MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN AND IRELAND.
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President : Mr. F. Howard Marsh. Vice-Presidents : Dr. G. ’,Vivian Poore, Dr. D. B. Lees, Dr. H. A. Lediard, Mr. A. E.Barker, Mr. R. Clement Lucas, and Mr. H. H. Clutton.Treasurer : Dr. Frederick Taylor. Council: Mr. J. KingotonBarton, Dr. J. Mitchell Bruce, Dr. C. W. Chapman, Dr. LeeDickinson, Dr. S. H. Habershon, Dr. H. P. Hawkins, Dr.F. H. Hawkins, Dr. Percy Kidd, Dr. Hector Mackenzie, Dr.A. F. Voelcker, Mr. Gilbert Barling, Mr. Leonard A. Bidwell, iMr. Walter Edmunds, Mr. J. Hutchinson, jun., Mr. RaymondJohnson, Mr. John D. Malcolm, Mr. H. Betham Robinson,Mr. Charters J. Symonds, Mr. C. S. Wallace, and Mr. F. C.Wallis. Honorary secretaries : Mr. Anthony A. Bowlby andDr. William Pasteur.
HARVEIAN SOCIETY OF LONDON.
Exhibition of Cases and Specimens.A CLINICAL evening of this society was held on May 22nd,
Mr. WATSON CHEYNE, the President, being in the chair.The PRESIDENT showed a boy the subject of Congenital
Syphilis who had suffered from Necrosis of his Nasal Bonesand the bridge of whose nose Mr. Cheyne reproduced by theinjection of paraffin having a melting point of 120° F. at thefirst injection and 104° for the second, after a week’sinterval, Mr. Cheyne having read of an injection by anothersurgeon with paraffin having a melting point of 104°. Afterthe two injections the point of the nose, which had been helddown during the operation, remained depressed and a
presentable organ resulted. The operation was difficulton account of the rapid freezing of the paraffin im-
mediately it touched the tissues. One objection to the
parraffin at 104° was that it had a tendency to run intothe space between the eyes, above the bridge of the nose.No inflammatory reaction had followed the injection.Greater improvement was possible but the skin was at
present stretched to its limit.-Dr. LEONARD HILL thoughtcosmetic operations such as the present were justifiable,provided there was no risk of complications. He instancedseveral operations that had been done on the continent inwhich the paraffin had travelled into other parts sub-
sequently. In one case shown before a meeting of theBritish Medical Association the results were splendid,but later some of the material escaped into the eyelidsand 12 months after the operation the eyes were com-
pletely closed by the escaped wax.-The PRESIDENT,in reply, said that his injecting needle went practi-cally down to the remains of the nasal bones. He usedan ordinary serum syringe. The great point was to havethe hot water quite close to the patient’s face so thatthere was no time for the paraffin to cool. No pain wascomplained of during the injection.
Dr. A. MORISON showed a boy, aged 11 years, the subjectof Early Mitral Constriction showing the triple rhythm.The boy had acute rheumatism two years ago and hadhad two attacks of chorea. He showed the usual pheno-mena of an ordinary mitral case. He did not think the
triple rhythm could be regarded as diagnostic of the condi-tion. The triple rub could be originated in pericarditicconditions, and under those circumstances the second soundmight be spurious. Dr. Morison gave a review of the varioustheories held-namely by Sansom, Stacey Wilson, andothers-and stated that in his view the triple rhythm wasvery much a matter of rate. If a patient with mitral diseaseand a triple rhythm was sat up in bed and the pulse-ratethereby quickened the triple character of the beat vanished.When the patient lay down and the pulse-rate slowed therewas a quadruplication of sounds. He had verified that bysphygmographic tracings. In mitral cases one could some-times, by the help of digitalis, produce quadruplicationsimply by slowing the heart.-Dr. SUTHERLAND thought Dr.Morison’s theory plausible but it required carefully thinkingout. He would have thought that the irregularity would havebeen more pronounced when the pulse-rate was increased thanwhen it was slowed. He could only recall one case-that of awoman, aged 60 years, in which there was quadruplication ofthe heart sounds and in that case he thought the innervaticnof the heart was at fault. An important diagnostic point inhis view wa the duplication of the second sound. If Dr.Morison had a case of slightly accentuated first sound anddefinite reduplication of the second sound, would he be pre-pared to diagnose mitral stenosis fom those signs alone?His own view was that if those two signs were present thecase was very likely one of mitral stenosis. In his experience,
also, especially in children, the typical dilatation of themitral orifice was more likely to be accompanied by irregu-larity of the heart’s action than stenosis.-Dr. MoRisoxreplied.
