AFTER TREATMENT. were Fowler position, Murphy irrigation. Bowels moved on second day after operation with compound licorice powder. On third day patient was eating regular meals. He was discharged-cured in two weeks. In British Medical Journal of October 9th, 1909, Dr. Radcliffie reports a case of traumatic rupture of small intestines, due to blow in epigastum by sharp end of plank. He was operated upon ten hours after injury. A longitudinal rupture three-fourth inch in length was found in jejunum about two feet from commencement. Rupture was closed with continuous Lembert sutures. A second suprapubic incision was made and drainage inserted in pelvis. Another incision was made through parietes over appendix for performance of appendicostomy. A continuous saline irrigation of normal salt was carried on through appendix stump for forty-eight hours. Patient recovered with faecal fistula which lasted for a week. I mention this case in order to obtain a discussion as to the value of appendicostomy in such cases, since having gotten such a splendid result without its perform ance. A CASUAL REVIEW OF THE WORK ON THE APPENDIX. Willis Jones, M.D., Atlanta, Ga. We find records of incisions for the purpose of draining abscesses in the right iliac fossa dating back as far as beginning of the Christian era, being about the year 50 B. C. The first recorded case of diseases of the appendix was reported by Mestivier in the year 1759, who incised and drained an abscess in the right iliac fossa in a man of 45 years of age. The patient died a few days later and an autopsy revealed a badly diseased appendix, and when opened it was found to contain a rusty pin. From the time Mestivier reported his case up to the year 1824, six other cases of abscess in the right ilia fossa were reported, where autopsy revealed advanced disease, and the presence of foreign bodies in the appendix. All of the reports, covering a period of 65 years, up to 1824 referred to the diseased condition found in the appendix, but considered it secondary to some lesion originating in the colon. In 1824 Louyer Villermay published an article in which he described the inflammations of the appendix as definite disease. In 1827 Melier, another Frenchman, published a paper on the subject even more striking in detail than his colleague, Louyer Villermay, calling particular attention to the fact, that at autopsies, the pathology of the appendix had been much overlooked, and predicted the possibilities of surgery for its relief. The accurate descriptions of Louyer Villermay and the well founded theories of Melier were not used by their contemporaries in the profession, because Dupuytren, the leading surgeon of his day, was too narrow to realize the importance of this great opportunity, and remained an exponent of the thought of his time, which referred to the colon, the origin of all right iliac inflammatory processes. The German surgeons in applying the name Perityphlitis to inflammations of the right iliac fossa, both encouraged and confirmed the erroneous opinion which has in some quarters hardly been obliterated in our own day. The interpretation of the symptoms and pathological findings of inflamations in the right iliac fossa had kept pace with the rapid evolution of surgery, and were now recognized and known to be characteristic of disease of the vermiform appendix. In 1884 Kronlein, of Germany, made a diagnosis of perforation of the appendix, and did the first operation for its removal. The wound was closed up without drainage and the patient died three days later. Two years afterwards, in 1886, Hall, of New York, did the first successful operation for the removal of the appendix with the recovery of his patient. Until this time dispute and contention was still rife as to the origin of abscesses in the right iliac fossa, and not until Reginal Fitz, of Boston, in the same year gave to the surgical world his epoch making paper, clearly defining relationship between disease of the colon and appendix, did the subject which had been buried under a mass of incoordinate facts and unstable theories, became cleared of all obscurity, and established upon a scientific basis. In this notable paper of his, we note the following dictum. It is the duty of every physician to be mindful that for all practical purposes, Perityphlitis, Perityphlitic Tumors, Perityphlitic Abscesses, mean inflammation of the vermiform appendix. And it is to Fitz we give the distinction of having named the condition appendicitis, he preferring the term rather than having it known as Fitz' disease. After the atmosphere had been cleared by Fitz' paper, it was not long before our aggressive surgeons realized the misdirection of their former efforts, and were hasty in their attempts to handle this important condition, along the lines suggested by modern surgical pathology. In 1889 McBurney gave a powerful stimulus to the surgical treatment of appendicitis by demonstrating the feasibility of doing the operation without destroying the continuity of the abdominal wall. Since that time the McBurney inter-muscular operation has been the standard-others simulate, but none excel. From this casual review of the literature on the subject of appendicitis, we readily see that the aggressive surgery of the appendix as it is practiced today, is only twenty-six years old, and though first suggested by a Frenchman, first executed by a German, all praise be to our American surgeons, who have brought the work up to its present high standard of perfection. The anatomy of the appendix is very interesting, and at times most perplexing, for its anatomical position is not fixed; in fact there is no portion of the abdominal cavity where the appendix may not be found. These anomalies of position are due first, to an abnormally long Meso-appendix; second, to an arrest of foetal development. A long appendix with a long Meso-appendix may extend across the media line of the body into the left iliac fossa, or extend upwards or inwards among the coils of the intestine, and it has been found firmly attached to the interior abdominal wall. When the caecum and appendix are found out by the right lower quadrant, this condition is due to an incomplete rotation of the gut during the process of foetal development, likewise, the cases of retrocaecal and retroperitoneal appendicitis, are due to faulty rotation. The average length of the appendix is 31⁄2 inches, but it has been found as long as nine inches and as short as three-fourths of an inch. Its lumen or cavity is as variable as its length. It is found to be partially or totally occluded in at least one-fourth of all specimens examined. This variability of the organ as to position, size, and structure, are considered by the evolutionist as a sign of degeneracy in the process, which is undergoing a gradual obliteration in the higher animals. Alimentation has an important bearing on the development of the cecum in many of the higher animals. Herbivorous animals have an enormously developed cecum, whereas, in carnivorous animals it is found small, and sometimes wanting. In man, apes, and many of the rodents where the food is midway between that of the Herbivorous and Carnivorous types, a retrograde deveiopment of the cecum is found, giving rise to a long wormlike projection from the base of the cecum which is known as the vermiform appendix. This retrogressio is probably due to changes in the character of food which has taken place during the history of the species. Our foremost students in comparative anatomy believe that the appendix is destined for further reduction in size and ultimate elimination. What is the etiology of inflammation of this little troublesome worm-like organ? Naturally, we look to the various mico-organisms as being the exciting factors. chief among which is the colon baccillus. In connection. with the exciting causes the predisposing must not be lost sight of. It must be borne in mind that the appendix is a vestigial organ undergoing an evolutionary and retrograde metamorphosis, and it is recognized that or gans of this structure are especially liable and susceptible to inflammation. The scarcity of its blood supply renders it a poor combatter of infection. The appendi cular artery, a branch of the ilio-colic, lying between the folds of the meso-appendix is very prone to circulatory disturbances from many conditions either physiologica! or pathological that increase intro-abdominal pressure. Acquired or congenital narrowing of its lumen precludes complete emptying of the organ, and fecal stagnation easily results. It is surrounded by a firm unyielding peritoneal coat, embracing structures composed of soft embryonal elements, so that in an infection we have added compression and tension, which explain the rapid |