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The symptoms certainly pointed very strongly to gastric or duodenal ulcer, rather to the latter condition than to the former. However, I have many times seen symptoms of these lesions counterfeited by a a chronically inflamed appendix. There is in most of these cases more or less gastrointestinal autointoxication, complicating the condition. As a result of the auto-intoxication, the patient suffers from neuralgias of various kinds and from malnutrition, which manifests itself in the form of emaciation and vasomotor disturbances, the cold hands and cold. feet being but a feature of the latter condition. Not infrequently in women the case is complicated by uterine or ovarian displacement.

I could not determine in this case what the condition of the generative organs was until after the abdomen was opened, for reasons. which I have already given. I was, therefore, compelled to begin my operation as an exploratory one, making a somewhat long incision in the median line of the lower abdomen. I found upon exploring the appendix that it was long and of at least twice its normal thickness, and filled full of fecal matter and fecaliths. I found that the uterus. was retroflexed; that the ovaries were down under the fundus, and that the right ovary was adherent. I did not, however, disturb either the appendix or the pelvic organs, for aseptic reasons, until I had made an exploration of the upper abdomen, for which purpose the long incision was made. I carried my hand over the omentum and over the colon, grasped the stomach between my thumb and fingers, and thoroughly explored the stomach and duodenum, as well as the gall-bladder area and the kidney. I could not find any gross lesions of any of those organs, although it is entirely possible to overlook a small ulcer of either the stomach or the duodenum in making an exploration of this kind. I was so firmly impressed with the idea that the lesion of the appendix and the displacement of the uterus and ovaries were the cause of the indigestion and gastro-intestinal autointoxication that I removed the appendix, broke up the adhesions of the ovaries, and did the internal Alexander operation by the Kelly method, reserving a gastroenterostomy for later work, should the operative procedures done from below not relieve the indigestion. I also dilated the rectum thoroughly, because I believe that in all instances where there exists constipation, with cold hands and cold feet, much benefit is derived from this procedure. I also overcame the obstruction of the hymen, as it could only give her trouble should she ever marry. There were lesions, too, of the clitoris, which I overcame for the purpose of relieving all terminal nerve impingement.

These operations were simple, were comparatively free from danger,

were done in a comparatively short space of time, and the patient was removed from the table in most excellent shape.

The whole question of gastrointesinal autointoxication and mucous enterocolitis was brought up to date by me in a recent article published in Surgery, Gynecology and Obstetrics, September, 1910. I am thoroughly convinced that the profession does not appreciate how frequently indigestion and malnutrition are due to lesions of the appendix and, in women, to lesions of the generative organs. While preparing the paper referred to, there appeared in the Proceedings of the Royal Society of Medicine of April 6, 1910, two articles by well-known English specialists and surgeons which are of great importance. Dr. Herbert J. Patterson gives several clinical cases in which it was exceedingly difficult to differentiate gastric symptoms, due to appendicular disturbance from gastric or duodenal ulcer. Five of his patients vomited blood on one or more occasions, the amount in one case being 50 ounces. In one case, when the stomach was opened the whole of the mucosa was studded with numberless bleeding points. He believes that the hemorrhage in these cases was due to the irritation resulting from the hyperacid gastric juice. In a large majority of the patients the pain followed the injestion of food, although the intervals between the taking of a meal and the onset of the pain were variable. In most cases the pain was referred to the epigastrium, usually to the right of the middle line. In 23 cases the stomach, duodenum, and gall bladder were explored, and in 15 of the cases were found healthy; the appendix was then sought for and, as it showed evidences of disease, was removed. In several of the cases where relief was derived from appendicectomy the appendix was not extensively diseased. The most common condition found was a thickening of the organ with constriction near its base, the distal end being bulbous. A concretion was found in exactly half the cases. In theorizing as to how the gastric symptoms are produced, Patterson believes that they are due to intestinal stasis. "This theory," he says, "is supported by the frequency with which the duodenum is found markedly dilated at operation, and by the fact that in one of the cases the stomach was dilated also. Further, as a rule, the quantity of gastric juice evacuated after a test meal is greater than in healthy individuals, the percentage of volatile acids is usually increased, and, in addition, flatulence and constipation are prominent symptoms. "

In another article entitled, the Clinical Significance of Gastric Hypersecretion and Its Connection with Latent Disease of the Appendix, which appeared in the same number of the Proceedings of the Royal

Society of Medicine, Dr. W. Soltau Fenwick says: "Until the year 1907 I had convinced myself from post-mortem evidence, as well as from the more limited data afforded by operation, that 88 per cent. of all cases of chronic hypersecretion were associated with a demonstrable lesion of the digestive organs, while in the remaining 12 per cent. no disease that appeared to have any immediate connection with the stomach could invariably be detected. I was, however, well acquainted with a peculiar type of hypersecretion in which death frequently occurred from appendicitis, and was in the habit of warning the subjects of this complaint of their especial liability to inflammation of the appendix, but it was not until an opportunity occurred in that year of discussing the subject with Dr. W. J. Mayo that the cause of this appendicitis, and also an explanation of the 12 per cent. of cases hitherto unexplained, at once became apparent." The following is an analysis of 112 consecutive cases of chronic hypersecretion reported by Fenwick:

Chronic ulcer of the stomach existed alone in
Chronic duodenal ulcer existed alone in.
Gall-stones existed alone in

12

46

_12

Disease of the appendix existed alone in

_22

Gastric and duodenal ulcers co-existed in

3

Duodenal ulcer and gall-stones co-existed in.
Gastric ulcer and diseased appendix coexisted in
Duodenal ulcer and diseased appendix co-existed in
Cancer of the pylorus existed alone in.