Mr. JAFFREY read notes of a case of Torsion of theTesticle and showed the specimen. The text-books men-tioned that torsion of the testicle most frequently occurredin undescended testes but in the present case the testiclewas completely descended. The patient, an errand boy,aged 15 years, came to the hospital with an ordinaryhydrocele of the tunica vaginalis. The swelling was of thesize of a hen’s egg. When riding a bicycle he fell over thehandle and struck his hydrocele which caused him muchpain. A week later he again fell off his bicycle and struckthe same part, causing him extreme pain, which brought himto the hospital. Haematocele was diagnosed. On operatingMr. Jaffrey found no hasmatocele, the swelling being moreor less due to oedema of the scrotum. The testicle was
enlarged, very hard, and black. On careful examination itwas found that the testicle, instead of being attached to theposterior wall of the tunica vaginalis. had a mesentery of itsown attached at the lower end of the epididymis. It was
twisted three half-turns inwards. As it was a useless testiclehe removed it.
Dr. E. CAUTLEY showed a specimen of Congenital Hyper-trophic Stenosis of the Pylorus. He said that the disease wasrare and was but seldom diagnosed during life. Dr. Cautleyhad seen two cases when he read his paper before the RoyalMedical and Chirurgical Society three years ago and collected18 others. Since then about 50 cases had been recorded. Hebelieved the affection was commoner than was supposedbecause the present was the fifth which he had had under hisown observation. The infant was two months old, the ageat which such subjects usually died, and the stomach wasdecidedly large for that age. The pylorus, instead of beinga thin ring, was three-quarters of an inch long and consistedof dense muscular tissue. Before it was laid open it formed
a very definite tumour, in shape like the last joint of thelittle finger. From the stomach side it was funnel-shaped,the funnel being closed largely by a fold of mucous
membrane. After death the constriction was so pro-nounced that only a fine probe could be passed and no
fluid could be squeezed from the stomach through theorifice. The infant was apparently born healthy, at fullterm, and seemed normal. After a period varying from afew days to weeks the child started vomiting, but itwas a regurgitant vomit ; two or three meals would perhapsbe kept down and then a very large quantity would be
brought back. The appetite seemed unaffected. The tonguewas clean and might remain so throughout the whole illness.The breath was not sour. Constipation was often, but notinvariably, present and was often noticed at birth. Occa-
sionally there was diarrhoea. No bile was found in thevomit. Towards the last such infants got very marasmicand died practically from starvation.-Dr. SUTHERLAND, Dr.MORISON, and the PRESIDENT discussed the specimen.-Dr. CAUTLEY replied.
MEDICO-PSYCHOLOGICAL ASSOCIATIONOF GREAT BRITAIN AND IRELAND.
