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Objectives To assign an accurate diagnosis to patients with dystonia based on the presence of sustained levodopa responsiveness and to determine whether motor fluctuations occur in patients with dystonia who are withheld from levodopa. Patients and Methods Patients with generalized dystonia who responded to treatment in the 1970s with levodopa/carbidopa were surveyed by phone and then examined during a 3-day levodopa holiday. Functional imaging with fluorodopa positron emission tomography was performed on a subset of patients. Results In the phone interview, 4 of 7 patients with a diagnosis of dopa-responsive dystonia reported the wearing-off effect a short while (within 4-8 hours) after missing a dose of levodopa. Five patients with dopa-responsive dystonia were examined repetitively during levodopa withdrawal, and 3 developed recurrent symptoms of dystonia as the drug was withheld. In each case, worsening of dystonia did not occur until 29 hours or more after levodopa withdrawal, providing evidence for a response profile similar to the long duration response described in Parkinson disease. No significant changes were seen in the dystonia scores of the 3 patients with idiopathic torsion dystonia who were withheld from levodopa. Conclusions We suggest that the subjective feeling of wearing off experienced by our patients with dopa-responsive dystonia may have been for one of the non–motor effects of levodopa, such as mood elevation. Our data provide objective evidence for the often-repeated assertion that motor fluctuations (analogous to those in levodopa-treated patients with Parkinson disease) do not occur in patients with dopa-responsive dystonia.

To the Editor: —In the article on "The Tools of Our Trade," by F. X. Dercum (The Journal, March 13, 1915, p. 878), a view is expressed regarding the "continued warm bath" in treatment of psychoses which does not represent the correct attitude, as I think, toward this means of treatment. Dr. Dercum remarks that "the continued warm bath is also a form of restraint." This is not the opinion or the usage of all. Since 1909, when I observed the Dauerbader as given at Kraepelin's clinic at Munich, where I took the "Fortbildungskursus," I have employed it as a method of treatment only when the patient was entirely willing. Previously I had occasionally used mild compulsion with it. I asked Kraepelin if he ever used compulsion. He replied that he did not—only persuasion, requesting the patient to get in and allowing him to get in and out as he

INTRODUCTION. The case of X. merits study from several points of view: First, with reference to diagnosis owing to the conflicting opinions expressed by experts during the patient's lifetime, as to the form of mental disease; also in a medicolegal sense, on account of the great number and variety of legal contests growing out of the patient's mental condition, in which he himself actively and often brilliantly participated. The case also incidentally involves the study of a remarkable personality, and the clinical history consists largely in the narration of extraordinary acts, "antics" and vagaries of a mad but acute and brilliant mind. Finally the findings resulting from the examination of the brain present much of interest in both a positive and negative sense. The following statement of the case has been prepared from personal observation of the patient when under my care in the State Hospital

When I came recently to consider attentively the subject assigned me in this discussion, I was so doubtful as to the production of anything of value that I asked the chairman to excuse me, but as both the present chairman and the chairman of last year renewed their request. I have complied with their wishes as well as possible. When one attempts to lay down the lines upon which the subject should be treated, several questions arise which require to be first taken into consideration. One is the evidence of syphilis. Another, the very frequent existence in these cases of causes other than syphilis which have their share in determining the mental state-such as alcoholism; senile changes; arterial disease; kidney and heart disease and tumors, of non-specific origin. If the rule were made and followed of first catching your specific lesion and then excluding alcoholism and non-specific vascular changes, etc.

• In this series of 21 patients with hemiballism-hemichorea we found an identifiable cause in all. Unlike most other studies in which stroke was the most important cause of the movement disorder, in almost half (10 of 21) of our patients some other cause was found. Hemiballismhemichorea was often the presenting feature of underlying medical disease. Besides the subthalamic nucleus, other subcortical structures may be involved in the pathogenesis of this hemihyperkinesia. While the movement disorder often improves spontaneously or with pharmacologic therapy, the underlying disease may result in serious consequences.

Prairie dogs were fed a 1.2% cholesterol diet for up to 24 weeks to evaluate the effects of lithogenic bile on the mucosa of the gallbladder. There was a progressive increase in the lithogenic index of the gallbladder bile (1.44 +/- 0.15 at 4 weeks, p less than 0.05). Fifty-five of 70 animals developed gallstones between the second and fourth week. Increasing stone burden was associated with a 27% (p less than 0.05) decrease in the electrical resistance of the epithelium and a 60% (p less than 0.05) decrease in net sodium transport when measured isotopically in an Ussing chamber (3 weeks). After 4 months, seven of ten animals developed inflammatory mucosal polyps characterized by a heavy infiltration of plasma cells into an expanded matrix. Cellular infiltration began as early as 2 weeks. These changes occurred without alterations in the ultrastructural appearance of the epithelium.

