is carefully analyzed in a series of interesting tables published in the Lancet of August 15th. Speaking of the data examined, the author says: "The material for the task lay ready to hand even if it involved a good deal of labor in classifying and tracing all the cases dealt with. In the first place the Registrar of the district provided returns showing date of birth, name of child, and parent, residence, and where born, for the last three years. The vaccinating officer, on the other hand, placed at my disposal his registers, showing the number vaccinated, and unvaccinated in the urban district for the same period. As Medical Officer of Health I received weekly returns of all deaths taking place therein, so that material for the inquiry was complete." All infants dying under one month were not included inasmuch as it was found that no child was vaccinated under one month. All infants who were not born in the district whether vaccinated or unvaccinated were excluded, although such were included in the vaccination and death returns they were absent from the birth returns, and hence could not be dealt with. All who had left the district, whether vaccinated or unvaccinated, were excluded, as it was impossible to trace what happened to them." In this way Dr. Mackenzie traced the history of 987 children, of whom 706 were vaccinated and 281 were not. Of the 706 vaccinated 60 died before reaching twelve months of age, giving a death rate of 8.5; of the 281 unvaccinated 45 died, giving a death rate of 16. It is thus seen that the death rate of the unvaccinated was double that of the vaccinated, exactly the opposite of what has been commonly stated. The author states that from personal observation, this high death rate of the unvaccinated is not to be attributed to the lower social status or poorer environment of the families concerned. On the contrary, the parents of the nonvaccinated were for the most part intelligent objectors with perverted understandings; what we should call "cranks." This condition of mind is often associated with neurotic tendencies and poor constitutions, which their children inherit. Furthermore, the author states that many were not vaccinated because their h alth was poor, and herein is to be sought the chief reason of the disproportionate mortality.

GYNECOLOGY AND ABDOMINAL SURGERY.

Under charge of S. B. KOBICKE, M.D.,

Adjunct to Chair of Gynecology and Abdominal Surgery, College of Physi cians and Surgeons of San Francisco; on the Staff of St. Winifred's Hospital and the California General Hospital of San Francisco.

An Improved Filigree for Large Defects in the Abdominal Wall.-Bartlett (Annals of Surgery) has devised a special form of wire filigree for strengthening extensive defects in the abdominal wall. He has observed that scars spread laterally, bút not longitudinally to any great extent, and it seemed to him illogical to strengthen the scar with a great number of needless wires parallel to the axis of the incision, which could only stiffen the abdominal wall and prevent perfect mobility. His filigree, therefore, consists of a series of transverse extensions along a central axis or a row of long, narrow loops, extending each side. Experience teaches, he says, that it makes no difference whether the muscles and fascia be or be not completely drawn together, as long as a suitable wire filigree extending sufficiently far out between healthy layers is promptly implanted and healed in. He gives the history of this method of using wire to strengthen the abdominal wall, and remarks that he has been able to observe his seven cases after operation for periods varying from two years down to eleven days, and has had in no case to remove the filigree or seen any disturbance that might be taken to indicate that such a contrivance might not rest indefinitely in its new bed. The logic of the operation is simple. No dependence is placed on preformed tissues. Faith is pinned on the new scar, which is prevented from stretching in extension by unyielding silver wires distributed through it in the proper directions. Of all the various forms of nettings that have been used, the simple one of flattened wire loops appeared to him as being the only one free from the evident disadvantages inherent to any sort of plate, as that is what a stiff filigree really is-one made up of wires which are of equal distance apart, and running in both directions.-The Journal of the Amer. Med Assoc.

Dysmenorrhea.-Dr. W. A. N. Dorland, of Philadelphia, quotes Herman as saying that only about 40 per cent of women menstruate without discomfort; 60 per cent have some pain; in about 11 or 12 per cent of young married

women this pain is bad enough to lay them up each month. There are two kinds of pain from which women may suffer when they menstruate. One pain is that produced by physiological congestion of the pelvic organs, which precedes menstruation. The other pain is caused by the contraction of the uterus which should expel its contents. The first pain is the commoner, and is felt more or less by most women when they menstruate. It is a general aching diffused through the whole pelvis and accompanied by aching of the breasts. It is continuous. The severity of pain depends not solely on its local cause, but also on the sensitiveness of the patient. The uterine contractions which expel the menstrual flow are little or not at all felt by most women, but in a few they are painful, and this is dysmenorrhea in the literal sense of the word. This pain may be the result of obstruction; it may be due to the discharge of fragments of mucous membrane, to stricture of the os internum (Dorland thinks that this is probably theoretical), and to imperfect development of the uterus. This spasmodic dysmenorrhea is far more severe than any other kind of menstrual pain, and has no tendency to spontaneous cure. The best drugs for the relief of uterine colic are antipyrine and phenacetine. Occasionally guaiacum will relieve the pain. The local treatment of spasmodic dysmenorrhea is dilatation of the cervix, which is best done by the passage of bougies. Dilatation, however, does not invariably cure. If all other treatments should fail and the dysmenorrhea should still be severe, the ovaries should be removed.-Amer. Surgery and Gyn.

