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HOSPITAL REFORM.
174 understand that it still costs something like 25s. a drachm, depression amounting in some cases to despondency, and but of course a demand for it would soon bring about a night alarm are of common occurrence," and that with reduction in price. It is further to be desired that some firm rehabilitation of the heart and vessels " all such nerve should furnish the drug in the form of gelatin discs of such suffering vanishes like a dream and the spirits rise to a plane of hope and energy." With the aid of the sphygmometer excellence, for instance, as Wyeth’s discs of homatropine. I have been able to verify the fact that depression, I am, Sirs, yours faithfully, the indefinable sense of impending disaster, irritability, and SNELL. SIMEON 1898. July 13th, insomnia are generally associated with high blood-pressure -
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SIMEON
COPYRIGHT IN PRESCRIPTIONS. To the Editors of THE LANCET. SIRS,-Now that the Royal Commission on Copyright is sitting would it not be a good plan to devise a scheme for bringing prescriptions under the law of copyright ? I mean that it should become legal for medical men to retain the in their prescriptions after a certain limited time after their issue. It is very common for patients to have some prescription which suits them renewed perhaps hundreds of times even to the end of their lives, so that the authors of the prescriptions get compensated with absurd insufficiency by the single fee they receive. The injustice of the present state of things is so palpable and our loss so enormous thereby that there can be no object in disguising the sordid nature of the proposal. It is quite possible that the injury done to us might be obviated in some such way as I suggest.-I am, Sirs, yours faithfully,
copyright
F. LUCAS Lucas BENHAM, M.D., M.R.C.P. M.&C.P. Lond. Elizabeth-street, S.W., July 12th, 1898.
HOSPITAL REFORM. To the Editors of THE LANCET. the SIRS,-In paper I read recently at the United Service Institution embodying certain suggestions as to the reform of the casualty and out-patient departments of London hospitals I macie a statement which I have since discovered is not warranted by fact: it was to the effect that in Scotland and in Ireland drugs were not given in the medical out-patient departments of the hospitals. Before I left the Institution I was informed that I was mistaken with regard to Ireland and Mr. Garrett Horder writes to me under date July 6th as follows : I have been making inquiries of the system adopted in the principal Scotch hospitals and I find that as a rule medicines are supplied to the out-patients." I regret having made the assertion, but I regret still more that the fact is not as I supposed, as I believe the plan to be a good one.-I am, Sirs, yours faithfully, W. HENRY KESTEVEN. I Hendon, N.W., July 8th, 1898. "
" BLOOD-PRESSURE IN THE INSANE." To the Editors of THE LANCET. SIRS,-The article on the above subject, from the pen of Dr. Maurice Craig, which appears in THE LANCET of June 25th, is of such importance that I venture to offer some observations which are based upon five months’ constant use of Barnard and Hill’s sphygmometer, which has been brought into requisition to such good purpose by Dr. Craig, with reference to those who are relatively sound in mind. Dr. Craig is careful to point out that although high intra-arterial pressure is uniformly found to exist in cases marked by depression, especially in melancholia, and infra-normal blood-pressure in those who exhibit excitement and mania, he does not for one moment believe that " any amount of altered bloodpressure can per se produce insanity in a perfectly stable person," and suggests that similar conditions of blood-pressure may exist in other individuals without inducing, or being associated with, mental alienation." In that view he is perfectly correct. Indeed, as far as my experience goes, not only is such the case, but in many persons a pressure of 200 and more mm. Hg. may exist without any psychic effect other than such depression of spirits and gloominess of anticipation as are constantly met with in people who pass as being in average health or as being affected with nothing more grave than the mental state commonly associated with gouty conditions. Writing on the subject of ’chronic diseases of the heart in 18951 I stated that ° intolerance of sound, irritability, difficulty of mental concentration, lessened power of work, 1
The Schott Treatment of Chronic Diseases of the Heart.
