thyroidism had been treated for months and some for years for neurasthenia, hysteria, nervous prostration, gastro-intestinal neurosis, functional heart disturbance, nervous heart, etc. These patients had complained to their physicians only of their most prominent symptom, and the underlying cause of the trouble had been wholly overlooked. A point which is not sufficiently recognized is the inconstancy of this one symptom, or the variability in its intensity.

ATTENTION TO LITTLE THINGS. Chas. E. Warren, in the Medical Fortnightly, reminds us that it is human nature to long for pretense and show. The druggist who has the largest plate-glass windows, the largest soda fountain, the greatest display within and without, is the most popular.

The druggist who dispenses your prescriptions in clear-glass bottles, with capped corks and other frills, is thought more of, and consequently has a larger trade than one who puts it in cheap, greenglass bottles, and wraps it in a scrap of newspaper, although the latter may be far more scrupulous in the compounding and conscientious regarding the purity and quality of the ingredients.

The doctor who lives in the "swellest"'-front house, who has the latest model of automobile, who dresses in the latest style, who makes the greatest display, will have the largest list of patients, if not the wisest, but of this more anon.

The doctor who prescribes drugs not in the common list, as commonly known, will gain a reputation for knowledge and progressiveness. But he who neglects to write a prescription for sodium chloride, C. P., and aqua destillata, when he desires to use a solution of salt, but merely asks for some salt and water from the kitchen, is apt to be branded with contempt and called an old fogy, away behind the times, who has not gone beyond the age of simples.

The public, in fact, does not want to be commonplace or economical in sickness, say what they may.

They will put off calling the doctor until the eleventh hour, but when they do call him they want to get their money's worth of attention.

In the urgency of acute illness all care for appearance is cast aside, nor do they question the means. But let the danger pass, let the crisis be o'er, and convalescence ensue, and all the innate pride for good appearance manifests itself in the best nightgown for the patient, the best spread and comforter for the bed, and numerous useful, more often uselessly ornamental accessories deck the table and otherwise adorn the room.

Should we ask the reason why this is done, we should be indignantly told it was, of course, for

love of the patient, that daintiness of environment is a powerful adjunct in the recovery of the invalid, a sentiment which cannot be denied, but it is also true, although the statement would meet with indignant denial, that it is partly for effect, to impress the doctor and sympathizing visitors with the display.

Realizing this, the doctor who is politic will take due notice of this weakness of human nature and notice some of these adornments of the sickroom with a true-hearted note of admiration, if he wishes to impress a good opinion of himself upon those with whom he comes in contact in his daily routine. For good opinion is reciprocal.

Moreover, patients and their friends will take due notice of the physician who is well equipped with conveniences, useful, if not necessary, but of a more or less attention-attracting character.

In the practice of medicine, as in other things, it is not the man who is "just like other folks" that gains fame; it is the one who is "different." Not ostentatiously so, but just sufficiently different to make folks "sit up and take notice."

A chronograph watch, for example, with its long sweeping second hand, is not only desirable for its usefulness in "taking the pulse," but folks will say of the doctor who has one, "he is so accurate and painstaking, he has a doctor's watch for counting the pulse," and the neighbors who hear this gossip will think they would like that kind of a doctor, and when in need will govern themselves accordingly. Nor is such a watch and similar things within the reach of the wealthy practitioner only, for a good watch, with a "timing second hand" may be bought for $5.75. Certainly, the benefit therefrom is worth more.

RAILWAY SANITATION.

Wertinbaker discusse this subject in the New York Medical Journal. He remarks that the feather duster and the "whisk" broom, with which the porter removes the dust from one passenger and scatters it over the others, have met with unqualified disapproval from sanitarians. In many cars the feather duster has been replaced by a damp cloth for removing dust from the window ledges and the backs and arms of seats, but the whisk broom of the porter is still in evidence. In these modern days it would seem to be a very simple process to install in each sleeping and chair car a vacuum cleaner, for removing dust from the car and the clothing of the passengers. Such a cleaner could be operated by the dynamo that furnishes the electric lights for the train, or a vacuum could be produced by utilizing the power from the moving wheels of the car itself.

