vegetative regulation of the central nervous system

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708 been ambulant for four months. Apparently full recovery except that cells in o.s.r: are still 20 per c.mm. CASE 5.-Aged 15 years. Admitted with very active tuberculosis of the uterus for which biopsy was performed under a streptomycin " umbrella " on June 26, 1950. The biopsy findings were positive for tuberculosis. Onset of tuberculous meningitis on July 3. Streptomycin given daily in doses of 100 mg. intrathecally and 1 g. intramuscularly. Spinal block threatened and streptomycin level in C.S.F. rose to 32 g. per ml. Dose of intrathecal streptomycin was decreased and of filtrate injections was increased to daily injections until some local allergic reaction seemed to appear, when these injections were stopped. The dose of filtrate was 1 ml. diluted with equal amount of sterile saline. c.s.F. became clear, and patient’s condition improved until there are now no abnormal symptoms or signs except in the c.s.F. Tubercle bacilli have not yet been found in the c.s.F. CASE 6.-Aged 14 months. Onset of tuberculous meningitis on Oct. 20, 1948. Intrathecal and intramuscular streptomycin started. Child’s condition deteriorated ; bilateral papillaedema and blindness developed, and there were extensive pareses. Four doses of filtrate given in November but supply ran out. Filtrate recommenced on Dec. 23. Eleven injections given, each of 0’35 ml. diluted with equal amount of saline. Improvement noted. Cell-count in c.s.F. progressively diminished, but signs of gross changes in the central nervous system persisted. Died of intercurrent bronchitis on Jan. 23, 1949. At post- mortem examination diagnosis of tuberculous meningitis confirmed ; amount of exudate in interpeduncular space not conspicuous. In the next three cases tuberculous meningitis developed after injections of filtrate had been given in the course of treatment for tuberculosis elsewhere. CASE 7.-Aged 24 years. During course of treatment for tuberculous hip had nineteen injections of filtrate. Later had osteotomy of hip, which was followed by tuberculous meningitis. Transferred to special centre, where she recovered. Tubercle bacilli never found in c.s.F., but were present in pus from hip. CASE 8.-Aged 12 years. Treated between 1945 and 1948 for tuberculous hip ; during 1946 course of filtrate injections was given. In 1948 developed tuberculous meningitis. Tubercle bacilli found in C.S.F. Transferred to special centre. Recovered. CASE 9.-Aged 10 years. Had been treated from 1942 to 1946 for tuberculous spondylitis. In 1942 had had five minimal injections of filtrate. Readmitted in 1948 with tuberculous meningitis. Transferred to a special centre where he died. Diagnosis confirmed at post-mortem examination. Lastly, there are four cases in which no filtrate was given at any time, and one of a patient who had recovered from tuberculous meningitis but who was given some filtrate injections later in the course of treatment for multiple lesions. CASE 10.-Aged 15 years. Tubercle bacilli found in c.s.F. Full recovery on streptomycin treatment. CASE 11.-Admitted with multiple tuberculous lesions, unilateral ptosis, and increased number of cells in c.s.F. Tubercle bacilli not found in C.S.F. With streptomycin therapy recovered from presumed tuberculous meningitis. Tubercle bacilli present in sputum. Given some filtrate injections later for multiple lesions. CASE 12.-Aged 11 months. Admitted with presumed tuberculous meningitis and tuberculosis of the knee. Tubercle bacilli not found in o.s.F. Treated with streptomycin. Died ; no post-mortem examination. CASE 13.-Aged 10 years. Admitted in 1947 with tuberculous arthritis of knee. Developed meningitis. Transferred to a special centre. Recovered. CASE 14.