on the way they pass almost as many going the other way under auspices of the Red Cross. There is really a certain fascination watching motor ambulances load up and get on the way; they never lose any time when they are empty, but with a load it's marvelous, the accurately, slow, steady pace at which the motor ambulances travel. No one can witness the transport service of the wounded without a thrill of admiration.

I told you about the cases of shell shock that I had met with while up front in August. Well, I had a long talk with an officer the other day, who had a most remarkable experience; he was in advance position; a shell burst near by, killing and wounding his comrades, but he had not a scratch. The trench he was in was raided by the Germans, and, being a medical officer, he was unarmed; however, he picked up a sand-bag and killed a German with it by hitting him on the head. Thereafter he had the same sort of a nightmare; he always found himself alone in a trench, being pursued by German soldiers; they were armed with bayonets; he had no arms and was always trying to run in sticky mud with heavy boots-you know the sensation. This nightmare repeated itself nightly, and he would awaken in a state of collapse; at last he was invalided home to England where he saw one of the consulting neurologists; this man did a bit of "Freud's research" and asked my friend if he had ever seen any of those Germans that chased him, and if they were always the same; he replied, after thought, that they were the same each night, and that the leader he now remembered had the face and appearance of the men he had killed with the sandbag. The consultant then told him that the next time he had the dream, to pick up the sand-bag and kill him (the German); and so my friend had the dream as usual; he was being chased through sticky clay in the trenches; he jumped behind a traverse, picked up a sand-bag, and the first German through was struck on top of the head with the sand-bag; he heard his neck. break and saw it was the same man he had killed before. My friend told me he awakened with a feeling of satisfaction; that from that time he has had no more nightmare and was on his way back to the front. He also told me many interesting things regarding the mental state of men standing in the trenches, fully knowing what it costs to dash over the parapet, but awaiting the order. Awaiting the order in suspense, with shell bursting about and machine-guns spitting hot lead, makes some cry, some laugh, others sing; while still others sit and doze and remain calm. When the order is given, they leap over the parapet with undaunted courage and wade through a shower of lead without the least hesitation; it's the suspense they cannot endure.

Monday, I had the pleasure of seeing the anti-aircraft defenses here cut loose on a "Fokker"-it was a beautiful sight. I was at the time walking in the garden when I heard a terrific bang and knew the guns at the fort near by were barking again at something. Looking skyward, I saw a "Fokker" coming right over the hospital, but very high; they let go with all sizes and kinds; they burst in front, behind, above and below, leaving black clouds; but the pilot displayed unbounded courage; he did not vary his course in the least; it must have been going something like a hundred; he went right on his way toward England. It has been a long time since a German aeroplant has ventured this way, and a still longer time since they have slipped anything overboard (bombs). "Zeps" attract little attention; they are reported so often over us on their way to and from England; but the only inconvenience is having all our lights put out just while one is in the midst of some little piece of work.

Winter is coming; it's been cold and rainy. How the poor dubs up to their knees in mud must hate it. Believe me, if I had a nice little dug-out I'd fight like the devil before I'd let it go. The German dug-outs are palaces-electricity, real beds, drainage as a matter of course. Although at war, one can appreciate a joke. Last year the airmen reported German trenches dry repeatedly, whereas the English were up to their rucks in mud and water. Investigation showed the Germans were pumping their trenches dry by delivering the water in the English trenches. In spite of the fact these people are such terrible enemies, one sees no signs of hatred; I am willing to wager there is a less excited crowd surrounding the bulletin-board when the "communiques" are posted than around the bulletinboards at home; no one talks about the war here; they talk about everything but that. I hope you people at home have given up peace talk; it only makes you more ridiculous and amounts to so much gibberish; the quicker the United States realizes that France and England will not tolerate outside interference, the better it will be for all concerned. The Americans are "in bad" all around.

If moving pictures of the Somme battle are shown, go to see it; it will show you something interesting especially "Tanks." It's a wonderful invention-a big catapillar-like engine that goes through houses, stone-walls or anything that happens in its way.

Colonel Leishman, of Leishman Donovan body fame-also Leishman stain-has been here the past three days; I had luncheon and dinner with him and the Colonel, Saturday. Last

week we had Lady Bagott here for three days; she has been getting money to establish hospitals in Belgium; she knew Morrow at LaPanne, and said he did good work there. She is a wonderful woman. I took her to tea Saturday, and Sunday she, the Colonel and myself started to visit another hospital about twenty-five miles out. We were tearing along the road when the steering knuckle broke; fortunately the driver had slowed down at the moment.

Thursday night we had ten German destroyers just off here; they sank a transport-the Queen.

POSITION FOR SIGMOIDOSCOPIC WORK

By Donly C. Hawley, A. B., M. D., Burlington, Vermont

A majority of writers express a preference for the kneechest position, while a minority prefer some other e. g. Hanes, Sim, or the exaggerated lithotomy position.

