The Johns Hopkins Medical Journal 15 (1904)

Embryology - 18 Apr 2024        Expand to Translate
Google Translate - select your language from the list shown below (this will open a new external page)
العربية | català | 中文 | 中國傳統的 | français | Deutsche | עִברִית | हिंदी | bahasa Indonesia | italiano | 日本語 | 한국어 | မြန်မာ | Pilipino | Polskie | português | ਪੰਜਾਬੀ ਦੇ | Română | русский | Español | Swahili | Svensk | ไทย | Türkçe | اردو | ייִדיש | Tiếng Việt    These external translations are automated and may not be accurate. (More? About Translations)

Historic Disclaimer - information about historic embryology pages

Pages where the terms "Historic" (textbooks, papers, people, recommendations) appear on this site, and sections within pages where this disclaimer appears, indicate that the content and scientific understanding are specific to the time of publication. This means that while some scientific descriptions are still accurate, the terminology and interpretation of the developmental mechanisms reflect the understanding at the time of original publication and those of the preceding periods, these terms, interpretations and recommendations may not reflect our current scientific understanding.     (More? Embryology History | Historic Embryology Papers)

The Johns Hopkins Medical Journal - Volume 15 (1904)

http://www.archive.org/details/johnshopkinsmedi15john

The Johns Hopkins Medical Journal

Vol. XV.— No. 1 54.

BALTIMORE, JANUARY, 1904.

Contents - January

• The Master-Word iu Medicine. By William Osleh, M. D., F. R. S., 1
• Tuberculosis of the Uriuary System in Women. Report of Thirty flve Cases. By Guy L. Hunner, M. D., 8
• The Second Hospital iu the Colonies, the "Code Springs of St. Maries," Maryland, 1098. By J. Hall Pleasants, M. D., . 18
• Some Unusual Forms of Malarial Parasites. By Mart E. Rowlet, M. D., 33
• Notes and News, 83
• Notes ou New Books, 34

THE MASTER-WORD IN MEDICINE

By William Osler, M. D., P. E. S., Professor of Medicine, Johns Hopkins University, Baltimore, Md.

Before proceeding to the pleasing duty of addressing the undergraduates, as a native of this province and as an old student of this school, T must say a few words on the momentous changes inaugurated with this session, the most important, perhaps, which have taken place in the history of the profession in Ontario. The splendid laboratories, which we saw opened tliis afternoon, a witness to the appreciation by the authorities of the needs of science in medicine, nmke possible the highest standards of education in the subjects upon which our Art is based. They may do more. A liberal policy, with a due regard to the truth that the greatness of a scliool lies in brains, not bricks, should build uj) a great scientific center which will bring renown to this city and to our country. The men in charge of the departments are of the right stam]). See to it that you treat them in the right way by giving skilled assistance enough to ensure that the vitality of men who could work for the world is not sapped by the routine of teaching. One regret will, I know, be in the minds of many of my younger hearers. The removal of tlie departments of anatomy and physiology from

' An address to medical students ou the occasion of the opening of the new Iniildinss of the Medical Faculty of the University of Toronto, October 1st, 11103.

the biological laboratory of the university breaks a connection which has had an important influence on medicine in this city. To Professor Ramsay Wright is due much of the inspiration which has made possible these fine new laboratories. For years he has encouraged in every way the cultivation of the scientific branches of medicine, and has unselfishly devoted much time to promoting the best interests of the Medical Faculty. And in passing let me pay a tribute to the ability and zeal with which Dr. A. B. Macallum has won for himself a world-wide reputation by intricate studies which have carried the name of this University to every nook and corner of the globe where the science of physiology is cultivated. How much you owe to him in connection with the new buildings I need scarcely mention to this audience.

But the other event which we celebrate is of nmch greater importance. When the money is forthcoming, it is an easy matter to Join stone to stone in a stately edifice, but it is hard to fiiul the market in which to buy the precious cement whicli can unite into an harmonious body the professors of medicine of two rival medical schools in the same city. That this Im.; been accomplished so satisfactorily is a tribute to the good sense of the leaders of the two faculties, and tells of their recognition of the needs of the profession of tlie province.

[No. i:

Is it too much to look forward to tlie absorption or alTiliation of the Kingston and London scliools into the Provincial University? The day has passed in which the small school without full endowment can live a life beneficial to the students, to the profession, or to the public. I know well of the sacrifice of time and money which is freely made by the teachers of those schools; and they will not misunderstand my motives when I urge them to commit suicide, at least so far as to change their organizations into clinical schools in affiliation with the central iiniversity as part, perhaps, of a widespread affiliation of the hospitals of the province. A school of tlie first rank in the world, such as tliis must become, should have ample clinical facilities under its own control. It is as much a necessity that the professors of medicine and surgery, etc., should have large hospital services under their control throughout the year, as it is that professors of patholog}' and physiologj' should have laboratories such as those in which we here meet. It shoiild be an easy matter to arrange between the provincial authorities and the trustees of the Toronto General Hospital to replace the present antiquated system of multiple small services by modern wellequipped clinics — three in medicine and three in surgery to begin with. The increased efficiency of the service would be a substantial quid pro quo, but there would have to be a self-den}iag ordinance on the part of many of tlie attending physicians. With the large number of students in the combined school, no one hospital can furnish in practical medicine, surgery and the specialties a training in the art an equivalent of that which the student will have in the sciences in the new laboratories. An affiliation should be sought with every other hospital in the city and province of fifty beds and over, in each of which two or three extra-mural teachers could be recognized who would receive for three or more months a number of students proportionate to the beds in the hospital. I need not mention names. We all know men in Ottawa, Kingston, London, Hamilton, Guelph and Chatham, who could take charge of small groups of the senior students and make of them good practical doctors. I merely throw out the suggestion. There are difficulties in the way; but is there anj-thing in this life worth struggling for which does not bristle with them ?

Students of medicine : may this day be to each one of you, as it was to me when I entered this school thirty-five years ago, the beginning of a happy life in a happy calling. Xot one of you has come here with such a feeling of relief as that which 1 experienced at an escape from conic sections and logarithms and from Hooker and Pearson. The dry bones became clothed with interest, and I felt that I had at last got to work. Of the greater advantages with which you start I shall not speak. Why waste words on what you cannot understand. To those only of us who taught and studied in the ding}' old building which stood near liere ir it given to feel the change which the years have wrought — a change which my old teachers, whom I see here to-da}' — Dr Richardson, Dr. Ogden, Dr. Thorburu and Dr. Oldriglit

— must find hard to realize. One looks about in vain for some accustomed object on which to rest the eye in its backward glance — all, all are gone; the old familiar places. Even the landscape has altered, and the sense of loneliness and regret, tlie sort of homesickness one experiences on such occasions, is relieved by a feeling of thankfulness that at least some of the old familiar faces have been spared to see this day. To me at least the memory of those happy days is a perpetual benediction, and I look back upon the two years I spent at this school with the greatest delight. There were many things tliat might have been improved — and we can say the same of every medical school at that period — but I seem to have gotten more out of it than our distinguished philosopher friend, J. Beattie Crozier, whose picture of the period seems rather hardly drawn. But after all, as some one has remarked, instruction is often the least part of an education, and, as I recall them, our teachers in their life and doctrine set forth a true and lively word to the great enlightenment of our darkness. They stand out in the backgroimd of my memory as a group of men whose influence and example were most helpful. In William E. Beaumont and Edward Mulberry Hodder, we had before us the highest type of the cultivated English surgeon. In Henry H. Wright we saw the incarnation of faithful devotion to duty — too faithful, we thought, as we trudged up to the eight o'clock lectiire in the morning. In W. T. Aikins a practical surgeon of remarkable skill and an ideal teacher for the general practitioner. How we wondered and delighted in the anatomical demonstrations of Dr. Eichardson, whose infective enthusiasm did much to make anatomy the favorite subject among the students. I had the double advantage of attending the last course of Dr. Ogden and the first of Dr. Thorburn on materia medica and therapeutics. And Dr. Oldright had just begmi his career of unselfish devotion to the cause of hygiene.

To one of my teachers I must pay in passing the tribute of filial affection. There are men here to-day who feel as I do about Dr. James Bovell — that he was one of those finer spirits, not uncommon in life, toiiched to fijier issues only in a suitable environment. Would the Paul of evolution have been Thomas Henry Huxley had the Senate elected the yoimg natui'alist to a chair in this university in 1851? Only men of a certain metal rise superior to their surroimdings, and while Dr. Bovell had that all-important combination of boundless ambition with cnergv' and industry, he had that fatal fault of ditfuseness, in which even genius gets strangled With i quadrilateral mind, which he kept spinning like a teetotum, one side was never kept uppermost for long at a time. Caught in the storm which shook the scientific world with the publication of tlie " Origin of Species," instead of sailing before the wind, even were it with bare poles, he put about and sought a harljor of refuge in writing a work on Natural Theology, which you will find on the shelves of second-hand bookshops in a company made rospcctalile at least by the presence of Paley. lie was an omniverous reader and transmuter, he could talk

January, 1901.]

])lea.santly, even at times transecuclentally, upon anything in the science ol' tlie day,, from protoplasm to evolution; but he lacked concentration and that scientific accuracy which only comes with a long training (sometimes indeed never comes), and which is tlie ballast of the boat. But the bent of his ininil was devotional, and early swept into the Tractarian movement, he became an advanced Churchman, a good .Anglican Catholic. As he chaffmgly remarked one day to his friend, the Reverend Mr. Darling, he was like the waterman in " Pilgrim's Progi-css,'"'" rowing one way, towards Eome, but looking steadfastly in tlie other direction, towards Lambeth. His " Steps to the Altar," and his " Lectures on the Advent " attest the earnestness of his convictions; and later in life, following the example of Linacre, he took orders and became another illustration of what Cotton Mather calls the angelical conjuction of medicine with divinity. Then, how well I recall the keen love with which he would engage in metaphysical discussions, and the ardor with which he studied Kant, Hamilton, Eeed and Mill. At that day to the Bev. Prof. Bevan was entrusted the rare privilege of directing the minds of the thinlciug youths at the Provincial University into proper philosophical channels. It was rumored that the hungry sheep looked up and were not fed. I thought so at least, for certain of them, led by T. Wesley Mills, came over daily after Dr. Bovell's four o'clock lecture to reason high and long with him

" Ou Providence, Foreknowleilge, Will aud FateFixed Fate, Freewill, Forekuowledge absolute."

Yet withal his main business in life was as a jjhysician, much sought after for his skill in diagnosis, and much beloved for his loving heart. He had been brought up in the very best practical schools. A pupil of Bright and of Addison, a warm personal friend of Stokes and of Graves, he maintained loyally the traditions of Guy's and taught us to reverence his great masters. As a teacher, he had grasped the fundamental truth announced by John Hunter of the unity of physiological and pathological processes, and, as became the occupant of the chair of the Institute of Medicine, he would discourse on pathological processes in lectures on physiology, and illustrate the physiology of bioplasm in lectures on the pathology of tumors to the bewilderment of the students. When in September, 1870, he wrote to me that he did not intend to return from the West Indies, I felt that I had lost a father and a friend; but in Robert Palmer Howard, of Montreal, I found a noble step-father, and to these two men, and to my first teacher, the Rev. W. A. Johnson, of Weston, I owe my success in life — if success means getting what you want and being satisfied witli it.

II.

Of the value of an introductory lecture I am not altogether certain. I do not remember to have derived any enduring iiciiclit from I he many that I have been called upon to hear, or from the not a few J have inflicted in my day. On the whole I am in favor of abolishing the old custom, but as this is a very

special occasion, with special addresses, I consider myself most happy to have been selected for this part of the programme. To the audience at large I fear that mut^h of what 1 have to say will ap]iear ti'ite and counnonplaco, but bear with me, since, indeed, to most of you how good soever the word, the season is long past in which it could be spoken 1o your edification. As I glance from face to face the most striking single peculiarity is the extraordinary diversity that exists among you. Alike in that you arc men and white, vou arc unlike in your features, very unlike in your minds and m 3^our menial training, and your teachers will mourn the singular inequalities in your capacities. And so it is sad to think will be your careers. For one success, for another failure ; one will tread the primrose path to the great bonfire, another the straight and narrow way to renown; some of the best of you will he stricken early on the road, and will Join that noble band of youthful martyrs who loved not their lives to the death; others, perhaps the most brilliant among you, like my old friend and comrade, Dick Zimmerman (how he would have rejoiced to see this day!), the Fates will overtake and whirl to destruction Just as success seems assured. When the iniquity of oblivion has blindly scattered her poppy over us, some of you will be the trusted counsellors of this community, and the heads of departments in this Faculty while for the large majority of you, let us hope, is reserved the happiest and most useful lot given to man — to become vigorous, wholesouled, intelligent general practitioners.

It seems a bounden duty on such an occasion to be honest and frank, so I propose to tell you the secret of life as I have seen the game played, and as I have tried to play it myself. You remember in one of the " Jungle Stories," that when Mowgli wished to be avenged on the villagers he could only get the help of Hathi and his sons by sending them the masterword. This I propose to give you in the hope, yes, the full assurance, that some of you at least will lay hold upon it to your jirofit. Though a little one, the master-word looms large in meaning. It is the open sesame to every portal, the great equalizer in the world, the true philosopher's stone which transmutes all the base metal of humanity into gold. The stupid man among you it will make bright, the bright man brilliant, and the brilliant student steady. With the magic word in your heart all things are possible, and without it all study is vanity and vexation. The miracles of life are with it ; the blind see by touch, the deaf hear with eyes, the dumb speak with fingers. To the youth it brings hope, to the middle-aged confidence, to the aged repose. True balm of hurt minds, in its presence the heart of the sorrowful is lightened and consoled. It is directly resijonsible for all advances in medicine during the past twenty-five centuries. Laying hold upon it, Hippocrates made observation and science the warp and woof of oiir art. Galen so read its meaning that fifteen centuries stopped thinking, and slept until awakened by the De Fahrica of Vesalius, which is the very incarnation of the master-word. With its inspiration Harvey gave an impulse to a larger circulation than he wot of, an impulse which we

[No. 154.

feel to-day. Hunter sounded all its heights and depths, and stands out in our history as one of the great exemplars of its virtues. With it Virchow smote the rock and the waters of progress gushed out; while in the hands of Pasteur it proved a very talisman to open to us a new heaven in medicine and a new earth in surgery. Not only has it been tlie touchstone of progress, but it is the measure of success in everyday life. Not a man before you but is beholden to it for his position here, while he who addresses you has that honor directly in consequence of having had it graven on his heart when he was as you are to-day. And the Master-Word is Work, a little one, as I have said, but frauglit with momentous sequences if you can but write it on the tables of your heart, and bind it upon your forehead. But there is a serious difficulty in getting you to understand the paramount importance of tlie work-habit as part of your organization. You arc not far from the Tom Sawyer stage with its philosophy " tliat work consists of whatever a body is obliged to do, and play consists of whatever a body is not obliged to do."

A great many hard things may be said of tlie work-habit. For many of us it means a hard battle; the few take to it naturally ; the many prefer idleness and never learn to love to labor. Listen to tliis : " Look at one of your industrious fellows for a moment, I beseech you," says Eobert Louis Stevenson. " He sows hurry and reaps indigestion ; he puts a vast deal of activity out to interest, and receives a large measure of nervous derangement in return. Either he alssents himself entirely from all fellowship, and lives a recluse in a garret, with carpet slippers and a leaden inkpot; or he comes among people swiftly and bitterly, in a contraction of his whole nervous system, to discharge some temper before he returns to work. I do not care how mucJi or how well lie works, this fellow is an evil feature in otlier people's lives." These are the sentiments of an overworked, dejected man ; let me quote the motto of Jiis saner moments : " To travel hopeful is better than to arrive, and the true success is in labor." If you wish to learn of the miseries of scholars in order to avoid them, read Part I, Section 2, Member 3, Sub-section XV, of that immortal work, the "Anatomy of Melancholy," but I am liere to warn you against these evils, and to entreat yon to form good habits in your student days.

At the outset, appreciate clearly tlio aims and objects cacli one of you should have in view — a knowledge of disease and its cure, and a knowledge of yourselves. 'J'he one, a special education, will make you a practitioner of medicine; the other, an inner education, may make you a truly good man, foursquare and without a flaw. The one is extrinsic and is largely accomplished by teacher and tutor, by te.xt and by tongue; the other is intrinsic and is the mental salvation to bo wrought by each one for himself. Tlie first may be had without the second; any one of you may become an acti\(! practitioner, without ever having had sense enough to realize that througli life you have been a fool; or you may have the second without the first, and, without knowing much of the ai-t, you may have the endowments of head and heart that

make the little you do possess go very far in the community. With what I hope to infect you is the desire to have a duo proportion of each.

So far as your professional education is concerned, what I shall say may make for each one of you an easy path easier. The multiplicity of the subjects to be studied is a difficulty, and it is hard for teacher and student to get a due sense )f proportion in the work. We are in a transition stage in our methods of teaching, and we have not everywhere got away from the idea of the examination as the " be-all and end-all ; " so that the student has continuallv before his eyes the magical letters of the degree he seeks. And this is well, perhaps, if you will remember that having, in the old phrase, commenced Baclielor of Medicine, you have only reached a point from which you can liogiii a life-long process of education.

So many and varied are the aspects presented by this theme that I can only lay stress upon a few of the more essential. The very first step towards success in any occupation is to become interested in it. Locke put this in a very happy way when he said, give a pupil " a relish of knowledge " and you put life into his work. And there is nothing more certain than that you cannot study well if you are not interested in your profession. Your presence here is a warrant that in some way you have become attracted to the study of medicine, but the speculative possibilities so warmly cherished at the outset are apt to cool when in contact with the stern realities of the class-room. Most of j'ou have already experienced the all-absorbing attraction of the scientific bracches, and nowadays the practical method of presentation has given a zest which was usually lacking in the old theoretical teaching. The life has become more serious in consequence, and medical students have put away many of the childish tricks with which we used to keep up their bad name. Compare the jiicture of the " sawbones " of 1842, as given in the recent biography of Sir Henry Acland, with their representatives to-day, and it is evident a great revolution has been effected, and very largely by the salutary influence of improved methods of education. It is possible now to fill out a day with practical work, varied enough to prevent monotony, and so arranged that the knowledge is picked out by the student himself, not trust into him, willy-nilly, at the point of the tongue. He exercises his wits, and is no longer a passive Strassbourg goose, tied up and stuffed to repletion.

How can you take the greatest possible advantage of your capacities with the least possible strain? By cultivating system. I say cultivating advisedly, since some of you will find the acquisition of sj-stematic habits very hard. There are minds congenitally systematic; others have a life-long fight against an inherited tendency to dilTuseness and carelessness in work. A few brilliant fellows try to dispense with it altogether, but they are a burden to their brethren and a sore trial to their intimates. I have heard it remarked that order is the badge of an ordinary mind. So it may be, but as practitioner? of medicine we have to be thankful to got into this useful class. Let nie entreat those of you who are here for the

Jaxvauv. litol.]

first time to lay to heart what I say on this matter. Forget all else, but take away this counsel of a man who has had to fight a liard battle, but not always a successful one, for the little order he lias had in his life : take away with you a profound conviction of the value of system in your work. I appeal to the freshmen especially, because you to-day make a beginning, and your future career depends very much upon the habits you will form during this session. To follow the routine of the classes is easy enough, but to take routine into every part of your daily life is a hard task. Some of you will start out joyfully as did Christian and Hopeful, and for many days will journey safely towards the Delectable Mountains, dreaming of them and not thinking of disaster until you find yourselves in the strong captivity of Doubt and imder the grinding tvranny of Despair. You have been over-confident. Begin again and more cautiously. Xo student escapes wholly from tliese perils and trials; be not dislieartened, expect them. Let each hour of the day have its allotted duty, and cultivate that power of concentration which grows with its exercise, so that the attention neither flags nor wavers, but settles with a bull-dog tenacity on the subject before you. Constant repetition makes a good habit fit easily in your mind, and by the end of the session you may have gained that most precious of all knowledge — the power to work. Do not imderestimate the difficulty you will have in wringing from your reluctant selves the stem determination to exact the uttermost minute on your schedule. Do not get too interested in one study at the expense of another, but so map out your day that due allowance is given to each. Only in this way can the average student get the best that he can out of his capacities. And it is worth all the pains and trouble he can possibly take for the ultimate gain — if he can reach his doctorate with system so ingrained that it has become an integral part of his being. The artistic sense of perfection in work is another mucli-to-be-desired quality to be cultivated. Xo matter how trifling the matter on hand, do it with a feeling that it demands tlie best that is in you, and when done look it over with a critical eye, not sparing a strict judgment on yourself. This it is that makes anatomy a student's touchstone. Take the man who does his " part " to ijerfection, who has got out all there is in it, wlio labors over the tags of connective tissue, and who demonstrates Meckel's ganglion in his part — this is the fellow in after years who is apt in emergencies, who saves a leg badly smashed in a railway accident, or fights out to the finish, never knowing when he is beaten, in a case of typhoid fever.

Learn to love the freedom of the student life, only too quickly to pass away ; the absence of the coarser cares of after days, the joy of comradeship, the delight in new work, the liappincss in knowing that you are making progress. Once only can you enjoy these pleasures. The seclusion of the student life is not alwaj's good for a man, particularly for those of you who will afterwards engage in general practice, since you will miss that facility of intercourse upon which often the doctor's success depends. On the other hand, sequestra

tion is essential for those of j'ou with high ambitions proportionate to your capacity. It was for such that St. Chrysostom gave his famous counsel, " Depart from the highways and transplant thyself into some enclosed ground, for it is hard for a tree that stands by the wayside to keep its fruit till it be ripe."

Has work no dangers connected with it? What of this bogey of overwork of wliich we hear so much ? There are dangers, but they may readily be avoided with a little care. I can only mention two, one physical, one mental. The very best students are often not the strongest. Ill-health, the bridle of Theages, as Plato called it in the case of one of his friends whose mind had thriven at the expense of the body, may have been the diverting influence toward books or the profession." Among the good men who have studied with me there stand out in my remembrance many a young Lycidas, " dead ere his prime," sacrificed to carelessness in habits of living and neglect of ordinary sanitary laws, iledical students are mucli exposed to infection of all sorts, to combat which the bodv must be kept in first-class condition. GrosstestC; the great Bishop of Lincoln, remarked that there were three thing.necessary for temporal salvation — food, sleep, and a cheerful disposition. Add to these suitable exercise and you have tlu? means by which good health may be maintained. Not that health is to be a matter of perpetual solicitude, but habits which favor the corpus sanum foster the jneiis sana^ in whicti the joy of living and the joy of working are blended in one harmony. Let me read you a quotation from old Burton, the great authority on morhi eruditoruin. There are " many reasons why students dote more often than others. The first i.-, their negligence. Other men look to their tools : a painter will wash his pencils ; a smith will look to his hammer, anvil, forge; a husbandman will mend his plough-irons, and grind his hatchet, if it be dull ; a falconer or huntsman will have an especial care of his hawks, hounds, horses, dogs, etc. ; a musician will string and unstring his lute, etc. ; only scholars neglect that instrument, their brain and spirits (I mean) which they daily use." '

Much study is not only believed to be a weariness of the flesh, but also an active cause of ill-health of mind, in all grades and phase. I deny that work, legitimate work, has anything to do with this. It is that foul fiend Worry who is responsible for a large majority of the cases. The more carefully one looks into the cause of nervous breakdown in students, the less important is work per se as a factor. There are a few eases of genuine overwork, but they are not common. Of the causes of worrj in the student life there are three of prime importance to which I may briefly refer.

An anticipatory attitude of mind, a perpetual forecasting, disturbs the even tenor of his way and leads to disaster. Years ago a sentence in one of Carlyle's essays made a lasting impression on me : " Our duty is not to see what lies dimly at a distance, but to do what lies clearly at hand." I have long maintained that the best motto for a student is, " Take

'Quotation mainly from Maisiliua Ficinus.

[No. 154.

no thought for the morrow." Let the day'ti work suffice; live for it, regardless of what the fviture has in store, believing that to-morrow should take thought for the things of itself. There is no such safeguard against the morbid apprehensions about the future, tlie dread of examinations and the doubt of ultimate success. Xor is there any risk that such an attitude may breed carelessness. On the contrary, tiie absorption in the duty of the hour is in itself the best guarantee of ultimate siiecess. " He that regardeth the wind shall not sow, and he that observeth the clouds shall not reap," which means you cannot work profitably with your mind set upon the future.

Another potent cause of worry is an idolatry l)y which many of you will be sore let and hindered. The mistress of your studies should be the heavenly Aphrodite, the motherless daughter of Uranus. Give her your whole heart and she will be your protectress and friend. A jealous creature, brooking no second, if she finds you trifling and coquetting with her rival, the younger, early Aphrodite, daughter of Zeus and Dione, she will whistle you off, and let you down the wind to be a prey, perhaps to the examiners, certainly to the worm regret. In plainer language, put your afliections in cold storage for a few years, and you will take them out ripened, perhaps a bit mellow, but certainly less subject to those frequent changes which perplex so many young men. Only a grand passion, an all-absorbing devotion to the elder goddess, can save the man with a .congenital tendency to philandering, the flighty Lydgate who sports with Celia and Dorothea, and upon whom the judgment ultimately falls in a basil-plant of a wife like Rosamond.

And thirdly, one and all of you will have to face the ordeal of every student in this generation who sooner or later tries to mix the waters of science with the oil of faith. You can have a great deal of both if you can only keep them separate. The worry comes from the attempt at mixture. As general practitioners you will need all the faith you can carry, and while it may not always be of the conventional pattern, when expressed in your lives rather than on your lips, the variety is not a bad one from the standpoint of St. James, and may help to counteract the common scandal alluded to in the celebrated diary of that gossipy old parson-doctor, the Rev. John Ward : " One told the Bishop of Gloucester that he imagined physitians of all men the most competent judges of all others' affairs of religion — and his reason was because they were wholly unconcerned witli it."

III.

Professional work of any sort tends to narrow the mind, to limit the point of view, and to put a hall-mark on a man of a most unmistakable kind. On the one hand are the intense, ardent natures, absorbed in tlieir studies and quickly losing interest in everything but their profession, while other faculties and interests " fust" unused. On the other hand are the bovine brethren, who think of nothing but the treadmill and the corn. From very different causes, the one from concen

tration, the other from apathy, both are apt to neglect those outside studies that widen the sympathies and help a man to get the best there is out of life. Like art, medicine is an exacting mistress, and in the pursuit of one of the scientific branches, sometimes, too, in practice, not a portion of a man's spirit may be left free for other distractions, but this does not often happen. On account of the intimate personal nature of his work, the medical man, perhaps more than any other man, needs that higher education of which Plato speaks, " that education in virtue from youth upwards, which enables^ a man eagerly to pursue the ideal perfection." It is not for all, nor can all attain to it, but there is comfort and help in the pursiut, even though the end is never reached. For a large majority the daily round and the common task furnish more than enough to satisfy their heart's desire, and there seems no room left for anything else. Like the good, easy man whom Milton scores in the Areopagitica, whose religion was a "traffic so entangled that of all mysteries he could not skill to keep a stock going upon that trade," and handed it over with all the locks and keys to " a divine of note and estimation," so is it with many of us in the matter of this higher education. Xo longer intrinsic, wrought in us and ingrained, it has become, in Milton phrase, a " dividual movable," handed over nowadays to the daily press or to the hap-hazard instruction of the p^^lpit, the platform, or the magazines. Like a good many other things, it comes to a better and more enduring form if not too consciously sought. The all-important thing is to get a relish for the good company of the race in a daily intereoiirse with some of the great minds of all ages.. Now, in the spring-time of life, pick your intimates among them, and begin a systematic cultivation of their works. Many of you will need a strong leaven to raise you above the level of the dough in which it will be your lot to labor. Uncongenial surroundings, an ever-present dissonance between the aspirations within and the actualities without, the oppressive discords of human society, the bitter tragedies of life, the lacrymae rerum, beside the hidden springs of which we sit in sad despair — all these tend to foster in some natures a cynicism quite foreign to our vocation, and to which this inner education offers the best antidote. Personal contact with men of high purpose and character will help a man to make a start — • to have the desire, at least, but in its fulness this culture — for that word best expresses it — has to be wrought by each one for himself. Start at once a bed-side library and spend the last half hour of the day in comnimiion with the sainvs of humanity. There are great lessons to be learned from Job and from David, from Isaiah and St. Paul. Taught by Shakespeare you may take your intellectual and moral measure with singular precision. Learn to love Epictetus and Marcus Aurelius. Should you be so fortunate as to be bom a Platonist, Jowett will introduce you to the great master through whom alone we can think in certain levels, and whose perpetual modernncss startles and delights. ]\[ontaigne will teach moderation in all things, and to be " sealed of his tribe " is a six'cial privilege. We have in the profession only a few great literary heroes of tlie first rank, tlie friendship and counsel of two of whom you cannot too earnestly seek. Sir Thomas Brown's " Eeligio Medici " should be your pocket companion, while from the " Breakfast Table Series " of Oliver Wendell Holmes you can glean a philosophy of life peculiarly suited to the needs of a physician. There are at least a dozen or more works which would be helpful in getting that wisdom in life wliicli only comes to those w'ho earnestly seek it.

