Salts of Lithia in Uric Acid Diathesis.

Rates to Pan-American Medical
Congress.

As a therapeutic agent in gout, the salts of lithia far exceed those of potassium on Physicians attending the Pan-American account of their greater saturating power as Medical Congress, which meets in Washan alkali for uric acid. Of the various salts ington, D. C., September 3 to 5, should reof lithia, the citrate is the most soluble and member that by taking the Atchison, Topeka most convenient for administration. It may & Santa Fe R. R. to Chicago they can have. be administered in doses of from five grains the benefit of the World's Fair rate and can to one dram in water. The most convenient secure the regular one and one-third rate form for administration is the effervescing from Chicago to Washington.

tablets, prepared by the New York and London Pharmacal Co. Dissolved in water, they make a very palatable drink, equal to any of the Natural Lithia Waters, and of much greater strength.

Official Delegates to the Pan-American
Medical Congress.

PARKE, DAVIS & Co., of Detroit, have recently issued a pamphlet on "Absurd Medicaments," showing the ridiculous tendency toward fanciful nomenclature in new pharmaceutical preparations. The frequent use of the ending "ine" given to some of these preparations has given rise to the criticism. The article is well timed and will doubtless result in much good.

Practically all of the governments have appointed official delegates to the Congress We are hardly prepared to pass judgment in response to the investigation by the pres- on the controversy with Dr. Hammond, but ident of the United States. The United judging from the facts presented would say States Government will be represented by the position assumed by Dr. Hammond, for six delegates. The larger cities of all the a physician and an author, is certainly a Latin-American countries have appointed very peculiar one. delegates to participate in the proceedings of the sections on hygiene, climatology and dermatology, and on marine hygiene and quarantine, and similar appointments will be made by the cities of the United States. Seventy-six similar delegates have so far been appointed by the governors of states in the United States. A large number of delegates have been chosen by the medical colleges of the United States and other American countries to attend the section on medical pedagogics under the presidency of Prof. J. Collins Warren, of Boston.

THE Therapeutic Gazette for July will contain the following articles:

Bowel in the Treatment of the Summer
The Employment of Irrigation of the
Diarrhoea of Infants. R. E. Muller, M.D.,
of Philadelphia.

The Value of Creasote in Tuberculosis.
Prof. James T. Whittaker, of Cincinnati.
The Treatment of Croupous Pneumonia.
Prof. J. A. Larabee, of Louisville.

Operative Treatment of Ear Disease. S. MacCuen Smith, M.D., of Philadelphia. The Treatment of Lachrymal Obstruction. Charles Hermon Thomas, M.D., of Phila

DR. ERNST HART, editor of the British Medical Journal, and Prof. Czerny, of Heidelberg, will be among the distinguished guests delphia. of the Pan-American Medical Congress. The Value of Rest as a Therapeutic The latter is booked for the Pan-American Measure. J. Madison Taylor, M.D., of excursion at Rome by the "Werra."

Philadelphia.

VOL. V.

TOPEKA, KANSAS,. SEPTEMBER, 1893.

ORIGINAL ARTICLES.

Appendicitis.

ton, July 6, 1893,

No. 9..

entiating the former from all other affections occurring in this region, and has helped the surgeon in establishing certain important points which will be alluded to, later on in this paper.

In a study of these cases he found that certain definite symptoms occur in welldefined order, viz.:: localized pain, fever (100° to 102°) and circumscribed swelling,

Read before the Golden Belt Medical Society at Herring-
By L. J. WARREN, M.D., Clay Center, Kansas. which assist us in differentiating appendi-

During the past few years, under our improved surgical methods, inflammatory affections of the vermiform appendix have assumed so much importance to the physician and surgeon as to afford an excuse for presenting a paper upon this subject.

citis from other affections, while general abdominal pain, following iliac pain, may be taken as evidence that a general peritonitis has occurred. In sixty per cent. of Dr. Fitz's cases this happened on the second, third and fourth days, showing that a laparotomy to be successful must be performed The writer does not presume to add ma- early or at the very onset of urgent sympterially to the knowledge already possessed, toms. Pain is present in a great majority but in the light of our present knowledge of cases, and may not be limited to the iliac desires simply to discuss certain facts in re-region, but diffused over a greater part of gard to pathology, diagnosis and treatment. the abdomen, especially in the early stages For the excellent work done in this de- of the disease. partment of medicine and surgery the profession is greatly indebted to Drs. Fitz, Weir, Sands, Gerster and McBurney, whose contributions are largely responsible for awakening present interest.

