THE REVIEWER'S TABLE

Books, Reprints, and Instruments for this department, should be sent to the Editors, St. Louis.

A TREATISE ON DIAGNOSTIC ME "HODS OF EXAMINATION. By Prof Hermann Sahli, Director of the Medical Clinic, University of Bern Edited with additions by Francis Kinnicutt, M.D, Professor of Clinical Medicine at Columbia University, and Nathaniel Potter, M D, Visiting Physician to the City Hospital and to the French Hospital, New York. Authorized translation from the fourth revised and enlarged German edition. Philadelphia and London: W. B. Saunders & Co, 1905. (Cloth $6.50 net.)

This timely work is not a compilation of ideas cemented in book form under the guise of being original, but is an evidence of absolute originality based on years of careful clinical observation and personal investigation. In the present revision the author strives to increase the scope of its usefulness by introducing the latest diagnostic innovations with as little increase in the size of the volume as possible. This is accomplished by eliminating the older methods which have not withstood the test and substituting the newer ones, consequently there is no padding the text with obsolete and irrelevant matter for the sole purpose of enlargement, as is so frequently the case. The intelligent and scientific manner with which Sahli treats the methods of examination for diagnostic purposes is an expression of system, thoroughness and ability. Explanations of the clinical phenomena from both physiologic and pathologic standpoints are fully given with abundant illustrations and charts to elucidate the text. The subjects of radioscopy and cystoscopy are entirely omitted, as the author frankly states that his personal experience with these diagnostic procedures is not sufficiently adequate in justifying the effort to teach them to others. Those of us who are acquainted with the original keenly appreciate the enormity of the task in translating this master-work, as such it may be rightly called. The English translation is remarkably good, and is a credit to the editors. A few notes have been added, especially where methods are described which differ from those commonly employed by American physicians, and a brief review written by Dr. Janeway on the value of the clinical estimation of blood-pressure, with a description of the modern instruments for this purpose. We regard Sahli's Diagnosis as belonging to a class of its own and worthy of the highest praise in every respect. O.E.L.

CARBONIC ACID IN MEDICINE. By Achilles Rose, M. D. 12mo, cloth, 288 pages. New York and London: Funk & Wagnalls Co., 1905. (Cloth $1.00 net.)

The object of this book is to present the beneficial properties and healing qualities of carbonic acid gas. The contents of the volume is most interesting and instructive. The reader will not only acquire a thorough knowledge of the therapeutic value of carbon dioxide, but also become familiar with the

mode of administration in the different diseases considered in the text. The author discusses at length the effects of carbonic acid baths on the circulation, describing in full the manner of its application, the indicatious and contraindications in diseases of the circulatory apparatus. O.E. L.

LEA'S SERIES OF MEDICAL EPITOMES. Edited by Victor Pedersen, M.D. Dayton's Epitome of the Practice of Medicine. A Manual for Students and Practitioners. By Hughes Dayton, M. D. Principal to the class in Medicine, New York Hospital, Out-Patient Department, etc. In one 12mo volume of 324 papers. Philadelphia and New York: Lea Brothers & Co., 1905. (Cloth $1.00 net.)

This compendium is a timely condensation of the realms of the practice of medicine, serving adequately the needs of those for whom the book is intended. The busy general practitioner, in particular, will find it a handy_volume for quick reference work.

L.

A PRACTICAL MASSAGE. By Hartvig Nissen, Instructor and Lecturer in Massage and Gymnastics at Harvard University Summer School. etc. With 46 illustrations. 168 pages. Philadelphia: F. A. Davis Company, 19.5. (Price, extra cloth, $1.00 net.)

The technical features of massage are fully described in the twenty lessons of this little volume. Although the book is mainly intended for the use of those taking up the study of massage, the general practitioner will gain many practical points by a perusal of its contents. There is no question of doubt that massage is a beneficial therapeutic agent, but we are very skeptical as to some assertions made by the author regarding the efficacy of its application in certain affections, particularly in the prevention of an attack of appendicitis through circular kneading and friction of the abdomen. O.E.L.

