toward carrying out a plan that has been urged by Dr. Hallock for several years, for an institution for neurasthenics of the indigent class and for suitable hospital provisions for those in the early stages of mental illness.

DR. STOLL (Hartford): Some of the foremost syphilologists in the country have made the statement that before a man is discharged as cured he should have a spinal fluid examination. Unquestionably that should be the routine in all the so-called "Wassermann fast" cases; i. e., the patients whose serum reaction remains positive after intensive treatment; also when headache continues in spite of active treatment. A case who has had four or five or six injections of salvarsan, and still has a four plus Wassermann almost surely has the trouble in the nervous system. We had two cases recently who showed this. One, a girl, who had not responded to many intravenous injections was found to have a positive spinal fluid. Another case, a tabetic with optic atrophy who was "Wassermann fast" gave a typical paretic curve, though entirely free from mental symptoms. A woman with spinal syphilis, also without cerebral symptoms, had a paretic curve.

Apparently these cases are really beginning paresis without symptoms. Two similar cases came to autopsy at Johns Hopkins. Both had a positive paretic curve but no symptoms of paresis, yet at autopsy both showed the typical picture of paresis. So we must realize we may get the paretic gold curve before we get the typical symptoms.

In regard to the children, I think we owe a very distinct duty to the wives and children of paretics. Paresis is syphilis, and the man who has syphilis usually has infected his wife and if she is not sterile she will usually bear syphilitic children. And the man does not do his whole duty, be he in an institution or in general practice, who when he finds a case of paresis, does not have the man's wife and children examined also.

DR. MAILHOUSE (New Haven): The early diagnosis of paresis depends upon the family observation and, perhaps earlier than that, upon the observation of the employer. It seems to me, and it has been my experience, that the employer or the boss or the man over the individual is the one who is first able to note the change in judgment and the change in character and the change in efficiency of the patient. The family is very apt to overlook the neurotic or neurasthenic manifestations which are so common in the beginning of paresis, and it is up to the general practitioner too to make a close observation and examination of these individuals who come in with neurasthenic symptoms. These are very often the early phenomena; many of the early phenomena are symptoms of depression.

Many a paretic comes to the practitioner or the specialist with symptoms of depression. He complains of nervousness, has some feeling that

something is wrong and it is very important that he be gone into carefully; and if you observe these phenomena carefully, generally two or more can be found. Loss of efficiency is often the first thing to attract attention. He himself observes that his attention is failing; he is unable to concentrate, and the boss finds that he is becoming lax, and these are many of the phenomena that he will first call attention to. When he comes to the doctor he repeats and repeats, goes over and over some of his unpleasant symptoms. These come in neurasthenic and psychopathic conditions, but these are the phenomena that should call the attention of the general practitioner to this disease. Epilepsy and apoplexy occurring between the years of 30 and 40 should create suspicion of paresis. Delusion of grandeur which was formerly and is still described in the books is rather unique in the early periods of paresis. I believe that delusions of grandeur are rather late and the impaired judgment is perhaps rather more commonly an early symptom, and that moral lapses also are not so common early in the disease. The early phenomena, the early symptoms, are the ones that should excite suspicion and that is where the need of a careful examination comes in. Changes in habits are more common than moral lapses, I should say. The loss of neatness in dress and of neatness in eating are perhaps much more common than the other conditions described.

Among the physical phenomena in addition to the tremor of the tongue, I have noted very frequently that the patient is unable to hold the tongue protruding owing to an incoördination in the muscles involved; and he constantly draws it backward and forward, the resultant being a backward movement. Of course the fine tremor is visible but we see that in so many other debilitated states that I consider it less characteristic.

DR. F. H. BARNES (Stamford): Mr. President and Gentlemen: I want to thank Dr. Haviland for his very fine paper.

Relative to what might be termed the neurasthenic stage of paresis, the neurasthenic stage so-called but nevertheless we are bound to have it; the term which is applicable not only to cases of general paresis, but also to cerebro spinal syphilis, tabes dorsalis and other diseases. It is a stage we are too prone to overlook. If we find the usual symptoms after careful examination and find no organic lesions of the bodily organs it is certainly up to us to have Wassermann or spinal cord tests made.

As far as the incarceration of such patients it is rather difficult especially during this stage. I saw a case recently, a man who became very irritable, very forgetful and it was very difficult for his family to live with him. He found fault with all those about him and was extremely ugly and vicious with his wife and children. These were the only symptoms that he gave. Suddenly he had a seizure, epileptiform in character, and after that developed the typical signs of paresis.

The man was

Another case I remember showed the sexual element. apparently normal but he did queer things in a sexual way. The sexual idea was in his mind continually and he showed so many sexual inversions and perversions that the family suspecting his mental state had him put under observation. Later he proved to be a clear case of paresis. This talk of adding psychopathic wards to general hospitals is not practical in my estimation. I notice that in certain hospitals I am associated with, when patients show a few signs of mental derangement they want them removed immediately. It is most difficult to know just when such cases should be put under observation. I want to emphasize Dr. Haviland's suggestion that in the diagnosis of neurotic states to look out for the physical signs that later on are followed by all the marked symptoms of this disease.

