The publishers have done their work well. There is an almost total absence of original illustrations, but the borrowed illustrations are well selected. The 'writer has arranged his material systematically, using types of various prominence to facilitate the finding of topics.

The opening article is on typhoid fever, to which the author devotes thirty-eight pages. In speaking of the bacteriological diagnosis of typhoid fever, the author tells us that this is not usually practicable, for the colon bacillus confuses the inexperienced physician in the examination of the urine and feces. This is rather striking to us, for we had come to lay considerable stress upon the importance of the bacteriological examination in, typhoid, especially the examination of the urine. However, the author refers here to the inexperienced physician; possibly it is of more value to the experienced physician. All in all, the subject is well treated and in a practical

manner.

Sixty-three pages are devoted to tuberculosis. Referring to the test injection of Koch's tuberculin, the author states that "in some cases positive reactions have been obtained in chlorosis, syphilis, leprosy, cancer and actinomycosis.' We might add that positive reactions have also been obtained in cases of corns and toothache. But in these cases, as in the cases mentioned by the author, there was a coincident infection by the tubercle bacillus. The tuberculin reaction means that there is an infection by the tubercle bacillus in some part of the body. The fact that it is found in so-called latent tuberculosis would seem to us to be an advantage in diagnosis. The author refers to the general use of tuberculin in diagnosis in veterinary medicine. But in the human he "no longer uses it, for. four cases of miliary tuberculosis have apparently resulted from its employment." This was one of the early objections to the use of tuberculin. But it was shown that miliary tuberculosis is much less frequent in the cases treated with tuberculin than in those not so treated. It is unfortunate that these old fallacies have been perpetuated in a modern text-book.

Referring to the prognosis of pneumonia, the author states that "pneumonia is the most fatal acute disease, and even has a greater death-rate than tuberculosis. In 1903, 4,629 persons died of pneumonia in Chicago, and in 1904, 8,360 died of it in New York City. From 1851 to 1890, the mortality in Chicago from tuberculosis was 35 per cent. than from pneumonia. From 1891 to 1901, the pneumonia death-rate was 9 per cent. more than the tuberculosis mortality.' This is in consonance with the increased severity of pneumonia along the Great Lakes and our eastern seaboard during recent years.

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Since Chicago is a sort of trichinosis centre, let us examine the article on that subject. Referring to the frequency of the disease, he says: "Though trichinæ are apparently about forty times as frequent in American as in German swine, the disease is more frequent in North Germany, where raw sausage, Westphalian ham and smoked ham are frequently eaten. Frankel denies that German trichinosis results from American pork." Nothing new is given in the treatment of the disease.

Medical Diagnosis: For Physicians and Students. By JOHN H. MUSSER, M.D., Professor of Clinical Medicine in the University of Pennsylvania. Fifth edition, illustrated with 395 wood-cuts and 63 colored plates. Over 1,200 pages. Lea Brothers & Co., Philadelphia.

Massive, methodical, monumental. The medical man who recalls the methods of diagnosis of a quarter of a century ago will find himself astonished at the wonderful expansion of the means to unravel the mysteries of man. A quarter of a century ago a few instruments of precision and a few chemical reagents were all that was at our command. The microscope, it is true, was employed to examine a few excretions and the blood. Behold, how the instruments of precision are multiplied and the scope of their explorations increased! Gastric mysteries are fathomed by chemistry and electricity. The microscope has extended its domain, and with new methods of staining has unlocked and is unlocking many of Nature's secrets. Bacteriology has come to our aid, and now through it we establish a diagnosis much earlier. A decided advance has been made in certainty of diagnosis. Diseases in which a positive diagnosis was formerly impossible are now made easy. New instruments and new methods are increasing daily, and they will surely prevail in extending the horizon of absolute knowledge far beyond its present confines. The use of all these methods requires much time, often hours or even days, but the patient profits thereby. This taxes the physician far more now than a few years ago. The physician of to-day who will scientifically diagnose his cases must have a limited clientèle or employ assistance.

Under family relations Dr. Musser says: "Is there trouble in the marital relation? Has there been sorrow, or sudden shock, or long nursing, or great care? Are the financial circumstances easy? Has there been recent malfeasance? How many invalid women arise out of such ashes?" The author calls attention to the vague and doubtful character of many answers to questions in securing a family history. They may be due to a lack of memory on the patient's part or a want of knowledge of technical terms. This want must be overcome by control questions, prompted by our knowledge of the nature of the disease and its frequency at different ages, by an inquiry for symptoms and by investigation into collateral and remote branches of the family.

