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-- from the journal a m a , sept 23, 1916 kora-konia report of the council on pharmacy and chemistrykora-konia is a “dusting powder” which at present buy a book reports is advertised to themedical profession through medical journals, circulars, post cards andsample packages it is put out by the “house of mennen, ” which sellsvarious toilet preparations such as talcum powder, shaving soap, etc on the trade package is the statement. “indicated in the treatment of acne, dermatitis, eczema intertrigo. In obstinate paper of chafing, prickly heat, nettle rash, chicken pox, measles, scarlatina and irritations of the skin. As a soothing absorbent and antiseptic dusting powder and as an umbilical dressing ”while a circular asserts that. “kora-konia is indicated in the treatment of acne, dermatitis, eczema and eczematous conditions of the utmost severity, eruptive fevers, ”what purports to be a physician testimonial reads. “i used kora-konia in a new born case of inherited syphilis and the eruption soon cleared up ”germicidal powers are claimed for kora konia in a medical journaladvertisement in view of the various claims made and the fact that itis advertised to the medical profession, the chemical laboratory of theamerican medical association was asked to analyze kora-konia this wasdone and the chemists reported as follows:laboratory reportkora-konia is a white powder, slightly greasy to the touch qualitativetests showed the presence of boric acid, zinc, magnesium, a solid fattyacid and material insoluble in hydrochloric acid containing magnesiumand aluminum starch was not found quantitative determinations gavethe following results. Acid-insoluble material talc 48 3 per cent magnesium mg soluble in dilute acid 1 2 per cent zinc zn 4 5 per cent stearic acid impure 39 2 per cent boric acid 3 0 per cent carbon dioxide co₂   1 5 per cent from this analysis it is concluded that kora-konia has essentially thefollowing composition. Zinc stearate u s p 44 per cent talc 48 per cent magnesium carbonate u s p 5 0 per cent boric acid 3 0 per cent essentially this dusting powder consists of the well-known substancestalc and zinc stearate in about equal proportions to which smallquantities of magnesium carbonate and boric acid have been added inasmuch as the claim is made, by inference at least, that kora-koniarepresents original investigation carried out “with the cooperation ofthe medical profession” it should be stated that the preparation ofcommercial zinc stearate was described and recommended as a dusting andtoilet powder nearly twenty-five years ago 9696 proc am pharm a 40:488, 1892 there is nothing new or original in any one of these substances or inthe combination the extravagant and unwarranted claims made for thissimple dusting powder are undoubtedly leading the public as well asessay thoughtless physicians, to place undeserved confidence in it in view of the small amount of boric acid present in the powder, itsantiseptic powers must be slight and its germicidal powers almost nil the council declared kora-konia ineligible for new and nonofficialremedies and authorized publication of this report -- from the journala m a , sept 30, 1916 the therapeutic value of the glycerophosphates report of the council on pharmacy and chemistrythe council has adopted the following report and authorized itspublication w a puckner, secretary glycerophosphates are the salts of glycerophosphoric acid, h₂c₃h₅ oh₂po₄ this acid is produced by the interaction of glycerinand phosphoric acid in general, only sodium glycerophosphate, na₂c₃h₅ oh₂po₄ 5-1/2h₂o, and calcium glycerophosphate, cac₃h₅ oh₂po₄ h₂o, are used in medicine, though theglycerophosphates of lithium, potassium, manganese, magnesium, iron, quinin and strychnin are claimed as constituents of proprietarypreparations at a time when certain disorders were assumed to be dueto a deficiency of phosphorus in the nerve structure in the body, glycerophosphates were introduced as “nerve foods” and “tonics” on thetheory that they would be assimilated more readily than hypophosphitesor ordinary phosphates what led to this assumption was the fact thatthe lecithins, which form a writing of the nerve structure, were known tocontain the glycerophosphate radical in the molecule the belief thatinorganic phosphates cannot supply the body need of phosphorus isimplied or expressed in most of the “literature” devoted to proprietaryphosphorus preparations thus, schering and glatz quote g meillière as saying that “theorganism is incapable of assimilating inorganic forms of phosphorus ”again, when exploiters of glycerophosphates admit that the body cansynthesize its phosphorus compounds from inorganic phosphates, theyattempt to counterbalance the admission by contending that the useof organic compounds “spares” the system the necessity of makingsuch synthesis this assumption rests on the theory that the organicphosphorus compounds are absorbed and stored as such this theory is contradicted by evidence which has been presented97that the organic phosphorus compounds are split up into inorganicphosphates before absorption 97 mccollum and hart, grosser and husler, plimmer, and bayliss andplimmer, quoted by marshall note 2 the council requested e k marshall, jr , to review the evidence forand against the therapeutic value of organic phosphorus compounds marshall study98 brings out the following points:98 marshall, e k.

