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.
====================================================================
CORRESPONDENCE.
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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.
At the last meeting of one of the city medical societies one of the
members reported a case of typhoid fever in which the pulse had
remained quite low for over a week. Several questions were asked
concerning the _normal_ pulse of the man. The doctor insisted that he
knew the normal pulse was higher, as he had examined it many times in
health. This was strange and so many members plied the doctor with
questions that he finally confessed that the young man was a member
of the family when he (the doctor) was courting his (the doctor's,
not the patient's) wife. Of course the entire society understood
at once that the doctor felt the pulse of the entire family during
this love-sickness. There are many ways of courting--Josh Billings
had a very good way. Some fellows buy the old gentleman a cane (very
appropriate and often _useful_); the small brother a box of candy, so
that he will vacate the parlor--and for the baby sister a wax doll with
long flaxen hair--which she invariably informs the neighborhood was
given to her "by Sallie's beau."
We once knew a nice young man who had been told that the best plan was
to court the mother for a while. He heeded the advice and was getting
along very finely, when one day he received an invitation to attend the
marriage of his girl to the fellow who had been courting _her_ and not
her _mother_.
This little occurrence turned our minds to the humorous things of our
experiences, and after adjournment of the society a number of "funny"
things were related as we walked homeward.
The following is interesting to the gynæcologists: