MANUAL OF OPERATIVE SURGERY. By H. J. WARING, M.S., M.B., B.Sc., F.R.C.S. Third Edition. London, Oxford University Press, 1909. Price, $3.75.

This book gives the surgeon and student a good practical description of the operations of surgery. It takes up the various operations and under each gives the indications for its performance, the selection of instruments, the technic of operation, and the after treatment. It also gives the general principles of surgery together with asepsis and anesthesia.

In describing vaginal hysterectomy and supra vaginal amputation of the cervix, the author, as in the first edition, still advises making the incision into the anterior fornix before incising the posterior fornix. Otherwise the book has been thoroughly revised. Many new pictures have been added. It is a practical book, and this edition is immensely superior to the previous editions. A SYSTEM OF Operative SurGERY. By Various Authors. Edited by F. F. BURGHARD, M.S., F.R.C.S. In four volumes. Vol. I. London, Oxford University Press, 1909. $40 per set; $10 per volume.

This is the first volume of this system of operative surgery which is to be written by twenty-five of the foremost surgeons of Great Britain. The editor is well known for his work in connection with other publications, especially Cheyne and Burghard's Manual of Surgical Treatment. By having a work such as this written by a large number of representative surgeons and the whole publication edited and supervised by so competent a surgeon and author as Mr. Burghard, an authoritative publication is bound to be secured.

This first volume deals with the principles and technic of wound treatment by C. B. Lockwood, Surgeon to St. Bartholomew's Hospital; methods of local analgesia, by Capt. J. W. H. Houghton, of the Royal Army Medical Corps; amputations, operations upon arteries, veins, lymphatics, nerves, muscles, tendons, tendon sheaths, bursal, and operations for non-tuberculous affections of bones and joints, by Mr. Burghard; and plastic surgery, by T. P. Legg, Surgeon to the Royal Free Hospital.

This book is practical, the illustrations are excellent, and it displays all of the evidence of careful preparation. The illustrations not only have the merit of showing what they are intended to show, but they are surgically correct and artistic. We believe that this work will be of much service and highly prized by the surgeons.

FIVE HUNDRED SURGICAL SUGGESTIONS-PRACTICAL BREVITIES IN DIAGNOSIS AND TREATMENT. BY WALTER M. BRICKNER, B.S., M.D., and ELI MOSCHCOWITZ, A.B., M.D. Second Series. New York, U. S. A. Surgery Publishing Co., 1907. 108 pp., 12mo. Price: Cloth, 50 cents.

This small volume consist of 500 short paragraphs on various surgical subjects. A few examples will give an idea of the quality of the book: "In determining whether or not to operate after injuries to the head, a surgical judgment of the case is usually better than one based strictly on the application of neurological rules." "At the onset of an attack of acute appendicitis the pain is usually referred to the gastric region."

"Patients will appreciate the use of black bandages for the scalp, where they are comparatively inconspicuous, and for the hands, where they do not soil."

Many of the "suggestions" seem sufficiently obvious, a few are obscure. A number of useful "wrinkles" are to be found scattered through the book.

DEATHS.

JOSEPH H. CHITTENDEN. M.D., of Binghamton, N. Y., died April 14, 1909.

ALBERT GROVES ELLENWOOD, M.D., of Attica, N. Y., died March 26, 1909.

CYRUS FULTON, M.D., of Lyons, N. Y., died March

22, 1909.

JOURNAL OF MEDICINE

RESOLUTION ON DEATH OF DR. WEY.

At a regular meeting of the Board of Health, held in and for the city of Elmira, April 13, the following resolutions were passed upon the death of Dr. Wey:

WHEREAS, This Board has learned with profound regret of the death of Hamilton Dox Wey, the Health Officer of the city of Elmira, N. Y., at Callo, Peru, on the 17th day of March, 1909; it is

Resolved, That the following memorial to the deceased be entered in the permanent minutes of this Board:

Hamilton Dox Wey was born at Wilkes-Barre, Pa., on the 29th day of July, 1854. He secured his preliminary education at the public schools and Academy at the city of Elmira and at St. Paul's School, Concord, N. H., and his professional education at the College of Physicians and Surgeons of New York. Upon being admitted to the practice of medicine he located in Elmira, where he practiced continuously until the time of his death.

