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INSANITY AND DIVORCE.
1267 country has advocated early 1the appendix, and long and constant observation has already most convincing of the contributionsgiven it to many. It is essentially a practical knowledge 3 C. A. Ballance (1905), who broughtand cannot be gained simply by reading symptoms in a book. forward statistics from many sources, including some of the ’Those who have it are justified in permitting a departure More than
one
surgeon in this
operation, probably the being a paper by Mr.
principal continental clinics. Early removal has also beenfrom what should be the recognised rule of treatment-earlv urged in " Diseases of the Vermiform Appendix and theirremoval of an appendix which is giving signs of disease. A consideration of some of the side issues raised by the Complications,"1 whilst in 1911 I read a paper before the Wimbledon Medical Society on the same subject.2 It is thediscussion at the Medical Society and by the correspondence only plan of treatment in a majority of the cases, for wein THE LANCET cannot be satisfactorily undertaken in any cannot expect everyone to possess the knowledge which will journal, however generous the editor might be in affording enable him to differentiate the more dangerous types from the hospitality of its columns. I am, Sir, yours faithfully, those which will run a mild course and subside without WILLIAM H. BATTLE. surgical interference. Those who do not operate frequently, still less those who never see an operation, cannot form an opinion as to the morbid processes in the appendix which led to the symptoms and local signs present in the case. INSANITY AND DIVORCE. These men are in the position which we all occupied some To tAe Editor of THE LANCET. years ago before the disease became so common. They that the has and that is all is immaterial what the exact wording of the recognise patient appendicitis, SIR,-It that concerns them. recommendations of the Royal Commissioners on Divorce Most surgeons have for years, I venture to say, examined may be ; what I object to is the principle, as stated by the appendix thoroughly after removal, and made a note of "E. A. A.," that incurable (?) insanity should form a the result of this examination after the diseased structure ground for divorce after five years’ confinement," even when has been opened up. To say that an appendix is gangrenous, safeguarded by the opinion of two experts. There are a or that it has perforated, is not enough ; we want to know large number of cases on record in which recovery has taken what causes the gangrene so frequently found in acute place after five or more years’ detention in an asylum, who attacks, for it may depend on many things. To publish a were at the expiry of the proposed term apparently inseries of cases of the early and successful removal of so curable. Expert evidence is not always infallible, and, to many scores of acutely diseased appendices does not do say the least of it, is at times contradictory. more at the stage at which we have arrived regarding I admit that cases occasionally arise in which curable or appendicitis than confirm our statement that early removal is incurable insanity may be a great hardship, but in my the most satisfactory treatment. The larger the number of experience these have almost invariably been cases in which the cases and the better the results, the more satisfied are previous attacks of insanity have been wilfully concealed. we that this is the right thing ; but to say that the lives of This, I think, is a perfectly legitimate ground for divorce. all of them would have been lost had this method not been "E. A. A." has not, however, criticised my chief objectioni employed is incorrect, and surely to tell many patients to the Royal Commissioners’ report-viz., "Why should that they will die unless they submit to immediate opera- insanity be pilloried as a ground for divorce more than any It has frequently been proved to be so. tion is wrong. other form of incurable illness, which is not directly due to --
Furthermore, I would add that
an attempt to recommend without any endeavour to differ’entiate between the varieties and potentialities of the morbid processes causing the acute attack does not lead to the advancement of our clinical knowledge or to the credit of the profession. Time after time a case is seen in which the question arises, Must operation be done at once ? for there are many reasons why it should be postponed unless it is imperative. There never was a time when the generalfpractitioner was so well educated or so well fitted to deal with abdominal emergencies. It is even possible that he may sometimes be too eager to exercise his skill. There is a growing reluctance to call in a doctor who always operates at once, because the idea prevails that if the patient has a stomachache, whether due to indigestion, constipation, influenza, or other common cause, the doctor will want to open the patient up. This is a great pity, because it leads to loss of valuable time in really grave attacks, for the friends wait to see if the child will not improve. Contrary to the opinion of Mr. Owen, I believe that many practitioners can give quite correct opinions as to the course of a particular attack, whilst surgical consultants can speak with considerable accuracy as to the nature of the process which has commenced in the appendix. We have had much experience during the past 20 years derived from constant observation and practice, whilst those in general work have been better instructed in the varying phases of the disease. Far more of the urgent cases are sent to the hospitals within the first 24 hours of illness than was formerly the case, the appreciation of the clinical condition is made earlier, and the operation is done as soon as possible in most institutions. In spite of this the supply of patients applying for operation in the quiet interval shows little diminution. Appendicitis is a septic disease, and will always be dangerous to the individual affected because of the nature of the membrane by which the organ is surrounded and the position which it occupies. There are also many types according to the primary cause of the attack, its extent, the history of previous attacks, the age, sex, and power of resistance of the individual. Experience will give the skill to say what is going on in
operation indiscriminately
1
Fattle and Corner : Constable and Co. 2 Clinical Journal, January, 1912.
vi1 livmo*"
T
am
ir_
vnnrc
J.
