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and that if an operation is done while the inflammation is confined to the wall of the appendix this mortality may be reduced to 2 per cent. or less. It is unfair to blame the operation as a cause of death in these cases, as in a large majority of cases in this country at any rate time is lost by waiting, and an operation is only performed when the case is hopeless, or nearly so. I feel sure many cases of appendicitis might be saved if operated on before the purulent stage is reached. The case quoted by Dr. Verco might be classed as a death from operation, when manifestly it was the general peritonitis that caused death and not the operation. Personally I have seen many cases die whilst the medical attendant was waiting for the symptoms to improve or get worse, whilst I have seen very few cases die if operated on in time. Deaver says 'it is better to anticipate pus than to combat it,' and gives the mortality of appendix operations done in the presence of pus as 10 to 18 per cent., whilst that operated on in the pre-suppurative stage present a mortality of 0.5 per cent. As regards operation in the quiescent stage, Treves points out in his recent paper on appendicitis that it is desirable to remove the appendix after the first definite attack. He as well as all other surgeons who have a large experience of appendicitis affirms that the majority of cases have a second attack. He has operated on 1000 cases in the quiescent stage with two deaths, and he says the risk of operation in this stage is almost infinitesimal.' It would be an interesting calculation to know how many of these cases would have died if allowed to go on having recurrences, so after a patient has had one attack the averages are against him. He may at any time have another and a fatal attack, whilst he can have his appendix removed in the quiescent stage with little risk.'

Dr. H. SIMPSON NEWLAND said that none of the previous speakers, nor the author of the paper, had mentioned the probable reason for an abscess in connection with the appendix arising in the right hypochondrium and so simulating pericholecystitis. The explanation was a morphological one. At one stage of its development in the foetus the cæcum and appendix lay just below the liver, but finally descended to their normal position in the right iliac fossa. An abscess occurring in connection with an appendix which had undergone imperfect descent might thus appear in the right hypochondrium. As regards Dr. Hamilton's statement that Sir Frederick Treves advocated appendicectomy after the first attack, the speaker was under the impression that one of the indications for removal of the appendix laid down by Sir Frederick was "repeated attacks of appendicitis."

Dr. LENDON said he was interested in Dr. Verco's first case, because he had recently been treating a case, a man of 30, as one of appendicitis in which the symptoms were referred to the right hypochondrium; the attack had subsided without suppuration. His attention had originally been drawn to this high situation for appendix trouble by some diagrams accompanying an article by Rutherford Morrison, F.R.C.S.

Drs. Hayward, Todd, and A. A. Hamilton also joined in the discussion, and Dr. Verco replied.

Drs. TODD and SWEETAPPLE read papers on cases of "Placenta Prævia." (See pp. 443 and 445.)

Dr. H. SIMPSON NEWLAND said that in considering the treatment to be adopted in a case of placenta prævia the life of the child was a factor. In certain cases it might be very important that a living child should be born. The treatment adopted by Dr. Todd almost invariably led to the death of the child. The use of Champetier

de Ribes bag, on the contrary, stopped the bleeding, and allowed the delivery of a possibly living child.

Dr. LENDON added some remarks.

Dr. J. A. G. HAMILTON said: I think the proper treatment in these cases is to rupture the membranes. The down coming head or body will, in many cases, stop the hæmorrhage; if not, and the cervix can be dilated, then apply forceps, or turn if the cervix cannot be dilated. I think a Champetier bag the best appliance to bring about dilatation. Sometimes the cervix may be too rigid and small to admit the bag. In these cases I would advise putting the patient in the lithotomy position, give an anaesthetic, and pack the uterus with long strips of iodoform gauze, then pack the vagina tightly with balls of cotton wool wrung out of vinegar and water, or some weak antiseptic, using a speculum for the purpose. In this way the hæmorrhage can be completely controlled, and in a few hours the cervix will be softened and dilatable, and Champetier's bag can then be easily introduced, when the labour will come on naturally. This is an absolutely certain way of dilating the cervix, and it also controls all hæmorrhage, and is, I think, much safer than making lateral slits in the cervix as suggested by Dr. Todd.

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Dr. REISSMANN then read a paper on (to appear in a future issue), which was illustrated by numerous diagrams and microscopic slides, all prepared by the writer of the paper, who was afterwards congratulated and thanked by Dr. Verco and others.

