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GUARDIANS AND THEIR MEDICAL OFFICERS.
1093
trotting at ten miles per hour, but the motorist confronted by a sudden obstacle 20 yards in front of him will have two seconds wherein to do what is needed and the driver of the horse in a like case will have four. In this we assume that the object to be avoided is inanimate or can do nothing to compass its own safety. If, however, it is alive and is endowed with a certain amount of intelli- ’, ’ gence, whether it be a dog, a child, an adult foot-passenger, or the driver of another vehicle, the horse will give it twice as much time as the motor-car wherein to make up its mind and to put its resolution into force. If we revert to Lord Russell’s figures the case against the motor-car is stronger still and in every fifth part of a second during which his chauffeur fails to observe or hesitates to act his car will shorten by three yards the distance between it and the point of danger. In estimating, moreover, the causes of the motor-car’s unpopularity we must remember that most people, if it were their fate to be run down and if they could have their choice of evils, would prefer the horsed vehicle to the motor-car, even apart from their respective speeds of 30 miles per hour and eight. Whether the speed of motor-cars is exaggerated or not can be estimated very fairly by anyone who owns a watch with a second hand. He has only to stand still watch in hand when he sees a car coming at all rapidly towards him, keep his eyes on his watch as it goes by, and note the spot which it has reached ten or 20 seconds after it has passed him. If he then paces in the same direction 100 or 200 yards, according to the period he has selected, he will possibly not have made as scientifically exact an observation as motorists seem to desire in the witnesses against them, but he may also have formed the opinion that no such high pitch of accuracy is necessary. He need not make his experiments in unfrequented main roads. He will find food for them in urban and suburban thoroughfares where the sudden excursion of a child into the roadway or the approach of a second vehicle at a blind corner is an incident that may occur at any moment. ____
STUDIES FROM THE DEPARTMENT OF NEUROLOGY OF CORNELL UNIVERSITY. THE custom of publishing annual or periodical records of scientific work carried out in the pathological laboratories attached to universities in the United States of America has been a noteworthy and increasing feature in American medical literature during the last few years. The Department of Neurology of the Cornell University, which is under the direction of Professor Charles Dana, has issued its first It includes clinical and pathovolume of "Studies." researches completed in the department during the logical of which is published in the present much year 1904, volume for the first time. Among the contributors we note he names of Professor Dana, Dr. Ramsay Hunt, Dr. Joseph Fraenkel, and other well-known workers in neurology. The range of subjects treated is wide and the matters dealt with are important clinically, pathologically, and therapeutically. Several of the papers are contributed by Professor Dana himself, and amongst those are four which deal respectively with special exercises for tabes dorsalis, the formal"" treatment of epilepsy, special exercises for aphasia, and special exercises for Parkinson’s disease. Experience after a good many years, says Professor Dana, sometimes brings us to definite methods of treating certain diseases. Thus in acute rheumatism there is a rather uniform agreement as to diet, local application, and internal medication. The methods of treatment in tabes dorsalis, migraine, and chorea are fairly well fixed and the special objects to be obtained may be said to be established. ’’ When such a stage in therapeutics is reached we possess what I would call a‘formal’ or conventional method, this being the plan arrived at after long experience by many competent observers and producing very
uniform results." It is now agreed that the best treatment of the average epileptic is that furnished by a farm colony life. Thus under the headings of Regulation of Daily Life, Exercise and Bathing, Diet, Removal of Reflex Causes, and Medication Professor Dana details his scheme of the formal treatment of epilepsy. Exercises for tabes are to be taken, he says, twice a day. Ten different series of gymnastic movements of graduated difficulty are prescribed for the hands and arms and twelve for the lower limbs and body. When these are mastered, supplementary exercises are added for improving co-ordination and skill of movements of the hands and fingers. The systems of exercise for Parkinson’s disease and for aphasia as described in the book are practical and have proved of benefit in Professor Dana’s practice. "The trouble in aphasia is not paralysis of the organs of articulation," he says, "but a lesion destroying the centres for the memory and ideas of language; hence the education should be one