Author's Tables.
Length in 107 Ci
20-30 years, 10.5 cm.
80-40 *• 8.1 cm.
40-^ ** 9.0 cm.
The length of the appendix was care-
fully determined in 107 cases at the time
of the operation. The method adopted
was to ascertain the exact length by
means of an aseptic graduated aluminum
rule after the mesentery had been tied and
cut. It was found impossible to record
the exact length by any other method
when the appendix was curved or bent
upon itself. Shrinkage of the appendix
after its removal renders laboratory meas-
urements far from accurate, especially if
the stump method of removal has been
employed.
The average length of tlie appendix in
107 cases was 8.5 centimeters. This
agrees very nearly with . the measure-v
nients of other observers. In Ribbert^s
400 cases the average length was 8.25
centimeters. The longest appendix was.
20 centimeters, the shortest 3.75. centi-
meters. Recently, however, L discovered
in the routine examination of. the appen-
dix in a non-inflammatory case, an appen-
dix measuring only 1 centimeter in length.
There were no adhesions, around this,
diminutive organ or any evidence that
it had been amputated. . Arranging
the 107 patients into decades according to
ages and comparing the average lengths
of the appendices during these various
decades, we see that the maximum length
is reached up to the age of .'^O, 10.5 centi-
meters. This agrees with Ribbert's find-
ings. There is a decrease in length in the
next decade to be followed by an increase
'in the last two decades, contrary to Rib-
bert's statistics, where the average length
decreases during each decade.
Arranging those with diseased appen-
dices according to decades and comparing
these with the corresponding decades of
those whose appendices were normal, we
see that the length of the appendix in the
normal group decreases as the age of the
patients increases, while in the inflamma-
tory cases the change in the length corres-
ponds to that recorded above, viz. : a
maximum length between 20 and 30, a
decrease in the next and an increase in the
next two decades.
It is possible, nay, even probable, that
inflammatory changes play an important
role in determining the length of the ap-
pendix, it may be inflammation rather
than atrophic changes due to old age
which causes a decrease in length as the
age increases.
Length of appendix in loy cases, aver-
aged according to groups and decades.
Normal Cases. (60)
20-30 years, 10.3 cm.
30-40 •* 9.8 cm.
40-60 *' 9.1 cm.
loflammatory Cases. (4-7)
Len^h.
20-^0 years, 9.4 cm.
30-40 •• 6.8 cm.
40-60 ** 9.0 cm.
Dysmenorrhea. — MacLaren has called
attention to the unsatisfactory results fol-
lowing the ordinary surgical treatment
for supposed cases of obstructive dysmen-
orrhea and suggests that some of these
oases may be explained by the presence of
an inflamed appendix, which manifests
itself by attacks of colic during the men-
strual period. He cites a number of illus-
trative cases. Other gynecologists have
advanced the same idea. Recently Guin-
ard has called attention to attacks of pain
in the female, which he designates as ap-
pendicalgia. Pain is the most prominent
symptom and the actual change in the ap-
pendix may be very slight -In the opin-i_
sligl
Digitized by
?t;i'b§l(
428
PELVIC DISEASES— PETERSON.
Jour. M. S. M. S.
ion of this writer also, in many cases of
so-(!alled dysmenorrhea, the fault may not
lie in the uterus or appendages but in the
appendix. My own experience and rea-
soning leads me to the same conclusion,
so much so that I continually bear this
cause in mjnd in the consideration of tiiie
etiology of dysmenorrhea, especially in
young single women whose pelvic organs
seem fairly normal. As having a possible
bearing on this question, I have noted the
presence or absence of pain at the men-
strual period in all of the 200 cases. Of
course the word dysmenorrhea is a rela-
tive one and must be defined nearly every
time it is used. Where there was but
slight pain, unaccompanied by clots, I have
classed it as absent. It must be remem-
bered also that in nearly all of the 200
cases the abdomen was opened for marked
pelvfc disease which in itself accounted
for most of the painful periods. We find,
however, that when the appendix is the
seat of chronic inflammation, the propor-
tion of cases having painful menstruation
is greater than in those cases where the
appendix was found normal. In the for-
mer group the percentage was 41.8, and
in the latter 36.9.
This brief consideration of a diseased
appendix as a causative factor in the pro-
duction of dysmenorrhea is unsatisfac-
tory. So many factors may be present,
any one of which may be responsible for a
large part of the dysmenorrhea in a given
case, that the question must be, by its very
nature, hard to solve. But that an appen-
dix, the seat of chronic inflammation, can
manifest itself at the menstrual period by
a sharp attack of abdominal pain, I am
thoroughly convinced.
