One of the first evidences we meet with is foul-furred tongue and frequent headaches. In all my female patients headache has been one of the predominating symptoms. Of course we have headaches in many diseases, though they are not of the same character that we meet in this variety of kidney trouble.

I have examined urine frequently with negative results. It is not an infrequent occurrence to find urine normal in quantity, and entire absence of albumin and casts; you have so far no symptoms to go upon, and it gives you restless days and sleepless nights to make a satisfactory diagnosis, and finally you have a hasty summons to see the patient, and find her in a partial stupor, with tendency to coma. In forty-eight to sixty hours you have complete coma; then for the first time the urine shows the characteristic evidence of kidney lesion.

You usually have increased tension of the pulse; it is hard and incompressible. You are unable to obliterate the pulse wave; in the interval between the vessel feels full and rolls under the finger.

Persistent high tension is one of the early and most important symptoms. Hypertrophy of the left ventricle of the heart is the most frequent disturbance of this organ. In fact in the majority of cases we find hypertrophy of left ventricle.

In the respiratory system I seldom observe any disturbance except the Cheyne-Stokes breathing, and this only toward the close of life. I have seen the Cheyne-Stokes respiration when patient was up and walking about. I have never seen any characteristic digestive disturbance. All these patients have poor appetites and no desire to take food. Beyond this I have never seen any of the grave disturbances that we frequently see stated by authors. You may have nausea and vomiting coming on as coma develops, due to the uremic absorption; it does not always occur. You always have the coated tongue. In regard to the nervous and mental system, Osler reports a few cases of mental derangement due to this form of Bright's disease.

I have had one case with mental disturbance. It lasted for several weeks. At one time it looked as if the patient's mind would never return to its normal condition. This condition lasted about eight weeks. She made a slow return to her usual health, and never showed any return of her mental delusion in the other attacks she had, and from which she died. The general nervous system shows a very decided impression from this trouble. I am convinced that the nervous disturbance that comes at the menopause is responsible for all kidney

trouble that we have at the change of life. These patients have the cirrhotic kidney, and it is the only variety you find with the menopause. It is so latent that the patient is practically dead before the kidney lesion is found out, and numbers of these patients go to their graves without a diagnosis ever being made. Another feature about this. variety is the absence of swelling of hands or feet, or puffiness under the eyes. You never see anasarca in the cirrhotic kidney, and it is the only variety of kidney disease in which it is not met with. Another point of this insidious disease is the evidence that ought to appear in the urine. You may not have albumin and casts appearing until serious and probably fatal symptoms have set in. In the female patient you have excessive nervousness. This is one of the prominent accompaniments of this disease. When you meet with just such conditions and fail to find evidences in the urine, put it down you have a cirrhotic kidney. It is the insidiousness of the disease that places the physician in a predicament. I will report a few cases in closing.

CASE I. Mr. C., aged sixty-four years. Saw him in January, 1895, suffering from extreme weakness; furred tongue, loss of appetite, slept badly, had frequent headaches, vision was slightly affected, no swelling of hands and feet. Urine examined; found albumin and casts. By regulating his diet and using Basham's mixture and infusion digitalis, I kept patient going fifteen months. He was able to be out on the street and attend to business until two weeks of his demise. He began his last bout with delirium and partial coma, finally coma becoming profound, and death.

CASE 2. Mr. B., aged fifty-eight years. Saw him in January, 1895; he was in bed; had gradually lost in strength for the past year. Was under charge of another physician, who had failed to recognize Bright's disease. He was passing very small quantity of urine, only twelve ounces in twenty-four hours; urine albuminous and casts very plentiful. No headache, pulse exceedingly slow-42 per minute (tension very great); very restless and sleeping badly. This was one of the very few cases in which morphine gave good rest and did no harm. He got % grain at bed-time, and usually had a good night's rest. The treatment was same as detailed above. He showed some improvement at the end of the week, and was so improved at the end of three months that he was able to go back to business, which he attended to until last December, when another physician took him in charge. The end was death.

CASE 3. Mrs. G., aged forty-two years. Saw her first in consultation in December, 1894. Previous health very much impaired for a year or more; kidney trouble not suspected by attending physician. Urine examined; found albumin and casts. She had had headaches for the past six months; just beginning the change, and had been exceedingly nervous since climacteric begun. In forty-eight hours from my first visit she had a convulsion, and they continued until the end came in about sixty hours. No swelling of any part of the body.

CASE 4. Mrs. B., aged forty-four years. Saw her in March, 1895. She had been a great sufferer with headaches for the past ten years. She continued to have severe headaches for a week. I was unable to find any medicine to give her relief. At this time she was passing about the normal quantity of urine. I had urine examined; found slight trace of albumin and a few casts, granular. The patient went from bad to worse, and at the end of two weeks she developed a decided mental trouble, which kept up for about eight weeks and finally cleared up, and patient made a partial recovery. At no time was there any swelling of hands or feet. Patient recovered sufficiently to go away for the summer, returning in the fall to end her life in a very short time, dying in November.