of memory rather than of muscular training of the articulatory organs. The exercises should therefore be such as will tend to stimulate and to revive these memories through every possible agency." The patient will often have to practise his exercises constantly for two or three years and the progress at first will be very slow. The exercises consist of repeating exclamatory words, monosyllabic words, letters of the alphabet and figures, after which attempts to read daily a paragraph or part of a page should be attempted. Copy-books should be filled up for practice in handwriting daily. The patient should allow himself to be read to for a short time twice a day and he should also try himself to read a quarter of a page every day. Many other papers of interest are included in the present work. Dr. Ramsay Hunt treats of tumour of the frontal lobe of the brain, tuberculosis and tuberculous myelitis, neuro-fibromatosis, and the pathology of paramyoclonus multiplex or Friedreich’s disease. The modern subject of cytodiagnosis in nervous disease is treated conjointly by Professor Dana and Dr. F. W. Hastings. Though yet in its infancy this method has already given valuable results in diagnosis and the operation of withdrawal of cerebro-spinal fluid by the method of lumbar puncture, although liable to give rise to disagreeable aftereffects in the form of headache, is unattended with serious symptoms or sequelae. In a paper dealing with the cerebrospinal fluid Dr. Fraenkel discusses the special subject of lymphocytosis. A more or less marked increase of leucocytes was found to occur in tabes dorsalis, in general paralysis of the insane, in syphilis of the central nervous system, and in multiple sclerosis, the total number of cases investigated by Dr. Fraenkel being 47. From a purely chemical standpoint as well as from the morphological, he says, much yet remains to be investigated in regard to the cerebro-spinal fluid. The first volume of "Studies" of the Department of Neurology of Cornell University is a credit to Professor Dana and his colleagues and must add to the advancement of neurological science in America.
GUARDIANS AND THEIR MEDICAL OFFICERS. IT is, unfortunately, often our lot to have to point out the devious ways which boards of guardians follow in their dealings with medical officers and we return to the charge with some faint hope that we may eventually see signs of improvement in this respect. Our attention has been directed by a correspondent to two of the conditions said to be laid down by the guardians of the St. George’s (Hanover-square) Union in regard to the appointment of a medical superintendent for their infirmary. These conditions, which are to be subscribed to by intending applicants, are, as stated by our correspondent, as follows: 1. He will be required to attend without extra fee any of the indoor
1094 staff at the infirmary, workhouse, and children’s home who maybe sick and report thereon to the guardians if required. (The italics are ours.) 2. For every alleged lunatic examined by order of a justice of the peace the officer shall accept a fee not exceeding 10s. 6d. per case. It will be seen that two important issues are here raised-(a) the right of guardians to compel a medical man in their employ to divulge information which he has obtained in his professional capacity ; and (b) the power of control which guardians can exercise over a magistrate in his administraOur English law relating to tion of the lunacy laws. laid down so explicitly as in is not professional secrecy for and its France, example, exposition here would occupy far too much of our space but it appears to us that any applicant for the post under the St. George’s board who signs such an undertaking as is given above will, if he observes it, lay himself open to legal proceedings of an embarrassing character. As to the second condition we may point out, as we have several times done before, that Section 285 of the Lunacy Act of 1890, which deals with the fees payable to medical men for the examination of alleged lunatics, gives to boards of guardians no right whatever to dictate to a justice what is to be regarded as a suitable fee for certifying cases. The stipulation appears to us to be an improper one and it can only be rendered effective by bringing the cases before a magistrate who will forfeit his freedom of action in deference to the wishes of the board. We presume that if the magistrate makes an order for the payment of a guinea, as has been, we believe, the practice at St. George’s and elsewhere, the officer appointed will have to hand over half the amount to the board’s exchequer. If, on the other hand, the justice should for any reason direct a smaller sum than half a guinea to be paid the guardians would have no power, even if they had the will, to increase the amount to that sum. As between the guardians and their medical officer the case is therefore one of " heads we win, tails you lose," and we trust that this aspect of the matter will be appreciated by any
intending applicants.
