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well to remember in cases of puerperal delirium. Dr.Danford Thomas pointed out that if such cases were

regarded as insane they might be treated legally as pauperlunatics and this would allow their speedy removal to theparochial infirmary. In private practice the difficulty ofmanagement is not so great, for the near relatives of the

patient will at once agree to any precautionary measureswhich can be confidently recommended. In a public hos-pital, however, considerable circumspection may be neededwhen patients become obstreperous. Thus if a patientsuffering from pneumonia attempts in his delirium to dis-charge himself through the window he would, of course,be restrained, but what if at an incipient stage of hismadness he insists on discharging himself through thedoor’? In both cases the consequences may be equally,if not as quickly, fatal. When a man suffering froman acute disease submits to skilled professional treatment,is he not presumed to recognise the appointed medicalauthorities as placed over him in loco parentis and does henot tacitly submit to any reasonable line of treatment thatthey may adopt for his benefit ? If this is the true relationit would justify the coercive duress necessary to prevent apatient from running headlong to wilful death, that is,unless and until a responsible person arrives who is able toappreciate the critical situation. No general hospitalshould be without an isolation room ready for the receptionof noisy patients, and further, where a patient threatens towork harm upon himself the responsibility for his safetyshould be at once shared by demanding the presence of thepolice who will then be officially associated in the solutionof a practical medico-legal problem.

THE WORKMEN’S COMPENSATION ACT AND

SURGICAL OPERATIONS.

AT the Southwark county court an application made underthe Workmen’s Compensation Act to discontinue weeklypayments made to an injured workman led recently to thediscussion of a point which arises from time to time in thesecases and will continue justly to form a subject for com-ment, although the law on the subject appears to be

settled. The employers contended that the man hadrecovered from his injury and in the presence of con-

flicting medical testimony a medical referee appointedunder the Act was called upon to report. This he did to the

.effect that the man was unable to perform his accustomedwork owing to the presence of conditions which had been- caused by the injury but which might be removed by surgicaloperation. The judge pointed out that he was unable toorder a surgical operation, although the employers mightpersuade the workman to submit to one, and in the cir-- cnmstances the application to discontinue the award was

dismissed with costs. This decision although in accord-ance with previous ones does not prevent such occur-rences from inflicting in some instances a considerableamount of injustice upon the employer or upon the com-pany in which he insures his risks. Surgical science is

capable of determining beforehand the varying prob- ability of success of a large number of the operations J

called for when workmen are hurt in the course of their f

employment. No one would wish the injured person to be I

compelled to submit to surgical interference the result of ’which was clearly doubtful and the failure of which would i

or might, leave him in a worse plight than before. At the 1

same time no one can consider it just that a man should 2

receive a pension and live in idleness when a reasonable E

man, independent of any pecuniary reward for his incapacity c

would certainly submit himself to a surgeon and by his aid i

regain the capacity for earning a living. In cases where a

jurors have to award damages according to their opinion of Lhe extent of the injuries sustained the difficulty does not 3

arise to the same extent, for the case can be presented tothe jury so that they can estimate the degree in which thedefendants should be held responsible. The damages underthe Workmen’s Compensation Act are simply measured bythe duration and the degree of the incapacity to do work andother cases besides that alluded to have proved that the

workman is fully aware of the advantages which the lawhas afforded him.

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MULTIPLE GESTATION.

Dr. A. Pinard has contributed an article on gestation tothe first part of the seventh volume of Charles Richet’s fineDictionnaire de Physiologie," published in January this

year. The last section of this article is devoted to multiplegestation and contains some interesting facts collected froma vast number of observations.’ In the first place, in regardto the circumstances that favour multiple pregnancies theyinclude race, heredity, multiparity, age, and development ofthe ovaries. The influence of race is undoubted. It was

demonstrated by Bertillon in an article which appearedin the " Dictionnaire Encyclopedique," and Tchouriloffin supporting the researches of Bertillon has pointedout that amongst racial characters height is-of greatimportance and has expressed this in the aphorism,"height and gemellity decrease together." Heredityhas a powerful influence on multiple gestation andthere is strong evidence derived from careful observa-

tions that paternal influence is exerted, though no explana-tion of the fact has been advanced. In regard to age, thestatistics of Lebel show that the largest number of multiplegestations occurs between the ages of 21 and 28 years ; thoseof Dr. Pinard are in accordance with this but those of Puech

