APPENDICITIS IN CHILDREN. 
A CLINICAL PAPER. 
By Irving S. Haynes, Ph.B., M.D., 
Professor of Practical Anatomy in the Cornell University Medical College ; 
Visiting Surgeon to the Harlem Hospital ; Member of the New 
York Academy of Medicine ; of the Society of 
Alumni of Bellevue Hospital ; of the 
Harlem Medical Association, 
New York. APPENDICITIS IN CHILDREN-A CLINICAL PAPER.* 
IRVING S. HAYNES, PH.B., M.D., 
Professor of Practical Anatomy in the Cornell University Medical 
College; Visiting Surgeon to the Harlem Hospital; Member 
of the New York Academy of Medicine; of the 
Society of Alumni of Bellevue Hospital; 
of the Harlem Medical Associ- 
ation, New York. 
My intention has been to make this paper more of a clinical 
than a theoretical one. Restricting myself, therefore, to the 
types of cases that have come under my own observation for 
operation, other types which would be necessary to make the 
paper logically complete will be omitted, but I hope that the 
gentlemen who shall take part in the discussion of the subject 
will supply the omissions. The histories of the cases will be 
given first, and the conclusions follow: 
Case 1.-Frank D., ten years of age. 
History.-January 5th, 1894. Boy ate a large quantity of 
raisins, nuts and such stuff. He was taken a short time after- 
wards with severe pain in the right side of the abdomen. His 
mother applied a belladonna plaster. 
January 6th. Child about the same, pain severe, constipation 
present. On the evening of the 7th, Dr. S. J. O'Neil was sent 
for. He found a temperature of 103°, rapid pulse, and pain on 
pressure in the right iliac fossa. Bowels had not operated. The 
doctor gave morphia sulphate and applied an ice bag to the seat 
of the pain. 
January 8th. The morning temperature was 990; the evening, 
ioi°. The ice bag was continued. 
January 9th. The morning temperature was 990; in the even- 
ing it had raised to 101.20 with a pulse of 110. At this time 
Dr. O'Neil asked me to see the case with him. 
Examination.-Child slight for his age, rather ansemic; face 
shrunken and anxious; abdomen slightly and evenly distended; 
some tenderness over the entire abdomen, but most marked at 
* Read before the Harlem Medical Association, May 9, 1898. 2 
Haynes: appendicitis in Children. 
McBurney's point, gradually diminishing as you pass away from 
this point. Bowels had not operated. 
Diagnosis.-To the doctor I said: "There is no doubt about 
the case being one of appendicitis. Judging from the tempera- 
ture, there is suppuration taking place, and in my opinion, the 
appendix is full of pus. I should judge from the temperature, 
pulse and abdominal tenderness that perforation was about to 
take place. I advise operation, and that as soon as possible." 
This advice was accepted, and the case was prepared for 
operation, which was begun at 11 p.m. Dr. Pulley adminis- 
tered the ether, and Dr. O'Neil assisted with the active work. 
Operation.-The abdomen was opened by an incision 3% 
inches long, parallel with the fibres of the external oblique, with 
its center over the point of greatest pain, and about one inch 
from the anterior superior iliac spine. The muscles were 
divided, the hemorrhage arrested and the peritoneum opened. 
The bowels at once protruded. Gauze pads were used to hold 
them back and to carefully work down to the appendix, which 
was found at the right of the caecum covered with a layer of 
plastic exudation, excepting about half of an inch of its distal ex- 
tremity, which projected directly forward. The appendix was 
distended with fluid so that it was nearly as large as my index 
finger. It was carefully liberated from its bed, ligated at its 
base and removed. During the manipulations to free the ap- 
pendix and raise it up for ligation, its contents were squeezed 
into the caecum, excepting a few drops which escaped through 
a minute perforation already present near the end of the organ, 
and which had been covered by the exudation. 
The stump of the appendix was thoroughly cauterized with 
pure carbolic acid. The iliac fossa sponged out with carbolized 
solution. Considerable peritoneal fluid came into the field of 
operation, and had to be frequently removed. 
The peritoneum was sutured with catgut. The transver- 
sals and internal oblique were sutured as one layer, and the ex- 
ternal oblique as another, with continuous sutures of catgut. 
The skin was stitched with interrupted sutures of silk. No 
drainage was used. Usual external dressings. Operation well 
borne. The appendix was opened and found to contain a few 
drops of very foul-smelling pus, the mucous membrane was 
necrotic for its entire area, and a point of perforation covered by 
plastic lymph where there would have been escape of the con- 
tents of the appendix in a few hours at longest. 
