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in the arrangements of the vaccine department, much yetremains to be done to place it in an emcient condition. Weare glad to learn that it is proposed to give to the localauthorities, who wish to avail themselves of it, power toinsist on compulsory vaccination.A brief summary is given of the sanitary works under-

taken, the epidemics which prevailed, and the general stateof health throughout the year in the different Local FundCircles. In the Appendix to the Report there is an interest-ing paper by Dr. Cornish on the Influence of Famine on theGrowth of Population, to which we shall take an earlyopportunity to refer.

Journal of the Royal Agricult2cral Society.THE current number contains a report by Prof. Greenfield

on the "Nature, Causes, and Prevention of Splenic Fever,Quarter-evil, and Allied Diseases," the results of an ex-perimental inquiry made at the Brown Institution. The

publication of this report at the present moment is of specialinterest to the medical profession from the light it throws

upon the form of anthracoid diseases known as "woolsorter’s

disease," recent occurrences of which, at Bradford, have ex-cited much painful interest, and for which we have beenindebted to Dr. John Henry Bell for the graphic and ad-mirable history given in the numbers of THE LANCET forthe 5th and the 12th inst. Previously, Professor Green-field had shown that anthrax or splenic fever may betransmitted to a bovine animal by direct inoculation from arodent ; that the disease thus given, though severe and pos-sibly fatal, is not usually so, and that the modified attackof the disease confers a certain degree of protection fromsubsequent attacks communicated in the same way, so far,at any rate, as the experiments had been carried. Theyshowed also that the fungus which constitutes the essentialcontagion, when grown in successive generations in a culti-vating fluid, was still capable of giving rise to the disease,being in one case fatal to a cow in the first generation ; inanother, fatal to a sheep in a fourth generation. The ex-

periments further showed that an attack thus communi-cated, causing severe symptoms, appeared to be equallyprotective against results from future inoculations with thedisease given directly from the guinea-pig. Professor Green-field pointed out with reference to these experiments that,although he had applied as severe tests as were at his com-mand to ascertain the degree of protection conferred, it wasdesirable to perform the more crucial test of direct contagionfrom another bovine animal; and that if the experimentswere successful the precise method of performing the pro-tective inoculation and the desirability of the protectionwould require further investigation.Keeping these points in view, he has continued his experi-

ments, and gives the results in the report above referred to.These results are similar to those obtained in the previousexperiments, and he has thus added three more cases ofsuccess by this method of inoculation, the protection con-ferred having been determined by further inoculations. Hehas not yet been able to perform the crucial experiment oftesting the apparently protected animals by exposure to

direct contagion from another bovine animal.In these later experiments another very interesting and

equally important point has become clear, which may proveof great value in the future. It is that when the virus ofthe disease (the fungoid organism known as Bacillus an-thracis) is artificially cultivated in an indifferent fluid, bythe method of successive generations, each successive gene-ration becomes less active than its predecessor, and wheninoculated acts not only with less intensity, but more gra-dually, and often in a somewhat different manner. Thismodification takes place in such a degree that when cultiva-tion has been carried to the fourteenth or fifteenth genera-

tion, it may be introduced with impunity into the system ofa mouse, which is one of the animals most susceptible of thepoison. Of this fact Professor Greenfield observes, that itwill doubtless prove of practical value, for by its means itwill be possible to obtain a virus of sufficient activity toproduce an attack of the disease which shall be protective,but not of sufficient severity to be dangerous, or in any wayinjurious to the animal inoculated. With regard to any illeffect upon the animals inoculated, Professor Greenfieldstates that the cows used have thriven remarkably well, andnone so well as the one which has been most severely tested.

In respect to quarter-evil, black quarter, or black-leg, Pro-fessor Greenfield’s experiments, as far as they have gone,tend to show that the disease must be different from anthrax,and that the danger of infection is as great or greater fromthe unaffected parts of the body as from the obviouslyaffected and gangrenous quarter; and in respect to " Capehorse sickness" and Loodiana (horse) fever, that, though pro-bably allied to anthrax, they present several characteristicdifferences.The report is valuable, both from the particular facts it

gives and from its great suggestiveness.

