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THE BRISTOL ROYAL INFIRMARY AND THE PLURALITY OF HOSPITAL APPOINTMENTS.
1171
question of the relation of nicotine poisoning to the conditions about which little need be said, since excessive smoking, although a potent cause of functional derangements of the heart, is not regarded as a marked factor in producing degenerative processes. A verdict of death from natural causes was returned, the members of the jury adding two riders, one dealing with the allegation made ’! by Mr. EVANS in regard to, the coroner’s officer, whom they acquitted of blame, and another in which they say, "We consider that the wordsattended during his last illness’ used in the form of certificate issued by the RegistrarGeneral should be defined in the instructions to medical practitioners who have to certify the cause of death and that’ attended’ should mean attendance within eight days of death and on at least two occasions during the last illness and in relation to the cause certified. We suggest that recommendation No. 3 of the Select Committee on Death Certification should be carried out." This recommendation runs as follows : " That a medical practitioner in attendance should be required before giving a certificate of death to personally inspect the body, but if, on the ground of distance or for other sufficient reason, he is unable to make this inspection himself, he should obtain and attach to the certificate of the cause of death a certificate signed by two persons, neighbours of the deceased, verifying the fact, of death." The certification of the cause of death in cases of sudden death or of unexpectedly rapid death is a very importanti matter and one for which it is highly desirable that there: should be recognised rules of procedure, not only in the: interests of the public, who must be thoroughly safeguarded, but also in that of the practitioner who is frequently face toI face with a situation requiring both judgment and tact to
found is
of which should be within eight days of death. Some such recommendation if adopted would be welcomed by our profession as it would define in precise terms what is now one
one
,
,
deal with satisfactorily. It is but natural that the relatives of a person dying suddenly from the effects of disease should wish to be spared the distress and pain likely to be caused by an unnecessary inquest, and where the practitioner has attended the patient for some malady which it is known may give rise to a sudden or rapidly fatal issue there should be no difficulty when the circumstances of the death are known to the practitioner and he has been in recent attendance. It is quite clear from the form of death certificate now in use that direct attendance during the last illness is required and, indeed, there is a note appended to the page of instructions at the beginning of the ordinary book of certificates supplied to the effect that "No medical practitioner is justified in giving a medical certificate of the cause of death unless he has been personally in attendance upon the deceased during the last illness." The difficulty which the practitioner has to contend with is to determine how long an interval between his last professional visit to the patient and the time of death constitutes attendance in the last illness. It is, of course, possible in the case of a chronic malady that this may be a matter of several days or even weeks and yet there may be no necessity for an inquest, for the cause of death may be quite obvious. The jury in its rider suggests that the recommendation of the Select Committee on Death Registration already referred to should be put into effect-viz., that attendance should be defined as personal attendance upon at least two occasions,
and would relieve the practitioner of responsibility and its attendant anxiety. It
a
grave may be objected that so short an interval as eight days before death would entail unnecessary investigations but after all if the coroner were satisfied from his inquiries that death was due to the disease for which the practitioner had attended the deceased at an interval longer than this but little difficulty or delay would be entailed and there would be less likelihood of mistakes. Another recommendation of the Select Committee to which attention may be drawn is that medical practitioners should be required to send certificates of death to the registrar instead of handing them to the representatives of the deceased. These certificates are of great importance as records and if they are to be accurate they must of necessity contain information which may be distressing to the relatives and which it is unnecessary that they
vague
should themselves have to deliver to the registrar, as where the primary cause of death is alcoholism or syphilis. The
question of payment
for these certificates is one with which we are not at present concerned, although it is somewhat of an anomaly that responsible work of this kind done for the State should be absolutely unpaid. The point we desire to emphasise is that in filling up a death certificate for a case of sudden death which he has only seen in artiaulo mortis or in which he has not been titioner undertakes
lightly assumed,
in attendance the pracresponsibility which should not be
a
even
recently
though
relatives from the distress of
an
undertaken to relieve the
inquest.
Annotations. "Ne quid nimis."