January 10th. Morning temperature, 101.4°; pulse, 120; 
evening temperature, 102. iQ; pulse, 130. Considerable pain 
over abdomen; bowels had not operated; enema of magnesium 
sulphate, followed by a wine glassful of magnesium citrate 
every two hours until free catharsis. 
January 11 th. Several movements from the bowels; abdo- 
minal tenderness diminished; everything favorable. Haynes: appendicitis in Children. 
3 
January i3th, 7 p.m. 1 saw patient with Dr. O'Neil, temper- 
ature, 103. i°; pulse, 130. Tongue dry and cracked. Wound 
dressed. Serum was escaping from the lower angle, parts were 
red and swollen. Three sutures were removed, and about a tea- 
cupful of foul pus escaped. Several sutures also removed from 
the upper part of the incision, and considerable pus evacuated. 
The abscess did not lead to deeper parts, it was only subcuta- 
neous. The abscess cavities were washed out and drained with 
rubber tubing. The case responded immediately and recovery 
was rapid. By the 21st of January the child was out of bed. 
Summary.-Cause, overindulgence in indigestible substances. 
Pain, severe from the beginning, and localized at McBurney's 
point. 
Temperature, highest 103°, on evening of second day of 
the attack. 
Duration of attack before operation, four days. 
In bed twelve days. Entire sickness covered sixteen 
days. 
The appendix showed suppurative appendicitis, gangrene of 
mucous membrane, perforation nearly completed and only 
arrested by a thin covering of plastic exudation. No attempt 
on Nature's part to limit the spread of the infection by walling 
off the inflamed area with matted intestines. 
Present State, May, 1898.-1 have not seen the patient, but 
Dr. O'Neil says the boy is in perfect health, and that the ab- 
dominal wound has remained solid. 
Case II.-Stella M., eleven years of age. 
History.-July 19, 1896. Taken sick with pain and tender- 
ness in the right lower abdominal region. 
July 22d. I saw the case with the family physician, Dr. A. 
J. Kuehn. 
Examination.-The abdomen was slightly distended, and an 
ill-defined mass in the right iliac fossa. The right rectus and 
abdominal muscles were rigid. The entire abdomen was tender, 
but more marked in the region of the appendix. The tempera- 
ture was 1020, pulse 160. Child's face had an anxious look. 
Diagnosis.-Suppurative peritonitis due to perforation of a 
diseased appendix. Immediate operation proposed. 
Treatment.-Child taken to the Harlem Hospital and operated 
upon as soon as the necessary preparations could be made. The 
usual incision was made. As soon as the peritoneal cavity 
was opened, thin yellowish fluid with whitish flakes escaped 
with a rush. All parts of the abdominal cavity were thoroughly 
irrigated with hot saline solution by means of a large-sized in- 
trauterine, glass douche tube. 
The appendix was freed from adhesions and brought into 
the wound. It showed a perforation at its tip, and another one 4 
Haynes: appendicitis in Children. 
inch from the first. The mesentery was ligated and divided. 
The base of the appendix was encircled with a silk suture 
passed well in the coats of the caecum; the appendix was 
clamped and divided near the caecum, and the distal portion 
removed. The stump was now inverted into the caecum, and 
the previously introduced suture tied. This puckered the per- 
itoneum nicely, and closed the orifice of the inverted appendix. 
A second continuous silk suture was introduced for safety; 
burying the first. The omentum had attempted to cover over 
the appendix, but had not succeeded, and a thickened portion 
adherent to the appendix, about two inches square, was re- 
moved. 
The abdominal cavity was treated to pure hydrogen per- 
oxide poured directly from the bottle into the wound. This 
was followed by the saline irrigation. A small iodoform gauze 
wick was placed about the site of the appendix, and let out 
of the lower angle of the wound. The peritoneum and mus- 
cular layers were separately sutured with fine silk, and the 
skin with silk-worm gut as far as the drain. The aristo-col- 
lodion dressing applied. 
On the second day the abdomen was distended, the note 
over the liver was tympanitic. The gauze wick was removed 
as it was feared that the drainage was not good, although 
the temperature was normal. There was no retention of pus. 
A second small gauze drain was introduced; the remaining part 
of the wound was neatly closed with a silk-worm gut suture. 
The distention of the abdomen was caused by gas in the in- 
testines, due to paralysis of their muscular coats from the 
peritoneal infection. An enema of hot saline solution contain- 
ing ten grains of quinine given. Result was good; patient 
passed flatus and faeces and the abdominal distension disappeared. 
Strychnine had also been given from the very first. 
Discharged August 22d, with a small sinus, which closed in 
a short time. 
Summary.-Cause, none assigned. 
Pain, severe and in the right iliac fossa. 
Temperature on entering hospital, 102°, pulse, 160. 
All the signs of general septic peritonitis due to a perforated 
appendix. 
