1. Letter-writing (the subject-matter on a topic relative to the practice of medicine)....

2. Anatomy and physiology (general questions on anatomy and physiology, and histologic or minute anatomy).... 3. Chemistry, materia medica, and therapeutics (elementary questions in inorganic and organic chemistry; the physiologic action and therapeutic uses and doses of drugs)...... 4. Surgery and surgical pathology (general surgery, surgical diagnosis; the pathology of surgical diseases)

5. General pathology and practice (the symptomatology, etiology, diagnosis, pathology, and treatment of diseases)....

6. Bacteriology and hygiene (bacteriologic methods, especially those relating to diagnosis; the application of hygienic methods of prophylaxis and treatment)

7. Obstetrics and gynecology (the general practice of obstetrics; diseases of women, their pathology, diagnosis, symptoms, and treatment, medical and surgical)

Total ...

5

10

15

20

25

10

15

100

Seven hours will be allowed for this examination. Age limit, 25 to 55 years on the date of the examination.

Men only will be admitted to this examination.

In accordance with a recent act of Congress an applicant for this examination will be required to be examined in the State or Territory in which he resides and to show in his application that he has been actually domiciled in such State or Territory for at least one year previous to the examination.

This examination is open to all citizens of the United States who comply with the requirements. This announcement contains all information which is communicated to applicants regarding the scope of the examination, the vacancy or vacancies to be filled, and the qualifications required.

Applicants should at once apply either to the United States Civil Service Commission, Washington, D. C., or to the secretary of the board of examiners at any place mentioned in the list printed hereon, for application Form 1312. No application will be ac cepted unless properly executed, including medical certificate, and filed with the Commission at Washington. In applying for this examination the exact of title as given at the head this announcement should be used in the application.

As examination papers are shipped direct from the Commission to the places of examination, it is necessary that applications be received in ample time to arrange for the examination desired at the place indicated by the applicant. The Commission will therefore arrange to examine any applicant whose application is received in time to permit the shipment of the necessary papers.

The Mississippi Valley Medical Association. The thirty-fifth meeting of the Mississippi Valley Medical Association, which is to convene in St. Louis

October 12, 13 and 14 next, gives promise of being an exceptional event in both scientific and medicosocial ways. Preparations are being made by the St. Louis committees, under the direction of Dr. Louis H. Behrens, for a considerably larger attendance than the society has before had and an increase in membership of decided character is expected. This association has always largely limited its attention to the scientific rather than to the political and other phases of medicine and, while it is so conducted, it is in no sense in competition with other bodies, its membership might well be tremendously increased and that to the scientific betterment of the profession, and to no disadvantage to other organizations. The programs which will be presented are exceptional in their excellence. The orations in medicine and surgery have always been a distinct feature of the meetings of this association, the choice of men who shall present these important addresses this year bears out the association's reputation: Dr. Sherman G. Bonney, of Denver, will deliver the oration in medicine and Dr. John B. Deaver, of Philadelphia, that in surgery. The joint session of the two sections which proved such a success at the Louisville meeting will be repeated at St. Louis, one morning will be devoted to such a session at which a symposium on Exophthalmic Goitre will be presented and the subject considered in all its phases, the discussion being introduced by four papers by authorities who have done special investigation on the subject. The parathyroid glands will naturally occupy somewhat of the attention of the association at the same meeting, a fifth paper thereon having been assured.

This meeting follows the Centennial Week of St. Louis and the local committees are finding it possible to have numerous of the attractions of that week continued for the benefit of the association. While it is not purposed that the social shall interfere with the scientific there has been prepared a scheme of entertainment which will be up to St. Louis' high standard of hospitality. Especial effort will made to make the entertainment of wives, daughters and other ladies accompanying members complete so that they may be pleasantly occupied while members are busied with scientific work. It is hoped that they may come in considerable number, and come with the assurance that their coming is desired.

be

The sessions, offices and exhibit hall of the association will be in the Southern Hotel, which has been chosen as headquarters. The Southern can entertain the whole membership if reservations are made sufficiently in advance, the hotel is easily one of the best and the most capacious in the country and it is hoped that it may be the selection of the members. For those who prefer to stop elsewhere the Planters, American, Laclede and Maryland will be found very convenient to the place of meeting.

St. Louis and the St. Louis profession bid you welcome.

