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THE DIAGNOSIS OF HEAD INJURY FROM DRUNKENNESS.
632 in India has made the following appointments:-Surgeoni F. P. Maynard to the medical charge of the 13th Bengal Infantry, vice Surgeon S. C. Nandi; Surgeon E. R. W. C. Carroll, from the medical charge of the Wing, 31st Punjab Infantry, to the medical charge of the 16th Lucknow Regiment, vice Surgeon-Major J.
633 those in charge, becoming alarmed, called the police surgeon, who ordered his removal to St. Thomae’s Hospital, where he died less than an hour after admission. This man had a fracture of the posterior fossa and subdural
hemorrhage.
man unless, in their opinion, he had acted carelessly or with evil intention. Failing this, I would have
any medical
certify
lunatics pay a small the medical men who intend to sum per annum to an insurance company, who would see them through their troubles when the day of reckoning
case of a cabman, somewhat similar, was published arrived. daily papers a few years ago. At a hospital to which My object in troubling you is to suggest that a subscriphe was taken after a fall from his cab his speech was thick, tion should be at once opened in favour of Drs. Carpenter and he appeared dazed, but insisted on going home. He and Dukes, to which, I need scarcely say, I should be died a few hours afterwards. Dr. James Morgan said death pleased to contribute my mite. I should not have suggested was caused by effasion of blood on the brain following this if I had not had their express permission to do so. I am, Sirs, yours obediently, fracture of the base of the skull, of which fracture there
The
in the
external indication. In the lectures on injuries to the head, which were given by meat the Royal College of Surgeons, and published in full in your columns last year, attention was drawn to the great danger there is of mistaking patients suffering from fracture of the posterior fossa of the base for those simply suffering from drunkenness, and several instances were given. I would refer for further information to THE LANCET, Vol. ii. 1890, p. 113, merelysubjoining a short extract from the third lecture :-" The difficulty presented in the diagnosis of fractures of the posterior fossa of the base before the appearance of ecchymosisover the mastoid process has already been mentioned, and I think that these form the most important section of cases occasionally sent from our hospitals as drunk and not suitable for admission. They have not uncommonly been dosed with brandy or other stimulant, the usual immediate popular treatment in this country for all accidents ; hence the breath smells of alcohol. Again, such patients sometimes show a
HENRY SUTHERLAND.
was no
P.S.-Since writing the above I have seen a letter from Dr. J. A. Austin (Norwood Review, Aug. 7th, 1891), in which he says: "am of opinion that it would be a wise plan to limiu the power of private practitioners to signing certificates in urgent cases only, and as a temporary measure, leaving the question of detention to be decided afterwards,
deliberately and carefully, by specially appointed experts,
whose decision must be held final."
PATHOLOGICAL POSITIVISM. To the Editors of THE LANCET. SIRS,—Whether the late Congress of Hygiene has proved financially successful or not, no one can fail to be gratified
lift it has given to sociological and It is only as the mass of conhas compacted becomes capable of from a certain historical remoteness that the consideration intrinsic value of its quality can be duly assayed. Pending the publication of its Transactions one or two reflections may perhaps be permitted; if these be critical in their nature, it is none the less with a generous regard that I appreciate the magnitude and value of the work the Congress has done. I cannot doubt that others as well as myself must have been struck with a tendency which manifested itself, mostly in the pathological departments, to what may be termed "positivism" or, less respectfully, "cock sureness," a certain assumption of the finality of the learned author’s conclusions after peror his friends to pay the fee of the surgeon when drunkenness haps only a few months of microscopising or test-tubing. is proved to have been the only reason for the fall ? There Such positivism is, I venture to submit, unworthy and would then be less hesitation in obtaining the necessary unsound ; when it piesumes to dictate legislation it is I am, Sirs, yours truly. skilled assistance. apt to be ridiculous and cast undeserved contempt upon WILLIAM H. BATTLE. more modest and not less valuable researches. Curiously enough, that which one would imagine should be the best corrective to this tendency-viz , the grievous and often THE LUNACY LAW AMENDMENT ACT AND unconfessed errors, no less "absolutely certain" in their day, of other or the same pathological positivists-appears THE RECENT ACTION AT CROYDON. to be wholly inoperative. A wholesome scepticism, or even To the Editors of THE LANCET. Heine’s "instinct of distrust," is accordingly the mental SIRS,—With the express permission of Drs. Alfred Car- attitude which such declaimants compel their audience to penter and M. Charles Dakes I write to call attention to assume in self-defence. Medical libraries and official records groan with the lumber the utter breakdown of the clause in the Lunacy Law Amendment Act of 1890 which professes to protect whichsuchexpertshavepiledup. Dr. Billings wittily observed from vexatious actions medical men who have signed cer- that medical bibliography had been compared to the animal tificates in lunacy, as exemplified by the case recently body, but there was one point in which the analogy failed : tried at the Croydon assizes, in which damages to the there was no means of getting rid of effete material This extent of i2000 were claimed from the medical defendants. thought, humbling to us all, might perhaps be impressed E have it in writing from Dr. Dakes that he