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 RD542 Ed2 Diagnostic palpation 
 
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 George M. Jidebohls 
 
 Diagnostic palpation of the appendix vermiformis, 
 
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 TTH COMPLIMENTS OF THE A UTHOR. 
 
 Diagnostic Palpation of the Appendix 
 Vermiform is. 
 
 Cases of Appendicitis. 
 
 -BY— 
 
 GEORGE M. EDEBOHLS, A.M..M.D., 
 
 Gynecologist to St. Francis Hospital, New York ; Professor of 
 
 Diseases of Women at the New York Post-Graduate 
 
 Medical School and Hospital. 
 
 Reprinted from the American yotirnal of the Medical Sciences, May, 1894. ; The 
 
 ■ Post-Graduate, April, 1894 ; and The New York yournal of Gynecology 
 
 and Obstetrics, February, 1804. 
 
\0- 
 
DIAGNOSTIC PALPATION OF THE VERMI- 
 FORM APPENDIX.* 
 
 BY 
 
 George M. Edebohxs, A.M., M.D., 
 
 Gynecologist to Sr. Francis Hospital, New York ; Professor of 
 
 Diseases of Women at the New York Post-Graduate 
 
 Medical School and Hospital. 
 
 Nothing systematic has, to the writer's knowledge, as yet been 
 published regarding diagnostic palpation of the vermiform ap- 
 pendix. The only conditions sought to be established by palpa- 
 tion have been either tenderness on pressure, or the presence of 
 a tumor or of fluctuation. The idea that the normal or slightly 
 enlarged appendix can, as a rule, be recognized by the touch, 
 previous to opening the abdomen, seems never to have been 
 seriousty entertained. 
 
 This a priori judgment upon the case is, however, founded 
 upon fallacious lines of reasoning and is not at all consonant with 
 the facts. The size of the appendix, its deep situation, and the 
 character of the structures overlying it, have all been deemed in- 
 surmountable obstacles to its successful palpation. It is the 
 writer's purpose, in this communication, to show how all these 
 obstacles can be easily and successfully overcome. 
 
 The author's practical studies upon palpation of the appendix 
 vermiformis extend back somewhat over a year. It may be 
 added that practical^ all of his experience has been gained upon 
 women, only three cases of appendicitis in the male having, dur- 
 ing that time, come under his observation. 
 
 * Read before the Medical Society of the State of New York, Albanj^ February 7th, 1894. 
 
4 EDEBOHI.S : DIAGNOSTIC PALPATION 
 
 The following methods have been employed in the practical 
 study of the subject :- 
 
 i. Palpation of the appendix vermiformis in practically every 
 woman whom the writer has had occasion to examine during the 
 past year. 
 
 2. Critical palpation of the appendix in every case upon 
 which a cceliotomy for any purpose was contemplated, and, when 
 practicable, comparison of the condition of the appendix, as as- 
 certained at the eoeliotomy, with that found at previous palpation. 
 
 3. Search for the appendix, during a eoeliotomy, by palpation 
 from without, and verification of the correctness or otherwise of 
 the finding by the finger within the abdomen. 
 
 4. The establishment of the diagnosis, appendicitis, by pal- 
 pation, with subsequent operation for removal of the appendix, 
 based upon the diagnosis thus made. 
 
 The practice of palpation of the vermiform appendix, as a 
 routine method, in the examination of every woman has led to a 
 recognition of the facility with which the appendix may, under 
 ordinary circumstances, be palpated. Such palpation is best per- 
 formed in the following manner : After completion of the ordinary 
 bimanual examination of the pelvic organs, the woman is drawn 
 upward upon the table to the extent of a foot or so, her feet still 
 remaining where they were placed for the vaginal examination. 
 This is done mainly for the purpose of unfolding the flexure of 
 the thigh upon the abdomen, and to render the right inguinal 
 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 
 introduced into the vagina, and very little assistance, and that 
 only very occasionally, by a finger introduced into the rectum. 
 
 The examiner, standing at the patient's right, begins the 
 search for the appendix by applying two, three or four fingers of 
 his right hand, palmar surface downward, almost flatly upon the 
 abdomen, at or near the umbilicus. While now he draws the ex- 
 amining fingers over the abdomen, in a straight line from the um- 
 bilicus to the anterior superior spine of the right ilium, he 
 notices successively 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 deep enough to recognize 
 distinctly, along the zvhole route traversed by the examining fingers \ 
 
OF THE VERMIFORM APPENDIX. 5 
 
 the resistant surfaces of the posterior abdominal ivall and of the pel- 
 vic brim. Only in this way can we positively feel the normal, or 
 the slightly enlarged appendix ; pressure short of this must nec- 
 essarily fail. 
 
 It is just here that the analogy between the conditions necessary 
 for a successful examination of the pelvic vi.scera, and those ob- 
 taining in a correct palpation of the appendix vermiformis, become 
 apparent. * A bimanual examination of the pelvic organs is the 
 only one regarded as satisfactory at the present day ; by a vaginal 
 examination alone, or by an external examination alone, we are 
 able to determine nothing of practical value. We need the 
 fingers of one hand to afford a point of counterpressure to enable 
 the palpating finger or fingers of the other hand to recognize the 
 structures they meet. Just so in palpation of the vermiform ap- 
 pendix. Here the firm posterior wall of the abdomen at this 
 point, the iliac fossa and the pelvic brim, form a good surface for 
 counterpressure . 
 
