and hyperæmic but no pus is present. An exudate is then thrown out which after a few days envelopes the offending member and the true condition becomes hard to recognize.

They do not operate in this stage and claim that if these cases are not interfered with they will heal spontaneously, whereas an operative procedure is liable to set up a peritonitis. Unless they have positive indications they never operate during the first attack. My informant assured me that relapses occur only in 20 to 30 per cent. of these cases. As a rule an operation is not advised until after the second attack. There are a very few German surgeons, notably Carl Beck and his school, who advocate the abortive operation and remove the appendix after the disease has lasted a few hours but they refuse to operate after the appearance of the exudate. Strümpell wisely advises that it is better to operate early than too late. The indications for the operation are:

1. When the acute condition has continued for more than two weeks with high fever and much pain.

2. When a large fluctuating abscess is detected.

3. When the process spreads and is no longer localized. 4. When a perforation occurs.

5. In the interval after the second attack.

To this

The treatment of appendicitis carried out in Professor Nothnagel's wards is as follows: A complete rest of the intestinal tract is the main object to be attained. end they give large and frequent doses of opium. One case I saw was receiving one and a half grains of opium every two hours. The first few days the patient is almost starved and is given only an occasional teaspoonful of milk. Throughout the entire disease a rigid milk diet is enforced. The patient must lie quietly in bed and an ice bag is kept constantly over the right iliac region. For the constipation produced by the opium they give no laxatives but later on low enemas are allowed.

The seed of intubation sown by O'Dwyer in Germany fell upon good ground and is now bearing fruit even an hundred fold in saving thousands of lives. In this case at least the Germans give honor to whom honor is due. In the four diphtheria pavilions I have visited, the only picture in three and the only one outside of religious subjects in the other

was either a photograph or engraving of Dr. O'Dwyer. All the children's hospitals are unanimous in advocating its use and the only divergence of views lies in regard to its utility in private practice. Before the recent Medical Congress in Munich Dr. Trumpp in a very strong paper pleaded for its more general employment outside of hospitals. He collected much information from practitioners of all lands as to their experience and the results gave a strong support to his plea for the use of intubation in private practice.

H. L. K. SHAW.

Editorial

In the annual address to the

American

"Psychopathic Medico-Psychological Association, Dr. Frederick Hospitals " Peterson (American Journal of Insanity, July, 1899) discusses the probable direction of progress in the future care of the insane, and points especially to the discrimination between acute or recent and chronic cases of insanity. In the care of the latter the custodial feature predominates, and what has long been known as moral and environmental treatment has been emphasized in hospitals for the insane. There remains little to be done for this class beyond provision now recognized as essential: home-life, employment, recreation, hygienic buildings and orderly living have been secured in many localities, and principles are well established. In respect of the recent cases, however, problems as to methods are still under consideration, and in process of solution. It has been determined that there must be a clear dividing line between the acute and chronic cases, and that the medical, hospital treatment of the former offers a distinct contrast to the demands of the latter. In the large State hospitals this distinction has in many instances been recognized, but structural and administrative changes come slowly, and the ideal is still to be attained.

The need of provision for prompt emergency treatment of acute cases is generally appreciated, and Dr. Peterson believes that the first twenty years of the coming century will develop special hospitals or special pavilions in connection with existing general hospitals for the reception of acute cases of

insanity in every city of from 50,000 to 100,000 inhabitants. Such institutions would be known as hospitals for nervous or mental diseases, or, as has been suggested, "psychiatric clinics," or "psychopathic hospitals." The name, however, is less important than the fact, but avoidance of all distinctive title would most emphatically place these patients where they belong, as subjects for general medical treatment.

There can be no reasonable dissent from the proposition which has been so concisely summarized by Dr. Peterson, and it is with no small degree of satisfaction that the ANNALS is able to announce that the pioneer institution of the kind is to be built as an additional pavilion to the new Albany Hospital. The abuses in the management of acute cases of insanity in Albany have long been known, and some especially flagrant instances during the last year attracted public notice and resulted in a concerted effort on the part of the practitioners of the county to secure a proper building. In response to their earnest representations the County Board of Supervisors have appropriated eighteen thousand dollars for the erection of this pavilion and plans are now under consideration. It is anticipated that cases of acute delirium, alcoholic or otherwise, may be here protected from dangerous delays and neglect; that doubtful cases may be observed during consideration of the proper disposition to be made; and that commitments may be carefully and judiciously considered to the advantage both of the patient and the State institution to which he may be sent. Other possibilities suggest themselves, and the development of the field of usefulness of the new institution will be watched with interest.

