420 THE NEED FOR A CENTRAL HOSPITAL BOARD.

dresses with only one under-garment ; but even now there ismuch need for the exercise of common sense in the changefrom morning to evening dress. Some woollen garment,however thin, should always be worn next the skin, clothingshould be as loose as possible, and the fact that two thin

things are warmer than one thick should be always borne inmind. If these precautions are taken those who have themeans to take them may reasonably hope to come to noharm in the frost. But let us not forget the sufferings ofthose poor who have neither food, fire, nor clothing. The

cold, so cruel to the young and the sick, is especiallycruel to the under-fed ; and all those of our poorer fellow-creatures whose vccations compel them to expose themselvesfor long hours to the bitter weather with insufficient clothingand insufficient nourishment should be made the subjectsof cur practical sympathy. They deserve it and require it.

.

C - - -a-;; aifficulty in the way of hospital reform inlLondcn is the isolation of the institutions. They act apartand somewhat competitively. Each has to fight for its ownhand and in its own way. Each has its own friends and is

dependent to a great extent on the idiosyncrasies of its ownsecretary. Each has its own methods and its own views.

The competition which obtains between hospitals has

reference not only to appeals for help from the benevolent

public, but to the number of patients attended. When

the isolation of such institutions is considered, and their

ever-increasing number, it will be seen how difficult it is toexercise any control over them. Their voluntary character,their peculiar glory, for the purposes of reform is apt tobe even a disadvantage. For these reasons any central

body with benevolent purposes which would take them

all into its purview and care ought to be a great blessing,and its suggestions ought to be received with gratitude. The

Charity Organisation Society therefore did good service byorganising a meeting on Monday last for discussing the

formation of such a board.

It is well known that such a recommendation was the

principal outcome of the deliberations of the Select Com-

mittee of the House of Lords in 1889 (Lord SANDHURST’SCommittee), and that for some reason or other the proposalcame to naught. The hospitals themselves have not

welcomed the idea, and for some time past it has

been in abejance. Colonel l4ZorTEmo$E, in the paperwhich he read at the meeting on Monday, gave a historyof the proposal and its fate, and in an elaborate surveyof the portion of hospitals gave weighty reasons whyin some form the suggestion should be accepted by the

London hospitals. His account of the out-patient systemwith its 1,200,OCO patients, exclusive of the casual system,(which is rapidly growing into large proportions), was almostapps.IliBg, whether we consider the interest of the patientsor that of medical practitioners who begin to see in

hospitals a Eort of conspiracy to ruin general practice.Only the grossest abuse of hospitals on the part of the publicexplairs why practitioners entertain Each views of insti-

tuicD.3 t3 which they owe so much in the way of instruc-tion. Tne medical speakers who took pait in the discussionsaid nothing in depreciation of hospitals when restrictedto the reception of proper cases and in proper numbers. Sir

JOHN ERICHSEN, in a dignified and thoughtful speech, touched’with great judgment on the question of pay wards.

He entirely disapproved of these as part of the systemof an ordinary hospital. He recognised that there was aclass needing the accommodation of a pay hospital, and thatsuch hospitals or h:>me3 should be provided on ordinarycommercial principles, and should in their charges meet the

requirements of the clerk or other person who in emergenciesmight not be able to command at home the nursing andaccommodation necessary for his case. Though the mon-strous proportions of the out-patient department and the

tendency to adopt the pay system were the principal evil&

dwelt on by the speakers on Monday, it was not denied thatthere were others-that some medical charities are excessive

in their cost, that in-patients are admitted who can wellafford to pay, and that the system of accounts is far fromuniform. Colonel MONTEFIORE did not speak pessimistiocally of the finances of hospitals ; but he showed the extremeuncertainty of legacies as a means of income, while it is onthem that hospitals seem to depend more than they do onannual subscriptions. Moreover, legacies are bequeathedwith so little system and so capriciously as to enrich some

hospitals and leave others impecunious.The promoters of the meeting were probably well advised

in being content with a general discussion and in not press-ing conclusions to the length of a resolution in favour