 Palpation with pressure short of reaching the posterior wall 
 fails to give us any information of value ; the soft and yielding 
 structures simply glide away from the approaching finger. When, 
 however, these same structures are compressed between the pos- 
 terior abdominal wall and the examining fingers they are recognized 
 with a fair degree of distinctness. Pressure deep enough to recog- 
 nize distinctly the posterior abdominal wall, the pelvic brim, and the 
 structures lying between them and the examining finger, forms the 
 ivhole secret of success in the practice of palpation of the vermiform 
 appendix. 
 
 Proceeding in this manner the appendix is recognized as a more 
 or less flattened, ribbon-shaped structure, when quite normal, or 
 as a more or less rounded and firm organ, of varying diameter, 
 when its walls have been thickened by past or present inflamma- 
 tion. When it is the seat of inflammatory changes, the appendix 
 vermiformis is always more or less sensitive on pressure ; the nor- 
 mal appendix exhibits no special sensitiveness on being squeezed. 
 
 A good guide, in searching for the appendix, is formed by the 
 right common and external iliac arteries, the pulsation of which 
 can be easily and plainly felt. The line of these vessels corres- 
 ponds to a surface line drawn from the left of the umbilicus to the 
 middle of Poupart's ligament. The appendix is generally found 
 almost immediately outside of these vessels. At its base it is 
 
6 EDEBOHLS : DIAGNOSTIC PALPATION" 
 
 separated from the vessels by a space of one half to one inch, 
 while lower down in its course it generally crosses very obliquely 
 the line of the arteries. 
 
 Theoretically, two conditions mainly militate against the suc- 
 cessful palpation of the appendix vermiformis after the method 
 above described ; practically, the difficulties offered by these two 
 conditions amount to very little or nothing. I refer to the vari- 
 able location of the appendix, and to the fact of its common deep 
 situation behind the caecum. 
 
 With the very rare exceptions of its situation far away from 
 its usual site, the origin of the appendix vermiformis is practic- 
 ally always found at what is known as McBurney's point. 
 In fact, it is this constancy of the situation of the appendix 
 which gives its practical value to McBurney's point in the diag- 
 nosis of appendicitis. The tenderness elicited by extremely local- 
 ized pressure at McBurney's point is due to the presence beneath 
 the finger of the inflamed appendix ; a fact of which I have had 
 abundant opportunity to satisfy myself. 
 
 The origin and first part of the appendix are practically, then, 
 constant in situation, or so nearly so, as not to interfere materially 
 with the working rule to first search for the appendix at 
 McBurney's point. Any deviations from its usual course, start- 
 ing from this point, can be usualfy recognized by the examining 
 fingers. Only that part of the appendix, however, situated above 
 the level of the pelvic brim can be distinctly recognized by the 
 finger. When the appendix in its course dips down into the pel- 
 vis, that part of it lying below the pelvic brim is recognized, if at 
 all, only with great difficulty. The surface for counterpressure is 
 lost below the iliac fossa. 
 
 The second condition, commonly assumed to render successful 
 palpation of the appendix vermiformis impracticable, if not im- 
 possible, is a time-honored, traditional myth. I refer to the as- 
 sumed constant or common filling of the caput coli with faecal 
 matter. In my own experience this condition is very rare ; in fact 
 I cannot recall a case, during the period of over a year in which 
 I have systematically practiced palpation of the vermiform appen- 
 dix, in which I have found it. In quite a number of emergency 
 cceliotomies, in which no opportunity was afforded for previous 
 catharsis, I do not recollect ever to have found a faecal impaction 
 in the caput coli. Indeed the systematic practice of palpation of 
 the vermiform appendix, after the method described, gives us in 
 
OF THE VERMIFORM APPENDIX. 7 
 
 addition a great deal of information about the caecum. We gen- 
 erally find it empty, collapsed upon itself from before backward, 
 with the inner and outer borders distinctly recognizable by the 
 fingers as they pass over them. The appendix, being in the 
 large majority of all cases situated behind the caecum, is of 
 course palpated through the apposed anterior and posterior walls 
 of the caput coli. 
 
 The second manner in which the study of the subject has been 
 pursued has been by especially careful and critical palpation of the 
 appendix in every case in which a cceliotomy was contemplated. 
 When feasible, the appendix was then examined on the occasion 
 of the coeliotomy, and its actual condition compared with that 
 previously diagnosticated by palpation. With very rare exceptions 
 we found our previous diagnosis of the position and size of the 
 appendix correct. 
 
 In five cases in which cceliotomy was undertaken upon other 
 indications, a diseased appendix, previously diagnosticated as 
 such by palpation, was removed at the same time. The opera- 
 tions combined with the ecphyadectomy in these cases were : 
 salpingo-oophorectomy for chronic salpingo-oophoritis in the first ; 
 removal of two pus tubes in the second ; salpingo-oophorectomy 
 and ventral fixation of uterus combined with plastic operations, 
 for total prolapsus of uterus and vagina in the third ; total extir- 
 pation of the uterus for fibromata in the fourth and fifth. 
 
 The third method of study, which has been pursued during the 
 past two months only, has been found exceedingly satisfactory and 
 instructive. After completing the intra-abdominal operation or 
 operations for which a cceliotomy is undertaken, and before clos- 
 ing the abdomen, the appendix is located by palpation from with- 
 out. While the palpating finger presses the integuments down 
 upon the appendix from without thus marking its location as 
 felt, and holding it down against the posterior abdominal wall, 
 two fingers of the other hand are passed within the abdomen to 
 verify or disprove the presence of the appendix immediately under- 
 neath the palpating outer finger. In the comparatively few tests 
 thus made I have never failed to locate the appendix exactly and 
 to diagnosticate correct^ both its thickness and direction. 
 