give the ages between 25 and 35 years as most favourable fortwin pregnancies. The observations of the last-namedwriter seem to show that one circumstance is not to be

overlooked, the superior development of the ovaries whichmanifests itself in the production of two or more perfectova capable of being simultaneously impregnated. Dr.Pinard has collected a considerable number of cases of

superfecundation or, as he properly terms it, successive

fecundation, such, for example, as the following recordedby Caillier, a veterinary surgeon at Mouhon. A mare was

covered by a stallion and an ass in the space of half an hour.This mare gave birth in due time to a foal and within anhour afterwards to a mule. Cases of multiple gestation havebeen recorded in the human female. Thus Dr. Brittain com-municated to the Edinburgh Obstetrical Society the case ofa woman who at the age of 47 years had given birth to 25infants in 14 accouchements. William Wood attended awoman in October, 1857, who gave birth to one boy and-two girls and in the following October, 11 months and 22days later, had twins. The wife of a Parisian shopkeepernamed Brunet had, according to Sue, 21 infants in sevenconsecutive years. This man seduced a young servant whoat the end of nine months presented him with triplets.These numbers are, however, far exceeded by the historical.case of a peasant named Kinlow who in 1753 was presentedto the Empress Catherine. He had been twice married.He had 57 children by his first wife-four times four infants,seven times three, and ten times two at a birth. Byhis second wife he had triplets once and twins six times.The French authorities have drawn their conclusions in.

regard to the frequency of multiple births in women fromlarge numbers of recorded cases. Thus Dubois in 484,350accouchements in Germany, England, and France found.3248 cases of twins, 78 of triplets, and four of four at a birth,)r putting it in another form there was one case of twinsn 78 deliveries, one case of triplets in every 6209 deliveries,and one case of four at a birth in 121,082 deliveries.Veit, basing his statement on the immense number of;

1,360,557 deliveries, found that twins occurred in 149,9(4

244

cases, triplets in 1689 cases, and quadruplets in 36 cases,giving the proportion of one twin delivery to 89 singlebirths, one triplet in 7910 births, and one quadruplet in

371,126 births. Dr. Pinard observes that the frequency ofmultiple pregnancies varies greatly in different countries.In France twins are delivered in the proportion of 1 to 92single births, in Germany 1 to 84 cases, and in GreatBritain 1 to 63 cases of single births. Bertillon expresses the

proportion in which twin births occur in a different way.He finds that in 1000 confinements twins occurred 9 ’ 9 timesin France, in Belgium 9’7, in Italy 11’ 4, in Austria 11’ 9, inNorway 12’5, in Prussia 12’5, in Holland 13’1, in Denmark14’20, and in Sweden 14’ 50. Dr. Pinard observes thatBertillon’s statistics in regard to Belgium are not in accordwith Constant Leroy’s experience who found 650 cases oftwins in 39,508 single births. Finally, Dr. Pinard adducesthe observations of Bertillon showing that in certain

departments of France women bring forth twins more fre-quently than in others. Thus in Gironde, Haute-Garonne,Correze, Charente, Ain, Ardeche, Lozere, Gers, Cantal, Puy-de-D6me, and Dordogne the proportion of twins in 1000 casesof pregnancy varied from 6’ 77 to 7’ 95, whilst in Finistere,Jura, Morbihan, Nord, Mayenne, Cher, Vaucluse, Vosges,Vendee, Moselle, Savoie, and Haute Savoie it varied from I11-36 to 12-90.

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TYPES OF ALCOHOLIC INSANITY.

AN important discussion on the above subject was held atthe Boston Society of Psychiatry and Neurology, an accountof which is published in the Journal of Nervozcs and MentalDisease for December, 1904. Dr. H. W. Mitchell of Bostonintroduced the discussion in a paper based on the study of148 patients (excluding cases of true dipsomania whichexhibited no insane symptoms) at the Danvers Hospital forthe Insane, or 13 per cent. of the male patients admitted.The cases were grouped as follows: delirium tremens, acuteand subacute alcoholic hallucination, delusional alcoholic

insanity, and alcoholic dementia. Two were cases of

Korsakoff’s psychosis polyneuritica of alcoholic origin. He

found that among cases of delirium tremens "nearly all

recovered without development of the graver forms ot

alcoholic insanity." The prognosis in cases of acutealcoholic hallucination was good for the attack but relapsesdue to renewal of drinking habits were common. These

cases were characterised by vivid auditory and visual

hallucinations, the former predominating, with little dis-turbance of consciousness and with transitory delusions

