- Email: [email protected]
MUSICOGENIC EPILEPSY
1236
workshop, approaches it from one angle ; the2 vile. Much information on such subjects has been paediatrician from another, for as BAUDOUIN gathered by W. F. PETERSEN in the United States remarks, the faulty adaptation shown by many and published in his " The Patient and the children should throw light on the means of Weather." Hitherto it has been customary mostly defence against external stimuli and the way they to rely on impressions ; but better even than and
For many morbid states climate "’ which we should seek to promote, and it is almost ridiculous, for example, that at this time of day we should still be uncertain whether children with pneumonia should not after all be nursed out of doors.3 Dr. GEORGE DAy4 lately mentioned that he was trying to discover the effect of certain types of weather on tuberculous patients and had reached the tentative opinion that they do best when it is positively
can
best be utilised.
there is
a
"
2 Baudouin, G. (1936) Rev. Physiothér. 12, 370. 3 See, for example, Wallace, H. L. (1937) Brit. med. J. March 27th, p. 657. 4 J. State Med. March, 1937, p. 157.
impressions are measurements, and the systematic studies made during the last twenty the best
on non-tuberculous children in the island of F6hrnear Heligoland are an example of serious effort to introduce precision where it is badly needed. We may be unable to guess whether the climate " we recommend-be it at the seaside or in a bedroom with closed windows-will benefit our patient, but we should at least try to find out what effect, if any, it has upon his bodily functions and the course of his illness. This is a part of clinical science where we want facts.
years
"
5 Kestner, O. (1937) Brit. med. J. March 13th, p. 555.
ANNOTATIONS MALARIA AND SYPHILIS
responsible for the mental hospitals of the County Council are anxious that the opportunities afforded at Horton for the treatment of neurosyphilis and general paralysis should be better known. A special unit for the treatment of syphilis of the nervous system was established there in 1925 by the L.C.C. and Ministry of Health jointly and some THOSE
London
have been treated. The unit has served a second purpose, because the malariotherapy given has allowed of valuable studies of induced malaria. The methods developed by the Institute for breeding and infecting mosquitoes have been copied in other parts of Europe: Wagner-Jauregg’s clinic in Vienna has adopted the Horton technique for examining blood films, and the plans of the insectarium have been reproduced in Germany, Roumania, and Holland. The research on malaria, which has attracted visitors and investigators from all parts of the world, has been made possible only by team-work. The cases have had medical care from one of the medical officers of Horton Hospital; the laboratory is in charge of Mr. P. G. Shute with two assistants ; the Ministry of Health, besides giving clerical aid, have allowed Colonel S. P. James, F.R.S., to direct the malaria work and establish a research centre. Since Colonel James’s recent retirement, Horton has formed a liaison with the London School of Hygiene and Tropical Medicine, and Prof. J. G. Thomson is carrying on the work. A whole-time investigator, Colonel J. A. Sinton, I.M.S., with a malaria research fellowship from the Royal Society, is now at the hospital, and we are glad to learn that another whole-time worker, Dr. E. L. Hutton, with a clerical assistant, is undertaking work from the neurdsyphilitic aspect, under supervision from Dr. W. D. Nicol, the medical superintendent, who last November visited WagnerJauregg’s clinic as well as hospitals and institutions in Germany. The records of cases already treated will furnish much good material; the incidence of syphilis in families of general paralytics is now being inquired into. The hospital is also keen to treat more and earlier cases, particularly as it is hoped that advantage will be taken of the facilities for treating patients on a voluntary basis at a stage long before the necessity for certification. In this type of case very favourable results are to be anticipated, and the duration of the patients’ stay 800
cases
in hospital should be considerably curtailed, being in suitable cases as short as 3-4 weeks. It is hoped that the opportunities for studying neurosyphilis will attract to Horton as many inquirers as the opportunities for studying malaria have attracted during the past ten years. SILICOSIS
OBSERVATIONS on the chemistry of some dangerous dusts made by a group of workers at the Imperial College under the leadership of Prof. H. V. A. Briscoe and summarised in two letters in Nature (May 1st, 1937, p. 753) may throw useful light on some of the perplexities of human silicosis. Briefly their discovery is that freshly made dust may be quite different chemically and mineralogically from the rock from which it has been derived: it quickly takes up water from damp air and readily yields alkali and soluble silica on extraction with water, much in excess of the solubility of natural quartz. The same dust when it has lain some time in contact with air is much less reactive, and this accumulated dust has often been used for experiments on animals whereas in actual practice men are of course exposed to dust immediately it has been made by rock-drilling or blasting. A natural inorganic particle is so arranged molecularly that, rather like an animal, it is coated with a relatively inert skin, and when it is mechanically broken its molecules are disarranged and it may become by comparison an active chemical agent. It has also been discovered that the solubility of silica from quartz dust is much reduced by mixing with finely divided charcoal, anthracite, ordinary coal, or lime, from which various possibilities in the way of prevention arise as well as some explanation of the difficulties about silicosis in some coal-miners. MUSICOGENIC EPILEPSY
IT has long been known that auditory stimuli may bring on epileptic attacks, the commonest form of stimulus being a loud and unexpected noise. Music may, rarely, be a determining cause of fits, and Dr. Macdonald Critchleyhas collected notes of 20 cases illustrating this sequence of events. Of these, 4 were under his own care, 7 were reported to him by colleagues, while the remaining 9 are 1
Brain, 1937, 60, 13.
