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empty out all their household refuse and soil into the streets.As there are no compulsory means of enforcing vaccinationit is easy to understand how quickly small-pox mayspread in such localities. On the other hand, where it hasbeen possible to enforce vaccination, its beneficent effect,even in the presence of bad sanitation, has been most con-clusively demonstrated. To make matters worse the inhabi-tants did all they could to conceal the cases which occurredamong them and the presence of small-pox was often onlyknown after a death had occurred. These poor Italians
object to see a medical man and are still more opposed to theprospect of being removed to the hospital. But the soldiers
belonging to the garrison of Nice often associate with thesepoor people and frequent the localities where they live.Every soldier is vaccinated ; and, if there is no result, he isagain vaccinated three times consecutively and then only ishe judged to be immune. The garrison at Nice this winteramounted to about 3800 soldiers and there has.not been onesingle case of small-pox among them. If, however, are
added to the garrison all those who are employed by thepublic municipal or departmental administrations, the Statetobacco manufactory, and the railway and tramwaycompanies, we find a grand total of about 10,000 personswho have now all been revaccinated. Among these 10,000people there were 14 cases of small-pox previously to vaccina-tion and two other persons who had avoided being re-
vaccinated had small-pox.With respect to the well-to-do classes and the visitors to
Nice there has been the same immunity from small-pox amongthose who had been revaccinated. But it would be a mistake,according to Dr. Balestre’s opinion, to consider such immunityas absolute. To his personal knowledge there have been afew cases among people who were successfully revaccinated.On the other hand, though this has been a most virulent
epidemic such cases among the revaccinated were of themildest type and the patients all promptly recovered.
Among his private patients Dr. Balestre noticed that in well-to-do families small-pox attacked the one member who hadnot been revaccinated while it spared all the others. Dr.Balestre is tempted to believe that the force of infectionvaries according to the virulence of the disease and thatvaccination is not so efficacious when the disease prevalentis of the worst type. This may explain why a tew personswho were revaccinated nevertheless contracted small-pox.It is true that they only suffered slightly but had the diseaseprevalent been of a milder character it is probable that
they would not have suffered at all. Whatever may bethe value of this conjecture, Dr. Balestre, as chief ofthe Bureau d’Hygiene, has had the best opportunity ofjudging and therefore I need make no apology for givinghis opinion.
I can only find record of six cases of small-pox occurringamong the members of the British and American colony atNice. Some of these cases were, however, very charac-teristic. Thus in one large household the servants andothers were revaccinated with the exception of two brothers.Shortly afterwards one of these brothers contracted small-pox ; the other hastened to be vaccinated. Together with allthe other members of the household he has escaped from theinfection. Another and a particularly dramatic case relatesto a lady who was a Christian Scientist. As such she wasmuch opposed to vaccination and had persuaded a younggentleman not to be vaccinated. Hearing of this a ladyremarked to her that she hoped that no evil would result fromher action. Within a week of this warning the ChristianScientist died from small-pox. The young gentleman, herconvert, thereupon once more changed his opinion and isnow to be congratulated on having been successfully vac-cinated. The third case was that of an old gentleman wholived so isolated a life in his villa, only going out in his owncarriage, that he thought he was quite safe. He would havebeen better protected by vaccination, for he contractedsmall-pox in spite of his isolation. Altogether, of the sixBritish and American visitors who contracted small-pox twodied and none of them had been revaccinated.One more incident may be mentioned as illustrating the
efficacy of revaccination. There is at Nice an almshousewhich contains 350 inmates. They were all revaccinatedexcept half a dozen bedridden and aged persons. None ofthe latter were under 70 years of age and it was not thoughtnecessary that they should be revaccinated. Nevertheless,one of these patients-he was 80 years old-contractedsmall-pox. This was the only case that occurred among the350 occupants of the almshouse In face of this experience
age is no longer accepted as an excuse and many very agedpersons have now been successfully revaccinated.Undoubtedly of the winter resorts Nice has suffered most
from the present visitation of small-pox but there have beencases in nearly all the other towns and even in one
of the very best hotels at Monte Carlo. With proper methodsand facilities for isolation such occurrences need not havecaused alarm. It is not as if small-pox had prevailed onlyon the Riviera. The reverse is the case, and the Riviera hasonly suffered from the reflex influence of what is occurringin many other parts of Europe. But until a proper isolationservice is organised throughout the Riviera the health resortswill continue to suffer from what are sometimes unjustifiablepanics and often exaggerated alarms.Nice, April 26th.
THE GERMAN SURGICAL CONGRESS.
(FROM OUR BERLIN CORRESPONDENT.)
