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THE ETIOLOGY OF GENERAL PARALYSIS.
1845 the blood and if the period of decompression is too short the gas is disengaged as bubbles in the capillaries and tissue spaces, with the result that embolism of a vessel may occur. The experiments confirm the conclusions of H. Hersent of Bordeaux and others which indicate clearly the danger connected with short decompression periods. Every death or case of paralysis from air embolism must be set down to the negligence of the contractor in not insisting upon a sufficient length of time for decompression. Mr. Hill and Mr. Greenwood have placed on record the subjective changes which they experienced during the progress of their work. They found that apart from changes in the voice and anaesthesia of the lip, the subjective effects of increased pressure depended upon psychical conditions such as anxiety and excitement. I One of the investigators had not practised beforehand the opening of the Eustachian tubes and accordingly was moat distuibed at the first experiment. The sensations of increasing deafness and intolerable discomfort in the ears with no obvious cause and the iuability togain relief by the recognised method of swallowing produced a condition of mental distress which led him to terminate abruptly the experiment. Bat after learning the method of cpening the Eustachian tubes the trouble did not occur in subsequent experiments. The investigation al o showed that changes in the percentage of carbon dioxide in the alveolar air are due solely to physical variations and not any increase or diminution in the respiratory metabolism ; and further, that, contrary to Snell’s opinion, the presence of carbon dioxide in the respired air does not exercise a pecularly unfavourable influence under high pressures.
OFFENSIVE
of foul gas-lime should be prohibited. We must confess considerable surprise that the incident in the House of Commons was allowed to end where it did and we should like to see the que’tion reopened in the interests not only of the Members of Parliament but of the public also.
disposing
A
DANGEROUS
MIXTURE.
IT has recently bfen shown by Mr. J. Rutherford Hill in the Pharmaceutical JL1lrnal that the solution of strychnine hydrochloride of the 1898 British Pharmacopeeia is incompatible with solutions of magnesium hydrato carbonate. It has been a common practice until recently among pharmacists to prepare peppermint and other aromatic waters by triturating the essential oil with light carbonate of magnesium, adding water and filtering. But owing to the slight solubility oE the magnesium salt in water it has been largely replaced by calcium phosphate, talc, and other insoluble substances. When aromatic waters prepared by the aid of magnesium carbonate were prescribed with the acid solution of strychnine hydrochloride of the 1885 Pharmacopœia no change took place, but in the case of the present official solution, which does not contain free acid, the strychnine gradually crystallises out. This change was noticed owing to an empty three-ounce dispensing bottle being sent to a pharmacist to be refilled with a mixture containing one fluid drachm of the official strychnine solution in three fluid ounces of peppermint water. The inside of the bottle was found to be coated with small crystals representing the greater part of the strychnine. It is obvious that an incompatibility of this kind presents two serious inconveniences. In the first place, the patient does not take the full amount of strychnine ordered by the prescriber and in the second place there is considerable danger of the patient taking the bulk of the alkaloid in the last dose. Mr. Hill’s valuable communication has probably given this unscientific method of preparing aromatic waters its death-blow, while it has afforded an interesting and important example of the unexpected results that may attend the modification, in however slight a degree, of official formulas. It emphasises, too, the necessity of a strict adherence to the Pharmacopoeia, which directs aromatic waters to be prepared by distillation and without the use of magnesia or other substances.
