" EVERY MAN HIS OWN DOCTOR."

AN APOLOGY FOR THE OUT-PATIENT DEPARTMENT. from the clinical records given, cases of multiple neuritis. Dr. WOOD of Philadelphia has recently drawn attention to another affection, the symptoms of which almost exactly simulate those of locomotor ataxy. In the first case he observed there had never been a doubt about the diagnosis till the necropsy was made, when the characteristic lesions of tabes were absent, but there was an infiltration, evidently of a syphilitic character, along the posterior part of the spinal dura mater, involving the posterior nerve roots. As 110 often happens, it was not long before an exactly parallel case came under observation, and, profiting by his recent pathological experience, Dr. WOOD treated his second case actively with antisyphilitic remedies, and a cure was the result. It is quite possible that some of the cases which improved so remarkably with suspension plus iodide of potassium may have been of this nature. It is probable that such an infiltration along the posterior nerve roots may bethecause of the permanently ataxic gait, which is occasionally seen in patients after recovery from paraplegia dependent on Pott’s disease of the spinal column, and one cannot avoid a suspicion that the case which suggested the treatment to MOTCHOUTKOWSKY may have been of this nature. The patient is said to have been suffering from spinal curvature and ataxy, and after only one suspension in SAYRE’s tripod and the application of a plasterjacket, his pains were xelieved and the ataxy practically cured. In other patients MOTCHOUTKOWSKY found no improvement from wearing a jacket, but a number improved while undergoing a course of suspension. Time has not been more kind to this mode of treatment than to many others which have been introduced to remedy intractable diseases, and carried out at first with singular enthusiasm and apparently good results, but which later on have disappointed the hopes they have raised and gradually fallen into disuse. Before long we expect that the suspension apparatus will be relegated to obscurity, alongwith PERKIN’S metallic tractors of a past generation, and BERJEON’S apparatus for the rectal injection of sulphuretted hydrogen for the cure of phthisis in recent times.

Annotations. 11 Ne quid nimis."

AN APOLOGY FOR THE OUT-PATIENT DEPARTMENT.

289

opportunity to the physician and the students of seeing, handling, and becoming familiar with disease in all its forms, and in its earlier stages. Sir Andrew Clark insisted, too, on the importance of the out-patient department for educational purposes. He used to work four or five hours in the out-patient department without difficulty, and now such work was much facilitated by each out-patient physician having a qualified clinical assistant and other helps. The educational value of the out-patient department is the chief argument with which its critics are confronted. But it is not so formidable as it looks at first sight. If the out-patient department were abolished to-morrow, the opportunities of seeing disease on a large scale would not be altogether abolished. The student might, by attending or putting himself into the position of a a to pupil general practitioner, see ordinary diseases in all their stages, and with a certain continuousness which is not secured in out-patient practice. But it is not proposed to abolish the out-patient system altogether, but only to greatly curtail its proportions. It would still remain ; but the cases would be much fewer and would receive an increased amount of attention, and the educational value would be correspondingly greater. The great blot of the present system is that it demoralises the patients by making them recipients of medical charity for ordinary ailments, and at the same time injures the general practitioner. It is difficult for a man in Sir Andrew Clark’s position to realise how dark this blot appears to men who lay themselves out for practice among the humbler classes, whose lives are most laborious, and whose remuneration is at all times disproportionate to their toil. We hold that every working man, especially one with a wife and family, should have a medical attendant retained on some understanding, available at all times, by night and day, and to whom he can look as confidently for help as a richer man does to his private medical adviser. Medical education can be carried out without sapping the independence and the self-respect of the working-classes; and the great arguments for hospitals, so lucidly set forth last year by Sir Andrew Clark, would remain if these out-patient abuses were remedied. With his views of special hospitals and his

dispensaries,

objections

thereto

we

heartily

concur.