-Aged 4 years. Treated for lupus of face. Devel- oped tuberculous meningitis (1947) and transferred to special centre. Recovered. Six patients, therefore, had treatment with strepto- mycin and filtrate. Of these, three have recovered ; one has almost fully recovered ; one with presumed tuber- culous meningitis is recovering ; and one infant who received filtrate late in her illness died. Of three patients who received filtrate injections in the course of treatment for tuberculosis but who later developed meningitis two recovered ; the third, a child who died, had six years previously received only a few minimal injections. On the other hand, of five patients who had no filtrate treatment four recovered. No claim is made for the efficacy of this filtrate. At present laboratory investigations are being considered; and if evidence is found that it has therapeutic value, a further report will follow. Black Notley Hospital, Braintree, Essex. M. C. WILKINSON. TROPHIC AND TROPIC SiR,&mdash;I observe that it is becoming current practice to speak of the action of a hormone in controlling an endocrine gland as trophic (e.g., thyrotrophic hormone and grotuxoop/uMs) ; ; and that this usage is common not only in America but also in this country. This is surely a misuse of words, from a confusion between trophic action (,po <p7j: nourishment) which is concerned with nutrition, as in " trophic nerves," and tropism (’P&Oacute;7rOC;: a turn ; in biology, the movement in a particular direction in response to some stimulus), which connotes control. The pituitary does not nourish the thyroid or the ovary though it does control their activity. Is it too late to revert to thyrotropic and gonadotropic, and the like 1 Department of Pathology, J. HENRY DIBLE. Postgraduate Medical School of London, W.12. VEGETATIVE REGULATION OF THE CENTRAL NERVOUS SYSTEM SiR,-It is known that single organs (e.g., heart, lungs, liver, and kidneys) function under the control of the vegetative nervous system, the regulation being exercised directly by nervous influences (sympathetic and para- sympathetic) or indirectly (humoral), though the proper. tion of each component may vary. When several organs are connected together in a system, functional adaptation is necessary to meet the needs of the whole organism ; and this adaptation too is accomplished under the influence of the vegetative nervous system. Up till now, the vegetative nervous -system has been accepted as affecting only the viscera, the blood-vessels, the sweat-glands, and other non-nervous organs not subject to voluntary control, while its significance for the central nervous system itself has not received any attention. Rein has written of the autonomic nervous system : " Today one may accept as definite that there is hardly any part of any tissue which is not vegetatively innervated." This statement is applicable not only to organs supplied by peripheral vegetative nerves, but also to the central ner- vous system itself, especially the cortex. Hess has shown that stimulation of vegetative centres of the diencephalon produces effects which we accept as vegetative phenom- ena (e.g., increase in the heart and respiration rates) and we can therefore accept, on the same level, the observa- tion of Murphy and Gellhorn 2 that when the hypo- thalamus is stimulated the productivity of certain areas of the cortex is altered, and that changes in the functioning of these same areas take place, only with simultaneous sympathetic effects at the periphery. These and other findings lead one to conclude that the cortex is subject to vegetative regulation, that this " central nervous vegetativum " is connected with the vegetative centres of the diencephalon, and that by these means all the organ systems, including the central nervous system (cortex), are coordinated. The idea is further supported by the finding of myself and Will 3 that electro-shock primarily affects the diencephalon, and that the reaction level (Reaktionslage) of the cortex (e.g., that of the area striata examined in the formation of the action potentials caused by rhythmically flashing 1. Rein, H. Einf&uuml;hrung in die Physiologic des Menschen. Berlin. 1941. 2. Murphy, J. P., Gellhorn, E. J. Neurophysiol. 1945, 8, 341. 3. Schuchardt, E., Will, R. Dtsch. Z. Nervenheilk, 1950, 163, 245.

