and former patients his agents incans rank touting at the best, and at the worst would give rise to a very undesirable state of affairs entirely beyond the control of the Council. The mere proposal indicates want of thought. A brass plate would be useless, for his time is limited, and of those interested few would see it, and most would never even hear of it. But if either by circular to the registered voters, or, by a notice in the columns of the local paper, he simply announces the date of his intended visit, he adopts the most dignified and effective, and only common-sense manner of making his intention known. He is advertising in the popular acceptation of the term, but to accuse him of doing so in a professional sense, is to insult him.

These are my parallel cases, and I fail to see in what they differ, save that the means adopted in either one of them are not employed, because not applicable, in the other. We are asked to believe that the legend presented daily on a brass plate to the indifferent eyes of thousands of passers-by is not an advertisement, while to insert the same for the information of a few hundreds in the columns of a small local newspaper is-disgraceful conduct! The proposition would be amusing, were it not for its injustice. To say that if justice were done advertising would get out of hand, is to charge the Council with incapacity. If it can dictate what shall appear on a brass plate (and apparently it can,) it can impose similar restrictions on a notice in a newspaper.

If it is difficult to circumvent the man who wishes to evade the law, why drive him to the attempt? I can imagine nothing more likely to bring the Council as a governing body into contempt, than to have its decisions reversed by the Supreme Court.

in a round-about-way, brought the entire question before the Council and asked for an opinion. That opinion has finally taken concrete form in the shape of the issuing of a resolution to all the medical men in the Colony. I am quite satisfied at the result as far as I am concerned and I may trust that with regard to the misuse of the obnoxious word I refer to, the Council will see fit to withdraw it, as it is to a certain extent in the nature of a reflection upon my discretion and commonsense in the practice of my profession and I certainly resent it as such.

With the issue of the circular containing the resolution to the profession in Natal the burden has been shifted from my shoulders, and a matter which at one time threatened to be personal has been made general, and it now remains for the "medieal men in country districts vide circular to express an opinion upon the subject.

Yours faithfully,

1

JOHN F. ELLIOTT, L.R.C.S., C.P., Lre. Indian Medical Officer,

Verulam District.

P.S.-The passes in question numbered a grand total of six covering a period of five and a half months and representing a district of some thousands of Indians.

J.F.E.

Verulam, Natal. 22nd August, 1904. To the Editor, SOUTH AFRICAN MEDICAL RECORD. DEAR SIR,

Unfortunately I mislaid my July copy of the S.A.M.R. and have now only read the report of the proceedings of the Natal Medical Council under the above heading.

mine)

The resolution mentioned therein as having been passed at the November meeting was to the effect that "while Dr. Elliott may have been acting in good faith in issuing passes to Indians in the way he has done" (the italics are winding up with advice to medical men to disguise stimulant whenever ordered with some flavouring matter. As you may remember I wrote to you a letter of remonstrance and mentioned that in reply to inquiries the Natal Medical Council did not intend to issue this resolution to the profession at the time. I took exception to the mention of my name in the resolution and to the fact that I was the only member of the profession to be favoured with a copy of the decision of the Council and as the result of continued remonstrance the resolution was modified to the extent of leaving out my name and it was decided to send a notice of the Council's decision to every medical man in the Colony. I have now written to the Council with reference to the use of the word indiscriminately in connection with my name as quoted in your report and I persist in saying I never granted passes indiscriminately. I took the greatest pains to explain to Council that I never issued a pass for stimulant without first seeing the patient and in every case the passes were written in the patient's house and at the bedside of the sick. The passes in question, as I assumed the Council knew, were issued only to those absolutely requiring stimulant, people I had known for years in my practice amongst them. It was indeed I myself who for the purpose of getting justice

A COMPARISON OF SALARIES.

