or (as happens in the great majority of persons over 40 years), chronic kidney disease. As the instrument has only been introduced in Europe a few months, we cannot value exactly its indications, nor give all those conditions which may be found to qualify those indications. The blood pressure is low in neurasthenia, debility and febrile conditions generally; where in a febrile disease like pneumonia, we find a pulse of high tension, we have the greatest reason to suspect granular contracted kidneys, and the prognosis of the disease is therefore very unfavorable. BIBLIOGRAPHY. 1 Medico-Chirurg. Transact., 1872. 'Mohamed, Guy's Hosp. Reports, 1879. Sam West, Lettsomian Lectures, Lancet, 1899. San Francisco Board of Health Reports, 1889-1890. • Purdy, Urinalysis. 7 Mohamed, Med. Chirurg. Transact., 1874. 8 Lindeman, Deutches Archiv. fuer klinische Med., Nos. 1 & 2, vol. 65. 9Op. cit. 10 N. Y. Med. Journal, 1882. 11 Dieulafoy, Soc. Med. des Hopitaux, June, 1886. 1s Lepine, Assn. Francaise Adv. Science, August, 1885. 13 Lehman's Physiological Chemistry. "Bradford, Gulstonian Lect., Lancet, 1898. 15 Purdy, Op. cit. 16 Mahomed, Op. cit. 17 Vogel, On the Urine. 1236 Market Street. SURGERY OF THE VERMIFORM APPENDIX. By WINSLOW ANDERSON, M. D., M. R. C. P., London, etc., Professor of Gynecology and Abdominal Surgery in the College of Physicians and Surgeons in San Francisco. Professor Charles McBurney, of Roosevelt Hospital, New York, has written an excellent article on this subject in the International Text-Book of Surgery, just received. After devoting some space to the anatomy of the appendix, Dr. McBurney takes up the etiology and general pathology of appendicitis. Among the causes of appendicitis he mentions predisposing and exciting, or remote and immediate, meaning by that any inflammatory action of the bowels such as enteritis, typhoid fever, peritonitis, colitis, dysentery, syphilis, tubercular ulceration of the bowel, acute exanthemata (scarlet fever), etc., would frequently affect the appendix if these pathological conditions were in the neighborhood of the caput coli, as is frequently the case. When the parts have been structurally weakened they are more liable to the infection of the bacillus coli communis, hence predisposing causes undoubtedly play an important part in appendicitis. Furthermore, in these predisposing causes such as prior inflammations or traumatism, so to speak, the lymph channels of the appendix become more or less occluded as the appendix is nourished by a single artery, and the return blood of a single vein. It naturally follows that the organ becomes more vulnerable. Among the active causes of course we have true foreign bodies which occur in about 7 to 10 per cent of all cases of operative appendicitis according to Jas. F. Mitchell, an undoubted authority. The true foreign bodies found have been many and varied, from the seed of an orange, a grape-seed, a date-seed or a cherry-stone to a pea-nut, part of an oyster-shell, a piece of bone, a tooth, an oat-husk, apple-pips, a bullet, a lumbricoid worm, tooth-brush bristle, wisp of broom, corn-husk, fin of a fish, dressing-pins, as many as 122 bird shot, gall-stones to the link of a tape-worm. This of course does not include the appendoliths or so-called enteroliths composed of fecal concretions found in the appendix. Besides the true foreign bodies causing appendicitis we have a large number of cases of appendoliths or fecal concretions finding their way into the appendix, there setting up inflam mation. Catarrhal appendicitis is claimed by the highest authorities to be a frequent result of la grippe or tonsillitis (Keen and DaCosta). Occupations involving straining, etc., may explain why men have appendicitis four times more frequently than women. Catarrhal appendicitis either from la grippe, tonsillitis, enteritis or colitis, or following typhoid, etc., is claimed to be responsible for at least 50 per cent of all cases of appendicitis. This fully agrees with our experience which has been quite considerable. The other 50 per cent is divided into true foreign bodies 7 per cent of all cases, appendoliths 15 per cent of all cases. Wandering kidney according to Edebohls is responsible for 60 per cent of cases of appendicitis. The right kidney pressing upon the head of the pancreas, thus compressing the superior mesenteric vein, resulting in venous stasis of the appendix. Ulceration of the bowel, cancer of the cæcum, contraction of the mesentery of the appendix, closing the lymph channels, etc., make the total causes of appendicitis. Appendicitis occurs most frequently between the ages of 20 and 35. One case according to Hartley occurred in an infant, age 7 weeks. We have ourselves operated upon several cases after the age of 60, but as a rule it is not a disease of childhood nor of old age. The symptoms of appendicitis are so well known as not to require any special mention. We are often asked why do we have more appendicitis now than we did 50 years ago. The answer is two-fold, namely: First, of recent years we have had very much more influenza epidemic than formerly. Second, we now diagnose, operate and cure appendicitis where 50 years ago a patient would die of "inflammation" of the bowels and peritonitis. Many of these cases undoubtedly were caused by perforative or gangrenous or suppurative appendicitis. - Varieties of Appendicitis.—The varieties of appendicitis may be well classified according to Professor Charles McBurney, M. D., of the Roosevelt Hospital (from the International TextBook of Surgery): 1. Appendicular colic. 2. Catarrhal appendicitis. 3. Suppurative appendicitis. 4. Perforative appendicitis. 5. Gangrenous appendicitis. 