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APPEI^DICITIS 
 
BY THE SAIVJE AUTHOR 
 
 TREATISE 
 
 SURGICAL ANATOMY 
 
 Large Octavo. Containing over 800 pages 
 and upward of 200 Illustrations drawn ex- 
 pressly for this work from actual dissections. 
 
 NOW ON PR ESS 
 
Dr. G. SANDERS 
 
 TREATISE 
 
 ON 
 
 APPENDICITIS, 
 
 JOHIN^ B. DEATER, M.D 
 
 SURGEON TO THE GERJIA^T HOSPITAL, PHILADELPHIA 
 
 CONTAINING 
 
 32 fuiUpagc plates au& ©tber IFUustrations 
 
 PHILADELPHIA 
 p. BLAKISTON, SON & CO 
 
 1012 WALNUT STREET 
 
 1896 
 

 
 Copyright, 1896, by P. Blakiston, Son & Co. 
 
 Press of Wm. F. Fell & Co., 
 
 1220-24 SANSOM ST., 
 
 PHILADELPHIA. 
 
TO THE MEMORY OF MY FATHER 
 
 J. M. DEAVER, M.D. 
 
 WHOSE CHAEACTEE AND STEELING QUALITIES AS A PHYSICIAN 
 
 HAVE BEEN THE GUIDING INFLUENCES OF MY 
 
 PEOFESSIONAL LIFE 
 
 S^^ts ^ooh is ^ffcctionatelg Jlcbitateir 
 
PREFACE. 
 
 The following work on appendicitis has been prompted by 
 the belief that the importance of this affection entitles it to a 
 more thorough and exhaustive study than has usually here- 
 tofore been accorded it. Appendicitis in a general way has 
 been so widely and thoroughly discussed that in its usual 
 forms its diagnosis is comparatively devoid of difficulty. No 
 inflammatory affection of the abdominal cavity, however, is 
 capable of such varied symptoms and of so many serious com- 
 plications, all of which demand the most thorough knowledge 
 for their proper treatment. 
 
 It has been my desire to present in this volume such a sys- 
 tematic study of the disease that not only the usual symptoms 
 may be traced from their inception to their termination, but 
 also that the various anomalous conditions so frequently met 
 with may be recognized with equal facility. 
 
 I have, therefore, endeavored to emphasize the aetiology, 
 symptomatology, and special technique in the operative treat- 
 ment. The observations herein contained are the result of an 
 experience in the treatment of over five hundred cases. 
 
 I wish to express my thanks to m}^ assistants. Dr. L. Brink- 
 mann, Dr. George Ross, Dr. A. D. Whiting, my brother. Dr. 
 H. C. Deaver, and to Dr. Wilmer R. Batt, for valuable aid in 
 the preparation of the book, and to Dr. W. S. Dougherty, my 
 surgical interne at the German Hospital, for preparing many 
 case reports and for correcting all the proof-sheets. 
 
 vii 
 
Vlll PREFACE. 
 
 A number of the pathological drawings were made b}^ Dr. 
 C. Frese, and to him and the excellent artistic work of Mr. F- 
 von Iterson is due the accuracy of that series. I wish also to 
 express my grateful acknowledgment of numberless services 
 performed by Dr. Frese as Medical Superintendent of the 
 German Hospital, where I have done the larger part of the 
 surgical work here represented. 
 
 John B. Deaver, M. D. 
 
 1634 Walnut Street. 
 
CONTENTS. 
 
 PAGE 
 
 History, 17 
 
 Anatomy, 23 
 
 Etiology, 31 
 
 Pathology, 45 
 
 Sy'Mptoms, 73 
 
 Diagnosis, 84 
 
 diffeeextial diagnosis, 94 
 
 Prognosis, 113 
 
 Treatment, 116 
 
 Complications and SEQUELiE, 148 
 
 Aftee-Teeatment, 161 
 
 IX 
 
DESCRIPTION OF PLATES. 
 
 PAGE 
 
 Plate I, 24 
 
 The four types of caecum, and relation of appendix to each. 
 
 Plate II, 26 
 
 The ileo-colic fossa. 
 
 Plate III, 28 
 
 The ileo-csecal fossa, and relative positions of appendix and meso- 
 appendix. 
 
 Plate IV, 30 
 
 The sub-ca;cal fossa. 
 
 Plate V, 30 
 
 An unusual position of the appendix, showing it adherent to the 
 posterior side of the cpecum and covered by its serous coat. 
 
 Plate VI, 36 
 
 Appendix containing pin which entered the canal point first, perfo- 
 rating the wall, the head afterward lodging in the distal end 
 of the canal. 
 
 Plate VII, 42 
 
 Appendix ulcerated oflf ceecum, showing gangrenous condition 
 caused by pressure of large faecal concretion. 
 
 xi 
 
Xll DESCRIPTION OF PLATES. 
 
 PAGE 
 
 Plate VIII, 44 
 
 Appendix, showmg gangrenous condition and perforations on distal 
 side of fnecal concretion. 
 
 Plate IX, 48 
 
 Fig. 1. The condition of the blood-vessels in acutely inflamed 
 appendix. 
 
 Fig. 2. Appendix laid open, showing gangrenous tissue, mucus, 
 and pus, the result of degeneration of the lining membrane. 
 
 Plate X, 52 
 
 Fig. 1. Appendix inflamed, showing adhesions and change in posi- 
 tion caused by occlusion of the lumen. 
 
 Fig. 2. Appendix laid open, showing pus cavities and complete 
 occlusion of the lumen. 
 
 Plate XI, 54 
 
 Appendix gangrenous and perforated, showing the result of occlu- 
 sion of the lumen, beginning at a point other than the tip. 
 
 Plate XII, 58 
 
 Fig. 1. Appendix congested, with point of beginning iilceration 
 near the tip. 
 
 Fig. 2. Appendix laid open, showing ulcerated area and oblitera- 
 tion of lumen. 
 
 Plate XIII 62 
 
 Appendix, showing formation of adhesions as a barrier against 
 general infection of the peritoneal cavity. 
 
 Plate XIV, 66 
 
 Fig. 1. Appendix adherent to csecum. 
 
 Fig. 2. Perforation in ca;cum, evident after detachment of appendix. 
 
 Fig. 3. Perforation in appendix corresponding to that in c£ECum. 
 
DESCRIPTION OP PLATES. Xlll 
 
 PAGE 
 
 Plate XV, 68 
 
 Appendix which was imbedded iu abscess Avail, showing eiilarge- 
 raeut, acute inflammation, and perforation. 
 
 Plate XVI, 106 
 
 Tubercular appendix. 
 
 Plate XVII, 128 
 
 Caecum laid open, showing necrotic area and two perforations. 
 
 Plate XVIII, 130 
 
 Location of the simple incision. 
 
 Plate XIX, 130 
 
 Fig. 1. Incision through skin and superficial fascia to aponeurosis 
 of external oblique. 
 
 Fig. 2. Division of aponeurosis of external oblique, expoi^ing apo- 
 neurosis of internal oblique and sheath of rectus. 
 
 Plate XX, 132 
 
 Fig. 1. Division of sheath of rectus, exposing the muscle. 
 Fig. 2. Rectus drawn aside, showing transversalis fascia and loca- 
 tion of epigastric veins. 
 
 Plate XXI, 134 
 
 Fig. 1. Division of transversalis fascia, showing pre-peritoneal fat 
 
 and epigastric veins. 
 Fig. 2. Exposure of peritoneum. 
 
 Plate XXII, 136 
 
 Fig. 1. Great omentum, seen through incision in peritoneum. 
 Fig. 2. Exposure of caecum and appendix. 
 
XIV DESCRIPTION OF PLATES. 
 
 PAGE 
 
 Plate XXIII, 136 
 
 Fig. 1. Gauze distributed around bowel, serous coat turned back, 
 
 aud appendix tied off. 
 Fig. 2. Serous coat of aijpendix sutured OA^er stump. 
 
 Plate XXIV, 138 
 
 Fig. 1. Stump of appendix invaginated. 
 
 Fig. 2. Caecum replaced and gauze laid beneath peritoneal covering. 
 
 Plate XXV, 140 
 
 Location of the McBurney incision. 
 
 Plate XXVI, 140 
 
 Fig. 1. Incision through skin and superficial fascia to aponeurosis 
 
 of external oblique. 
 Fig. 2. Delicate fascia covering internal oblique. 
 
 Plate XXVII, 142 
 
 Fig. 1. Internal oblique muscle. 
 
 Fig. 2. Fibres of internal oblique and transversalis separated, 
 showing transversalis fascia. 
 
 Plate XXVIII, 142 
 
 Fig. 1. Division of transversalis fascia, and pre-peritoueal fat, and 
 
 exposure of peritoneum. 
 Fig. 2. Great Omentum. 
 
 Plate XXIX, 144 
 
 Fig. 1. Exposure of csecum, appendix, and meso-appendix. 
 Fig. 2. Gauze distributed around bowel, serous coat turned back, 
 and appendix tied off. 
 
 Plate XXX, 146 
 
 Fig. 1. Serous coat sutured over stump. 
 Fig. 2. Stump invaginated. 
 
DESCRIPTION OF PLATES. XV 
 
 PAGK 
 
 Plate XXXI, 146 
 
 Fig. 1. Caecum replaced, preparatory to closure of wound. 
 Fig. 2. Position of layers when wound is ready to be closed. 
 
 Plate XXXII, 158 
 
 Fig. 1. Appendix, of which part sloughed away after evacuation of 
 
 abscess. 
 Fig. 2. Fistulous tracts in communicatiou with sloughing appendix. 
 
APPENDICITIS. 
 
 HISTOKT. 
 
 A review of the history of the inflammatory affection in the 
 right iliac fossa, now recognized as a disease of the vermiform 
 appendix, discloses many facts that account for the great 
 diversit}'- of opinions of earlier observers. During the first 
 half of the present century, although cases had been reported 
 in which perforation of the appendix had been found, almost 
 all inflammatory conditions localized in the right iliac fossa 
 were ascribed to diseases of the caecum. It is probable that 
 lack of knowledge of the distribution of the peritoneum served 
 in part to account for this condition of affairs, as the older 
 writers held that this serous membrane was found only as a 
 covering for the solid viscera contained in the abdominal 
 cavity. In the year 1803 Laennec first gave a complete 
 description of the peritoneum. His investigations stimulated 
 further observations of this membrane, but as yet there was no 
 association of the fact of inflammation of the general peri- 
 toneum with disease in the right iliac fossa, — that is, the latter 
 condition was not considered as causal of the former inflam- 
 mation. The symptoms of the affection found in the right 
 iliac fossa were described with minuteness and accuracy, but 
 the conditions were not held responsible for the general 
 peritonitis. Even in post-mortem records of cases of peritoni- 
 tis, no mention is made of the affection of the appendix as a 
 direct cause of the fatal peritonitis. 
 2 17 
 
18 APPENDICITIS. 
 
 The first authentic record of the distinct localization of a 
 lesion in the vermiform appendix was that of Mestivier, who 
 in 1759 recorded a case of perforation of this organ. Nothing 
 of importance was gained by the knowledge of this case, except 
 that such a lesion could exist. 
 
 In 1827 Husson and Dance described the diseases of the 
 csecum more in detail, and in 1824, Louyer Villermey reported 
 a case of fatal peritonitis, giving perforation of the appendix 
 as the direct cause. This was the first recorded case in which 
 the true seat of the origin of the disease was recognized. 
 Melier, in 1827, reported four cases, three of which he described 
 as cases of perforative appendicitis with fulminating peritonitis ; 
 the fourth was a case of relapsing appendicitis. Both Louyer 
 Villermey and Melier, however, believed that diseases of the 
 appendix and of the CEecum were separate and distinct. Melier 
 described the appendiceal disease very fully, and made special 
 mention of two distinct symptoms in the perforative cases, viz., 
 more or less severe abdominal colic, and fixed pain in the 
 right iliac fossa. He considered the causes, the character, and 
 the consequences of appendicitis, and even anticipated the 
 possible advantage of operation. He says : — 
 
 " If it were possible to establish with certainty the diagnosis of 
 this affection, we could see the possibility of curing the patient by 
 an operation. We shall, perhaps, some day arrive at this result." 
 
 In 1831, Ferrall published a monograph on " Phlegmonous 
 Tumors in the Right Iliac Fossa," in which he held that in 
 these conditions the csecum is the organ primarily involved, 
 and that the appendix and the peritoneum do not enter as 
 factors in the production of the phlegmon to as great an extent 
 as does the retro-csecal connective tissue. He recognized three 
 varieties of tumors, (a) a faecal impaction or distention of the 
 caecum without inflammation; (6) a malignant tumor of the 
 caecum ; (c) a true inflammatory or phlegmonous tumor, the 
 
HISTORY. 19 
 
 result of irritation of the mucous membrane of the caecum, or 
 the result of ulceration and perforation of its wall. He also 
 mentions a thickened condition of the peritoneum covering 
 the ceecum as having been found in the phlegmonous tumor. 
 
 In 1833, Dupuytren recorded observations showing the con- 
 nection between abscess of the right iliac fossa and disease of 
 the csecum, and it is largely due to this great authority that the 
 caecum as the primary seat of the cause of peri-typhlitis was so 
 widely accepted. In Dupuytren's post-mortem reports, no 
 mention is made of the appendix as the original seat of the 
 disease, and nowhere in his writings does he associate the 
 appendix with the cause of the inflammation of the csecum. 
 
 In 1834, Copland, in his " Dictionary of Practical Medicine," 
 made an advance in the pathology of the troubles in the right 
 iliac fossa. He entered upon the study of the diseases of the 
 CEecum in great detail, and claimed that inflammation of the 
 appendix can be the primary cause of serious affection in the 
 region of the csecum. He also speaks of the mortification of 
 the appendix, followed by a fatal peritonitis, as the result of a 
 foreign body found within that organ. 
 
 In 1837, Burne strove to separate clinically the appendix from 
 the csecum, although he agreed with the writers of that time, 
 that in the troubles of the right iliac fossa the csecum is 
 primarily the seat of the disease. He mentions ulceration of 
 the appendix due to a process set up by foreign bodies, such as 
 cherry-stones, raisin-seeds, and fsecal concretions, and adds : — 
 
 "So long as ulceration is limited to the mucous membrane, 
 it is of little consequence, but immediately the peritoneum is 
 perforated inflammation ensues ; then there is general peri- 
 tonitis, or local peritonitis with abscess." 
 
 In 1839 he wrote a second paper, in which he endeavors to 
 show that the csecum is of little importance in affections of the 
 right iliac fossa. 
 
20 APPENDICITIS. 
 
 In 1838, Albers noted the possibility of disease of the right 
 iliac fossa occurring as the result of inflammation of the 
 vermiform appendix, but he thought that it is more frequently 
 caused by disease of the caecum. Under the name typhlitis, 
 he described the following varieties of inflammation localized 
 about the csecum : — 
 
 1. Stercoral typhlitis — stagnation of faecal matter in the 
 csecum, with subsequent irritation. 
 
 2. Simple typhlitis — catarrhal inflammation due to a multi- 
 tude of causes. 
 
 3. Peri-typhlitis — extension of the inflammation of the mu- 
 cous membrane to the external coat of the csecum and to 
 the surrounding parts. 
 
 4. Chronic typhlitis — in which there is a prolonged and slow 
 course. When pus is present and associated with a perforated 
 appendix, he believed that the perforation occurs as a con- 
 sequence of the pus formation. 
 
 In writing of the csecum, in 1839, Grisolle made mention 
 of fatal cases of appendiceal gangrene. In 1840, Villerfne}^ 
 reported cases of inflammation of the appendix that termi- 
 nated rapidly in gangrene and death. In 1843, Voltz published 
 a paper on " Ulceration and Perforation of the Appendix, 
 Occasioned by Foreign Bodies." His general conclusions 
 were that the appendix was responsible for more of the 
 affections of the right iliac fossa than was the csecum. Roki- 
 tansky was the first to describe catarrhal inflammation of 
 the appendix as due to fsecal concretions or foreign bodies, 
 and believed that this might result either in ulceration or 
 in a chronic morbid condition. He also suggested that a 
 general peritonitis, as a consequence of perforation of the 
 appendix, is not always necessary, because of adhesions to the 
 surrounding structures prior to the perforation. He thought 
 these adhesions were due to a previous irritation. 
 
HISTORY. 21 
 
 Although the view that the grave and fatal forms of typhli- 
 tis are due to perforation of the appendix gained ground, yet 
 all of the benign and curable forms were considered as the 
 result of inflammation of the caecum and of the surrounding 
 cellular tissue. This theory has still a few advocates, but, 
 fortunately, they grow less numerous each year. 
 
 This much-vexed question has been restored to the status to 
 which Melier advanced it by the surgeons and physicians of 
 the United States, who, by early operation, have demonstrated 
 that inflammation of the right iliac fossa is invariably due, 
 primarily, to disease of the vermiform appendix. Hancock, 
 in ] 848, operated on one case. He advocated early operation 
 in disease of the appendix, but his ideas met with no encour- 
 agement. In 1867, Willard Parker, of New York, first proved 
 that early operation would save 75 per cent, of all cases. In 
 1883, Dr. F. F. Noyes reported 100 cases operated upon, 90 per 
 cent, of the operations having been performed in America. 
 
 " The epoch-making memoir on this subject " (I quote from 
 Talamon) "is the paper of Reginald Fitz, of Boston, published 
 in the American Journal of the Medical Sciences for October, 
 1886, ' On Perforative Inflammation of the Vermiform Appen- 
 dix.' In this work Fitz collected reports of 209 cases of 
 t3'^phlitis and peri-typhlitis, and 257 cases of perforative appen- 
 dicitis. He showed that the sj^mptoms are the same in the 
 latter as in the former class of cases. He studied with care the 
 consequence of perforation. He established the fact that the 
 peritonitis is not always generalized, that it may be circum- 
 scribed under the form of an encysted purulent collection. He 
 gave the characters of the tumors formed by this localized 
 peritonitis, the different modes of the evacuation of the pus, 
 the complications that may supervene if the disease be left to 
 itself. He insisted on the frequency of faecal concretions as a 
 cause of the perforation of the appendix. He concludes in 
 
22 APPENDICITIS. 
 
 favor of early operation." In 1<S88, Fitz published a second 
 paper in which he advanced the radical but sound theory that 
 the diseases described as typhlitis, peri-typhlitis, para-typhlitis, 
 appendicular peritonitis, and peri-typhlitic abscess are all 
 varieties of one and the same affection, namely, appendicitis. 
 Since 1888 the subject of appendicitis has occupied a large 
 proportion of the time and labor of the medical profession, and 
 many able papers have been published advancing widely dif- 
 ferent views and ideas in regard to it. The most debated 
 points have been concerning the diagnosis and the treatment, 
 and about these the discussion has waged, generally with 
 physicians and surgeons as the opposing disputants. 
 
 The frequency of the affection ; the rapidity with which the 
 disease may proceed from bad to worse ; the fatality in a large 
 percentage of cases ; its marked tendency to occur or recur in 
 those who apparently recover from an attack, — these things 
 make appendicitis the most important intra-abdominal lesion 
 of to-day. The work of McBurney, Richardson, Murphy, 
 Morris, and others has greatly advanced the state of our 
 knowledge of the affection, and has done much to present the 
 subject in such a light that the surgeon has been enabled 
 to cope with the disease in a more satisfactory and life-saving 
 manner. Physicians generally, however, take the stand that 
 only a minority of cases require the services of the surgeon, 
 and they claim that only those cases that advance to suppura- 
 tion, gangrene, and perforation should be seen by the surgeon. 
 Thus the controversy still continues, although prominent 
 physicians of the present day grant that it is advisable to have 
 a surgeon in consultation, even if they do not always give the 
 surgeon the privilege of treating the disease as, in my opinion, 
 it invariably should be treated, — namely, by early operation. 
 
Al^ATOMY. 
 
 The appendix vermiformis of man is the undeveloped true 
 CEecum of some of the lower animals. In the embryologic 
 development of the human intestinal tract, there is at first 
 no csecum present, the original tract consisting of a straight 
 tube, which has been divided into the foregut, midgut, and 
 hindgut, each division giving rise to different structures. 
 From the midgut springs a diverticulum marking the divi- 
 sion between the large and the small intestine. This 
 conical projection lengthens to form the caecum, " but the 
 terminal portion does not keep pace with the growth of the 
 base, and consequently becomes much narrower in calibre. 
 The basal portion eventually grows so large that it is com- 
 monly called the csecum, while the true csecum is designated 
 as the vermiform appendix." During the early stages of 
 intra-uterine life, the csecum with the vermiform appendix 
 lies near the umbilicus, its descent into the right iliac fossa 
 occurring about the sixth month. 
 
 In the adult, the csecum occurs as one of four types, and 
 in each the appendix holds a different position. (Plate I.) 
 
 1. In the foetal type, the appendix is the narrow inferior 
 end of a conical csecum, the apex of the cone being directly 
 continued into the appendix. 
 
 2. A second type consists of a csecum, with two equally 
 large sacculi at its inferior termination ; between the sacculi, 
 which are separated by the anterior longitudinal band, the 
 appendix arises. 
 
 3. In the third class, the external sacculus is large, while 
 the internal one is small, thus bringing the base of the appen- 
 
 23 
 
24. APPENDICITIS. 
 
 dix nearer the ileo-CEecal valve. In addition, the anterior wall 
 of the caecum grows more rapidly than the posterior, so that 
 the root of the appendix is posterior. 
 
 4. In the fourth and last class, the internal sacculus has 
 disappeared entirely, and the base of the appendix is attached 
 posterior to the receding angle, between the ileum and the 
 csecum. 
 
 In cases of non-descent of the caecum, the appendix will hold 
 a correspondingly abnormal position, and, under such cir- 
 cumstances, may even lie to the left of the median line. Len- 
 nander mentions the case of a boy of sixteen in whom the 
 csecum and appendix were found in the left hypochondriac 
 region, lying against the spleen. In this case the appendix 
 measured nine inches in length. Although the average length 
 of the appendix is about four inches, it may vary from half an 
 inch to nine inches. When the appendix is long, the csecum 
 is, as a rule, somewhat shortened. The diameter of the 
 appendix is that of a goose quill, or about the same as that of 
 a large earthworm. (Holden.) 
 
 Before entering upon a consideration of the structure of the 
 appendix, it would be well to trace its peritoneal covering, 
 together with that of the csecum. The csecum is almost always 
 entirely covered with peritoneum, although cases have been 
 recorded in which the peritoneum, instead of entirely investing 
 the csecum, was reflected from its posterior surface, thus form- 
 ing a "meso-csecum. Generally, the peritoneum is not, as a 
 mesenter}^ reflected to the abdominal walls from the beginning 
 of the large bowel until the commencement of the ascending 
 colon is reached. It will thus be seen that the csecum is free in 
 the abdominal cavity, and that from various causes it is liable 
 to change of position. Its mobility may depend upon the 
 presence or absence of a meso-csecum or of an ascending meso- 
 colon, or upon the length of the large bowel between the tip of 
 
Plate I 
 
ANATOMY. 25 
 
 the csecum and the point of reflection of the ascending meso- 
 colon. The organ may hang over the brim of the pelvis, or it 
 may even occupy the pelvis, and cases have been recorded in 
 which it formed a part of the contents of an inguinal hernia 
 on the right side. 
 
 The peritoneal covering of the appendix is reflected from the 
 left or inferior layer of the mesentery of the ileum, and may 
 entirely or in part invest the appendix. The folds of the 
 peritoneum reflected from the ileum to the appendix usually 
 form a mesentery for the appendix, triangular in shape, the 
 base of the triangle being formed by the free edge of the folds. 
 The attachment of the meso-appendix may extend along the 
 entire length of the appendix (as I have usually found it), or 
 it may be attached onl}'^ to the proximal one-third or two- 
 thirds, thus leaving the tip free. At times the meso-appendix 
 is absent, the appendix, under such circumstances, being free 
 in the abdominal cavity ; generally the meso-appendix has the 
 appearance of being too short, and thus the twists and curves 
 often found in the organ may be explained. 
 
 The meso-appendix consists of two folds of peritoneum, 
 between which run the appendicular artery and vein, lymph- 
 atics, and a few sympathetic nerve-fibers. Occasionally it 
 contains a considerable quantity of fat, which renders it more 
 liable to be torn in the removal of the appendix. The mobility 
 of the appendix depends upon the width and the length of the 
 attachment of the meso-appendix. 
 
 At times an opening may be found in the meso-appendix 
 through which a coil of the small intestine has been known to 
 form a hernia and become strangulated. 
 
 In some cases the iliac vessels have passed through the 
 layers of the meso-appendix. This anatomic condition proba- 
 bly accounts for the manner in which collections of pus in the 
 right iliac fossa may find their w^ay beneath the fascia lata into 
 
2G APPENDICITIS. 
 
 the thigh. In the female the meso-appendix has a prolonga- 
 tion running to the ovary, which is described by Clado as the 
 appendiculo-ovarian ligament. It conveys an additional 
 supply of blood to the appendix. 
 
 Owing to the various angles and projections formed by the 
 csecum and the ileum, there are fossse formed by the reflection 
 of the peritoneum between these parts of the intestinal tract, 
 and they clinically may play an important role. Lockwood 
 and Rolleston first called attention to these fossee and have so 
 carefully described them that I cannot do better than follow 
 their description : They are three in number, the ileo-colic, the 
 ileo-csecal, and the sub-C8ecal. 
 
 The ileo-colic fossa (Plate II) is a peritoneal pouch formed at 
 the angle of junction of the ileum and colon. The floor is 
 formed by the mesentery and sometimes by a portion of the 
 ileum. The ileo-colic fold of peritoneum forms its roof. This 
 pouch is variable in size and depth, and as it is too high up 
 does not play a very important part in appendicitis. A branch 
 of the ileo-colic artery runs through the ileo-colic fold, crossing 
 in front of the ileum. 
 
 The ileo-csecal fossa (Plate III) is a peritoneal pouch, situated 
 behind the angle of junction of the ileum and csecum. To 
 expose it both the ileum and the csecum must be elevated. 
 It is bounded on the right by the mesentery of the ascend- 
 ing colon, and on the left by the mesentery proper. The 
 roof is formed by the ileo-c8ecal fold, a bloodless fold of 
 peritoneum extending from the free border of the ileum 
 to the csecum and finally joining the surface of the meso- 
 appendix. This fossa may be very deep and long, at times 
 extending upward behind the ascending colon as far as 
 the kidney and duodenum. The mesentery of the appendix 
 sometimes divides the fossa transversely, thus forming two 
 fossfe, known as the superior and inferior ileo-csecal fossse. 
 
UJ 
 
 i— 
 <C 
 _l 
 Q_ 
 
ANATOMY. 27 
 
 The ileo-c<ecal fossa is important, as the appendix is often 
 found in it, thus explaining why this location is often the site 
 of certain products of appendicular disease. 
 
 The sub-csecal fossa (Plate IV), as its name implies, is immedi- 
 ately under the csecum, the latter portion of the bowel requir- 
 ing to be raised in order to view it. It is less constant than 
 the other fossse. The mouth of this fossa is found at the junc- 
 tion of the caecum with the colon, the fossa separating the la3'ers 
 of the meso-colon. On account of its high position, it does not 
 clinically play a prominent part. If, however, a meso-csecum 
 were always present, this fossa would be a very important one, 
 as the mouth of the fossa would then be flush with the tip of 
 the csecum, at the base of the appendix. Lockwood and 
 Rolleston have described this condition as occurring, but I 
 have never yet seen a case with a meso-ceecum. The appendix 
 may occupy either of these fossse, but more often it is found in 
 the ileo-C8ecal or the sub-csecal. On account of the various 
 complications that may arise if the appendix occupy either of 
 these fossse, the operator may be led to form an incorrect con- 
 ception of the true state of affairs. Thus at times the 
 appendix might constitute a retroperitoneal hernia ; or if the 
 appendix should occupy one of these fossse and the mouth of 
 the fossa should close over the organ, the organ might be 
 thought absent. Suppuration of the appendix so walled in 
 would be entirely circumscribed. 
 
 In the majority of cases, the appendix will hold one of eight 
 positions. Dr. Bristow suggests a very simple method of clas- 
 sifying these positions and directions, which consists in locat- 
 ing a central point in the right iliac fossa which, in its most 
 common position, will represent the attachment of the appen- 
 dix to the csecum, and from this central point lines are drawn 
 that radiate- in eight different directions. To indicate the 
 course of the different lines, Fowler has modified this method 
 
28 APPENDICITIS. 
 
 by substituting the initial letters of the points of the compass 
 for the numbers used by Bristow. The central point is located 
 by drawing a line from the anterior superior spine of the 
 ilium to the umbilicus ; a point on this line, from two to two- 
 and-a-half inches from the anterior superior spine, correspond- 
 ing to the central point from which the lines are drawn. 
 
 Although, normally, the appendix may occupy any of the 
 eight j)ositions, it is most commonly found in one of the 
 following five : 1. It may lie under the inferior layer of the 
 mesentery, being directed toward the spleen, in the N. E. posi- 
 tion. 2. It may lie on the ilio-pectineal line or project into 
 the pelvis, its course being S. or S. E. 3. If there is a long 
 meso-appendix, it may lie to the right of the caecum and as- 
 cending colon, running upward, in a northerly direction, 
 parallel with the colon and over the kidney toward the right 
 lobe of the liver. 4. It may lie in front of the colon and 
 caecum, its course generally being N. or N. E. 5. It may lie 
 under the caecum, holding generally a northerly direction. If 
 the appendix has a long and wide mesentery, it may hold any 
 of the other three positions, freedom of motion generally being 
 required in order to assume these positions. 
 
 Abnormally, the appendix may hold a position in either of 
 the ileo-caecal fossae ; it may lie behind the peritoneum and be- 
 hind the caecum and adherent to its posterior muscular wall 
 (Plate V), being covered in this position by the peritoneal 
 covering of the caecum ; it may be adherent to the peritoneum 
 along the right border of the caecum and ascending colon ; it 
 may be adherent to the peritoneum at any point in the neigh- 
 borhood of the caecum ; or it may lie in the inguinal canal. 
 
 The structure of the appendix is very similar to that of the 
 large intestine, but varies somewhat from the latter. The 
 mucous membrane lining the appendix is composed of a deli- 
 cate retiform tissue containing numerous lymphoid cells within 
 
LU 
 
 < 
 _l 
 
 Q_ 
 
ANATOMY. 29 
 
 its meshes, and has dipping into it a plentiful supply of solitary 
 glands and glands of Lieberkiihn. The latter glands vary 
 much in size and number and are often entirely absent. As a 
 rule, the retiform tissue is lined with a basement membrane on 
 which are found columnar epithelial cells covered with clusters 
 of various micro-organisms. Between the mucous and submu- 
 cous coats, a thin layer of circular muscular fibers may be dis- 
 tinguished, forming the muscularis mucosse. The submucosa is 
 formed of areolar tissue, is much denser than the mucous coat, 
 and contains numerous lymphoid glands. In the submucosa 
 are numerous small arteries and veins supplying the mucous 
 membrane ; it generally contains a small quantity of fat. 
 
 From within the caecum there is seen a prominence of the 
 mucous membrane, partially or completely surrounding the 
 orifice of the appendix, due to an increase of the lymphoid 
 tissue. This, under certain circumstances, may act as a valve, 
 and thus favor occlusion of the orifice. 
 
 The muscular coat consists of two layers. The inner is a 
 thick layer of circular fibers, at times constituting fully one- 
 third the entire thickness of the appendiceal wall. The outer 
 layer is composed of longitudinal fibers. It is not so thick as 
 the inner, nor are the muscular fibers as regular, as at times 
 they are bunched at certain points in a manner similar to this 
 layer in the csecum. 
 
 Probably one of the strongest points of evidence as to the 
 existence of the longitudinal muscular fibers is demonstrated 
 after the removal of the vermiform appendix, when the organ 
 rapidl}'- shrinks by their contraction, sometimes one-third of 
 its original length. The circular fibers possess the same power, 
 for when the appendix has been incised to expose its canal 
 there will be immediately noted a contraction of the circular 
 fibers,- thus bringing the mucous lining into view. 
 
 The peritoneal coat, or serous covering, of the appendix is 
 
30 APPENDICITIS. 
 
 similar to the peritoneum in general. Its extent in regard to 
 tlie appendix has alread}^ been described. 
 