3

_5

4

4

Again, bearing upon the diagnosis of this subject, Christopher Graham, who is with the Mayos, under the caption of "Differential Diagnosis of Diseases Causing Gastric Disturbance," says: "Chronic recurring appendicitis is a type that usually gives stomach symptoms. There is no appendical tenderness, no pain at McBurney's point, no fever, no tumor, no symptoms that usually mark appendicitis, except those referred to the stomach. There may be pain, gas, vomiting, sour stomach and pyrosis, but when compared with peptic ulcer they are irregular, and when gall-stones are considered the attack is too prolonged. The whole train of symptoms is caused more often immediately by food, but this meal gives one effect and the next meal another; there is no regularity, meal after meal, as in chronic ulcer, and rarely does food give ease. Pain is often a queer, rather continuous distress, which is epigastric or indefinitely abdominal, which the patient describes as epigastric. There is no clear-cut day by day repetition, as in ulcer, and no attacks like gall-stones of definite location of pain.

Nausea, distress, a gassy, bloated condition covers the bad feeling of more cases of chronic appendicitis than of chronic ulcer or gall-stones. Exertion is a factor in appendicitis, and sufferers from it are seemingly often unable to work. Pain may be epigastric only, but often indefinitely of the epigastric and abdominal regions, or low gall-bladder or high appendix areas. If we have dyspeptic attacks, with epigastric pain and radiation to the umbilicus or lower abdomen, consider, first, appendical disturbance. "

I can do no better in concluding this paper than to append my conclusions in the article referred to:

1. The most diverse views prevail at the present time regarding the causation, pathology, and treatment of gastrointestinal autointoxication and so-called entero-colitis:

2. The association of the two conditions is frequently observed.

3. A most common symptom of chronic appendicitis is the discharge of mucous per anum, because of the enteritis excited and perpetuated by the inflamed appendix.

4. There is increasing evidence going to show that a casual relationship exists between chronic appendicitis, with or without mucous enterocolitis, and gastrointestinal autointoxication.

5. Lesions of the female reproductive organs may also, either by interfering with intestinal peristalsis through the direct pressure or reflexly, so interfere with digestion as to cause gastrointestinal autointoxication.

6. In dealing with the symptom-complex of gastro-intestinal autointoxication and mucous enterocolitis, it is usually necessary to have recourse to surgery before permanent relief is obtained. This statement presupposes that intelligent dietetic, hygienic, and medicinal measures have been faithfully observed previous to operation.

7. Relief following surgical work, when indicated, is usually immediate. It may be necessary, however, to keep the patient, especially if neurotic, under observation and treatment for some months following the operation.

The patient's convalescence from the foregoing operation, which is typical of many coming under my observation, was entirely uninterrupted, and she obtained almost immediate relief from her gastrointestinal symptoms. Within two weeks from the time of the operation she was able to eat almost anything she cared to, and at this writing has gained 30 pounds, has returned to her work, and is in most excellent shape.

HOW TO STUDY AND APPLY THE MATERIA MEDICA.
HYDRASTIS CANADENSIS.*

T. BACMEISTER, JR., CHICAGO.

It is said that one who writes must be full of his subject. When the author sat down to pen this paper he found there was no surfeit of hydrastis within him, but there was an over-abundance of other thoughts crowding his brain, and no relief from this cerebral congestion would come until he had set these same thoughts, in part, upon the paper. If any came here seeking light upon hydrastis canadensis you are wasting time, and are warned that now is the time to withdraw. Because there must be a reason or excuse for everything under the sun, hydrastis canadensis has been made the title of this paper-the excuse for what I have to say.

The golden seal is one of the oldest known medicinal substances of this hemisphere. At present, like the majority of one-time favorites, it is in disrepute among the elect of the dominant school, and is no longer "official" because the Bureau of Pharmacology of the A. M. A. has found no proof of the poor drug's efficacy. However, we of the new school continue to employ the remedy, and find it just as curative as before it was dropped from the American Pharmacopeia, and that in tincture or high potency, when given according to the law of similia.

Hydrastis grows pretty extensively throughout the earth. The moon is some two hundred and thirty-eight thousand eight hundred and forty miles away, and we know not whether the golden seal lines. its dead canals or no. The sun, source of our light and life, scorches its path through space at a distance from us of ninety-two million miles, and in its gaseous flames no hydrastis grows. The nearest fixed star swings through the ethereal vault twenty trillion miles away, and we are assured that heavenly bodies exist so far placed in the illimitable depths of the sky that their light reaches us only after five hundred thousand years of travel!

No human intellect can cope with this idea of limitless space-infinite space-through which vast systems of worlds spin on their endless way to nowhere during infinite eons of time, and yet, in simple. trusting faith, we accept the unbelievable words of the astronomer and say "it is the truth."

The mighty Sequoia rears its proud head a tenth of a mile to give thanks for its life. The greatest oaks are scarce a fifth so tall. Man * Read before the Illinois Homeopathic Association, May 15, 1912.

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