45

and the tissues about the wrists (not the joints). The puscontained gonococci. The identification of the organismwas confirmed by Professor Welch of the Johns HopkinsHospital. In the eight cases all the patients were infantsunder the age of three months and, strange to say, sevenwere males. On the other hand, of over 70 females suffering 111from vaginitis only one had arthritis. In six cases there C(

were purulent polyarthritis, peri-arthritis, and myositis. In eitwo cases only one joint (the knee) was involved. The b,ankles and wrists were the joints most frequently affected inIn two cases the temporo-maxillary joints were involved and win three the toe- or finger-joints. The treatment consisted p,of aspiration or arthrotomy with application of wet dressings. mThe incisions healed and the joints were restored to normal e1with remarkable rapidity. No history of gonorrhoea in the 01parents or of ophthalmia neonatorum could be obtained. Six f,

. of the eight cases were fatal and at the time of the report the a

recovery of the two survivors was doubtful. In three cases

necropsies were obtained. Arthritis, purulent infiltration of the muscles about the joints, and broncho-pneumonia were 0found. In one case there were laryngeal abscesses and the r,

pus as well as the laryngeal mucus yielded biscuit-shaped r,

diplococci not retaining Gram’s stain. In three cases a ‘form of stomatitis resembling thrush was present and in 1one case intracellular diplococci not retaining Gram’s stain

r:

were found in the scrapings from the mouth, but the 1.organism could not be isolated and proved to be the r

gonococcus. Cases of gonorrhoeal stomatitis in the newly Iborn have been previously described. Dr. Kimball suggests xthat during cleansing of the mouth infection may have

1

ctaken place from the nurse’s hands and that the resulting Istomatitis was the source of the pysemia. i

- 11

THE medical officer of health of the Cape Colony reports fthat for the week ending Dec. 5th 1903, no cases of plaguewere notified in the Colony. Plague infected rats continued rto be found at various places in the Colony, but of 400 rats

1 ]

which were examined in the Cape Town and harbour boardarea during the week none was affected with plague. 1

- i

Dr. Arthur Newsholme will deliver the inaugural address inconnexion with the post-graduate lectures and demonstrationsat the Mount Vernon Hospital for Consumption and Diseasesof the Chest, 7, Fitzroy-square, W., on Thursday, Jan, 7th,at 5 P.M. The subject of Dr. Newsholme’s address will bePublic Preventive Measures against Tuberculosis in Relationto the Medical Practitioner. )

AT the next meeting of the Incorporated Society of MedicalOfficers of Health, to be held at 9, Adelphi-terrace. Strand,London, W.C., at 8 P.M., on Friday, Jan. 8th, Dr. J.

Spottiswoode Cameron will open a discussion on Sophisti-cation of Foods and important motions will be proposed.The meeting is open to public analysts and those interestedin the subject.

-

THE Royal Commission on Sewage Disposal at its meetingon Dec. 22nd settled its report on the contamination ofshellfish by sewage. The report will be published in a fewdays.

THE LONDON SCHOOL OF TROPICAL MEDICINE.-Of the students of the above school who presented them-selves for the examination at the end of the October-December, 1903, session the following have passed: A. EHorn (Colonial Service), A. H. Barclay (Foreign Office),G. Wilson, W. J. Radford (Foreign Office), D Cowin(Colonial Service), J. E Mitchell, S G. Ranaday, C. H. Allan(Colonial Service), J. T. Cartaya, F. A. Baldwin (ColonialService), T. F. G. Mayer (Colonial Service), F. C. Sutherland,and Guy Ruata.

THE WORKING OF THE INEBRIATESACTS.