 The vascular supply of the right iliac fossa is derived from a 
 loop formed by the anastomosis of branches of the superior 
 mesenteric, the right colic, the ileo-colic, and the middle colic 
 arteries ; from this loop secondary loops are given off and from 
 these are derived the arteries to the appendix and to the ileo- 
 csecal region. The branch to the appendix, the appendicular 
 artery, passes along the free edge of the meso-appendix, if that 
 structure is present. In the absence of the meso-appendix, the 
 artery usually passes beneath the peritoneal coat of the appen- 
 dix. In exceptional cases the artery may pass directly to the 
 tip of the appendix, in which instances it will not give 
 off branches until it has entered the submucosa. 
 
 In the female, at times, there is an additional supply of 
 blood brought to the appendix through the folds of the 
 appendiculo-ovarian ligament. The lymphatics of the appen- 
 dix pass to a chain of glands in the angle formed by the 
 junction of the appendix with the caecum. The lymphatics 
 may empty into those of the ovary by passing along the 
 appendiculo-ovarian ligament, in this way forming a com- 
 munication between the appendix and the ovary. 
 
 The nerves of the appendix are derived from the superior 
 mesenteric plexus of the sympathetic, the branches of this 
 plexus, which accompany the ileo-colic artery, sending filaments 
 to the appendix. As this plexus gives numerous twigs to the 
 small intestine, it is easily explained why pain, due to disease 
 of the appendix, may be referred to the whole abdomen or to 
 any region of it. 
 
DIVIDED'i 
 
Plate V 
 
 End 
 
 white ba 
 
 leading 
 
 append 
 
 Appendix 
 
 Back View of Caecum, with appendix attached, the latter covered 
 by serous coat of Caecum. The illustration shows the difficulty encoun- 
 tered in the removal of an adherent appendix 
 
ETIOLOGY. 
 
 The earlier writers on appendicitis usually held that the 
 main cause of this affection was the presence of a foreign 
 body in the appendix. Since, however, the true character of 
 the disease has become known, the presence or absence of a 
 foreign body, such as a cherry-stone, a grape-seed, etc., has 
 played little part as an setiologic factor. Two classes of causes 
 of appendicitis, the predisposing and the exciting, are at present 
 recognized. 
 
 Predisposing Causes. — Among these the anatomic structure 
 of the appendix must be considered, because its liability to 
 variations, in position and size, is probably one of the principal 
 causes of the affection. The appendix, functionless and unde- 
 veloped, is a narrow, musculo-membranous tube, lined with 
 mucous membrane, ending in a blind extremity having a 
 common orifice of entrance and exit ; its blood-supply is 
 limited, consisting of one small artery, with no anastomoses to 
 make up for the deficiency of suppl}^ ; it is an organ of low 
 vitality on account of the retrograde metamorphosis it is 
 undergoing in the process of evolution ; it is rich in lymphoid 
 tissue, a fact that vastl}' increases its absorptive powers, and 
 when attacked by inflammation is, therefore, more liable to 
 progressive destructive processes. If the appendix hold a 
 pendent position, there will necessarily be more resistance 
 offered to its efforts to empty itself of any material lodging 
 in it. If it lie in a position in which gravity can pla}^ a part 
 in the discharge of the contents, there will be correspondingly 
 less liability to disease. The attachment of the meso-appendix, 
 together with its length, also act as factors of some moment. 
 
 31 
 
32 APPENDICITIS. 
 
 If the mesentery be long, the tube will probably be straight 
 and not subject to twists and kinks. If, on the other hand, 
 the meso-appendix be short, the organ will always be curved 
 on itself and at times twisted, thus favoring the retention of 
 any material that may have become lodged within it. These 
 anatomic conditions predispose the appendix to catarrhal in- 
 flammation, producing infiltration of the submucous layer 
 resulting in thickening, which impairs appendicular peristalsis 
 and also interferes w^ith free drainage. 
 
 A marked predisposing factor in recurring inflammation of 
 the appendix is the fact that it has already been the seat 
 of disease. In the apparent recovery from the first attack, 
 the mucous membrane of the appendix undergoes a healing 
 process by which the lumen of the organ is constricted either 
 at the orifice or at points along its length. If these con- 
 strictions completely close the lumen at any part, they must, 
 of course, prevent the egress of any material that may have 
 lodged beyond them. Even if not entirely closing the lumen, 
 the constrictions are liable to act as hindrances to the drain- 
 age of the organ and to the expulsion of any contents, and 
 thus there will be retained in the cavity a nidus for further 
 trouble. While it is true that these constrictions may be 
 thought to possess the power of preventing the ingress of 
 foreign material, yet it must be acknowledged that there is 
 greater liability to the ingress of material than to its egress, 
 owing to the great difference between the propelling force of 
 the bowel and the repelling force of the diseased and weak- 
 ened appendix. 
 
 In a very few cases, it is probable that the cicatricial process 
 extends along the whole length of the appendicular canal, in 
 this way entirely obliterating its lumen, and, consequently, 
 absolutely preventing further attacks of the disease. The 
 number of cases in which this occurs is, however, so small 
 that it may be set aside. 
 
.ETIOLOGY. 33 
 
 Mucous membranes throughout the body, e.g., of the throat, 
 bladder, intestinal tract, stomach, etc., are liable to a catarrhal 
 inflammation, and there seems no good reason for believing 
 that the mucous membrane of the appendix is an exception to 
 the rule. The same causes that are effective in the production 
 of catarrhal inflammations elsewhere, are probably equally 
 active in the appendix. While in other localities they may 
 provoke no serious results, they cause disastrous lesions in the 
 appendix. 
 
 Age is a predisposing cause. Although the disease is most 
 common in those between the ages of ten and thirty, about 
 15 per cent, of all cases occur in persons under fifteen years. 
 The youngest patient in whom I met with the disease was not 
 two years of age, and the oldest seventy. An explanation for 
 this marked susceptibility, up to adolescence, may be found in 
 the disturbances of the gastro-intestinal tract, so frequently 
 induced by indiscretions in diet. 
 
 As to sex, males are much more prone to attacks of appen- 
 dicitis than females. There is but one reasonable explanation 
 for this, viz., the fact that females are supposed to have a 
 greater blood-supply than the males, both in actual quantity 
 and in proportion to the size of the appendices in the two 
 sexes. Clado has described a fold of peritoneum extending 
 from the appendix to the ovary, the appendiculo-ovarian liga- 
 ment, which carries a blood-vessel to the appendix. This, 
 together with the fact that the appendix of the female is 
 smaller than that of the male, may account for the compara- 
 tively small per cent, of attacks among women and girls. 
 
 It is not probable that either constipation or diarrhoea play 
 a very important role in the causation of appendicitis, as 
 statistics have shown that the large majority of cases have 
 a normal, condition of the bowels prior to and during an 
 attack. 
 
 3 
 
34 APPENDICITIS. 
 
 When tuberculosis, secondary to the involvement of the 
 caecum, is more pronounced in the appendix, it is likely to 
 be followed by a result similar to that of acute perforative 
 appendicitis. 
 
 I have had cases due to exposure to cold and wet. In one 
 the attack was provoked by taking a cold shower after coming 
 out of a warm bath, another was the result of wet feet, and 
 a third from being chilled by lying in a cold room shortly 
 after a heavy meal. 
 
 I believe tj'-phoid fever to be one of the remote causes in 
 the production of appendicitis. The appendix contains many 
 solitary glands which at times are the seat of typhoid ulcers, 
 and, as a result of the cicatricial contraction of these ulcerated 
 patches, obstruction to the lumen of the appendix occurs. 
 
 In certain cases of chronic appendicitis, developed post- 
 typhoid, I have been unable to elicit a history of previous 
 acute intestinal disturbance. Yet in these I have found a 
 train of symptoms — intestinal dyspepsia, vague pains in the 
 abdomen, etc., the origin of which was traced, without doubt, 
 to an attack of typhoid fever that had occurred months or 
 years previous. This is illustrated in the following case : — 
 
 Miss I. M. W. , first troubled with mucous discharge from bowel in the 
 summer of 1889, when she had an illness called tj'phoid fever, attended by 
 frequent watery, and in some instances, bloody discharges. Was confined to 
 bed about three weeks. Tedious recovery. Since this illness she has been 
 subject to attacks of catarrhal enteritis, never escaping for more than four 
 months, although well during that time. These attacks, which could be 
 traced to cold, unusual exertion, sea-sickness, etc., were less frequent in the 
 autumn and early winter, after the change of air and rest during the summer. 
 Two years ago in June she had a persistent attack lasting several weeks. 
 Vague pains were present in right iliac fossa and a distinctly enlarged and 
 tender appendix could be made out on palpation. 
 
 Operation. No adhesions ; the appendix contained pus, and was indurated. 
 The mucosa and submucosa were thickened, and showed marked evidences of 
 chronic catarrhal inflammation. 
 
 Recovery followed with total disappearance of symptoms. 
 
ACUTE APPENDICITIS. 
 
 Mrs. A. G., aged thirty-three, was admitted to the Grerman Hospital, 
 May, 1896, with the following history : Ten days previously she had been 
 suddenly seized by sharp pains in her right side, attended by vomiting. The 
 abdominal wall was rigid and markedly tender on pressure over the region of 
 the appendix. Constipation was present. The vomiting lasted for two days, 
 but the pain, tenderness, and rigidity continued for one week, gradually 
 decreasing meanwhile. 
 
 On date of admission her temperature was 101° ; pulse rate 112 ; stomach 
 not irritable. Her abdomen was slightly swollen, and in her right iliac fossa 
 close to the iliac spine was a mass the size of an orange, which was 7iot pain- 
 ful on pressure, though moderate tenderness existed upon deep palpation. 
 Appendicitis was diagnosed, but on account of the absence of pain and tender- 
 ness in the mass over the appendix, which seemed an anomalous condition, 
 operation was deferred for one day. Her temperature, however, steadily rose 
 to J 03°, and immediate surgical interference was considered necessary. 
 
 Section of the abdominal wall showed the muscles infiltrated. The 
 parietal peritoneum was closely adherent to a mass which was composed of 
 omentum, and the appendix bound together by organized exudate. No pus 
 was found. The appendix was freed, tied off, and removed, and upon exami- 
 nation proved to contain a black pin, which had entered the canal point first. 
 This case is particularly interesting from the fact that, despite the mass, pain 
 and tenderness were not marked. It also illustrates that in the absence of 
 great local tenderness, a diagnosis of pus in or about the appendix is not 
 warrantable. 
 
^ 
 
 i 
 
 Plate VI 
 
 Showing Appendix containing Pin 
 
 (Twice natural size) 
 
ETIOLOGY. 37 
 
 Another of the predisposing causes is the fact that the base- 
 ment membrane of the mucous lining of the appendix is almost 
 alwaj'S the seat of clusters of micro-organisms that are ever 
 ready for an opportunity to attack the structure of the organ 
 and thus set up an acute inflammatory condition. The role 
 played by micro-organisms will be more fully discussed under 
 the chapter on pathology. 
 
 Exciting Causes. — It is probable that all cases of appendicitis 
 are directly due to the invasion of micro-organisms. This may 
 occur independently of any other change in the region of the 
 appendix or of the intestinal canal, or it may be directly due 
 to disturbances brought about by several causes. For instance, 
 changes in the blood-supply of the appendix, the result of a 
 bend or twist, may so lower the little resisting force the organ 
 possesses that the micro-organisms are given full play. Dis- 
 turbances of digestion are claimed by many authors to be 
 exciting causes. Fowler holds that these play a very unim- 
 portant part. Talamon, on the other hand, thinks that per- 
 istalsis, induced by the presence in the intestinal tract of 
 irritating material, is liable to engage a stercoral calculus 
 within the orifice of the appendix, and that this gives rise to 
 symptoms found in the first stages of the disease. It is 
 claimed, also, that this erratic peristalsis awakens the micro- 
 organisms to a more virulent condition, thus enabling them 
 to inaugurate more easily inflammatory conditions. I am 
 positive that acute indigestion plays a very important role in 
 the aetiology of appendicitis. I have seen this demonstrated so 
 often that I express this opinion unhesitatingly. The intro- 
 duction of foreign substances into the lumen of the appendix, 
 such as cherry- or date-stones, pins, etc., is an infrequent cause 
 of appendicitis. It is true that seeds, pits, pins, etc., have been 
 found in the appendix. The case of Mrs. A. G. (page 36, Plate 
 VI) illustrates this, but it is probable that in the large majority 
 
38 APPENDICITIS. 
 
 of these cases the supposed seeds, etc., were fsecal concretions, as 
 these concretions bear a very striking resemblance to such 
 foreign bodies. 
 
 Fsecal concretions, though not the direct cause, are probably 
 the most frequent exciting cause of acute affections of the appen- 
 dix. It was formerly the accepted opinion that fsecal concre- 
 tions, having formed in the small intestine, migrated into the 
 appendix and there set up inflammation with its disastrous con- 
 sequences. This view is no longer held. The course of events 
 seems rather to be as follows : A small normal fsecal particle 
 being carried into an appendix, the mucous membrane of 
 which is inflamed, is there retained, the swollen membrane, the 
 inflamed muscle, and the abnormal adhesions inside the appen- 
 dix preventing its egress. The concretion is gradually increased 
 in size by concentric layers of mucous and purulent products 
 deposited on it. As it grows the appendix is dilated (Fig. 1). 
 At first no injurious eflect may be evident. When, however, the 
 concretion has attained considerable size it becomes directly 
 harmful to the mucous membrane, causing then pressure- 
 necrosis and gradual perforation of all the histologic layers of 
 
 the appendix. (In the case of Wm. , herewith presented 
 
 [Plate VII], perforation was imminent, the walls of the appen- 
 dix having become so friable that they parted upon the 
 slightest pressure.) 
 
 The fact that the large concretions often found could not 
 possibly have been introduced without tearing the appendiceal 
 opening, is sufficient proof of the growth of the concretions 
 after their lodgment in the appendix. 
 
 We conclude, therefore, that while the formation of coproliths 
 stands in close relation with diseases of the vermiform appen- 
 dix, they are not the primary cause, but rather a consequence 
 of the disease. They develop when an appendicitis already 
 exists, and only afterward assume dangerous tendencies ; they 
 
CHEONIC APPENDICITIS. 
 
 Wm. , age thirtj'-six. Had always enjoyed good health ; had been a 
 
 member of the crew when a student at Hai-vard College. 
 
 On November 15, 1895, was seized suddenly, after a long ride in a cold, 
 damp wind, with what seemed at first to be a severe attack of indigestion. 
 Within a few hours pain became intense, with marked tenderness on pressure 
 over the appendix, soon followed by general abdominal distention. Constipa- 
 tion present. Calomel and ounce doses of Rochelle salts were given by mouth, 
 followed by an enema of Epsom salts (two ounces in hot water). After 
 copious evacuations the tenderness subsided, and in a few days he was up and 
 attending to business, though not entirely well. 
 
 On December 15th, after a heavy meal, a second attack was excited, which 
 likewise subsided upon free purgation, leaving him in the same condition as 
 before. 
 
 On January 7th a third attack occurred, which subsided but slightly after 
 above treatment. Surgical interference was then decided upon. 
 
 The operation (performed January, 1 896) was complicated by a very fat 
 and muscular abdominal wall. Appendix pointed N. and lay behind the 
 caecum, which was tied down ; meso-appendix contained a small purulent collec- 
 tion. Very fat and long omentum and meso-colon ; caecum perforated ; per- 
 foration closed under most unfavorable conditions. The appendix, which con- 
 tained a large fsecal concretion, giving it the appearance of the fundus of a gall 
 bladder, was removed. It was ulcerated ofi" the caecum. Iodoform gauze 
 drainage was carried down to and covering the sutures in caecum, in case the 
 sutures should not hold. 
 
 Recovery uninterrupted. In protecting the peritoneum and in the technic 
 of the peritoneal toilet in this operation, ninety pieces of gauze were used. 
 This case is rather exceptional, in that the gangrene occurred on the proximal 
 side of the concretion. 
 
 40 
 
Plate VI 1 
 
 Appendix ulcerated 
 off caecum 
 
 Tissue at lower end exceedingly 
 friable, slight pressure causing 
 it to break with extrusior\ of 
 coprolithi 
 
CHEONIC APPENDICITIS. 
 
 F. Zollers, age twenty-one. First attack : was seized, after eating, witli 
 acute abdominal pain, vomiting, etc. Cardinal symptoms marked. 
 
 Operation was performed on the seventh day of the disease ; a large quan- 
 tity of pus was present. Appendix was perforated in two places, at and near 
 the tip. It contained near the middle a large faecal concretion. In the plate 
 this concretion has been shown by cutting the appendix at that point. 
 Patient died two weeks after operation. Autopsy showed field of operation 
 clean. Gangrenous patch two inches in length, involving half the circumfer- 
 ence of a loop of ileum occupying the pelvis. Gangrenous patch perforated, 
 allowing escape of small quantity of fascal matter into pelvis. No pus was 
 found in the pelvis. No connection between disease of ileum and field of 
 operation. The involved coil of ileum enveloped in mass of exudate. The 
 exudate evidently the result of the peritoneal infiammation which had ex- 
 tended from the appendix by contiguity. 
 
 42 
 
Plate VI i 
 
 Proximal end 
 
 Coprolith exposed 
 
 ;/ Iriflamed and tliickened 
 meso-appendix 
 
 \ Perforation at tips 
 
 Perforation 
 
iETIOLOGY. 
 
 43 
 
 then serve as pathologic factors by mere interference with drain- 
 age, thereby preventing the emptying of the appendix. Again, 
 by constricting the lumen, and causing pressure and interfer- 
 ence with the circulation, they favor gangrene of the organ on 
 the distal side of the concretion (see case of F. Z., Plate VIII). 
 Moreover, by inducing pressure-necrosis, they allow micro- 
 
 FiG. 1. — Showing Situation of Fsecal Concretion and Dilatation of the Appendix in the 
 
 Case of Win. , Before Occurrence of Gangrene and Sloughing of Appendix, 
 
 See Plate VII. 
 
 organisms to invade the structure of the organ, and thus set up 
 the true inflammatory disease. This pressure-necrosis also in- 
 duces greater probability of a perforation. It is a well-established 
 fact, demonstrated by abdominal section performed for other dis- 
 eases, that feecal concretions are often found in perfectly normal 
 appendices, and it has also been proved that we may have 
 
44 APPENDICITIS. 
 
 acute inflammation of the appendix, and even perforation and 
 gangrene, without the presence of fsecal concretions or inspis- 
 sated mucus. In these cases it is probable that there has been 
 some interference with the circulation or with the activity of 
 the expelling force of the organ. 
 
 To sum up : I believe that there are many factors that pre- 
 dispose to appendicitis, among them being the anatomic struc- 
 ture of the appendix, its position, its inadequate drainage, 
 the length of the appendix and of the meso-appendix, a pre- 
 vious attack of local inflammation, tj^phoid fever, age, and 
 sex. I believe that all cases of appendicitis are directly due to 
 the invasion of certain micro-organisms ; that fsecal concretions 
 act as a pathologic factor by stenosis of the lumen of the 
 appendix, or by interference with the circulation, or by setting 
 up pressure-necrosis ; that there are cases in which the fsecal 
 concretions play no part in the cause of the affection ; that 
 foreign bodies, such as grape-seeds, cherry-stones, etc., may, at 
 times, be the direct cause of the invasion of the micro-organisms, 
 but that this rarely occurs. 
 
PATHOLOGY. 
 
 We recognize four stages in the pathology of appendicitis ; 
 these Fowler has given as follows : — 
 
 1. Endo-appendicitis, in which there is more or less inflam- 
 mation of the mucous membrane and sub-mucosa. 
 
 2. Parietal appendicitis, in which the inflammation attacks the 
 interstitial or intermuscular tissue of the body of the appendix. 
 
 3. Peri-appendicitis, in which inflammation attacks the serous 
 covering of the appendix, being limited by adhesions to that 
 portion of the peritoneum between the appendix and the 
 serous surfaces immediately adjoining. 
 
 4. Para-appendicitis, in which the inflammation attacks the 
 tissues in relation with the appendix. In the last stage we 
 find pus formation either localized by the limiting adhesions 
 formed during the third stage, or general involvement of the 
 peritoneum, etc. 
 
 It must be remembered that these stages are not marked by 
 distinct lines of separation, because any one of them may be 
 absent as a distinct stage, or, again, they may so merge into 
 each other that it is impossible to distinguish between them. 
 
 In an attack of appendicitis, the primary condition is 
 catarrhal inflammation. The changes are similar to those 
 of inflammation of mucous membranes in general. We 
 first notice a rapid shedding of the epithelium. The reti- 
 form tissue forming the groundwork of the mucous mem- 
 brane becomes the seat of an infiltration of leucocytes ; while 
 many of the crypts of Lieberkiihn become obliterated from 
 the pressure exerted by the infiltrate. This is followed by 
 destruction of the basement membrane and increase of the 
 
 45 
 
46 APPENDICITIS. 
 
 leucocytal infiltration, the mucosa taking the form of a 
 dense cellular layer with a raw internal surface. Numerous 
 pockets containing degenerating remains of epithelial cells are 
 
 seen (see case of Miss B , Plate IX). In the lumen will be 
 
 found leucocytes, granular debris, mucus, pus, etc., often molded 
 into a definite mass by the muscular contractions of the organ. 
 
 The outcome of the attack depends upon several important 
 factors : 1. Drainage of the organ. 2. The character and 
 virulence of the micro-organisms present, 3. The presence 
 or absence of fsecal concretions or foreign bodies. 
 
 If the appendix lies in such a position that gravity favors 
 drainage, the products of the inflammatory process may be 
 readily discharged, followed by amelioration of all the symp- 
 toms. If, however, the organ holds a position in which gravity 
 opposes drainage, there may be retention of inflammatory 
 products, with consequent increased inflammation. If the 
 lumen remains unobstructed, the debris may be expelled by 
 the peristaltic contractions of the organ. There is no doubt 
 in my mind that the peristaltic contraction plays an import- 
 ant part in appendicitis, both as regards the causation and 
 the result of an attack. In those cases in which drainage is 
 perfect, we generally find apparent recovery, and the reverse is 
 true if there is interference with the drainage. 
 
 The micro-organisms found in the first stage play a very 
 important part in respect to the outcome of an attack, both by 
 their species and by the virulence they individually possess. 
 Thus, if the colon bacillus {bacillus coli communis) is present, 
 unassociated with any other form, and if this bacillus is not 
 virulent, the attack may terminate favorably. If we find the 
 streptococcus present, we may look for a less favorable result. 
 Generally speaking, the association of two or more forms of 
 micro-organisms means a more rapid course and one of greater 
 intensity. 
 
Miss B., aged twenty years, was admitted to the hospital November 16, 
 1895, with a typical attack of acute aijpendicitis. Immediate operation was 
 performed. 
 
 Operation revealed an acutely inflamed appendix which was very tense to 
 the touch. The meso-appendix was also highly inflamed. The blood-vessels 
 were engorged and prominent. After opening the appendix masses of debris, 
 mucus, pus, and gangrenous tissue, having a very bad odor, were exposed. 
 The mucous membrane was rough and presented nearly all shades of color. 
 
 Recovery rapid and uninterrupted. 
 
 48 
 
Plate IX 
 
 Fig. I 
 
 I qf lamed 
 rneso-appendix * 
 
 ---Blood vessels 
 
 Fig. 2 
 
 Meso-appeqdix. 
 
 ^iS 
 
 
 
 Appendix oper\ed 
 sf\owir;g gangrenous 
 and purulent coqtents 
 
PATHOLOGY. 49 
 
 The action of these micro-organisms is greatly influenced by 
 the drainage of the organ, and by the presence or absence of 
 fecal concretions or foreign bodies. If fiaecal concretions or 
 foreign bodies are present, they are liable to block up the 
 lumen of the organ and thus induce the retention of inflam- 
 matory products. In this case the process will immediately 
 proceed to the second stage, and attack the parietes of the 
 organ. 
 
 If the appendix recovers after the catarrhal process has 
 been in force, there will be a replacement of the destroyed 
 mucous membrane by a tissue rich in cells. We often find a 
 cicatricial condition in this healing process of the mucous 
 membrane, that in places narrows the lumen of the canal, and 
 at times obliterates the entire cavity of the organ. Ribbert 
 makes the interesting statement that among 400 post-mortem 
 examinations of the appendix, he found 99 (25 per cent.) in 
 which there was partial or complete occlusion of the lumen of 
 the appendix (see case of H. C. D., Plate X, also Plate XI). Of 
 the 99 obliterations 16 were found to be total. There is in 
 these cases generally a disappearance of the normal glands, and 
 the walls of mucous membrane grow together, although the 
 remaining layers of the organ remain normal. 
 
 As shown by the statistics of Ribbert, there may be in a 
 small percentage of cases of disease of the appendix, if 
 checked in the first stage, perfect recovery by the total oblit- 
 eration of the lumen. This process of obliteration may begin 
 at any point and extend in either direction until complete, or, 
 as most frequently happens, it may start at the tip of the organ 
 and proceed toward the base, in this manner expelling before 
 it any inflammatory products. 
 
 If, however, the process begins at any point but the tip, we 
 shall almost always find mucus and fsecal matter confined 
 within a closed cavity. The results of this confined material 
 4 
 
50 APPENDICITIS. 
 
 may be determined by one of several conditions. There is 
 generally extension of the inflammation into the parietal 
 layers of the organ, in which case it will burrow through the 
 walls and cause perforation ; or the mass may interfere with 
 the circulation, thus causing gangrene and perforation (see case 
 of C. J. E., Plate XI) ; or by pressure it may cause necrosis of 
 the walls of the organ, ending in perforation. If the cellular 
 tissue-layer that has replaced the mucosa is exceptionally dense, 
 we shall find the material retained within the walls. As the 
 amount of the debris increases, the walls of the appendix dilate 
 to a remarkable degree and give to the organ various shapes, 
 depending upon the number and position of the constrictions 
 and upon the amount of debris contained within the lumen. 
 In one instance I found the appendix distended to such an 
 extent that I at first thought it was a small ovarian cyst. In 
 this case the constriction was at the mouth of the appendix. 
 In a second instance there was a constriction at the mouth 
 and another about the middle of the organ, with an hour- 
 glass-shaped bulging of the walls. In this connection the 
 following case may be of interest : — 
 
 LARGE CYSTIC APPENDIX. 
 
 Miss C. , twenty-five years of age, had had two attacks of appendicitis, the 
 last being very severe and complicated by general peritonitis. Temporary 
 recovery was secured under saline treatment. 
 
 Operation showed a cystic appendix the size of a small orange, and adher- 
 ent both to neighboring coils of bowel and to the right broad ligament. The 
 appendix was occluded at proximal end one-quarter of an inch from its caecal 
 attachment, and contained albuminous material. 
 
 Recovery was uneventful. 
 
 At times, instead of recovering, or instead of progressing 
 into the parietal stage, the catarrhal state lapses into a 
 chronic condition. There is marked infiltration, with decided 
 thickening and rigidity of the walls of the organ, due to 
 
CHEONIC APPENDICITIS. 
 
 H. C. D. , physician, has presented the following report : — 
 
 On July 20, 1894, I was awakened by a feeling of discomfort in the 
 abdomen, located chiefly around the umbilical region. It gradually grew 
 worse until I had severe pain in this region. I took one-fourth of a grain of 
 morphia, which gave me relief. I was able to get up and attend to my work 
 two hours afterward. There was some soreness, discomfort, and tenderness on 
 deep pressure over the region of the appendix. In four or five days I was 
 feeling very much better. 
 
 I remained apparently well until September 20th, when I had a similar 
 attack which was more severe and confined me to bed for six hours. Vomited 
 freely, principally bilious matter. After being purged freely by citrate of 
 magnesia I was relieved, but the soreness over the appendix remained for one 
 week. 
 
 For three months I had perfect health and gained in flesh. On December 
 30th I had another attack, accompanied by severe pain and distress in abdo- 
 men ; vomited freely without any relief. Stomach was irritable for thirty-six 
 hours after this ceased. I took a dose of castor oil, which acted in four hours. 
 After the first bowel movement I felt greatly relieved. Temperature ranged 
 from 99° to 10l|°. This attack was due to cold. After this attack I was not 
 well. Had more or less soreness over the appendix, attended with obstinate 
 constipation and dyspeptic symptoms. At times I had a great deal of pain 
 in right testicle. 
 
 Was operated upon March 26, 1896. Recovery. 
 
 52 
 
Plate X 
 
 Pus cavity 
 
 Poiqt of parti a 
 occlusioq 
 
 hesions to coil of ileum 
 J sing acute flexure 
 
 Pus cavity 
 
 Orrieqtat adhesioris 
 
 Fig, 2 
 
ACUTE APPENDICITIS. 
 
 C. J. E. , age fifty-six, was taken suddenly ill on the evening of July 23, 
 1895, with severe abdominal pain. Examination by attending physician dis- 
 closed a distended abdomen and local tenderness in the right iliac region. Had 
 pain with persistent tenderness over region of appendix. Grave a history of 
 several similar attacks which had been treated as ordinary colic. The evening 
 of the second day I saw the patient and advised operation, which was delayed 
 for two days. Operation disclosed a very long and gangrenous appendix lying 
 post-caecal and post-colic ; perforated ; bathed in pus ; contained several faecal 
 concretions. Pus in pelvis. Grlass and gauze drainage were used. Recovery 
 followed. 
 
 Remarks. — Patient the subject of chronic interstitial nephritis. For two 
 days following operation vomiting and hiccough were persistent. 
 
 54 
 
.-Fsecal concretion 
 
 Plate XI 
 
 .Perforation 
 
PATHOLOGY. 55 
 
 great increase of the fibrous element. This thickening and 
 rigidity prevent the collapse of the walls, hinder obliteration? 
 and interfere with peristaltic contractions of the organ, thus 
 rendering difficult the expulsion of any inflammatory products 
 present. The lining membrane continues as a pus-secreting 
 granulation-tissue. 
 
 In the second stage of the disease, there is inflammatory 
 involvement of the muscular walls of the appendix, with 
 slight encroachment upon the serous covering. Although 
 this may be induced by infection along the lymphatics with- 
 out involvement of the mucous lining of the tube, it is 
 generally secondary to the first stage. There is engorgement 
 of the organ with deposit of exudate in the perivascular 
 tissue. The appendix is enlarged, congested, and hard. We 
 often find ulcers in the walls, caused by the pressure of the 
 exudate in the interstitial tissues, extending into the lumen of 
 the organ and by perforation soon communicating wnth the 
 peritoneal cavity (see case of Mrs. R., Plate XII). These 
 ulcerations may also be due to a necrotic process caused by 
 the pressure of a fsecal concretion or foreign body. The con- 
 cretions are generally soft and friable. They may harden, 
 however, as the disease progresses, on account of the deposi- 
 tion upon their surfaces of lime-salts, usually the carbonate 
 and the phosphate of lime. As the pressure increases, the 
 epithelium, the mucous membrane, the submucosa, the mus- 
 cular layer, and, finally, the peritoneum are in turn destroyed, 
 and the pressing mass is expelled into the abdominal cavity. 
 Perforation caused in this way, however, cannot always be 
 ascribed to an ulcerative process, as evidences of inflammation 
 are often absent. In these instances the destruction of the 
 tissues is due to an atrophic condition produced by pressure. 
 
 Gangrene may be caused by interference with the circulation ; 
 by pressure ; by strangulation due to twisting of the appendix. 
 
56 APPENDICITIS. 
 
 or by embolism of the solitary artery or one of its branches. 
 In this stage we often find a rapidly spreading phlegmonous 
 inflammation due to the formation of pus, or, as demonstrated 
 in the case reported on page 95, the pus may be collected in 
 minute abscesses. 
 
 In this stage paresis of the appendix is often found conse- 
 quent upon the inflammatory infiltration of its muscular coats. 
 This paralysis interferes with the expelling force of the organ, 
 and thus gives the debris and micro-organisms an opportunity 
 to collect in the canal and hasten the process into the third 
 stage. 
 
 In the third stage we find the peritoneal covering of the 
 appendix severely affected. There are adhesions between the 
 appendix and the adjacent serous surface, thus limiting the in- 
 flammation and, in case of pus formation, forming a barrier 
 against infection of the general peritoneal cavity (see case of 
 M. S., Plate XIII). If these adhesions are strong and plenti- 
 ful, thus forming a firm wall around the inflamed area, we 
 shall have the inflammatory process confined entirely to the 
 right iliac fossa. The disposition of this wall of adhesions 
 plays an important part in the subsequent treatment of the 
 disease, — so far, at least, as the removal of the appendix is 
 concerned. The adhesions may form between the csecum and 
 the adjacent coils of intestine and the parietal layer of the 
 peritoneum (see case of Mrs. H., Plate XIV). In this condition 
 the appendix will lie free in the enclosed area. In other states 
 the appendix and part of the csecum will be confined within 
 the walls of adhesion (see case of M. T., Plate XV) ; or the base 
 of the appendix may be outside the enclosed area, part of the 
 appendix forming a portion of the wall and the rest emerging 
 into the portion of the right iliac fossa that is shut in by the 
 limiting membrane. In any of these instances, the proper 
 procedure in the treatment is to remove the organ, even if the 
 
CHRONIC APPENDICITIS. 
 