The dental cuspidor to be used when cleaning

the teeth has made its appearance in some of the more modern sleeping cars, but it is doubtful if the results will be all that are desired. The object of the dental cuspidor is to prevent passengers from spitting in the washbasins when brushing the teeth. Experience has shown that while many passengers appreciate and use the dental cuspidor, there are many who either do not know its use, or ignore it, and it is with this class of passengers we have to reckon.

A careful consideration of all the questions connected with the sanitation of washbasins on trains, and in public places generally, leads to the inevitable conclusion that the only way to prevent spitting in them is to abolish the washbasins; that is to say, so arrange them that they will not hold

water.

This can be accomplished in a simple and inexpensive manner by entirely removing the plugs that retain the water in the basins, and by connecting the water supply to a single pipe that rises some twelve or more inches above the basin, and curving over, discharges the water in the basin from that height; a "goose neck" is the name given such an arrangement by the makers.

This arrangement permits the washing to be done from a falling stream of water, while the basin acts as a sink from which the water runs off as soon as it enters. Under these circumstances, water cannot be retained in the basins, consequently spitting in them is not so objectionable as at present.

The abolition of the basin for holding water will cause no inconvenience, as at present the more fastidious passengers never use the basins; they wet the ends of a towel and perform their ablutions with that. It is evident that the removal of the plugs from basins will make them more sanitary, while under present conditions it is impossible to keep them clean. This alteration in the provisions for washing in cars is so important from a sanitary standpoint, and the cost of making the changes so insignificant, that it is hoped it will be done at an early date.

The general cleanliness of Pullman cars is good, and will compare favorably with that of the best hotels. It is understood that these cars are given a thorough cleaning at the end of each run, great care is taken with the linen, and the blankets are frequently washed. Inclosing the blankets in a linen bag is a great step in the right direction. If some means could be devised for keeping dust and smoke out of cars it would be a great boon to travelers, and many "colds" and other troubles of the nasal passages would be averted.

The use of the common drinking cup should be abolished on trains, as well as in waiting rooms,

and passengers encouraged to carry individual drinking cups.

The kitchen on dining and buffet cars should be screened to keep out flies, and care taken to protect the food from infection.

The danger to passengers of infection from cooks, waiters, or porters, suffering from tuberculosis, syphilis, or other infectious diseases, is real, and careful attention should be given to the health of such individuals. A monthly inspection. with the prompt discharge of any infected person, would afford the necesasry protection.

If examining surgeons promptly reject any applicant for such positions who is infected with any transmissible disease, they will greatly aid in protecting the health of passengers.

With the awakening of the public mind to the necessity for proper sanitation, it is hoped that the question of infection from these sources, and in fact the whole question of the care, preparation and service of food on common carriers, such as railroads, passenger vessels, etc., will receive the attention it so much needs.

OPERATION FOR PELVIC CANCER. Alexander Don, in the Lancet, records that in a case of cancer of the uterus he on one occasion was compelled to sacrifice a portion of the bladder with both ureters, and though the patient survived for a considerable time and died from an indefinite lung trouble the method adopted to benefit the urinary discomfort does not deserve more than a passing ontice. In separating the uterus from the bladder the latter was opened, as was immediately evident, by tearing through the growth. Palpation revealed malignant infection of the bladder mucosa, covering an area of 1 by 11⁄2 inches, with its long axis antero-posterior and involving the base of the bladder about the ureteric openings. This area, along with about half an inch of margin of healthy bladder tissue, was clipped away and removed along with the uterus. The ureters were divided before they reached the uterus but were not otherwise disturbed. After removal of the growth a few cat-' gut sutures fixed the edge of the cut bladder to the front of the rectum a drainage-tube being left in each corner fixed by a catgut suture and protruding from the vagina. The patient made a normal recovery from the operation, but all the urine escaped per vaginam. This was rectified later by closing the vaginal orifice, and when the patient was last seen, a year after the second operation, she expressed herself as quite comfortable.