A conscientious pursuit of Plato's ideal perfection may teach you the three great lessons of life. You may learn to consume your own smoke. The atmosphere of life is darkened by the murmurings and whimperings of men and women over the non-essentials, the trifles, that are inevitably incident to the hurly-burly of the day's routine. Things cannot always go your way. Learn to accept in silence the minor aggravations, cultivate the gift of taciturnity and consume j'our own smoke with an extra draught of hard work, so that those about you may not be annoyed with the dust and soot of your complaints. More than any other the practitioner of medicine may illustrate the second great lesson, that we are here not to get all we can out of life for ourselves, but to try to make the lives of others happier. This is the essence of the oftrepeated admonition of Christ, " He that findeth his life shall lose it, and he that Jo-cth his life for my sake shall find it," on which hard saying if the children of this generation would lay hold, there would lie less misery and discontent in the world. It is not possible for anyone to have better opportunities to live this lesson than you will enjoy. The practice of medicine is an art, not a trade, a calling, not a business, a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, the wise upon the foolish. To you as the trusted family counsellor the father will come with his anxieties, the mother with her hidden griefs, the daughter with her trials, and the son with his follies. Fully one-third of the work you do will be entered in other books than yours. Courage and cheerfulness will not only carry you over the rough places of life, but will enable you to bring comfort and help to the weak-hearted, and will console you in the sad hours when, like Uncle Toby, you have " to whistle that you may not weep."

And the third great lesson }-ou may learn is the hardest of all — that the law of the higher life is only fulfilled by love or charity. Many a physician whose daily work is a daily round of beneficence will say hard things and will think hard thoughts of a colleague. Xo sin will so easily beset you iis uncharitablencss towards your brother practitioner. So strong is the personal element in the practice of medicine, and so many are the wagging tongues in every parish, that evil speaking, lying and slandering find a shining mark in the lapses and mistakes which are inevitable in our work. There is no rea

son for discord and disagreement, and the only way to avoid trouble is to have two iiJain rules. From the day you begin practice never under any circumstances listen to a tale told to the detriment of a brother practitoner. And when any dispute or trouble does arise, go frankly, ere sunset, and talk the matter over, in wliich way you may gain a brother and a friend. Very easy to carry out, yon nuxy think ! Far from it; there is no harder battle to fight. Theoretically, there seems to he no difficulty, but when the concrete wound is rankling, and after Mrs. Jones has rubbed in the cayenne pepper by declaring that Dr. J. told her in confidence of your shocking bungling, your attitude of mind is that you would rather see him in purgatory than make advances towards reconciliation. Wait until the day of your trial comes and then remember my words.

And in closing may I say a few words to the younger practitioners in the audience whose activities will wax, not wane, with the growing years of the century which opens so auspiciously for this school, for this city, for this country. You enter a noble heritage, made by no efforts of your own, but by generations of men who have unselfishly sought to do the best they could for suffering mankind. Much has been done, much remains to do ; a way has been opened, and to the possibilities )u the scientific development of medicine there seems to be no limit. Except in its application, as general practitioners, you will not have much to do with this. Yours is a higher and a more sacred duty. Think not to light a light to shine before men that they may see your good works; contrariwise, you belong to the great army of quiet workers, physicians and priests, sisters and nurses, all over the world, the members of which strive not neither do they cry, nor are their voices lieard in the streets, but to them is given the ministry of consolation in sorrow, need and sickness. Like the ideal wife (if whom Plutarch speaks, the best doctor is often the one of \iliom the public hears least; but nowadays in the fierce light that beats upon the hearth, it is increasingly difficult to live the secluded life in which our best work is done. To you the silent workers of the ranks, in villages and country districts, in the slums of our great cities, in the mining camps and factory towms, in the homes of the rich and in the hovels of the poor — to you is given the harder task of illustrating in your lives the old Hippocratic standards of learning, of sagacity, of humanity and of probity. Of learning, that you may apply in your practice the best that is known in our art, and that with the increase in that priceless endowment of sagacity, so tliat to all everywhere skilled succor may come in the hour of urgent need. Of a humanity that will show in your daily life tenderness and consideration to the weak, infinite pity to the suffering and a liroad charity to all. Of a probity that will make you under all circumtances true to yourselves, true lo your high calling, and true to your fellowmen.

TUBERCULOSIS OF THE URINARY SYSTEM IN WOMEN. REPORT OF THIRTY-FIVE CASES.

By Guy L. Hdnner, M. D.,

Associate in (hjnecolo<jij, .Johns Ilopldns Unircrsiiij, Baliiiiiore.

This paper will deal chiefly with diagnosis. I shall speak briefly of the treatment and the final results, time forbidding a technical review of the operations. There will be no attempt to jjresent a systematic and comprehensive treatise on the subject of tuberculosis of the urinary system — this yon can find in the text-books and special monographs. I hope to present a few practical and lielpful facts and conclusions that may be drawn from a study of 35 cases which have occurred in the service of Dr. Howard A. Kelly and his associates.

THE SECOND HOSPITAL IN THE COLONIES, THE "COOLE SPRINGS OF ST. MARIES," MARYLAND, KIDS.*

By J. Hall Pleasants, M. D.

SOME UNUSUAL FORMS OF MALARIAL PARASITES.

By Mauy E. Rowley, M. D.

{From the Clinico-Pathological Laboratory, Massachusetts General Ho.ii)ital. Photoi/raijhs by Louis A. Brown.)

The varieties of parasites ordinarily to be found in the blood of Aestivo Autumnal Malaria are : I. Eing-shaped bodies.

II. Crescents and ovoids.

In the blood of three eases of this fever, I noticed a number of parasites quite different from the above.

Those to which I desire to call attention are of two classes :

I. The first set of bodies are intracellular, elongated and sausage-shaped, extending transversely across the red cell nearly from side to side. The body of the parasite contains irregular openings, iisually situated at its extremities.

The chromatin is in the form of dots arranged in a short series parallel to the long axis of the parasite and about midway between its extremities (Figs. 1-6).

Pigment was present in all the forms observed and was either scattered about the parasite without special arrangement or grouped at its ends.'

' In KoUe ifc Wassermanu's Atlas of Handbucli Path. Mikroorganismen, Berlin, are Hgured some forms of quartan parasites not unlilie tliose wbicli I liave found in aestivo-autumnal fevers.

II. The other forms found would suggest a transition between the bodies just described and " crescents; " for example, Pig. 7, which shows a form distinctly curved on itself like a crescent, but of much looser structure, the chromatin arranged in a string of dots near one end, and the pigment at the periphery and not at the center as in most crescents.

Figs. 8 and 9 are evidently crescents, but show much more of the corpuscle than is usually to be seen and approach quite distinctly the appearance of Fig. 7, which I should hesitate to call a crescent.

We have, then, a suggestion of the means of formation of " crescents " out of the elongated intracellular forms above described, wliile these in turn can probably be connected (through intermediate forms) with the larger and heavier forms of ring bodies such as are shown in Figs. 1 and 3.

I wish to express my appreciation of the kind assistance given me by Dr. Eichard C. Cabot in studying and interpreting the parasites above described.

n^otes A^jy xews.

Dr. Joseph Akerman, appointed House IMedical Officer in 1900, but did not serve, is Superintendent of the James Walker Memorial Hospital, Wilmington, N. C.

Dr. Ilorliert W. Allen, House Medical Officer during 1900 and 1901, is Assistant in Clinical Pathology and in Medicine in the Medical Department of the University of California. Address : 546 Sutter Street, San Francisco, Cal.

Dr. John JI. Berry, House Medical Oliicer during 1901 and 1902, is surgical assistant to Dr. W. G. Macdonald, of Albany, X. Y. Address: 1.86 State Street, Albany, X. Y.

Dr. Joel I. Butler, House Medical Oflicer during 19iil und 1902, is Resident House Officer in Surgery in the Massachusetts General Hospital, Boston, Mass.

Dr. \\L J. Calvert, appointed House Medical Officer in 1898, but did not serve, is Assistant Professor of Internal Jlodieine, University of Missouri. Address: Columbia, Mo.

Dr. C. N. B. Camac, Assistant Resident Physician in 1896 and 1897, is Instructor in Medicine, Cornell Medical College, and Chief of Staff in the Department of General Medicine of the Cornell Dispensary. Address: 108 East 6511) Street, Xcw York City.

Dr. M. B. Clopton, Assistant Eesident Surgeon in 1898 and 1899, is Visiting Surgeon to St. Luke's Hospital. St. Louis. Address: 260-1 Locust Street, St. Louis, Mo.

Dr. Sydney 'M. Cone, Assistant Eesident Surgeon in 1891 and 1897, is Clinical Professor of Orthopedic Surgery, Baltimore Medical College. Address: 821 Park Avenue, Baltimore.

Dr. George W. Dobbin, Assistant Resident Obstetrician from 1894 to 1896, and Eesident Obstetrician from 1896 to 1899, is Professor of Obstetrics, College of Physicians and Surgeons. Address: 56 West Biddle Street, Baltimore.

Dr. William W. Farr, Assistant Resident Gynecologist during 1890 and 1891, resides at 39 Gowen Avenue, ]\[oimt Airy, Philadelphia, Pa.

Dr. A. L. Fisher, House Medical Oliicer during 1900 and 1901, is Assistant in Surgery in the Medical Department of the University of California, and Assistant Visiting Surgeon to Mt. Zion Hospital, San Francisco. Address : 54() Sutter Street, San Francisco, California.

Dr. 11. ,\. ImiwIit. House Medical Officer in 1901 and 1902, resides at 'i'he Cuiiil)crl:ind, Washington, D. C.

THE JOHNS HOPKINS HOSPITAL BULLETIN, JANUARY, 1904.

PLATE 1.

FIG. 9.

jANUAItY. TOOL]

23

Dr. I?. Edward Garrett, Assistant Resident Surgeon from 1895 to 1897, is First Assistant I'liysieian, Maryland Hospital for (lie Insane. Address: Catonsville, Md.

Dr. McPlieeters Glasgow, Assistant Resident Gynecologist in 189G, resides at 151 North Spruce Street, Nashville, Tenii.

Dr. Henry Harris, House Medical Officer during 1899 and 1900, is Assistant in Principles and Practice of Medicine, Cooper Medical College, First Assistant in the Medical Clinic, Cooper ]\redical Dispensary, and A^isiting Physician, Pacific Hebrew Orphan Asylum. Address: 502 Sutter Street, San Francisco, Cal.

Dr. Thomas W. Hastings, House Medical Officer during 189S and 1899, is Instructor in Clinical Pathology, Cornell Medical College, and Assistant Attending Physician, Department of General Medicine, Cornell Dispensary. Address : 72 West 8rth Street, New York City.

Dr. R. F. Hastrciter, House Medical Officer during 1901 and 1902, is Physician in Charge of the Milwaukee Branch of the Summit Lake Sanitorium, Physician to the Protestant Home for the Aged, and Instructor in Anatomy in the Wisconsin College of Physicians and Surgeons. Address: 203G Wells Street, Milwaukee, Wis.

Dr. Joseph H. Hathaway, House Medical Officer during 1901 and 1902, is Resident Pathologist, Free Hospital for Women, Brookline, Mass.

Dr. Carl H. Horst, House Medical Officer during 1902 and 1903, resides at 208 West Galaia Street, Butte, Montana.

Dr. J. A. Luetscher, House Medical Officer during 1899 and 1900, resides at 1025 Madison Avenue, Baltimore.

Dr. Irving P. Lyon, House Medical Officer during 1897 and

1898, resides at 531 Franklin Street, Buffalo, N. Y.

Dr. J. D. Madison, House Medical Officer during 1898 and

1899, is Chief of the Medical Dispensary, and Adjunct Professor of Medicine, Wisconsin College of Physicians and Surgeons. Address: 199 23rd Street, Milwaukee, Wis.

Dr. E. W. Meisenhelder, House Medical Officer in 1902 and 1903, is a member of the staff of the Barnes Hospital, Washington, D. C.

Dr. J. F. Mitchell, House Medical Officer during 1897 and 1898, Assistant Resident Surgeon from 1898 to 1900, and Resident Surgeon from 1900 to 1902, is Professor of Surgical Pathology, Columbian University, and Surgeon to the Dispensary of the University Hospital, Washington. Address: 1311 Connecticut Avenue, Washington, D. C.

Dr. G. II. P. Nuttall, Assistant Bacteriologist from 1891 to 1893, is President of the Tropical Medicine Section, British Medical Association, Examiner in Bacteriology and Tropical Medicine to the Royal Army Medical Corps, and Accessory Member of the Tropical Diseases Committee appointed by the

Council of the Royal Society. Address: 3 Cranmcr Road, Cambridge, England.

Dr. Mary S. Packard, House Medical Officer during 1897 and 1898, resides at 425 Angell Street, Providence, R. I.

Dr. Clement A. Penrose, House Medical Officer during 1897 and 1898, resides at 21 West Mount Royal .\ venue, Baltimore.

Dr. Lindsay Peters, Assistant Resident Obstetrician during

1897 and 1898, and Assistant Resident Gynecologist during

1898 and 1899, resides at 1414 Gervais, Street, Columbia, S. C.

Dr. Hunter Robb, Resident Gynecologist from 1889 to 1892, is Professor of Gynecology, Western Reserve University. Address: 702 Rose Building, Cleveland, Ohio.

Dr. Carey P. Rogers, House Jledical Officer during 1902 and 1903, resides at the Bisbee Building, Jacksonville, Fla.

Dr. Maurice Rubel, House Medical Officer during 1901 and 1902, resides at 4452 Ellis Avenue, Chicago, 111.

Dr. Glauville Y. Rusk, House Medical Officer during 1900 and 1901, is Assistant in the Pathological Institute of the State of New York. Address: Pathological Institute, Ward's Island, New York.

Dr. Florence R. Sabin, House Medical Officer during 1900 and 1901, is Assistant in Anatomy, Johns Hopkins Medical School. Address: 1415 Linden Avenue, Baltimore.

Dr. Georgiana Sands, House Medical Officer during 1898 and 1899, resides at 348 North Main Street, Port Chester, N. Y.

Dr. C. P. Smith, Assistant Resident Surgeon during 1893 and 1894, is Surgeon to the Buffalo, Rochester and Pittsburgh Railway Company. Address: 481 Franklin Street, Buffalo, X. Y. '

Dr. C. N. Spratt, House Medical Officer during 1901 and 1902, is a member of the staff of the Massachusetts Charitable Eye and Ear Infirmary. Address: 233 Charles Street, Boston, Mass.

Dr. A. L. Stavely, Assistant Resident Gjmecologist in 1891 and 1892, and Resident Gynecologist from 1892 to 1894, is Gynecologist to the Garfield Memorial Hospital, and Clinical Professor of Gynecology, Columbian University. Address : 1207 Connecticut Avenue, Washington, D. C.

Dr. J. M. Taylor, Assistant Resident Gynecologist in 1900 and 1901, is located at the Pierce Building, Boise, Idaho.

Dr. Harry Toulmin, Assistant Resident Physician in 1889 and 1890, is Assistant Medical DircH'tor of the Pcnn Mutual Life Insurance Comjiany. Address: 921 Chestnut Street, Philadelphia, Pa.

24

[No. 1'

NOTES ON NEW BOOKS.

A Narrative of Medicine in America. By James Ghegory MuitroRD, M .D., Assistant Visiting Surgeon to the Massacliusetts General Hospital and Instructor in Surgery In the Harvard Medical School. Octavo, 508 pages. (Pliiladelpliia and London: J. B. Lippincott Company, IDOS.)

The work done, during the past few years on the history of medicine in the United States should be especially gratifying to all who take an interest in the recital of matters medical. The enthusiasm aroused for this study shows that the labors of Thacher, Beck, Toner and Quinan have not been in vain, for the subsequent delvings of Cordell, Packard and a host of others have brought to light much worthy of record about our doctors of former times and their surroundings. Mumford, already known by his writings on former Boston worthies, has recently published a most readable book, narrating many of the principal facts in the medical history of our own country. His charm of style causes the work to be with difficulty laid aside until the last page has been read.

He starts with the colonial era — a time when most of the doctors obtained their knowledge from apprenticeships, for few there were who could go abroad to Leyden, Paris, Padua or Great Britain, for a more complete education. The early doctors in Virginia are here touched upon and some mention is made of good old Deacon Fuller, of Mayflower fame. John Winthrop, Jr.. is also referred to but is erroneously spoken of as Governor, in 1G57. of the New Haven Colony instead of Connecticut, and asserted to be a founder of the Royal Society. As a matter of fact the Royal Society was organized in 1660, but was not incorporated until two years later, at which time Winthrop was proposed for membership by William Brereton and admitted some twenty days thereafter.

Other names, though not quite so luminous, are given full attention by Mumford. In his list of eighteen of the best known early Massachusetts physicians, Giles Firmln is written as Giles Fairman. An interesting man he was and we wish some account of him had been given other than the mere recital of his name, for he, in those early days, " did make and read upon the one Anatomy (skeleton) on the country very well" but despairing of earning his living as a doctor was " strongly set upon to study divinitie." His studies else must be lost, he says, for he found physick " a meene help," and later he did follow this course, returned to England and died in the ministry.

We must take strong exception to the statement that the seventeenth century record of Maryland was all but inarticulate. Previous numbers of this Bulletin have contained the record of those early times, as well as Dr. Quinan's articles in the Maryland Medical Journal and Dr. Cordell's recent book. These, with other data now accessible, show that the first suggestion for a hospital in the colonies was made in Maryland in 1638 (see Father White's letter to Cecilius, second Lord Baltimore) ; that the first carefully recorded autopsy was done five years later in this colony and was probably performed by George Binx, who is elsewhere styled Licentiate in Physick. There was. however, another doctor on the jury, Robert Ellyson, a barber-surgoon. This autopsy was on an Indian boy shot by his master and the report shows well how thorough and successful efforts were made to trace the course of the bullet and find its scat of lodgement. Then, too, some fifty-five yeais later the first sanitarium in the colonies was established at " Coole Springs" (now Charlotte Hall), St. Mary's Co., Maryland. Thomas Gerard and Luke Barber, alike prominent as x'l'ysicians and statesmen, should have received some mention.

On page 29, it is stated that the physicians of the period no

where sided with the madr.ess of witchcraft. We wish this were true but the account of Bryan Rossiter's autopsy on " Kellies child " (see September number of this Bulletin), shows there was at least one notable exception to this statement. We regret that no reference is made to certain well-known Connecticut doctors of this period who have been brought clearly to light by the labors of Russell and others. Gershom Bulkeley, especially, should have been rescued from an undeserved oblivion.

In the story of the eighteenth century the trials and ultimate success of Boylston in introducing inoculation is attractively presented, but we think that Dr. Adam Thompson of Prince George's County, Maryland, should also have been named as he originated the " American Method " of inoculation. This method consisted mainly in the preliminary use of mercury and was also extensively employed by Muirson of Brookhaven, L. I., (Ezra Stiles in his diary says he was the first to use it) and Benjamin Gale, one of Connecticut's most famous clerical physicians. The latter especially should not have been slighted, for he was " one of the pre-Revolutionary American physicians who have left published records of valuable medical observations" (Welch).

tn the pages following Colden, Cadwallader, the Charleston coterie, Morgan, Shippen and others of their time come in for their share of notice, and the founding of the early hospitals and medical schools in this country, is well told. The story of the Revolu tion, with the sorry ending of Church's career as well as the cruel injustice meted out to Morgan, makes an interesting chapter. For Benjamin Rush more space is reserved, and rightly we think, than for any of the others. Elihu Hubbard Smith, the founder of the first medical periodical in America, has a whole chapter devoted to him. Great ability is shown in selecting for special mention the most prominent physicians and surgeons of the early part of the nineteenth century. Among those of lesser notice, Waterhouse is said to have been the first to introduce vaccination to his countrymen. A common error, it is true, for John Crawford of Baltimore, practiced vaccination simultaneously with Waterhouse, in the summer of 1800. Dr. James Smith, also of Baltimore, is not spoken of at all, yet he did more than any one in this country to popularize vaccination and has been called by Quinan " the Jenner of America."

The later physicians and surgeons are finally considered — Chapman, Francis, Gibson, Jackson and Drake being given special mention. It seems to us that Charles Frick, of Baltimore, is entitled to be mentioned in this group, for he, cut off in his prime, was a well-known physician of marked scientific attainments. The story of the ether tontroversy and the founding of the American Medical Association, are well told in two of the concluding chapters. Altogether the author has written a most pleasing narrative and we congratulate him most heartily upon it. W. R. S.

A Text-Book of Operative Surgery. Covering the Surgical Anatomy and Operative Technic Involved in the Operations of General Surgery. By Warrex Sto.ne Bickuam, Phar. M. M. D., Assistant Instructor in Operative Surgery, College of Physicians and Surgeons, New York; Late Visiting Surgeon to Charity Hospital, New Orleans, etc. Octavo of 984 pages, with 539 illustrations. (Philadelphia, New "5 orfc, London: W. B. Saunders and Company, 1903.)

In this volume of nine hundred eighty-four pages the author attempts to describe most of the operations of general surgery, and a number of special operations of gynecology as well as of the surgery of the eye, ear, and genito-urinary tract. The descriptions are necessarily concise, but in most cases are suflficiently full to give a fairly satisfactory idea of the operations under consideration. The ilhistrations are numerous and add very decidedly to the value of the book. A special feature which the author in

Januaky,, 1901. 1

25

trocUices is a brief description of sursif'al anatomy preceding the description of the operation. We question the value of this lor we believe that in most cases the surgeon will get his anatomv much more satisfactorily from a text-book than from such a brief review as is given in this book. As would be expected at a time when the progress of surgery is so rapid, many procedures are included which are not to be found in most of the older standard text-books; for example all the later methods of intestinal anastomosis are quite satisfactorily described, the modern methods of amputation, operations on the brain and heart, the Matas operation for aneurysm, etc. The author states in his preface that he has omitted the principles of operative surgery and anaesthesia, as well as the operations of plastic surgery, many of the operations more properly classed as the operations of special branches of surgery, and some of the variations of the operations of general surgery. Some of these omissions very greatly lessen the value of the book and we fail to see the reason for omitting some operations usually considered as belonging to general surgery while others are included; for example such operations of tn.e specialty of gynecology as hysterectomy and oophorectomy are included while a large proportion of operations on the male urethra, testicles, scrotum and prostate have been omitted as belonging to special genitourinary surgery. We regret also to notice the omission of several important methods introduced by American surgeons, which are considered by many competent men the most satisfactory operations of their class; for example, Mayo's vertical over-lapping method of operating for the radical cure of umbilical hernia, Finney's gastroduodenostomy as a substitute for the older methods of plyloroplasty. Fowler's method of decortication of the lung for chronic empyema (often improperly credited to De Lorme), Halsted's latest method of operating for the radical cure of hernia, and his improvements on the operation for excision of the breast for carcinoma. Some of these are included in a recent text on surgery by a foreign writer. A number of out of date procedures are given, such as Loreta's divulsion of the pylorus, which has been abandoned by its originator, as well as practically every other surgeon in favor of other more effectual methods; cholecystendysis which is now practically never used. Such omissions and inclusions are a common fault of practically all textbooks, but to our mind the greatest fault of this book is that frequently several methods are described without any suggestions being given as to their comparative advantages or disadvantages, or the conditions under which each operation would be preferable; for example we read in the description of sequestrotomy, " bone chips may be used in the cavity — or the entire thickness of the soft parts including periosteum may be inverted into the bottom of the cavity from each side and held in place by a nail or peg, or the cavity may be packed throughout with gauze." We believe that there are certain conditions under which some of these procedures would oe absolutely contra-indicated, and that in most cases there is a choice which methods shall be adopted. Without a surgeon has experience enough to know which method would best be used it avails him little to know the operative technic. The lack of completeness of the book and the fact that in many cases it does not give any advice as to the choice of operation, will make some other book on operative surgery necessary for the less experienced surgeon, or for the general practitioner who is occasionally called upon to operate, and it contains no features of such value as to make it especially helpful to the experienced surgeon, who already has on his shelves the standard works on operative surgery. The systematic arrangement and concise, accurate descriptions together with numerous, excellent, illi^trations of the sections on amputations, excisions, and liga

tions of arteries, the operations most frequently practiced by students on the cadaver, however, make the book well suited for use in the laboratory of operative surgery.

Atlas and Epitome of Operative Surgery. By Dii.Otto ZuckeuKA>-i)i„ privat-docent in the University of Vienna. Second edition, revised and enlarged, authorized translation from the German, edited by J. Ciiai.meus Ua'Costa, M. D., with 40 colored plates and 278 illustrations in the text. (Philadelphia and London: W. B. Saunders and Company, J002.J In the preface to the first edition of this volume the authors state that the book was designed mainly for students and that the operations described fully are those most suited for practical instruction in operative surgery on the cadaver. " Other operations, whose performance falls largely to the lot of the skilled surgeon, and whose practice upon the cadaver appears less important, are described concisely." As might be expected from this introduction a large portion of the book, over one-third the entire number of pages, is taken up with a description of amputations and the ligation of the main arteries of the body. Amputations are described in the main quite satisfactorily. In the remaining two hundred pages all the other operations are given; for most practitioners the most important part of operative surgery. It is almost unnecessary to state that in such a short space the descriptions of the operations are not only concise, but in many cases so brief as to be of no value to the operative surgeon, who is in search of information. A striking example of this is found in the description of operations on the biliary passages, which, at the present day, are of such great importance. Within the limits of a single page three important operations are "concisely" described; cholecystectomy, choledochotomy, and cholecystenterostomy. Three operations for hemorrhoids are also described on one page. It is needless to say that any adequate description is impossible within such short space. The book is distinctively German, and many operations frequently employed by American surgeons are entirely omitted. As an example of this may be mentioned Halsted's operations for the radical cure of hernia;, and excision of the breast for carcinoma; the overlapping method for large umbilical hernias, and the simpler methods of operating for femoral hernia. Another decided disadvantage of the book Is that when several operations are mentioned nothing is said with regard to which is considered the operation of choice under various circumstances. The illustrations are numerous, many of them being showy colored illustrations, but for the purpose of the student and operative surgeon ihey are many of them far from satisfactory. With judicious, careful editing the book might have been made of considerable value, but the editorial notes are limited to a few lines of fine print scattered here and there through the book. The book may be well suited to the use of German students, but there are several hooks in English which we believe are better adapted to the use of American students.

THE JOHNS HOPKINS HOSPITAL BULLETIN.

The Hospital Bulletin contains details of hospital and dispensary practice, abstracts of papers read, and other proceedings of the Medical Society of the Hospital, reports of lectures, and other matters of general interest in connection with the work of the Hospital. It is issued monthly.

Volume XIV is now completed. The subscription price is $2.00 per year. The set of fourteen volumes will be sold for $50.00.

26

[No. 154.

THE JOHJ^S HOPKINS HOSPITAL EBPOETS.

Volume I. 433 pages, 99 plates.

