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1008 Medical Societies. ROYAL SOCIETY OF MEDICINE. DERMATOLOGICAL SECTION. Exhibition of Cases. A MEETING of this section was held on March 19th, Dr. H. RADCLIFFE CROCKER, the President, being in the chair. Dr. H. G. ADAMSON showed : (1) a case of Urticaria Pigmentosa in a child, aged three years ; and (2) a case of Ringworm (tinea circinata) in a child, the ringworm having in all probability been derived from a horse. The father of the patient was a harness repairer. Dr. T. P. BEDDOES showed for Dr. P. S. ABRAHAM a case of Favus in a Mouse (exhibited). The mouse had been caught by a woman whose husband was attending Dr. Abraham for trichophytic sycosis in which large-spored mycelium had been demonstrated. Dr. Abraham regarded the association in this case of favus with ringworm as fortuitous. Mr. G. W. DAWSON showed a case of " Ringed Eruption " of the Left Hand and Fingers, of the type of lichen annularis, in a man, aged 18 years, who asseverated that he had had the condition for seven years.-The PRESIDENT considered that it was probably an instance of lichen planus.-Dr. J. GALLOWAY thought that it was rather like what he had called lichen annularis. Dr. T. COLCOTT Fox showed a case of " Bilateral Telangi- ectases " of the Trunk in a woman who gave a history of marked epistaxis in childhood and of recent rectal hoemor- rhage. There was no family history of similar conditions, which differentiated this case from a group in which these symptoms had been associated with family inheritance. A section of one of the telangiectases showed dilatation of capillaries without other changes. Dr. WILFRID S. Fox showed a case of Dermatitis Artefacta in a young girl, the lesions consisting of sharply demarcated rounded patches on the chest and left side. The agency of production was not demonstrated. . Dr. GALLOWAY showed a case of an Acute Scarlatiniform Eruption which had apparently resulted from the adminis- tration of quinine. The eruption had commenced to show itself within two hours of taking a dose of one grain of quinine and the temperature had risen suddenly to 102° F., with symptoms of shivering’, nervous depression, and swelling of the fauces. The rash was followed by widespread super- ficial desquamation. Similar symptoms had been noted 12 months previously on taking a patent preparation said to contain quinine. Dr. E. G. GRAHAM LITTLE showed a case of Granulo- matous-looking Tumours and Nodules, the result of Ingestion of Bromides, in an infant who had never had that drng but whose mother (who suckled her child) had been daily taking large doses of bromide for two years. Dr. J. H. SEQUEIRA showed : (1) a case of Lupus of the Face, with a Lymphatic (Edema of the Hands resembling the condition which had been called " Lupus Pernio " ; and (2) a case of X Ray Warts which had appeared on the Hands in the course of four years’ work of an operator in an x ray department. The warts had been removed from one hand by exposure to measured doses of x rays administered therapeutically. - ODONTOLOGICAL SECTION. Exhibition of Specimen8.-Treatme.7zt of Suppurative Peri- odontitis in Displaced Teeth.-Treatment of Children from the Dental Point of View. A MEETING of this section was held on March 23rd, Mr. J. HOWARD MUMMERY, the President, being in the chair. Mr. A. HOPEWELL-SMITH, through the honorary secretary, exhibited and described specimens of (1) Jaws of Hemi- rhamphus and (2) Developmental Defects in the Upper Jaw of a Pike (Esox Lucius), which he presented to the museum. Mr. E. STURRiDGE read a casual communication on the Treatment of Suppurative Periodontitis in Displaced Teeth, which he contended could not be cured except by the replacement and retention of the teeth in their correct positions. He showed a method of retaining such teeth by means of a wire and small pins cemented to the teeth which had previously had small holes drilled in them. In the discussion which followed it was admitted that the gum did not re-unite with the tooth and that the "pockets" always remained. Mr. W. HERN opened a discussion on Mr. J. F. Colyer’s paper on the Treatment of Children from the Dental Point of View. He opposed Mr. Colyer’s views and said he believed that caries occurred in inverse ratio to the amount of care exercised in cleansing the teeth with brush and silk, and that the use of the brush was more important than thorough mastication for preseIVing the teeth. He was always anxious not to extract the deciduous teeth.-Mr. C. ROBBINS advocated and practised the habit of rewarding his small patients with sweetmeats.-Mr. W. RUSHTON still advocated the use of a toothbrush but did not believe that caries occurred in inverse proportion to its use. He agreed with Mr. Colyer that they did not know the causes of dental caries at all thoroughly -Dr. J. 81M WALLACE asked why, if the toothbrush was efficient, there had not in recent years been a great decrease in the amount of dental caries, and con- tended that it was quite possible to bring up children immune from caries who had never used a toothbrush, and instanced cases under his care. He believed that thorough mastication was most important and blamed "pap feeding for the craving for sweets, the lack of proper mastication, and a great deal of caries. Mouth-breathing was another cause.- Mr. STANLEY P. MUMMERY thought that the interference of civilisation with the laws of survival of the fittest was a cause of the prevalence of caries.-Mr. COLYER, in reply, said he was satisfied to have proved by the discussion which he had provoked that there was a wide difference of opinion among dental surgeons as to the causes of caries. It was a fact that the chemical composition of modern food-stuffs had changed. He did not think that heredity was an etiological factor and he strongly believed that dental surgeons would be able by discovering the causes of dental caries to remove them, and that in the future a healthy and functional mouth would be far more common than at the present day. THE MEDICO-LEGAL SOCIETY OF LONDON. -Discussion on Post-mortem Examainations in Cases of Death under Anæsthetics.-The Legal Liability of the .4nes. thetist. CONSIDERABLE interest was manifested in a meeting of this society held on March 24th, when Mr. Justice WALTON, the President, occupied the chair. The discussion on Dr. L. Freyberger’s paper read at the last meeting, entitled " An Analysis of 74 Cases of Sudden Death while under the Influence of Anaesthetics," had been adjourned and the proceedings were commenced by Mr. R. HENSLOWE WELLINGTON who read a short paper on the Legal Liability of the Anaesthetist, in the course of which he said : Dr. Freyberger read his paper on "Deaths under Anaesthetics" before this society on Feb. llth, 1908. That paper was limited to a narration of 74 cases upon which he had made post-mortem examinations for the purpose of inquests in the Westminster and South- Western jurisdiction of the coroner. Out of the 74 deaths, 71 occurred at the five large hospitals and three in private practice. Though Dr. Freyberger gave an interesting narrative of these cases he drew no deductions from them. But during the short discussion which followed Dr. Frederic W. Hewitt gave us to understand that the majority of deaths from or under an anaesthetic were preventable, and that if death took place it was, as a rule, not the patient nor the operator that was at fault but the anaesthetist. I take it, then, that in his opinion the patient dies from an overdose of the anæsthetic-i.e., that he or she is poisoned owing to a want of care on the part of the anæsthetist. That we all value Dr. Hewitt’s opinion goes without saying, but it must first be proved that these deaths are due to the anaesthetic itself, and secondly to the want of reasonable skill, care, and attention on the part of the anxsthetist and not due to any contributory cause on the part of the patient from an idiosyncrasy, or to his pathological condition at the time of the operation, or on the part of the operating surgeon, and how can one differentiate between these, or say that there is not a combination of them as causes con- tributing to the death and so exonerate everyone concerned ? "! It would be well for the Privy Council, with whom this matter rests, to make it a penal offence for an unqualified

THE MEDICO-LEGAL SOCIETY OF LONDON

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1008

Medical Societies.ROYAL SOCIETY OF MEDICINE.

DERMATOLOGICAL SECTION.Exhibition of Cases.

A MEETING of this section was held on March 19th, Dr.H. RADCLIFFE CROCKER, the President, being in the chair.

Dr. H. G. ADAMSON showed : (1) a case of UrticariaPigmentosa in a child, aged three years ; and (2) a case ofRingworm (tinea circinata) in a child, the ringworm havingin all probability been derived from a horse. The father ofthe patient was a harness repairer.

Dr. T. P. BEDDOES showed for Dr. P. S. ABRAHAM a caseof Favus in a Mouse (exhibited). The mouse had been caughtby a woman whose husband was attending Dr. Abraham fortrichophytic sycosis in which large-spored mycelium hadbeen demonstrated. Dr. Abraham regarded the associationin this case of favus with ringworm as fortuitous.Mr. G. W. DAWSON showed a case of " Ringed Eruption "

of the Left Hand and Fingers, of the type of lichen annularis,in a man, aged 18 years, who asseverated that he had hadthe condition for seven years.-The PRESIDENT consideredthat it was probably an instance of lichen planus.-Dr. J.GALLOWAY thought that it was rather like what he hadcalled lichen annularis.

Dr. T. COLCOTT Fox showed a case of " Bilateral Telangi-ectases " of the Trunk in a woman who gave a history ofmarked epistaxis in childhood and of recent rectal hoemor-rhage. There was no family history of similar conditions,which differentiated this case from a group in which thesesymptoms had been associated with family inheritance. Asection of one of the telangiectases showed dilatation ofcapillaries without other changes.

Dr. WILFRID S. Fox showed a case of Dermatitis Artefactain a young girl, the lesions consisting of sharply demarcatedrounded patches on the chest and left side. The agency ofproduction was not demonstrated.

.

Dr. GALLOWAY showed a case of an Acute ScarlatiniformEruption which had apparently resulted from the adminis-tration of quinine. The eruption had commenced to showitself within two hours of taking a dose of one grain ofquinine and the temperature had risen suddenly to 102° F.,with symptoms of shivering’, nervous depression, and swellingof the fauces. The rash was followed by widespread super-ficial desquamation. Similar symptoms had been noted 12months previously on taking a patent preparation said tocontain quinine.

Dr. E. G. GRAHAM LITTLE showed a case of Granulo-matous-looking Tumours and Nodules, the result of Ingestionof Bromides, in an infant who had never had that drng butwhose mother (who suckled her child) had been daily takinglarge doses of bromide for two years.

Dr. J. H. SEQUEIRA showed : (1) a case of Lupus of theFace, with a Lymphatic (Edema of the Hands resemblingthe condition which had been called " Lupus Pernio " ; and(2) a case of X Ray Warts which had appeared on the Handsin the course of four years’ work of an operator in an x raydepartment. The warts had been removed from one handby exposure to measured doses of x rays administeredtherapeutically. -

ODONTOLOGICAL SECTION.

Exhibition of Specimen8.-Treatme.7zt of Suppurative Peri-odontitis in Displaced Teeth.-Treatment of Children fromthe Dental Point of View.A MEETING of this section was held on March 23rd, Mr.

J. HOWARD MUMMERY, the President, being in the chair.Mr. A. HOPEWELL-SMITH, through the honorary secretary,

exhibited and described specimens of (1) Jaws of Hemi-rhamphus and (2) Developmental Defects in the Upper Jawof a Pike (Esox Lucius), which he presented to the museum.Mr. E. STURRiDGE read a casual communication on the

Treatment of Suppurative Periodontitis in Displaced Teeth,which he contended could not be cured except by the

replacement and retention of the teeth in their correct

positions. He showed a method of retaining such teethby means of a wire and small pins cemented to the teethwhich had previously had small holes drilled in them. In

the discussion which followed it was admitted that the gumdid not re-unite with the tooth and that the "pockets"always remained.

