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Blood is often absent from the urine in these cases and,moreover, is often overlooked when present. One of myformer teachers used to advise his patients to patronise acertain line of omnibuses which were famed for their rigidsprings and also for the rugged roads that they traversed.After this he had the urine which was passed during thefollowing 24 hours collected in a conical vessel. Anexamination of the deposit very rarely failed to detect blood-cells. I believe that attacks of ’’ colic " are only present ina minority of cases of stone in the kidney. In many the

pain is constant and although subject to exacerbations-which, however, are not paroxysmal in nature-is un-

accompanied by sickness or haematuria. Increased fre-

quency of micturition is common,’ but as it also occurs in

many other conditions is not of great value as a. diagnosticsign. Any reaction to Mr. Jordan Lloyd’s test is in myexperience exceptional.And now as regards two points in the technique of the

operation. We are frequently told that it is advisable to

plug the wound in the kidney. I fancy that most surgeonshave now discarded this practice. The kidney substance isbest brought together by mattress sutures. No urine exudesand no drainage either of the kidney or the outer wound isrequired. In reference to the site of the incision into the

kidney the experience of those who have used that advocatedby Brodel would be of great value. I used it in a recentcase but cannot say that I noticed any marked diminution inthe amount of bleeding.

I am ,G’irc yours faithfully

Lancaster, April 21st, 1902. A. STANLEY BARLING.

THE ROYAL NAVY MEDICALSERVICE.

To the Editors of THE LANCET.SIRs,-In the regulations in connexion with the above

recently issued by the Admiralty it is stated that early pro-motion to the rank of staff-surgeon may be granted to thosesurgeons who before entry held the post of house surgeon to a

I

civil hospital. Would it not be better that a naval surgeonshould be allowed to hold a house surgeoncy for six monthsat. his hospital at any time within 12 months of his enteringthe service, provided he could obtain nomination for sucha post, his time and pay counting during such house

surgeoncy ? At present candidates are deterred from seek-ing the post of house surgeon before entering the service onaccount of the loss of time and seniority it would entail. If

they were to be permitted to hold such a post after enteringit would be for the benefit of the service and would inducethe best class of men to join. The candidate who takes hishouse surgeoncy before entry will always run the risk of find-ing himself junior in the service to his junior in experience.There is a further rule requiring naval surgeons to undergo

a post-graduate course of three months’ duration at a metro-politan hospital once in every eight years, receiving full pay,lodging, and provision allowance, &c., but being required topay himself the necessary fees for such a course. The ruleconcludes by stating that the officer will be required to

produce separate certificates of efficient attendance in thefollowing: (1) medical and surgical practice of a hospital,(2) a course of operative surgery on the dead body, (3) acourse of bacteriology, (4) a course of ophthalmic surgery,and (5) a practical course of skiagraphy. The fee for thiscourse, 33 guineas, is a severe tax.Ought it not rather to be required that the naval surgeon

should put in a three or six months’ course quite free of allexpense at least once in every six years, or preferably once inevery three years-i.e., at the end of each commission ?Should he not also be encouraged to take higher qualifica-tions ? A course of six months’ study of State medicinewould be of the greatest value in the service, and a surgeonwho was willing to qualify and take the diploma in PublicHealth should, I think, be considered eligible for special pro-motion quite as much as a surgeon who has been fortunateenough to hold the post of house surgeon. As matters standat present as warden of a medical college I am obliged toadvise candidates for the Naval Medical Service to enter theservice as early as possible and without seeking to holdhouse appointments, but if the suggestions I have made wereadopted the candidates could enter just as early and provefar more valuable men in the end.

I am, Sirs, yours faithfully,MUNRO SCOTT,

April 30th, 1902. Warden of the London Hospital Medical College.

SMALL-POX ON THE RIVIERA.

(FROM OUR SPECIAL SANITARY COMMISSIONER.)

A Bad Season.-The Efficacy oj -Revaccination at Nice.-S7nall-pox and the British and American Colony.

THE Riviera winter season which has just concluded hasproved disastrous in some places and nowhere is it qualifiedas a good season, although, as usual, the Principality ofMonaco is the last to be affected by any evil circumstancesthat may arise. Indeed, the hotels, in spite of their numbers,have been well filled ; and early in March, when I arrived at

Monaco, it was with some difficulty that I could secure asuitable room. Now, of course, the great bulk of visitorshave left and this is the moment when all concerned havetime to pause and to consider the situation.

There are two principal causes that have produced theunfavourable result-namely, small-pox and the war. Noexplanation is necessary to show that the war has compelledmany British families and tourists to postpone the pleasureand the expense of wintering in the south. This is an

unhappy circumstance over which local enterprise and themunicipalities of the Riviera resorts had no control. Thesame cannot be said with regard to the prevalence of small-pox. Ever since British visitors have frequented the Rivieraand English papers have published descriptions of the variousattractions of this favoured coast, protests have been utteredagainst the want of proper sanitation and efficient drainage.As a consequence there have been various improvementseffected ; but more remains to be done than has actuallybeen achieved. In one respect especially there has beenthe most reprehensible neglect and that is in regard tothe provision of isolation hospitals for infectious cases.

This great grievance was rendered distressingly obvious

during this winter’s season by the prevalence of small-pox.Nothing can be more alarming and painful than the positionof a person away from home and country and strickendown by small-pox while staying in an hotel. In England astranger would be removed in a proper ambulance by well-trained attendants to the fever or small-pox hospital wherehe would find the best sanitary conditions, medical attend-ance, and highly trained nurses. The room in his hotelwould be thoroughly disinfected and the risk incurred by theother inhabitants of the hotel would be reduced to a minimum.If, on the Riviera, the authorities insist on removing thepatient they can only take him to the general hospital wherehe will be nursed by untrained sisters who know more aboutproselytising than about nursing and he will be a source ofdanger to the other patients. If he is allowed to remain inthe hotel he endangers his fellow residents and is not insuitable surroundings for efficient treatment.

In such circumstances it is not surprising that the fearof small-pox has kept many intending visitors away from theRiviera. That it should have this effect is so obvious thatthe authorities concerned have done their best to conceal thefact that small-pox cases have occurred in several of thewinter resorts. But the policy of concealment always defeatsits own ends. Absolute concealment is impossible and theabsence of official information naturally gives rise to exag-gerated rumours. Thus, we find in the New Free Press ofVienna a statement that there were during the season from 400to 500 deaths from small-pox at Nice. This is undoubtedly anexaggeration. A few cases of small-pox occurred at Niceduring the month of November, but it was not till Dec. 14ththat several cases were notified on one and the same

day, and the disease may then be said to have assumedan epidemic aspect. The disease was exceptionally virulent :the proportion of mortality was equal to about 32 per cent.of the cases. But this outbreak has in any case servedone good purpose, for it has once more demonstratedthe efficacy of vaccination. It may also be claimed thatit has not been unconnected with economic and insanitaryconditions. Dr. Balestre, director of the Bureau d’Hygieneof Nice, informs me that the inhabitants of the old townsuffered most. He visited the two worst streets and thepoverty, overcrowding, and filth prevailing there were beyondall description. The tall houses in these narrow, winding,steep, and picturesque streets have simply no sanitaryaccommodation at all. In the streets there are some

gratuitous latrines but there are no closets in the houses.The inhabitants, for the most part very poor Italian labourers,

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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