SMELLS IN THE HOUSE OF COMMONS. THE proceedings in the House of Commons on June 21st were interrupted by a Member suddenly asking whether the Government was aware of the presence of sewer gas in the House? "The same thing occurred yesterday. Can anything be done to purify the atmosphere of the House? It is simply poisonous." Mr. Harcourt subsequently reported that what had happened was that a barge filled with gas liquor had The same been taken down the river for disposal at sea. barge the day before had given rise to a similar complaint and he would endeavour to make arrangements with the gas THE ETIOLOGY OF GENERAL PARALYSIS. company for the adoption of some other hour for conveyance. AT a recent meeting of the New York Neurological Society There are two interesting points in connexion with this incident. First of all, it is evident that the system of venti- a discussion, the report of which appears in the Journal of lation at the House of Commons must be in working order, as Nervous and Mental Disease for March, was opened by Dr. otherwise the smell complained of would not so quickly have J. Collins upon the subject of General Paralysis of the pervaded the chamber. It is also clear that the air-supply is Insane, turning chiefly upon the question of etiology. drawn from the direction of the river and it is open to question Having analysed 100 cases of this disease which had whether this is the best source, apart altogether from the fact occurred recently in his practice Dr. Collins found that of barges with offensive cargoes floating down the stream. in 23 there was a family history of organic or functional A subsequent speaker elicited a like It is conceivable that bad river air may have some connexion nervous disease. with the frequent complaints made of the want of vitality history in 32 per cent. of 250 cases. Recent works on insanity of the air in the House of Commons and with the marked state that insane or neurotic inheritance is present in from way in which so many of its members are attacked by in.uenza. 40 to 50 per cent. of cases. The views held upon this point The other point is that apparently the carrying down the have changed of recent years, f. r 15 or 20 years ago it was river of matters which are admittedly offensive is tolerated commonly taught in this country that general paralysis was even by His Majesty’s First Commissioner of Works, for he i, peculiar amongst mental diseases in that insane or neurotic said that he would make arrangements with the gas company ’I inheritance was but seldom found in cases of that disease. for the adoption of some other hour for conveyance. In our ’, Various speakers gave their experience in regard to the opinion this pestilential traffic should be stopped altogether relationship of syphilis and general paralysis ; these had ascerand it is simply monstrous that such offensive stuff should tained syphilis to be present respectively in from 55 to 62 per be dumped into the sea. Mr. Harcourt said that it was cent., in from 59 to 64 per cent., and in 45 per cent. of their This must be a mistake as gas liquor is a cases ; in the last instance the figures refer to males only, gas liquor. valuable asset, being a source of ammonia, cyanides, and females having been found to be infected in 20 per cent. of other substances. He most probably meant spent gas-lime the cases. In many of these instances syphilis was regarded for which there is practically no use. This waste product is as having been acquired merely on the " admission " of the a singularly offensive material and, moreover, is very patient, without any corroborative evidence, objective or destructive to fish life. In all these circumstances surely it otherwise ; and therefore the deduction made is of limited Statistics as to the causal influence of syphilis in is time that this clumsy and offensive method of value.
high
1846
general paralysis vary enormously, modern authors giving figures ranging from 20 to 90 per cent. Moreover, a point which is frequently lost sight of and the neglect of which
policy succeeds in one or more cases there can be no reason why it should not succeed in others. If, as many declare it to be the fact, the public prefer light grain spirit detracts much from the value of statements made upon this or a blend to a pure full all-malt spirit, the fact that the subject is that syphilis is very rarely present alone but exists spirit is correctly described on the label, as the case may be, usually in combination with other causative agencies the should not disturb this preference in the least degree. The possible influence of which cannot be ignored. As regards public must be the judge in the question of taste and they the interval between the date of infection with syphilis and would welcome being frankly dealt with. The hatchet the appearance of the earliest symptoms of general paralysis, might thus be buried and an end put to costly and vexatious the opinion expressed was that whilst this might in rare proceedings. cases be even less than one year it is commonly very much THE ROYAL SANITARY INSTITUTE. longer, a perioi of about 11 