ing liquid escaped. This fluid was carefully removed by means of gauze wipes and a very careful search for the appendix made. A piece of necrotic and gangrenous tissue was removed which was evidently a portion of the appendix which had sloughed away. A loop of intestine which was thought to be the caput was brought into the wound, but on account of the adhesions it could not be positively identified. A portion of this bowel was found to be necrotic and in this necrotic area was a small opening into the lumen. The necrotic area was invaginated as well as possible, after which a piece of omentum was sutured over the area. While manipulating the bowel to effect its closure a brisk hemorrhage occurred from an artery which was thought to be one of the larger mesenteric. The bleeding point was found with considerable difficulty after a rather alarming hemorrhage, and was tied, after which no more hemorrhage occurred. The wound was closed by interrupted through-and-through silkwormgut sutures. The peritoneum and fascia were brought together with catgut, and the superficial layers closed with silkwormgut. A strip of gauze and a rubber tube were left in the wound for drainage.

The patient stood the operation well, pulse being 124 and of good quality when the operation was completed. The patient was well recovered from the anesthetic by 10 o'clock that evening when his pulse was 98 and was full and strong, temperature normal. On the following day the patient was placed in the Fowler position and slow saline started. He was fairly comfortable, had two movements of the bowels during the day, which the orderly described as large, liquid-brown stools. His highest temperature during the day was at 2 P. M. when it was 102.2°, pulse 130, respiration 36. The dressings were very foul and contained a large amount of pus but no feces. On the second day the patient's condition was somewhat improved. The temperature did not go so high, the pulse was slower and of much better quality. The gauze drain was removed; no fecal discharge. On the third day the patient continued to improve. Highest temperature 101.4°, highest pulse 118. The dressings, however, showed considerable fecal matter. Patient was now taking liquid nourishment with relish. From the third to the ninth day there was nothing of note except that the fecal discharge increased in amount. In fact, prac

tically all the discharge from the bowel came through the wound, the bowels moving but once in the normal way. The patient felt fairly well; his pulse and temperature slowly approached normal and his general condition seemed quite favorable. The stitches were removed on the eighth day. The wound gaped considerably, only the upper portion having healed.

In the forenoon of the ninth day patient had a formed stool. In the afternoon of that day he complained of a desire to cough but refrained from doing so as he said the effort caused severe pain in the wound. At i P. M. the patient told the nurse he felt warm fluid running down his side. An examination disclosed the fact that the dressings were blood-soaked and that blood was running down the patient's side. The intern, upon being called, immediately removed the dressings, packed the wound, and put on a firm compress. The patient's pulse was but little affected by the hemorrhage. That evening the pads were well soaked but there

was no fresh hemorrhage. The patient continued to cough considerably, however, for which turpine hydrate and codeine were prescribed. On the tenth day patient was feeling fairly well until about noon when another very brisk hemorrhage occurred which was very much more profuse than on the preceding day. This was stopped by very firm compresses over the packing already in the wound. Following this hemorrhage the patient's pulse shot up to 142, and became very weak, and his temperature, which had previously been above 100° during the afternoon was this afternoon subnormal. The patient was pale and very weak. He was kept warm by means of hot water bottles and hot saline was given per rectum.

On the eleventh day the patient's condition was somewhat improved. Highest temperature 101.2°, pulse 132, respiration 26. Up to this time the rubber drainage tube had been left in place. It was now removed and the wound thoroughly packed with gauze. The patient coughed considerably in spite of the turpine hydrate and codein. He took nourishment well. On the twelfth day the patient's condition was unsatisfactory. His pulse did not go below 120 and was 140 much of the time; its quality was poor. He coughed considerably, was drowsy much of the time and his extremities were cold. He continued to take nourishment fairly well, however. On the thirteenth day the patient continued in bad condition and did not take nourishment. The temperature arose to 103.2° in the afternoon, pulse 144, respiration 30. Fecal matter now came out around the gauze packing. From the fourteenth to the nineteenth day the patient's condition improved slightly, but he remained very weak and his pulse was high and of very poor quality. During this time the bowels were flushed daily, but practically all of the water came through the wound. . On the nineteenth day occurred another very severe hemorrhage, the most severe of them all, which was controlled after considerable difficulty by packing and pressure. Although this hemorrhage was very severe and the movement on the following day showed that considerable amount of blood had escaped into the bowel, the patient's general condition did not become markedly worse. The pulse on the following day did not go above 104, was of fair quality and the temperature did not become subnormal as on one previous occasion. The patient, however, was quite weak and complained of mucus collecting in his throat, which he raised. with great difficulty.

