marked feature in his case, and is explained by the re- I found the appendix atrophied, and its canal comcognition of the fact that the psoas and iliacus muscles pletely occluded (appendicitis obliterans). Length of

are relaxed while the thigh is thus passively flexed upon the abdomen. Any disturbance of these muscles cause more or less movement of the inflamed appendix through its mesenteric attachments, thus giving rise to the increased pain. The genito-crural and anterior crural and ileo inguinal nerves being immediately (in part of their course) beneath the peritoneum, were more or less disturbed in this case as manifested by the referred pains in the course of their distribution: During the acute attacks he has been treated by as many as six physi cians, in three states. Some of the six are probably reporting this as a cured case of appendicitis without surgery. The attacks were so severe that he would barely throw off the effects of one until another exacerbation would intervene. The appendix could easily be rolled under the finger before operating. Operation July 3,

1895.

The appendix was found to be greatly thickened and indurated as a sequela of the repeated attacks of inflam mation. Its walls were one-fourth of an inch thick. The operation was performed in the interval of the at tacks. His recovery was perfect.

This is one of the most dangerous forms of the dis ease, as the repeated attacks bring about vascular and other structural changes that favor the death of the ap. pendix (gangrene) and that, too, with no walling in by the protective surrounding adhesions.

appendix about one and one-half inches. It rolled
under the finger like a tendon or a fibrous cord. An
inflammatory band the size of the finger was attached
to abdominal parieties near internal ring and crossed a
coil of bowel and attached itself to the mesentery, thus
making a partial intestinal obstruction.
This was
divided and the appendix removed! He left the hospi
tal in two weeks, and has been entirely relieved of all
his painful symptoms.

We have in this case one of the best appeals for an operation in all similar attacks in view of the prolonged suffering and dangers incident to these repeated attacks, and the damage wrought by the delays. Each attack that this man had endangered his life far more than an operation in skilled hands, having in view a permanent cure and relief for his sufferings.

CASE V.-Appendicitis. Gangrene of the appendix. Operation. Recovery. A. K., male, age 20.

Was taken on a Saturday night with pain and uneasi ness in right iliac region, the pain extending down the inner side of the thigh and in the course of the distribution of the external cutaneous and genito.crural nerves. Very little elevation of temperature (99.5). Pulse 84. Hypodermics of morphia were given by the attending physician. The pain and his general condi. tion remained about the same up to Monday afternoon, when I saw him for the first time. Pulse 92 full and "vicious." Temperature 100.5 F. Bright and cheerful except when pains would come on caused by any peristalsis of bowel or movement of thigh. Bowels acted during the night. Tenderness over area size of hand, and a false sense of induration over appendix due to rigidity of the abdominal muscles. This condition is often misleading, and added to the edema that frequently attains, may be easily mistaken for a walled off intraperitoneal mass or abscess. At the operation the appendix was found to be gangrenous and entirely free from surrounding protective barriers. His recovery was complete.

Without an operatión his blood vessels would have been filled with embalmer's fluid within thirty-six hours. An appendix with no walling off, when gangrenous or perforated, kills quickly unless the surgery is immediate.

CASE IV.-Appendicitis obliterans, followed by symp. toms of intestinal obstruction. H. G., male, age 28. Nine years ago he had an attack of what he called inflammation of the bowels, and his right side "caked" and was extremely tender. He had a high fever, and was very sick for a number of weeks. This soreness and pain continued with varying intensity up to the next attack, one year later. This is a diagnostic feature of this form of appendicitis; that is, the soreness and tenderness persist in the interval of the attacks. This second attack was very much the same as the first, last ing three weeks. After this relapse he had fairly good health for four years, with the exception that there was always uneasiness in the region of the appendix and many attacks of what he called "colic" and indigestion, often having to resort to cathartics to keep the bowels regular. At the end of this four years of freedom from severe attacks another "spell" was initiated by severe pain in the region of the appendix and "back ache." Had fever, increased pain and tenderness, lasting two weeks, leaving him seemingly in about the same condi Had had a number of attacks lasting from a few weeks tion as before. He was often troubled with gas pains to two months. After last attack, six months ago, he and distention, and had "colic spells." He had several had repeated colic spells, accompanied by obstinate con. mild attacks between the last severe attack and last stipation. The cecum would become enormously dis. June, or four years after last severe spell. In June he tended with gas, resembling, as he described it, a crocame down with a severe attack very much like previous quet ball in size. Operation revealed the appendix long paroxysms except that the tenderness was less; no tumor and hard to the touch. (Appendicitis obliterans in its was discoverable, and that he had much more gaseous early stage). The distal end was firmly attached to the distention and difficulty in getting his bowels to move. Soon after this sickness I saw him and advised an iliac vessels. It was ligated near the cecum and again operation. near its distal extremity and removed. The position of