 Finalfy, in a fourth series of three cases of chronic and one of 
 acute appendicitis, the diagnosis was positively made by palpa- 
 tion and cceliotomy was performed solely for the purpose of 
 removing the diseased appendix. These four cases are additional 
 
8 EDEBOHLS : DIAGNOSTIC PALPATION 
 
 to the five already mentioned, when discussing the second method 
 — -in which the diseased appendix was removed as a secondary 
 or additional measure when performing cceliotomy for other 
 purposes . The acute and two of the chronic cases of appendicitis 
 were successfully operated upon by myself. The third case I 
 turned over to my colleague, Dr. G. F. Shrady, for operation, 
 after making the diagnosis of chronic appendicitis by palpation. 
 
 In reference to this case Dr. Shrady writes {Medical Record, 
 January 6, 1894, P a g e 2 ) : — 
 
 " In this connection I may state that my attention has been 
 called by Dr. Edebohls to the possibility of diagnosticating recur- 
 rent appendicitis by actually feeling the appendix through the 
 abdominal wall, and demonstrating the cause of tenderness by 
 direct pressure upon the organ. In one case I was able to do 
 this, to recognize the appendix rolling under the fingers, to limit 
 tenderness to direct pressure upon the process, and afterward to 
 remove the organ by operation from that exact locality." 
 
 And again {ibid., page 23) in summing up the discussion upon 
 this paper : — 
 
 " He had expected some one would question the diagnosis of 
 the appendix by touch through the abdominal walls, for he had 
 not supposed this possible until it had been suggested to him to 
 make steady pressure until resistance was encountered from the 
 posterior walls, when, if the appendix was present in that locality, 
 it might be felt as a cord rolling under the finger. Probably this 
 would be possible only where the appendix was turgid and bulb- 
 ous, as it was in one case in which he mapped out its location, and 
 on cutting down found it directly under the mark made on the 
 abdominal wall, about two inches and a quarter from the anterior 
 superior spine, in line with the umbilicus. ' ' 
 
 It needs but a fair, unprejudiced trial of the method of palpation 
 of the appendix vermiformis as described to convince others, as 
 Dr. Shrady has been convinced, that it is possible to diagnosticate 
 chronic appendicitis by palpation. The members of the house 
 staff of St. Francis' Hospital who have worked with me during 
 the past year have, by repeated practice, become expert in this 
 method of examination. 
 
 It is within the memory of possibly each one of you that not 
 ten years ago the man who claimed to be able, as a rule, to re- 
 cognize and map out by bimanual examination the normal Fall- 
 opian, tubes was looked upon with suspicion. Where to-day is the 
 
OF THE VERIFORM APPENDIX. 9 
 
 gynecologist who cannot do this ? And yet palpation of the 
 appendix vermiformis, after a little practice, becomes quite as easy, 
 if not easier, than palpation of the Fallopian tubes. Indeed, I 
 would lay it down as an axiom that successful palpation of the 
 appendix vermiformis, except in cases of acute appendicitis, is 
 possible in all female patients, in whom the absence of excessive 
 stoutness, abnormal rigidity of abdominal walls, or other more 
 exceptional unfavorable conditions permits us to accurately define 
 by bimanual palpation normal sized Fallopian tubes. 
 
 The practical importance of palpation of the appendix vermi- 
 formis is apparent at a glance. Chronic appendicitis, in the 
 future, is to be diagnosticated, not on subjective symptoms but on 
 objective signs. Unless, in cases of suspected chronic appendi- 
 citis, the surgeon can recognize by palpation the thickened appen- 
 dix and to limit tenderness on pressure to the diseased organ, he 
 will not be justified in operating. A strict observance of this rule 
 will prevent in future a not infrequent error of the past that of 
 performing a cceliotomy for appendicitis, only to find the appen- 
 dix perfectly healthy. 
 
 One broad rule, governing the question of operative inter- 
 ference in appendicitis, should be, not to operate in chronic cases 
 unless you can feel the diseased appendix, nor in acute cases 
 unless by palpation you can recognize either the diseased appendix 
 or the presence of a tumor. Anaesthesia may be necessary, in 
 exceptional instances, to decide the question. 
 
 Palpation of the appendix vermiformis possesses practical im- 
 portante in the early stages of acute appendicitis, at the time of 
 operation, apart from its value as a diagnostic measure. In two 
 instances in which I have operated early for acute appendicitis — 
 in one on the second, in the other on the third day of illness — 
 nothing but a small tumor could be felt in the right inguinal 
 region before the patient was anaesthetized. After full anse- 
 thesia, the inflamed, enlarged appendix could be distinctly felt in 
 both cases. This enabled me to make the incision directly over 
 the diseased organ and thus to remove the strangulated appendix 
 with greater facility and through a smaller opening than if the 
 incision has been made further away. 
 
 In conclusion I may remark that I have on two occasions fore- 
 stalled an operation for supposed chronic appendicitis, proposed by 
 eminent surgeons, by being able to recognize a normal appendix 
 by palpation, and on this finding to advise against operation. 
 
IO EDEBOHLS : DIAGNOSTIC PALPATION 
 
 REMARKS MADE IN CLOSING THE DISCUSSION. 
 