THE BRISTOL ROYAL INFIRMARY AND THE PLURALITY OF HOSPITAL APPOINTMENTS. IN THE LANCET of Oct. 12th we made our readers the facts of the dispute which has recently arisen between the medical staff and the committee of the Bristol Royal Infirmary on the subject of the holding of other hospital appointments by members of the former body. The situation has now developed into something like an impasse owing to the united action of the members of the staff in defending what they believe to be the best interests of their professional successors and of the infirmary, for it is to be especially noted that their own position is in no way prejudiced by the recent decision of the governors, the resolution not being retrospective. The staff have issued a memorial to the governors calling their attention to the situation preceding the meeting on Sept. 24th and to the resolution then passed which greatly limits the freedom of future members of the staff in taking other public professional appointments and which we have already published. They further explain that they are prepared to accept a less drastic rule than that which now awaits confirmation and that they have been advised by a largely attended gathering of the Bath and Bristol branch of the British Medical Association two take the strongest possible measures in resisting this or any rule which, in effect, embodies the substance of this rule." They point out that
acquainted with
1172 although the president of the hospital in his speech on members of the medical profession in each territorial area Sept. 24úh instanced several hospitals as having similar after conferring with one another, the results of the conrules, yet the chief hospitals in London, Edinburgh, ference being submitted to the Director-General of the Army and many other towns place no such restrictions on Medical Service, by whom it is proposed the training shall their honorary staff, and that in no other hospital in be administered." the United Kingdom is there a rule preventing mem-
bers of the full staff from holding " any other professional public appointment other than Professorship or Lectureship ......," the words of the said rule. Finally, they acquaint the governors with their decision in these words, which are signed by 20 members out of the 22 constituting the staff. " We shall therefore feel bound to tender our resignation to the governors unless this rule is withdrawn ; and we further wish to make it clear that we cannot hold office tender any similar rule that we consider opposed to the best interests of our infirmary and our successors." The secretary of the hospital has issued to the governors a copy of the president’s speech at the meeting of Sept. 24th, which is largely concerned with negotiations between himself and an individual member of the staff previously to the meeting. The governors have now to decide if the rule shall be carried and we await the issue with interest; should they accept the resignation of their staff en Moo they may find it harder to replace them under their new conditions than they imagine.
THE
SALE
OF FOOD: SOME CONVICTIONS.
RECENT
No more satisfactory result ever rewarded the prosecution of one of those persons who in their reckless greed endanger the public health than that which followed recently in the He was case of Edward Hughes, a street hawker of milk. trade-that milk from a hand on his of selling carrying cart-in Earl-street, Westminster, when Inspector M’Nair, employed by the Westminster city council, took a sample from his churn, which contained about a gallon, and finding it extremely filthy seized the contents of the churn and of the hand can wh1ch were afterwards destroyed by order of the magistrate at the Westminster police-court. The evidence given there by Dr. F. J. Allan, medical officer of health of the City of West minster, was to the effect that there were a large number of smuts floating on the surface of the milk and an accumulation of filth at the bottom of the can, the fluid itself having a most offensive odour. The microscope THE MEDICAL SERVICE FOR THE PROPOSED showed among the foreign matter of a recognisable TERRITORIAL FORCE. description seeds, bits of straw and of tomato skin, grit, WE commented last week upon the proposals which Mr. hairs, some of which were human and some not, and particles Haldane has recently laid before his constituents at North of human skin; the kind of refuse, in short, which might ]3erwick for the formation of an adequate medical service be due to exposure of the cans or of the milk in a for his projected Territorial Force. The medical profession dirty stable or in the street. The defendant was only in Scotland during the course of last week was taken into able to suggest the foggy state of the atmosphere on the counsel on this important matter by Sir Alfred H. Keogh, morning of the Eeizure of the milk in order to account for its Director-General of the Army Medical Service, who met condition and Mr. Horace Smith inflicted the extreme penalty representative gatherings of Scottish medical men at Edin- allowed by the law-namely, six months’ imprisonment with burgh, Glasgow, anAberdeen, and laid his scheme before hard labour. This is none too much if we consider the them with a cordial invitation to discuss it and to suggest insidious nature of the wrong done to the poor and any emendations which might occur to them. Sir Alfred particularly to their children by traders of this class Keogh will continue to hold his professional councils in im- and the difficulty of tracing the source of the evil portant English centres and invitations have been issued when illness has followed upon such conduct as his. to medical men in the Manchester and Leeds district to ’ It is almost unnecessary, moreover, to point out that meet him, with the object of exchanging views, on