An event which might cause momentary anxiety to one individual may cause profound dread to another, and hence it is very difficult to state categorically that such and such an event could not possibly have led to the death of an individual. The emotions act very differently in different persons, and again in the same person they act dissimilarly at different times. A healthy woman who was brushing her teeth accidentally swallowed a mouthful of harmless mouth-wash, and died from fright, under the belief that it was poisonous. The bursting into her bedroom in the middle of the night by an insane Irishman in a state of nudity caused the death of a healthy woman of 48 years. 

A vigorous and very restless man had been seized, more than three days before I saw him, with acute pain and vomiting. The vomiting was copious and persistent. I was shown several basins and pots, some in one room some in another, all containing the usual brown fluid. This man had walked from one room to the other, so that practically he had never been at rest. One might be inclined to criticize the action of his medical adviser in allowing the patient to have so much of his own way; in this, to my thinking, lay his wisdom. The doctor was a man with a sense of humour, and realizing that only the use of sedatives would keep his patient quiet, he instead wisely let him have his way, while keeping a close watch on the symptoms.

Complete and incomplete fractures of the upper end of the humerus are more frequently associated with the dislocation than was ever realised before X-rays threw light on a problem which had caused much argument, doubt, and disbelief in the mind of surgeons who were authorities in the old school. In these very serious cases I wish to repeat again that the foot-in-the-axilla method gives a better chance to reduce dislocation than any other method.

Presuming a man has had syphilis, and, so far as modern methods indicate, has recovered and is free from taint and the risk of contaminating his wife or progeny, even in such a case, many medical doctors would hesitate, or even object, to sanction his marriage with a girl in whom they were closely interested. Yet, I think, to demand this altruistic code is outside the medical man’s jurisdiction. I know both men and women to whom the door of matrimony is closed for ever by an innocent kiss, if syphilis is to establish a permanent barrier.

Mrs A. was a stout lady, about 45, who was the mother of a family of twenty, all alive. Her husband had met with some business reverses, and they had to give up their house in London. She stated her present condition came on gradually until she lost power of her lower extremities. In reply to my question, if there and then taken out of bed what did she think would happen, she said if she attempted to stand, her legs would give way and she would collapse on the floor. In every other way she was healthy. On examination, there was no atrophy or rigidity of the muscles; the knee-jerks, though faint, were present. Sensation was, as well as I can remember, not affected.

Massage stands foremost  in the forms of physio-therapeutic treatments that can be brought to the patient at his place or business. It is possible in most cases to give sufficient relief to allow the patient to work. This will enable him to cope with pressing business, or tide him over a particularly busy period.

One seats oneself at the side of the bed, and if the child is asleep so much the better. Slipping the warm hand under the bedclothes, one lays it on the abdomen of the child, and waits. Quite often without doing anything else the tumour will be felt to harden, and the diagnosis is made then and there. If no peristalsis is felt, slight movements should be made with the fingers to induce it, when it can at once be felt.

Too often one finds that a doctor has been in attendance for some weeks without having made any attempt to examine the bowel, with the result that some gross error in diagnosis has been made. The patient naturally resents such maltreatment when he discovers, as he must do, that the condition might have been found much earlier. 

The busy general practitioner, who must read as he runs, has to take patients as he finds them, and do the best he can for all who come before him. Educating the patient so that he may recover quickly, and avoid his favourite pitfall, and make the most of himself as a healthy human being, is within the physician’s province, but more time and a new system of medical service would be necessary to give it full effect.

I remember when there was considerable discussion whether the child or the mother should be sacrificed. It is not necessary to sacrifice either of them today, because a Caesarean operation will almost certainly save them both. If the child is alive, it should be a practical certainty to deliver it alive, and I am confident that the risk to the mother is considerably less than it is after craniotomy. Some say that if the child is dead, a craniotomy should be performed. I consider that it is sometimes difficult to decide that the child is dead. It is no easy matter to auscultate the foetal heart even under favourable circumstances, and in the bustle of a confinement I should hesitate to express a positive opinion that it had cease to beat. Even when the child is known to be dead, I should prefer a Caesarean section as being less dangerous for the mother. Such an operation as craniotomy should never be resorted to in these days.

Morbid anxiety, like true anxiety, is often a defence mechanism, for if a patient ignores the warning of his phobia, he would soon find himself in a much worse mental state as a result of his temerity. So may an organically determined anxiety-state act as a defensive measure. A painter and decorator, 55 years of age, had been troubled for six months by a phobia of ascending ladders, the mere thought of having to do so brought on an acute anxiety-state. His occupation suggested a reason: paint; so arteriosclerosis due to the lead in paint, so giddiness. The suspicion was justified, for he was found to have markedly thickened and tortuous arteries. He admitted that for two years past he had been subject to transitory attacks of giddiness, especially as might be expected, after the effort of climbing a ladder and had several times feared that he might fall from the scaffolding. It would appear that the phobia prevented him from putting himself in a position of danger.

The following are typical cases of high blood pressure that if one was to go on what one observed at the primary interview, a grave error in prognosis must inevitably result. ..... One patient, aged 39, was seen last year. She  complained mostly of headaches, easy fatigue and shortness of breath. Pressure 160 for some time. Through lack of servants during the war, the strain of many air-raids, much pain from severe haemorrhoids, and a good deal of worry, this patient was nervously exhausted. The piles were removed, and the patient had three months’ rest in a nursing home. From that time the blood pressure has never risen above 130.

A doctor’s wife had fluid in her chest. She was seen by another doctor in the same town, who aspirated her chest and did not notice whether the fluid contained albumen. Fearing that it was a tuberculous case, he sent her away for six months. She was not benefited. She passed through London on her way back – and I was asked to see her. I put a needle into the chest and aspirated fluid containing no albumen. She was operated on, and hydatids were evacuated from the chest. Unfortunately, just after the operation, a yellow fog set in over London, lasting three or four days, and that killed her. Nevertheless, if we had known six months earlier that the fluid was hydatid, and not tuberculous, it is quite likely that the woman’s life would have been saved.

The importance of this fact of rejuvenation of the womb is the bearing it has on the question of sterility. No case of sterility should be regarded as hopeless until electrical treatment has failed. In 1915, I was able to bring about pregnancy in a woman of over 30, who had considered it was a hopeless impossibility. She had always remembered profuse and painful periods; and the first sign of improvement after 12 treatments was the occurrence of a painless period – the first painless flow she had experienced for over 14 years.