Volume II. 570 pages, with 28 plates and figures.

Volume III. 7GG pages, with 69 plates and figures.

Volume IV. 504 pages, 33 charts and illustrations.

Report on Typliold Fever.

By William Osler, M. D., with additional papers by W. S. Thayeb. M. D., and J. Hewetson, M. D.

Report in NenroloETT*

Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The Intrinsic Pulmonary' Nerves in Mammalia; The Intrinsic Nerve Supply of the Cardiac \'entricles in Certain \'ertebratcs; The Intrinsic Nerves of the Submaxillary Gland of Mug imt^crtluft ; The Intrinsic Nerves of the Thyroid Gland of the Dog; The Nerve Elements of the Pituitary Gland. By Hbnhi J. Berkley,

The Results of Operations for the Cure of Cancer of the Breast, from June, 1889, to .January, 1894. By W. S. Halsted. M D.

Report in Gyneeology.

Hydrosalpinx, with a report of twenty-seven cases; Post-Operative Septic Peritonitis; Tuberculosis of the Endometrium. By T. S. Collen, M. B.

Report in Patliolo^y.

Deciduoma Malignum. By J. Wiiitridge Williams, M. D.

Volume V. 480 pages, with 33 charts and illustrations.

CONTENTS:

The Malarial Fevers of Baltimore. By W. S. Thayer, M. D., and J. Hewetson,

M. D. A Study of some Fatal Cases of Malaria. By Lewellys F. Barhj:r, M. B.

Stadies In Typhoid Fever.

By William Osleh, M. D., with additional papers by G. Blumer, M. D., Flexner, M. D., Walter Reed, M. D., and H. O. Parsons, M. D.

Simon

Volume VI. 414 pages, with 79 plates and figures.

Report in IVenroIogy,

studies on the Lesions Produced by the Action of Certain Poisons on the Cortical Nerve Ct-11 (Studies Nos. I to V). By Henry J. Berkley, M. D.

Introductory. — Recent Literature on the Pathology of Diseases of the Brain by the Chromate of Silver Methods; Part I. — .\lcohol Poisoning.— E.xperimental Lesions produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. Experimental Lesions produced b.v Acute Alcoholic Poisoning (Ethyl Alcohol) ; Part 11. — Serum Poisoning. — Experimental Lesions induced hy the Action of the Dog's Serum on tlie (Cortical Nerve Cell; Part 111. — Ricin Poisoning. — Experimental Lesions induced b.y Acute Ricin Poisoning. 2. Experimental Lesions induced by Chronic Ricin Poisoning; Part IV. — Hydrophobic Toxaemia. — Lesions of the Cortical Nerve Cell produced by the Toxine of Experimental Rabies; Part V. — Pathological Alterations in the Nuclei and Nucleoli of Nerve Cells from the Effects of Alcohol and Ricin Intoxication; Nerve Fibre Terminal Apparatus; Astlienic Bulbar Paralysis. By Henry J. Berkley, M. D.

Report In Patholoey.

Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Thomas S.

CULLBN, M. B.

Pregnancy in a Rudimentary Uterine Horn. Rupture, Death. Probable Migration of Ovum and Spermatozoa. By Thomas S. Cullen, M. B., and G. L. Wilkins. M. D.

Adeno-Myoma Uteri DifTnsum Bcnignum. By Thomas S. Cullen, M. B.

A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By William D. Booker. M. D.

The Pathology of Toxalfjumin Intoxications. By SiMOS' Flkxner. M. D.

Volume VI f. 537 pages with illustrations.

I- A Critical Review of Seventeen Hundred Cases of Abdominal Section from the

standpoint of Intra-peritoneal Drainage. By J. G. CJlark, M. D. II. The Etiology and Structure of true Vaginal Cysts. By James Ernest Stores,

M. D. HI. A Review of the Pathology of Superflcial Burns, with a Contribution to our Ivnowledge of the Pathological Changes in the Organs in cases of rapidly fatal burns. By Charles Russell Bardeen, M. D. IV. The Origin, Growth and Fate of the Corpus Luteum. By J. G. Clark, M. D. V. The Results of Operations for the Cure of Inguinal Hernia. By Joseph O. Bloodgood, M. D.

Volume VIII. 553 pages with illustrations.

On the role of Insects, Arachnids, and MjTiapods as carriers in the spread of Bacterial and Parasitic Diseases of Man and Animals. By George H. F. Nuttall, M. D., Ph. D.

StadicH in Typlioid Fever.

By William Osler, M. D., with additional papers by J. M. T. Finney, M. D., S. Flexner, M. D., I. P. Lyon, M. D., L. P. Hamburger, M. D., H. W. Cushino, M. D., J. F. Mitchell, M. D., C. N. B. Camac, M. D., N. B. Gwyn, M. D., Charles P. Emerson, M. D., H. H. Yodsg, M. D., and W. S. Thayer, M. D.

Volume IX. lOGO pages, 66 plates and 210 other illustrations.

Contribations to the Scienee of Medicine.

Dedicated by his Pupils to William Henry Welch, on the twenty-fifth anniversary of his Doctorate. This volume contains 38 separate papers.

Volume X. 51G pages, 12 plates and 25 charts.

structure of the Malarial Parasites. Plate I. By Jesse W. Lazear, M. D.

The Bacteriolog.v of Cystitis, Pyelitis and Pyelonephritis in Women, with a Consideration of the Accessory Etiological Factors in these Conditions, and of the Various Chemical and Microscopical Questions Involved. By Thomas R. Brown, M. D.

Cases of Infection with Strongyloides Intestinalis. (First Reported Occurrence in North America.) Plates II and HI. By Richard P. Strong, M. D.

On the Pathological Changes in Hodgkin's Disease with Especial Reference to its Relation to Tuberculosis. Plates IV-\'U. By Dorothy M. Reed, M. D.

Diabetes Insipidus witli a Report of Five Cases. By Thomas B. Fhtcher, M. B. (Tor.)

Observations on the Origin and Occurrence of Cells with Eosinophile Granulations In Normal and Pathological Tissues. Plate VIII. By W. T. Howard, M. D., and R. G. Perkins, M. D.

Placental Transmission with Report of a Case during Typhoid Fever. By Frank W. Lynch, M. D.

Metabolism in Albuminuria. By Chas. P. Emerson, A. B., M. D.

Regenerative Changes in the Liver after Acute Yellow Atrophy. Plates IX-XII. By W. G. MacCailum, M. D.

Surgical Features of Tj-phoid Fever. By Thos. McCrae, M. B., M. R. C. P. (Lond.), and James F. Mitchell, M. D.

The Symptoms, Diagnosis and Surgical Treatment of Ureteral Calculus. By Benjamin R. Schenck, M. D.

Volume XI. 555 pages, with 38 charts and illustrations. Now ready.

Pneumothorax: A historical, clinical and experimental study. By Charles P.

Emerson, M. D. Clinical Observations on Blood Pressure. By Henry W. Cook, M. D., and John B.

Briggs, M. D. The value of Tuberculin in Surgical Diagnosis. By Martin B. Tinker, M. D.

The set of eleven volnnies -will be sold for sixty dollars, net. Voliiiiie.s I nnd II T\-iII not lie sold separately. Volnnies III, IV, V, VI, VII, VIll, X, and XI will be sold for five dollars, net, each. Volume I.\ T»-ill be sold for ten flollars, net.

CONTENTS.

Historic Outline of Cardiac Pathology and Clinical Aspects of Chronic Myocarditis. By C. N. B. Camac, A. B., M. U., . . 27

The Efficiency of the Periureteral Arterial Plexus, and the Importance of its Preservation in the More Radical Operations for Carcinoma Cervicis Uteri. By John A. Sampson, M. D., 39

Two Cases of Leukokeratosis Buccalis; Comparison with the Histological Changes in a Case of Tylosis Palmie et Plantie. By Sylvan Rosenheim, M. D., 47

The Effects of X-Rays upon Lower Animal Life and the Tube Best Suited to their Destruction. By Kennon Dunham, M. D., . . 51

An Anopheles Mosquito which Does not Transmit Malaria. By Leonard K. Hikshberg, A. B., M. D., 53

Proceedings of Societies :

The Johns Hopkins Hospital Medical Society, 57

Demonstration of Medical Cases [Dr. McCuae]; — Demonstration of Surgical Cases [Dr. Follis];— Some Recent Cases of Extra-Uterine Pregnancy [Dr. Cullen] ; — A Case of Typhoid Arteritis [Dr. Steiner] ; — The Treatment of General Infections, with Especial Reference to the Use of Silver Nitrate in Such Cases [Dr. Hume]; — Exhibition of Cases of Typhoid Meningitis [Dr. Cole] ; — The Late Effects of Typhoid Fever on the Heart and Blood- Vessels [Dr. Thayer] ; — A Preliminary Report on a New Method of Treating Tinnitus Aurium [Dr. Reik]; — Exhibition of Appendices Showing Unusual Conditions [Dr. Burnam] ; — Aneurism of Arch of Aorta and Innominate [Dr. Osler] ; —A Case of Generalized Neuritis from Lead [Dr. ThomasJ ; — A Case of Blastomycetic Infection [Dr. Gilchrist] ; — Metabolism in Pregnancy [Dr. Slemons]

Notes on New Books 67

HISTORIC OUTLINE OF CARDIAC PATHOLOGY AND CLINWAL ASPECTS OF CHRONIC

MYOCARDITIS.^

By C. N. B. Camac, A. B., M. D., Visiting Physician to City Hospital; Chief of Medical Staff, Cornell University Medical College Dispensary, Xeir York City.

I. Introduction.

II. Historic outline— Chronological Charts. Ancient Literature. 1. Morgagni, 2. Avenbrugger, 3. Corvlsart, 4. Laennec.

III. Anatomy — Radiographs.

IV. Physiologj' and Physiologic Chemistry.

V. Pathology. PathologicalClassiflcationinContrast to Clinical Classification. VI. .litiology.

VH. Clinical Symptoms and Signs— Diagnosis. VIII. Prognosis. IX. Troatmout. X. Modern Literature— Conclusion.

PLATE IV.

Fig. 1. — Hunt. Feb. 12. Before bath So. 1, strengtli No. 1. Point max. imp., 5th space, 13J^ cm. from median line; after bath, point m•^x. imp., .Tth space, 11 em. from median line. Feb. 13, no bath given. Point max. imp., .5th space, 10 cm. from median line. Feb. 14, bath No. 2, strength No. 1. Point max. imp. after bath 5th space, S cm. from median line. Feb. 15, no bath given. Point max. imp. not located. No signs (physical or post-mortem) of elfusion.

Fig. 2. — Larber. Before bath No. 1, strengtli No. 1, point max. imp. 14 cm. from median line. After bath, point max. imp., 12 cm. from median line. Length of time in bath, five minutes.

Figs. 1 and 2 illustrate the iinineduiti- influence of the baths upon the point max. imp.

Fig. :5.-C'oulbourn. Oct. 13, 1896. I, strength No. 1. Riaht border 2-'., eiglit minutes.

Cardiac outline before bath No. m. from median line. In bath

Fig. 4. — Coulbourn. Oct. IS, 1896. Cardiac outline after bath No. 6, strength No. 1. Kight border I ..; cm. from median line. In bath eight minutes.

Note. — In Figs. 3 and 4 the outline on the right side of the chest extends too far laterally. It did not extend beyond the nipple. There was no change in this line after treatment.

Figs. 3 and 4 illustrate change of 1% cm. iu cardiac area after six baths of strength No. 1.

Fkom the "Suott Tke.4T.\iest " OF Cardiac Diseask by C N. B. Camac, M. D. ; J. A. M. A., Aug. 28, 1S97.

February, 1904.]

39

THE EFFICIENCY OF THE PERIURETERAL ARTERIAL PLEXUS, AND THE IMPORTANCE OF ITS PRESERVATION IN THE MORE RADICAL OPERATIONS FOR CARCINOMA CERVICIS UTERI.

By Jonx A. Sampson, ^I. D.

Resident Gynecologist, The Johns Hopkins Hospital. Instructor in Gynecology, Johns Hopkins University.

A knowledge of the clinical eflBciency of the blood-supply of the tireters is most important in all operations involving the ureter, and especially so in the more radical operations for carcinoma cervicis uteri. Clinical experience has taught us that the operative treatment of cancer of the cervix of the uterus has been unsatisfactory, for only about 12 per cent of the cases operated upon in this hospital are free from recurrence at the end of 5 years. (Statistics taken in October, 1902.) The only hope of bettering these statistics is by operating on the cases earlier, and doing the most radical operation possible in so-called favorable cases, for in these there is the best chance for a cure. The question arises: what is the most radical operation that can be done without too great a primary mortality? A study of the parametrium ia those cases in which the more radical operation has been done shows that it is necessary to remove as much of the parametrium as possible, and that it is very difficult to diagnose clinically the presence of carcinoma in the parametrium, for the growth may metastasize to verj- small parametrial lymph-nodes, which may not have a diameter of over 1 to 1.5 mm., and cannot be palpated even after the specimen has been removed. From a study of the pathological findings, the indications of the operation which was described by me' over a year ago are only too evident. This operation consists in the removal of the lymphatics from the sides of the pelvis and ^vith them the litems and growth, en masse, and all the tissue from pelvic wall to pelvic wall. The question arises : What should be done with the lower ends of the ureters? If the lower 3-4 cm. of the ureters are removed with the growth and the renal ends of the ureters are implanted in the bladder there is danger of an ascending renal infection, for cystitis is an only too frequent sequel of such an operation. On the other hand, if the pelvic portion of the ureters are dissected free, ureteral necrosis may occur and at the same time the tissue has not been removed intact. I have done 11 of the more radical operations for carcinoma of the uterus, resecting one or both ureters in 3 cases. Three of the 11 cases have died, one on the 5th day from intestinal obstruction, and two from ascending renal infection, one dying on the 9th day and the other on the 17th day. In these last two cases the ureters were resected in one and not in the other. In the eight cases in which the ureters were not resected, they were dissected free as two cords and all the tissue from pelvic wall to pelvic wall was removed. Of these cases, one died of ascending renal infection, and ureteral necrosis occurred in one of the remaining 7 cases. These cases demand a better knowledge of the anatomy and physiology of the ureters and bladder and the etiological factors in the causation of cystitis, ascending renal infection and necrosis of the ureters. I have studied the etiological factors in the causation of renal infection and have published the results of these studies. In this article " attention was called to the importance of lowered local resistance and to the fact that injury to the kidney was a most important accessory etiological factor, and also that a stricture of the ureter was probably the most frequent cause of the lowered renal resistance. As cystitis occurs so frequently in these operations and as the ureter is implanted in a bladder which is very apt to become infected, the kidneys are not as well protected when the ureter is implanted as when it has its natural ureteral orifice. Nevertheless, as I shall try to show in this and subsequent articles, the advantages of the resected over the bared ureter are many, and as apparentl}- the cystitis may be controlled by making a vesicovaginal fisttila, future clinical experience may decide in favor of the resection of the ureters. In eleven cases in which' I have followed the bladder conditions after these operations, both by cystoscopic examination and by taking cultures, a marked cystitis has occurred in seven cases, in two of which it resulted in renal infection and death. In four cases the bladder appeared normal on cystoscopic examination, and yet in two of them when cultures were taken the colon bacillus was found present. An accidental vesico-vaginal fistula existed in three of these four cases and apparently controlled the bladder infection in these three cases.

The clinical efficiency of the blood-supply of the ureters must be understood whether one shall resect the ureters or dissect them free in these operations. Such knowledge can only be gained by a study of the blood-supply of the ureter, combined with animal experimentation and clinical experience.

The Blood-Supply of the Ureter.

In reading over the descriptions of the blood-supply of the ureter, which may be found in the various Anatomies and other works dealing with the surgery of the ureter, one is impressed with the meagre account usually given, and the great variability of its source, for it is seldom that any two authors will agree, and furthermore very little seems to be Icnown in regard to the efficiency of the blood-supply. This latter point is of the greatest surgical importance.

Quaiii ' makes the following statement in regard to the blood-supplj' of the ureter: "The ureter is supplied with blood from small branches of the renal, the spermatic, the internal iliac, and the inferior vesical arteries. The veins end in various neighljoring veins."

Morris ' treats the subject a little more fully : " The arteries which supplj' the ureter are branches of the renal, the spermatic or ovarian, and the vesical; they anastomose freely together in the walls of the ureter, and the blood is returned by corresponding veins." In this manner one will usually find the blood-supply of the ureter disposed of in most of the Anatomies and in the surgical works on the ureter.

The best description of the blood-supply of the ureter which I have been able to find has been given by Disse.° According to him the arteries supplying the ureter come from many sources. The pelvis of the kidney is supplied by a branch from the renal artery which extends down over the abdominal portion of the ureter. The spermatic artery also furnishes a branch to the abdominal portion of the ureter as it crosses the ureter. The pelvic portion of the ureter is supplied by branches from the middle hemorrhoidal and inferior vesical arteries. These main arteries run along the ureter and are attached to its wall by loose connective tissue. The large arterial branches, visible to the naked eye, lie in the adventitia of the ureter and run in a longitudinal direction in such a manner that the ureter is encompassed by these vessels. From these larger vessels, branches arise at short intervals, which pierce the muscular coats of the ureter and extend to the propria; here they divide and give rise to small branches extending in a longitudinal direction from the bladder to the kidney. These small arteries are separated from the larger branches of the adventitia by means of the miiscular coat. From the small arteries of the propria, capillary systems extend in two directions, one to the epithelium, and the other to form a capillary network inside of the muscular layer. The veins begin within the propria and receive the blood from the capillary network within this membrane. From these small veins, relatively larger vessels are formed which give rise to a venous plexus situated inside of the muscular layer. The main branches of this plexus lie principally in a longitudinal direction and are united together by other vessels. This is called the venous plexus of the mucosa. From this plexus the blood empties into still wider venous branches which lie in the adventitia, alongside of the main arterial trunks.

During the last year 1 made several experiments in order to determine the efficiency of the blood-supply of the ureter in human beings and the part played by each ureteral artery in nourishing the ureter. In five instances the arteries of the ureter for its entire length were injected by inserting a canula into the renal artery through the incised aorta, using an aqueous solution of Prussian blue in two cases and a 15 per cent solution of gelatine colored with ultra-marine blue in the other three. See Figs. I, II and III. In another instance the internal iliac artery was injected with a 15 per cent solution of gelatine colored with ultra-marine blue, and as a result the arteries of the ureter were injected for its entire length, and, on opening the kidney, a few small vessels in the kidney .substance were found to be filled with the blue mass. Fig. V was drawn from this specimen. I have injected the internal

iliac artery in another case, the ovarian in one, and the abdominal aorta in two, first clainj)ing the renal and iliac arteries in the latter two cases, so that the coloring material could not enter these vessels. This latter group of cases was not quite as satisfactory as the first six cases referred to, as the work was done after the organs had been removed; nevertheless, they all demonstrated the free anastomosis of the arteries of the ureter giving rise to a periureteral arterial plexus ami also that probably one could inject the entire plexus through any ureteral artery if the plexus were intact. Through this plexus there is established an arterial communication between the kidney and the bladder.

The periureteral arterial plexus from which the ureter is nourished is formed as follows: Branches, which we may call uretero-subperitoneal arteries, arise from the larger vessels, as the aorta, the renal, ovarian, iliac, uterine, etc., arteries. The source of these branches varies in different cases. See Figs. I, II, III and IV. These uretero-subperitoneal arteries usually divide into two branches, first a ureteral branch which helps to form the periureteral arterial plexus ; second, a subperitoneal branch, which supplies the tissue about or near the ureter. The ureteral arteries on reaching the ureter divide into asscending and descending branches both running along the ureter, and united to it by loose fibrous tissue ; the ascending branches anastomose freely with the descending branches of the ureteral artery above, and the descending with the ascending branches of a lower ureteral artery; thus there arise about the ureter, relatively large arterial trunks, running in a longitudinal direction from the kidney to the bladder. From these large trunks smaller branches arise which are more deeply imbedded in the perimuscular fibrous tissue of the ureter than the larger branches, and some of these anastomose with each other, thus forming, with the main trunks, a peri-ureteral arterial plexus extending the entire length of the iireter, up over the pelvis of the kidney and accompanying the ureter through the bladder. From this plexus, still smaller vessels arise which penetrate the walls of the ureter. In addition small twigs may arise from the plexus which leave the ureter to supply the tissue about it (Br. P. Fig. I), and these twigs may anastomose with branches of other vessels supplying these parts (Anas. Br. P. Fig. I).

The subperitoneal divisions of the uretero-subperitoneal vessels supply the tissue about the ureter and also, in places, the peritoneum. These vessels may anastomose with each other and with branches from neighboring vessels, including lu'anches from the ureteral plexus, and thus may serve as a means of nourishing the ureter. The ureter may indirectly receive additional nourishment from other anastomoses, as the uterine and vesical arteries of one side anastomose with thos.' of the other, and in addition there is a free anastomosis between the uterine and ovarian arteries and the branches from the latter anastomo.se with branches from the renal. The periureteral arterial plexus thus receives its blood-supply from definite ureteral arteries and may be nourished indirectly through tlie anastomosis of these arteries and branches from the plexus itself with the branches of vessels supplying the tissue about the ureter.

It is easy to demonstrate the anastomoses of the vessels in the outer fibrous coat of the ureter. A very important question associated with the efBciency of the blood-supply of the ureter is to know whether or not there is a free anastomosis between the branches of the deeper ureteral arteries. In sections cut from specimens injected with Prussian blue the free anastomosis of the capillaries can be very easily demonstrated. On the other hand, I have never been able to demonstrate whether or not there was any anastomosis between the small arteries found within the muscular coats. These vessels are not very numerous and are very small, as is shown in Fig. Y, where the internal iliac artery was injected with a 15 per cent solution of gelatine colored with ultra-marine blue. Ultra-marine blue being granular, only the arteries are injected, the granules being too large to pass into or through the capillaries.

From a knowledge of the blood-supply of the ureter it would seem that many liberties could be taken with the ureter without causing necrosis. As, for instance, the ureter could be dissected free from the bladder to the kidney, severing all vessels coming to the ureter between those organs, and yet necrosis would not occur if the periureteral arterial plexus was intact. Also in instances where the arteries supplying the ureter were tied, the anastomosis of branches from the plexus with the branches of neighboring vessels as well as the other arterial anastomoses which I have mentioned, would aid in maintaining the nourishment of the ureter. On the other hand, one would suppose that the destruction of the periureteral arterial plexus for only a short distance would lead to necrosis of the ureter, for even if there should be a free anastomosis of the deep arteries of the ureter, on account of their size and small numbers, one would not suppose that they would be capable of maintaining the nourishment of the ureter for any great distance. One must resort to animal experimentation as well as clinical experience in order to fully determine the efficiency of the blood-supply of the ureter.

Experiments ox Dogs, Demonstrating the Efficiency OF THE Blood-Supply of the Ureter.

The blood-supply of the ureter of the dog has been studied by several investigators, ilargaroucci " thought that the principal source was derived from two small branches of the renal artery which accompanied the ureter as far as its opening into the bladder. Monari ' has made some very interesting experiments in regard to the efficiency of the blood-supply of the ureter in dogs. He calls attention to the fact that the vessels supplying the dog's ureter run, in the perimuscular connective tissue, parallel to the ureter and are imited to each other by numerous branches. He states that the ureter should not become necrotic when it is isolated for its entire length. He showed that the ureter of a dog could not only be freed for its entire length, but could also be free from the connective tissue surrounding it for a distance

of l'-3-13 cm., and if replaced in this tissue necrosis could not occur. On the other hand, when he isolated the ureter for a distance of 6 cm. and placed gauze about it, necrosis occurred. Protopopow ' has written a very extensive article on the anatomy and physiology of the ureter, in which he describes the blood-supply of the dog's ureter, calling attention to the free anastomosis of the vessels in its outer coat, thus demonstrating an arterial anastomosis between the bladder and the kidney. He states that he does not know if such a condition exists in human beings.

I have made several experiments in order to determine the efficiency of the blood-supply of the ureter in dogs. There is an arterial plexus about the ureter of a dog very similar to that found in man. It receives branches from the vessels near it and presents variations much as are found in human beings. The main trunks of this plexus tend to arrange themselves in two relatively large branches, one on each side of the ureter, which are loosely bound to the ureter. The smaller branches arising from these trunks anastomose with each other, thus forming the meshwork of the plexus, and are more closely united to the ureter than the larger vessels, as is also the case in man. On this account it is quite easy to injure the large trunks but not the smaller branches.

I. In seven dogs, the ureter was isolated for its entire length and an attempt was made to strip off the periureteral arterial plexus with my finger-nails. The dogs were killed in from 1 to 4 weeks and ureteral necrosis occurred in only two eases. In 5 cases the descending aorta was injected with a 15 per cent gelatine colored with ultra-marine blue, and very satisfactory injections of the ureter were obtained. It could be seen in these specimens that in trying to strip off the arterial plexus, I had removed only portions of the main arterial trunks and the large veins, while most of the smaller branches, which are imbedded more deeply in the outer coat of the ureter and form the meshwork of the plexus, were uninjured and were able, in five instances, to maintain the arterial plexus, and thus the blood-supply of the ureter.

II. In three dogs the ureter was isolated for about 4 cm. and in order to completely destroy the plexus, the ureter was scraped on all sides with a very sharp knife for a distance of 2 cm. Necrosis occurred in each instance.

III. In three dogs a ureter was isolated for nearly its entire length and then the larger vessels of the plexus were torn off by the finger-nails and mouse-tooth forceps, as in the first experiments. Both uterine vessels were tied, thus ligating the ureteral artery which completes the lower end of the plexus and arises from the uterine. Necrosis occurred in each instance.

IV. An attempt was made to simulate the condition sometimes found after the more radical operations for cancer of the uterus. In eight dogs the ureter was isolated for about its lower one-third and the tissue about it, including portions of the larger vessels of the plexus, were torn off as above. Both uterine arteries were tied and necrosis occurred in seven of the eight cases.

Y. In two dogs the above was done, except the uterine ar

42

[No. 155.

tery on only one side was tied. Necrosis occurred in one case.

VI. In 2.5 nretero-vesical implantations in dogs, there was but one failure and that occurred in one of nine cases where organisms had been introduced into the bladder, in order to see the results of implanting the ureter in the presence of infection. In three of these nine cases the kidney became infected, and in each instance there was quite a marked stricture of the ureter at the seat of the implantation.

VII. In another dog tlie ureter was freed and stripped, as in previous operations. A small rubber tubCj 8 cm. long, was split, and, by springing it apart, the ureter was placed within its lumen. Necrosis of the ureter occurred for a length of 7.5 cm.

It is evident that in a dog the ureter may not only be freed for its entire length, but its larger vessels may in part be destroyed by stripping them off, yet necrosis will not necessarily occur, for the plexus may be maintained by the smaller branches which are more adherent to the ureter and are very difficult to remove, and also by such portions of the larger trunks which have not been destroyed. On the other hand, when the ureter is scraped with a sharp knife, thus destroying the smaller branches as well as the larger, then necrosis will occur, even though the distance be very .short. Again, when the ureter is freed but a short distance and the plexus interfered with, and in addition the arteries supplying the lower end of the ureter are ligated, then necrosis is very apt to occur; for the portion of the ureter stripped and also that below the injury, must receive most of its blood-supply from the blood-vessels in the plexus above the injury, and the stripping may interfere with the blood reaching these parts through the injury to the plexus.

In injury to the ureteral plexus, veins are destroyed as well as arteries, but as there is a very free anastomosis between the veins of the ureter, one would expect much less trouble from injury to the vein. Nevertheless, it must embarrass the circulation to a degree, varying with the extent of the injury.

Infection, exudates and foreign material, as gauze, must all he considered as accessory etiological factors in the causation of ureteral necrosis.

So far, the results of the study of the blood-supply of the iireter in man and experiments on animals tally. The next question which must be considered is what may be learned from clinical experience.

Clinical Cases showing the Efficiency of the BloodSupply OF THE Ureter.

The clinical efficiency of the blood-supply of tlie ureter lias been demonstrated by many operators.