Mr. W. HERN opened a discussion on Mr. J. F. Colyer’spaper on the Treatment of Children from the Dental Pointof View. He opposed Mr. Colyer’s views and said he believedthat caries occurred in inverse ratio to the amount of careexercised in cleansing the teeth with brush and silk, andthat the use of the brush was more important than thoroughmastication for preseIVing the teeth. He was alwaysanxious not to extract the deciduous teeth.-Mr. C. ROBBINSadvocated and practised the habit of rewarding his smallpatients with sweetmeats.-Mr. W. RUSHTON still advocatedthe use of a toothbrush but did not believe that cariesoccurred in inverse proportion to its use. He agreed withMr. Colyer that they did not know the causes of dental cariesat all thoroughly -Dr. J. 81M WALLACE asked why, if thetoothbrush was efficient, there had not in recent years beena great decrease in the amount of dental caries, and con-tended that it was quite possible to bring up children immunefrom caries who had never used a toothbrush, and instancedcases under his care. He believed that thorough masticationwas most important and blamed "pap feeding for thecraving for sweets, the lack of proper mastication, and agreat deal of caries. Mouth-breathing was another cause.-Mr. STANLEY P. MUMMERY thought that the interference ofcivilisation with the laws of survival of the fittest was acause of the prevalence of caries.-Mr. COLYER, in reply,said he was satisfied to have proved by the discussion whichhe had provoked that there was a wide difference of opinionamong dental surgeons as to the causes of caries. It was afact that the chemical composition of modern food-stuffs hadchanged. He did not think that heredity was an etiologicalfactor and he strongly believed that dental surgeons wouldbe able by discovering the causes of dental caries to removethem, and that in the future a healthy and functional mouthwould be far more common than at the present day.

THE MEDICO-LEGAL SOCIETY OFLONDON.

-Discussion on Post-mortem Examainations in Cases of Deathunder Anæsthetics.-The Legal Liability of the .4nes.thetist.

CONSIDERABLE interest was manifested in a meeting ofthis society held on March 24th, when Mr. Justice WALTON,the President, occupied the chair.The discussion on Dr. L. Freyberger’s paper read at the

last meeting, entitled " An Analysis of 74 Cases of SuddenDeath while under the Influence of Anaesthetics," hadbeen adjourned and the proceedings were commencedby Mr. R. HENSLOWE WELLINGTON who read a shortpaper on the Legal Liability of the Anaesthetist, in thecourse of which he said : Dr. Freyberger read his paperon "Deaths under Anaesthetics" before this society onFeb. llth, 1908. That paper was limited to a narration of 74cases upon which he had made post-mortem examinations forthe purpose of inquests in the Westminster and South-Western jurisdiction of the coroner. Out of the 74 deaths,71 occurred at the five large hospitals and three in privatepractice. Though Dr. Freyberger gave an interestingnarrative of these cases he drew no deductions fromthem. But during the short discussion which followed Dr.Frederic W. Hewitt gave us to understand that the majorityof deaths from or under an anaesthetic were preventable, andthat if death took place it was, as a rule, not the patient northe operator that was at fault but the anaesthetist. I takeit, then, that in his opinion the patient dies from an

overdose of the anæsthetic-i.e., that he or she is poisonedowing to a want of care on the part of the anæsthetist.That we all value Dr. Hewitt’s opinion goes without saying,but it must first be proved that these deaths are due to theanaesthetic itself, and secondly to the want of reasonableskill, care, and attention on the part of the anxsthetist andnot due to any contributory cause on the part of the patientfrom an idiosyncrasy, or to his pathological condition at thetime of the operation, or on the part of the operatingsurgeon, and how can one differentiate between these, or saythat there is not a combination of them as causes con-

tributing to the death and so exonerate everyone concerned ? "!It would be well for the Privy Council, with whom thismatter rests, to make it a penal offence for an unqualified

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man to administer any anæsthetic, whether local or general.Perhaps the coroner’s court is not the fons et origo of exactscientific knowledge upon the matter of the immediatescientific cause of death in these cases, though it must beadmitted that the court certainly has a useful function toperform in the matter and should ascertain if there has beenany malpraxis. But I am struck with the idea that a mostuseful office might well be created by the county councils ifthey would appoint some one with a medical training and acoroner’s experience to act as a registrar, such as the

hospitals possess, to make an abstract or digest from thedepositions, taken at inquests by the coroners, upon theseand all other deaths. These depositions are at present amass of wasted material, but would be a source of muchuseful information if in the hands of such an officer or

registrar. It has been argued by some (though not at thissociety) that if the anaesthetic were not required then theanæsthetist is liable at law. Surely if an operation is

necessary an anæsthetic is, humanely speaking, equally so.It is then the operating surgeon who is to be calledinto question if anyone for malvraxis, but who can

controvert his opinion as to whether the operationwas necessary or not? ? If the anæsthetist is an un-

qualified practitioner and is engaged by the qualifiedoperator, or if an unqualified operator engages a qualifiedanaesthetist, then the qualified and registered man, surgeon,or dentist is guilty of "covering," under the regulationsof the General Medical Council, whether the patient livesthrough or dies under the anesthetic. And here I will sayen passant that it is very doubtful as to whether the dentistwho has the L.D.S., without the full qualification of thephysician or surgeon, is qualified to give any anaesthetic atall, or whether he is not limited to the administration ofnitrous oxide gas and must call in a qualified practitioner togive the other anesthetics ; he is then in the same position asthe unqualified man. If the anaesthetist is engaged by asurgeon to adminster the anesthetic, the surgeon is theservant of the patient and agent to find a capable an2es-thetist, and if both show reasonable care, skill, and atten-tion neither of them is liable for malpraxis whether thepatient lives or dies. Again, if the operating surgeonengages an anæsthetist who gives an anesthetic for an

