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630 Medicine and the Law Death after Measles Immunisation AN inquest on the deaths of three children, which was adjourned on Sept. 20, was resumed on Sept. 26. These children, all aged 3 years and a few months, died of acute hepatitis some 7 weeks after the intramuscular injection of serum given on July 1 to immunise them against measles. At the request of Dr. Bentley Purchase, the coroner for St. Pancras, Dr. F. E. Camps described the post-mortem findings in two of these three cases. Both showed advanced liver necrosis, the condition being slightly less severe in one child. He had no doubt from the evidence, he said, that the liver damage was due to the transmission of a substance in serum, used in this case for measles immunisation. Virus transmitted in this way cannot be identified until a case of hepatitis occurs. He was satisfied that the syringes were not responsible ; several were used, and a large number of children were immunised on the same day. The syringes were changed after every fourth child, and a new needle was used for each child. ’It seems that the four children who developed hepatitis (one is still ill) were not injected in succession but were scattered through the whole group treated ; it is therefore improbable that the same syringe was used for each of them. It is very unlikely, Dr. Camps said, that the virus would be transmitted by a syringe used for intramuscular injections ; contamina- tion is usually the result of intravenous injections, in which a little blood is drawn back into the barrel before the injection is made. The four children infected, with one other child who has not developed jaundice, all received serum from a single batch, only a small quantity of which was used. At the previous hearing; Dr. R. A. Zeitlin, director of the Tottenham blood-transfusion department, said - that of the sixty donors who had contributed blood to this batch of serum, five had had jaundice in the past, but all many years ago, well beyond the period within which it was thought to be dangerous. Dr. Alfred Piney said that pathological examination confirmed that there was severe necrosis of the liver, of the type which occurs with virus infections. The coroner, summing up, recalled that the three children who died had, with many others, been given the injections at a day nursery, because they- were thought to be measles contacts. This method of immunisation is well established, not new, and one local authority has practised it for years without the appearance of any such cases. Of the sixteen children immunised that morning, the five who had the same batch of serum were scattered through the group. Three died and one was ill. Hepatitis shows itself within 60-100 days. It was no fault of the method, he said, that three children died : the danger of infection by hepatitis virus through a serum injection is no greater when the serum is given to protect against measles than when it is given for some other reason. He was satisfied by the evidence of Dr. J. Harrington, who gave the injections, and Dr. Zeitlin, who has charge of the laboratory where the serum is collected, that there had been no sort of neglect or lack of care. The experience gained from these unfortunate cases might be of practical use in serum immunisation, in the future, but that was not the province of his court. He was satisfied that the deaths were due to injections of serum given in July, and he brought them in as deaths by misadventure. The Wrong Cylinder In Dublin District Court last week, the judge rejected the prosecution’s case against a house-surgeon charged with having unlawfully killed a patient who died while under an anaesthetic. At earlier hearings and in a previous statement the house-surgeon had testified that on May 30 she decided to administer nitrous oxide and oxygen to an outpatient, for the purpose of operating on a septic thumb. She, the house-surgeon, noticed that the oxygen cylinder on the apparatus was empty, and she asked a nurse to get a full cylinder; she did not check the cylinder brought by the nurse but tightened it up and turned on , the nitrous oxide fully and the oxygen partly. She noticed that the patient was becoming cyanosed ; and she then turned the nitrous oxide off and the oxygen fully on. The patient became still more cyanosed ; and it was found that both cylinders contained nitrous oxide. Oxygen was administered from a fresh cylinder, two intracardiac injections were given, and artificial respiration was begun and was continued for some time, without success. In cross-examination the house- surgeon said that she knew that one or other of the nitrous oxide or oxygen cylinders had a white top, but she did not know which. For the firm supplying the cylinders it was stated that those containing nitrous oxide and oxygen were each distinctively marked; but nothing in the apparatus used was to prevent interchange of the two cylinders. District Judge Mangan found that the State had not established that the house-surgeon had failed to take care and that death had been due to that failure. There had been default by the accused, but the prosecution had not shown that death had resulted from the default. The possibility of death from other causes had not been excluded ; there was no evidence that a post-mortem examination had been made. Legal Proceedings in the N.H.S. A memorandum lately circulated -to boards and management committees indicates that the Ministry of Health is anxious to be kept out of legal proceedings against hospitals. The proper course for a claimant’s solicitor is to institute proceedings against the manage- ment committee or the board of governors. "’here appropriate, the management committee should have assistance from the solicitor of the regional hospital board. The Ministry should be consulted in cases involv- ing the construction of the Act and the regulations, in cases where an application is being threatened for leave to apply for a writ of mandamus, and in cases involving legal questions of first-class importance. , W’here a claim is based on negligent treatment by a nurse, it is to be expected that the claim will be against her employer, and the nurse will not be made a separate defendant. If, however, the nurse is joined in the proceedings, the employer is authorised to see to her defence if she so desires, and in such cases the solicitor acting for the employer would normally act for the defendant nurse as well. Where, on the other hand, the nurse has acted quite outside the scope of her authority, the Ministry holds that she ought to be left to conduct her own defence. Though it is stated that such cases should be referred to the Ministry for consideration, nothing is said about whether a nurse conducting her own defence would also be expected to pay for it. It looks as though she would. If so, nurses may well decide that the time has now come when they should form a defence organisation like those that have protected members of the medical and dental professions for years. The memorandum points out that, generally speaking, authorities are not authorised to undertake the defence of hospital doctors who may be sued in respect of alleged negligence," ; if it is sought to make an authority liable for negligent acts of a doctor, it should normally take such steps as are open to it under the Law Reform (Married Women and Tortfeasors) Act, 1935, to obtain a contribution from the doctor in respect of damages that may be recovered. This makes it clearer than ever that every doctor and dentist should have means of providing for their own defence. There may well be occa-
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Page 1: Medicine and the Law

