(44 ALIFORNIA :STATE JOURNAL OF MEDICINE VOL. XV, No. II

Original ArticlesTHE VEGETATIVE NERVOUS SYSTEMVI

IN RELATION TO GENERALMEDICINE.*

By FRANCIS M. POTTENGER, A. M., M. D., L. L. D.,Monrovia, California.

We are just beginning to realize, after manvs-ears of study in pathological anatomy, which hasheretofore been considered the basis as well as thesuperstructure of modern medicine, that it fails toexplain those conditions which are of most interestto the clinician.1 Pathological anatomy may ac-quaint us with the changes in tissue which areproduced by the disease process, likewise thechanges which result from it; but the gap betweenthese two has been left unbridged. It can bebridged successfully only by an understanding ofbiochemistry and pathological physiology.

After many years of close study, we are con-fronted with many facts which we are unable toexplain; largely because our field of investigationhas been too narrow. The agencies through whichthe disease process produces its effects throughoutthe body, have not been sufficiently investigated.In order to understand this phase of medicine, wemust realize the manner in which the workings ofthe human body are controlled. The various con-trols may be classified under sensori-motor; physio-chemical; and psychical. Disturbance in any ofthese controls alters function and produces func-tional pathology or a pathological disturbance inthe normal physiology.

It is to a better understanding of these variouscontrols of the body that medicine will address it-self in the immediate future. They have beenomitted heretofore because of their general abstruse-ness. Our knowledge has been so slight that wefelt our inability to understand them; but nowthat we have advanced in our study of normalphysiology; and now that we better understand thepathology underlying disease processes and theeffects of the disease processes in body tissues otherthan those in which the main lesion is located, weare able to trace the relationship between the twoin a way that we were unable to do heretofore.The field is not so difficult as would seem at firstthought. Many independent observations havebeen made and many fundamental truths have beenalready discovered, which, when put together, willgreatly elucidate the subject. It will be necessarv,however, for medical men to address themselves tothis phase of medicine with the same earnestnessand the same eagerness for truth, as they have ad-dressed themselves in the past to the problemsof physiology, pathological anatomy and generallaboratory study.The pleasure in the study of disease comes from

our ability to explain the phenomena observed;and not until' we are able to think in terms of

i Read before the Medical Society of the State ofCalifornia, San Diego, Cal., April 19, 1917.

1. Pottenger. The Importance of the Study of Patho-logical Physiology in Internal Medicine; Illustrated bythe Analysis of the Symptomatology of Tuberculosis.(Read before the Forty-second Annual Meeting: of theMississippi Valley Medical Association held at Indian-apolis, Ind.. October, 1916.)

visceral neurology, biochemistty and psychicalchange, shall we be able to explain the facts whichpresent themselves in our every day practice.At the outset of one's study in this field, it is

necessary for him to understand that there willbe incomplete answers to manv of his questions.Many seemingly contradictory facts will be met.He must not waive aside the whole matter on thisaccount for there are innumerable primary princi-ples which are thoroughly established; and thenumber of these will increase with increasedfamiliarity with the subject.Our symposium this afternoon will deal with

pathological physiology. We hope to bring beforeyou-not the symptoms and the signs of the dis-ease alone-but we hope to offer a basis for theirexplanation. A symptom is a disturbance in nor-mal physiological function. As long as functionproceeds in its normal way, no symptoms are pre-sented; but when the normal course is altered,then they arise. In medicine we have made theridiculous mistake in the past of trying to ignorefunctional disease; we have tried to brush it asideand consider nothing but organic change; but nowwe have learned that organic change expresses it-self in functional derangement, and it is functionalderangement that gives the patient most concertnand demands study and relief at the hands of thephysician. We shall endeavor by the papers herepresented to take up two phases of normal physiol-ogical control; that of the vegetative nervous sys-tem and the endocrine glands. It can be seen thenthat the foundation for this symposium is normalphysiology or an inquiry into the manner in whichnature carries on the intricate activities of thebody.