and have observed that the lowering of that pressure is followed by very satisfactory results. The instrument referred to indicates the line of treatment which may be required. Of cases of mental excitement associated with infra-normal pressure I have seen so little that I do not venture to express an opinion. There is, however, one point in Dr. Craig’s article which, if I may venture so to say, requires further and closer examination, and that is the state of the bowels. He attaches much importance, and doubtless in the main rightly, to the relief of constipation and to the maintenance of somewhat free action of the bowels ; but it must not be overlooked that a considerable proportion of the subjects of mental depression with high blood-pressure suffer from chronic intestinal catarrh, involving from two to three actions of the bowels a day, of which only the first may be formed or fragmentary and the others fluid. With regard to the relation of the state of the bowels to the condition under consideration, it is suggested that the depression may be due to sensory nerve stimulation affecting the general arterial pressure through the splanchnic mechanism rather than to self-infection. If such be the case the existence of fæcal accumulation and of inordinate action of the bowels must both be regarded as having a similar disturbing effect on the sensory nerves in question, and I do not deny that such may be the case. On the other hand, I do think that the question of auto-toxication cannot be excluded, the more so as, whether the condition relieved be fæcal accumulation or chronic intestinal irritation, an important point is gained in the lowering of blood-pressure and at the same time a striking change is exhibited in the renal function by the great increase of the excretion of urine and the diminution of its toxicity. The question, therefore, arises : What may be the clinical and therapeutic import of the association between mental depression and high bloodpressure ? The observations of some years, which have been strongly confirmed since I have brought the sphygmometer into general use, show that those conditions of the blood which are betrayed by scantiness or concentration of the urine and by increased toxicity are themselves the causes of contraction of arterioles, of high intraarterial pressure with increase of peripheral resistance, of venous engorgement, and of deficient oxygenation of the blood, and that all these conditions, which together constitute a serious pathological condition, are rapidly relieved by increase of arterial capacity and the relief of peripheral resistance resulting in improved oxidation and metabolism and the repair, among others, of the cerebral and other nerve tissues. It is a matter of observation that faecal impaction and chronic looseness may both be associated with high intra-arterial pressure ; and there are strong clinical grounds for believing that the presence of imperfectly digested substances in the descending colon is causatively connected with re-sorption of toxins which should be excreted and with blood-contamination with products of fermentive decomposition. For these reasons I think that auto-toxication is an important factor in the production of mental
depression. In illustration I give, from many others, the following On May 26th I saw a woman, aged thirty-seven years. Her radial pulse was thready and the pressure was 160 mm. Hg. The apex was 1 in. outside the nipple line. There was dyspnoea on the levels and inclines. She woke with a sense of impending suffocation associated with pain in the prascordium and the inner aspect of the left upper arm. The bowels acted twice or thrice daily ; the motions were yellow, second and third being liquid. The patient was very depressed and unwilling to submit to treatment, as she said that she could never be better ; she was never without headache, extending from the frontal region to the vertex and occiput. On June lst the pressure was 126 mm. Hg., she had scarcely any headache, she felt and looked better, On the 7th there was no headand was more hopeful. ache, the appetite and spirits were good, the apex was in the nipple line, the bowels acted once daily, and When last seen, on June 30th, the motions were healthy. she was very bright and cheerful; she had no headache and slept well; the bowels were regular; there cases.
the
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SIMEON
COPYRIGHT IN PRESCRIPTIONS. To the Editors of THE LANCET. SIRS,-Now that the Royal Commission on Copyright is sitting would it not be a good plan to devise a scheme for bringing prescriptions under the law of copyright ? I mean that it should become legal for medical men to retain the in their prescriptions after a certain limited time after their issue. It is very common for patients to have some prescription which suits them renewed perhaps hundreds of times even to the end of their lives, so that the authors of the prescriptions get compensated with absurd insufficiency by the single fee they receive. The injustice of the present state of things is so palpable and our loss so enormous thereby that there can be no object in disguising the sordid nature of the proposal. It is quite possible that the injury done to us might be obviated in some such way as I suggest.-I am, Sirs, yours faithfully,
