203

THE LANCET.

LONDON: SATURDAY, FEBRUARY 7, 1874.

THE NEW PARLIAMENT AND THE PROFESSION.-PYÆMIA.

MR. GLADSTONE’S appeal to the country has not, so faras the elections have yet gone, been justified by the result.At the moment of our going to press the leader of theOpposition is in the majority, which may possibly prove a

working one. In that case there is no doubt that he will

form a Government; and it will mainly depend on themeasures he brings in whether his place on the right handof the Speaker will be of long or of brief duration. Liberal

as THE LANCET has always been in politics; identified asit has been from the outset with the party of reform,-itwould be affectation to avow any particular regret at the

change of Government. Mr. GLADSTONE and his colleaguesdeserve but little at the hands of the profession. Whilst

making domestic policy their chief concern, to the ex-

clusion of foreign, they have neglected the main conditionson which the well-being of the British people depends.Salus populi suprema lex has practically had no meaning forthem. Nay, more; positive neglect does not exhaust thesum of their delinquencies. They have been actively hos-tile to the great question of sanitary reform and to its pro-moters. In the person of Mr. STANSFELD the Government

has deliberately pursued the policy of utilising medicalmen while ignoring their scientific opinions. It has in-

sulted them by subordinating them to officials who are

ignorant of the very alphabet of hygienic science. The

Local Government Board has ostentatiously rejected theadvice unanimously tendered by the representatives of the ’,

profession. It has heaped studied indignities on its medicalofficials. In every possible way it has paraded its intentionto administer the sanitary affairs of the whole country on

precisely the same preposterous principles which inspiredthe old Poor-law Board’s administration of the workhouses

and their infirmaries. The profession, indeed, would havebeen wanting in self-respect or in care for the public wealif it had allowed such conduct to pass without an emphaticand effective protest when the opportunity for making itarrived. Mr. GLADSTONE’S pronunciamiento has furnishedthat opportunity; and we doubt not that it is in some

measure owing to the concerted action which we called

upon the profession to put forth that Mr. GLADSTONE hashad to give way to his political antagonist.But let us not be too sanguine that a Conservative

Government will acquit itself much better of its duties tothe public and the profession. Mr. DISRAELI, indeed, an-nounced it as a shibboleth of his policy that the sanitarywelfare of the people and the interests of its custodiers

should have his chief care. Sanitas sanitatum omnia sanitas

has been as familiar in Conservative mouths as household

words; and Lord DERBY himself, in speeches and addressesinnumerable, has illustrated and enforced the adage. But,for all that, we saw with some dismay the entire negationof sanitary and medical reform in the Conservative pro-

gramme. Not a word has Mr. DISRAELI or any of his fol-

lowers yet said on the subject. On the contrary, they havecondemned the conduct of the Government not so much in

domestic as in foreign affairs. The Straits of Malacca have

figured more largely in their addresses and speeches thanany home question. Nor is this all. They owe much oftheir electioneering success to publican interest-an interestdiametrically opposed to the sanitary welfare of the people.Hygiene will make little progress if the gin-palace and theshebeen are allowed to remain in unchecked activity, asthe main source of destitution, pauperism, and crime. The

alliance of the publicans with the Conservative party augursill for the repression of drunkenness, proving as it must alet and hindrance to the reformer of the people’s habits andthe promoter of their sanitary welfare. The frigid supportwhich the late Mr. DALRYMPLE received from the Govern-

ment is not likely to be replaced by any heartier counte-nance from the Opposition. But let us not prejudge thepolicy of the Conservatives too severely. If they have notrepeated their promises of sanitary reform, they have notrevoked them. In one direction we see an element in their

policy the absence of which in the Liberal programme was

perhaps the main cause of the neglect of sanitary reform.The care of the public health and the efficient working ofits machinery mean expenditure, and expenditure is pre-

cisely the point which the Government takes most creditfor retrenching. To enable Mr. GLADSTONE to dangle awell-filled money-bag before the electors every domestic

