263

THE LANCET.

LONDON: SATURDAY, AUGUST 14, 1880.

REGINA v. INGLE.

THE trial of PLEASANCE LOUISA INGLE, a nurse of Guy’sHospital, for the manslaughter of LOUISA MORGAN, a

patient under her care, is happily without precedent, andwe have the authority of Sir H. HAWKINS, the presidingjudge, for stating that a hospital nurse has never beforebeen tried on a charge of criminally neglecting a patient.Medical practitioners have often been compelled to undergoa trial for manslaughter, but in such cases any nurses whomay have been implicated have been considered merely asthe instruments of their chief’s treatment, and not them-selves responsible. This trial has taken place, not probablybecause the nurses of the present day are either more orless humane than their predecessors, but rather because onewho is the representative of a vicious" system" " (so-called)of nursing, has discovered too late that those who assumethe dignity of responsibility must be prepared for the con-sequences of their assumed position.The facts of the case are simple enough. The deceased,

LouiSA MORGAN, was admitted to Guy’s Hospital on

June 9th, 1880, under the care of Dr. PAVY, who con-

sidered her to be suffering from consumption, affectingchiefly the left lung, and hysteria. On or about June 25th

it was directed that she should be got up, in order

that she might not become weaker. On July 2nd shecomplained of pains in the left leg, and on July 5th she hadan evacuation cf the bowels in the bed. This was the vera

causa of the trial. INGLE, about 8.30 on the morning, ofJuly 5th, asked CROCKETT, the " sister " in charge of the

ward, if she might give MORGAN a cleansing bath, as shehad soiled the bed in the manner stated. Deceased was

made to walk to the bath-room in her night-gown and bootsabout 8.45, and at 10.15 she was still in the bath-room. It

was conclusively proved that for a great part of this timeshe was sitting in an almost empty bath, with water nearlycold (the hot water being only tepid at that hour of themorning) ’’nearly covering her hips." It was proved alsothat on her way back from the bath the deceased draggedone leg, and that the prisoner jumped " the deceased, andhandled her violently, saying, "It is obstinacy; you canwdk if you like." On July 5th Dr. PAVY saw the patientthree times. On the first occasion, between three and four,he was "struck by her altered appearance." She was

feeble, cold, and shivering, and made a disconnected state-ment as to the treatment she had received, and cried andsobbed a good deal. At the second examination, Dr. PAVYfound bruises on her body, on both arms, and abrasions onthe skin. At night her condition was unaltered. On Thurs-

day, July Stli, the symptoms of tubercular meningitis werefully established, and on July 22nd LOUISA MORGAN died.The questions for the jury to decide were two in

number. 1. Had the prisoner, by administering the bathin the manner described, been guilty of "gross and

culpable " misconduct ? :’ On this head they had presumably

no difficulty in coming to a conclusion in the affirmative, forwitnesses on both sides admitted that such a bath was un-

warrantable, and indeed it would have been unwarrantableto have administered such a bath in such a manner to a

healthy woman. And to a woman suffering from tuberculardisease, no matter of what organ, such a bath would be a

grave source of danger. 2. Had the bath hastened the

patient’s death ? " If," said Sir H. HAWKINS, "it was

accelerated by a single day, that in the eye of the law wouldbe manslaughter as much as if the death had been accele-

rated by years." Seeing that the only medical witness forthe defence (Sir WM. GULL) admitted that the giving of sucha bath to a patient with the symptoms presented by thedeceased would be "most improper," and that the onlypossible reason for this opinion would be the danger of aggra-vating the disease and accelerating its termination, the jurynaturally came to the conclusion, in the absence of any dif-ference of opinion between the medical witnesses as to themain point at issue, that the prisoner had been guilty ofmanslaughter. She was accordingly sentenced to three

months’ imprisonment without hard labour.The defence was singularly lame and impotent. It consisted

in an endeavour to show that the prisoner was warranted byDr. PAVY’S view of the case in doing what she did, and thatit would not have been grossly culpable to have treated anhysterical woman in the way described. Dr. PAVY’S dia-

gnosis was proved to. have been from the first one of

"phthisis," a diagnosis which the post-mortem proved to becorrect. Dr. PAVY said that the deceased had some " hys-terical symptoms, but there was no evidence that he

had ever regarded hysteria as anything more than quite asecondary element in the case, or that he had given theleast countenance or encouragement to any such brutal andobsolete treatment as that pursued by the prisoner. Sir