 Dr. G. M. Edebohls : As my own part of this subject, that 
 which relates to palpation of the vermiform appendix, or the diag- 
 nosis of appendicitis by palpation, has not been discussed, I shall 
 not have much to say in reply. But as in preparing my paper 
 I have had occasion to go over all of my cases of the past year, I 
 happen to be in a position to answer, in a degree, Dr. Mynter's 
 question. As a consequence of this recent review of all my work 
 in the field of appendicitis during the past year, the subject is 
 very fresh in my memory, and my experience, limited though it 
 be, may perhaps give some idea of what can be accomplished in 
 some of the worst of these cases. I have removed ten appendices 
 vermiformes during the past year ; of these, five were removed in 
 the course of cceliotomies performed for other conditions. In 
 each of these five the diseased appendix was recognized by pal- 
 pation before operation. Of the remaining five two were cases of 
 what I prefer to call chronic appendicitis ; some call them relaps- 
 ing or recurrent appendicitis. These two chronic cases were 
 readily diagnosed by palpation, i. e. by feeling the enlarged and 
 tender appendix, and limiting tenderness on pressure exactly to 
 the diseased organ. In these two cases the operation was under- 
 taken and the appendix removed on the diagnosis thus made. A 
 third case of chronic appendicitis in which I made the diagnosis 
 by palpation I transferred to my colleague Dr. G. F. Shrady, 
 who removed the diseased appendix on that diagnosis after first 
 satisfying himself of its correctness. These are the cases to which 
 Dr. Morris' inch-and-a-half incision applies. 
 
 L,astly come the cases of acute appendicitis, three of which I 
 have operated upon during the past year. Two of these occurred 
 in girls in their teens, the third in a man of twenty-eight. The 
 first of the acute cases was operated upon sixty-three hours after 
 the beginning of the attack ; a gangrenous appendix as thick and 
 large as my thumb was removed. The interior of the appendix 
 was in direct and free communication with the peritoneal cavity, 
 the gangrenous appendical wall having fallen away in several 
 places. The adjacent peritoneal surfaces were smeared with pus, 
 but there were no adhesions to limit the spread of infection. The 
 patient made a good recovery. In the second case the alertness of 
 the family physician enabled me to operate thirty-four hours after 
 the beginning of the attack, and within six hours after perforation. 
 We found a partially gangrenous appendix with a large perfor- 
 
OF THE VERIFORM APPENDIX. I I 
 
 ation at its middle portion through which fluid faeces were, under 
 our eyes, escaping into the free peritoneal cavity. Sixty grammes 
 of mixed scrum and faeces were removed from the peritoneal cav- 
 ity, the appendix was ablated, and the patient recovered both from 
 the operation and from a severe pneumonia which occurred on the 
 sixth day. Both of these cases I have recorded in detail elsewhere 
 (New York Journal of Gjmaecology, Feb., 1894.) 
 
 The third case of acute appendicitis, occurring in a man of 28, 
 I operated upon within the past two weeks. The operation was 
 performed 72 hours after the incipiency of the acute attack, the 
 patient's second within a year. We found and removed an ad- 
 herent appendix, almost black from intense congestion. No per- 
 foration and no evidences of peritonitis. It was a perfectly smooth 
 and easy case in every way, and the prognosis immediately after 
 operation seemed the most favorable possible ; yet the patient died 
 42 hours after operation of heart failure due to fatty degeneration 
 of that organ. 
 
 Thus of three cases of acute appendicitis, two very bad ones 
 with perforation and well-started peritonitis got well ; the third, 
 without perforation and without peritonitis, succumbed. I may 
 add that in the first of the acute cases the enlarged and diseased 
 appendix could be readily palpated on the day preceding operation . 
 In the two other acute cases the presence of a tumor was all that 
 could be recognized, owing to excessive tympanites and tension of 
 the abdominal walls. As soon, however, as the patient was re- 
 laxed by anaesthesia, and before beginning the operation, the 
 diseased appendices could be readily palpated. As a result of such 
 palpation we were enabled to make the incision directly over the 
 diseased organ, thus minimizing the length of incision required 
 and facilitating operative procedures. Such information from 
 palpation can, in acute cases of appendicitis, only be obtained in 
 the early stages of the attack. 
 
12 EDEBOHLS : A CLINICAL LECTURE ON PALPATION 
 
 A CLINICAL LECTURE ON PALPATION OF 
 THE VERMIFORM APPENDIX. 
 
 Delivered at the New York Post-Gratuate Medical School, March 5, 1894 
 
 By Professor George M. Edebohls, M.D. 
 
 Gentlemen.— At the close of our meeting last week we spent 
 five minutes in searching for the appendix vermiformis in two 
 patients who happened to be upon the tables at that time. We 
 were able to palpate a normal appendix vermiformis in each. 
 From the lively interest you all manifested in the subject, and 
 from the look of pleased surprise on the faces of some of you as 
 you realized that you had for the first time, and perhaps at the 
 first trial, succeeded in palpating distinctly a normal appendix, I 
 hope that my proposal to bring the matter before you to-day in a 
 more systematic manner, and to devote the hour to the appen- 
 dices vermiformes rather than to the pelvic organs of our patients 
 will meet your approval. 
 
 We have to-day some half a dozen patients, women of various 
 ages and of varying degrees of stoutness. We will palpate the 
 abdomen of each, in the order in which they happen to come 
 before us, for the appendix vermiformis. 
 
 Now palpation and palpation are two quite different things, 
 varying according to what region of the body and which organs 
 are to be palpated. The external obstetric palpation of the par- 
 turient uterus in the latter months, the palpation of normal-sized 
 tubes and ovaries, the palpation of a movable kidney, etc., etc., 
 constitute, each of them, an art sui generis, and it by no means 
 follows that having mastered one, one immediately becomes, by 
 reason of such mastery, master of all the others. Kach one re- 
 quires special practice, patient and painstaking to produce the 
 best results. Just so with palpation of the vermiform appendix ; 
 it has its own peculiar technic, and there is only one proper and 
 best way of performing it. 
 
