TULEY'S DISEASES OF CHILDREN. Diseases of Children. By Henry Enos Tuley, M. D.; late Professor of Obstetrics at the University of Louisville, Medical Department; visiting physician to Masonic Widows' and Orphans' Home; secretary of the Mississippi Valley Medical Association, etc. With 106 engravings and three colored plates. Second revised edition. C. V. Mosby Company, St. Louis, 1913. Price $5.50.

As Dr. Tuley explained in his first edition, this book is intended primarily to meet the needs of the general practitioner and student. This in the main it does in an excellent way. The chapters giving the fundamentals of treatment are especially interesting, particularly the one upon methods of examination, which is very full and complete and gives such niceness of detail that even the tyro should hardly go astray. The chapter upon infant feeding deserves the same praise and is most excellent. The discussion of the different diseases is also good, and as complete as can be expected in a book of this moderate size. If we were to offer any criticism, it would be that hardly space enough is given to the matter of treatment. However, the therapeutics is practical, simple, and probably sufficient for the needs of the average practitioner, although some amplification as regards detail would certainly add to the attractiveness of the book.

The appendix contains a good deal of matter which will be of interest; for instance, the various equations for the computation of milk mixtures will be found helpful to every reader who does any pediatric work. The suggestions concerning the care of babies in hot weather are also excellent, while the numerous milk mixtures described will undoubtedly serve the purpose of many physicians for ready reference. A discussion of the medical milk commission and the requirements for the production of certified milk are all good. In fact, there is so much to commend in this book that we feel like endorsing

While the butcher, the grocer, the plumber, the hod-carrier and the milliner are getting more for their work than they did ten years ago, and while food, clothing, instruments, medicines, office hire and office help are more expensive than they ever have been, the doctor's fees remain stationary, while collections are constantly getting worse. This fact inspires the editor of the California State Journal of Medicine to make a few pertinent remarks:

"If you consult a lawyer about a transfer of some lot, or the signing of a deed or a contract or something of the sort involving, let us say, only a thousand dollars or so, he will charge you from $25 to any old number. But the lawyer will take his pregnant wife to a doctor for an opinion-which he gets for from $2.50 to $10: or his child, whose life or death may depend on the diagnosis and advice given by the physician, and if the doctor charges more than $10 or $20 the lawyer will be furious. We forget that it is not our moments of time that we are selling to our patients or more often giving to themit is our brains, our thought, our experience, the years of suffering we have felt and seen-and which we have so heartbreakingly tried to prevent. Perchance it is just because we have suffered so much in ourselves and our patients and feel first for the life of the patient, that it leaves us the poor fools that we are, unable to put a charge on our advice that would in a measure pay us for the hours of work, anxiety and study that have made it possible to give that advice. Who can put a price on life, on health, on happi

APPENDICITIS IN CHILDREN.

Discussing those special features which differentiate appendicitis in children and in adults, Isaac Wod, writing in Pediatrics, says, among other things:

"Anatomically, we find: (1) That the appendix in the child is relatively larger and longer. (2) The walls are thinner, the meso-appendix is shorter, often less than half the strength of the tube. This tends to kink or bend the appendix and to limit the blood supply, especially to the distal half. (3) The entrance from the cecum is funnel-shaped, the lumen is larger, the mucous membrane smoother, and the valve of Gerlach often absent or ineffective, hence, foreign bodies or morbid materials more readily find their way into the tube. (4) The lymphoid tissue in the appendix of the child is more abundant and the blood supply is poor, hence, destructive processes go on more rapidly and the liability to gangrene and perforation is greater. (5) The omentum is relatively smaller and less effective in walling off a gangrenous or perforated appendix.

"Pathologically, we note: (1) These inflammations of the appendix induce a greater effusion of serum in children than in adults. (2) That this effusion quickly becomes purulent. (3) The occurrence of gangrene and early perforation is more frequent in the child. (4) That abscesses are more likely to form and to rupture in children than in adults. (5) That there is greater tendency to spreading peritonitis. (Sprengel found 46.8 percent among his cases.) (6) That intoxication of the system is more rapid and intense in children.

