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PROF. SPITZKA AND HIS PATIENTS.
626 conducted for profit, or for other specific reasons cannot be included in Class B. One college, which refused to have inspections carried out, is listed as " unclassified," with a note to the effect that, from information obtained, no rating higher than C should be given to it. Of the total of 81 medical schools thus classified, 74 are described as non-sectarian, 3 as homoeopathic, 1 as eclectic, and 3 as nondescript. The decline of homoeopathic and eclectic schools is shown by the fact that in 1901 they numbered 22 and 10 respectively. The American student is urged, before choosing a medical school, to obtain information of its requirements of preliminary education, of its teaching, classification, and fees, and of the extent of recognition of its diplomas. At present 38 (73 per cent.) of the State licensing boards require that before beginning the study of medicine a student must have completed two years of work in an approved college of liberal arts, in addition to a four-year high school education. All the better medical colleges now require this standard of preliminary education, and the student is warned that requirement of any lower standard is an indication that the medical education given will be correspondingly low. Adequate instruction can be given only in the Class A medical schools. Although a favourite bait offered by the inferior medical schools is that of low fees, the fees charged by some of the best (Class A) schools-particularly the medical departments of some State universities-are lower than those charged by several of the poorly-equipped Class C institutions. The better schools which charge higher fees spend several times the amount of the fee per year on each student, being enabled to do so by endowments or State aid. There are now more than 300 free scholarships available for deserving students in the better medical schools. The student is warned against accepting without confirmation the statements made in the extensive newspaper and magazine advertisement carried on by some schools. A serious pitfall to the student in the United States appears to be the number of institutions representing various unscientific or pseudo-scientific cults (osteopathy, chiropractic, &c.) which profess to train those who desire to cure diseases ; the necessity of a thorough training in all the fundamentals of medicine is therefore emphasised. The essentials of an acceptable medical college are detailed, both as regards its educational requirements in the student himself, and in its organisation, clinical and other facilities, instruction, and financial basis. A list of classified medical schools is given, and the reader is left wondering-supposing the Educational Number of the J ouma of the American 3ledical Association to havethe circulation it deserves -how any but the Class A medical schools can continue to exist. ____
DENTAL BENEFIT. REFERENCES recently made in the daily press to the acceptance by the Incorporated Dental Society on
August 31st of a scheme similar to that already adopted by the British Dental Association for the supply of dental benefits to members of approved societies show that there exists a widespread belief that such benefits are only about to be established and constitute an innovation. The fact is, of course, that dental panels have now been in pa,rtial operation for about a year. In August, 1921, a series of panels was formed in the nine central counties, the panels consisting of dental practitioners who were already on the register before the passing of the Dentists Act of last year. In April of the present year it was decided to organise a system of panels of registered dentists throughout the country. Executive committees elected from the panels in each area are now selecting representatives to a central panel committee ; when this selection is completed a meeting will be held in London (probably during October) to formulate a general scheme for the carrying out of dental benefits in conjunction with approved societies. With regard to the work already done in this direction, the X ational 1 ostcrmuee Gazette for
August
12th
pointed
out that
in the experience of many societies dental benefit is the most popular and at the same time the most costly of the additional benefits offered by the larger insurance societies which found themselves enabled by accumulation of funds to extend their scope beyond the ordinary sickness, disablement, and maternity benefits. It was found that even where generous amounts were set aside for purposes of dental benefit, Thus, they were barely enough to meet the demands. " a society with a membership of 20,000 good lives " made provision for 21000 per annum dental benefit, to cover the full cost of dental treatment and half cost of dentures ; this sum barely sufficed for the purpose. It may be argued, as the Gazette points out, that the first year of such benefit was bound to show exceptionally heavy claims, the whole membership being entitled to claim at one time, and that lighter demands may be anticipated in following years; on the other hand, a large percentage of the insured population were sceptical as to their title to additional benefit, and the claims of succeeding years may therefore be as heavy as in the first year. The Gazette goes on to emphasise the fact that the popularity of dental benefit should be welcomed by those responsible for the working of the National Insurance Acts, since digestive upsets account for a considerable proportion of the cost of sickness benefit, and prevention of these disorders will materially strengthen the position of any benefit society. PROF. SPITZKA AND HIS PATIENTS. THE death, reported from New York last week, of Dr. Edward Anthony Spitzka, sometime professor of anatomy in Jefferson Medical College and director of the Daniel Baugh Institute of Anatomy in Philadelphia, recalls the remarkable opportunity which he possessed of verifying his clinical diagnoses
