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Moreover, nearly all the vitamin B being a rich source of the pernicious anaemia, be extracted with cold water. factor, is extremely rich in the pellagra-curative Among the rats which were kept on a vitamin B2- factor. It should presumably provide a better deficient diet for over nine weeks, a large proportionImaterial than yeast for the cure of human pellagra. developed a curious form of depilation. The fur As it is not yet clear that pellagra is due to a fell aff in a manner such that the animals developed simple deficiency of one factor, it is suggested, in order a " close-cropped " appearance, without there being to have greater clarity in this domain of research, any bare patches on the skin. Within four to fivethat the factor, which is assayed by means of rat days of the feeding of the liver concentrate the fur growth tests, be called vitamin Bs, while the factor to lengthen and soon resumed the normal or factors which are specifically concerned with began " " lying-down appearance. A very minor proportion the cure and prevention of experimental pellagra of the animals developed lesions in the feet and paws in rats and which are assayed by means of curative and near the mouth, and in those that did, these and preventive tests, be called the P-P (pellagra or the A-P (anti-pellagra) factor. This. symptoms cleared up very rapidly under administra- preventive) I tion of the liver extract.provisional arrangement would probably prevent It thus appears that the commercial liver extract,:some confusion.

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MEDICAL SOCIETIES antipathy to his mother and to milk in any form : he had been a homosexual. In all cases the trouble had arisen from a perverted attempt at sublimation,and this origin was probably more common than The protest against swaddling-clothes was realised. AT a meeting of this society, held on April 9th, was more likely to appear when the patient experiat Chandos-street, W., the chair was taken by Dr. a conflict between the two urges in life. Behind 0. H. WOODCOCK, the President, and Dr. LANGDON enced the of sometimes lurked shadow nervosa anorexia BROWN opened a discussion on the of anorexia subject dementia praecox, though was often extraverted ; if introversion occurred in Anorexia Nervosa. He put forward anorexia nervosa as a pathological such a case the prognosis was bad. example of the painful process of detachment of the INFANTILISM. individual from its parents. The name had been I ’ remarked that the tendency to carry Keith had given to the condition in 1873 by Sir Wm. Gull, who ’, infantile adult life had played a characteristics into in had previously described it 1868 as apepsia hysterica. He had recognised the importance of the mentallarge part in human evolution. But just as this state and had called attention to the slow pulse- andmight be a source of strength, so it might prove a. respiration-rates, the clean tongue, and the incidence weakness. Everyone tended to grow up in patches.. in young women between 16 and 21. The prognosisThe infantile psychical attitude in the psychohe had regarded as good, saying that there was hope neurotic was the manifestation of a characteristic Dr. Brown also quoted thewhich had a high evolutionary value. as long as life lasted. of Gee and Clifford Allbutt, ’i Dr. F. G. CROOKSHANK remarked that the work graphic descriptions and said that the condition was not uncommon. on this subject had all been done within living I and described a fatal case he had seen in Anorexia was usually profound and was rationalised memory, I At that time the condition had been comon one of three grounds : humanitarian grounds, the 1892. desire for slimness, or religious grounds-more often monly supposed to be the result of latent tuberin the rare male cases-allied to a repugnance against culous infection; no advance had been made on the ’, all bodily functions. After a time the inability to psychological side. He was quite sure that the cases. I much more frequent in certain cultural and take food became genuine, owing to atrophy of the digestive organs. The practitioner must always be religious milieux than in others. They were seen by on the look-out for clever ways of disposing of the physicians rather than by psychologists-often only food. It might be given to animals, or hidden in a few days before death. Most cases had had some curious places such as the piano. Constipation was form of vaceiiie treatment based on irregularities of the invariable and should be treated by paraffin andintestinal flora, and many had been in sanatoriums agar, and never by drastic aperients. Amenorrhœa for calcified glands at the hilum. The age-incidence was always present, and the return of the periods was not a rigid one ; refusal of food might occur in. was a good sign. Wasting was extreme, and thevarious types of mental case. There was, however, skin had a rough, dry character. The facies a difference in psychology between the adult case. either resigned or frightened and the nose congested ; ’and the typical adolescent case as described by Gull. the cheeks were cyanotic, and the hands cold Anorexia nervosa might also be seen in children. In blue. The expression was childish for the the typical case the individual had long shown signs of negativism and digestive disturbance, the mother age. Patients generally admitted reluctance to having paid special attention to the alimentary up, and usually showed undue dependence on the tract from an early age. The condition did not break father and hostility to the mother ; the latter might out suddenly ; there was alimentary organ inferiority. be concealed by an exaggerated show of affection, Possibly marasmus in babies might provide precocious. with constant opposition on small points ; it might examples. be admitted in the mother’s absence, or might be C. Lasegue had written an important paper in quite frank. Dr. Langdon Brown described the four 1873 describing ten cases. He had restricted the male cases he had met. One of them had developed age to 15 to 20, and had seen both male and female tuberculosis and died ; this disease was a constant cases. While appreciating the psychological origin danger to these patients. Another had had a violent and nexus, he had not gone so far as to suggest MEDICAL

