[Reprinted from the New York Journal of Gynaecology and Obstetrics 
for February, 1894.] 
REPORT OF FIVE CASES OF ACUTE APPENDICITIS* 
Professor of Gynaecology, Post-graduate Medical School of New York. 
G. M. Edebohls, M. D., 
Case I.—Miss O. 8., aged nineteen, was seen in consultation with 
Dr. E. J. Gallagher, from whom the following history was obtained ; 
Her periods, up to the last, had always appeared with regularity. On 
July 6, 1893, her menses appeared, one week overdue. On July 7th 
she was caught in a rainstorm and wet through and through. Dur- 
ing the night menstruation ceased, and sharp abdominal pains sud- 
denly developed ; these pains soon became localized in the right 
groin. 
Dr. Edebohls first saw the patient with Dr. Gallagher on July 9th. 
They found her in shock ; temperature, 103.250 ; pulse, 140 and very 
small ; bowels tympanitic; abdomen sensitive to pressure in several 
places, but especially over Mcßurney’s point, where a thickened, 
rounded cord, running over the pelvic brim into the pelvis, could be 
distinctly palpated. 
Examination per vaginam revealed a tender mass behind and to 
the right of the uterus. The mass was of about the size of the nor- 
mal uterus, and was continuous outward and upward with the mass 
felt in the right iliac fossa. Uterus and left annexa normal in size 
and position. Right annexa not palpable, being lost in the pathologi- 
cal mass. 
Diagnosis.—Acute appendicitis, with a mental reservation of pos- 
sible ruptured tubal pregnancy. 
Operation advised and performed at the patient’s home on July 
10th, at 3 p. m.—sixty-three hours after the beginning of the attack— 
with the assistance of Drs. E. J. and William Gallagher and John 
McParlan. Ten-centimetre incision along outer border of right rectus 
* Read before the New York Obstetrical Society G. M. Edebohls, M. D. 
abdominis, the lower end of incision reaching down to Poupart’s liga- 
ment. The presenting intestines were deeply injected and inflamed, 
and covered with a thick fibrinous layer, but not adherent in such a 
manner as to shut off the general peritoneal cavity. After lifting the 
intestines out of the right iliac fossa the acutely inflamed and very 
much enlarged right Fallopian tube, covered with plastic exudate and 
embracing a normal right ovary, was encountered. The condition of 
the tube was so bad that it was removed together with its ovary. 
The anpendix vermiformis was now sought for and found extend- 
ing from behind the caput coli along the posterior aspect of the right 
broad ligament downward and inward into the pelvis, where it occu- 
pied Douglas’s sac, which, with its surrounding exudate and pus, it 
almost entirely filled. 
The appendix measured fully eight centimetres in length by about 
two centimetres in average diameter, being altogether the size and 
much the shape of a large thumb. More than half of its circumfer- 
ence, that distal from the attachment of the meso-appendix, was gan- 
grenous along its entire length, the remainder of the wall being-in- 
tensely congested and swollen. Parts of the gangrenous wall had 
fallen away, leaving the interior of the appendix in free communica- 
tion with the peritoneal cavity. Two bean-shaped masses of hardened 
faecal matter were found inside of the appendix, which was surrounded 
by a great deal of exudate and a small quantity of pus. 
The diseased appendix was shelled out of Douglas’s sac, the intes- 
tines being held out of the wray and the peritoneal cavity protected by 
sterilized gauze, tied off with fine silk and removed. The rotten con- 
dition of the caecum at the site of origin of the appendix did not 
permit of the usual Lembert suture over the inverted stump of the 
appendix. 
The bed from which the pathological masses were removed, and 
the adjacent inflamed coils of intestine, were dried with sterilized 
gauze, touched with gauze wrung out of i-to-i,ooo sublimate solution, 
and again dried. No irrigation. The bed was then packed with iodo- 
form gauze, the end of which was led out of the lower angle of the 
wound. The upper two thirds of the wound were closed with through- 
and-through silkworm sutures. Usual dressing of sublimated gauze. 
