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Medical Societies.ROYAL MEDICAL AND CHIRURGICAL

SOCIETY.

The Relations between Bodily DeveZopment, Nutrition, andBrain Conditions in their Pathological Aspects.

A MEETING of this society was held on April 27th, thePresident, Dr. HOWSHIP DICKINSON, being in the chair.

Dr. FRANCIS WARNER read a paper on the Relationsbetween Bodily Development, Nutrition, and Brain Con-ditions in their Pathological Aspects. The purpose of thepaper was to show, as the result of.extended observationamong children, that: 1. Points of abnormal developmentin the body are very common and have important significa-tion. 2. Abnormal nerve signs, or points in balance andmovement, have been defined ; they are much associatedwith defective development as well as with the causes ofmental dulness, and are of clinical importance. 3. There isa close empirical relation between (a) defective developmentof the body, (b) abnormal nerve signs, (e) low nutrition ofthe body and its tissues, and (d) mental dulness and back-wardness. Some explanations of the relations among theclasses of defect were offered. After referring to his paperon Postures of the Hand as Indications of the Condition ofthe Brain, read before the society in 1882, Dr. Warner saidthat in that investigation and a subsequent one he was

enabled to examine between 1888 and 1894 100,000 childrenindividually, in conjunction with other medical men, theresults of which had been published in a report ;1 notes of18,127 cases in some respect below normal were taken. Afterbriefly describing the method of the statistical examination offacts four main classes of defect observed were described:(a) Defect in development in size, form, proportion of

parts of the body, principally in cranium, palate, ears, andfeatures, as well as more gross deformities; such signs weredisproportions in ratios of growth. (b) Abnormal nerve

signs in balance and action or reaction in movement andcoordination as seen in the face and eyes, the upperextremities, the hands, digits, and balance of the body.(c) Low nutrition ; cases pale, thin, or delicate. (d) Casesdull or backward mentally, as reported by the teachers. The

developmental signs were disproportions in growth; the nervesigns were abnormal in the time of action or in the ratios ofaction among the nerve centres. Movements were classifiedas: 1. Uniformly repeated series of movements, the sameparts moving in similar combinations and series of acts on Isuccessive occasions. Athetosis and athetoid movement of the frontal and corrugator muscles, with grinning, were typesof this class. 2. Augmenting series of movements, thearea of movement spreading from part to part. The expres-sion of mental excitement and emotion, awaking from deepsleep to activity, the extra movements of fidgetiness, themarch of the spasm in epilepsy, and convulsions affordedillustrations. 3. Diminishing series of movements, as seenwhen excitement subsided, as sleepiness came on, and as theconvulsion subsided or chorea passed away. 4. Coordinatedmovements, such as were adapted in their relations in timeand in quantity of action by the environment, and thereforein harmony with it. It was shown that in each class thecharacter of the movement depended upon the attributes oftime and quantity of action in nerve centres. The inferencefrom the ob,erved co-relation of development defect withabnormal nerve signs was that when proportional growth inbody was abnormal, as a sequence of inheritance or other-wise, the nerve centres were commonly so built up that insubsequent action they did not work in the normal relationsof time and quantity under the influence of the environment.It was shown that disproportion in growth and develop-ment of the body was commonly accompanied by a

status of the tissues prone to atrophy under adverse cir-cumstances. This was especially the case with girls, whowere, therefore, liable to fall into permanent ill-health withneuroses. Incoordinated nerve action, such as fidgetiness,awkward habits, or chorea, commonly occured with a lowered

1 Report on the Scientific Study of the Mental and Physical Con-ditions of Childhood, with particular reference to Children of DefectiveConstitution, and with Recommendations as to Education and Training,based on the Examination of 100,000 children, 1888-94. Published bythe Committee, Parkes Museum, London, W.