interest has more or less suffered ; above all, the movementfor sanitary reform was practically reduced to a standstill bythe withholding of funds. Mr. DISRAELI and his party donot stand committed to penny-wise policy, and we trustthat, in whatever direction the burdens of the taxpayer are

lightened, the consideration of his health and the health ofthe community will not be postponed to the economisingspirit. Mr. DISRAELI has a splendid opportunity of asso-ciating himself and his party with a great and gloriousreform. In supporters like Lord DERBY in the Upper House -

and Sir C. ADDERLEY in the Lower he has auxiliaries alreadyapproved by the public and the profession as enlightenedguardians of the national health. Let him but be true to

his sanitary programme, and we promise him not only theapprobation if not the backing of nearly every medical manthroughout the country, but the goodwill, if not the poli-tical adhesion, of every enlightened member of the com-

munity.

WE can only hope to disentangle the various and con-

flicting statements regarding pyaemia by subjecting themto rigid scrutiny. Clinically, whether the patient dies inprivate or hospital practice-whether his disease has beenautogenetic, induced by foul conditions of atmosphere, or

by contagion, the symptoms and morbid appearances are

very much the same. The important pathological positionassigned by VIRCHOW to thrombosis and embolism explainsthe mechanism of the morbid processes set up, and the

occurrence of metastatic abscesses; in other words, whatwas denominated phlebitis and its consequences may arisein any case, and after the most trivial injuries. A largeproportion of these cases can scarcely be ascribed to con-

204 PYÆMIA.

tagion. But we are not satisfied that cases such as these they are placed approximates to that of the purity of open airought to be regarded as identical in causation with those the better. Sir JAMES SIMPSON advanced much of what the

described by Mr. ERICHSEN. Gangrene, erysipelas, and Pall Matl Gazette would term " soft stuff "about hospitalism,pyaemia are diseases incidental, but not by any means ex- but the principle he laid down of dispersion of the sick has

clusively attributable, to hospital conditions. They occa- not been invalidated as regards this class of cases. As

sionally arise, and perhaps more frequently than has been you increase the aggregation you augment the unfavourable

supposed, in private practice; and their occurrence is conditions : every patient adds his share of pollution to the

notably influenced by the nature of the injury, consti- atmosphere; and it stands to reason that the risk of propa-tutional conditions, and other causes unconnected with gating diseases liable to contaminate or spread is increaseddefective hygiene. Still, the fact remains that pyæmia is in proportion to the number and proximity of susceptibleliable to originate and spread under certain conditions- subjects. The chemical analyses of the air of even the bestsuch as the overcrowding of a surgical ward with sup- of our large hospital buildings show how very difficult it ispurating wounds. Even if we assume that pyæmia cannot to maintain a state of purity equal to that of the externalbe generated de novo under such circumstances, there can- atmosphere, to say nothing of the organic and other matters

not be a doubt that, when:once engendered, it will be pro- discoverable in the air of a ward by microscopical examina-pagated among those susceptible of, and exposed to, its tion. The tenacity with which odours diffused into a wardinfluence just in proportion to the facilities offered for its will adhere to the walls and furniture is well known. These

so doing. To lessen or to obviate this convection of the and the soil itself of a hospital become contaminated inpoison of pyæmia is the problem, as Dr. ROBERT BARNES process of time, as a result of its occupation. The principlevery properly urges, to be solved both in hospital and of spreading out surgical cases by distributing them in aprivate practice. If pyaamia falls within the category of number of small detached wards seems to us, then, a sound

specific blood diseases, and depends upon the action of an one; and not the least so in this-that some of the wards

animal poison which can be generated by, as well as repro- will admit of being periodically emptied and thoroughlyduced in, the body, like erysipelas or puerperal fever-to cleansed, and if they are constructed of simple and in-

