APPENDICITIS OBLITERANS.Read before the Chicago Academy of Medicine, March 16, 1894.

N. SENN, M.D., Bti. D., 8.8.D.CHICAGO.

PROFESSOR PRACTICE OP SURGERY AND CLINICAL SURGERY RUSH MEDICAL COLLEGE ; PROFESSOROF SURGERY CHICAGO POLICLINIC ; ATTENDING SURGEON PRESBYTERIAN

HOSPITAL ; SURGEON-IN-CHIEF ST. JOSEPH’S HOSPITAL.

REPRINTED FROM THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION,MARCH U, 18%.

APPENDICITIS OBLITERANS.Read before the Chicago Academy of Medicine, March 16, 1894.

N. SENN, M.D., jPIi. D., 8.1v.D.CHICAGO.

PROFESSOR PRACTICE OF SURGERY AND CLINICAL SURGERY RUSH MEDICAL COLLEGE ; PROFESSOROF SURGERY CHICAGO POLICLINIC ; ATTENDING SURGEON PRESBYTERIAN

HOSPITAL ; SURGEON-IN-CHIEF ST. JOSEPH’S HOSPITAL,

APPENDICITIS OBLITERANS.

N. SENN, M.D., Ph.D., L.L.D.

The successful surgical treatment of peritonitiscaused by infective lesions of the appendix vermi-formis constitutes the most brilliant chapter of mod-ern aggressive surgery. The surgeons have taughtphysicians by scientific research, as well as by les-sons learned from clinical experience, that periton-itis, in the majority of cases, is a secondary affection,and that its successful treatment depends largelyupon the detection and removal of the primarycause.The present large amount of knowledge concerningappendicitis arid its complications is largely the re-sult of the work of American surgeons. The Euro-pean surgeons are slow in accepting the teachingsand practice, as developed and promulgated in thiscountry, but in the near future they will have tosubmit to the most convincing proof—the results ofclinical experience. During the last five years somuch literature on the surgical treatment of inflam-matory affections of the appendix has accumulatedthat this subject has become somewhat threadbareand confusing. For a number of years it was cus-tomary for a certain class of abdominal surgeons toreport the result of their annual work on ovarioto-my ; then it becanie the fashion to give the statisticsof tubal surgery, but at the present time the appen-dix vermiformis is the favorite topic of discussion,and to it is assigned a liberal space of the medicalpress and the programs of medical societies, bothlarge and small.

It appears to me that it would be more profitablein the future for this department of abdominal sur-gery to write less concerning individual experience,and elaborate more thoroughly upon a pathologicbasis the conditions which demand surgical inter-ference. The surgeon must bring more convincingproof than the simple recovery from the operation,viz.: The reasons for the necessity of operative in-tervention, in order to convince the mass of the pro-fession of the correctness of the ground taken by anumber of surgeons, that the appendix should inva-riably be removed when it is the seat of an infectivelesion. There are exceptions to nearly all rules, andthe surgery of the appendix vermiformis has not ad-vanced sufficiently to enable us to lay down cast ironrules when and when not to operate. Pelvic surgeryhas been degraded by the modern furor operativus,and the same fate threatens the surgery of the ap-pendix. The conscientious surgeon must bring hiswork in consonance with the pathologic conditionswhich he is expected to correct or remove. If itwere my intention to report the result of my ownwork in the surgery of the appendix, I should cer-tainly feel inclined to offer an apology in view of

what has been presented by the medical journals,especially those of our country during the last fiveyears, but as I propose to limit myself to the descrip-tion of a special pathologic form of appendicitis, Iam confident that I have opened up a field that willafford ample space for future investigations of a sim-ilar character and which will, in the course of time,furnish a foundation for accurate diagnosis and animproved technique.

I have, for a long time, been convinced that ap-pendicitis is an infective disease, caused by patho-genic microbes which reside in the normal intestinalcanal and exercise their specific pathologic proper-ties in the appendix whenever the essential locusminoris resistentise is produced by other conditions.The anatomic location of the appendix is such thatretention of its secretions is liable to occur, particu-larly in cases in which the lumen at the proximalend has become narrowed by congenital stenosis orantecedent affections of the cecal wall. From a bac-teriologic aspect the appendix may be regarded asan open test tube, and the retained secretions a cul-ture medium. I have but little doubt that futureresearch will demonstrate that the most frequentmicrobic cause of appendicitis is the bacillus colicommunis. Pus microbes undoubtedly enter largelyinto the etiology of mixed infections here as else-where. Intensity of the inflammation is determinedmore by the quantity than by the pathogenic qualityof the microbes. The same cause which in one caseproduces a mild form of inflammation may in othersdetermine speedy death from gangrene or perforationand acute sepsis.