years being frequent, and even the latter may be largely exceeded. In the course of the THE Twenty third Congress of the Royal Sanitary Indiscussion Dr. Allen Starr made the statement that in about stitute will be held from July 9th to 14th at Bristol under 80 per cent. of a large number of cases of general paralysis the presidency of the Right Hon. Sir Edward Fry. On the which he had analysed physical symptoms appeared before first day at noon there will be a reception of members and mental symptoms.. Whilst it is known that physical in the Council House by the Lord Mayor of disorders are sometimes the earlier to appear the above pro. delegates Bristol, Mr. A. J. Smith, after which a public luncheon will portion iso enormous that we are almost compelled to be held in the Royal Hotel. The inaugural address will believe that subtle mental changes, as of character, be delivered in the Victoria Rooms by the President at judgment, and aptitude, must in very many instances have 8 P.M. The sectional meetings will commence on July 10th, been overlooked. The discussion brought out the importance the first, that of "Sanitary Science and Preventive Medi-of making a careful physical examination in cases of so-called over Sir William Collins, M.P.; the neurasthenia, by means of which significant early symptoms cine," being presided and by second, Architecture," by Mr. Edwin T. Engineering of general paralysis, such as facial tremor, alteration of and the third, "Physics, Chemistry, and Biology," by Hall ; pupillary reactions and of knee-jerks, may be recognised. The Mr. W. N. Shaw, F.R.S. The special conferences include difficulty of diagnosing the disease from conditions due to cere"Municipal Representatives," "Medical Officers of Health," bral syphilis and the importance of carrying out a course of " Sanitary Inspectors," Inspectors." There anti-syphilitic treatment in doubtful cases were alluded to. A will also be conferencesandof "Veterinary women on " Hygiene " and on history of the abuse of alcohol had been obtained by certain "The Hygiene of School Life." The lecture to the Conobservers who took part in the discussion ; of 250 cases this will be delivered by Professor C. Lloyd Morgan who gress was ascertained in about 25 per cent., a proportion which for his subject " Relation of Heredity to will take agrees with that given in recent works-namely, from 20 to 30 Physical Degeneration." Nearly 200 authorities, including per cent. But here again the observation made above reseveral county councils and county boroughs, have already specting the causative influence of syphilis will apply: to the Congress. With the object of alcohol can but rarely be dissociated from other factors in appointed delegates of the application and carrya illustration causation. It is nevertheless looked upon by many com- giving practical out of and methods discussed at the the principles petent observers as a genetic factor only second in import- ing a health exhibition of and appliances ance to syphilis. Syphilis and alcoholism, however, prevail meeting to health and domestic useapparatus is beicg organised. to an extent compared to which general paralysis is a rare relating malady and observation shows that in most cases of the OPERATIONS FOR NON-EXISTENT latter disease a combination of causes, psychical and APPENDICITIS. physical, is present. Much labour is clearly necessary before we can adequately appreciate the relative value of AT a meeting of the Académic de Medecineon May 29th these and ascertain whether they act directly or merely by M. Dieulafoy made the statement that many persons sufferpreparing the way for the operation of toxic agencies. ing from typhlo colitis are operated on for appendicitis which does not exist.’ The importance attaching to any a
-
..
WHAT IS WHISKY? THE Mr. rordhams view that
spirit produced by
the
by the eminent French surgeon is increased in this instance by the fact that he is one of the most extreme advocates of the operative treatment of appendicitis, holding that it is the sole efficacious and rational method. "Remove the toxi-infectious appendicular focus before it can become fatal " is his rule. He related 12 cases of which the following are some examples. A man was admitted into the Hôtel Dieu who had undergone operation for " appendicitis." The surgeon sent with him the appendix which was sound. The patient was suffering from an attack of mucomembranous typhlo-colitis which followed the same course as other attacks which occurred before the operation. In a second case M. Dieulafoy saw in consultation a young man who had suffered for a long time from muco-membranous typhlocolitis. Finding a scar in the right iliac fossa he said, "You have been operated on for appendicitis." "Yes," replied the patient, " for appendicitis which I had not." In a third case a woman suffering from the same disease gave the same history. She continued to suffer just as before operation. On examination there was pain in the right iliac Eossa like that of appendicitis. In a fourth case M. Dieulafoy saw in consultation a young woman who had suffered for announcement
APPEAL.