1237 extracted from the literature, mostly, be it noted, of Russian origin. The clinical histories show little in common, though it is worth noting that in 11 out of the 16 cases in which it is recorded the age of onset of the epilepsy was over twenty-five years. Dr. Critchley is satisfied that the fits showed the usually accepted characteristics of epilepsy, and could in no case be classed as hysterical. Often the determining factor could be exactly specified. Thus in one the music must be classical and jazz tunes were ineffective; in another it must be sad or reminiscent in quality ; in another only the deep notes of a wind instrument in a brass band would cause the seizure ; in another one tune only would be effective ; in another only a tune that was unfamiliar ; and so on. Perhaps the most interesting part of the paper is an account by a Russian man of letters, who was a sufferer from musicogenic epilepsy, of his own sensations and experiences when listening to music. In some of the cases the stimulus was specific ; fits always occurred in response to the music, and never in the absence of music ; but other cases lacked this specificity. In discussing the pathogenesis Dr. Critchley comes to no definite conclusions. He doubts if hyperventilation or variations in cerebral blood-supply are of much importance. He is inclined also to reject the proposition that the phenomenon is a conditioned reflex in the Pavlovian sense, but it is not clear that he has sufficient grounds for doing so. It is recognised that certain emotional states-notably fear or anxiety-may determine fits in one who is already epileptic, and surely music may induce a variety of emotional response in those who listen to it. It might be near the truth to regard musicogenic epilepsy as epilepsy in which the fits are a response to one form of emotional stimulus. Consideration of this uncommon but fascinating sequence opens up wide issues. PERNICIOUS ANÆMIA AND LIVER THERAPY
VARIOUS attempts have been made to deduce from the recorded mortality-rates from pernicious ansemia the degree of success that has been attained with treatment by liver in various forms-success, that is, in the community as a whole rather than in the individual case. It is generally agreed that with an adequate use of liver a fatal termination may be indefinitely postponed in most instances. How far is that objective being attained ? Following the introduction of liver therapy in 1926 the mortalityrate in England and Wales declined abruptly and has remained at a relatively low level, though in late years there has been some tendency for a rise to occur. P. Stocks has computedthat since 1926 there has been an average lengthening of life of all affected persons The of about three to three and a half years. decline in mortality has been noted in other countries -notably in New Zealand, the United States, Norway, and Canada. In Canada and particularly in Ontario the registered mortality has invariably been high, higher according to Hardisty Sellers2 than in any other country in the world. This excess cannot, he thinks, be attributed in any large degree to differences in diagnostic acuity or to medical teaching and its influence on the certifying practice of doctors. Here too, however, there has been a dramatic reduction in mortality. In 1934 the mortality-rates of both males and females were less than half those prevailing in 1921-26. The deaths actually recorded in 1934 numbered 268, whereas if 2
