SSallP'IfASEJg?^ 
 
 RECAP 
 
 RD542 Mfl!i^^'*°^704i """ LAMMATION 
 
 OF THE 
 
 VERMIFORM APPENDIX: 
 
 ^ ITS 
 
 EESULTS, DIAGNOSIS, AND TEEATMENT, 
 
 TOGETHER WITH THE 
 
 REPORTS 
 
 OF SEVEN CASES OF EXCISION OF THE VERMIFORM APPENDIX 
 
 FOR PERFORATIVE APPENDICITIS, WITH EXHIBITION 
 
 OF FIVE OF THE PATIENTS. 
 
 BY 
 
 THOMAS G. MORTON, M.D., 
 
 One of the Surgeons to the Pennsylvania Hospital; Surgeon to the Philadelphia 
 ^ Orthopedic Hospital ; Professor of Orthopaedic Surgery at the Philadelphia 
 Polyclinic and College for Graduates in Medicine, etc., etc. 
 
 Eead before the College of Physicians of Philadelphia, 
 January 1, 1890. 
 
 PRINTED BY 
 
 J. B. LIPPINCOTT COMPANY, 
 
 PHILADELPHIA. 
 1890. 
 
Rdsm 
 
 ns± 
 
 College of ^Jpsiicians; anb ^urseons; 
 
Digitized by tine Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/inflamationofverOOmort 
 
IKFLAMMATIOlSr 
 
 OF THE 
 
 VERMIFORM APPENDIX: 
 
 ITS 
 
 EESULTS, DIAGNOSIS, AND TEEATMENT, 
 
 TOGETHER "WITH THE 
 
 REPORTS 
 
 OF SEVEN CASES OF EXCISION OF THE VERMIFORM APPENDIX 
 
 FOR PERFORATIVE APPENDICITIS, WITH EXHIBITION 
 
 OF FIVE OF THE PATIENTS. 
 
 BY 
 
 THOMAS G. MOETON, M.D., 
 
 One of the Surgeons to the Pennsylvania Hospital ; Surgeon to the Philadelphia 
 
 Orthopaedic Hospital ; Professor of Orthopgedic Surgery at the Philadelphia 
 
 Polyclinic and College for Graduates in Medicine, etc., etc. 
 
 Read before the College of Physicians of Philadelphia, 
 January 1, 1890. 
 
 PRINTED BY 
 
 J. B. LIPPINCOTT COMPANY, 
 
 PHILADELPHIA. 
 
 18 90. 
 

INFLAMMATION 
 
 OF THE 
 
 VERMIFORM APPENDIX: 
 
 ITS 
 
 EESULTS, DIAGNOSIS, AND TREATMENT* 
 
 When the abdomen is believed to contain pus, 
 whether intra- or extra-peritoneal, encysted or dif- 
 fused, the rule of surgical procedure now is to 
 make a section, remove the offending organ or the 
 sloughing tissues or pus, thoroughly cleanse the 
 surroundings, and drain. 
 
 This method has also been practised in the treat- 
 ment of suppurative peritonitis ; in perforating ulcer 
 of the intestine, whether typhoid, tubercular, trau- 
 matic, or simple in character ; and, more recently, in 
 those inflammations and abscesses called perityph- 
 litic or pericsecal, which now are acknowledged to 
 be almost invariably the result of some form of ap- 
 pendicitis. It is to the latter affection that I wish 
 to call attention this evening, and, in doing so, to 
 present a number of patients from whom I have 
 removed a diseased appendix vermiformis, which 
 
 * Read before the College of Phj'-sicians of Philadelphia, at the 
 stated meeting held January 1, 1890. 
 
 3 
 
iu every case had given rise to peri-appendicular 
 abscess threatening general suppurative peritonitis, 
 which, indeed, in several had already begun. 
 
 Laparotomy for perforative appendicitis, with re- 
 moval of the organ, is now an established surgical 
 procedure, and yet so recently has this operation 
 been introduced that I am able to present the 
 patient upon whom I operated in April, 1887, for 
 pericgecal abscess with peritonitis, which I believe 
 represents the first successful operation for the re- 
 moval of the vermiform appendix in a case of this 
 kind, based upon correct diagnosis. 
 
 It is true that Hall, of JS'ew York, in 1886, in 
 an abscess associated with right inguinal hernia, 
 after evacuating the abscess, had discovered and 
 removed an ulcerated appendix, and the patient 
 recovered ; but the diagnosis of perforative appen- 
 dicitis was not made until after the abscess was 
 opened. More recently, a number of cases of 
 excision of the appendix have been reported by 
 Weir, Treves, ITancrede, and others. 
 
 In the case to which I have referred and now 
 present, general peritonitis was developing; the 
 history and symptoms indicated abscess, and pointed 
 to the appendix as the cause of trouble. Upon 
 incision, an abscess cavity was entered at a depth 
 of an inch or more below the external surface, a 
 free flow of pus followed, and the caecum and its 
 diseased appendix, which was perforated, came into 
 view. The latter was excised, the peritoneal cavity 
 washed free of pus and drained, with immediate 
 relief and prompt recovery. 
 
I have operated since upon six other cases. Of 
 these seven, five recovered and two died; of the 
 latter, both were unavoidably operated upon in 
 extremis, and, although dying within a few hours, 
 the fatal termination was in no wise, I think, has- 
 tened by the operation. 
 
 Each case presented a distinct history of a num- 
 ber of previous attacks of pain in the ileo-csecal 
 region, which occurred generally at irregular inter- 
 vals, covering periods varying from a few months 
 to several years. 
 
 Four were males, and three were females ; their 
 ages were respectively nine, eleven, seventeen, 
 twenty-six, twenty-eight, thirty-four, and fifty-two 
 years. The final attack, during which perforation 
 took place, presented symptoms very much alike in 
 each : intense local pain, increased on pressure, dis- 
 tention of the ileo-csecal region, fluctuation of tem- 
 perature, slight rigors or marked chills, moderate 
 or decided sweatings, acceleration of pulse, coated 
 tongue, constipation, and a depressed, anxious facial 
 expression. 
 
 IvTo tumor could be detected in any case, but in 
 one instance there was some deep hardening of the 
 tissues. Percussion in this, as in fact in the other 
 cases, was markedly tympanitic. 
 
 A lateral incision was made in each, and the 
 peritoneal cavity was found invaded by pus in four 
 of the cases. In all more or less intestine came 
 into view, either as part of the limiting abscess 
 wall or penetrating the opening through it to the 
 general peritoneal cavity. The appendix was found 
 
6 
 
 attached its entire length to the caecum in three 
 cases, and quite free in the other four. 
 
 Fecal concretions were found in every case but 
 one, either lodged in the perforation or free in the 
 abscess or peritoneal cavity. 
 
 The abdominal cavity of each was washed out and 
 drained from the lowest part of the pelvis. The 
 abscess cavities were treated by irrigation and 
 partial curetting. The wound of operation was 
 brought together by interrupted sutures of silk, 
 but in each case, owing to increased tension, some 
 of the sutures had to be cut within twenty-four 
 hours, and healing by granulation took place. 
 From the time of operation the symptoms were 
 invariably promptly relieved. Convalescence was 
 uneventful except in one instance, which will be 
 referred to again. 
 
 The operations were performed at periods vary- 
 ing from the third to the ninth day after the first 
 symptoms had appeared. 
 
 The post-operative treatment consisted, in a gen- 
 eral way, in keeping the abdominal cavity drained 
 and the bowels acting freely. 
 
 Hypodermic injection of morphine was reluct- 
 antly used upon two occasions, shortly after the 
 operation, to relieve pain and restlessness. 
 
 Milk and broths were freely given, while stimu- 
 lants and quinine were early required. The his- 
 tories of these cases are briefly as follows : 
 
CASE I.— (Exhibited.) APPENDICITIS — PERFORATION — PERI- 
 TYPHLITIC ABSCESS— GENERAL PERITONITIS— LAPAROTOMY— 
 EXCISION OF THE VERMIFORM APPENDIX— RECOVERY. 
 
 This patient was under the charge of Dr. Frank 
 "Woodbury, with whom and Dr. James C. Wilson I 
 saw the case in consultation. 
 
