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ANGINA PECTORIS AND XANTHOMATOSIS
1275
manship of Mr. P. M. Evans who was chairman of the union’s committee. The object of every worker, says the handbook, is to help the blind to lead a normal life, to recognise their limitations in a natural lame man recognises that he cannot run a them to mix with other blind people, but also with the sighted; to teach them to train themselves to do well the many things the blind are able to do well; and above all to help them not to " think of themselves as blind in a blind world." way,
as a
race, to
help
ANGINA PECTORIS AND XANTHOMATOSIS ,
INVESTIGATIONS
by Harbitz
into the
deposition
of
xanthomatous substances in the body have inspired
Norwegian physician, Carl Müller,1 to make further inquiries. Having once begun to associate xanthomatosis (in the form of xanthelasma of the skin and xanthoma tuberosum) with angina pectoris, he was soon impressed by the familial character of this association; indeed including his first case of xanthoma tuberosum and angina pectoris observed in April, 1937, he has collected 79 cases of xanthomatosis, distributed over 17 families, in 69 of which there were signs of heart disease and in 59 angina pectoris. Most of his patients were employed in business or professions, and there was not a single representative of the " working classes," although much of Muller’s practice is among them. The association of the two conditions is explained by saying that xanthomatous deposits are laid down in the coronary arteries and give rise to ischsemia of the myocardium with resultant attacks of angina pectoris. In 5 of Muller’s cases the deposits were held responsible for valvular disease of the heart, but patients may also show xanthomatosis without signs of heart a
disease.
together
The two conditions may, he says, be found at almost any age. THE INSANITY DEFENCE
THE ordinary rules of procedure in criminal as well in civil trials lay down that the evidence for the Crown or the plaintiff shall be heard first, and then the evidence for the defence. Exceptions are made where the judge considers them necessary, but that is the ordinary practice. Dr. L. A. Weatherly, that veteran and never-ageing expert in forensic psychiatry, urged before the Medico-Legal Society on May 25 that a rule of procedure should be introduced laying down that, when insanity is pleaded as a defence to a criminal charge, the expert evidence called by the Crown to rebut that defence should be heard after the expert witnesses for the prisoner have spoken. Such a rule might be made by decision of the Court of Criminal Appeal, by the rule committee of the Supreme Court, or, of course, by Parliament. In support of his argument he recounted-without a single note-five cases in which he had been concerned at various times during this century. In four of them the procedure he proposed had been followed by direction of the judge. In two of them the Crown experts had refused to go into the box, so clearly was the defence of insanity made out ; and in two others they agreed with the defence. In the fifth case the judge insisted on hearing the rebutting evidence first. The Crown expert said he could find no trace of insanity in the prisoner, and Dr. Weatherly, who followed for the defence, was laughed out of court. The prisoner was sentenced to death, but was reprieved and four days later was sent to Broadmoor, hopelessly insane. Shortly afterwards as
1. Nord. Med.
April 22, 1939, p. 1183.
the judge’s own brother, a doctor, became suddenly insane and died in an asylum. The judge sent for Dr. Weatherly and confessed that the insanity defence had always been to him like a red rag to a bull, but he now realised that he had sentenced many insane persons to death, and had been quite wrong in that particular case in allowing the medical witness for the Crown to go into the box before the evidence for the insanity defence had been heard. Dr. Weatherly’s point is that this arrangement should not be left to the discretion of the judge; and arising from that point he made another-namely, that the Medico-Legal Society should appoint a standing committee on legislation, to investigate cases in which it appears to them that the law should be altered or amplified, and to promote the necessary legislation. This certainly seems a possible function of a body which exists to reconcile the differences between law and medicine. Whether Dr. Weatherly’s example is a fitting one for the attention of such a committee is, as he recognised, debatable ; for, as Judge W. G. Earengey pointed out in the discussion, the rule he proposes has been very generally adopted. There is, however, scope for a considerable variety of medicolegal legislation. The society could render valuable assistance, for example, in such matters as the use and regulation of blood-tests in bastardy cases, the treatment of delinquency, and the reform of workmen’s compensation. TUBERCULIN TESTS IN CATTLE
WHILE the tuberculin test in man and in cattle has a fundamental similarity in indicating sensitisation due to tuberculous infection, there are important differences between the two species both in the sphere of usefulness of the test and in the technique of its application. In man the chief use of tuberculin testing lies in the negative reaction : to exclude tuberculous disease in clinically suspect cases, and to identify young adults who are in contact with the disease but have still to acquire a sensitising firstinfection (e.g., nurses and medical students). The positive reaction-except in infants and in adults known recently to have been negative-is of minor use, since it cannot satisfactorily distinguish tuberculous infection which is progressive from that which is quiescent or healed. In cattle, on the other hand, infection and disease are more nearly synonymous, all naturally acquired tuberculous lesions being regarded as a potential source of danger whether accompanied by clinical evidence or not. Since the test in cattle can be made sufficiently sensitive for the positive reaction to detect, and the negative to exclude, tuberculous lesions with considerable accuracy, the two reactions are of equal value and the test has rightly become the sheet anchor in the eradication of bovine tuberculosis from herds. On the technical side the chief differences between herd and human testing are due to the much lower sensitivity of cattle. Although-as for man-the intracutaneous technique is the one generally employed in this country, a double test is widely used to enhance the reaction, the tuberculin being injected in undiluted form-a procedure that might produce severe local necrosis and a febrile response in a highly allergic human being. While this method on the whole gives satisfactory results in the field, a number of difficulties and discrepancies are associated with it. Among them may be mentioned the confusing non-specific reactions that are sometimes produced in the skin of normal animals with certain types of tuberculin, the desensitisation that may occur around
manship of Mr. P. M. Evans who was chairman of the union’s committee. The object of every worker, says the handbook, is to help the blind to lead a normal life, to recognise their limitations in a natural lame man recognises that he cannot run a them to mix with other blind people, but also with the sighted; to teach them to train themselves to do well the many things the blind are able to do well; and above all to help them not to " think of themselves as blind in a blind world." way,
as a
race, to
help
ANGINA PECTORIS AND XANTHOMATOSIS ,
INVESTIGATIONS
by Harbitz
into the
deposition
of
xanthomatous substances in the body have inspired
Norwegian physician, Carl Müller,1 to make further inquiries. Having once begun to associate xanthomatosis (in the form of xanthelasma of the skin and xanthoma tuberosum) with angina pectoris, he was soon impressed by the familial character of this association; indeed including his first case of xanthoma tuberosum and angina pectoris observed in April, 1937, he has collected 79 cases of xanthomatosis, distributed over 17 families, in 69 of which there were signs of heart disease and in 59 angina pectoris. Most of his patients were employed in business or professions, and there was not a single representative of the " working classes," although much of Muller’s practice is among them. The association of the two conditions is explained by saying that xanthomatous deposits are laid down in the coronary arteries and give rise to ischsemia of the myocardium with resultant attacks of angina pectoris. In 5 of Muller’s cases the deposits were held responsible for valvular disease of the heart, but patients may also show xanthomatosis without signs of heart a
disease.
