MR. GARLICK AND THE BOARD OF GUARDIANS OF THE HALIFAX UNION.

701 one in every 548 deliveries,) individual experience which effusion was accompanied, in one of them, by great could not fairly settle the question, and therefore Dr. Tyler hypertrophy of the dura mater. Now the eclampsia and state Smith had done good service in desiring to collect the units of of coma in the latter were more nearly allied than the others individual experience, any generally existing con- to apoplexy and epilepsy, proceeding from irritation and nexion between the two diseases could be proved or disproved. hyperæmia in the nervous centres; whereas the cerebral conHis own experience of genuine puerperal convulsions had been gestion, which followed the cardiac and pulmonary congestion, limited to a verv few cases which he had seen in the practice with attendant convulsions of the latter, were results of periof others; and in those he was not aware of any previous epi- pheral irritation of the extremities of the sentient and motor leptic attacks, while he certainly knew one instance, where nerves, in connexion with the spinal marrow, as usual in cases epilepsy occurred during gestation, caused sanguineous iniil- of puerperal convulsions, where the irritation is peripheral, tration into the labium, but had not been followed by puerpe- and the convulsions reflex, giving them a characteristic differral convulsions, in either that or a succeeding labour. In ence from those of pure epilepsy, where the hyperesthesia, or another instance, epileptic seizures had occurred since mar- exalted sensibility, is centric in the brain or medulla oblonriage, but no convulsions attended her first or subsequent gata, and irradiates on the motor nerves so as to produce conpregnancies. With reference to the influence of marriage vulsions. No essential distinction of the two diseases can be made out from any difference of symptoms, but the marked over future attacks, the enquiry should not be limited to the female, but extended to the effect of the disease over the chil- pathological one, between epilepsy generally and puerperal dren of the marriage, and their progeny. It certainly hap- convulsions, is, that the former has its origin in irritation and pened, that facial resemblance was so transmitted, and most exalted sensibility of the brain as a nervous centre; the latter, likely internal predispositions and peculiarities also. Much in a like state of the peripheries of the nerves and spinal happiness would arise, and much grief and disappointment be marrow. Epilepsy and epileptic delirium tremens are freavoided, by a strict obedience to the laws of breeding, which quently the result of toxmmia; but puerperal convulsions are not usually so associated. Epilepsy and delirium tremens were so carefully studied and observed in horses and other animals ; but he feared that medical opinions would be only originate generally from centric nervous irritation, but the sought during negotiations for hymeneal alliances," for the latter from peripheral. Epilepsy may be therefore regarded purpose of justifying the intentions of the contracting parties. as a state of psychical hyperesthesia of the nervous centres; One rule might, however, be safely laid down, to carefully puerperal convulsions, as hyperesthesia of the peripheries of avoid a similar defect, or tendency, in the male parent. The the nerves; and as this exalted sensibility, in either kind of term epilepsy was far too loosely applied to every convulsive convulsion, may be conjoined with a state of hypersemia, or movement attended with temporary insensibility. He thought with an opposite state of ansemia, it requires a very different it should be restricted to convulsive attacks, implicating not system of treatment under the two complications. Mr. WING had seen two cases of puerperal convulsions, in only the general muscles, but also those of the face, the tongue, the larynx, and respiratory organs. He regarded the both cases with the first child. In both instances, also, there true puerperal convulsion as nearly allied to the single attacks was retention of urine, drawing off which fluid produced reof acute epileptic convulsions in children. The frequency lief. He referred to Dr. Burrows’ work on Insanity, with rewith which vegetable poisons produced convulsions led him to gard to the prominence of the eye in persons predisposed to favour the toxmn-iie or humoral theory of puerperal epilepsy, epilepsy-the eye had also a peculiar glaze. It was necessary rather than the osteophytic or solidist causation, proposed by to distinguish this eye from the prominent eye attending Dr. Cormack. At the same time these were both, to his mind, short-sightedness. He