by immediate post-mortem examination. He it was who performed the autopsy on and examined the brain of Leon F. Czolgosz, the assassin of President McKinley, and he had many opportunities of observing the changes found in other criminals after electrocution. In regard to Czolgosz, the character of mental disease from which he was suffering was not determined. There was no evidence of insane delusion or hallucination ; he had no morbid mental exaltation or expansiveness of ideas suggesting mania, none of the mental gloom of melancholia, none of the conjoint mental and motor symptoms eharacteristic of general paresis, nor was there anything in his manner or conduct to suggest persecutory ideas or transformation of personality. Nothing beyond the absurdity of his statements and acts gave ground for any assumption of mental unsoundness. Prof. Carlos F. Macdonald, ex-President of the New York State Commission in Lunacy, recorded his unqualified opinion that Czolgosz, when he assassinated the President, was sane legally and medically and responsible for his act. It was therefore to be expected that the post-mortem examination should reveal nothing in the brain to account for intrinsic cerebral defect ; Prof. Spitzka noted, however, that -the brain did not exhibit that especial kind of asymmetry of gyral structure in the cerebral halves which he held to be characteristic of the brains of highly endowed individuals. The few peculiarities noted in the arrangement of the cerebral fissures were insignificant, the slight asymmetry of the skull being well within the normal range of variation. The examination was conducted with especial care in view of the attempt in those days to found a " school of degeneracy " to explain crime and social wickedness in terms of accidental persistence of lower types of human organisation. Spitzka was unable to confirm any such correlation of structural anomaly with criminal delinquency. His opinion on Czolgosz was that he was " socially diseased and perverted," but not mentally diseased. " The wild beast slumbers in us all " was the concluding sentence in his report. Ten years later Spitzka published an account of the changes which he found in the brains of five other electrocuted
627
criminals, removed and fixed within 15 minutes of death. In each case a number of perivascular lesions, 25-300 iL in diameter, were found scattered through the lower parts of the brain, the vessels showing beading, with an area of condensation surrounding them. The lesions suggested sudden liberation of gas from electrolysis, and might have an obvious bearing in medico-legal cases where death from electric current was alleged. Spitzka made a study of the brains not merely of criminals but of many eminent men of various races, and he found time to edit the eighteenth He was American edition of Gray’s Anatomy. 46 years old at the time of his death. GRASS DISEASE AND BOTULISM. SOME allusion has been made during the last few weeks in the daily press to the possible relation between botulism and a disease of horses in Scotland " which goes by the name of grass disease " or " grass sickness." It is not generally known that the Scottish Grass Disease Committee has been working on this matter for the last four years, and that Dr. J. F. Tocher, of Aberdeen, a member of this committee, was concerned in the earliest detection of the Bacillus botulinus in this country in 1919. The limitations of our present knowledge were set out in a paper by Mr. J. B. Buxton, F.R.C.V.S., read before the Section of Pathology of the Royal Society of Medicine in January last. The grass sickness of Northern Britain appears to be identical with the forage poisoning of horses and cattle described in America, and an organism indistinguishable morphologically from B. botulinus was recovered bv Dr. Tocher from the intestine and spleen of horses dead of this disease. An attempt was made last year to devise some means of controlling the incidence of the disease, and a
botulinus-antitoxin prepared by the Wellcome Physiological Research Laboratories was employed, chiefly at first for curative purposes, although it was realised that, with the precedent of tetanus, its preventive application was more likely to command success. But
even
in
cases
which did not
recover
the acute
symptoms of disease appeared to be checked temporarily by intravenous administration of the antitoxin. Further investigation revealed the presence in the blood of several chronic cases of an appreciable amount of antitoxin, type A. One of these animals had, it is true, received injections of high value botulinus-antitoxin some weeks previous to the blood examination. As, however, in a control experiment, antitoxin even to the extent of 25 c.cm. of high value was eliminated from the blood within 10 days, it was deemed at all events highly probable that chronic cases of grass disease do develop a certain degree of active immunity, as shown by the presence of antitoxin. Complement-binding antibodies were also found, although it was not possible clearly to indicate the presence of agglutinins. The Wellcome Laboratory has, we understand, been preparing botulinusantitoxin of both types A and B during the last two years, and has, in conjunction with the Scottish Committee, recently initiated an experiment in preventive inoculation.
