1027ROYAL SOCIETY OF MEDICINE : PSYCHIATRY.

ROYAL SOCIETY OF MEDICINE.

SECTION OF PSYCHIATRY.

THE Presidential Address to this Section was

delivered by Sir MAURICE CRAIG on Nov. 13th andwas entitled

A Survey of Some Conditions Condiccive to JJ1 entalDisturbanee w-ith Suggestions as to their Treatment.

He agreed wholeheartedly with the belief thatmuch mental disorder is preventable ; the fatalisticattitude of the public was pathetic but the apathyof the medical profession was harder to understand.The influence of stresses upon the mind was as

important with the normal man as with the abnormal, ’,and the mental reaction might be the determining ’’factor in recovery from any condition. The study ofthe mind was a study of interaction and relationship.Granted that inherited tendencies largely determinedthe danger areas in any given mind, the physicianshould try to find what stresses might reinforce thattendency so as to make it operative. One of the mostimportant potential factors in the production of mentaldisorder was variation in sensitivity. Hypersensitivitywas frequently associated with weak inhibition orlessened control, and might be followed by physicalor mental changes. On the mental side the changeswould be in the emotions and would carry inevitablebodily changes with them. It was therefore mostimportant to treat the hypersensitivity before theemotions became involved. Certain types of children Icould be kept continuously on small doses of bromide ;grs. 2-1 for a child under 4 and twice that amount forone over 4. Children who were almost uneducablefrom their over-reaction to stimuli might, under thistreatment, become quiet and teachable. If the dosewere withdrawn they would regress slowly, some-

times even developing epileptic fits. This suggestedthat small regular doses of bromide might be prophy-lactic against epilepsy. In the same way, grs. 5 ofbromide a day might be most valuable for tropic-dwellers and for certain types of active men and I,women. Pavlov, in his work on the conditioned Ireflexes in dogs, had remarked : I

" It must be noted that as a result of the administration ’’

of bromides there was no diminution in the magnitude ofthe positive reflexes ; on the contrary, they were extremelyconstant. According to these and all previous experimentsbromides should not be regarded as sedatives diminishingthe excitability of the central nervous system; they simplyregulate the activity of the nervous system by strengtheningthe intensity of internal inhibition."

The President’s clinical experience supported thisview. A small dose of bromide taken regularly overmany years did not diminish the mental powers butin fact increased them, no doubt through preventingwastage. In larger doses bromide could be an

extremely toxic drug, and its beneficial effects werelessened or destroyed. There was much to supportthe view that mental disorder was often due to theweakening of lowered inhibition and not to anypositive condition. When the inhibitory functionhad become weak the emotions became involved,

’’

and this in turn caused pre-occupation and false Ireasoning, and in time failure of adaptation toenvironment. All this was accompanied by corre-sponding physical changes, and after weeks or Imonths it might be difficult to decide the initial causeof the mischief. Clinical experience favoured a

sceptical attitude towards the endocrine system asprimary cause ; the changes in the vegetative nervoussystem were usually secondary, although when estab-lished they might have an important bearing on theillness. Accurate and careful case-taking was Iessential in seeking the first cause. Here as in every- ’,thing else there were many sides to truth, and eachphysician tended to find his own specialty dominant.Much might be done to localise an illness by pointingout to the patient the dangers of false reasoningabout his symptoms, the direction in which his

reasoning would lead him, and the beginning fromwhich false reasoning had arisen.

insomnia.The fact that healthy people could do without

sleep at will, he said, did not mean that sleeplessnesswas harmless to everybody ; it was for the physicianto discern those who were likely to suffer seriously.There was much experimental and physiologicalevidence for the importance of sleep. Pavlov haddistinguished two types of neurotic dog-in one theinhibitory function, and in the other the excitationof the cortical elements was affected. In the maniacalpatient hypnotics were of little use and even seemedto increase the excitement, while the patients recoveredspontaneously if left alone-like Pavlov’s second typeof dog. But in the other kind of patient sleeplessnesswas quickly corrected by suitable methods. Addictionwas an extremely rare sequel to the prescription ofordinary sedative drugs, and the addict was usuallya person from whom hypnotics had been withhelduntil he had reached a state of terror ; it was toavoid a repetition of this terrifying experience thathe clung to his drug. The term " addiction " mostcertainly ought not to be applied to a person whotook a sedative every night on medical advice andthus preserved sleep, good health, and full mentalactivity. " Sleeping draught " was another term usedincorrectly; properly it could only be applied toamylene hydrate and paraldehyde, which wouldproduce sleep whenever they were given. Thebarbitone group, for instance, caused no desire forsleep if given in the daytime, and further researchmight show that their action was to strengthen aweakened inhibition, and that sleep was only a,