MISTAKES MAY BE CLASSIFIED under two headings: trivial errors made by ourselves, and glaring blunders made by other people. This second article in my series continues to highlight the mistakes of other people.

Ten and a half years ago I saw in consultation a lady of 62 years of age. Blood pressure, 195 mm.Hg. She had obvious shortness of breath, even when lying in bed. The heart was considerably enlarged, the rhythm tick-tack. She had persistent headaches and there was a mild grade of cyanosis. The vessels were degenerate, and she was sleepless and depressed. As onerous duties devolved on her, I was pressed by the relatives for a definite opinion on the outlook. I gave it as an opinion that, at the rate she was deteriorating, the chances were that she would not survive for more that a year. That was in 1909, and I still have the pleasure of seeing her now in 1921.

It is not rare to see a confirmed belief, or a vague dread of impotence develop in men who are about to marry. It may occur in those who have masturbated in early life, or who have been subject to frequent seminal emissions, or any form of previous venereal disease may give rise to it. The fear or idea at first worries, then depresses, and thus alone or combined, as it frequently is, with an undue exaggeration of the responsibilities of the step to be taken, may produce a definite neurasthenic state. In others, the dread of impotence leads to delusions of non-existent disease, and thus produces a state of hypochondria, from which a neurasthenia may develop later. It is these hypochondriacal cases – but the same may occur in neurasthenia that develops along the same lines – that become so depressed and feel so incapable of the duties they are about to undertake, that either commit suicide or abscond on the eve of marriage.

A middle-aged stockbroker had been told by a ‘specialist’ that the pains in the feet of which he complained were caused by chronic gout. He was put on a strict diet, but, being fond of the pleasures of the table, did not take kindly to the treatment, especially as he found that it did him no good. One day, however, when ordering a pair of new boots, he complained bitterly to his bootmaker of the pains, and of the disagreeable treatment he was undergoing for them. The bootmaker promised to cure him by introducing instep supports, which he did with complete success. The patient’s sarcasms on ‘gout specialists’ afterwards were amusing but, to a doctor, humiliating hearing.

Leyden and Mauneyne have reported two cases of cancer of the stomach in doctors, one of whom swallowed vomited matter from a cancer patient by mistake, and died of cancer of the stomach, and the other did the same thing voluntarily in order to show that cancer was not contagious, and promptly developed cancer. 

MISTAKES MAY BE CLASSIFIED under two headings: trivial errors made by ourselves, and glaring blunders made by other people. The following examples belong to the latter class and have all come under the personal observation of the writer.

It was now about 7 a.m. there was a sweet shop next door, and it was shuttlecock season. I went in and bought a wooden battledore, sawed off the end, hollowed it out with a knife, cut down the sides to the right width, placed it on the woman’s teeth, which were, fortunately, pretty sound, kept it there firmly by pressing the palm of my right hand under the chin, put the end of the handle on my left shoulder, grasped the middle with my left hand, and was delighted to find that I had leverage enough and to spare for easy replacement.

M.B., 22, had suffered from trench feet in January, 1916, for which he had been in hospital for six months. He applied for treatment last summer on account of pain in his feet describing his condition as if he were “walking on hot plates.” The pain would generally last for half an hour to four hours, though occasionally it might be present for a whole day. After a few séances of percussion of the seventh cervical spine, complete freedom from discomfort ensued.

Let me quote a case which I take to be one of an habitual high range of arterial pressure very well borne, but upon which any accession of tension is hazardous. A gentleman of splendid physique, aged 74, height 6 ft 3 in, weight 17 stone, of calm temperament, a soldier and a sportsman in the past, has been under my observation for some fifteen years. His average health has been excellent. He has presented slight gouty symptoms from time to time, but the kidneys are healthy. He suffers occasional giddiness when walking or turning quickly in bed. There  is some naso-pharyngeal catarrh which is liable to extend to the larger bronchial tubes. For the past eight years his blood pressure has been observed to be high; 180, 200, 170 and 160 as the lowest maximum with diastolic 90-100. The pulse ranges 72-80.The vessels are good, the gums are sound.

Hope is the greatest motive power in the world. As a strong moral force alike in matters temporal and spiritual, it would be strange if such a powerful incentive to action did not find its place in the practice of medicine.  It is a good rule never to “give up” on a patient; exceptions will occur no doubt in this as with most rules. To give up hope is to give up effort, and it is here the tragedy comes in. Cases illustrating the value of a “never give up hope” attitude crowd on the memory. Of course the most sanguine and persevering must expect failure at times, but he will have the satisfaction of having had a good try.

Doctors have done little to discourage the entry of the unskilled into becoming practitioners of psychoanalysis, a field which belongs to the trained physician. Unqualified practitioners abound both here and in America. Some medical men have encouraged lay efforts and are apt to express contempt for those who believe that mental ills may supervene on physical infirmities, or may be but evidence of a disorganized function.

The pandemic of influenza that has during the last 12 months swept over the world started in China or Russia, where it is endemic, became epidemic, spreading to neighbouring countries along the ordinary channels of human intercourse, and from persons to persons, and finally took on pandemic proportions, passing over the whole world. The seriousness of the disease is shown by the mortality returns, which were  enormously increased everywhere.

The case gave rise to some suspicion, it was referred to a medical man, who fearlessly  reported that the case was one of malingering; but his opinion was not acted upon, and A.E. for many months was paid compensation for right-sided “drop-wrist”. He appears to have been no mean actor, for whilst he simulated paralysis of the right wrist so well as to obtain weekly certificates of incapacity, he was actually engaged in giving performances as a professional strong man. Every night at a music hall, clad only in gorgeous harness, he lifted enormous weights. One of his demonstrations consisted in stiffening the muscles of the right forearm and wrist, and breaking with his right hand a thick strap which passed diagonally over from his right shoulder to his left hip!

A CHILD OF EIGHT once said to me: “I like going to sleep, because I dream, and when I dream I can be as naughty as I like without being punished.” That, indeed, contains the whole essence of the dream science.  In our dreams we are as naughty as our primitive self desires to be; we get what we want and  hang the consequences, but the moral censor within us insists on camouflage, and the dream as it presents itself to our consciousness is but an anaemic representative  of the full-blooded wish which inspired it.