WILLIAM GULL’s evidence was clearly intended by Sir JOHNHOLKER to produce the impression that Dr. PAVY’S view ofthe case was not a correct one, or at least less correct than

that which would have been taken by Sir WILLIAM GULL,who figured before the jury as a prophet of past events, a -41e.which it is easy enough to play. But there was no evidence

whatever that Dr. PA VY’S view was ever anything but correct,for up to July 2nd there had been no symptoms of brain

mischief. On that day there was pain in one leg, a subjectivephenomenon to which no physician of large experience wouldpay any great amount of attention. Dr. PAVY did not see

the patient again until July 5th, and in the interval there hadoccurred the involuntary evacuation, the dragging of oneleg, and the bath, and from that time the character of thecase was clear. There can be no doubt that the brain mis-

chief had begun before the bath was given, but the elementsfor a diagnosis clearly did not exist before July 5th, onwhich day the criminal act of the nurse took place. The

post-mortem showed old and recent tubercular disease of the

brain ; to what extent the bath and its attendant excite-

ment had contributed to the establishment and aggravationof the latter was the point most difficult to determine, andone concerning which no wise man would, we think, be in-clined to speak dogmatically.

THE lamentable occurrence in Guy’s Hospital has servedto bring into light again certain clinical and pathological

264 REGINA v INGLE; PATHOLOGICAL ASPECTS.

problems, which are of grave importance, not merely with wise after the event, and to discern in these vague symptomsregard to the present case, but to many other like cases. the indications of a cerebral disease which was discovered

The case seems to us to afford another illustration of the after death, but we have no evidence that there was any-great difficulty which attends the recognition of the initial thing upon which to ground a diagnosis at the time. Indeed,symptoms of cerebral tuberculosis, and the need of further we may go further, and say that a very large number of

study of the causes which excite or accelerate the progress cases of chronic tuberculosis affecting the cerebral hemi

of the disease. Setting aside all the other points which spheres are not only not diagnosed, but that they may givemay be raised with regard to the case, and the various rise to no appreciable symptoms. And it is incredible that

opinions which have been expressed upon it, we shall in a hospital like Guy’s, which abounds with acute clinical

endeavour briefly to discuss it from a clinical and patho- observers, such symptoms should not have been detected or

logical point of view, and try to arrive at an inde- suspected had they existed in any marked degree. At the

pendent opinion as to its clinical history. This we can same time it must be allowed that there is often in the

unfortunately only do upon very incomplete data, for the general condition, the facial expression, and the mental atti-entire clinical and pathological record has not been pub- tude of the patient, a ground for suspicion and anxiety suchlished. It is due to the eminent physicians who have as appears to have been felt in this case, apart from anyexpressed different opinions upon the case, and to the pro- declared symptoms, and that the commencing mental inertiafession at large, that this record should be published in full and torpor, simulating wilful obstinacy, especially if com-

at as early a date as possible, in order that a correct judg- bined with pain in the limbs, hypereesthesia, or temporaryment on the points at issue may be arrived at. weakness of one limb, are always to be regarded with sus-The points which seem especially to require consideration picion.

