preceding the attack, there would be a very marked increase in the appetite; the patient would feel unusually well, but would be very hungry at intervals during the entire day; he would eat much more than usual at his regular meals, and would remark that the food tasted better and that his meals afforded him more satisfaction than usual. This symptom I have noted so frequently that upon my advice the patient has been more than ordinarily careful in his diet at such times, and has refrained from gratifying the appetite; but I never could see that it made a particle of difference with regard to the oncoming attack of migraine. It came just the same, whether the patient starved or whether he stuffed himself. I have found, however, that if immediately upon the appearance of this symptom an effective dose of calomel or blue mass was given, to be followed in the course of about six hours by a purgative dose of sodium sulphate, the threatened attack might frequently be averted. The symptoms of anorexia and nausea are more prominent in early life than in those patients who have passed the meridian; in fact, my observation has been that while the disease may recur at regular intervals during an entire lifetime, the attacks lessen in severity and the intervals between them lengthen after the age of about forty-five years. In women there is possibly some connection between the menstrual function and the migraine, and there are many instances in which the attacks have ceased altogether after the climacteric.

With very few exceptions, patients subject to attacks of migraine also suffer from constipation, but treatment directed solely to the correction of this condition accomplishes very little toward the relief of migraine.

Rachford states that "under pathological conditions, either through a weakened functional capacity of the liver or through excess of poisons produced, the liver is no longer able to destroy these poisons, and a periodic, acute, functional incompetency of this organ results, thereby throwing these poisons into the general circulation and producing an acute auto-intoxication (migraine). Under aggravated pathological conditions the liver may remain for a long time in a state of chronic incompetency, thus allowing the greater portion of these poisons to filter through into the general circulation, producing a state of chronic auto-intoxication (chronic migraine with neurasthenic symptoms). In this condition the liver is commonly enlarged. And this fact I have so often confirmed by my own observation that I have come to regard it as the principal etiological factor. That it is not, however, the sole cause of the condition is proven by the fact that the patient may for a number of weeks be in apparent perfect health, when, without any change in his ordinary mode of life, without any indiscretion in diet or interruption of his regular habits, without mental trouble having occurred, he is suddenly stricken. with a severe attack of migraine.

Commenting on this peculiarity of the disease, Kinsman says: "The periodicity of its attacks lends support to the view that during the intervals the victim stores up energy in the nerve cells, and with this storing of energy their equilibrium becomes unstable, and then sudden noises like the report of a gun, odors, flashes of light on the retina, fatigue or night vigils, precipitate the attacks. The 'discharging lesion' comes like lightning from the sky and the victim falls."

I have noticed that with some persons any variation from the daily habit will usually bring on an attack of migraine. Many of these unfortuate sufferers are obliged to forego the pleasures of travel for this reason, and some such persons actually have better health when they continue at their daily work throughout the year than they do when they travel for health and pleasure even under the most favorable conditions.

In the treatment of migraine most writers claim that much can be done by judicious regulation of the diet and habits of the patient; and while this appears reasonable, yet extended observation has convinced me that it has no influence whatever, some of the most inveterate cases occurring in persons whose mode of life was in every respect above criticism, while in other persons, whose habits were reprehensible in every particu. lar, the attacks of migraine were, if anything, more amenable to treatment. I have, however, noted that in several patients who were accustomed to have regular, daily movements of the bowels, either naturally or induced by the systematic administration of laxatives, that constipation would abruptly occur which could not be relieved by even large doses of purgatives unless calomel or blue mass was first given. In others, the color of the stools would abruptly change from the normal to clay color; here again the mercurial alone was effective in restoring the normal stool, and, unless it was given, the ordinary symptoms of a bilious attack would soon present themselves and an attack of migraine promptly follow.

The treatment recommended by Kinsman I only mention to condemn. He states that he gives from one twenty-fifth to one-sixteenth of a grain of morphine, and puts the patient to bed. The putting to bed part is all right, if we can do no better, but I do not believe that morphine should ever be prescribed in this condition. Kinsman recommends extract cannabis indica in one-fourth grain doses, three times daily, given for a period of some weeks to lengthen the interval between the attacks. The result of this method of treatment in my hands has been one of utter failure. He recommends hot or cold applications to the head, but I have observed little benefit from them.

