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He Cites the Analogous Early Appendix Symptoms of Abdominal Sy

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He Cites the Analogous Early Appendix Symptoms of Abdominal Sy differentiation is possible, by noting that tenderness is Confusions arise not merely in pleurisy, empyema absent over the subjectively painful abdominal area and and lower-lobe pneumonias, but also in bronchopneu- that thoracic examination or respiratory symptoms give monia, upper-lobe hepatization (Bennecke7 and Her¬ some clue to the nature of the affection'. Indeed, the rick8) and, as in my second case, pericarditis with clinician customarily, in instances of abdominal pain, effusion. halts till he can exclude the triad of confusions—tabetic In conclusion, it is not my object to canvass the crises, respiratory infections and vertebral disease. entire literature of this subject or to claim that the The pain is variously depicted. Some, as Henoch, clinical picture described is wholly unique, since doubt¬ speak of it as superficial only, yet Raillet describes the less many have experienced the same situation. It is pain as deep and over McBurney's point. Dieulafoy has proper, however, to insist on the following points: found that pain in appendicitis does not begin with full 1. Pneumonia, pleurisy and pericarditis, at their very intensity, as it does in perforation, e. g., of a gastric onset, may present absolutely no symptoms other than ulcer, but this dictum certainly does not always hold. the abdominal findings. Melchior1 places special differential reliance on the con¬ 2. These phenomena of invasion may completely trast between the slight local findings and the severe resemble appendicitis, peritonitis of other etiology, or general symptoms, as the sharp pain, the high fever, the even the collapse of perforation. involvement of the sensorium, involuntary evacuations, 3. Diagnostic errors and unnecessary operations may etc. ; he cites the analogous early appendix symptoms of be unavoidable. Immediate operation is imperative and as an is held that and other typhoid example. It pain the small percentage of error is negligible in comparison abdominal symptoms of this pseudoperitonitic group with the benefits of early operation in genuine indica¬ cease suddenly and characteristically, which is con¬ tions (particularly as 80 per cent, of patients operated sidered differential from appendicitis. Against this on under a mistaken diagnosis, recover). statement, a strong protest must be made, inasmuch as 4. The tenderness does not always remit with deep, every clinician has learned to dread the sudden treacher¬ flat pressure, and that relaxation of the abdominal ous improvement witnessed in appendicitis, when gan¬ parieres, between respirations, is not invariable. grene or rupture relieves the tension of the part involved. 5. The general symptoms do not over¬ It invariably Tenderness and rigidity are frequently described. shadow the local, the latter at times being the more may be local or general. Richardson2 speaks of rigidity salient.9 and universal tenderness. Arron finds that the muscular defense is less than in perityphlitis. Mignon found generalized abdominal rigidity, and Barnard's3 patient THE HISTORICAL COLLECTION OF MEDICAL almost hard abdominal muscles. exhibited spasmodically CLASSICS IN THE LIBRARY OF THE Melchior's exhibited tension of the abdominal patient SURGEON-GENERAL'S OFFICE walls. In my experience moderate abdominal tension is common in pneumonia. FIELDING H. GARRISON, M.D. Immobility in bed is also described by Mirande. In WASHINGTON, D. C. Griffith's4 and Richardson's2 the knees were reports In of size the of to drawn any library problem what do with up. its rarer and costlier books is is seldom described. In Martens'5 three usually solved by stowing Collapse them either in or out of in at first resembled sight, show-cases, drawers, pneumonias, the symptoms perfora¬ and coffers, and in the was till the cupboards Surgeon-General's tion, but operation suspended pneumonic at this has been in force for cleared the In Barnard's6 the Library Washington policy signs diagnosis. report, some years so far as its erotica on the incunabula, elephantines, patient collapsed street; epigastric rigidity, pain and curiosa are concerned. and a and tenderness, the rapid thready pulse, history The recent of the Col. Walter D. Mc- of ulcer led to which revealed neither plan librarian, gastric operation Caw, to put the more medical classics under ulcer nor the disclosed bilateral important peritonitis; autopsy glass, for purposes of safe keeping, has resulted in a col- lower-lobe pneumonia. Barnard comments on the relax¬ lection of unique interest and value, for the nation's ation of the abdominal walls between respirations, which medical library is singularly rich in these literary treas- was lacking in our cases. ures, the accumulation of which is mainly due to the The general symptoms generally in some way suggest untiring zeal and vigilance of Dr. Billings and Dr. a or localization. The general infection respiratory Fletcher in the past. The fact that nearly every volume significance of fever, higher than is