"Clinically, these differential features assume more than ordinary interest and importance. Some of the general principles are: (1) That appendicitis in the child is more sudden in its onset, more rapid in its progress and intense in its symptoms than in the adult. (2) That the unstable condition of the nervous system (peculiar to children) may lead to confusion or error and may delay or prevent a positive diag

nosis. (3) That abnormal conditions are frequently met with in children which render the clinical phenomena vague and misleading, for example, right-sided pleurisy or pneumonia may simulate appendicitis-the pain, tenderness and rigidity being located in the right iliac fossa. Or in abnormal positions of the appendix (common in children), the pain and other symptoms may be found on the left side of the abdomen— in the epigastric region or under the costal arch. "We feel that a due appreciation of the anatomical. pathological, and clinical features already noted should enable us not only to differentiate appendicitis in children from the same disease in adults, but to set it apart as a subject for special and separate consideration in its diagnosis, its prognosis, and treatment.

"We are told by eminent authorities that the diagnosis of appendicitis is generally easy. This may be true in adults-it is not true in children. The recognition of appendicitis in the early stages-when operation would be successful-is extremely difficult. The cardinal symptoms of appendicitis-sudden acute pain in the right iliac fossa, tenderness over McBurney's point, rigidity of the right rectus muscle, vomiting, elevation of temperature, acceleration of pulse, etc., which are quite constant in the adult -are irregular, uncertain, and have little diagnostic value in the child.

"Dr. J. B. Murphy says, 'We should have no deaths from appendicitis,' but we do have them. What are we going to do about it? Where does the responsibility rest for this terrible mortality, this veritable slaughter of the innocents?

"From a careful review of the literature of appendicitis and from observation, we have come to the following conclusions: (1) That the occurrence of appendicitis in children is much more frequent than it is generally supposed to be. Selter found that appendicitis was seven times more frequent before the age of 15 than it was from 15 to 30. (2) A large percentage of cases that occur are not diagnosed. (3) A large percentage of cases are diagnosed too late for successful treatment. (4) That the current literature of appendicitis should be revised and those features of the disease peculiar to children should be clearly set forth and strongly emphasized. (5) Our 'diagnostic senses' should be awakened and trained to recognize the earliest, the initial symptoms of the disease. (6) Physicians and surgeons should be made to realize that an early diagnosis is imperative in the case of children. (7) That diagnosis should be followed immediately by operation.

VASO-MOTOR DERANGEMENTS.

The part played by the vaso-motor system in countless diseases is at last thoroughly recognized. As a consequence, circulatory disorders are among the most common functional ailments that the modern physician is called upon to correct. Various heart tonics and stimulants are usually employed, but the effect of these is rarely more than temporary. To re-establish a circulatory equilibrium that offers real and substantial relief from the distressing symptoms that call most insistently for treatment requires a systematic building up of the whole body. Experience has shown that no remedy at the command of the profession is more serviceable in this direction than Gray's Glycerine Tonic Comp. For nearly 20 years this standard tonic has filled an important place in the armamentarium of the country's leading physicians. Its therapeutic efficiency in restoring systemic vitality and thus overcoming functional disorders of the vaso-motor or circulatory system is not the least of the qualities that account for its widespread use. The results, however, that can be accomplished in many cases of cardiac weakness have led many physicians to employ it almost as a routine remedy at the first sign of an embarrassed or flagging circulation.

A RECONSTRUCTIVE AFTER WINTER

DISEASES.

The unanimity of opinion among medical men in choosing cod liver oil as the reconstructive par excellence after diseases of the respiratory tract proves beyond doubt its value.

The only question which can arise in connection with cod liver oil's employment is the form in which to give it, and this question has been settled in the minds of those physicians who prescribe Cord. Ext. 01 Morrhuae Comp. (Hagee). With this product the patient enjoys every advantage of the raw oil, but is spared its nauseating effects.

PAPINE IN PAIN.

The wide popularity of Papine (Battle) has logically followed as a consequence of its value as a prompt anodyne, and one that is free from most of the evil features attaching to morphine. When opiates become clearly necessary for the relief of pain in nervous women or in children, physicians will find Papine (Battle) to be as effective as opium, and with the distinct advantage of being free from most of opium's disagreeable effects.