Operation and recovery. 
Duration of attack before operation, four days. In the hos- 
pital, one month. 
Present Condition, May 7, 1898.-Child has grown very 
rapidly. Scar bulges somewhat, but seems generally firm. No 
point of hernial protrusion. 
Case III.-Julia R., aged three years. 
History.-Father died of phthisis. Mother was also infected 
and died this year from tubercular laryngitis. Child has been Haynes: appendicitis in Children. 
weakly from birth, and subject to constipation. About September 
14, 1896, child felt badly. Was temporarily relieved by castor oil. 
Vomiting, fever, and pain over the abdomen set in. She was ex- 
amined by Dr. Sharp, the family physician, who pronounced the 
case one of appendicitis and advised removal to the hospital. The 
child was admitted to the Harlem Hospital on the afternoon of 
September 21 st. Temperature 102°, pulse 140, respirations 32. 
Face flushed, tenderness over the entire abdomen, very restless. 
Treatment.-Enema administered, strychnine hypodermi- 
cally with whiskey. Operation conducted as previously outlined. 
Pus escaped as soon as the peritoneum was divided. The pus 
was not walled in, but was free in the abdominal cavity. 
It was thoroughly removed by copious irrigation with saline 
solution; then peroxide of hydrogen, and with saline a second time. 
The appendix was gangrenous; had ruptured in several 
places; was adherent to the intestines and so soft that it had to 
be removed piecemeal. It offered no substance for applica- 
tion of a ligature, and as the opening into the caecum seemed to 
be firmly closed, none was applied. The base of the appendix 
and the surrounding tissues were thoroughly treated with pure 
peroxide of hydrogen and the abdominal cavity again flushed 
with the hot saline solution. Drainage was applied by strips of 
iodoform gauze placed over the caecum and left at the lower 
angle of the wound. The peritoneum, muscles, and skin were 
closed en mass with through and through silk-worm gut 
sutures. 
September 22d. Temperature ioi°, pulse 120, respirations 
30. Beef tea retained. Dressings changed. The gauze drain 
was removed on the 26th, and a fresh one inserted. Case made 
a fair convalescence. Discharged October 9th, with wound 
healed. Ten days later the wound reopened and a slight dis- 
charge of pus followed. On the 20th, vomited and was restless. 
On the 21 st, abdomen was tender on the left side. Bowels were 
freely moved by calomel in divided doses. The sinus was en- 
larged and a small abscess cavity drained with a rubber tube. 
This was retained until November. By December the sinus had 
healed. The scar was a weak one, however, on account of fail- 
ure of close apposition of the peritoneum and the layers of the 
abdominal wall, and a hernia as large as a hen's egg had ap- 
peared. The child was readmitted to the hospital on January 5th, 
'97, and an operation performed for ventral hernia, the details of 
which I do not care to introduce here at this time; suffice to say 
that she was discharged on January 22nd, with a firm scar which 
has remained perfect to this date. 
Summary.-Cause, none stated; possibly tubercular. 
Pain, diffused over the abdomen. 
When admitted there was general septic peritonitis. The 
appendix was gangrenous and had several openings in it. 6 
Haynes: appendicitis in Children. 
Recovery with ventral hernia into the scar. Hernia cured by 
later operation. 
Duration of sickness preceding operation, one week. Time 
in hospital for appendicitis, eighteen days. Treated as out-patient 
for six weeks before sinus closed. 
Present Condition.-Child has grown fat and healthy. Ab- 
dominal scar firm, not tender. No sign of hernia. 
Case IV.-Agnes B., seven years of age. 
History.-January 12th, 1897. While eating figs patient was 
seized with pain in the right lower abdominal region. This 
continued with fever and prostration, the patient steadily grow- 
ing worse until the 17th, when Dr. Eynon was called. He had 
the child taken to the Harlem Hospital. 
Examination.-Temperature 102.8°, pulse 118, respirations 
26. There was rigidity of the right rectus muscle, and the ab- 
domen was tender to pressure, especially in the region of the 
appendix, where an ill-defined swelling was found. 
Operation.-The usual incision three inches long in the 
right iliac region. Pus flowed as soon as the abdominal cavity 
was opened, but the abscess cavity was walled off from the 
general abdominal cavity by adherent coils of intestines. The 
usual irrigation of saline, peroxide of hydrogen and saline solu- 
tion. The cavity was sponged dry, the appendix freed and 
brought into the wound, its mesentery ligated and the appen- 
dix removed. An attempt was made to invaginate the stump 
of the appendix into the caecum, but the tissues were so much 
thickened with inflammatory exudate that it was impossible. 
