SOMNIFEN TREATMENT IN THE PSYCHOSES.

1155 3. Miss C., aged 32. Case of ten years recurrent attacks of excitement and depression with hallucinations ; was confused,I incoherent, hallucinated, and restless. M. and H. followed by somnifen, two ampoules, and then 11doses in five days ; constant drowsiness ; stopped because pulse became weak. BY W. S. DAWSON, M.D. OXF., Marked improvement for about a week, accessible, clear, no SENIOR ASSISTANT MEDICAL OFFICER ; hallucinations, then relapsed into alternating between days of normality and days of hallucination and incoherent AND chatter. M. R. BARKAS, M.D. LOND., 4. Miss D., aged 19 ; acute mania ; noisy and destructive. M. and H. followed by somnifen ; kept drowsy and quiet ASSISTANT MEDICAL OFFICER, MAUDSLEY HOSPITAL. for seven days with 22 doses of one ampoule ; had retention of urine and cystitis. Required other sedatives for a time, " " for the production of a then lapsed into confused depressed state and finally recovered Somnifen THE use of state of twilight sleep in psychotic cases has had a some months later. No evident benefit from somnifen over considerable trial abroad since the first publication other sedatives. 5. Miss E., aged 28 ; acute mania ; three months noisy, by Elasi in 1922.1 The general opinion held after destructive, and dirty ; M. and H. followed by somnifen, three years was summed up by Muller2 in 1925then one ampoule b.d. with a few doses of paraldehyde ; while the induction a that of such namely, twilight remained drowsy and quiet; total nine doses in five days ; sleep lasting about a week has proved of sufficient quiet and rational for two days after, then relapsed comvalue to be accepted as a useful form of treatment, the pletely. Stopped because pulse became weak. use of somnifen for its production has dangers and 6. Mrs. F., aged 31 ; recent melancholia, screaming in Given digitalin (nativelle) 1/600 with each dose, disadvantages-the death-rate among cases recorded agitation. as pulse poor from start ; had one ampoule eight-hourly being about 5 per cent.-that this drug should be for five days, needed 1 drachm of paraldehyde in between, used only as one of the many available hypnotics, with this remained quiet and drowsy ; treatment stopped and that suitable combinations of these should be as pulse weaker. No subsequent improvement. tried according to the requirements of the individual 7. Mrs. G., aged 27; puerperal mania. Received six case. ampoules of somnifen in four days in addition to three In England the new drug was first tried at the injections of4 gr. morphine and 1/100 gr. hyoscine. The Maudsley Hospital in September, 1924. The advan- excitement was reduced, but the periods of drowsiness were tages claimed for it over the other drugs of the very brief. The course of the excitement was not influencedAcute depression with Males.-8. Mr. H., aged 47. barbituric acid group are that it is soluble and, thereand phases of vivid hallucinosis. Treatment was. fore, readily absorbed and excreted, and its solution agitation is stable; so that it can be kept and used conveniently begun with M. and H., followed by nine ampoules of somnifen over a period of five and a half days. The patient for intramuscular and intravenous administration. given remained drowsy while the drug was given, but afterwards In the annual report of the medical superintendent relapsed to his former state. The treatment was repeated of the hospital for 1925 mention is made of the effects two months later and ten ampoules were given over a produced. In view of the recent notice in THE LANCET period of six days, but there was no physical or mental beyond a gain of a pound in weight. (Sept. 25th, p. 662) of the results achieved abroad, improvement 9. Mr. I., aged 43. Manic phase of manic depressive it seems worth while to report a series of cases in which psychosis. After M. and H. he received seven ampoules in it has been used in this country. seven days, together with several doses of paraldehyde.. Klasi emphasises that it should be used strictly The excitement was controlled and drowsiness maintained.. according to his method-namely, giving at first an but there was no lasting benefit. 10. Mr. J., aged 41. Mania. Received seven ampoules injection of morphine gr.and hyoscine gr. 1/100, followed in half an hour by two ampoules each con- in six days as well as bromides, and was quiet and drowsythis period, but relapsed afterwards. taining 2 c.cm. of somnifen solution (diethylamine during 11. Mr. K., aged 60. Tabes with agitated depression. diethyldipropenylbarbituric acid). The injection must Received six ampoules in five days when the treatment was: be injected deeply into the muscles if not given intradiscontinued owing to signs of cardiovascular failure. venously, as subcutaneous injection produces sloughing. 12. Mr. L., aged 55. Agitated depression with arterioAfter this a twilight sleep condition must be main- sclerosis. Received five injections in four days, togethertained by doses of one ampoule at intervals, usually with several doses of paraldehyde. He became collapsed, of six to eight hours. The treatment is best carried but the signs of cardiovascular failure passed off when the out in a darkened quiet room ; fluid diet, attention drug was discontinued. The course of the depression was to excretion, and careful watching of the pulse are not influenced. 13. Mr. M., aged 23. Acute excitement, probably schizoneeded, and the patient can be roused for attention exalted with hallucinations and rather phrenic. and will doze off again. If he is allowed to become fantastic EmotionallyHe received six ampoules in five days delusions. the must restarted. awake treatment be Contrafully and seemed to be better for some days afterwards, but then indications are heart or kidney disease or extreme relapsed to his former state.

SOMNIFEN TREATMENT IN THE PSYCHOSES.

emaciation. The treatment must be stopped if vomiting or cardiac failure occur, and during menstruation. The cases treated may be divided into (1) those given the full course according to Klasi’s plan, being kept in a twilight sleep state for five days or more ;-, (2) those started in this way and stopped for some reason ;(3) those given in a different way. 1. The first group contains seven female and six male cases. Females.-l. Mrs. A., aged 30 ; post-puerperal confusion with hallucinations, five months duration. Morphine and hyoscine (M. and H.) followed by two ampoules somnifen,

2. In four

cases

treatment

by somnifen was stopped

prematurely.

1. Mrs. 0., aged 35. Anxiety state passed into agitated depression with hallucinations ; restless, impulsive, confused. M. and H. and somnifen started, six doses given in three days ; no twilight sleep could be maintained and pulse got very weak and rapid, so that treatment was stopped. 2. Miss P., aged 50. Agitated melancholia with fears of torture, &c. Given M. and H. and 2 ampoules somnifen, slept well all night but awoke next day with persecutory delusions about the injection and very agitated and resistive ; treatment was not continued as she had been getting more and ten subsequent doses of one ampoule in five days, with agitated for some time and no benefit appeared from the somnifen sleep. two doses of paraldehyde in addition ; only occasionally 3. Mrs. Q., aged 28. Acute confusion with hallucinations ; restless and slept most of the time ; stopped as she became and restlessness following childbirth-possibly more restless and vomited. Rather quieter and more agitation lethargica. Somnifen one ampoule was given, accessible for about one month, though still hallucinated ; encephalitis but her pulse became bad and no further doses were given. and no further relapsed then, improvement. 27. Acute mania of some months duration. 1. Mrs. 2. Miss B., aged 28 ; acute melancholia with delusions Given oneR., aged somnifen twice and ampoule slept well on it, but of unworthiness ; agitated but not hallucinated. Had strict her and colour bad, so it was discontinued. became weak pulse somnifen treatment (M. and 1-1. followed by two ampoules) and then ten ampoules in five days ; slept constantly, cyanosed 3. One other case-a long-standing hypochondriacal hands became warm and moist, pulse became rapid and woman of 27 with vague ideas of suspicion and weak, so that treatment was stopped. Improved considerably intractable sleeplessness which resisted all drugs, was for about a week, during which she was interested in occupations and mildly depressed, but relapsed badly after that, given M. and H. followed by somnifen every night and became hallucinated for sight and hearing and acutelyfor four nights ; on two she slept well, another night .

suicidal.

she needed

paraldehyde

in

addition,

and then she

1156

kept awake by a sore arm from some necrosis around the site of injection of somnifen, so that treatment was stopped. Here there seemed only slightly better sedative effect than with other drugs, and her sleeplessness and general mental condition was unaffected. was

Summarising most

cases

Conclusion. these results, one may say that in

where the treatment

can

be continued

twilight sleep state can be maintained ; that any improvement following this treatment is quite transitory, there being no change at all in some cases ; a

that there are considerable risks attached to the’ use of somnifen, as in many instances the pulse becomes progressively weak, rapid, and often irregular ; and that while in our series there have been no deaths- this is largely owing to careful watching of the heart’s action and stopping treatment in good time. Only one case had retention of urine and cystitis. The improved contact with the environment claimed by Klasi was not conspicuous, a few cases showing it for a few days only and then relapsing. Generally speaking, one may say that somnifen, as a soluble sedative which can be given intramuscularly, has its place in the list of available sedatives for psychotic patients, but has considerable risks and no special advantages. If a twilight sleep of some days duration is of benefit in some cases, this has not been evident in our series, and the advice of Muller may well be taken, to produce it where desirable by means of combinations of hypnotics rather than by somnifen.

We wish to thank the medical superintendent of the Maudsley Hospital, Dr. Edward Mapother, for his permission to publish these cases. References.—1. Kläsi, J. : Über die therapeutische Anwendung der " Dauernarkose " mittels Somnifen bei Schizophrenen. Zeitschr. für. die ges. Neur. und Psychiatr., 1922. 2. Müller, M. : Die Dauernarkose mit Somnifen in der Psychiatrie, Ibid., May, 1925. See also Epitomes, Journal of Mental Science, 1925, pp. 333 and 775.

A CASE OF

LYMPHATIC LEUKÆMIA OF UNUSUAL TYPE. BY A. E.

NAISH, M.B., F.R.C.P. LOND.,

LECTURER ON MEDICINE, SHEFFIELD UNIVERSITY, AND PHYSICIAN TO THE SHEFFIELD ROYAL HOSPITAL ;

AND

CLARA TINGLE, M.D. SHEFF., PATHOLOGIST,

SHEFFIELD

ROYAL

HOSPITAL.