survived for only one hour. At 9.30 the placenta was expelled after moderate pressure on the uterus. During the labour, and especially after the expulsion of the placenta, there was considerable hoemorrhage. The puerperium was practically normal. The children were of the development of six months and their weights ranged from 500 to 750 grammes. There was a single oval placenta measuring 18-5 by 25 centimetres and weighing 890 grammes. The uterine surface presented no more than the usual lobules. The five cords were inserted into distinct amniotic sacs. Three foetuses were in one chorion and the remaining two were in separate choria. As the cords varied in thickness, shape, and arrangement of vessels it was not difficult to connect each foetus with its own cord: The three sacs inclosed in a common chorion corresponded to the first, second, and fifth foetuses. Thus these arose from one ovum and the other two from separate ova. It is of interest that the three foetuses which arose from one ovum were of the same sex, while those that arose from separate This would seem to support the ova were of different sexes. view that the sex is predetermined in the ovum before fecundation, i.e., that there are male and female ova. Uniovular twins are always of the same sex. Therefore the quintuplets arose from three ova. In the woman’s family several cases of multiple pregnancy had occurred. Her mother once had twins. Two uncles were the fathers of twins and an aunt was delivered of triplets. Professor Nijhoff refers to another Dutch case of quintuplets which occurred in 1719 and he has collected 27 cases from obstetrical literature between the years 1694 and 1900. The case recorded above may be instructively compared with one of quadruplets reported last week in our columns.l The foetuses appeared to be of six and a half months development. Unlike the present case, each had a separate chorion and had therefore developed from one ovum. -
A CENTRAL HOSPITAL BOARD FOR BRIGHTON.
an influential meeting recently held in Brighton it resolved to unite for administrative purposes under a A CASE OF QUINTUPLETS. central board the various local hospitals-namely, those of THE birth of quintuplets is one of the curiosities of Brighton and Hove and the Sussex County Hospital. There medical literature. In the t7bM?’?M of Obstetrics and Gynae- are seven such institutions in the district. Some are special cology of the British Empire Professor G. C. Nijhoff of hospitals and some are not but the lines of demarcation Groningen (Netherlands) has recorded the following case in between their several spheres of activity are not precisely The account of the drawn and there is in consequence a good deal of overwhich he examined the placenta. It has been felt for some time past that labour is furnished by Dr. de Blecourt who attended the lapping. an was a robust woman, endeavour should be made to classify and to disThe mother woman in confinement. aged 34 years, and had been married for eight years. She had tribute the work which falls to them so as to reAfter been delivered seven years before at term of a boy. The last duce expenditure while increasing efficiency. At the conference of several and months of careful investigation beginning period terminated on Jan. 20th, 1903. May there was a discharge of a small quantity of yellow not limited to those immediately interested the Mayor of fluid, at times tinged with blood. This ceased but returned Brighton and his helpers have been able to set before the in the beginning of July. Quickening was first felt early public meeting already referred to a basis for united action. in June. On July 10th severe pains recurring every three The result is the adoption in principle of the central board. minutes began at 8 A.M. At the height of the pains It is not intended that this body shall concern itself with the bag of membranes was visible at the vulva. The the internal management of any hospital. It will act fundus uteri was a hand’s breadth above the umbilicus. rather as an advisory committee and its expressed objects Foetal heart sounds were heard on both sides and in the are : (1) to obviate overlapping of local medical middle of the abdomen. Vaginal examination showed the charities ; (2) to promote economy of administration, paros completely distended and a small foetal head in the first ticularly in connexion with capital outlay on buildings; At soon after the of the 8.30, membranes, and (3) to prevent the abuse of medical charities by persons position. rupture an immature but living female child was born. Ten minutes who are not proper objects of charitable assistance. As later a second female in footling presentation followed. At bearing upon the advantages to be expected from such an 9 a male was born in vertex presentation and was soon arrangement as the above the following facts are instructive. followed by a female in footling presentation. Dr. de At the beginning of the year the Women’s Hospital issued Blecourt was then surprised to find a fifth child concealed in an appeal for a sum of .620,000 to build a new gynascologicat a corner of the uterus and presenting transversely. Some department. After some deliberation with the local authominutes later a female was born in footling presentation. rities and others it was decided to convert the wards. Before the birth of the fourth and fifth children no bag of 1 THE LANCET, Oct. 8th, waters was observed. The five children were all alive but p. 1020. -
