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it is similar to the one in Vienna. This is the only hospital in Graz and different grades of accommodations are offered, the first class paying a gulden and a half per diem, the second one gulden, and the third a few kreuzers. This inevitable continental class distinction is also in vogue about funerals and people can order a first, second or third class display in accordance with their purse or family pride.

The Children's Hospital is a separate building and situated about half a mile from the General Hospital. A few months ago extensive alterations and additions were made so that now it is one of the most complete and best arranged Children's Hospitals in this part of the world. It contains about eighty beds including medical and surgical cases. The laboratories are a special feature and exceedingly well equipped. Original investigations are welcomed and the men given every opportunity for research. The assistants now working there are all engaged in some special work in bacteriology, chemistry or pathology. There has been an atmosphere of work in this building for a number of years. Professor v. Jaksch was the director until 1890, when he was called to Prague, and it was here that he did most of the clinical work necessitated in writing his well known book on Clinical Diagnosis. Professor Escherich is a bacteriologist of no small fame and is the most indefatigable worker I have

His private practice is swallowed up in his thirst for knowledge and he spends most of his time at work in his private laboratory in the hospital. He takes great interest in his little patients and his morning visits are very thorough and most instructive, as he takes pains to demonstrate the interesting features and frequently throws out valuable hints.

Among many interesting cases is one of acute gonorrheal urethritis, vaginitis, cystitis and proctitis in a child of six. The patient was brought to the out-patient department with a vaginal discharge which on microscopical examination was rich in gonococci. The child suffered much pain on urination and the urine was cloudy. Stained preparations of the sediment showed pus cells, many of which contained the characteristic gonococci. The stools were observed to contain pus and the microscope revealed here also the presence of the gonococcus. Agar and blood serum cultures made

yet met.

from the urine and fæces contained pure colonies of this microorganism. The primary infection was undoubtedly in the vagina and extended from there into the bladder and rectum. This extension into the rectum is probably often overlooked as it produces few symptoms. Recently a number of cases were reported of gonorrhæal proctitis found in prostitutes. Gonorrhea in children is of lamentable frequency. Its cause is more often accidental than vicious. In the poorer families an infection in either of the parents can very easily be transmitted to the children. Entire families using the same bathing water is a not infrequent source of contagion. The gonococcus seems to have a special virulence on the genitals of small girls.

Surgical treatment in all cases of appendicitis, advised and championed by American surgeons, is looked upon with much disfavor in Austria and Germany. One accustomed to seeing frequent operations preformed for appendicitis is almost startled by the very small number of such operations in the German surgical clinics. Dr. Edgar Van der Veer called attention to this in one of his letters to the ANNALS, and Dr. MacFarlane wrote of the medical treatment employed by Leube in Wurzburg and the wonderful results obtained. In Vienna I saw four cases of appendicitis completely recover in the medical wards and was led to make some inquiries concerning the treatment employed and advised by the German school. Nothnagel, by the way, seriously objects to the term appendicitis and would inflict upon us the word skoi koiditis, of Greek derivation. Four forms of appendicitis are recognized :

1. The catarrhal form which is by far the most frequent. The prognosis in this form is very good.

2. The stenotic form, where, owing to contraction in the lumen of the appendix, there is much pain of a coliky character. The prognosis is considered good.

3. Purulent form. This is generally a perityphlitis and the prognosis is unfavorable.

4. Abscess. This may become encapsulated and open into one of the neighboring organs.

Surgical interference is indicated in the third and fourth forms.

In the first stages of the disease the appendix is inflamed 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.

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. To this 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

Glenard, who has done such good work in

bringing to the attention of the medical profesHepatic

sion the frequency and significance of gastroDiathesis

ptosis, shows in his recent volume "Les Ptoses Viscerales" how narrow and circumscribed such original work

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