are—(1) What was the condition of the patient previous to Coming now to the time of the bath. It appears that this

the giving of the bath on July 5th, and how far was her was given in consequence of the patient having fouled the bed.condition calculated to excite any suspicion of cerebral It is almost clear from the way in which this was treated byaffection ? (2) Did the giving of the bath produce or merely the nurse, that it was regarded as merely an exaggeration ofcoincide with the onset of graver cerebral symptoms ? a wilful, obstinate, and careless condition which had previ-(3) Is there any reasonable ground for a belief that it excited ously existed, and which she regarded as deserving of

or intensified the more acute cerebral inflammation which punishment. It is strange indeed that no one of the nursescaused the patient’s death ? or the sister of the ward should have seen in this a graveThe main facts of the case are already before our readers, symptom of cerebral disease. Apart from involuntary

and we will restate only such as may require to be emphasised. defecation in some cases of diarrhoea in phthisis, or someThe patient, LOUISA MORGAN, a married woman twenty- local disease of the rectum, we are not aware that this

six years of age, was admitted, on June 9th, to Guy’s Hos- would be likely to occur in such a patient except as thepital, under Dr. PAVY, with consumption associated with result of cerebral or mental disease. If there were evidence

hysterical symptoms. From the history it appeared that she that such an occurrence had previously been reported, or

was married at an early age, had one child about a year having occurred, had failed to be reported, a grave oversightafterwards, had since suffered from symptoms of pelvic in- on the part of the sister or the house-physician must beflammation, though whether of the nature of pelvic cellu- assumed; but there is no hint that such was the case. We

litis, ovarian abscess, or what not, we are not told. The may rather regard it as the crucial point of the diagnosis,lung disease did not appear to be advanced or active, which would declare plainly that the vague symptomsbut there were considerable weakness and irregular slight previously observed were really indicative of grave disease

febrile temperature, pointing to some progressive tubercu- of the cerebral hemispheres, such as was actually found tolosis. But for about a month, from June 9th to July 5th, exist after death, unless, indeed, there was local mischief iiithere were no other notable symptoms beyond those de- the rectum connected with the pelvic abscess.scribed as hysterical. The question of the nature of these Turning now to the condition at the time of and afterhysterical symptoms becomes important in the light of the the bath, and the question how far the latter may havesubsequent events. They appear to have consisted in a excited or accelerated the acute inflammation, we find thatdisinclination to exertion, complaints of vague wandering the patient evidently underwent a very severe shock, bothpains in the limbs, for which no cause could be discovered, mental and physical. Terror and anxiety were combinedand now and then some transient sense of weakness in one with a prolonged exposure to one of the most powerful de-or other limb, equally inexplicable by her general condition. pressants known ; with the manifest result of a collapsedIt is not surprising that these symptoms, lasting as they did physical condition, added to a state of anxiety and fright.for some weeks, with no definite cerebral symptoms, should But it may well be asked whether this could possibly causehave led to the supposition that they were of a " hysterical

" acute tubercular meningitis, and whether in the present

nature. After all, hysteria is a term which is very loosely case there is any reason to believe that it actually did so.used, and is often employed to denote merely a certain com- As regards the possibility, it must be allowed that we knowbination of defective will-power, and a tendency to exaggerate very little of the exciting causes of tubercular meningitis.slight symptoms, which are common enough in sickly women. There is, however, a gradually accumulating mass of

There are few medical men, we imagine, who do not very evidence that both local and general conditions may deter-frequently speak of such a condition as "hysterical," but mine the incidence of tuberculosis on a particular organ orwho would draw a sharp line between a "hysterical part of an organ, and there is no reason to believe that the

patient and a patient with hysteria. It is easy to be brain is any exception to this rule. If, for example, in a

265REGINA v. INGLE : MEDICO-ETHICAL ASPECTS.

