perpetuate a mucous enteritis, and the other symptoms to which I have called attention. For an extended discussion of the subject I direct the reader to the paper referred to and which is published in the Surgical and Gynecological Association Transactions for 1900. Rarely does the surgeon find that the appendicitis alone is responsible for the invalidism. In women not infrequently there are cervical and perineal lacerations, catarrhal conditions of the uterus and vagina, rectal lesions, uterine displacements, and various pathologic conditions of the ovaries and tubes. In men it may be necessary to dilate the rectum and, if there is irritation about the glans penis, do a circumcision. I cannot better illustrate the benefit to be derived from work of this kind than by introducing a few typical cases.

Case I.-J. S. Male, aged 24. When a child eight years old had an attack of "inflammation of the bowels. Since that time has had indigestion with gastralgia so that he has never been able to eat without distress, or anything but the most carefully prepared and easily digested articles of food. For 16 years he has had recurring attacks of appendicitis at intervals varying from two months to one year. His tongue was coated, his breath was bad, there was constipation, the stools being covered with mucus. He was emaciated, so that he weighed but 108 pounds. The appendix could be easily palpated and was felt as a hard, cord-like mass, lying almost at right angles with the iliac vessels. He had a long fore-skin with preputal irritation. The hands and feet were cold, and he was exceedingly nervous. On Nov. 7, 1903, I divulsed the rectum, did a circumcision, opened the abdomen in the median line, removed the appendix, inverted the stump, closed the abdominal wound and placed the patient in bed. On the fifth day he sat up, and on the tenth returned to his home. He began to improve at once and within two months from the operation was eating freely and almost indiscriminately. The bowels became regular, he gained in flesh, and now weighs 150 pounds. I attribute not a little of the improvement to the orificial work which was done. Nevertheless the orifiicial lesions did not give rise to the attacks of appendicitis.

Case II.-This patient, also a male. is aged 18. He has had four attacks of appendicitis, and during the interval between the attacks had the well marked dyspepsia symptoms which I have emphasized. He was, however, well nourished and there was no circulatory disturbance as in Case I. I therefore did nothing but the appendicectomy. He was operated upon March 4th, 1903, through a short gridiron incision over McBurney's point. He sat up on the fourth. day and returned to his home on the sixth. Two weeks from the date

of operation he was back in school. The appendix here was but slightly thickened, although there was an inflamed area of the cæcum about it. The gastro-intestinal trouble has entirely disappeared.

Not all cases of appendicectomy get on as well as did these two, but they are nevertheless typical of a class in which an irritable appendix is responsible for indigestion and malnutrition. Then, too, no one can tell at what moment an appendix infiltrated and thickened will become acutely inflamed and end in fatal perforation. I have introduced these cases because both are men and, therefore, gave rise to the peculiar symptoms which it is chiefly the purpose of this paper to describe, independently of ovarian implication.

Intestinal Strictures and Adhesions.-It is not my purpose to discuss acute intestinal obstruction. I desire simply to call attention to the fact that strictures of an inflammatory character frequently occur as a result of appendicitis long continued, or because of pressure within the pelvis from inflammatory exudates. Upon four different occasions have I found it necessary to resect from 6 to 18 inches of the bowel in the ileo-cæcal region, and twice have I found it necessary to resect a portion of the sigmoid and rectum, because of inflammatory thickening with consequent narrowing of the calibre of the gut.

Disease of the Uterus and its Adnexa.-This is such a wellworked field that it is almost presumption on my part again to call attention to the various lesions of these organs which give rise in a reflex way to indigestion and gastralgia. Since time immemorial an ovarian pain caused by pressure has been described in the text-books as a "sickening pain." This means simply that an ovarian pain is oftener reflected to the stomach and the solar plexus than to any other region. We have then, when the ovary is implicated, an indigestion of purely reflex origin. With the indigestion there is usually malassimilation and emaciation.

It is, therefore, all important that the condition thus induced should be carefully distinguished from organic disease of the stomach and bowels. A gastric neurosis can usually be differentiated from organic disease by observing the following points:

1.-The symptoms subside upon curing the local lesion.

2.- Articles of diet which would aggravate organic lesions are frequently the only ones retained in a neurosis.

3.- Exacerbation of the gastric symptoms occurs simultaneously with an exacerbation of the pelvic symptoms.

4.

Entire absence of evidences of organic disease.

If now there be found upon local examination of the pelvic or

gans, disease on prolapse of the ovary; or if the uterus is displaced, lacerated, or subinvoluted, it is more than probable that the physician has to do with a neurosis, rather than an actual disease of the stomach.

The elder Byford called attention to mucous entero-colitis as a symptom of utero-ovarian disease. For years I tried to cure this condition by directing attention to the pelvic organs alone. After making it a practice always to examine the appendix when the abdomen is opened for other purposes, I become convinced that it is the appendicular rather than the ovarian lesion which excites the entero-colitis. The frequent association of disease of the pelvic organs and the appendix in women is now well known. The surgeon should therefore, at all times, remove all possible disturbing lesions, unless counterindications prevail. Permit me again to introduce a few typically illustrative cases.