“liquor legislation and insanity” buy a book reports. Medical record 84:791, 1913 “the liquor question in medicine”. Medical record 85:612, 1914 “inebriety as a medical problem”. Post-graduate 29:603, 1914 “the problem of inebriety”. N y medical journal 101:940, 1915 “aspects of inebriety in alcohol”. British journal of inebriety 13:9, 1915-1916 “the peace and war footing of alcohol”. Medical record 88:226, 1915 “alcohol and therapeutics”. Medical record 92:666, 1917 -- from the journal a m a , nov 30, 1918 biologic therapeutics and its commercial dominationthe danger of commercialized therapeutics has been enormously increasedby the introduction of biologic products these substances offer a richfield for the commercially minded, first, because of the remarkableresults which seem to have followed the use of certain products ofthis type. Second, because the field is new and the mode of actionof these substances not readily understood and, third-- and mostimportant-- because, by the very nature of the problems involved, fewphysicians are well informed concerning them the influenza epidemic oflast year was widespread and fatal in character it stimulated earnestresearch in methods of prevention and cure we were all in a frameof mind to grasp at any straw here and there essay worker would cry“eureka”-- only to be disappointed when his product was actually put tothe test however, there were more than enough manufacturers ready toplace any product on the market with specious claims that could notbe positively denied vaccines, serums, proteins-- all were advancedwith such glowing statements as to their properties that only thosephysicians who kept their feet firmly on solid ground could resistthe appeal now we have had another epidemic-- mild, it is true-- butthe memories of last year make the average physician ready to acceptanything which promises hope, and the manufacturers “make hay while thesun shines ” physicians have been and are being deluged with literatureon the prophylaxis and treatment of influenza so far as we know, fewpublications have contained any word of warning on these matters oneexception has just come to notice.

But themanner in which this knowledge is to be applied in the treatment andcure of diseases has been, and will probably continue to be, open todiversity of opinion no one system of practice has been uniformlyfollowed, but physicians from the days of hippocrates have been dividedinto opposing sects and schools the sects of the dogmatists and theempirics divided the ancient world for centuries, until the rise ofthe methodics, who, in their turn, gave way to innumerable sects theories of practice, believed to be infallible in one age, have beenutterly rejected in another for thirteen centuries europe yieldedto the authority of galen he was implicitly followed his practicestrictly pursued everything that seemed to conflict with his preceptswas rejected. And yet, in the revolutions of medical opinion, theworks of this undoubtedly great man were publicly burned by paracelsusand his disciples. And for centuries following, the medical worldwas divided between the galenists and the chemists, until a completeascendency over both was obtained by the sect of the vitalists thisstate of things has been occasioned by the circumstance that medicalpractitioners have often been more given to the formation of theoriesupon the nature of disease and the mode of its treatment, than tothat careful observation and patient accumulation of facts, by which, in other sciences, the phenomena of nature have been unravelled iam far from undervaluing the great benefits conferred upon mankindby the study of medicine, and have no wish to minister to any vulgarprejudice against a useful and learned profession, but it is not to beoverlooked that, as an art, it has been characterized, in a greaterdegree, by fluctuations of opinion as to its principles and the modeof its practice, than, perhaps, any other pursuit that it has beendistinguished by the constant promulgation and explosion of theories, that it has alternated between the advancement of new doctrines andthe revival of old ones, and that its professors in every age havebeen noted for the tenacity with which they have clung to opinions, and the unanimity with which they have resisted the introduction ofvaluable discoveries they still continue to disagree in respect to thetreatment of diseases as old as the human race. And at the present day, when great advances have been made in all dewritingments of knowledge, aradical and fundamental difference divides the allopathist from thefollowers of hahnemann, to say nothing of those who believe in thesovereign instrumentality of water “in fact, nothing comparatively is known of the philosophy of disease its eradication or cure, where the result of human agency is, inthe great majority of instances, attributable rather to the carefulobservation, judgment and experience of the writingicular practitioner, than to the application of general or established methods available toall the popular axiom, that ‘doctors differ, ’ is as true now as itever was, and as long as it continues to be so, it is impossible forthe law to recognize any class of practitioners, or the followers ofany writingicular system or method of treatment, as exclusively entitledto be regarded as doctors in adverting to the conflicting viewsand differences of opinion, that exist and have ever existed in thepractice of the healing art, it is not to call in question the valueof learned, skilful and experienced physicians, but merely to showthe error of attempting, in the present state of medical science, to recognize, as matter of law, any one system of practice, or ofdeclaring that the practitioner who follows a writingicular system is adoctor, and that one who pursues a different method is not ” and seealso white v carroll, 42 n y , 161. Ordronaux’ “jurisprudence ofmedicine, ” 27 this decision was prior to the statute of 1874 and the provisions ofthe penal code before noted since those statutes, it is a misdemeanorto practise except as permitted by the provisions of those statutes in new york and elsewhere practitioner without license cannot sue andrecover for his fees since the passage of the new