INDIANA is now experiencing an epidemic of smallpox, and from the present outlook those in charge will not take the necessary steps to check its ravages until they are compelled to do so. It would seem that men high in authority should know better than to permit a disease like smallpox to continue when its spread can be prevented. Unless the State of Indiana takes some active measures to stay the progress of smallpox it is certain that the State of Kentucky will quarantine against her. We again assert that there should be a compulsory law as to vaccination. No man has a right to put his neighbor in jeopardy, and that is just what the unvaccinated man and the man that is roving about over the country with smallpox is doing.

OUR city Health Officer, Dr. M. K. Allen, is doing good work in the matter of keeping a sharp eye on the vendors of swill milk, stale meat, fish, etc. There should be a law prohibiting the exposure of fresh meats on blocks, shelves, or benches during this hot weather unless they are enclosed with screens in such a manner as to keep the flies away, as flies are known to be the bearers of all kinds of filth. The market-men need to be taught at least some of the lessons of cleanliness.

Current Surgical and Medical Selections.

ON THE TREATMENT OF DIABETES MELLITUS.—(Williamson, R. I. The Medical Chronicle.) In trying to form an opinion as to the value of any method of treatment in this disease, it is important to bear in mind that occasionally in some of the milder cases the sugar excretion may for a time disappear, apart from any influence of diet or drugs; also that the occurrence of complications such as phthisis, nephritis, etc., may cause a marked diminution in its excretion which, if care be not exercised, may appear to be the result of treatment. Furthermore, it is important to distinguish between the results due to diet and those due to drugs. For therapeutical purposes three forms of the disease are recognized:

1. The mildest form, in which the sugar excretion ceases when a rigid diet is given these cases are to be distinguished from those of temporary glycosuria by the persistence of the excretion.

2. The more severe form, in which the sugar excretion does not cease on a rigid diet.

3. The most severe form, in which not only does a rigid diet fail to arrest the sugar excretion, but in addition the urine gives a dark brownish red coloration with perchloride of iron. In this form there is great danger of coma developing.

This classification of cases is not a scientific one, but is a very practical one for treatment. Before prescribing, it is also important to examine the lungs for signs of phthisis, especially in the second and third forms, and to examine the heart for signs of dilatation or other disease, especially in patients of more advanced age.

The weight of the patient should also be taken, and a record kept of it at regular intervals. In Dr. Williamson's opinion the weight of the patient is even a more important guide in carrying out treatment than is the exact amount of sugar excreted.

In prescribing a dietary, continental physicians have endeavored to calculate the value of the various food ingredients in calories according to the rule that one gram of proteid equals about four calories; one gram of carbohydrates equals about four calories; one gram of fat equals about nine calories.

From the total value of the diet in calories thus estimated the value in calories of the sugar loss is subtracted and the remainder should be not less than twenty-three hundred calories, the amount required daily by a healthy man. Such an estimation may be of service in indicating when the diabetic diet is deficient, but there are reasons for believing that such an estimation is not quite so scientific and valuable as at first sight may appear.

In commencing the dietetic treatment of diabetes a very rigid diet of nitrogenous and fatty food is prescribed at the outset to ascertain whether it is possible to arrest the sugar excretion thereby. This is useful in the first and second forms of the disease, but in the third form, in which the urine gives a reaction with perchloride of iron, it should not be tried, lest with a too rigid diet coma may supervene. Although a careful diet will cause the sugar excretion in the mildest cases to cease, in some the addition of even the smallest quantity of carbohydrates to the diet will induce a return of the sugar excretion, while others will be found to tolerate a certain amount of the carbohydrates, and in such cases it will be necessary only to restrict the diet sufficiently to prevent the excretion of sugar. It is also found that sometimes after an arrest for a short time by a rigid diet that the patient can tolerate more and more carbohydrate, but in others again, even after a prolonged period of rigid dieting, the addition of a small amount of bread or other carbohydrate will bring back the glycosuria. In such cases, should the patient on a rigid diet be found to lose weight rapidly, it will be necessary to relax and to be content if by moderate restriction we can keep the daily excretion of sugar down to about five hundred grains. In the second form the diet demands much care; if it is found that on a rigid diet the sugar excretion remains abundant and the patient's general condition becomes worse, a certain amount of carbohydrate food must be allowed in the form of ordinary bread and milk, fatty food, and especially cream and butter.

