VIII, B, 2 Gilman: Appendicitis 147 



pain referable to the gall-bladder region. There has been a gradually 

 increasing discomfort and sensation of weight in the lower right side of 

 the abdomen, which became actual pain, accompanied by soreness, when 

 the yellow color of the eyes and skin was most marked. During the last 

 attack, a month ago, the patient suffered some pain below the right costal 

 margin, was definitely jaundiced, and the appendix region was very tender 

 with increased rigidity of the superimposed walls. 



At the operation the gall bladder was found rather thickened and did 

 not empty readily. For this reason, following the removal of an adherent 

 chronically thickened appendix, the gall bladder was opened, a tarry bile 

 evacuated, and the bladder drained. No evidence of stone was found in 

 this case. Already the jaundice has completely cleared, the digestion has 

 been restored to practically normal, and a gain of several pounds has been 

 made. 



The above are but a few of a considerable series of cases 

 showing concurrent disease of the appendix and gall bladder. 

 Given these conditions, a simple drainage of the gall bladder 

 without the removal of the appendix will not insure a freedom 

 from recurring trouble with the biliary apparatus. 



In looking over our records of gall-bladder disease where it 

 was possible to follow the patients for any length of time after 

 their operations of drainage for a simple cholecystitis, we find 

 in some instances a fairly prompt recurrence of the jaundice 

 and so-called "stomach trouble." Might not these cases have had 

 enough symptoms above the umbilicus to cause the examining 

 physician to overlook the presence of trouble in the appendix? 



Another group of cases of appendicitis with which we have 

 had a rather fortunate experience is the group made up of 

 cases in which the mildness of the symptoms has been out of all 

 proportion to the condition found at operation. 



Case I. — American, aged 32, married, clerk. Entered the hospital 

 complaining of stomach trouble. The patient was very stout, and examina- 

 tion was difficult, but a slight tenderness was elicited over the right iliac 

 fossa in which region a slight general abdominal pain was localized. 

 The leucocyte count upon admission was 8,000. There was practically 

 no fever, and the patient's wife refused her consent to an operation for 

 appendicitis. Twenty-four hours later the pain had increased somewhat, 

 although it was not very severe, the temperature had risen to 38°. 2 C, 

 and the leucocytes were 15,000. Operation was again advised and con- 

 sent given rather reluctantly, as the patient did not appear very un- 

 comfortable. At operation, performed about thirty hours after the first 

 complaint, the appendix was found gangrenous and free in the abdominal 

 cavity, together with a general collection of bowel contents and pus with 

 practically no attempt at localization on the part of the peritoneum and 

 viscera. The caecum was found greatly thickened and in places puckered 

 and pigmented as though from the old dysentery from which this patient 

 had suffered two years previous to the operation. The patient fortunately 

 recovered from the peritonitis, and is to-day well. 