I have performed at least 150 operations for le-sions of the appendix, but instead of giving a de-tailed account of these it is my intention, in writingthis paper, to call the attention of the profession toa pathologically and anatomically well-defined formof appendicitis that has heretofore not been sepa-rately described. For a number of years I have no-ticed in the examination of specimens removed fromcases of recurring appendicitis, varying degrees ofcontraction of the lumen of the appendix, differingin extent from slight stenosis to complete oblitera-tion. In recent cases I have invariably found thewall of the appendix more or less thickened at theseat of constriction. Similar observations havebeen made by other surgeons, but I have not seenanywhere special mention of this particular form ofappendicitis. The Medical Record , July 15, 1893, al-ludes to a specimen described by Dr. Biggs, whichhad been removed from a man dying of chronic al-coholism. The appendix consisted of a small pouch

4 APPENDICITIS OBLITERANS.

about 3.1 ctm. in length, and beyond this a fibrouscord 2 mm. in diameter, which, apparently as a resultof an old inflammation, had been united by adhe-sions to the neighboring tissues. The effect of thisappendicitis had been to cause a complete oblit-eration of more than one-half of the lumen of theappendix. Sections of the fibrous cord showed, un-der the microscope, unstriped muscular tissue, fibroustissue and many small round cells. Fenger (“Re-marks on Appendicitis,” American Journal of Ob-stetrics, No. 2, 1893), has described a similar speci-men. Nearly one-half of the appendix on the distalside was found obliterated. (Fig. 1. “Obliterationof Appendix on Distal Side.” Fenger’s case.) T.Gr. Morton (“Two Recent Cases of Excision of theVermiform Appendix for Chronic Relapsing Appen-dicitis in the Interval,” Medical and Surgical Re-porter, Dec. 23, 1893) has recently removed an ap-pendix for recurring inflammation in which obliter-ation had taken place on both sides. “It measuredrather more than three inches in length; it wasgreatly distended near its middle, and the proximaland distal ends were thickened and swollen; a sec-tion showed total obstruction of the organ except itsmiddle or distended portion, which was filled withabout two drachms of very offensive pus.” Lange,of New York, has also described several similar cases.

My attention has recently been called forcibly tothis form of appendicitis, as within the short spaceof two months four cases have come under my ob-servation. I have designated this form of appendi-citis as appendicitis obliterans, because the mostconspicuous pathologic condition presented by thespecimens is an obliteration of the lumen by cicatri-cial contraction. The pathologic processes resemblevery closely a similar condition in the terminal arte-ries designated here as arteritis obliterans. The pa-tients presented before the operations a complexusof clinical symptoms which, when grouped together,will enable the surgeon to at least suspect, if notpositively predict, this condition. I will briefly re-port the four cases of appendicitis obliterans whichhave recently come under my observation, and laterutilize them as a text upon which to base some gen-eral remarks on the pathology of this form of ap-pendicitis.

Case 1.—H. M. Stewart, aged 26; business, book-keeper;residence, Lyons, Kansas. Admitted into St. Joseph’s Hos-pital, Sept. 30,1893.

The patient states that his health had been fairly gooduntil three years ago, when he suffered from an attack of“cramps in the stomach,” and pain and tenderness in theileo-cecal region. This attack lasted about eight hours.Similar attacks followed at intervals of two or three*months, becoming more frequent until during last year theyoccurred every four to six weeks. The acute symptomswould, as a rule, subside in from six to fourteen hours, tobe followed by a dull aching pain in the right iliac fossaaccompanied by tenderness on pressure which would con-tinue for ten days to two weeks when he would be able to

resume his occupation, but more or less soreness and ten-derness remained. The last attack which was unusuallysevere occurred in June. Operation was performed Oct. 2,1893. The appendix was found behind the cecum directedinward and upward. It was adherent to the cecum and aloop of the ileum, mesenteriolum shortened and muchthicker than normal. The organ when removed measuredabout three inches in length and presented a peculiar club-shaped appearance, the constricted portion being on theproximal side while the free end was bulbous. (I am in-debted to Dr. Mellish for the illustrations in this paper).The wall of the free bulbous portion was much thickened.About one-third of the lumen on the proximal side wascompletely obliterated. The excluded part contained aviscid fluid, of a brownish color. The temperature rangedbetween 99 and 100 degrees F., for four days when itreached 101% degrees F., on the fifth day, after which itbecame normal. The patient left the Hospital at the endof the fourth week.