Queensland.

A GENERAL meeting of the Branch was held on Friday, Sept. 5th, Dr. Robertson in the chair, and 12 members were present. Visitor, Dr. Effie Stillwell.

An apology for absence was received from Dr. Hopkins, V.P.

Drs. Cuppaidge (Gympie), Holt and Egan (Warwick) were elected, and Dr. Effie Stillwell nominated members of the Branch.

Dr. BROCKWAY gave notice of motion--"That a subcommittee be formed to ascertain if a more suitable room

could be obtained for the use of the Branch."

Dr. CAMERON read a paper upon "Records from General Practice-I. Abortion " (see page 458).

Dr. SALTER said that he had noticed that a threatened abortion was frequently preceded by a rise of temperature, which disappeared when the abortion had taken place. He advocated the use of ovum forceps for the extraction of remains of fatal product, preferring them to the finger.

Dr. TAYLOR said that he relied upon the ovum forceps and curette for emptying the uterus, and had also found ergot, combined with vaginal plugging, useful.

Dr. CARVOSSO agreed with Dr. Cameron in reference to the relatively greater seriousness of pains as compared to hæmorrhage in threatened abortion.

Dr. HARDIE approved of the vaginal plug, and advocated the free use of intra-venous saline injections in cases where there had been copious hæmorrhage. He had always found the finger more satisfactory than the curette for emptying the uterus and was of the opinion that the finger should always be used, even after the curette had been employed. He had often found bromide of potassium more useful than opium for allaying the pains of threatened abortion, and was in the habit of employing ergot in cases where there was hemorrhage. Dr. CLOWES found difficulty in reaching the fundus with the finger, especially if the patient were not under the influence of an anesthetic; he found the flushing curette a very useful form of instrument.

South Australia.

THE monthly meeting was held at the University at 8 p.m. on Thursday, August 28th, 1902. Present: Drs. A. A. Hamilton (president) and 27 members.

Minutes of last meeting were taken as read.

The PRESIDENT reported the result of the recent deputation to Hon. J. L. Parsons.

Exhibits Drs. GILES and SYMONS showed some cases. Dr. MARTEN and Dr. H. SIMPSON NEWLAND showed1. Renal calculi in the kidneys of a sheep.

2. Two fibro-adenomata (one of unusual size) from the same breast.

3. Two rodent ulcers removed from the right and left cheek of the same patient.

4. A right-sided pyo-salpinx existing with a cystic ovary of the same side.

Dr. LENDON showed specimens illustrating stricture of the appendix :—

1. An appendix removed from a girl of eight years who had recently had two attacks in three months. The appendix was somewhat difficult to find, as the cæcum could not be brought outside the abdomen, but it was ultimately recognised as lying in the retro-cæcal fossa: a loop of silk was passed through its mesentery at the base, and the apex gradually separated from its adhesions, leaving, however, the extreme tip behind. On opening it there was found a stricture in process of formation.

2. An appendix removed from a single woman of 28 years during an interval of quiescence, after the third attack in 15 months. The tip was adherent both to the abdominal wall and to the outer side of the cæcum. On laying it open there was found a stricture which would just admit the passage of a bristle about three-quarters of an inch from its extremity.

3. An appendix removed from a married woman of 36 years of age, upon whom öophorectomy had been performed some eight years previously. It shows an impermeable stricture, and a bulbous apex containing in its cavity minute concretions. (Exhibited on behalf of Dr. J. A. G. Hamilton.)

4. Also the front of the chest of a child who succumbed to perforation of a typhoid ulcer, showing congenital, or absence of portions of the ribs.

Dr. JOSEPH C. VERCO showed a left kidney with a large solid growth attached, removed by operation from a young woman, the details of which will appear in a future issue.

