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senses through the eye and ear, through the brain-sweat, and the constant drill of memory and by hard work, and not merely by the ear.

It may be very nice and wonderfully easy to listen to the learned professor; but we must study the authorities for our selves, and there is no better test of exact knowledge than by recitation.

There are two distinct methods of human culture: one refers to the great fact of receptivity, or the receiving of facts, and data from all history, science, and thought—that is, what men have said and done. The true scholar is always a receiver, and in his profession he must give account of his receivership, "qui non proficit, deficit." In this sense the mind and the memory are a sort of hopper, to gather facts and history, and adjust the same. While this is of the last importance, it is not all by any means. The mind must give out as well as take in, and this is the true process of education.

Grass and grain are good for milk and cream, but the digestive and internal arrangements are necessary to convert the coarse material into the finer product; so the knowledge poured into the mind must be worked out by internal processes to get the best results. For what is education? It is a grand word full of meaning; it is the culture, the educing of the mind, not filling it up with outside matter; it is the leading out of the mental powers, an intellectual development, an evolution.

The original Latin word education means the culture and discipline of the mental forces; thus training the faculties to act upon whatever comes in contact with the mind as fact, a science, a theory, or a philosophy.

The medical student is not merely to be receptive automaton, and to receive his education through the auditory nerve alone. With every sense and faculty alert he must use the midnight oil; he must dig, and delve, and develop, and put into shape, for active duty, what he knows, and this he can best do by faithful study and recitation. And all his professional study and work must be based upon a preliminary classical education; Latin and mathematics should come before professional duties. I believe in a thorough education. "Non doctior, sed meliore im butus doctrina" (Not more doctors, but doctors better taught). "Let us, then, be up and doing, With a heart for any fate; Still achieving, still pursuing

Learn to labor, and to wait."

"Now, my little man, describe your symptons." "I haven't dot any symptoms,

I dot a pain."

SOME REMARKS ON APPENDICITIS.

BY ALONZO BOOTHBY, M.D., BOSTON, MASS.

[Read before the American Institute of Homeopathy.]

Among the diseases characterized by pain and swelling in the right inguinal region are prominently mentioned typhlitis, perityphlitis and appendicitis. According to many recent authorities perityphlitis, as a distinct pathological condition, does not occur, and typhlitis is rarely found except in a secondary inflammatory process, but the appendix vermiformis is held to account for nearly all of the trouble.

Concerning this point I shall express my views later on.

By most authorities typhlitis (inflammation of the cæcum) is recognized, associated with lodgement of feces. Males between three and thirty years of age seem to be most susceptible, and there is usually a history of constipation, errors in diet, or, not unfrequently, traumatism. There is pain in the right iliac fossa, constipation, nausea, slight fever, rarely above IOI F.; usually there is discomfort on extension of the right thigh. On pressure there is tenderness, and in many cases a doughy, "sausageshaped" tumor may be detected. The attack lasts from three days to a week. The pain and tenderness gradually subside, the tumor disappears, and recovery is completed in the majority of cases. Rarely fecal ulcer occurs with perforation and its consequences.

Perityphlitis, or inflammation of the connective tissue about the cæcum, may coexist with inflammation of the cæcum itself, or occasionally may exist primarily. Pus may form, and perforation into the bowel take place, or resolution may occur, as in typhlitis.

Appendicitis is described as occurring under three forms: Catarrhal, ulcerative, and perforative. In the catarrhal form the entire tube is thickened, firm and stiff, the mucosa covered with tenacious mucus; slight circumscribed peritonitis may have occurred, so that adhesions are often formed with adjacent structures. Very frequently small fecal concretions are present. The ulcerative and perforative forms of appendicitis may be due to tuberculosis, typhoid inflammation, irritation from foreign bodies or enteroliths, or from obliteration of the cæcal end and distention of the lumen with fluid.

The results of perforation may be as follows: (a). No adhesions forming, perforations may at once produce diffuse and violent suppurative peritonitis. (b). Quite commonly adhesions. do form, and peritonitis remains local with circumscribed abscess, following which resolution may take place. (c). If the appendix passes behind the cæcum and colon, and is not in the

peritoneal cavity at all, the perforation causes retroperitoneal abscess, which may burrow in various directions.

If we consider appendicitis alone as being responsible for the greater portion of the disturbances in the right inguinal region, we must acknowledge its diagnosis from certain other inflammatory conditions, especially typhlitis or perityphlitis, as extremely difficult.

It is very important that we notice the variability of the location of the appendix in different subjects, and the different relations which it may hold to adjacent parts. Perhaps its most common position is behind the ileum, with the tip pointing toward the spleen. I have, however, occasionally found it turned up behind the cæcum, and in a few instances lying upon the psoas muscle, with its tip at the margin of and even in the pelvis. It is said to have been found in almost every region of the abdomen, in relation with the bladder, adherent to the ovary and broad ligament, in contact with the gall-bladder, and, in one or two instances, in relation with the sigmoid flexure at the left of the median line. My colleague, Prof. Sutherland, had the position of the appendix noted in a large number of subjects in the dissecting-room last winter, and he confirms the statement in regard to the variability in position of this small appendage of the bowel. Such unreliability in location renders the mere presence of pain and tenderness in a small area - spoken of as "McBurney point" of very doubtful significance, especially as pressure in any part of the right flank, or in various parts of the abdomen, during the inflammatory process, causes acute distress.