Case 2.—J. Barzhof, aged 25 ; German-American ; dentist;residence, Manitowoc, Wis. He entered St. Joseph’s Hos-pital at the request of his attending physician, Dr. Pritchard,Nov. 4, 1893. Operation on the following day. Generalhealth fair. In the summer of 1888 he was taken with thefirst attack in the form of severe vomiting, diarrhea andintense pain in the abdomen, radiating upward and down-ward to the right of the median line. The first seizurelasted about four days. Similar attacks occurred aboutfour times every year. In the spring of the present year itappeared that the attacks were provoked by change indiet. Pain often more severe when stomach was empty.Dietetic treatment had no effect in preventing recurrenceof the difficulty. No constipation. Last and most severe

Appendix laid open from tip to near proximal end; Mrs. W.; Nov.13, 1893 1. Bulbous extremity. 2. Everted exceedingly vascular mu-cous membrane. 3. Obliterated portion. 4. Central part showingloca-tion of obliterated lumen.

attack about September 20. This was preceded by a some-what hard swelling extending from umbilicus to the rightinguinal region which was followed by a severe chill,vomit-ing, diarrhea and the characteristic sharp lancinating painmore severe in the ileo-cecal region. Highest temperature102 degrees F. The pain and tenderness in the ileo-cecalregion never disappeared completely after this and wererelieved only by rest in the recumbent position. On open-ing the abdominal cavity the appendix was seen at once.It measured at least five inches in length and was firmlyattached to the caput coli and extended behind the colon.The distal bulbous end was small. A similar bulbous expan-sion was found near its attachment to the cecum. Betweenthese bulbous expansions the organ was not larger than asmall lead pencil, anemic and very dense. Owing to thelength of the mesenteriolum it had to be tied in four sec-tions. The glands in the vicinity were found much enlarged,some of them had attained the size of an almond but noneof them presented any evidences of caseation. Exam-ination of the specimen after its removal showed thatnearly the entire lumen had been obliterated, only a smallportion on the distal and proximal side remaining patent.The open spaces contained a catarrhal viscid secretion ofa brownish color. The temperature in this case neverreached 100 degrees F., and the patient left the Hospital atthe expiration of four weeks.

Case 3.—Mrs. E. A. West, aged 28, American, housewife;residence, Decatur, HI. Entered St. Joseph’s Hospital atthe suggestion of the family physician, for the purpose ofhaving the appendix removed for a recurrent inflammatoryaffection in the right iliac region of long standing. Hermother died of pulmonary tuberculosis when patient

APPENDICITIS OBLITERANS. 5

was only six months old, and the latter has always beenin delicate health. Married two years; no children. Sixyears ago was taken suddenly ill with symptoms indicat-ing peritonitis. The pain was diffuse and of a grindingcharacter. The acute symptoms subsided in five or sixhours, but she was confined to the bed for four days.The tenderness in the right iliac region remained for anumber of days. Later, in the same year, had a similarattack and during each of the succeeding four years thesame experience was repeated from two to four times. Be-ginning with September, 1892, she had an attack each monthuntil February, 1893, six in all. The attack in February wasso severe that a physician was called for the first time. Asin all previous attacks, pain passed off in a few hours butpatient was confined to bed for four or five days, and ten-derness persisted for as many more days. She was neveraware of the exact location of tenderness until she was ex-amined by her physician. The last and most severe attackoccurred in July of the present year, which lasted twelvedays. She was attended by Dr. Bumstead, who recognizedthe difficulty and advised a radical operation. During thelast attack the temperature reached 103 degrees F. Vomit-ing and nausea were not conspicuous symptoms during anyof the attacks. In the beginning of the acute exacerbationsthe pain was generally diffuse; later, localized in the ileo-cecal region. Hot applications always afforded prompt relief,

was no nausea or vomiting; a little tympanites and consti-pation. He attributed the difficulty to a strain produced bylifting. The second attack in April, the following year,commenced with a sudden, sharp, intense pain confined tothe right side in the region of the appendix. The acutesymptoms continued for one month, during which time hewas confined most of the time to bed, but at any time, ifassisted to his feet he could walk with the aid of a cane.During the second month he improved sufficiently to resumehis work. A sense of soreness and tenderness in the ileo-cecal region remained. Vomiting occurred on the eveningof the second day. Tympanites absent. Diagnosis of ap-pendicitis was made on the fourth day by the attendingphysician. Third attack February, 1893, resembled the sec-ond in every respect. There remained not so much tender-ness on pressure, as a soreness or pain from a slight jar, aswould happen when riding in a buggy when the wheel strucka stone. Could not stand perfectly erect, but would inclinethe body slightly forward and to the right with feet about"twelve inches apart. Examination before operation revealedtenderness in the region of the appendix on deep pressure.Operation Dec. 8,1893. The appendix was readily found asit was directed forward and to the right, occupying a groovein the caput coli. During its separation from the cecum Iexpected every moment to make a rent in the bowel as theperitoneal coat of the latter appeared to be absent and the

Obliterated appendix showing small pervious spaces at each end, the intervening part converted into a solid cord