630

Medicine and the Law

Death after Measles ImmunisationAN inquest on the deaths of three children, which was

adjourned on Sept. 20, was resumed on Sept. 26. Thesechildren, all aged 3 years and a few months, died of acutehepatitis some 7 weeks after the intramuscular injectionof serum given on July 1 to immunise them againstmeasles. At the request of Dr. Bentley Purchase, thecoroner for St. Pancras, Dr. F. E. Camps described thepost-mortem findings in two of these three cases.

Both showed advanced liver necrosis, the condition

being slightly less severe in one child. He had no doubtfrom the evidence, he said, that the liver damage wasdue to the transmission of a substance in serum, used inthis case for measles immunisation. Virus transmittedin this way cannot be identified until a case of hepatitisoccurs. He was satisfied that the syringes were notresponsible ; several were used, and a large number ofchildren were immunised on the same day. The syringeswere changed after every fourth child, and a new needlewas used for each child. ’It seems that the four childrenwho developed hepatitis (one is still ill) were not injectedin succession but were scattered through the wholegroup treated ; it is therefore improbable that the samesyringe was used for each of them. It is very unlikely,Dr. Camps said, that the virus would be transmitted bya syringe used for intramuscular injections ; contamina-tion is usually the result of intravenous injections, inwhich a little blood is drawn back into the barrel beforethe injection is made. The four children infected, withone other child who has not developed jaundice, allreceived serum from a single batch, only a small quantityof which was used. At the previous hearing; Dr. R. A.Zeitlin, director of the Tottenham blood-transfusiondepartment, said - that of the sixty donors who hadcontributed blood to this batch of serum, five had hadjaundice in the past, but all many years ago, well beyondthe period within which it was thought to be dangerous.

Dr. Alfred Piney said that pathological examinationconfirmed that there was severe necrosis of the liver, ofthe type which occurs with virus infections.The coroner, summing up, recalled that the three

children who died had, with many others, been given theinjections at a day nursery, because they- were thoughtto be measles contacts. This method of immunisation iswell established, not new, and one local authority haspractised it for years without the appearance of anysuch cases. Of the sixteen children immunised thatmorning, the five who had the same batch of serum werescattered through the group. Three died and one was ill.Hepatitis shows itself within 60-100 days. It was nofault of the method, he said, that three children died :the danger of infection by hepatitis virus through aserum injection is no greater when the serum is given toprotect against measles than when it is given for someother reason. He was satisfied by the evidence of Dr. J.Harrington, who gave the injections, and Dr. Zeitlin,who has charge of the laboratory where the serum iscollected, that there had been no sort of neglect or lackof care. The experience gained from these unfortunatecases might be of practical use in serum immunisation, inthe future, but that was not the province of his court.He was satisfied that the deaths were due to injectionsof serum given in July, and he brought them in as deathsby misadventure.

The Wrong CylinderIn Dublin District Court last week, the judge rejected

the prosecution’s case against a house-surgeon chargedwith having unlawfully killed a patient who died whileunder an anaesthetic.At earlier hearings and in a previous statement the

house-surgeon had testified that on May 30 she decided

to administer nitrous oxide and oxygen to an outpatient,for the purpose of operating on a septic thumb. She,the house-surgeon, noticed that the oxygen cylinderon the apparatus was empty, and she asked a nurse toget a full cylinder; she did not check the cylinderbrought by the nurse but tightened it up and turned on

, the nitrous oxide fully and the oxygen partly. Shenoticed that the patient was becoming cyanosed ;and she then turned the nitrous oxide off and the oxygenfully on. The patient became still more cyanosed ;and it was found that both cylinders contained nitrousoxide. Oxygen was administered from a fresh cylinder,two intracardiac injections were given, and artificialrespiration was begun and was continued for some time,without success. In cross-examination the house-surgeon said that she knew that one or other of thenitrous oxide or oxygen cylinders had a white top, butshe did not know which.For the firm supplying the cylinders it was stated that

those containing nitrous oxide and oxygen were eachdistinctively marked; but nothing in the apparatusused was to prevent interchange of the two cylinders.