THE report of Dr. R. Welsh Branthwaite, H.M. Inspectorunder the Inebriates Acts, which has recently been issued,contains even more information than its predecessors andeither with or without them might usefully be studied

by every county and borough councillor and magistratein the kingdom. Indeed, it is difficult to see how,without the careful consideration by all concerned of the

points to which Dr. Branthwaite calls attention in his com-ments upon the statistics which he presents, thoroughlyefficient working of these important Acts can ever beobtained. The progress which he shows is satisfactory asfar as it goes, but some of the defects which he also criticisesappear to be unnecessary and capable of remedy. Thosewho consider the question of the responsibility of the com-munity for the care of the habitual inebriate should, in orderto avoid confusion, bear carefully in mind the distinct formsof establishment provided by law for this purpose. Theretreat established under the Inebriates Act, 1879, is for thereception of habitual drunkards voluntarily submitting them-selves to its restraint. The State Inebriate Reformatoryinstituted under the Inebriates Act, 1898, is primarily forhabitual drunkards convicted on indictment of offencespunishable with imprisonment under Section 1 of that Act.As its name implies it is a State institution, provided andmaintained at the expense of the Treasury. The CertifiedInebriate Reformatory, also a creation of the Act of 1898,may be instituted by county or borough councils or privateindividuals and is primarily for the reception of inebriatesconvicted under Section 2 of the Inebriates Act, 1898, ofminor offences connected with drunkenness four times with-in 12 months. Persons originally cOLofined in State InebriateReformatories may be removed to Certified InebriateReformatories and vice versti, and in practice this trans-ference has been frequently found desirahle, as the person

, who has been convicted of an indictable offence com-

mitted through drink often proves more tractable than

, the person who has become liable under Section 2 and so

‘ may be advantageously treated in the less rigorously dis-l ciplined surroundings provided by voluntary effort, whereasthe comparatively harmless soaker who cannot be committedto any but a certified reformatory sometimes proves notamenable to the restraints that are there available. An

l

important element of weakness in the administration of the’ Act of 1898 to which Dr. Branthwaite refers lies in the fact; that it does not cover the whole ground of habitual, inebriety coming before courts of law owing to the

voluntary element introduced into the working of

1 certified reformatories. Acceptance into these is de-

pendent upon whether the managers of the institution arewilling to receive the inebriate offered to them. A pro-portion of those convicted under Section 2 may fairly be

I described as cases hopeless of reform, at all events within theperiod for which detention is ordered. No case, perhaps,

’ should be pronounced with authority to be beyond pos-- sibility of improvement, but persons of the type of Jane- Cakebread and Tottie Fay, whose sad cases contributed. largely to the institution of the certified reformatory, are pre-I cisely those whom managers of these institutions are likely to

reject. This operates in two ways ; the unfortunate inebriateafter a short time in gaol is left at large to do mischief tohimself and to the community and the magistrate who finds

g a drunkard thrown back upon his hands is discouraged fromIf committing other inebriates to the reformatory. He mayv even misunderstand the causes at work, denounce the Act

as mefficient, and delay its operation in the district where he- presides. Dr. Branthwaite makes out a strong case for the-

admission even of the worst cases to the institutions pro-- vided by local authorities for the benefit of their localities,i- although to do so would necessitate taking charge ofr- inebriates who as such would be probably irreformable and who, moreover, might be immoral, unruly, physically), defective, and in all respects undesirable inmates. Moreover,n the possible rejection of an apparently irremediable casen encourages the magistrate to attempt to discriminate in theil future for himself as to which case is capable of beneficial

J, treatment and which is not, a matter as to which he cannot

possibly be in a position to form a correct opinion.