illegal operation, the anæthetist if ignorant of the ille-gality of the operation cannot be held liable whetherthe patient survives or dies, but if the anesthetist knowsthe nature of the operation to be illegal he is equallyliable to answer with the surgeon for felony if shesurvives and for murder if she dies. If the causii causansof the death is due to a pathological condition of thepatient, unknown until the patient is upon the operating-table, the death must of necessity be one of misadventure, orif due to a recognised pathological condition and the patientor his representative had been warned of any risk and

accepted that risk the patient then accepted full responsi-bility and exonerated both the surgeon and the anæsthetist.Supposing that the anæsthetist sees danger from the anoes-thetic after he has commenced its administration and with-holds his hand, at the same time warning the operatingsurgeon that to proceed is dangerous, the onus probandi isperhaps thrown upon the surgeon if he proceeds withthe operation, though it may be well-nigh impossible tofinish it forthwith. But naturally the two must worktogether and do their best for the life that is in theirhands and then no one can reasonably find fault or

sustain any action at law for malpraxis. When a

patient enters any hospital and an operation under ananassthetic is required the patient expects, and the lawimplies, that a competent anæsthetist will give the necessaryanaesthetic, and if a qualified practitioner administers it anduses reasonable care and skill he cannot be held liable formalpraxis if unforeseen death supervenes. Further, if anunqualified man, as pupil, is manipulating the anaestheticapparatus under the supervision of a qualified anæs-

thetist the former is not acting illegally, nor is thelatter liable for "covering," as this is permissible underthe regulations of the General Medical Council. Butthere is often the risk that the young anesthetist is hurriedin his work by the busy hospital surgeon who is anxious tohurry on the operation and get away to his private practice,consequently the anesthetist runs the risk of administeringa poisonous dose of the anesthetic. This is an argument infavour of special resident anoesthetists at all our largehospitals. In conclusion, the immediate cause of deathattributable to the anæsthetic, per se, as a poison, must first

be proved beyond any reasonable doubt ; and then a furtherproof that the administrator of that anaesthetic or poison-and it matters not whether he be a qualified or an unqualifiedpractitioner-did not use reasonable care, skill, and attentionmust be shown before he can be made answerable to the lawfor damages or punishment. But the administration of anyanaesthetic, whether for a local or a general anaesthesia, byunqualified practitioners-which is carried on to a very largeextent throughout the kingdom-is a grave public dangerand should, perhaps, be made a penal offence by statute.The PRESIDENT then suggested that Dr. F. W. Hewitt

should propose the motions standing in his name. The

question before the meeting was not primarily the medicalor the scientific side of the matter but rather the question ofpublic policy. Of course, it would be important to have theopinion of gentlemen who spoke not only with great scientificknowledge but with practical experience.

Dr. HEWITT then moved that the two following motionsbe forwarded in the name of the Medico Legal Societyto the General Medical Council and to the Privy Councilrespectively :-

1. That in view of the importance of the administration of an2es-thetics this society is of opinion that it is highly desirable, in thepublic interest, that every member of the medical profession before heis registered shall have received instruction in the administration ofanaesthetics. It therefore earnestly begs the General Medical Councilto consider whether they can see their way to include a course ofinstruction in anaesthetics amongst their requirements in regard toprofessional education.

2. That as the administration of any drug or drugs with the object ofproducing generalised insensibility to pain or actual unconsciousnessfor any medical and surgical operation, or during child-birth, cannotbe safely undertaken without medical knowledge ard skill, yourpetitioners humbly pray that legislation be granted whereby theadministration of any drug or drugs with either of the aforesaid objectsby any person other than a duly registered medical practitioner orsome one acting immediately under his supervision, direction, andinstruction be made a penal offence.

One question seemed to Dr. Hewitt to come to the frontbefore all others on that occasion-namely, the means whichshould be adopted for protecting the public against accidentsunder general anaesthetics. It was one of the most vital andpressing questions of the day. The present state of things hecould only describe as antiquated and slipshod. In the firstplace what was the present position of the law ? He felt thathe was treading on most delicate ground because he was nota lawyer. It appeared that any person, whether qualified orunqualified, experienced or inexperienced, reputable or dis-reputable, might administer an anaesthetic, and providedthat he did this to the best of his ability and with nounlawful motive he was not likely to be punished or evenblamed if his patient died as the result of the anaestheticgiven. Was it right in the public interest that someof the most powerful drugs in the British Pharmaeopcelashould be at the disposal of ignorant, if well-inten-tioned, persons? The community was protected againstrisks incidental to the sale of poisons, the adulteration offood, milk, and the like, but the advertising bone-setter,the herbalist, or in fact anyone might freely employ chloro-form without any infringement of the law. When anaes-thetics were first introduced, more than half a century ago,they were often intrusted to unqualified persons, nurses,and others; but surgery had completely changed since thenand the requirements of the surgeon and of the public weresuch that the administration of an anaesthetic, in the modernsense of the term, could only be safely undertaken by thosepossessing medical knowledge and skill. Possibly theattractions of medicine and surgery had taken away menof brilliant abilities whose work would have been welcomed

by those who had interested themselves in this particularbranch, but at the present time the average medical manwho gave an anæsthetic and the general practitioner inthe country had not had the amount of training which heought to have had and that amount of experience whichwould entitle him to administer these drugs. Secondly, hewould refer to the share which the educational authoritiestook in the matter. The General Medical Council, whichgoverned the various examining bodies, did not makea course of instruction in anesthetics one of its re-

quirements. It recognised that some instruction shouldbe given. He had written recently to the 22 examiningbodies of England, Scotland, and Ireland and he foundthat only eight made it compulsory for candidates tohave received any instruction in anaesthetics. So that a manmight graduate in medicine and surgery at one of our leadingUniversities without ever having administered an anaesthetic.In England there were 11 examining bodies; of these seven