The Lancet CommissionON

WORKHOUSE INFIRMARIES.

INTRODUCTORY (Conc11Ided).

IN our first article we endeavoured to show how the wantof prompt attendance in the earlier stages of acute disease,and the insufficient relief supplied to patients convalescingfrom such diseases, were important factors in the productionof pauperism among the respectable poor. We also expressedan opinion that the existing system of medical relief woulddoubtless work well were it not for the insuperable objectionsthe poor have to entering the workhouse, or contracting thestigma of pauperism which the reception of relief confers.We therefore advocated that in order to deal effectually withthis cause of pauperism at its very commencement it wouldbe necessary that the sick necessitous poor applying for reliefshould be treated in buildings, and, we may add, lookedafter by officers distinct from those set apart for the relief ofsick paupers. A step in this direction we remarked hadalready been taken by the separation of many of the work-houses in this metropolis from their infirmaries, and the sickare treated in distinct buildings from those set aside for theable-bodied, the aged, and infirm. Still the objection remainsthat the sick poor and the sick pccuper are treated in thesame wards, and it is very evident, from an examination ofthe class of cases at present in the wards of these infirmaries,that they receive only a small proportion of the acute diseasesarising among the poor. No difficulty, as far as the metro-polis is concerned, ought to arise in making provision for therelief of the sick poor distinct from that given to the pauper,since at the present time most of the unions have combinedto provide infirmaries separate from their workhouses, andit would only require an extension of the present system tomake provision for the separate relief of the two classes.There can be no doubt that if the acute diseases and generalill-health among the poor were promptly and effectuallydealt with at their onset by thorough medical treatment, andadequate relief in the shape of nursing and food, far fewercases would drift into that hopeless condition which ulti-mately renders them a burden on the rates for months oryears.The erection of infirmaries separate from the general

workhouse marks a distinct advance in the treatment of

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the sick pauper, and shows that the public have re-cognised the claims these unfortunate beings have upontheir sympathies. The guardians, too, are to be congratu-lated on the noble manner in which, as far as the metropolisis concerned, they have carried the scheme into effect. It isno uncommon thing to hear hospital physicians and surgeons,when speaking of hospital improvements, compare thecondition of the old hospital wards with that of workhouseinfirmaries. But the comparison has lost its point, and thenew workhouse infirmaries that have been recently erectedare in every respect equal to any hospital we have ever visited;and in the case of some-for instance, Lambeth and Stepney-leave nothing to be desired in the matter of arrangementand accommodation. Nor have the guardians been sparingin providing the necessary appliances for the treatment ofthe sick. Only in one respect have they been niggardly, andthat, unfortunately, in a particular that is most essential-the medical and nursing staff are quite inadequate, in pointof number, to deal with the overwhelming amount of sick-ness and suffering that comes under their care. The

guardians have been sufficiently liberal in regard to

,salary to induce good men to come forward for the posts,but they have neglected to provide that subsidiary medica]assistance without which it is impossible to carry out theefficient treatment of disease. A glance at the appendedtable will show how extremely underhanded these institutions are in respect to their medical and nursing staffs :-

in the form of surgical relief, or at least in the

supervision of the dressings, &c., to show that our

estimate of the duties that fall upon the residentofficers of these institutions is not exaggerated. Thehighest credit is due to the medical officers of the insti-tutions we have visited for the manner in which they en-deavour to perform their arduous duties, and the acquaintancethey possess with the clinical details of the cases under theircharge. It is surprising that they should find time to keepany records at all of even the most important ones. Thatthe work is done as well as it is, is due to the fact that theresident staff have been well selected in the first instance,and are men in the full vigour and prime of life. We cannotconceive it possible that work maintained at such highpressure can for long retain its efficiency ; and after a fewyears one of two things must happen-the occupant willseek for work in a direction that brings less strain, andperhaps affords a better remuneration, or else sink into mereroutine practice. Either alternative will involve sufferingto the pauper, and loss to the ratepayer. There can bevery little doubt that when once the guardians have secureda highly -trained and efficient medical officer it is falseeconomy to make a change. His experience with regard tothe management of the institution under his care increasesyear by year, and he will be able to effect many savings inmatter of detail and administration that a man new to theplace would probably overlook or ignore. On the other

