Two aspects of this educational work must be given consideration. The physician coming to the Congress, if he will profit through his attendance, should be aware of the advantages offered him, and approach them with a seriousness of intention. He should have some idea of the especial advantages offered by each Congress, of the men and their work, and of the things he needs most, or cares most to acquire. His program should be studied in advance. He should not attend under the incentive of curiosity alone, but with a realization of the opportunities offered him, and with the intent to secure satisfaction of any questions he may have in his mind bearing upon the especial lines of work represented by the men appearing in that Congress. Individual contact with these men may open up unsuspected capabilities of creative thought within his own mind, and clear many a doubtful horizon of vague speculation. On the other hand, the men who appear before a Congress have a very manifest duty of appearing at their best. Their talks and demonstrations should be carefully prepared and given in a clear and concise manner. They are also on inspection and trial and should have a keen conception of the didactic importance of their presentations. No slipshod, careless work should be given, but the importance of the occasion should be fully realized, and the best possible preparation made to rise to it.

Of great importance, also, is the purely social side of the Congress. Nevertheless, it is not its chief function. Nothing can be better for the cause of medicine, than the meeting and social intercourse of physicians representing the best class of the profession from all parts of the country; but this may be carried out with too little profit if it is regarded too superficially. What is needed is a real contact and exchange of ideas, and this can rarely be carried out in the environment of a large banquet or smoker at which formal entertainment is at the same time presented. Physicians should go to the Congress, not as boys let out of school, but as men going to a post-graduate university course. This does not mean that the purely recreational side of the Congress should be neglected. Every large city offers advantages in the form of art galleries, theaters and concerts that may not be available to the physician from a smaller town. The Congress should give time for its members to utilize these recreational and educational opportunities. But, after all, one of the best things of the social side of the Congress is the opportunity offered for mutual interchange of thought, through the association with single individuals or with small groups, in quiet conversation at luncheon or dinner, or in the backwaters of hotel corridors, outside of the main currents of the Congress; under such conditions of a more quiet intimacy a real acquaintanceship is often first begun.

The Effect of Experimental Exclusion of the Liver on the Formation of Bile Pigment. J. W. M'Nee and B. Prusik have made a further contribution to the study of hemolytic icterus in the Journal of Pathology and Bacteriology, Vol. XXVII, 1924, p. 95. Positive statements in regard to the conversion of haemoglobin into bile-pigment within the blood-stream, and of the occurrence of a true hemolytic icterus are the rule in the text-books and medical journals of the day, yet an examination of the literature of the experimental research along this line reveals an astonishing, almost shocking, paucity of actual experimentation and control. That positive declarations should be based on such inadequate evidence is rather a sad commentary on supposed scientific medicine. After all, the experiments upon which the present knowledge of this question is based are those of Minkowski and Naunyn (1886), M'Nee (1913), Whipple and Hooper (1913) and Rich (1923). The assumption of a hematogenous jaundice has been chiefly based upon the experiments of Minkowski and Naunyn upon geese. Although it was carried out in 1886, no control of their work was ever attempted until the experiments of M'Nee in 1913. He obtained results that at first sight seemed similar to those of Minkowski and Naunyn, but were interpreted in an entirely different way, the functional activity of the reticuloendothelial system in its relationship to blood-destruction and bile pigment formation being emphasized. The work of Whipple and Hooper in the same year, consisted in the introduction of free hemoglobin into the circulation of dogs, from which the liver had been excluded through the production of a "head and thorax circulation." In 4 experiments they found that bile-pigment appeared in the serum of 3 dogs, but was

absent in that of the fourth. From these three positive experiments the claim was made that in higher animals, such as the dog, the liver was not essential for the rapid change of hemoglobin into bile-pigment within the circulation, and that an actual and visible icterus could occur in animals in which there was exclusion of the liver. Although based upon only three positive results, and without any control by other workers, Whipple and Hooper's conclusions have been almost as widely accepted as those of Minkowski and Naunyn. Not until 1923 was this line of experimentation again taken up, in the work of Rich who examined critically the work of Whipple and Hooper. He criticized the "head and thorax circulation" method on the ground that the possibility of some circulation through the liver was not wholly excluded. He, therefore, adopted a method by which the liver, stomach and intestines, spleen, kidneys and pancreas were completely removed, the space being filled with warm towels. With this technique dogs could be kept with active circulation in the head and thorax for some time. Laked red cells were introduced into the circulation, and in 8 experiments no trace of bilirubin could be found in the serum by either the van den Bergh or Huppert tests. Seven experiments lasted from one hour up to two hours and ten minutes, the eighth for five hours and twenty minutes. These results being in flat contradiction of the results obtained by Whipple and Hooper, Rich then tested the validity of their technique as a method of excluding the liver. By carrying out the operation as described by them, and then injecting India ink into the external jugular vein or aorta, Rich showed that the ink readily found its way into the liver through vessels in the diaphragm which enter the