The Roentgen ray in medical diagnosis is supplied by Dr. Henry Pancoast, the ray man at the University of Pennsylvania. The chapter is very full and complete, and as near up to date as it can be on a subject which advances by strides while one has a book in course of preparation on the subject. The chapter on examination of the eye and ear was prepared by Dr. W. C. Posey and that on nervous diseases by Dr. Joseph Sailer. Gynecological diagnosis is omitted.

In searching seriously for criticism we can only say that the book fails in that point where most German medical literature fails, viz., it is too heavy for this rapid age.

E. S. M.

Fatal cases of staphylococcus septicemia and pyemia are rare enough to justify most careful study and report on the part of any observer under whose care they may happen to come. The very interesting circumstances surrounding and the very full history supplied by the intelligent physician who had most at interest and most at stake in this case, make it, I believe, of peculiar value. I have therefore felt it a duty to make a full report of the case, and to compare it with some other cases that I have been able to find in the literature, so as to fix, if possible, the symptomatology on a more definite basis, as the reader will, without doubt, notice the period of uncertainty in diagnosis through which all these cases pass before finally, by a laborious process of bacteriologic and hematologic tests, a diagnosis by exclusion is made.

The bacterial pathology of this infection. is so well and tersely summed up by Ohlmacher in a single sentence that I quote it entire:

"From a local lesion like an infected wound, osteomyelitis or phlegmon, infection may travel the lymph-channels (lymphangitis) to reach the regional lymph-glands (lymphadenitis), and, while generally stopped by these barriers, it may proceed either by the lymphvascular or blood-vascular route to more remote parts. Invasion of the systemic blood stream, taking the form of a bacterial septicemia (bacteremia), is a possible consequence, or the cocci may set up suppurative foci in various remote tissues or viscera, producing the condition known as pyemia. In certain parts of the body, particularly from the phlegmons about the nose, retrograde infective thrombosis of adjacent veins may be produced, the thrombi reaching the cranial sinuses and setting up inflammatory or suppurative changes in the meninges or entering

1 "American Text-Book of Pathology," Philadelphia, 1902.

the general venous blood stream to be taken to the heart, whence the bacteria may be conveyed to the body at large. Again, from the local seat of infection the staphylococci are carried to the heart, here to establish vegetative endocarditis, fragments of the infective vegetations being swept away as emboli to reach certain viscera, where infarction is quickly followed by inflammation and often abscess. An ordinary external saprophytic coccus, also found as a lodger in the healthy nose, mouth and throat, which occasionally plays a parasitic and pathogenic rôle in man, is micrococcus tetragenus. . . . As a pathogenic micro-organism it has been found in localized suppurations, such as abscesses about the teeth, nose, mouth, neck and axilla; in bronchitis, pleuritis, pericarditis, peritonitis, and even meningitis. Several cases of septicemia ascribed to it have been recorded. It has been noted also in pseudo-membranous angina with severe constitutional disturbance."

The history of the case under discussion is as follows:

M. H., aged nine and a half years, daughter of Dr. M. F. H., of Sidney, O., was brought to my hospital on the morning of Tuesday, May 7, with the following history:

About ten weeks previously she had had an attack of diphtheria (diagnosis not verified by bacteriological examination), for which she had received injections of antitoxin. Recovery was prompt and appeared to be satisfactory. She was kept at home from school for about two weeks and then returned to her studies. About two weeks previous to her admission to the hospital she again appeared to be ill. She lost weight, was pale and languid, and had a slight fever. Mouth-breathing at this time caused an examination of her upper air-passages, and a diagnosis of adenoids and hypertrophied middle turbinal on the right side was made. It was proposed to operate within a day or two. Meanwhile the child became worse, a profuse discharge began from

the right nostril and patches appeared on the anterior surface of the soft palate, one on either side and quite a little above the free edge. Her temperature was 104° F. A consultation was called. The father thought the condition was a recurrence of the diphtheria, and had already given her 4,000 units of antitoxin, but his consultants disagreed with him and made a diagnosis of empyema of some of the facial sinuses. The child was then brought to Cincinnati after a rather fatiguing journey.

