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THE TREATMENT OF WAR NEUROSIS.
37
and function of organs
was
studied
on
the still
body. In this way the systolic and diastolic heart, of
exact form of the the contracted and rugao of the gastric
warm
relaxed stomach, of the membrane, of peristalsis in the bowel, and of the relations of rectum to prostate and vesicles was determined. A statistical appendix attached to the paper resumes the volume of the work carried out. It is here recorded that more than 10 million doses of tetanus serum and more than 1212 million doses of small-pox vaccine were given, while antityphoid vaccine ran up to a total amount of 103,000 litres and that of cholera serum to 80,000. It cannot fail to strike the careful reader of Otto von Schjerning’s introductory chapter that the record of medical achievement and of medical sacrifice on the other side of No Man’s Land was not widely different from the record with which Sir John Goodwin has familiarised us. THE TREATMENT OF WAR
NEUROSIS.
THE advance which has been made, as a result of experience gained during the war, in the method of treatment for cases of neurasthenia, shell shock, and functional nervous disorders in general has been considerable, for no other form of medical disability has received greater or more intelligent attention. The medical men who have been brought directly into contact with cases of this nature, and whose duty it has been during the war to undertake the care of this class of patient, have learned to appreciate the dangers which attend delay in treatment, while experience has shown that special methods will very generally ensure satisfactory results. The of Pensions has established neurological hospitals for in-patients and psychotherapy clinics for out-patients where these tried forms of treatment can be applied, but the Ministry feels that full use is not being made of these institutions. Many general practitioners, it is suggested, have cases of war neurosis among their patients which are not benefiting to the full by modern developments in therapeutics. Consequently the Medical Service Department of the Ministry is inviting general practitioners who have cases of war neurosis under their charge to communicate with the Service at 14, Great Smithstreet, Westminster, S.W.1, with regard to any case, even if the condition is not severe, which is not progressing rapidly towards recovery. In a severe case this should always be done, and, where necessary, the Ministry will certainly arrange for treatment at one of its special institutions.
to follow it upwards or downwards until the level was reached at which thrombotic occlusion ceased This and distinct pulsation could be observed. method gave gratifying results in the following A man, aged 56 years, was admitted to the case. Michael Reese Hospital, Chicago, with marked evidence of arterio-sclerosis and gangrene involving Pulsation was the entire dorsum of the foot. absent as high as the upper femoral region. Amputation through the lower third of the thigh by the Gritti-Stokes method was decided on. On exposing the femoral vessels at the middle of the thigh for preliminary ligation they were greatly surprised to find the femoral artery completely occluded by thrombosis. Following the vessel upwards they could not find pulsation until close to Poupart’s ligament. Here the artery was ligated just above the occlusion-that is, through the lowermost pulsating portion. Amputation was performed at this level, and the patient, who had been extremely septic, made an uneventful recovery. However, in spite of the high level of amputation, there was moderate gangrene of the skin flaps. Dissection of the arteries of the limb revealed many calcareous areas in the femoral and a firm clot occluding it up to a point close to the femoral canal. The clot was adherent in many places, and extended into the tibial arteries. The veins were normal. Dr. Eisendrath and Dr. Bettman consider that exposure of the femoral artery in order to determine the upper limit of the occlusion is the simplest and most accurate. method of deciding on the level of amputation. MIDWIFERY AND THE UNQUALIFIED MIDWIFE.
Ministry
____
THE RIGHT LEVEL FOR AMPUTATION ARTERIO-SCLEROTIC GANGRENE.
Dr. D. N. Eisendrath and Dr. R. B. Bettman have
the thrombosis from the femoral to the iliac artery, and then to the opposite iliac. Dr. Eisendrath and Dr. Bettman felt that the ideal method of choosing the level to amputate would be to expose the femoral artery at the middle of the thigh, and Journal of the American Medical
Association,
Dec.
6th, 1919.
from puerperal sepsis may actually be diminished thereby, since the Mother Gamps now rapidly being hustled out of practice by age, infirmity, and the vigilant hand of the supervising authority, and the newer type of midwife, while of a markedly better stamp and education, is at the same time sufficiently afraid of consequences to shrink from undue interference with Nature’s deliberate methods of delivery. She will therefore tend to eliminate that fertile source of dangers and of discomforts-instrumental delivery by practitioners too hurried or too tender-hearted to let natural processes take their In many areas the midwife has a serious course. rival in the completely unqualified handy-woman who assists at confinements for which a doctor has nominally been engaged, but at which he does not attend; so that in fact, though not in law, the woman practises as a midwife without the necessary qualifications. There is pressing need
mortality
are
IN
pointed out’the error of the majority of surgeons in being guided as to level to amputate by the area of arterio-sclerotic gangrene. Not infrequently the amputation is followed by extensive sloughing of the flaps, and either death from sepsis follows or the opposite limb becomes affected by extension of
1
IT is common knowledge that the proportion of births attended by midwives tends steadily to rise. In a large number of areas considerablv over one-half of the total births are thus attended. In Preston, for example, the medical officer of health, Dr. H. O. Pilkington, in his annual report for 1918, shows 75 per cent. of the births as having been attended by midwives, and only 9 per cent. by medical practitioners, while in St. Helens in the same year Dr. H. J. Cates’s annual report shows actually that 99 per cent. of the births were attended by midwives. While this teridency indicates, on the one hand, that patients are likely to be exposed to certain risks which might be avoided by skilled medical attention, it must, on the other, be conceded that there are possible recompenses to the patient. For it is quite arguable that the sickness and
I
’
and function of organs
was
studied
on
the still
body. In this way the systolic and diastolic heart, of
exact form of the the contracted and rugao of the gastric
warm
relaxed stomach, of the membrane, of peristalsis in the bowel, and of the relations of rectum to prostate and vesicles was determined. A statistical appendix attached to the paper resumes the volume of the work carried out. It is here recorded that more than 10 million doses of tetanus serum and more than 1212 million doses of small-pox vaccine were given, while antityphoid vaccine ran up to a total amount of 103,000 litres and that of cholera serum to 80,000. It cannot fail to strike the careful reader of Otto von Schjerning’s introductory chapter that the record of medical achievement and of medical sacrifice on the other side of No Man’s Land was not widely different from the record with which Sir John Goodwin has familiarised us. THE TREATMENT OF WAR
NEUROSIS.
