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THE CARDIAC REFLEX OF ABRAMS.
619 can be put under guardianship of a relative and model lodging-house where he lived reported the and he was removed to an isolation hospital. His during such period of guardianship he is to be regarded defence to the charge was a flat denial of the truth of the with reference to contracting capacity as equal to a minor evidence and of the fact that he had had a rash visible seven years of age. He is only responsible to a limited The expressions upon him, although a medical witness stated that it must extent for damages done to others. have been observable for two or three days before the "insane"and "feeble-minded"are thus in law of an To this the defendant added essentially legal nature. authorities were informed. The expert is asked by the judge that he had his living to get-a reason which must always " to what degree does the abnormal state of mind affect the win sympathy for those to whom illness may mean very con- capacity for conducting affairs ? " And this degree, not the siderable loss, but which should also cause magistrates to character of the cerebral or mental disease of an idiot, a remember those other persons in poor circumstances to whom paranoiac, or a maniac, will determine which of the two conillness is no less serious than it is to the man or woman who ditions, insanity or feebleness of mind, is to be declared as It is obvious, however, adds Dr. exposes them to the danger of it. Here is a case in point. existing in the case. At Newcastle-upon-Tyne police-court on August 18th a man Kornfeld, that the desire of the law to protect the feeblenamed John Cockburn was charged with having on minded has here been secured only with a sacrifice, July 21st and 22nd unlawfully and wilfully exposed him- and that this could have been obviated by dividing the self while suffering from a dangerous infectious disorder-to feeble-minded into two classes : first, those who are feeblewit, small-pox. He was a journeyman tailor and evidence minded to a degree equalling insanity as regards incapacity for conducting affairs ; and secondly, those of a minor degree was given that he came to work on June 29th with spots on his face. For some three weeks he went about without any of enfeeblement in whom a restricted capacity for business is precautions but was eventually sent to the small-pox hospital. found. Insanity affecting a limited part of the mind-e. g., On the two counts defendant was fined 7 and costs or one in the form of a fixed insane belief or delusion-may induce month and seven days’ imprisonment. The master tailor in a person to make an unjust will or to damage others, but whose shop Cockburn had worked caught the disease and when such a person appears to have been in all other died from it, the source of infection being presumably respects sane, when his motives do not differ from those of normal people in similar circumstances, and when he, Cockburn. notwithstanding his apparent " partial insanity," has INSANITY AND THE JUDICIAL POINT OF VIEW. managed his affairs reasonably, it might be argued that his IN the New York Medico-Legal Journal for June Dr. soundness of mind was practically that of the average or Herman Kornfeld of Gleinitz, Silesia, calls attention to the normal man. For many persons of sound mind have fixed fact that in Germany, as in England and America, jurists errors of belief and of sentiment, though their soundness of and psychiatrists view the insane from widely different stand- mind is unquestioned. The theorythe lesser the guilt the the punishment," says Dr. Kornfeld in agreement with points. For psychiatrists hold that the insanities are lesser other psychiatrists, is a false one, and in conformity with it diseases or affections of the brain, while jurisprudence, conholds that has to take the lead in laying the he sidering only the psychical side of the question, considers foundation for psychiatrynew penal laws. It is not for venentirely that the responsibility of the alleged lunatic should be he that evil-doers should be punished but concludes, geance, judged from his conduct and from his ability to know right because of the to every honest man satisfaction necessary and wrong in criminal acts. When a diseased or abnormal condition of the brain is proved to exist, says Dr. Kornfeld, that crime should be avoided and abhorred, as its consethe medical testimony of an expert should have preponderat- quences are just and inevitable, The insane criminal should be for life if necessary, in an asylum, so that ing weight, as this is a matter which cannot be controverted his sequestrated, for evil is abolished. power or But as is.
II affairs
the
case
____
,
.