To The Editor, SOUTH AFRICAN MEDICAL RECORD. DEAR SIR,

Comparisons are odious, but I cannot help making one between the remuneration accorded to the officials of the Colonial Health Department and that of District Surgeons. It has just come out that the Plague Medical Officer at Port Elizabeth has been drawing, until the matter was drawn attention to by a paper which, although very ill-natured towards the medical profession, happened to be right for once, a salary nearly equal to that of a Cabinet Minister, that is £800 per annum, plus a guinea a day, plus house allowance, a total of about £1,400 a year. And this in addition to the fact that he is a permanent Civil Service official, entitled to all sorts of privileges, including a free holiday, and a pension. Now, I have no objection to my brethren receiving as high a salary as any one can be induced to pay them, but I think that the persistent refusal of the Government to raise the remuneration of the hardworking District Surgeon beyond what it was half a century ago when there was not more than a fraction of the work, and when money had double its present value, seems very inconsistent with this sort of thing. I was a District Surgeon before, I imagine, the gentleman in question entered at a Medical School, and have been one ever since, slaving at a pittance which never increases. I am supposed to have a good practice, and I believe I have been quite as successful as the ordinary man, a good deal more so than many, but I do not clear even the regular salary of the official in question, after paying expenses, out of public and private practice combined. And I question if there are six District Surgeons in the Colony who do.

If the Government can afford to pay salaries which put a man in so much better a position than he would be in private practice, the least that could be done is to offer the posts to District Surgeons before importing men. I am growing grey in the service of the Government, and would jump at one.

ANAESTHESIA UNDER ETHYL CHLORIDE.

East London.

Reviews.

To the Editor, SOUTH AFRICAN MEDICAL RECORD. DEAR SIR,

I inhaled from a special inhaler I have, 7 c.c. of Ethyl Chloride and under its influence endured without pain the free movement of an elbow joint that was stiff after a severe sprain some time ago. I am told the adhesions cracked loudly as they were broken down.

I had my usual breakfast at 8 a.m., and was anesthetized at 10.30 a.m. By 10.45 the whole operation was over and I was able to walk out a few minntes later.

I am told I was unconscious for about two minutes.

Ethyl Chloride is as safe as gas and is much more handy as inhaler and glass cylinder can be carried in a small hand bag. Without doubt it will be a boon to the Profession and to the public.

I am, Yours truly

CHAS. J. HILL AITKEN, M.D.

Adenoids. By W. Wyatt Wingrave, M.D., Physician and Pathologis to the Central London Throat and Ear Hospital. Medical Monograph series. Bailliere Tindal & Cox, London. 1p. 128. Illustrations 32. Price 2/6.

In this neat little volume we have a comprehensive and lucid description of the aetiology, symptoms and treatment of adenoids. In the chapters on aetiology, especially, the author shews his intimate knowledge of the subject. He prefers nitrous oxide anesthesia and the upright posture, for the removal of adenoids. In a chapter on the relative value of the various anæsthetics for the operation, Mr. Horten George, anæsthetist to the Cential Throat Hospital, upholds the author's view. Ethyl Chloride as an anesthetic is also discussed. A useful chapter on after treatment will prove welcome to many readers.

The illustrations in this monograph are well executed, and include instructive ones on the anatomy of the naso-pharynx and the histology of adenoid growths. We can warmly recommend the work to the profession, for its reliability and comprehensiveness.

J. L.

Notes on New Preparations, etc

ROGERS' SPRAYS.

These very handy and simple instruments commend themselves for use in throat, ear and nasal work. They throw an extremely fine spray, can be easily asepticised, and have no fragile parts. The feed tube goes right to the bottom of the bottle, thus allowing of the last drop of the solution being utilised, a matter of much importance when using such things as adrenalin or cocain. The mounts can be had in either vulcanite or metal, and small sizes can be obtained for such solutions as the two we have just named. These sprays can be used for either oily or aqueous solutions. The price is extremely moderate, ranging from 5/6 to 8/6. Messrs. P. J. Petersen & Co. are the South African agents.

THE NATURAL BODY BRACE.

We have inspected this article, which is advertised in another column. It strikes us as being contrived on sound mechanical principles, which is more than can be said of a good many much vaunted appliances, and to fulfil all the purposes of an efficient abdominal support. It is, moreover, light and comfortable, and most moderate in price.