Sleep in relation to llccrcotics in the Treatment of MentalDiseases.-Surgical Treatment of Delusional Insanity.AN ordinary general meeting of this society was held on
May 21st, Dr. OscAR T. WOODS being in the chair.Dr. HENRY RAYNER read a paper entitled " Sleep in rela-
tion to Narcotics in the Treatment of Mental Diseases." He
pointed out the importance of the subject at the present.time, when so many narcotics were being introduced andsupplied to the public with little check or control. He ex-
pressed the opinion that a considerable portion of the nervou-and mental disorders of the well-to-do classes was due to theabuse of those drugs. He alluded to the various theories ofsleep and adduced arguments indicating the large sharewhich the body took in the production of sleep. Contrast-ing sleep and narcotic stupor, he described the psychic statein the former as one of unconsciousness without loss ofsensibility and the latter as unconsciousness with insensi-bility. Dr. Rayner said that the general physiological statein sleep was one of increased rather than decreasednutritional activity, while in narcotic conditions secre-
tion, excretion, and general nutritional repair were greatly
interfered with. The vaso-motor, respiratory, circula-tory, and other centres were depressed. The reparativeeffects of sleep on the brain cells, as described by Hodge and I.others, was contrasted with the evidences of disordered-nutrition found by Hamilton Wright, especially in the brain-cells of narcotised animals, corresponding to the psychiccells in man. The defects in insomnia, however caused,were summed up as consisting in defective nutrition of thebrain cells, variously associated with toxic conditions of theblood, with anasmia and hyperasmia of the brain andirritation of it, either from the body or from the environment.The question was asked whether narcotics could be shownto be curative of these states of disorder, or whether benefitcould be expected from their use, except in states of physicalor mental pain from irremoveable conditions in the environ-ment. Dr. Rayner arrived at the conclusion that in narcoticdoses any good resulting from their use must be in spite ofthe disorder of nutrition to which they gave rise, and ifgiven to produce sleep that object could be more satis-
tactoriiy attained by other remedial agencies, which helped.at the same time to restore the associated vascular andnutritional conditions. He believed the occasions for the useof narcotics were very few, and stated that for many years hehad rarely had occasion to use them. He hoped in a futurepaper to discuss the methods of treatment by which he had beenable to obviate the use of narcotics.-Dr. G. F. BLANDFORDsaid it was evident that Dr. Rayner had a great prejudiceagainst sedatives and narcotics of all kinds, but thatwas not his own view. He had been treating patients for 40years, many of whom had come to him in a state threateninginsanity, in which insomnia was a very marked feature ; andhe felt as certain as he could of anything that a greatnumber of those patients had been materially benefited bythe use of medicines given to induce sleep. Of course, suchmedicines could be abused and could be given until thatstate of insensibility had been produced to which Dr. Raynerreferred. But doses could be given which would have athoroughly therapeutic effect and produce a state which wasindistinguishable from natural sleep. But it was necessaryto select the drug suitable to the particular case. He wasconvinced that among the general body of the profession fartoo large doses of sedatives were given and that they werecontinued for too long a time. With so many drugs availablechloral was now much less used than formerly. One of thebest and safest was paraldehyde. At one. time the only drugavailable for acute mania was morphia, which did not sendthe patient to sleep, and if it were pressed death resultedfrom opium-poisoning, especially since the introduction of
hypodermic injection. There was the class of case wherethere was no danger of death from want of sleep and inwhich the giving of narcotics night after night prolonged thecase. In such cases it was better to give no drug at all.-Dr. G. H. SAVAGE said that the symptom which more than anyother he was consulted about was sleeplessness. Of course,if sleep could be obtained by natural means so muchthe better, but the cause of the sleeplessness must firstof all be ascertained. One heard much about anaemia ofthe brain but in many cases he was certain that a
nightcap of grog and a little food were more likely to pro-duce sleep than sedatives of the opium type. He agreed that Ithere were cases in which hydro-therapy was of the utmost (use-namely, those already loaded with toxic agents, thosewho had taken too much alcohol, or who were gouty. Forsuch patients a dose of calomel followed by saline waters andbaths would be of great value in inducing sleep and curingthe patient. It was a working axiom with him that in pain-ful conditions opiates and narcotics assisted in procuringsleep, especially in cases with mental pain. Though opiumgenerally upset the digestion the rest it procured was themeans of the digestion being improved. He had seen
IIextremely mischievous patients narcotised into dementia andon recovery from that get perfectly well. A morphinomaniaccould be given an ounce of bromide per day for several daysand be found to have recovered at the end of that time. Onecould say much the same of narcotics as of restraint. Inyears gone by his character was taken away because hedeclined to bow to the worship of non-restraint. It had beensaid of narcotics that they produced simply a form of lazi-ness-that the alienist thereby made a desert of the mind andcalled it peace. He agreed with Dr. Bland ford that in many cases narcotics were of the greatest benefit in warding offthreatened attacks of insanity.-Dr. FLETCHER BEACH saidthat his work lay more in nervous diseases than in actual ii-isanity. In nnny cases of neurasthenia and brain fag, unless I