With regard to the third form, Dr. Williamson emphasizes Ebstein's rule that the appearance of a perchloride of iron reaction in the urine is an

indication for diminishing the albumin and increasing the carbohydrates in the diet. In this form fatty food is especially indicated, and a small quantity of spirits may frequently be of service in aiding its digestion. Milk contains about 4 per cent of objectionable milk sugar, but also much valuable fat and albumin; cream contains less milk sugar and seven times the amount of fat, and therefore may be allowed freely in all forms of diabetes. Dr. Williamson has prepared an artificial milk, practically free from sugar, which he says may be taken in unlimited quantities by diabetic patients in all forms of the disease. Four tablespoonfuls of cream are added to a pint of water and well mixed; the mixture is allowed to stand in a cool place and at the end of twelve hours the fat of the cream will have floated to the surface and can be skimmed off; to this are now added water, the white of an egg, and a little salt, and, if desired, a trace of saccharine. By practice an artificial milk can thus be prepared modified to suit the patient's taste.

In preparing the dietary for diabetes it is to be remembered that of the various carbohydrates starch is less injurious than sugar; fruit sugar is less injurious than cane and grape sugar, but fruit which contains much sugar should as a rule be forbidden. Bread is the article of diet which gives the greatest difficulty when a rigid diet is demanded. The substitutes usually employed are often unreliable and their taste disagreeable. Dr. Williamson prefers to have the bread substitute prepared in the patient's house or in the hospital, as being less expensive and more reliable. The following are, in his opinion, the most useful: gluten, soya biscuits and bread, almond cakes, and cocoanut cakes. The directions for preparing these are as follows: four ounces of almond or cocoanut flour is mixed with a little water and German yeast, the mixture allowed to stand in a warm place for about twenty minutes; an egg is then beaten up and a little water added, and the whole made into a paste. This is divided into cakes and cooked for fifteen or twenty minutes. Ebstein recommends aleuronat as an excellent substitute, and Dr. Williamson says that he has found that from mixed aleuronat and cocoanut powder very palatable cakes can be easily prepared. His directions are two ounces of desiccated cocoanut powder mixed with a little German yeast and water and kept in in a warm place for about twenty minutes, then two ounces of aleuronat are added and one egg and a little saccharine solution. The whole is well mixed, divided into cakes, and baked. When freshly prepared they are said to be very palatable, but by keeping the taste may become unpleasant. Recently Ebstein has recommended another vegetable albumin, ergon, an albumin from rice, and Pickardt has employed roberat, an albumin derived from corn. All these may be used in the preparations of puddings and other articles of food for diabetic patients. For the relief of thirst, dilute acid drinks are preferable to beer.

The patient should be relieved of mental anxiety and worry as much as possible, and the hours of work, business, or study should be diminished; a holiday with complete rest from work often has an excellent effect on such patients. While in the mild form open-air exercise may be of service, in the more severe forms vigorous exercise is injurious, and the fatigue induced by long railway journeys may be dangerous. It is well known that marriage has a most injurious effect on diabetic patients.-Montreal Medical Journal.

THE WEARING OF GLOVES AT OPERATIONS AND THE INFECTION OF WOUNDS FROM THE ATMOSPHERE. (Alexis Thomson, M. D., F. R. C. S. Ed.) While all surgeons are agreed as to the necessity of reducing to a minimum the number of organisms gaining access to any wound, a considerable proportion are prejudiced against such refinements of technique as the wearing of gloves during operations. To these we cordially recommend the perusal of an interesting communication on this subject by Heile, of Breslau. Having arrived at the conclusion that it is impossible by any method to get rid of all the organisms from the skin of the hands, Mikulicz adopted the practice of wearing cotton gloves at aseptic operations, not with the object of doing away with the necessity of disinfecting the hands as thoroughly as possible, but as a means of further diminishing the number of organisms introduced into the wound. Some of the hand bacteria may filter through the meshes, but the great majority are retained in the gloves. The author has investigated this question of permeability by a number of experiments. Having smeared his hands with a culture of the bacilli of rabbit septicemia, he carried out a number of operations on rabbits, in one series with gloves and in another without them. The operation -a deep incision in the back along one side of the vertebral column, closed by sutures was the same in all, and lasted exactly the same time, fifteen minutes; all the animals in both series died. An exactly similar set of operations was then performed, only the hands, after being infected, were mechanically washed for one minute, i. e., very incompletely disinfected; under these conditions the wearing of gloves made an important difference, for all the animals operated upon without gloves died, while nearly half of those in which gloves were worn recovered.

