Page images

Mr. S. W. NORTH (York) said that it seemed to have been forgotten that the whole basis of their position and knowledge in this matter was the Registration Act and the results of it; and that without it, it would be quite impossible to approach the question of the statistics of disease, or of the general causes of death prevailing throughout the country. Whilst they spoke of minor defects, they must not be understood to be condemning the Act generally. They must also bear in mind that many of the faults complained of were not faults of the Act, but faults of the profession. He had had an opportunity some years ago of examining the death returns at an early period of such registration, and the difference between then and now was astonishing. He did not think any of them could hope to get the certificate as precise as Dr. Carpenter's observations seemed to point to; that was for the future of medicine. Dr. Vacher referred to alcohol as being seldom recorded as the cause of death. Alcohol produced its evil effects by causing disease, but he did not know that the medical attendant was always in possession of facts to show that alcohol was the cause of pneumonia or other diseases, and thus to certify it as the actual cause of death, although they had good sound ground for believing that alcohol did kill a large number of people, their knowledge was not then enough to assign alcohol as a cause of death in the same way as they might with other poisons. The zymotic causes of death were scarcely sufficiently known to form the basis of certification. As to the Coroner's Court, the object was not so much to enquire into the cause of death as they understood it medically, as to get at the cause socially. So long as the law was as it is, the Coroner's Court would be satisfied by asserting that the cause of death had been proved to be due to violence, natural causes, or otherwise, without being more specific. With regard to uncertified cases, the Officers of Health should be asked to make a personal enquiry, and to report to the Coroner; this would bring about a greater and increasing accuracy in those cases; he certainly thought they might aid the Coroner by investigating these cases. They could not hope to attain to a knowledge of the remote cause of disease, and could not blame the Coroner for this inability. The certification of deaths had rapidly improved, owing to the fact that they were overhauled by competent persons, and that this fact was generally known. Improved notification of the cause of death rests rather with the medical profession than the law; want of clearness greatly impairs the value of the certificate for the purposes of public health and scientific medicine.

Dr. J. F. J. SYKES (London) said it appeared to him that the point was to get a more accurate certification as well as a more scientific definition of disease, so that they could properly classify it. One of the difficulties was that extraordinary terms were used, and that, not in proper order. It was the custom in classifying, to select the zymotic cause first as the primary, although not so stated, then to select the constitutional, thence they passed on to the local, then to the developmental, and lastly they fell back upon the symptomatic. The

underlining process giving prominence to a particular disease or cause of death was not sufficient for him. It ought to be an orderly process which he would describe presently. He thought the suggestion that the certificate should be sent direct to the Registrar, would assist very materially in getting more correct certification. The Coroner had at present two functions, he had originally one-the social functionbut now he had the medical function of defining disease, as well as the function of defining the social cause of death. These two points could very well be met by appointing a medical assessor, and in his opinion this should be done, as the medical question should not be strangled by the legal one. This brought him to the finding of Coroners' Juries. The Coroner as well as all others certifying, ought to be bound to certify apart from the verdict according to a fixed certificate. A year or so ago, he proposed before the Medical Officers of Health Society, to improve the death certificate, but the matter appeared to have been under consideration ever since. The mistakes as to the primary and secondary cause of death were very frequent, and he would suggest that the certificate should have three distinct items (1) "Immediate cause of death"; (2) "Proximate"; (3) "Predisposing"; and the duration of each cause. If they had a certificate of that form in which all were bound to certify, a more accurate record would result from the Coroner as well as from medical men generally. Although only ten per cent. of the deaths were uncertified, probably fifty per cent. were certified in an unsatisfactory manner, largely owing to the form of certificate, and proper certification was the basis of proper classification.

Dr. MEACHAM (Manchester) said he was a poor law officer at Manchester. He believed a great deal of truth to be suppressed in death certificates. He had had numbers of deaths against which if he had written alcohol he would have been correct, and he believed there were many deaths arising from alcohol which were in no way known so far as the death certificate was concerned.

Dr. VERNON (Southport) said that the certificates had been described as perfectly useless, as had all the statistics based upon them; but his experience was that they were completely satisfactory for administrative purposes. But as regarded classification, he sympathized strongly with Dr. Vacher, and thought the members of the medical profession were mainly, if not entirely, to blame for any difficulty that arose from these causes. A vast improvement had taken place, but as they were aware, there was still room for further advancement. It seemed to him that the less complicated a certificate was, the better it would serve its purpose; and although Dr. Sykes's suggestion was a very ingenious one, he hardly thought it was adapted to the average intellect. Elaborate details as to the sequence of systems were not wanted: what was really wanted was the killing disease. He was strongly in sympathy with the suggestion that the Coroner should have at his command a medical man as assessor, and that the assessor should be the Medical Officer of Health.

He thought it quite necessary too that there should be more attention paid to the qualifications of those who are selected to conduct post mortem examinations, for it appeared to him that many men engaged in the hurry and bustle of general practice were scarcely possessed of the minute and accurate chemical and pathological knowledge required by a witness at assizes.

Mr. ARMSTRONG (Newcastle) said that Dr. Vacher's paper was full and suggestive. To his mind, the criticisms in it were severe, but just, and such as every Medical Officer of Health would confirm. Feeling that the discussion that morning would be incomplete without practical action, he would propose a resolution, which, although it did not go so far as his own opinion, would, he believed, fairly embody the general sentiment of the meeting. Individually, he considered that in large towns the Medical Officer of Health was the proper person to fill the office itself of Coroner; but without prejudice, he moved the following resolution, which was a step in the right direction, viz. "That in the opinion of this meeting, the appointment of a registered medical practitioner, and, where practicable, the Medical Officer of Health, to the office of assessor to the Coroner, is likely to be advantageous to the public by conducing to a more accurate return of the cause of death in suspicious and uncertified cases.