AT
was
’
trotting at ten miles per hour, but the motorist confronted by a sudden obstacle 20 yards in front of him will have two seconds wherein to do what is needed and the driver of the horse in a like case will have four. In this we assume that the object to be avoided is inanimate or can do nothing to compass its own safety. If, however, it is alive and is endowed with a certain amount of intelli- ’, ’ gence, whether it be a dog, a child, an adult foot-passenger, or the driver of another vehicle, the horse will give it twice as much time as the motor-car wherein to make up its mind and to put its resolution into force. If we revert to Lord Russell’s figures the case against the motor-car is stronger still and in every fifth part of a second during which his chauffeur fails to observe or hesitates to act his car will shorten by three yards the distance between it and the point of danger. In estimating, moreover, the causes of the motor-car’s unpopularity we must remember that most people, if it were their fate to be run down and if they could have their choice of evils, would prefer the horsed vehicle to the motor-car, even apart from their respective speeds of 30 miles per hour and eight. Whether the speed of motor-cars is exaggerated or not can be estimated very fairly by anyone who owns a watch with a second hand. He has only to stand still watch in hand when he sees a car coming at all rapidly towards him, keep his eyes on his watch as it goes by, and note the spot which it has reached ten or 20 seconds after it has passed him. If he then paces in the same direction 100 or 200 yards, according to the period he has selected, he will possibly not have made as scientifically exact an observation as motorists seem to desire in the witnesses against them, but he may also have formed the opinion that no such high pitch of accuracy is necessary. He need not make his experiments in unfrequented main roads. He will find food for them in urban and suburban thoroughfares where the sudden excursion of a child into the roadway or the approach of a second vehicle at a blind corner is an incident that may occur at any moment. ____
STUDIES FROM THE DEPARTMENT OF NEUROLOGY OF CORNELL UNIVERSITY. THE custom of publishing annual or periodical records of scientific work carried out in the pathological laboratories attached to universities in the United States of America has been a noteworthy and increasing feature in American medical literature during the last few years. The Department of Neurology of the Cornell University, which is under the direction of Professor Charles Dana, has issued its first It includes clinical and pathovolume of "Studies." researches completed in the department during the logical of which is published in the present much year 1904, volume for the first time. Among the contributors we note he names of Professor Dana, Dr. Ramsay Hunt, Dr. Joseph Fraenkel, and other well-known workers in neurology. The range of subjects treated is wide and the matters dealt with are important clinically, pathologically, and therapeutically. Several of the papers are contributed by Professor Dana himself, and amongst those are four which deal respectively with special exercises for tabes dorsalis, the formal"" treatment of epilepsy, special exercises for aphasia, and special exercises for Parkinson’s disease. Experience after a good many years, says Professor Dana, sometimes brings us to definite methods of treating certain diseases. Thus in acute rheumatism there is a rather uniform agreement as to diet, local application, and internal medication. The methods of treatment in tabes dorsalis, migraine, and chorea are fairly well fixed and the special objects to be obtained may be said to be established. ’’ When such a stage in therapeutics is reached we possess what I would call a‘formal’ or conventional method, this being the plan arrived at after long experience by many competent observers and producing very
uniform results." It is now agreed that the best treatment of the average epileptic is that furnished by a farm colony life. Thus under the headings of Regulation of Daily Life, Exercise and Bathing, Diet, Removal of Reflex Causes, and Medication Professor Dana details his scheme of the formal treatment of epilepsy. Exercises for tabes are to be taken, he says, twice a day. Ten different series of gymnastic movements of graduated difficulty are prescribed for the hands and arms and twelve for the lower limbs and body. When these are mastered, supplementary exercises are added for improving co-ordination and skill of movements of the hands and fingers. The systems of exercise for Parkinson’s disease and for aphasia as described in the book are practical and have proved of benefit in Professor Dana’s practice. "The trouble in aphasia is not paralysis of the organs of articulation," he