Breslau University, Children's Clinic. Satisfactory results were obtained with a food made of 50 gm. of wheat flour stirred into one-third of a liter of water at 50° C., and adding to this 10 c.c. of an 11 per cent. solution of potassium carbonate. A malt extract mixture is then stirred into the preparation of flour and milk, and the whole cooked together. Rapid gain in weight is reported in twenty-eight infants under six months fed upon this food. It was also found to be adapted to cases of gastro-intestinal disease.

Operative Treatment of Labor Complicated by Pelvic Deformities.

Dobbin (Obstetrics, vol. 1, no. 8) summarizes a critical review of the first thousand patients delivered in the obstetrical department of the Johns Hopkins Hospital, thusly:

1. In 131 cases of contracted pelves there was necessity for operative delivery 46 times, 35.11 per cent.

2. The pelves most frequently requiring operation are the rachitic and the irregular forms. The generally contracted pelvis, though very common in the negro race, is comparatively rarely sufficiently deformed to seriously obstruct labor.

3. Pelves in which the degree of contraction is slight, and those in which the contraction is very marked, are the easiest for treatment, as in both cases the indications are definite, and should give the operator little trouble in deciding upon the treatment to be pursued.

4. On the other hand, the pelves possessing a medium degree of contraction are the most perplexing, and call for the exercise of greater skill and judgment. When proper appliances are at hand such cases are best treated by the tentative application of forceps, and this failing, immediate Cæsarean section.

5. In general, forceps give a lower fetal mortality than version, but version done as a primary operation on a movable head, in a slightly contracted pelvis, is a safer operation for the child than a difficult high forceps operation.

6. Except in very exceptional cases, symphysiotomy is not to be compared with Cæsarean section, for the former operation, besides causing great injury to the mother, is always an uncertain procedure.

7. Operations on contracted pelves are rarely uncomplicated. Among the commonest accidents may be mentioned premature rupture of the membranes and prolapse of the umbilical cord.

8. The only rational and scientific method of obtaining "corrected morbidity" statistics is by the bacteriological examination of the uterine lochia, for only in this way can we say definitely which infections are the result of operation.

Operation for Complete Tear of the Perineum.

Kelly (Amer. Jour. Obstetrics, etc., vol. 40, no. 260) proposes, in repairing a complete tear of the perineum, to liberate the internal sphincter muscle from the surrounding tissue and then unite the freed ends by buried sutures.

The operation is performed as follows: An incision is carried across the septum at least a centimeter-more if the tear is a deep one - above the margin between the junction of the rectal and vaginal mucosa. This incision extends across the whole septum and above and beyond the sphincter ends. Taking this as a base line, the operation on the vulvar and vaginal portion of the rent is then made in the usual manner, as in the case of repair of an ordinary relaxed

vaginal outlet. Having completed the denudation of these parts, with the bilaterally symmetrical triangles in the south side and the undenuded tongue of tissue on the posterior column, the operator then turns his attention to the complicating condition, the rectal side of the tear. He inserts his left index finger into the bowel and draws the septum a little forward, and then carefully dissects the strip of undenuded tissue described above so as to free it and to turn it down like an apron. A carefully conducted dissection will expose the internal sphinc ter muscle and avoid buttonholing the bowel. At the sides of this flap the ends of the sphincter muscle are caught up and liberated in the manner described in a previous paper. The purpose of this flap is to turn down an apron or fold of tissue, which, when the sutures are all in place, projects out of the anal orifice and points in a direction away from the impact of the fecal masses. By making this apron the operator is able to avoid the presence of a wound on the rectal surface, and thus the most serious complicating condition is removed. When the denudation is complete, and the apron turned down, the operator will then be able to avoid the second complication, the presence of a dead space in the center of the septum, by the following plan of suturing: About three or four catgut sutures are applied in the form of the figure of eight, beginning above and introducing each suture so as to grasp the fibers of the internal sphincter muscle well to one side of the median line sutures, then carried to the opposite side, then passed through the tissues in the septum, well above the internal sphincter; it then returns to the first vaginal surface, approximating the triangles there. The next sutures are applied on the perineal surface, and here Kelly commonly uses two or three common silkwormgut sutures, in addition to the catgut sutures, between them.

CLIMATOLOGY AND PHTHISIOLOGY.

UNDER CHARGE OF LLEWELLYN P. BARBOUR, M.D., BOULDER, COLORADO.

The Present Aspect of Some Vexed Questions Relating to Tuberculosis, with Suggestions for Future Research Work.

