in these cases, and that concretions have been found in about 60 per cent. of them.

A final comparison shows the recovery of 58 per cent. of those operated on as against the recovery of only 6 per cent. of those not operated on. In chapter I, under the heading of traumatic rupture, he mentions 23 cases which have been operated on successfully, and in chapter II, 3 cases which have been operated on unsuccessfully, death having been due to shock, infection and hemorrhage.

In chapter III, he records 14 cases in which death resulted without operation, showing peritonitis to have been the ruling cause of death, and in chapter IV, 4 cases which have recovered without operation, recovery having probably been due to drainage. Comparison of all traumatic ruptures shows the recovery of 88 per cent. of those operated on as against the recovery of only 22 per cent. of those not operated on.

Two Cases of General Paralysis Successfully Treated by Urotropin.

BY N. F. MACHARDY, M. B., Ch.B.,

Assistant Medical Officer at the Coton Hill Hospital for the Insane, Stafford, England.

[British Medical Journal, January 28, 1905.]

THE following cases are of interest as showing recoveries, at least temporary and probably permanent,—from general paralysis of the insane, associated in the first case with locomotor ataxia. The treatment was urotropin. These are the only two cases treated, and both have maintained their recovery up to date of publication:

CASE I.-G. W., aged 44; admitted October 11, 1902; dangerous and violent; marked general paralysis. Suffered from locomotor ataxia for over two years before admission, and for one week from mental symptoms. Grandiose delusions as regards wealth and strength. Progress till put on urotropin; delusions became worse. November 13, said he was worth £300,000,000. Steady progression of disease affecting walk and speech till September, 1903, when he was confined to bed, lead a catheter life, and had to be attended to like an infant. By November 15, he became very weak, and I then commenced with 5 gr. urotropin daily.

Progress while on urotropin: December 29, urine is beginning to pass naturally. Patient able to sit up, and be assisted about by an attendant; is talking, but full of delusions.

January 20, 1904, physically much stronger, is up and has regained power over limbs. Passes all urine naturally, is full of delusions, says he is a girl, is a king, is very wealthy, and the like. February 20, considerable mental and physical improvement. Plays billiards, but not well; ataxia diminishing; memory affected and illusional; now on 10 gr. urotropin daily. March 20, talks more distinctly; is losing delusions; plays billiards better; worth only £30,000. April 20, had no lightning pains for three months; plays whist and billiards constantly; lost chief delusions; now on 15 gr. urotropin daily. May 11, memory still imperfect; is still a little boastful, but has no delusions; can talk well; physically very fit. June 10, no lightning pains since January; memory improving; no delusions or signs of general paralysis; pupil contracts to light. July 1, home on probation. August 1, I hear he is still better and now only appears nervous. Is still on 15 gr. urotropin; discharged today. October 1, he is as well as he has been and shows no signs of breaking down.

CASE II.-A. F. G., aged 38; admitted May 28, 1904. Attacks since January, 1904. Improvement in February and then became much worse. On admission he had Argyll Robertson pupils and very exaggerated knee-jerks, with ankle clonus, twitching of facial muscles, slurring speech, and the like.

June 2, leads a catheter life. Put on urotropin, 21⁄2 gr. twice daily. Is recovering from his semicataleptic condition, but hardly talks. June 9, some improvement. Passes a little urine by himself and helps to dress himself. Once or twice quite talkative. Told me he was buying a yacht, 250 feet long for £10,000. June 14, improvement continues. Gave him 5 gr. urotropin twice daily, but he had some hematuria, so I stopped it for a time. June 23, has gone back. Catheter life again; 21⁄2 gr. urotropin twice daily. June 29, improving daily. Delusions of exaltation. passing. Walks without assistance. Says he is a poor man. Passes water freely. July 8, improved very rapidly. Walks about and talks like a sane man. No delusions. Progress almost unbelievable. July 12, apparently well in every respect. Slight inequality of pupils only physical symptom. July 15, went home on probation. August 16, discharged "cured." September 10. got a letter from him today, very sensible. His friends think he is better than for years. Starting in business again. October 2, still well and continuing urotropin.

In conclusion, I would state that the influence of urotropin is marked from day to day. If the patient shows signs of reiapsing, an increased dose stops the tendency. As before remarked, these two cases are the only ones treated, so this method deserves a trial in similar cases, as so far I have no failures to chronicle.

TOPICS OF PUBLIC INTEREST.

Canal Zone Sanitation.

The Panama Problem.

Report to the Government by Dr. Charles A. L. Reed, on the Status of Sanitation in the Canal Zone and in the Cities of Panama and Colon.

WASHINGTON, D. C., March 2, 1905.

Honorable William H. Taft, Secretary of War.

DEAR SIR-Pursuant to your request I have the honor herewith to submit the report of my observations relative to the status of sanitation and of the sanitary department in the canal zone and in the cities of Colon and Panama.

I arrived at Colon on the 7th of February and sailed from that city on the 22d of the same month, thus affording me fifteen days in which to study, with more or less care, the conditions of organisation and the details of administration as they relate to the public health interest.

SANITARY STAFF EFFICIENT.

I was given every facility in this regard by General Davis, the Governor of the Zone; by Mr. Wallace, the Chief Engineer; by Colonel Gorgas, the Chief Sanitary Officer; as well as by his associates, Major La Garde, Lieutenant Lyster, and Dr. Carter. As a result of this investigation I became impressed with the efficiency and the zeal of the sanitary staff; with the fact that very much has been accomplished in the way of sanitation under exceedingly adverse circumstances; that much remains to be done which cannot be done unless better facilities are afforded; and that very much more ought to be done and would have been done if the facilities had been properly furnished.

