REVIEW
ARTICLE
Appendicitis
Mark M. Ravitch, MD
From the Departments of Surgery, Montefiore Hospital and University of Pittsburgh School of Medicine, Pittsburgh
ABSTRACT. The mortality from acute appendicitis has
been reduced, but the sharp difference in the morbidity
and complications associated with perforation demands
a policy that will minimize the possibility of delay in
operation or failure to diagnose acute appendicitis. The
decrease in mortality is largely due to the quality of care within the hospital, and possibly to the less frequent use of cathartics, but not to a decreased incidence of perfo-ration. The suggestion is made that the failure to decrease
the incidence of perforation of the appendix may be
related to the nature of pediatric practice. Pediatrics 70:414-419, 1982; appendicitis, pediatric practice.
Although those with an antiquarian interest in
the disease will refer back to Mestivier, Claudius
Amyand, M#{233}lier,and Dupuytren, to all intents and
purposes, the modern story of appendicitis begins
with Fitz, and, of course, the classic 1889 paper by
McBurney’ (Fig 2). Speaking before the New York
Surgical Society on Nov 13, 1889, McBurney said it
was now accepted by almost everyone that, acute
inflammation of the right lower quadrant usually
had its origin in the appendix, that any involvement
of the cecum, retroperitoneal tissues, etc, was
sec-ondary, and so the words perityphlitis and
para-typhlitis could be dispensed with. I am accustomed
to quote to my students, who usually describe
McBurney’s point as two thirds of the way from the
umbilicus to the anterior superior spine,
Mc-Burney’s own statement. McBurney described “the
Received for publication Sept 10, 1981; accepted Oct 14, 1981.
Presented before the American Academy of Pediatrics, Detroit,
Oct 29, 1980.
Reprint requests to (M.M.R.) Department of Surgery,
Univer-sity of Pittsburgh School of Medicine, Montefiore Hospital,
Pittsburgh, PA 15213.
PEDIATRICS (ISSN 0031 4005). Copyright © 1982 by the American Academy of Pediatrics.
seat of greatest pain, as determined by the pressure
of one finger to have been very exactly between an
inch and a half and two inches from the anterior
spinous process of the ilium on a straight line drawn
from the process to the umbilicus” (Fig 3). What is
perhaps more important today than his mildly
pe-dantic statement-obviously inaccurate inasmuch
as it takes no account of the size of the
patient-was his attitude toward recognition of the disease
and the indications for operation (Fig 4).
We do know that the cases which are recognized and
which die are numerous, and it is safe to assert that a
very large number of fatal cases of peritonitis commence
with an unrecognized inflammation of the vermiform
appendix. No one will dispute that if we could so improve
our methods of diagnosis that we could recognize within
the first few hours the serious nature of many cases, we
would operate in these cases at once, willingly preferring
to incur the risks of an operation rather than face the
certainty of death that septic peritonitis implies. How
may we improve our methods of diagnosis? At present, I
see no clearer road than the exploratory incision permit-ting a direct inspection of the parts and a complete study of the disease. If it can be shown by future experience
with improved methods of operation, and with more
perfect antiseptic precautions, that the exploratory mci-sion for inspection of the diseased appendix is much more
free from danger than the expectant treatment, then
there could be but one answer to the question. What is
the best treatment?
We have come a long way in the 90 years since
McBurney gave this talk. The risk of appendectomy
for unruptured or normal appendices is almost nil,
certainly far lower than McBurney could have
hoped for. Nevertheless, we find vigorous attempts
being made by serious students to see whether it
might not, after all, be worthwhile to eliminate the
possibility that in undertaking early operation, one
was undertaking operation on a certain number of
There has, of course, been a progressive reduction
in the mortality of appendicitis.