which pyæmia seems to have the strongest points of expensive material, as they should be, they might even beaffinity,-we have an obvious way of accounting for its destroyed and the site changed. The avoidance of a pysemia-propagation. This is an aspect of the question which has infected hospital was pointed out as a necessary precautionnot been lost sight of by us. We have for some time been in the case of the American war; and we think it is open to

instituting inquiries in various directions to obtain evidence question whether a surgeon who has had the misfortune toof an indubitable character of the contagious properties of meet with two or three cases of pysemia in his wards had notpyaemia, but without success. We shall, however, take an better temporarily close his wards and cease his hospitalprac-early opportunity of adverting to this and other points. The tice. We consider that there should be no waterclosets, drains,questions we now propose to discuss, as succinctly as pos- sinks, or urinals connected with these wards, but that these

sible, are : the principle of hospital construction best suited should be separate and detached, and that all excreta shouldfor surgical cases; the most practical methods of improving be received into proper vessels containing disinfectants andexisting institutions; and the personal (bedside) hygiene at once removed. During the summer months we see noand surgical management of the sick. reason why surgical cases should not be treated, whereverWherever there are great centres of population, hospitals circumstances admitted of its being done, in small hospital

must of necessity be provided; but much of the expense marquees, without being placed within the hospital build-attending many of our modern structures might have been ing. Of course there will still remain all the matters ofsaved if a greater amount of attention had been given to nursing, cleanliness, and administration, which would bethe different requirements of various classes of cases. It is requisite under other circumstances.a waste of money and space to provide the same, or any- It will be at once urged that the foregoing procedurething like the same, amount of cubic and superficial space would be simply impossible as regards many of our existingand ventilation for ordinary medical as for surgical cases; hospitals, and it remains to indicate the direction in whichand, further, we hold that, as regards the latter, it would these might be improved. Some of our metropolitan hos-be preferable to make an entirely separate provision, pitals are no doubt of such a construction as to preventwherever practicable, for operation cases and suppurating much being done, but it would surely be practicable to im-wounds. Speaking generally, medical cases, other than in- prove the ventilation of most of them. The principles wefectious fevers, ordinarily admitted into public hospitals, hold to be correct are-to cut off every ward from all but itsare not of such a character as to require or be benefited by own sources of impurity, to ventilate by natural means toa large amount of air and ventilation. They are drawn the utmost, and to supplement the natural by an artificialfrom the poorer classes, have been badly clothed, underfed, system in such a way that there should be two sources ofand are very intolerant of the effects of cold. It is during ventilation, one within and the other beyond control. Theconvalescence that they stand in need of fresh air ; and first should be only limited by the maximum amount ofthey should then be no longer inmates of the wards of a ventilation obtainable ; the last should be the minimumcity hospital, but be drafted away to some sanatorium in amount of ventilation considered necessary. Surgical wards,connexion with the parent institution. at any rate, should not participate in the common air of aFor the requirements of surgical cases, however, with hospital by communicating with narrow passages and closed

open wounds, we hold that the nearer the condition in which corridors, probably containing waterclosets. The corridors

205HOSPITAL NURSING.

might be ventilated at the ends by windows, large skylights, tive merits can be fairly canvassed and criticised. We mayor shafts; the openings from them into the surgical wards remind those interested in the question that this importantclosed, and an entrance effected from without by an open subject has been many times alluded to in these columns,balcony and stairs. Parian cement cracks, and white paint, and specially in the articles on "Night Nursing" by ourwell varnished, is on the whole, perhaps, the cheapest and Sanitary Commissioner some time ago.most effective application for the walls of wards, In canvassing carefully and deliberately the experiencesSo far for one, and an important element-the build- of those best calculated to form a correct judgment upon

ings; and now for the details connected with the in- this question-viz., medical men of all ranks connected

ternal administration, the nursing and dressing of wounds. with hospital work,-it is astonishing to find how greatWe regard these details as of such importance that we a diversity of opinion exists among them as to the absoluteverily believe the worst constructed hospital, were they and relative merits of the systems that we have indicated.