patient with slowly-progressing tuberculisation of the lung, one of hysteria till within twelve hours of the fatal issue.there is by any means excited an acute inflammation, this Such facts should lead to caution, both in making a dia-is very apt to be accompanied or succeeded by especial gnosis and in expressing an opinion as to facility of diagnosisdeposit of tubercle in that part ; it may become, in fact, in any particular case.either a tubercular inflammation, or may tuberculise instead of resolving. The immediately exciting causes of tubercular IT cannot be disguised that the professional aspects of themeningitis have been very incompletely studied, but no fact case REGINA v. INGLE are very grave and call for serious,seems better established than that the inflammation is often albeit strictly impartial, consideration. The appeal now liesquite disproportionate to the amount of tuberculosis, and formally to the Censors’ Board of the Royal College of Phy-that it often appears to be rather a sequel to, than a con- sicians, but that body has, on former occasions, scarcelycomitant of the latter. Cases occur to our mind in which shown the wisdom, tact, and independence which wouldthe symptoms certainly appeared to be directly excited by entitle it to the implicit confidence of the profession atsome exposure to cold or mental shock. There is therefore large, and the case must therefore be judged by anothersome ground for the belief that these may have been opera- tribunal-namely, medical opinion. Looking at the mattertive in the present case. But does the clinical evidence from this point of view we cannot but feel that the questionsbear out this view ? If it is urged that the carelessness at issue between Sir WILLIAM GULL and Dr. PAVY are of

about the evacuations was a symptom of acute tubercular a nature to require very careful but exhaustive handling.meningitis, it would of course be idle to seek any subsequent The broad facts are fairly before us, and we see no reason tocause. In the absence of evidence of other brain disease withhold an expression of opinion which may or may notthis might perhaps be fairly alleged, but the more chronic accord with that formed by the College of Physicians, buttuberculosis appears to be a sufficient and more probable will, we believe, be that at which the profession ultimatelycause, though the symptom is rare in both forms. It is arrives.

stated also that no more definite symptoms of inflammation The first question that arises is whether the step taken inappeared for three days afterwards, during which time the this most deplorable case was determined upon at a formaltemperature continued low, and the patient apparently under meeting and after a general consultation of the medical

the influence of a mental shock. Death did not occur until staff, or was the independent act of Dr. PAVY, who con-sixteen days after the bath. In the absence of fuller in- sidering the circumstances found himself unable to giveformation we cannot follow the case. It would be of great the usual certificate of death ? Looking to the exceedingvalue to know what the course of the symptoms was, in magnitude and importance of the medico-legal issues to beorder to judge how long the active symptoms were in raised, we think it was due to the hospital as a medical insti-progress. But having in view the great variety in the tution, and the profession as represented thereby, that a pre-course and duration of tubercular meningitis, we should vious deliberation should take place. The need of such a pre-hesitate to draw any absolute conclusions. The duration, caution has been made painfully evident by what has ensued.indeed, is often very much shorter than fifteen days from For example, if there had been a preliminary consultation,the first declared symptoms, a fact which favours the view no question could possibly have been raised at the trial orthat the onset was excited by the bath. It would, however, elsewhere as to the character and value of the clinical notes

be very difficult to allege with certainty that the bath was of the case and the record of the post-mortem examination,the exciting cause of the meningitis, or that it might not upon which the conflicting opinions expressed were based.have occurred without its influence. The direct evidence of It should have been clearly settled at the outset whetherthe marked change in the patient’s condition is here of the documents to which we allude were or were not the

value in forming an estimate of the probabilities of the case. private property of the physician in attendance on the case.If it were not travelling somewhat beyond the immediate If they were regarded as private, we are at a loss to understand

questions at issue, it would be of interest to consider the how they came to be placed before any members of the staffvarious modes of manifestation of acute tubercular menin- without the consent of the physician to whom they belonged.gitis in the adult. The distinction drawn between the If, on the other hand, it was held that these records wereresults of chronic tuberculisation, yellow tubercle nodules in the property of the hospital, then they must be assumed tothe cerebral cortex, or more rarely in the more central por- have been at the disposal of the governing authority of thetions of the brain, and acute meningitis, usually of the base, hospital. It argues a surprisingly strange state of mattersis not always sufficiently borne in mind. The diagnosis of that so simple a point as this should be involved in obscurity.the more chronic form is, we do not hesitate to say, judging Either there is a clinical record kept in each case, to which thefrom the recorded experience of many physicians, a matter governors may have access-although it is difficult to divineof the greatest difficulty. Such cases, especially when in for what purpose the lay authorities of a hospital can needthe adult and affecting the cerebral hemispheres only, have to refer to a medical and technical report-or the papers werebeen diagnosed as syphilitic, as pachymeningitis, as acute the property of Dr. PAVY alone. If they belonged to themeningitis, or chronic rheumatic meningitis, even by the hospital, the governing body of the institution had certainlymost able physicians. On the other hand, in a not incon- a right to submit them to whom they pleased, and particularlysiderable number of cases of acute tubercular meningitis, to the consulting officers. If they were the private property ofthe earlier symptoms are purely mental, and very frequently the physician to whose case they related, and were to besimulate hysteria or hysterical mania, the mental symptoms used in evidence at the trial, they ought to have been sub-being far more predominant in the early stages in adults mitted to both sides previously. It is a rule of practice inthan in children. We have known a case to be regarded as courts of law, and one which ought to be observed in all

