assumes after a few days a distinctly fecal character.
There are other types of septic intoxication accompanying gangrenous ap-
pendicitis which, though fatal in the end, run by no means so stormy a course.
These are cases already described of septic thrombophlebitis of the portal vein
SYMPTOMS AND DIAGNOSIS OF APPENDICITIS 1.31
with suppuration in the liver, to which is sometimes added pyemic abscesses in
the lung, in the kidneys, in the spleen, and elsewhere. These cases often nm
a subacute course, and life may be prolonged for several weeks. In the most
favorable cases when the surgeon is fortunate enough to operate on his patient
before the septic intoxication lias advanced too far, or before the entire thick-
ness of the wall of the appendix lias become gangrenous, or septic thrombosis
of the mesenteric veins has occurred, the prognosis is fairly good, depending
largely upon the resisting powers of the individual.
• i. Chronic Appendicitis. — An appendix which has once been inflamed is
nearly always a menace i<> the health and life "I" the individual. Tn a large
proportion of cases successive attacks of inflammation occur, and the tendency
is rather for the attacks to become more severe in character; sometimes they are
distributed at irregular intervals over a period of years; in favorable cases the
successive attacks of inflammation lead to obliteration of the appendix, and thus
to a cure of the disease. In other cases the appendix is left in a damaged state,
such that the individual is never entirely free from discomfort; the lesion is
sometimes a hydrops of the appendix or a mucous inclusion, as the condition is
designated by Robert T. Morris. Sometimes an empyema. In some of these
cases the appendix will have formed adhesions to the cecum, a small abscess
will have been produced which perforates the large intestine. Thus an open-
ing may be left, communicating, on the one hand, with the appendix, and on
the other with the cecum. In these cases the individual will never be free from
discomfort, and the disease may go on for years with or without another attack
of acute appendicitis, depending upon the local conditions, as already described.
When a patient sutlers from repeated attacks of appendicitis separated by con-
siderable intervals, the condition is spoken of as relapsing appendicitis. When
the intervals between the attacks are very short, or when the patient continues
to suffer more or less constantly, the condition is known as recurrent appendi-
citis. The symptoms of these chronic forms of appendicitis vary somewhat;
in the relapsing cases the successive attacks are accompanied by the ordinary
symptoms of acute appendicitis more or less severe. In the relapsing eases the
patient may sull'er from a continuous sense of discomfort in the region of the
appendix, oftentimes with localized tenderness. There will usually be a
tendency to constipation of the bowels rather than to diarrhea. From time to
time the patient will have a sharp attack of pain, accompanied by nausea and
vomiting and moderate prostration. The symptoms accompanying malposi-
tion of the appendix, and sometimes attending involution changes in the organ,
have already been mentioned.
Diagnostic Value of the Blood Count in Suppurative Conditions, especially
Appendicitis. — In no other acute inflammatory disease has the diagnostic value
of leucocytosis been more carefully studied than in appendicitis, and up to
within a rather recent time with at best but indefinite results. At present our
knowledge of the subject is becoming somewhat more precise. While 1 do
not think I have ever decided for or againsl an operation for appendicitis solely
132
APPENDICITIS
on the evidence of the blood count, nor have ever based a positive or negative
diagnosis upon this evidence, yet from a prognostic point of view there can
be no question but that certain types of leucocytosis furnish very valuable data.
In the New York Medical Record of March 25, 1905, Dr. Frederic E. Sondern
published a short article on the " Present Status of Blood Examinations in
Surgical Diagnosis." Dr. Sondern's reputation, large experience, and careful
methods entitle his opinions to respect, and the conclusions briefly stated in his
paper are so carefully and conservatively drawn, and agree so completely with
my own experience in surgery, that I shall utilize in the following paragraphs
the data given in his paper to a considerable extent. As a general proposition,
it may be stated that in acute suppurative and gangrenous conditions an
increase in the number of the leucocytes of the blood may be present or absent.
