The Journal of the Melbourne Medical Students' Society

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Si Speculum Placa, Inspice.

tbe Zpecutum

THE JOURN'AL OF THE

MELBOURNE MEDICAL STUDENTS' SOCIETY.

Voari.) of Management:

Editor .. C. CRAIG.

Sub-Editor H. C. MALING.

Business Manager H. MAUNDER.

112epresentative6

The Faculty of Medicine PROFESSOR R. J. A. BERRY.

Graduates DR. F. L. APPERLY.

MR. H. R. DEW.

Melbourne Hospital Clinical School . W. C. DONALDSON.

Alfred W. J. SAXTON.

St. Vincent's W. J. O'LOUGHLIN.

3rd Year .. K. MeG. STEELE.

2nd Year C. B. MELVILLE.

Women Students MRS. E. 1VIcDONALD-WHITTLE.

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TAKING BLOOD FOR THE WASSERMAN TEST

Suggestion for a New Technique

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tbe Zpeculum

No. 112. JULY, 1923

3 JTew 1Remarhe on t berapeutics an treatment.

By DR. R. H. STRONG.

It would seem that we are passing through a period in which, notwithstand- ing our wonderful advances, there still exist those who, for lack of knowledge, endeavour to ridicule the procedures which are of ten resorted to by competent and experienced men. Their tendency is to throw doubt upon any method which fails to stand before what they call "known scientific facts"—meaning by scientific facts, laboratory results—and to ignore the fact that, even if the explanation given as to the means by which a remedy does good is wrong, this in no way impairs the value of the statement that it does good. Such critics do good in that they push to the front the need of rational processes in treatment, and because they cause the practitioner to hesitate and think before he proceeds to the use of a remedy on hearsay or the advice of someone else. They of ten do harm, in that they discourage those who are doing their best, with the knowledge that scientific investigation and clinical experience has given them, and, like the religious agnostic, they take away faith and give nothing in its place, although this faith is often founded on years of careful bedside experience, and hundreds of tests made under most severe conditions.

Until recently the accepted means of treatment consisted solely in drugs, in climate, in hydrotherapy and electrotherapy. Now, the wide fields of therapeutics covered by serum therapy and vaccine therapy have been developed with more approach to specific treatment than we have ever possessed. During the time that these advances have been made to pharmacologists, the chemist and pharmacist have enriched the Materia Medica lists, with the result that remedies are better understood, new ones of great value have been evolved, and all of them placed in such a form that they can be easily employed.

The skill of the individual physician in adjusting his doses to the needs of a particular case, in choosing one drug instead of another of the same type for a particular action, is still the skill of the empiric, and not the skill of the laboratory investigator. If a given dose of a given remedy were suitable for a given ailment, there would be little need for the physician, except as a diagnostician.

The man with bedside experience gains his great value from his experience of the many changes in all living persons, and the different effects of disease in different individuals. The pharmacologist may lay down the fundamental processes, but the clinician must make the distinctions in their use which develop results which we desire. The variation from the normal in the body affected by disease may completely reverse the known effects of a drug upon a healthy organism.

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There can be no doubt that remedies often gain a reputation that they do not deserve, chiefly because of coincidence of improvement with their administration, when in reality there is no relationship of cause and effect, or because the imagination of the physician or of the patient plays a role which in the physician should be controlled, but which in the patient is advantageous. In either case a remedy may seem to be beneficial when it is really inert. Frequently remedies have proved themselves of value, even if their effects are inexplicable. In many instances the advance of knowledge and investigation has discovered how they do good after many years of use. This is exemplified in the case of quinine, which was used for many years before the methods of action were determined, and of digitalis, the physiological action of which was for a very long time thought to be quite the reverse of what we know it to be to-day. Frequently our faith in the efficiency of a drug is shaken when untoward results occur. Nothing happens without a cause, and careful investigation will often make the unexpected result clear. Claude Bernard stated : "In physiological studies we must always carefully note any fact which does not accord with received ideas. It is always from the examination and the discussion of this exceptional fact thal a discovery will be made, if there is one to make."

Between the time of writing a prescription by the physician and the actual taking of the medicine by the patient many possible causes of unexpected results may occur. The prescription itself may be at fault, either as regards the dosage of the drugs, or in using of some incompatibility which may quite neutralise or completely alter the action of the ingredients. Wrong dispensing of a correct prescription may happen, and fatal consequences have occurred from these mistakes. The risk of a wrong prescription is lessened by the fact that it must pass under the eye of the dispenser, though even that does not remove all risk.

It behoves practitioners who do their own dispensing, in places where there is no druggist, to check their work carefully. Nowadays most dispensers check prescription and preparation, and even mark that fact on the label.

Untoward effects may be due to the drugs rather than to the patient.

Strengths and compositions of preparations are laid down in pharmacopoeias, yet many are prone to alter with time. Ergot and hyoscyamus depreciate and become useless by keeping. Spiritus wtheris nitrosi also easily degenerates, and loses the nitrite of ethyl, to which principle it owes its vasodilating and diuretic action. Oxidation causes it to become inert. Morphine, if kept for a time, becomes partly transformed by slow oxidation into apomorphine, and this change will explain many cases of emesis after administration of the drug. Chloroform, too, degenerates, especially in the presence of light. Other preparations, like alcoholic solutions, tend to become stronger by evaporation of alcohol. It is necessary, therefore, to make sure that drugs are reliable in every way, as other- wise treatment, however well thought out, may fail. The best way to be sure is to use only preparations that are made by reputable manufacturers. Even then untoward effects may be met with, which are due to various causes. One of these is the method or manner of administration of a drug. Capsules are convenient, and are used fairly generally, but occasionally they give rise to nausea and vomiting, while, if such preparations were taken in mixtures, no ill effects occur. Certain drugs require the proper amount of dilution, and these should not be ordered in capsules. Tablets and pills are commonly prescribed.

In fact, there is a great tendency nowadays to use these forms rather than trouble to write prescriptions. Often, owing to the solidity, the patient may fail to react to the medicine, and may appear to be exhibiting an abnormal tolerance

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to the drug, when, as a matter of fact, the medicine passed through the alimentary canal unchanged. This is seen in the case of iron and of quinine preparations.

