THE SURGICAL TREATMENT OP CHRONIC 
CATARRHAL APPENDICITIS. 
R. HARVEY REED, M. D. (UNIVERSITY OF PENNA.), MANSFIELD. 
In searching for the practical uses of the appendix ver- 
miformis, I am constrained to repeat the old adage, 
“ Everything can something do, 
But pray of what use are you ?” 
Unless it is to get up a disturbance with humanity, and 
give employment to the surgeon and the undertaker. 
We are told that the only mammals which are so fortu- 
nate as to have escaped this rudimentary conclusion of a 
once lengthened caecum are the orang-outang and the wam- 
bat, excepting an occasional anomalia found in the human 
family who has fortunately got beyond this rudimentary 
decoration. 
So much has been said and written about this useless 
appendage in the last ten years, that I shall not take up 
your time discussing its anatomy and anatomical relations, 
nor in trying to find an excuse for its existence by at- 
tempting to hypothesize some imaginary-, trivial benefit 
it might be, under certain circumstances, in aiding the 
process of digestion, but will proceed at once to the con- 
sideration of the surgical treatment of chronic catarrh of 
this distinguished appendage. 
Whilst catarrh in the more limited sense of the word is 
intended to indicate a flow or discharge from a mucous 
surface, according to the older authors, yet bv the more 
recent writers it has'been given a wider scope, and conse- 
quently it has been applied to general inflammations of 2 
8URGICAL TREATMENT OF CATARRHAL APPENDICITIS. 
the mucous membranes, which of course may be either 
acute or chronic. 
Again, whilst catarrhal inflammations of the mucous 
membranes are usually accompanied by more or less dis- 
charge, yet we may have a chronic inflammation of a 
mucous membrane with little or no discharge, in which 
case there is usually an atrophic condition of the mem- 
brane. Usually, however, there-is hypertrophy of this 
membrane with an excessive mucous or even muco-puru- 
lent discharge, which is not infrequently associated with 
a circumscribed necrosis of the mucous membrane, which 
in chronic catarrhal appendicitis frequently extends to 
and may even involve the serous coat of the appendix, 
producing a complete perforation. 
The peculiar location of the appendix vermiformis, as- 
sociated with its anatomical construction and relations, 
predisposes this particular portion of the digestive tract 
to chronic catarrhal inflammation more than any other 
one portion of the intestinal canal. 
Some one has said that the absorbent properties of this 
rudimentary attachment were greater in proportion to its 
size than any other portion of the alimentary tract; and 
hence the liquid portions of the contents of the intestine 
which found their way into the appendix were more rapidly 
absorbed and therefore left a concrete mass which be- 
comes a foreign body, and sets up an inflammation of the 
mucous membrane which soon becomes chronic. 
As to the veracity of this statement, I am not prepared 
to give any definite opinion, but it seems to me that ow- 
ing to the small diameter of this appendage, which in ad- 
dition is closed at its most pendent portion, and which 
opens above into the caecum, from which gravity alone 
will promptly supply it with both liquids and solids at all 
hours of the day or night, it is easy to account for the 
formation of concretions in this appendicular attachment. 
Under the circumstances there must be more or less 
stasis of the contents of the appendix vermiformis, which R. HARVRY REED, M. D. 
3 
ordinarily must be emptied of its contents by a sort of a 
vis a tergo process, which we must all concede is not very 
active. 
Consequently, owing to the imperfect circulation of the 
contents of the appendix and the continued absorption 
of the liquid portions therein, it is easy to account for the 
formation of these concretions which are liable to be 
followed with chronic catarrhal inflammation and ulcer- 
ation of its mucous membrane, which so frequently re- 
sult in perforations or acute suppurative inflammation 
which not only threatens the patient’s life but often de- 
stroys it altogether. In addition to these concretions 
which are found so frequentl}7 in the appendix, it is liable 
to be invaded by cherry pits, grape seeds and the like, 
which have the same effect on it as the concretions which 
may accumulate in it from the contents of the bowel. 
Again, we may have a chronic appendicitis following an 
attack of acute enteritis or even an attacf of peritonitis, 
metritis, salpingitis or ovaritis, which often results in ad- 
hesions of the appendix to some of these parts. It is 
only a few weeks since I operated on a case, where I 
found the appendix vermiformis firmly attached to the 
fundus of the uterus and which was greatly enlarged and 
thickened by chronic inflammation. 
Again, I have found it adherent to the broad ligament, 
the fimbriated extremity of the Fallopian tube, and even 
the ovary. 
The next important question is, how shall we determine 
the existence of chronic catarrhal appendicitis with prac- 
ticable accuracy ? 
Wemusfrall admit that simple acute appendicitis or 
suppurative perityphlitis is easily diagnosticated; but 
when it comes to making an accurate diagnosis of chronic 
catarrhal appendicitis, it is much more difficult. It is true, 
that many cases of chronic catarrhal appendicitis fail to 
come under the notice of a surgeon until they are suffer- 
ing from an exacerbation of their chronic trouble, or an 4 
SURGICAL TREATMENT OF CATARRHAL APPENDICITIS. 
acute attack of appendicitis which is threatening life. 