Approximate relationship between number of Sick and strength of Medical and Nurs6ng Staff at sixof the 1JrÍ1wi1Jal Workhouse Sick AsvlU1ns. Mall-June. 1880.

* Nine of these are assistant nurses. t Six of these are probationers. t Twenty-one of these are assistant nurses.§ Not yet distinct from workhouse buildings. 11 With a pauper nurse to each ward. ’ Eighteen are assistant nurses.

** About one-third are acute cases. tt Non-resident. tt Resident. Sometimes there are four assistants.§§ Including twenty-seven probationers

From this t bile it will be seen that the average numberof sick persons under the care of each medical officer amountsto quite 200, and that too at a period of the year when theasylums are far from being crowded. In the winter monthswe believe the figures are far in excess of those given, with nocorresponding increase in the strength of the medical staff.Physicians and surgeons accustomed to hospital work willappreciate the enormous labour thrown on the gentlemenwho have to contend with this immense amount of sickness.In large hospitals with all the appliances for case-taking,without which it is impossible for the resident physicianto get a proper grasp of his case, fifty to sixty beds are foundto be quite as much as the medical officer can adequatelysupervise. In these sick asylums, however, the patientsunder the care of the medical officers are more thanfourfold this number, and in addition to this they have theburden of watching and recording the progress of each case.It may be urged that their duties are not in reality greaterthan those of hospital residents, because the proportion ofchronic to acute cases is higher in workhouse infirmariesthan it is in general hospitals. But such is not the fact, asthose who have had much experience of the treatment ofchronic disease will testify. Take, for instance, chronic pulmonary affections: what constant care and watchingthey require to relieve the ever-varying forms of suf-fering they successively pass through ; at one time to dealwith exacerbations of pyrexia, at another with increase ofcough and expectoration, to say nothing of intercurrentattacks of dyspepsia, diarrhoea, &c. Then, again, there isthe time requisite for the electrical treatment of paralysedlimbs, muscular atrophy, Parkinson’s disease, a class ofcases especially numerous in these asylums. Nor need weallude to the cases of stricture, chronic bladder affection,diseases of bone, ulcerated legs, all of which requiredaily some portion of the medical officers care, either

hand, if the medical officer should be overworked and over-strained he will speedily lose his clinical acumen, and sinkto mere routine work. The difference to the sick betweenthe man fresh and full of clinical training and instinct, andthe worn-out, harassed man, who falls back on mereroutine,it is impossible to estimate.The question now arises, How shall the medical staff be

increased without throwing an additional burden on theratepayers ? The plan of securing one responsible medicalhead for the management of these asylums is indisputablythe best, but instead of, as at present, his undertaking themultifarious duties with regard to the sick, we would recom-mend that his position should be made more analogous tothat of visiting physician to an ordinary hospital. At thesame time it must be remembered that there is muchadministrative work now thrown on the shoulders of themedical superintendent from which it would not be easy torelieve him without a radical change in the presentl’éghne. The assistant medical officers should hold the

position of house-physicians, and their number increasedto that their duty might be limited to one hundredbeds, the estimate being taken for the fullest time of theyear. In addition to this there ought to be a clinicalassistant for every thirty beds, whose duty it should be tosake full notes of every case, record the temperatures, passcatheters, dress the ulcerated legs, &c.,-in fact, to performall the subsidiary duties that now press so heavily on theordinary staff, and distract their attention from more seriousduties. It may be suggested that a difficulty would arisein obtaining the required clinical assistance, but we thinkthat if facilities were offered, there would be no lack ofcandidates for the posts. In the first place, owing to theincreasing prominence given to clinical work and methodsat the final examinations of the chief examining bodies, therequirements of students with regard to this important

