History of Appendicitis
When one considers the frequency of diagnosis and treatment of appendicitis nowadays, one might imagine that the condition was known and well treated far back in antiquity. Most of the history of appendicitis and appendectomy has been made and written during the past two generations, however. This does not mean that light has not been sought on this subject ever since the time of the Father of Medicine. And considering the difficulties at hand, these forebears of ours did exceedingly well. Yet, as Dr. Deaver says, “So many times does it appear that acute observers stumbled on the very threshold of the discovery that the original lesion in these conditions (of the right iliac fossa) was in the vermiform appendix, that it seems scarcely credible that for less than forty five years have we had any adequate knowledge of appendicitis.”
Of course, abdominal surgery as practiced today is not an old art, therefore, one might not have expected an appendectomy to have been performed so many years ago (although considering the prevalence of appendicitis in both sexes, it might have been expected to antedate ovariotomy, for example). In Hypocrites’ time they were “cutting for the stone,” when an appendix was not even known to exist. What was not known to exist surely could not be prognosticated or treated. Anatomical findings: Galen, who of all the ancients gave by far the most complete anatomical descriptions, found no appendix because he dissected only monkeys, which have no appendix. And what Galen did not see or describe, no one saw or quoted throughout the Middle Ages.
So it was that Berengarius Carpus, professor of surgery at Pavia and Bologna, gave us our first description of this structure in 1522. He speaks of there being found at the end of the aecum a certain “additamentum” empty within, and in breadth less than the smallest finger of the hand, and of a length of three inches or thereabouts. Vesalius, writing twenty-one years later, augments this description and gives several illustrations (q.v.). Much confusion appeared to exist at this time between the caecum and the appendix, shown in the writings of Stephanus (1545) and enlightened by Ambrose Pare’ in 1582. Vesalius insisted on calling the appendix vermiformis the caecum because of its true blind pouch nature; whereas, as he points out, the so-called caecum as three openings, namely, the colon, ileum and appendix.
Fallopius, writing in 1561, appears to have been the first writer to compare the appendix to a worm; and Bauhin (1579) to ascribe thereto a function. He proposed the ingenious theory that the appendix served in intrauterine life as a receptacle for the faexes; from which it seems not improbable that he confounded it with the diverticulum described nearly two hundred years later by Meckel, whose name it bears. Laurentiue, (1600); Vidus Vidius; Fabricius ab Aquapendente; Morgani (1706); Verheyn, (1710); Santorini, (1724); Vosse (1749); Weitbrecht, (1747); Haller, (1778); and Sapatier, (1781); all names of anatomists to be conjured with, added more or less insignificant ideas concerning the structure of the appendix and entered upon useless controversy concerning the name, function, position, etc., of the appendix vermiformis.
Since the close of the eighteenth century the gross anatomy of the appendix has been fairly well known; its three coats; its mucous glands, and their abundant secretion; the meso-appendix and the folds produced by the peritoneum in this region- these were discussed in more or less detail by all anatomical writers in the early part of the century just closed. In the succeeding decades, among an innumerable number of articles on this phase of the subject, a few stand out as of preeminent importance. Gerlach in 1847 called renewed attention to the fold of mucous membrane which may act as a valve in occluding the orifice of the appendix and which has since gone under his name; and in 1859 he still further discussed the anatomy of this organ.
Trietz, in 1857 described the pericecal fossae, but no adequate account of these folds of peritoneum appeared until 1891, when Lockwood and Rolleston published their elaborate studies, while Clado, in the next year aroused interest in a fold of peritoneum running from the ovary to the meso appendix, and since known as Clado’s Ligament. The minute anatomy of the appendix has received attention only in recent years, some of the best studies being those of Lockwood.