proceeding.
Further work in this direction is ____
CONTROL OF CONCEPTION BY IRRADIATION. MOST of the methods which have been devised for the control of conception, ingenious though many of them are, have been found to possess drawbacks for one or other of the consenting parties. In a recent number of the Deutsche rnedizinische Wochenschrift Dr. Emmerich Markovitz sets out a method which emanates from the Central X Ray Laboratory of the Vienna General Hospital. He submits that recent investigations have shown that the parenchymatous constituents of the genital glands are affected by X rays to the point of actual degeneration, while the interstitial tissue more or less escapes change. He proposes in cases where temporary cessation of conception is desirable to obtain it by alternately 1 Since published in the Veterinary Journal, April, 1922.
dosing the husband and the wife. In the early of Gauss, of ten women about the age of 30 years, nine were rendered temporarily sterile by X ray radiation, whereas before the treatment they were bearing children at an average of one in 18 months. Weber went on to show that sterility set in within six months of irradiation, and M. Frankel
experiments
observed the return of menstruation and normal pregnancy a few months after stopping the X rays. More recently Seitz and Wintz have set out the exact dosage of X rays required to attain sterility with minimal damage to other than the immediately ripening follicles. In regard to the male, analogous results have been obtained, and Markovitz quotes especially the experience of Kriser, who at the X Vienna Central Ray Laboratory produced azoospermia in a patient by means of minimal doses, giving in fact only thrice at two-month intervals 1 H through 0-3 mm. brass filter on the skin. Markovitz’s programme would consist in irradiating the man before the ability to conceive returns in the woman, as indicated by the recommencement of menstruation. Since the duration of the sterilisation in the man is as yet unknown, he admits that periodical examinations of the spermatic fluid will be necessary. The morbid conditions for which the treatment is suggested are slight tuberculosis of good prognosis, Graves’s disease after successful operative or X ray treatment, diabetes of slight grade, morphinism when not too pronounced, and such like. The treatment has the merit of avoiding finality. Prof. Holzknecht, under whom it is being carried out, lays down the principle that the doctor has no right to destroy more tissue than is necessary in the individual case ; a partial exovulation not affecting more than 6 to 12 ovula should meet the case. The method implies agreement on the side of both parties. Dr. Markovitz appends a limited but useful bibliography to his paper. ____
MALARIA IN THE MALAY STATES. FROM the annual report for 1921 of the Chief Secretary to the Government (Mr. W. G. Maxwell, C.M.G.) it appears that, as usual, malaria heads the list of fatal diseases in the Federated States. The actual number of deaths from malaria was 17,168, a considerable decrease from the 20,595 recorded in 1920, but still nearly half the total for all diseases, giving a rate of 13-16 per mille as compared with 15-24 in 1920 ; but the disease is, of course, a contributory factor in many deaths attributed to other causes, and when the malaria sick-rate and death-rate are reduced, the total death-rate of the country will fall in proportion. The Malaria Advisory Board meets every month, and almost every district has its mosquito destruction board. Any estate that requires an anopheline survey can obtain one, free from cost, together with a report and the health officer’s recommendations, but to be effectual, anti-malarial measures must be carried out under the direct supervision of the estate medical officer, and constitute a duty of the owners of estates. The district mosquito destruction boards function in the town areas, villages, and kampongs. The (central) Malaria Advisory Board merely advises, controls, and coordinates the work of the district boards. The advisory board is endeavouring to achieve a policy of combined anti-malarial action by contiguous estates ; where anti-malarial work is carried out under expert supervision upon an estate, and neighbouring State land or small holdings also requires to be treated, the Government considers applications for a fair contribution in order to render the operation effective. The anti-malarial works at Kuala Lumpur cover 6600 acres, and were maintained during the year at a cost of$22,126 ; the sum of$105,000 was expended The Port Swettenham on the erection of new works. anti-malarial area of 3100 acres was maintained at a cost of$4623 ; at Seremban a drained area of 1500 acres was maintained at a cost of$8283. Surveys at Taiping, Kuala Lumpur, Gemas, and Raub were At the car ied out over an area of 2600 acres.