THE advance which has been made, as a result of experience gained during the war, in the method of treatment for cases of neurasthenia, shell shock, and functional nervous disorders in general has been considerable, for no other form of medical disability has received greater or more intelligent attention. The medical men who have been brought directly into contact with cases of this nature, and whose duty it has been during the war to undertake the care of this class of patient, have learned to appreciate the dangers which attend delay in treatment, while experience has shown that special methods will very generally ensure satisfactory results. The of Pensions has established neurological hospitals for in-patients and psychotherapy clinics for out-patients where these tried forms of treatment can be applied, but the Ministry feels that full use is not being made of these institutions. Many general practitioners, it is suggested, have cases of war neurosis among their patients which are not benefiting to the full by modern developments in therapeutics. Consequently the Medical Service Department of the Ministry is inviting general practitioners who have cases of war neurosis under their charge to communicate with the Service at 14, Great Smithstreet, Westminster, S.W.1, with regard to any case, even if the condition is not severe, which is not progressing rapidly towards recovery. In a severe case this should always be done, and, where necessary, the Ministry will certainly arrange for treatment at one of its special institutions.
to follow it upwards or downwards until the level was reached at which thrombotic occlusion ceased This and distinct pulsation could be observed. method gave gratifying results in the following A man, aged 56 years, was admitted to the case. Michael Reese Hospital, Chicago, with marked evidence of arterio-sclerosis and gangrene involving Pulsation was the entire dorsum of the foot. absent as high as the upper femoral region. Amputation through the lower third of the thigh by the Gritti-Stokes method was decided on. On exposing the femoral vessels at the middle of the thigh for preliminary ligation they were greatly surprised to find the femoral artery completely occluded by thrombosis. Following the vessel upwards they could not find pulsation until close to Poupart’s ligament. Here the artery was ligated just above the occlusion-that is, through the lowermost pulsating portion. Amputation was performed at this level, and the patient, who had been extremely septic, made an uneventful recovery. However, in spite of the high level of amputation, there was moderate gangrene of the skin flaps. Dissection of the arteries of the limb revealed many calcareous areas in the femoral and a firm clot occluding it up to a point close to the femoral canal. The clot was adherent in many places, and extended into the tibial arteries. The veins were normal. Dr. Eisendrath and Dr. Bettman consider that exposure of the femoral artery in order to determine the upper limit of the occlusion is the simplest and most accurate. method of deciding on the level of amputation. MIDWIFERY AND THE UNQUALIFIED MIDWIFE.
Ministry
____
THE RIGHT LEVEL FOR AMPUTATION ARTERIO-SCLEROTIC GANGRENE.
Dr. D. N. Eisendrath and Dr. R. B. Bettman have
the thrombosis from the femoral to the iliac artery, and then to the opposite iliac. Dr. Eisendrath and Dr. Bettman felt that the ideal method of choosing the level to amputate would be to expose the femoral artery at the middle of the thigh, and Journal of the American Medical
Association,
Dec.
6th, 1919.
from puerperal sepsis may actually be diminished thereby, since the Mother Gamps now rapidly being hustled out of practice by age, infirmity, and the vigilant hand of the supervising authority, and the newer type of midwife, while of a markedly better stamp and education, is at the same time sufficiently afraid of consequences to shrink from undue interference with Nature’s deliberate methods of delivery. She will therefore tend to eliminate that fertile source of dangers and of discomforts-instrumental delivery by practitioners too hurried or too tender-hearted to let natural processes take their In many areas the midwife has a serious course. rival in the completely unqualified handy-woman who assists at confinements for which a doctor has nominally been engaged, but at which he does not attend; so that in fact, though not in law, the woman practises as a midwife without the necessary qualifications. There is pressing need
mortality
are
IN
pointed out’the error of the majority of surgeons in being guided as to level to amputate by the area of arterio-sclerotic gangrene. Not infrequently the amputation is followed by extensive sloughing of the flaps, and either death from sepsis follows or the opposite limb becomes affected by extension of
1
IT is common knowledge that the proportion of births attended by midwives tends steadily to rise. In a large number of areas considerablv over one-half of the total births are thus attended. In Preston, for example, the medical officer of health, Dr. H. O. Pilkington, in his annual report for 1918, shows 75 per cent. of the births as having been attended by midwives, and only 9 per cent. by medical practitioners, while in St. Helens in the same year Dr. H. J. Cates’s annual report shows actually that 99 per cent. of the births were attended by midwives. While this teridency indicates, on the one hand, that patients are likely to be exposed to certain risks which might be avoided by skilled medical attention, it must, on the other, be conceded that there are possible recompenses to the patient. For it is quite arguable that the sickness and
I
’