Clinical Observations: Because specialization had hardly taken hold in these early centuries B.C. and A.D., we find our anatomist, physiologist, pathologist and theraputist as one. Thus, the names of many of the men just mentioned find a prominent place in the development of the clinical observations concerning the appendix. An aphorism of Hippocrates, “Suppuration upon a protracted pain of the parts about the bowels is bad” has led many to believe that he knew and spoke of appendiceal abscess. In fact, Peter Lowe, in 1612, says in quoting Lonicerius, “Hippocrates did die of this disease.” Like, as not many of these abscesses were not in connection with the appendix. But it is a common thing to find these ancients speaking of the iliac and the colic passion. Celsus and Galen observed that the iliac passion affected the small bowel, having its seat above the navel, while the colic passion (situated in the large bowel) was found below the umbilicus, more often on the right and was very apt to recur. Aretaeus (100), Oribasius, (4th Cent.); Avicenna (of the Arabian School) Villanovanus, (1300); Fernelius (1567) added little to the observations of the above. The condition did not appear, as serious to these men until a large abscess was formed or complete ileus with sterocoraceous vomiting was present. A case report by Fernelius is typical of these early day ideas and methods: A child, nine years old, had been suffering form diarrhea, and her grandmother, taking counsel “with other old women”, decided to give her a quince, this fruit being known form the time of Disocorides for its extreme astringency in the green state. As a consequence of this dose the diarrhea was not only checked, but no passage form the bowel occurred at all that day ad the following night. A physician was called and administered active enemata and soothing abdominal applications, without relief. Finally stercoraceous vomiting gook place and death followed in two days. At autopsy, the interior of the appendix was found to be constricted by the remains of the quince. Perforation above the obstruction had filled the whole abdominal cavity with “corrupt matter.” Curiously enough, even those who autopsied these cases rarely ever blamed the appendix for the pathology found. The ileo-cecal valve was usually blamed, as by Hildanus, who ingeniously adds “most of these cadavers smelt so horribly that he was not very minute in his examinations.”
If there is any curiosity among my audience (as there is in me) as to why more of these unoperated cases did not die in these early years, let me cite here the patient of Saracenus (1642), showing the hand of the Almighty. This woman had a large abscess in the right groin, which broke, forming a fecal fistula. Form this fistula, among other things, came 14 lumbricoid worms at various times. Yet she recovered with out treatment.
In 1666l, Sydenham almost “out –McBurneyed” McBurney by observing that in the commencement of this disease the pain is less fixed than it is later when it is wont to settle in one spot and remain there. He seems to have had an inkling that these symptoms arouse form a disease that was distinct in its causation from volvulus, intussuscepting, strangulated hernia, and all other intra-abdominal affections. This is one of the earliest attempts at differential diagnosis in the abdominal field chronicled.
It was just at this time that Helmont (1664), attributing all abdominal symptoms to flatus, suggested that all obstructions might be removed by swallowing lead bullets. Boerhave, in his “Aphorisms” of 1709 counsels against such folly with a caution which is not without its value at the present day; “As long as this malady continues in its inflammatory stage, it often imposes upon those who are incautious under the name of a colicky pain, by whom it is, with the most dangerous events, ascribed to cold, to wind and to flatulencies, and accordingly ill treated by carminative and hot medicines, with the most fatal consequences.” That his advice was not universally accepted is shown by the case of Herlin (1768). An autopsy on a man who had died of the iliac passion and who had been made to swallow three large balls (in the hope of overcoming the obstruction), showed these same balls in the appendix, which was dilated by fecal matter nearly, to the size of the rest of the gut. Other post-mortem examinations revealed worms, pins, stones, pecoliths, and other appendiceal lodgers.
Many other names, such as Willis, Santorini, Ruyschius, Amyand, Crellius, Heister, Wedels, Mestevier, LaMotte, etc. all might be mentioned as contributing their bits of light on the subject, but full illumination did not appear until the nineteenth century.
Parkinson, a London physician, started the precession of case reports in 1812. This was quickly followed by many others the first American reporting being Prescott in 1815. By 1828 groups of cases, instead of single instances, were being reported, 13 being collected by meniere in this year. Melier and Dupuytren of France, Genzman and Schmidt of Germany, Hodgkin Bright and Addison of England, Becchi of Italy, Welcott Richards (1837 of Cincinnati) and Hallowell of America, and others too numerous to mention followed with reports.
It was at this time, however, that the great controversies arose as to where the true pathology f the right iliac fossa lay. Such terms as “Stercoral Typhitis”, “Simple typhlitis”, perityphilitis, chronic typhilitis, apophysitis, epityphlitis, pericaecitis, etc. filled the literature of the day. Confusion reigned until 1886, when Reginald H. Fitz of Boston, clarified the atmosphere somewhat with his memorable article. He showed that the symptoms in 209 cases of Typhlitis or Perityphlitis were identical with those observed in 257 cases of perforation of the appendix, and convinced the medical world of the practical contention that in all inflammation of the right iliac fossa, the “fons et origo mali” was the vermiform process of the caecum. It seems in this article that the term “appendicitis” was first used, but it quickly took hold and soon was almost universally used. What Fitz had done in America, Matterstock had also accomplished in Germany.