york act of 1844 laws of 1844, p 406, there has been no precise statutory provision in that state prohibitingin terms persons who practise physic or surgery without a license, from suing to obtain a recovery for services performed but this is oflittle consequence, for, as we have already stated, so practising hasbeen declared to be a misdemeanor by the penal code of new york it is a well-settled principle that when any act is declared by statuteto be criminal, a contract calling for the performance of such an actis illegal and void the early english authorities on this point arefully collated in wheeler v russell 17 metc , mass , 258, and thelater english and american paper may be found in “american and englishcyclopædia of law, ” title “contracts, ” vol iii , p 872 et seq. Seealso id , vol xviii , p 440 further consideration of the validityof contracts for medical and surgical services will be had hereafter a full synopsis of the statutes of the different states regulating thelicensing of physicians and surgeons in force at the time this volumegoes to press will be placed in another chapter in a suit between a person who has performed medical and surgicalservices, and one who employed him, it is said that the personperforming the services is presumed to have been licensed to doso 157 if the state sues for a penalty, a different rule is claimedto prevail 158how may a diploma or license be proved in a court of law?. It is evident from the foregoing considerations that in any proceedingsto punish for practising without license or legal authority, and inactions to recover payment for professional services in the states andcountries, where a license or diploma of a regularly chartered schoolor college is required by statute to entitle the person to practise, itmay become important to establish first, the legal authority to grantthe license or diploma. And second, the genuineness of the license ordiploma produced it frequently happens that the diploma or license hasbeen obtained in another state or country under the new york statutes, especially the laws of 1880 and 1890, it was made necessary to file adiploma when it had been issued by a chartered school of another stateit must be certified to by essay lawfully incorporated medical collegein this state, before being received for filing, or regarded by the lawas conferring upon its possessor the right to practise in that state as to the chief element of authenticity, namely, the legalincorporation or authority of the body or institution granting thediploma, it is clear that the act of incorporation itself would bethe best evidence of the incorporation of the college or school, anda special act granting the power to license to a board of censors orother official body or board would have to be produced to show theright vested in that board or body to grant a license in georgia ithas been held hunter v blount, 27 ga , 76, that to prove a diplomagiven to a physician in another state, the existence of the college, and the fact of its being a chartered institution, must be shown byproducing its act of incorporation in thornton case 8 term rep , 303. Same case, 3 esp , 4, it washeld that the mere production in court of a diploma under the sealof one of the universities, is not of itself evidence to show thatthe person named in the diploma received the degree which the diplomaspecified in another and later case, however, simpson v dunmore 9 m & w , 45. Same case, 5 jurist, 1012, it was held that it wasunnecessary for the person producing a license from the apothecaries’company an incorporated body to practise as an apothecary, the sealon which license was proved to be genuine, to give any additionalevidence of his identity with the person named in the license thereason for this doctrine is probably to be found in the well-known ruleof evidence, that identity of both christian name and family name, issufficient to raise a presumption of fact that the person bearing thename is the identical person so named in any written instrument in walmsley v abbott 1 k & p , 309. Same case, 5 d & r , 62, proof of the signature of one of the examiners who signed a certificateof examination was held sufficient to warrant the acceptance of thecertificate in evidence in the first instance in another case theproof was that a person previously a stranger to the place went to atown which was the seat of a university, and was told that a certainbuilding was the college, and that a certain person whom he saw therewas the librarian, and that this librarian showed him what purportedto be the seal of the university, and also a book which the librarianstated was the book of acts or records of the university, and the sealso shown him was compared with the seal of a certain diploma, thegenuineness of which was in question, and a copy was made from the saidbook of acts, of an entry stating that the degree of m d had beenconferred by the university upon a person bearing the same name as thatin the diploma, and this proof was held a sufficient authentication ofthe diploma, and of the act or authority of the university conferringthe degree collins case, 1 addison & ellis, 695. Same case, 3 n & m , 703 159the rule in criminal prosecutions - we have seen above, that in acriminal prosecution the burden is on the defendant to produce andprove his license, but to warrant a conviction for practising withouta license it must be shown that the accused actually practised itis not enough to show that he is called by persons whom he attendspersonally, that is, for whom he prescribes, or to whom he givesmedicine or whom he treats there must be proof shown that he has donethis on his own account or for his own profit but proof of a singleact connected with other circumstances, such as tend to show that heheld himself out as a physician, is enough burham v state, 116ind , 112. Hill v bodie, 2 stew and p ala , 56. Pedgrift v schiller, 8 c b , n s , 200 same case, 6 jurist, n s , 1341 andif he simply practises “massage, ” he does not fall within the actsagainst practising medicine, even though he pretends to accomplish asmuch good as could have been accomplished by a regular physician smithv lane, 24 hun, n y , 632 but see also leech v ripon, 12 cent l j , 479.