1. Proximal end completely obliterated. 2. Narrow stricture dividing completely the remaining lumen into two unequal portions; greatthickening of wall near distal end.and she believes that they were the means of cutting shortseveral of the attacks. Whren examined after her admissioninto the Hospital the appendix could be felt as a firm cord,andtenderness was limited to this structure. Operation Novem-ber 14. In this case the appendix was directed downwardand inward toward the pelvis ; adhesions old and firm. Mes-enteriolum very short and adherent to appendix. It wastied in several sections.' About one-fourth of the lumen onthe proximal side was obliterated and the correspondingportion of the appendix transformed into a firm fibrous cord.(Fig. 4.) Beyond this obliterated part the lumen was muchdilated, and subdivided into two unequal portions by a thinpartition composed of cicatricial tissue. Wall of appendixmuch thickened and dense. Both compartments containedinspissated pus which resembled liquefied caseous material.Lymphatic glands in the vicinity of the appendix muchenlarged and exceedingly vascular. Patient recovered with-out an untoward symptom. A small stitch abscess at theend of a week gave rise to a slight elevation of temperature,and slightly retarded the healing of the wound.

Case 4.—J. H. Croskey, aged 33, American ; farmer by oc-cupation ; residence Farmer City,lll. Entered St. Joseph’sHospital Dec. 5, 1893. Family history good. Patient wasnever sick until November, 1891, when after a hard day’swork, he experienced a dull pain in right side and lowerpart of abdomen. He was able to sit up but could do nowork for three days, when all symptoms passed away. There

muscular coat very much attenuated. The dissection wasmade slowly and carefully and mainly with the aid of bluntinstruments. The mesenteriolum was incorporated sofirmly in the adhesions that ligation was rendered superflu-ous. A number of bleeding points were ligated. The ap-pendix when removed measured three inches in length, andon slitting it open it was found that about one-third of itslumen on the distal side was completely obliterated. (Fig.5.) The distal end tapered into a sharp point. Wall of re-maining portion only slightly thickened. Mucous mem-brane intensely congested. At a point about half an inchdistant from obliterated part, both the wall of the appendixand its lumen showed changes which indicated the firststages of the formation of a circular stricture. Mucousmembrane much thickened.

In this case the second attack of appendicitis pro-duced an intense localized plastic peritonitis whichgave rise to the extensive and firm adhesions of theappendix to the cecum, rendering the operation oneof great difficulty. During the dissection I fearedthat a perforation at the tip of the appendix hadtaken place, followed by rupture of a small abscessinto the cecum, and on this account anticipated in-juring the wall of the bowel. Examination of the

6 APPENDICITIS OBLITERANS.

specimen, however, proved conclusively that this hadnot occurred and that the adhesions were caused bya plastic peritonitis without perforation.

Since writing this paper the following interestingcase of appendicitis obliterans has come under myobservation in the clinic of Rush Medical College:

Case 5.—Jas. McOhane, occupation, farmer, aged 35 years,married; mother died of phthisis. Personal history : Nevera very robust man. Had “ague” eight years ago lastingthree months. Regular in habits ; no venereal history.

In August, 1893, the patient, while threshing wheat, wasattacked with a severe paroxysm of pain in the right lum-bar region. He had to stop work but did not go to bed. Hehas not been able to do a day’s work since, although he hasnot been confined to his bed. The pain is always present, adull aching pain, and the least exertion aggravates thedifficulty and tenderness. The pains are always referredto the same point, a few inches to the right and below theumbilicus.

The bowels have been constipated and the patient resortsto the use of enema to relieve them. The appetite is verypoor and he has been steadily losing flesh. When admittedthe patient’s temperature is normal in the morning with aslight evening rise.

On physical examination, a point of tenderness foundcorresponding to Mcßurney’s point, with some indurationand fixation of head of cecum.

From the clinical history and existing symptoms I wasable to make the diagnosis of appendicitis obliteransbefore the operation. The operation was performed in theclinic. Photograph of specimen herewith shown. The dis-tal end was patulous and is slit open, showing interior viewwith the obliterated portion at the proximal end.

Appendix, about one-third natural size.

GENERAL REMARKS.The cases just reported present many clinical

features in common. The age of the patients variedfrom 25 to 38. Four were males and one female.In all of them the acute exacerbations were charac-terized by symptoms of peritonitis of varying inten-

a Appendix laid open from proximal end as far towards distal endas it is pervious, and a little farther, b—Transverse section of same,showing bulging of the mucous membrane.1. Narrow circular strip of appendix much thickened, lumen muchcontracted; early stages of circular stricture. 2. Distal obliterated endtapering into a sharp point.