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attacks of over-eating, after which she would take an emetic and fast for several days. The father and mother had disagreed and he had left the home when she was six. She had had a terrible time later with a stepmother and younger stepsister, and had begun to fast from the time when she had been wrongly accused of pregnancy. It had been an attempt not to be’a womanany longer. J. F. Venables’s cases all seemed to arise from fear either of the father or of Jehovah-i.e., fear of sex. Dr. C. ScuiFF thought that there must be some profound reason for the amenorrhoea. It might be due to some central lesion-some refusal of the whole body-common to it and the anorexia. The condition occurred in decades and in people when the bodily functions were particularly despised. The association with asceticism in history was interesting. Dr. LANGDON BROWN said that there might be a gonadal hypofunction accounting for the amenorrhoea. The fear of nocturnal emissions after a large evening meal might be the start of anorexia. Sexual suppression was, however, a minor factor. Dr. CROOKSHANK pointed out that amenorrhœa only appeared at the third stage.. Dr. M. MARCUS described a case under his care. Her improvement had begun from an engagement but had continued although the engagement had been broken. Another girl had admitted annoyance at the engagements of her brother and sister; she had had an adoring father and a nagging mother. A third patient had shown the typical first stage of pain ; her-mother had swaddled and spoiled her, but the father had now decided to send her away from home. Dr. J. asked why older cases were to be regarded as suicidal; was the type different, or was the patient hopeless ? He also asked what was the value of symptomatic treatment. Dr. LANGDON BROWN said that Sir Wm. Gull had recommended " the treatment suitable for persons of unsound mind." Glucose and insulin might be useful, but the chief lines were separation from the parent, moral suasion, and filling the bowel with

of the past. He had mentioned strong Several people had emotion and contrariety. remarked on the importance of the marriage of a younger sister. Dickens had drawn an example in Sarah Crewler, mentioned in " David Copperfield." Most of the cases had been an only child or a rival child. Lasegue had stressed the importance of studying both patient and entourage, as they were He had also pointed out how the Solidaires. was "trained" by the environment to patient the symptoms. produce Dr. Crookshank’s impression was that the fathers of female patients were weak rather than dominating. The mothers who identified with their daughters in this way were not having a satisfactory sexual life and all their libido went to the supervision of the daughter. They were smothering mothers. The children shrank from growing up because they knew that they were incapable of taking their place among their contemporaries, owing to this smothering process ; they longed to get out. It was doubtful how far the sexual element entered into these cases; the patients took to masturbation in the later stages, but it was not a primary condition. The purposive character of the manifestations had been recognised by Lasegue, who had divided the progress into three stages. The first was ushered in by some acute complaint-some severe dyspepsia. Then the patient began to say that she could not eat because of the pain; it was important at this stage not to declare that she " ought " to eat, as this drove her into a campaign of hostility, which she conducted with cunning and implacability. She should be treated gently. The second stage was that of systematisation or organisation, where the patient had her scheme mapped out and began to triumph. She suffered no more, led an active life without thirst or amenorrhcea, and ate just what she liked:*’ She would not make the slightest concession, as that would admit caprice, and any insistence only increased her resistance. The third stage was marked by thirst and amenorrhoea, and then the patient became alarmed and would accept treatment if the doctor had been wise during the earlier stages, or would go to another doctor. No patient developed tuberculosis unless she had been discouraged ; it had a definite psychological