266 .THE DEFENCE OF THE APOTHECARIES’ SOCIETY.

these matters, that the papers which relate to a dispute are obligations, and responsibilities of a consultee-whether ineither "put in or not quoted. The opinion given in evidence relation to the governing body and medical staff of a

by Sir WILLIAM GULL was based solely on the data supplied hospital, or to the family and ordinary medical attendant of aby these papers, which he seems to have seen without the private patient-can be more clearly defined than they seemknowledge of the physician in charge of the case, and the to be at the present moment, good may come out of evil,profession should be informed as to their nature. and this we are convinced will be a result over which everyThe appearance of Sir WILLIAM GULL in the witness-box, one interested in, or concerned with, this most painful contro-

in a position even seemingly antagonistic to the medical staff, versy must find occasion to rejoice.is greatly to be regretted. Such a spectacle would probably ———————————

have been prevented by a general consultation. Sir OUR readers may remember that last year the Select

WILLIAM is the senior consulting physician to the hospital, Committee of the House of Commons on Medical Bills were

and as such holds an office the first and principal obligations disappointed in not receiving the evidence of Mr. BRADFORD,of which are towards the working staff. Nothing short the courteous representative of the Apothecaries’ Companyof a subpœna—unfortunately compelling the interven- in the General Medical Council. Mr. BRADFORD was indis-

tion of a consulting officer as a witness to give critical posed, and unable to give his evidence. The circumstance

evidence on the work of his colleagues-could, in our was the more to be regretted as several witnesses, while ad-judgment, have e justified his appearance before the mitting that the Society had done good in the past, hadCourt. Once in the box, it is easy to see that he must advocated the view that it was no longer necessary in thespeak the whole truth, and therefore state fully and clearly economy of things, that it was decidedly superfluous, andhis views. The question in which the profession has an its further continuance, with a seat at the Council, scarcelyimmediate interest is whether the data upon which Sir WM. defensible. Yet every Englishman is interested in the

GULL arrived at a conclusion, differing widely from that of defence set up for an old institution. Though we are a pro-the physician who had seen the case, were of a nature to gressive people, we like to see a good fight made by thecompel the line of conduct he pursued. It must be conceded friends of what is established and incorporated. Hence it is

that a physician can be ruled only by his own judgment in gratifying to us to be furnished with a copy of the evidencethe opinion he forms of a case, and his own conscience must which Mr. BRADFORD intended to have given before thedetermine the course he takes in expressing that opinion. Committee, in refutation of adverse evidence given byWe have no right, and certainly no desire, to obtrude various witnesses. The reasons for excluding the Societyconsiderations of professional interest or etiquette between from further representation in the Medical Council, andconscience and conduct ; but if ever there were circum- excusing it generally from further work in the medical ex-stances in which a physician so placed must see cause to amining system, were briefly these :—1. That there was a

question his sense of duty, those by which Sir WM. GULL sufficient number of examining bodies without it, and that itfound himself encompassed when he opposed his judgment was unjustifiable to ask that it should be maintained in

