that the variation in the mortality during different epidemics varies considerably without apparent cause. It is stated, however, that since the use of the antitoxin at the St. Anna Kinderspital, the death rate has decreased 50 per cent. Parenthetically it may be noted that in this hospital the prevailing opinion is that about 75 per cent. of all cases of nephritis in children are the result of scarlet fever. In all these cases, a fading rash or evidence of desquamation is carefully sought. As a result, almost all of the nephritic children at the St. Anna Hospital are in the scarlet fever wards.

Only the more severe cases are treated with antitoxin-such as have high temperature, rapid pulse, cyanosis or symptoms of nephritis. Evidence of nephritis in these children-in the order of their appearance-are: increased blood pressure, increased weight (due to edema), and finally changes in the urine. Frequently an affection of the kidneys is diagnosed three or four days before casts are disclosed. These severe cases receive hypodermic injection of 150 to 200 c.c. of the antitoxic horse serum. Moser has not yet made any concentrated antitoxin -such as is used in the treatment of diphtheria. The injection may be repeated in twenty-four hours, if the results do not correspond to expectations. If the cases are seen early, the treatment is most effective; unfortunately, many are not seen until they are moribund. The effect of the injections varies in individual cases. As a rule, there is said to be within six hours a much more marked decrease in the fever than is to be expected in the ordinary course of the disease; the temperature then rises again, but not nearly to its former height. The rash fades, the mind becomes clearer and the heart action more regular. Even incipient uremia, resulting from post-scarlatinal nephritis, is said to abate.

In addition to these results, the presence of the horse serum is usually in evidence. In most cases an intense urticaria appears about two weeks after injection of the antitoxin. This cannot be avoided as long as such large quantities of horse serum must be used, but the eruption disappears rapidly and no other toxic symptoms are seen.

Marmorck's antistreptococcus serum, which was used before the discovery of the new seruin in all diseases in which the streptococcus was believed to be the exciting cause, has proved utterly worthless in the treatment of scarlet fever. (L. M. L.)

BALTIMORE LETTER.

ARTHRITIS DEFORMANS. PLAGUE IN INDIA. A CONSERVATIVE
PERINEAL PROSTATECTOMY.

On May 18th the Johns Hopkins Hospital Medical Society held its regular meeting. The program was opened by the exhibition of a case of arthritis deformans by Dr. McCrae. The patient is a man 56 years of age and was admitted complaining of pain in the right side and leg. His family history is unimportant. He has been a moderate user of alcohol, but never to excess. His present illness began two years ago with a pain in the back which has been constant. The pain has been worse at night and he has been in the habit of getting up in the night and walking the floor to obtain relief. The pain has recently become more severe and it has gone down the right leg. Movements now aggravate the pain. The patient gives an almost pathetic history of consulting a dozen or more physicians with no relief. Most of them treated him for rheumatism, but a few called it "abdominal trouble." In walking the patient favors the right leg. There is little to be made out on Examination. The patient is well nourished. The joints are negative and the reflexes diminished. There is no muscular wasting. The case on casual examination would be put down as one of neurasthenia, chronic rheumatism or sciatica.

The examination of the spine, however, gives the diagnosis. Inspection is negative. The back is a little bowed in the upper thoracic region, but no more than would be expected in a man of 56 who had worked hard all his life. The muscles of the back are all held very rigid. On having the patient pick up something from the floor he goes down with a perfectly stiff back. In stooping forward there is no movement below the 10th dorsal spine. The X-ray shows deposits of bone between the vertebræ thus clinching the diag nosis of spondylitis deformans. The only treatment in such cases is rest and this is best obtained by the plaster jacket.

In his remarks on the case, Dr. McCrae said that the process begins at the anterior aspect of the body of the vertebræ and advances along the anterior ligament. The symptoms will depend on the rapidity of the involvement. In rapidly advancing cases the Poker Spine is the result. On the other hand when it developes slowly the cartilages between the vertebræ are absorbed and in consequence the patient becomes bent forward. If the process extends posteriorly the nerves are pressed upon and peripheral disturbances result in the form of pain along the distribution of the roots involved. The process may be confined to only a few vertebrae or it may be a general process. Thus many of the minor complaints of pain in the back may be explained. During the day when the muscles are held rigid, the pain may be slight, but at night when relaxation takes place the pain may become very severe. The process may go on to complete ankylosis. Absolute rest is the first essential in the treatment. At first it is best to use a plaster jacket. This is worn for two or three weeks and then a lighter jacket is substituted and finally a light brace. Some support will probably be permanently necessary. In his remarks Dr. McCrae referred to the paper read at the recent meeting of the American Medical Association by Dr. Walsh on the "Passing of Chronic Rheumatism.” Dr. McCrae's ideas are entirely in accord with those of Dr. Walsh, and he

thinks that the more these cases are studied, the less we will hear of chronic rheumatism.

Dr. McCrae's talk was followed by a paper on the Plague in India, by Dr. B. Rosalie Slaughter, of Washington. While in India she had an opportunity to study an epidemic of bubonic plague and was interested especially in the results obtained by the use of Haffkine's serum for rendering human beings immune to the disease. From the statistics she had gathered, the serum renders an individual immune for from four to six months. Reinoculation during the epidemies is, however, practiced every 3 months. After reinoculation it becomes active within 24 hours. The question has been raised as to whether the serum may not be harmful if injected into a person who is incubating the disease, but Dr. Slaughter's statistics seem to show that, far from doing harm, the serum seems to make the attack milder. It, however, has no effect on the course of the disease after the development of symptoms.