Further, that a mere general increase of leucocytes indicates a good resistance
on the part of the individual rather than the intensity or gravity of the infec-
tion, and that, further, in the most severe forms of infection with poor resist-
ance, leucocytosis may be and usually is absent or slight. Thus a very slight
infection with good resistance may produce a leucocytosis of 25,000 or more,
while a sudden grave septicemia in a feeble individual may show no increase
at all. On the other hand, a marked relative increase in the polynuclear neu-
trophiles is found to be a very valuable indication indeed. As a practical
measure of comparison of considerable value, I insert a table prepared by
Dr. Sondern, based upon the examination of about five thousand blood speci-
mens taken from healthy adults of the upper and middle classes of society in
the city of New York, with but few hospital patients among them :
Leucocytes in 1 c.mm. of blood from 5,200 to 9,600, the average being 6,700.
These figures were determined by the use of the Thoma-Zeiss chamber, almost
invariable dilution 1 : 100 and actual count of corpuscles in 0.1 c.mm. of blood in
most instances.
The same tables show a normal differential count of leucocytes to be as follows :
Leucocytes.
Small lymphocytes
Large lymphocytes
Polynuclear neutrophils
Eosinophiles
Basophiles
Percentages.
Low.
24
3
59
0.2
None
High.
35
10
68
4
0.
Average.
28.0
7.5
62.0
1.0
0.2
Actual number in
1 c.mm. based on
average leucocyte
count of 6,700.
1,876
502
4,154
67
7
These figures are based on percentages obtained from actual count of at least
500 corpuscles in the center, and not on the margin of the blood smear.
The following conclusions may be drawn in regard to- the value of the
differential count : First, a relative percentage of polynuclear cells below seventy
with an inflammatory leucocytosis of any degree excludes the presence of gan-
SYMPTOMS AND DIAGNOSIS OF APPENDICITIS 133
grene or pus al the time the examination is made, and usually indicates
good resistance toward infection. A relative increase in the polynuclear cells
with little or qo inflammatory leucocytosia is a positive indication of an inflam-
mation, ;iinl the percentage increase of polynuclears varies directly with the
severity of the infection. With n polynuclear percentage below seventy neither
pus nor gangrene is to be expected. Children have a lower percentage of poly-
nuclear cells than adults, and among them a percentage only slightly above
seventy may indicate suppuration. In adults, pus or gangrene is usually ac-
companied by a relative increase of polynuclear cells of al leasl eighty per cent.
Sondern says eighty-five per cenl or over of polynuclear cells always indicates a
purulent exudate or a gangrenous process, irrespective of the total leucocytosis.
Ninety per cent of polynuclear cells always indicates a severe degree of infection
and poor resistance. Ninety-five per cent, especially with a low general leuco-
cyte count, is almost of fatal significance. "When the general leucocyte COunl
is bigh, similar conclusions may be drawn from the presence of similar per-
centages <>f polynuclears. The absolute grade of general leucoeytosis remains
a fair index to the reaction of the tissues, and with a given percentage of poly-
nuclears a high leucocyte count indicates a better resistance than a low one.
That is to say, with a given inflammatory lesion and a polynuclear percentage
'of, say, 85, a leucocytosis of 30,000 indicates much better resistance than one
of 15,000. If with a very high polynuclear count the total number of
leucocytes is only 7,000, it indicates that the system is offering little or no
resistance to the infection. This is the type of leucocytosis which we com-
monly find in the worst forms of peritoneal sepsis and diffuse purulent peri-
tonitis. Gibson has constructed a chart, the coordinates of which are the
leucocytosis and the relative increase in polynuclear cells. His conclusions
are as follows:
The differential blood count and its relation to the total leucocytosis is to-day
the most valuable diagnostic and prognostic aid in acute surgical diseases that is
furnished by any of the methods of blood examination.
It is of value chiefly in indicating fairly consistently the existence of suppu-
ration or gangrene, as evidenced by an increase of the polynuclear cells dispropor-
tionately high as compared to the total leucocytosis.
The greater the disproportion the surer are the findings, and in extreme dis-
proportions the method has proved itself practically infallible.
As the relative disproportion between the leucocytosis and the percentage of
polynuclear cells is of so much more value than the findings based on a leucocyte
count alone, this latter method should be abandoned in favor of the newer and
more reliable procedure.
The negative findings showing no relative increase or even an actual decrease
of the proportion of the polynuclear cells, while of less value, shows, with rare
exceptions, the absence of the severer forms of inflammation.
In its practical applications, the method is of more frequent value in the inter-
pretation of the severity of the lesions o\' appendicitis and their sequelse.