OF THE VERIFORM APPENDIX. 13 
 
 The very possibility of palpating the appendix vermiformis de- 
 pends upon the presence, behind that organ, of the firm and un- 
 yielding posterior abdominal wall. Palpation is practiced by the 
 fingers of one hand only, applied externally. The fingers must 
 carry the anterior abdominal wall down before them until the firm 
 resistance of the posterior abdominal wall is encountered. As the 
 fingers, flatly applied, now pass over the right inguinal region 
 from the umbilicus outward to the right anterior superior spine 
 of the ilium, it is absolutely essential that the posterior abdom- 
 inal wall be distinctly felt along the whole route traversed. As 
 the organs, and amongst them the appendix vermiformis, pass re- 
 view, as it were, b3^ gliding in succession between the fingers and 
 the posterior abdominal wall, the touch soon learns to distinguish 
 between them and to recognize the appendix. After the appendix 
 is detected it is well to pass the fingers over it, backward and for- 
 ward, a number of times in succession ; a more correct impression 
 of its size, outlines, etc. , is thus obtained. 
 
 As regards the position of the patient, palpation of the appen- 
 dix, like the pelvic bimanual palpation, requires relaxation of the 
 abdominal walls. The positions most suitable for both examin- 
 ations are practically the same, except that palpation of the ver- 
 miform requires less flexion of the thighs upon the abdomen. 
 
 There are two useful landmarks in practicing palpation of the 
 vermiform appendix : McBurney's point, and the line of the right 
 iliac arteries, and for your guidance we will mark both of them on 
 the skin of this patient's abdomen. The origin of the appendix 
 from the caecum, whatever course its continuation may run, is 
 almost uniformly at McBurney's point ; hence the diagnostic 
 value, in appendicitis, of pressure over this point. The iliac ar- 
 teries are useful in a two-fold way : firstly, because to feel their 
 pulsation distinctly means that the fingers have reached the pos- 
 terior abdominal wall ; and secondly, because the normal appen- 
 dix is very constantly found about a finger's breadth outside of 
 the artery, on a line between the umbilicus and the anterior sup- 
 erior spine of the right ilium. 
 
 We have now examined five women in succession and in all of 
 them but one, this Very stout woman, I feel certain I have felt the 
 normal appendix vermiformis. Some of you who examined the 
 patients after me believe they also have felt the appendix, while a 
 few of you remain in doubt. Further practice will lessen your doubts 
 and give you greater confidence in the results of yoiir findings. 
 
14 EDEBOHLS : A CLINICAL LECTURE ON PALPATION 
 
 Why I do say that we have felt a normal appendix ? I say so 
 first of all because there is absolutely no tenderness on pressure 
 over the appendix ; secondly, because the calibre of the appendix 
 is not increased in size ; and thirdly, because the appendix, as 
 felt, is not hard and rigid, but a soft yielding structure. When 
 ever so mildly inflamed, the appendix vermiformis is tender on 
 pressure, and more or less rigid from inflammatory thickening of 
 its walls. 
 
 We are therefore able to say, as a result of positively recogniz- 
 ing a normal appendix, that whatever these four women are 
 suffering from, they certainly have not appendicitis. The prac- 
 tical importance of being able to decide this in cases where 
 appendicitis may be suspected from the symptoms, is apparent. 
 
 Our last patient is a young married woman who came to us 
 two months ago, complaining of pain in the right groin of three 
 days duration. I recognized by palpation an enlarged appendix, 
 very sensitive on pressure, and made a diagnosis of appendicitis. 
 That same evening I presented her at a meeting of the New York 
 Obstetrical Society, where she was examined by three of the 
 most distinguished gynecologists of this country. Two of them 
 reported that they could feel the enlarged appendix ; the third 
 was not certain that he could. 
 
 This patient's appendicitis, her first attack by the way, ran a 
 favorable course and was over in two weeks. Still to-day, six 
 weeks after the subsidence of the attack, the appendix can be 
 felt, slightly thickened, rigid, and sensitive on firm pressure. I 
 believe this appendix ought to be removed now, and have so 
 advised ; the patient, however, is timid, and w r e have compro- 
 mised that the operation should be done either during or after 
 the next attack, should such occur. 
 
 Her appendix is very easy of palpation, but in view of the fact 
 that it is still slightly sensitive on pressure I will request you to 
 be gentle in handling it. In discussing the subject of palpation 
 of the appendix recently, a prominent surgeon warned against it, 
 and took occasion to say that when you palpate an appendix you 
 should be ready to operate. He fortified his ^position by narrat- 
 ing a case in which he felt for the appendix in the evening and, 
 as a result, he thought, of such palpation, had to operate for 
 acute appendicitis early the next morning. I am afraid the 
 sarcasm which he meant to hurl at palpation of the vermiform 
 proved a boomerang. COur patient was examined by seven or 
 
OF THE VKRIFORM APPENDIX. 15 
 
 eight members of the class and no trouble of any kind followed.; 
 
 A few days ago a young lady was brought to my office by her 
 physician, who suspected that his patient was suffering from 
 movable right kidney. I made a physical examination without 
 asking any questions, found both kidneys in place, the pelvic 
 organs normal, the appendix vermiformis enlarged, thickened, 
 tender on pressure. The diagnosis, chronic appendicitis, made 
 solely on the physical signs, was corroborated by the history 
 subsequently obtained from the patient. 
 
