men's work, lead me to hold emphatic views on these questions. As to the case of sarcoma, would say that in several cases I have removed sarcomatous ovaries resulting in cure without recurrence. DR. GILES S. MITCHELL: Dr. Withrow is certainly to be congratulated upon the brilliant success obtained in the thirty-five cases reported. He is the only gynecological surgeon in Cin. cinnati, so far as my knowledge goes, who has made thirty-five consecutive laparotomies without a death. Such a record is strong testimony to the thorough asepsis and skill of the surgeon. I assisted at several of the operations, two of which were difficult in the extreme. The case of sarcoma operated upon at the Presbyterian Hospital was a most difficult and unpromising case. The patient came near dying on the table, but normal salt solution and subcutaneous injections of strychnia tided her over. She made a rapid recovery, but died some months subsequently from a return of the disease. DR. RUFUS B. HALL: I think Dr. Withrow has had a very fortunate experience, and is to be congratulated upon his results. In listening to the report of his cases there was one thing that impressed me forcibly. It is in such striking contrast to my own every-day work. In the thirty-five cases reported he mentions but one pus case. I do not see how a man in this work could be so fortunate. Taking all the cases passing through my hands during the past five years, I believe more than 20 per cent. have been pus cases. This, I am sure, is a low estimate. I would not be surprised, if I were to tabulate the cases, I would find more than 30 per cent. were pus cases. More than 30 per cent. of fibroid tumors operated upon in the past five years years have had pus on one or both sides. I have operated upon a large number of patients who have been confined to bed for from three to five weeks, and more than half of them had pus. To-day I operated upon a patient who had been confined to bed for eight weeks, with an obscure pelvic tumor the size of a cocoanut. The tumor was a suppurating ovary infected from a pyosalpinx, and held one and a half or two pints of pus with as offensive an odor as that from an ischio-rectal abscess. Such facts as these make me think the doctor has been a fortunate man to have such a series. As to the cure of hystero-epilepsy by removal of the ovaries, I am by no means convinced. I have watched with interest some six cases that have been operated upon, but improvement was more apparent than real. My own personal experience is limited to one case. This patient developed epilepsy with her first menstrual period, and continued to have seizures every month, and sometimes oftener, extending over a period of six years, until she was operated upon. Both ovaries were cirrhotic. For two months following the operation she was free from any convulsive manifestation, and her relatives were ready to believe that she was cured. However, this was but the prelude to the storm. The convulsive seizures returned, were none the less violent, and were much more frequent. In addition, she suffered intensely from abdominal pains almost constantly. An intercurrent affection terminated her life two years subsequent to the operation is commenced, the operation can ation-a sufficient length of time to convince me that the operation had been of no service. In the twelfth case reported, the operation not completed but the cyst stitched to the abdominal wall, I do not agree with the gentleman who discussed that phase of the subject. He says that is the best method to pursue. In my opinion it is bad surgery to leave a part of the cyst. There is eventually more danger to the patient to do so than there is in removing it completely. We all realize that an operation for the removal of an intra-ligamentous cyst is not an easy one. If the ovarian artery is tied at the pelvic brim and at the uterine side of the tumor before enucle be done without much loss of blood. The risk to the patient would be nothing like as great as that of septic infec One has passed two years since the operation without an attack, the other is too recent to comment upon. tion following long-continued suppu- | dages. My two cases both had marked ration, which does ensue in a large trophic changes in the ovaries. percentage of the cases that are tapped and drained. Besides, many of them are not cured when a portion of the cyst remains, and must have, at a later date, a second operation for the dissection out of the remaining cyst wall. This is a good deal more dangerous and difficult, after the long process of suppuration, than it would have been at the primary operation. No operation for abdominal tumor should be left incomplete except for malignant disease. I hardly know what to say or where I stand in regard to ovariotomy in hystero-epilepsy. The practice I have always followed in these cases is to advise against operation unless I can detect palpable disease of the