VOL. XXXI, No.

Acute Appendicitis

Case Review of Twenty-five Consecutive Cases of

Acute Appendicitis
ROSCOE C. GILES, M.D.
Chicago, Ill.
URING the four year period from 1934 to

1938 there were 1,270 major surgical operations performed by the surgical staff of Provident
Hospital, Chicago, and among these were 109
cases of pathologically proven acute appendicitis,
or 8.5 per cent. Ninety-six were operated and
thirteen of these died, a mortality of 13.6 per
cent. Many of these cases were admitted late,
over 65 per cent had been subjected to repeated
catharsis, applications of hot water bottles or ice
bags, and enemata at the behest of benighted parents or interested friends, counter-prescribing, and
occasionally by physicians.
Despite the monumental work of Reginald Fitz
of Boston in separating acute appendicitis as a
clinical entity in 1886, there occur in the United
States and Canada about 25,000 deaths annually
from acute appendicitis, and this mortality is
greater than that for ectopic pregnancy, pyosalpingitis, gall stones, pancreatitis, splenic diseases,
and thyroid disease combined, according to McDonald of Duluth, and according to T. Wright
quoted by Flannery, nearly equals that for gastric
ulcer, duodenal ulcer, intestinal obstruction, and
gall stones, exceeds that of measles, scarlet fever,
and whooping cough together, equals that of automobile accidents, and nearly equals that for diabetes. While it is true that the mortality from appendicitis in the city of Philadelphia from 19231933 was reduced from 5.95 to 3.54 by the campaign of education initiated by Dr. John 0. Bower
and his associates, which caused earlier hospitalization of patients and less frequent administrationi
of laxatives, yet even in that city the mortality of
spreading peritonitis, the cause of 81.5 per cent
of the deaths was not materially reduced.
The only justification for the presentation of
such a small series occurring on our service in a
two year period, from 1936 to 1938, is the importance of this major problem in public health,
and the lessons to be learned from the individual

cases. If the mortality is to be materially reduced,

in addition to education of the public, there must
be education on the part of physicians as to early
diagnosis and unanimity as to treatment as well.
That such is not the case can be gained from a
perusal of the literature in which thousands of
articles have been written on the subject by many
physicians, some openly advocating palliation
early, and many after 48-72 hours. No less an authority than Sir James Berry of the Medical Society of London in 1933 decried the tendency to
early operative interference on the part of the
younger men.
The cases herein presented were of the following types:
(1) acute, including the obstructive, suppurative, gangrenous, etc. 10 cases.
(2) acute with localized peritonitis. 6 cases.
(3) acute with generalized peritonitis. 6 cases.
(4) acute with abscess formation. 3 cases.
There were six in children and the rest young
adults except two cases in males sixty-five and
sixty-seven years respectively. Five cases, or five
per cent were in females, sixty-one in males, coinciding with the preponderance of males to females throughout the literature. Only about 50
per cent gave the "typical" history of severe epigastric distress, gradually lodging in the right
lower quadrant, nausea and vomiting, the triad
popularized by Dr. John B. Murphy years ago.
Dr. Mont R. Reid of Cincinnati in a series of
1,465 cases obtained the so-called typical history
in only 53 per cent of the cases. (Quote) "When
I give a student a grade of 55 per cent for such a
reply he is astounded, for the picture of the disease he has presented is emphasized in all the textbooks. Likewise, when a practitioner is told his
patient has peritonitis from a ruptured appendix,
he is frequently amazed because 'the pain was general and mild; there was no nausea or vomiting;
the temperature was normal, or only slightly ele-

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

vated; and there was diarrhea or rectal tenesmus.'