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Page 1: VEGETATIVE REGULATION OF THE CENTRAL NERVOUS SYSTEM

708

been ambulant for four months. Apparently full recoveryexcept that cells in o.s.r: are still 20 per c.mm.CASE 5.-Aged 15 years. Admitted with very active

tuberculosis of the uterus for which biopsy was performedunder a streptomycin " umbrella " on June 26, 1950. The

biopsy findings were positive for tuberculosis. Onset oftuberculous meningitis on July 3. Streptomycin given dailyin doses of 100 mg. intrathecally and 1 g. intramuscularly.Spinal block threatened and streptomycin level in C.S.F. roseto 32 g. per ml. Dose of intrathecal streptomycin wasdecreased and of filtrate injections was increased to dailyinjections until some local allergic reaction seemed to appear,when these injections were stopped. The dose of filtrate was1 ml. diluted with equal amount of sterile saline. c.s.F.

became clear, and patient’s condition improved until thereare now no abnormal symptoms or signs except in the c.s.F.Tubercle bacilli have not yet been found in the c.s.F.CASE 6.-Aged 14 months. Onset of tuberculous meningitis

on Oct. 20, 1948. Intrathecal and intramuscular streptomycinstarted. Child’s condition deteriorated ; bilateral papillaedemaand blindness developed, and there were extensive pareses.Four doses of filtrate given in November but supply ran out.Filtrate recommenced on Dec. 23. Eleven injections given, eachof 0’35 ml. diluted with equal amount of saline. Improvementnoted. Cell-count in c.s.F. progressively diminished, butsigns of gross changes in the central nervous system persisted.Died of intercurrent bronchitis on Jan. 23, 1949. At post-mortem examination diagnosis of tuberculous meningitisconfirmed ; amount of exudate in interpeduncular spacenot conspicuous.

In the next three cases tuberculous meningitisdeveloped after injections of filtrate had been given inthe course of treatment for tuberculosis elsewhere.CASE 7.-Aged 24 years. During course of treatment for

tuberculous hip had nineteen injections of filtrate. Laterhad osteotomy of hip, which was followed by tuberculousmeningitis. Transferred to special centre, where she recovered.Tubercle bacilli never found in c.s.F., but were present in pusfrom hip.

CASE 8.-Aged 12 years. Treated between 1945 and 1948for tuberculous hip ; during 1946 course of filtrate injectionswas given. In 1948 developed tuberculous meningitis. Tuberclebacilli found in C.S.F. Transferred to special centre. Recovered.CASE 9.-Aged 10 years. Had been treated from 1942 to

1946 for tuberculous spondylitis. In 1942 had had five minimalinjections of filtrate. Readmitted in 1948 with tuberculous

meningitis. Transferred to a special centre where he died.Diagnosis confirmed at post-mortem examination.

Lastly, there are four cases in which no filtrate wasgiven at any time, and one of a patient who had recoveredfrom tuberculous meningitis but who was given somefiltrate injections later in the course of treatment formultiple lesions.CASE 10.-Aged 15 years. Tubercle bacilli found in c.s.F.

Full recovery on streptomycin treatment.CASE 11.-Admitted with multiple tuberculous lesions,

unilateral ptosis, and increased number of cells in c.s.F.

Tubercle bacilli not found in C.S.F. With streptomycin therapyrecovered from presumed tuberculous meningitis. Tuberclebacilli present in sputum. Given some filtrate injections laterfor multiple lesions.CASE 12.-Aged 11 months. Admitted with presumed

tuberculous meningitis and tuberculosis of the knee. Tuberclebacilli not found in o.s.F. Treated with streptomycin. Died ;no post-mortem examination.CASE 13.-Aged 10 years. Admitted in 1947 with tuberculous

arthritis of knee. Developed meningitis. Transferred to a

special centre. Recovered.CASE 14.-Aged 4 years. Treated for lupus of face. Devel-

oped tuberculous meningitis (1947) and transferred to specialcentre. Recovered.

Six patients, therefore, had treatment with strepto-mycin and filtrate. Of these, three have recovered ; onehas almost fully recovered ; one with presumed tuber-culous meningitis is recovering ; and one infant whoreceived filtrate late in her illness died. Of three patientswho received filtrate injections in the course of treatmentfor tuberculosis but who later developed meningitis tworecovered ; the third, a child who died, had six years

previously received only a few minimal injections. Onthe other hand, of five patients who had no filtratetreatment four recovered.No claim is made for the efficacy of this filtrate. At

present laboratory investigations are being considered;and if evidence is found that it has therapeutic value, afurther report will follow.Black Notley Hospital,

Braintree, Essex.M. C. WILKINSON.

TROPHIC AND TROPIC

SiR,&mdash;I observe that it is becoming current practiceto speak of the action of a hormone in controlling anendocrine gland as trophic (e.g., thyrotrophic hormoneand grotuxoop/uMs) ; ; and that this usage is common

not only in America but also in this country.This is surely a misuse of words, from a confusion

between trophic action (,po <p7j: nourishment) which isconcerned with nutrition, as in " trophic nerves," andtropism (’P&Oacute;7rOC;: a turn ; in biology, the movementin a particular direction in response to some stimulus),which connotes control. The pituitary does not nourishthe thyroid or the ovary though it does control theiractivity. Is it too late to revert to thyrotropic andgonadotropic, and the like 1

Department of Pathology, J. HENRY DIBLE.Postgraduate Medical School of London, W.12.