In order to have some standard to measure disproportion of the polynuclear
134 APPENDICITIS
percentage, it is suggested that a trial be made of the chart which is tentatively
recommended under the arbitrary designation of " standard." 1
DIFFERENTIAL DIAGNOSIS OF APPENDICITIS
While in a typical case the signs and symptoms of acute appendicitis are
so distinctive that if the patient is kept under observation for a few hours or a
day the disease can scarcely be confounded with any other, yet conditions may
arise such that the diagnosis may be very difficult indeed, or even impossible.
Sudden perforations of the gastro-intestinal tract occurring from other causes
than appendicitis may closely simulate the latter, among them perforating
ulcer of the stomach, the duodenum, acute inflammation or perforation of
the gall-bladder, perforation of the ileum in typhoid fever, the very rare soli-
tary ulcers of the ileum, nontubercular, and in fact sudden perforation of the
intestine from any cause. In these cases much will depend upon our knowl-
edge of the previous history of the individual and a good deal upon our ability
to locate the origin of the process in the right iliac fossa. In typhoid perfora-
tion it sometimes happens that the individual, although feeling ill, has been
going about for many days, and that perforation of the typhoid ulceration
occurs without warning. In these cases it may be quite impossible to differen-
tiate the two conditions. A positive "Widal's reaction may not aid us because
the reaction may have persisted from a previous attack of typhoid and the
patient may still have appendicitis. In the early days of typhoid fever with-
out perforation an error is quite possible; localized pain and tenderness in
the right iliac fossa, vomiting, and fever are all present in certain cases.
Widal's reaction will usually be negative in either case. A leucocytosis char-
acteristic of suppuration may aid. Diarrhea is the rule in the early days of
typhoid, constipation in appendicitis. Still a good many patients in the early
days of typhoid have been operated upon for appendicitis by competent sur-
geons. Fortunately, the removal of the appendix during the first week of
typhoid does not usually render the prognosis of the disease any worse. In
affections of the gall-bladder we must rely upon a history of gall-stone pains,
the passage of gall-stones per rectum, of jaundice, and upon the presence
of the signs of intraperitoneal irritation, pain, tenderness, and rigidity at a
higher point than in appendicitis, sometimes a palpable gall-bladder. In
women it is often difficult, sometimes impossible, to differentiate between dis-
ease of the right tube and ovary and appendicitis. This is especially true
because an inflamed appendix often becomes adherent to the tube and ovary,
or, on the other hand, an inflamed tube or ovary may become adherent to and
involve the appendix. A careful inquiry into the previous history and a care-
ful abdominal and vaginal examination are the only diagnostic means at our
disposal. Fortunately, both conditions may be reached with comparative ease
1 For details, see Annals of Surgery, April, 1906. C. L. Gibson, "The Value of Differential
Leucocyte Count in Acute Surgical Diseases."
DIFFERENTIAL DIAGNOSIS OF APPENDICITIS 135
through ;m intermuscular incision <>r some of its modifications in the righl
iliac fossa. Tuberculous peritonitis, tuberculosis of the appendix, and tuber-
culosis of the cecum have all been repeatedly operated upon for appendicitis,
and carcinoma of the cecum as well. A tumor of the kidney, a floating kidney,
or an inflammatory affection of the kidney, renal calculus, and ureteral cal-
culus — have all been mistaken for appendicitis. Many surgeons believe thai
movable kidney is frequently associated with painful affections of the appen-
dix. While this is true in some cases, many of these patients are neurasthenic
women Buffering from general enteroptosis. I have nol found thai they are
materially benefited by taking out their appendices. The pain accompanying
renal colic is often attended by vomiting and prostration. Tf the stone is in
the pelvis of the right kidney or in the right ureter, this condition may closely
resemble appendicitis. Absence of fever and leucocytosis, of tendeme - ami
rigidity in the right iliac fossa, and especially the sudden cessation of pain
common in renal colic, will usually suffice after a few hours to make the dif-
ferential diagnosis. Among children, the occurrence of blood in the stools is
the most distinctive difference between intussusception and appendicitis The
sausage-shaped tumor of the former is movable and is not especially tender.