46

We have suggested above that the Blue-book containing Dr.Branthwaite’s rrport might usefully be read by all countyand borough councillors and by all magistrates, because uponthe provision of accommodation for inebriates by the formerand upon a proper appreciation of the work done by reforma-tories on the part of the latter the successful working of theAct of 1898 entirely depends. With regard to the provisionof accommodation we have suggested that the reception ofall cases, if possible, is desirable in the public interest. Apart,however, from questions of discrimination we find by thereport for 1902 that at the end of that year a numberof counties and boroughs had entirely failed to avail them-selves of the Act or had done so to a v.-ry slight degree only.A study of Dr. Brantb waited figures will show this in detail.It may be summarised by saying that on June 30th, 1903,out of 495 inmates of inebriate reformatories 259, or morethan 50 per cent. of the whole, came from London andthe metropolitan district. Lancashire added approximatelyanother 25 per cent. and the remaining 25 per cent. weremade up by the whole of the rest of England and Wales.The contribution of Wales at the end of 1902 amounted to

12 only, of whom 11 came from Glamorganshire and one fromCarnarvonshire. We are not aware that any feature ofuniversal sobriety entitles the rest of the plincipality to dis-pense entirely with the assistance which the Act under con-sideration offers, and the same observation applies toBedfordshire. Cambridgeshire, Cornwall, Derbyshire, Here-fordshire, Huntingdonshire, Lincolnshire, Oxfordshire,Rutland, Suffolk, Westmorland, and Wiltshire, from none ofwhich at the same date had any person been committed toan inebriate reformatory. Four more counties had made ueof the Act in one instance only, one on two occasions only,and Cumberland and Leicestershire, while ufficiently awareof the Act to contribute four each to the total, had not foundit desirable to exceed that number.The failure to make use of the powers given lies partly at

the door of local authorities who are, however, in manyinstances making efforts to obtain the best possible accom-modation for the treatment of their inebriates. Countiesand boroughs may contribute to the construction and main-tenance of a certified reformatory or may arrange for theaccommodation of inmates in such institutions by payment.The majority of the. certified reformatories which came earlyinto existence were to be found in the southern portion ofEngland. The Lancashire reformatory at Langho was notcompleted at the time when the Blue-book before us wascompiled and the Yorkshire reformatory, the plans of whichare given, had been but recently commenced. The comple-tion of these two should inspire the building of othersbesides setting free accommodation elsewhere.

In addition, however, to that of the local authority thegoodwill of the occupants of the bench is necessary.Magistrates may have been discouraged by the failure toobtain treatment which has followed their committal ofindividual ca-es. Want of accommodation and the unwilling-ness to treat apparently hopeless cases have contributed tothis, but magistrates must be reminded with reference to thelatter cause that the hopeless cases of the present dayare due to the want of power to deal with cases not yetirremediable in the past. Reformatories are primarily forreform and must be used for those who are not too far gone tobe treated if the treatment is to be effeebual. Any tendencyto give the drunkard "one more chance " to reform himselfwhen he is qualified for compulsory treatment is false kind-ness which may result in his final ruin, and anv attempt tominimi-e his sentence is no less creel to him. The reforma-tory cannot do him much good during a term of a fewmonths only. If it proves effective in less than the periodfor which his committal has taken place those who manageit have powcr to allow him out on licence, and considerablecare is exercised to render such period of probation a usefulpart of the treatment.

It is possible, moreover, that the judges, who at assizeshave the opportunity of calling marked attention to theInebriates Act of 1898, do not always exercise their influencewith regard to it to their fullest extent. Mr. JusticeGrantham by his observations at the last Durham ass’zesand by the controversy in which he has involved him-elfwith the licensed victuallers his drawn a good dealof public notice to the connexion between drunkennessand crime He has, however, thrown upon the publicansa very large proportion of the blame which in many casesmay be deserved and has not, so far as we are aware, con-tributed in any marked degree to the effectual working of

, the Act, either by reference to the powers which it gives orr by criticising, with the aid of his experience, its merits andI demerits. The man or woman whom drink converts into a. violent criminal is a person whom most publicans would

gladly be rid of, but it is for judges and magistrates to placesuch inebriates under salutary restraint. "

I Section 1 provides as follows:-Where a person is convicted on indictment of an offence punishable

with imprisonment or penal servitude, if the court is satisfied from theevidence that the offence was committed under the influence of drinkor that drunkenness was a contributing cause of the offence, and theoffender admits that he is, or is found by the jury to be, an habitualdrunkard, the court may in addition to, or in substitution for, anyother sentence order that he be detained for a term not exceeding threeyears in any State reformatory or in any certified inebriate reformatorythe managers of which are willing to receive him.