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required a course of instruction and four did not. In Scotlandthere were six examining bodies but only one required acourse, and in Ireland there were five, none of which requiredit. That was not a satisfactory state of things and somethingwas required to remedy it. Then what was the state of thingsat the hospitals ? ? There was some improvement in thisdirection but at a certain number of them there might be arather better system, both of instruction to students and ofadministering the department responsible for the use ofanaesthetics. He thought that there ought to be some menof the highest professional and academical attainments atthe head of the teaching portion of this study, and thatespecially there was room for resident anæsthetists at

many of the large hospitals. The result of this un-

satisfactory state of things was shown by the annualreturns of the Registrar-General and by the weeklyrecords of cases of death under anaesthetics. Hewas not contending that deaths could be avoided.He was not dealing in any way with the question ofspecialism ; he was dealing merely with the average medicalman, and he maintained that the average medical manpassed from his hospital without having the proper equip-ment in this department of practice in the public interest.Statistics must be looked upon as absolutely valueless. Whocould say what particular share the anaesthetic, the opera-tion, or the pathological condition of the patient had incausing the death ? ? A committee of the British MedicalAssociation sat some years ago upon the subject and all itslabours were practically thrown away. Nothing came fromthat most carefully conducted clinical inquiry simply becauseit knew in discussing any given case that there was thisdifficulty. The two proposals which he submitted would,he personally believed, have the effect of very materiallylessening the evil with which they were confronted. The

Society of Anxsthetists had, he believed, approached theGeneral Medical Council and had been told that there wasno room for another subject, but be thought that it mustappeal to everyone who recognised the importance of the

subject that some alteration was necessary. He congratulatedthe society in occupying the happy position of being of greatuse not only to the public but to the medical profession ingeneral, which by reason of being split up into a greatnumber of bodies was not able to act as could a single societyof this character.

Mr. HENSLOWE WELLINGTON seconded the motions.Sir ALFRED FRiPP said that the question was an extremely

complicated one because there were many different points ofview from which it might be approached. Dr. Hewitt’s pro-posal that every student should have a course of instruction had, of course, won hearty support. The second motionshould have the support of the medical profession, but ifsuch a law was passed that none but qualified men shouldadminister anaesthetics, it would be hitting a large numberof the public who got their tooth extracted and a whiff ofgas for the modest half-crown. They would be driven intothe hospitals and dispensaries and the large body of themedical profession who made their money by small dribletswould suffer. Speaking as coming from a hospital with alarge dental department he thought that they would findthemselves overburdened with work. It opened up the pos-sibility of having to face a very large social question ofwhether there was not already more than enough donefor that very large class that could afford somethingbut could not afford to pay the full fee for medicalor surgical attendance and who were very prone to

get their services for nothing at all. As regardsoperations in the country very difficult circumstances werefound and where it was not always possible to procure theservices of a special anaesthetist. Whether this should bemet by the creation, or rather the multiplication, of thespecial class of anaesthetists, or whether it would be bettermet, as Dr. Hewitt had suggested, by the leaveningup of the whole profession by requiring students to take acourse in anaesthetics, as was done at many hospitals, wasworthy of consideration. He was surprised to find that theresponsibility of the administration of anaesthetics was uponthe surgeon. He had certainly thought that the surgeonwho availed himself of the assistance of the skilled anæs-thetist shifted the responsibility. If the surgeon dared tointerfere no anassthetist would brook that interference for amoment. In his hospital they took proper care that everystudent should have attended a course in the administrationof anaesthetics and should have seen them administered andhave taken part under the skilled anæsthetist attached to

the hospital. He believed that such a course tended to th&turning out of a class of men much more likely to be able to>avoid those common mistakes of the past.

Dr. R. J. PROBYN-WILLIAMS regretted that the discussionwas confined to the two motions, which would receive thehearty approval of anæsthetists present. He thought thatDr. Hewitt was rather extreme when he said that he wishedfor more teaching in anmsthetics and at the same time saidthat the drugs were safe. If he had been fortunate enoughnot to see a patient die on the operating-table it was excep-tional. There were many cases at any rate in which therpatient was in the absolute extremity of danger and nothing-but the greatest skill had saved his life. It was a good dealowing to the efforts of the Society of Anaesthetists that atany rate the Royal College of Surgeons of England had made-this important branch of practical science a part of its-curriculum.

Dr. F. J. SMITH referred to Dr. Hewitt’s statement (mad&at the February meeting of the society) that nine out of tendeaths under anaesthesia could be avoided by greater careupon the part of anaesthetist and said that it surely wentbeyond the limits of fair criticism of the whole body of skilledanæsthetists. He thought that motion No. 2 contained apious opinion which he was afraid would go the way whichgood intentions were said to go. He could not imagine thelegislature passing anything like an Act based on those?lines, or interfering with quackery, of which perhaps nineteen-twelitieths of the members availed themselves. There must behundreds of operations performed by the medical man which,the student had never seen performed. He contended that.if a man did his level best he was not responsible for anyparticular catastrophe. He asked the coroners present ifthey honestly thought that any 12 jurymen they called

together were fit judges to decide the question as to who was.responsible for the death ? What would be the effect of themotion upon some unfortunate practitioner who met witha catastrophe when one of the jury asked what steps he hadtaken to resuscitate life and who on receiving the answerwhich he would not understand would say that he was goingto stick out for a verdict of manslaughter. He protestedagainst coroners holding inquiries in these cases. He was.

heartily with Dr. Hewitt in wishing that the students shouldbe educated, but it must be remembered that whilst in,London there was nothing easier than to get a skilledanaesthetist it was very different with a man say in Wiltshire.A degree of skill would be expected from Dr. Hewitt whichwould not be expected from a practitioner in the country.

