Ladies and Gentlemen:-The case I have to present to you this morning is one of no little mystery so far as the diagnosis is concerned. The patient has been in my household for a number of years as a domestic. She is of Swedish extraction and is 38 years of age. So far as the family history is concerned, there is nothing bearing upon the case, except that one brother died of appendicitis. Her father is living and is of old age and her mother died of an intercurrent disease when she was also old. She has a number of sisters who are healthy and strong. Up to three years ago she enjoyed good health and has always worked hard, having been raised on a small farm in Sweden where it is customary for women to do much of the outdoor work. Three years ago, during my absence on a vacation, she had a severe attack of indigestion with tenderness over the appendix, which was diagnosed by my then assistant, Dr. Earle V. Gray, as appendicitis. She ran some temperature, there was marked obstipation and she was ill for two weeks. Her acute symptoms, however, subsided, leaving her the victim of indigestion and hyperchlorhydria. As a result of her indigestion she became anaemic, her skin being almost waxy in appearance. So marked was the latter symptom that I had the urine examined several times, always to find it practically normal. Her symptoms became more severe as time went on, the indigestion being of a character which was relieved by taking food, especially milk, and was always worse after the stomach emptied itself, suggesting gastric or duodenal ulcer. She lost in flesh, she felt tired the greater part of the time, she had backache, mucous stools, gaseous distension, cold clammy hands and cold feet.

The latter part of November, 1911, her suffering became so marked that I placed her in the hospital, and under strict dietetic and medicinal treatment she improved. She returned to her work but was unable to endure anything. She finally became so bad, the gastralgia suggesting perforation of the stomach, that I again removed

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her to the hospital in an ambulance on the evening of Jan. 22d. After getting her to the hospital she was so much relieved by dioscorea 2x that I did not deem it necessary to operate immediately. The hymen is intact and therefore it has been impossible for me to make a vaginal examination. Latterly the menses have been scant, but not particularly painful.

The symptoms certainly point very strongly to gastric or duodenal ulceration, rather to the latter condition than to the former. However, I have so many times seen symptoms of these lesions duplicated by a chronically inflamed appendix that I make it an invariable rule before operating upon the stomach to explore the appendix. This is especially so if such a history as this case affords presents itself. Indigestion with gaseous distention, with obstipation, or alternate obstipation and diarrhea, and with mucous stools, present a symptom complex which is so typical of chronic appendicitis as to be almost pathognomonic of that condition. There is in most of these cases more or less gastrointestinal autointoxication complicating the condition. As a result of the autointoxication the patient suffers from neuralgias of various kinds and from malnutrition, which manifests itself in the form of emaciation and vasomotor disturbances, 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 cannot determine in this case what the condition of the generative organs is until after the abdomen is opened, for reasons which I have already given. I shall therefore begin my operation as an exploratory one, making a somewhat long incision in the median line of the lower abdomen. I find upon exploring the appendix that it is long and of at least twice its normal thickness and filled full of fecal matter and fecaliths. I find that the uterus is retroflexed, the ovaries down under the fundus and that the right ovary is adherent. I shall not, however, disturb these organs until I make an exploration of the upper abdomen, for which purpose the long incision was made. By carrying my hand over the omentum and over the colon I am able to grasp the stomach between my thumb and fingers and to thoroughly explore the stomach and duodenum, as well as the gall bladder area and the kidney. I do not find any gross lesions in this locality, although it is entirely possible to overlook an ulcer of either the stomach or the duodenum in making an exploration of this kind. But I am so firmly impressed with the idea that the lesion of the appendix and the displacement of the uterus and ovaries are the cause of the indigestion and the gastrointestinal autointoxication that I am going to remove the appendix, break up the adhesions of

the ovaries and do an 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 have also thoroughly dilated the rectum in this case because I believe that when there is constipation with cold hands and cold feet. much benefit is derived from this procedure. I shall also overcome the obstruction of the hymen as it can only give her trouble should she ever marry. There are adhesions, too, of the clitoris which I shall overcome for the purpose of relieving all terminal nerve impingement.

These operations are simple, are comparatively free from danger, can be done in a comparatively short space of time, and as you see the patient is removed from the table in most excellent shape.

The whole question of gastrointestinal autointoxication and mucous enterocolitis has been brought up to date by me in a recent article published in Surgery, Gynecology and Obstetrics. * 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 hemorrhages in these cases is due to the irritation resulting from the hyperacid gastric juice. In a large majority of the patients the pain followed the ingestion of food, although the intervals between the taking of a meal and the onset of the pain were variable. In most cases the pain is referred to the epigastrium, usually to the right of the middle line. In 24 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