Richardson,2 that great stalwart of the
Massachu-setts General Hospital, reported in 1899 a 12.6%
mortality in 569 appendectomies; but of these, only
331 had been for acute appendicitis, and the
mor-tality for them was 21.7%. The mortality in 238
“interval operations” was 0. Deaver,3 of
Philadel-phia, discussing the paper that Richardson had
given before the American Surgical Association,
said that what was of particular importance in his
own series was that he had a 5.5% mortality within
the first 24 hours (only one of 18 patients died) but
33.3% (ten deaths of 30 operated upon) within 48
hours. In fact, the flamboyant, assertive, and
agres-sive Deaver was rather in advance of most of his
colleagues in the American Surgical Association, in
insisting, in 1899, on immediate operation upon
diagnosis of probable appendicitis. Harte,4 also of
Philadelphia, stated in supporting Deaver, that “In
the early operation of appendicitis, I cannot see
what harm has been done if the appendix has been
removed. The perfect man is the man without an
appendix.”
There was also the lovely classification of
sur-geons by the elegant French. In appendicitis, an
“interventionist” was one who “will operate on the
patient at once regardless of the stage of the
dis-ease or his general or local condition.” The
“abstentionist” “...will not operate in the acute
stage unless after a period of observation it is
evi-dent that the patient has failed to improve or
per-haps is worse.” And, finally, the French classified
an occasional surgeon as an “opportunist” “who
will operate at once if the attack has lasted no more
than thirty-six to forty-eight hours, but after that
will wait for conditions to improve or even resolve
entirely before risking operative intervention.”
Bal-four5 in 1922 said that at the Mayo Clinic the
current mortality for patients with appendicitis,
operated upon in the first 12 hours, was 0, in the
second 12 hours was 3%, 6% in the second 24 hours,
16% on the third and fourth days, and thereafter
dropped to 6% and stayed there for some time.
Lehman and Parker6 from the University of
Vir-ginia, in 1938, reported a .24% mortality for simple
acute appendicitis, 5% for abscess, and 40% for
diffuse peritonitis. From the University of
Michi-gan, Coller7 then reported 1.9% overall mortality in
574 patients with acute appendicitis, but eight dead
of the 32 patients who came in with diffuse
perito-nitis, and three of 46 dead who were admitted with
an abscess. Horsley8 reported a mortality much
better than most, .6% for acute appendicitis and 2%
for appendicitis with peritonitis. His
recommenda-tion is one that I stifi find compelling, “Immediate
operation for acute appendicitis, as soon as the
diagnosis is made, no matter what the stage of the
disease.” From Toronto, in 1938, Graham9 reported
a 3% mortality overall, but the mortality for patients
with masses was 22%, and for perforative
appendi-citis was 17%. In 1942, Penberthy, Benson (who is
the recipient at this meeting of the Ladd Award for
contributions to pediatric surgery), analyzing
ap-pendicitis in infants and children, from this city of
Detroit and Weller’#{176}reported 742 acute unruptured
appendices, with a .44% mortality; 183 ruptured
with peritonitis, .55% mortality; 94 with diffuse
peri-tonitis, and 61 deaths, 64.9% mortality; 292 patients
with appendiceal abscess, 11 deaths, a 3.6%
mortal-ity. At the same time, Ladd” reported 466 cases of
acute appendicitis from the Boston Children’s
Hos-pital, with two deaths (0.42% mortality) and one of
those due to hemophilia. Penberthy et al’#{176}pointed
out that Ochsner himself had said that there was
no place for his expectant treatment of the ruptured
appendix in children, with their small omentum and
poor resistance to infection. A long-term
perspec-tive was provided by Schullinger’2 from
Presbyte-nan Hospital in New York, and his ifiustrations are
worth looking at (Figs 5 and 6). And, finally, in
1950, Hawk and associates’3 compared their more
recent 1943 to 1948 series with their 1933 to 1937
series. The mortality was now 0.24% for simple
appendicitis, had decreased from 5% to 0% for local
peritonitis, and from 40.6% to 7.5% for diffuse
peri-tonitis. The overall mortality for the entire group
had decreased from 3.2% to .8%. During a discussion
of Lehman’s paper, Lanman’4 of Boston, presented
the figures of the Children’s Hospital. In the six
years since 1944, they had had 588 consecutive cases
of appendicitis with no deaths, all operated upon
soon after admission. “We, therefore, feel it is
im-portant that we discard in our teaching the so-called
‘waiting policy’ and we think it is particularly
im-portant to discard that teaching in ... cases ... in
which there is a diffuse peritonitis.” Now, this
im-provement in results, as this audience perfectly well
knows, had absolutely nothing to do with the earlier
recognition and referral of cases of acute
appendi-citis to the hospital. In that series from the
Chit-dren’s Hospital of Boston, the annual incidence of
ruptured appendices varied from 50% to 60%. The
incidence at the Children’s Hospital of Pittsburgh
is approximately the same.