sleep could be procured very little could be done in the wayof treatment. He practically always used sulphonal for thepurpose and he had not been able to find any evidences ofemaciation or any kind of indigestion likely to lead to emacia-tion. On the contrary, he believed it to be instrumentalin keeping up the weight of the patient. He thought thatit was wrong to give narcotics continually for weeks. He
thought it important for all the bodilv functions to be madeactive. In a case of hysterical mania he tried the effect ofhyoscine injections, beginning with one-two-hundredth grainand working up to one-seventieth, and in three weeks thepatient was cured.-Dr. T. B. HYSLOP said that it was im-portant to know what normal sleep was, not from the physio-logical or pathological points of view, but from the clinical.He referred to the investigations of Russian and Germanauthorities and the charts they had constructed, andspoke of the importance of distinguishing between restful
sleep and that produced through the agency of narcotics.He had always been a little doubtful about the experimentsof Hodge and the effects of fatigue upon the nerve cell ofsmall animals. He thought that the effect of an electriccurrent upon such a cell would be commensurate with theeffect of lightning upon an ordinary person ; and the amountof previous preparation of the cells was enough to make onesceptical about the results. He defended the practiceof physical restraint. The great point, which he hadverified by experiment, was that if one cut off thephysical expression of emotions one also cut off theemotions themselves. The questions of food and thefree action of the skin were important.-Dr. T. CLAYESHAW thought the discussion had taken an experi-ential form, whereas he had hoped to have heard morescientific facts about sleep. Very little was known abouteither sleep or narcotics. Sleep was either a nervous or avascular condition ; and where insomnia was connected withthe vascular state it was probably unwise to treat it bynarcotics. He suggested that in many cases of insanity thehighest functions were inactive, that those parts of the brainwere really at rest. In such cases was it not wise to abstainfrom poisoning the cerebral cortex with narcotics ?—Dr. R.PERCY SMITH referred to those violent cases which required.to be dealt with at once in the patient’s own home, of whichhe gave an instance. He thought Dr. Rayner would agreethat in such a case a sedative was required. With regard tosulphonal, at Bethlem Hospital he had found it to give rise insome cases to indigestion and haematoporphyrinuria. Somepatients could not sleep at nights and he thought that theyshould be allowed to sleep when they felt inclined. General
practitioners as a body did not yet realise that other drugswould produce sleep without the very bad effects of morphia.It was undesirable to continue narcotics without giving thepatient a chance to do without them.-Dr. ERNEST W.WHITE spoke of the importance of a regular round of eventsin asylum life as a factor in producing quiet nights. Hebelieved that there were many forms of melancholia inwhich morphia was the sheet-anchor. In acute maniahe had given up the exhibition of bromide and chloralfor many years ; the cases were taken for an hour or
two’s exercise and they gradually fell into line with theother patients and got to sleep without drugs.-Dr. J. S.BOLTON said that he had had considerable clinical and
pathological experience of sulphonal. Pathologically for everycase of haematoporphyrinuria he had seen 10 of haematopor-phyrinaemia. The prolonged use of sulphonal was most
pernicious from the point of view of auto-intoxication.
Clinically the drug was most valuable in early cases of
insanity, but in ordinary acute insanity with extreme rest-lessness and sleeplessness sulphonal, even in moderate doses.was injurious.-Dr. L. A. WEATHERLY spoke of the value ofcontinually renewed air in the induction of sleep as seen
in sanatoriums.-Dr. W. JULIUS MiCKLE thought that thechief necessity was that narcotics should be given withbrains-i.e., that the medical man should make a
careful estimate of each particular case before givingany drug. In most cases he would find that the patientdid not require a narcotic at all.-Dr. WOODS thoughtthat there were three stages or periods which requiredto be taken into consideration : (1) that before theonset of actual insanity : (2) acute insanity : and (3)chronic insanity. In the first class the judicious employ-ment of sedatives would do a great deal of good. In manycases the dose given was much too large. In cases ofinsanity with a great deal of motor excitement in whichexhaustion rapidly ensued it was necessary to produce sleep
by means of sedatives but they should not be continued toolong. He laid great stress upon diet and hygienic measuresin the third class and feared that sedatives were administeredmuch too freely.-Dr. RAYNER briefly replied. He said thatif the injunction to use one’s brains were obeyed the practi-tioner would rarely wish to use a narcotic. The necessityto give a narcotic to avoid alarming the household wasquite apart from its curative merits. He agreed withthe use of narcotics in cases of bodily pain. In’all cases
one should try to get rid of the cause of the sleeplessness.Altogether the speakers seemed to be in fair agreementwith him.