CASE VI.-Appendicitis, recurring, with symptoms of bowel obstruction due to adherent appendix. Operation. Recovery. Mr. N., age 44.

the appendix was such that it was pulled upon when the cecum became distended and added to the cause of the symptom, producing attacks simulating bowel obstruc tion. His recovery was complete. He has no return of his old painful attacks.

To me it seems that there are no plausible grounds for a diversity of opinion as to the proper course to pursue in the management of those cases when once a diagnosis is made. Let us, as practitioners and surgeons, get together on this subject. It is not necessary

CASE VII.-Appendicular abscess. Operation. Re to provoke any ill feeling (which I have often seen covery. W. K., male, age 19.

Was taken down one week before I saw him with fever-102. Pulse 80 to 96. Pain and tenderness grad ually getting more severe; constipated bowel, tym panitic, well marked induration in region of appendix. Operation consisted in simply opening the abscess, packing with gauze and leaving wound open to granu late from bottom. Recovery in a few weeks.

This case was one in which nature had time to wall off the appendix before it hod perforated, but the barrier sooner or later would have been torn down and a death from peritonitis recorded.

CASE VIII.-Perforative appendicitis. operation. Recovery. Mr. Wilson, age 22.

Immediate

done) in discussing this topic. Let our deliberations be friendly and gentlemanly, and sooner or later the truth will prevail and our patients will reap the beneficent harvest, the fruits of our mutual deliberations.

A Case of Biliary Calculi From Birth, With
Leucocythemia as a Complication,
Which Resulted in Death.

BY T. W. BASINGER, M.D., PETERSBUrg, ind. That hepatic calculi are sometimes found in new-born children is an established fact. But this is the excep. This man, stout and healthy, was taken with the most tion, rather than the rule. It is a trouble, according to intense pain in iliac fossa, accompanied by a subnormal medical authority, which is rarely met with under the temperature (shock), but with a pulse of only 90. Abdo-age of twenty five years, In three hundred and ninetymen distended. A diagnosis of perforative appendici- five cases collected by Hein, he found fifteen in persons tis was made and operation performed within two hours of the development of the symptoms of perforation. He had been having an "uneasiness there for three days." A septic peritonitis was already inaugurated, but a thorogh irrigation with a normal saline solution and gauze and rubber drainage saved him.

CASE IX. Perforative appendicitis followed by a diffused septic peritonitis. Operation two days later. Death. Miss H., age 16.

under the age of twenty years. In two hundred and thirty cases collected by Durand-Fardel, there were only two cases in persons under twenty years of age. Statistics also show that a great many more females are affected with this trouble than males. Durand-Fardel shows that of the two hundred and thirty cases reported by him, one hundred and forty two were women, and eighty eight were men. So far as I have examined, the authorities all agree that females are more subject to the disease than males. Sixty-one per cent of Hein's cases were females. Osler says that three fourths of all cases of gall-stones are women. Strumpell thinks the proportion about three females to two males. Flint says: "Gall stones may form at any age, but they are most apt to form in middle or advanced life, and in females

A lovely young girl. Had been complaining for a week, with pain or uneasiness in the region of the ap pendix. Constipation. Little elevation of temperature. Two days before I saw her a most intense pain was felt about the cecum followed by a condition of shock from which soon rallied, but the pain spread rapidly over the abdomen. This subsided in eighteen hours. oftener than males." At the time I saw her she had a pulse of 90. Tempera- The history of gall-stones is a subject of much inture 100.5; free from pain except a sense of distention terest. Cholelithiasis constitutes by far the most im. in abdomen. (Tympanitis.) Was bright and cheerful. portant affection among diseases of the biliary passages, Insisted, in fact, upon getting out of bed and having her both to physician and patient, on account of the frephotograph taken standing not over half an hour before quency of its occurrence, the severity of its attacks and the operation. These septicemic patients often mani the manifold sequels and dangers to which it gives fest this cheerful disposition up to within a few moments rise. Gentilis von Foligno, in the fourteenth century, of death. Operation revealed a diffused septic peritoni- and Johann von Tornamira, at the end of the fourteenth tis with a perforated appendix. The intestines were as and the beginning of the fifteenth century, were said to lifeless as a rubber hose. The abdomen contained fully be the first to find gall stones in the human body. Since half a gallon of septic fluid. Irrigation and drainage their day the profession has taken a good deal of interfailed to save the case because he diaphragm, spleen est in the subject, and many investigations and dis and liver were bathed in pus, and she was thoroughly coveries have been made, but, notwithstanding the zeal saturated with the products of bacterial chemical with which the profession has pursued its investigations, changes. An early diagnosis and speedy surgery would there still remain many points to be cleared up. It was have saved this case also. With the laymen operations not until the eighteenth century, however, that the on dying patients bring reproach to surgery because pathology of gall stones was thoroughly worked up, but they fail to save the cases. This is true not only with almost every decade since then, there has been some. the laymen but with some members of the profession. thing added to the literature of the subject. Gall-stones

