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					  838 NOV. 12, 1927]                                     CORRESPONDENCE.                                                  TDA   IOEA

  CONVULSIONS DURING LOCAL ANAESTHESIA.                                 ability as regards patient, guardian, environment, and
  SIR,-I have read with interest Dr. Liston's letter on                 acoessibility. The ideal solution of the difficulty of providing
this subject in the BRITISH MEDICAL JOURNAL of October                  for leave of absenoe and discharged cases lies in the scheme
29th (p. 806).                                                          of hostels. These would afford the patient a feeling of pro-
  On March 6th, 1925, I extracted the right upper lateral incisor       motion and change, combined with the knowledge that he
sf a man of about 40 years of age. The local anaesthetic used           or she was at least a partial wage-earner; would relieve
 yas locosthetic, a preparation containing 0.75 per cent. of. cocaine   the ratepayers by producing a class of partial wage-earners,
hydrochloride and one part in 50,000 of adrenaline chloride; and        and would afford a feeling of safety, as to the disposal of
the quantity was something less than the recommended dose of            patients, to the authorities concerned. I am quite aware
1, which contains one-ninth of a grain of cocaine. After
waiting three or four minutes after the injection the extraction        of the difficulties involved in the scheme, but most difficul-
was carried out without difficulty or pain. The patient rinsed his      ties can be overcome. For instance, in* the more rural
mouth with two tumblers of water in succession, and then,               districts agricultural and road work might replace the
probably 10 to 15 minutes after the injection, he had a violent
epileptiform convulsion. He lost: consciousness, his breathing          usual work of the more ordinary hostel. I may here
became stertorous, and his skin and conjunctivae assumed a              remark that sterilization might usefully be employed in
jaundiced hue-not purple, as in Dr. Liston's case. In this condi-       many cases suitable for a hostel.
tion the patient kick-d a bracket table, two feet higher than the          8. Mental Deficients in Mental Hospitals.-I agree that
seat of his chair, and drove it through a plate-glass window.
  A few seconds later he recovered; but was not able to leave           this is in every way undesirable. Should the ordinary
the house for an hour, at the end of which time I sent him home         inmates in any way become aware of the presence of idiots
under escort in a taxi-cab.                                             and such-like, the effect upon their unbalanced minds. might
   He stated that he had never had a fit before. On two                 be devastating.
occasions since 1925, using novocain, I have extracted                     9. Encephalitis Lethargica.-There is little doubt that we
teeth for this patient, without any unpleasant results.-                are now seeing many results of this in police courts and
I am, etc.,                                                             elsewhere. In looking over reports from our school medical
  London, W.1, Nov. 1st.      A. J. MAURICE, L.D.S.Ed.                  inspectors -I-am much interested to note quite a number
                                                                        of children, classed dull and backward, who have definitely
                                                                        or indefinitely suffered from this disease. I am keeping
       MANAGEMENT OF MENTAL DEFICIENCY.                                 a special record of these cases in order to be able to com-
   SIR,-The report of the Board of Control must interest                pare their past and future histories. I am doubtful
greatly those engaged in mental deficiency work. Taking                 whether these cases should be returned as normal to an
the remarks seriatim:                                                   ordiinary school, though a large number of them are
   1. I agree entirely as to the good results obtained from             certainily not certifiable under the Mental Deficiency Act.-
institutional treatment, provided the cases go there early              I am, etc.,
enough. Those institutions are undoubtedly better planned                 Exeter, Nov. 6th.                  CLAUDE A. P. TRIUMAN.
in which patients are disposed in separate blocks, such as
Monyhull, and, in the case of simple epileptics, at Chalfont
St. Peter. This arrangement allows of much more accurate           CONTRIBUTORY SCHEMES: HOSPITAL CLUB
classification, and has several other considerable advan-                                  PRACTICE.
tages not touched upon in the report. I am convinced             SIR,-In your issue for October 22nd last (p. 751) you
that any prospective colony should be arranged upon these refer to a scheme proposed for Birmingham which, in its
lines.                                                        injustices, fairly beats all other schemes so far heard of.
