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DECEMBER 2, 1922.

A LectureON THE

MEDICO-LEGAL POSITION OF THEANÆSTHETIST.

Delivered before the Fellowship of Medicine onNov. 27th, 1922,

BY J. D. MORTIMER, M.B. LOND., F.R.C.S. ENG.,SENIOR ANÆSTHETIST TO THE ROYAL WATERLOO HOSPITAL,

ST. PETER’S HOSPITAL, ETC.

Ix this lecture I intend to consider only the medico-legal position of the holder of a diploma, who givesan anaesthetics for some purpose, such as the per-formance of an operation or the relief of pain. Thereare important questions-for instance, the possibilityof forcibly anaesthetising someone in order that a

crime may be committed, or the use of anaestheticsby unqualified persons, but these seem to me to bebeyond its scope, and are fully dealt with in certainbooks on forensic medicine and anaesthetics. Otherequally important questions are, in most of thesebooks, hardly noticed or quite ignored. In a work ofover 500 pages lately published I find on consult-ing the index one reference to anaesthetics. This" discuases " responsibility in a death from anaesthetics,stating in about three lines that such a death will bejudged by the same rules as a death from an operation.

SURGEOX AXD ANAESTHETIST.Whilst an anaesthetist is bound by certain rules-

obligatory by statute or Common Law, or by customand moral law-that govern the conduct of allregistered practitioners. as regards his special dutieshis position is ill-defined and subject to circum-stances. This is to a great extent due to the factthat it is only within the last 30 years or so thathe has been acquiring some independence, and thereare few authoritative decisions available for guidance.Formerly, operations were comparatively few andsimple. The surgeon took entire responsibility, andsupervised the administration of the anaestheticbesides performing the operation, and the anaestheticwas, in fact, often administered by an assistant or bysome unqualified person. Even now such conditionsmay be unavoidable in emergencies, but the obliga-tions of both operators and anaesthetists have so ex-tended that the majority of surgeons prefer to work withone to whom they can give a free hand, and, indeed,it is often impracticable for them to do otherwise,because their own work requires unremitting attention.

It is now generally considered that the anaesthetist.having to observe the patient’s general conditionshould warn the operator when this is unsatisfactorywhether from the anaesthetic or otherwise. Theresponsibility of the surgeon being thus diminished,he can hardly expect that his authority shouldremain as before.Some irreconcilable difference of opinion may arise

between surgeon and anaesthetist with regard to theanaesthetic or method to be employed. Dr. DudleyBuxton has suggested 1 that under such conditionsthe anaesthetist should retire, unless he had beenspecially called in by the patient or the practitioner.in .which case he is on the same footing as the surgeon.It may also happen that differences of opinion ariseto the course to be pursued in some emergency-forinstance, the entry of fluid into the air-passages, orthe completion of an operation when the patient is ina desperate condition. or when the operator or anas-thetist has shown himself to be very incompetent.One cannot lay down any general rule about suchcases, because tile respective professional or ofTicialstanding of the anaesthetist and the operator andtheir previous relations to the patient may widelydiner. The operator may offer to assume all respon-sibility but it cannot be thus shifted unless theanathetist is legally under his control. Such

1 THE LANCET, 1908, i., 151.

disputes can generally be averted by explanationand forbearance, but may persist when the operatoror anaesthetist is inexperienced, prejudiced, or toomuch inclined to consider his own aims and his ownsecurity without due regard to the effect of his pro-ceedings on his colleague’s work and effect of both onthe patient. The need for unselfish " team-work " isnot always realised.

