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Coroners' Inquests on Deaths under Anæsthetics.
327
death; the intangible is that
patient may be practically moribund state brought about by surgical procedure; its very intangibility prevents
in
a
a
such a factor from receiving the attention for which it cries aloud to the expert. Yet the anaesthetist in a coroner’s court may not belittle the effect of his share in the terrible eventuality, nor emphasise the dangers that must have attended his surgical LONDON: SATURDAY, JANUARY 31, 1914. colleague’s manipulations in any particular case. man it is axiomatic that To the heedless on Deaths under Coroners’ some of those who have to submit to the Anæsthetics. ministrations of the skilled surgeon may die; Is it desirable in the interests of the public that their death is due, he believes, to causes which inquests should be held in all cases of death under Providence alone can control. But death as a The vexed question has been result of anaesthesia usually suggests to the an anaesthetic ? recently reopened. The coroner for Southwark, Dr. public that something went wrong. No one was F. J. WALDO, who has contended before that inquests ’, to blame, but why did it occur ? Mr. BENNETT in these cases are beneficial in so far that they observed very justly that no note is taken of the afford an opportunity, if not for censure, at countless thousands of successful anaesthesias; the least for admonition, pointed out on a recent one death looms large in the forefront of the occasion that owing to representations made coroner’s court. This is the natural result of the from his court the system of giving anaesthetics accepted views about the terrors of surgical operain a large general hospital had been carefully tions and the ease of producing anaesthesia. The overhauled, with the result that the number coroner’s inquiry, no doubt, was originally intended of specially selected men serving as anaes- to ascertain whether a person died as a result of thetists had been increased, while the fatalities I crime, of accident, or of natural causes ; it now from anaesthetics in the institution had become I attempts to appraise the merits of the technical fewer. Dr. WALDO is a very wise and experienced side of the anaesthesia, and the anaesthetist is official, and is not alone in the belief that the placed at a disadvantage in dealing with " twelve holding of inquests in every case of death during good men and true " who incidentally are guiltless the administration of an anaesthetic is advan- of special knowledge, so that he cannot go tageous, since the publicity engenders greater into technical details. He is practically being caution, while raising the standard of excellence placed on trial at every one of these inquests achieved by the persons who administer anoes- for an offence, and his evidence is not infrethetics, Some go further than this. It has, indeed, quently met by that of a pathologist who knows been suggested that all patients who die during nothing about the clinical aspects of the caseaspects which are essential to forming an accurate or as the result of operations in public institutions This would seem to indicate that should have their deaths made the subject of a judgment. coroner’s inquisition. This suggestion we do not whatever advantages a coroner’s inquiry may discuss; it appears to be made in direct opposition have, and we submit all medical men will recogto public interest, which demands that the officers nise that such advantages exist under favourable of our hospitals should do their best without fear. conditions, yet the inquiry is in many cases of The matter presents grave difficulties and complex little utility, and is useless from the point of view of problems enough when we are considering only the. scientific investigation. In many serious cases the anaesthetist must be question of fatalities during the use of anaesthetics. Mr. T. I. BENNETT, an anaesthetist to Guy’s Hos- placed in a difficult position. His knowledge may pital, at the recent inquest held by Dr. WALDO, convince him that the patient’s condition is so while admitting that the verdicts of coroners’ grave as to make the attempt at inducing anæsjuries had subserved a useful purpose, accentuated thesia almost a forlorn hope, and yet he cannot the view that there is another side to the matter. allow the patient to sacrifice one scintilla of his The anaesthetist subpoenaed to give evidence, he chances. He may do his best, but no man can gauge contended, suffers in many ways. The coroner what resisting power remains to the patient, and so ,is not an anaesthetist, and although among coroners death may follow. Strive as he may, a certain stigma rests on the anaesthetist, especially if death occurs are many medical men who possess great before operative measures have commenced. Besides blended considerable forensic with knowledge it is for acumen, yet any coroner, such considerations, another weighty aspect of the impossible unless aided by expert help, to differentiate question remains. All the narratives of "deaths between deaths due solely to the use of under anaesthetics"" which are detailed at coroners’ an anaesthetic and those resulting from the courts find 3their way into the daily press. The depressed vitality of the patient, or the unavoid- reports are compressed into a few lines, and able collapse incident to surgical or accidental almost invariably the death appears as if it had The obvious factor is the anaesthetic, been caused by the anaesthetic. These newspaper trauma. is which known to be capable of producing paragraphs recur day after day, and the sick, and
THE
LANCET.
