938 THE HARVEIAN ORATION.

THE LANCET.

LONDON: SATURDAY, OCTOBER 24, 1891.

WE venture to congratulate the Royal College of Phy-sicians and the esteemed orator himself on the style andcharacter of the oration which Dr. DICKINSON deliveredlast Monday. He might well have been daunted by thefact that his predecessors in the office, whom he so worthilyfollowed, numbered no fewer than 172; but when ib is

remembered that this annual celebration not only serves tocommemorate HARVEY and his work, but to mark the

progress of knowledge in the application of physio-logy to pathology and practice, we cannot but be gratefulfor its annual observance. The theme chosen by Dr.DICKINSON was that of the bearings of HARVEY’S immortaldiscovery of the circulation upon medicine since his day. Hedid not dwell, as some of his predecessors have done, uponthe historical details of that memorable research, or seek tovindicate the claims of experimental physiology that datetheir birth from HARVEY. In felicitous and simple phraseo-logy he brought vividly before his distinguished audiencethe conditions of the era in which HARVEY lived, and thestate of physiological darkness in which the medical prac- ,,

titioner of that time pursued his calling. He showed, too,how the old notions of vital spirits were impressed on forms ofspeech still current amongst us; whilst, with much homelywit and shrewdness, he called to mind examples of practicewhich would seem to have been almost inspired, since theyso long preceded any notion of the true conditions whichreally give them sanction and justification. Similar

examples were cited by Dr. LAUDER BRUNTON in his recentaddress at Bournemouth, and they testify to the wisdomand sagacity of the professors of ancient physic, whilst atthe same time they encourage the continuance of a certainamount of empirical treatment which, in days to come, maybe found to have a rational basis. But, as Dr. DICKINSONremarked, there are other lines of practice which widerknowledge would seem to have deprived of any basis ofsupport; and yet their efficacy seems indisputable. For

such no doubt there is an explanation, different from theoriginal one that has to be discarded, but which has stillto be found by science.In tracing the effects of HARVEY’S discovery, com-

pleted as it was by MALPIGHI’S work upon the capillaries,Dr. DICKINSON instanced in historical order a few of the

most obvious and striking acquisitions to art and

knowledge that have accrued therefrom. The inven-

tion of the tourniquet, the ligature of arteries for

aneurysm, the application of auscultation to the diagnosisof cardiac diseases, the doctrine of embolism (so fertilein the explanation of many obscure conditions), that ofpysemia, of inflammation, and the pathological bearings ofthe circulatory mechanism as controlled by the vaso-motorsystem,-surely in this record there is a splendid catalogue

of the abundant fruit that has been garnered from the treethat HARVEY planted. Still, as Professor ViRCHOw has

lately been reminding us, we must be careful not to limitour conceptions of morbid processes to the influence of thecirculation and the blood. For wide as the sphere of theiraction is, it is not capable of explaining the ultimate reasonof pathological states; rather does the circulation act as thegreat intermediary between the vital processes, which areunseen, but always acting, and constitute the outward andvisible result of their activity.

Dr. DICKINSON selected for special consideration a topicupon which he is well entitled to speak; and his ingeniousendeavour to attribute the phenomena of the dropsy ofrenal disease to mechanical circulatory conditions must bestudied with that respect which is due to authority. It is

right to add that he himself deprecated having attained anyfinal conclusion on the matter. That he disproved the doc.trine of hydraemic dropsy-i.e., of a dropsy due to osmosisalone-will be generally accepted. This, which was the notionadvanced by no less an authority than BARTELS, wassufficiently disposed of by the experiments of LICHTHEIMand of COHNHEIM. But we do not think the Harveianorator met the arguments adduced by the last-named

pathologist, whose acute intellect was too early quenched,COHNHEIM having assured himself of the insufficiencyof a purely hydrsemic explanation for renal dropsy,and being conscious also of its peculiarities in siteand varieties in mode of occurrence, laid the greateststress upon changes in the vascular lining as favour-