The proper claims of the insane are now met, and the experience to be developed in this annex to the Albany Hospital will reveal in great measure the extent to which it is desirable to carry the plan for the treatment of the acute insane in local hospitals.

The

Hepatic Diathesis

Glenard, who has done such good work in bringing to the attention of the medical profession the frequency and significance of gastroptosis, shows in his recent volume "Les Ptoses Viscerales" how narrow and circumscribed such original work

ers often become and how a small fact may in their minds. become the most important. He lays great stress on the existence of a hepatic diathesis and claims that certain diseases of metamorphosis are often associated with changes in the liver and the functions of this organ. This change is the beginning and cause of the group of diseases commonly classed in France under the name "arthritisme." This hepatic diathesis-recognized by palpable changes in the liver descent, total and partial enlargement, deformity of the individual lobes, variations in the form, consistence and sensitiveness of the lower border-determines not only diabetes, gout, adiposity, chronic rheumatism, gall and renal stones, but a number of other diseases as forms of enteroptosis, many diseases of the gastro-intestinal canal, neurasthenia, migraine, asthma and some affections of the skin.

These all show manifestations of this hepatic diathesis and indicate developmental periods as they may follow one after another in the same person. This diathesis is either inherited or developed from causes of a toxic, infectious, emotional or traumatic nature.

Status Lymphaticus and

The unexpected and sudden death in young children which formerly were unexplainable and recently attributed to the hypertrophy of the Diphtheria thymus, have been investigated by Dant in the Jahrbuch für Kinderheilkunde, more especially in reference to their recurrence in the course of diphtheria when antitoxin or cardiac failure without any previous heart weakness is said to have been the cause. Dant refers to Paltauf's opinion that the hypertrophy of the thymus together with the swelling of the spleen and hyperplasia of the lymphatic tissue is only part of an abnormal physical constitution of a lymphaticchlorotic nature. Escherich also attributes many unexpected deaths occurring in the course of diphtheria to this cause and divides twenty-seven such cases in the years 1894 to 1897 into three groups:

1. Cases in which this condition was the direct cause of the unexpected rapid death as it was strikingly prominent and other cause of death could not be discovered.

2. Cases where in the presence of complications, as pneu

monia, occlusion of bronchi, the status lymphaticus had a marked influence on the course of the disease.

3. Cases of septic diphtheria in which post mortem the status lymphaticus was determined and the clinical symptoms did not indicate such a rapid ending of the disease.

Unfortunately the clinical picture of this lymphatic dyscrasia is not yet so distinct that a diagnosis can with certainty be made from the symptoms but it is often first suspected from the rapid occurrence of death. It is highly probable that a number of sudden deaths in children with acute diseases are due to this condition.

Scientific Review

Pathogenesis and Surgical Treatment of Hysteria. E. LAMBOTTE. Presse Médicale Belge, 29 Oct., '99.-From the earliest times observers have supposed a relationship between hysteria and some unknown lesion of the genital apparatus, and this belief, having become popular, has been continued till now. The evident correlation of neurosis with puberty, gestation and the menopause are among the causes for this pathogenic conception. It must be recognized, however, that this has always been and still is only a vague hypothesis, an obscure intuition haunting the medical mind. The nature, seat or physiologic mechanism of the lesion has never been precisely stated. Even the hypothesis has many adversaries. The malady was long supposed to be exclusively feminine and the uterus was specially incriminated. The discovery of male hysteria seemed to shake the foundation of the theory. "Reflex irritation" became the shibboleth. The classic neurosis remained distinct by the very obscurity of its origin. Antisepsis induced some surgeons to seek an operative solution of the problem. Uterine ablation, one-sided or bilateral ovariectomy, tubal resections, uterine repositions and even clitoridectomy resulted. Tait removed the annexes. The aim was either artificial menopause, sterility, frigidity, the suppression of chronic pains or a vague modification of the nervous system. The attempt to explain or cure by surgical, operative intervention, failed; then followed the reaction.