Etiology of Appendicitis 
WHY IS IT MORE COMMON IN THE 
ANGLO-SAXON RACE? 
BY 
JAMES S. CHENOWETH, M. Dv 
LOUISVILLE, KY. 
Read before the Louisville Surgical Society, November 23, 1896. 
LOUISVILLE: 
JOHN P. MORTON & COMPANY. 
1897 [From Mathews’ Quarterly Journal, January, 1897.] 
ETIOLOGY OF APPENDICITIS* 
WHY IS IT MORE COMMON IN THE ANGLO-SAXON RACE ? 
BY JAMES S. CHENOWETH, M. D., 
LOUISVILLE, KY. 
I dislike to preface a paper with an apology, but I feel that I 
am taking an undue advantage of my guests in inflicting upon 
them a paper of this length with its somewhat tedious recital of 
details, with which many of you are doubtless familiar, without 
a word in extenuation. 
When I entered the ranks of the profession, seven years ago, 
the importance of the appendix as a factor in the production of 
inflammatory affections of the peritoneum was just beginning to 
be generally recognized. 
We need not go back to even so recent a period to recall 
earnest discussions over the very existence of the appendix as an 
intraperitoneal structure, or the more heated arguments as to 
the necessity, or not, of surgical interference in any case of ap- 
pendicitis. 
The whole subject of appendicitis has been so earnestly and 
thoroughly worked over in this society since that time, and our 
ideas have undergone such a rapid and continuous process of 
evolution that we have been all but ready to declare the argu- 
ment closed. However, at least so far as the etiology is con- 
cerned, I am becoming more and more convinced that this evo- 
lutionary process has been too rapid to thoroughly eliminate the 
“ unfit,” and I present this paper for the purpose, first, of 
reviewing the evidence upon which our present opinions are 
based ; second, of introducing new evidence, direct and circum- 
stantial ; third, of obtaining a candid criticism of this evidence, 
the deductions that I have drawn from it, and of theories which 
seem to me plausible. 
It is not without some diffidence and hesitation that I present 
this paper to the Louisville Surgical Society, realizing only too 
well its imperfections. 
The explanations that I have suggested of some of the more 
important phenomena noted in connection with this subject are 
* Read before the Louisville Surgical Society, Nov. 23,1896. 2 
CHENOWETH : ETIOLOGY OF APPENDICITIS. 
in my opinion justified by the data at our command, but these 
data are insufficient to justify any sweeping generalizations. I 
have purposely avoided any detailed report of personal cases, 
which from the very nature of things can only in exceptional 
instances be more than corroborative, and whether future observa- 
tions confirm the opinions expressed herein or not, I am satis- 
fied that a more extended investigation of the etiology of ap- 
pendicitis along the lines suggested will amply repay us. 
That we may fully appreciate all the factors concerned in this 
complex disease process which we term appendicitis, let me 
briefly recall to your mind the more salient features in the 
anatomical relations of this organ as well as its histological 
structure, The appendix vermiformis, the atrophied remnant of 
the true cecum, is found attached to what was originally the apex 
of the cecum, usually on the inner and posterior aspect of the 
bowel, close to the ileo-cecal valve. The relative position of the 
appendix is subject to many variations, which have not, however, 
been shown to bear any constant relation to disease of this struct- 
ure. The appendix varies, likewise, in length and caliber in 
individuals, in the male and female, and at different periods of 
life. Its length will average at its greatest development from 
three to four inches, being four-fifths inch longer in male than 
the female. It is usually entirely invested by peritoneal folds 
derived from the inferior layer of the mesentery of the ileum; 
these folds forming as a rule a triangular mesentery for the 
appendix, the base of the triangle being formed by the free edge 
of the folds. The attachment of this meso-appendix may extend 
along the entire length of the appendix, more often only to the 
proximal two thirds; more rarely the meso-appendix is absent 
and the appendix floats freely in the abdominal cavity. 
The appendix is commonly found curved upon itself, owing 
to the shortening of its mesentery. Along the free edge of this 
meso-appendix runs the appendicular artery, the essential 
nutrient artery of the appendix. It is a terminal branch given 
off from an anastomotic loop, formed by the superior mesenteric 
and the ileo-colic; and where the mesentery is absent it runs 
beneath the peritoneal coat of the appendix. 
The lymphatics of the appendix pass into the appendicular 
lymphatic ganglion, which lies in the angle formed by the ap- chenoweth: etiology OF APPENDICITIS. 
pendix and the cecum. In the female lymphatic channels pass 
along the appendiculo-ovarian ligament between the folds of the 
peritoneum, forming this structure aud establishing communica- 
tion between the appendix and ovary. (Clado.) 
The nerve supply of the appendix is derived from the supe- 
rior mesenteric plexus of the sympathetic through filaments given 
off by the branch accompanying the ileo-colic artery. 
The appendix is made up of four layers: (1) A more or less 
complete covering of peritoneum which we have noted. (2) A 
muscular coat made up of two layers, an outer portion consisting 
of a few long non-striated muscular fibers mingled with a vary- 
ing amount of fibrous tissue and an inner portion of circular 
fibers, thicker and more regularly distributed than the outer. 
(3) The submucosa, a thick layer formed of areolar tissue, con- 
taining numerous lymphoid glands, and through which ramify 
numerous small arteries and veins supplying the mucous mem- 
brane; between this layer and mucous membrane a thin layer 
of circular muscular fibers may be distinguished, the muscularis 
mucoste. (4) The mucous coat is composed of a delicate recti- 
form tissue, with a basement membrane, lined with columnar 
epithelial cells. It contains in its meshes numerous lymphoid 
cells and has dipping into it a number of mucous glands. About 
the orifice of the appendix the lymphoid tissue is oftentimes 
deposited in increased amount and may partially obstruct the 
opening. I have not attempted, in thus running over the 
anatomy of the organs, to more than refresh your memories on 
the more salient points. 
The earlier observers looked upon foreign bodies as the chief 
factors in the production of appendicular disease, but this idea 
has not been borne out by more extended experience, as they 
have been found in only about four per cent, of operative cases. 
They may act, however, by producing abrasions of the mucous 
membrane and opening an avenue of infection by mechanically 
interfering with the exit of the mucous secretion from the ap- 
pendix, or by direct pressure effects interfere with the nutrition 
of the organ and bring about necrosis. 
Fitz, in his paper, laid special stress on the influence of fecal 
concretions as most frequently causing disease of the appendix, 
and this view has been very generally accepted. On close 4 
CHENOWETH: ETIOLOGY OF APPENDICITIS. 
investigation this seems to be a very questionable matter. 
'Klebs, in an examination of four hundred specimens,concludes 
that the vermiform appendix has usually very little contents, 
which he attributes to the fact that the normal musculature 
regularly voids its contents. He found fecal stones in thirty- 
eight of the four hundred specimens, and equally in both sexes; 
this tallies with the reports of other observers. These stones 
have been found repeatedly in appendices in which their pres- 
ence had given rise to no imflammatory action, and moreover 
have only been found in about fifteen or twenty per cent, of 
operative cases of appendicitis. The evidence tends to show 
that these fecal stones form in the appendix from the absorption 
of the liquid portion of the fecal mass, and as the result of the 
inability of the appendix to normally void its contents; and 
while it is not questioned that by these pressure effects necrosis 
and infection may be brought about, their very presence in the 
appendix presupposes an inability of the appendix to empty 
itself. If this were due to lack of development of its muscular 
coat, it should be manifested in very early life, otherwise the 
natural presumption would be that some alteration in the struct- 
ure of the appendix must take place, interfering with the 
evacuation of its contents, and clinical experience has shown 
stricture of the appendix to be a frequent source of trouble. 
Another possible element in the production of appendicitis, to 
which I have called attention several times, is the overdisten- 
sion of the appendix by gas or fecal matter during violent 
muscular efforts ; given a colon distended with gas and fecal 
matter, it is not difficult to understand how the increased pres- 
sure brought about by lifting or straining at stool, coughing, 
vomiting, etc., might forcibly distend the appendix and produce 
sufficient trauma to start an inflammatory process. 
Another source of appendiceal trouble,although doubtless not 
a frequent one, lies in the extension of an inflammatory process 
to the appendix from other organs by continuity or contiguity 
of tissue. That a catarrhal or ulcerative process beginning in 
the cecum may extend thence to the appendix, or that an 
appendix becoming adherent to diseased pelvic organs may 
become thus secondarily infected, is unquestionable. 
Annual of the Universal Medical Sciences, 1894. CHENOWETH: ETIOLOGY OF APPENDICITIS. 
From a practical standpoint the most important factors in the 
development of appendicitis are the pathogenic bacteria, and of 
these the colon bacillus seems to be most in evidence. It is 
almost invariably found in the intestinal tract, and in the pres- 
ence of sound mucous membrane seems to be without power for 
evil. However, when the mucous membrane has been destroyed, 
or the intestinal canal has been subjected to constriction and its 
circulation interfered with, the colon bacillus may penetrate the 
intestinal wall and show both pathological and pyogenic prop- 
erties. It has been found in almost all cases of perforative 
appendicitis, frequently alone, sometimes associated with other 
pus-forming organisms. Typhoidal and tubercular ulceration 
have also been observed in the appendix in a not inconsiderable 
number of instances. 
A most fertile source of appendix trouble is believed by most 
authorities on this subject to exist in a special liability of the 
appendix to nutritive disturbances, from interference with its 
blood supply, by an insufficient mesentery or by torsion. This 
point is especially dwelt upon by Fowler in an exhaustive report 
of his 2 “ Observations Upon Appendicitis.” In answer to the 
question, Why, if the same pathological laws govern the tissues 
of the appendix that govern the other tissues of the body, do 
they assert themselves so much more frequently here than else- 
where? he says there is one prime factor which more than 
any other is responsible for this fact, to wit, that here, as no- 
where else certainly in the abdominal cavity, the parts are 
peculiarly exposed to circulatory and hence to nutritive dis- 
turbances. Prof. Van Cott’s careful examination of many speci- 
mens furnishes convincing proof that vascular and nervous 
lesions'are important factors to ultimate disease of the appendix. 
In addition to this, proof is furnished by the interesting fact 
that females are less frequently stricken with the disease than 
males; and that, as already stated, in the female sex an extra 
supply of blood is furnished to the appendix through the medium 
of the appendiculo-ovarian ligament, a fact bearing notably on 
the question of nutrition. In all of the specimens examined, 
thirteen in number, there was revealed the presence in the 
mesenteric vessels of some form or other of obstruction to the 
?A finals of Surgery, 1894. CHENOWETH: ETIOLOGY OF APPENDICITIS. 
blood current, either endo-vasculitis or organized thrombus, con- 
ditions which must in the nature of the case have long preceded 
the intense, small round-cell infiltration, coagulation necrosis and 
purulent foci present in the walls of the appendices themselves. 
In several cases, in addition, a distinct neuritis interstitialis 
chronica supervened ; in one, the hyperplastic endo- and peri- 
neurium being so abundant as to have caused extensive atrophy 
of the nerve fibers. It is indisputable that such lesions of ves- 
sels and nerves can only result ultimately in a most profound 
disturbance of the appendical tissues, with lessened resistance 
and localized necrosis. Why the appendix, for example, should 
be free from the consequences of anemic infarct so certain in 
the renal and other tissues endowed with a terminal circulation, 
is difficult to comprehend. On the other hand, if the trophic 
fibers which must exist in the nerves of the meso-appendix be 
subjected to pressure through hyperplasia of their connective 
tissue sheath to the extent of causing atrophy, trophic changes 
must necessarily occur in the appendix itself, and will be co-ex- 
tensive with the nerve lesion. 
