Another fact to be emphasized is the futility of drugs in the treatment of this disease-futile, because harmful habits can not be cured by drugs. A large percentage of the patients who present themselves bring with them their bottles of codeine. It is an unfortunate fact that many physicians still seem to harbor the belief that arsenic possesses virtues not to be found in the official preparations, and, moreover, that it has lost the dangerous qualities inherent in it. The author states that he has seen so many patients with the codeine habit and aggravated cases of constipation superimposed on the diabetes, and so many with wrecked digestive systems due to the long-continued use of arsenic solutions, that he utters a word of warning against the employment of these drugs.

Codeine and arsenic may have their uses in a limited number of cases, but in the great majority they should be left. severely alone. If these drugs were merely worthless, there might not be any serious objections to their use, but they are a positive detriment, and their continued use lessens the patient's chances of recovery. Not only that, but whenever a drug is given to a diabetic he is usually less careful in his method of living than if he realizes that his recovery depends on diet and hygiene alone.

PERITONEAL ADHESIONS. Richardson, in Annals of Surgery, thus summarizes a study on this subject:

Peritoneal adhesions are of two kinds, those which are useful and those which are harmful and dangerous. It is futile to search for some agent that will banish adhesions from the realm of abdominal surgery, inasmuch as the processes involved in their formation are identical with those involved in peritoneal repair. In dealing with peritoneal adhesions, the surgeon has recourse to three classes of procedures: (1) measures which prevent their formation; (2) measures which restrict their formation to the

harmless variety; (3) measures which aid in their absorption.

Certain anatomical and physiological characteristics of the peritoneum have. an important bearing on the problem of peritoneal adhesions; notably its extensive area, its remarkable absorptive power and ability to successfully cope with infection, the variable sensibility of different portions, the continuity of its endothelial surface, the rapidity with which it can form adhesions, and the completeness with which it can later absorb them.

Injury or death of the highly vulnerable surface endothelium is sufficient to set in motion the chain of pathological events which may terminate in dense adhesions.

Etiologically, there are a number and variety of factors involved, but they can all be grouped under the two heads-sepsis and trauma.

As specific prophylactic and curative. measures, emphasis should be given to: (1) rigid asepsis; (2) the use of moist hot gauze; (3) careful covering of all raw surfaces; (4) avoiding unnecessary exposure; (5) restricting trauma; (6) gastroenterotomy and enteroenterostomy; (7) returning the viscera to their proper anatomical relationship; (8) spreading out of the omentum over the visceral surfaces before closing the abdomen; (9) careful closure of the peritoneum. number od additional safeguards are available which have been tested and proved to be of value under certain conditions. The most reliable of these for general use are: (1) viable grafts of omentum or peritoneum; (2) lubricants; (3) judicious ante- and post-operative therapy-especially with reference to posture, catharsis, enemata, and length of stay in bed.

The field of specific chemotherapy offers the brightest hope in future prog

ress.

Success in the management of the more aggravated adhesion case depends largely upon accurate clinical diagnosis,

followed by intelligent operative procedures.

In properly selected cases, the use of adjacent mesentery for covering raw bowel surfaces offers distinct advantage over all methods hitherto proposed.

TREATMENT OF MISCARRIAGE. Young and Williams, in the Monthly Cyclopedia, present the following conclusions from a study of two thousand

cases:

1. Spontaneous emptying of the uterus takes place in but about 13.2% of all miscarriages.

2. The likelihood of a miscarriage to complete itself increases with the duration of pregnancy.

3. When it becomes necessary to use artificial means to complete the miscarriage, the use of the finger followed by the curette in later miscarriages, and of the curette alone in earlier months of pregnancy, has given uniformly satisfactory results.

4. Experience has shown that where the cervix is extremely rigid it is better. to introduce the curette and break up the fetus and placenta and remove them piecemeal than to attempt to dilate the cervix sufficiently to introduce the finger.

5. Packing the vagina and lower uterine segment is an unsatisfactory and often unsuccessful method of emptying the uterus. No success whatever was obtained in treating incomplete miscarriages in this way.

6. Packing is, however, of great value in two classes of cases: First, in exsanguinated patients, to stop the hemorrhage and give the woman a chance to recover somewhat from the loss of blood before emptying the uterus. Second, when the cervix is very rigid, a tight cervical pack for twenty-four hours will soften it so that dilatation may be attempted with safety.

7. The results of artificial methods are as good as, but not better, than where

nature has succeeded in emptying the

uterus.