History of Appendicitis. — It must be
remembered that the cases under consid-
eration were strictly gynecologic cases.
The chief disease demanding operative
treatment was supposed to ^originate, in
every case, in the pelvis. The decision
was arrived at after a careful considera-
tion of the history and the pelvic findings.
While in quite a proportion of the cases
the involvement of the appendix was sus-
pected, it was judged to be secondary to
and of less importance than the pelvic
lesions. We know now, what was not the
case in the first consideration of appen-
dicitis, that nearly as many women are
attacked by the disease as men. Einhom
shows that of 18,000 autopsies performed
at the Pathological Institute at Munich
from 1854, in .55 per cent, there was
perforative appendicitis in males, while
the percentage in females was .57.
Again, Kriiger states that in Sonnen-
burg's clinic, in the seven years previous
to 1897, out of 209 cases of appendicitis,
127, or 59 per cent., were men, while
41 per cent, were women. Or, take
such a clinic as Ochsner's at the Augus-
tana Hospital, of 90 patients suffering pri-
marily from appendicitis, 39 were male
and 51 were female. This may be from
the peculiar nature of the clinic, but it is
significant as showing the proportion of
males attacked by this disease is not so
greatly, if any, in excess of the females.
The gynecologic service at the University
Hospital is made up of material rich in
new growths and chronic pelvic inflamma-
tory lesions. Acute inflammatory cases
do not predominate as is the case where
the material is supplied from the poorer
districts of a large metropolis. Hence, in
one way, diagnosis is easier ^n when
called upon to diflferentiate between appen-
dicitis and pelvic exudates. To quote
Ochsner again, besides the 90 cases treated
in one year at his clinic, there were 13
cases in which the primary ^'^p?5^^ft§ i^
October, 1904.
PELVIC DISBA8ES-PETERS0N.
429
the adnexa or both appendix and tubes
were so extensively implicated that it was
impossible to determine the primary seat
of the jnflanimati(»i.
An analysis of the 200 cases in refer-
ence to the history of possible appendiceal
pain shows that such pain was present in
45 per cent, of the cases where the micro-
scope showed the appendix was or had
been diseased. Such pain was present in
only 33 per cent, of patients whose
appendices were subsequently shown to
be normal. Of course, this is rea-
soning backwards and is of value
only as showing that a more care-
ful consideration of the location, per-
iodicity and kind of pain in pelvic disease
may give us a clue to coexisting involve-
ment of the appendix. As before stated,
patients giving a distinct history of ap-
pendicitis would have been referred to the
surgical service. These figures simply
mean that in 33 per cent, of the cases, the
pain by its location and other character-
istics was such as might have led to a sus-
picion of possible coexisting appendicitis,
if it were possible to differentiate between
pelvic pain and that originating from a
subacute or chronic appendicitis.
Appendiceal Adhesions. — It is much
easier to determine whether the appendix
be free or buried in adhesions than it is
to decide some of the questions just under
consideration. Accurate observations
were made as to adhesions in 146 of the
200 cases. The appendix was adherent 27
times, or in 18.5 per cent. Adhesions were
twice as frequent in those cases where
examination showed past or present dis-
ease as in those cases where the appen-
dices were found normal. It is worthy of
note, however, that in 6.1 per cent, of the
normal cases adhesions were present.
Shape of the Appendix, — The. shape of
the appendix was noted as being abnor-
mal in 52 out of the 200 cases, or 26 per
cent. These abnormalities have been ar-
ranged in a table according to the divi-
sions already referred to.
Table shozving abnormalities of appen-
dix in 5^ cases:
Total No. Club- Con- Benton
Clan. of Caws, shaped, stii'ctad. itself.
1. Negative. 65 7 (10.7* 6(9.2jO 6(9.2«
2. ChfQDiGlnfla.» 57 2(8.4^) 7 (12.8f ) 9(15.8)1)
8. DoubtMSis.. 41 6<14.6)() 1(2.8* 3(7.8*
4. Former Infia., » 1(8^) 8(10.751) 4(14.8*
Cases of acute and peri-appendiceal in-
flammation were omitted because the
small number interfered with the aver-
ages. A study of this table reveals a num-
ber of significant facts. In the first place,
it clearly demonstrates that mere shape
of the appendix cannot serve as an index
of its normality or disease. Out of the
52 cases the appendix was noted as abnor-
mal in shape 27 times where the micro-
scopic findings showed no disease. The
appendix was noted as being club-shaped
in 13 cases, yet subsequent investigation
showed no disease. In 25 cases, however,
where the shape of the appendix was
noted as abnormal, different degrees of in-
flammation were found on microscopic
examination.