From the large number of cases met with to-day, in comparison with the small number formerly reported, the conclusion is obvious that formerly many cases failed to be recognized as cases of appendicitis and were treated under a mistaken diagnosis.

Not many years ago typhilitis and perityphilitis were considered the prominent affections of the right iliac fossa, while now they are considered only as secondary to the primary lesion, appendicitis.

The point of greatest pain on pressure will be found at the "McBurney point", midway between the anterior superior spine of the ilium and the umbilicus.

Circumscribed tenderness at this point is considered by McBurney as almost pathognomonic of appendicitis.

An oval tumor of variable size, usually small at first, can usually be detected beneath "McBurney's point", but its absence should not exclude the disease. A few cases have marked symptoms of intestinal obstruction. Rigidity of the abdominal muscles on the affected side, McBurney considers an important symptom.

A fæcal cæcitis should be diagnosed from A few years since, Dr. R. H. Fitz, of appendicitis by a history of prolonged conBoston, carefully analyzed 257 cases of stipation, late appearing fever, pain of long perforating appendicitis and 209 cases of duration and a doughy tumor of considertyphilitis and perityphilitis, and gave us able size in the lumbar region. important information with regard to differ

To help us in the pathology of the dis

ease, the writer wishes to emphasize the which incommode the patient, it is not following well-established facts:

1. That the position of the vermiform appendix is extremely variable, as is also that of its attachment, thereby serving to make the diagnosis of appendicitis quite obscure and the surgical procedure somewhat difficult.

2. That the cæcum and appendix are entirely surrounded by serous membrane, and that therefore they are intra-peritoneal.

3. That primary inflammation of cellular tissue in the right iliac fossa is unknown.

necessarily attended with great risk of life.

The question is, how shall we diagnosticate these simple and harmless types of the disease from the more serious conditions ending in perforation?

We must bear in mind that the acuteness or mildness of the symptoms, general or local, at the onset of the disease is not an invariable index as to the gravity of the

case.

One case with a very mild beginning may prove fatal, while many cases of severe acuteness, as indicated by alarming symptoms, may be followed with resolution. Several of the last-named cases have come under the writer's observation - cases where

4. That all perityphilitic abscesses are of intra-peritoneal, and not extra-peritoneal origin, and are due to an inflammatory process starting from the appendix. The last proposition Weir confirmed by an an operation was advised, and in two of analysis of 100 autopsies. which preparations for an operation had

From the history and progress of appendi- commenced, when the symptoms began to citis it would seem that this organ is subject show evidence of the amelioration of the to at least two kinds of inflammation-one, disease, and convalescence was soon esthe simple catarrhal variety, producing tablished. swelling of the mucous membrane and follicles with occlusion of the duct and tumefaction; the other, the ulcerative variety, going on to perforation and accompanied by local and general peritonitis.

There is yet much to learn concerning the simple and more common variety which does not go on to perforation, but usually ends in resolution.

Dr. Fitz states that post mortem examinations show that one in three at some period in their life must have suffered from simple appendicitis.

That these cases are not diagnosed in life is probably due to the lack of characteristic symptoms on account of the appendix being deeply seated behind the cæcum and below the mesentery of the ilium.

Therefore, after the physician or surgeon has recognized a case as one of appendicitis, he has much graver problems to solve.

Is it a simple catarrh which will resolve in a few days? Will pus form and ulceration and perforation take place? If perforation does occur, have sufficient adhesions formed to protect the peritoneal cavity? Is there danger of a general or suppurative peritonitis? Shall we operate or pursue an expectant treatment?

These are questions upon the correct answer of which may depend the life of our patient.