Assuming the correctness of these conclusions, it is evident 
that two things are possible: (1) That the real cause of the 
locus minoris resistentiae, which admits of bacterial infection of 
the appendix, must be sought, not in trauma of the mucosa but 
rather in trophic disturbances of the appendix, resulting from 
(a) chronic vascular lesion, (6) chronic nervous lesion, or (c) both 
of these combined ; and (2) that this trophic disturbance will be 
intense or moderate, depending upon the nature of these lesions 
Hence it must follow that ulcerative processes in the appendix, 
while they may be increased by bacterial invasions, may, never- 
theless, owe their origin to the trophic conditions. Therefore 
it must always be difficult to prove that a given ulcerating pro- 
cess or pus-focus in the appendix is due to bacterial invasion 
primarily, and the more especially is this true when lesions of 
the vessels and nerves of the mesentery obtain. It would seem 
much more cogent reasoning to assume that bacterial invasions 
were made possible by the lessened resistance of the part through 
defective nutrition than that primary necrosis is the result of 
direct invasions of germ through a normal mucosa. 
The American Text-Book of Surgery, after noting the rela- CHENOWETH: ETIOLOGY OP APPENDICITIS. 
tions of the peritoneum to the appendix, says: “ We have here 
the factors which enter into the production of a large number 
of cases of appendicitis; distension of the caput-coli with gas or 
fecal matter will cause dragging on one or the other of the folds 
already too scanty, increase the torsion of the appendix, interfere 
with its blood supply through its single vessel, and according to 
the degree of torsion produce congestion and tumefaction, 
catarrhal inflammation, ulceration or gangrene, with the clinical 
symptoms which belong to each.” 
To those less familiar than are the members of this society 
with the protean manifestations of this disease, it would seem 
that the subject of the etiology of appendicitis had been 
exhausted ; but when in the light of our present knowledge we 
attempt an explanation of even the most notable phenomena of 
the disease we find how incomplete and unsatisfactory our 
knowledge is. Almost without exception writers on this subject 
have recognized the appendix as an atrophied rudimentary 
organ, poorly supplied with muscular power, and in consequence 
voiding its contents with more or less difficulty; its circulation 
as terminal and easily obstructed by causes which would produce 
little serious effect in other portions of the digestive tract, and 
its lymphoid tissues as of low vitality and of feeble resistant 
power. In connection with these factors, its dependent position, 
its communication with the cecum by an orifice more or less 
narrowed, with the consequent liability to impaction of feces, or 
foreign bodies and the entrance of infectious organisms, have 
accounted satisfactorily for the frequency with which this organ 
becomes diseased; but how little light this throws on the 
questions, Why is appendicitis so much more frequent between 
the ages of ten and thirty ; in the male that in the female sex ; in 
the Anglo-Saxon race? What is the influence exerted by climatic 
conditions and by heredity ? 
It is asserted that “ in very early life the funnel-shaped 
appendix offers fewer opportunities for the formation and reten- 
tion of masses of inspissated feces, while in old age atrophy of 
the mucous membrane about the cecal orifice again widens it, 
but we lack positive knowledge on these points.”3 If we accept 
the usual description of the anatomy of the parts concerned, 
3 The Amer. Text-Book of Surgery. 8 
CHENOWETH: ETIOLOGY OF APPENDICITIS. 
there seems to be no good reason why appendicitis should be 
found in men four or five times more frequently than in the 
female, but if future observation confirms the assertion of Clado, 
that a fold of peritoneum passes from the right ovary of the 
meso-appendix, the appendiculo-ovarian ligament, and if this 
fold carries a blood-vessel, an obvious and sufficient explanation 
has been found. 
It has been shown (Bryant) that the male appendix is four- 
fifths of an inch longer than that of the female; that its caliber 
is slightly larger, and possibly as a result of the latter fact con- 
tains fecal concretions in a larger percentage of cases, but these 
circumstances do not seem to throw much light on the subject. 
“ The reasons advanced (Fowler) for this very decided com- 
parative immunity of the female sex from appendicitis have been 
unsatisfactory heretofore. Morphological differences wTould natur- 
ally first attract the attention of the original investigator. The 
presence or absence of structural variations have not, to my 
knowledge, been determined as between the two sexes. Histo- 
logically, so far as I am aware, the appendix of the female is 
identical with that of the man. In its location and direction the 
differences are not sufficiently marked to even base a theory 
upon. The nerve supply is believed to be precisely the same in 
the two sexes. 
“The existence of a process of peritoneum passing from the 
right ovary to the meso-appendix (the appendiculo-ovarian liga- 
ment, of Clado) was not demonstrated to exist in but a single instance 
in ten cases studied with reference to this point. When present 
it is believed to assure some degree of immunity against the dis- 
ease by increasing the blood supply and thus increasing the local 
vital resistance. 
“ The only other anatomical variation as occurring between the 
sexes wliich has been noted, is that relating to the arrangement 
of the lymphatic vessels. Between the folds of the appendiculo- 
ovarian ligament of Clado, the latter observer has noticed the 
existence of lymphatic channels which establish a communication 
between the appendix and ovary. Whether a communication be- 
tween the lymphatic vessels of one organ and those of another may 
serve in affording protection of either the one or the other against 
diseased conditions can not, in the light of our present knowledge, 9 
CHENOWETH : ETIOLOGY OF APPENDICITIS. 
be intelligently discussed. While, generally speaking, the lym- 
phatic vessels of the appendix pass directly into the appendicular 
lymphatic ganglion which lies in the angle formed by the appen- 
dix and the cecum, this arrangement may vary, particularly in 
the case of the female. In at least one instance of appendicitis 
occurring under my observation, in a female child of eight years, 
there existed a chain of enlarged lymphatic glands along the free 
border of the meso-appendix. Some of these were as large as the 
tip of the little finger and were so located as to bring more or 
less pressure to bear upon the appendicular artery. The appen- 
dix in this case was gangrenous at its distal extremity.” 
In other words, we are to believe that the larger caliber of 
the appendix in infancy and old age offers fewer opportunities for 
the formation and retention of inspissated feces, while the larger 
caliber of the male appendix as compared with the famale makes 
it more liable to contain fecal concretions, and thus more liable 
to inflammation. But if fecal concretions only play a small part 
in the causation of the disease and are found with equal frequency 
in both sexes, even this accommodating theory is insufficient. 
Again, a short mesentery causes dragging on the appendix 
and an interference with its blood supply; a long mesentery 
allows such freedom of movement that torsion must result. 
Truly, the appendix, like “ man born of woman, is of few days 
and full of trouble.” 
However, Fowler, after a critical study of the conditions 
which govern the blood supply, a study specially directed to the 
presence or absence of a meso-appendix, concludes, “so far as I 
am able to judge from the examinations of appendices removed 
in a diseased condition, the disease occurs quite often in those 
individuals in whom a well-formed and vascular meso-appendix 
is present as in those in whom the mesenteric attachment is but 
slightly developed or altogether absent.” 
The freedom of the female sex from appendicitis is not 
accounted for by the supposed additional blood supply to the 
appendix, as the ligament of Clado has only been found to exist 
in about one woman in ten; and, if the observation just quoted 
from Fowler be correct, its presence would seem to make little 
difference. Admitting, however, that this ligament does exist 
more frequently and that it carries a blood-vessel, and that this 10 
CHENOWETH: ETIOLOGY OF APPENDICITIS. 
is a protection to the appendix, we would still be as far as ever 
from an explanation of the frequent occurrence of the disease at 
certain periods of life. If irritative conditions, such as are 
associated with constipation or diarrhea, dragging on the meso- 
appendix by distension of the cecum with gas or fecal matter, or 
the presence in the appendix of pathogenic bacteria, were of 
prime importance in the causation of appendicitis, it is difficult 
to understand why the disease should be most frequent about 
puberty, when the vital forces are most active, and when the 
factors above mentioned are probably less active than at any 
other period of life. 
Do we not lose the key to the situation when we consider the 
appendix as a functionless organ, or that at most its function 
consisted only in the secretion of a little mucus? I take it that 
no one considers the function of the appendix as a vital one, or 
even of any great physiological importance, but is it reasonable 
to hold the tissues of the appendix subject to different physio- 
logical and pathological laws from similar tissues in other 
portions of the body? Have we any reason to believe that the 
lymphoid tissue of the appendix differs materially from the 
lymphoid tissue in other portions of the digestive tract, or is 
subject to other physiological and pathological changes, except 
as modified by its anatomical relations. 
Clado4 found the structure of the appendix similar to that of 
the large intestine, and, according to the same author, it must 
be looked upon as a glandular organ rather than an organ of 
absorption. Its mucous glands and lymphoid tissue are much 
developed, and in the normal state the appendix never contains 
fecal matter. 
Ribbert5, of Zurich, in a microscopical and macroscopical 
study of four hundred specimens, concluded that the appendix 
undergoes a process of retrogression during the life of the indi- 
vidual, which manifests itself in, first, shortening; second, 
changes in the histological structure of its walls, and, thirdly, 
spontaneous obliteration of its lumen. That in the newborn 
its length averaged 3§ centimeters; up to five years, 7f centi- 
meters ; five to ten years, 9 centimeters; ten to twenty years, 9f 
centimeters; twenty to thirty years, 9J centimeters ; thirty to forty 
4 Annual, vol. 1, ’93. 
5Annual of ’94. CHENOWKTH: ETIOLOGY OF APPENDICITIS. 
11 
years, 8f centimeters; forty to sixty years, 8J centimeters; over 
sixty years, 8i centimeters; the greatest length thus being between 
theagesof ten and thirty years. Its dimensions are relatively larger 
in the newborn than the adult. Twenty-five per cent, were found 
partially or completely obliterated ; the shorter the appendix the 
more frequent its obliteration. This obliteration he considered 
a retrogressive process and not pathological. In the ninety-nine 
cases out of four hundred the percentage of obliteration accord- 
ing to age was: One to ten years, 4 per cent.; ten to twenty, 11 
per cent.; twenty to thirty, 17 per cent.; thirty to forty, 25 per 
cent.; forty to fifty, 27 per cent.; fifty to sixty, 36 per cent.; 
sixty to seventy, 53 per cent.; seventy to eighty, 58 per cent. 
Thus we see that the appendix, after steadily increasing in size, 
reaches its greatest development between the ages of ten and 
thirty years. After this age retrogressive changes are marked 
and very constant, twenty-five per cent, being obliterated. This 
is in perfect harmony with the behavior of similar tissue in other 
parts of the body, notably the thymus, the solitary and agmi- 
nated gland of Peyer, and the tonsils, all of which reach their 
greatest development at or before puberty, and normally atrophy 
after this period. 
