PSYCHOLOGICAL ASPECTS OF GYNÆCOLOGY.

1265 In asthma the scanty tough material, most difficult expectorate, is due to the excess of calcium cement poured out into the bronchial tubes, and this calcium contributes to the spasm of the bronclii. The more alkaline the blood the less lime will it hold. With the alkalosis of which Dr. Cammidge speaks, the alkali being saturated with CO2, the lime is thrown down as insoluble carbonate ; hence we get a natural but clumsy attempt at cure, nature making the best use of the material at hand. Many years ago in an address on the use and abuse of the lime salts in health and disease, I said1 :to

Asthma.—In the attacks there is an excess of free calcium ions in the blood, and in the treatment, both during and between the paroxysms, the intake of calcium in the diet should be strictly regulated. During the paroxysm not merely antispasmodics, but also decalcifying agents should be freely prescribed. A milk diet should be rigidly

For convenience, and especially in view of the frequent absence of normal markings, the pre-pyloric inch is taken as the equivalent of the " pyloric canal," while the " lesser curvature region " (of Tables X. to XIII.) consists of the line of the lesser curvature together with 1 in. on each side of it but stopping short 1 in. from either ostium. The centre of the lesion, be it ulcer or growth, is. assumed to have been the starting point of the pathological process, and this is probably a sufficiently accurate assumption in the great majority of I am, Sir, yours faithfully, cases.

M. J. STEWART.

PSYCHOLOGICAL ASPECTS OF MEDICINE. l’o the Editor

excluded.

I like to draw a distinction between the free and fixed calcium in the blood, but this would carry us too far afield. The excess of calcium is often used up in making rigid costal cartilages, mischief which should be prevented by the free use of decalcifying agents and those which increase calcium metabolism, such as the citrates, iodides, and thyroid. Of course agents such as adrenalin which act on the sympathetic should not be neglected, while synergists of the parasympathetic, such as pilocarpine, should be eschewed. Dr. Cammidge and I are about the use of agreed purgatives, hepatic stimuNo doubt the lants, and intestinal antiseptics. bronchitic element is often the predominant factor when a lime salt may be required, in which case I prefer the acid salt, calcium chloride. Ammoniun chloride will also be often found useful. I am, Sir, yours faithfully, JAMES BARR.

THE ANATOMICAL SUBDIVISIONS STOMACH.

To the Editor

of THE

LANCET.

OF THE

of THE

LANCET.

general practitioner, I venture to express opinion, derived from experience, that of ignorance psychology in its relations to healingor a neglect to study those relationships-is as disastrous to the practice of the science and art of healing as is ignorance of scientific medicine. Science deals with the part, psychology with the whole individual. I have seen cases of physical disease treated psychologically, with very indifferent results, and also many cases treated physically whose aetiology was mainly psychological-e.g., a gastropexy (followed perforce by a gastro-jejunostomy) for as plain a case of negativism as could be found in any psychological text-book. And I have seen a case of SIR,—As

a

an

carcinoma of the rectum treated (in the absence of a correct diagnosis) on psychological lines. The points I would emphasise are : (1) A sound working knowledge of psychology, adequate for

general practice, is not difficult to acquire. (2) It extends the sphere of usefulness of the general practitioner to his patients. (3) It is complementary, not antagonistic, to his scientific medical knowledge. (4) It greatly enhances his interest in his work and

brings

him much nearer to his patients, for he has lines of approach to every case of illness. two ’ It is no great credit to me that I treated a man for some months for " irregular heart " until, making a study of psychology, my eyes were opened to the possibility of a psychological background to his illness. Investigation showed a dramatic story of having been shut up alive " in a huge gas oven and being rescued " at the last gasp." Frank discussion of this story completely removed a multitude of associated symptoms too numerous to set out in detail, and the man has remained well for months. One can imagine a pre-Listerian practitioner feeling about scientific medicine much what the modern practitioner sometimes feels about applied

H. M. Turnbull has drawn my attention somewhat serious omission from my recent Croonian lectures on Precancerous Lesions of the Alimentary Tract. In the section dealing with chronic gastric ulcer2 there is no sufficient indication of the exact anatomical subdivisions of the stomach " to which reference is made, for example, in Tables X. to XIII. In current anatomical nomenclature the stomach is divided into cardiac and pyloric portions, which are separated from one another by the incisura angularis of the lesser curvature. The cardiac portion in turn consists of two parts : the fundus, which lies above a horizontal plane passing through the cardiac orifice, and the body, which lies below it. psychotherapy. The pyloric portion is also subdivided into the pyloric I am, Sir, yours faithfully, canal (which terminates in the pylorus), and the HOWARD E. COLLIER. pyloric antrum, leading up to it. The pyloric canal varies in length from in. to 1 in., and is said to be separated from the pyloric antrum by the sulcus PSYCHOLOGICAL ASPECTS OF GYNÆCOLOGY. intermedius of the greater curvature. These various divisions are physiological rather To the Editor of THE LANCET. than anatomical, and in the post-mortem room it is SIR,—The Bradshaw lecturer and Dr. Crookshank often impossible to distinguish with any certainty Educate the gynecologist in psychology." either an incisura angularis or a sulcus intermedius. cry " Dr. Edwards follows, " Educate the general practiOur routine procedure is to lay open the stomach tioner." May I, as a general practitioner, add along the line of the greater curvature and to spread " Educate the public " ? It is human nature to try it out for examination on a flat (wooden) surface. to shift responsibility. So many of us would prefer a mechanical explanation of our illnesses ; it excuses 1 Brit. Med. Jour., 1910, ii., 833. us from all blame. A woman will always accept as a 2 THE LANCET, Sept. 19th, p, 617.

