In

The work opens with a history of the disease. The first authentic removal of the human appendix, during life, was by Amyand, in 1735. In 1848, Hancock performed the first deliberate laparotomy for peri-appendicular suppuration. 1884, Kroenlein first removed the appendix for acute disease and Treves, in 1888, did the first "interval" opration.

Th plates illustrating the anatomy are excellent. Physiology, etiology and pathology are covered in a thorough and interesting manner. The author divides acute appendicitis into catarrhal, interstitial, ulcerative and gangrenous and the chronic, into catarrhal, interstitial and obliterating. The symptomatology, fully discussed, is summed up as follows:

There is no constant relationship between the symptomatology and the pathological alterations.

Of acute appendicitis there are three cardinal symptoms-pain, tenderness and rigidity of the abdominal wall.

The pain usually develops after eating. At first it is colicky and is referred to the epigastrium; later, it becomes localized at the site of the appendix. Tenderness on pressure is always present.

The rigidity of the abdominal wall is usually right sided.

Vomiting is common at the onset of the attack. It desists in favorable cases. Its continuance is an unfavorable symptom.

In chronic appendicitis, the history is important. Localized pain and tenderness are the most constant symptoms. Palpation is a most valuable means of diagnosis.

The differential diagnosis is covered in great detail and a special chapter is devoted to the blood count. These sctions are especially valuable to the practitioner.

The author has always been a keen advocate of early operation and has seen the opposition with which he met in the earlier years gradually disappear. Full directions for carrying out the medicinal treatment are given, but are to be employed only when, for any reason, prompt surgical interference is impossible. The plates illustrating the operation and the accompanying text are excellent.

The book is one to be strongly recommended and should be read by every practitioner both of medicine and surgery.

B. R. S.

RECEIVED:

(Grateful acknowledgement of the receipt of the following is hereby made. Further notice in our review column may be given).

Fourteenth Annual Report of the Ohio Hospital for Epileptics, Galliopolis. A. P. Ohlmacher, M. D., Superintendent, 1905.

Two Cases Presented to the Clinical Society of the N. Y. Post-Graduate Medical School and Society.

1. Multiple Herniae and Angioma Hypertrophicum.

2. A Case of Extensive Carcinoma of Tongue and Neck, Presenting Points of Special Interest. By Wm. Seaman Bainbridge, M. S., M. D., New York. Reprints.

A Handbook of Nursing. Published under the direction of the Connecticut Training School for Nurses, New Haven. Philadelphia: J. B. Lippincott Co., 1905. Program of Seventh Annual Meeting of the American Proctologic Society, Pittsburg, May 5-6. A. B. Cooke, M. D., Secretary, Nashville, Tenn.

Alling & Griffin's Diseases of the Eye and Ear. In Lea's Series of Medical Epitomes. Lea Bros. & Co., New York.

Program of Sixth Annual Meeting of the American Therapeutic Society. Philadelphia, May 4-5-6. Noble P. Barnes, M. D., Washington, D. C., Secretary. Thirty-fifth Annual Report of the State Board of Health of Massachusetts. Boston, 1904.

The "Specific Therapy of Tuberculosis," by Charles Denison, A. M., M. D., Denver, Col. Reprint. Some Points of View in Regard to the Time When to Perform the Myrnigotomy and the Mastoid Operation, by Emil Amberg, M. D., Detroit. Reprint. Leukemia: The Ultimate Failure of the Roentgen Rays as a Therapeutic Agent, by Everett J. Brown, M. D., and Cecil M. Jack, M. D., Decatur, Ill. Reprint.

In the prevention and the cure of the vast majority of diseases. known to us today our main stay is general hygiene, which may be defined as whatever brings up into the best condition to resist disease.

But what will accomplish this end? What is positively known today about personal hygiene? We know a good deal more than we did about public hygiene-about water supplies, food adulteration and the like, but in regard to personal hygiene, diet, exercise, rest, bathing, we are now in one of those periods which occur not infrequently in any growing science-a period when we known considerably less than we used to or rather than we used to think we knew. Our long-venerated hygienic dogmas are being analyzed back into their constituent prejudices and superstitions, and no new ones have yet gained currency or

confidence.