I was forced to this conclusion, not only by what I saw and heard while on the Isthmus, but by a careful study of the published proceedings of the Isthmian Canal Commission, by a study of the laws of the canal zone formulated by that commission, and by a careful consideration of their first annual report, submitted under date of December 1, 1904.

THE ORGANISATION OF THE HEALTH DEPARTMENT.

At the meeting of the commission, held at Ancon, August 28, 1904, Mr. Grunsky, as the committee on a proposed health department, presented a report which began by stating that "after repeated conferences with" Colonel Gorgas and with practically the entire sanitary staff, "it has been agreed," but which should

have stated that "in certain important particulars Mr. Grunsky has agreed with himself"; for, as a matter of fact, much of the report was formulated over the respectful protest of the medical men who were invited to the conference. By this report the commission, more especially Mr. Grunsky, provided for the creation of a board of health with power to formulate regulations which would become effective only after approval by the commission, or, in cases of emergency, only on the approval of the governor of the canal zone. Thus the chief sanitary officer who had been sent to the zone to clear it up and to make it ready for the actual work of the engineers had his discretion limited to the enforcement of regulations that had first been adopted by the commission or by a board of health; in which latter event it had to be sent generally to Washington to be endorsed by the commission, or, in cases of emergency, it could be approved or rejected by the governor of the zone.

THE EXTRAORDINARY SUBORDINATION OF THE SANITATION

STAFF.

It thus came about that the chief sanitary officer, whom and whose department the medical profession had asked to be made largely autonomous, whom and which the President himself had obviously intended should be largely autonomous, was, by the action of the commission, more especially Mr. Grunsky, subor dinated to the governor of the zone; to the chief disbursing officer; to the chief of the bureau of material and supplies; to Mr. Grunsky; to the commission; to the Secretary of War; to the President; subordinated in fact in the seventh degree from the original source of authority. And this is the state of affairs on the Isthmus today. One cannot but be impressed with the anomalous condition by which a man of Colonel Gorgas's distinction, the foremost authority in the world in solving the peculiar prob lems that are connected with sanitation on the Isthmus, is being made subordinate of a whole series of other subordinates who are confessedly ignorant of the very questions with which he is most

familiar.

HOW THE MACHINE DOES NOT WORK.

It is interesting to inquire into the working of this wonderful mechanism. Thus, if Major La Garde, superintendent of Ancon due form, take it for approval to the chief sanitary officer, then to the governor of the zone, then to the chief disbursing officer; whence it goes to the commission at Washington; then to Mr. Grunsky as committeeman; then back to the commission; then, if allowed, bids are advertised for; awards are made; the requisition is filled under the supervision of a purchasing agent notori ously ignorant of the character and quality of medical and surgical supplies; the material is shipped to the Isthmus, consigned to the chief of the bureau of materials and supplies, who notifies

the disbursing officer, who notifies Colonel Gorgas, who in turn notifies Major La Garde, who applies to the quartermaster,-the boss of a corral,-for transportation, and so much of the stuff as in the judgment of, first, the governor, next the chief disbursing officer, next the commission, next, and more particularly, Mr. Grunsky, ought to be allowed to the superintendent of Ancon Hospital finally arrives or does not arrive at its destination. This is no fanciful picture; it is exemplified in practically every ordinary requisition that goes forward. And what is true of Ancon Hospital is true at Colon, at Culebra, at Miraflores and at all points along the line that require supplies of this description. It is true that in the presence of emergency it is not necessary to send clear to Washington, and certain purchases are permitted and authorised in the open market at Panama, but always, of course, at greatly increased prices.

An instance in point occurred a few days before my departure from Ancon: A woman in the insane department was delivered of a child; her condition was such that she could not nurse her offspring; the nurse applied to Major La Garde for a rubber nipple and a nursing bottle; he had none, the requisition of last September had not yet been filled; he made out a requisition, took it to Colonel Gorgas for indorsement, then to Mr. Tobey, chief of the bureau of materials and supplies for another indorsement, then to a clerk to have it copied and engrossed; then a messenger was permitted to go to a drug store and buy a nursing bottle and a nipple, which finally reached the infant two days after the necessity for their use had arisen. The articles ought to have cost not more than 30 cents, but counting the money value of the time of the nurse, of Major La Garde, of his clerical help, of Colonel Gorgas, of Mr. Tobey, of Mr. Tobey's clerks, of the messenger, the cost to the government of the United States was in the neighborhood of $6.75,-all due to the penny-wise and pound-foolish policy of the commission, more especially of Mr. Grunsky.

THE SANITARY DEPARTMENT DENIED THE RIGHT TO DECIDE ON THE SUITABILITY OF ITS OWN SUPPLIES.

The commission at Ancon last August adopted a resolution creating a department of the zone government to be known as the "material and supplies department," the chief of which is "charged with the receipt, inspection on the Isthmus, custody, care, shipment, transfer, issue and disposition of all supplies, material, equipage and floating equipment unissued and not in actual use. It is, however, specifically provided that:

The governor of the Canal Zone, acting for the executive branch of the government of the zone, and the chief engineer, acting for the Department of Engineering and Construction, shall have authority to decide on the suitability of any and all supplies furnished, and their requisitions