!
by lawyers psychologists. pathological anatomy far from perfect, especially as regards the morbid conditions THE CARDIAC REFLEX OF ABRAMS. of the brain which result in insanity, the proper expert to decide whether insanity may really be present or not is not IT has recently been shown by Abrams that if the prsecordial the general practitioner but the specialist who combines the region is stimulated by friction or light percussion the knowledge of general medicine with the special knowledge cardiac dulness diminishes in consequence of reduction of Diffi- the volume of the heart (Medical Recort-1, Jan. 5th, 1901). of the diagnosis and pathology of insanity. culties are met with, however, as to the interpretation This phenomenon, which he termed " the cardiac reflex," is of symptoms. Thus the delirium of many fevers is un- important because it throws considerable light on the modern doubtedly a "phrenopathy"-a mental disorder-though treatment of heart disease by baths. At the meeting of the the duration may not be more than a few days or hours. Societe Medicale des Hopitaux of Paris on July 24th "Is there then," inquires Dr. Kornfeld, "no fundamental M. Pierre Merklen and M. Jean Heitz read a valuable paper difference between febrile delirious insanity and, for instance, on this reflex and both confirmed and extended Abrams’s paranoia supervening quite unforeseen, not accompanied by observations. They found that the reflex was of variable any bodily symptom and not showing post mortem any intensity, almost always present in health, and more change in the brain which could account for the insane marked when the heart is dilated. Abrams provoked delusions of the patient." The theory that the brain must the cardiac reflex by energetic friction of the prascoralways be the seat of disease or disorder before madness can dium with a piece of indiarubber, producing intense manifest itself is, adds Dr. Kornfeld, justified in most but redness of the skin, but M. Merklen and M. Heitz had not all cases, for our methods of detecting abnormalities recourse to light percussion with the ulnar border of the and lesions of the brain are still imperfect ; but for legal hand for from one to five minutes. The skin first becomes The Civil Law of pale at the places stimulated, then it becomes red more or purposes the theory is unimportant. Germany in force since Jan. lst, 1900, declares that those less rapidly. These superficial reactions were accompanied persons cannot transact valid business or make a will whose mind is clouded by morbid disturbance of its functions (or faculties) at the time, whether such morbid disturbance be temporary or lasting in duration. Moreover, any person who by reason of disease of mind (insanity) or feebleness of mind (imbecility or idiocy) is incapable of conducting his
Abrams a deep reaction-diminution of cardiac dulness. showed by radioscopy that this diminution coincided with The superficial diminution in the volume of the heart. dulness is most reduced, the deep only slightly. Hence the reduction of volume of the heart is principally at the expense of the right ventricle which corresponds to the
by
620 cardiac dulness. The right ventricle is the most dilatable and the most contractile part of the heart. If in consequence of dilatation of the right heart there is passive congestion of the liver the hepatic dulness will simultaneously diminish with the reflex diminution of the cardiac. M. Merklen and M. Heitz found the cardiac reflex absent in health only once, in a man, aged 32 years, given to athletics. Abrams has remarked that the reflex is more easily produced in children and in subjects with little adipose tissue and slightly developed thoracic muscles. It is more transitory in healthy persons than in those with dilated hearts. In the former it lasts scarcely two minutes, in the latter it may be prolonged for several hours. In cardiac neurasthenia it is well marked. The cardiac reflex may be temporarily absent in extreme cases of dilatation of the heart. It was absent in a woman with a systole, enormous cardiac dilatation, cyanosis, and much anasarca, but when she was relieved and diuresis established it returned. The cardiac reflex is permanently absent in pericardial effusion and in adhesion of the visceral and parietal pericardium. Hence the presence of the reflex in cases of difficult diagnosis enables these affections to be excluded. Finally, it is permanently absent, or almost absent, in profound degeneration of the myocardium and may thus be of prognostic import. The cardiac reflex is a similar phenomenon to the reduction ’i of cardiac dulness produced by stimulation of the skin with saline effervescent baths. A reduction of cardiac dulness is also produced by exercises. Heitler of Vienna has produced it not only by stimulation of the prsecordium but also by stimulation of the hepatic region and other parts and even by movements of flexion and extension of the joints. Thus the cardiac reflex may be produced by stimulation of the most diverse regions, but it is most marked and most constant after stimulation of the prsecordium. The action of stimuli arising from the skin and viscera on the vaso-motor nerves and the consequent changes in size of the arteries and veins are well known. The heart evidently is susceptible to the same stimuli. Hence "the cardiac reflex.""