status of nutrition, and suggested the hypothesis of a rever-sion of spontaneity in action, which was characteristic ofthe normal infant brain (microkinesis) Dr. Warner sub-mitted the following propositions : 1. Disproportioned bodilydevelopment is very common ; it is co-related with low nutri-tion of body and incoordinated brain action. The co-relationwith low nutrition is highest with girls of all ages and is spe-cially marked among children seven years of age and under; Yit is much lower at eleven years of age and over. The co-relation with nerve signs increases with age for girls, andless so with boys. Finally, the proportion of the develop-mental cases that have not acquired either low nutritionor nerve signs is highest for boys in the oldest group,while for girls it remains about the same in each agegroup. It seems that the environment is apt to producemore harm and less good in girls than in boys of im-perfect development. 2. Incoordinated brain action ismuch associated with mal-development, and the presenceof nerve signs is more co-related with the causes ofmental dulness than are the signs of defective develop-ment. The co-relation of nerve signs with mal-developmentis highest for children seven years of age and under andlowest in the oldest group of cases; while the propor-tion of nerve cases that have nerve signs only withoutlow nutrition is highest with the oldest group. The environ-ment appears to favour the occurrence of simple cases ofnerve incoördination and weakness, which in many instancesmight be removed by training ; such signs are much asso-ciated with mental dulness. 3. Delicate children are in alarge proportion of cases ill-developed in some part of the.body. Among children without developmental defect theredoes not seem to be a larger number of delicate girls thanboys ; it is the girl who has some defect that is delicate, not

, all girls. Developmental cases tend to remain thin and. delicate in all social classes, least so in resident institutions.. Dr. NORMAN MOORE said that he could not pretend to be

fully acquainted with the methods of investigation adopted, by Dr. Warner, but speaking as an outsider it seemed to

him that there were some flaws in the argument. Every-t one who worked much in the post-mortem room wished, to find some law of correlation between defects of

different parts of the body, but had to abandon the hope.. It was only exceptionally, for instance, that abnormalities of

other organs were found in cases of congenital disease of the; heart, and he thought it by no means proved that there

was any regular correlation between mental and structural; defect. Antics and abnormal gestures might, as in the

E case of Dr. Johnson, be accompanied with mental

l qualities of an unusually high order. He did not thinkthat a child should be put down as dull merelybecause he had difficulty with his lessons ; the fault

E might lie with the teacher. Large ears, again, were notnecessarily signs of mental defect, as they were often seen

> in those of high capacity. From post-mortem observations: on such variable arrangements as the number and attach-

ment of the cords of the mitral and tricuspid valves he couldi not confirm Dr. Warner’s statement that variations were more

common in males than in females. The uniformly re-

peated series of movements " on which Dr. Warner laid suchE) stress he should regard as merely habits, and as often

I associated with high as with defective mental development.3 It would be important to know what was the ultimate mental3 development of the children described as dull, as Johnson;

Pope, and many others had been classed as dullards whenE young. He thought that there was an insufficient basis of

observed facts to enable dogmatic conclusions to be drawnat present with regard to the painstaking investigations of

3. Dr. Warner.Dr. FLETCHER BEACH expressed his general agreement

with the criticiiims of Dr. Norman Moore. The abnormal’s mental development could not be ascertained by any simple,

test, but by the weighing of a host of separate observationswhich were of very unequal value, but taken together ofgreat importance. Nerve signs alone were insufficient to.enable one to form a dogmatic opinion. Many of these

o signs were prominent in children with marked neuroticheredity, but who were bright and quick. Before accurate-conclusions could be drawn it would be necessary to followup the cases and also to extend the scope of the inquiry to

_ other parts of the country besides London, and especially to.’L- agricultural districts, where the children were presumablye less highly nervous.

Dr. SHUTTLEWORTH said that he could testify to the-y conscientious and accurate way in which. Dr.. Warner had’

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conducted his observations, although he might not be ableto follow him in all his conclusions. His experience hadbeen chiefly among imbecile children, and there was no

doubt that in them there was associated physical defect,both as regards weight and stature and also as regards theskin, viscera, and bony parts. The same arrestive cause wasprobably operative in both mental and physical conditions.Twenty-eight of the cases had a tuberculous family history,and the mortality was eight or.ten times as great amongimbeciles in asylums as in the outside population. Pope andJohnson could not be taken as healthy types. They illus-trated Dryden’s lines :-

" Great wits are sure to madness near allied,And thin partitions do their bounds divide."