The rest of the section deals with the procedure tobe adopted should the prisoner refuse to admit hishabitual drunkenness so as to necessitate evidence beingheard upon the subject. Up to the end of 1902 there hadbeen no State reformatory available and so the figures givenin Dr. Branthwaite’s report refer only to certified reforma-tories willing to receive the inebriate convicted on indict.ment. This accounts in a measure for the number ofcommittals to reformatories being small, coupled as it is.with the neces-’ity which still remains for convictionupon indictment at quarter sessions or assizes. It is,however, to the nature of the offences which have ledto committals to reformatories under this section that.Dr. Branthwaite points in support of his suggestion thatinsufficient use has been made of it. There have bFen infour years 96 such committals, of which no less than 78 havefollowed convictions under the Cruelty to Children Act.This is equivalent to saying that but for the efforts of theNational Society for the Prevention of Cruelty to Children tosave children from neglect and ill-treatment (not to reformdrunkards) this useful section would have been almostinoperative. This state of affairs must to some extent.be due to the apathy of judges and magistrates, althoughthere is one cause which no doubt prevents it from beingput into effect in some otherwise suitable instances. To thisDr. Branthwaite does not appear to give weight. It is thenecessity, which reference to the section cited will show,of proving by evidence that the convicted person is a-

habitual drunkard in cases where he denies it. In some in-stances this may be easy—as, for example, where frequentconvictions at a police-court for offences connected withdrunkenness have preceded the conviction on indictment.Oa the other hand. the convicted person may not be a" habitual" drunkard at all, or he may be one, and yet theremay be considerable difficulty in proving him to be such tothe satisfaction of the jury. Again, apart from lack ofevidence, juries have their prejudices ; there may be personsupon any jury who for various reasons would rather seethe convicted person punished without reference to theInebriates Act. It is, however, for judges and chairmenof quarter sessions primarily to render this section effec-tive if the community and the victims of inebriety areto reap the full advantage of it. Imprisonment mayprecede the term in a reformatory as the section shows.The statistics which relate to the use of retreats under the

Act of 1879 by persons consenting to be treated in themare not very encouraging, although they show some increasein the number of those admitted. There were 552 receivedinto retreats in 1902, a against 433 in 1901 and 422 in 1900.In 1899 there were 437. The increase for 1902 is accom-

panied by a curious rise in the number of females admitted.This rose to 305. as against 186 in the previous year. As a rulethere has been a preponderance of women among those com-mitted to reformatories and a preponderance of men amongthose voluntarily consigning themselves to retreats, and thenew condition may be merely temporary and accidental.That the use made of the power of self-committal to restraintof this kind should be small compared with the number ofhabitual drunkards is not surprising when we consider thatthe drunkard in his soberest moments is not a person whose

good resolutions are likely to last long and no doubt theyhave often time to weaken before the formalities imposed bythe Act are complied with. At present the inebriate in

England cannot as such be compelled to accept treatment, ashe can in some countries. To the possibility of providing forthis Dr. Branthwaite refers, as well as to the other causewhich has militated against the success of the retreat. Thisis simply the lack of funds. The poor patient finds little-accommodation provided for him and the destitute inebriate-

47

finds none unless charity will come to his aid. These personsare, in fact, in a worse position than if drunkenness ledthem toB offend against the law. On the whole the Blue-book shows regular if somewhat slow progress in the workof the two classes of reformatory and of retreats, and theperusal of its contents may be recommended to those who canaccelerate a development which is much to be desired.

in

POST-GRADUATE WORK ABROAD. an

VIII. CHICAGO.1

BY J. B. MURPHY, A.M., M.D., PROFESSOR OF SURGERY IN THE NORTH-WESTERN UNIVERSITY SCHOOL,

CHICAGO ; SURGEON-IN-CHIEF, MERCY HOSPITAL, CHICAGO, ETC.

