430

THE LANCET.

LONDON: SATURDAY, FEBRUARY 15, 1896.

CAMPION 2. HAYWARD.

AT the Totnes County Court on Feb. 5th a case was triedwhich exemplified in a very striking manner the difficultiesthat present themselves to juries in cases where medical

evidence forms a leading feature. A Brixham trawler

named CAMPION had the misfortune in May of last year tobe crushed between the boom and the capstan of his boat.He received an injury to his shoulder, and on going ashorenext day he went at once to Mr. HAYWARD and told him ofthe accident and of the pain he was suffering. At the sur-

geon’s request he stripped, and after an examination hewas assured that there was no dislocation or fracture,and that he must rest his arm and rub in a liniment.

Ten days after the injury CAMPION consulted another

surgeon, Mr. MAYER, who told him there was a

dislocation of the acromial end of the clavicle and

inflammation of the bone as a result of this unreduced

displacement. He proceeded to treat this inflammation, andon a subsequent visit " set the bone and bandaged up theshoulder." It is unnecessary to follow the case through allthe intervening stages. It is enough for our purpose to statethat CAMPION, influenced no doubt by Mr. MAYER’S opinion,brought an action against Mr. HAYWARD for ’’ negligenceand carelessness." The trial lasted several hours and con-

sisted almost entirely of medical evidence. Mr. MAYER,Mr. SQUARE, Dr. McBEATH, Mr. KAY, and Mr. VICKERS all

agreed that the acromial end of the clavicle was dislocatedupwards on to the acromion, that such a dislocation could be

easily detected and ought to have been detected when thepatient was first seen. They were followed by Mr. HAY-WARD, Mr. ELLIOTT, Mr. PICKERING PICK, Mr. PAUL

SWAIN, and Mr. Lucy, who were all equally emphatic intheir evidence that the clavicle was not dislocated now

and had not been dislocated in May last. The judge verynaturally referred to this case as presenting difficulties as

great as had ever occurred to him in all his experience. The

jury, after considerable deliberation, found a verdict in

favour of the defendant, and judgment was entered

accordingly.It is impossible not to feel that the public must view such

a case as this with the gravest dissatisfaction. The man. in

the street will say that the collar-bone is one that is easilyhandled and felt, and that it ought not to be possible to have

conflicting evidence on such a simple matter of fact as

whether its acromial end is or is not dislocated. So arguesthe man in the street, and he will probably explain the dis-

crepancy in the evidence by the influence of professional ’’

rivalry on the one hand and professional friendship on theother. With such a view of this case we cannot for one

moment agree. We do not doubt that the difference of

opinion was honest and that it arose from the inherent diffi-culty of the case. For it must not be lost sight of that thesecases are difficult. Although the clavicle is a subcutaneous I

bone, and its outline is plainly to be felt from end to end,yet its acromial articular facet is very small, and unless

great care is taken a mistake is easily made in deter-

mining a dislocation. There is normally an elevation

at the acromio-clavicular joint, and this is readilymistaken for a displacement of the clavicle. But

in the present case all the witnesses seem to have agreedthat the acromial end of the bone was enlarged ; some

looked upon this as the result of the man’s laborious occu-

pation, and others attributed it to the injury. But all agreedit was present. This enlargement no doubt simulated a

dislocation and must have rendered the diagnosis even moredifficult than usual.

But when we have granted that the diagnosis of this

particular dislocation is always a little difficult, and thatin this special case there was a complication that renderedit more than usually difficult, we are still face to face withthe fact that several medical men who saw the case

made a serious error of observation. Accurate observation

is the most difficult of all arts, and only those attain it whocultivate it constantly and with infinite pains and care. In

drawing inferences from facts there is room for difference,but in observation we ought to be able to exclude it. This

case reminds us once more that the chief aim of medical

education should be to make students accurate observers.