In opening the symposium, I shall confine mydiscussion to the vegetative nervous system. Itmust be remembered at the outset that there canbe no serious change in the equilibrium of thevegetative nervous system without causing. disturb-ances in internal secretions; neither can there beany serious change in internal secretions withoutdisturbing the equilibrium of the vegetative system..THE VEGETATIVE OR INVOLUNTARY NERVOUS

SYSTEM.In order to make my meaning clear. I shall

define the terms used in this discussion before pro-ceeding. In speaking of the vegetative nervoussystem, I mean the same system as is spoken of byvarious writers as involuntary and autonomic.(The autonomic is also applied by some writers tothe greater vagus division of the vegetative sys-tem.) It is that system which acts without an actof the will. It presides over those body functionswhich are necessary to life; and which would beendangered were they left to voluntary control.The vegetative system supplies nerve fibers to

the pilo motor muscles and sweat glands; to thegastrointestinal tract and all glands connectedwith digestion; to the heart and blood vessels;the respiratory mucous membranes and muscula-ture; the genito-urinary system and all of thesecretory glands and all smooth muscles of thebody.The vegetative system consists of two divisions

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which are physiologically antagonistic. The sym-pathetic system, which takes its origin from thethoracic and upper lumbar segments of the cord;*and the greater -vagus, the fibers of which arisefrom the mid brain, bulb and sacral portion of the*cord. The fibers of the greater vagus run in thethird, seventh, ninth and tenth cranial nerves,and in the pelvic nerve. This division of thevegetative system is sometimes spoken of as theautonomic, but should not be because of the con-fusion which it fosters, on account of the vegeta-tive system as a whole being called autonomic.The vagus is the greatest nerve of this system.

The vegetative fibers in the third, seventh and.ninth cranial nerves, likewise those in the pelvicnerve, have practically the same action as thetenth cranial, usually called the vagus nerve;consequently, I prefer to speak of them collective-ly 2 (following Eppinger and Hess), as the ex-tended or greater vagus; and by so doing we ar-range the fibers of the vegetative system in twodivisions in which all of the fibers belonging toeach division have similar action, and so that thetwo divisions as a whole antagonize each other.

In order to make clear the importance of sodividing the vegetative system, it must be under-stood that wherever the sympathetic and the greatervagus fibers meet in an organ, their action is an-tagonistic. It must further be understood thatthis antagonism preserves equilibrium and is ac-countable for the normal 'physiological action ofthe organ. If the fibers in one system are over-stimulated, then a disturbance in physiological ac-tion results and symptoms appear.

It must not be thought, however, that evervextra stimulus of one division is going to over-come the action of the other division and destroythe normal equilibrium. The normal equilibriumis not so easily upset. An adequate stimulus isnecessary. An adequate stimulus is -one whichwill overcome the action cf the opposing nerve.It may be slight in one case and severe in an-other. The more stable the nerve equilibrium,the greater the stimulus must be before it be-comes adequate. Herein lies the explanation ofthe oft noted fact that one patient shows symp-toms easier; or shows more nmarked symptomsthan another patient under apparently the sameconditions.THE ACTION OF THE SYMPATHETIC AND GREATER

VAGUS IN THE IMPORTANT VISCERA.

In order to understand more fully the actionof these two systems, it might be well to takeup the important organs and show the tendencywhich will result from overstimulation of eachof the divisions of the vegetative system. In theeve, we have the fibers of the greater vagus run-ning through the third nerve, stimulation of whichproduces a contraction of the pupil and ciliarybody (accommodation spasm), and a widening ofthe palpebral fissure. Stimulation of the sympa-theties on the other hand dilates the pupil andcauses contraction of Mueller's muscle, throwing

the eyeball forward. Thus we can see that a dis-turbance in the equilibrium in the vegetative sys-tem in the eye, influences accommodation; and thisshows us why it is extremely difficult to fit glassesto patients whose nerve equilibrium is disturbed(neurasthenics). It also explains the disturbancein accommodation during toxemia, because toxemiaacts upon the sympathetic system, and disturbsthe normal equilibrium. It can be seen also howthe eye symptoms are produced in exophthalmicgoitre. Stimulation of the vagus increases thesecretion of tears; while stimulation of the sym-pathetic, decreases it.

In the gastrointestinal tract, vagus stimulationincreases appetite, increases gastric secretion, in-cluding hydrochloric acid; increases the secretionof the mucous glands of the gastro-intestinal tractand the secretion of the liver and pancreas. Sym-pathetic stimulation decreases appetite, decreasesthe gastric secretions, including hydrochloric acid;decreases the secretions from the mucous glands ofthe intestinal tract, liver and pancreas. Vagusstimulation increases motility of the stomach andintestines. Sympathetic stimulation decreases mo-tility of the stomach and intestines.Thus we can understand the dry furred tongue,

decreased digestive capacity and constipation whichaccompanv toxemia, particularly that of the acutetype such as is found in the acute infectious dis-eases. This is an indication of marked sympatheticstimulation. Hyperacidity, hypermotility (eitheigastric or intestinal), pylorospasm, and spasticcolon, are all indications that the equilibrium ofthe vegetative nervous system has been upset andthat the vagus has been the division which hasbeen overstimulated.