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46

The discussion on Dr. J. C. Verco's paper on Appendicitis "at the last meeting was opened by Dr. J. A.G. HAMILTON, who said: "I had not an opportunity of reading Dr. Verco's paper before making these few notes, as the August number of the Australasian Medical Journal had not come to hand; but as the title of the paper was Appendicitis or Perityphlitis" it leads one into temptation to wander a little beyond the subject of the two cases cited. First of all, I think it is a pity that this condition should be called by a double-barrelled name, as almost all inflammatory conditions around the caput coli originate in the appendix; so I think 'Appendicitis a better title than Perityphlitis.' The case cited by Dr. Verco, in which the appendicular abscess pointed under the liver, contained a useful object lesson. If this organ confined its vagaries to its own particular fossa it would be much easier to deal with; but abscesses connected with it point under the liver, in the pleura, in the pelvis, in the loin, down the thigh, and even when the appendix is somewhere near its

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natural position we expect to find pain in connection with inflammatory conditions of that organ referred to the right iliac fossa, but as a matter of fact the pain is often referred to the other side or other regions of the abdomen. This is particularly the case in women. It is often very difficult to make a differential diagnosis between inflammatory conditions of the pelvic organs and appendicitis. In gynæcological practice one frequently finds the appendix involved in inflammatory conditions of the pelvic organs; so much so that in every abdominal section, no matter for what purpose, I have made it a point to carefully examine the appendix. During the last few weeks I have operated on four cases of appendicitis, in all of which the symptoms pointed to the pelvic organs rather than to the appendix. In one case the pain was referred to the left iliac fossa, and was thought to be due to adhesion, as the lady had had a double salpingo-öorphorectomy done nine years previously and had complained of pain over lower part of abdomen, but chiefly in left side, ever since operation. In this case a very much thickened and enlarged appendix was found at back of cæcum, and firmly bound down to posterior peritoneum. The appendix was divided at its proximal end, and carefully stripped down to its tip and removed entire. In another case the woman had laceration of pelvic floor with retroflexion and prolapse of the uterus. She complained of constant and severe pain in right iliac fossa; this was thought to be due to the uterine condition. After repairing the pelvic floor, the abdomen was opened with the object of suspending the uterus. The appendix was found in much the same condition as the other case. An attempt was made to strip it after dividing it at its proximal end, but the tip, which was very much enlarged, was so firmly fixed behind that the appendix broke away in pieces. An incision was made in the loin, and the tip pushed out and removed through the incision in that position. I think that all morbid growths of the abdomen are better explored without delay, especially if the symptoms are obscure, and we cannot satisfy ourselves of the exact nature of the condition. This is particularly the case when the symptoms such as pyrexia, rapid pulse, etc., point to an acute, if not purulent, inflammation. With the present-day improved technique an abdomen can be explored with little danger, and that waiting for symptoms to improve or grow worse, I think, costs many lives. I think it will be generally admitted that an immediate operation is called for when there is any suspicion of the presence of pus, whether the pus is situated in the usual position for an appendicular abscess or not. Time will not allow me to fully discuss the muchvexed question, When is the best time to operate for appendicitis?' but I should like to say a few words on this question. I strongly hold with the American teaching that the sooner the operation is done in the acute stage the better. Treves says that the death rate from operation in the acute stage comes out at about 20 per cent., but it must be remembered that the teaching in England is to give the expectant treatment a trial and wait for operation until the symptoms are urgent. On the other hand Carstens, in the Journal of the American Medical Association, says: Statistics of cases operated on as they came along, easy cases, severe cases, purulent cases, and those actually moribund, gave a mortality of only 8 per cent. He quotes 227 cases of appendicitis. Of these 160 were operated on, with 14 deaths, or about 8 per cent., while 57 were treated medically, with 11 deaths, or a mortality of over 20 per cent." He also points out that over 60 per cent. have recurrences, while the patients operated on are, as a rule, cured, so that we see that statistics on this subject are entirely misleading. John B. Murphy, in the International Journal of Surgery, says that the mortality from appendicitis is 10 per cent.,

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and that if an operation is done while the inflammation is confined to the wall of the appendix this mortality may be reduced to 2 per cent. or less. It is unfair to blame the operation as a cause of death in these cases, as in a large majority of cases in this country at any rate time is lost by waiting, and an operation is only performed when the case is hopeless, or nearly so. I feel sure many cases of appendicitis might be saved if operated on before the purulent stage is reached. The case quoted by Dr. Verco might be classed as a death from operation, when manifestly it was the general peritonitis that caused death and not the operation. Personally I have seen many cases die whilst the medical attendant was waiting for the symptoms to improve or get worse, whilst I have seen very few cases die if operated on in time. Deaver says it is better to anticipate pus than to combat it,' and gives the mortality of appendix operations done in the presence of pus as 10 to 18 per cent., whilst that operated on in the pre-suppurative stage present a mortality of 0·5 per cent. As regards operation in the quiescent stage, Treves points out in his recent paper on appendicitis that it is desirable to remove the appendix after the first definite attack. He as well as all other surgeons who have a large experience of appendicitis affirms that the majority of cases have a second attack. He has operated on 1000 cases in the quiescent stage with two deaths, and he says the risk of operation in this stage is almost infinitesimal.' It would be an interesting calculation to know how many of these cases would have died if allowed to go on having recurrences, so after a patient has had one attack the averages are against him. He may at any time have another and a fatal attack, whilst he can have his appendix removed | in the quiescent stage with little risk.'