 Charles M. N. K. ; aged twenty-six years ; born in Phila- 
 delphia ; a paper-hanger ; not married ; of spare frame ; had 
 always had good health, except that for the last three or 
 four years he had been subject to sudden and severe attacks 
 of abdominal pain. These attacks came on without warning 
 while he was in excellent health, and would completely pros- 
 trate him. The pain was of a stabbing character, and most 
 intense across the lower part of the abdomen and around 
 the umbilicus ; it was attended by great irritability of both 
 rectum and bladder ; sometimes there would be diarrhoea. 
 These attacks, after lasting a few hours, passed away gradually, 
 leaving him rather weak for a short time ; but he rapidly re- 
 covered, and enjoyed uninterrupted good health until the next 
 attack came on. He consulted Dr. Woodbury on the 20th 
 of April, 1887, complaining of having taken cold ; looked 
 haggard, skin and conjunctivae rather sallow, tongue coated, 
 no appetite, bowels constipated, frequent micturition, and was 
 passing a remarkably large quantity of pale urine. At this 
 time he did not complain of abdominal pain. He was given 
 fractional doses of calomel and sodium bicarbonate with 
 pepsin, and was directed to keep his room. The urine con- 
 tained a large proportion of albumen (one-fifth on boiling), 
 and under the microscope showed many leucocytes and a few 
 hyaline casts. 
 
 April 22. — Nauseated during the night ; bowels moved satis- 
 factorily ; great irritability of the bladder ; much prostration. 
 
 April 23. — Spent the day lying upon a lounge ; complained 
 of abdominal pain ; had not slept, and was very restless. 
 
 April 24. — During the night had suffered intensely and did 
 
8 
 
 not sleep ; several copious movements ; pain persisted ; point of 
 greatest tenderness about midway between the umbilicus and 
 the middle of Poupart's ligament. A resisting mass could be 
 detected upon pressure in this locality, but examination caused 
 severe pain. Temperature 103.5° ; pulse 140. 
 
 Ap7^il 25. — Had a very bad night ; pain in right iliac region 
 excruciating ; swelling somewhat larger, very tender ; skin not 
 discolored. Dr. James C. Wilson saw the case in consulta- 
 tion : diagnosis, either intussusception or perityphlitic abscess. 
 Leeches were applied over the spot of tenderness. 
 
 April 27. — Symptoms continue about the same ; general con- 
 dition poor ; face pale ; features pinched ; beads of perspiration 
 on forehead. I was called and advised operation. At this time 
 his condition was discouragingly wretched, that of a man in the 
 dying stage of purulent peritonitis. At 2 p.m. performed lapar- 
 otomy. The field of operation was cleansed with soap and water, 
 and neighboring hair removed ; the surface was again washed 
 with ether, followed by corrosive sublimate solution (1 to 
 2000). The usual antiseptic precautions were observed as to 
 instruments, and the field was surrounded by towels wet with 
 the mercuric solution. The incision was made directly over 
 the swelling, and, finding the deep muscles infiltrated with pus, 
 it was extended until it measured nearly ten inches; com- 
 mencing just above, and two inches to the right of the umbil- 
 icus, it continued obliquely downward nearly to the pubes. The 
 peritoneum was opened and a free flow of pus followed, having 
 a decidedly fecal odor ; general purulent peritonitis present. 
 In the abscess cavity, near the appendix, was found a fecal 
 concretion about the size of a cherry-stone. The vermiform 
 appendix was greatly swollen, and exhibited a perforating 
 ulcer extending three-fourths around its circumference, and 
 very near to the point of origin. A silk ligature was applied 
 close to the caecum and at the terminal portion of the appen- 
 dix, and the intervening portion, comprising almost the whole 
 organ, was removed, together with a large portion of omentum 
 which projected into the abscess cavity, the walls of which 
 were then scraped with a curette and douched with simple 
 hot (110°) water. The peritoneal cavity was likewise douched 
 
9 
 
 until free of pus, and a drainage-tube was carried into the 
 lowest part of the pelvic basin. 
 
 Following the operation, he entered upon convalescence, 
 which was uninterrupted. He was free from all pain ; the 
 bowels moved naturally. The temperature fell after the opera- 
 tion, and did not again rise above 100°. The drainage-tube 
 was removed piecemeal, the last portion being taken away on 
 the fifteenth day. Went out May 21st. His recovery was as- 
 sured by careful nursing, and by the administration of milk 
 and small quantities of prepared liquid foods. 
 
 CASE II.— APPENDICITIS — PERFORATION — PERITYPHLITIC AB- 
 SCESS—GENERAL PERITONITIS— ABDOMINAL SECTION— EXCI- 
 SION OF APPENDIX— DEATH. 
 
 This case I saw in consultation with Dr. Ed. G. 
 Stone, of Philadelphia, and operated upon it for 
 him. 
 
 Mrs. G. ; set. thirty-four ; mother of one child ; had been per- 
 fectly healthy up to time of last illness, save for occasional 
 attacks of colic, which had readily yielded to anodynes. It was 
 said that she had had a severe attack of pain and vomiting 
 some months before. For two days previous to February 18, 
 1887, she severely exerted herself while the menses were over- 
 due. On that day she had severe abdominal pain accompanied 
 by vomiting. The pain was described as starting in the right 
 hypochondriac region and darting to the umbilicus. No tumor 
 was perceptible, neither was there tenderness upon pressure. 
 Anodynes and counter-irritation were ordered. February 
 19, pain less; no emesis nor rise of temperature; some sore- 
 ness and tenderness to the right of the umbilicus. Pain re- 
 turns as anodyne effects pass off. Bowels have not moved for 
 several days. Abdomen somewhat tympanitic, tongue coated 
 and dry at tip. Evening temperature, 100° ; pulse 90. Treat- 
 ment continued. 
 
 February 20. — Eestless night. Vomits yellow material freely. 
 
10 
 
 Abdomen tympanitic and tender. Temperature 101° ; pulse 
 110. Operation urged but refused. 
 
 February 21, — Symptoms continue. She is more quiet but 
 weaker. Abdomen very large and tender. On the morning 
 of this day I first saw the case, and, although her condition 
 was very unfavorable, urged abdominal section as her only 
 chance for life. My diagnosis was perforated appendix and 
 subsequent peritonitis. 
 
 Free incision was made laterally over the csecal region, and 
 the appendix found greatly enlarged and perforated in two 
 places, each hole measuring a little more than one-fourth inch in 
 diameter. A silk ligature was placed upon the appendix close 
 to the caecum, and the ofiending organ then removed. There 
 was also present difiuse purulent peritonitis. The abdominal 
 cavity was thoroughly irrigated, the region of abscess cleansed, 
 and a drain inserted. She died in a few hours. 
 
 CASE III.— APPENDICITIS— PERFORATION— PERITYPHLITIC AB- 
 SCESS-GENERAL PERITONITIS— ABDOMINAL SECTION— EXCI- 
 SION OF APPENDIX— DEATH. 
 
 On the 13th of January, 1888, 1 was called in consultation 
 with Dr. B. Trautmann, of this city, to a child nine years of 
 age. It seemed that she had suffered from headache, and fre- 
 quent attacks of pain in the abdomen. She attended school 
 until just before Christmas, when she had a severe colicky 
 attack, but subsequent to this was apparently quite well, and 
 on December 31 was out with her sled for several hours. On 
 January 6 she was seized with nausea, abdominal pains, and 
 developed high fever. After this she was so much better that 
 she was down stairs, and ate of sausage and rolls. Soon after 
 she was seized with violent abdominal cramps, the right iliac 
 region being exceedingly painful. Upon January 12 she had 
 an attack of pain which was most excruciating in character. 
 The following day, when I first saw her, the condition was 
 wretched, almost that of collapse, but not to such an extent 
 as to justify denial of her only chance of life, as I had diag- 
 nosticated peritonitis originating in a perforated appendix 
 
11 
 
 and advised operation. Upon making lateral abdominal in- 
 cision, as soon as the peritoneum was opened a great flow of 
 putrid pus took place, then the caecum and appendix came 
 into view ; the latter was greatly swollen, and both it and the 
 caecum were covered with greenish-yellow pyogenic membrane 
 and lymph. The appendix was gangrenous for some distance, 
 and its end had sloughed off. One foreign body was found in 
 the abscess cavity, another was partly held in the sloughing 
 end of the organ, while two other concretions were in the 
 canal near the caecum. The appendix was ligatured at its base 
 and exsected. The whole abdominal cavity and its intestinal 
 contents, which were in a state of purulent inflammation, 
 were then thoroughly inundated with hot water ; a glass tube 
 was carried into the pelvis, and the wound was closed and 
 dressed in the usual manner. The child never reacted fully, 
 but died seven hours afterwards. 
 
 CASE IV.— (Exhibited.) APPENDICITIS — PERITYPHLITIC AB- 
 SCESS—INCISION AND DRAINAGE (1886)— RECURRENCE OF AP- 
 PENDICITIS — PERFORATION — PERITYPHLITIC ABSCESS— AB- 
 DOMINAL SECTION— EXCISION OF APPENDIX— RECOVERY (1888). 
 
