VOLUME III

ORIGINAL ARTICLES

THE INTER-RELATIONSHIP OF GALLSTONE DISEASE AND APPENDI

CITIS.*

FRANK W. FOXWORTHY, PH.B., M.D.

INDIANAPOLIS, IND.

The following abdominal case came under my observation with masked symptoms, and three different diagnoses were made by three different physicians, and each was partially right.

On September 30, 1909, I was called in consultation with the family physician in a neighboring city to see Mr. G. R. M., age 54; occupation, cashier in a bank. As no chart had been kept by the nurse, I was compelled to rely entirely upon the memory of the attending physician and family for any preceding symptoms, as well as for a record of his pulse and temperature. Respiration was shallow and slightly increased above normal; mind was clear; perspiration was apparent on face; complexion sallow but not jaundiced; temperature, 98.2; pulse, 84, and though regular was quite weak; the lungs and heart were normal; examination of the abdomen showed a normal contour; percussion gave an empty stomach, intestines empty except the lower part of the descending colon, and a dull percussion note in the right inguinal region; deep pressure was made on the right upper quadrant during forced respiration without any pain being elicited; deep pressure over McBurney's point made patient flinch. A mass seemed to be present in the right inguinal region without any defined boundaries and of fairly soft consistency; remainder of the abdomen was negative; there were no painful spots along the spine. Urinaly sis negative. Several blood slides were taken,

Read before the Indianapolis Medical Society.

NUMBER 8

which showed an increase of polynuclear cells. The history, as given by the attending physician, follows: Four days previously patient had had a severe headache, some nausea and vomiting; later he complained of indefinite pains in the abdomen and general abdominal tenderness, but no localization of the pain. This continued for two days, his headache being exceedingly severe and the pain in the abdomen being greater and the attending physician not being available, ancther physician was called in, who gave him a hypodermic of morphia, either one-fourth or onehalf grain, sufficient, however, to relieve his suffering and also to render him constipated, his stools previous to this having been regular. During the next two days his pain became less, though his weakness increased markedly; further questioning of the family gave the information that ten years before he had had a severe headache, followed by a severe pain in the abdomen, was nauseated and vomited repeatedly, had general abdominal tenderness but no localized pain, was enemic but not jaundiced, with slight eruption on the face; after a rest in bed for a couple of weeks he recovered. Each year since then he had a similar attack with the same symptoms and the same recovery; he would often have severe headaches between attacks and the headache seemed to give him more trouble than the abdominal distress; his appetite was always poor and he would commonly be called a spare man, weighing about 135 pounds.

He had discussed his case with several physicians, some of whom advised him to have an exploratory incision made, but as his family physician did not so advise him, he would not consent to it; he had at no time passed any gall stones. His family physician informed him that he probably had had gall-stone disease. I believe him to be suffering from chronic appendicitis with abscess formation and with a possible involvement

of gall-stone disease. As his heart was very weak I ordered heart stimulants, small doses of calomel often repeated and sufficient enemata to unload the bowels. Conditions being unfavorable for an operation at home and his condition being too bad to allow a removal to a hospital, fifty miles away, and as he had nine or ten of these same attacks before, I advised nourishment and stimu

lants until he was sufficiently strong to be moved to the hospital. On the second day after my visit I took with me Dr. George J. Cook, of Indianapolis, who made a careful examination of the patient. At this time we found the temperature slightly subnormal; pulse, 72, very weak; abdomen moderately distended; Dr. Cook was unable to elicit any pain from the right inguinal region, indeed the patient had no pain at all; he seemed to be prostrated and short of breath; there had been no movement of the bowels since my for

tive interference, yet both agreed that it would have been futile with such a weak heart. We both advised operation if the patient became strong enough to be moved to a hospital.

Autopsy. The findings of the autopsy which was made within a few hours by myself, assisted by two local physicians, was, first, an enlarged gall bladder filled with numerous stones, as is hereby shown; second, a perforated appendix partially gangrenous, adhering to the cecum and buried under an abscess cavity in which there was probably twelve or fourteen ounces of pus; third, an occlusion of the bowel formed by the walls of the abscess, as well as by the exudation of the inflammation. The tissues surrounding the appendix were massed together and it was exceeding difficult to remove the appendix at all, the inflammation having been so severe.

mer visit excepting by enema, which brought forth a brownish flocculent material. Dr. Cook's diagnosis was obstruction of the bowels and while there gave the patient a high enema of glycerin, castor oil and warm water, instructing the nurse to repeat this at intervals. The next day, although I found the patient a little better, the bowel movement had been from the enema only. At Dr. Cook's suggestion an ounce of alboline oil was given every hour; the pulse was very weak. The following night I found the patient in extremis, abdomen enormously distended, pulse barely perceptible and the patient rapidly lapsing into unconsciousness and expiring shortly after I entered the room.