VAPO-CRESOLENE.

Whatever may be the bacterial fons et origo mali of whooping cough, there can be no doubt about the fact of its habitat being mainly located in the upper portions of the respiratory tract, a locality easily and continuously open to vapour medication. The main aim being to destroy the infection at its site, inhalations seem the only logical treatment, as internal medication can be only palliative, even that effect being doubtful. Now vaporisation is practically the only method available in children, in whom, of course, the vast majority of cases occur. Insufflations and sprays simply will not be tolerated by children, even if they always reached the seat of trouble, which is doubtful. And probably no more effective means of vaporisation medication exists than the administration of Cresolene by the apparatus which is sold with it. This preparation has now been before the profession a good many years. We have had ample experience of its use, and can frankly confirm the opinion of a good many others as to its efficacy.

Cleft Palate and Harelip: The Earlier Operations on the Palate. By Edmund Owen, M.B., F.R.C.S. Crown 8vo. pp. 111. Price 2/6 nett. London, Bailliere, Tindall and Cox.

This small volume, one of the very useful Medical Monograph Series, records the quarter of a century experience of a general surgeon in this delicate and important branch of operative work.

Its chief purpose, however seems, to be to bring into more general notice the treatment adopted by Mr. Brophy of Chicago, who not only operates upon the palate before the lip, as others have done, in early infancy, but deals with the palatine cleft by bodily thrusting the maxillary and palatine bones together in the middle line, a method, we believe, not original except in details, not without increased risk, and not required in the majority of cases. Mr. Owen states, however, that the most favourable time for operation is between the ages of two weeks and three months, but we should doubt the wisdom of selecting this age in the majority of cases except in the hands of those of great experience, and working under the most favourable circumstances. Even then we doubt if the advantages compensate for the risk run. The operation is a decorative and not a vital one, and a dead child with a palate closed is a tragedy.

We think that Mr. Owen's recent conversion to the early operation for cleft palate is not shared even by the majority of surgeons specially skilled in this branch of surgery, and it is certainly not advisable for the inexperienced to follow it. The book, however, is full of numberless practical hints of sterling value, as one would expect from such a skilled and practical surgeon as the author.

S.W.F.R.

We notice what appears to us to be a new departure in Natal. the advertisement of a vacant District Surgeoncy. The Natal Government usually fills up these appointments without calling for applications.

A witty writer in the Guy's Hospital Gazette enumerates amongst the ideals of the freshman medical student, that of some day wearing "the gorgeous garb which the Licentiate of the Society of Apothecaries dons on high days."

VOL. II.-No. 10.

Index.

SIDE PATHS OF MEDICAL PRACTICE

By S. H. RowSON, B.A., LL.B., Advocate of the Supreme Court of the Cape Colony.

In every State where even a comparatively advanced condition of civilisation obtains, the necessity has been felt semper ubique et ab omnibus of taking certain of the learned professions under State supervision, and (directly or indirectly) under State control, and this principle has been from time immemorial specially applied to the profession of medicine. That this should be so is necessary :

(1) In the interests of the general public, who must be protected alike from the artifices of ignorant and

t

PRICE 1/6

unscrupulous unqualified persons, and from abuses of trust on the part of duly qualified members of the profession, who, holding, as they do, a responsible and semi-official position, possess almost unlimited opportunities of doing harm as well as good.

(2) In the interests of the medical profession itself, the bona fide members of which have expended much money, time and toil before obtaining a diploma. It would be most unfair that they should be exposed to the open competition of any ignorant quack who possesses a smooth tongue where with to beguile dupes, and a few hundred pounds to expend on advertisements. As the privileges and duties of medical practitioners in the United Kingdom are probably well known to the readers of the Record, I propose to allude to these only incidentally, and to confine myself to the position of the profession in its relation to the law of this Colony. The Common Law as propounded by such authorities as Matthaeus, Voet and Van der Linden, deals chiefly with the duties of medical practitioners in relation to crime. To the views of these writers I may find occasion to allude en passant, but, for all practical purposes we must look chiefly to our Statute Law. Taking this, therefore as our basis, I propose to deal with, (1) The qualifications the practitioner must possess before he can legally practice in this Colony, (2) With his privileges, (3) With his duties.