 Mrs. R. , age thirty. Had always been rather deUcate, but enjoyed a com- 
 paratively good degree of health except for a chronic intestinal dyspepsia of 
 mild character with occasional exacerbations. In May, 1895, she had an 
 attack of what was believed to be intestinal indigestion of more than usual 
 severity, accompanied by diarrhoea and pain referred to region of appendix ; 
 recovered in a few days. December 7, 1895, she was suddenly seized with 
 acute agonizing pain in abdomen, followed by rigidity of whole abdominal wall 
 and diflFuse tenderness. This condition yielded to the administration of laxa- 
 tives and to hot applications locally. Nausea and vomiting, which at first 
 were persistent, gradually subsided, with the tenderness becoming localized 
 over the appendix. The temperature never rose above 102°. 
 
 On the tenth day a slight exacerbation of pain was caused by an indiscre- 
 tion in diet. Two hypodermics of morphia were given in the course of the 
 attack of pain, to quiet nervous excitement. Copious enemata were admin- 
 istered twice daily, and rectal feeding instituted until the stomach became 
 quiet and retentive. 
 
 Although patient was recovering satisfactorily, operation for the removal 
 of the appendix was decided upon and performed January 18, 1896. 
 
 The operation showed the appendix enlarged, congested, and hard, and a 
 point of beginning ulceration near the tip. Upon opening the appendix the 
 mucous membrane at the base was found much inflamed and thickened, pre- 
 senting superficial ulcerated areas. The lumen beyond the ulcerated part was 
 totally obliterated. 
 
 The recovery was uninterrupted, and was followed by decided improvement 
 of the old condition. 
 
 58 
 
Fig. I 
 
 Point of beginniqg ulceratiori 
 
 Fig. 2 
 
 Plate XII 
 
 Inflarqed aqd thickened 
 mucous membrane 
 
 Obliterated lumen 
 
PATHOLOGY. 59 
 
 wall has to be broken through, for in no other way can we 
 assure ourselves that we have removed all chance of subse- 
 quent complications. 
 
 At this period there is marked engorgement of the peri- 
 vascular tissues, swelling and hardening of the organ. We 
 may find dark and soft necrotic patches containing within the 
 tissues colonies of micro-organisms ready to perforate. Gan- 
 grene will often be noticed, due to interference with the cir- 
 culation. In either the second or third stage, as will be 
 explained later, we are likely to find necrotic or gangrenous 
 patches in the meso-appendix, caused by obstruction of the 
 circulation. 
 
 In the fourth stage, there is involvement of the para-appen- 
 dicular tissues, associated with pus formation, which is due to 
 direct invasion of pus through a perforated or gangrenous 
 appendix, or to the spread of the phlegmonous inflammatory 
 process along the contiguous tissues. If, during the third 
 stage, the course of the inflammation has been slow enough to 
 allow nature to throw a strong retaining wall around the 
 aflected area, we shall find the results of this stage limited by 
 the boundary-membrane. Very often the process has been so 
 rapid in its course that nature has had no opportunity to 
 protect the surrounding structures, and the result is that we 
 find involvement of the peritoneum, generally in the form of 
 a purulent inflammation, with pus free in the peritoneal 
 cavity and in the pelvis. If the pus is limited to the right 
 iliac fossa we may have a period of apparent quiescence so far 
 as any more extensive trouble is concerned, or we may find 
 the pus burrowing in almost any direction, or ending in 
 metastasis along the various lymphatic or blood channels. 
 Thus, in the following case, the history of which has been 
 furnished by Dr. 0. Rath, the abscess had worked its way 
 upward behind the liver and inward to the vertebral column. 
 
60 APPENDICITIS. 
 
 November 25, 1895, I was called to see W. D. H., physician, thirtj'--one 
 years old. He had been sick since November 22, 1895, suffering from a severe 
 follicular tonsillitis. Previous history negative, with exception of an attack 
 of pneumonia during childhood. At first visit he complained of severe pain 
 over the stomach, nausea, loss of appetite, constipation, and violent headache. 
 On examination found temperature 102°, pulse-rate 100, respiration 26. No 
 action of bowels for two days ; nausea, but no vomiting. The abdomen was 
 much distended ; severe pain on pressure over epigastric region, with slight 
 pain and resistance on pressure in the right iliac fossa. Lungs and heart 
 negative. Urine high-colored, slight amount of albumen, and a few granular 
 casts. 
 
 November 26th and 27th, continuous vomiting of biliary matter. Vomiting 
 was relieved by cocain and bismuth subnitrate. The bowels were moved by 
 small doses of calomel. November 28th, vomiting ceased. Condition about 
 the same, no pain in right iliac fossa, but pain over epigastrium as before. 
 Temperature 101° to 102°, pulse-rate 90 to 110, respiration 24. Patient 
 restless ; no sleep except after injections of morphia sulph. Bowels moved 
 only after the administration of calomel or glycerin enemata. This condition 
 continued until December 7th, 4 P. M. , when the patient had a slight chill 
 followed by a temperature of 105°, pulse 150, respiration 40. At 9 A. M., 
 December 8th, a second chill ; temperature rose to 104°, pulse 130 ; three grs. 
 quinine, and stimulants administered every two hours. 
 
 December 9th and 10th, chills, followed by profuse sweating. December 
 11th to 15th no chills, but slight sweating. Temperature from 101° to 102°. 
 Condition otherwise the same ; pain in epigastrium as before and over region 
 of liver. December 1 5th and 16th, severe chills followed by sweating in after- 
 noon ; patient very restless, and had had no sleep for three or four nights. 
 On examination, cedema and dilated veins over region of liver were noticed ; 
 pain in right iliac fossa upon deep pressure ; pain over stomach the same. 
 December 17th, Dr. J. B. Deaver in consultation. December 18th, patient 
 was removed to the German Hospital. 
 
 Post-Mortem. — Thorax. — No effusion. Adhesions over right and left 
 apices and left base. 
 
 Lungs. — An old tubercular lesion in left apex about the size of a walnut 
 healed by fibroid calcareous changes. Congestion and cedema in remaining 
 portions. 
 
 Heart. — Cloudy swelling of myo-cardium ; no valvular lesions. 
 
 lAoer. — G-all ducts patulous. In removing liver and cutting through the 
 suspensory ligament, there was a gush of purulent fluid apparently sub- 
 diaphragmatic. On further investigation there was found an opening in the 
 upper back part of the right lobe. An abscess was discovered, about the size 
 of an apple, occupying the right lobe and lobus quadratus. 
 
 Pancreas. — Normal. 
 
 Kidneys. — Cloudy swelling of parenchyma and cortex. 
 
 Appendiv. — Appendix lay post-caecal and post-colic, was perforated and 
 surrounded by pus, which was in communication with the collection found be 
 hind the liver. 
 
ACUTE APPENDICITIS. 
 
 M. S. , female, twelve years of age, was admitted to the Grerman Hospital 
 January 22, 1 896. She had been ill six days with severe abdominal pains. The 
 child was constipated ; the attending physician ordered an enema ; owing to 
 continued pain, castor oil, and, later, salines were prescribed. The patient's 
 condition not improving, the physician advised removal to the hospital for 
 operation. 
 
 The appendix, post-caecal, was bound down by adhesions. It was nearly per- 
 forated at various points and contained a small quantity of pus. The tissues 
 were covered with a large quantity of lymph. There was no pus in the pelvis. 
 Gauze packing was used. 
 
 Recovery followed. 
 
 62 
 
Plate XI I 
 
 .Adhiesioqs 
 
 -..Plastic lymph 
 
 Front view 
 
 Threatened 
 perforation 
 
 -Garigrerious spots 
 
 """"--Plastic lymph 
 
 Back view 
 
PATHOLOGY. 63 
 
 Jn another case the pus had burrowed along the iliac 
 vessels, and had presented on the anterior surface of the 
 thigh, near the knee. If the appendix holds a southerly 
 position we shall find the pus in the pelvis. 
 
 The lymph-spaces found in the lymphoid tissue and the 
 lymphatic vessels of the appendix and the meso-appendix 
 may become occluded by the exudate, or, together with the 
 veins, they may become the channels through which septic 
 infection takes place. Lymphangitis, from infection, may 
 extend to the lymph-channels of the colon and mesentery 
 and thus set up widespread inflammation. Following this 
 condition we often find a general non-purulent peritonitis: the 
 inflammation becoming purulent through invasion from the 
 intestine brought about by the increased virulence of the 
 micro-organisms. 
 
 The veins of the appendix are often the seat of thrombi, the 
 result of infection, and in these cases we may find an exten- 
 sive thrombo-phlebitis, pyle-phlebitis, portal embolism, and 
 abscess of the liver. The last may be found in any stage of the 
 disease, and often occurs in cases that are apparently too mild 
 to attract attention to the original seat of the trouble. 
 
 The arterial supply of the appendix is often so interfered 
 with that it gives rise to striking and interesting phenomena. 
 The appendicular artery is the seat of a proliferating endarte- 
 ritis, round sloughs forming at the openings of the arterial 
 twigs, causing obliteration of their calibre. This brings about 
 a gangrenous condition of the part supplied by the particular 
 twigs affected. At times on account of a deficient blood supply 
 the whole appendix sloughs. When the endarteritis does not 
 cause total occlusion of the vessel, we find a slow ulcerative 
 process in the parts supplied by the affected branches. The 
 endarteritis present is caused by septic infection, the intima as 
 a result undergoing rapid proliferation (Morris). 
 
64 APPENDICITIS. 
 
 The infection may travel along the sub-peritoneal connective 
 tissue and cause phlebitis of the veins of the lower extremity. 
 Through this method of infection, we may find encysted extra- 
 peritoneal foci of suppuration, the limiting walls being formed 
 by adhesions due to infection. 
 
 The nerves of the appendix are affected by an acute inflam- 
 mation during the progress of the disease, and the result of this 
 nerve-complication may be found long after the symptoms of 
 the attack have subsided. In the cicatricial condition following 
 apparent recovery, we may have the nerve-fibres so pressed 
 upon by the contracting tissues that they will be the cause of 
 constant discomfort. Another cause of this condition may be 
 the sclerosed condition of the nerves themselves, the interstitial 
 connective tissue undergoing marked hypertrophy. I can 
 recall cases in which the appendix had almost entirely disap- 
 peared, the remnant being but a fibrous cord, and yet the 
 patient presented the marked pain and tenderness of chronic 
 inflammation. The invalidism present was no doubt caused 
 by this sclerosed condition of the nerves. The following case 
 will illustrate this condition : — 
 
 On October 17, 1893, I. E. T., age fourteen, was taken with severe cramps 
 in his abdomen. Similar attacks, but not nearly so severe, were always relieved 
 by teaspoonful doses of paregoric. The attacks had always been produced by 
 indiscretion in diet. 
 
 When seen the morning of the 18th he was suffering very much and com- 
 plained of severe pain all over the abdomen, which was associated with 
 general abdominal tenderness and decided rigidity of the abdominal walls, but 
 more severe in the right iliac region. His stomach was irritable ; he vomited 
 dark-greenish fluid. Temperature 102°, pulse 120. Diagnosis, acute appen- 
 dicitis with general peritonitis. 
 
 Minute doses of calomel were given which allayed the irritability of the 
 stomach ; this was followed by small doses of saline, when he was purged freely. 
 Turpentine stupes and flaxseed poultice locally. He gradually improved from 
 day to day, and in two weeks was convalescing. After the severe attack he 
 always complained of soreness and discomfort in the region of the appendix. 
 Palpation over this region never failed to elicit tenderness, though the ap- 
 pendix could not be made out. 
 
CHRONIC APPENDICITIS. 
 
 In the following case the patient was the wife of a physician, and he has 
 kindly furnished me with a detailed history and analysis of the treatment. 
 
 ]Mrs. H. early in April, 1895, had several attacks of abdominal pain accom- 
 panied by diarrhoea. (These attacks were not considered of any importance.) 
 On April 28th, another severe attack came on suddenly at 2 A.M. At 10 A.M. 
 she had excruciating pain, which, though general throughout her bowels, was 
 particularly severe in the region of the navel and right iliac fossa. The pain 
 finally became localized in the right side, and was accompanied by extreme 
 tenderness, nausea, vomiting, and diarrhoea. Her physician gave her a 
 hypodermic of morphia ; had hot poultices applied and ordered small and 
 repeated doses of calomel. The abdomen soon became distended ; the pain 
 and tenderness increased, and on palpation thickening and induration were 
 detected. Appendicitis was diagnosed. Consultation was held as to the 
 advisabihty of operation, but was not concurred in, as the consultant held that 
 it was not a case of appendicitis, but ordinary catarrh of the bowels. 
 
 Discontinued the morphia and continued the poultices ; and also ^^ grain 
 doses of calomel, on account of the constipation which had followed the original 
 diarrhoea. For the first week, there was little change in her symptoms, calomel 
 kept the secretion in a liquid condition. After the first week she showed signs 
 of improvement, but upon the slightest touch she complained of soreness, and 
 the induration remained. Four weeks from the time of the last attack her 
 condition was fair, and upon other advice operation was decided upon. 
 
 Operation : Parietal peritoneum not adherent. Mass of omentum covering 
 and adherent to caecum, which was deeply congested and infiltrated, resembling 
 in appearance a cock's comb. Adherent omentum freed, tied ofi", and cut away. 
 Caecum exposed with small collection of foul pus post-caecal. Appendix 
 adherent to caecum. Appendix liberated and tied ofi" and removed, when per- 
 foration was seen both in caecum and appendix, allowing the appendix to empty 
 its contents into the caecum. Margins of perforation in the caecum freshened 
 and the opening closed. Gauze drainage. Wound closed up to point of exit 
 of drain with interrupted worm-gut sutures. 
 
 Recovery, though somewhat tedious, owing to a stitch abscess, was com- 
 plete. 
 
 66 
 
Plate XIV 
 
 Appendix adherer[t to caecunri 
 
 Appendix dissected off sl^owiqg perforation into caecum 
 
 Perforation upoq detaclied surface of appendix 
 
ACUTE APPENDICITIS. 
 
 M. T., age twenty-one years, a theological student, was admitted to the 
 German Hospital December 11, 1895. The first attack occurred one year 
 before admission, characterized by severe pain in the right iliac fossa and 
 vomiting. He was confined to his bed for five days. In June, 1895, he had 
 another slight attack. One week before admission he was seized with violent, 
 cramp-like pains and severe vomiting, with temperature 102°. Examination 
 showed marked tenderness in the right side, rigidity, and swelling. 
 
 The operation, performed December 12, 1895, revealed an appendiceal 
 abscess with considerable foul-smeUing pus. The appendix pointed S. E., 
 was imbedded in the abscess wall, and perforated near the middle. It was 
 long, much thickened, and covered with plastic lymph ; it was about the size 
 of an adult finger and very friable. Faecal concretions were found in the 
 abscess cavity. Gauze drainage was used. 
 
 Patient made a good recovery. 
 
 G8 
 
PATHOLOGY. 69 
 
 Operation the following May showed an obliterated appendix, with two 
 small adhesions. 
 
 Recovery uninterrupted, with complete cessation of previous symptoms. 
 
 The interference with the abdominal sympathetic accounts 
 for the neurasthenic condition which in some cases precedes or 
 follows operation. 
 
 Any of these complications mentioned above, — thrombo- 
 phlebitis, pyle-phlebitis, portal embolism, abscess of the liver, 
 infective peritonitis, neuritis, lymphangitis, — prove that at any 
 period there may be invasion through the lymph-spaces. 
 Any of the stages may develop independently of the others, 
 and in the course of the disease we may find the changes of 
 one stage with little, if any, evidence of the other. This is 
 accounted for by the various channels of infection. 
 
 Summary. 
 
 Four stages in pathology, but no distinct line of demarcation 
 between them : — 
 
 1. Endo-appendicitis. 
 
 2. Parietal-appendicitis. 
 
 3. Peri-appendicitis. 
 
 4. Para-appendicitis. 
 
 The primary condition is catarrhal inflammation followed 
 by microbic invasion. Outcome of attack depends upon : — 
 
 1. Drainage. 
 
 2. Character and virulence of micro-organisms. 
 
 3. Presence or absence of faecal concretions or foreign 
 bodies. 
 
 Cicatricial tissue prominent following catarrhal inflamma- 
 tion, but complete obliteration by it rare. 
 
 Ulceration of appendix walls frequent, and caused by inter- 
 stitial exudate or pressure necrosis. 
 
 Gangrene due to : — 
 
 1. Interference with circulation. 
 
 2. Twisting of appendix. 
 
 3. Embolism of solitary artery or branch. 
 
70 APPENDICITIS. 
 
 Paresis of appendix common and due to inflammatory^ infil- 
 tration of muscular wall. 
 
 Adhesions between appendix and adjacent serous surfaces 
 limit pus collections. 
 
 In some acute cases there is not time enough for adhesions 
 to form and pus is found free in the general peritoneal cavity. 
 
 Local and general infection, with suppurative foci in distant 
 parts, as liver, takes place by means of lymphatic and venous 
 channels. Nerve filaments of appendix are irritated by inflam- 
 matory exudate and cicatricial contraction and give rise to 
 reflex pain. 
 
 Bacteriology. 
 
 Although the micro-organisms of appendicitis belong to a 
 consideration of the aetiology of the disease, I prefer to describe 
 them in connection with the pathologic changes they induce, 
 as the part they play in the disease can be thus more readily 
 understood. 
 
 Investigators have found about fifteen varieties of micro- 
 organisms in the normal intestine of man, although only four 
 of them are clinically prominent, viz. : the bacillus coli com- 
 munis ; the staphylococcus pyogenes aureus; the streptococ- 
 cus pyogenes ; and the proteus vulgaris. The micro-organisms 
 line the intestine, being separated from the absorptive lym- 
 phoid tissue by a thin basement membrane. 
 
 The same condition is found in the normal appendix. In 
 all investigations, the bacillus coli communis has been the one 
 most frequently found, pure cultures of it having been made 
 not only from the normal, but from the diseased intestine and 
 appendix. 
 
 On account of its lessened vitality and its anatomic peculi- 
 arities, invasion of the appendix occurs more frequently 
 than that of any other part of the intestinal tract. The 
 appendix is a useless organ, undergoing retrograde metamor- 
 phosis, its powers of resistance being, necessarily, decreased. 
 
Plate XV 
 
 Perforation 
 
 Pus cavitL] -•-■ 
 
PATHOLOGY. 71 
 
 The intestine, on the other hand, is always active, and if 
 it is in a fairly normal condition, can resist almost any direct 
 invasion. The appendix, moreover, is a dependent pouch, 
 with a common entrance of ingress and egress, and is thus a 
 favorable nidus for the collection and multiplication of germs, 
 whether pathogenic or non-pathogenic. Anything that inter- 
 feres with the drainage of the organ, either by obstructing the 
 lumen or impairing the force of its peristaltic contractions, 
 adds to the probability of infection. 
 
 The most important determining cause of an invasion by the 
 micro-organisms is the existing virulence of the colon bacilli. 
 The variability of the virulence of the bacillus coli communis 
 is probably greater than that of any other known micro-organ- 
 ism. Why this is so, what it is that causes this change in the 
 virulence of the germ, is not understood, but that it is so is 
 clearly demonstrated in the pure test-tube cultures, the growth 
 in some being much more active than in others ; while inocu- 
 lations from the different tubes show decided differences in 
 degree of virulence. If the colon bacillus is non-virulent the 
 appendix may possess the resistant power required to over- 
 come its action ; but if this bacillus is virulent, the resistant 
 strength of the appendix will be of little account. Hodenpyl, 
 in an investigation of 61 cases of peritoneal inflammation 
 consequent upon appendicitis, obtained the colon bacillus in 
 57 cultures, and in 50 of these it was unassociated with any 
 other germ. In cases of mixed infection, we generally find 
 the staphylococcus or the streptococcus associated with the 
 colon bacillus, the latter combination being much more 
 intense in its action. 
 
 The character of the attack depends, to a great extent, upon 
 this infection ; upon the power of resistance possessed by the 
 organ at th'e time of the invasion ; upon the condition of the 
 lymphatics and blood-vessels ; and upon the condition of the 
 
72 APPENDICITIS. 
 
 muscular coats of the organ. We may, however, have just as 
 severe cases in which the bacillus coli communis is the only 
 factor in the causation. If the lymphatics, blood-vessels, and 
 muscular fibres are in a healthy and active condition, there is 
 less liability of a severe attack, as the appendix will be enabled, 
 at least to some extent, to check the disease. If the opposite 
 conditions prevail, the micro-organism will have full play, and 
 the severity of the attack will be correspondingly increased. 
 Thus, if we have the debris of mucus, and fsecal matter re- 
 tained within the appendix, or if fsecal concretions are present, 
 there will necessarily be a greater degree of inflammation and 
 a more rapid course of the disease. 
 
 As before mentioned, the outcome of the micro-organismal 
 invasion will be modified by the freedom of drainage to a 
 greater extent than by any other factor. At times the layer 
 of cellular tissue that replaces the mucous membrane is so 
 dense that it resists the invasion of micro-organisms, but 
 dilates under the increased pressure caused by the contained 
 action of the germs, and in such cases we find the hour- 
 glass-shaped bulging of the walls of the appendix, or, if the 
 obstruction be at the entrance to the canal, the ballooning of 
 the whole length of the organ. 
 
 The micro-organisms of typhoid fever, of tuberculosis, and of 
 actinomycosis have been found in the appendix, but their 
 presence in this locality is rare. 
 
SYMPTOMS. 
 
 In considering the symptoms of appendicitis, it must be 
 borne in mind that it is not always possible to determine the 
 pathologic change by the apparent symptoms. Any attempt 
 to describe symptoms which positively indicate the progress 
 of the disease would be futile. While it is true that the 
 symptoms become more marked when perforation, pus forma- 
 tion, or gangrene supervene, it is also a fact that remission 
 of all the symptoms, except local tenderness, may occur, and 
 yet the disease may be progressing steadily to a fatal termina- 
 tion. 
 
 I shall speak of two forms of appendicitis, the acute and 
 the chronic. 
 
 The acute form embraces those varieties described as ulcera- 
 tive, perforative, and gangrenous. These terms represent 
 only the differences in the degree of local inflammation, 
 between which it is clinically impossible to draw a line of 
 distinction. It, therefore, appears more practical to describe 
 them under one collective heading. The same is true of 
 chronic appendicitis, under which heading are included the 
 varieties described as subacute, relapsing, and recurrent. 
 
 There are three symptoms of appendicitis so constant, and, 
 when associated, so characteristic of the affection, that I style 
 them the " Three Cardinal Symptoms ; " these are pain, 
 tenderness, and rigidity, each of which I will describe in 
 detail. 
 
 Pain is the initial symptom, and usually follows the 
 ingestion of foods, either indigestible, improperly masticated, 
 or hastily swallowed. At the onset, the character of the pain 
 
 73 
 
74 APPENDICITIS. 
 
 is paroxysmal and colicky, to this extent simulating an 
 attack of acute indigestion or bilious colic. The term appen- 
 dicular colic has been applied to this initial pain, but to this 
 name objection has been raised, since the cause of pain is 
 inflammatory and not functional. While acknowledging such 
 to be the case, I am, nevertheless, convinced that the pain may 
 be paroxysmal because otherwise it is difficult to explain 
 the wave-like exacerbations, so vividly described by intelligent 
 patients. 
 
 Palpation over the affected area, motion involving the 
 action of the right psoas muscle, bending the body to the 
 left, deep inspirations, or coughing, — all these excite and 
 intensify the peculiar, undulating, characteristic pain. As 
 the pain is partly due to appendiceal inflammation, its general 
 colicky character is probably the result of irritation, reflected 
 along the numerous branches of the superior mesenteric 
 plexus of the sympathetic, one of which supplies the appendix. 
 This irritation is held to be the result of the presence of fsecal 
 concretions or foreign bodies. I cannot think that the 
 mere presence of these substances will account for the irrita- 
 tion, as we are compelled to acknowledge the fact that such 
 are found in many normal appendices. And again, we have 
 attacks of this colic due co disease of the appendix, in which 
 the lumen is entirely free from all concretions. In its efforts 
 to expel material from its canal, the peristalsis of the appendix 
 has been given as a definite cause of this irritation, but I 
 cannot entirely agree with this view, because of the fact that, 
 without any such symptoms, the normal appendix empties 
 itself during health. I believe, however, that the paroxysms 
 of colic are largely due to the erratic peristalsis of the inflamed 
 appendix, induced by the effort to rid itself of foreign material. 
 Fowler has taken exception to the term appendicular colic, 
 offering as an argument against it the fact of the imperfect 
 
SYMPTOMS. 75 
 
 development of the circular muscular fibres of the appendix, 
 whence its inability by expulsive efforts to cause colicky pain. 
 I cannot agree with this view, and particularly as regards the 
 absence of circular muscular fibres, as this organ possesses a 
 continuous circular muscular coat. I grant fthat the circular 
 muscular fibres are not always so well developed as the 
 longitudinal ones, but I am convinced that the appendix 
 usually possesses sufficient contractile power to cause colicky 
 pain by muscular contraction. The study of pathologic 
 appendices cannot be relied upon to demonstrate normal 
 histologic facts. The dissection of normal appendices proves 
 the presence of circular muscular fibres. The irritation, 
 arising from simple catarrhal inflammation of an appendix, 
 in which there is no faecal concretion or foreign body, is 
 capable of inducing expulsive efforts that cause colicky pain, 
 just as in an inflamed rectum or bladder. Under such cir- 
 cumstances, the presence of a foreign body serves merely to 
 intensify the pain. 
 
 The Location of Pain. — As described by the patient, the 
 primary pain is most frequently referred to the umbilicus or 
 peri-umbilical region ; next in order of frequency to the epi- 
 gastrium ; and last of all to the region of the appendix. In 
 fact, the pain of appendicitis may be referred to any portion of 
 the abdomen. And this it is that has led to so many mistakes 
 in diagnosis. After the occurrence of localized peritonitis in 
 the right iliac fossa the pain is there located. Not infrequently 
 it is referred to the left side of the abdomen. 
 
 The location of the secondary pain to a large extent depends 
 upon the position of the appendix. If the appendix is long, 
 with its tip overhanging the brim of the pelvis, the pain will 
 be referred to the left side of the abdomen, along the course 
 of the spermatic cord toward the testicle, or to the pelvis. If 
 the appendix is post-csecal and pointing north, the pain may be 
 
76 APPENDICITIS. 
 
 referred to the loin or back ; at times, if the appendix points 
 north, lying either in front or back of the caecum, the pain 
 may be referred to the kidney or to the liver. As a rule, 
 the pain will be more marked in the right iliac fossa. If, 
 however, the tip of the appendix occupies the left iliac fossa 
 the greatest amount of pain will be referred to that region. In 
 a certain class of chronic cases the pain which is increased on 
 motion may be referred to the leg along the course of the 
 anterior crural nerve or even to the knee. This occurs when 
 the appendix occupies the pelvis. 
 
 The Character of the Pain. — Too much stress cannot be laid 
 upon the paroxysmal nature of the initial pain. In fact, I 
 have seen numerous cases in which this has been attributed to 
 biliary or nephritic colic, being quite as severe as in those 
 affections. 
 
 Tenderness upon pressure is one of the most valuable and con- 
 stant of all the signs of appendicitis. It is always present. If 
 the appendix is post-csecal and the rigidity of the abdominal 
 walls marked, the tenderness is more difficult to elicit, and 
 requires deep palpation. It is sometimes best elicited through 
 the rectum or vagina. In women the possibility of a right- 
 sided pyo-salpinx or salpingitis must also be borne in mind. 
 In rare cases the tender spot ma}'^ be located in the loin, and 
 discovered only by deep palpation. After the advent of sup- 
 puration with the increased amount of pus the tenderness in 
 the right iliac fossa becomes more general. Frequently after 
 the remission following the sudden, sharp primary attack, 
 tenderness and rigidity alone remain to tell the attending 
 physician that trouble still exists. The point of greatest in- 
 tensity is usually over the inflamed appendix, but to this rule 
 there are exceptions. Recently in a young adult male I found 
 the point of greatest tenderness to the left of the left rectus 
 muscle, a little above the level of the anterior superior spine 
 
SYMPTOMS. 77 
 
 of the ilium. By rectal examination a small but very sensi- 
 tive mass was detected occupying the recto-vesical space. 
 Operation demonstrated the appendix occupying this position. 
 The point of greatest intensity, however, usually corresponds 
 to the so-called McBurney's point, which is located midway 
 between the umbilicus and the right anterior superior iliac 
 spine, 
 
 I recall two cases in which the point of greatest tenderness 
 was immediately above the middle of Poupart's ligament. 
 This, as demonstrated by operation, corresponded to the angle 
 of curve in the appendix ; in both cases the origin was from 
 the postero-external aspect of the base of the caecum, descend- 
 ing in front of the latter as far as the apex, where it abruptly 
 curved upward. 
 
 Rigidity of the Abdominal Walls. — Next to pain this is one of 
 the most reliable signs. It is usually confined to the right side 
 of the abdomen, is most marked over the inflamed region, and 
 immediately follows the localization of pain in this locality. 
 In some instances the rigidity is so pronounced that it pre- 
 vents deep palpation, and in addition makes the percussion- 
 note of higher pitch. When the pain has been referred to the 
 left side and suppuration has supervened, the pus collection 
 occupying the pelvis, there will be marked bilateral rigidity of 
 the recti muscles and of the lower abdominal wall. 
 
 Although the " three cardinal symptoms " are the most im- 
 portant indications of appendicitis, there are others presenting 
 themselves with more or less regularity. Among these should 
 be noticed disturbances of the gastro-intestinal tract, elevation 
 of temperature, increase of the pulse-rate and of the respiration, 
 abnormality of the urine, etc. 
 
 Vomiting. — Coincident with the onset of the initial pain 
 there may be vomiting. In favorable cases this usually does 
 not persist, and subsides with the localization of pain in the 
 
78 APPENDICITIS. 
 
 right iliac fossa ; in unfavorable cases it is continuous and un- 
 controllable. The ejecta consist first of the gastric contents, 
 later of bile, and lastly, if intestinal paresis has followed a 
 septic peritonitis, of stercoraceous matter. When the vomitus 
 becomes stercoraceous, it is thrown off by regurgitation, and 
 indicates a fatal termination. Nausea and vomiting may 
 sometimes be absent. 
 
 Constipation. — In the majority of cases of appendicitis con- 
 stipation is present, but diarrhoea sometimes ushers in the 
 attack, particularly in those cases which from the onset bear 
 an unfavorable appearance. Obstinate constipation early in 
 the disease is due either to intestinal paresis, the result of 
 infection, or to the indiscriminate use of opium. Although 
 these conditions seem to play but little or no part in the 
 causation of an attack, the bowels being previously in a 
 normal condition, yet, as soon as infection takes place, there 
 is almost always a decided change. This constipation, with 
 vomiting, has in the early stage of the disease led to many 
 errors in diagnosis, the affection of the appendix having been 
 mistaken for acute strangulation or some other form of intes- 
 tinal obstruction. The constipation is probably due to reflex 
 paralysis of the large bowel. 
 
 The temperature and the pulse-rate bear no direct relation to 
 the gravity of the attack. At the onset there is usually an 
 elevation of temperature varying from 100° to 102° or 103° F. 
 We may have early perforation and gangrene of the appendix 
 with but a moderate rise of temperature ; on the other hand, 
 there may be a decided rise with a simple catarrhal inflamma- 
 tion. The pulse in the former class, i. e., those with early per- 
 foration and gangrene, more nearly corresponds to the gravity 
 of the attack. A sudden fall of temperature to the normal or 
 subnormal by no means warrants a favorable outlook, as it too 
 often indicates the lull immediately preceding the storm of 
 
SYMPTOMS. 79 
 
 destruction, perforation, or a ruptured abscess. The thermom- 
 eter is, therefore, a most unreliable instrument as an indicator 
 of the gravity of an attack. 
 
 Restlessness. — Marked restlessness occurring in the course of 
 an attack, especially in children, denotes the presence of pus. 
 
 Tumescence. — In a few cases there will be a bulging of the 
 right iliac region not due to distention of the bowel. This is 
 not frequently observed unless an abscess is present. 
 
