155

from diphtheria, 62 (20) from diarrhoea and enteritisunder two years, and 64 (11) from influenza. Thefigures in parentheses are those for London itself.The 3 deaths from enteric fever outside London all

occurred at Newcastle-on-Tyne. Stoke-on-Trent and Wiganeach reported 4 deaths from measles, West Ham andManchester each 3. Cardiff reported 3 deaths from whooping-cough. Diphtheria claimed 4 victims each in Birminghamand Merthyr Tydfil. Of the deaths attributed to influenza6 were reported from Birmingham, 5 from Bradford.

The number of stillbirths notified during the week was262 (corresponding to a rate of 37 per thousand births),including 50 in London.

Special Articles.DENTAL TREATMENT AND NATIONAL

HEALTH.

REPORT BY THE NATIONAL DENTAL SERVICE

COMMITTEE.

A REPORT issued by the British Dental Association,23, Russell-square, London. W.C.1, is based on certainunfulfilled recommendations of the DepartmentalCommittee on the Dentists Act (Cmd. 33, 1919),and deals with the dental services which are necessaryto the national health under the following heads :-

1. Dental treatment of expectant and nursing mothersand for children up to 6 years of age.

2. Dental inspection and treatment of all children ofschool age.

3. Dental treatment of adolescents.4. Dental treatment for all persons insured under the

National Health Insurance Act, and for all other adultswho are unable to afford dental treatment by private dentalpractitioners.

5. Dental treatment as an essential element in cases oftuberculosis and of venereal disease.

6. The institution of a coordinated scheme for educationin oral hygiene, which would be simple in its applicationand general in its incidence, but with particular attentionto the young, with the object of preventing dental disease.

The suggestions made are in general agreementwith the scheme outlined in the Interim Report ofthe Ministry of Health Consultative Council onMedical and Allied Services (Cmd. 693, 1920). Meansare also suggested for the organisation of such dentalservices, and for the supply of the necessary personnel.

Recommendations.

In brief the recommendations of the Service Com-mittee are these :-

1. That dental treatment be organised at every maternityand child welfare centre.

2. That in the first place the efforts of the professionshould be concentrated on obtaining a complete schooldental service.

3.,That by a suitable scheme of dental treatment foradolescents the complete school dental service be linkedup with statutory dental benefit under an amended NationalHealth Insurance Act.

4. That effective supervision and inspection of all publicdental services should be carried out by dental practitionersresponsible to the controlling authority.

Finally, stress is laid on the importance of educationin dental hygiene being consistently emphasised.

KING EDWARD’S FLTND.-During the absence of thePrince of Wales in Africa his power as President of theFund have been confided to a commission consisting of theLord Chancellor, the Speaker of the House of Commons,and the Governor of the Bank of England.

MEDICAL REFEREES ON INDUSTRIAL

DISEASES.

(FROM A SCOTTISII CORRESPONDENT.)

IT is notable what a large proportion of experiencein all matters relating to the compensation code forworkmen occurs in Scotland. Recently this hasbeen specially observable in the case of miner’snystagmus. The case of Lowe v. Wilsons and ClydeCoal Co., decided in the Scottish Court of Appeal andreported in 1930 Scots Laiv Times, 28, makes importantreading, for the main point in it applies to the functions.of medical referees in all compensation cases basedon disablement following on an industrial disease.

The medical referee in that case stated that miner’snystagmus does not necessarily prevent the workmanfrom working underground and drawing full wages ;implying a distinction between the date of the com-mencement of the disease and the date of disablementto earn full wages. It was the failure to make thisdistinction which tended to create a tangle in theLowe case. Before the days of compensation in

industrial disease cases many nystagmic miners kepton at their work underground, driven by necessityto do so in order to support themselves, their wives,and families. This is still done by determined men,because full wages are more than the compensationallowance.