Gould, of course, attributes all attacks of migraine to eye strain, and as it must be admitted that eye strain may be a predisposing and contributing cause of migraine, any errors of refraction should, as a measure of prophylaxis, be corrected; but I do not believe there is any large ratio of cases of migraine which may be cured by this measure alone.

G. A. Moore (New York Medical Journal, September 1, 1906), says: "most important measure is to promote a thorough elimination, and this is well done by administering epsom salts in fairly good sized doses. Whether called early or after the case is well advanced, order a dose of salts; send the patient to bed in a quiet, darkened room; apply heat or cold, according to which is more beneficial, to the head and neck; sometimes a mustard paste over the sympathetic is of value. Prescribe acetanilid, with or without caffeine, as is indicated. The acetanilid is not given solely for the relief of pain, but also to promote the excretion of uric acid, which it does better than sodium salicylate, though this last is a favorite agent with many in these cases."

This method of treatment meets my own views to but a very limited extent. The epsom salts is all right, but I think that acetanilid is only

second to morphine in possible harmful results. It does not cure, and at the best it does no more than to annul the pain. Dr. Moore would bave better results, I believe, if he would discard the acetanilid altogether.

Isaac W. Brewer, in the same number of the New York Medical Journal, recommends practically the same line of treatment, except that he advises small doses of calomel; and my experience has been that in certain cases of migraine calomel is one of the most efficient remedies at our disposal.

B. M. Randolph, in the same publication, also advises the administration of small doses of calomel.

The mere fact that Styll refers to so large a number of remedies for this condition is evidence in itself that none of them has proven satisfactory in his hands. He states that in a great majority of cases cannabis indica is the most satisfactory remedy.

After a very careful and fairly extended study of the treatment of migraine, which has included the use of a great number of remedies and combinations of remedies recommended by various writers upon the subject, as well as those which my own ingenuity has evoked, I have come to the conclusion that Rachford's plan of treatment is the only one which is not injurious to the patient and which can be depended upon for relief in most cases, and for cure in a considerable ratio of chronic cases. This treatment consists in the daily administration of the following prescription:

This preparation is put up in syphons and charged with carbonic acid. Occasionally Dr. Rachford makes some slight variation in the formula, but, as a rule, adheres to that which is here given.

As this form of dispensing the prescription is not only very inconvenient, but expensive to a prohibitive degree for most persons, I determined to try it in the form of a granular effervescent salt, and I had a quantity manufactured for experimental purposes. I have dispensed fully one hundred pounds of this granular effervescent salt during the past three years, and am convinced that the prescription in this form is fully as efficient as in the more expensive form of a carbonated solution.

In the treatment of an acute attack, I have sometimes given as many as eight or ten doses at intervals of from one-half to one hour. The first effect noticed in most cases is the gradual relief of the pain, and in most instances the purgative effect of the remedy is promptly manifested. Strange as it may seem, repeated doses, so far as my observation gces, have not produced violent catharsis. In very severe attacks I have sometimes also prescribed calomel, one-tenth grain every half hour, until one grain has been taken; but most of my recent cases have been treated with the Rachford prescription alone. It is not, however, in the treatment of acute attacks, but as a means of prophylaxis, that this remedy proves of

the greatest value; and in order to prevent recurrence of the attacks, the patient should take one dose daily, half hour before breakfast, for a considerable period of time-for months in all cases, and for years in some. As the prescription is not at all unpleasant to the taste, this is no hardship, and most sufferers from migraine would be willing to undergo such a treatment for a year rather than suffer one severe attack of the malady. It is not necessary to enter into an analysis of the action of the various ingredients of this prescription, but Dr. Rachford emphasizes the fact that sodium salicylate is the remedy par excellence of the prescription, and that only the true salicylate prepared from natural wintergreen oil should be used in compounding the prescription.

APPENDICITIS.*

Charles G. Geiger, M. D., St. Joseph, Mo.

PPENDICITIS has been one of the most important diseases to the
physician and surgeon for the past ten years.
Abundant statistics

dealing with the relative frequency of the different types of appendiceal and periappendiceal lesion exist; and the anatomical characteristics of the different varieties of this disease, together with the secondary lesions accompanying the primary appendiceal inflammation, have been described.