In the respiratory system, vagus stimulation in-creases the irritability of the mucous membraneof the nose and throat;. increases the secretion'of-mucus in both the nose and throat; also, pro-duces bronchial spasm and increases bronchial se-cretion. Sympathetic stimulation decreases the se-cretion and irritability of the nose and throat, anddecreases the bronchial secretion and relaxes bron-chial spasm. Hay fever and asthma then, are bothexpressions of increased vagus stimulation. Bothmay be ameliorated or relieved by the administra-tion of atropin, which is a direct pharmacologicalantagonist of the vagus, or by adrenalin whichstimulates the sympathetic nerves and causes themto oppose the vagus.

In the circulatory system, conditions are dif-ferent from what thev are in the respiratory anddigestive systems. In the respiratory and digestivesystemis, the greater vagus is the system whichproduces increased muscular activity, while thesympathetic causes muscular relaxation. In thecirculatory system, however, the opposite is true.Stimulation of the sympathetic produces vaso-constriction, increases the rapidity of heart action,and raises blood pressure; while the vagus systemslows the heart's action, causes reductidn of bloodpressure, and in some instances apparently opposesvasoconstriction, although other factors come inhere which make this phase of the subject ex-tremely difficult to understand.2. Eppinger and Hess, Vagotonia. (English Trans.)

Nervous and Mental Disease Pub. Co.. New York. 1915.

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442 CALIFORNIA STATE JO

Nearly all secreting organs (suprarenals andthyroid are exceptions) have their secretory powerincreased by vagus stimulation, and it seems thateach organ produces metabolites during its action,which act upon the arterioles and produce vaso-dilatation. In this way we account for the factthat each organ during activity shows a dilatationof its blood-vessels, which affords the opportunityfor the increased supply of blood necessary forthe extra work thrown upon it.The innervation of the sweat-glands is as yet

difficult to understand. Sweating seems to 'be apart of both increased sympathetic and increasedvagus stimulation. Pilomotor muscles are suppliedbv the sympathetic system.SYMPATHETIC AND GREATER VAGUS SYNDROMES.

From our discussion thus far, it will be recog-nized that when the tonus in either the sympa-thetic or greater vagus systems is increased, weshould have more or less definite pictures. Thesemight be spoken of as the syndrome of increasedsympathetic tonus and the syndrome of increasedvagus tonus.

In order to appreciate the result of excessivestimulation in either of these divisions of thevegetative system,, it is necessary to fix definitelyin our minds these two syndromes.Our study of the vegetative system has been

facilitated by the fact that there ar'e certain phar-macological remedies and certain internal secre-tions which act largely or wholly upon one or theother division. For example: Adrenin acts uponthe sympathetic system; and when injected intothe body, produces the same symptoms as thoughthe sympathetic system itself were stimulated.Pylocarpin, on the other hand, produces for themost part the same group of symptoms as iscaused by increased vagus stimulation. Atropinhas proven to be antagonistic to the greater vagusalthough its effect is not so strong in some di-visions as in others. Its action' is particularlyweak on the sacral branches. Ergotoxin is alsoused at times as a paralyzant of the sympatheticfibers.

Sy,n pathetic Syndrome.-From the use ot theseremedies we have learned that the syndrome ofpredominant sympathetic stimulation results insome of the following symptoms: Dilatation ofthe pupil; pushing forward of the eyeball; de-creased lacrymal secretion; decreased salivary se-cretion; decreased secretion of the gastric and in-testinal glands, including the liver and pancreas;decrease in the secretion of the mucous membraneof the air passages, both upper and lower; relaxa-tion of the muscles of the air passages; increasedtonus of the ileocecal valve; increased 'rapidity ofthe heart's action; lengthening of the rest pausein the heart; vasoconstriction; increase of bloodpressure; increase of the amount of glycogen inthe blood stream; contraction of the pil'omotormuscles; contraction of the muscles of the sweatglands; and an increase in the leucocytes, particu-larly the neutrophiles.3 4

3. Pottenger. The Syndrome of Toxemia; An Ex-nression of General Nervous Discharge Through theSympathetic System. (Journal of American MedicalAssociation. January 8, 1916.)