MANY WORKING MEN adopt a line of conduct which seems to necessitate their being branded as malingerers; but so to characterize them should never be done only when prepared with incontestable evidence of fraud.  However confident you are that the plaintiff is grossly exaggerating, is untruthful, and is attempting to deceive the Court, it is unwise to allege malingering unless it can be proved up to the hilt. Nothing pleases the plaintiff’s counsel better than for a medical witness to use the word malingerer, for he knows that he can then appeal to the class prejudice of the jury.

WOMEN FORM an important element in the new electorate, and are already beginning to take an increasing interest in the administrative activities of local authorities in connection with maternity and child welfare. Medical services should be readily available for all needing them, and not confined, as at present, to insured persons, to persons under the poor law, and to mothers and children under local schemes and to children of school age under educational authorities. In other words, every person should have the right to command the best medical services throughout his or her life, including expert and consultative facilities, institutional treatment, and, of course nursing advantages.

TO APPRECIATE TO THE FULL his recovery, a few observations on his condition on arrival are noteworthy. He was a most pitiable sight. The stretcher on which he had travelled was saturated with urine, which, during the journey from France, had been extravasating over his abdomen from the still open bladder wound. Thin and emaciated, the boy was obviously very ill from septic absorption, and the want of mental as well as of bodily rest was aggravating the miseries of his condition. On examination of the abdomen, there was an unhealthy, lacerated, saucer-like wound about 4 inches in diameter, just above the symphysis pubis, and in its lower quadrant was an opening into the bladder, through which thick, foul-smelling urine was flowing over the abdomen. The skin of the abdomen, especially around the wound area, was excoriated and septic from the constant chafing of urine-sodden masses of dressing. The catheter had been given up at an early date. The urine itself was thick with pus, phosphates, and mucus.

BY WHAT AMOUNTED TO the accidental cure of a profound anxiety neurosis, my attention was directed, or rather redirected, from the use of suggestion in treatment to the great importance of carefully examining the emotional history in this condition; and it appeared worth while to test, in a series of cases, the result of reducing the suggestive factor to a minimum, and to rely solely upon the simple expedient of going through each detail of the patient’s war history.

IN JANUARY 1907, I contributed  an article to the Special Influenza Number of The Practitioner. In 1919 it must be admitted that for actual control over influenza we are practically no further advanced than in 1907. Nor are we much further advanced in our knowledge of the bacteriology of influenza. We have no knowledge whether the pandemics of the past mean the excitation in microbes always with us, or increased pathogenicity and greater striking-power, or the introduction of an equally mysterious virus from some unknown centre or centres.

About this time, it occurred to me that in children enuresis often ceases spontaneously about puberty – i.e., among other things coincidentally in the development of the prostate. I determined to stimulate this organ electrically in incontinent young men and chose a high-frequency condenser electrode for the purpose. It consisted of a small test tube, filled with water, and corked. Through the cork was thrust a stiff wire, having a loop on the outside for attachment to the lead from the solenoid. The test tube was vaselined and introduced about 2 to 3 inches into the rectum. It was then connected with the generator, and the high-frequency current turned on for 15 minutes. The treatment was given daily. An improvement in results was very soon evident. Cures rose from 25 to 60 per cent

Before man learnt to till the soil his supply of pure sugar was limited to wild honey. Now he extracts thousands of tons from artificially grown sugar-cane and beet. The consumption of sugar has within recent times increased enormously in our country, and many people eat much more than is good for them

The general practitioner  is often puzzled to know how to deal with a case in which suicide is frequently threatened,  but, provided his diagnosis of an anxiety neurosis is correct, it is probably better to treat these cases by psychotherapeutic methods, and take the slight risk of suicide than adopt such a course as warning and consequently scaring the relatives, or advising a constant attendant or admission to an institution, for such steps are often productive of more harm than good. On the other hand, in manic depressive conditions and paranoia, the risk of suicide is real and ever present. Too great watchfulness cannot be exercised, and such patients should only be sent to institutions for the treatment of mental diseases where the condition is fully understood and effective precautions are taken; for it is remarkable what cunning will be displayed, even by an apparently stuporous melancholic, to elude the vigilance of his attendants and seize an opportunity to kill himself.

THE SHAME AND OBLOQUY of introducing poison-gas as a weapon in modern war must rest for ever with Germany, who, in spite of, or perhaps, because of, her signed agreements not to use gas, attacked the Allied line in the neighbourhood of Ypres on April 22 1915 in a chlorine gas cloud. Poison-gas, now one of the deadliest and most dreaded weapons of modern war, is not, as popularly held, an entirely new method of warfare. Poisonous fumes were used in warfare centuries before the rifle or shell were thought of. 

IF ONE REVIEWS THE LITERATURE ON prevention of venereal disease, one finds much on the inspection and segregation of prostitutes, but comparatively little on measures which are applicable to men. Yet I am sure that it should be very much the other way about.

THE TREATMENT OF WAR PSYCHONEUROSES by making the sufferer face his memories and grow accustomed to them is directly opposed to the old-fashioned plan of urging him to “forget all about it.” The men have almost invariably been trying to forget, and need lengthy argument before they are convinced that the opposite process will help them, but an intelligent patient who has been through the “cure” is often able to overcome their objections, and help them to recall memories with the result that the emotional effect of these disappears as the patients grow more familiar with them. There are degrees of “forgetting,” from a mere reluctance to think of terrifying episodes up to a complete amnesia, even for the whole of a man’s experience in France.

Great is youth – equally great is old age.
Great are the day and night.
Youth, large, lusty, loving – youth, full of grace, force, fascination.
Do you know that old age may come after you,
With equal grace, force, fascination?

In a pure neurasthenia, unless complicated by organic disease, the blood pressure is usually sub-normal. In a conversion hysteria, it is generally  normal. In an anxiety neurosis, it is more often considerably above the normal. If we are dealing now with young patients, and we find that their blood pressure is anything from 135 mm to 150 mm, we have strong reason for thinking that their condition is a pure anxiety-neurosis.