CONSENT.As a general rule, no person can be legally anies-

thetised without consent, obtained in the case of achild from the parent or guardian, and in the caseof an insane person from someone who has authorityto give it. Ansesthetisation, without consent, wouldbe as much an assault as the performance of an

operation without consent. If there are peculiarrisks in taking an anaesthetic, one should give somewarning to the patient, but people ought not to bealarmed by discussing remote possibilities. It hasbeen decided in a foreign court of law that failure toimpress a patient that there is risk of death from anyanaesthetic is not a culpable omission, since in all butexceptional cases the risk is small and there is commonknowledge that it exists ; and that an increased riskwould be thereby caused to an impressionable patient. 2Difficulty may arise when a person is not in a conditionto give consent on account of delirium, shock, or

intoxication, and in the case of a child if the parentscannot be immediately communicated with, and theoperation is urgent-in such circumstances theanaesthetist can only do as the surgeon generallydoes. and be guided by circumstances that may makethe performance of an operation under an anaestheticjustifiable, although possibly illegal. It is advisablethat consent should be given in the presence of awitness, more particularly if the patient is able to talkand understands what is said, but still is not in quite-a normal condition. For instance, one under theinfluence of a narcotic may consent, apparently withclear understanding, but afterwards have no recollec-tion of having done so.

Until recent years it was considered that thepower of a parent to withhold consent in the case ofchildren was absolute. Parents have, however, beenconvicted for withholding operations needed toimprove health, and so one may assume that anoperation to save life, for instance, in a case ofstrangulated hernia, may be legally performed, evenif the parents object. One must not forget thatmany young people, 20 years of age or so, thoughpractically independent of their parents, are stilllegally infants. A case in Canada some years agoturned on this point. A patient agreed to an opera-tion not absolutely necessary, but his parents had notconsented, and brought an action against those whowere concerned. The case was decided againstthem, but rather on its own merits than for anyreason of general application. Consent may havebeen given by an adult who changes his mind imme-diately one starts to give the anaesthetic. Then theanaesthetist must desist. If the anaesthetic has beentaken to such a degree that one may reasonablysuppose that the power of judgment has been lost,one is justified in going on in spite of protests. Some-times a surgeon finds he cannot keep within thelimits of the operation intended, or he may find thathe has to give it up and do a different one, perhaps amore serious one. He may, for example, have to dolithotomy instead of litholapaxy. The anaesthetistis probably entitled to assume that consent has beenobtained to a possible variation, but if he is awarethat the consent has been strictly limited, he mayget into trouble if he aids the surgeon to do somethingof which the patient or the patient’s relatives mayafterwards disapprove, or which may even result ina fatality.

PRESENCE OF A WITNESS.An anaesthetic should never be given except in the

presence of a third person. There are at least threeQ’nnd l’PHsons for* that rule.

2 See Glaister’s Medical Jurisprudence, 1921, p. 755.Z

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(1) Actions have been brought for alleged administra-tion without consent-the patient and the anaesthetist,who was also the operator, being alone together-and though these actions have failed on the groundsthat the anaesthetic could not have been fully givenby force, and that there was collateral evidence ofconsent, it is obvious that the anaesthetist-operatormay be unable to prove this, and he would, at anyrate, be exposed to considerable trouble and expenseand have to make up a defence.

(2) Difficulties and dangers may arise during anyadministration, even when it is expected to be quitesimple. If struggling occurs the anaesthetist or

patient may be injured, and in the latter event theremay be an action for damages. Various mishaps,vomiting, asphyxia, and so on may make assistanceessential at a moment when it is impossible to procureit. Supposing there is no third person present, inthe event of a fatality, the anaesthetist would beseverely blamed, if no more serious consequencesbefell him.

(3) In the case of a woman, the presence of a thirdperson is especially important, because any anaestheticmay cause an erotic hallucination, either duringinduction or during recovery, and an accusation maybe made afterwards with perfect good faith-or,without any such excuse, it may be made for thepurpose of extortion.