The stump of the appendix was then ligated and its mucous mem- 
brane destroyed with carbolic acid. The abscess cavity was 
then irrigated for the last time, a strip of iodoform gauze placed 
about the stump of the appendix and the caecum and left at the 
lowest portion of the incision. The peritoneum and muscular 
tissues were then sutured separately and in accurate apposi- 
tion as far as the drain. The wound dressed as usual. The 
appendix showed thickened walls, a perforation on one side, and 
it contained a faecal concretion about the size of a pea. 
January 18th. At 4 p.m. temperature 105.8°, pulse 128, and 
respirations 45. Patient was delirious all night, but retained 
medicines and milk. 
January 19th. 7 A.M. temperature 101.4°, pulse 122, respira- 
tions 22. Patient passed fairly good night, slept about four 
hours. Complained of pain in abdomen. Retained all medicines 
and nourishment. In the afternoon the dressings were changed. 
Gauze drain loosened up and partially removed. Wound doing 
nicely. Improvement progressed steadily. Developed a hard 
cough, treated by the muriate and carbonate of ammonium and 
Tr. opii camphorata. 
Temperature fluctuating between 99° and ioo° up to the 21st. Haynes: appendicitis in Children. 
7 
when the gauze was removed. From now on the temperature 
fell, reaching normal on the afternoon of the sixth day, January 
22nd. Light diet begun in addition to milk. Movements several 
each day. Cough troublesome, temperature rising to 990 for 
highest, but mostly normal up to the ninth day, January 26th. 
Cough better, temperature normal all day, pulse running 
about ioo°. Course now uneventful to complete recovery. 
Wound healed rapidly with exception of a small sinus. Dis- 
charged February 12th, with small sinus; February 19th, sinus 
healed. 
April 5th. Came to office. Small sinus persisting. This 
remained open until the first week in May, when the end of a 
silk suture appeared in the wound; this was removed and the 
sinus closed at once. 
Summary.-Cause, assigned to eating figs. 
Pain, in usual location. Fever and prostration. 
Localized suppurative peritonitis due to ruptured appendix. 
Duration of attack preceding operation, one week. In the 
hospital, twenty-five days. Time until loosening and removal of 
silk suture and permanent healing of the sinus, about four 
months. 
Present State.-Child seen May 6, 1898. In perfect health, 
has grown rapidly since the operation. The scar is perfectly 
solid, and no signs of weakness or hernia. Scar and right iliac 
fossa not sensitive to deep pressure. 
Case V.-Edward R., about fourteen years of age. 
History.-Boy, an inmate of the House of Refuge. Was con- 
fined to the bed with abdominal pain, tenderness and fever for 
several days. The tenderness was not typical in its location, 
being in or near the median line. The case was in the service 
of Dr. Van Santvoord, who transferred him to the Harlem Hos- 
pital, January 16th, 1897. 
Examination on Entrance.-Temperature 102.8°, pulse 122, 
respirations 24. Marked pain all over the entire abdomen, but 
greatest in the right iliac region. The abdominal muscles were 
very rigid, especially on the right side. Face, drawn, anxious, 
and dusky. 
Operation.-On opening the abdomen by the usual incision 
pus and fluid at once flowed from the wound. The entire 
abdominal cavity was filled with a thin yellowish fluid. Saline 
solution, peroxide, and saline irrigation freely used to remove it. 
The perforated, gangrenous appendix was removed as quickly as 
possible by simply ligating it close tqthe caecum. The stump was 
cauterized with pure carbolic acid. Abdominal cavity again irri- 
gated, iodoform gauze drain inserted so as to drain pelvic cav- 
ity, and the region about the ascending colon and caecum. The 
abdominal wall was closed in separate layers as far as the drain. 
During the operation whiskey and strychnine were freely given. 8 
Haynes: appendicitis in Children. 
After removal to the bed an enema of half a pint of saline solution, 
with ten minims of Tr. digitalis and two ounces of whiskey was 
given. In spite of free drainage, and full stimulation the boy 
died on the 18th. 
Summary.-Cause, not stated. 
Pain, near the middle line not directed towards the appendix 
until after it had ruptured. Marked muscular rigidity especially 
on right side. 
Case of general suppurative peritonitis following perforation 
of an inflamed appendix. 
Operation, drainage, death on second day. 
Case VI.-Edith L., aged seven years. 
History.-This is rather indefinite as at the beginning of her 
sickness she was prescribed for by one physician, and as she 
temporarily improved, she was under no medical supervision 
until the day before her entrance to the hospital. As obtained 
the child did not vomit at the beginning and she was not sick 
enough to go to bed, but was dressed and up and about, lying 
down at times on a sofa. She was not well, but complained 
very little. She was in this condition for about five days, when 
being taken worse with vomiting and pain on the right side of 
the abdomen, a second physician was called in, who recognized 
the nature of the attack and had her removed to the Harlem Hos- 
pital. 