6

Dr. H. SIMPSON NEWLAND said that none of the previous speakers, nor the author of the paper, had mentioned the probable reason for an abscess in connection with the appendix arising in the right hypochondrium and so simulating pericholecystitis. The explanation was a morphological one. At one stage of its development in the foetus the cæcum and appendix lay just below the liver, but finally descended to their normal position in the right iliac fossa. An abscess occurring in connection with an appendix which had undergone imperfect descent might thus appear in the right hypochondrium. As regards Dr. Hamilton's statement that Sir Frederick Treves advocated appendicectomy after the first attack, the speaker was under the impression that one of the indications for removal of the appendix laid down by Sir Frederick was “repeated attacks of appendicitis.”

Dr. LENDON said he was interested in Dr. Verco's first case, because he had recently been treating a case, a man of 30, as one of appendicitis in which the symptoms were referred to the right hypochondrium; the attack had subsided without suppuration. His attention had originally been drawn to this high situation for appendix trouble by some diagrams accompanying an article by Rutherford Morrison, F.R.C.S.

Drs. Hayward, Todd, and A. A. Hamilton also joined in the discussion, and Dr. Verco replied.

Drs. TODD and SWEETAPPLE read papers on cases of "Placenta Prævia." (See pp. 443 and 445.)

Dr. H. SIMPSON NEWLAND said that in considering the treatment to be adopted in a case of placenta prævia the life of the child was a factor. In certain cases it might be very important that a living child should be born. The treatment adopted by Dr. Todd almost invariably led to the death of the child. The use of Champetier

de Ribes bag, on the contrary, stopped the bleeding, and allowed the delivery of a possibly living child.

Dr. LENDON added some remarks.

Dr. J. A. G. HAMILTON said: I think the proper treatment in these cases is to rupture the membranes. The down coming head or body will, in many cases, stop the hæmorrhage; if not, and the cervix can be dilated, then apply forceps, or turn if the cervix cannot be dilated. I think a Champetier bag the best appliance to bring about dilatation. Sometimes the cervix may be too rigid and small to admit the bag. In these cases I would advise putting the patient in the lithotomy position, give an anesthetic, and pack the uterus with long strips of iodoform gauze, then pack the vagina tightly with balls of cotton wool wrung out of vinegar and water, or some weak antiseptic, using a speculum for the purpose. In this way the hæmorrhage can be completely controlled, and in a few hours the cervix will be softened and dilatable, and Champetier's bag can then be easily introduced, when the labour will come on naturally. This is an absolutely certain way of dilating the cervix, and it also controls all hæmorrhage, and is, I think, much safer than making lateral slits in the cervix as suggested by Dr. Todd.

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Dr. REISSMANN then read a paper on (to appear in a future issue), which was illustrated by numerous diagrams and microscopic slides, all prepared by the writer of the paper, who was afterwards congratulated and thanked by Dr. Verco and others.

Queensland.

A GENERAL meeting of the Branch was held on Friday, Sept. 5th, Dr. Robertson in the chair, and 12 members were present. Visitor, Dr. Effie Stillwell.

An apology for absence was received from Dr. Hopkins, V.P.

Drs. Cuppaidge (Gympie), Holt and Egan (Warwick) were elected, and Dr. Effie Stillwell nominated members of the Branch.

Dr. BROCKWAY gave notice of motion--" That a subcommittee be formed to ascertain if a more suitable room could be obtained for the use of the Branch."

Dr. CAMERON read a paper upon "Records from General Practice-I. Abortion " (see page 458).