 L. A. B., a stout girl, of healthy parentage, and with no 
 family history of caecal or appendicular disease, had a severe 
 fall upon the buttocks in March, 1884. She was almost im- 
 mediately seized with a terrible attack of vomiting and retch- 
 ing, which lasted hours. From this time until September, 
 1885, she suffered with extremely painful menstrual epochs, 
 and from time to time, when tired, had a recurrence of vomit- 
 ing similar to that immediately succeeding her fall. On Sep- 
 tember 10, during the progress of one of these vomiting spells, 
 she experienced severe pains in the right caecal region, the 
 whole seizure lasting about ten days. Another attack devel- 
 oped on September 29, and still others on November 10 and 
 23. The latter was brought on by taking cold, and in five 
 hours she was compelled to go to bed, and endured the most 
 excruciating drawing pain, which radiated from the right 
 caecal region to the shoulder-blade of the same side. Vomit- 
 ing continued for some hours, Emesis then ceased, but the 
 
12 
 
 pains continued off and on until January 10, 1886, when I 
 first saw the patient. A hardening was then present in the 
 right ileo-csecal region. Poultices and mercurial inunctions 
 were ordered, which gave very marked relief. She daily 
 seemed to improve, and before March 19 had resumed her 
 household duties. On that date she was much overworked 
 in caring for company, and about midnight was seized with 
 torturing pains in the region of the hardening. These con- 
 tinued until April 3, 1886, when I incised the now greatly 
 enlarged mass, liberated a large quantity of fetid pus, and 
 introduced a drainage-tube. There was apparently no commu- 
 nication with the caecum or its appendix. The tube remained 
 for a long time, and the wound did not completely close until 
 August. Her condition, however, had meanwhile improved 
 amazingly, and she was soon quite herself again, being up 
 and about the house in four weeks. 
 
 After this, especially when tired out or at a menstrual 
 period, the patient suffered with pain localized about the 
 csecal region. The attacks resembled colic. Three months 
 after operation she had quite a severe attack of local pain 
 which lasted a number of hours. These attacks, at long in- 
 tervals, presented about the same characteristics. The last 
 occurred in January, 1888, which was accompanied by more 
 severe pain than any of the others. 
 
 During the evening of Friday, March 15, of the same year, 
 she was taken with violent vomiting and purging. These 
 symptoms continued all night, and through Saturday, when 
 the pain was most intense. On Sunday her symptoms ap- 
 peared grave. Pain was increased on pressure in the right 
 ileo-csecal region. Abdomen soft; fever; rapid pulse and 
 dry tongue. On Monday the symptoms continued the same, 
 with a temperature of 102°. In the afternoon the general 
 symptoms were more serious. No tumor could be felt, pain 
 increased. Skin was bathed with sweat. There was marked 
 resonance over the part. On Tuesday the pulse was feeble, 
 nausea and occasional sick stomach prevailed. The other 
 symptoms remained about the same ; diagnosis of perforated 
 appendix with abscess was then made. The same morning 
 
13 
 
 she was etherized and the usual lateral incision, five inches 
 long, was made. This came about an inch further externally 
 than the line of incision of the first operation. The deep 
 tissues of the abdominal wall were somewhat oedematous, 
 and just before the peritoneum was reached a large quantity 
 of most fetid pus was liberated. At the base of this cavity 
 the caecum and appendix were clearly visible. The latter was 
 enormously enlarged and thickly covered with lymph and 
 abscess-lining membrane. A large opening in the abscess 
 wall communicated with the cavity of the general peritoneum. 
 Through this small intestines were forced when she coughed. 
 
 The appendix was firmly attached to the caecum, from 
 which it was separated with some difficulty. It was then 
 firmly ligatured with a stout silk at its junction with the caecum 
 and excised. The communication with the general perito- 
 neum was then enlarged by tearing, and through it the intes- 
 tines were most thoroughly washed by means of hot water 
 irrigations. The abscess cavity proper and surrounding parts 
 were sponged with one to one thousand mercuric solution. A 
 glass drainage-tube was then carried to the bottom of the pelvis 
 and brought out through the lower angle of the wound, while 
 a larger rubber tube drained the abscess cavity proper and 
 emerged at the upper extremity of the wound. 
 
 The incision was then closed and an antiseptic dressing 
 applied. She reacted well. On the following day immense 
 swelling necessitated cutting of all the stitches, whereupon 
 the caecum lay in full view at the bottom of the wound, but 
 no prolapse of intestine at any time took place. 
 
 Great sloughs kept coming away for many days, also much 
 pus, in spite of every eflbrt to keep the wound aseptic. The 
 deep glass or pelvic drain became dry on the fourth day and 
 was removed on the fifth. From that time the wound was 
 kept lightly packed with antiseptic material and rapidly gran- 
 ulated to the surface, when a few strips of rubber plaster were 
 applied and cicatrization became complete. 
 
 Patient's bowels, from time of operation, were kept in a 
 freely moving condition by means of citrate of magnesia and 
 enemata. In less than a month the patient was well, and has 
 
14 
 
 since married. The appendix was found to be the seat of a 
 very large perforating ulcer, situated near its caecal attach- 
 ment, but no foreign body was discovered. 
 
 Eighteen months after operation, as result of immense 
 obesity and continued bronchial cough, a hernia of consider- 
 able dimensions appeared beneath the double cicatrix. This, 
 however, has not increased in size; is easily kept reduced by a 
 truss, and gives the patient scarcely any annoyance. 
 
 CASE v.— (ExMbited.) APPENDICITIS — PERITYPHLITIC AB- 
 SCESS— PERFORATION— LAPAROTOMY— EXCISION OF THE AP- 
 PENDIX—GANGRENE OF THE C^CUM— FECAL FISTULA— RE- 
 COVERY. 
 
 Seen in consultation with Drs. Eich and Sailor, 
 of Williamsport, Penna. 
 
 J. W. C, seventeen years of age, usual weight one hundred and 
 eighty pounds, had a severe attack of ileo-caecal pain some time 
 in November, 1887, while at school, which laid him up for three 
 days, and in the following spring he had a similar but less severe 
 attack. On July 4, 1888, he indulged in an enormous amount 
 of peanuts and cherries, but felt no special inconvenience, save 
 constipation, until three days subsequently, when he experi- 
 enced colicky pains and had a somewhat watery stool. For 
 two days there was some looseness of the bowels associated with 
 severe cramps. At this time there developed great tenderness 
 in the right iliac region and he could not stand erect. On 
 July 11, a telegram from Williamsport, Pa., reached me at 
 Newport, E. I., but I was not able to reach the patient until 
 the 13th, when I found him in a most serious condition. Al- 
 though he had symptoms of obstruction, yet the diagnosis of 
 perforation of the appendix, abscess, and peritonitis was in- 
 stantly made. The pain, violent variations of temperature, 
 profuse sweating, and profound exhaustion indicated pus, 
 while the previous history of attack of colic and pain in the 
 ileo-csecal region, all pointed to the appendix as the source 
 of trouble. 
 
 I promptly made a lateral abdominal section, evacuated an 
 
15 
 
 abscess of considerable size, and soon came upon a perforated 
 appendix, which was closely attached to the caecum its entire 
 length. The end of the appendix had sloughed off, and in 
 this disorganized tissue I found a large oval fecal concretion, 
 which evidently had been the cause of the disturbance. Two 
 very large portions of omentum were so constricted by lymph- 
 bands that gangrene had occurred, and there was general 
 peritonitis. The appendix was tied and cut off close to its 
 csecal attachment ; two large portions of the gangrenous omen- 
 tum were removed, and the abscess cavity cleansed, as were 
 likewise the entire abdominal contents. The csecum had very 
 much the shape and feel of a sausage, was firm and dark in 
 color, and bound down as the result of inflammation. Thor- 
 ough drainage of the abdominal cavity was secured by a glass 
 drainage-tube passing to the bottom of the pelvic cavity, 
 while a rubber tube drained the abscess proper. 
 
 No attempt was made to approximate the wound, but its 
 cavity was lightly packed with antiseptic gauze, with the 
 usual dressing upon the abdomen. 
 
 The patient did fairly well after the operation ; took food 
 well, but there was no action of the bowels. Two days later 
 he had marked rise of temperature and great restlessness ; 
 passing water frequently, and had almost constant desire to 
 evacuate the bowels, but without succeeding in doing so. In 
 response to a telegram stating that the patient was desperately 
 ill, my son. Dr. T. S. K. Morton, went to Williamsport, and 
 upon examination discovered an impaction of faeces in the 
 large bowel which extended from caecum to anus. After some 
 twelve hours' work with the rectal tube and half-hourly doses 
 of calomel and podophylliu, the colon was cleared of several 
 pounds of fecal matter, and the patient's condition immedi- 
 ately became much improved, and continued to do so steadily 
 until convalescence took place. At the time of the impaction 
 it was discovered that fecal matter was passing into the ab- 
 dominal wound, and examination showed that the caecum had 
 given way, for two gangrenous spots were found, each about 
 half an inch in diameter, on the uppermost part of the ex- 
 posed bowel. These soon coalesced into one opening. Sub- 
 
16 
 
 sequently the patient rapidly improved and regained his usual 
 rugged health. The wound of operation and fecal fistula 
 closed naturally in five months. 
 