Such findings as these must at least
throw some doubt upon the correctness of
the assertions of those who claim to be
able to tell whether the appendix be dis-
eased by its mere shape.
Fecal Concretions. — Fecal concretions
were noted 12 times out of 146 observa-
tions, or 8 per cent. This does not include
fecal concretions as revealed by the micro-
scope. Such concretions are of microscopic
interest only and are of no value clinically.
Th^ 12 concretions referred^to were pal-
Digitized by LjOOQIC
\30
PELVIC DISEASES— PETERSON.
Jour. M. S. M. S.
pable and could be taken into account in
deciding whether to leave or remove the
appendix. No other foreign bodies were
found in this series of cases. Ribbert
found 10 per cent, of fecal concretions in
his 400 cases. They vyere slightly more
common in men than in women, 10.5 per
cent, being noted in the former and 9
per cent, in the latter. Kelly reports
Robert Abbe as being of the opinion
that the perfectly normal appendix
never contains fecal concretions. This
statement is not borne out by the results
of microscopic examination of the cases
referred to. Out of the 12 cases showing
fecal concretions, four showed inflamma-
tory changes, while eight were normal.
This shows conclusively that the presence
or absence of fecal concretions cannot be
taken as a criterion of a diseased appen-
dix. The removal of an appendix con-
taining one or more concretions on the
ground that their presence is a source of
danger and renders the appendix more,
liable to disease is, on the other hand,
logical and seems to be supported by
abundant clinical evidence.
Pelvic Pathology and the Condition of
the Appendix. — The 200 cases which have
been used as the basis for this investiga-
tion were not selected ones. They repre-
sent the ordinary cases which the g>'ne-
cologist is called upon to treat, with the
possible exception of being more purely
gynecologic on account of the rules under
which the patients are assigned to the var-
ious services.
While the various lesions for which the
200 laparotomies were performed have all
been carefully tabulated, only illustrative
groups in their relations to the gross and
microscopical condition of the appendix
will he considered.
Chronic 'Disease of the Appendages. —
In this group have been placed all cases
where the appendages were the subject
of chronic inflammation. It includes de-
generative changes in the tubes and ovar-
ies, as well as active inflammatory pro-
cesses. In some there were slight, in
others dense adhesions binding down the
appendages and uterus to the pelvic floor
or coils of intestines. Other cases, how-
ever, were free from adhesions, the oper-
ations being performed for degenerative
changes in the ovaries with or without
retrodisplacement of the uterus.
Of the 106 cases of chronic disease of
the appendages, 63 or 58.4 per cent, were
accompanied by normal appendices, while
44 or 41.5 per cent, showed past or pres-
ent changes in the organ. As regards the
side affected it may be noted that the dis-
ease was confined to the right side of the
pelvis in 8 cases, to the left side in 6 cases,
while both sides were affected in 30 cases.
The frequency with which the appen-
dix is diseased in infllammatory pelvic
affections of the right side has been dwelt
upon by numerous observers. MacLaren's
experience is notable. He had 58 cases
of inflammatory disease of the appendages
out of 200 laparotomies. In 20 of these
cases the appendix showed enough evi-
dence of disease to require its removal.
The appendix may be infected from its
contigxiity to the appendages, usually the
right, at times the left. Infection may
travel to the appendix from the append-
ages or vice versa by way of the appendi-
culo-ovarian ligament, a peritoneal fold
joining the right ovary to the appendix,
as was first pointed out by Clado and since
verified by numerous observers.
Contiguity. — It is not uncommon to
meet with the normal or abnormal appen-
dix situated within the pelvis. It may or
Digitized by VjOOQIC
OCTOBBR, 1904.
PELVIC DISEASES— PETERSON.
