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the medical man presiding at the table with a great clatterof chairs on the concrete floor as if we were at school. Thefood was excellent both in quality and cooking; our own poorpeople would call it luxury if they had the French taste-two meat courses, two vegetables, a soup, and a dessert witha flask of red wine. But forced feeding is not attempted ;the appetite only is forced and that only by natural means.Serving at meals is done by the healthiest patients in turn,ten or 12 being detailed for the purpose each day. Thebedrooms are similarly tended ; the beds are made and allclothes and boots are brushed by the patients themselves.Clothes and boots are brushed in separate cloak-roomswhere the boots are always exchanged for slippers on

’entrance after a walk, prevention of dust and waste matterbeing considered more effective than accumulation andremoval. The bedrooms, containing two or three bedsin each, are small but unencumbered by furniture ofany kind, with windows which are kept open by a patentlock, being shut only for half an hour before bedtimeand in the rare event of a storm driving straight into theroom. The patients are unable to close them but they canbe closed if necessary. Two or three patients were keepingtheir beds by order and one was allowed to receive a visitor. IIn such cases it is obvious that windowless windows are adrawback. All washings take place in the lavatory attachedto each bedroom, kept with scrupulous care, or in thedouche room in the basement. The douche is a wave,not a spray, and begins at a temperature of 30° C.,.declining to 12°.

On the ground floor of one wing, passing on account of theslope of the hill into the basement of the central block, arethe kitchens, linen store, douche, bottle-washing, dispensary,and medical rooms. The bottle-washing room is of especialinterest. Every patient has his numbered pigeon-hole and a

couple of pocket spittoons, "crachoirs de poche," flat two-ounce bottles of blue glass with a rubber-lined metal capwhich screws on to the neck. One of these the patientkeeps always in his pocket, so that no spittoons are seenanywhere about the premises and there is no need forinfecting handkerchiefs with tuberculous sputum. Whenthe bottle is nearly full the patient takes it to the bottle-

washing room which opens directly both to the outsideand to the passage, and exchanges it for the cleanbottle. The bottles are cleaned by an assistant. The

sputum is mixed with dry sawdust and burnt. A speciallydevised, jacketed metal sink receives the bottles, steam isturned on, and the whole is kept boiling, caps, rubber

lining and all, for thirty minutes. They are then stood on awooden stack to dry and when dry are returned to the pigeon-holes. All rags, papers, and soiled materials are thrown intocovered metal bins also to be burnt. The medical roomsare of considerable interest. The most important medicalinstrument of all-the scales-takes a prominent place ; andby its side are various strange versions of Laennec’s originalstethoscope. There are a complete skiagraphic installationwith a good developing room which is little used, althoughthere are already a few good skiagrams of caseous lungs tobe seen ; a high-frequency equipment; apparatus for testingthe lung capacity, shape of the chet, and variationsof the pulse ; and all requisites for bacteriologicalwork, section cutting, and examination of the blood.Some of this outfit, all of the first quality and care-

fully selected, may at first appear superfluous. Butthe three medical officers-Dr. Guinard, Dr. Bertelon,and Dr. Dieuzaide-are experts and enter into thedetails of their special subject with all the single-minded- enthusiasm which distinguishes Frenchmen and Germansfrom ourselves who, as a rule, prefer general knowledge tospecial. Far from time hanging heavy on their hands itwas evident that they take little leisure from their work and6eldom go into Paris. All three of them study every singlecase and study with them is no light task. Besides theusual methods of examination the most detailed microscopicand bacteriological investigation of sputum, blood, and urineis carried out. This is repeated for each patient once in everythree weeks and six or seven complete "analytic essays

"

have therefore to be made out every day. The mass ofdetail thus collected is made easily available by being- entered on a comprehensive sheet of printed questions inwhich all useful information is properly classified and

arranged. Thus the space headed "Personal Antecedents"includes the following sub-headings : growth, habitualhealth, military service, style of life (genre. d’existence),antihygienic work, privations, overwork, excess, alco-holism, tobacco, promiscuity, and particular circumstances,

besides the more usual details. In examination of the

sputum other bacteria besides the bacillus tuberculosis,elastic fibres, and cellular elements are expressly described ;in that of the urine cryoscopy and the diazo reaction ;and in that of the blood the agglutinating power.As to therapeutics, little is done beyond giving the most

minute attention to general health. Drugs are given onlyfor symptomatic treatment. Local lesions are treated in theusual way. A surgical table and instruments in a glass casehave not yet been used but admirable electric laryngeal andnasal lamps and cauteries are in common use, worked from aswitchboard at the physician’s hand. Dry-cupping is infavour. One man on the day of my visit was sitting in achair with 20 glass cups of the usual size on his back.There are two outhouses. In one is the laundry, devised

with proper attention to the special requirements of infectedclothes, equipped with the most efficient washing churnsand centrifugal driers, propelled by water-power, and witha Geneste-Herscher disinfecting apparatus running througha wall between two adjacent rooms. In the other is a doublegas-engine which works the electric light and pumps up thewater. Drinking water is filtered in Pasteur-Chamberlandapparatus. The sewage is disposed of by being water-carriedinto hermetically sealed iron chambers in the basement,from which it is removed in carts. mixed with disinfectant,and, I think, buried at a distance. There is room here forimprovements which are being undertaken. The parkincludes a kitchen garden in which a few of the strongerpatients are occasionally encouraged to do some light work.There is at present no satisfactory means of transportbetween the sanatorium and the nearest railway station.