thoroughly and efficiently attended to, would afford re- There are hospital physicians and surgeons of very highsults superior to those of the best hospital where they standing who laud the " sisterhood " system to the skies,were entirely neglected. Hospital statistics are misleading and there are others who as emphatically object to it.

when they do not extend over long periods of time, because Education, refinement, and, as a natural result, skill and

an outbreak of disease will occasionally occur after years of gentleness in their work, and a certain amount of enthu-

immunity, where the conditions have been the same. But siasm produced probably by religious sentiment, are all onwe would counsel our readers to turn to Mr. CALLENDER’S the side of the lady superintendent and her satellites; but, onexcellent and highly practical paper in the " St. Bartholo- the other hand, there appears sometimes to be a dispositionmew’s Hospital Reports" (vol. ix.), to see what can be on the part of the nurse, or sister, or superintendent, to advise

effected in this direction. We are convinced that more and even prescribe, and so almost to ignore the existence ofattention might be given to matters of personal hygiene- the house-physician, house-surgeon, and other professionalin preserving the utmost cleanliness, in the regular and juniors. It appears to us just now that the case is as to the

systematic removal of all excreta, and in the isolation, success or non-success of the sisterhood system. The

dressing, and antiseptic treatment of wounds. There is columns of several daily journals have, even during this busyone suggestion we would make, and it is this: irrigation election week, been occupied by letters and communicationsis insufficiently made use of, considering how simple and respecting the nursing staff of King’s College Hospital,effective it might become. If a certain number of our and we may assume from this correspondence that the

hospital hair-mattresses were made in separate pieces of Council of that institution will, at their next meeting, settlethe same size, it would be very easy, by withdrawing definitely this important question. As the authorities at

one of the pieces from beneath an injured portion of King’s were, we believe, the initiators of the sisterhoodthe body- especially if it happened to be the lower nursing system at our London hospitals, it is probable that,,extremity,-to adjust a cradle, with a vessel containing whatever the verdict be in this case, those hospitals thatsome disinfectant, and, with a piece of india-rubber sheet- are "nursed" under the same’ plan, will be disposed to

ing, to subject a wound to continuous irrigation, without follow suit. Hence the issue to be determined is eminentlydetriment to the bed or discomfort to the patient. consequential. We do not care to enlarge or to comment. on the causes that have led to this very warm debate at

THE public, as well as the profession, are now thoroughly the hospital in question, but venture to indicate briefly thealive to the fact that skilled nursing is the most important chief cardinal regulations necessary for the maintenance

section of hospital administration; that without such aid (as apart from the acquisition) of good nursing in all hos-all medical and surgical skill is in many instances of little pitals. The senior medical officers should, directly or

or no avail; and that hence no pains should be spared to indirectly, have entire control over the nursing staff, so

obtain and retain the best possible nursing staff in all our that if any want of skill, neglect, or any other derelictioninstitutions. It is probably well known to the majority of of duty occur, affecting perhaps the resident medical

our readers that three systems of nursing are now in vogue officers as well as the nurses, the merits of the matter may

at one or other of the metropolitan hospitals: (1) The old be decided by those who must, as a matter of necessity,system, modified and improved, in which a sister has entire know most of the subject, and have on all grounds the

charge of a ward, with a certain number of nurses under strongest possible interest in bringing the question to

her, and is responsible only to the chief lay authority, as at an impartial issue. To forward the end above indi-

St. Bartholomew’s. (2) The mixed system, in which pro- cated, it is of course necessary that the medical element

bationers and others are introduced, and the staff is in some should be properly and adequately represented on theinstances supervised by a lady superintendent-as at Guy’s. Committee of Management. The authorities at many