The function of the vascular glands is now generally recog- 
nized as intimately concerned in the formation and preservation 
of the blood corpuscles. The almost constant presence in their 
tissues of larger quantities of uric acid as well as the nitrogenous 
bodies, xanthin, hvpoxanthin, etc., than in other tissues less rich 
in nucleated cells ; and the fact that these uric acid leucomaines 
occur as decomposition products of nuclein render the inference 
a fair one that some special nitrogenous matabolism must occur. 
6“The opinion that the vascular glands serve for the higher 
organization of the blood is supported by their being all especially 
active in the discharge of their function during fetal life and 
childhood, when for the development and growth of the body 
the most abundant supply of highly organized blood is necessary. 
The bulk of the thymus gland in proportion to the body appears 
to bear almost a direct proportion to the activity of the body 
development and growth; and when, at the period of puberty, the 
development of the body may be said to be complete, the gland 
6Kirke, Hand-book Physiology. 12 
CHENOWETH: ETIOLOGY OF APPENDICITIS. 
wastes and finally disappears. (The spleen more nearly retains 
its proportionate size and enlarges nearly as the whole body 
does.) Although the function of all the vascular glands may be 
similar in so far as they may all alike serve for the elaboration 
and maintenance of the blood, yet each of them probably dis- 
charges a peculiar office in relation to the whole economy and to 
that of some other organ.” 
Not only do we find this close analogy in the development of 
the lymphoid tissues of the appendix and similar tissues in other 
situations, but we find it likewise in the disorders of these 
structures. Take the tonsil, for example. In speaking of the 
predisposing causes of tonsillitis, 7 Delavan says “ the first and 
most important factor seems to be youth, since it is most prev- 
alent between the age of fifteen and twenty-five.” It is rare in 
early childhood and after fifty. McKenzie, out of 1,000, found 601 
occurred between ten and thirty; Delavan found 165 out of 260. 
McKenzie believes “that sex is not without influence in produc- 
ing chronic hypertrophy of the tonsil, for out of the 1,000 cases 
673 were males and 327 females.” Delavan, out of 260 cases, 
169 were females and 91 males; 162 of the 169 females were 
under thirty years of age, while of the males, 84 out of 91 were 
under thirty. 
“Hypertrophy of the tonsil greatly increases the liability of 
the individual to acute attacks of tonsillitis. Sometimes this seems 
to be due to retention of excrementitious matter in the enlarged 
lacunae, which acts as an irritant to the tissue and excites inflam- 
mation ; and again the tonsil seems, in many cases, to be a 
vulnerable spot which is apt to sympathize with various irregu- 
larities of the body and to be subject to inflammation as the 
result of dyspepsia, the strumous diathesis, and, most important of 
all, rheumatism and gout. General conditions of ill-health may 
predispose to tonsillitis. It may be caused by mental depression 
and by unusual care and anxiety. Exciting causes are exposure 
to cold and wet; there can be no doubt, however, that septic 
influences often play an important part in their production, but 
it is highly probable that without some predisposing general con- 
dition the chilling of the surface of the body through exposure 
to cold would have little effect. The disease is more prevalent 
7Encyloped. Dis. Chil., Keating. CHENOWETH : ETIOLOGY OF APPENDICITIS. 
during the spring months than the three winter months; finally, 
it may arise from various traumatisms, such as wounds, impac- 
tion of foreign bodies in swallowing ; and from the irritation due 
to secretion in the tonsillar crypts.” 
Again, the same author says, “ In many cases the tendency 
to tonsillar inflammation seems to be directly hereditary and not 
referable to any mediate condition, for while in such instances it 
might be supposed that the presence of such an inheritance might 
be due to the existence in parent and child of a common diathesis, 
the rheumatic for instance, nevertheless more than one case has 
been known to the writer in which no such diathesis could be 
traced. Climate may also play an important part.” 
To go back to appendicitis: At least four years ago my atten- 
tion was first attracted to a seeming connection between the so- 
called rheumatic diathesis and the occurrence of appendicitis. I 
was forcibly impressed by several cases in which tonsillitis or 
other manifestations of the rheumatic diathesis were associated 
with or followed disease of the appendix, and also with the appar- 
ent beneficial results of treatment directed to this condition. 
The belief that there was some connection between disease of 
the appendix and some general constitutional conditions was 
further strengthened by noting the occurrence in more than one 
instance of the disease in several members of the same family; 
the frequent occurrence of the disease under certain atmospheric 
conditions; and finally, by the frequency with which a history of 
unusual muscular exertion, fatigue, and exposure to cold and wet 
preceded the appendix trouble. Several of these points have 
been noted by other observers, but not satisfactorily explained. 
Talamon8 reports instances in which appendicitis occurred in 
several members of the same family, and refers to similar instances 
reported by other anthers, but does not attempt to explain 
wherein the hereditary predisposition lies; whether in the length 
of the appendix, its breadth, or its structure, or in the disposition 
of Gerlach’s valve. To his mind the frequency of appendicitis 
among the Anglo-Saxon race can not be explained by peculiari- 
ties of their habits of living. 
Deaver9 says, “ I have had cases due to exposure to cold and 
wet. In one the attack was caused by taking a cold shower just 
8 Med. Mod., 18%, vol. 9; American Medico-Surgical Bidletin. 
9 Treatise on Appendicitis, 14 
CHENOWETH: ETIOLOGY OF APPENDICITIS. 
after coming out of a warm bath; another was the result of wet 
feet, and a third from being chilled by lying in a cold room 
shortly after a heavy meal.” 
While looking up the subject of the appendix vermiformis 
Dr. North10 had been startled by the number of cases of appendi- 
citis reported and referred to. In seeking the explanation he 
had visited the health office of Brooklyn and studied the relative 
number of deaths for the several years since 1880 from perito- 
nitis, perityphlitis, typhlitis, appendicitis, intussusception, obtruc- 
tion of the bowels, colic, perforation of intestine, ulceration of 
bowels, perforation of appendix, and constipation. The percent- 
age of deaths from these combined causes had been, in 1880, 1; 
in 1888, 1\, and for the successive years to 1895 it had been 1£, 
1tu> li> Isb 1£. It was obvious that since there were more 
deaths from these causes there must be more cases in the aggre- 
gate, else the treatment was faulty. It was not likely surgical 
technique would much further diminish the death-rate from oper- 
ative interference, and Dr. North thought the difficulty lay in 
practitioners giving up as soon as a patient complained of a pain 
in the right side and calling in a surgeon, instead of resorting to 
early local antiphlogistic and internal remedies. 
It would have been more charitable to the surgeon and nearer 
to the truth in my estimation, had Dr.North concluded: Not- 
withstanding the improvement in surgical technique during the 
past five years and the great number of lives saved by operative 
interference, the percentage of mortality from appendicitis has 
increased. This can not be explained by the small percentage of 
deaths from operative interference and due to preventable causes; 
and would not be effected by the much larger percentage of 
deaths due to delayed operation where the usual medical treatment 
had been employed, and obviously can only be due to a vastly 
increased number of cases occurring during these years from 
some unknown cause. And I would suggest that the epidemics of 
influenza during these years bear a casual relation to this great 
increase. 
Haig11 gives the notes of a case of Garrod’s. It was that of a 
very gouty man, aged fifty, in whom, after exposure to cold, gout 
retroceded to the intestines, producing intense inflammation of 
10 Medical Record, Nov. 24, 1896. 
11 “Uric Acid as a Factor in tbe Causation of Disease.” CHENOWETH: ETIOLOGY OF APPENDICITIS. 
the last eighteen inches ot the ileum, as found after death, and 
also of a case recorded by Prof. Hayem, where enteritis occurred, 
the villi being strewn with small uratic incrustations, and he con- 
tinues: 
“ Such a concentration of urates in the fibrous walls of in- 
flamed intestine just as they concentrate around the lower alka- 
line fibrous tissues in joints, spleen, and kidney, in several of which 
they may be present in sufficient quantities to be visible to the 
naked eye, constitutes what I have spoken of as gout of the intes- 
tine, and forms, I believe, the anatomical condition behind such 
troubles as colic, enteralgia, and not a few cases of typhilitis.” 
At the risk of being unduly tedious, I shall quote some further 
observations of Haig. Pie says : “ My clinical and experimental 
experience have led me to believe that a very large number of 
cases, such as I have mentioned, are neither more nor less than a 
gout of the walls of the intestinal tubes, and that a knowledge 
of their true pathology places us at once in a position to effect a 
complete and satisfactory cure by the use of the same drug which 
in my hands gives the best results in cases of arthritis due to 
uric acid, and I shall further point out that such colic or enteritis 
can be produced hy giving certain drugs, all of which have the 
same action on uric acid, viz., that of driving it out of the blood 
into the tissues.” Prominently among these drugs he mentioned 
mercury. “As in several other matters connected with gout, it 
was my personal experience that first directed my attention to 
the points that I am now bringing forward. Some eight or 
nine years ago I noticed that when I was suffering from 
some gastro-intestinal trouble, such as that which commonly 
produces an attack of uric-acid headache, and that when I 
treated this trouble by taking a small dose of calomel I some- 
times produced pretty severe intestinal pain, which was gen- 
erally located in or about the right iliac fossa. On one occasion, 
when a small dose of calomel, one grain, produced slight pain in 
this way, I thought that the purgative action had been insufficient 
and that a larger dose was indicated; the result of this, however, 
was to produce very severe pain indeed, which confined me to 
bed and the house for several days and made me quite unhappy 
about myself, as I feared that I had typhlitis. At this time, how- 
ever, I knew very little about gout of the intestines, and nothing 
at all about the solubility of the urates of mercury, hence, 
beyond a mental note to avoid as far as possible the use of 
calomel for the future, the lesson was lost upon me. A year or 
two later, when taking some cocaine for purposes of experiment, 
I was surprised to find that it was followed on several occasions 
by somewhat similar pain, and this pain, which was partly due, I 16 
chenoweth: etiology of appendicitis. 
think, to cocaine and partly the result of cold and occasionally 
wet feet late in the autumn, became chronic with relapses, and 
awakened my old fear of typhlitis and serious organic disease. 
So much was this the case that I consulted a friend on the 
matter, and at his suggestion was making up my mind to take 
several months’ rest and change of climate when I chanced, still* 
following out my experiments to some extent, or possibly 
prompted by some previous experiences, to take a few doses of 
salicylate of soda, and the effect was magical; pain was better 
soon after the first dose, and in two days was gone for good and 
all. 
“ I now began to see that I was not suffering from serious 
organic disease, but from a gout of the cecum accompanied by a 
certain amount of colic or enteralgia and enteritis, and when I 
afterward found out the insolubility of the urates of mercury I 
was easily able to understand why this metal had produced the 
pain on a previous occasion and why salicylate of soda had cured 
it so completely on this last occasion. 
“ Since this time I have had no further anxiety on the score 
of this intestinal disorder; I have often had it, and will under- 
take to produce it any time by the use of any of the other drugs 
I shall mention presently, but I have now complete confidence 
that I can put an end to it in a few hours’ time by means of sali- 
cylate of soda. I have also treated several cases that were 
clinically typhlitis in the same way, and have every reason to be 
satisfied with the results. 
“ One of the most recent of these was in the person of a rel- 
ative of my own, who is a member of the profession. I hap- 
pened to hear that he was ill with what sounded like typhlitis, 
and I also heard that he had taken a dose of calomel before the 
attack begun. It at once struck me that this was a repetition of 
my own experiences, and I went to see him as soon as I could. 
