} the associated Out-Patient Clinics of the City of New York—an association, by-theway, which should have come into existence long ago but which is none the less welcome by reason of the delay in its birth. In the first place dispensaries must stop their habit of creating paupers.

Parasitism is easily acquired and invariably destructive of efficiency of both helper and helped. It is amazing how long a man will remain a healthy efficient worker when he knows he must, and how soon he sinks into inefficiency when the prod of necessity is removed. This is an old story and we must profit by it. Whenever we confer unpaid-for benefits we invariably strike a deadly blow at the recipient's manhood. It is highly necessary, then, to take more care to exclude those able to pay for advice and to collect later from those temporarily disabled. This is a large order, to be sure, and not likely of fulfilment, but it is the objective point even if we never reach it. Then again, if dispensaries are such social necessities, why put them in control of the least experienced? Surely public welfare demands that the work be given to men of experience, if not the best of us, and all this is impossible unless liberal salaries are paid. All civilized nations are taking up some form of public relief for the sick and injured, and perhaps we are to approach the problem through the medium of our dispensaries rather then by the friendly societies of Great Britain or the compulsory insurance of Germany. With fewer patients and with experienced paid doctors, there would be less complaint of neglected scientific material to show to students. It seems to us that the general aims of the reformers, though good as remedial measures, do not strike at the roots of the evil the unnaturalness of the

dispensary as organized at present. It is all very well to coordinate their work, promote proper standards of treatment and increase economy, but it seems futile to go on creating more semi-paupers as we surely will do with greater efficiency. Any man who applies for treatment confesses thereby to inability to care for himself and the welfare of society demands that we find out why he is financially disabled. Every case must be followed up, with a view of prevention rather than cure. This field for social workers is of such enormous extent that it almost appals one against entering it-fully one-tenth of mankind will require study, if we are to believe some investigators. Would it not be well to restrict the number of dispensaries, and thus prod a certain percentage of patients into consulting a family physician? We put out these ideas not to discredit dispensaries entirely, but with a view of eliciting suggestions as to whether we are drifting with the present enormous equipment, and whether or not it is not time to class them as public utilities of some kind, and not solely the resort of paupers. They seem to be drifting to something like the status of our public schools. Society has almost entirely taken over the parental duty of education and though we can well doubt whether it will ever take over the treatment of adult invalids, we cannot doubt that aid to the temporarily helpless is already a social duty and that we seem destined to render aid through the medium of dispensaries rather than panel doctors or insurance. If this is so, the stigma of pauperism disappears with the realization that the service rendered is paid for or is a mere loan. The profession is tired of being called on to render free service to the poor-no lawyer is ever expected to defend a low criminal gratuitously-so

, 1913

, Vol. VIII

why should he be paid for legal service and we be compelled to render free medical service to the same man? Dispensaries surely do need reformation.

"Imitational Suicide" is again attracting attention as though it were something mysterious. A person who has a suicidal mania, would not kill himself at all, if he did not know how. Consequently the act is accomplished by means well known to the sufferer. Violent death has always been such a common occurrence that everyone knows how to kill himself, and the means selected depend upon the sufferer's education and environment. No one hangs himself if he knows of easier ways. Hence it often happens that such a person will adopt a plan to which his attention has been recently directed. That is, publication of details of suicides does not create the mania in others, but as a rule merely determines the manner of executing the morbid impulse. They are devoid of judgment, of course, and frequently go about the matter in a most illogical way— luckily sometimes defeating their own aims. The idea that sane persons ever commit suicide is about given up. We invariably find some nervous or mental disturbances, with more or less suffering, which destroy judgment sufficiently for us to consider the person unbalanced, and not sane enough to repress a desire which many a sane person entertains for a few fleeting moments in the agonies of great disappointments, afflictions and humiliations. There is a possibility of course that an insane sufferer contemplating suicide may have his intentions strengthened by reading of suicides, but we doubt whether this leads to the act in many cases which

would have otherwise resisted the impulse. Some cases of self-destruction are not intentional suicides, by-the-way. The insane, for instance, not infrequently kill themselves jumping from windows, to escape from some imaginary dreadful danger about to overtake them in the room. That is, they are trying to save themselves, or are actuated by some other delusion not connected with suicide in any way. These are not cases of "imitational suicide," indeed there is little evidence that suicides. ever imitate prior ones as the result of suggestion except in the way of suggesting means to an end already determined. upon. Newspapers are not responsible for these deaths as some writers assert.