In all, this establishment at Bligny would seem to leavelittle, if anything, to be desired and its scope of usefulnessis soon to be doubled by the erection in the grounds of asimilar sanatorium for 120 women. But it is difficult to

keep many patients in the institution for much over the threemonths to which they are held hostage by the amount of theirwashing bill and even in the first year’s working there havealready been several relapses after discharge and not a fewintractable cases even in the very favourable group selectedfor the treatment. It is more useful as a school for con-

sumptives than as a hospital. Would it not be still more

useful, as Dr. Newsholme and others have long insisted, iflooked on only as a school, giving at the same time a goodopportunity for accurate diagnosis, dismissing all idea of

hospital functions, and limiting tl-e term of education to afortnight ’?

MEDICINE AND THE LAW.

The Law Relating to Jledicol Practitioners in America.SEEING that the laws now in force in the United States

are to a large extent founded upon English jurisprudence itis not unprofitable to consider the reports of cases heard inthe American courts. The decisions of American judgesare not, of course, in any sense binding upon an Englishcourt of law, but in so far as the judgment of an Americancourt is based upon principle it is at least entitled to respectif cited to an English judge. It should be remembered,however, that in some states of the Union Acts have beenpassed which have no parallel in this country-as, forinstance, the Act which is in force in some States (e.g.,New York) which prevents a medical man disclosing thesecrets of the consulting room even in the witness-box.In the recently published "General Digest of AmericanCases " there are some decisions of interest to medicalpractitioners in England. It is proposed to give an

account of some of these decisions in the somewhatpeculiar language which appears to be used by theAmerican law reporters. Actions for malpractice appear tobe of frequent occurrence in America, if it is fair to judgefrom their constant appearance in the law reports. The

question constantly atises as to what degree of negligencewill render the practitioner liable to an action for damages.A physician who is merely a general practitioner cannot beheld liable in damages to a patient for diagnosing andtreating a disease of the eye as conjunctivitis when it wasin fact glaucoma, when the evidence showed that glaucomais a very rare disease, that it is incurable in character, thatits certain diagnosis could be made only by a skilled expertof special training and experience and that it should betreated with remedies and appliances which are never ex-pected to be within reach of the general practitioner of

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medicine, that its prominent symptoms were so nearlyidentical with those of conjunctivitis that the diagnosismade by the defendant was one reasonably to be expectedfrom a general practitioner, and that the treatment givenwas not found faulty by any general practitioner or expertwho testified in the case (Wohlert v. Seibert, 23 Pa. Super.Ct. 213). If a charge of negligence is preferred it is clearthat the plaintiff must be in a position to substantiate thecharge. Thus the burden of proof on the plaintiff is toshow that the defendant did not exercise reasonable care,skill, and diligence. In the case of De Long v. Delaney,which was heard in Pennsylvania, an action was broughtagainst a physician for failing to use a tourniquet after anaccident. There was no evidence from any witness com-petent to express an opinion that a tourniquet should havebeen used or that the tight bandage which had, in fact, beenused by the defendant was not fully as good. It was heldthat in the circumstances the judge was right to withdrawthe case from the jury. In the case of English v. Free

(55 A. 777) it was decided that in an action for mal-practice against a surgeon evidence that he made an

error in diagnosis is insufficient. Some interestingAmerican cases are also recorded in which questionshave arisen with regard to fees. Where no fee has been

arranged beforehand it is for the jury to say what re-

muneration shall be paid to the physician for his servicesand it is often a matter of difficulty to state the criterionaccording to which the jury must decide the question.In the case of McKnight v. Detroit (97 N.W. 772) an actionwas brought by a physician of high standing for " compen-sation"-i.e., for fees. The judge told the jury that theyshould consider the skill and experience of the physicianand the character of the services and limit the plaintiff’sclaim to such sum as would compensate the plaintiff forthose services. He would not say that if the defendant wasliable at all it was only in a fair and reasonable amount. Healso refused to tell the jury that the plaintiff had no right tofix an arbitrary fee and that no number of physicians couldagree on a fee to be charged and that it did not make

any difference how many patients the plaintiff attended.These matters were to be taken into consideration. It washeld in a superior court that this charge was correct.

Disputes sometimes arise as to how much is agreed upon tobe paid for an operation. In the case of Abram Bros. v.