8. Artificial methods are necessary in a majority of cases, however, simply lecause nature has failed.

9. In infected cases the essential thing is to get rid of the infectious material by emptying the uterus.

10. The later in pregnancy miscarriage occurs, the smaller the liability to become infected, but the greater the likelihood of developing grave septic complications if infection does take place.

11. The mortality is practically the same at all periods of pregnancy.

12. Induced abortions have a greater mortality than accidental. The mortality of patients admitted to the hospital after criminal abortions was 10%.

像

HODGKIN'S DISEASE AND TUBERCULOUS ADENITIS.

Melland, in the Edinburgh Medical Journal, says that tuberculous adenitis, though in its early stages particularly amenable to medical treatment, is a condition which is liable to drift into the hands of the operating surgeon. The complete removal of the glands is a speedy and direct route to results which other methods attain more slowly. Operation in Hodgkin's disease is always unsatisfactory and in some cases disastrous. In advanced cases of Hodgkin's disease, there is almost always a severe grade of anemia, though in the earlier stages often little or none. The distinctive feature is a diminution in the number of leucocytes with a relatively. high proportion of lymphocytes. With a case with enlarged glands, in which the temperature, after keeping quiet for a while, suddenly begins to rise, suspect Hodgkin's disease. The temperature in tubercular adenitis is either normal throughout or else shows the regular hectic character of tubercular infection, and never takes on this recurrent type. Calmette's ophthalmic tuberculin re

action is of value in differentiating these affections.

FORMS OF VERTEBRAL RHEUMATISM.

Regnault, in Progrès Médical, describes two forms of rheumatic disease of the spine, the osteophytic and the rheumatoid. In the first form there is an overgrowth of bony osteophytes. which causes ankylosis of the bones of the spinal column, since the osteophytes overlap the intervertebral cartilages. The articular apophyses are deformed and bony growths cause intense pain through pressure on the spinal nerve. This condition is common in adult and advanced life. Deforming rheumatism causes a kyphosis of a uniform but irregular arc. The articular ankylosis comes from ossification of the interspinous and supraspinous ligaments. The articular ligaments of the apophyses especially are ossified. Horses have the same forms of rheumatism that are seen in man.

THOUGHTS OF AN ELDERLY PHYSICIAN.

1. Care for as you would be cared for.

2. A good physician is one who can individualize.

3. Never show anger towards a child. 4. Show to the patient that you perceive the why of his ailment, but do not render him as wise as yourself.

5. Go, when the patient requires you, but do not go beyond his desires.

6. Treat a question in detail : A massage may be measured by the proportion of talc expended.

7. A doctor in a vehicle never looks like a fool.

8. Always remember, by the bedside. that you have treated a similar case and that you relieved your patient.

9. Everybody requires a miracle, a sick person most of all.

10. Make people understand frequently that your conception of your profession differs from theirs.

11. Take any payment when offered (adds the French monitor). It is customary in England, and English people are acquit of false sentiment.

12. In regard to your fee, remember that people will weigh your science in proportion to the number of dollars you receive.

13. It is never permissible for a doctor to be in a hurry except in the midst of an operation, or when he finds a patient sleeping.

14. Never explain to a wise patient: you may thereby conflict with his ideas. and his theories of treatment.

TIC SALAAM.

The tic salaam is a rare condition. As Cenzi reports a case in an infant two and a half years of age. At the age of nineteen months, when dentition was well advanced, the infant began showing the attacks of inclination of the head, with fixation of the eyes. These attacks were repeated from two to ten times a day in about two minutes. Accompanying these attacks there was general rigidity of the body and a mental distraction. Neurological examination of the infant was negative. The attack ceased under bromide treatment. The author considers that this case was epileptic in nature. He discusses also the possibility of spasms of inclinations of the head being due to infectious diseases, dentition, rickets, brain tumor and reflexes from labyrinthine disease.

pean medical center. Budapest, he reminds us, is situated on the beautiful blue Danube, about 150 miles southeast of Vienna, has a population of nearly one million, and is fast becoming celebrated for the number and character of its educational institutions. The Hungarians have made wonderful progress in the last thirty years, especially in the science and art of medicine and surgery. Their hospitals are nearly all modern buildings, well situated as regards light and air, with pleasant surroundings, and well equipped with the latest and best appliances for X-ray, laboratory, and pathological and clinical work.

I was connected, says the author, with the second of the two gynecological hospitals, which are a part of the Royal Hungarian University, and can speak from practical experience. The hospital contains 150 beds, half of the building being devoted to the gynecological cases and the other half to obstetrics. There is a separate building for septic cases and one for dispensary cases. In the latter department from forty to fifty patients are examined and treated every morning from 8 to 11 o'clock.