has been respectfully upon the class of investigators to which I have mulcted to a large amount for legal expenses, with, as been alluding. Dr. Burdon Sanderson, in introducing the far as we know at present, no possibility of recouping him- discussion on Tuberculosis, observed : " It is our duty to self for the loss of time, possible loss of connexion, and, insist on the right of science to dictate; but in doing so we above all, for the extreme anxiety and annoyance caused to must be careful not to do so until we have looked at the him by the constant idea that he was liable to pay the full question from all sides, and heard the whole evidence." So - extent of the damages claimed. far, no doubt, Dr. Sanderson was on safe ground ; whether I cannot do better than quote a few words of his letter to the suggestions with which he concluded his address are me, with which I am sure all hard-worked members of our equally acceptable is more problematical. He advised an profession will thoroughly sympathise. Dr. Dukes says, efficient system of skilled experts to inspect suspected meat "Ihave always paid my way and worked hard, but I con- and make a diagnose précoce of tuberculosis. Such experts fess this bill of costs and the loss of time have crippled me, were not to be veterinarians, whose skill Dr. Sanderson and kept me awake at night often, for the two years they seems to distrust, but they were to be a sort of tuberculosis threatened for jE2000 damages." I have subscribed largely tea-taster, whose judgment would be reliable " because he is to the Messrs. Few’s able endeavours to protect, not only responsible for it and paid for it." If this view represents my own speciality, but the profession in general, from these: that of the tuberculosis Commissioners it will, of course, be disgraceful attacks. And it doe3 seem hard that, after theiseriously considered. No doubt some will inquire whether fair promises held out by the new Act, such a state of things skilled experts of the kind in question have not in the should exist. It may be asked what remedy should I suggeso. past shown many of the qualities of the pathological I reply that the Commissioners in Lunacy ought to be made positivist, and whether the mature deliverances of official responsible, and that no action should be commenced against; , wisdom in matters medical have been invariably charac-
curious, half-silly expression, are mentally confused, drowsy, complain of headache, and sometimes vomit material smelling of the beer or spirit which they have taken. The injury to the head is not found unless careful search be made, having been inflicted on a parb thickly covered with hair, and the blood, if there be a wound, is rarely in large amount. The period of unconsciousness may be very slight or absent." These cases give additional proof of the difficulty attending the diagnosis of drunkenness, and I think call for such an alteration in the police regulations as shall provide for the attendance of the police surgeon as soon as possible. It should not be left to the police inspector or sergeant to give an opinion on the subj ect. Why not compel the prisoner
with the
enormous
pathological science. glomerated material it
633 those in charge, becoming alarmed, called the police surgeon, who ordered his removal to St. Thomae’s Hospital, where he died less than an hour after admission. This man had a fracture of the posterior fossa and subdural
hemorrhage.
man unless, in their opinion, he had acted carelessly or with evil intention. Failing this, I would have
any medical
certify
lunatics pay a small the medical men who intend to sum per annum to an insurance company, who would see them through their troubles when the day of reckoning
case of a cabman, somewhat similar, was published arrived. daily papers a few years ago. At a hospital to which My object in troubling you is to suggest that a subscriphe was taken after a fall from his cab his speech was thick, tion should be at once opened in favour of Drs. Carpenter and he appeared dazed, but insisted on going home. He and Dukes, to which, I need scarcely say, I should be died a few hours afterwards. Dr. James Morgan said death pleased to contribute my mite. I should not have suggested was caused by effasion of blood on the brain following this if I had not had their express permission to do so. I am, Sirs, yours obediently, fracture of the base of the skull, of which fracture there
The
in the
external indication. In the lectures on injuries to the head, which were given by meat the Royal College of Surgeons, and published in full in your columns last year, attention was drawn to the great danger there is of mistaking patients suffering from fracture of the posterior fossa of the base for those simply suffering from drunkenness, and several instances were given. I would refer for further information to THE LANCET, Vol. ii. 1890, p. 113, merelysubjoining a short extract from the third lecture :-" The difficulty presented in the diagnosis of fractures of the posterior fossa of the base before the appearance of ecchymosisover the mastoid process has already been mentioned, and I think that these form the most important section of cases occasionally sent from our hospitals as drunk and not suitable for admission. They have not uncommonly been dosed with brandy or other stimulant, the usual immediate popular treatment in this country for all accidents ; hence the breath smells of alcohol. Again, such patients sometimes show a
HENRY SUTHERLAND.
was no
P.S.-Since writing the above I have seen a letter from Dr. J. A. Austin (Norwood Review, Aug. 7th, 1891), in which he says: "am of opinion that it would be a wise plan to limiu the power of private practitioners to signing certificates in urgent cases only, and as a temporary measure, leaving the question of detention to be decided afterwards,
deliberately and carefully, by specially appointed experts,
whose decision must be held final."
