1606 T

Dr. MERCIER read a paper entitled "To Examine theAlleged Exceptions to the Rule of Secrecy." He referred tothe fact that neither the Royal College of Physicians ofLondon, nor the Royal College of Surgeons of England, northe British Medical Association had made any official pro-nouncement upon the question of professional secrecy, andpointed out reasons which made the subject more importantto that branch of the profession dealing with mental diseasethan to any other-namely, that (1) to no member of theprofession were secrets so important habitually confided ;and (2) the revelation to a third person of informa-tion gained by examination of a patient was a matterwhich seldom came up for the consideration of the generalpractitioner, the physician, or the surgeon, but to those

dealing with insane patients it was a matter of daily andhourly necessity. The decision had to be made constantlyand upon the spur of the moment, often with no time forconsideration. The accusation had, however, never beenmade against alienists of unduly and unnecessarily revealingthe secrets of their patients. The knowledge imparted by apatient to a medical man as to his disease was conceded onthe implied obligation of secrecy. He impugned the dogmalaid down recently that the medical man must be the solejudge of the circumstances under which the secret of thepatient might be published. He examined the allegedexceptions as to the rule of secrecy. 1. As to evidence in acourt of law. He held that there were still circumstances inwhich a man was bound to act according to his conscienceeven if in doing so he incurred the terrors of the law.2. As to the revelation of the fact of a crime having beencommitted. He did not consider it part of the duty of themedical profession to transform itself into an auxiliarydetective force, and that it was neither usual nor desirableto use against a patient information gained under the sealof the medical confessional. 3. As to the protection of themedical man’s own wife and children. The admission ofsuch an exception he considered would be so one-sided as tovitiate the contract of secrecy altogether, and that it hadno foundation in principle or practice. 4. To prevent animpending crime. There being no legal guidance on thisquestion individual judgment must be relied upon. Prac-tically the instances seemed limited to one particular crime-viz., the procuring of abortion, as in other cases the know-ledge was not usually gained from the criminal. 5. Casesin which the malady of the patient involved danger to thecommunity. This difficulty could generally be effectivelydealt with in ways which did not involve the divulging of aprofessional secret, and in the notification of infectiousdiseases the patient might be said to have given his consentthrough his representative in Parliament. He concluded thata medical practitioner was not under any circumstancesjustified in revealing the confidence of a sane patient withouthis consent, and with regard to an insane patient theinformation obtained from him might be revealed when, andonly when, it was expedient for the welfare of the patientor for the public safety.-The paper was discussed by Dr.RAYNER, Dr. BLANDFORD, Dr. SAVAGE, Mr. KESTEVEN, andDr. WHITE and general agreement expressed, but furtherdiscussion was postponed till the annual meeting, when Dr.Mercier proposed to embody his conclusions in the form ofresolutions.

Dr. C. H. BOND read a paper on Further Points inthe Relation of Diabetes and Glycosuria to Insanity. This

paper was a continuation of one on the same subjectpublished in the Journal of Mental Science for February.By a combination of the results then reported withthose since obtained the conclusion was arrived atthat out of 355 recent cases examined 5’35 per ceut.showed sugar in the urine on admission to BansteadAsylum. Cases of glycosuria far exceeded cases of truediabetes ; only two of the 355 suffered from the latter, whileapparently about 5 per cent. of all recent cases of insanitymight be expected to show glycosuria. By the administra-tion of uranium nitrate the excretion of sugar in the urinecould be entirely stopped and thus the question of the

dependence of mental symptoms upon glycosuria could bestudied. He concluded that the saccharine urines met withamong the insane occurred in two main groups, those of truediabetes and those of glycosuria. The former embracedinstances where the disease developed during the progress ofthe mental malady and could in no way be said to cause it,and also included cases where the insanity might be con-sidered as caused by the diabetes, the treatment of whichby nitrate of uranium appeared to be very encouraging.