sity. Swelling does not appear to have been a con-stant feature, either during or after the acute attack.In most instances the pain was at first diffuse or re-ferred to epigastric region; later, localized in theileocecal region. In most of the cases, tendernessin the region of the appendix remained a long time

after the subsidence of the acute symptoms, or re-mained as a permanent condition. In all of the casesI was able to produce pain on making deep pressuredirectly over the appendix. The point of tendernesstherefore varied according to the location of the ap-pendix. The febrile disturbance during the acuteattack appears to have been moderate and of shortduration. Nausea and vomiting were not constantsymptoms. Tympanites depended on the extent ofthe peritoneal involvement. The most constant andcharacteristic feature was recurrence of the acuteexacerbations which set in from once a year to everyfew weeks. As a rule, the attacks became graduallymore frequent. In two out of the four cases, some ofthe most important symptoms remained in a maskedform during the intermissions. This was noted par-ticularly in the cases in which the appendix was ob-literated on the proximal side. I should suspect,very strongly, appendicitis obliterans in cases of re-current appendicitis in which no complete intermis-sion takes place during the interval between theacuteattacks, and no appreciable swelling can be foundin the region of the appendix. From what has beensaid it will be seen that the most conspicuous symp-toms of this form of appendicitis are : 1, short dura-tion and moderate intensity of the acute exacerba-tions; 2, slight or no swelling in the region of theappendix; 3, recurrence of acute attacks varying infrequency from ayear to several weeks ; 4, persistenceof some soreness and tenderness in the part affectedduring the intermissions.

Appeudix of rabbit, lymphatics injected. //—Outer follicles withlymphsinus, ss. /’/’—Inner follicles. I I —Lymph vessels which leavethe lymph follicles, m—Mucous membrane with dilated glands; e—-their epithelial cells; rr—their recesses, r’ —Recess; point of entrancedoes not correspond with level of section (Orth).

Etiology.—l have already made the statement, inthe introductory remarks, that this as well as otherforms of appendicitis is caused by pathogenic mi-crobes, and therefore regard all acute inflammatoryaffections of the appendix as infective lesions. Aglance at the anatomy of the appendix, as well as anexamination of the most constant pathologic condi-tions, will corroborate the correctness of this asser-tion, The appendix is richly supplied with lymphaticvessels, and it is through these that infection mostfrequently takes place. Orth (Cursus dcr NormalenHistologic , etc., Berlin, 1878,) has fully described thelymphatic structures in the appendix of the rabbit,and Morris has recently alluded to the lymphaticchannels of this structure as a route of infection inman.

It is not difficult to understand that an ordinary

7APPENDICITIS OBLITERANS.

catarrhal inflammation would render the mucousmembrane permeable to the passage of pathogenicmicrobes, rendering it possible for them to pass fromthe lumen of the appendix into the lymphatics, theessential cause of the inflammation thus coming indirect contact with every anatomic constituent ofthe wall of the appendix, its serous investment andeven the free peritoneal cavity without any ulcera-tion or perforation. The distribution of the micro-bic cause through the lymphatic route has beendemonstrated by many postmortem examinationsand appendices removed by operative treatment.Minute miliary abscesses have often been found inthe wall of the appendix and underneath the peri-toneal coat, and usually in locations formerly occu-pied by lymphatic channels. There can be noquestion that the exciting cause can often be tracedto a trauma, indiscretion in diet and exposure tocold. In none of the cases of appendicitis obliteransdid I find a foreign body or an enterolith. In Fen-ger’s case in which the obliteration was on thedistal side, two grape seeds, one fecal concretion the

examinations. He found partial or complete oblit-eration in 25 per cent, of these cases. He believesthat this change is due to involutionary changes inthe majority of cases. One reason for entertainingthis idea is that this condition of the appendix ismet with more frequently in persons advanced inyears. The influence of age is shown in the follow-ing table:

1 decennium 4 per cent.2 “ 174 “ 27 “

5 “ 866 “ 537 “ 58

In favor of the inflammatory origin of appendi-citis obliterans it can be said that appendicitis is acomparatively rare affection in children, and thatthe longer the person lives the greater the liabilityto suffer from an attack. I have no doubt that ob-literation of the appendix occasionally occurs as acongenital condition. Atresia of the lumen of thisorgan is probably more liable to occur during intra-

Appendix (Stewart). + section through cicatrix, one-half circumference. The upper border of drawing represents the mucous surface—X25 diameters. a —Muscular tissue, b—Empty glandular spaces, e—Granulation tissue, d—Remnants of mucous membrane, e—Eibrousand granulation tissue. /—Cicatricial tissue.

size of a split pea, and the husk of an oat were foundin the appendix. In the event of incarceration of aforeign substance or fecal concretion on the distalside of the obliteration, I should expect more pro-nounced symptoms during the intervals between theacute attacks, and apprehend great danger of perfo-ration with all its immediatedisastrous consequences.In only one case did the inflammation result in sup-puration on the distal side of the obstruction, and inthis case the pus had become inspissated. In allthe other cases the excluded part of the lumen of theappendix contained from one.to a few drops of viscidfluid stained a brownish color. It is evident that aplastic peritonitis in the vicinity of the appendixcan be produced by pyogenic microbes without visi-ble pus within the appendix or its wall.

