MEDICINE AND THE LAW.
2
89 OPEN-AIR TREATMENT OF SURGICAL TUBERCULOSIS. A VISIT TO ALTON. THE vice-presidents, companions, and local honorary secretaries of the Queen Alexandra League were entertained by Sir William Treloar at Alton, Hants, on July 4th, on the occasion of the visit of Sir Clifford Allbutt. Sir William Treloar, before introducing Sir Clifford Allbutt, stated that the League was founded 17 years ago by Queen Alexandra for the purpose of collecting money for the Lord Mayor Treloar Cripples’ Hospital and College, and during last year had raised over 29000. Address by Sir Clifford Allbutt. Sir Clifford Allbutt, after expressing his great pleasure at having this opportunity of seeing the remarkable work in progress at Alton, quoted Sir Anthony Bowlby as saying that the glory of Alton had abated surgery and that the old treatment of excision of joints had passed into oblivion. He gave a brief outline of the progress of medical knowledge in respect to tuberculosis, recalling the coddling treat- ment of this disease when even the kevholes were stuffed with cotton-wool in order to lessen the possi- bility of a draught reaching the patient. Tubercu- losis, spread by infection, was a general disease, therefore local excision was not the best treatment. The value of open air, good food, and above all sunlight as means to increase the natural resistance was very potent. He stressed the importance of precise dosage and careful distribution in sunlight treatment in order that perils should be avoided and successes won. From Hippocrates onwards the law of reciprocal action, the ability of Nature to hit back, had been continually demonstrated. The intrinsic natural reaction of the individual was often strong enough to withstand infection. Open air increased the fortifica- tions of the physiological reactions and replaced natural exercise in keeping the patient healthy. Alton was fortunate in having a pavilion with 50 beds I at Hayling Island. Sir Clifford Allbutt paid a tribute to Rollier for his work in heliotherapy and occupation therapy ; at Alton 14 teachers and four technical instructors were employed to keep the patients happily occupied. To the importance of early treat- ment and the value of following up cases after dis- charge he largely attributed the successful results, exclusive of accidents, in 95 per cent. of the cases sent to Alton. Sir Clifford Allbutt concluded by stating the two modern events which had given him the greatest pleasure-the remarriage of surgery with internal medicine after their long divorce, and the formation of an institute of comparative medicine at Cambridge. The R’ork at Alton. The work at Alton is too well known to need detailed description. Amongst its many interesting features may be mentioned the observation ward where each new patient admitted is kept for a period of at least a fortnight in quarantine. Each child occupies a separate cubicle and during his stay the case is worked up, his educational standard ascer- tained, X rays taken, and necessary splints manu- factured. After that the patient is warded-or rather gradually acclimatised to open air and sun- light-not according to age or medical classification, but according to his standard of intelligence and school class. Non-inflammable perforated celluloid plasters and various splints and methods of extensions invented at Alton are in use with remarkable results. The difference in degree of pigmentation was con- siderable, every child having an individual reaction to sunlight. The red-haired, much freckled white- skinned type are unable to tolerate exposure and have consequently a less hopeful prognosis. The beds in the " Hampshire " ward are heated electric- ally, Alton being the first hospital to adopt this method. In sharp contrast to cases of surgical tuberculosis as seen in a general hospital or out- patient department is the total absence of muscular wasting. This is attributed to the action of open air on the skin-a loin cloth and sun hat is generally the only covering. The effect of fresh air on naked skin has been proved by Dr. Leonard Hill, Dr. Argyll Campbell, and Sir Henry Gauvain to increase greatly the metabolism of the body. It is stated that the pigmented patients at Alton, even though suffering from surgical tuberculosis, have their working capacity increased on an average by 37 per cent. beyond that of normal healthy children. Alton is a striking example of what a hospital, situated in ideal country surroundings, supplying its own vegetables, fruit, pigs, and eggs can do for its patients. MEDICINE AND THE LAW. LIABILITY FOR IMPURE VTATER-SUPPLY. AFTER litigation extending over two years the High Court of California, U.S.A., has recently awarded substantial damages, to be paid by the city authorities, to 19 persons who contracted typhoid fever at Pittsburgh, in consequence of a breakdown in the apparatus for purify-ing the city’s water-supply. This is drawn from the Sacramento river, the water of which is recognised as unfit for drinking until properly treated, and at a date preceding the outbreak of typhoid, from which