In 1893, Kelly," in attempting to remove the; uterus in an advanced case of carcinoma of the cervix, ligated both internal iliac and ovarian arteries. The growth was not all removed and ureteral necrosis did not occur, although the left ureter was imbedded in cancerous tissue and was dissected free.

In 1896, Pryor" advocated the ligation of both internal iliacs in advanced cases of cancer of the uterus with the view

of starving tlie growth. He refers to instances where these vessels have been ligated for other purposes and the pelvic organs have not been injured by the procedure. The following year he " reported a case where he ligated both internal iliac arteries for post-operative recurrence of carcinoma cervicis uteri in the vaginal vault. Necrosis of the pelvic organs did not occur.

Kronig has reported three cases of extensive carcinoma of the cervix of the uterus, where he had ligated both internal iliac and ovarian arteries with satisfactory palliative results.

Iwanow " has reported five cases of inoperable carcinoma cervicis uteri where he had ligated the round ligament, the ovarian and internal iliac arteries with results similar to Kronig's cases.

From a review of such cases reported in the literature it becomes evident that the simultaneous ligation of the internal iliac, ovarian arteries and round ligament does not lead to necrosis of the ureters ; for, as would be inferred from a study of the blood-supply of the ureter, as long as the arterial plexus is intact, necrosis would not occur. In addition, the other pelvic organs where the blood-supply has been injured by the ligation of these large vessels, would receive nourishment through the ureteral plexus, for by means of a canula inserted in the renal artery alone, one may not only inject the entire ureter, but also the uterus and bladder will be found to be partially injected. See Figs. II and III.

Cases may be found in the literature where the ureter has been freed for a long distance and yet ureteral necrosis apparently has not occurred.

Sanger" reports two such cases where the ureter was dissected free, in the removal of two intraligamentary cysts, without any apparent injury to tlie ureter.

Chrobak," in the removal of an intraligamentary myoma, isolated the ureter for a distance of 8 cm. and at the close of the operation sutured the peritoneum over it and the patient recovered without any symptoms referable to the injury.

Eiihl," during a hystero-myomectomy, found that the ureter passed through an intraligamentary myomatous nodule for a distance of 7 cm. The ureter was dissected free and the convalescence was uneventful.

In 1894, Durante " removed a large adeno-cystoma of the ovary which was intraligamentary and had pushed the organs from the wall of the pelvis, including the left ureter, which was dilated to a diameter of 17-18 mm. It was found necessary to free the ureter from the kidney to the bladder. At the close of the operation the ureter fell back into the abdominal cavity like a loose cord. The convalescence was uneventful.

Frequently in this hospital the ureter has been exposed for long distances in the removal of intraligamentary cysts and myomata, and yet in not a single instance has necrosis followed sucli a procedure in these cases.

One realizes tliat when both internal iliac arteries are ligated, as in the cases above referred to, the arteries supplying the pelvic portion of the periureteral arterial plexus are destroyed, but necrosis does not occur, for the plexus is intact, and if so, it coidd probably be supplied by the renal artery

February, 1904.]

43

alone. On the other hand, when the ureter is dissected free, tliere is danger of injuring this ple.xus. Yet one realizes that still necrosis may not occnr, for the ple.xus may not be injured, or such injury as may occnr may be compensated by the smaller vessels of the plexus. Operators, both in this country and abroad, frequently ligate both internal iliac vessels and dissect the ureters free in hysterectomy for cancer of the uterus, and yet necrosis does not necessarily occur. On the other hand, necrosis of the ureters does sometimes occur in the more e.xtensive operations for cancer of the uterus.

Clinical Cases Showing that Necrosis of the Ureters May Occur.

There have been six instances of ureteral necrosis in 156 hysterectomies for cancer of the uterus in this hospital, and in each instance, in addition to ligating the uterine or anterior branch of the internal iliac artery or the internal iliac artery itself, the ureter has been exposed and dissected free. These procedures would not only probably cut off all vessels supplying the lower portion of the ureter, but by dissecting the ureter free the periureteral arterial plexus was also injured, thus interfering with the blood-supply coming from above. These cases will be reported in full in a subseqvient article on ureteral necrosis.

Instances of ureteral necrosis following hysterectomy for cancer of the uterus may be found reported by several writers. Of interest are the cases of Wertheim. He had five cases of post-operative ureteral fistula in his second series of thirty cases of hysterectomy for carcinoma cervicis uteri. Three of these cases were double, making in all eight instances. His operation consisted, first, in the isolation of the pelvic portion of the ureters from a point above their entrance into the parametrium down to the bladder. Thus the ureters were out of harm's way and a wide dissection of the parametrium was possible. The uterine arteries were ligated where they crossed the ureter.

At the instigation of Wertheim, Feitel " studied the bloodsupply of the ureter in infants, especially as related to the operation of hysterectomy for carcinoma of tlie cervix. Feitel showed that the upper part of the pelvic portion of the ureter receives its blood-supply from the mesial side, i. e., from the aorta, the common and internal iliac vessels, and the lower portion receives its blood-supply from vessels lateral to the ureter, i. e., the uterine and vesical arteries. When it is necessary to expose the ureter, he advises that the upper part of the pelvic portion should be exposed by opening the peritoneum lateral to it, carrying the incision across the ureter, at the middle of the pelvic portion, and continuing down along the lower pelvic portion of the ureter mesial to it. Thus the nutrient vessels will not be injured. Wertheim,"" in his next thirty cases, followed the suggestion of Feitel and did not dissect the ureter free as in the previous cases, but carried his dissection down mesial to the ureter, i. e., between the cervix and the ureter, in order to avoid vessels coming to the lateral side of the ureter. As a result of this procedure tiiere were only two

ureteral fistulre in the thirty cases, as compared with eight in the previous thirty cases; and in these instances in which necrosis occurred the fistula resulted from dissecting free I lie ureters, which were adherent to the growth, and thus he injured the periureteral arterial plexus.

The Eelation retween the Ureters and Carcinoma Cervicis Uteri.

In order to understand tiic dilficulties in freeing the ureters in hystercetoniy, one must undertand the anatomical relation between the ureters and the cervix of the uterus. If one will examine the ureters at autopsy, a very good idea may be obtained of certain anatomical features which are of the greatest importance in all operations involving the lower end of the ureters.

If the abdominal portion of the ureter is exposed and partially freed, and traction is made upon it, it can be drawn out from what is apparently a sheath, which seems to be derived from the subperitoneal connective tissue and is continuous with that surrounding the kidney above and accompanies the ureter into the pelvis below. Cross-sections of the abdominal portion of the ureter do not bring this out very clearly and it requires some play of the imagination to make out a definite sheath about this portion of the ureter. If the dissection is carried down into the pelvis, this apparent ureteral sheath becomes more definite, and cross-sections of this portion of the ureter show a definite sheath about the ureter which seems to be but a thickening of the pelvic tissue through which the ureter plays and is apparently continuous with the subperitoneal connective tissue about the abdominal portion of the ureter. In Fig. V, which represents a cross-section of the ureter taken about 1.5 cm. above the uterus, one can see the definite ureteral sheath and how it is apparently derived from the tissue about the ureter and acts as a protection to the ureter and the periureteral arterial plexus. If the dissection is carried on down to the bladder, the lower jjortion of the ureter will be found to be reinforced by muscular bundles which apparently extend up from the bladder over the ureter.

Waldeyer"^ has called attention to the fact that there is pictured in Krause's anatomy, longitudinal muscular bundles which extend from the l)ladder up to the ureter, but the cut is not accompanied with any description. Waldeyer describes them as longitudinal muscular bundles, which are united to each other by connective tissue and separated from the ureter by a space which can be injected. This sheath has a thickness of .5 to .75 mm., and he says extends 3-4 cm. up in the ureter. The lumen he considers to be a lymph-space.

Disse" refers to Waldeyer's sheath and says that these musculai' l)undles which are greatly hypertrophied, do not arise from the bladder as they appear to do, but from the ureter, and suggests that their hy]iertrophied condition as well as the space between them ami the ureter arises from the contractions of the bladder pulling on the outer ureteral coat.

There are present about the pelvic portion of the ureter possibly two sheatlis instead of one. the so-called sheath of Waldeyer, which Disse claims arises from a hypertrophy and

44

[No. 155.

splitting of tlie outer ureteral muscular coat, and the second sheath, which apparently encircles the upper portion of the former sheath, blending with it, and extending upwards along the ureter. Further studies may show that this second sheath is but a continuation of the other, but from the few cases I have studied, it would seem to be different in origin, and although it blends with the other, it encircles the upper end of it, and extends further up along the ureter. The relation between the two sheaths needs further investigation. Tliis latter sheath apparently arises from the tissues about the jielvic portion of the ureter and is continuous with the subperitoneal tissue surrounding the abdominal portion of the ureter. This sheath, which may be called the pelvic or ureteral .sheath, is composed of fibrous tissue with an occasional muscle-bundle. Its lumen is, for the most part, filled witli adipose tissue and fine fibrous tissue strands, thus acting as a cushion surrounding the ureter. One finds in the hardened specimens empty spaces which may be lymph-spaces, or possibly artefacts. This sheath is of great importance, for it not only furnishes a channel in which the ureter may slide as it contracts, but is also a protection to the ureter from the invasion of cancerous growths or inflammatory processes, and during operations in that portion of the pelvis. Of special interest in connection with this work is the fact that the periureteral arterial plexus lies within this sheath and is thus protected by it. See Figs. V and VI.

If one will study serial sections of the parametrium, one can see how adherent this ureteral sheath may be to the other structures in that part of the pelvis, especially the utero-vaginal and vesico-vaginal plexuses of veins, for it is from these structures that it is apparently partially derived. It is evident that the isolation of this sheath in the parametria! portion of the ureter is very difficult on account of its association with the structures above referred to, niiich more so than in that portion of the ureter above the parametrium, for here it lies just beneath the peritoneum and by freeing the peritoneum the ureter with its sheath may be moved about on the peritoneal flap. When the ureter is bared in these more radical operations, it is dissected out from this sheath and lies as a loose cord in the pelvis and there is the liability not only of necrosis from injury to the plexus, but the ureter has been deprived of its sheath and must now become fixed in scar-tissue, and thus its function will be interfered with and there is the opportunity for ureteral adhesions and partial or complete ureteral obstruction; and we realize how important an accessory etiological factor stricture of the ureter is, in the causation of renal infection. These statements have been confirmed by experiments on dogs and also, in one instance, where I made a uretero-vesical implantation for necrosis of the ureter, I found the ureter imbedded in dense scar-tissue.

What shall be done in hysterectomy for cancer of the uterus ? Feitel and Wertheim solved the problem as far as the prevention of ureteral necrosis is concerned. When Wertheim removed the parametrium mesial to the ureter in order not "to injure the vessels supplying that portion of (lie ureter

which comes in lateral to the ureter,"' he did something of still greater importance as far as the blood-supply of the ureter is concerned, viz. : that the ureter with its periureteral arterial plexus, as well as its sheath, is probably not injured. As stated, Wertheim did this in 30 cases and necrosis resulted in only two and in these the growth had extended out to the ureters, making it necessary to bare the ureters and thus the sheath was not only destroyed but the plexus was probably injured sufficiently, to cause necrosis of the ureters. We realize that when the parametrium is involved either by a direct extension of the growth or by metastases, it takes but very little involvement to go to or beyond the ureters, as I shall show in a subsequent article; therefore, when Wertheim did a hysterectomy inesial to the ureters and also removed the pelvic lymph-nodes, the intermediate tissue between the primary growth and tlie pelvic lymph-nodes about or lateral to the ureter had been left behind.

If one were sure of the prevention of ascending renal infection, the resection of the ureters would be the most rational procedure, for the ureters could be cut off just as they enter the parametrium 1.5 cm. below the place from which illustration. No. Y, was made and afterwards the peritoneal flap carrying the ureter with its sheath could be carried down to the bladder, and after implanting the ureter into the bladder, the sheath with the peritoneal flap could be sutured to the bladder, and thus the plexiis would be iminjured and the ureter would be provided with a sheath which could help to prevent stricture and protect the blood-supply of the ureter. In addition, all tissue from pelvic wall to pelvic wall could have been removed and with it the early extension and metastasis of the growth into the parametrium. Some may claim that when the parametrium is involved either by direct extension or by metastasis, the case is hopeless. If so, the vaginal operation is the one of choice in all cases. This statement needs confirmation, and it is too early to make any definite statements either way, and the more radical operation is demanded on the basis of the pathological findings and the results of the less radical operations. If the cystitis and ascending renal infection can be controlled by making a vesico-vaginal fistula and if the implantation can be made without too much tension, thus avoiding a stricture, then this is the operation of choice, for it offers the greatest chance for a cure. The suturing of the ureteral sheath and the peritoneum to the bladder will undoubtedly in great measure relieve tlie tension of the implantation.

The dissecting free of the ureters is difficult, more so than resecting them. While there is less danger of ascending renal infection there is a greater chance of ureteral necrosis. A hysterectomy mesial to the ureters offers less chance of a cure than the above and also little danger of either ascending renal infection or ureteral necrosis.

Conclusions.

1. The ureter is nourished by a periureteral arterial plexus, (he main trunks of which run in a longitudinal direction, from the kidney to the bladder, in the outer loose perimuscular

I

Febri-auy, 1904.]

45

fibrous ooats of tlie ureter. From tliese longitudinal vessels, smaller branches arise, some of which anastomose freely with each other, thus forming the mesh-woi-k of the plexus. These smaller branches are for the most part more deeply imbedded in the outer coat of the ureter than the main trunks, which in places nuiy be but loosely united to the ureter.

2. This plexus is nourished mainly by the ureteral arteries which arise from branches of large vessels along the course of the ureter, as, the aorta, the renal, ovarian, iliac, uterine, and other arteries. The ureteral vessels are not the same in all cases, as a branch from one artery, as for instance, the ovarian, present in one case may be absent in another and its place taken by a branch from another artery, as the aorta, a ureteral branch of which may not be present in the first case. See Figs. I. 11. Ill, and IV.

.3. The plexus may receive additional nourishment from small branches arising from the plexus, which supply the tissue about the ureter and may also anastomose with the branches of other vessels supplying these parts.

4. It is possible to inject the entire plexus from such arteries as the renal and internal iliac, and also probably from any one artery which furnishes a ureteral artery.

5. The ureter with its plexus is protected by the tissue in which it lies, and in the pelvis this tissue is converted into a definite sheath, which is apparently derived from the tissue through or along which the ureter passes. This sheath acts as a protection to the ureter and its plexus from the invasion of cancerous growths and inflammatory processes, and should be recognized in all operations involving the pelvic portion of the ureter.

6. Animal experimentation shows that many liberties may be taken wdth the ureter and even when the plexus is injured that the blood-suppiy of the ureter may be maintained by the smaller branches of the plexus which are more deeply embedded in the outer coat of the ureter than the larger vessels, and so are more difficult to injure. The ureter of a dog may not only be dissected free for its entire length, but even the plexus may be injured and yet necrosis may not occur. On the other hand, the complete destruction of the plexus for only a short distance, or the partial destruction of the same, which ordinarily would not cause necrosis if combined with the ligation of the vessels supplying the vesical end of the plexus, is apt to cause necrosis.

7. Clinical experience confirms the results of anatomical studies and animal experimentation and shows that w'hile many liberties may be taken w-ith the ureter, the plexus should be guarded in all operations involving the ureter. The ureter has been freed for its entire length and yet necrosis has not occurred. Both internal iliac, the ovarian and the vessels of the round ligament have been tied with similar results. On the other hand, when the ureter is dissected free from some adherent mass, even for a short distance, as, for instance, from a carcinomatous cervix of the uterus, there is danger of necrosis, for the larger vessels of the plexus may not alone be destroyed, but also the smaller branches which are more intimately united to the ureter. In operations for cancer of

the cervix this danger is increased where vessels supplying this portion of tiie ureter are ligated, as, the uterine, anterior brancli of the iiilcnial iliac or the internal iliac artery. I cannot see that there is any operative advantage to be gained in ligating either the internal iliac or its anterior branch, over the ligation of the uterine alone, and there is this disadvantage that the chance of ureteral necrosis is not only increased but there is danger of lowered local resistance for the portion of the pelvis supplied by these vessels which would predispo.se these parts to infection.

8. Other accessory etiological factors must be considered in the causation of ureteral necrosis; as, infection, exudates, destruction of tissue about the ureter as would result from the use of a cautery, foreign bodies against the ureter (as gauze), pressure on the ureter, stricture of the ureter, and lowered general resistance. In addition, injury to the ureteral veins, although there is a free anastomosis between the veins in the wall of the ureter, must embarrass the ureteral circulation to a degree varying with the extent of the injury and so woidd interfere with the nutrition of the ureter.

9. Hysterectomy in carcinoma cervicis uteri, where the parametrium is removed mesial to the ureter, must leave cancer either in the form of metastases or as an extension of the growth into the parametrium in many cases. On the other hand, the chance for ureteral necrosis is slight, for the ureteral plexus surrounded by the pelvic ureteral sheath is uninjured.

10. The more radical operation with dissecting the ureter from its sheath offers a greater chance for cure than the above, but there is the danger of iireteral necrosis, for by freeing the ureter the vessels supplying that portion of the plexus are destroyed and the lower 3-4 cm. thus freed must be nourished by blood coming from the upper portion of the ureter through the periureteral plexus, and unless great care is taken this may be injured sufficiently to cause ureteral necrosis.

In addition, the ureteral sheath has been destroyed and that portion of the ureter becomes imbedded in scar-tissue, and its fiinction is impaired with the danger of partial or complete ureteral obstruction, with the accompanying lowered renal resistance and liability to renal infection.

11. Eesection of the lower 3-4 cm. of the ureters and the implantation of the renal end of the ureters into the bladder offers the greatest chance for a cure, and at the same time there should be less chance for ureteral necrosis, for the ureter above the parametrium can be brought down to the bladder with its plexus intact, surrounded by the pelvic ureteral sheath, and after implanting the ureter into the bladder its sheath may be sewed to the bladder and also the peritoneal flap in which this portion of the ureter with its sheath lies. The drawback to this procedure is the possibility of renal infection and stricture of the ureter from implanting the ureters under tension. The renal infection may possibly be controlled by the formation of a vesico-vaginal fistula and the freeing of the bladder and suturing the pelvic ureteral sheath with the peritoneal flap to the bladder should relieve the tension of the implantation.

46

[No. 155.

12. Whichever course is followed in these operations, from the basis of anatomical studies and confirmed by animal experimentation and clinical experience, the periureteral arterial plexus and also the ureteral sheath should he preserved. As stated, this is in a measure met by resecting the lower portion of the ureters and implanting their renal ends into the bladder, as described above. This is the only operation justifiable where the growth has involved the ureteral sheath. On the other hand, in so-called favorable cases, one could free the tissue between the two jjelvic walls and instead of resecting the ureters, the ureters with their sheath could be freed from an incision made through the parametrium lateral to the ureters, and thus all the tissue would be removed except the ureters and their sheath, and the dangers of ureteral necrosis and stricture would be reduced to a minimum. This plan looks well on jjaper, but the sheath is very adherent to the surrounding tissues and a careful dissection would prolong an already exhausting operation : and again, the chances of leaving minute metastases in the pelvis are greater than when the ureter is resected. For only by the use of the microscope can one with surety diagnose the presence of cancer in the parametrium. However, clinical experience alone can decide which method offers the greatest percentage of cures combined with the lowest primary mortality.

I am sure that many of us who are only too well acquainted with the mental and physical torture, the pain, the vesical and rectal fistulse, etc., so generally associated with the clinical course of cancer of the cervix not operated upon, and the fact that such a large per cent recur after operation, which means that they have not escaped the above mentioned misery, will agree that any operation, no matter how severe, which gives the highest percentage of cures, is the one to be developed, not only in the advanced cases, but especially in the early ones, for in these there is the greater chance for a cure.

Keferences.

1. Sampson : The Importance of a More Kadical Operation in Carcinoma Cervicis Uteri, as Suggested by Pathological Findings in the Parametrium. Johns Hopkins Hospital Bulletin, 1902, XIII, 299-307.

2. Sampson: .\scending Eenal Infection; with Special Eeference to the Keflux of Urine from the Bladder into the Ureters as an Etiological Factor in its Causation and Maintenance. .Johns Hopkins Hospital Bulletin. 190.'5, XIV, 334352.

3. Quain: Quain's Anatomy. Longmans, Green & Co., London, 189C. A'ol. III. Part IV. 205.

4. Morris: Surgical Diseases of the Kidney and Ureter. Cassell & Co., London, 1901. Vol. II, 284.

5. Disse: Von Bardeleben, Ilandbuch der Anatomic. Gustav Fi.scher, Jena, 1902, Band VII, Theil 1, S. 110-111.

6. Margaroucci : Quoted by Monari and Protopopow.

7. Monari: Ueber Ureter-Anastomosen. Beitriige zur Klin. Chirurgie, 1896, XV, 722-723.

8. Protopopow: Beitriige zur Anatomii' uiid Physiologie

der Ureteren. Arch. f. die Gesam. Physiologie (Pfliigers), 1897, LXVI, 21-22.

9. Kelly : Ligation of both Internal Iliac . Arteries for Hemorrhage in Hysterectomy for Carcinoma Uteri. Johns Hopkins Hospital Bulletin, 1894, V, 53.

10. Pryor: The Surgical Anatomy of the Internal Iliac Artery in Woman and a More Eadical Operation for Malignant Disease of the Uterus. Am. Jour. Obs., 1896, XXXIII, 801-817.

11. Prvor: Transperitoneal Simultaneous Ligation of Both Internal Iliac Arteries for Kecurrence in the Cicatrix Following Vaginal Hysterectomy for Carcinoma Uteri. American Journal of Obstetrics, 1897, XXXV, 511-517.

12. Kronig: Die doppelseitege L^nterbindung der Aa. hypogastrica und ovarica zur palliativen Behandlung des uterus carcinoma. Cent. f. Gyn., 1902, XXVI, 1073-1074.

13. Iwanow: Zur Kasuistik der Palliativebehandlung des uterus karzinoms durch Unterbindung der Becken gefasse. Berich fiber die geburtshilflich-gjiiakologische Sektion des VIII Pirogowschen Kongresses russischer Arzte in Moskau. Zent. f. Gyn., 1903, XXVII, 118-119.

14. Sanger : L'reteren chirurgie biem Weibe, medicinische Gesellschaft zu Leipzig, Xov., 1898. Eeported in Miinchener med. Wochenschrift, 1899, XLVI, 33.

15. Chrobak : Demonstration eines Falles von subserosem Uterus myom, Frcilegung des Ureter. Geb. imd Gyn. Gesellschaft in Wien, 1893. Eeported in Cent. f. Gj-n., 1893, XVII, 346.

16. Euhl : L'eber einer seltenen Fall von Ureteren verlauf bei Beckentumoren und dessen praktische Bedeutung. Cent. f. Gyn.. 1898, XXII, 1056-1058.

17. Durante: Bolletino della E. Accademia medica di Eoma. Anno XX, Vol. XV, 59. Eef. Boari, Anat. del Uretere, and Frommel, X, 351.

18. Wertheim : Ein neuer Beitrage zur Frage der Eadikaloperation beim Uterus-krebs. Archiv fur Gjoiaekologie, 1902, LXV, 1-39.

19. Feitel : Zur arteriellen Gefass versorgung des Ureters, insbesondere der Pars pelvina. Zeitschrift zur Geb. und Gyn., 1901, XLVI, 269-281.

20. Wertheim: Kurzer Bericht fiber eine 3. Serie von 30 L""terus krebs-operationen. Cent. f. Gyn., 1902, XXVI, 250-251.

21. Waldeyer: Ureter-scheido. ^'erhandlungen der Anatomischen Gesellschaft, 1892, 259-260.

22. Disse: L. C, S. 107 and 109.

THE JOHNS HOPKINS HOSPITAL BULLETIN.

The Hospital Bulletin contains details of hospital and dispensary practice, abstracts of papers read, and other proceedings of the Medical Society of the Hospital, reports of lectures, and other matters of general interest in connection with the work of the Hospital. It is issued monthly.

Volume XIV is now completed. The subscription price is ?2.00 per year. The set of fourteen volumes will be sold for $50.00.

THE JOHNS HOPKINS HOSPITAL BULLETIN. FEBRUARY, 1904.

PLATE V.

Ui'. 1*. lijuiuli I'riiiii tlie iiLMiuri'teral iirterial plexus, sup|jlyintf tlio tissue about the uietir.

Anast. Br. I'. Anaatoinosi.s betwccu the subperitoneal branch of the aortic uretero-subperitoneal artery, and a branch arlsiuj; from the plexus.

Sup. Ves. Anast. Anastomosis of the superior vesical artery of one side with the superior vesical artery of the other side.

Fu;. I. — The Pekiukktekai, Auteiuai, Plexus ekom a Woman 31 Yeaus Olii, X 4/.5. Left Uretbk.

The reft renal and riirht internal iliac arteries were injected witli a LI per cent solution of ijclatine, colored with ultramarine blue. The organs were removed and hardened in 10 per cent formalin. The draw in^ was made from the dissected hardened specimen.

The periureteral arterial jilcxus in this instance is derived from branches ot the aorta, renal, ovarian, internal iliac, uterine, and va^'lnal arteries, marked. A, R, (), I, I', and V.

Uterus drawn upwards and to thi> riyht, the tube and ovary have hern removed.

Contracted bhulder, drawn downwards iiinl to llie rinht.

Ovario-Kenal Anast. Anastomosis between the subjieritoneal branches of the uretero-subperitoneal arteri(^s, arisini; from the renal and ovarian arteries.

• Anastomosis between the uterine and ovarian arteries, cut awiiy

by the removal of the tube and ovary.

Fig. it. — The Pekiuueteral Aktekial Plexus fkom a Gnu. 7 Years Oli>, x 1. Left Ureter.

The left renal artery was injected with an aqueous solution of Prussian blue. The organs were removed and hardened in 10 per cent formalin. The drawiui;' was made from the dissected hardened siiecimen.

The origin of the plexus differs slitthtly from that shown in Fig. L

The aortic bran<'h is absent, and the branch from the ovarian artery arises from that artery after it has crossed the ureter. There are two branches from the internal iliac artery and one from the uterine.

• Utero-ovarian anastomosis, cut away by the removal ot the

tubes and ovaries.

Uterus drawn upwards and slightly to the right.

Distended bladder, drawn downwards.

THE JOHNS HOPKINS HOSPITAL BULLETIN, FEBRUARY, 1904.

PLATE VI.

Fio. III. — The Periuretekal Arterial Plexus from a Girl o Years Old, x 1. Right Ureter.

Both remil arteries were injected with a 1.5 per cent solution of gelatine, colored Willi ultramarine blue. The orjjaus were removed and hardened in 10 per cent formalin. The drawing was made from the dissected, hardened specimen. This represents another variation in the arteries giving rise to the periureteral arterial plexus. There are two branches, K and K', from the renal, one from the aorta. A, one from the ovarian, which is recurrent, O, and has the form of an anastomosis of an artery derived from the plexus witli a subperitoneal branch of the ovarian artery. The pelvic portion of the plexus is nourished by a branch, 1, from the internal iliac, a branch M. V., from the middle vesical, which, in this instance, arises from the uterine also a branch, V, from the vaginal artery, which ap)iroaches the ureter from its jiosterior surface.

• Uterf>-ovarian anastomosis.

Uterus drawn upwards and slightly to the left.

Bladder ilrawii downwards.

Fig. IV The Periureteral Arterial Plexus from a Newborn

Girl, x 1. Left Ureter.

The abdominal aorta was injected with an aqueous solution of Prussian blue. The organs were removed and hardened in 10 per cent formalin. The drawing was made from the dissected hardened specimen.

This again represents another variation in the origin of the periureteral arterial plexus. There is one branch, R, from the renal, the ovarian branch is not present, the other branches were derived from the aorta, A, internal iliac, I, and uterine, U, arteries. The uterus is drawn u]Jwards and to the right.

These four illustrations represent four variations in the origin of the periureteral arterial plexus, wliich might be found in four adult specimens.

