- Email: [email protected]
BRAKES FOR TWO-WHEELED CARTS.
820 some unsteadiness of gait with tenderness of the calf muscles, her speech was slightly stammering, and there was tremor of the-facial muscles. Weakness of the legs grew more marked and distinct polyneuritis with muscular atrophy of the affected muscles supervened. The knee-jerks were absent but the cutaneous plantar reflex was lively. Her mental confusion grew worse and she remained bedridden with neuritis for some months, after which a slight improvement In seven months distinct improvement began set in. to show itself, memory began to improve, her physical weakness and incapacity disappeared, and in June, 1903, after a year’s steady improvement she was discharged from In Case 2 the patient was the asylum as recovered. He was admitted a man, aged 63 years, a cab driver. to Colney Hatch Asylum four weeks after the onset of his illness, which was probably a mild mental delirium, in the course of which he would get out of his bed at night, wander
aimlessly about the ward (of the workhouse infirmary), stating that he heard cab bells ringing and demanding fares from the other inmateson the ground that he had just driven them in a cab. Here was an example, adds Dr. Cole, of an "occupation delirium," a very characteristic feature of Korsakoff’s psychosis-viz., defect of observation and memory, illusions as to the identity of persons, false ideas as to his relation to time and space, and pseudoreminiscence. His gait was unsteady and ataxic and the knee-jerks were exaggerated. There was profound loss of memory for recent impressions extending back for many months. After several months’ stay in the asylum he began to improve slightly but a permanent degree of mental defect remained. Dr. Cole points out that in almost all his cases the amount of mental derangement as to the patient’s position in regard to his surroundings was such as to constitute His waking life was quiet and dreama marked delusion. in he lived the like ; past and had no memories of recent events. In a case recorded by Liepmann this loss of memory was more far-reaching and extended back to about 30 years. Dr. Cole concludes by emphasising the paramount influence of alcohol as an etiological factor. Dr. Soukhanoff and Dr. Boutenko, in their contribution already referred to, state that Korsakoff was not only the first psychiatrist to draw attention to the disease but published the largest number of studies on the subject. His teachings had been accepted by Regis, Seglas, Ballet, and others in France ; Jolly, Bonhoffer, and Wernicke in Germany; Krafft-Ebing in Austria ; and Percy Smith and Turner in England. They also give statistical tables as to age and sex showing that the fourth and fifth decades of life are most frequently affected with this disease; that it is rare before the age of 20 years or after the age of 60 years. As regards the sexes, while the majority of cases in males occurred between the ages of 40 and 50 years, the disease was most women between the ages of 35 and 40 years.
prevalent in
THE "PAINFUL PRONATION" OF CHILDHOOD. IN a recent number of the Gazette des Bôpitauae of Paris Professor A. Broca has drawn attention afresh to a condition of no little practical importance. The patient, who is always a child, after a slight injury keeps the arm hanging down by the side, the elbow is slightly flexed, and the forearm is pronated so that the thumb touches the side of the thigh. Any attempt to change from this position is resisted with cries and evidently gives rise to severe pain. The con. dition has been described by Daverney, Malgaigne, and Chassaignac, and more recently by other writers, but there has been much uncertainty as to the exact lesion present. So complete appears to be the loss of use of the limb that Ohassaignac attributed the lack of movement to some lesion of the nervous system. A careful examination of a case shows that the want of mobility of the limb depends entirely
fear of pain, the seat of which is in the neighbourhood of the elbow, there being especial tenderness over the head of the radius. The mode of origin is wonderfully uniform. It is produced by sudden traction on the hand. Often there is a history of a fall and the injury is attributed to this but it is really produced by the effort to raise the child from the ground by traction on the forearm. The age of the patient is nearly always under five years and in most of the Of 189 cases only 11 were more cases under three years. than five years old and 141 were under the age of three years. The injury occurs in young children because they are lifted up steps or on to a pavement by the hand of the mother grasping the child’s hand. Of 130 cases 80 occurred on the left side and Professor Broca considers that this is due to most people leading a child by their own right Of207 hand and so grasping the child’s left hand. cases 137 were girls and 70 were boys but Professor Broca offers no explanation of this preponderance of girls. on a
The treatment is extremely simple. Even if nothing be done, in a few days the child’s arm will have regained its mobility. However, the condition can be immediately put right by a very simple procedure The surgeon takes the child’s hand in his left hand and extends the elbow and then sharply supinates the forearm. Then he bends the elbow while he presses firmly on the head of the radius with the thumb of the right hand ; at the same moment a " click"is heard and the child’s arm becomes perfectly mobile, the movements being restrained only by the remembrance of the pain he has already suffered. This rapidity of recovery shows that there can be no question of fracture of the neck of the radius, as has been suggested by some. Denuc6 has suggested that the pain is due to a fold of synovial membrane being caught between the annular ligament and the transverse ligament but this is very unlikely. It ha5 also been suggested that the bicipital tuberosity in extreme pronation passes behind the outer border of the ulna and finds it difficult to return. This theory, also, is far from probable. Professor Broca believes that the lesion present is a subluxation forwards of the bead of the radius and he thinks he can feel a slight prominence anteriorly. Unfortunately, a skiagram affords no information, for both the capitellum and the head of the radius are cartilaginous and give no shadows. There is a slight tendency to a return of the condition should the exciting cause recur but Professor Broca considers that after reduction no splint nor even a sling is needed. -
BRAKES FOR TWO-WHEELED CARTS.