Oct. 25th although the defendant said something about a vendor at and 26h respectively, whilst he will visit Oxford and Walworth from whom he had purchased, the guilt was possibly other towns during the course of November. We beyond question his, for the horrible condition of the fluid are able to print in this issue a summary of the scheme which he was selling as milk was patent to the eye and nose we do not to deal with it of the ordinary observer and the cans were articles for the although (page 1180), fully propose until it has been placed before our English readers by the state of which he alone was responsible. His fate should Director-General in person but the method of its promulga- be a warning to others in his position and should be noted tion has our complete sympathy. Mr. Haldane has taken a by them. Among other prosecutions of milk-sellers may be wise course in the matter, for, as his public utterances prove, mentioned that of Messrs. Jenkins and Sons of Finsbury, he is prepared to give to Sir Alfred Keogh his full support in who in the same week in which Hughes was sent to prison the development of a national medical service which, it is were fined .E20 by Mr. Cluer at Old-street police-court hoped, will be completely adequate as a branch of for selling milk adulterated with 28 per cent. of home defence. The action of the Director-General is no added water. The defence which they put forward was that less commendable, for he has had the good sense to the liquid from which a sample was taken by the inspector recognise that it is useless to dictate the conditions to the was sold as milk and water at 3d. a quart and that the can civil medical profession on which they shall be asked to carried in the street was*so marked. They do not appear to undertake military duties, as the past history of volunteering have suggested a reason for anyone buying milk and water has proved, and he is sparing no effort to get thoroughly well in a city where the latter is so plentiful as in London, or to acquainted with the views of those who will form the have explained in what proportions ’’milk and water " would personnel of the new force. From the cordial reception with be supposed by a would-be purchaser to have been combined. which he met in Scotland it is reasonable to hope that his A fine of .E1O with <62 2s. costs, imposed at the instance of English audiences will give him an equal measure of support the Holborn borough council upon Elward Wright, a butcher, and sympathy and it is much to be desired that his audiences for exposing for sale 60 pounds of meat in an advanced will not be unduly backward in expressing their views state of decomposition concludes a list of recent convictions of his proposals. We may here reproduce Mr. Haldane’s which at any rate show that the local authorities and their words at Berwick on the matter. "Put shortly, the posi- inspectors are fully alive to their duties and that the tion which the Army Council seek to attain in regard magistrates are prepared to support them when cases deto medical organisation and training is one in which the serving exemplary punishment are fully proved before them. general arrangements year by year shall be made by the r The effect of a sentence of imprisonment as an example is,
question of the relation of nicotine poisoning to the conditions about which little need be said, since excessive smoking, although a potent cause of functional derangements of the heart, is not regarded as a marked factor in producing degenerative processes. A verdict of death from natural causes was returned, the members of the jury adding two riders, one dealing with the allegation made ’! by Mr. EVANS in regard to, the coroner’s officer, whom they acquitted of blame, and another in which they say, "We consider that the wordsattended during his last illness’ used in the form of certificate issued by the RegistrarGeneral should be defined in the instructions to medical practitioners who have to certify the cause of death and that’ attended’ should mean attendance within eight days of death and on at least two occasions during the last illness and in relation to the cause certified. We suggest that recommendation No. 3 of the Select Committee on Death Certification should be carried out." This recommendation runs as follows : " That a medical practitioner in attendance should be required before giving a certificate of death to personally inspect the body, but if, on the ground of distance or for other sufficient reason, he is unable to make this inspection himself, he should obtain and attach to the certificate of the cause of death a certificate signed by two persons, neighbours of the deceased, verifying the fact, of death." The certification of the cause of death in cases of sudden death or of unexpectedly rapid death is a very importanti matter and one for which it is highly desirable that there: should be recognised rules of procedure, not only in the: interests of the public, who must be thoroughly safeguarded, but also in that of the practitioner who is frequently face toI face with a situation requiring both judgment and tact to
found is
of which should be within eight days of death. Some such recommendation if adopted would be welcomed by our profession as it would define in precise terms what is now one
one
,
,