Compare the relation in size between the hypogastric artery and its branches in the infant and the adult, and the relatively greater size of the ovarian and uterine arteries in adult woman.

The ureter in this illustration has purposely been drawn, a trifle enlarcred.

THE JOHNS HOPKINS HOSPITAL BULLETIN, FEBRUARY, 1904.

PLATE VII.

SUcIJe

y-t

Carcinoma

Ureter, Vrrtercl SAeafA

P^yi-Vreterat Cr^ertal Plexus

o

-; f

i.utnen at-Shtei/i

•* «»

t

Vreterai Sheath.

Fig. V. — Cross Section of Uketer Showing the Perihretekal

Arterial Plexus, and the Ureteral Sheath, in a

Woman 31 Tears Old, x .5. Right Ureter.

The left renal and the right internal iliac arteries were injected with a 1.5 per cent solution of gelatine, colored with ultramarine blue. The organs were removed and hardened in 10 per cent formalin. Tlie drawingwas made from a cross section of the right ureter taken about 1.5 cm. above the uterus. Same case as one from which Fig. I was made.

For the sake of clearness only the ureteral arteries are drawn, as in jected. The capillaries and the veins were not injected.

The periureteral arterial plexus situated within the ureteral sheath can be seen cut across, as well as small arteries within the ureter. This sheath of fibrous tissue which apparently is derived from the pelvic connective tissue, in this situation is adherent to the peritoneum and in freeing the peritoneum from the wall of the pelvis this portion of the ureteral sheath remains attached to the peritoneal flap thus formed This sheath serves as a protection to the ureter and its periureteral arterial plexus. See Fig. VI.

Fio. VI. — Relation of Carcinoma Cekvicis Uteri to the Uketek.

Transverse section of the parametrium and one-half of the cervix from a specimen of hysterectomy for carcinoma cervicis uteri in which the lower portion of the right ureter was sacrificed and the renal end of the ureter implanted into the bladder, x2}{. Gyu. No. 10,494. Gyn. Path. No. 7.51.5.

Section, right side, lower third of the parametrium. The carcinoma has extended out into the parametrium and has invaded the ureteral sheath thus causing it to hypertrophy and serve as a protection to the ureter from the growth, and later this progressive hypertrophy of the sheath will compress the ureter giving rise to a stricture and renal insufficiency.

The periureteral arterial plexus can be seen in transverse section, situated about the ureter within the sheath.

One can see that the growth does not have to extend far into the parametrium in order to reach the ureter.

FEBlirAEY. 1904.]

47

TWO CASES OF LEUKOKEKATOSIS BUCCALIS; COMPARISON WITH THE HISTOLOGICAL

CHANGES IN A CASE OF TYLOSIS PALMiE ET PLANTiE.

By Sylvan Rosenheim, M. D.,

Assistant in Laryngolocjij, Johns Hopkins University.

(From the Clinic of Dr. Mackenzie, Johns Hopkins Hospital.)

Dermatologists have been acquainted with disease of the skin, characterized principally by an increase in the horny layer for a much longer time than with similar disease of the mucous membrane. Consequently it is not surprising that the terms icthyosis (Hulke), tylosis (Hutchinson), keratosis (Kaposi), and psoriasis, applied to the former, have been used to describe the latter, since the clinical picture is so similar. Moreover, the disease was at first described by dermatologists and syphilographers and usually in connection with similar diseases of the skin. Alibert and Plumbe, in a case of icthyosis of the skin, describe similar whitish patches on the tong-ue.

THE EFFECTS OF X-RAYS UPON LOWER ANIMAL LIFE AND THE TUBE BEST SUITED TO THEIR DESTRUCTION.'

By Kennon Dunham, M. D.

Cincinnati. Ohio. >

I. The immediate object of this research was to ascertain wliat effects, if any, X-rays have upon several of the lower forms of animal life; to discover if any of such organisms are destroyed by X-rays and if so, what technique best produces such destruction.

II. The reason for such research is based upon the analogy existing between such lower organisms and the new cells of a malignant growth. What I really wish to establish is a scientific method by which to determine the best form of tube with which to treat such growths; and it seems but fair to allow, upon such analogj', the supposition that the condition of tube that is most destructive to one of these forms will be most destructive to the other.

AN ANOPHELES MOSQUITO WHICH DOES NOT TRANSMIT MALARIA.

By Leonard K. Hirshberg, A.B., M.D. (From the Pathological Laboratory of the College of Physicians and Surgeons.)

Anopheles punctipennis abounds in the neighborhood of Eoland Park, a suburb of Baltimore, as was demonstrated by us ' some time ago. Even at that time, in a careful investigation of the health records and specimens sent to Dr. William E. Stokes, City Bacteriologist, I was unable to trace any autochthonous cases of malaria in that neighborhood. After carefully searching through much of the literature ' on mosquitoes and malaria, and not finding any malaria traceable to A. punctipennis as carriers of the parasite, it was determined last summer to put the question to a proof.

The few cases of malaria which occur in Baltimore have their origin as a rule at Sparrow's Point and upon the Eastern Shore of Maryland. At the former place, situated some twelve miles from the city, we found Anopheles maculipennis in abundance, but found no other species of Anopheles in numbers. Malaria is constantly endemic there and most of the Baltimore cases are imported from that place. Anopheles maculipennis captured there contained malarial parasites in the stomach walls. On the other hand, I have never been able to demonstrate the parasites in the walls of .4. punctipennis found at Eoland Park or elsewhere.

Contents

• The Relation of Leucocytes with Eosinophile Granulation to Bacterial Infection. By Eugene L. Opie, M. D., 71
• The Relation between Carcinoma Cervicis Uteri and the Ureters, and Its SigniBcance in the More Radical Operations for that Disease. By Johx A. Sampson, M. D., 72
• Georsje CUeyne, an Old London and Bath Physician (1(571-174.'!). By Thomas McCrae, M. D., M. R. C. P., 84
• A Case of Amaurotic Family Idiocy. By Eknest Sachs, ... 94
• Summaries or Titles of Papers by Members of the Hospital or Medical School Staff Appearing Elsewhere than in the Bulletin, 9.5
• Notes on New Books, 100

Books Received, 106

The Relation of Leucocytes with Eosinophile Granulation to Bacterial Infection

By Eugene L. Opie, M. D.

Associate in Pathology, Johns Hopkins University; Fellow the Rochefeller Institute for Medical Research.

(Fro)n the Pathological Laboratory of the Johns Hopkins Uideersily and Hospital.)

Certain bacteria (Bacillus tuberculosis, Bacillus choleras suis) producing somewhat chronic, fatal infection in guinea pigs, cause the eosinophile leucocytes to disappear gradually from the circulating blood. After death few eosinophile cells can be found in those tissues in which they are usually present in abundance. Hence the study of tissues removed at autopsy gives little indication of the behavior of the eosinophile leucocytes during the course of bacterial infections. During more acute infections produced by inoculating bacteria into the peritoneal cavity of guinea pigs (Bacillus mucosus capsulatus of Friedlander, Bacillus pyocyaneus, Streptococcus pyogenes) eosinophile leucocytes quickly disappear almost completely from the periplieral circulation.

After the inoculation of an organism (Bacillus pyocyaneus), producing an infection from which the animal is capable of recovering, eosinophile leucocytes almost completely disappear from the peripheral circulation so that within twentyfour hours the proportion may fall from five or ten per cent to less than one per cent. The number of eosinophile leucocytes then gradually increases and at the end of four or five days both the relative and absolute number of these cells may considerably exceed that present in the peripheral circulation before inoculation. At the end of six or seven days the number of eosinophile leucoc}'tes is again normal.

Read before the .lohns Hopkins Hospital Medical Society, March 7, 1904.

GEORGE CHEYNE, AN OLD LOiNDON AND BATH PHYSICIAN. (1GT1-1T43.)'

By TiioirAS McCr.ve, U. D., M. R. C. P.,

Associate in Medicine, The Johns Ilopl-ins Unirrrsifi/. and Ncsidcnl Pliysicinn, The Johns Hopkins Hospital.

" XJie palate hills more Ih.an the sword. — Old Proveub.

The advice has been given to the younger of our profession to leave the reading of new books to the older men and to devote ourselves to the writings of previoiis generations. By so doing we may be delivered from what has been termed " an inapt derision and neglect of the ancients." Perhaps too truly might the words of Job be applied to some of us, " No donbt but ye are the people and wisdom sliall die with you."' However that may be deserved, it does not require mucli study of the works of those who have gone before to realize that wisdom was not born with us. Much wisdom is of all time and the fact cannot be brouglit home too strongly. To some of us the acceptance of this comes slowly. There are few impressions stronger than the personal realization that many ideas we are apt to think peculiar to our own time have long since been old. To find certain things dating back to Hippocrates gives one a comforting sense of the permanence of the profession.

A CASE OF AMAUROTIC FAMILY IDIOCY.

By Ernest Sachs.

(^From f?ie Nenrolofjifal Clinir, The Johns Hopkins Hospital Dispensary.)

The case reported here is of interest as being the first example of this disease observed at the Jolins Hopkins Hospital, and though it was impossible to obtain an autopsy, it is, nevertheless deemed worth while to put it on record as another example of a rather rare condition. I am indebted to Dr. Thomas both for the privilege of following the case as well as of reporting it.

D. K. — Nerv. Dis. No. 14634, age 14 months, was first seen at the neurological dispensary of the hospital on June 6, 1903. The diagnosis was at once apparent from the general condition and the typical retinal picture.

F. H. — Father and mother both healthy and well; not related to one another. They arc Russian Jews. No history of syphilis in either parent. This is the third child. The oldest, 5 years, a boy, is healthy and has never shown any symptoms of a similar trouble. The second child when several years old died of diphtheria. There is no history of a similar disease in either the father's or mother's family.

P. H. — This patient was a full term child, the labor was normal and the child seemed perfectly healthy. No history of convulsions or any .symptoms pointing to hereditary syphilis. When six weeks old the child had bronchitis ; has had some cough at intervals ever since. When 1 year old had measles and from this time mother dates the illness. Child was breast fed, the feeding being supplerjjented with cow's milk of excellent quality. C'liild has never spoken or crawled. 'I'he bowels have always been constipated and are moved with considerable difficulty.

P. E. — Patient is a weak, sickly looking child. Its face is expressionless, but at times seems to smile. Cannot hold its head up, it falls back or forward. Pupils are equal and moderately dilated, and react to light. Child takes notice of objects and follows them about, but does not seem to see so well at the periphery. Child seems to hear. Starts violently at a sudden sound. Every now and then has a spasmodic jerk of its muscles. Some stiffness of arms on passive motion ; no contractures. At a sudden sound legs and arms are stiffened.

Ecflexcs. — Deep reflexes much exaggerated in arms and legs. Jaw jerk is active, and associated with this is a contraction of the orbicularis. No ankle clonus but an active tendo Achillis reflex. Flexor response of all the toes on plantar stimulation. No local atrophy; no paralysis of any muscles. Sensation seems to be present everwhere. The prick of a pin is responded to at times by a jerking all over the body. The ophthalmoscopic examination revealed the characteristic picture of this disease. The patient was referred to the eye department where Dr. Randolph made the following note : " Around the fovea in botli eyes there is a cherry red spot, surrounded by a gray area. Tlie optic discs look a little pale."

From this time on the patient, although watched carefully and seen repeatedly, grew progressively weaker. In October

Makcii, lUOl.]

JOHNS HOPKINS HOSPITAL |BULLET1N.

05

the following note was made : " Child is getting weaker ; no loiiirei' fiiii hold anything in its hands. Has been weaned.

S}-mptoms remain as previously descriljed." About this time the child developed difficulty in deglutition and could not

swallow its food. This .symptom continued and became morn marked. Vision seemed completely gone, and the patient no longer responded to a bright light or speech, but starts at a loud sound. The patient continued, to get weaker. Eigidity of arms and legs became very much more marked. Slight contractures appeared in the legs. On several occasions the child had attacks of explosive laughter which seemed to come without any apparent outside stimulus.

The child grew continually weaker, lost weight and Ijccame very much emaciated, presenting a typical picture of marasmiis, and died February 29, 1904.

Remarls. — This case is undoubtedly an example of the spastic form of amaurotic family idiocy. It shows all the cardinal .symptoms of the condition as well as two features which have only been observed in a few instances by Falkenhein, namely, the explosive laughter and disturbances in deglutition.

The most recent views about this disease with a fairly complete bibliography may be found in the Journal of Nervous and Mental Disease, January, 1903.

SUMMARIES OR TITLES OE PAPERS BY MEMBERS OF THE HOSPITAL OR MEDICAL SCHOOL STAFF APPEARING ELSEWHERE THAN IN THE BULLETIN.

John J. Abel, M. D. The Function of the Suprarenal Glands and the Chemical Nature of their So-Called Active Principle. — ('Qiitribiitions to Medical Research, Dedicated to Victor C. Vaughan, Ann Arbor, 1903.

Samuel Ambekg, M. D. Sublingual Growth in Infants. — American Journal of the Medical Sciences. August, 1903.

Charles Eussell Baedeen, M. D. Variations in the Internal Architecture of the M. Obliquus Abdominis Externus in Certain Mammals. — Anatomischer Anzeiger, June 24, 1903.

John S. Billings, Jr., M. P. The Work Performed by the Diagnosis Laboratory of the Department of Health in Connection with Ehrliclfs Diazo Eeaction during 1902. — New York Medical Journal, April 18, 1903.

The Value of Confirmatory Cultures in Diphtheria.

— Kew York Medical Journal, September 12, 1903.

The Administration of Antitoxine in Diphtheria by

the Department of Health During 1902.— Vc«; York and Philadelphia Medical Journal, December 12, 1903.

E. Bates Block, ^I. I). Parotitis Following Typhoid Fever. — Alluula Journal Record of Medicine, February, 1903.

Male, age 34 years, developed parotitis of the left side on the 47th day of the disease. 16 days after his temperature reached normal. The involvement of the parotid .i;land was followed by a rise of temperature to 101.3° F. and ran an irregular course for five days. There was no evidence of suppuration.

The original paper mentions the various inflammatory lesions produced by the typhoid bacillus, and the occurrence of parotitis

following other diseases of the abdominal, or pelvic, viscera, or generative organs.

The Eelation of the Nervous System to Unilateral

Sweating. — Transactions of the Medical Association of Georgia, 1903, page 291. A Russian tailor, aged 47 years, was admitted to Dr. Thomas' Clinic in the Johns Hopkins Hospital Dispensary on the 23rd of April, 1901, complaining of excessive paroxysmal sweating on the right side of the head and body which had existed for twelve years and was most marked on the right half of the face, head and shoulder and the upper part of the chest, and limited sharply by the mid-line. The right ear and the left side of the face and body did not sweat during the paroxysms. The mouth was drawn a littk upward at the right corner which extended further lateral than to the left, the right labio-nasal groove being much deeper and more distinct than the left. During the paroxysms, the right side of the face becomes redder than the left. The right fore-arm and hand sweat more than the left. After cleaning the face with neutral alcohol, the sweat was always found to be slightly acid and contained sodium chloride. Sensation was normal for all varieties. Many experiments were tried, to observe the effect on the sweating. Drinking hot water caused most profuse perspiration, the sweat pouring in streams down the right side of his face. The right side of the face became warmer and redder than the left during the sweating attacks, and the axillary temperature ranged from 0.1° P. to 0.5.° F. higher in the right axilla than the left. In thirteen observations on the pupils, both during the sweating attacks, and between them, the right pupil was slightly smaller than the left ten times, while on three occasions both pupils appeared equal. The pupillary reactions were all retained. There was myopia of both eyes, greater in the right. After pilocarpine injections, the sweating began first, and was more pronounced, on the ri.ght side.

After a general discussion of the literature, a case of per

96

[No. 156.

ipheral nerve paralysis was reported, which seemed to indicate that a complete nerve paralysis was accompanied by anidrosis, while a partial paralysis was accompanied by hyperidrosis, while on a return of the nerves to normal function, the sweat secretion also became normal.

Statistics were collected from 107 cases, and the syndrome of myosis. redness, increased temperature, and unilateral sweating on the same side was present in such a large majority of cases that they must at least be regarded as the rule.

The temperature on the sweating side in thirty-two cases, was increased in twenty-seven, equal in four, decreased in one. (In the case reported above, the right axillary temperature was 0.2° F. lower than the left between the sweating attacks).

Redness was present in twenty-nine cases, and not present in three cases, out of thirty-two cases in which a note was made on this point.

Myosis has not proven such a constant concomitant. Thus in forty-seven cases, the pupils were larger on the sweating side in nine, smaller in twenty-three, equal in fifteen, but it is very probable that a slight difference in the size of the pupils in the last group was unnoticed in some cases. Moreover, many of these cases in which the pupils were equal or larger, were evidently not cases of sympathetic affection, so that the occurrence of myosis has really a greater relative frequency than appears in this table.

In regards to sex, there were fifty-seven males to twenty-five females affected with unilateral sweating.

Forty-four cases occurred on the right side, and thirty-three on the left.

In eighteen cases some affection of the parotid gland was noted.

Further statistics may be seen in the original article.

Joseph C. Bloodgood, M. D. Rare Case of Appendicular Abscess Sittiated between the Layers of the Mesentery of the Small Intestine. — American Jniirnal of ihc Medical Sciences, October, 1903.

Intestinal Obstruction Following Operation for Reducible Left Inguinal Hernia Due to a Loop of Small Intestine caught in Freitz's Fossa. — Annals of Siirfieri/, December, 190 o.

George Blumer, M. D. A Note on the Embryonal Glandular Tumors of the Kidney. — Albany Medical Annals, .Vugusl, lii.i:;.

and H. C. Gordinier, M. D. A Case of Chronic

Lymphatic Leukaemia without Enlargement of the Lymph Nodes. — Medical News, October 31, 1903.

.loii.v Jii{.\i)KORD Briggs, M. D. A Note on the Association of a Rise in Systolic Blood Pressure, with the Onset of a Perforative Peritonitis in Typjioid Fever. — Boston Medical and Surgical Journal, September 24, 1903.

T110MA.S R. Brown, M. D. The Blood in Health and Disease with a J{eview of the Recent Important Work on this Subject. — The Tnfrrnafinnal (llinirs. Vol. 4, 18th .Series.

Enteroptosis, its lOtiolog}', Svinptoinatology, Treatment, and Prognosis. — American Medicine, Vol. 6, August 15, 22, 29, 1903.

The Diuretic Value of Salt Solution I'jncmata, Es

pecially After Renal Operations. — Maryland Medical Journal, August. 1903.

The Value of Leucocyte Counting in Differentiating

Post-Operative Auto-Intoxication from Peritonitis. — Maryland Medical Journal, August, 1903.

— The Gastric Contents in Gastroptosis. — New York and Philadelphia Medical Journal, September 26, 1903.

— The Value of Albuminuria in Differentiating Pyelitis from Cj'stitis. — New Ynrl- and Philadelphia Medical Journal, October IT, 1903.

Urinary Hyperacidity. — Netv York and Philadelphia

Medical Journal, November 1-i, 1903. C. H. Bunting, M. D. The Effects of Lymphotoxins and Myelotoxins on the Leucocytes of the Blood and on the Blood-forming Organs. — University of Pennsylvania Medical Bulletin. July-August, 1903.

Primary Sarcoma of the Spleen with Metastases.

Report of a Case. — University of Pennsylvania, Medical Bulletin, July-August, 1903.

W. J. Calvert, M. D. Plague Serum in Three Cases. — Boston Medical and Surgical Journal, January 8, 1903.

Transmissibility of Plague. — American Medicine,

January 24, 1903.

Plague Bacilli in the Blood. — Centralblatt f. Bakter iologie, Parasitenhunde v. Infrrtionsl-ranl-heiten. 1 abt., XXXIII Bd., No. 4. 1903.

Comment on Plague Memorandum. — American Medicine, March 7, 1903.

Tropical Diseases: General Introduction. — Buck's

Reference Handbook of the Medical Sciences, V^ol. VII, 1903.

Record of Parasitic Infections in the Philippines. —

Boston Medical and Surgical Journal, October 23, 1903. C. N. B. Camac, M. D. A Preliminary Report of the Venous Hum in Relation to the State of the Blood. — Medical News, March 21, 1903.

Demonstrated from cases that the venous hum may be and frequently is present with normal blood.

Some Observations on Aneurism and Arteriosclerosis. — The Matter Lecture, delivered December 1, 1903, at the College of Physicians, Philadelphia.

A historic review of the development of our knowledge of vascular diseases and pathological and historical consideration of the initial changes in the vessel wall in arteriosclerosis and aneurism.

John G. Clark, M. D. Address in Obstetrics, delivered before the Meeting of the Medical Society of the State of Pennsylvania, York, September 22, 1903. I. The Treatment of Cancer of the Uterus by Roentgen Rays. II. The Etiology of Eclampsia. — University of Pennsylvania Medical Bulletin, November, 1903.

Lessons from the Life of Pasteur. — Northwest Medicine, Vol. I, No. 6, 1903.

Histogenesis of Glandular Cysts of the Ovary. —

Transactions of the American Gynecological Society, 1903.

March, 1904.]

97

Hexky \V. Cook, M. 1). The Accurate Estimation ot Pulse Tension. — The Old Dominion Journal of Medicine and Surgery, October, 1903. — Virginia Medical SemiMonthly, November 13, 1903.

Thomas S. Cullen, M. B'. Uterine Myomata and their Treatment. — Canada Lancet, July, 1903.

Sarcomatous Transformation of Myomata. — Journal

of the American Medical Association, October 24, 1903.

Adeno-Myome des Uterus. Berlin, 1903.

George W. Dobbin, M. D. Management of Normal Labor. — Buck's Reference Handbook- of the Medical Sciences, 1903.

ARTUtR W. Eltixg, M. D. The Unusual Symptoms of the ^Yeakened Foot, with Illustrative Cases. — Albany Medical Annals, April, 1903.

John M. T. Finney, M. D., and Omar B. Pancoast, M. D. Enterostomy, with Eeport of Cases. — American Medicine, August 22, 1903. The paper calls attention to certain additional indications for

the performance of the operation of enterostomy:

1. To drain temporarily a distended intestine, thus allowing it to regain its normal tome.

2. To enable one to nourish a patient whose stomach and rectum are unaolo to retain or absorb a sufficient amount of nourishment.

After calling attention to several general considerations which had been noticed in the author's experience, seven cases of enterostomy were reported for various causes.

Simon Flexxer, ]\I. D. A Xote on Autolysis in Lobar and Unresolved Pneumonia. — University of Pennsylvania Medical Bulletin, July-August, 1903.

An Aspect of Modern Pathology. — American Journal

of the Medical Sciences, August, 1903.

and HiDEYO jSTogdchi, M. D. On the Plurality of

Cytolysins in Snake Venom. — University of Pennsylvania Medical Bulletin, July-August, 1903. \V. W. Ford, M. D. Classification and Distribution of the Intestinal Bacteria in Man. — Studies from the Royal Victoria Hospital, Vol. I, No. 5, ilay, 1903.

T. B. FuTCiiER, M. B. The Occurrence of Gout in the United States. — The Practitioner, July, 1903, p. (J.

1. The apparent infrequency of gout In the United States is due in large part to failure to recognize the disease.

2. Out of 15,69 7 medical cases admitted to Dr. Osier's wards at the Johns Hopkins Hospital during a period of 14 years, there were 41 casts of gout, or 0.26 per cent of the total number ot medical patients. For the same number of years at Saint Bartholomew's Hospital there were 124 cases out of a total of 33,356 medical admissions, or 0.37 per cent of the medical cases.

3. The ratio of admissions of gout to the two hospitals is respectively a little greater than as 2 is to 3; or, in other words, the admissions of gout to a general hospital are a little less than one-third more freauent in London than in Baltimore.

4. All of the 42 cases were males. There was only one colored patient in the sei ies. The negro race appears to possess a relative immunity from the disease. The largest number of cases, 13, occurred in the fifth decade. Of special interest is the fact that 32 of the patients were native-born Americans.

5. The majority of the cases appear to have earned rather than inherited their gout. Alcohol and lead seemed to be the most potent aetiological factors.

6. Thirty-nine of the 42 cases had reached the chronic stage before they came under observation. In 19 of the cases tophi were present.

7. Among the most interesting complications may be mentioned four cases of gouty bursitis; one case of parotitis, one of pericarditis, one of retrocedent gout with symptoms simulating intestinal obstruction.

8. There was evidence of disease of the kidneys in the majority of cases. Albuminuria occurred in 32 and hyaline or granular casts in 26 instances.

9. Arterio-sclerosis ot varying degree was present in 29 cases and a mitral systolic murmur in 8.

10. The diPiculty of differentiating the disease from rheumatism was illustrated by the fact that four of the cases were repeatedly diagnosed as the latter on their early admissions to the hospital, the appearance of tophi later revealing the true nature of the disease

11. The series illustrates the great importance of examining the ears and the vicinity of the joints for the presence of tophi in all cases of multiple arthritis of doubtful origin.

Some Points on Metabolism in Gout: With Special

Eeference to the Eelationship between the Uric-Acid and the Phosphoric- Acid Elimination in the Intervals and During Acute Attacks. — The Practitioner, August, 1903, p. 181.

The analyses in the cases reported above suggest very strongly a close parallel relationship between the uric-acid and phosphoric-acid excretion in gout. They further point in favor of the view that both are products of nuclein-disintegration. In the quiescent intervals both phosphoric acid and uric acid are markedly reduced below normal. Two or three days after the acute arthritic symptoms commence the phosphoric acid and uric acid gradually increase until they reach the average output, or even the upper limit for normal. As the acute manifestations subside both steadily fall and remain below the lower limit for normal until the onset of the next acute attack.

A Study of the Cases of Amoebic Dysentery Occurring at the Johns Hopkins Hospital. — The Journal of the American Medical Association, August 22, 1903, p. 480.

In nearly fourteen years 120 cases of amoebic infection have been admitted to the Johns Hopkins Hospital. Of these, 119 were cases of amoebic dysentery and amoebic abscess of the liver, the remaining case being one of amoebic abscess of the floor of the mouth. Of the 120 cases' 118 were admitted to the medical wards. During this time there were 15,817 medical admissions, the amoebic dysentery cases constituting 0.74 per cent of the cases. Of the 119 cases of dysentery, 82 were apparently contracted in Baltimore and 13 in the State of Maryland outside Baltimore, or a total of 95 cases within the borders of Maryland. The largest number of cases occurred in the third decade. The youngest patient was a child two years and eight months old. and the oldest a man of 71. A point of special interest is the comparatively large number of cases in children under 10 years. Eleven cases, or 9.4 per cent, occurred in the first decade, 6 of these belonging in the first hemi-decade. There were lOS males and 11 females. The series comprised 107 whites and 12 blacks, or a proportion of 9 to 1. The total ratio of whites to blacks in the hospital is about 7 to 1. A secondary anaemia of moderate grade occurs. Occasionally there is a polycythemia. The average leucocyte count in the uncomplicated dysentery cases was 10,600. In the hepatic abscess cases it was 18,350. Hepatic

98

[No. 156.

abscess occurred in 27, or 22.6 per cent, of the cases. Nine of these ruptured into the right lung and 2 into the right pleura. Three opened into the inferior vena cava. In 10 cases of the 18 abscess cases that came to autopsy there vi'as a single large abscess in the upper part of the right lobe. In 8 cases there were multiple abscesses. Perforation of the colon with peritonitis occurred in 3 cases, and severe intestinal hemorrhage in 3 cases. Five cases were complicated by malaria; 1 by typhoid; 1 by pulmonary tuberculosis; and 1 by a strongyloides intestinalis infection. The agglutinative blood reaction with Bacillus dysenteriae was negative in all cases tried. A marked feature of the disease is the great tendency to relapse. The mortality was high; 2S. or 23. .5 per cent, terminated fatally. Hepatic abscess is a serious complication, 19 of the 27 cases terminating fatally. Five were cured out of 17 operated on. Two of the hepato-pulmonary abscess cases were discharged very much improved. One abscess case did not remain to be treated. Quinine irrigations still seem tc- give the best results in the treatment of the dysentery.