1 Brit. med. J. 1935, 1, 1013. Amer. J. Hyg. March, 1937, p. 259.
the death-rates at ages in 1921-26 had continued to prevail as many as 562 would have occurred. At ages 30-49 years the mortality in 1934 was only 22 per cent. of the rate in 1921-26, at 50-69 it was 36 per cent., but at ages over 70 years the mortality has changed relatively little, being 89 per cent. of the previous rate. This picture is best explained, as Sellers suggests, by the prolongation of life of persons affected, particularly those at the younger ages. In fact, the average age at death of -persons certified as dying of pernicious ansemia was 62-1 years in 1926 and 67.7 in 1934. Allowing for the general ageing of the population the average lengthening of life since 1926 is about 5 years. This fesult, it must be noted, relates to all cases, treated, adequately or inadequately, and untreated. Sellers notes that it may be regarded as a " conservative estimate of the objective efficacy of modern therapy in this disease." It is some measure of the advantage reaped by the community; if treated cases alone were considered much greater improvement would doubtless be
apparent. THE OLD ASHMOLEAN MUSEUM
WE add to
suggestion in these columns present position of the Old Ashmolean is one calling for a sympathy that should take practical The fine Jacobean building was form in money. probably designed by Sir Christopher Wren, though it was built by one of those working masons who took a pride in their work. It faces Broad Street, is next to the new buildings of Exeter College, and is only separated by a pathway from the Sheldonian Theatre. Few know its history, fewer still of late years have entered its noble portico and finely lighted It was built at the cost of the University rooms. a
recent
that the
between 1679 and 1682 to house the collection which Elias Ashmole had obtained from John Tradescant. Ashmole was a man of many parts, solicitor, exciseman, freemason, astrologer, botanist, chemist, anatomist, physician, herald, and author of " The History of the Garter." John Tradescant, traveller and botanist, had a garden in South Lambeth, where his name is still perpetuated in Tradescant Street just off the South Lambeth Road. He collected curiosities in many countries, and Ashmole thinking them worthy of preservation added his own coins, medals, paintings, and the library of Lilly, the astrologer. He presented them to a grateful university which caused the house to be built for their reception. The museum was housed in the top floor ; the middle floor was used as a school of natural history where lectures were given on chemistry, and the basement was occupied by a laboratory with furnaces and a library of books treating of chemistry. Changes took place in course of time. The books went to the Bodleian ; natural history specimens were transferred to the new museums in the parks ; some of the curios to the Bodleian galleries, others to the Taylorian and university galleries ; chemistry was abandoned by the university and was taken care of by the colleges. The Arundelian marbles, which had long rested against the wall of the Ashmolean, found a The more suitable home at the British Museum. old Ashmolean had practically ceased to exist as a museum, and was used as a mere adjunct or store for the Bodleian and as a scriptorium for those who were preparing successive volumes of the New
English Dictionary. Then
came upon the scene Mr. R. T. Gunther, LL.D., energetic fellow of Magdalen College, who began to write on the history of science in Oxford. He soon an
workshop, approaches it from one angle ; the2 vile. Much information on such subjects has been paediatrician from another, for as BAUDOUIN gathered by W. F. PETERSEN in the United States remarks, the faulty adaptation shown by many and published in his " The Patient and the children should throw light on the means of Weather." Hitherto it has been customary mostly defence against external stimuli and the way they to rely on impressions ; but better even than and
For many morbid states climate "’ which we should seek to promote, and it is almost ridiculous, for example, that at this time of day we should still be uncertain whether children with pneumonia should not after all be nursed out of doors.3 Dr. GEORGE DAy4 lately mentioned that he was trying to discover the effect of certain types of weather on tuberculous patients and had reached the tentative opinion that they do best when it is positively
can
best be utilised.
there is
a
"
2 Baudouin, G. (1936) Rev. Physiothér. 12, 370. 3 See, for example, Wallace, H. L. (1937) Brit. med. J. March 27th, p. 657. 4 J. State Med. March, 1937, p. 157.
impressions are measurements, and the systematic studies made during the last twenty the best
on non-tuberculous children in the island of F6hrnear Heligoland are an example of serious effort to introduce precision where it is badly needed. We may be unable to guess whether the climate " we recommend-be it at the seaside or in a bedroom with closed windows-will benefit our patient, but we should at least try to find out what effect, if any, it has upon his bodily functions and the course of his illness. This is a part of clinical science where we want facts.
years
"