 It has been urged that while palpation of the normal appendix 
 might be possible in women, in men it would prove impossible. 
 While I have on several occasions palpated the diseased appen- 
 dix in males, I have, until quite recently, not been in a position 
 to speak from experience as to the palpation of the normal appen- 
 dix in men. Through the courtesy of my colleagues at St. 
 Francis' Hospital, I have enjoyed the privilege of going from bed 
 to bed in the male wards to find the appendix, and have satisfied 
 myself that the normal appendix may be palpated in men in 
 about the same proportion of cases, and with practically the same 
 facility as in women. 
 
CASES OF APPENDICITIS. 
 
 New York Obstetrical Society, December 5, 1893. 
 
 Dr. G. M. Edebohls presented the specimens from five cases 
 of appendicitis which he had recently operated upon, together 
 with two of the patients upon whom operation had been per- 
 formed. Two of the five were cases of 
 
 Acute appendicitis with perforation. 
 
 Case I. Miss O. B., aged nineteen, was seen in consultation 
 with Dr. E. J. Gallagher, from whom the following history was 
 obtained. Her periods, up to the last, had always appeared with 
 regularity. On July 6, 1893, her menses appeared, one week 
 overdue. On July 7, she was caught in a rain storm and wet 
 through and through. During the night menstruation ceased, and 
 .sharp abdominal pains suddenly developed; these pains soon be- 
 came localized in the right groin. 
 
 Dr. Edebohls first saw the patient with Dr. Gallagher on 
 July 9th. They found her in shock; temp. 103^°; pulse 140 and 
 very small ; bowels tympanitic ; abdomen sensitive to pressure in 
 several places, but especially over McBurney's point, where a 
 thickened, rounded cord, running over the pelvic brim into the 
 pelvis could be distinctly palpated. 
 
 Examination per vaginam revealed a tender mass behind and 
 to the right of uterus. The mass was of about the size of the 
 normal uterus, and was continuous outwards and upwards with 
 the mass felt in the right iliac fo.ssa. Uterus and left adnexa 
 not palpable, being lost in the pathological mass. 
 
 Diagnosis : Acute appendicitis, with a mental reservation of 
 possible ruptured tubal pregnancy. 
 
 Operation advised and performed at the patient's home on 
 July 10, at 3 p. m., sixty three hours after the beginning of the 
 attack, with the assistance of Drs. E. J. and Win. Gallagher and 
 John McParlan. 
 
 Teh centimeter incision along outer border of right rectus 
 abdominis, the lower end of incision reaching down to Poupart's 
 ligament. The presenting intestines were deeply injected and 
 inflamed, and covered with a thick fibrinous layer, but not ad- 
 herent in such a manner as to shut off the general peritoneal 
 cavity. After lifting the intestines out of the right iliac fossa, 
 the acutely inflamed and very much enlarged right Fallopian tube 
 covered with plastic exudate and embracing a normal right 
 ovary, was encountered. The condition of the tube was so bad 
 that it was removed together with its ovary. 
 
[8 KDKBOHLS : CASES OF APPENDICITIS. 
 
 The appendix vermiformis was now sought for and found ex- 
 tending from behind the caput eoli along the posterior aspect of 
 the right broad ligament downward and inward into the pelvis 
 where it occupied Douglas' sac, which, with its surrounding ex- 
 udate and pus, it almost entirely filled. 
 
 The appendix measured fully eight centimeters in length, by 
 about two centimeters in average diameter, being altogether the 
 size and much the shape of a large thumb. More than half of its 
 circumference, that distal from the attachment of the meso-appendix, 
 was gangrenous along its entire length, the remainder of the wall 
 being intensely congested and swollen. Parts of the gangrenous 
 wall had fallen away, leaving the interior of the appendix in free 
 communication with the peritoneal cavity. Two bean-shaped 
 masses of hardened fecal matter were found inside of the appendix, 
 which was surrounded by a great deal of exudate and a small 
 quantity of pus. 
 
 The diseased appendix was shelled out of Douglas' sac, the 
 intestines being held out of the way and the peritoneal cavit)' pro- 
 tected by sterilized gauze, tied off with fine silk and removed. 
 The rotten condition of the caecum at the site of origin of the 
 appendix did not permit of the usual Lambert suture over the stump 
 of the appendix. 
 
 The bed from which the pathological masses were removed, and 
 the adjacent inflamed coils of intestine were dried with sterilized 
 gauze, touched with gauze wrung out of i-iooo sublimate sol- 
 lution, and again dried. No irrigation. The bed was then packed 
 with iodoform gauze, the end of which was led out of the lower 
 angle of the wound. The upper two-thirds of the wound was 
 closed with through and through silkworm sutures. Usual dress- 
 ing of sublimated gauze. 
 
 Patient rallied well from the operation. Pulse and temperature 
 became normal on the third day, and convalescence thereafter was 
 uninterrupted. The united part of the abdominal wound healed 
 by first intention and Dr. Gallagher took care of the cavity and 
 the wound until complete closure some three weeks later. 
 
 Case II. Miss A. K., aged fifteen, was seen in consultation 
 with Dr. D. J. Ruzicka, her attending physician, and Dr. H. C. 
 Hoefling. She had been well all her life, with the exception of 
 an attack of appendicitis in March, 1893, for which she was 
 treated by Dr. Ruzicka. The attack was of a mild type, lasted 
 about ten days, and was followed by a still milder relapse at t he- 
 end of ten days. 
 