In these compensation cases based on disablementto earn full wages owing to an industrial diseasethere is a special sub-code. The workman applies tothe certifying surgeon for a certificate that he issuffering from an industrial disease and is therebydisabled from earning full wages. If the certificateis granted the surgeon is to state the date of commence-ment of disablement if he can ; if not, the date of thecertificate is taken. Of course, the surgeon mayrefuse to give a certificate, and then he is not con-cerned with any date. In either case there may bean appeal to a medical referee. The Act says that,if the referee grants a certificate where the surgeonhad refused it, the referee shall fix the date of com-mencement of disablement. It does not say that,if the referee agrees with the surgeon that the workmanis entitled to a certificate, the referee may alter thedate which has been fixed by the surgeon. Power" to alter or not to alter," that is the question. Thereis no judicial decision upon it. It has never even beenargued, except in this latest case in Scotland. Therehave been judicial opinions expressed in England andin Scotland in favour of the medical referee possessingthis power, but they are merely obiter dicta, and sois the very definite reasoned opinion to the contrarypronounced. by one of the judges of the ScottishCourt of Appeal in the recent case. It is worth whileto draw attention to the doubt surrounding thisquestion and this latest judicial opinion on it.The case also has a bearing on the proper way for

medical referees to draw up their reports in suchcases. They went considerably astray in this respect.The report had to be sent back to the referee to stateplainly whether he sustained or refused the appealfrom the certifying surgeon, who had found theworkman entitled to a certificate. Then the referee

added " I therefore sustain this appeal." Even afterthat, parties were at sixes and sevens as to what thereport meant. Probably that was due to the word"

therefore," which gave a connexion with precedingmatters, some of which was irrelevant and may havebeen ultra vires. It has to be kept in view thatmedical men in these cases are not entitled to legaladvice, and it is said that the forms supplied to themare the reverse of helpful. Clearly the ordinaryprofessional curriculum should include some degree-of instruction in such matters. But the doctor mustread the Acts and other documents ; he must attendto the specific questions put to him ; these he mustexhaust ; at that point he must draw the line

156

and refuse to step beyond into matters with which Ihe has nothing to do, and which he may not be Iqualified to deal with. Reasons and reasonings,comments and explanations, including the process bywhich he has arrived at his decision, will usually beunnecessary and may be damaging.

Neglect of these rather obvious guides may leadto a report being sent back to its author to explain,not a mere detail, but the cardinal point whether thereport is " Yes " or " No." That ought to have beenfound in a few unqualified and unambiguous wordsin the first line of the report. The history of thiscase shows that it must be clearly understood what isthe question to which an affirmative or negativeanswer is being given. The reporter appears to havebeen misled into importing into his functions a questionas to the commencement, not of the disablement, butof the disease. Not only so, but there were also inthe report words which appeared to express or suggest’that the doctor was applying his mind to the legalquestion whether a previous cash settlement with theworkman amounted to compensation in respect of thedisablement for which he was now claiming. It isall in the medical man’s own interest that his sphereof function in such matters should be as circumscribedas possible. It may well be that he could add muchaccurate and valuable information and advice, buthe is not instructed to do so nor safe in doing so.

MEDICINE AND THE LAW.

ALLEGED NEGLIGENCE : DIPHTHERIA INFECTION.

As a legal correspondent points out on another ’

page, the recent Scottish case of Carmichael v. Milleris of considerable interest. Indeed, the issues of factin the case, in which a series of allegations of negli-gence against the late Dr. Miller was dismissed byLord Fleming at the close of last year, are almost aswell worth notice as the issues of law.Duncan Carmichael, a dairyman near Fort William,

had a son Duncan, 2 years old, who on Dec. 31st,1925, was admitted to the local hospital suffering fromscarlet fever. The disease took a normal course till26 days later, when what appeared to be a secondaryattack supervened with sore-throat. pyrexia, andcopious rash, desquamation meanwhile continuing.Dr. Miller, medical officer of health for the burgh andmedical superintendent of the hospital, and hisassistant, Dr. Mackintosh, diagnosed this as a