IN the early hours of Friday morning, March llth, an accident occurred in London which was fortunately attended with no loss of human life although it involved a certain destruction of property and the loss of a horse. At about 3 A.M. a horse drawing a cart loaded with building rubbish was being led down St. James’s-street when from some cause it became frightened. The carter being unable to control it let it go and the horse and cart going fast down the hill failed to make the complete turn and dashed against the parapet of the Oxford and Cambridge Club. This gave way and the horse and the shafts of the cart fell into the area, some 20 feet below the street level. The unfortunate animal was killed. Some years ago a similar accident happened in Bedford-street when the fore part of the horse disappeared into Messrs Dent’s window and cellar in the Strand. We have never been able to understand why the very simple two-wheeled brake which is universally used for two-wheeled vehicles in France is not adopted here. Now that nearly every part of London is being grubbed up or rebuilt the contractors’ carts which are seen about the streets are innumerable and the strain on the horses going down a
821 that of Piccadilly or St. James’s-street, is iu .uterest as the a d From of view we letermine. merely pecuniary point very great. should have thought that it would have paid contractors to fit their carts with the brake to which we have referred. I Such an appliance would save the horses and so would save the contractors’ money, to say nothing of obviating the chances of such an accident as that described above with its opportunities for destruction of life and property. But the average Briton is so-shall we say conservativethat he will not use anything new or to which he is unaccustomed. We think that the legislature should step in and should make the use of such a brake compulsory. It is true that some modification would have to be made to allow for the cart being tipped but surely this would not be beyond the powers of our mechanicians.
hill, such
as
degree
of
responsioility
may be hard to
7
SENILE FORMS OF MENTAL FAILURE. THOUGH old age brings with it a decline in mental as in physical power and capacity the alteration is a gradual process and is on the whole unattended by serious mental disturbance. Senile dementia is that form of mental decay occurring after the fifth decade of life, in which various forms of mental disorder of a somewhat grave character ZIhe delusional cases are especially important from a n medico-legal point of view, as these patients may become manifest themselves. It is very rare before the age of 50 t troublesome and even dangerous to their families, though years in men and it is found that at least two-thirds of all v patients over the age of 50 years admitted to public asylumswhen placed in asylums they soon subside into the category are cases of senile dementia. In the Journal of Nervous and oof uninteresting"senile dements. The chief delusions to Mental Disease for February Dr. William Pickett, instructor vwhich they are liable are those of persecution by unseen and in neuro-pathology and insanity at Jefferson Medical College,nmalign agencies, poisoning, and marital infidelity, the last Philadelphia, publishes an article on the subject of theCof which may cause much distress and trouble to the family. I mental decay and disorders of old age in which an attempt patient’s is made to analyse and to classify the various forms and to THE METROPOLITAN STREET AMBULANCE furnish a practical basis for prognosis, the material studied ASSOCIATION. comprising 200 cases-100 males and 100 females. Senile THE following is an abstract of suggestions approved by insanities other than dementia are rare; they comprise a delusional form and a melancholic form which are liabletthe committee of the Metropolitan Street Ambulance’Assoto occur, strictly speaking, in the pre-senile period which(ciation as the basis of a plan for providing London with an corresponds with the climacteric period in women (from iefficient street ambulance service.45 to 50 years of age) or with a slightly later period 1. That there should be one controlling authority responsible for a I and well-organised ambulance service and that that body (from 50 to 55 years of age) in man. Analysis of theuniform should be the London County Council. 2. That London should be divided into districts or "accident areas" clinical symptoms shows that the following are the and that a properly organised service should be arranged in each. This general characteristics of oncoming senile dementia : en- would necessitate the establishment of horse or motor as well as hand feeblement of attention and slowness in the association of ambulances. 3. That the fire brigade and the ambulance services could be most ideas, inexact perception of relations to surroundings advantageously carried out conjointly. 4. That where possible these ambulances under the control of the and to time (disorientation), marked defects of memory London County Council fire brigade should be stationed at, or in (amnesia) for recent events, poverty of ideas, blunting of immediate connexion with, the principal London hospitals. 