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largest possible number of physicians and surgeons, and particularly by those whose professional duties make it necessary that the journey be performed in an expeditious manner, a special overland limited train has been arranged for, and a special party is being organised to leave Chicago via the Chicago, Union Pacific and Northwestern Line the evening of July 6, to make the trip to Portland surrounded by every luxury that modern travel can provide, upon schedules occupying a little less than seventy hours.

en route.

It is not often that so congenial a party as this is available, traveling under such highly favorable surroundings for comfort and enjoyment of the trip. A description of the train and route is included in the attached circular, and you are most cordially invited to become a member of the party.

Arrangements have been made with the railways for the movement of this special overland limited train without any extra charge for the unusual service thus secured.

The round-trip rate Chicago to Portland and return is $56.50, and proportionately low rates from other points will be in effect. Ask your ticket agent for your tickets via the Chicago & Northwestern and Union Pacific lines. Return trip may be made via Oregon Short Line, Salt Lake City, and through Colorado without extra charge, or via the Northern Pacific, Great Northern or Canadian Pacific without extra charge, or via San Francisco and Los Angeles on the payment of $11.00 additional at time of purchase. Sleeping car rate Chicago to Portland for double berth in special train, $14.00. Drawing room, $53.00. Stop-overs will be permitted at and west of Colorado common points, Cheyenne or Trinidad, inclusive, or Saint Paul and Minneapolis and a tour of the Yellowstone Park may be made either via Monida or Livingston at a rate of $49.50 additional, covering the usual tour through the park, including stage transportation and hotel accommodations.

Will you please, upon receipt, advise Mr. H. A. Gross, General Agent, Passenger Department, Chicago & Northwestern Railway, 212 Clark street, Chicago, Ill., or the nearest representative whose name and address appears on the accompanying circular, whether you desire to be included in the party, and how much sleeping car space you desire reserved?

Further information in regard to the trip will be cheerfully furnished on application.

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S. C. STANTON, M.D., Room 1609, 59 State St., Chicago, Ill.
HEINRICH STERN, M.D., 56 East 76th St., New York, N. Y.
LEWIS S. MCMURTRY, M.D., 1912 Sixth St., Louisville, Ky.
WM. WARREN POTTER, M.D., 284 Franklin St., Buffalo, N.Y.
FLORUS F. LAWRENCE, M.D., Columbus, O.

SIMON P. SCHERER, M.D., Indianapolis, Ind.

CHARLES A. L. REED, M.D., The Groton, Cincinnati, O.

BUFFALO MEDICAL JOURNAL.

VOL. XLIV.-Lx.

JULY, 1905.

No. 12

ORIGINAL COMMUNICATIONS.

Concerning the Etiology of Appendicitis.1·

BY E. L. SHURLY, M. D., Detroit.

N VIEW of the great amount of literature extant upon the subject of appendicitis, I would scarcely have the temerity to present a paper on any phase of the topic to any body of scientific men who were not so near and dear as fellow alumni. It is therefore only in the atmosphere of the family, so to speak.— that I dare breathe forth suggestions on this world widely thrashed topic. I shall not surprise you by offering anything new, nor will I awe you with an abstract of so many hundred operations. I will not go so far as that. I will merely present to your notice a few suggestions regarding what is probably not known of its etiology, and what no fellow seems inclined to find out. I shall endeavor to give you as few platitudes as possible for a basis upon which to plant these humble suggestions.

To quote Morris:

The cecal appendage is vermiform in man and in all of the man like apes, also in certain Lemurs. In man, the cecal appendage is apparently a rudimental structure which once formed an important part of the alimentary tract. It is supposed that this organ, like the wisdom tooth, has degenerated during the process of evolution, as would any other unused structure. The appendix vermiformis in man was recognised as a structure in the 16th century and was described in the 18th century. (Lammoricre, however, believes this to be untrue). It appears at about the tenth week of fetal life. As you know, the length of an average appendix vermiformis in the young adult is not far from three and three quarter inches, with a diameter of a goose quill.

1. Read at the thirtieth annual meeting of the Alumni Association of the University of Buffalo, May 30, 1905.

It varies, however, in length from two inches to six inches, or a little more.

The contents of the appendix usually consists of mucus with more or less fecal matter and microorganisms. Under ordinary circumstances semisolid fecal matter and gas, find easy entrance to, and exit from, an appendix with a large lumen, as the appendix has abundant muscular ability to empty itself, and has at the seat of its attachment to the cecum a good fixed point for muscular action. In some of them the lumen is small, either naturally or from a little hyperplasia, and it is then, obviously, not so easy for the appendix to empty itself of its concretions. There are very many normal appendices containing concretions which cannot escape for this reason. Appendix concretions are of three principal sorts-fecal, phosphatic, and fatty: Insoluble salts may be precipitated out of the fermenting mucus, and as the stagnant mucus is very apt to undergo decomposition, the fecal concretions are usually arranged in layers with calcium salts.

Phosphatic concretions are formed in normal appendices, and in chronically affected appendices, as the result of decomposition of mucus.