His sudden death showed that little vitality was present when Dr. Cook and I made our examination, and though we both discussed opera

As this case had shown complex symptoms as well as the absence of symptoms and as appendicitis seemed to be the real cause of death, although the gall stones must have been present for a long time, and as the case had been diagnosed for ten years as gall-stone disease, I was interested to know what the experience of others had been in similar cases. With this end in view, I briefly detailed this case to a number of the leading diagnosticians and abdominal surgeons in the United States, whose replies I will shortly give. It had seemed to me that there was a relationship between the appendicular disease and the gall-stone disease. To get at this matter rightly it is necessary to show how the two discases originate, their simple symptoms, their complex symptoms, the symptoms of the two when concurrent.

Stengel, in Osler's Practice of Medicine, gives the simple symptoms of appendicitis, first, pain, which is primarily diffuse and then localized in the right iliac region; second, rigidity of the abdominal walls; third, nausea; fourth, constipation; fifth, chills; sixth, fever; seventh, acceleration of the pulse. He reminds us, however, that little importance is to be attached to the fever and accelerated pulse. Taking that as the classical symptomatology we may turn to Moynihan in his "Gall Stones and their Surgical Treatment" for the simple symptoms of gall-stone disease. You will notice the similarity of the symptoms to appendicitis, first, pain localized

2.

Fig. 2.-Appendix. 1. Opening into the cecum. Toothpick running between perforation above and gangrenous opening below where appendix was torn loose from abscess wall. 3. Portion of the abscess wall.

and referred; second, nausea; third, jaundice, which he states is rare; fourth, fever; fifth, tumor, which is also rare. He states that the referred pain is usually in the right subscapular region, rarely the left; or in the neck, down the arm or in the epigastric region; he also laconically remarks, "the most common symptom is indigestion." That is in line with A. O. J. Kelly, in Osler's Practice of Medicine, who states that the simple symptoms of gall-stone disease are but two-first, chronic indigestion; second, gall-stone colic.

In regard to the special symptoms of appendicitis may be mentioned Widmer's sign, in which

the right axillary temperature is distinctly higher than the left; Morris' tender point is one and one-half inches from the navel in a line drawn from the navel to the anterior superior spinous process of the ilium. If deep pressure be made at that point over the lumbar ganglia on both sides and tenderness is found it indicates pelvic trouble; if the right side alone, appendix trouble. Head's areas of tenderness are three in number: first, beginning at the back, close to the middle line at the eleventh dorsal vertebra and running to the right, a narrow band sloping slightly downward, the lower edge at the crest of the ilium; second, a triangular area bounded below by Poupart's ligament, above by a line drawn out from the umbilicus and to the inner side by a line just to the right of the middle line. Its apex is at the anterior superior spine of the ilium; third, a circular area just below the center of a line joining the anterior superior spine of the ilium and the umbilicus. Tenderness in any of these points is presumed to show appendicitis. The Rovsing-Chase sign is made by deep pressure, beginning at the left over the descending colon and following its course upward and across the transverse colon and down the ascending colon, endeavoring to press the gas in the bowel toward the cecum. Distention will be produced if inflammation of the cecum or appendix be present, giving sharp pain in the right iliac fossa. Blumberg's sign is pain upon deep pressure over the appendix and shows inflammation limited to appendix; pain upon removing the hand after the pressure means peritoneal involvement. Illoway's manipulation is the forcible. flexion and extension of the right leg and thigh when the patient is lying on the back, causing pain in the right iliac region. Sonneburg's test is the administration of castor oil on all patients with the appearance of simple catarrhal appendicitis. If they don't get better within twentyfour hours then operate. Many pathologists speak of the importance of the blood count in appendicitis and especially the relative number of polynuclear cells, although Gibson states that the differential blood count and its relation to the total leukocytosis is of value chiefly in indicating fairly consistently the existence of suppuration and gangrene. It is of more frequent value in the interpretation of the severity of the lesions of appendicitis and their sequela. Wilson remarks that the diagnostic importance of blood counting may be readily over-estimated and Murphy states that blood count is only corroborative. The summing up of the symptoms of appendicitis was made by Mynter when he said that few diseases present so many stages, each char

acterized by a different set of symptoms, while on the other hand every one of these cardinal symptoms may be absent or if present may indicate other affections.