PREVENTION OF POSTERIOR URETHRITIS. It is said that the salicylate of sodium, though of comparatively little value in the inflammation. of the anterior urethra, exerts a beneficial effect in posterior urethritis. Under its influence the urine rapidly clears, and the acute distressing symptoms disappear. It is upon the theory that this drug renders the urine markedly acid, and thereby helps in preventing the extension of the inflammation to the bladder and the production of cystitis. Apart from the administration of salicylate of sodium, the treatment must also be directed to combating the prominent symptoms of acute posterior urethritis, vesical tenesmus, terminal hemorrhage, etc. Sanmetto should be given, and the use of the hot sitz bath prescribed. Should the distress be very great, small doses of morphine may be administered.

THE PNEUMONIA CONVALESCENT. While the course and progress of acute lobar pneumonia is short, sharp and decisive, the impression made upon the general vitality is often profound, and apparently out of proportion to the duration of the disease. Even the robust, sthenic patient is likely to emerge from the defervescent period with an embarrassed heart and general prostration. In such cases the convalescent should be closely watched and the heart and general vitality should be strengthened and

Volume XXXVII.

Number 2.

FEBRUARY 1914

COUNTY SOCIETY BETTERMENT. The Medical Council has launched a most praiseworthy movement for the betterment of the work of the county medical societies. They certainly stand in need of stimulation, for it must be admitted that generally speaking they are doing very little. Aside from a few of the larger city societies, the writer knows of none that has a real program for constructive work. Throughout the country, generally, the principal advantage of belonging to a society is the social one only. It is a good thing to become acquainted with other physicians and to learn, what it is hard to learn, when engaged simply in the bitter fight of competition, that your neighbor is a good fellow who has other ideas in his head than the thought of cutting your throat in a professional way.

The "programs" of the average medical society are pretty poor stuff, take them as they run. The papers are generally rehashes of things every doctor is supposed to know. Their preparation is a mortification of the flesh and their reading an agony of the spirit-to author as well as audience. There are too many of them. Too often they have no other merit than that of permitting some ambitious visitor from the city to "show off" what he knows, the remote purpose-not always so very remote-being the drumming up of business. Not one paper in ten-perhaps we could safely stretch it to one in a hundred-has anything in it of decided originality or real helpfulness to the audience. It is this everlasting round of the commonplace which destroys interest in society work and makes it so difficult to keep these organizations really alive.

Yet there is work for the societies to do, and if our Philadelphia colleague can arouse interest in it the movement will be worth while. Our slogan would be: "Fewer papers and better papers." Lay out the work months ahead. One paper for every meeting is enough, but that paper should be high class also, it should be prepared by one of the society's own number.

Papers to be read at society meetings should fall into one of the three following classes: First,

research; second, interpretation; third, experience. Assign the papers of the first two classes mainly to the young men. They are likely to have more time on their hands; they have the technical training for original research, which most of the older men do not have; and, finally, they have the enthusiasm of youth and their spurs are yet to be won. When it is understood that the reading of a paper which represents six months or a year of original work is really an event in the history of the society the young fellows will see in a place on the program a real opportunity.

There are all kinds of research. The essayist may take up an unusual case, and exhaust its possibilities from the standpoint of the laboratory; or he may take up a prevailing disease of his own locality, and collate all obtainable facts concerning it; or he may take up a line of historical or other literary research. Every locality is alive with topics of special interest, and most of these localities have men who need but stimulus and sympathy to do work of a high order. Some subjects are broad enough to invite the interest of several men in the community, to each of whom some special phase may be assigned. But to make such inquiries worth while they must be original, the purpose of every investigator being to elicit new facts or to explain old ones. Research of this kind will make big men-will encourage the bright young fellows to develop along lines in which their interests are naturally awakened.

The interpretative papers are also for the young men, and they may serve a most valuable purpose, in intensifying interest in the society and making it useful to the physicians of the community. There are new and wonderful things coming out all the time, and about which every doctor ought to know at least the essentials, but which he rarely has the time to study as he would like to, if he is a busy man.

Right now the writer is interested in three very suggestive but rather technical subjects, i. e., sensitized vaccines, Abderhalden's preoteolytic tests for cancer, pregnancy and various other con