tuberculosis itself, how far it is due to disturbing intercurrent causes."

Types of Pulmonary Tuberculosis.-1. Cases Resembling Infantile Athrepsia. Owing to the similarity of incipient tuberculosis in general to several other diseases, a great deal of confusion in its symptomatology may occur. So also in the various types in which the tuberculous process is confined almost entirely to intrathoracic structures may a differential diagnosis be impossible before considerable destruction of lung tissue has taken place. In infants there are no characteristic symptoms. The paleness, loss of weight or continued daily failure to gain weight, languor, loss of appetite, and failure in strength, in spite of the ingestion and apparent digestion and assimilation of food of proper quality and sufficient quantity, are strongly suggestive of infantile athrepsia. Such cases are usually seen in infant asylums and may remain obscure until the necropsy reveals the deep-seated tuberculous process. Sometimes, however, the terminal stage of the disease is recognized by the irregular temperature, from 100.5° to 102.5° in the rectum, slight, dry, hacking cough, and breathing more frequent than is consistent with the character of the pulse and temperature. Physical signs, if present, point to scattered areas of bronchopneumonia or bronchitis. One is also apt to be misled by evidences of disturbances in the gastroenteric tract, such as occasional vomiting and greenish, watery, undigested stools. If such general symptoms should immediately succeed whooping cough, measles or influenza, it is at least strong presumptive evidence of military tuberculosis, and the physical signs would determine its location in the lungs.

There have been a few cases of this kind among our cases, but the occasional failure to obtain necropsies on infants has still left us in doubt as to its frequency.

2. Cases Resembling One of the Continued Fevers. In older children there is usually a period of several weeks during which marked but indefinite symptoms occur to excite the anxiety of the parents. There is a gradual decline in health, marked by anemia, a change of disposition-a bright, vivacious child becoming sluggish and fretful-loss of appetite, and indigestion. Such cases are sometimes seen in the early school life and may be attributed to overtaxing the child mentally and physically. He is now taken from school with the hope of improvement, but a daily rise of temperature soon sets in and is suggestive of typhoid or malarial fever. There are no local symptoms to account for the fever, but

examination of blood and urine may, by exclusion, strengthen the suspicion of tuberculosis. A positive diagnosis, however, can only be made after the disease has so far advanced in the lungs as to give the characteristic local signs and symptoms. Such cases are rarely seen in hospital practice in their incipiency; the marked symptoms of tuberculous infection usually are present when the child is admitted.

3. Cases Running a Rapid Course.-In such cases the occlusion or destruction of pulmonary tissue is so rapid and extensive as to suggest bronchopneumonia, to which the symptoms are due rather than to the numerous miliary tubercles scattered in groups, with intervening areas of inflammation, throughout both lungs. The symptoms are cough, dyspnea, rapid respiration, fever and prostration. The range of temperature is not always as high as would be expected from the severe general symptoms and wellmarked physical signs. Bloody expectoration or hemorrhage from the lungs is rare in children, but one of my cases of this type died during the second severe hemorrhage, and another, under the care of Dr. Acker, had a number of profuse hemorrhages before the last fatal one. These are the only cases of hemoptysis mentioned in our series. We may detect several cavities of varying size. The physical signs of complete consolidation of a large area, as in croupous pneumonia, are seldom present. Of 99 cases in this series, 32 were improved, 5 unimproved, and 62 died. It may be assumed that the 32 improved and 5 unimproved were removed from the institution when the hopeless nature of the ailment was explained to the parents.

4. Cases Running a Protracted Course.-In such cases caseous nodules, large and small areas of caseous pneumonia, spots of broken down tissue are found in both lungs. This is the type of pulmonary tuberculosis most frequently seen in infants and young children. Its course is irregular and may vary from one to six months. If the general tuberculous condition precedes the localization in the lungs, cough, rapid breathing, loss of weight, prostration, etc., develop slowly. When the pulmonary symptoms develop first, they resemble those of bronchopneumonia. When it occurs as a sequel of measles, whooping cough, or influenza which has been complicated by bronchopneumonia, the early symptoms may be marked. The general local symptoms abate, but the cough continues. In a few weeks the child becomes worse, the cough increases, the temperature rises to 103°, and well marked physical signs are detected. Fever, though not high, is always present in

children. Of 80 cases, one was cured, 31 were improved, 5 unimproved, and 43 died.

5. Chronic Form.-This is usually the result of one of the acute forms, which results in a chronic interstitial pneumonia with tuberculous caseous deposits. The child apparently recovers from an acute attack, but does not regain his health and spirits, showing a decline in health. A careful physical examination will give evidence of structural changes in the lungs. The course of this type may extend over two or three years. The physical signs are identical with those of bronchopneumonia. Of the 21 cases of chronic tuberculosis in our series, 9 were improved and 12 died.

TUBERCULOSIS OF THE PERITONEUM.

