pneumonia. Of the pneumonias occurring in this age-period a large majority are true lobar pneumonia. Fifty-eight and one-half per cent. of the population of the United States and 66.5 per cent. of the population of cities are between the ages of 15 and 60. The incidence of lobar pneumonia on a major part of the population is therefore diminishing.

"2. The returned mortality of the United States for ages above 60 indicate that the mortality from the class of respiratory diseases commonly returned as pneumonia has increased from 21.9 per cent. to 22.6 per cent. in 10 years, the population at the same age in the same period having increased from 6.2 to 6.6 per cent. The urban mortality for the same age has grown in 10 years from 16.1 per cent. to 19.5 per cent., and has been accompanied by an increase of population in that age-period laterally from 5.23 to 5.27 per cent. Several pathologic conditions added to the group of pneumonias, and not provided for in statistics, are included in the returned mortality of pneumonia for ages above 60. For 6 per cent. of our total population lobar pneumonia may have increased in the past 10 years, though satisfactory evidence of an increase has not been. offered.

"3. The returned mortality of the United States for ages under 15 (about one-third of the total population) shows an apparent rise of mortality for the group of respiratory diseases commonly classed as pneumonia. The acute respiratory diseases of children were in former years commonly mistaken for affections of the nervous system. Year by year for 30 years increasing numbers of deaths formerly found in the indefinite accounts and in the class of nervous diseases have been transferred to the class of respiratory diseases, and especially to the pneumonia account. Of the mortality recorded as due to pneumonia under the age of 15 years not more than 10 per cent. is due to lobar pneumonia. A small, though considerable, incidence of lobar pneumonia in children under the age of five has come into view of late years, but there is no evidence that lobar pneumonia has increased in this age-period. The remaining 90 per cent. of the recorded mortality ascribed to pneumonia includes the conglomerate group of broncho-pneumonias, nearly all of which are secondary or complicating causes of death, and should be referred in the mortality tables to the primary causes. of death.

"4. Since 1890 a new cause of infantile mortality has come into view, an acute respiratory infection, attacking infants of two years old and under, commonly returned under the diagnosis of pneumonia, sometimes returned as due to a disease of the nervous system, and probably due to influenza.

"5. The mortality registration of American cities is in general. very poor. The crude rates and ratios offered by certain cities as evidence of a rising pneumonia mortality are inconsistent with the mortality statements concerning other causes of death and with the characteristics of the populations concerned. They represent

a perversion of statistics which must eventually bring discredit on American mortality registration."

THE TREATMENT OF CANCER BY SUBCUTANEOUS INJECTIONS. Renault (La Presse médicale, November 16, 1904) discusses the results obtained by Adamkiewicz and others in the treatment of carcinoma by the method of subcutaneous injection originally described by Adamkiewicz. According to the Viennese professor, carcinoma must be considered a parasitic affection of which a special toxin isolated by him from the carcinomatous secretion and designated cancroin is the material which destroys and affects the normal tissues. From his point of view the chemical composition of this substance is a combination with carbolic and citric acid of a trimethylated base of ammonium. His treatment consists in subcutaneous injections of cancroin, the dose being progressively increased from 2 to 2 c. cm., the dose and number of injections being regulated by the reaction produced and the improvement noticed. As a rule, the effects are very rapid and the results obtained are manifest very soon.

Recently Adamkiewicz (Aertzliche Rundschau, 1904, Nos. 21 and 24) reports 18 new cases which he has treated by this method, including seven cases of cancer of the breast, two of the uterus, two of the intestines, two of the stomach, and five of various other portions of the body. In regard to the first of these, the majority of cases had already undergone one or several operations when they were seen by Adamkiewicz. In these cases the improvement noted after the injections was very marked. In two cases of epithelioma of the cervix uteri the improvement noted after the injections is extremely marked, and was characterized not only by an improvement in the general health of the patient, but by the complete cessation of the local symptoms, notably pain and hemorrhage. In all these 18 cases marked amelioration of symptoms and in some apparent cure were produced, notwithstanding the fact that one of the patients was 79 years old, another 72.