On admission she was evidently profoundly ill. Her temperature was 103.6° F., pulse 140, respiration 24. She was very anemic and quite emaciated. (She was a tall and slender child for her age.) Fairly well developed. Tongue badly coated, offensive breath, constipation, some tympanites. No discharge from nose, no headache, no tenderness over any sinus. Patches on the soft palate as described. Cultures were made from these patches which were fairly well defined, granular in appearance, and of a yellowish color; and, while they were incubating a tentative diagnosis of diphtheria was made by the house surgeon, who immediately gave an injection of 4,000 units of antitoxin. By the next morning these cultures showed a pure growth of staphylococci (variety not determined), and another culture was made from the same patches, which had not materially changed in appearance.

By this time (second day in hospital) the clinical picture had changed quite a little. The child was in a typhoid state. She slept a disturbed sleep with her eyes but half-closed. Her nose was dry without occlusion. Her tongue was brown and dry with clean tip and edges. She had occasionally a dry, short cough. There was very marked tympanites with a diffused tenderness over the whole abdomen, more marked, it seemed, in the region of the ileo-cecal valve. The tympanites was so great that it was difficult to mark out the lower border of the spleen or of the liver. Lungs and heart negative. A drop of blood was taken, but the Widal test was negative. A culture taken from the patches on the palate on this day also showed an almost pure culture of staphylococci. There were, in addition, a few darkly-staining and rather large diplococci and a few streptococci. On account of the tympanites, and the fact that some undigested curds of milk were appearing in the stools, milk was discontinued and albumen water substituted in the diet.

The next day (the third day in the hospital) the clinical picture materially changed again. There began a profuse muco-purulent and

somewhat dark, bloody discharge from the right side of the nose, which caused the child to blow the nose with distressing frequency and thoroughness. She was much brighter; her tongue, though still coated, was moist; the tympanites was markedly decreased, her temperature ranged from as low as 101.4° F. to 103.2°. There was a fetid diarrhea and the nasal discharge and her breath were very offensive. A second Widal test having proved negative, a diagnosis was made of acute gangrenous amygdalitis of the pharyngeal tonsil, with a possible involvement of some of the right ethmoidal cells. Ophthalmoscopic examination of the eyes negative. At this time Dr. H. J. Whitacre and Dr. Alfred Friedlander saw the case in consultation.

The fourth day in the hospital found. the original yellowish patches on the soft palate not very greatly changed in size, position or appearance, and additional small patches, similar in color, on the edges of the tongue and the inside of the cheek. Excessive flow of mucus, a small quantity of pus and some blood from the right nostril. The child allowed her throat to be inspected readily, but resisted an examination of her nose, the taking of her temperature and all attempts to feed her, taking but very little nourishment, although an attempt was made to tempt her appetite with her favorite articles of diet. The submaxillary glands were swollen, the right one very much so. Transillumination of the sinuses negative and no tenderness over the antra of Highmore or the frontal.

On the fifth day in hospital, the child's general and local condition being about the same, blood was taken from the right median vein for bacteriological examination. Thirtysix hours later a report was received trom the hematologist, Dr. A. P. Cole, that the cultures showed a staphylococcus infection. On this day an endocarditis with rough breathing over the upper lobe of the left lung developed. The temperature had reached 103.8° F. at 6 P. M. on the previous evening, and varied between 102° F. and 103.2° F. on this fifth day, respiration about 30, and pulse about 130.

On the morning of the sixth day a lobar pneumonia of the upper lobe of the right lung was found. The temperature ranged from 101.6° F. to 103.6° F., respiration 32 and pulse 132. From this time on, although the fetid nasal discharge continued and the patches on the palate, tongue and cheeks showed little change, the clinical picture was that of pneumonia and a damaged heart with progressive exhaustion. The child complained only of feeling "very tired," and the senso

DR. COLE'S HEMATOLOGICAL REPORT.