 CASE VI. — (Exhibited.) APPENDICITIS — PERITYPHLITIC AB- 
 SCESS — PERFORATION — LAPAROTOMY — EXCISION OF THE 
 A PPENDI X— RECOVERY. 
 
 H. A. R., aged fifty-two ; has always had good health, with 
 the exception of a mild attack of bronchitis several years ago, 
 which did not confine him to bed. Four months ago he had 
 the first attack of pain in the right ileo-caecal region ; this 
 had since recurred several times. The pains generally 
 awakened him at night, but usually were soon relieved by 
 stimulants. Pressure over the csecal region always increased 
 his sufiering. On September 4 he called upon Dr. Bernard 
 Bereus, of this city, and complained of being stifi" and sore 
 all over, particularly in thighs and abdomen. His tongue 
 was furred, pulse 72, skin moist. Was ordered calomel and 
 opium. On the 6th he called again, with more abdominal 
 pain which was diffuse, but this time not increased by pressure. 
 Some difficulty in walking and some anorexia were present, 
 but not enough to prevent him from attending to business. 
 On the 7th he again saw Dr. Bereus, when his condition was 
 found to be more serious. He had great pain in the abdomen, 
 and now had tenderness on pressure ; pulse 72 ; skin dry ; was 
 obliged to leave his business office at noon, and took to bed. 
 At 8.30 that evening he had rigors, but not a full chill ; pulse 
 98, temperature 102f °, skin hot, tongue dry, abdomen distended, 
 tympanitic, and tender to touch over its entire surface. On 
 the 8th, had passed a good night with morphine ; bowels were 
 freely moved by sulphate of magnesia ; condition of abdomen 
 unchanged ; morning temperature 100|° ; evening temperature 
 103°. The next day, September 9, condition about the same 
 except increased pain over the appendix region. On the 10th, 
 the morning temperature was 101° ; pulse 92 ; facial appearance 
 dusky ; pain especially severe in right iliac region with well- 
 defined fulness, and intense pain on pressure at that point. 
 
17 
 
 From the intense pain, more especially over the appendix, 
 the slight sweat, the fluctuating temperature, the anxious 
 facial expression, depressed appearance and gradual increase 
 of symptoms, the diagnosis of typhlitic abscess and peritonitis 
 was made. At 12.30, the same day, I saw the patient, con- 
 firmed the diagnosis, and at once made preparations for 
 evacuating the abscess and excising the appendix, which 
 was believed to be the subject of perforation. At 4.30 p.m., 
 the usual lateral incision was made, six inches in length, di- 
 rectly over the site of the appendix. The abdominal walls 
 were very thick, and it was not until the caecum was reached 
 that pus was found. This was exceedingly offensive and in 
 considerable amount. It had worked its way into the right 
 side of the pelvis. With some diflBculty the under surface 
 of the csecum was brought into view and two very similar 
 masses of tissue, either one of which might, from its appear- 
 ance, have been taken for the appendix, were found lying near 
 each other and quite firmly attached to the under part of the 
 csecum. These masses seemed made up of fat and cellular 
 tissue, and were about two inches long, judging from the 
 position of the one nearest the caput coli, and the position 
 the appendix should occupy, this one was carefully separated 
 from the intestine, and a ligature placed upon it as near its 
 csecal attachment as possible, and it was then cut ofi*. It 
 proved to be the appendix embedded in lymph. A ragged 
 perforation was found in it about one-fourth of an inch from 
 its distal end. The second intestinal appendage proved to be 
 an hypertrophied epiploic body. There was considerable 
 recent lymph surrounding the appendix and colon. The ex- 
 posed parts were carefully curetted and douched. During the 
 search for the appendix, and subsequently in the course of the 
 operation, intestines protruded considerably. The abdominal 
 cavity was very thoroughly washed out ; and, subsequently, 
 a glass drainage-tube was placed at the bottom of the pelvis, 
 a large rubber drain was also placed up along the ascending 
 colon. With some difficulty the intestines were returned, 
 and the wound was finally brought together with silk thread. 
 The temperature, three hours after the operation, was 101 1°, 
 
 2 
 
18 
 
 but gradually lessened, never reached 101° again, and on the 
 tenth day was normal. 
 
 Three hypodermic injections of one-sixth of a grain of mor- 
 phine were administered to relieve pain, two at intervals of 
 five hours after the operation, and the last one eight hours 
 subsequently. Calomel in doses of one-sixth of a grain was 
 given every hour after operation until the bowels moved very 
 freely. Milk, coffee, and champagne, in small and frequently 
 repeated doses, were given from the first, also twelve grains 
 of quinine daily. 
 
 Great tension of the wound necessitated cutting away the 
 sutures on the second and third days, after which large sloughs 
 kept coming away for ten days. Healing by granulation took 
 place. Glass drain worked out on twelfth day ; the rubber 
 one on the fifth day. 
 
 The wound was dressed and fresh cotton placed in the glass 
 drain every four hours for the first five days, and gradually 
 the dressings were changed morning and evening only, until 
 final cicatrization occurred. 
 
 Convalescence was uneventful and rapid. 
 
 CASE VII.— (Exhibited.) PERFORATIVE APPENDICITIS— AB- 
 SCESS— LAPAROTOMY— EXCISION OF THE APPENDIX— RECOV- 
 ERY. 
 
 On November 5, 1889, I saw in consultation with Dr. 
 C. H. Shivers, of Haddonfield, New Jersey, and Dr. J. T. 
 Hampton, of this city, Lemuel O., a lad of eleven years 
 of age, who, a few days before, when playing in the garden, 
 had been accidentally struck in the right iliac region by 
 the handle of a spade. Intense pain followed ; but the boy 
 was not wholly confined to his bed until the day subse- 
 quent to the injury ; on the fifth day there was a tempera- 
 ture of 101|°, pulse 120, respiration 44, dry tongue. Eight 
 iliac region was very tense, swollen, and exceedingly painful 
 to the merest touch ; there was no pain in any other part of 
 the abdomen, no localized tumor, and not the least dulness 
 on percussion; the bowels had been kept open by salines. 
 The boy had two days before a slight but positive rigor, which 
 
19 
 
 was followed by decided perspiration ; careful inquiry brought 
 out the fact that, on very many occasions during the previous 
 two or three years, he had had sudden attacks of colic, which 
 had been ascribed to "internal hernia." The pain had al- 
 ways been located in the appendix region. During the inter- 
 vals of the attacks he had been quite well. With this history, 
 I felt convinced that there had been chronic appendicitis, with 
 probably a foreign body in the organ, and that the injury 
 produced by the blow of the spade-handle had lighted up an 
 attack of acute inflammation in the already diseased appen- 
 dix, which, becoming ulcerated, had ended in perforation ; and 
 although all the symptoms of abscess were not present, yet 
 that unqestionably pus had formed, and, since the patient had 
 progressively grown worse, danger of extension of inflamma- 
 tion or of the abscess opening into the peritoneal cavity was 
 very great. Hence I was able to confirm Dr. Shivers's able 
 diagnosis, and to urge — as he had already done and for which 
 I had been summoned — an immediate operation. Lateral 
 abdominal section was performed on November 6. The 
 incision began an inch above the middle of Poupart's liga- 
 ment, and was continued upward and outward four inches ; 
 on reaching the colon (the tissues were all normal so far) and 
 turning it up in search of the appendix, an abscess was found 
 which contained an ounce and a half or two ounces of very 
 fetid pus. The appendix was found glued to the caecum ; it 
 was enlarged, thickened, covered with lymph, and presented 
 a perforation about a quarter of an inch from the extremity. 
 In the perforation was found a small fecal concretion. A 
 silk ligature was placed on the appendix close to its root, and 
 the distal extremity was excised. The peritoneal cavity was 
 then flooded with large quantities of recently-boiled water ; 
 a large glass drain was carried through the coils of the intes- 
 tine to the bottom of the pelvis, and a rubber drain was placed 
 in the abscess cavity alongside of the colon ; then the wound 
 was brought together with silk sutures, and a dressing, held 
 in place by a four-tailed binder, was applied. Milk was given 
 at short intervals, and the bowels were kept freely open by 
 calomel and salines. Convalescence was uninterrupted. The 
 
20 
 
 day following the operation there was great tension of the 
 wound, and all the sutures were cut, leaving the wound gap- 
 ing open. Peroxide of hydrogen worked like a charm in 
 keejDing the wound and drain sweet and clean and in assisting 
 slough separation. 
 
