VIII, B, 2 Gilman: Appendicitis 145 



the blood examination, where for example a marked leucocytosis 

 may be the most prominent feature of an otherwise masked in- 

 flammatory process. The leucocytes are of diagnostic signi- 

 ficance when they are increasing. 



The highest count met with in these cases of acute appendiceal 

 trouble was 28,000, the operation in this instance revealing an 

 appendix already perforated with localized peritonitis. The low- 

 est count was 6,600 in a case presenting marked rigidity of the 

 lower abdomen with severe pain and tenderness, in which the 

 process, however, was limited to the appendix. One-third of 

 the cases yielded a count below 10,000, all of these being simple 

 acute processes confined to the appendix; another third made 

 up of similar cases gave a count of between 10,000 and 17,000; 

 while those with a higher count included the complicated cases 

 with abscess and peritoneal invasion. Only 4 of this series gave 

 a history of previous dysentery. 



The clinical picture presented by the above group of acute 

 cases is too well known to necessitate further elaboration here. 

 It is our purpose to endeavor to emphasize in this communica- 

 tion some of the findings in those cases of more or less obscure 

 nature which manifest themselves in disturbances of varying 

 severity in the digestive apparatus. As our knowledge of the 

 pathology of this probably functionless rudiment is increased, 

 we are forced more and more to regard the appendix as the 

 underlying cause of numerous subacute and chronic disturbances 

 heretofore ascribed to other organs or groups of organs. 



It appears a far cry indeed from a case of acute inflammation 

 of the appendix, with its sudden severe pain localized in the 

 right lower quadrant of the abdomen accompanied by nausea, 

 vomiting, diarrhoea, increasing fever, and climbing leucocyte 

 count, to a case of neurasthenia with slight stomach trouble, 

 chronic constipation, and a power of assimilation varying from 

 a little to considerably below normal; and yet we must ascribe 

 the two conditions to the disease of the same organ. 



These two apparently widely separated states are linked 

 together by a series of intermediate cases. 



To illustrate this latter group of cases, it will be well to give 

 a brief resume of a few typical cases, illustrating various results 

 of chronic pathological change in the appendix: 



Case I. — American woman, age 40 years, single. For a number of 

 years she had been treated by various physicians for chronic constipation 

 and general nervousness. The patient was well nourished, in spite of 

 troublesome fullness and flatulency of the stomach after taking food, 



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