(3) The sisterhood system, in which the charge of the nursing hospitals have already seen the wisdom of putting this

throughout the entire building is under the control of the principle into practice, and indeed, as we remarked somelady superior of a nursing sisterhood, who is responsible to time ago, unless senior medical officers are consulted, andthe Managing Committee that a sufficiency, both in quan- consulted constantly, committees will never get beyond atity and quality, of nurses shall be provided for the hos- 11 fringe " of information as to the internal administrationpital inmates-as at King’s College. Each and all of these of their hospital. No individuals, not even the patientssystems have been in action for some eight or ten years at themselves, can be more alive to the importance of goodleast; and the time has now arrived when their compara- nursing than the members of the professional staff, whose

206 ABSORPTION BY THE LARGE INTESTINE.

reputation (quite apart from all charitable considerations) at about 240 square centimetres, showed that in the

depends so much upon the attention paid to the patients by course of seven hours the quantity of water that could

nurses as well as by hospital juniors. We shall recur to be taken up was from 617 to 772 grains. They showed alsothis subject again shortly, present our readers at the that although the intestinal juices exerted no digestivesame time with a list of those hospitals the committees of action on albumen, and no emulsifying action on fat, yetwhich include a medical element, and likewise indicate to that the walls of the intestine were capable of absorbingsuch of our readers who have no opportunity of judging both albumen when introduced in the soluble form, and oil

for themselves to what extent, as a result, the nursing staff if it had been previously emulsified. The quantity of

in each instance has changed for better or for worse. soluble albumen absorbed was always proportionate to the- time. Any irritation applied to the intestine checked the

AN interesting case of hernia that has lately occurred in process of absorption, and, if violent, stopped it altogether.Germany has enabled CZERNY and LATSCHENBERGER (ViR- Raw white of egg was found to be an unfavourable form for

CHOw’s Archiv, Band lix., Heft ii.) to make some important absorption. The best mode of preserving life by means ofphysiological experiments in regard to the process of absorp- injection is often an important subject of consideration,tion in the large intestine. The patient was a man nearly especially in cases of cancer of the intestine; and these ex-fifty years of age, who for five years had suffered from an periments accord with the observations and recommenda.irreducible scrotal hernia. Inflammation supervening, the tions of LEUBE, that whilst comparatively little benefit cansac was opened, and a loop of large intestine nine inches in be obtained from the injection of the raw material of ourlength presented itself, parts of which were gangrenous, and ordinary diet, considerable quantities can be absorbed, andwhich could not therefore be returned. Erysipelas followed, much improvement can be produced in the strength andwith great loss of the integument; but ultimately a good health of the patient, if the substances have been pre-

recovery was made, though with the persistence of three viously subjected to operations by which they are partiallyfistulous openings. The portion of intestine extending from digested-as, for instance, if fat be emulsified, if albumenthe lowest fistulous opening to the anus, which was about a be reduced to the soluble state, and if starch have beenfoot in length, was the part subjected to experiment. It was converted into glycose.computed to have an internal surface equivalent to 240 square centimetres. It was absolutely insensible to tactile impres- WE desire to register the hope that, when the memberssions, and the prick of a needle caused no visible contraction. of the Epidemiological Society meet on Wednesday, theIt did not respond to induction currents, but lively con- llth instant, for the purpose of discussing the utility oftractions were excited with the constant current obtained quarantine regulations in relation to cholera, the questionfrom two STÖHRER’S elements, the contraction lasting as may be as thoroughly ’sifted as possible; for, indeed,

long as the current passed. With six elements violent con- there are few other subjects of greater practical import-traction was produced, and the patient complained of colic. ance, and none upon which medical opinion appears to be