The Colonial legislation dealing directly with the medical profession is comprised in Ordinance 82 of 1830, and Acts 34 of 1891 and 7 of 1899. It may be well to mention ab initio that Ordinance 82 of 1830 has been repealed in its entirety by Act 34 of 1891, and has therefore only an antiquarian interest.

As regards then the qualifications of medical practitioners, the Act 34 of 1891 provides (Sec. 17) that all persons theretofore duly admitted and lawfully qualified to practise as physician, surgeon, accoucheur, dentist, apothecary, chemist and druggist, should, on registration, continue to practise. It likewise, and this was confirmed in the later Act, provided that certain persons, of whose competency the Governor was satisfied, and who could prove that they had been in practice for a period of twenty years, should, on applying within a certain prescribed period, be entitled to registration even though they possessed no diplomas and had not been admitted. A few persons availed themselves of this last provision, and four or five of them are still on the Medical Register and more on that of Dentists. The Act, however, provided for the constitution of two corporate bodies, the Colonial Medical Council and the Colonial Pharmacy Board. Any person who desires to practise in this Colony as a physician or surgeon must obtain a licence signed by the Colonial Secretary, and

issued on the recommendation of the Medical Council, which body has full power to prescribe from time to time what diplomas it will accept. Its regulations, however, require the confirmation of the Governor in Council. Before the Council can grant a recommendation, the applicant must submit to it his diplomas or certificate of regi-tration shewing that he is duly authorized to practise in the country wherein the diploma was granted. At present the regulations require two main conditions, one being that the course of study represented by the diploma must be equal to that prescribed by the General Medical Council of the United Kingdom, and the other that the country wherein it is issued must grant equivalent privileges in the way of permission to practise within its bounds to the holders of British diplomas. At present this "reciprocity regulation" practically excludes all but British diplomas. as no foreign country, saving Italy, accepts British diplomas, and that country limits the privilege to that of practising amongst the diplomate's own countrymen, which is not, of course, an equivalent to the full right of practice granted here. But it is important to notice that there is no discrimination against foreign diplomas as such. The question has recently been raised as to whether, in this connection, a federated country should be considered as whole, or whether if one State of such Federation granted due reciprocity, and the others did not, holders. of diplomas from that particular State could be admitted. The Supreme Court decided that States could be considered separately, but no practical effect has been given to this ruling, as the applicant in the case concerned was not able to prove that his individual State did give reciprocity. According to Act 34 of 1891, should the Council refuse to approve of any diploma submitted to it, the applicant may approach the Supreme Court, and if the Court, after communicating with the Council, is of opinion that the Council has not abided by its own Regulations, as sanctioned by the Governor, it may order the name of the applicant to be entered on the list of practitioners (Sec. 19). The writer has not been able to discover any case in which such application has been made. By Act 20 of 1884, a stamp duty of £5 must be paid by every person licensed to practise medicine or surgery. Every duly licensed medical practitioner is entitled to practise as an accoucheur, and he may compound and dispense medicines prescribed by himself or his partner upon payment of an annual dispensing licence of £2 10s. It must, however, be clearly understood that this does not entitle him to carry on any other portion of the business of a chemist and druggist.