copyright
F. LUCAS Lucas BENHAM, M.D., M.R.C.P. M.&C.P. Lond. Elizabeth-street, S.W., July 12th, 1898.
HOSPITAL REFORM. To the Editors of THE LANCET. the SIRS,-In paper I read recently at the United Service Institution embodying certain suggestions as to the reform of the casualty and out-patient departments of London hospitals I macie a statement which I have since discovered is not warranted by fact: it was to the effect that in Scotland and in Ireland drugs were not given in the medical out-patient departments of the hospitals. Before I left the Institution I was informed that I was mistaken with regard to Ireland and Mr. Garrett Horder writes to me under date July 6th as follows : I have been making inquiries of the system adopted in the principal Scotch hospitals and I find that as a rule medicines are supplied to the out-patients." I regret having made the assertion, but I regret still more that the fact is not as I supposed, as I believe the plan to be a good one.-I am, Sirs, yours faithfully, W. HENRY KESTEVEN. I Hendon, N.W., July 8th, 1898. "
" BLOOD-PRESSURE IN THE INSANE." To the Editors of THE LANCET. SIRS,-The article on the above subject, from the pen of Dr. Maurice Craig, which appears in THE LANCET of June 25th, is of such importance that I venture to offer some observations which are based upon five months’ constant use of Barnard and Hill’s sphygmometer, which has been brought into requisition to such good purpose by Dr. Craig, with reference to those who are relatively sound in mind. Dr. Craig is careful to point out that although high intra-arterial pressure is uniformly found to exist in cases marked by depression, especially in melancholia, and infra-normal blood-pressure in those who exhibit excitement and mania, he does not for one moment believe that " any amount of altered bloodpressure can per se produce insanity in a perfectly stable person," and suggests that similar conditions of blood-pressure may exist in other individuals without inducing, or being associated with, mental alienation." In that view he is perfectly correct. Indeed, as far as my experience goes, not only is such the case, but in many persons a pressure of 200 and more mm. Hg. may exist without any psychic effect other than such depression of spirits and gloominess of anticipation as are constantly met with in people who pass as being in average health or as being affected with nothing more grave than the mental state commonly associated with gouty conditions. Writing on the subject of ’chronic diseases of the heart in 18951 I stated that ° intolerance of sound, irritability, difficulty of mental concentration, lessened power of work, 1
The Schott Treatment of Chronic Diseases of the Heart.
and have observed that the lowering of that pressure is followed by very satisfactory results. The instrument referred to indicates the line of treatment which may be required. Of cases of mental excitement associated with infra-normal pressure I have seen so little that I do not venture to express an opinion. There is, however, one point in Dr. Craig’s article which, if I may venture so to say, requires further and closer examination, and that is the state of the bowels. He attaches much importance, and doubtless in the main rightly, to the relief of constipation and to the maintenance of somewhat free action of the bowels ; but it must not be overlooked that a considerable proportion of the subjects of mental depression with high blood-pressure suffer from chronic intestinal catarrh, involving from two to three actions of the bowels a day, of which only the first may be formed or fragmentary and the others fluid. With regard to the relation of the state of the bowels to the condition under consideration, it is suggested that the depression may be due to sensory nerve stimulation affecting the general arterial pressure through the splanchnic mechanism rather than to self-infection. If such be the case the existence of fæcal accumulation and of inordinate action of the bowels must both be regarded as having a similar disturbing effect on the sensory nerves in question, and I do not deny that such may be the case. On the other hand, I do think that the question of auto-toxication cannot be excluded, the more so as, whether the condition relieved be fæcal accumulation or chronic intestinal irritation, an important point is gained in the lowering of blood-pressure and at the same time a striking change is exhibited in the renal function by the great increase of the excretion of urine and the diminution of its toxicity. The question, therefore, arises : What may be the clinical and therapeutic import of the association between mental depression and high bloodpressure ? The observations of some years, which have been strongly confirmed since I have brought the sphygmometer into general use, show that those conditions of the blood which are betrayed by scantiness or concentration of the urine and by increased toxicity are themselves the causes of contraction of arterioles, of high intraarterial pressure with increase of peripheral resistance, of venous engorgement, and of deficient oxygenation of the blood, and that all these conditions, which together constitute a serious pathological condition, are rapidly relieved by increase of arterial capacity and the relief of peripheral resistance resulting in improved oxidation and metabolism and the repair, among others, of the cerebral and other nerve tissues. It is a matter of observation that faecal impaction and chronic looseness may both be associated with high intra-arterial pressure ; and there are strong clinical grounds for believing that the presence of imperfectly digested substances in the descending colon is causatively connected with re-sorption of toxins which should be excreted and with blood-contamination with products of fermentive decomposition. For these reasons I think that auto-toxication is an important factor in the production of mental
depression. In illustration I give, from many others, the following On May 26th I saw a woman, aged thirty-seven years. Her radial pulse was thready and the pressure was 160 mm. Hg. The apex was 1 in. outside the nipple line. There was dyspnoea on the levels and inclines. She woke with a sense of impending suffocation associated with pain in the prascordium and the inner aspect of the left upper arm. The bowels acted twice or thrice daily ; the motions were yellow, second and third being liquid. The patient was very depressed and unwilling to submit to treatment, as she said that she could never be better ; she was never without headache, extending from the frontal region to the vertex and occiput. On June lst the pressure was 126 mm. Hg., she had scarcely any headache, she felt and looked better, On the 7th there was no headand was more hopeful. ache, the appetite and spirits were good, the apex was in the nipple line, the bowels acted once daily, and When last seen, on June 30th, the motions were healthy. she was very bright and cheerful; she had no headache and slept well; the bowels were regular; there cases.
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