Inquests
there
328 those whose lives depend upon a successful operation being undertaken, become obsessed with an unreasoning dread of taking an anaesthetic. This dread is doubly dangerous ; on the one hand, it may lead the patient to refuse treatment and betake himself to one of the many quacks who batten on such folk; or, on the other, it may throw him into a state of panic, thus engendering the worst state possible for successful and safe anaesthesia. When, then, the whole matter is looked at dispassionately we see that the advantages and disadvantages of publicity much counterbalance each other, and, further, that some changes in the law are necessary.
and the Science of Medicine.
Hospital Statistics
THE numbers of patients that come under observation at a large hospital should form a basis upon which statistics of value to medical science might be founded. Experience, however, has taught that unless careful and skilled precautions are taken fallacies- are so likely to arise that the final conclusions are not to be relied upon. The reasons for this are sufficiently obvious. Amongst the most prominent are the class of patients from whom the necessary information with regard to family and personal histories has to be obtained, the difficulty of always procuring a sufficient number
of instances of the disease under investigation, and the manner in which the records’of the cases are collected. These points were frequently apparent in the discussion on the Influence of Heredity in Disease whichtook place at the Royal Society of Medicine in 1908. Professor KARL PEARSON then remarked that it was extremely difficult in a London hospital to obtain material for accurate deductions, and all the staffs of large metropolitan hospitals will corroborate this. It is not that the patients wilfully make wrong statements as regards their family history, but often they are in ignorance of the true cause of the deaths of their parents and relatives, and often they have grave defects of memory. Professor PEARSON expressed the that the opinion memory of the peasant in the north of England and in Scotland is far better, and the pride of family is far more intense than in the average Londoner of the general hospital population. A sufficient number of cases is very necessary for statistical purposes, as it is evident that nothing can be more fallacious than forming opinions on a review of a small number of cases, and yet we must feel that a good many cases The are recorded in an untrustworthy manner. clinical records of our hospitals leave much to be desired, but the defects are difficult to remedy. In many of the hospitals the notes are made by students or the resident officers, and these are supervised by the registrars and the members of the visiting staff. The value of the notes, especially when taken by the students, largely depends upon the manner in which they are corrected
and amended
by the physicians
and surgeons, and
then, although perhaps useful from a purely clinical point of view, for the purposes of obtaining statistics for any investigation they may be of even
little worth. Omissions which are of little con. sequence in one direction may have great signifi. cance in the other. One of the most frequent uses for which statistics are prepared is to demonstrate the The difficulties here met results of treatment. with are well shown in the attempts that have been made to arrive at conclusions as to the therapeutics of pulmonary tuberculosis in hos. pital and sanatorium practice. In the first place, a definite diagnosis must be arrived at, and much difference of opinion, which we need not enter into here, exists in regard to the methods of diagnosis. Next, too much stress has been laid on the results obtained in a small number of cases. In order that any true criterion may be formed many hundreds of cases must be observed. Again, in hospital practice, a further and greater difficulty is experienced-namely, that after leaving the institution a large number of patients are lost sight of, so that their future progress cannot be recorded. Every effort may be made to keep in touch with discharged patients, but the number of those who do not report themselves, or cannot be heard of, is so big as greatly to invalidate the result of any investigation. In such inquiries, too, it is difficult to eliminate the personal equation. Taking all these things into consideration we see that in compiling medical statistics the services of one skilled in the science should be obtained whenever possible. This was suggested in an interesting article in The Hospitab recently, in which it was proposed that a bureau might be formed under the supervision of a statistical committee nominated by the authorities of the different hospitals concerned. In this way certainly an orderly manner of keeping our hospital records would be much expedited. In some other branches of medical service, how. ever, hospital statistics may be of true value if ordinary care is taken. The results obtained in the treatment of the infectious fevers at the special hospitals are not so open to the objections we have mentioned, and the after progress of these cases may be more easily followed by the help of the health authorities. So, too, on a smaller scale in the general hospitals, the results of operations may Also the frequency be compared and checked. of complications and their results in various diseases form a subject for statistical investigation less open to fallacy. The main difficulty in instances of this nature would be to obtain a sufficient number of cases. The a of central bureau for the of collection suggestion statistics was made in a discussion at the Royal College of Physicians of London in reference to tuberculosis, and an extension of this idea might perhaps be made in other pathological directions. A director at the bureau whose formation has been ’