Panorama of the

The Review of Operation of Cancer of the Cervix, by Palmer Findley, in the Western Medical Review, July 1909, is well worthy of reproduction. He states that:

"While the primary mortality of Wertheim's operation is still high, it is encouraging to note the advance made from year to year. In Wertheim's first thirty cases the mortality was 40 per cent; in his last thirty cases it was 7 per cent. Berkeley has collected the records of 313 cases and finds an average mortality of 18.5 per cent. Doderlein records a mortality of 14.8 per cent in 715 reported cases.

Comparing the mortality of Wertheim's operation with that of vaginal hysterectomy, we find Doderlein reports 4,368 vaginal hysterectomies with a mortality of 9.1 per cent. The lowest mark is reached by Leopold at 5.7 per cent and Amann at 4 per cent. If we take into consideration the fact that the cases which fall within the scope of the radical abdominal operation are in many instances more vanced than are those removed by means of simple vaginal hysterectomy, we will look with increasing favor upon the operation of Wertheim. Berkeley affirms that in cases of a similar nature the mortality of the Wertheim operation is no higher than of simple vaginal hysterectomy.

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It is admitted by all that the percentage operability is greater in the radical operations than in simple hysterectomy, hence greater possibilities of cure. Doderlein and Kronig give the percentage operability as 68 in the radical abdominal operation. Bumm has operated 90 per cent of his cases, Wertheim 49 per cent. For simple vaginal hysterectomy the percentage operability is much less. Chrobak and Schanta give 15, Waldstein 14.7, while several of the German clinicians record 30 to 32 per cent.

his cases free of recurrence five and more years after operation as compared with 2.5 per cent of Gusserow's cases, 9 per cent of Pozz's and Doderlein's, 12 per cent of Polosson's and 8.2 per cent of Leopold's operated by simple vaginal hysterectomy. We note therefore that the percentage of cures is vastly in favor of the Wertheim operation, that the percentage operability is likewise greatly in its favor and that these two factors overbalance the somewhat greater immediate mortality.

A far greater percentage of serious but not necessarily fatal complications occurs as the result of the Wertheim operation than of simple vaginal hysterectomy.

Wertheim admits that cystitis followed in nearly all of his cases, and in some instances the infection spread to the pelvis of the kidney. Direct injury to the bladder is more liable and as a result vesico-vaginal fistula may develop. This accident has occurred in about 5 per cent of cases. Schindler collected 362 cases from nine operators in which the bladder and ureter were injured ninety times (24.8 per cent), as contrasted with 3 per cent of like injuries in simple vaginal hysterectomy."

Cancer of the Breast.

According to Dr. M. H. Richardson, Boston (Journal A. M. A., May 15, 1909), the treatment of cancer of the breast still demands the most complete and early excision. His own methods have grown more thorough as his experience has enlarged. Cases must be judged at the time of the operation as favorable, unfavorable, or hopeless, and each of these headings permits greater accuracy of subdivision: very favorable, favorable, not positively favorable, doubtful and hopeless. A small tumor in the center of the breast, if there are one or two small lymph nodes involved, must be regarded as an early axiliary nodes, but easily movable and dissected makes a favorable case. A tumor, no matter what size, so long as it can be removed by a wide margin of safety, presents a favorable outlook. Infiltrations are unfavorable though not perhaps hopeless, and wide infiltrations, involvements of ribs and axillary vessels make the outlook practically without hope. The chief cause of delay. in mammary cancer is in the patient's unwillingness to admit that serious trouble exists, and this is increased by the advertisement in the lay press of cancer cures, etc. A second cause is in the too favorable diagnosis of inexperienced physicians. Richardson goes at length into the diagnosis, empha

sizing the symptoms that are most likely to lead to error. He gives little weight to pain, which justifies operation in total absence of other signs only for its own relief. But he gives it great weight when in the absence of other signs the breast is large and evidently has something in it. The influence of heredity on a doubtful diagnosis should be very great, and he would not exclude the possibility of a beginning cancer except after exploration. Tumors in both breasts do not exclude malignancy, and there is no safe rule in such cases, except as treating them all alike as malignant until they have been proved benign. The examination of the axillæ gives important evidence, and in all cases the surgeon