The development of institutions for nervous and mental maladies forms no exception to the rule that increased complexity (and perplexity) follows the process of finer adaptation to the requirements of advancing medical science and social evolution. Change and growth are so rapid that the conservatism which necessarily characterizes all institutions, keeps them lagging behind in the advances of the day in the art and science of both neurology and psychiatry. It is not necessary to prove in this audience that there is in our own time a very great increase of nervous diseases, both in variety of forms and in the number of sufferers. The same is also true of mental diseases, and hence the subject of provision for patients of this class is a pressing one in all our communities. In this paper I seek to consider only hospital treatment largely for recent and curable cases. Thus far it

Wauwatosa, Wis., July 13, 1899. To the Editor. —Your journal does me an injustice in reporting a paper (Journal, xxxii, p. 105) read by me on "Contagion and Infection in Nervous and Mental Diseases," at the late meeting of the American Medico-Psychological Association in New York. Your words are, "Incidentally he advocated the somewhat radical measure of judicially ending the lives of the hopelessly insane." It would scarcely be necessary to explain that this was an error to those versed in these matters, but as many readers may be misled, I wish to say that in my paper I proposed to inquire whether various radical measures frequently advocated, among them electrocution for incurable insane, castration, etc., were practicable measures and the conclusion at which I arrived, distinctly given in my paper, was that such measures were not practicable. Please make this correction and oblige, Yours truly

To the Editor: —The Fortbildungs or "extension" course in psychiatry given at the University of Munich, Bavaria, is unequaled in its advantages for men interested in this branch. At the head of it is Professor Kraepelin, who was induced to come from Heidelberg to Munich by a carte blanche offer of an opportunity to have ideal conditions created. The "klinik" was built and equipped to meet his views and in construction and arrangement, both for treating insanity and teaching psychiatry, is without a rival. Alzheimer, one of the foremost brain histologists, teaches his subject not only in a complete but in a fascinating manner. Liepman, of Berlin, gave this year a course on "Aphasia, Apraxia and Agnosia," illuminating this difficult subject by the clear presentation of principles and of the findings in a most remarkable series of cases, both ante-mortem and post-mortem. He seems to have gone a step farther

The temptation to mark out new lines in the field of psychiatry is one that assails all who write on this many-sided subject, and every writer yields to it, the difference being mainly in the completeness of the surrender. One must classify indeed to write at all, and classification is an alluring and agreeable exercise. Yet I shall indulge in it only to a very limited extent, even though there are few barriers as yet erected in the neuronic territory to keep us from wandering at will. Classifications have, furthermore, contributed much to neurologic and psychologic gaiety, which, in itself, is perhaps a good thing. With all possible respect, one may liken the classifications to a flock of geese, each one of which, however, is to its particular proprietor, a beautiful swan. Beside the enjoyment to be gotten out of classifications, there is a more substantial good. Doubtless each

To the Editor: —Apropos of the recent circular letter of the Secretary of the Navy to the commanding officers, in which that official refuses to authorize the issue of the "preventive or prophylactic packet" to the sailors on our war ships, I wish to inquire whether it is not possible to change the method of furnishing this packet so that the responsibility for its use would be squarely placed where it belongs-wholly on the men who use it? I grant that it is questionable whether the government should countenance immorality by providing against the consequences thereof. At the same time if the use of this packet is discontinued, this discontinuance will indubitably have as a practical result a greater incidence of disease. On the other hand its use, as is well known, has resulted and would continue to result in conserving health and effecting a considerable economy. It is manifest

To the Editor: —Just after reading in your issue of July 24, page 269, "A Display of Fakirism," I chanced to read in L'Illustration of July 3 a short article on "La supercherie [humbug] du fakirisme." This article, by a French scientist, M. Paul Heuze, described the demonstration before a body of scientists and journalists in Paris of some of the same acts exhibited by "Dr. Tahra Bey," who had hat pins thrust through his cheeks and across his throat, apparently through the larynx, and who also reclined on the points of nails. Dr. Heuze insisted that there was no anesthesia in his case. He did not swallow his tongue, go into a cataleptic state or have weights put on. These phenomena, including apparent death, burial and resurrection, are discussed in one of Robert Louis Stevenson's novels.

To the Editor: —In a note inThe Journal(July 28, 1917, p. 290) Sir William Osler warns examiners of recruits against certain defects which will render men unfit for service in the field, and mentions "the neurasthenic." This reminds me of facts also worthy of recognition in connection with the examination of recruits which deserve to supplement in a measure the caution given by Dr. Osler. A certain number of men of unstable brain and nervous system will present themselves who, while all surface indications seem favorable, still are especially apt, whenever brought under severe or strenuous conditions, to suffer a breakdown or collapse of brain and nervous system. Many of the neurasthenics mentioned by Dr. Osler are also "psychasthenics." By this I mean persons lacking in power of adaptation to severe external conditions, such as necessarily occur in connection with active military service. It is especially important to

This paper is suggested by the experience I have had in seeing a large number of cases in which travel or change of scene has been employed without resulting in benefit, or with apparent injury; also, to a less extent, in seeing patients improve or recover for whom travel had been recommended after they had received all the benefit they could be given by home, hospital or sanitarium treatment. Other patients have been observed who were incurable from the start, e. g., victims of paresis, who were sent traveling with the fallacious hope of benefit or palliation—in some cases the disease not being recognized—with useless trouble and sometimes disastrous results—explosion of maniacal excitement in public places, death in a foreign land or other distressing occurrences. Again, I have encountered cases of melancholia with suicidal impulses, or patients with delusions of persecution, who have made suicidal or homicidal attempts while traveling

In the latter half of the nineteenth century, many problems connected with the public care of the insane presented themselves for solution which developed conflicting views. Some of these questions were: the advisability of separate provision for the acute and chronic classess; the extent to which mechanical restraint was necessary or admissible; the need of establishing laboratories for psychopathologic research, of instituting training schools for attendants, of broadening and diversifying industries among the inmates and of increasing their privileges, and even of maintaining in some instances "open" instead of locked doors. Among all the questions, however, that which for a time took precedence of others concerned the introduction of a new type and style of building — the substition of modern "segregated" or "detached" buildings, domestic in style, for the antiquated "congregate" structures previously in universal use. This paper is intended, among other things, to describe the new departure in