As it is as necessary for the profession to be kept worthy as it is to keep unworthy people out of its ranks, the Medical Council has extensive disciplinary powers, It may formally censure or caution for conduct which it judges to come under the heading of "improper and unprofessional conduct," or may recommend to the Governor the erasure of a name from the Register for any offence which it considers to be "infamous and disgraceful," in either case after due enquiry, at which the practitioner whose conduct is complained of has had the opportunity of being heard in defence, either personally or by counsel. The Council does not, in practice, ever initiate proceedings against practitioners, but complaint

may be lodged by either the Minister in charge of the Department of Public Health, or by "any member of the public." Further, complaint may be laid not only of alleged misconduct in a purely professional sense, but on almost any grounds. The Act is plain on this point, using the words "in a professional or other respect." So far as the writer can ascertain, the Council has only recommended erasure on four occasions. One case was that of a practitioner found guilty of having made false statements in a life assurance examination report; another that of one found guilty of adultery with a patient; a third that of a Member of Council adjudged to have made scandalous allegations against another Member; and the fourth the recent one of a dentist found guilty of what the Council considered a gross disregard of its regulation against advertising. The two former cases were confirmed by the Governor, and carried into effect, although the offenders were subsequently restored; the third was not confirmed, on the ground that the punishment was considered excessive; whilst the fourth, although confirmed, was subsequently quashed on an appeal to the Supreme Court. It must be clearly understoon that the Council has no actual power of erasure. It can only recommend, and the decision as to whether the recommendation shall be carried into effect rests entirely with the Government. In this respect its powers are less than those of the corresponding body in the United Kingdom, which has full power of removal from the Register.

No unregistered medical practitioner can recover fees, even though he may be the holder of a diploma which would entitle him to a license, and he must prove the fact of being so licensed either by the production of his license in Court or by a certificate given under the hand of the Colonial Secretary (Act 34 of 1891, Sec. 60). The mere statement made on oath in the witness box, "I am a duly licensed medical practitioner," is not sufficient proof of status (Louw v. Fryer, C.T.R., 253), not even in the case of a District Surgeon (Nqumbela v. Culligan, 13, C.TR, 489). Medical fees, however, in common with all other professional fees, are prescribed at the expiration of three years from the time when the cause of action first accrued (Act 6 of 1861, Sec. 5). The latter words are of importance as shewing that the prescription begins to run, not from the time when the patient was cured or sied, but from the time at which each separate profesdional service was rendered, in respect of that service, because, although it is the custom o! the profession to render accounts to well-known patients only at stated intervals, there can be no doubt that the practitioner has a legal right to demand his fee for each professional service as soon as it is rendered. In this connection the case of Walker v. Fenele (12, C.T.R., 660) is instructive. An attorney sued a client in a Magistrate's Court for certain fees and disbursements. The professional services rendered extended over a considerable period, and the defendant took exception to certain of these fees on the ground that they were prescribed by Act 6 of 1861. The Magistrate allowed the exception, and the plaintiff appealed. After full argument, the Supreme Court remitted the case back to the Magistrate to take further evidence as to the dates on which (1) the various services were rendered, and (2) when judgment in each case was given. The given. The Court, however, clearly intimated that

prescription runs from the time when proceedings for the recovery of the fees could be taken. Of course, prescription will be interrupted if any payment is made on account, and will commence anew from the date of such payment. It may also be interrupted by the debtor giving a written acknowledgment of his debt, and such a document will not be prescribed till eight years have lapsed from the time when an action could first have been brought on such written acknowledgment. Accounts due for medicines, surgical appliances, and the like, are not prescribed till eight years after they could have been recovered by legal process.

With regard to the Court in which an action for the recovery of fees must be brought. The Resident Magistrates have ordinary civil jurisdiction in all cases in which is involved a question of professional fees up to £20. Should the claim exceed this amount the action must be brought in one of the Superior Courts, or in a Circuit. Court. It is often found advisable, however, when a claim only slightly exceeds £20, to reduce it to that sum and forego the balance, in order to bring it within the jurisdiction of the RM. and avoid the greater costs incurred in the superior Court. In all cases in which the claim is for goods sold and delivered (which of course includes medicines, surgical appliances, and the like), the Resident Magistrates have jurisdiction up to £100. In all cases founded on a bill of exchange, promissory note, good-for, or other acknowledgment of a debt for a certain specific and clearly stated sum, the Magistrate's jurisdiction extends to £250. It may here be as well to point out that what is known as provisional sentence, may be obtained in the higher courts on such documents as the above, the costs in all cases in which these can be put in will probably not amount to a quarter of those which would be incurred in a regular trial case. Should the creditor and debtor reside in different magisterial districts, the former must either bring his action before the Magistrate within whose jurisdiction the debtor resides, or in a superior Court (i.e. either in the Supreme Court, no matter in what part of the Colony the parties may be domiciled, or in the E.D. Court or High Court of Griqualand West, if both are domiciled within the respective jurisdictions of those Courts, or in a Circuit. Court under similar circumstances). Not only may such litigants bring their cases into a superior Court, but the successful party will be entitled to costs on the scale of such Court, no matter how small the sum recovered (Sluiter and Another v. Metcalf, 8 Juta, 211). practice of the High Court of the Orange Free State appears to have been the same (Brumend v. Jacobsdal Municipality, 4, O.F.S. Rep. 291).