But in my opinion, the question as to whether the appendix itself be inflamed, or the bowel from which it has its origin, or the connective tissue around it, need not so deeply concern us in the matter of diagnosis, as so many surgeons of the dav would emphasize; but we are to carefully differentiate between right inguinal inflammation, more or less acute, and certain other pathological conditions which may call our attention to the same locality. It is neither safe nor scientific at the present day to stand in the presence of a case of peritonitis and speak of its idiopathic origin. Some definite cause, aside from “taking cold," must be sought for, and to the abdominal and pelvic viscera we have learned to direct our inquiries. Here, as in all investigations regarding diagnosis, the method by exclusion is of the greatest value. It is often easy to decide that certain condi tions do not exist. If we are quite certain that it cannot be anything else it makes it extremely probable that it is the disease under consideration. The prominent affections likely to demand consideration are: inflammation of the right ovary and broad

ligament, renal disease of the right side, tuberculous disease of the mesenteric glands or of the spine, resulting in psoas abscess, volvulus, intussusception, malignant disease of the bowel, fecal abscess resulting from perforation of the bowel from various causes, and incomplete strangulated hernia. The anatomical structure of the bowel, in the region of the appendix, is such as to favor the lodgement of foreign bodies at this point, which may result in ulceration and perforation.

It is not my purpose to go into the differential diagnosis of these various diseases very minutely; but I shall content myself with reference to a few diagnostic points. In women, the fact that pelvic inflammation occurs so much more frequently than so-called appendicitis may tend to mislead us, but the light which vaginal examination throws upon the former should render errors quite unnecessary. The location of kidney disease would be above the usual site of this trouble, and would be likely to be preceded or accompanied by some abnormality of the urine.

The passage of a renal calculus is unaccompanied by tumefaction, and there are often blood and concretions in the urine. Tuberculous disease is preceded by other symptoms, as cachexia; it is not acute in its onset, is less painful, and there is frequently no peritonitis.

Complete obstruction of the bowel may quite closely simulate right inguinal disease from other causes; but bloody discharges, or complete stoppage, and later fecal vomiting, will not leave us long in doubt.

Malignant disease of the cæcum is of very moderate growth; there is a fixed, firm swelling, which has developed slowly, frequently a marked cachexia, and usually increasing obstruction of the intestine.

Abscess in the abdominal wall may be extremely difficult to distinguish from abscess about the cæcum, but the former is not associated with intestinal irritation; neither is peritonitis present.

When neither of the above-mentioned conditions seems evident, what symptoms will especially point us to the vicinity of the cæcum and its appendix? I should say here, that I do not consider it possible to distinguish between typhlitis and appendicitis in a large number of cases. In fact, until quite recently, typhlitis has been described as an inflammation of the cæcum and its appendix. First of all pain; but remember that the locality of the pain is often misleading, and, according to Fritz, only about one half the cases refer the pain in the beginning to the real site of inflammation.

However, if there is distress on extension of the right thigh, and a more or less circumscribed tenderness, especially to deep

pressure in the right flank with tumefaction, accompanied by unaccountable gastro-intestinal disturbance, particularly if there be a history of constipation, we shall most carefully watch our patient. As the position of the appendix varies so much and so frequently, it is self-evident that the point of tenderness, if due to inflammation in the appendix alone, must vary to some exent; still tenderness on pressure in a comparatively limited space is of considerable value. While bearing in mind that it is the combination of symptoms that establishes certainty in diagnosis, we must look to the general condition of the patient for a portion of the facts that are to guide us in giving an opinion. importance of the case depends upon the course the disease pursues; whether it remains local or extends to a general peritonitis, or ulceration with perforation occurs, followed by an abscess. If the disease remains local, and there is no abscess formation, then the case is one that will be diagnosed according to the peculiar views of the medical attendant - appendicitis, typhlitis, local peritonitis, or possibly "slow fever.'

The question of treatment in every case of right inguinal disease certainly demands a deliberate consideration, fully as much by the surgeon as by the medical practitioner. In the early stages by all means give the patient the advantage of rest in bed, limited quantities of liquid food, hot or cold compresses (in most cases hot compresses are preferable), not merely to the site of pain, but encircling the entire body, and wide enough to cover the whole abdomen; and instead of large doses of opium, according to the teaching of our old-school contemporaries, and, I am sorry to say, to the practice of some of our own school, which benumb the patient, obscuring to us his real condition, and lessening moreover his chances by its undoubted interference with the natural forces at work toward effecting resolution, give him the indicated homoeopathic remedy, which may quite likely be found among the preparations of aconite, bryonia, mercurius, arsenicum, or gelsemium.

At the same time do not fail to be alert for conditions, which may require the most prompt and radical interference.

It is always well to make digital examination per rectum, for in extended suppuration there may be a tendency to pointing in this direction.

One surgeon of Boston has recently reported two cases of drainage by rectum, with recovery; but in the present status of abdominal surgery very little hesitation should be made in such cases in opening the abdomen, for investigation at least, even though rectal drainage be also established.

The question of when to operate is one which demands the best judgment, and into which are brought the finest profes

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