4. Ibid. Cliniral Tuberculosis. (C. V. Mosby Co., St.Louis, 1917.)

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Greater Vagus Syndrome.-On the other hand,the syndrome of predominant vagus stimulationconsists of contraction of the pupil; contractionof the ciliary body, shortening of the focal pointof the eye; increased lachrymation; increased sali-vary secretion; increased secretion of the glands ofthe gastric and intestinal tracts, including thoseof the liver and pancreas; increased motility ofthe stomach and intestines, the former leading tonausea and vomiting, the latter to spastic consti-pation or diarrhea, according to the degree ofstimulation or according to whether the circular orlongitudinal fibers are particularly irritated; spasmof the pylorus; spasm of the anal sphincter; in-creased irritability of the mucous membranes ofthe upper and lower air passages, causing sneezingand at times laryngeal spasm or bronchial spasm;increased secretion in the upper and lower airpassages; slowing of the heart beat; lowering ofblood pressure; decreased coagulability of theblood; vasodilatation in certain areas; a generaltendency to perspiration; eosinophilia and lympho-cytosis.

In these two syndromes, one will find a largenumber of the symptoms met with on the part ofthe internal viscera. Their variability dependsupon the normal tonus of the sympathetic andgreater vagus in each individual; also upon thefact that a person may show an increased tonusin one part of the syl pathetic or greater vagusdivision and not in all.CLASSIFICATION OF SOME OF THE COMMON SYMP-

TOMS INDICATIVE OF FUNCTIONALDERANGEMENT.

Analysis of the above syndromes shows that inthe respiratory tract, the digestive with the excep-tion of the ileocecal valve and the internal analsphincter; and the genito-urinary tract, increasedsympathetic stimulation produces a hypofunction,both *in muscular and secretory structures. Inthe circulatory system, on the other hand, in-creased sympathetic stimulation produces a hyper-function, giving an increased rapidity of heartbeats and a general vasoconstriction, with resultantincrease in blood pressure.

Increased stimulation of the greater vagus, onthe other hand, produces a hyperfunction in therespiratory, gastro-intestinal and genito-urinary sys-tems, increasing secretion and motility. In thecirculatory system, on the other hand, it slows theheart beat, lengthens diastole and weakens theventricular contractions; and in certain locationsat least, produces vasodilatation.

If we take up some of the common symptomsand syndromes met in every dav practice, we shallfind that they may be analyzed according to their'relationship to these two divisions of the vegetativesystem.Hay Fever.-Hay fever' shows as an increased

lachrymation; increased irritabilitv of the nasal-mucous membrane, resulting in sneezing; increasedsecretion of the nasal mucous membrane; andsometimes both increased secretion of the bronchialmucous membrane, and bronchial spasm. Thus itcan be seen that this is a definite picture of in-creased irritation of the respiratorv and ocularbranches of the greater vagus.

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Asthma.-Asthma is a condition which is ac-companied by bronchial spasm and increased bron-chial secretion; sometimes an increase of secretionin the upper air passages; and a tendency tocough; and often eosinophilia. This is also in-dicative of increased vagus stimulation. It oftenoccurs in patients who have other symptoms ofincreased vagus tonus; and may be accompaniedby them, such as hyperacidity and spastic consti-pation. The heart beat, which would naturallybe slow if it showed the same increased vagusirritation, is increased in its rapidity by, the dyspneapresent.5

Hyperchlorhydria.-There are manv functionaldisturbances on the part of the gastro-intestinaltract that can be separated according to their ac-tion upon the sympathetic and greater vagus.Hyperacidity must be looked upon as a functionalderangement. It may result from an organic dis-ease of the stomach itself or from any irritationwhich expresses itself in increased tonus of thegastric branches of the vagus. It is extremelycommon as a symptom of gall bladder disease andof appendicitis. It likewise comes in tuberculosisas a result of the inflammation of the lung tissue;and can be found as a result of inflammation inmany of the other important internal viscera.Hyperacidity is usually accompanied by either anincreased tone of the stomach wall or increasedmotilitv. It is very- likelyr to be accompanied bvsome degree of increased tone in the pylorus whicha-t times may result in definite spasm.