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subject are greatly increased, and in many cases farexceed what their hospital can afford. Opportunity forfurther clinical study is therefore much needed. Moreover,these asylums furnish a class of cases which are of thegreatest value to those who intend to enter general practice.As a rule, the class of disease met with in hospital cases areexceptional examples of a practitioner’s daily work, whilstthe treatment of chronic forms of disease form the chief partof his duties. It is with this class of cases that the youngpractitioner finds himself at a disadvantage on commencingpractice, simply because so few have come under hisobservation in hospital practice. Six months spent in thewards of a workhouse infirmary would prove of the greatestadvantage to him. For it is a great mistake to suppose thatthe workhouse infirmary contains only those cases whichhave been rejected as unsuitable by hospitals. Were thisbelief ever cherished it would soon be dispelled by therecords of many a case that has been published in thisjournal. Some most interesting and important contribu-tions to clinical work have come from some of theseinfirmaries, where officers have had both time andinclination to observe well and record carefully. Andwe have, in our recent visit to a few of these institu-tions, been enabled to see examples of disease seldom ifever met with in the wards of hospitals. It has beenrecently remarked in an able pamphlet by Mr. Dolan, themedical officer of the Halifax Union Infirmaries,l that theworkhouse hospitals are especially fertile in cases of nervousdisease, and he points to the work that has issued from thegreat Paris Infirmary of Salpetriere as evidence of whatsuch institutions may be made to yield. Indeed, the oppor-tunities afforded to the zealous and earnest worker withinthese infirmary wards are very great; but however zealousor earnest he may be, it is quite impossible for him underpresent conditions to avail himself of these opportu-nities. Nor do we think that many obstacles are likely tobe offered to such an extension of the work carried on at someinfirmaries by the lay authorities. We have evidence ofthe willingness of the guardians to provide scientific andsurgical appliances that is most commendable and praise-worthy ; and it is but bare justice to these gentlemen,who have so great a trust imposed on them, to mentionthis fact. But of what avail is their liberality in thisrespect if the employment of these appliances is restrictedowing to the conditions under which the medical officerswork ? It is thereby impossible to have observations carriedon and facts recorded unless there be a large assistant staffsuch as we have indicated. Whether, then, we look to theadvantages these infirmaries offer from the educational pointof view or from the purely scientific, it seems at least un-fortunate that such advantages are not made the most of.We believe that if resident clinical clerkships and dresser-ships were established in connexion with these infirmariesthey would be eagerly sought after, and an additionalstimulus might be held out if the Local Government Boardwould make the holding such an appointment for sixmonths an indispensable qualification for a Poor-law ap-pointment.But in order that such a scheme might be carried out there

requires to be effected another change of the greatest im-portance. The writer to whom we have just referred pleadsstrongly for the introduction of greater facilities in the per-formance of post-mortem examinations. At present suchexaminations, if not absolutely forbidden, are so hamperedby restrictions that only a minority of cases are availablefor such a purpose. We would plead most strenuously forthe abrogation of these restrictive measures. It is tooobvious that much of the value of these infirmaries, con-taining, as they do, examples of disease under observationsometimes for years, as fields for pathological research, is atpresent almost nil. Doubtless it is urged that this is neithertheir main object nor a necessary part of it; they are refuges ’,for the sick, not laboratories for the pathologist to work in,rich as the field may be. This is true enough, but surely ’’iit is a short-sighted policy at the best which places undue irestriction upon that which we are bound to regard as thecorner-stone of our care of the sick-a knowledge of the ’,nature of the diseases from which they suffer. Nor, in ouropinion, would it be after all so great a gain to encouragemore extended clinical work within these institutions, wereit not also understood that equal facilities should be afforded ’,for the complementary pursuit. ,

