Part 4

The author stated that among the many trials which physicians have to encounter in the practice of their profession is the ever-existing liability of being blackmailed. This may either assume the more frequent form of a so-called malpractice suit, or the relatively less frequent charge of a criminal assault, according to the viciousness of the complainant. Such suits against physicians are increasing. One reason quoted was the fact that every city is overrun with petty lawyers, who have little or nothing to do, and are always willing to encourage any suit whatever, if there be the least prospect of getting something out of the defendant. The author stated that since investigating the matter he became convinced that many of these blackmail schemes were settled before being made public. Many a physician preferred being robbed of one or two hundred dollars, rather than incur the publicity, the loss of time and the endless expense of a lawsuit. Again, the average jury, composed of the ignorant and illiterate, will always have a strong leaning toward the complainant and against the defendant in a malpractice suit, as physicians are popularly supposed to be capitalists. The author stated that personally he had never been sued or even threatened with a suit, and it was therefore from no motive of selfish interest, but from a sincere regard for the welfare of the profession, that he advocated the formation of an association for the mutual protection of physicians against blackmailing suits of all kinds. His plan is to organize a society composed of two or three hundred members of the regular profession, all of whom shall be of acknowledged ability, possessing a good moral character and standing in the community. Said association to employ the best legal talent attainable, by the year, to furnish the members such legal advice as they may desire at any time and defend any suit against the members arising in the discharge of their professional duties. It was stated that the expense to each member of an association composed of about two hundred would not exceed five dollars per annum, and that an initiation fee of five dollars would create a sufficient fund for court expenses. Such an association would be a power in preventing suits. Let it be known that the individual physician is backed by the financial and moral support of a few hundred of the best physicians, and aided by the best legal talent obtainable, and he will be let severely alone by the offscouring and dregs of society who constitute, almost without exception, the blackmailing element in our professional life. The author stated that he was not aware of the existence of such an association as the one proposed in any other city, but the principle at least has been carried out recently by the New York County Medical Society, in voting $500 to assist in the defense of the Drs. Purdy, members of the Society, in the case of Brown _vs._ Purdy. After reading a number of letters from prominent physicians in favor of forming a protective association, and presenting several legal opinions sustaining the advisability, practicability and legal status of such a society, the author concluded by stating his firm belief that such an association for mutual protection was needed, that it would be a power for good, that it would draw the profession closer together, that, in short, it would be based on the principles of a common brotherhood, viz.: equality, harmony, justice and unity.

Dr. F. C. Hotz said that the extract of his letter to Dr. Doering, which was incorporated in the paper, indicated that at the time it was written he did not think favorably of the project. And, after listening with much interest to the doctor's arguments, he saw no reason for changing his opinion. Professional reputation and honor is the most personal of all personal property; if he lost it, it does not hurt anybody but himself, and therefore if any attack be made on it he should certainly wish to employ among the able lawyers the one in whose ability he had the greatest confidence. But he was not sure whether the lawyer retained by this protective union would be the one to whom he should like to trust the defense of his reputation. The attorney might be able, or abler, than the lawyer of his own choice; but should the case go against him, he should never feel satisfied that the lawyer had done all that could be done for him unless he had full confidence in him. It is with the lawyer as with the physician, a question of confidence, and his patrons find no fault with his treatment as long as they have implicit faith in his ability.

An objection of greater weight, however, has been urged by several of the doctor's correspondents in asking what possible effect it might have if the fact was brought out in court that the defendant belonged to such a union? The lawyers whose opinions were obtained and read by the doctor, say it cannot legally affect the case. There is no doubt but what this is true. But the verdict of a jury in malpractice suits is not determined by the legal aspect of the case; and circumstances which cannot have any legal effect upon the case have often made a deep impression upon a jury and decided the case against the physician. To illustrate: In Dr. Bettman's first trial, the experts of the prosecution testified so unreservedly in the doctor's favor that had the case been submitted to the jury without arguments, the doctor would have been acquitted at once. To fortify his cause Dr. Bettman's lawyer called a number of experts, whose testimony was of course only cumulative. Now what did the prosecuting lawyer do? Did he make an effort to break down the expert evidence by scientific arguments? No, sir; but he wiped out its effect upon the jury by the mere waving of his hand, speaking thus: "The defense has piled up a mountain of expert evidence. But, gentlemen of the jury, what does it all amount to? These doctors are working together in the same hospital. Don't you see they have a common interest to sustain each other, because every one of them may be in the same fix some day? Don't you know they are clannish? They wont admit that one of them can make a mistake. O, no!" One could fairly see the impression this harangue made upon the jury, and they rendered a verdict against the doctor, though it is certain the lawyers will say the fact of his being associated with the experts in the same hospital should and could legally not prejudice the jury. But it evidently did, all the same. And after such experience, can you for one moment believe it would not damage the physician's cause if he and his experts belonged to a society formed for the express purpose of mutual assistance in malpractice suits. A mighty poor lawyer he would be who could not make a great deal out of it before a jury.