 Abdominal distention may be due to several causes: to 
 mechanical obstruction by bands of adhesions; to paralysis 
 of the intestine ; to septic causes ; to obstinate constipation 
 with resultant collection of gas. Richardson points out the 
 possible differential diagnosis, by means of auscultation, 
 between distention due to accumulated gas and that due 
 to paralysis of the intestine the result of infection, the sounds 
 of peristaltic action being clearly heard in the former condi- 
 tion but not in the latter. The distention may sometimes be 
 limited to the right side of the abdomen ; in this condition 
 only that portion of the gut contiguous with the inflamed 
 area is affected. This local distention may be marked, because 
 the still functionally active intestine will force more gas into 
 the affected portion. If peritonitis becomes diffused, the 
 abdomen, though generally distended, is sometimes flat with 
 its walls rigid and hard, a condition appearing early and 
 arising from the complete paralysis of the intestinal canal, 
 which prevents the entrance of gas. A distended abdomen, 
 or one in which the distention is particularly marked over the 
 epigastrium, either condition being associated with persistent 
 and uncontrollable vomiting, is a combination pointing to an 
 unfavorable termination. 
 
 The tongue is furred, and if diffuse peritonitis occurs, may 
 become dry; and associated with a deposit of sordes upon the 
 teeth. In severe types the tongue is fissured. 
 
80 APPENDICITIS. 
 
 The Urine and the Bladder. — The urine is usually diminished 
 in amount, and often contains albumin and indican. Several 
 theories have been advanced to explain this diminution in 
 quantity and presence of albumin in the urine. The most 
 tenable of these is that there is decreased activity of the 
 glomerules of the kidney, due to the general fall in arterial 
 tension. From the first, frequency of urination is often a 
 prominent symptom and is probably due to disturbance of the 
 sympathetic nerves, and, when an inflamed appendix occupies 
 the pelvis, to a directly communicated irritation of the bladder. 
 In peritonitis involving the serous coat of the bladder, reten- 
 tion of urine may occur, necessitating the use of the catheter. 
 It is uncertain what influence inflammation of the appendix 
 may have upon the function of the kidneys, but experience has 
 taught me that acute and subacute nephritis is of frequent 
 occurrence. Whether the two conditions exist in the relation 
 of cause and eff'ect I am not prepared to say. Theoretically 
 the causal relation would not appear to exist, but as practice 
 and theory are so often totally diff'erent it must, until further 
 demonstration, remain an open question. I have records of 
 numerous cases in which there were present blood, granular, 
 compound granular, and hyaline casts, with albumin, and a 
 marked diminution in the amount of urine secreted, in most 
 of which the urine became perfectly normal during conva- 
 lescence. This observation is purely clinical and, like many 
 such, must stand as true. It may be that the sympathetic 
 system, as it is in other intra-abdominal inflammations, is 
 responsible, although not to the same extent as in appendicitis. 
 Respiration. — Respiration plays a comparatively unim- 
 portant part in the symptomatology of most cases of appen- 
 dicitis, although early in the attack there is a voluntary 
 limitation in breathing, the patient favoring costal respiration. 
 If the distention is pronounced, the respiration is correspond- 
 
SYMPTOMS. 81 
 
 ingly labored, while if there is active peritonitis the resjDiration 
 is thoracic. In advanced cases of appendicitis with a diffuse 
 peritonitis, I have noticed a peculiar reflex condition of the 
 pharynx, described by the patient as a difficulty in swallowing. 
 Very rapid respiration due to septic absorption becomes a 
 grave symptom, as in a very large percentage of such cases it 
 indicates pulmonary involvement. 
 
 Leucocytosis, according to Richardson, is an invariable symp- 
 tom in perforative appendicitis. I cannot, however, consider it 
 of any marked value, as the condition of the appendix will 
 demand its removal long before leucocytosis can be demon- 
 strated. 
 
 Palpation of the Appendix. — During an acute attack there 
 will, as a rule, be such marked tenderness over the region of 
 the appendix that it will be practically impossible to palpate 
 the diseased organ. Moreover, in the acute stage of the 
 disease, the rigidity of the abdominal walls will also hinder 
 proper palpation. The method described by Edebohls is, 
 therefore, of little value, although in the diagnosis of chronic 
 appendicitis it plays a most important part. I shall, there- 
 fore, describe his method when considering the symptoms of 
 the latter affection. 
 
 Chronic Appendicitis. — The symptoms of chronic appendi- 
 citis are more variable than those of the acute affection. The 
 most constant of all is pain, which is usually confined to the 
 right iliac fossa, is subacute in character, and varies with the 
 condition of the general intestinal tract. 
 
 If there is exudate with adhesions, and especially if a 
 portion of the great omentum is involved, palpation will 
 demonstrate more than if the appendix alone is affected. In 
 chronic appendicitis, palpation reveals an enlarged and in- 
 flamed appendix, with more or less tenderness, the severity of 
 which depends upon the presence or absence of pus. Edebohls 
 6 
 
82 APPENDICITIS. 
 
 describes his method of palpating the appendix in women 
 as follows : " After completion of the ordinary bimanual 
 examination of the pelvic organs, the patient is drawn upward 
 upon the table about a foot, her feet still remaining where 
 they were placed for the vaginal examination. This is mainly 
 for the purpose of unfolding the flexure of the thigh upon the 
 abdomen, and to render the right iliac region more accessible 
 to the palpating hand. One hand only, applied externally, 
 is required for the practice of palpation of the vermiform 
 appendix. No assistance can be rendered by a finger intro- 
 duced into the vagina, and very little assistance, and that 
 only occasionally, by a finger introduced into the rectum. 
 Standing at the patient's right, the examiner begins the search 
 for the appendix by applying two, three, or four fingers of the 
 right hand, the palmar surface downward, almost flatly upon 
 the abdomen, in a straight line from the umbilicus to the 
 anterior superior spine of the right ilium. He notices suc- 
 cessively the character of the various structures as they come 
 beneath and escape from the fingers passing over them. In 
 doing this, the pressure exerted must be sufficiently deep to 
 recognize distinctly, along the whole route traversed by the 
 examining fingers, the resistant surfaces of the posterior ab- 
 dominal wall and of the pelvic brim. Only in this way can 
 we positively feel the normal, or the but slightly enlarged 
 appendix; pressure less than this must necessarily fail." 
 Not infrequently such examinations excite an acute exacer- 
 bation from the irritation produced by the manipulation. 
 
 If the tenderness and pain are marked, we shall usually 
 find pus encapsulated either within the appendix or between 
 the layers of the meso-appendix. Associated with the 
 presence of the chronically inflamed appendix there are 
 evidences of intestinal indigestion, discomfort, of pain in- 
 creased by exertion and referred particularl}^ to the right 
 
SYMPTOMS. 83 
 
 iliac fossa, and mucous diarrhoea alternating with constipa- 
 tion. There is indisposition and general debility. Neuras- 
 thenia is often an associated condition. Exercise or un- 
 digested food, by increasing peristalsis and thus pulling upon 
 the adhesions, frequently cause exacerbations of pain. Fever 
 is of importance only when of the hectic type. 
 
 Summary. 
 No distinct relation between symptoms and pathologic 
 change. 
 
 Acute Appendicitis: — 
 
 1. Ulcerative. 
 
 2. Perforative. 
 
 3. Gangrenous. 
 
 "Three cardinal symptoms : " — 
 
 1. Pain. 
 
 2. Tenderness. 
 
 3. Rigidity. 
 
 Pain usually appears after eating; at first is colicky and 
 referred to epigastrium ; later becomes localized usually to site 
 of appendix. 
 
 Tenderness is always present, sometimes best elicited by rec- 
 tal or vaginal examination. 
 
 Point of greatest tenderness usually over appendix. 
 
 Rigidity usually right sided ; follows localization of pain and 
 is most marked over inflamed area. 
 
 Vomiting common at onset of attack. Desists in favorable 
 cases ; its prolongation is a serious symptom. 
 
 Chronic Appendicitis. — History important. Palpation 
 most valuable means of diagnosis. 
 
 Localized pain and tenderness most constant symptoms. 
 
DIAGl^OSIS. 
 
 The diagnosis of appendicitis is, ordinaril}^, quite simple. 
 When the three cardinal symptoms are present, viz., sudden 
 onset of acute abdominal pain, with or without vomiting, 
 occurring in one previously well ; unilateral rigidity of the 
 lower abdominal wall ; tenderness over the site of the ap- 
 pendix, — the diagnosis of appendicitis is unexceptionally 
 warranted. That the diagnosis is not always made ma}^ be 
 variously accounted for, but chiefly by the still-lingering 
 picture of an inflamed caecum, its lumen filled with faecal 
 matter, and general inflammation surrounding the organ, — 
 the appendix being placed far in the background, so far, in 
 fact, that absolutely no significance is attached to its condition. 
 If, from the mental picture, the caecum could be entirely 
 removed, and in its place be put an inflamed and angry 
 appendix, mistakes in diagnosis would be of less frequent 
 occurrence. 
 
 Failures in diagnosis may often be explained by the fact 
 that the initial symptoms are lost from sight, or have been 
 entirely concealed by the injudicious use of opium. The 
 ushering in of an attack of appendicitis very closely simulates 
 acute indigestion, with the same vomiting, colicky j)ains, 
 often extending over the entire abdomen, and soreness of the 
 abdominal walls. In appendicitis, however, the general ab- 
 dominal pain soon becomes localized in the right iliac fossa, 
 when we should at once suspect the presence of more serious 
 trouble than simple indigestion. The tenderness on pressure 
 also becomes localized, the point of greatest intensity usually 
 corresponding to the position of the inflamed organ. This 
 
 84 
 
DIAGNOSIS. 85 
 
 tenderness is one of the most important and constant signs on 
 which to base a diagnosis. It is alwaj^s present, and may be 
 eUcited by simple pressure of the tip of the finger. As a rule, 
 there is a distinct relationship between the degree of tender- 
 ness and the degree of inflammation. Although the point of 
 tenderness generally corresponds to McBurney's point, much 
 depends upon the position of the appendix, whether it be 
 anomalous or otherwise. It is here that the value of a rectal 
 or vaginal examination must be remembered. 
 
 If the appendix holds a southerly direction, and overhangs 
 the brim of the pelvis, the point of greatest tenderness will be 
 found by rectal or vaginal examination, although, except a 
 sense of fulness, nothing else by such means will be demon- 
 strated. In these cases, one may err by the fact that, when 
 palpating the abdominal wall, no especial point of tenderness 
 will be found there ; but either a rectal or a vaginal examination, 
 or a combination of the two, must, nevertheless, be made,- 
 whereby a point of marked tenderness will often be detected. 
 
 The point of greatest tenderness may be immediately above 
 the middle of Poupart's ligament, or to the left of the linea 
 alba, or in either the lumbar or hepatic regions, the location 
 depending upon the position of the appendix and the site 
 of the inflammation. 
 
 In acute cases, it is usually not at all difficult to elicit 
 tenderness. When asked where the greatest intensity of pain 
 is located, the patient himself will, almost invariably, direct 
 our attention to the appendix ; palpation over this region will 
 elicit tenderness, while wave-like exacerbations of pain are 
 provoked. In chronic cases, it may be more difficult to locate 
 the tenderness, but deep, firm pressure will rarely fail to 
 provoke flinching and pain, thus demonstrating the presence 
 of a diseased organ. 
 
 Between the extent of the disease and the degree of tender- 
 
86 APPENDICITIS. 
 
 ness there is generally a close relation. As a rule, increase of 
 tenderness denotes a progressive inflammation, while decrease 
 of tenderness, accomplished without the administration of 
 anodynes, usually indicates a favorable course. 
 
 If pus is present, the degree of tenderness will be so great 
 that no difficulty should be experienced in localizing the point 
 of greatest intensity. If, however, septic absorption has pro- 
 gressed so far that paralysis of the nerve-filaments has been 
 caused, we may find that the tenderness has almost disap- 
 peared, and this without a corresponding diminution in the 
 progress of the disease. Under such circumstances, the other 
 signs will be so marked that there should be no difficulty in 
 reaching a diagnosis. 
 
 With few exceptions, localized tenderness will increase ac- 
 cording to the development of the disease. Thus, the forma- 
 tion of pus gives rise to excruciating pain ; over an appendix 
 undergoing gangrenous change the tenderness is marked ; 
 perforation, with the formation of a large abscess, causes in- 
 creased tenderness, although this may not be so decided as in 
 those cases wherein a small abscess is confined to the lumen 
 of the appendix, or to a small area of the meso-appendix. If 
 the peritoneum becomes generally infected, the tenderness will 
 be more widespread, and may extend over the entire surface 
 of the abdomen ; at first general, or more or less confined to 
 the umbilical or peri-umbilical region, the pain, as the disease 
 continues, becomes more localized, generally to the right iliac 
 fossa. 
 
 The position of the pain will vary with the position and 
 direction of the appendix. Thus, in cases in which the 
 appendix points north, the pain may be referred to the lumbar 
 or hepatic regions. In certain cases, the pain is referred 
 entirely to the left side, although this does not, as a rule, 
 indicate that the appendix points east, as in these instances it 
 
DIAGNOSIS. 87 
 
 more generally points south, and occupies the pelvis. This 
 fact should be emphasized, as I have seen a number of exam- 
 ples in whicli the attending physicians, who were familiar 
 with the general symptoms of appendicitis, were totally misled. 
 The citation of one case, that of the son of a ffhysician, will 
 serve to illustrate the importance of pain referred to the left 
 side as indicative of the pelvic position of the appendix. 
 
 Master A. , shortly after a meal of indigestible food, was suddenly seized 
 with acute abdominal pain, vomiting, and rigidity of the right lower abdomi- 
 nal wall. Symptoms of acute peritonitis developed in three days, at which 
 time the father consulted me, saying that he would have regarded the case as 
 one of appendicitis had not the pain been referred to the left side. I told 
 him that in my opinion the disease was appendicitis, and that operation was 
 immediately demanded. Two days later I was hastily summoned to see the 
 boy, whom I found suiFering from a diffuse peritonitis of an active tyi^e, the 
 pulse-rate 130, with a " leaky" skin, and constant retching and constipation. 
 I declined to interfere except to advise total discontinuance of opium or any 
 of its preparations, and ordered, instead, small, repeated doses of calomel to 
 the extent of free purgation. I believed this a wiser course to pursue than to 
 operate. Apparent recovery followed. I then advised operation in order to 
 prevent recurrence, but the father could not agree to have his son operated 
 upon when in apparent good health. Within ten days a second attack 
 occurred ; I was again summoned, but being absent from home, other counsel 
 was sought ; operation was again deferred, resulting in a second incomplete 
 recovery. Again I was consulted, and as before I advised operation, which 
 this time was consented to. The appendix, the tip of which contained a pus- 
 collection, and the whole surrounded by an encysted abscess, was found occupy- 
 ing the pelvis, adherent to its floor and to the right of the rectum. The 
 appendix was removed and recovery was uneventfiil. 
 
 In those cases, therefore, in which the pain is referred to 
 the left side, with the point of greatest tenderness immediately 
 above the pubis, or in the left iliac fossa, the greatest intensity 
 of the inflammation will be confined to the tip of the ap- 
 pendix. It is in the class of cases in which the appendix 
 occupies the pelvis that vesical symptoms, such as irritability, 
 frequent micturition, and retention, are, from a diagnostic 
 standpoint, of value. 
 
 The abrupt cessation of pain previously located in the region 
 
88 APPENDICITIS. 
 
 of the appendix, followed by a fall of temperature, increased 
 pulse-rate, and an anxious expression, are symptoms which 
 indicate the occurrence of gangrene. 
 
 From experience in operating upon a number of cases in 
 which the appendix invariably pointed south, I am prepared 
 to say that when pain is referred to the left side, the appendix 
 occupies the pelvis. Also, that when in these suppuration has 
 taken place, resulting in a large pelvic collection, bilateral 
 rigidity of the abdominal wall is always pronounced. When 
 I am asked to see a patient, the diagnosis of whose ailment is 
 not clear, with a history of the three cardinal symj)toms, with 
 the pain referred to the left, rather than the right side, with a 
 temperature denoting a hectic condition, and with a bilateral 
 rigidity of the lower abdominal w^alls, I am convinced that it 
 is one of suppurative appendicitis, in which both the pus 
 collection and the appendix occupy the pelvis. An illustrative 
 case is the following : — 
 
 During the past summer I was asked to see Miss . About two weeks 
 
 previously she had been suddenly attacked by what was at first supposed to be 
 acute indigestion, which, however, did not yield to the ordinary remedies. In 
 view of the fact that the spleen was enlarged, characteristic spots present, and 
 the temperature suggestive of an irregular type, a i:)rovisional diagnosis of 
 typhoid fever had then been made. But the suddenness of onset, accompanied 
 by acute abdominal pain, with decided bilateral rigidity of the lower abdomi- 
 nal walls, the temperature-record, the vaginal and rectal examinations, which 
 excited great pain, with the characteristic fulness, stamped the case one 
 of suppurative appendicitis with a pelvis full of pus. I advised immediate 
 operation. Adverse opinion of other counsel caused a delay of two days, 
 when upon operation a large collection of foul pus was found, the appendix, 
 which was perforated and gangrenous, occupying the pelvis. The appendix 
 was removed and recovery was uneventful. 
 
 Under these circumstances rectal or vaginal examination 
 will demonstrate a sense of fulness. The contrast between 
 this condition, and that of suppuration in the pelvis dependent 
 upon infection of any of the uterine appendages, will be 
 discussed later. 
 
DIAGNOSIS. 89 
 
 In almost all cases of appendicitis there will be more or 
 less rigidity of the lower abdominal walls. Simple pressure 
 with the tips of the finger will demonstrate it. In the 
 majority of cases it will be found more marked over the right 
 iliac fossa ; in others, if the pain is referred to the left side, 
 the rigidity will be more pronounced there. When the 
 appendix occupies the pelvis, and is the seat of a pus col- 
 lection, there will be bilateral rigidity. 
 
 Fulness. — In the early period of the affection, little, if any, 
 fulness in the right iliac fossa is observed. It appears late in 
 the course of the disease, after inflammatory exudate has 
 been thrown out and adhesions have been formed. In con- 
 nection with this fulness, there may be a doughy feeling, or 
 even oedema, both of which may be indicative of pus, although 
 excessive tenderness is a more reliable sign. CEdema of the 
 abdominal walls, with symptoms of another disease, may lead 
 to the false impression that the seat of the trouble is not in 
 the appendix, as is shown by the subjoined instance : — ^ 
 
 Miss H. was attacked ten days prior to examination. She had had the 
 usual symptoms of acute appendicitis, but owing to slight jaundice, and 
 decided oedema of the parts overlying the hepatic region and the lower right 
 chest, there was some doubt in the mind of the attending physician as to the 
 location of the inflammatory process. Upon pressure there was more pain 
 over the oedematous area than over the normal position of the appendix. 
 After considering the character of the symptoms from the beginning of the 
 attack I concluded that purulent appendicitis was present, and that the organ 
 was located post-caecal, pointing north. Operation confirmed this diagnosis. 
 The appendix, gangrenous and separated from the caecum, was post-caecal and 
 surrounded by a collection of pus extending upward behind the liver and 
 inward to the vertebral column. Recovery followed. 
 
 With the development of any fulness or bulging, the con- 
 tour of the abdomen becomes asymmetrical. The bulging 
 may at tirnes be found to the outer side of the right rectus 
 muscle, caused by a distended csecum floating over an encysted 
 abscess ; or at times fulness will be found above the outer half 
 
90 APPENDICITIS. 
 
 of Poupart's ligament, due to the presence of pus, exudate, 
 or inflated bowel. 
 
 Late in the attack I have noticed a prominent, rounded 
 swelling immediately above the symphysis pubis; operation 
 has proved this to be a collection of pus. 
 
 Distention. — In the beginning of an attack of appendicitis 
 there is little, if any, distention, and in favorable cases the 
 disease may terminate with no distention whatever. Gener- 
 ally, however, in the later stages of the disease, we find either 
 localized or general distention. It may be caused by mechani- 
 cal obstruction of the bowel, by adhesions, or by kinking of 
 the bowel itself. Localized distention is due to a localized 
 peritonitis, with paralysis of the bowel in the affected portion. 
 When distention becomes general, and is not due to mechanical 
 causes, it probably results from paralj'sis caused by irritation 
 of Auerbach's plexus, or from a general peritonitis. Marked 
 constipation and the use of opium also cause distention, and 
 thus hinder recognition of the true condition. By ausculta- 
 tion, we may generally distinguish functional from paralytic 
 distention, peristaltic rumblings being heard in the former 
 but not in the latter variety. In cases of profound septic 
 infection, consequent upon a purulent peritonitis, we may, at 
 times, find a scaphoid condition of the abdomen due to com- 
 plete paralysis of the bowel. 
 
 The Presence of a TuTnor. — In many cases it is impossible to 
 determine the existence of tumescence, owing to marked 
 rigidity of the abdominal wall and excessive pain ; rigidity, 
 however, should never be mistaken for a tumor. Althougli it 
 has been claimed that a tumor can be found in every case of 
 appendicitis, such is not my experience. The csecum is never 
 the seat of a collection of faeces, and this fact, together with the 
 knowledge that the appendix is not much enlarged at the 
 onset of the attack, is sufficient in most cases to disprove the 
 
DIAGNOSIS. . 91 
 
 presence of a tumor. After the disease has somewhat ad- 
 vanced, with exudate and adhesions present, a distinct tumes- 
 cence may usually be diagnosticated by palpation. But if the 
 appendix hold the pelvic position, abdominal palpation will, 
 with few exceptions, fail to reveal an}" tumor whatever. In 
 these cases a rectal or vaginal examination may be the means 
 of discovering a mass. When the appendix is located in the 
 abdominal cavity, its position can generally be determined, 
 especially if the disease has progressed so far as localized peri- 
 tonitis. Thick abdominal walls or the destruction of the ana- 
 tomic relations by excessive tympanites might cause some 
 difficulty. Another condition that might hinder the location 
 of an appendiceal mass would be a post-csecal position of the 
 appendix, with rigidity of the abdominal muscles and disten- 
 tion of the bowel. 
 
 The presence of inflammatory exudate presents to the pal- 
 pating fingers a hard, unyielding mass, wdiich I believe has been 
 frequently mistaken for an accumulation of fseces in the cgecum. 
 
 It is exceptional for a chill to mark the advent of pus- 
 formation in appendicitis — this, despite the widespread belief 
 among physicians that the absence of a chill precludes the 
 possibility of suppuration. 
 
 Coincident with the onset of an acute attack there is 
 always a rise of temperature, similar to that observed in all 
 acute septic conditions. This is more marked in children. 
 In the diagnosis of appendicitis, however, the temperature is 
 so variable that, except in making a differential diagnosis, it 
 is, as a guide, of little value. 
 
 The Respiration. — As a rule, the breathing, in acute appendi- 
 citis, becomes shallow or even thoracic, and, if general peri- 
 tonitis supervene, is markedly so. An attempt to take a full, 
 deep breath causes severe pain, clearly showing itself by the 
 expression of the face. 
 
92 APPENDICITIS. 
 
 Sudden contraction of the abdominal walls, consequent upon 
 an effort to cough, will excite pain over the affected area. 
 
 Summary. 
 Diagnosis, " three cardinal symptoms," viz. : — 
 
 1. Sudden acute pain in one previously well. 
 
 2. Unilateral rigidity of lower abdominal wall. 
 
 3. Tenderness over site of appendix. 
 
 After onset, tenderness on pressure soon becomes localized 
 and corresponds approximately to degree of inflammation. 
 Location of tenderness usually over McBurney's point, but 
 varies with position and condition of appendix. 
 
 Rectal or vaginal examination, or both, should always be 
 made, particularly in those cases in which abdominal palpa- 
 tion gives negative results. In these, rectal examination dem- 
 onstrates points of marked tenderness, sometimes fulness. Is 
 of greatest value when appendix points south. 
 
 Tenderness increased — 
 
 1. Early pus formation. 
 
 2. Gangrenous change. 
 
 3. Perforation. 
 Tenderness decreased — 
 
 1. Discharge of fsecal concretion, 
 
 2. After free evacuation. 
 
 3. In late pus cases with enough septic absorption to 
 paralyze nerve filaments. 
 
 Abrupt cessation of pain indicates gangrene. 
 
 Pain and Tenderness on left side : appendix points south 
 (rarely east) and occupies pelvis. Vesical symptoms common. 
 
 Pain on left side with tenderness over pubis : appendix 
 points south ; tip of appendix affected and contains pus. 
 
 Pain on left side with bilateral rigidity: appendix points 
 south with pus collection surrounding it. 
 
 Pain over hepatic or right renal region with tenderness over 
 course of ascending colon : appendix lies post-csecal or post- 
 cfecal and post-colic, and points north. 
 
 Fulness appears late, after pus formation. 
 
 Excessive tenderness most reliable sign of pus. 
 
DIAGNOSIS. 93 
 
 Distention : — (a) Localized — is due to localized peritonitis. 
 (6) General : — 
 
 1. Constipation. 
 
 2. Opium. 
 
 3. Paralysis of intestines. 
 
 4. Mechanical obstruction. 
 
 5. General peritonitis. 
 
 Tumor is often impossible to detect on account of tenderness 
 and rigidity. When adhesions and infiltrations are present 
 detection usual. Rectal examination often successful when 
 abdominal palpation is of no avail. 
 
 Chill is rare in denoting pus formation. 
 
DIFFEREl^TIAL DIAGl^OSIS. 
 
 TYPHOID FEVER. 
 
 There are several diseases which may be mistaken for 
 appendicitis, chief among which are typhoid and the various 
 affections of the genito-urinary tract. Some of the rarer cases 
 in which a differential diagnosis is difficult wdll be touched 
 upon below. 
 
 Typhoid fever and appendicitis are most frequently sources 
 of diagnostic perplexit}'-, — so much so, indeed, that upon more 
 than one occasion I have seen the surgeon forced to defer ope- 
 ration in appendicitis, because the opinion of the majority of 
 the medical attendants was opposed to such a procedure, they 
 holding the case to be one of typhoid fever. Yet in the 
 early stages of the two affections the characteristic symptoms 
 are distinct. The sudden onset in one previously well, the 
 rigidity of the right lower abdominal wall, and the tenderness 
 limited to the position of the appendix, are collectivel}^ pathog- 
 nomonic of appendicitis. In typhoid fever, the slow onset 
 attended by lassitude, the headache, the epistaxis, the tempera- 
 ture record ; the diffused abdominal tenderness with the re- 
 laxed condition of the abdominal walls, the enlarged spleen, 
 and the absence of rigidity should be sufficient to establish a 
 differential diagnosis with absolute certainty. If, in connec- 
 tion with these differential points, a digital examination of the 
 rectum demonstrates a sensitive mass, then any doubt of ap- 
 pendiceal inflammation should be at once dispelled. Spots 
 may be found, but they are not of absolute diagnostic value, 
 since they may be present or absent in both affections and are 
 in each due to sepsis. 
 
 94 
 
DIFFERENTIAL DIAGNOSIS. 95 
 
 Follicular abscesses of the appendix are responsible for some 
 mistakes in the differential diagnosis between appendicitis and 
 typhoid. The minuteness of the collections account for the 
 mildness and the j)rolongation of the sepsis, and the lessened 
 degree of the local symptoms. In this type of appendicitis we 
 have a constant source of absorption with a small amount of 
 tissue involved. The temperature record and the general con- 
 dition in such cases in many respects closely simulate irregular 
 typhoid, and much care in examination is essential, since it is 
 not uncommon to find supposed typhoid fever cases in which 
 operation has demonstrated the presence in the appendix of 
 macroscopic follicular abscesses, varying in size from a millet 
 to a mustard seed, an eroded mucous membrane, and a more or 
 less infiltrated organ. 
 
 The points to be borne in mind in making a differential 
 diagnosis between appendicitis and the later stages of typhoid 
 are of sufficient distinctness, but each symptom must be con- 
 scientiously studied. The early history and the local symp- 
 toms on the one hand; the general abdominal and mental 
 symptoms, with dry tongue, and the temperature record on the 
 other, are quite sufficient to make differentiation clear and dis- 
 tinct. The spleen is enlarged in both affections. The enlarge- 
 ment, however, due to septic infection from an active suppura- 
 tive process like appendicitis, is apt to be associated with pain 
 caused by a peri-sj^lenitis. Difficulty, however, exists, and the 
 following case is related to illustrate the fact that follicular 
 abscesses in the appendix are capable of causing a train of 
 symptoms which suggest typhoid fever : — 
 
 Dr. M. consulted me about his little girl, because the uature of her illness 
 was not clear to him. He related to me the histoiy of the case and showed 
 me the temperature record. I suggested that the symptoms resembled 
 those of subacute appendicitis. An appointment was made with a physician, 
 one of my assistants, and Dr. F. of the German Hospital. In consultation 
 the following conditions were noted : there had been slight epistaxis 
 
96 APPENDICITIS. 
 
 about seven days previous to date of examination ; the temperature record 
 was irregular, dropping suddenly on the fifth day from 103 degrees to normal. 
 The tongue was dry and coated, with red borders, and while headache was 
 present the mental condition was quite clear. The spleen was somewhat 
 enlarged, and on the abdomen, which was slightly tympanitic, were noticed 
 some indistinct rose-coloted spots. Only very careful questioning of the 
 mother elicited the fact that the child had been ailing for several months with 
 digestive troubles, which, never severe, had always yielded to a purgative dose 
 of castor oil. Examination of the right ihac fossa demonstrated distinct ten- 
 derness, also gurgling. No mass could be made out. One of the consulting 
 physicians inclined to the diagnosis of typhoid and advised delay. The two 
 other consultants diagnosed appendicitis, basing their conclusion on the pre- 
 vious history, the absence of mental symptoms, and the distinct tenderness 
 in the right iliac fossa. On the following day I saw the case, with permission 
 to operate if I concurred in the diagnosis of appendicitis. This I did, and 
 operated at once. The following conditions were found : The appendix was 
 situated behind the colon, to which it was adherent ; the mucous lining of the 
 tip of the appendix, which was club-shaped, contained several follicular 
 abscesses, the largest of which was the size of a split pea. Recovery was 
 uninterrupted and rapid. The symptoms which had suggested typhoid dis- 
 appeared immediately after the removal of the appendix. 
 
 Before directing attention to the points of differentiation 
 between appendicitis and the affections attended with pus 
 formation which may be confounded with it, I desire to say 
 that the occasion for having to make a differential diagnosis 
 between appendicitis with pus formation and other forms of 
 pus collection should never arise, as in all cases of appendi- 
 citis, the appendix should be removed before pus has formed. 
 
 PYO-SALPINX AND OVARIAN ABSCESS. 
 
 The presence in the recto-uterine cul-de-sac of an inflamma- 
 tory mass in intimate relation with the uterus, which renders it 
 partially or completely immovable, and which can be clearly 
 outlined by vaginal, bimanual, or combined vaginal and 
 rectal examination, together with the history of a vagino- 
 uterine infection, and the presence of a septic fever, establish 
 the diagnosis of pyo-salpinx, or ovarian abscess. The essential 
 points in the differentiation between these two affections and 
 
DIFFERENTIAL DIAGNOSIS. 97 
 
 appendicitis are the absence of the history of the three 
 cardinal symptoms of the latter affection. 
 
 Inflammation of the right ovary may be confounded with 
 appendicitis, as it is attended with pain, tenderness in the 
 right iliac fossa, nausea, and fever. It is, however, always 
 accompanied by disturbances of the uterine functions and is 
 demonstrable by vaginal or bimanual examination. The ten- 
 derness is never so intense as in appendicitis and is not accom- 
 panied by a perceptibly enlarged appendix. 
 
 SUPPURATING OVARIAN CYST. 
 
 An appendiceal abscess and a suppurating ovarian cyst on 
 the right side present some symptoms in common which may 
 give rise to difficulties in diagnosis. These symptoms are: 
 painful tumor in the right iliac fossa, which may be made 
 out by vaginal, bimanual, and external examinations ; vague 
 symptoms of septicaemia; hectic temperature, and history of 
 previous gastric and urinary irritation. The differences, how- 
 ever, are marked and can be distinguished by careful consider- 
 ation. In ovarian cyst the onset is gradual and a history of 
 some infection can generally be elicited. The pain is constant 
 and of a dull character ; by pressure the significant " ovarian 
 pain " may be produced, differing from the colicky appendiceal 
 paroxysms. The rigidity of the abdominal wail is not so 
 marked as in appendicitis, while the tumor itself is more elastic, 
 having apparently thinner walls and a more regular outline. 
 