of a central board. This was done out of consideration to

hospital authorities, and wisely done. But these authori-

ties on their part will do well to take note of this meetingas an index of growing public opinion in favour, not onlyof the retention of voluntary hospitals, but also of their

being restricted to the relief of persons gravely affected

with disease and unable to command medical advice and

comforts proportionate to their need. The creation of Il>central board would in no way injure well-conducted hos-

pitals. The chairman of one hospital and the chairmanof the Hospital Saturday Fund thought there would be

difficulty in defining the duties and functions of such a

board. But it will be to the discredit of the able and

experienced business men who administer our hospitals if

they cannot agree on some general functions-friendly andadvisory-which would tend to support our much-threatened

hospital system.

Annotations....I.’t6 quia mmis.

THE DUKE OF CONNAUGHT ON ST. THOMAS’SHOSPITAL.

PRACTISED orators to a certain extent all of our RoyalFamily tend to become, but it required more than verbalfacility to speak as sympathetically and as accurately as

His Royal Highness the Duke of Connaught did at theMansion House on Wednesday last, when appealing to thepublic for 100,000 to place St. Thomas’s Hospital, of whichinstitution His Royal Highness is the president, on a securerfinancial basis. It required an intimate acquaintance with thesubject and a deep sympathy with the needs of the sufferingpoor to speak at once so broadly and so precisely, and wecannot doubt that the practical outcome of the appealwill be substantial, although-to put it colloqnially-

421

times are very hard. During the whole of the period theopportunities that the institution has of doing good havebeen seriously crippled by alack of funds, and the authoritiesnow find themselves face to face with the following crucialquestion: How best can they help the sick of an enormouslyincreasing neighbourhood when their own funds compel themto offer a rapidly decreasing accommodation. For there

can be no doubt that if substantial aid is not forth-

coming yet more wards will have to be closed. His

Royal Highness pointed out that it was through no faultof the hospital authorities that their expenditure had grownwhile their income had dropped. The vast spread of SouthLondon threw an ever acuter strain upon their resourcer,while agricultural depression lessened their income, bothdirectly by depreciating the hospital property and in-

directly by affecting their subscription list. Many andmany wide and vexed questions in hospital constitution

and hospital administration in the metropolis were touchedupon, to which we do not at the present moment intend tomake reference, considering that we shall most efficaciouslyback His Royal Highness’s appeal by simply summing upthe immediate situation. St. Thomas’s Hospital is allowed onall hands to be doing splendid charitable work, and it cannotcontinue to do so unless the public will come to its immediaterescue. This we hope earnestly they will do, and in such abountiful manner that this great charity will be able topursue its beneficent life, and, by closing its pay wards,pursue it on proper lines-those of pure and undefiled

charity. -

THE PATHOLOGY OF PNEUMONIA.

FACT and hypothesis were happily blended in the com-munications made at the last meeting of the PathologicalSociety by Dr. Washbourn and Dr. Wright bearing on thepathology of acute lobar pneumonia. Dr. Washbourn rigidlyconfined himself to observations upon the microbe that hasbeen proved to be the almost constant concomitant of thisdisease; whilst Dr. Wright, in his suggestive reasoningsfrom analogy, put forward sundry explanations of theremarkable phenomena that characterise it. The bacterio-

logical history of acute pneumonia is instructive, sincein the first instance the bacillus discovered by Fried] underwas thought to be-and the view received supportfrom many sides-the pathogenic organism responsible foreiciting it. Bat Dr. Washbourn’s statement that the real

