found in the duodenum, while in one | by Korte (Deut. med. Woch., Leipzig, February 28, 1894) the point of lodgment was in the ileum, ten inches above the ileo-cecal valve. In both instances the stones were removed by incision, followed by recovery.

Among the still rarer sequelæ of gall-stones may be mentioned intestinal obstruction caused by bands the result of localized peritonitis, this in turn having been caused by previous gallstone impactions. An illustration of this condition was furnished by Korte's case, to which I have just alluded, and in which recovery followed the operation for obstruction of the ileum due to gall-stone impaction (Med. News, April 28, 1894). This patient died ten weeks later from obstruction of the jejunum by old inflammatory bands. I was called a few years ago, in company with Drs. Millikin, Skinner and Fitton, to operate for intestinal obstruction in a middle-aged woman in the practice of Dr. Harry Smith, of Riley, O. The patient, who had been stricken suddenly, gave a history of unimpaired previous good health, with the exception of a single severe attack of hepatic colic, lasting a week or more, a number of years previously. The operation revealed the fact that the jejunum had become looped over an adventitious band. That this band had its origin in the attack of cholecystitis experienced several years previously, while not demonstrated, is yet probable.

My only apology for engaging the attention of the Academy with this particular phase of cholelithiasis is the fact that nowhere, to my knowledge, is it presented in a distinct form. On the contrary, the impression generally prevails that gall-stones, having once completely escaped, or having been once thoroughly removed, the patient, in the event of primary recovery, is completely restored to health. This is an optimistic view that is not justified by the truth. The fact should take deep hold upon the profession that cholelithiasis, even when viewed in the light of its consequences, is a dangerous condition, and that the dangers are largely proportionate to the severity of the

attacks, to the frequency of recurrences, and to the time embraced in the persistence of the disease.

[FOR DISCUSSION SEE P. 411.]

TUBERCULOSIS.

BY H. H. SPIERS, M.D.,

RAVENNA, O.

As my view of the origin of tuberculosis is at variance with established teaching, perhaps a simple statement of belief is necessary.

1. Tuberculosis is a constitutional disease, dependent largely on the evils of civilization, and governed by the followihg law: The death-rate from tuberculosis is in direct ratio to suspension of atmospheric influence.

2. The suspension or abeyance of atmospheric influence may take place from within or from without. From without through impure or impoverished atmosphere; from within through defective lung tissue, original or acquired.

3. Abeyance of atmospheric influence, in whatever way induced, causes a depraved tissue or dyscrasia, through which the tubercle bacilli enter and grow.

4. The growth of tubercle bacilli, being dependent on the precedent state or condition of the individual, is never per se the primary cause of tuberculosis.

5. Tuberculosis may exist, though infrequent, in the absence of tubercle bacilli, but can never exist without the precedent state or condition.

6. The plant growth being a secondary condition or modifying influence in this most fatal disease, treatment directed against this growth must ever remain barren of permanent curative results and dangerous to the patient.

7. The precedent or primary condition being subject to law, and under control, tuberculosis is under control.

A question is anticipated. If tuberculosis be under control, why don't you control it? Why don't you control it?

The control of tuberculosis pertains to no one physician, only in pointing out the way. These seven propositions point the way, and on these the writer rests.

HOSPITALS OF PARIS.1

BY E. S. M'KEE, M.D.,
CINCINNATI,

MEMBRE DE LA SOCIETE FRANCAIS D'ELECTROTHERAPIE
DE PARIS.

Hospital is derived from the Latin adjective hospitalis, and also from the Latin noun hospes, a host or guest. The French word hospice is from the Latin hospitium, the place in which the guest was received.

The three French terms, Hôpital, Hospice and Hôtel, though from the same source, are now used with very different meanings. The first, being restricted generally to a place for temporary occupation for the sick and hurt for the purpose of medical and surgical treatment; the second, hospice, applied to places for permanent occupation by the sick and poor, the infirm, the incurable or the insane; and the third, hôtel, to dwellings, either public or private, for ordinary occupation. To the last there is, however, one marked exception -Hôtel Dieu is applied to the chief hospital or infirmary of a town or city, as the Hôtel Dieu of Paris. In English we have no equivalent for Hospice.