5 Kestner, O. (1937) Brit. med. J. March 13th, p. 555.
ANNOTATIONS MALARIA AND SYPHILIS
responsible for the mental hospitals of the County Council are anxious that the opportunities afforded at Horton for the treatment of neurosyphilis and general paralysis should be better known. A special unit for the treatment of syphilis of the nervous system was established there in 1925 by the L.C.C. and Ministry of Health jointly and some THOSE
London
have been treated. The unit has served a second purpose, because the malariotherapy given has allowed of valuable studies of induced malaria. The methods developed by the Institute for breeding and infecting mosquitoes have been copied in other parts of Europe: Wagner-Jauregg’s clinic in Vienna has adopted the Horton technique for examining blood films, and the plans of the insectarium have been reproduced in Germany, Roumania, and Holland. The research on malaria, which has attracted visitors and investigators from all parts of the world, has been made possible only by team-work. The cases have had medical care from one of the medical officers of Horton Hospital; the laboratory is in charge of Mr. P. G. Shute with two assistants ; the Ministry of Health, besides giving clerical aid, have allowed Colonel S. P. James, F.R.S., to direct the malaria work and establish a research centre. Since Colonel James’s recent retirement, Horton has formed a liaison with the London School of Hygiene and Tropical Medicine, and Prof. J. G. Thomson is carrying on the work. A whole-time investigator, Colonel J. A. Sinton, I.M.S., with a malaria research fellowship from the Royal Society, is now at the hospital, and we are glad to learn that another whole-time worker, Dr. E. L. Hutton, with a clerical assistant, is undertaking work from the neurdsyphilitic aspect, under supervision from Dr. W. D. Nicol, the medical superintendent, who last November visited WagnerJauregg’s clinic as well as hospitals and institutions in Germany. The records of cases already treated will furnish much good material; the incidence of syphilis in families of general paralytics is now being inquired into. The hospital is also keen to treat more and earlier cases, particularly as it is hoped that advantage will be taken of the facilities for treating patients on a voluntary basis at a stage long before the necessity for certification. In this type of case very favourable results are to be anticipated, and the duration of the patients’ stay 800
cases
in hospital should be considerably curtailed, being in suitable cases as short as 3-4 weeks. It is hoped that the opportunities for studying neurosyphilis will attract to Horton as many inquirers as the opportunities for studying malaria have attracted during the past ten years. SILICOSIS
OBSERVATIONS on the chemistry of some dangerous dusts made by a group of workers at the Imperial College under the leadership of Prof. H. V. A. Briscoe and summarised in two letters in Nature (May 1st, 1937, p. 753) may throw useful light on some of the perplexities of human silicosis. Briefly their discovery is that freshly made dust may be quite different chemically and mineralogically from the rock from which it has been derived: it quickly takes up water from damp air and readily yields alkali and soluble silica on extraction with water, much in excess of the solubility of natural quartz. The same dust when it has lain some time in contact with air is much less reactive, and this accumulated dust has often been used for experiments on animals whereas in actual practice men are of course exposed to dust immediately it has been made by rock-drilling or blasting. A natural inorganic particle is so arranged molecularly that, rather like an animal, it is coated with a relatively inert skin, and when it is mechanically broken its molecules are disarranged and it may become by comparison an active chemical agent. It has also been discovered that the solubility of silica from quartz dust is much reduced by mixing with finely divided charcoal, anthracite, ordinary coal, or lime, from which various possibilities in the way of prevention arise as well as some explanation of the difficulties about silicosis in some coal-miners. MUSICOGENIC EPILEPSY
IT has long been known that auditory stimuli may bring on epileptic attacks, the commonest form of stimulus being a loud and unexpected noise. Music may, rarely, be a determining cause of fits, and Dr. Macdonald Critchleyhas collected notes of 20 cases illustrating this sequence of events. Of these, 4 were under his own care, 7 were reported to him by colleagues, while the remaining 9 are 1
Brain, 1937, 60, 13.
