THE ADRENALS, LEUCOCYTOSIS AND PHAGOCYTOSIS. 615 



Harvey Gushing refers to abdominal pain, rigidity and 

 tenderness of the abdominal walls as having been observed by 

 him in all cases some time before the perforation occurred. 

 Are these symptoms due to the direct effect of the intestinal 

 lesion upon neighboring structures, or are they localized ex- 

 pressions of a general perturbation? Lennander, of Upsala, 6 

 has recently shown that, while the parietal peritoneum that 

 immediately underlying the abdominal walls was sensitive 

 and painful even when only touched, rubbed, or stretched, the 

 visceral peritoneum, on the contrary, could be rubbed, incised, 

 cauterized, or chilled without causing the least discomfort. 

 Neither here nor in the greater part of the small intestine, 

 its mesentery, the great omentum, the caecum and appendix, 

 and the colon was there the least evidence of the presence of 

 nerves capable of transmitting tactile, thermal, or painful 

 impulses. If intestinal pain does appear, therefore, before 

 perforation, the parietal peritoneum must be included in what- 

 ever protective process the threatened complication may 

 awaken. The occurrence of this symptom elsewhere than in 

 the neighborhood of the lesion further sustains this fact. E. 

 Palier, 7 for example, describes a case in which abdominal symp- 

 toms were so marked that the diagnosis of appendicitis was 

 made by a consultant and an operation performed. The au- 

 topsy showed pneumonia with empyema, the abdomen being 

 normal. J. L. Morse 8 also refers to the danger of mistaking 

 a case of so-called "abdominal pneumonia" in children for one 

 involving the abdominal organs, and states that he has seen 

 two cases in which the abdomen had been opened by experi- 

 enced surgeons, because appendicitis was supposed to be pres- 

 ent. Mirande 9 even goes so far as to suggest, in this connec- 

 tion, that a special form of pneumonia be distinguished: i.e., 

 that to which the name "appendicular pneumonia" has been 

 given, owing to the predominance of the symptoms simulating 

 appendicitis. These symptoms only occur, he found, in the 

 early stages of the disease, and rarely persist longer than the 



6 Lennander: Centralb. fiir Chirurgie, Feb. 23, 1901. 



7 E. Palier: New York Medical Journal, Sept. 16, 1899. 



8 J. L. Morse: Annals of Gynaec. and Pediatry, Nov., 1 

 Mirande: Medical Press and Circular, June 5, 1901. 