Antiperistaltic movements were not clearly observed. The so unsettled. As Dr. JOHN MURRAY remarked in a valu-

mucous membrane was bright-red, and a clear, tenacious, able paper read before the Society on the 14th ult., quaran-and highly alkaline mucus could be obtained from it in tine has a political and a commercial as well as a sanitarydrops without much difficulty. The fluid contained a few aspect. Granted, for the nonce, that a rigid quarantine-protoplasmic corpuscles and, on slight irritation being ap- would keep away the epidemic from this kingdom, the com-plied to the membrane, epithelial cells. The faeces were mercial element is still sufficiently strong to override ques-always intensely acid. tions of health. The political aspect tends to favour theIn the experiments upon digestion, comparative trials sanitary view of the question. For when cholera is known

were made between the materials introduced into the large to exist in Europe, unless some sort of quarantine regu-intestine, and the same acted upon outside of the body with lations are prescribed and carried out by our own Govern-the secretion obtained from the mucous membrane. Por- ment, we run the risk, commercially speaking, of havingtions of hard-boiled white of egg and shreds of fibrine re- our vessels quarantined at all foreign ports (whether themained unchanged, preserving the sharpness of their angles disease has reached us or not), and our foreign trade thusand borders, when exposed to the action of the mucus at a considerably crippled. It remains, therefore, to be con-

temperature of 100° for two or three hours. No emulsion sidered what are the best practical arrangements that cancould be obtained by shaking up olive oil and the mucus; be made under the circumstances, so as to afford any sort ofand no conversion of starch into sugar could be thus pro- reliable security against the importation of the disease.duced, even after the lapse of several hours. Similar cubes An attempt was made in the autumn of last year-feeblyof hard-boiled white of egg were retained in the rectum in at some ports, and energetically at others-to institute asmall perforated capsules for no less a period than ten medical inspection of all vessels arriving from ports in-weeks, and yet on withdrawal exhibited no indication of any fected with, or suspected of, cholera. The Customs and the

digestive action. Experiments made with soluble albumen Port or Riparian Sanitary Authorities were, by the terms ofin like manner showed that the large intestine of man exerts an Order in Council issued in July last, instructed to workno digestive action upon it. together, the aid of the former being, in the first instance,Other experiments, made with a view of determining undoubtedly indispensable to the success of any action

the absorptive capacity of the portion of intestine under taken by the latter. We are enabled to state that, in someobservation, and which, as before stated, was estimated few small outports, the system worked well. All vessels

207CHOLERA, QUARANTINE, AND PORT SANITARY AUTHORITIES.

from suspected ports, whether there were sick persons onboard or not, were inspected by the health officer of thesanitary authority, on information given by the chief officerof Customs. At the ports to which we refer, however, thenumber of such arrivals is, under any circumstances, ex-

ceedingly small, and the geography of the ports such thatsanitary surveillance of this sort is, comparatively speaking,not at all hurtful to commercial interests. But in the largeports, and notably at Liverpool, this system was not at-tempted. Indeed, even if its utility had been recognised,the machinery did not, and does not, exist; and it is saidthat the maintenance of any systematic medical inspec-tion of vessels arriving at the mouth of the Mersey fromthese infected ports, without causing a ruinous obstruc-tion to commerce, would be all but impossible. The

same line of argument has been put forward as regardsthe port of London, although the lowest moorings or

docks commonly used by vessels arriving in the Thamesare nearly twenty miles up the river. We take leave

to demur to the impracticability of systematising at a

large port a scale of operations that is carried on success-fully at a small one; and submit that the whole business issimply a matter of multiplication and organisation, and ofcordial co-operation between the Customs and Port SanitaryAuthorities.

But a more serious and much more scientific questionmust first be decided; and this, as we take it, should

mainly occupy the time and energies of the members ofthe Epidemiological Society on Wednesday evening, unless,indeed, the uselessness of quarantine and of any measuresakin thereto be conceded or proved. What is the duration

of the incubation of cholera ? We know that there are

still those among us who acknowledge no first stage of pre-monitory diarrhoaa, but hold that the attack commences"fulminante," and collapses the patient at once. It is

hardly necessary to remind our readers that those ports inthe North of Europe into which cholera appears to find its

way most readily, and in which it appears to linger longest,are only from sixteen to forty hours’ steaming from the

metropolis, with most of which the metropolis has dailycommunication. We have indicated the drift which, in our

opinion, this discussion should take, and hope that all whohave matured views on, or practical experience of, the sub-ject will attend and take part in the debate.