patent
still from a mash consisting to a large extent of maize, to which a " dash " of whisky made from barley malt had been added, cannot be considered as either Scotch or Irish whisky must so far stand, inasmuch as the proceedings for appeal concluded at the sessions house, Newington, on Monday last, with the announcement that the bench of magistrates was - equally divided and therefore there could be no judgment. It is possible that the appellants will make application to quarter sessions for a re bearing of the appeal, in which event we should not be justified in making any comment on the aspects of the case. The proceedings are costing a considerable sum of money and it is unfortunate that they should have ended in this fiasco. We cannot help thinking that the trade would be well advised if they ceased to fight the matter out in court and if they would come to an agreement all round to make a clean breast of it and adopt an honest, straightforward description of their goods. There are firms who do not hesitate to declare accurately the nature of the goods they are selling, whether they are pot-still all-malt or patent-still spirits, or a mixture of both, and surely if such
1
THE
LANCET, June 23rd, 1906, p. 1793
,
OFFENSIVE
of foul gas-lime should be prohibited. We must confess considerable surprise that the incident in the House of Commons was allowed to end where it did and we should like to see the que’tion reopened in the interests not only of the Members of Parliament but of the public also.
disposing
A
DANGEROUS
MIXTURE.
IT has recently bfen shown by Mr. J. Rutherford Hill in the Pharmaceutical JL1lrnal that the solution of strychnine hydrochloride of the 1898 British Pharmacopeeia is incompatible with solutions of magnesium hydrato carbonate. It has been a common practice until recently among pharmacists to prepare peppermint and other aromatic waters by triturating the essential oil with light carbonate of magnesium, adding water and filtering. But owing to the slight solubility oE the magnesium salt in water it has been largely replaced by calcium phosphate, talc, and other insoluble substances. When aromatic waters prepared by the aid of magnesium carbonate were prescribed with the acid solution of strychnine hydrochloride of the 1885 Pharmacopœia no change took place, but in the case of the present official solution, which does not contain free acid, the strychnine gradually crystallises out. This change was noticed owing to an empty three-ounce dispensing bottle being sent to a pharmacist to be refilled with a mixture containing one fluid drachm of the official strychnine solution in three fluid ounces of peppermint water. The inside of the bottle was found to be coated with small crystals representing the greater part of the strychnine. It is obvious that an incompatibility of this kind presents two serious inconveniences. In the first place, the patient does not take the full amount of strychnine ordered by the prescriber and in the second place there is considerable danger of the patient taking the bulk of the alkaloid in the last dose. Mr. Hill’s valuable communication has probably given this unscientific method of preparing aromatic waters its death-blow, while it has afforded an interesting and important example of the unexpected results that may attend the modification, in however slight a degree, of official formulas. It emphasises, too, the necessity of a strict adherence to the Pharmacopoeia, which directs aromatic waters to be prepared by distillation and without the use of magnesia or other substances.
SMELLS IN THE HOUSE OF COMMONS. THE proceedings in the House of Commons on June 21st were interrupted by a Member suddenly asking whether the Government was aware of the presence of sewer gas in the House? "The same thing occurred yesterday. Can anything be done to purify the atmosphere of the House? It is simply poisonous." Mr. Harcourt subsequently reported that what had happened was that a barge filled with gas liquor had The same been taken down the river for disposal at sea. barge the day before had given rise to a similar complaint and he would endeavour to make arrangements with the gas THE ETIOLOGY OF GENERAL PARALYSIS. company for the adoption of some other hour for conveyance. AT a recent meeting of the New York Neurological Society There are two interesting points in connexion with this incident. First of all, it is evident that the system of venti- a discussion, the report of which appears in the Journal of lation at the House of Commons must be in working order, as Nervous and Mental Disease for March, was opened by Dr. otherwise the smell complained of would not so quickly have J. Collins upon the subject of General Paralysis of the pervaded the chamber. It is also clear that the air-supply is Insane, turning chiefly upon the question of etiology. drawn from the direction of the river and it is open to question Having analysed 100 cases of this disease which had whether this is the best source, apart altogether from the fact occurred recently in his practice Dr. Collins found that of barges with offensive cargoes floating down the stream. in 23 there was a family history of organic or functional A subsequent speaker elicited a like It is conceivable that bad river air may have some connexion nervous disease. with the frequent complaints made of the want of vitality history in 32 per cent. of 250 cases. Recent works on insanity of the air in the House of Commons and with the marked state that insane or neurotic inheritance is present in from way in which so many of its members are attacked by in.uenza. 