The pain of intussusception is very intense, but is usually intermittent or remit-
tent; that of appendicitis is continuous. When appendicitis occurs in the course
of the acute exanthemata, during severe forms of malarial fever, during pneu-
monia, the symptoms may be, for a time, at least, obscured. I have, moreover,
seen a very competent surgeon make a probable diagnosis of appendicitis in
a case of central pneumonia of the right lung with probably diaphragmatic
pleurisy. The muscles of the right side of the belly were quite rigid. The
peritoneal irritation with localized tenderness and even muscular rigidity which
often precedes an attack of acute epididymitis may, if upon the right side,
simulate appendicitis to a slight extent. The tenderness and pain are felt
opposite the internal abdominal ring, or a little higher. The absence of
vomiting, the history of a recent urethral discharge, and the early appearance
of a swollen testicle render the diagnosis plain; and yet I have seen the error
made a number of times, although never to the extent of doing an operation.
Inflamed retroperitoneal lymph nodes in the right iliac fossa have simulated
appendicitis in my experience. Vomiting is wanting; a palpable, tender tumor
is present in the iliac fossa, sometimes with marked septic symptoms. Pain,
if present, is dull. The acute attack characteristic of appendicitis is wanting.
(For other conditions, see, also, Diagnosis of Abdominal Diseases.)
CHAPTER V
THE INJURIES AND SURGICAL DISEASES OF THE LIVER AND OF THE
BILIARY PASSAGES
INJURIES OF THE LIVER
From its great size, from its position, and from its peculiar physical
qualities, -want of elasticity and firm attachments such that it does not readily
escape when violence is directed against it, the liver is more often injured
than any of the other solid abdominal viscera. Among 365 cases of subcu-
taneous injuries of the solid abdominal viscera the liver was injured in 189
and the spleen, kidney, and pancreas combined were injured 176 times. The
right lobe of the liver, lying, as it does, wedged in between the ribs and the
spinal column, is peculiarly susceptible to crushing injuries. It is, moreover,
very often injured by indirect violence, as in falls from a height upon the
buttocks or upon the feet. Certain general conditions predispose to ruptures
of the liver: alcoholism, tuberculosis, tumors of the liver, syphilis of the liver,
amyloid degeneration, malarial fever, or any condition in which the liver is
enlarged and softened from general or local pathological processes. Subcu-
taneous injuries and gunshot wounds are much more common in the right
lobe ; stab and incised wounds, on the other hand, are more common in the
left lobe on account of the protection afforded by the ribs. Subcutaneous rup-
tures of the liver occur, as stated, in falls from a height by indirect violence,
by falls in which the right wall of the chest strikes against some rigid body,
from crushing injuries such as run-over accidents, being caught between the
buffers of railway cars, occasionally from heavy blows with a club or other
blunt object on the thoracic wall. In the city of Xew York, rupture of the
liver occurs quite commonly among children who are knocked down by a heavy
wagon or the like while playing in the streets. The rupture may occur in
several forms ; there may be a tear of the liver substance, including its capsule,
the liver may be contused with the formation of a hematoma in the liver sub-
stance. The liver may be, as in one case of my own, torn away from the
diaphragm, though doubtless in this case the rupture actually took place through
the liver substance. A so-called liver apoplexy was described by Wilms. A
central rupture with the formation of a cystlike cavity in the liver which, if
it becomes infected, may produce a liver abscess. The right lobe of the liver
is injured subcutaneously six times as often as the left, and the convex surface
136
CNJURIE8 OF I HE LIVEK L37
twice as often as the concave. The subcutaneous ruptures may be linear tears
or stellate; a portion of the liver tissue may be completely torn away, or the
liver Bubstance may be pulpified and crushed. A common character of both
subcutaneous ruptures and stab wounds of the liver is profuse bleeding; gun
Bho1 wounds of the liver usually do qoI bleed so violently, [njuries of the
liver, whether subcutaneous or open wounds, are very frequently complicated
by injuries of other organs. This is especially true of ruptures and of gun-
shot wounds. In the former, fracture of the base of the skull in a fall from
a beighl upon the feel or buttocks is not infrequently associated with rupture
of the liver. In crushing injuries of the liver, fracture of the ribs, rupture
of* the lung, of the kidney, of the spleen, more rarely of the alimentary canal,
may occur. Gunshol wounds of (lie liver arc often associated with wounds
of the diaphragm ami of the lung and of the stomach, intestines, and kidney.
