Landmark knew as much about insanity as the Superintendent of the Asylum of which he (the editor) is a Director, I do not think he would have written such a statement. In the first place the "good opportunity for observation" cannot be had in jail unless one be incarcerated with the prisoner to play the detective; for in many cases the true mental condition can be ascertained only after frequent, close and prolonged contact, and such conditions are furnished alone in asylums and to those who have daily intercourse with the patients. Another statement of the Landmark: “The asylum physician who is conscientiously working for the good of his patients is unfit for the detective duty that such a law would impose on him " Per contra, I will state that the "asylum physician who is conscientiously working for the good of his patients" must of necessity, by his every day contact and study of his patients, come in possession of a knowledge of his patients that is "detective" in its completeness. It seems to me that it requires but a limited knowledge of hospital life to convince any doubting Thomas that there are many means of information and opportunities to detect the malingerer enjoyed by the hospital doctor, that no one else can have, and the statement that any intelligent physician can detect feigned insanity in a jail as well as out of jail, is, I must believe, a hasty judgment, resulting from a crude digestion of the subject. I will here reiterate the statement contained in my suggestion: that any man of good average intelligence who is accused of murder can feign insanity with sufficient success to cloud the mind of expert witness and jury as to his mental status, and it is becoming a popular dodge, and the history of our courts is recorded evidence that the dodge is often successful. But not only should the dissimulation of the malingerer be detected, but the irresponsibility of the mentally diseased should be clearly demonstrated. Time would fail and space would be forbidden were I to enter at length into a discussion of the manifold forms and phases of insanity, showing how necessary is time, daily contact and a most intimate acquaintance to appreciate the moral responsibility of many of our unfortunate fellow-creatures. Another objection of the Landmark: "Nor has he (the hospital doctor) time to leave his work and dance attendance at the courts for an indefinite period." The hospital doctor is in the employ of the State, and the State has a right to his services, not only in the hospitals, but as an expert in

courts when necessary to further the ends of justice by furnishing intelligent and reliable testimonry as to the responsibility or irresponsibility of the class under consideration.

We have three Insane Asylums in our State and eight hospital doctors, each one of whom would be a reliable witness in such cases, and as such cases as we are now considering are few, and days are set for their trial, the time lost would be inappreciable to each hospital, and the duties of the "dancing attendance at court" could without embarrassment be performed by the remaining doctors. While I am clearly of the opinion that an expert, trained in the examination of the insane, is the most competent person to pass upon the character of the alleged insane, I presume it is hardly necessary that I should here, both for myself and for my brethren of insane asylums, disclaim any and all desire to "dance attendance at our courts." Such a duty, I am sure, would be distasteful and impose delicate and irresponsible duties that would rather not be assumed.

I fully agree with the Landmark in all he says in the way of objections to mixing the criminal and the alleged criminal with other classes of our insane population in hospitals. This, however, is being done now in every asylum in our State, and the addition of the small class in question would not materially add to the trouble now existing. But my suggestion is that this class be committed to an Insane Asylum. Of course a criminal Insane Asylum is the kind of an asylum for such a class, and every State should have one. On this question there will be no diversity of opinion among those who have experience in the care of the insane. But in the absence of such an hospital my suggestion contemplates their commitment to such asylums as we have as the next best thing that can be done. Let us now look at the Landmark's suggestion: "That the State provide for its criminal insane at the State Penitentiary and so forever rid the asylums of this burdensome class; then there would be less feigning and less need for expert testimony." As above stated, I heartily agree with him as to the desirableness and even necessity of an hospital for our criminal and alleged criminal insane; but I am not sure that at the Stafe Penitentiary is the best place for it. But what about the conclusion of the whole matter, as drawn by the Landmark? "Then there would be less feigning and less need for expert testimony." A great man has said that

every man comes into the world asking why? I would like to ask why would the erection of a hospital for the class under consideration prevent, or even diminish, the number of malingerers? The Penitentiary does not prevent many men from stealing, though it may diminish crime; but neither the Penitentiary, nor jail, nor dungeon, much less a criminal insane asylum, would, in my humble judgment, prevent one man from feigning insanity in order to save his neck from the halter. I have looked at the Landmark's conclusion closely and have studied the question patiently, but I am still wondering how, by what process of reasoning he ever reached such a conclusion from the premises laid down. Does the suggestion carry with it implied cruelty? Must I conclude that the criminal and alleged criminal insane's environments at the Penitentiary are to be so revolting to even depraved humanity, his treatment so cruel that the malingerer would rather pay the penalty of his crime upon the gallows than suffer the slow, torturing process of dying in the insane cells of the Penitentiary? The known good sense and humane feelings of the Landmark's editor forbid such an inference; and the Christian character of Coi. Hicks gives assurance that even the criminal insane as well as the alleged criminal insane committed to his care-keeping would receive humane treatment. What, then, does the Landmark mean? I confess I cannot tell. I will state in this connection that many of the so-called criminal insane demand as kind treatment and as thoughtful consideration as other insane. Many such led as pure lives as the best of our citizens, but, dominated by an irresistable impulse or a strong delusion, they have shed innocent blood, and are not morally or legally responsible for these acts. What shall we do with this class confine them in a penitentiary? Surely not. For all such and for the class more particularly considered let us have a special Asylum-not at the Penitentiary—but under the management of the authorities of North Carolina Insane Asylum at Raleigh; but in the absence of such an Institution I still insist upon the practicability and expediency of my suggestion, believing it will work no material ill, and that it will further the ends of justice by furnishing the best means of demonstrating the responsibility of the malingerer, and the irresponsibility of the insane criminal.