Dr. T. CLAYE SHAW read a paper entitled, The SurgicalTreatment of Delusional Insanity, based upon its Physio-logical Study." He said that it was often necessary to arguefrom effect to cause on account of want of knowledge ofthe details of the machinery. He proceeded to argue as towhat might be supposed to be the physical conditions of apsychic content and from this to draw conclusions as to theprobability of there existing a system of ’’ local signature"
in the brain in completion of Kulke’s theory of specificqualitative colouring. The difficulties under which they atpresent laboured in treating directly localised lesions in thebrain were referred to, and it was suggested that attemptsshould always be made to trace in which centres they for themost part arose. The importance of localisation was insistedupon and it was argued that if this could be perfected theproper plan was to deal with the disorder surgically, so asto have immediate access to the seat of disturbance-a method attended by little danger and likely to affordvaluable results as to progress and ultimate cure.-Dr.HYSLOP referred to his investigations on the same subjectand thought that the time was far distant when surgery couldbe employed with success in the class of cases referred to.-Mr. C. B. LocKWOOD said the patients he had operated uponfor Dr. Claye Shaw were, in his opinion, proper subjects, andwhere there was a chance of relieving patients from intensepain by surgery it should be done. He gave details of some
very successful cases so treated.-Dr. CLAYE SHAW brieflyreplied.
ROYAL ACADEMY OF MEDICINE INIRELAND.
SECTION OF SURGERY.
Intestinal Resection.-Perforated Gastric Ulcer.-Exhibitionof Cases and a Specimen.
A MEETING of this section was held on May 9th, Mr.THOMAS MYLES, the President, being in the chair.
Mr. R. LANE JOYNT read a paper on a Successful Case ofDouble Resection of the Intestine for Injury. The patientwas a youth, aged 16 years, who had been struck in theabdomen by the shaft of a van. He was taken to theMeath Hospital, Dublin, and laparotomy was performed. A
portion of the jejunum was found to be torn from its
mesentery. The bowel above was severed from the lastportion of the duodenum. The rents in the mesenteryextended deeply to its roots. The injured bowel, 22inches in length, was removed, and end-to-end anastomosiswas effected by a Murphy’s button. The transverse meso-colon was also torn through and only a tube of intestinalmucous membrane over one inch in length stripped of itsperitoneal and muscular coats was left connecting the colon.This was excised and a second end-to-end anastomosis waseffected with sutures by Cheatle’s method. The button was
passed on the seventeenth day and recovery was perfect; nodisturbance of nutrition had followed. Surgeons were at somedisadvantage from want of practice in suturing bowels. Thedifficulty was to get bowels to suture, for the intestines inthe cadaver were so wholly unlike those in the living subjectthat they were of no use for the purpose. He intendedto try the suturing on the carcasses of pigs. The Cheatlesuture he found easy to use and capable of being rapidlyexecuted. It had the great advantage that in its applicationthe bowel was not mauled.-The PRESIDENT said that he
agreed with Mr. Joynt as to the inadvisability of using aMurphy’s button in the operation on the large bowel, especi-ally as one had been used to connect the surgical woundsurfaces in the small bowel. The Murphy’s button, beingliberated earlier in the small intestine, would very probablyocclude the Murphy’s button in the colon. Suturing the
bowel had the great advantage of being free from the risk ofocclusion ; the surgeon was not kept for 17 or 18 days in a.state of anxiety waiting for the passing of the button, andwith a little practice the bowel could be sutured almost as.quickly as the button could be fixed in position. He was mucbimpressed with the fact that the boy was kept for some days.without food. Abdominal operations had taught surgeons.that food might be safely withheld from patients for some.days. In this case delirium supervened but was quicklysubdued by the giving of some nourishment.—Mr. L. H.ORMSBY said that when he came to assist Mr. Joynt the case-looked hopeless. The operation took two hours to perform.He saw the boy a few days since and found him lookingstrong and well.-Mr. J. P. DOYLE, Mr. A. J. McA. BLANEY,Mr. JOHN LENTAIGNE, and Dr. A. R. PARSONS also discussed;the case.