Case I.-Patient, aged 43. Has been under my care for the past three years, and I repeatedly urged her to submit to operation. Indigestion most distressing. The left tube had become distended with pus and discharged through the uterus. Four weeks preceding her last illness she was taken seriously ill with a severe attack of pelvic inflammation, the temperature reaching 104 F. She came very near dying, and had many symptoms of appendicitis, with a great deal of pain and distress. She, however, got up from this attack and came into my office on October 28, 1901, pale, anæmic, and suffering from a severe bearing-down sensation in the pelvis. I found, upon examination, that there was a mass projecting into the vagina through the cul-de-sac of Douglas as large as a fetal head. I urged her to go into the hospital at once, which she did. On the following morning I placed her in the lithotomy posture and punctured the mass with a pair of sharp-pointed scissors, letting out at least a quart of fluid. It was purely a peritoneal exudate. Both tubes were greatly distended and adherent, so that I found it necessary to open the abdomen. With great difficulty I removed the left tube, which was distended with pus, tying off the pedicle with catgut. The intestine and omentum were adherent to the uterine fundus, and in stripping off the intestine I found it necessary to close a peritoneal rent with a Lembert suture. The appendix vermiformis was diseased and thickened, and was, therefore, tied off with silk-the only silk used in the operation. All stumps were cauterized with carbolic acid. I then carried a double drainage tube through the opening into the vagina. I closed the abdominal wound with interrupted silkworm gut sutures, two of the sutures penetrating the uterine fundus, thus fixing the uterus firmly to the anterior abdominal wall. Previously to closing

the abdomen the denuded areas were wiped with a 1 to 1000 bichlorid solution. Patient removed from table in fairly good shape, though considerably shocked. Convalescence was ideal, and she is now perfectly well.

Case II.-Patient aged 48. Has had from 3 to 10 attacks of appendicitis a year, for the past five years. Has been in much distress throughout this time. She runs a boarding-house, and therefore has to be on her feet a great deal. Characteristic gastro-intestinal symptoms. Operated on October 20th, 1902. Abdomen opened in median line in "T" posture. The appendix was a little short, thickened affair, more or less adherent to cæcum, and was distended with fecaliths. Appendix tied off and the stump inverted in the usual way. Both ovaries were cirrhotic and atrophied. They were, therefore, tied off with catgut, and the uterus, which was sharply retroflexed, stitched in front with catgut. The short abdominal incision was then closed with two layers of catgut, silkworm gut tension sutures and a subcuticular silkworm suture. Patient removed from table in excellent shape. Convalescence ideal and she is now in perfect health.

Case III.-Patient aged 32. Five years ago a Toronto surgeon made a trachælorrhaphy, removed the left ovary, but left a piece of the right ovary behind. She has not been well since and has had frequent attacks of what her attending physician called "appendicitis." Since the first attack, four years ago, she has had indigestion with flatulence and constipation. On July 14th, 1903, I did a divulsion, a curetting, re-opened the cervix and cut away a large amount of cicatricial tissue, built up the pelvic floor, removed several papillæ from the rectum, freed the clitoris, opened the abdomen, removed the left broad ligament, which contained a cyst as large as an orange and which ruptured during removal, removed a fibroid as large as a hen's egg from the posterior uterine wall and closed the same with interrupted buried catgut sutures, stitched the uterus in front, removed the appendix, which was thickened, and closed the abdomen with two layers of catgut, silkworm gut tension sutures, and a subcuticular silkworm gut suture. Menorrhagia was a prominent symptom. On Jan. 15th, 1904, this patient reported to me. While she is not yet entirely well, she is gaining rapidly. The gastro-intestinal symptoms are gone, she is rapidly gaining in flesh and all distress in the pelvic region has disappeared.

Case IV. Patient aged 42. Has had repeated attacks of appendicitis. Abdomen opened in median line. Cystic ovarian tumor the size of fetal head removed from right side. Appendix was completely

S

circumscribed by an inflammatory mass and it required extensive dissection to free it, although the thickening was confined largely to the ileo-cæcal region. The appendix was torn off from the bowel in dissecting it loose. The bowel was closed with eight or ten Lembert sutures, after which, the mesentery was utilized to protect the wound. The cæcum for three inches was greatly thickened. The abdominal wound was closed with two layers of catgut and a subcuticular silkworm gut suture. Patient was much emaciated.

Pathologist's report: "Slides from the appendix show a profuse infiltration of the mucosa and submucosa with small round cells and many polynuclear leucocytes. There is also a considerable increase in the connective tissue with the formation of many new capillaries. The blood vessels show greatly thickened walls. No tubercle bacilli. Diagnosis-chronic intestinal appendicitis." Results of operation equally as good as in Cases I and II.

Case V.-Patient aged 33. Two children, aged respectively 12 and 14 years. Married before she was 18. At the birth of her last child she had septic involvement of some kind and has not been well since. Has had attacks every two or three months of "pelvic inflammation" with marked symptoms of appendicitis. Had one attack some twelve months ago, after which a large quantity of pus escaped through the rectum. Examination on Feb. 5th, 1902. A large mass was felt on either side of the uterus and the uterus was fixed. The appendix could be felt extending into right pelvis. She had a great deal of gaseous distension; had indigestion at all times; bowels were obstinately constipated and the stools covered with mucus. Mouth tasted bad in the morning and breath was foul. Operation on Feb. 6th. Abdomen opened in Trendelenberg posture. Large double pyosalpinx, the cyst on the left side being much larger than that on the right. The appendix was attached to the tube of the right side. A loop of small intestine was attached to the fundus of uterus. High attachment of the bladder on the abdominal wall, so that an incision one inch long was made into the bladder in making the usual abdominal incision. This was immediately closed with catgut. The tubes and ovaries of both sides were removed, the appendix amputated and inverted, and all adhesions overcome. The uterus was then fastened in front with two catgut sutures, and the bladder wound attached to the abdominal wound in front with catgut sutures passed through the muscles, fascia and peritoneum.

The abdomen was closed with two layers of catgut, silkworm gut tension sutures and a subcuticular silkworm gut suture. Patient re