I told him what I had found out in my own case, and persuaded 
him to let me add a little salicylate of soda to the mixture he 
was taking. The result was in every way as satisfactory as in 
my own case. 
“ He at once began to improve, and in two or three days was 
up and about, while prior to the administration of this drug it 
appeared only too probable that his illness would be a matter of 
weeks. The history of this case is as follows : After one or 
two rather extensive dinners and champagnes he had a little 
disturbance, and with the intention of putting this right he took 
a few grains of calomel, and a few hours later was seized with 
violent colicky pains in the right iliac region. The pain came in 
attacks which were worse at night and caused nausea; there was 
an ill-defined fullness with tenderness in the right iliac fossa, CHENOWETH: ETIOLOGY OF APPENDICITIS. 
and temperature about 100° F. He asked a neighbor to come to 
see him, and lay in bed often groaning with pain, and with warm 
poultices constantly applied to the painful region ; he took a 
carminative mixture, and a nurse was obtained for him ; this was 
the condition of things when I went to see him, and, with the 
concurrence of a neighbor who was looking after him, added 
salicylate of soda to the mixture, with the result mentioned. 
“ There was, I think, no doubt in the minds of many of us 
that we were dealing with typhlitis, or a condition so like it that 
it deserved to be treated with great respect; but there was also 
in my mind no doubt, from the history of its causation, but that 
it would yield at once to salicylate of soda, and this proved to be 
the case. 
“I have mentioned the pain produced by cocaine, and coca- 
ine also diminishes the excretion of uric acid; likewise acids, 
mix vomica, and sulphates, especially sulphate of soda, occa- 
sionally acting the same way, may cause some intestinal pain of 
a similar kind; they diminish its excretion in the urine, clear 
it out of the blood and drive it into the liver, spleen, and fibrous 
tissues, especially into the fibrous tissues that have their alkalin- 
ity diminished by any previous irritation or inflammation. They 
produce this effect on uric acid, either by forming insoluble 
compounds wdth it, as in case of the metals, or they diminish the 
solvent powers of the blood through the absorption of acids 
from the intestines by the lymphatics, thereby diminishing its 
alkalinity, and under slightly different conditions any of them 
may produce gout of a joint instead of gout of the intestines. 
“No one, I suppose, will deny that there is a large amount of 
fibrous tissue in the walls of the intestines, and if the fibrous 
tissues in fascia, tendons, and joints are liable to have urates 
deposited on them when they have had their alkalinity dimin- 
ished by injury or irritation, I see no reason why the fibrous 
walls of the intestines should not be affected in exactly the same 
way. 
“Thus the case just quoted from Sir A. Garrod might have a 
causation somewhat as follows: A gouty man has some more or 
less acute intestinal irritation (of dyspeptic origin), causing some 
nausea; this caused uricacidemia; on this there unfortunately 
follows exposure to cold, which raises the acidity and drives the 
urate out of the blood again, and as in other cases a large amount 
of it goes into that piece of fibrous tissue which is most irritated 
and least alkaline, in this case the fibrous structure in the walls 
in the last eighteen inches of the ileum. This still further 
increases the irritation, acute gouty inflammation of this por- 
tion of the intestines ensues and becomes so serious a§ to cause 
death. 18 
CHEXOWETH: ETIOLOGY OF APPENDICITIS. 
“ I have no doubt that if after death an extract had been 
made of this portion of the ileum it would have been found to 
contain far more urate than any other portion of the intestine of 
the same weight, and we have seen from the case previously 
mentioned that the gout may go on to deposit of urate visible 
to the eye. 
“ I have recently had an opportunity of testing a piece of 
inflamed intestine for uric acid in the case of Alice C., age twelve, 
admitted under my care at the Royal Hospital for Children and 
Women on November 11, 1895. 
“ She had been suffering from appendicitis or perityphlitis 
for some three weeks, and this had probably gone on to local 
suppuration before she was seen. She was put on salicylate of 
soda, which was given by rectum when her stomach rejected it; 
but this did not produce any marked effect, and she died on the 
fifth day after admission, with general peritonitis. 
“ I am in doubt in this case whether she got enough salicylate, 
owing to the vomiting which was present on admission ; or 
whether the salicylate failed because suppuration had already 
taken place, as in my experience it is quite useless in gouty 
arthritis once suppuration has set in. 
“At the post-mortem a local abscess round the appendix was 
found which had burst into the general peritoneal cavity shortly 
before death. 
“ I then took a portion of the cecum with the appendix, at 
the seat of the local abscess, and also a portion of the colon from 
the opposite side of the abdomen, near the splenic flexure, and 
tested them for uric acid in the ordinary way. 
“ I found in the portion of cecum and appendix .053 grains 
to ounce of uric acid and xanthine, but in the splenic flexure so 
little that I could not feel certain that there was any at all, 
while in the extract of cecum the precipitate with nitrate of 
silver was quite visible. 
“I think it probable that the pus of the local abscess would 
have contained more uric acid had we been able to get it, and 
that the inflamed intestine would have contained more earlier in 
the disease. 
“I should lay absolutely no weight on my results in this 
single case, but report it here merely for the purpose of getting 
others to repeat my observation whenever they have a chance, 
either in perityphlitis or the colic produced by lead or other 
metals. 
“Again, we have some evidence pointing in the same direc- 
tion in the part of the intestine commonly affected. Why 
should the last eighteen inches of the ileum, or, in my experi- 
ence, t})e cqcurj) and lower ileum bq the parts affected ? CHENOVVETH: ETIOLOGY OF APPENDICITIS. 
“ I would suggest that the reaction of the intestinal contents 
has something to do with it; it is well known that those of the 
large intestinal have an acid reaction, and it is not improbable 
that the alkalinity is diminished in the small intestines before 
the ileo-cecal valves are reached. 
“Again, Bouchard12 has shown that in certain dyspeptic 
conditions, especially in dilatation of the stomach, there is an 
excess of acid throughout the whole intestinal canal, and such 
acidity may cause local irritation and thus form the starting point 
fora concentration of urates in the intestinal walls and an attack 
of gout. 
“ Then any local irritation due to impacted feces or foreign 
bodies may act in the same way, setting up a local inflammation 
with fall of alkalinity which is soon complicated by a concentra- 
tion of urates on the irritated spot; in this way the irritation 
in the vermiform appendix may precipitate a local attack of gout 
which, as in other parts, the joints and the valves of the heart, 
for instance, recurs and recurs, till a more or less extensive 
lesion (perityphlitis) has been produced. 
“I notice that recent writers on this subject generally make 
use of the term appendicitis ; aud if proof is forthcoming that the 
trouble generally originates in the appendix there is no objection 
to this. As regards its gouty or rheumatic origin, it makes no 
difference whether it begins in the appendix, the cecum, or the 
lower ileum, as in the case reported by Sir A. Garrod; the only 
thing that concerns us is that these portions of intestine contain 
fibrous tissues, upon which urates may be precipitated if their 
alkalinity is diminished by such things as dyspepsia, cold, or 
irritating substances. And the irritation so caused may recur 
and recur and lead on to ulceration and sloughing just as in any 
other fibrous tissues.” 
“One swallow does not make a summer,” nor does the fact of 
Dr. Haig having colic after a dose of calomel, and his relative 
recovering from a supposed typhlitis, after having taken a cer- 
tain quantity of salicylate of soda, prove that either had a deposit 
of urate of mercury in the fibrous tissues of the intestine, which 
was removed by the salicylate, nor does the finding of considerable 
quantities of xanthine bodies in the inflamed tissues of the child 
Alice C. prove that there had been a gouty deposit in the fibrous 
walls of the intestine, for we know that adenine and guanine are 
normal constituents of the cell nucleus and are readily converted 
into hypoxanthine and xanthine respectively, during the process 
12“Lecons sourles Auto-intoxications,” p. 172. 20 
CHENOWETH: ETIOLOGY OF APPENDICITIS. 
of putrefaction, and consequently may be found in all suppurat- 
ing tissues where nucleated cells are abundant; but these cases 
are suggestive, and we know it to be a fact that a deposit of 
urates may and does take place in the lower part of the ileum 
and the cecum under some circumstances, as evidenced by the 
cases reported by Garrod, Hayem, and others, and it is not at all 
improbable that such a deposit does occasionally cause sufficient 
irritation to start what may become, through infection, a fatal 
inflammation. 
The causation of appendicitis by such a gouty deposit would 
naturally be expected to occur more frequently, as in the reported 
cases, in males after middle age, and may account for woman’s 
relative immunity from this disease, but only in just such measure 
as is she relatively free from other forms of gout. 
I have quoted these cases in detail mainly for two reasons. 
First, I wanted to direct your attention to the fact and manner 
of the occurrence of these gouty deposits, but at the same time to 
the fact that such gouty deposits do not, like appendicitis, belong 
to early life; and to suggest at this period of life, it is the pres- 
ence of the large amount of lymphoid rather than fibrous tissue 
in the last eighteen inches of the ileum, the cecum, and the appen- 
dix that determines the frequency with which it becomes the 
seat of disease. Secondly, to emphasize the unquestionable fact 
that no matter what the primary cause of the appendicitis may be, 
that neither salicylate of soda, opium, nor any other drug will restore 
the circulation in a disorganized appendix, prevent the leakage of 
intestinal contents or delay the inevitable consequences following the 
rupture of an encysted appendiceal abscess into the peritoneal cavity. 
The occurrence of appendicitis after violent muscular exer- 
tion has been noted by numerous writers and attributed to torsion 
of the appendix. In a paper read before the Kentucky State 
Medical Society in June, 1894, Dr. A. M. Cartledge says: “My 
observations, confirmed by others, that external violence from 
falls, blows, and contortion of the trunk may cause rotation of 
the appendix and twisting of its mesentery lead to another 
explanation of the frequency of appendicular disease in males, 
viz., the occupations of the two sexes.” “ That torsion alone by 
cutting off the blood supply is a cause of destructive changes in 
the appendix there can be no doubt. One such case, operated upon a few hours (five) after the accident by Dr. J. S. Cheno- 
weth, demonstrated the twisted appendix perfectly. I have seen 
undoubted evidence of such a condition in cases operated upon 
after infection and perforation.” 
In the discussion following this paper one member is reported 
as saying: “ If the case be appendicitis, and you inquire into the 
cause, you will find there has been something in the occupation 
of the man that predisposes to it. To illustrate, I have had four 
cases within the last year, two caused by the men using a wood- 
saw. If a man who is not accustomed to using a buck-saw uses 
one vigorously, and has colic the next day, you may put it down 
that it is a case of appendicitis. The third case was caused by 
a man following a pond-scraper, and the fourth by riding a 
horse. Exercise is one of the points (o be taken into considera- 
tion in the causation of appendicitis. If it is appendicitis, a 
violent exercise produces it; if it is a colic, it is imprudence in 
diet. I am perfectly satisfied that in following a pond-scraper, 
using a buck-saw, and riding horseback, the anatomical relations 
are such that we have in these forms of exercise an important 
point which may enable us to make an early diagnosis.” 