The

Another important question connected with the subject of fees is, "Who is liable?" Of course, in the case of persons who are "sui juris et compotes mentis," evidently the patient who consults the doctor. In such a case no difficulty can arise. The cases of minors or of married women are no less clear. In the case of the former, the practitioner is entitled to look to the father of a legitimate child, or, failing him, to the mother or other legal guardian. In the case of an illegitimate child the mother, as legal guardian, is obliged to provide necessary medical attendance. The woman married out of community will be herself responsible if she retains the administration of her separate estate, but if not (and the presumption

always is that she does not), then, as in the case of all women married in community of property, the husband as administrator of the whole estate, will be responsible. So far the question is simple enough, but even these simple rules may (as we shall see) admit of certain modifications. When, however, we come to consider the question of a person who is non compos mentis, the case is not so clear. Suppose, for instance, that a person is knocked down in the street by a passing vehicle, and rendered unconscious. A medical practitioner happens to be passing, or is speedily summoned by a charitablyminded bystander. He hurries to the scene, applies "first aid," sees the unconscious person conveyed home, and then proceeds to do his best for him. A difficulty may arise then both as regards liability for eventual payment, and the right of the practitioner to do what he considers best for the unconscious patient. Possibly a limb has been crushed, and the surgeon considers amputation necessary. If there are any responsible relatives present, he would, of course, urge them to consent. What if they refuse? If they happen to be very near relatives, as a wife or adult sons or daughters, I am afraid that he can only do his best short of the means which they refuse to sanction, for the patient, wash his hands of the whole affair, and inform these relatives that should the patient die they may very likely render themselves liable to a prosecution for culpable homicide. He would in such a case be blameless, inasmuch as it would be obviously impossible to operate in face of their opposition, and "nemo tenetur ad impossibile." But let us suppose that the sufferer is an inmate of a boardinghouse, and that no one is accessible with an actual responsibility with regard to the patient. Then the surgeon is at liberty either to perform the operation which he judges necessary, or if delay is not too dangerous, insist on the patient being conveyed to a hospital, where he can be dealt with under more favourable circumstances.

Having so far discussed the practical view of these cases, let us consider them in their legal aspect. In this connection I fear that neither our Statute Law nor Case Law will afford much assistance, and we must, therefore, fall back on the Common Law of the Colony, that is the Roman Dutch Law. This law clearly recognises what is termed the "Negotiorum gestor," or the person who acts for an absent friend, even without a direct mandate, in order to preserve his property. Now, surely, if I may undertake the business of my absent friend in order to preserve his property, I may also look after the bodily injuries of my unconscious friend in order to preserve his life or facilitate his restoration to health. Clearly, then, the practioner incurs no liability, civil or criminal, by performing an operation upon an unconscious patient in the cases supposed. And here English law agrees with our own. "It is not an assault for the first passer by to pick up a man rendered insensible by any accident, or for a competent surgeon, if he perceives that an operation ought forthwith to be performed, to save the man's life without waiting for him to recover consciousness and give his consent." (Pollock on Torts, p. 164, 5th edition).

Since a qualified practitioner may and ought to operate in cases such as those suggested, is he entitled to any fees for his services, and if so, who is liable for them? For the present we will consider these questions quite