The last paper on the program was on the subject of "A Conservative Perineal Prostatectomy", by Dr. Young. The operation is one devised by Dr. Young himself. After the median incision in the perineum and the division of the central tendon and the constrictor urethra, an opening is made into the urethra and through this a special instrument is introduced into the bladder. This instrument is so arranged that, after introduction, by turning a handle at the external end, the internal portion becomes T-shaped and can thus be used as a tractor. On making traction on this instrument the prostate is drawn up into the wound and enucleated. Dr. Young takes special care in his operation not to disturb the ejaculatory ducts. The bladder is irrigated for some time after the operation is completed. (R. G. W.)

THE MILITARY HOSPITAL AT MADRID, SPAIN.

By H. V. Wurdemann, M.D., Milwaukee.

During a recent visit to Spain, through the kindness of Dr. Angel Morales Fernandez (Medico de Sanidad, Militar del Yereito, Espanol) Captain and Oculist to the great Military Hospital of Madrid, I had the opportunity of a thorough inspection of this modern and most excellent collection of hospital buildings.

The Madrid Military Hospital was founded in 1843, and occupies a large edifice within the old city on the Rue de la Princesse, which had been used by the "Company of Jesus" for the education of the children of the nobles. Modern sanitary science, however, showed the Spanish that this building was inadequate. It was used for a cholera hospital during the epidemic of 1885.

The new hospital was projected in 1873 under the direction of the Sanitary Military Corps, but the site was not selected until five years afterwards, when plans were drawn for buildings to contain 1,000 beds; however, it was not started until 1879, when orders were given for construction of edifices to contain 500 patients. . The years went on

until finally, in April, 1887, most of the present construction was well under way, and at this date building operations are still continuing. The site is on an eminence in the environs of the little village of BasCarabanchel, about five miles from the west gate (Puerta del Sol) of Madrid, and for this reason it is sometimes called by the name of the village.

Being some distance from Madrid and unsanitary people and at an elevation of nearly a mile above the sea, the air is pure and conducive to good health. Although so near Africa, the climate of the Spanish highlands is remarkably cool except when the sirocco blows from the south off the Sahara, when the air is dry, dusty and suffocating. The winters of this locality are decidely severe (for Southern Europe) because in the north and west there are no near mountain chains to mitigate the wintry blasts.

The buildings are well arranged to meet these varying climatic conditions. A fair electric tramway system and a nearby railway station give easy access from the city and country.

The hospital is composed of twenty-four two-story brick buildings, some of them communicating with each other by glass walled galleries, the bricks being of porous red clay and laid in mortar without pointing, which method allows, together with the excellent ventilating system, of free percolation of air. I was particularly interested in this architectural feature, and wonder if the sacrifice of strength from the non-use of cement will make a great difference in the lasting qualities of the materials.

These twenty-four buildings are arranged in an irregular hexagonal reservation of about 100 acres and cach pavilion is reserved for special work or cases. The central and front building is devoted to the guard, to the direction, and the resident surgeon; back of this is the convalescent building; in the central area are the chapel and other buildings devoted to genito-urinary diseases, infectious diseases, internal maladies, surgical cases, tuberculosis, insanity. These are twostory and basement buildings, with four large wards, each extending from the central hallways. The post-mortem building, that for the laboratory and teaching of post-graduate military medicine and the operating theater, are models.

Operations are conducted in a separate pavilion, but this is connected by a covered way with the two surgical pavilions, so that no exposure of patients to inclement weather is necessitated.

The laboratory, drug and subsistence departments are in the same building and are thoroughly modern.

I was much interested in the preparation of microscopic specimens of pathogenic organisms which are prepared in large numbers here by Dr. Morales, and in the wax models of various external diseases which are made by his assistant for teaching purposes in the "school for instruction of medical officers" held in the same building.

There is likewise a complete photographic department, the intelligent use of which is attested by numerous photographic prints. A Roentgen-ray apparatus is likewise in constant use.

There are isolation pavilions for mental diseases (los locos) and for infectious diseases, and separate wards for syphilitic and gonorrheal cases, which here, as in other armies, make up a large proportion of the medical cases. Syphilis among the Spaniards seems more severe than with us; many cases do not apply for treatment until the deeper lesions appear. There were a number of cases of syphilitic peri- and osteitis (including a severe case of orbital periosteitis and cellulitis) in the wards; the wax models before mentioned, which were made from casts of patients, showed the prevalence of the gravest syphilitic lesions, such as we rarely see in America.

The steam laundry, disinfection rooms, stables and heating plant (hot air) are thoroughly modern.

There are about a dozen surgeons in daily attendance, of whom only the surgeon-in-chief and the medical officer on duty for the day reside in the hospital. The others live in Madrid and have a little time for private practice. Surgeons when not on duty spend their time. about the grounds or in the administration building, where there is a library and large well furnished rooms for their accommodation.

There are twenty Sisters of Charity and a company of men from the Sanitary Corps. Ample accommodations are provided for 400 patients (at the time of my visit there were 325), but the hospital could readily take care of double the number.

The tout ensemble of the hospital and the personnel of the staff shows that as regards military surgery the Spanish have reached the stage of asepsis and sanitary science. The military surgeons of Spain. may well feel proud of this institution.