Very interesting was that part of the paper in which the doctor evolved his idea how his new society could prevent, ward off, malpractice suits. He believes the shysters would not be so eager to engage in this business if they knew they had to fight a corporation with plenty of means to employ the best legal talent. Why this should discourage those fellows it is hard to understand. They do not sue poverty-stricken doctors. Whom they select for their victims they suppose to be rich, and consequently able to employ a good lawyer. They do not expect to have all easy game, but why should they not try it? They don't risk anything by it. The blackmailer's stake is only two dollars and a half for filing his application, and his lawyer's stake is his time, which is not worth much anyhow. So you see they have nothing to lose, but much to gain. What difference should it make to them whether the opposing counsel is engaged by one physician or by one hundred? If you wish to devise means by which this blackmailing nuisance can be stopped, or at least reduced to a minimum, you must try to get to the roots of the evil; that is, you must find the causes which usually bring it forth. And you will not go far to find them, for you find them right at your door, in your own profession, in the shape of _indiscriminate dispensation of gratuitous services and of unkind remarks of one physician about another_. Physicians are altogether too quick to give their services gratis to almost any body at any time. But you know very well people do not value very much what they can get for the mere asking; they do not think much of what they get for nothing. And it is also a widespread notion (especially among the lower educated people) that the quality of service is regulated by the amount of money they pay for it; that the treatment at a free dispensary, because gratuitous, is not the same, not as good as at a physician's office where they have to pay for it. These people cannot persuade themselves that a physician will take the same interest in a case whether or not he is paid for his services. The poor, therefore, are always suspicious that they do not get their full share of attention. They are quickly ready to charge their physician with carelessness if the case goes wrong. And with a patient in this frame of mind, it takes but very little encouragement to begin a suit for damages. And in nine out of ten cases, doubtless, this encouragement is furnished by the members of our own profession. He did not mean to charge physicians with purposely, wilfully, instigating a lawsuit against a brother. Though this has been done, such extraordinary baseness is a rare exception.

What Dr. Hotz had reference to is the inconsiderate careless, thoughtless habit of expressing an opinion about a case, or a colleague. To illustrate: A physician at a dispensary shows a bad case to professional friends, and without thinking of the possible evil consequences, makes in the presence of the patient some remark like this: "Well, perhaps I ought to have done this or that." The patient, already laboring under the impression that he was not fairly treated because he could not pay, sees in the doctor's remark the strongest confirmation of his suspicion, goes to a shyster and begins a suit for damages. And doubtless, in a similar way the mind of a patient is often poisoned and set against his physician by a careless or unkind remark of another physician. So many physicians are always ready to express their opinion about their colleagues in the presence of anybody, or to criticise their professional acts upon the information received from a patient or some old woman. Now you all know how these people misconstrue the words of a doctor; how they pervert the facts inadvertently. You must admit you cannot rely on what patients tell you, and you cannot form an opinion that is worth anything of a case you have not seen or been informed about by the attending physician. Why, then, don't you say so when somebody asks you what you think about the case of Dr. H.? Or if you know the physician, say he is competent to attend to his own business; if you don't know him, change the subject. But at all events, unless he be a notorious quack, refrain from uttering any words which even only insinuate the possibility of a mistake or want of skill of your colleague.

Stop running each other down; stand by each other; sustain each other, "stick together and be clannish;" let it be understood in public that no reputable physician will prostitute himself by going to court as expert for a blackmailer. If all the reputable physicians of this city adopt and act on this principle, blackmailing the medical profession would soon be a thing of the past, and malpractice suits more effectually prevented than by the organization of a protective union.

Dr. P. S. Hayes said that, from his costly experience in a malpractice suit, he felt that an association such as suggested by Dr. Doering would be of great service. The lawyer employed by such an association would speedily acquire such a fund of medical knowledge that he would be considered an expert in malpractice cases. He would not require an amount of coaching necessary to prepare for any given case, as would be requisite in the case of a lawyer who had no experience in such cases. His opportunity for obtaining information in a given case would be largely extended, for each member of the association to whom he might apply would be interested in giving him the desired knowledge. He would soon become acquainted with medical witnesses and know which would give the best testimony in any case.