how are we toexplain the fact that they buy a book reports are the almost invariable accompanimentof the most diverse methods of treatment?. i have already quoted thestatement of ledoux-lebard that every therapeutic novelty appears toexercise a favorable effect on cancer paper the same fact has beenobserved in a variety of other diseases, such as locomotor ataxia in order to arrive at a safe and reliable estimate as to the valueof any new or experimental procedure in paper of cancer, it seemsadvisable to accept certain definite therapeutic criteria by which thepaper are to be judged in the absence of such a method, alterationsin symptoms which are actually of no real value or importance receiveundue emphasis the natural course of the disease is associatedwith such fluctuations that a sanguine therapeutist can gain essayencouragement from even the most hopeless paper hence it follows thatevery mode of treatment has found adherents the market is floodedwith cancer drugs, and cancer charlatans flourish in the most highlyeducated communities unfortunately, even well trained, honest andreputable physicians have fallen victims to this fallacy, and havelent their names to the support of modes of treatment which in realityproduce no determinable effect on the natural evolution of the disease it was the desire to combat this unfortunate tendency which led meessay time ago to attempt to establish a reliable set of criteria oftherapeutic effects in cancer these were embodied in an article280which appeared two years ago, and i may be here permitted to quote themin extenso. Criteria of therapeutic effects in determining the effects of any given mode of treatment on a tumor, a variety of criteria may be relied on circulatory changes in the tumor, the relief of pain and the restoration of a secondarily impaired function are certain of the criteria on which stress has been laid by the majority of observers in the past important as are these criteria in determining the progress of purely inflammatory processes, it is unquestionable that their value in judging of the effects of therapeutic methods when applied to malignant disease is open to criticism it is a curious and interesting fact that almost every therapeutic claim made in recent years in connection with cancer has included among its virtues the relief of pain this is true of vaccination with cancer tissue, of hodenpyl method and of thesis others in view of this very general effect, not much stress can be laid on this symptom, and it is probably fair to assume that in the great majority of these paper the result is in no small measure psychic the improvement of function is also largely a subjective phenomenon, and as such requires most careful criticism osler relates that he has known a patient with gastric cancer to be relieved of digestive disturbances and to gain 18 pounds in weight as the result simply of the visit of a sanguine consultant who denied the presence of a tumor improvement in the ability to chew food, to articulate words or to move a limb are phenomena familiar to those who attempt to treat paper of cancer the victims of this disease seem to be in a very high degree “suggestible” and impressionable and respond nobly to every therapeutic effort circulatory changes in tumors offer an interesting group of clinical symptoms the observation has often been made, especially in ulcerated new growths, that treatment is associated with swelling, peripheral hyperemia, and an altered character of the discharge in spite of the fact that there is no reasonable relationship between this congeries of symptoms and the actual cure of the tumor, they generally receive considerable emphasis and are cited as an indication of the specific local action of the agent employed it is also true, however, that the growth may continue to advance in spite of their presence it is of essay importance to inquire into the mechanism which produces these circulatory changes and into their clinical interpretation it is a well known fact that thesis drugs, when introduced into the body either by the mouth or through the skin, are excreted not only by the normal channels of elimination, such as the kidney or the intestine, but also from such ulcerated surfaces as may be present on the body this is easily shown to be true, for example, of certain of the anilin dyes, which, when introduced by way of the veins, produce an intense discoloration of the dressings over ulcers it is likewise true of certain of the metals, such as arsenic in order to understand the series of events previously enumerated it is therefore only necessary to assume that the therapeutic agent is excreted from the ulcerated surface of tumors if an irritant, it will tend to produce hyperemia of the margins of the ulcer, and an increase of the secretions if an astringent, however, it may produce just the opposite of these effects such a result, however striking, is purely accidental, and has no necessary bearing on the growth or destruction of the tumor itself it constitutes a symptom on which no reliance should be placed excluding from consideration all of these secondary factors, we may conclude that the observation of the size of the tumor itself is the sole criterion on which we can place reliance in judging of the effect of therapeutic measures this implies, in the first place, that a tumor must be accessible to fairly accurate measurement tumors of the uterus, for example, and intra-abdominal growths will only exceptionally fall into this class in the second place, indirect evidence of a decrease in the size of tumors, such as is afforded by the increased permeability of obstructed passages, as in the case of tumors of the esophagus, pylorus or intestine, must be accepted only with great reserve remissions in the obstructive symptoms characteristic of such tumors are a frequent feature of the normal evolution of the clinical history of such growths the relief of obstruction, however, may be due either to necrosis of the obstructing portions of the tumor, while the remainder continues to grow progressively, or to a relief of the accompanying muscular spasm finally, evidence of decrease afforded by the roentgenogram is not sufficiently exact in most paper to afford ground for so important a conclusion as that at present in question not only must there be unquestionable evidence, however, of the diminution in size of the tumor, but this diminution must be of a kind not ordinarily attributable to the natural evolution of the tumor it is safe to say that multiple tumors offer enormous difficulties in the matter of interpreting therapeutic results at present we have in the wards of the hospital a patient with multiple metastatic carcinomas of the skin for several months we have at intervals made accurate measurements of certain of these tumors and have found that essay have undergone retrogression, others have entirely disappeared, while still others have continued to grow steadily in the case which afforded the ascitic fluid used in hodenpyl experiments, thesis of the lymphatic metastases underwent complete retrogression, while the metastatic process in the liver, as was demonstrated at necropsy, increased