T. Caspar Gilchrist, M. D., and W. Royal Stokes, M. D.

The Presence of Pecnliar Calcified Bodies in L\ipns-like

Tissue. — Journal of Cutaneous Diseases, October, 1903. Henry Harris, M. D. A Case of Progressive Muscular

Atrophy of Spinal Origin. — California State Journal of

Medicine, January, 190.3. Importance of cold and fatigue shown aetiologically in a case resulting two weeks after excessive cold and fatigue while the patient was traveling in Alaska.

William H. Howell, Ph. D., M. D. Obervations upon the Cause of Shock, and the Effect upon it of Injections of Solutions of Sodium Carbonate. — Contributions to Medical Research, Dedicated to Victor C. Vaughan, Ann Arbor, 1903. Guy L. Hunner, M. D. An Interesting Complication in the Diagnosis of Gallstone. — American Medicine. May 2, 1903. Two cases are reported, in one of which was made a possible, and in the other a positive diagnosis of gallstone. Operation in each case demonstrated that the symptoms were due to the omentum being adherent to a former operation wound. The symptoms were probably caused by traction on the parietal peritoneum at the base of the mesocolon.

One Hundred Consecutive Cases of Myoma of the

Uterus. — Ame7ican Medicine, July 11, 1903.

The writer reports one hundred consecutive cases of myoma of the uterus occurring in the gynecological service at the Johns Hopkins Hospital.

Eighty per cent of these patients were between 30 and 49 years of age. Eighty per cent were married and 32 per cent of these had never been pregnant. Of the 54 women who had been pregnant, 11 or about 20 per cent had borne but one child, and G had never carried a child to viable age. One patient had miscarried six times, the fetus never going beyond the fifty month. Of the 54 women who had been pregnant, 20 had miscarried at some period in life.

At times the diagnosis between fibroid tumor and pregnancy can not be made even when the patient is fully anesthetized.

Of the chief sjmpfoms noted, 35 patients complained of an abdominal tumor. Pain, either in the abdomen or pelvis, or in the form of dysmenorrhoea, was complained of by 53 patients. Increased menstrnal flow was noted in 41 cases and copious hemorrhages at or between the menstrual periods in 15 cases,

making 56 per cent in which myoma was associated with unusual loss of blood.

Gastric symptoms were prominent in 6 cases. Sixteen patients complained of bowel symptoms, and 28 patients of bladder symptoms.

Carcinoma of the fundus occurred in 3 cases, of the cervix in 2 cases. Sarcoma was present in 2 cases. Adenomyoma existed in 2 cases.

The following operations were done for the 100 cases: Myomectomy, 19; panhysteromyomectomy, 14; supravaginal hysterosalpingooophoromyomectomy, 40; supravaginal hysteromyomectomy, leaving one or both ovaries, 16; vaginal myomectomy, 5; vaginal hysteromyomectomy, 6.

Six patients died In five of them the tumor was complicated by serious pelvic inflammatory disease. One died on the sixth day from septicemia, one on the third day from general peritonitis, one on the fourth day from thrombosis of the left common iliac vein with embolus carried to the pulmonary artery, one suffered with an infected tumor and died in 10 hours from shock, which was profound even before operation. Two died in 20 hours and 4 hours, respectively, from shock due to loss of blood at operation.

Tuberculosis of the Urinary System in Women. Report of Thirty-Five Cases. — Charlotte Medical Journal, November, 1903.

Henry M. Hued, M. D. The Duty and Responsibility of the University in Medical Education. — Science, July 17, 1903. — Yale Medical Journal, July, 1903.

Henry Barton Jacobs, M. D. Maryland's Need of a Mountain Sanatorium for Indigent Consumptives. — Maryland Medical Journal, October, 1903.

Howard A. Kelly, M. D. The Early History of Appendicitis in Great Britain. Glasgow Medical Journal, August, 1903.

On the Labia Urethrae and Skene's Glands. — American Medicine, September 12 and 19, 1903.

The Selection of Methods in Abdominal Hysterectomy. — Journal of Obstetrics and Gyncecology of the British Empire, 1903, Vol. IV.

J. H. ]\I. Knox Jr.. M. D. A Contribution to the Study of the Summer Diarrhoeas of Infancy. — Journal of the American Medical Association, July 18, 1903.

W. Harmon Lewis, j\I. D. Wandering Pigmented Cells Arising from the Epithelium of the Optic Cup, with Observations on the Origin of the M. Sphincter Pupillte in the Chick. — American Journal of Anatomy, Vol. II,

No. 3.

Irving P. Lyon, M. D. Artcrio-sclerosis and the Kidney. — Transactions of the Medical Society of the State of New York, 1903, p. 96, and reprinted in Albany Medical Annals, March, 1903.

Blood E.xamination in General Practice. — Transactions of the Medical Society of the State of Neiv York, 190.3, p. l.'il. and rejirintcd in Buffalo Medical Journal, June, 1903.

A Statistical Study oC a Rural Cancer District in the

State of Now York — Brookfield. Fourth Annual Re

March, 1904.]

99

port of tlie Work of the Cancer Laboratory of the Xew York State Board of Health, for the year 1902-3, Albany, 1903, pp. 97-119.

A Cancer District in the Towns of Plaiufield and

Edmeston, New York. Fourth Annual Report of the Work of the Cancer Laboratory of the N'ew York State Board of Health, for tlie year 1902-3, Albany, 1903, pp. 120-123.

A Review' of Echinococcus Disease in North America. — American Journal of the Medical Sciences, January, 1902.

This paper analyzes 241 American cases, citing the original report of each case, where published, and adding many unpublished cases. The cases are considered under the following headings: Age; Sex; Nationality; Geographical Distribution, by States and Provinces; ALatomical Location, by Organs Involved; Diagnosis; Is the Disease on the Increase in America? ; The Distribution of the Disease in Animals in America; The Occurrence in Dogs of the Adult Tapeworm. Taenia Echinococcus; Prophylaxis; Commercial Considerations.

"W. G. MacCallum, M. D. On the Production of Specific Cytolytic Sera for Thyroid and Parathyroid, with Observations on the Physiology and Pathology of the Parathyroid Gland, Especially in its Relation to Exophthalmic Goitre. — Medical News, October 31, 1903.

'Thomas McCkae, M. D. Acute Articidar Rheumatism. A Report of the Cases in the Johns Hopkins Hospital, 1902-1903. — American Medicine, August 8, 1903.

J. D. Madison, M. D. A Case of Brain Tumor in .a Woman Seventy-Eight Years of Age. — American Journal of Insanih/. .January. 1903.

T. P. Mall, il. D. On the Circulation through the Pulp of the Dog's Spleen. — American Journal of Anatomy, Vol. II, No. 3.

On the Transitory or Artificial Fissures of the

Human Cerebrum. — American Journal of Anatomy, Vol. II, No. 3.

Spleen. — Buck's Reference Handbook of the Medical

Sciences, 1903.

Second Contribution to the Study of the Pathology

of Early Human Embryos. — Contributions to Medical Research, Dedicated to Victor C. Vaughan, Ann Arbor, 1903.

Harry T. Marshall, M. D. Osteoma.— Buck's Reference Handbook of the Medical Sciences, 1903.

Side Chain Theory of Paul Ehrlich.— 5mcA:'s Reference Handbook of the Medical Sciences, 1903.

G. Br.owx Miller, IL D. Congenital Dilatation of the Gall Bladder and Bile Ducts. — The American Journal of Obstetrics, Vol. XLVIII, No. 2, 1903. The patient, a girl 2i/^ years old, was born with a very large abdomen, which measured a few days after birth 24V'> inches in circumference. She was well developed, learned to walk about the usual age, and except some trouble with digestion and inconvenience due tc the size of the abdomen, was apparently in

good general health. Her stools varied from clay color to a light brown. The size of the abdomen was due to a tumor, which proved to be an enormous dilatation of the gall bladder and bile ducts, and occupied most of the abdominal cavity. Three litres of thin bile containing mucus were evacuated after stitching the tumor to the abdominal wall. No gall stones could be found. The bile continued to flow through the fistula and the stools showed an absence of bile for three months, when after a great outflow of thick bile-stained mucus the fistula closed and the stools assumed a normal color. She is now quite well, 1% years after the operation.

The liver was represented by a very small left lobe and a mass of liver substance the area of the palm of the hand and about 1-2 cm. thick, lying intimately adherent to the cyst and separated from the left lobe by an interval of 5 cms. The ligaments of the liver were attached to the cyst.

G. H. F. NuTTALL, M. D. In Meiuoriam : Walter Reed. — Journal of Hygiene, Vol. 3, pp. 292-296.

• In Memoriam: Edniond Nocard. — Journal of Hygiene, Vol. 3, pp. 517-522.

and A. E. Shipley, M. A.

Studies in Relation to Malaria. II. (Concluded). The Structure and Biology of Anopheles. — Journal of Hygiene, Vol. 3, pp. 166215.

E. L. Opie, M. D. Disease of the Pancreas; Its Cause and Nature. — •/. B. Lippincott Company, Philadelphia and London, 1903.

Protozoa-like Bodies of Carcinoma, Smallpox and

Leukffimia. — Twentieth Century Practice of Medicine, Vol. XXI, p. 553.

Plasmodium Malariae. — Buck's Reference Handbook

of the Medical Sciences, 1903. — SjTnptoms and Treatment of Pancreatic Disease.

International Clinics, 1903.

WiLLiAJi OsLER, M. D. Chronic Cyanosis, with Polycythjemia and Enlarged Spleen : A New Clinical Entity. — American Journal of the Medical Sciences, August, 1903.

On the So-Called Stokes-Adams Disease (Slow Pulse

with Sj'ncopal Attacks, etc.). — The Lancet, August 22, 1903.

The Home in Its Relation to the Tuberculosis Problem. — Medical Neivs, December "12, 1903.

Typhoid Fever and Tuberculosis. — American Med

icine, December 26, 1903.

Mart S. Packard, M. D. An Encapsulated Diplococcus in

Mastoiditis. — Journal of Medical Research, March, 1903. Otto G. Ramsay, M. D. A Discussion of the Etiology and

Modern Treatment of Eclampsia. — Yale Medical

Journal, September, 1903. Robert L. Randolph, M. D. The Bacteria Concerned in

the Production of Eye Inflammations. — Journal of the

American Medical Association, October 3, 1903. Hunter Robb, M. D. The Mortality following Operations

for Pus in the Pelvis. — Journal of the A merican Medical

Association . Januarv, 1903.

100

[No. 156.

— The Vaginal Incision in Sepsis following Abortion. — American Gijnecolo(jy, June, 1903.

Ovariotomy. — Buck's Reference Uandhoolc of the

Medical Sciences, June, 1903. Benjamin K. Schenck, M. D. Results in a Series of Fortyeight Kidney ri.\ations. — Detroit Medical Juuinal, December, 1903.

Some Essential Points in the Use of the Kelly Female Cystoseope. — Journal of the Michigan State Medical Society, December, 1903.

An Eighty-eight Ponnd Ovarian Cyst Successfully

Eemoved from a Patient Seventy-seven Years of Age. — Journal of the American Medical Association, December 19, 1903.

Charles E. Simon, il. D. A Case of Myelogenous Leukaemia with Severe Unusual Features (absence of eosinophilic leucocytes). — American Journal of the Medical Sciences, Vol. CXXV, June, 1903, p. 984.

On the Occurrence of Ehrlich's Dimethylamidoben zaldehyde Reaction in the Urine. — American Jovrnal of the Medical Sciences, Vol. CXXVI, September, 1903, p. 471.

Frank R. Smith, M. D. Extracts from the Writings of Wilhelm Griesinger, a Prophet of the X^ewer Psychiatry. — American Journal of Insanity, July and October, 1903.

Walter R. Steiner. M. D. Report on the Progress of Medicine, 1902.- — Transactions of the Connecticut Medical Society, 1903, pp. 113-125.

William S. Thayer, M. D. On Arteritis and Arterial Thrombosis in Typhoid Fever. — New York State Journal of Medicine, January, 1903, III, 21-28.

Preliminary Report of the Tuberculosis Commission

of Maryland, December 14, 1903.

Henry M. Thomas, M. D. The Anatomical Basis of the Argyll-Robertson Pupil. — American Journal of the Medical Sciences, December, 1903.

J. II. J. Upiiam, M. D. Some of the Unusual Complications of Chronic X'opliritis. — Columbus Medical Journal, 1903.

Water-borne Diseases. — Columbus Medical Journal,

1903.

Louis W. Warfield, M. D. Acute Ulcerative Endocarditis Caused by Meningococcus (Weiclisclbaum). — University of Pennsylvania Medical Bulletin, July-August, 1903.

A Mild Case of Acute Dysentery Yielding Bacillus

dysentcriac (Shiga) in Large Numbers. — Bulletin of the Ayer Clinical Laboratory of the Pennsylvania Hospital, No. 1, October, 1903.

A Plea for the Microscoj)ic Examination of the

Blood in Die Continued and Remittent Fevers Common to our Southern States. — Atlanta Journal-Record of Medicine, November, 1903.

Some Practical Points tauglit by the Discovery of B.

dysenteriae in the Stools of Infants Suffering from Sum

mer Diarrhoea. — Medical Record, Vol. 64, November 7, 1903.

— The Report of a Series of Blood Cultures in Typhoid

Fever.

Andrew H. Whitridge, M. D. The Significance of Intermittent Albuminuria in Life Insurance Work, with a Report of a Case. — Medical Examiner and Practitioner,. November, 1903.

J. Whitridge Williams, M. D. Obstetrics. A Text-Book for the Use of Students and Practitioners, 1903. — D. Appleton tC- Co., New York, pp. 845.

Indications for and the Most Approved Methods of

bringing about Premature Labor and Accouchement Force. — American Gynecology, Vol. Ill, 1903, pp. 13-31.

• A Sketch of the History of Obstetrics in the United

States up to 1860. — American Gynecology, 1903, pp. 366294, 340-366. Also Siehold-D ohm's Geschichte der Geburtshulfe. Vol. Ill, Tiibingen, 1903.

J. L. Yates, M. D. Notes on the Experimental Production of Specific Cytolysins for the iVdrenal, Thyroid and Parathyroid Glands of Dogs. — University of Pennsylvania Medical Bulletins, July-Augiist, 1903.

Dissecting Aneurysm of the Aorta, with a Report of

a Case. — Wisconsin Medical Journal, December, 1903.

Hugh H. Young, M. D. Conservative Perineal Prostatectomy. A Presentation of New Instruments and Technic. — Journal of the American Medical Association, October 24, 1903.

n^otes on new books. Human Placentation; an Account of the Changes in the Uterine Mucosa and in the Attached Fetal Structures during Pregnancy. By J. Clakexce Webster, B. A.. M. D. (Edin.)^ P. R. C. P. E., F. R. S. E. With 233 illustrations. {Chicago: W. T. Keener and Co., 1001.) The author of this book deserves credit for the breadth of view with which he approaches his subject. It is, he says, his conviction that a satisfactory knowledge concerning the development of the human placenta can only be obtained by carrying on a careful phylogenitic study in connection with the direct investigation of the human uterus. In pursuance of this idea, he has not only examined the pregnant uterus in all its different stages of development, but has made a careful study of the same periods in a number of animals, e. g., the rat, pig, sheep and cow. He has, moreover, examined a number of complete abortions in the early weeks, besides investigating the normal mucosa of the nonpregnant uterus, without which he does not think the changes occurring in pregnancy can be rightly understood. These elaborate and painstaking researches cover a period of eleven years. Their results are clearly and concisely presented, and their value is greatly enhanced by the number of excellent illustrations, which were prepared largely by the author himself, and represent much time and pains. It is, perhaps, a matter for regret that they should be separate from the text, since this arrangement necessitates a constant shifting of attention; but, on the other hand, it has the advantage of enabling the reader to follow the plates with their accompanying descriptions consecutively, and

March, 1904.]

101

thus gain a better general impression of the process of evolution they depict than woulii otherwise be possible.

The American Textbook of Obstetrics. Edited by RiciiAitD C. Noiuus. M. D.. and Roiskkt L. Dickenson, M. D., Art Editor. Second edition, revised; with nearly 9t)0 illustrations. (PhiladeJphia and London: W. B. Saunders and Company, li)U,i.)

The object of this volume, as stated in the preface, is, par excellence, that " of making clear those departments of obstetrics which are at once so important and usually so obscure to the medical student." As this is its avowed purpose, it is perhaps unreasonable to object that too much time and space are devoted to the pathologic side of labor and too little to the physiologic or normal side. Nevertheless, it is impossible to forbear a protest as to the unnecessary prominence given to the unusual and abnormal aspects of labor. Out of 1054 pages (exclusive of indices) contained in the two volumes only 173 are devoted to normal labor, including its mechanism, and it is impossible to avoid the reflection that a student educated along these lines might come to the first labor case, for which he is individually and primarily responsible, fully prepared to do a podalic version or a Caesarean section, but not altogether equal to the demands of a normal parturition.

Apart from this defect, however, the book is prepared in the best possible manner. The choice of writers, originally carefully and prudently made, has been correspondingly carried out in the changes which death has made necessary in this, the second edition, and their respective subjects have received thorough treatment. Some of the chapters, those, for instance, on dystocia and the pathology of pregnancy, are written in a style unusually animated and interesting, while the constant introduction of illustrative cases, briefly cited, adds greatly to their readable qualities.

Both volumes are liberally illustrated, and the illustrations have been executed on a carefully considered scheme which gives them additional value. The invariable selection, for instance, of the left half for sagittal sections, in preference to the practice hitherto employed, of using right or left indifferently, is a most desirable change. A little too much realism may possibly characterize some of them, but on the whole they are suitable and valuable, especially those in the section on dystocia arising from abnormalities of the fetus.

The section on the new-born infant is unusually full and complete, as well as that on obstetric surgery.

The manner in which the names of contributors are presented is not, in our opinion, sufficiently emphatic. They are appended, in parenthesis, to the titles of their respective sections in the table of contents, and the fact that the type used for the author's name is smaller than that used for the title of the subject must cause it (we speak from experience) to be sometimes overlooked.

In spite of such defects, however, the work is well calculated to fill a valuable place in the literature of its subject, namely, that of presenting the views of a number of individuals, each especially well informed on the subject of which he treats, in such a manner as to form an harmonious whole.

Modern Obstetrics; General and Operative. By W. A. Newmax DoRLAND, A.M., M. D. Second edition, revised and enlarged; with 201 illustrations. {Philadelphia and London: W. B. Saunders and Co., 1001.)

This volume is characterized by an unusual and very pleasing display of common sense on the part of the writer. The section on normal labor, he fitly denominates " Physiologic Obstetrics," and lays strong emphasis on the fact that although in our present advanced stage of civilization parturition is too often accompanied by difficulties and dangers wholly unknown under simpler

<onditions of life, it should never be forgotten that labor is essentially a purely physiologic process.

The pathological side of the book, however, in no way suffers from the prominence given to the physiological. The utmost care has evidently been taken to collect the fullest possible information in regard to every abnormal condition and the essentials have been discreetly selected and concisely expressed. The chapter on puerperal sepsis is especially valuable, treating as it does of a condition only recently understood, and one in regard to which our knowledge is still undergoing evolution. Dr. Dorland's division of this subject into two classes — general and local — is sensible and useful, and his treatment of the different indirect manifestations accompanying each condition is well calculated to give them the prominence they deserve.

In considering the question of diagnosis between puerperal sepsis and other pathologic conditions, Dr. Borland remarks acutely that " the general physician is so averse to admitting, even to himself, that he has a case of sepsis on his hands that he is very prone to argue himself into believing that his patient is suffering from an attack of some other intercurrent affection, as an enteric fever or an influenza." In our large cities, obstetrics is becoming yearly more and more the work of a specialist or semi-specialist, but elsewhere it is, and must remain, almost entirely in the hands of the general practitioner, and therefore the truth contained in the above remark, and the hints accompanying it for the guidance of the physician at large in this particular, are especially worthy of attention. All the most modern forms of treatment of puerperal sepsis are given very fully, and the reasons for or against each are stated with fairness.

The section on diseases of the genito-urinary tract is also very complete, especially as regards puerperal eclampsia, which receives its due meed of consideration. It is perhaps to be regretted that the text is quite so much burdened with statistics and percentages, but this is a trivial defect.

The number of illustrations is not large, but it is sufficient, and it is, on the whole, rather pleasurable than otherwise to find ourselves reading a text-book in which the process of thought is allowed opportunity for exercise without pictorial distraction, in contrast to the numbers of such volumes in which the succession of illustrations is so constant and so rapid that reflection and deduction are rarely allowed fair play.

No book is without faults, and one who looks for them here will, of course, be able to find them, but the work is a valuable one and the literature of the subject is the better for it.

Atlas and Epitome of Labor and Operative Obstetrics. By. Db. OsKAR ScHAEFFER, Privat Docent in Obstetrics and Gynecology in the University of Heidelburg. Authorized translation from the fifth revised German edition; with 14 lithographic plates in colors and 139 other illustrations. (Pliiladelphia: W. B. Saunders and Co., 1901.)

This book, as its name indicates, is essentially a volume of illustrations, the text being really but complemental in function. To express the amount of information requisite for such a purpose in so condensed a form is not an easy matter; the writer, however, is evidently thoroughly familiar with the practical details of his subject and possesses a grasp of its fundamental principles sufficiently firm to permit of his attaining his object in a satisfactory manner. To say that condensation is carried a little loo far may be treason to the purpose of the book, nevertheless, a ]iassing doubt arises as to whether the information imparted would not in the end be better assimilated if it were somewhat loss condensed; or rather, to put the matter on a broader basis, whether other and fuller methods of instruction are not really Miose best adapted to the real end in view, namely, the acquisition of knowledge. This is not the time and place, however, to engage in the discussion of so fundamental a question, and the

102

[No. 1.56.

number of editions through which the book has passed seem to afford sufficient guarantee that it meets with popular requirements. The general arrangement of the book is excellent, and its main divisions are well calculated to give the student a clear understanding of the broad outlines of the subject. The illustrations which form so integral a part of the work are well chosen for their purpose, and arranged to advantage. A word of favorable comment is due to the translator, whose work is not only accurate and clear, but. so far as the extreme condensation of style permits, is smooth and easy.

A Text-Book of Pathology and Pathological Anatomy. By Dr. Hans Schmaus; translated from the sixth German edition by A. E. Thayer, M. D.; edited with additions by James EwiNG, M. D. 602 pages, with 351 engravings, including 35 colored plates. (Philadelphia and JS'ew York: Lea Bios. £ Co., 191)2.)

As we already have several satisfactory elementary text-books of pathology written in the English language, it is difficult to appreciate the necessity of a translation of Schmaus's text-book. But granting the desirability of a translation, it is unfortunate that more care was not given to the English in which it is clothed. One is impressed throughout the book by the fact that he is reading a translation. There is a close adherence to German order and a studied avoidance of the English idiom, which seems often to obscure the meanings, and would leave a beginner in pathology quite in the dark.

The general scope of the booli is well stated by the editor in the preface, in the following words: "The author has not attempted to compete with the more discursive works of his countrymen, but has endeavored to write a shorter, more compact but equally comprehensive book, embodying all the important principles and facts that should be brought before students of pathologj'. There is a notable absence in these pages of the argumentative style, the quotation of authorities and the pursuit of personal opinion that are prominent features in the larger works and likewise absent is the full discussion of many topics that properly belong to a work of jeference."

As a work of that nature, the book is to be commended. It is short and compact, so much so that the chapters at times seem but a series of definitions. It is comprehensive, including sections on general pathological processes, on parasites and on special pathologj'. There is almost an entire absence of the quotation of authorities for statements, and yet in spite of lack of " pursuit of personal opinion " one finds positive statements on subjects not generally accepted as entirely settled. The illustrations are, as a rule, good, though some of the colored plates, those which are printed in but a single color, would seem to be a useless expense, for though bright colors may be pleasing to the eye and also an important factor in making a book sell, the true value of a colored plate is supposed to lie in the detail that may be brought out by contrasting colors. But all in all it may be said that, barring the English, the author and editor have well fulfilled their intention. It is toward their " intention," or the condensed, comprehensive, elementary text-book in the abstract, that further criticism is directed. It does not seem to the reviewer that pathology in all its phases is a subject that can be treated in a highly satisfactory manner in a book of 600 pages of large type well leaded, and with a goodly proportion of space taken up by illustrations. Subjects must necessarily be treated in a sketchy, inexact, unscientific manner, without evidence to warrant conclusions drawn, or discussion of mooted questions, a condition which must fail to meet the demands of the student of pathology, who is, as a rule, an individual of a more, rather than less, mature mind, which has outgrown the habit of swallowing unquestioned what is placed before it. Nor does it seem just to the student to give him but one side of a question; for example,

in speaking of cirrhosis of the liver, to tell him only, that " the essential element is the formation of granulation tissue between the lobes and its conversion into contracting cicatricial tissue with consequent atrophy of the hepatic cells" when "the other half-Rome" believes the hepatic atrophy primary. Even if the student were not able to decide for himself between the two views, statement of both would leave him with an open mind. To fall from the abstract to another concrete example; how firm a basis for the understanding of the etiology of dysentery is given the student, when to the author's statement that " In tropical cases the presence of amoebae is characteristic and it is questionable whether our dysentery of hot weather is identical with the tropical type," is appended the editor's parenthetical note, " Both are probably referable to a specific bacillus — Bac. of Shiga."? If author and editor are in doubt, is not the reader entitled to a plain statement of pathological findings lest he be in worse darkness than simple ignorance? Briefly the ideal text-book seems, to the reviewer, one in which facts and their intepretation are clearly separated — and labelled — in which authority for statements is given, and in which important questions shall be discussed and the opinion of the author given in a critical review of existing opinions.

Clinical Pathology of the Blood. By James Ewing, A. M., M. D., Professor of Pathologj-, Cornell University Medical College, New York City. Illustrated with 43 engravings, and 18 colored plates drawn by the author. Second edition, revised and enlarged, (yeic York and Philadelphia: Lea Brothers d Co., 1903.)

In discussing this book, it should be borne in mind that its subject is " clinical pathology." It is the work of a pathologist, not of a clinician, and all the matter contained therein which concerns the clinical side of the question is quoted from literature. But the pathologj' of blood diseases is, perhaps, more than that of any other one branch of medicine, a subject of speculation and theory, with scarcelj' a single chapter (even the origin of red blood cells) resting on a basis of generally accepted ideas. Hence we may expect each edition to differ markedly from the preceding. This book is of very great assistance to those who are following current literature. It is, in fact, chiefly an epitome of literature, most of which deals with parts of the subject in which the author claims no authority or experience; hence his conclusions, based not on his own work but on the study of literature, are often inconclusive, the words " possibly " and " probably " being often repeated. We regard it unfortunate that a set of new plates was not prepared for this edition. The representations of leucocytes and malarial parasites are surely inadequate. Had some of the English writers seen these plates earlier, they would never have wasted their term " chromocytes " on red blood cells.

The author's English is not above reproach. No one can dispute his right to coin a new word if he wishes to do so, but he should be careful not to take too many liberties with old terms. The word " englobe " (page 176 et alt.) is a case in point. The use of " eflagellation (page 431), "spore" and " sporulation " (page 435 et alt.) applied to the malarial parasite, and " endothelia " (page 178), referring to cells, is, we think, open to criticism, although it may be a matter of taste. But surely the term " crioscopy " (xu/ot ram instead of xpfos- cold) will please college fraternity men more than teachers, and the description of the same will be appreciated by the physical chemist who does not consider the " laws " governing cryoscopy as absolutely " invariable," nor " elements " a proper term for the substances in solution, and Donng's name is repeatedly misspelled.

In the chapter on blood plates (which, by the way, deserves mention in the index), page 18G, the very important method of IJeetjen deserves more mention, and, even though his opinions

March, 1904.]

103

are not accepted, the very positive opinions expressed must offend some of the best authorities on the subject.

The change mentioned on page 239 in the bulli of blood in leuiviemia may occur in some cases, but the reverse also occurs.