An association of the character suggested by the paper might be a means of educating its members in regard to laws bearing on the rights of physicians and their patients, now not generally understood. For one he is heartily in favor of such an association, and should give it his hearty support.

Dr. G. C. Paoli said Dr. Doering's paper is not only a valuable one, but contains such a high, noble, charitable feeling that the Society ought to be grateful to him. He wondered that such steps had not been taken before, because so many of our professional brethren have not only suffered annoyance, but pecuniary loss as well. How can we expect, from an ignorant jury, a decision based on scientific knowledge and justice?

Dr. F. M. Weller said that the subject of the paper was worthy of consideration; that the discussion of the formation of an association with an object so widely different from the Medical Society seemed out of place; the one essentially scientific, the other in the nature of an insurance. The right to form such an organization was unquestioned; the policy should be considered by each individual. That while any one might be made the object of blackmail, he believed that charges of malpractice more frequently arose from the ignorance of physicians of the statutes affecting the practice of medicine, especially those of the criminal code, and of the rulings of the courts in cases.

PROCEEDINGS OF THE CUYAHOGA COUNTY MEDICAL SOCIETY, NOVEMBER 5, 1885.

[Reported for the Gazette by L. B. Tuckerman, M. D., Cor. Sec.]

COMPULSORY VACCINATION.

Dr. Himes presiding.

Dr. Hart said that thirty years ago, in a country region of western Pennsylvania, he met an epidemic of smallpox. Over thirty years earlier, under a State law, the whole community had been vaccinated. Out of about fifty persons exposed to the disease the most were adults who had been vaccinated at the time referred to, or earlier. Referring to an article on the epidemic prepared at the time, he finds that fully half had the disease in some form, from the mildest varioloid to confluent smallpox, one case of secondary smallpox occurring. While he believed that fifty per cent. of those vaccinated in infancy are protected for a lifetime, still he regards the presence of the most distinct cicatrix as no criterion by which to determine who are thus secure. From twelve to twenty years of age, probably, fully one-half will have a more or less perfect result from revaccination, and will in most cases be thenceforth protected from all ordinary exposure to smallpox. But in the presence of the varilous atmosphere of an epidemic of the disease, revaccination is the only absolute safety. He has always revaccinated himself as often as exposed, and advised the same course for others. While smallpox prevailed here, say from 1865 to 1873, where patients were not removed to a pest house, and the only precaution enforced was the notice on the house, he attended a considerable number of cases. He always insisted on vaccinating every exposed person, and although there were often unvaccinated children and adults who had a thorough effect from revaccination, he never had a second crop of calls in the same house.

He referred to the complete revaccination of the Forty-first Regiment, O. V. I., before going South. Many of the men with a fair cicatrix had a perfect revaccination, while two hundred or three hundred had more or less result. Humanized virus was used. During their term of service, while repeatedly exposed to smallpox, and where other regiments about them suffered severely from the disease, they entirely escaped. This immunity could only be referred to their revaccination, and certainly affords the strongest proof of its prophylactic power.

While frequent renewals of the humanized virus is desirable, he regarded it, when selected with the care which ought to be observed, as milder in its effects and much more certain than cowpox. In vaccinating with cowpox he has had severe effects follow much more frequently than when he made use of the humanized virus.

Dr. Dutton did not believe that the profession should insist on compulsory revaccination, at least until it was proven that revaccination was absolutely necessary. A second vaccination often produces a serious inflammatory sore, quite unlike the true vaccine pustule, and an ulcer sometimes follows.

Dr. Preston stated that, as he had observed, a large percentage of those who were not revaccinated were liable to have varioloid.

Dr. Scott stated that we must either vaccinate or inoculate. He was vaccinated by his mother fifty years ago, and was protected yet. He had been revaccinated many times without effect. He regarded the humanized scab the best. He believed that the proportion that take again is less than Dr. Hart is inclined to suppose. Every community has a right to compel vaccination, and the question here is not of revaccination. Bovine virus removes the danger of the communication of syphilis, but the cultivation of the virus should be under State control. Much of the trouble had come from scabs or points from pustules where the lymph had been drawn off and the pustules allowed to refill. A refilled pustule can communicate almost anything.

Dr. Smith said he had seen some of the worst arms he ever saw from revaccination. He would rather have a mild case of varioloid than such a case. It is not certain that a second sore is evidence that the patient will not have varioloid.