ing the escape of fluid from the vessels. (This seems

to be allied to the doctrine of Dr. WAYMOUTH REID,alluded to by Dr. DICKINSON.) On the other hand, Dr.DICKINSON contends that renal dropsy is so markedly re-lated to evidences of increased arterial pressure, that it is

rather in the circulatory mechanism that is to be found thesolution of its pathogeny. There is evidence, he holds, of

primary obstruction in the capillary circulation, rather thanin the arterioles ; and this, together with the heightenedsystolic action of the heart, forces the fluid elements tofilter from the vessels ; but-and here comes the apparentparadox-as arterial tension increases, the dropsy lessens, forthe obstruction is transferred from the capillaries to the

arterioles ; and the vis a fronte of the cardiac suction, whichgains with the increase in the muscularity of the heart,favours a freer return of venous blood to the central organ.The subsequent reappearance of a true cardiac dropsy, fromthe giving out of the heart muscle, is a familiar fact, andneeds no special description. Dr. DICKINSON will doubt-less on some future occasion still further develop his

interesting thesis; and he may succeed in provingthat the most marked examples of renal dropsy-those of chronic parenchymatous nephritis (which, as

SIBSON demonstrated, were not associated with heightenedpulse-tension or with cardiac hyperbrophy)-belong strictlyto the class of purely mechanical dropsies of central andnon-peripheral origin. Whatever Dr. DICKINSON says is

sure to be suggestive, and likely to lead to much earnestthought and reflection. His choice of a topic for his

Harveian Oration has in this respect been as happy as ithas been clearly presented, and it will doubtless pave the

939"DEEMED LUNATIC": THE OFFICIAL PROGRAMME.

way for renewed searchings out of the secrets of Nature in pretending (after discovery) to be insane; for such evi-

the manner commended by the great master himself. dences of mental activity as trying to mend a fence with aneedle and thread, giving six home addresses, raving loudly,

.

kicking violently, using disgusting and impertinent lan.A LUNACY case of some interest came before Mr. GLOVER, guage to the magistrate, appear to us to be at least as com-

a county magistrate at Highgate, on the 9th inst., and is patible with sham insanity as they are with the real disease.reported in The Times of the following day. A shabbily Hence the question that must arise in cases of this sort,dressed man, who said that he was " GEORGE SMITH," and when a man is arrested and taken to the police station, isforty-four years of age, was charged with having been found of a threefold character: are we dealing with a lunatic andwandering and deemed to be a lunatic. The policeman stated a lunatic only, or with a lunatic who was about to committhat the occupant of a place called Silver-hill, in Highgate, a felonious act, or with a would-be criminal (possibly aninformed him soon after midnight that there was a man in old prison bird) who is shamming insanity ? or, to

his garden who was behaving very strangely and trying to put it briefly, is he a lunatic or is he an impostor ?mend the fence with a needle and thread. The policeman Was " GEORGE SMITH" at the police-station a lunatic orfurther testified that, going towards the house and meeting was he an impostor? According to the special policetheprisonercomingoubof the garden, he spoke to him, where 11 order," the inspector appears to have had no alternativeupon the intruder at once commenced to rave loudly. He in the case but to deal with him as a lunatic, and send himgave six different addresses, and was very violent on the to the workhouse. According to the magistrate, the in-

way to the station. Whilst this evidence was being given, spector ought, under the given circumstances, to have had nothe prisoner, who was held by three constables, kicked alternative but keep him as best he might in the police-cellviolently, used most disgusting language to the magistrate, all night. If SMITH was a feloniously disposed loiterer andtold him he was too inquisitive, and asked him if there was an impostor, the magistrate was right and the police "order"anything else he would like to know. Mr. GLOVER said wrong ; if he was insane, the police order" was right andthat the man would be sent to the workhouse for the state the magistrate wrong. If " SMITH " was an impostor, theof his mind to be inquired into. The inspector said that inspector played his game and contributed towards estab.the prisoner was sent to the workhouse as soon as he was lishing a prima facie case for the genuineness of the insanitybrought to the station. There was the cab fare to pay for by sending him to the workhouse; if he was a genuinethere and back and the fare there again now. Would the lunatic, the magistrate would, unwittingly of course, bemagistrate certify for the expenses in the usual way? the means of compelling some amount of injustice to beMr. GLOVER said he did not think it quite necessary done to the man by insisting upon his being lockedthat a man who was only charged at midnight up and detained for a prolonged period as a criminal

should be sent to the Edmonton Workhouse, a distance offender, possibly to the still further detriment of his

of eight or nine miles, and brought back again by mind.

9 o’clock in the morning. Together with the fare back We are strongly of opinion that no hard-and-fast, and at

again now there was 24s. to pay, and that was a large the same time just, rule of an official sort can be laid downsum for such a short time. Could they not have kept to meet such a case as this, where the nature of the respon-the man in the cells until morning ? The inspector said sibility and the character of the issues are so mixed up andthat as the man was not charged with any offence he could conflicting, and where there is something like an even

not be detained in a cell. It would not be safe to keep a chance that the procedure will tend either to help a criminalviolent lunatic in a police cell all these hours, and if he was in his attempt to evade punishment or to inflict an injusticedetained in an ordinary room it would have required three upon a harmless lunatic.

men to look after him. There was a special police order There are amongst our lay authorities doctrinaires whoon this subject, which stated that when the particulars as preach that it does not require a medical education or ato the finding of the alleged lunatic had been put on the medical experience to detect the existence of insanityproper form, and it was impossible to convey him directly (whatever that may be taken to be) as contra-distinguishedand without delay before a magistrate, he was to be con- from mere eccentricity or abnormality or deformity of

veyed to a workhouse of the union of the parish in which mind, or to determine that certain mental manifesta-

he was found. Mr. GLOVER said it all turned on the tions are or are not counterfeit presentments. But we

meaning of the words " without delay." He did not think hold that there are a great many cases, especiallyit applied to a case of this kind, where it was known that criminal cases, where the fullest lay knowledge and

the prisoner would be brought before a magistrate so experience must be supplemented by the fullest technicalsoon after being taken into custody. He would certify and medical knowledge and experience before a sound andfor the expenses, but he wished that his view of the trustworthy estimate of the actual mental state can be"order" might be represented to headquarters, in order arrived at. It is our belief that the only consistent rulethat they might be guided in future. The inspector said whereby such a difficulty as that which shows itself in thehe would acquaint the Commissioner with his worship’s case of "GEORGE SMITH "-a minor case, it is true-

remarks. can be avoided is to call in the divisional police surgeon,Taken upon the evidence here given, there is nothing to and let him decide upon the merits of the individual

prove either that "GEORGE SMITH" was a lunatic or that case what are the proper steps to be taken. It comes to

he was not a loiterer bent on committing a felony, this in the end, and the medical opinion might as well be

940 PROFESSOR VIRCHOW ON CELLULAR PATHOLOGY.

taken first as last, thereby placing the responsibility on theright shoulders, and avoiding much circumlocution and

waste of time.

To the current number of his .c/M—the first of its

126th volume-Professor VIRCHOW contributes an article1

upon the position of the doctrine which is linked with hisname-viz., cellular pathology. He says that he felt im-

pelled for several reasons to discuss this topic. One of

these was the fact that the above journal, founded forty-four years ago, was in its first decade largely concerned withthe development of that doctrine in all its manifold bear.

ings, and that it has continued ever since to be a mediumof the exposition of the fact that our conceptions of morbidprocesses must be founded upon a histological basis.

Another potent reason for his present review of the subjectwas that he was on the eve of reaching that term whichhas been from of old accepted as completing the naturalspan of human life ; so that his personal share in pro-

moting the teaching identified with himself and the Archivcould not be of much longer duration. The great inter-national gathering at Berlin, and a reperusal of the

Transactions of that Congress have also had their influencein turning his thoughts in this direction-the endeavour tofind what common foundation underlies the vast amount of

individual inquiry which such a collection of work exhibits.Has there been any real advance made in root principlesat all commensurate with the enormous progress effected

in every department of practice ? It would seem rather as

if there were a tendency to ignore these principles, so thatthe study of general pathology is becoming less cultivatedand the grasp of it more lax, and this in proportion asachievements in practical matters are deemed to be thehighest qualifications of the physician or surgeon. Pro-

fessor VIRCHOW does not hesitate to hold specialismresponsible for this narrowing of ideas, and he thinks ithas reacted injuriously upon general training in medicine.Nevertheless, he is hopeful that the pursuit of specialismwill in the end cause a reaction towards a better con-

ception of the medical art, and the recognition that heis the most useful practitioner who can turn his knowledgeof general principles to account in particular instances.

As an illustration of his meaning, he says that when a

special topic is being exhaustively discussed most of thespeakers deal, not with pathological processes as such, butrather with their results and causes alone. The more

difficult matter of explaining the nature of the morbid

lesions is shelved, or facts which could only be gleaned byarduous investigation are set aside in favour of some hypo-thetical explanation of an alleged cause. Hence such

phrases as "hyperoemia," "stasis," "pressure," "tran-

sudation,"" malnutrition," "dyscrasia," and the like, aregiven greater prominence than the conditions underlyingthem. This he deems to be the outcome of empirical ]methods of education, for they are terms which are

thoroughly eclectic and arbitrary. In the use of such lan- ‘

guage and the mode of thought which it implies, he sees thesame tendency at the present day to arbitrary generalisa-

1 Der Stand der Cellularpathologie, Archiv f. Path, Anat., Bd. cxxvi.,Hft. 1.

tion as characterised the speculations of the past. Humoral

pathology, the more modern mechanical and chemical

views, and bacteriology itself, have all added their quota tothis imperfect and irrational method of interpretation,Indeed, the declaration at that Congress by the first of all

bacteriologists, that in most of the acute specific diseases no

bacteria are to be found, or at least none which could beheld to be the excitants of the disease, must, he says, havecome like a thunderclap upon the modern student, who hasbeen encouraged to believe that all such diseases are causedby bacteria. So, again, the experience that exudation isusually preceded by hypersemia favoured the simple expla.nation that increased blood-pressure causes exudation; butthere was no explanation here of the undoubted concurrenceof hypersemia and heightened pressure without exudation.From the time of HARVEY the action of the heart and

bloodvessels has been considered the main agency in vital

processes ; and it is surprising how in later days so great aninfluence in disease has been assigned to alterations in blood.pressure. The newer development of humoral pathologysought to find in the circulating blood the key to all

nutritive disorders, and this notion, which availed itself of theold formulse, was the starting-point of modern eclecticism,from which our conception of vital action has not yetentirely escaped. In formulating his hypothesis of cellularpathology, VIRCHOW endeavoured to get at the root of

all vital activity, and he reminds us that his point of

view differed from that of SCHWANN, who sought to

explain the formation of cells rather than their functions,VIRCHOW started with the idea that every cell arises from

a pre-existing one, and that only such tissue could be con-sidered endowed with life which was composed of cells;and, having this conception, he was led to emphasise theessential importance to medicine of a study of cell physiologyand pathology.There runs through this article a strain of disappointment

at the apparent neglect with which this doctrine has beentreated. It may or may not be warranted, but we shouldlike to assure the veteran pathologist that this indifierenceto what must always be regarded as the basis of all patho.logical inquiry is more apparent than real. The fact is,we believe, that" cellular pathology " is not spoken of nowbecause it is almost taken for granted. It is so eminentlyreasonable and so obviously a deduction from the facts ofanatomical research that it is difficult to conceive of its

3

being wholly discarded. He does well, however, to remindus that there is a vast difference between the standpoint ofthose who look to the cell elements of the body as beingmerely passive objects for the operation of blood or nerve,and of those who regard them as not in themselves endowedwith active properties which are essential to the mainten-ance of the life of the organism, and the derangement ofwhich constitutes disease. It is this distinction between

the activity and passivity of the tissues which, he avers,has failed to be grasped even by distinguished physicians,and yet it is one which should dominate our whole eon-

ceptions of the causes and even of the treatment of disease.For the recognition of cell action requires that nutritionshall be held to be not a mere matter of cardio-vascular

action, of quality or quantity of blood, or of blood-pressure,but a process dependent rather on the special stimulation

941NURSING GRIEVANCES AT THE GLASGOW ROYAL INFIRMARY.

of the cells themselves. Variations in nutrition are to in the Scottish newspapers recently concerning the nursingbe met with in different individuals ; indeed, in the arrangements at the Glasgow Royal Infirmary. Complaintssame subject at different times. One organ may atrophy, as to overwork and bad provision of food had been madeanother hypertrophy, from the same nutritional disorder. by the nurses, and had attained to notoriety through theThe formation of new cells and his doctrine of prolifera- columns of the North British Daily Mail. The publica-tion have, however, been the points which have been tion in that journal of a strongly worded letter of com-most vigorously attacked; but he maintains them steadily, plaint from a probationer nurse at the institution led

and contends that they were unaffected by COHNHEiM’s to the appointment of a committee of inquiry, whichdiscovery of leucocytal emigration. Hence it ’Was with has just made its report. From the tenour of this

peculiar pleasure that he found the speakers at the document it is clear that the nurses had only too muchPathological Section of the Berlin Congress of 1890 reason to be dissatisfied with the arrangements under which

relegating the leucocyte to its indifferent position, and they have been working. The committee are of opiniononce more speaking rather of " proliferation " than of that some of the complaints made, and in particular those"transudation" " or "infiltration." Nevertheless, he which relate to the food-supply, were, if not unfounded, atthinks the reaction may go too far ; for, as he says, in least greatly exaggerated. But whether any abatement

abscesses and allied processes there is ample evidence should or should not be made under this head from the

of a true infiltration, apart from any new formation statement of grievances laid before the committee, enoughof cells. In the modern researches in karyokinesis he has been made out under other heads to prove that atten-

sees an extension of the cell doctrine, without effecting any tion has been given none too soon to the nursing adminis-change in its standpoint. So, too, he claims that bacterial tration of the infirmary. The remedies which the com-

pathology is quite consistent with cellular pathology. mittee recommend comprise an improved dietary, a

VIRCHOW himself long since urged that it was not bacteria, monthly holiday, improved regulations to prevent overwork,but their virulent products, that caused diseases; and he and the appointment of a nurses’ committee of managers,also expressed the opinion that infective disease may to sit regularly and take a general oversight of the nursingconsist in a struggle for existence between cells and staff. The case with regard to overwork is a singularlybacteria, an idea which has been so remarkably illus- instructive one, and illustrates in a very striking way thetrated in the" phagocytism" of METCHNIKOFF. Much danger which always exists,that thebest considered andmosthas yet to be done in this subject. It may be that carefully drafted regulations may become ineffectual, orphagocytes do not indeed exist, but their non-existence even inoperative, through the silent upgrowth of a customwould not destroy the cell theory. For if the alterna- or etiquette which sets them at naught. The time-table

tive hypothesis of BuclER be true-viz., that it is the of the infirmary has been so arranged as to set night nursesblood-serum that is the bactericidal agent,-it may owe free after a period of eleven and a quarter hours-net-this property to cell changes ; or if to external sources, of duty at ten o’clock in the morning. But althoughthen cellular pathology would not enter into the ques- entitled to release at this hour, apart from any specialtion at all. Ib is unlikely that cell action plays no circumstances demanding her longer attendance at her post,part in the production of the bactericidal poison ; but, the night nurse is expected to hold herself in readiness toshould it be so, it would not affect the fundamental doc- assist at the visit of the visiting physician or surgeon iftrine. For the characteristic lesions of infectious disease need be, and in course of time a custom has grown upall testify to the fact that bacterial action is exerted on that the nurse should wait for an intimation that her

the tissues rather than on the blood; and the study assistance would not be so required before leaving herof these tissue changes, recognised long before bacterio. ward. This innocent-seeming custom appears to have

logy entered the field, may still be objects of inves- undermined the rule. The committee say: "It is true

tigation when etiological problems are all solved. It that many years ago a custom crept in which has becomewould seem, says Professor VIRCHOW in conclusion, that more or less general in the wards, that no night nursethe ultimate aim of cellular pathology is the localisa- should leave e her ward until the visit of the visit-

tion of disease-the determination of the particular parts ing physician or surgeon is over, unless by specialwhich are selected for separate morbid actions ; and this permission. The visit begins in the case of the surgeons atleads by but a small step to local therapeutics, which 9 A.M., and in the case of the physicians at 10 A.M., andmeans nothing less than a revolution of the old lines of extends from one to three-sometimes even to four-hours,treatment. This revolution is hastening on ; it is being according to the number of operations, the gravity of thepromoted by distinguished physicians ; and it is not cases, and other special circumstances. The night nursesonly the direct outcome of a cellular pathology, but it frequently remain of their own free will to see the opera-will advance under its protection, in spite of all attacks tions ; while, even after the visit is over, the superintendentthat it may be exposed to. Therefore he trusts that the of nurses states that she has great difficulty in getting someArchiv may continue to maintain its position in the world, of them to leave the wards." We think the committee havein pursuance of the work it commenced, and in prospect of wisely recommended that a regulation for the correction ofsteady progress in the knowledge of morbid action. this bad custom should be at once adopted and strictly

__________

enforced. Not only is the matter one nearly affecting the.

well-being of the nurses who have to do night duty, but theA DISCUSSION characterised by great warmth of feeling existence of an unwritten rule like this, which conflicts

and corresponding vigour of expression has been carried on with the written code of the institution, is a fruitful

942

source of mischief in other ways. It weakens the

authority of the responsible managers, and fosters the

growth of that irresponsible personal ascendancy of subor-dinate officials which is the ultimate source of so much

friction and discomfort in the working together of large andbadly organised bodies of men or women-of the latterespecially, since, generally speaking, women display lessfaculty than men of combining and cooperating for acommon object, and proportionately diminished power ofmaking use of the strength of numbers to supplement thedeficiencies, either in power or ability, of the individual.

Annotations.

THE DIRECT REPRESENTATION ON THEGENERAL MEDICAL COUNCIL.

"Ne quid nimis." 11

SIGNS are not wanting of the approach of the time whenthe tenure of office of the present direct representatives ofthe medical profession upon the General Medical Councilwill terminate, and when they must be prepared to appealfor re-elestion or to contest the election against new comers.Some five months ago we had to refer to this subject, andit is satisfactory to find that the point upon which we thenlaid stress is precisely that which finds prominent place in theaddress of the English direct representatives to the electorspublished in our advertisement columns-viz., the value ofthe experience that has been acquired in the work of theCouncil. From its constitution the work of the GeneralMedical Council must prove embarrassing to new comers,and it speaks well for the energy, perseverance, and patienceof the direct representatives that they should be able to issuea manifesto asking for re-election, not in virtue of vaguepromises, but because of actual achievements. They havebeen asked by Dr. Rentoul certain questions about theirintentions, and they answer that their reply can be gatheredby an appeal to their past history. They have 11 acted welltogether," and they have "done their best" in advancingmedical education, especially "in its practical aspects."Some of Dr. Rentoul’s questions clearly touch upon matterswhich are beyond the powers of the General Medical Council ;hence answers to these become mere expressions of opiniondevoid of practical value, but they serve to indicate that theviews of the present direct representatives are in generalsympathy with the profession rather than with the examin- I

ing bodies. They have not only strengthened the Councilin protecting the public and the profession from illegal anddiscreditable forms of practice, but they have also been

largely instrumental in guiding the Council in the con-sideration of many of the difficult questions connectedwith the extension of the curriculum. The interests of

the profession have been so well cared for by the directrepresentatives that we cordially hope their re-election maybe carried by a unanimous vote.