investigation

basis. The refusal to eat might be analogous to the wild flying about of a bird in a room : a primitive behaviour which eventually found the way out. Animals suffered from anorexia nervosa. It might be a revolt against loss of liberty. The greatest psychological force active in these cases was resentment at loss of liberty. The art of treatment lay in managing both patient and mother and in separating them at all costs. Relapses were rare. Anorexia nervosa over 30 was really constructive suicide. Dr. LANGDON BROWN mentioned two adult cases in married women. One was a remarkable example of the " relentless campaign," and had succeeded in starving herself to death ; her husband had denied her the children for which she had longed. The father was often weak-" a darling "-but in some cases he was very well balanced. The CHAIRMAN mentioned a girl who had nearly died of anorexia nervosa but had recovered after her father’s death and become a great traveller. Dr. JAMES YouNG said that anorexia nervosa was a profound reaction against authoritarianism, and

quoted a case where the patient had recovered but had subsequently developed dementia praecox. An allied condition had been seen in a girl who had had

roughage.

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Dr. CROOKSHANK said that the apparent purpose of the plan in adolescence was to achieve independence, and the best way to treat the patient was to hold out hopes of that independence. The older cases were up against a dead-end and wanted to die. Brudenell Carter, in his book on hysteria, recognised the psychological basis to an astonishing extent, but he had regarded the circumstances as perfect and attempted to break the patient to them, whereas the modern therapist tried to modify the circumstances. Dr. G. GORDON described mild cases among men over 30 in suicidal wards. He thought that they were all patients who were in hospital under protest. Their refusal of food was an anti-authority protest, and he had treated it by trying to get them to make, friends with the hospital and realise the amount of liberty allowed. The condition might arise from protest against any authority-even a Government

department. Dr. S. D. ISAACS described a case in a married woman who had intensely disliked sexual intercourse, and had began to refuse food after procuring an abortion. Some 20 years later she had developed septic teeth, with complete disorganisation of the digestive tract. She had always shown intense obstinacy. Dr. E. L. TAYLOR described an adult case occurring after the fifth pregnancy, which had been complicated by threatened eclampsia. The history showed