the plaintiffs suffered, the chlorinating plant was for a time inoperative owing to the fixtures upon a drum containing chlorine gas not permitting of its attachment to the pumping system until the necessary alteration of the fittings had been made. The court has held that an obligation lies upon the city authorities who distribute the water to use all reasonable precaution to render it fit and wholesome. Presumably, in terms familiar in our courts, the judgment was to the effect that there was negligence in not securing a supply of chlorine gas in a receptacle suitable for use in the machinery installed for the purpose, and in allowing water to be supplied in a condition known to be unsafe, and without warning to the public. Subject to any special provision not likely to be inserted in any water company’s Act, there can be no reason why such an action should not lie in this country in similar circumstances. AUTHORITY TO ENGAGE AN AMBULANCE. At Romford County Court recently his honour Judge Crawford tried an unusual action, in which the Romford Urban Council sued a Mr. Thwaites for payment for the use of the town ambulance to convey him to a London hospital. Mr. Thwaites denied liability and said that he could have travelled by omnibus or similar conveyance, and that the ambu- lance had been ordered by his medical attendant, Dr. V. Levy, without his authority. Accordingly the Council had joined Dr. Levy as a defendant and he was represented at the trial by Mr. H. F. Dickens, briefed by the solicitor to the Medical Defence Union. As to the main facts there was no dispute. Dr. Levy had attended Mr. Thwaites, who was suffering from severe abdominal pains, and on receiving a second summons decided that the case was one of urgency, and accordingly, on his way to his patient’s house, asked for an ambulance to be sent at once to take him to a hospital. He told the court that he would have been running a great risk if he had allowed any delay to occur. On Mr. Thwaites saying that he could have travelled in an omnibus or tram-car ., Judge Crawford asked, " Don’t you think that the doctor was the best judge of that ? " In giving his decision, Judge Crawford compared the case to that of the captain of a ship who when out of reach of his owners had to come to a decision and take responsi- bility on their behalf. A doctor in a similar case of great urgency became, in his opinion, an " agent by necessity " and was fully justified in taking whatever steps he might think necessary in his patient’s
Transcript of MEDICINE AND THE LAW.
89
OPEN-AIR TREATMENT OF SURGICAL
TUBERCULOSIS.A VISIT TO ALTON.
THE vice-presidents, companions, and local honorarysecretaries of the Queen Alexandra League wereentertained by Sir William Treloar at Alton, Hants,on July 4th, on the occasion of the visit of Sir CliffordAllbutt. Sir William Treloar, before introducing SirClifford Allbutt, stated that the League was founded17 years ago by Queen Alexandra for the purpose ofcollecting money for the Lord Mayor Treloar Cripples’Hospital and College, and during last year hadraised over 29000.
Address by Sir Clifford Allbutt.Sir Clifford Allbutt, after expressing his great
pleasure at having this opportunity of seeing theremarkable work in progress at Alton, quoted SirAnthony Bowlby as saying that the glory of Altonhad abated surgery and that the old treatment ofexcision of joints had passed into oblivion. He gavea brief outline of the progress of medical knowledge inrespect to tuberculosis, recalling the coddling treat-ment of this disease when even the kevholes werestuffed with cotton-wool in order to lessen the possi-bility of a draught reaching the patient. Tubercu-losis, spread by infection, was a general disease,therefore local excision was not the best treatment.The value of open air, good food, and above allsunlight as means to increase the natural resistancewas very potent. He stressed the importance ofprecise dosage and careful distribution in sunlighttreatment in order that perils should be avoided andsuccesses won. From Hippocrates onwards the law ofreciprocal action, the ability of Nature to hit back, hadbeen continually demonstrated. The intrinsic naturalreaction of the individual was often strong enough towithstand infection. Open air increased the fortifica-tions of the physiological reactions and replacednatural exercise in keeping the patient healthy.Alton was fortunate in having a pavilion with 50 beds Iat Hayling Island. Sir Clifford Allbutt paid a tributeto Rollier for his work in heliotherapy and occupationtherapy ; at Alton 14 teachers and four technicalinstructors were employed to keep the patientshappily occupied. To the importance of early treat-ment and the value of following up cases after dis-charge he largely attributed the successful results,exclusive of accidents, in 95 per cent. of the casessent to Alton. Sir Clifford Allbutt concluded bystating the two modern events which had given himthe greatest pleasure-the remarriage of surgery withinternal medicine after their long divorce, and theformation of an institute of comparative medicine atCambridge.