E. L. Trudeau in Bulletin of the Johns Hopkins Hospital, July, 1899. Etiology. We need to know more as to the cause of the wide variations in the manifestations of the disease. Are these due to differences in the virulence of the infecting germ, to variations of the resisting power of the tissues, or to both these factors? What constitutes virulence in the infecting bacilli ? Is it due to an increased capacity for elaborating toxins in quantity or to the elaboration of more highly toxic products, or is it merely due to an inherent capacity of the germ to grow and spread more rapidly in the body? In this connection I may state that in my own experience tuberculin made from the culture fluid in which bacilli, attenuated by long cultivation, have grown is apparently as efficient in all ways as tuberculin derived from the most virulent cultures.

What is predisposition? It may be inherited or acquired. It is in either case greatly influenced by all factors which tend to produce lowered vitality and imperfect nutrition, and which may be grouped under the terms heredity and environment. Racial susceptibility presents many curious problems for study which show that the line which divides immunity from susceptibility is a narrow

one. Thus we find chickens highly susceptible to the avian variety of the tubercle bacilli while they resist inoculation with the bovine, and especially the human bacillus. They resist feeding for months on tuberculous sputum, and author has made repeated intra-peritoneal inoculations of large quantities of the most viru. lent cultures of human bacilli in a great number of chickens without the least deterioration of health resulting, and these chickens, when autopsied, have shown no trace of the injections or any evidence of disease in any organ. The guinea pig, on the contrary, succumbs to inoculation with human bacilli, and is killed even more quickly by the bovine variety, but resists injections of the avian cultures. However, some slight artificially-produced variations may efface the resistance of chickens to the human, and that of the guinea pig to the avian bacillus. Nocard has recently reported that by cultivating for some time human tubercle bacilli, enclosed in celloidin capsules within the peritoneal cavity of chickens, he could obtain cultures which not only grew well within the capsules when in the peritoneum of these birds, but had the power of killing them when inoculated in the usual way. Again, although guinea pigs resist avian bacilli, Dr. Baldwin has noted that this variety of bacilli if passed through several rabbits, which it kills in twenty-five to thirty days, has acquired virulence for the guinea pigs and will then kill these animals as well as the human bacillus does. Pathology. Among the problems in pathology which require to be studied are: 1. The chemical changes in the digestive secretions and the immediate causes of these changes.

2. Further studies of the blood. Whether the anemia in this disease is due directly to the effect of the toxins on the blood cells, blood-forming tissues or indirectly to the effect of the toxins on the nerve centers, and the nature of this process.

3. We also need light on the exact pathologic changes which result in cure in peritoneal tuberculosis after laparotomy.

4. Does tubercle represent a defensive effect on the part of the organism, or is it a nidus which favors the multiplication of the germs?

5. Again, what are the causes which lead occasionally to entire disappearance of the bacilli before death in acute miliary tuberculosis, and what evidence is there that we may interpret this disappearance as indicative of acquired immunity?

6. Is it true, as Koch has pointed out, that the tuberculous individual is relatively immune to reinoculation with the virus, just as the syphilitic cannot be reinfected during active progress of the disease? And if this is true, how are we to harmonize it with, first, local extension of the disease; second, extension of the disease in other regions, i. e., development of laryngeal, secondary to pulmonary tuberculosis?

7. The question ought to be settled as to whether there can be excretion of tubercle bacilli from glands, as the mammary gland, kidneys, testicles, etc., without tubercle deposits in those glands.

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8. The meaning of the production in the body and outside of "beading" of the tubercle bacilli. Are such beaded" forms degenerate or resistant forms? Is there any relationship between "beading" and spore formation?

Prophylaxis. We need further studies on the various sources of infection. That the dried sputum and other tuberculous deposits are not the only sources

of danger has been shown by the recent work of Flügge, who has demonstrated that the throat and mouth secretions of most tuberculous patients when atomized by the act of coughing may be a real source of infection to those about them. Dr. Baldwin has also shown that the hands of those patients using handkerchiefs may be the carriers of bacilli. Practical suggestions as to the education of the masses in regard to the sources of infection are needed, also suggestions as to the care of dust in living rooms, cars and public buildings, and better methods of disinfection of these places. A promising prophylactic measure would be the establishment of State and municipal sanitaria.