"Speeding-Up."-Working along with his partner, the "efficiency engineer," the speeder-up has managed to obtain from the factory worker a larger output in the same period of time. This is done by eliminating the so-called superfluous motions of the arms and fingers, i. e., those which do not contribute directly to the fashioning of the article under process of manufacture. Hailed at first as a great reformer, with joy by the manufacturer and with a sort of pride by the worker, the speeder-up is destined soon to become anathema to the latter, while the employer will ere long reluctantly have to admit that there has been something wrong in the premises. Just as the wise employer now finds it cheaper by welfare work to conserve the life and health of his workmen, so will he find it more economical in the long run to relax the newly found speed.

The reason is of interest to the physician because it is purely physiological.

The movements thought to be superfluous simply represent Nature's attempt to rest the strained and tired muscles. When ever the muscles of the arms and fingers, or of any part of the body for that matter, undertake to do a definite piece of work, it is physiologically imperative that they do not accomplish it by the shortest mathematical route. A rigid to and fro movement is possible only to machinery; muscles necessarily move in curves and that is why grace is characteristic of muscular movement and is absent from a machine. The more finished the technic of a workman and the greater his strength, the more graceful are his movements, and, what is important in this connection, vice versa. A certain flourish, superfluous only to the untrained eye, is absolutely characteristic of the efficient workman's motions.

"Speeding-up" eliminates grace and the curved movement of physiological repose and thus induces an irresistible fatigue, first in the small muscles, second, in the trunk, ultimately in the brain and nervous system. The early result is a fagged and spiritless worker of the very sort that the speeder-up's partner, the "efficiency engineer" will be anxious to replace by a younger and fresher candidate, who in his turn will soon follow his predecessor if the same relentless process is enforced.

It will always be necessary to consider workers as human beings, and charity and moderation in the exaction of results will usually be found the part of wisdom, as representing a wise economy of resources. This scientific charity, however, is something quite apart from the moral effect on a personnel of due recognition of their long service and of the loyalty which is likely to accompany it.

The Newest Mind Reader.- Hugo Münsterberg, the psychologist, has rendered an invaluable service to sanity and common sense by his report in the May issue of the Metropolitan Magazine on Beulah Miller, the Rhode Island child mind reader. Not only had the wildest reports concerning this girl's simple tricks been spread broadcast through the newspapers, but the well known credulous pests who become conspicuous on these occasions were preparing to rivet superstition in the minds of the readers of certain periodicals whose editors grant a strange and dangerous liberty to them, as well as to a few undoubted charlatans, to prance through their columns waving their gaudy banners of quackery or pseudopsychology. As Professor Münsterberg states, the ten year old heroine of this latest sensation is innocent of fraud and is no doubt

delighted with what is to her an exciting game that seems to amuse a great many serious but otherwise pleasant grown-ups. Her programme is the usual one of reading playing cards placed face downward on the table, calling out the dates on coins, and spelling out messages written on folded slips of paper; all that is necessary is that her mother or sister or both should share her knowledge with the experimenter.

Dr. Münsterberg quickly discovered that the mother and sister were giving the child unmistakable signs by some sort of code, which relegated the phenomena at once to the realm of parlor magic, save that the parlor magician does not lay claim to supernormal power. With rare tact and discrimination the talented investigator alleges the possibility-he would say likelihood-that the mother's and sister's signs are given unconsciously and irresistibly owing to their

natural anxiety that the experiments should succeed. We think that fully qualified experts-members of the Society of American Magicians, for example-would leave Dr. Münsterberg here. These skeptical gentlemen would insist that the mother's code. was of such disingenuous simplicity that if she desired, for instance, to indicate to Beulah the figure 3 or the letter C, she would hold three fingers down or up where the child could see them, but where they would not be likely to attract the attention of the gaping audience. Perhaps American magicians are over cynical. Physicians, however, will prefer to agree with them rather than to allow themselves to be floored by the oft quoted remark of Hamlet to Horatio, "There are more things in Heaven and earth, etc." This bit of poetry is often cited as an argument, which it is not; and there are now fewer "things" of the kind referred to than there were in the reign of Elizabeth. We are willing to admit that Professor Münsterberg is perfectly correct in his diagnosis; but if he is thoroughly familiar with the works of Hoffman, Sachs, David Devant, and especially of David P. Abbott, we cannot help wondering how he can be as charitable as he is.