Mr. BLANEY read a paper on two cases of PerforatedGastric Ulcer. The first patient, a female, aged 24 years, wasoperated on 21 hours after the occurrence of perforation. Theaperture, situated on the anterior surface near the pylorus,was readily found and sutured. The abdomen was flushed,out and was closed without drainage. The patient did wellfor the first six days’ but her temperature then rose andeventually she died from general peritonitis due to the
bursting of a localised abscess into the general peritonealcavity. The second patient, a female, aged 21 years, was.operated on 19 hours after the perforation took place. Theulcer was found on the anterior surface near the cardiacend and lesser curvature. There was a great amount ofsurrounding induration, rendering the application of sutures.very difficult. On the eighth day a slight rise of temperaturetook place ; the fever continued, and on the eleventh day the’wound was reopened and a large perisplenic abscess was dis-closed. This was drained through the ninth intercostal space,a portion of the anterior wound being packed with gauze.The temperature did not subside for a considerable time.Eventually both wounds healed and all stomach symptoms.disappeared, but another abscess formed under the scar anc1it was opened more than two months after the originaloperation. The patient took raisin tea as it was desirableto avoid the use of proteids in such cases. She was nowquite well. .
Mr. D. KENNEDY exhibited (1) a case of Excision of the-Shoulder for Necrosis of the Humerus and (2) a case ofCongenital Dislocation (Sub-spinous) of both Shoulder-joints,with skiagram.
Mr. LENTAIGNE exhibited a case of Tuberculous Disease.of the Ankle-joint, with extensive Disease of the Tibia,Astragalus and Os Calcis, cured by raclage. The patienthad been already exhibited on March 30th, 1900, and was,again exhibited by special request.
Mr. W. TAYLOR exhibited a Prostate removed by the.
SOCIETY FOR THE STUDY OF DISEASE IN CHILDREN..-A meeting of this society was held on May 16th, Dr.W. A. Wills being in the chair.-Dr. James Taylor showed(1) a case of Paroxysmal Hasmoglobinuria in a child whc,had suffered from Syphilitic Ulceration of the Palate Yand (2) a case of Raynaud’s Disease in a boy who had lostthe Terminal Phalanges of several Fingers and in whoseurine oxalates were present in abundance.-Mr. Herbert L.Carre-Smith showed a case of Sporadic Cretinism that hadbeen under treatment for four years with thyroid extract.The mental and physical condition had greatly improved, buta relapse was experienced as soon as the treatment wasomitted.-Mr. A. Bruce Roxburgh showed a child with a,
fatty growth occupying the left side of the perineum andscrotum. The testicle lay in the perineum and a hydro-cele of the tunica vaginalis was present. The enlarge-ment was noticed a few months after birth.-Dr. J. PorterParkinson showed two instances in the same family of a,
curious congenital depression of the frontal and parietalbones on one side of the cranium. The children, aged)respectively 11 months and two years and a quarter,seemed to be intelligent and had never suffered from fits.There were no other evidences of maldevelopment.—Mr.E. W. Clapham alluded to a similar case shown by him before-the Clinical Society of London last year.-Mr. SydneyStephenson showed a case of Keratomalacia in an emaciatedinfant of the age of seven months who was suffering fromtuberculosis, probably of the disseminated variety. Thedisease already had led to complete destruction of one eye.In the remaining eye the corneal ulceration had healed witb