The operation was done five years ago and was by no means a complete one, and had the patient

lived or even been available for examination of the pelvis a couple of years or so after removal of the tumor, in all probability some recurrence would have been noted; but as it happened she left the district, and only a meagre account of her last illness was obtainable from her friends. In discussing this case with another surgeon, the author learned that in at least one case where part of the ureter had to be sacrificed a German surgeon had successfully grafted a shaving from the skin, cut slightly thicker than a Thiersch's graft and coiled in the form of a tube. Though no opportunity has yet been afforded of trying an alternative method, it seemed likely that if such a graft lived the ureters themselves would act better if they could be attached to another immovable part of the bladder. The usual method of attaching them to the peritoneal surface exposes the ureters to periodic changes of tension, besides leaving them uncovered by peritoneum.

The following operation was done with comparative ease on a male cadaver. A Mackenrodt's incision, extending from one superior iliac spine to the other, and reaching to within half an inch of the symphysis pubis, divided all the structures of the abdominal wall. With the cadaver in the Trendelenburg position, the bowels were pushed upwards, an abdominal gauze cloth was packed in, leaving sufficient edge outside to cover the convex upper flap, which was then stitched at its center to the tissues of the sacral promontory by one silkworm-gut suture. This effectually retained the intestines and gave an excellent view of the whole pelvis. The ureters and anterior division of the internal iliac vessels were located and the peritoneum opened by a vertical slit over the vessels, which were at once tied with a catgut ligature. The slit in the peritoneum was extended upwards to the division of the common iliac, and downwards along the side of the pelvic colon to the base of the bladder. The peritoneum was reflected outwards on both sides. The central flap of peritoneum was reflected upwards. The uterers were freed, from the brim of the pelvis to the base of the bladder, by blunt dissection and a few slips of a knife or scissors, care being taken not to injure them or their vessels by too close dissection or rough handling. The lower end of the ureter was gently pulled upon, and a pair of artery forceps occluded its vesical end, below which it was cut across. An opening was next made over the front of the bladder in the space of Retzius by reflecting the peritoneum from the lower side of the abdominal wound, and a pair of dressing forceps was passed from this opening under the peritoneum along the pelvic brim and out under

the flap that had been dissected up. The end of the ureter was grasped by this forceps, and brought along the tunnel and pushed through a hole made in the front of the bladder. This can be done without the least tension on the ureter, especially if the outer edge of the fixed part of the bladder be utilized. A single silk suture fixed the ureter. The whole of the pelvis could then be cleaned out.

The operation was continued as for cancer of the rectum. The sigmoid flexure was pulled down till it became taut, and ligature of its mesentery was begun at this point. After the superior hæmorrhoidal artery is secured the rest of the mesentery can be stripped clean off from the brim of the pelvis down to about the top of the coccyx. There would be some hæmorrhage from the middle sacral artery, and probably from the lateral sacrals, but with a clear view of the pelvis these could easily be secured. If the base of the bladder be infected part of it can be removed without hæmorrhage as the vesical arteries are already controlled. Nothing need be left on the pelvic wall except the nerves and muscles. The colon was next ligatured in two places as low down as convenient, and divided between the ligatures with a knife, which was then discarded. The ends of the cut bowel are immediately covered with gauze to prevent any leakage. This is a speedier method than inverting the ends and needs less handling. It is also preferable to division by cautery, the handle of which cannot easily be kept aseptic. The long piece of colon was brought out at the left extremity of the wound and covered over, while the short end was dropped into the bottom of the pelvis. Division of the colon at this point does not make such a perfect specimen for preservation, and suggests a possibility of malignant infection, but this with the precautions mentioned above is hardly possible. The peritoneal flaps were next stitched together and completely closed the floor, and this diaphragm would be pushed right down to the bottom of the pelvis by the weight of the bowels. The upper end of the bowel was fixed into the left corner of the abdominal wound, and the rest of the incision closed by layer sutures. A rubber drain would be left in the space of Retzius as a precaution against urinary leakage. The rest of the operation could be done quickly and bloodlessly by any of the usual methods from below. If part of the bladder had been removed, there would be leakage of urine for a time and a drain would be necessary. In every case a two-hourly catheterization of the bladder must be done for ten days to allow the ureters to get quite firmly fixed.