From this time on the patient's improvement was steady and uninterrupted. The hemorrhages ceased, the pulse and temperature gradually approached normal and the patient gained rapidly in strength. However, practically all of the fecal stream came by way of the wound. It was our hope at that time to improve the patient's condition sufficiently to an operation for closure of the fistula. The patient was given a very liberal diet, the bowels were flushed daily, most of the enema coming out of the wound. About the thirty-fifth day it was noticed that less discharge came through the wound and that, following the flushing, more fecal matter came the normal way. On the thirty-ninth day the patient was removed to the ward. At this time about one-half of the fecal discharges came through the normal passage. The fecal discharges from the wound

became less each day and the wound healed in very rapidly. On the fifty-seventh day the patient sat up. At this time very little fecal matter came from the wound. Patient was discharged on the eighty-first day with wound completely healed.

DISCUSSION..

DOCTOR FREDERICK R. WALDRON: How do you explain the hemorrhage?

DOCTOR PETTIS: We thought the hemorrhage came from the same vessel that had caused the bleeding during the operation and had been ligated. It is quite likely that the thrombus, formed in the vessel as a result of ligation, became infected and the breaking down of this led to the first hemorrhages.

DOCTOR JOHN A. WESSINGER: I am glad to have the opportunity of listening to Doctor Pettis' report of this rather unusual case, and would like to speak of another which I regard as very unusual. The patient, a girl, two years ago last July was suddenly taken with appendicitis. Symptoms. developed Monday morning and on Tuesday noon I referred her to Doctor Peterson for operation. This was done in the usual way without any difficulty. The appendix was necrotic and about to rupture. Everything went very well until about four or five days when there was much pain in the left leg and thigh, with increased temperature and pulse rate. The unusual thing about the case is that while the girl left the hospital in good condition at the end of the third week, and the leg lost its tenderness, it remained large, and is still so today. It measures an inch more than the other leg. What is the cause of the permanent enlargement of this leg? Has it anything to do with the appendix condition, or is it coincident? Even now, the girl has pains in that leg. The unusual thing, too, is the development of this condition in the left leg, when the operative procedure was on the right side.

DOCTOR REUBEN PETERSON: Fecal fistulæ after appendicitis operations are not uncommon. Usually they heal spontaneously unless the bowel mucosa becomes attached to the muscles of the abdominal wall. Then the fistula is liable to be permanent, like similar gall-bladder fistulæ.

I have never seen a postoperative hemorrhage like the one just described. Its origin can be explained, probably, in the necrotic changes in some large artery induced by the sepsis.

Thrombophlebitis, right or left, is not uncommon after suppurative appendicitis. The infected vein on the left side can be explained by the free anastomosis of the pelvic veins. In my experience, thrombophlebitis is not met with so frequently after appendicitis as after pelvic operations, such as hysterectomy for uterine fibroids. The affection is quite similar to puerperal thrombophlebitis although not so virulent in type. However, in both varieties the swelling and disability of the affected limb may last. a long time. Recently I saw a patient who had had a milk leg over twenty years before. The leg was over one inch larger than the opposite one and caused her considerable inconvenience from the swelling even after that length of time.

Postoperative thrombophlebitis is apt to give the patient considerable inconvenience for years after the operation. At first very painful, the pain and soreness soon subside, but the swelling and edema may persist for years. It is not an uncommon experience to receive letters from patients who have suffered from thrombophlebitis in the hospital, years after the operation saying that the leg still causes them inconvenience and that they still have to wear a bandage. Thus our prognosis should be guarded in these cases.

DEMONSTRATION OF TWO BRAIN TUMORS.

ALBERT M. BARRETT, M. D.

Department of Psychiatry.

The first brain I desire to demonstrate shows a large tumor involving the choroid plexus of the fourth ventricle. The specimen is from a man who died in one of the State hospitals for the insane at the age of forty. At about fifteen years of age he had some sort of mental disorder which brought about his commitment to an insane hospital. His condition seemed to be one of a mild type of depression and he was regarded as recovered after one year's treatment.