Dr. Wey served several terms as Health Officer of the city of Elmira, N. Y., and in that capacity performed great and enduring services for the public health of the city. As Health Officer, he established an efficient system of laboratory aids in diagnosis of disease. He was largely instrumental in the rebuilding of the Detention Hospital of the city and contributed largely to the work of preparing the Sanitary Code of the city of Elmira. He was honored by his profession in the State of New York by being elected to the Presidency of the Medical Society of the State of New York, in which capacity he served with great distinction. In this office Dr. Wey was a successor of his father, thus possessing the unique distinction of being the only son who succeeded his father in this office. Dr. Wey served two terms as President of the Elmira Academy of Medicine and one term as President of the Chemung County Medical Society, and for many years was a censor of both organizations. He was regarded as an authority on many subjects pertaining to his profession and contributed works and papers to the literature of medicine, surgery and criminology, which are of great force and value. He was the Medical Officer of the New York State Reformatory for twenty years and instituted the system of physical culture now in force at that institution. He was a close student of infant criminology and was regarded as an authority on that subject.

Dr. Wey early attained a position in the front rank of his profession, which he occupied until the time of his death. His knowledge of his profession was thorough, his skill was great and he kept pace with all discoveries appertaining to medicine. His experience was wide and comprehensive and he was admirably equipped for the performance of the arduous and exacting duties of a physician. He had the highest regard for the best ethics of his profession and held firmly at all times to its ennobling traditions. His fidelity to his patients was strikng and he never failed to respond to the call of those who needed his services. In recent years when stricken by severe physical infirmities he responded to the call of the sick at great personal sacrifice, and at such times exhibited the greatest courage and fortitude. One of the chief characteristics of Dr. Wey was his firmness and devotion to duty. No matter how distasteful the task, if he regarded it as a duty, it was done. It might truly be said of him, "In him there was no changing or shadow of turning." Dr. Wey was a man possessed of great personal dignity. His manner at times was austere, but to those admitted to the intimacy of his friendship he was a most delightful companion. The passing of Dr. Wey is a distinct loss to his profession and to the city of Elmira; it is further

Resolved, That a copy of this memorial be published in all the papers of the city of Elmira, N. Y., and a copy transmitted to the family of the deceased.

Vol. IX.

P

EHRLICH'S SIDE CHAIN THEORY. ROBABLY the greatest discoveries in medical science during the latter part of the century just past, and belonging to the very greatest of the epoch-making discoveries in all medical history, are those of Prof. Paul Ehrlich, of Germany, of the now famous Side-Chain Theory; and of Eli Metschnikoff of the Pasteur Institute in France, of the equally famous phenomenon of Phagocytosis. These taken together, with the more recent Opsonin Theory of A. E. Wright, of England, form the basis of our present knowledge of the nature of immunity to infectious diseases. The concepts of these investigators are, in a certain sense, developments from the older doctrines, on the one hand of the humoral pathologists (Ehrlich), and on the other of the solidists, or cellular pathologists (Metschnikoff, Wright).

As an interesting picture of the intense eagerness of these great men in their work, this story may be told of Ehrlich when he visited Wright in London.

They lunched together at a restaurant, and Ehrlich consumed most of the time writing graphic formulæ of his side-chain theory upon some cards he picked up on the lunch counter. When the bill was rendered, he was surprised to find several shillings charged up for the cards; and, on investigation, discovered that they were excellent picture postals of places of interest in England.

Ehrlich's side-chain theory predicates, that

No. 6

the somatic cells of our bodies contain groups of molecules with unbonded or free ends

"receptors"-capable of becoming bonded and attached to extracellular molecular groups, and also capable of becoming detached from the cells, under certain conditions. The extracellular molecules are of various kinds and derived from various sources-food, bacterial products, etc., and differ in their effects upon the intracellular molecular groups, or side-chains. Some nourish the cells, some stimulate or depress them, while others poison them. In the application of his theory to the problem of immunity, Ehrlich assumes three varieties of side-chains, receptors or intracellular molecular groups, as follows:

I. Those of the first order, which lock to a molecule of toxine, and by over-production make anti-toxines, which neutralize toxic molecules.