Dr. SALTER said that he had noticed that a threatened abortion was frequently preceded by a rise of temperature, which disappeared when the abortion had taken place. He advocated the use of ovum forceps for the extraction of remains of foetal product, preferring them to the finger.

Dr. TAYLOR said that he relied upon the ovum forceps and curette for emptying the uterus, and had also found ergot, combined with vaginal plugging, useful.

Dr. CARVOSSO agreed with Dr. Cameron in reference to the relatively greater seriousness of pains as compared to hæmorrhage in threatened abortion.

Dr. HARDIE approved of the vaginal plug, and advocated the free use of intra-venous saline injections in cases where there had been copious hæmorrhage. He had always found the finger more satisfactory than the curette for emptying the uterus and was of the opinion that the finger should always be used, even after the curette had been employed. He had often found bromide of potassium more useful than opium for allaying the pains of threatened abortion, and was in the habit of employing ergot in cases where there was hæmorrhage. Dr. CLOWES found difficulty in reaching the fundus with the finger, especially if the patient were not under the influence of an anaesthetic; he found the flushing curette a very useful form of instrument.

Dr. WILTON LOVE had abandoned the use of the vaginal plug in favour of plugging the cervix with iodoform gauze. He had noticed that cases in which haemorrhage occurred during pregnancy often gave considerable trouble at the time of labour, either from placenta prævia or adhesions. He had never used ovum forceps for emptying the uterus. He narrated two cases in which perforation of the uterine wall had resulted from the use of the curette. He relied upon the liquid extract of viburnum for checking the hæmorrhage of threatened abortion.

Dr. WIELD preferred the use of the finger for emptying the uterus, and the flushing curette when there was difficulty in using the finger. His experience of vaginal plugging was unsatisfactory, retention of urine often resulting from its use. He preferred using long thin plugs of iodoform gauze to the cervix and vagina, not too tightly. Large doses of opium were often of value in checking threatened abortion.

The CHAIRMAN joined with the other speakers in their thanks to Dr. Cameron for his eminently practical and useful paper. He had found no difficulty in reaching the fundus with the finger if the other fingers were introduced into the vagina, the patient being under thǝ influence of an anesthetic.

Dr. CAMERON replied.

Victoria.

THE usual monthly meeting of the Victorian Branch of the British Medical Association was held in Pleasance's Building, Collins-street, Melbourne, on August 18th.

The President (Dr. McCansh) in the chair, and a fairly large muster of members were in attendance.

The minutes of the previous meeting were taken as read. Dr. BECKETT read a paper on The Treatment of Cancer by the X-Rays." (See page 450.)

The PRESIDENT suggested that, as it was getting late, it would be wise to leave the discussion of this interesting paper until next meeting; and he thanked Dr. Beckett for the great amount of time and care he must have spent in giving the Branch the results of his experience in the use of the X-rays.

Ballarat.

THE ordinary quarterly meeting was held at the Ballarat Hospital on Thursday evening, July 31st. Present-Dr. W. Beattie Smith (president), Drs. Bennett, Champion, Courtney, Gardiner, C. F. Lethbridge, Martin, Mitchell, Morrison, McGowan, Naylor, Steele, Salmon, G. A. Scott, R. Scott, Usher and Wilson, and Mr. T. R. Treloar.

Apologies were received from Drs. Richards, Davies and Hardy.

The minutes of the previous meeting were read and confirmed.

Accounts amounting to £1 1s were passed for payment. Correspondence was received from Drs. W. A. Wood, Alex. Lewers and Fox, and Mrs. Pinnock.

Mr. TRELOAR then introduced a large number of cases of lupus, rodent ulcer, etc., which had been or were still under X-ray treatment. These were of the greatest interest to the members present, and the extraordinary results were commented upon most favourably, the general opinion being that although this treatment was as yet in its infancy, it held out hope in a class of cases hitherto beyond treatment.

Dr. HARDY being absent through illness, his paper on "Surgical Gleanings was ordered to be placed upon the notice paper for the next meeting.

Dr. ROBERT SCOTT then moved-" That this Branch recommends to the Board of Public Health the advisability of appointing specially qualified medical officers of health; such officers to confine their attention purely to matters relating to sanitation, general hygiene and State pathology; such appointments to be made, so far as possible, without prejudice to existing appointments." A discussion followed, in which Dr. AFFLECK SCOTT thought that the last clause spoiled the effect of the resolution.