superficial
and finally precipitating itself upon an enemy. With a moderate degree of intoxication three or four epileptic attacks would occur. Finally a condition of stupor was reached, succeeded, if too large a dose had not been given, by recovery.. The conditions above described were brought about by using the essences which manufacturers mix with spirit of suitable strength to form absinthe, so that alcohol was not in any way responsible for them ; indeed, alcohol by itself merely gave rise When to slight agitation rapidly passing into coma. for doses in small the essences were long given periods so as to produce chronic poisoning the dog was found to lose weight and appetite, to develop tremor and weakness of the posterior extremities, and to suffer from gingivitis, buccal ulceration, albuminuria, and hsematuria, while mentally it became stupid and illtempered. It would seem, then, that to the evils of simple drunkenness, surely sufficiently potent, there is often added in France the disastrous influence of a powerful nerve poison. That this was so has always been assumed by observant persons, medical and lay, but Dr. Lalou’s experiments prove the assumption. They may therefore become very valuable to the community, for their lessons can be used by the law as arguments upon which to base legal prevention of the grave physical and moral evils due to the drinking of
with
a
menacing air,
imaginary
THE ABSINTHE
EVIL.
WHILE it is generally recognised that the influence of absinthe upon the human body is pernicious there has hitherto been some doubt as to the respective parts played by the alcohol which forms the basis of the fluid and the derivatives, such as of wormwood, angelica, and fennel, which give it its peculiar character. In France the law prohibits the sale of dangerous essences. Some importance therefore attaches to the researches conducted in
the
physiological
labora-
tory of the Sorbonne by Dr. S. D. Lalou and published in his "Contribution a 1’Etude de l’Essence d’Absinthe et de Quelques Autres Essences." Experiments were made on dogs and other animals and the preparations to be tested were administered in various ways. The results obtained were substantially the same in all cases and as the method most frequently employed was to introduce the material, mixed with a little yelk of egg, sugar, and water, into the stomach of the dog by means of an oesophageal tube, it will suffice to speak only of the toxic effects so produced. The first symptoms observed were agitation and restlessness, the animal wandering about and eating fragments -e. g., of paper, which were lying on the floor. Convulsions of transient character supervened, leading up to a definite epileptiform seizure in which the animal bit its tongue, foamed at the mouth, and passed its excretions involuntarily. Similar fits followed at intervals and were accompanied by vomiting and unconsciousness. After a time the dog returned to consciousness and gave evidence of suffering from hallucinations, sometimes wounding itself, adopting an attitude of defence, or exhibiting great fear. Sometimes it became very aggressive, barking
absinthe. ____
STUDIES RELATING TO THE QUESTION OF IMMUNITY IN THE HUMAN MOUTH. D. Miller, professor of dental surgery in the University of Berlin, has during the last few months publishedan account of some preliminary studies of immunity in its relation to the diseases of the mouth and the teeth. His results, although negative, are of interest, inasmuch as they will help to clear the pathway for future investigations. A large number of experiments were undertaken with regard to the antiseptic action of the saliva. Dr. Miller refers to the work of various investigators in this direction and points out that the views expressed have been very diverse. In Sanarelli’s experiments, which for many years were considered to be conclusive, he considers that a source of error was in the removal from the saliva of the greater part of the nutrient matter, thus rendering it unfavourable for the development of bacteria. To overcome this source of error Dr. Miller experimented with saliva filtered through porcelain to which he added a solution of bouillon. The salivas of individuals immune to caries and susceptible to caries were subjected to investigation, with the result that he was unable to determine any retarding influence whatever on the part of the germ-free saliva. In caries of the teeth the numbers of the bacteria have not so much to be dealt with as their potency or capacity for bringing about processes of fermentation. With a view of determining whether the saliva had any influence in the production of acid a series of experiments was carried out with a mixture of four parts of filtered saliva to one part of bouillon (five-fold strength). The salivas of different individuals were again used with the result that as much acid was formed in the tubes in which the bouillon was diluted with saliva as in those in which it was diluted with water-in other words, 80 per cent. solution of saliva does not seem to exert a retarding influence on the process of fermentation. Undiluted saliva gave similar results. A series of control experiments with non-filtered saliva was next undertaken. The difficulty of obtaining saliva free from bacteria was overcome by experimenting with bacteria which develop rapidly at the temperature of the room, Dr. Miller maintaining that as the bacteria normally present in saliva Dr.
W.
1 Dental Cosmos, January and February, 1903; Transactions Odontological Society of Great Britain, March, 1903.
of the
II affairs
the
case
____
,
.