The chapter on malaria is not at all satisfactory. We wonder if it has the same effect on others living in regions where malaria is common and who have plenty of opportunity to study fresh blood specimens in preference to using " improvised" (page 435) polychrome methylene blue; yet if the author can really get the details he pictures in the organism he is to be congratulated; it is the plates which to us seem " improvised." Considering the subject of the book, here is just the place one would expect to find the mosquito side of the subject well discussed, yet it is much neglected.

For a discussion of recent theories on the many problems of blood, this book is interesting, but beyond this little can be said in its praise.

Functional Diagnosis of Kidney Disease, with Especial Reference to Renal Surgery. By Dr. Leopold Casper and Dr. Paul Friederich Riciiter. (Philadelphia: P. Blakiston's Son d Co., 1903.)

This little book appeared at a very opportune time, for cryoscopy was fast becoming the popular fad, and these two observers are particularly able to estimate its value. All the ordinary methods of determining the functioning power of each kidney, the vital problem for the surgeon, are discussed. The authors conclude that the only method of value is to examine the urine secreted simultaneously by each kidney, and to do this catheterization of at least one ureter is necessary. These urines are examined as regards both the molecular concentration, determined by the freezing method, and the excretion of sugar after the injection of phloridzen. The cases cited are very instructive.

The Practical Medicine Series of Year Books; under the General Editorial Charge of Gustavus P. Head, M. D. Vol. VI. General Medicine. Edited by Frank Billings, M. D., and J. H. SALisBtjRT, M. D. (Chicago: The Year Book Puhlishers, J/O Dearborn Street, May, 1903.)

This is a good, clear, satisfactory resume of the literature chiefly on diseases of the digestive organs, published during the year 1902. The many reviews are suflSciently long and are well digested.

A Guide to the Practical Examination of Urine. For the Use

of Physicians and Students. By James Tyson, M. D., Pro _ fessor of Medicine, University of Pennsylvania. Tenth edi P tion, revised and corrected. (Philadelphia: P. Blakiston's

Son <& Co., 1902.)

This excellent work has now reached its tenth edition. It is

small, compact and contains just what and only what a physician

needs to guide him in ordinary urine analysis. That, however,

it is a good book for students we are not quite so sure. At least

once in his education a student should read and practice a good

deal of urine analysis which may not now be practical, but a

knowledge of which is necessary if he would understand much

of current work, which we hope may be practical in the near

future.

Clinical Examination of the Urine and Urinary Diagnosis. A Clinical Guide for the Use of Practitioners and Students of Medicine and Surgery. By J. Bergen Ogden, M. D., Assistant in Clinical Pathology, Boston City Hospital. Illustrated. Second edition, thoroughly revised. (Philadelphia, New York, London: "II'. B. t<aiindcrs <£ Co., 1903.) This is a splendid text-book, and much to be recommended.

The chapters on qualitative examination are especially good; as

regards the quantitative work, we very much doubt if it fulfills the author's hope that the student and practitioner who have not had special training in urinary analysis may by its use obtain accurate results. Methods of quantitative analysis cannot be thus condensed in half a page, and a student witliout previous training would be forced to use a book like Neubauer and Vogel, which, although written for those with previous training, discusses minutely each step of a process which this author merely states. For instance, we can imagine the perplexity of one who tries for the first time to determine total nitrogen. (The indexing of this chapter is peculiar.) On the other hand the hypobromite methods of urea determination are carefully described although we fear their value is doubtful, and the Schijndorff method, in our opinion, the best, although the hardest, is omitted.

It may seem a small point, but experience has taught us its value, and that is to avoid the use of the term " polariscope " for the instrument used in the quantitative estimation of sugar (page 162). As a physical instrument the polariscope has a scale which reads degrees, and tubes of 10 cm. length or some multiple of this, and such an instrument is seldom used in the clinic. That the instrument may read per cent of glucose, either the scale or the length of tube is modified, hence the term " saccharometer " is safer. Of course, if the observer has had no experience with the polariscope of the physical laboratory this point will not trouble him, but if his preliminary education has been thorough the instrument of the clinical laboratory will bother him, for he will try to use the specific rotation of glucose as the coefficient of the reading.

The chapter on ^ oxybutyric acid is, we think, very insufficient. This body is of considerable clinical interest and approximate quantitative determinations are within reach of one with a polariscope without undertaking the terrible procedure the author describes, which is the only one for isolation. The difference, rotation of a urine before and after fermentation, and, better still, the difference between the amount of sugar calculated with the polariscope and careful titration with Fehling's solutions will, due allowance being made for other optically active bodies, give an idea of the amount of the acid present.

The chapter on urinary sediments is excellent. We, however, also have had " exceptional opportunities for the study of cells from the ureter, but confess our inability to recognize from an epithelial cell its source in the urinary tract (see page 246).

The part on Diagnosis almost takes one's breath away. It occupies over one hundred pages. The classification of forms of nephritis may be pathological, but clinically it is too fine, and the aid the urine gives us in differentiating them could have been put in ten or fewer pages. Recognizing, however, that it is not safe to criticise an excess of the knowledge of another over our own, we confess with humility that we have not yet attained unto the skill in the urinary diagnosis which the author of this chapter must possess.

While we believe that in the chapters on chemistry the author has condensed methods to such an extent that it is difficult to follow their description, and while we think that the chapters on diagnosis are much too minute, we believe the hook to be the best in English, and recommend it with pleasure.

Tuberculosis of the Female Genitalia and Peritoneum. By John B. MuRPiiT, M. D. (Chicago: 1903.)

This is an elaborate presidential address delivered before the Chicago Surgical Society in October, 1903. In the first portion of the monograph, Murphy deals exhaustively with the avenues through which the organisms gain entrance to the pelvic structures. The literature on the subject is carefully reviewed. Tuberculosis of the vulva and vagina is interestingly discussed from the clinical and pathological standpoints. The chapter on tuberculosis of the cervix is full and most instructive. Consid

104

[No. I.jO.

erable space is allotted to tuberculosis of the body of the uterus, and Murphy sums up by saying, " The diagnosis in most cases must be cleared up by an examination of the uterine scrapings." We thoroughly agree with him in advocating complete removal of the uterus. He prefers the vaginal route, since by this avenue there is less danger of contaminating the peritoneum. Murphy thinks that the portion of the tube first involved is that within about half an inch of the uterus and that the lodgment at this point is due to extreme narrowing of the tube lumen. Prom several experiments Murphy found that tuberculous tissue introduced into the abdomen, produce lesions in the lower half of the abdomen, and in the few months intervening between the inoculation and the animal's death that neither the mucosa of the tubes nor that of the uterus showed any evidence of tuberculous involvement.

Excellent details of the clinical phenomena of cases of tuberculosis of the tubes are given and a very careful and conservative treatment recommended. Tuberculosis of the ovary is briefly and yet satisfactorily discussed.

Tuberculosis of the peritoneum is accorded a liberal consideration. The various modes of infection are outlined, especial emphasis being laid on the role played by tuberculous Fallopian tubes. These expell from time to time caseous material into the pelvis and occasion exacerbations of the tubercular peritonitis. Murphy thinks that primary tuberculosis of the appendix is frequently responsible for subsequent tubercular peritonitis. Peritonitides of this character are grouped as follows: (1) The disseminated exudative and non-confluent serous variety. (2) The nodular ulcerative or perforative variety. (3) The adhesive fibro-plastic cystic circumscribed abscess partition or obliterative variety. (4) Tubercular peritonitis with mixed infection.

Under treatment. Murphy says, " The surgical or medical treatment of tuberculosis of the peritoneum involves four propositions: (1) To remove or shut off the source of supply to the peritoneum of new tubercular debris. (2) To remove the products of the infective process from the peritoneum. (3) To increase the tissue proliferation for the encapsulation of the foci already present. (4) To avoid mixed infection.

After reviewing the results of others. Murphy shows his faith in operative interference by the following: "The value of operative intervention can no longer be said to be in question."

In the disseminated serous variety mere abdominal section is of little value. For success it is necessary to remove the original focus, which is likely to be a Fallopian tube, the appendix, or possibly a mesenteric gland. It is in this class of cases that the most gratifying results have been noted.

In the nodular ulcerative and perforative variety, and also in the adhesive form, the sphere of surgical interference is limited and is on the i^hole unpromising. Murphy lays especial stress on the dangers of producing ftecal fistula in these cases as the intestines are often intimately blended with the abdominal wall and are readily cut into as the peritoneum is being opened. Or, again, when gentle traction is made on adherent intestinal loops, they are liable to rupture.

In dealing with the mixed infection variety where circumscribed abscesses exist, or where general suppuration is present, he advises evacuation followed by closure without drainage. Drainage was abandoned on account of the uncontrollable and permanent purulent discharge that followed where the open treatment had been employed.

This contribution of Murphy's has entailed much labor, is of Interest to the pathologist and contains many practical hints for the surgeon and general practitioner. It is worthy of a thorough perusal by every medical man.

The Surgical Diseases of the Genito-Urinary Organs. By E. L. Keyes, a. M., M. D., LL. D., and E. L. Keyes, Jii., A. B., M. D.,

Ph. D. With one hundred and seventy-four illustrations In the text and ten plates, eight of which are colored. (New York and London: D. Appleton and Company, 1003.)

This volume of 800 pages is a second revision of Van Buren and Keyes' Genito-Urinary Diseases with Syphilis, which was written some thirty-five years ago. Since the first appearance of this book the tendency has been to make it less venereal and more genitourinary, hence the change in title. In the present edition syphilis has been entirely eliminated, as it is a genital disease only in its manner of attack. Gonorrhoea, however, although a venereal disease, has received the extended consideration which its overshadowing importance demands. It is so intimately associated with the inflammatory conditions of the urethra and so far-reaching in its effects that it merits the space and careful attention given it.

We hesitate to criticise the opinions of the authors based, aa they are, on such wide and extensive personal experience. But on such important questions as the treatment of prostatic hypertrophy, ureteral catheterization and the use of the cystoscope we feel that their attitude is too conservative. In the treatment of prostatic hypertrophy in the class of cases suitable for a cautery operation we doubt very much if any who have had a considerable experience with the Bottini operation would admit the advantage claimed by the authors for Chetwood's operation.

We are very much surprised to find the indications for cystoscopy summarized as follows: (1) In tuberculosis of the bladder to decide a question of operation; (2) ureteral catheterization; (3) tumor, and (4) in obscure cases, for diagnosis. Just what is included under the last heading, obscure cases, will depend largely on the individual operator's interpretation of the term obscure, but in no way can it be interpreted to apply to cases of hypertrophy of the prostate. To quote, " Many surgeons constantly employ the cystoscope for the diagnosis of hypertrophy of the prostate, stone in the bladder and cystitis. I do not consider it a proper routine method of diagnosis for any of these conditions."

In our experience there is no method of examination so simple and giving data at once so accurate and indispensable in cases of hypertrophy of the prostate as cystoscopy. Indeed, we do not understand how a surgeon can intelligently perform any of the cautery operations without first making a careful cystoscopic examination of the prostatic orifice. And the same holds good for any operative interference with the prostate.

We are sorry the silk filiform bougies with steel followers and the Kollmann dilators have not found greater favor with the authors. We believe they deserve greater consideration than they have received.

But these are doubtless minor points about which there is at present a great variety of individual opinion. And they do not detract from a text-book which is easily the best we have in this branch of surgery. It is also the best book on the subject to put into the hands of students.

Diseases and Injuries of the Eyes, with their Medical and Surgical Treatment. By Geouge Lawso.v, F. R. C. S. Eng., Surgeon Oculist-in-ordinary to her Majesty the late Queen Victoria; Consulting Surgeon to the Royal London Ophthalmic Hospital and to the Middlesex Hospital. Sixth Edition, with 249 illustrations. Revised and in great measure rewritten by Aitxoi.i) Lawson', F. R. C. S. Eng.. Assistant Surgeon to the Royal London Ophthalmic Hospital; Consulting Surgeon to the Paddington Green Children's Hospital, etc. (London: .Smith. Elder rf Co., 15 Waterloo Place, 1903.) Eighteen years have elapsed since the last previous edition of this work was issued, and probably the majority of ophthalmologists practicing to-day are entirely unfamiliar with it, but those who do recall that it was a standard manual in its day, or who

March. 1904.1

105

have been in the habit of referring to it even later, regard it very highly because of the excellence of its practical advice on the treatment of the various eye affections. The son has done well to retain this distinctive feature.

A better illustration of the advances that have taken place in ophthalmology in the last two decades could scarcely be found than is afforded in a comparison of the fifth and sixth editions of this work. The volume of material has been multiplied three or four times and still the enlarged edition contains the concise, condensed form of the smaller. The increase consists of new subjects introduced, numerous new illustrations, and a new and broader treatment of old topics.

We can very heartily commend the book to all persons interested in a study of eye diseases, especially to the specialist as a reference book, on account of the broad and complete consideration of pathology and treatment. One feature that particularly pleases us is the attention given to errors of refraction. It is refreshing to see an English text-book treat this subject so well and we hope our European confreres may soon be following the good example. There are a few points in the chapter on hypermetropia that might be criticised, and there are evidences that the Americans are still leading in the amount of care and attention given to the correction of small errors, especially of an astigmatic nature. However, we need not push the criticism too hard, since we have evidence of a marked advance and the future is hopeful.

Any allusion to the differences between American and foreign practice reminds us that the book contains very slight reference to American work, almost ignoring it, in fact, and, by virtue of that fact, we miss some of the seemingly really important advances in ophthalmology. Neither do we find any mention of the newer remedies, such as protargol, argyrol, etc.

In the chapter on Diseases of the Lachrymal Apparatus no more attention is paid to the work of Bowman, a fellow-countryman of the author, or of Theobald than if they had never existed. The book is, throughout, rather the expression of the author's personality, and we like it for that fact, but the epoch-making discoveries I refer to should not be ruthlessly cast aside. We have shown elsewhere that the opposition to large probes is without any reasonable support, and we wonder at the persistent refusal even to try them.

Beyond these few slight adverse criticisms, we wish to record our endorsement of Lawson's work. It is a very valuable addition to our working library and a book that we shall certainly appeal to frequently. The publisher's part has been very well done and the paper upon which it is printed is particularly deserving of remark. H. O. R.

A System of Physiologic Therapeutics. Edited by S. Solis Cohen, A. M., M. D. Vol. X. Pneumotherapy, including Aerotherapy and Inhalation Methods and Therapy. By Dr. Paul Louis Tissier, Chief-of-Clinic in the Faculty of Medicine of the University of Paris. Illustrated. (Philadelphia: P. Blakiston's Son £ Co.. 1903.) The tenth volume of this system deals with the subject of

" Pneumotherapy, including Aerotherapy and Inhalation Methods

and Therapy."

In general the plan of this book agrees with that of the previous ones of the system, except that in the second part — that part dealing with inhalation methods — the application of various drugs by this method has been discussed at considerable length. While this constitutes a departure from the strict letter of the title of the system, nevertheless the value of the book has been materially increased, thereby, this chapter being one of the best of the book.

A large part of the book is taken up with a discussion of physiological questions. While much of this discussion is very interesting, the relation of some of it to the subject in hand is not very apparent, and not infrequently some of the best work on the

topics discussed has been overlooked. Much space has been taken up with a description of the various kinds of complicated apparatus used for the application of condensed and rarefied air and combination of the two. On the other hand, the discussion of the therapeutic uses to which this apparatus is to be put occupies relatively a very small space and the conclusions are not always very clear. Some of the procedures are said to be beneficial for a remarkable number of conditions, the condensed air bath, for instance, being valuable in the treatment of many disorders — from heart-disease to toothache. As a multitude of remedies advised in a given disease raises skepticism in the student's mind as to the value of any, so a very extensive list of diseases in which a given procedure is said to be beneficial might tend to cause some undiscriminating readers to doubt its value in any.

Some curious statements are made in places as to the nature of the diseases treated, not always in accord with generally accepted views. For instance, the author says: " I consider emphysema as an attenuated, benign form of pulmonary tuberculosis, fibrous in its development from the beginning."

On the whole we cannot see that the author has made a very effectual plea for the more general employment of the procedures treated of in this book. A book one-fourth of the size could have contained all the matter of any importance which has a bearing on the subject treated, and, by careful editing and presenting the opinions and experiences of the author rather than those of a host of observers, it might have had much influence in bringing this somewhat neglected branch of therapeutics into greater repute among the medical profession.

Manual of Medicine. By Thomas Kibkpatbick Monko, M. A., M. D., Professor of Medicine in St. Mungo's College. (Philadelphia and Neiv York: W. B. Saunders d Co.)

The author makes no claim for originality in this text-book of medicine, except in the matter of size, stating that some of the English treatises are too small, others are too large for the average student even to attempt to master. This seems rather an inadequate reason, if one were needed, for the appearance of this book — as though the study of medicine were a matter of linear measure. A perusal of the book convinces one, however, that the average student, like the student of the multiplication table or catechism, will still have much to learn, even after he has mastered all of its pages.

Possibly there is need for such a book. If so, the author has accomplished his purpose very well. Very few errors are apparent, and the author has chosen his material wisely, omitting a discussion of all debatable points and of newer work not definitely confirmed. This may make the book of more value for those students who desire bare facts, but certainly offers very little attraction to those who look for stimulation to thinking.

The book is very comprehensive, treating not only of all conditions usually included in the text-books on medicine, but containing in addition a section on diseases of the skin, and also considering briefly those subjects usually treated of in text-books on physical diagnosis and clinical miscroscopy. It cannot be considered very satisfactory, however, to treat of the physical diagnosis of the chest (heart and lungs) in about thirty pages, and to condense a discussion on the urine, including methods of examination, into about thirteen pages. It is to be feared that such conciseness and omission of detail may induce in the student a similar attitude of mind in the application of his knowledge to practical purposes. The directions of the author also do not always guard against this possibility. For instance, the statement is made that in the practical study of the heart, as a rule, the outline of the relative cardiac dulness is not of much value and only the outline of absolute cardiac dulness need be carefully studied.

106

[No. 156.

In order to reduce the size of the book the publishers have cut down the margins of the pages, and in other respects the book is not attractive.

To those students desiring at a moderate price a small book covering a great field this book will probably appeal.

A Manual of the Practice of Medicine, prepared especially for Students. By A. A. Stevens, A. M., M. D., Professor of Pathology, Woman's Medical College of Pennsylvania. Sixth revised edition, enlarged. Illustrated. (PhiladelpJiia, New York and London: W. B. Saunders <£ Co., 1903.)

Most readers are familiar with the former editions of this small book. The good features of the former editions have been retained In the present sixth one and a considerable number of minor changes have been made to bring this book up to date.

The selection of material has been made with care, and the work of editing has been well done. The paragraphs on treatment are very concise, but the directions are quite clear and in general the treatment advised has a rational basis.

The make-up of the book is attractive, the typographical work being excellent, and the flexible binding used on former editions being retained.

This book has in the past been largely used by students and practitioners for purposes of review and in preparing for examinations, ana it is probable that this will continue to be the main use made of it. The danger, however, that students will use such books as text-books and in place of more extensive reading is great and should be guarded against by teachers.

When properly employed, however, books of this kind are of considerable value, and this is the most valuable one of its class that we have seen.

Atlas of the External Diseases of the Eye. By Prof. Dk. O. Haab, of Ziirich. Second edition, thoroughly revised. Edited, with additions, by G. E. De Schweinitz, A. M., M. D., Professor of Ophthalmology in the University of Pennsylvania. With 98 colored lithographic illustrations on 48 plates, and 232 pages of text. (Philadelphia, New York, London: W. B. Saunders it Co., 1003.)

It seems surprising that we have had for so many years works containing accurate pictures of morbid conditions of the inner structures of the eye without any accompanying illustrations of the external diseases of this organ. It is true that the external diseases of the eye, especially inflammations of the cornea, do not lend themselves easily to illustration, but there are many infections which can be portrayed with considerable suggestiveness and the pictures of these conditions will be found a substantial help by all who attempt to do any work in the field of ophthalmology. Haab's contribution is the best of its kind and the appearance of a second edition is an evidence not only of the need for such a work but that the earlier edition was weighed and found to contain material of high grade. For many years Zurich has been strong in ophthalmology and hardly a year passes without some fresh and valuable token that the science still flourishes there. Most of the first half of the work is taken up with practical descriptions of the external diseases of the eye and their treatment and of the usual methods of examination, matter to be found In all text-books on the eye. The plates are forty in number and they illustrate every disease which can be recognized with one's naked eye. The paintings are all from nature and accompanying each of them there is a history of the patient. Occasionally we find a condition somewhat idealized, but the painting is none the less suggestive and with very few exceptions the collection contains truthful reproductions of old and familiar scenes, and we have no hesitation in advising its purchase and in predicting for it a growing popularity.

BOOKS RECEIVED.

Mammalian Anatomy, with Special Reference to the Cat. By Alvin Davison, Ph. D. With over one hundred illustrations made by W. H. Reese, A. M., from the author's dissections. 1903. 8vo. 250 pages. P. Blakiston's Son & Company, Philadelphia.

A Treatise on Orthopedic Surgery. By Royal Whitman, M. D. Second edition, revised and enlarged. Illustrated with five hundred and seven engravings. 1903. 8vo. 848 pages. Lea Brothers & Company., Philadelphia and New York.

Functional Diagnosis of Kidney Disease. With Especial Reference to Renal Surgery Clinical Experimental Investigations. By Dr. Leopold Casper and Dr. Paul Friederich Richter. Translated by Dr. Robert C. Bryan and Dr. Henry L. Sanford. 1903. 12mo. 233 pages. P. Blakiston's Son & Company, Philadelphia.

Clinical Treatises on the Pathology and Therapy of Disorders of Metabolism and Nutrition. By Prof. Carl von Noorden. Authorized American edition translated under the direction of Boardman Reed, M. D. Part IV. The Acid Autointoxication. By Prof. Dr. Carl von Noorden and Dr. Mohr. 1903. Svo. 80 pages. E. B. Treat & Company, New York.

Infectious Diseases; Their Etiology, Diagnosis, and Treatment. By G. H. Roger. Translated by M. S. Gabriel. Illustrated with forty-three engravings. 1903. Svo. 874 pages. Lea Brothers & Company, New York and Philadelphia.

Clinical Talks on Minor Surgery. By James G. Mumford, M. D. 1903. 16mo. 115 pages. The Old Corner Book Store, Boston.

Elements of Surgical Diagnosis. By A. Pearce Gould, M. S. Lond., F. R. C. S. Eng. Third edition, revised and enlarged. 1903. IGmo. 607 pages. W. T. Keener & Company, Chicago.

The Medical Epitome Series Normal Histology. A Manual for Students and Practitioners. By John R. Wathen, A. B., M. D. Series edited by V. C. Pedersen, A. M., M. D. Illustrated with one hundred and fourteen engravings. 1903. 12mo. 229 pages. Lea Brothers & Company, Philadelphia and New York.

The Right to Life of the Unlorn Child. A controversy between Professor Hector Treul, M. D., Reverend R. van Oppenraay, D. D., S. J., Professor Th. M. Vlaming, M. D., 1903. 12mo. 125 pages. Joseph F. Wagner, New York.

A Non-Surgical Treatise on Diseases of the Prostate Gland and Adnexa. By George Whitfield Overall, A. B., M. D. 1903. 12mo. 207 pages. Rowe Publishing Company, Chicago.

Philadelphia Hospital Reports. Volume 5, 1902. Edited by Herman B. Allyn. M. D. 1903. Svo. 178 pages. Philadelphia.

Transactions of the American Surgical Association. Volume the twenty-first. Edited by Richard H. Harte, M. D. 1903 Svo. 630 pages. Printed for the Association, Philadelphia.

Medical and Surgical Reports of the Boston City Hospital. Fourteenth Series. Edited by Herbert L. Burrell, M. D.. W. T. Councilman, M. D., and Charles F. Withington, M. D. 1903. Svo. 178 pages. Published by the Trustees, Boston.

A Text-Book of Practical Gynecology. For Practitioners and Students. By D. Tod Gilliam, M. D. Illustrated with 350 engravings, a colored frontispiece, and 7 full-page half-tone plates. 1903. Svo. 634 pages. P. A. Davis Company, Philadelphia.

Ar.VRCH, 1904.]

107

The Lymphatics. General Anatomy of the Lymphatics, by G. Delaniere. Special Study of the Lymphatics in Differont Parts of the Body, l)y P. Poirier and B. Cuneo. Authorized English edition, translated and edited by Cecil H. Leaf. With 117 illustrations and diagrams. 1904. Svo. 301 pages. W. T. Keener & Company, Chicago.

Atlas of the External Diseases of the Eye. Including a Brief Treatise on the Pathologj' and Treatment. By Prof. Dr. 0. Haab, of Zurich. Authorized translation from the German. Second edition, revised. Edited by G. E. de Schweinitz, A. M., M. D. With 98 colored lithographic illustrations on 48 plates. 1903. 12mo. 232 pages. W. B. Saunders & Company, Philadelphia, New York, London.

The Anatomy of the Human Peritoneum and Abdominal Cavity. Considered from the Standpoint of Development and Comparative Anatomy. By George S. Huntington, M. A., M. D. Illustrated with 300 full-page plates containing 582 figures, many in colors. 1903. 4to. 292 pages. Lea Brothers & Company, Philadelphia and New York.

Blood-Pressure in Stcrgery. An Experimental and Clinical Research. The Cartwright Prize Essay for 1903. By George W. Crile, A. M., M. D. 1903. Svo. 422 pages. J. B. Lippincott Company, Philadelphia and London.

A Pocket Book of Clinical Methods. By Charles H. Melland, M. D., Lond., M. R. C. P. 1903. 16mo. 88 pages. John Wright & Company, Bristol. Simpkin, Marshall. Hamilton, Kent & Company, Ltd., London.

The Practical Care of the Baby. By Theron Wendell Kilmer, M. D. With sixty-eight illustrations. 1903. 12mo. 158 pages. F. A. Davis Company, Philadelphia.

The Self-Cure of Consumption Without Medicine. With a Chapter on the Prevention of Consumption and Other Diseases. By Charles H. Stanley Davis, M. D., Ph. D. 1904. 12mo. 176 pages. E. B. Treat & Company, New York.

The Blues (Splanchnic Neurasthenia). Causes and Cure. By Albert Abrams, A.M., M. D. (Heidelberg), F. R. M. S. Illustrated. 1904. Svo. 140 pages. E. B. Treat & Company, New York.

Third Biennial Report of the Board of Control of State Institutions of loica. For the biennial period ending June 30, 1903. Svo. 1085 pages. Des Moines.

Practical Medicine Series of Year Books. Comprising Ten Volumes on the Year's Progress in Medicine and Surgery. Issued monthly, under the general editorial charge of Gustavus P Head, M. D. Volume III. The Eye, Ear, Nose and Throat. Edited by Casey A. Wood, C. M., M. D.. D. C. C. Albert H. An drews, M. D.. Gustavus P. Head, M. D. December, 1903. 12mo. 332 pages. The Year Book Publishers, Chicago.

Diseases of the Nervous System. A Text-Book for Students and Practitioners of Medicine. By H. Oppenheim, M. D. Translated and edited by Edward A. Mayer, A. M., M. D. Second American edition, revised and enlarged. With three hundred and forty-three illustrations. 1904. 8vo. 953 pages. J. B Lippincott Company, Philadelphia and London.

The Complete Medical Pocket-Formulary and Physician's VadeMecum. Containing upwards of 2500 prescriptions, collected from the practice of physicians and surgeons of experience, American and foreign, arranged for ready reference under an alphabetical list of diseases. By J. C. Wilson, A. M., M. D. Third revised edition. 1903. Svo. 268 pages. J. B. Lippincott Company.

International Clinics. A Quarterly of Illustrated Clinical Lectures and Especially Prepared Original Articles on Treatment,

Medicine, Surgery, Neurology, Pediatrics, Obstetrics, Gynecology, Orthopedics, Pathology, Dermatology, Ophthalmology, Otolo.gy, Rhinology, Laryngology, Hygiene, and Other Topics of Interest to Students and Practitioners. Edited by A. O. J. Kelly, M.D. Volume IV. Thirteenth Series, 1904. Svo. 321 pages. J. B. Lippincott Company, Philadelphia.