 FIBROID TUMOR. 
 
 Appendicitis may be confounded with a local inflammation 
 of a portion of the broad ligament overlying an intralig- 
 mentary fibroid tumor. The main points in the differential 
 diagnosis are the history of metrorrhagia ; the presence of a 
 growth, detected upon vaginal examination; the tenderness 
 
 7 
 
98 APPENDICITIS. 
 
 and pain, which is elicited by bimanual palpation, and which 
 is confined to the part of the wall overlying the mass. 
 
 EXTRA-UTERINE PREGNANCY. 
 
 The history in these cases is usually that of partial or com- 
 plete cessation of the menstrual flow for one, two, or more 
 periods, generally accompanied by other symptoms of preg- 
 nancy, with collapse supervening upon an attack of acute 
 abdominal pain. The pain is long-continued and paroxysmal, 
 but not colicky. An irregular, bloody, vaginal discharge, 
 generally lighter in color than the normal menstrual flow, and 
 containing shreds of tissue, portions of the decidua, is present. 
 Vaginal examination will detect a tender and sensitive mass 
 in the cul-de-sac, unless the pregnancy be an abdominal one. 
 In the majority of these cases there is a history of sterility for 
 five or six years previous to the abnormal conception. 
 
 PAINFUL MENSTRUATION. 
 
 A condition which may be misleading in the differentiation 
 from appendicitis is the sudden onset of pain occurring in 
 young unmarried women of a neurotic temperament at the 
 ushering in of the menstrual period. The onset is sudden, the 
 pain is paroxysmal and accompanied by nausea. There may 
 be more or less rigidity of the lower abdominal walls, unilateral 
 or bilateral. The presence and the degree of the rigidity of 
 the abdominal walls depends upon the amount of congestion 
 of the ovaries, whether one or both be involved. The pain, at 
 first paroxysmal, is most severe during the first day of the 
 menstrual flow. After this it may become continuous and, in 
 some instances, lasts during the entire period. The tenderness, 
 like the rigidity, corresponds to the amount of the ovarian 
 congestion. If Ijoth ovaries are involved the tenderness will 
 be bilateral. 
 
DIFFEKENTIAL DIAGNOSIS. 99 
 
 The pain at the onset differs, however, from that of appendi- 
 citis, being non-inflammatory and localized from the begin- 
 ning, while in appendicitis there is general abdominal pain, 
 which later becomes localized in the right iliac fossa, while 
 marked intestinal symptoms are present. 
 
 MENOPAUSE. 
 
 Some women during the climacteric occasionally com- 
 plain of symptoms resembling appendicitis. They suffer from 
 localized pain in the right side, gastric and intestinal dis- 
 turbances, and irregular temperature. As absence of the 
 menstrual flow often exists, some difficulty may be experi- 
 enced in reaching a correct diagnosis, particularly in those 
 cases associated with obesity. The exact condition, however, 
 may be established by careful inquiry into the previous his- 
 torjT^ and by local examination, which latter means demon- 
 strates absence of rigidity of the abdominal walls and no 
 palpable swelling about the appendix. The flushes, back- 
 aches, and mental symptoms incident to the menopause will 
 clear up the diagnosis. In this connection, hysteria may be 
 alluded to, particularly as appendicitis gives evidence of 
 becoming a ' fashionable ' disease. The mere mention, how- 
 ever, of the nervous affection, with its ubiquitous symptoms, 
 will suffice. 
 
 FLOATING KIDNEY. 
 
 Floating kidney is differentiated from appendicitis by the 
 absence of the three cardinal symptoms and of fever, by 
 depression in the right flank, by the presence of a movable 
 tumor, characteristic in shape, which, by properly directed 
 pressure, can be restored to its normal position. This con- 
 dition occurs most commonly in emaciated females of a 
 neurotic temperament. 
 
100 APPENDICITIS. 
 
 FLOATING KIDNEY, WITH A TWISTED PEDICLE. 
 
 From floating kidney with a twisted pedicle, appendicitis 
 may be diagnosticated by pain which radiates in the line of 
 the ureter, is not increased to any marked degree by pres- 
 sure ; by the absence of rigidity of the abdominal wall ; by a 
 history of a movable tumor prior to the attack ; by a depres- 
 sion in the right loin corresjDonding to the site of the kidney ; 
 by the presence of blood in the urine, and possible symptoms 
 of uraemia. 
 
 NEPHRITIC COLIC. 
 
 Ordinarily, it should not be difficult to differentiate be- 
 tween nephritic colic and appendicitis, but misleading conclu- 
 sions may be reached, owing to the fact that in exceptional 
 cases of appendicitis there exist together pain referred to the 
 umbilicus, retraction of the testicle associated with vesical 
 tenesmus, and painful and frequent micturition. Error, how- 
 ever, can only occur in the early stages of appendicitis, as the 
 symptoms later on are entirely dissimilar. 
 
 Renal colic is usually ushered in by a distinct chill, followed 
 by excruciating pain in the loin posteriorly, which is relieved'" 
 by pressure. This pain radiates along the course of the ureter 
 and is much diminished by the voiding of urine, which often 
 amounts to large quantities. In appendicitis, the pain at the 
 onset is more diffused, is increased by pressure, and is in no 
 way affected by micturition. In renal colic there is no rigidity 
 of the abdominal wall, no tender mass in the right iliac fossa 
 can be palpated, and urine examination shows characteristic 
 alterations, e. g., uric acid or phosphatic deposits, blood, etc. 
 
 I recall the case of a physician, in which the diagnosis of renal cohc had 
 been made, and in which the ureter was supposed to have been ruptured by 
 the passage of a calculus. The autopsy revealed a gangrenous and perforated 
 appendix with diffuse suppurative peritonitis. 
 
DIFFERENTIAL DIAGNOSIS. 101 
 
 PYO-NEPHROSIS. 
 
 From abscess of the kidney appendicitis diflfers in that the 
 pain in the former radiates to the groin and testicle with 
 retraction of the latter organ. Tenderness is elicited on pres- 
 sure over the kidney. There is irritability of the bladder and 
 diminished excretion of urine, which contains pus and possibly 
 blood. In the absence of urinary symptoms, abscess of the 
 kidney, and particulary if it be a floating kidney, necessarily 
 presents greater difficulty in dilEferentiation. In the latter 
 instance, however, the tumor will be movable. I have recently 
 operated on a case of acute suppuration of the kidney in which 
 the urine was normal, and the diagnosis was made on the 
 anatomic situation of the swelling. Nausea, sometimes with 
 vomiting, is a fairly constant symptom in the renal cases, 
 though of not much diagnostic value. 
 
 PERI-NEPHRITIC ABSCESS. 
 When the appendix holds a retro-csecal position or occupies 
 a deep ilio-csecal fossa, together with the formation of pus, it 
 may be mistaken for a peri-nephritic abscess, but the absence of 
 intestinal disturbance and of the cardinal symptoms of appen- 
 dicitis will be sufficient to clear up the diagnosis. 
 
 GROWTHS OF THE KIDNEY. 
 
 Neoplasms of the kidney are detected by palpation of the 
 loin space, absence of inflammatory symptoms, continuous 
 dull pain, frequent micturition, hsematuria, and pyuria. Cysto- 
 scopic examination of the bladder with catheterization of the 
 ureters may be necessar}^ 
 
 URETERITIS. 
 
 Inflammation of the ureter occurs as a sequela to inflam- 
 mation of the bladder, or in connection with tubercular and 
 
102 APPENDICITIS. 
 
 calculous disease of the kidney. The differential points are : 
 the history ; the presence of tenderness at the bladder extremity 
 of the ureter, as made out by vaginal or rectal examination ; 
 the presence of deep-seated tenderness along the line of the 
 ureter; the absence of rigidity of the abdominal walls, and 
 the presence in the urine of pus, blood, and ureteral epi- 
 thelium. 
 
 RENAL IRRITATION OF APPENDICITIS. 
 
 Too much stress cannot be laid upon the importance of 
 urinary examinations, not only in the supposed kidney affec- 
 tions before mentioned, but also in appendicitis. 
 
 It is true that in most cases of appendicitis examination of 
 the urine reveals slight abnormalities, such as traces of 
 albumin, cylindroids, hyaline casts, renal and ureteral epithe- 
 lium, pus, and, rarely, blood corpuscles. In the affection in 
 which the kidney and its adnexa are primarily involved the 
 urine will show pathognomonic peculiarities. The renal irri- 
 tation of appendicitis is probably due to disturbances of the 
 sympathetic nervous system, but may be the result of actual 
 contact of the appendix and some part of the urinary tract. 
 To cite an extreme case, I have recently operated upon a 
 patient whose urine contained pus and epithelium from the 
 pelvis of the ureter. There was present a swelling in the 
 right loin accompanied by tenderness, extending in the direc- 
 tion of the attachment of the appendix, and the history of the 
 three cardinal symptoms was elicited. I opened up the right 
 iliac fossa, finding the appendix, which was post-colic and 
 contained pus, pointing north, adherent to and in communi- 
 cation with the pelvis of the ureter, through which the 
 contents of the appendix were being emptied into the bladder, 
 thus explaining the urinary symptoms. The recovery was 
 uneventful. 
 
DIFFERENTIAL DIAGNOSIS. 103 
 
 INTESTINAL OBSTRUCTION. 
 
 In intestinal obstruction the onset is more abrupt than in 
 appendicitis, and the pain, remissive in character and of 
 severer type, may be referred to the seat of the obstruction, 
 or more commonly to the umbilicus; there is absolute consti- 
 pation and inability to pass flatus, while persistent and uncon- 
 trollable vomiting occurs early and soon becomes fsecal. The 
 temperature is normal or subnormal, until the advent of peri- 
 tonitis. With the onset of peritonitis, regurgitant vomiting 
 begins. The vomiting becomes fascal, a condition that rarely 
 occurs except in the later stages of appendicitis. Intussuscep- 
 tion is the most common form of obstruction in children, 
 while obstruction from bands and volvulus is more common 
 in adult life. Tumors from these forms of obstruction are 
 generally to the left of the linea alba. When obstruction 
 is the result of intussusception, blood and mucus will be 
 discharged from the rectum, and upon examination through 
 this canal a tumor ma}'' be felt. The development of 
 peritonitis in acute intestinal obstruction is marked by great 
 abdominal distention. Shock and collapse appear early in 
 obstruction. Such is not the case in appendicitis, unless it be 
 of the fulminating type, and even then collapse appears later. 
 
 PERFORATION OF SOME PART OF THE ALIMENTARY TRACT. 
 
 This can only occur as the result of a pre-existing localized 
 inflammatory condition, and should not be confounded with 
 the perforation of an inflamed appendix, as perforation the 
 result of appendicitis takes place as a sequence to the three 
 cardinal symptoms. 
 
 GASTRIC ULCER. 
 
 Rarely appendicitis and gastric ulcer may be confounded, 
 especially when both have become chronic, since in both the 
 
104 APPENDICITIS. 
 
 pain is similar in character and increased by pressure. The 
 location of the painful area in either varies, and is, therefore, 
 not an absolute guide for a differential diagnosis. Gastric 
 disturbances are common to both. However, the mode of 
 onset differs in the two affections, gastric ulcer being of slow 
 development, while even in chronic appendicitis a history of 
 an abrupt onset can generally be obtained. In gastric ulcer, 
 the relief of nausea and pain by vomiting, the appearance of 
 the vomited matter, which is frequently streaked with blood, 
 and the occurrence of gastric haemorrhage, are symptoms 
 sufficiently striking to distinguish it from appendicitis. In 
 this connection, it might be mentioned that diseases of the 
 pancreas, such as abscess, cyst, or impaction of calculus, 
 which may give rise to symptoms resembling appendicitis, 
 may have to be diagnosed by the exclusion of the latter. 
 
 CANCEE OF THE CJECUM. 
 This should not be confounded with chronic appendicitis. 
 In the former instance, there is absence of inflammatory 
 symptoms ; palpation reveals the presence of a nodular swell- 
 ing of slow growth, attended by progressive loss of flesh ; 
 the disease occurs usually late in life ; there is absence of 
 marked rigidity of the overlying abdominal walls, and absence 
 of decided tenderness. When the disease has advanced to the 
 extent of offering an obstruction to the fsecal circulation, there 
 will be attacks of diarrhoea, associated with mucus and blood 
 in the stools, and paroxysms of acute abdominal pain, the 
 result of peristaltic action of the bowel. The peristaltic wave 
 can be excited by manipulation of the growth, and can often 
 be seen through the thin abdominal walls. 
 
TUBERCULAR APPENDICITIS. 
 
 H. W. , aged fourteen, was admitted to the Grerman Hospital February 1 5, 
 1896, with the following history : During the past ten months he had had six 
 typical attacks of appendicitis, but each time operation had been refused. On 
 the day before admission he had complained of pain in his right side, which 
 had rapidly grown worse until the entire abdomen had become involved. 
 When examined his temperature was 104f° ; pulse rate 116; his abdomen 
 was enormously distended, tympanitic, and tender, particularly in the region 
 of the appendix, although the tenderness here was less marked than the 
 amount of distention seemed to warrant. Rigidity was present only as part 
 of the general distention and was equally distributed. There was no record 
 of tuberculosis in his family ; an area of dulness was found in his left lung 
 posteriorly, but no tubercle bacilli were detected in the sputum. 
 
 On the day after admission his temperature fell to 101°, rising again in the 
 evening to 104°. From the symptoms a diagnosis was made of tubercular 
 appendicitis, with subsequent involvement of the general peritoneum, and 
 operation was suggested and agreed to. 
 
 Operation : Upon section of the peritoneum a small quantity of a dark, 
 odorless fluid escaped. The caecum and appendix were bound together in a 
 dense mass of lymph and the whole covered with tubercular patches, which 
 were also distributed throughout the peritoneum. The cavity was irrigated, 
 glass drainage introduced, and the wound closed. Patient died two months 
 afterward. 
 
 106 
 
Plate XVI 
 
 Tubercular appeqdix 
 
 The white spots represent nqiliary tubercles. 
 
DIFFERENTIAL DIAGNOSIS. 107 
 
 DYSENTERY AND COLITIS. 
 
 While dysentery may resemble some of those rarer and 
 unfavorable cases of appendicitis, in which diarrhoea with 
 bloody stools and tenesmus are added to the three cardinal 
 symptoms, yet differentiation can be established by local 
 examination. In dysentery, though, there is diffused abdom- 
 inal pain, there is no localized tenderness, and no mass is 
 palpa])le. With respect to colitis see page 159. 
 
 TUBERCULAR PERITONITIS. 
 
 The early stages of tubercular peritonitis, especially in cases 
 in which the appendix is perhaps primarily affected by the 
 specific bacilli, offer great difficulty in diagnosis. The cardi- 
 nal symptoms of appendicitis may be present and the endeavor 
 must be to diagnose the tubercular nature of the affection. 
 Careful examination of the patient for infection elsewhere, e. g., 
 family history, sputum, chest, glandular involvement, bone 
 and joint diseases, may lead to the recognition of the cause. 
 
 The hectic temperature and night sweats may be of value. 
 However, the most significant symptom is the presence of 
 ascites, which in tubercular peritonitis appears early and 
 amounts to a considerable quantity, though its recognition is 
 often obscured by the intestinal distention. The pain and 
 tenderness usually tend to diminish with the increase of 
 abdominal tumescence. The case of H. W. (Plate XVI) is a 
 typical illustration of the disease, which probably originated in 
 the appendix. 
 
 SPLENIC ABSCESS. 
 
 This rare affection may sometimes be confounded with those 
 exceptional 'cases of appendicitis in which pain is referred to 
 the left hypochondriac region. In both there are gastric dis- 
 turbances, pain, tenderness on pressure, rigidity over the 
 
108 APPENDICITIS. 
 
 affected area, and similar irregularities in temperature. The 
 previous histor}'- of the two diseases is, however, unlike. Trau- 
 matism usually plays a prominent part in the causation of 
 splenic abscess, this being rarely the case in appendicitis. 
 Then, too, splenic abscess occurs in general septic infections 
 and in those constitutional diseases in which enlargement of 
 this organ takes place and is due to embolism in the paren- 
 chyma of the spleen. In neglected cases of appendicitis 
 splenic abscess is a grave complication, and the symptoms 
 referable to the spleen may then predominate. 
 
 HEPATIC AND PERI-HEPATIC ABSCESS. 
 
 Appendicitis can be confounded with abscess of the liver or 
 about the liver only when, late in the disease, a circumscribed 
 collection of pus is in close relation with the appendix which 
 holds a post-csecal position and points toward the liver. The 
 previous history, the hectic temperature of hepatic or peri- 
 hepatic abscess, and the absence of a history characteristic of 
 an acute appendicitis will be sufficient to establish the diag- 
 nosis. 
 
 RUPTURE OF THE GALL-BLADDER 
 will occasion severe pain, rigidity of the right rectus muscle 
 and of the flat muscles of the upper abdominal walls. The 
 symptoms presented may be so similar to those of a perforated 
 appendix that an operation alone will reveal the true state of 
 afl'airs. A previous history may help in the diagnosis. 
 
 ABSCESS OF THE ABDOMINAL WALL. 
 Between abscess of the abdominal wall and appendiceal 
 abscess there should be but little difficulty in arriving at a 
 correct conclusion. If the collection be in the superficial 
 fascia it will be circumscribed, but if between the abdominal 
 muscles it is likely to be diffused. The purely local character 
 
DIFFEEENTIAL DIAGNOSIS. 109 
 
 of the abdominal abscess, the swelling moving with the 
 abdominal walls, the absence of intestinal symptoms, the 
 presence of local and constitutional evidence of pus, coupled 
 with the history of the case, should be enough to render a 
 differential diagnosis possible. 
 
 INCIPIENT INGUINAL HERNIA. 
 What must not be confounded with the discomfort attendant 
 upon a chronic appendicitis is that of incipient inguinal hernia. 
 I have frequently met with cases of marked intestinal indiges- 
 tion in the absence of a palpably diseased appendix, accom- 
 panied b}^ more or less discomfort if not pain in the lower 
 abdomen, described in some instances as being dragging in 
 character. In these a careful examination of the inguinal 
 canal showed weakness of the abdominal walls at the site of 
 the internal ring, and the application of a light truss was soon 
 followed by the disappearance of all symptoms. 
 
 ENLARGED MESENTERIC GLAND. 
 
 An enlarged mesenteric gland may be mistaken for the 
 appendix when palpating the abdomen in cases of supposed 
 appendicitis. Their presence, however, is not significant unless 
 accompanied by the evidence of acute inflammation. 
 
 MESENTERIC HEMATOCELE. 
 
 As a result of traumatism, rupture of the mesenteric blood- 
 vessels sometimes occurs, followed by the formation of a 
 mesenteric hsematocele. Under ordinary circumstances absorp- 
 tion takes place. When the heematocele undergoes suppura- 
 tion, symptoms closely resembling chronic appendicitis may 
 be observed. 
 
 But by bearing in mind the character of the onset and the 
 absence of the cardinal symptoms of appendicitis a diagnosis 
 is readily made. 
 
110 APPENDICITIS. 
 
 A CIRCUMSCRIBED COLLECTION OF PUS 
 
 in relation with the iliac artery and occurring in acute or 
 chronic appendicitis may be confounded with aneurism of that 
 vessel. Though the pus formation may have transmitted 
 pulsation, this is not expansile nor accompanied by a bruit. 
 
 HIP-JOINT DISEASE. 
 
 The presence of the characteristic deformity; inability to 
 execute the normal movements of the joint ; pain referred to 
 the knee ; arching of the lumbar spine when the limb is 
 brought into the fully extended position, and absence of 
 intestinal symptoms, should determine the diagnosis. 
 
 PSOAS-ABSCESS. 
 
 The difficulty attending the diagnosis between chronic 
 appendicitis, and incipient psoas-abscess, that is, before the 
 pus has passed any distance down the psoas-sheath, I have 
 had forcibly brought to my mind. The chief points in favor 
 of a forming psoas-abscess are the appearance of the patient, 
 usually suggestive of tuberculosis; the information to be 
 obtained by an examination of the spine; a complete tem- 
 perature record, and a tendency to flexure of the thigh of 
 the affected side. While the flexure of the thigh may be 
 and is present in some cases of chronic appendicitis, it is, 
 nevertheless, a far more frequent accompaniment of psoas- 
 abscess. Palpation will in the great bulk of cases of chronic 
 appendicitis determine the presence of enlarged appendix, 
 while deep pressure over the right iliac fossa will, in case of 
 psoas-abscess, reveal tenderness of the psoas muscle, but fail to 
 disclose the presence of either enlarged appendix or the 
 characteristic rigidity of the flat muscles of the abdominal 
 walls. 
 
DIFFERENTIAL DIAGNOSIS. Ill 
 
 LUMBAR ABSCESS. 
 In this affection the liistory of spinal disease, the position of 
 the swelling, the oedema of the overlying tissue, the slow onset, 
 and the absence of acute tenderness, rigidity, and intestinal 
 disturbances, will suffice to make the differential diagnosis. 
 
 PNEUMONIA AND PLEURISY. 
 
 The onset in these two diseases is sometimes very acute and 
 the pain in the side so severe as to cause rigidity in the abdom- 
 inal muscles. If the right side be affected, the diagnosis is 
 sometimes quite difficult, especially in children, who are 
 unable to exactly describe their pain. Careful physical exam- 
 ination will, however, clear up the diagnosis. 
 
 BILIARY COLIC (Gall-Stones). 
 
 The diagnosis between biliary colic and appendicitis is at 
 times difficult. 
 
 The onset in both is somewhat similar, namely, acute pain 
 coming on suddenl}^ accompanied by persistent vomiting, 
 which is more severe and prolonged in the former than in the 
 latter affection. History of cases will generally show differ- 
 ences sufficiently marked to distinguish the two diseases. 
 
 Less severe attacks of biliary colic will probably have 
 occurred at intervals of several years, accompanied by jaun- 
 dice, which later almost invariably becomes pronounced, and 
 with characteristic color and itchiness of the skin may persist 
 in a slight degree during the entire interval between the 
 attacks. 
 
 Biliary colic is frequently ushered in by a chill. Fever is 
 absent, particularly in early stages of the disease. The bowels 
 are usually constipated, as in appendicitis; when moved, how- 
 ever, the stools have a dark green color and peculiar mouldy 
 
112 APPENDICITIS. 
 
 odor. If gall-stones are found, as is frequently the case, diag- 
 nosis is established. 
 
 The location and degree of pain differs from that of appen- 
 dicitis, being in biliary colic more continued and severe, and 
 radiating usually from the lower right chest margin to the 
 umbilicus. 
 
 While in later stages pain may become constant, and involve 
 the whole epigastric region, or extend even lower, it will, 
 nevertheless, usually at intervals of two or three days, become 
 localized and more acute in the region of the gall-bladder. 
 
 In appendicitis the localization of pain is always toward, 
 if not directly in, the right iliac fossa, while between severe 
 paroxysms there is marked tenderness at this point, and 
 characteristic rigidity of the overlying abdominal wall. 
 
PROGNOSIS. 
 
 The prognosis to be given in any case of appendicitis will 
 depend more upon the form of treatment instituted at the 
 onset, than upon any other factor. 
 
 If the appendix is skilfully removed within twenty-four 
 hours from the commencement of the attack, the prognosis is 
 favorable, and recovery will ensue in nearly all of the cases. 
 If, however, the opium treatment is resorted to, an unfavorable 
 termination is more likely, because by this method there will 
 be an apparent amelioration of symptoms and the attending 
 physician will receive the false impression that the disease has 
 either been held in check or completely cured. It is much 
 more likely, however, that the disease is progressing rapidly, 
 and the attention of the physician will be at length attracted 
 to the true state of affairs by a tympanitic abdomen, a 
 " leaky " skin, and a running pulse. 
 
 It is true that some cases will entirely recover by medical 
 treatment (16 in 400, according to Ribbert), and a slightly 
 greater number wdll apparently recover from an attack. But 
 the course of the disease is so variable that one cannot say 
 positively, or even with a slight amount of assurance, what 
 case will recover, so long as the diseased appendix remains 
 within the abdomen. The exception to this rule is found in 
 those cases which respond immediately to laxative treatment. 
 These often temporarily recover from an attack without opera- 
 tive interference. 
 
 Those cases which apparently recover, but still have tender- 
 ness over the site of the appendix, often lapse into chronic 
 inflammation, and warrant an unfavorable prognosis as long as 
 8 113 
 
114 APPENDICITIS. 
 
 operation is deferred, for the inflammatory process may light 
 up at any moment with renewed vigor, and jeopardize the 
 patient's life. 
 
 Rarely we find the inflammatory process so fulminating that 
 a widespread purulent peritonitis develops in such a short 
 time that the surgeon cannot be called early enough to prevent 
 it. The prognosis in these cases is less favorable, but the 
 patient's chances are enhanced by immediate operation. 
 
 In other cases there may be a thrombus of the appendicular 
 artery, followed by sloughing of the entire organ, and the con- 
 sequent emptying of the contents of the caecum and appendix 
 into the general peritoneal cavity. Here again the prognosis 
 is unfavorable, but surgical interference off'ers the only hope. 
 Fortunately the number of instances in which the above con- 
 ditions are found is small, and, therefore, the general prognosis 
 in cases in which operative treatment has been immediately 
 established is favorable. 
 
 Why the prognosis is unfavorable in the cases not treated 
 by operation is plainly seen by reference to the pages on the 
 pathology of the disease. It is impossible to foretell what will 
 be the outcome of any attack. Some authorities claim that 95 
 per cent, of all cases will recover without operation ; I cannot 
 agree with this statement. Too often have I seen cases which, 
 apparently recovering, or seemingly entirely recovered, had in 
 a moment lapsed into a most critical condition. As far as 
 general health is concerned, I believe that an unfavorable 
 prognosis must be given to all those cases of apparent recovery 
 in which appendiceal inflammation has become chronic. I 
 consider a chronically inflamed appendix a menace to life on 
 account of the indisputable fact that an acute attack is liable 
 to supervene at any time. The case reported on page 126 
 will illustrate this point. 
 
 Another condition to be considered in connection with the 
 
PROGNOSIS. 115 
 
 prognosis of chronic appendicitis is the danger caused by 
 adhesions which may exist between the appendix and the 
 surrounding structures, or between the csecum and the bowel, 
 or between adjacent coils of the intestine. No one can tell 
 when these may produce mechanical obstruction of the bowels. 
 Every band or adhesion formed in the peritoneal cavity 
 makes the prognosis more unfavorable, and the probable 
 presence of these adhesions must be considered in giving a 
 prognosis. 
 
 The prognosis to be given after or during an operation will 
 depend largely upon the conditions found. If there is a 
 general purulent peritonitis, with " leaky " skin and running 
 pulse, the outlook is ominous. If the pus is confined to the 
 right iliac fossa by a limiting wall of lymph, the prognosis is 
 better, but, again, it will be modified by the treatment pre-, 
 viously instituted. 
 
 The prognosis to be given in cases complicated by abscess of 
 the liver, pyle-phlebitis, phlebitis of the veins of the leg, etc., 
 must be modified by the extent and intensity of the compli- 
 cations. 
 
TREATMENT. 
 
 In the treatment of appendicitis my observation has forced 
 me to the conclusion that there is but one course to pursue 
 in order to obtain the best possible results, viz., to remove 
 the appendix as soon as the diagnosis has been made. The 
 appendix should be removed so early in the attack that there 
 will be no danger of septic absorption, purulent peritonitis, or 
 perforation supervening, and in those cases of a fulminat- 
 ing character which have been almost instantaneous in their 
 progress from the initial symptoms to the inauguration of a 
 purulent peritonitis from perforation or gangrene early opera- 
 tion is positively demanded. Sometimes it is impossible to 
 institute early operative treatment for one of several reasons : 
 the patient may not live within reach of a competent surgeon ; 
 he may not be willing to have this treatment carried out until it 
 has become evident that his only chance of recovery is by 
 operation; or there may be some serious underlying con- 
 dition, as advanced Bright's disease, diabetes, tuberculosis, 
 etc., which would forbid active measures. Under such cir- 
 cumstances, expectant treatment is the only alternative. This 
 embraces rest in bed, the judicious administration of laxatives, 
 restricted diet, and the alleviation of pain. 
 
 At the onset of an attack presenting symptoms which are at 
 all suspicious of appendicitis, the patient should be put to bed 
 at once and kept there until the disease has been either cured 
 by surgical interference, or subdued temporarily by medical 
 treatment. The latter consists mainly in the administration of 
 laxatives. In most cases castor-oil should be given. If the 
 nausea and vomiting are persistent, or if the stomach will not 
 
 IIG 
 
TREATMENT. 117 
 
 tolerate castor-oil, recourse should be had to saline cathartics 
 or calomel. In some instances, with early and continuous 
 nausea, with or without vomiting, it is advisable to administer 
 calomel at once, and thus take advantage of its dual action, 
 i. e., of allaying the irritability of the stomach and of producing 
 laxation. The best method of administering calomel under 
 these circumstances is in the powdered form ; compressed 
 tablets or triturates are popular, but they are not as service- 
 able as the powder, and, particularly if not freshly made, are 
 not only insoluble and inert, but also liable to cause mechan- 
 ical irritation of the stomach and provoke further emesis. 
 The addition of a little bicarbonate of soda will hasten the 
 laxative effect of the calomel. At times small and repeated 
 doses of calomel will fail to alleviate the irritation of the 
 stomach, and in these cases I have found that a solid dose 
 of from five to 20 grains, repeated in an hour, if necessary, 
 will often have the desired effect. If the nausea still persists, 
 a small fly-blister, applied immediately below the ensiform 
 cartilage, often proves of decided service. 
 
 I believe that laxatives should be administered in the 
 beginning of every attack of appendicitis. Diarrhoea does not 
 act as a contra-indication, as they are generally as urgently 
 called for under this condition as under the opposite one of 
 constipation. I give a laxative with threefold purpose: 1. 
 To relieve pain by clearing the intestinal tract of all irritating 
 materials. 2. To diminish the virulence of the attack, as I 
 believe the presence of foreign or irritating material in the 
 intestinal tract, and especially in that portion of it adjacent 
 to the csecum and appendix, has a favorable influence upon 
 the development of the invading micro-organisms. 3. To set 
 up an active peristalsis in the intestine and the appendix, 
 and so help the latter to empty itself. 
 
 As a general rule, I prefer castor-oil, because it unloads the 
 
118 APPENDICITIS. 
 
 bowel of faecal matter without causing an outflow of serum 
 from the intestinal circulation. Salts, on the other hand, 
 cause liquefaction of most of the bowel contents, but solid 
 particles of faecal matter are liable to remain. In the later 
 stages, however, where peritonitis has developed and a deple- 
 tion of the intestinal circulation is desirable, salts are pre- 
 ferable. 
 
 I am perfectly familiar with the unfavorable opinions 
 of a number of other writers upon the advisability of the 
 administration of laxatives in appendicitis, but my experience 
 has taught me that it forms the only successful, and there- 
 fore justifiable, treatment when operation cannot be performed. 
 I do not hesitate, therefore, to offer it to my readers as sound 
 and rational therapeutics. I repeat that laxatives should be 
 given earl}^ and in sufficient quantity to produce thorough 
 evacuation of the bowel, for they accomplish the most good 
 when given thus, and before adhesive inflammation has 
 resulted in a matting of the neighboring coils of intestine, 
 which is the method by which nature imprisons the inflamed 
 appendix, and tends to prevent infection of the peritoneal 
 cavity in the event of perforation. I am certain that in the 
 presence of commencing adhesive inflammation of the appen- 
 dix and its neighborhood, less danger attends the evacuation 
 of the bowel than that caused by a full bowel. The benefit 
 of unloading the bowel far outweighs the danger of breaking 
 up any adhesions that may be forming. In the later stages 
 of the disease, after the barrier which protects the general 
 peritoneal cavity from the inflamed and septic appendix has 
 been formed, I do not advise active purgation, as the peristaltic 
 contractions will tend to break down nature's safeguard against 
 the spread of the affection. 
 
 Of all the therapeutic agents that have been used in the 
 treatment of appendicitis, opium is the one which has been 
 
TREATMENT. 119 
 
 most often responsible for the mistakes made in diagnosis, for 
 the unsuspected development of untoward symptoms, and for 
 the call for the surgeon when too late. There is a percentage 
 of deaths from appendicitis which, beyond doubt, is due to the 
 indiscriminate and injudicious use of this drug. 
 