SIR,—Prof.

to

a

1266 I

In a case of urticaria of internal origin, whether a known primary antigen-e.g., fish or egg-is responsible (and this is relatively uncommon) or not, the liberation of histamine is presumably due to the damage resulting from the reaction of the antigenic substance with specific fixed antibodies in the dermal tissues. In a person who develops urticaria on the ingestion of a certain food, the application of it to the skin by the scratch or intradermal method will naturally cause a local urticarial reaction. When epidermal hypersensitiveness, on the other hand, is present, the reaction in the skin is an eczematous one, and it is now held that this depends upon sensitiveness of cells in the rete Malpighii. This type of cutaneous reaction is entirely distinct from the " triple response " that produces the urti. carial wheal. It is apparently independent of histamine-production, for even in eczematous persons I have never succeeded in provoking an eczematous reaction by bandaging histamine on the skin. To histamine the response is always urticarial. Although an eruption consisting of mixed urticarial and eczematous elements may occur, for example in serum sickness and fish-poisoning, thus indicating simultaneous dermal and epidermal sensitisation, it is exceptional; but an eczematous response to one antigen and an urticarial reaction to another in the same person is not very uncommon. It is owing to this difference in cutaneous reaction according to the part of the skin in which the hypersensitiveness is localised that dermatologists now use in investigating " " cases of eczema the contact or patch test, first indicated by Jadassohn, which consists in the application for 24 hours to the uninjured surface of the skin of suspected substances. As Sulzberger and Wise, MacKee, and others have recently pointed out, positive results-i.e., an acute eczematous reaction at the site of application-are often obtained by this method after the scratch and intradermal tests have

for uterine inertia that " her bones are a little too small," but she will be indignant if the cessation of her " pains " is attributed to her lack of courage, loss of confidence, and fear of pain. A patient with dysmenorrhoea will agree to an explanation of a kinked cervix, but she will rebel if the " masculine ’, protest " is served up as the true cause. I agree that the general practitioner is in the best position to assess the domestic factors in gynaecological complaints. He has seen the patient perhaps in parturition and lactation, and knows how she generally reacts to problems in general. And she will be more willing to discuss with him her marital and social problems. But all these opportunities without knowledge of their application are useless. Here is a fresh field for the general practitioner, whose constant complaint is that his field of work is rapidly contracting. As Dr. Edwards writes, the general practitioner would find a course in psychotherapeutic technique most valuable. I am, Sir, yours faithfully, FRANK BODMAN. cause

’I

CÆSAREAN SECTION.

To the Editor

of

THE LANCET.

indebted to your reviewer in the issue SIR,—I of Nov. 14th (p. 1084) for calling my attention to an error which had escaped notice in my little book on Csesarean section. The words " utero-vesical pouch " should be substituted for " cave of Retzius " on pages 67 and 69. May I also be allowed to point out that in the am

technique for suspect cases the uterus is opened as low as possible in the upper segment, and great care is taken to prevent contamination of the peritoneal cavity with infected liquor amnii. Uterine massage is employed, along with pituitrin and ergotin, to ensure the good retraction specially necessary in potentially septic cases. At the operation normal proved negative. Two other points of great importance, which have saline solution is administered with, or at the same time as, antistreptococcal serum, to avert anaphylaxis, been established by the patch test, are: (1) that and the Fowler position is adopted as soon as the phases of extreme hypersensitiveness, lesser hypersensitiveness, and non-sensitiveness occur, so that a condition of the patient allows it. In the after-treatment enemata are employed early, person may give a strongly positive reaction at one time and a negative one at another-the nonas well as purgatives, to assist elimination, while sensitive phase is particularly likely to occur after uterine retraction. to pituitrin helps promote good At the same time I believe that peritoneal drainage an acute exacerbation of the patient’s symptom; and and the early use of serum were extremely important (2) that one area of skin may be hypersensitive to a factors in the successful results obtained in my series given irritant and another non-sensitive, for example of cases. The careful nursing they received enabled the skin of the eyelids may be sensitised and that of the forearm or other parts not so. complications to be dealt with early. to I am, Sir, yours faithfully, FRANCES IVENS-KNOWLES.

RESEARCH IN ASTHMA. THE

URINARY PROTEOSE.

To the Editor

of THE LANCET. Freeman’s remarks on the " proteose," SIR,—Dr. isolated from the urine by Dr. Oriel in certain morbid conditions, reveal a misapprehension as to its significance and incidentally to that of what he terms the dermal reaction. I will deal with the latter first. To begin with, it is essential to distinguish between epidermal and dermal sensitisation. The urticarial wheal is the commonest response when dermal hypersensitiveness exists. It is due, as the researches of Lewis and his colleagueshave shown, to the liberation of histamine or some allied substance by the skin in response to injuries of various kinds.

It will be clear from what has been said that as Dr. Freeman appears to do, upon dermal reactions, provoked, I presume, by the scratch or intradermal tests, as evidence of hypersensitiveness or allergy towards a given substance is to misconstrue their significance. They indicate dermal sensitisation and no more. As has been seen, they may be negative even when another part of the skin, the epidermis, is sensitised. To expect them necessarily to be positive when other structures, such as the bronchial, intestinal, and uterine musculature, or the mucous membranes of the respiratory and alimentary tracts are sensitised is, to say the least of it, unreasonable. To come now to the " proteose," the proofs that in certain acute and chronic allergic states it contains what may be justly termed a specific substance may be considered under two headings—experimental and clinical. (1)Experimental.-Dr. Freeman does not refer to the careful and laborious experiments carried out by

depend,