Medical Annotations."Ne quid nimis:’

THE UNIVERSITY OF LONDON AND THECONJOINT SCHEME.

THE Senate of the University of London at a recent

meeting resolved-"That the Aet of 36 and 37 Vic., ch. 55, having now re-

moved the legal difficulties which prevented the Universityfrom co-operating with other medical authorities of

England in the formation of a Conjoint Examining Boardfor qualifications to be registered under the Medical Act,and the Senate having already expressed its desire so to co-operate, it be now provided by regulation,-That from andafter the institution of the examination of the ConjointExamining Board, no person shall become a Doctor or

Bachelor of Medicine or Master in Surgery in this Univer-sity, unless (in addition to passing such examination, ifany, and complying with such other conditions, if any, asmay be prescribed by any bye-laws in force for the timebeing made in pursuance of any charter of the University)he shall have passed such examination for qualification tobe registered under the Medical Act, and complied withsuch conditions relating thereto, as may be agreed upon be-tween this University and the college or body, colleges orbodies, with whom the University may be united or co-operating as aforesaid; provided always that this regula-tion shall not apply to any person who shall have passed thePreliminary Scientific Examination of this University pre-viously to the institution of the examination of the ConjointBoard."

This further addition to the already many hard condi-tions of the gift of the degree of the University of Londonwill tell powerfully in favour of the Scotch universities.

THE SALARY OF THE MEDICAL OFFICER OFTHE LOCAL COVERNMENT BOARD.

A CORRESPONDENT, under the signature of 11 Diogenes,"has written to us much perturbed in mind as to the reportthat Mr. Simon still holds the office of medical referee tothe "Crown Assurance Company," and he is of opinionthat a State medical officer in receipt of .82000 per annumshould relinquish all other public appointments as well asprivate practice." When noticing "Lex’s" maliciousobservations on this subject, we had not deemed it neces-sary to make any special observations on the questionswhich disturb our correspondent. We had considered it as

sufficiently plain that if the State thought fit to accept orto seek Mr. Simon on these terms, there was nothing moreto be said to professional men about the matter. It cer-

tainly did not occur to us that anyone who knew what theprofessional incomes were of men of Mr. Simon’s status, ashospital surgeons, would hold that the salary he receiveswas at all out of proportion with the income he had foregone,or might, if he thought fit, still obtain. " Diogenes," how-ever, does so hold, and it is worth while at this time to satisfyhis doubts. Mr. Simon is still medical referee to the CrownAssurance Office, as he has been for many years; he is stillalso one of the surgeons to St. Thomas’s Hospital, as hehas been for many years. Both appointments are held aspart of his agreement with the State, and the State hasnever had a claim upon the portion of time involved infulfilling the duties required by these offices. He has no

private practice, nor has he practised privately since hewas appointed medical officer to the Privy Council. Theseare the facts. As to the sentiment, it is no doubt un-

advisable that a State medical officer should hold privateappointments, but in this case we have to deal with anappointment which has been made one of the conditions ofaccepting office, not with an appointment taken by the in-cumbent of his own motion after accepting office, and in-consistently with the spirit at least of its tenure. As to the

hospital appointment, so far from condemning this, wewould make some such appointment an essential conditionalmost of service of the senior State medical officials. At

any rate, a wise Government would facilitate any arrange-ments which, as in Mr. Simon’s case, without affectingofficial work, would enable its medical officials to keepabreast of the pathology of the day. If the State does notdo so, how are these men to maintain that advanced pro-fessional knowledge which is the special reason of theirelection ? As to the salaries of Mr. Simon and his staff, themarvel is that, with the incomes of practice at theircommand, men of the stuff who form it can consider themanything like an equivalent for what they give up. Norindeed would they, but that special proclivities of study andwork in some, a distaste for medical practice in others, and