The R’ork at Alton.
The work at Alton is too well known to needdetailed description. Amongst its many interestingfeatures may be mentioned the observation wardwhere each new patient admitted is kept for a periodof at least a fortnight in quarantine. Each childoccupies a separate cubicle and during his stay thecase is worked up, his educational standard ascer-tained, X rays taken, and necessary splints manu-factured. After that the patient is warded-orrather gradually acclimatised to open air and sun-light-not according to age or medical classification,but according to his standard of intelligence andschool class. Non-inflammable perforated celluloidplasters and various splints and methods of extensionsinvented at Alton are in use with remarkable results.The difference in degree of pigmentation was con-siderable, every child having an individual reaction tosunlight. The red-haired, much freckled white-skinned type are unable to tolerate exposure andhave consequently a less hopeful prognosis. Thebeds in the " Hampshire " ward are heated electric-ally, Alton being the first hospital to adopt thismethod. In sharp contrast to cases of surgical
tuberculosis as seen in a general hospital or out-patient department is the total absence of muscularwasting. This is attributed to the action of openair on the skin-a loin cloth and sun hat is generallythe only covering. The effect of fresh air on nakedskin has been proved by Dr. Leonard Hill, Dr. ArgyllCampbell, and Sir Henry Gauvain to increase greatlythe metabolism of the body. It is stated that thepigmented patients at Alton, even though sufferingfrom surgical tuberculosis, have their workingcapacity increased on an average by 37 per cent.beyond that of normal healthy children.
Alton is a striking example of what a hospital,situated in ideal country surroundings, supplying itsown vegetables, fruit, pigs, and eggs can do for itspatients.
________
MEDICINE AND THE LAW.
LIABILITY FOR IMPURE VTATER-SUPPLY.
AFTER litigation extending over two years theHigh Court of California, U.S.A., has recentlyawarded substantial damages, to be paid by thecity authorities, to 19 persons who contracted typhoidfever at Pittsburgh, in consequence of a breakdownin the apparatus for purify-ing the city’s water-supply.This is drawn from the Sacramento river, the waterof which is recognised as unfit for drinking untilproperly treated, and at a date preceding the outbreakof typhoid, from which the plaintiffs suffered, thechlorinating plant was for a time inoperative owingto the fixtures upon a drum containing chlorinegas not permitting of its attachment to the pumpingsystem until the necessary alteration of the fittingshad been made. The court has held that an obligationlies upon the city authorities who distribute the waterto use all reasonable precaution to render it fit andwholesome. Presumably, in terms familiar in ourcourts, the judgment was to the effect that therewas negligence in not securing a supply of chlorinegas in a receptacle suitable for use in the machineryinstalled for the purpose, and in allowing water tobe supplied in a condition known to be unsafe, andwithout warning to the public. Subject to anyspecial provision not likely to be inserted in anywater company’s Act, there can be no reason whysuch an action should not lie in this country insimilar circumstances.
AUTHORITY TO ENGAGE AN AMBULANCE.