secondary result. Patients who showed evidence ofexhaustion with defective sleep, due either to advanc-ing years or to prolonged over-stimulation of thenervous system, might have their mental stabilitystrengthened, so that their activity of mind remainedon a high level for many years, by taking a small doseof dial or medinal every might. There was noevidence of any deleterious effect. Sedatives shouldbe given over prolonged periods, and there wasnever any difficulty in withdrawing them whenrequired. Daily medinal might moderate the pha.sesof a manic-depressive mental disturbance.The seriousness of insomnia in children was seldom

fully appreciated. In some it would cause nutritionaland digestive disturbances, in others emotional diffi-culties or mental confusion, and in course of timeboth physical and mental deterioration would appear.Grs. 5 of potassium bromide, with or without grs. 5of chloral hydrate, every night for some time wasexcellent. Prolonged treatment was necessary toprevent relapses and induced a much higher levelof physical health than short courses.Minor mental disturbances were not uncommon

after surgical operations and for their preventionsleeplessness must be relieved immediately. Somesurgeons gave drachm of paraldehyde per stoiieweight of the patient rectally on the operating table,or 1 drachm rectally an hour before the operationfor very apprehensive patients, so that they neverknew they were being anaesthetised. Medinal, dial,or allonal could be given with profit for some daysbefore and some weeks after an operation, and wouldmake convalescence more rapid and complete if thepatient were at all nervous. If medical men prescribedeffective sedatives for insomnia there would be less

taking of drugs by patients on their own initiative.Patients did not tend to go on taking drugs aftersleeplessness had been corrected.

Toxcemia.Almost anything could act in a toxic manner, the

President said, provided the nervous system weresensitive or had an " idiosyncrasy " towards it.The difficulty in diagnosis arose when the mentalsyndrome was not typical of toxaemia. The longerthe condition of focal sepsis had lasted the moredifficult and less effective treatment became. Medical

1028 ROYAL SOCIETY OF MEDICINE : THERAPEUTICS, ETC.

men should devote more time and study to mindreactions, for minor mental disturbances might be the

, earliest indication of physical disease due to some infec-tion. Insomnia was frequently associated with toxaemia,often preceding it and allowing the toxic process tobecome active. Serious mental symptoms couldoften be prevented by treating the insomnia at once.Each person had his own way of reacting to stress,internal or external, mental or physical. Much falsereasoning or rationalising resulted from the failure ofthe doctor to explain the mental condition or toappreciate the morbid sensibility of the patient.If the faulty attitude of a patient to stress was dueto weakened inhibition it was unnecessary, andmight be harmful, to spend months in tracking theoriginal cause. Psychological medicine would gainfrom making the language it used more simple.Clinical experience had, year by year, driven thespeaker back into general medicine. To him the theoryof weakened inhibition explained so much : whycertain brilliant children or adults broke down andwhy at first there was no interference with theirnormal mental activity, which only became involvedas sleep and other bodily functions became affected ;why a toxaemia might affect the nervous system ofcertain people; why a breakdown might followsurgical operation; why some people broke downfrom over-stimulation or with advancing years ; whysome persons relapsed when certain treatment was,discontinued; why treatment should at times becontinuous and why patients might remain in goodhealth and full mental activity for many years undertreatment. Research from that standpoint wouldbring about much knowledge of value in preventionand treatment of " functional nervous disorder."

COMBINED SECTIONS OF THERAPEUTICS

AND TROPICAL DISEASES.

THE SPECIAL USES OF ANTIMONY.