According to Renault, these and previous observations of cases treated by the same method demonstrate beyond a doubt that cancroin has an undeniable effect upon cancer, whatever its situation. Adamkiewicz has never pretended to claim that by this method all cases of cancer may be cured. He does, however, affirm that his serum possesses sufficient power to eliminate the parasite and in the least hopeful cases to undoubtedly prolong life. So much adverse criticism has been published of late in regard to the parasitic theory of cancer that one cannot help feeling indisposed towards accepting any treatment based on such an hypothesis; nevertheless the clinical results obtained by Adamkiewicz and others are so favorable that the method should not be generally condemned, but more cases should undoubtedly be tested by cancroin, so that its real effects may be more definitely determined.

THE EXPERIMENTAL STUDY OF CONSTIPATION.

Glaessner (Wiener klinische Wochenschrift, 1904, No. 45) gives the results of his experiments on animals in regard to constipation which he has been recently carrying on and which he reported to the Medical Society of Vienna on November 4, 1904. After first insisting upon the importance of a better comprehension of this condition, and the fact that all grades of constipation, both as regards degree and variety, are to be met with, he takes up first the various views held in regard to this condition, notably the view first suggested by Bouchard and later insisted on by Müller, that the majority of cases are characterized by an autointoxication from the gastrointestinal tract, which is of especial importance in the explanation of the multitude of symptoms produced in this condition. It was Nothnagel who first insisted that in some cases the condition might be purely functional-in other words, where the etiology of the condition is to be found in disturbances of the intestinal nerve and muscle apparatus, a view which Schmidt and Lohrisch have considerably emphasized. According to the last of these it is due to the presence or the formation of substances not sufficiently irritating that this type of constipation is produced. Another type is that in the etiology of which changes of a chemical nature play an extremely important rôle.

Glaessner has devoted his attention largely to attempts at producing constipation artificially in animals and to studying the deviations from the normal metabolism produced by this artificial constipation. At first he attempted to produce this by the administration of enormous doses of opium, but he found that no definite changes in the secretions were produced by this method. In the second place he produced an artificial stenosis of the intestines by surgical means, but he found here, again, no essential change produced. Recently he has followed the suggestion of Prutz and Ellinger and produced constipation by the production of antiperistalsis, that is, by section of a certain portion of the intestine and its anastomosis in the reversed direction. By this means lasting constipation was produced, associated with a marked dilatation of the proximal part. Animals treated this way became gradually more and more emaciated, notwithstanding the administration of large amounts of food and the presence of a good appetite.

Very careful determinations were made regarding the various secretions in these cases, which, of course, presupposed the careful weighing of all the food administered. Nitrogen determinations of feces and urine were made-in other words, the attempt was made to determine just exactly what was the effect upon the bodily secretions of the gastrointestinal autointoxication produced by this extreme constipation of experimental type.

The special change noted was that while under normal conditions the nitrogen in the feces was present to a large extent as coagulable albumen, in the cases of experimental constipation this is not the case, but the amounts of coagulable and noncoagulable albumen were approximately the same. There were also present more

products of proteid destruction than under normal conditions, especially of a basic nature; also there was a diminution in the stools of the animals experimented on of nitrogen and of total dried residue.

The urine showed a gradual increase in nitrogenous excretion, but the most interesting fact shown in this connection was the fact that although the ammonia excretion was normal immediately after a stool, there was a steady increase in its excretion from that time until the next movement, sometimes reaching an amount more than twice the normal. This is peculiarly interesting in relation to Czerny's views regarding acid autointoxications.

While these results are not especially striking in their practical application, they are of interest in suggesting some of the effects which may be due to constipation, in the hope that further investigations may be stimulated thereby.

REVIEW IN SURGERY.

