you not think the study of the waste and repair of the sympathetic nerve ought to be most important of medical consideration, and has it not been in your experience and in your medical education the least important? In your college did they lay any stress on the consideration of the sympathetic nerve or the involuntary muscles? Did they not spend most of their time with osmosis chemism, forgetting that chemism cannot act unless there is something to act on? The blood stream has to be there, it has to meet the tissues, to meet the nervous forces in order that the electrical currents of the body shall be generated; and it all depends on the blood stream. The tubes of the body carry on all its commerce except the chemism and osmosis, and the steam that runs those tubes is the sympathetic nerve." Dr. Pratt also said that orificial surgery is the greatest force in the domain of medicine, simply because it flushes the capillaries.

Dr. H. T. Patrick of Chicago spoke on "Apoplexy.” He called attention to and differentiated four pseudoapoplexies, brain tumor, the pseudo-apoplexy of uremic conditions and the less common condition in multiple sclerosis. In the apoplectoid attacks of general paresis there is nearly always a history of mental failure, of emotional or intellectual change, the Argyll-Robertson pupil and absence of deep reflexes. As the attack passes off there is a mental improvement. Greater difficulty in differentiation is met when the apoplectoid attack in general paresis occurs early. In brain tumor there is a gradual progressive headache before stroke with a double optic neuritis. A true apoplexy stroke is caused either by hemorrhage or thrombus, and it is essential to differentiate the two forms, either for treatment or prognosis. Those caused by thrombus are many times more frequent. Those that die in attack or within a few days are usually due to hemorrhage. Those occurring between the ages of 20 and 40 years are usually syphilitic, for brain syphilis almost always occurs within five years of the initial lesion. Miliary aneurysm is a factor in the production of hemorrhage. It is a disease of middle life and is associated with small granular kidney, hypertrophied heart and increased blood tension. Arteriosclerosis and atheroma, associated with myocarditis, fatty heart, valvular disease, low tension pulse, coronary disease and cardiac malnutrition and angina-a disease of old age-results in thrombosis. Prodromes are absent in hemorrhage, present in thrombosis, and consist of temporary symptoms such as aphasia. numbríess, stiffness of tongue, and dizziness. A complete hemiplegia without loss of consciousness is never due to hemorrhage. Monoplegias are due to thrombosis. In thrombosis there may be a local convulsion-no rise in temperature; in hemorrhage a general convulsion and rise in temperature. As to treatment, in those attacks due to hemorrhage, keep ice to the head, keep head high, purge, perhaps bleed; if due to thrombus do not bleed nor purge, nor put ice to head, but keep the head low, give plenty of fluids and keep up nutrition.

Dr. J. P. Simonds of the laboratory of the State Board of Health spoke informally of the work of the laboratory and the manner in which it may be of service to the general practitioner. Beyond doubt the laboratory is not sufficiently appreciated by many physicians, and when its province and methods are better understood it will become one of the most helpful of agencies for diagnosis and the improvement of sanitation.

The regular meeting of the Kosciusko County Medical Society was held February 22. Dr. G. W. Anglin of Warsaw read a paper on "Pathology, Symptoms and Treatment of Burns, with Case Report." Dr. Burket of Warsaw, in discussing the paper, spoke of the value of bicarbonate of soda in light burns. He also recommended castor-oil and the use of iodoform in sterile vaselin. Dr. F. J. Young of Milford suggested the following: (a) Carron oil and absorbent cotton for 24 to 36 hours, then sterile vaselin; (b) etherize and trim off charred tissue and dress aseptically; (c) nitrate of silver gauze-1 per cent. solution. Dr. Yocum of Mentone, president of the society, spoke of the value of sterile vaselin. Dr. C. E. Thomas, Leesburg, mentioned the value of stearate of zinc powder in the treatment of large burns. Dr. W. L. Hines, Warsaw, advised raw linseed oil and soda made up into a mush and applied. Dr. L. W. Ford, Syracuse, called attention to the possibility of producing ptyalism by the use of bismuth subnitrate in the treatment of burns.