The special symptoms of gall-stone disease might be headed by Boas' sign, who states that it is always present, namely, pressing the fingers on a point to the right of the tenth dorsal spine a painful area is elicited, which extends from one inch external to the spine of the tenth dorsal vertebra laterally to the posterior axillary line. The characteristic and most constant sign of gall-bladder hypersensitiveness, according to Murphy, is the inability of a patient to take full inspiration when the physician's fingers are hooked deep beneath the right costal arch below the hepatic margin. Abraham's special symptom is a painful point midway between the umbilicus and the costal cartilage of the ninth rib in the right hypochondriac region. Douglas tells of a definite point of tenderness at the tip of the tenth rib. Mayo Robson indicates the special diagnostic sign as pain upon pressure over some point of a line drawn from the ninth costal cartilage to the umbilicus. On the other hand, Waterhouse shows that a considerable number of cases of gall-stone disease have no symptoms or, as he qualifies it, "perhaps I should say none recognizable by the medical attendant."

Concurrence of gall-stone disease and appendicitis is not uncommon to many diagnosticians. The bacillus coli is found in both an inflamed gall bladder and in an inflamed appendix. Staphylococcus pyogenes aureus is found in both in some cases; hence the same infection should produce the same symptoms whether in the appendix or gall-bladder, and as but a few inches of space separate the two and the connection between the two transmits infections easily, it will be readily seen that a relation between the two diseases can exist. Symptoms in such cases must necessarily be the profound symptoms of an abdominal infection more serious than when the diseases be present separately. Pain localized in separate diseases becomes diffuse. Tenderness which may be marked at first may be lessened later, on account of the profound prostration caused by the severity of the infection, the senses having been dulled so that the patient may not apparently have any pain or tenderness as in the case given above. The pulse, which may have been rapid, may drop back to normal, but is thready and weak, chills and rigors with perspiration may continue on account of the pus formation. Jaundice, as Mayo states, has no part in the diagnosis of gall-bladder stones and when present means a complication. Rigidity should

continue throughout the course of the disease. Vomiting, which may have been present at the beginning of either disease, may continue throughout, even to fecal vomiting; constipation is very obstinate and may lead to complete obstruction as in the foregoing case. Distention occurs in both, but more in appendiceal cases. It becomes extreme as the general peritoneum becomes involved and is one of the gravest symptoms of general peritonitis, although as Kelly states, the abdomen may be flat, hard and boardlike or soft and natural even in severe diffuse peritonitis; he also remarks when this disease is accompanied by perforation, there is an exceedingly large extravasation of septic material which causes sudden excruciating pain, followed by symptoms of shock. The violent impression made upon the great nerve centers, causing collapse, is a sign common to all acute disorders within the abdomen, according to Treves. He cites a case of a middle aged man, seized with pain in the hepatic region; rise of temperature, jaundice supervened, the patient dying within two weeks. The liver was found to be filled with abscesses, the appendix was disorganized and filled with pus and it had been the seat of a long standing disease. Intestinal obstruction is given as a common symptom or termination of both gall-stone disease and appendicitis. Kelly, in Osler's Practice of Medicine, speaks of the pain of cholecystitis being referred downward to the right lower quadrant, suggesting appendicitis. that as a matter of fact the two may be concurrent and Stengel, in the same work, declares "the pain of cholecystitis may be referred to the lower right quadrant of the abdomen and whatever tenderness there may be is most decided in the same region. The symptoms of onset might be practically the same as appendicitis. On the other hand, in cases of appendicitis the pain may be referred to the region of the gall-bladder or when the appendix lies posterior to the cecum it may be more marked in the back, posterior to the liver." Moynihan tells us that appendicitis is not uncommonly associated with gallstones. In rare cases he states that gall-stone colic may be mimicked by appendicular colic. In a certain, perhaps not inconsiderable, number of patients a recent attack, one among a series, may have been experienced as a precursor of gall-stone colic.