The French Revolution was the turning point in the management of the hospitals of Paris. Prior to that time they were in a very imperfect state of organization, not being subject, as at present, to the Central Board of Charity at the Ministry of the Interior, but existing for the most part quite independently of the State. This irregular and independent mode of government naturally led to abuses. The management devoted legacies and donations intended for the care of the sick to other measures more in keeping with their interests. These abuses had become so great, mostly through religious corporations, that the citizens unanimously demanded of the National Assembly of 1789 that radical changes be made in the management and care of the property intended for the care of the sick and poor. The hospitals of Paris, however, have always been more numerous, better organized

I Read before the Sojourners, a literary society of Cincinnati, March 20, 1897.

and better governed than those of the Provinces.

The control of the most important charitable institutions was vested in the two principal boards of management, the Committee of the Hôtel Dieu and the Committee of the General Hospital, dating from the time of the Revolution.

The general administration of public relief in Paris at present comprises: (1) The central administration; (2) hospital establishments, subdivided into twentythree hospitals, one sanitorium, five alms-houses, three retreats and eleven endowed foundations; (3) six establishments of general utility and a special institution, viz., an anatomical theatre; (4) the domiciliary relief provided for by twenty charity boards and fifty-five refuges; there are also five hospital establishments of trifling importance dependent on various charity boards; (5) the pauper children's service, with thirty agencies and a reformatory school. There are also three schools for male and female hospital attendants.

The commissary department in the French hospitals tends ever to centralization. The substitution of the wholesale for the retail purchase-the one buyer instead of the many. Bread for the hospitals and alms-houses has for many years been made at the central bake house, situated in the Place Scipion.

The grinding of the grain intended. for the bread is connected with the baking. The quality of the bread made is irreproachable, the direct method of manufacture being a sure guarantee against false weight and trade adulteration. The bread is baked in four-pound loaves, and is delivered fresh from this bakery every morning.

The drugs are prepared at the central pharmacy, situated in the Rue de la Tournelle. It is worthy of remark that the wine purchased for the hospitals exceeds in cost that of the drugs.

Milk is supplied by their own dairy, and is much better than we get in Cincinnati.

Hours for meals in the hospitals are: First dejeuner, 7 A.M.; second dejeuner, IO A.M.; dinner, 5 P.M.

duties have detained, or who have been Physicians and surgeons whom their

Medical staff: The physicians of the charity board are appointed for four years by the Minister of the Interior. At the expiration of the four years. they are eligible for re-appointment, and so on. No physician can remain in hospital practice after his sixty-fifth At the end of every year the Mayor sends to the director of the Administration of the Assistance Publique a report of the way in which each doctor has performed his duties. The Mayor is obliged to send on to the director any written complaints against the doctors. A physician once dismissed can never be again on the medical staff of the charity boards.

French law requires every commune or territorial division to provide assistance for its indigent members who may require aid. As early as 793 Charlemagne decreed that certain hospitals should be royal establishments, and made rules for the proper care of the poor population. Paris is bound by the same law to look after its poor; this gratuitous treatment extends, however, only to the indigent. After admission to the hospital inquiry is made, and if the patient be found in a position to pay the sum of three francs thirty centimes he is required to do so; as a matter of fact, the sum is rarely claimed. In 1886 the total sum thus paid for hospital assistance was 2,501 francs.

the edict of May, 1607, ordered the construction of a hospital designed exclusively for the treatment of the pest. It was his wish that it should bear the name of Saint Louis, who had died of that malady.

Hospice de la Viellesse Femmes, aged women, commonly called Hospice de la Pitie, or La Salpetrière, from its location on ground formerly occupied by a saltpetre manufactory, is probably the largest institution of its kind in the world. It is about one-third of a mile in length, and contains more than 700 beds. The qualifications for admission are bodily or mental infirmities, or having attained the age of seventy years. The thousands of old women, excepting on Sundays and fete days, when they may dress as they please, wear the uniform of the hospital, which is blue in summer and gray in winter.

A similar institution is the Hospice Des Femmes Incurables, in the Rue de Sevres, a hospital for old, indigent and incurable women, which has accommodations for several hundred patients.