result from the precipitation of certain substances held velopment of gall-stones. Among the predisposing in solution in the bile, amorphous or crystalline precipi- causes are age and sex, which have already been referred tate uniting to form larger or smaller concretions. The to. Heredity, certain diatheses, faults of constitution, formations of these concretions takes place chiefly in faulty diet, fatty food, too long an interval between the gall-bladder. Here almost any number of these meals and corpulence have all been given as causes of stones may be found, usually from five or six to one or this disease, but it is now questionable whether any of more hundreds. Occasionally there is only one found, them play an important part in producing this trouble. which is usually large, bat thousands have been found It is claimed by good authority that gall-stones are more in one bladder. Otto found 7,802 in one bladder, that frequent among the favored classes than among working being the largest number that I can find on record. The people. Sedentary habits are certainly favorable to the dimensions of the stones is a matter of great importance, production of the disease. Any anatomical changes in as the severity of the symptoms will depend upon the the liver and gall ducts, which have a tendency to renrelation the size the stone bears to the width of the gall der the excretion of bile more difficult, favor the forpassages. These dimensions vary greatly in different mation of gall stones. Finally catarrh of the biliary cases, generally standing in an inverse ratio to the passages must be mentioned as a prominent cause of number of calculi present. The more stones the smaller cholelithiasis. they are likely to be; the fewer the number, the larger they are apt to be. Exceptions to this rule, however, occur. From a practical point of view, biliary calculi Mr. E. D.-Male, aged forty-eight, married; two may be divided into three sizes-small, medium and children living, a daughter ten years of age and a son large. Small stones embracing those from the size of a eight years of age; one child dead, who died in infancy. grain of sand to that of a small pea. Medium-sized I have obtained the following family history: The stones are those from the size of a pea to that of a huzel- father was subject to attacks of colic, had a jaundiced nut. Large stones include those the size of a walnut skin. He died at the age of seventy five years of burns and larger. Where large stones occur, there is usually received while in a house which was on fire. He lived but one, which moderately fills the gall bladder. Large only a few hours after receiving the injury. The stones are rarely met with. J. F. Meckel, in the mother died at the age of sixty seven years of pneu"Transactions of the Berlin Academy," describes pro- monia. There were eleven children born to these parbably the largest stone on record. This was fifteen ents, five of whom are still living, four sisters and one ctm. long and six ctm. in diameter (6 inches by 21). brother, the oldest of whom is fifty-eight years of age The shape of gall-stones is extremely varied. The round and the youngest is forty two years of age; one sister ones predominate, though many polyhedral stones are died at the age of twenty-two of a congestive chill and found. a brother died of dysentery at the age of seventeen years; three children died in infancy.

HISTORY OF A CASE.

The color of the stones may show every grade from black, brown, yellow to almost a clear white. Choles The subject of this article was, at the age of seventerine forms the chief constitutent of most gall stones, teen or eighteen years, apprenticed to D. W. Horton, some of them being formed entirely of this substance, Petersburg, Ind., to learn the trade of shoemaker. From and but few being formed entirely without it. Biliary coloring matters are found in varying quantities in nearly all stones. Biliary acids and their salts are found in small quantities in most calculi. Lime is said to be the only inorganic substance which forms an important ingredient in the formation of many gall stones. Fatty acids are sometimes found in biliary calculi in very small quantities.