In

DR. BRADY'S NEW NOVEL, "THE PATRIOTS."-Cyrus Townsend Brady's "The Patriots" is announced for a serial by The AllStory Magazine. The first instalment will begin in the December issue, out November 1st. It will run until April. To quote the doctor's letter on the subject, "This is the last serial story, long novel that is, that I shall write for some years. It is along the lines of his previous novels of Southland, but is beyond a doubt the most dramatic and thrilling story of the kind that has come from his pen since he has been in literature. the first instalment of "The Patriots," Dr. Brady has written a description of the Battle of Gettysburg that will stand comparison with Victor Hugo's pen picture of Waterloo. It is of the sort that will thrill both North and South alike. The love story running through this serial is everything that a love story of that period should be; a love story that literally vibrates with telling situations and stirring moments. Dr. Brady will be remembered as the author of "The Southerners, ""A Little Traitor of the South," etc.

REPORTS ON PROGRESS

Comprising the Regular Contributions of the Fortnightly Department Staff.

SURGERY.

JOHN MCHALE DEAN, M. D.

Spina Bifida, with a Report of Three Hundred and Eighty-five Cases Treated by Excision. In searching the literature on spina bifida James E. Moore reports (Surgery, Gynecology and Obstetrics) 385 cases. The author calls attention to the presence of an unusual growth of hair in spinal region that often obscures a so-called "hidden spina bifida. The analysis of the above cases showed 23 per cent sacral, 34 per cent lumbar, 29 per cent lumbo sacral, 4 per cent dorsal, 9 per cent cervical and two cases occipital. From the above we note the lumbar spina bida is most frequently found, with lumbo sacral next in order. Regarding the prognosis of spina bifida the author claims without operation the cure is impossible. Injecting with iodine and compress has long been abandoned as unsurgical and dangerous. With operation the prognosis depends on the age of the patient the size of sack and the presence of paralytic symptoms. In large spina bifida with much fluid and paralysis of the lower extremities or the sphincters operation offers less hope. In mild cases not of tender age, the prognosis is fair. Hansen reports 150 cases of excision with 27 per cent mortality. Boyer's statistics shows 59 per cent mortality. He claims he will operate only in future where there is no decided hydrocephalus, where there is no paralysis, and when no clinical manifesations are present. Mikulicz reports out of a series of thirty cases, eighteen were operated, six dying, twelve locally cured and five only completely cured. The causes of death the author claims are either shock, convulsions, meningitis, hydrocephalus or late infections. As to the manner of operating the latest procedures have not heen in the direction of using a bony flap, but merely excision of the sack, sewing with fine chromic catgut and usage of a muscular flap from the neighborhood. Much has been said as to the treatment of the nerve filaments of the sack and much time has been lost in attempting to separate and preserve same. Where these filaments are easily separated they are dissected out and returned, but where they are adherent they are either returned with the sack or removed with same. These nerve filaments do not possess much function and are disposed of without serious effect. Where they can be preserved particularly in paraly. tic cases it is best to do so. The skin is sewed

in the usual way and the wound sealed with collodion to prevent subsequent contamination with urine or feces. The author concludes his article as follows: "1. Operation upon children of very tender age is scarcely worth while, because it is accompanied by so large a mortality rate, and because it does not stop the progress of progressing cases. 2. Patients five or more years old can be operated upon safely. 3. Patients with large or rapidly growing tumors, with hydrocephalus and with paralysis or deformities of the extremities are not cured. Finally, all we can hope to accomplish by operation for spina bifida, is to relieve the patient of an unsightly and annoying tumor after he has survived the dangers of the af. fliction per se."

A Safe, Simple and Sure Cure for Ganglion. -In Surgery, Gynecology and Obstetrics, Cates gives a simple treatment for ganglion. It consists, after sterilizing the region properly, in injecting with a hypodermic syringe fifteen to twenty drops of campho-phenol and bandaging. Campho-pheuol is prepared by mixing equal parts of orystalized carbolio acid and gum camphor. The author has never been compelled to use more than one injection.

A Study of Perforation in Typhoid Fever. -In J. A. M. A. Richard H. Harte discusses the subject of perforation in typhoid fever. As to etiological factors he concludes after a study of the statistics on this subject that it occurs more frequently in the white race, in women than men, and between the ages of fifteen and thirty years. Season of the year can scarcely be considered important on account of the most prevalent time for typhoid is spring, summer and fall. Osler claims perforation may occur at any stage of ty. phoid, but most frequently it occurs during the third week. Severity of disease is not a criterion, as frequently very mild attacks have perforation. In cases with severe hemorrhages we should be on our guard as they denote deep ulcerations. Intestinal parasites and severe emotions have been known to favor the development of perforation. The seat of perforation may be anywhere, but is mostly seen in the lower part of the ileum. location is generally found distal to the mesenteric attachment on account of the lessened metritine supply at the region. Somewhat of interest is the inference drawn by the author from the appearance of the perfora. tion. Small ulcers or cribiform ones are due to ulceration; large circular perforations are due to sloughing; the oblong, slit-like perforations are due to traumatism. As to the bacteriology we find typhoid and colon bac