It has often been my experience to see malarial cases fail to react to quinine, and, on enquiry and investigation, it has been found that solid preparations of the drug have been used, which would not dissolve, and might just as well not have been given. In a similar way cases of anaemia fail frequently to show any benefit from prolonged treatment by iron because of the insolubility of the pills used.

The time of day at which a drug is given may influence its action—for example, a soporific given in the morning will not produce sleep nearly so easily as when given at the end of the day, when the tired condition of the individual predisposes him towards sleep.

Very many people find that certain articles of food do not suit them, and, without being able to give any further reason, they learn to avoid such things.

Certain foods are specially apt to affect some persons in a special way, and everyone has met individuals who could not take strawberries or shellfish without being more or less disturbed. In the same way certain drugs are apt in certain individuals to produce untoward effects, which follow a very small dose, or they may produce symptoms in susceptible people which apparently have no resemblance to the ordinary toxic effects of such drugs. Potassium iodide is a well-recognised example.

These conditions may occur in the apparently healthy, but in disease many drugs may have most dangerous effects which are not seen when the individual taking them is healthy. Opium preparations are dangerous if used freely in bronchitis with profuse expectoration, because opium dulls the bronchial reflex, and depresses the respiratory centre, and hampers Nature's efforts to keep the respiratory passages free by frequent coughing. In nephritis also opium may have untoward effects, as it is difficult for the injured renal epithelium to get rid of it.

It has been said, "Treatment is an art and an inspiration." Only the properly educated man can hope to attain to it, because the ignorant may have the inspiration, but not possess the discrimination necessary for the art. Many, even after a lone, course and attendance at numerous lectures, never achieve it either as an art or as an inspiration. Treatment is based on several factors—physiology, pathology, chemistry and pharmacology. All these combined form the basis for therapeutics. This art is attained only by the person who learns the necessity for correlating these, and who recognises the human element in each and every individual case. The man who learns therapeutic management and human management knows how to treat a case, whereas the man who knows only pharmacology does not know how.

Treatment can be learned only at the bedside. Therapeutic efficiency is just as hard to acquire as is surgical technique, and its learning comes in the same way. One cannot learn either in a laboratory or a lecture room, although very much that helps can be learned in both. "It takes a lot of experience to make a commercial florist of a botanist, and a world of it to make a therapeutist of a pharmacologist" is a very true statement. Experience counts just as much in medicine to-day as it ever did, and medicine is still an art as well as a science.

A well-known London physician in one of his books wrote : "I am disposed to think that medicine as an art is now in some danger of being lost amidst futile efforts to exalt it into an exact science. I maintain that a great physician' is, and must be, a great artist." The trend of medical teaching and writing is to

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make medicine an exact science. The student is encouraged to be strictly scientific in the methods employed for arriving at a diagnosis, and to base treatment on proved facts. The medical man who fails to keep himself abreast with the recent march of science, or to whom the study of new ideas is irksome, can never have a firm grasp of his profession, and it would be the better for everyone if he decided that some other vocation were more congenial. It is unfortunate that a few men, as they grow older, are inclined to become sceptical about the value of all treatments, old or new. It will be generally found that these men have never thoroughly mastered their profession; they have managed to get a diploma or degree, and are able to go through the daily routine of work, but it can hardly be with much satisfaction to themselves or benefit to their patients.

One advantage the elder practitioner has, or should have, over the younger is his greater ability to separate the wheat from the chaff. Hardly a week elapses without the announcement of some new drug or some sensational system of treatment. A great majority of these are only introduced to die an early death

—most are useless. Many are mischievous, and others have a value that is purely negative, and only make confusion worse confounded.

Sometimes, however, a contribution of importance and worth is made, such as the recent treatment of diabetes mellitus, various vaccine treatments, and sera therapy. The general idea prevails that the older generation of practitioners cannot know the new discoveries in medicine that have been made since their student days—that they are not "up to the new tips." It is forgotten that the best and most valuable parts of any medical practitioner's education is obtained during his post graduate days, and that a practitioner is always a student. No member of the medical profession can afford to say to himself, "I know enough."

A stumbling block in the way of students and young practitioners is the multiplicity of drugs with which the market is flooded. They come chiefly from overseas, and are accompanied by volumes of literature extolling their particular virtues. The result of this is that official remedies are apt to be supplanted by compounds of proprietary nature, and prescription writing is rapidly becoming a lost art. The young doctor is saved, or, rather, saves himself, the trouble of thinking and combining official drugs in an ordinary prescription. The aim of the present communication is to direct the attention of readers of "The Specu- lum" to the necessity for a practical knowledge and acquaintance with the official drugs and preparations of the British Pharmacopoeia. Such familiarity will enable students and practitioners to have a better understanding and appre- ciation of pharmacology, and be less dependent on the pharmacologist for pro- tected proprietary preparations. Each will thus be enabled to trust to his own judgment based on the only safe foundation—clinical experience.

"The whole of the English-speaking press will watch with interest the court- ship of the Duke of York," stated a recent issue of a Chicago newspaper. It would surely be less embarrassing for His Royal Highness if a Select Committee were appointed.

--"Punch" (Eng.).

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--•- • ----

Albert Abrams. foot or %age?

A PLEA FOR AN INVESTIGATION OF HIS NEW PERCUSSION METHODS.

If originality be the criterion of genius, Albert Abrams must be ranked among the immortals.

A graduate of Heidelberg University, and the possessor of the degrees M.A., M.D., LL.D., he became eventually Professor of Medicine in the Stanford University, San Francisco. With these qualifications he must be regarded as a man of considerable intellectual ability.

He has written voluminously, and as late as 192o and 1922 articles by him have been accepted by such reputable publications as the "Lancet" and the

"Journal of the American Medical Association."

His refreshing originality is perhaps best exemplified by his completely novel views on the art of percussion and his peculiar technique. The basis of his contentions is that tonicity is conferred to the viscera by the magnetic lines of force which traverse them. Hence, the orientation of the patient counts for much—for accurate percussion he must face due west.