Hv,pochlorhydria.-Hvpochlorhvdria is common-ly found in patients suffering from acute infec-tiotus diseases or chronic infectious diseases, duringstaaes of actute exacerbations. The depression of.astric secretion, including hydrochloric acid, isdue to the toxemia acting through the sympatheticnervous system. This accounts for the long rec-ognized fact that hydrochloric acid is indicated intherapy in convalescence from acute infections.Nausea and Vomiting.-Nausea and vomiting

are also symptoms due to increased vagus tonus.A patient suffering from hyperchlorhydria oftenshows slight nausea and sometimes shows vomitingas well. These symptoms are common wheneverany portion of the gastro-intestinal tract is inflamed.They frequjently accompany inflarnmation of thegall bladder or appendix, or inflammation furtherdown the bowel. They are also frequently pres-ent in pulmonary tuberculosis, the irritation com-ing from the lung and reflexly influencing thegastric muscle.

Intestinal Stasis.-The subject of lessened mo-tility in the intestinal canal has received muchattention during recent years, but it has been at-tacked too much from the standpoint of being a-disease entity of itself, which it is not, except inrare cases of mechanical obstruction.

Intestinal stasis may be due to either stimulationof the sympathetics or vagus, but more often thelatter. The motilitv of the ileocecal valve is con-

5. Ibid. Asthma: Considered in Its Relationship tothe Vegetative Nervous System. (Read before Thirty-fourth Anniual Meeting of the American Climatolovicaland Clinical Association held at Lakewood, N. J., May,

trolled bv the' sympathetic nervous svstem. Wherewe have marked stimulation of- the sympatheticsystem, as occurs in acute toxemia and in the pres-ence of acute infectious diseases, it would be nat-ural that there should be some interference withthe ileocecal valve, retarding the emptying time ofth-e ileum. Such conditions are also accompaniedby a relaxation of the gastric and intestinal mus-culature and a lessening of the secretion of thegastric and intestinal mucous membranes, whichwould also have an influence in retarding the on-ward movement of the intestinal contents. Themotility of the colon being also decreased by thesame stimulation,. the stasis of the intestinal con-tents is continued on throughout the entire bowel.

Ileostasis due to vagus stimulation is of anothertype. Moderate vagus stimulation has a tendencyto increase the tone of the muscles of the intes-tinal tract and if it exerts itself particularlv uponthe circular muscle fibers, we have a constrictionwhich interferes with the movement of the' intes-tinal contents, leading to the verv common condi-tion of spastic constipation.

Spastic constipation is nearly always accompaniedby some degree of hyperchlorhydria. The reverseis also true. If the longitudinal fibers are over-stimulated, diarrhea results.

Bradycardia.-Bradycardia is a symptom of in-creased vagus tonus. It has been noted in in-flammation of the gall bladder, sometimes as asymptom of appendicitis, and also in inflammationof the stomach and intestine. We note it com-monly also as a result of inflammation of pul-monarv tissue. It can result wherever markedirritation of the vagus takes place, providing itexpresses itself reflexly in the cardiac branch ofthat system.

Disturbance in Juriculo-ventricular Conduction.-Very often we find as a result of vagus stimu-lation, a disturbance in conduction of the impulse,so that the auricular contraction is not properlyconducted to the ventricle. This forms a partialheart block. This is the type of irregularity thatis produced by digitalis. It can be overcome bylessening the vagus irritation by the administrationof atropin, or by overcoming it bv stimulating thesvmpathetics with adrenalin.

Tachycardia.-Tachycardia is sometimes a symp-tom of direct sympathetic stimulation. This is thetype that we find in the presence of acute toxemia;also that which is produced bv the administrationof adrenalin and by such depressive emotions asworry, fear, discontent and discouragement.

Toxemia.-Toxemia in its general expression isa widespread stimulation of the sympathetic nerv-ous system, in which the system seems to be stimu-lated in its entirety. There is a general inhibitionof action on the part of the gastro-intestinal, res-piratory and genito-urinary systems; increased stim-ulation in the circulatory system producing rapidheart action and vasoconstriction, which interfereswith heat dissipation, causing rise in temperature;and increased motility in the subdermal muscula-ture (goose flesh).De pressive Emotions.-There is a group of

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444 CALIFORNIA STATE JOURNAL OF MEDICINE VOL. XV, No. I]

svmptoms which is generally recognized as follow-ing such emotional states as pain, fear, anger, dis-appointment, discontent and worry. These re-cently have been made the subject of careful phys-iological study by Cannon 6 and others, with theresult that they are found to belong physiologi-callv to the group which express themselves throughgeneral sympathetic stimulation.

In all conditions in which there is central svm-pathetic stimulation, there is a stimulation of theadrenal gland. The adreniin, which results fromthe stimulation, acts upon all structures suppliedby the sympathetics, producing and prolonging thesame effect.