corroborated the assertions of those only predisposing causes,the immediate one was irritation of the who had witnessed epileptic seizures chiefly in the night, by the relation of an interesting case. nerves of the lower segment of the uterus-the utero-cervical Dr. RouTH believed that the cause of most puerperal conbranches supplying the os and cervix, and which were exposed to injurious pressure, and the irritation of extension during the vulsions was toxaemia from renal disease. Renal disease was passage of the child. He always sedulously endeavoured to re- very common in England, and more particularly among the lieve this by gently pressing back the head at the end of each lower classes: in Vienna it was rare. He had noted that pain, when the dilating stage was attended with unusual during his residence at Vienna, out of about 3000 cases of suffering. This manipulation freed the parts from continuous labour, there were only two cases of convulsions. He also pressure between the pains, and often gave marked relief. concurred with Dr. Cormack in believing, that the greater The large proportion of cases in first pregnancies pointed to, frequency of puerperal convulsions in primiparse, was to be eccentric rather than osteophytic irritation; but the influence explained by the backward pressure of the uterine tumour of emotional and centric irritation was evidently shown by the upon the kidneys, through the greater rigidity of the abdogreater frequency of the disease in unmarried females. He minal parietes. A priori, we might expect a patient affected dwelt upon the mutual influence of the centric and excentric with Bright’s disease to have puerperal convulsions, even causes of nervous and convulsive diseases; regretted the absurthough the renal disease was slight. He thought that the dity of still clinging to names invented before the physiology etiology of puerperal convulsions could only be made out by of the nervous system had been studied, and exhibited aL an examination of the urine—not merely during labour, when tabular view of the data, furnished by an analysis of 144 cases! it was almost always albuminous, but likewise before and which he had formerly constructed, for the purpose of regis- after. If the epilepsy, under which a patient laboured before pregnancy, was due only to ovarian excitement, a priori, tering the phenomenaand studying the disease. Hr. JAMES BIRD said he had listened with much interest to) we ought not to expect convulsions during labour. Dr. Cormack’s observations on the occasional occurrence of (To be continued.) puerperal convulsions from toxaemia, and such, he appre.hended, must be the nature of those epileptic convulsions, which, according to Mr. Druitt’s experience, as mentioned at a former meeting, so frequently happened among those addicted to beer-drinking. As to the influence which habits of "Audi alteram partem." beer-drinking might have in producing convulsions, he could not speak from his own experience, though he possessed many - facts to show that habits of spirit-drinking were very influen- MR. GARLICK AND THE BOARD OF GUARDIANS tial in producing them in connexion with attacks of delirium OF THE HALIFAX UNION. tremens, the pathological relation, character, and origin of the To Charles Barstow, Esq., Clerk of the Halifax Union. epileptiform varieties of which disease were calculated, he DEAR SIR,—I shall feel obliged if you will lay the enclosed thought, to throw some light both on the analogies and differences of puerperal and other convulsions. But of seventy account before the board of guardians on Wednesday next, as the payment has been refused by the relieving officer. The cases of delirium tremens which he had seen from 1835 to 1840, six of them were attended by epileptic symptoms, which simple facts of the case are as follow:On Thursday night, (October 18,) I was returning home at proved fatal in five of them. Of these five, three terminated in death by asphyxia, and two by coma. Of the asphyxiated nine o’clock, and was accosted in the street by two women in cases, two were accompanied, during life, by almost complete breathless haste: " Doctor, we are wanting you immediately; is a woman in strong labour in King’s Arms-yard." suppression of urine, and were fatal from toxæmia; the other there " was associated with endocarditis and fatty degeneration of the Well," I said, " have you got an order ?" " No, Sir; we have been to the relieving officer, and he will eart, as revealed by the necroscopic examination of the body. he two cases of coma terminated by the copious effusion of not give us one." " But you know very well," I replied,that I require an bloody serum into the ventricles and substance of the brain,

