and condensing facts into tables. In this work he has been ably seconded by Walter L. Pyle. R. J. E. Scott has taken up the work and extended and revised it. For economic reasons, a cyclopedia of medicine or any other science or technical art should not represent too much invested capital nor too much requirement of time in research since, in any event, it cannot reach the maximum required of an elaborate special treatise nor can it be permanent. On the other hand, it should be more elaborate than a dicitionary whose function is merely to define words and to give a general idea of what they mean-which a formal definition usually does not do. In our opinion, this cyclopedia has struck the proper medium of size, scope and expense.

DISEASES OF THE GENITO-URINARY ORGANS AND THE KIDNEY, by Robert Holmes Greene, A. M., M. D., and Harlow Brooks, M. D., New York; published by the W. B. Saunders Co., Philadelphia. 3d edition, revised and enlarged, 639 pages, 339 illustrations, many of them being full page plates. $5.00.

This is a standard work, complete in its scope, already possessing the confidence of the profession. The revision brings it up to date. It would be useless to single out any part of the work for special comment.

DUODENAL ULCER. B. G. A. Moynihan, M. S., F. R. C. S., Leeds. Eng., published by W. B. Saunders Co., Philadelphia, second enlarged edition, 486 pages, illustrated, cloth, $5.00, half morocco, $6.50.

Moynihan is one of the few great authorities on this subject. Speaking with an operative experience with 168 cases, he has had the following results: Died as result of operation,

Died of other causes

Cured

Improved

Doubtful, no better or not
traced

4

2.14%

He very frankly states that he was at first led by reports of internists to regard hyperchlorhydria as definitely diagnostic but he has modified his view as actual examination has shown it to be present in only 40% of cases. There are few conditions about which such glittering and foolish generalizations have been made, as hyperchlorhydria. It is not a very common condition, statistically, and is mimicked by various other conditions. It may, apparently, be an organic disease of itself but it is also symptomatic of many causes of irritation. While the work is mainly surgical, Moynihan views the problems broadly and his book is perhaps of greatest service to the medical practitioner, in whose hands the primary diagnosis and decision as to treatment, mainly rest.

PELLAGRA, by Stewart R. Roberts, S. M., M. D., Atlanta. Published by the C. V. Mosby Co., St. Louis. 272 pages, 90 illustrations, $2.50.

The author has presented practically all that is known on the subject, in a systematic way and apparently without bias. He does not consider any theory as definitely proved. In particular, he opposes the time-honored corn theory and that of Mizell as to nondrying oils. While he shows that the simulium theory of conveyance is not proved, he apparently leans toward the existence of a specific organism. In a series of twenty cases, free HC1 in the gastric contents was lacking in 14 and present in normal proportion in 6 (although it must be admitted that some who very easily discover hyperchlorhydria might make this diagnosis on an acidity of 30-38 degrees.) The fæces of this whole series were stated to contain nothing not found in ordinary diarrhoea and dysentery. An allusion to indican might be of interest.

There is one point in his logic as to etiology which deserves criticism: "It cannot be produced by the poisons of both corn and protozoa." The flaw in the logic is that there may be an etiologic factor in the case of any disease which is predisposing or even necessarily cooperative with a specific infecting organism. For instance, in yellow fever, the stegomyia is not the specific cause but is practically, the determining one. In tetanus the nature of the wound in determining anærobic conditions, is practically necessary to the infectivity of the bacillus mallei. In tuberculosis for practical prophylactic and therapeutic purposes, we have got back to the old nutritive and hygienic theories of disease notwithstanding the demonstration of the bacillus. As previously stated, we do not personally regard pellagra as a specific disease at all and we hold no brief for the corn theory but it is not impossible that corn or any other article of diet or some other factor may be an essential predisposition to the implantation of a specific organism.

KIDNEY DISEASES, by W. P. Herringham, M. D., F. R. C. P., with chapters on Renal Diseases in Pregnancy, by Herbert Williams, M. D., F. R. C. P., London. Oxford Press. 378 pages, 30 illustrations, $5.50.

It should be distinctly understood that this book is not one on urinary analysis, although such methods are necessarily included and there is an especially interesting chapter on albumin. It discusses broadly, kidney diseases, including anomalies, movable kidney, the relation to cardio-vascular disease, eclampsia and many other topics. We would derive more benefit from the chemic and microscopic study of the urine if more of us read this book and if we considered the kidney as something more than an excretor of material for examination.

TUBERCULIN TREATMENT by Clive Riviere, M. D., F. R. C. P., and Egbert Morland, M. B. and B. Sc., the former of London, the latter of Arosa, Switzerland. The Oxford Press. 277 pages, with charts, $2.00.

While admitting the existence of human and bovine varieties, the authors consider these to be essentially identical and hence that there is no priori absurdity in using bovine tuberculin for human tuberculosis, or vice versa, in fact they consider that, at present, the choice should be according to empiric results. The statements are conservative yet favor strongly the use of tuberculin, especially in closed cases. A great many technical details deserve attention yet would lead to too lengthy a review. While we would not admit that American authors on this subject have been unduly biased by personal enthusiasm, this book representing experience in two other countries, with the elimination of local socialogic and other features, is corroborative and of value to the American physician, on account of the independent viewpoint of the authors.