"pneumococcus" " is that discovered by Fi aeiakel and

Talamon, and studied by Sternberg and Weichselbaumand many others, is in accord with general opinion,although we note in a recently published text-book of

high standing in this country the pneumonic P61e is still

assigned to the bacillus of Friedländer. Dr. Washbourn

pointed out that the occurrence of the pneumococcus in

healthy secretions did not militate against its patho-genic property, instancing diphtheria as an exampleof this. Now although practically the same conclu-sion was arrived at some years ago by Dr. Sternberg, itmust be admitted that the fact enlarges the view of themicrobic origin of disease. It seems to demand the inter-vention of a second factor, disposing the body to the actionof the organisms. Indeed, for pneumonia such a factor hasbeen assumed in the phrase "lowered vital resistance,"such as may be produced by cold or exhaustion, render-ing the subject more vulnerable. Experimentation uponanimals with regard to the pneumococcus has broughtoat many interesting facts as proving its relation to

inflammatory processes in various tissues and organs ;but it cannot fail to strike the clinical observerthat the parts mostly attacked by inflammation after

"pneumococcal" inoculation are not those which are

prone to such lesion in the human disease. This was partly

explained by Dr. Wright’s statement that the pneumococcushad mainly a local action, and in acute pneumonia itsentrance is obviously by the respiratory tract. The questionof immunity and the allied subject of the use of I I curativeserum " has been studied experimentally in pneumococcusinfection for some time, notably by Drs. G. and F. Klempererof Munich ; indeed, some of the earliest work on "antietoxins " was that done on the occasion in question by theseobservers. It is clear, however, that more requires to be provedbefore the practical application of such researches can beadopted. Moreover, in a self-limited diseasefdlike pneumonia.it will be assuredly a difficult matter to determine whetherthe abatement of symptoms is due to the administration ofserum from an immunised subject-e.g., the blister Eerumfrom one who has just passed through an attack-or to

the natural termination of the process. Amongst the strikingphenomena of this remarkable disease must be reckoned theoccurrence of crisis and the reabsorption of the mass ofexuded leucocytes, which convert the spongy tissue into asolid grey mass. Dr. Wright advanced an interesting ex-

planation of the crisis when he compared it with the pheno-mena of spirillum fever. Criss is denoted by a rapid fallin the excessive leucocytosis that precedes it, and this means.the withdrawal of pneumococci from the blood ; yet neither-the height of the fever nor the degree of crisis is influencedby the amount of lung involved-i.e., of leucocytal emigra-tion from the blood ; nor do signs of resolution ccncur withthose striking changes in the functions of the whole bodywhich supervene at the crisis ; nor finally, as Dr. Washbournsays, do the pneumococci exist to any marked extent in the-b’ood. That the reabsorption-sometimes with great rapidity-of the large amount of nucleo-albumen of which exudedleucocytes are composed does not lead to intra-vascular

thrombosis, in accordance with the late Dr. Wooldridge’s.beautiful demonstration, is remarkable, and was explainedby Dr. Wright by assuming an equally rapid elimination bythe urine, and in some cases, perhaps, by the bowels, of the-absorbed material. It is well known, however, that the

periods of crisis and that of commencing resolution are oftenthose at which the need for free stimulation is most urgent ;.and we are far from saying that some of the deaths at thisperiod of the disease attributed to cardiac failure may notreally be due to cardiac thrombosis. On either view alcoholiis indicated, and we may add that ammonia, another time-honoured remedy, would equally answer the indications, andthat most physicians would rather trust to it than to citric:ac:d to prevent the tendency to coagulation within the blood-vessels.

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LIFE ASSURANCE SCHEMES.

Two life assurance schemes have been recently pressedupon public notice, one devised by an American the other byan English company, being the Mutual;:Life Assurance

Company of New York and the Royal Exchange AssuranceCompany respectively. Of the ability of both companies tomeet their obligations it is possible to speak with a largemeasure of confidence, for each is prudently managed andpossessed of ample means. In this respect there is no

need to choose between them. Bat the two plans are

very distinct in character, and we cannot hesitate to give thepreference from a professional point of view to the Englishscheme. The object of its originators has been to give as.large an immediate return as possible upon the premiumcharged, and for this purpose the distant future is sacrificedto the near. That is to say, the Royal Exchange Com-pany is prepared to issue policies at extraordinarilylow rates of premium upon the condition that the remittedbalance of the ordinary premium rate shall be representedby an accumulating debt chargeable against the policymonies when these fall due for payment. This growing debt