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Correspondence.

"VITALITY."

.. Audi alteram partem."

To the Editors of THE LANCET.

SIRS,-I have read Dr. Lionel Beale’s "Appeal and

Challenge" in an entirely unprejudiced spirit, but ’theformer does not convince my understanding’ and I am there-fore reluctantly compelled to take up the gauntlet he hasthrown down to his brother practitioners.

It seems to me more logical and more easy of com-

prehension to regard vitality as a peculiar play of forcesbelonging to the inanimate world than as a force per se

essentially different in nature from these forces. Onthe former assumption vitality is due to the working offorces inherent in the elements of bioplasm and of thoseenvironmental forces which share in the reaction betweenthe bioplasm and its environment. If vitality is distinctfrom these forces it must exist apart from matter and if isuch is the case how and where, I would ask, does it exist 7 IDr. Beale would seem to argue that it is a sort of intelli-

gence existing apart from matter, capable of directing theoperation of the forces belonging to matter-a position asuntenable as that of the spiritualists, who assume that theimmaterial can act upon the material.Dr. Beale will, I presume, allow that the quantity of

vitality in an organism tends to vary with its bulk. Otherthings equal, the quantity of vitality in an organism con-taining a million cells is a million times greater than that ofa one-celled organism. The human organism starts practi-cally as a single cell, but by the process of segmentation itdevelops into one consisting of millions of cells, and whenthis has happened the sum of its vitality is many milliontimes greater than that of the primitive embryo. Nowwhence has come this augmentation of vitality ? Force, likematter, cannot be created any more than it can be annihi-lated. The answer surely is that it comes in the last resortfrom the nutrient fluids, oxygen, &c., conveyed from theworld without. It is carried into the house by the milkman,grocer, butcher, and is borne in by the atmosphere.

I cannot think of vitality as a force per se. I conceivethat the behaviour of bioplasm is essentially the outcome ofphysical conditions-that it depends upon the nature andarrangement of the atoms in the bioplasmic molecules, uponthe arrangement of the molecules among themselves-uponthe structure of the bioplasm in fact-and other purelyphysical conditions. Dr. Beale’s assumption that bioplasmis structureless is to my mind wholly illogical. He assumesit to be so because he is unable to detect any structure in it.In our journey into the world of the infinitesimal wecome sooner or later to a point at which we cease

to detect structure, but this point is a pmely arbitrary oneand is continually receding as our means of investigationimprove. It marks the limit of our perceptions aided

by the most powerful microscopes we can devise, but bearsno relation whatever to any grand fact of nature. To mymind bioplasm is highly complex in structure as comparedwith inorganic matter. We are so apt to forget that theworld of the infinitesimal is as unlimited as that of theimmense. If we take a single cell as our unit of size, thenas regards its relation to space it is no nearer the limit ofthe infinitely small than of the infinitely great, for neitherhas any limit; our cell may be divided or multiplied ad’i/lfi/âtll’/n. Imbued with this conception we shall the betterrealise the vastness of the infinitesimal, so to speak, andshall be cautious in regarding bioplasm as altogether devoidof structure.One further point. On Dr. Beale’s view it is most difficult

to account for the evolution of life on this planet. If vitalityis not correlated with the forces of inanimate nature whencecame it ? On the assumption that it is a peculiar play orcoordination of physical forces, the evolution of life, thecoming-into-being of vitality, is to be explained by thecoming together of certain atoms in a peculiar way. Formy part I believe in the spontaneous evolution of life. Thefact that those forms of life which we regard as the mostprimitive cannot evolve from inanimate matter is no argumentagainst this belief. A proper appreciation of the vastnessof the infinitesimal prepares us for the conclusion that the

most primitive forms of life known to us are highly complexas compared with those which are actually the most primi-tive. Such I should expect to consist of a comparatively fewmolecules and to be altogether too minute for detection bythe most powerful microscope.

I am, Sirs, yours faithfully,Wimpole-street, W., June 26th, 1898. HARRY CAMPBELL.HARRY CAMPBELL.

PENALTIES FOR UNREGISTEREDPRACTICE.

To the Editors of THE LANCET.

SiRS,—In view of the general interest, public as well asprofessional, aroused by the Collins case, the time seemsfavourable, in spite of the lateness of the session, for an

attempt to penalise disregistered practitioners, to the extent,of disqualifying them from further practice. As the casestands Dr. Collins retains his degree, in spite of a doubleconviction for felony and a sentence of penal servitude, andsigns are not wanting that other cases of the same kind mayspeedily transpire. In view of these facts the council of the

Incorporated Association of Medical Practitioners hasdetermined to seek an interview with the Home Secretary atonce, with the view of inducing him to bring in a Bill on thelines of the oie which I enclose.We recognise fully that the time available i, very short,

but there can be little doubt that if the profession willbestir itself the object may be effected. Every day is, how-ever, of consequence, and we earnestly appeal to everypractitioner who has the dignity of the profession and the,

safety of the public at heart to communicate with his Parlia-, mentary representative at once to secure his support for the

proposal. There is no doubt that the action of the Home: Secretary will be greatly influenced by the prospects of themeasure as regards opposition, and time is of the last

importance. I shall be most happy to supply a copy of theproposed measure to any member of the profession who may

apply to me for one enclosing a halfpenny stamp, and shallbe glad to hear from any who would be willing to join with,

me in impressing its importance upon our legislators.’ I am, Sirs, yours faithfully,

EDWD. C. BOUSFIELD.363, Old Kent-road, S.E., July llth. 1898.

