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"A SUPERIOR PERSON" ON " HOW THE POOR ARE MEDICALLY TREATED IN LIVERPOOL."
579 in each of these towns and none allusion to the special diseases of tropical of them make any than other climates malaria, or to any epidemic except the Dr. Rankine and Mr. Clindening undermentioned. one on the remark high temperature prevalent in their localities In summer. in Ichang the thermometer rose to 109° F. in At to 106’ in the following month. and July, 1898, maximum in the the in 1898 temperature Kiukiang "true shade" was 105° in July, 104.6° in August, and 100° in September. In the other three towns the heat was not Dr. Rankine makes mention of a peculiar ,so great. epidemic, for which, however, he does not suggest any The whole of his reference to it is as name or pathology.
iemperature in nystero-epuepsy naa Deen stuaiea out llttle and the conditions of the pulse in all the three types of epilepsy referred to above were known but very slightly. Marchand, as the result of his observations on 300 patients, was able to collect a vast mass of clinical data on these points. These data were on the whole concordant and pointed to important features in pulse and temperature which
follows :In 1897
its maximum in 20 minutes after the fit. This maximum elevation lasts only 10 minutes. 3. Attacks of epileptic vertigo cause a decidedly less but still noticeable elevation of temperature. 4. Regarding epileptiform attacks those of general paralysis cause a marked elevation of temperature comparable to that occurring in true epilepsy. 5. In all cases, whether of epilepsy or of epileptic vertigo, there is in general no relation between the maximum height reached by the temperature and the age of the patient, and in the same patient different attacks may produce slightly different temperatures. 6. The pulse rises about 31 beats in frequency per minute above the normal after a fit, but 50 minutes after the fit it has fallen to normal. The maximum pulse-rate is attained 16 minutes after the attack and this rate persists for five minutes. 7. Both temperature and pulse fall after maximum slowly and steadily to normal or only with slight oscillations during subsidence. 8. In epileptic vertigo the pulse rises in proportion to the intensity of the attack. 9. The elevation of temperature in epileptic vertigo is 0’3 C.; it lasts 40 minutes. The temperature attains its maximum 15 minutes after the attack and persists at the maximum for 13 minutes, after which it gradually subsides. 10. Hysteroepilepsy increases the temperature by 0.4° C. and this elevation lasts 35 minutes. There is a direct ratio between the length of the attack and the elevation of temperature. In two-thirds of the cases the temperature is at its maximum at the onset of the period of " attitudes passionels."" The duration of the maximum temperature is eight minutes and the fall thereafter to normal is gradual. 11. The pulse in hysteroepilepsy rises 57 beats and the acceleration of the pulse lasts 24 minutes. The maximum pulse-rate is attained at the onset of the attack (epileptoid period) and this rate lasts for four minutes. The subsidence thereafter is irregular and marked by considerable oscillations of the pulse-rate. 13. There is no relation between the duration of an attack and the maximum rate attained by the pulse in hysteroepilepsy. On the whole the cardiac disturbance (modification and irregular fall of the pulse) is much more marked than the temperature variations in hystero-epilepsy.