431
may not be adherent to the aj^ndages of
the right or left side according to the in-
flammatory conditions present. While
the appendix is more liable to come
in contact with the appendages of the
right side, it is perfectly possible, as I
have demonstrated many times, in the
presence of enteroptosis, or with a very
movable cecum, for the appendix to rest
upon the left tube or ovary. The appen-
dix lies within the pelvis in a considerable
proportion of cases. I have recorded it as
within the pelvis in many of the cases
where changes were found in the appen-
dix. I am now noting its exact location,
whether adherent or not, and it is sur-
prising the number of times it lies within
the pelvis. Poncet and Dormoy, in order
to suggest a rational treatment of certain
forms of appendicitis through the rectum
or vagina, have adopted pelvic as a dis-
tinct classification. Kelly makes it a rule
to remove long free appendices in all
right sided pelvic operations. It would
seem more logical to remove such appen-
dices, no matter what part of the pelvis
has been (grated upon, since such free
appendices can become adherent to any
portion of the pelvis.
Interesting in this connection are the
gross appearances of the appendix noted at
the time of the operation. These have
been arranged in the form of a table and
are of value in the way of comparison.
It will be noted that in the inflammatory
group (44 cases) there were 18 cases or
40.9 per cent, of adhesions, while in the
negative group there were only 11 adher-
ent appendices or 17.7 per cent. In the
same way the inflammatory group showed
14 cases, or 31.8 per cent, of constrictions,
while there were only 11 per cent, of con-
strictions in the negative group. On the
other hand there were more club-shaped
appendices and fecal concretions in the
negative than in the inflammatory group.
This proves that even in chronic disease
of the adnexa, where the appendix is more
liable to be diseased, the mere gross ap-
pearance of the organ is no safe guide for
its removal. Adhesions of the appendix
to adjacent organs, even to the append-
ages, constrictions of its lumen, fecal con-
cretions and a marked relative increase in
the size of its distal end, does not neces-
sarily denote that the appendix is diseased.
Table showing condition of appendix in
106 cases of chronic disease of the append-
ages.
§,
I
11 r
h is
^ £ ^ (S 5» h o£ £ £^ £
^eroupT "* ^-^ " ^'•^ ^ ®-^ 7 n 6 9.6
^^Jl^^^' ** 41.5 18 40.9 a 4.5 14 31,8 8 6.8
In one of my cases the appendix was re-
moved unwittingly. A right-sided ectopic
gestation sac was removed through a pos-
terior vaginal incision. A careful exami-
nation of the specimen at the laboratory
showed that the adherent and diseased ap-
pendix also had been removed. A mo-
ment's consideration will convince one that
such an appendectomy must be of the
crudest kind, and is an argument against
the pelvic route for the treatment of pelvic
lesions. Had the abdominal route been
employed, not only could the ectopic sac
have been more easily dealt with but the
diseased appendix would have been dis-
covered and removed in a surgical man-
ner.
Uterine Fibromata. — ^There were in all
26 of these growths, arranged in two
groups according to the presence or ab-
sence of adhesions. There were 19 in the
non-adherent class, while iiy7 cases there
Digitized by VjOOQIC
432
PELVIC DISEASES— PETERSON.
Jour. M.S. M.S.
were adhesions either of the appendages
or some other portion of the growths.
Nine of the patients with non-adherent
tumors had normal appendices, while the
remaining 10 showed inflammatory
changes. Of the seven patients with ad-
herent fibromata, four had normal appen-
dices while in three inflammatory changes
were present.
Of the entire number of patients with
fibromata, 13 or 50 per cent., had normal
appendices. Abnormalities in the gross
appearance were noted in 4 cases, fecal
concretions, adhesions, a constriction, and
club-shaped being recorded in one case
each. Of the 13 inflammatory appendices,
two were adherent and three constricted.
Hence, as far as the gross appearances
were concerned, the appendices appeared
diseased in only one less case in the nega-
tive than in the inflammatory group.
Ovarian Cystomata, — The two hun-
dred cases included 24 ovarian cysts, vary-
ing in size from growths whose upper
limits reached midway from the pubes to
the umbilicus to very large tumors reach-
ing to the ensiform. In 17 or 70.9 per
cent, of these cases, the accompanying ap-
pendices showed inflammatory changes,
while in 7 or 29.1 per cent, the appen-
dices w^ere normal. Thus the proportion
of cases with diseased appendices is much
larger than with fibroids. In nine of the
17 cases abnormalities of the appendix
were noted at the time of the operation,
one was club-shaped, two had fecal con-
cretions, two were constricted, while three
were adherent to the cyst wall. Of the
seven negative appendices, one was bent
upon itself and two were club-shaped.
Thus, again it can be seen that the mere
gross appearance of the appendix is no
criterion of the microscopic picture.
