before. That is all the more reason why

How far does the piety that so measures the we should save now and buy War Savings Infinite escape the grossest impiety that would Stamps. We have the opportunity to help the arrogate to its little, the boundlessness of Omnis- Government and to provide for our own future. cience?

Pope's epigram, "Whatever is, is right,” was The motive that keeps men and women at and is the summit of Faith that accepts what is as work after their animal needs have been met is a part of Plan and Purpose, beyond the faint the desire to satisfy wants which are known as glimmerings of circumscribed intelligence.

luxuries. Winter, with its death and desolation is fol- redninum.

G o mminimum

monument lowed by the compensating beauties of springtime, death brings sorrows whose sole measure is the love given the one who was stricken, yet I Medical Society Calendar 1918 who would forego love and springtime to shrink from grief and storm? He who questions the "why” blasphemously

NATIONAL pits his puny against measureless Omnipotence

American Assn. of Electro-Therapeutics and deservedly meets predoomed failure, Faith

Boston, Sept. 10-12 turns trusting eyes to the east and murmurs

American Assn. of Obstetricians.. Detroit, Sept. 23-25 “'Twill be sunshine in the morning."

American Assn. of R. R. Surgerons. Chicago, Oct. 16-18

American Roentgen-Ray Society........ Do you think you have done all that should

Ft. Oglethorpe, Ga., Sept. 4-6

American Public Health Assn.... Chicago, Oct. 14-17 be required of you when you loan your money Clinical Congress of the American College of out of your abundance while other men give Surgeons, New York City.........Oct. 21-26, 1918 their lives? Sacrifice a little, indulge yourself Med. Society Missouri Valley...... Omaha, Sept. 19-20 less, save more, loan all you can, and then be Med. Association Southwest. Dallas, Tex., Oct. 15-16-17 sorry you can do no more.

Mississippi Valley Med. Assn............No meeting

Southern Surgical Assn.... Baltimore, Md., Dec. 17-19 The only fellow in the market house these

Southern Medical Assn.... Asheville, N. C., Nov. 11-14 days who doesn't buck at changin' a $20 bill is

Secretaries of societies are requested to send us the butcher.

dates of their meetings.


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