 The rubber drain was taken out on the third day, and the 
 glass drain worked out on the ninth day. The wound was 
 closed on the twenty-eighth day, and the boy was about the 
 house during the fifth week. 
 
 In presenting the foregoing cases, I feel war- 
 ranted in making a few practical observations 
 upon the operation of removal of a diseased appen- 
 dix ; its relations to typhlitis and peritonitis ; and 
 especially upon the time and indications for opera- 
 tion, with the details of treatment before and after 
 operation. One thought naturally presents : it is, 
 that only a short while ago, under the ideas then 
 prevailing with regard to the treatment of such 
 cases, each of the patients here presented either 
 would have perished, or would be living in constant 
 fear of the repetition of an attack which might at 
 any time prove fatal. If we review the progress of 
 this operation of exposing the diseased appendix 
 and excising it, thus removing the cause of repeated 
 attacks in simple or in perforative appendicitis, it 
 is interesting to note the gradual development of 
 the procedure. 
 
 Mr. Hancock, of London,* in 1848, appears to 
 have been the first to urge operative interference 
 in perityphlitic abscess by free incision and drain- 
 age, but this did not meet with much favor until it 
 
 * London Medical Gazette, 1848, p. 547. 
 
21 
 
 received the endorsement and able advocacy of 
 Willard Parker,* in 186,7. 
 
 In 1878, Sands, of New York, v^as able to report 
 twenty cases treated in this way, and in 1883, 
 William Pepper, at a meeting of the Pennsylvania 
 State Medical Society, presented the statistics of 
 one hundred cases contributed by l^oyes, of Rhode 
 Island. From these, and numerous other con- 
 tributions to the literature of the subject, it was 
 fully and finally demonstrated that surgical inter- 
 ference in cases of so-called perityphlitic abscess 
 largely reduced the mortality of this afi*ection. 
 This was a decided step in advance upon the old 
 method of non-interference, which, strange though 
 it may appear, is still advocated in some medical 
 text-books. Surgical writers, on the contrary, now 
 generally urge early operation, which, as has been 
 shown, does not increase the risk to the patient, 
 but places him in a position greatly more favora- 
 ble to recovery. 
 
 After the remarkably successful abdominal sur- 
 gery of Tait, Keith, and others had shown that 
 the peritoneal cavity might be opened and ex- 
 plored with comparative impunity, it was but 
 natural that surgeons should be led to apply the 
 same rules to the treatment of perityphlitic ab- 
 scess, and open it more freely than before; then 
 to explore its cavity, examine the vermiform ap- 
 pendix, and to amputate this unnecessary and 
 dangerous organ when the subject of appendicitis 
 
 * Medical Kecord, New York, 1887. 
 
22 
 
 or ulceration, whether perforating or not. This 
 has been the final step in the operative treatment 
 of perityphlitis. 
 
 To the diagnosis, indications for operation, and 
 details of treatment before, during, and after sur- 
 gical interference, I shall now direct attention. 
 
 Diagnosis. — One of the earliest and most constant 
 symptoms of acute appendicitis is pain, which may 
 be slight or stabbing in character, and usually is 
 increased very much by pressure. It comes on in 
 attacks or paroxysms (which may be years or months 
 apart), during which there may be nausea and even 
 vomiting, but not necessarily. The temperature is 
 slightly elevated ; constipation is commonly present; 
 the pulse is generally accelerated; the ileo-csecal 
 region may be tympanitic, or it may be more or 
 less dull. These symptoms sooner or later may 
 disappear, and convalescence be established, but a 
 relapse or recurrence would indicate that a source 
 or irritation continues. After a variable period 
 the attack is renewed, and perhaps with graver 
 symptoms, or, during an apparently mild attack, 
 the sudden advent of violent, local, and constitu- 
 tional symptoms announces very positively the oc- 
 currence of inflammation of the appendix, with 
 pus-formation, or peritonitis. 
 
 The fact of occurrence of an attack of appendi- 
 citis, although apparently entirely recovered from, 
 is serious enough to give rise to apprehensions for 
 the future; for the patient is liable at any time, 
 from a blow, fall, undue exercise, straining, indi- 
 gestion, or even without apparent cause, to have a 
 
23 
 
 recurrence of irritation in the appendix, which 
 may terminate in inflammation, ulceration, and 
 perforation. The number of attacks or relapses 
 or recurrences before ulceration takes place varies, 
 but when several have occurred it is almost cer- 
 tain that the appendix is seriously diseased. After 
 one or more attacks the patient may remain ap- 
 parently well, but as a rule this is not the case, and 
 attack upon attack at gradually shortening inter- 
 vals very conclusively demonstrate that the appen- 
 dix is the source of the trouble, and that perfora- 
 tion, if not actually present, is liable to occur at any 
 time. The subject of such an attack may occasion- 
 ally recover without surgical interference, through 
 atrophy of the organ or adhesion to the caecum with 
 more or less complete obliteration of its calibre. 
 But such a favorable result must be the great 
 exception in the vast number of cases, and its oc- 
 currence in any given case cannot be depended 
 upon. 
 
 In cases presenting the symptoms above men- 
 tioned, pain, tenderness, deep swelling, or tympan- 
 ites in the appendix region, associated with pros- 
 tration, nausea, fever, and constipation, these phe- 
 nomena coming on suddenly, and especially where 
 there has been a history of previous attack, — such 
 an array of symptoms would warrant the diagnosis 
 of appendicitis. When to these symptoms is added 
 a sudden accession of intense pain increased on 
 pressure in the right iliac region, with perhaps 
 moderate pain over the rest of the abdomen, a 
 fluctuating temperature reaching 102° or perhaps 
 
24 
 
 higlier, slight rigors or decided chills, moderate 
 perspiration or decided sweating, and an increase 
 of tympany over the pericsecal region, unquestion- 
 ably there will be found pus. 
 
 It is also usual in abscess formation to have a 
 dusky or sallow skin, an anxious expression, and 
 prostration. 
 
 In a case presenting the symptoms of pus, with 
 a history of former attacks of pain, or relapses, it 
 is certain that we have to deal with an abscess, the 
 result of appendix perforation. 
 
 In case of doubt, rectal exploration might be 
 cautiously resorted to, but, owing to the sigmoid 
 flexure being attached upon the left side, it would 
 only rarely occur that this could yield any positive 
 information. 
 
 In a small recent abscess it is scarcely probable 
 that it could be discovered through the rectum, 
 while if the abscess was large and encysted there 
 would be no difficulty in detecting it through the 
 abdominal walls. 
 
 The use of the aspirating needle I mention but to 
 condemn. It should never be used, for, if it does not 
 find pus we cannot be sure that none is present, 
 while its own dangers are not inconsiderable. It is 
 in these cases a poor and especially unsafe diag- 
 nostic resource. 
 
 Differential Diagnosis — From Disease of the Ccecum. 
 — From disease of the csecum the diagnosis of ap- 
 pendicitis cannot always be clearly made, so close is 
 their relation ; both giving rise to local disturbance 
 in the right iliac region. 
 
25 
 
 In the region under consideration we have the 
 caecum and vermiform appendix, both are invested 
 through more or less of their extent with peri- 
 toneum ; both organs are subject to irritation, in- 
 flammation, ulceration, and perforation. While it 
 is extremely rare to have a perforation of the ccecum, 
 it is just the reverse as to the appendix. Abscess 
 around the csecum in almost every case is due to 
 appendix disease; even in those cases where csecal 
 perforations have occurred it is highly probable 
 that they may have resulted from previous ap- 
 pendix perforation or disease. One such case came 
 under my observation. On the second day after 
 the removal of a gangrenous appendix, faeces came 
 from the wound in considerable amount, and upon 
 careful inspection two gangrenous perforations were 
 found involving the anterior and lower part of the 
 caecum. At the time of the appendix-removal the 
 caecum and colon were somewhat impacted, and 
 the violent inflammation about the appendix had 
 extended to and involved the intestines, gangrene 
 resulting, due in part to contiguous inflammation 
 and also in part to impaction. But if this abscess 
 cavity had been simply opened and the appendix 
 not reached, the subsequent appearance of faeces 
 would at once have established the diagnosis of 
 simple caecal perforation, while the appendix dis- 
 ease would have been overlooked. So that in sup- 
 posed caecal perforations, primary ulceration of the 
 caecum being extremely rare, the probability is that 
 it is secondary to appendix disease. 
 
 Between perforative caecitis and perforative ap- 
 
26 
 
 pendicitis, the history of previous attacks of pain 
 would make the diagnosis in favor of the latter; 
 even without the history of relapsing typhlitis, it 
 would be fair to accept the diagnosis of appendix 
 disease, for csecal perforations are exceedingly rare 
 indeed, but three or four such cases have, it seems, 
 been reported and verified by post-mortem. The 
 necessity for abdominal section is the same in both, 
 so that the diagnosis can be left open in cases of 
 uncertainty until section is made. 
 