death; the intangible is that
patient may be practically moribund state brought about by surgical procedure; its very intangibility prevents
in
a
a
such a factor from receiving the attention for which it cries aloud to the expert. Yet the anaesthetist in a coroner’s court may not belittle the effect of his share in the terrible eventuality, nor emphasise the dangers that must have attended his surgical LONDON: SATURDAY, JANUARY 31, 1914. colleague’s manipulations in any particular case. man it is axiomatic that To the heedless on Deaths under Coroners’ some of those who have to submit to the Anæsthetics. ministrations of the skilled surgeon may die; Is it desirable in the interests of the public that their death is due, he believes, to causes which inquests should be held in all cases of death under Providence alone can control. But death as a The vexed question has been result of anaesthesia usually suggests to the an anaesthetic ? recently reopened. The coroner for Southwark, Dr. public that something went wrong. No one was F. J. WALDO, who has contended before that inquests ’, to blame, but why did it occur ? Mr. BENNETT in these cases are beneficial in so far that they observed very justly that no note is taken of the afford an opportunity, if not for censure, at countless thousands of successful anaesthesias; the least for admonition, pointed out on a recent one death looms large in the forefront of the occasion that owing to representations made coroner’s court. This is the natural result of the from his court the system of giving anaesthetics accepted views about the terrors of surgical operain a large general hospital had been carefully tions and the ease of producing anaesthesia. The overhauled, with the result that the number coroner’s inquiry, no doubt, was originally intended of specially selected men serving as anaes- to ascertain whether a person died as a result of thetists had been increased, while the fatalities I crime, of accident, or of natural causes ; it now from anaesthetics in the institution had become I attempts to appraise the merits of the technical fewer. Dr. WALDO is a very wise and experienced side of the anaesthesia, and the anaesthetist is official, and is not alone in the belief that the placed at a disadvantage in dealing with " twelve holding of inquests in every case of death during good men and true " who incidentally are guiltless the administration of an anaesthetic is advan- of special knowledge, so that he cannot go tageous, since the publicity engenders greater into technical details. He is practically being caution, while raising the standard of excellence placed on trial at every one of these inquests achieved by the persons who administer anoes- for an offence, and his evidence is not infrethetics, Some go further than this. It has, indeed, quently met by that of a pathologist who knows been suggested that all patients who die during nothing about the clinical aspects of the caseaspects which are essential to forming an accurate or as the result of operations in public institutions This would seem to indicate that should have their deaths made the subject of a judgment. coroner’s inquisition. This suggestion we do not whatever advantages a coroner’s inquiry may discuss; it appears to be made in direct opposition have, and we submit all medical men will recogto public interest, which demands that the officers nise that such advantages exist under favourable of our hospitals should do their best without fear. conditions, yet the inquiry is in many cases of The matter presents grave difficulties and complex little utility, and is useless from the point of view of problems enough when we are considering only the. scientific investigation. In many serious cases the anaesthetist must be question of fatalities during the use of anaesthetics. Mr. T. I. BENNETT, an anaesthetist to Guy’s Hos- placed in a difficult position. His knowledge may pital, at the recent inquest held by Dr. WALDO, convince him that the patient’s condition is so while admitting that the verdicts of coroners’ grave as to make the attempt at inducing anæsjuries had subserved a useful purpose, accentuated thesia almost a forlorn hope, and yet he cannot the view that there is another side to the matter. allow the patient to sacrifice one scintilla of his The anaesthetist subpoenaed to give evidence, he chances. He may do his best, but no man can gauge contended, suffers in many ways. The coroner what resisting power remains to the patient, and so ,is not an anaesthetist, and although among coroners death may follow. Strive as he may, a certain stigma rests on the anaesthetist, especially if death occurs are many medical men who possess great before operative measures have commenced. Besides blended considerable forensic with knowledge it is for acumen, yet any coroner, such considerations, another weighty aspect of the impossible unless aided by expert help, to differentiate question remains. All the narratives of "deaths between deaths due solely to the use of under anaesthetics"" which are detailed at coroners’ an anaesthetic and those resulting from the courts find 3their way into the daily press. The depressed vitality of the patient, or the unavoid- reports are compressed into a few lines, and able collapse incident to surgical or accidental almost invariably the death appears as if it had The obvious factor is the anaesthetic, been caused by the anaesthetic. These newspaper trauma. is which known to be capable of producing paragraphs recur day after day, and the sick, and
THE
LANCET.
