257THE AFTER EFFECT OF ETHYL CHLORIDE ANAESTHESIA.

A full’ translation of Dr. Lancereaux’s remarkable com-munication will appear in the September number of theParis Medioal Journal.May I be allowed to supplement your Paris correspondent’s

note by pointing out that Dr. Lancereaux has used thismethod since 1899, has found it free from danger in anexperience of over 1200 injections, and that he has been ledto consider it as the only method meeting the indications fortreatment. In this, his latest, communication on the subject,Dr. Lancereaux gives full details of three cases of aneurysm-of the abdominal aorta, of the first part of the aorta withpre-sternal tumour, and of the ophthalmic artery withthrobbing exophthalmos-all apparently cured. The injec-tion, consisting of 200 grammes of a 7 per 1000 salinesolution containing five grammes of gelatin, is made into thegluteal region every five or six days (being generally com-pletely absorbed in a few hours), from 30 to 40 being usuallyrequired. Successful cases have been recorded even whenthe skin over the sternum was thinned by the aneurysmalsac. Such treatment surely holds out more hope than canbe expected from rest, diet, potassium iodide, &c. II am, Sirs, yours faithfully,

Paris, July 19th, 1906. A. A. WARDEN.

ASSOCIATION OF MEDICAL DIPLOMATESOF SCOTLAND.

To the Editors of THE LANCET.

SIRS,—May I ask (through the medium of THE LANCET)those holding Scotch qualifications kindly to reinform me ofthe various disabilities and grievances they may knowappertaining to these qualifications, in order that they maybe investigated and redressed, if possible, by the aboveassociation.-I am, Sirs, yours faithfullv,

CLAUDE ST. AUBYN-FARRER,7, Westbourne Park-road, W., July 18th, 1906. President.

THE AFTER-EFFECT OF ETHYLCHLORIDE ANÆSTHESIA.

To the Editors of THE LANCET.

SIRS,—I have followed with interest the reports on ethylchloride as an anaesthetic, especially in dental work. Ihave used it for that purpose in a large number of cases andfind it a good anxsthetic, as there is a period of analgesiaafter the patient is conscious. As yet I have had no fatal ’,cases but have noticed bad after-effects. I always fill thebag with nitrous oxide and then gradually drop intothe bag from a side tube three cubic centimetres of ethylchloride (for an adult). Dr. A. B. Kingsford in hisreports says that he has noticed two forms of rigidities,but according to his experience they come on duringthe anxsthesia. In all my cases the rigidity was onlynoticed after the dental operation was past. The localspasm I found most frequently in the fingers ; the patientcomplained of great pain and it took considerable force torelax the same. This form of rigidity occurred very frequently.As to the second form of rigidity the patient took the anaes-thesia all right and after the teeth were out he suddenlytook what to me looked exceedingly like an epileptic fit.Then he became quite rigid in the opisthotonos positionalong the dental chair. The pulse could hardly be felt, thebreathing ceased for a few seconds, his head was retractedto the one side, the teeth were clenched, and the eyes staringand fixed with the pale grey ash colour of death. He

suddenly became conscious and felt sick and vomited, buton trying to get out of the dental chair he had a tendency tobecome rigid again. His pulse was 39 but it gradually became e53 after a hypodermic injection of one-fortieth of a grainof strychnine. It may be interesting to state that his pupilswere unequal for 48 hours after the operation, the rightdilated and the left pin-pointed. On examination of hisheart the first sound in the mitral area was not hearddistinctly but otherwise he seemed in good health. Thedifficulty I find in using nitrous oxide alone in dental work-and rather to get the patient to sit different times-is thatwith some patients you cannot get a proper anassthesia withgas at all. I am strongly of the opinion that there is alwaysgreat danger in giving ethyl chloride in the sitting posture.I may state that I always prepare my patients for the opera.tion as if I was going to give chloroform. Thanking you inanticipation, I am, Sirs, yours faithfully,

JOSEPH STARK, L.R.C.P. & S. Edin.Fruitfield, Airdrie, July 23rd. 1906.

THE GENERAL MEDICAL COUNCIL: THEDIRECT REPRESENTATIVE FOR

SCOTLAND.To the Editors of THE LANCET.

SIRS,—We have been instrumental in promoting a

requisition to Dr. Norman Wa]h>r inviting him to be acandidate for the post of Direct Representative for Scotlandon the General Medical Council. Dr. Walker received solarge a measure of support on the last occasion and hassince continued to take so active and useful a part in thepromotion of the improvement of medical education as wellas in other matters of medical politics that we have everyreason to believe that on this occasion his candidature willbe successful.The requisition has been largely signed by practitioners

from all parts of Scotland and Dr. Walker has indicated hiswillingness to accept it. We shall be glad to hear fromthose who wish to join the general committee.

We are, Sirs, your faithfully,G. A GIBSON,

3, Drumsheugh-gardens, Edinburgh.F. W N. HAULTAIN.