WITH THE END OF THE WAR an apt occasion is offered for a survey of work done, so that we may mobilize our ideas to attack the problem of neuroses in peace. Neuroses of war have been referred to by the term “shell-shock.” It is almost universally agreed by neurologists that this is a bad term, more borne in on us to-day, when shells are a thing of the past. Neuroses of war are essentially similar to the neuroses of peace, dependent on the same mechanisms and amenable to the same treatment. Three groups of cases seem to stand out: neuroasthenia; hysteria; and neuroses dependent on the occurrence of mental conflicts.

THE RECENT DECISION in the High Courts of Justice, in which the petitioner denied paternity of a child on the grounds of gestation being prolonged into ten months, lends peculiar piquancy to the following case which occurred quite recently in my own practice in which gestation lasted for 12 months.

At noon of August 23, 1918, a group of people came to my clinic, carrying a boy, Aboudy Morsi by name, eight years of age, from Talkha, a town on the opposite side of the Damietta branch of the Nile. The boy was nearly dead. The people with him related to me that he was on the Nile, shore fishing. He caught, first, a small trout, which he carried between his teeth, while he had another in his hand.  The first fish glided into his pharynx and lodged there and he was asphyxiated. All this took place half an hour before I saw him.

Three factors – a long prepuce, slight urethritis, and highly sensitive nature of the part (increased by constant irritation, naturally and unnaturally) – have a great bearing on the continuance of the obnoxious practice. Another factor in many cases consists in the perusal of literature that is suggestive and sometimes even pornographic. French novels, which merely relate travesties of love and deal with the ‘sublime passion’ in gross and vulgar fashion are avidly read by these patients, just that their sensitive imaginations may be stimulated by the suggestive descriptions and hardly veiled innuendoes.

The preventive treatment is carried out by medical officers of health, sanitary inspectors, nurses and health visitors, who visit the homes of notified cases, investigate home conditions and give advice in a more or less conventional way.But it often happens that a child has been notified, or a young adult, when the chief source of infection is one of the patient’s grandparents, a relative staying in the house...A notified tuberculous father may be given a room to himself, while his wife, who has chronic tuberculosis and is the source of his infection, is sent to sleep with, and infect, the children.  Or a child with enlarged glands is removed from the company of other children, some of whom have glands equally large (but unnoticed), and sent to sleep with the tuberculous grandmother.

On being asked in her Scripture class to draw the story of the “Three Wise Men,” she cried bitterly because she was unable to depict them walking towards the manger. Her effort shows the three figures walking away from the manger. She was encouraged by her teacher to use her right hand and a year later was able to write and draw normally with that hand. However, she preferred to use her left hand, and on leaving the infants’ school, her teacher began to re-educate her left hand with the result that she now, at the age of nine, draws and writes normally with both hands.

It is easy to see the ill-effects of circumstances which add new force to the fear of failure or shake the confidence in the control which has been regained.  Thus, a boy, an only child, who had suffered from enuresis till his seventh year, had regained complete control till his eleventh year, when he went to school. In his dormitory at school was a boy who had enuresis, and was being fined and punished by the schoolmaster. The enuresis at once reappeared and continued unchecked while he was at school.

Able seaman, J.C., aged 23 years, was a member of a gun’s crew during an action, in which our own and enemy light forces were concerned. A direct hit was obtained by the enemy on his gun,  and all the crew but himself were killed. He was thrown to the deck unwounded, but on regaining his feet an explosion  occurred, caused by a torpedo, and he was thrown into the sea. He began to swim, and succeeded in regaining the ship which was still above water, but she sank within a few minutes. He jumped overboard before she went down and began to swim again; a dull explosion took place almost immediately, whereupon he felt a severe pain in his back and lost consciousness. He stated that he thought he heard other men in similar plight around him cry out just before he became unconscious, but recollected nothing else until he found himself on shore.

THE AVERAGE GENERAL PRACTITIONER is wont to regard electricity as a faddist treatment which he would fain relegate to the domain of medical quackery. The following case, one of many, may be quoted to illustrate the high therapeutic virtues of D’Arsonvalization in neurasthenia pura, inspite of the lifelong and progressive existence of emotive aberration, and the predominance of cerebral symptoms.

Above all, we must hide from the child that we care at all if he eats too little. The nurse, more often than the mother, is apt to persist in the policy of coaxing, urging and commanding. The nurse who urges a child to eat, like the nurse who leaves the room with the parting injunction to the children not to put beads up their noses, has much to learn in the management of children.

'If possible, Caesarean section should be done before the woman is damaged and not after, and if this truth was recognized by the whole profession, I feel sure that Caesarean section would be almost as safe as natural labour. The adoption of rubber gloves, made compulsory by public opinion, if not by law, would undoubtedly save thousands of lives every year. Infection by midwives and sometimes by practitioners makes the operator’s death rate nearly 30 per cent more.'

“It is evident that the indications for Caesarean section will go on increasing from year to year as women, by greater complexity of life and intellectual development, become less and less healthy animals”

It seems to have been established beyond doubt that about 70 per cent of the inflammatory affections met with in married women are due to infection by the gonococcus. The reason why the disease is so common in women, who do not, in many instances, know what they are suffering from, is because they have been infected immediately after marriage by their husbands who are suffering from the effects of the disease, and who have imagined themselves cured and ready for marriage.

“His history showed he had been wounded in the head in the retreat from Mons and sent home. On account of these fits he had been discharged from the army. There was no epileptic history in the family and organically he was sound. He told me he had had these fits since he returned wounded, but that before that he was perfectly well”

The sleep-walker is guided by the motive which actuated his waking moments, and he sometimes executes performances with a degree of perfection which is not even possible to one in perfect possession of his senses. I have known a nurse get up in the middle of the night, collect all the patients’ day attire, and arrange the clothing for about 40 patients at the foot of each bed, after which she proceeded to collect all plants and flowers from an adjoining bathroom and place them in the ward, as in the daytime. She then retired to rest, but, upon awakening, she had forgotten all the details of the sleep-walking incident.

WHAT IS THE ASSOCIATION of dreams with crime? I have questioned insane criminals about their dreams in connection with specific crimes, and although there is always some reserve about admitting revelations in connection with criminal acts, I find that they dream much as do other people. In this class, there is a considerable difficulty in proving their hidden personal secrets, and in overcoming the resistance of the so-called “censor”.

