No. 4389.

OCT. 12, 1907.

A Post-Graduate LectureON

SOME ASPECTS OF APPENDICITIS,ESPECIALLY WITH REFERENCE TO CUTANEOUS

HYPERÆSTHESIA AS AN AID TO DIAGNOSISIN CERTAIN COMPLICATIONS.

Delivered at the London School of Clinical Medicine (Seamen’sHospital),

BY SIR WILLIAM H. BENNETT, K.C.V.O.,F.R.C.S. ENG.,

CONSULTING SURGEON TO ST. GEORGE’S HOSPITAL, ETC.

GENTLEMEN,-The subject of appendicitis does not at firstsight seem likely to afford much scope for useful discussionat the present time, and you will, I fear, hardly think itlikely that anything is to be learned about it which you donot already know, and in this you will probably be right.At the same time, if I may judge from what I see in theordinary course of practice, there are one or two matterswhich are not entirely understood by all people, their im-portance not being perhaps always realised.

I have recently been concerned in three cases, in one ofwhich a purely thoracic lesion led to a diagnosis of acuteappendix disease; in the remaining two cases gangrene ofthe appendix was associated with thoracic symptoms. As a

group they form a useful combination for clinical purposes,so I propose to deal with them this afternoon, relating thestories of the cases first and then considering the lessonswhich they seem to me to teach.Case 1 was that of a boy aged 14 years who was in the

country. He was quite well so far as was known until oneafternoon when it was rather damp and he had been bowlingfor several hours he felt some aching in his right shoulder, notsufficiently acute to attract much attention and he himselfdid not attach any importance to it. He went to bed andawoke apparently all right again. But on the next day hewas feeling indolent and did not care about bowling as hehad done before. 48 hours later he was seized with acuteabdominal pain of a very intense type, with a high tempera-ture ranging from 101° to 103° F. He was sent at once to

bed, and on being examined shortly afterwards it was foundthat he was lying on his right side with the knees bent upand that he had acute pain in the right side of his abdomenwhich was quite rigid and any attempt to touch it caused thepatient to flinch ; the cutaneous hyperaesthesia was very acute.So, taking all things into consideration and seeing that he hadbeen constipated for two or three days, it was concluded thathe was suffering from appendicitis, and help was summonedfrom London. Upon seeing this boy I found him in verymuch the condition I have mentioned, except that insteadof lying on his side he was on his back with the

right lower limb drawn up and the left one extended.The pulse was very rapid, the breathing was also quick, andhe had an anxious look about his face. And as I have saidbefore, the right side of his abdomen was rigid. But on

making a little more careful investigation it was ascertainedthat although the rigidity, tenderness, and the pain seemedto be intensified in the right iliac region, hypersesthesia of theskin-and this is the important point-was more markedabove the level of the umbilicus than it was below. More-over, after the boy’s abdomen had been handled in the courseof examination for some time gently, it was noticed that ashe got used to the manipulation the lower part of hisabdomen began to move comparatively freely, whilst theupper part remained quite rigid. Those points were, ofcourse, rather significant. He had only vomited once Ithink so far as I recollect ; the tenderness overMcBurney’spoint was not pronounced as it sometimes is in appendicitiswhen I saw him. Personally I do not attach very muchimportance to tenderness over McBurney’s point as a

specific indication of appendicitis. I have often seen itequally well marked in pelvic conditions other than appen-dicitis, in gall-bladder cases, in gastric ulcer, and in otheraffections. To cutaneous hyperaesthesia in certain abdo-ntnal cases I attach great importance as a diagnostic sign,especially in connexion with some of the worst forms ofappendicitis. In this case it was intense, especially over theupper half of the right segment of the abdomen, a fact which