Patient rallied well from the operation. Pulse and temperature be- 
came normal on the third day, and convalescence thereafter was un- 
interrupted. The united part of the abdominal wound healed by first 
intention, and Dr. Gallagher took care of the cavity and the wound 
until complete closure some three weeks later. Report of Rive Cases of Acute Appendicitis. 
3 
Case II.—Miss A. K., aged fifteen, was seen in consultation with 
Dr. D. J. Ruzicka, her attending physician, and Dr. H. C. Hoefling.. 
She had been well all her life, with the exception of an attack of ap- 
pendicitis in March, 1893, for which she was treated by Dr. Ruzicka. 
The attack was of a mild type, lasted about ten days, and was fol- 
lowed by a still milder relapse at the end of ten days more. 
From that time she was perfectly well until Thursday, November 
16, 1893, at 11 p. m. Then, very suddenly, great pain in the right 
groin, radiating into the thigh, and vomiting ; pulse, 120 ; no elevation 
of temperature. No great change until the next day, Friday, at 9 
p. m., when the temperature ran up to 102°, the pulse still remaining 
at 120. On Saturday, at 3 a. m., sudden very acute pain, profound 
shock, and great prostration; temperature, 103°; pulse, 136, small 
and thready. 
This was still her condition when Dr. Edebohls first saw her, on 
Saturday, at 6A. m. Dr. Ruzicka had diagnosticated acute appendi- 
citis, with rupture occurring three hours previously, and in this diag- 
nosis Dr. Hoefling and he concurred. Immediate operation was ad- 
vised and accepted by the girl and her family. 
Operation, November 18th, at 9 a. m., thirty-four hours after be- 
ginning of the attack, and six hours after perforation. Ten-centimetre 
incision, slightly oblique, its center corresponding to a point midway 
between the anterior superior spine of the ilium and the umbilicus. 
When the peritoneal cavity was opened, about sixty grammes of soft- 
ened faeces, mixed with serum, ran out. There were absolutely no 
adhesions to shut off this collection in the free peritoneal cavity, 
although the angry congestion and some soft deposits of fresh lymph 
indicated the beginning of acute peritonitis. 
Sterilized gauze was at once placed in such a way as to protect the 
general peritoneal cavity, and the fluid faeces were mopped up and re- 
moved by means of dry gauze serviettes, without irrigation. The ap- 
pendix was found on the inner and posterior aspect of the caecum. It 
was but moderately thickened, partially gangrenous, and doubled up 
on itself in the middle, so that the free end was attached by adhesions 
to its point of insertion into the caecum. The perforation had occurred 
at the point of flexure, on its inner aspect, and soft faecal matter was 
escaping thence into the peritoneal cavity. The appendix was tied 
off at its base and the stump inverted into the caecum by suturing the 
peritonaeum over it. After another dry cleansing and touching all ap- 
proachable contaminated surfaces with gauze wrung out of i-to-i,ooo 
sublimate solution ; the region about the site of the removed appendix 4 
G. M. Edebohls, M. D 
was packed with iodoform gauze, the end of which was led out at the 
lower angle of the wound. No irrigation whatever, the danger of 
spreading infection by means of it being considered greater than any 
possible advantage that might accrue from its use. The upper two 
thirds of the wound were closed by through-and-through silkworm 
sutures. 
Patient bore the operation well. The gauze packing was removed 
three days later and a rubber drain substituted. An acute pneumonia, 
involving the lower two thirds of the right lung, supervened on the 
sixth day and sent the temperature, which had been normal for two 
days, up to 104.5°. The pneumonia ran a pretty tempestuous course 
for five days, when it subsided. The patient has since made a good 
recovery. 
Chronic Appendicitis. 
