156

THE LANCET.

LONDON: SATURDAY, FEBRUARY 3, 1872.

SIR WILLIAM GULL’S ADDRESS.

THE address of Sir WILLIAM GULL at the Clinical Societywas a kind of recreation to the members of that somewhat

exacting body. They require of those who read commu-nications to them a certain severity of accuracy and de-finiteness, a certain bondage to facts, and reasonable infer-ences from them. And the Society prides itself above allon a penchant for practical facts of the clinical and thera-

peutical order. Sir WILLIAM’s address-genial and enter-

taining as it was-was distinguished mainly by an absenceof all these characteristics. It was vague, airy, and Ispeculative; too nice a diagnosis of disease was rather dis-

’’

couraged ; and so also was the notion that we were to

expect to cure a great deal of the disease that comes to usto be treated. Many people were born with faulty or-ganisms, the equilibrium of which was easily disturbed.They were incapable of health, in the ordinary sense of theword; and all the tonics of the Pharmacopoeia would not

give them health. Then Sir WILLAAM displayed a longingfor a knowledge of the essence of disease, and a corre-

sponding contempt for mere symptoms. Indulging thismood, he escaped successfully from the clinical regioninto one of fancy; and we fear that not a few of the

more clinical of his hearers lagged sadly behind him as hesoared. Small-pox was not a certain eruption accompaniedwith fever and preceded by pain in the back; these weremerely its symptoms. Pneumonia was not hurried breath-

ing preceded by rigor, with the accompaniments of pyrexiaand certain physical signs. Scarlatina was not to be de-

scribed as a disease with an eruption, a sore-throat, hightemperature, and very infectious. Sir WILLIAM wanted to

know what tissues were first infected; and expressed hisbelief that the blood was not primarily at fault, and that ifa man consisted only of blood he could not have scarlet

fever. Sir WILLIAM did not tell his hearers what small-

pox was, nor what pneumonia was. In fact, it was a partof his mood to eschew definitions, and he spoke of themas if they included everything but the essence of the

thing to be defined; and it was only essences about

. which he seemed to care on that particular night. From

all this followed, not unnaturally, certain contemptuousremarks about the treatment that contemplated the reliefof mere symptoms; and even the theory that takes thekindliest views of symptoms and credits them with a posi-tive curative intention, as if they were human beings or

something higher, came in for no mercy at the hands ofthe distinguished Baronet. The eliminative theory of theevacuations of cholera was more than disclaimed; so farfrom believing that nature meant by them to cure the

patient, Sir WILLIAM adopted Dr. HAUGHTON’s untheo-logical view, and charged nature with meaning to put thepatient into his coffin. The President enchained the sur-

gical half of the Society by promising them new regions

of practice when we shall have discovered more about the

dispensableness of certain parts of our organisation andtheir peculiar liability to disease-such as tonsils, which

Sir WILLIAM thinks he would leave out of any man that he

should make. We are well aware that both medical and

surgical practitioners find occupation in the abnormal statesof the tonsils; but whether Sir WILLIAM’S man without

tonsils will feel comfortable or not is another matter. We

should expect him to apply for medical assistance muchmore frequently than men with tonsils do.As we have said, Sir WILLIAM clearly designed recreation

to himself and the Society over whose careful labours he ablypresides. His duller hearers, whose imagination was notequal to the conception of a man consisting only of blood orwithout tonsils, doubtless expected him to talk of diseases,of the great success with which they have been differenti-ated, and of the valuable results which follow a treatmentdirected unavoidably to a large extent against symptoms.They may have hoped that so eminent a physician wouldhave dropped a few words that might have sharpened theirdiagnostic faculties or helped them in their therapeuticalstruggle with disease. All this would have been too much

like ordinary practice and the common habit of the Society.As it was, Sir WILLIAM threw physic to the dogs, andshowed his audience how possible it is for a physician tothink of disease as only another form of health. The dullerhearers to whom we have referred would doubtless fail to

appreciate many of Sir WILLIAM’S speculations. Tethered to

the bedside, they would demand an answer to urgent thera-peutical questions. They would argue, perhaps, thus: if the

physician throws physic to the dogs, the public will ask,what, then, is the use of the physician? But all this is to

be logical and practical; and for once, as we have said,Sir WILLIAM meant to be neither the one nor the other, but

only to speculate about nature, and wonder whether a manmade of blood only could have the scarlet fever. We seein the President’s address a kind compliment to the Clinical

Society. He has evidently noticed its laborious investi-

gations into actual disease, and he treats it to a series of

speculations which bear the same relation to medical know-

ledge as his man made of blood would bear to the ordinarycompound of flesh and blood.