!
by lawyers psychologists. pathological anatomy far from perfect, especially as regards the morbid conditions THE CARDIAC REFLEX OF ABRAMS. of the brain which result in insanity, the proper expert to decide whether insanity may really be present or not is not IT has recently been shown by Abrams that if the prsecordial the general practitioner but the specialist who combines the region is stimulated by friction or light percussion the knowledge of general medicine with the special knowledge cardiac dulness diminishes in consequence of reduction of Diffi- the volume of the heart (Medical Recort-1, Jan. 5th, 1901). of the diagnosis and pathology of insanity. culties are met with, however, as to the interpretation This phenomenon, which he termed " the cardiac reflex," is of symptoms. Thus the delirium of many fevers is un- important because it throws considerable light on the modern doubtedly a "phrenopathy"-a mental disorder-though treatment of heart disease by baths. At the meeting of the the duration may not be more than a few days or hours. Societe Medicale des Hopitaux of Paris on July 24th "Is there then," inquires Dr. Kornfeld, "no fundamental M. Pierre Merklen and M. Jean Heitz read a valuable paper difference between febrile delirious insanity and, for instance, on this reflex and both confirmed and extended Abrams’s paranoia supervening quite unforeseen, not accompanied by observations. They found that the reflex was of variable any bodily symptom and not showing post mortem any intensity, almost always present in health, and more change in the brain which could account for the insane marked when the heart is dilated. Abrams provoked delusions of the patient." The theory that the brain must the cardiac reflex by energetic friction of the prascoralways be the seat of disease or disorder before madness can dium with a piece of indiarubber, producing intense manifest itself is, adds Dr. Kornfeld, justified in most but redness of the skin, but M. Merklen and M. Heitz had not all cases, for our methods of detecting abnormalities recourse to light percussion with the ulnar border of the and lesions of the brain are still imperfect ; but for legal hand for from one to five minutes. The skin first becomes The Civil Law of pale at the places stimulated, then it becomes red more or purposes the theory is unimportant. Germany in force since Jan. lst, 1900, declares that those less rapidly. These superficial reactions were accompanied persons cannot transact valid business or make a will whose mind is clouded by morbid disturbance of its functions (or faculties) at the time, whether such morbid disturbance be temporary or lasting in duration. Moreover, any person who by reason of disease of mind (insanity) or feebleness of mind (imbecility or idiocy) is incapable of conducting his
Abrams a deep reaction-diminution of cardiac dulness. showed by radioscopy that this diminution coincided with The superficial diminution in the volume of the heart. dulness is most reduced, the deep only slightly. Hence the reduction of volume of the heart is principally at the expense of the right ventricle which corresponds to the
by
620 cardiac dulness. The right ventricle is the most dilatable and the most contractile part of the heart. If in consequence of dilatation of the right heart there is passive congestion of the liver the hepatic dulness will simultaneously diminish with the reflex diminution of the cardiac. M. Merklen and M. Heitz found the cardiac reflex absent in health only once, in a man, aged 32 years, given to athletics. Abrams has remarked that the reflex is more easily produced in children and in subjects with little adipose tissue and slightly developed thoracic muscles. It is more transitory in healthy persons than in those with dilated hearts. In the former it lasts scarcely two minutes, in the latter it may be prolonged for several hours. In cardiac neurasthenia it is well marked. The cardiac reflex may be temporarily absent in extreme cases of dilatation of the heart. It was absent in a woman with a systole, enormous cardiac dilatation, cyanosis, and much anasarca, but when she was relieved and diuresis established it returned. The cardiac reflex is permanently absent in pericardial effusion and in adhesion of the visceral and parietal pericardium. Hence the presence of the reflex in cases of difficult diagnosis enables these affections to be excluded. Finally, it is permanently absent, or almost absent, in profound degeneration of the myocardium and may thus be of prognostic import. The cardiac reflex is a similar phenomenon to the reduction ’i of cardiac dulness produced by stimulation of the skin with saline effervescent baths. A reduction of cardiac dulness is also produced by exercises. Heitler of Vienna has produced it not only by stimulation of the prsecordium but also by stimulation of the hepatic region and other parts and even by movements of flexion and extension of the joints. Thus the cardiac reflex may be produced by stimulation of the most diverse regions, but it is most marked and most constant after stimulation of the prsecordium. The action of stimuli arising from the skin and viscera on the vaso-motor nerves and the consequent changes in size of the arteries and veins are well known. The heart evidently is susceptible to the same stimuli. Hence "the cardiac reflex.""
