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CEREBRAL BLOOD-FLOW IN EPILEPSY
612 GLISSONIAN RICKETS IT has for long been a puzzling feature of the original descriptions of rickets that the disease should have been most prevalent in the rural areas, whereas nowadays it has a largely urban incidence. Other features which have given rise to difficulty are the extreme severity of the disease as observed by Glisson in the 17th century, and the epidemic proportions of its first appearance. These difficulties are solved by Dr.] C. E. Kellett in a paper describing the social factors which have operated to change Glissonian rickets into the comparatively mild malady with which we are to-day familiar. Dr. Kellett was moved to his task by his experience of two cases of rickets, so severe as to recall Glisson’s description of the disease, admitted to These cases, twin Great Ormond-street Hospital. children of a Soho tailor, had been breast-fed for 18 months by their mother whose diet was found to be entirely lacking in vitamins Throughout lactation she had been helping the tailor at his work, so that the children were deprived of fresh air and sunshine. Dr. Kellett draws a striking parallel between the conditions under which the under-paid and ill-fed Soho tailor and his wife live and breed to-day, and the similar conditions which obtained in large areas of rural England at the height of the wool trade in the late 16th and early 17th centuries. The discrepancy between the steadily rising price of wheat and the diminishing wages of labourers reached a maximum in the years between 1620 and 1660, exactly the period in which severe rickets became epidemic. At this time the real value of wages had undergone
great depreciation ; these scanty wages were earned by preparing and spinning wool, and weaving it into cloth, the whole family working in their cottage throughout the daylight hours. Dr. Kellett gives reasons for thinking that the distribution of the severe rickets described by 17th century writers corresponds with the distribution of the wool industry, and that the diminution in its severity accompanied the decline in England’s wool trade following the Thirty Years’ War, and the impoverishment of her most important market. The occurrence of severe epidemic rickets was no mere coincidence but the
direct result of the economic situation which arose in England in Glisson’s time; it may still occur sporadically where a rachitogenic diet is combined
with
unremitting
incarceration.
CEREBRAL BLOOD-FLOW IN EPILEPSY THE state of the cerebral vessels in epilepsy has been a matter for speculation, illuminated by little direct evidence. Extremely interesting observations have recently been made in Boston, however,
long
which provide important information on this point.22 If the changes in temperature of a heated stylet, introduced through a hollow needle into a vessel, are recorded, it is found that the temperature of the stylet varies inversely as the blood-flow ; the greater the amount of blood passing the instrument in a given time, the more heat is carried away from it, and vice versa. The stylet was devised and tested by Dr. F. A. Gibbs, and he and his co-workers have succeeded in introducing it into the internal jugular vein of several epileptic subjects, some in status epilepticus and some suffering from petit mal. The main result in all cases is quite clear-namely, that 1 Arch. Dis. Childhood, August, 1934, p. 233. 2 Gibbs, F. A., Lennox, W. G., and Gibbs, E. L. : Arch. Neurol. and Psychiat., August, 1934, p. 257.
all disturbances of cerebral blood-flow occur after the seizure has started, and therefore play no part in its causation. In general the convulsions are a in blood-flow, but often there rise by accompanied is a sharp fall at first. The investigators state that any change in flow is registered immediately by the instrument ; so it cannot be said that the decreased flow in these cases occurs actually before the seizure and is not recorded until after it has begun. " Light pressure on the neck over the jugular vein in which the recorder is located produces evidence of a decrease in flow within a fraction of a second. When the contralateral jugular vein is compressed there is evidence, within a fraction of a second, of an increase in flow." The published tracings bear out the claims of their authors, and in addition include respiratory records which suggest an accumulation of carbon dioxide during the attacks. The consequent vasodilatation, coupled with the rise of blood pressure which almost certainly occurs, is probably sufficient to account for the actual changes in blood-flow observed. Artificially produced cerebral anaemia fails to produce convulsions, and the oxygen content of the jugular blood gives no evidence of a chronic stasis of blood having preceded the spontaneous attacks. It is pointed out that only generalised vasoconstriction has been ruled out as a causal factor; a small focus of ischaemia would be unlikely to affect the jugular flow, and cannot be excluded on the basis of these experiments. Other reasons are advanced, however, which tend to discount this
possibility. THE EHRLICH MEDAL
THE Paul Ehrlich
gold
medal
was
this year awarded
to Dr. Walter Kikuth at a special medical meeting held, under the presidency of Prof. W. Kolle, on Sept. 7th, at Frankfort-on-Main. Dr. Kikuth, who is well known in England, has gained his laurels in the realm of chemotherapeutics. Born in Riga, he began his studies at Dorpat and completed them in Germany at the conclusion of the late war. After an assistantship in the Eppendorfer Krankenhaus in Hamburg,
tropical medicine in that city and worked in the Institute Oswaldo Cruz subsequently in Rio de Janiero. He then joined the staff at Elberfeld of the I.G. Farbenindustrie and was appointed successor to Dr. Roehl. Subsequently, in 1931, he became attached to the Medical Academv of Diisseldorf University. Dr. Kikuth has important work on pulmonary carcinoma, and with Prof. Mayer has confirmed Noguchi’s work on Oroya fever and verruca peruviana-studies which led him to embrace the whole of the bartonella group. It is however in immunology and chemotherapy as applied to malaria that his main achievements lie, culminating in the working out of the new synthetic drug Atebrin for the treatment of that disease. he took
up
published
IT is
reported that the Middlesex Hospital has bought from the Berners Estate the freehold of the rectangular island site of nearly three acres fronting on Mortimer-street on which it stands. The hospital holds its site on leases which expire in the year 2753, and pays an annual ground rent of 2750. When it first built in 1745 it occupied two small houses off the Tottenham Court-road. In 1754 it acquired from Mr. Charles Berners land in what was then known as Marylebone Fields. This land was leased " for 999 years at a rent of 2s. for every foot in front of the said ground." was
great depreciation ; these scanty wages were earned by preparing and spinning wool, and weaving it into cloth, the whole family working in their cottage throughout the daylight hours. Dr. Kellett gives reasons for thinking that the distribution of the severe rickets described by 17th century writers corresponds with the distribution of the wool industry, and that the diminution in its severity accompanied the decline in England’s wool trade following the Thirty Years’ War, and the impoverishment of her most important market. The occurrence of severe epidemic rickets was no mere coincidence but the
direct result of the economic situation which arose in England in Glisson’s time; it may still occur sporadically where a rachitogenic diet is combined
with
unremitting
incarceration.