Professor J. GLAISTER (Glasgow) considered that the

present state of the law was anomalous. It was news to himthat herbalists and bone-setters gave chloroform ; he neverheard of it in Scotland. It had been his misfortune to haveto make inquiries into deaths under anesthetics in everyhospital, small and large, in and around Glasgow and somein private cases. He was inclined to think that chloroformwas one of the most uncertain drugs in its operations becausethe factor that was not constant was the person to whom itwas being administered. Dr. Hewitt must consider the.

living factor a little more. Each man in the hospital schools-in Glasgow received tuition in the administration of an sea-thetics. Dr. Hewitt would find himself on dangerous ground’in stating that nine out of ten of the cases of death could beavoided by attention on the part of anaesthetists. In hospitalsmen of the highest rank as anaesthetists had deaths. Therewas surely a share in the condition of the patient which must.be considered. There were two classes of operation-theoperation of necessity and the operation of expediency.Surgeons had not infrequently to operate to give a patient a.chance of life when he would not be justified in withholdingthat chance. He did not think the profession should adver-tise itself as incompetent to do its work. The second motion,he agreed, was but a pious opinion ; he quite supportedthe first but unfortunately everybody was crying forlengthening the medical curriculum and if they weremedical students they would think it long enough already.

Dr. F. J. WALDO said that from an examination of themachinery whereby the facts relating to invesfjtgated deathswere recorded he was led to believe that the data wereworthless as to the ratio of deaths to the administration of-anaesthetics. He referred to his article on this subject thathad already appeared in THE LANCET.

Dr. C. TEMPLEMAN (Dundee) said that at St. AndrewsUniversity no student was allowed to graduate without

1 THE LANCET, March 21st, 1908, p. 851.

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having had several opportunities under skilled supervision ofthe administration of chloroform, but they were not requiredto show a certificate on coming up for examination. All- cases of death under anaesthetics in Scotland were inquiredinto by the Procurator Fiscal in precisely the same way aswere other caEes of sudden death, with the addition that theCrown required that the whole of the precognitions with thereport should be submitted to some qualified man who was:asked to report (1) whether the operation ought to have

;required the administration of an anaesthetic ; (2) whetherthe patient had been previously examined to see if there wasanything to contra-indicate the administration ; and (3)- whether the anæsthetic had been properly given. All these

inquiries were held without the facts coming before the,public at all.

Professor H. HARVEY LITTLEJOHN (Edinburgh) said that,he thought the subject far too wide to lead to any gooddiscussion. There was no advantage in holding a publicinquiry. Surgeons must give chloroform for operativepurposes and there was no object in setting up the publicmind against the use of it and in making people believe thatthere were greater dangers than was really the case. Hewent most strongly against Dr. Hewitt if he said there wasno danger connected with the administration of anaesthetics.They knew that people died not from chloroform but underchloroform, sometimes during the operation but sometimes from causes apart from chloroform. Then patients came i

out from chloroform and sometimes died afterwards. What was the proof that death had taken place from chloroform ?Could it be obtained from a post-mortem examination ? No.He had made many post-mortem examinations and foundnothing diagnostic. Could they get proof from a chemicalexamination ? Certainly not. What did the inquest lead to ?How were they going to prove any fault either on the part-of the surgeon or the administrator so long as he could sayhe used ordinary precautions? There was no object in having- public inquiry. The only object was to make out whatwas the cause of death, though he thought there ought to bea post-mortem examination to try to find out what was thecause of death in circumstances entailing the properscientific examination of the organs. If competent men didthat after a time there might be material to lead to anunderstanding of the state which led to a predisposition insome people, because no doubt there was a predisposition tosuffer from the effect of chloroform in individuals.

Dr. J. BLUMFELD referred to Dr. Hewitt’s statement thatnine out of ten deaths were preventable. If deaths wereinevitable then those who performed the largest number ofoperations should have the largest number of deaths, but thereverse was the case. A year’s cases were reported in the news-.papers numbering 74, and out of these five happened in thehands of men who were constantly engaged in giving anæs-

thetics and the other 69 in the hands of men with whom itwas only an occasional duty. It did not seem to him to be afair argument that because they did not believe Parliamentwould ever be induced to legislate on the lines suggested thesociety should not endeavour to introduce the thin end of thewedge, even if there was no immediate result.

Dr. J. F. W. SILK wished to dissociate himself from the old-fashioned idea that to say that some cases were inevitablewas incorrect. He believed that there were cases in whichit was perfectly impossible to avoid death. He believedthat things had very much improved and although it mightbe that the licensing bodies did not require any particularform of definite instruction, in most medical schools, at anyrate, training was given. He entered a most emphaticprotest against the statement that inquests should be held inall cases. One of the favouring factors in causing thesedeaths was the state of terror which was often induced in apatient by reading sensational literature on the subject.’They could not muzzle the press but he would muzzle thecoroners.

Dr. W. H. WILLCOX thought that post-mortem examina-tions were of great value in many cases.

Mr. HARVEY MURPHY, barrister-at-law, thought that solong as a qualified man was doing his best the law wasperfectly clear but what was wanted in the interest of thelaw and the public was to prevent unqualified men fromdealing with dangerous drugs.

Mr. W. ScHRODER said that the coroner had no power totold a private inquiry. He had a discretion in certain casesbut that did not apply to any deaths occurring from un-natural causes. It was clearly laid down in the CoronersAct of 1887 that he should inquire in all cases due to violence

and where he has. reason to believe that the death was un-natural. He held that death from anaesthesia was unnaturaland as the law stood an inquest should be held in everycase.