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tragic domination and dislike by the mother, cruelty LIVERPOOL MEDICAL INSTITUTION AND in childhood, seduction by her first employer, and MANCHESTER MEDICAL SOCIETY. repeated pregnancies. She could not face the future and was refusing food, although protesting that she must get better to look after the children. A JOINT meeting of these societies was held at Dr. BEVAN BROWN doubted whether the condition He had Liverpool on March 5th, when Mr. GEOFFREY was always a protest against authority. a known cases where the first reaction was a feeling JEFFERSON read paper on the and of being superfluous unloved ; later the mother Surgery of the Pituitary Body. tried to make up for her failings and became After referring to the two main groups of pituitary " smothering." The degree of lack of insight might he spoke of the symptoms once regarded approach that of dementia præcox. Patients often dysfunction, as of pituitary origin but which now seemed to be vomited if they ate or were forced to eat a little more tuberal. Striking hypopituitary pictures might be than they thought correct. induced, he said, by tumours at a distance-notably Dr. CROOKSHANK said that the feeling of not being those in the cerebellum with retention dilatation wanted was common to almost all neuroses ; the by of the third ventricle and damage to the hypothalamus. protest against authority was more peculiar to The acromegalic group of cases were no longer the anorexia nervosa. most important clinically for they represented the minority of pituitary enlargements. In this disease the glandular change was not a true tumour, but a BRIGHTON AND SUSSEX hypertrophy with toxic secretion. The commoner chromophobe adenoma appeared to be a true tumour MEDICO-CHIRURGICAL SOCIETY. and produced its effects by interfering with the normal pituitary secretions. Mr. Jefferson thought that AT a meeting of this society on April 4th, with too much attention was paid in teaching and disMr. H. NETHERSOLE FLETCHER, the President, in cussion to the somatic effects of pituitary tumours. the chair, a paper on These required some time for their development, and an adenoma might become large enough to cause Acute Intestinal Obstruction blindness by compression of the optic nerves before He began by was read by Mr. J. R. H. TURTON. any gross signs of general body change made their presenting statistics of 300 cases of acute obstruction appearance. He thought this fact ought to be more admitted into the Royal Sussex County Hospital widely known because the diagnosis of pituitary during the past ten years-96 of these being cases of tumour was often very considerably delayed or missed obstruction from intra-abdominal causes, and 204 altogether because of the absence of those signs which cases of strangulated hernia. The total mortality the clinician had been taught to expect in pituitary proved to be about 30 per cent.-52 per cent. for the lesions. Conversely it seemed to him that the most internal cases and 20 per cent. for the hernias. It obvious pictures of hypopituitarism were given by was found that the average age of the former group who had no pituitary tumour at all. In persons was 49 and of the latter 59 years, and the duration these some infection or acute illness seemed to have of acute symptoms before hospital admission was I damaged the gland. At all events it was unwise to 2 days 20 hours, and 1 day 21 hours respectively. diagnose tumour on somatic changes alone. The highest mortality-rates were among. cases of Mr. Jefferson said that at operation he was using internal hernia, carcinoma of the colon, and multiple the trans-frontal route as worked out Frazier ,adhesions, while the lowest rates were among cases and Sargent, but he thought that for theby moderateof obstruction caused by a single band or by impacted sized cyst the trans-sphenoidal route was safer. The gall-stones. The average duration of acute symptoms was to know beforehand which was the better before admission differed widely among the different route for any given case. The risks of post-operative classes of obstruction, and the different mortalitywere certainly less by the nasal route, hyperthermia rates in the several classes could not be attributed but it was an for the more to the different periods of delay in their diagnosis. solid tumours. unsatisfactory approach Among the strangulated hernias, the mortality was Sanocrysin. 22 per cent. for the inguinal (91 cases), 12 for the femoral (90 cases), 44 per cent. for the umbilical Dr. H. T. ASHBY read a paper on the Treatment of (16 cases), and 43 per cent. for the ventral (7 cases). Pulmonary Tuberculosis in Children by Sanocrysin. The mortality among the femoral cases in the female This drug, which was introduced in 1925, was not Of received favourably, he said, when first tried in this was especially low-64 cases with four deaths. these four cases, two were late ones, each having country, the reason being that it was used in unsuitable been strangulated six days and necessitating resection cases and given in too large doses.. As time went on of the bowel for gangrene ; one was a case of toxic its value as an adjuvant was being more widely goitre which proved fatal suddenly three days after recognised. It was best used - in the so-called where there was a fresh area of operation ; and the fourth a case of chronic nephritis exudative in which the cause of death was suppression of urine. spreading disease, and was unsuitable for abdominal Fæculent vomiting was present in 24 per cent. of or renal tuberculosis. Sanocrysin was well tolerated the internal cases (mortality 56 per cent.), and in by children and was given them by intramuscular 16 per cent. of the hernia cases (mortality 50 per injection of a 3 per cent. solution, the initial dose cent.). Of the 40 cases in which obstruction was due being 0-01 g. A course consisted of 10 to 12 injections to adhesions, 21 had undergone previous abdominal with a maximum dose of 0-5 g. With these amounts operation, and in all of these the obstruction was a the children had been entirely free from undesirable direct sequel. symptoms and most had shown an increase in weight Mr. F. E. FEILDEN showed a case of intestinal and steady improvement of symptoms. The dangers obstruction due to a malignant adenomatous polyp to watch for were diarrhoea and albuminuria. The results, especially in severe cases of bad prognosis, occupying the lumen of the jejunum. ,

difficulty

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