Clinical Pathology of the Blood. A Treatise on the General Principles and Special Applications of Hematology. By James Ewing, A. M., M. D. Second edition, revised and enlarged. Illustrated with forty-three engravings, and eighteen colored plates drawn by the author. 1903. Svo. 495 pages. Lea Brothers & Company, New York and Philadelphia.

Diseases of the Eye. By L. Webster Fox, A. M., M. D. With five colored plates and two hundred and ninety-six illustrations in the text. 1904. Svo. 584 pages. D. Appleton & Company, New York and London.

Social Diseases and Marriage. Social Prophylaxis. By Prince A. Morrow, A. M., M. D. 1904. Svo. 390 pages. Lea Brothers & Company, New York and Philadelphia.

The Treatment of Fractures. With Notes upon a Few Common Dislocations. By Charles Locke Scudder, M. D. Fourth edition, thoroughly revised, with 688 illustrations. 1903. Svo. 534 pages. W. B. Saunders & Company, Philadelphia, New York, London.

Lectures on Diseases of the Nervous System. Second Series. Subjective Sensations of Sight and Sound, Abiotrophy, and Other Lectures. By Sir William R. Gowers, M. D., F. R. C. P., F. R. S. 1904. Svo. 250 pages. P. Blackiston's Son and Company, Philadelphia.

Biographic Clinics. Volume II. The Origin of the III Health of George Eliot, George Henry Lewes, Wagner, Parkman, Jane Welch Carlyle, Spencer, Whittier, Margaret Fuller Ossoli, and Nietzsche. By George M. Gould, M. D. 1904. 12mo. 392 pages. P. Blakiston's Son & Company, Philadelphia.

The Practical Medicine Series of Year Books. Comprising Ten Volumes on the Year's Progress in Medicine and Surgery. Issued monthly, under the general editorial charge of Gustavus P. Head, M. D. Volume II. General Surgery. Edited by John B. Murphy, M. D. November, 1903. 12mo. 556 pages. The Year Book Publishers, Chicago.

The Physiognomy of Mental Diseases and Degeneracy. By James

Shaw. 1903. 12mo. S3 pages. John Wright & Company,

Bristol. Simpkon, Marshall, Hamilton, Kent & Co., Ltd., London.

A Text-Book of Legal Medicine and Toxicology. Edited by Frederick Peterson, M. D., and Walter S. Haines, M. D. Volume II. 1904. Svo. 825 pages. W. B. Saunders & Company, Philadelphia, New York, London.

A Handbook of Ophthalmic Science and Practice. By Henry E. Juler, F. R. C. S. With Illustrations. Third edition, revised and enlarged. 1904. Svo. 733 pages. Lea Brothers & Company, Philadelphia.

Infant-Feeding in its Relation to Health and Disease. By Louis

Fischer, M. D. Containing 54 illustrations, with 24 charts

and tables, mostly original. Third edition. 1903. Svo. 357 pages. F. A. Davis Company. Philadelphia.

The American Year-Book of Medicine and Surgery. Collected and arranged with critical editorial comments, by Samuel W. Abbott, M. D., Archibald Church, M. D., et al. Under the general editorial charge of George M. Gould, M. D. Volume I. Medicine. Volume II. Surgery. 1904. Svo. W. B. Saunders & Company, Philadelphia, New York, London.

108

[No. 15G.

THE JOHNS HOPKIISrS HOSPITAL REPOKTS.

Volume I. 433 pages, 99 plates.

Volume II. 570 pages, with 28 plates and figures.

Volume III. 7GG pages, with 69 plates and figures.

Volume IV. 504 pages, 33 charts and illustrations.

Report on Typliold Fever.

By William Osler, M. D., with additional papers by W. S. Thayer, M. D., and J. Hewetson, M. D.

Report In Neurology.

Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of the Submaxillary Gland of JMus musculus ; The Intrinsic Nerves of the Thyroid Gland of the Dog; The Nerve Elements of the Pituitary Gland. By Henet J. Berkley, H. D.

Report in Snrserj-.

The Results of Operations for the Cure of Cancer of the Breast, from June, 1889, lo January, 1894. By W. S. Halsted. M D.

Report in GyTiecology.

Hydrosalpinx, with a report of twenty-seven cases; Post-Operative Septic Peritonitis; Tuberculosis of the Endometrium. By T. S. Cdllen, M. B.

Report In Pathology.

Deciduoma Malignum. By J. Whitridqe Williams, M. D.

Volume V. 480 pages, with 33 charts and illustrations.

CONTENTS:

The Malarial Fevers of Baltimore. By W. S. Thayer, M. D., and J. Hewetson,

M. D. A Study of some Fatal Cas^ of Malaria. By Lewellys F. Barker, M. B.

Stuclies in Typlioiil Fever.

By William Osler, M. D., with additional papers by G. Blumer, M. D., Simon Fleiner, M. D., Walter Reed, M. D., and 11. C. Parsons, M, D.

Volume VI. 414 pages, with 79 plates and figures.

Report in Neurology.

Studies on the Lesions Produced by the Action of Certain Poisons on the Cortical Nerve Cell (Studies Nos. I to V). By Henry J. Berkley, M. D.

Introductory. — Uct-ent Literature on the Patliolofry of Diseases of the Brain by the Chromate of Silver Metiiods: Part I. — .\lcohol Poisoning. — Experimental Lesions produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. E.xperimental Lesions produced by Acute Alcoholic Poisoning (Ethyl Alcohol); Part II. — Serum Poisoning. — Experimental Lesions induced by the Action of the Dog's Serum on the Cortical Nerve Cell; Part III.— Ricin Poisoning.— Experimental Lesions induced by Acute Ricin Poisoning. 2. ExjKrimental Lesions induced by Chronic Ricin Poisoning: Part IV. — Hydrophobic Toxaemia. — Lesions of the Cortical Nerve Cell produced by the Toxine of Experimental Rabies: Part V. — Pathological Alterations in the Nuclei and Nucleoli of Nerve Cells from the Effects of Alcohol and Ricin Intoxication; Nerve Fibre Terminal Apparatus; Asthenic Bulbar Paralysis. By Henry J. Berkley, M. D.

Report In l*iitliolo^y.

Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Thomas S.

CnLLEN, M. B. Pregnancy in a Rudimentary Uterine Horn. Rupture, Death, Probable Migration of

Ovum and Spermatozoa.' By Thomas S. Cdi.len, M. B., and G. L. Wilkins, M. D. Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. Ciillen. M. B. A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By

William D. Booker, M. D. The Pathology of Toxalbumin Intoxications. By Simon Fleiner, U. D.

Volume Vlf. 537 pages with illustrations.

1. A Critical Review of Seventeen Hundred Cases of Abdominal Section from the standpoint of Intra-peritoncal Drainage. By J. 0. Clark, M. D.

II. The Etiology and Structure of true Vaginal Cysts. By James Ernest Stokes, M. D.

III. A Iteview of the Pathology of Superficial Burns, with a CJontribution to oui linowledge of the Pathological Changes in the Organs in cases of rapidly fatal burns. By Charles Russell Bardeen. M. D.

IV. The Origin, Growth and Fate of the Corpus Luteum. By J. G. (3lakk, M. D. V. The Results of Operations for the Cure of Inguinal Hernia. By Joseph 0.

Bloodoood, M. D.

Volume VIII. 552 pages with illustrations.

On the role of Insects, Arachnids, and MjTiapods as carriers in the spread of Bacterial and Parasitic Diseases of Man and Animals. By George H. F. Ndttall, M. D., Ph. D.

Studies in Typliold Fever.

By William Osler, M. D., with additional papers by J. M. T. Finney, M. D., S. Fleiner, M. D., I. P. Lyon, M. D., L. P. Hamburger. M, D., H. W. Cosbino, M D J F. Mitchell, M. D., C. N. B. Camac, M. D., N. B. Gwyn, M. D., Charles P. Emerson, M. D., H. H. Young, M. D., and W. S. Thayee, M. D.

Volume IX. 1060 pages, 66 plates and 210 other illustrations.

Contributions to the Science of Medicine.

Dedicated by his Pupils to William He-ney Welch, on the twenty-fifth anniversary of his Doctorate. This volume contains 38 separate papers.

Volume X. 516 pages, 12 plates and 25 charts.

structure of the Malarial Parasites. Plate I. By Jesse W. Lazear, M. D.

The Bacteriologv of Cystitis, Pyelitis and Pyelonephritis in Women, with a Consideration of the Accessory Etiological Factors in these Conditions and of the Various CHiemical and Microscopical Questions Involved. By Thomas K. beown, M. D.

Cases of Infection with Strong.vloidcs Intestinalis. (First Reported Occurrence in North America.) Plates U and HI. By Richard P. Strong, M. D.

On the Pathological Changes in Hodgliin's Disease with Especial Reference to its Relation to Tuberculosis. Plates IV-VU. By Dorothy M. Reed, M. D.

Diabetes Insipidus with a Report of Five Cases. By Thomas B. Futcher, M. B. (Tor.)

Observations on the Origin and Occurrence of Cells with Eosinophile Granulatiom In Normal and Pathological Tissues. Plate VUI. By W. T. Howabd, M. D.. and R. G. Perkins, M. D.

Placental Transmission with Report of a Case during Tj-phoid Fever. By Frank W. Lynch, M. D.

Metabolism in Albuminuria. By Chas. P. Emerson, A. B., M. D.

Regenerative Changes in the Liver after Acute Yellow Atropliy. Plates IX-XII. By W. G. MacCalluu, M. D.

Surgical Features of Typhoid Fever. By Thos. McCrae, M. B., M. R. C. P. (Lond.), and James F. Mitchell, M. D.

The Symptoms, Diagnosis and Surgical Treatment of Ureteral Calculus. By Benjamin R. Schenck, M. D.

Volume XI. 555 pages, with 38 charts and illustrations. Now ready.

Pneumothorax: A historical, clinical and experimental study. By Charles P.

Emerson, M. D. j t n

Clinical Observations on Blood Pressure. By Henry W. Cook, M. D., and John a.

BRiaas, M. D. The value of Tuberculin in Surgical Diagnosis. By Martin B. Tinker, M. D.

The set of eleven volumes will be sold for sixty dollars, net. Volumes I nnd 11 v. ill not be sold sepiirntely. \oIuiiies HI, fv V VI VII Vlll. \, «nd XI will be sold for five doUnrs, net, encli. Volume IX will be sold for ten dollars, net.

SEPARATE MONOGRAPHS RRPRINTnH FROM THE JOHNS

HOPKINS HOSPITAL REPORTS. Studies In DermntolOBy. By T. C. Gilcurlst, M p., and Emmft R.xford. M n 1 volume of 1(1 1 ,.ages an.l 41 full-page plates. Price, bound m paper, 3.1)0.

'flu. Malarial Fevers of Ualtimore. By W. S. Thayer, M. B »" ^ IlFwrisoN M D And A Study of some Fntul Cases of Malaria. RvI^'i.vsF Barker, M. B. i volume of 2S(> pages. Price, bound in paper. $2.76. , „

PntholoBV of Toxnlbumln Intoxications. By Simon Flexner. M. D. 1 volume" of l.W pages with 4 full-p.ige lithographs. Price, m paper, $2.00.

Studies In Typhoid Fever. 1. II. III. By William Osler, M. D, and others Extracted from Vols. IV, V and VIII of the Johns Hopkins Hospital Reports.' 1 volume of 881 pages. Price, bound in cloth, $5.00. Orders should be addressed to

The Johns HopUins Press, Baltimore, Md.

The Johm WopMns HoHpUal UulMiMH arc i„med mnnlMv. They arc prinled by the FHIKDKNWAhn CO., BaUimm-e. Single copies may he l'™^"'^ jj'"'" l)i« CUSiriNO CO. and the nALTIMOIlK NEWS CO.. Ballimnre. Suhscriplims. $-2.<«> a year, may he addressed to the vuhlMieis. BOPKINS PRKSS, BALTIMORE; tsingle copies will he sent hy mail fur twenty-flve cents each.

BULLETIN

OF

THE JOHNS HOPKINS HO

Entered u Second-Clasa Hatter at the Baltimore, Maryland, Postofflce.

Vol. XV —No. 1 57.]

BALTIMORE, APRIL, 1 904.

[Price, 25 Cents.

Contents - April

• Vaccine and Vaccination. By George Dock, M. D 109
• Concerning the Sinns Frontales in Man with Observations Upon Them in Some Other Mammalian Slinlls. By Adelbert Watts Lee, M. D., 115
• A Modified Nocht's Stain. By T. W. Hastings, M. D., . . . .122
• Complications Arising from Freeing the Ureters in the More Radical Operations for Carcinoma Cervicis Uteri, with Special Reference to Post-Operative Ureteral Necrosis. By John A. Sampson, M. D., 123
• The Silver Bolt as a Means of Fixing Ununited Fractures of Certain Long Bones. By Stephen H. Watts, M. D., 135
• Exhibition of Four Appendices Vermiformes Showing Unusual Pathological Conditions (from the Service of Dr. Kelly). By 0. F. BuRNAM, M. D. 136
• Notes on New Books, 141

Vaccine and Vaccination

By George Dock, M. D., Ann Arbor, Mich.

I intend to limit myself to a narrow part of the subject, and especially to the practical as distinguished from the scientific or theoretic side.

When we think of vaccination we must remember that if we are not wholly ignorant of the specific germs, we are still unable to make them serve as an index to the purity or qualitjof material, and we should also remember that we have no methods of dosage, such as make the application of diphtheria antitoxin and tuberculin fairly controllable. We recognize the effects of vaccine by the local results or by the immunity produced. For the former we have a more or less characteristic set of changes, ending in a peculiar and permanent scar. The immunity is not so easy to recognize in single cases, because we cannot tell how effective natural immunity might have been, and we rarely have more than the crudest notion of the degree of danger in a given case. When variolation was practiced the conditions were somewhat different, but with only casual exposure we are obliged to fall back, as proofs, on experiences with large numbers of people, where various de

' Read before the Johns Hopkins Hospital Medical Society, January 4, 1904.

grees of thoroughness of vaccination and various degrees of danger of infection can be considered as neutralized by force of niunbers.

The Material Used.

In the earliest days of vaccination the so-called lymph from vesicles on human beings was used. In Jenner's memorable experiment on James Phipps he used the virus from a cowpox vesicle on the hand of a dairy-maid, but later he inoculated from a vesicle on the nipple of a cow. After a few transfers this stock died out, as the former had done, but soon after the publication of Jenner's first work several new strains were obtained. Many of these were kept on by inoculating from arm to arm, or indirectly, and so were spread all over the world. It is interesting to remember that in America the virus was introduced by Waterhouse in Boston and Hosack in New York, the Southern States being early supplied by Waterhouse through the interest of President Jefferson. Some of the early vaccine was kept up for a long time. Drake tells us that he could see no change in course or phenomena in that used in the West in the forty-four years following its introduction in 1803. According to Kaposi, the

110

[No. 157.

material in the Vienna Vaccine Institute was descended from some sent by Jenner to De Carro in 1803, and retained its efficiency in the late SO's. But it did not always keep so well. L. PfeiSer mentions some that he saw a few years ago, of the same origin, so degenerated that it gave only a minimal areola and the scab dropped ofE on the 13th day.

Even in the first few years after Jenner's announcement the degeneration of virus was often observed, and the search for new cow-pox virus was made. It became more lively in the 20's, stimulated by the revival of small-pox in many countries, often affecting vaccinated persons. Partly from the incomplete protection thus shown, partly from the imperfect development of the vaccine lesions, it was believed that the material in use was not as potent as it had been in the beginning. But as a result of the lessened prevalence of smallpox, natural cow-pox was much less frequent than in Jenner's time. Eewards were offered in some countries for the discovery of cow-pox. Eetro-vaccination, or the inociilation of the cow with human virus, was used for the purpose of reviving the stock. About the same time, that is in the end of the first third of the nineteenth century, the value of revaccination became known, though it took many years to be fairly appreciated, and it is still ignored in some parts of the world.

Experiments for the production of cow-pox, by inoculating animals with small-pox virus, had been made by some in the early part of the century, and these were repeated, and in the hands of Ceeley and especially of Badcock, of Brighton, were successful. Badcock himself vaccinated over 13,000 persons with the virus, and furnished material to many physicians and apothecaries. It is an interesting fact that Dr. W. E. Coale, of Boston, " suspecting the efficiency of the virus then in use," obtained some of Badcoclr's material. In 18-52, Badcock sent him some " crusts from a variolated cow, a glass charged with the same material, and some points charged from a vesicle on a child's arm," caused by some of the primary lymph. Badcock sent Dr. Coale some more material in 1855, though this was not direct from the cow. Drs. Adams, of Waltham, and Putnam, of Boston, repeated Ceeley's experiments successfully, according to a letter by Dr. Coale, dated April 6, 1852, in the Boston Daily Advertiser. Other experiments made from the time of Badcock down to a recent period, by various investigators, have demonstrated the possibility of obtaining vaccine virus by variolating cows, and although the results were opposed by Chauveau and his colleagues, their scientific and economic value is now universally recognized, while the occasional propagation of small-pox by vaccination from such animals is explained by obvious errors in technic.

But the great bulk of material used for vaccinating, down to the 70's, was humanized virus, inoculated either from arm to arm or indirectly. In large cities it was not difficult to keep up the succession, though the chief localities for that, foundling asylums, had certain important disadvantages. In the country and in small towns the supply often failed, or gave poor results. The methods used for keeping and inocu

lating vaccine in this period, other than by operating from arm to arm, are of some interest.

One of the earliest methods of preservation was by drying the lymph, obtained by pimcturing a vesicle, on a piece of glass. This was tied together with another glass and the two kept dry until wanted. Another was to soak threads in the virus, dry them and keep them in bottles. Or the virus was dried on elongated glass stoppers and the stoppers fixed in bottles, or it was dried on lancets, quills, or even thorns. On account of the rusting of steel instruments, with damage to the latter if not to the virus, silver or gilt lancets were used. Needles were used sometimes, and a Dr. Carl, in Prague, invented a forked silver needle. Small glass tubes,, such as barometer tubes, were also used, sealed at the ends by fusing. The use of crusts or scabs came comparatively late.

The Eahly Technic.

There were many modifications of the method of inoculating, though the details were for the most part derived from the earlier small-pox inoculations. Jenner first used short incisions, or punctures. When threads were used, they werecut in short lengths, placed in shallow incisions, and kept there by adhesive plaster. From the fact that some operators renewed the threads on the third day we may assume that the method was not always successfid. Sometimes the dried material, on threads, glass or instruments, was softened by soaking in blood, or by exposing to the vapor of boiling water, or soaking in water, or even saliva. More complicated methods of getting an inoculating surface were sometimes followed. Cross-scratching seems to have been a later invention. Fly-blisters were used at an early period, even a skin-trepan was invented, and as late as 1902 a cautery-hammer was devised, for raising a blister, in the cavity of which vaccine was to be inoculated. At various times since the invention of the hj-podermic syringe, that instrument has been used for injecting vaccine virus into the skin or subcutaneous tissue. Although it seems to serve the purpose, it has no great advantage, and some disadvantages.

One of the common details of vaccinating developed from the use of humanized virus, viz., the practice of making multiple lesions. It was thought that the taking of part of the lymph lessened the effect on the vaccinifer, and so several vesicles were produced, one at least being untouched. Although the protection afforded by one good vesicle has always been recognized, there is some reason for believing that protection is in proportion to the area of typical scar.

Bovine Vieus.

The growing realization of the inconveniences of humanized virus gradually led to the development of another method, but there were other reasons besides the technical ones. In the 60's the fear of transmitting syphilis by vaccination became intensified, and although investigation showed that the risk was slight, considering the large number of people vaccinated, it also proved that the danger was real.

April, 1904.]

Ill

The possibility of transmitting tuberculosis was also suggested by the work of Villemin, and was for a time much exaggerated. So attention was directed more and more to the use of bovine virus, that is, material raised purposely on the animal. In this way it was thought that the danger of setting up syphilis and tuberculosis could be avoided, and although the fear of transmitting inflammatory diseases was not absent, it did not retard the movement. In fact, then as now, there were some who thought that severe local reactions were desirable.

The use of bovine vaccine goes back directly to Negri, who cultivated virus on animals, in Naples, from 1843. It is said that the same method was begun in Naples early in the century, but prohibited by law. Negri's method and material were introduced in Paris in 1864, by Lanoix, who, however, adopted cow-pox virus from the celebrated spontaneous case discovered at Beaugency, France, in 1866. The method spread rapidly. It was introduced in Brussels in 1865, by Warlomont. and in Berlin, in the same year, by Pissin, and soon afterwards in Vienna. In 1870, Dr. Henry A. Martin, of Boston, an indefatigable investigator and cultivator of vaccine, imported some of the Paris material, just before the strain died out during the siege. For some time after bovine virus came into use, the method of preservation was chiefly that of coating ivory slips with virus obtained by puncturing vesicles, the bases of which were compressed by forceps. Scabs were also used. On the continent of Europe a popular method consisted in vaccinating directly from the calf, the animal being taken to the domicile or to a central location, as was most convenient.

The Use of Pulp.

At first the material used was the liquid part of the contents of the vesicle, as was necessarily the case in using human virus before the scab stage, but in the 80's the so-called pulp came into use. The reason for the change was complex, and had reference partly to the greater tenacity of the liquid part of the bovine vesicle as compared with that of the human one, and its greater tendency to coagulate. The pulp is the whole vesicle, made up of the cells of the skin in the lesion, leucocytes, red-blood corpuscles, fibrin, fat, specific and nonspecific micro-organisms, and debris. Many objections have been made to the use of pulp vaccine, and from time to time tliese are brought forward in articles, but the arguments advanced are misleading, to say the least. Thus, it is said that pulp contains more pus and more bacteria than the liquid part obtained either by puncture of the vesicle or by tearing off the top of the vesicle and permitting liquid to exude from the base. But at the time the pulp is taken there is no pus in the ordinary sense, and it has never been demonstrated that the whole pulp contains more bacteria, bulk for bulk, than does the liquid part. Careful observations are needed in this connection, biit at the present time it should be borne in mind that the best vaccine in every respect, that is, the virus that causes least accidental infections and gives the best protec

tion, is pulp vaccine. By this I mean the virus used over most of Western Europe and in England, and notably in Germany, where the statistics on all the points concerned arc most complete.

Many methods of treating the pulp have been experimented with. It is not necessary for my purpose to discuss these, and I shall consider only the method now almost universally used, describing it in some detail from the beginning.

Calves are used, generally from 3 to 6 months old, sometimes younger or older. Females are usually preferred on account of the greater cleanliness of bedding, though some operators use young bulls, which they inoculate on the scrotum. The animals are examined with reference to soundness, and are sometimes tested with tuberculin, though this is not necessary, as they are usually killed soon after the operation and can then be examined for disease, before the vaccine is distributed. After being under observation a few days the calves are thoroughly cleaned. Just before the operation, the animal selected having been fastened on a suitable table, the abdomen is shaved and washed with soap and warm water. In some institutions sublimate, carbolic acid or other antiseptic is used. A final washing is done with large quantities of sterlized water and the skin dried with sterilized towels. The operators,- in sterilized clothing, observe the usual aseptic precautions. A series of incisions is made in the skin of the abdomen, about an inch apart, extending as far forwards as the navel and laterally to the inner sides of the thighs. Sometimes the anterior abdomen, and even the side and back of the body have been used, but the thicker skin in these parts interferes with the best results. If more than slight bleeding follows the incisions it is checked by pressure with sterilized towels. The " seed " vaccine is then spread over the prepared surface with a spatula and allowed to dry. The seed is of various kinds. Sometimes it is bovine virus, selected with care from well-developed vesicles and of tested bacterial purity. Sometimes it is selected humanized vaccine, sometimes material derived more or less remotely from human variola. Often the makers either do not know, or are unwilling to state, the source and nature of the seed, and often misrepresentation has occurred. It is clear that in order to make an accurate study of the effects of vaccination the history of the material used is essential. .

Dressings of various kinds have been used to protect the site of operation, but usually they are not considered necessary. The animals are kept in clean stalls, and carefully observed until the time for removal of the material, between the fourth and sixth days. The vesicles are then of fairly good size, but should not show evidences of suppuration. The calf is again fastened on the table, the abdomen thoroughly scrubbed with soap and warm water, rubbed by hand, and finally washed with sterilized water and dried. This removes the superficial dried epidermic scabs, and does not break the vesicles. For the removal of the pulp the common method is lo scrape each row of vesicles with a large curette, though it is said that some still use the forceps to clamp the bases. The

112

[No. 157.

pulp is then made homogeneous by grinding, mixed with 50 per cent glycerine, and kept for several weeks to " ripen."

Up to the early 80's pulp was used according to the earlier methods, but after that great activity was displayed in treating pulp with various antiseptics, the details reminding one of the complicated antiseptic dressings used in general surgery at the same period, but since 1891 the use of glycerinated lymph has been general. The addition of glycerine to vaccine virus is much older. Cheyne employed it as early as 1850 to keep lymph fluid; Mueller in 1866 to increase the bulk; Warlomont patented a method in 1883, and there are dozens of references to its use before him. But Copeman, by a series of careful investigations, showed that glycerinated pulp lost some of the bacteria it originally contained, and that they might even disappear completely at a time when the specific virus was still unimpaired in strength, and since then the method has been adopted by the leading vaccine institutions with little or no modification. Drying the pulp or lymph has a similar action on the bacteria, but glycerine has other advantages, one of the most important being the facility with which tests can be made on the glycerinated pulp, rendered fairly imiform by mixing in special apparatus.

The tenacity of life of the specific germs has long been known to vary much, even under conditions apparently similar. In the glycerine preparations this is also true, but the real state is easy to fix by experiment in any specimen. It has been shown that glycerinated vaccine may be effective as long as a year after removal. Though the usual dilution is slight, from half to several times the weight of pulp being added in 50 per cent sterilized glycerine, dilutions of 1 to 2000 will give good results if carefully used. By the present method one calf will furnish from several hundred to several thousand portions of vaccine, three to four thousand being not unusual, and perfect vaccination has been obtained from calves giving as much as 15,000 portions.

Copeman has summarized the advantages of glycerinated vaccine, and I quote from him the following :

" 1. Great increase in quantity can be obtained without any consequent deterioration in quality, the percentage of insertion success following on its use being equal to that obtained with perfectly active fresh lymph.

" 2. It does not dry up rapidly, as does unglycerinated lymph, thus simplifying the process of vaccination.

" 3. It does not coagulate, so that it never becomes necessary to discard a tube on this account.

" 4. It can be produced absolutely free from the various streptococci and staphylococci which are usually to be found in untreated calf lymph, and which are, under certain circumstances, liable to occasion suppuration.

" 5. The streptococcus of erysipelas is rapidly killed out by the germicidal action of the glycerine. The danger of ' late ' erysipelas is diminished by reason of there being no necessity to open the mature vesicle for the purpose of obtaining lymph.

" 6. The bacteriological purity and clinical activity of large quantities of the lymph can be readily tested prior to distribution."

But no one who knows the subject claims perfection for glycerinated virus. Many efforts to improve on it have been made, by using other germicides, and many more will doubtless be made, until something still more satisfactory can bi; discovered. In the meantime it is necessary for all who have to use vaccine to know just what can be expected with the present methods.

The Vaccine Lesions.

Let us now examine some of the peculiarities of the vaccine lesions. From the beginning it has been recognized that the vaccine pock presents peculiarities by which it can be distinguished from all other skin lesions, and especially from smallpox, varioloid and chicken-pox; and by which one can form some opinion as to the quality of the change produced in the organism by vaccination. In his first publication, Jenner gave some pictures that have always been accepted as of the greatest value. All of Jenner's contemporaries admitted the fidelity of the illustrations, and Cuff, who colored them, and who made others for later writers, insisted on their accuracy after he had seen many hundreds of lesions. I show lantern slides of these plates, viz. : The original cow-pox vesicle on the hand of Sarah Nelmes; a vesicle, the second remove from horsepox ; a vesicle in a late stage, the second remov