Before the days of the pneumatic sigmoidoscope the position was of necessity such as would admit of inflation by atmospheric pressure. Here the knee-chest position was doubtedly the most satisfactory.

The knee-chest position is trying and disagreeable for the patient and not easy nor always convenient or the operator. Its use is frequently attended with embarrassment and fear on the part of the patient.

With the pneumatic tube the older method may be done away with.

Place patient in left lateral prone position with left arm drawn out behind back, the patient lying well over on left chest and stomach, the knees flexed, the right more than the left and placed above and well over and beyond the left on the table and with the back concaved as much as possible.

In this position the abdominal muscles are relaxed, while in the knee-chest position they are apt to be contracted.

In a majority of cases the instrument may be passed easily and quickly over the brim of the pelvis and into the sigmoid colon as far as required or to its full length.

This method not advocated exclusively, but a more thorough trial is urged.

SURGICAL CLINIC

Kenneth A. J. Mackenzie, M.D., C.M., L.R.C.P. and L.R.C.S. Edin., Portland, Oregon.

The first case brought to the clinic was a myoma of the uterus, which afforded an opportunity for the discussion of the respective merits of the operations myomectomy and hysterectomy for the relief of the severe conditions which attend this disorder. The case was that of a woman, aged 56, who had had three children and who had been lacerated somewhat in childbirth. The perineum had been torn and the pelvic outlet was very much relaxed. The uterus on examination was found enlarged but no tumor could be differentiated. There was a tendency to prolonged bleeding at the menstrual periods and from year to year this state was accentuated. There was much abdominal pain and her general health had undergone severe deterioration during the past two or three years. Abdominal section revealed the uterus which was enlarged, soft and edematous, on the surface and in the substance of which one could palpate at least seven small fibroid tumors ranging in size from a bean to a walnut.

Doctor Mackenzie discussed the two operations which are considered for the relief of such cases and spoke of this case. in particular as offering the opportunity for the performance of a conservative operation. Those of the tumors which were subserous were divided at their bases with scissors and removed and the serous edges were brought together by suture. The intramural tumors were removed after an incision had been made through the walls to the level of the tumors and then enucleated with a blunt dissector. The advantages of this procedure were that the tumors were removed without the extirpation of the uterus, there was less hazard in the operation and it seems to be specially adapted to women who have not passed the menopause and who might be desirous of bearing children. The operation is quickly done and there is no risk of wounding the viscera, the bleeding being negligible and easily controlled. The drawbacks of the operation referred to are that it might not prove to be radical inasmuch as one or more small tumors left behind might grow and call for further operation. Doctor Mackenzie spoke of the ease with which single pedunculated tumors could be removed and also spoke of the wisdom of conservative operation in cases in which the tumor was found in the canal of the uterus under the mucous membrane, so-called mucous fibroids or uterine polypi.

The second case presented was a man of sixty suffering from a tumor occupying a position in the right side of the dorsal aspect of the sacrum and coccyx. The history revealed that an injury had been sustained over the site of the tumor three or four years before. The tumor grew slowly and was accompanied by pain which latterly was felt reflected down the thighs on both sides. The tumor was firm and elastic, as large as the fist and imparted the sense of deep fluctuation. There was no temperature and four conditions were suspected and considered in relation to the diagnosis of the case. (1) Fibroma springing from the connective tissue of the parts involved. (2) Tuberculosis. (3) Syphilis. 4) Sarcoma springing from the depths and growing progressively to the surface. Wasserman test was negative. The operation: An incision was made about six inches in length over the center of the tumor and was extended deeper and deeper until finally the mass was reached at a depth of an inch and a half or more. It was then dissected out and was readily separated from its attachments. It was found to spring from the anterior wall of the sacrum and pressed its way upwards through the posterior sacral wall. It pressed upon the cauda equina but had not caused any absorption and there was very little sign of infiltration. It lay at its lower levels against the posterior rectal wall. The large gap created by its removal wsa packed with gauze.

The tumor proved to be a teratoma and two months later there was no sign of recurrence, and the large space has filled up and healed by granulation.

The third case was one of disease of the head of the tibia, a chronic osteomyelitis being suspected. The patient was a man, age 35. X-ray revealed small areas of absorption in the head of the tibia corresponding to the seat of pain, etc. Accordingly an incision was made over the front of the head of the tibia below the tuberosity and extending obliquely upwards toward the head. A section of the compacta was removed two inches in length by three-quarters of an inch in width which was cut to the depth necessary to expose both the cancellous tissue and medullary space. Thereupon the area involved was scraped away. The lid removed was carefully preserved and immersed in warm salt solution.

There being no evidence of necrosis of bone, the cavity was then allowed to fill up with blood clot. The lid was replaced and the wound closed entirely without drainage. The subsequent progress of this case was most satisfactory.

Given before the Alumni meeting, Oregon Medical School, June, 1916.