MANY PERSONS have endeavoured to read into dreams some hidden meaning whilst others consider them to be only a confused and jumbled record of sleep-memories unworthy of serious reflection. Possibly the truth in regard to dreams lies between these two extremes of undue scepticism and a too facile credence.

IT MAY SEEM OUT OF PLACE that we should be discussing the realms of dreamland, whilst we are face to face with so grim a reality as a War for our very existence; a War which has so deeply affected the life of every individual in this country as well as within the Empire. But we may claim that the “Bowman” in the early days of the War laid particular emphasis upon dreams — for to these of our brave warriors appeared the “Angel of the Mons,” and the “unconscious mind” has thus been drawn, in literature at any rate, into the tragedies of the War. [Written in 1917 in The Practitioner] 

 In this article, cases have been selected which illustrate some of the difficulties confronting a medical man during an examination into the cause of death related to the respiratory system.

The most difficult cases are those in which death is the result of shock, uncomplicated by any recognizable morbid condition. It is only when the circumstances attending the death are known, or can be deduced, that an opinion can be given that death resulted from shock. The regions with which this danger is associated are the genital organs, the upper part of the abdomen, as a result of pressure or a blow in the epigastrium, the throat, and the nose. The fatal knock-out blow in boxing is the most familiar example of sudden death resulting from a blow in the epigastrium. Cases of sudden death from shock due to manipulation of the female genital organs are rare, but I have seen several cases in which an attempt to induce abortion has led to death from shock.

Written a hundred years ago by Bernard H. Spilsbury, Pathologist to St Mary’s Hospital, London. To any medical man may come an urgent summons to a case of sudden and unexpected death. Sometimes he is unable to certify the cause, even after post-mortem. It is in such circumstances that my assistance as a pathologist is invited. It is customary, for medico-legal purposes, to regard death as the result of failure in function of one of the three systems: nervous, circulatory, and respiratory. This the first of three articles presents some circulatory causes of death.

I have several hypodermic syringes of the latest patterns, and keep them in an excellent condition, but I very seldom use them except by the express wish of a patient who has had injections before. A syringe will not lie idle for very long before it becomes faulty, and the constant attention one has to pay to the fine wires within the needle is a serious handicap to the physician. By the sublingual method, all that I have just mentioned is negatived, the exhibition of the remedy is a direct one, and no mechanism of any kind is required.

NORMAN CHEVERS, in his work on Diseases in India, records that early in its history, Bengal became notorious for asthma. Also that the reason why Clive was given command of the relieving forces, proceeding from Madras to Calcutta in 1756 after the Black Hole catastrophe, was because his senior officer, being subject to asthma, was considered unfit for service in Bengal. Asthma is still very prevalent in Calcutta. I have obtained most promising results in a number of cases by vaccine treatment on very simple lines. I would like to put my experience on record.

Some years ago, a practitioner sent for me to attend to a case of placenta praevia in which haemorrhage had recurred. When I arrived, she was almost in extremis, with a pulse of 160, and severe bleeding. The placenta was presenting and bulging into the vagina. I turned, left the breech plugging the lower uterine segment, and proceeded to transfuse her, but she sank and died quickly. I do not think anything could have saved her. This case left on my mind a deep impression of the perilous condition of a patient who has had one severe flooding due to placenta praevia. This is just the sort of case in which Caesarean section may help us to save mother and child. 

PROBABLY of all the symptoms that a malingerer can simulate, one of the most baffling is incontinence of urine. When medico-legal cases are sent for examination and report, there is usually only an opportunity for a single examination, lasting perhaps under an hour, which makes it well nigh impossible to disprove allegations of this disability.

The idea of employing the electrically provoked activity of the muscles as a therapeutic agent in obesity has been made practical by the perfection of the present apparatus. Its application is not restricted by any crippling condition of the joints, and, whilst avoiding any dangerous strain upon the heart, it provides an amount of exercise sufficient to start a more or less rapid lipolysis. Perhaps the most interesting and surprising feature is the rapidity with which physical activity may be regained under treatment.

WITH SIR CLIFFORD ALLBUTT as its high priest, bleeding, with restraint, is in the process of coming by its own again. I first heard Sir Clifford Allbutt speak in praise of blood-letting in 1907, and I find this view confirmed in his recently published book. Blood letting has been advocated during the last fifteen years by those best qualified to speak of it from experience, namely, the general practitioners. However, they speak furtively, shamefacedly, and in the fear of the pseudo-scientific superman. These gentle counsellors have been assailed with such vociferous energy by the pseudo-scientist, that their timid voices have scarcely been heard.

As soon as the acute stage has passed off, usually in a week or two, it is inadvisable to prolong the Weir-Mitchell treatment. The course usually prescribed is six weeks, but this is, in very many cases, harmful. The ennui and monotony are prejudicial, and will engender a feeling of helplessness, feebleness, and dependence upon others. I believe the majority would be far better to begin in a fortnight or three weeks to interest themselves in some pursuit or hobby. It is an interest in life that these people need. This will prevent them from drifting into the chronic stage from which it is so difficult to remove them. In neurasthenia, it is the person rather than the disease that demands treatment.

DISLOCATIONS, even rare ones, have a knack of cropping up in general practice. One of the most unmanageable and disastrous is undoubtedly congenital dislocation of the hip. Failures gall me, as I suppose they do most people, and the verdict, “Nothing can be done,” always, I fear, arouses my obstinacy.

One case of headache was a peculiarly pathetic one – that of a fine young fellow who had enlisted in a Guards’ regiment. He was eager to be sent out to the firing line, and had made up his mind that if he did not feel better when he got there, he would make it easy for the enemy to end an existence which had become intolerable. This form of suicide is probably more common than we think.

Much good may be done by suggestion in hysterical cases. By encouraging a patient and assuring him that he can use a paralysed limb, we may gradually bring back his control over it. Suggestion is especially useful in hysterical blindness: the patient is told that he will see, at a certain time, the exact minute being specified. Thus, Mr. Walter Jessop succeeded in curing a blind patient by getting the nurse to awake him in the middle of the night and saying to him, “Now you can see!”

Conditions more calculated to shatter the strongest “nerves” it would be hard to imagine. Days and nights spent in wet, insanitary trenches, clothes swarming with vermin, food never very appetizing and often insufficient in amount, death or mutilation always imminent, comrades falling and fallen around, the groans of the wounded mingled with the ear-splitting din of bursting shells, to say nothing of the unspeakable horrors of the bayonet – all this, one would think, would more than suffice to upset the equilibrium of the most stable nervous system.

