Under these circumstances early operation is clearly contraindicated. However, should the symptoms persist without amelioration, an explanatory laminectomy under suitable circumstances may be considered within the limits of propriety, on the grounds that the persistence of symptoms may be the result of hemorrhage or an undetected injury of the vertebral column. Be it remembered here, as in other parts of this discussion, that the clinical evidence of a total or complete transverse lesion does not signify an irreparable injury to the cord.

When dealing with direct injuries to the cord by bullet shrapnel, or bone splinters the propriety of a laminectomy admits of little discussion. This general dictum, with certain qualifications, has been subscribed to quite generally by neurologists and surgeons alike who have had opportunity for abundant observation during the European War.

While it may be true of the individual case, as it is no doubt of a large number, that the damage to the cord is accomplished at the time of the accident, and that the persistence of symptoms is the result not of continued compression but of the intramedullary changes in the cord due to the original impact, an exploratory laminectomy should be performed, whether the picture be one of a complete or incomplete lesion.

One may assume that if the injury is due to shrapnel, the cord is more apt to be hopelessly damaged than by a bullet. But after all, the nature of the cord lesion is largely a matter of conjecture and there is the temptation to take the position, endorsed as it is by Oppenheim, that operation is indicated even in cases of total transverse lesion, for there is nothing to lose, and perhaps, something to be gained. In twenty operations for gunshot injuries of the spine, Guleke found the cord completely crushed in ten, and while only five of the twenty cases recovered, three of these would have died had not fragments of bone or bullets been removed.

As to time of the operation, there are those who urge immediate operation, and those who advise waiting from three to five weeks, or until the likelihood of recovery seems remote. Whatever may be the view of the individual surgeon, it is at least true that no operation should be undertaken until the patient has recovered from shock, and not until the patient reaches a base hospital from which he will not have to be transferred until the fractured spine has been well repaired. Authorities agree that secondary changes are more likely to develop as a result of early transportation, and therefore, absolute rest is advisable in the convalescent period if the condition offers any prospect of useful recovery.

There seems to be a difference of opinion among surgeons with extensive military experience as to whether the dural incision should be closed in all cases. In deciding this question the surgeon must take into consideration two factors: one, the presence or absence of infection in the bullet tract, and the other the condition of the cord. As to the former, every precaution must be taken to guard against

infection of the subarachnoid space and, if the wound be septic, closure of the dural incision is the safer course to pursue. In the absence of infection, should the cord be so swollen and oedematous that closure of the dural incision exerts undue pressure, a condition of rare occurrence, the dural incision may be left unsutured. On general principles, leaving the dural incision open as a routine practice should be condemned.

To avoid infection of the bladder and the inevitable ascending infection, the cathether must not be used. Either a suprapubic cystotomy, which has been found so effective in civil practice, may be resorted to, or the bladder may be allowed to empty itself by overflow, a practice which has become popular in many of the war zone hospitals.

GEORGE EARL.

EPIDEMIC OF

ETIOLOGIC FACTORS IN AN ACUTE CONJUNCTIVITIS AT CAMP SHERMAN: Major W. E. Kershner, M. R. C. (Amer. Jour. of Ophth., Series 3, Vol. 1, No. 7, p. 480) discusses tersely an epidemic of conjunctivitis which developed at Camp Sherman the latter part of October, 1917, running well into January, 1918. This epidemic was very widespread affecting over twelve hundred men part of which were treated at the base hospital, others in the regimental infirmaries.

Owing to the rapidly constructed barracks at Camp Sherman arrangements for heating were not entirely satisfactory, with the result that the attempts to conserve what was obtainable resulted in inadequate ventilation.

Dust formed an important etiological factor in both infected and non-infected cases. This arose from two sources, from the roads and from the air as a result of sweeping and tramping upon the floors of quarters, the floors of which had not been oiled. The conjunctival irritation thus produced, augmented by smoke and gas fro mthe stoves, provided a fruitful field for bacterial invasions.