Various observers have called attention
to the frequency with which the appendix
may be attached to the wall of an ovarian
cyst. Sutton mentions this frequency and
claims that the adhesions often arise from
inflammation of the appendix. He quotes
Doran as having had six such cases. Such
an adherent appendix may easily set up an
inflammation of the cyst wall, and the in-
fection even extend to the cyst contents,
giving rise to a suppurating ovarian cyst.
Chognon, writing of the adhesions of the
appendix to adjacent organs, collected
from the literature 20 cases where it was
adherent to ovarian cysts. My own sta-
tistics (three out of 24 cases) would show
it even more common. Its position in re-
lation to the cyst wall is important. Not
only can appendicitis result but the cyst
itself can be infected from the inflamed
appendix.
Technique of Appendectomy as a Con-
comitant to Other Pelvic Operations. —
Except in the case of the appendix acci-
dentally removed through a vaginal inci-
sion for ectopic gestation, tlie appendices
were all removed through the median
abdominal incision. This is always made
long enough to admit the operator's hand.
So important do I consider the thorough
exploration of the abdominal cavity, when
once the peritoneum is incised, that I hax-e
dispensed with the small median incision.
If the pelvic disease be severe enough to
necessitate a laparotomy, a thorough ex-
ploration of the abdominal cavity is also
called for unless there be contraindica-
tions. Pus in the pelvis would centra-
indicate the passing of the hand upw-ard
to the diaphragm for fear of septic con-
tamination. It would not, . however, pre-
vent an examination of the appendix. On
the other hand the general condition of
the patient may be such as^to preclade any
Digitized by LjOOQIC
OCTOBBR, 1904.
PELVIC DISEASES— PETERSON.
433
treatment except that directed towards the
pelvic lesion. The appendix, with rare
exceptions due to an extremely short
meso-cecum or to adhesions, can be drawn
to the median line with ease. The white
band of the cecum serves as the best guide
for the location of the latter. The hand
is swept under the abdominal wall into the
iliocecal fossa until the forefinger locates
the band. The latter is then drawn into
the incision and traced until the appendix
is located. The appendix and cecum are
then surrounded with gauze sponges to
protect against possible fecal contamina-
tion and the appendix removed, the stump
being touched with pure carbolic acid and
buried by a purse string peritoneal suture.
The mortality attending the removal of
appendices, the seat of chronic, not acute
inflammation, should be nil. As far as
could be ascertained in no one of the 200
cases was the mortality or even morbidity
increased by the appendectomy.
Two years ago Howard Kelly secured
through correspondence with 74 promi-
nent surgeons in this country their opin-
ions as to the advisability of removing the
apparently normal appendix when the
abdomen was opened for other purposes.
Their replies showed that a large major-
ity were against the removal of the nor-
mal appendix, simply because the oppor-
tunity arises to do so. An overwhelming
majority, however, were in favor of the
removal of the appendix when it deviates
in the slightest degree from normal. This
last opinion was brought out by the ques-
tion whether the slightest adherent appen-
dix when the abdomen is opened for other
purposes should be removed. If the study
detailed above has proved any one thing
conclusively it is that adhesions of the
appendix do not necessarily mean depar-
ture from the normal, viz. : a diseased ap-
pendix as revealed by microscopic exami-
nation. While adhesions were twice as
frequent in those cases where the appen-
dices showed past or present inflammation
in 6.1 per cent, of the normal appendices
adhesions were recorded as being present
The same may be said of club-shaped and
constricted appendices and those contain-
ing fecal concretions. In other words the
surgeon cannot tell in the class of work
under discussion by gross appearance
alone whether the appendix be or be not
diseased. The surgeons quoted above
would and do remove those appendices
which they consider abnormal. They con-
fess that the patient is much better off
without the appendix if there be the slight-
est question of its being diseased. The
reason they do not remove every appendix
when the abdomen is opened for other
purposes is because they feel that by in-
spection and paJpation they can identify
such a diseased appendix. I was of the
same opinion before I began the above
series of investigations. Now I am will-
ing to confess to my inability to so deter-
mine.
I am convinced that in the past many
of the failures to cure my patients after
subjecting them to various surgical pro-
cedures via the suprapubic incision has
been through neglect in not examining
and removing the appendix. Appen-
diceal disease need not find expression in
every case in an acute attack. The chronic
form of appendicitis, with its rather fre-
quent exacerbations, gives rise to pain,
tenderness, or at least to an uncomfortable
feeling in the right lower abdomen. I