Dr. L. W. Ford, Syracuse, was the essayist on the subject, "Diabetes Mellitus-Prognosis and Food Tolerance." In the discussion which followed Dr. Burket spoke of the value of nitroglycerin, but considered the prognosis very bad after the symptoms have become well established. Dr. C. C. DuBois, Warsaw, cited the case of a patient whom he had observed, who had first applied for medical relief in September. At that time the general condition was apparently good, but the urine was found to be loaded with sugar. He died in January in a diabetic coma. Dr. E. E. Haworth, Claypool, spoke of the three main types of the disease from the pathological standpoint—the alimentary, pancreatic and nervous types. He also spoke of the value of a proteid diet and alkaline drinks in the treatment of the disease. Dr. Thomas mentioned the fact that sodium salicylate will sometimes produce sugar in the urine. Dr. C. N. Howard, Warsaw, spoke of the need for care in considering the simple finding of sugar on a first examination as absolutely indicative of the disease, because frequently patients will have sugar as result of an increased ingestion of carbohydrates, particularly around Christmas time. The sugar in the urine then disappears when the amount by mouth is lessened.

Dr. C. W. Burket, Warsaw, read a paper entitled, "The Use and Abuse of Forceps in Obstetrics." In the discussion Dr. C. T. Long, Pierceton, brought out the point that he did not believe in applying forceps simply to save his own time; but uses them more particularly where there is failure of expulsive force and patient is getting worn out. As Dr. Burket has had an unusually long and successful experience with forceps, covering a period of over forty years, much of the discussion was taken up with questions and answers.

It was decided that Dr. DuBois be instructed to procure a blackboard for the use of the society. Adjourned. C. NORMAN HOWARD, Sec.

LAKE COUNTY.

Lake County Medical Society met in regular session in Hammond, January 6. Amendment made to Section 2 of by-laws, changing time of meeting from first to second Thursday of each month.

Dr. J. R. Simonds of Indianapolis read a paper on "Facts Concerning Diphtheria Revealed by Laboratory Examinations at State Laboratory." Some practical points brought out were: 1. Systematic school inspection followed by treatment of pathological throats. Many of these may be diptheria carriers. 2. The fact that a large number of cases diagnosed not diphtheria clinically prove positive on bacteriological examination and vice versa demonstrates the importance of taking cultures from every sore throat regardless of age or severity of symptoms, as also those who have been exposed to diphtheria. 3. All cases with positive findings should be quarantined whether having clinical symptoms or not. 4. An arbitrary time limit of quarantine in diphtheria is not justifiable. Release should be governed by results from throat culture.

An informal discussion by all of the members present followed, with reports of cases.

Dr. W. Weisser of Indiana- Harbor and Dr. White of Hammond were elected to membership. Adjourned.

H. C. GROMAN, Sec.

Dr.

The regular meeting of the Montgomery County Medical Society was held at Crawfordsville, February 15. Papers were read by Drs. J. C. Burkle of New Ross, J. S. Beatty and G. T. Williams of Crawfordsville. Burkle's theme was the "Etiology, Symptoms and Diagnosis of Diphtheria." "The Treatment, Prophylaxis and Prognosis of Diphtheria" were presented by Dr. Beatty, and Dr. Williams discussed the subject of "Tonsillitis. A general discussion followed.

Several members of the County Nurses' Association were present as the invited guests of the society. The subject for discussion at the March meeting will be "Organic Heart Disease." Adjourned.

J. L. BEATTY, Sec.

RANDOLPH COUNTY.

The Randolph County Medical Society met in the Court Library, Winchester, Ind., Jan. 11, 1910, with fifteen members present. The essayist of the day was Dr. C. S. Bond of Richmond, Ind., who gave a talk and demonstration on "Blood Pressure and Its Consequences."

The Randolph County Medical Society met in regular session at the Federal Club in Union City, Ind.,

W. B. Saunders Company, the medical publishers of Philadelphia and London, have just issued a new edition-the thirteenth-of their handsome Illustrated Catalogue. It contains some twenty new books and new editions, and besides numerous black-and-white illustrations, there are two color cuts of special value. We strongly advise every physician to obtain a copysent for the asking. It will prove a ready guide to good medical books-books that we all need in our daily work.

EXAMINATION OF THE URINE: A Manual for Students and Practitioners. By G. A. De Santos Saxe, M.D., Instructor in Genitourinary Surgery, New York PostGraduate Medical School and Hospital. Second edition, enlarged and reset. 12 mo of 448 pages, illustrated. W. B. Saunders Company, Philadelphia and London, 1909. Cloth, $1.75 net.

Among the numerous works on analysis of the urine now published, the second edition of Dr. Saxe's work deserves a foremost place.

In this edition the new subjects introduced are the Cammidge reaction, a section on pentoses, a description of the methods of preserving and staining urinary sediments, and of preparing sediments for bacteriologic examinations, and researches on urethral shreds, vesicular sago-bodies, etc.