TREATMENT OF SPINAL INJURIES.

A. R. Shands, in the International Journal of Surgery, says that in all cases a most rigid support should be used, such as in the treatment of Pott's disease. In these patients the very best means of immobilizing the spine is a snugly fitting plaster-of-Paris jacket. If there is any deformity it should be reduced as much as possible before applying the jacket. The repair in such cases is slow, and the support should be continued just so long as there is any indication for it, whether it be one month or twelve months. If the seat of the injury is above the sixth and below the third dorsal vertebra it will be necessary to extend the jacket over the shoulder to produce anything like a sufficient support. If the fracture is above the third dorsal vertebra, the plasterof-Paris should be extended over the head. After the acute stage has subsided a removable jacket may be used, and for this purpose the author makes one after the style of that devised by Calot with the opening down the back instead of down the front..

The jacket should be applied with the spine extended as much as possible. This is best obtained with the ordinary upright extension apparatus, but in many cases the pain and muscle spasm are so great that the patient cannot stand this ordeal. Under these circumstances the recumbent method should be used either in a hammock, or on the steel frame devised by Goldthwait. My preference is the hammock; this method, with two assistants keeping up countertraction, is quite efficient in producing traction, and causes little or no discomfort to the patient while the plaster-of-Paris is being applied.

The plaster-of-Paris jacket has many advanttages over the recumbent method of putting an injured spine at rest. In the first place it is impossible for the spine to be at perfect rest without a rigid support, for every time the patient moves in bed there must be some motion between the vertebræ, and this will cause muscle spasm and pain; this is not the case with a snugly fitting jacket. The patient with a jacket, can roll about in bed just as much as he pleases, and can be put in a rolling chair and carried out of doors, and if he is unsteady on his legs, he will soon be able to get around on crutches with little or no jar to the painful spine. If the injury is below the mid-dorsal region, the jacket should reach well over the brim of the pelvis. The author's rule is to extend it down to the tip of the great trochanter and well over the pubic bone. will give well-nigh perfect antero-posterior and lateral support to the spine. This is absolutely necessary when the sacroiliac joint is injured,

This

which is generally the case whenever the injury is in the lumbar region.

The subject of injury to the sacroiliac joint of late has received a great deal of attention from numerous writers, and cannot be spoken of in anything like an adequate way in this paper. In passing, however, the author thinks it is a subject that has been undoubtedly "overworked" of late. There is undoubtedly such an injury, but he thinks many a case of ordinary backache and lumbago has been treated as a relaxed sacroiliac joint. If every injured spine resulting in a painful and relaxed sacroiliac joint were recognized at the time of injury and supported with a properly applied plaster-of-Paris jacket extended well over the hips, there would be but very few cases to go beyond the acute stage.

In applying a plaster-of-Paris jacket there are many points in the technic to be considered. There are many patients that cannot be suspended in the usual way without causing great pain, nor is such procedure free from danger of producing asphyxia in cases of injury to the cervical spine, with great pain and muscle spasm; this difficulty can be easily overcome by using a cheese-cloth hammock instead of the suspension apparatus. All of the bony prominences should be well protected from undue pressure by being well padded with some soft material. Use for this purpose a cotton felting such as every good housekeeper uses under the dining table cloth.

斑斑

CAUSE OF STAMMERING.

William Lilliendahl, in the Medical Times, declares that nine-tenths of all cases of this affliction come from a too highly organized nervous structure; hence, strictly, stammering is the object of treatment for the physician just as much as any other disease or neuroses.

But, once acquired, stammering takes on a new phase; the original cause has weakened with the advance of age, because like all other disorders in it the tendency of the body is to equilibrium, and many recover normal speech when the nerve centers are quieted and calm down; this is seen in the fact that those afflicted always enjoy almost complete immunity from speech difficulty when their health is improved-the better the health the better the speech-and some do obtain permanent relief by simply improving the general health.

The usual course is as follows: the long continued speech defect makes the child conscious of his defect, and now there are two troubles to consider, the nervous physical one and the mental state which soon gets into a chronic state of fear, and the physician has now a double thing to con

sider, and the mental is often the most troublesome. It is the purpose of this article to indicate just what this mental trouble is.

