236

SPECIAL ARTICLES

MEDICINE AND THE LAW

Traffic Casualties : What is EmergencyTreatment ?

A MEDICAL practitioner a few days ago obtained asatisfactory decision at the Gloucester county court ona claim for emergency treatment to the victims of atraffic accident. The accident happened at Whit-minster just before midnight; six people were injuredand the police called up Dr. W. G. Murray-Browne atStonehouse. On arrival at the scene the doctorexamined one patient and found him dead; he thenwent to Whitminster police station and examined theother five patients. Section 16 of the Road Traffic

Act, 1939, lays down that the person using the carwhich causes bodily injury (including fatal injury)is to pay the doctor 12s. 6d. for each person receivingemergency treatment and also travelling expenses atthe rate of 6d. a mile for any distance over twomiles which must be covered in proceeding from theplace whence he is summoned to the place where hegives the treatment. Dr. Murray-Browne claimedJE3 17s. The defendant motorist said that the act con-fines itself to cases " where medical or surgical treat-ment or examination is immediately required." Thetreatment, he said, was given an hour and a quarterafter the accident; this could not be the emergencytreatment " immediately required" within the statute.The defendant’s contention would perhaps have beenstronger if the act had said " immediately rendered"instead of " immediately required." The argument didnot convince the court. Judge Kennedy said he hadno doubt that the medical treatment or examinationwas " immediately required " and that Dr. Murray-Browne’s services were given as quickly as possible.He gave judgment for the sum claimed.Not long ago a similar claim was dismissed in rather

different circumstances. A woman was injured inthe middle of London and was taken to her homein the suburbs where her doctor was summoned toexamine her. The court held that the interval andthe journey home prevented the treatment from being"emergency treatment" which was " immediatelyrequired." In the recent case at Gloucester, it wouldhave been hard if the plaintiff doctor, summoned atmidnight, had been deprived of his statutory fee. Adecision against him would have meant that, if theaccident were in a remote place, no doctor could everclaim under the 1934 Act, and that, the longer thedoctor’s midnight drive, the less chance of his succeed-ing in obtaining the statutory fee.

Desertion of Wife in Mental HospitalNot long ago the divorce court decided that a wife

who was an inmate of a mental hospital must beincapable of the matrimonial offence of desertion.Being insane, she could not form the intention todesert her husband. In Sotherden v. Sotherden,the Court of Appeal has now considered the con-verse case; if the wife was detained in an asylum,could her husband be guilty of deserting her 1 Wasshe in a position to make a home for him, if hewished to live with her ° The marriage had takenplace in 1915. In 1931 the wife entered a mentalhospital. Her husband visited her there at first; butabout February, 1932, his visits ceased and in thefollowing July he disappeared. The wife was dis-charged from the asylum in September, 1936, andpresently petitioned for divorce on the statutory

ground that her husband had deserted her for morethan three years immediately preceding the date ofher petition. Mr. Justice Bucknill dismissed her

petition because during part of the three-year periodshe had been detained in the mental hospital and couldnot have made a matrimonial home. The Court ofAppeal reverses his decision. In Pulford v. Pulford(1923), where the wife had been in a poor-law asylum,Lord Merrivale observed that desertion was not with-drawal from a place but from a state of things; thewhole conduct of the parties must be reviewed. Apply-ing that principle, the Court of Appeal has held thatMr. Sotherden withdrew in 1932 from the state ofthings to which his wife had a right while she wasan inmate of the mental hospital. The fact that itwas not possible for the pair to have a matrimonialhome was immaterial.

THE LONDON MEDICAL SCHOOLS

IT is now possible to complete the account given inour issue of Jan. 13 (p. 100) of the arrangements thathave been made for teaehing at the London schools.