DR. Guy has rendered a great service in pointing out thenecessity of separating lunacy from those other questionswith which it is now so unfortunately mixed up. At pre-sent every department of the Government, and it mayalmost be said every class of society, has its own method of

’ determining this important question ; and the Government! would no doubt obtain very general support if it would

institute a simple, inexpensive, and well-constituted tri-o bunal to which may be referred the question of personal, responsibility, whether it be in relation to destitution, to! personal and social safety, to the administration of pro-

perty, or to the commission of crime. Under the presentanomalous system, there are no less than four or perhaps

- five authorities engaged in the supervision and manage-ment of lunatics. Of these, the most ancient and still the

- most important is the Court of Chancery. The lunacybusiness of this Court is conducted by two masters,

157LUNACY AND LA.W.

a registrar, and three visitors, of whom two are medical men. but it is obvious that the lunatic is placed at a considerableAll are appointed by the Lord Chancellor. They appear in the disadvantage, as every one about him is more interested incivil service estimates for .823,000 a year, but a portion of £ keeping him insane than in restoring him to liberty, and itthis is recouped by a small charge upon the estates dealt is probable that one of the most difficult duties of the

with when the annual value is more than .8100 j in no case masters and visitors is to protect the lunatic against thedoes the charge exceed .8200 per annum for a single lunatic. selfishness of his relations and of those who have chargeAlthough the masters have X2000 salary, they are not of his person and estates.

entrusted with any independent power. Their duty is So much for the rich; but for the moderately well-to-dosimply to inquire and report to the Court, and every step there is positively no resource. A man may be hopelesslythey propose to take may be opposed. Even when the insane, and yet his friends may be deterred by expense andpatient is pronounced insane, they cannot sanction an other considerations from prosecuting a petition to theagreement or a lease without reference to the Lord Chan- Court of Chancery. In such cases the lunatic often wastes

cellor. To make a man insane by law is still, therefore, a his property in all sorts of follies, his family is beggared,tedious and expensive process ; and, as the intervention of and, although he may be taken to an asylum at an earlya solicitor becomes necessary at every step and for every stage of his complaint, his wife and friends incur con-

after-transaction, the process of petitioning for what is siderable risk in dealing with his property for want of acalled a " commission of lunacy" is one which can only be simple and inexpensive machinery for declaring him insane.had recourse to by the rich, and even by them it is often But the Lord Chancellor has also the nominal charge ofpostponed until the lunatic or his family are suffering from another department. The Lunacy Commissioners makewant of funds, there being no sufficient authority for giving their annual report to him. This Commission consists of

a receipt. eleven members, of whom six are paid. All are appointedIt will be observed that two totally distinct questions are by the Lord Chancellor. The total cost of this Commission

brought before the masters: first, that of lunacy; secondly, is .815,432 a year. The Commissioners may be regarded asthat of administering the property of the lunatic. With re- the wandering police of lunacy. They have the generalgard to the first, it is determined by one of the Masters supervision of all lunatics except those declared so by thein Lunacy, with the assistance of his clerk. Both are Court of Chancery. They visit and report on the state of

lawyers, and their report is based on a personal examina- all public lunatic asylums, workhouses, and private esta-tion of the lunatic and the affidavits of the medical prac- blishments for the insane, and they have power to ordertitioners and others who have had charge of him. In the discharge from the latter of patients who are well. Theyninety-nine cases out of a hundred the inquiry is perfectly reported on 56,755 lunatics last year, of whom 50,185 were

superfluous. The patient has been a confirmed lunatic for paupers.

years. He has been visited over and over again by the Here it is that the third authority having to deal withLunacy Commissioners, and the learned masters, who are lunacy comes in. The Local Government Board, the Poor-

supposed to know so much of lunacy, but who in reality law inspectors, and the medical officers of the Poor Law,acquire what little knowledge they have after their appoint- really have as much to do with the question as the Lunacyment, make a solemn report to the Lord Chancellor. Now Commissioners. The duties of the two authorities clash with

and again the lunacy is challenged; sometimes by the and overlap each other at every point. Complaints andlunatic himself, oftener by the solicitor who acts in his differences of opinion are constant, giving rise to confusion,behalf, and who has the prospect of increasing his bill by recriminations, and delay. Common sense would say that