When I reply to the student that the clinical
picture of acute appendicitis is as varied as is the
position of the appendix and his description fits
accurately only 50-60 per cent of the cases, he usually will find out what I mean if he wants a passing grade." (unquote)
These facts were well substantiated in our
series. Six cases had normal temperatures, in fact
unless some complicatiQn has occurred such as
rupture with spreading peritonitis, a temperature
over 101.5 should be looked on with suspicion.
Eight cases had normal blood counts. There was
slight muscle defence, and only moderate tenderness on pressure over the right lower quadrant,
and yet in three of the cases the appendices were
gangrenous. It cannot be too strongly emphasized that the appendicular infection may produce
little or no symptomatology until the inflamed organ comes in contact with the abdominal peritoneum. If the appendix is buried in folds of the
ileum or in a retrocaecal position, or if it is in the
pelvis, the symptomatology may be very misleading. Collins of the Los Angeles General Hospital
has recently reported 751 (25 per cent of acute
retrocaecal appendices among 3,003 consecutive
cases of pathologically proven acute appendicitis,
and has emphasized the difficulty of diagnosis. It is
his belief that these cases deceive the uncautious
diagnostician and cause many of the deaths. Collins has also shown that many of the adherent retrocaecal appendices derive their abnormal position from previous attacks of appendicitis.
In seven of our series the appendices were in
the pelvis, rendering the diagnosis particularly
difficult in females. Such cases are apt to give a
history of dysuria or tenesmus with frequent
bowel movements which are misinterpreted as diarrhea, as Dr. Mont R. Reid has pointed out. In
such cases the white blood count and rectal examination are imperative. Often tenderness, induration, or a mass may be found by the examining finger. Diarrh,ea, which not infrequently occurs in children, may be misleading, especially following the use of cathartics.
G. G. (Provident Hospital Unit No. 47307),
thirty-six years old, Negro male, admitted 9-27-

JANUARY, 1939

37, 6:30 p.m., with a history that one day previously he ate some canned beans. About midnight
he was awakened with cramp-like pains in the
lower abdomen, which he attributed to the beans.
He took Sal Hepatica, salts, and enemas, and
got no relief. Thereupon he took more laxatives
and applied a hot water bottle to his abdomen. His
temperature on admission was 101, pulse 110,
B. P. 130/80.
Hb
RBC
WBC
82
3,920,000
13,450
9-27-37
81
3,960,000
11,650
9-30 37
82
14,500
10- 1-37
Refused operation until 9-28-37, at which time
he was operated with a diagnosis of acute appendicitis with spreading peritonitis. Gangrenous appendix removed, three drains inserted. He remained in the hospital until 10-16-37. On 10-3037 he was readmitted with a diagnosis of recurrent abscess. WBC 15,800, Hb 65 per cent, 3,850,000 RBC, temperature 102, pulse 120. Under local anaesthesia a right rectus incision was
made, a pint of foul smelling pus was evacuated.
Under repeated blood transfusions and the exhibition of Sulphanilamide the patient recovered and
was discharged 12-6-37. Blood cultures were continuously negative. Culture of the peritoneal fluid
showed a hemolytic streptococcus.
Two of our cases raised the problem of the therapy of appendicular abscess.
C. B. (Provident Hospital Unit No. 49046)
thirty-six years old colored man, chef on a railroad, was seized with abdominal pain while
enroute to New York. The pain was so severe, followed by vomiting, that he was taken from the
train at Pittsburgh, examined by a company physician, who advised him to continue the journey
because the attack was an enteritis. On arrival
in New York he was taken to the main office and
given another examination by a company physician, who told him whatever else it was it was
not acute appendicitis. When seen in Chicago six
days later the patient had a definite appendicular
abscess, palpable by rectum. Admitted to Provident Hospital 12-30-37; WBC 11,575; 90 per
cent Hb; 5,600,000 RBC (concentration doe to
enemas and loss of blood, chlorides; acids); tem-