That the difference in the occupations of the two sexes does 
exert some influence upon the relative frequency of appendicitis 
in the sexes I take to be a fact, but I question whether it is 
through an increased liability to torsion of the appendix in the 
male. The case referred to by Dr. Cartledge, in which, five 
hours after the development of the acute symptoms, I found a 
gangrenous appendix twisted at its base, I have thought over 
many times in all its bearings. I believed at the time that torsion 
of the appendix was the primary factor in the disease process. 
In the light of subsequent experience and thought I question 
very much whether the sharp twist in the appendix was the 
cause rather than the result of the necrosis. 
It would certainly seem that the few cases in which an acute 
twist of the appendix has been found, whether viewed as a pri- 
mary factor in the process or secondary to necrosis of the appen- 
dix, would be at least offset bv the possible nutritive disturbances 
in the appendix occurring in the female during pregnancy, from 
displacements of uterus and ovaries, or from the pressure of uter- 
ine and ovarian tumors. We have noted that the tonsils, com- 
CHENOWETH: ETIOLOGY OF APPENDICITIS. 
21 22 
CHENOWETH : ETIOLOGY OF APPENDICITIS. 
posed of very similar tissue to the appendix, are most subject to 
inflammation at those seasons when sudden alterations of tem- 
perature are apt to occur. And as previously intimated, although 
I can find no statistics on this point, I believe from my personal 
observations that the same will prove true of the appendix, and 
that there is something more than mere coincidence in the famil- 
iar grouping of these cases. 
Diseases of both these organs occur more frequently in men 
than in women, and occur at the same period of life; are both as 
a rule associated with or preceded by intestinal disturbances; 
from their anatomical situations are alike subject to traumatism 
from impaction of foreign bodies or retained secretions, and are 
alike prone to bacterial infection. 
The influence of heredity upon ultimate disease of the appen- 
dix can be reasonably accounted for, as in the case of tonsillitis, by 
the presence in parent and child of a common diathesis, the stru- 
mous or rheumatic, with a resulting tendency to hypertrophy and 
hyperplasia of the lymphoid glands at puberty, a most active 
predisposing cause of acute inflammatory attacks. 
Let me call your attention to syme other common affections 
usually considered as dependent upon the rheumatic diathesis, 
which my personal experience has convinced me are not infre- 
quently associated with appendicitis and dependent upon the 
same general causes. 
Speaking of valvular heart lesions, the author13 says: “In 
118 cases there was absence of rheumatic history in 40; in 10 of 
these chorea was manifest; in 13 there was no evidence of any 
antecedent or probable cause of the valvular trouble. Signs of 
rheumatism may be very slight in a child, skin eruptions consti- 
tuting the only obvious signs of rheumatic condition, notably 
erythema, more rarely purpura or chorea or recurring bronchitis 
or asthma.” 
Bowen (quoted by Morrow) in speaking of purpura and acute 
circumscribed edema, says: “The close relationship and even 
interchangeability of certain of these cases of purpura with urti- 
caria, with erythema, nodosum, and with angio-neurotic edema, 
favor the suggestion that the entire group may depend upon some 
poi§on, an alkaloid perhaps, the result of faulty chylo-poetic 
>*Keating, Ency. Dig. of Children. metabolism which in varying doses in different constitutions ex- 
cites in one urticaria, another peliosis rheumatica, a third fatal 
purpura.” 
“ Purpura occurs more commonly in the young. According 
to Gintrac one hundred cases were observed before twenty 
years of age, ninety in five subsequent decimal periods. The 
blood changes observed in purpura were diminution in the 
quantity of red blood cells and solids, in constant varia- 
tions in fibrin, which was diminished in infectious diseases, 
and purpura hemorrhagica, and increased in scurvy and pur- 
pura simplex. An increase of the white cells, a change in 
form of the red cells, the presence of embryonic elements and 
bacteria, and lastly fatty degeneration and inflammation of the 
small vessels, vascular dilatation and stasis. The disturbance of 
the capillary system and increase of blood tension should be con- 
sidered to arise through vaso-motor disturbance of innervation. 
Hemorrhage may occur into the skin or mucous membrane, epis- 
taxis is frequent, hematemesis is less so. When it does occur it 
is generally accompanied by pain in the left hypochondrium and 
splenic enlargement, and the stools sometimes contain blood ; 
hematuria, hemorrhage from lungs and intestine, or cerebral 
hemorrhage may occur. In purpura rheumatica there is pain in 
the fibrous tissues of the joints from effusion or hemorrhage into 
the joints. A variety of so-called rheumatic purpura is not 
infrequently met with when in addition to the rheumatoid pain 
there is violent epigastric pain and colic; the pain being followed 
not infrequently by bloody vomiting and bloody stools.”14 
The frequency of these cases has lately been called attention 
to by several authors, notably Osier, who considers them as the 
visceral manifestations of exudative erythema. We find that with 
these disorders the history of one is the history of all. They 
are pre-eminently diseases of adolescence; they seem to occur 
more frequently in women than men, most frequently between 
twenty and thirty; may be produced under favorable conditions 
in certain individuals by many drugs, various articles of diet or 
disturbance of the digestive and generative organs, malaria, 
trauma, mental or bodily fatigue, or chilling of the surface of the 
body, and are almost without exception markedly influenced by 
the seasons, being more prevalent in early spring and fall and in 
CHENOWETH: ETIOLOGY OF APPENDICITIS. 
23 
14Keating, Ency. Dis. of Children. 24 
CHENOWETH : ETIOLOGY OF APPENDICITIS. 
cold, damp seasons. A predisposition to these disorders seems to 
be hereditary; but, as with tonsillitis and appendicitis, it is highly 
probable that without some predisposing general condition the 
chilling of the body, etc., would have little effect. 
I would like to call especial attention at this point to the 
striking similarity in the blood changes found in these cases of 
purpura rheumatica to those observed in appendicitis, viz., 
increased leucocytosis, fatty degeneration and inflammation of 
the small vessels, vascular dilatation and stasis, the disturbance 
of the capillary system and increase of blood tension being con- 
sidered to arise from vaso-motor disturbance of innervation. 
Another point: if such vaso-motor circulatory disturbances, 
varying from a mere temporary congestion to actual hemorrhage, 
may take place in the brain, lung, joints, skin, kidney, stomach, 
and colon, why not much more rapidly in the vermiform appen- 
dix, considering that its circulation is so easily and disastrously 
disturbed by causes insufficient to produce such disturbances in 
other parts ? We may put the question in another way : If such 
circulatory disturbances occur in other portions of the digestive 
tract, as a result of general constitutional conditions, when sim- 
ilar pathological conditions are found in the appendix, why 
should we attribute them to local accidents alone, more especially 
when such an assumption utterly fails to account for their more 
frequent occurrence at a certain period of life ? 
Rheumatism, which is considered the typical manifestation of 
this constitutional condition, is attributed by Angel Money “to 
a retention in the system of fatigued products of nitrogenous 
metabolism, the nervous system forming the secondary element.” 
“Tonsillitis is very commonly the forerunner of rheumatism, 
and indeed some have claimed it as a part of the rheumatic pro- 
cess ; but if this is the case it must often be its only sign, as there 
may be no other symptom of rheumatism either before or after- 
ward ; but tonsillitis, in my experience, is very often associated with 
conditions of fatigue and overexertion, and these are just the con- 
ditions which bring about considerable uricacidemia, and when 
tonsillitis with fever supervenes upon this it is hardly to be won- 
dered at that we should have some joint pain or even acute rheu- 
matism.” (Haig.) “ The curve representing the rise and fall ot 
rheumatism by months, shows it to follow with considerable reg- 
ularity the rise and fall of atmospheric temperature. The curve CHENOWETH : ETIOLOGY OF APPENDICITIS. 
25 
for rheumatism follows the curve for tonsillitis. Clinical observ- 
crs have noticed and recorded an apparent relationship between 
tonsillitis and rheumatism, and although most of them have con- 
cluded that the tonsillitis was rheumatic, the fact that usually 
tonsillitis precedes rheumatism seems to indicate that if there is a 
casual relation between the two diseases, tonsillitis is the most 
likely to stand as the first link in the chain.” (Hare.) 
‘‘Acute rheumatism may be produced by any thing which 
produces a sharp rise of acidity or fall in the alkalinity of the 
blood at a time when there is considerable supply of urate in the 
circulation (uricacidemia); but if there is no urate a rise of acidity 
may produce little or no effect; hence, those who eat much meat 
aud drink most beer and have in consequence most uric acid 
stored in their body will be most likely to have occasionally con- 
siderable uricacidemia, and when exposed to cold and wet, or the 
sudden onset of any fever supervenes upon this, acute rheuma- 
tism may result.” (Haig.) 
“Age has an important influence on another factor of uric 
acid arthritis, namely, the absolute quantity of uric acid that is 
formed, for while in an adult urea is formed in about the propor- 
tion of 3 or 4 grains per pound of body weight per day, and uric 
acid in its natural relation of one to thirty-five would be about 
.09 to .11 to a pound daily; in a child of three or four urea may 
be as much as nine or ten grains per pound and uric acid .27 to 
.30 grains to a pound. A child or young person is thus by 
nature placed much in the position of an adult who eats largely 
of meat.” (Haig.) 
“ The daily formation of uric acid is large, and uricacidemia 
and the arthritic irritation, so far as they depend upon for- 
mation for supplies, are correspondingly easily produced. It is 
little wonder, then, that when young persons who have tins ex- 
tensive nitrogenous metabolism increase it by eating largely of 
meats, meat extracts, juicies, and essences, the introduction and 
formation of uric acid should be very great and the probabilities 
of resulting mischief considerable; and that, as pointed out by 
Bouchard, children fed on meats and meat extracts should often 
suffer from gastro-intestinal derangements, skin disease, and early 
migraine, and that rheumatism and its most serious manifesta- 
tions should come early. 
“Another point is, that in children and young persons 
(probably in consequence of their more active metabolism), 
slight disturbances will produce great increase of temperature, 
and rise of temperature means, as we have seen, rise of acidity, 
the two things (fever and acidity) being probably co-resultants of 
increased metabolism. Thus the extraordinarily rapid develop- 
ment of girls at the age of thirteen may quite account for their 26 
CHENOWETH : ETIOLOGY OF APPENDICITIS. 
liability to acute rheumatism about that age, as well as to chlorosis 
and anemia a few years later. 
“Young persons then are, from the action of natural causes, 
often liable to have considerable uricacidemia, and, whenever 
external cold or light febrile disturbance supervenes upon this, a 
powerful rise of acidity will drive the uric acid out of the blood 
into the joints and other tissues, for these tissues no doubt share 
largely in any general fall of alkalinity. 
“A child with gastro-intestinal disturbance and loss of appe- 
tite has a headache and slow pulse and the signs of uricacidemia. 
On this there follows exposure to cold and wet, a slight sore in the 
throat, a peridental abscess, or other cause of febrile movement, 
and the resulting fall in alkalinity quickly produces a multiple 
arthritis with endopericarditis and changes the picture to that 
of acute rheumatism.” (Haig.) 
In this way the production of acute rheumatism may be com- 
pletely accounted for by the action of causes that are to be met 
with every day, and the wonder is that any children should 
escape an attack, but it is fortunately necessary that a good many 
causes should act together, and this can only occasionally be 
possible. 