A JOINT meeting of these Sections was held onNov. 13th to discuss the special uses of antimony.Prof. J. A. GUNN, President of the Section of Thera-peutics, who took the chair, said that Valentine,who was largely responsible for the introduction ofantimony in modern medicine, stated that one man’slife was too short to become perfectly acquaintedwith all its mysteries. It had become clear, said thechairman, that even the 300 years which had elapsedsince then had not sufficed for the discovery of allthe mysteries of antimony.

Dr. J. B. CHRISTOPHERSON, in opening the dis-cussion, first dealt with the question of the early useof antimony. In England it was of but little accountas a medicinal agent until the sixteenth century, butit had figured in an interesting way in the evolutionof medicine since remote times. First it was usedas a cosmetic, and later as a medicinal application forthe eye. From 1500 to 1825 in this country peopleused antimony empirically for many diseases ; andfrom 1905 to the present day could be looked upon.as the period of its scientific administration. Itbelonged to the same chemical group as nitrogen,phosphorus, bismuth, and arsenic. The close chemicalrelationship between antimony and arsenic led to theidea that their biochemical reactions were similar.The Assyrians found - he metal near Ispahan in Persia,and were the first to use it as an article of femaleadornment. It was still used by Arab women, bywhom it was called the eye-paint. Doubtless theAssyrians taught the Israelites how to use eye-paint. Certainly it was used a long time ago for thetreatment of granular eyelids, also as an astringentfor eye discharges, for ulcers, burns, recent wounds,and dog-bites. In the sixteenth century Paracelsusintroduced antimony into medicine, and he stronglyrecommended its use for the plague, under the term" mercurius vitae," though it contained no mercury.It was in 1604 that antimony found a place in theBritish Pharmacoepia. In 1619 " the Earl of War- I

wick’s powder," containing antimony sulphide, I

appeared in Italy, and this was the precursor oftartar emetic, the most important of the antimonyderivatives. Louis XIV., when 19 years of age, wasseized by an illness which baffled the physicians, buta quack was said to have cured him by giving himtartar emetic. Following a violent controversy con-cerning the drug in 1566, it was banished from medi-cine for a hundred years. In 1822 Prowse obtainedthe sesqui-oxide of antimony, and there were twofamous antimony preparations, James’s powder andPlummer’s pill. Pulv. antimonialis was the officialsubstitute in 1787, and it was still in the 1914 BritishPharmaccepia.

In 1906 two workers in the Pasteur Institute,Paris, proposed the use of antimony salts for trypano-somiasis. In the same year Plimmer and Thompson,at the Lister Institute, tried, on the suggestion ofCushing, antimony potassium tartrate. Of all thevarious drugs used for trypanosomiasis, sodium anti-mony tartrate had the most marked influence on thedisease in the human body. Its first use was bysubcutaneous injection, but sloughing and the forma-tion of abscesses followed. And oral administrationdid not prove more satisfactory. In 1906 a veryimportant discovery was made-namely, that anti-monium tartrate could safely be injected intra-venously, and cases of cutaneous leishmaniasis werecured by potassium antimony tartrate. In 1915 casesof kala-azar were cured with it in Sicily, and thiswas repeated by Sir Leonard Rogers in India andDr. Aldo Castellani in Ceylon. The speaker himself,in 1917, had investigated the action of potassiumantimony tartrate in bilharzia. In 1913 two workersin Brazil had successfully treated granuloma inguinalewith potassium antimony tartrate intravenously,proving the important fact that it was efficacious notonly in two protozoal diseases, but was also a specificin a bacterial infection. Later it was shown to bespecific for a helminthic affection too. It was pro-bably specific for rhinoscleroma, which was causedby a diplococcus of the Friedlander type.THE PRESIDENT said his personal experience with