6. Chronic appendicitis, relapsing, and recurrent. Appendicular colic, according to Wharton, Curtis, and Pick, has been demonstrated time and again without any subsequent inflammatory changes. Catarrhal appendicitis is practically the same as catarrhal enteritis on a small scale with hyperemia and inflammation of the appendicular mucosa which, according to McBurney, soon becomes "harmless and quiescent." All symptoms will abate in from one to three or four days, although a temperature of 103° F. has been attained. In suppurative appendicitis there is of course a solution of continuity allowing the entrance of bacilli, and the usual suppurative manifestations. In perforative appendicitis we have a rapid perforation of the appendix, with suppurative inflammation and peri-appendicular abscess. In gangrenous appendicitis there is a rapid necrosis of part of the appendix with more or less immediate infection of the general peritoneal cavity. In chronic appendicitis, relapsing and recurrent, we have a mild form of the disease with relapsing or recurrent attacks. In our experience fully 50 per cent of well marked cases of appendicitis recover wilhout operative interference. We have operated upon about 50 per cent of cases seen. About 25 per cent of cases operated upon have required drainage because they contained pus. In drainage cases 14 years to 7 days had elapsed between the onset of the disease and the time of operation. About 10 per cent of our cases were operated upon for recurrent appendicitis. In our opinion no case of appendicitis, if seen at the onset, would die if operated upon when necessary. In no case have we thought a case necessarily fatal if seen at the onset of the disease. We do not believe in operating upon all cases of appendicitis when first seen, as our experience and the best authorities we have prove that 50 per cent of all cases recover without any operative interference. When to operate in a case of appendicitis is a matter of individual experience. Some men operate when it is really not necessary, others defer the operation until the case has gone on to suppurative or perforative appendicitis with pus formation. These represent two extremes. The points that should guide us are the general condition of the patient, his temperature, sub-normal or above normal, the condition of his heart, the presence of albumen and urobilin in the urine, showing infection, nausea, vomiting, the condition of the alimentary canal, persistent pain, symptoms of peritonitis, the remains of an exudate after the first orisis. We do not believe in operating upon every case of appendicitis. We do not believe in the prophylactic operation, namely in the removal of appendices in children of three or four years of age so that they may not have appendicitis; for it is known that less than 1 per cent of any community ever has appendicitis, and under ordinary circumstances, less than 2 per cent of those who are afflicted with appendicitis prove fatal. A CASE OF NATURE'S SURGERY. By ERNEST S. PILLSBURY, M. D., Professor of Pathology and Bacteriology, College of Physicians and Surgeons of San Francisco. While surgeons nowadays perform nearly everything imaginable in the way of operations, it is the surgery of Dame Nature that is truly marvelous. Her operations are slow, but not sure, besides being extremely painful. The long continued pain has its severe enfeebling effect on the intellect, and the emaciation of the body may be extreme, but when the operation is completed to Nature's satisfaction, there may be complete and rapid recovery, with a surprisingly small scar remaining to give trace of the operation. As particularly creditable examples of Nature's surgery, Halstead mentions two which are similar in many respects to the two I wish to report. In the one I will recount the gall-passages were shortened to just the length of the two large stones which completely filled them. One occupied the gall-bladder, the other the pancreatic portion of the common duct. The duodenum was not only adherent to the gall-bladder, but served in place of its anterior wall, which had been destroyed; the stone in the gall-bladder, therefore, rested on the wall of the duodenum, which was pasted, so to speak, over the great hole in the front wall of the bladder. There was nothing that could be called cystic duct; the choleductus was almost completely covered by the duodenum, the hepatic duct was much distended, admitting easily one finger. All signs of inflammation, except its results, had disappeared. The simplest conditions had been produced, and those most favorable to the expulsion of the stones were in some subsequent attack; gall-bladder and common duct were reduced to a short, wide, nearly straight tube, which bore a striking resemblance to an atheromatous aorta. The stone in the common duct was behind the duodenum and buried in its wall. The first case I wish to report was in a man of about 48. There was no clinical history as is the case with so many of our patients at the City and County Hospital. The skin of the entire body was markedly yellowish as was also the sclera. On opening the abdominal cavity, the lower border of the liver was noted to extend from the tip of the ensiform cartilage along the lower border of the ribs on the right. The parietal peritoneum was smooth and dry, presenting no evidence of any adhesions, old or recent. At the location of the gall-bladder the liver was indented as by a contracted cicatrix, from the center of which there was a band about the size of a goose quill one centimeter in length attached to the ascending colon. This attachment was cut in removing the intestine, and was found to contain a sinus, open from the intestine to the remnant of the gall-bladder, in which was lodged a gall-stone one centimeter in diameter. The gall-bladder was contracted to the size of this gall-stone, and from it no opening could be detected leading to the liver or |