Once more, we see that modern anesthesia,
intra-venous fluids, and antibiotics, and sophisticated
postoperative care have diminished the ultimate
penalty of misdiagnosis and even of poor initial
care, and possibly of an improperly performed
op-eration. To fail to diagnose appendicitis early, or to
operate on it ineptly, was formerly considered a sin;
as far as the patient was concerned, it was
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DISlSE ()F ‘I’ll E \-l-:11M1 l 11M 1l’i’J-Nl)lX.
Br (IlAI1l.E MIUTIINEY, M. I).,
VlUItU4fl tft’:”N tO TII:
I vicsiis: to introdiicc once ,nor(’ a subject that I,:iq
be.,, .n ally Iri,t#{248}ilby ;isi,it’r’;s writir, Ii’o.inn I h.i-,
for some tune lccn devoting my attentio,s in suitable cascs
to a particular line of treatment, and because I have beeti
fortun;ite enoLigli t#{248}have had recently a considerable ber of cases of (lL’CflC of the nppcn’lix tinder ny care.
Nearly two )cars ago the account of a case of successful
laparotomy for pert)ratioI of tin vcriniforu appendix was
read before this society by OU ui,,cl,-la,nented colleague,
1)r. henry B. Sotnds. The case as a most brilliant one
throughout, and illustrated I1artc11larlY well the cleverness
of diagnosis ani the rapidity of successful action which we
all remember as so characteristic of the reader of that paper.
It should not he forgotten that at that time stich action was
a very bold step into ground that was almost ,inknown.
Ve did not all agree with l)r. Sands in the views which he expressed in regard to the pathology of perityphlitis, hut
these views did not prevent him, when the proper case
c.c-curred, from making, in regard to treatment, a brilliant
stride in advance of others. This case gave an impulse to
the study of inflammatory affeeti”’ of the veln3iforn,
ap-pendix from wl,icli we shall not recover for a lo1g time.
During the following months 1)r. Sands devoted much
at-tention to this study, and it was my privilege to assist l,im
in a number of 5i0s5f1I operations for the removal of the
Fig 2. First page of McBurney’s classic article “Experience with Early Operative Interference in Cases of Disease of the Vermiform Appendix.”
‘JE
I’E!:J!zPoi:.l!
APPENDIX. N.Y. Mc,. 1: :pressed. ‘l’l,c exact locality of tlc rcatest sc11sit1vtn
las SeCt3C(l to inc to be usual lv one of it,ipw#{149}t
\\ lat ever IL’’ he the position ()t the lealtly ptidi
fo,, uI in 3he (lc:,(l-l,o,3sc-a,3d I tin svcll to are t bat it p
t0)11 sltti iii,in tlaI!It’(l varies .rt:tt Is-- I have t iiri(I 11::
II). ol)crati()ns that it las, ci
t
lcr tl,i1tucl, -l,ort.,l(1,adherent. very close to its poitt of ;ttt;tl,incnt ti tlic
CLHO. ‘l’l,is, Of coirse, must, in earl st:cs 01’ the lt:
(leternunc the seat of greatest pain on pressure. And I i.
I ce that in every case the seat of .rc:tt(st ai n, deter,,i,,
in the pressure qi one fiuiqer, l,:is bee,, very cxatl- let w,:
an inch and a lalf and two Itie lies troii tlie ai,t erior spin.
PF0CCSS of the ili,i,,, -ii a st raiglt line d rass n froii that Ir.