Glycosuria in association with insanity might be persistent,Þ or intermittent, or remittent. The majority of cases suffered, from melancholia. Maniacal patients, epileptics, and con-

genital cases were apparently exempt. In many there was a. distinct history of alcoholic intemperance and traumatism in

a few cases. In some glycosuria disappeared pari passuj with mental symptoms. But freeing the urine of sugar by

uranium nitrate in this class of cases seemed unattended by: beneficial results mentally.-The PRESIDENT considered that; anything lowering the nutrition of the nerve centres might. produce mental breakdown and that in some individuals the.

presence of glycosuria just turned the scale. He pointed out. that nitrate of uranium had been used more than thirty years

ago for throat affections associated with glycosuria.-Dr.. SAVAGE laid stress on the frequency with which glycosuria. alternated with insanity.-Dr. GOODALL quoted foreign, observers as to the frequency with which glycosuria had beenmet with in cases of general paralysis, and observed that

, they did not appear to have observed alternation.-, Mr. BOWES supported the theory of alternation.-Mr.

DOUGLAS asked as to the age of patients and said he had, found great benefit from the use of bromide of potassium in

diabetes.-Dr. BOND considered the mental symptoms didnot depend on the glycosuria, but thought it was importantto remove the sugar by the use of uranium. He was struckby the absence of young cases of diabetes with insanity.The next meeting was announced to be held at Notting-

ham on Feb. 18th.

SOCIETY OF ANÆSTHETISTS.

Anæsthesia in Cases with Obstructed Air Passages.-A NewEther Inhaler.

A MEETING of this society was held at 20, Hanover-squareon Nov. 19th, Mr. G. H. BAILEY, the President, being in thechair.Mr. H. BELLAMY GARDNER read a paper on Two Cases

with Obstructed Air Passages requiring an Anaesthetic.Such patients could be ansesthetised with chloroform remark.ably well when the obstruction was of gradual onset. Thefirst patient was a boy aged eight years with multiplepapillomata in the larynx under the care of Dr. Willcocks inthe throat department of Charing-cross Hospital, and he wasrequired to be ansesthetised for removal of the growths pervias naturales without laryngotomy. He had considerabledyspncea, with retraction of the lower six intercostal spaces,and a small rapid pulse ; his voice was lost and the lips wereslightly cyanosed. The operator desired to have him in thesitting position to use the laryngoscope. Mr. Gardnerdecided that ether and its mixtures were inadmissible,that morphia taken before the anaesthetic would addto its danger, and that gas with a percentage ofoxygen would not give the operator time enough. He there-fore chloroformed the little patient lying on his left side,and when corneal reflex was abolished he inserted Hewitt’stubular mouth-gag and, introducing chloroform with Junker’sapparatus, raised the child against his own chest in themid-line. There had been six several operations at intervalsof a fortnight or more and the patient was greatly improved.It was now very difficult to abolish the coughing reflex, as thechild took much larger quantities of chloroform. The secondcase was that of a powerful man aged twenty-four years, over6 ft. 2 in. in height, whose cheeks, gums, and tongue werefirmly cicatrised and bound together after an attack of purpurahæmorrhagica in November, 1895. In May, 1896, Mr. StanleyBoyd desired to operate upon him in Charing-cross Hospitalfor complete closure of the jaws produced by contraction ofthe cicatricial tissue. Mr. Carter Braine anæsthetised him,using six drachms of chloroform on Esmarch’s mask beforehe was ready for operation, and lint well soaked withchloroform as well as Junker’s nasal tube was needed to keephim asleep. He was laid supine, with slightly dependenthead, so that all blood getting into the mouth should flowaway from the larynx, it being impossible to sponge out themouth in any way; the lower lip was split and dissected offthe jaw and a large flap raised from the chin to the neck toline the cheek on the left side. Screw-gags effected a slightseparation of the teeth (half an inch), then Mr. Gardnercontinued with Junker’s apparatus alone. Once the

patient showed pallor from loss of blood, but by the useof A.C.E. in the Junker’s apparatus his colour and pulseimproved. The operation lasted three hours in all, and threesimilar operations were subsequently performed on the same

