the cervix uteri the ureter suffers from compression and flexion, causing obstruction and dilitation of the ureteral stream. The periureteral lymph nodes become hypertrophied from various disease as tuberculosis, typhoid fever, malignancy, syphilis and infectious processes radiating from the tractus intestinalis. In observation of the ureter during autopsies I have noted enlarged adjacent lymph nodes compress the ureter, producing flexion and marked proximal ureteral dilitation. Damaging compression of the ureter by hypertrophied adjacent lymph nodes, I have observed only in the iliac and pelvic ureteral segments. Enlarged adjacent lymph nodes compromise the ureter more than adjacent tumors because they cling so close to the ureteral walls.

FIG. 2 (Author). Illustrates the lymph nodes found along the ureter. In disease the glands may become enlarged. In autopsy I have noted the glands at the flexura Iliaca ureteris so much enlarged that the ureter was kinked and dilated proximal to the obstruction.

(c) The effect of operations on the ureter through the tractus lymphaticus is of such importance that ureteral operations are designated extra-peritoneal or transperitoneal. This

signifies that the relation of the ureter to the peritoneum assumes importance because of the susceptible nature of the peritoneum to infection. It must not be forgotten, also, that the ureter has important relations with the tractus vascularis, has so far as operations are concerned as transperitoneal operations are not alone dangerous for peritoneal infection, but the right and left colic vessels are liable to be lacerated, endangering colonic gangrene-as has been reported.

The Ameican Electro-Therapeutic Association, at its recent meeting in Atlantic City, elected the following officers: President, Dr. Rockwell, of New York; First Vice-President, Dr. Willis P. Spring, of Minneapolis; Second Vice-President, Dr, Wm. Winslow Eaton, of Danvers, Mass.; Treasurer, Dr. Richard J. Nunn, of Savannah, Ga.; Secretary, Dr. Clarence Edward Skinner, of New Haven, Conn. The meeting is said to have been a very interesting and profitable one.

RACE SUICIDE.-Another small after-clap following President Roosevelt's and President Eliot's thunder appears in The Nineteenth Century and After in the shape of an article by Frances Albert Doughty, of Baltimore, called "The Small Family and American Society." American readers will be interested to see how an American woman presents the question to English readers. The Living Age reprints the article for their benefit in the number for October 10.

The University of Chicago has purchased a site for the Rush Medical College on the Midway Plaisance, for $1,450,000. The McCormic Memorial Institute for infectious diseases will occupy part of the ground.

STOKES-ADAMS' SYNDROME AND ACQUIRED SYPH

ILIS-CASES.

BY FRED FLETCHER, M. D., COLUMBUS, O.

I. STOKES-ADAMS' SYNDROME.

Definition. A symptom complex whose fundamental feature is that of a permanent bradycardia, with syncopal, epileptic or apoplectiform seizures.

Nervous manifestations vary both in type and severity 1according to the susceptibility of the nervous centers to the circulatory disturbance induced by the slow pulse.

Symptoms. Simple vertigo may occur or paleness of the face usher in an attack of syncope and render the patient insensible for a few minutes. There may be a complete loss of consciousness with convulsions (epileptiform type), or, what is less common, the apoplectiform type without paralysis. Prodomata are not infrequent. A distinct aura may occur, or "sinking spells," precordial oppression and headache usher in an attack. Extreme pallor, staring eyes, a cold skin, and moaning usually accompany the paroxysm.

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The pulse rate may be 40 or 5 per minute, and even lower as in a case which came under my own observation. Usually, the pulse frequency bears a distinct relation to the severity of the nervous symptoms. There may be a perfect synchronism between the heart beats and the respirations, there being an inspiration for each beat of the heart.

Etiology. More men suffer than women. Severe bodily efforts, not necessarily extremely prolonged, and mental and emotional strain, come the nearest to being frequent causes. Senility and extreme grades of arterio-sclerosis predispose. It may, however, occur in childhood, and1 sclerotic changes in the arteries is not essential for its production.