McBurney in 1889 contributed his classical sign to the diagnosis of appendicitis, and much bacteriological work on the appendix claimed the attention of authors in the early nineties. Form that time on, however, the chief subject of discussion became “treatment”, so we shall now turn to that.
Treatment: just as there was duplication in the names of those doing clinical and anatomical work on the subject of appendicitis, so do we find this present in the treatment of this condition. The names of Dupuytren, Helmont, Amy and, Mestiver, Hancock, Parker and McBurney, to mention a few, appear in both connections. But let us get back to the beginning of the matter.
As far back as the early Christian era, the old dietum of “open and drain” applied t abscesses in general, and was sparingly made use of in collections of matter in the right iliac fossa. For example, Aretaeus, in the second century, opened an abscess in the colon on the right side, but it was near the liver and some doubt exists as to whether or not this was a perinephric abscess or one associated with the colon. At all events surgical treatment was always postponed until the last possible moment, when an abscess was actually pointing. In fact, many to the ancients preferred to let the matter evacuate itself spontaneously or allow the patient to die a peaceful death, without subjecting him to the discomfort of the abscess being opened at all, and without laying themselves open to the charge of having killed the patient to die a peaceful death, without subjecting him to the discomfort of the abscess being opened at all, and without laying themselves open to the charge of having killed the patient by the operation. And oddly enough this was the form of treatment persisted in until less than fifty years ago, the only possible modification being that some men advocated an earlier drainage of pus than others.
As adjuncts to treatment, Venesection and purging played a large part in these early cases. A course of treatment ran somewhat as follows: “Immediate venesection form the veins at he elbow, and, if retention of urine was present, from the saphenous vein at the ankle as well, blood being drawn in severe cases ad deliquium annimi. Emetics if the pain were above the navel; purgatives, however, should its chief intensity be below; but in cases where there was manifest inflammation, these remedies were not used, evacuation of the bowels being attempted by large and repeated enemata, forcefully injected. Sedatives were given sparingly, because it was thought that purgatives best overcame obstruction of the bowels, although they were directed to be applied locally; and the patient was made to sit in a bath of hot oil in which various drugs were dissolved. A very few of the ancient physicians caused their patients to swallow leaden pills in the hope that by their weight they might force a way thru all obstructions, and finally cause a satisfactory faecal evacuation. Hear Van Helmont on this subject “No one can perish of the Iliac passion if he do but swallow musket balls of lead, which by their superincumbent weight may drive forward the obstacle seated in the intestines”; and that the larger these balls were, and the greater the number of them swallowed, the more expeditiously would they be useful, especially if the patient could be kept upon his feet and walking about in an erect proturo. Par’e in the sixteenth century and Sanctus insist that many were cured of the most deplorable iliac passions by drinking three pounds of quicksilver in hot water, “which even saved them form imminent death.” It is curious to find this remedy still in use at so late a date as 1830.
Oribasius and the Arabian physicians encouraged the opening of an abscess into the bowels by hardening the overlaying skin with astringents; and were and emallient cataplasms were only applied when rupture externally appeared unavoidable.
Sydenham’s favorite applicati9n to the abdomen in these cases was the body of a freshly slain puppy-dog, slit open. In those cases where the pain returned after recovery, or where symptoms of abdominal discomfort persisted after an attack of the iliac passion, he recommended constant horseback riding, to jolt the noxious matters of out the caecum, where they were prone to accumulate.
Riverius in 1668 narrated the following incredible case, quoted form Matthew de Grade; “A girl of twelve years was afflicted with the iliac passion, and reversed peristalsis became strong, and faecal vomiting so constant, that not only were ordinary suppositories vomited from the mouth shortly after being placed in the rectum, but even one tied by four strong threads to the thigh was drawn upward, the strings snapped, and the suppository, with parts of the threads still attached shortly afterwards rejected from the stomach. Besides giving the usual directions as to treatment Riverius lays great stress on abstinence, allowing only three spoonfuls of broth every day for four or five days.
Beerhave, the most learned of all medical writers, in 1709 advised the following treatment of cases such as these:
1. Large and repeated bloodlettings.
2. Laxative and cooling clysters, three, four, or more in a day.
3. Similar drinks, with a “prudent interposition of opiates.”
4. Fomentations to the abdomen, more especially of living animals that are young and of sound health, split open and applied.