He states further that the area of dullness of any organ is increased "pari passu" with the tonicity. Many of his statements should be easily proved or disproved by anyone who likes to devote a few hours to his methods.

He claims that there is a variation of ²curs. in the position of the upper border of liver dullness when the patient turns from west to north. The upper border of deep cardiac dullness varies similarly by i cm., and other organs show corresponding changes.

His percussion technique varies considerably from the orthodox text book method : "Stand the patient facing due west, with his legs separated, on an earthed copper plate. With the middle finger of the right hand tap the acromial

end of the left clavicle. At the same time draw the left forefinger across the chest from the axilla towards the sternum." As soon as the finger reaches the left border of the heart the percussion note on the clavicle changes. The upper and right borders may be similarly obtained.

An extraordinary claim—one which, by the way, is accepted by Sir James Barr—is that cancer of any organ will .result in demonstrable dullness over an area of 5 ems. in the left interscapular region.

No reason is adduced, but the area is only apparent when the patient faces due west.

Other claims which are easily investigated are that the blood pressure varies as the patient turns from west to north, and that a slightly lower reading is obtained if the feet are brought together—i.e., the circuit is completed and tonicity in the vessels diminished.

We admit the apparent absurdity of these contentions, but would plead for an investigation by students and honoraries. To disprove should be easy, and would stimulate the very difficult art of percussion.

Dr. Abrams' originality shows no decline with his advancing years. Long distance diagnosis has now claimed his attention. He issues his instructions : Collect a sample of blood, and spread it over ⁴sq. ins. of blotting paper—the patient during the process must stand facing the west—the light must be subdued, and there must be no red or yellow colouring in the room. By examinations of the blood Abrams claims to be able, not only to diagnose the disease, but to tell

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the race, sex and age of the patient. Most remarkable of all, however, is a machine of his own invention—the oscilloclast—an electrical device whose vibration rate can be varied. Ahams states that each drug has a specific vibration rate, which 'can be ascertained [how ?]. The oscilloclast is then tuned to this rate, and allowed to play upon the patient, who thus receives all the benefits derived from taking the drug by mouth ; for example, if the machine is set at the vibratory rate for atropine, the patient who is subjected to its oscillations will develop a dry mouth, dilated pupils, etc.

Can we regard Abrams seriously? Hardly. He is probably an example of another able man gone very wrong. And yet we wonder whether there may not be a germ of truth at the bottom of his wierd conceptions. Has anyone ever troubled to disprove his statements about percussion? It is worth trying. Occa- sionally it is the unconventional that is true.

CI

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Ebe Vanning of 36occaccio.

A BALLAD OF BOOKS UNBANNED.

I.

Now this is a ballad most meek and sedate, Though it fails to solve its own query ; It has as its aim the casting of blame

On an undemonstrable theory--

The theory that Laws are made with good cause By people who quite understand,

And so could give reason why only this season Boccaccio's books have been banned.

II.

Casanova may speak, with his tongue in his cheek, Of how he escaped from "The Leads,"

Of the Ladies he captured and those he enraptured, While the moralists go shaking their heads.

Of his low escapades and the gaming-house raids, And how he escaped reprimand :

He may garnish each story with guilt or with glory—

So why is Boccaccio banned?

HI.

And though Rabelais writes of his greatest delights, Not caring a rap for the rules ;

With the wit of a monk most shockingly drunk He tilts at both pedants and fools.

Though he's lewd and outrageous, his mind is courageous, He heeds not the Censor's demand ;

If he tickles his rib with the point of his nib—

Then why is Boccaccio banned ?

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IV.

And Jonathan Swift, with ironical gift, Oft stepp'd o'er the bounds of good taste ;

Of the Church he was Dean, and therefore quite "clean"—

In fact, he is utterly "chaste."

But his sacrosanct brother, Lawrence Sterne and none other, Had humour both modest and bland,

While a prurient smirk spiced the whole of his work—

Then why is Boccaccio banned?

V.

Would ye send William Blake to his death at the stake For his songs giving tongue to desire?

Would ye banish romance from Anatole France, And have Fielding put to the fire?

Does Gautier sicken the pious, or quicken?

Is Congreve of infamous brand?

Aristophanes' plays set the smoke room ablaze—

VI.

Droll tales and pert plays of Love's devious ways From Chaucer to Balzac and Sue,

And the risque ref rains of literary swains In Ballet and Masque and Revue :

All sing to the sway of our Goddess to-day, All bow before her command ;

Though the Law come between us we still worship Venus—

So why is Boccaccio banned ? VII.

Leander and Hero, the vices of Nero, And Heliogabulus to boot,

The sins of Agrippa, the Pompadour's slipper, Are tales that one dare not refute.

And Villon may sing of a harlot or king In Ballades most graciously planned,

Without an embargo restricting his "Margot"—

So why is Boccaccio banned ? VIII.

The Arabian Nights have increased our delights By a thousand and one naughty stories ; For this we are certain that old Richard Burton

Added much to our literary glories.

And Catullus' lyre stirs up our desire With music that none can withstand ;

While Swinburne re-sings to the same muted strings—

Then why is Boccaccio banned ?

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IX.

And Sappho herself, who sang not for pelf, )t Yet in tones more sweet than a dove,

Would ye have her songs burnt because she had learnt The delights of her Lesbian Love ?

Would ye set up a bar to the Queen of Navarre, And the Tales that came from her hand?

Would ye mutilate Scarron until he was barren?—

X.

Must Dryden be read in secret and dread?

Must Byron be studied in stealth ?

Is Beaumont and Fletcher the fare for a lecher?

Is Chaucer compounded of filth?

Must Shakespeare bow down to the Moralist's crown, Must he suffer the Peckniffs' command ?

Should he take off his hat to such petticoat chat ?—

Then why is Boccaccio banned ? XI.

