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ments, for the moment, regardless of the salary, but solely withthe view of acquiring experience, and in the hope of gettingan introduction into private practice. On the other hand,there are established practitioners who take the appointmentsat any salary, sooner than let them fall into the hands of, andgive a footing to, the young adventurers, who might, in time,out of such a beginning, become their too successful compe-titors in private practice.Such men, in the one case or in the other, have no right to

complain, yet they are scarcely settled in office, when theybegin to grumble, and, as was the case at the Hanover-square-rooms, the vials of their wrath are poured forth most abun-dantly on the devoted heads of the pinch-pauper guardians.The guardians, it must be admitted, incompetent as they areto fix a scale of remuneration for the Union-doctors, are notfree from moral guilt in this business. They see clearlyenough the motives of the competing candidates, and sordidlytake advantage of them, playing the one party off against the Iother. This is, to say the least of it, very reprehensible, forthe commissioners and the guardians must know, judging fromthe main-springs of human actions, that when the doctor isinsufficiently paid, the pauper-patient must in one way oranother be the sufferer. This, in fact, was admitted, avowed,and by no one contradicted, at the late convocation at Hanover-square.

It is now established beyond a doubt, that a grievance anda loud crying evil do exist in the medical department of thenew Poor Law. The question, then, is, what is the remedyfor this evil ? whence is it to come 1 who is to apply it ? tFrom the guardians, the doctors say that there is nothing tobe expected. From the commissioners, just as little. I ven-ture to say that neither the commissioners nor the guardiansknow how to devise a remedy. Who, then, does? Why,medical men themselves; but, strange to say, often and vehe-mently as they complain, it has never entered into their headstodothis. The resolutions passed at the Hanover-square Roomsdo nothing towards so desirable an end. A committee hasbeen appointed, with various instructions, but it has not beenreferred to that committee to collect the necessary evidence,and settle upon a scale or scales of remuneration adapted totown and country practice respectively. Without agreeingupon such scales it is utterly useless to memorialize the com-missioners or the Secretary of State. These functionarieswould say, ’Gentlemen, you do not state exactly what youwant, and, therefore, we cannot help you.’Let the poor-law medical officers agree upon such scales

of remuneration, and then approach the commissioners andthe Secretary of State with memorials signed by all theUnion surgeons, declaratory of their inability to do justice tothe poor, without injury to themselves, for less than that re-muneration. Above all, let them go to Parliament withpetitions to the same purport, and similarly signed. Thefixing upon such scales of remuneration would, at all events,have a great moral influence, but the probability is, that itwould lead to legislative enactments that would settle thequestion definitely and satisfactorily.In arranging such scales of remuneration much useful

information could be derived from the dispensary system, asrespects the cost of drugs and medical appliances for everythousand, or for every hundred, or for any given number ofcases. It would be well to enter into such statistics, andadduce such evidence to meet any objections that might bemade to the statements of Union surgeons, as coming fromparties too deeply interested. The probable cost of medicinesfor any given number of cases being once settled upon, itwould be easy to regulate the payment for the purely profes-sional services of the medical attendant, which would of coursebe less in great cities and towns, where the duty lay within anarrow compass, than in rural districts, more extended, withgreater distances between the residences of the patients.When I inform you that I passed twelve years of the most

active part of my life in dispensary and parochial practice, youwill admit that I have had ample opportunities of forming anopinion upon this very important subject; and perhaps youwill think, as I do myself, that at this trying crisis I ammorally bound to express it.When I was engaged in parochial practice as surgeon to the

parish of St. Pancras, in this metropolis, then containing apopulation of one hundred and twenty thousand souls, themedical officers had nothing to do with supplying the medi-cines to the patients. There was, at the workhouse, a dis-pensary, and a medical assistant resided there to dispense themedicines, and distribute them to the patients, as prescribedby the physician and surgeon.