2. Those of the second order, which may lock to toxic molecules and cause them to precipitate, thus constituting precipitines; or lock to bacteria and cause them to cohere, thus forming agglutinines.

3. Those of the third order which, when locked to certain receptors of bacteria, or foreign cells, destroy by dissolving them.

The chemistry of these processes is complicated and not wholly understood; but they are known to constitute a part of the mechanism of defense of living tissues against toxines, and parasites.

A brief description of what is really supposed to occur in the course of cell activity in this ef

fort to combat the evil influences of parasites and their toxines may be made as follows, taking the three molecular groups in their order: 1. Anti-Toxic Molecular Groups.-The best and widest known reaction in this first order of receptors is that originally described by von Behring of immunization to diphtheria. Injection into living tissues of minute quantities of the toxine of Loeffler's bacillus diphtheria, and subsequent injection at regular intervals of slowly increasing doses of the same toxine, causes the production in the cells of the body of a specific side-chain, or receptor of the first order, which has the power to lock to and neutralize, or render inoccuous, a certain quantity of the diphtheria toxine. According to the law of over-production, as time goes on these receptors far exceed in number the molecular groups of toxine, and are shed from the cells in a manner analogous to the shedding of the plumes of a dandelion after it has ripened, and circulate, suspended in the blood and lymph (Humoral pathology). These free specific receptors thus contained in the blood serum constitute the antitoxine of the market.

2. Precipitine and Agglutinine Groups. In this second order of side-chains, certain specific intracellular molecular groups respond to other specific extracellular molecular groups, either emanating from or remaining in the substance of the invading parasites, and, by their locking or combining properties, cause either precipitation of the free molecular groups, or agglutination of the parasites themselves. The actual physical phenomena are, first, in the case of a precipitine, the throwing down of a fine deposit in a test tube containing in solution free molecular groups from the specific parasite, to which has been added serum from the blood of the animal invaded by this parasite; second, in the case of agglutination, certain intracellular molecular groups responding to molecular influence from specific parasites, cause these parasites to adhere to each other in clumps, very much as do red blood corpuscles in a drop of blood, under the microscope. From a practical viewpoint, this group has proven very important; for upon the phenomena here involved depend certain reactions of clinical diagnostic value; e. g., detection of traces of human blood in forensic medicine, the Widal reaction in typhoid fever.

JOURNAL OF MEDICINE

Cytolysines.—This

third

3. Bacteriolysines, order of side-chains or intracellular molecular groups has formed the basis of an enormous amount of the highest grade of scientific investigation, and involves phenomena of a more elaborate nature than the mere shedding of side-chains capable of locking to and rendering inert toxic molecules from a pathogenic micro-organism under the influence of such organism in the tissues of the host. Here, it would seem to the writer is displayed the consummate genius of the discoverer of the sidechain theory; and here, also, do we find results which crown forever the works of such men as Fodor, Buchner, Pfeiffer, Bordet, and Ehrlich in a splendid and untiring effort to unravel the mysteries of immunity to disease. The power possessed by a living being of destroying, by dissolving, bacterial or animal cells, seems to depend upon the presence in the circulating fluids of the living being, of at least two molecular groups, each having specific origin and properties, and both being essential to cell destruction. If living cholera vibrios be sown in minute quantity into the peritoneal cavity of a rabbit or guinea pig, and if, after the lapse of a certain period, serum be withdrawn from the peritoneal cavity of the animal thus treated, the cholera organisms will be seen to be splitting up into fine granules (Pfeiffer's phenomenon). If the red blood cells of a rabbit be injected in small quantity into the peritoneal cavity of a guinea pig, they will, after a time, disappear. What seems more remarkable is the fact that, in the course of such experiments the animal thus treated acquires increasing power to destroy these foreign bacteria and cells, and in this way becomes immunized. The fundamental principle involved must be regarded as identical with that obtaining in the production of receptors of the first order, i. e., over-production of molecular groups, which, while more complex than those of the first order, are, nevertheless, similarly endowed with specific activity. In brief, the phenomena presented by Ehrlich's third group may be best described by considering what takes place in the process of hemolysis. The rabbit's red blood cells in the circulation of the guinea pig, excite overproduction of a molecular group, having two distinct properties; first, the power to lock to a receptor of the red blood corpuscles of

