appendix also in 70.9 per cent. of patients with ovarian cysto mata. He and other writers state that only a little over 50 per cent. of appendices removed during the course of operation on pelvic lesions will be found microscopically to be normal. The remainder will show forms of acute and chronic inflammation or the result of former inflammation. The appendix is adherent twice as often in those cases where microscopic examination shows past or present disease. A certain proportion of adherent appendices are, however, perfectly normal microscopically. Mere shape of the appendix can not serve as an index of its normality or disease. Appendices may be club-shaped, constricted or bent upon themselves, and yet be perfectly normal microscopically. Championniere believes that appendicitis is comparatively a new disease and that its advent is in some way related with la grippe. He gives various statistics to show that its prevalence is coincident or sequent upon endemics of la grippe or influenza. Besides this, he calls attention to facts which he supports by statistics to show that the majority of cases occur among the meat eaters; that in countries in Europe where the people subsist mostly upon vegetable food, cases of appendicitis are rare. Many writers believe that the contributory cause is constipation or subacute disease of the intestines; such as, enteritis or dysentery. Among them Sherrill believes that constipation and resulting malnutrition are important causes. The concensus of opinion, however, seems to be that the important cause is the accession and activity of various bacteria, and specifically the colon bacillus through abrasion of the lining membrane; but to assign to these bacteria any more than a secondary or exciting role in the causation of the disease would seem irrational, when we come to reflect that there are millions of colon bacilli in the intestines of every individual, and even on the face and hands and in the mouth all the time, and that there are large numbers of staphylococcus, streptococcus and various saprophytes (which may become pathogenic) continually on and about one's person, and the appurtenances with which we come in contact. Concerning the formerly supposed causation of appendicitisby the presence of concretions and various foreign bodiesmodern experience has brought to light, as indicated by the quotations which we have already made, that many appendices harbor such things as well as the bacteria without becoming necessarily diseased. Modern research has also demonstrated that all sorts of anatomical variations in the form of the appendix has been observed without the organ thereby becoming diseased, and that previous diseases of the uterine appendages are not invariably the causes. In explanation of all this the theory is advanced that if through mechanical action, or otherwise, an abrasion or atrium is formed by which these microorganisms-especially the colon bacillus (which is always dwelling in this little pocket)-secure an entrance into the connective tissue and lymph vessels, they thereby set up irritation, then infection, and so on; that in this habitat-which has been liken to a culture tube-they are constantly setting up fermentation, forming toxins which are ready to gain access through some accidental abrasion, to the lymph or capillary vessels with the usual result of producing infection, and the like; and, further that concretions, etc., are probably the principal agents in producing such abrasions by mechanical action. Although this undoubtedly is the process which actually takes place after the initial step-namely, the abrasion-has been made, the questions still remain whether in all cases an abrasion constitutes the first step? And what previous condition must exist to provide an atrium or abrasion? For we have seen, according to the present state of our knowledge, that anatomical abnormalities exist, concretions and other foreign bodies are tolerated. Various pathogenic bacteria including the colon bacillus are, probably, always present-being shown in over 50 per cent. at least of appendices examined and found healthy; to say nothing of the thousands of appendices which are never brought to light, and which are never diseased throughout life, and which it is fair to presume are in like circumstances. Besides the evidence first advanced, a general survey of human pathology and human physiology would seem to suggest an insupperable objection to making this little accident (the formation of an atrium) the pivot around which the pathogenesis of the disease in all cases must revolve. This would hardly account for the large number of cases among healthy people of all ages, from infancy to senility, which are met with. There must therefore be something beyond, or before, which induces the accession of the disease. It seems to me, therefore, that more enterprise is needed in studying the domestic history of cases of appendicitis in order to work out antecedent causes. For instance: what are the details of life which the infant or child has been subjected to, who is attacked with appendicitis? What influence has the diet, the exercise or play had? What injuries, if any? What abnormalities, if any? What characterises the life of this infant or child? With adults, what has been the antecedent habits, mental and physical, of the patient? What particular occupation? Whether any previous diseases of the in testines or stomach has existed? What particular sort of dietwhether vegetable or animal? Has an irregular fermentation of the food or drink waged an influence? What, if any, effect has the alcoholic habit or social condition of the patient had? Or, in other words, do persons addicted to the moderate or excessive use of alcohol become liable or not to appendicitis? Do persons consuming principally a vegetable or an animal diet render themselves liable to appendicitis? Do persons who take their food without proper mastication thus become liable? Do persons of sedentery occupations thus become liable? Do persons of active occupation, such as the laborer or mechanic, thus become more or less liable? Do persons living an out-door or an in-door life thus become more or less liable? Are persons of certain nationality more liable than others? Is the white man particularly liable, or the negro and Malay less liable? hereditary dyscrasia or diathesis anything to do with it? Has These are suggestions which I am sure have entered the mind of every one of you present today. Yet how few surgeons and physicians have tried to trace up the etiology of appendicitis along any of these lines? In the town which I live, I think it can safely be stated that, very