Ten c.c. of blood were drawn from vein at bend of elbow. Of this blood 5 c.c. was used in inoculating each test-tube of solid media (two Loeffler's blood serum and two agar-agar). The remaining 8 c.c. were used in inoculating Erlenmeyer flask of nutrient bouillon (25 c. c. broth in flask). The testtubes and flask were then placed in incubator at 37° C. They were examined in about thirty hours for growth. The broth examined on cover-slip stained with methyl blue showed growth, staphylococcus. One of the Loeffler serum tubes showed small white colonies, which on cover-slip smear with methyline blue stain proved to be staphylococcus. The two agar tubes and one Loeffler tube gave no growth on several days' stay in the incubator. The one Loeffler tube with growth after two days in incubator showed well-marked white colonies. On inoculating agar-agar tube with thebroth from flask and incubating for thirty-six hours, white characteristic colonies of the staphylococcus were found. This coccus was the only organism found. It produced no pigment on agar, gelatin or potato. It coagulated milk in seven days. It liquefied gelatin more slowly than a virulent staphylococcus in stock, inoculated in gelatin test-tube and used as control. Inoculated a large unusually vigorous Belgian hare with c.c. broth culture in ear vein. For several days the animal was apparently very ill, refused all food, rectal temperature ranging from 102° F. to 104.5° F. At the end of ten days the animal had lost much weight. For following two weeks the animal took food much more freely and gained in weight. Temperature per rectum 990 F. The general appearance of animal was much better, but it died rather suddenly three weeks after inoculation. A smear taken from blood in heart, post-mortem, showed staphylococcus bacteremia.

It is difficult to deliver a positive opinion as to the course of the infection in this most puzzling and interesting case. The little patient's father is inclined to attribute it to an infected diphtheria antitoxin carrying a pure staphylococcus culture. As every circumstance attendant upon the case is interesting and of value, I quote extensively from a letter written by the doctor a few weeks after his daughter's death:

"To me, I must say, at first the case was an enigma, but after I returned home and my mind

worse.

began to clear up, I felt that I could see the whole thing. Mildred had never been sick except a mild attack of scarlet fever about two years ago. About the 15th of March she came down one morning complaining somewhat, but of nothing definite. I gave her 1-2 gr. of mild chloride; the next day oil and the following day her condition was Temperature 1030, pulse 140. She had seemed to have some nasal trouble for a day or so. My suspicion was aroused as to nasal diphtheria; our town at this time had many cases, and I had been treating quite a number. I made an anterior and posterior rhinoscopic examination and felt quite positive of a membrane in the posterior nares and vault extending down low enough so that on inspiration through the mouth, causing an elevation of the palate, I could distinctly see it. I called in Dr. Geyer, who bore out my observation. I gave her immediately (7 P.M.) 3,000 units of antitoxin. The druggist had then only what is called "The Board of Health' serum. He did not want to let me have it, but I demanded it and he yielded. The next morning early more came, but not of the Board of Health kind. I gave her then 4,000 units more. The day following her temperature was normal and she seemed on the rapid road to recovery. After keeping her out of school for two weeks she returned, seemingly about well, but pale, especially noticeable at times. She did not complain; her appetite was irregular. About the 10th of April I weighed her and again in a week, and she had lost one pound. Since her attack of diphtheria I had kept her pretty regularly on iron, arsenic and strychnia. I now dropped that and used guaiacol, creasote and hematic hypophosphites, and sprayed the nasal cavities with Dobell's solution occasionally.

About the 2nd day of May I took her to Dr. Grosvenor for an examination of the nose, as there seemed to be some obstruction there, with some discharge, but no odor. He examined her carefully and reported that he found some few adenoids and the lower turbinated impinging on floor of nasal passage, and recommended surgical interference, to which I consented. At noon on his way to dinner he dropped in and suggested deferring the operation, but to treat her tentatively a few days and look for results. I began the instillation of adrenalin and normal salt irrigation, but used great caution with the latter. During all this time I could plainly see that she was declining. I had not up to this time taken her temperature, but had frequently noted the increased rate of the pulse, thinking it to be due to the effects of the diphtheria. About three days after beginning the last treatment, I took her temperature and found it to be 1020 in the afternoon. I called Dr. Grosvenor and we concluded it possibly an infection of diphtheria, and gave 4,000 units of antitoxin with no benefit. I then called in Drs. Silver and Costolo also. I was then using per cent. solution of permanganate and biborate of soda for nasal irrigation and giving her tincture ferri chloridi. This continued three days, when I took her to the city. Pretty nearly all this time I observed some stiffness of the muscles of the back of the neck and suspected at one time cervical necrosis, and made a thorough examination, but with negative results, thinking then that it was due to the antitoxin, which I still believe. During all this time I noticed an augmented mentality. Missing in March half the month of school and taking her term examinations in April she attained almost 100 in every branch. General average 96. I sat down one evening after I had taken her out of school and I was completely astonished at the readiness and accuracy with which she handled (mentally) fractions. I spent ten years as teacher, and thought I knew what children could do. I called at the drug

gist's and it is impossible to procure any antitoxin from that consignment. He was getting it almost daily from where have a store-room.

