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same with mental hygiene. The day will come when the demands upon us will become even more onerous. It is important that the State Hospitals should continue to have oversight of their discharged patients; they should be watched and not be left so much liberty; it is a matter of common knowledge that a physician in New York was killed by a paroled patient. The State Boards should have a list of all such cases and they should be kept under constant supervision,-just as disease carriers and germ carriers are now beginning to be watched.

The matter of psychiatric pavilions in general hospitals is a matter that we have been talking about for a number of years, but we are still far from a realization of any material development on this subject. Psychiatric clinics or wards in general hospitals should bear the same relation to the hospitals for the insane that out-patient departments or dispensaries of hospitals bear to the hospitals. There ought to be places where early and mild cases can be received and observed and later on if necessary be referred to their proper sphere.

A point of considerable importance is the question of the potential and incipient insane aliens. The State and Federal Governments in a large measure fail in excluding this class of individuals. It is very easy for them to be received into this country; later they become public charges and it is very difficult to have them sent back to where they belong.

Another matter is that of the mental deviate. The deviates should be discovered and uncovered in the public schools, and once uncovered should be followed up and not allowed to become public charges.

DR. R. L. LEAK (Middletown): During the reading and discussion of Dr. Terhune's paper I was somewhat impressed of the necessity of getting these mental cases under proper care early. In Connecticut, unfortunately, the police officer has more to do with the early handling of these cases than the physician, and this creates a false impression in the mind of the patient, which it is frequently difficult to overcome: namely, the feeling that they are under arrest and treated as a criminal usually is, rather than being treated in the way that a sick person should be treated.

The fear that many people have of a person who has been called insane is unnecessary, for, as a rule, they are no more dangerous than anyone else when properly handled. It would therefore seem advisable to carry out the suggestion of Dr. Terhune's paper so that we have these patients under the observation of medical men entirely up until the time of their admission to the hospital.

There is another point that perhaps all physicians are not familiar with, and that is the voluntary commitment. By the use of this method it is not necessary to wait the process of the law in order to have a patient admitted to the institution. It is always best to be perfectly frank with the patient and explain to him his needs and the necessity of immediate hospital treatment, and if this is done you will usually find

the patient willing to take your advice and be admitted voluntarily. In order to be admitted voluntarily the patient must sign a statement to the effect that he wishes to be admitted as a voluntary patient and will abide by the rules and regulations of the hospital and give ten days' notice to the hospital authorities in writing before leaving without the consent of the superintendent.

The earlier these patients can be placed under proper care the better, for it is frequently found that a considerable number of them could be restored, whereas when they are kept at home, or under unfavorable surroundings too long a time, their mental symptoms become chronic.

DR. THOMPSON: Two years ago we received at the Retreat 342 persons; of these seventy-five were alcoholic. Of the entire number more than 300 were voluntary. That emphasizes what Dr. Leake has said. Only twenty-seven cases were actually committed by the Court.

DR. W. B. TERHUNE: The reason for bringing this matter before you this afternoon is that in the last two months there has been some discussion in state circles about establishing a State Mental Hygiene supervising body as part of the state government. I simply wished to outline the advantage of such a procedure.

X-Ray Intra-Abdominal Diagnosis by the
Oxygen Inflation Method.

L. F. WHEATLEY, M.D., New Haven.

This method of Roentgen Ray examination of the abdominal parenchymatous organs, after gas inflation, is based on the fact that air or gas intensifies the shadows of soft parts producing more contrast and thus bringing out more detail than can be obtained by any other method. It is the application of this same principle which we daily utilize in chest and sinus examinations where fine detail and minute alteration in structure can be obtained through contrast with the air contained therein.

It is not an entirely new procedure, although it has not been utilized to any extent for intra-abdominal diagnoses until within the past year. The credit for the original idea should be given to Kelling, who employed it in 1902 as an aid in diagnosing a case of ascites and a carcinoma of the stomach. In 1910 and 1911 Jacobus of Stockholm emphasized the safety of the abdominal puncture on the basis of over twenty experiments on cadavers in which the trocar was pushed through the abdominal wall and reached the peritoneal cavity invariably without damaging the viscera.

Webber in 1912 first applied this method to the roentgenologic technic and conceived the idea that sterile air or oxygen introduced within the abdominal cavity might help to render visible a number of organs and regions which hitherto were considered somewhat inaccessible to satisfactory Roentgen examination.

Experiments on animals and fresh cadavers confirmed his theory. His roentgenogram showed that the following viscera and areas may be rendered visible by means of gas inflation: liver and spleen as a whole, gall bladder region, kidneys, subphrenic space, coils of intestine without bismuth filling, bladder filled with urine and intra-abdominal tumors.

In 1914 Doctors W. H. Stewart and Luckett demonstrated roentgenographically the ventricles of the brain in a case of frac

ture of the skull where air had entered the interior. This fact was taken advantage of by Dandy of Baltimore, who injected air into the cerebral ventricles and who describes the method as invaluable in the diagnosis of internal hydrocephalus and other intra-cranial conditions. This injection of air into the ventricles had no injurious effects on 20 children between the ages of 6 months and 12 years.

Within the past year W. H. Stewart of New York has developed the method more intensively, and elaborated an improved technic. At a meeting of the American Roentgen Ray Society in January, he demonstrated the diaphragm completely separated from the liver which showed a detail not hitherto considered possible. The spleen with its pedicle, the kidneys, pelvic conditions, and intra-peritoneal adhesions, especially those involving the anterior abdominal wall. He thus demonstrated that this method opened up a new field for investigations of the parenchymatous abdominal organs.

The technic is very simple and is practically a paracentesis. The point of election is usually about an inch below and to the left of the umbilicus. This point was selected because the inflation appeared to be more satisfactorily accomplished here than elsewhere. It was purely arbitrary there being no reason why it should not be done elsewhere if there are special contraindications such as adhesions or abdominal scar or tumor mass. While the deep epigastric artery and vein course in this vicinity, the dangers to these vessels was thought to be negligible as the vessel walls, unless confined, would tend to roll from under a needle point, and even if they resisted, the presence of a stylet in the lumbar puncture needle employed, would prevent any serious damage being done. The intestinal tract is thoroughly emptied, the patient lies on his back, and strict surgical asepsis is observed in the entire procedure. The area to be punctured is anaesthetized with novocain and the puncture accomplished. This should be done gradually and the process halted at the tranversalis fascia and then one more thrust made into the abdominal cavity. Oxygen from the ordinary oxygen tank is used, passing through sterile water in the wash bottle, which aids in determining

[graphic]

Showing clear edge of liver, spleen and kidney.

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