Yet, when these chronic cases do present themselves to 
the surgeon during the intervals of their recurrent at- 
tacks of acute inflammation, then is the time for the sur- 
geon to determine the exact nature of his case and follow 
it with practical and timely advice, and not wait for an 
inflammatory eruption to occur before he decides what it 
is, or what he will do for it. 
The point was well taken by Fitz when he claimed 
that usually the primary causes of every perityphlitic 
abscess were the result of a perforated appendicitis (and 
we might add) or a chronic inflammation of the appendix 
which so frequently results in perforation sooner or later. 
This being true then, it is easy to see the importance 
of making a clear diagnosis of a chronic catarrhal inflam- 
mation of this rudiment of the caecum as early as possible. 
In order to do this you will find it important to ascertain 
the condition 6f the bowels; for if you have constipation 
alternating with diarrhoea and accompanied with circum- 
scribed tenderness over the region of the right iliac fossa, 
it is well to be on the lookout for a case of chronic catar- 
rhal appendicitis, and especially so if there is a history of 
having had an attack of acute perityphlitis. If the case 
is a woman, you may be able to feel the thickened ap- 
pendix by placing one of the index fingers well up in the 
right horn of the vagina whilst you palpate over the 
region of the appendix with the other, excepting in cases 
where the abdominal walls are very thick and firm. 
In this class of cases you can easily distinguish be- 
tween the ovary and the appendix by remembering that 
when you squeeze the ovary it produces a sen- 
sation, whilst pressing on the inflamed appendix 
produces only pain without this peculiar sensation of 
nausea. 
In the male there is no occasion for making a diagno- 
sis of this character. The very fact that you have a 
circumscribed tenderness over the region of the right R. IIARVEY REED, M. D. 
5 
iliac fossa is sufficient evidence, barring the bare possi- 
bility of a hernia, to arouse your suspicions. 
If the irritation is very marked, you may have vomit- 
ing as well as constipation with all the symptoms of 
intestinal obstruction. I have seen numerous cases of 
this character when there was every apparent evidence 
of obstruction to the intestinal tract, but which in reality 
was not obstructed at all only so far as the inflammation 
of the appendix extended to the muscular walls of the 
cmcum and produced temporary paralysis resulting in 
obstruction. 
I recall one case in particular which I reported some 
years ago, in which there was a strangulated hernia of 
only the appendix vermiformis, in which there was 
every symptom of occlusion of the bowel, which was 
relieved by an operation just as promptly as if we had 
had a real obstruction of the intestines. I speak of 
this to show you that inflammation of the appendix will 
produce constipation and even stercoraceous vomiting 
just the same as in complete obstruction of the bowel. 
In the severer forms of chronic catarrhal appendicitis 
the pain may occasionally be referred to the umbilical 
or epigastric region. Again, the patient, if a close ob- 
server, may notice mucous or muco-purulent discharges 
attached to his stools, which of course might come from 
some other part of the intestinal tract, but if he has 
circumscribed tenderness over the region of the appendix 
and no marked tenderness elsewhere along the alimen- 
tary canal, it is reasonable to conclude that it is more 
probable that it comes from the appendix than elsewhere. 
Again, if a patient comes to you complaining of 
either gastric or intestinal indigestion or both, accom- 
panied with a circumscribed tenderness over the region 
of the right iliac fossa, look out for a case of chronic 
catarrhal appendicitis. 
In a patient where the abdominal wall is very thin 
and the appendix is very much thickened, you may be 6 
8URGICAL TREATMENT OF CATARRHAL APPENDICITIS. 
able to trace it by a careful digital examination associ- 
ated with percussion. 
Rectal examinations are only beneficial for obtaining 
negative results; for instance, a patient is having 
mucous and muco-purulent discharges associated with 
the stools, and it is a question whether the mucus 
comes from the rectum or higher up, then an examina- 
tion may decide the question which previously may have 
been one of doubt. 
We have already spoken of attachments which may 
occur in the female between the appendix and the uterus 
or some of its appendages; of course in the male these 
can all be excluded, but we may have omental attach- 
ments, which are common to both. 
I remember of holding a post-mortem a few years ago 
on a physician who died of rupture of the heart, who, 
during life, had frequently referred to a tumor in the 
right iliac fossa, and who had frequent attacks of gastric 
and intestinal indigestion, which the autopsy revealed to 
be undoubtedly the result of chronic catarrhal appen- 
dicitis, as we found the appendix attached to a roll of 
omentum, no doubt the sequela of chronic inflammation. 
You will readily concede that we might have the same 
condition of affairs regarding attachments of the omen- 
tum and appendix in the female as well as in the male. 
Having cleared up your diagnosis and fully decided 
that you have a case of chronic catarrhal appendicitis, 
the next important question that confronts you is, how 
shall we treat it? 
Of course, the timid and uncertain doctor will always 
advise the expectant treatment, and is ever ready to 
“ wait for something to turn up,” which advice the un- 
suspecting patient is usually very ready and willing to 
accept. 
Arnica, poultices, liniments and blisters form the chief 
weapons of external “ warfare ” under these circum- 
stances, whilst “ blood medicine,” “ liver pills ” and R. HARVEY REEt), M. t). 