ovaries. If I find organic disease, and the attacks are distinctly associated with the menstrual epoch, there is a prospect of relief. I have operated on a number who have remained permanently well, but the large percentage of the most carefully selected cases have not remained well except for a time. In a year or two after operation the convulsions returned, and were just as violent and as frequent as ever. This brings up the question of differentiation between which should and which should not be operated, with the hope of cure. I must confess that I am unable to do it, and that is the reason I have always adhered to my plan of advising no operation unless I can detect organic disease; in other words, disease that would justify operation if the patient did not have epilepsy. DR. C. A. L. REED: Dr. Withrow certainly deserves our congratulations upon such a successful list of cases. Such success in these days is certainly most encouraging. A striking part of the report to me was that portion related to hysteroepilepsy. I believe this is a most important step in abdominal surgery-the relief of these cases-but there should not be an indiscriminate performance of the operation; but it is best in those cases where there is a manifestation in relation to the uterus and its appen I had not noticed before, but Dr. Hall's remarks has called my attention to so few pus-tube cases in the series, which we can attribute to chance. I recall in my own experience recently that in a series of twenty cases fourteen had pus in the abdominal cavity. In reference to the antiseptic arrangement so vigorously carried out by the essayist, it is a fact upon which this success depends, yet there appears to me to be a great deal of superfluity unless such was intended for discipline. The white garments and baker's cap I hardly think necessary to remove a few stitches. DR. WITHROW: In regard to the cases of hystero-epilepsy, there were two, but no disease of the ovaries and none suspected. The attacks were closely confined to the menstrual period, none between. One of the cases has been free from attacks since the operation, which will be two years in June; in the other so short a time has elapsed that it cannot be considered. Respecting the frequency of pus cases, it was about 7 per cent. There is another thing to be considered, and that is the class of cases that come to the Presbyterian and Christ Hospitals, which are not of the same character that go to the City Hospital. It may be said that my colleague has had more pus cases than I have. Upon the subject of asepsis and antisepsis, several of the details were for discipline, for developing the aseptic conscience of the nurses, and I believe if you instruct your assistants in these details and have them thoroughly carried out it will be to the interest of your case. While I do not always wear the cap when simply making after-dressings or in the removal of stitches, yet if I thought it would improve the chances of the case I should most certainly do so in every instance. It would be far better to take a score of unimportant aseptic precautions than to omit a single necessary detail. Translations. NEW PREPARATIONS OF TUBERCULIN.' BY ROBERT KOCH, BERLIN. Ever since my first publications on tuberculin I have been uninterruptedly occupied with studies of the use of cultures of tubercle bacilli in the treatment of tuberculosis, and have come now so far to a conclusion as to justify the publication of the results. The product of each year's work may seem simple and in many regards quite self-evident. But anyone who has occupied himself in the study of tuberculosis will appreciate how extraordinarily laborious and tedious such studies are, and what exhausting demands they make upon the time and patience. I take this first occasion, therefore, to express my thanks to Dr. M. Beck, who has assisted me faithfully and unweariedly in my work. The use of bacteria and their products in treatment and prophylaxis depends always upon a kind of immunization, and I consider it proper, therefore, to define my position in reference to these questions to avoid any future misunderstandings. TWO KINDS OF IMMUNITY. This question of immunity against the infectious diseases was originally regarded as something simple and indivisible, but the opinion has gradually gained ground that immunity may be simple, but it need not be so necessarily; that it is composed of two elements, perhaps even of more. I may illustrate this view best by a few examples. IMMUNITY TO TOXINEs. Behring and Kitasato succeeded in demonstrating that animals could be immunized against tetanus. They used I Deutsche medicinische Wochenschrift, April 1, 1897. The translation has been made as literal as possible to get the exact meaning of the author. The translator is responsible for the headlines, which have been inserted for convenience of reference. for this purpose filtered culture fluids, i.e., the products of