Krakower (84 N.Y.S. 529) the plaintiff testified that it was

agreed that he should perform an operation for thedefendant. Another surgeon was to be present and to

receive$500, while the plaintiff was to receive$250.The other surgeon was called as a witness and provedthat he attended and received a cheque four 500. The

patient (who defended the suit) alleged that the contractwas that the plaintiff was the only person to be paidand that he was to receive$750 if a certain operationproved necessary and only$250 if merely the operationactually performed proved necessary. He also allegedthat the cheque for$500 had been made payable to theother surgeon at the plaintiff’s request, his reason being thathe would have the other surgeon at the operation. Upon thesefacts the court gave judgment for the plaintiff, holding thatthe defendant’s story was improbable. It sometimes happensthat a husband resists a claim for services rendered to hiswife. In McCoy 1’. Fletcher (85 N.Y.S. 1022) a surgeonbrought an action against a husband to recover fees for anoperation performed on the wife. It was proved that theoperation was performed with the husband’s knowledge.The jury, nevertheless, found for the husband. On appeal,judgment was entered for the plaintiff on the groundthat the verdict was against the weight of evidence.It is now a matter of common knowledge that in manyStates of the Union Acts have been passed which prohibit aphysician from disclosing professional information acquiredfrom a patient. Divers questions have arisen as to the effectof this rule. In one case (Crago v. City of Cedar Eapids,98 N.W. 354) it was decided that the expert testimonyof a physician, based upon hypothetical questions, as to thecause of an injury to a person whom he had attendedas a patient cannot be rejected under Section 4608 ofthe Code of Iowa, which provides that no physician shall beallowed in giving testimony to disclose any confidential com-munication properly made to him in his professional capacity.Again, the testimony of a physician limited to the identificationof the plaintiff, to the fact that he had treated her, togetherwith the place and length of time of such treatment, did notdisclose, or have any tendency to disclose, any communica-tion which she inade to the physician. He was therefore not

r prohibited from giving such evidence (Deutschmann v. Third3 Ave. Ry. Co., 84 N.Y.S. 887). Nevertheless, in an action on.i a policy issued by a benefit society which was defended oni the ground of false statements in the application, theb testimony of a physician as to the physical condition of the-. deceased when he was treated by the witness was excluded ;. but the exclusion only extended to the time of treatmenta (Dubcich v. G. L., 74 P. 832).’ The Dnties of the PolioB.’ At a recent inquest at Hackney it was shown that the

deceased, a plasterer, after a drinking bout had suffered fromj delirium tremens and in this condition had attacked his wifel and children first with a saw and afterwards with a chopper..

After a violent and prolonged struggle he had appeared to-: fall asleep and was left by his terrified family on the’ bed where he was afterwards found to be dead. The-

medical evidence was to the effect that death was-.

due to heart failure following upon an attack of, delirium tremens and upon the struggle which had taken;

place. Fortunately, no other death than that of the manhimself was the result of the incident, a fact which was.

in no way due to any assistance received by his unfortunatewife and offspring from the police. They had sent a

neighbour for assistance and two constables had actuallyarrived but had refused to enter the house. As many areaware the police, while not backward in maintaining law andorder in the streets, are extremely diffident in asserting them--selves when their aid is required within doors. An inquirywas asked for by the coroner’s jury as to the conduct of thepolicemen in the case referred to above and it is to be hopedthat the Chief Commissioner has had his attention calledto the matter. Every Englishman likes to regard his houseas his castle but he does not push this to the point of pre-ferring to be murdered or wounded in it to enduring the"intrusion of the civil authority. He regards the police asexisting for the prevention, as well as for the punishment, ofcrime, and will be likely to excuse what may technically bean act of trespass if it is honestly undertaken in the beliefthat a dangerous act is being committed and can be stopped.

Looking Back.FROM

THE LANCET, SATURDAY, Jan. 13, 1827.

Medical Police, and Secret Remedies.M. DOUBLE read before the Royal Academy of Medicine

of Paris, the first part of a work which he had undertaken.in order to prove,-lst. That for several centuries, by thevigilance of the administration, in concert with the most.

distinguished medical men, the strongest efforts have beenmade to rid society of the pestilence constantly springing:’from secret remedies. 2. That the most favourable circum--stances are at present combined to free them from the tribute-of money and life, which, on no consideration, ought longerto be tolerated.* *

In France, the first decree relative to this object was.

issued by Philip IV., called the Bel, in 1311 ; it prohibitedthe exercise of the healing art to all those who had not beenrecognised by sworn masters (maitres jures) capable of

practising the art. Louis XIV., especially by his decl>aratio&bgr;<’of 1696 and 1702, and the decree of 1767, manifested asincere wish to repress the abuses which had introducedthemselves into the exercise of medicine. He prohibited to.every person, not provided with a valid title, the practiceof medicine as well as the sale or gratuitous distribution ofmedicaments, and included in this prohibition the religious-orders. Louis XV. formed, in 1772, a special commission forthe purpose of examining and deciding on secret remedies,inspecting the mineral waters, and pronouncing on epidemics.The unfortunate Louis XVI. erected for the same purpose.the Royal Society of Medicine. Louis XVIII. gave thesame powers.The decree of the 10th of August, 1810 may be considered!

as the resume of preceding legislation on the subject, and!it positively establishes, that secret re7ned-ies ought no longep,and could no longer, be tolerated.* M. Double’s observations cannot apply to England, for quark

medicines and quacks abound, and will continue to abound, as-long asour government encourages the sale of the one and the constitutedmedical authorities possess no power to prevent the existence of theother.-ED. L.