The portion devoted to the clinical side of urine analysis has been amplified somewhat. A new chapter on diabetes, as well as one on the toxemias of preg nancy, are of interest.

In the account of the present-day methods of functional renal diagnosis, considerable space is given to cryoscopy, a method that has fallen into disuse because of its unreliability.

The general practitioner as well as the student will find this a comprehensive treatise and a reliable guide in urinary analysis.

TREATMENT OF THE DISEASES OF CHILDREN. By Charles Gilmore Kerley, M.D., Professor of Diseases of Children, New York Polyclinic Medical School and Hospital, etc. Second revised edition. Octavo of 629 pages, illustrated. W. B. Saunders Company, Philadelphia and London, 1909. Cloth, $5.00 net; half morocco, $6.50 net.

The appearance of a second edition within relatively so short a time from the initial one, speaks well for the reception accorded Dr. Kerley's very 'practical work on pediatric treatment.

In the new edition there has been a very satisfactory rearrangement of certain sections that are in thorough keeping with the purport of the work, viz., convenience for ready reference.

In places the work has been abridged, as in the omission of certain illustrative case reports, while enough

has been added to bring the total number of pages over thirty more than in the first edition.

The enumeration of the various general rules to be observed in sickness is most commendable as is the condemnation meted out to the use of artificially-soured and buttermilk as a substitute for modified cow's milk, the criticism having been based on definite series of observations undertaken by the author with disastrous results.

The work remains, as in the former edition, one of the most practical and satisfactory contributions of its kind that has yet appeared.

A PRACTICAL TREATISE ON OPHTHALMOLOGY. By L. Webster Fox, M.D., LL.D., Professor of Ophthalmology in the Medico-Chirurgical College, Philadelphia, etc. Cloth. 810 pages. Price, $6. D. Appleton & Co., New York and London, 1910.

This work is a worthy successor of Dr. Fox's "Diseases of the Eye," which appeared in 1904, and was the outgrowth of a series of lectures delivered by the author at the Medico-Chirurgical College and Hospital. This latter work is a comprehensive treatise on ophthalmology in which not only the author's own views of ophthalmology and methods of treatment have been freely incorporated, but in which has been included references to the many researches and advances which others have made in this department of medicine and surgery in recent years.

As might be expected from one of such wide experience and undisputed operative skill, the discussion of operative measures is particularly comprehensive and interesting as advocating the latest and most approved methods and technique, though the latest therapeutic measures which have yielded reliable results in combating ophthalmic diseases have also been given fully and comprehensively.

Very valuable and well written chapters are those relating to the bacteriology and pathology of the eye, and a special chapter devoted to laboratory technique in which the most approved methods of preparing and staining bacteriological and pathological specimens is given, will prove particularly valuable to the student or practitioner who is just beginning ophthalmological work.

Six colored plates and over three hundred illustrations in the text, many of which are original, add materially in giving a thorough understanding of the subject under discussion.

MYOMATA OF THE UTERUS. By Howard A. Kelly, M.D., Professor of Gynecologic Surgery at Johns Hopkins University, and Thomas S. Cullen, M.B., Associate in Gynecology at Johns Hopkins University. Large octavo of 700 pages, with 388 superb original illustrations by August Horn and Hermann Becker. Philadelphia and London: W. B. Saunders Company, 1909. Cloth, $7.50 net; half morocco, $9.00 net.

No better denomination can be given to this work than to say that it is truly a classic upon the subject of uterine myomata. Based as it is upon a grand total of 1,674 cases with histories and histologic findings almost complete, and supplemented by an unusually rich postoperative record of patients treated, the gynecologist should count himself fortunate indeed to have available this wealth of data. One can readily believe, upon careful perusal of the volume, that the ten years spent by the authors in the study of their material

preparatory to publication, have been busy ones indeed, but remuneration is at hand in the gratitude that is due from the profession for the excellent service rendered.

The volume deals almost exclusively with the work done by those connected with the gynecological department of the Johns Hopkins Hospital and of the Johns Hopkins University, from the opening of the hospital in 1889 to Jan. 1, 1909, a period of twenty years; and while much of the earlier data was incomplete, yet it has all been gone over, recent and more complete pathologic examinations were made, where indicated, and an earnest effort made to bring all records up to the maximum degree of accuracy.