Inquests
there
328 those whose lives depend upon a successful operation being undertaken, become obsessed with an unreasoning dread of taking an anaesthetic. This dread is doubly dangerous ; on the one hand, it may lead the patient to refuse treatment and betake himself to one of the many quacks who batten on such folk; or, on the other, it may throw him into a state of panic, thus engendering the worst state possible for successful and safe anaesthesia. When, then, the whole matter is looked at dispassionately we see that the advantages and disadvantages of publicity much counterbalance each other, and, further, that some changes in the law are necessary.
and the Science of Medicine.
Hospital Statistics
THE numbers of patients that come under observation at a large hospital should form a basis upon which statistics of value to medical science might be founded. Experience, however, has taught that unless careful and skilled precautions are taken fallacies- are so likely to arise that the final conclusions are not to be relied upon. The reasons for this are sufficiently obvious. Amongst the most prominent are the class of patients from whom the necessary information with regard to family and personal histories has to be obtained, the difficulty of always procuring a sufficient number
of instances of the disease under investigation, and the manner in which the records’of the cases are collected. These points were frequently apparent in the discussion on the Influence of Heredity in Disease whichtook place at the Royal Society of Medicine in 1908. Professor KARL PEARSON then remarked that it was extremely difficult in a London hospital to obtain material for accurate deductions, and all the staffs of large metropolitan hospitals will corroborate this. It is not that the patients wilfully make wrong statements as regards their family history, but often they are in ignorance of the true cause of the deaths of their parents and relatives, and often they have grave defects of memory. Professor PEARSON expressed the that the opinion memory of the peasant in the north of England and in Scotland is far better, and the pride of family is far more intense than in the average Londoner of the general hospital population. A sufficient number of cases is very necessary for statistical purposes, as it is evident that nothing can be more fallacious than forming opinions on a review of a small number of cases, and yet we must feel that a good many cases The are recorded in an untrustworthy manner. clinical records of our hospitals leave much to be desired, but the defects are difficult to remedy. In many of the hospitals the notes are made by students or the resident officers, and these are supervised by the registrars and the members of the visiting staff. The value of the notes, especially when taken by the students, largely depends upon the manner in which they are corrected
and amended
by the physicians
and surgeons, and
then, although perhaps useful from a purely clinical point of view, for the purposes of obtaining statistics for any investigation they may be of even
little worth. Omissions which are of little con. sequence in one direction may have great signifi. cance in the other. One of the most frequent uses for which statistics are prepared is to demonstrate the The difficulties here met results of treatment. with are well shown in the attempts that have been made to arrive at conclusions as to the therapeutics of pulmonary tuberculosis in hos. pital and sanatorium practice. In the first place, a definite diagnosis must be arrived at, and much difference of opinion, which we need not enter into here, exists in regard to the methods of diagnosis. Next, too much stress has been laid on the results obtained in a small number of cases. In order that any true criterion may be formed many hundreds of cases must be observed. Again, in hospital practice, a further and greater difficulty is experienced-namely, that after leaving the institution a large number of patients are lost sight of, so that their future progress cannot be recorded. Every effort may be made to keep in touch with discharged patients, but the number of those who do not report themselves, or cannot be heard of, is so big as greatly to invalidate the result of any investigation. In such inquiries, too, it is difficult to eliminate the personal equation. Taking all these things into consideration we see that in compiling medical statistics the services of one skilled in the science should be obtained whenever possible. This was suggested in an interesting article in The Hospitab recently, in which it was proposed that a bureau might be formed under the supervision of a statistical committee nominated by the authorities of the different hospitals concerned. In this way certainly an orderly manner of keeping our hospital records would be much expedited. In some other branches of medical service, how. ever, hospital statistics may be of true value if ordinary care is taken. The results obtained in the treatment of the infectious fevers at the special hospitals are not so open to the objections we have mentioned, and the after progress of these cases may be more easily followed by the help of the health authorities. So, too, on a smaller scale in the general hospitals, the results of operations may Also the frequency be compared and checked. of complications and their results in various diseases form a subject for statistical investigation less open to fallacy. The main difficulty in instances of this nature would be to obtain a sufficient number of cases. The a of central bureau for the of collection suggestion statistics was made in a discussion at the Royal College of Physicians of London in reference to tuberculosis, and an extension of this idea might perhaps be made in other pathological directions. A director at the bureau whose formation has been ’