demanding a jury. In that case we have all the expensive the Commissioners in Lunacy, having the practical super-arrangements of a public Court, in which the various in- vision of 50,000 pauper lunatics, should be subject ratherterested parties must be represented by counsel, to the to the Local Government Board than to the Court of Chan-

very serious diminution of the lunatic’s estate. When de- cery. The Lord Chancellor has no interest in the appoint-clared insane, the lunatic is committed to the care of one ment of Lunacy Commissioners beyond the exercise of

person-entitlecl ’" a. committee"—and his estate to an- patronage, and the Commissioners are too apt to ignoreother; and he is placed in charge of the three visitors, those principles of economy which Mr. STANSFELD is boundwho are bound to see him every six months, if in a licensed to maintain. The principal idea of the Commissioners is

asylum, or every three months if resident in a private to shut up the lunatics in huge asylums, where they mayhouse or with friends. There are said to be about 700 be inspected with very little trouble; whilst they have nolunatics in charge of the Court, and their united income provision for looking after the treatment of the 7333 paupersis between .8300,000 and .8400,000 a year. With the ad- who are residing with their friends. The district medical

ministration of this we have now nothing to do; but we officer visits them once a quarter, but he is not called uponmay observe, in passing, that the ignorance of the com- to report as to the sufficiency of the maintenance providedmittee men and their forced dependence on the Court of for them, nor is it any part of his duty to insist upon theChancery give rise to perpetual litigation, and that a vast administration of adequate relief. In Scotland the whole

improvement would be effected by placing the property of of this class is visited by the Commissioners; and if thelunatics in the hands of official assignees or professional Lunacy Commissioners in England were transferred fromcommittees similar to those now acting in the case of bank- the Lord Chancellor to the Local Government Board more

ruptcy-power of appeal being given to the higher Court. efficient supervision of this class might easily be managed,In case of recovery, the proceedings have to be repeated; the effect of which would be to diminish the necessity for

158 THE CORONER’S COURT.

building new asylums, and to give to a large number of the coroner may frequently say, after the examination ofharmless insane the advantage of greater liberty. witnesses, that if he had known the facts before he might

Lastly, we have a fourth authority, new to the constitu- have dispensed with the inquiry. We believe, however,

tion, and virtually an extension of the Royal prerogative. that the holding of frequent inquests adds greatly to theNow we have no desire to curtail the powers of an English security of life in this country; and that such securityjury, or to withdraw any points from their consideration would be distinctly diminished by any appreciable dimi-which affect the question of guilt. There are, indeed, nution in their number. The Coroner’s - Court has been a

great advantages in having the whole of the attendant very frequent means of bringing to light crimes that wouldcircumstances connected with the crime perpetrated by otherwise have remained not only concealed, but even un-the insane brought publicly to light. But, it having been suspected; and the knowledge that sudden death is fol-

repeatedly found that a jury is not the best tribunal for lowed by inquiry has, no doubt, a powerful effect in re-determining the responsibility of the convict for the crime straining poisoning and other forms of murder. We knowhe has committed, it is a serious question whether the of one coroner who very distinctly checked the excessiveHome Secretary should refer the matter to a shifting and infantile mortality of his district by holding an inquestirresponsible tribunal like that employed in the case of on every illegitimate child for whom the cause of deathCHRISTIANA EDMUNDS. was not certified; and it is manifest that a sagaciousIn conclusion, we believe that a good case has been made man, guided by local knowledge and experience, may

out, on grounds both of superior efficiency and economy, often so conduct himself as to produce very salutaryfor reconstituting the Lunacy Commissioners under the changes. In Nottingham, some years ago, there existed aLocal Government department, and making them the sole workhouse which would probably have been standing to thisauthority to determine the question of lunacy and its treat- time had not the coroner for the borough, during severalment in all ranks and conditions of life. months, held an inquest on every person who died within0 its walls, and thus rendered a succession of juries acquainted