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[ENCLOSURE.]. AN ACT to prevent persons who have been removed from the Medical

Register under the provisions of Section XXIX. of the Medical Act,L 1858, from continuing to act as Medical Practitioners.l

WHEREAS it is expedient that persons who have been removed fromthe Medical Register by the General Council of Medical Education and

l Registration under the powers conferred upon it by the twenty-ninth’ Section of the Medical Act, 1858, should be prevented from continuingL to act or practise as Medical Practitioners: Be it therefore enacted by,

the Queen’s Most Excellent Majesty, by and with the Advice and’ Consent of the Lords Spiritual and Temporal, and Commons, in this. present Parliament assembled, and by the Authority of the same, as

follows:-

; 1. This Act may for all purposes be cited as "The General Medical,

Council (additional Powers) Act."2. This Act shall commence and take effect from the First Day of

L September, One thousand eight hundred and ninety-eight.1 3. Any person whose Name shall have been removed from the Medical

Register by the General Council of Medical Education and Registration,under the powers conferred upon the said Council by the twenty’ninthSection of the Medical Act, and who shall thereafter practise Medicine or Surgery, or Medicine and Surgery, as the case may be, in any partof the United Kingdom of Great Britian and Ireland, shall, upon asummary Conviction for any such Offence, pay to the said Council aSum not exceeding Twenty Pounds.1 4. The General Council of Medical Education and Registration shall be entitled to receive all Fines inflicted upon Offenders convicted under

Section XL. of the Medical Act.r

__

EDWD. C. BOUSFIELD.

MYDRIN : A NEW MYDRIATIC.To the Editors of THE LANCET.

SIRS,-THE LANCET of July 2nd contains an interestingj note by Dr. Sydney Stephenson on a New Mydriatic. He

kindly alludes to my observations on this mydriatic in theClinieal Journal in 1895, which were, I think, the first

L’ published in this country. 1 would like to add that I againrefer to the value of mydrin in my volume on the Examina-tion of the Eye (Pentland), published this year. My objectr in writing now is to reiterate my opinion of the efficacy of3 mydrin as a rapid pupil dilator without affecting thet accommodation and the effects of which quickly pass off,t features marking it as specially adapted for producings mydriasis for ophthalmoscopic purposes. The present priceof the drug is, however, almost prohibitive of its use. I

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understand that it still costs something like 25s. a drachm,but of course a demand for it would soon bring about areduction in price. It is further to be desired that some firmshould furnish the drug in the form of gelatin discs of suchexcellence, for instance, as Wyeth’s discs of homatropine.

I am, Sirs, yours faithfully,July 13th, 1898.

- - -- SIMEON SNELL.SIMEON SNELL.

COPYRIGHT IN PRESCRIPTIONS.To the Editors of THE LANCET.

SIRS,-Now that the Royal Commission on Copyright issitting would it not be a good plan to devise a scheme forbringing prescriptions under the law of copyright ? I meanthat it should become legal for medical men to retain thecopyright in their prescriptions after a certain limitedtime after their issue. It is very common for patients tohave some prescription which suits them renewed perhapshundreds of times even to the end of their lives, so that theauthors of the prescriptions get compensated with absurdinsufficiency by the single fee they receive. The injusticeof the present state of things is so palpable and our loss soenormous thereby that there can be no object in disguisingthe sordid nature of the proposal. It is quite possible thatthe injury done to us might be obviated in some such way asI suggest.-I am, Sirs, yours faithfully,

F. Lucas BENHAM, M.D., M.&C.P. Lond.Elizabeth-street, S.W., July 12th, 1898.

F. LUCAS BENHAM, M.D., M.R.C.P. Lond.

HOSPITAL REFORM.To the Editors of THE LANCET.

SIRS,-In the paper I read recently at the United ServiceInstitution embodying certain suggestions as to the reformof the casualty and out-patient departments of London

hospitals I macie a statement which I have since discoveredis not warranted by fact: it was to the effect that inScotland and in Ireland drugs were not given in the medicalout-patient departments of the hospitals. Before I left theInstitution I was informed that I was mistaken with regardto Ireland and Mr. Garrett Horder writes to me under date

July 6th as follows : " I have been making inquiries of thesystem adopted in the principal Scotch hospitals and I findthat as a rule medicines are supplied to the out-patients."