should examine for remote metastases, lest he subject his patient to a useless operation. Of all the metastases the most malignant are those of involvement of the cerebrospinal axis. Metastases in the abdomen, however, most lend their weight to a doubtful diagnosis, and a persistent cough without adequate signs in the lungs always strengthens the diagnosis. Richardson condemns the use of the hollow punch or knife section of doubtful tumors on account of the danger of autoinfection, and he has seen disastrous results from their use. There remains in many cases, however, the hope in human frailty; that the operation will reveal a better condition of things than we have anticipated, and he gives illustrations from his own experience. The prognosis depends on the operative findings and sometimes the surgeon's instinct makes him decide the outlook bad without being able easily to give a reason for it. Prognosis based on the statistics of many surgeons is, in his opinion, not of very much service. Cases that are recognized early enough to permit the widest removal, are widely different as regards prognosis from those in which thorough dissection is doubtful. We probably err most frequently we give one that is worse than the facts justify. He does not put implicit confidence in the three-year limit. Recurrence is influenced in favorable cases in giving a too favorable prognosis, but sometimes especially by the thoroughness of extirpation, and except for pain and annoying discharges the prognosis in advanced cases is such as to forbid operation. In considering the immediate prognosis he looks on the most extensive operation for breast cancer in patients with good vital organs as practically free from mortality. The great blot in the surgical treatment of this condition is unjustifiable delay. The burden of proof of the nonmalignancy of the disease is on those who advise palliative measures. The only exception to the rule of the universal exploration are those cases of multiple tumors, of both breasts which are clearly retention cysts, and another exception is the breast tumor which appears after the removal of a benign growth or simple cyst, still another is the appearance in the other breast of a tumor like a benign one that has been removed from the first. But, barring contraindications, such as are found in the breast, lungs, kidneys and other organs, and

in certain constitutional diseases, a better rule is to remove every tumor of whatever nature and at any age.

Excision of Larynx for Carcinoma.

James Bell (Annals of Surgery, July, 1909), has removed the larynx in twelve cases of carcinoma, seven of these operations were for intrinsic laryngeal cancer all far advanced; and in one of these the disease had extended to the pharynx. In five, the primary disease was in the pharynx and had invaded the larynx secondarily. Of the 12 cases operated upon, seven recovered; one of the seven died on the fifty-eighth day from recurrence, or rather extension along the carotid glands into the mediastinum; of the five deaths, two were from pneumonia, seven and fifteen days, respectively, and two from cardiac causes four and five days respectively after operation.

Of the seven cases of intrinsic laryngeal cancer, four recovered and three died; and of the five cases in which the disease was primary in the pharynx, three recovered and two died.

In the first four cases he did a preliminary tracheotomy and removed the larynx from above downwards. In the last eight cases no preliminary tracheotomy was done, and the mass was removed from below upwards after fixation of the tracheal stump to the skin. In all cases operation was done with the patient in the exaggerated trendelenburg position, and the patient kept in this position with the part of the bed elevated for several days after operation. He is of the opinion that this attention to posture is most important.

In conclusion, I desire to express my opinion that compete laryngeotomy is an operation which should have almost no essential mortality and whose diagnosis is made early, which can be so readily done, there should be no recurrence of the disease, moreover, the patient's comfort should be greater than after most operations which involve the ablation of an important organ.

Adequate Drainage the Essential Step in the Successful Surgery of Brain Abscesses.

Fred Whiting, of New York, says that the question of the after treatment of brain abscess is important. Many a brilliant operation is spoiled by the failure of the after treatment. Infected tracts are produced by laceration of brain substance in attempts at introduction of gauze into the cavity. The author has originated an instrument called the encephaloscope, by which the interior of the abscess cavity may be inspected and drainage introduced by sight. The first step should be to evacuate

completely all pus from the cavity. Adhesions of the walls of the cavity may cause pus to be dammed up in the lower part of the cavity. The author believes it a bad practice to introduce forceps or the finger into the cavity to separate the walls. Irrigation is also bad for such

a soft substance as brain tissue. With the encephaloscope the cavity may be quickly cleared of all macroscopic infective material. In judiciously selected cases the curetting of the cavity to remove the lining membrane is allowable. In small superficial abscesses there is little choice between gauze and tubular drains. The author has supplanted all other drains by sterilized or iodoform gauze. In acute abscesses only a very small wick of gauze is needed. In chronic abscess the sloughing of the lining membrane is slow and quantities of pus will come away. Sufficient iodoform gauze is introduced to distend the cavity, and it must be changed daily until all fetor is over. When there is no recognizable discharge, drainage may be discontinued. Gratuitous infection of healthy tissue by misdirected efforts at introduction of gauze must be avoided.-Medical Record, January 23, 1909.

The Practical Value of Tincture of Iodine and Iodine Catgut in Major Surgery.