In spite of all this accumulative knowledge, the subject of the etiology and pathology of appendicitis is not by any means a closed chapter. Fitz, in his classical paper in 1886, first outlined the pathology of this disease; however, long before this, the profession knew that there was a disease in, or around, the head of the colon, that had a large mortality. Even the ancients recognized a fatal swelling in the right inguinal region.

It was in the sixteenth century that the appendix was first recognized anatomically. Beginning in the early half of the nineteenth century, saw an increased interest in this much-talked-of disease. Fitz's statements, based on thorough post-mortem study, revealed the fact that many cases of peritonitis had their origin in an appendix, and he gave us a foundation for sound pathology.

Much knowledge has been gained since this by anti-mortem examinations of the healthy and diseased appendices. About 1897-'98 much of the pathology found in the lower right abdominal quadrant, previously termed "typhilitis," and "perityphilitis," now changed its name to "appendicitis. It was not until this date that appendicitis was considered a surgical disease.

The majority of cases are first seen by the general practitioner, and therefore the safety of the patient depends on the wise co-operation of the physician and the surgeon. The lowering of the present mortality depends on getting these men who see a few cases each year, to recognize appendicitis early, to appreciate the pathology and to recommend the proper treat

Read before the Missouri State Medical Society.

ment, and urge that it be carried out; this can best be done by the general practitioner taking enough interest in his cases to follow them into the operating-room. A more ready appreciation of the condition in his next case will be accomplished in this way.

Considerable reliance should be placed on a group of three almost pathognomonic symptoms. First, presence or history of pain not produced by pressure. Second, tenderness elicited by pressure at a fixed point or area, not necessarily McBurney's point, within the lower right abdominal quadrant. Third, more or less lower right rectus rigidity in obedience to the rule, that overlying muscles attempt to protect underlying tenderness, by increased tonicity. Little reliance should be placed on pulse or temperature, for you may have with an actual or impending perforation these symptoms nearly normal. I wish to emphasize, never regard lightly an acute abdominal colic, no matter how much the early symptoms may suggest an attack of ordinary indigestion. Watch such a patient for a period of twenty-four or forty-eight hours, to make sure whether or not localized pain and tenderness in the lower right quadrant, may reveal an appendicitis. In every sudden abdominal pain the probability of an appendicits should be borne in mind, and no other diagnosis considered until this disease can be definitely excluded. However, in infancy, abdominal pain is of such common occurrence, that an appendiceal colic is very apt to go unrecognized. This is especially true in the first year of infancy and in cases where comparatively mild local symptoms are certainly rarely diagnosed.

If the process goes on to abscess formation, then the condition is more readily discovered, if the probability of an appendicitis is not forgotten. Lack of common sense and ordinary intelligence in eliciting the history of the attack, or the negligence of the use of the only instrument of any service in the diagnosis of this disease, the palpatating hand of the practitioner, is responsible for much of the mortality.

With nearly a unanimous agreement among experienced surgeons that operationis indicated in the early hours of the attack, the great importance of prompt diagnosis can be clearly perceived. The failure to make an early diagnosis of acute appendicits, as before stated, is responsible for most of the factors entering into the mortality of the disease.

One of the greatest fallacies that has ever been propagated to account for appendiceal symptoms, is rheumatism. Having had considerable experience with appendicitis, I have always found true appendiceal symptoms to be due to a diseased appendix in every case, even where rheumatism has been held responsible for the symptom-complex prior to operation. It is now recognized by the profession that we may have ulcerative or necrotic perforation of the appendix without any symptoms of any consequence until after the perforation has taken place.

I can call to mind three fulminating cases that came under my observation, and were operated upon within twenty-four hours from the time of the onset of the symptoms, and at this early date each case had a welldeveloped general peritonitis. The abdomen partially filled with a seropurulent fluid, bowels glued together with an inflammatory exudate. There is no doubt in my mind that the great pain or sudden onset was the result of the rupture of the appendix in these three cases. We can have an ulcer of the stomach with little or no pain, but should we have perforation it is followed with great pain and virulent peritonitis.