William Brown

The Pneumatic Aspirator in Retention of Urine from Enlargement of the Prostate Gland.

uvula, so as to cxcite reflex contraction of these parts. In this way, when the throat is moderately capacious, we may bring into view the posterior openings of the nasal fossxe, the turbinated bones, the opening of the Eustachian tube, the septum narium, and the roof of the pharynx. In illustration of the practical value of rhinoscopy, I may refer briefly to one case. A gentleman, twenty-four years of age, consulted me on account of an obstruction of the right nostril, which had existed for two years. On examination with the mirror, the posterior opening of the right nasal fossa was seen to be obstr-ucted by a globular tumour (fig. 4), as large as a full-size(d marble, and of a yellowish-green colour. I asked my colleague, Mr. John Wood, to devise a plan for removing the tumour. He introduced a slender curved polypus-forceps through the anterior opening of the nostril, and grasped the tumour, which burst, and discharged a glairy fluid like white of egg. The patient felt immediately that the obstruction was removed; and, on rhinoscopic examination, the shreddy remainis only of the tumour were seen attached to the middle turbinate(d bonie, whichl had before been concealed by the tumour. (Fig. 5.) The tumour had evidently been a mucous cyst. This

A Lecture ON PSYCHOPATHOLOGY AND DISSOCIATION

HYSTE.RIA AS A DISSOCIATION. THI followina case illustrates the conception of hysteria as a dissociation, involving mental conflict and repression, in a specially clear way, and seems wortlh reporting in some (letail. A soldier, aged 47, unmlarried, liad had three bysterical attacks in his life. The first attacli occurrod at the age of 26, the second at the age of 36, anid the third attack a month or two boefore I saw lhim. WhIien lhe caine to me lhe was suffering from extremne loss of memory, and couild remember very little of whvbat had bappened during the war. He was suffering also fromu weakness of the leas, a teondency to anaesthesia, especially in tlle rialgt leg, anid a very definite tendency towards dissociation-towards dreamy states, states of mental distraction, wvhen he is unable to concentrate on wlhat is before him. I will consider tlle ease in the order of mny gradual insighlt into hiis mental condition. All that is emphasized in the luedical case-slheet is that he has recently had an hysterical attack, in wlhichl he lost consciousness for somiie tinle, and has sinice suffered fromn paralysis of the riglht side, wvithi anaesthesia of the right leg below the knee. In talling to hlim I do not at first get very muclh lhelp. He does not tell me very much about hiimself. And so I procced to use the method of word association which Jung was the first to introduce into psychology-that is, I draw up a list of -words and call them out one after another to my patient. (One calls out the word and starts the watch going, after first instructing the patient to reply witl the first word wlhicll comes into hlis mnind. If one calls out the word house, hie mnay reply with tlle word garden. Thuis: Stimulus eato. Association Word. Reaction. Time. Houise Garden 1.8ft Grals Green 1.2

HYPNOTISM AND SUGGESTION

In any consideration of the nature of suggestion we cannot omit reference to the extraordinary and startling phenomena which may sometimes be observed in hypnotized subjects. But it would be a mistake to look upon hypnosis as something uncanny, mysterious, and occult. Although we have even yet no thoroughly satisfactory theory of hypnosis, we understand it in general terms, and can bring it into line with other facts and phenomena of psychology known in everyday life. The hypnotic subject, and the phenomena of hypnosis, can be explained firstly in terms of mental dissociation, of the tendency for certain forms of psychical activity to occur independently of the rest of the mind, independently of other considerations; and, secondly, in terms of suggestion, of increased suggestibility. And these two, the phenomenon of dissociation and the phenomenon of suggestibility, are not unrelated to one another. They are related, but not to the extent of being identical with one another. It was the Nancy School of Hypnotism, led by Bernheim, who considered that hypnosis could be explained in terms of suggestibility. Charcot had previously explained hypnosis as an artificial hysteria-as a dissociation of the highest levels of the nervous system, a dissociation of mental and physiological activity at the higher conscious level. But the theory I am trying to sketch is the theory that combines both these statements. In my own view, based on the study of many hundreds of cases, hypnosis is explained both by dissociation and by increased suggestibility. We certainly do find increase of suggestibility occurring, partly explained in terms of dissociation, but not entirely so. On the other hand, the dissociation in its more pronounced forms may show itself independently of suggestibility. Which is the cause and which the effect of these two ? Dissociation as a cause may bring with it increase of suggestibility. We can understand why that should be so. Does increased suggestibility on its side bring dissociation? It may tend to do so. A person who is in an increasingly suggestible state responds to just the one stimulus before him-it may be a stimulus from the outer world, or an idea aroused in his mind by the experimenter. He responds with his whole mind and strength to the 1 Being part of a paper on The Self: Psycho-Analysis and PsychoTherapy, read before the Church Congress, Newport, Mon., on October 8,