Case 111.—Miss M. 8., aged eighteen, came under observation in 
January, 1893. She had suffered for nearly two years past with symp- 
toms due to a movable right kidney, and had during that time had 
several attacks of appendicitis. 
On examination, there were found an endometritis and a right kid- 
ney movable to the extent of ten centimetres. The appendix vermi- 
formis could be palpated as a distinct hard cord, about the diameter 
of a lead pencil, sensitive on pressure. 
On February 10, 1893, Dr. Edebohls performed curettage of the 
uterus, and nephrorrhaphy for fixation of the right kidney. During 
convalescence from these operations she had an attack of appendicitis, 
which was treated by blisters and internal medication. She was dis- 
charged on March 27th, the appendix being still enlarged and sensi- 
tive on pressure. 
The symptoms of appendicitis persisted, with exacerbations, until 
her readmission a month later. During this time repeated examina- 
tions showed the appendix more or less enlarged at various periods. 
On April 28th he removed the appendix vermiformis by operation. 
The appendix was found elongated, thickened to the size of a lead 
pencil, and rigid, representing the so-called chronic catarrhal appen- 
dicitis. No packing or drainage, but complete closure of the abdom- 
inal wound with buried silkworm sutures. 
She remained perfectly well until August, when some of her old 
symptoms returned. An examination showed the left kidney to have 
become movable to the extent of ten centimetres, the right kidney re- 
maining securely anchored to the lumbar scar. The left kidney, it 
may be added, was not movable at the time of operation upon the Report of Rive Cases of Acute Appendicitis. 
5 
right kidney. He uroposed to moor the left kidney by nephrorrhaphy 
in the near future. (Patient presented.) 
Case IV.—T. L., aged thirty-one years, married, mother of two 
children, was sent to him by Dr. Gerrit Blauvelt, of Nyack, N. Y. 
She considered herself fairly well up to the birth of her first child ten 
years ago. Since then she has suffered much from backaches, head- 
ache, leucorrhoea, nervousness, and dyspepsia. Following the birth 
of her second child, four years ago, all the above symptoms became 
aggravated, menorrhagia and bearing-down sensations in the pelvis 
being superadded. 
In February, 1893, she was operated upon by a distinguished sur- 
geon of this city, who performed trachelorrhaphy and shortening of 
the round ligaments at one sitting. 
Although the anatomical results attained by these operations were 
perfect, no therapeutical results followed, the patient remaining the 
same as before operation. In August, 1893, by the advice of her 
family physician, she consulted Dr. Edebohls. 
Examination showed the uterus in normal anteversion, the cervix 
well repaired and a trifle conical, endometritis, bilateral catarrhal 
salpingitis of a mild type, and a right kidney movable to the extent 
of five centimetres. 
The movable right kidney being held responsible for most of her 
symptoms, nephrorrhaphy was advised and performed on October 20, 
1893, curettage of the uterus being done at the same sitting. 
During convalescence an attack of pain in the right groin, accom- 
panied by digestive disturbances, first called attention to the appendix 
vermiformis. The patient volunteered the statement that she had 
had similar attacks repeatedly during the past eight years. On pal- 
pation, the appendix was found to be of the thickness of a lead pencil, 
rigid, and painful on pressure. 
Ecphyadectomy was performed on November 17, 1893, after the 
method practiced and advocated by Dr. Robert T. Morris, of this 
city : an inch and a half incision over the appendix, carried in the 
direction of the fibers of the external oblique ; drawing the ascending 
colon out of the wound, and following its well-marked band of longi- 
tudinal fibers down to the origin of the appendix ; delivering the lat- 
ter; circular incision of its peritoneal and muscular sheaths close to 
the point of origin ; ligation of the mucous coat and ablation of the 
appendix ; inversion of the stump into the caecum, and closure of the 
peritonaeum over it by the pursestring suture. 
