ture in the Lancet, December 7, 1907, states that the diagnosis of dysentery is not difficult to physicians trained in the examination of the excreta. The diseases most often confounded with dysentery are carcinoma, polypi and syphilis of the rectum, hæmorrhoids, and, in those returning from the tropics, bilharziosis. Bacillary dysentery can be distinguished from amoebic dysentery. The following points should be remembered: 1. Amoebic dysentery, unless skillfully treated at the beginning, usually runs a chronic course, while the bacillary lasts only from four to eight days in mild cases, and from three to six weeks in the serious ones. 2. In the amoebic form no bacilli can be found unless there is, as is rare, but quite possible, a mixed infection of both amoebic and bacillary dysentery. 3. Toxic symptoms, such as high fever, rapid emaciation and nerve complications, exist in bacillary dysentery, but not usually in the amoebic form. 4. Liver abscess is a very frequent complication of amoebic dysentery, and does not exist in the unmixed bacillary form. The conditions necessary for a certain diagnosis of bacillary dysentery are the positive agglutination reactions of the dysentery bacillus with the

blood serum of the patient, or the isolation of the bacillus from the fæces of the patient or from the organs after death. The bacilli are obtained more readily and in larger numbers from the mucous membrane of the rectum than from the stools. They do not enter the general circulation. The treatment of the acute form calls for rest in bed as the first essential. Physiological rest for the intestines should be obtained by stopping all solid food and giving small quantities of milk every two or three hours. When the tongue is thickly coated and the patient cannot take milk, give broths, whey or rice water for a few days. Alcohol will not help the dysentery, and is bad for the liver. All food should be given tepid. Castor oil, sulphate of magnesia or calomel should be given first to clear out the bowel. Small enemata of saline solution will diminish tenesmus, and cocaine or opium suppositories may be given for the same purpose. Where there is much hæmorrhage from the bowels an ice bag should be placed over the abdomen and opium given internally. For collapse the subcutaneous injection of normal saline solution is of service. Ipecac and large enemata of silver nitrate are not useful in the acute cases. Serum treatment, which is bactericidal as well as antitoxic, is of

great value in early cases (second or third day), the blood and mucus disappearing, the pain and tenesmus ceasing and the patient getting refreshing sleep. In mild cases only one injection of 10 cubic centimeters is given; in severer cases this is repeated after 6. to 10 hours, and in grave cases the injections must be repeated twice daily for two or three days. Amobic dysentery is the form met with so frequently in the tropics, and in London is seven times as frequent as the bacillary form. The symptoms of liver abscess are sometimes the first to attract attention to the intestinal disease. The general treatment is the same as that of the acute bacillary form; rest is especially necessary. Bismuth is the most useful drug by the mouth as a continuance; the salicylate in wafers of 15 grains every four hours is to be preferred. The rational treatment is to destroy the amoeba by means of rectal irrigations. Quinine (1 to 1000), nitrate of silver (1 to 1000) and sulphate of copper (I to 1000) are all useful. The enemata need not be retained for more than five minutes and should be given warm. Once a day is usually sufficient, a simple cleansing enema being given at night. It is impossible to produce a vaccine for the amoebic form of dysentery, because there is no evidence of any creation of toxine. The writer does not think highly of the surgical treatment of dysentery, consisting in colostomy or in washing out the bowel through the appendix.

sodium citrate to the fluid withdrawn to prevent coagulation, then centrifuge and examine the sediment for leucocytes, tubercle bacilli and other micro-organisms. If the case be tuberculous, the cells will be mostly lymphocytes, whereas if the pleuritis be due to other micro-organisms the polymorphonuclear cells will predominate. Even in undoubted tuberculous cases one generally fails to find the tubercle bacilli, and the injection of the fluid into the guinea-pig is a very slow and often impracticable test. A blood count often assists, as in tuberculous pleurisy there is no leucocytosis, whereas in that associated with other processes there usually is. A hæmorrhagic effusion is usually associated with tuberculous or malignant disease. A specific gravity of 1018 is generally put down as the dividing line between a transudate and an exudate, but it does not always hold good, as in some undoubtedly inflammatory cases the author has found the specific gravity of the fluid as low as 1006.

cal Journal, December 26, 1907), summarizes his conclusions concerning the X-ray diagnosis of pulmonary tuberculosis in the following statements, some of which are quoted from "Brook and Green :"

"1. In no single case where the physical signs have pointed to disease have the X-rays failed to detect the mischief.

"2. In some cases where physical signs have been absent the rays have shown a deposit in the lungs, and in these cases physical signs have subsequently been detected.

"3. That the early diagnosis is certainly helped.

"4. That the extent of the disease in

"5. That the progress and results of treatment can be watched with great accuracy.

"X-ray examinations are difficult to carry out. Proper precautions should be taken to protect the practitioner as well as the patient.