5. That the police should be kept efficient in "first-aid" training; the feelings of affection, and irritability of disposition with should be available, as at present, for rendering first aid to the injured, The essence of and tendencies. senile tyrannical exacting summoning an ambulance by telephone, and taking charge of the until the ambulance and attendant arrive; but should not. as dementia is quantitative but irregular reduction of the patient a rule, be expected to accompany patients to home or hospital. mental and moral capacities and the degenerative process is 6. That the 800 fire-alarm telephone posts now existing and all other should, if possible, be made available for calling these usually accompanied by attacks of temporary excitement, telephones ambulances and that the police should be instructed in their use. 7. That the experience gained in working such services for many emotional depression, and delusion, so that the superficial years in such cities as New York, Paris, Liverpool, and many others is of and are mania, melancholia, symptoms paranoia more than sufficient to justify the London County Council in underwork in London on a scale large enough to provide simulated, though these affections rarely occur in old age. taking the for the 13,000 to 15,000 street casualties requiring removal Mental confusion of some degree is present in all types adequately each year. That 8. there should be no charge for the use of the ambulance. of senile dementia; it appears episodically in many (66 per cent. of) cases, being one cause of the familiar street The suggestions, it will be observed, are only set forth as wandering of such dements." The excited, depressed, and a basis for a scheme and we are not quite clear as to delusional types rank next in order of frequency. Physical whether the committee suggests that the whole of the wasting and weakness are greatest in the common or con- work should be undertaken by the fire brigade or only fusional type and are progressively less marked in the other that the ambulances, whether horse or motor, should be types mentioned, a point which is of prognostic value. On kept at the fire stations. But then we see that sugthe other hand, the depressed and paranoid types are of less gestion 4 proposes that the ambulances should be kept favourable prognosis as regards the mental life than are the at, or in immediate connexion with, the hospitals. In other two types of dementia. The exaltation or ephemeral that case where does the fire brigade come in? Everyone excitement of some cases is not true mania ; "probably, knows how admirably organised Is the fire brigade and no " says Dr. Pickett, "true mania never arises in old age." The doubt the machinery of that body would do the ambufollowing table gives a summary of the symptoms and the lance work excellently but we have not yet heard the peculiarities of conduct of the 200 patients investigated. brigade’s opinion on the matter. If the fire alarm Some of the peculiarities of conduct have a medico-legal posts and the machinery of the brigade are utilised .,
-
’’
aimlessly about the ward (of the workhouse infirmary), stating that he heard cab bells ringing and demanding fares from the other inmateson the ground that he had just driven them in a cab. Here was an example, adds Dr. Cole, of an "occupation delirium," a very characteristic feature of Korsakoff’s psychosis-viz., defect of observation and memory, illusions as to the identity of persons, false ideas as to his relation to time and space, and pseudoreminiscence. His gait was unsteady and ataxic and the knee-jerks were exaggerated. There was profound loss of memory for recent impressions extending back for many months. After several months’ stay in the asylum he began to improve slightly but a permanent degree of mental defect remained. Dr. Cole points out that in almost all his cases the amount of mental derangement as to the patient’s position in regard to his surroundings was such as to constitute His waking life was quiet and dreama marked delusion. in he lived the like ; past and had no memories of recent events. In a case recorded by Liepmann this loss of memory was more far-reaching and extended back to about 30 years. Dr. Cole concludes by emphasising the paramount influence of alcohol as an etiological factor. Dr. Soukhanoff and Dr. Boutenko, in their contribution already referred to, state that Korsakoff was not only the first psychiatrist to draw attention to the disease but published the largest number of studies on the subject. His teachings had been accepted by Regis, Seglas, Ballet, and others in France ; Jolly, Bonhoffer, and Wernicke in Germany; Krafft-Ebing in Austria ; and Percy Smith and Turner in England. They also give statistical tables as to age and sex showing that the fourth and fifth decades of life are most frequently affected with this disease; that it is rare before the age of 20 years or after the age of 60 years. As regards the sexes, while the majority of cases in males occurred between the ages of 40 and 50 years, the disease was most women between the ages of 35 and 40 years.