THE readers of provincial newspapers must lately have with its construction, and with some, at least, of the detailsobserved indications, in various parts of the kingdom, of of its management. The workhouse authorities stormed

a rising up of constituted authorities against the dis- and vociferated in vain, and tried in vain to conceal the

cretionary powers of coroners. In former times the coroner occurrence of deaths from the vigilant public officer. Even-

was called upon to present his bill of costs for inquests at tually the coroner carried the day, the workhouse was

each Court of Quarter Sessions, and was liable to have any pulled down and a new one built, and then the inquestsinquests disallowed for which, in the judgment of the were discontinued. County magistrates are the very lastassembled quorum, sufficient cause was not manifest upon persons who should exercise the smallest jurisdiction over athe face of the evidence. The discretion thus vested by coroner; for the simple reason that they manage and con-law, in persons often but slightly gifted with discretion by trol large establishments, such as prisons and lunatic

nature, was found to lead to manifold hardships and abuses. asylums, containing numerous helpless inmates for whomIt led to hardships, because the coroner was liable to lose the coroner’s court is an indispensable protection. We

not only the fees due to himself, but also the sums that he have heard of many and fatal cruelties in such establish-

had paid out of his own pocket to witnesses and others; ments; and if the victims could be buried without inquiry,and to abuses, because, when the tendencies of the Bench these cruelties would not only never come to light, butwere economical, coroners abstained from holding inquiries might be perpetrated upon many who now escape them. It

in any but flagrant cases. As a remedy for these evils, the is quite possible that some check upon inquests may beplan was devised of paying coroners by salary, this to be desirable, but it should not be placed in the hands ofrevised triennially; and a coroner has now no pecuniary guardians or magistrates, or of any authority less thaninducement to hold an inquest, except the slight one of its that of one of the superior courts of law or of the Homeinfluence upon his averages against the next period of re- Secretary; and the necessity for an inquest should not bevision. Now again, however, a cry is being got up against judged by the evidence given upon oath before the jury, soH unnecessary" inquests. It proceeds most loudly from the much as by the preliminary statement by which the de-board of guardians of St. Pancras; and, if it proceeded cision of the coroner must be determined. It is a pitifulfrom them alone, might safely be neglected. But the thing for a county to haggle over a few guineas of remune-magistrates of various counties are joining in it with con- ration to coroners or to witnesses, or to attempt, for thesiderable vigour; and it therefore becomes worth while to sake of such paltry saving, to remove a protection to lifesee upon what kind of foundation it is based. and a frequent cause of the discovery of crime.We do not for a moment dispute that many inquests are 0:>

held for which there is no necessity-so far as the fact is M. QUATREFAGES has resumed his course of lectures onconcerned that inquiry dispels suspicion or removes doubt. Anthropology, interrupted by the war, at the Musee

But it is very easy to be wise after the event; and a death d’Histoire Naturelle de Paris; and has taken for his subjectmay well be surrounded by rumours which render an in- 11 The Formation and Characters of the Hybrid Races of

quest expedient, even though it should turn out that the Man." Two causes bring about the formation of mixeddemise was a purely natural one. The Irishman, when races. The first is the action of surrounding conditions,asked to plead guilty or not guilty, inquired how he could which lead to certain modifications in a newly-introducedtell which he was before he had heard the evidence; and race that cause it to approximate the local races. Thus

159CHARACTERS OF THE HYBRID RACES OF MAN.

M. RECLUS states that in America the negro and the white

man alike tend to acquire a red tint of skin. Secondly,crossing; and, thirdly, the combined influence of sur-

rounding conditions and crossing. The results of crossingmay be shown in three different modes:-I. Each type,more or less completely subdued in certain points, declaresitself supreme in others; hence we see the juxtapositionof characters borrowed, so to speak, from each parent. 2.

Each type may act on the whole organism as well as oncertain details; hence arise characters intermediate to thetwo parents. 3. The characters of the parents may be sofused as to produce a resultant necessarily distinct fromits factors.

M. QUATREFAGEs next considers the objections that havebeen raised, especially by Dr. NOTT, in respect of the fer-tility of the white man and the negro. Dr. NOTT thoughtthat though progeny were produced by the first crossing,yet that the race would not continue by reason of the feeble-ness of the male mulatto, the small fecundity of the female,and the fact that the latter made a bad nurse. Dr. NoTT,however, admits that this was only the case in South Caro-lina ; and that he had seen large and healthy families ofmulattos of the first, second, and third degree in Louisianaand Florida. This however he explains by maintainingthat in Carolina the Anglo-Saxon element prevailed, whilstin the other the French or Spanish Celtic element was pre-dominant-a race much more nearly allied to the negrothan the Anglo-Saxon. M. QUATREFAGES disposes of these

objections by recounting the history of the States in ques-tion, showing that the Anglo-Saxon element is largely pre-sent in them; and thinks that what differences do exist are

due, not to the nature and characters of the white element,but of the surrounding conditions. The hybrid races ofman have multiplied to an extraordinary extent since thevery end of the fifteenth century. In the 400 years that

have elapsed since the discovery of America and the doublingof the Cape, it is calculated that one-sixty-sixth of theentire population of the globe - the latter reckoned at

1200 millions-has become mixed, and the greater pro-portion of the mixed races are also hybrid-that is, havebecome mixed by inter-crossing.