The responsibility of errors of refraction in causing headache is now an article of medical belief. But some of the many other manifestations of eye-strain are less widely known, such as the attacks of sickness of children, vertigo and certain migraines; the prescription of correcting lenses then may lead to rapid amelioration or complete relief from the trouble.

When you get gangrene like that, the local symptoms are, very often almost absent; the abdomen may move quite freely, there may be no rigidity, there may not be any pain on pressure, and the temperature is not necessarily raised. The pulse, however, is always quicker. When the pulse is increased, there is a case for operating early. If high, you must operate, whatever else happens. I can recall cases in which, because there were no marked symptoms, and because attention was not paid to the pulse, the patient was allowed to go on for over a week, carefully watched with a masterly inactivity.

The apparatus used for local treatment of acute anterior urethritis is an ordinary douche-can, four feet of indiarubber tubing, a clip, and a glass nozzle, which is fined down to a blunt point, and is flattened. The can is suspended five or six feet above the patient, filled with a pint of water which is a little too hot for the hand to bear with comfort. By the time the fluid has reached the nozzle and one is ready to begin, it will not be too hot.

A YOUNG woman, pale, thin, and tired, walked into my consulting room, and sat heavily down in the chair opposite me. There, her cheeks hollowed, her chin sharp and pointed, her body thin, and her aspect haunted, she confronted me. Occasionally, she passed her tongue between her lips to moisten them, as if she felt them dry and uncomfortable. There was a slight flush on the prominences of both cheeks, and she looked like an animal which had nearly been starved, and which licked its lips in anticipation of a meal....

In New York city itself, the deaths registered from eclampsia in 1902 numbered only 97, but in 1912 they numbered 171. Today in England and Wales, out of every 2,000 confinements one woman dies and seven, roughly speaking, are the subjects of eclampsia, while, strange to say, in Scotland this ratio is nearly doubled.

In reporting him unfit I detailed the circumstances, and ventured to predict that, after receiving his pension, he would be at work within six months…[And] that was the exact period at which he did in fact return to work, with, of course, his pension of twenty-five shillings a week for life!

WRITTEN IN 1915: [In acute cerebral meningitis of childhood] I have many times witnessed striking recoveries from full doses of mercury by the skin, after profound coma had almost obliterated all hope of improvement. I believe it to be unjustifiable to abandon the patient to his fate without resorting to vigorous treatment by this drug.

He believed the patient was dead, for he had ceased to breathe, and no pulsation could be detected. By way of a last chance, I inserted a strychnia and two apomorphia discs under his tongue, and rolled him over on to his left side. Well within a minute he made a valiant effort, and vomited, and finally recovered.

WRITTEN IN 1915:A considerable number of women admitted into the London Hospital as obstetric cases have, to an almost inconceivable extent, a lacerated and bruised lower genital tract, cervix, vagina, and perineum. A combination of lack of experience and judgement, lack of adequate time to devote to a midwifery case, and a mistaken sense of pride in refusing to take advantage of skilled advice which is nowhere remote in the London area, still renders some of our metropolitan midwifery a blot on the reputation of modern obstetrics.

WRITTEN IN 1915:While there has been a demand for medical women to take the place of medical men in every capacity, the larger proportion of the posts that have been offered to women are for newly-qualified or quite junior practitioners. There are practically none for the older and more experienced women doctors. The majority of members of the profession are willing for women to take their places as hospital residents or other appointments so as to release them for the front, but they will expect the women to give up their positions with smiling faces when they return at the end of the War. However, many will not return, and, consequently, the preservation of the health of the nation will tend to be more in the hands of women than was the case before the War.

Written in 1915: In many cases, there is doubt as to the organic nature of the paralysis. Numerous cases occur to which, in civil practice, the term “hysterical” would be applied. Many of the patients are, however, men who have proved their bravery in the field, and it seems to me that “psychical” is a fairer term to use. The frightful sights and sounds of a battle-field, combined with some amount of actual personal injury, undoubtedly inflict at times a psychical trauma, which in all probability could be shown to have a definite physical basis, had we means fine enough to investigate it. Nothing could be further from the truth than to suggest any trace of malingering in such cases, yet it is undoubtedly true that in many instances that paralysis would vanish under sufficient mental stimulus - such as the classical “house on fire.”

FROM THE PRACTITIONER 1914. In the process of analysing this case of insomnia, I discovered that several years before there had been a great intimacy between the patient and Mademoiselle X. The patient’s husband – the mildest of men – had grown uneasy about it, and refused to allow the friendship to go on. In his desire to do everything to render the proposed visit to Paris attractive, he had suggested staying in the house of Mademoiselle X, although he and his wife had never alluded to her for all these years. Instead of stimulating the patient’s recovery the opposite effect had been produced, because, in point of fact, the attachment had been a Lesbian one, and the whole complex was so painful that the patient shrank from the proposed awakening of the memory.

WRITTEN A HUNDRED YEARS AGO. The incidence of the disease was not upon children and invalids, who are generally speaking the principal milk consumers. The children may have escaped owing to the custom in better class houses of cooking milk that is to be consumed by them, or it may be that they consumed nursery milk, obtained locally, and not from the Sussex infected farm.

WRITING A HUNDRED YEARS AGO: “No patients are more suicidal than those who believe themselves impotent or affected by a sexual disorder”

WRITTEN A HUNDRED YEARS AGO: I believe that spontaneous cure of an infectious disease is due to entrance into the blood-stream of the unmodified toxins, developed in the focus of infection. When this occurs the power of the blood-serum is raised, the activity of the leucocytes stimulated, with the resultant development of specific anti-bodies. In all acute infections, in which it is possible to obtain the toxins, a speedy cure may be expected. With few exceptions, all chronic infections are benefited more by the autotherapeutic remedy than by any other curative agent. Autotherapy is being used successfully by hundreds of physicians throughout the United States. A patient may abort infection by simply chewing his own blood dressings twice daily. This is a fact, and we cannot know too many facts.