(e.g., European) residents
epidemic raged here as elsewhere in the Yangtze Valley’and carried off the natives by scores. I did not see any cases amongst them, but I was called one day to the convent to see one of the sisters who was reported to have this disease. I found her lying in a comatose condition and got a history that such attacks were intermittent. She had lucid intervals, became quite conscious, talked .rationally, then suddenly without warning she would become unconscious; twitching of the facial muscles would begin and convulsive movements of the limbs ; the lips became cyanosed; she became delirious, then comatose. She was nourished by the mouth and by rectal enemata. Quinine was given in solution per rectum. One day her temperature suddenly rose to over 105°. She was comatose. A cold bath was ordered ; the temperature fell to 102°. When the temperature went up, this was repeated in half an hour, and it fell to 101’50. The administration of quinine was continued. The crisis was past and she gradually recovered. For a long time she had symptoms of peripheral neuritis, but these cleared off in time. Dr. Hickin describes a case of purpura followed by rheumatic fever. The purpuric spots were extremely .abundant over the whole body but declined in the course of a few days. The total duration of the illness was about two and a half months. Dr. Macdonald severely condemns the sanitary shortcomings of the town of Wuchow. These reports are published by the Inspectorate General of Customs, ’Shanghai, and may be obtained in London from Messrs. P. S. King and Son. an
-
ON
THE
TEMPERATURE AND PULSE IN
EPILEPSY, EPILEPTIC VERTIGO, AND HYSTERO-EPILEPSY. AN important study of the variations of temperature and of pulse in attacks of idiopathic epilepsy, epileptic vertigo, .and hystero-epilepsy is published by Marchand.1 The observations were made on 300 patients suffering from these affections in the St. Anne’s Asylum at Paris. Immediately ,at the close of an attack the patient was placed on a couch and covered with a sheet to prevent chilling and the temperature was taken when the convulsions had ceased sufficiently to render this practicable. All the temperatures were taken in the rectum with verified standard thermometers and were read in sit1t. The pulse-rates were taken .simultaneously and at intervals of five minutes. Mr. F. W. Gibson2 was the first to show that an elevation of temperature occurs in epileptic attacks, and four years later (1870) Bourneville3 showed that isolated epileptic attacks cause a - slight elevation of temperature. Bourneville’s results, however, were controverted by Witkowski ; 4 and though the former, from a series of 60 fresh cases, was able shortly after to show (1887) that isolated epileptic attacks increased the internal body-temperature by about from 0.5° to 06° C., .yet the whole subject seemed to require re-investigation .in view of its practical and diagnostic importance. The 1 Thèse de Paris, 1899. Journal of Mental Science, 1866, p. 497. 3 Études de Thermométrie Clinique dans l’Hémorragie Cérébrale et dans quelques Maladies de l’Encéphale. 4 Berliner Klinische Wochenschrift, October, 1886.
2
sufficiently characteristic to constitute signs of diagnostic value. The general conclusions are summarised as Eollows: 1. Epileptic attacks cause an elevation of bodytemperature of 0.5°C. on an average and lasting generally about 40 minutes after the fit. 2. The rise of temperature is distinctly noticeable 10 minutes after the fit and attains were
"A SUPERIOR PERSON" ON
" HOW THE POOR
ARE MEDICALLY TREATED IN
LIVERPOOL."
"ONE Who Knowstells us much and insinuates much as to the fate of the poor in Liverpool, and especially as to their sufferings at the hands of medical men. The death-rate is very high. The medical men are ’’ making money fast"in their cheap dispensaries and with their corresponding medicines, which he suggests should be analysed by the medical officer of health. He is not content with being anonymous, but he decidedly assumes an air of superiority. I I We wish," he says in his letter to the LiverpoolDaily Courier of August 19th, to call attention to the illegal practice frequent among this class of medical practitioners of charging for death certificates." We refuse to believe any such story on the faith of an anonymous accuser of men who fight the death and disease of Liverpool_among thepoor when he is probably
more
580 at home at ease." Let him come out into the open with any facts and we will give them publicity and consideration. Meantime he must be regarded as a coward and not taken seriously. The plight of the poor and the sick in Liverpool and the efforts to improve it are a problem of constant interest to us, but it is not to be solved by stabs in the dark aimed at their medical advisers who get little "
p.