VEGETATIVE REGULATION OF THE CENTRALNERVOUS SYSTEM

SiR,-It is known that single organs (e.g., heart, lungs,liver, and kidneys) function under the control of thevegetative nervous system, the regulation being exerciseddirectly by nervous influences (sympathetic and para-sympathetic) or indirectly (humoral), though the proper.tion of each component may vary. When several organsare connected together in a system, functional adaptationis necessary to meet the needs of the whole organism ;and this adaptation too is accomplished under theinfluence of the vegetative nervous system.Up till now, the vegetative nervous -system has been

accepted as affecting only the viscera, the blood-vessels, thesweat-glands, and other non-nervous organs not subjectto voluntary control, while its significance for the centralnervous system itself has not received any attention.Rein has written of the autonomic nervous system :"

Today one may accept as definite that there is hardly anypart of any tissue which is not vegetatively innervated."This statement is applicable not only to organs supplied byperipheral vegetative nerves, but also to the central ner-vous system itself, especially the cortex. Hess has shownthat stimulation of vegetative centres of the diencephalonproduces effects which we accept as vegetative phenom-ena (e.g., increase in the heart and respiration rates) andwe can therefore accept, on the same level, the observa-tion of Murphy and Gellhorn 2 that when the hypo-thalamus is stimulated the productivity of certain areasof the cortex is altered, and that changes in the

functioning of these same areas take place, only withsimultaneous sympathetic effects at the periphery.These and other findings lead one to conclude that the

cortex is subject to vegetative regulation, that this" central nervous vegetativum " is connected with the

vegetative centres of the diencephalon, and that bythese means all the organ systems, including the centralnervous system (cortex), are coordinated. The idea isfurther supported by the finding of myself and Will 3that electro-shock primarily affects the diencephalon,and that the reaction level (Reaktionslage) of the cortex(e.g., that of the area striata examined in the formationof the action potentials caused by rhythmically flashing1. Rein, H. Einf&uuml;hrung in die Physiologic des Menschen. Berlin.

1941.2. Murphy, J. P., Gellhorn, E. J. Neurophysiol. 1945, 8, 341.3. Schuchardt, E., Will, R. Dtsch. Z. Nervenheilk, 1950, 163, 245.

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709

a light on the eye) reveals a condition which can only beexplained by assuming the existence of vegetativeregulation. - _

Anatomisches Institut, Giessen. E. SCHUCHARDT.

REVOLT AT KINGSTON

SiR,-Unfortunately Dr. Stark Murray’s letter lastweek shows little sign of his having benefited from anyof the wisdom of your leading article of Nov. 11.Rarely, if ever, do " revolts " arise from purely

unilateral causes ; and surely this " revolt," if notbased on any unwisdom in the decision, must implysome inadequacy in the regional hospital board’s effortsto enlist the cooperation of all the persons likely to beaffected. To take two examples from Dr. Stark Murray’sletter : the assistance of the press can surely be securedmore effectively than by handing its representativessix foolscap pages ; and surely the board can exert moreeffective medical leadership than to announce such adecision when " the staff at Kingston Victoria havenever held a meeting to discuss this question."We all hope that this and other regional boards will

always remember their responsibilities, not only forcorrect decisions, but also for leadership, more especiallywhen the led show signs of being refractory.

St. Margaret’s, Twickenham Bridge,Middlesex.

RUSSELL FRASER.

INTEGRATIVE SOCIAL RESEARCH

SiR,-The effort to follow up the constructive socialwork of Wilfred Trotter continues at Braziers Park, anda second discussion and conference will be held thereduring the weekend Dec. 8-10.

It may be of interest to a larger circle of your readersthan those -who can attend such a conference to mentionthat a little inquiry into the treatment of Trotter’s workby professional sociologists has revealed a rather curiousfact: there seems to be no disposition on their part to takeseriously the implications of Trotter’s conception of a unitaryorganism based upon a number of human minds, consideredin conjunction with the tendency of maturing minds to

differentiate either towards a " resistive " or towards a

"mentally unstable" type, with the notable exception ofSigmund Freud.