Dr. SALMON would keep to pathology and public health, and would not include the care of boarded-out children and vaccinations in the duties.

Dr. NAYLOR Would advise that only those holding D.P.H. diplomas should be appointed.

Dr. COURTNEY wished the last clause withdrawn, as he thought that the present incumbents would be very glad to resign in favour of a central man.

Dr. SCOTT then withdrew the last clause, and with this alteration the motion was carried unanimously.

The whole question was then referred to the Council of the Branch for consideration, a report to be presented to the next meeting suggesting the best method of putting the scheme before the authorities.

Dr. W. E. DAVIES being unavoidably absent, his notice of motion was postponed till the next meeting."

Dr. SALMON moved-"That it is not conducive to the interests of the profession that lecturers to the St. John Ambulance Association should give their services in an honorary capacity."

This was seconded by Dr. Mitchell and carried unanimously. The hon. secretary was instructed to forward a copy of the resolution to the local secretary of the St. John Ambulance Association.

Dr. MORRISON opened a discussion on the relation of the Ballarat Nurses' Training School to the newlyformed Victorian Trained Nurses' Association. He did this at the request of the honorary medical staff of the Ballarat Hospital, who were anxious that their trainees should have more equitable treatment than was proposed by the association. Most of the members present took part in the discussion, and a general opinion was expressed that it was unfair to tax country nurses 10s 6d per annum without giving some compensating advantages. The idea seemed to be that this money was to be used to assist in training other nurses to come into competition with them. The difficulty of carrying out the examinations on the lines laid down by the association was pointed out, and improvements were suggested.

On the motion of Drs. R. Scott and Morrison, it was resolved-"That the Council draft a circular to be sent to all country hospitals stating our objections, and enquiring their views upon the subject; and further, that a copy of the circular be sent to the secretary of the V.T.N.A."

The PRESIDENT Suggested the desirability of erecting a memorial to the memory of the late Dr. R. D. Pinnock, and the hon. secretary was instructed to invite all the members of the profession in the district to co-operate.

The hon. secretary was instructed to purchase a bookcase for the Branch, the cost not to exceed £20. Dr. Bennett exhibited the following specimens:

:

1. Atheroma of Aorta (? Syphilitic). (Dr. Champion's case).

2. Endocarditis in a newly-born infant. (Dr. Champion's case.)

3. Double Hydronephrosis. (Dr. Morrison's case.) The meeting then closed.

Mr. L. Shannon, Mayor of Cooma, has paid to Dr. Ryan £100, together with all expenses, besides making a public apology, for alleged slander in connection with the recent hospital meeting.

REVIEW OF CURRENT MEDICAL

LITERATURE.

SURGERY.

Inflammation of the Vermiform Appendix.

Treves (Lancet, June 28, 1902) made the above the subject of "The Cavendish Lecture" which he delivered before the West London Medico-Chirurgical Society on June 21st. He thought, although the subject of appendicitis was not a novel one, there were certain points in connection with it which were open to discussion. The sudden appearance of the disease now known as appendicitis at the end of the nineteenth century was remarkable. It is proportionately the very commonest acute malady met with in the abdomen, excepting hernia. It was not till 1886 that the name had any existence, and many now object to the uncouth term appendicitis; it lacks precision, but has been accepted by the public with an extraordinary amount of generosity. Of course, under no circumstances can appendicitis be regarded as a new disease. It is not new, but newly discovered, having been hidden for centuries under a lot of clinical facts and medical verbiage. It is a pure peritonitis; until the peritoneum is involved there is no malady. An acute attack of appendicitis is an attack of peritonitis. Fritz used the term to describe a malady that had no symptoms; he described it to indicate those changes in the appendix which preceded the implication of the peritoneum. Three facts deserved emphasising :—(1) That quite extensive changes may take place in the appendix without the production of a solitary symptom. (2) An attack of appendicitis, as we know it, may be preceded by a number of minor disturbances for which we have no name but what may be included under the title " appendicular colic." But this term is actually wrong, as there is no muscle in the appendix capable of producing the phenomenon of colic. (3) More heed must be taken of a condition that should be called chronic appendicitis, as seen in patients who have an abiding trouble in the right iliac fossa, but never an attack of appendicitis. These attacks are common enough; there is a sense of discomfort in the abdomen, a gnawing pain, a burning pain, a griping pain, a feeling that there is something coming away there, a desire to support the back. These symptoms come under the proper heading of chronic appendicitis, and should be more fully recognised than they are now. The attempt to classify cases as catarrhal or suppurative is ridiculous. Appendicitis is an inflammatory trouble due to certain micro-organisms, and it begins as a catarrh, excepting cases of actual torsion. Eighty per cent. of cases occur in people under 30 years of age, and 73 per cent. in males. Climate appears to have considerable influence in the causation; Tropical or sub-tropical climates such as India, the Straits Settlements, China and South Africa-countries in which intestinal trouble is inevitable-contribute a