REASON FOR VARIABILITY OF SYMPTOMS ON TH E

PART OF INTERNAL VISCERA.

One thing that we cannot fail to notice in ourstudy of these various functional disturbances, isthat the group of symptbms which is produced bystimulating certain branches of the vegetative sys-tem, are not always all present under what seemto be the same conditions. This may be due to adifference in the individual. One person has avagus system that is more irritable than another;likewise, one has a sympathetic system which ismore irritable than another. Where infection in-volving an important viscus is present, we nowunderstand that expected symptoms may not ap-pear because we have stimulation of both divisionsof the vegetative at the same time. The toxemiastimulates the sympathetics, while the inflammatoryprocess itself has a tendency to produce reflexaction in other structures thr'ough the vagus. Theseverity of the symptoms in a given case, as wellas the individual symptoms which appear, are de-termined by the relative strength of the stimulationthrough the sympathetics and the vagus. Thus,one patient with gall bladder disease will sufferseverely from nausea and vomiting, while anotherwill not; one will have marked hyperchlorhydria,and another will notice no increased acidity. Thesame is true of appendicitis. In our tuberculouscases we see many instances of slow heart due tothe reflex stimulation from the inflammation in thelung acting upon the cardiac branch of the vagus.We often see this most marked during periods ofacute inflammation in the lung when marked tox-emia is present, stimulating the sympathetics andtending to produce a rapid heart. On the other hand,in other cases we see the heart assume about itsnormal ratio' to the temperature curve, the reflexirritation of the vagus showing no signs of ac-tion 4 7

With this 'brief analysis, I hope that I havebeen able to impress upon you-not only the im-portance of the study of visceral neurology, butalso to point out some practical points which willaid in the 'better understanding of many of ourcommon symptoms.

6. Cannon. Bodily Changes in Pain, Hunger, Fearand Rage. (Appleton, 1915.)

7. Pottenger. The Relationship of Pulmonary Tu-berculosis to the Vegetative Nervous System. (Readbefore American Medical Association Annual Meeting,held at New York, May, 1917.)

REPORT OF FORTY-FOUR APPENDICI-TIS OPERATIONS IN CHILDREN UN-DER FOURTEEN YEARS OF AGE.*

By EMMA K. WILLITS, M. D., F. A. C. S., andMALVINE I. JUDELL, M. D., San Francisco.

From a review of these cases we wish to accen-tLmate the following points:

i. Delayed operation led to abscess in the greatmajority of cases.

2. Cathartics were given in nearlv all the cases--to their detriment.

3. Our patients have made more rapid recov-eries since we have removed the appendix in ab-scess cases.

4. 'riie low mortality in our cases leads us tobelieve that the periteneum of the child is moreresistant to infection than that of the adult.

Considering the cases of delayed operation, wefound, although there is practically a unanimity ofopinion that appendicitis in children is a surgicalcondition, nevertheless we received our cases too late.In 44 cases we had 24 abscesses, six cases in whichthe abdomen was filled with pus, and onlv I4catarrhal appendices. Looking over the symptomsAve feel, in a great majority of the 30 patients,that the diagnosis was possible before the case cameto operation. In some cases, medical advice wascought late; in others, the physicians waited forclassical symptoms to develop. The days of suf-fering and the possible future complications, tosay nothing of the possible fatal issue, may beavoided in many cases by early operations.

In comparing our statistics with those of Deaver,Fowler, Sprengel, Peple, Stiven and Comby, wefind the abscess cases predominating.

According to the histories of our cases, ruptureof appendices occurred as follows:75% when operated upon at the end of the Ist day107c ss ss !' " " " 2nd2j " " " " 3rdI5 tW <4thThat is, 65% exploded appendices in the first fourdays of illness. The other 35% were operatedupon up to the end of the second week.There is no doubt that these appendices for the

most part ruptured in the first 48 hours, for thecases operated upon in the early stage showed smallperforations, limited pus formation, and good gen-eral condition.How is the earlv abscess formation in the child

to be Accounted for? By the undevelopment of thechild.

i. The appendix is located higher up in theabdomen, favoring general peritonitis according tosurgical experience.

2. The opening into the cecum is proportion-ately larger than in the adtult, thus permitting theentrance of feces and infectious material from thebowel.

3. Lymphoid tissue being more abundant, it is* From the Surgical Service of the Children's Hospital* Read before the San Francisco Coulnty Medical So-

ciety, March 21, 1916.