CEREBRAL BLOOD-FLOW IN EPILEPSY THE state of the cerebral vessels in epilepsy has been a matter for speculation, illuminated by little direct evidence. Extremely interesting observations have recently been made in Boston, however,
long
which provide important information on this point.22 If the changes in temperature of a heated stylet, introduced through a hollow needle into a vessel, are recorded, it is found that the temperature of the stylet varies inversely as the blood-flow ; the greater the amount of blood passing the instrument in a given time, the more heat is carried away from it, and vice versa. The stylet was devised and tested by Dr. F. A. Gibbs, and he and his co-workers have succeeded in introducing it into the internal jugular vein of several epileptic subjects, some in status epilepticus and some suffering from petit mal. The main result in all cases is quite clear-namely, that 1 Arch. Dis. Childhood, August, 1934, p. 233. 2 Gibbs, F. A., Lennox, W. G., and Gibbs, E. L. : Arch. Neurol. and Psychiat., August, 1934, p. 257.
all disturbances of cerebral blood-flow occur after the seizure has started, and therefore play no part in its causation. In general the convulsions are a in blood-flow, but often there rise by accompanied is a sharp fall at first. The investigators state that any change in flow is registered immediately by the instrument ; so it cannot be said that the decreased flow in these cases occurs actually before the seizure and is not recorded until after it has begun. " Light pressure on the neck over the jugular vein in which the recorder is located produces evidence of a decrease in flow within a fraction of a second. When the contralateral jugular vein is compressed there is evidence, within a fraction of a second, of an increase in flow." The published tracings bear out the claims of their authors, and in addition include respiratory records which suggest an accumulation of carbon dioxide during the attacks. The consequent vasodilatation, coupled with the rise of blood pressure which almost certainly occurs, is probably sufficient to account for the actual changes in blood-flow observed. Artificially produced cerebral anaemia fails to produce convulsions, and the oxygen content of the jugular blood gives no evidence of a chronic stasis of blood having preceded the spontaneous attacks. It is pointed out that only generalised vasoconstriction has been ruled out as a causal factor; a small focus of ischaemia would be unlikely to affect the jugular flow, and cannot be excluded on the basis of these experiments. Other reasons are advanced, however, which tend to discount this
possibility. THE EHRLICH MEDAL
THE Paul Ehrlich
gold
medal
was
this year awarded
to Dr. Walter Kikuth at a special medical meeting held, under the presidency of Prof. W. Kolle, on Sept. 7th, at Frankfort-on-Main. Dr. Kikuth, who is well known in England, has gained his laurels in the realm of chemotherapeutics. Born in Riga, he began his studies at Dorpat and completed them in Germany at the conclusion of the late war. After an assistantship in the Eppendorfer Krankenhaus in Hamburg,
tropical medicine in that city and worked in the Institute Oswaldo Cruz subsequently in Rio de Janiero. He then joined the staff at Elberfeld of the I.G. Farbenindustrie and was appointed successor to Dr. Roehl. Subsequently, in 1931, he became attached to the Medical Academv of Diisseldorf University. Dr. Kikuth has important work on pulmonary carcinoma, and with Prof. Mayer has confirmed Noguchi’s work on Oroya fever and verruca peruviana-studies which led him to embrace the whole of the bartonella group. It is however in immunology and chemotherapy as applied to malaria that his main achievements lie, culminating in the working out of the new synthetic drug Atebrin for the treatment of that disease. he took
up
published
IT is
reported that the Middlesex Hospital has bought from the Berners Estate the freehold of the rectangular island site of nearly three acres fronting on Mortimer-street on which it stands. The hospital holds its site on leases which expire in the year 2753, and pays an annual ground rent of 2750. When it first built in 1745 it occupied two small houses off the Tottenham Court-road. In 1754 it acquired from Mr. Charles Berners land in what was then known as Marylebone Fields. This land was leased " for 999 years at a rent of 2s. for every foot in front of the said ground." was