" REASONABLE CARE AND SKILL."No one may give an anaesthetic for an illegal

operation, and it is also likely that one might getinto trouble by giving an anaesthetic for a fraudulentor otherwise indefensible operation. Nor may onegive an anaesthetic for the purpose of " covering"or assisting persons without legal qualifications, evenwhen they make no pretence to possess them. Theadmission to the Dentists’ Register of all bona fidepractising dentists has in this respect eased theposition with regard to such not holding diplomas.As to charges of malpraxis or civil actions for damages-in a general sense every registered practitioner isentitled to administer an anaesthetic, and as defenceagainst a charge of malpraxis is only required to showits necessity and that he exercised reasonable careand skill in so doing. But there is no exact definitionas to what constitutes reasonable care and skill. Ahigher standard of skill, although not a higher standardof care, would reasonably be expected from one whoholds a hospital appointment as an anaesthetist. Ifanyone who may be supposed to possess only theaverage skill of a practitioner gives an anaestheticwhere no unusual difficulty could be expected, or ifhe gives it even when obviously risky, but for somegood reason no specialist can be engaged, he wouldnot be liable for any disaster in a criminal sense,unless it could be shown that he displayed extremeignorance or carelessness. On the other hand, it isquite possible in the present day that if one who hasonly average skill undertakes this task when thebenefit of special knowledge is required and could havebeen obtained, he may be penalised in some way inthe event of any ill-effects ensuing, unless he is actingunder the orders of someone in authority, such asa house surgeon directed by his chief, or an assistantdirected by his principal. It has been suggested thatwhen this is not the case, not only the anaesthetist butalso the surgeon who engaged him or permitted himto give the anaesthetic may find himself in difficultiesfrom a medico-legal point of view. Therefore anypractitioner who is doubtful about his ability to giveanaesthetics ought to study not only the patient’sinterests and his own, but also those of the surgeon.One of the conclusions at which a Commission on

Anaesthetics arrived a good many years ago wasthis-that in many cases an anaesthetisation is ofsuch importance and gravity that it is absolutelyessential it should be conducted by an administratorwith large experience. If that conclusion was

justified when it was written, it is even more justifiedat the present time, because for a large proportionof the operations now performed special skill and

experience are as necessary in the anaesthetist as in thesurgeon. It need hardly be said that some practi-tioners are excellent anaesthetists, just as some prac-tioners are excellent operators, but it is not possiblefor the majority to deal successfully with those casesthat require special training and experience. Althougha faulty administration is not often the direct causeof death, one hears much too often of cases in whichit has caused considerable anxiety and materiallydelayed the operation and interfered with its success.The apportionment of responsibility between the

surgeon and the anaesthetist in the event of disasterhas not recently been determined in court. Formerlyit was, as I said, customary to consider the surgeonsolely responsible for the actions of all those takingpart in the proceedings. But it is unlikely that atthe present day this view would still be taken. Itmay be supposed that legally, as practically, thesurgeon’s responsibility has diminished and theanaesthetist’s has increased.

Disasters consequent upon anaesthetisation, apartfrom death, may be slight or may be serious. Forinstance, a tooth may be broken from forcibly openingthe mouth ; injury may be sustained in struggling, orbruising of the tongue from dragging and clamping;or something very serious, such as the loss of an eyefrom movement of the head (the patient being in-completely anaesthetised) or actual inability of thesurgeon to complete the operation; or after-effects,such as persistent vomiting, more or less due to somemistake made in the way in which the anaesthetic hasbeen selected and given. The anaesthetist may thenfind himself a defendant in an action for damages,although, supposing death to have occurred, there mayhave been no prosecution for manslaughter, nor anyprobability that if there had been one there wouldhave been a conviction. He may also be called as awitness in an action brought against the operator-for instance, when a swab has been left in the abdo-minal cavity, or in an action against an insurancecompany, or against employers under the Workmen’sCompensation Act, and in many other ways.

It has been suggested that if the anaesthetist is verymuch afraid of this kind of thing happening he shouldget the patient to sign an indemnity freeing himfrom responsibility. But that would be of hardlyany value from a legal point of view, because it wouldnot afford any protection against the consequences ofwrong-doing. It would only indicate that a patienthad been warned that risks existed ; one need hardlysay that a nervous patient would be extremelyalarmed by any request of this sort, and altogetherit is not to be recommended. An anaesthetist on thestaff of a hospital is not by his position exemptedfrom an action brought by a patient for negligence,either his own - or that of a student under hissupervision. The hospital authority would not beliable, having discharged its duty to the patients bydue care in appointing members of the staff.