The following table is the result of the laboratory examinations:

in the adult usually runs a fulminating and destructive course.

The presence of epidemic meningitis in the command accounts for the few cases of like infection underlying the conjunctiva.

In only one instance did a serious complication arise, a severe corneal ulcer, the result of a pneumococcic infection.

PAUL D. BERRISFORD.

EFFECT OF STIMULI FROM THE LOWER BOWEL ON THE RATE OF EMPTYING THE STOMACH: Franklin W. White, M. D. (Amer. Jour. of Med. Sciences, Vol. CLVI, No. 2) has employed the roentgen-ray method to study the effect of stimuli from the lower bowel on the rate of emptying of the stomach; the effect of mechanical filling and distention of the colon by enemata in men and cats; the effect of chemical irritation of the cecum in cats; the effect of diseases of the lower bowel in 120 cases of chronic colitis, tubercular ulceration and cancer of the colon, chronic and acute appendicitis and adhesions of the lower ileum and colon.

His results all point the same way: (1) delay in emptying the stomach is the exception, not the rule, in lesions of the lower bowel; (2) a strong stimulus is needed from the lower bowel to show the stomach, for it was found that the stomach emptied a barium meal within the normal time in some cases of ileal stasis of two or more days' duration, and in most cases with good-sized twelve-hour residue in the ileum, also when the colon was distended with a large enema, also in most cases of chronic appendicitis and chronic inflammations and tumors of the colon.

Experiments on animals showed that when the colon was irritated by injections into the cecum variable results were obtained; intense irritation caused vomiting; less marked irritation caused either delay in emptying the stomach up to about twice the normal time or rapid emptying of the stomach and whole digestive tract; moderate or slight irritation had no effect. The results were not perfectly graded, evidently because of variable spasm.

There is evidently a definite correlation of different parts of the digestive canal by a protective mechanism which works under a powerful stimulus, such as intestinal surgery or injury or strong irritation, but which does not work under a moderate stimulus or simple mechanical condition. The action of this mechanism is complicated by the contrary results of spasm and hyperperistalsis.

Marked delay in emptying the stomach is far more often the result of actual lesions about the pylorus than of reflexes from the bowel. "Stomach symptoms" in intestinal cases are not, as a rule, the result of slow emptying of the stomach.

ERNEST T. F. RICHARDS.

BOOK REVIEWS

THE PRACTICAL MEDICINE SERIES. OBSTE TRICS. (By JOSEPH B. DE LEE, A. M., M. D., Professor of Obstetrics Northwestern University Medical School. Vol. VII, Series 1917. Published by the Year Book Publishers, Chicago. Price $1.35.)

In this convenient volume of a little more than two hundred pages the editors have condensed a large amount of information, comprising abstracts of the most important papers on obstetrics for the preceding year.

The subject matter is divided into five parts: 1, Pregnancy; 2, Labor; 3, the Puerperium; 4, the Newborn; 5, Obstetrics in general.

As the material for the review is gathered from widely scattered sources not always accessible to the busy practitioner it fills a distinct need and should be in the hands of everyone who wishes to keep abreast of the advances being made in this important subject.

The editorial comment which follows the abstract affords the reader a valuable guide as to the soundness of the view expressed in the paper.

We heartily commend this review and believe that the entire series should be in the hands of every practitioner.

J. L. ROTHROCK.

SYPHILIS AND PUBLIC HEALTH. (By EDWARD B. VEDDER, A. M., M. D., Lieutenant-Colonel, Medical Corps, United States Army. Published by Permission of the Surgeon-General United States Army by Lea and Febiger, Philadelphia and New York. Price, $2.25.)