In the obstetric division, from six to eight women are confined daily, and one can see here in a short time the various abnormalities of the pelvis and any number of difficult labor cases, ranging from forceps operations to the extraperitoneal Cesarean sections. A great many cases of craniotomy were performed during my residence there, as it is their conclusion that where there is no question of the death of the child in utero, in case of contracted pelvis, it is far better to open the head and deliver the child easily

with a cranioclast than to apply the forceps to the head at the superior strait and subject the mother to the delay, pain and danger of a prolonged forceps operation, when nothing is to be gained by it.

In post-partum hemorrhages, Momburg's method is used to control the hemorrhages. In the cases in which it was demonstrated in the clinic, it was successful with the exception of one case, the patient being in extremis when she arrived. The case was one of accidental separation of the placenta, the patient having been flowing profusely prior to her admission. Version was quickly performed, but when the belt was applied the patient was pulseless and died soon after its application.

The method of its use is as follows: A good, strong rubber gas-tube, about five yards long, having about the thickness of the index finger, is passed through under the back of the patient, to be grasped by the hand of an assistant who stands at the other side of the operating table. The tube is stretched to the utmost, and is passed by the surgeon around the abdomen, two turns being sufficient in slim individuals. In stouter patients it sometimes requires four or five turns, sufficiently to compress the circulation, which can be ascertained by noting the cessation of the femoral pulse. When a patient is fairly anemic. the obstetrician resorted to Trendelenburg's posture, and where the anemia was of a serious character, both extremities were bandaged with elastic bandages from the toes up.

For any physician wishing to do postgraduate work in gynecology or obstet. rics this place has a great many advan tages over other large European cities. Every opportunity is afforded to make the examinations, treat the patient, and follow the case from beginning to end.

The supply of material is unlimited, and the number of physicians coming here for work is not so large as in some other medical centers, so that one can have plenty of opportunity to work along the lines most desired.

Emergency cases are treated, when practicable, at the homes of the patients, and at least from twelve to fifteen new patients are attended daily. Even in the poorest of homes, the most wonderful results are obtained, and seldom is there a case of infection following confinement or miscarriage, as the asepsis. is the most thorough and rigid that could be put into practice.

In the gynecological division there are two main operating rooms, which are of modern construction and contain all improved methods. An apparatus devised by Roth, in which the exact number of drops of ether and chloroform can be measured, and in which oxygen is given at the same time, is used for anesthesia. Most of the operative work is done by the abdominal route after the method of Wertheim. No soap or water is allowed on the abdomen, but the skin is hardened by an application of equal parts of acetone and alcohol, after which tincture of iodine is applied. All sutures used are catgut, treated with iodine after the Billmann method.

They are having considerable success in the treatment of annexa tumors by the method suggested by Professor Zweifel, of Leipzig.

Obstructive dysmenorrhea is treated by a posterior incision of the cervix, inserting a Bossi dilator, leaving in for two weeks, the patient remaining in bed for eight to ten days. They assert excellent results by this method.

I saw, during my service in the clinic, a great many cases of induced abortion, especially in tuberculosis. Where there are the slightest evidences of tuberculous infection, the assistant does not hesitate to inject into the uterus from ten to fifteen c.c. of alcohol, which is found

to be effective. Sometimes a second and

third injection is necessary. An alcoholic solution of iodine was used, but this was found to cause considerable pain when it penetrated into the tubes, so they discontinued using it.

One of the pleasantest recollections of my life will be my association with the men of the women's clinic of Budapest. Having lived in the clinic as I did, and being closely associated with them in their work, I learned to know them as a hard-working, sincere lot of men, men of experience, displaying great skill and some doing original work of a high order. To the assistants, Scipiades and Frigyesi, I shall ever be grateful for their many acts of kindness and the personal interest shown me during my residence in Budapest, and also to the other assistants who contributed so much to make my stay one long to be remembered.

DUTY OF PHYSICIANS TO EACH
OTHER.

Arthur J. Huey, in the New York Medical Journal, regards all physicians as partners, and asks us to consider the duties that we owe one another as partners. If a partner is doing his work conscientiously one has no right and should have no wish to interfere with his success, either directly by assuming charge, or as is so often done by indiscreet and meddlesome gossip with his patients concerning his treatment and the results obtained-often criticising with only the slightest knowledge of the case and the difficulties with which he has had to contend. Rather should we uphold one another, remembering how often our own best efforts fail, and even the results of which we are justly proud are misinterpreted and criticized.

If a partner finds himself in difficulty and asks for help, it should be given, freely and generously, aiding one another with our varied experiences and observations. If he has been wrong we