deal with satisfactorily. It is but natural that the relatives of a person dying suddenly from the effects of disease should wish to be spared the distress and pain likely to be caused by an unnecessary inquest, and where the practitioner has attended the patient for some malady which it is known may give rise to a sudden or rapidly fatal issue there should be no difficulty when the circumstances of the death are known to the practitioner and he has been in recent attendance. It is quite clear from the form of death certificate now in use that direct attendance during the last illness is required and, indeed, there is a note appended to the page of instructions at the beginning of the ordinary book of certificates supplied to the effect that "No medical practitioner is justified in giving a medical certificate of the cause of death unless he has been personally in attendance upon the deceased during the last illness." The difficulty which the practitioner has to contend with is to determine how long an interval between his last professional visit to the patient and the time of death constitutes attendance in the last illness. It is, of course, possible in the case of a chronic malady that this may be a matter of several days or even weeks and yet there may be no necessity for an inquest, for the cause of death may be quite obvious. The jury in its rider suggests that the recommendation of the Select Committee on Death Registration already referred to should be put into effect-viz., that attendance should be defined as personal attendance upon at least two occasions,
and would relieve the practitioner of responsibility and its attendant anxiety. It
a
grave may be objected that so short an interval as eight days before death would entail unnecessary investigations but after all if the coroner were satisfied from his inquiries that death was due to the disease for which the practitioner had attended the deceased at an interval longer than this but little difficulty or delay would be entailed and there would be less likelihood of mistakes. Another recommendation of the Select Committee to which attention may be drawn is that medical practitioners should be required to send certificates of death to the registrar instead of handing them to the representatives of the deceased. These certificates are of great importance as records and if they are to be accurate they must of necessity contain information which may be distressing to the relatives and which it is unnecessary that they
vague
should themselves have to deliver to the registrar, as where the primary cause of death is alcoholism or syphilis. The
question of payment
for these certificates is one with which we are not at present concerned, although it is somewhat of an anomaly that responsible work of this kind done for the State should be absolutely unpaid. The point we desire to emphasise is that in filling up a death certificate for a case of sudden death which he has only seen in artiaulo mortis or in which he has not been titioner undertakes
lightly assumed,
in attendance the pracresponsibility which should not be
a
even
recently
though
relatives from the distress of
an
undertaken to relieve the
inquest.
Annotations. "Ne quid nimis."
THE BRISTOL ROYAL INFIRMARY AND THE PLURALITY OF HOSPITAL APPOINTMENTS. IN THE LANCET of Oct. 12th we made our readers the facts of the dispute which has recently arisen between the medical staff and the committee of the Bristol Royal Infirmary on the subject of the holding of other hospital appointments by members of the former body. The situation has now developed into something like an impasse owing to the united action of the members of the staff in defending what they believe to be the best interests of their professional successors and of the infirmary, for it is to be especially noted that their own position is in no way prejudiced by the recent decision of the governors, the resolution not being retrospective. The staff have issued a memorial to the governors calling their attention to the situation preceding the meeting on Sept. 24th and to the resolution then passed which greatly limits the freedom of future members of the staff in taking other public professional appointments and which we have already published. They further explain that they are prepared to accept a less drastic rule than that which now awaits confirmation and that they have been advised by a largely attended gathering of the Bath and Bristol branch of the British Medical Association two take the strongest possible measures in resisting this or any rule which, in effect, embodies the substance of this rule." They point out that
acquainted with
1172 although the president of the hospital in his speech on members of the medical profession in each territorial area Sept. 24úh instanced several hospitals as having similar after conferring with one another, the results of the conrules, yet the chief hospitals in London, Edinburgh, ference being submitted to the Director-General of the Army and many other towns place no such restrictions on Medical Service, by whom it is proposed the training shall their honorary staff, and that in no other hospital in be administered." the United Kingdom is there a rule preventing mem-
bers of the full staff from holding " any other professional public appointment other than Professorship or Lectureship ......," the words of the said rule. Finally, they acquaint the governors with their decision in these words, which are signed by 20 members out of the 22 constituting the staff. " We shall therefore feel bound to tender our resignation to the governors unless this rule is withdrawn ; and we further wish to make it clear that we cannot hold office tender any similar rule that we consider opposed to the best interests of our infirmary and our successors." The secretary of the hospital has issued to the governors a copy of the president’s speech at the meeting of Sept. 24th, which is largely concerned with negotiations between himself and an individual member of the staff previously to the meeting. The governors have now to decide if the rule shall be carried and we await the issue with interest; should they accept the resignation of their staff en Moo they may find it harder to replace them under their new conditions than they imagine.
THE
SALE
OF FOOD: SOME CONVICTIONS.
