there be sloughing and these other symptoms the infection and development is farther in and up the chain of lymphatics and he did not see how this treatment would affect the development higher up.

The infection following labor or miscarriage from injury is usually through a different route than gonorrhea.

In injuries after abortion or labor at term the infection is usually taken up by the lymphatics and the irritation is entirely different from that in gonorrhea.

Tuberculosis is undoubtedly quite common, but he was surprised to learn it is so frequent as was stated; he supposed three or four percent would be high enough for the uterine structures; it certainly had not been more than that in his experience or observation.

2. Some Stomach Surgery Observations as Illustrated by the Stereopticon, by N. Stone Scott, who showed that many phases of the subject of stomach surgery are very difficult of being depicted by photography because of the complex arrangement of the parts involved, making it next to impossible to get them all in the field at one time, and yet, as a means of class room demonstration the stereopticon is ahead of every other means of illustration except the demonstration upon the cadaver, not excepting the operation upon the living subject.

He claimed that the subject of stomach surgery was greatly stimulated and in fact, in America, practically began with the work of that master surgeon, the late Nicholas Senn.

A short review of the development of the operation of gastro-enterostomy was given, showing how his own work, beginning with a simple gastro-enterostomy, first performed in September, 1891, had gone through the same stages of development as illustrated by the work of Wolfler, Von Hacher, Lücke, Döyen and others, and in recent years coming back again to the more simple “no loop" operation, as practiced at the present time by Moynihan.

Photographs were shown illustrating the rapidity with which some cases recover, as, for instance, the new pylorus will assume its sphincteric action in 10 days and the enlargement of the stomach, so marked before operation, will disappear even more rapidly.

Of especial interest, however, were the photographs taken from a case of congenital stenosis of the duodeum showing changes in the portion of the alimentary tract which was exposed to the atmosphere at the time of the operation, which changes were not apparent to the eye but were clearly demonstrated in the photographs. The patient died in shock 14 hours after operation. The changes in the tissues were evidently due to light, heat, air, or some influence exerted at the time of operation, and were not due to traumatism or hemorrhage, as all the parts exposed to the air, both those near the operation site and those remote, were equally involved. This again demonstrates that not only can the camera show the presence of the exanthemata before a rash is apparent to the eye, but here also are changes in the tissues of the deeper parts, not due to disease, which the eye cannot detect, but which are clearly shown in the photograph.

W. E. Lower in discussing the paper said that surgery of the stomach is really divided into two periods—before and after the interesting work of Cannon. During the first period the stomach was supposed to be a mere sac without any definite physiologic function, and during this time anastomosis was done for dilatation and various forms of so-called stomach disorder in neurasthenic cases. Cannon's very interesting work demonstrated that no matter how well a gastro-enterostomy was made, if the pylorus remained patent, the stomach contents would pass through the pylorus and not drain out through the new opening as was supposed. This at once suggested the impropriety of trying to drain the stomach by gastro-enterostomy with an open pylorus.

The second period dates from the discovery referred to, and has limited the indication for gastro-enterostomy to practically two conditions.

First, a stenosis of the pylorus, and, secondly, ulcer of the duodenum. In the former condition (complete stenosis of the pylorus) it does not matter much what operation is done, good results are obtained. In the second instance (ulcer of the duodenum) the best results are obtained when the pylorus is closed by some form of plication and the contents of the stomach forced through the new opening. The ideal method is undoubtedly the short posterior no-loop operation.

He would like to have heard more of the speaker's results in stomach surgery. We should look more to results than to methods and to select the proper cases for gastro-enterostomy. One thing is certain, that nothing is to be gained by operations on a large class of neurasthenic cases in which there is gastroptosis and no obstruction.

N. Rosewater said that he often wondered why it was that he had had so few cases to send to the surgeon. In a period of 11 years he had sent five cases to the surgeon. All his drainage cases yielded better to treatment, and the only ones requiring operation were those in which there was stenosis. Those cases spoken of as duodenal ulcers do well with proper drainage. He had seen cases of dilatation, as bad as those shown, that inside of three months time with proper abdominal support, rest and proper diet, begun with rectal feeding until the stomach contracted as far as the umbilicus, then two meals a day, finally got proper drainage. In fact one gets perfect drainage as long as there is no stenosis. If patients stand on their feet one cannot get drainage.

M. D. Stepp asked whether the speaker still closed off the pylorus as formerly. Also how far away from the gastro-enterostomy he made his entero-anastomosis and whether he used the stitch method or Murphy button. If he used the latter to any extent what had been his experience with its being followed by other gastric troubles, such as gastric ulcer.

N. S. Scott in closing the discussion said he thought that N. Rosewater had done pretty well to have five stomach cases to refer to the surgeon in 11 years. The cases that need to go to the surgeon are not so very common, and yet they are more so than they seem to be at first.

The results are what we are after, the method is not of much importance. He had had beautiful results from all of the methods. In these cases of true stenosis of the pylorus, if one does a gastro-enterostomy or any other operation upon an hysterical patient one will not get results. This is true in all cases of surgery. An hysterical patient after any operation is going to complain as much afterwards as before.