“Thus uricacidemia means a large excretion of urate, and 
where this has gone on for several days the amount in circula- 
tion will be reduced. Again, gastro-intestinal disturbance means 
diminished metabolism and lessened formation of urate, so that, 
unless external cold or febrile movement supervenes at an early 
stage, there will not be enough urate to produce the most severe 
effects on the fibrous tissues.” (Haig.) 
Whether we believe with Haig that uric acid is formed side 
by side with urea in definite proportion, and that any excess in 
the system comes from deficient elimination and excessive intro- 
duction in our food, or believe with Fothergill in an excessive 
uric acid production, as a reversion to a primitive formation, is 
of little moment to us at present. Whether or not we believe 
that certain cases of appendicitis, tonsillitis, purpura rheumatica, 
or exudative erythema and rheumatism itself are due to one and 
the same cause, and believe that cause to be uric acid, or attribute 
these disorders to other products of metabolic activity, is also of 
secondary importance. It suffices us to know that as a matter 
of fact the Anglo-Saxon race is especially subject to dyspepsia, chenoweth: etiology of appendicitis. 
rheumatism, and gout; and the children of these dyspeptic and 
gouty individuals, whether as a result of heredity or of dietetic 
and climatic conditions, show a marked tendency to hypertrophy 
and hyperplasia of the lymphoid glands at or before the period 
of puberty, with a corresponding liability to disease of these 
structures about the same time; and that these structures, rich 
as they are in nucleated ceils, are intimately concerned in the pro- 
duction or elaboration of the relatively larger quantities of nitrog- 
enous products found in these individuals and at this period. 
It is quite sufficient for our present purposes, when we recog- 
nize the various conditions which favor the excretion or cause 
the retention in the system of waste products, or interfere with 
their elaboration, to note their constant relation to the disorders 
which we are considering, and that when by diet, drugs, or what 
not, we control the introduction and excretion of these leuco- 
maines we largely control these disorders. 
With this knowledge we have a most reasonable explanation 
of the part played by heredity in the production of appendicitis, 
as well as that by dietetic and climatic conditions, and an obvious 
explanation of its frequency in the Anglo-Saxon race is presented. 
The frequency of the disease between the ages of ten and thirty 
is seemingly due to several factors. As previously noted, the 
lymphoid tissue in the appendix, like that of the tonsil, normally 
reaches its greatest development and function about the period 
of puberty, then undergoes like atrophic changes; it is a reason- 
able assumption that it may undergo similar hypertrophic and 
hyperplastic changes under like constitutional conditions. I 
have found this hypertrophic condition in several cases just 
before puberty in which operation was done sufficiently early to 
permit of its recognition. The same findings are recorded and 
commented upon by Fowler in his “Observations upon Appen- 
dicitis/’ although attributed by him to a supposed torsion of the 
appendix. 
(Fowler.) “ Reasoning from the findings in the group of speci- 
mens of diseased appendices furnished from my own operative 
work, already alluded to, another source of trophic disturbances 
would seem to be in progressive hyperplasia or chronic stasis 
through defective venous return. 
“ It is not to be denied that other causes are operative in pro- 
ducing necrosis of the mucosa without consequent infection, as, 28 
CHENOWETH: ETIOLOGY OF APPENDICITIS. 
e. g., angulation of the appendix, the presence of foreign bodies 
in the lumen of the parts (a very rare circumstance, however), 
enteroliths, etc. It may he definitely stated in this connection, 
however, all efforts to establish the existence of a specific 
bacterium which is responsible for appendicitis had failed ; and 
it is now known that when microbic infection occurs it may be 
simple or mixed, and that several varieties of organisms may 
find their way into the peritoneal exudate at once. This goes 
far to prove the presence of other etiological causes than micro- 
organisms ; this in its turn strengthens the assumption that the 
local disturbance of tissue nutrition and resistance are operative 
to the production of the inflammation. 
“ Consideration of the so-called relapsing cases of appendi- 
citis throw a different light upon the whole subject, not only in 
its pathology but also in the practical deductions which should 
aid the surgeon in his decision regarding operative interference. 
The cases now under consideration behave in a manner entirely 
consistent with the microscopic and macroscopic findings. The 
meso-appendix is hyperplastic, and so also is the appendix itself 
the seat, in many instances, of progressive hyperplasia. Every- 
where in the specimens derived from this class of cases were 
found new-formed connective tissue; and vessels regularly show 
hypertrophic changes involving sometimes all and sometimes 
one or two of their coats. 
“ Of the circulatory disturbances in the appendix it may be 
further said that oligemia will supervene where progressive 
obliterating endarteritis is at hand, or where torsion is severe, 
or where a foreign body is present in the lumen of the tube; 
while hyperemia may originate either from torsion upon the 
vein, or secondarily as a result of local infection. Both con- 
ditions may undoubtedly obtain as a result of nerve lesions. 
That these conditions may produce effects upon the vitality and 
resistance of the appendix has already been shown. 
“ In speaking of non-specific inflammation, it is not intended 
in this connection to convey the idea that bacteria play no role 
in the process, for it is beyond dispute that they always do. 
The point here lies in the effort to discriminate between appendi- 
citis resulting from such organisms as tubercle bacilli and those 
forms of the disease in which several pyogenic organisms seem 
equally competent to produce the inflammatory condition, and 
do so in conjunction with the trophic changes. 
“ Summing up all the facts at our command, it is evident: 
(1) That appendicitis results primarily from circulatory and 
nervous disturbances which greatly lower the resistance of the 
part, and that the vascular and nervous disturbances are due 
either to immediate torsion of the meso-appendix or chronic 
progressive hyperplasia of the same. CHENOWETH: ETIOLOGY OF APPENDICITIS. 
“ (2) That the nature of the inflammation in the given ease 
will be, (a) catarrhal, (b) purulent, (c) fibrinous, (d) a combina- 
tion of the above named, or (e) interstitial. These in turn will 
depend upon the degrees of circulatory and nervous disturbance, 
and upon the nature of the micro-organisms present. 
“ (3) It can now be certainly shown that, in the given case 
of acute appendicitis, this initial attack is resultant from sudden 
torsion, and it is not the first warning of a chronic infective 
meso-appendicitis with progressive trophic lesions of the 
appendix. 
“ The results of vascular obstruction are directly analogous 
to ulcus ventriculi, dependent upon endarteritis of the gastric 
vessels; those of trophic nerve lesions to perforatory ulcer due 
to trophic nerve lesions of an extremity. 
“ It has been already shown that the great mobility of the 
appendix and its mesentery render these structures liable to 
torsion, and it can scarcely be doubted that this stands in direct 
etiological relation with the vascular and nervous degeneration.” 
Given, then, at puberty (or preferably a little later when the 
lymphoid tissue is still present in considerable amount, but its 
resistance lessened by the retrogressive changes taking place), an 
hyperplastic appendix or tonsil, a relatively large quantity of the 
products of retrograde tissue change stored up in the tissues, and 
an impressionable nervous system, and we have the foundation of 
many cases of appendicitis, tonsillitis, and rheumatism. 
Under such conditions let a boy indulge in an all-day bicycle 
run, a violent game of foot-ball, a hard horseback ride, a long 
tramp with dog and gun, or handle a fork in the hay-field on a 
hot summer’s day (and I have seen appendicitis develop under 
just these circumstances), or even let him follow a pond-scraper 
or dally with the fatal bucksaw—only let him get hot and tired, 
and as a result of muscular exertion and excessive perspiration 
bring a large amount of fatigue products into his circulation, and 
let him follow this up with a hearty supper, the next day he is 
“ bilious,” digestion is imperfectly accomplished, and fermenta- 
tive changes begin in the intestine, with the formation of more 
leucomaines and ptomaines which may be absorbed and afterward 
eliminated by the kidney or may be deposited in the tissues. 
The hyperplastic lymphoid tissue in the lower portion of the 
ileum, the cecum, and the appendix has its burden doubled, while 
the absorption of the acids of fermentation may render the solu- 30 
chenoweth: etiology of appendicitis. 
bility and elaboration of these substances more difficult. Accord- 
ing to Brunton the effect of dilute acids on the small vessels is 
to cause their dilatation, with a tendency to increase the exuda- 
tion of fluids from the vessels and produce edema of the sur- 
rounding tissues, and this might further complicate the matter. 
The irritation of the sensory nerves in the appendix by these 
intestinal and bacterial products would further increase the local 
congestion by the dilatation of its arterioles, while at the same 
time the reflex contraction of the vessels in other parts of the 
body would raise the blood pressure and increase the rapidity of 
the stream of blood in the locally dilated vessels; the swollen, 
obstructed lymph glands, their outlet already inadequate and 
pressed upon by the exudation, surrounded as they are by a 
dense and unyielding musculo-fibrous sheath, their vitality thus 
so lowered would offer but a fertile soil for the development of 
pathogenic bacteria, which with a few hours’ time are only neces- 
sary to complete our picture of acute perforative appendicitis. 
There is another important factor which we would naturally 
expect to be most active in the years immediately succeeding 
puberty, found in the retrogressive changes normally taking place 
in the appendix, as pointed out by Ribbert; these changes con- 
sist in shortening, changes in histological structure of its walls, 
and narrowing of its lumen, tending to complete obliteration. 
Deaver15 ascribes this obliteration to pathological conditions, and 
quotes Ribbert’s findings to show its frequent occurrence, but 
fails to note Ribbert’s unavoidable conclusion that this change 
was not pathological, but the normal retrogressive process, which 
takes place (not in the life of the race, but in the life of the 
individual). As previously suggested, the retention and inspissa- 
tion of fecal matter doubtless results from some such narrowing 
of the lumen of the appendix and not from lack of muscular 
development; and as the lymphoid tissue is irregularly distrib- 
uted these strictures may occur at several points. 
From the greater amount of lymphoid tissue usually deposited 
about the orifice of the appendix we would expect stricture most 
frequently at this point. Some members of this society may 
recall in this connection the first appendix that I exhibited to 
this society, in which this condition was beautifully shown. The 
16“Treatise on Appendicitis.” CHENOWETH : ETIOLOGY OF APPENDICITIS. 
liability to accidents from the retention of fecal matter or secre- 
tions during this stage of retrogression would be in inverse ratio 
to the age of the individual, the percentage of obliterations of the 
lumen of the appendix increasing directly with age. 
Why does appendicitis appear four times as often in men as 
in women? This is about the proportion as given by most 
writers, but it is very probable that this is too high, as many 
mild cases especially are apt to be overlooked in the young 
female and during pregnancy. 
Rheumatism, gout, and tonsillitis are more frequent in the 
male, all ages considered, but rheumatism is more frequent in 
the female from about twelve to fifteen years of age, while pur- 
pura rheumatica and its allied affections are more frequent in the 
female at a little later period. If all these affections are influ- 
enced by the same general conditions, why should appendicitis 
alone occur with greater frequency in the male at all ages (admit- 
ting for sake of argument that it does)? The male appendix 
averages four fifths of an inch more in length than the female ; 
its caliber is larger, and it is more liable to hypertrophy or 
hyperplasia. It would consequently be more liable to circula- 
tory disturbances and acute inflammation. The obliteration, 
partial or complete, of its lumen would not occur so early, and 
its originally larger caliber and greater length would increase 
the chances of the retention of fecal masses as this narrowing of 
the lumen progressed. 