THE conditions underlying post-graduate study in Chicago tbm

are entirely different from those obtaining in Europe, and plespecially in Berlin, Vienna, or Paris. The great majority in

of hospitals are not under government or municipal control T

and we have no "faculty of medicine" in a public official c<

sense. Neither have we bodies like the Assistance Pub- 1&deg; Tlique" whose ticket entitles the holder to admission to the UIvarious hospitals under its control. The place of these two pbodies is largely taken by the post-graduate schools, of whichmore anon. Chicago, like Gaul, is divided into three parts, a:

separated by the Chicago river and its branche3. Each of Tthese has a post-graduate school, one or more medical 9colleges, and many hospitals. o

The largest division-the west-has the so-called "medical hcentre " ot Chicago, with the County Hospital for a nucleus. hThis institution is one of the largest general hospitals in the a

United States, having 1200 bsds. The county morgue and o

the Detention Hospital for the Insane are on the same 6

grounds. Clinics are held in the amphitheatre continuously t:

throughout the day by various members of the attending vstaff but there is no bedside instruction. A ticket, good for 2one year, admitting the holder to all clinics and necropsies tcosts five dollars (one pound). Within a square or two are a

four medical colleges, a pot-graduate school, and three c

hospitals, which are the Presbyterian Hospital, the West ISide Hospital, and the Women’s Hospital. SThe south division has the new but very prosperous B

Chicago University. The medical schools and hospitals are E

again located close to each other but some miles nearer the (city proper than the university. The principal hospitals are 1the Mercy Hospital, with 260 beds, the Wesley Ho-pital,with about halt the number, and St. Luke’s Hospital. Thenorth side has fewer hospitals and medical schools. The !’most important of these are the Alexian Brothers’ Hospital ifor men only (this is the best constructed and equipped l

hospital in Chicago and has 280 beds ; all of the patients 1may be used for clinical purposes, though many of them Jare pay patients), St. Joseph’s Hospital, and the Augustana cHospital. ,

A prospective seeker for post-graduate instruction couldwrite to the secretaries of the various post-graduate schools Ifor their annual announcements. Their adrese- are as I

follows: west side, Dr. W. L. Noble, 819, West Harrison-street ; south side, Dr. F. H. Martin, 2400, Dearborn-street ;and north side, Dr, M. L. Harris, 176, East Chicago Avenue.After perusing the lists of faculties and weighing the advan-tages offered by each institution he will probably make adecision or possibly he may delay it until arriving in the

Icity. The clerks at the schools are provided with lists of Irooms, boarding houses, &j. The faculties of the schoolsare all connected with a hospital, sometimes with several,and schedules of the various operations and medical clinicsfor the day and the day following are displayed on thebulletin board. The time is pretty well occupied with theclinics in the schools and at the hospitals near by. How-ever, most physicians find time for a course in some specialline-operations on the cadaver, bacteriology, pathology,histokgy. and the like. As a general rule, tickets fortwo or three months stay at a post-graduate school will

1 No I. (Paris). No. II. (Berlin), No. III. (Vienna). No IV. (Budapest),Nos. V. (Florence) and VI. (Milan), and No. VII. (New York) werepublished in THE LANCET of Sept. 12th (p. 781), Sept. 26th (p. 912).Oct. 17th (p. 1121), Oct. 24th (p. 1194), Nov. 21st (p. 1465), and Nov. 28th(p. 1534), 1903, respectively.