 Opium is dangerous in the treatment of this disease or of 
 any intra-abdominal inflammation, because it hides all the 
 symptoms of the affection ; it blocks up the bowels ; it causes 
 distention of the intestinal tract, and very often adds to the 
 nausea. The worst objection to the use of the drug is its 
 power to mask all symptoms, and too much stress cannot be 
 laid upon this point. It is essential that there should be 
 nothing at an}^ time in the course of an attack of appendicitis 
 to prevent a clear conception of the progress of the disease. In 
 many cases, indeed, the symptoms will be ameliorated after a 
 free evacuation of the bowels. On the other hand, there are 
 so many that go from bad to worse, that we must be always 
 in a position to observe symptoms of advancing trouble, which 
 is impossible if opium is given. 
 
 One of nature's most reliable signs of disease is pain, 
 and in appendicitis this pain is generally in proportion to 
 the degree of the inflammation. If then our patient be dosed 
 with opium, it will be impossible to judge what is taking 
 place within the abdomen ; there is, even for a short time, 
 freedom from pain, which gives the impression that the disease 
 is progressing favorably. Possibly it may be, but more often 
 we find that the very case that is so quiet and restful now will 
 shortly be writhing in agony and presenting all the symptoms 
 of perforation or purulent peritonitis. The surgeon is then 
 called, but is unable to tell accurately whether the distention 
 of the bow^els is caused b}^ peritonitis or by opium ; the patient 
 is drowsy and cannot respond intelligently to questions ; the 
 pain is alleviated for the time, and the presence or absence 
 
120 APPENDICITIS. 
 
 of tenderness cannot be determined. Had laxatives been 
 given, the attending physician would have known that every 
 symptom appearing was due solely to the disease ; that dis- 
 tention of the bowel must be due to peritonitis ; he would 
 probably have had a surgeon in counsel days before the 
 trouble had reached such a stage. It is true that there is 
 nothing that appeals to the sympathies of a doctor more than 
 suffering, and it is natural that he should attempt to relieve it 
 at once. But instead of giving opium, which will block up the 
 bowels, cause the retention of all irritating material, and mask 
 all symptoms, he should order a laxative, cause free evacuation, 
 and thus remove much of the irritation that is causing pain. 
 
 The use of opium to the exclusion of laxatives is, in 
 my opinion, therefore, unjustifiable, most dangerous, and 
 should never be countenanced. In the majority of cases, after 
 the complete evacuation of the bowels the pain subsides. In a 
 few, however, the pain returns with renewed vigor. This con- 
 stitutes one of the strongest indications for operation, as it de- 
 notes perforation of the appendix. 
 
 The use of such remedies as veratrum viride, aconite, fever 
 mixtures, etc., have no place in the therapeutics of appendi- 
 citis. The only remedies locally applied that have any bene- 
 ficial effect are ice-bags and turpentine stupes, though occa- 
 sionally hot applications may prove more grateful. Dry cold 
 should always be preferred, as it acts as a local anaesthetic, 
 modifies the degree of inflammation if applied early, and thus 
 hastens resolution. The application of tincture of iodine, 
 leeches, and blisters is especially contra-indicated, not only 
 because they do no good, but also because they add to the 
 patient's discomfort. Blisters are particularly objectionable 
 on account of their macerating effect upon the skin, thus 
 making a septic field for operation. The latter is also true 
 of leeches. 
 
TREATMENT. 121 
 
 The indications for enemata are the same as for the ad- 
 ministration of laxatives ; they should be given, however, only 
 as an aid to the laxative, and not to its exclusion. Forced 
 enemata should never be given to overcome the constipation 
 consequent upon a paralytic condition of the intestine; for 
 obstruction due to paralysis usually indicates perforation of 
 the appendix, and a forced enema, under such conditions, 
 may be emptied into the peritoneal cavity, as happened in 
 the following case : — 
 
 Mr. B. , twenty-seven years old, was seized suddenly with cramp-like pain 
 in the abdomen, accompanied by nausea and vomiting, for which he was given 
 morphia, gr. i, by his physician. The pain, nausea, and vomiting immedi- 
 ately ceased. Twelve hours later pain reappeared but was located in the 
 right iliac fossa, and tenderness upon deep palpation could be elicited. 
 There was but a shght rise in temperature — 100°-101°, pulse 96. 
 
 His condition remained unchanged apparently for ten days, when obstinate 
 constipation associated with tympanites set in. Calomel, Rochelle salts, and 
 castor-oil were successively administered without effect. A high enema was 
 then given, very little returning from bowel. Obstraction of bowel diagnosed. 
 
 Upon examining the case I found excessive distention of the abdominal 
 walls, which were extremely sensitive to the touch, a rapid pulse, temperature 
 102°. The excessive tympanites precluded palpation of the abdominal walls ; 
 examination per rectum nil. Diagnosis from history, appendicitis with septic 
 peritonitis from perforation. 
 
 Operation by incision through right semilunar line. Upon opening the 
 peritoneum a large quantity of pus, faeces, and fluid escaped. Csecum lifted 
 up, when it was found that the appendix had sloughed off, leaving a large 
 ulcerated opening in the caecum through which the high enema had been 
 forced into the abdominal cavity, possibly at the same time tearing the 
 appendix from its csecal origin. Opening in caecum closed, abdominal cavity 
 washed out, glass drainage introduced, wound closed. 
 
 Result, death ; patient never reacted from operation. 
 
 Asafoetida suppositories are useful in relieving pain and 
 aiding peristalsis. 
 
 The diet in all cases of acute appendicitis should consist 
 of liquid foods, such as broths, the main object being to give 
 only what- will leave little, if any, residue in the intestinal 
 tract. Beaten eggs, pancreatized milk, or buttermilk may be 
 ffiven. 
 
122 APPENDICITIS. 
 
 In cases of chronic appendicitis, the patient should eat 
 sparingly and avoid all foods that will overload the bowels 
 with residue. All coarse or hard foods, such as grits, coarse 
 oatmeal, tough meats, fibrous vegetables, etc., should be for- 
 bidden. Fruits which do not contain seeds, and from which 
 the skin has been removed, may be eaten without danger. 
 
 To recapitulate : In acute attacks, when operation is impossi- 
 ble, the following measures promise the best results : Absolute 
 rest in bed ; liquid diet, as peptonized milk, champagne, 
 broths, etc. ; castor-oil or salts or calomel in small, repeated 
 doses. Ice-bag applied locally. Asafoetida suppositories. For 
 persistent nausea, small fly blister just below ensiform cartilage. 
 
 Although there may be a few cases that for one or all 
 
 of the reasons stated cannot or will not have the benefit of 
 
 early operation, yet the vast majority will depend upon the 
 
 physician for advice. In every one of these, unless constitu- 
 
 ♦ 
 tionally contra-indicated, I believe that the appendix should 
 
 be removed as soon as the diagnosis has been established. I 
 
 recognize the fact that a very small percentage of all cases 
 
 will temporarily recover without the use of the knife, but no 
 
 one can tell which case will terminate favorably or which will 
 
 go on to perforation and gangrene, with the train of fatal 
 
 complications that is liable to follow. The best result in all 
 
 cases is obtained by removal of the appendix in the beginning 
 
 of the attack. Appendicitis is a surgical affection, and should be 
 
 treated as such. 
 
 The first question that arises, after the diagnosis has been 
 
 established, is concerning the character of the attack and its 
 
 probable outcome. It is here that we come against the stone 
 
 wall of fact, reinforced by logical conclusions founded upon 
 
 experience. We cannot foretell, with even the slightest amount 
 
 of assurance, the issue of any attack of appendicitis. The 
 
 main point to consider is, then, shall we risk the patient's 
 
TREATMENT. 1 23 
 
 life, or shall we accept the only alternative and remove the 
 organ in its incipient inflammation ? In this affection early 
 operation is a conservative and not a radical procedure. We 
 are not governed by the same reasons that influence us to 
 perform the radical operation for the cure of simple hernia or 
 for the removal of the uterus for a fibroid. In appendicitis 
 we have before us the probable consequences of suppuration, 
 gangrene, and perforation. The proportion of cases that have 
 but one attack, remaining perfectly well after its subsidence, 
 is so infinitely small, compared to those that have repeated 
 attacks with an interval of invalidism, that I do not believe 
 the rare exception should interfere with the rule, viz., that 
 where practicable all cases of appendicitis should be operated 
 upon as soon as the diagnosis has been established. Of course, 
 I do not include cases in collapse. 
 
 It is sometimes advised to delay operation until there is 
 evidence of pus, and that if there is any doubt as to pus forma- 
 tion the operation should be deferred. I could cite many cases 
 where the operation was delayed until there was unmistakable 
 evidence of pus, some of them having been delayed so long- 
 that the patient was moribund when the surgeon was called. 
 To defer operation a certain number of days or even hours is 
 to expose the patient to risks not justifiable in the light of the 
 present status of appendiceal surgery. The best results and 
 the smallest mortality are obtained when the operation is per- 
 formed at the earliest possible opportunity. The diagnosis 
 can and should be made in a few minutes, and the operation 
 should follow as soon as possible. Why should we wait for 
 the formation of pus with its dangerous sequelae, since such a 
 condition greatly adds to the dangers of an operation, particu- 
 larly when -that greatest of all absorbing surfaces, the perito- 
 neum, is involved? One has but to picture to himself the two 
 operations, one for the removal of an appendix without pus 
 
124 APPENDICITIS. 
 
 formation, the other the removal of an appendix bathed in 
 pus, to arrive at the only reasonable conclusion. In the first 
 case we have a clean abdominal incision ; the appendix 
 readily removed and the stump covered with a serous coat and 
 then invaginated into the walls of the caecum ; the external 
 wound is aseptically closed. In the second case we open up a 
 collection of fetid pus which in its escape comes in contact with 
 the incision and its contiguous parts ; we remove the appendix 
 under unfavorable circumstances with possibility of infecting 
 the general peritoneal cavity ; the wound cannot be closed, but, 
 instead, must be drained or packed with gauze, thus risking a 
 subsequent ventral hernia. With these pictures in mind, I can- 
 not see how the claim is tenable that it is better to wait for 
 pus before advising operation. That delay is dangerous in 
 the great majority of cases is certain ; that a few cases will 
 recover from the disease (16 in 400, according to Ribbert) 
 cannot be denied ; that some cases will have a subsidence of 
 acute symptoms must also be granted ; but that any one can 
 foretell the outcome I most emphatically deny. Those men 
 who are the least decided upon the question of operation are 
 those who have been limited in their experience. One must 
 see the cases in all stages to realize the dangers of delay ; one 
 must observe the effects of the various methods of treatment to 
 be convinced that there is but one sure road to recovery, 
 viz., early operation. 
 
 An analysis of 50 consecutive cases, selected from my case 
 book, of primary attacks of appendicitis in which operation 
 was performed, will illustrate the importance of the position I 
 have taken in reference to early operation in this class of cases. 
 
 The length of time elapsing between the onset of the disease, 
 as reported by the attending physicians, and the date of opera- 
 tion varied greatly : — 
 
 5 were operated on within 24 hours. 
 
TREATMENT. 125 
 
 18 were operated on within 48 hours. 
 12 were " " " 72 hours. 
 
 1 was " " " 4 days. 
 3 were " " " 5 days. 
 9 were " " " 6 days. 
 
 2 were " " " 7 to 9 days. 
 
 Of the 35 cases operated on within seventy-two hours, 28, or 
 80 per cent., recovered and seven died. 
 
 Of the remaining 15 cases operated on between the third and 
 the ninth day, ten, or 66 per cent., recovered and five died. 
 
 With the exception of faecal concretions, which were fre- 
 quently met with, the only foreign body discovered was the 
 accumulation of a number of strawberry seeds in one case. 
 
 In those cases in which, for some reason, the operation was 
 not performed in the first stages of the disease, and where the 
 patient apparently recovers from the attack — the appendiceal 
 inflammation becoming chronic — I believe the appendix 
 should always be removed between the attacks, when the 
 disease is more or less quiescent. There is no doubt in my 
 mind that, without exception, every appendix that has been 
 the seat of an inflammatory process is a source of danger to 
 the life of the patient, liable at any time to acute inflamma- 
 tion, and should, therefore, be removed. The mortality from 
 the operation in chronic cases is exceedingly small. In 
 cases of so-called recovery, most often we find the patient 
 a chronic invalid, with constant dread of another attack, 
 troubled with indigestion and obstinate constipation or 
 diarrhoea. We must also consider the results of inflam- 
 mation that are not apparent to the patient, such as 
 bands of adhesions that are liable to cause mechanical ob- 
 struction or chronic inflammation, that may spring into 
 activity at any moment; we must consider the effect of the 
 previous attacks, with the resulting mass of exudate and ad- 
 hesions, binding the appendix down so firmly that there will 
 
126 APPENDICITIS. 
 
 be added difficulty and corresponding danger wlien the organ 
 is removed. That grave trouble may arise in a chronically 
 inflamed appendix at any time is well illustrated by the fol- 
 lowing case : — 
 
 Dr. , while witnessing one of my operations for the 
 
 removal of the appendix, told me that he had been troubled 
 with a chronic appendicitis for some time. I volunteered the 
 advice that he should have the appendix removed, and he 
 concluded to do so as soon as he could arrange his business 
 satisfactorily. About six weeks after our conversation I was 
 telegraphed for to come to his home at once, as he was suffer- 
 ing from an acute attack. On my arrival, I found him 
 suffering from purulent peritonitis, the result of perforation. 
 Operation disclosed the belly full of fetid pus ; the peritoneum 
 the seat of a most virulent form of inflammation; the ap- 
 pendix gangrenous and perforated, and a gangrenous patch 
 in the csecum. Death ensued in about eight hours. 
 
 This is but one of many instances I have seen, and it is 
 hardly necessary to say that in most of such cases operation 
 promises but little. 
 
 If pus has formed in an attack of appendicitis, I believe it 
 should be removed at the earliest possible moment. The prac- 
 tice of deferring operation, in the presence of a purulent col- 
 lection, for a few days, in the hope that the limiting membrane 
 that forms the partition between the collection and the general 
 peritoneal cavity will become stronger, is a procedure which I 
 regard as unwise and attended by risks both immediate and 
 remote. The immediate risks are from general septic infec- 
 tion, metastatic abscess, pyelo-phlebitis, and abscess of the 
 liver. The remote risks are gangrenous perforation, sponta- 
 neous separation of the appendix from the ceecum, spontane- 
 ous separation of the appendix in its continuity, or necrosis 
 and perforation of the csecum from pressure of the collection 
 against its walls. 
 
H. W., age twenty -five, admitted to German Hospital January 15, 1896. 
 Had his first attack ten days previous to admission, with sudden onset of pain 
 in his right ihac fossa immediately after eating, followed by rigidity and 
 marked tenderness. Remained in bed two days and symptoms abated, though 
 there was still pain on right side, which increased by motion. No vomiting ; 
 constipation. At the time of admission he had the following symptoms : 
 Tenderness on pressure over McBurney's point and marked rigidity on right 
 side ; by deep palpation mass could be made out ; tongue coated ; tempera- 
 ture normal. 
 
 Operation. — The apijendix through nearly its whole length lay in front of 
 the csecum. The tip, however, was adherent to the posterior surface of the 
 caecum. [See Fig. 2, page 129.] It was covered by dense adhesions, upon 
 the loosening of which about one pint of thick, fetid pus was discharged 
 from behind the caecum. The cavity was wiped out with dry gauze (no 
 irrigation) ; the appendix was freed and tied oiF; gauze drainage was left in 
 and the abdominal wound closed. 
 
 For sixteen hours after operation the patient did well and suffered little. 
 Suddenly he had a sharp accession of pain over the epigastrium, was nauseated, 
 and finally began vomiting greenish matter in which blood was discernible. 
 Distention slight. Wound was dressed, gauze taken out, and cavity cleansed. 
 Delirium set in, vomiting became continuous, and death ensued on third day 
 after operation. 
 
 Post-Mortem. — Incision closed and in good condition. In the upper 
 posterior aspect of the caecum were two small perforating ulcers surrounded 
 by necrotic areas. Cicatrix of appendix amputation scarcely discernible. 
 
 128 
 
Plate XVII 
 
 Perforations 
 surrour^ded 
 by -.=-::::: 
 
 qecrotic area 
 
 eo-caecal valve 
 
 *.— Lumeri of appendix 
 
TREATMENT. 
 
 129 
 
 In these cases the csecum may be so involved from pressure 
 that at any time it may rupture with consequent fsecal fistula, 
 opening externally or into the peritoneal cavity. 
 
 Fig. 2. — Showing Position of Appendix in Case of H. W. [Page 128.] 
 
 The case last reported as well as the following, both terminat- 
 ing fatally, perfectly illustrate this serious condition. 
 
 W. P. , age thirty-six, was admitted to the German Hospital March ] , 
 1 896, with the followiug history : For three weeks previous he had been com- 
 plaining of gastric disturbance, headache, pain in his right side, and general 
 malaise. Temperature was irregular, 99°-101° ; tongue was coated ; there was 
 occasional vomiting and constipation. There were repeated attacks of pain, 
 located in the right iliac fossa, at intervals of three or four days, dating from 
 the beginning of his sickness. 
 
 At the time of admission his temperature was 101|°. He had slight sweats, 
 and complained of pain in his right iliac fossa. Tenderness was marked, but 
 nothing else could be determined by palpation on account of the rigidity and 
 great thickness' of the abdominal walls. 
 
 Operation. — A large abscess was found behind the csecum. The appendix 
 pointed N. , and was so fragile that it was picked out in shreds from the lake 
 of pus that contained it. The abscess-cavity was gently irrigated and a glass 
 9 
 
130 APPENDICITIS. 
 
 drainage tube inserted to the site of the appendix, around which was packed 
 iodoform gauze, and the abdominal incision closed. 
 
 For four days the patient did well, the temperature and pulse were normal, 
 and the stomach retentive. On the fifth day he had sudden, sharp pain, ab- 
 dominal distention, vomiting which became persistent, and died in a few hours. 
 
 Post-Mortem. — Purulent peritonitis ; caecum perforated on the posterior 
 wall. The opening corresponding to the site of the appendix was large enough 
 to admit the end of the thumb. 
 
 Most of these conditions are liable to result in a fsecal fistula. 
 I consider that the danger of leaving a diseased appendix in the 
 abdominal cavity is greater than the damage likely to accrue 
 from rupturing the partition wall in an attempt to remove 
 it. I believe it is possible, and always advisable, to remove the 
 organ and thus make the operation complete, as in no other 
 way will recovery be assured, though I must emphasize the 
 fact that this practice is only justifiable in skilled hands. 
 For the occasional operator it is far safer that he content him- 
 self with a simple evacuation of the abscess. To leave within 
 the abdomen an appendix which has sloughed ofi^, or which 
 has a perforation in it, or which has been intensely inflamed 
 by migration of micro-organisms through its walls, I believe 
 to be incomplete surgery. An appendix which is deeply 
 imbedded in a wall of lymph, whether it form a portion of 
 the abscess wall or not, can be removed. The proper dispo- 
 sition of gauze and careful attention to technique will, in 
 experienced hands, render the dangers which attend the re- 
 moval of the appendix much less than those which will 
 threaten if it be allowed to remain. A practice which, I 
 believe, is a frequent one, is to evacuate the abscess-cavity 
 and, after affording drainage, to close the wound partially, 
 without any effort to remove the appendix unless it happen 
 to lie in plain sight. If the surgeon has a perfect knowledge 
 of the anatomy of the right iliac fossa in the normal condition, 
 and has seen enough cases to familiarize him with the con- 
 
Plate XVIII 
 
 fWWWsir] 
 
 The Location of the Simple Incision 
 
Fig. I 
 
 Plate xix 
 
 Superficial fascia 
 
 Apor\eurosis of Ext, Oblique 
 
 Fig. 2 
 
 Apoqeurosis of Ext. Oblique 
 
 Aponeurosis of Int. Oblique 
 
 Aporieurosis of Ext, Oblique 
 
 Sheath of Rectus 
 
TREATMENT. 131 
 
 ditions generally found after disease, I fail to see why the 
 organ cannot be found, as is claimed by some operators, 
 though I grant that sometimes search is tedious and attended 
 by difficulty. 
 
 Although I am a strong advocate of the removal of the 
 appendix in almost every case of appendicitis, yet there are 
 a few conditions in which I prefer to defer operation. Per- 
 sistent vomiting, a leaky skin, a rapid pulse in the presence 
 of a diffuse peritonitis, and approaching collapse, in my judg- 
 ment forbid operation. 
 
 I have frequently been asked, when refusing to operate in 
 such cases, why we should not give the patient his only 
 chance. It is my belief that operation at this time is in- 
 variably attended by fatal results. 
 
 In these cases, ice to the abdomen, calomel given to the 
 extent of moving the bowels freely, a small fly blister applied 
 immediately beneath the ensiform cartilage, nutritious enemata, 
 stimulants, as whiskey, dry champagne, hypodermics of strych- 
 nine, promise more than radical treatment. When by such 
 means the general peritonitis subsides and the constitutional 
 condition warrants it, operation may be done with the hope of 
 a successful issue. 
 
 Though the technique of the operation for appendicitis varies 
 with the nature of the case and the conditions present at the 
 time of operation, there are, nevertheless, certain features, com- 
 mon to all, which should be carried out when feasible. 
 
 If the patient has chronic appendicitis, he should be con- 
 fined to bed for from one to two days before the time set for 
 operation. The diet should be light and easily digested, in 
 order to leave a minimum of residue. The urine must be 
 carefully examined, at least once, and oftener if time permits. 
 This measure should never be neglected. The day preceding 
 operation the bowels should be thoroughly evacuated by a 
 
132 APPENDICITIS. 
 
 laxative and on the morning of the operation an enema 
 given. 
 
 The patient is to be prepared for operation as follows: 
 A general bath of hot water and soap, rinsing off with a 
 saturated solution of boracic acid. An entire change of 
 clothes, including bed linen. The immediate site of the opera- 
 tion is now to be scrubbed with thymol or green soap, hot 
 water, and a soft brush, particular care being paid to the 
 umbilicus. The immediate site and surrounding skin are to be 
 shaved, so that hair, dead epidermis, and dirt may be removed. 
 The abdomen should now be rescrubbed with soap and water. 
 This is followed by the successive application of ether and 
 alcohol upon a wad of aseptic cotton in order to remove any 
 fatty material. Lastly, a thorough scrubbing with corrosive 
 sublimate of the strength of 1 : 1000. A sterile towel or a 
 large piece of gauze moistened with the sublimate solution is 
 next to be placed upon the abdomen and retained by a 
 bandage. The patient is then ready to be placed upon the 
 table on the following day. After etherization and the arrang- 
 ing of sterile sheets and towels, the abdomen should be again 
 washed in 1 : 2000 bichloride solution. We are now prepared 
 to go on with the operation. 
 
 Of course, it is not always possible to carry out this detailed 
 preparation in all cases, as it not infrequently happens that 
 the operation has to be done at once or under unfavorable 
 circumstances. 
 
 Incisions. — The two incisions most suitable for the operation 
 of appendicitis are those which go through the abdominal 
 walls to the right of the median line. They are the simple 
 and the McBurney incisions. The median incision for appen- 
 dicitis operations is not anatomical, is irrational and danger- 
 ous, particularly if pus complicates the case. 
 
 The simple incision divides the layers of the abdominal 
 
Plate XX 
 
 Sheath of Rectus 
 
 Rectus nr\ 
 
 i/ if \ Sheath of Rectus 
 
 \l 'J 
 
 Fiq, 2 
 
 a, b — Epigastric veiqs beneath 
 Transversalis fascia 
 
 Rectus iTi 
 
 I Traqsversalis fascia 
 
TREATMENT. 133 
 
 wall in the same longitudinal line, displacing the outer edge 
 of the right rectus abdominalis inward, and is made a little to 
 the inner side of the right semilunar line. The incision down 
 to the peritoneum should be about three inches long, and 
 begins one inch above a line drawn between the anterior 
 superior iliac spine and the umbilicus ; the incision intersects 
 this line at a distance varying from one-half to one inch to 
 the umbilical side of its centre. (See Plate XVIII.) 
 
 In pus cases where the collection is circumscribed it is often 
 advisable to make the incision well to the right, running 
 parallel and just above Poupart's ligament. This incision 
 permits of better drainage and greatly decreases the danger of 
 breaking through the inner wall of the abscess cavity in the 
 manipulations necessary for the removal of the appendix. 
 
 The incision in the peritoneum should at first be one inch 
 in length, simply large enough for the insertion of the index 
 finger. Through this incision the csecum can be picked up 
 and brought out, and with it the appendix. If the caecum or 
 appendix be bound down, or if pus be present, it will be wise 
 to enlarge the peritoneal incision. Bleeding should be con- 
 trolled with hsemostats before the peritoneum is opened. The 
 steps in this operation are illustrated in Plates XIX to XXIV 
 inclusive. 
 
 McBurney has suggested a method of opening the abdomen, 
 which, while more difficult of execution than the simple 
 incision, is far less liable to be followed by ventral hernia. It 
 is only applicable to those cases uncomplicated by pus. 
 
 The skin incision in this, the McBurney operation, is 
 slightly curved, with the convexity outward. It is about two 
 inches long and is midway between the right semi-lunar line 
 and the anterior superior spine of the ilium. (See Plate 
 XXV.) The section of the external oblique muscle and 
 aponeurosis should correspond, great care being taken to 
 
134 APPENDICITIS. 
 
 separate these tissues in the same line, and not to cut any 
 fibres. This is easily accomplished. 
 
 When the edges of the wound in the external oblique are 
 now strongly pulled apart by retractors, a considerable expanse 
 of the internal oblique muscle is seen, the fibres of which cross 
 the opening formed somewhat obliquely. Next divide the 
 delicate fascia covering the internal oblique in the direction 
 of its fibres. With a blunt instrument, such as the handle of 
 a knife or the point of closed scissors, the fibres of the internal 
 oblique and transversalis muscles can now be separated in a 
 line parallel with their course, without cutting more than an 
 occasional fibre. Blunt retractors should now be introduced 
 into this incision in turn and the edges separated. 
 
 The transversalis fascia is now well exposed and divided in 
 the same line, separating with it the preperitoneal fat. Last of 
 all a transverse section of the peritoneum is made. 
 
 Two sets of retractors must at times be in use, one holding 
 open the superficial wound from side to side, the other separat- 
 ing the edges of the deeper wound from above downward ; 
 ordinarily, however, I find one set of small retractors sufficient. 
 A considerable opening is thus formed, through which, in 
 suitable cases, the caput coli can be easily handled and the 
 appendix removed. 
 
 The appendix having been amputated and the stump 
 buried, the transverse wound in the peritoneum is then closed 
 by continuous catgut suture. The parallel wound in the 
 fascia transversalis is sutured in the same way. The fibres of 
 the internal oblique and transversalis muscles fall together 
 as soon as the retractors are withdrawn, but with a couple 
 of fine catgut stitches tiie closure can be made more com- 
 plete. The wound in the external oblique aponeurosis is 
 closed with a continuous catgut suture. The skin and super- 
 ficial fascia are now closely united by a continuous, sub- 
 
Plate XXI 
 
 Fig. 
 
 Pre-peritoqeal fat 
 
 Epigastric veir\s 
 
 Fig. 2 
 
 Peritoneum 
 
TREATMENT. 135 
 
 cuticular suture and the wound hermetically sealed by iodoform 
 collodion. 
 
 When the operation is completed it will be seen that the 
 gridiron-like arrangement of the muscular and tendinous 
 fibres, to which the abdominal wall largely owes its strength, is 
 almost as completely restored as if no operation had been done. 
 
 Plates XXVI to XXXI inclusive show the various steps of 
 the operation done by this method. 
 
 In performing this operation I have noticed several ad- 
 vantages. 
 
 In the first place, muscular and tendinous fibres are separated, 
 but not divided, so that muscular action cannot tend to draw 
 the edges of the wound apart, but, on the other hand, actively 
 approximates them. Except during the incision of the skin, 
 almost no bleeding occurs. The fascia transversalis, not being 
 drawn away by the retraction of the deepest layer of muscular 
 fibres, is easily sutured, and thus greater strength of repair is 
 assured. No muscular fibres or large nerves having been 
 divided, pain after operation is almost absent. The ilio- 
 hypogastric is the only nerve encountered and should be pushed 
 aside. The operation requires rather more time than the 
 simple one. The opening into the peritoneal cavity is not 
 large, but may be made larger, if necessary, by continuing the 
 separation of the fibres of the internal oblique and trans- 
 versalis, and dividing the conjoined aponeurosis in the same 
 line with scissors. In the opposite direction the separation of 
 muscular fibres may, upon necessity, be carried as far as the 
 crest of the ilium, or the conjoined aponeurosis may be divided 
 vertically. 
 
 In both operations it will sometimes be necessary to enlarge 
 the incision after the peritoneum has been opened. When 
 adhesions are strong and numerous, tying down the csecum and 
 appendix, it is wiser to have plenty of room in which to work. 
 
136 APPENDICITIS. 
 
 This also is true when pus is present, and when, from the 
 appearance of the right iliac fossa, secondary collections are 
 suspected. 
 
 As soon as the peritoneum is opened, the csecum should be 
 delivered and with it the appendix. After the appendix is in 
 the grasp of the thumb and finger the csecum should be 
 replaced in the abdominal cavity. 
 
 The meso-appendix is now to be tied off and cut away from 
 its appendiceal attachment. This is accomplished by trans- 
 fixing its base by a small pair of forceps. A piece of catgut is 
 engaged in the jaws of the forceps, which are then withdrawn 
 and with them one-half of the catgut ligature. After tying the 
 ligature, the meso-appendix is cut away with a pair of scissors. 
 
 A circular incision is now made through the serous eoat of 
 the appendix one quarter of an inch from its junction with the 
 c£ecum. The serous coat is next stripped back toward the 
 csecum, leaving a cuff of peritoneum, after which the appendix 
 is ligated with silk and the organ removed. The mucous 
 membrane of the stump of the organ is curetted and anti- 
 septicized with a solution of mercury bichloride and carbolic 
 acid (1 : 4000 and 1 : 60 respectively). The serous coat is 
 stitched with a fine needle and silk over the stump thus 
 left. The stump now covered with peritoneum is invag- 
 inated into the wall of the csecum with continuous Lem- 
 bert sutures. By this method of disposing of the stump, fsecal 
 fistula is impossible, and therefore it is a method which should 
 be carried out whenever circumstances permit. When the ap- 
 pendix is gangrenous or friable, or is much involved in inflam- 
 matory lymph, we often have to content ourselves with a 
 simple ligature taking in all the coats of the organ. The 
 stump thus remaining should, if possible, be invaginated into 
 tlie csecum. 
 
 Very often, in cases where pus complicates the operation, there 
 
Fig, 
 
 Plate xxil 
 
 Great omentum 
 
 Fig. 2 
 
 Caecum. 
 
 Base of appendix 
 
Fig. 
 
 Plate XXlll 
 
 Gauze 
 
 Gauz 
 
 Gauze distributed around bov^el, serous coat turned back ar^d appendix tied off 
 
 Fig. 2 
 
 Gauze 
 
 Gauze 
 
 Serous coat of appendix sutured over stump 
 
TREATMENT. 137 
 
 is no confining wall of lymph, or if present it is incomplete or 
 so delicate that the appendix cannot be removed without 
 endangering the general peritoneal cavity. It is, therefore, a 
 matter of the first importance that some method be instituted 
 by which the spread of infection will be rendered impossible 
 during the necessary manipulation for the removal of the 
 organ. This is conveniently and thoroughly accomplished by 
 the proper disposition of sterilized gauze. Pieces about six 
 inches in length by four inches in width will be found most 
 useful. 
 
 Since the success in the operative treatment of appendicitis 
 complicated by pus formation will largely depend upon a 
 knowledge of the anatomical varieties of this form of abscess, 
 as well as upon a complete understanding of the safest method 
 of evacuating the pus and removing the appendix without 
 peritoneal infection, a brief description with the operative 
 technique is here given. 
 
 Depending upon the location of the pus, appendiceal abscess 
 is met with as one of four varieties : First, and the most com- 
 mon in my experience, is the collection located post-csecal, or 
 between the layers of the ascending meso-colon ; second, the 
 collection is immediately beneath the anterior parietal peri- 
 toneum, being confined by the ceecum, coils of small intestine, 
 the omentum, the appendix, the parietal peritoneum, and 
 masses of lymph ; third, the collection is located in the pelvis, 
 which is usually entirely shut off from the general peritoneal 
 cavity ; fourth, pus is free in the general peritoneal cavity. 
 