CHOLERA AND YELLOW FEVER.

THERE are again rumours of cholera extension, not onlyon the eastern shores of the Red Sea, but also in Syria.At Constantinople and at Alexandria quarantine has beenimposed on all arrivals from Syrian ports, not only owingto a fear that cholera may be imported by means of troopsreturning from Yemen, but also on account of a somewhatsudden extension of the disease in the neighbourhood ofDamascus. Aleppo is also stated to be a centre of thedisease a recrudescence of cholera having taken place there.

Yellow fever is announced to prevail at the Brazilian porti of Santos, and owing to this, and to the prevalence of

small-pox at Rio Janeiro, intending emigrants are warnedthrough the Emigrants’ Information Office not to sail forBrazil.

THE EASTERN HOSPITALS INOUIRY.

ON Saturday last, at the fortnightly meeting of the Metro’politan Asylums Board, a further long communication wasread from the Local Government Board on the subject ofthe alleged maladministration of the Eastern Hospitals,more particularly dealing with the question of Dr. Collie’sresignation. This communication, while confirming the pre.vious decision of the Central Board, was in the main a replyto the letter of vindication addressed to the Managers by Dr.Collie, and by them referred to the Board. It) was evidentlyby way of justifying their extreme action in calling for Dr.Collie’s resignation, and was doubtless evoked by the adversecriticisms which have appeared in the medical and dailypress. Certain statements in this communication donot carry that conviction which the Local GovernmentBoard seem desirous to establish. For instance, in refer.ence to the dietary, the Managers are reminded that, atthe inquiry held in 1885, the extras supplied by Dr. Collieto his patients were very numerous, and were held by theLocal Government Board to be excessive; whereas since hisreinstatement in office the modifications of the diet were

very few indeed. This-viz, to pass from the extremeof extravagance to that of monotony - the LocalGovernment Board now regard as evidence of " con.siderable indiscretion." Looking, however, to the factthat on this charge of extravagance Dr. Collie was

for nine months deprived of his living, and that on his re-instatement in office he was especially enjoined, both bythe Local Government Board and by its inspector, to

practise economy, it may seem to unbiased persons tobe evidence of considerable discretion on Dr. Collie’s part;beyond which, it is hardly fair to compare the prescribingof extras with the monotony of diet, the extras probablybeing ordered in special cases, with definite purpose. Onthe subject of disinfection the Board admit the efficacyof Dr. Collie’s method - viz., that of boiling thelinen ; but hold that he was culpable in not exer-

cising sufficient watchful supervision over the pro-cess. Dr. Collie has borne witness to the practicalsuccess of the method as carried out for many yearsin the hospital, and, unless his attention had been speciallydirected to the matter by any evidence of failure, it is notunreasonable to expect that the many duties of his officewould have compelled him to trust to a great extent tothose who were responsible for its actual working. TheLocal Government Board are of opinion that practicalwisdom dictated that precautions should be used in the

hospital such as the medical administrator might not per.sonally believe to be essential, but which were believed to benecessary by many of the highest authorities. Now autho-rities differ widely as to the confidence they repose in themany chemical disinfectants; but it would probably bedifficult to find one who denied the complete superiority ofboiling water. As to Dr. Collie’s knowledge of the hissingwhich took place on Nurse Halkin’s departure, the Boardseemed to have somewhat shifted their position, and state; z"Dr. Collie must have had sufficient warning that it waslikely to occur, and should have used his authority toprevent its occurrence." The Board now state that ita in connexion with the performance of his duties as

Ldministrative superintendent, not as medical (attendant,ihat they have come to their decision in reference to Dr.collie. In their former communication they said that itvas mainly in connexion with three matters, one of whichvas a purely medical point-viz., the unvarying nature of