Mr. H. BELLAMY GARDNER thought that they were 50years behind the time. Chloroform was used everywhereand surely death from it was as natural as any form ofdeath. It could not be differentiated from death arisingfrom the injection of antitoxin to save a patient fromdiphtheria. He had been an anæsthetist for 13 years andstood in constant terror of being dragged before the coronerand his reputation and living taken away from him in con-sequence. He had given chloroform in over 20,000 cases andhe could not conceive of anything more terrible than havingto go before a jury who knew nothing about the subject. Thesimplest thing would be for the coroner to accept thecertificate of two medical men which should be taken incases of deaths while under anaesthetics as sufficient.

Mr. HUBERT SwEENEY, barrister-at-law, thought thatstatistics were of value, for otherwise the present discussionwould not be taking place. He thought that even when themedical man did his best he should not be entirely exoneratedfrom responsibility. He might use a drug about- which heknew nothing and with regard to which he had not taken theprecaution to be properly qualified. If death occurredsurely some responsibility attached to him for neglecting tobring himself up to date in his profession. As regarding thesuspicion which resulted from inquiries, suspicion would beten thousand times greater if there were no coroner’s inquestsas advocated by some of the speakers.The PRESIDENT said that he quite agreed with the last

speaker, and if a person killed a man in performing someoperation on him it would not be an absolutely sufficientexcuse for that person to say that he had done his best.With regard to the subject of inquests, although that was alittle outside the special matter which they were considering,it was impossible to confine the discussion to the resolutionsaltogether because, after all, it was a discussion on Dr.Freyberger’s paper. The law was perfectly simple andplain. The difficulty arose from the facts. The lawsaid that a coroner must hold an inquest if he thoughtthe death was an unnatural one. The coroner was

the judge, and if he had reason to think it an un.

natural death he must hold an inquest. That involvedvarious questions. To apply it to the death from anass-thetics, in the first place there must be reason tothink that the death was caused by chloroform ; that wasthe kind of death they were considering. And then he hadto consider whether death by chloroform administered as ananassthetic in the ordinary course of medical or surgicalpractice was such a death as an unnatural death. That ques-tion might perhaps be considered by the court some day andtherefore he (the President) was not going to deal with it now.If death by chloroform was an unnatural death, and thereforeif the coroner had reason to think the death was a death bychloroform, he must open an inquest. It seemed to him (thePresident) to follow that if the death was by an operation, ifthe man died from an operation, that plainly would be anunnatural death and there would be an inquest in every casein which a man died from an operation. The two thingsseemed to be on the same footing. With reference to thesecond of the resolutions, he had not had time to look intothe matter carefully, but he thought that undoubtedly theonly medical practitioner who committed an offence bypractising without a qualification was the apothecary. He

thought the Act of George III. was still in force by whichpersons were forbidden to practise as apothecaries unless theywere qualified apothecaries. So far as he knew to practise asa physician, he (the speaker) did not mean to say to pretendhe was a physician, but to do the work of a physician or asurgeon was not in itself a penal offence. To practise as anapothecary appeared to be a penal offence. Why, he did notknow. But a man might perform operations or administermedicines and so forth provided he did not practise as anapothecary, whatever that meant, without committing anoffence in doing so in itself. Of course, if he killed some-body in the course of his practice and he was not qualifiedhe (the speaker) quite agreed that it was not sufficient forhim to say he had done his best if he was doing somethingwhich was in itself a dangerous thing likely to cause deathunless done with great skill and he knew he had no skill.In such a case he thought it would be obviously man-slaughter and probably wilful murder.The first proposition was unanimously agreed to.

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Dr. HEWITT, replying on the second, said that the oneobject before them all was the safety of their patients. Thereshould be no hair-splitting. When he said that nine casesout of ten were preventable he was speaking of thecases which had been described by Dr. Freyberger andothers which clearly indicated that in a large number ofcases the patients died from intercurrent asphyxial con-

ditions which might have been avoided. Again, a gentlemanwho had recently died with an honourable record passedthrough a life of anas sthetic cases without having ever lostone-he had tens of thousands of cases. He (Dr. Hewitt)contended that the average medical man if properly trainedon the principles such as a master of the art would be ableto transmit to his students would be able to save life in aboutthe proportion he had indicated. He had never intended tosay that chloroform or any drugs could be regarded as safe.By careful treatment it was possible to render them com-paratively safe-that was to say, if given in a haphazard wayit was a dangerous drug, if given on a proper scientificprinciple it was not a dangerous drug. Dentists in thecountry administered gas because there were no properlytrained men. The very large number of deaths occurredfrom asphyxia and unless a man had been highly trained hewas not able to watch the respiration and guide it alongthrough its various abnormal phases in such a way as

thoroughly to protect the life of the patient.Dr. FREYBERGER having brieily spoken the second

proposition was put to the meeting and carried.

LIVERPOOL MEDICAL INSTITUTION.

Reminiscences of 42 Years’ Professional Life in Liverpool.A MEETING of this society was held on March 19th, Mr.