 From Acute Intestinal Ohsti^ciion. — A careful ex- 
 amination of the patient will usually exclude fecal 
 impaction, intussusception of the bowels, internal 
 strangulation, or volvulus. In ordinary fecal im- 
 paction there are no general symptoms, although 
 there may be nausea or vomiting; there is no 
 special pain or tenderness, and the outline of the 
 colon can be made out by palpation. There is 
 usually a history of increasing constipation for 
 weeks or months previous. Intussusception is 
 accompanied by frequent desire to empty the 
 bowels, with discharges of mucus or blood; the 
 tumor is sausage-shaped and is not very tender; 
 and the true character of the case may often be dis- 
 covered by rectal examination. In volvulus there 
 is more pain, but it is referred to the neighborhood 
 of the umbilicus ; there is neither pain nor tender- 
 ness in the iliac region. Strangulation may be 
 caused by diverticula and frequently by constriction 
 bands, the sequence of former peritonitis. The in- 
 testines may be adherent to the omentum and be- 
 come revolved upon it. In one case an adherent 
 
"11 
 
 appendix vermiformis strangulated the ileum. Ob- 
 struction may also be simulated by enteritis or 
 peritonitis, owing to the paralyzing effect upon the 
 bowel. When the obstruction is intestinal the 
 symptoms advance very rapidly, even more so than 
 in appendicitis. 
 
 From Spinal or Perinephritic Abscess. — Attention 
 to the history of the case and to the local signs 
 of disorder will enable us to diagnosticate these 
 forms of abscess. The treatment being almost 
 identical, at least as far as laparotomy is con- 
 cerned, we need not waste much time in making 
 refinements of diagnosis, although such diagnosis 
 can generally be made. In the following case, 
 it was not positively made until some time sub- 
 sequent to the operation. 
 
 In !N"ovember, 1888, 1 saw in consultation with Dr. 
 Bartleson, of Clifton Heights, a young man twenty- 
 eight years of age, who had been confined to his bed 
 for three weeks, and presented symptoms of pus 
 formation in the inguinal region. His temperature 
 fluctuated between 100° and 104° ; he had sweatings 
 and pronounced chills; yet the pain, which was 
 local, was not severe, but it was increased by press- 
 ure. He had no history of former pain in the 
 appendix region. There was, however, a tumor 
 which could readily be made out, but at a consider- 
 able depth : I decided to explore this by operation. 
 Incision opened into an abscess, but the cavity 
 seemed closed, and it was not so deep as I had 
 usually found in suppurative appendicitis. N"either 
 the caecum nor the appendix came into view, nor 
 
28 
 
 could they be found in the cavity or its borders. 
 The pus-cavity was drained, and subsequently 
 closed. The case subsequently proved to be one 
 of psoas abscess, originating in the lumbar verte- 
 brae, but no positive diagnosis could be made for 
 several months after operation, by which, neverthe- 
 less, he was completely cured of both abscess and 
 the spondylitis. 
 
 In psoas abscess, especially in young children, 
 some difficulty may be experienced, at times, in 
 differentiating it from pericsecal inflammation. But 
 in the former there is generally a history of long- 
 present ill-health and pain in the dorsal region, 
 usually with symptoms of vertebral disease (z.e., 
 gastric irritation, intercostal pains, constriction 
 band, or pains in the thighs). The pains are 
 colicky and associated with flatulence; and there 
 is more or less pain or irritation of the bladder. 
 Abscess from disease of bodies of the spine generally 
 points in the groin, either just above or below 
 Poupart's ligament ; it is associated with a history 
 of ill-health, and difficulty in walking. Iliac ab- 
 scess may occur unconnected with the spine or 
 cgecum, arising within the abdominal cavity near 
 the spine. In such cases the symptoms of systemic 
 disturbance are quite decided: chill, more or less 
 pronounced, with hectic fever and night-sweating 
 are very apt to occur. As soon as the existence 
 of pus is recognized, an exploratory incision should 
 be made in order to detect the source if possible. 
 
 Tumors may appear in this region, both malignant 
 and non-malignant, and their nature may be in- 
 
29 
 
 ferred from their physical characters and the clini- 
 cal history, which shows their gradual increase in 
 size, etc. 
 
 The history of the mode of onset or invasion 
 of the disease will be of service in making its diag- 
 nosis. Strangulation of the bowel, intussuscep- 
 tion, peritonitis, volvulus, generally come on very 
 suddenly. Impaction of faeces, psoas or iliac ab- 
 scess, and tumors come on gradually. Csecitis 
 and perforative ulcer of the caecum are also more 
 or less rapid in their course, and point superficially 
 more quickly than does the abscess to which appen- 
 dicitis gives rise. 
 
 Treatment. — The treatment of pericsecal inflam- 
 mation, no matter whether its origin is in or about 
 the caecum or in the appendix, may be divided into 
 two divisions : that of the pre-purulent and that of 
 the post- purulent stage ; or, first, before formation 
 of pus or of appendix-perforation ; and, secondly, 
 after that event. 
 
 The treatment of the pre-purulent, irritative, 
 catarrhal, or simple inflammatory disorders of the 
 caecum, its surroundings, or the appendix, should 
 consist in absolute rest in bed, restriction of diet to 
 nourishing liquids, hot poultices or fomentations 
 frequently replaced upon the parts, perhaps local 
 depletion, and possibly the hypodermic exhibition 
 of morphine to control pain; while the bowels 
 should be kept open and free from accumulations 
 of gas and faeces by the administration of calomel 
 or salines and enemas. 
 
 Prompt resolution should take place in cases 
 
30 
 
 which are not to go on to the stage of pus-forma- 
 tion. Tedious recovery, relapse, or recurrence of 
 symptoms, would point to the probable presence of 
 conditions exceedingly dangerous to the patient 
 from the liability to general peritonitis or perfora- 
 tion at any time, and further, they would point, as 
 a rule, to the appendix as the source of irritation 
 and danger. 
 
 That treatment of pericsecal inflammation which 
 places the bowels " at rest" from the start, or in 
 " splints," commonly so called, has probably been 
 the cause of more serious, often fatal, results than 
 can well be estimated. The use of opium without 
 question masks the symptoms which indicate pus- 
 formation, causing loss of diagnostic symptoms and 
 of valuable time at a most critical period ; the 
 apparent improvement due to lack of pain, often 
 causing postponement of operative interference 
 until the patient is practically in a hopeless con- 
 dition. Intense pain is more often an indication 
 for operation than for morphine; the knife will 
 remove both pain and danger and give radical 
 relief for all time, as recurrence cannot occur when 
 the cause of the malady, the appendix, has been 
 removed. 
 
 In the second division, the process has gone be- 
 yond the simple irritative or inflammatory stage and 
 pus has formed. 
 
 Pus in contact with, or in the cavity of, the 
 peritoneum (and such is precisely the situation in 
 abscess surrounding the appendix or caecum) is 
 vastly more serious than would be an abdominal 
 
31 
 
 section for its relief. So, the diagnosis of pus 
 having been made, apd, indeed, often without posi- 
 tive diagnosis, operation is positively indicated ; 
 many other risks are to be taken rather than those 
 of general purulent peritonitis, for early interfer- 
 ence will save almost if not all cases from this 
 much-dreaded complication, while the danger of 
 operation becomes slight compared with that of 
 general abdominal inflammation. 
 
 Local or general peritonitis supervening in a 
 person who has a history of caecal trouble would 
 more than justify operation. 
 
 At a later, or even, perhaps, in the chronic stage of 
 the disorder, all available diagnostic skill must be 
 exerted when pericsecal abscess may have pointed in 
 an anomalous situation, and we must ever adhere 
 to the modern surgical rule, always to attack pus 
 at its source if possible. When the caecum is nor- 
 mally placed, this is always feasible, if the disease 
 be recognized. 
 
 Preparation for the Operation. — There is generally, 
 from the very nature of the case, very little time 
 for any special preparatory treatment. 
 
 The field of operation should be made clean with 
 soap and water, then shaved, washed with ether or 
 turpentine, soapsuds again, and then douched with 
 a mercuric bichloride solution (1 to 1000) ; the um- 
 bilicus having been carefully cleansed and its cavity 
 rubbed with iodoform. 
 
 If possible, the disinfecting process should be 
 completed some hours before, and the abdomen 
 kept covered with a wet bichloride dressing. The 
 
32 
 
 field of operation should be protected by towels 
 wrung out of hot mercuric solution. 
 
 The instruments should be treated by boiling, 
 and then kept in a three-per-cent. carbolic acid so- 
 lution, or used from cooled boiled water. 
 