Dr. WARNER, in reply, said that in his paper he hadpurposely left out any consideration of the abnormal signs tomental states, but he might say that out of 1900 boys and1000 girls who showed well-marked nerve signs 40 per cent.of the boys and 52 per cent. of the girls were found to bedull. He believed that anatomical defects were often asso-ciated with these abnormal mental cases, and mentioned onein which there was an abnormal arrangement of the cerebralconvolutions, a congenital deficiency in the size of one eye, adefective septum ventriculorum, and a horseshoe kidney. Itwas only by the multiplication of observations of signs thatit was possible to say that a person was abnormal. LJniformrepetition of one set of movements was certainly morecommon in defective children, and it passed off when themental condition was improved.

MEDICAL SOCIETY OF LONDON.

Election of 0fficers.-Exclusive Red Meat Treatment of ’

Certain Cases of Gout.-Excision of Rectum. ’

THE annual general meeting of this society was heldon May 10th, the President, Mr. REGINALD HARRISON, beingin the chair.The reports of the council and treasurer were adopted,

and the following gentlemen were appointed to hold officeduring the ensuing year :-President : Or. A. Ernest Sansom.Vice-presidents : Dr. Constantine Holman, Mr. A. Pearce ’,Gould, Dr. J. Kingston Fowler, and Mr. John H. Morgan. Treasurer : Mr. David H. Goodsall. Librarian: Dr. William ’,Henry Allchin. Honorary Secretaries : Dr. Robert Maguire I,and Mr. William H. Battle. Honorary Secretary for Foreign ’,Correspondence: Mr. Alban H. G. Doran. Council: Dr. ’,Theodore D. Acland, Dr. John Anderson, Dr. E. Clifford ’,Beale, Dr. Frederick L. Benham, Dr. Robert L. Bowles,Dr. William Ewart, Mr. Reginald Harrison, Mr. HenryE. Juler, Dr. Norman Kerr, Mr. Charles B. Lockwood,Mr. Jonathan F. C. H. Macready, Dr. James W. J. Oswald,Mr. C. J. Rayley Owen, Dr. Amand Routh, Mr. MortonSmale, Dr. John C. Thorowgood, Mr. George R. Turner,Mr. W. Dakin Waterhouse, LL.D., Mr. Joseph White, andMr. Arthur K. Willis.The adjourned discussion of the paper by Mr. W.

Armstrong on the value of an Exclusive Red Meat Diet incertain cases of Gout, was resumed by Dr. ARCHIBALDGARROD, who said that he had met with many cases ofChronic rheumatic arthritis which had been treated in this

way, in some instances with advantage, in most without result.It was really carrying to an extreme degree the plan offeeding up these patients, who were often harmed by a toorestrioted diet. Probably no single explanation would beadequate to account for the improvement in all the cases."Very few of the successful methods of treatment, such asthe relief afforded by colchicum during the acute

paroxysms, had yet been explained on scientific grounds.’It was obvious that there was a fundamental differencebetween the cases in which there was acute gouty arthritiswith a deposit of urate of soda around and in the joint,and cases of chronic articular gout in which there wasan alteration of the nutrition of the joint leading toextensive changes in its whole structure. In the case

of uric acid calculi there was another process, the decom-position of the quadri-urate, the occurrence of whichdepended on many variable conditions, such as theamount of saline constituents in the urine, or even