usual in appendi¬ in this exhibit is a first edition should interest the med- citis, is emphasized by Griffith, Barnard, Richardson ical bibliophile, and at the same time an arrangement of color and Sprengel. The gray (teint plombé) of the the classics in strictly chronological order affords a bird's skin in appendicitis is important, in Kirmisson's opin¬ eye view of the textual history of medicine to the student ion. Anxiety is especially remarked in one of Griffith's and casual visitor, while giving the specialist chapter patients and in my first one. Headache, severe cerebral and verse, as it were, by enabling him to put his finger toxemia, chills, cough, rate and character of the breath¬ on the particular locus classicus in each case. Then, ing are important. Obstinate constipation is not uncom¬ many of these old medical classics are fine specimens of mon, and initial vomiting, especially in children, or typography in themselves, bearing on title-page or colo¬ even renewed emesis,, may be confusing. phon the stately names of the great printers of the past. 1. Melchior, Edward: Mitt. a. d. Grenzgeb. d. Med. u. Chir., 7. Bennecke: Med. Klin., 1909, No. 7. xxi, part 3, article xxiii, p. 469. 8. Herrick: The Journal A. M. A., Aug. 29, 1903. 2. Richardson: Boston Med. and Surg. Jour., 1902. 9. Aside from the references mentioned in the text, the following 3. Barnard: Lancet, London, Aug. 2, 1902, p. 280. may be referred to : 4. Griffith, J. P. Crozier: Reports of Interesting Cases, Contain- Hampeln: Ztsch. f. klin. Med., xlv, 1902. ing an Article on Peritonitic Pneumonia, Arch. Pediat., June, 1899, Kuttner: Beitr. z. Chem. Phys. u. Path., 1906, li. p. 418; Pneumonia and Pleurisy in Early Life Simulating Appendi- Lowett-Morse: Ann. Gynec. and Pediat., November, 1899. citis, The Journal A. M. A., Aug. 29, 1903, p. 531. Morris: New York Med. Jour., lxix, 1899. 5. Martens: Med. Clin., 1908, No. 49, p. 1857. Palier: New York Med. Jour., lxix, 1899. 6. Lancet, Aug. 2, 1902, p. 280. Printed by permission of the Surgeon-General, U. S. Army. Downloaded From: http://jama.jamanetwork.com/ by a University of Iowa User on 06/17/2015 In preparing this chronological exhibit, which will, The Surgeon-General's Library possesses an unusually when completed, be provided with a suitable catalogue rich collection of some 900 volumes relating to the Hip- raisonné, it was thought best that the historical collection pocratic Canon, including fifty-two different editions of proper should begin with Greek medicine, for the reason the Opera Omnia, 441 separate treatises, and 408 com¬ that, apart from the works of the Jewish and Arabian mentaries and critical compendiums. Of these, the fol¬ physicians in the Middle Ages, Oriental medicine has lowing are on exhibition : mainly an anthropologie or esoteric interest. The lead¬ 1. The folio Latin text of the Opera Omnia, translated and ing monuments of pre-Hippocratic medicine, including edited by Fabius Calvus, the friend and patron of Raphael, the Ebers Papyrus, the Code Hamurabi, the Charaka and published at Rome under the auspices of Pope Clement VII in This was first Samhita and the Suruta, are, of course, on exhi¬ 1525. the complete edition of Hippocrates to be bition in the library hall, and no one will chal¬ printed. the of these documents. From the 2. The folio editto princeps of the Greek text, published the lenge importance following year (1526) by Aldus at Venice. hieratic of the we a clear idea of writings papyri get 3. The Basel Opera Omnia edited Janus Cornarius and the of the ancient by priest-like dignity physician's calling, printed by Froben (1538), highly prized on account of its the various diseases and the extensive materia medica textual and critical accuracy. known to the ancient Egyptians. From the Code Ham¬ 4. The Greek text and Latin translation of Hieronymus urabi we sense the importance attached to physicians' Mercurialis, printed by the house of Giunta at Venice in 1588. fees even 2,200 years before Christ. From the Suruta, 5. The Frankfort edition of 1595, containing the valuable the great storehouse of Aryan surgery, we learn that to translation and commentary of Anutius Foesius, the most their Brahminical code of ethics the ancient Hindu learned, industrious and able of the Hippocratie commentators lofty before the time of Littré. physicians united a highly specialized knowledge of and of instrumentation that 6. The first Latin text of the aphorisms, edited by François operative procedure surgical Rabelais 1532). was not on the Greeks and Eomans who (Lyons, improved by 7. The tiny Leyden editions of the aphorisms ( 1607 and came after them. skill in has been an Aryan surgery 1628), the first a Plantin imprint, the second a vest-pocket unbroken tradition, even through the Dark Ages, when Elzevir. was most under a ban. But with this surgery single name after that and in the face of the researches of savants The greatest scientific Hippocrates is exception of "the master of those who know," the like Ebers, Joachim, von Oefele, Jolly, Preuss and Bar¬ Asclepiad tels, it is doubtful whether the records of Egyptian, Aristotle (384 to 322 B.
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