5. Avoiding all things that re acrid, forcing or heating.
6. Holding on in the same course until complete cure is assured, that is, until all symptoms have been absent for three days.
While Claudius Amyand, F.R.S. records the first removal of the human appendix in 1735, during the course of operation for hernia and Mestivier in 1759 tells of being the first to willfully open and appendiceal abscess, to Hancock belongs the distinction of contributing the greatest surgical advance up to his time on this subject. In 1848 he performed the first deliberate laparotomy for peri-appendicular suppuration, and proposed such treatment for all cases with abscess before pointing or fluctuation had occurred, or even before adhesions to the anterior abdominal wall had formed. Many as a procedure looked this upon temerarious in the extreme, in spite of the excellent recovery made by his patient. Lewis in 1856 repeated this advice of Hancock, supporting his statements with the analyses of 40 cases, but Willard Parker of N.Y. in 1867 was the first to again practice this “bold” method of treatment. While Parker advocated just what Hancock and-namely, operation between the fifth to the seventh, and the eleventh to the fourteenth day; his announcement came at a more fitting time and met with a prompt response. Sir Joseph Lister introduce his principles of antisepsis at this time, and Parker succeeded where Hancock failed because antisepsis stood ready as his handmaiden to step and reduce the risk to a minimum.
Meanwhile many improvements in technique had transpired. Early in the 19th century, Grav4es and Stokes f Dublin inaugurated the use of opium in large doses; Chassiagnae introduced drainage tubes in 1859; Munchmeyer, Buck, Symonds and others advocated new incisions, counter incisions etc., Homans is said to have employed gauze packs first in 1886.
By 1882 the all-important question was being asked “How shall we treat that great class of cases of perforation of the appendix vermiformis in which there is no circumscribed collection of pus?” Byrd answers it despondently “I fail to find any recorded cases in which this procedure (laparatomy) has been attempted with success. However plausiblo and important this operation really is, the difficulty of a certainty of diagnosis will stand as an almost insurmountable obstacle to its adoption. Medicine is useless in these cases, except for the production of euthanasia, and surgery cannot even accomplish this.” In contradiction one welcomes the more cheerful views of Samuel Fenwick and professor Mickuliez, of Markow; that is, “It would seem to be much better if we could cut down directly upon the appendix as soon as the diagnosis was tolerantly certain, tie it above the seat of perforation and remove from its neighborhood any concretion or decomposing material that might be the cause of irritation.” These words represent the conclusion of the preceliotomy period in the history of the appendix, when simple incision and the evacuation of the pus were recognized as the proper surgical treatment. The actual removal of the appendix now became the focal point of the surgical world, and the modern era of medical surgery was bout to begin.
Shortly after this, Kronlein (1884) first removed the appendix for acute disease employing an incision thru the linea alba but his patient did not recover. It was just about this time, you will recall, that Reginald Fitz made his great clinical contribution to the subject. Then followed operations in all parts. Sands, in 1887, successfully closed a perforation of the appendix by suture, while in 1888 Treves has been credited with doing the first “interval” operation (though some claim this honor for charter Symonds, an Englishman, in 1885). In 1889, Lawson Tait split open and drained an inflamed appendix without removing it, and his patient recovered. And so it goes. By 1890 one author has listed nearly a hundred appendiceal operators, and his collection is far from complete.
But to Thomas G. Morton of Philadelphia belongs the credit of the first successful operation for the removal of the appendix, deliberately undertaken with an alternative diagnosis of disease in the organ. Through the kindness of Dr. Ellson, of Philadelphia, I am able to give you a report of this case just as presented to the College of Physicians, June 1, 1887 by Dr. Woodbury.