There is no class of patients so thankful for the relief they get as the stomach cases with a stenosis. The cases reported as cured are not completely cured. They have troubles, but people, not having had a gastroenterostomy, have troubles. All gynecologists will recognize the fact that their patients have bilious attacks, and have to be careful of their stomachs. These cases having had a gastro-enterostomy have to be careful, but they are extremely thankful for the relief they get.

In regard to technic, he was not a very warm advocate or very diligent user of the Murphy button, favoring rather the needle and thread, and yet there are cases in which the Murphy button is very useful. In two conditions it is particularly useful, in making an anastomosis between the gall-bladder and intestine, the gall-bladder wall being too thin to suture, and in malignant stomach disease. At first he operated upon quite a number of malignant stomach cases and they nearly all died, but lately he had refused to operate in such cases when a positive diagnosis could be made. He hoped the time would come when the medical men would cooperate more fully with the surgeons. They are in the place now with stomach surgery that, they were with appendicitis 15 years ago. He hoped the time would come when these cases of malignant disease of the stomach will come to operation early. The complicated operations which were so pretty to read about and interesting to study are going out of vogue largely and the simple operations have been used more in recent years. The simplest of all is the posterior gastro-enterostomy with no loop.

3. Essential Hemorrhage of the Kidney, F. E. Bunts. (Appearing in full in June issue). W. E. Lower in discussing the paper said that essential hemorrhage of the kidney implies bleeding without demonstrable cause. He doubted if there really were such cases for it is hard to conceive that we have a bleeding without some lesion. In many cases, however, no lesion seems to be apparent, yet no doubt by proper methods and a more careful search the cause would be found. He thought fewer cases of essential hemorrhage were being reported each year because of better methods of determining the cause. Nephritis might be responsible in many of these cases, but one would expect more constitutional disturbances than many of these cases show. In 139 cases of hematuria under his observation about onehalf of them showed renal hemorrhage and the causes were mainly tuberculosis, renal and ureteral calculus. There remained, however, 22 cases which were unclassified. In these cases he was unable to definitely determine the cause. Several of them were operated upon because of the extreme debility on account of loss of blood. In two cases he did nephrectomy. In one case a small calculus about the size of the head of a pin was found. In the other case there was an area of softening, but it was not tuberculous. A later pathologic report was never had. In a number of cases the hemorrhage after continuing for a certain period spontaneously stopped. In one case there had been bleeding for six years. The patient was told that if this did not stop within a short time he must be operated upon. Within three days the hemorrhage stopped and he has not had any since. This was more than two years ago. In one case in which there was pronounced nephritis the hemorrhage was present only on one side.

One notable and rather interesting fact in hematuria is that a large percent are painless; the first thing noticed is blood in the urine and there is no pain unless there is clotting, but in 85% of the cases there is a definite pathologic lesion responsible for the hematuria. He had seen hematuria in pregnancy, typhoid fever, and several other cases of pyelitis. He thought all cases of hematuria should be thoroughly investigated for the cause, for in a number of cases it may be the first symptom of begining malignancy or some other grave lesion.

F. W. Hitchings thought there was some possibility of these cases being successfully treated by other than surgical measures. He had closely followed the work of Weil, of Paris, in controlling pathologic hemorrhage of various kinds by injecting the fresh serum from man, horse, or rabbit. Cases of hemophilia and purpura which had failed to respond to all the ordinary hemostatics had been controlled completely by this simple means. The serum must be comparatively fresh-cannot be over six days oldin order to obtain results. In cases of apparently essential hematuria in which no definite lesion can be discovered, it might be advisable to try injections of this kind. Weil had had no cases of hemolysis as far as he had been able to ascertain.

F. E. Bunts in closing the discussion said that of course a large percentage of hemorrhages of the kidney must come from lesions really demonstrable. In these 70 cases lesions were not present; the kidney was cut down upon and no stone found in any of them, and in only one case was tuberculosis deemed present. There was no question but that some very small lesion is sufficient. Abbe reports such a case in which a small piece of gravel seemed responsible.

He had been very much interested in this matter of serum injection. He had not used it in any of his own cases but had advised it in consultation in a case of hemophilia in which the man had been bleeding for four or five days. The hemorrhage ceased, whether the serum stopped it he could not say. However it was well worth trying.

Book Reviews

An Index of Treatment by Various Writers, edited by Robert Hutchison, M. D., F. R. C. P., Physician to the London Hospital, and Assistant Physician to the Hospital for Sick Children, Great Ormond Street; and H. Stansfield Collier, F. R. C. S., Surgeon to St. Mary's Hospital; Joint Lecturer on Surgery in St. Mary's Hospital Medical School; Surgeon to the Hospital for Sick Children, Great Ormond Street. Revised to conform with American usage by Warren Coleman, M. D., Professor of Clinical Medicine and Instructor in Therapeutics in Cornell University Medical College; Assistant Visiting Physician to Bellevue Hospital, New York. William Wood and Company, New York, 1908.