VOL. XXXI, No. 1

Acute Appendicitis

perature 102; pulse 110; respiration 22. Under

ethylene anaesthesia a McBurney incision was
made. Approximately one pint of pus was evacuated, a culture of which showed B. coli. A gangrenous appendix was removed at this time, and
the abdomen drained. Patient discharged 2-15-38
with a fecal- fistula which closed spontaneously in
two months.
The second case, M.T. (Provident Hospital
Unit No. 47321) thirty-four year old male, presented himself in our office October 9, 1937, with
the history of right sided abdominal pain of five
weeks duration, followed by nausea and vomiting,
no epigastric distress. On examination fluctuation
could be felt in the right lower quadrant and
rectally an abscess palpated on the right side. Temperature 98.4; pulse 90; WBC 4,050; 90 per cent
Hb; 4,800,000 RBC. Under ethylene anaesthesia a McBurney incision was made. On opening
the abdomen a large fecalith exuded from a rupture in the appendix about 1.5 cm from its base.
This case was drained, made an uneventful recovery, discharged 10-15-37.
These two cases illustrated the early and the
late operation for appendicular abscess, both with
recovery.
Two cases complicated pregnancy, both with
early operation, with recovery.
Occasionally the attack may be ushered in with
chills. Chills arouse the suspicion of malaria or
pneumonia, or a complicating thrombophlebitis.
Hawks of Newark, N. J., has reported thrombophlebitis of the appendicular vein and has advocated ligation of ileocolic artery early in order to
prevent more serious extension. With this method
we have had no experience. Interesting enough is
the fact that in the current issue of the Annals of
Surgery there is an article by Drs. Gordon W.
Murray and Charles H. Best of Toronto on the
use of Heparin, an anticoagulant in the blood,
discovered in Howell's laboratory, and now obtainable in crystalline form as a barium salt, which
will prevent thrombosis, and which bids fair to
be one of the most valuable contributions in the
prophylaxis of phlebitis and embolism, especially of
the pulmonary variety. Dr. Frederick Bancroft of
New York has had a wfde experience in its use

and has reported its extensive use with the same

gratifying results as Dr. Gallie of Toronto and
his associates.
In one of the cases with chills, Mrs. G. E.
(Provident Hospital Unit No. 72813) admitted
7-3-38, fourth day after an attack of epigastric
distress followed by nausea and vomiting and unrelieved by free purgation taken by the patient herself. On admission WBC 12,250; 80 per cent
polys; 3,780,000 RBC. A gangrenous appendix
was found, removed, abdomen drained, and patient discharged 7-16-38. No further chills occurred after the removal of the appendix.
In twelve of our cases fecaliths were found. A
tremendous amount of experimental work has been
done on the etiology of appendicitis. For years
Aschoft of Freiburg has insisted upon a systemic
infection being responsible, especially in children,
as the result of an upper respiratory infection, and
believed appendicitis was a true specific bacterial
disease. Surgeons, however, have been convinced
of the importance of obstruction with retained
and continuing secretion, which produces an increased virulence of the retained bacteria, gangrene of the appendix wall, and thrombosis of
the veins, and finally, rupture of the organ. Recently, Wangensteen and his associates have made
exhaustive studies of the obstructive phenomena,
a disturbance of the blood supply with kinking, obstruction as necessary factors in the production of
a gangrenous appendix. As Dr. Royster has
pointed out even with all the obstruction one might
produce, the appendix will probably not become
gangrenous unless the appendicular artery is occluded by a thrombosis. In three of our cases fecaliths were found free in the abdominal cavity,
a fortuitous event in the prevention of fistulous
tracts. We believe with Strauss and Tomarkin
that fecaliths are directly responsible for a greater
virulence of an attack by tending to produce
earlier and greater pathologic change although
they produce no earlier symptomatology.
Time will not permit us to discuss the methods
used in handling these cases except to say that
spinal anaesthesia was used in three cases, and in
the rest ethylene anaesthesia. Bliss and Heaton of
Fort Sam Houston report 2,100 operations with