tal, (about

by which

.

’

.

Correspondence.

702 order before it devolves upon

me

to attend

a case

of this

kind." " Yes, yes, we know very well, but we cannot get one! Now, doctor, do not stand here a minute, the woman is very bad." Without more ado,1 went, first of all, at nine o’clock, stayed a little time, and then returned home. Went again at eleven o’clock, and after a short time returned home again and went to bed. Was rung up at half-past twelve, and, finally, got the labour over about two on Friday morning, the 19th. On presenting the enclosed account to the relieving officer, (an account for ten shillings,) it was returned to me, and payment refused.

Now, the relieving officer had offered this woman " the workhouse," thereby tacitly admitting that she was a pauper, and

his services into requisition,-the " fearful responsibility," in case of neglect of this proper course, shifts from the medical officer to the relieving officer, and there all blame in any

undoubtedly rest. case. On Saturday afternoon, Nov. 3, I was passing Chapel Fold, at half-past four o’clock. Two women stopped me, and desired me to go to a woman in labour in that place. Have you got an order ?" I asked. "No, Sir; we have been to the relieving officer, and he will give us one. But, Sir, if you will go to the woman, we not will go up to the relieving officer again, and try to get an casualty

must

But to my

"

order."

had she been removed thither, the medical officer would have Accordingly I went, and found the woman in labour; but been entitled to that fee which the relieving officer now with- not requiring my immediate services, I left. At nine o’clock Iwas summoned again, and I now stayed until one o’clock on Jiolds from me. With this explanation I throw myself on the justice and in- Sunday morning. The labour was tedious and severe, and the telligence of the board, and I am particularly desirous that child was born dead. ’they should afford me such instruction as will enable me to ! Now, Sir, two distinct applications had been made to the meet cases of this description. I wish to know what I am to relieving officer in this case, and both times an order was say to parties who apply to me in this way, without an order, peremptorily refused. I contend that, in equity, I had no at all hours of the day and night. The board little know right to attend this woman, after an order had been refused; what a medical officer has to do at a pauper midwifery case. and supposing I had declined, and any casualty had unfortuIn several instances, I have had to sit for hours on the floor nately occurred, no person pcssessing an atom of justice could in an Irish apartment, my only protection being an Irish- have laid any blame upon me. I inclose the account, and shall be glad if you will lay this - woman’s cloak, there being no bedstead in the room, and the patient, consequently, being necessitated to lie upon the floor. matter again before the board, and favour me with their In this position, I repeat, I have sat for hours, until it has opinion.—I am, dear Sir, your obedient servant, FREDERICK SMITH GARLICK. pleased the continuous efforts of Nature to set me at liberty. I seek no commiseration; I ask for British justice. I am willing to discharge my duty so long as I have strength,—a more painful duty than the board can possibly imagine, and such as no gentleman at the board would tolerate for an hour.

But there is one consolation pre-eminent above all; and that is, by the administration of medical aid, to see the pauper’s dull eye become bright; his sickly, discoloured cheek resume its natural hue; his stricken frame regain its wonted strength; and to see him again refitted for that labour by which he earns his daily bread. Hoping you will lay this letter before the board, and favour xne with a reply, I beg to subscribe myself, Dear Sir, vour obedient servant. FREDERICK SMITH GARLICK. Halifax Union, Nov. 1, 1849.

DEAR

SIR,—Iam directed by the board of guardians tc acknowledge the receipt of your letter, of the30th ult., (2 mistake, 29th ult.) enclosing an account for 10s., for attending the delivery of Bridget Cash, and to inform you that undo the circumstances

- charge.

attending

this case,

they

have allowed thE

With respect to the other subject mentioned in your letter I am desired to say that the guardians cannot take upon themselves the responsibility of giving you any special ’directions for your guidance in such cases, but would observE that a fearful responsibility would attach to any medical officer who endangered the life of any poor person because, ir, .a case of emergency, an order had not been obtained from the relieving officer. I am further desired to observe that the guardians rely upon your using It proper discretion in attending these cases, and that they will be willing to give a favourable consideration tc your claim to remuneration according to the circumstances oj

each

case.

I am, dear

Sir, yours faithfully, CHARLES BARSTOW.

To Charles Barstow, L’sq. SIR,—It again devolves upon me to lay before you a precisely similar case to the one to which I drew your attention last week, and I would fain hope that this may lead to As it is, there might as some decided method of procedure. well be no relieving officer if I am expected to act without an order. The form,tlity of an order seems to be unnecessary. You tell me that a *’ fearful responsibility would attach to any medical officer who endangered the life of any poor person because, in a case of emergency, an order had not been obtained from the relieving officer." Now, Sir, all midwifery cases are cases of emergency, inasmuch as they demand prompt attention both from the relieving officer and the medical officer. But a medical officer does not endanger the life of any poor person, if he be not that functionary, whose duty it is to call duly apprized

DEAR

by

Halifax

Union,

Nov. 10, 1849.

DEAR SIR,—I beg to acknowledge the receipt of your letter of the 5th instant, inclosing an account for attendance upon Catharine Riley, and to inform you that, under the circumstances of the case, the charge has been allowed by the board. With respect to your being called upon to attend, in cases of this nature, without an order, I am directed to refer you (in addition to my letter of the 1st inst.) to Article 182 of the General Consolidated Order of the Poor-law Commissioners, dated Juiy 24, 1847; and the note thereon numbered 52, in the duties of a medical officer in these cases are clearly

which

pointed

out.-I am, dear

Sir, yours faithfuliy,

CHARLES BARSTOW.