The Bible, of course, is a spiritual force—

There are chapters one thinks of with dread ; Tpough often excused, they are seldom perused,

Being usually taken as read. . And yet as it stands in the innocent hands

Of those in our Christian land,

One puzzles in vain and seeks to explain—

Why Boccaccio ever was banned.

12/4/23. —R.S.E.

A LABORATORY DEMONSTRATION TO THE PUBLIC.

The professor's instructions to his assistants :—

"This department is to be open to the public on Thursday. Let us prepare for them.

Miss B—, set the mechanical stirrers going at twice their usual speed.

Put about a number of jars of coloured water. Scatter round plenty of pink gauze. Make a great show of activity.

Mr. B—, put a mouse under the bell-jar, and fake the manometer at ioo atmospheres pressure. Set out the sphygmograph that amused the ladies last year. Show the great models of the eye and the ear. Everywhere let there be an appearance of scientific progress."

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Greatraho anb (Dr. bichson.

A recent rummaging in an obscure shelf brought to light an old book called

"Family Romance, or Episodes in the Domestic Annals of the Aristocracy,"

by Sir Bernard Burke, Ulster King of Arms. All the episodes are highly enter- taining, but there is one of outstanding interest. It is "The Personal History of Valentine 'Greatraks," whose rise to greatness as a faith-healer created as much agitation three centuries ago as did that of Hickson to-day. Greatraks, or the "Irish Stroker," was born in County Waterford, Ireland, in 1628. He came of a good family, and is described by his son as "one that had a liberal education, and a competent estate left him by his father (who was known to be a worthy person, and well esteemed in his country), a man looked upon to be of generous spirit, but one that had a mind above his fortune."

Of the possession of such a "mind" he gave no indications until the year 1662. Then an extraordinary change came over him. "I had an impulse," he writes, "or a strange persuasion in my own mind (of which I am not able to give any rational account to another), which did frequently suggest to me that there was bestowed on me the power of curing the King's Evil, which, for the extraordinariness of it, I thought fit to conceal for some time." At length he told his wife, who wouldn't believe him. But one William Maher brought his son to the house, and within a month the child was perfectly cured. The career of Greatraks was started. He next touched Margaret MacShane, who had been given over by the famous physician, Dr. Anthony, and her he cured in six weeks.

Greatraks' method was to rub the affected place with his •hand, whence he was called by his contemporaries the "Stroker," and offering at the same time prayer

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to Jesus that the sufferer might be healed. Shortly after this he cured several other people of the Evil. So great was his success in this direction that he decided to 'extend his activities, and to include the Epidemical Ague within his sphere. In this he was equally successful.

After these triumphs it is no wonder that in 1665, on the Sunday after Easter, he should feel "that the gift of healing was communicated to him by God." This apparently was the feeling he had been waiting for, for immediately afterwards he set up as a healer of all ills. His fame had spread all through Ireland, and the sick crowded in on him from every quarter. "I was left no time," he says, "to follow my own occasions, nor enjoy the company of my family and friends." Three days a week he set aside, from six in the morning till six at night, to lay hands on all who came.

About this time he was assailed with many inquiries. "Some demand of me why some are cured and not all? To which question I answer that God may please to make use of such means, by me, as shall operate according to the dispositions of the patient, and therefore cannot be expected to be alike effected in all. Some will know of me, why or how I do pursue some pains from place to place till I have chased them out of the body, by laying my hands outside of the clothes only (as is usual), and not all pains. To which I answer that—and others have been abundantly satisfied that it is so—though I am not able to give a reason, yet I am apt to believe there are some pains which afflict men after the manner of evil spirits, which kind of pains cannot endure my hand, nay, not my gloves, but fly immediately, .though six or eight coats and cloaks be put between the persons and my hand. Now another question will arise, whether the operation of my hand proceeds from the temperature of my hand, or from a Divine gift, or from both? To which I say that I have reason to believe that there is some extraordinary gift of God." The confidential source of his "reason to believe" he does not reveal.

The star of Greatraks was rapidly rising. Soon he received a summons to England, and, shortly after this again, received the royal mandate to appear at Whitehall. He proceeded in triumph to London, was presented at court, and set up in lodgings at Lincoln's Inn Fields. Then he publicly cured the sick, and filled the city with amazement. St. Evremond, a cynical Frenchman, who was in London at the time, derived a great deal of sardonic enjoyment from the spectacle of one of Greatraks' assemblies.

"The Irishman made them wait a considerable time for him, but came at last, in the midst of their impatience for him, with a grave and simple coun- tenance, that showed no signs of his being a cheat. The cripples and others pressed round so impatiently to be the first cured that the servants were obliged to use threats, and even force, before they could establish order among them.

"The prophet affirmed that all diseases were caused by evil spirits. Every infirmity was with him a case of diabolical possession. The first that was presented to him was a man suffering from gout and rheumatism, and so severely that the physicians had been unable to cure him. `Ah,' said the miracle worker,

`I have seen a good deal of this sort of thing in Ireland. They are watery spirits, who bring on a cold shivering, and excite an overflow of aqueous humours in our poor bodies.' Then, addressing the man, he said, 'Evil spirit, who hast quitted thy dwelling in the waters to come and afflict this miserable body, I command thee to quit thy new abode, and return to thine ancient habitation!' This said, the sick man was ordered to withdraw, and another brought in his place.

This newcomer said he was tormented by the melancholy vapours. In fact, he

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looked like a hypochondriac. 'Aerial spirit,' said the Irishman, 'return, I command thee, into the air ; exercise thy natural vocation of raising tempests, and do not excite any more wind in this sad, unlucky body !' A third patient then came forward, who, in the Irishman's opinion, was only tormented by a little bit of a sprite, who could not withstand his command for an instant. Turning to the company, he said, 'This sort of spirit does not often do much harm, and is always diverting.' To hear him talk, one would have imagined that he knew all about spirits, their name, their rank, their numbers, their employment, and all the functions they were destined to."