10

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

a mortality of 47 per cent. They attributed this

low mortality to early operation and the use of
spinal anaesthesia.
In 75 per cent of our cases the gridiron, or
muscle splitting, incision was made as described
by McBurney, although priority for the incision
has recently been claimed by Dr. Lewis Linn McArthur. Dr. Charles Mayo uses a right rectus incision, preferably reserving the McBurney for the
cases he expects to drain.
The appendix was inverted in fourteen cases.
Simple ligation was done in seven cases because
of advanced pathology in the wall of the caecum
which made it impossible to invert. No effort was
made to remove the appendix in four cases. Simple
ligation has long been practised. However, Drs.
Alton Oschner and Lilly of New Orleans have
shown the inherent dangers of simple ligation and
have described a technic of inversion without ligation of the appendix that does not carry with it
those dangers.
Drainage was used in all cases of spreading
peritonitis or abscess formation, although Strauss
and Tomarkin of Cleveland, reporting 1,325 consecutive operations on acutely inflamed appendices,
drain only for walled off abscesses. The cases that
were drained showed a mortality of 14.5 per cent,
the mortality of the undrained cases being 5.3 per
cent.
These authors believe that abscess formation,
wound infection, fecal fistulae, and consequent
prolonged hospitalization were more common in
the drained cases. In our series intraperitoneal
drainage was used. We have had no experience
with subfascial drainage. We have two deaths in
this series, both in cases of general peritonitis
after four days of the disease.
Wherever possible, we prefer pre-operatively
X-Ray plates of the chest and abdomen, the latter especially valuable in detecting ileus, ureteral
stones, and sometimes fecaliths. Water balance
electrolyte balance must be maintained pre- and

post-operatively.
We have had no experience with serum therapy
as advocated by Weinberg of the Pasteur Institute. In 200 cases of acute appendicitis, he found
anaerobic organisms in 30 per cent, more fre-

JANUARY,

1939

quently associated with gangrenous appendicitis.

He believes that the anaerobic bacteria create a
more favorable environment for the growth of
streptococci, B. coli, and other aerobic organisms.
He made two sera, one for anaerobi, one a colon
bacillus serum, and later a complementary serum
to control srteptococci and staphylococci. In this
country, Priestly of the Mayo Clinic, has advocated its use and also Dr. Dragstedt of the
University of Chicago. As a factor in the reduction of mortality, Altemeier of Detroit, after a
comprehensive review of the literature and a careful bacteriological study of 100 cases of acute perforated appendicitis with abscess formation, concludes, "It is impossible to predict the course of
appendicitis peritonitis from the type of bacteria
isolated in any given case."
In post-operative therapy we have resorted frequently to repeat blood transfusion, the preservation of salt and water balance, and decompression of the abdomen by intranasal tube. One must,
however, issue a warning against the prolonged
use of such drainage as death may ensue if the
fluid intake and output are not carefully watched,
and the judicious use of some agent to increase
intestinal peristalsis such as Prostigmine.
BIBLIOGRAPHY

1. Allen, Philip L., N. Y., Appendicitis in Children,

Journal, A.M.A., Vol. 109, No. 2, June 10, 1937.
2. Bliss, Raymond W. and Heaton, Leonard D., Appendicitis in Army Service, Annals of Surgery,
Vol. 107, No. 2, Feb. 1938, p. 242.
3. Bower, John C., et ali. The Bacteriology of
Spreading Peritonitis Complicating Acute Appendicitis, Surgery, C. V. Mosby & Co., Vol. 3, No. 5,
May 8, 1938, p. 645
4. Caldwell, E. H., Appendicitis in Children, Sur-

gery, Gynecology and Obstetrics, Vol. 67, Aug.