says, "but a lesion destroying the centres for the memory and ideas of language; hence the education should be one of memory rather than of muscular training of the articulatory organs. The exercises should therefore be such as will tend to stimulate and to revive these memories through every possible agency." The patient will often have to practise his exercises constantly for two or three years and the progress at first will be very slow. The exercises consist of repeating exclamatory words, monosyllabic words, letters of the alphabet and figures, after which attempts to read daily a paragraph or part of a page should be attempted. Copy-books should be filled up for practice in handwriting daily. The patient should allow himself to be read to for a short time twice a day and he should also try himself to read a quarter of a page every day. Many other papers of interest are included in the present work. Dr. Ramsay Hunt treats of tumour of the frontal lobe of the brain, tuberculosis and tuberculous myelitis, neuro-fibromatosis, and the pathology of paramyoclonus multiplex or Friedreich’s disease. The modern subject of cytodiagnosis in nervous disease is treated conjointly by Professor Dana and Dr. F. W. Hastings. Though yet in its infancy this method has already given valuable results in diagnosis and the operation of withdrawal of cerebro-spinal fluid by the method of lumbar puncture, although liable to give rise to disagreeable aftereffects in the form of headache, is unattended with serious symptoms or sequelae. In a paper dealing with the cerebrospinal fluid Dr. Fraenkel discusses the special subject of lymphocytosis. A more or less marked increase of leucocytes was found to occur in tabes dorsalis, in general paralysis of the insane, in syphilis of the central nervous system, and in multiple sclerosis, the total number of cases investigated by Dr. Fraenkel being 47. From a purely chemical standpoint as well as from the morphological, he says, much yet remains to be investigated in regard to the cerebro-spinal fluid. The first volume of "Studies" of the Department of Neurology of Cornell University is a credit to Professor Dana and his colleagues and must add to the advancement of neurological science in America.
GUARDIANS AND THEIR MEDICAL OFFICERS. IT is, unfortunately, often our lot to have to point out the devious ways which boards of guardians follow in their dealings with medical officers and we return to the charge with some faint hope that we may eventually see signs of improvement in this respect. Our attention has been directed by a correspondent to two of the conditions said to be laid down by the guardians of the St. George’s (Hanover-square) Union in regard to the appointment of a medical superintendent for their infirmary. These conditions, which are to be subscribed to by intending applicants, are, as stated by our correspondent, as follows: 1. He will be required to attend without extra fee any of the indoor
1094 staff at the infirmary, workhouse, and children’s home who maybe sick and report thereon to the guardians if required. (The italics are ours.) 2. For every alleged lunatic examined by order of a justice of the peace the officer shall accept a fee not exceeding 10s. 6d. per case. It will be seen that two important issues are here raised-(a) the right of guardians to compel a medical man in their employ to divulge information which he has obtained in his professional capacity ; and (b) the power of control which guardians can exercise over a magistrate in his administraOur English law relating to tion of the lunacy laws. laid down so explicitly as in is not professional secrecy for and its France, example, exposition here would occupy far too much of our space but it appears to us that any applicant for the post under the St. George’s board who signs such an undertaking as is given above will, if he observes it, lay himself open to legal proceedings of an embarrassing character. As to the second condition we may point out, as we have several times done before, that Section 285 of the Lunacy Act of 1890, which deals with the fees payable to medical men for the examination of alleged lunatics, gives to boards of guardians no right whatever to dictate to a justice what is to be regarded as a suitable fee for certifying cases. The stipulation appears to us to be an improper one and it can only be rendered effective by bringing the cases before a magistrate who will forfeit his freedom of action in deference to the wishes of the board. We presume that if the magistrate makes an order for the payment of a guinea, as has been, we believe, the practice at St. George’s and elsewhere, the officer appointed will have to hand over half the amount to the board’s exchequer. If, on the other hand, the justice should for any reason direct a smaller sum than half a guinea to be paid the guardians would have no power, even if they had the will, to increase the amount to that sum. As between the guardians and their medical officer the case is therefore one of " heads we win, tails you lose," and we trust that this aspect of the matter will be appreciated by any
intending applicants.