THE thirty- first Congress of the German Surgical Associa.tion met in Berlin on April 2nd, Professor KOCHER (Berne,Switzerland) being in the chair. The great hall of Langen-beck House was overcrowded, the number of the membershaving increased from 130 in 1872 to nearly 1300 in 1902, ofwhom 659 were present, so that many had to find accommo.dation in the galleries. A remarkable fact was the relativelylarge proportion of foreign members, especially Dutch,Scandinavian, and Russian. France was represented byDr. Doyen who spoke several times during the congress,and Great Britain was represented by Mr. W. ArbuthnotLane. Professor Kocher in his inaugural address mentionedthe members of the association who had died during lastyear, making especial reference to Staff Surgeon-GeneralDr. von Coler, to Professor Julius Wolff, well known as
an orthopedist, to Dr. Schuchardt, to Dr. Langenbuch,and to Sir William Mac Cormac. The association then
unanimously agreed to the election as honorary membersof the following gentlemen, whose names were proposedby the committee : Professor von Bergmann and ProfessorKonig of Berlin, Professor Guyon of Paris, Professor WilliamMacewen of Glasgow, Professor Keen of Philadelphia, andProfessor Durante of Rome.
Military Surgery.The first meeting was devoted to a discussion on the
dressing of wounds on the battle-field, especially in the
light of the experience gained during the present war in BSouth Africa.
i Professor VON BRUNS (Tubingen) said that from a bacterio-. logical point of view a bullet-wound must be regarded asI infected, for bacteria were present everywhere. During the
early years of the antiseptic era military surgeons in theTurco-Russian war tried to apply the principle of Lister’s
. method even on the battle-field by carrying out thorough! disinfection, drainage, &c. It was the merit of Professor: von Bergmann, then in the service of Russia, to have shownthat this was practically a failure and that uncomplicatedgunshot wounds had a marked tendency to run an asepticcourse if they were only covered with an antiseptic dress-L ing to the exclusion of any other procedure. This was stillL more the case at the present time when the small-calibrer bullet produced wounds with a very small aperture of
entrance. These principles were also followed in the South. African war, the wounds being merely covered with a dress-I ing, and this being done on the British side as early as
l possible and previously to the removal of the patient from theplace where he fell. Professor von Bruns insisted especiallyl on the importance of the latter precaution, as the removal ofa wounded man even for a short distance without anadequate dressing was likely to have the worst pos-
sible consequences. The early dressing of the woundedt on the place where they were found during a battle! was a great advantage to them and was, of course, veryl dangerous to the military surgeon, who had to work some-f times under the fire of the enemy. Professor von Bruns
stated that the members of the Royal Army Medical Corps, were often to be seen attending to the wounded in positionst exposed to the fire of the Boers. Alluding to Count Bulow’s; words in the German Parliament he said that the Royal Army; Medical Corps had thus proved, like the other corps of the
army, that its members knew how to die. Under an earlJand simple dressing the wounds dried up and healed withoutsuppuration. A crust was formed when a powder like dermato:or xeroform was put on the wound, but impermeablematerial, such as caoutchouc tissue, protective silk, ancthe like, were to be avoided because they hindered thewounds from drying. Instead of the powder a dermatolpaste might also be used, but bandages were sometimesrather difficult to apply on the battlefield and might be
replaced by caoutchouc plaster. Fractures of bones must be- immobilised previously to the removal of the wounded man.It was not only the first dressing but also the first removal
which, according to the late Professor Volkmann, decidedthe man’s fate.
In the discussion Dr. BERTELSMANN (Hamburg), who hadserved with the Boers at the siege of Mafeking, said that he’had seen 52 wounds heal without suppuration. This took
place although the hygienic conditions in the Boer campswere far from being satisfactory and the transport and otherarrangements were quite unsuitable for their purpose. Inhis opinion the good results were obtained because thewounds were scarcely touched by the finger or by an instru-ment ; he only applied some gauze and fixed it by adhesiveplaster. Perhaps it was due to the dryness of the SouthAfrican atmosphere that the wounds healed well under acrust of dried blood.
Professor KUTTNER (Tubingen), who had been with theGerman Red Cross Ambulance in the South African war, aswell as in the Turco-Greek war and in the China expedition,was of opinion that climatic conditions had but little influenceon wounds, as he had obtained the same results in countriesfar removed from one another, provided that the aseptic andconservative method was used and the wounds were touchedas little as possible. In this way the wounds produced bythe modern rifle when uncomplicated healed very well andmuch better than did those inflicted by the bullets of thelarge-bore rifles formerly used. Of all his bullet wounds
only 12 per cent. suppurated and of the shell wounds 40per cent.
Dr. HILDEBRANDT, one of the medical officers of theGerman Red Cross Ambulance with the Boers, spoke on thetreatment of abdominal wounds. There was at present amarked tendency to abstain from laparotomy in these casesbecause they were believed to have the best chance of
recovery when they were left alone, but this was in Dr.Hildebrandt’s opinion erroneous, for the mortality was still atthe rate of 70 per cent. Men who after two or three days hadcome to the field hospitals without complications generallyrecovered without operation, but when perforation of the in- ’,testines had led to peritonitis operation at that stage was nearlyalways unavailing. If, therefore, perforation of the intestineswere known to exist laparotomy and suture of the intestinemight be performed at once, even at the dressing station ofthe field ambulance at the front ; notwithstanding the con-trary opinion of other military surgeons, and especially ofthe late Sir William Mac Cormac, he thought that theseoperations were justifiable.