It has been always my opinion, that if the same system were

practicable in the new unions, it would be the best. Soonafter I resigned the office I held, that system was abolished,the physician denied a salary, and the whole medical esta-blishment broken up as too expensive. The poor have beenever since farmed out, and it has been found the cheaper way.

If every Union workhouse were in a central position, sucha system might be advantageously established, and it would,in the aggregate, be less troublesome to the poor to send to theUnion for the medicines prescribed, than to the houses of themedical attendants. In any case there ought to be a medicalattendatzt for every parish. One for a whole Union would beinsufficient, even if all his time were given, exclusively, to theUnion practice.London, 1848.

THE FATAL CHLOROFORM CASE AT NEWCASTLE.

JOHN SNOW.

To the Ed1:tOJ’ of Tas -LANCET.

SiR,—The recent fatal case of inhalation of chloroformappears to confirm in a melancholy manner the remarkscontained in my paper in THE LANCET of the 12th instant,respecting the danger arising from the cumulative propertyof the agent when administered on a handkerchief. Thealarming symptoms came on after the cloth with chloroformwas removed from the patient’s face. Some of Dr. Simpson’sobservations on this case confirm the view I have taken.He says-" have seen in a few cases such a blanched stateof the lips and features come on, under the use of verypowerful and deep doses of chloroform, simulating syncope,and with the respiration temporarily suspended." It may bepresumed, that the cases Dr. Simpson has seen were underhis immediate superintendence; and this makes the dangerstill more evident; for if any one could prevent his patientfrom getting into a state which cannot be looked on otherwisethan as one of imminent peril, it would be the authoritywho introduced the agent, and recommended this method ofits administration.On January 10th, two days after I read the remarks at the

Westminster Medical Society, respecting the effects of chloro-form increasing after the inhalation was left ot’l; M. Scdillotrelated, in the Academy of Sciences of Paris, that he hadobserved the pallor, smallness of pulse, feebleness of respira-tion, and coldness, to augment in an alarming manner afterthe employment of the chloroform had been discontinued.His observations were reported in the Gazette .J.’Wédicale ofJanuary 15th.

I agree with Dr. Simpson, that it was not advisable to givebrandy, or even water-the more so, as I do not think withhim that there was syncope; but that these liquids causedsuffocation, filling up the pharynx, and being partially drawninto the larynx, seems improbable. This question, however,can be only determined by those who observed the symptomsat the time of death, and the nature of the froth found in thebronchi afterwards, as there is nothing in the reported evi-dence of the appearances on dissection which might not becaused by the kind of asphyxia liable to be induced when theeffects of chloroform are carried too far; and these appearancesare quite incompatible with Dr. Simpson’s supposition thatthere was syncope. Preventing the recovery from syncopewould not cause the state of the heart and lungs, which ischaracteristic of the opposite kind of death-that by asphyxia.In a certain number of those who are drowned, the heart andlungs are not congested, but the contrary, and it is believedby medical jurists, that those persons have fainted on fallinginto the water.-I remain, Sir, your obedient servant,

Frith-street, Soho. JOHN SNOW.

THE ALLEGED DEATH FROM CHLOROFORM ATNEWCASTLE.

To the Editor of THE LANCET.SIR,-For the sake of science, humanity, and justice, I am

glad to observe Dr. Simpson’s able and triumphant reply to thepathological verdict of the jury in the case of the girl Greener.I am glad also to observe the manly tone of THE LANCET insupporting Dr. Simpson’s views, and vindicating the cause oftruth. Dr. Simpson had a painful duty to perform, but hecame boldly forward, and put the case on a proper footing, forwhich he well deserves the thanks of the profession.