that time until his death he attended strictly to business, adhering very closely to his trade. Mr. O. was, as I have been informed by Dr. Byers (who ascertained the fact from Mr. O.'s mother), born in a jaundiced condition, and so remained through life. I have been informed by his sisters, who are older than he was, that he had from infancy, or at least from early childhood, been subject to attacks of what the family called colic. His widow says of late years he has suffered frequently with severe pain in stomach. His icterus was always easily observed, but at times it was well marked. The yellowness of the conjunctiva was so great sometimes that it gave him a frightful appearance. The subject of this sketch was watched with interest all through life by the members of the medical profession with whom he came in contact. In the year 1864, at the age of

The mode of origin of gall-stones has always been a subject of much thought with physicians. But it is now understood that biliary calculi are formed by those components of the stones which exist in a soluble state in normal bile, separting themselves in solid form, being thrown down and uniting into a conglomerate mass. But these substances can not be separated as long as the bile remains in its normal state. The stones are principally formed in the gall bladder, but some have seventeen years, he offered to enlist in the United States been found in the hepatic duct and its branches. The immediate cause of the formation of gall-stones is, therefore, the chemical change in the bile, with retarda tion the flow of this fluid. Many conditions, both phy sical and social, are regarded as favorable to the de

army, but was rejected by the Board of Examining Surgeons at Evansville on account of his jaundice. The clinical history was as follows: On December 14, 1894, was first called to attend Mr. O.; found him suffering with symptoms of hepatic colic, viz., severe pain re

ferred to the epigastrium and right hypochondrium occurred in the afternoon of February 7th a discharge There was a great deal of vomiting, with very obstinate of blood from the bowels which continued at interuals constipation. He suffered more or less pain for five or through the night. On the 8th of February at A. MI six days. The jaundice became very marked, rather a found patient in a weak and debilitated condition, greenish yellow. He said that he had always been threatened with collapse. The temperature was 97° troubled with constipation, seldom an action without Fahr., pulse 90, and very weak. I observed at this time taking a purgative. some blood on gums and teeth. He remained in a state When I visited him on the 18th of December, I found of weakness and prostration, with temperature subnor. him apparently better; had but little pain, bowels had mal, all day, with but very little hemorrhage. As there acted well, patient had taken nourishment. The pain had been no urine voided for twenty-four hours a cathewas relieved by the administration of morphia and ter was introduced at 9 P. M. and about four ounces of atropia hypodermically. One quarter grain morphia black colored fluid was drawn off, which was probably and 1/150 grain of atropia were used at each administra. a mixture of blood, bile and urine. Three or four tion. All other indications for treatment were met as ounces of blood escaped from the bowels during the they were observed. As soon as the acute symptoms night. He rested fairly well and slept some at inter had passed, I began with drachm doses of phosphate of sodium three times a day. So, in the course of four or five days more patient was able to walk to his place of business, a distance of four squares. On the 26th of December he again had another attack of pain in the stomach with vomiting, but in a few days he was able to be out again. He still had some uneasiness in the region of the stomach. I found upon first examination that he had an enormously enlarged spleen, seemingly the largest I ever found in any patient. After the pain in the region of the stomach had become less severe the spleen was found to be very painful and tender to touch. The inner and lower edges of the spleen could be easily outlined, apparently nearly filling that part of the abdo minal cavity left of the median line,extending nearly as far down as the umbilicus.

All through the month of January, 1895, the patient was at his place of business almost every day, but was able to work only a part of the time. He continually complained of great weakness and seemed to gain very little strength. Had an impaired appetite, consequently he took but little nourishment. Again, on the first day of February, 1895, patient had another severe attack of pain in the region of liver and stomach, with vomiting and constipation as in the first attack. For four or five days morphia and atropia were required once or twice a day, hypodermically, to relieve the pain; from grain to nearly grain of morphia being required as a dose. On the sixth day of February and also the sixth day of the attack there was suppression of the urine, which had been scanty ever since the beginning of the last attack. Patient became, as before, very much jaundiced, taking but little nourishment and gradually becoming more anemic.

The last four days of illness he complained of no acute pain. Therefore, the narcotics were discontinued, There seemed to be in this case somewhat of a hemorrhagic tendency. Patient stated that he had frequently observed some hemorrhage from the bowels after taking a cathartic. When he becaine convalescent after the first attack in December there was quite a good deal of hemorrhage of the bowels. After the pain had ceased, or at least became more endurable and patient seemed to be better, with the exception of great weakness, there

vals. By 5 A. M. the next morning, which was February the 9th, I found that a reaction had taken place. Temperature was again normal, with pulse 100, and stronger than it was the day before and the patient feeling better. But our hopes were of short duration because of hemorrhage of the lungs, which occurred at 7 or 8 A. M. and continued gradually producing prostration and death at 5 P. M.