1607

patient, lasting respectively fifty minutes, two hours, andhalf an hour. The danger under the anaesthetic was thatof obstruction in the pharynx from the tongue or blood, butthe partly dependent head and retention of the coughingreflex tided over the difficulty. Here, again, toleration was- shown by the larger doses of chloroform required. Respira-tion needed constant care in both these anxious cases.-Mr. CARTER BRAINE said that he remembered the last case- very well; it was an entremely anxious one. The patient’s,mouth was so cicatrised up that only the tip of the littlefinger could be introduced and the teeth were firmlyclenched together. Chloroform was obviously the onlyanaesthetic to be administered, and any attempt at vomiting,which could only have been of a fluid nature, would havenecessitated immediate tracheotomy.Mr. GARDNER also described a new Ether Inhaler which

he had devised to provide a very free breathing channel, aplentiful reserve of ether, and a very gradual method ofintroduction of ether upon the sponge inside by means of anexpansion chamber working on the principle of Dalton’s law.

I

NORTH LONDON MEDICAL AND CHIRUR-GICAL SOCIETY.

Exhibition of Cases and Specimens-A MEETING of this society was held at the Great Northern

’Central Hospital on Nov. 8th, Mr. J. MACREADY, President,being in the chair.Mr. STANFORD MoRTON showed several cases illustrating

the Treatment of Lacrymal Stricture by means of Styles.The style used was made of lead wire of such a length that4he lower end passed through the stricture. The upper endwas bent so as to lie almost hidden in the incised canaliculus.’This method of treatment was particularly adapted to those- oases in which stenosis constantly recurred, and also whereby reason of distance the patients could not be seen suffi-ciently frequently. One of the cases shown had worn thestyle for more than two years without discomfort and inother cases this period had been exceeded, -Mr. MORTON alsoshowed a case of Extirpation of a suppurating Lacrymal Sac’done as a preliminary to cataract extraction. The case had,done well and there was scarcely any epiphora.

Dr. SYERS exhibited a case showing marked Dilatation of’the Superficial Veins of the Thorax and Abdomen. The patientwas a widow, aged forty-four years, and was in her normal"health until a year previously, when she began to cough andto complain of shortness of breath. About six months agothe veins became enlarged ; now they were greatly distendedand some of them were very tortuous. The current of blood,in them flowed from above downwards. The superficial veinsof the neck and of the upper limbs were also somewhat

"enlarged. The face was dusky. There was dulness withdeficient breath sounds at the base of the right lung. Ontwo occasions a needle had been inserted and blood-stainedfluid withdrawn. This fluid, submitted to microscopic ex-amination, showed principally blood corpuscles. The case

appeared to be one of mediastinal growth causing pressure onthe superior vena cava, probably also implicating the rightpleura. The appearance of the chest was strikingly similarto that of a case recorded in vol. ii. of Sir Thomas Watson’s"Principles and Practice of Physic," in which case thepressure was on the inferior vena cava and was due to hydatidof the liver.

Dr. JAMES GALLOWAY drew attention to a new pre-paration described by Dr. Unna of Hamburg under thetitle "Gelantham: a New Watery Varnish." RecogDiriagthe advantages such a preparation should possess in thetreatment of many skin affections especially ecz,ma, he h-’ldattempted to obtain some of the material for trial. Failing- in his efforts to obtain the substance from the firm men-tioned in the article referred to, he had consulted withMr. Skinner, dispenser at the Great Northern Hospital, whohad produced a very satisfactory preparation, making :1!:-e ofprocesses which were a modification of those described byDr. Unna. Dr. Galloway then described the method Vth chMr. Skinner had made use of, by which he bad ma,le the. preparation in a considerably shorter period than that descr bedas necessary in the above-mentioned article. Specimensof the remedy were shown to the members. Dr. Galloway,remarked that it was as yet too soon to speak o’ the results’of treatment. He had, however, used the preparation in

several cases of eczema with satisfactory results. Thesubject had been brought forward especially with the pur-pose of showing that the preparation was not a difficult oneto make and to suggest its use in treatment.

