2. This extension can be prevented by removing the appendix while the infectious material is still confined to this organ.

3. The distribution or extension of the infection is accomplished by the peris

taltic action of the small intestine.

4. It is also accomplished by operation after the infectious material has extended beyond the appendix and before it has become circumscribed.

5. Peristalsis of the small intestine can be inhibited by prohibiting the use of every form of nourishment and cathartics by mouth, and by employing gastric lavage in order to remove any existing food or mucus from the stomach.

6. The patient can safely be nourished during the necessary period of time by means of nutrient enemata.

7. In case neither food nor cathartics are given from the beginning of the attack of acute appendicitis, and gastric lavage is employed, the mortality is reduced to an extremely low percentage.

8. In cases which have received some form of food and cathartics during the early portion of the attack, and are consequently suffering from a beginning diffuse peritonitis when they come under treatment, the mortality will still be less

than four per cent if peristalsis is inhibited by the use of gastric lavage and the absolute prohibition of all forms of nourishment and cathartics by mouth.

9. In this manner very dangerous cases of acute appendicitis may be changed into relatively harmless cases of chronic appendicitis.

10. In my personal experience no case of acute appendicitis has died in which no food of any kind and no cathartics were given by mouth from the beginning of the attack.

II. The mortality following operations for chronic appendicitis is exceedingly low.

12. Were peristalsis inhibited in every case of acute appendicitis by the methods described above-absolute prohibition of food and cathartics by mouth, and gastric lavage-appendectomy during any portion of the attack could be accomplished with much greater ease to the operator and correspondingly greater safety to the patient.

Penetrating Wounds of the Abdomen.

M. L. Harris (Annals of Surgery) discusses this subject, and cites a number of cases, concluding as follows:

I. In penetrating wounds of the abdomen, there are absolutely no known symptoms which indicate injury to any of the viscera, except those in connection with the urinary tract, stomach, and occasionally the lower bowel.

2. Except those relating to general shock, all symptoms following such

wounds indicate either internal hemorrhage or peritonitis.

3. To wait for symptoms of perforation of the intestine means to wait until peritonitis has developed, therefore,

4. Every bullet or stab wound which penetrates the abdominal cavity should. be operated on at the earliest possible moment in order to anticipate the advent of peritonitis.

5. No time should be wasted in attempting to demonstrate the presence or

absence of intestinal perforation by such means as the rectal insufflation of gases or vapors, or the analysis of recollected intraperitoneally injected air or liquids.

6. It is essential to systematically examine the entire gastro-intestinal canal in all cases, regardless of the point of entrance of the wounding body.

7. Whenever the alimentary canal has been perforated, suitable drains (the author prefers the so-called cigarette drains) should be placed either through the operative incisions or counter-incisions, as may appear best suited to the individual case.-Progress of Med.

Science.

Multiple Chancres.

Since the majority of text-books put as one of the cardinal symptoms of syphilitic chancre the fact that it is a single sore, and since this characteristic is usually expected by those who, occupied with a general practice, see comparatively few cases of syphilis, it is important that it should be generally known. that the true syphilitic chancre is multiple in about 25 per cent of all cases. Thus, Gaillard has collected the cases from the Hospital Ricord, and note that in 12,069, 3,065 were multiple. These statistics were taken from the service of four men, and the percentage of each was practically the same, excepting the service of Mauriac with 22.84 per cent.

Fournier in his comments on Ricord's writings finds that over 25 per cent of chancres are multiple. Jullien finds the percentage even higher-i. e., 33.26 per cent whilst Fournier in his treatise on syphilis finds that of 9,754 cases, 1,744 were multiple, which is a percentage of about 18.

These figures are important as serving to show that in one of four or at least five cases the sign upon which, perhaps, most importance is placed, in making a diagnosis, will be absent.

Those who believe that the treatment of syphilis should not begin until the

entire system is permeated with the poison, as expressed in the enlarged lymphatics, deteriorated blood, and eruptions upon the skin and mucous surfaces, may place but little value on this peculiarity of the affection; but those who are taught that treatment should begin as soon as the diagnosis is reasonably certain will understand the importance of recognizing this multiplicity of chan cre lest otherwise they be misled and their patients lose valuable time.-Ther. Gazette.

Source of Typhoid Fever.