Examination on Entrance.-July 17th, 1897,9 A.M. Tempera- 
ture 99.4q, pulse 104, respirations 26. There was a tumor in the 
right iliac fossa, oblong in shape, about two by three inches, 
tender to pressure. The general symptoms were so mild that 1 
told the house staff that only for the presence of the tumor 1 
would not operate then. Yet, inasmuch as the tumor was 
present it was probably formed of matted coils of intestines, and 
possibly there was a small abscess present, but I expected to 
find only a catarrhal appendicitis. 
Operation.-On opening the abdomen by the usual incision, 
the appendix was found immediately beneath and adherent to 
the peritoneum and surrounded by agglutinated coils of intestines. 
The omentum was also present and formed adhesions about 
the appendix and intestines. There was no pus present, though 
we were greatly surprised to find the appendix gangrenous 
throughout its entire extent, and only covered over by a thin 
layer of plastic exudation. Its walls ruptured in several places 
when its removal was attempted, but the surrounding parts had 
been protected by a packing of gauze pads. The base of the 
appendix and the adjacent wall of the caecum were much thick- 
ened and were very hard and stiff from inflammatory exudation, 
and it was impossible to invaginate the appendix into the caecum 
so the old method of ligating the appendix and cauterizing the 
stump was performed. The portion of the appendix removed Haynes: -Appendicitis in Children. 
9 
was about three and a half inches in length and from one-fourth 
to three-eights of an inch in diameter, and showed several per- 
fections. 
The wound was irrigated with pure peroxide of hydrogen and 
all the little pockets were thoroughly separated without rupturing 
the adhesions, and the peroxide allowed to penetrate to them; 
then the saline solution was turned in and the parts washed clean. 
The caecum at the base of the appendix looked so very bad I 
feared that the spot would slough out and a faecal fistula result. 
With this in view the caecum was carefully surrounded with 
iodoform gauze, which was brought out at the lower angle of the 
wound. The abdominal walls were sutured through and through 
with silk-worm gut. The course of the case was most satisfac- 
tory. The highest temperature was ioi° at 4 p.m., on the day of 
the operation, and the pulse 130. The temperature and pulse 
reached normal on the third day and remained so thereafter. On 
the fourth day the gauze drain was removed and two small sized 
rubber tubes side by side introduced. 
The recovery was rapid and the wound healed without a 
single drawback. She was discharged cured, August 4th. Dura- 
tion of attack before operation, about one week. Time in the 
hospital, eighteen days. 
Summary.-Onset, without characteristic symptoms, and 
those present very mild. 
Almost normal temperature and pulse even, with the appendix 
gangrenous for its entire extent. 
Absence of pain of any amount until the day before the oper- 
ation. Localized plastic peritonitis, gangrenous appendicitis, 
operation, recovery. 
Present State.-Have not been able to trace the patient. 
When discharged from the hospital she had a firm scar. 
In generalizing I shall confine myself to the cases here reported; 
as these are all of the severer types our considerations will not 
be complete in that those milder forms of appendicitis which 
recover without an operation being really indicated are omitted. 
Of the cases given, five were females, one a male. The oldest 
was fourteen, the youngest three years of age. 
The shortest duration of sickness preceding the operation 
was four days, (two cases) the longest seven days (four cases). 
The onset of the sickness was marked with localized pain in 
the right iliac fossa in four cases, sufficient to direct the atten- 
tion of the parents to this spot. In one case there was more 
of an uneasiness all over the abdomen, which later become 
localized in the usual place, and in another case the pain 
began about the middle line of the abdomen and did not be- 10 
Haynes: z/lppendicitis in Children, 
come localized until the appendix was on the point of rupturing 
or had ruptured. 
The temperature and pulse records are not available from the 
beginning of the attacks, they are therefore given as found a few 
hours preceding operation. 
Classifying the cases according to the conditions found in and 
about the appendix we find: one case where the appendix was 
distended to bursting with pus, but rupture had not taken place. 
Here, the temperature in the morning was 990, and in the even- 
ing a short time before operation 101.2°, with a pulse of 110. 
A second case showed a gangrenous appendix perforated in 
several places, but the perforations soldered temporarily 
with plastic lymph. The temperature was 99.4° and the 
pulse 104. The third case showed the appendix ruptured 
with a localized abscess. Here the temperature was 102.8° and 
the pulse 118. 
In the three remaining cases the appendix had ruptured 
into the peritoneum and a general septic peritonitis was present. 
One case had a temperature of 102°, and a pulse of 160. Another, 
a temperature of 102°, and a pulse of 140. The last, a tem- 
perature of 102.8°, and a pulse at 122. 