(of a case he had not seen, on the ground of the report of a perpetuity. 2. That room was needed in the Medical

post-mortem examination at which he had not been present) Council for the direct representation of the profession, andto that of the physician-a colleague and a man of acknow- that one way of creating such room was by discontinuingledged eminence in the profession-who had treated the the representation of certain bodies, including that of thepatient and personally examined her body, were of that Apothecaries’ Society. 3. That the Apothecaries’ Companycharacter. Look at the matter as we may, it is impossible was ceasing to be a licensing body. 4. That the Societynot to feel that the conviction that there had been an error was more or less a trading company.in the diagnosis of this case must have been very strong The evidence before us, which we may hope will one dayindeed, and the pressure of duty to humanity and justice- next session be actually put before a Select Committee, is.a pressure we distinctly recognise and respect-must have not a satisfactory or convincing refutation of the argumentsbeen exceedingly great to satisfy a man of high and honour- of those who seek to elevate and simplify the organisationable instincts that duty compelled him to a course from which of the examining bodies and to improve the constitution ofevery other feeling must have recoiled. the Council. In effect, it aims at proving two points:We have no wish to over-estimate the obligations of First, that the Apothecaries’ Society, as such, never was a

professional etiquette. There may clearly be circumstances trading company, though it allowed some of its members,amid which such considerations must sink into comparative formed into a copartnership, to carry on for their personalinsignificance. Still less would we willingly say anything, benefit the business of chemists and druggists in the nameor pursue a line of argument, which might seem to treat the of the Society. Admitting this, it must yet be concededinter-relations of members of the medical body as of a that the Society was in close contact with trade ; the morenature to override the paramount claims of public duty; so as, under the deed of the Joint Stock Company, it wasbut it is not expedient that professional obligations should be required that its business should be conducted by thirtylightly set aside. It will be necessary to hear more of this shareholders, all of whom were to be members of the Societymatter than we have yet heard before a definitive judgment or Corporation, and practising apothecaries, and eight of

can be pronounced; but the opinion of the profession must be whom were to be members of the Court of Assistants (thethe ultimate court of appeal, and by the unwritten law of governing body of the Society or Corporation). Besides

the medical body as interpreted by the common-sense instinct this, the Master and Wardens of the Society were, in addi-of its individual members the final award will be made. If, tion, ex officio members of the Committee of Management.in the course of the inquiry which must ensue, the relations, Surely all this was sailing very near the trade winds. It

267TYPHUS IN IRELAND.-METROPOLITAN WATER-SUPPLY.

will be seen that we have used the past tense, for in a noteadded it is said that "since the evidence was prepared,the United Stock of the Society of Apothecaries has

(from circumstances in no way connected with the questionraised before the Select Committee) been dissolved. The

relation therefore (the italics are ours) laitherto subsistingbetween the Society and that body has entirely ceased." Wecongratulate the Society on the cessation of a relationshipthat was decidedly objectionable. The coincidence of this

cessation with the public objections to it is curions, but wemust accept the assurance that it is accidental.The other objection which it is attempted to refute in the

evidence is that " the Apothecaries’ Company is fast ceasingto be a licensing body. Mr. BRADFORD’S answer is this :"As a matter of fact, the average of licences granted bythe Society between 1870 and 1879 was about 213 annually,showing the Society to be numerically the second licensingbody in the three kingdoms." The objection is put in toostrong language, which always tends to defeat the objectin view. Nevertheless, it probably remains true that

the Apothecaries licence is not in so much demand as

it used to be, and it certainly is true that there is no reasonin the public interest, as there is none in public law,why men entering the profession should ally themselveswith a Society which reminds ns of a somewhat low concep-tion of the medical function, and of a time when the body ofthe profession was thought to be of a different brand from

that of the consulting class. We willingly admit that theSociety has done good service, and did at one time the workof the College of Physicians, because that College, as it doesyetsometimes, conceived very erroneously and inadequately ofits great duties. But seeing that the Colleges are nowdriven by the force of public opinion to higher conceptionsof duty, and that medical men now aim at being not"apothecaries," but veritable physicians and surgeons, andseeing further that the Apothecaries’ Society cannot, by thevery terms of its own creation, give a perfect examination,we can certainly perceive no adequate reason for the furthercontinuance of the Apothecaries’ Society as an examiningbody, with a seat in the Council.