 The operator and his assistant — one is sufficient — 
 should likewise observe the rules of strict antisepsis, 
 which should rigidly prevail throughout. 
 
 Operation. — The line of abdominal incision should 
 be lateral, not median. The advantages of the for- 
 mer are very obvious and positive. It is made di- 
 rectly over the appendix region and abscess cavity. 
 If a median incision were made the peritoneal cavity 
 would not only be often needlessly opened, but the 
 section would be at a point remote from the caecum 
 and appendix, in a position in which they cannot 
 well be reached. Indeed, it would often be quite 
 impossible to deal with a diseased appendix unless 
 the incision were lateral, for the difficulties ex- 
 perienced in bringing into view and separating 
 this organ when it is firmly bound by adhesions to 
 the caecum, as is often the case, are not inconsider- 
 able. If pus have gained access to the peritoneal 
 cavity, or the intestines come to view, thorough 
 cleansing can be effected as well by a lateral in- 
 cision, while the sloughs of cellular and other 
 tissues, which always may be expected from the 
 abscess cavity and surrounding parts, can more 
 readily discharge through an opening contiguous 
 to the disease. 
 
 Usually there occurs within a few hours after 
 operation great swelling of the wound and ileo- 
 
33 
 
 csecal region. This requires removal of the sutures ; 
 the wound gapes and the caecum is fully exposed, 
 but the latter is held naturally in position, and 
 there is no danger from intestinal protrusion; 
 drainage by such a free opening is proportionally 
 favored. 
 
 The incision should be from four to six inches in 
 length and correspond with the appendix region ; 
 it should extend from an inch above the middle of 
 Poupart's ligament upward through the right linea 
 semilunaris and down until peritoneum, csecum, 
 or pus is reached. Occasionally pus is not dis- 
 covered until the caecum is displaced, when the 
 abscess cavity and the appendix come in view. 
 Bleeding should be arrested by the use of haemo- 
 static forceps and the application of hot water. 
 
 I have found that the appendix is normally 
 situated immediately under a point two inches dis- 
 tant from the right anterior superior iliac spinous 
 process, on a horizontal line drawn from this pro- 
 cess towards the median line of the body, so that 
 this incision is directly over the organ. When the 
 abscess cavity is reached, gas may be first discharged, 
 then, when pus, which is always offensive, has been 
 reached and sponged or washed away, the appen- 
 dix is found either lying free or attached to the 
 caecum or abscess wall. It is not always an easy 
 matter to distinguish the appendix ; on one occasion 
 this organ and an epiploic appendage, both of the 
 same size, and resembling each other in general ap- 
 pearance, were side by side and both firmly glued 
 to the caecum. The most inferior of these bodies 
 
34 
 
 was correctly judged to be the appendix. The 
 anatomical relations will always differentiate the 
 appendix. 
 
 Irrigation with recently boiled or distilled water 
 at a temperature of 105° to 110° gives a clear view of 
 the surroundings of the caecum and its appendix ; at 
 this time it may be necessary to enlarge the wound 
 in order to obtain sufficient space to conduct the 
 necessary manipulations ; this will be found es- 
 pecially indicated when the appendix is more or 
 less firmly glued to intestine. 
 
 The appendix is practically always found to be 
 the seat of trouble ; in any case it should be ex- 
 cised, — unquestionably so if swollen, inflammed, 
 perforated, containing masses of faeces, or harbor- 
 ing foreign bodies. 
 
 The removal of the appendix after gently freeing 
 it from any adhesions which it may have formed 
 can best be accomplished by ligaturing it close to its 
 csecal attachment with a silk ligature, and excising 
 it just outside the point of ligation. If the general 
 peritoneal cavity has not been involved by the ab- 
 scess nor during the necessary manipulations of ex- 
 cising the appendix, the abscess cavity should simply 
 be washed out with a mercuric chloride solution (1 
 to 1000), and a good-sized rubber drainage-tube 
 carried to the bottom of the cavity, and brought 
 out near the most dependent part of the wound. 
 In all of the cases which have come under my 
 care the peritoneal cavity has been invaded by pus, 
 either before or during the operation, so that the 
 entire abdominal cavity had to be thoroughly 
 
35 
 
 cleansed and drained. Irrigation of the abdomi- 
 nal cavity can best be accomplished by a fountain 
 (or other form of) syringe, carrying sterilized 
 water of a temperature of 105° to 110°. Every 
 part of the abdominal cavity should be thoroughly 
 and repeatedly drenched if pus has entered it. 
 
 Should far-advanced peritonitis be found, the in- 
 testines must be withdrawn, and all adhesions parted 
 with the finger or knife during the process of 
 cleansing and before they are returned to the peri- 
 toneal cavity. 
 
 In any abscess of the ileo-csecal region we should 
 always suspect appendix disease, and an effort should 
 always be made to expose this organ. In no case 
 should a simple evacuation of pus be considered 
 sufficient, especially if the history of the case pre- 
 sented any account of probable, former appendix 
 trouble. A case of this character came under my 
 care, in which at first, in 1885, I simply evacuated 
 an abscess situated in the ileo-caecal region, and 
 made no investigation of the appendix, as the ab- 
 scess cavity seemed a closed one. Three years 
 later I was obliged to make abdominal section and 
 remove a diseased appendix, which undoubtedly 
 had existed at the time of the first operation. 
 
 Csecal perforations should be cleansed, curetted, 
 and closed by Lembert suture. If this be difficult 
 or impracticable from the position of the perfora- 
 tion or otherwise, no danger need be apprehended, 
 for such fistules close naturally ; one such compli- 
 cation occurred in a case in which I excised a 
 sloughing appendix. At the time of operation 
 
36 
 
 the csecum seemed somewhat distended and its 
 color unnaturally dark ; forty-eight hours after- 
 wards fseces were observed in the wound, which 
 was sufficiently open to see a gangrenous perfora- 
 tion ; the fistule gradually contracted, but continued 
 discharging a small amount of intestinal contents 
 for some months, when it permanently closed of 
 its own accord. 
 
 If the inflammation should be found in the caecum 
 itself, due to the presence of a foreign body or to 
 impaction of the faeces, they should be either ex- 
 cised or urged by prudent force along the bowel. 
 
 In their operative removal a simple incision, after- 
 wards united by Lembert sutures, would answer 
 every purpose. 
 
 When the general peritoneal cavity has been in- 
 volved by the abscess, or broken into during opera- 
 tion, it requires, after cleansing, to be drained, and 
 for this purpose a large, glass, perforated tube, 
 slightly curved (Keith's) is carried down between 
 the coils of intestines to the most dependent part 
 of the pelvic cavity and allowed to emerge at a 
 convenient point near the lower part of the wound. 
 It is safer in all cases also to insert a perforated 
 rubber drain to the bottom of the abscess cavity. 
 The wound is then brought together by interrupted 
 silk sutures. 
 
 A piece of protective tissue perforated for the 
 tube exit is then applied to the wound. To the 
 bottom of the glass tube is carried a cotton rope 
 which absorbs the secretions, and over its outlet 
 a wad of cotton is placed and enveloped in rubber 
 
37 
 
 tissue in the usual manner. Iodoform is now dusted 
 over the wound surroundings and a large dressing 
 of wet bichloride gauze and cotton is then applied 
 and held in position by a four-tailed flannel binder. 
 
 Post- Operative Treatment. — After the effects of the 
 anaesthetic have passed off, a hypodermic injection 
 of morphine may be required to relieve pain, or 
 check vomiting or restlessness. The ordinary rules 
 of abdominal surgery are to be observed. The 
 cotton rope should frequently be changed, gener- 
 ally every three hours is sufficient for the first few 
 days ; before it is replaced the tube should be irri- 
 gated with boiled or distilled water, peroxide of 
 hydrogen, or weak carbolic-acid solution, especially 
 when, as is often the case at first, the secretions are 
 more or less offensive. 
 
 Milk should be given at short intervals, and in 
 small doses, and stimulants are, as a rule, early re- 
 quired ; if there has been much exhaustion cham- 
 pagne should be freely given. 
 
 It is important that the bowels should be promptly 
 opened and kept so; and for this purpose small 
 doses of calomel should be given, say -^^ or ^ of 
 a grain hourly or half-hourly, with an occasional 
 ^-grain dose of podophyllin ; after this salines can 
 be substituted. Quinine and the malt extracts are 
 strongly indicated. Opium should not be used in 
 any form internally ; morphine in small doses hypo- 
 dermically rarely may be required subsequent to 
 operation to relieve pain or restlessness, but should 
 be regarded as a dangerous agent and used with great 
 reluctance. 
 