This small work of some 300 pages consists of an introduction, four chapters and an appendix. The chapters are as follows: The Prevalence of Syphilis, Methods of Transmission, Personal Prophylaxis and Public Health Measures. The Appendix, besides giving the technic of Wassermann for the complement fixation test, gives the laws of Western Australia for the control of the disease and abstracts of the laws and regulations of some of our states and cities and of our army relative to the same. The introduction treats the subject as a whole and the importance of the subject from the public health viewpoint is stated and explained. The author has carefully gathered his material and confines himself to statements of facts and has no theories to justify or controversies to enter into. Surely no one can read the introduction and the chapters following without realizing, if one has not already done so, the great importance of the control of this disease by the state. We cannot but believe that the author has accomplished his purpose admirably. Personal prophylaxis which most

writers, writing for a lay as well as a profession audience, might pass over with a few brief statements, is given the prominence this method for the control of the disease certainly merits. We urge all medical men and others interested in our country's welfare to obtain this book and read it carefully from start to finish. A sufficient bibliography and indexes accompany the text.

JOHN M. ARMSTRONG.

A MANUAL OF OTOLOGY. (By GORHAM BACON, A. B., M. D., F. A. C. S., Formerly Professor of Otology in the College of Physicians and Surgeons, Columbia University, New York; Aural Surgeon, New York Eye and Ear Infirmary, etc., Assisted by TRUMAN L. SAUNDERS, A. B., M. D., Assistant Professor of Laryngology and Otology, College of Physicians and Surgeons, Columbia University, New York, etc. Seventh Edition, Revised and Enlarged, with 204 illustrations, and 2 plates. Published by Lea and Febiger, New York and Philadelphia. Price, $3.00.)

Bacon's Manual of Otology is written for students and general practitioners. The volume, while not pretentious, fulfills all necessary requirements attested by the fact it has now reached its seventh edition. The text treating on suppurative inflammation of the labyrinth has been entirely rewritten and there has been added a section dealing with the requirements demanded by the United States Government for candidates entering the aviation service.

PAUL D. BERRISFORD.

CAMPBELL

CLINICAL DIAGNOSIS. (By JAMES TODD, Ph. B., M. D., Professor of Clinical Pathology, University of Colorado. Illustrated. Fourth Edition, Revised and reset. Published by W. B. Saunders Company, Philadelphia and London. 1918.)

Todd's Clinical Diagnosis presents undoubtedly the most valuable tests and practical methods in the investigation and examination of blood, sputum, urine, feces, and gastric contents. The chapters dealing with animal parasites, bacteriologic methods, preparation and uses of vaccines, and sero-diagnostic methods make possible and accessible, examinations of many heretofore obscure and undiagnosed conditions.

The following features deserve special emphasis:

1. Presentation of the material. The simplicity, conciseness, and completeness in the presentation of any part as well as the whole volume is unique. The author avoids complicated methods and long descriptions, availing himself wherever possible with illustrations, many of which are colored plates.

2. Changes and additions in

(a) Microscopic morphology.

(b) Use of colorimeters.

(c) Pocket spectroscope.

(d) Matching blood for transfusion. (e) Bass and John's concentration method for malarial parasites.

(f) Vital staining of blood corpuscles. (g) Resistance of red corpuscles.

(h) Spinal fluid examinations.

(i) Urobilin estimation as an aid in diagnosis

of pernicious anemia.

(j) Estimation of amylase in urine and feces in the diagnosis of pancreatic disease.

3. Interpretation. This volume being intended as a manual for students and practitioners contains only, therefore, the most important interpretations. It serves rather as a guide than a reference book on clinical diagnosis, and as such can be highly recommended.

JOHN A. LEPAK.

DISEASES OF THE MALE URETHRA, INCLUDING IMPOTENCE AND STERILITY. (By IRVING S. KOLL, B. S., M. D., F. A. C. S., professor of Genito-Urinary Diseases, Post-Graduate Medical School and Hospital; Associate Genito-Urinary Surgeon, Michael Reese Hospital, Chicago. Illustrated. Published by W. B. Saunders Company, Philadelphia and London. 1918. Price, $3.00.)