 In dealing with the first variety, as soon as the peritoneal 
 cavity is opened the first thing to be done is to protect the gen- 
 eral peritoneum bj^ the proper disposition of gauze, as has been 
 described. The next step is to open the collection by breaking 
 through either the outer layer of the ascending meso-colon or 
 through the layer of lymph, attaching the outer wall of the 
 
138 APPENDICITIS. 
 
 c?ecum to the floor or the side of the iliac fossa, as the case 
 may be. Turn the patient well over upon the right side and 
 irrigate the cavity until the water returns clear. The cavity is 
 now to be wiped out first with dry iodoform gauze, then with 
 gauze wet with a solution of bichloride and carbolic acid. After 
 drying the cavity with iodoform gauze the appendix is located 
 and removed. After the removal of the appendix, and, when 
 possible, the invagination of the stump, the cavity is to be 
 lightly packed with narrow strips of iodoform gauze and the 
 abdominal wall sutures introduced but left untied. The pieces 
 of gauze used in walling off the general peritoneal cavity are 
 now removed carefully and the wound aseptically dressed. 
 After forty-eight or seventy-two hours the gauze packing is 
 removed, first saturating it with sterilized salt or boracic acid 
 solution; the sutures are tied and the wound dressed. It is 
 not always possible to completely close the wound after the 
 removal of the packing, but this must depend upon the condi- 
 tion of the wound. If there is escape of pus following the 
 removal of the gauze, it will be necessary to allow the central 
 portion of the wound to heal by granulation. It is in this 
 variety of abscess, i. e., with the collection post-csecal, that the 
 greatest difficulty is encountered in the removal of the 
 appendix. 
 
 The evacuation of the collection located behind the caecum and 
 colon must of necessity entail opening the general or larger of 
 the two peritoneal cavities unless an incision is made through 
 the loin, as in opening a nephritic or peri-nephritic abscess. 
 This method would suffice were the exact location of the collec- 
 tion known definitely beforehand and if the operator's inten- 
 tion was simply to evacuate the abscess and not to attempt 
 to remove the appendix. The operator who believes it bad 
 practice to take out the appendix in pus cases unless it appear 
 right under his eye and finger, after having opened from in 
 
Gauze 
 
 F,g. I 
 
 PLATE XXIV 
 
 Stump of appendix invaginated 
 Fig. 2 
 
 Gauze 
 
 Gauze 
 
 Caecum replaced and gauze laid beneath peritoneal opening 
 
TREATMENT. 139 
 
 front and determining that the collection is in this situation, 
 can accommodate himself by closing the anterior incision and 
 then proceed to do the loin operation. It is unnecessary to say, 
 however, that this would subject the patient to an incomplete 
 operation. 
 
 In the second variety, immediately upon carrying the in- 
 cision through the parietal peritoneum, the collection is opened. 
 The pus cavity is evacuated and antisepticized without irri- 
 gating. Irrigation in this variety is dangerous on account of 
 the delicacy of the confining wall, rendering dissemination of 
 infection more liable. Evacuation is ordinarily accomplished 
 without risk of infecting the peritoneum since the incision 
 which corresponds to the most prominent part of the swelling, 
 or if no swelling is present, to the point over the involved 
 region most sensitive to pressure, comes directly down upon the 
 collection. This variety of abscess can usually be said to be 
 present when the abdominal muscles along the line of the in- 
 cision are found to be oedematous and infiltrated. If the mus- 
 cles are not thus affected the abnormality will be found in the 
 transversalis fascia and pre-peritoneal fat. Unless the case be 
 of several days' standing, the amount of pus in this variety is 
 small in comparison to the first class, and is therefore readily 
 disposed of by mopping with pieces of iodoform gauze. After 
 locating the appendix, it is dissected free and small pieces of 
 gauze inserted as it is loosened from its bed, so that when the 
 appendix is entirel}^ free, its original site will be occupied by 
 the pieces of gauze which were introduced during the dissec- 
 tion. It can now be tied off and removed, and the cavity and 
 wound treated as in the first instance. 
 
 In this second variety of abscess it frequently happens that 
 the collection is not completely shut off at its lower end, but is 
 in communication with the pelvis ; therefore, I make it a prac- 
 tice to pass a glass drainage tube down to the floor of the pelvis 
 
140 APPENDICITIS. 
 
 to definitely determine its condition. I have on many occa- 
 sions, when operating with this form of abscess present, 
 evacuated but a drachm or two of pus upon cutting through 
 the peritoneum. Upon passing a glass drainage tube into the 
 pelvis as much as half a pint of pus has escaped. 
 
 In the third variety, the peritoneal cavity being opened it 
 should be walled off down to the roof of the pelvis. The finger 
 is then carried over the brim of the true pelvis down to the 
 collection, and a glass drainage tube introduced with the finger 
 as a guide. Irrigation is carried out through the glass tube. 
 The appendix is now located and removed. After the removal 
 of the organ the glass drainage is reinserted and left in place 
 for from one to four days, depending upon circumstances. The 
 gauze packing is to be removed and replaced by a small piece 
 which is allowed to remain until adhesions have formed which 
 will close off the cavity, usually in twenty-four or forty-eight 
 hours. The upper portion of the wound is to be closed and 
 only the lower portion, through which the glass tube and the 
 end of the gauze packing protrudes, is allowed to remain 
 open. 
 
 The evacuation of the collection through either the rectum 
 or the vagina in the third variety of abscess, i. e., pelvic, I re- 
 gard as unsurgical and attended by more risk than incision 
 through the abdominal walls. By the latter means it is 
 definitely known what is being done, nothing being taken for 
 granted. 
 
 In operating through the belly walls, the appendix can be 
 removed at the time of evacuation of the abscess, a procedure 
 which, in my judgment, is so important. Operation in these 
 cases of pelvic collections has, in my hands, been among the 
 most successful of all the cases of acute appendicitis attended 
 Vjy pus formation. 
 
 In the fourth variety, the general peritoneal cavity is to be 
 
Plate XXV 
 
 ^ 
 
 V 
 
 The Location of the McBurney Incision 
 
Fig. I 
 
 Plate xxvi 
 
 Skiq 
 
 Aponeurosis of Ext. Oblique 
 
 Superficial fascia 
 
 Fig. 2 
 
 Delicate fascia covering int. oJDlique m, 
 
TREATMENT. 141 
 
 thoroughly irrigated, appendix removed, glass drainage intro- 
 duced into the pelvis, and wound closed. 
 
 If the case is of long enough standing to have allowed ex- 
 tensive adhesions to form throughout the peritoneal cavity, it 
 may be necessary to provide capillary drainage by means of 
 strips of gauze distributed in various directions, because irriga- 
 tion will not reach all the nooks and crannies of the peritoneal 
 cavity when extensive adhesions have formed. 
 
 The fourth variety is met with in the very rapidly develop- 
 ing cases of appendicitis which call for immediate operative 
 interference, and I have met with this condition within twelve 
 hours after the onset of an acute attack, as the following case 
 will illustrate : — 
 
 Annie B. , colored, age forty-two, was suddenly seized on the morning of 
 June 15, 1895, with acute abdominal pain accompanied by nausea and vomit- 
 ing. She attempted to cook breakfast but was compelled to go to bed. Not- 
 withstanding the use of home remedies and two large doses of castor-oil, 
 which had moved her bowels very freely, she suifered excruciating pain. 
 
 Immediately after seeing her I advised operation, to which she gladly con- 
 sented. I sent her to the German Hospital and operated the same evening. 
 Found the abdominal cavity full of pus ; a very much enlarged and acutely 
 inflamed appendix which was covered with strips of inflammatory exudate. 
 Removed appendix ; washed out abdominal cavity with sahne solution, and 
 introduced glass drainage into pelvis. 
 
 Recovery speedy and uninterrupted. Returned to the house in three weeks, 
 and resumed her duties as cook at the end of the fourth week. 
 
 There usually should be little or no difficulty in finding and 
 removing the appendix in the fourth variety of abscess, as the 
 anatomic landmarks are but slightly, if at all, impaired or 
 distorted by the inflammatory process. 
 
 In the first three varieties it requires skilful manipulation 
 to find and remove the appendix without infecting the general 
 peritoneal cavity. In the first and third varieties, i. e., the post- 
 csecal and pelvic collections, equally great care must be exer- 
 cised to avoid infecting the peritoneum during the simple pus 
 evacuation. 
 
142 APPENDICITIS. 
 
 In cases where there has been no attempt upon the part of 
 nature to wall off, or where there are no adhesions between the 
 anterior layer of peritoneum, the omentum, and the underlying- 
 bowel, it will be necessary to place a series of pieces of gauze 
 in different directions so that they will drain the general 
 peritoneal cavity. This is accomplished by packing each piece 
 in endwise and allowing the outer end to protrude from the 
 wound. In closing the wound the stitches between which the 
 ends of the gauze project are to be left long, so that they can 
 be tied after the removal of the gauze. 
 
 Frequently after the completion of a toilet of an abscess 
 cavity in the right iliac fossa, and particularly in that class of 
 cases where immediately upon opening the peritoneum pus 
 escapes, the general peritoneal cavity not having been com- 
 pletely shut off, a glass drainage tube carried down into the 
 bottom of the pelvis will bring to light a hitherto unsuspected 
 collection of pus. 
 
 In closing the abdominal wound one of several methods 
 may be used : 1. Interrupted sutures including all the layers. 
 2. Buried sutures uniting the different layers separately. 
 
 However, the plan of procedure which I most often carry out 
 in closing the abdominal wound in the simple incision, and 
 which I believe to be the strongest safeguard against hernia, is 
 that of buried sutures, the peritoneum and skin being stitched 
 separately with continuous cat-gut suture and the muscles and 
 fascia by mattress suture or simple uninterrupted suture of 
 kangaroo tendon, silver wire, or worm-gut. The materials 
 used in closing the incision are silk, silk-worm gut, kangaroo 
 tendon, and silver wire. The last is most readily rendered 
 aseptic and is the only one about the asepsis of which we 
 can be absolutely positive. Where, on account of drainage, 
 it is not possible to close the entire wound, place as many 
 buried sutures as will close the wound to the point of exit 
 
Fig. I 
 
 Plate xxvil 
 
 Int. oblique m. 
 
 Fig. 2 
 
 Fibres of internal oblique and transversalis separated shiowing 
 Transversal is fascia, a 
 
Fig. I 
 
 Plate XXVII 
 
 Traqsversalis fascia 
 
 "- Peritoneum 
 
 Fig. 2 
 
 X ^Peritoneum 
 
 Great omentumi 
 
 Traqsversalis fascia 
 
TREATMENT. 143 
 
 of the drain, where two or more simple or buried sutures of 
 silk-worm gut are placed. These two sutures are allowed to 
 remain long and untied, so that the edges of the incision 
 corresponding to the drain can be drawn together after the 
 removal of the gauze or tube. 
 
 In closing by buried sutures, it will not be necessary in all 
 cases to stitch the peritoneum, as sometimes its cut edges come 
 evenly together when the edges of the wound are approximated. 
 If, however, they do not approximate well, it will be necessary 
 to stitch them together first with a continuous cat-gut suture. 
 
 The next layer consists of mattress sutures or simple 
 interrupted sutures of kangaroo tendon, which, on account of 
 its great strength, its durability against absorption, and com- 
 paratively easy aseptization, is an excellent suture material. 
 The needle best adapted for this suture is a French instrument 
 (Reveridan's) with the eye in the point, which can be opened 
 and closed by a thumb service arrangement in the handle. 
 A curved Hagedorn needle with a holder will answer the 
 purpose, but is less convenient. 
 
 To introduce the mattress suture we begin on the outer side 
 of the wound. The needle is thrust through the aponeurosis 
 of the external oblique and through the internal oblique and 
 transversalis muscles about one-half inch to the outer side of 
 the incision. It next traverses the transversalis fascia, con- 
 tinuing out into the wound between the pre-peritoneal fat and 
 the peritoneum, which last is not usually included in the stitch. 
 After carrying the needle across the incision, it is thrust 
 through the pre-peritoneal fat of the side opposite its point of 
 introduction one-half inch from the inner edge of the incision. 
 It now pierces the transversalis fascia, the rectus muscle, and its 
 posterior and anterior sheath. A strand of kangaroo tendon 
 is threaded into the eye of the needle, and by holding one end 
 of the suture and withdrawing the needle, the needle end of the 
 
144 APPENDICITIS. 
 
 tendon will be drawn through and the first part of the stitch 
 will be in place. Disengaging the needle, we again thrust it 
 through the tissues in the order above described, beginning 
 one-half inch from the outer edge of the incision and one- 
 quarter inch above the first point of introduction of the needle. 
 When, following the course above described, the eye of the 
 needle has penetrated the anterior layerl of the sheath of the 
 rectus, we thread one end of the suture which is already in 
 place and withdraw the instrument, carrying with it the tendon. 
 Now both of the ends are through the aponeurosis of the exter- 
 nal oblique muscle to the same side of the incision, but one- 
 quarter inch apart, thus giving us a U-shaped suture with two 
 free ends. When these ends are tightly tied together we secure 
 a firm suture, which brings together and retains those tissues, 
 both muscular and fascial, which when united form a barrier 
 to ventral hernise. The only objection which can be raised 
 against this method is the formation of a ridge along the line 
 of opposition of the tissue included in the buried sutures. By 
 using the simple interrupted buried suture this bunching of 
 the tissue is overcome and the edges of the wound exactly 
 proximated. I therefore prefer the latter method. In Fig. 3 
 the result with the mattress suture is shown ; in Fig. 4 that 
 with the simple suture. The skin wound is closed by a 
 continuous, sub-cuticular suture as follows : — 
 
 Starting at the lower end of the incision, the needle is thrust 
 horizontally in and out through the dermis of first one side, 
 then the other, for distances of one-quarter inch until the skin 
 edges are approximated throughout. The suture is fastened 
 in the upper end of the wound. Silver wire is preferred by 
 some surgeons for the continuous subcutaneous stitch, because 
 it is not absorbable and therefore keeps the edges of the wound 
 in apposition until perfectl}^ healed, after which it can be with- 
 drawn. 
 
Fig. 
 
 PLATE XXIX 
 
 Caecum 
 
 Appendix and 
 nqeso-appendix 
 
 Fig, 2 
 
 Gauze 
 
 Gauze 
 
TREATMENT. 
 
 145 
 
 The dressing for these cases consists of a layer of iodoform 
 collodion and a strip of iodoform gauze, over which is painted 
 a second layer of the iodoform collodion. The dressing is 
 completed by placing a pad of sterilized gauze over the wound, 
 retaining it in place by strips of adhesive plaster. The latter 
 part of the dressing is to guard against sudden tension on the 
 wound from muscular action due to coughing, straining, etc. 
 
 If in closing the wound when the simple incision has been 
 used, the method of interrupted sutures including all the layers 
 
 Fie. 3. 
 
 Jk= 
 
 5fe 
 
 ^- 
 
 Fig. 4. 
 
 is followed, a long, straight needle, not too large in diameter, 
 should be employed. The needle is thrust through the skin 
 about one-fourth of an inch from the edge of the incision, pierces 
 all the layers, running obliquely backward so that the opening 
 it makes in the peritoneum will be about one inch from the 
 edge of the incision. This insures contact of the edges of the 
 cut peritoneum. The stitches are interrupted, being about one- 
 fourth of an inch apart. Superficial stitches of silk can be used 
 to overcome any gaping in the skin. Before the stitches for 
 closing the wound are introduced, a piece of gauze should be 
 spread over the underlying intestines so that they may be free 
 
 10 
 
146 APPENDICITIS. 
 
 from danger of puncture. Bleeding which may occur will be 
 absorbed by this gauze, which is to be removed before the 
 stitches are tied. 
 
 A frequent accident in closing the simple incision is the 
 puncture of one of the deep epigastric veins. I know of one 
 case where such an occurrence caused the death of the patient 
 from hemorrhage. If this accident occurs, the surgeon is not 
 justified in closing the wound until the vein is ligated. 
 
 The deep epigastric veins can be exposed by lifting up and 
 drawing inward the rectus muscle, separating it from the 
 transversalis fascia, beneath which they run. By remember- 
 ing this fact, it is a simple matter to find and ligate the injured 
 vein. 
 
 Some surgeons prefer the straight, round needle, as they 
 think it less liable to puncture these vessels. I use the 
 straight, spear-pointed needle, as it is much easier to mani- 
 pulate and I believe does not increase the danger of puncture. 
 
 The armamentarium necessary for a complete appendiceal 
 operation is as follows : — 
 
 Knife. 
 
 One pair of toothed forceps. 
 
 One pair of dissecting forceps. 
 
 Probe. 
 
 Six haemostatic forceps. 
 
 One pair of simple retractors. 
 
 Catgut. 
 
 One straight needle, one long curved Hagedorn needle, or a 
 handled needle with an eye in the point (Reveridan's), and 
 twelve strands of silk-worm gut. 
 
 Kangaroo tendon. 
 
 Silver wire. 
 
 Small needle and fine silk. 
 
 Ten yards of sterilized gauze. 
 
Plate XXX 
 
 Fiq. 
 
 Serous coat sutured over stump 
 
 Fig. 2 
 
 Sturqp Invaginated 
 
Plate XXXI 
 
 Fig, I 
 
 Caecum 
 
 Per 
 
 qsversalis fascia 
 
 Great omenturY\ 
 
 Fig 2 
 
 Traqsversalis fascia 
 
 Caecum 
 
 Peritoneum 
 
TREATMENT, 147 
 
 Two yards of sterilized iodoform gauze. 
 Sterilized cotton, adhesive strips, bandage, rubber dam. 
 Corrosive sublimate and carbolic acid. 
 Irrigating apparatus — salt solution ; boric acid solution. 
 Drainage tubes, rubber, glass, various sizes. 
 Glass syringe. 
 
 The more the fingers displace instruments, the better the 
 results. 
 
COMPLICATIONS AND SEQUELAE. 
 
 The complications of appendicitis may be divided into those 
 which are encountered at the time of removal of the organ 
 and those which arise during the course of the disease and 
 interfere with the prompt recovery of the patient after opera- 
 tion. 
 
 Complications of the Operative Treatment of Appendicitis. — The 
 condition of the abdominal walls may offer serious difficulty 
 in removing the appendix. If, on account of a great deposi- 
 tion of fat, the belly walls are very thick, they will be harder 
 to manage and increase the difficulty, both in finding the 
 caecum and appendix and bringing them into the wound ; this 
 difficulty can be overcome only by enlarging the incision. If 
 the caecum and appendix are tied down by adhesions, the 
 difficulty in the operation will be correspondingly increased. 
 
 In a recent operation abdominal walls were encountered 
 over two inches thick ; the csecum and appendix were firmly 
 bound to the floor of the iliac fossa by exudate and adhesions. 
 The appendix, which was very difficult to free on account of 
 the thickness of the abdominal walls, was so friable that it was 
 torn off in the endeavor to ligate it. The stump, moreover, 
 could not be brought into the wound on account of the firm 
 adhesions of the caecum. A ligature, thrown around the 
 stump, below a pair of hsemostats, was then tightly tied, and the 
 stump invaginated into the walls of the c£ecum and covered 
 by stitching the coats of the caecum over it by means of a 
 short curved needle in a needle holder. These accidents and 
 technical difficulties were largely due to the thickness of the 
 
 148 
 
COMPLICATIONS AND SEQUEL^*:. 149 
 
 belly walls, which prevented free access to the seat of the 
 trouble. 
 
 Much inconvenience and delay, moreover, is frequently 
 caused by difficulties in effecting proper anaesthesia. Patients 
 are often seen in whom it is almost impossible to produce 
 complete muscular relaxation; in such cases there are rigid 
 abdominal walls with the bowels bulging out of the wound 
 at most inopportune times. A few drops of chloroform added 
 to the ether will, however, generally overcome this trouble. 
 
 Unusual positions of the appendix will often cause the 
 surgeon difficulty. I have frequently met with cases in which 
 the organ might be supposed to be absent, being finally found 
 lying against the posterior wall within the peritoneal covering 
 of the caecum, the one layer of serous membrane being reflected 
 over both. 
 
 If, under these circumstances, a pus collection surrounds it, 
 the appendix is sometimes exceedingly difficult to find, and its 
 removal is correspondingly arduous. Under such conditions it 
 is advisable to cut through the external layer of the meso-colon 
 in order to gain free access to the appendix. This plan also dim- 
 inishes the liability of infecting the general peritoneal cavity. 
 
 The appendix may be so rolled up in a fold of the great 
 omentum that it is most difficult to decide which is appendix 
 and which is omentum. In these cases it is proper to tie ofi^ 
 and cut away the omentum along its attachment to the appen- 
 dix, which last can then be stripped loose. This method 
 ensures control of haemorrhage from the omentum, and allows 
 greater ease in dealing with the appendix. 
 
 The appendix is often encapsulated in a mass of exudate. 
 If this cannot be stripped away, the thickest and firmest 
 portion of it is cut through, whereupon the organ can be 
 readily found, for that part of the exudate corresponds to the 
 primary site of inflammation in the appendix. 
 
150 APPENDICITIS. 
 
 Unless properly treated a meso-appendix loaded with fat will 
 complicate the removal of the appendix, often by troublesome 
 bleeding. A fat meso-appendix is always friable and liable to 
 tear in handling, especially in tying off. It is best to remove 
 it in sections, cutting away as the ligatures are tightened. 
 This procedure minimizes the danger of tearing and the 
 resulting heemorrhage. 
 
 At times a necrotic or gangrenous condition of the apex of 
 the caecum is met with where it is impossible to find any tissue 
 healthy enough to hold stitches introduced for the purpose of 
 invagination. Under these conditions, I pack off the general 
 peritoneal cavity and leave the gangrenous patch in situ. In 
 a few dsLjs this separates, leaving a fsecal fistula which can be 
 closed at a subsequent period if repair does not take place 
 spontaneously. I consider this advisable rather than attempt- 
 ing to remove the gangrenous portion at the time of operation 
 when one cannot be sure of the vitality of the tissue into 
 which the sutures are introduced. If the gangrenous patch 
 be invaginated and the abdominal wound immediately closed, 
 fatal peritonitis due to perforation is imminent. 
 
 Conditions that may complicate the course of appendicitis and in- 
 terfere with recovery. 
 
 Of these peritonitis is the most frequent. The prognosis 
 depends upon the condition of the peritoneum at the time of 
 operation. In all cases where the disease has advanced beyond 
 simple infection of the mucous membrane of the appendix, 
 inflammation of its serous coat is found ; this, of course, can 
 hardly be considered a complication. 
 
 Infection of the general peritoneum, however, may be the 
 result of lymphangitis, of gangrene, or of perforation of the 
 appendix or caecum. A mild form is met with in which the 
 peritoneum is injected, turbid, and stick}^ but where there 
 is neither effusion nor deposit of lymph. Prognosis good. 
 
COMPLICATIONS AND SEQUELJ<:. 151 
 
 Again, the serous surfaces may be found glued together and a 
 small quantity of a turbid effusion in the cavity. Prognosis 
 good. If pus be present, one of two conditions will be 
 encountered. In some, the peritoneum will be bathed in a 
 quantity of odorless pus, the serous surfaces smooth and 
 shiny, and the coils of intestine not glued together. Prognosis 
 fairly good. In others, the pus will be less in quantity, but 
 of a foul odor ; the serous surfaces will be intensely injected 
 and of a scalded appearance, and large masses of lymph, in 
 different stages of organization, will be abundant. In these 
 the streptococci or staphylococci are always present. When 
 such conditions exist, the prognosis is unfavorable. 
 
 Obstruction of the bowel due to adhesions, the appendix 
 itself acting as a band, is a frequent complication of appendi- 
 citis, especially in the chronic cases. The appendix is most 
 apt to be at fault when holding some anomalous position. I 
 saw a case where a band, the result of chronic appendiceal 
 inflammation, was stretched between the appendix and a 
 Meckel's diverticulum. Obstruction was caused by a coil of 
 intestine becoming engaged beneath this band. 
 
 The appendix may be found adherent to any of the abdomi- 
 nal or pelvic viscera. It has even been found attached to the 
 iliac blood-vessels. When the appendix is attached to any of 
 the abdominal or pelvic viscera, great care must be taken in 
 its removal, on account of the haemorrhage liable to ensue. 
 Fowler reports a case in which the gangrenous process caused 
 by the inflammation of the appendix was communicated to 
 the iliac vein. The vein is more often the seat of the gan- 
 grenous process than the artery. 
 
 Inflammation or thrombosis of the right iliac vein, associated 
 with oedema of the corresponding lower extremity, is a compli- 
 cation sometimes seen due to a localized appendiceal abscess. 
 If a fragment of the thrombus is carried into the general 
 
152 APPENDICITIS. 
 
 circulation, sei^tic pneumonia or general septicfemia may be 
 the result. 
 
 If the appendix is very long and overhangs the brim of the 
 pelvis, it may lead to disease of the pelvic contents, although 
 such trouble may not be recognized until some time after 
 apparent recovery from the attack or until after the removal 
 of the appendix. 
 
 At times an appendiceal abscess will burrow upward behind 
 the liver, either through or beneath the diaphragm, and finally 
 rupture into the lung tissue. I have seen several cases where 
 the abscess following appendicitis has been evacuated through 
 the mouth. The following will be of interest in this connec- 
 tion : — 
 
 R. S. , male, age nineteen, was admitted to the Grerman Hospital, August 
 28, 1895, with the following history : Had always enjoyed good health until 
 three days before admission, when after a heavy meal he began to suffer 
 from pain in the epigastric region attended by vomiting, which afforded no 
 relief. Pain increased in severity and became localized to the right iliac fossa, 
 which was markedly tender upon pressure ; vomiting ceased but nausea per- 
 sisted. 
 
 Patient thought himself suffering from mere colic and did not summon 
 assistance until pain became unbearable. Was immediately sent to the Ger- 
 man Hospital, where following condition was noted : Temperature 102° ; pulse 
 94 ; abdomen slightly distended and rigid, especially upon the right side ; 
 pain diffused but tenderness marked in the right iliac fossa, the slightest 
 touch causing the patient to flinch. 
 
 Diagnosis, appendiceal abscess. 
 
 By ice-bags locally applied and by free saline purgation the pain and ten- 
 derness abated, and operation was strongly advised, but absolutely refused by 
 the parents. At this time the temperature ranged from 99-99|°, with a cor- 
 responding pulse rate of 84-100, the boy being fairly comfortable meanwhile, 
 despite occasional nausea and vomiting ; the abdomen continued tender, 
 though not to the same degree as previously. He remained in this condition 
 until the fourth day after admission (making the seventh day from the initial 
 symptoms), when he grew suddenly worse, the temperature rising to 104° and 
 the pulse rate to 120. He vomited continuously, and was seized with dyspnoea, 
 expectorating large quantities of fetid and purulent mucus tinged with blood. 
 No tubercle bacilli found. Patient became exhausted and died nine days 
 after admission. At the post-mortem, a perforated appendix, pointing north 
 and lying just below the diaphragm, was found. The abscess surrounding the 
 
COMPLICATIONS AND SEQUELyE. 153 
 
 appendix had penetrated into the lung, in which gangrenous patches were 
 detected. The expectorated matter was evidently pus from the appendiceal 
 abscess. 
 
 In some cases abscess of the liver is produced by frag- 
 ments of thrombi being swept into the portal or general cir- 
 culation. When the freedom of anastomoses among the veins 
 of the mesentery is considered, it is not strange that this com- 
 plication should occur, although it is not as common as might 
 be supposed. There may be purulent infection of the pleura 
 and pericardium as a sequence of the abscess of the liver. If 
 the hepatic abscess attains considerable size, it may push 
 through the diaphragm by ulceration and perforation. The 
 symptoms attending this complication simulate those of 
 pleurisy with effusion, or of pyo-pericarditis, or of gangrene of 
 the lune. 
 
 ABSCESS OF LIVER— CASE NOT OPERATED UPON. 
 
 The following case came under my notice only post-mortem, 
 and I submit it for several reasons : 1. To show the preva- 
 lence of pylo-phlebitis and liver abscess as sequelae of appendi- 
 citis. 2. To demonstrate the importance of first excluding 
 primary appendiceal inflammation in the diagnosis of all 
 abdominal affections, particulary when pain and tenderness 
 are not referred to the right iliac fossa. 3. To emphasize the 
 value that should be attached to a previous history of attacks 
 of colic, with gastric irritation, as indicating early involve- 
 ment of the appendix, from which, as a source, remote organs 
 may become infected. 
 
 A. R., white, age twenty-one, bartender. Family history, negative. 
 Previous history, usual diseases of childhood. During the past eighteen 
 months has had three or four attacks of colic, attended by vomiting. No 
 mention was made of localized pain, and in a few days patient would appar- 
 ently recover and go about his work as usual. 
 
 On March 1st patient developed sore throat, with stiffness in all the 
 limbs, followed by excruciating griping pains in the epigastrium, which were 
 
154 APPENDICITIS. 
 
 increased upon deep inspiration. Had headache and backache ; also chill, 
 fever, and sweats at irregular intervals ; appetite fair ; bowels somewhat loose. 
 When seen on March 15th by his attending physician he presented the fol- 
 lowing symptoms : Temperature 103|°, pulse-rate 96 ; hectic flush on cheeks ; 
 had extreme pain and tenderness over epigastrium, and slight tympany ; 
 rest of abdomen, negative. Tongue was thickly coated, pupils normal ; 
 lungs and heart healthy ; urine contained trace of albumen and a few 
 granular casts ; blood-count and haemoglobin normal, though microscopically 
 intra-cellular organisms resembling amoeba of Laveran were noticed. 
 
 On March 1 6th, at 5 A. M. , temperature 98° ; pulse-rate 80. Had had a 
 severe chill during the night, with profuse sweating ; other symptoms same, 
 except that a serous diarrhoea had set in. 
 
 Quinine exhibited without relief There was no change in the symptoms 
 until March 19th. Morning temperature 99|° ; pulse-rate 104. However, a 
 diffuse peritonitis had developed, there being extreme general abdominal 
 tenderness, tympany, and rapid, irregular pulse. Diarrhoea continued and 
 patient grew weaker. At 5 P. M. , March 20th, temperature was 97° ; pulse- 
 rate 120. Death supervened early April 4th. 
 
 At the post-mortem, held eight hours after death, a general peritonitis 
 directly due to a ruptured liver abscess was found. The appendix was per- 
 forated and imbedded in a mass of gangrenous adhesions. Purulent inflam- 
 mation of the portal vein extended into the liver substance, and in the upper 
 part of the right lobe were numerous embolic abscesses, one of which, situated 
 upon the surface of the liver immediately beneath the diaphragm, had rup- 
 tured. 
 
 Appendicitis may complicate a hernia, and if the latter is 
 strangulated or if a strangulation be suspected, the symptoms 
 of the appendiceal inflammation may be entirely lost sight of, 
 as the following case will show : — 
 
 Mrs. X. , set. forty -two, admitted to the German Hospital with the following 
 history. Two days previous she had been attacked with general abdominal 
 pain, associated with vomiting and absolute constipation. The attending 
 physician found a mass in the right inguinal canal which the patient stated 
 was an old hernia. The mass was tender and irreducible by taxis. Ether 
 was administered also with no result. The patient steadily grew worse, and 
 the next morning she was again etherized and another attempt was made to 
 reduce the mass. This again was futile. She was then removed to the 
 hospital, where I saw her. The mass was tender and inflamed, the abdomen 
 ■was distended, the bowels were absolutely obstructed, and vomiting occurred 
 frequently. Incision over the tumor showed that it was but the sac of an 
 old hernia, and not the seat of the trouble at all. The peritoneal cavity 
 was oj^ened by extending the original wound, and a general purulent peri- 
 tonitis was found. But the appendix was the seat of marked disease ; it 
 
COMPLICATIONS AND SEQUELS. 155 
 
 was removed ; the peritoneal cavity was thorouglilj' irrigated, drainage 
 introduced, and the wound closed. The patient did not rally, and died in 
 eighteen hours. The original site of the inflammation was undoubtedly in 
 the appendix, but the mass in the right inguinal canal had misled both the 
 attending physician and myself. 
 
 Abscess in the lumbar region may be found as a complica- 
 tion of a purulent appendicitis, and results from infection, by 
 direct continuity, or by the vessels going to that region. 
 
 An abscess of the abdominal wall, consequent upon an 
 appendicitis, may be found ; this occurrence, however, is rare. 
 The following case will be of interest in this connection : — 
 
 A boy of thirteen was referred to me by my friend, Dr. P. Moylan, with a 
 history of three attacks of appendicitis. During the last attack he was under 
 the care of Dr. Moylan, who said to me that at the time of his first visit a 
 general peritonitis was present, and was attended with so much distention 
 that he was unable to make out by examination the cause of the peritonitis. 
 There was apparent recovery from this attack. 
 