tetanus bacilli soluble in water, one of which represented the specific tetanus poison. The immunized animals were protected against this poison, and even against very large doses of it, but only for a certain time. The immunization had no influence upon the tetanus bacteria themselves, as they continued to vegetate in the immunized body without hindrance, in so far as opportunity was offered to them in their necessarily anaërobiotic growth. We have thus to deal here with the simple and pure immunity to a poison, so that when this artificial immunity had disappeared in the course of a few weeks the tetanus poison continuously produced by the tetanus bacilli in the immunized body was no longer rendered innocuous, and the animal succumbed to tetanus without having been infected anew with tetanus bacilli. IMMUNITY TO BACTERIA. Now we find the very opposite condition in cholera and typhold fever. The investigations of Pfeiffer proved of these diseases that the animals immunized with fresh agar cultures are protected absolutely against the living bacteria, but not against the poison which they produce. For the living bacteria of cholera and typhoid fever perish in a surprisingly short time in the bodies of immunized animals, but no one has ever succeeded in immunizing these animals against a certain dose of the poison. In this case the immunity is a pure bacterial immunity, i.e., an immunity directed exclusively to the bacteria themselves. THE IDEAL IMMUNITY. The ideal immunization will always be that which will protect the animal, i.e., the human body, not only against one of the injurious agents, but against all of the injurious agents produced by pathogenic microorganisms. These considerations play a great rôle in tuberculosis. IMMUNITY TO TUBERCULOSIS. It would appear, in the first place, as for if there could be no immunity against | tuberculosis, because the disease lasts years in man without any diminution in the susceptibility. Even the cure of a case, where a cure has occurred, does not render the individual immune against a new invasion of tubercle bacilli; on the contrary, as experience shows, this individual is rather more susceptible to a fresh tuberculous invasion. And yet there are intimations which speak for the fact that under certain conditions there is a kind of immunization to tuberculosis. I find such intimations, for instance, in the observations which have been made in the miliary tuberculosis of man and in the experimental tuberculosis of the guinea-pig. There sets in, as a rule, a stage in these cases in which the tubercle bacilli, which were present at first in large number, disappear so completely as to necessitate a careful search to detect even relics of them. This is a very remarkable fact, as we shall see later that tubercle bacilli experimentally introduced into the body are absorbed exceedingly slowly. It would seem in the cases mentioned as if we had to deal with the process of immunization which was purely bacterial. Unfortunately, this protection comes too late for the organism to be of any value to it. But these observations have furnished a stimulus to me from the start to search without ceasing for some process which might introduce this immunity at a stage of tuberculosis early enough to be of use. The two processes mentioned have one thing in common, that the body in a short time is inundated with tubercle bacilli, and this circumstance seems to me to show that tuberculosis does not bring with it under ordinary conditions any distinct immunity. For it is usually the case that tubercle bacilli grow only very slowly in the tissues of the human body, and increase but slightly in numbers. They are found for the most part surrounded by necrotic tissue, and it is only after a long time, after they will have perished themselves and have probably become subjected to profound chemical alterations, that they may be absorbed. Where tubercle bacilli exuberate in great numbers, e.g., in cavities and on the surface of mucous membranes, they are not absorbed but are cast off unchanged. Under such circumstances there can be no immunization, which may only occur when numerous bacilli are rapidly disseminated over the whole body and come into quick contact with living tissue, as in the case of miliary tuberculosis and the tuberculosis of guinea-pigs. DIFFICULT ABSORPTION OF TUBERCLE BACILLI. To bring about an artificial immunity it will be necessary, then, to imitate these conditions as nearly as possible. In the attempt to do this we encounter at once almost insuperable difficulties. All the attempts which I made to secure the absorption of unchanged living or even dead tubercle bacilli in any number by the subcutaneous tissue, by the peritoneal cavity, or by the circulation, failed; and many observers have failed in the same way. When dead tubercle bacilli are injected subcutaneously they regularly produce suppuration, and they may be demonstrated and thoroughly