MEDICAL AGENTS AND THEIR CLIENTS: LARA AND WALTERS VERSUS WARD.

are not, therefore, nullified. The resolutions either not suppose I write from prejudice, or am actuated by sinister represent the feelings of the Association or they do not. If motives, I adduce some of the evidence from which my opinion they do, your criticism needs alteration; if they do not indi- has been formed. The evidence consists of facts copied from cate the opinions of the "physicians," how was it they were the lunacy certificates granted by men of undoubted profespermitted to be issued stamped with the authority of the Asso- sional ability, but this only strengthens the views of the Asso-

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ciation ? ciation. This is followed by the assertion that " the public has ample I leave it to yourself to judge whether the conclusion is confidence in the practitioners of medicine ; it harbours an in- wrongly drawn, when I declare that during the last eighteen stinctive distrust of those whose vocation it is to combine the months medical men have stated in the certificates granted for " custody with the treatment of the insane." Here you assert, the admission of lunatics to asylums the following, amongst by inuendo rather than by making the charge boldly, that the other evidence, as facts indicating il1sanit.1l Ob%lTed l,p t7te?)tlicensed proprietor has greater power than the county asylum selves :-In one certificate it is stated that the patient ’’its very superintendent, and that he uses it only for his own benefit. weak;" that he " appears to have been bled;" tha t " his pulse This is most unjust. The license of a private house derives as is exceedingly feeble." In another I find that "she is very much, if not greater advantage from a. "cure," than from the good-tempered;" and again, that a male patient is " very badresidence of a patient. And who merits most the tempered, and imagines his coming into some property." Is it prolonged title of " custodian :" he who has no power against the will of any indication of insanity that a man confined in a workhouse the patient’s friends, or he who has the power to keep the should " dwell forcibly upon being detained." and "be most lunatic in his pauper palace contrary to the wish of relatives ? anxious to get his liberty"? " Inability to retain his urine" is The term "lodging-house keeper" might well have been brought forward as a fact indicating insanity; whilst one man omitted when writing of professional brethren ; for we all know has the melancholy occurrence that his son died in the East the title might be more appropriately applied to those gentle- Indies, stated in such a manner as to make it uncertain whemen " whose houses are larger than the requirements of their ther the son really was dead or the patient labouring under family," or " are delightfully situated, and suitable for a ner- this delusion amongst others. The fact was that the death of£ the son in great measure caused the patient’s alienation. Of a vous patient or lady in delicate health," than to the respectable and responsible proprietor or superintendent of a house under man in a state of acute mania, the only indication of insanity the examiner could find was " violent swearing and preachthe supervision of the Commissioners. The remark quoted as made by Dr. Conolly is, it must be ing." Of a melancholic female, it is stated, she ’’ refuses to allowed, an unfortunate one, and it is a statement which would answer questions as o where she lived,"and is weak." To not have been expected from so enlightened and amiable a these examples, which could be considerably extended, I shall man; but his fellow " specialists " (as they have been called) add one more. the facts of which as stated might apply either do not swear by him, nor are they to be judged by what he to a man suffering from cerebral congestion, or to one under says. The correct explanation of the inquiry which called forth the influence of a narcotic--namely, that "the only sign of inhis reply appears to be, that unless the insane patient be re- telligence was a recognition" of his wife and a friend; and, moved from certain causes, and placed under particular disci- again, that the practitioner was unable to " ascertain if he was pline suited to each case, the chances of recovery are decreased. sufficiently intelligent to understand what was said, or even to Look at the ultimate difference in the poor lunatics kept at recognise anyone except his wife." home or confined in a workhouse, and those sent early to an Sufficient, I believe, has been stated to show good cause why asylum ! So the " alienist" finds that unless the patient be those interested in the proper treatment of the insane, apart placed