Unrecorded Cases of Death by Chloroform: And the Need of a Suitable Room for Injured Persons in connection with Mines and other similarly dangerous Places of Labour

be added to or removed from the body ;-a state of things analogous to the old demoniac possession. Every disease is supposed to have its remedy-every bullet has its billet, and if the practitioner called do not supply the required cure, it is because he will not or knows it not, not that it does not exist. The poet may write What drug can make A withered palsy cease to shake ? But hope is eternal, and a friend is always ready to say- Try Dr. Soand-So. He is tried, and the patient, if not the disease, is attacked with a zeal and vigour that merit the highest success if it had only been attempted to compass the possible. Of course failure is inevitable, but what then ? Blot out that word impossible from the dictionary, said Napoleon, and in a similar spirit. Another confidential friend whispers - In these cases there is none equal to Dr. Thus-and-Thus. Bat a more effective reason for the presenit condition of our art is that, by the regular administration of several or many renmedies at the same time, we have made the problem of recognition of the separate action of each insoluble. The human body is the most highly organised and perfect machine in creation, and being so, it is the most complex. Now, when a physician is called in to correct some deviation from the normal condition of function or organ, what does he do? Hie orders a change in the action of the mind, change in the position and motion of the body, change in the diet, change in the habits, and then a combination of more or less active remedial agents, from two to twenty in number. lf after that he can apportion to each its proper share and merit in contributing to the cure, he is a wonder of judicial discernment, imitation of whom with me would be perfectly hopeless. The effects are disastrous to the profession. The attempt to get precise knowledge is never made. It is said-- What does it matter if the patient be cured? Articles of diet are given mixed, why not those of pharmacy? The fallacy is palpable, but from age to age the ignorance is perpetuated. The very fault against which the tyro is also warned on his entrance into the profession, that he must not believe that post hoc is p opter hoc, is inculcated by the practice of the oldest practitioner. That the system is artificial and not natural, is proved by the fluctuations in the favour with which differenit remedies are regarded. MNIulta renascentur quae jam cecidere, cadentque Qua: nunc sunt in honore. To judge of the value of treatment by the more broad result of the case, is to put ourselves in the same category with the charlatan or heretic. Here I again join issue with the medical orator at Birmringham, who said that the best doctor was he who was most successful. Best, certainly, as far as his own intercsts are concerned ; but we all have duties to our profession. I should say that he is the best doctor who most accurately connects cause and effect, and who applies no more remedies than he is certain of obtaining distinct results. Unfortunately, the regular as well as the irregular practitioner, is ever ready to credit his appliances with the bodys return to health, really due to other causes, or to its own inherent powers .........In truth, the natural tendency of the body to revert to the state of health after exposure to poisonous agentz, or morbific conditions of life, has never since history began been studied without remedial interference. Among tribes of savages, so rude as to have no knowledge of the Deity, there is yet found the medicine man, to whom the treatment of disease is entrusted. And it seems one of the most distinctly inherent instincts of humanity that that office shall be perpetiial. What, it matters not ; but some system there shall be, and nature shall never have the tceaus of working out her own salvation. What might not be the effect of commissions of competent persons to report on the evidence of disputed questions, and what happy results might not ensue, if instead of being the stepping-stones of professional success, scientific investigation were made the sole lifelong occupation of those philosophical temperaments fitted for such pursuits. But our inquiries are left to haphazard or to energies of such associations as our own; and the only wonder is that so much is achieved when the opposite difficulties are so great and the temptations to desert so seductive. The history of the introduction of a new remedy puts the weak points before us of fortuitous individual effort. Started with a few dexterous puffs in the medical journals, the little stranger flies with progressively increasing speed over the whole medical world. The stately hospital gives its letters of recommendation to the humble dispensary, the consulting-room to the rural surgery.........The inevitable reaction sets in. The too confident expectancy is doomed to disappointment in case after case, until at last it is well if the real properties of the remedy are not denied because it bas not proved the panacea it was once supposed. Oh, happy he who still can hope Ouit of this sea of error to arise. We long to use what lies beyond our scope, Yet cannot use even w%hat within it lies. As says the learned Dr. Faust. The last feature in the process of evolution to which I shall allude is the elevation of certain members of the profession above the gross atmosphere of an empirical art to the pure empyrean of the savant or professor of science. Practitioners of medicine may be said to occupy the position of middlemen between the cultivators of abstract and natural science and the general mass of the public. Herein they exercise the useful function of being translators of a language unintelligible to the multitude, or, to speak technically, they are the media of dilution of scientific ideas. But at no time has the profession wanted members to hold the front rank amongst the pioneers of truth-the original thinkers and the workers among the hidden things of the heavens above, and the earth beneath, and the waters that are under the earth. What distinguished names at once rise to the lips when we dwell on this fact of those who have gone from amongst us not to return, but whose wholesome influence is felt through every rank of the profession at large. Every year, every week indeed, furnishes evidence of the incessant intellectual activity which is being exerted towards some solution of the manifold problems of life; and though at present we may only have to admire the ingenuity and the beauty of the hypothetic speculation, we may rest assured that every discovery of truth will have its phase of practical utility. .-. . It may be that the laborious investigations which are being carried on to elucidate the subject of spontaneous generation may also incidentally illustrate the abnormal condition of the blood, and that ready tests may be supplied by which we may be able to detect and exhibit the presence of foreign agents or poisons which now we can only recognise in their effects. It may be that our pathological theories may pass from the region of speculation through the discoveries perhaps already trembling to their birth, of the influence of the different portions of the nervous system over the blood-supply, and the share in the complicated phenomena of mal-nutrition and inflammation. It may be that the study of the causation of diseases may receive large aid from meteorology. For though in spite of the large accumulations of facts, the laws by which the phenomena of atmospheric change are regulated are not yet discovered, yet does it seem quite feasible to associate the simultaneous appearance of instances of disease with certain conditions of the atmosphere altogcther independently of the more palpable changes produced by alteration in temperature ... . The influence of the savant is, moreover, not only felt through the profession as a guide through unexplored regions, but there is an absolute gain in his companionship. We learn from his example and from his careful and precise habits of observation, to avoid hasty generalisation and that precipitate jumping to conclusions which has ever been the bane and disgrace of the art of medicine. Another lesson we may too learn, that with us as with him, there is no stage of completeness or perfection to be reached where we can stand still-no rest and be thankful-until waning powers and failing senses warn us that the time has arrived when we must hand over our task to our successors. It is better to avoid the complacent survey of the past and to look with humility on the vastness of the future, though the pride might be pardonable with which we pass in view the changes which the process of evolution has wrought in us, and the large spheres of activity, general or special, which we claim as our own in the right to diminish human suffering, and in counteracting the evils of modern civilisation to prolong human life. Lowly though our origin, we have almost reached in stature to the skies, nor need we fear comparison with any other profession in the purity of our intentions or the nobility of our aim. Most excellent of all is it that our success, our very existence is identified with progress, and that we can adopt as our motto the laureates lines, Not in vain the distance beacons, forward, forward let us range, Though the great world spin for ever down the ringing grooves of change.