The skilled laparotomist, accustomed to open the abdomen on the least provocation, would say: "Make your diagnosis, if in doubt, and answer your questions by an exThe vague and ill-defined pains in the ab- ploratory incision, for there is less risk in domen, accompanied by constipation and an operation, or at least in an exploratory symptoms of indigestion and tenderness in incision, than in the expectant plan of treatthe right iliac region, would doubtless ment."

characterize most of these cases. Childhood If this were done, I fear that often an is probably the period of greatest liability organ would be removed which was the seat to this simple type of the affection. of only a temporary catarrhal obstruction,

It would seem worthy of remark that and the adhesions of an incision would be while this milder form of appendicitis may substituted for the adhesions of a transient give rise to frequent and painful attacks inflammation.

That the average patient prefers the ex-localized about the region of the inflammapectant treatment, though attended with tion. greater risk, to the operative treatment should not deter the surgeon from laying before his patient the danger of delay, and request an operation, when in the best judgment of the surgeon one is demanded.

In the more serious cases adhesions form, thereby shutting off the general peritoneal cavity and localizing the disease, so that when perforation takes place a circumscribed abscess results.

Dr. Bridge, of Chicago, has expressed his Nearly all the so-called perityphilitic ab-. opinion as to operation thus: "Surgery is scesses have their origin in this way: imperative in those cases of acute inflam- through perforation of the appendix. mation in the cæcal region with rather pro- In all the cases which the writer has seen tracted high fever that does not show the inflammatory process has been localized positive evidence of the subsidence within by a walling off of the peritoneum, and all two or three, or three or four days from the the abscesses have tended toward the beginning." Dr. Fitz makes this similar surface.

brief summary: "Operate for urgent symp

When we consider that the position of the toms (rising pulse and temperature, increas- appendix is favorable for the forming of ading distention and spreading pain) with or hesions and the tendency of abscesses to bewithout tumor." This last is the opinion come localized, it would seem that the danger of a physician and corroborates that of the from general peritonitis is overestimated. surgeon. Yet, this danger must be considered in The severe recurrent types of appendicitis every case, no matter how mild; and when it does occur or seems liable to occur, the often renders the existence of the patient miserable and depressed, and each return of case demands prompt and efficient treatment. the disease seems more painful and danger- by operation as the only means offered to

ous.

upon

Whether these should be operated

save the life of the patient. In regard to treatment, I submit the fol-. in the quiescent stage is still sub judice. lowing propositions, all of which I trust Yet, it would seem that an operation per-will be thoroughly discussed: formed in the interval of the attacks is both 1. For catarrhal and subacute appendijustifiable and reasonable as affording a citis-expectant treatment, chiefly laxahopeful means of relief, and in the opinion tives, in the form of salines, and opiate in of the writer ought to be advised.

Weir, however, mentions the fact that he had known some ten cases where an operation performed during the quiescent stage had revealed no adhesions, no evidence of peritonitis, and that in nearly all the cases the appendix was apparently healthy.

moderate amount if pain is severe.

2. For cases of appendicitis with an increasing tumor, showing evidence that pus. is forming or has formed-extra-peritoneal incision or laparotomy, and if pus is found, thorough drainage of the cavity.

3. For cases showing urgent symptoms. and an appreciable tumor-exploration with. a needle over "McBurney's point" or an ex

From the anatomical position of the appendix, perforating appendicitis is a condition of grave importance. The normal ploratory incision. appendix is always found completely sur- 4. For cases with or without tumor with rounded by peritoneum, as is also in a vast alarming symptoms, such as persistent majority of cases, the cæcum from the ileo- vomiting, spreading pain, abdominal recæcal valve downward. Hence ulceration sistance and rising temperature, showing and perforation of the appendix without in- evidence of a general peritonitis — a lateral volvement of the peritoneum are physical laparotomy should be performed at once, the impossibilities. In all inflammatory action region of the appendix explored, and, if pus. of the appendix, catarrhal or otherwise, the is found, the cavity packed with iodoform. peritoneum has a part, though usually gauze and thoroughly drained.