I now wish to combine with the opinions of the above authors as given in the literature on the subject, the opinions of a number of competent men in personal communication to the author. To each one of these the following questions were propounded: 1. Do you find that ap

pendicitis and gall-stone disease are inter-related? 2. If so, what per cent. of gall-stone disease have an inflamed appendix, or vice versa? 3. Have you any special diagnostic symptoms for gall-stone disease? 4. Have you any special diagnostic symptoms for appendicitis? 5. Would any new symptoms be present if a patient is suffering from both gall-stone disease and appendicitis? 6. Would any of the usual symptoms of gall-stone disease be modified or wanting by a concurrent appendicitis or vice versa?

The answers to these questions are as follows:

DR. GEORGE W. CRILE, Cleveland, Ohio: I find both diseases at the same time in a small minority of cases. I cannot quote per cents. I have only the classical symptoms for the two diseases. Speaking of the symptoms of the concurrent diseases, it would depend upon circumstances, that is, if the appendicitis is severe and the gall-stone mild then the very prominence of the symptoms would overshadow them; there are, of course, many exceptions.

DR. CHRISTOPHER GRAHAM, Rochester, Minn.: Answers yes to the question of the inter-relationship of appendicitis and gall-stone disease, places the per cent. as 10 per cent. in men and 5 per cent. in women. Not necessarily any new symptoms present, would depend on previous history and the findings at the examinations.

DR. JOHN B. DEAVER, Philadelphia: Yes to the first question. I am unable to give the per cent., but several cases have occurred in my experience. The special symptoms for gall-stone disease are flatulence with distress shortly after eating, relieved partially by belching and entirely by vomiting, pain more likely to occur during the night, the longest time after digestion, tenderness on deep pressure at the right costal margin and occasional pain or discomfort in the right shoulder, back, etc. The special symptoms for appendicitis, a patient previously well, suddenly seized with acute abdominal pain referable to the umbilical or epigastric region, followed by nausea and vomiting, and all these followed by pain referred to the right abdominal quadrant with rigidity of the abdominal muscles overlying the appendix and tenderness upon pressure. In regard to the new symptoms, "not necessarily so, as acute inflammation of the gall-bladder may be simulated by acute inflammation of the appendix holding a high position and vice versa, but must be governed by previous history." In regard to the modification of symptoms he says, "not the symptoms of long standing gall-stone disease but those continuing after the prodromal symptoms."

DR. MAX EINHORN, New York City: Appendicitis and gall-stone disease are not inter-related. No per cent. given. In gall-stone disease the liver is somewhat usually swollen and pain radiates to the back and right shoulder blade. In appendicitis pain at McBurney's point, extending rather downward from the right lumbar quadrant and through the right limb, liver not swollen. If there would be a combination of the two diseases, the severity of one affection may mask the symptoms of the milder disease.

DR. AUGUSTUS CAILLE, New York City: In answer to question one, no, but they may have the same origin, i. e., infection from the colon. Gall-stones form after the gall-bladder becomes affected. Per cent. unknown. The special diagnostic symptom for gall-stone disease is pain when the edge of the hand is forced upward under the border of the ribs; the usual symptoms are described in books. The special diagnostic symptoms for appendicitis are pain and discomfort by direct pressure upon the appendix; without feeling the appendix, diagnosis would be nothing but guesswork. With both diseases present the symptoms would be a combination of both conditions. The case you cite was too far advanced to make a differential diagnosis between gall-stone disease and appendicitis easy. At an early stage, before abscess formed, the differential point could have been brought out by a careful examination or exploratory incision.

DR. JOHN H. MUSSER, Philadelphia: Appendicitis and gall-stone disease are not inter-related but may be co-incident in chronic or subacute cholecystitis and appendicitis. Do not know per cent. No other special diagnostic symptoms for gall-stone disease than those given by the best modern authorities. The answer to the question, have you any special diagnostic symptoms for appendicitis is "Some." Answers no to the question in regard to new or modified symptoms of the two concurrent diseases; he states it is important not to confound gall-store disease and cholecystitis. He also writes a note on the letter sent him in regard to the foregoing case, asking the question, "Would it be chronic appendicitis. or an acute attack on top of a chronic inflamed appendix?"

DR. CHARLES M. Fox, Chicago: Appendicitis and gall-stone disease are not inter-related. Merely the same per cent. for gall-stone disease without involvement of the appendix. The special diagnostic symptoms for gall-stone disease: (a) history of an acute attack followed by (b) tenderness in the gall-bladder region, and (e) referred pain to the right shoulder-blade, jaun