E. N. C. Insane Asylum, May 12, 1890.

J. F. MILLER.

UNCONTROLLABLE VOMITING AND ALBUMINURIA DURING PREGNANCY.

A primipara, age 22, menstruated last in the beginning of July, 1889. During August she began to suffer from nausea and vomiting; at first only in the morning, from 7 a. m. to 11 a. m., immediately after rising; but during September the vomiting became more severe, commencing during the night and lasting all morning. She vomited everything she took. At about this time she came under my observation; and all the ordinary remedies were prescribed in succession but without resnlt, and the vomiting became almost continuous. When I saw her again, after an interval of several weeks, she was much emaciated and looked very ill, her face wore an aspect of anxiety, and there existed slight jaundice. Her bowels were unusually constipated, but sometimes her motions were loose and black. No physical sign of hepatic disease. No fever, heart and lungs healthy; uterus presented normal characteristics of five months pregnancy; urine contained ulbumen and bile pigment, but no casts could be discovered. I prescribed hydrate of chloral, in 1-grain doses, every quarter of an hour, and iced milk. Three days later she was much better, had only vomited a few times, had kept down a considerable quantity of milk, and had slept fairly well. Next day when called in I found her in convulsions. I at once administered chloroform to her and the convulsions ceased, having lasted for one hour and a half. After a coma of several hours she awoke quite confused, talked unintelligibly, and would not answer when spoken to. A few hours later she had another attack of convulsions which lasted about an hour and was followed again by coma from which she awoke in similar condition as before. Vomiting had ceased; the urine was very albuminous and contained casts. Chloral and bromide of potassium were administered; and I now decided to induce miscarriage, which terminated naturally, five hours later. During labor she had another attack of convulsions, and had to be kept, more or less, under the influence of chloroform. There was considerable post-partum hæmorrhage; the fœtus was natural. She had no more convulsions after confinement, but remained comatose for about four hours, when she became gradually conscious, and when I saw her six hours after labor she was quite

rational. She made an uninterrupted recovery. The urine became gradually less albuminous, and on the seventh day after confinement the albumen in the urine had entirely disappeared.

I called this case of vomiting uncontrollable, because all the usual remedies had failed to relieve it and it affected the health of the woman seriously. The hydrate of chloral, which appeared to relieve the vomiting somewhat, when prescribed later, had failed when I prescribed it at an earlier stage. Numerous theories have been advanced to account for this obstinate vomiting of pregnancy. It has been regarded as peculiar to the rigidity of the uterine muscular fibres, to a rigid state of the os, to uterine lesions, to flexions and distortions of the uterus, etc.; but all these conditions, though so frequent in pregnant women, are often not present in cases of vomiting. I have seen this vomiting in multipare where the uterine tissues are lax and where the os is soft, easily dilatable, and even patent enough to admit two figures.

In every case of rigid os I have met with vomiting was absent. How many cases of pregnancy do we not meet which are complicated with cervical endometritis, flexions, etc., and which are uncomplicated even by simple vomiting? And, if they should be so occasionally, how do we explain the disappearance at the end of a few months' pregnancy of even severe vomiting, and that, too, spontaneously, often very suddenly. I rather think that it arises simply and purely from an idiosyncrasy in the individual, predisposing her to morbid reflex actions. Vomiting, of course, may be aggravated by other conditions present, such as irregularity in the diet, undigested matters in the alimentary canal, etc. Therefore we often may cut short the vomiting and prevent the severer form by regulating the diet in the beginning. The case I reported here was entirely free from any uterine abnormalities, but was complicated by albuminuria; but I do not think that the vomiting and the albuminuria stand in any casual relation to each other; on the contrary, they occurred together in the same individual accidentally. It has been shown that even in normal pregnancy the liver and the kidneys undergo what is called by pathologists cloudy swelling, and occasionally this change may proceed farther and pass into acute fatty degeneration. The same may occur in other glands. Whether this has something to do with the vomiting in pregnancy, as some think, is very questionable.-A. A. Henske, M.D., in St. Louis Clinic.