Not the least commendable feature of the work is that their mistakes and failures have been given the same or even greater emphasis by the authors than their successes, and this factor alone adds greatly to the value of the work. One of the world's greatest operative gynecologists on the one hand, and, on the other, a surgical pathologist, especially as relates to gynecology, should be, and are, able to teach as much by their failures and errors as by their cures, for their mistakes are, in the main, those for which there has been ample reason. An instance of this latter statement is the case cited of hysterectomy upon a pregnant uterus, where, although from the appearance of the organ pregnancy was suspicioned, yet the history and physical findings were such as to lead most any obstetrician to exclude pregnancy.

The work abounds with so much that is interesting and instructive that one hardly knows what features to emphasize in a short review.

The mortality record of the series is certainly illus trative of the progress that surgery of the uterus has made, in that whereas the total mortality of the series. taking all cases from 1889 to 1906, was between 5 and 6 per cent, that of the last two and a half years, July 1, 1906, to Jan. 1, 1909, was less than 1 per cent.

Sarcomatous changes were found taking place in fully 1 per cent. of all myomata removed, while in over 2 per cent. there was associated with the myomata carcinoma of the fundus. These points are sufficient to emphasize the importance of immediate examination of the specimen removed in any but the most radical operations upon the uterus.

One of the most interesting features of the work is the analysis of the autopsy records as concerns uterine myomata, from the opening of the hospital in 1889 to July 1, 1906. Out of 2,740 autopsies held, complete data are available in 2,729 cases, certainly a remarkable showing. From this study we learn that in about 20 per cent. of all women 20 years of age or over, coming to autopsy, the uterus is the seat of a myomatous growth, and that while only 10 per cent. of white women are thus affected, 33.7 per cent. of all black women of the age mentioned are subjects of uterine fibroids.

The illustrations in the work are most excellent, coming as they do from the hands of Messrs. Horn, Becker and Brödel, which, as the editors remark, precludes further comment.

One or two slight typographical errors have crept in, but on the whole the work of the publishers is in thorough keeping with the excellence of the contents.

ALBERT E. BULSON, Jr., B.S., M.D.. Editor and Manager

VOLUME III

NUMBER 4

ORIGINAL ARTICLES

VACCINATION PROPHYLAXIS IN TYPHOID FEVER.*

METIUS M. ECKELMAN, A.B., M.D.

ELKHART, IND.

My only apology for presenting this paper to-night is that, having failed to offer voluntarily a subject to help make up the first half year's program, your committee assigned this subject to me. I have had no personal experience with antityphoid vaccination, and the matter given you has been gleaned from the literature with the hope of acquainting you with the subject from its inception to the present date, as well as with the general principles necessary for its correct understanding.

In 1798 Jenner announced his discovery of vaccination as a prophylactic against smallpox. By referring to our text-books we see that smallpox is classified as an infectious disease, along with typhoid, malaria, and a host of others. And by an infectious disease we understand one whose causation is bacterial, or rather micro-organismal, whether the micro-organism has been isolated or not. And so, as smallpox is placed in the same category with typhoid and other infectious discases, the question naturally arises, Does it not seem strange that so many years intervened between the discovery of vaccination for smallpox and vaccination for other infectious diseases? To this question we readily answer, No, for we know that the discovery of vaccination in smallpox was not one of a truly scientific nature, but rather a haphazard discovery. And, furthermore, we know that we do not understand by vaccination as applied to smallpox what we understand by vaccination as applied to typhoid and

Read before the Elkhart Academy of Medicine, Nov. 16, 1909.

other infectious diseases. In the one it is cowpox; in the others it is the bacterial vaccines, or what we sometimes call the "bacterins." We see, therefore, that the investigations carried on in the infectious diseases at the present day are truly scientific. They depend largely upon a knowledge of bacteriology and upon that department of bacteriology which we know as immunity. And in order to understand our subject to-night it is necessary to review briefly certain of these principles of immunity-principles which, thanks to the American Medical Association's post-graduate studies pursued in this academy last winter, are quite at my tongue's end.