Walter L. Dannreuther, of New York, advocates the use of iodine for sterilizing the hands, irrigating wounds, and preparing catgut for use in operations. The author has found its use most satisfactory. He gives the strength of solutions to be used in each of these processes. He prepares his own catgut from the inexpensive raw product, and it is made both aseptic and antiseptic by his process, which he describes. The technique described has the merits of simplicity, reliability, and economy. It has been made use of by the author for two years, without his having had a case of stitch abscess or an infected wound.-Medical Record, January 16, 1909.

Operative Treatment of Heart Wounds. By CEAS. H. PECK, M. D.

(Annals of Surgery)

The suggestion that wounds of the human heart might be sutured was made by Dr. Roberts of this association in 1881. Faima of Rome, in 1896, is credited with the first operation, and Behm of Frankfort, in 1897, with the first recovery. In this coun try Nieteit and Vaughan led the way in 1901, and up to the present time 16 cases have been operated upon with seven recoveries. The rarity of the opportunity and the importance of prompt and definite action makes it desirable that every surgeon to whom such a case may come should be familiar with the best plans of operative proceedure, in order that the choice of method may be instantaneous and the steps executed without delay. These steps involve the consideration of anaesthesia, local preparation of the operative field, choice of exposure, temporary control of hemorrhage while sutures are being placed, and sutures, stimulation and resuscitation.

A tabulation of the 160 operative cases is appended:

Suture of Heart Wounds.

G. T. Vaughan, Washington, D. C., (Journal A. M. A., February 6), gives a historical sketch of the operative surgery of the heart and reports a case of suc

cessful suturing of a wound, one-third of an inch in length, opening into the right ventricle. Two rows of silk sutures were used and two bleeding points caught up and ligated with catgut. The pericardium was closed with a continuous catgut suture without drainage. He tabulates and analyzes the reported cases, and summarizes his conclusions substantially as follows: 1. There is no question as to the propriety of operation, since 35 per cent of the patients recover, as compared with 15 per cent (according to Holmes and Fisher, 1881) of recoveries after nonoperative treatment of heart wounds a gain of 20 per cent. 2. The mortality is practically the same as that of twelve years ago, when the operation was first attempted, and it behooves the surgeon to study the matter and seek for some improvement. 3. The two chief causes of death are hemorrhage and inflammation of the pleura or pericardium. Probably nearly everything possible has been done to prevent hemorrhage, but since more than half the patients who survive over twenty-four hours become infected, there is room for great improvement in this respect. 4. To prevent this, besides the observance of strict asepsis, the question of opening the pleura and the drainage of the pleura and pericardium must be considered of the greatest importance. 5. As a rule, therefore, the pericardium and pleura should not be drained. The article is illustrated.

Book Notices

Progressive Medicine for June, 1909.

A Quarterly Digest of Advances, Discoveries and Im. provements in the Medical and Surgical Sciences. Edited by Hobart Amory Hare, M. D., Professor of Therapeutics and Materia Medica in the Jefferson Medical College of Philadelphia. Per annum, in four cloth-bound volumes, $9.00; in paper binding, $6.00, carriage paid to any address.

In the June issue of Progressive Medicine William B. Coley gives an extensive review of the literature on Hernia covering forty-two pages.

Edward M. Forte reviews the Surgery of the Abdomen exclusive of Hernia. The review covers seventy pages and is carefully prepared and as complete as such a review can be made.

John Clark covers the subject of Gynecology in seventy pages of well edited review.

Alfred Stengel's review of Diseases of the Blood Diathetic and Metabolic Diseases, Diseases of the Spleen, Thyroid Gland and Lymphatic System shows the result of an immense amount of reading and familiarity with the subjects such as is seldom found in work of this kind.

Edward Jackson's review of Ophthalmological progress is worthy of the consideration which that author's products generally receives.

The volume on the whole lives up to the high standard which it has maintained for many years.

International Clinics.

Treat

A Quarterly of Illustrated Clinical Lectures and Especially Prepared Original Articles on ment, Medicine, Surgery and the Allied Sciences. By leading members of the medical profession throughout the world. Edited by W. T. Longscope, M. D., Vol. II, Nineteenth Series, 1909. Immunization Against Typhoid Fever is discussed by Harlan Shoemaker who reaches the following conclusions:

1. Unquestionable evidence exists regarding the immunity conferred by inoculation.

2. Two or more inoculations are necessary to make the immunity of some duration.

3. More investigations of the blood in typhoids for the strength and duration of protective substances are necessary.

4. At present the method for determining the strength of a vaccine is liable to considerable error. These conclusions are reached after painstaking work. The article is distinctly worth while.