-
fnithfiillv-
BATTY
TUKE, jnr., M.D,
INTRACRANIAL COMPLICATIONS OF MIDDLE-EAR DISEASE. To the -Editor of THE LANCET. SiR,-I have read with very great interest the article by Mr. Hunter F. Tod, in THE LANCET of April 19th, on Extradural Abscess at the Apex of the Petrous Bone. Let me say at once, I am not an aurist and lay no claim to knowledge on that subject except in so far as relates to intracranial disease. Without criticism, and in an inquiring spirit simply, I wish to ask Mr. Tod if, in his experience, the commencing statement he writes is undeniableviz.,"An extradural abscess is the most frequent complication of acute inflammation of the mastoid process, being due to direct extension of the infective process through the bone to the outer surface of the dura mater, and is almost or of invariably found in the region of the tegmen tympani " the lateral sinus, the latter being most frequent." Being a disciple of Macewen, with a knowledge of his masterly work on the ’’ Pyogenic Infective Diseases of the Brain and Spinal Cord," for some years a humble co-worker with him and (I hope) an interested observer of all surgical brain cases, I am naturally influenced by such causes, and wish to state simply and briefly my experience of intracranial suppuration and an easy way of grouping complications. Geometrically considered there are six simple directions in which infective spread may occur from the middle earnamely, (1) backwards, (2) forwards, (3) upwards, (4) downwards, (5) outwards, and (6) inwards. 1. Backward spread is the most important, leading to infection, viic the iter, of the mastoid antrum, followed by rapid sepsis of the communicating cancellated bone and the horizontal and vertical mastoid cells. The mastoid bone is made up of spongy tissue, and its infections are really in the Further backward spread involves. nature of osteomyelitis. first, the space around the sigmoid portion of the lateral I sinus ; next the sinus itself (infective sinus thrombosis) ; then the membranes, causing extradural abscess or meningitis ; or, lastly, the meninges in relation to the cerebellum under the
one
surgeon in this
operation, probably the being a paper by Mr.
principal continental clinics. Early removal has also beenfrom what should be the recognised rule of treatment-earlv urged in " Diseases of the Vermiform Appendix and theirremoval of an appendix which is giving signs of disease. A consideration of some of the side issues raised by the Complications,"1 whilst in 1911 I read a paper before the Wimbledon Medical Society on the same subject.2 It is thediscussion at the Medical Society and by the correspondence only plan of treatment in a majority of the cases, for wein THE LANCET cannot be satisfactorily undertaken in any cannot expect everyone to possess the knowledge which will journal, however generous the editor might be in affording enable him to differentiate the more dangerous types from the hospitality of its columns. I am, Sir, yours faithfully, those which will run a mild course and subside without WILLIAM H. BATTLE. surgical interference. Those who do not operate frequently, still less those who never see an operation, cannot form an opinion as to the morbid processes in the appendix which led to the symptoms and local signs present in the case. INSANITY AND DIVORCE. These men are in the position which we all occupied some To tAe Editor of THE LANCET. years ago before the disease became so common. They that the has and that is all is immaterial what the exact wording of the recognise patient appendicitis, SIR,-It that concerns them. recommendations of the Royal Commissioners on Divorce Most surgeons have for years, I venture to say, examined may be ; what I object to is the principle, as stated by the appendix thoroughly after removal, and made a note of "E. A. A.," that incurable (?) insanity should form a the result of this examination after the diseased structure ground for divorce after five years’ confinement," even when has been opened up. To say that an appendix is gangrenous, safeguarded by the opinion of two experts. There are a or that it has perforated, is not enough ; we want to know large number of cases on record in which recovery has taken what causes the gangrene so frequently found in acute place after five or more years’ detention in an asylum, who attacks, for it may depend on many things. To publish a were at the expiry of the proposed term apparently inseries of cases of the early and successful removal of so curable. Expert evidence is not always infallible, and, to many scores of acutely diseased appendices does not do say the least of it, is at times contradictory. more at the stage at which we have arrived regarding I admit that cases occasionally arise in which curable or appendicitis than confirm our statement that early removal is incurable insanity may be a great hardship, but in my the most satisfactory treatment. The larger the number of experience these have almost invariably been cases in which the cases and the better the results, the more satisfied are previous attacks of insanity have been wilfully concealed. we that this is the right thing ; but to say that the lives of This, I think, is a perfectly legitimate ground for divorce. all of them would have been lost had this method not been "E. A. A." has not, however, criticised my chief objectioni employed is incorrect, and surely to tell many patients to the Royal Commissioners’ report-viz., "Why should that they will die unless they submit to immediate opera- insanity be pilloried as a ground for divorce more than any It has frequently been proved to be so. tion is wrong. other form of incurable illness, which is not directly due to --