Remarks on Dislocations of the Clavicle, Humerus, and Elbow.

are stated by some to do occasionally ; it is certainly very exceptional). The first symptoms in paresis are chiefly cerebral ; viz., mental excitement, great garrulity, noisy hilarity, bragging, early violence of behaviour, and very usuallv some exhibition of libidinous conduct ; and on the subsidence of excitement, the mind is found to be weak, and the motor phenomena gradually make their appearance. On the other hand, in ataxy, to describe the case most likely to be confounded with paresis, the commencement is in the spinal functions. There is first an attack of pain of some remote part-of pain likened to the pain of toothache-occurring most frequently in the lower extremities, and dating several years back, considered at the time perhaps to be rheumatic ; this pain is worse towards evening, or when the patient is not mentally occupied; it may improve or disap?ear for a time and return. Then follows a slight degree of numbness of the part ; the patient feels as if he trod on wool ; occasionally pins and needles attack the part ; in fact, those phenomena which we have all experienced after sitting in an awkward position, when ones own leg has gone to sleep. There is, as most of us know, want of feeling, want of recognition of the member, especially as to its size, and even its ownership, then atrocious pain and pins and nieedles. In the disease, on the subsidence of the pain, the patients exhibit some awkwardness in gait; the ataxy or want of order on the movement is evident. These symptoms may extend over ten or twelve years with very little change. Except, perhaps, increasing awkwardness in gait, there is doubtless some numbness of the cutaneous surface in the course of the disease ; the phenomena appear to spread upwards by involving the functions of the nerves higher up; the erection of the penis, and soon afterwards the sexual appetite are lost, and the disease ascends ; the expulsory power of the bladder and rectuim become impaired. All this occurs while little change takes place in the mental functions; but in other cases the mind appears imbeci!e, the memory is affected, and there is distinct alteration in behaviour and conduct; but there are no lofty ideas, no excessive excitement and garrulity, and in no case have I met with paroxysms of violence or libidinous ideas. The differences may be better seen in a tabulated form.