Considering the prominent constitutional symptoms of dis- 
ease, temperature and the pulse, we see that appendicitis is a 
disease of very low temperature and pulse rate. The tempera- 
ture and pulse do not reflect the serious nature of the inflam- 
mation until perforation of the appendix is imminent or has 
already taken place. This fact increases the difficulties of diag- 
nosis and may give the physician a feeling of security which 
may be suddenly disturbed by the perforation of the organ and 
the lighting up of a general septic peritonitis. 
We cannot pin our diagnosis, then, to the pulse and tempera- 
ture; in fact there are no one or two symptoms which can be 
decided upon as pathognomatic; we have to consider all the 
evidences in each case and then perhaps are undecided. 
Other constitutional symptoms are the facial appearance of 
the child; this is especially marked in cases that have developed 
peritonitis. It is not diagnostic in the mild cases, and at best is 
only suggestive of a severe or mild sickness, yet the considera- 
tion of the facies should not be overlooked. 
The local symptoms are by far the most important and are 
those upon which we must make our diagnosis consulting the Haynes: appendicitis in Children. 
11 
state of the temperature and pulse for confirmatory evidences. 
It is of the greatest importance that the examination of the abdo- 
men should be thorough and productive of results. In examin- 
ing children gentleness is the first requisite; this is especially 
true in abdominal affections, therefore be gentle with the child. 
Uncover the abdomen, look it over, noting the state of fulness; 
if it is distended in one part alone or generally. Consider the 
manner of respiration, whether the abdomen rises and falls, 
showing that the diaphragm is working, or whether the breath- 
ing is thoracic alone, indicating that the diaphragm is inhabited 
by the peritoneal inflammation. 
Percussion.-Percuss the left side, gradually working around 
to the location of the most tender region. The percussion 
should be light at first, and if no information is obtained, then 
stronger to locate deeper foci of inflammation. Percussion is 
chiefly useful in detecting the extent of the gaseous distension 
and the degree of tenderness of the bowels. As a means 
for locating an appendicular tumor or abscess, it is of slight 
usefulness, as there may be a localized abscess giving a 
tympanitic note, because it is covered by coils of intestines 
filled with gas. If a tympanitic note is obtained in the region 
of the usual liver dulness it shows that the intestines are 
greatly distended with gas or that it has escaped through a per- 
foration into the abdominal cavity, and indicates a most serious 
condition. 
Palpation.-Lay the whole hand gently upon the abdomen 
on the side away from the painful spot as told by the child. Do 
not make point pressure with the fingers but carefully depress 
the abdominal wall with the flat of two or three fingers. In this 
examination note the ease with which the abdominal wall can 
be depressed, the degree and area of tenderness, and especially 
the state of the muscles themselves, whether they are flaccid all 
the time or contract on deep pressure, or if they contract when 
making a superficial examination showing increased irritability, 
or if they are in a state of reflex spasm all the time. 
The degree and area of this reflex muscular contraction or 
spasm is a very valuable indication of the intra-abdominal con- 
dition. The more severe the inflammation and the greater its ex- 
tension from the original focus, the more general and acute the 
muscular spasm. In most cases you will find a point where the 12 
Haynes: in Children. 
tenderness and pain are greatest; this is usually at the place des- 
ignated as " McBurney's point," one-third to one-half of the dis- 
tance from the anterior superior iliac spine toward the umbilicus. 
The degree of sensitiveness at and about the appendix gives us a 
clue to the condition of that organ. The more sensitive it is the 
more acute the inflammation, as a rule. After perforation has 
taken place the local signs are masked by the general ones im- 
mediately lighted up. 
In most cases you will not find a well-defined tumor but a 
state of fulness which is very suggestive, for it means that the 
intestines are being massed and matted together and their per- 
istaltic movements inhibited by the irritation of the inflamed 
appendix. 
With a well-defined tumor you expect to find a localized 
abscess or coils of agglutinated intestines surrounding the ap- 
pendix. With an abscess already formed besides the tumor 
which it produces, there may be a sense of imperfect fluctuation 
but unless there is considerable fluid in the abscess, or it be 
formed close to the surface, or the reflex muscular rigidity of the 
abdomen be slight, you cannot detect fluctuation. This is a 
symptom of little value at all events and is not necessary to the 
diagnosis. 