THE ANSTI3ETIST’S EVIDENCE.

In giving evidence the anaesthetist should follow thegeneral advice given in books on forensic medicine. Heought to study the subject of inquiry very carefullybeforehand and consider what questions are likelyto be put to him, and how his evidence may be regardedby anyone outside the medical profession. He mustremember that he will have to deal with a coronerwho may have had no medical training, or with ajudge and counsel and jury who certainly have hadnone, and that an answer which would satisfy a

board of medical experts may not satisfy such atribunal ; he should consider any weak points thatmay be seized upon to his disadvantage. If he goesbefore the coroner or before a magistrate or a countycourt judge, he ought to remember that the case maybe carried further and copies of the evidence givenmay be produced, and there should be no discrepanciesfrom carelessness or lapse of memory between theevidence given on the two occasions. He shouldanswer deliberately and distinctly, carefully avoidany approach to levity, irritation, or discourtesy, and,

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as far as possible, reply in simple language free fromtechnical terms and from vague and exaggeratedexpressions. As far as possible, he should give plainanswers to plain questions, not stray beyond thequestion asked, and confine himself to facts, or tocomments on facts disclosed in evidence if summonedas an expert witness. Objection should be made toany questions that are involved or suggestive, or

depend upon some hypothesis, and if a brief answersuch as " Yes " or

" No " would be misleading, heshould ask to be allowed to give an answer whichwould be more satisfactory. If in doubt he shouldnot evade the question, but say he is in doubt, andgive his reasons for being in doubt; also avoid i,expressing any decided opinion when the data are ’,insufficient-e.g., not give an opinion about the I

cause of death in the absence of a post-mortemexamination, preferably made by a skilled patho-logist, even when this has apparently been unmistak-able. Instances have occurred of sudden death (fromembolism, rupture of aneurysm, &c.) which might,but for the autopsy, have been attributed to theanaesthetic.Lastly, we come to the coroner’s court. Some

coroners always hold an inquest when death occursduring anaesthesia, and some consider they are entitledto exercise discretion. Some coroners are extremelygood and impartial, and know all they can about thesubject in the absence of practical experience. Some,unfortunately, are just the reverse. A coroner’sjury is obviously unfit to decide in what ought to bea scientific investigation. The consequence of allthis is that an anaesthetist who has really been verymuch to blame may get off scot-free, whereas one whodone his best in difficulties, and is perfectly competentand careful, may find his reputation considerablydamaged. That is evident from the reports that onereads in the newspapers of inquests on people whohave died under an anaesthetic. Some few yearsyears ago the Coroners’ Society drew up a series ofquestions. Dr. F. J. Smith, in " Taylor’s MedicalJurisprudence," dubbed it with vigorous criticism" The Coroner’s Catechism," and it is also condemnedin the new edition of " Hewitt’s Anaesthetics andtheir Administration."

"THE CORONER’S CATECHIS3]:."I quote it because such questions may be asked

not only in the coroner’s court, but at other investiga-tions.

1. What anaesthetic or anaesthetics were employed, andwhat influenced your choice ?-Fatalities and troublesshort of fatalities are very often due to a faulty selection ofthe anaesthetic. Something may be given which is unsuitableeither to the particular patient or the particular operationor to the position in which the patient is to be placed, orsome other condition. For instance, nitrous oxide maybe given to an elderly full-blooded person for the openingof a tonsillitic abscess. Chloroform may be given to ananeemic girl for the extraction of a tooth. Fatalities haveoccurred in such cases. If a new or unusual drug or methodhave been used, a severe inquiry may be expected.

2. When and where was the anaesthetic administered ?-State if in an operating theatre, casualty room, out-patientdepartment, or private house.

3. What was the temperature of the operating room ?-Had the room, previous to the operation, been well aired ?-(It is the duty of the anaesthetist to attend to the generalwelfare of the patient and the purity and temperature ofthe air.)