WE have provisionally classed this case as lymphoid leukaemia. It presents certain remarkable features, and is recorded in view of the interest that is now being taken in the pathology of blood diseases and the difficulty of classification of border-line cases. MaIe, aged 16, admitted to Sheffield Royal Hospital on March llth, 1925, and died on Sept. 30th, 1925. He was working as a hammer driver in October, 1924, of his right hand. when he wounded the middle finger It became septic later and was " lanced." Three weeks afterwards a lump appeared above the right elbow and another in the right armpit. They were at first painful, but the tenderness gradually disappeared, though the lumps remained up to death. In the latter half of November lumps were noticed behind both ears, and a little later in other parts of the neck and under the chin. In December the eyes became bloodshot and shortly after this he had to About February his cease work on account of weakness. face became puffy and discoloured and dark patches began to appear on the skin wherever it was rubbed. At this time also some lumps were noticed over the shoulders. The appetite was becoming more and more impaired, he vomited

sometimes, and he had particular difficulty in swallowing

condition of half closure ; large subconjunctival hemorrhages both sides. The skin of upper part of chest shows numerous purple lines, suggesting subcutaneous haemorrhage caused through scratching himself. Deep purple discoloration Ears : Old -standing otitis media around both nipples. suppuration with loss of both tympanic membranes. Larynx : General infiltration, swelling, superficial ulceration, and ecchymosis of the epiglottis. Hard and soft palate, including the alveolar portion, swollen and infiltrated with areas of ecchymosis. Lymphatic glands : In the neck there was widespread moderate enlargement of glands in both anterior and posterior triangles ; there was a chain of rather smaller glands running the anterior border of each trapezius muscle. Numerous glands in both axillae and groins showed enlargement. The right supratrochlear considerably enlarged and somewhat tender, left only slightly enlarged. Some comparative dullness for two inches to the right of sternum in No glandular enlargement first and second interspaces. detected in the abdomen. Besides the enlarged glands there were some other subcutaneous lumps, evidently not in the position of normal lymph glands. The largest are four about the size of a bean, one above and one to the outer side of each scapula. Heart : No apparent enlargement. A faint systolic bruit heard along left border of sternum. Lungs and pleurae : At left base there was a small area of comparative dullness with diminished breath sounds and voice sounds. Abdomen : Liver somewhat enlarged ; margin reached about one finger’s-breadth below ninth costal cartilage. Spleen just palpable ; its area of dullness considerably enlarged. No evidence of ascites detected. Ophthalmoscopic examination : Both retinae appear to be a brighter red than normal; edges of both discs blurred, especially that of left eye. Nohaemorrhages detected. Wassermann reaction and blood culture give negative results, Blood count : Red blood cells, 4,260,000 ; haemoglobin, 78 per cent.; colour-index, 0-91; white cells,’ 10,10’; Differential count (per cent.) : polymorph. neutrophils, i polymorph. -eosinophils, 1-5 ; small mononuclears, 40; large, 49 ; cells transitional between the two last, 5’5. The small mononuclear cells were comparable in size to the small lymphocytes found in normal blood. The cytoplasm was, if anything, a little more in proporF1. fit. 1 tion to the nucleus, out in otner respects such as appearance and staining properties they were indistinguishable from a normal small lymphoon

__

cyte. The large mono-

nuclear cells, on the other hand, showed c e r t a i n differences from the usual large lymphocyte. In the first place they were sharply marked off in size, being of at least twice the circumference of the small mononuclears. (Cells of intermediate size were always counted separately and were found to be comparatively few; in most counts being not more than 1 per cent. of the whole, and never reaching above 5-5 per The nucleus cent.) of these large cells,

although staining rather less deeply than that of the small cells, was not comparable in pallor to that of the large cells described by Sternberg as characteristic of leukosarcoma; neither was it vacuolated or honeycombed as in his description and no mitotic figures were seen. The cytoplasm was abundant, clear, and free from granules ; it surrounded the nucleus on all sides, the radius of the cytoplasm being about equal to half that of the nucleus, which is placed nearly centrally.

hard solids. The bowels were opened regularly, and None of the mononuclear cells gave a positive oxidase reaction. The erythrocytes appeared normal in size, shape, occasionally the stools were noticed to be very black. Previous History.-Scarlet fever at 5, followed by glandular and staining properties. No nucleated red cells seen. swelling in the neck and operation. Influenza at 8 ; in bed Progress of the Case.-For the first week after admission two months. Has always bled freely when cut. the temperature was not raised, but subsequently it was Condition on Admission.-The whole face was puffy and always raised for some part of every successiveweek; at swollen ; very marked purplish discoloration of the cheeks, first only slightly and at irregular periods, but gradually eyebrows, and chin. Eyelids swollen so as to produce a tending to become higher without showing any definite type.