“I have the honor of presenting this evening to the College a private patient who five weeks ago today was apparently I articulo mortis, with perityphlitis abscess. Dr. Thomas G. Morton, the abscess evacuated and the appendix veriformis removed at its origin, almost divided by an ulcer, skillfully performed Laporatomy. I also present the specimen taken from the patient; the appendix, a portion of the omentum, which was included in the abscess and removed with the appendix. Accompanying these is a small fecal or phosphatic concretion, resembling in size and general appearance a cherry stone (which it was at first supposed to be) that evidently was the cause of the ulceration. The notes of the case are briefly as follows: C.M.N.K. age 26, paperhanger by occupation, not married, of spare frame and of good habits, had always had good health except for the past three or four years he had been subject to sudden and severe attacks of abdominal pain. These attacks came on without warning while he was in excellent health and would completely prostrate him. Pain was of a stabbing character and was most intense across of the lower part of the abdomen, and especially around the umbilicus; it was attended by great irritability of both bladder and rectum. Sometimes there would be watery diarrhea but there was always a marked increase in the amount of water voided, the urine being red “blood like” in color. He is of the opinion that he has at times passed blood in his urine. The attacks after lasting a few hours, usually passed away gradually leaving him rather weak for a shot time, but he rapidly recovered and enjoyed uninterrupted health until the next attack came on. I first saw him on the twentieth of April, when he came to my office complaining of having taken cold, he looked haggard; skin and conjunctive rather sallow, tongue coated, no appetite and bowels constipated. He said that he felt miserable with pains in all his muscles, except those of this abdomen. He was given fractional doses of calomel with soda and pepsin and told to keep to his room next day his urine showed albumin (1/5 on boiling) with pus cells and haylin casts. Two days later he felt nauseated and took mustard water to produce emesis, bowels having moved meanwhile from the calomel. Emesis gave no relief. During the day he had great irritability of the bladder and was much prostrated, so that when he came to my office he was so weak that he had to rest for an hour and take stimulants before he could go home. (April 23rd) Spent the day lying upon a couch, now complaining of abdominal pain. He had not slept and was very restless. Bowels not moved for two days. Repeated calomel in fractional doses (one tenth of a grain every hour until five doses were taken) and ordered quinine grains 12 daily. Poultices to abdomen. (April 24th) at morning visit found that during the night he had suffered intensely and did not sleep at all. Bowels not yet moved. Ordered a cupful of hot water every hour to assist the action of Calomel given yesterday. In the afternoon he had several copious movements but the pain persisted. He indicated the point of greatest tenderness about midway between the umbilicus and the middle of the Pouparts ligament. A resisting mass the size of a small egg could be detected upon deep pressure in this locality but examination caused severe pain. Morphine sulphate in ½ grain doses was given every two hours until pain was relieved. Poultices again applied over abdomen. Temperature 103.5 degrees, pulse 140. (April 25) Had a very bad night. Pain in tumor excruciating, swelling somewhat larger, very tender. Skin not discolored, tumor evidently beneath the peritoneum. Passed urine, which was said, to contain small blood clots. Dr. James Wilson saw the case in consultation. Diagnosis either intusscusption or perityphlitie abscess. Ten foreign leeches were applied over the spot of tenderness with great relief to the patient. (April 26th) Skin around leech bites inflamed. Tumor more flat and tender. Apparently nearer the surface. Bowels not moved since the 24th. A pint of warm sweet oil was thrown into the colon with a large tube- this felt comforting and later produced evacuation of the bowels. (April 27th) skin around leech bites more swollen, injected and tender. The right lower half of the abdomen was dull on percussion, the dullness extending over the middle line from the point just above the anterior inferior spine of ilium. External to this the percussion note was clear. General condition poor, face pale, features pinched, beads of perspiration on forehead. It was decided on consultation with Dr. Wilson that opening the abdomen would be justifiable. Dr. Morton saw him at 11A.M.; at 2 P.M laparatomy was performed. The leech bites were noticed to be suppurating. An ounce of whiskey was given before either was administered. The usual antiseptic precautions were observed as to instruments, and the field surrounded with towels wet with mercuric solution. The incision was made directly over he swelling, and finding the muscles infiltrated with pus, it was extended until it measured ten inches. Commencing just above and two inches to the right of the umbilicus it continued obliquely downward to the pubis. The peritoneum was opened and a free flow of pus followed having a decidedly fecal odor. In it was found a concretion resembling a cherry stone. The vermiform appendix was greatly swollen and exhibited a perforating ulcer extending three-fourths around its circumference and very near to the point of origin. A silk ligature was applied close to the caecum and at the terminal part of the appendix, and the intervening portion, comprising almost the whole organ was removed together with a large part of the omentum, which projected into the abscess cavity. The walls were then scraped with a curette and douched with simple warm water.