together
The two conditions may, he says, be found at almost any age. THE INSANITY DEFENCE
THE ordinary rules of procedure in criminal as well in civil trials lay down that the evidence for the Crown or the plaintiff shall be heard first, and then the evidence for the defence. Exceptions are made where the judge considers them necessary, but that is the ordinary practice. Dr. L. A. Weatherly, that veteran and never-ageing expert in forensic psychiatry, urged before the Medico-Legal Society on May 25 that a rule of procedure should be introduced laying down that, when insanity is pleaded as a defence to a criminal charge, the expert evidence called by the Crown to rebut that defence should be heard after the expert witnesses for the prisoner have spoken. Such a rule might be made by decision of the Court of Criminal Appeal, by the rule committee of the Supreme Court, or, of course, by Parliament. In support of his argument he recounted-without a single note-five cases in which he had been concerned at various times during this century. In four of them the procedure he proposed had been followed by direction of the judge. In two of them the Crown experts had refused to go into the box, so clearly was the defence of insanity made out ; and in two others they agreed with the defence. In the fifth case the judge insisted on hearing the rebutting evidence first. The Crown expert said he could find no trace of insanity in the prisoner, and Dr. Weatherly, who followed for the defence, was laughed out of court. The prisoner was sentenced to death, but was reprieved and four days later was sent to Broadmoor, hopelessly insane. Shortly afterwards as
1. Nord. Med.
April 22, 1939, p. 1183.
the judge’s own brother, a doctor, became suddenly insane and died in an asylum. The judge sent for Dr. Weatherly and confessed that the insanity defence had always been to him like a red rag to a bull, but he now realised that he had sentenced many insane persons to death, and had been quite wrong in that particular case in allowing the medical witness for the Crown to go into the box before the evidence for the insanity defence had been heard. Dr. Weatherly’s point is that this arrangement should not be left to the discretion of the judge; and arising from that point he made another-namely, that the Medico-Legal Society should appoint a standing committee on legislation, to investigate cases in which it appears to them that the law should be altered or amplified, and to promote the necessary legislation. This certainly seems a possible function of a body which exists to reconcile the differences between law and medicine. Whether Dr. Weatherly’s example is a fitting one for the attention of such a committee is, as he recognised, debatable ; for, as Judge W. G. Earengey pointed out in the discussion, the rule he proposes has been very generally adopted. There is, however, scope for a considerable variety of medicolegal legislation. The society could render valuable assistance, for example, in such matters as the use and regulation of blood-tests in bastardy cases, the treatment of delinquency, and the reform of workmen’s compensation. TUBERCULIN TESTS IN CATTLE
WHILE the tuberculin test in man and in cattle has a fundamental similarity in indicating sensitisation due to tuberculous infection, there are important differences between the two species both in the sphere of usefulness of the test and in the technique of its application. In man the chief use of tuberculin testing lies in the negative reaction : to exclude tuberculous disease in clinically suspect cases, and to identify young adults who are in contact with the disease but have still to acquire a sensitising firstinfection (e.g., nurses and medical students). The positive reaction-except in infants and in adults known recently to have been negative-is of minor use, since it cannot satisfactorily distinguish tuberculous infection which is progressive from that which is quiescent or healed. In cattle, on the other hand, infection and disease are more nearly synonymous, all naturally acquired tuberculous lesions being regarded as a potential source of danger whether accompanied by clinical evidence or not. Since the test in cattle can be made sufficiently sensitive for the positive reaction to detect, and the negative to exclude, tuberculous lesions with considerable accuracy, the two reactions are of equal value and the test has rightly become the sheet anchor in the eradication of bovine tuberculosis from herds. On the technical side the chief differences between herd and human testing are due to the much lower sensitivity of cattle. Although-as for man-the intracutaneous technique is the one generally employed in this country, a double test is widely used to enhance the reaction, the tuberculin being injected in undiluted form-a procedure that might produce severe local necrosis and a febrile response in a highly allergic human being. While this method on the whole gives satisfactory results in the field, a number of difficulties and discrepancies are associated with it. Among them may be mentioned the confusing non-specific reactions that are sometimes produced in the skin of normal animals with certain types of tuberculin, the desensitisation that may occur around