June, 1909

the rabbit; second, the power to lock to a molecular group, which seems to be normally present in the blood serum of most (if not all) animals. This molecular group has been denominated alexine (Buchner) complement, because of its relation to the molecular group from the guinea pig's red cell which cannot destroy the rabbit's cell without being locked to the complement. The origin of complement is not yet absolutely certain, although, since the master-work of Buchner, the white blood corpuscles, and principally the polymorphonuclear-neutrophiles are supposed to furnish it. The complement is itself complex, containing at least two important groups of atoms; first, those which possess the power to lock the group from the guinea pig cells; second, those which possess the power to so sensitize this group when locked to it, as to render it destructive to the rabbit's red blood cells when both are locked to its specific receptor. In other words, a specific receptor (3d order) from the guinea pig's cell-called "amboceptor" or "immune body," locks to a molecular group called complement and normally in blood serum, and the two thus combined, when locked to the receptor of the rabbit's cell, will dissolve this cell. This phenomenon is called hemolysis, and typifies all simiar actions on foreign cells in general and bacteria. The sensitizing power of the complement seems to depend upon a group of atoms in its molecular complex, having the nature of an enzyme, and called a zymotoxine. This atomic group is thermolabile, for, as Bordet first showed, when complement is heated for a half hour at 56 degrees c., it loses its power to sensitize the amboceptor, but regains it upon the addition of fresh normal serum.

The solid, or cellular pathology of immunity has been brought into prominence by the celebrated discovery of Eli Metschnikoff, of what he has denominated phagocytosis. This phenomenon consists of the action of the white corpuscles of the blood principally, possibly other cells of the body-connective tissue corpuscles, endothelial cells, etc., in consuming and digesting bacteria and other parasites. These phagocytes are chemotactic to the parasites; that is, they respond to chemical influence exerted by the parasites—an influence produced, according to Metschnikoff by substances elaborated by the parasites and called by him "stimulines," and

supposed by him to furnish the active principle in passive immunity. Not all parasites are capable of exciting chemotaxis, a fact which is supposed to account for the absence of lencocytosis in such diseases as typhoid. Metschnikoff's work has helped to place our knowledge of inflammation upon a scientific basis.

The last of this group of known phenomena in the process of immunization has been promulgated by A. E. Wright, who discovered the remarkable fact, that emulsions of dead bacteria excite tissue reactions which, in many instances, greatly augment their power to antagonize and conquer invading parasites. His teaching is, that the presence of dead bacteria in living tissues causes the production of a molecular group which acts to sensitize the living bacteria of the same species infecting the tissues, in such manner as to increase chemotaxis, and, therefore, phagocytosis. This substance he denominated "opsonine;" and he further devised a method whereby an index of the opsonic action could be formulated. This consists in the very simple but somewhat difficult technical operation of comparing the phagocytic power of the white corpuscles of a healthy person taken as a normal standard, with that of an infected individual

before, and after vaccination with the emulsion

of dead bacteria. White cells from normal blood are mixed with a known dilution of living bacteria, c. g., the staphylococcus pyogenes aurens, and after a certain interval of time, at a temperature of 37.5 degrees C., a smear preparation is properly stained, and the number of staphylococci incorporated in the phagocytes is averaged. This forms the normal opsonic index to the staphylococcus. The same operation is then repeated with the blood of an individual infected with say a furuncle-before and after vaccination. It commonly obtains that after the vaccination, phagocytosis is shown, by taking the opsonic index, to be markedly increased. Aside from its scientific value, this method of vaccination has proven of great clinical value in many varieties of infection.