Medical Annotations."Ne quid nimis."

MEDICO-LEC4AL RESPONSIBILITY AT THEANTIPODES.

FROM: a series of papers which have been forwarded to us,we learn that a recent trial, in which a surgeon was success-fully sued for malpraxis by his patient, has much exercisedthe profession in Melbourne; and the question has, accord-ing to custom, been warmly taken up by the local press,both lay and medical. A Mrs. Turner, whose age, accord-ing to opposite statements, ranged from fifty to seventy, I

was unfortunately tripped up by a dog on Oct. llth, 1870.She called in Mr. Van Hemert, who, after a careful exami-nation of the limb, failed to detect either shortening, ever-sion, or crepitus-the ordinary symptoms, we need hardlysay, of fracture of the neck of the femur,-and thereforeannounced that no fracture existed. A bruise of the knee

was carefully treated, and the patient was doing perfectlywell, when on Nov. 15th she informed her surgeon that

during the preceding night, whilst turning in bed, a suddencrack had been heard. On examination, Mr. Van Hemertfound the limb shortened and the foot everted, and crepituswas readily produced. He applied a splint at once, but fourdays after was abruptly dismissed by Mrs. Turner, who putherself under the care of Mr. Crooke. This gentlemancalled in Mr. Beaney, and they together made an examina-tion under chloroform on the 22nd, and subsequently ap-plied a splint and starch bandage, in which the patient waskept for some months (!), and recovered with a shortenedand damaged limb. For this she brought an action againstMr. Van Hemert (who had attended her gratuitously), andthe jury awarded =8230, her earnings having been about .81permeek. An appeal to the higher court was unsuccessful,and Mr. Van Hemert was finally saddled with the amountmentioned and legal expenses. At the trial, both Mr.Crooke and Mr. Beaney swore that there was crepitus to bereadily felt when they examined the patient, and that therewere shortening and eversion of the limb. This shorteningthey attributed partly to muscular contraction and partlyto adhesions between the broken surfaces, and they pro-tested that the fracture could not have been recent. It issomewhat difficult to reconcile these views with the un-doubted fact that crepitus existed; for if there were cre-

pitus there could not be adhesions, and if there were adhe-sions there could not be crepitus ! Nevertheless, the judgeand jury, finding the patient damaged and the doctors dis-agreeing, gave heavy damages for a result which was, aswe believe, inevitable, and in no way attributable to wantof skill on the part of Mr. Van Hemert. It is obvious fromthe summing up of the judge that he was unable to appre-ciate the necessity for the change in treatment adoptedby Mr. Van Hemert when evidence of fracture was appa-rent ; and yet we venture to say that treatment by pillowsonly, when no evidence of fracture existed, and the subse-quent application of a splint, would be supported by thebest authorities.We notice that both the Åustmlian Medical Journat and

Austmlian Medical Gazette take Messrs. Crooke and Beaney totask for their evidence, and we cannot but think them,to blamein having given evidence against a brother practitioner whoappears to have been the victim of circumstances. TheAustralian Medical Gazette strongly maintains that the casewas one of spontaneous fracture of the neck of the thigh,but we see no necessity for seeking such an exceptional ex-

planation. The case is one which is well known, and of

which there are plenty of examples on record-cases inwhich intracapsular fracture of the neck of the thigh-boneoccurs without laceration of the tough periosteum, and,therefore, without any displacement until by some move-ment of either patient or surgeon this is brought about,with the immediate production of deformity, crepitus, andall the ordinary signs of fracture. The theory set up byMessrs. Crooke and Beaney, that the fracture must havebeen complete at the time of the accident, because of theadhesions which prevented the limb being elongated, issufficiently confuted by their own evidence that crepituswas readily felt, and the contraction of the muscles wouldalone be quite sufficient to produce this effect.The only satisfactory feature in the case is the manner in

which Mr. Van Hemert’s brethren have come forward tovindicate his professional character, and assist him in pay-ing the heavy expenses incurred. A special meeting of theMedical Society of Victoria was held, under the presidencyof Professor Halford, at which a unanimous feeling as tothe injustice of the verdict was expressed, and a sub scription entered into for Mr. Van Hemert’s assistance. It will ..