Professor TRENDELENBURG (Leipsic) showed a patient whoseheart had been entered by a bullet and who had been con-veyed to the hospital in a state of severe shock but withouthaemorrhage into the pericardial or pleural cavity. It wasa striking spectacle when by means of the Roentgen rays thebullet was seen moving freely within the ventricle ; at
present the bullet was adherent to the cardiac walls and onlymoved in unison with the cardiac movements. The patientwas now in good health and he complained of nothing.
Treatment of Fractures.Dr. NiiLKER (Heidelberg) recommended the suture of the
fragments in certain cases, namely, in compound fractures,in fractures of both bones of the same limb-for instance,the tibia and fibula-and in fractures where the displacementof the fragments rendered exact apposition impossible. Thedangers of suture after the injury were not very great,especially when only one bone was broken ; in bones coveredby thick layers of soft tissue, such as the femur, or in theneighbourhood of joints, the operation was more complicatedand therefore not without risks. Sutured bones healed some-what slowly because the development of callus was notassisted as in other cases by the mutual friction of thefragments.
Mr. ARBUTHNOT LANE gave an account of about 150fractures in which the fragments had been sutured by him.He recommended the use of silver wire.An animated discussion took place with respect to the
r methods to be followed, the time of operation, and theb material to be used. Some surgeons recommended that theL fragments should be secured with nails or screws. Professor SCHEDE (Hamburg) used ivory pegs which wereL left in the wound.
Professor SCHLANGE (Hanover) uttered a warning againstL operating without proper indications. In the majority of; cases fractures did not require operation but united under treatment by extension and fixation, which must continue to
be the normal procedure. Suture was, however, ometimesindispensable, as in the so-called spiral fractures, in frac-
. tures of the tibia, and in fractures in the neighbourhood ofthe joints. Professor Schlange had obtained good resultswith aluminium-bronze wire.
(To be continued.)
NOTES FROM INDIA.
(FROM OUR SPECIAL CORRESPONDENT.)
An Epidemic of -Dengue Fever in Rangoon.-A Petitionfrom the Bombay Medical Union.-The Plague Epidemic.IT is reported that after an absence of about 30 year:
dengue fever has appeared in Rangoon and has spreacrapidly. The disease is very contagious, several case;
occurring in the same house. It is said to have beer
prevalent of late in Penang and Singapore, so that it hasprobably been brought from the Straits.The Bombay Medical Union has submitted a petition to the
Viceroy in which it is urged that whereas the Govern-ment has in the past refused to appoint Indian medica]men to the public service unless they had passed a specialcompetitive test, several medical officers brought out for
plague duty have now been posted to the Indian MedicalService without competitive examination ; the BombayMedical Union prays that Government will consider theclaims of graduates of Indian universities and of othernatives to appointments in the Indian Medical Serviceand will also increase the number of civil surgeon-cies allotted to civil assistant surgeons. This isthe old question of admitting native medical men
without going through the prescribed competitive exa-
mination in England. After all, very few of the Europeanplague officers have accepted the commissions offered so thatthe commissions must be looked upon more as rewards forservices rendered rather than as any intention of altering theconditions upon which medical men can enter the service. Itis generally acknowledged in the service that it would be
very undesirable to relax the conditions now existing exceptn very special circumstances.The last returns of plague deaths in India show that the
lisease is still spreading. There were 26,108 deaths in theweek ending March 22nd, as against 25,655 for the previousseven days. The Punjab shows the chief increase-16,829leaths having been there recorded. In the Bombay Presidencyas well as in the Bengal Presidency there was a decline and soLlso in the Madras Presidency. There were more deaths (932)n Kashmir and also in Karachi city (74). Returns issuedater show that the diminution in Calcutta (420) was onlytemporary—the last week showing a rise again to 550 deaths.Notwithstanding the special precautions to keep plague out)f Simla the disease is approaching closer and closer and itwill probably be only a short time before the native
quarters become invaded. In Bombay city the advance of;he outbreak has apparently made a halt as the deathsecorded from plague were only eight more than in the pre-ceding week. The general mortality of this city is very high,,he total deaths for the week ending March 27th being 1676,vith a rate of 112’30 per mille. As there is very little:holera or small-pox or other epidemic disease in Bombayhe high mortality suggests that there must be more plagueleaths than are accounted for. This, however, has been thetatistical history since the plague first appeared in 1896.April 3rd.
The Plague Epidemic. -Medical Reform Before the Universities’, Commission.
The high plague mortality throughout India continues.This week there have been registered 23,286 deaths, as
against 23,836 during the previous seven days. There hasbeen an increase in Bombay city (957 against 816), inKarachi (128 against 70), in Calcutta (689 against 550), and