probably based upon the hallucinations. In the case ofsubacute alcoholism there were auditory, visual, olfactory,and tactile hallucinations, with more prolonged persistenceof delusions. Periodic relapses were seen in these cases

during their stay in hospital, the intervals between the

attacks being periods of practically normal mental con-

dition. Permanent mental deterioration and dementia were

the ultimate goal of this class of cases. Alcoholic delusional

insanity was the term used for cases showing a developmentof delusions somewhat resembling paranoia. In many cases

the delusions are elaborated from hallucinations. "Ideasof marital infidelity, poisoning, and persecution were mostcommon in this class of cases." A tendency to incurablechronicity was observed in many and only a small proportionof cases recovered. Alcoholic dementia comprised cases inwhich marked mental deterioration and decay of intelligenceand morality were the predominant symptoms and thisoccurred as the result of many years of more or less con-tinuous use of strong spirits. Permanent mental deteriorationwas observed in all the cases studied. Among the variousalcoholic psychoses were seen many cases resembling generalparalysis, the exact diagnosis being possible only after pro- longed observation-weeks or months. 10 per cent. of the

total cases suffered occasionally from epileptiform con’

vulsions, while suicidal attempts and acts of violence werecommon in all classes of cases-points of medico-legalinterest. An alcoholic or an insane parentage was commonand made the prognosis bad. Somatic and grandiose de-lusions with alteration of the sense of personal identity wereunfavourable symptoms in delusional cases. In continuingthe discussion Dr. Woodbury said that 90 per cent. of casesrecovered from first attacks of delirium tremens. Dr.

Philip C. Knapp said that in the wards and clinics

of the Boston City Hospital cases of delirium tremens,hallucination, and alcoholic dementia were fairly common,while paranoid forms were quite rare. Dr. Mitchell, in

reply, said that alcoholic pseudo-paresis resembling generalparalysis was fairly common. Such patients had sluggishpupils which, however, reacted to light. Inequality of thepupils and failure of the reflex to light were found practi-cally only in cases which had had syphilis. The delusionalor paranoid cases in his series amounted to nearly one-fifthof the total. Parental intemperance was a common etio-logical factor. The milder forms of alcoholic psychosisoccurred in early life frequently in association with habitsof drinking. Alcoholic dementia showed itself in middle

age or later and was the result of heavy and continuous

drinking for many years. -

SEÑOR MANUEL GARCIA’S CENTENARY.

IT has now been definitely arranged that on the date ofthe centenary, Friday, March 17th, a celebration will take

place at noon in the rooms of the Royal Medical andChirurgical Society, 20, Hanover-square, London, W., in thecourse of which His Excellency the Spanish Ambassadorwill convey to Senor Manuel Garcia the congratulations ofthe Spanish Government. This will be followed by the

presentation of an address on the part of the Royal Society,-before which. Senor Garcia almost exactly 50’years ago readhis paper entitled " Physiological Observations on the

Human Voice," in which the invention and the method ofapplication of the laryngoscope were described. Other

addresses on the part of musical bodies, old pupils of SenorGarcia, and various laryngological societies will follow. Sofar as is known at present, the Berlin, South German, French,Dutch, and Belgian laryngological societies will be repre-sented by special deputies. In conclusion of this part of thecelebration Senor Garcia’s portrait, painted by Mr. JohnSargent, R A., and presented by admirers from all parts of theworld, will be handed to him, together with an album contain-ing the names of the subscribers. In the afternoon the LondonLaryngological Society will hold a special meeting at whichthe foreign delegates will be present and in the evening abanquet will take place, probably at the Hotel Cecil, inwhich all those who wish to do honour to the distinguishedguest on the occasion of the hundredth anniversary ofhis birth will join. The banquet will be attended by ladies.Further particulars will be given when the time approaches.

THE ETIOLOGY OF CARCINOMA.

WE publish in another column an article by Dr. W. FordRobertson and Mr. Henry Wade on the protozoon plasmodio-,hora as a cause of cancer in man, in which a further account; given of investigations already reported on at the meetingf the British Medical Association at Oxford on July 28th,904.1 The writers claim for their work that it has yieldedconfirmatory results along three parellel lines : (1) in aries of figures presented by stages in the life-cycleE the plasmodiophora brassicæ in turnips ; (2) in a

Jries of figures of intracellular and intranuclear in-fusions found in carcinomata in man; and (3) in the

1 THE LANCET, August 13th, 1904, p. 469