Is hygiene a set of rules valid for all? A set of averages obtained by the erasure of individual differences? We think it can be shown that the only rules valid for all are so vague as to be almost useless. We can say that a man must eat something and sleep sometimes, but if we try to advance beyond these ludicrously vague generalities we find ourselves at once on very uncertain ground.

If, on the other hand, we try to state the matter in terms of averages we are not likely to get useful guidance for any particular individual. It is like averaging on a map the routes of all the transcontinental roads; the resulting line would run across the country and at about its middle, but would not afford you or me any assistance in finding the best route for our own travels, whatever they may be.

I.

Suppose you went to a general information office, such as Raymond's or Cook's, and asked: "What's the best railroad to travel on?" the clerk would very naturally reply: "That depends on where you want to go." The individual desire is the first and decisive factor, and to attempt to ignore it is folly. But the attempt to answer the question: "What railroad should I travel on?" without knowing where the questioner wants to get to, is no more absurd than the attempt to tell a man the best rules of hygiene without first knowing what kind of life he wants to lead. "Good morning, Colonel," said the stranger on a visit South, "How do you feel this morning?" "How do I feel, sir" (said

*Read before the Chicago Medical Society, March 22, 1905. Detroit, Mich., June 15, 1905.

VOL. 5, NO. 3.

the Colonel), "I feel like the devil, sir, as every gentlemen should, sir, in the morning."

Note the individual factor in the Colonel's hygiene, the individual modification imposed on his rules of living by his general ideal of the position of a gentleman. This is the first of the individual factors in hygiene to which we wish to direct attention-the factor introduced by the man's aim in life-the destination at which he wishes to arrive. Knowing that a man wants to go to San Francisco as cheaply as he can you may be in a position to offer him some advice as to the best means of fulfilling his desire; otherwise it would be absurd to try to advise him. "If you want to get the most work out of yourself and keep yourself always at your best I should advise you not to drink and to smoke." "Oh, but I don't care at all to get the most work I can out of myself," your patient may (and not infrequently does) reply. "I want to have more variety, more fun in my life than a mere working machine has."

Hygiene is a branch of ethics and like ethics finds the ultimate warrant for its "Thou shalt" and "Thou shalt not" in the ideals of the individual.

II.

A second set of individual factors is introduced as soon as we begin seriously to consider the differences of race, climate, occupation, age and sex. This is more familiar ground. We are pretty well accustomed in our practical dealings with patients to modify or restate the traditional canons of hygiene in accordance with the differences just mentioned. We know in a general way that the hygiene of men differs from that of women and we have begun to recognize a hygiene for children which takes account of other differences besides those of weight. We recognize (though our school boards do not) that young children ought to be allowed a very large amount of running about, climbing, yelling, and other exercises of large groups of muscles rather than the minutely focused activities that "wag the tongue and wag the pen," as Stanley Hall says. Yet we recognize that the same amount of violent exercise would probably be bad for an adult and that in all probability no adult except a maniac would attempt it.

Deeper study will we believe carry these distinctions much further. We shall grow to be less local, less parochial in our views of hygiene and recognize a hygiene for Caucasions, a hygiene for Orientals, a hygiene for brain-workers, a hygiene for adolescence, and one for those who have reached Osler's age of chloroform; very possibly one for San Franciscans and one for New Yorkers. All this is more or less a matter of guess work and prophesy, but already our knowledge has gone far enough in this direction to make some of the text books of hygiene smack ludicrously of the town that produced them. The German text books are unmistakably German in their point of view and yet undertake to dogmatize for us all; no doubt ours sound as strange to them.

We shall allude but for a moment to the extraordinary disregard of individual differences that is apt to afflict those physicians who are themselves strongly individual in their hygienic habits. The physician

who finds that coffee disagrees with him is apt to preach a crusade against all users of coffee and proclaim it rank poison. The doctor who happens to need no exercise is tempted to assume that all exercise is a fad, and so on.