4. Was the anaesthetic given by artificial light ?-Statewhat kind. If gas, was the flame exposed ?

5. For what purpose was the anaesthetic administered ?-State the nature of the operation, with name and addressof the surgeon operating.

6. How many patients were placed under anaesthesia byyou that day, and how much time was occupied in producingcomplete anesthesia in each case ?

7. Was there any, and, if so, what reason for administeringthe anaesthetic quickly ?

8. How was the anaesthetic administered ?-If by meansof an inhaler, state what kind and make.

9. How was the mixture of air with the vapour of theanaesthetic secured, and in what proportion ?

10. What quantity of the anesthetic was used (a) fromthe beginning of the administration until complete anws-thesia was produced ; (b) from then until the administration

was stopped ? Was the anaesthetic supplied by drops ormeasurement ?-The question about quantity is constantlyasked. If a small quantity, especially of chloroform, hasbeen used, the coroner and jury seem to think it quitesatisfactory. If a comparatively large quantity has beenused, they seem suspicious, not knowing how the amountused, particularly if given by the drop method, may beinfluenced. For instance, in ansesthetising a person whosebreathing is shallow, the patient takes a long time to gounder, and comparatively a large amount is used, althoughonly a little of that is really absorbed, and a good anaesthetistmay use more than a bad anaesthetist, because he will go onsteadily. Again, the small quantity may be due to the factthat the operation was begun too soon, the patient beingimperfectly anaesthetised, and therefore more liable to shock.

11. How was the deceased prepared for the anaesthesia, asregards food, clothing, and so forth ? Was there mechanicalor other obstruction to the respiration ?-Proper preparationof a patient for anaestheia is extremely important, and inemergency operations it is essential to inquire when thelast meal was taken, and of what it consisted. There is onerecorded case in which a man had been assaulted, and it wasnecessary to give him an anaesthetic in order that his woundmight be examined. The anaesthetist made this inquiry,and was told that he had his last meal many hours before.However, the man, during the giving of the anaesthetic,vomited undigested food and was choked and died. Theman who had assaulted him was consequently put uponhis trial for manslaughter, but when it was stated that thedeceased person had deceived the anaesthetist he escapedconviction. If the anaesthetist had not put the question, orif the patient had answered him correctly, there would havebeen a very different result.

12. What was the condition of the heart, lungs, andkidneys of the deceased previous to the administration ?Were you satisfied that the patient was in a safe conditionto be placed under the anaesthetic ? Had the patientpreviously been anesthetised ?-A patient may be in a safecondition to be " placed under an anaesthetic." but it doesnot follow that he is in a safe condition to undergo anoperation under an anaesthetic. (See questions 13 and 19.)The necessity for the operation would have to be proved ifthe patient’s state was unsatisfactory.

13. Was the deceased, at the time of the administration,suffering or recovering from any acute or chronic illness,or from alcoholism ?-One must, I suppose, take it thatthis refers to some illness additional to the one thatnecessitated the operation. (See questions 14 and 19.)

14. Was the deceased excited or violent during the firststage ?-There is very good reason for asking this question,because violent struggling at the onset may have an effecton the heart that continues after the struggling has ceased,and may result in failure later on. Alcoholic persons, Ineed hardly say, are particularly bad subjects ; they needmuch anaesthetic to get them under, they commonly strugglevery violently, and their hearts are, at any rate, aftermiddle age, in a degenerated condition, and very apt tobecome over-dilated and give out altogether.

15. Was the pulse and respiration watched during theadministration, and if so, by whom ? State the conditionsobserved. What was the state of the pupils and of reflexirritability generally ?

16. At what period, during the administration of theanaesthetic, was the first symptom of impending deathnoticed ? What was it ? Did the deceased vomit at anytime ? If so, when and how often ?

17. Did the deceased die during the administration of theanaesthetic ? If not, how long after it had been discontinued ? ?IWas the operation then completed ? If so, for how long ?