The general habits of life (diet, exposure to weather, exer- 
cise,) of the two sexes may also render the male more liable to 
the disturbing influences which would bring about disease of the 
appendix. 
The ligament of Clado, when it exists, would seem to me to be 
rather a detriment than otherwise, and would increase the liabil- 
ity of the individual to disease of the appendix, in that the 
appendix would be more than likely to participate in the circula- 
tory and septic processes so frequent in the pelvic organs, or 
have its functions interfered with by traction from displacements 
of these organs, or from the assaults of the progressively aggres- 
sive gynecologists. (They have been accused of all the other 
crimes in the calendar, we might add this.) 
We must consider another marked difference in the sexes, 32 
CHENOWBTH : ETIOLOGY OF APPENDICITIS. 
however, than these mentioned. The development of girls, as 
shown by the annual increase of weight, as well as by other signs 
of metabolic activity, is greatest about the thirteenth year, and 
takes place very rapidly and precipitately, while with boys this 
development is much more gradual, and not obtained until the 
sixteenth year, and this yearly increase in weight in the male 
continues, although in lessened amount, for several years later. 
“ This very rapid growth and development in girls (according 
to Haig) entails a corresponding rapidity of tissue change, with 
a very large formation of uric acid and urea per pound of body 
weight, this being always much greater in the child than in the 
adult. But high urea formation is always accompanied by high 
acidity, that is to say, the urine will be highly acid and the blood 
lowly alkaline. The blood alkalinity being low it will be but a 
bad solvent of uric acid, and hence a considerable portion of the 
large amount of urate formed in these years of active metabolism 
will not be held in solution in the blood and excreted, but will 
be retained and deposited in various parts of the body, giving 
local signs of which we will speak presently. 
“ Unfortunately, later on, a girl’s metabolism falls very greatly, 
and by the end of the eighteenth year her increase in weight is 
almost nil; with this there is a great fall in the formation of urea 
and of acids, and the blood becomes more alkaline; as a result 
of this it becomes also a better solvent of uric acid, and it now 
takes up and passes into the urine so much uric acid, probably 
several hundred grains, as was stored in the tissues during the 
preceding period of active metabolism, from twelve to fourteen ; 
hence from sixteen to nineteen, or later, she will have an excess 
of uric acid passing through her blood and will sulfer from its 
effects on the blood decimal, namely, chlorosis. 
“ Now I think that girls in their more early development will 
probably form more uric acid and urea per pound than boys in 
their later development, and when later on the girl’s increase is 
almost nil, the uric acid previously retained will pass through the 
blood both in greater quantities and more suddenly than it does 
in boys, whose increase is for several years later very considera- 
ble and their acidity not so low; I therefore add a line represent- 
ing the probable effects of the girl’s increase in weight on the 
formation of urea and acids, and a broken line below showing 
the effects of this on the excretion of uric acid, and from these 
we see at a glance that the chlorosis and anemia of eighteen are 
the result of the passage of an excess of uric acid through the 
blood, which again is the result of a previous storage of this 
substance from twelve to fifteen. Add to this that just at the CHENOWETH: ETIOLOGY OF APPENDICITIS. 
time when a girl’s increase of weight is coming down, and her 
urea and acidity falling, menstruation is established ; and that, 
even if this does not upset digestion and appetite, it often obliges 
girls to keep quiet for several days, so that its result is to still 
further reduce urea and acidity and still more markedly flood 
the blood with uric acid, thus completely accounting for the 
increase of her chlorosis and the functional troubles so often met 
with at the menstrual period.” 
We can thus account for the liability of girls about the 
thirteenth year to rheumatism, as well as to chlorosis and pur- 
pura rheumatica a little later on. 
It seems evident that while rheumatism results from the sud- 
den precipitation of urates (possibly influenced by the lactic acid 
or other products of muscular activity), tonsillitis and appendi- 
citis and the vascular disturbances and the blood changes of 
chlorosis, which with the irritable condition of the nervous sys- 
tem (most marked in women about the menstrual period) are apt 
to result in exudations or hemorrhages, are due to the circula- 
tion of these suboxidation products in the blood for a variable 
length of time. It is interesting to note that these local disturb- 
ances are prone to occur in tissues that have acid secretions, and 
it is not improbable that the capillaries are mechanically ob- 
structed by local precipitation as well as by being chemically 
irritated. That these more severe blood vascular disturbances 
are capable of producing acute attacks of appendicitis I know to 
be a fact, and that appendicitis is not infrequently produced in 
this manner I believe to be equally true. This opinion was 
forced upon me long before any explanation of its occurrence 
was apparent. 
I briefly report two cases in which this relation of cause and 
effect was unquestionable in support of my positive statement of 
fact. The first was that of a boy, age fourteen years, taken sick 
early in the summer, a year and a half ago; this boy I had pre- 
viously attended in two slight attacks of tonsillitis; his sister, 
twenty-four years of age, had been under my care on several 
occasions during a period of three years. She was chlorotic, 
suffered with dysmenorrhea, indigestion, and tonsillitis. Several 
times she sent for me, complaining of violent colicky pain, usually 
located in the left hypochondrium, and for which I could find no 34 
CHENOWETH: ETIOLOGY OF APPENDICITIS. 
assignable cause; on one occasion this was attended by vomiting 
and an outbreak of urticaria. 
A second sister, seventeen years old, suffered two attacks of 
tonsillitis and a mild rheumatic attack two years ago; last year 
she stopped school on account of sick-headaches. 
I first saw this boy about 12 o’clock in the day; he had been 
employed in a milk depot for about a week, and the day before 
my visit had done an unusually hard day’s work for a boy of 
his age, handling the heavy cans, etc.; while overheated he drank 
quite a quantity of cold milk before he left the dairy, and the 
next morning awoke, nauseated, and with a sore throat. A little 
later a number of large erythematous wheals appeared over the 
body, and almost simultaneously he complained of a violent pain 
in the region of the appendix. A diagnosis of appendicitis was 
made at my visit a few hours later, the classical signs being all 
present; his temperature was 100.2° F., pulse 90. No remission 
of symptoms following the action of a saline and an enema, he 
was removed to the Norton Infirmary and operated upon at nine 
p. m. the same day. He was taken to the infirmary at the special 
request of his sister, who informed me that they were all com- 
pletely broken down nursing her father (whom I had never 
attended), a man sixty-six years old, who was then in his fifth week 
of a typhoidal attack and in a condition of septic delirium. Ten 
days later, when the boy went home, I was asked to look at the 
father, who was still holding on; the typhoid proved to consist 
of an enormous collection of pus surrounding the remains of a 
disorganized appendix. The pus had worked up behind the 
liver and down under Poupart’s ligament along the femoral 
vessels; a free opening, front and back, gave him relief, but his 
constitution was completely shattered, and he died eight months 
later. 
On opening the abdomen of the boy the appendix was found 
pointing downward and partially overlapped by the cecum; its 
walls were hyperplastic and quite hard from the dense infiltra- 
tion ; the meso-appendix was thickened and extended almost to 
the tip of the appendix. The distal third of the appendix and 
the corresponding portion of the meso-appendix presented a dark, 
somewhat mottled appearance from extravasation of blood into 
this hyperplastic tissue ; the lumen of the appendix was pervious, CHENOWETH: ETIOLOGY OF APPENDICITIS. 
though somewhat compressed, and contained only a little mucoid 
material and soft fecal matter. There was no torsion of the 
appendix, nor any other apparent mechanical obstruction to the 
circulation, and no reasonable doubt could exist but that the 
circulatory disturbance in the appendix and that taking place in 
the skin were identical. 
Seco’nd case was in a boy, age fifteen, operated upon January 
5, 1895. This boy’s mother has suffered from tonsillitis and 
rheumatism; one aunt has had rheumatism, a second, exudative 
erythema. His father has been a great sufferer from rheumatism 
and migraine, and now has a heart-murmur. He also frequently 
shows evidence of nutritive disturbances in the skin by an out- 
break of boils, which the most vigorous antiseptic treatment has 
always failed to relieve until used in conjunction with the 
salicylates, colchicum, etc. 
I first saw this case in the fall of 1890; he was then suffering 
from tonsillitis and nose-bleed ; from that time until the spring 
of’94 I attended him at various times with tonsillitis, nose-bleed, 
colic, and one attack of urticaria ; none of these attacks were very 
severe. In May, 1894, after a horseback ride, he had a severe 
attack of colic, attended with vomiting; bis pain was general 
over the abdomen, and unattended by any local tenderness or 
muscular regidity; his temperature was slightly above normal. 
His mother stated at the time that he had complained of pain, 
and had vomited after eating on several occasions in the week 
immediately preceding this severe attack ; no appendicular 
trouble could be made out. 
The following August he had a second attack, more severe 
than the first, and accompanied by fever and vomiting, with con- 
siderable pain in the right iliac region, which had passed off at 
the end of a week when I saw him. This attack followed a 
fatiguing ride out into the country. On November 22d follow- 
ing he started for a several days’ hunt in Indiana. The first 
day out, the weather turning very cold, the frozen ground making 
walking very tiresome and uncertain, late in the afternoon he 
made a misstep and fell, cutting a deep gash in his hand, which 
necessitated a return home that night. Next day he had an 
attack of bronchial asthma, accompanied by nose-bleed. This 
attack lasted, with intermissions, until December 6th. On Jan- 36 
CHENOWETH: ETIOLOGY OF APPENDICITIS. 
uary 6, 1895, I was hurriedly called, to find him suffering from 
severe colic and vomiting. He was very nervous and rolling 
around over the bed; temperature 99.2° F.; pulse 100; abdomen 
was not distended; the pain was most intense under the border 
of the ribs on the left side and in the right iliac region; tender- 
ness on pressure and rigidity of right rectus. No.cause for the 
attack could be assigned. Enema of glycerine and water brought 
away only a little gas; calomel, gr. was retained, but saline 
was rejected. Five hours later he began to cough again and his 
nose to bleed. 
Twenty-two hours after the commencement of the attack his 
temperature was 100.6° F. ; pulse 105; he had vomited several 
times and his bowels had not moved. An increasing tenderness, 
etc., in the region of the appendix warned me against further 
delay, and notwithstanding many misgivings as to his general 
condition his abdomen was opened; the appendix immediately 
presented. There were no adhesions or other evidences of pre- 
vious inflammatory trouble. The appendix, which was exhibited 
shortly afterward in this society, was three inches long, the meso- 
appendix extending about half its length ; it was tensely dis- 
tended, containing some muco-purulent fluid with fecal odor and 
a good-sized blood clot; hemorrhage had also occurred into the 
walls of the appendix, which were almost black in color and on 
the verge of rupture; there was no evidence of torsion. The 
case went on without special incident until the eighth day, when 
the stitches were removed from the very small wound, union 
being perfect. On the ninth day his stomach became deranged 
from some little error in his diet; this was followed by severe 
abdominal pains, chiefly in the left side; as he expressed it him- 
self, the region of the wound was the only place that did not hurt. 
He became quite hysterical after this and presented every possi- 
ble phase of purpura rheumatica: pain and edema in the mus- 
cles and joints, urticarial lesions of all styles, bleeding from the 
nose, stomach, intestine (always preceded by a severe colic), and 
the kidney ; purpuric spots developed on the legs, but the rest of 
the body was free, perfect recovery finally taking place. Could 
the presence of the wound in the abdominal wall over the cecum, 
through reflex nerve action, have accounted for the freedom from 
pain in this locality, while he suffered repeated attacks in other 
portions of the abdomen ? CHENOWETH: ETIOLOGY OF APPENDICITIS. 