We gladly accept the finding of the jury, and we con-gratulate Mr. HAYWARD on his success. It is certainlymore easy to accept this view than the other ; it is easier

to believe that competent surgeons may have mistaken

the prominence of an enlarged acromial end of the claviclefor a displacement of that bone than that equally competentsurgeons should have overlooked a dislocation of such a

bone, especially when its enlargement would have renderedthe recognition of the dislocation more obvious than usual.In the evidence much stress seems to have been laid upontwo points which to us appear to be of quite secondaryimportance. It was urged that a dislocation could not

have been caused by the particular injury the man sus.tained. This is a most fallacious argument to use. In

the first place there is nothing more difficult than

to determine the exact amount, direction, and characterof any given injury, and therefore to base an argument onsuch an uncertain predicate is dangerous in the extreme.

A wide experience makes men very chary of using the word

"impossible." Another point upon which stress was laid

was that if the alleged dislocation had occurred the manwould have been unable to execute a particular movement-

put his hand to the back of his head. It is by relying onpoints of that kind that nearly all mistakes in the diagnosisof dislocations are made. It cannot be too plainly or toooften said that a dislocation is in every case to be

diagnosed only by the absence of the articular end of a

bone from its proper position and by its detection

in an abnormal position, and not by alteration in the

contour or measurement of a limb or by alteration

in the function of the part. If surgeons would fix

their attention more rigidly and exclusively on the

essential factors of the problem they have to solve, andwould realise that right judgment must rest upon accuracyof observation, we should certainly witness less often than

431DEPILATORIES.

i

we do such discrepancies of opinion as were afforded by theevidence in the case of CAMPION v. HAYWARD.

IT is idle to ignore the fact that a great deal of

unhappiness is often caused by bodily defects which areso slight as to be almost beneath the notice of a medicalman ; yet in so far as remedies can be found for such

trifiing ills it is better that they should be intelligentlyprescribed by those who have had the requisite trainingand knowledge. It is the neglect of trivial ailments thatis often responsible for much quackery, and it is the dutyof the medical profession to save people from that resortas much as they can. Therefore, and in reply to more thanone appeal from practitioners, we do not hesitate to makea few comments on a subject which is barely mentioned intext-books, but is yet a real source of trouble and annoy-ance to many. Hair in the wrong place, if it does no

worse, reminds us unpleasantly of our remote ancestry.The growth of hair on a woman’s chin certainly does notenhance her appearance, and, if we may judge by com-munications we receive from our readers, there are manyof their patients who would wish to be rid of the disfigure-ment ; and the advertisement columns of the lay presscontain many announcements of patent preparations forthat purpose.The ordinary components of these so-called depilatories

are quicklime, soda, and a combination of sulphur andarsenic. The powder is made into a paste, spread on theface or other part, and washed off as soon as dry. It

acts by desiccating and dissolving the hair-shaft, and byreason of its irritating nature in unskilled hands is apt togive rise to troublesome consequences. ERASMUS WILSON

narrates the case of a young lady who had been making an

experiment of this sort on her forehead for the purpose of

getting rid of a tuft which interfered with the then fashion-able mode of wearing the hair. She had unfortunatelyallowed the depilatory to remain on too long, and it resultedin a slough the size of a shilling, followed by an unsightlyscar. The safest of such applications is a paste of barium

sulphide and starch applied by skilled hands, regulatedin strength to the delicacy of the skin. KAPOSI mentions

that in the Orient among the Jews a paste is used for the

periodical removal of the stubble of the beard consistingof orpiment and slaked lime boiled with water. In this

instance the after-growth does not appear until two or threeweeks have elapsed, when the application has to be repeated.But all these methods are at best only palliative, for theformative organ remains, and they are all equally apt to befollowed by a stronger growth of the hair, and some-times they give rise to ugly marks and scars. Oint-

ments have been employed, but in general are to be

deprecated, for greasy applications tend to promote the

growth of hair, as on the backs of the hands when vaselineis used to prevent chapping in cold weather. Nevertheless

a strong resorcin ointment, accompanied by powerfulfriction, has in the practice of a few found favour. The

introluction of chromic acid and other caustics into the

hair bulb by means of a needle is uncertain on account ofthe difficulty of regulating the resulting inflammation.AnDt.hp.r nonula,r method of disnn.ino- of pxt,rl1.TIp.ons hairs is

by the tweezers, a painful process and, like the precedingand the razor, only temporary.