I regret having made the assertion, but I regret still morethat the fact is not as I supposed, as I believe the plan to bea good one.-I am, Sirs, yours faithfully,

W. HENRY KESTEVEN. IHendon, N.W., July 8th, 1898.

W. HENRY KESTEVEN.

" BLOOD-PRESSURE IN THE INSANE."To the Editors of THE LANCET.

SIRS,-The article on the above subject, from the pen ofDr. Maurice Craig, which appears in THE LANCET ofJune 25th, is of such importance that I venture to offersome observations which are based upon five months’constant use of Barnard and Hill’s sphygmometer, whichhas been brought into requisition to such good purposeby Dr. Craig, with reference to those who are relativelysound in mind. Dr. Craig is careful to point out thatalthough high intra-arterial pressure is uniformly foundto exist in cases marked by depression, especially inmelancholia, and infra-normal blood-pressure in thosewho exhibit excitement and mania, he does not forone moment believe that " any amount of altered blood-

pressure can per se produce insanity in a perfectlystable person," and suggests that similar conditionsof blood-pressure may exist in other individuals with-out inducing, or being associated with, mental aliena-tion." 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 thansuch depression of spirits and gloominess of anticipation asare constantly met with in people who pass as being inaverage health or as being affected with nothing more gravethan the mental state commonly associated with goutyconditions.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.

depression amounting in some cases to despondency, andnight alarm are of common occurrence," and that withrehabilitation of the heart and vessels " all such nerve

suffering vanishes like a dream and the spirits rise to a planeof hope and energy." With the aid of the sphygmometerI have been able to verify the fact that depression,the indefinable sense of impending disaster, irritability, andinsomnia are generally associated with high blood-pressureand have observed that the lowering of that pressure isfollowed by very satisfactory results. The instrument referredto indicates the line of treatment which may be required.Of cases of mental excitement associated with infra-normalpressure 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, requiresfurther and closer examination, and that is the state of thebowels. He attaches much importance, and doubtless in themain rightly, to the relief of constipation and to the main-tenance of somewhat free action of the bowels ; but it mustnot be overlooked that a considerable proportion of thesubjects of mental depression with high blood-pressuresuffer from chronic intestinal catarrh, involving from twoto three actions of the bowels a day, of which only the firstmay be formed or fragmentary and the others fluid. Withregard to the relation of the state of the bowels to the con-dition under consideration, it is suggested that the depres-sion may be due to sensory nerve stimulation affecting thegeneral arterial pressure through the splanchnic mechanismrather than to self-infection. If such be the case theexistence of fæcal accumulation and of inordinateaction of the bowels must both be regarded as having asimilar disturbing effect on the sensory nerves in question,and I do not deny that such may be the case. On the otherhand, I do think that the question of auto-toxication cannotbe excluded, the more so as, whether the condition relievedbe fæcal accumulation or chronic intestinal irritation, animportant point is gained in the lowering of blood-pressureand at the same time a striking change is exhibited in therenal function by the great increase of the excretion of urineand the diminution of its toxicity. The question, therefore,arises : What may be the clinical and therapeutic import ofthe association between mental depression and high blood-pressure ? The observations of some years, which have been

strongly confirmed since I have brought the sphygmometerinto general use, show that those conditions of the bloodwhich are betrayed by scantiness or concentration ofthe urine and by increased toxicity are themselvesthe causes of contraction of arterioles, of high intra-arterial pressure with increase of peripheral resistance,of venous engorgement, and of deficient oxygenation of theblood, and that all these conditions, which togetherconstitute a serious pathological condition, are rapidly re-

lieved by increase of arterial capacity and the relief of

peripheral resistance resulting in improved oxidation andmetabolism and the repair, among others, of the cerebral andother nerve tissues. It is a matter of observation that faecalimpaction and chronic looseness may both be associated withhigh intra-arterial pressure ; and there are strong clinicalgrounds for believing that the presence of imperfectlydigested substances in the descending colon is causativelyconnected with re-sorption of toxins which should be excretedand with blood-contamination with products of fermentivedecomposition. For these reasons I think that auto-toxica-tion is an important factor in the production of mentaldepression.

In illustration I give, from many others, the followingcases. 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. Therewas dyspnoea on the levels and inclines. She woke with asense of impending suffocation associated with pain in theprascordium and the inner aspect of the left upper arm. Thebowels acted twice or thrice daily ; the motions were yellow,the second and third being liquid. The patient was verydepressed and unwilling to submit to treatment, as she saidthat she could never be better ; she was never without head-ache, extending from the frontal region to the vertex andocciput. On June lst the pressure was 126 mm. Hg., shehad scarcely any headache, she felt and looked better,and was more hopeful. On the 7th there was no head-ache, the appetite and spirits were good, the apex wasin the nipple line, the bowels acted once daily, andthe motions were healthy. When last seen, on June 30th,she was very bright and cheerful; she had no head-ache and slept well; the bowels were regular; there