1111, and May 20th, p. 1376, of the current year. In issue of the latter date we showed, on the strength
our
of figures the accuracy of which will scarcely be impugned, that the registered mortality from malignant disease in England and Wales has at least doubled within the last 50 years z, among males, indeed, there has been an uninterruptedi increase from 195 per million of the male population in the earlier years to 571 per million in the later years of the last, pay and deserve the greatest respect. half-century. On the other hand, in THE LANCET of April. 22nd, we showed that within the same period the mortality’ AMERICAN VIEWS ON THE PREVALENCE OF from pulmonary consumption at all ages in England and, CANCER. Wales had fallen from a rate of from 2579 to 1532 perWE have received a lengthy communication from a legal million among males, and from 2774 to 1162 per million gentleman in Buffalo, U.S.A., in which the writer, who among females. It will thus be seen that in both cases. 1 tendency of the English national statistics is appends to his name the letters M.A., B.C.L., protests the 1 to confirm American experience as set forth in Dr. York that against the assertion of Dr. Roswell Park of New Roswell Park’s article in the Practitioner. There is, cancer is seriously increasing both in England and in the one aspect of the question which will, we areUnited States. Our American correspondent deprecates the however, I as be confident, he gratifying to our correspondent as it is. publication of Dr. Roswell Park’s views both because that both in the United States and to ourselves-viz., are believes them to be erroneous and because they producing in Great Britain scientific agencies are already at work a species of cancer scare both there and in this country. The subject of cancer prevalence in England and Wales has for the investigation of the nature and causes of this terrible. been dealt with recently in THE LANCETat considerable malady; and we shall both concur in hoping that effective length, and we would suggest a perusal of our article means may eventually be discovered of checking its progress-a feat which has’already been accomplished in the case of on the statistics of cancer if our correspondent should wish for detailed information as to what is known concerning the that not less dreadful complaint pulmonary tuberculosis. incidence of fatal cancer in this country during a long series of years. Although it is against our rule to publish letters on strictly medical subjects from non-medical writers, still, PUNITIVE MEASURES IN THE TREATMENT OF the to interest which to attaches having regard exceptional THE INSANE. the subject, we willingly insert a summary of the main DR. T. DRAPES, medical superintendent of the Ennispoints in our correspondent’s letter and we trust that our corthy District Asylum, Ireland, contributes to the July correspondent will acquit us of discourtesy to him in number of the Journal of Mental Science an article on the’ adopting that course. The April number of the Practi- subject-Are Punitive Measures Justifiable in Asylums ? On tioner contains an article on Cancer by Dr. Roswell Park, this question it appears that great diversity of views existsProfessor of Surgery in the University of Buffalo and those having the care and treatment of the insane. Director of the State Pathological Laboratory in New amongst Much of the disagreement seems to have arisen with regard York. In that article, which we have read with much to the meaning of the term " punishment." It would appearinterest, Dr. Roswell Park discusses the nature of cancer according to Dr. Drapes’s contention that punishment may and its prevalence in different parts of the world, but be of two kinds-positive or negative. "When we say to a more particularly in the United States of America; and childYou have been naughty ; you shall not have any inasmuch as the facts on which he relies are derived from sweets at dinner to-day,’ or‘You shall not go for a ride with. the returns of the State Board of Health, we should have the others,’ that is punishment of a negative kind, punishthought that they would be accepted in that country ment by deprivation, but as certainly punishment to the as beyond question. Passing by certain points of relatively child as if it took the positive form of bodily chastisement."’ minor importance, we note that the main inference which Similarly to treat a lunatic patient who had been refractory Dr. Roswell Park draws from his study of the New York or mischievous by stopping his regular allowance of tobacco statistics is to the following effect : That whereas the or disallowing his attendance at the dance or circus was mortality from malignant disease in the United States has punishment. "To say," continues Dr. Drapes, "that a liner enormously increased during the last half-century, the of action which in the one case is called, and meant tomortality from consumption, another prevalent national be, punishment, should in the other be styled ’treatment* scourge, has decreased even more rapidly during the same or ’aid to control ’ or any other plausible euphemism period. According to our legal correspondent the soundness is illogical."" The punishments which are meted’ of Dr. Roswell Park’s deductions has been called in quesout are in immediate relation to the (faulty) behaviour, tion in the columns of the Ne7v Fork Medical News by a relation which can be made quite intelligible to both Dr. John Pryor, another physician of Buffalo City, who the child and the insane. As degrees and depths of to have formed the opinion that Dr. Roswell seems are various and it would happen, variable Park’s facts and conclusions are alike unworthy of insanity that what might be keenly felt and keenly realised by, We have not seen the correspondence in confidence. one patient would scarcely affect another. The milder question, and consequently are unable to weigh the and kinds of mental of alienation, oddity and of evidence adduced on either side; but we may point grades need not be associated with irresponeccentricity, inevitably out, as a fact of some importance, that Dr. Roswell in On the other the hand the progress subject. Park’s conclusion concerning the recent terrible in- sibility of symptoms might continue till the patient-an actively crease of cancer and the concurrent decrease of tubersuicidal melancholiac or a raving maniac-is in a condition of culosis in the United States tallies singularly with the total mental and moral irresponsibility for his conduct. All experience of this country and we are surprised that our grades and degrees of mental alienation-and pari passu of correspondent, who is avowedly conversant with the lie between these extremes. In pararesponsibility-may literature of the subject, has omitted to notice our own noiaes there is often a relative mental soundness and observations to this effect in THE LANCET of April 22nd, integrity outside the special sphere of the particular ordominating delusion which he is under. "II have known," 1 THE LANCET, May 20th, 1899, p. 1376. ......