The doctor then goes on to describe the case of a little girl of eleven years who had an attack of diphtheria, and whom he saw in consultation with Dr. Geyer. She was given 3,000 units of antitoxin on April 8. Dr. H. did not see the child again, but has since ascertained that she soon began to run down, became pallid, lost appetite, and died of endocarditis May 27." He considers this a similar case to that of his own daughter, with identical causation-an infected antitoxin.

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Of course, the two interesting practical points about this dread disease are the symptomatology and treatment. In the matter of symptomatology we find this infection assuming protean forms, so that in many, very many, cases the diagnosis is a matter of doubt for days, possibly for a week or so. Sometimes the fact that the patient is seriously ill is not apparent until after abundant opportunity has been afforded for the multiplication of the germ in the tissues of the body, and even then the nature of the affection may take hours or even days to determine. As for definite diagnostic points, one will find from a study of the recorded cases that the presence of a grave febrile disease without the history of a decided chill is perhaps all that can be said, and yet when we consider the onset of many cases of typhoid fever this absence of chill in staphylococcus septicemia has little or no value. With this extreme indefiniteness of symptoms I prefer to give as an exposition of the symptomatology of the disease an abstract of some of the few recorded cases I have found. They supplement the history of the case I am reporting, and exhibit the great variety of manifestations that we may expect to meet in this infection.

Libman (Medical News, April 18, 1903) gives a most interesting bacteriological review of twenty-three cases observed in the Mt. Sinai Hospital, New York. Eighteen of these cases died. Most of them were cases of osteomyelitis in children, which leads Libman to say: "Jordan has very well called the condition the septicemia of adolescence.' In other words, children with systemic staphylococcus aureus infection are apt to have the bones involved, whereas adults with a similar infection are more liable to have other forms of metastatic lesions. . . . The cases are to be looked upon simply as a form of sepsis, the primary focus of which in many of the instances cannot be determined." As some of Libman's cases are very interesting, I note some of the important points as follows:

Case 1.-Osteomyelitis of tibia; culture, staphylococcus aureus; two days later blood showed some organism. Patient died three days later. Staphylococcus found in heartblood, in an empyema, in infarctions of the lung, in an area of pneumonia, and in an abscess of kidney.

Case 2.-The first blood-culture showed staphylococcus aureus; the second, made several weeks later showed bacillus pyocyaneus. Post-mortem, staphylococcus aureus was found in a metastatic abscess in the right vastus externus and the bacillus pyocyaneus in the viscera.

Case 4.-Case of carbuncle of neck with supposed diabetic comą. Blood culture, staphylococcus aureus. Post-mortem, staphylococcus cultivated from miliary abscesses of the lung.

Case 6.-Osteomyelitis of femur. Culture sent from operating-room showed no growth. Blood on day of admission showed staphylococcus aureus. Two days later, the same. Three weeks later urine showed a pure culture (elimination going on). On two occasions later showed no organisms. Blood-culture several days later found sterile. Recovery.

Case 8.-Staphylococcus aureus present in metastatic foci in skin. These cutaneous metastases do not occur in other infections. Case 11.-Osteomyelitis of tibia. Pus aspirated from pericardium contained pure culture of staphylococcus.

Case 12.-Post-partum sepsis. Staphylococcus found in blood twice. Recovery.

Case 22.-Post-partum sepsis. Staphylccoccus found in blood one day after admistion, and two days later found pure in the urine. Subsequently it was isolated from a pus kidney on the right side and again from the urine. Later blood-culture negative. Re

covery.

Case 23.-Staphylococcus found in blood and later in abscess over left hip. Subsequently found in urine twice and blood once. Post-mortem was isolated from an abscess of the sclera of the left eye, from a peri-articular abscess over the shoulder, from an abscess cavity in dorsal region leading to vertebra, from an abscess under left pectoralis major, from a purulent pericarditis, and from purulent infarcts of the kidney.

W. P. Manton, of Detroit (Journal A. M. A., October 31, 1903), reported to the Section on Obstetrics of the American Medical Association a case of general staphylococcus infection following upon staphylococcus abscesses of both breasts of a young primipara. The noteworthy symptoms were