[ocr errors]

Dr. J. TATHAM (Salford) seconded the resolution, and said he desired to allude to one aspect of the question which had not been previously touched upon, namely-what was to be the future position of the Medical Officer of Health in regard to it. At present when that officer devoted the whole of his time to the duties of his office, he was nothing more nor less than the Registrar of his Committee. He had not the position which a highly educated man ought to occupy. They had heard described that morning some of the duties of such an officer, but Mr. Armstrong had fully set forth in an excellent paper, what in his judgment should properly be the functions of the Medical Officer of Health. He (Dr. Tatham) would recommend those present who had not already done so, to read that paper. By virtue of his position, the Health Officer ought to be in reality the guardian of the public health, not simply a carrier out of resolutions of Committees. He ought to be the recipient of the death and sickness certificates of the medical men, and it should rest with him, to say whether inquests were necessary in certain cases, instead of with the Registrar as at present. Another serious matter had been omitted from the paper, and that was, that according to the law no registration of still births was necessary. They knew that a very large proportion of children were certified informally, on bits of paper, as having been still-born, by midwives and other ignorant persons present at birth. In the speaker's judgment, that was not a state of things that ought to be allowed.

Dr. KENYON (Chester) said he had listened with considerable impatience to the references to the office of Coroner, and the idea of

combining it with the duties of Medical Officer of Health. The existing duties of each officer were sufficiently onerous, and it was ridiculous to think that an officer could advantageously discharge the duties of both. He was particularly opposed to the Medical Officer of Health, as such, being called upon to undertake any enquiry into the causes of uncertified deaths. Such enquiry would be utterly useless, unless witnesses could be examined on oath and under formalities, i.e., so far as it could be conducted by a man in the position of Medical Officer of Health. A policeman or detective might go about amongst people and collect information, which might afterwards be tested in a court of law; but a Medical Officer had quite enough to do in his own department, and he deprecated the tendency of speakers advocating the annexation of duties belonging to other departments foreign to its scope. He thought however a medical man was quite as well fitted to be a Coroner as was a lawyer; it was clearly intended to be for the purpose of making an enquiry in a common sense, rough and ready practical way for the people by one of the people.

Mr. MACASSEY, though neither a medical man nor a lawyer, asked permission to speak, and was allowed. He thought the view he took might be considered an impartial one. It was a fact that often the Coroner's Court was the ground for ridicule, but one reason for this was forcibly pointed out by Mr. North. The real object of the Court was to determine whether or not the death had been caused in such a way that any one was criminally responsible. Who was the best man to preside over that Court? The Jury brought in the verdict, but it was the duty of the Coroner to put the facts clearly before them. He contended that the lawyer was most suited for the office, inasmuch as he was best accustomed to weighing and dealing with evidence. The lawyer could always have competent medical witnesses, and therefore he did not see the necessity for passing that resolution nor the need that a medical man should even be the assessor. As to the classification of the causes of death, he thought the proposed simplification would be found difficult to accomplish, although Dr. Sykes had struck a keynote in giving the immediate and proximate causes of death, for by these they would see at once what was the cause of death. It was always difficult to put into simple words the multiple meanings often necessary in the classification of death causes.

The conference then adjourned. The afternoon proceedings were conducted under the presidency of Dr. Tatham, of Salford, Professor Corfield having to leave to attend the Vienna Congress.

Immediately on resuming, the following amended resolution was moved by Mr. Henry E. Armstrong (Newcastle-upon-Tyne), seconded by the Chairman, and carried unanimously :-" That the Council of


the Institute be recommended to consider the desirability of the Medical Officer of Health acting in the capacity of assessor to the Coroner in all cases of death in which there has been no medical attendant, or none from whom a certificate of death can be obtained, and that in such capacity it should be the duty of the Medical Officer of Health to make full inquiry into all cases of suspicious or uncertified death."

Dr. F. VACHER (Birkenhead) said all the gentlemen who had spoken, appearing to be in favour of the proposals made, he had not much to say in reply. With reference to the remarks he made upon the Registration of Births and Deaths Act (1874), at the time they were written, he had not expected that Lord Basing (who was instrumental in framing the Act) would be sitting by his side to hear them read. He desired to say he appreciated the value of the Act as a whole, and he wished Lord Basing were present to hear him say so; it was through this Act that the causes were duly certified in ninety per cent. of the deaths registered; but, as might have been expected, thirteen years' experience of the Act had shown its imperfections. He had been asked to say why he had not called his paper "Death causes and their certification"; the word "classification" appeared to be more comprehensive, especially as he was dealing with deaths certified and uncertified; it was the difficulty in classifying death. causes that made careless certification a medical officer's question.

On "Provision of Fever Hospitals for Rural Districts," by G. A. KENYON, M.B., L.R.C.P.


Dr. KENYON pointed out that Rural Districts vary much in character. In places surrounding large towns they were frequently of a suburban character, and on the sea coast had a large floating population of visitors. In such localities, Hospital accommodation for Infectious cases was imperatively needed, not necessarily of an expensive character, but once

« PreviousContinue »