“tonics” are given to fortify the inner man against the 
invasion of this subtle foe. 
The patient gets better and worse, alternately, from 
time to time, until finally a crisis comes. By this time, 
however, the catarrhal inflammation has done its work, 
and a perforation has taken place, and the result is an 
attack of perityphlitis. Acute, circumscribed, or even 
general peritonitis has set in, and death is staring the 
patient in the face. A surgeon is sent for, but it is too 
■late, and the undertaker completes the work of expec- 
tancy. If, however, nature comes to the rescue and 
throws up a fortification, so to speak, of plastic material 
around the perforation, and confines the escaping con- 
tents of the perforated appendix to a limited area, then 
you will most likely have a perityphlitic abscess, which 
the surgeon’s knife may relieve and permit your patient 
to get well, with a lot of peritoneal adhesions and general 
thickening around the end of the caecum, which may pos- 
sibly involve the ileo-caecal valve, and lay the foundation 
for a case of intestinal stenosis at some time in the 
future. 
In illustration of the above I recall a case, to which I 
was called in counsel a few years ago, of a young man 
whom I found dying from acute peritonitis, which I 
diagnosed as a result of a perforation somewhere in the 
region of the appendix. 
A post-mortem confirmed my opinion, and revealed a 
concretion in the appendix which had set up a chronic 
catarrhal appendicitis, followed with perforation, general 
peritonitis and death, in proof of which I will ask you 
to examine the specimens which I obtained from this 
case, and which I will now pass around the room for 
your inspection. 
In the same connection I recall another case to which 
I was called a few hours before death, which the post- 
mortem revealed to be a case of acute peritonitis, the 
result of a perforation of the appendix from chronic  SURGICAL TREATMENT OE CATARRHAL APPENDICITIS. 
appendicitis. In this case, however, I was not fortunate 
enough to secure the specimen. 
I might go on multiplying these cases, but that would 
only be occupying your time to no advantage, and would 
prove nothing more than I have already proven ; for as 
has been said, “by the mouth of two or three witnesses, 
every word shall be established.” 
There is no question in my mind but that a timely 
amputation of the appendix in each of these cases would 
have saved their lives and secured them health and com- 
fort for years to come. 
It was my good fortune on one of my visits to Pro- 
fessor Senn’s clinic, at the Milwaukee Hospital, to see 
him examine a case and diagnosticate chronic catarrhal 
appendicitis, and witness him operate the same case and 
remove from a young man a thickened appendix, the 
result of chronic inflammation, the walls of which had 
almost ulcerated through in several places, producing a 
perforation which no doubt would have occurred in a 
short time, had he not been operated upon and the ap- 
pendix amputated. 
In answer then to my question, “ How shall I treat 
these cases 1 ” I will reply: By all means amputate the 
appendix just as soon as you are positive of the existence 
of chronic catarrhal inflammation of the same. Don’t 
wait for something to turn up—those days are gone by ; 
be accurate and active, and don’t wait for the undertaker 
to come to your rescue and bury the results of your pro- 
crastination beneath the sods of the valley. The opera- 
tion is an easy one and not attended with any marked 
danger to life, if properly performed under strictly asep- 
tic precautions. In fact, the patient assumes more 
danger every day he lives harboring a difficulty of this 
character than he does in having it removed by an oper- 
ation. Again, you have the satisfaction of knowing, 
that like a sheep’s tail, the appendix is neither useful nor 
ornamental, and the sooner it is cut off the better. In amputating the appendix, it is only necessary to 
make an incision over the region of the appendix parallel 
to Poupart’s ligament just large enough to expose the end 
of tlie crncum and its rudimentary attachment. Then 
ligate the appendix as close as possible to the caecum with 
an aseptic silk ligature, nip off the offending rudiment 
with a pair of scissors, cover the stump carefully with 
a hood of the omentum which should be held in place 
with a few aseptic silk stitches, make your toilet carefully 
and close up the external wound and cover it with an an- 
tiseptic dressing ; place your patient in bed and keep him 
.there until the parts are thoroughly united and have re- 
gained strength enough to resist the tendency to ventral 
hernia. 
When this operation has been successfully performed, 
you have removed the ax, so to speak, which was hanging 
by a frail thread over the head of your 'patient and daily 
threatening his life. You have given him a new lease of 
life with an extended expectancy of the same, and made a 
patient who was once uninsurablea fit subject for insur- 
ance, saying nothing of the comfort, both mental and phy 
sical, you have afforded him by the operation. 
Then, as Solomon says, uthe conclusion of the whole 
matter is: ” 
R. HARVEY REED, M. D. 
1st. That the appendix vermiformis is a useless rudi- 
ment of the caecum. 
2d. That chronic catarrhal appendicitis is always dan- 
gerous and liable to be followed at any time with hazard- 
ous and even fatal results. 
3d. That medical treatment is of little or no perma- 
nent value in this class of cases. 
4th. That the only safe and reliable method of treat- 
ing chronic catarrhal appendicitis, and the only treatment 
that will promise permanent relief to your patient, is 
prompt amputation of the appendix.