Dr. Corlett stated that in the London Smallpox Hospital they had for twenty years made it a rule to vaccinate every attendant, and for twenty years there had been no case of smallpox among the attendants. There is more attention paid to instruction in vaccination there than here. Each student must go at least six times to one of the dozen government stations and receive instruction. Vaccination is done from arm to arm. As soon as the vesicle is formed, and before pustulation, a capillary tube is inserted and a portion of the lymph withdrawn. They do not believe that there is danger of scrofula or syphilis if there be no admixture of blood cells, either white or red, with the lymph. He believes that the cases of eczema and scrofula so often attributed to vaccination are really due to a dyscrasia of the patient.

Dr. Millikin inquired how long the lymph retained its activity after being withdrawn into the capillary tube. Dr. Corlett stated that it could be used for six weeks or two months.

Dr. Vance stated that the Germans of Cincinnati, irrespective of creed, preferred inoculation to vaccination. Hence there was always smallpox in Cincinnati. In spite of the stringent laws against it, inoculation was systematically carried on. The parent would take the infant to a neighboring hillside and leave it with a dollar-bill beside it, and go away. In a few minutes he would return, the dollar-bill would be gone, and the child was inoculated. The law against it cannot be enforced.

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CORRESPONDENCE.

NEW YORK LETTER.

THE USES OF COCAINE IN SURGERY.

It is not the object of this communication to speak of the discovery of this drug and the experiments which were necessary to bring it before the profession as a reliable and trustworthy agent. That cocaine is a valuable addition to the armamentarium of the surgeon, I think no one will doubt, but how beneficial, I think but few fully realize.

Cocaine is constantly growing in favor with the surgeons here in New York. New fields of usefulness are opening, and in nearly all of the minor and many of the major operations it is taking the place of ether and chloroform. These older anæsthetics, although so useful, were accompanied by danger, and many deaths are attributed to their use, while so far, I know of no well authenticated case where death or serious symptoms have resulted from the use of this new anæsthetic. Its first use was restricted almost exclusively to the eye and mucous membrane, but the hypodermic syringe has made it as useful to the general surgeon as to the oculist.

There is not a day passes but that we see operations of more or less magnitude performed under its influence at some of the clinics or hospitals of New York. Circumcision, hemmorrhoids, fistula in ano, felon, ingrowing toe-nails, hydrocele, cutting for foreign bodies, removal of small tumors, etc., are some of the operations for which we very seldom see an anæsthetic given.

At St. Luke's hospital an operation for ventral hernia was performed by the use of cocaine alone, where it was necessary to open the abdominal cavity for three inches and reach into the abdomen with the fingers to draw up the peritoneum, and all done with perfect success. Amputations of the fingers and toes are not uncommon, and amputation of the leg and fore-arm have been successfully performed by its use.

External and internal urethrotomy and cleft palate are usually performed by its aid. I have seen large stones removed from the urethra in this way without any expression of pain from the patient, he talking with the surgeon about the case while it was in progress.

Dr. Corning, of New York, has devised a method by which the local effect of the drug may be indefinitely prolonged. His theory was that the drug was washed from the tissues of the blood and its effects thus lost. To prevent this he applies elastic ligatures around the part, between the injection and the heart, about two or three minutes after the injection is made. When the injection is on the body or face where the ligature can not be used, he uses large rings to surround the part, so arranged that firm pressure can be made upon them, and thus cut off the active circulation. He claims for this that a weaker solution can be used and the effects continued for a much longer time.

The mode of proceeding is usually to inject from ten to fifty drops of a 4 per cent. solution around the part to be operated upon, using an ordinary hypodermic syringe. From three to five drops of this solution are injected at short intervals in a zone surrounding the part to be operated; or a larger quantity is injected near the body of the nerve supplying the part. If this is reached the anæsthesis is complete. In two or three minutes the knife can be freely used, and the patient feels no pain, although they look at the knife as it divides the tissues. In the throat clinic a solution of cocaine is used with an atomizer to allay the irritability of sensitive parts, that a more thorough examination may be made. At the eye clinic cocaine is used as a mydriatic, atropia being seldom used for the purpose of examinations.

Patients usually dread the action of an anæsthetic; the nausea, headache, and lassitude following its administration are things not pleasant to contemplate, but with this new drug none of these are encountered.

The conclusions are, then, from our present experience, that cocaine is a pleasant, safe and efficient local anæsthetic.

O. T. Maynard. ----------

BALTIMORE LETTER.