The following is St. Evremond's analysis of the influence gained on the popular mind :—"So great was the confidence in him, that the blind fancied that they saw light, the deaf imagined that they heard, the lame that they walked straight, and the paralytic that they had recovered the use of their limbs. An idea of health made the sick forget for a while their maladies ; and imagination, which was not less active in those merely drawn by curiosity than in the sick, gave a false view in one class, from the desire of seeing, as it operated a false cure on the other from the strong desire of being healed. Nothing was spoken of in London but his prodigies, and these prodigies were supported by such great authorities that the bewildered multitude believed them, almost without examination, while more enlightened people did not care to^, reject them from their own knowledge. The public opinion, timid and enslaved, respected this imperious and apparently well authenticated error. Those who saw through the delusion kept their opinion to themselves, knowing how useless it was to declare their disbelief to a people filled with prejudice and admiration."

r

re

Ebe 'neuroses.

Few medical men have any real patience with the neuropath; there is ample physical disease in the world to occupy their minds and tax their energies without the bother of imaginary ills, so-called. It is hard, when one looks closely, to see the reason for the prevalent belief that physical pain is real and mental anguish only imaginary. Both have their causes. The physical is obvious.

The origin of mental suffering is always there for those who will seek it ; but it is often extraordinarily difficult to find, and very seldom sought. It is almost invariably, in the neurotic, unconscious, and can only be brought to light by definite method. The neurotic is always in an exceptionally difficult position, because he is the object of an attack by a phantom enemy, the nature of which he is entirely unconscious. Once conscious of his enemy, he can return the assault and come out the victor. It is because he can only state his symptoms and cannot give the cause that we regard him as unreasonable. I wish to give you a short summary of the practical treatment of the neurotic. We may pro- ceed by first of all dividing the neuroses into some practical working form.

Following the classification of Ernest J ones, we may divide all neuroses into ( ) Actual and (2) Psychoneuroses. In the actual neuroses the pathogenic agents are operative at the actual time, as when the symptoms are being mani- fested. In the psycho neuroses the pathogenic agent always precedes the symptoms commonly by many years.

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Terms are confusing, for all these varieties are often clinically blended. For the purpose of this discussion I shall ask you to simply consider-

(i) The Neurasthenic.

(2) The Psychoneuroses.

Now let us form a rough concept of a typical individual in each of these groups upon which we can base our treatment methods.

The Neurasthenic.

This type of case is one in which the cardinal symptoms are an inordinate sense of mental and physical fatigue ; "brain fag," with difficulty of concentration, attention, and application to work ; with often gastro-intestinal and other minor symptoms. In such cases there is, so to speak, a quantitative loss of physical and mental energy. The treatment is essentially one of physical and mental rest and generous diet. The neurasthenic, an actual neurosis, is essentially different to the psychoneurotic, where the psychic energy is not quanti- tatively at fault, but qualitatively so.

The Psychoneurotic.

Every psychoneurotic is a seat of conflict between his will and his emotions.

His personality is the battle ground. His emotional state is the crux of the situation. It always has a cause, and, when we find the cause, we can cure the condition ("Turn demum" in the Latin). The psychoneurotic is a vicious circle of ever-increasing intensity, in which a fight between reasoning and unbidden emotion and physical reaction stand at either end of the diameter. Emotionalism begets emotionalism, and the individual, perceiving his new-born emotion and its associated ideation controlling his will and reason, and increasing his conflict, vaguely fights for a release, which, if not successful, gradually undermines his confidence in himself, and it is this lack of confidence and a false magnifica- tion of the importance and difficulties of his condition which is so very apparent.

His mental unrest clouds his life, and, with emotional mental tension continuous, the effort to correct things is always with him. Life loses its correct perspective.

The mind for any period of time can only be held by one emotion. Where anxiety and self-worry prevail, joy and other, emotions have no room to enter.

The pleasures of social intercourse are lost, because he cannot respond. Memory is faulty from lack of attention, concentration is impossible, and symptom upon symptom ensues, each of which produces further worry and concern, always forcing introspection and increasing the circle. It is essentially an unhappy illness. Consider this emotional state. What is its cause? We may answer briefly thus. Life is to a great extent a matter of wishing and striving—i.e., of desires. Certain desires we cannot gratify for many and varied reasons. So we have to repress them, and consciously forget them as such, pushing them to the limbo of forgotten things—the so-called unconscious mind. These repressed desires remain there, but are dynamic, and effect consciousness by producing mental conflict unless in some way gratified or sublimated. We have two forces

—first, the wish, and, secondly, the repression of the wish.

The result is a compromise. The repressed wish gains fulfilment by appear- ing in the person's unconscious phantasy, and is only admitted to consciousness in distorted form, such form being determined by the individual's association of ideas. Repression is not absolute, but it as a rule prevents the significance of the wish from reaching consciousness—i.e., our enemy is unknown. The resulting emotionalism and ideation is a mystery to the person afflicted with it. He

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attributes it to any but the right cause, and nearly always seeks a physical explanation. Of human desires the greatest are undoubtedly the sexual and those pertaining to self-preservation. Such desires usually produce the greatest psychic trauma.

The Hysteric.

Here the origin of the condition is the same, but we have physical manifestations as a solution of the mental conflict. Every hysteric's symptoms are the means by which he has gained mental peace. Every good physician is therefore a disturber of this peace.

Hysteria is divided into-

i. Anxiety Hysteria.—Where repressed mental complexes produce a certain emotional state, a morbid anxiety with physical manifestations of this anxiety.

2. Conversion Hysteria.—Here, by a process not involving mental anxiety, the mental processes directly produce the symptom. The symptom is the symbol of the complex.

(The term complex signifies a set of ideas repressed.) Treatment.

General.—Treat your patient as a reasonable human being in very great difficulties with an understanding as nearly scientific and real as you can give.

No neurotic understands his condition. If he did he would cure himself without your aid.

Prove to him that you really understand him. Show him the cause of his condition in general terms. Give him something definite to work upon, and throw the onus of cure upon him. Give him an objective interest in himself.

Asking him to use every effort to struggle against his emotion is obvious folly. Make him analyse and slowly work with you. It will reserve his strength.

Show him that a cause is discoverable for his condition, and assure him the road to cure is a sinuous track, and see that he keeps this track.