CHARIXG CROSS

After being dispersed to sector hospitals for fourmonths, most of the clinical students of Charing Crosswere brought back on Jan. 1. At present two centresare being used for their instruction. The first-yearclinical students are accommodated in the Bonar LawCollege at Ashridge, Herts, where they are receivingpreliminary courses, including systematic lectures, inpathology, medicine and surgery. After completingthe preliminary work they are appointed to medicalclerkships and surgical dresserships. The instructionis given by members of the school’s own staff, thematerial is fully sufficient and the students are keptfully occupied. The second and third year clinicalstudents are in attendance at the medical school andthe hospital itself, and they are getting a full serviceof instruction which closely approximates to thenormal. The inpatient facilities are somewhat re-stricted, but in conjunction with Ashridge they aremore than sufficient for the limited number of stud-ents accepted. The time-table of classes, includingpathology, is almost as complete as in normal timesand all the special departments of the hospital, withone exception, are functioning. The exception is themidwifery department, and arrangements have beenmade which are providing students with more thanthe required number of cases. All outpatient ses-sions, which are held daily, are used for teaching aswell as the formal ward rounds.

THE LONDONT

The organisation of the London Hospital medicalschool is now based entirely on the London Hospital.There 230 beds have been in use for civilian sicksince the outbreak of war and students have gone onworking as clerks and dressers in the wards. System-atic lectures and demonstrations were started onNov.1. The museum, library, pathological department,students’ hostel and athenaeum are open. The out-patient departments and clinics, including the mater-nity district, are now in full swing nearly at theirpre-war level. On Feb. 1, 150 additional beds arebeing brought into use for ordinary civilian cases, andthere will be 30 beds for obstetrics and gynaecology.There will therefore be approximately 500 beds in all,150 of these being reserved for service sick and air-raidcasualties. The medical professorial unit will be re-established, and there will be three medical and threesurgical firms, the aural firm, the cardiac departmentwith beds and the department of obstetrics and

237

gynaecology. The preclinical school with staff andequipment remains in Cambridge. It has beenthought inadvisable to bring it back to the " London

"

at present but the school will undoubtedly return inthe autumn unless the situation is changed by air-raids during the summer.Over a third of the clinical students are actually

working at the London Hospital and more than two-thirds attend there for part of the day. Students arebeing withdrawn from all upgraded institutions, thatis from all mental hospitals and public assistanceinstitutions which have been converted into E.M.S.hospitals. These hospitals receive " transferredsick" from the hospitals in Central London andsuch cases are not satisfactory for medical edu-cation. They are usually cases already investigatedand diagnosed or cases of a special kind transferred to acertain hospital so as to be under a particular specialist,and they give the beginner a false perspective ofthe practice of medicine. Students are, however,being kept at all the existing municipal and voluntaryhospitals in sectors 1 and 2 with which the LondonHospital is now associated. These afford unrivalledopportunities to gain experience in all branches ofmedicine and surgery.Under the present organisation junior clinical stud-

ents will spend their first year at the London. Duringthe first six months they will work as clerks anddressers in the wards and then attend for three monthsas dressers in the special departments. They willnext be given a course in pathology, and will attend at a,fever hospital and a mental hospital. After instructionin anaesthetics, midwifery, and gynaecology, studentswill be sufficiently senior to be attached for six monthsto one of the municipal hospitals to gain further prac-tical experience. This work will in most cases bedone at one of the seven large L.C.C. hospitals withintwo miles of the London Hospital which togethermaintain over 2500 beds, and the student will alsobe able to attend the London Hospital in the after-noons for systematic teaching and visit the Queen’sHospital for Children and the London Chest Hospitalat Victoria Park. Alternatively, some (about a

third) will spend their whole time at the West Hamborough council hospital at Whipps Cross with 1430beds, at the Essex County Hospital at Romford with985 beds, at the North Middlesex County Hospitalwith 1380 beds or at the Southend General Hospital.All these are general hospitals and provide a wealthof clinical material which has never hitherto been usedfor teaching. After six months at one or more ofthese hospitals senior students will return to the Lon-don to attend the outpatient departments and forrevision work preparatory to their final examinations.