DENTAL BENEFIT. REFERENCES recently made in the daily press to the acceptance by the Incorporated Dental Society on
August 31st of a scheme similar to that already adopted by the British Dental Association for the supply of dental benefits to members of approved societies show that there exists a widespread belief that such benefits are only about to be established and constitute an innovation. The fact is, of course, that dental panels have now been in pa,rtial operation for about a year. In August, 1921, a series of panels was formed in the nine central counties, the panels consisting of dental practitioners who were already on the register before the passing of the Dentists Act of last year. In April of the present year it was decided to organise a system of panels of registered dentists throughout the country. Executive committees elected from the panels in each area are now selecting representatives to a central panel committee ; when this selection is completed a meeting will be held in London (probably during October) to formulate a general scheme for the carrying out of dental benefits in conjunction with approved societies. With regard to the work already done in this direction, the X ational 1 ostcrmuee Gazette for
August
12th
pointed
out that
in the experience of many societies dental benefit is the most popular and at the same time the most costly of the additional benefits offered by the larger insurance societies which found themselves enabled by accumulation of funds to extend their scope beyond the ordinary sickness, disablement, and maternity benefits. It was found that even where generous amounts were set aside for purposes of dental benefit, Thus, they were barely enough to meet the demands. " a society with a membership of 20,000 good lives " made provision for 21000 per annum dental benefit, to cover the full cost of dental treatment and half cost of dentures ; this sum barely sufficed for the purpose. It may be argued, as the Gazette points out, that the first year of such benefit was bound to show exceptionally heavy claims, the whole membership being entitled to claim at one time, and that lighter demands may be anticipated in following years; on the other hand, a large percentage of the insured population were sceptical as to their title to additional benefit, and the claims of succeeding years may therefore be as heavy as in the first year. The Gazette goes on to emphasise the fact that the popularity of dental benefit should be welcomed by those responsible for the working of the National Insurance Acts, since digestive upsets account for a considerable proportion of the cost of sickness benefit, and prevention of these disorders will materially strengthen the position of any benefit society. PROF. SPITZKA AND HIS PATIENTS. THE death, reported from New York last week, of Dr. Edward Anthony Spitzka, sometime professor of anatomy in Jefferson Medical College and director of the Daniel Baugh Institute of Anatomy in Philadelphia, recalls the remarkable opportunity which he possessed of verifying his clinical diagnoses
by immediate post-mortem examination. He it was who performed the autopsy on and examined the brain of Leon F. Czolgosz, the assassin of President McKinley, and he had many opportunities of observing the changes found in other criminals after electrocution. In regard to Czolgosz, the character of mental disease from which he was suffering was not determined. There was no evidence of insane delusion or hallucination ; he had no morbid mental exaltation or expansiveness of ideas suggesting mania, none of the mental gloom of melancholia, none of the conjoint mental and motor symptoms eharacteristic of general paresis, nor was there anything in his manner or conduct to suggest persecutory ideas or transformation of personality. Nothing beyond the absurdity of his statements and acts gave ground for any assumption of mental unsoundness. Prof. Carlos F. Macdonald, ex-President of the New York State Commission in Lunacy, recorded his unqualified opinion that Czolgosz, when he assassinated the President, was sane legally and medically and responsible for his act. It was therefore to be expected that the post-mortem examination