The poor of Paris who fill these hospitals are neat and clean and comfortable to a degree not found among the same class elsewhere. We fail, on visiting them, to find anything which might add opprobrium to poverty; their manners are almost invariably polite. The poorest cobbler, "Who lived in a stall, which served him for parlor, kitchen and all," lived neatly, and with a degree of comfort quite impossible on his income in England or America.

La Charité was founded in 1607 by Marie de Medicis. It was originally managed by the monks of St. Jean de Dieu, or Brothers of Mercy. Their old chapel, higher up, is now the site of the Academy of Medicine, founded in

The Neckar was founded by Madame de Stael, and named by her for her mother. She used a sum given her for charitable purposes by Louis XVI to establish this hospital.

Another interesting charity in the hospital line is the Hospice des Enfans Trouves. A Parisian once, after a very merry champagne dinner, entered a

fiacre, and to the inquiry of the coachman as to where he should drive him, replied: "To the Devil." The coachman started off at a rapid rate, as if he knew where he was going, and after some time stopped at the corner of a street, wakened up his passenger and demanded of him: "What number, Monsieur ?" The gentleman, rousing up, saw inscribed on the wall, "Rue de Enfer "—"Hell street." Here is situated the hospital for the little ones, who are always described as coming from Heaven. The "Tour" was one of the most interesting old sights about this place. It was an unpretentious piece of wood in the wall, which, on being turned, presents a cushion of straw, where the poor mothers of Paris, after nightfall, deposited their infants, turned the wooden arrangement, placing the child on the inside of the wall, rang a bell and passed on. These children, as rapidly as possible after being received, are sent out to nurse among the peasantry. Often a mother who has thus deserted her child makes application as wet nurse, and receives a child, possibly her own, and is paid a small sum for its care. Some touching, some amusing, sights are seen among these deserted waifs of humanity; in one room was a tray or box containing a dozen babies a few days old packed together like sardines, which were crying and yelling to their hearts' content, not appearing in the least to discommode or distress the attendants.

The Trousseau, founded in 1660, is also a hospital for sick children.

Near the Pantheon is the Nationale Institution des Sourds-Muets, for the reception of deaf and dumb children between the ages of eight and fifteen years, the condition of admission being perfect destitution. Here these children are cared for when sick, taught trades, are educated and instructed, and made useful members of society. The entrance court contains an elm tree one hundred feet in height, planted in 1605 by Sully, minister of Henry IV. It is of enormous size, and considered the oldest tree in Paris.

pitals of Paris where pay patients only are received. Prices vary from five to twelve francs per day, according to room, and whether one to four are in a room. Surgical cases are usually somewhat more expensive than medical.

The total number of patients in the Paris hospitals on January 1, 1889, was 21,504, about three males to two females. The total number of beds in all the hospitals of the city was 25,122.

The Polyclinic of Paris, where walking patients only are treated, after an existence of only six years, has an annual number of consultations reaching a quarter of a million. This contains a rich collection of rare, interesting and instructive cases.

Libraries for the internes who reside at the various hospitals are situated in most of the institutions, and contain from 500 to 2,500 volumes each.

The Hertford British Hospital, or Hospital Wallace, is a large Gothic edifice in the Rue de Villiers, built and maintained by Sir Richard Wallace. It has accommodations for thirty-four patients, and is surrounded by a beautiful garden.

The Hotel des Invalides, with its beautiful gilded dome, is a vast hospital occupying about thirty acres, founded in 1670 by Louis XIV. Soldiers disabled by wounds and those who have served for thirty years are entitled to be received into the Invalides. The building was intended to accomodate 5,000 inmates, but there are only about 450 now, as most of the old soldiers prefer to live independently on their pensions. It is an interesting sight, however, to see the old pensioners reposing on their laurels or hobbling about in the sunshine, eager to show the many relics and curiosities of the place. Those old soldiers who have no appetite to eat their allowance of food may claim money instead, and to those who have wooden legs their allowance of shoe money is honestly refunded.

The dome of the Invalides, by Mansard, is lustrous with abundant gilding, and on a bright day shines over Paris with the most brilliant effect. Reflected