District Judge Mangan found that the State had notestablished that the house-surgeon had failed to takecare and that death had been due to that failure. Therehad been default by the accused, but the prosecutionhad not shown that death had resulted from the default.The possibility of death from other causes had not beenexcluded ; there was no evidence that a post-mortemexamination had been made.

Legal Proceedings in the N.H.S.A memorandum lately circulated -to boards and

management committees indicates that the Ministry ofHealth is anxious to be kept out of legal proceedingsagainst hospitals. The proper course for a claimant’ssolicitor is to institute proceedings against the manage-ment committee or the board of governors. "’hereappropriate, the management committee should haveassistance from the solicitor of the regional hospitalboard. The Ministry should be consulted in cases involv-

ing the construction of the Act and the regulations, incases where an application is being threatened for leaveto apply for a writ of mandamus, and in cases involvinglegal questions of first-class importance. ,

W’here a claim is based on negligent treatment by anurse, it is to be expected that the claim will be againsther employer, and the nurse will not be made a separatedefendant. If, however, the nurse is joined in the

proceedings, the employer is authorised to see to herdefence if she so desires, and in such cases the solicitoracting for the employer would normally act for thedefendant nurse as well. Where, on the other hand, thenurse has acted quite outside the scope of her authority,the Ministry holds that she ought to be left to conducther own defence. Though it is stated that such casesshould be referred to the Ministry for consideration,nothing is said about whether a nurse conducting herown defence would also be expected to pay for it. Itlooks as though she would. If so, nurses may well decidethat the time has now come when they should form adefence organisation like those that have protectedmembers of the medical and dental professions for years.The memorandum points out that, generally speaking,

authorities are not authorised to undertake the defenceof hospital doctors who may be sued in respect of allegednegligence," ; if it is sought to make an authority liablefor negligent acts of a doctor, it should normally takesuch steps as are open to it under the Law Reform(Married Women and Tortfeasors) Act, 1935, to obtaina contribution from the doctor in respect of damagesthat may be recovered. This makes it clearer than everthat every doctor and dentist should have means ofproviding for their own defence. There may well be occa-

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sions when a management committee, to avoid publicity,wants to settle a case and looks - to the doctor for acontribution towards the cost of settlement. The interestsof the doctor, however, may demand that the case shouldbe fought in open court for the vindication of his goodname and reputation. Such conflicts of interest haveoften occurred in cases where the Service authoritiesand municipal bodies have been involyed, and the medicaldefence societies know how to handle them.

ObituaryJ. TYLOR FOX

M.A., af.D. CAMB., D.P.M.

Dr. Tylor Fox, who died on Sept. 20, aged 64, hadworked for over thirty years on epilepsy, and especiallyon the daily life and employment of epileptics. Hemaintained that the social handicap of this disease isout of all proportion to the physical handicap, and thatit is based largely on public misconceptions which canand must be removed. He did much to create a morehopeful and understanding outlook.A member of the Society of Friends, he was the

only son of R. Hingston Fox, F.R.c.p., biographer ofFothergill. He was sent to theFriends’ schools at Ackworthand Bootham and to the Cityof London School, from whichhe won a scholarship to SidneySussex College, Cambridge.Qualifying from the LondonHospital in 1910, he held a

house-appointment at Ipswichand then spent several yearsin general practice in NorthLondon.’ Next, in 1916, hewent to Russia as chief medicalofficer of the Friends WarVictims relief expedition toa famine area.

" His aim,"-writes J. R., " wasto establish on the remote

steppe a hospital of as higha standard as circumstances

permitted, and he endured with fortitude and his ownquiet humour the many modifications of his ideal whichconditions demanded. He would not have been so successfulwith the peasants if he had not won their affection as aman and their respect as clinician. It was not easy to con-vince them of the value of modern sanitary requirements,and to persuade them that illness was not a visitationof God’s displeasure proved even more difficult.

‘‘ On his return to England his report on the war moraleof the people late in 1917 was received by High Authoritieswith incredulity, because it did not coincide with those ofthe diplomats. But events proved that he was right ;reports usually are when based on direct observation. Hewas, besides a clinician of the individual, a good observerof the masses."