Tuberculous infection of the peritoneum is probably of secondary origin from the disease located in the intestinal tract. There may be either acute or chronic tuberculous peritonitis, but there is little likelihood of recovery in either. Spontaneous recovery is said to have occurred in some cases and relief is often given by laparotomy. Our results with laparotomies have not been so favorable and the spontaneous cures have usually led to a change of diagnosis. Of 30 cases of this variety, 2 were cured, 8 improved, 3 unimproved and 17 died.

A summary of the 400 cases would show:

A mortality of 63.5 per cent. would look well for the treatment of tuberculosis were we not reminded that, although we have not a record of the cases that left the hospital, nevertheless, we are justified in assuming that most, if not all, of them died within a reasonable time after being discharged.

TREATMENT.

Doubtless it would be interesting to review the history of the medical treatment of tuberculosis, but the enormity of the task would be impressed upon one should he attempt to examine the literature upon this subject. Indeed, the stack of cards in the Surgeon General's library showing the number of articles upon this subject since 1900 is so large that even a review of them would require many days. However, a superficial examination of the older writers convinces us of the futility of the claims of those

who are vaunting modern methods. More than 150 years ago tuberculosis was considered a contagious disease, and as a prophylactic measure, the Venetians ordered the destruction by fire, of the clothing and furniture of those dying of tuberculosis. The Sicilians also deserted the tuberculosis patient, and, after his death, ordered the destruction of his clothing.

In the face of this statement, fifty years later, Thomas asserts that tuberculosis is not infectious.

By the early history we find that the disease was treated as an inflammation, and various remedies were used for this purpose. The patient was nauseated, bled and cupped for the disease.

If I should attempt to entertain you by the various remedies used, I would be compelled to exhaust the drugs described in the pharmacopeia.

During the past twenty-eight years I have had the opportunity of witnessing the various methods of treatment, many of them lauded as curative and specific, but each, in its turn, has been found wanting. If I should divide this period into periods of five vears each, we would find that, during the first five years, codliver oil, internally and externally, was generally used as a curative measure. This drug was given in increasing doses until the tolerant stomach refused to hold the increasing doses, and the skin was rendered so foul that the patient was a nuisance to himself and his friends.

Next came the treatment by insufflation of sulphuretted hydrogen into the rectum. Well do I remember repairing to the bedside of a poor consumptive, in the last stages of the disease, with an apparatus for the generation and insufflation of this gas. Great hope was held out to him in this supposed curative measure, and at this late date I shudder to think of the suffering that unfortunate man must have endured from the great distention caused by the gas. He would tell me to go on with it, even after his abdomen was painfully distended, and on more than one occasion I have known the gas to be emitted from his mouth in volumes. This treatment was short-lived. During this period we witnessed the treatment by the pneumatic cabinet and doubtless some will remember how the poor sufferer's lungs were stretched, in the hope of effecting a cure. This method was of shorter duration than some of the others, and the expensive cabinets were not even marketable in the junk shops.

About 1890 we received a "sure cure" fresh from the laboratory of Koch. A favored few received the lymph direct, but it was

not long before this remedy was found wanting, and even Koch himself finally admitted that it was never intended as a curative measure, but that his friends, in their enthusiasm, had misrepresented his intentions.

About 1895 the treatment by creosote found its advocates, and the patients were now saturated with creosote. I admit that, in the hope of benefiting this class of sufferers, I too, gave as high as 40 drops of creosote three times a day and urged the patient to take more. During the present decade numerous remedies, most of them proprietary, the principal of which is Russell's Emulsion, have been placed upon the market as cures for tuberculosis.

From my experience, I am prepared to say that I know of no specific for the disease. That we can relieve many of the symptoms by the application of well-known and well-tried remedial agents, I will admit, but there is no specific medical treatment.

THREE CASES OF REPAIR OF INJURY TO THE URETER; TWO BY TRANSPLANTATION INTO THE BLADDER, AND ONE BY END-TO-END

SUTURE.

BY

A. LAPTHORN SMITH, B.A.; M.D.; M.R.C.S., Eng.,

Professor of Gynecology in the University of Vermont, Burlington; and or Clinical Gynecology in Bishops University, Montreal; Surgeon in Chiet of the Samaritan Hospital for Women; Gynecologist to the Montreal Dispensary, and to the Western Hospital and Consulting Gynecologist to the Women's Hospital, Montreal, Canada; Fellow of the American, British and Italian Gynecological Societies.

THERE are three principal ways in which the ureter may be injured so as to give rise to a ureteral fistula. First, by being compressed between the child's head and the pelvic wall during prolonged labor, with impaction of the head; second, by being compressed between the blades of the clamps during vaginal hysterectomy for cancer; third, by being accidentally cut during the removal of a large abdominal tumor, especially when the latter occupies one of the broad ligaments. The relative proportions, as appear in a paper by Yeergman, who collected 68 cases, were: Parturition, 25 cases; vaginal hysterectomy, 12 cases; abdominal section, 3 cases. I have to report three cases in which the injury occurred in each of these three ways.

Case I, which was due to parturition, has already been reported at the 1901 meeting of the Canada Medical Association, at Win