All these methods, however, are unsatisfactory, and it isto our American cousins that we owe the introduction of the

only efficient means for the destruction of hair bulbs. It

was an ophthalmologist-MicHEL of St. Louis-who first

employed electrolysis with success for epilation in cases oftrichiasis, and it was afterwards extended to dermatology byHARDAWAY. The procedure has now become perfected, andhas come to be recognised as the least unsatisfactory one forthe eradication of superfluous hairs. A blunt needle con-

nected with the negative pole of a galvanic current

of one-half to one milliampere or more is intro-

duced into the hair follicle, if possible without

injuring it, and the papilla is destroyed by the decom-

position products formed, these probably being caustic

alkalies. The hair is then either removed or allowed to dropout, and the operation is followed by a minute red mark,which disappears either without a trace or leaving an

extremely fine, shallow depression. Very occasionally thesetiny scars subsequently take on a keloid growth. But

electrolysis is a tedious process, for no more than

twenty or thirty hairs can be removed at a sitting, a

circumstance which is open to misinterpretation if the

patient be not warned beforehand of the number of

sittings required; and though these hairs never grow

again, others come forward and have to be dealt

with from time to time until all are eradicated. But in

the hands of a skilled practitioner this method gives asufficiently satisfactory result in a limited localised tuft,provided the patient does not mind the inevitable little red

spots which temporarily appear after each sitting. But if

the growth of hair be in any sense diffuse, on the femalechin for example, the tiny hairs beside the old ones keepgrowing up as the others are destroyed month by monthand year by year, so that an almost unlimited attendance is

necessary. Indeed, so indefinite is the treatment and so

frequently do complaints arise on that account, and if thecurrent be not very carefully adjusted so difficult is it to

prevent temporary disfigurement, that many professionalmen of standing refuse to undertake these cases. This

determination on their part we believe to be a mistake, asthe unsuccoured sufferer flies to quackery.

Electrolysis is the only means known up to the presenttime which in capable hands is able to destroy the papillawhence the hair grows without risk of producing serious

consequences. All the other procedures, including those

above mentioned, only result in destruction of the hair-

shaft, in which case they are not much superior to the

razor; or if the cuticle be penetrated widespread suppura.tion and resulting scars are apt to be produced. It is

therefore the bounden duty of practitioners to warn

their patients against them and especially against trust-

ing themselves to treatment by these powerful remedies

at the hands of unqualified, irresponsible, and often

wholly unscrupulous persons.

IT is impossible to withhold sympathy from Dr. NORMANMooRE in his endeavour to amend and improve the regula-tions relating to the Dronosen t,.3rnmination in nhnTma.oolos’v

432 PHARMACY AND PHARMACOLOGY.-THE NEW PHOTOGRAPHY.

at the Royal College of Physicians of London. The difficultyof dealing adequately and fairly with the subject of materiamedica has frequently been mentioned in these columns, 1

and more recently 2 reference was made to the relative

hardship of the regulations as they stand at present.It may not be inopportune to remind our readers of

a few matters of ancient history before dealing with the

present, and the future. So far back as 1891 it was felt

generally that the examinations in materia medica were notgiving satisfaction to anyone concerned. Students were

then allowed to present themselves for examination at anydate after registration, and, as to a large extent the synopsiscovered elementary matters connected with the drugs of

the British Pharmacopoeia, there was something to be saidin favour of early examination. Some students were then,it was presumed, fresh from dispensing in country surgeries,and were to a large extent prepared to state the

origin of drugs, to name their active principles, and

to answer questions on the composition and dose of

the more important pharmacopceial preparations. Un-

fortunately, however, the synopsis also made mention of

" medicinal action," and the interpretation of this term

formed the stumbling-block both for students and examiners.It was recognised that the examination was taken before thenames of diseases could have any real meaning, and the con-

sequence was that in practice the term ’’ medicinal action "

was treated as though synonymous with physiological action.Even in this restricted sense the percentage of rejections was

very high, as so many students presented themselves, asempowered by the regulations, when their knowledge of phy-siology was either rudimentary or non-existent. Complaintsshowered from all sides ; parents protested against the highpercentage of rejections, examiners in materia medica com-

plained of the difficulty experienced in applying the samestandard to all candidates, and the examiners in

medicine were not behind in finding ignorance in pre-

scribing, and even in dosage and composition of importantdrugs and preparations.Some change was obviously desirable, and two direc-

tions were indicated in which reform might be effected.

