a medico-legal point of view? What is the practical difference between an hallucination occuring in an acute mania and melancholia, as to prognosis, as to homicide and to suicide? What is the difference in a medico-legal aspect between an hallucination of hearing and sight? What is the difference between an hallucination and an illusion of sense? What is the difference between an hallucination and a delusion? Why is it that an hallucination is a delusion and a delusion may not be an hallucination? These are some of the questions which I bring to your notice as a contrast to the many others pertaining to the general physical organism, which are usually studied by students of medicine. Yet we will find that the symptomatology of insanity has been neglected, notwithstanding these may become important factors in testimentary capacity, or of grave importance in criminal responsibility. In the one case, involving the disposition of estates, and in the other, the honor or disgrace of a large family connection. How many of us have studied the relation of suicide to insanity? and how at any time we may be called upon to express an opinion for the enlightenment of a jury in such a case, which opinion may deprive a widow and orphans of an insurance policy; or still further, cast a lasting blight on the honor of an innocent man, besides making him a criminal, when he is suffering from a subtle disease-insanity. This has occurred, yet how many men of our profession acting more upon their individual common sense, will assert their opinions with an M.D. to it? At the same time that selfreliant M.D. would curl his lip in contempt at some layman who equally with himself, had never attended a lecture on the subject of insanity, nor had either ever read a treatise on the subject, nor had they both ever seen half a dozen cases of insanity. Yet the M.D. curls his lip at the layman. What is the difference in point of knowledge of these two witnesses? Not one whit-except that one has an M.D. to his name, and the other has not; that is all. These are plain, practical truths, which we must stare in the face as honest men, and consider them. All of us, doubtless, have witnessed the truth of what I have said.

Gentlemen of the medical profession, I mean to talk this plain story to you, unvarnished; as you yourselves have seen enacted in our courts of law. For my own part I have several times been witness to the painful fact.

Let us be frank and candid with ourselves, and our relation and responsibility to justice, both to our patients who confide in us as medical men, as well as to the State and ourselves.

How many medical men are competent to examine an eye with ophthalmoscope and diagnose a glaucoma, an atrophied optic disk, or a myopia, or hypermetropia? Yet, there are many who will dare to assert an opinion upon the witness-stand, in a question of insanity which he has never studied.

A distinguished gynecologist in the Guiteau case, was positive of the prisoner's insanity, yet he was a gynecologist. The consequence of such self-assertion is that which so often brings the profession in contempt.

Lastly where may be found the cause of much of all that I have said concerning the relation of the profession to insanity? I regret to say that it is to be found in the system of our medical education. The medical college which gives us our right under a charter of the State to declare us competent in the practice of medicine and surgery whether we be so or not.

How is it in this commonwealth at present? We have two or three schools of medicine in the State, under charter of the State, one of which is one of the oldest in the Union, the others comparatively recent. Each one has a faculty of repute and acknowledged ability. One has only in the last two years taught the subject of insanity in its curriculum-the others have never done so.

Here, gentlemen, is a solution of the question of the ignorance of the profession in the matter of insanity, and just here lies the fault of our opinions as compared to that of any layman upon a question of insanity, before a court of law. Had any one of us attempted to practice medicine or surgery without the certificate of these or some other college, would we not have been classed as charlatans? Yet have any of us been taught by lectures, or clinical study in hospitals, the great and increasing subject of insanity? In this respect our own State is not very far behind others. It is in the past few years only that other medical colleges have included insanity in their curriculum as a special part of medical education.

The result of the neglect of our schools to teach the subject of insanity as a special course, has shown itself in the management of our State and City Hospitals for the Insane, and cast upon the profession of the City and State the odium of incapacity. I refer to the necessity of the managers of these institutions being compelled to ignore the medical profession of their own State by seeking competent medical men from other States to treat the insane of the city, and those of the state at large.

DISCUSSION ON DR. CONRAD'S PAPER.

DR. JAS. C. THOMAS. In regard to Dr. Conrad's charge against the profession, as remarked by Dr. Williams at my side, it is disproved by himself (Dr. Conrad). If it be true, as he says, that there are no cases of unjust sending of people to the Insane Asylums, what higher tribute could be given to the ability of the rank and file of the profession whose certificate had sent them there. A physician's education begins but does not end in the college. He learns to distinguish those symptoms which characterize insanity, and there are very few who put their name to a certificate without reading up the case. If there is no systematic investigation of the pathology of insanity, it is the fault of those in charge of asylums who have the opportunity.