’the amount of pigment. The line of treatment recom-mended by Mr. Armstrong was calculated to increase theamount of uric acid produced and was therefore unsuit-able in cases in which there was any evidence of kidney

disorder, which he thought was the rule, at any rate to aslight extent, in cases of gout. The improvement in manycases was probably due to the fact that many of the digestiveorgans obtained an almost complete rest, and the suddenchange appeared often to be beneficial. In true gout hethought that the app’icability of this mode of treatment waslimited, and that it was by no means free from risk.-Dr. A. P. LUFF said that he had shown that there was nodifference between the metabolism of animal proteids andthat of vegetable proteids. Probably their different effectsas articles of diet depended on the accompanying salineconstituents. The mistaken idea that a meat diet causedthe introduction of increased quantities of uric acid into theblood was responsible for the objection to meat as an article ofdiet for the gouty that many held. He believed that in healthypeople uric acid was formed in the kidney only from urea andglycocin which came from the liver. In morbid states ofthe kidney, structural or functional, the uric acid wasabsorbed from the kidney, and it might be derived from thebreaking down of nuclein in leucocythæmia. A person onanimal diet excreted more urea, but not more uric acid thanwhen he was taking purely vegetable diet. At the previousdiscussion Dr. Haig had abandoned his former contentionthat meat diet introduced uric acid irto the blood, but saidthat xanthin, which he considered as physiologicallyequivalent, was so introduced. He appeared to rely onI7iayeraft’s process for detecting this, but in 1891 Dr. Haighimself showed that Haycrafb’s method was unsuitable fordetecting xanthin, and there was no proof that xanthin ifintroduced would contribute to the production of gout. He

agreed with Dr. Garrod that there was almost always somerenal disability in cases of gout, and that this plan of treat-ment could only be safely carried out in a few carefullyselected cases.-Dr. P J. FREYER said it was impossible toaccuse a meat diet of being the cause of the deposit of uricacid in the face of the fact that the people most subject tomanifestations of gout were the vegetarian inhabitants ofNorth-West India.-Dr. R MAGUixE said that the questionwas not one of chemistry, of diet, or of microbes, but ofvitality. In the carnivorous serpent uric acid was passed prac-tically in the form of a calculus; the graminivorous bird passedit in the form of urates, and the most highly evolved man inhealth passed it in solution in the urine. Bat when hisvitality was lowered there was a process of devolution, anduric acid was deposited. The Hindoo was a man of verylow vitality, and deposition of uric acid readily occurred evenon a purely vegetable diet.--Mr. ARMSTRONG in reply, tookexception to Dr. Haig’s view that the meat acted only as astimulant, or that its action was the same as that of theCarlsbad waters. The effect of these Mr. Armstrong believedto be due to increased elimination of uric acid by the kidneysand the skin. The influence of the nervous system in

deranging the normal chemical processes in the body was avery potent one, and he had seen worry repeatedly producea deposition of uric acid in a woman who never touchedmeat. He thought that much of the benefit was due to thesudden cleavage in the habits of diet. SeveIaI of his patientshad previously suffered much from amylaceous dyspep ia.He wished to insist that this mode of treatment was not apanacea. The cases had to be carefully selected, and onlyabout 3 per cent. proved to be suitable.

Mr. F. SWINFORD EDWARDS read a papE:r on FourteenConsecutive Cases of Removal of High-Iyicg Cancer of theRectum by Kraske’s Method. The object of the paper wasto show that many cases of rectal cancer hitherto dtemedbeyond the reach of operation are by the saoro.ccccygealor coccygeal route quite capable of removal without unduErisk to life, and that after the resection in certain cases

rectorraphy may be successfully carried out, with restorationof the part. Cases were quoted in which patients were aliveand well, with no signs of recurrence, after periods varyingfrom one and a half to six years. Mr. Elwards thought thata preliminary colotomy was usually unnecessary, as itinvolves a waste of time and may prevent a rectal anasto-mosis by fixing the colon, and so make it impossible to pulldown the upper rectum; and it is the more unnecessarysince there is little liability to subsequent stricture afteroperations by this method. Besides, if patients have tosubmit to the formation of an artificial anus, they prefer tohave it in the perineum, in the neighbourhood of the originaloutlet. Mr. Edwards considered that if a rectorraphy is tobe successfully carried out the peritoneum and sub-peritonealtissue should be freely incised to allow the upper rectum tobs approximated to the lower. Out of fourteen cases