This is a new work upon treatment, and comprises within a single volume, of moderate size, a most satisfactory summary of the most recent and approved methods of practice. It is alphabetically arranged, and is essentially a practical work, its contributors representing the leading British practitioners. It has been adapted to our use by Warren Coleman, who has brought the prescriptions into conformance with the preparations of the U. S. Pharmacopoeia. In the non-operative treatnient of acute general peritonitis the value of hypodermoclysis is urged. In hysteria, suggestion plays a prominent part, drugs being of minor value, and hypnotics and analgesics are to be avoided. In arteriosclerosis, special stress is placed upon the use of mercurials, and the concise summary of the uses and indications of the cardiac tonics in cardiac valvular disease is excellent. In the treatment of nephritis the true position of renal substance or extracts is stated to be unsettled, or still in the experimental stage, although the authors' results in this line justify further use. The present status of bacteriotheraphy is well defined. The work includes surgical treatment, although that of obstetrics scarcely comes within its scope and is omitted. The book throughout shows careful preparation, and is a most complete and convenient therapeutic guide.

Diseases of the Heart. By Prof. Th. von Jürgensen, of Tübingen; Prof. Dr. L. von Schrötter, of Vienna. Edited, with additions, by George Dock, M. D., Professor of Medicine, University of Michigan, Ann Arbor. Octavo of 848 pages illustrated. Philadelphia and London: W. B. Saunders Company, 1908. Cloth, $5.00 net; Half Morocco, $6.00 net.

This book of 826 pages is a very complete and exhaustive treatise on diseases of the heart. The contents are divided into five subdivisions, viz: Insufficiency (weakness) of the Heart, Endocarditis, and Valvular Disease by Theodor von Jürgensen; Diseases of the Myocardium and Nervous Diseases of the Heart by L. Krahl, and Diseases of the Pericardium by L. von Schrötter.

The causes of cardiac insufficiency are divided into two main groups: (1) Those which directly affect the heart and injure its mechanism. (2) Those which affect the heart indirectly by preventing it from receiving the amount of blood necessary to enable it to perform the work required of it. These causes are taken up in great detail by the author, and the clinical histories and pathologic reports of numerous cases are cited to exemplify these conditions. These clinical reports are printed in fine

type so that they do not add much to the size of the book. The symptomatology and treatment of cardiac insufficiency are exhaustively considered.

In the chapter on endocarditis the author states this fact, which is becoming more and more recognized by clinicians: "I do not think it is correct to regard endocarditis as a separate entity. 'Pancarditis' will be the diagnosis of the future. But he who makes this diagnosis must know how to distinguish the various parts which compose the whole, and to weigh the relative importance of each. The object should be, of course, in each individual case to analyze the composite picture of pancarditis into its constituents-endocarditis, myocarditis and pericarditis. We must remember, however, that these elements are only parts of the same disease."

The general pathology of valvular disease forms a very interesting chapter. This, as well as the course, diagnosis and prognosis of valvular diseases in general, is considered before the individual valvular lesions. Under tricuspid stenosis Dock has added a summary of the work of Thayer and MacCallum, who showed in their experiments on animals with what ease murmurs could be produced in the pulmonary artery.

Diseases of the myocardium occupy 342 pages. The author takes up in detail the examination of the heart and expresses the wish that internists would unite in the interests of medical instruction on the method and terminology to be employed in determining the size of the heart. This is the most complete and instructive chapter in the book.

In the last subdivision, diseases of the pericardium are exhaustively studied by von Schrötter.

Numerous additions to the original text have been made by Dock. He has also added many valuable references to English and American literature. An extensive bibliography of the literature of cardiac disease is given.

This book is one that every physician should read, and Dock has done a great service to the medical profession by this translation."

Surgery: Its Principles and Practice. In five volumes. By 66 eminent surgeons. Edited by W. W. Keen, M. D., LL. D., Hon. F. R. C. S., Eng. and Edin., Emeritus Professor of the Principles of Surgery and of Clinical Surgery, Jefferson Medical College, Phila. Volume III. Octavo of 1132 pages, with 562 text-illustrations and 10 colored plates. Philadelphia and London: W. B. Saunders Company, 1908. Per volume: Cloth, $7.00 net; Half Morocco, $8.00 net.

This volume of Keen's Surgery contains some of the most important chapters in the whole work. There are 276 pages devoted to the Surgery of the Head by Harvey Cushing. In this masterly article we have a full and modern presentation of a department of surgery in which much remains to be done, to perfect it. Cushing's advanced work has made him an unquestioned authority in "Neurological Surgery."

E. W. Andrews writes on the Surgery of the Neck; the explanations of certain congenital defects on an embryologic basis should have been revised, for they have been to a large extent inaccurately and carelessly compiled.

The chapter on the Surgery of the Thyroid Gland is by Albert Kocher, who is well qualified to speak on this subject. In the section on the nose and its accessory sinuses one would like to see a more detailed