few cases of appendicitis occur among the laboring class, which is composed largely of Poles, Hungarians, Italians and negroes. If so, why? There is much investigation needed, the evidence so far on this point being far from clear, because the data recorded are too insignificant to lead to a definite conclusion. Concerning constipation which many surgeons believe to be the principal predisposing cause, we shall find a small percentage of constipated persons who are attacked with appendicitis. In my small range of observation I have been very much puzzled to observe that many persons who are in the habit of taking more or less mineral water or saline cathartics, or even vegetable cathartics, have been attacked with appendicitis. Among these many will be found who are great eaters; and strange as it may seem, but a very small percentage of alcoholic drinkers seem to become subjects of appendicitis. This observation has also amazed me, and I have been wondering whether the alcohol has anything to do with either changing or obstructing certain fermentations, or whether its irritant effect upon the peripheral nerve ends of the intestines stimulated peristalsis to such an extent as to prevent the occurrence of the disease by changing the contents of the appendix oftener. All of these questions and many others naturally crowd upon us when we think over the large number of cases which are occurring and the total inadequacy of the preliminary causes as laid down to account for them. I would, therefore, in conclusion suggest that a thorough investigation into the antecedent daily life of every patient afflicted with appendicitis be made-very much in the same manner that an attorney with a given case proceeds to trace up circumstantial evidence. I would suggest that this evidence might include the details of occupation, and the details concerning the eating and drinking of the individual; as to the kind of food and the amount; the kind of drink, be it water or anything else, and the quantity of such drink that has been ingested for some time previous to the attack. In short, a thorough investigation into all the domestic vicissitudes relating to the patient, in order to ascertain causes concretions, and the like, of the appendix, and how comes the abrasion. what In this way it seems to me that we might be enabled to cliscover what prediposes to make this little pouch a culture tube, what deflects the natural course of fermentation into one of infectious fermentation, and what the necessary conditions are for such a deflection of natural processes. As we cannot open the abdomen of every individual who comes to us and ascertain by our vision just what is going on, it seems to me that this method, although more tedious, should be adopted in the hope that we may arrive at the anterior causes and by our advice direct the people toward such physiological methods of living as would prevent the development of this prevalent and serious disease. There is but one other course before us in the way of prevention, until the time shall come when this rudimentary appendix shall finally disappear as an element of human intestinal anatomy, and that is, to extend to the realm of surgery the task of opening every child's abdomen and removing the appendix soon after birth. This idea, however, is too utopian for the present, unless perhaps we could get such a procedure adopted as part of a religious code -in which case undoubtedly appendicitis might the sooner be stamped out. 32 ADAMS AVENUE, WEST. MORTALITY AMONG AMERICAN PHYSICIANS.-During 1902 the deaths of 1,400 regular practitioners of the United State S were noticed in the Journal of the American Medical Association, which number is probably 5 per cent. of the total mortality in the profession of this country. The number of regular practitioners in the United States is about 95,000, making the death rate for the year about 14.74 per thousand, a lower rate than is usually sup posed to obtain. The mean average age at death was 58 years, 7 months and 29 days, and the average previous duration of practice was 28 years, 10 months and 28 days.-Denver Med. Times. The Graduate Nurse Yesterday, Today, and Tomorrow.' IT BY F. PARK LEWIS, M. D., Buffalo, N. Y. T IS a pleasure to unite with you this evening in the exercises which complete the year of your hospital training. No one, perhaps, who has not been actively engaged in work of this character can have an adequate realisation of its full significance. No one who has not actually experienced it can know how much it means to endure the hard discipline of hospital work, with its long hours, its rigid requirements and its drudgery, for the woman who has chosen for herself one of the finest, one of the most noble, as it is one of the most womanly occupations possible to her, that of the trained nurse. In her laborious hours of preparation she must master an unfamiliar nomenclature, she must conquer the difficulties of modern asepsis, she must school herself to stand by the surgeon without growing faint; she must learn to govern her tongue, to control her temper, to be quiet, to be ready, to be dextrous,to have the qualities of a soldier while retaining the heart and sensibilities of a woman. All this she must learn besides the technical points of the work she has undertaken, and it takes character and courage to plan such a career and successfully carry it through. Therefore, I congratulate you, young women, members of this graduating class, each of whom must possess in no small degree the quality of initiative which Hugo Munsterberg says is the distinctive trait of American character. I know, also, something of the thought and effort that anticipated the establishment of your training school. I know something of the evenings devoted to meetings for the consideration of plans and projects which resulted in that which made your education possible; the study of ways and means to meet the added burden which such work always involves. I congratulate, therefore, your training school committee in that they are able to present to the world so admirable a product of their labors tonight. But this is not all. The demands made daily upon the time and energy of the busy physician make it no easy task for him to lecture before a school, and much that is best of brain and strength goes into the fitting a class for its life work. Hence, I congratulate the teaching faculty in sending out this class of trained women to help in the world's work; since, arduous though their task may sometimes have seemed, they are getting 1. Address delivered at the commencement exercises of the Brooks Memorial Hospital, Dunkirk, N. Y., May 12, 1095. |