The Mental Attitude of Stammerers. Naturally, the "mind" takes its impressions through the five senses; feeling, hearing, seeing, smelling and tasting-body and brain impressions are vital to the mind for they determine just what it is, so that if these impressions are disturbing we have a "disease of the mind'-such impressions may come from a poor digestion, bad habits, shocks to the nerve centers, etc., and they produce similar conditions of a disturbing nature in the mind-they may become lasting impressions in the mind-they are distorted and abnormal just like the body troubles are they cause in the mind confusion and want of body poise-the mind refusing to work in harmony with the body, as it normally does.

Thought and its expression in language are inseparable-when we think the natural impulse is speech, and the clearer we think the more accurate we express ourselves in speech. Now stammerers think in circles-their thoughts travel like as from a center of a wheel (the hub), and spread out to its rim along the many spokes of the wheel, and all at one time.

This has been noted by Dr. Scripture, who stated it in this way: Speech when normal proceeds in a direct course from the brain to the vocal organs, and in stammering this course is indirect-the thought to be expressed takes an abnormal course, and he shows just what this course is by a diagram, and when the attempt is made to utter the thought there is confusion.

But, clearer does it seem that the hesitating speech corresponds to a hesitating mind; stammering in speech indicates a stammering thought in the mind; confusion of utterance shows that there is likewise a mental state of confusion. The actual condition is as follows: The mind which normally wills to express a single thought, at one time, is really attempting to express many thoughts at the same time; for, in the stammerer's mind there is not only the original single thought which it started out to express in language, but it is saddled with some of these: There is the thought of the effect on others, the words that are being used, and all overshadowed by fear of failure, etc.-with all of these in his mind at one time can we wonder at the speech confusion?

This is vitally important, if we expect to treat this disorder from every standpoint, and it indicates clearly the methods of treatment to effect a cure. It is almost useless to try to correct the trouble only by training the vocal organs. Please observe, that stammerers can speak fluently when

alone at any time-the vocal organs are all right, and to try to cure the defect in this way only is certain to result in many failures. Undoubtedly, some stammerers do talk in an abnormal voice, and try to speak way down in the throat, but when alone they can speak in just that same way fluently. The record of 167 cases, under treatment by vocal training methods, show failure in more than 80 per cent. It can truly be stated that the other 20 per cent were of lesser severity, more easily treated, and might have responded to different impressions than the treatment was intended to convey to them. "Why is it," stammerers have frequently said to me, "I am puzzled at the fact that I can speak well and without hesitation when alone, and only hesitate when talking to others."' How futile to try to cure by vocal training there is no defect in the vocal apparatus. VE VE VE

SURGICAL STERILIZATION.

Neef, in the American Journal of Surgery, asserts that the process of sterilization by steam under pressure involves the following steps: Packing of the sterilizing space.

1.

3. Exhausting the air and filling the compartment with steam.

4. Permeation of the parcels by steam under a pressure of 15 pounds to the square inch and a temperature of 250° F. (121° C.) for 30 minutes.

5. Final drying of the parcels; the desiccation taking from 10 to 20 minutes.

The total time required for the work of sterilization in preparing for an operation may vary considerably and usually exceeds an hour, but the time consumed by the actual sterilization itself with the thermometer registering 250° F. and the manometer indicating a pressure of 15 pounds, should never be less than 30 minutes. Practically speaking in hospital routine the contents of each parcel have been subjected to the sterilization process twice before they are used at an operation. It is the practice to sterilize the contents of the parcels immediately after they have been made up to be put away in a parcel closet. When needed they are resterilized, and can then be taken directly from the sterilizer for use.

One object of this double sterilization is to attack spores, which initially show considerable resistance. But liberated from the bacterial bodies and made to germinate these are more likely to be destroyed during a second sterilization. Fortunately the pathogenic organisms which most commonly produce wound infections are cocci-streptomonly produce wound infections are cocci-streptococci, staphylococci, pneumococci, gonococci and