prevalent in
THE "PAINFUL PRONATION" OF CHILDHOOD. IN a recent number of the Gazette des Bôpitauae of Paris Professor A. Broca has drawn attention afresh to a condition of no little practical importance. The patient, who is always a child, after a slight injury keeps the arm hanging down by the side, the elbow is slightly flexed, and the forearm is pronated so that the thumb touches the side of the thigh. Any attempt to change from this position is resisted with cries and evidently gives rise to severe pain. The con. dition has been described by Daverney, Malgaigne, and Chassaignac, and more recently by other writers, but there has been much uncertainty as to the exact lesion present. So complete appears to be the loss of use of the limb that Ohassaignac attributed the lack of movement to some lesion of the nervous system. A careful examination of a case shows that the want of mobility of the limb depends entirely
fear of pain, the seat of which is in the neighbourhood of the elbow, there being especial tenderness over the head of the radius. The mode of origin is wonderfully uniform. It is produced by sudden traction on the hand. Often there is a history of a fall and the injury is attributed to this but it is really produced by the effort to raise the child from the ground by traction on the forearm. The age of the patient is nearly always under five years and in most of the Of 189 cases only 11 were more cases under three years. than five years old and 141 were under the age of three years. The injury occurs in young children because they are lifted up steps or on to a pavement by the hand of the mother grasping the child’s hand. Of 130 cases 80 occurred on the left side and Professor Broca considers that this is due to most people leading a child by their own right Of207 hand and so grasping the child’s left hand. cases 137 were girls and 70 were boys but Professor Broca offers no explanation of this preponderance of girls. on a
The treatment is extremely simple. Even if nothing be done, in a few days the child’s arm will have regained its mobility. However, the condition can be immediately put right by a very simple procedure The surgeon takes the child’s hand in his left hand and extends the elbow and then sharply supinates the forearm. Then he bends the elbow while he presses firmly on the head of the radius with the thumb of the right hand ; at the same moment a " click"is heard and the child’s arm becomes perfectly mobile, the movements being restrained only by the remembrance of the pain he has already suffered. This rapidity of recovery shows that there can be no question of fracture of the neck of the radius, as has been suggested by some. Denuc6 has suggested that the pain is due to a fold of synovial membrane being caught between the annular ligament and the transverse ligament but this is very unlikely. It ha5 also been suggested that the bicipital tuberosity in extreme pronation passes behind the outer border of the ulna and finds it difficult to return. This theory, also, is far from probable. Professor Broca believes that the lesion present is a subluxation forwards of the bead of the radius and he thinks he can feel a slight prominence anteriorly. Unfortunately, a skiagram affords no information, for both the capitellum and the head of the radius are cartilaginous and give no shadows. There is a slight tendency to a return of the condition should the exciting cause recur but Professor Broca considers that after reduction no splint nor even a sling is needed. -
BRAKES FOR TWO-WHEELED CARTS.
IN the early hours of Friday morning, March llth, an accident occurred in London which was fortunately attended with no loss of human life although it involved a certain destruction of property and the loss of a horse. At about 3 A.M. a horse drawing a cart loaded with building rubbish was being led down St. James’s-street when from some cause it became frightened. The carter being unable to control it let it go and the horse and cart going fast down the hill failed to make the complete turn and dashed against the parapet of the Oxford and Cambridge Club. This gave way and the horse and the shafts of the cart fell into the area, some 20 feet below the street level. The unfortunate animal was killed. Some years ago a similar accident happened in Bedford-street when the fore part of the horse disappeared into Messrs Dent’s window and cellar in the Strand. We have never been able to understand why the very simple two-wheeled brake which is universally used for two-wheeled vehicles in France is not adopted here. Now that nearly every part of London is being grubbed up or rebuilt the contractors’ carts which are seen about the streets are innumerable and the strain on the horses going down a
821 that of Piccadilly or St. James’s-street, is iu .uterest as the a d From of view we letermine. merely pecuniary point very great. should have thought that it would have paid contractors to fit their carts with the brake to which we have referred. I Such an appliance would save the horses and so would save the contractors’ money, to say nothing of obviating the chances of such an accident as that described above with its opportunities for destruction of life and property. But the average Briton is so-shall we say conservativethat he will not use anything new or to which he is unaccustomed. We think that the legislature should step in and should make the use of such a brake compulsory. It is true that some modification would have to be made to allow for the cart being tipped but surely this would not be beyond the powers of our mechanicians.
