MEDICAL DEFENCE.

524 reaches its maximum size during the third year of life,. and shows signs of degeneration which rapidly progresses after the age of ten." In the same way in certain families the vital force on which the life of " Ne quid nimis." the crystalline lens depends may be deficient, and so with the ocular muscles, the optic nerve, retina, choroid, or cornea. Metchnikoff would have us believe MEDICAL DEFENCE. that the symptoms we speak of as senile degeneration WE print this week in our correspondence columns are all the outcome of auto-intoxication. Collins a letter from six distinguished surgeons and pracbelieves that it is as unreasonable to attribute all titioners who charged themselves voluntarily with variations , in the time of degeneration of tissues to putting right a miscarriage of justice which befell a toxic influences as it would be to account for all colleague. The action for negligence brought against variations in the time of development of tissues to Dr. H. Wood-Hill, of Beccles, at the Suffolk County such influences. Just as we sometimes meet with Assizes in November last was reported in THE LANCET Ii precociousness in development, so sometimes we meet at the time and the main facts are recapitulated in the with precociousness in degeneration. letter signed by Sir Robert Jones and others. The Asexamples of these hereditary ocular affections, aspect of the assize judgment, is pointed out a large number of pedigrees of post-natal cataractz serious in this letter. Heretofore a medical practitioner, were recorded by the late Edward Nettleship. using the ordinary care and skill which might rightly Collins records a family of seven-two males and five be expected of him, has felt some confidence that he females-all of whom were operated on for cataract would run little risk of an adverse verdict in an action at ages from 42 to 58. Their father and two paternal for alleged negligence. That is no longer so, and the uncles were also operated on for cataract. In a moral is that no medical man in practice can wisely family such as this it seems necessary to assume trust entirely to his sense of conscious rectitude. He some inherent defect in the vitality of the lens fibres must join with a group of other practitioners similarly which results in their degeneration. Similarly in the situated in order to avoid such a fate as overtook Dr. case of non-syphilitic hereditary ocular palsies the Wood-Hill. He exercised all the skill at his disposal, phenomenon is interpreted as an abiotrophy, either he adopted modern methods of treatment, and yet he of the cells of the nerve nuclei, or of the musole fibres incurred an adverse verdict when the case finally did themselves. Retinitis pigmentosa is similarly internot do well after it had passed out of his hands. There preted as an abiotrophy of the neuro-epithelium was, of course, some divergence of opinion among the which constitutes the retina. In hereditary disease experts called to give evidence at the assizes-it is a of the macula the degeneration affects the macular privilege of experts to find a region where they can region alone, and the difference in appearance between differ-but the overwhelming consensus of opinion that and retinitis pigmentosa is accounted for by the that Dr. Wood-Hill was hardly treated is evident fact that in the latter the retinal pigment migrates from the result of the appeal which brought in a net into the lymphatic sheaths surrounding the retinal total of oB1730 subscribed by his professional col- vessels and so assumes a bone-corpuscle shape, leagues in all parts of the world. The sum is still whereas in the former, there being an absence of unfortunately oB500 short of the total costs of the blood-vessels at the macula, the pigment appears action and of the damages awarded. The special merely as round dots. In the case of amaurotic virtue of participating in a medical defence scheme is family idiocy the degeneration affects the ganglion that in nine cases out of ten the action is withdrawn cells, and the appearances are different again. In the at an early stage before enormous costs accrue. Zest case of Leber’s optic atrophy there has been much for fight with imperfect weapons deserts the com- speculation as to the pathological condition. and batant and his legal advisers when faced with a well- especially as to whether it is connected with disease of the pituitary body, but in default of post-mortem equipped unit such as a " defence union." evidence this is one of the problems that remains unsolved. It will probably be found that the failure HEREDITARY OCULAR DEGENERATIONS. of the optic nerves to maintain their vitality is IN a paper read at the recent International (Jongress inherent and comparable with the failure of other of Ophthalmology held at Washington,’ Mr. Treacher parts of the nervous system which we get in Collins dealt with the causation of hereditary oculai Friedreich’s disease. A similar explanation would The conditions included in the term account for those hereditary affections of the choroid degenerations. " " of the cornea which have already been mentioned. degenerations comprise post-natal (as distinguished and from congenital) cataracts, ocular palsies, including but which have not yet been observed for a sufficient time for any definite conclusions to be drawn as to ptosis and various forms of ophthalmoplegia, retinitis their causation. about and affections the some other pigmentosa, pathology of which little is as yet known-Leber’s THE PREVENTION OF DIPHTHERIA. optic atrophy, and certain degenerative conditions A MEMORANDUM and macular thethe recently issued by the Ministry of affecting cornea, the choroid, region of the retina. All these diseases are hereditary Health calls attention, in view of the persistent high in some families, and in all of them there exists incidence and mortality of diphtheria, to the supply degeneration in certain groups of cells-cells which, and administration of diphtheria antitoxin, to the having reached a full degree of development and use of the Schick test, and to methods of active functional efficiency, have then undergone degenera- immunisation against the disease. Reference is tion. The occurrence of the same degeneration in made to the Diphtheria Antitoxin Orders issued by several successive generations of the same family the Local Government Board in 1910, by which local precludes the absorption of any exogenous toxic authorities were empowered to supply serum to substance or the absence of any exogenous essential medical practitioners, and were required to keep and nutritional material such as a vitamin as a cause. distribute supplies on the advice of their medical As far as we know there is no endocrinal secretion officers of health. The necessity of early administrawhich either by excess or defect is capable of pro- tion of antitoxin is strongly emphasised, on the ducing these hereditary affections. We are bound grounds that it reduces mortality from diphtheria., to fall back, says Mr. Collins, on the theory of a shortens the course of the disease and decreases its want of vital force in the structures involved, or severity, and lessens infectivity, thereby minimising what Sir William Gowers termed " abiotrophy." pressure on bed-space in isolation hospitals. So soon " Physiologically, in the human body, the vital force as diphtheria is diagnosed on clinical evidence, the fails sooner in some tissues than others-e.g., the practitioner should either give antitoxin without thymus gland is highly developed during foetal life, waiting for bacteriological confirmation, or have the-

Annotations.

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1 American Journal of Ophthalmology, July, 1922.

2

Bowman Lecture, 1909, Trans. Ophthal. Soc., vol. xxix.