Ribbert ( Virchow’s Archiv, 1893,) wished to ascer-tain the frequency with which the appendix vermi-formis undergoes obliteration, and for this purposenoted the condition of this organ in 400 postmortem

uterine life than the same condition in other partsof the gastro-intestinal canal.

Pathology and Morbid Anatomy.—Ranvers (ZurPathologic and Therapie der Perityphlitis DeutscheMed. Wochenschrift, 1891, No. 5,) found the appendixcompletely obliterated in thirteen postmortem ex-aminations. All of the specimens showed evidencesof circumscribed plastic peritonitis. He believed thatin some of these cases perforation had taken place,and that the disease ultimately cured itself. In onespecimen he found a small fecal concretion, surround-ed by a capsule of cicatrical tissue. The most strik-ing morbid changes in obliterating appendicitis arefound in the different tissues of the organ, and theseare directly concerned in the gradual and progressiveobliteration of its lumen. A stricture of the appen-dix, like that of any other hollow organ, may bebrought about by : 1, destruction of the mucous mem-brane by ulceration; 2, infiltration, thickening andcontraction of the muscular coat; 3, prolonged cica-

8 APPENDICITIS OBLITERANS.

tricial contraction of exudates upon its serous cover-ing; 4, or, in consequence of a combination of twoor more of these causes. In a former communica-tion on relapsing appendicitis, (“A Plea in Favor ofEarly Laparotomy for Catarrhal and Ulcerative Ap-pendicitis, with the Report of Two Cases,” Journalof the American Medical Association, Nov. 2,1889.) I described an appendix in which the mucousmembrane was extensively ulcerated. “

. . . .

On inspection of the mucous membrane lining it,an oblong ulcer was discovered near the middle andopposite mesenteric attachment. The ulcer measuredabout half an inch in length, and a quarter of aninch in width. Its greater diameter corresponding tothe long axis of the appendix. The margins of theulcer were regular in outline and not undermined.It presented no evidences of repair. Its greatestdepth corresponded to its center. The whole mucousmembrane was exceedingly vascular and much thick-ened, the submucous infiltration being uniform overits entire area. A transverse section of the appen-dix through the center of the ulcer, examined under

circumference of the appendix near the occludedpart. Most of the spaces shown in the scar tissuewere evidently formerly occupied by submucousglands. A few of them represent lumina of bloodvessels.

The mucous membrane is almost completely de-stroyed, only a few remnants at d remaining. Theplace formerly occupied by the mucous membrane isnow the seat of active cell production from the sub-mucous connective tissue. The numerous vacantspaces in the fibrous tissue are empty glandular andlymph spaces, in which the parenchyma of gland tis-sue was destroyed, either by the infective inflamma-tion or later by pressure from cicatricial contraction.The inflammation started in this case either in themucous or submucous tissue, and extended towardsthe periphery of the organ, as indicated by the path-ologic changes. The peritoneum, with the exceptionof the adhesions, had undergone but slight texturalchanges, while the tissues underneath were not muchaffected.

Fig. 7 represents the same section under higher

Same section as represented in drawing No. 6, showing remains of mucous membrane mingled with granulation tissue—X 75 diameters

the microscope, showed that the entire thickness ofthe mucous membraneand part of the muscular coatwere destroyed by the ulcerative process, and thatthe remaining thickness of the wall, as far as theperitoneum, was infiltrated with embryonal cellsand leucocytes which were closely grouped togetherin the connective tissue reticulum. The submucoustissue and part of the muscular coat were similarlyinfiltrated throughout.” The healing of such an ulcerwould naturally produce stenosis and eventuallycomplete obliteration of the lumen of the appendix.Such an event would presuppose subsidence of theinfective inflammation, the lining of the floor of theulcer with active granulations and the transforma-tion of embryonal into cicatrical tissue endowedwith the characteristic intrinsic tendency to pro-gressive contraction. Such a mode of obliteration isshown by illustrations, Figs. 6, 7 and 8. The sec-tions were taken from near and under the obliter-ated part of the appendix removed from Mr. Stewart.

Fig. 6 represents a section through a portion of the

power. It shows the remnants of glandular tissueand the almost complete destruction of the epithelialcells lining the interior of the appendix, and anabundance of scar tissue taking largely the place ofmuscular tissue. (Fig. 8). This section was takenfrom near the distal extremity of the excised appendixwhere the mucous membrane was least affected, anddemonstrates that(he primary lesioncommenced somedistance from the terminalend of the lumen, and thatthe process of obliterating cicatrization extendedfrom here in both directions. It also illustrates thatthe fibrous thickening of the wall takes place largelyby proliferation of the submucous connective tissue.It appears from these illustrations that while theprimary microbic cause in such cases acts with suf-ficient intensity to destroy the mucous membrane,producing more or less suppuration, the destructionof tissue is limited to the epithelial lining and per-haps the submucous glandular and lymphoid tissue;when it comes in contact with the connective tissueits pyogenic function is limited and an abundance of

APPENDICITIS OBLITERANS.

granulation tissue is formed, which not only limitsinfection but likewise brings about obliteration ofthe lumen which in many instances assumes a pro-gressive character. The adjacent mucous membranenot only suffers from continual exposure to the pri-mary infective cause, but also from impairment ofnutrition from gradually increasing cicatricial con-traction. It is probable that in this way obliterationof the entire lumen would be finally accomplished,and that this termination is most likely to occur ifthe obliterating process begins in the distal part ofthe appendix.