This very brief sketch of the more important phenomena of immunity, leads to the following conclusions: First, no single phenomenon, but a number of phenomena are concerned in protecting the body tissues from parasites and their toxines. Second, immunity must be classified under two great heads: 1, Natural; 2, Acquired, and acquired immunity may be further

subdivided into active and passive. In natural immunity, the individual is already protected against parasitic invasion, as, e. g., in the natural immunity of the white rat to anthrax.

Of acquired immunity there are two kinds: (a) active; (b) passive. Active immunity results from the reactionary processes called forth by the presence in the tissues of living parasites. Passive immunity results from the injection into the affected individual's tissues of a serum, or vaccine, or both, or the use of some chemical known to possess specific neutralizing powers, such as atoxyl in trypanosomiasis. Third, that the present tendency of scientific opinion is towards the belief, that the processes of immunity consist in a combination of the phenomena comprehended in the doctrines of the humoral and cellular pathologists.

J. M. VAN COTT.

THE TREPONEMA PALLIDUM AND

T

SYPHILIS.

the zealous scientific spirit of Schaudinn we owe the discovery of the specific inciting agent of syphilis-the Treponema pallidum. This discovery, modestly proclaimed, furnished a new point of orientation in the study of luetic etiology and pathology, and has further served to place specific therapy upon a more rational basis.

The Treponema pallidum (formerly the Spirochaeta pallida) is probably a protozoan. It may be briefly described as a motile spirillum 4 to 14 microns long, about 0.25 microns wide, and having sharp convolutions. The number of its convolutions, the degree of their angularity, the slenderness and refraction of the cell body and its slight affinity for the usual laboratory stains constitute a complex of definite diagnostic char

acters.

The presence of this microorganism is easily demonstrable in the untreated lesions of both the primary and secondary stages, and to a certain degree-depending upon the mode of examination employed-in the gummata of the tertiary stage. In all of these lesions it appears to be present in greater abundance at the juncture of the sound with the necrotic tissue. The serum from such a locus, when examined microscopically in the fresh state by means of the

recently developed appliances for the production of dark-ground illumination, usually exhibits the Treponema in sufficient numbers to render a diagnosis immediately practicable. When this method is unavailable a drop of the serum may be spread on a glass slide as in making a thin blood film, and when properly fixed and stained (preferably with the Giemsa solution according to a recently modified procedure), the Treponema may be demonstrated with an accuracy rendering its diagnosis a matter of comparative

ease.

In some of its biological characters it is relative to the non-pathogenic spirilla of the mouth (Spirochaeta dentium, Spirochaeta buccalis) the spirochetes of balanitis, and to the spirochata refringens of chancroidal lesions, yet in the manifestations of its pathogenicity it is unique. The lesions of the primary and secondary stages of syphilis are richer in Treponemata than are the less active manifestations of the tertiary stage, yet the presence of this spirillum in all luetic lesions affords proof of their infectivity. Toward this infection man apparently possesses no natural immunity, the only means of protection being the sound and unbroken epidermis. Let material from a syphilitc lesion come in contact with a break in the skin of mucous membrane and, unless immediately prophylactic measures are applied, infection inevitably follows. Contrary to the older theories the infection does not remain temporarily localized. While a period initial exhibition of the infection at the point of about twenty-one days elapses before the of inoculation, yet during this period the Treponema pervades the body tissues and a general systemic infection results. By the demonstration of these spirilla in the primary lesion an immediate diagnosis is possible, whereas prior to the establishment of the identity of the infecting organism the appearance of the secondary eruption was awaited in order to confirm an uncertain diagnosis. Recent experiences seems to show that treatment when begun immediately upon the finding of the Treponema in the primary lesion tends to abort the more serious ultimate manifestations of the disease.

The facts pointing to the Treponema as the specific agent in a syphilitic infection are its almost constantly observed presence in the specific lesions of man, its presence in the lesions of experimental syphilis in apes and rabbits, and its absence from all lesions of a non-syphilitic na