A HUNDRED YEARS AGO: The results of abdominal wounds are very bad. One school of thought recommends immediate operation; the other advises no operation at all. Consider what it means to operate on the abdomen. There must be an absolutely first-class hospital and a first-class nursing staff at our disposal for at least 1½ hours, whilst for each case three highly-skilled medical men are needed: an expert abdominal surgeon – a man who can really tackle big abdominal work, a first-class anaesthetist, and the surgeon’s assistant. In the end, perhaps one out of three, perhaps one out of five, may recover. It is a terrible thing to have to place a man’s life in the balance, when we think we could save it by a great effort. But when there are 50 or 60 other wounded men lying around, and the labour being expended on one may mean lack of attention to the others, it becomes a very difficult question.

A HUNDRED YEARS AGO: In older individuals, in whom the powers of reason have become developed, the direct influence of suggestion may be counteracted by innumerable inhibitions, but in babies, animals and hypnotized individuals the call of suggestion is imperative, and the exact form the response takes is determined by the nature of the previous responses, in other words by habit.

A HUNDRED YEARS AGO: When I saw her, at the beginning of 1912, she was very pallid and weak, and was obliged to spend ten days out of every month in bed. Even during the intervening time, she was by no means altogether free from haemorrhage. Her doctor informed me that there was absolutely nothing to be made out by physical examination. Six months later, on enquiry, I learned that she continued in perfect health, despite the fact that she had plunged into a whirl of social excitements; joys which had been altogether forbidden to her for more than a year previous to her treatment. Applied in the precise manner I do it, X-rays, should they fail to do good cannot possibly do harm.

Psychotherapy represents one of the important elements in therapeutics, and we must learn to use it in a way suitable to our patients. We have to learn to use our drugs in accordance with the nature and physical make-up of the patient... Just in the same way, our psychotherapy must be dosed out according to the special need of each individual, the form of the affection and the particular kind of mind that is to be dealt with.

'There was one type of scald, a grievous type, caused by the parents (with that modicum of wisdom which is infinitely worse than ignorance)  enveloping their children’s nether extremities in boiling rags, not wrung out dry, the very travesty of a fomentation. I saw many more or less severe cases of this kind; one poor child, a little girl aged about four, was brought up with her thigh literally cooked, and died some few days after admission.'

'If toxaemia can cause mental disorders, and movable kidney can cause toxaemia, there is no difficulty in recognizing movable kidney as a cause of mental disorders'

'To give a dose of bromide when the child has had a fit is only shutting the stable door when the steed is stolen; and to say that he or she will grow out of it, is courting disaster for the child, disappointment for the parents, and a considerable loss of prestige for ourselves.'

The sister was asked to send herself to sleep, which she promptly did; she was then told to get in touch with her sister’s subjective mind; this was accomplished in about two minutes; she was further told to communicate with the other mind that the pain was to cease immediately, which it did. This lady knew nothing whatever about transference or the subjective mind, nevertheless she was able to say when en rapport with the sister’s subjective mind, so presumably she did know, more particularly as her suggestion was at once obeyed.

My experience and the experience of others, together with the testimony of my patients, convinces me that a treatment of inebriety that does not include the skilful use of psycho-therapeutic methods in their widest sense is inadequate and incomplete. The first stage of the treatment should consist principally of physical treatment, by drugs, and isolation from alcohol. When the withdrawal has been accomplished, beyond a tonic treatment by drugs and general hygiene, the treatment indicated is psychical treatment first, last, and all the time.

'Almost all the subjects of migraine learn that alcohol, especially in  spirits, is harmful as is tobacco; probably nothing is more likely to bring on an attack than a visit to a music hall or a smoking concert, possibly owing to the smoke-laden atmosphere and the custom of taking spirit'

The modus operandi consists in hypnotizing a subject and haing seated him in a chair opposite to the patient, join  hands and then make your suggestions, without in any way directly influencing your patient, or putting him in a state of hypnosis....The recipient will probably show by his feelings and possible contortions, very frequently, that he has experienced the neurological condition of the patient; you then wake him. I have known many instances in which the recipient has, in every way, described the exact symptoms of the patient. On the moment of awakening all the symptoms leave the recipent and in most cases the patient.

IT IS VERY EVIDENT that the mineral content of our food-stuffs is a matter of some concern, and any misgivings we may have regarding its sufficiency are due to the fact that there is in this century an ever-increasing tendency on the part of manufacturers and traders to tamper with, and affect prejudicially, many of our staple food-stuffs. On account of the introduction, nearly a quarter of a century ago, of the roller process of milling wheat, and of a growing demand for white flour, a very large percentage of the mineral constituents of wheat are now eliminated from marketable flour. Within recent years even the wholesomeness of this has been lowered by the injudicious exposure of much of the flour on the market to the influence of some bleaching reagent like nitrogen peroxide.

The Chinese conjuror’s tale: “He was only anxious to get the coin back because the Chinese New Year was at hand, which is the great holiday time when all debts have to be paid off”

I ONCE told a lady, who asked me what was her disease, that her brains were blue, and I believe she still regards it as quite a bon mot, for she has sent others of enquiring mind that I might discover the colour of their intellect...

'A child’s face is frequently a clear index of the severity of the illness, or indeed of the actual complaint...'

GIOVANNI BOCCACCIO has fallen upon evil days. No one reads the Decameron now, and if, by chance, a copy of that work finds itself in the library of a respectable person, it stands in the darkest corner of the top shelf of the bookcase, where the dust accumulates from spring to spring. This year the Italians will celebrate the sixth centenary of Giovanni Boccaccio’s birth, and surely there is no name in their literature, rich as it is in great names, that deserves more honour. We know that Giovanni Boccaccio studied law; it may be that he also studied medicine...

ASTHMA is one of the diseases in which additions to exact knowledge during recent years have been few and comparatively unimportant. I wish to call attention to the form of asthma – in my belief the form most frequently seen – in which the disease depends largely upon the interaction of an abnormally sensitive nasal mucous membrane, and in this respect an abnormally excitable condition of a portion of the nervous system. ... Nothing gives more relief to the majority of those who suffer from this disease than the use of various nasal sprays of cocaine.

'The graver mistakes of practice arise not so much from ignorance as from a want of thorough and routine examination'

That lead is a powerful abortifacient has repeatedly been emphasized and fully established during investigations into many industrial processes, and that it has been, and is still being, used illegally for that purpose is equally beyond question.