survived for only one hour. At 9.30 the placenta was expelled after moderate pressure on the uterus. During the labour, and especially after the expulsion of the placenta, there was considerable hoemorrhage. The puerperium was practically normal. The children were of the development of six months and their weights ranged from 500 to 750 grammes. There was a single oval placenta measuring 18-5 by 25 centimetres and weighing 890 grammes. The uterine surface presented no more than the usual lobules. The five cords were inserted into distinct amniotic sacs. Three foetuses were in one chorion and the remaining two were in separate choria. As the cords varied in thickness, shape, and arrangement of vessels it was not difficult to connect each foetus with its own cord: The three sacs inclosed in a common chorion corresponded to the first, second, and fifth foetuses. Thus these arose from one ovum and the other two from separate ova. It is of interest that the three foetuses which arose from one ovum were of the same sex, while those that arose from separate This would seem to support the ova were of different sexes. view that the sex is predetermined in the ovum before fecundation, i.e., that there are male and female ova. Uniovular twins are always of the same sex. Therefore the quintuplets arose from three ova. In the woman’s family several cases of multiple pregnancy had occurred. Her mother once had twins. Two uncles were the fathers of twins and an aunt was delivered of triplets. Professor Nijhoff refers to another Dutch case of quintuplets which occurred in 1719 and he has collected 27 cases from obstetrical literature between the years 1694 and 1900. The case recorded above may be instructively compared with one of quadruplets reported last week in our columns.l The foetuses appeared to be of six and a half months development. Unlike the present case, each had a separate chorion and had therefore developed from one ovum. -
A CENTRAL HOSPITAL BOARD FOR BRIGHTON.
an influential meeting recently held in Brighton it resolved to unite for administrative purposes under a A CASE OF QUINTUPLETS. central board the various local hospitals-namely, those of THE birth of quintuplets is one of the curiosities of Brighton and Hove and the Sussex County Hospital. There medical literature. In the t7bM?’?M of Obstetrics and Gynae- are seven such institutions in the district. Some are special cology of the British Empire Professor G. C. Nijhoff of hospitals and some are not but the lines of demarcation Groningen (Netherlands) has recorded the following case in between their several spheres of activity are not precisely The account of the drawn and there is in consequence a good deal of overwhich he examined the placenta. It has been felt for some time past that labour is furnished by Dr. de Blecourt who attended the lapping. an was a robust woman, endeavour should be made to classify and to disThe mother woman in confinement. aged 34 years, and had been married for eight years. She had tribute the work which falls to them so as to reAfter been delivered seven years before at term of a boy. The last duce expenditure while increasing efficiency. At the conference of several and months of careful investigation beginning period terminated on Jan. 20th, 1903. May there was a discharge of a small quantity of yellow not limited to those immediately interested the Mayor of fluid, at times tinged with blood. This ceased but returned Brighton and his helpers have been able to set before the in the beginning of July. Quickening was first felt early public meeting already referred to a basis for united action. in June. On July 10th severe pains recurring every three The result is the adoption in principle of the central board. minutes began at 8 A.M. At the height of the pains It is not intended that this body shall concern itself with the bag of membranes was visible at the vulva. The the internal management of any hospital. It will act fundus uteri was a hand’s breadth above the umbilicus. rather as an advisory committee and its expressed objects Foetal heart sounds were heard on both sides and in the are : (1) to obviate overlapping of local medical middle of the abdomen. Vaginal examination showed the charities ; (2) to promote economy of administration, paros completely distended and a small foetal head in the first ticularly in connexion with capital outlay on buildings; At soon after the of the 8.30, membranes, and (3) to prevent the abuse of medical charities by persons position. rupture an immature but living female child was born. Ten minutes who are not proper objects of charitable assistance. As later a second female in footling presentation followed. At bearing upon the advantages to be expected from such an 9 a male was born in vertex presentation and was soon arrangement as the above the following facts are instructive. followed by a female in footling presentation. Dr. de At the beginning of the year the Women’s Hospital issued Blecourt was then surprised to find a fifth child concealed in an appeal for a sum of .620,000 to build a new gynascologicat a corner of the uterus and presenting transversely. Some department. After some deliberation with the local authominutes later a female was born in footling presentation. rities and others it was decided to convert the wards. Before the birth of the fourth and fifth children no bag of 1 THE LANCET, Oct. 8th, waters was observed. The five children were all alive but p. 1020. -
AT
was
’