stained in great numbers in the abscesses thus produced for many months. They are somewhat better absorbed when introduced into the peritoneal cavity of animals, and I have succeeded in securing a distinct immunity in this way, but with such circumscribed inflammations, adhesions, agglutinations of the abdominal organs, such occlusion of the intestine, as to sacrifice a large per cent. of the animals. Dead bacilli introduced into the circulation of animals, e.g., rabbits, produce in the lungs exactly the same tuberculous nodules as the living ones do, and in these nodules we may for a very long time demonstrate the unchanged tubercle bacilli. This absorption did not take place here in any desirable way. As it was thus proven that tubercle bacilli in unchanged state could not be used for purposes of immunization, I turned my attention to try to make them absorbable by some chemical attack. The only method which seemed to furnish anything in this direction consisted in the treatment of the tubercle bacilli with dilute mineral acids, or with | groundless. My own individual exstrong alkalies under boiling heat. In perience in the use of tuberculin in this way we may succeed in so changing the early diagnosis of tuberculosis in tubercle bacilli that they will be ab- man, in more than 1,000 cases, coincides sorbed slowly, it is true, but absolutely with and supports this view. Stabsin toto-in great numbers by the subcu- arzt Dr. Nietner will report in detail taneous tissue. But there is no sign of upon these cases. In all these cases immunity achieved in this way, and we there was never the slightest intimation have to believe that this chemical attack of anything like any mobilization or has produced a change so profound in transmission of tubercle bacilli. This the substance of the bacilli as to destroy experience should entirely annul the their immunizing properties. foolish prejudice which exists regarding the making mobile of tubercle bacilli, and it should put the diagnostic value of tuberculin, in the recognition of tuberculosis in man, upon the same plane as in animals. I repeat here what I said before, that in the combat of tuberculosis the prophylaxis is infi nitely more important and more advantageous than all therapy. Thus as nothing was to be accomplished in this way I turned my attention towards the extraction of absorbable constituents from a mass of tubercle bacilli, and to use them for purposes of immunization. THE DISCOVERY OF TUBERCULIN AND Here I experimented first with glycerine extraction, which led to the discovery of tuberculin. Tuberculin has the extremely valuable property that, introduced subcutaneously in very small quantity, it produces a characteristic reaction in animals and man affected with tuberculosis. This property may be utilized in the recognition of tuberculosis in the very earliest stages; thus at a time when a physical diagnosis will disclose nothing and when the best outlook is offered for successful therapy. This use of tuberculin as a diagnostic means, upon which I laid the most stress in my first publications, has become more and more appreciated in the course of time. Tuberculin is now used in most of the States under civilization for the early diagnosis of tuberculosis in cattle (Perlsucht). A systematic attack upon this widespread disease is based upon this discussion, and this attack has already led to excellent results. TUBERCULIN IS ABSOLUTELY The fear that in consequence of the reaction the tubercle bacilli would be rendered mobile and would be thus transmitted to healthy animals has been shown, in many thousands of tuberculin injections made upon cattle for this purpose, to be perfectly TUBERCULIN IN TREATMENT, THE BEST REMEDY HITHERTO. The further use of tuberculin consists in the employment of it in the treatment of tuberculosis. As an unmistakable improvement in the tuberculous process occurs after every reaction produced by tuberculin, it would seem to be proper to continue the reaction so long as any improvement continues to show itself. But this improvement cannot be indefinitely continued, for the reaction against tuberculin is gradually lost, and with it, of course, the effect of the tuberculin, so that finally there comes a period of perfect immunization against the tuberculin, and this period may last for several months. This immunization has no effect upon the tubercle bacilli themselves; it is a pure toxic immunity, and not a bacterial immunity. Unfortunately, the reaction against tuberculin is very often lost before there is anything like a perfect cure of the disease. Hereupon, relapses set in, which must again be treated with tuberculin reactions so soon as the capability of reaction is established. But treated in this way, with the necessary skill and patience, a cure, or, if not cure, at least very great improvement, may be secured, if not in all, at least in very many cases of uncomplicated tuberculosis. I would |