Book Reviews.

Shell Shock and Its Lessons. By ELLIOT SMITH and T. H. PEAR. Cloth $1.00. (New York: Longmans, Green & Co., 1917.)

The book was written as a simple non-technical exposition of the ascertained facts of shell shock and seems to fill a definite want. It is divided into chapters describing the nature of shell shock, treatment of the condition, psychological analysis and re-education, general consideration and a final chapter on some lessons of the war especially directed toward increasing the general interest in mental diseases.

Shell shock is essentially an emotional disorder rather than an intellectual or sensory disturbance, and every case must be treated as an individual rather than grouping one case with several others under one name and attempting to treat all in the same fashion.

Shell shock usually begins after a period of intense emotional stimulus which may have existed for days or weeks. Outward signs of the emotions are rare, in many instances all of them are completely suppressed until the final collapse. After a sudden strong stimulus such as a shell bursting near him he falls with or without loss of consciousness. The most obvious phenomena following the onset are undoubtedly the disturbances of sensation and movement. A soldier may be struck deaf, dumb and blind by a bursting shell and these troubles may vanish after a short space of time as suddenly and dramatically as they appeared. Contractures, tremors, stammers, loss of memory, insomnia, dreams, pains, emotional instability, diminution of self-confidence and self-control, attacks of unconsciousness or of changed consciousness, sometimes accompanied by convulsive movements resembling those characteristic of epileptic fits, incapacity to understand any but the simplest matters, obsessive thoughts, usually of the gloomiest and most painful kind, even in some cases hallucinations and incipient delusions may be present in varying degrees.

In treating these cases every effort must be made to gain the patient's confidence and to gain an insight into his mental life and especially into his emotional life. Firmness and isolation, suggestion in its various forms, and hypnosis, while all useful in their proper place, often prove to be of no avail in cases of psychoneurosis. Psychological analysis, not merely the resolution of the patient's mental condition into its essential elements but rather the dissection of the normal as well as the abnormal phenomena into their functional elements is the method of treatment by which the best results are obtained. Unconscious factors of great importance play an influential part in the production of shell shock, as in other mental disorders, and in every case an effort must be made to uncover these submerged streams. The man's mental make-up must be studied and his

dreams, his "slip of the tongue," "slip of the pen," the mislaying of important objects, the forgetting of significant facts, or conversely, the inability to get an apparently unimportant memory out of one's mind must be fully investigated if his condition is to be fully studied and all done for him which can be done.

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A neurosis may be regarded as the failure of an act of adaptation. The resultant mental disturbances do not seriously affect the reason or the "intellect" as was formerly supposed, but are in character predominantly instinctive and emotional. Therefore, any attempt to restore equilibrium between himself and his social environment must be accompanied by a similar endeavor to bring about his inner harmony, and, in such cases, a certain amount of psychological analysis is indispensable. The two final chapters are purely a plea for better asylum conditions in England, where all scientific work in the care of mental diseases is subordinated to the housing of the patients. At present in England, as well as in America, the attitude of the general public towards insanity is a mixture of ignorant superstition and exaggerated fear. To counteract this attitude it is necessary that the medical profession as well as the general public be instructed in the nature of mental disorders and that clinics for instruction of students and research laboratories be built in order that even a start may be made to better conditions.

From the above synopsis of the book it is evident that it is a valuable one not only in England, but also in America where conditions are not essentially different and where the attitude of the public towards mental disorders is the same. The war will bring us a number of cases of mental disorders and unless an attempt is made to teach the public that such cases should receive the same care as those suffering from physical disorders, such patients in a short time will be shunted off into some custodial institution and the cause of their disorder forgotten.

The book is well written and can be recommended to the public as well as to the general medical profession. C. R.

Neurosyphilis Modern Systematic Diagnosis and Treatment Presented in One Hundred and Thirty-Seven Case Histories. By E. E. SOUTHARD, M. D., Sc. D. Bullard, Professor of Neuropathology, Harvard Medical School; Pathologist, Massachusetts Commission on Mental Diseases; Director Psychopathic Department, Boston State Hospital, etc., and H. C. SOLOMON, M. D., Instructor in Neuropathology and in Psychiatry, Harvard Medical School; Special Investigator in Brain Syphilis, Massachusetts Commission on Mental Diseases, etc. With an Introduction by JAMES JACKSON PUTNAM, M. D., Professor Emeritus of Diseases of the Nervous System, Harvard Medical School. (Boston: W. M. Leonard, 1917.)

Drs. Southard and Solomon have produced in this volume a most admirable and valuable work upon a subject, the importance of which is daily being more generally recognized by the profession.

Aside from the work of Nonne there has been no text book available which could with confidence be placed in the hands of the student or the inquiring practitioner.