I must ask you to bear carefully in mind. This, inspite of other symptoms, diverted my mind from theappendix region and led me to examine the chest very care.fully, with the result that distinct pleuritic friction could beheard. I decided in the circumstances not to operatefor appendicitis, for which I had gone prepared, becauseI felt fairly certain that the case would turn out to be not,appendicitis but some thoracic condition, probably pleurisyor perhaps pleuro-pneumonia. That is the first typeof case, that in which appendicitis was simulated bya thoracic condition. Now see what happened. Wehad the boy moved to London in an ambulancealmost at onC3 and I saw him the same evening. Ofcourse, he was not very well after the shaking up due tothe journey, but the symptoms, speaking generally, remainedthe same. After a night’s rest, on further examination wefound that the lower part of the abdomen had become quite-freely moveable, and that deep pressure in the iliac fossa andover McBurney’s spot and round about it produced no-

material pain or resistance. The hypersesthesia, however, ofthe upper portion of the abdomen still continued. And nowon making further examination of the chest it was clear that-there was fluid in the pleura. To make a long story short,the fluid in his pleura suppurated and we opened anempyema which was of the ordinary septic type. The boyprogressed slowly but finally completely recovered. I do notthink that he had been the subject of any affection of the-appendix at all.

It must, I think, be admitted that the temptation to regardthis case as one of appendix trouble requiring immediateoperation was very strong ; at the same time I suppose it i&obvious that an operation could have done nothing but harmto the patient. Moreover, the operation of rib resection, &c.,necessary for dealing with the empyema coming so soonafter the abdominal operation had it been performed wouldhave been a much graver matter than it was in thecircumstances described, when it was indeed sufficientlyserious, as the condition of the patient during the 24 hourssucceeding was highly critical. The case is, I venture tosubmit, an excellent one to show that an exploratoryoperation is not always the only available means for arrivingat a diagnosis in acute abdominal pain

Case 2 is a good contrast with this. A girl, 15 years ofage, had a little pain about her stomach, which her mothercalled stomach-ache, on a certain Thursday. She was givena dose of castor oil which removed the ache and she feltfairly well. So much so that she went to a party on theSaturday and on Sunday went to church. On the eveningof Sunday she was seized with an acute pain in the lowerpart of the abdomen. She was seen by a medical man for thefirst time on the day following, and he, recognising that thecase was probably one of appendicitis, called in a secondopinion. When seen at the consultation the girl waslying flat on her back, her pulse was very quick (130),whilst the temperature was 100° F. ; she was flushed buthad not the abdominal look; the breathing was 25 to theminute. The abdomen was rigid all over, and there wasintense cutaneous hyperaesthesia limited to the right iliacregion, gradually diminishing in degree in an upwarddirection until at the level of the navel it was

non-existent. The thorax, so far as could be ascer-

tained, was normal. The relation of the degree oftemperature to the pulse-rate is important. Whenever ina case of appendicitis of this type you find a tem-

perature which is under the range of the pulse you maygenerally be sure that the case is a very serious one ; in fact,in almost all the cases in which the symptoms justify adiagnosis of appendicitis, and in this instance there wasno doubt about that, you will find that if rapidity of thepulse-rate is greatly out of proportion to the temperature,gangrene of the appendix to some extent is imminent if itdoes not actually already exist, and further, this symptom isone of the surest signs of the necessity of immediate opera-tion ; if in addition the cutaneous hypersesthesia rapidly orsuddenly disappears you may be certain that gangreneCM NMMsc has happened. It is sometimes said that the surestsign of gangrene of the appendix is the sudden or very rapiddisappearance of this extremely acute hyperoesthesia. Some-times that is so, but sometimes it is not. But so far as thevery rapid pulse associated with a comparatively low tem-perature is concerned I have not known it to deceive.