One was to leave the scope of the examination as it stood,but not to allow students to present themselves until after

they had passed the examinations in anatomy and phy-siology. The other course, which, we believe, received the

support of teachers and examiners, was the division of the

subject into three parts-pharmacy, pharmacology, and

therapeutics. It was suggested that the first subject mightbe taken at any stage, but that examination in pharmacologyand therapeutics should come at some date subsequent toexamination in anatomy and physiology. For some reason,

which was not very obvious, this scheme was only accepted in

part. The subject of therapeutics was linked to medicine,pharmacy became attenuated to a vivâ-voce, and pharmaco-logy was suddenly raised to the importance of an inde-

pendent examination. Interest, therefore, centred in the

scope of the proposed examination in this subject, as well asin the definition of the term. If defined in the sense in

which the word is employed in foreign countries, the pro-

1 THE LANCET, May 30th, 1891; THE LANCET, Feb. 20th, 1892;THE LANCET, May 6th, 1893.

2 THE LANCET, Jan. 4th, 1896.

posed examination became a very serious innovation. The

schedule, which appeared in due course, did not tend to

relieve anxiety. Under the heading of pharmacology camethe words: "The action of medicinal agents on the

body in health and disease." It is not stated that

this is intended as a definition, but to all intents

and purposes it widens the ordinary scope of the term, soas to embrace much of what is commonly understood as

therapeutics. In that sense, and in that sense only, wewelcomed the schedule as a praiseworthy effort to improveeducation. Regarding examinations in their proper func-

tion-not as so many opportunities for rejecting candidates,but as indications of the course of study which it is most

profitable to follow-the scheme of an examination into theaction of drugs appeared to be a step in the right direction.

Statistics of the examination in pharmacy show thatstudents now find much greater ease in satisfying theexaminers, and it might have been hoped that the samehappy result would have attended the examination in

pharmacology, but the objection has been urged that

candidates may now be rejected twice in what is reallyone subject. It may be doubted whether this risk is as

real as it appears, especially in view of pharmacologybeing taught when physiology has been mastered. Still,the risk has to be reckoned with, and Dr. NORMAN

MooRE’s proposal is intended to remove this objection. He

suggests the revival of the term medicinal action " and itsinsertion in the schedule of pharmacy, and he proposes toomit a separate examination in pharmacology. He also pro.

poses that the examination in pharmacy shall in future

be conducted after the examinations in anatomy and

physiology. What medicinal action" has to do with

pharmacy seems difficult of explanation. It is certainlynot included under that heading in the definitions in the

first pages of most books on materia medica, and fromthe official standard of pharmacy, the British Pharmacopoeia,it is excluded. If these proposals are accepted by the

Royal College of Physicians of London, the course of

examination and of teaching during the transition stagewill become very involved. The task of students and

of teachers is not easy when regulations are subject to

such frequent changes.

Annotations.

THE NEW PHOTOGRAPHY.

"Ne quid nimis."

ALL sorts of crude ideas seem to be current as to the appli-cation in medicine of the new radiations our 11 x " rays. Wehad an enquiry from a lay correspondent last week as towhere the apparatus producing these new radiations couldbe obtained, " as it was wanted for a case of consumption."But a very general impression appears to be that the rayshave been obtained in such abundance as to be able to

permeate through any thickness. This is not so, and thesource of the rays must be infinitely more powerful thanis obtainable by present means if they are to be capableof assisting in the exploration of remote cavities in

the human organism. Excellent photographs have been

produced of bodies such as the hand, which are not suffi-ciently thick to offer a complete resistance to the passage of