iemperature in nystero-epuepsy naa Deen stuaiea out llttle and the conditions of the pulse in all the three types of epilepsy referred to above were known but very slightly. Marchand, as the result of his observations on 300 patients, was able to collect a vast mass of clinical data on these points. These data were on the whole concordant and pointed to important features in pulse and temperature which
follows :In 1897
its maximum in 20 minutes after the fit. This maximum elevation lasts only 10 minutes. 3. Attacks of epileptic vertigo cause a decidedly less but still noticeable elevation of temperature. 4. Regarding epileptiform attacks those of general paralysis cause a marked elevation of temperature comparable to that occurring in true epilepsy. 5. In all cases, whether of epilepsy or of epileptic vertigo, there is in general no relation between the maximum height reached by the temperature and the age of the patient, and in the same patient different attacks may produce slightly different temperatures. 6. The pulse rises about 31 beats in frequency per minute above the normal after a fit, but 50 minutes after the fit it has fallen to normal. The maximum pulse-rate is attained 16 minutes after the attack and this rate persists for five minutes. 7. Both temperature and pulse fall after maximum slowly and steadily to normal or only with slight oscillations during subsidence. 8. In epileptic vertigo the pulse rises in proportion to the intensity of the attack. 9. The elevation of temperature in epileptic vertigo is 0’3 C.; it lasts 40 minutes. The temperature attains its maximum 15 minutes after the attack and persists at the maximum for 13 minutes, after which it gradually subsides. 10. Hysteroepilepsy increases the temperature by 0.4° C. and this elevation lasts 35 minutes. There is a direct ratio between the length of the attack and the elevation of temperature. In two-thirds of the cases the temperature is at its maximum at the onset of the period of " attitudes passionels."" The duration of the maximum temperature is eight minutes and the fall thereafter to normal is gradual. 11. The pulse in hysteroepilepsy rises 57 beats and the acceleration of the pulse lasts 24 minutes. The maximum pulse-rate is attained at the onset of the attack (epileptoid period) and this rate lasts for four minutes. The subsidence thereafter is irregular and marked by considerable oscillations of the pulse-rate. 13. There is no relation between the duration of an attack and the maximum rate attained by the pulse in hysteroepilepsy. On the whole the cardiac disturbance (modification and irregular fall of the pulse) is much more marked than the temperature variations in hystero-epilepsy.
(e.g., European) residents
epidemic raged here as elsewhere in the Yangtze Valley’and carried off the natives by scores. I did not see any cases amongst them, but I was called one day to the convent to see one of the sisters who was reported to have this disease. I found her lying in a comatose condition and got a history that such attacks were intermittent. She had lucid intervals, became quite conscious, talked .rationally, then suddenly without warning she would become unconscious; twitching of the facial muscles would begin and convulsive movements of the limbs ; the lips became cyanosed; she became delirious, then comatose. She was nourished by the mouth and by rectal enemata. Quinine was given in solution per rectum. One day her temperature suddenly rose to over 105°. She was comatose. A cold bath was ordered ; the temperature fell to 102°. When the temperature went up, this was repeated in half an hour, and it fell to 101’50. The administration of quinine was continued. The crisis was past and she gradually recovered. For a long time she had symptoms of peripheral neuritis, but these cleared off in time. Dr. Hickin describes a case of purpura followed by rheumatic fever. The purpuric spots were extremely .abundant over the whole body but declined in the course of a few days. The total duration of the illness was about two and a half months. Dr. Macdonald severely condemns the sanitary shortcomings of the town of Wuchow. These reports are published by the Inspectorate General of Customs, ’Shanghai, and may be obtained in London from Messrs. P. S. King and Son. an
-
ON
THE
TEMPERATURE AND PULSE IN