In my humble opinion, however, Dr. Simpson has omittedsome points of importance. The medical report states, " therewas congestion of the brain, of the lungs, of the liver, of thekidneys, and of the spleen." Now, by what medical logic wasthe cause of death fixed on " congestion of the lungs"? Why,

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not on " congestion of the brain," or the liver, the kidneys, orspleen ? I should like to see an answer to this. ,

Another view of the case might have suggested itself. Didthe girl Greener not die from the shock of the surgical operationrather than from the effects of the chloroform? I would

strongly recommend Sir John Fife and Dr. Glover to peruseMr. Travers’ work own Constitutional Irritation," wherein,after his excellent remarks on the subject, he relates several casesof death while the patients were on the operating table. Indeed,every one knows that hundreds of deaths have occurred whilethe patients were under the operator’s knife. A case of thiskind happened in the Edinburgh Hospital towards the end oflast harvest, a woman having died while being operated on forhernia, without ether.

0

Thousands have inhaled chloroform without a single fatalresult up to the present alleged case. Reasoning from analogy,then, the death in this case was more likely caused by the shockto the system than by the inhalation of the chloroform vapour.

Dr. Simpson’s reasons for supposing asphyxia the cause ofdeath are unanswerable, and put the matter beyond a doubt; butI have been induced to make these few remarks to show thaton no consideration should death have been attributed to "con-,gestion of the lungs from chloroform." MEDlcus.

TOE-NAIL OPERATION SUCCESSFULLY PERFORMEDUNDER THE INFLUENCE OF CHLOROFORM.

RICHARD HINDLE, M.D.

To the Editor of THE LANCET.SiR,ŃThe unfortunate case of death from the use of chloro- ’,

’form, reported in one of your late numbers, having forciblyarrested public as well as professional attention, I have beeninduced to transmit you the following case, more by way ofcounteraction to the impression imparted by such an occurrence,than from any peculiarity presented in its features. ’,A farmer’s daughter, aged seventeen, living at Dinckley,

Ribblesdale, had long suffered from disease of the great toe-nail.She says that it commenced two years ago, and she has neverlain in bed for the last six months, owing to the pain at nightbeing so extremely acute. She preferred sitting in a chair allnight, with the diseased foot generally resting on the cold floor.On visiting her, I found her general health much impaired;

pulse 96; tongue white and dry; face pale and haggard; legsimmensely swollen, owing apparently to her confined and con.stantly sitting posture. In short, there was much constitutionalirritation, without any obvious visceral disease. ’

Every application had been tried to heal the sores without anyeffect. The second great toe also was beginning to be very’painful, from the same disease.

After a short trial with various constitutional remedies, and- Seeing no prospect of any success, I proposed the evulsion of:both nails, and promised to give her chloroform. Dr. Irvingand Dr. R. T. Martland, of Blackburn, met me in consultation,- and it was decided that the operation should be performed as soon as possible. Sunday, the 6th of February, was fixed upon.

I may here state, that the first time I learned anything aboutthe fatal case at Newcastle happened on the previous Saturdayevening, whilst looking over the pages of THE LANCET; andthe two cases proving almost identical in character and features,I must confess that the reading of it impressed me with certain ’,misgivings as to the result, and in which feeling, I suspect, mytwo medical friends participated. However, the operation wasperformed. About five drachms of chloroform was expended on ’,the handkerchief, the patient being so agitated as greatly toresist the inhalation.The success was everything that could be wished, and the

sores have assumed a very healthy aspect. She slept soundly inbed the first night after the operation, and has no particularwish as yet to encounter the risks of her former posture. The

swelling of the legs has subsided, and her spirits are quiterevived, and she hopes she may be permitted to take the

sleeping stuff" again, should any other operation on her personever become necessary.-Yours most obediently,Ribblesdale, Lancashire. RICHARD HINDLE, M.D.

SALARIES OF ASSISTANTS TO POOR-LAWMEDICAL OFFICERS.

To the Editor of THE LANCET.