should reveal nothing in the brain to account for intrinsic cerebral defect ; Prof. Spitzka noted, however, that -the brain did not exhibit that especial kind of asymmetry of gyral structure in the cerebral halves which he held to be characteristic of the brains of highly endowed individuals. The few peculiarities noted in the arrangement of the cerebral fissures were insignificant, the slight asymmetry of the skull being well within the normal range of variation. The examination was conducted with especial care in view of the attempt in those days to found a " school of degeneracy " to explain crime and social wickedness in terms of accidental persistence of lower types of human organisation. Spitzka was unable to confirm any such correlation of structural anomaly with criminal delinquency. His opinion on Czolgosz was that he was " socially diseased and perverted," but not mentally diseased. " The wild beast slumbers in us all " was the concluding sentence in his report. Ten years later Spitzka published an account of the changes which he found in the brains of five other electrocuted
627
criminals, removed and fixed within 15 minutes of death. In each case a number of perivascular lesions, 25-300 iL in diameter, were found scattered through the lower parts of the brain, the vessels showing beading, with an area of condensation surrounding them. The lesions suggested sudden liberation of gas from electrolysis, and might have an obvious bearing in medico-legal cases where death from electric current was alleged. Spitzka made a study of the brains not merely of criminals but of many eminent men of various races, and he found time to edit the eighteenth He was American edition of Gray’s Anatomy. 46 years old at the time of his death. GRASS DISEASE AND BOTULISM. SOME allusion has been made during the last few weeks in the daily press to the possible relation between botulism and a disease of horses in Scotland " which goes by the name of grass disease " or " grass sickness." It is not generally known that the Scottish Grass Disease Committee has been working on this matter for the last four years, and that Dr. J. F. Tocher, of Aberdeen, a member of this committee, was concerned in the earliest detection of the Bacillus botulinus in this country in 1919. The limitations of our present knowledge were set out in a paper by Mr. J. B. Buxton, F.R.C.V.S., read before the Section of Pathology of the Royal Society of Medicine in January last. The grass sickness of Northern Britain appears to be identical with the forage poisoning of horses and cattle described in America, and an organism indistinguishable morphologically from B. botulinus was recovered bv Dr. Tocher from the intestine and spleen of horses dead of this disease. An attempt was made last year to devise some means of controlling the incidence of the disease, and a
botulinus-antitoxin prepared by the Wellcome Physiological Research Laboratories was employed, chiefly at first for curative purposes, although it was realised that, with the precedent of tetanus, its preventive application was more likely to command success. But
even
in
cases
which did not
recover
the acute
symptoms of disease appeared to be checked temporarily by intravenous administration of the antitoxin. Further investigation revealed the presence in the blood of several chronic cases of an appreciable amount of antitoxin, type A. One of these animals had, it is true, received injections of high value botulinus-antitoxin some weeks previous to the blood examination. As, however, in a control experiment, antitoxin even to the extent of 25 c.cm. of high value was eliminated from the blood within 10 days, it was deemed at all events highly probable that chronic cases of grass disease do develop a certain degree of active immunity, as shown by the presence of antitoxin. Complement-binding antibodies were also found, although it was not possible clearly to indicate the presence of agglutinins. The Wellcome Laboratory has, we understand, been preparing botulinusantitoxin of both types A and B during the last two years, and has, in conjunction with the Scottish Committee, recently initiated an experiment in preventive inoculation.
proceeding.