Rich

liver along the wall of the inferior vena cava. Other experiments confirmed the fact that the liver in the experiments of Whipple and Hooper may have both an open arterial and venous circulation. then tried another method, ligating the inferior vena cava below the diaphragm, and also the portal vein and hepatic artery. By this method he states that no blood gets to the liver as shown by negative controls with India ink. In 5 experiments of this kind lasting from one and one-half hours up to three hours and twenty minutes not a trace of transformation of hemoglobin into bile-pigment could be demonstrated after the introduction into the circulation of laked red cells. Rich, therefore, concluded that the methods of Whipple and Hooper were faulty in technique, and that there is no evidence that hemoglobin is rapidly changed into bilirubin within the bloodstream of dogs after complete exclusion of the liver from the circulation. In the present article, M'Nee and Prusik carried out two sets of experiments on dogs, one set with the "heart-lung" preparation, and another with the "head and thorax" circulation used by Whipple and Hooper, but with the inferior vena cava tied above the diaphragm. The van den Bergh and the Huppert tests for bilirubin were both employed, as well as the method of examining the subcutaneous fat for bilirubin employed by Whipple and Hooper. Fifteen experiments were carried out in which hemoglobin was introduced into the dog's circulation with the liver excluded; the heart-lung circulation of Starling was used in 6 cases, and in 9 others the "head-thorax" circulation of Whipple and Hooper. In 13 experiments no trace of bile-pigment could be

found in the blood-serum. These included all of the "heart-lung" preparations, and 7 of the 9 "head and thorax circulation" experiments. In 2 "head and thorax" experiments a small amount of bilirubin was found. In one of these horse-hemoglobin had been injected, and in the other hemoglobin laked from the blood corpuscles of the animal itself. In a control experiment the liver was left intact and bile collected from a gall-bladder fistula after the introduction of hemoglobin into the circulation. No bilirubin appeared in the serum, but the change in color of the gall-bladder bile pointed strongly to the excretory activity of some part of the liver, either the Kupffer cells, glandular cells, or both. In this experiment the spleen was also left to function. Another control experiment to bring about an obstructive jaundice by ligation of the main bile-ducts showed that bilirubin was absent from the serum at one hour, but was easily recognizable two hours after the operation. This experiment also showed, in contradiction of Whipple and Hooper's results, that not a trace of visible icterus may be found in the subcutaneous fat of a dog, even when there is a considerable amount of bile circulating in the blood. The conclusion drawn from M'Nee's and Prusik's experiments is that hemoglobin is not rapidly changed into bile-pigment within the circulation when the liver has been excluded, and a "head-thorax" circulation only maintained. This supports the results obtained by Rich and contradicts the view of Whipple and Hooper. The site of origin of the bile-pigment in hemolytic icterus remains, therefore, undetermined at the present time.

Modern Methods of Treatment. By LOGAN CLENDENING, M.D., Assistant Professor of Medicine, Lecturer on Therapeutics, Medical Department of the University of Kansas; Attending Physician, Kansas City General Hospital; Physician to St. Luke's Hospital; Physician to St. Mary's Hospital, Kansas City, Missouri. With chapters on special subjects by H. C. Anderson, M.D.; J. B. Cowherd, M.D.; Carl O. Rickter, M.G.; F. C. Neff, M.D.; E. H. Skinner, M.D.; and E. R. DeWeese, M.D. 689 pp. and 79 illustrations. St. Louis, Missouri. C. V. Mosby Co., 1924. Price, cloth, $9.00.

The author states in his preface that the object of his book is to present a comprehensive statement of the best modern thought and practice upon the treatment of diseases included in the general specialty of internal medicine. As a teacher of therapeutics for several years he has been unable to find any text-book on therapeutics that he would recommend to his students. His criticisms of the available books are that they are either badly balanced, include too much, are not sufficiently detailed, do not represent modern thought and methods, are written in atrocious English in a deadly boring style, and are not sufficiently unified. These imperfections he has striven to avoid. To what extent he has achieved this will depend largely upon the reader's predilec

tions and taste. To some it will appear snappy and practical, to others too much in content and style resembling the abstracts of current literature in the Journal of the American Medical Association. But as this is just what a large number of medical students desire, the book will be valuable to such in satisfying their needs for therapeutic dicta and dogma. To the reviewer it seems to be a glorified quiz-compend on therapeutics, as this branch of medicine has stood during the last ten years. It is, however, a vast improvement over any of the older short works on therapeutics, and many of its condensations will be of value to the student who has passed through a scientific course of pharmacology and therapeutics, and wishes to assort and arrange his knowledge in a categorical form. The book consists of two parts: I, on general therapeutics and the methods used in treatment; and II, on special therapeutics and the application of therapeutics to particular diseases. The subject matter is extensive. Many of the conditions mentioned are given very inadequate characterization, but this is, of course, inevitable in a condensed work of this kind. Typographical errors or inaccuracies in spelling and in Latin, and grammatical peculiarities can be found without much searching, and a more careful proofreading would have caught some of these.