Following the operation, the patient entered upon convalenence, which was uninterrupted. He was entirely free from abdominal pain, except from distension of the bladder, requiring the use of the catheter for a week. The bowels were moved on May 1st after he had yolks of two eggs in milk. The temperature fell after the operation and did not again rise above 100 degrees. The drainage tube was removed piecemeal; the last portion was taken away on the 13th of May. He sat up on May 11th and rapidly regained strength. He was out riding on May 21st. his recovery was assured by careful nursing, the administration of a small quantity of whiskey, (a teaspoon full every two hours) and the use of Bovine, and Hoff’s Extract of Malt, (a tablespoonful every two to four hours.) At present the wound is healed and he appears to be in his usual health.
At the same meeting Dr. Morton discussed another similar case; a woman, form whom he had removed a perforated appendix on February 21, 1887, but who died from shock three hours later. In answer to Dr. Morton’s discussion as to the advisability of removing the human appendix, Dr. Chapman replied: a true vermiform appendix is found only in six animals; viz, man, gorilla, chimpanzee, orang, gibbon and wombat. There can be no doubt, there fore, that the cecal appendix is one of those parts of the human body having no particular function of significance, being of use only in animals were it is expanded so as to supplement the functions of the stomach. In the human being it ought to be removed with no bad effect whatsoever, so that I thoroughly agree with Dr. Morton in what he has to say regarding the opening of the abdomen and taking out the appendix. It seems to me that the human being is better off without the appendix than with it, for it is nothing but a trap to catch cherry stones and other foreign bodies.”
Sir Frederick Treves raised the question of priority some five years later. He really has no claim to Morton’s credit, however, for Morton’s paper was published before Treves’ (date of publication and not date of action taking precedence); and furthermore, Treves operation was orthopedic in nature, while Morton’s was exsective. And, anyhow, there is glory enough for all of these pioneers in this all-important field.
Since 1890 the history of appendicitis has been one of refinement in technique and diagnosis. Battle in 1895, by Kammerer in 1897, and Lennander in 1898 modified the simple straight incision thru the right rectus muscle. McBurney proposed his original muscle splitting operation in 1893 and this was modified by Weir in 1900. Laboratory refinements in diagnosis followed. And so it goes until today we have a multiplicity of signs and symptoms, as aids to the diagnosis of appendicitis, while there are as many techniques for operation as there are operator, with little essential difference throughout. Concerning the history of appendicitis during the twentieth century by audience is probably more informed than the speaker, so I shall desist forthwith.
In closing let me draw attention to a very excellent article concerning Perityphlitis by our own Dr. W.C. Dugan, appearing in the Louisville, Medical News, Vol. XIX, 1885. I wish that I might have time to read it in its entirety, as it is most interesting, what dr. Dugan did at that time had been done many times before, - namely, aspiration and drainage of an abscess in the right l9ower quadrant in a moribund patient. What he advocated doing, however, namely early and radical interference with removal of the appendix was quite in advance of the thought of his time. He proposed to do (in 1845) what Morton actually did and reported in 1887. I was unable to ascertain in the literature if Dr. Dugan ever performed this radical operation, which he advocated, in these early days. I am told that the above-mentioned case report of Dr. Dugan’s was the first appearing in the Southwest, and I am sorry it has not found its merited place in the general historical writings on the subject. As evidence of the great interest being manifest in the subject along about 1885, there appear two other articles on Perityphlitis and appendicitis in the volume of the “Louisville News” containing Dr. Dugan’s case report. One was from the “Lancet” and the other by Dr. McCoy, of Columbus, Ind. Both articles agree with the views expressed by Dr. Dugan, i.e., that perforation with abscess formation should be tackled early. None suggest operation, however, for what Dr. Dugan calls primary or simple Perityphlitis (a condition that would be called today accurate appendicitis, I imagine.) let me once again state my great admiration for the fine judgment, skill and courage, which these pioneers showed in light of the knowledge then at hand. Dr. Dugan is to be congratulated and I feel honored by his presence here tonight.
Appendicitis- Its Diagnosis and Treatment, John B. Deaver. Pp 1-53.
Vermiform Appendix and Its Diseases, Kelley & Burdon. Pp 1-43
Proceedings of Phila. Co. Medical Soc. Vol. VIII, 1887. Pp 101.
Transactions College Physicians Vol. IX. 1887.
Lancet, Vol. I. 1888. Pp 527.
Phila. Medical News. 1887, 1892.
Private Correspondence, Dr.
J. Vernon Ellson, Phila. 1927.