progressively, and ultimately almost destroyed that organ thus, in multiple carcinosis, the retrogression of individual nodules is no indication that therapeutic intervention has produced an improvement i shall not delay to emphasize those variations in the size of solid tumors which accompany hemorrhage and its absorption, edematous swelling, necrosis in the depths, and other familiar factors which clinically simulate, or induce, the softening and the reduction that are so often attributed to therapeutic interference but it is important to draw attention to a similar feature in that type of superficial epithelioma known as rodent ulcer these new growths not infrequently advance at one point of the periphery, while they recede at another, and thus cicatrization and contracture may simulate a writingial recovery this effect is due in writing to alterations not in the growth itself, but in the accompanying ulcerative process the secretions from the growths, especially if confined under dressings, may have eroded and destroyed the surrounding skin, and it is tempting to interpret a recession of the associated ulcerative disease as an indication of a favorable effect on the new growth it is unquestionably this aspect of rodent ulcers which plays so generously into the hands of the numerous venders of nostrums for this disease in brief, the demonstrable reduction in size of a tumor, of a kind not to be attributed to the natural processes of evolution of that tumor or of its associated lesions, is the one essential feature of effective therapeutic intervention when the various methods of treatment which have been discussed inthis paper are judged by the standard advocated above, it is apparentthat none of them can lay claim to therapeutic effectiveness themodifications of the disease attributed to them are modifications whichoccur spontaneously in a very large proportion of paper as a resultof the natural evolution of the disease process this is a fact whichcannot be too strongly emphasized owing unfortunately to the hopelesscharacter of cancer, men are not prone to study with care all thelesser changes which the disease and the patient present under ordinaryconditions. But when a “cure” is under investigation, the patient andhis medical attendant note every apparent improvement with painstakingattention and enthusiasm as a result, essay evidence of improvement intreatment is entered on the books -- from the journal a m a , april17, 1915 the direct sales companyduring the past four or five years, the journal has had inquiriessimilar in effect to this, just received from dr e p jewett ofgardner, mass. “will you kindly inform me regarding a drug manufacturing company by the name of the direct sales company, buffalo, new york?. are their products standard and reliable so far as you know?. ”the direct sales company, inc , buffalo, has, according to itsletterhead, the following officers. Geo j dotterweich, president and treasurer, c k dotterweich, vice-president, louis b seufert, secretary this concern circularizes physicians and emphasizes that it sells“only by mail ” it also features a “profit sharing rebate” scheme, whereby purchasers receive a coupon representing 10 per cent of theinvoice value of each purchase after $100 worth of merchandise hasbeen purchased the $10 worth of coupons when “presented for redemptionat one time” will be “honored as cash”-- presumably on the purchase ofadditional goods the direct sales company catalogues have for essay years, carried aguaranty, which reads, in writing. “we absolutely guarantee all preparations to be in exact accordance with the national pure food and drugs act, june 30, 1906 “we also absolutely guarantee all preparations bearing our label to be equal, if not superior, to any on the market ”in one of the quarterly bulletins of the state board of health of newhampshire, issued last year, this paragraph appeared. “the direct sales company, inc , buffalo, n y , is a pharmaceutical concern which until recently has done business direct with new hampshire physicians in two or three instances complaints have been received by this dewritingment that the preparations sold seemed to be lacking in potency essay time ago a physician sent us a specimen of codein sulphate tablets, one-fourth grain, concerning which he was suspicious, admission being made that the price paid was very much less than current quotations the amount of codein sulphate actually found per tablet proved to be but one-sixteenth grain later on, having subsequently received a new lot from this source, the same physician sent us a second sample, the composition of which was found to be practically identical with the first acting under the federal law, 500 lot packages of the following preparations were next purchased of the company direct, the analytical results indicating serious deficiency in every case, as follows.

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No human beingcould survive the passage through his body of an alternating currentof more than 1, 500 volts for a period of even twenty seconds, contactbeing perfect ”the physical phenomena caused in the body by electrocution as atpresent conducted are comparatively simple, and such as we shouldlogically expect the instant the body of the patient enters into thecircuit of the current, all the voluntary muscles appear to be throwninto a condition of violent contraction which continues so long asthe current lasts, and on cessation of the current is replaced bya condition of extreme muscular relaxation all consciousness isapparently lost immediately on the application of the current thisprobably has never returned in any case, but on the removal of the bodyfrom the circuit of the current the relaxation of the muscles causesmovement, and essaytimes, as in the case of kemmler, slight spasmodicmovements of the chest have occurred the pupils in this case weredilated the condition of contraction and rigidity is renewed at eachnew application of the current, to cease immediately when the currentis removed in kemmler chest movements and possibly heart-beat occurred after thefirst contact, the former perhaps half a minute after the cessation ofthe current in slocum there were chest movements and radial pulsation after thefirst contact in smiler no movement of the chest, but radial pulsationafter the third contact in jugigo a slight fluttering of the radialpulse when final contact was broken, which rapidly ceased in hood nomovement or pulse-beat in essay of the patients superficial burns have been caused by imperfectcontact of the electrodes, either on the head or at the position of thelower electrode in kemmler case the cerebral cortex was essaywhataffected under the head-electrode the practical effect of the application of the current to the criminalfastened in the death-chair, as seen by the bystander, is thatimmediately on its reaching him the whole body is straightened andrendered rigid in extension, the extremities tend to straighten out, and the face may grow red and turgid there is reported at timesswelling and turgidity of the neck the whole body remains in thistetanic, stiffened condition until the removal of the current, when allthe muscles relax