The formation of fecal and phosphatic concretions, while more apt to occur in persons whose intestinal contents easily ferment, may be independent of any disease of the appendix, while fatty concretions probably occur as the result of long ulceration of the lymphoid coat only. Morris says, bacteria are by all means the most important things found in the appendix. Colon bacilli which have their normal habitat in the colon are almost invariably present in the lumen of the appendix. They are harmless dwellers there unless an infection atrium gives them an opportunity to migrate into the tissues. The pyogenic streptococci are also pretty constant dwellers in the normal appendix. Many of the less important pyogenic bacteria and saprophytes, or bacteria of fermentation harmlessly lurk in the appendix. When an infection atrium is made, the infection is at first mixed in character. The streptococci are apt to outstrip other bacteria in the second part of the race, and the colon bacilli are apt to lead finally. Thriving colonies of bacteria are daily swept along through the normal colon and are moved in and out of most appendices. Some of the higher entozoa are frequently found in the appendix. The nematode oxyuris, for instance, is often found there.

Various kinds of seeds are closely resembled by concretions. Morris and other surgeons state that they have not yet found a seed in any of the appendices which they have operated upon. The appendix is the seat of fecal concretions in at least 8 per cent. of all cases. Their existence does not denote that the appendix is diseased!

Morris's definition of appendicitis is, that it is an infectious exudative inflammation of the appendix vermiformis ceci, originating in any local cause for the production of an infected atrium in the tissues of the appendix, and progressing by bacterial invasion into the layers of connective tissue, and into the layers of lymphoid tissue-all of which are partially or completely disabled by interstitial exudate compression within the narrow muscular peritoneal sheath of the appendix. The principal cause of appendicitis is mixed bacterial infections from the lumen of the appendix. The chief cause of bacterial infection from the lumen of the appendix is the formation of an infection atrium in the mucosa of the appendix by force applied in any way. He further says, I formerly surmised that the appendix was sometimes injured by pressure between a full cecum and a hard pelvic wallsupposing that the cecum was often filled with fecal matter. But after extensive opportunities and observation, I have not as yet seen fecal matter in the cecum at any operation, and there is doubt if the so-called impaction is not often lymph exudate instead. Excepting in elderly people, I believe that injury to the mucosa occurs most often from accidental twisting of the appendix upon part of its long axis. An infection atrium is also commonly produced by erosion of the mucosa at the site of a concretion, or by entozoa. Bacterial infection may extend into the tissues of the appendix from the infected cecum, as in typhoid fever or dysentery. An infection atrium is formed consequent upon peritonitis, extending from adherent infected oviducts or other nearby structures.

Dr. J. B. Murphy, as you all know, has written some fine papers on this subject. The etiology he gives is about as follows:

When the disease was first recognised as a surgical affection, the acute infective lesions were considered to be due to the usual causes which produced enteritis in the remaining portion of the intestine and it was considered essentially a disease of the summer months. Now, since we have become more familiar with it, we find that it is almost as common in winter as in the summer. We find that it does not come on under the same climatic or dietary conditions as the other types of enteritis; that it most commonly follows exposures such as would produce socalled "cold" of the respiratory tract. So commonly is it a sequence of such exposure that a very prominent Chicago physician at one time considered it essentially a rheumatic manifestation. This, however, we do not accept.

Foreign bodies, as fruit seeds, gallstones, capsules, and the like, were present in a little less than 2 per cent. of the cases coming under observation; fecal concretions were found in 38 per

cent. and we believe that the erosion of the appendiceal mucosa by these foreign bodies produces an atrium for the admission of the infective flora into the tissues and precipitates under favorable conditions the acute attack. Indiscretions in diet appear to have little if any effect as an etiological factor.

The types of infective flora found in cultures and stainings from the appendices vary in the following order of frequency: bacillus coli communis, staphylococcus pyogenes aureus and albus; streptococcus, bacillus tuberculosis, actinomycoses.

Appendicitis occurs in all classes with about equal frequency. In my work it has been a little more frequent in males than in females. I do not consider that it is contagious or infectious. It does seem, however, to have family predilections. This I would rather consider due to the conformation of the appendix or the diminished resistance to infection in some families and the comparative immunity to infection in others. I have not infrequently had two members of the same family in bed with the disease at the same time.

Many surgeons believe in an anatomical cause for this disease, maintaining that appendices which are spiral, club-shaped, too - long, with too much lymphoid tissue, or bent in their formation, or adherent, will act for the supervention of the disease. Some writers adduce as evidence, the advent of attacks of appendicitis in families where abnormalities or peculiar anatomical types are supposed to occur through hereditary succession. Still other writers seek to account for the occurrence of the disease in females by assuming previous disease or malformation of the uterus or its appendages.

In a report of Peterson on 200 cases of chronic disease of the uterine appendages, 106 or 58.4 per cent. were accompanied by normal appendices, while 41.6 per cent. showed past or present changes in the organ. In this same report, Peterson says that the appendix was adherent in 18.5 per cent. Fecal concretions were noticed twelve times out of 146 observations or 8 per cent. The shape of the appendix was noted as being abnormal in 52 out of the 200 cases or 26 per cent. Out of the 200 cases, 106 or 53 per cent. showed practically no evidence of disease!

Peterson also states that in chronic diseases of the uterine appendages adhesions of the accompanying appendices are present in nearly 50 per cent. of the cases where microscopic examination. shows the latter to be diseased. In a certain proportion of cases. however, although the appendix may be adherent it is also perfectly normal. In chronic diseases of the uterine appendages the appendix which is club-shaped, constricted or contains fecal concretions, is not necessarily diseased. In 30 per cent. of patients with uterine fibromata there is accompanying disease of the

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