The Early Detection of Insanity.The astute Dr. F. G. Crookshank, of London,1 has pointed out that the asylum is not the best place in which to study the insane, just as a zoological garden is not best. adapted to study the nature of the polar bear. It is in his home or accustomed haunts that we must observe and scrutinize the victim of brain disorder. It is the general practitioner who has, although he sadly neglects it, the best opportunity of

'Essays and Clinical Studies, London, H. K. Lewis, 1911.

studying insanity, and if he is a skilled man he may have the good fortune to diagnose a case in its incipiency when there is the best hope of cure. The family doctor can best appraise the share which the routine of middle and working class life, the bitterness. of social trivialities and of daily worries, the absence of contact with anything either beautiful or noble, have in formulating insanity. . . . . "the deadly wheel of suburban routine, perhaps the most joyless and petty form of existence that there is." Proper stress must be laid upon the necessity for careful physical examination of all patients suspected of insanity and a visit to the dentist as a valuable aid in treatment. Dr. Crookshank points out, with the caution of an Englishman addressing the English, that an irregular sexual life is not very uncommon as a cause of insanity in middle age and begs the therapeutist to make sure, in ordering a change of scene and habits, that the patient is freed from the temptation to such irregularity and that his symptoms be not ascribed falsely to "overwork" as a sop to the relatives or even to the patient himself.

The conception of the mind as an entity is fading, as indeed it is high time it should, from the popular as well as the professional psychology and it is frankly to the student of the brain and nerves and their disorders that we now send the insane patient. At the bottom of all insane cases, or closely allied therewith, is some physical stigma, an irregularity of the pupil, some aural abnormality, which should inevitably reveal itself to the careful diagnostician and enable him to distinguish without fail the real insane case from one which, occuring in a normal patient, is due solely and simply to overstrain and will readily respond to treatment. Not that the insane cases taken

MEDICINE

Series

in their incipiency are at all hopeless; on the contrary, the great value of the early diagnosis by the family practitioner is that these insane patients can be treated with perfect success. If, on the other hand, their symptoms are allowed to proceed to such lengths as to become perfectly apparent to friends as well as relatives, there is grave danger of chronicity. In the great majority of cases it is best to remove the afflicted patient to a sanitarium, and never should a relative be allowed to act as nurse, for these cases demand the best of trained attendance at the hands of persons noted for self control and rigid obedience to the doctor's orders.

The lower mortality rates of women seem to prove the benefits of living at lower pressure than that forced on the breadwinner. The perils and drains of childbearing and rearing have been greatly exaggerated it appears and as women are not exposed to the worst of the dangerous trades they suffer from fewer accidents of all kinds. In spite of the tuberculosis following their indoor employments, it seems that the other factors to which men are exposed are worse and that this disease carries off more men than women. Indeed it is said that, in England at least, the mortality rates of females are less than those of males in every decade from birth to extreme old age. We are much afraid that this is carrying the matter a bit too far, as the figures would indicate that some women never die. That is, if 100 per cent. of males die, and fewer women die in every decade there must be some left over. As far as we know, it has always been a rule among fighting animals that the males have shorter lives than the females, and that if the males do not kill each other, something

an

else kills them. The amazing thing is the manner in which civilization has succeeded in eliminating the lethal factors, so that the two sexes are now so nearly on equality as to length of life. Those who are alarmed at their increasing risks and envy the women, may rest assured that the trend of events is in the opposite direction, and that in time sanitation and civilization will allow both sexes about equal chances of living into a worthless stage of demented senility. Why everyone wants to live that long is one of the things nobody knows.

The misuse of statistics is best illustrated by the remark imputed to Walter Bagehot, the mathematician:-"there are three degrees of deception, the positive or lies, the comparative or damned lies and the superlative or statistics." In the first place, a great blot on the medical profession has always been the manner in which we report and emphasize facts favorable to our works or theories, and minimize or actually suppress facts which prove us wrong. Sad experience has taught all older physicians to doubt figures published by partisans or opponents and to wait patiently until some judicially minded person takes up both sides carefully weighs the evidence and decides exactly what the facts do prove. No research work is possible without some definite aim and this necessitates some kind of a preliminary hypothesis based on what is already known. Minor discoveries are sometimes stumbled upon by men who have not even had their eyes open, but the great work of the world has been accomplished by idealists. It is only too true that a man with a theory can always find some facts to support it. The wonder is, that so many men are big enough to acknowledge adverse facts when found and then modify their