and the body sinks back into the chair in a state ofcomplete muscular collapse mental or psychical symptoms the third class of results which are found after electrical shocksfrom high-tension currents are the mental or psychical by the use ofthese terms we do not wish to imply that they are voluntary they are, however, so far as our present knowledge of pathology reaches, largelyfunctional this is precisely the class of paper which, when resultingfrom railway accidents, are placed under the head of railway-brainor railway-spine they may be considered in the present state of ourknowledge as traumatic functional neuroses, though it is probable thatwhen our means of examination and investigation are more completewe may succeed in discovering a visible or perceptible lesion thesymptoms affecting motion and sensation in these paper are frequentlyaccompanied by others of an emotional character, and in thesis paperthere seem to be writingially or wholly voluntary conditions and symptomswith the involuntary there is in thesis paper a characteristic loss ordiminution of the force and power of volition, but in others this isnot perceptible these conditions are so well known when produced by other causes thatwe do not consider it proper to enter into a full consideration of themhere, but we cannot leave this important subject without a few generalremarks no form of affection or disease has caused more discussion among themedical profession or figured more prominently in the courts than this, and even now there are thesis questions in relation to these conditionsstill under dispute our own view, confirmed both by observation andexperience, is that the tendency in new england, at least, has beenon the whole to underrate the severity, the duration, and the amountof suffering caused by these conditions that because there havebeen paper of malingering, of deception, and of rapid cure afterthe receipt of damages, and because in addition to this a certainvisible emotional and at times apparently controllable element exists, the profession, and above all the laity, are led to conclude thatthis forms the essential condition and basis of the disease on thecontrary, in a very large proportion of paper the symptoms are such ascannot possibly be voluntarily assumed. They produce extreme discomfortand often much suffering for the patient, and frequently last foryears, rendering their victims incapable of carrying on their formeroccupations fortunately in the patients suffering from electric shock theseverer forms of these affections are not so common in most of thepaper reported recovery has been more or less rapid paper in whichprevious hysteria or neurasthenia have existed are more liable tothese manifestations than persons of a previously equable nervousconstitution, but these latter are by no means wholly exempt toconsider these conditions, as is essaytimes done, as the fault of thepatient seems to us both unwarrantable and unjust lightning we now come to the consideration of the action of electricity inanother form, that of natural electricity or lightning the effectsof this are practically the same as those of the forms previouslydescribed, except such differences as seem to be fairly accounted forby the vastly greater force of the currents with which we have todeal injuries and deaths from lightning stroke have been recognizedand described for thesis centuries, and we have now a large collectionof careful observations on them they occur in most temperate regionswith comparative frequency in france the number of deaths from 1835to 1852 inclusive eighteen years was 1, 308 in england, includingwales, there were in twenty years, 1865 to 1884 inclusive, 416 deaths in 1846 mr eben merriam, of brookline, wrote to mr arago that in thethree last years about 150 persons had been killed by lightning in theunited states in thirty years, from 1855 to 1884 inclusive, we find101 deaths in massachusetts from this cause exposure - injuries and deaths from lightning may occur in variousplaces and under various conditions the severe lightning strokes arepopularly supposed to occur only during thunder-storms, and in thislatitude this is undoubtedly, as a rule, true, but lightning strokesare reported to have occurred, writingicularly in the south, from a clearsky, and there seems no reason to doubt that this may happen it issaid also that dangerous discharges from the earth to the atmospheremay take place at a considerable distance from an atmospheric storm as a rule, the lightning is more likely to strike essay tall object, as a tree or a tower or steeple, and for this reason, and to avoidinjury from falling branches, the shelter of trees should not be soughtduring thunder-storms if lightning stroke be dreaded ships at sea arefrequently struck by lightning, writingly perhaps on account of the heightof the masts and writingly on account of the metal in or on them lightning obeys the same general laws as the other forms ofelectricity and naturally follows the paths of least resistance persons, therefore, who are in the neighborhood of or in contactwith good conductors are in more danger of injury by lightning thanwhen surrounded by or in contact with poor conductors the proximityor contact of a large metallic object exposed in a thunder-storm isconsequently more or less dangerous on the other hand, the absenceof tall objects or of specially good conductors of any kind does notinsure safety in thesis paper persons in fields are struck, and paperare related of persons struck on the prairies in the west in fredetcase a shepherd was found dead in the midst of the barren moors landes in southern france more accidents appear to occur directly to persons out-of-doors thanto those in houses or other buildings when inside buildings, personsstruck are usually near an open door or window through which thelightning enters, and they are more exposed to danger from this sourceif there be essay metal object or good conductor in the vicinity persons carrying or wearing metallic objects render themselves therebymore liable to be injured in this way not only does the liability to injury from lightning vary essaywhataccording to the exposure or position of the person, both in relationto the free access of the atmospheric air and to the contact with orneighborhood of metallic objects or other good conductors, but alsothe severity of the injuries may be largely dependent upon what theyare wearing or carrying and the condition of their clothing at thetime if the clothing be wet it will act as a good conductor, as willalso any metallic object about the person we have already referred tothe action of metallic objects upon the passage of the electricity toand from the body and to the condition of the skin in relation thereto the laws of conduction and resistance are precisely the same for theelectricity of lightning as for the other forms hence the greater theresistance to the electricity at the points where it enters or leavesthe body, the deeper will be the burn thus we find not infrequentlythat the lightning, in its course from the head to the feet, meets witha chain or a truss, and almost invariably at least a portion of thecurrent follows this, causing a deep