Here, then, was a girl suffering from s mewhat the samesymptoms as the boy, the differences in this case beingmainly these: first of all the hypersesthesia was more marked

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over the- lower part of the abdomen. The temperature waslow in proportion to the pulse-rate and those two points areof very great importance. In the boy you will recollect thehyperassthesia was more intense over the upper part of theabdomen and with a quick pulse he had a temperature of103°, or something of the sort. We concluded that thisgirl had appendicitis of a very bad type, the appendix beingprobably gangrenous, and we operated at once, removing agangrenous appendix four inches long which lay in a bathof stinking sanious fluid. Under ordinary circumstances in acase of this type, as soon as you have got rid of thegangrenous structure and have well cleaned the parts thepatient immediately begins to improve. In this case, inspite of the operation, no marked improvement directlyfollowed. The only noteworthy point was the behaviour ofthe cutaneous hyperassthesia, which being intense in spiteof the occurrence of gangrene at the time of the opera-tion changed its position within 24 hours from theiliac region to the level of the umbilicus and aboveit. Careful examination now elicited a distinct frictionsound at the level of the diaphragm. A sub-diaphragmaticabscess developed and was two or three weeks later followedby empyema. The case was naturally a tedious one, but atthe present time the entrance upon the convalescent periodhas apparently commenced.

Case 3 was a girl, about 16 years of age, who had a some-what similar clinical history to that in the last case, althoughthe symptoms were not quite so acute, and the operation wasperformed on the fifth day after the onset of the trouble.A gangrenous appendix was removed and immediate im-provement followed, so that four days after the operationshe seemed convalescent-a marked contrast to whatoccurred in Case 2. On the fifth day after the operation thetemperature rose from the normal to 101°F. and she began tocomplain of " pain in the stomach," of indigestion, andof flatulence. Now, in any case of this type in whicha patient-I am speaking of the gangrenous type of,appendicitis-complains of indigestion and great flatulencethree or four days after the operation, always be on thelook-out for a diaphragmatic development-that is to say, asubdiaphragmatic abscess or a diaphragmatic pleurisy-andif these symptoms are associated with cutaneous hyper-sesthesia on the right side of the abdomen at or above thelevel of the umbilicus you may be sure that one of theseconditions is developing and that it will almost certainlybe subdiaphragmatic abscess. In the case now under con-sideration this cutaneous hyperassthesia showed itself and asubdiaphragmatic abscess of the usual stinking kind wasopened after a resection of a piece of rib, a rapid recoveryfollowing, as would be expected.

In passing, it may be pardonable to remind you of a factwhich is comparatively new to me-viz., that it is not

always possible to differentiate by the ordinary physical signsbetween a subphrenic abscess and empyema in cases of thekind we are now dealing with. It is only a short time sincethat a most accomplished physician and a very acute general Ipractitioner failed to differentiate the two conditions in acase in which I was concerned, an apparent empyematurning out to be a subphrenic collection of pus after it hadbeen opened far back at the sixth interspace, a portion of ribhaving been resected. In the same case an empyema sub-

sequently formed and, of course, had to be opened when thediaphragm could be felt separating the two cavities. Indeed,I think it quite possible for an operator of comparativelysmall experience to be deceived in this matter even after theabscess has been opened, as on introducing the fingerthrough the operation wound the under surface of the

diaphragm shut off in part by adhesions feels very like theunder surface of a compressed lung, whilst the convex

upper surface of the liver is singularly like the archingdiaphragm, especially if the operator has started possessedwith the idea that the case is one of empyema. It mayseem at first sight almost foolish to suggest a possibilityof error in this respect but that it is possible I happen toknow.Each of the three cases described has an individual point

of interest; in the first the exact simulation of acute

appendix trouble, including tenderness over McBurney’spoint, by a purely thoracic lesion; in the second the im-portance of the want of proper relation between the tem-perature and the pulse-rate as a warning of trouble to come,and in the third the suddenness with which a metastatipleuritic infection may occur in a case doing apparentlyremarkably well. These points require no further comment.The three cases have, however, one point of much interest

s in common because each shows the importance of cutaneousa hyperaesthesia in connexion with cases of the kind and to: this point I wish to devote a few remarks.