" EVERY MAN HIS OWN DOCTOR." SELF-TREATMENT is no new practice. We cannot doubt that it has been employed for the cure of disease in all ages. It did good when perchance it hit the mark ; it haply did no harm when it merely missed what were better let alone. Evil it has done, and is daily doing, and this to no trifling extent. We need not quote illustrations. The records of coroners’ courts afford many such. Little favour, therefore, can be claimed by those who seek, by means of popular handbooks, to instruct the casual reader in details which bear not only on the preservation of health, but on the

WHATEVER Sir Andrew Clark does he does thoroughly, recognition and the treatment of disease. This is no mere and it is this thoroughness that gives his opinion great matter of household hygiene. If it implied no more than weight with the public. It is so with his defence of the such necessary teaching its useful purpose and its advantages hospital system. His speech last year at the Mansion could not be gainsaid; but it aims at further and more House was probably the most effective that has yet been perilous chances. The accurate management of one’s own pronounced in this great cause, though it has been well case in sickness may be said to demand even more followed by Mr. Hutchinson’s speech on a similar occasion than skilled medical opinion. It requires that such this year. Sir Andrew Clark, in his defence of hospitals, opinion should be used objectively. We admit that mcluded the out-patient department, and minified the abuses this fact is not duly recognised even by all medical with which it is generally charged. In his recent evidence practitioners, and its force undoubtedly is in their case not before the Lords’ Committee he repeated with the same so great as in that of less instructed persons. Cool and heartiness his defence of the out-patient department, and shrewd self- observation, combined with exact professional has given it as his opinion that the shutting-up of this knowledge, will go as far as anything can to justify subdepartment of a general hospital would be the greatest jective therapeutics. Yet even medical men have repeatedly calamity that could happen to the public, and most dis- paid the death penalty for incautious reliance on such partial astrous to the art of medicine. The advantages it secures, experience. They have, in spite of ample skill, misunderin his view, are that the very profusion of cases gives the stood and sacrificed themselves. The obvious lesson afforded