Further treatment will fall into two categories :—

I. Symptomatic.—By suggestion instilling ideas of equal potency and directed against the morbid ideas. Displacing one emotional state by another of an opposed nature.

2. Radical.—Psycho-analysis.

The decision is of ten difficult, and must be as the individual case dictates.

Psycho-analysis is in most cases a necessity, but suggestion is of great use, and more often the only practical method available. It is only with difficulty that we realise the power of the idea. It is the preliminary of all action and progress.

The following are the methods of suggestion one may use :-

I. By art create an emotional state in your patient which gives him a new viewpoint. Such an effect can only be produced by great mental energy and an absolute conviction in one's own powers to influence another. A religious conversion by the emotions is an equivalent example.

2. Hypnosis.

3. Suggestions given in semi-hypnotic state (Bramwell's method).

4. Baudoin's method, used by Coue.

5. The method of completely tiring the patient, used in hysterical symptoms.

Opposing your personality to the patient's for a period of five or six hours if

(26)

necessary. Such a method seems to unconsciously convince a hysteric that he can move or feel.

6. Isolation, as a means of strengthening suggestion by cutting off unneces- sary interests and forcing introspection and attention to the ideas suggested.

Finally, suggestion is always more likely to be effective if given absolutely whole-heartedly, with absolute quiet and perfect confidence. Be half-hearted and doubt your power and you will attain little result.

If you regard general psychotherapy and suggestion as unlikely to do good, you will always surely prove your contention, for with lack of confidence in your methods you will never instil the expectancy of cure in your patient.

If, on the other hand, you will openly and with care use mental therapeutics for cases whose condition is possibly all or mainly psychic, your results will at times amaze you, and you will slowly come to realise that in many cases of vague nature, where you suspected physical causes, but could not find them, that these physical conditions are but symptoms of a psychic lesion.

—CLIVE T. STEPHEN.

El ID CI 1:1 a 13

Romital ZiEbouettes.

I.

Your mind's a blank, and life's purged of joy, When he sadly murmurs, "My darling boy !"

The brainy heads and the blob of the group Beneath his brilliant sarcasm droop.

He rubs your nose in the mud, and then He tells you he's one of the mildest men ! You crawl from his clinics limp and depressed, But still convinced that he's one of the best.

II.

"Now this is a case of—Where's that man?

You prescribe for him. Yes, you can.

Here is a papule and there's a crust.

Nonsense, my boy, of course you must ! This is a case of—Where's the pen?

. . . Tell him to wait with those other men ! This is a case of—Dear me, no !

Is it half past five ? Well, I'll have to go."

III.

(To a pathologist, in absentia.) Tall, well-groomed, and pink and shy, He blushed on catching anyone's eye.

He whispered low of tumour and cyst, That confidential pathologist !

As he slopped the livers about in the sink, I'd look at him, and I'd sometimes think,.

"You're not a bigamist or a crook,

But, Charles, are you really as good as you look?"

—BLUE PETER.

(27)

Ebe Ipersonal element in Clinicing.

We wish to avoid in this article the impertinence of "giving hints to young clinicians." There are, however, one or two things about clinicing that seem so important from the students' point of view, that they are worth emphasising.

The first of these is the part played by the clinician in providing for the student the inspiration for work.

The great trouble about the Medical School training is undoubtedly the difficulty of giving responsibility to the student. The result is that he misses a very great deal of what goes to make up the interest of medical work. He takes no part, for instance, in the interplay of personality between physician and patient—the working for and gaining of the patient's confidence and gratitude.

Again, he has little part to play in the actual struggle between health and disease, and misses altogether the extreme gratification of working a cure. In short, the student is rarely in action. He is doomed everlastingly to the dull and stagnant part of onlooker. This is true of practically all parts of the hospital training.

There are one or two exceptions. The Women's is one ; the Children's is another.

But for the rest—it is work in "dead water; the whole time.

We are not "moaning" about this. It seems without a remedy in itself.

There is, however, one person who can do a great deal towards making things better—and that is the clinician. The clinician can, if he will, do much towards providing a stimulus to work. How can he do this? By introducing a more personal element into his clinicing. Teaching power is a varying thing, and a property of individual personality. It must vary from man to man. Every clinician, however, can know the names of his students, and can call his students by them. This probably seems a small thing to the clinician. To the student it means much. It gives him the impression that his teacher—a noted and eminent man—has in him a more than academic interest ; that he perceives and is sympathetic towards his own individual doubts and difficulties ; that he sizes up and is appreciative of his own personal capabilities. And this is immensely stimulating and inspiring; more so than anything else in clinicing. To be able to deliver a clinic in a masterly and consecutive manner is a great thing. To know and be able to name the students at the clinic is still greater.

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1Report of the f11).%.%. Committee, Mar, 1923.

COMMITTEE, 1923.

Chairman: Mr. C. Craig.

Hon. Sec.: Mr. J. J. Searby. Hon. Treas.: Mr. J. M. Buchanan.

Hon. Asst. Sec.: Mr. D. 0. Brown. Hon. Asst. Treas.: Mr. H. L. Maunder.

Fifth Year.

Melb. Hosp. Reps.: Mr. C. Craig.

Mr. F. Ross.

Alfred Hosp. Reps.: Mr. W. Saxton.

St. Vincent's Hosp. Reps.: Mr. L. S. Loughnan.

Third Year Reps.: Mr. A. Henderson.

Second Year Reps.: Mr. C. B. Melville.

First Year Reps.: Mr. Dixon.

Fourth Year.

Mr. T. Dawes.

Mr. F. Stephens.

Mr. N. Freeinantle.

Mr. Casey.

Mr. H. Burns.

Mr. I. Wood.

Mr. Philpott.

The Annual Meeting was held on April 13th, 1923, in the Physiology School. Sir Harry Allen again occupied the chair. The attendance was poor, considering the large number of members, but the ladies were well represented.

Sir Harry gave an excellent address. Professor Osborne gave a highly enter- taining account of his recent trip abroad.

The Annual Dinner was to have been held in the last week of first term, but it was found impossible to obtain any suitable place during that week ; it was therefore unavoidably postponed, probably till early in third term.