I am, however, inclined to believe that in the ma-jority of cases the obliterating appendicitis has adeeper and more serious origin in the direction ofthe lymphatic glands and channels. In such in-

illustration of this type of obliterating appendicitis.The clinical symptoms in this case pointed to severecircumscribed plastic peritonitis, and the pathologicconditions revealed at the time of operation exten-sive and very firm adhesions. The appendix removedwas occluded for about an inch at the distal extrem-ity. The non-occluded portion showed the presenceof catarrhal inflammation with the characteristicbulging of the mucous membrane after the appendixwas laid open.

Fig. 9 represents a section through one-third toone-half of the entire circumference of the obliteratedportion of the appendix. The section includes only asmall part of the peritoneum which was very muchthickened and the subserous vessels dilated.

As compared with the other illustrations the sec-

Showing remnants of mucous membrane with granulation tissue. At lower edge is shown a few muscle fibers. X 75diameters; + section.Peritoneal surface not shown.

stances the mucous membrane at some point fur-nishes the necessary infection-atrium through whichthe microbes enter the lymphatic channels resultingfinally in an interstitial inflammation, with more orless involvement of the peritoneal coat. The acuteexacerbations in this variety of appendicitis obliteransare more intense, because the primary seat of infec-tion is nearer the peritoneal coat, and the route of in-fection towards it more direct. The interstitial inflam-mation may result in the formation of small inter-mural abscesses which are more likely to reach themucous than the serous surface. The mucous liningof the lumen of the appendix becomes implicated bythe inflammation extending fromglandular structuresand connective tissue underneath it, and later fromcicatricial contraction. Case 4 furnishes a good

tion through the obliterated part shows fewer empty-glandular spaces and more bloodvessels. The gland-ular structure was destroyed by the inflammation atan early date and not starved out, as was the case inthe former instance. The former lumen of theappendix is here indicated by a mass of embryonaltissue in various stages of transformation into con-nective tissue. Reduction in the size of the obliter-ated part of the appendix was brought about in part,at least, by constriction of the peritoneal adhesions.

Fig. 10 represents the appearance of the tissuesin a section near the obliterated part. At a , thesuperficial glands remain while in close proximityto it at 6, the epithelial lining and glands aredestroyed and their places are occupied by granula-tion tissue. The submucous tissue is again the seat

10 Appendicitis obliterans.

of active tissue changes, especially under the mucousmembrane at a. The continuance of inflammationat the proximal end of the obliterating process, isindicated further by the presence of an extravasationof blood at/, and the masses of embryonal cells nearthe muscular coat at g. The thickening of the wall ofthe appendix is most marked during the acute ex-acerbations and in the excluded part. In the obliter-ated part the diameterof the organ is gradually dimin-ished until it is transformed into a firm solid cordwhile its length, owing to adhesions, is often elong-ated instead of undergoing shortening (Case 2).

Among the cases which I have reported there is noinstance of obliteration from cicatricial contractionsof peritoneal adhesions alone, nor have I been ableto find such a case in literature; but that such anoccurrence is possible we know from analogy. InCase 4, we have reason to assume that the extensiveand firm peritoneal adhesions aided the obliterating

puratiye type, are produced. I found more or lessenlargement of the lymphatic glands in all cases inwhich the product of the inflammation was thusimprisoned. In Cases 2 and 5 a number of lymphaticglands the size of almonds were found. The opera-tive removal of such glands is superfluous as theremoval of the depot of infection will be promptlyfollowed by resolution. The great thickening of thewall of the appendix in the part excluded must beattributed, in part at least, to the vain attempts ofthe organ to evacuate its contents.

Operative Technique.—The operation performed inthese cases for the removal of the appendix, as inother forms of relapsing appendicitis, was in allessential points the same as described in my paperreferred to above. The abdominal incision was madefrom a point half way between the anterior superiorspinous process of the ilium and the umbilicus in avertical direction down to near Poupart’s ligament.