It will usually be found that tlie cellular tissues 
 surrounding the abscess are hopelessly infected and 
 necrotic, perhaps for a long distance ; it will like- 
 wise be found impossible adequately to remove or 
 cleanse them. Hence the wound will almost in- 
 variably run a foul septic course, great sloughs will 
 keep coming away for many days, and it will event- 
 ually, in from six to eight weeks, heal firmly from 
 the bottom by granulation and cicatrization. I 
 have advised, nevertheless, that the wound always 
 be primarily sutured, for by so doing and subse- 
 quently cutting suture after suture as the wound 
 becomes tense, we secure an anchorage of the 
 caecum in the bottom of the wound by lymph exu- 
 date which prevents prolapse or hernia subsequent 
 to cutting the sutures, or after cicatrization. 
 
 As a rule, one or two sutures must be cut at the 
 end of twenty hours, others subsequently as ten- 
 sion may demand. When these are cut the already 
 anchored caecum, and perhaps other intestines, come 
 into view as the wound widely gapes, but they show 
 no tendency to prolapse even when the patient 
 strains or coughs, although the latter — indeed all 
 active motions — are to be strenuously avoided. 
 
 The gaping wound should be packed with strips 
 of gauze, which are to be frequently changed and the 
 parts cleansed with peroxide of hydrogen until the 
 tubes are away and the granulations approach the 
 surface, then adhesive straps are used to approxi- 
 mate the wound edges. A binder, or good abdomi- 
 nal belt, must be worn for six months or a year 
 after complete closure of the wound. 
 
39 
 
 Symptoms of periioniiis after operation should be 
 met by free saline purgation (Epsom salts hourly or 
 half hourly) or by reopening and washing out the 
 abdomen. 
 
 The time for the removal of the glass pelvic 
 drain vrill depend altogether upon the amount and 
 character of the secretion ; usually it can be dis- 
 pensed with by the fifth or sixth day, but frequently 
 is retained until the tenth or twelfth. It is com- 
 monly forced out by the action of the intestines at 
 the proper time. When it is removed, it is well to 
 introduce in its place a small rubber drain, which 
 can be each day brought nearer the surface and 
 then cut away piecemeal. 
 
 The dressings should be replaced as often as they 
 become soiled, and this is generally every six or 
 eight hours for the first few days, afterwards at 
 longer intervals. 
 
 I have thus gone over, in a more or less brief 
 manner, the symptoms which should guide in mak- 
 ing the diagnosis of appendicitis and pus formation 
 in or about the pericsecal region, and have presented 
 in as strong a manner as possible the necessity, in 
 such event, for early operative interference. 
 
 The details of the operation and post-operative 
 treatment have been given with some minuteness, 
 and this seems proper, because such specific direc- 
 tions have not been published. 
 
 In conclusion it may be said that although ab- 
 dominal surgery can show many brilliant achieve- 
 ments, yet scarcely in any other instance does an 
 
40 
 
 operation so completely afford its own justification, 
 or, when properly timed, present such satisfactory 
 results, as laparotomy when performed for perfora- 
 tive appendicitis. 
 
 adde:n'dum. 
 
 The preceding paper, it will be observed, has been 
 confined strictly to a consideration of acute forms 
 of appendicitis. It is proposed in this additional 
 note to consider in brief the subject of surgical 
 interference with chronic appendicitis and those 
 conditions which give rise thereto. 
 
 I have long been an advocate for removal of the 
 diseased appendix in the interval between acute 
 attacks ; indeed, so long ago as in my first writing 
 upon this topic, I urged that recurring attacks of 
 appendicitis or perityphlitis should be considered 
 an absolute indication for removal of the appen- 
 dix ; preferably after entire subsidence of an acute 
 paroxysm, when every condition is so much more 
 conducive to prompt recovery, and primary heal- 
 ing of the wound. I would now again aver that re- 
 curring attacks, or persistent chronic appendicitis, 
 whether due to protraction in milder degree of the 
 acute seizure or even originating and continuing 
 without intercurrent acute attacks, not only jus- 
 tify operation, but absolutely demand excision of 
 the appendix to insure the future safety of the 
 patient. For it must now be acknowledged that 
 recurring attacks of appendicitis usually, sooner 
 
41 
 
 or later, eventuate in that most dangerous of acute 
 affections, perforatio-n of the organ and pericsecal 
 abscess, which, as likely as not, will take place when 
 the person is situated where adequate medical re- 
 lief cannot be had. How much better, then, to 
 place him at once and for all time beyond the possi- 
 bility of danger from this source, by a compara- 
 tively trivial operation at a time and under con- 
 ditions when prompt and permanent relief and 
 recovery can almost invariably be secured ! 
 
 A study of the pathology of appendix disease 
 shows that many cases commence as ulcerations 
 of the mucous membrane of the appendix, which, 
 with or without the formation and presence of con- 
 cretions, progress to perforation, and, in either case, 
 originate symptoms of intermittent or continuous 
 chronic — perhaps disabling — appendix inflamma- 
 tion ; and, earlier or later, either in the primary or 
 a subsequent attack, give rise to perforation, abscess, 
 and, when improperly dealt with, to death. 
 
 I would, then, reiterate my belief that symptoms 
 of continuing appendix disease, whether continuing 
 after acute attack, or due to primarily chronic 
 disease, or simply indicative of ulceration of the 
 lining mucous membrane of the appendix, invaria- 
 bly demand excision of the offending organ. 
 
 All of the various distressing and often disabling 
 symptoms of the various appendicular disorders, 
 including those arising from inflammatory adhe- 
 sions of the organ to neighboring viscera, are re- 
 lieved, as if by magic, by excision of the appendix. 
 This has been amply proved by the brilliant cases 
 
42 
 
 of Treves, Senn, Hoegh of Minneapolis, Bernardy, 
 and Shober of Philadelphia. 
 
 Operation for Chronic Appmdix Disease. — The 
 premeditated operation permits the careful prepa- 
 ration of the patient beforehand by rest in bed, 
 regulated diet and bowels, and thorough general 
 and local disinfection. 
 
 Incision should be made directly over and carried 
 down through the right linea semilunaris. It 
 should be at least three inches in extent and should 
 be enlarged as may be required for necessary manip- 
 ulation. After the peritoneum has been exposed to 
 the full length of incision, all bleeding points are 
 carefully ligatured with fine catgut and the wound is 
 sponged entirely free of blood or other fluid. I^ow 
 the peritoneum is incised. If the appendix does 
 not at once present in the wound it will be neces- 
 sary to press the intestine upward with the finger. 
 If, as may happen, the appendix is found to be 
 partially or wholly attached to the csecum or else- 
 where, the adhesions must be separated by the 
 finger, or, if strong, be divided between double 
 ligatures. The appendix may be entirely free of 
 mesentery or the latter may extend throughout 
 its whole extent; if so, this, as it were, meso- 
 appendix must be ligatured in portions and cut 
 through between the ligatures and the appendix. 
 The latter organ is then included in a ligature at 
 its caecal origin and cut off". 
 
 A number of methods have been adopted for 
 dealing with the resulting stump of the appendix. 
 If it is to remain projecting from the caecum, the 
 
43 
 
 csecal peritoneum should be brought over it and 
 there united by Lembert sutures. 
 
 Although I have had no experience in the re- 
 moval of the appendix for chronic disease, yet, from 
 experiments made upon the cadaver with a view of 
 getting entirely rid of the stump and hence of all 
 subsequent danger from it, I have found that it can 
 very readily be inverted and completely invaginated 
 into the csecal cavity. 
 
 The proposed manipulation consists, after ligatur- 
 ing and cutting away the appendix, in grasping the 
 stump at its distal extremity with forceps and push- 
 ing it into the caecum ; the peritoneum is then ap- 
 proximated over the inverted stump by means of 
 three or four Lembert sutures which retain it in 
 the caecum, and effectuall}^ prevent its subsequent 
 prolapse. 
 
 This is easily accomplished, and absolutely re- 
 moves all source of danger from any future irrita- 
 tion in the cul-de-sac or that part of the appendix 
 between the point of ligation and the caecum. After 
 the parietal wound has been carefully sponged and 
 all clots removed, it is brought together by two rows 
 of interrupted sutures, — a deep set for the closure of 
 the peritoneum, and a superficial series to unite the 
 edges of the external or skin-and-muscle wound. 
 Drainage is not necessary unless under very ex- 
 ceptional circumstances. The external wound is 
 to be dressed after the usual method, as previously 
 described. 
 
 The diet for the first few days should be con- 
 fined to liquids, especially milk, often and in small 
 
44 
 
 quantities. The bowels (which are supposed to 
 have been opened well upon the morning of opera- 
 tion) need not be disturbed for two or three days, 
 when they should be stimulated to gentle activity 
 by mild mercurial or saline laxatives. The dress- 
 ings need not be disturbed for a week or ten days, 
 when the sutures — if of silk — should be removed. 
 A supporting binder or abdominal belt should be 
 worn until the cicatrix is quite firm. 
 
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