As it is not my purpose to discu-s treatment in this paper, will suffice it to say that the treatment ordinarily used in such cases was resorted to, viz., heart tonics and supportive treatment.

THE POST MORTEM.

On February the 10th, at 1 P. M., assisted by Dr. J. T. Kime, in the presence of Drs. Adams, Byers, Link, Hunter and Byers, junior, an autopsy was made. The spleen was found to be enormously enlarged. It was not weighed, but its measurements were about as follows: Thirteen and one-half inches long, about six and onehalf inches in width at the broadest part, and three and one-half inches in diameter at the lower end. The liver was considerably enlarged, but no dimensions were taken. There was an impaction of a gall stone in the cystic duct near the neck of the gall bladder. The stone was not large-about the size of a hazelnut. There was also a catarrhal condition of the common duct. There were no abscesses nor adhesions. The gall-bladder was distended to the capacity of about six or seven ounces, which was so filled with stones and a dark, thin fluid that it gave the appearance, to the touch, of a sack of pebbles. They were from the size of a pin's head to that of a large hazelnut; a few were probably some larger. They were of various forms and shapes. On the surface they are black, but on the inside they are yellow or copper colored, as you can see. As soon as dry they began to crumble, the outside coming off in layers. There were two hundred and seventeen of these stones before they began to crumble. These are the larger ones, being the more readily separated from the fluid. There were no means of conveniently ascertaining the exact number of these small stones, owing to their color and size; they resembled ground coffee. The tissues of the body were all very yellow, almost as much as the skin. The lungs, heart and kidneys were not ex

amined, as there were no symptoms of disease of these organs.

MEDICAL REVIEW.

EDITORIALS

L. T. RIESMEYER, M.D., EDITOR.

DEPARTMENT EDITORS:

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I will now proceed to close the article by giving con clusions drawn from the case under consideration. Be cause of its phenomena it has been, to me, a very inter esting case, and more especially on account of its long standing or chronic character. That the cholelithiasis existed at birth can hardly be questioned. But the ques tion which concerns us most is-what were the causes that led to the man's death? Was it due to the obstruction produced by the stone in the duct? As was stated above, there were no abscesses, ulcerations nor adhes ions. Was the re absorption of bile the cause of death? Was it due to the catarrhal condition of the ducts? Was the chronic enlargement of the liver and spleen in some way responsible for the result? Were the hemorrhages the primary cause of death, or were they the re sult of the general condition? Are you aware, it is very YEARLY SUBSCRIPTION, $3.50. SINGLE COPIES, 10 Cents. seldom that the severe paroxysms, produced by gall. stones, terminate fatally. But a fatal result may be brought about by perforation of the gall-bladder or the ducts, by peritonitis, by cholecystitis and pyemic fever. But none of these complications seemed to exist in this case. My opinion was, at the time of patient's death, and has been ever since, that the cholelithiasis, the chronic enlargement of the liver and spleen, with the re absoption of bile, were the primary and principal causes of death. These factors brought on, as I believe, a condition known as leucocythemia, which literally means white cell blood.

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But Strumpell and Osler prefer the term leukemia, a disease accompanied by enlargement of the liver and spleen, and sometimes marked changes are found in the bone marrow and lymphatic glands. Strumpell says: "In the temporary cases, where the increase of white blood corpuscles is usually not very great, we find one Entered at the St. Louis Postoffice as Second-Class Matter. white corpuscle to one hundred red, or even to fifty, the normal ratio being one to three hundred." But in some cases of this disease there may be one white to only two of the red. Genuine leukemia is said to be a rare disease. As the patient's blood was not examined with the microscope to ascertain the increase of the white blood corpuscles, we are therefore deprived of a positive diagnosis. But I hold that the symptoms in the case warrant us in making probable diagnosis. My partner, Dr. J. R. Adams, who has had an extensive practice for over forty years, assisted me in treating the case, and was also of the opinion that we had leucocythemia as a complication. The post-mortem showed all the anatom ical changes necessary to establish our diagnosis. The age and sex of the patient, the chronic character of the disease, his weak and anemic condition, the pallor and wattery character of the blood, which was observed be fore death, and also the hemorrhages, were characteris. tic of this disease. We considered the propriety of performing cholecystotomy, but it was thought not to be advisable nor justifiable because of the anemic condition of the patient, disease of some of the viscera and exhaustion of the vital powers.

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