The demonstration that practically all epidemics of typhoid fever were waterborne led to the belief that a contaminated water-supply was the sole source of infection. That this is true of epidemics is now conceded, but in the last few years there is an increasing recognition of other methods of infection. It is this sort of infection that furnishes the "normal" morbidity from typhoid fever in every populous community. HortonSmith has recently added considerable to our knowledge of the direct transmission of typhoid fever. Other cases have been traced to insects, particularly flies, but by far the largest number is probably to be attributed to infected food. Strong suspicion has been thrown upon shellfish, and this source of infection has been rigidly investigated both in England and this country during the last few years. It is now about four years since the first cases were definitely assigned. contaminated oysters. At a recent meeting of the Medical Society of the Coun ty of New York, it was shown that a large proportion of the oysters used in that city were obtained from beds which might readily be contaminated from nearby sources of infection. Even if the original bed escaped the oysters are put into comparatively brackish water, that they may imbibe a large amount of fluid and present that succulent appearance which is supposed to be so attrac

SO

tive. The oyster crates are submerged near the openings of sewers in contaminated waters.-Medicine.

Pneumonia and Pleurisy in Early Life Simu

lating Appendicitis.

Griffith reviews the literature on this subject and reports in detail several cases of his own. He says in conclusion: There is especially in early life, a wellrecognized, long-known, but frequently forgotten, tendency for patients with pneumonia or pleurisy to refer to the abdomen the pain really produced in the chest. This is more liable to happen when the disease is situated in the lower part of the thorax, but there is reason to believe that it may also occur when it has attacked the upper portion. It is also more deceptive when the right side of the thorax is affected, since the right side of the abdomen is then liable to ex

hibit pain, and the presence of appendicitis is suggested. Combined with the abdominal pain in these cases there is also constipation and abdominal tenderness and distension. These symptoms, together with the vomiting which quite commonly ushers in an attack of pneumonia in childhood, easily produce clinical picture very closely simulating that of appendicitis.

a

The distinction is to be made by giving due consideration to (1) the sudden rise of temperature to 103 degrees F. or thereabouts, and the tendency to maintain this degree; (2) the acceleration of respiration, which is out of proportion to the pulse rate or the pyrexia; (3) the relaxation of the abdominal walls between the respirations; (4) the diminution or the disappearance of tenderness. on deep pressure with the flat of the hand; (5) the possible presence of cough. Finally, no operation for appendicitis should ever be performed until after a careful, or perhaps repeated, examination. of the lungs has been made. All these points will, however, frequently fail to

make the diagnosis certain, as the experience of able observers has shown.Journal A. M. A.

Sterility Due to the Man.

E. H. Grandin emphasises the importance of gonorrhea and syphilis as etiological factors in the production of sterility, and enters a vigorous protest against present educational methods, by which young men are kept in ignorance of the wide-spread dangers attending the con

traction of these diseases. Gonorrhea is responsible not alone for sterility, but also for many cases of pelvic disease in women and blindness in children. Man is responsible for race suicide in its true sense; in fully 45 per cent of the cases of sterility in women the man is the responsible party. With syphilis, while a woman might conceive she as a rule miscarries, which practically amounts to sterility. The laity fails to realize and physicians do not lay sufficient stress upon the preponderant influence of the role played by men in the etiology of sterility in women. In every case of sterility the semen of the male should be examined, because although a man may be able to copulate he may be incapable of impregnation. In from 6 to 8 per cent sterility is due to the fact that the man is sterile in that his semen does not contain spermatozoa, although he possesses the power to perform the sexual act. Every young man should be instructed as to the risk he runs when he contracts gonorrhea or syphilis, and the possible risk he carries to the woman whom he marries. By proper educational methods the operating gynecologist will be deprived of nearly 60 per cent of his work, while on the other hand the human race will be immeasurably benefited.Medical Record.

Ringworm of the Scalp.

Hodara employs in this form of ringworm, a mixture of equal parts of gly

20

In a case of pericarditis with effusion, in a lad, 19 fluidounces of serum were withdrawn from the pericardium, but a reaccumulation rapidly followed. The patient's condition becoming critical the paracentesis was repeated, ounces of fluid being withdrawn with immediate improvement in the quality. of the pulse. Forty minims of solution adrenalin chloride, 1-1,000, were injected into the pericardium. The pulse at the wrist disappeared, the boy became of an ashy leaden hue and had an anxious expression. Immediately Immediately nitroglycerin nitroglycerin and atropin were administered and the boy quickly rallied. No further tapping

was required. The same patient had a subsequent attack of left pleurisy with effusion. Ten fluidounces of serum were withdrawn from the chest and one fluidrachm of adrenalin chloride solution were injected. There was no reaccumulation.