18. What efforts were made to restore animation, andhow long were they continued ?

19. To what immediate cause do you yourself attributethe sudden death of the deceased ?-This gives an oppor-tunity to explain about the part which may have beenplayed in the fatality by defective health or by surgicalshock, haemorrhage, asphyxia from vomiting or blood in theair passages, and so forth. In this connexion it may bepointed out that a large proportion of deaths during anws-thesia are not due to simple over-dose, but to some combina-tion of causes, and the anaesthetic sometimes has little or

even nothing to do with the fatality. The answer shouldindicate as briefly as possible all the causes-e.g., " failureof a diseased heart in an alcoholic man during excitementcaused by anticipation of an operation and by inhalationof anaesthetic." If it arose from some effect of the operation,over which the anaesthetist had little or no control, he shouldnot undertake to give evidence which ought to be given bythe operator. There is still in some surgeons a belief thatall inconvenient or dangerous reflexes, including operationshock, may be blocked completely by general anaesthetics.

20. In how many cases have you given an anaestheticpreviously ? If any fatal cases, say how many.-It has oftenbeen pointed out that statistics concerning fatalities are of

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little value. A man may have been so unfortunate as to havehad two deaths in 500 casos, but one may have been thatof an infant in a dying state from internal obstruction, andanother that of a brewer’s drayman with impeded breathingfrom cellulitis in the neck. It would be extremely unfair torequire him to say simply he had had two deaths in 500 cases.It would give a perfectly erroneous notion of his capacity.The question of consent may also arise, especially when

the administration was for any reason risky, and there maybe also inquiry as to the quality of the anaesthetic used.

Several of the questions, suggesting carelessnessor incompetency, or entailing explanations whichwould not be- understood by the laity, are open toobjections. However, any or all of them maypossibly be asked of an anaesthetist, and they showthat before giving an anaesthetic the anaesthetistshould be thoroughly acquainted with the subject,and realise his heavy responsibility, not only as

regards the patient, but also as regards the surgeonand himself. The administration should be conductedwith the utmost attention, and notes taken, at leastin any unusual case, because the anaesthetist may becalled upon at some future time to justify hisactions. I need hardly add that membership of amedical defence society may in this, as in any kindof practice, prove to be a wise precaution.

THE

INTERNAL SECRETION OF THE PANCREASAND ITS APPLICATION TO THE

TREATMENT OF DIABETES MELLITUS.*BY R. L. MACKENZIE WALLIS, M.D. CAMB.,

CHEMICAL PATHOLOGIST, ST. BARTHOLOMEW’S HOSPITAL,LONDON ; LECTURER IN CHEMICAL PATHOLOGY TOST. BARTHOLOMEW’S HOSPITAL MEDICAL COLLEGE.

THE association of the pancreas with diabetesmellitus has been known for many years, but itwould be beyond the purpose of this paper to referto all the literature which has accumulated, especiallyof recent years. The work of Dr. Banting and hisco-workers in Toronto has excited world-wide interest,and a brief résumé has appeared in the columnsof THE LANCET. 1 They have been working uponthe same lines as myself and have apparently metwith similar difficulties in the preparation and isola-tion of the active principle

" insulin " in a stableform. They have found their preparation possessesthe power of reducing the blood-sugar when givensubcutaneously, but is quite inactive by the mouth.The observations I have made are communicated

with the view to calling attention to the mode ofpreparation I have worked out, and certain observa-tions which appear to be of importance at the presentjuncture. The fact that this pancreatic preparationis rendered stable, and so capable of oral administra-tion, is undoubtedly of interest, and for this reasonas full an account as possible of the mode of prepara-tion is included in the text. The intention was torefrain from publication until more detailed resultswere available as regards its application in treatment,but it is hoped that such data will soon be available.The work of Allen in America deserves particular

mention, since it supplies very strong evidence infavour of an implication of the pancreas in truediabetes mellitus. My work has been concentratedupon the same problem for over ten years, and inOctober, 1920, I published a paper dealing withdiseases of the pancreas. 2 In this paper it was statedthat the results, although giving no definite positiveevidence of disturbance of function of the pancreasin diabetes mellitus, yet gave an insight into thepossible site of disease. The " tripod " of tests-viz.,the Loewi adrenalin mydriasis test, the occurrence ofglycosuria, and a high diastase content of the bloodand urine-have proved to be remarkably constantin diseases of the pancreas. This association was

* My thanks are due to the staff of St. Bartholomew’sHospital for permission to use their cases.