Chairon de la Carriere discusses the use of mineral waters as adjuncts to treatment of syphilis.

Louis Fischer writes a very good article on Diag. nosis and Treatment of pneumonia in children.

Psychasthenia is discussed on the basis of three cases by Bradford Loveland.

Allyn lectures on Serofibrinous Tuberculosis Pleuresy and its Treatment, and Niles' remarks on Hyperchlorbydria, both contain a few good points.

F. Parkes Weber writes with his usual skill on Congenital Familial Splenomegaly with Chronic Alcoluric Jaundice. His article is supplied with complete and well selected reference.

Wells lecture on Diabetes adds but little to what may be found in any text book.

Daniels discusses Congenital Ideopathic Dilitation of the Colon with the aid of some very good skiograms which are well reproduced. The article covers 34 pages, well selected references are appended.

Dumarest speaks in favor of surgical pneumothorax as a Treatment for Phthisis.

The Present Status of the Cammidge Reaction is a well presented review of the subject by Edward Goodman.

Schwatt's article on the Treatment of Abscess in Hip Disease gives some logical conclusions based on cases treated.

Woods writes on Kraurosis Vulvar reporting two

cases,

Hibbitt gives a clinical lecture on Diagnosis of Pelvic Diseases in Women of which little need be said.

Intra-Ocular Tumors are discussed briefly by Bu

chanan.

Reik's article on "Refrigeratory Facial Paralysis: How is it Produced?" is well written and accompanied by a good bibliography.

Anorectal Fistula and its Treatment is another clinical lecture by Asman.

Tom A. Williams gives some illustrations of the Advantage of Psychometric Methods-Diagnosis, Prognosis and Treatment of Cerebral Disorders.

Buchnell Q. Fletcher report a case of Perithelioma Testis.

The last article in this volume is a study of the Pathogenesis of Spontaneous Cerebral Hemorrhage by A. G. Ellis. This article is from the laboratory of Dr. Ludwig Pick of Berlin and is an exhaustive study of an extremely important subject.

The volume as a whole is a very good one and the series deserves the liberal support which it receives.

BOOKS, PAMPHLETS, ETC., RECEIVED. From W. B. Saunders, Co., Philadelphia: Principals of Pharmacy, by Henry V. Arny Ph. G., Ph. D. Octavo of 1175 pages, with 246 illustra tions, mostly original. Price, $5.00 net.

Bier's Hyperemic Treatment, by Willy Meyer, M. D., and Prof. Victor Schmieden. Second revised edition. Octavo of 280 pages, illustrated. Price, $3.00 net.

The American Pocket Medical Dictionary, edited by W. A. Newman Dorland, M. D., Sixth revised edition, 30 mo of 598 pages. Price, $1.00 net, thumb indexed, $1.25.

Diet in Health & Disease, by Julius Friedenwald, M. D. Third revised edition, octavo of 764 pages. Price, $4.00 net.

Treatment of Diseases of Children, by Charles Gilmore Kerley, M. D. Second revised edition, octavo of 629 pages, illustrated. Price, $5.00 net. Myomata of the Uterus, by Howard A. Kelly, M. D. Octavo of 700 pages, with 388 superb original illustrations by August Horn and Herman Becker. Price, $7.50 net.

Atlas and Epitome of Ophthalmscopy and Opthalmoscopic Diagnosis, by Prof. Dr. O. Haab, of Zurich. Second revised edition with 152 colored lithographic illustrations and 94 pages of text. Price, $3.00 net.

Atlas and Epitome of External Diseases of the Eye, by Prof. Dr. O. Haab, of Zurich. Third revised edition with 101 illustrations on 46 plates and 244 pages of text. Price, $3.00 net.

From Ginn & Co., New York City:
Civics & Health, by William H. Allen, introduction
by Wm. T. Sedgwick.

From D. C. Heath & Co., Boston, Mass.:
Diseases of the Bones, by Joel E. Goldthwait, M. D.,
Chas. F. Painter, M. D., Robt. B. Osgood.
trated.

Illus

From Joseph McFarland, M. D., Philadelphia:
Physician & Nurse-An Idealization.
From Bulletin of Washington University:
Annual Review July, 1909, Series 11 Vol. VII, No.
VI.

From Playground Association of America:

The Play Ground, Seth Thayer Stewart, Editor, Vol. III, No. IV, July, 1909.