CASE 5. Mrs. A., aged forty-five years. Saw her in 1889; treated her for headaches on numerous occasions. Examined urine a number of times; found nothing. In June, 1897, I was called hurriedly one day to see patient, as she seemed to be in a stupor. The family had become alarmed, and necessarily so, for upon questioning patient could get very little satisfaction. I was able to get specimen of urine, and had it examined; found albumin. The patient passed into coma so quickly that treatment did no good, and patient died in sixty hours. No swelling of hands or feet.

We know that all these patients die. The only advantage in being able to recognize the disease early is to see if we can by judicious management keep our patients alive for a few years. We know that some of these patients live for several years and spend a fairly comfortable life. By regulating the diet and habits you can add very much to staving off the fatal attack. I do not find any great advantage in treatment. The medicines I have gotten the best results from are Basham's mixture and infusion digitalis. Regulation of the diet and habits is all that can be done.

LOUISVILLE.

THE DIAGNOSIS AND TREATMENT OF APPENDICITIS.*

BY LOUIS FRANK, M. D.

Visiting Gynecologist to Louisville City Hospital.

Notwithstanding the fact that much has lately been written upon appendicitis, and that the points which will be brought out in this paper have probably been elsewhere more fully elaborated, I have thought that it would not be amiss to call your attention to some of the practical aspects of the subject.

I have nothing new to offer, either in fact or in theory, and will limit myself to the consideration of the symptoms from a diagnostic standpoint, and to the treatment of the disease. We all recognize the high importance of the subject, and I take it that in a society of this kind, composed for the most part not of surgeons but of general practitioners, that the discussion should be particularly interesting.

The papers which have been written upon appendicitis have been almost invariably read before Surgical Societies and discussed by surgeons. Rarely do we hear the ideas of the general practitioner upon this subject. I anticipate censure, or at least disagreement, upon the part of many of the members in my consideration of the treatment of this dangerous trouble; but it is the experience of the doctor that we are after. Surgeons want to know how many cases he has seen which have gone through an attack without operation; we want to know how many cases he has seen upon which no operation has been performed that have had a recurrence; we want to know what has been the ultimate outcome in these cases; how many of them were really or permanently cured. I feel sure that I shall meet with opposition when I speak of operating upon all cases of appendicitis. I might say here that I believe that as soon as the diagnosis of appendicitis is made, the case is no longer a medical case; at the same time I recognize the fact that many patients positively refuse to have the surgeon called in. To this class of cases I will also devote a little attention.

My own work in this line has not been so extensive as that of some others, but my experience with quite a number of cases has given me some decided opinions, or I might better say has made me more fixed than ever in the ones which I had.

We are very much indebted to Deaver, Fowler, Morris, and Mynter for the excellent expositions which they have given. They have done

*Read before the Kentucky Midland Medical Society, at Shelbyville, Ky., January 13, 1898.

more than any others in the development of the technique of appendicitis operations and bringing our understanding of the disease to its present status. The masterly articles of Richardson and McCosh must also be mentioned in this connection.

The diagnosis of appendicitis should be a comparatively easy matter, though not always as much so as some would have us believe. There may be great difficulty at times in making the diagnosis, though this is far less frequent in the male than in the female. In the male I think we may say that 99 per cent of all cases of peritonitis, not due to trauma, are appendiceal in origin; but we should not look upon all pains that occur in the abdomen or that are referred to the abdomen as due to peritonitis. Appendicitis may be confounded with several affections. For instance, I had a case under observation which had been treated for a week for appendicitis, the patient being a man about fifty-six or fifty-eight years of age; I was called to see the patient with the idea of operating. I could not agree in the diagnosis, and was inclined to look upon the case as one of renal colic. The patient was put upon treatment, and my diagnosis was verified by his passing two days latter a small renal calculus. This man had rigidity, pain, vomiting, constipation, with pulse increased in rapidity, due to pain and not to elevation of temperature. There were other symptoms, however, which in connection with his age made me feel sure his trouble was not appendiceal. Gall-stones have also been mistaken for appendicitis. We should analyze our cases very carefully. The tendency now is to diagnose all acute abdominal troubles as appendicitis. This is due to over-zealousness, and careful consideration of each case will prevent it. I think that few cases of appendicitis go undiagnosed, and those that do have as a rule been improperly treated. This calling every abdominal pain appendicitis has also done much to prejudice people against operation, and also physicians, as they look upon them as cured cases. They are the cases that have no recurrence. The symptoms of appendiceal disease are so constant that by careful examination differentiation is most always possible. Among the most important of these symptoms are pain referable in almost all cases to the McBurney point, tenderness and rigidity in the right iliac fossa; the other symptoms which we would mention are vomiting, constipation, distension, tumor, rapidity of pulse, and elevation of temperature.

Let us analyze the symptoms separately: The first sympton is usually pain. This pain at first may be rather indefinite in location;