"Practitioners who are devoting themselves to diseases of the chest should have a suitable X-ray apparatus, just as an ophthalmologist has an ophthalmoscope, but the task of the latter is far lighter than that of the physician who desires to make a complete examination of the chest."

The Treatment of

L. Kuttner (Deutsch. Chronic Diarrhoea. med. Wochenschr., October 24, 1907) states that regulation of the diet is of great importance in all but the nervous type; here restriction does more harm than good and they are often checked with surprising rapidity when the patient returns to a mixed diet. Schmidt's test diet should be used as a basis for regulation. As this or that article of food is seen to be imperfectly digested, the diet is changed accordingly. In fermentative processes the carbohydrates and in putrefactive processes the albumins are chiefly concerned. Ocher-colored stools in adults suggest disturbances in the small intestine; green stools suggest jejunal diarrhoea in adults; in infants they are due to increase of alkali in the upper parts of the intestine or to an oxidizing ferment. Fermenting stools are usually light brown, foamy and have an acid or cheesy smell; they generally indicate the milder intestinal disturbances. Putrefying, darkcolored stools indicate serious trouble, such as dysentery or carcinoma of the

mon in "nervous congestion." Macroscopic traces of pus always mean ulceration or perforation of the mucosa. If nuclei are present in the muscle scraps, some disturbance in the pancreatic digestion. may be suspected; the absence of nuclei is not conclusive, as putrefactive processes are likely to destroy them. Remains of starch point to the small intestine. Af fections of the pancreas are not always followed by the passage of a larger proportion of fats, yet the stools in such cases show much less splitting of fats, consequently microscopic examination shows. neutral fat present. When pure mucus without the admixture of fæcal matter is present, the catarrh is in the lower part of the large intestine, rectum, flexure or descending colon. Fluid fæcal masses mixed thoroughly with mucus indicate the upper part of the large intestine. The small intestine is indicated whenever there are flakes of mucus, cell nuclei, abundance of muscle fibers, free grains of starch, positive bilirubin test and fermentation. Acute catarrh of the large intestine causes diarrhoea, but catarrh of the small intestine does not necessarily cause it unless the upper part of the large intestine be involved. Cancerous affections often begin with diarrhoea, and with elderly people, who previously have had regular stools, such diarrhoeas should cause suspicion. High rectal cancer can sometimes be palpated as the patient stands, stooping forwards. If examination of stools shows no mucus or putrefaction. pointing to catarrh, and there is nothing to indicate organic trouble, then the diet should not be restricted, but if scraps of

Primary Carcinoma of Zaaijer (Beitr. 2. the Appendix. klin. Chir., Vol. 54, 1907). The number of positive cases of cancer of the appendix as reported in the literature amounts to about 60, to which may be added about 24 less certain cases. The frequency of cancer of the appendix is estimated by the author as I per cent. of all cases of appendicitis, and the condition accordingly assumes increased practical importance. Upon the basis of clinical experience cancer of the appendix may be assumed to originate frequently upon the foundation of preliminary at tacks of appendicitis. This interpretation is confirmed by the coincidence of the site of predilection of both cancer and chronic inflammation—namely, at the apex. The majority of these observations concerned very small cancers, which often preceded the large fully-developed intestinal tumors, with distinct clinical symptoms, for a period of 10 years and over. These cases are apt to present as cancers of the cæcum in the further course of the dis

ease.

With special reference to their morphological character, all the types of carcinoma are represented, but the round-cell and polymorphous carcinomata essentially preponderate in youthful individuals as compared to the total frequency of this form of cancer in the bowel. While it is claimed that the prognosis of cancer of the appendix is favorable, the histological impression conveyed by these

The Diagnosis of R. T. Morris, New Appendicitis. York (Journal A. M. A., January 25), calls attention to the value of tenderness over the right sympathetic lumbar ganglion (one and a half inches from the navel on a line with McBurney's point) as a diagnostic sign in appendicitis in addition to the well-known McBurney's point. He gives the following general statement: "1. In the early stages of an acute infective process of the appendix the right lumbar ganglia are tender and the left lumbar ganglia are not tender. (The left lumbar ganglia may be described for diagnostic purposes as lying an inch and a half to the left of the navel.) Under these circumstances the point here described is of secondary importance, while McBurney's point is of prime consequence. 2. (a) When an acute inflammatory process of the appendix has subsided, leaving a mucous inclusion or scar tissue, there may be no tenderness on pressure at McBurney's point, but there is tenderness at the point here described and no tenderness at the point of the left lumbar ganglia. (b) When the appendix is undergoing a normal involution process, with replacement of its lymphoid coats by connective tissue, digestive disturbances and various local neuralgia may be due to nerve filaments entrapped in the new connective tissue. There may be no tenderness at McBurney's point, but there is persistent tenderness at the point here. described. There is no tenderness at the point of the left lumbar ganglion. 3. When the appendix is congested without the presence of in