But we pass on at once to another class of differences-dependent not, like my first type, on our conscious ideal of life, nor, like my second, on environment and circumstances, but on certain characteristics which seem to be inherited, yet which we are often very backward in discovering. We shall try to exemplify some of these differences in each of the following matters:

(a) The average Caucasian has come to take his sleep in one dose and his food in several; but the American Indian often takes his sleep in divided doses and sometimes takes his food in one. Here is an interesting difference in hygiene. How common each of the two methods. is seems to me a question on which considerable statistical study might profitably be spent. Some persons habitually wake up in the night, get up, do a bit of work, and then go to bed again. The mid-day siesta so commonly taken in the tropics is another example of divided doses of sleep.

(b) The total dose of sleep necessary is a matter on which there are so far as we know very few statistical data. It is common belief that women need more sleep than men, but it is hard to find a statistical backing for that statement.

(c) What preparations are necessary if we are to secure good sleep? Certain persons, if they are to sleep well must arrange that the vigor of their activities shall taper off and not rise in a crescendo as the evening goes on. Others do not find this so.

There are many other interesting questions about sleep to which we have no time to allude here.

2. Waking up.

One of the most interesting individual differences concerns the simultaneity or lack of simultaneity with which the different organs wake up. In some persons the brain seems to wake before the stomach; in others the stomach gets ahead of the brain, while in a third group the organs wake all together. Some have to wake their systems up by using dumb-beils, some by drinking coffee, some by work. Habits of course plays a large part. One who is used to breakfast at eight and is forced to breakfast at three or four a. m., may find that his stomach is not awake and being unready for its work does it so badly that indigestion results. Very possibly the rise of the "no breakfast" idea is due to the fact that some persons' stomachs (or general metabolic processes) can not be wakened except by work; it is probably a matter of individuality, but we need a great deal more statistical evidence on this point.

People differ enormously in regard to what time of day they become so thoroughly wide awake that they can do their hardest work. Whether a brain worker should do his hardest work in the morning or later in the day is a matter which we hope to investigate statistically and in comparison with tasks of other kinds. We have been told that marksmen shoot more accurately after luncheon than before.

3. Work.

We believe that it is not sufficiently realized that work is a great, if not the greatest factor, in keeping us well. Physicians sometimes tell a man to give up work without realizing that they are compelling almost as serious a change as if they told him to give up eating. To take away a man's work is almost as serious a thing as to take away his food. We may feed him by some other channel. So may we send him on a vacation and try in this way to make up for the loss of that nutrition which comes to him by work; but often good working of the organism is not secured in this way. It may be as hard to accustom him to loafing (and as unnatural) as it is to rectal feeding. Nervous patients sometimes. say: "I don't feel fit to work" and the answer is "You will never be fit to work if you wait till you feel like it. The only thing that will make you feel better is the tonic and stimulus of getting to work." This is true not merely in regard to neurasthenic cases. Balfour, the recent Premier of England, was miserable physically until he was induced by a wise physician to take up his present strenuous work.

4. Rest.

one.

Of the many problems about rest and recreation we will cite but Is it not true that persons may be divided into two classes CXpressing individual differences, according as they can rest by change of work, going from work to another, or cannot? There is nothing more important than for a man to find out early in life to which of these classes he belongs.

5. Exercise.

Almost all doctors prescribe exercise. How many healthy doctors. ever take any? Did it ever occur to you to ask whether there is any word in any language other than English which corresponds to "exercise" in our sense? We can think of none in French, German or Italian, and we are interested to know whether exercise, like athletics, is an Anglo-Saxon peculiarity. Other languages have words that seem to us to translate it after a fashion, but not very precisely. If this is true we think it is a very important hint to take account of.

Some of the older men here may remember Bleakie's book, "How to Get Strong," a book much in vogue fifteen years ago. It dealth with the question of exercise on the assumption that to "get strong" is the same thing as to develop muscle. In fact the book should have been entitled "How to Develop Muscle." But we know that a man may develop muscle to any extent and yet have no health. We knew a man in college who developed by gymnasium work the most extraordinary set of muscles that we have ever seen except on Sandow, yet he was never well or healthy and never could put through