At Romford County Court recently his honourJudge Crawford tried an unusual action, in whichthe Romford Urban Council sued a Mr. Thwaitesfor payment for the use of the town ambulance toconvey him to a London hospital. Mr. Thwaitesdenied liability and said that he could have travelledby omnibus or similar conveyance, and that the ambu-lance had been ordered by his medical attendant,Dr. V. Levy, without his authority. Accordinglythe Council had joined Dr. Levy as a defendant andhe was represented at the trial by Mr. H. F. Dickens,briefed by the solicitor to the Medical Defence Union.As to the main facts there was no dispute. Dr. Levyhad attended Mr. Thwaites, who was suffering fromsevere abdominal pains, and on receiving a secondsummons decided that the case was one of urgency,and accordingly, on his way to his patient’s house,asked for an ambulance to be sent at once to take himto a hospital. He told the court that he wouldhave been running a great risk if he had allowedany delay to occur. On Mr. Thwaites saying thathe could have travelled in an omnibus or tram-car
.,
Judge Crawford asked, " Don’t you think that thedoctor was the best judge of that ? " In giving hisdecision, Judge Crawford compared the case to thatof the captain of a ship who when out of reach of hisowners had to come to a decision and take responsi-bility on their behalf. A doctor in a similar case ofgreat urgency became, in his opinion, an
"
agent bynecessity " and was fully justified in taking whateversteps he might think necessary in his patient’s
90
interest. Ambulances were modern inventions tosecure the safe conveyance of patients, and though heknew of no parallel case, the principles of the commonlaw would apply. If the man had died he had nodoubt that his relatives would have blamed the doctorif he had not taken proper precautions. Such casesmust often arise, but the question of payment had notbefore been contested by the patient. The defencewas one of the most discreditable he had ever known.He agreed that the matter was of great interest tothe general public and to the medical profession, andin giving judgment with costs against Mr. Thwaitesfor the amount claimed by the Urban Council, heordered him to pay Dr. Levy’s costs and certifiedfor the costs of counsel who appeared for him. Dr.
Levy is to be congratulated and also the MedicalDefence Union, who no doubt will record the case asa valuable precedent for the application of the lawof " agent by necessity " in medical matters.
VIENNA.
(FROM OUR OWN CORRESPONDENT.)
Treatment of G.P.I. by Inoculation of 111alaria.INTEREST has been aroused by a further communica-
tion made to the Vienna Neurological Society byProf. Wagner-Jauregg, dealing with the results oftreating 300 severe cases of general paralysis of theinsane by infecting them with tertian malaria. In1890 Prof. Wagner-Jauregg produced a " curative "febrile condition in such patients by inoculating oldtuberculin (Koch). Cases were taken without selection,and it was apparent that the febrile cases had a betterexpectation of life. He then combined the tuberculintreatment first with mercurial treatment, later withsalvarsan, and the results were comparatively satis-factory. In 1909 a report on these results was givenat the International Medical Congress in Budapest;some of the patients referred to in that report are stillalive and actively working. Of the total number of86 cases, 23, or 27 per cent., could be classified ashaving regained full fitness for work ; 50 per cent.had lasting remissions. Early cases had betterchances of recovery than inveterate cases. Improvedresults were obtained by the use of polyvalent typhoidvaccine (Besredka),which produced more lasting febrileattacks, and remissions after its use were decidedlylonger. Wagner-Jauregg noted that an intercurrentinfectious disease, occurring in such patients when ithey were under the influence of tuberculin or typhusvaccine, produced a definite cure. In 1917 he resolvedto infect such patients with the plasmodium of tertianmalaria. Nine patients were taken as a first experi-mental group ; of these, 6 are at present (i.e., six yearslater) perfectly well and fit for work ; three had longperiods of remission. Having kept this first group underobservation for two years, Wagner-Jauregg thenconducted large-scale experiments, and his clinic nowcontains records of over 300 cases treated in this way.The method seems to be the most successful of allknown and is applied as follows : Tertian plasmodiaobtained in vivo are injected intravenously; an
incubation period of 8-14 days follows, and thencomes the typical attack. The patient is allowed toundergo 8-10 attacks of fever, and quinine sulphateis then given in the orthodox way ; this treatment isfollowed up by neo-salvarsan injections, which havelately been combined with cerabro-spinal drainage.In 1920 a series of 25 cases, with 9 complete cures, wasdemonstrated at the meeting of German naturalscientists at Nauheim. In 1922 the number had goneup to 294 cases, with 112 complete cures, and 88 longremissions (reported at Leipzig). The improvementis noted some time after the fever treatment ; itcontinues to increase gradually until a full remissionis observed. It was found possible to transform anincomplete remission into a complete one by repeatingthe whole series of treatment. Reports of observationsof the same nature have come from numerous other
places-e.g., Graz, Heidelberg, Gottingen, and Munich.Another important observation has been made byProf. Kyrle (assistant of Prof. Zinger) on the treatmentof secondary manifestations of syphilis by injection oftertian malaria with very satisfactory results. Theexperiments are not yet concluded, the time being stilltoo short for definite conclusions to be drawn, butthere seems reason to envisage the possibility ofradical cure of syphilitic infections by combinedmalaria-salvarsan treatment.