The

illi, staphylococci and streptococci. In the presence of streptococci we have more serious subsequent peritoneal symptoms. As to the symptomatology, we must consider, firstly, pain, sudden and severe localized, generally in the right lower quadrant. This may be also moderate and merely colicky in nature. As pain is common abdominal symptom in typhoid, especially due to flatus and other conditions we must not rely on it entirely in our diagnosis. Patients have been known to have had a sudden and acute appendicitis during typhoid, as well as having passed renal and biliary calculi. Patients have developed diaphragmatic pleurisy and peritonitis during typhoid, and have complained of sudden acute pain. Pain by itself would not make a diagnosis positive without other symptoms. Sweating, secondly, a consequence of the presence of shock, located most frequently about the head and neck must also be considered. Vomiting, thirdly, also helps to make up the composite picture. But how often we find vomiting after food and medicine in typhoid fever. Abdominal rigidity, fourthly, is a very important symptom when taken with the others in the case. So often we find practitioners unable to elicit this symptom The rigidity is localized in the right reotus and oblique muscles and not of voluntary origin, but due to distention resulting from paresis of the intestine and from inflammation and pain. Tenderness, fifthly, is not very reliable, for it is generally more or less present in all cases. In unconscious or delirious patients this would not be a well marked symptom. Pulse rate, sixthly, is reliable as the pulse becomes rapid and weak, and with it the temperature drops to sometimes below normal. If the case is seen late the pulse may have improved and the temperature have risen. But at the moment of perforation we have a rapid pulse and a drop in the temperature. The countenance, seventhly, is somewhat marked, but difficult to describe. The facial expression is that wrought with anxiety, pain and great depression. The alae nasi become active, the pallor and cyanosis often being marked. Dullness of percussion, eighthly, is not important as well as the tympanitis and absence of liver dullness. Distension in any typhoid may reduce the liver dullness. Dullness in the region of the perforation is only marked in cases of long standing. Recently developed perforations show little or no dullness. Ninthly, the blood examination shows leucocytosis usually, though in some cases little increase in leucocytes are found. In hospital practice it is well to make this count, but in private work it would be consumption of time better spent in activity and

life-saving. The treatment consists simply in prompt interference and rapid execution. The perforation should be closed by black silk suture placed perpendicular to the long axis of the intestine. Scrupulous asepsis and antisepsis with subsequent lavage of the abdominal cavity and thorough proper drainage are points to be well observed. Should it not be easy to close the perforation then an artificial anus should be established by either suture or gauze properly placed. Intestinal resection or excision of the ulcer are procedures only to be considered indicated in unusual cases. The mortality from this procedure is placed at 76 per cent. In concluding the author goes on to say:

1. Perforation of the bowel in typhoid fever is a much more common condition than is generally supposed, being responsible for about one death in every three cases.

2. The most common time of perforation is between the fourteenth and twenty-first day of the disease, and occurs in all grades of severity, from the ambulatory to the hem. orrhagic type, and does not seem to be any more common in the hemorrhagic than in the milder types of the disease.

3. The ileum is the most frequent site of perforation, in the majority of instances the perforation occurring within 12 to 18 inches of the ileocecal valve. The next most frequent sites of perforation are the appendix and the cecum.

4. In a large percentage of cases pain is present, although it may be transitory in character. In about one-half of the cases the onset is sudden, severe, and with increasing intensity, localizing itself in the region of the right iliac fossa.

5. Tenderness and rigidity are present to a certain extent in all cases. The latter symptom I regard as a most valuable sign, and it is never wanting except in patients with unusually large and pendulous abdomens.

6. When perforation is suspected the temperature should be taken every hour, as it is only in this way that definite conclusions can be drawn with regard to any marked variation in this symptom.

7. Distention is a late symptom of perforation, usually not making its appearance until some hours after the perforation has occurred. The obliteration of the liver dullness is not regarded as a reliable sign of perforation.

8. The study of the leucocytes is of little aid, although occasionally their increase may make you more positive of the diagnosis. The differential count is of no practical value.