Dr. MALCOLM brought a case of Congenital Malformationof the Heart. The patient, a man aged thirty-five years,presented in a marked degree the usual signs of such a con-

! dition, while the clubbing of the finger ends was excessive., Dr. Malcolm particularly drew attention to the age of the: patient as being remarkable when considered in connexion, with the marked incompetence of the heart. The cyanosis.

was increasing., Mr. ALLAN HAIR exhibited a case of Gumma of the Bursa: Patellae in a woman about forty years of age. On the skin

of the lower half of the leg of the same limb there weresome typical tertiary syphilitic ulcers. There was an opening

, in the skin over the bursa through which the sloughing! anterior wall of the latter protruded.t Mr. TRAER HARRIS showed a case of Fracture of the

Lower Jaw treated by Hammond’s interdental splint. Thefracture was in the usual position between the canine andlateral incisor teeth, but the displacement had been thereverse of that commonly met with, since in this case the

- smaller fragment was displaced downwards. The patient,

had been wearing the splint for eight weeks-that is, for aperiod rather above the average, because there was still asmall sinus leading down to the fracture and because it was

. feared that there was necrosis causing a delay in the unionof the fragments.

, Mr. MowER WHITE showed (1) a case of Rupture of theLeft Adductor Longus Muscle, the result of an accident

while riding ; and (2) a case of Fracture of the Olecranon. treated by wiring.t Dr. FREYBERGER exhibited pathological specimens illus-

trating Tuberculous and Typhoid Ulceration of the Intestine.. Of special interest were the intestines of a boy aged seven years who had died from hypostatic pneumonia at the end of the: fourth week of typhoid fever. The small intestine contained- numerous ulcers, some of which were already healing; but: in the last ten inches of the ileum and in the cascum,

ascending and transverse colon, were numerous solitary) follicles, swollen, infiltrated, and in many instances necrotic., Two brothers and a sister under treatment at the same time

for typhoid fever were doing well.

MIDLAND MEDICAL SOCIETY.

Exhibition of Cases and Specimens.-Gastrostomy forŒsophageal Obstruction.

AN ordinary meeting of this society was held on Nov. 25th,Dr. ALFRED H. CARTER, President, being in the chair.Mr. T. F. CHAVASSE showed a man aged eighty-six suffer-

ing from Multiple Lipomata of the Tongue. The largest wasof the size of a Tangerine orange, and had been growing fortwenty years. The patient declined to undergo any operativetreatment.

Dr. KAUFFMANN showed a lad aged sixteen years whosuffered from Pseudo-hypertrophic Muscular Paralysis ofa somewhat unusual form. He had never been able to run,and ever since he had walked had worn irons " on his legs.He was now able to walk quickly, but the gait was character-istically waddling from weakness of the extensors of the

hips. The glutei and all the muscles of the thighs weregreatly wasted, the right side being afEected slightly morethan the left. The muscles of the calves were enlarged andshortened, pointing the feet to a slight degree; the knee-jerks were nearly absent. The shoulder-girdle muscles were,however, entirely free from either wasting or pseudo-hyper-trophy. The mental condition was excellent, and the

patient had two sisters and one brother neither of whomshowed a trace of this disease No account of similaraffection on the mother’s side could be elicited.

Professor SAUNDBY showed part of the Intestine with

Typhoid Ulceration, from the body of a girl who was sentinto hospital as a case of pneumonia ; but he had diagnosedtyphoid fever, mainly on the balance of probabilities. Shewas extremely emaciated, but had only taken to her bed aday or two before admission. While in hospital she wassemi-comatose, the abdomen was flat, slightly tender andfree from rash ; the spleen was not enlarged; the bowelswere confined and the stools atypical. The temperature wasirregular, sometimes as high as 104° F., at others subnormal.