I July 24th, 1906. 12, Charlotte-square, Edinburgh.

A NECESSARY REPUDIATION.To the Editors of THE LANCET.

SIRS,-My attention has recently been drawn to an articlein the British Medical Journal of July 14th where, under thecolumn Medico-Legal and Medico-Erhical, reference is madeto a weekly paper called the Free 1 ance and to a Dr. A. W.Wheatly advertised in its columns.On applying at the offices of the General Medical Council

I find that I am the only man with those initials and nameon the Medical Register. The subject being, as the BritishMedical Jourrnal describes, " Touting for Patients (and Imay add in a very objectionable way), I take this my earliestopportunity of disclaiming any knowledge of the personthere described, or connexion of any kind with him or hismethods.Your sense of justice and your knowledge of the injury

that may accrue to me from this base use of my name will,I feel sure, enlist your sympathy and help by publishing thismy disclaimer in the next issue of THE LANCET.

I am, Sirs, yours faithfully,ARTHUR W. WHEATLY, M.B.Durh.,

Consulting Surgeon, Western Ophthalmic Hospital.Kensington, S.W., July 24th, 1906.

*** We sympathise warmly with our correspondent, whohas a right to feel intensely annoyed with the Free

Lance.—ED. L.

THE UNIVERSITIES AND THE FUTUREOF DENTISTRY.

To the Editors of THE LANCET.

SIRS,-The progress and development of the profession ofdentistry must always be matters of interest to medicalmen. Whether in the future the two professions will tendto be differentiated more clearly or to become amalgamatedcompletely the aims and objects of the practitioners ofmedicine and dental surgery are so analogous that anymovement on one side will naturally be watched sym-pathetically by the other. Considerable changes are at themoment taking place in dental education which are likely tohave far-reaching effects upon the ultimate development ofthe profession. With regard to the movement for the estab-lishment of university degrees in dentistry a hope has beenvery generally expressed that it might be found possible togrant to the members of a learned profession the customaryhall-mark of a liberal education. In the practical carry-ing out of this idea a very distinct division in the views ofthe teachers of dentistry has been disclosed. While one pointof view has been shown to be held by a majority of theteachers in most provincial centres of dental education,an antagonistic view seems very strongly held by an

: important majority of metropolitan teachers. So distinctlylocal does the cleavage in the teaching profession seem to

. be that I may conveniently speak of the two opposingviews as the metropolitan and the provincial ideals for thedevelopment of the dental profession. The metropolitanideal appears to be the establishment of dentistry as aspecial department of medicine on lines analogous to the

258 TWO POINTS OF MEDICAL ETHICS.-WHAT IS A SPECIALIST ?

position at present occupied by ophthalmology or laryngology, whilst in the provinces the aim of the teachers irather the development of an independent or sister profession working hand in hand with medicine but under ;separate organisation and having an educational curriculunplanned to meet its own special needs. In theiattitude towards the proposals that have been mad,

by various universities with regard to the regulationfor degrees in dentistry the two parties have ver;clearly indicated the hopes which they entertain for thfuture of the profession. In London the majority o

teachers have expressed the opinion that no degree it

dentistry should be conferred on any person who does noalready possess a university degree qualifying him to practise medicine and surgery. Several provincial universitieshave, on the other hand, already established degrees it

dentistry, the regulations for which merely require thaicandidates shall have worked out a more elaborate curriculum and have attained a higher standard of knowledge otheir own special subjects than those hitherto demanded ocandidates for a licence in dental surgery. It does not

appear that the University of London has yet decidedwhether to fall in with the wishes of the majority oj

metropolitan teachers or to follow the example of th(

provincial universities which have already instituted inde.pendent degrees. It is, indeed, not quite clear whether thEUniversity would best meet the wishes of metropolitanteachers of dentistry by offering a special dental degree tcits medical graduates or by withholding a degree in dentistryaltogether.To withhold degrees altogether would obviously be the

best means to secure that in the University dental surgeryshould be treated on the same footing as any other specialbranch of medicine or surgery. But whether this course ispursued or whether special degrees in dentistry are offeredto medical graduates, or whether the degree of Master ofSurgery is modified so as to be adapted to the requirementsof surgeons wishing to show special knowledge of dentistry,the University of London in thus supporting the metropolitanideal of dental development may inflict a serious blow todental education in London, as well as to the best interestsof the dental profession and of the public. The attemptto secure that the practice of dentistry should be confinedto the members of the medical profession is one upon whichthe medical profession is justified in having a very strongopinion, and I am sure that my views are shared-by many.If the ideal of some that all dentists should be fully qualifiedmedical men ever had any prospect of fulfilment it wasentirely shattered, I think, by the passing of the DentalAct. Some progress towards the absorption of the dentalinto the medical profession has hitherto been possible,because the taking of diplomas or degrees in medicinehas hitherto been the only method of satisfying theambition of a dental student who felt that a mere