DR. WILLIAMS. Dr. Conrad's criticism of the profession is unjust. An ordinary physician is as a rule abundantly able to diagnose insanity. Of the special variety of it, of the prognosis and treatment, he may be ignorant. Therefore he sends to a specialist. But it is impossible for a man to be a specialist in everything, and so we seek consultations when we need them. There are men in and out of asylums who are in the borderland of insanity.

DR. EARLE. The cases are being carefully studied at Bay View, both clinically and pathologically.

DR. MORRIS charged that Bay View is wretchedly conducted.

DR. COUNCILMAN answered that since Dr. Morris visited the institution the regime has been changed and things have greatly. improved; it is not yet all that could be desired, but it is fully abreast of any institution of the kind.

DR. GUNDRY said he had done a great deal of pathological work and mentioned other institutions where it is carried on and DR. CONRAD explained that he meant minute pathological work in a laboratory. This he said was done only in Utica. The difficulty was lack of funds.

Report of the Section on Ophthalmology, Otology and Laryngology.

PERSONAL OBSERVATIONS OF THE VALUE OF COCAINE IN NOSE AND THROAT SURGERY.

BY FRANK DONALDSON, M.D.,

Clin. Prof. Throat and Chest Diseases, University of Maryland.

Laryngology asserts its claims of priority in the use of the hydrochlorate of cocaine as a local anaesthetic. It had been employed for years by foreign laryngologists, especially by Fauvel, of Paris, in the form of fluid extract of coca, and by Mackenzie and Lennox Brown, of London, the wine of coca in cases of hyperæmia and irritable conditions of the pharynx and larynx. Koller states that he was led to experiment with it on the eye from his knowledge of the control it had over the sensibility of the mucous membrane of the mouth, pharynx and larynx. The isolation of this alkaloid of the plant Erythroxylon coca was first made by a German chemist, Dr. F. Gardeke, who named it erythroxyline. The credit of discovering its benumbing and paralysing influence on the tongue is due to an American, Dr. S. R. Percy, who isolated the alkaloid and named it Erythroxyline. His paper was read before the New York Academy of Medicine in November, 1857. Unfortunately, Dr. Percy did not give sufficient publicity to his discovery nor did he follow up by experi ments the results he had obtained. In 1859, two years afterwards, Nieman published the results of his thorough chemical analysis of cocaine.

In 1862, Prof. Schroff, of Vienna observed its remarkable local anæsthetic properties when applied to the tip of the tongue. It was further known that cocaine through its effects upon the vaso-motornerves contracted the peripheral arteries. Such being the facts in regard to the effects of this substance, it is indeed remarkable that the profession generally in Europe and America should never have

availed themselves, except to a very limited extent, of so valuable a therapeutical agent, until Dr. Karl Koller read his paper before the Medical Society of Vienna in September, 1884.

The enthusiasm of the profession in this country was roused to a high pitch by a letter from Dr. Noyes of New York, published in New York, (Medical Record, Oct. 11th, 1884) in which he spoke of the extraordinary anæsthetic power of this drug upon the cornea and conjunctiva.

In common with many others the writer had been longing for some local anesthetic to facilitate operations upon the larynx, naso-pharynx, and the nose, ever since Czermak published his work on the use of the laryngoscope, in 1858. He had tried ether and rhigolene by spray, the bromides, ice, and had run a great risk by using morphia locally as Schrotter had recommended, but all to no avail. He had become resigned to the conclusion that frequent manipulations were the only efficient method of lessening laryngeal sensibility. After reading Dr. Noyes' letter he obtained the rare alkaloid and he has had it in daily and constant use for seven months. He has employed it in a large number of operations of greater or less importance on the nose, the naso-pharynx, the omo-pharynx and on the larynx. He has watched and carefully studied the local effects of the cocaine, and he hopes the Faculty will not consider him egotistical if he submits to them candidly and, as briefly as possible, the results of his personal observations of its value.

Before speaking of its most prominent effects in producing local anesthesia, he wishes to speak of its influence upon the capillaries and blood vessels of the mucous surfaces, and especially upon the erectile tissue over the turbinated bones of the nose. Its action in his hands proved it to be powerfully astringent, and he noticed that soon after applying it, it contracted the soft tissues on their bones and literally bleaches them. Dr. Bosworth, of New York, explains the effect upon the venous sinuses and the blood vessels as the consequence of its action in producing rigid contraction of unstriped muscular fibres wherever it comes in contact with them. In this way we can understand how it completely empties the large veins of the nose, while it only diminishes the calibre of the capillaries and small blood vessels, for in the intra-venous spaces of the nasal mucous membrane are found large bundles of unstriped muscular fibre, which in contracting enlarge the field of vision, not only on the periphery of the sinuses, but also on the membrane itself, draw