Methods of Intestinal Anastomosis.-The Lancet is authority for the statement that the earliest description of intestinal suture is found in a somewhat obscure passage in the Sanscrit Veda; that Celsus advises the use of sutures for wounds of the large intestine, but says nothing as to how they are to be employed; that Galen favored suturing the stomach and large intestine, but warned against usual death from suturing the small intestine. It is further stated that the Arabian physician, Abulcasis, recommended catgut for suture of the wounded bowel, and that Roger, of Parma, and Roland in the thirteenth century made use of a little elderwood tube, which was placed within the bowel and the edges of the wound were united with silk. All of

this, together with much else that is recorded, should serve to remind us that the principles involved in the present multiplicity of methods in intestinal anastomosis are old rather than recent. It was not that our medical forefathers did not appreciate the feasibility of intestinal anastomosis which prevented its becoming a customary surgical procedure, but rather that sepsis and death were almost universally consequent upon laparotomy. The first successful resection and anastomosis of the bowel was performed by Reybard, in 1833, some three inches of the colon being removed. In 1836 Dieffenbach resected the gangrenous bowel involved in a strangulated hernia, did an anastomosis, and the patient recovered. These cases, considering the condition of surgery at that time, are phenomenal, and because of this and the rarely successful performance of laparotomy then, they remain conspicuous in surgical evolution. It was not, however, until surgical cleanliness made it reasonably safe to enter the abdominal cavity that intestinal suturing, or anastomosis, became more than a surgical curiosity. Since the attainment of this comparative safety an array of methods, which for variety and ingenuity are truly remarkable, have been introduced, each having its enthusiastic advocate. The authority previously quoted places the number at over 200. The multiplicity is a sufficient commentary upon the fact that no one method possesses many and distinct advantages over all others. Mayo Robson's bone-bobbins were ingenious and served a useful purpose, but are now rarely used; Senn's plates are less popular than formerly; Halsted's inflatable rubber cylinder is now not much employed; the ingenious methods of O'Hara and Laplace have never become widely popular; and Abbe's catgut rings are now no longer used. In this connection, however, distinction should be made between those methods which leave a foreign body within the gut to assist in the approximation, and those like the devices. of Halsted, O'Hara, etc., which merely assist in effecting the operation. Among the former the mechanic apparatus which has achieved the widest popularity and use is the ingenious metal button of Murphy. It has served a most useful purpose and is still widely employed, but the evidence is plain that its popularity is distinctly waning. In the hands of the less skillful and in emergency cases it will

remain an exceedingly useful device, but the present tendency among those skilled in visceral surgery is to discard any and all methods which require that a foreign body be left within the intestine, unless speed, often an important factor in intestinal anastomosis, is urgent. There is an ever-present danger, even if not great, in leaving an extraneous body of considerable size in this situation. Of the various methods of effecting anastomosis by suture none appears simpler and easier than that of O'Hara, and yet complaint has been made that it leaves a diaphragm within the lumen of the gut, which practically amounts to a stricture. There are certain inherent disadvantages in relying on any mechanic device to assist in effecting the operation; it may not be at hand; it may be out of order-any one of many hindrances may occur. Manifestly, then, the fingers of the surgeon, together with needle and thread, are the only implements which can at all times be relied upon, and the progressive abdominal surgeon will cultivate his manual dexterity in this regard. What particular method of suture anastomosis he shall choose, whether lateral implantation, lateral anastomosis, circular enterorrhaphy, or the ingenious methods of Maunsell, Wiggin, Connell, and others, depends entirely upon the choice of the operator and the exigencies of the case. The probabilities are, however, that the near future will see a reduction rather than an increase in the number of methods and devices actually used, and that the suture alone will be the means chiefly employed by the skillful surgeon even when time is an important factor.-Ed. American Medicine.

Ureteral Implantation.-Dr. C. B. Reed reported a case at the meeting of the Chicago Gynecological Society. The woman entered Wesley Hospital for pyosalpinx. The opening of the abdomen revealed very dense adhesions which bound the tumor to the pelvic floor, to the intestines and to the uterus. In separating these he came across what seemed to be an unusually dense adhesion or band which seemed to pass over the tube and behind it to the pelvic floor. The assistant cut this band, at his request, and immediately revealed the ureter, which was further identified by the intermittent gushes of urine from the upper end. The upper end of the lower section was immediately tied, an incision made in its side, into which the