Furthermore, I would add that
an attempt to recommend without any endeavour to differ’entiate between the varieties and potentialities of the morbid processes causing the acute attack does not lead to the advancement of our clinical knowledge or to the credit of the profession. Time after time a case is seen in which the question arises, Must operation be done at once ? for there are many reasons why it should be postponed unless it is imperative. There never was a time when the generalfpractitioner was so well educated or so well fitted to deal with abdominal emergencies. It is even possible that he may sometimes be too eager to exercise his skill. There is a growing reluctance to call in a doctor who always operates at once, because the idea prevails that if the patient has a stomachache, whether due to indigestion, constipation, influenza, or other common cause, the doctor will want to open the patient up. This is a great pity, because it leads to loss of valuable time in really grave attacks, for the friends wait to see if the child will not improve. Contrary to the opinion of Mr. Owen, I believe that many practitioners can give quite correct opinions as to the course of a particular attack, whilst surgical consultants can speak with considerable accuracy as to the nature of the process which has commenced in the appendix. We have had much experience during the past 20 years derived from constant observation and practice, whilst those in general work have been better instructed in the varying phases of the disease. Far more of the urgent cases are sent to the hospitals within the first 24 hours of illness than was formerly the case, the appreciation of the clinical condition is made earlier, and the operation is done as soon as possible in most institutions. In spite of this the supply of patients applying for operation in the quiet interval shows little diminution. Appendicitis is a septic disease, and will always be dangerous to the individual affected because of the nature of the membrane by which the organ is surrounded and the position which it occupies. There are also many types according to the primary cause of the attack, its extent, the history of previous attacks, the age, sex, and power of resistance of the individual. Experience will give the skill to say what is going on in
operation indiscriminately
1
Fattle and Corner : Constable and Co. 2 Clinical Journal, January, 1912.
vi1 livmo*"
T
am
ir_
vnnrc
J.
-
fnithfiillv-
BATTY
TUKE, jnr., M.D,
INTRACRANIAL COMPLICATIONS OF MIDDLE-EAR DISEASE. To the -Editor of THE LANCET. SiR,-I have read with very great interest the article by Mr. Hunter F. Tod, in THE LANCET of April 19th, on Extradural Abscess at the Apex of the Petrous Bone. Let me say at once, I am not an aurist and lay no claim to knowledge on that subject except in so far as relates to intracranial disease. Without criticism, and in an inquiring spirit simply, I wish to ask Mr. Tod if, in his experience, the commencing statement he writes is undeniableviz.,"An extradural abscess is the most frequent complication of acute inflammation of the mastoid process, being due to direct extension of the infective process through the bone to the outer surface of the dura mater, and is almost or of invariably found in the region of the tegmen tympani " the lateral sinus, the latter being most frequent." Being a disciple of Macewen, with a knowledge of his masterly work on the ’’ Pyogenic Infective Diseases of the Brain and Spinal Cord," for some years a humble co-worker with him and (I hope) an interested observer of all surgical brain cases, I am naturally influenced by such causes, and wish to state simply and briefly my experience of intracranial suppuration and an easy way of grouping complications. Geometrically considered there are six simple directions in which infective spread may occur from the middle earnamely, (1) backwards, (2) forwards, (3) upwards, (4) downwards, (5) outwards, and (6) inwards. 1. Backward spread is the most important, leading to infection, viic the iter, of the mastoid antrum, followed by rapid sepsis of the communicating cancellated bone and the horizontal and vertical mastoid cells. The mastoid bone is made up of spongy tissue, and its infections are really in the Further backward spread involves. nature of osteomyelitis. first, the space around the sigmoid portion of the lateral I sinus ; next the sinus itself (infective sinus thrombosis) ; then the membranes, causing extradural abscess or meningitis ; or, lastly, the meninges in relation to the cerebellum under the