T. H. BiCKERTON, the President, being in the chair.Dr. W. CARTER gave an address on Reminiscences of 42

Years’ Professional Life in Liverpool. He remarked thatowing to recent reviews of the advances in medicine andsurgery by Dr. A. T. H. Waters and Professor W. RushtonParker during a period almost contemporaneous with the timeof his residence in Liverpool, he would confine himself to astatement of some of those public controversies and eventsin which he had taken part. The first, and perhaps the mosttrying, was the Contagious Diseases Acts. Believing thatthese degraded both the womanhood and the manhood of thecountry he was obliged to oppose them. In conjunction withthe late Dr. Nevins, Dr. Ewing Whittle, and others theyestablished a national association for their repeal in March,1875, at a meeting at St. George’s Hall, Liverpool, and ’decided to start a journal, the Medical Enquirer. He was

honorary secretary to the association and sole editor of thejournal, also a purely honorary position. The work lasteduntil the repeal of the Acts in 1886, Dr. Nevins distinguish-ing himself above all others by his zeal and work. Thenext public controversy was that concerning the position ofthe public abattoirs and hide market in a densely populatedpart of the city and very near to the Royal Infirmary. Onbehalf of a deputation from the Medical Institution he pre-sented in 1884 to a meeting presided over by the then mayorstatistical tables proving the greater unhealthiness of thedistrict than of any other district generally similar anywherein Liverpool. This was confirmed by a subsequent reportmade by Dr. Stopford Taylor, the then medical officer ofhealth, and later still, in February, 1903, he was requestedby the committee of the Royal Infirmary to meet the estatecommittee and to endeavour to dissuade it from renewingthe lease of the abattoir. With the late Sir William Banksand Mr. Robert Gladstone he strongly urged this course onthe authorities and trusted that this evil would ere long beremoved. Dr. Carter next spoke of his prolonged efforts inthe promotion of total abstinence both in Liverpool andelsewhere. Another controversy which was maintained formany years was that concerning the notification of infectiousdiseases without the slightest discretion being allowed in anycase. He presided over a large meeting of the medical pro-fession in that theatre in September, 1882, on the subject.After prolonged discussion and numerous meetings a com-promise was agreed upon and the form now employed wassanctioned. The attempt to persuade the late Sir WilliamJenner to found a medical defence union, its subse-quent formation, and later still the presidency bythe late Mr. Lawson Tait, with Dr. Carter as a vice-president, were mentioned and everyone present was urged to

join the present ably conducted union. In 1870-71 thevisitation of Liverpool by a severe outbreak of small-pox wasthe occasion of Dr. Carter’s writing a series of articles in theMedioal Time.ç and Gazette, after examination of all thereturns supplied by the parish medical officer in chargeof the public sheds. The mortality was strikinglyinverse to the number and size of the cicatrices. Manyyears later, therefore, when the practice had arisen ofsome medical men making one small pin-prick and term-ing that efficient vaccination he felt bound to bring thematter before the Lancashire and Cheshire branch of theBritish Medical Association on Feb. 28th, 1889, at which aresolution adverse to this was come to at a large meeting.On March 23rd, 1904, at a large public meeting heldat the Philharmonic Hall, under the presidency ofMr. Emmott, M.P., the Protestant Bishop of Liverpoolproposed, and Dr. Carter seconded, motions which hadthe effect of starting the Congo Reform Association. Aschairman of the professional subcommittee of the TropicalDiseases School since its formation, he felt much em-

barrassment at times owing to his having to protest againstthe extravagant laudation in the annual reports of the schoolof King Leopold of Belgium, and when invited to accompanythe president of the school and some of his colleagues toBrussels to luncheon with the King last August twelvemonths he was obliged to refuse the invitation. When themidwives registration controversy arose he felt bound, underthe conviction that many humble homes were wreckedthrough the spread of puerperal fever owing to unedu-cated and ignorant women, strongly to support the Bill forthe education and registration of midwives. The matter wasvery hotly discussed on May lltb, 1894, at a large meetingheld in that room, when his motion on the subject waslost by a large majority. He published his speech, copiesof which were requested by the Royal College of Physiciansof London for its library table, and finally, as everyonenow knew, an Act was passed in 1902 compelling the educa-tion, certification, and supervision of all women practising asmidwives. Dr. Carter lastly drew attention to the generosityand public spirit of the wealthy men of Liverpool, especiallymentioning Mr. Sutton Timmis who after the death of his wifecommunicated to Dr. Carter through his friend Mr. WadeDeacon his desire to place L10,000 in the hands of trusteesfor promoting a cancer research, over the committee forcarrying out which he (Dr. Carter) had presided, and stillcontinued to preside, as chairman. He mentioned othersplendid acts of generosity on the part of the same gentle-man, and finally spoke of the extraordinary response to theappeal made by himself a few years ago for the family of thehero Mr. William Smyth, Liverpool contributing hundreds ofpounds. Rich and poor alike gave, one poor man sending2d. and another 6d., while a poor dressmaker begged to beallowed to make clothes for the children and was overjoyedwhen allowed to do so; but no class contributed so generouslyor so generally as the medical profession who alone couldestimate the great risks and the noble way in which thatheroic man, like a true soldier, had met them.A hearty vote of thanks, proposed by Dr. W. MACFIE

CAMPBELL and seconded by Professor W. RUSHTON PARKER,was accorded to Dr. Carter for his excellent address.

BRADFORD MEDICO-CHIRURGICAL SOCIETY.-Ameeting of this society was held on March 17th, Mr. H.Shackleton, the President, being in the chair.-Dr. F. W.Enrich read a paper on Tuberculosis of the Lung, in whichhe said that recovery was often spontaneous and thatto obtain a cure nature’s own methods must be employed.The outcome of this was the modern sanatorium treatment.Since the treatment had been restricted to suitable earlycases the results had considerably improved. Experienceseemed to show that the cases suitable for sanatorium treat-ment were those (1) with simple catarrh at one apex;(2) infiltration or consolidation at one apex, with or withoutcatarrhal symptoms ; and (3) infiltration with consolidationof one upper lobe. The other lung should not be appreciablyaffected. Contra-indications seem to be: (1) cavity forma-tion ; (2) repeated severe haemorrhages; (3) persistentelevation of temperature ; (4) albuminuria or glycosuria ;and (5) severe tuberculous affections of other organs. Butwhat about the cases whose disease had died down inspite of the fact that their lives had been spent in theslums under conditions in which every law of healthwas violated 7 The only explanation was that the