By immunity we mean the power to resist disease divided into natural and acquired. Natural immunity-the inherited immunity of certain species and varieties of animals. The lower animals cannot become infected with scarlet fever or measles, nor man with chicken cholera. It is also inherited family or individual immunity. Some families are immune from tuberculosis, or one child may contract scarlet fever, while a conditions, may escape it. brother or sister, living under exactly similar

Acquired immunity-that immunity which protects one from a second attack of the same disease divided into active and passive. And here let us try to get a clear conception of what is meant by active immunity and what is meant by passive immunity. Dictionaries and textbooks do not appear to make the matter clear. By active immunity is meant the immunity which is produced by injecting the bacteria or toxins directly into the one to be acted upon, while by passive immunity we mean the immunity produced by the injection of ready-made immunizing substances prepared through the serum of other animals. In the preparation of the various antitoxic and antibacterial serums for commer

cial use (diphtheria antitoxin, for example) a condition of active immunity is deliberately proNuced in the animal by the injection of the toxins or of the bacteria, while the serum of that animal injected into man produces a case of passive immunity. Both active and passive immunity may be either antibacterial or antitoxic. In the antibacterial we have the bacteria secreting soluble toxins, the bacteria themselves remaining intact.. As in the case of tetanus, the soluble toxin is secreted by the bacteria in the wound where they reside. This poison or toxin is carried from the wound to the nervous system through the lymphatic or blood circulation, the bacterium itself not being transported. By the introduction of an antitoxin we have this soluble toxin neutralized without necessarily injuring the micro-organism itself. In the antibacterial we have no soluble toxins secreted by the bacteria, but the poisonous substances seem to be integrally associated with the bacterial protoplasm. They are spoken of as intracellular toxins, or endotoxins. These endotoxins are liberated only after the bacteria have been killed and dissolved. To those of us to whom the bacterial vaccines are unfamiliar we wonder what they are, and think at once that perhaps they are like the antitoxin of diphtheria. This leads us, then, to formulate our own definition of a "vaccine" and of an "antitoxin" according to these terms of immunity. By a "vaccine" we mean a substance composed of bacteria inoculated into the human system for the purpose of producing an acquired active antibacterial immunity. By an "antitoxin" we mean a suitable serum of another animal inoculated into the human system for the purpose of producing an acquired passive antitoxic immunity. We see that an antitoxin, then, is capable of producing only a transient immunity, that is, one lasting only a few hours to a few days, while a vaccine is one capable of producing a more lasting immunityone extending over a period of from six months to two or three years. For any infectious disease, then, capable of forming either an antitoxin or a vaccine, we see that the vaccine is the more preferable because it produces a more lasting immunity. The leading diseases for which antitoxins can be formed are diphtheria and tetanus, and the leading diseases for which vaccines can be formed are typhoid, cholera, plague and anthrax.

We should also mention the law of phagocytosis. The great Metchnikoff observed that the successful resistance of an animal against bacteria depends upon the power of certain white blood corpuscles known as phagocytes to destroy

the invading bacteria. And then comes Wright, who goes a step further and explains that this power of phagocytosis is due to certain substances in the blood which he calls "opsonins.”

I have just stated that the principal diseases for which vaccines can be formed are typhoid, cholera, plague and anthrax. It is interesting to see how typhoid vaccination came about. It was Pasteur who first adopted preventive inoculation in the case of anthrax by the use of cultures of living attenuated micro-organisms. It was Haffkine who next made preventive inoculations against cholera and plague along the same lines as Pasteur. Haffkine, knowing of Wright's large experience with typhoid fever in the British army, suggested to Wright that he carry out the same treatment in typhoid by the use of living attenuated micro-organisms. But here is just where Wright balked. He said he would not run the grave risk of disseminating the germ of the disease and of producing the disease in a very grave form in a patient especially susceptible to the infection by the use of living bacteria; that if such a grave experiment as that were expected to be carried out at his hands, it would never be carried out at all. But about this time Wright was in communication with Professor Pfeiffer, who told him he was able to produce in man the specific agglutination reaction to typhoid by the subcutaneous inoculation of heated typhoid cultures. This changed the situation and led up to Wright's discovery of the production of typhoid vaccine by the use of dead bacteria instead of living, the first two cases of which he reported in the Lancet in September, 1896.

In considering the mechanism of typhoid vaccination we find that it is of a chemical nature, but just what its chemistry is is still involved in obscurity. It has to do with the protoplasm of the typhoid bacillus, and especially with the proteid elements of that protoplasm. As far as we now know, the process of immunization in typhoid is a specific reaction on the part of the body cells to the protein molecule making up the cellular structure of the bacterium. We know that by the introduction of a vaccine we have certain antibodies formed; or what Wright calls antitrophic elements or more briefly antitropins. The inoculation of bacterial elements is responded to by the elaboration of bacteriotropic elements. By inoculation with the typhoid bacillus we have typhotropic elements formed.

And let us see in what different ways the antitropins may render protective service to the organism.

1. An antitropin may combine with the chemical element to which it stands in antitropic rela