1938, p. 169
5. Collins, Donear C., Acute Retrocaecal Appendicitis, Archives of Surgery, Vol. 36, No. 5, May
1938, p. 729
6. Flannery, Appendicitis at the Jameson Memorial
Hospital, Archives of Surgery, Vol. 36, No. 1,
June, 1938, p. 977
7. Harper, John R. and Wilkey, J. Lester, Chicago,
Ill., The Management of Post Operative Distension and Ileus, Journal, A.M.A., Vol. 110, No. 15,
April 9, 1938, p. 1165

VOL. XXXI, No. 1

Diagnosis and Treatment of Neurosyphilis

Thrombophlebitis Appendiceal Vein,

Surgery, Gynecology and Obstetrics, Vol. 66, Jan.
1938, No. 1, p. 62
Journal, A.M.A., Editorial-Vol. 110, No. 11,
March 12, 1938, p. 816, Pylophlebitis Complicating
Appendicitis
Mayo, Charles W., Appendicitis, Collected Papers
of the Mayo Clinic, Vol. XXVI, 1934, p. 154
Murray, Gordon D. W., M.D., and Best, Charles
H., M.D., Toronto, Can. The Use of Heparine in
Thrombosis, Annals of Surgery, Vol. 108, No. 2,
August, 1938.
McArthur, Selim W., Chicago, Ill. The Muscle
Splitting or Grid-Iron Incision for Appendectomy,
Surgery, Gynecology and Obstetrics, Vol. 65, No.

8. Hawkes,

9.

10.
11.

12.

5, Nov., 1937

11

13. Oschner, Alton, M.D., and Lilly, George, The

Technique of Appendectomy, Surgery, Vol. 2, No.
4, Oct., 1937, p. 532
14. Priestley, James T. and McCormack, Christopher
J., Generalized Peritonitis Secondary to the Rupture of the Appendix: With Special Reference to
Serum Therapy, Collected Papers of the Mayo
Clinic, Vol. XXVIII, 1936
15. Reid, Mont R., The Appendicitis Problem, Suirgery, C. V. Mosby & Co., Vol. 3, No. 21, April,
1938
16. Strauss, A. and Tomarkin, Joseph, Cleveland, O.,
Acute Appendicitis, Surgery, C. V. Mosby & Co.,
Vol. 3, No. 1, Jan. 1938, p. 111
17. Wagenstein, Owen H., M.D., et ali., Studies in
the Etiology of Acute Appendicitis, annals of
Surgery, Vol. 106, No. 5, Nov. 1937, p. 911

Diagnosis and Treatment of Neurosyphilis*

G. C. BRANCHE, M.D.
Chief, Neuropsychiatric Service, Veterans' Administration Facility
Tuskegee, Alabama
A EROLOGICAL survey conducted by The U. S.
Public Health Service of 33,234 Negroes in
six counties in as many southern states showed
that 205 per thousand were infected with Syphilis.
Furth,er study as to the prevalence rates per 1000
population for early and late syphilis revealed
a much higher incidence of late syphilis-nearly
two to one. Practically all of the patients with
syphilis admitted to our Veterans' Hospital comprise the very late variety as one would suspect
owing to the present age incidence of the veteran.
It is well known that the most advantageous
moment to treat syphilis is in the early stages.
However, since there is this larger group of late
cases, it would appear equally worthwhile to encourage an increased interest in the detection and
proper treatment of syphilis in the early latent
*Published with the permission of the Medical Director of the Veterans' Administration who assumes
no responsibility for the opinions expressed or the
conclusions drawn by the writer.
Read before the John A. Andrew Clinical Society,
April, 1938.

period thus preventing in a majority of cases serious later visceral damage to the cardio-vascular
apparatus and the nervous system. We shall confine our remarks to the diagnosis and treatment
of that stage of latent syphilis wherein the cerebrospinal axis or central nervous system has been
involved.
Approximately 35 per cent of all patients with
syphilis develop neurosyphilis. In order to diagnose and adequately treat this condition, on,e
should have a clear concept of the anatomical distribution of the disease process as it relates to the
various types of neurosyphilis.
It is well known that the brain and spinal cord
are composed of neurons and neuroglia cells. Both
are formed from the ectodermal layer. The neurons are formed from true parenchymatous tissue. The meninges and blood vessels are derived
from the mesoderm and are in no sense true nerve
tissue, but because of their close relationship with
the brain and spinal cord, any pathological changes
in them directly influence these latter structures.
Hence, from the viewpoint of morbid anatomy,