803

of songs, and will sing during the whole time out. Our

patient’s merriment may very soon change to angryirritation. She becomes very abusive and, as the impulsemoves her, will attack any one, and it requires considerablerestraint to prevent her doing damage.What are the significant features of our patient ? 1 The

most prominent is the divertibility. Some accidentalattraction at once arrests her attention, but this is imme-

diately thrown out and some new attraction is forced intoconsciousness, to be at once departed from. This divertibilityis shown equally in mood-merriment to anger ; in thought-changing ideas ; and in action-her continued changing ofposition and movements. The patient has not the ability toprevent herself being ruled in thought, mood, and actionby the influences of the moment. Next one wouldnote the "night of ideas." " Her thoughts are to no

purpose. The train of thought is broken at once byone idea being driven out by another. Again we wouldnote the impulsiveness, in the fact that she will attack any-one. Here we note the same thing: there is no check on thetransposition of impulses of the will into action. We wouldalso note the deficient attention. We cannot retain our

patient’s attention on any subject. The rapid change of thesensations which are forced into consciousness, and each inturn receiving attention, makes it impossible for her to con-centrate her mind on any subject.The whole condition may be summed; up thus :-There is

no check on the number of ideas which force themselvesinto consciousness no check on the sensations received, andeach in turn may show itself in mood, action, or speech.Looking at all those cases, what have we ? 7 There are

certain features different in them all. First take attention.Case 1 can attend and can comprehend what is said to himto a certain extent, but is soon taken up with his hallucina-tions of sight. Case 2 can be aroused to attention, but ismore confused than Case 1, and soon mentions his delusionsof grandeur. Case 3 understands what is said to her, canattend, but will not let you see she does attend, except inthe fact that she is negative. Case 4 is stupefied and cannotattend. Case 5 can attend, but she has no interest in whatis said to her; she is languid and listless, and would rathernot be troubled. Case 6 cannot attend on account of the

divertibility ; the rapid change of the sensations forced intoconsciousness and then put into action.

All our cases showed excitement, but all have showed somepoints of distinction. It would only be taking up spacewere I to add a note about each, as to which had delusions,hallucinations, or as to the condition of the memory, &c.

Enough will be got in the short commentary at the end ofeach case for an accurate diagnosis. My paper is onlyclinical, but it may serve a useful purpose if it stimulates a

proper investigation into all cases of "Mania."Loebgilphead.

_________________

Clinical Notes:MEDICAL, SURGICAL, OBSTETRICAL, AND

THERAPEUTICAL.

HYSTERECTOMY FOLLOWED BY DOUBLEPHLEBITIS.

BY H. MACNAUGHTON-JONES, M.D. R.U.I.,F.R.C S. IREL. & EDIN.,

PRESIDENT OF THE OBSTETRICAL AND GYNÆCOLOGICAL SECTION OFTHE ROYAL SOCIETY OF MEDICINE.

THE patient, aged 48 years, a nullipara, had suffered forsome years from severe haemorrhages, for which she hadbeen curetted a few years previously. At the time of opera-tion for tumour of the uterus she was greatly emaciated andextremely ansemic, and altogether in a most unfavourablecondition for operation. The tumour was delivered withgreat difficulty, being firmly wedged in the pelvic cavity.It was a multinucleated myoma, one mass of isolated nodulesfrom cervix to fundus. On the fifth day after operationproctoclysis was commenced, and as there was some disten-sion of the abdomen the wound was opened and a supra-pubic drain inserted. Exploration revealed nothing, andonly some serous fluid escaped. The proctoclysis was con-tinued on and off for five days, but the suprapubic opening

was not cloaed for ten days. The first symptoms of

phlebitis appeared in the left femoral region on thethirteenth day after operation, and the swelling extendedto the entire limb. It had returned to its normal size by thetwenty-fifth day. On the thirtieth day the right thighcommenced to swell, and it followed the same course as theleft, becoming the more swollen of the two. The swellingsubsided completely in about ten days, and from that timethere were no untoward symptoms. The patient has sincedone well.

This is the only instance of phlebitis in both legs as apost-operative complication that I have been confrontedwith. The important lesson to be learnt from the case-andone that is often overlooked-is the increased risk run fromgrave ansemia, the result of bleeding from fibroids, and alsothe unfavourable conditions consequent upon this complica-tion which increase the operative mortality. Whatever bethe precise physiological cause or causes, there is no doubtthat the condition of the blood in such cases tends to

thrombosis ; also the possible effect of traumatism in theforcible delivery of these tightly wedged pelvic tumours hasto be remembered.As generally occurs, the left leg was the one first affected,

and it was rather remarkable that the attack in the rightdid not begin until the thirtieth day after operation. In

Kelly’s" Operative Gynaecology " (1898 edition) it is statedthat out of some 1100 operations he had had phlebitis in bothlegs in only one instance, and in his last classical work onmedical gynaecology, written with Noble, the authors statethat out of 7130 women operated upon thrombosis occurredin 48. Of these, 727 had fibroid tumours, and 19 of the 48cases resulted from operations on fibroid, a relation regardingthe greater risk of thrombosis from fibroids which is inaccord with the experience of other surgeons.The therapeutic points of interest in the case were the

good results following the proctoclysis with suprapubicdrainage, as recommended by Dr. J. B. Murphy, and thebenefit obtained on two occasions when the bowel wasobstinate from subcutaneous injections of infundibulin-

"pituitary extract." It may also be interesting to notethat in this, as in other cases in which I have had to dealwith extreme anf3emia, the patient was kept on "carnine,"in the present instance for 17 days, in addition to othernourishment.

Harley-street, W.

NOTE ON A CASE OF PANCREATIC CYST IN ACHILD AGED 14 MONTHS.

BY D. I. CONNOLLY, M.B., CH.B. VICT.,ASSISTANT RESIDENT MEDICAL OFFICER, CRUMPSALL WORKHOUSE,MANCHESTER ; LATE ASSISTANT HOUSE SURGEON, STAFFORDSHIREGENERAL INFIRMARY, STAFFORD ; LATE HOUSE SURGEON, ST.

MARY’S HOSPITALS FOR WOMEN AND CHILDREN,MANCHESTER.

THE patient was admitted into the Staffordshire GeneralInfirmary on Jan. 29th, 1910. The history, as given by themother, was as follows. The child had been breast-fed up toabout the age of 10 months, when she was weaned. She hadnot had a day’s illness up to three or four days beforeadmission to hospital. The mother then noticed that thechild became listless and refused food, also that diarrhoea.set in. At the same time the little one developed difficultyin swallowing, apparently having a "sore-throat." Themother became alarmed at the child’s condition, because, asshe said, "she was always so lively and full of play," andorought her to hospital.On admission the child looked fairly well-nournished, but

wore an anxious expression, and was quite listless. Thejongue was furred, the papillse were prominent, and therewas some injection of the fauces. Nothing was to benade out in the chest. On examining the abdomen, itwas found to be distended and tympanitic all over. Palpa-jion elicited a feeling of resistance in the right hypo-chondrium. The movements of the intestine were audiblem auscultation. The pulse was rapid, reaching from 160 toL80 per minute, and the temperature at first was about 990 F.In the nervous system there was nothing of note except thegeneral languor previously noticed. It was not foundpracticable to obtain a specimen of urine. There were no

signs of rickets or any deformity.Treatment consisted of milk only. The diarrhoea not

mproving, albumin water was substituted. Of drugs, grey