Appendix (J. H. Croskey). Distal end, occluded, + section through about one-third of its circumference—X 25 diameters. a—Non-stripedmuscle fibers. 6—Blood vtssels. c—Collections of round or oval cells, d—Peritoneum, be—Granulation tissue partially converted intoconnective tissue.

process. In reference to the contents of the excludedportion of the appendix we find that in two cases itconsisted of a small quantity of viscid fluid devoidof odor and stained a brownish color, while in onecase the cavity contained inspissated pus. In Mor-ton’s case it contained two drachms of fetid viscidmaterial. In distal obliteration the proximal patentlumen usually contains the characteristic catarrhalsecretion. One of the interesting pathologic condi-tions attending proximal obliteration which attractedmy attention is the implication of the lymphaticglands in proximity to the vermiform appendix. Insuch cases the escape of septic material into theintestinal canal is prevented by the occlusion, andindefinite accumulation is prevented only by thepassage of the products of the septic inflammationthrough the lymphatic channels. In this way lym-phangitis and lymphadenitis, usually of a non-sup-

The cecum was used as a guide to the appendix.The free abdominal cavity was protected by sterilizedgauze during the isolation and removal of the appen-dix. The mucous membrane of the stump was cau-terized with pure liquid carbolic acid, the surplusacid carefully removed with a gauze sponge, thestump dusted with iodoform and buried by three ormore Lembert sutures of fine silk, which includedthe serous and muscular coats of the cecum on eachside. The line of suturing was made in accordancewith the conformation of the cecum, in a directionwhich would cause the least tension, and withoutcausing any unnecessary encroachment upon itslumen. I look upon this method as the ideal one indisposing of the stump, as it most efficiently guardsagainst the two most serious after complications insuch cases—infection and formation of a fecal fistula.I appreciate more and more the difficulties which so

APPENDICITIS OBLITERANS. 11

often confront the surgeon in performing this opera-tion. Although I have had but one death in aboutthirty-five operations, for recurring appendicitis, I amalways prepared to meet unexpected complicationsand inform the patient of the possible risks whichhe assumes in subjecting himself to the operation.As in none of the cases of obliterating appendicitispus was found outside of the appendix, flushing anddrainage were dispensed with. The external incisionwas invariably closed by four rows of sutures, the firstof catgut including the peritoneum only,the second ofthe same material embracing the fascia of the ex-ternal oblique, the third of silkworm gut includingall of the tissues, and, finally, the fourth of very finecatgut in the form of a continued suture, to bringthe skin in accurate contact. As I have observed anumber of cases of ventral hernia following opera-tions upon the appendix in my own, as well as in

the submucous connective tissue which by transfor-mation into connective tissue and cicatrical contrac-tions starves out remnants of glandular tissue, andfinally results in obliteration.

3. The obliterating process manifests a progres-sive tendency, and may finally result in completedestruction of all glandular tissue and obliterationof the entire lumen.

4. The incipient pathologic changes occur eitherin the mucous membrane of the appendix, in theform of superficial ulceration, or as an interstitialprocess following lymphatic infection.

5. The most constant symptoms which attend thisform of appendicitis are relapsing acute exacerba-tions, of short duration, moderate or no appreciableswelling at the seat of disease, and persistence ofsoreness and tenderness in the region of the appen-dix during the intermissions.

Appendix (J.H. Croskey). Proximal end; + section through about one-sixth of its circumference—X 25 diameters. a —Glands. s—Granula-tion tissue, the deeper portion more or less fibrous, c—Connective tissue, d—Non-striped muscle fibers, e—Blood vessels. /—Extravasatedblood, g—A collection of cells like granulation tissue cells. The peritoneum is not shown.

the practice of other surgeons, I am exceedinglyanxious to prevent this occurrence by bringing themost important tissues in accurate contact by sepa-rate rows of the buried suture. I never permit pa-tients to leave the bed in less than four weeks, andI advise them to wear a well-fitting bandage for sixmonths as an additional safeguard against this ex-ceedingly undesirable remote complication.

CONCLUSIONS.

1. Appendicitis obliterans is a comparatively fre-quent form of relapsing inflammation of the appen-dix vermiformis.

2, It is characterized by progressive obliterationof the lumen of the appendix, by the gradual disap-pearance of the epithelial lining and glandular tis-sue, and the production of granulation tissue from

6. The process of obliteration may begin at thedistal or proximal end, or at any place between, or itmay commence simultaneously, or in succession atdifferent points.

7. Obliteration on the proximal side gives rise toretention of septic material which finds an outletthrough the lymphatics giving rise to non-suppura-tive lymphangitis and lymphadenitis.

8. Circumscribed plastic peritonitis is an almostconstant concomitant of appendicitis obliterans, andhastens the process of obliteration.

9. Complete obliteration of the lumen of the ap-pendix results in a spontaneous and permanent cure.

10. In view of the prolonged suffering incident toa spontaneous cure by progressive obliteration, andthe possible dangers attending it a radical operationis indicated, and should be resorted to as soon as apositive diagnosis can be made.