in an asylum or house under his immediate care, the from other reasons, object to the appointment of " medical chances of recovery are greatly lessened, and the probability of examiners" from amongst the general body of practitioners. the case becomingincurable increased. This is the true expla- Asylum officers know how repeatedly certificates are impernation, I believe, why asylums for the better classes must be fectly filled up; how peculiar the evidence stated frequently continued. Were it necessary to quote opinions in support of is, and this not in doubtful cases, but in those well marked, these views, could I refer to higher authorities than Esquirol, and of which the mental alienation cannot be doubted. They are aware how frequently " general paralysis is not recognised Jacobi, or Prichard? That lunatics are kept for profit no one will deny, but in till the patient" is sent to the asylum certified, it may be, as any circumstances (unless at home, where the recovery is pro- free from paralysis, and to be a curable case; they are aware, longed and uncertain) the charge that they are kept for profit too, how frequently insanity and delirium tremens are conmay be made. Is there anything derogatory in this? Is in- founded, and that melancholics are sent to asylums so excreased anxiety, responsibility, and expense to be incurred hausted that they soon swell the numbers of the deaths. It is for reasons such as these that asylum officers object to without corresponding benefit? Is charity to be given by him who, it may be, can least afford it, to him who asks not for it, their patients being examined whilst under their care by pracand requires it not? tioners untrained in observation of mental disease, unskilled in " The inspecting capacity of the Commissioners is inade- its treatment, and who, if appointed examiners, will be irrequate," you say. No doubt it is; but not, as you allege, be- sponsible for their opinions. I fear I have already occupied too much of your valuable cause it is impossible for the Commissioners to maintain a sufficiently minute and frequent supervision of the numerous space, and shall, therefore, add no more on a subject on which. private houses within theÍl’ jU1’isdiction; but because they have so much might be written. I am, Sir, your obedient servant, to visit prisons, workhouses, and county asylums, which may M.D. be regarded as beyond their jurisdiction. That county asylums May, 1859. are beyond their jurisdiction, no stronger proof could be adand We are aware that most insufficient perfectly illogical : duced than an article in THE LANCET of Sept. 5th, 1857, in reasons are frequently assigned in medical certificates as justiwhich it is shown that, although the Commissioners may recommend, they cannot enforce, improvements which their fying the diagnosis of insanity. We are also aware that certiexperience tells them to be necessary. Not only are their ficates of the character quoted by our correspondent might be suggestions unattended to, but their reports have been treated selected from the contributions of special " alienists" of high with contempt by prejudiced and conceited justices. repute, as well as from those of general practitioners. But The subject which follows affords you an opportunity to cases of this kind, affording as they do only presumptive evihave one hit more at the asylum proprietors. It is when dence of imperfect knowledge in the individuals signing them, the of the of Association to the writing objections appointment of "medical examiners." One would suppose the general do not prove the proposition that a knowledge of mental alienapractitioners would object to their appointment, rather than tinn is +hc mnnnnnlv nf a class-En T. the asylum officers, for their duty will be to confirm or condemn the certificates granted by their professional brethren. With the Association, I too must object; for the gentlemen MEDICAL AGENTS AND THEIR CLIENTS: selected for these offices are to be chosen from amongst the LARA AND WALTERS VERSUS WARD. general body of practitioners, a large proportion of whom, To the Editor of THE LANCET. , of though excellent in the various branches general practice, know but little, practically, of what is necessary to minister to SIR,--Having permitted Dr. Ward to publish in your columns the mind diseased. Insanity is beyond their province. They evidence not given in this trial, unsupported, and with his own have a general idea from books of what the symptoms ought to comments, we trust you will kindly allow us a brief and unbe, but, from deficient education in this division of medical varnished reply. Dr. Ward requested us to sell his practice. We gave him science, are unsuited for" medical examiners." That you may