licence in dental surgery allowed him insufficient scope forshowing his determination to rise to the higher ranks inhis profession. This means of satisfying his ambition hasbeen encouraged by the Royal Colleges and by the medicalschools, and has been undoubtedly successful in helpingdentists, who become also qualified medical practitioners, tosecure appointments at hospitals, the recommendations forwhich are generally made by the medical staff. These

proceedings have been watched by some interested indental education with complacency and by others with muchanxiety. The medical curriculum can hardly be regardedas an ideal education either of mind or hand for thosewho do not wish to practise medicine ; and many haveinsisted that to require a dentist to be also educated as adoctor of medicine is not more certain to make him a betterdentist than if he were required to be educated also as adoctor of divinity or of music. The education of thosedentists, whose ambition leads them to qualify also asmedical men, must be crowded and cramped, while thereis risk that the curriculum for all dentists may bebadly arranged because it may be dominated by theideas of those who wish to make it easy for a dentalstudent at any time to become also a medical student.Another serious result of this policy of amalgamationhas been the constant bleeding" of the dental profes-sion of its best material. It is only the students of goodpreliminary education and keen enthusiasm who can facethe hard work and strain of securing a medical as well as adental qualification. It is stated by those thoroughly con-versant with the facts that a large proportion of these best

.- dental students so soon as they are qualified desert dentistrys and practise either medicine or surgery.- In considering this important question it must not bea forgotten that a qualified medical practitioner has conferreda upon him by the Dental Act all the rights and privilegesr of a qualified dental surgeon. The attempt thereforee to amalgamate the professions practically amounts tos an attempt to eliminate the specially qualified dental

7 surgeon. To many it appears that its ultimate result woulde be to throw back the practice of dentistry into the hands off the barbers and unqualified and uneducated persons whoi performed these duties for the public before the Dentalt Act was passed. To me it seems inconceivable that a- sufficient supply of dentists to deal with the immense public3 need should ever be admitted through the portal of thei medical profession, although I know that many, andb probably you, Sirs, hold the opposite view. But the- action of the provincial universities has removed the leverE which the metropolitan idealist hitherto possessed for thef promotion of this view. The ambitious student can nowj seek a university degree in dentistry in addition to hisI dental diploma, confident that the extra training to whichE he will be required to submit will improve his capacity either as a practitioner of dentistry or as a reseacher inthe departments of dental therapeutics or pathology. If

he cannot secure such a degree in the university of hisown city he will seek it elsewhere. It seems probable,therefore, that those cities the universities of which refuseto recognise special dental attainments unless they are

accompanied by the technical knowledge required of a

, qualified medical practitioner, will be seriously handicappedin their attempt to maintain efficient schools of dentistry.

I am, Sirs, yours faithfully,A LONDON PHYSICIAN AND TEACHER.

TWO POINTS OF MEDICAL ETHICS.To the Editors of THE LANCET.

SIRS,—I have the honour to write to you to ask for adecision on two points of medical ethics which refer

chiefly to medical officers in military employ attached to

regiments.1. When a regimental officer reports sick with some

disease such as gonorrhoea, scabies, or acute alcoholism, towhich, rightly or not, a certain amount of shame attaches,what should be the medical officer’s procedure as regards hisdaily report of sick to his commanding officer, such sickreport being a printed form with a space for the names anddiseases of sick officers and being in no way a confidentialreport ? Besides being seen by the commanding officer, it isseen by numerous clerks, sergeants, and officers, hence thequestion arises on which I ask a decision-viz., What is one’sduty considering both one’s duty as a medical officer to theofficer commanding (who writes the regimental officers’annual confidential report) and one’s duty as his doctor tothe patient ?

2. The other point on which I ask your opinion is asfollows. All regimental officers are, of course, entitled tothe services of their medical officer. A case occurs in whicha medical officer is attending a regimental officer for illness,the regimental officer, without informing his medical officer,goes to see another medical man (not connected with theservice) who attends the officer for two or three days ; theofficer then deciding to revert as a patient to his ownmedical officer, sends for him, maintaining he (the regi-mental officer) has a right to any services he may call for.The medical officer, after protesting against the professionalindignity to which he had been submitted, continues to treatthe regimental officer. A few months later the same

officer again falls ill and again behaves in an exactly similarmanner and the medical officer cannot, according to regula-tions, refuse to attend the regimental officer in future.What should he do ? I inclose my card.

I am, Sirs, yours faithfully,June 1st, 1906. I.M.S.

WHAT IS A SPECIALIST?lo tlte Editors of THE LANCET.

SIRS,—A little while ago I wrote to you virtually askingthis question : Can any medical man, especially an old man,if he chooses to practise as a specialist, call himself such onhis door-plate ? You courteously replied in the negative butwith your permission I would like to enlarge my plea,as follows:-