After this

notes, for

ten

correspondence, I had occasion to fcrward three shillings each, to the relieving officer, for attend-

upon cases for which I received no order. These notes returned by the relieving-ofiicer the same evening, with a verbal message that they would not be paid. In consequence of this, I wrote the following noteance

were

To Charles Barstow, Esq. SIR,—The inclosed accounts have been handed to Mr. Walmsley, (the relieving olficer,) as usual, and he has this evening done me the honour to return them. I have now, therefore, no alternative but to lay them before you. I am. dear Sir. vours respectfullv. FREDERICK S. GARLICK. DEAR

Halifax Union, November 16, 1849. DEAR SIR,—Iam directed by the board of guardians of this union to acknowledge the receipt of your note of the 13th inst., inclosing accounts for attendance, in cases of labour, without an order from the relieving officer; and in reply, to inform you that your charge in the case of Sarah Bird is allowed, and will be paid by Mr. Walmsley; that Mary Taylor’s case stands over for inquiry; and that in the case of Catherine Duffy your fee cannot be paid, as it is understood you were not in attendance during the labour; nor were you called in afterwards, under circumstances of difficulty or

danger.—Yours truly, CHARLES DEAR

BARSTOW, Clerk.

To Charles Barstow, Esq. SIR,—I duly received your communication of the 16th

of November, in which you inform me that the board of guardians had allowed the usual fee for attendance upon

Sarah Bird in labour, but that in the case of Catherine Duffy you are instructed to say, that the fee cannot be paid, as it is understood you were not in attendance during the labour, nor were you called in afterwards under circumstances of difficulty or danger." This, I submit, is of no consequence, as Article 182 fully and clearly laysdown. Now, Sir, Catherine Duffiy was coniined about seven o’clock

703 i the morning without any medical assistance whatever, and this circumstance reflects very little credit on that wretched parsimonious system, which, apparently intended to consign poor lying-in women to chance-women, too, who are afterwards acknowledged to be paupers, relieved out of the parish funds, and yet most unjustly denied the services of the medical officer in the time of their utmost need, because it involves I would rather be the man an expenditure of ten shillings ! to attend these cases for nothing than him who would refuse all just remuneration. Supposing Catherine Duffy, or any other of the five cases I have lately attended without, an order, had been the wife of a poor-law guardian instead of a poor, destitute Irishman, she would undoubtedly have had some consideration bestowed upon her, and not been allowed to struggle through the pains and penalties accompanying childbirth without prompt and able assistance. What difference is there, I would ask, between the Queen in labour and Catherine Duffy ?&ic rc; None whatever. I repeat, Sir, the system which would deny medical aid to poor lying-in women cannot be too severely deprecated. It is not only un-English, but grossly barbarous. Now, with regard to the refusal of the fee. Article 182 says—" In cases in which any medical officer, either for the workhouse or a district, shall be called on, by order of a person legally qualified to make such order, to attend any woman in, or immediately after, childbirtll," &c. This settles the question at once, and on these words I found my claim. I was called into the house of Catheriue Duffy by her husband on the afternoon of the same day on which she was confined; I supplied her with medicine, and visited her again; besides this, I prescribed for and supplied her husband with medicine. In fact, I saw the woman fairly over the puerperal state, and discharged my duty conscientiously, and in strict compliance with the plain provision in Article 182. In your letter there is some ingenuity; at all events, there is a lamentable oversight in your quotation (it may have been dusk, as it soon is in November), I mean, in omitting the words which I trust I have rendered so legible as not to be overlooked this time, and confining yourself with all stress (the gas no doubt had just been lit) to the following, nor were you called in aftewards under circumstances of difficulty or danger. Now, I would liumbly ask, how do you knowthis ? The board certainly cannot tell the circumstances-the relieving officer cannot tell-nor can you yourself tell. In fact, the circumstances of the case, in a medical point of view, are only known to myself; and, therefore, I beg to submit to your good judgment that the words I have underlined above, are neither I would remind more nor less than a gratuitous assertion. you, in all humility, that Article 182 awards ten shillings for all ordinary cases, but for extraordinary cases, in. volving "circumstances q/ difficulty or danger," the medical offic2r is entitled to twenty shillings; and it is right such a distinction should be made. I mean no offence by these remarks, nor do I harbour any ill-will. I but follow out the law, and I desire nothing but what is reasonable and just. In conclusion, Sir, I am of opinion that a medical officer, who, in order to discharge faithfully a most responsible duty, is compelled to walk about the streets at all hours of the day and night; to sit for hours together in garrets and in cellars, amidst filth and destitution, amidst squalor and wretchedness, unseen it may be, but no less useful on that account; such a man, I say, ought not to be deprived by any chicanery, however subtle, of a paltry sum of ten shillings, especially when the law has provided for its honourable pay-