It can thus he readily seen that injuries of the liver are very grave accidents
indeed. In the statistics of Terrier and Auvray, which included 45 cases. ;ill
of which were operated upon, the mortality was 30 per cent. Among 25 cases
occurring in the hospitals of the city of \ew York during the ten years from
1895 to L905, and collected by Tilton, the general mortality was 44 per cent;
20 of the cases were treated by early operation. Among these the mortality
was 40 per cent. The mortality among ruptures that were operated upon was
62.5 per cent. Stab wounds, 33 per cent. Gunshot wounds, 28.5 per cent.
I have had one fatal case from bleeding in an uncomplicated rupture of the
righl lobe of the liver. The man had hcen struck by a falling beam in the lower
right chest. The rupture of the liver was transverse and near the entrance
of the portal vein. Gauze packing failed to check the bleeding permanently.
The man steadily hied to death.
Symptoms and Diagnosis of Subcutaneous Injuries of the Liver. — With a
history of a subcutaneous injury of the abdomen or of the lower part of the
thorax upon the right side the existence of a rupture of the liver is to he
regarded as a possibility. If, in addition, the abdominal or thoracic wall be
Severely contused over the liver, if fractured ribs are present low down upon
the right side, our attention would in the presence of intra-abdominal symp-
toms be directed toward the liver. Ordinarily there will be present the
symptoms of shock combined with tlie general symptoms of hemorrhage. As
already stated in regard to rupture of the other abdominal viscera, shock
and collapse may be entirely wanting immediately after the injury, and
the symptoms of hemorrhage developing only after some hours will be the
sole indication of a rupture of the liver extensive enough to bleed the pa-
tient to death. In ordinary cases, along with the symptoms of shock and
of internal bleeding the patient will suffer from severe pain in the abdomen,
BOmetimes referred to the right side and due largely to the irritation of the
peritoneum caused hv the effused blood. The abdominal muscles of the right
side will he rigid; there will he focalized tenderness in the region of the liver:
the costal arch will be less movable on thai >ide; there will often he dyspnea;
138 INJURIES AND SURGICAL DISEASES OF THE LIVER
in some cases there will be pain referred to the shoulder or scapula. In
ruptures of the right lobe of the liver the blood tends to accumulate upon the
right side of the abdomen, sometimes beneath the liver, but usually finding
its way as far down as the right iliac fossa. The blood may accumulate in
sufficient quantities to cause dullness on percussion in the right flank. There
may be diminution or disappearance of liver dullness at once if the stomach
or bowel are also ruptured from the presence of free gas between the liver
and the diaphragm. Disappearance of liver dullness occurring at a later
period may arise from distention of the bowel with gas due to peritoneal
irritation or peritonitis. After the first day or later there may be increased
liver dullness from swelling of the liver or, as in one case already cited, the
liver dullness may be increased from the formation of a hematoma between
the liver and the diaphragm shut in by adhesion. In a case which occurred
in the service of Dr. Robert Abbe at the Roosevelt Hospital, a little boy was
brought into the hospital a week or ten days after he had been run over in
the street. He had recovered from the early effects of the injury and was
only moderately ill. There was marked increase of liver dullness ; the right
lobe of the liver could be plainly felt three fingers' breadth below the border
of the ribs. Upon separating adhesions between the surface of the liver and
the abdominal wall a large cavity was entered lying between the liver and the
diaphragm, which contained a quantity of brownish fluid somewhat bile-stained
and many large masses of fibrin. A partly healed rupture of the convex
surface of the liver was discovered. The child survived.
After ruptures of the liver jaundice may appear after from two to four or
more days. It is caused by the absorption of bile from the peritoneum. It is
present in only about twenty per cent of the cases. After ruptures of the gall-
bladder or biliary passages it is much more common. Jaundice appearing at
a later period will usually be due to abscess of the liver. In many cases it
will be impossible to make a certain diagnosis of subcutaneous rupture of the
liver. The history of a fall or of some blow or crushing injury of the abdomen
without any external signs to locate the seat of the lesion in some particular
region, the occurrence of shock, general symptoms of hemorrhage, abdominal
pain, vomiting, and hiccough are common to all serious intra-abdominal in-
juries. In many cases the surgeon will open the belly with the diagnosis
merely of abdominal hemorrhage or probable injury of some viscus. More-