9. Before a positive diagnosis is made, pain caused by a pleurisy, pneumonia, cholecystitis, acute gastro-intestinal indigestion, iliac

thrombosis, appendicitis, peritonitis, the passage of a renal calculus, distended urinary bladder, or even a hemorrhagic exudate into the abdominal muscles, must be carefully considered. Any of these conditions may cause symptoms similar to those caused by intestinal perforation.

10. Nature may occasionally close one or more perforations, but the only rational procedure where perforation occurs is surgical intervention. No case is too desperate for an attempt, as it has not infrequently been noted that the mild cases sucumb and the more desperate ones recover.

11. In cases of doubt where the symptoms point to perforation, the safest procedure is to operate. As a rule, cases operated on and no perforation found seem rather to be benefited than otherwise by the operation.

12. When the diagnosis has been made, I know of no condition, except possibly that of hemorrhage, where speed in operating is so important a factor in securing success as is in intestinal perforation. Everything should be carefully prepared beforehand and all conditions considered, so that when the knife is once taken in hand things may move with rapidity and without interference. In too many instances it is a race with death and there are often anxious moments when it is questionable which will win, yet in only five reported cases has death occurred before the operation was completed. A death on the table is always a most distressing occurrence in surgery, but doubly so if the surgeon has in any way to blame himself for delays which might have been prevented by care and forethought.

DERMATOLOGY.

ROBERT H. DAVIS, M. D.

Micro-Biologic Researches in Syphilis. (Menage's translation, Revue pratiq. des malad. cutan. syphil. et vener., June, 1905.) --Metchnikoff and Roux in the above article review the work of Schaudinn and Hoffman besides giving the results of their experiments, along this line, with apes. A spirillum had been observed in syphilitic and other genital lesions by several observers previous to Schaudinn, especially Rona and Bordet, and Gengou. Schaudinn claims, however, the discovery of the existence of two distinct types of genital spirochoetae, one the spiril. lum refringens, the other the spirillum pallida. The first of these is characterized by its form, which resembles naves, by its relatively large size, and by the ease with which it is stained with ordinary coloring sub

stances. The spirillum pallida is differentiated by its small size, by its corkscrew appearance, and by the difficulty with which it takes ordinary stains, necessitating the special staining mixture of azur and eosin of Giemsa. Possibly some of the observers before Schaudinn may have seen the spirillum pallida. They did not recognize, however, its specific identity, except in the case of Messrs. Bordet and Gengou, who found in a chancre a fairly large number of fine spirilla, lightly stained and corkscrew in shape. Failing, however, to find them in five sucessive, subsequent cases, they became discouraged and stopped. All the other observers have hitherto described the spirillum refrin gens which occurs in non-syphilitic as well as syphilitic lesions and in the smegma of the genitals of both sexes. Up to the present time, Schaudinn and his co-workers have studied twenty-six cases of primary lesions and macous patches of the genitals, and have always found the spirillum pallida, although very few were present in some of the cases examined. They were often so thin and pale that it took a long time to find them, but they were detected not only in the secretions of syphilitic lesions of the genitals, but also in the deeper tissue of chancres and mucous patches, as well as in eight syphilitic, inguinal buboes, during the primary and secondary manifestations. Schaudinn, however, is very conservative in his conclusions, saying, "Although we have succeeded in finding regularly, in eight well studied cases, in the secretions of syphilitic buboes, the pale spirochoete, which appears to differ from all other known species, we are none the less far, at this moment, from expressing a positive opinion upon its etiologic role. The authors experimented with six monkeys, previously inoculated with syphilis, and determined the presence of the spirilla in four cases, a chimpanzee, a paprion and two baboons. One of the baboons that gave a negative result, was so nearly well that the absence of the microbe, or failure to find to it, was not surprising, so there remained only one baboon that gave a certainly negative result. The lesions from which the exuate was examined were, in the case of the chimpanzee, a chancre on the penis, and in the two baboons and the paprion, a primary lesion of the skin of the supra orbital region. The authors say it is impossible to deny the syphilitic nature of the lesions on the baboons and paprion, and that the identity of the spirilla found in syphilitic lesions in man, and in the syphilitic lesions of these monkeys, is certain. They then examined scrapings from a papular syphilide on the human skin, and located at a distance from the initial le

sion of the genitals. Of six cases, four showed the spirillum pallida, and, in some cases, the papules examined were the first to appear, indicating that the spirochoetae were not the result of accidental contamination, but were carried there through the blood, or lymph, circulation. They rely on the presence of these microbes to differenitate secondary syphilis in chimpanzees, from a variety of other skin lesions, resembling syphilis, to which they are liable, and they report that it has been impossible for them to find the spirrillum pallida in any non-sypilitic cutaneous disease in man, such as psoriasis, scabies and acne. As yet it has been impossible to obtain a pure culture of the spirochoetae in question, but "a synopsis of all we have said pleads strongly in favor of the theory that syphilis is a chronic spirillum disease caused by the spifochoetae pallida of Schaudinn."