The date for the Annual Ball was fixed for Monday, June 18th, and a full account will appear in the next issue.

With regard to the Union grant of £15o, some new furniture has been placed in the Students' Rooms at the Melbourne Hospital, and it is hoped to make these rooms still more comfortable at some time in the near future. There is a possibility that the grant may become an annual one.

At a Special General Meeting, held on April 27th, a motion was passed altering the constitution of the M.S.S. The main feature of the new constitution is the division of the M.S.S. into five branches—one at each of the Melbourne, Alfred and St. Vincent's Hospitals, one at the University, and a Women's Branch. These branches will each have a committee, which will send delegates to the General Executive of the M.S.S.

The Committee would like to take this opportunity to thank the Melbourne Hospital staff for their generous donation of £20 to the Library fund.

At the Annual General Meeting the following gentlemen were unanimously elected life members of the Society :—Dr. A. S. Anderson, Dr. R. H. Morrison, Dr. J. P. Ainslie (former Hon. Sec.), Mr. H. W. Charlton (former Hon.

Treas.), Mr. C. W. Courtney (former Chairman and Editor of the "Speculum").

It was with great regret that we learned of the illness of our President, Sir Harry Allen, and we wish him a speedy recovery. J. J. SEARBY, Hon. Sec.

The University, 12th April, 1923.

LECTURE ATTENDANCES WHILST AT WOMEN'S.

Dear Sir,—I beg to advise you that your letter asking that students be exempt from attendance at lectures during their course at the Women's Hospital and in the Casualty Ward has been considered by the Faculty of Medicine.

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It has been the practice to excuse the students their attendances during their three weeks' residence at the Women's Hospital—that is, any student whose attendances were short would be treated as having kept the course if the lectures missed whilst at the Women's Hospital would have put him right. The Faculty approved of this practice, and resolved that, while resident at the Women's Hos- pital for intern work, students will be excused from attending University lectures.—Yours faithfully,

(Signed). J. P. BAINBRIDGE, Registrar.

The Secretary, Medical Students' Society.

El ID El CI 0

Business fil)anager'o Vage.

Old Boys' Subscriptions.

Below you will perhaps see a wafer, or a number of them. This is one way of reminding you that your subscriptions for back years are owing. The "Specu- lum" cannot run itself. Money is required to produce the Magazine, and one of the principal sources of revenue is the subscriptions from Old Boys.

PAY UP. Don't let your subscriptions get into arrears. The Committee would like to produce a better and a bigger Magazine—better even than the past few issues—and you can help us to do this by forwarding subscriptions early.

Will you ?

Each wafer represents an indebtedness of 5/--that is, a year's subscription.

This year's subscription is now due, but the wafers indicate indebtedness for past years only. The Committee hope that, by next issue, it will not be necessary to show wafers for back numbers !

An Appeal.

You probably know of Medical graduates who are not subscribers to the

"Speculum." The Committee are endeavouring to increase the circulation, and assistance in this connection would be greatly appreciated. Every graduate owes it to his old Union to become a subscriber !

Recent Graduates.

In the past it has been the practice to forward a copy of the "Speculum" to the newly-graduated, the subscription for the current year being then confidently looked forward to. The response, however, has not always been as good as it might be.

Recent graduates, who are not already subscribers, are requested to send in their names and addresses as soon as possible.

Don't lose touch. You are surely interested still in the places where you spent a few not altogether unpleasant years, and the Magazine contains the latest news of the Hospitals, the "Shop," the Colleges, and Old Boys.

Advertising Matter.

Those firms that advertise in the "Speculum" help to support the Magazine

—but they expect some return ! Give it to them on all possible occasions.

Address communications to Business Manager, Students' Room, Melbourne Hospital.

•

25

(30)

tit a 1Little neabacbc, 3Doctor !

Two years ago last Monday I had a headache. Quite a mild one it was, but, unfortunately, my young friend Brown, a Fifth Year student, happened to visit me that day.

He greeted me cordially : "Well, old chap, how are you ?" "Oh, all right,"

I replied, "have a slight headache." His face lengthened. He felt my pulse ; a triumphant gleam of intelligence overspread his features. "Hyperpiesis," he murmured ; "you should see your doctor. Can't trifle with these things. Saw three cases of arterial haemorrhage yesterday ; all men about your age ; no symptoms at all except headache. Fascinating subject, arterio sclerosis. I always think I should like to specialise in it. Great paying game. You know, we really understand nothing about it, and there is absolutely no cure." He waxed enthusiastically eloquent.

As a result of his conversation I visited my physician next morning.

"I'm afraid of apoplexy, doctor," I said.

He sounded my chest, and took what he called the systolic pressure.

"Apoplexy !" he snapped. "Rubbish ! Rubbish ! Blood pressure i io.

Apoplexy ! What nonsense these students talk. . No ! you have pyorrhcea- that's what's the matter with you. See a dentist. I can do nothing for you.

Yes, yes ! Always moving with the times, you know. Ten years ago I should have diagnosed your complaint as a chill on the liver, and cured you with two bottles of medicine. Now we know you have a disease no doctor can cure.

Wonderful the strides science has made."

This was most consoling. I paid him a guinea and went to the dentist.

"I have pyorrhoea," I said. He assumed a pose of superb gravity, and motioned me to his chair.

After a prolonged examination he snorted. "Pyorrhoea," he sniffed. "Non- sense ! No more pyorrhoea than I have ! You have several root abscesses. I can do nothing without an X-ray."

I thanked him for his advice, and made an appointment with the dental .radiologist.

He X-rayed me, and then announced he could give no report until he had conferred with several colleagues. The shadows were obscure, he said. It looked as though my antrim was infected. As a result of their combined skill they were convinced that I had no root abscesses, but, as there was rarefaction of bone, the removal of all my teeth was indicated. "And you probably have an antrum"

--they smiled cheerily—"you must see a rhinologist."

Three days later I had all my teeth extracted, to the great detriment of my appearance and my digestion. From that day I suffered with dyspepsia. I told my. dentist.