40 to 50 per cent. of cases. The views held upon this point The other point is that apparently the carrying down the have changed of recent years, f. r 15 or 20 years ago it was river of matters which are admittedly offensive is tolerated commonly taught in this country that general paralysis was even by His Majesty’s First Commissioner of Works, for he i, peculiar amongst mental diseases in that insane or neurotic said that he would make arrangements with the gas company ’I inheritance was but seldom found in cases of that disease. for the adoption of some other hour for conveyance. In our ’, Various speakers gave their experience in regard to the opinion this pestilential traffic should be stopped altogether relationship of syphilis and general paralysis ; these had ascerand it is simply monstrous that such offensive stuff should tained syphilis to be present respectively in from 55 to 62 per be dumped into the sea. Mr. Harcourt said that it was cent., in from 59 to 64 per cent., and in 45 per cent. of their This must be a mistake as gas liquor is a cases ; in the last instance the figures refer to males only, gas liquor. valuable asset, being a source of ammonia, cyanides, and females having been found to be infected in 20 per cent. of other substances. He most probably meant spent gas-lime the cases. In many of these instances syphilis was regarded for which there is practically no use. This waste product is as having been acquired merely on the " admission " of the a singularly offensive material and, moreover, is very patient, without any corroborative evidence, objective or destructive to fish life. In all these circumstances surely it otherwise ; and therefore the deduction made is of limited Statistics as to the causal influence of syphilis in is time that this clumsy and offensive method of value.
high
1846
general paralysis vary enormously, modern authors giving figures ranging from 20 to 90 per cent. Moreover, a point which is frequently lost sight of and the neglect of which
policy succeeds in one or more cases there can be no reason why it should not succeed in others. If, as many declare it to be the fact, the public prefer light grain spirit detracts much from the value of statements made upon this or a blend to a pure full all-malt spirit, the fact that the subject is that syphilis is very rarely present alone but exists spirit is correctly described on the label, as the case may be, usually in combination with other causative agencies the should not disturb this preference in the least degree. The possible influence of which cannot be ignored. As regards public must be the judge in the question of taste and they the interval between the date of infection with syphilis and would welcome being frankly dealt with. The hatchet the appearance of the earliest symptoms of general paralysis, might thus be buried and an end put to costly and vexatious the opinion expressed was that whilst this might in rare proceedings. cases be even less than one year it is commonly very much THE ROYAL SANITARY INSTITUTE. longer, a perioi of about 11 years being frequent, and even the latter may be largely exceeded. In the course of the THE Twenty third Congress of the Royal Sanitary Indiscussion Dr. Allen Starr made the statement that in about stitute will be held from July 9th to 14th at Bristol under 80 per cent. of a large number of cases of general paralysis the presidency of the Right Hon. Sir Edward Fry. On the which he had analysed physical symptoms appeared before first day at noon there will be a reception of members and mental symptoms.. Whilst it is known that physical in the Council House by the Lord Mayor of disorders are sometimes the earlier to appear the above pro. delegates Bristol, Mr. A. J. Smith, after which a public luncheon will portion iso enormous that we are almost compelled to be held in the Royal Hotel. The inaugural address will believe that subtle mental changes, as of character, be delivered in the Victoria Rooms by the President at judgment, and aptitude, must in very many instances have 8 P.M. The sectional meetings will commence on July 10th, been overlooked. The discussion brought out the importance the first, that of "Sanitary Science and Preventive Medi-of making a careful physical examination in cases of so-called over Sir William Collins, M.P.; the neurasthenia, by means of which significant early symptoms cine," being presided and