Under the Supervision of Wm. A. Fisher, M.D., of Baltimore. TOTAL EXCLUSION OF THE LARGE INTESTINE IN COLITIS ULCEROSA. Ludwig Moszkowicz, M.D. Mitteilungen a. d. Greuzgebeiten d. Med. u. Chir., Band XIII, Heft. 4 and 5.

Moszkowicz opens his paper with an enumeration of the opera

tions for ulcerative colitis as follows:

Enteroanastamosis: anastamosis between ileum and sigmoid or ileum and rectum, producing a total exclusion of the colon above the anastamosis; 2. Anus in the ileum; 3. Anus at cecum or on ascending colon; 4. Anus on descending colon or sigmoid; 5. Valve fistula at cecum.

Nehrkorn prefers a colostomy placed as low as possible, since the discharge is less annoying to the patient, and is opposed to any of the forms of anastamosis on account of the weak condition of the patients, and because without a fistula no local treatment can be carried out.

Moszkowicz gives the history of a patient upon whom he did a colostomy in the transverse colon (as recommended by Nehrkorn) for ulcerative colitis. The patient improved rapidly under treatment with irrigations and gained weight; the stools reduced in number, and only occasionally was there any blood passed through the anus. At the end of six months, however, the patient declared that she could not stand the artificial anus any longer. For this reason half the transverse colon, the descending colon, and sigmoid were excised, but the patient was badly shocked and died two days later. At autopsy it was found that the colon was ulcerated from the colostomy as high up as the ileocecal valve. Therefore in this case, as in many others, a fistula in the cecum or in the ileum would have been better.

The great objection of patients to a fistula, especially in men of middle age who would be prevented from engaging in almost any occupation, and the possibility of cicatricial stricture following deep ulceration, induced Moszkowicz to undertake a series of experiments on animals to determine whether an operation which would not be too long or too severe for patients in a weakened condition could not be devised which would entirely exclude the large intestine and at the same time allow the feces to pass out through the anus under control of the sphincter.

He therefore operated upon five animals in the manner described later, except that in the case of the first two no attempt was made to form a substitute for the ileocecal valve. In the case of the last three animals a valve was formed which was very successful, the latter animals having stools of much firmer consistence and much less frequency. All the animals died, but from causes which could be prevented in man.

The experiments proved two important points-i. e., the operation was well borne and there was continence of feces. The technical details of the operation were worked out on the cadaver as follows: The patient is first placed in the lithotomy position, and a transverse incision about 5 cm. long is made close to the border of the anus anteriorly. In men the upper border of the prostate is exposed by blunt dissection, then the base of the bladder and seminal vesicles. This brings you to the recto-vesical fold of the peritoneum. In women the dissection of the rectum from the vagina is easier, and brings you to the recto-uterine fold of the peritoneum. The perineal wound is then packed with iodoform gauze and the patient put in the Treudelenberg position for laparotomy-median incision. The ileum is divided transversely about 20 cm. from the ileocecal valve, the mesentery being longer at this point. The peripheral end is then closed with sutures, and the central end covered with gauze held in place by a silk suture whose ends are left long. The ileum may be lengthened about 10 cm. by carefully making a nick in the mesentery, which allows it to pull well down to the perineum without tension. The cul-de-sac of Douglas is next exposed and the peritoneum incised over the iodoform gauze, which is seen shining through. The end of the ileum is pushed through this opening, and the ends of the silk suture are caught in forceps and pulled through the perineum. About 20 cm. above the end of the ileum a slight invagination of the gut is made and held by sutures, forming a ring-shaped eminence of mucous membrane, which is to form a substitute for the ileocecal valve. The abdominal wound is then closed and the patient again put in the lithotomy position. The external sphincter is then carefully separated from the mucosa of the rectum, and the end of the small intestine is drawn through inside the sphincter and sutured to the skin and mucous membrane of the rectum. After the colitis is cured the ampulla of the rectum may be used by dividing the septam between it and the ileum.

In the milder cases of colitis Moszkowicz recommends a Witzel