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terms in which it is

expressly and unequivocally stated that shown by the cases reported by the Society of Observation, but commission shall become due when any particulars have which the following remarks will provewere probably not inbeen obtained here by a purchaser, however and by whomsoever tended to bear on the question of the rate of mortality. The the negotiation may have been conducted. We found, shortly whole number of these cases, collected, we are told, in all the afterwards, that he was employing other agents, and at once London hospitals during a period of six years, amount to little suggested the withdrawal of his business from us, warning him more than the average number of operations performed in the that, otherwise, he might have to pay two, if not more, com- London hospitals during one year, and were probably only a missions. He declined this, and we explained to him that we selection of those having most interest. The respectable re,could not take the initiative because it would have invalidated porters of these cases will be not a little surprised to learn that our claim to remuneration had he subsequently closed with any they and their colleagues were losing 50 and 44 per cent. of gentleman previously introduced by us. We continued our those on whom they performed the least dangerous (or pathoexertions, and eventually met with Dr. Williams, to whom we logical) thigh and arm amputations. Such a slaughter probably described the practice in detail; if he had already heard of it, did not occur in the days when red-hot knives and caustics we were in entire ignorance of the circumstance. A week were used in this operation. Another rule in statistics is, that the cases compared shall be afterwards, Dr. Ward withdrew it from our books, being " determined to remain in Kensington for at least six months similar. I am told that my charge of dissimilarity in the data longer." Within two or three days, as we learned by accident, adduced is unfounded. If I erred, it was by mistaking imahe disposed of it to Dr. Williams, and refused to pay our " ex- ginary for dissimilar data. I could not for a moment suppose traordinary demand," amounting, by the way, to £25 5,s. 6d. that pathological amputations of the thigh and upper extreSo that after, in a manner, forcing us to act for him against mity in any British hospitals could produce a mortality of 50 and 44 per cent., and concluded that the cases had occurred in our wish (as was admitted by him on cross-examination), Dr. Ward declined to be bound by the terms to which he had military practice under very unfavourable circumstances, or in agreed, and escaped payment, not from the " weakness" of some crowded foreign hospital. On reading the pamphlet with more care, I perceive that, as has just been related, they are our case, but merely through an unprecedented and unforeseen decision of Mr. Adolphus in these words: that by " consenting said to have occurred in the London hospitals about twenty to a withdrawal, our whole contract with the defendant had years ago. Upon what sort of evidence does this been rescinded."" I his was the sole ground of his judgment I rest?°? We find in a table at page 12 (if we take the trouble of making the calculation for ourselves) that the rate of mortality against us. The actual and only defence set up was that we had given after amputations for disease of the thigh, leg, and arm, during no particulars. Dr. Ward intimates to you that the reverse, six years in London and before the introduction of chloroform, " as reported in your journal, was nothing beyond a statement was, respectively, 29, 44, and 23 per cent.; but in page 17 of Williams have of counsel," and that Dr. would proved his the same work, when an "overwhelming" evidence in favour plea. The facts being that Mr. Lara swore to having furnished of chloroform is to be adduced, we meet with a wonderful augfull particulars, and that had Dr. Williams, through want of mentation of even these high figures : weare told that, in the memory, contradicted him, an agent of Dr. Ward, with pre-chloroform period, the same data show that pathological we were personally unacquainted, could have been called to amputations of the thigh were fatal in 50 per cent., those of whom Dr. Williams had acknowledged everything to which the leg in 29, and those of the arm in 44 per cent. of the cases. To make the contrast between the pre-chloroform and postMr. Lara deposed. If Dr. Williams is still oblivious, the gentleman to whom we chloroform periods more striking, we are, moreover, informed refer will, we have no doubt, write you two lines confirming that, while the tables of the London Medical Society of Obserour assertion far more strongly than we have put it. vation show that in arm amputations for disease the mortality We think Dr. Ward will scarcely descend to deny a single ’, amounted in the former period to 44’8 per cent., in the tables word of the above. We had nothing to do with his contracts I, showing the mortality in the London hospitals from the same with other agents ; and if he chose to retain the services of all operation during eighteen months of the latter period " no in London-as we believe, without exception, he did-we were ’ death is recorded." On examining these latter tables, I find a not debarred from recovering according to our agreement with I record of six deaths during that period : two from amputation him, simply because he considered himself liable to pay one’ for disease of the elbow and carpus, and four from amputation for phlegmonous erysipelas. other. I regret that these and other statements of a similar chaWe are as willing as himself to leave the matter, not only to the " judgment of the public and the profession," but of every racter should be contained in a "Prize Essay, "< apparently lawyer in England, save him who tried the question, and against ’, with the sanction of the authorities of the King’s College Hoswhose verdict there is, unfortunately, no appeal, as too many pital School. On this account alone have I noticed them. It is natural, as I have said, that those who have employed chlo’medical gentlemen have already discovered to their cost. roform in every operation should wish to be justified in conWe remain, Sir, your obedient and obliged servants, LARA AND WALTERS. ’, tinuing to do so; but advocacy of so singular a description is Temple, May 21st, 1859. not calculated to delay that restriction in the use of this agent which our experience of its immediate and ulterior evil effects THE imperatively demands.-I am, Sir, yours &c., JAMES ARNOTT, M.D. London, May, 1859. EFFECT OF CHLOROFORM ON THE RESULTS our

allegation

whom

i

OF THE SEVERER OPERATIONS.

(LETTER

FROM

To the Editor ’

DR. J. ARNOTT.)

of

THE LANCET.

MONUMENT TO THE LATE DR. SNOW.

[NOTE

FROM DR. B. W.

To the Editor

RICHARDSON.]

of THE LANCET.

SiR, -As my letter on the " Statistics of Amputations" has, SIR,-A few professional friends have been kind enough to - contrary to my expectation, been replied to in your last number, I must beg permission to state the facts on which I founded join with me in undertaking to place in the Brompton Cemetery the assertion, that in the work upon this subject, lately re- a plain, but durable, monument over the grave of the late Dr. viewed in THE LANCET, the rules of statistical evidence had Snow, as a last and fitting memorial of the esteem in which he not been adhered to. I regret that I am under the necessity of was held by those of his professional brethren who enjoyed the doing so. pleasure of his friendship. One of these rules is, that the facts or data compared togeHaving ascertained that such mark of remembrance would ther must be sufficiently numerous. Granting that the data be congenial to the feelings of Dr. Snow’s relatives, I take the quoted from the records of the London Medical Society of opportunity of making the project widely known through your Observation are correct, their number (184) is too small for columns, feeling sure that a great many members of the medical comparison, particularly when they lead to an inference so body will be glad to co-operate in paying this simple tribute to different from that proceeding from other similar data at least ten times as numerous. My estimate of the rate of mortality from the severer amputations is not only founded on the published and unquestionable data of Messrs. Potter. South, and other London surgeons, but is corroborated by Dr. Simpson’s return of 680 amputations before the introduction of chloroform, and other collections, including those of Mr. B. Phillips. All these show a much smaller mortality than is said to be

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the memory of our late estimable and distinguished brother in science. A committee will be organized shortly to carry out this object to completion; meantime, subscriptions for the memorial may be forwarded to Dr. Hawksley, 26, George-street, Hanover-square, W., or to myself. I am, Sir, yours, &c., 12, Hinde-street, May, 1859, B. B. W. RICHARDSON. RICHARDSON, M.D.