There are now 26 resident house-appointments at theLondon Hospital and additional clinical assistants willbe appointed as outpatient work increases. Another50 London men are holding house-appointments insectors 1 and 2. A post-graduate course in surgery’for the final F.R.C.S. examination will begin at theLondon Hospital in February and a course in ad-vanced medicine for the M.D. and M.R.C.P. will bestarted, circumstances permitting, in April.

WESTMINSTER

All the clinical students at Westminster Hospitalare now in London, and, since the honorary staff havejoined the part-time E.M.S. scheme, there is a fullprogramme of lectures. In the hospital medical,surgical and special units have been formed. Theseunits, owing to the reservation of beds for air-raidcasualties, are necessarily small, but it is hoped tocarry out a rapid turnover of patients in the unit bedsthrough the sector hospitals. Teaching rounds arealso being given in some of the L.C.C. hospitals.There will therefore be no question of studentssuffering from a lack of clinical material. The pre-clinical- students have gone to Glasgow with King’sCollege. They may remain there for the present, sothat the academic year will not be interrupted, butwill certainly be back in London by October. -

BART’S

Further details are now available about teaching atBart’s. The preclinical students are at Cambridge,mainly at Queen’s College. The first-year men (justover 50) do their work at the Leys School, and thesecond and third year (about 208) at various Cam-bridge laboratories, but all are under their originalBart’s teachers. The first clinical year (140) work atHill End Hospital under the Bart’s staff there. Thesecond (about 130) and half the third clinical years(80-90) are taught at Bart’s, and the other half of thethird year at Friern Hospital. The museum hasbeen distributed between all three hospitals.

DARK ADAPTATION

THE dual form of the dark-adaptation curve provesthat two mechanisms, proceeding at different rates, areconcerned. Lythgoe 1 points out that the initial partof the curve lasting about seven minutes representsthe photopic mechanism of the retinal cones, whereasthe later part of the curve represents the scotopicmechanism of the rods which continues for as longas an hour. Now, visual purple, in whose synthesisvitamin A plays an important part, is found inassociation with the rods but not with the cones. Atfirst sight this conception appears to conflict with theexperience of numerous workers, who hae used dark-adaptation tests for the detection of vitamin-Adeficiency and based their results on readings takenafter ten minutes, or five minutes, or even less. Thus,Harris and Abbasy 2 used the ten-minute interval asthe crucial reading in their earlier tests, though inlater work they included readings up to twentyminutes and beyond.The solution of this apparent ’dilemma is to be

found in the experiments of Hecht and Mandelbaum.3 4

They proved that both of these retinal systems, conesand rods, behave in a parallel manner during thedevelopment of vitamin-A deficiency and during itscure. As they say, " vitamin A is just as essential forthe restoration of cone function as for rod visualfunction." For their experiments Hecht and Mandel-baum kept a group of four volunteers on a dietpartially deficient in vitamin A. After the very firstday the effect of the deficiency could be detected inthe adaptation curve, and within a week it wasunmistakable.4 To cite an example, one of the subjectsexamined after the lapse of a month on the deficientdiet showed approximately a ten-fold drop in- hispowers of adaptation, during the whole of the firstseven minutes or so of the curve. At seven minutesthe curve abruptly changes from cone to rod vision;this interval of seven minutes was found to be thesame for all subjects irrespective of their diet ordegree of deficiency. After the sharp break at sevenminutes, the curves for the deficient and the normaleye show a gradually increasing further divergence,adaptation becoming virtually complete at about thirtyminutes.As Hess and Mandelbaum comment, the significant

thing is the almost parallel behaviour of both rod andcone thresholds during the development of deficiency,as also during its slow cure. They venture thespeculation that " just as vitamin A enters into thechemical cycle of rod vision due to its association

1. Lythgoe, R. J., Brit. J. Ophthal. January, 1940, p. 21.2. Harris, L. J., and Abbasy, M. A., Lancet, 1939, 2, 1299.3. Hecht, S., and Mandelbaum, J., Science, 1938, 88, 219.4. Hecht and Mandelbaum, J. Amer. med. Ass. 1939, 112, 1910.