 From that time she was perfectly well, until Thursday, Nov. 16, 
 1893, at 11 p.m. Then, very suddenly, great pain in the right 
 groin, radiating into thigh, and vomiting ; pulse 120 ; no elevation 
 of temperature. No great change until the next day, Friday, at 
 9 p. m., when the temperature ran up to 102 , the pulse still re- 
 maining at 120. On Saturday, at 3 a. m., sudden, vers* acute 
 
EDEBOHES : CASES OF APPENDICITIS. 1 9 
 
 pain, restlessness and great prostration ; temp. 103, pulse [36, 
 small and thready. 
 
 This was still her condition when Dr. Kdebohls first saw her on 
 Saturday, at 6 a. m. Dr. Ruzicka had diagnosticated acute- 
 appendicitis, with rupture occurring three hours previously, and 
 in this diagnosis, Dr. Hoefliug and he concurred. Immediate 
 operation was advised and accepted by the girl and her family. 
 
 Operation, Nov. 18, at 9 a. m., thirty four hours after beginning 
 of the attack, and six hours after perforation. Ten centimeter 
 incision, slightly oblique, its centre corresponding to a point 
 midway between the anterior superior spine of the ilium and the 
 umbilicus. When the peritoneal cavity was opened, about sixty 
 grammes of softened faeces, mixed with serum, ran out. There 
 were absolutely no adhesions to shut off this collection in the free 
 peritoneal cavity, although the angry congestion and some soft 
 deposits of fresh lymph indicated the beginning of acute peritonitis. 
 
 Sterilized gauze was at once placed in such a way as to protect 
 the general peritoneal cavity, and the fluid pieces were mopped up 
 and removed by means of dry gauze serviettes, without irrigation. 
 The appendix was found on the inner and posterior aspect of the 
 caecum, It was but moderately thickened, partially gangrenous, 
 and doubled up on itself in the middle so that the free end was 
 attached by adhesions to its point of insertion into the caecum. 
 The perforation had occurred at the point of flexure, on its inner 
 aspect, and soft facal matter was escaping thence into the perit- 
 oneal cavity. The appendix was tied off at its base and the stump 
 inverted into the caecum by suturing the peritoneum over it. 
 After another dry cleansing and touching all approachable con- 
 taminated surfaces with gauze wrung out of 1-1000 sublimate 
 solution, the region about the site of the removed appendix was 
 packed with iodoform gauze, the end of which was led out at the 
 lower angle of the wound. No irrigation whatever, the danger 
 of spreading infection by means of it being considered greater than 
 any possible advantage that might accrue from its use. The upper 
 two-thirds of the wound was closed by through and through silk- 
 worm sutures. 
 
 Patient bore the operation well. The gauze packing was re- 
 moved three days later and a rubber drain substituted. An acute 
 pneumonia, involving the lower two-thirds of the right lung super- 
 vened on the sixth day and sent the temperature, which had been 
 normal for two days, up to 104 V>°. The pneumonia ran a pretty 
 tempestuous course for five days when it subsided. The patient 
 has since made a good recover}'. 
 
 Chronic Appendicitis. 
 
 Case III. Miss M. B., aged 18, came under observation in 
 January, 1893. She had suffered for nearly two ye&rs past with 
 symptoms due to a movable right kidney, and had during that 
 time had several attacks of appendicitis. 
 
20 KDKKOHI.S : CASKS OF APPENDICITIS. 
 
 On examination there were found an endometritis and a right 
 kidney movable to the extent often centimeters. The appendix 
 vermiformis could be palpated as a distinct hard cord, about the 
 diameter of a lead pencil, sensitive on pressure. 
 
 On Feb. 10, 1893, Dr. Edebohls performed curettage of the 
 uterus, and nephrorrhaphy for fixation of the right kidney. 
 During convalescence from these operations she had an attack of 
 appendicitis, which was treated by blisters and internal medication. 
 She was discharged on March 27, the appendix being still enlarg- 
 ed and sensitive on pressure. 
 
 The symptoms of appendicitis persisted, with exacerbations, 
 until her readmission a month later. During this time repeated 
 examinations showed the appendix more or less enlarged at various 
 periods. 
 
 On April 28, he removed the appendix vermiformis by operation. 
 The appendix was found elongated, thickened to the size of a 
 lead pencil, and rigid, representing the so-called chronic catarrhal 
 appendicitis. No packing or drainage, but complete closure of 
 the abdominal wound with buried silkworm sutures. 
 
 She remained perfectly well until August, when some of the old 
 symptoms returned. An examination showed the left kidney to 
 have become movable to the extent of ten centimeters, the right 
 kidney remaining securely anchored to the lumbar scar. 
 
 The left kidney, it may be added, was not movable at the time of 
 operation upon the right kidney. He proposed to moor the left 
 kidney by nephrorrhaphy in the near future. [Patient presented.] 
 
 Case IV. T. L-, 31 years of age, married, mother of two 
 children, was sent to him by Dr. Gerrit Blauvelt, of Nyack, N. Y. 
 She considered herself fairfy well up to the date of the birth of 
 her first child, ten years ago. Since then she has suffered much 
 from backaches, headache, leucorrhcea, nervousness and dyspepsia. 
 
 Following the birth of her second child, four years ago, all the 
 above symptons became aggravated, menorrhagia and bearing 
 down sensations in the pelvis being superadded. 
 
 In February, 1893, she was operated upon by a distinguished 
 surgeon of this city, who performed trachelorrhaphy and shorten- 
 ing of the round ligaments at one sitting. 
 
 Although the anatomical results attained by the operations were 
 perfect, no therapeutical results followed, the patient remaining 
 the same as before the operation. In August, 1893, by the advice 
 of her family physician, she consulted Dr. Edebohls. 
 