In 1918, soon after coming back, Fox visited theLingfield Epileptic Colony to help in an emergency ;and he remained, as medical superintendent, until 1945.Established in Surrey by the Christian Social ServiceUnion as a home for unemployable epileptics, the colonywas already taking children, with the help of grantsfrom local authorities. LTnder Fox’s care it grew steadilylarger and became fully self-supporting ; by the beginningof the late war it had the biggest epileptic school in thecountry, with about 250 children, and some 200 adultsalso had their home there. But despite its size, it stillcontrived to have something of a family atmosphere ;and this was due not least to the medical superintendent.He was very conscientious, taking pains to know everypatient; and " when Dr. Fox speaks to you," said oneof them, " you feel as though you matter." His particularblend of caution, solemnity, and humour, and theknowledge of his solid kindness, pleased the Lingfieldpopulation as it had pleased the Russians. He hadintegrity without either hardness or self-esteem. He was at

the same time a wise physician, and also a keen investi-gator who was always ready to test any promising methodof treatment and to put the resources of Lingfield at thedisposal of outside workers. His own clinical contribu-tions included papers in our columns on phenobarbitone(1927) and, with Dr. Gwenvron Griffiths, on rhythm inepilepsy (1938). Though the war brought to Lingfieldmany difficulties, culminating in flying bombs andevacuation, it also saw some valuable advances on theoccupational side. " Occupation and interest," said thesuperintendent, " are direct anticonvulsants."When diminishing health obliged Fox to retire from

Lingfield in 1945, he was glad of the chance to do morein the campaign for the better care of epileptics. Thoughgenerally reserved in manner, and sometimes shylyformal even to old friends, he could speak well and writewell; and he had something important to say.

" Until the week of his death," writes D. J. W., " hewas working for the social and economic improvementin the lives of epileptic people. He was in touch withclinical neurologists, electrophysiologists, and pharmaco-logists, but his real interest was in the social field and hiswork was complementary to theirs. Personally, and insuch offices as president of the British branch of the Inter-national League against -Epilepsy, he was influencing publicbodies towards enlightenment in the education, employ-ment, and care of epileptics. His paper on the Social

Aspects of Epilepsy, published in THE LANCET in 1947,expressed the aims of that work."He was most quiet and retiring ; he did not often

speak at medical meetings, nor did he write much, althoughhe had great experience of the sheltered epileptic. Hischoice of epilepsy as his main interest in medicine wasfortunate, for his qualities matched a great need. Asocial reformer must have patience, and it is certain thatmuch that Tylor Fox worked for has still to be done.But he has left behind organisations and enthusiasms tocontinue the work. Those he cared for in his years at

Lingfield are only a few of those he will have helped."His interest in epilepsy, however, was by no meansexclusive. His other public work included member-ship of the London committee of the Lebanon Hospital forMental Diseases, and for two years he acted as itschairman.

Dr. Fox married, in 1912, Elsie, daughter of the lateEdwin Gilbert, and she survives him. He leaves threechildren ; and in his elder son, already a doctor, thefamily has reached its seventh medical generation.

GEOFFREY COMMELINE WILLIAMS

O.B.E., M.A. OXFD & CAMB., M.R.C.S., D.P.H.

Dr. G. C. Williams, senior administrative medical officerof the Oxford regional hospital board, died on Sept. 21at the age of 57. Born at Thornbury, Gloucestershire,where his father was in medical practice, he was educatedat Clifton College, Caius College, Cambridge, and BristolRoyal Infirmary. After qualifying in 1916 he servedoverseas as a captain in the R.A.M.C. for two years, andon demobilisation he became assistant medical officerto the Bristol city fever hospital and sanatorium. In1921 he took the D.P.H. and in the same year he wentto Oxford as assistant medical officer of health, laterbecoming deputy M.o.H., and in 1930 M.o.H.

Already an M.A. of Cambridge, in 1937 he took hisM.A. Oxfd by incorporation. becoming a member ofBrasenose College. In 1942 he was appointed o.B.E.

for his services to public health and to civil defence.Formerly an examiner in public health in the Universityof Oxford, he was also a past chairman of the Oxfordand district public medical service, and a member of thecommittee of the Nuffield Institute of Social Medicine,and of the council of the medical staff of the UnitedOxford Hospitals.

N,B7. S. writes : " Men like Billy Williams can ill be

spared in these days when so much hinges on a fairand equitable administration of the new health services.A first-class administrator, he always tended to approachproblems from the human side rather than from thepoint of view of regulations and orders. He was perhapsat his best in times of stress, when his calm and equable


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