290 to be insisted on. The lay- heart of the embryo executes rhythmical contractions long man’s case is different, and the difference is not in his favour. before it possesses nerves or ganglia, and he is confirmed in His attempt excels in its temerity, for the safeguard of his statements by the researches of Wooldridge. Concerning medical training which alone can even seem to justify self- the function of the cardiac ganglia themselves, Romberg treatment is absent. The prospect of success is in most and His say little. They suggest that they possibly may Let him therefore be content to transmit impulses to the central nervous system, which cases immeasurably less. seek self-preservation by following a rational rule of daily govern by reflex action the movements of the heart through life, without essaying further and hazardous efforts at self- the paths of the vagus and accelerans, and likewise regulate Life and health are worth more than blind efforts of the calibre of the bloodvessels. If we must give up the idea cure. this kind, and the mere pocket economy which comes of of an automatic nervous system for the heart, we must pro. " doing without the doctor" is dearly purchased at the cost visionally accept as an explanation of its rhythmical action an of health. automatism of the heart muscle, which may help to explain many of the anatomical and physiological difficulties which VACCINATION AT KEIGHLEY. have never been satisfactorily disposed of. If these views muscle must be taken as the autoTHE Keighley School Board have unanimously objected be correct, the heart’s of the circulation, without deriving its matic motor power to the Education Department’s requirement that pupil from nervous elements. There has always been movements teachers should be vaccinated, on the ground that this is an uncertainty in ascribing certain irregularities of the making the Board do the work of the vaccination officer, heart’s action to morbid conditions of the ganglia, but it is and that in a town like Keighley it would virtually deprive easier to imagine that the cardiac complications of typhoid the Board of local teachers, because of the insignificant and are due to changes in the muscular elements proportion of the town children who for many years past thandiphtheria that the ganglia are at fault. The condition of the have been submitted to the operation. If this is a correct heart’s muscle will now be a very important factor in the statement of the condition of the Keighley population in of disease of that organ. regard to vaccination it is obvious that none but well- pathology vaccinated persons should undertake the office of school teacher. Sooner or later Keighley will be attacked with MORTUARIES IN LONDON. small-pox, and the younger members of the community THE need for mortuary accommodation in the metropolis will suffer exceptionally severely. The position of a school has long been matter of notoriety. Although in some pajishes teacher unprotected against small-pox would under these mortuaries have been erected, but little progress is made circumstances be one of considerable risk, and for this the vestries and district boards to provide themgenerally by reason there is greater need for compliance in Keighley selves with proper accommodation for the temporary dis. with the requirement of the Education Department than of the dead, notwithstanding the fact that they ’posal there would be elsewhere. There is only one argument the have had the necessary power for nearly a quarter of Keighley School Board can urge-viz., that it may be a century. Under the Public Health Act of 1875, the anticipated that during an epidemic prevalence of small-pox Local Government Board is enabled to compel sanitary in that town it would be impossible to continue school authorities in the provinces to provide mortuary accomand therefore the of the illness teacher would attendance, modation, but in London this power does not exist; it is be of less moment. one that should be supplied when the Public Health Acts relating to the metropolis are amended. The London INNERVATION OF THE HEART. County Council are now applying for powers to provide and, AN interesting series of observations, confirming those of maintain two mortuaries in the metropolitan district for Gaskell, have lately been made by E. Romberg and W. His, the deposit of unidentified corpses. There can be no doubt jun., on the innervation of the heart. These observers that these will serve a useful purpose, and that they will, adopted the method of examining fcetal hearts. The nerves give facilities for the recognition of the bodies which at of the heart begin to appear at the end of the first month. the present time are buried unclaimed. They arise from the wandering ganglion cells of the sympathetic system. The fibres which unite these cells with THE HUMAN SUBJECT FORTY YEARS the sympathetic trunk run in companionship with branches UNDER WATER. from the vagus ; with this latter nerve, however, the A VERY interesting report hasjust been issued by Dr. Konig, ganglion cells have no communication. Later on in foetal " Gerichtsarzt" (judicial physician) of Hermannstadt, om found in of cells are the walls the life, sympathetic ganglion heart itself. The cardiac nervous system, the formation the state in which the human subject, after forty years’ of which takes place during the second and commencement immersion in water, may be found by the physiologist. In of the third month, is formed as a plexus on the posterior the revolutiouary upheaval of 1849, a company of HonnBds, aspect of the ascending aorta (plexus aorticus profundus) ; as the Hungarian militia are called, having fallen in the this gives branches to the ganglia of the auricle, and also vicissitudes of war, were consigned to the waters of the sends branches to a plexus, rich in ganglion cells, between Echoschacht, a pool of considerable depth not far from the ascending aorta and ductus Botalli (plexus aorticus Hermannstadt. After some forty-one years their bodies superficialis). From the latter is derived the plexus coro- have been brought up again to the light of day, and narii. The ventricle has no ganglia. The cardiac ganglia, subjected to a careful and minute investigation from the then, owe their origin to the sympathetic ganglia ; these physiologist’s point of view. Dr. Konig found them in latter belong, according to the researches of Onodi, to the perfect preservation, without a single trace of any decomdivisions of the posterior roots, therefore to the sensory posing process. Externally, they had the appearance of tract. Thus the ganglia of the heart are also derived from the having been kept in spirit, like so many preparations in an anatomical museum. The epidermis was of a whitish.grey same source. The cardiac ganglia possess no motor functions; automatic are neither centres for the nor have colour; the muscles rose-red, feeling to the touch like heart, they or in If action the heart beat. we freshly slaughtered butcher’s meat. All the inward inhibiting slowing any of these as the results observers the correct, accept physio- parts-the lungs, the heart, the liver, the spleen, the heart’s action can be of the satisfactorily explained. kidneys, the bladder, the stomach, the alimentary logy out that Redner They point emphasises the fact that the canal - were of the consistence of those in a newly

by their example hardly needs

__

-"

,J>

___

’)