by second, Architecture," by Mr. Edwin T. Engineering of general paralysis, such as facial tremor, alteration of and the third, "Physics, Chemistry, and Biology," by Hall ; pupillary reactions and of knee-jerks, may be recognised. The Mr. W. N. Shaw, F.R.S. The special conferences include difficulty of diagnosing the disease from conditions due to cere"Municipal Representatives," "Medical Officers of Health," bral syphilis and the importance of carrying out a course of " Sanitary Inspectors," Inspectors." There anti-syphilitic treatment in doubtful cases were alluded to. A will also be conferencesandof "Veterinary women on " Hygiene " and on history of the abuse of alcohol had been obtained by certain "The Hygiene of School Life." The lecture to the Conobservers who took part in the discussion ; of 250 cases this will be delivered by Professor C. Lloyd Morgan who gress was ascertained in about 25 per cent., a proportion which for his subject " Relation of Heredity to will take agrees with that given in recent works-namely, from 20 to 30 Physical Degeneration." Nearly 200 authorities, including per cent. But here again the observation made above reseveral county councils and county boroughs, have already specting the causative influence of syphilis will apply: to the Congress. With the object of alcohol can but rarely be dissociated from other factors in appointed delegates of the application and carrya illustration causation. It is nevertheless looked upon by many com- giving practical out of and methods discussed at the the principles petent observers as a genetic factor only second in import- ing a health exhibition of and appliances ance to syphilis. Syphilis and alcoholism, however, prevail meeting to health and domestic useapparatus is beicg organised. to an extent compared to which general paralysis is a rare relating malady and observation shows that in most cases of the OPERATIONS FOR NON-EXISTENT latter disease a combination of causes, psychical and APPENDICITIS. physical, is present. Much labour is clearly necessary before we can adequately appreciate the relative value of AT a meeting of the Académic de Medecineon May 29th these and ascertain whether they act directly or merely by M. Dieulafoy made the statement that many persons sufferpreparing the way for the operation of toxic agencies. ing from typhlo colitis are operated on for appendicitis which does not exist.’ The importance attaching to any a
-
..
WHAT IS WHISKY? THE Mr. rordhams view that
spirit produced by
the
by the eminent French surgeon is increased in this instance by the fact that he is one of the most extreme advocates of the operative treatment of appendicitis, holding that it is the sole efficacious and rational method. "Remove the toxi-infectious appendicular focus before it can become fatal " is his rule. He related 12 cases of which the following are some examples. A man was admitted into the Hôtel Dieu who had undergone operation for " appendicitis." The surgeon sent with him the appendix which was sound. The patient was suffering from an attack of mucomembranous typhlo-colitis which followed the same course as other attacks which occurred before the operation. In a second case M. Dieulafoy saw in consultation a young man who had suffered for a long time from muco-membranous typhlocolitis. Finding a scar in the right iliac fossa he said, "You have been operated on for appendicitis." "Yes," replied the patient, " for appendicitis which I had not." In a third case a woman suffering from the same disease gave the same history. She continued to suffer just as before operation. On examination there was pain in the right iliac Eossa like that of appendicitis. In a fourth case M. Dieulafoy saw in consultation a young woman who had suffered for announcement
APPEAL.
patent
still from a mash consisting to a large extent of maize, to which a " dash " of whisky made from barley malt had been added, cannot be considered as either Scotch or Irish whisky must so far stand, inasmuch as the proceedings for appeal concluded at the sessions house, Newington, on Monday last, with the announcement that the bench of magistrates was - equally divided and therefore there could be no judgment. It is possible that the appellants will make application to quarter sessions for a re bearing of the appeal, in which event we should not be justified in making any comment on the aspects of the case. The proceedings are costing a considerable sum of money and it is unfortunate that they should have ended in this fiasco. We cannot help thinking that the trade would be well advised if they ceased to fight the matter out in court and if they would come to an agreement all round to make a clean breast of it and adopt an honest, straightforward description of their goods. There are firms who do not hesitate to declare accurately the nature of the goods they are selling, whether they are pot-still all-malt or patent-still spirits, or a mixture of both, and surely if such
1
THE
LANCET, June 23rd, 1906, p. 1793
,