Diagnosis.-The symptoms which are most useful in deter- 
mining the state of the inflamed appendix, and especially those 
which point to an early rupture of the tube, are these: there 
will be abdominal tenderness, usually not extending beyond the 
median line with its most sensitive area over the appendix; 
there will be found reflex muscular rigidity of the right abdo- 
minal muscles, this reflex contraction becoming more marked as 
you approach the right iliac region. If you can press the abdo- 
minal wall backward sufficiently far you may detect a tender 
mass, oblong in shape, in the region of the appendix, which is 
probably that organ. But I would warn you against making 
such pressure as will hurt and alarm the child, or even in making 
too much pressure in any case, as from the histories previously 
given you will see how early perforation takes place, and in- 
judicious and too forcible pressure may rupture an already 
thinned and distended organ. I do not think it wise, therefore, 
to try and palpate the appendix in all cases, unless as a prelimin- 
ary examination just before an operation, but to determine its Haynes: appendicitis in Children. 
13 
probable condition by careful palpation of adjacent parts, for 
they in their tenderness and spasm reflect the degree of 
inflammation present in the appendix. 
In connection with the question of threatened perforation of 
an appendix giving the symptoms of an acute inflammation the 
temperature and pulse offer a clue; before perforation the tem- 
perature may range from 990 to ioi° F., and the pulse from 
too to no; but as soon as perforation has taken place, although 
the temperature may only show a rise to 102° or 103°, the pulse 
jumps up to 140 or 160. So in a case of tender abdomen, rigid 
right rectus and abdominal muscles, severe pain on pressure 
over McBurney's point with or without a tumor, with a tem- 
perature not far from ioo°, but with a pulse relatively constant to 
it at about 110, although it may be full and bounding, you may 
be sure that rupture has not yet taken place but is very near at 
hand, and an early operation is demanded. 
If rupture has taken place into the peritoneal cavity the 
changes in abdominal symptoms are more in degree than in 
kind; the tenderness increases and spreads all over the ab- 
domen, though it is greatestover the region of the appendix; 
the entire abdomen is hard from the contraction of the 
muscles, though the spasm is still more marked to the 
right of the median line; a tympanitic note may be obtained 
in place of the normal liver dulness, the respiration is thoracic, 
the temperature at first shows very little disturbance, be- 
ing between 102° and iO3°;the pulse, however, has chang- 
ed markedly and will be running at the rate of 140 to 160; 
it is thin, hard and wiry; in fact, the pulse usually described as 
that of peritonitis. 
The appearance of the patient with general septic perito- 
nitis is characteristic; there is a striking shrinkage in the 
face; it is drawn and anxious, in fact, the so-called Hippo- 
cratic visage. 
Cases which begin very mildly may present the most serious 
conditions on the operating table, as did Case VI. This child 
laid about the house for a week before developing alarming 
symptoms. Case V. also, who was sick with indefinite ab- 
dominal symptoms for several days, and then in a few hours 
presented the evidences of septic peritoneal infection. You 
must be on your guard, therefore, for these so-called mild and 14 
Haynes: appendicitis in Children. 
indefinite cases may very unexpectedly become the most 
dangerous. 
The case that died was in extremis when placed on the oper- 
ating table and the operation was undertaken to save life, as 
death was sure without it. Some surgeons advise to let such 
cases alone, saying that they will die anyway and to use the knife 
only discredits the operation. But I do not think we can afford 
to become the judges in such cases and sentence the patient to a 
certain fatal termination, especially for the reason assigned. 
Our judgment may prove true in the great majority of cases, 
still we have the satisfaction of knowing that we have done 
our utmost, and in those few cases which live we have the 
greater satisfaction of knowing that we have been instru- 
mental in saving life. Therefore give the desperate cases 
a chance to fight for their lives, even at the risk of in- 
creasing our death rate. It may help you to my way of 
thinking to know that in seven cases of severe general septic 
peritonitis following perforation of the appendix occurring in 
children and adults upon whom I have operated, four patients 
recovered and three died. Of the other cases, nine in number, 
all recovered. 
Regarding the Operation Itself.-If time permits, the 
patient is to be carefully prepared by securing an opera- 
tion of the bowels, scrubbing the abdomen and the use of 
an anticeptic dressing, with the careful administration of 
stimulants, such as whiskey, strychnine and digitalis, if 
necessary. The details of preparation for the operator, as- 
sistants and patient just before the operation are too well 
known to need repetition here. I would say this, that after 
the preparations are all made only decinormal salt solution 
is used for irrigating the parts. 
The incision by preference is made in a line parallel with the 
fibres of the external oblique, about one inch from the anterior 
superior iliac spine with its center over McBurney's point. The 
length of the incision is of little moment. It is better to make 
the incision long enough at the beginning than to lacerate the 
soft parts by forcible retraction, or to have to enlarge the original 
incision during the operation. From two to three inches is 
enough, according to the size of the child. In cases of mild 
catarrhal appendicitis the very small incision may be sufficient, Haynes: appendicitis in Children. 