In a case of tuberculous peritonitis. and ascites 200 fluidounces of serum were drawn and two fluidrachms of solution adrenalin chloride introduced into the peritoneal cavity, with four pints of aseptic air (to prevent adhesions). Thirteen days later 237 fluidounces of serum were withdrawn and two fluidrachms of adrenalin chloride solution and two pints of air were injected. Upon a third occasion, eleven days later, 196 fluidounces of serum were obtained by tapping, and three fluidrachms of adrenalin chloride solution and four pints of sterile air were injected. No reaccumulation of fluid oc

curred.

A female child of seven years was the next patient. One pint of fluid was withdrawn from her pleural cavity and one fluidrachm of adrenalin chloride solution and half a pint of sterile air were injected. Though it was highly probable that the pleurisy was tuberculous there was no reaccumulation of fluid and the patient recovered.—British Medical Journal.

SCURVY IN INFANTS.-In the treatment of this disease three measures are indicated: (1) Discontinue the proprietary food; substitute a mixture of fresh milk diluted with water or with oatmeal water. (2) Give fresh orange juice, in dose of one or two teaspoonfuls three times a day. It is surprising how babies. with scurvy take to this and seem to enjoy it. (3) Give freshly expressed beef juice, squeezed from rare steak, in doses of one or two teaspoonfuls three times a day.

BOOKS

ESSENTIALS OF BACTERIOLOGY. By M. V. Ball, M. D., formerly Resident Physician at the German Hospital, Philadelphia. Fifth Edition, Thoroughly Revised. By Karl M. Vogel, M. D., Assistant Pathologist at the College of Physicians and Surgeons (Columbia University), New York City. 12mo volume of 343 pages, with 96 illustrations, some in colors, and six plates. Philadelphia, New York, London: W. B. Saunders & Company, 1904. Cloth, $1.00

net.

Within the last few years rapid progress in bacteriology has involved many radical changes in the science, necessitating a thorough revision in the preparation of this edition. It is with pleasure we note the inclusion of all the recent advances in the subjects of Immunity. Tuberculosis, Yellow Fever, Dysentery, Bubonic Plague and other infectious diseases, making the work reflect as faithfully as possible the present status of Bacteriology. We can confidently say that this book in the present fifth edition will be found of intestimable service to the student.

ESSENTIALS OF NERVOUS DISEASES AND INSANITY: Their Symptoms and Treatment. By John C. Shaw, M. D.; late Clinical Professor of Diseases of the Mind and Nervous System, Long Island College Hospital Medical School. Fourth Edition, Thoroughly Revised. By Smith Ely Jelliffe, Ph. G., M. D., Clinical Assistant, Columbia University, Department of Neurology; Visiting Neurologist, City Hospital, New York. 12mo volume of 196 pages, fully illustrated. Philadelphia, New York, London: W. B. Saunders & Company, 1904. Cloth, $1.00 net.

Of the progress made in every branch of medicine during the past few years, none has been more prominent than that considering diseases of the nervous system and of the mind. Dr. Smith Ely Jelliffe, therefore, in making the revision for this new fourth edition, has

found it necessary to recast the work entirely, bringing the order of arrangement in accord with the present knowledge of these important subjects. Quite a commendable change in arrangement is the grouping of subjects in such a way as to bring out the natural relations of affiliated nervous disorders. This will be found of great service to the student.

In the section on disorders of the mind, the general views of such leading psychologists as Ziehen, Weygandt, Kaepelin, Berkeley and Peterson have been carefully weighed. This new fourth edition is well worthy our recommendation, and we give it most heartily.

ESSENTIALS OF MATERIA MEDICA AND PRESCRIPTION WRITING. By Henry Morris, M. D., College of Physicians, Philadelphia. Sixth Edition, Thoroughly Revised. By W. A. Bastedo, Ph. G., M. D., Tutor of Materia Medica and Pharmacology at the Columbia University (College of Physicians and Surgeons), New York City. 12mo volume of 295 pages. Philadelphia, New York, London: W. B. Saunders & Company, 1904. Cloth, $1.00 net.

Dr. Bastedo, in making the revision of Dr. Morris' "Essentials of Materia Medica," has furnished the student with a work complete and up to date in every particular. Much of the text has been in great part rewritten. There have been introduced articles on adrenalin, stypticin, and on the iodine and silver synthetics. The present sixth edition is all that could be desired.

ESSENTIALS OF ANATOMY; including the Anatomy of the Viscera. By Charles B. Nancrede, M. D., Professor of Surgery and Clinical Surgery in the University of Michigan, Ann Arbor. Seventh Edition, Thoroughly Revised. 12mo volume of 419 pages, fully illustrated. Philadelphia, New York, London: W. B. Saunders & Company, 1904. Cloth, $1.00 net.

This work, now in its seventh edition, has met with a most cordial reception. In this revision the entire book has been