'My results suggest a decided value must be placed upon the eucalyptus inunction method of treating measles, not forgetting, of course, the antiseptic treatment of the mouth and throat...'

'JULY, AUGUST and September, 1911, represent dark days in our history; the lives of many hundreds of previously healthy and vigorous infants having been lost. The total number of deaths from all causes for the quarter ending September 30th, 1911, in the Dublin registration area was 2,172. Diarrhoeal disease in children under two years of age accounted for 426 (18.6 per cent of all deaths) and of these 118 were registered as enteritis...'

'As regards radio-activity, for which some claim has been made as regards this mud, I must confess to some doubts, for its chief effect must be looked upon as due to either thermal or mechanical action. Taking into account its uniformly fine and entirely homogenous character, the absence of any conductivity for heat, and its perfect plasticity, fango must be regarded as a practically ideal cataplasm....'

Selected notes from readers of The Practitioner in 1912 on rheumatic disorders: Treatment by bee stings, The country doctor and acute rheumatism, and Dr Percy Wilde’s Method

'There is no doubt that in severe cases, and especially in acute rheumatism, the constant inhalation of strong radium emanation with oxygen to saturation of the system is of the greatest value; and no apparatus has given such excellent results as that which is shown here – the joint invention of Pro. Paul Zazarus and Dr. Saubermann. This apparatus is most useful when it is desired to highly charge the blood with radium emanation in order that it may exert its bactericidal power.'

'IN ANY TOWN where there are works of any kind one is constantly seeing accidents of various degrees of severity. Minor accidents are common. These generally affect the fingers and toes and vary from simple contusions and scrapes to complete amputations. I write from Earlestown, Lancashire, and being surrounded by several large works a great number of minor accidents are met with in practice. During the last two years I have personally attended over 250, the number in one month reaching as high as 27. As it is of the first importance that a workman should have all his digits, it is of even greater importance that none of them should be stiff or useless, because then they are only in the way and had better be amputated...'

By J. Mitchell Bruce, M.A., LL.D. (Hon.), MD, F.R.C.P. Presidential address delivered in 1911 before the Medical Society of London: 'Is the object of the Medical Society entirely fulfilled in the routine work of our meetings? I find that, whilst those who are in general practice constitute one-third of our number, only one communication in 15 comes from them – that they have read but four papers before the Society during the past 10 years...Let me call to mind some of the great things that have been accomplished by the family practitioner. I have but to mention the name of Edward Jenner, Fellow of our Society. Was not Koch a general practitioner; and Duchenne of Boulogne? And was it not the work that Manson did on filarial disease, when a practitioner in China, that led him to the induction of the relation of malaria to blood-sucking insects? Something short of the results of the achievements of these men in general practice would satisfy me.' 

100 years ago: 'Tuberculin plays an important part in the treatment of pulmonary tuberculosis in certain cases, and that its efficacy is greatly increased when it is diluted with a 1 per cent. solution of carbolic acid. However, tuberculin cannot take the place of sanatoria. Too much value is placed on tuberculin by tuberculin enthusiasts. It has an important place in the treatment of pulmonary tuberculosis, but must on no account be allowed to usurp sanatorium treatment. Its use is restricted to certain cases.' 

   “It is only when the patient is seized with the intolerable agony of angina pectoris that the nitrites should be used with any freedom”. By J. Campbell McClure, M.D., Clinical Assistant, West End Hospital for Nervous Diseases, and Mount Vernon Hospital, writing 100 years ago.

The number of deaths from measles in the County of London for the three months February, March, and April, 1911, was no less than 1,640, a weekly average of 126, constituting about 8 per cent of the total mortality during that period. The greatest mortality occurred in the poorer districts of London amongst children under five years of age. During the same period the total number of deaths from scarlet fever totalled only 29, though the average number of cases under treatment each week at the hospitals of the Metropolitan Asylums Board and at the London Fever Hospitals exceeded 1,000.

"Sir James Paget used to urge elderly men to educate their bladders and not allow them to dictate to their masters"

The ordinary means of bathing is from a machine, a contrivance which has not progressed in luxury or convenience with the lapse of time. Of course for those who cannot swim the attractions of the open sea and the dive from the boat are inaccessible. Delicate people and children should make use of a machine or tent, if obtainable, in preference to undressing in the open air, because the mere exposure to the air in the act of stripping is a potent means of loss of animal heat. It is best to avoid loitering about after undressing, and to run rapidly into the water and immerse the whole body under the first available wave.

A HUNDRED YEARS AGO: A Gilbertian school of physicians has arisen who place breast-feeding in the same category as original sin and other evils of human heritage; and who stridently proclaim the superhuman virtues of unsterilized cow's milk.

Practitioner 1911:Mrs. H. Aged 35, a lady of good social position, came to me in 1905. She had been ill for five years and had undergone many forms of treatment, including two rest cures, a course of high-frequency electricity, and osteopathy. She was a clever vivacious woman of highly artistic temperament, and felt her disability to take her place in society most acutely. The least exertion, mental or physical, left her exhausted; she had almost constant headache, and her sleep was disturbed by harassing dreams. She proved a most susceptible subject, falling at once into a state of somnambulism with amnesia on waking. She responded at once to suggestions, recovered the habit of dreamless sleep, and in three weeks was able to return home cured. I meet her occasionally, and she continues perfectly well and full of all kinds of activities. In this case the nervous breakdown followed a time of prolonged nursing and great anxiety aggravated by morbid remorse. She reproached herself for the illness of one of her children whom she had sent to a new school against the advice of her friends. This state of things was revealed after a little questioning, and the suggestions aimed at removing the feeling of remorse, which had become almost an obsession, by assuring her that she was not to blame in the matter and that everything would turn out for the best and end happily. Of course she had been told this hundreds of times by all sorts of people in her waking state, but it was only when mental receptivity had been insured by hypnotism that suggestions were accepted as true and acted as curative impulses.

Practitioner 1911: These facts are in a large proportion of cases known only to general practitioners, and very often to practitioners other than those who referred the patients to the operating surgeon. If all practitioners would make a practice of sending to the operating surgeon a brief record of every case of cancer that has been treated by operation, whether it show recurrence of the disease or not, and particularly would notify to the surgeon the fact of the patient's death, and whether due to cancer or not, our knowledge of the real value of operations for cancer would soon become more nearly exact than it is at present.