GONOCOCCAL INFECTIONS, by Major C. E. Pollock and Major L. W. Harrison of the Royal (British) Army Medical Corps. Oxford University Press, 222 pages, unillustrated, $2.00.

While the word gonorrhoea was coined under a false impression of its nature, the word signifying a flow of sperm, and the name gonococcus is correspondingly inaccurate, both are, neverthe-less, Greek and the proper adjective is gonococcic and not gonococcal. However, the meaning is clear and the book is excellent. The authors devote considerable space to the vaccine treatment, agreeing that a good stock vaccine is all right. The chapter on gonococcic septicemia is also especially valuable.

LANDMARKS AND SURFACE MARKINGS OF THE HUMAN BODY. L. Bathe Rawling, M. B., B. C., F. R. C. S., London. Published by Paul B. Hoeber, 69 E. 59th St., N. Y., 96 pages, 29 plates, $2.00.

Some of the illustrations are photographic with added markings, some colored diagrams, most are full page, a few half page in size. All are clear. The text is arranged systematically and is much more complete than corresponding portions of standard anatomies. An appendix gives the length of various passages, tubes, etc. It is difficult to explain in a brief review just how the author has woven in a mass of interesting and practical information that renders his work of value to the general practitioner and not merely to the anatomist and operator. It may not be out of place to compliment the publisher both on the high grade of the book from the mechanic side and on his skill in selecting. authors who have something out of the ordinary to present to readers.

BUFFALO MEDICAL
MEDICAL JOURNAL

VOL. LXVIII

OCTOBER, 1912

Immunity

No. 3

With Reference to Some of Its Relations to Surgery

Being the Harrington Lectures before the Alumni Association of the University of Buffalo, May 29 and 30, 1912.

By LUDVIG HEKTOEN, M. D.

Director of the Memorial Institute for Infectious Diseases

Chicago

(Continued from last month.)

THE FORMATION OF ANTIBODIES UNDER VARIOUS CONDITIONS. By measurement of antibodies as they appear in the blood after the introduction of antigens, much has been learned of the manner of antibody formation, and the most important facts bearing on this point are shown in the antibody curve. The simplest curve, that obtained after one injection of antigen in a normal animal, shows that for two to three or four days, there is, as a rule, either no change or there may be a fall in the specific antibody if such is already present. At the end of this period of latency new antibody appears. This increases until an acme is reached, which in most cases seems to be about the 10th or 12th day; before long begins the last phase of the curve, namely a gradual return to normal, which may last only a few days or several weeks and even much longer.

Animals, including man, normally carry in the blood small amounts of a large number of antibodies, which possess specific affinities for antigenic substances and which probably do not differ much from the corresponding bodies that arise on immunization. In favor of this conclusion is the fact that the primary fall in antibody in the blood on immunization is specific, that is, affects only the antibodies for the particular antigen injected. This fall, which occurs also on reinjection in previously immunized animals, is regarded as the result of neutralization of the existing antibodies, although the amount of antigen introduced often seems too small to cause the fall in this way.

The height and duration of the simple curve vary depending on the kind and amount of antigen as well as on the place of introduction, and also, of course, on the individual animal. It is important to note that the yield of antibodies does not increase in the same ratio as the antigen is increased. Small amounts of bacteria and other antigens may cause more antibody to form.

on intravenous than on subcutaneous injection. In animals previously acted on by an antigen, the antibody mechanism may be especially sensitive to that antigen and respond more promptly and fully than in the fresh animal. In this way is explained the quick rise of opsonin, often seen on therapeutic injections of vaccines in chronic infectious conditions, as well as other phenomena of allergy which I shall discuss a little later.

When many injections of antigen are given at intervals more or less variations of the simple curve result. It is the rule in immunization with toxins and bacteria to begin with small quantities and to reinject with increasing quantities, carefully graded to avoid severe reactions, at intervals of a few days for a considerable period. A continued and more or less cumulative production of antibodies may be induced also by daily injections of small and constant doses of antigen. In some cases, however, it seems difficult to secure marked cumulative effects. Animals under the continuous influence of antigens eventually lose the power to produce antibodies, to regain it, if at all, only after periods of rest.

A cellular antigen, like bacteria or other cells, may give rise to lysin, agglutinin, opsonin, and other antibodies at the same time. In some cases these different antibodies appear to describe parallel curves; in other cases, there is no such parallelism which would seem to indicate that we are dealing with distinct sub

stances.

When several antigens are introduced at the same time, as occurs in secondary and multiple infection, the amount of antibody produced for a particular antigen probably is less than when that antigen alone is introduced. Secondary infections in typhoid fever, such as pneumonia, depress the agglutinin curve. In dogs pneumonic infection (distemper?) may suspend almost completely the production of antibodies for foreign corpuscles. It would seem from this that the same mechanism is concerned in the production of all antibodies as it probably would be different if wholly distinct cell groups were charged with the production of different antibodies. The observations suggest also that the streptococcus and other infections of eruptive diseases, notably small-pox and scarlet fever, and of tuberculosis, may depend in a measure on the inability of the body to respond freely to the stimulus of more than one antigen at a time; and the aggravation of the primary disease, e. g. tuberculosis, as secondary infection sets in, may be due to depression in the production of antibodies for the primary disease, as illustrated by the suspension of the tuberculin reaction by an attack of measles. Here we may assume with v. Pirquet that the measles