1 THE LANCET, 1922, August 19th, 398. See also Nov. 18th, 1081,1086. 2 Mackenzie Wallis : Quart. Jour. Med., 1920, xiv., 57.

regarded as of particular importance, since it pointedthe way to a possible solution of the problem of theexact function of the pancreas in controlling carbo-hydrate metabolism. The early appearance of the" tripod " of tests, and their just as rapid disappear-ance, suggested a sudden disturbance of some chemicalmechanism. From all the data available, it waspossible to devise a plan of campaign which has beensedulously followed out. This plan was to find outthe nature of this chemical mechanism. The internalsecretion of the pancreas was isolated by me overtwo years ago, and has been applied to a fairly largenumber of cases, some of which are recorded in thispaper. The preliminary results were detailed at theannual meeting of the Biochemical Society held atthe Lister Institute in 1921.

Data on which the Theory of the Pancreatic Or-if/in ofD-icbetes lilellittcs is Based.

The conviction that the pancreas is the primaryseat of the disease has gained ground of recent years.An excellent summary of the present state of ourknowledge of this phase of the problem was given byDr. Graham in his Goulstonian Lectures. In theyears 1916, 1917, and 1918, I had an opportunity ofstudying several hundred cases of glycosuria and milddiabetes mellitus whilst serving in India, and thisinvestigation laid the foundation of all my subsequentwork upon this subject. Many of these have provedto be true pancreatic diabetes. A detailed study ofsuch cases revealed the following results :-

1. It is practically confined to those who consumelarge quantities of fats and carbohydrates-viz., thewell-to-do classes (confirmation of McCay).

2. The glycosuria shows hourly variations, beingalmost negligible in the morning, and graduallyincreasing towards night.

3. The tolerance to carbohydrates decreases as theday proceeds,’ and this is well shown by hourlydeterminations of the blood-sugar. It is also muchreduced for two hours after each meal.

4. The glycosuria yielded rapidly to treatment, ifall the carbohydrates were consumed before midday,a mode of life which is carried out by the working-classnatives, who rarely suffer from glycosuria.

5. Starvation treatment is rarely necessary.6. Once the tolerance to carbohydrates is restored

and the chemical mechanism of control re-established,the blood-sugar remains within normal limits, and thepatient is able to return to a normal dietary.

These observations were all in accord with thoseI had obtained previously in cases of pancreaticglycosuria.The cases of acute pancreatitis are of particular

interest in this connexion, viz., (1) the almostconstant occurrence of positive results with the" tripod " of tests ; (2) the complete disappearanceof these signs, especially the glycosuria, with recovery ;and (3) the return of the positive findings with anexacerbation of the disease.

In cases of pancreatic insufficiency and mild diabetesmellitus, the glucose tolerance test 3 has shown twovery characteristic features-viz., the slow andcontinuous rise of blood-sugar up to one hour afterthe glucose has been consumed, often reaching veryhigh figures, and the rapid disappearance of thesugar from the blood. This suggested the possibilityof a dual control by the pancreas. The portal entryof the sugar into the liver, and the systemic outflowfrom the liver, would appear to be controlled, in part,by the pancreas. In cases of pancreatic insufficiencythe control over the storage of glycogen is deficient,as well as the control over the distribution andutilisation of sugar by the tissues. Abundant evidenceis obtained from glucose tolerance tests, and thesewill form the subject of a separate communication.This control would appear to be almost perfect inthe early morning, and hence the unlimited toleranceto glucose before breakfast, and the low sugar contentof the blood at this time. The liver and tissues are

3 Mackenzie Wallis and Bose : Jour. Obst. and Gynæc. of theBritish Empire, vol. xxix., No. 2, Summer, 1922.