"Probably your stomach is at fault," he said. "One often sees chronic dyspepsia resulting from numerous extractions. I shall give you a note to a specialist."

I consulted him. He amused himself by alternately starving and overfeed- ing. He gave me alkalies because my stomach was too acid ; then he gave me a fractional test meal, and, as the result, told me that I had no acid at all.

"Most interesting work," he remarked. "Only a few years ago we thought we could diagnose these conditions, but, of course, that is absurd. If you had come to me before the war, I would have told you you had hyper-acidity. I could have cured you with diet and alkalies. But recent researches show that

(31)

alkalies tend to make it worse, and there is no treatment that alters it at all. It is all reflex—we know that now—and, as there are no localising symptoms, it seems almost certain yours is the result of chronic appendicitis. You must see a surgeon."

For this "complete gastronomical investigation," as he termed it, he charged me the purely nominal fee of 25 guineas.

On his advice the great surgeon removed my appendix. As I was leaving hospital he told me that my appendix was really quite healthy, but hastened to add, "But of course it might easily have become diseased." I was fortunate—

he only charged 5o guineas for removing a healthy apendix, and he gave me some parting advice free. "I think your antrum is causing your trouble," he told me confidentially. "See a rhinologist when you have some spare time."

I managed to spare an hour a few days later, and was interviewed by .a particularly profane gentleman. I understand profanity is a mark of eminence in this branch of surgery. He completed his examination. "Who said antrum?

These surgeons ! Antrum ! Rot ! Your septum is deviated. I must straighten it—it is a very simple matter." He did. At my final visit he said, as I was about to go, "I doubt whether you will get much improvement, because you are suffering from nerve strain, the result of astigmatism. An oculist could clo more than anyone else."

Undismayed, I saw an oculist, who told me I had no refractive error at all, but had definite evidence of albuminuric retinitis.

"You must have your kidneys tested," were his parting words.

For this I had to retire from the world into the privacy of a hospital for six weeks.

At the end of that time I was to receive the verdict. The doctor arrived smiling. "You are fortunate," he said. "Only yesterday I got the most recent work on this subject, which completely contradicts all we previously believed.

You must stay longer." The modern view, he told me, was that tests should extend over nine weeks, and be repeated every three months for two years. By this method, he informed me, the date of the patient's death could be foretold to within one week. "It is one of the greatest clinical triumphs of recent years,"

he added, with professional pride.

"But what about my case, doctor ?" I inquired. "Well, in your case it tells us very little, but suggests a liver or gall bladder obstruction. Removal of the gall bladder is probably the best thing, seeing you would not survive a removal of the liver." I took his advice—and then the advice of many more stars of the profession.

As a result I am now penniless. I have a jejunal peptic ulcer instead of my hyperacidity. I have had diarrhoea ever since my colectomy. I cannot eat because my false teeth have to be kept out—they obstruct the drainage from my antrum.

I have to take thyroid to prevent post operative trouble. My ton- sils have gone, and my spleen has atrophied—the result of deep X-ray therapy, which was then in the experimental stage.

But I am not hopeless.

Two weeks ago my charwoman advised me to rub a mixture of onion juice and beeswax over my kidneys. "It cooled the blood," she said, and helped to open the pores. I did so, and I have felt a new man since. I reckon another bottle will just about put me right.

(32)

Dear Dulcie,—

Here we are—some of us adrift in the horrors of Fifth Year, deeply depressed to find that we must work all day and swot all night, and regard food, rest, and sleep as sensuous indulgences to be sternly avoided until March, 1924;

others of us, after being told exactly what to do in the nursery, the school, the Uni. and the hospital for the last twenty years or more, suddenly find ourselves pushed out into a cold, strange and apparently jobless world, with no one to tell us what to do now, or to care a hang whether we do it or not—a nasty, draughty, unsupported feeling! Others of us still in the egg stage at the Uni. look forward hopefully to the time when we shall arrive at hospital, and all our troubles will be over; and Fourth Years are beginning to realise that it does not work out quite that way after all.

Various engagements have come to light—laughing Peachy and Dick Brown, bonnie Jean Apperly and her Fred. (We regard you as a sort of honorary Med., Jean. There's an honour for you, West ce pas ?) Bea has promised to look after the welfare of a desperately popular ex-college man who has given medicine a miss in baulk, and taken up a commercial life ; and Champ and Roy's engage- ment, which has had such a long incubation period, has at last declared itself.

Please goodness, there will therefore be still a little space left to squeeze a little brass plate or two on to palings in Collins Street.

Cheers for Dr. Kathleen Daly ! We are proud of you, Kath, and of Mrs.

Ossie and Percy, too.

Did you hear that a commission was appointed last year to find out why so many of the tram-men on the Brunswick line were suffering from heart failure ? Its finding was that the condition was caused by seeing certain of our colleagues hurl themselves off the tram daily, as it went whizzing full speed past Little Lonsdale Street. One of the ladies in question was enabled by her superior height to get a good take-off. Leaping high in the air, she would shut off her engine and land in a graceful spiral ; while her confederate, being little hampered by her rudimentary skirts, would descend almost equally well. The others would, however, land on the flat of their feet with a crash which would almost drive their cervical vertebrae through j their hats. The tram-men were worried at the

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MILLEDGE BROS

TRIUMPH

TRUSTY TRIUMPH

tbe Zpecutum

MELBOURNE MEDICAL STUDENTS' SOCIETY.

LEVIATHAN

"AQUATITE"

RAINCOATS

”..=.3..m...

.•

...

1

los ri

tbe Zpeculum

3 JTew 1Remarhe on t berapeutics an treatment.

Albert Abrams. foot or %age?

* tr;

Ebe Vanning of 36occaccio.

Greatraho anb (Dr. bichson.

re

Ebe 'neuroses.

Romital ZiEbouettes.

Ebe Ipersonal element in Clinicing.

1Report of the f11).%.%. Committee, Mar, 1923.

Business fil)anager'o Vage.

•

tit a 1Little neabacbc, 3Doctor !

* ^tr;