has written his book; he has brought the affair to a tangible shape, and he must endure the consequence. THE LANCET of January 13th, 1849, contained an article from me, " On Employing Instruments in Midwifery," in which I stated, that of 1484 labours, three only were delivered by the forceps, being rather less than one in 494. And this I stated in furtherance of the late Dr. D. D. Davis’s reasonings on this important subject, as contained in the following passage from his "Elements of Operative Didwifery":—" Upon the whole, therefore, I am much inclined to the opinion, that cannot be absolutely necessary to have recourse to the use of the forceps or the lever more frequently than once in 300, or at most in 250 cases, in order to ensure for puerperal women the greatest possible advantages attainable from the employment of these obstetric powers." Eight months passed away, when, in THE LANCET of September 22nd, appeared the first letter of Mr. C. Stewart, Sen., containing a graceless and illiberal attack upon me and my practice, winding up with these remarkable words:—" I cannot coincide with the opinion of Dr. Davis, thatit cannot be absolutely necessary to have recourse to the use of the forceps more frequently than once in 300, or, at most, 250 cases,’ and unhesitatingly give it as my conviction, that such a limited use of them is far fromensuring for puerperal women the greatest possible advantages attainable from these obstetric powers: Indeed, I would not readily affirm that they may not be emas one in fifty." ployed with advantage in as great an average To this bumptious letter I gave a " laconic" reply in THE LANCET of November 24, simply calling the serious attention of Mr. Stewart to some midwifery statistics of Dr. F. H. Ramsbotham, by which it appeared, that of 26,776 women, only thirty-four were delivered by the forceps, being less than one in every 787 cases! THE LANCET of Saturday last contains a second letter from Mr. Stewart, wherein lie says,-" The object of his paper was, to show that the instrument, as recommended by almost all teachers and writers on the obstetric art, is rarely had recourse to, and always as a desperate resource, and that therefore its use is much more limited than safety dictates, or reason demands." Here, then, we are at issue. My object in publishing a statistical record of midwifery cases occurring in my private practice, was just the reverse. I believe the forceps are very often had recourse toJashly, and unnecessarily, in order to save time and trouble, and more particularly by practitioners who pride themselves upon their mechanical abilities. Mr. Stewart next finds fault with what he callsa half table of statistics." Why a " half table "? Why travel out of the record, when the question between us only refers to

it ’,

ment.

Under these circumstances, I protest, respectfully yet the decision of the board, and I ask, again, for a. more rational and considerate management of these important cases. I may just observe, that Catherine Duffy, Mary Taylor, and Sarah Bird, have all received parochial reliefimmediately subsequent to confinement, and that I was called out of bed to attend upon the two latter. I have the honour to be, dear Sir, your obedient servant, FREDERICK SMITH GARLICK. Halifax, Nov. 19, 1849. P.S.-To this letter I have as yet received no written reply, but I understand the fees have all been allowed, with the F. S. G. exception of that for Catherine Duffy.

firmly, against

ON THE EMPLOYMENT OF THE FORCEPS IN MIDWIFERY. To the Editor of THE LANCET. SIR,—"Oh that mine adversary had written a book !" claimed the most patient of mankind. My waspish adversary

ex-

forceps

cases ?

I now desire to call Mr. Stewart’s attention to Dr. Simpson’s able letter, " On Operative Midwifery," in the same LANCET, wherein he gives a table showing the proportion of deliveries bv forceps in different obstetric institutions-thus :

Will Mr. Stewart, after

this, continue to maintain that the may be employed with advantage in as great an average as one in fifty cases ? Did he use the forceps eighty times in attending the 4000 accouchements spoken of by him ? If so, how forcibly the words he quoted from the Mantuan bard, " Quæ ipse miserrima vidi, et quorum pars magna fui," apply to himself, and the words which immediately follow," Quis talia fando temperet a lacrymis ?" to the numerous readers of THE LANCET.—I am, Sir, yours obediently, JOSHUA WADDINGTON, F.R.C.S.E. forceps

MR. SAXTON OF MARKET DRAYTON, IN REPLY TO THE LETTER OF DR. WOOD.* Market

Drayton,

December 1849.

SIR,— Before again asking Mr. Wakley to give his opinion on the question of medical etiquette at Market Drayton, it is necessary to point out to him the misrepresentations you have made; and of this my intention, I think it proper to give you

intimation. In the first place you state that I made use of this expression to you—" They ought to have known better than to have sent for you, and you ought to have known better than to have gone to see him." This is totally incorrect, a ruse to draw attention from my real charge against you-viz., of omitting * Vide the Lancet, No. 21, 1849, p. 568.