DR. HAVILAND (Middletown): I am grateful to the gentlemen who discussed the paper, and who emphasized the importance of early diagnosis of general paresis. The points made by Dr. Mailhouse and Dr. Barnes are reinforced by the fact that in the majority of unrecognized cases of early paresis, the diagnosis of neurasthenia has been made, thus indicating the bewildering assemblage of indefinite nervous symptoms, which cause the case to be consigned to that diagnostic scrap basket, which holds so many carelessly, erroneously diagnosed nervous states. Such fact results from lack of definite characteristic features in the early stages, although, as Dr. Mailhouse has indicated, whatever symptom complex may be presented, there are always evidences of impaired judgment and loss of efficiency, which are usually the earliest significant symptoms to attract attention.

The point mentioned by Dr. Thompson regarding psychopathic wards is most important. At present, with a total lack of such wards in Connecticut, there is great need of psychopathic wards in general hospitals for the care and treatment of mental cases pending commitment. The need is possibly greater as regards mental cases other than cases of paresis, as in such cases the lack of early treatment may mean the difference between recovery and chronicity. In the vast majority of curable mental cases, the period pending commitment is one in which treatment is of the greatest value as regards the outcome. Over ninety per cent of manic-depressive cases recover if they receive immediate treatment, but such a percentage of recoveries is not obtained if treatment be deferred. In the absence of psychopathic wards, mere custodial care is alone available prior to commitment, which means that manic-depressive cases, considering but a single form of recoverable mental disease, are much more likely to lapse into so-called "chronic-mania." In Connecticut mental cases are consigned to almshouses and jails pending commitment, and it does seem a deplorable situation when one sees cases brought to the

state hospital, manacled with handcuffs and accompanied by police officers and jailers, who know and use only police methods in caring for the mentally sick.

The fear of psychopathic wards in general hospitals appears very largely to result from misapprehension. Such wards do not disorganize or interfere with other hospital activities, but actually supplement them, a fact which has been fully demonstrated wherever such wards have been established. A psychopathic ward has been in existence fifteen years in connection with the Albany General Hospital, with material benefit to both psychopathic ward and surgical and medical wards resulting from the association. A practical result of the greatest value is the diminished percentage of mental cases committed to the state hospital from the neighboring community. Cases are received at the psychopathic ward at the first appearance of mental symptoms, they receive prompt treatment, and in a considerable number of instances are able to return home without the unjust, but none the less real stigma of "insanity." Such a result is of the greatest benefit to the community, and greatly aids in the inculcation of the idea that mental disease is a medical problem, rather than some strange and ill-defined entity, generically termed insanity, with which medicine has little to do.

May I add a word in regard to Dr. Stoll's remarks? The matter of tracing up the families of the paretic, with regard to possible luetic infection, is of importance. No state hospital can be assumed to perform its full duty when there are no trained social workers associated with it for follow-up and after-care work. A hospital's activities should include extramural as well as intramural work. A hospital's work is but partially accomplished unless it reaches out into the community, as only thus can it participate in that most important work of all—prophylaxis.

The Differential Diagnosis and Treatment of Some

of the Rarer Urological Conditions.

THOMAS N. HEPBURN, M.D., HARTFORD.

My excuse for appearing before you to-day is not that I have a formal paper which treats of any single urological condition but to present to you a few pictures of some cases involving urological surgical problems which have been more or less unusual. My hope is that in presenting to you these problems you will be stimulated to discussion and to the avoidance of some of my mistakes.

The first picture which I will show represents what may be called a case of bilateral renal pelvic calcified casts. This is the picture of a married woman, twenty-eight years of age, who came in complaining of dysuria and pain in her back dating from the birth of her baby six months previously. Four years previously she had had her appendix removed and five months previously she had had a complete hysterectomy done with excision of ovaries and tubes. She had pussy urine and cystoscopy showed mild chronic cystitis. Both ureteral ossii were normal in appearance and in no way suggested that any inflammatory material was coming down from the kidneys. At my first cystoscopy I was unable to catheterize either ureter because of the bladder spasm; therefore I did a chromoscopy with indigo carmine. This was ejected from each kidney in twelve minutes and in excellent density. Judging from this test the function of the kidneys is nearly normal and equal. The x-ray picture then taken showed the pathology as you see it here on the screen (Slide I). The clinical picture was therefore that of a woman without fever, with fairly normally functioning kidneys as judged by the indigo carmine test but with a mildly annoying cystitis and pain in the back. We decided to remove the left calculus first. The left kidney was easily exposed and the cortex was apparently normal. The calculus could easily be felt and