 Operation was by incision through the right semilunar line, opening up a 
 cheesy mass situated beneath the transversalis muscle. The peritoneum be- 
 neath the collection had been destroyed and the posterior wall was formed by 
 the great omentum. The cheesy material was curetted away and the cavity 
 antisepticized. The great omentum was tied ofi" around the involved portion 
 and the latter cut away. The caecum contained two perforations, which were 
 brought to view after the removal of the diseased and adherent omentum. 
 The appendix lay post-caecal, imbedded in a mass of lymph. It was perfor- 
 ated at its base. The pelvis contained a collection of pus which was confined 
 by adherent coils of small bowel. 
 
 The patient recovered. 
 
 Pregnancy may complicate appendicitis. If the inflamma- 
 tory condition occurs during the early stage of gestation, 
 abortion generally follows. The usual risks of leaving a dis- 
 eased appendix in the abdominal cavity are much increased 
 by the pregnant state, and the evil consequences of another 
 attack, i. e., gangrene or perforation, wall be correspondingly 
 greater. The removal of the appendix is attended by few, if 
 any, additional dangers to mother and foetus. 
 
156 APPENDICITIS. 
 
 It is a noticeable fact that quite a considerable number of 
 patients who are neurasthenics suffer from appendicitis in the 
 chronic form. Whether the dyspepsia, in the widest sense of 
 that term, induced by the appendicitis leads to auto-infection 
 and thus affects the nervous equilibrium of these patients must 
 at present remain an open question. Some of such patients 
 suffer in addition from colitis -with mucous stools, which are 
 even sometimes tinged with blood ; in other cases the nervous 
 symptoms are absent and only the colitis may be complained 
 of. 
 
 Miss P. , age forty-four, was referred to me with the following history : 
 For the past three years she had suffered from a mucous diarrhoea which had 
 been variously diagnosed entero-colitis, dysentery, etc. , and treated, without 
 benefit, by every method, from bismuth by mouth to quinine and nitrate of 
 silver injections by rectum. 
 
 Upon admission to the German Hospital she was emaciated and markedly 
 neurasthenic. Her bowel movements averaged four to eight daily, and con- 
 tained mucus, shreds of mucous membrane, and blood. Upon careful exam- 
 ination the appendix was found enlarged and painful upon pressure ; no 
 rigidity. 
 
 She gladly consented to operation in the hope of relief, and the appendix, 
 when removed, was found to be in a typical state of catarrhal inflammation. 
 
 Recovery uninterrupted. However, the bloody and mucous stools, the 
 neurasthenia, and the emaciation did not markedly improve for over three 
 months after operation, when her symptoms rapidly abated. She gained 
 flesh, and within one year she presented herself as perfectly cured. The 
 digestive functions were normal, the neurasthenia had disappeared, and she 
 had increased in weight over twenty pounds. 
 
 The removal of the diseased organ, which latter is probably 
 the primary cause of these troubles, leading as it does to inade- 
 quate digestion in the large intestine, colitis, etc., or simply to 
 mal-assimilation, auto-intoxication, and neurasthenia, is primar- 
 ily only of utility in removing the constant danger to life by 
 which these patients are threatened. 
 
 The immediate effects of the operation on both the colitis 
 and neurasthenia, however, are not so apparent. It often takes 
 months or even a year and a half before decided improvement 
 
F , aged seventeen years, suffered from acute appendicitis with abscess. 
 
 At the time of operation his condition was very low and it was thought 
 advisable to evacuate the abscess only. Instead of the abdominal wall healing 
 completely there were left two fistulous tracts, from which faecal matter 
 escaped (Fig. 2). 
 
 Ten weeks afterward the appendix was removed, when it was found that 
 with the exception of the tip, the upper half alone remained, these parts 
 being connected by a band of the meso-appendix (Fig. 1). 
 
 The opening in the appendix was in communication with the two fistulous 
 tracts. 
 
 Recovery followed. 
 
 158 
 
Fig. 
 
 Plate xxxii 
 
 Orifice ir^ coiTirT\unication ..- 
 with fistulous tracts 
 
 Fig. 2 
 
 Wf-Y-^iL"- 
 
 Granulations surrouridirig fistulous tracts 
 
COMPLICATIONS AND SEQUELS. 159 
 
 is noticeable. But with appropriate treatment these patients 
 in the end recover. 
 
 After operation for appendicitis a constipated condition of 
 the bowels sometimes supervenes, which is occasionally quite 
 obstinate and gives the patient considerable trouble. A sys- 
 tematic course of gentle purgation remedies this very unpleas- 
 ant sequelae. In this connection may be mentioned the appar- 
 ently rational treatment by intestinal antisepsis. If a drug or 
 a method of treatment were known by which the intestinal 
 tract could be sterilized, no doubt the most gratifying results 
 would be obtained. But, unfortunately, the various drugs, as 
 naphthalin, creasote, etc., or high enemata, have proven quite 
 inadequate, while some of the drugs employed are even dan- 
 gerous. 
 
 These considerations emphasize the necessity for the physi- 
 cian to carefully examine even slight cases of colitis, mucous 
 enteritis, neurasthenia, and allied disorders for possible appen- 
 dicitis, since it is rational to expect that the sooner the cause 
 of these various ailments is removed the sooner will the patient 
 be cured of these disagreeable and annoying sequelse. 
 
 Fsecal fistula is the most frequent and the most annoying of 
 the sequelse of appendicitis. In pus cases this is often due to 
 the appendix being allowed to remain after evacuating the abscess; 
 in others, it is due to a gangrenous area of the caecum which 
 was too large to close in at the time of the operation, or 
 which developed after the removal of the appendix as a result 
 
 of the original disease (see case of F , Plate XXXII). A 
 
 second operation may sometimes be necessary to abolish the 
 fistula, but generally it heals without surgical interference. 
 Fistulse appearing early after the operation show much greater 
 tendency to spontaneous closure than those supervening after 
 some time has elapsed. 
 
160 APPENDICITIS. 
 
 Hernia, following the operation, may occur in those cases 
 where it had been necessary to introduce drainage. Some 
 surgeons claim that they have never seen a hernia as a sequel 
 of the operation, but this has not been my experience. 
 
 Where drainage has been introduced the wound closes by 
 granulations, leaving cicatricial tissue which is decidedly weak 
 and unable to stand the strain exerted upon it by the intra- 
 abdominal pressure. I have never seen a hernia follow the 
 McBurney operation, however, and seldom the ordinary opera- 
 tion, for if the wound can be closed immediately, the careful 
 introduction of sutures will almost always prevent it. The 
 relative frequency of hernia following pus cases with drainage 
 is, of course, another argument for early operation. 
 
 While it may be a simple matter to operate upon a patient 
 who has a hernia the result of an appendicectomy, it should, 
 nevertheless, be borne in mind that any operation, however 
 slight, is attended by danger ; therefore, should a patient be 
 subjected to the risk of a secondary operation, when one per- 
 formed before pus formation will obviate this necessity ? 
 
 A truss applied with the idea of curing or relieving these 
 hernise causes more damage than benefit, as the pressure thins 
 the abdominal wall and makes a future operation less likely to 
 be successful. If a hernia occurs after the operation for appen- 
 dicitis, I believe it more satisfactory to immediately correct this 
 defect. 
 
 When infiltration of the abdominal wall is found during 
 operation, it generally signifies the presence of collections of 
 pus. This infiltration is confined to the deeper structures 
 mainly, the muscular tissue and transversalis fascia, from 
 both of which serum exudes upon section. This exudation is 
 pathognomonic of pus, and the peritoneum beneath is found 
 infiltrated, thickened, and at times the pus is visible through it. 
 
AFTER-TRE ATMEN T. 
 
 Since the welfare of the patient after the operation for appen- 
 dicitis depends upon close attention to details, the treatment 
 outlined below may be considered as a safe guide. 
 
 The cases conveniently divide themselves into — 
 
 1. Simple, uncomjDlicated cases in which the wound is closed 
 throughout at the time of operation. 
 
 2. Cases in which glass or rubber drainage is used. 
 
 3. Cases in which gauze is allowed to remain in the abdom- 
 inal cavity, either for drainage or for protection of the general 
 peritoneum. 
 
 For all cases, however, the following directions apply : — 
 Patient should be isolated and under charge of a competent 
 nurse. Temperature and pulse-rate should be taken every 
 three hours for first two days. 
 
 After-effects of ether, as vomiting, tossing about in bed, 
 should be guarded against. If great restlessness develops, 
 knees should be tied together by a towel. 
 
 Patient should be kept warm by hot bottles. 
 
 Body should be protected against pressure of bed-clothes by 
 a bed-cradle. 
 
 Rubber air-ring under gluteal region is a great comfort to 
 the patient and relieves the pain in the back that is constantly 
 complained of. 
 
 Urine should be drawn by catheter, if necessary, and care- 
 fully examined. 
 
 If stimulation is necessary, hypodermatic injections of strych- 
 nia (^), atropia (yo-q)' ^^^ whiskey (syringeful) may be 
 employed. 
 
 11 161 
 
162 APPENDICITIS. 
 
 No MORPHIA. 
 
 Absolutely nothing by mouth for the first four hours. After 
 that small pieces of ice may be given at fifteen minutes' inter- 
 vals and the mouth and lips occasionally cooled by a moist 
 cloth. 
 
 N"o nourishment should be given for at least the first 
 eighteen hours after operation. If at the expiration of that 
 time the stomach shows no evidence of irritability, tablespoon 
 doses of peptonized milk with a teaspoonful of whiskey are 
 cautiously given every two hours, which quantities are grad- 
 uall}^ increased according to individual circumstances. If 
 vomiting supervenes during this period absolute abstinence 
 for a time is again necessary. 
 
 For the relief of pain, which is always present, and which is 
 due in most cases to intestinal distention, asafoetida supposi- 
 tories (gr. V e'ach) may be given as required ; or if these fail, 
 enemata containing two ounces of milk of asafoetida and three 
 or four ounces of warm water ma}'' be injected, usually with 
 marked benefit. 
 
 Calomel, gr. \, with bicarbonate of soda, gr. ^, in powders, 
 are begun twenty-four hours after operation at hourly intervals, 
 and continued until eight are taken. 
 
 Persistent vomiting, which is liable to develop in any case, 
 is treated by the application of a fly blister (two inches square) 
 over the epigastrium ; or b}^ one-quarter grain doses of cocaine 
 every two hours ; or by teaspoonful doses of hot, strong, black 
 coffee. Iced champagne may be of service. 
 
 We may now consider in greater detail the classification 
 above mentioned : — 
 
 1. Simple Cases. — If the temperature and the general condi- 
 tion of the patient show no abnormality the wound requires 
 no attention for tlie first five days. After that the dressing is 
 removed, the stitches are taken out, and a simple aseptic dress- 
 
AFTER-TREATMENT. 163 
 
 ing is applied and allowed to remain for from three to five 
 days. An abdominal supporter is then put on and the patient 
 permitted to leave bed. 
 
 A sharp rise of temperature or much local pain with disten- 
 tion necessitate immediate renewal of the dressing, at which 
 time a careful search should be instituted for the source of 
 irritation. 
 
 Stitch abscesses should be opened and treated on general 
 antiseptic principles. If pus has formed, the case merges into 
 one of the varieties described below. 
 
 2. Cases in ivhich Glass or Rubber Drainage is Used. — Since 
 this method of drainage follows long and exhausting operations, 
 careful attention to stimulation is necessary. If much blood 
 has been lost and there are evidences of exsanguination, hypo- 
 dermoclysis should be employed and from six to 20 ounces of a 
 normal salt solution, at temperature of 100°, should be injected, 
 preferably over the infra-clavicular or inguinal regions. 
 
 The glass drainage tube should be cleaned sufficiently often 
 to avoid a large collection of fluid in the pelvis. When, after 
 a three-hour interval, the fluid withdrawn is of an amber color 
 and not more than one drachm in amount, the tube should be 
 aseptically removed and the stitches, previously introduced 
 and left untied, should now be drawn together and the wound 
 closed. 
 
 The case thus becomes a simple one and should be so treated. 
 
 Rubber Drainage. — In these cases the cavity is carefully 
 syringed daily with a warm five per cent, boric acid solution 
 and the tube , gradually withdrawn. After its removal the 
 wound is closed and treated as above. 
 
 3. Gauze .Drainage. — The dressing is left undisturbed until 
 the second day after operation. At this time the pieces of 
 gauze remaining within the cavity, having been carefully and 
 thoroughly softened by copious applications of a warm five 
 
164 APPENDICITIS. 
 
 per cent, boric acid or normal saline solution, are cautiously 
 disengaged from adhesions and very slowly withdrawn. The 
 cavity is then gently irrigated, packed with iodoform gauze, and 
 dressed aseptically. The next dressing takes place after two 
 days in the same manner. If the cavity is then clean the 
 sutures Inserted at the time of operation may be tied and the 
 wound closed as above. 
 
 In the vast majority of cases involvement of the general 
 peritoneum does not occur. Occasionally, however, as the 
 result of perforation or lymphatic infection, or when it is pres- 
 ent at the time of operation, this condition demands vigorous 
 treatment. In such cases we are of the opinion that the local 
 application of ice bags with calomel purgation and susjDension 
 of nourishment b}'' mouth offer the best chance of recovery. 
 While salines would be better adapted for draining the 
 engorged peritoneal vessels, unfortunately the stomach will 
 not often tolerate them. 
 
 AVhen the constitutional condition indicates it, nutritious 
 enemata of peptonized milk, bouillon, eggs, etc., may be of 
 service. 
 
 In conclusion, it may be fitting to say that my attitude in 
 the consideration of appendiceal surgery is the result, not of 
 theoretical deductions, but of that best of teachers — experience. 
 Therefore, after a close observation of over 500 of my own 
 operative cases I give the foregoing views as my earnest con- 
 victions. 
 
INDEX. 
 
 A BSCESS, appendix in wall of, 56 
 
 appendiceal, 137 
 
 varieties of, 137 
 
 extending behind liver, 153 
 
 of liver, 153 
 
 in lumbar region, 155 
 
 of abdominal wall, 155 
 
 psoas, 110 
 
 lumbar, 111 
 
 splenic, 107 
 
 hepatic, 108 
 
 of abdominal wall, 108 
 
 of kidney, 101 
 Acute appendicitis, symptoms of, 73 
 Abdominal wound, closure of, 142 
 
 dressing of, 145 
 Adhesions, formation of, 56 
 J5tiology, 31 
 After-treatment, 161 
 
 in simple cases, 162 
 
 in cases in which drainage is 
 used, 163 
 Age as predisposing cause, 33 
 Albers, investigations of, 20 
 AuEesthesia, 149 
 Anatomy, 23 
 Appendiceal abscess, 137 
 
 varieties of, 137 
 
 extending behind liver, 152 
 Appendiculo-ovarian ligament, 26 
 Appendix, types of, 23 
 
 anatomy of, 23 
 
 peritoneal covering of, 25 
 
 abnormal position of, 28 
 
 structure of, 28 
 
 blood-supply of, 30 
 
 nerves of, 30-64 
 
 Appendix, position predisposing to 
 inflammation, 32 
 palpation of, 81 
 Asafcetida suppositories, 121 
 
 1)ACTEEI0L0GY, 70 
 
 Biliary colic. 111 
 Blisters contra-indicated, 121 
 Blood-supply of appendix, 30 
 Bristow, definition of position, 27 
 Burne, investigation of, 19 
 
 nJECTJM, peritoneal covering of, 24 
 
 cancer of, 103 
 
 perforation of, 126 
 Calomel as laxative, 117 
 Canal, obliteration of, 49 
 Cancer of caecum, 103 
 Castor-oil as laxative, 117 
 Causes, predisposing, 31 
 
 exciting, 37 
 Chill as symptom of pus-formation, 
 
 91 
 Chronic appendicitis, 81 
 
 typhlitis, 20 
 Closure of abdominal wound, 142 
 Cold applications, 120 
 Colitis, 107 
 
 accompanying appendicitis, 156 
 Complications, 148 
 
 of operative treatment, 148 
 
 interfering with recovery, 150 
 Concretions, fajcal, as exciting cause, 
 38 
 
 165 
 
166 
 
 INDEX. 
 
 Constipatiou as symptom, 78 
 following operation, 159 
 Copland, investigations of, 19 
 
 niAGNOSIS, 84 
 
 differential, 94 
 Diet in acute appendicitis, 121 
 
 in chronic appendicitis, 122 
 Differential diagnosis, 94 
 Distention, 90 
 
 of abdomen as symptom, 79 
 Drainage-tube, use of, in evacuating 
 
 pus, 139-142 
 Dressing of abdominal wound, 145 
 Dupuytren, investigation of, 19 
 Dysentery, 107 
 
 PAELY operation, reason for, 124 
 
 Endo-appendicitis, 45 
 Enemata, indications for, 121 
 Enlarged mesenteric gland, 109 
 Epigastric veins, ligation of, 146 
 Etiology, see Etiology, 31 
 Examination, rectal, 85 
 
 vaginal, 85 
 Exposure to cold as predisposing 
 
 cause, 34 
 Extension of pus formation, 59 
 Extra-uterine pregnancy, 98 
 
 FAECAL concretions as exciting 
 cause, 38 
 
 fistula, 159 
 Ferrall, monograph by, 18 
 Fibroid tumor, 97 
 Fitz, investigations of, 21 
 Floating kidney, 99 
 
 with a twisted pedicle, 100 
 Follicular abscesses of appendix 
 
 simulating typhoid, 95 
 Foreign bodies as exciting cause, 37 
 Fossa, ileo-colic, 26 
 
 ileo-ca^cal, 26 
 
 sub-ctecal, 27 
 
 Fourth stage of disease, 59 
 Fowler, definition of position, 27 
 Fulness, 89 
 
 as symptom, 89 
 
 n ALL-BLADDER, rupture of, 108 
 
 Gall-stones, 111 
 Gangrene, caused by pressure, 55 
 
 from interference with circula- 
 tion, 63 
 
 by pressure of concretion, 43 
 Gastric ulcer, 103 
 
 Gauze, disposition of during opera- 
 tion, 137, 142, 145 
 GrisoUe, cases reported by, 20 
 
 TJiEMATOCELE, mesenteric, 109 
 Hancock, operation by, 21 
 
 Hepatic abscess, 108 
 
 Hernia following operation, 160 
 incipient inguinal, 109 
 
 Hip-joint disease, 110 
 
 History, 17 
 
 Hodenpyl, investigations of, 71 
 
 Hot applications, 120 
 
 Husson and Dance, 18 
 
 TLEO-C^CAL fossa, 26 
 
 Ileo-colic fossa, 26 
 Incision, simple, 132 
 
 McBurney, 133 
 Indigestion as exciting cause, 37 
 Infiltration of abdominal wall, si§ 
 
 nificauce of, 160 
 Inflammation, spread of, 63 
 Instruments required, 146 
 Intestinal obstruction, 103 
 Iodine contra-indicated, 120 
 
 T7IDNEY, abscess of, 101 
 growths of, 101 
 
 neoplasms of, 101 
 
INDEX. 
 
 167 
 
 T AENNEC, investigations of, 17 
 Laxatives, 116, 118 
 purposes of, 117 
 Leeches contra-indicated, 120 
 Leucocytosis as symptom, 81 
 Ligament, appendiculo-ovarian, 26 
 Location of pain, 75, 86 
 Lumbar abscess, 111 
 
 McBURNEY'S incision, 133 
 operation, 133 
 
 advantages of, 135 
 Melier, cases reported by, 18 
 Menopause, 99 
 Menstruation, painful, 98 
 Mesenteric bsematocele, 109 
 
 gland, enlarged, 109 
 Meso-appendix, anatomy of, 25 
 Mestivier, investigations of, 18 
 Micro-organisms as exciting cause, 37 
 
 of typhoid fever, 72 
 
 of tuberculosis, 72 
 
 of actinomycosis, 72 
 Muscularis mucosse, 29 
 
 "M"EOPLASMS of kidney, 101 
 
 Nephritic colic, 100 
 Nerve-supply of appendix, 30 
 Neurasthenia accompanying appen- 
 dicitis, 156 
 Noyes, reports by, 21 
 
 ABSTRUCTION of bowels follow- 
 ing operation, 151 
 
 intestinal, 103 
 Operation, favorable time for, 125 
 
 reasons for delaying, 123 
 
 in presence of pus, 136 
 
 preparation for, 140 
 Opium, why contra-indicated, 118 
 
 contra-indicated, 84 
 Ovarian cyst, suppurating, 97 
 
 abscess, 96 
 
 pAIN, position of, 86 
 
 character of, 76 
 
 as a symptom, 73 
 
 location of, 75 
 Painful menstruation, 98 
 Palpation of appendix, 81 
 
 Edebohl's method of, 81 
 Para-appendicitis, 45 
 Parietal appendicitis, 45 
 Parker, reports by, 21 
 Pathology, 45 
 
 Perforation by pressure of concretion, 
 43 
 
 of alimentary tract, 103 
 
 of caecum, 126 
 
 from pressure, 50 
 Peri-appendicitis, 45 
 Peri-nephritic abscess, 101 
 Peritoneal covering of appendix, 25 
 
 caecum, 24 
 Peritonitis following operation, 150 
 
 tubercular, 107 
 Peri-typhlitis, 20 
 Pleurisy, 111 
 Pneumonia, 111 
 
 Position predisposing to inflamma- 
 tion, 32 
 Predisposing causes, 31 
 Pregnancy complicating appendicitis, 
 
 155 
 Prognosis, 113 
 Psoas-abscess, 110 
 Pulse-rate as symptom, 78 
 Pus, circumscribed collection of, 110 
 
 extension of, 59 
 Pyo nephrosis, 101 
 Pyo-salpinx, 96 
 
 "DECTAL examination, 85 
 
 Eenal irritation of appendicitis, 
 100 
 Eespiration as symptom, 80 
 
 in acute appendicitis, 91 
 Eestlessness as symptom, 79 
 Eibbert, statistics of, 49 
 Eichardson's method of diagnosis, 79 
 
168 
 
 INDEX. 
 
 Rigidity of abdominal walls as symp- 
 tom, 77 
 Rokitansky, investigation of, 20 
 Euptnre of gall bladder, 108 
 
 a ALTS as laxative, 118 
 
 Second stage of disease, 55 
 Sequelae, 148 
 
 Sex as predisposing cause, 33 
 Simple incision, 132 
 Splenic abscess, 107 
 Spots, significance of, 94 
 Stercoral typhlitis, 20 
 Structure of appendix, 28 
 
 as predisposing cause of inflam- 
 mation, 31 
 Sub-csecal fossa, 27 
 Suppurating ovarian cyst, 97 
 Sutures, materials for, 142 
 
 mattress, introduction of, 143 
 
 objections to, 144 
 
 simple, introduction of, 143-145 
 
 advantages of, 144 
 Symptoms, 73 
 
 npEMPERATURE as symptom, 78 
 Tenderness as symptom, 76 
 location of, 84 
 in presence of pus, 86 
 
 Third stage of disease, 56 
 
 Tongue, condition of, as symptom, 
 
 79 
 Treatment, 116 
 Tubercular peritonitis, 107 
 Tumescence, 90 
 
 as symptom, 79 
 Turpentine stupes, 120 
 Typhlitis, stercoral, 20 
 simple, 20 
 chronic, 20 
 
 named by Fitz ' ' Appendicitis, ' ' 
 22 
 Typhoid fever, 94 
 
 as predisposing cause, 34 
 
 TTLCERATION of lining membrane, 
 
 55 
 Ulcer, gastric, 103 
 Ureteritis, 101 
 Urine, condition of as symptom, 80 
 
 examination of, 102 
 
 VAGINAL examination, 85 
 
 Villermey, case reported by, 18 
 Voltz, monograph by, 20 
 Vomiting as symptom, 77 
 
 WOUND, abdominal closure of, 142 
 abdominal dressing of, 145 
 
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 be used with either Morris's or Gray's Anatomy. 117 Illustrations and 16 Lithographic Plates of Nerves and 
 Arteries, with Explanatory Tables, etc. By Samuel O. L. Potter, m.d.. Professor of the Practice of 
 Medicine, Cooper Medical College, San Francisco; late A. A. Surgeon, U. S. Army. 
 
 No. 2. PRACTICE OF MEDICINE. Part I. Fifth Edition, Revised, Enlarged, and Improved. By 
 Dan'l E. Hughes, m.d. , Physician-in-Chief, Philadelphia Hospital, late Demonstrator of Clinical Medi- 
 cine, Jefferson Medical College, Philadelphia. 
 
 No. 3. PRACTICE OF MEDICINE. Part II. Fifth Edition, Revised, Enlarged, and Improved. Same 
 author as No. 2. 
 
 No. 4. PHYSIOLOGY. Seventh Edition, with new Illustrations and a table of Physiological Constants. 
 Enlarged and Revised. By A. P. Brubaker, m.d.. Professor of Physiology and General Pathology in the 
 Pennsylvania College of Dental Surgery ; Demonstrator of Physiology, Jefferson Medical College, Phila- 
 delphia. 
 
 No. 5. OBSTETRICS. Fifth Edition. By Henry G. Landis, m.d. Revised and Edited by Wm. H. 
 Wells, m.d., Assistant Demonstrator of Obstetrics, Jefferson Medical College, Philadelphia. Enlarged. 
 47 Illustrations. 
 
 No. 6. MATERIA MEDICA, THERAPEUTICS, AND PRESCRIPTION WRITING. Sixth 
 Revised Edition (U. S. P. 1890). By Samuel O. L Potter, m.d. Professor of Practice, Cooper Medical 
 College, San Francisco : late A A. Surgeon, U. S. Afmy. 
 
 No. 7. GYN.ffiCOLOGY. A New Book. By Wm H. Wells, m.d., Assistant Demonstrator of Obstetrics, 
 Jefferson College, Philadelphia. Illu-^trated. 
 
 No. 8. DISEASES OF THE EYE AND REFRACTION. Second Edition. Including Treatment and 
 Surgery. By L Webster Fox, m d., and George M. Gould, m.d. With 39 Formulae and 71 Illustrations. 
 
 No. 9. SURGERY, Minor Surgery, and Bandaging. Fifth Edition, Enlarged and Improved. By 
 Orville HoRWiTZ, B.S., M.D., Clinical Professor ot Geni to-Urinary Surgery and Venereal Diseases in Jef- 
 ferson Medical College ; Surgeon to Philadelphia Hospital, etc. With 98 Formulae and 71 Illustrations. 
 
 No. 10. MEDICAL, CHEMISTRY. Fourth Edition. Including Urinalysis, Animal Chemistry. Chemistry 
 of Milk, Blood, Tissues, the Secretions, etc By Henry Leffmann, m.d.. Professor of Chemistry in 
 Pennsylvania College of Dental Surgery and in the Woman's Medical College, Philadelphia. 
 
 No. II. PHARMACY. Fifth Edition. Based upon Prof. Remington's Text-Book of Pharmacy. By F. 
 E. Stewart, m.d.,ph.g., late Quiz-Master in Pharmacy and Chemistry, Philadelphia College of Pharmacy; 
 Lecturer at Jefferson Medical College. Carefully revised in accordance with the new U. S. P. 
 
 No. 12. VETERINARY ANATOMY AND PHYSIOLOGY. Illustrated. By Wm. R. Ballou, m d.. 
 Professor of Equine Anatomy at New York College of Veterinary Surgeons ; Physician to Bellevue Dis- 
 pensary, etc. With 29 graphic Illustrations. 
 
 No. 13. DENTAL PATHOLOGY AND DENTAL MEDICINE. Second Edition, Illustrated. Con- 
 taining all the most noteworthy points of interest to the Dental Student and a Section on Emergencies. By 
 Geo. W. Warrkn, d.d s.. Chief of Clinical Staff, Pennsylvania College of Dental Surgery, Philadelphia. 
 
 No. 14. DISEASES OF CHILDREN. Colored Plate. By Marcus P. Hatfield, Professor of Dis- 
 eases of Children, Chicago Medical College. Second Edition, Enlarged. 
 
 No. 15. GENERAL PATHOLOGY AND MORBID ANATOMY. 91 Illustrations. By H. New- 
 berry Hall, ph.g., m.d., Professor of Pathology and Medical Chemistry, Chicago Post-Graduate Medical 
 School ; Member Surgical Staff, Illinois Charitable Eye and Ear Infirmary ; Chief of Ear Clinic, Chicago 
 Medical College.^ 
 
 No. 16. DISEASES OF NOSE AND EAR. Illustrated. Same Author as No. 15. 
 
 Price, each, .80. Interleaved, for taking- Notes, $1.25. 
 
 P. BLAKISTON, SON & CO., Publishers. 
 
 IOI3 Walnut Street, Philadelphia. 
 The Prices of all Books are Net. 
 
Published Annually for 45 Years. 
 
 The PHYSICIAN'S Visiting List. 
 
 (LINDSAY & BLAKISTON'S.) 
 
 Special ImproYed Edition for 1896. 
 
 In order to improve and simplify this Visiting List we have done away with the two 
 styles hitherto known as the " 25 and 50 Patients plain," We have allowed more space 
 for writing the names, and added to the special memoranda page a column for the 
 "Amount" of the weekly visits and a column for the ''Ledger Page." To do this with- 
 out increasing the bulk or the price, we have condensed the reading matter in the front 
 of the book and rearranged and simplified the memoranda pages, etc., at the back. 
 
 The Lists for 75 Patients and 100 Patients will also have special memoranda page as 
 above, and hereafter will come in two volumes only, dated January to June, and July to 
 December. While this makes a book better suited to the pocket, the chief advantage is 
 that it does away with the risk of losing the accounts of a whole year should the book 
 be mislaid. 
 
 Before making these changes we have personally consulted a number of physicians 
 who have used the book for many years, and have taken into consideration many sugges- 
 tions made in letters from all parts of the country. 
 
 CONTENTS. 
 
 PRELIMINARY MATTER. — Calendar, 1896-1897 — Table of Signs, to be used in keeping records— 
 The Metric or French Decimal System of Weights and Measures — Table for Converting Apothecaries' 
 Weights and Measures into Grams — Dose Table, giving the doses of official and unofficial drugs in both 
 the English and Metric Systems — Asphyxia and Apnea — Complete Table for Calculating the Period of 
 Utero-Gestalion — Comparison of Thermometers. 
 
 VISITING LIST. — Ruled and dated pages for 25,50, 75, and 100 patients per day or week, with blank page 
 opposite each on which is an amount column, column for ledger page, and space for special memoranda. 
 
 SPECIAL RECORDS for Obstetric Engagements, Deaths, Births, etc., vpith special pages for Addresses 
 of Patients, Nurses, etc., Accounts Due, Cash Account, and General Memoranda. 
 
 SIZES AND PRICES. 
 
 REGULAR EDITION, as Described Above. 
 
 BOUND IN STRONG LEATHER COVERS, WITH POCKET AND PENCIL. 
 
 For 25 Patients weekly, with Special Memoranda Page, $1 00 
 
 50 " " " " " I 25 
 
 ,, ,, ,, , f January to Tune "1 ' _, 
 
 qo " " " " " 2 vols. ^•Ti.-T-il y......200 
 
 -' (July to December J 
 
 " " " " '* ■> \ j ]^^^^'^V to June 1 2 00 
 
 '^ '(July to December/ ••:••■ 
 
 100 " « " " " 2 vols iJ^""^^y ^° J""^ \ 7.2^ 
 
 ' \ July to December J ' ' * 
 
 PERPETUAL EDITION, without Dates. 
 
 No. I. Containing space for over 1300 names, with blank page opposite each Visiting List page. 
 
 Bound in Red Leather cover, with Pocket and Pencil, ^i 25 
 
 No. 2. Same as No. I. Containing space for 2600 names, with blank page opposite 15° 
 
 MONTHLY EDITION, without Dates. 
 
 No. I. Bound, Seal leather, without Flap or Pencil, gilt edges, 75 
 
 No. 2. Bound, Seal leather, with Tucks, Pencil, etc., gilt edges, i 00 
 
 jji^" All these prices are net. No discount can be allowed retail purchasers. 
 Circular and sample pages upon application. 
 
 P. BLAKISTON, SON & CO., Publishers, Philadelphia. 
 
COLUMBIA UNIVERSITY LIBRARIES (hsi.stx) 
 
 RD 542 D34 1896 C.I 
 
 A treatise on apP6''|,S'|!uMn.|iiimiiii|iiiii|iil^ 
 
 2002096404