The exact pathological criterion is not known. It is supposed to result from changes in the vagus center, due to disease of the arteries of the medulla. Sclerotic degeneration, aneurisms,

and 1a fibrosis of the upper part of the ventricular septum seem prone to occasion the trouble.

Prognosis is dependent upon the degree of bradycardia, the age of the individual, the severity of the nervous symptoms, the cause, and the type of the disease. Three and a half years has been metioned as the probability of life.

Exceptions to this rule are not uncommon. Osler mentions a case in which the symptoms complex occurred at irreguiar intervals for a period of thirty years. I have in mind a gentleman (under the care of a physician in another state), age 62 years, who has had an average of one epileptiform seizure every two months for the past sixteen years. He enjoys excellent health during the intervals, and has a normal pulse which varies between 40 and 36. Its frequency has been reduced to 20, and will beat for hours at this rate subsequent to a paroxysm.

Treatment. There is no specific. Rest in the recumbent posture should be enjoined, and cardiac stimulants administered. "Theoretically, the bromids might lessen the reflex action of the vagus. Cohen reported a case in which adrenilen was used, hypodermically, without success.

Unfortunately the history of the following case is vague. The patient could neither speak nor be made to understand English. No very careful observation was made by the attending physician, and it follows that no bedside record was kept. I saw the patient in consultation twelve hours before his death. Personal History. Mr. M., a Hebrew, aged 92 years. No specific disease. He had never been sick. Hearing was acute, and he could read without the aid of glasses. For the past six months he has been deeply interested in the building of a church, and worried constantly over factional controversies. Up until the time of his being stricken with supposed apoplexy he was unusually active, walking one-half mile each day for exercise.

Present Trouble. One morning while conversing with a friend he fell to the ground; was unconscious, and on being removed to his room was treated for cerebral hemorrhage. There was no paralysis, no frothing at the mouth, or epileptic movements. The pupils were of equal size. Urinary incontinence occurred.

In this, as in the subsequent apoplectic seizures, there was neither nausea, vomiting, dysphalgia, nor a very pronounced

cyanosis. The attack lasted twenty minutes, and in the course of an hour he was up and about, although he felt dizzy and said he was weak. Later in the day he had frequent epileptic seizures-always with a reduction to eight beats per minute in the pulse rate. He complained bitterly of precordial oppression, and feared the paroxysms since they were attended by a sensation of impending death. In the interim the normal pulse frequency varied between 24 and 16 beats. Each attack had a duration of from 1 to 5 minutes and was preceded by a distinct aura. The expression would become anxious, and the patient restless. He would press both hands over the precordium, gasp for breath, cry out as if pained, and, with the advent of the epileptiform movements, grasp the side or head of the bed for support.

Seemingly, at its very acme, relaxation would replace the muscular rigidity and a momentary period of unconsciousness ensue. Dyspnea was marked, especially when the paroxysm was general or of a violent type. Syncopeal attacks were not infrequent. They were marked by quietude.

On the second day the patient felt comfortable; slept several hours, and took nourishment. The pulse was 22 per minute. Six epileptic paroxysms were noted.

On the morning of the third day an apoplectiform seizure occurred which resembled the incipient attack. Others followed at intervals of every three to four hours. Each succeeding attack had a longer duration than the previous one, and was characterized by a more pronounced type of Cheyne-Stokes' respiration. He had eight in all, with an average duration of 20 minutes each.

Examination. Weight 165 pounds and well nourished. Lips cyanotic and facies pinched. Pupils were of equal size and reacted. The thorax symmetrical.

The cardiac impulse was perceptible in about its normal position. The carotids pulsated, but contained no murmurs. There was no cardiac lesion; no thrills palpable, nor a very marked degree of arterio-sclerosis of the superficial arteries. The aortic sound was accentuated-of a booming character-and heard over the entire precordial area. The pulse was 16, full, regular, and non-compressible. Its frequency bore a distinct relation to the severity of the attacks. The radials pulsated synchronously. Peripheral circulation seemed good, and nothing ab