Further work in this direction is ____
CONTROL OF CONCEPTION BY IRRADIATION. MOST of the methods which have been devised for the control of conception, ingenious though many of them are, have been found to possess drawbacks for one or other of the consenting parties. In a recent number of the Deutsche rnedizinische Wochenschrift Dr. Emmerich Markovitz sets out a method which emanates from the Central X Ray Laboratory of the Vienna General Hospital. He submits that recent investigations have shown that the parenchymatous constituents of the genital glands are affected by X rays to the point of actual degeneration, while the interstitial tissue more or less escapes change. He proposes in cases where temporary cessation of conception is desirable to obtain it by alternately 1 Since published in the Veterinary Journal, April, 1922.
dosing the husband and the wife. In the early of Gauss, of ten women about the age of 30 years, nine were rendered temporarily sterile by X ray radiation, whereas before the treatment they were bearing children at an average of one in 18 months. Weber went on to show that sterility set in within six months of irradiation, and M. Frankel
experiments
observed the return of menstruation and normal pregnancy a few months after stopping the X rays. More recently Seitz and Wintz have set out the exact dosage of X rays required to attain sterility with minimal damage to other than the immediately ripening follicles. In regard to the male, analogous results have been obtained, and Markovitz quotes especially the experience of Kriser, who at the X Vienna Central Ray Laboratory produced azoospermia in a patient by means of minimal doses, giving in fact only thrice at two-month intervals 1 H through 0-3 mm. brass filter on the skin. Markovitz’s programme would consist in irradiating the man before the ability to conceive returns in the woman, as indicated by the recommencement of menstruation. Since the duration of the sterilisation in the man is as yet unknown, he admits that periodical examinations of the spermatic fluid will be necessary. The morbid conditions for which the treatment is suggested are slight tuberculosis of good prognosis, Graves’s disease after successful operative or X ray treatment, diabetes of slight grade, morphinism when not too pronounced, and such like. The treatment has the merit of avoiding finality. Prof. Holzknecht, under whom it is being carried out, lays down the principle that the doctor has no right to destroy more tissue than is necessary in the individual case ; a partial exovulation not affecting more than 6 to 12 ovula should meet the case. The method implies agreement on the side of both parties. Dr. Markovitz appends a limited but useful bibliography to his paper. ____
MALARIA IN THE MALAY STATES. FROM the annual report for 1921 of the Chief Secretary to the Government (Mr. W. G. Maxwell, C.M.G.) it appears that, as usual, malaria heads the list of fatal diseases in the Federated States. The actual number of deaths from malaria was 17,168, a considerable decrease from the 20,595 recorded in 1920, but still nearly half the total for all diseases, giving a rate of 13-16 per mille as compared with 15-24 in 1920 ; but the disease is, of course, a contributory factor in many deaths attributed to other causes, and when the malaria sick-rate and death-rate are reduced, the total death-rate of the country will fall in proportion. The Malaria Advisory Board meets every month, and almost every district has its mosquito destruction board. Any estate that requires an anopheline survey can obtain one, free from cost, together with a report and the health officer’s recommendations, but to be effectual, anti-malarial measures must be carried out under the direct supervision of the estate medical officer, and constitute a duty of the owners of estates. The district mosquito destruction boards function in the town areas, villages, and kampongs. The (central) Malaria Advisory Board merely advises, controls, and coordinates the work of the district boards. The advisory board is endeavouring to achieve a policy of combined anti-malarial action by contiguous estates ; where anti-malarial work is carried out under expert supervision upon an estate, and neighbouring State land or small holdings also requires to be treated, the Government considers applications for a fair contribution in order to render the operation effective. The anti-malarial works at Kuala Lumpur cover 6600 acres, and were maintained during the year at a cost of$22,126 ; the sum of$105,000 was expended The Port Swettenham on the erection of new works. anti-malarial area of 3100 acres was maintained at a cost of$4623 ; at Seremban a drained area of 1500 acres was maintained at a cost of$8283. Surveys at Taiping, Kuala Lumpur, Gemas, and Raub were At the car ied out over an area of 2600 acres.