The importance of changing the gloves at intervals was shown by another series of experiments: if the same gloves were used for a number (four) of operations, one after the other, they no longer protected the wound from infection; whereas, if they were changed after each operation, the number of organisms which passed through the meshes became smaller and smaller. For the details of these and other experiments the reader is referred to the original paper, but the author presents a strong case for the efficacy of gloves in diminishing the risks of wound infection so far as the hands of the operator and his assistants are concerned.

The next point investigated was the deposit of bacteria from the air of the theater upon the surface of the gloves. The author estimated the number of organisms deposited from the air of the theater by exposing large agar plates. The number varied with the disturbance of the atmosphere and with the presence and number of individuals in the theater, whether participants or spectators. While on the days between operations only three points of growth resulted after half an hour's exposure, the number rose during an operation to sixty or more. The number of points of growth was materially increased by merely walking about the theater, although clothed in an aseptic over-all, or by waving a sterilized towel so

as to circulate the air and its floating particles. The number was remarkably increased after the entrance of spectators into the theater. The effect of disturbing and separating dressings in which discharge had dried by evaporation was not only to disseminate organisms throughout the air of the theater, but it was found that they tend to cling in large numbers to the coat of the operator, rendering the latter a carrier of infectious material. Every one who is to enter the operating theater should put on an aseptic over-all immediately before entering, and preparations for the operation should be made as far as possible in an anteroom, so as to disturb the atmosphere of the theater as little as possible. The operator and his assistants must persistently avoid any contact with septic material, and must wear rubber gloves when obliged to operate or handle septic wounds or suppurating conditions, such as appendicitis. In aseptic work rubber gloves are not only a hindrance to manipulation but may be a source of danger, for if they are punctured or torn the accumulated perspiration and bacteria of the hand escape into the wound. Cotton gloves are worn in all aseptic procedures, especially in the handling of ligatures and sutures, and they should be changed at intervals during the course of the operation.

Surgeons who have not personally tried operating in cotton gloves are apt to think they will interfere with their manipulations, whereas the contrary is the case; they give a better grasp of the instruments, and especially of the ligatures and sutures. Doubtless they impair the accuracy of touch, for example in exploring the abdomen with the fingers introduced through a small incision; but for this purpose the glove is removed, the fingers are washed in saline solution, and are introduced into the belly; the necessary information having been obtained, the subsequent manipulations are performed with the gloved hands. In practice it is convenient to have several pairs of cotton gloves sterilized along with the gauze, towels, and over-alls in the metal drums in everyday use.-Centralbl. f. Chir., Leipzig.

AN UNUSUAL Tumor of the Soft Palate.- (Ernest R. Brown, M. D). The patient whose history is here presented was a male of about fortyfive years of age. He came to the writer's clinic with the following complaint For the past twenty-four or forty-eight hours he had been suffering great pain and inconvenience with what he described as a painful swelling of the throat.

On questioning him, the following information was elicited: He had always been strong and healthy, never having suffered from any illness, with the exception of two or three attacks of pain and swelling in the metatarsophalangeal joint of the great toe, and about the same number of attacks of a similar lesion to that for which he now sought relief.

Examination of the mouth and pharynx demonstrated a tender mass of vivid pink color, the size of a marble, situated on the right half of the soft palate.

This, on palpation, was firm and without fluctuation. The following interesting fact was mentioned by the patient at the time of examination :