EPILEPSY, EPILEPTIC VERTIGO, AND HYSTERO-EPILEPSY. AN important study of the variations of temperature and of pulse in attacks of idiopathic epilepsy, epileptic vertigo, .and hystero-epilepsy is published by Marchand.1 The observations were made on 300 patients suffering from these affections in the St. Anne’s Asylum at Paris. Immediately ,at the close of an attack the patient was placed on a couch and covered with a sheet to prevent chilling and the temperature was taken when the convulsions had ceased sufficiently to render this practicable. All the temperatures were taken in the rectum with verified standard thermometers and were read in sit1t. The pulse-rates were taken .simultaneously and at intervals of five minutes. Mr. F. W. Gibson2 was the first to show that an elevation of temperature occurs in epileptic attacks, and four years later (1870) Bourneville3 showed that isolated epileptic attacks cause a - slight elevation of temperature. Bourneville’s results, however, were controverted by Witkowski ; 4 and though the former, from a series of 60 fresh cases, was able shortly after to show (1887) that isolated epileptic attacks increased the internal body-temperature by about from 0.5° to 06° C., .yet the whole subject seemed to require re-investigation .in view of its practical and diagnostic importance. The 1 Thèse de Paris, 1899. Journal of Mental Science, 1866, p. 497. 3 Études de Thermométrie Clinique dans l’Hémorragie Cérébrale et dans quelques Maladies de l’Encéphale. 4 Berliner Klinische Wochenschrift, October, 1886.
2
sufficiently characteristic to constitute signs of diagnostic value. The general conclusions are summarised as Eollows: 1. Epileptic attacks cause an elevation of bodytemperature of 0.5°C. on an average and lasting generally about 40 minutes after the fit. 2. The rise of temperature is distinctly noticeable 10 minutes after the fit and attains were
"A SUPERIOR PERSON" ON
" HOW THE POOR
ARE MEDICALLY TREATED IN
LIVERPOOL."
"ONE Who Knowstells us much and insinuates much as to the fate of the poor in Liverpool, and especially as to their sufferings at the hands of medical men. The death-rate is very high. The medical men are ’’ making money fast"in their cheap dispensaries and with their corresponding medicines, which he suggests should be analysed by the medical officer of health. He is not content with being anonymous, but he decidedly assumes an air of superiority. I I We wish," he says in his letter to the LiverpoolDaily Courier of August 19th, to call attention to the illegal practice frequent among this class of medical practitioners of charging for death certificates." We refuse to believe any such story on the faith of an anonymous accuser of men who fight the death and disease of Liverpool_among thepoor when he is probably
more
580 at home at ease." Let him come out into the open with any facts and we will give them publicity and consideration. Meantime he must be regarded as a coward and not taken seriously. The plight of the poor and the sick in Liverpool and the efforts to improve it are a problem of constant interest to us, but it is not to be solved by stabs in the dark aimed at their medical advisers who get little "
p.
1111, and May 20th, p. 1376, of the current year. In issue of the latter date we showed, on the strength
our
of figures the accuracy of which will scarcely be impugned, that the registered mortality from malignant disease in England and Wales has at least doubled within the last 50 years z, among males, indeed, there has been an uninterruptedi increase from 195 per million of the male population in the earlier years to 571 per million in the later years of the last, pay and deserve the greatest respect. half-century. On the other hand, in THE LANCET of April. 22nd, we showed that within the same period the mortality’ AMERICAN VIEWS ON THE PREVALENCE OF from pulmonary consumption at all ages in England and, CANCER. Wales had fallen from a rate of from 2579 to 1532 perWE have received a lengthy communication from a legal million among males, and from 2774 to 1162 per million gentleman in Buffalo, U.S.A., in which the writer, who among females. It will thus be seen that in both cases. 1 tendency of the English national statistics is appends to his name the letters M.A., B.C.L., protests the 1 to confirm American experience as set forth in Dr. York that against the assertion of Dr. Roswell Park of New Roswell Park’s article in the Practitioner. There is, cancer is seriously increasing both in England and in the one aspect of the question which will, we areUnited States. Our American correspondent deprecates the however, I as be confident, he gratifying to our correspondent as it is. publication of Dr. Roswell Park’s views both because that both in the United States and to ourselves-viz., are believes them to be erroneous and because they producing in Great Britain scientific agencies are already at work a species of cancer scare both there and in this country. The subject of cancer prevalence in England and Wales has for the investigation of the nature and causes of this terrible. been dealt with recently in THE LANCETat considerable malady; and we shall both concur in hoping that effective length, and we would suggest a perusal of our article means may eventually be discovered of checking its progress-a feat which has’already been accomplished in the case of on the statistics of cancer if our