antimony compounds was only slight. The use ofantimony for specific diseases was largely a matterof the last 20 years. In early times it seemed to havebeen used for every known disease, and this greatlyreduced the credit attached to the observation ofwhich ailments it seemed to benefit most. In itsearlier use it was mixed with such a variety of com-pounds and was prepared in so many ways that onewondered whether some such form as that employedto-day was not happened upon. Research on anti-mony had gone on pari passu with research onarsenic. In the case of arsenic the pentavalent com-pounds had first been tried, then gradually theworkers had passed on to the trivalent ones, such assalvarsan. The reverse order was followed in regardto antimony. It had been shown that if a compounddid not act on trypanosomiasis it probably would notact on bilharzia. Trial with other substances in placeof tartaric acid-such as citric or lactic-did not givebetter results. Lithium had now largely replacedthe potassium salt. The substitution of ethyl hadgiven good results in trypanosomiasis. The firstpentavalent compound which was made was an

analogue of atoxyl. It was tried in trypanosomiasis,but it was no better than potassium antimony tar-trate. The next preparation made was stibenyl ;this was tried in leishmaniasis and in experimentaltrypanosomiasis. It was effective, but the resultswere not dramatic. Next, one of the hydrogenmolecules was replaced by chlorine, and the substance

was named stibosan, the von Heyden " 471." It, was a distinct success. Urea compounds had alsobeen made. One was stibol. A substance used a

: good deal now was stibamine glucoside, and there,

was no doubt about its efficacy in kala-azar. For the. latter disease the best drug was considered to be, " 693." Attempts had also been made to combinei antimony with dyes ; it was said that only the com-, pounds which stained trypanosomes were active., There had not yet been any report made about their

1029BRIGHTON AND SUSSEX MEDICO-CHIRURGICAL SOCIETY.

action on man. He asked whether any member hadused antimony per rectum.

Dr. GEORGE Low first spoke of the successfulexperiments of Plimmer on rabbits infected with

trypanosomiasis. But when antimony was injectedsubcutaneously in man the local reaction was so

severe that it had to be discontinued. It was then

given orally, but the vomiting which followed adminis-tration of a large dose ruled that method out. Onthe Congo, where many were dying of sleeping sick-ness, it was tried intravenously, in small doses atfirst. The expected sloughing of veins did not follow,and by gradual increments massive doses couldsafely be given. Even grs. 2! to 3 could be givenwithout causing more than a cough. It was nexttried in leishmaniasis, and Castellani used it withsuccess for kala-azar in Ceylon. Then came the greatdiscovery by Christopherson of the efficacy of themetal in bilharziasis. When the speaker began tostudy tropical medicine, bilharzia showed a highmortality, but Christopherson’s discovery broughtthe figure down greatly. Large doses, however, mustbe given. For ulcerating granuloma a total of grs. 54would bring about a complete cure in one case, whilein another this did not ensue after grs. 114. Of thevarious derivatives he had used, the one he liked bestwas stibamine glucoside. Neostam could be usedintramuscularly for children without harm.

Dr. PHILIP MANSON-BARR said that the new

pentavalent compounds had no effect on Schistosoinahcematobium. The more poisonous the compoundused, the more effective it was against schistoso-miasis. Antimony killed off the bilharzia worms bya slow and painful process ; it was specific for theovarian tract of the female worm, and neutralisedits egg-laying capacity first, and then the wormslowly died. Good results were not claimed for thepentavalent compounds in schistosomiasis. The newpentavalent compounds, if exposed to great heatbefore being injected, were rendered practicallyuseless. An important point was told to him byDr. H. M. Hanschell-namely, that if antimony wasdissolved in a 5 per cent. glucose solution, many ofthe poisonous effects were thereby obviated. Manypatients complained so much of rheumatic painsafter injection that further injections were renderedalmost impossible, but since he adopted Dr. Han-schell’s advice, he had not heard such complaints.It was a distinct advance in technique. Some kala-azar patients seemed to be antimony-resistant-i.e.,no dosage cleared up the illness. In such cases Dr.Manson-Bahr advocated a trial of them all in turnuntil the particular efficacious one was found. Evensix-tenths of a gramme (nearly grs. 8) should be given.The reaction was grave, but afterwards the clinicalimprovement was obvious. A curious fact, of whichhe had not seen any explanation, was that Leishman-Donovan bodies could be recovered and grown inculture almost up to the time of the patient becomingquite well of his disease. He had had a case ofulcerating granuloma, lasting three years, in whichgrs. 300 of antimony tartate was given, the finalresult being good. In this disease the pentavalentcompounds of antimony were more valuable than theoriginal tartar emetic.