1237 extracted from the literature, mostly, be it noted, of Russian origin. The clinical histories show little in common, though it is worth noting that in 11 out of the 16 cases in which it is recorded the age of onset of the epilepsy was over twenty-five years. Dr. Critchley is satisfied that the fits showed the usually accepted characteristics of epilepsy, and could in no case be classed as hysterical. Often the determining factor could be exactly specified. Thus in one the music must be classical and jazz tunes were ineffective; in another it must be sad or reminiscent in quality ; in another only the deep notes of a wind instrument in a brass band would cause the seizure ; in another one tune only would be effective ; in another only a tune that was unfamiliar ; and so on. Perhaps the most interesting part of the paper is an account by a Russian man of letters, who was a sufferer from musicogenic epilepsy, of his own sensations and experiences when listening to music. In some of the cases the stimulus was specific ; fits always occurred in response to the music, and never in the absence of music ; but other cases lacked this specificity. In discussing the pathogenesis Dr. Critchley comes to no definite conclusions. He doubts if hyperventilation or variations in cerebral blood-supply are of much importance. He is inclined also to reject the proposition that the phenomenon is a conditioned reflex in the Pavlovian sense, but it is not clear that he has sufficient grounds for doing so. It is recognised that certain emotional states-notably fear or anxiety-may determine fits in one who is already epileptic, and surely music may induce a variety of emotional response in those who listen to it. It might be near the truth to regard musicogenic epilepsy as epilepsy in which the fits are a response to one form of emotional stimulus. Consideration of this uncommon but fascinating sequence opens up wide issues. PERNICIOUS ANÆMIA AND LIVER THERAPY
VARIOUS attempts have been made to deduce from the recorded mortality-rates from pernicious ansemia the degree of success that has been attained with treatment by liver in various forms-success, that is, in the community as a whole rather than in the individual case. It is generally agreed that with an adequate use of liver a fatal termination may be indefinitely postponed in most instances. How far is that objective being attained ? Following the introduction of liver therapy in 1926 the mortalityrate in England and Wales declined abruptly and has remained at a relatively low level, though in late years there has been some tendency for a rise to occur. P. Stocks has computedthat since 1926 there has been an average lengthening of life of all affected persons The of about three to three and a half years. decline in mortality has been noted in other countries -notably in New Zealand, the United States, Norway, and Canada. In Canada and particularly in Ontario the registered mortality has invariably been high, higher according to Hardisty Sellers2 than in any other country in the world. This excess cannot, he thinks, be attributed in any large degree to differences in diagnostic acuity or to medical teaching and its influence on the certifying practice of doctors. Here too, however, there has been a dramatic reduction in mortality. In 1934 the mortality-rates of both males and females were less than half those prevailing in 1921-26. The deaths actually recorded in 1934 numbered 268, whereas if 2
1 Brit. med. J. 1935, 1, 1013. Amer. J. Hyg. March, 1937, p. 259.
the death-rates at ages in 1921-26 had continued to prevail as many as 562 would have occurred. At ages 30-49 years the mortality in 1934 was only 22 per cent. of the rate in 1921-26, at 50-69 it was 36 per cent., but at ages over 70 years the mortality has changed relatively little, being 89 per cent. of the previous rate. This picture is best explained, as Sellers suggests, by the prolongation of life of persons affected, particularly those at the younger ages. In fact, the average age at death of -persons certified as dying of pernicious ansemia was 62-1 years in 1926 and 67.7 in 1934. Allowing for the general ageing of the population the average lengthening of life since 1926 is about 5 years. This fesult, it must be noted, relates to all cases, treated, adequately or inadequately, and untreated. Sellers notes that it may be regarded as a " conservative estimate of the objective efficacy of modern therapy in this disease." It is some measure of the advantage reaped by the community; if treated cases alone were considered much greater improvement would doubtless be
apparent. THE OLD ASHMOLEAN MUSEUM
WE add to
suggestion in these columns present position of the Old Ashmolean is one calling for a sympathy that should take practical The fine Jacobean building was form in money. probably designed by Sir Christopher Wren, though it was built by one of those working masons who took a pride in their work. It faces Broad Street, is next to the new buildings of Exeter College, and is only separated by a pathway from the Sheldonian Theatre. Few know its history, fewer still of late years have entered its noble portico and finely lighted It was built at the cost of the University rooms. a
recent
that the
between 1679 and 1682 to house the collection which Elias Ashmole had obtained from John Tradescant. Ashmole was a man of many parts, solicitor, exciseman, freemason, astrologer, botanist, chemist, anatomist, physician, herald, and author of " The History of the Garter." John Tradescant, traveller and botanist, had a garden in South Lambeth, where his name is still perpetuated in Tradescant Street just off the South Lambeth Road. He collected curiosities in many countries, and Ashmole thinking them worthy of preservation added his own coins, medals, paintings, and the library of Lilly, the astrologer. He presented them to a grateful university which caused the house to be built for their reception. The museum was housed in the top floor ; the middle floor was used as a school of natural history where lectures were given on chemistry, and the basement was occupied by a laboratory with furnaces and a library of books treating of chemistry. Changes took place in course of time. The books went to the Bodleian ; natural history specimens were transferred to the new museums in the parks ; some of the curios to the Bodleian galleries, others to the Taylorian and university galleries ; chemistry was abandoned by the university and was taken care of by the colleges. The Arundelian marbles, which had long rested against the wall of the Ashmolean, found a The more suitable home at the British Museum. old Ashmolean had practically ceased to exist as a museum, and was used as a mere adjunct or store for the Bodleian and as a scriptorium for those who were preparing successive volumes of the New
English Dictionary. Then
came upon the scene Mr. R. T. Gunther, LL.D., energetic fellow of Magdalen College, who began to write on the history of science in Oxford. He soon an