correspondent should wish for detailed information as to what is known concerning the that not less dreadful complaint pulmonary tuberculosis. incidence of fatal cancer in this country during a long series of years. Although it is against our rule to publish letters on strictly medical subjects from non-medical writers, still, PUNITIVE MEASURES IN THE TREATMENT OF the to interest which to attaches having regard exceptional THE INSANE. the subject, we willingly insert a summary of the main DR. T. DRAPES, medical superintendent of the Ennispoints in our correspondent’s letter and we trust that our corthy District Asylum, Ireland, contributes to the July correspondent will acquit us of discourtesy to him in number of the Journal of Mental Science an article on the’ adopting that course. The April number of the Practi- subject-Are Punitive Measures Justifiable in Asylums ? On tioner contains an article on Cancer by Dr. Roswell Park, this question it appears that great diversity of views existsProfessor of Surgery in the University of Buffalo and those having the care and treatment of the insane. Director of the State Pathological Laboratory in New amongst Much of the disagreement seems to have arisen with regard York. In that article, which we have read with much to the meaning of the term " punishment." It would appearinterest, Dr. Roswell Park discusses the nature of cancer according to Dr. Drapes’s contention that punishment may and its prevalence in different parts of the world, but be of two kinds-positive or negative. "When we say to a more particularly in the United States of America; and childYou have been naughty ; you shall not have any inasmuch as the facts on which he relies are derived from sweets at dinner to-day,’ or‘You shall not go for a ride with. the returns of the State Board of Health, we should have the others,’ that is punishment of a negative kind, punishthought that they would be accepted in that country ment by deprivation, but as certainly punishment to the as beyond question. Passing by certain points of relatively child as if it took the positive form of bodily chastisement."’ minor importance, we note that the main inference which Similarly to treat a lunatic patient who had been refractory Dr. Roswell Park draws from his study of the New York or mischievous by stopping his regular allowance of tobacco statistics is to the following effect : That whereas the or disallowing his attendance at the dance or circus was mortality from malignant disease in the United States has punishment. "To say," continues Dr. Drapes, "that a liner enormously increased during the last half-century, the of action which in the one case is called, and meant tomortality from consumption, another prevalent national be, punishment, should in the other be styled ’treatment* scourge, has decreased even more rapidly during the same or ’aid to control ’ or any other plausible euphemism period. According to our legal correspondent the soundness is illogical."" The punishments which are meted’ of Dr. Roswell Park’s deductions has been called in quesout are in immediate relation to the (faulty) behaviour, tion in the columns of the Ne7v Fork Medical News by a relation which can be made quite intelligible to both Dr. John Pryor, another physician of Buffalo City, who the child and the insane. As degrees and depths of to have formed the opinion that Dr. Roswell seems are various and it would happen, variable Park’s facts and conclusions are alike unworthy of insanity that what might be keenly felt and keenly realised by, We have not seen the correspondence in confidence. one patient would scarcely affect another. The milder question, and consequently are unable to weigh the and kinds of mental of alienation, oddity and of evidence adduced on either side; but we may point grades need not be associated with irresponeccentricity, inevitably out, as a fact of some importance, that Dr. Roswell in On the other the hand the progress subject. Park’s conclusion concerning the recent terrible in- sibility of symptoms might continue till the patient-an actively crease of cancer and the concurrent decrease of tubersuicidal melancholiac or a raving maniac-is in a condition of culosis in the United States tallies singularly with the total mental and moral irresponsibility for his conduct. All experience of this country and we are surprised that our grades and degrees of mental alienation-and pari passu of correspondent, who is avowedly conversant with the lie between these extremes. In pararesponsibility-may literature of the subject, has omitted to notice our own noiaes there is often a relative mental soundness and observations to this effect in THE LANCET of April 22nd, integrity outside the special sphere of the particular ordominating delusion which he is under. "II have known," 1 THE LANCET, May 20th, 1899, p. 1376. ......