secondary attack of scarlet fever. Another doctor,and also the fever nurse and matron, agreed. Therash was typical scarlet fever rash and none of theclinical appearances of diphtheria was observed.There was otorrhoea, but this was slight and inter-mittent, and on March 1st, 1926, the child was senthome. Six days later a sister, aged 8, and a brother,aged 7, were notified as suffering from diphtheria andwere admitted to the diphtheria ward of the hospital.The girl died ; the boy recovered. Another brotherwas admitted on April 24th suffering from virulentdiphtheria; he eventually recovered. The originalpatient, Duncan, was readmitted on April 24thsuffering from a recurrence of otorrhoea, a brushing ofwhich had shown bacilli resembling those of diph-theria. He was kept in hospital till August 3rd,then discharged as cured (the otorrhoea having ceased),readmitted on August 16th on a recurrence of thedischarge, removed to Glasgow in November forenucleation of tonsils and adenoids, readmitted at theend of 1926 on a further recurrence of the discharge,and at length finally released from hospital in June,1927. This long series of illnesses might well haveled his father to suppose that the treatment was insome way at fault: he brought his action against Dr.Miller, alleging negligence in various ways. First, itwas suggested, the child, when originally discharged-from hospital, showed typical post-diphtheriticsymptoms, a squint, nasal speech, and unsteady gait.’The evidence of these symptoms was vigorously

disputed, and the judge held there was no proof ofthe presence of diphtheria at the date of originaldischarge from hospital. Lord Fleming thereforedecided that there was no negligence on Dr. Miller’spart in failing to diagnose diphtheria if the childreally suffered from it. The next allegation was thatit was negligent to release the patient from hospitalwhile the ear was still discharging. It was proved inevidence that otorrhoea after scarlet fever may con-tinue for years. Lord Fleming said the evidencefailed to establish that it was in contravention of theusual or reasonable medical practice to dischargepatients suffering from intermittent scarlet feverotorrhcea. He refused to say that Dr. Miller hadfallen short of the ordinary standard of professionalcare and skill in sending the child home before theotorrhoea ceased; thus the second allegation was

disposed of. It was, however, argued alternatelyagainst Dr. Miller at this point that he ought to havehad a bacteriological examination of swabs fromthe ear. But there was no proof of any practice athospitals to take this precaution in the absence ofcomplications. The judge held that there was at thisstage nothing to cause Dr. Miller to suspect a

diphtheria complication, nor did he so suspect; if,therefore, the child was discharged in an infectiouscondition, Dr. Miller was not to blame or legallyresponsible. In view of this finding, Lord Flemingheld it to be unnecessary to consider whether thebrother and sister became infected with diphtheriaowing to contact with the original patient; as,however, the point was pressed in argument, the judgedealt with it. The subsequent bacteriologicalexaminations of swabs from the child’s ear were

apparently positive in seven cases and negative infive as regards diphtheria. This indicated to thejudge that the evidence was far from strong ; therewas, he said, no clinical history to show conclusivelythat the child ever suffered from diphtheria ; it wasnot proved that the diphtheria bacilli present in thechild’s system were of the virulent type. " If I hadto decide this question," said Lord Fleming, " I thinkI should be bound to hold that the pursuer had failedto prove that the diphtheria of which the sister diedhad been contracted by infection from Duncan."Finally he observed that not only was Dr. Miller notguilty of any negligence, but that the children hadreceived every proper care and attention while in hishands. He added a sympathetic reference to theunhappy misfortunes of the family. Without failingin sympathy to the father of these unfortunatechildren, the medical profession will have some

sympathy, too, for the doctor whose professionalreputation was attacked. The proceedings are esti-mated to have cost Dr. Miller’s representatives notless than 21000. As it is understood that there isscant chance of recovering this sum from the unsuc-cessful claimant, the case (in which the Medical andDental Defence Union of Scotland undertook responsi-bility) is another instance of the importance to themedical practitioner of being adequately coveredagainst such losses.

The Question of Law.

With regard to the broader question of law whichthe legal correspondent has raised, the nature of theclaim is similar to that in the action of Evans againstthe Liverpool Corporation, tried by Mr. Justice Waltonin 1906. On that occasion the alleged facts were thata boy, 6 years old, had a mild and ordinary attack ofscarlet fever, that he was removed to the corporation’sfever hospital for acute cases, and was passed out tothe corporation’s convalescent home a month later;a few days afterwards one brother, and subsequentlytwo other brothers, developed the disease. Theplaintiff said the visiting physician of the convalescenthome was negligent in allowing the boy to leave whilestill infectious ; also that the matron and nurses werenegligent in examining the boy and reporting hiscondition. The jury found the physician was

negligent, and that the damage complained of wassuffered in consequence ; the matron and nurses were