Just in the midst of this affair his sister, a year younger, who 
was also subject to tonsillitis, nose-bleed, and rheumatism, while 
skating fell into an air-hole and became thoroughly chilled before 
her wet garments could be changed. This was quickly followed 
by an attack of fever, her temperature reaching at its highest 
point 104° F.; this lasted for three weeks and was attended by 
nose-bleed, some puffiness and pain about the knee-joints, erythe- 
matous nodes over the tibia, and an apparent swelling of the 
liver and spleen; a diagnosis of typhoid fever was made by two 
experienced consultants. 
The question at once suggests itself, why, if these more 
violent vascular disturbances are more common in the female, 
should they involve the appendix more frequently in the male? 
These disorders, we have noted, are usually brought on about 
the menstrual period, when this function is deranged, the meta- 
bolic changes disordered, and the nervous system in an irritable 
condition. 
Brunton calls attention to the great difference existing be- 
tween the vessels of the intestine and those in some other situa- 
tions, noting the fact that the former are more under the control 
of the vaso-motor center, and that when this is stimulated they 
contract greatly ; and further, that this may be produced by irri- 
tation of the vaso-motor center or the peripheral terminations— 
directly by the action of drugs, indirectly by the accumulation 
of carbon dioxide in the blood, and refiexly through the sen- 
sory nerves. 
These conditions are so perfectly fulfilled in the dysmenorrheaic 
female that it is not surprising that she suffers at this period with 
vaso-motor disturbances, whether these are produced altogether 
through the vaso-motor system or in addition there exists an 
actual blocking of the capillaries from colloid precipitates, but it 
is not improbable that the irritating waste products and carbon 
dioxide accumulating in the blood would cause contraction of the 
intestinal vessels and diminish absorption and the functional 
activity of the intestine; the amount of blood in the intestinal 
vessels would doubtless be further diminished by the congestion 
of the pelvic organs and by the reflexes acting on the intestinal 
vessels. 
This reflex influence on the intestine from an irritated ovary 38 
chenoweth: etiology of appendicitis. 
was thought by Brunton to be a frequent cause of constipation 
in neurotic females, and the truth of this opinion is supported by 
the effect of small doses of opium in such cases, which by inhib- 
iting or transferring this reflex nerve influence he found to exert 
a laxative action; and it seems to me altogether probable that this 
irritation of the ovary and uterus at the menstrual period and its 
reflex influence on the intestinal circulation may be another 
important factor in the relative immunity of the female at this 
time from circulatory disturbances in the appendix. 
This might account for the infrequency with which the appen- 
dix is involved in comparison with other organs in women, the 
subjects of purpura rheumatica, but even admitting that no such 
influences exist, and that these acute vaso-motor disturbances when 
they do occur are as apt to involve the appendix of the female as 
that of the male, it is by no means certain that such disturbances 
occur so much more frequently in the female than in the male 
as to materially affect the general result. 
The cases reported, however, in which exudation and hemor- 
rhage took place into the appendix during the progress of an 
attack of purpura rheumatica in the two boys, while their two 
sisters, presenting much the same lesions in other situations, failed 
to develop any appendix trouble, are at least suggestive. 
Another point to be taken into consideration is the relative 
infrequency of these severer vascular disturbances even in the 
female, for as a rule as soon as the menstrual functions are well 
established the susceptibility to these affections is markedly 
diminished. 
Some light may be thrown upon the influence of menstruation 
upon appendicitis in the future by noting the frequency of the 
primary attack in women before puberty, during the sexual 
period, and after the menopause. The influence of pregnancy 
would be two-fold, first, through its influence on the metabolic 
processes; secondly, by the pressure effects of the rapidly enlarg- 
ing uterus. 
The points to which I would especially direct your attention 
are briefly these: We find no evidence to justify the assumption 
that the lymphoid glands of the appendix differ materially in 
their development and function from similar glands in the ileum 
and colon or other situations ; therefore, in the absence of such CHENOWETH: ETIOLOGY OF APPENDICITIS. 
evidence I see no reason to doubt the findings of Ribbert in the 
four hundred appendices examined by him; nor the correctness 
of his conclusion that the appendix, by virtue of the lymphoid 
tissue of which it is largely composed, reaches its greatest devel- 
opment at puberty, and soon thereafter undergoes a process of 
retrogression, consisting of shortening, changes in the histological 
structure of its walls, and more or less complete obliteration of 
its lumen, similar atrophic changes being known to take place in 
other lymphoid glands at this same period. 
We find no evidence to support the assumption that the lym- 
phoid glands of the appendix are uninfluenced by constitutional 
conditions and other agencies which tend to bring about hyper- 
plasia or acute inflammation of the tonsils or the lymphoid glands 
of the colon and ileum; therefore, when such changes are observed, 
taking place coincidently in the appendix and these other struct- 
ures, we must conclude that the same conditions are at work 
rendering the soil favorable for bacterial invasion. 
Again, we have noted the practical identity of the vascular 
and nerve lesions of appendicitis with those found in the intesti- 
nal lesions of exudative erythema and similar affections depend- 
ent upon the rheumatic diathesis. We find the same patholog- 
ical conditions in ulcers of the skin dependent upon this same 
diathesis. 
“ Quenu16 found in the microscopic study of the skin and 
other tissues in so-called varicose ulcers of the leg, the veins 
varicose, dilated, and surrounded by new connective tissue, 
which was forming and condensing at the same time. The 
arteries were affected by endarteritis and atheroma, and occa- 
sionally there was thrombosis of large branches. In the 
nerves there was a new growth of connective tissue, begin- 
ning around the dilated capillaries and surrounding the 
nerve fibers, which afterward degenerated on account of the 
pressure exerted by this tissue as it contracted. These altera- 
tions were found in nerves at a long distance from the point of 
ulceration, and even in those nerves which were not distributed 
to that part of the leg. He thinks the changes began in the 
vessels, then attacked the nerve, and finally caused trophic altera- 
tions and ulcerations of the skin. He believes himself able to 
18 Ref. Hand-Book Med. Science. 40 
chenoweth: etiology of appendicitis. 
exclude an ascending neuritis secondary to the inflammation of 
the ulcer.” 
“ Shrieder17 investigated a number of cases of ulcer (that could 
not be ascribed to any specific cause) and found in the great 
majority of them evidence of atheroma, varicose veins, chronic 
bronchitis, skin eruptions, heart affections, headache, joint troubles, 
ribbed nails, and other symptoms of that peculiar constitutional 
vice known as gout or lithiasis by England writers. The cause 
or causes which produce this inveterate disorder of the system 
are as yet but poorly understood. 
“ But the extensive trophic changes which it occasions in all 
the tissues of the body form a reasonable basis for the hypothe- 
sis that it may also be responsible for the nutritive changes upon 
which depend the occurrence of ulceration in cases in which no 
more definite cause can be detected.” 
In the face of such evidence we can but conclude that the 
similar vascular and nerve changes found in the appendix are the 
results of nutritive disturbances of constitutional origin, and not 
secondary to torsion of the appendix and bacterial infection, as 
heretofore thought. 
Strictures of the appendix may be due to inflammatory bands 
or to the contraction of cicatricial tissue, the result of previous 
ulceration, but certainly such an origin is most improbable in the 
majority of such cases, and it seems unquestionable to me that 
the great majority of these contractions are the result of the 
retrogressive changes taking place in the appendix after puberty. 
The more frequent occurrence of appendicitis about puberty 
and in the years immediately following would strongly indicate 
the part played by the functional disturbances in this hypertro- 
phied lymphoid tissue in its production. 
Acute cases have been reported where the mucosa was ex- 
truded from its muscular sheath intact, which could scarcely 
occur if the whole blood supply to the appendix were cut off* by 
torsion or the submucosa had become necrotic by means of 
infection through the mucosa which remained intact. In the 
present state of our knowledge, or, more properly speaking, 
ignorance, the vascular disturbances which give rise to necrosis 
of the lymphoid glands of the tonsil, cecum, or appendix, or in 
milder cases only to such nutritive changes that the lessened 
17 Ref. Hand-Book Med. Science. CHENOVVETH: ETIOLOGY OF APPENDICITIS. 
resistance permits of bacterial invasion, seem to be brought 
about by, first, blocking of the capillaries by the precipitation of 
colloid nitrogenous bodies; second, disease of the walls of the 
small vessels from the presence in the blood of deleterious sub- 
stances; or, third, vaso-motor disturbances, (a) irritation by 
chemical products, (6) refiexly. The important point to us just 
at present, however, is that these vascular disturbances are so 
intimately connected with the rheumatic diathesis, which we all 
recognize but do not as yet thoroughly understand. Whether 
calomel or any other drug can cause a precipitation of colloid 
bodies in the capillaries of the lymph glands by combining with 
their metabolic activity, just as such precipitation takes place in 
the products of the laboratory, is a matter purely of conjecture. 
This is equally true of the action of salicylate of soda in the 
removal of such deposits; but may we not find that it is by some 
such influence on the metabolic processes going on in these 
glands, rather than by their direct antiseptic action, depends the 
beneficial results of salicylate of soda, guaiac, and guaiacol in 
appendicitis, tonsillitis, and typhoid fever? 
Finally, I would have you note the two cases reported in 
which actual hemorrhage occurred into the appendix during an 
attack of purpura rheumatica. I have been able to find one 
case in the literature of the subject where peritonitis and death 
resulted from necrosis and perforation of the stomach from such 
a hemorrhage into its walls, but no mention of even the possi- 
bility of such an acute vaso-motor disturbance causing hemor- 
rhage and necrosis of the appendix. This, in my opinion, is not 
because such cases are so rare, but because they have been unrec- 
ognized. The consideration of the treatment of appendicitis has 
no place in this article, nor have I any suggestion at present to 
offer the members of this society, but for the benefit of those who 
stand less in awe of a necrotic appendix than do we, and who by 
my incidental allusions to the action of drugs might be encour- 
aged to place undue reliance upon medicinal treatment in this 
disorder, I would recall the result in the case of the child treated 
by salicylate of soda that I have previously quoted from that 
most interesting work of Haig; and while I have never advocated 
immediate operation in all cases of appendicitis as soon as the 
diagnosis was made, regardless of time, place, or circumstances, 4'2 
CHENOWETH: ETIOLOGY OF APPENDICITIS. 
nor regarded the physician as possessed of less intelligence and 
diagnostic ability than the surgeon, I have always advocated an 
immediate diagnosis, and I would most earnestly insist that with 
our present knowledge of the frequency and the rapidity with 
which necrosis and perforation may take place in seemingly mild 
cases of appendicitis, and the almost inevitably fatal result fol- 
lowing without immediate surgical interference, that the physi- 
cian who treats an acute attack of appendicitis, even of mild 
character, without making provision for immediate operation, 
should the necessity arise, does his patient a grave injustice; and 
if he does not allow the surgeon, upon whom he will shift the 
responsibility of this operation and the ultimate result, to see the 
case at the earliest moment and have a voice in determining when 
this necessity does arise, he does both a grave injustice. 
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