superficial
and finally precipitating itself upon an enemy. With a moderate degree of intoxication three or four epileptic attacks would occur. Finally a condition of stupor was reached, succeeded, if too large a dose had not been given, by recovery.. The conditions above described were brought about by using the essences which manufacturers mix with spirit of suitable strength to form absinthe, so that alcohol was not in any way responsible for them ; indeed, alcohol by itself merely gave rise When to slight agitation rapidly passing into coma. for doses in small the essences were long given periods so as to produce chronic poisoning the dog was found to lose weight and appetite, to develop tremor and weakness of the posterior extremities, and to suffer from gingivitis, buccal ulceration, albuminuria, and hsematuria, while mentally it became stupid and illtempered. It would seem, then, that to the evils of simple drunkenness, surely sufficiently potent, there is often added in France the disastrous influence of a powerful nerve poison. That this was so has always been assumed by observant persons, medical and lay, but Dr. Lalou’s experiments prove the assumption. They may therefore become very valuable to the community, for their lessons can be used by the law as arguments upon which to base legal prevention of the grave physical and moral evils due to the drinking of
with
a
menacing air,
imaginary
THE ABSINTHE
EVIL.
WHILE it is generally recognised that the influence of absinthe upon the human body is pernicious there has hitherto been some doubt as to the respective parts played by the alcohol which forms the basis of the fluid and the derivatives, such as of wormwood, angelica, and fennel, which give it its peculiar character. In France the law prohibits the sale of dangerous essences. Some importance therefore attaches to the researches conducted in
the
physiological
labora-
tory of the Sorbonne by Dr. S. D. Lalou and published in his "Contribution a 1’Etude de l’Essence d’Absinthe et de Quelques Autres Essences." Experiments were made on dogs and other animals and the preparations to be tested were administered in various ways. The results obtained were substantially the same in all cases and as the method most frequently employed was to introduce the material, mixed with a little yelk of egg, sugar, and water, into the stomach of the dog by means of an oesophageal tube, it will suffice to speak only of the toxic effects so produced. The first symptoms observed were agitation and restlessness, the animal wandering about and eating fragments -e. g., of paper, which were lying on the floor. Convulsions of transient character supervened, leading up to a definite epileptiform seizure in which the animal bit its tongue, foamed at the mouth, and passed its excretions involuntarily. Similar fits followed at intervals and were accompanied by vomiting and unconsciousness. After a time the dog returned to consciousness and gave evidence of suffering from hallucinations, sometimes wounding itself, adopting an attitude of defence, or exhibiting great fear. Sometimes it became very aggressive, barking
absinthe. ____
STUDIES RELATING TO THE QUESTION OF IMMUNITY IN THE HUMAN MOUTH. D. Miller, professor of dental surgery in the University of Berlin, has during the last few months publishedan account of some preliminary studies of immunity in its relation to the diseases of the mouth and the teeth. His results, although negative, are of interest, inasmuch as they will help to clear the pathway for future investigations. A large number of experiments were undertaken with regard to the antiseptic action of the saliva. Dr. Miller refers to the work of various investigators in this direction and points out that the views expressed have been very diverse. In Sanarelli’s experiments, which for many years were considered to be conclusive, he considers that a source of error was in the removal from the saliva of the greater part of the nutrient matter, thus rendering it unfavourable for the development of bacteria. To overcome this source of error Dr. Miller experimented with saliva filtered through porcelain to which he added a solution of bouillon. The salivas of individuals immune to caries and susceptible to caries were subjected to investigation, with the result that he was unable to determine any retarding influence whatever on the part of the germ-free saliva. In caries of the teeth the numbers of the bacteria have not so much to be dealt with as their potency or capacity for bringing about processes of fermentation. With a view of determining whether the saliva had any influence in the production of acid a series of experiments was carried out with a mixture of four parts of filtered saliva to one part of bouillon (five-fold strength). The salivas of different individuals were again used with the result that as much acid was formed in the tubes in which the bouillon was diluted with saliva as in those in which it was diluted with water-in other words, 80 per cent. solution of saliva does not seem to exert a retarding influence on the process of fermentation. Undiluted saliva gave similar results. A series of control experiments with non-filtered saliva was next undertaken. The difficulty of obtaining saliva free from bacteria was overcome by experimenting with bacteria which develop rapidly at the temperature of the room, Dr. Miller maintaining that as the bacteria normally present in saliva Dr.
W.
1 Dental Cosmos, January and February, 1903; Transactions Odontological Society of Great Britain, March, 1903.
of the