Dr. ALDO CASTELLANI said he believed he wasthe first to use antimony in the treatment of Indiankala-azar. Previously he had used tartar emetic inother diseases, for instance, in yaws. He had alsoemployed it in broncho-spirochsetosis, the existenceof which some denied, and found it very useful. Hementioned that he had been carrying out investiga-tions into the closely allied element phosphorus.The great difficulty concerned its method of adminis-tration. The oral route was very unsatisfactory, butit could be used conveniently by the subcutaneousmethod if the phosphorus oil of the British Pharma-coepia were employed-i.e., 2, 3, 5, up to 10 q of thephosphorated oil. It produced no pain. In chronicmalaria it was an adjuvant to quinine, and he advisedit in rickets and osteomalacia, with good results.

He had also used it in dermal leishmaniasis, and inmost of the cases phosphorus answered better thanantimony. If there was no ulceration 5 Tl1. was thequantity injected twice a week. When the nodulewas ulcerated, the technique was very simple ; theulcer was cleaned up and a few drops were let fallon the fundus of the ulcer from a glass rod.

Dr. H. B. DAY said he had seen many thousandsof cases of bilharzia treated by Dr. Christopherson,and he knew of no instance in medicine in whichone could so intimately and accurately follow thetherapeutic result. The progress could be watchedday by day under the microscope. He described theprogress of a serious case from the time it was firstseen to its ultimate cure, remarking on the importanceof concentrating treatment in the first week.The opener briefly replied.

BRIGHTON AND SUSSEX MEDICO-CHIRURGICAL SOCIETY.

AT a meeting of this Society on Nov. 1st, with Mr.GEOFFREY BATE, the President, in the chair, Mr.St. G. B. DELISLE GRAY read a paper on the

Injection Treatment of Varicose Veins.He began by outlining the anatomy of the superficialveins of the lower limb as described by Kosinski,1and said that the anatomical factors making forvarices were : (1) The height of the column of blood,the average length of the great saphenous vein being85 cm. ; (2) the thinness of its walls and lack ofmuscular support; and (3) possible variations in theanatomical course of the small saphenous and itsanastomotic channels. The first intravenous injec-tions of drugs had been made on animals in 1657,at the suggestion of Sir Christopher Wren, thearchitect of St. Paul’s Cathedral, but intravenoustherapy had been impracticable until the invention ofthe Pravaz syringe in 1851. Shortly after this dateexperiments had been made with the injection ofsolutions of ferric chloride into varicose veins ; therehad been many successes, but also many failures dueto septic sequelse, embolism, and the like. Duringsubsequent years various solutions had been used forinjection, and there had been many successful cases,although some caused great pain to the patients,whilst others caused sloughing, scarring, and recur-rence. He himself had found that sodium salicylatecaused severe pain, though admittedly the results wereexcellent. He now used quinine and urethane, andalways gave the injections with the patients standingup. He saw no reason for injecting the fluid slowly,as it must surely militate against the success of theinjection if the fluid became diluted. In women itwas important to exclude pregnancy as a cause or aconcomitant of varicose veins, as the injection ofquinine might possibly lead to abortion. After givingan account of a series of experiments at the MayoClinic by L. G. Rowntree and Takuji Shionoya.,2 withthe object of directly observing thrombus formation,he drew attention to the fact that most solutions usedin the injection treatment of varicose veins were self-sterilising. In the treatment of haemorrhoids he used20 per cent. carbolic acid, and he suggested thatsimilar fluids might be injected into subcutaneousnaevi, and that varicocele might be amenable totreatment by injection. The alleged risk of quinineblindness after injection of quinine he regarded asnegligible.

After reading the paper, Mr. Gray showed a tabledesigned by himself for the patient to stand on, anddemonstrated two cases.

Dr. H. M. GALT showed microscopical slides illus-trative of changes in the vessels.

1 Jour. Anat., 1926, lx., 131.2 Jour. Exper. Med., 1927, xlvi., 7, et seq.