He again came into the same hospital when he was twenty-five. Then he was dull and showed a considerable defect in memory. His speech was slurring and ataxic. His eyesight was much impaired; this progressively grew worse and at the time of his death he was almost blind. Soon after his admission, there occurred a discharge of cerebrospinal fluid from his nose. This passed from the nose in drops, about a second apart. When recumbent there was a steady flow of fluid back into the pharynx. He failed progressively and died eleven months after his admission.

At the autopsy the brain showed evidences of increased intracranial pressure. The cribriform plate of the ethmoid was crowded so that the brain membranes bulged downward into the nasal cavity. In places the floor of the anterior fossa was eroded. When the formalin-hardened brain was sectioned, there was found a large tumor mass which involved the choroid plexus of the fourth ventricle. In the gross it had a cauliflower appearance, or like densely massed small blood-vessels. It was irregular in outline, extending laterally into the wings of the ventricle, forward into the aqueduct and backward into the central canal of the medulla. It thus had greatly widened the ventricles and canal. All of its surfaces were free. The third and lateral ventricles were much dilated. In size it measured twenty-five by thirty-five millimeters. Sections through the tumor show it to be made up of densely massed loops and cross sections of tubes whose walls are a single layer of epithelium. In appearance they closely resemble the papillæ of the choroid plexus. In the center of each passes a blood-vessel, or in some of the larger tubes there may be several. Many of the tubes are distended into cysts. These and the wide tubes contain a homogeneous material like a coagulated fluid, in which are scat tered lymphoid nuclei and rarely polynuclear leukocytes. In many tubes there is a considerable increase of connective tissue.

In general the structure seems to be that of a greatly overgrown

choroid plexus, and corresponds to what has been described as a papillary epithelioma. From the glandular arrangement of the epithelium such tumors have been sometimes called adenomata.

The position of the tumor is such as to produce a marked degree of internal hydrocephalus, as was evidenced by the much widened ventricles. The flow of fluid into the nose must have been occasioned by the erosion of the tissues by pressure from the dilated ventricles.

The second tumor is a diffuse invasion of the pia mater of the brain by a diffuse gummatous tumor.

This specimen is from the brain of a man who died in one of the State Hospitals for the Insane at the age of forty years. Very little was known about him previous to his admission to the hospital in June, 1910. For a few months preceding this he had been gradually becoming deranged in his mind. He was depressed and suspicious, and held delusions that he had been deserted by his family and friends. His physical condition had rapidly weakened, and at the time of his admission he was moved about in a wheeled chair. The day following his admission he was much excited and there were twitchings and jerkings of the muscles. Death occurred. three weeks after his admission.

The chief autopsy findings centered in the condition of the brain. After this had been hardened in formalin the pia mater of the entire brain and over the cerebellum was found thickened and opaque. It had a gelatinous appearance and gave the impression that there was present a diffuse purulent leptomeningitis. Longitudinal sections through the brain showed a large tumor lying in the white substance of the right temporooccipital region. In size this measured 40 by 38 millimeters. Το the left the tumor had pushed into the posterior horn of the lateral ventricle, completely filling it. Elsewhere the tumor was differentiated from the surrounding brain substance by its darker color and its softer consistency. Close to the left posterior corpora quadrigemina there was a small superficial yellow softening.

Histologic examination of the tumor in the temporooccipital region shows it to be a cellular glioma with some degeneration of its structure and an infiltration of the area immediately surrounding the tumor with. bands and groups of glia cells. Several blood-vessels passing through the tumor show the lymph spaces of the vessel wall packed with glia cells. The space between the pia mater and the brain surface is filled with neuroglia cells. In form and many characteristics they correspond to the cells present in the tumor and leave no doubt as to their being glia cells. They follow the blood-vessels which extend down from the pia mater and lie surrounding the vessel and in the vessel wall. The pia over the entire brain showed this same condition. The glia cells were particularly numerous in the pia of the cerebellum and that surrounding the pons and medulla. Nowhere do the cells directly invade the brain substance from the pia mater. But in the substance of the pons, just below the posterior corpora quadrigemina, there is a small cut in which the blood