PATHOLOGICAL POSITIVISM. To the Editors of THE LANCET. SIRS,—Whether the late Congress of Hygiene has proved financially successful or not, no one can fail to be gratified
lift it has given to sociological and It is only as the mass of conhas compacted becomes capable of from a certain historical remoteness that the consideration intrinsic value of its quality can be duly assayed. Pending the publication of its Transactions one or two reflections may perhaps be permitted; if these be critical in their nature, it is none the less with a generous regard that I appreciate the magnitude and value of the work the Congress has done. I cannot doubt that others as well as myself must have been struck with a tendency which manifested itself, mostly in the pathological departments, to what may be termed "positivism" or, less respectfully, "cock sureness," a certain assumption of the finality of the learned author’s conclusions after peror his friends to pay the fee of the surgeon when drunkenness haps only a few months of microscopising or test-tubing. is proved to have been the only reason for the fall ? There Such positivism is, I venture to submit, unworthy and would then be less hesitation in obtaining the necessary unsound ; when it piesumes to dictate legislation it is I am, Sirs, yours truly. skilled assistance. apt to be ridiculous and cast undeserved contempt upon WILLIAM H. BATTLE. more modest and not less valuable researches. Curiously enough, that which one would imagine should be the best corrective to this tendency-viz , the grievous and often THE LUNACY LAW AMENDMENT ACT AND unconfessed errors, no less "absolutely certain" in their day, of other or the same pathological positivists-appears THE RECENT ACTION AT CROYDON. to be wholly inoperative. A wholesome scepticism, or even To the Editors of THE LANCET. Heine’s "instinct of distrust," is accordingly the mental SIRS,—With the express permission of Drs. Alfred Car- attitude which such declaimants compel their audience to penter and M. Charles Dakes I write to call attention to assume in self-defence. Medical libraries and official records groan with the lumber the utter breakdown of the clause in the Lunacy Law Amendment Act of 1890 which professes to protect whichsuchexpertshavepiledup. Dr. Billings wittily observed from vexatious actions medical men who have signed cer- that medical bibliography had been compared to the animal tificates in lunacy, as exemplified by the case recently body, but there was one point in which the analogy failed : tried at the Croydon assizes, in which damages to the there was no means of getting rid of effete material This extent of i2000 were claimed from the medical defendants. thought, humbling to us all, might perhaps be impressed E have it in writing from Dr. Dakes that he has been respectfully upon the class of investigators to which I have mulcted to a large amount for legal expenses, with, as been alluding. Dr. Burdon Sanderson, in introducing the far as we know at present, no possibility of recouping him- discussion on Tuberculosis, observed : " It is our duty to self for the loss of time, possible loss of connexion, and, insist on the right of science to dictate; but in doing so we above all, for the extreme anxiety and annoyance caused to must be careful not to do so until we have looked at the him by the constant idea that he was liable to pay the full question from all sides, and heard the whole evidence." So - extent of the damages claimed. far, no doubt, Dr. Sanderson was on safe ground ; whether I cannot do better than quote a few words of his letter to the suggestions with which he concluded his address are me, with which I am sure all hard-worked members of our equally acceptable is more problematical. He advised an profession will thoroughly sympathise. Dr. Dukes says, efficient system of skilled experts to inspect suspected meat "Ihave always paid my way and worked hard, but I con- and make a diagnose précoce of tuberculosis. Such experts fess this bill of costs and the loss of time have crippled me, were not to be veterinarians, whose skill Dr. Sanderson and kept me awake at night often, for the two years they seems to distrust, but they were to be a sort of tuberculosis threatened for jE2000 damages." I have subscribed largely tea-taster, whose judgment would be reliable " because he is to the Messrs. Few’s able endeavours to protect, not only responsible for it and paid for it." If this view represents my own speciality, but the profession in general, from these: that of the tuberculosis Commissioners it will, of course, be disgraceful attacks. And it doe3 seem hard that, after theiseriously considered. No doubt some will inquire whether fair promises held out by the new Act, such a state of things skilled experts of the kind in question have not in the should exist. It may be asked what remedy should I suggeso. past shown many of the qualities of the pathological I reply that the Commissioners in Lunacy ought to be made positivist, and whether the mature deliverances of official responsible, and that no action should be commenced against; , wisdom in matters medical have been invariably charac-
curious, half-silly expression, are mentally confused, drowsy, complain of headache, and sometimes vomit material smelling of the beer or spirit which they have taken. The injury to the head is not found unless careful search be made, having been inflicted on a parb thickly covered with hair, and the blood, if there be a wound, is rarely in large amount. The period of unconsciousness may be very slight or absent." These cases give additional proof of the difficulty attending the diagnosis of drunkenness, and I think call for such an alteration in the police regulations as shall provide for the attendance of the police surgeon as soon as possible. It should not be left to the police inspector or sergeant to give an opinion on the subj ect. Why not compel the prisoner
with the
enormous
pathological science. glomerated material it