No hand book of this size can be entirely satisfactory though the author has managed to put a great deal of information into 134 pages, and at the same time give the book an individuality of its own. The inquirer wishing to find the "best prescription" for gonorrhea will not find it here; but if he reads with understanding will discover that urethral conditions should be treated intelligently and not with different injections. We, therefore, recommend the consideration of this small book and believe its publication worth while even in war times. We thank the author for eliminating many routine observations and prescriptions and also for introducing new illustrations, especially the colored plates of the urethra as seen through the urethrascope. The author states these last are original, and we believe it. They certainly are not the same that have appeared in every text book for the past twenty years. The author seems to have a predilection for metallic urethral instruments, or at least they are the only ones that receive much notice, and at no place is the information vouchsafed that urethral instruments should be lubricated before introduction. Operative surgery is briefly referred to. As regards external urethrotomy without a guide the author states that it sometimes has to be done. The chapters on the treatment of sexual disorders are very good, though not entirely satisfactory. There is as much information of real value as is to be found in any larger treatise the reviewer has seen. The book deals only with diseases of the urethra of the male.

JOHN M. ARMSTRONG.

A MANUAL OF CLINICAL DIAGNOSIS. (By CHARLES E. SIMON, B. A., M. D., Professor of Clinical Pathology and Physiological Chemistry in the University of Maryland Medical School and the College of Physicians and Surgeons, Baltimore, Maryland. Ninth Edition, Enlarged and Thoroughly Revised. Illustrated with 207 Engravings and 28 Plates. Published by Lea and Febiger, Philadelphia and New York. Price, $6.00.)

This is a very comprehensive book on laboratory methods. The author divides the subject matter into two parts, the first taking up the detailed description of laboratory technique, the second part presenting all the laboratory findings under the heads of the various diseases. The writer goes into the technique most thoroughly taking nothing for granted. Illustrations are shown wherever they will aid the reader in giving a greater understanding of the subject. The subject of animal parasites is especially well illustrated. Much new subject matter has been introduced in the edition, bringing the contents quite complete up to the present time.

ARCHIBALD LEITCH.

THE PRACTICAL MEDICINE SERIES. (Under the General Editorial Charge of CHARLES L. Mix, A. M., M. D., Volume III-Eye, Ear, Nose and Throat, Edited by CASEY A. Wood, C. M., M. D., D. C. L., ALBERT H. ANDREWS, M. D., and GEORGE E. SHAMBAUGH, M. D. The Year Book Publishers, Series 1918.)

In compiling the text of this volume consisting of some 380 pages, the authors have scouted the vast domain of literature published during the year 1917 relating to these specialities. While foreign publications have been few, writings on military surgery with respects to its various phases have been most voluminous.

The frontispiece and the chapters relating to the war are especially interesting and the clear concept with which all is written is surprising. By no means is it a text book, but it can always be used as a valuable reference when seeking for the advanced progress in these specialities.

GEORGE C. DITTMAN.

ing interesting, for here we have the opinions without restraint of many of the leading surgeons in this country and in England.

There must, of necessity, be repetitions in a work of this kind, but this also adds to its value, as we obtain the individual opinions of well known surgeons who not infrequently differ with one another.

Many of the sections show careful preparation and much thought, and each author was evidently chosen because of his experience in a certain field of work. Among these may be mentioned the sections on "The Breast" by J. C. Bloodgood; and "Intestinal Obstruction" by F. T. Paul.

Most of the illustrations are new and have not before appeared.

L. E. DAUGHERTY.

A TEXT BOOK OF THE PRACTICE OF MEDICINE. (By JAMES M. ANDERS, M. D., Ph.D., LL.D., Professor of Medicine and Clinical Medicine, Medico-Chirurgical College Graduate School, University of Pennsylvania, Thirteenth Edition, Thoroughly revised with the Assistance of JOHN H. Musser, Jr., M. D., Associate in Medicine, University of Pennsylvania. Octavo of 1,259 pages, fully illustrated. Philadelphia and London: W. B. Saunders Company. 1917. Cloth, $6.00 net; Half Morocco, $7.50 net.)