SiB,ŃA great deal has been lately said respecting the inade-quate remuneration of Poor-law surgeons, and every unprejudicedman must allow, very properly; but notbinghas been said to promotethe benefit of that ill-used class,-medical assistants,-on whomgenerally the onus of attending the Unions is thrown by their

employers, who requite their hard services with the footman’susual wages of thirty pounds a year. It would be well if Poor-law medical officers and others would approach nearer home, andask themselvesŃAre they acting justly in givingto those who assistthem a salary so very disproportionate to the labour? This is anabuse which ought to be remed:ed, and as long as it remains as itis, will be a disgrace to the profession.

I am, your very obedient servant,A SUFFERER.

THE NATIONAL ASSOCIATION AND NATIONALINSTITUTE.

To the Edit01’ o/"TnE LANCET.SiR,ŃWhatever may be said by others regarding the National

Association, the hole-and-corner gentry of our diploma-sellingmedical bodies may well exclaim, somewhat like the owl in theEastern fable, " God bless the National Association; so long asit continues we sha’n’t want for ruined doctors." Since theestablishment of this Association, the corporate bodies, whoseAugean stables are yet uncleansed, have enjoyed a state of reposeto which they had been strangers for many years.When the National Association was formed, upwards of three

years since, the glorious cause of medical reform, to which youand your fellow reformers had devoted your lives, was all buttriumphant ; the profession were aroused to its nece ssity,.thepress supported it, the public advocated it, and her Majesty’s Go-vernment had interposed to accomplish it.At that moment the National Association took the good cause

in hand; and what has been the result ? Let the professionanswer in your columns.The medical corporate bodies have again gained strength and

confidence, and proceed in their old course of taking care ofthemselves, but of nobody else; they have lost all that apparentfear and trembling which denoted a foregone conclusion, andproceed now, afraid and ashamed of no one, not even of them-selves.The medical profession were elate with the prospects of victory

already all but in their grasp, and joyfully awaited the esta-blishment of a body which would yield to them some protection,some support, some shelter,-to which they might refer whenoppressed by Boards of Guardians, or otherwise ill-treated; butalas ! their joy has been turned to despair,-their confidence hasbeen betrayed,-their money has been spent; and the Burkers ofmedical reform remain unpunished.

Not content with thus strangling medical reform, they mustinterpose in every effort on the part of the profession to eman-cipate themselves, and shake off the galling fetters which an in-human law, created by inhuman monsters, has imposed uponthem. A Poor-law Union Medical Association is formed, theNational takes it under the shadow of its wing, and spreading itsupas poison around, extinguishes it for ever!To whom are we to ascribe the disgraceful treatment of Dr.

Berncastle, and the thousand others who have been equally ill-treated ? To the National Institute !

Another Association has been formed at the East-end ofLondon, for mutual protection; pray recommend them to theNational Institute.What have we now, in return for our exertions, our confidence,

our money? A nominal Association, which exists only in nameand in its spirit of evil, with a perpetual president, perpetualsecretaries, and something like a perpetual committee, all of whomwill doubtless continue until Messrs. Snipe and Sneak find abetter berth for themselves, unless the profession grow wise intime, and stop the supplies.

Put your Herculean shoulders to the wheel once more, and theincubus will be cast off. We are not yet, Promethean-like,bound to a rock, that this bird of prey may feed on our vitalswith impunity.-Your obedient servant,

A MEMBER OF THE NATIONAL ASSOCIATION.

SUGGESTION TO USE ELECTRO-GALVANISM INTHE SYNCOPE FOLLOWING THE ADMINISTRA-TION OF CHLOROFORM.

To the Editor of THE LANCET.SIR,-I was somewhat surprised to find that Dr. Simpson,

from his being practically so well acquainted with the propertiesand power of the electric fluid, in commenting on Mr. Meggi-son’s fatal case after the inhalation of chloroform, did not moststrongly recommend the immediate use of electro-galvanism, inaddition to withdrawing the handkerchief or inhaler from themouth, the admission of free air, and the sprinkling of the facewith cold water, (see THE LANCET, No 1276, p. 176.) Having