hill, such
as
degree
of
responsioility
may be hard to
7
SENILE FORMS OF MENTAL FAILURE. THOUGH old age brings with it a decline in mental as in physical power and capacity the alteration is a gradual process and is on the whole unattended by serious mental disturbance. Senile dementia is that form of mental decay occurring after the fifth decade of life, in which various forms of mental disorder of a somewhat grave character ZIhe delusional cases are especially important from a n medico-legal point of view, as these patients may become manifest themselves. It is very rare before the age of 50 t troublesome and even dangerous to their families, though years in men and it is found that at least two-thirds of all v patients over the age of 50 years admitted to public asylumswhen placed in asylums they soon subside into the category are cases of senile dementia. In the Journal of Nervous and oof uninteresting"senile dements. The chief delusions to Mental Disease for February Dr. William Pickett, instructor vwhich they are liable are those of persecution by unseen and in neuro-pathology and insanity at Jefferson Medical College,nmalign agencies, poisoning, and marital infidelity, the last Philadelphia, publishes an article on the subject of theCof which may cause much distress and trouble to the family. I mental decay and disorders of old age in which an attempt patient’s is made to analyse and to classify the various forms and to THE METROPOLITAN STREET AMBULANCE furnish a practical basis for prognosis, the material studied ASSOCIATION. comprising 200 cases-100 males and 100 females. Senile THE following is an abstract of suggestions approved by insanities other than dementia are rare; they comprise a delusional form and a melancholic form which are liabletthe committee of the Metropolitan Street Ambulance’Assoto occur, strictly speaking, in the pre-senile period which(ciation as the basis of a plan for providing London with an corresponds with the climacteric period in women (from iefficient street ambulance service.45 to 50 years of age) or with a slightly later period 1. That there should be one controlling authority responsible for a I and well-organised ambulance service and that that body (from 50 to 55 years of age) in man. Analysis of theuniform should be the London County Council. 2. That London should be divided into districts or "accident areas" clinical symptoms shows that the following are the and that a properly organised service should be arranged in each. This general characteristics of oncoming senile dementia : en- would necessitate the establishment of horse or motor as well as hand feeblement of attention and slowness in the association of ambulances. 3. That the fire brigade and the ambulance services could be most ideas, inexact perception of relations to surroundings advantageously carried out conjointly. 4. That where possible these ambulances under the control of the and to time (disorientation), marked defects of memory London County Council fire brigade should be stationed at, or in (amnesia) for recent events, poverty of ideas, blunting of immediate connexion with, the principal London hospitals. 5. That the police should be kept efficient in "first-aid" training; the feelings of affection, and irritability of disposition with should be available, as at present, for rendering first aid to the injured, The essence of and tendencies. senile tyrannical exacting summoning an ambulance by telephone, and taking charge of the until the ambulance and attendant arrive; but should not. as dementia is quantitative but irregular reduction of the patient a rule, be expected to accompany patients to home or hospital. mental and moral capacities and the degenerative process is 6. That the 800 fire-alarm telephone posts now existing and all other should, if possible, be made available for calling these usually accompanied by attacks of temporary excitement, telephones ambulances and that the police should be instructed in their use. 7. That the experience gained in working such services for many emotional depression, and delusion, so that the superficial years in such cities as New York, Paris, Liverpool, and many others is of and are mania, melancholia, symptoms paranoia more than sufficient to justify the London County Council in underwork in London on a scale large enough to provide simulated, though these affections rarely occur in old age. taking the for the 13,000 to 15,000 street casualties requiring removal Mental confusion of some degree is present in all types adequately each year. That 8. there should be no charge for the use of the ambulance. of senile dementia; it appears episodically in many (66 per cent. of) cases, being one cause of the familiar street The suggestions, it will be observed, are only set forth as wandering of such dements." The excited, depressed, and a basis for a scheme and we are not quite clear as to delusional types rank next in order of frequency. Physical whether the committee suggests that the whole of the wasting and weakness are greatest in the common or con- work should be undertaken by the fire brigade or only fusional type and are progressively less marked in the other that the ambulances, whether horse or motor, should be types mentioned, a point which is of prognostic value. On kept at the fire stations. But then we see that sugthe other hand, the depressed and paranoid types are of less gestion 4 proposes that the ambulances should be kept favourable prognosis as regards the mental life than are the at, or in immediate connexion with, the hospitals. In other two types of dementia. The exaltation or ephemeral that case where does the fire brigade come in? Everyone excitement of some cases is not true mania ; "probably, knows how admirably organised Is the fire brigade and no " says Dr. Pickett, "true mania never arises in old age." The doubt the machinery of that body would do the ambufollowing table gives a summary of the symptoms and the lance work excellently but we have not yet heard the peculiarities of conduct of the 200 patients investigated. brigade’s opinion on the matter. If the fire alarm Some of the peculiarities of conduct have a medico-legal posts and the machinery of the brigade are utilised .,
-
’’