RECENT
No more satisfactory result ever rewarded the prosecution of one of those persons who in their reckless greed endanger the public health than that which followed recently in the He was case of Edward Hughes, a street hawker of milk. trade-that milk from a hand on his of selling carrying cart-in Earl-street, Westminster, when Inspector M’Nair, employed by the Westminster city council, took a sample from his churn, which contained about a gallon, and finding it extremely filthy seized the contents of the churn and of the hand can wh1ch were afterwards destroyed by order of the magistrate at the Westminster police-court. The evidence given there by Dr. F. J. Allan, medical officer of health of the City of West minster, was to the effect that there were a large number of smuts floating on the surface of the milk and an accumulation of filth at the bottom of the can, the fluid itself having a most offensive odour. The microscope THE MEDICAL SERVICE FOR THE PROPOSED showed among the foreign matter of a recognisable TERRITORIAL FORCE. description seeds, bits of straw and of tomato skin, grit, WE commented last week upon the proposals which Mr. hairs, some of which were human and some not, and particles Haldane has recently laid before his constituents at North of human skin; the kind of refuse, in short, which might ]3erwick for the formation of an adequate medical service be due to exposure of the cans or of the milk in a for his projected Territorial Force. The medical profession dirty stable or in the street. The defendant was only in Scotland during the course of last week was taken into able to suggest the foggy state of the atmosphere on the counsel on this important matter by Sir Alfred H. Keogh, morning of the Eeizure of the milk in order to account for its Director-General of the Army Medical Service, who met condition and Mr. Horace Smith inflicted the extreme penalty representative gatherings of Scottish medical men at Edin- allowed by the law-namely, six months’ imprisonment with burgh, Glasgow, anAberdeen, and laid his scheme before hard labour. This is none too much if we consider the them with a cordial invitation to discuss it and to suggest insidious nature of the wrong done to the poor and any emendations which might occur to them. Sir Alfred particularly to their children by traders of this class Keogh will continue to hold his professional councils in im- and the difficulty of tracing the source of the evil portant English centres and invitations have been issued when illness has followed upon such conduct as his. to medical men in the Manchester and Leeds district to ’ It is almost unnecessary, moreover, to point out that meet him, with the object of exchanging views, on Oct. 25th although the defendant said something about a vendor at and 26h respectively, whilst he will visit Oxford and Walworth from whom he had purchased, the guilt was possibly other towns during the course of November. We beyond question his, for the horrible condition of the fluid are able to print in this issue a summary of the scheme which he was selling as milk was patent to the eye and nose we do not to deal with it of the ordinary observer and the cans were articles for the although (page 1180), fully propose until it has been placed before our English readers by the state of which he alone was responsible. His fate should Director-General in person but the method of its promulga- be a warning to others in his position and should be noted tion has our complete sympathy. Mr. Haldane has taken a by them. Among other prosecutions of milk-sellers may be wise course in the matter, for, as his public utterances prove, mentioned that of Messrs. Jenkins and Sons of Finsbury, he is prepared to give to Sir Alfred Keogh his full support in who in the same week in which Hughes was sent to prison the development of a national medical service which, it is were fined .E20 by Mr. Cluer at Old-street police-court hoped, will be completely adequate as a branch of for selling milk adulterated with 28 per cent. of home defence. The action of the Director-General is no added water. The defence which they put forward was that less commendable, for he has had the good sense to the liquid from which a sample was taken by the inspector recognise that it is useless to dictate the conditions to the was sold as milk and water at 3d. a quart and that the can civil medical profession on which they shall be asked to carried in the street was*so marked. They do not appear to undertake military duties, as the past history of volunteering have suggested a reason for anyone buying milk and water has proved, and he is sparing no effort to get thoroughly well in a city where the latter is so plentiful as in London, or to acquainted with the views of those who will form the have explained in what proportions ’’milk and water " would personnel of the new force. From the cordial reception with be supposed by a would-be purchaser to have been combined. which he met in Scotland it is reasonable to hope that his A fine of .E1O with <62 2s. costs, imposed at the instance of English audiences will give him an equal measure of support the Holborn borough council upon Elward Wright, a butcher, and sympathy and it is much to be desired that his audiences for exposing for sale 60 pounds of meat in an advanced will not be unduly backward in expressing their views state of decomposition concludes a list of recent convictions of his proposals. We may here reproduce Mr. Haldane’s which at any rate show that the local authorities and their words at Berwick on the matter. "Put shortly, the posi- inspectors are fully alive to their duties and that the tion which the Army Council seek to attain in regard magistrates are prepared to support them when cases deto medical organisation and training is one in which the serving exemplary punishment are fully proved before them. general arrangements year by year shall be made by the r The effect of a sentence of imprisonment as an example is,