This work is to the point, plainly and concisely written and with a substantial addition of new material. The text is well arranged with the headings and subdivisions in heavy type, the modern orthography and terminology being used. The definitions of the diseases, and then the pathology, allows a better association of the clinical symptoms with the morbid lesions. A helpful feature is the tabulation of the differential diagnoses. The treatment is well taken care of and the therapeutic formulae given in both the apothecaries' and metric systems.

GILBERT KVITRUD.

A TREATISE ON REGIONAL SURGERY. 1917, Vol. I and II. (Edited by JOHN FAIRBAIRN BINNIE, A. M., C. M., F. A. C. S., Kansas City, Mo. Published by P. Blakiston's Son and Co., Philadelphia. Price, each volume, $7.00.)

The author states that he requested each of the authors to write practical articles and not what "he thought other people would think he ought to think." It is this one suggestion that makes this work exceed

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Vol. I

ORIGINAL ARTICLES

THE EFFECTS OF UNDERFEEDING AND REFEEDING UPON THE GROWTH OF THE VARIOUS SYSTEMS AND ORGANS OF THE BODY.*

C. M. JACKSON, M. S., M. D., AND
C. A. STEWART, PH. D.

Institute of Anatomy, University of Minnesota.

Minneapolis, Minn.

A few years ago, Waters ('08) made a remarkable discovery. He found that calves stunted by underfeeding continue to grow in height and width, even when the body weight

fails to increase. Thus under these conditions the skeleton persists in growth at the expense of the remainder of the body, which becomes greatly emaciated. Aron ('10, '11) confirmed this result in dogs, finding that in puppies underfed for several months the skeleton, and apparently also the brain, continue to grow at the expense of the rest of the body. The loss was found to fall chiefly upon the fat and muscle, the viscera apparently undergoing but little change in weight. A few clinical observations by Variot ('07, '08), Freund ('09), Birk ('11), and Hess ('16) show a persistent tendency to increase in the length of the body in malnourished infants. This would indicate that the skeleton in young children likewise may continue to grow under conditions of chronic underfeeding or malnutrition with retarded or stationary body weight.

An extensive investigation of this matter was therefore undertaken in the Department of Ana

*Presented before the Annual Meeting of the Minnesota State Medical Association, held at Duluth, Minn., Aug. 29 and 30, 1918.

No. 11

tomy at the University of Minnesota in order to determine: (1) what changes take place in the various organs and parts of the entire body as the result of underfeeding; (2) whether the effects are different at different ages or with different degrees of inanition; (3) how the results on young individuals compare with those in adults subjected to acute or chronic inanition; and (4) how various periods of underfeeding the young, may affect their growth later when they are fully fed.

I. Effects of Underfeeding upon Growth in the Young.

The white (albino) rat was selected as the most convenient form for the experiments. It breeds rapidly and thrives in captivity. Its small size and rapid growth (reaching sexual maturity at 10 weeks, and adult size within a year) make it possible to obtain extensive data in a comparatively short time. The normal growth and variability of the rat and its various organs have also been worked out very thoroughly (chiefly by Donaldson, Hatai, Jackson and Lowrey), and normal growth tables by Donaldson ('15) are available for comparison. This is a matter of great importance, for the lack of knowledge concerning the normal structure and variability of the animal used frequently makes it very difficult to draw trustworthy conclusions from the results of experimental work.

The results of our investigations showing the relative changes in the weights of the component systems and organs are summarized in the accompanying table. The data are based upon the observations of Jackson ('15, '15a) and Stewart ('18). The relative changes in weight are indicated in percentages of increase (+), or decrease (—), in the weight of the organ or part