The method of Dr. Morris was followed in every detail with the 6 
G. M. Edehohls, M. D. 
exception of the closure of the abdominal wound, which Dr. Edebohls 
preferred to do with buried silkworm sutures. He wished to embrace 
this opportunity of expressing his indebtedness to Dr. Morris for the 
neat and surgically perfect method, which he had elaborated and pre- 
sented to the profession, for the removal of the appendix in cases of 
chronic, or often so-called recurrent, ecphyaditis. 
The patient made a smooth recovery, left bed on the eighth day, 
and was discharged on the fifteenth day. 
Case V.—T. F., aged thirty years, married, was sent to him by 
Dr. G. D. McGauran. She had been ill, ever since her marriage ten 
years ago, with symptoms due to endometritis, bilateral salpingo- 
oophoritis, and movable right kidney. She had received local treat- 
ment for about five years past without improvement. 
On November 24, 1893, he operated upon her for removal of the 
diseased appendages, curettage and ventral fixation of the uterus 
being performed at the same sitting. While removing the right an- 
nexa, the appendix vermiformis, thickened, chronically inflamed, and 
elongated to a length of thirteen centimetres, was found broadly an- 
herent to the posterior surface of the right broad ligament. It was 
tied off and removed with the annexa, the stump being turned into 
the caecum. He presented the case as parallel with those more or 
less frequently encountered by every operator, in which the appendix 
becomes involved in the course of inflammatory affections of the 
appendages, and is removed together with the latter. He had thus 
incidentally removed it some seven or eight times. 
Remarks. 
Dr. Edebohls did not wish to open up for discussion the entire 
broad subject of appendicitis ; he merely desired to comment upon 
one or two phases of the question. The first two cases—those of 
acute gangrenous appendicitis with perforation—he had presented as 
a type of a class inevitably doomed to a rapidly fatal issue unless 
saved by the knife. The difficulty lay in recognizing this class of 
cases as such, and great credit is due the attending physicians for 
their accurate diagnosis and prompt insistence on operation. The 
profound prostration, shock, and involvement of the vital functions 
in these cases of early perforation made it evident that symptomatic 
treatment can be of no avail; that the only hope for the patient lies 
in radical measures promptly executed. 
The only point of the technique that he wished to touch upon was 
that of irrigation of the peritonaeum in these cases. He could not Report of Five Cases op Acute Appendicitis. 
7 
help but feel that the danger of spreading the infection by irrigation 
was greater than any possible good that might be hoped for from the 
measure. He had, therefore, contented himself with dry cleansing. 
In regard to the cases of chronic appendicitis, he desired especially 
to emphasize the fact that the time had arrived when we are to deal 
with these cases on indications parallel to those which govern us in 
dealing with cases of salpingo-oophoritis. Just as an operation for 
the removal of the uterine appendages is unjustifiable, save on one or 
two exceptional indications of comparatively rare occurrence, unless 
a lesion of these organs can be demonstrated by bimanual examination, 
so, before proposing an operation for the removal of the appendix in 
chronic cases, we should be able to recognize the diseased condition, 
the chronic appendicitis, by palpation. More than one abdomen had 
been opened for the purpose of removing a presumably diseased ap- 
pendix, the latter being found in a perfectly healthy condition. In 
other words, we are to operate in cases of chronic appendicitis—as in 
cases of salpingo-oophoritis—on objective, not on subjective, indica- 
tions. He would not detain the society longer with this subject of 
palpation of the vermiform appendix, to which he had given consider- 
able attention for about a year past, as he was engaged in the prepa- 
ration of a paper (soon to be published) detailing his observations in 
the matter and the practical deductions he had derived therefrom. 
A feature of special interest, to the surgeon as well as to the gynae- 
cologist, is presented in the reciprocal relations existing between ap- 
pendicitis and inflammatory diseases of the right uterine appendages. 
Thus, the salpingo-oophoritis in Case I was certainly the result, while 
in Case V it was possibly the cause, of the appendicitis.