Annotations.

TYPHUS IN IRELAND.

" Ne quid nimis."

Ix another part of THE LANCET we publish an importantpaper from the pen of Dr. Nixon, on the epidemic of"Fever" in the Swinford Union, County Mayo. It must beobvious to those who give careful attention to Dr. Nixon’sstatements that the Government has been perilously near to thepoint of committing, if it has not actually to some extent com-mitted, the blunder which converted the famine in SouthernIndia into so awful a disaster-namely, underrating theeffects of chronic starvation upon the distressed communitiesin Ireland. The condition of the patients suffering from" fever as described by Dr. Nixon, and the number andpeculiarities of the cases of diarrhoea and dysentery in theunion, prove that although deaths from starvation may havebeen staved off, it by no means follows that the hardly lessconsiderable and not seldom fatal mischief arising fromchronic starvation has been obviated.The conditions under which typhus and enteric fever ar{

observed in the union (apart from the immediate distress)are such as to give rise to the gravest considerations. Theyare conditions by no means limited to this particulardistrict of Ireland. It is difficult to realise a state ofexistence which at the best is barely distinguishable from acondition of chronic starvation, and circumstances of housingand habits of domestic life which are revolting in their dis-regard of what we look for amidst a civilised community.The endemicity of typhus and enteric fever in the district,as described by Dr. Nixon, is the normal result ofsuch conditions. When last we referred to this sub.

ject we spoke of the application of the provisionsof the Public Health Law to Swinford Union and dis-tricts similarly situated in despairing terms. Dr. Nixon’s

paper does not permit us to regard the subject from a morehopeful point of view, but it enables us to form a justerestimate, perhaps, of what is needed if we look for a bettersanitary future of the districts referred to. Obviously nomerely palliative measures, such as have been chiefly in

view, or measures determined solely with regard to the

present distress, can be regarded as sufficient. Whatis needed is the institution of measures founded upon a

comprehensive view of the requirements of the districts,and an administrative organisation which can be dependedupon for carrying them out with certainty, however slowly,and with due regard to the impoverishment of the peopleand their rooted habits : a hard and it may be a thankless

task, and one which looks to the future rather than thepresent-a task which has regard to the next generation andeven to the generation following.

Dr. Nixon’s paper further suggests a question for our con-sideration in England which is worthy of immediate con-sideration, and which we commend to medical officers ofhealth. The migration of labourers from Ireland to Englandin the autumn still continues, although in less proportionthan was the case when machines had not invaded agricul-tural regions. Swinford contributes a considerable number of,

. labourers to our harvest fields, and it is well that the medicalofficers of health of our western ports and rural districtsshould be alive to the probability of the labourers from thedistricts in Ireland where typhus now exists bringing thedisease in their train.

___

THE METROPOLITAN WATER-SUPPLY.

THE report of the Select Committee on the expediency ofacquiring on behalf of the inhabitants of London the under-takings of the existing metropolitan water companies, hasbeen published. It leaves the question pretty much as itwas before the late Government took it in hand, decidingagainst the provisional agreement with the water companies,which they had promoted, and making certain suggestionswhich we should venture to term crude, if crudeness dare beinferred of the proceedings of a committee of selected mem-bers of the Legislature. They hold it expedient that thesupply of water to the metropolis should be placed under thecontrol of a Public Body, to be created for the purpose, andwhich shall represent the interest and command the confi-dence of the ratepayers. This public body they think should,in the absence of a single municipal body, which could under-take the duty, include elements derived from the MetropolitanBoard of Works, the Corporation of London, and representa-tives of those districts beyond the limits of the metropolitanarea to which the companies distribute water. But this

body, besides having to look to a greater efficiency, economyof water-supply, and equality of charge than now exist,will have to give regard to arrangements for extinction of

fire, and the making of better provision for the health of thecommunity. Nevertheless, no suggestion as to the mannerin which this new body is.to secure competence in its judg-ment on the complex question of health is made, and the