Bacteriology. Studies relating to artificial methods of exalting and attenuating the virulence of the tubercle bacillus are much needed, as they bear directly on the possibility of producing artificial immunity by preventive inoculation. Further light on tuberculin, the best methods of obtaining this toxin of standard strength, the influence of the virulence of the germs from which it is produced, and of the culture medium on which they grow, the technique of manufacture, etc., would be of great value. It is greatly to be desired that physiologic chemistry shall separate the various substances elaborated by the bacilli or contained in their bodies, and that the toxicity of each of these shall be determined and their influence on the cell and the living animal studied. A promising field of research has recently been opened by the successful cultivation by Nocard of various microorganisms enclosed in colloidin capsules and inserted into the peri. toneal cavities of living animals. Experiments by these methods offer two very wide fields: the study of the influence of cultivation under such conditions on the germs, their virulence and their products, and the study of the effect of freshly and continuously elaborated toxins on the living organism while the latter is protected from the direct pathogenic consequences of the spread of the microbe throughout the system at large. We may hope by this line of research to obtain more light on the mechanism of infectious diseases and the reaction of the living tissues to the toxic products of the microbes, and it would seem to open new possibilities in attempts at successful production of artificial immunity and the obtaining of antitoxic substances for the treatment of diseased conditions. Nocard's experiments in this way with the avian, bovine, and human tubercle bacillus are mentioned above. We need further knowledge on the relative pathogenic properties for man of these three recognized varieties of the tubercle bacillus.

Diagnosis. We should no longer be content to wait for the appearance of expectoration containing the bacilli, for marked physical signs, or for an unmistakable clinical picture before making our diagnosis of tuberculosis. In the tuberculin test we have a most delicate and searching means of detecting tuberculous disease when this cannot be done in any other way. We need more exact knowledge concerning the practical application of the tuberculin test in man, and we greatly need more light on the best method of applying this test, its exact value, its errors, their cause, and its possible dangers, in what other pathologic conditions the reaction to tuberculin may occur, and are the reactions which take place with considerable frequency in other diseased conditions due to them, or do they invariably indicate a concomitant and unsuspected tuberculous focus in some part of the body? The application of X rays promises to be of great assistance in the diagnosis of incipient pulmonary tuberculosis.

Treatment. Climatic and open air treatment of tuberculosis in a specially constructed sanitarium is at present conceded to offer the patient the best chance of recovery, but we need studies which would afford more exact indications as to the proper application of rest or exercise, exposure to the air, feeding, hydrotherapy, etc. The obtaining of a serum that would be antitoxic for the septic infections concurrent with tuberculosis would make us much less hopeless in the presence of such cases, while at present we must be content to rely on fresh air, food and alcohol to relieve this desperate condition.

The remainder of Dr. Trudeau's paper is devoted to a quite lengthy discussion of preventive inoculations. He recites his own experience with living attenuated cultures of tubercle bacilli. The cultures used originated from plants made on serum from the lesions of a rabbit infected with human tuberculosis in 1891 and grown on various media ever since. As to what the attenuation is due is still a matter of doubt. Trudeau's suggestion is as follows:

It is a well-known fact that any living organism loses any attribute which through many generations its environment does not call into use. While living

a saprophytic existence the tubercle bacillus has no need for the exercise of that characteristic which is known as its virulence and which means the power to cope successfully with the resisting elements of lung tissues, and it may be that this attribute is lost to it by its disuse through the millions of generations the germ passes through while growing so long on artificial media.

In Dr. Trudeau's experiments animals are "vaccinated" with this attenuated virus. After three months they are inoculated with virulent cultures. The following are his results: In 36 controls the average life was 57 days, and in the 66 vaccinated animals it was 154 days after the virulent infection, so that the vaccinated animals lived nearly three times as long as the controls. Some of the guinea pigs lived as long as eighteen months after the virulent infection. The results were about the same with rabbits, except that with them the protection seems in a few cases to have been absolute.

It would seem at first sight that these experiments proved positively that at least relative immunity had been produced in these animals. The evidence is complete, however, in so far as it relates to the complete recovery of the animals from the protective inoculation. Some of the vaccinated pigs lived three years in apparently good condition, and yet died ultimately of chronic tuberculosis. It is possible therefore that these experiments only prove that the disease is not inoculable, and an animal in which a very chronic form of tuberculosis has been induced artificially is not susceptible to inoculation with a more virulent infecting material. This the author believes is true of syphilis-a disease which closely resembles tuberculosis in its course and various manifestations.

The Diagnosis of Early Phthisis Without the Use of Tuberculin.

L. P. Barbour (Journal of Tuberculosis, July, 1897). [This paper was written in reply to some very enthusiastic advocates of the use of tuberculin in diagnosing early phthisis.]

Very few patients come into the hands of the doctor before the disease is not advanced enough to give some pronounced symptoms. Patients without sickness and without symptoms do not consult a physician. Nor is the golden opportunity for successful treatment lost if the disease is recognized with the first bacilli, the early hemorrhage, the first pronounced symptoms. It is lack of