I shall be very glad to send an invitation to thisconference to anvone interested.

J. NORMAN GLAISTERDirector of Studies.

Braziers Park School of Integrative Social Research,Ipsden, Oxon.

STUDY OF DELINQUENCY

SiR,-While Dr. Stott is to be congratulated on hisprovocative study of delinquency, and particularly onhis insistence on observation and avoidance of " blanket "terms, I do deplore the unfair and one-sided picture ofclinical psychiatry that is proffered.A bias against doctors appears to raise its head, almost

worthy of the late G. B. Shaw. Is it really true that the" psychiatric examination at the best discovers nothingthat the most ordinary inquiry into the behaviour of thepatient would not reveal " ? ‘? In my own experienceI have found the various projection techniques veryvaluable substitutes for actual behaviour studies. I amastonished that Dr. Stott imagines that the standardtreatment interview for the adolescent delinquent isan hour on the analytic couch. Such a phantasy wouldbe comic if it were not so grotesque. Dr. Stott’s experi-ence of the psychiatric treatment of delinquents appearsstrangely limited.In my practice, which includes boys and girls from

hostels for maladjusted children and from approvedschools, I spend a very considerable proportion of thesession in consultations with the wardens, matrons,housemasters, and headmasters, and discuss the family

situations not only with the patients themselves, butalso with the probation officers and other welfare officerswho have visited the homes ; as far as my knowledgegoes, this is current practice amongst the colleagues whoare doing similar work.

Dr. Stott speaks of the " inadequacies of our old-fashioned brethren " whose ideas and methods have beenborrowed from physical medicine ; but a few paragraphsback he had been denouncing their mystic beliefs aboutthe value of analysis, or the reality of character traits.Materialists or mystics ’? Can he have it both ways ?I note that Dr. Stott is not without his own beliefsand disbeliefs : he apparently does not believe in

projection techniques but does believe in habits. Inci-

dentally when does a habit become irreversible Andwhat is the difference between an irreversible habit anda character trait ? Or is an irreversible habit merelya " dominant pattern of reaction " While warmly commending Dr. Stott’s clinical observa-

tions, I must correct the biased picture of psychiatricpractice presented in his paper. Dr. Stott’s experience,some of it obviously based on hearsay evidence, has beenunfortunate, and it is to be hoped that a wider experiencewill lead him to modify the generalisations based on a fewparticular instances, and that he will regain mastery ofhis " statistical steed."

Bristol. FRANK BODMAN.

CHLORAMPHENICOL IN TYPHOID FEVER

SiR,-Last week’s case-report by Dr. Colquhoun andLDr. Weetch undoubtedly presents interesting features.It would be more interesting still if they would explainhow and why a case of typhoid fever came to be treatedfor a period of two months in a large general hospitalrather than in a hospital for infectious diseases, wherethe staff are specially trained in the precautions necessaryto avoid further spread of the infection.

Gateshead.JAMES GRANT

Medical Officer of Health.

" SITTING IN " ON PRACTICES

SIR,-Ill his report on the state of general practice,.Collings 1 described his method of " sitting in " with ageneral practitioner at work. Collings was concerned.to assess standards of practice, but it occurred to usthat the same technique could be used as a means ofpostgraduate education, and for sharing knowledge-between practitioners.

Of the new illnesses seen by the practitioner in hisdaily work, 85-90% are treated by him from beginning-to end. On entering practice, doctors have only generalideas about handling such illnesses, which are not

regularly seen during their hospital training ; but intime the doctor invents for himself methods of handling-patients, short-cuts to diagnosis, and techniques oftreatment. These personal advances do not ordinarilyenter into the general body of medical knowledge ; and,with the practitioner isolated as he now is, they diewith him.One of us therefore " sat in " on the practice of the-

other for a week, attending surgeries, accompanying himon visits, questioning patients, making examinations,.discussing diagnosis and treatment, and comparingmethods of organising work. We found this greatly toour mutual advantage, and propose a return visit nextyear.

In the correspondence following the Collings report,,it was suggested that patients might resent the presence-of a second doctor. This was not found to be so. Aftera friendly word of introduction, no patient seemed inany way inhibited by the presence of a professionalcolleague.

1. Collings, J. S. Lancet, 1950, i, 555.