The one hundred and thirty-seven case histories have been so thoroughly worked up and the essential points of each so clearly pointed out, that they convey to the reader a picture of the disease which, to quote from the introduction by Dr. Putnam, is neither "too diagrammatic" nor "too concise."

The work is divided into seven sections: Section I, Nature and Forms of Syphilis of the Nervous System; Section II, The Systematic Diagnosis of the Forms of Neurosyphilis; Section III, Puzzles and Errors in the Diagnosis of Neurosyphilis (including Non-Syphilitic Cases); Section IV, Neurosyphilis, Medico-Legal and Social; Section V, The Treatment of Neurosyphilis; Section VI, Neurosyphilis and the War; Section VII, Summary and Key.

The authors assume as the result of their studies and work a hopeful attitude as regards neurosyphilis. The prognosis, they say, "is not worse than that of the chronic diseases in general. In fact the prognosis of neurosyphilis quoad vitam is either good or dubious, certainly not bad.” Summing up the lessons of the book in a general way they "emphasize again (1) the unity-in-variety of the phenomena of neurosyphilis, (2) the value of a hopeful approach to the therapy of all cases of neurosyphilis, even the paretic form, and (3) the value of applying syphilis tests to every case of neurosis or psychosis.”

The treatment chiefly employed by the authors has been what they term the intensive systematic intravenous treatment. This consists of the intravenous injection of salvarsan or of one of its substitutes in doses of about 0.6 gram, repeated twice a week over a period of a number of months. In addition, injections of mercury salicylate averaging 0.065 gram, once a week, are given and potassium iodide by mouth. The important point has been to keep up the treatment for a long time.

The work is a distinct and valuable addition to the literature and one which should be studied by every worker in the fields of neurology or psychiatry.

AMERICAN

JOURNAL OF INSANITY

THE CENTRAL CANAL OF THE SPINAL CORD.' BY S. P. KRAMER, M. D.,

Surgeon, Cincinnati Hospital, and Professor of Clinical Surgery at the University of Cincinnati.

In March, 1912, I called attention to the possible importance of the central canal of the spinal cord, in the pathogenesis of poliomyelitic disease. I was able to demonstrate in the dog by the injection into the spinal canal of vital stains a circulation of cerebrospinal fluid upward through the central canal of the cord to the ventricular system of the brain. Available literature on the central canal in the human subject is very limited. All authors agree that it is open in the lower animals and in young children. In the adult the results of investigation vary. Bidder, Wagner, Schroeder, V. d. Kolk, and Stilling held that the central canal persists in adults. Koelliker found that not infrequently the canal was obliterated in places, most often in the cervical region. Clarke also found the canal frequently blocked. Frommann found the canal open throughout its entire length in three out of the twenty-five adults' cords examined. Owing to the kindness of Dr. E. E. Southard of Harvard University and Dr. George M. Kline, superintendent of Danvers State Hospital, I was able to go over the material at the latter institution for the purpose of determining in what percentage of adults the central canal was patent throughout the length of the cord. In all, 206 spinal cords were examined. At Danvers they had preserved these cords, as well as sections from the lumbar, dorsal and cervical segments. These sections were first examined, and when the central canal was found open in all three sections of a given cord, the cord itself was set aside for further investigation. Such cords were then sectioned five millimeters apart throughout their length.

'A contribution to the William Leonard Worcester Memorial Series of Danvers State Hospital papers, presented November 19, 1915.

The segments were examined with a high power lens to determine whether the central canal was open at every point of section throughout the length of the spinal cord.

Now as to the results: of the 206 cords examined, the central canal was open throughout in 15 instances or 7.23 per cent. There follows a table showing the incidence of an open canal in the different decades as they were found.

In my original communication, the persistence of the central canal of the cord was offered as an explanation of the occasional paralysis of the respiratory center following the lumbar injection of cocaine for the purpose of anesthesia. That is, in the presence of an open central canal the drug may be carried up to the fourth ventricle and affect the respiratory and other vital centers. The symptoms of lumbar cocaine (or stovaine) anesthesia speak for the transmission of the drug throughout the central canal. These patients have a partial motor paralysis, with loss of the sense of pain and temperature. The muscle and tactile senses are not abolished. This disturbance of sensation corresponds to that which is found in syringomyelia, where the lesion is about the central canal. It is here that the cocaine comes in contact with the fibers of pain and temperature sense as they pass upward in the central gray matter. The fibers for tactile and muscle sense do not reach this area and are unaffected by the drug. The cocaine also reaches the motor cells in the anterior horns by diffusion through the gray matter from the central canal.

I have also called attention to the deaths by respiratory failure that occasionally follow the injection of serum containing trikresol into the spinal canal in cases of cerebro-spinal meningitis. I demonstrated by experiments on lower animals that this might be due to the carrying upwards of the trikresol, a neural poison, through the central canal to the fourth ventricle.