CUTANEOUS HYPEEJESTHESIA OF THE ABDOMINAL WALLf IN DIAGNOSIS.

, For clinical purposes the areas of the hyperaesthesia inacute abdominal conditions may be said roughly to corre-1 spond to the anatomical division of abdominal walls, atleast, so far as the point of greatest intensity of the hyper- assthesia is concerned. There are, for example : (1) a

hyperassthesia which is most intense about the situation of1 McBurney’s spot ; (2) another in which the point ofintensity is at or about the level of the navel; and (3)E another in which the intensity corresponds with the level ofj the ninth rib. On the right side the first of these is. associated with certain acute cases of appendix disease, the. second with inflammation or abscess about the lower surface; of the diaphragm, and the third with implication of thel pleura on the upper surface of the diaphragm. The conditionis not, however, limited to the right side, being sometimesl met with in the left side (area No. 1) in abscess or malignant; disease of the sigmoid flexure assuming an acute type. Inl the development of this hypersesthesia it is essential that

the peritoneum or pleura should be involved ; it is, for, instance, never met with in abscess in the liver, in the lung,

or in the spleen in the absence of peritonitis or plenrisy. So, far as appendicitis is concerned the occurrence of acute,

hyperaesthesia of the abdominal wall may be generallyregarded as indicative of surgical complications ; forexample, grave appendix disease, probably with impendinggangrene, subphrenic abscess, or empyema, according to thesituation of the point of intensity.Case 1 affords an admirable illustration of how a due

appreciation of the importance of the situation of the pointof intensity in cutaneous hypersesthesia may help to avoidan error in diagnosis. Case 2 is instructive in showinghow acute hypersesthesia may persist in spite of gangrene ofthe whole appendix. That rapid disappearance of acutecutaneous hyperassthesia is not always an indication of

gangrene is shown by the following case. A boy, 12 yearsof age, was suddenly seized with the usual symptoms ofacute appendix trouble. There were vomiting, iliac pain,rigidity, and intense superficial hypersesthesia around theregion of McBurney’s spot. The pulse was 120, the

temperature three hours after the onset of the attackwas 101° F. and a little later 103°. On the third

day the pain rapidly disappeared as did also thecutaneous hyperaesthesia, the temperature fell in 24 hours tonormal, and the pulse-rate sank to 76 ; a rapid and completerecovery followed. The point of importance in this case layin determining whether the almost sudden disappearance ofpain and hyperassthesia was a serious indication or not.Apart from the general aspect of the patient the questionwas readily decided by the behaviour of the pulse, which

diminished in rate in proportion to the degree of dropping ofthe temperature. Had the pulse-rate remained high in spiteof the very rapid fall in temperature the position would havebeen grave and an immediate operation indicated.

It cannot be too distinctly understood in cases of acuteappendicitis that a very rapid or sudden disappearance ofany one prominent symptom-e.g., pain or high fever-without a corresponding change in all the other symptoms is,as a rule, a sign of danger and not of improvement, amatter which should by this time be common knowledge; itclearly is not so, if one may judge by the tendency stilloccasionally shown to postpone active interference on theground of the rapid and marked improvement in a singlesymptom, especially high fever.

KING’S COLLEGE HOSPITAL AND MEDICALSCHOOL.—The following scholarships have been awarded inthe Faculty of Medicine: Medical entrance universityscholarship, .S50, H. A. Treadgold; and Warneford medicalscholarship (Arts), 100, A. S. Wakeley.CHARING CROSS HOSPITAL MEDICAL SCHOOL.-

The following entrance scholarships have been awarded :The Epsom scholarship (115 guineas), J. E. Ashby;and the Huxley scholarship (55 guineas), E. M. Morris.Entrance scholarships have also been awarded to A. E.Hallinan (40 guineas) and to W. Leslie (30 guineas).University scholarships of 72 guineas each have beenawarded to W. R. Thomas and C. W. Shepherd, both of theUniversity of London.

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