cost from$75 to$100 (from 15 to 20 pounds) ; the’

special courses each cost from$10 to$25 (from two to fivepounds), depending on the number of sessions, &c. Some re-duction is generally made when a stay of two, three, or moremonths is made. No precise figures can be given for boardor lodging, as individual tastes differ so much. The formerin families will run from 15s. per week, the latter from;8s. to 10s., including heat, light, and attendance Thereis no lack of opportunities for special work. For instance.in ophthalmology and otology the Illinois Eye and KarInfirmary, which is maintained by the State, is located hereand has a very large out-patient department in addition tothe wards. Clinic tickets, good for one year, cost fivedoJlars. There is also a private Eye, Ear, Nose. and ThroatHospital (Dr. J. R. Hoffman, secretary, 206, East

Washington-street) which gives regular instruction indiseases of any or all of these organs For laboratory workthere are abundant facilities also. Arrangements may bemade with the instructors in the schools or colleges topursue any desired subject, the cost depending on theimportance of the subject and the lengrh of time necessary.The University of Chicago offers courses on every con-

ceivable subject-advanced anatomy, pathology, bacterio-logy, anatomy of the eye and ear, neuro.pathology, &c.These usually occupy one quarter (three months) of the

university year and cost from$25 to$50 (from five to ten,pounds) each.

For those interested in psychiatry the Detention Hospitalaffords a wide field. The Insane Court is held here everyThursday and all patients brought in since the previoussession are examined. If committed to the asylums they aregenerally sent to the county one at Dunning, some 15 milesout in the suburbs (fare, six cents) The infirmary, or poorhouse, is located here also, the two institutions combinedhaving a capacity of some 2500. The nearest State asylums

, are at Elgin, 25 miles west (fare$1, or 4s ), with a capacityof 1500, and Knkakee, 50 miles south (fare$1. or

i 6s ), with a capacity of 2500. As regards medical libraries,, the Newberry Library on the north side (ten minutes’ ride),; while of recent origin, has some 20,000 volumes and about. 200 current periodicals. Chicago has nothing to boast of in; the way of pathological museums. These are of slow growth and as the medical colleges were burned in the great fire or; have been started since there is little but a nucleus as yet.t, In generdl museums the Field Columbian Museum (south,

30 minutes’ ride), though less than a decade old, has a really5 wonderful collection of specimens in comparative anatomy, anthropology, zoology, &c. The Academy of Sciences

(north, 20 minutes’ ride) has a similar but smaller col-s lection., The various medical societies, surgical, gynaecological,.a &c., have been recently combined with the Chicago Medicala Society and are now branches of it. The parent society and.1 its branches have meetings once a week or more often.i Little or no influence is exerted by the season of the year ons the character of the work. The summer is never unduly hota for any length of time and the nights are generally coola owing to the lake breezes. Early in the spring-February

and March-there is (as elsewhere) some raw, damp weather-d for a few days. For physicians desiring to spend a few dayss only in the various medical centres of the United States,,s combining business with pleasure and coming over, as theL- Hindoos say, "to smell the air," the presentation of a

; professional card will insure them courteous attention and;. admission to the clinics for the short time of their stay.i- The advantages of Chicago post-graduate students are thea accessibility of the different institution". All distances were-e measured from the court house and the principal hospitals,)f colleges, &c., are within a radius of two miles in eachIs direction. By a series of electric trams (fare five cents.,1, or 2-2d.) nearly every desired point can be reached3s within a square or so. The surgeons in Chicago rarelyie ever operate in private reidences ; all of their operations are-ie made in the hospitals. Visiting physicians are admitted tov- the private operations. The custom adds enormously to theal opportunities for witnessing surgical work in Chicago.y, Next, the hospitality of the Chicago people which, ofor course, includes the physicians. The latter take especialill pains to interest their visiting brethren and divide their-stores of wisdom with them The enterprise which has

t), made Chicago world-famed from a commercial standpoint2 extends to the medical fraternity also. Nowhere in the

th country do we find the doctors more harmonious, skilled,and progressive.