burn where it again passes intothe skin all the external burns of the lightning, except the initialone, are determined by the position and conditions of the body, theclothing, and the conductors near all electricity obeys the same lawand, roughly speaking, follows the path or paths of least resistance the clothing worn by a person when struck by lightning may be actedupon in the most various ways essaytimes it is wholly stripped off theunfortunate sufferer, who, as in a case reported by cook and boulting, may have to be protected with sacks or other hastily improvisedcoverings in a case reported by nason, a girl of thirteen was struckwhile in the street and most of her clothes stripped off and torn toshreds, and the top of her hat, which contained steel wires, was tornfrom the brim in the case of wilks the body was stripped entirelynaked and absolutely nothing left on except a portion of the left armof the man flannel shirt the clothing is essaytimes torn to thefinest shreds, like those of a mouse nest, as described by van horn, and in another case claes, where the patient was struck while onboard ship, his woollen jacket was torn into fine bits, which stuckto the ropes, and the deck was covered with fibres of wool as fine asthose of cotton-wool in this case the woof of the trousers was said tohave been wholly destroyed, while the web was untouched the clothing is also often burnt not only are holes burnt in it as isusually the case at the point where the lightning strikes and at thepoint where it leaves the body, but it may be set on fire it may befound smoking or in flames of all portions of the clothing injured, perhaps the coverings of thefeet are the most frequently so, as the electricity is very apt toleave the body through the feet, and the resistance opposed is great hence the boot or shoe is frequently injured essaytimes it is piercedas by a bullet, or a large hole is torn in it, or it may be torn topieces or reduced almost to lint, while the foot remains uninjured itmay be torn, shrivelled, and burnt in one case the soles of the shoeshad disappeared. In another the leg of the boot was clearly dividedfrom the sole and both straps were torn out. While again in another theshoe was carried wholly off the amount of injury to the clothing does not necessarily correspond tothe amount done to the body a person may be killed by lightning whilethe clothing is uninjured on the other hand, the clothing may be tornto pieces, carried away, or even writingially burnt, while the portion ofthe body underneath remains unhurt symptomatology - the symptoms of stroke by lightning resemble, in ageneral way, those due to high-tension currents of electricity as inthe case of the latter, they can be divided into the direct, producedimmediately by the lightning itself, and the indirect, or secondary, produced through the medium of other factors in the milder paper the person struck feels dazed and benumbed andmay or may not lose consciousness for a short time at the momentstruck they may have the sensation of a blow, and they often see ablinding flash on recovery of their faculties there may be a temporaryanæsthesia or weakness of one or more extremities, which rarely lastsmore than twenty-four hours there is a general shock to the system, essaytimes slight loss of memory for a time, and occasionally nauseaand vomiting there are often discolorations of the skin of mediumextent, and frequently burns and blisters these persons have usuallyreceived the stroke on one extremity or have escaped the full force in the more severe paper the patient loses consciousness immediatelyand may continue unconscious for essay hours he passes into a conditionof collapse with rapid, feeble pulse and cold extremities, and thepupils are dilated on recovery of his senses the same symptoms as inthe less severe paper, only more pronounced, are found the loss ofmemory may be marked and the intellect temporarily weakened, while theweakness and anæsthesia of the extremities persist longer the externalinjuries, burns, and wounds are liable to be more severe in the fatal paper where death is directly due to the electricity it isusually instantaneous or at least without recovery of consciousness itmay be caused by shock or by apoplexy, i e , intracranial hemorrhageor by the direct effect of the electricity on the brain of coursedeath is often due to burns or to indirect traumatic injuries the indirect traumatic injuries caused by lightning are due either tothe loss of consciousness of the patient, which causes him to fall andthus sustain injury, or to the direct action of the electricity uponhim, knocking him down or throwing him to essay distance, essaytimeswith great violence, or lastly, and perhaps the most frequent cause, to the impact or pressure of objects which are torn or cast down bythe electricity and by striking or falling on a person produce greatinjury thus persons have been killed by the fall of buildings, sheds, or trees which were struck by the lightning, or their branches ofcourse all kinds of traumata may be produced thus the direct external injuries caused by lightning are burns, subcutaneous hemorrhages, discolorations and markings of the skineither dendritic or metallic, lacerations or wounds burns occur in nearly all, perhaps all, severe paper of lightningstroke they may be of any or all degrees, and may extend over verysmall points or over the whole or nearly the whole body they mayconsist in a simple singeing of the hair, or they may be very deep andextend to the bone as before stated, the deep burns are found at thepoints of resistance to the current, at its points of entrance and exitfrom the body, and, to a lesser degree, at all points where its courseis impeded this occurs wherever the clothes are fastened tightly orpressed against the body, hence especially at the neck, waist, knees, and essaytimes at the ankles the position of the burns is determined, therefore, by the point at which the lightning strikes the person, theposition at the moment, and by the arrangement of the dress and thepresence of metallic substances in the large majority of paper theupper portion of the body is the writing first touched by the lightning, and thence it descends along the body to the ground we are apt, therefore, to find a severe burn about the upper portion of the body, the head, neck, or shoulders. Then a scorching, singeing, or burning, more or less severe, in the form of a stripe or stripes more or lessbroad down the body. The burns being deeper where the clothes aretighter or where metallic objects come into contact with or are nearthe body. And finally a deep burn at the nearest point of contact withthe ground, usually the heel or essay portion of the foot the burns, however, vary greatly the eyes may be burnt and severelyinjured or destroyed the lightning has been known to enter the mouthand burn the mucous membrane within the deeper burns not infrequentlyassume the form of holes in heusner paper about twenty whitish-grayspots, varying from the size of a lentil to that of a pea, were foundon the soles of the feet the hair is usually singed and may be burntoff in large areas, or wholly as in a case reported by bernard wounds - these may be direct or indirect we shall speak here onlyof the first like burns they occur usually at the points of greatestresistance, that is, the places of entrance and exit, but they maybe found in any writing of the body they may be clean-cut, as if madeby a sharp knife, or they may be lacerated and ragged with the edgescontused or burnt they may consist of holes which look as if they hadbeen punched out contusions or ecchymoses these may also be produced directly by thelightning, and like burns and wounds are most apt to occur where theresistance is greatest they may be of considerable importance in amedico-legal sense, as in fredet case, where there were ecchymoseson the neck similar to those produced by the fingers of a hand appliedfor strangulation in the case related by cook and boulting the rightside of the body appeared like an exaggerated example of post-mortemstaining there are essaytimes found also dark-brown spots, small orlarge, which may be soft and, when cut, containing fluid blood, or theymay be hard and like parchment, dry, and bloodless on section closely connected with these are the so-called dendroid or dendriticmarks, which are dark-colored reddish bands or stripes, often more orless dichotomously branched, not disappearing under pressure, found onthe bodies of those struck by lightning though usually of the formmentioned, they may assume other shapes, as that of an irregular starwith zig-zag rays balfour has figured an excellent example of these metallic staining of the skin has been known to occur where metalswere in contact with it at the time of the lightning stroke thesestains may be permanent and are due to the introduction of the finelydivided metal richardson has succeeded in producing this artificiallyin animals he found two conditions required, that the metallicconductor should be sufficiently fine to offer resistance to thecurrent and that the current itself should be an electric discharge oflow tension loss of hair is said to have occurred from lightning, though the hairwas not burnt one case has been reported where after a severe strokeall the hair on the body is said to have fallen out symptoms under this heading we shall consider only such symptoms as are, so faras can be ascertained, the direct result of the electricity and notthose secondary to injuries we will consider first those relating to the nervous system loss of consciousness - this occurs to a greater or less extent inall but the very mildest paper it varies throughout all degrees froma slight momentary benumbing of the faculties to the most profoundstupor or coma it may then last hours or even days on recoverythe patient is apt to have essay loss of memory, to be dazed andconfused for essay time, and a certain obtuseness or blunting of theintellectual faculties may persist for a considerable period thisloss of consciousness is often accompanied by flushing of the face anddilatation of the pupils, or on the other hand the patient may presentall the symptoms of collapse loss of memory in regard to the lightning stroke after recovery ofconsciousness is not rare it is frequently complete so far as anyrecollection of the lightning goes, and there may be no remembrance ofthe thunder-storm essaytimes a defective memory persists together withgeneral mental impairment james mental disease - a condition of mental impairment lasting at leastweeks or months may occur mania and the delirium of terror are said tohave occurred various symptoms of the disturbance of the nervous equilibrium are notuncommon among these we may mention tremor, insomnia, and nervousdread of thunder-storms and of electricity there is no doubt that essaypersons who have been exposed to lightning stroke do, at least for atime, become unusually susceptible to the influences of atmosphericelectricity loss of motion paralysis - this is a very frequent result of astroke from lightning hemiplegia is not uncommon in bonnet casethe patient was struck on the head by the lightning, which caused alacerated wound in the left temple, but did not injure the aponeurosis on recovery of consciousness the patient was found to have a lefthemiplegia involving the face and both extremities accompaniedby a diminution of sensation over the left half of the body thesensation became normal in two days, but a writingial hemiplegia remainedpermanently in the case of durand there was a nearly complete righthemiplegia with accompanying hyperæsthesia and essay affection ofspeech deglutition and mastication were difficult, and there waspersistent hiccough there was photophobia and hyperæsthesia thepatient improved in two weeks and finally recovered there is often atemporary hemiplegia nearly all forms of paralyses of the extremities may occur we mayhave paralysis of all the extremities or of both arms or legs, ormonoplegias paraplegia occurs not very rarely it is usually of shortduration it may be accompanied by paralysis of the bladder singlemuscles or muscle groups only may be affected ptosis may occur with paralysis of other branches of the third nerve, causing diplopia facial paralysis occurs also alone. In one case itlasted only twenty-four hours, in another one month difficulty in mastication is essaytimes found, but much more frequentlydifficulty in deglutition is reported retention of urine, dysuria, or incontinentia urinæ may all occur, andthere is essaytimes a paralysis of the rectum, usually temporary, andessaytimes obstinate constipation, which in one case was combined withparalysis of the bladder and monoplegia aphasia in various degrees and various forms of dysphasia or difficultyin speech are not uncommon they are apt to be temporary loss of co-ordination in the lower extremities with writingial paralysisof bladder and rectum is reported convulsions - epilepsy may be brought on by lightning. This wouldbe more likely to occur in a person previously subject to epilepticattacks hysterical convulsions and spasms may also be produced, both immediately and as a more remote result, usually in personspredisposed tetany and catalepsy are said to occur clonic spasms of the whole body and convulsive movements of the limbsare not very infrequent in essay paper a marked sensitiveness remainsfor a time in the limbs struck, so that if touched they are immediatelythrown into clonic spasms disturbances of sensation - pain occurs in nearly all paper it ismost frequently a secondary result of the burns and other injuries not rarely, however, it exists as a direct symptom in the form of aburning or stinging neuralgia in the limb or limbs affected essaytimesthe first sensation on the recovery of consciousness seems to be painall over the body or confined to essay portions only, but the amountand character of the pain, aside from that produced by the injuries, varies much one patient had a burning pain in the back and leg lastingonly half an hour after recovery of consciousness in another casethere were pains all over at the end of the first week on the whole, severe pain in essay or all of the limbs, and less commonly in thehead, without paralysis and lasting essay days is not rare in one casereported by paige the patient had intense pain in the head, neck, arms, and chest.