 Examination showed the uterus in normal anteversion, the 
 cervix well repaired and a trifle conical, endometritis, bilateral 
 catarrhal salpingitis of a mild type, and a right kidney movable 
 to the extent of five centimeters. 
 
 The movable right kidney being held responsible for most of 
 her symptoms, nephrorrhaphy was advised and performed on 
 Oct. 20, 1893, curettage of the uterus being clone at the same 
 sitting. 
 
EDEBOHLS : CASKS OP APPENDICITIS. 2T 
 
 During convalescence an attack of pain in the right groin, 
 accompanied by digestive disturbances, first called attention to 
 the appendix vermiformis. The patient volunteered the statement 
 that she had had similar attacks repeatedly during the past eight 
 years. On palpation the appendix was found to be of the thick- 
 ness of a lead pencil, rigid and painful on pressure. 
 
 Ecphyadectomy was performed on Nov. 17, 1893, after the 
 method practiced and advocated by Dr. Robert F. Morris of this 
 city : an inch and a half incision over the appendix, carried in 
 the direction of the fibres of the external oblique ; drawing the 
 ascending colon out of the wound, and following its well marked 
 band of longitudinal fibres down to the origin of the appendix; 
 delivering the latter ; circular incision of its peritoneal and mus- 
 cular sheaths close to the point of origin ; ligation of the mucous 
 coat and ablation of appendix ; inversion of stump into the caecum 
 and closure of the peritoneum over it by the pursestring suture. 
 
 The method of Dr. Morris was followed in every detail, with 
 the exception of the closure of the abdominal wound, which Dr. 
 Edebohls preferred to do with the buried silkworm suture. He 
 wished to embrace this opportunity of expressing his indebtedness 
 to Dr. Morris for the neat and surgically perfect method which 
 he had elaborated and presented to the profession, for the removal 
 of the appendix in cases of chronic, or often so-called recurrent, 
 ecphyaditis. 
 
 The patient made a smooth recovery, left bed on the eighth day 
 and was discharged on the fifteenth day. 
 
 Case V. T. F., aged 30, married, was sent to him by Dr. S. 
 D. McGauran. She had been ill ever since her marriage, ten 
 years ago, with symptoms due to endometritis, bilateral salpingo- 
 oophoritis and movable right kidne3 r . She had received local 
 treatment for about five years past without improvement. 
 
 On Nov. 24, 1893, ne operated upon her for removal of the 
 diseased appendages, curettage and ventral fixation of the uterus 
 being performed at the same sitting. While removing the right 
 adnexa, the appendix vermiformis, thickened, chronically inflamed 
 and elongated to a length of thirteen centimeters was found 
 broadh' adherent to the posterior surface of the right broad liga- 
 ment. It was tied off and removed with the adnexa, the stump 
 being turned into the caecum. He presented the case as parallel 
 with those more or less frequently encountered by every operator, 
 in which the appendix becomes involved in the course of inflam- 
 matory affections of the appendages and is removed together with 
 the latter. He had thus incidentally removed it some seven or 
 eight times. 
 
 Remarks. 
 
 Dr. Edebohls did not wish to open up for discussion the 
 entire broad subject of appendicitis; he merel} 7 desired to comment 
 
22 EDRBOHES : CASES OK APPENDICITIS. 
 
 upon one or two phases of the questions. The first two eases — 
 those of acute, gangrenous appendicitis with perforation — he had 
 presented as a type of a class inevitably doomed to a rapidly 
 fatal issue, unless saved by the knife. The difficulty lay in recog- 
 nizing this class of cases as such, and great credit is due the 
 attending physicians for their accurate diagnosis. The profound 
 prostration, shock and involvement of the vital functions in these 
 cases of earl)- perforation, make it evident that symptomatic treat- 
 ment can be of no avail ; that the only hope for the patient lies in 
 radical measures, promptly executed. 
 
 The only point of the technique that he wished to touch upon 
 was that of irrigation of the peritoneum in these cases. He could 
 not help but feel that the danger of spreading the infection by 
 irrigation was greater than any possible good that might be hoped 
 for from the measure. He had, therefore, contented himself with 
 dry cleansing. 
 
 In regard to the cases of chronic appendicitis, he desired espec- 
 ially to emphasize the fact, that the time had arrived when we 
 are to deal with these cases on indications parallel to those which 
 govern us in dealing with cases of salpingo-oophoritis. Just as 
 an operation for the removal of the uterine appendages is unjusti- 
 fiable, save on one or two exceptional indications of comparatively 
 rare occurrence, unless a lesion of these organs can be demonstrated 
 by bimanual examination, so before proposing an operation for 
 the removal of the appendix in chronic cases we should be able to 
 recognize the diseased condition, the chronic appendicitis, by 
 palpation. More than one abdomen had been opened for the pur- 
 pose of removing a presumably diseased appendix, the latter being 
 found in a perfectly health)- condition. In other words, we are 
 to operate in cases of chronic appendicitis, as in cases of salpingo- 
 oophoritis, on objective, not on subjective indications. He would 
 not detain the Society longer with this subject of palpation of the 
 vermiform appendix, to which he had given considerable attention 
 for about a year past, as he was engaged in the preparation of a 
 paper, soon to be published, detailinghis observations in the matter 
 and the practical deductions he had derived therefrom. 
 
 A feature of special interest to the surgeon as well as to the 
 gynecologist, is presented in the reciprocal relations existing be- 
 tween appendicitis and inflammatory diseases of the right uterine 
 appendages. Thus, the salpingo-oophoritis in Case I, was certain- 
 ly the result, which in Case Y , it was possibly the cause of the 
 appendicitis. 
 
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