1 Some Remarks on Workhouse Hospitals. 1879.

Passing from matters which some may think lie almostoutside the scope of these institutions, or at least to embraceschemes which border on the unattainable, we may turn, inconclusion, to the subject of nursing-one of the most im-portant practical subjects within the management of theinfirmaries, and one too which has not only made greatadvance of late years, but promises to yield more fruit inyears to come. When we contrast the care of the sick underthe old régime with that at present obtaining in all thebetter-class infirmaries, we are astonished at the revolutionthat has been effected on this essential point. The ignorant,rough, well-meaning pauper nurse has been replaced in theseinstitutions by a class of intelligent, trained, paid nurses,who perform their onerous duties skilfully and well. TheLiverpool Workhouse has the honour of leading the way inthis much-needed reform; and lasting credit is due toMr. W. Rathbone, who originally proposed the change inthat infirmary, and actually maintained the new system athis own expense during its years of trial, until the ex-periment was overwhelmingly proved to be successful.We hope shortly to speak more particularly of the Liver-pool Infirmary. Suffice it to mention here that it is nowrecognised as one of the best training schools for nursesin the kingdom, for from it come many highly-qualifiedwomen to take responsible posts in our metropolitan hos.pitals. The system now in vogue at the larger infirmariesand sick asylums is similar to that obtaining at hospitals andinfirmaries unconnected with workhouses. A matron, or insome cases a lady-superintendent, controls the department; .°,then there are a certain number of head nurses, one to twoor three wards, and an assistant nurse to each ward. In afew the proportion may be a little under this ; in most it isabout this, or slightly over it. At any rate, even this hardlyseems adequate to meet all that is desired. At first sightit might be thought amply sufficient, for there are always alarge number of cases of chronic disease which require butlittle attention-patients who are up all day, and for whomfood and shelter are the chief requirements. But, onthe other hand, the infirmaries also abound in sickwho are confined to bed, who require every possibleattention to keep them clean - and it is these whichmust tax the resources of the nursing staff, to say nothing ofthe acute cases which demand constant supervision; and inthe winter time especially the nurse’s duties are very heavy.Every now and again we hear of misadventures arisingwithin infirmaries which go to prove the necessity of theincrease of staff-to which we have alluded. Coroners’juries in rightly censuring cases of error and neglect, shouldbe careful to place the blame in right quarters ; and seeingthe underhanded conditition of these infirmaries withregard to their medical and nursing staf], the wonderis not at the occurrence of such mischances, but thatthey do not happen more frequently. It would bewell if some certain fixed proportion of nurses to sickwere established and carried out uniformly throughoutthe infirmaries-a proportion not less than one nurse toeight or ten beds. By increasing the staff of probationernurses this might be effected without much addition to theoutlay. In that way we might come to see the infirmaryutilised-as it is, for example, at Liverpool-for the supplyof trained nurses not only to the infirmaries themselves butalso to the hospitals, which are ever in need of fresh hands,as their nurses pass out to take up appointments as " sisters’3to country hospitals, or attach themselves to private-nursinginstitutions. There can be no better training-school thanthe infirmary; and the advantages so gained would be greatnot only to the sick within its walls, but to the wider com-munity outside of them.

IRISH MEDICAL ASSOCIATION. -The followingoffice-bearers have been elected for the ensuing year :-President : J. H. Chapman. Vice-Presidents : EdwardBagot, Samuel Chaplin, Edmond Coates, James Molony.Council: P. Berry, Robert Browne, Samuel Browne, HenryGray Croly, Thomas Darby, Thomas Drapes, George Duffey,Robert Gray, J. R. Harvey, Robert Hayes, A. H. Jacob,David Jacob, J. Bellew Kelly, George H. Kidd, RichardKinkead, James Martin, Robert McDonnell, F. V.McDowell, G. Monogh, Andrew Nolan, Edward Peele,William Perceval, James Pollock, George H. Porter, ThomasPurcell, J. Ridley, Edmund Sharkey, H. J. Smith, A.Speedy, Robert Tagert, W. Thomson, Thomas LoweWhistler.