15 
but 1 hold that to attempt to disengage and remove a swollen 
appendix through a small incision is poor surgery, because of 
the danger of rupturing this organ by the manipulation neces- 
sary for such procedure. 
In children it is better to divide the transversalis and internal 
oblique in line with the external oblique, because the interval 
between the anterior superior iliac spine and the linea semilu- 
naris is not great enough for the performance of the operation 
advised by McBurney in adults, of separating the muscles in the 
direction of their fibres. Make clean cuts through these muscles 
for the entire extent of the skin incision. 
Reaching the peritoneum, pick it up between thumb forceps 
and divide it, keeping in mind that often the intestines are 
tightly adherent to it. Having entered the abdominal cavity you 
proceed according to the case. If a simple case without adhe- 
sions, bring up the appendix, ligate its mesentery, place a con- 
tinuous sature in the caecum about its base, clamp the appendix 
and divide it a fourth of an inch from the caecum; while the 
appendix is being divided, have the purse-string suture tight- 
ened, sponge off the end of the stump of the appendix with pure 
carbolic acid, invert it into the caecum, tie the encircling suture, 
then insert a continuous suture at a little distance from the first, 
so as to cover it in. 
Suture the peritoneum with fine chrome catgut, the trans- 
versalis and internal oblique, as one muscle, with a little heavier 
strand, and the external oblique with a similar one. In handling 
the external oblique be careful not to strip it from the deeper 
parts, as by so doing you tear off its blood supply and favor 
necrosis of the fascia. Suture the skin with plain sterilized 
catgut. Seal with aristo-collodion. The case will not need 
attention for two weeks. If the appendix is found buried amid 
coils of intestines, these must be carefully separated, remember- 
ing that at the center of such a mass you may find a pus-pocket, 
hence the necessity of first carefully walling off the general 
abdominal cavity with gauze pads, each one of which has a tape 
sewed to it and a clamp fastened to the tape. 
If the appendix is found still whole remove it as just indi- 
cated. If the caecum and stump of the appendix are so thickened 
by the inflammatory exudate as to render the inversion impossi- 
sible, one plan is to do the old operation of ligating the appendix 
and cauterizing the stump with pure carbolic acid; the newer 16 
Haynes: appendicitis in Children. 
and better way, but which I have not tried yet, is to cut off the 
appendix level with the caecum and close the hole with two 
rows of continuous Lambert sutures. 
Of course, in the last case you run the risk of having the con- 
tents of the bowel escape, but by compressing the caecum before 
the division and keeping the part tightly grasped by the assist- 
ant, this risk is diminished. If the appendix has ruptured and 
a localized abscess formed, remove the appendix, or as much of 
it as possible, dealing with it according to the preceding plans. 
In your anxiety to be thorough do not tear up the protecting ad- 
hesions, unless absolutely necessary to complete the opera- 
tion. As soon as such an abscess cavity is opened, wash it 
out with saline solution, then with pure peroxide of hydro- 
gen, followed by more saline, then dissect out and remove the 
appendix. 
Such a case as this should be drained, and the best drain is 
gauze, plain or iodoformized, around which has been wrapped 
thin rubber tissue. This is the cigarette-rubber-gauze drain of 
Morris. 
If you find that the appendix has ruptured and discharged its 
contents into the peritoneal cavity, it is necessary to flush it out, 
and nothing is any better than a glass intrauterine tube with a 
diameter of half an inch. Pass this tube up to the spleen, to 
the liver, into the left iliac fossa, into the pelvic cavity, and use 
quarts of hot sterilized salt solution, wash until the fluid returns 
perfectly clear, then turn in pure hydrogen peroxide and remove 
this with a second saline irrigation. Sponge out the excess of 
fluid, place your gauze dam and deal with the appendix. Drain 
such a case. If in doubt, drain, if not needed it can be removed 
in twenty-four hours and no harm result. If needed, but not 
used, you will lose the patient, as a rule. 
In closing the abdominal walls around a drain you follow the 
same steps as given in the first case, closing the layers separately 
as far as the drain, and protecting the sutured portion of the 
incision with the aristo-collodion dressing. 
In case the patient is in extremis and haste must be made, do 
not bother with refinements. Cut quickly into the abdominal 
cavity, flush it out, ligate and cut off the appendix, turn in the 
peroxide of hydrogen, and irrigate again. Insert the drain, placing 
the gauze about the stump of the appendix. Close the abdo- Haynes: appendicitis in Children. 
17 
minal wound with silk-worm sutures through everything. If the 
patient lives and a hernia results, you can repair the abdominal 
wall at some future time. Life is at stake, and death will win 
unless you can defeat him by fast work and removal of the in- 
fection. 
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