dition could ultimately result in stenosis of the orifice, and possibly of the entire lumen of the appendix, by producing hypertrophy of its mucous and muscular membranes; and should such a narrowing of its orifice obtain I can well understand how disease of a very grave character might at any time ensue.

But here again nature has arranged for its protection against an active inflammatory process by refusing to supply it with a highly organized arterial system; depletion being one of the most powerful natural agencies in preventing and abating the inflammatory process in any organ.

In this connection it may be well to suggest that not every case of suspected appendicitis is such in reality. I have known of a number of cases of pelvic cellulitis or parametritis to have been mistaken for appendicitis; and in two instances nephritic colic, on account of its severity, and because the right ureter was involved, was supposed, at first, to be well-developed cases of appendicitis.

In November, 1886, I was asked to see a case of appendicitis in consultation with an eminent physician of an adjoining neighborhood. The case was that of a robust negro, middle-aged, who had been attacked four or five days before with a very severe pain in the lower portion of the right iliac region. The pain was incessant, and several rigors followed each other at irrregular intervals during the first two or three days, and fever of a remittent type was present continuously.

None of the symptoms having abated, I was asked to see the case, with a view to operative interference, on the fifth day. Before I arrived at the negro's house I learned that he was dead. Having obtained the assent of his family, we made a post-mortem exploration the following day. The autopsy proved the diagnosis to be altogether incorrect-the appendix being intact and apparently free from disease of any kind. The negro had died of strangulated inguinal hernia. A very small knuckle of intestine had been forced by some means beneath Gimbernat's ligament and had been held there, undetected by the physician, sufficiently well to produce strangulation, inflammation, necrosis and dissolution.

Appendicitis, however, does occur, more frequently in the cities, less frequently in the country; and when a case has fully developed, or when it has not yet fully developed, but suspected of being such, it demands the most thoughtful and careful attention; and when a case has fully developed to the extent of unmistakable diagnosis, no clinician, however eminent he may be, can determine at once whether it belongs to the domain of medicine or to that of surgery; and to assert that every case belongs exclusively to the domain of either science is to assume what no man can establish.

I have not found it necessary to operate upon any of the five cases which have fallen into my hands-every case having yielded promptly to the depleting influence of small doses of the sulphate of magnesia frequently repeated. I agree, however, that it would be quite unreasonable to contend that every other case would yield as readily to the same plan of treatment.

Should any hard substance, angular, spiculated or otherwise rough enough to produce irritation, enter the body of the appendix, or should an enterolith form within its lumen which could not be thrown out by systaltic contraction, or should stenosis exist, especially about its open end, and should acute suppurative inflammation ensue, then, it seems to me, operative interference would be imperative. I would as soon expect such a case to get well without surgical aid as that a case of cystitis could be cured by medicines while an irritating calculus remained within the walls of the urinary bladder. Again, it seems to me that it would be just as unwise and unphilosophic to contend for an operation upon every case of recent catarrhal appendicitis. While it would be wise to interpose surgical aid in a given case of empyemic or suppurative pneumonitis, no one would think of using the knife for every case of simple lobar or catarrhal pneumonia. The inference is easy. All inflammations do not result in suppuration, and those inflammatory processes which tend to suppuration may be inhibited by proper and prompt means.

In conclusion: In a recent acute appendicitis I usually commence with one or two grains of calomel, and repeat every hour until three or four doses have been given; then follow with sulphate of magnesia 60 grains and bicarbonate of soda 10 grains, given in half a glass of chloroform water, and repeated every half hour until free catharsis is established; and if, in the meantime, pain is unbearable, I resort to the alleviating and soothing influence of chloroform given from time to time by inhalation. In this manner I have kept my patients from suffering and have brought them safely through in every instance.

I have found this plan of treating appendicitis admirably adapted to pelvic and other forms of peritonitis.

ANALYSIS OF APPENDICITIS OPERATIVE
METHODS.

BY JOSEPH PRICE, M.D., PHILADELPHIA, PA.

In the discussion of my subject it is needless, before a body of men representative of the best scientific culture of the profession to more than in a casual way refer to history, pathology, therapeutics and nomenclature. The pathology of appendicitis has perplexed the profession, and much that pertains to the subject remains unsettled or unsatisfactorily explained. We are without explanation of the function of the appendix; we know, as demonstrated by our surgery, that it can be removed without disturbance of the anatomical or normal relations and functions of other organs, without any consequent disturbing sequence. There are various causes of trouble about the head of the cecum, many of which have not been satisfactorily explained. We have reached simplicity in nomenclature. Disease of the appendix takes the name of the organ; appendicitis goes direct to the thing it names, definitely locates and defines the trouble. This is a gain in suggestiveness and simplicity of terms which could be very profitably extended in medicine and surgery. Simple common sense terms, those with pith and significance, will fully express all of the very little we know and are easier for tongue and brain to manage.

For long it was difficult to persuade the profession that surgical interference was clearly indicated in about all cases of appendicitis. This scepticism and hesitancy marks the early history of all our surgical procedures. The oracles of our new surgery are many, their teaching in very many respects is confusing and mistaken. Many explanations with which books and papers are replete are merely speculative.

There are a few facts, experience confirms as suchthese we can take hold of and be guided; they are primary facts, upon which we can build, not mere theory, but a practical surgical faith. We often find it safe to follow the teaching of some of the old general practitioners. They built our temple for us; none of us have the keys to all its. doors. Amid the much that is new we are disposed to forget the wise teachings of many of the old priests of our science. The following of plain, simple lines gives us our greatest and most gratifying successes. Like many of the early intrapelvic and intraperitoneal operations, that for appendicitis was imperfect, failed of complete and satisfactory results. The failure of many of the early and not. yet altogether abandoned procedures is not of difficult explanation. In many cases instead of simple incision, open treatment and drainage, there should have been a complete operation, the removal or extirpation of the appendix, the freeing of all adhesions, toilet, drainage, closure. The inflexible rule should be where appendicitis exists remove the appendix by extirpation, free all adhesions, repair all lesions of both large and small bowel and remove the dirty and infected portion of the omentum, cleanse, and drain if

necessary.

It is incomplete surgery to simply make an incision for drainage purposes at the common seat of operation, it is unsurgical to open the loin for drainage purposes as practiced by the homeopathic school of surgeons, it is unsurgical to amputate the appendix by either transfixion or circular ligature. The transfixion method contaminates the liga