Closing of All Schools for Dental Mechanics.By an order of the Board of Health the existing
schools for technical dentistry open for non-medicalpupils will be permanently closed at the end of thesummer term. This is the final result of the " DentalMechanics Act," introduced in July, 1920, by which alldental work in the mouths of patients is handed overto medical men only. The dental mechanic will infuture only serve as an apprentice or qualified workmanin the workshop of a dental surgeon ; instruction intechnical dentistry will be obtainable exclusively indental clinics, open only to doctors of medicine. Thenon-medical dentists at present practising will retaintheir position, which will even be a little extended in sofar as they are permitted to extract teeth and to filland treat diseased roots. The apparatus of the oncefamous Dental Mechanics School of Vienna will behanded over to the Vienna Dental Clinic. The Actalso terminates dental practice under titles such as" doctor of mechanical dentistry " and " licentiate ofdentistry " obtained abroad.
Vaccination Against Measles.At a recent meeting of the Vienna Medical Society
a report from the " Mautner Markhof Children’sHospital," presented by Prof. Leiner, recorded resultsobtained by the method of Dr. Degkwitz, of Munich,of vaccination against measles. This disease has atendency to become very dangerous every third year,especially with children below the age of one year.In the 1919-20 epidemic older children were alsofrequently fatally affected, and in 1922-23 the winterseason was again accompanied by severe mortality,particularly in several children’s hospitals. Dr.Degkwitz took 60-80 g. of blood from children in theconvalescent stage of measles and prepared from ita serum, of which 3 c.cm. were injected intramuscu-larly into children in direct contact with measlespatients. The earlier this prophylactic immunisationtook place the better were the results seen. If set up onthe second to the fifth day after contact it was stillefficacious, being less protective on the sixth to theeighth day, although even then the course of the diseasewas mild and transient. The control experimentsconducted in Vienna have fully confirmed the claimsmade at Munich, and the serum will be manufacturedin large quantities for use in private practice.
Prophylactic Inoculation of Dogs Against Rabies.In my letter of June 13th a paragraph referred to
anti-rabies measures in Austria. The following inform a-tion may now be added. Prophylactic inoculation ofdogs against rabies has been undertaken in Vienna ;of 90 animals inoculated according to Pasteur’smethod, and then subjected to an " experimental "bite by a diseased animal, not one developed rabies.There is a growing desire among the public for generalanti-rabies inoculation of the dog’population. Fourinjections of vaccine on four consecutive days would,it is estimated, cost 30,000 kroner (2s.).
Autumn Post-Graduate Courses.The Medical Faculty of Vienna will hold a post-
graduate course for Austrian and foreign practitionersfrom Sept. 17th-29th. Lectures will be as follows :-Sept. 17th : Errors in Diagnosis of Diseases of theEye ; Diagnosis and Treatment of Trachoma ;Cataract; Strabismus.-Sept. 18th : Vertigo ; Painin the Study of Otology ; Important Surgical Indica-tions in Diseases of the Ear ; Deafness ; Tonsillec-tomy.-Sept. 19th : Traumatic Neuroses ; Diagnosis
1THE LANCET, June 23rd, p. 1284.
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