large number of cases. No person suspected of trouble in the appendix should be allowed to go to a tropical country. In females the attack is often associated with the menstrual period. The appendix is situated so closely to the right ovary that it should be a routine practice to examine the latter organ in any operation for the removal of the appendix in the female. If there is one solitary factor in the production of appendicitis which is overwhelming it is a loaded cæcum. It is only a slight exaggeration to say if overloading of the cæcum could be avoided there would be little appendicitis.

Bad teeth and bolting food play an important part in the causation. The most important prophylactic treatment is to keep the cæcum free from undigested food. As regards symptoms, tenderness at McBurney's point

has become a sort of talisman. The hand of the experienced man is put on the spot, and there is tenderness, and the patient has appendicitis! Tenderness is said to be always present in appendicitis at McBurney's point and not in other diseases of the abdomen. McBurney says that it indicated the precise space of the appendix. There is a certain tenderness in the right iliac fossa in appendicitis, and McBurney's point corresponds roughly with the centre of the right iliac fossa, and therefore it is reasonably the place where tenderness is exhibited. It is a symptom quite common in other maladies, most notably in colitis. At the suggestion of Treves, Dr. A. Keith investigated the matter, and McBurney's point was found to be the seat of the ileocæcal valve; and the base of the appendix was found to be one inch below that point in 50 bodies prepared by formalin. A phantom appendix, described as vertical, is really due to constriction of the uppermost fibres of the rectus muscle excited by stimulating the nerve as it enters the muscle.

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Operative Treatment. It is remarkable that this subject is perfectly bewildering by divergent opinions coming from men whose authority one cannot repudiate and must recognise, and we are still lacking in reliable statistics. The mortality in hospital cases may be taken at 15 per cent., while the general rate of mortality in all cases of appendicitis may be stated as 5 per cent. As regards treatment, the whole crux is, What is to be done during an acute attack? Some say that you must operate in every case of appendicitis as soon as the diagnosis is made; others operate only on compulsion. They say, No, the majority of the patients get well," and they only operate in exceedingly acute cases in which pus is evident, or in cases that run to an abnormal length. Treves objects to the comparing of a perforation of the appendix with a perforation of the stomach or bowel, stating that "it is moustrous, and the analogy is absolutely unjustifiable." The second fact which he pressed was: The very great majority__of all cases of appendicitis get well spontaneously. The facts that operation during an acute attack of appendicitis is attended with great risk to life, and that the removal of the appendix during the quiescent period is attended with infinitely small risk, were also emphasised. If these facts are admitted, the line of treatment may be defined as follows:-1. All that we know of the pathology of inflammation of the appendix is positively opposite to the teaching that operation should be carried out the moment the diagnosis is made. 2. An immediate operation should be carried out in all the ultra-acute cases. 3. An immediate operation should be carried out as soon as there is any suspicion of pus. In 1887 Treves suggested that appendicitis when relapsing should be treated by removing the appendix during the quiescent period. Since that time he has removed over 1000 appendices with two deaths. When should this operation be carried out? What is the probability of relapse? It is safe to say that the great majority will relapse, therefore it is desirable to remove the appendix after the first definite attack. If there has been an abscess in the first attack an operation may be put out of court altogether, as that abscess will, in certainly 95 per cent. of the cases, obliterate the organ and render it harmless. With regard to chronic appendicitis, he thought that in every such case the appendix should be removed when there is no other treatment for it.

A Case of Severed Spinal Cord, in which Myelorrhaphy was followed by partial return of function.

Stewart and Harte (Philadelphia Medical Journal, June 7th, 1902) report the above, which they believe to be the first myelorrhaphy performed in man, as evidence

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