   2. Marriage of Defectives.-This is so obviously undesir- You express an opinion on such schemes which happens to
able that no comment is needed.                               be .on all fours with statements made by myself at the
   3. Sterilization.-While at once ad-mitting that the opera- July Meetinig of the Representative Body (BRITISH MEDICAL
tion, in its most successful issue, would not obviate the JOIURNAL, SUPPLEMENT, July 30th, p. 75), and it is a matter
niecessity of institutions, I believe that suitably selected of surprise that so far no one has commented on that
cases would relieve pressure elsewhere and afford many opinion. It is this:
cases the.greater freedom they can reasonably claim. While       "Contributory schemes are forms of insurance. They are
agreeing with most of what Dr. Turner (Report, p. 44) much insurance as the insurance of one's house against fire. just
says,  I still think that a minority, however small, have a is a tendency in some quarters to attempt to disguise this fact by
                                                                                                                   hospitals.' Sukh
claim to special consideration both on their own account, a haze rightphilanthropic zeal on should not the allowed to :blind
                                                                        of                         behalf of
                                                                    is        and laudable,
and also for financial reasons. I refer to this point again zeal critical eye, so that it but it to scrutinize be details of,.- the
                                                              the                            fails              the
in my memorandum upon hostels.                                policy of insurance which is enacted under the guise of ,sich
   4. Ascertainment, however accurate, is not to be con- contributory schemes. A lack of care in the initiation of these
                                                                                      a world of
sidered an end in itself. It is equivalent only to acquiring schemes may mean between the trouble later on, schemes,
                                                                                                                      and possibly
                                                                                                   authors -of
ground for a colony and in proceeding no further. Asoer- strained and the contributors, which might the avoided bythe
                                                              hospitals,                                         be               a
tainment in Devon is commendably high. I think I may little cool criticism at the outset."
say that all engaged in the work here take this as a strong      Everyone who concentrates on this question must agree
incentive to renewed activity for some tangible results to with your statement; especially had you referred in the last
their labours.                                                sentence to the " private practitioners." No distinction
   5. Supervision to a oertain extent is the supplement to can be drawn between a scheme for the provision of
ascertainment, and, pending increased institutional treat- domiciliary medical attendance for services within tlle
ment, is perhaps the best means of keeping in touch with competelncy of a general practitioner and another scheme
known defectives. The size and geographical nature of for services which, as a rule, are beyond his competency.
Devon, however, make both ascertainnment, and especially Both are forms of " club practice," however hidden under
supervision very difficult-more so, I fancy, than is realized a euplhemism. Under both the premiums paid should be
by the Board of Control itself.                               adequate in order to make a reasonable payment to. tbe
   6. Occupation centres are admittedly excellent, and do practitioner for the services guaranteed by the scheise.
imiuch both in reaching those cases for which institutionis If a practitioIer refuses payment it does not make itt *y
have no room, and those whose parents are unwilling, to less a case of club practice, whilst he lays himself oAn
send them from home. We have few in Devon, and, were to the accusation that he is underselling his profess'oe a'
there more, access to themn would be difficult unless special colleagues; for, in fact, he places himself on somewbita
transport facilities were provided. The want of them lower plane than the doctor who opens a house to,...
might conceivably be mnet by setting up special classes in patients for sixpence (with medicine ninepence) i, a
some of the smaller towns and larger villages..               district where half a crown is recogpized by all as reaadn-
   7. Guardianship.-I do not share the Board's optimism able. And yet at the moment this is the attitude of ia4y
with regard to tlhis scheme. It is most difficult, often im- visiting staffs of hospitals.f
possible, to get the right sort of guardian in the right        The policy- of the Associationi states distinctly that the
locality. Most cases suitable for modified "discharge" beneficiaries under these insurance schemes are no longer. to
require great care in the choice of environment in every be considered objects for charity, but that they should.- be
sense of the word, and it is most difficult to combine suit- requiired to pay, by adequate premiums, the full cost of

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