[Kiolemenoglou and Von Rube in the Munsche Med. Wochenschrift, July 4, 1905, claim to have observed the spirochoetae pallida in other lesions than those of syphilis, namely: 1. In the discharge in a case of inflamed phimosis. 2. In the pus from a gonorrheal abscess. 3. In the discharge of balanitis. 4. In the pus from a scrofula dermatic abscess. 5. In the degenerative products of suppurating cancer. 6. Tissue juice from condyloma acuminata. They claim to have observed the spirillum refringens also in these cases.]

A Method of Giemsa for Staining the Spirochaetae Pallida. (J.A.M.A. Oct. 7, 1905.)-Hirschberg gives the following technique from the Deutsche Med. Wochenschrift, June 29, 1905, No. 26:

Giemsa's Stain.-Azur II, eosin 3.00 grns, azur II 0.8 grms. glycerin (C. P.) 250 c.o., methyl alcohol 250 c.c. 1. Fix by spreading the specimen very thinly over the cover slip; dry it in the air. 2. Harden in absolute alalcohol, for from 25 to 60 minutes, and blot with filter paper. 3. Dilute the stain with distilled water. Pour it into a wide graduated reagent glass by shaking one drop of the stain to each c. c. of water out of a drop bottle which first has been rinsed in absolute alcohol. 4. Cover the preparation with the diluted stain for from 10 to 15 minutes. 5. Wash off with running water. 6. Blot with filter paper, dry and mount in Canada balsam. 7. Overstained specimens may be differentiated in distilled water for from one to five minutes.

Schaudinn's method is as follows: 23c.c.of a one per cent watery solution of eosin to 500 o.c. of water. Take twelve parts of this mixture and add to it three parts of a 1:1000

watery solution of azur I. Then add three parts ofan 8-10 to 1:1000 solution (watery) of azur II. Fix the specimen for 15 to 30 minutes in absolute alcohol a stain over night in the above.

care

His

An Inquiry Into the Etiology of Infantile Eczema. (British Journal of Dermatology). -Hall completed a series of four articles on this subject in the August number of the above mentioned journal. He bases his interasting conclusions on the results of the observation of sixty cases, which were fully inquired into in every detail. summary contains the following statements: Sex. Seventy-eight per cent were males. Family History.-(a) Age of mother. More of the children were born in the middle, or late, rather than in the early period, of maturity. (b) On the whole, they were not children of large families. First borns were not more frequently affected than others. (0) Only a very small proportion (13%) of the mothers had suffered from an actual outbreak of eczema; 31% showed stigmata of seborrha, and 44.5% of the mothers had never had

any skin trouble. (d) Over 90% of the

other children of the families from which the patients came had never had any skin disease. (e) Most of the cases began between the end of the first and the beginning of the fifth month. (f) In 95% the rash appeared, first, on some part of the head. (g) Out of 59 cases extending over a period of six years, only three occurred during the quarter, June to August, the warmest quarter of the year, while twenty-four began in the quarter, December to February (the coldest quarter). The number for the quarter September to November was eighteen, for the spring quarter, fourteen. (h) 86% of the cases were breast fed when the rash appeared. The remainder were bottle-fed. (i) The greater number of the cases had not been vaccinated before the rash appeared. In the few that had been, the interval between the time of vaccination, and the appearance of the rash varied considerably. (j) In most cases the eruption preceded the first dentition, often by an interval of months. (k) In most of the cases there was no wasting, vomiting or diarrhea. In about 15% there was rickets, in more than 50% there was none. (1) The character of the eruption varied according to the duration, cleanliness, amount of secondary infection, etc. The distribution was extensive, certain parts, as the head, almost always being affected, others, hardly ever. The symmetry of the eruption on the two sides of the body was usually noticeable in all parts affected. As to the etiology he divides all the various theories into three