(‘(‘55 to t1it (It!tl)il1(’t15. ‘l’liis n,:iv app:u to c
iii
:AtYc’t..tO)13 of accur;c-, but, so far as ins exlcrien-e goes, th
ol,servatin is (.(brr(.t*
* Since reading this paper I have carefully observed three other
cases. In two the point of pain shown by pressure ssith one finger
was two inches, and in the other an inch and seven eighths from the anterior spine.
Fig 3. Passage in McBurney’s vermiform appendix
pa-per, giving his method for determining seat of greatest
pain.
\‘Sc d kiiow that the cases
which are recognized aiiO wIiicI (li( are nuiiiciotis, and it is
safe to assert that a s’er’ large nhlml)er of fitt:,l cases of
pen-tonitis commence with an tirtrecognized intlau,mation of the
vcrn,ifo,-m appendix. No one will disptite.that if we could
so improve our methods of diagnosis that we could recognize within the tirst few hours the serious nature of nany cases, we would operate in these cases at once, willingly preferring to incur the risks of an operation rather than face the cer-tainty of (leatli that septic peritonitis implies. how may we improve our methods of diagnosis I At present I see no clearer road than the explcratory incision permitting a di-rect inspection of the parts and a complete study of the dis-ease. If it can be shown by future experience with im-proved methods of operation, and with more perfect anti-septic precautions, that the exploratory incision for in-spection of the diseased appendix is much more free from
danger than the expectant treatment, then there could be but one answer to the onestion. \Vhat is tho lwst troatm’nt
Fig 4. McBurney’s thoughts on need for early
opera-tion, vermiform appendix paper discussing methods of
diagnosing.
the risk of paying the ultimate penalty for such a
sin has been very sharply reduced, at least in the
very good institutions whose figures have been
quoted, and has diminished progressively.
Never-theless, (1) there is essentially no mortality
associ-ated with the removal of an unruptured appendix
whether inflamed or not, except the small mortality
associated with coming into a hospital and having
an anesthetic; (2) there is still some mortal risk
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TABLE VI
ACUTE APPEEHCITIS AT THE PUSIYTER.IAN HP1TAL. YOU CITY
January 1. 1b16 to Dutember 31. 1943
C1ai&ation
MtaHty L.astFiveVear 1943
R.*te Average Mortality
1916-1945 Mortality Rate Rate
Allcaaeso(acuteappendk4tls 3.35% 1.37% 0.43%
Simple acute appendicitis 0.49% 0.39% 0.00%
Acute appendicitis with acute 1a1 peritonitis. .. . 2.06% 1.35% 0 00%
Acute appendicitis with peritonl (appendiceal)
abeis... . . 9.04% 4.16%
Acuteappendicitiswithacutedifluaeperitonitia. . 15.48% 4.0$ 0 00
Acute appendkitis with peogrrnve fibrinopurulent
pentonitti 82.35% 80 00% 0 00
S No cai for l94!l
Fig 6. Mortality from acute appendicitis at Columbia-Presbyterian Hospital by form of
appendicitis, and by time period (Reproduced with permission from Schullinger’2).
,R
I, r
C’
q
P
.7
5
1
,tI Ai
7
4.
It
0
-‘ri. ‘ , 1
‘a
i ‘i t ‘a I 3 Irub.
I . i Gnaph ihowing k*si atmi*l *th rs (r 1916 I94. 3’
(w’ ‘f acutr append.citis with its u.ocisttd ksscms. Total .ber #{232}*th$ : iQ3 ; YTO‘rtalstv rate. 3 cc wr cent Mortality rate los’ ws 0.4..) pet cfsit.
Fi. 2 -4;rph for compsrison with thst b Fur ‘. show ttw a1 PrO1T’$Si
f,se 7ear average death rate fran sg,6 to lsIfve. for all cans d cvt’ a-‘Iw,Ii wtth ts a.wiciated le.wws. Mortality rate for tv to ioi#{216}wa. I..t7 pSI’ Cf
Fig 5. Mortality from acute appendicitis at Columbia-Presbyterian Hospital: top, yearly
death rates; bottom, average death rates by quinquennia (Reproduced with permission
from Schullinger’2).
some institutions, it is higher than others; (3) once
the appendix has been ruptured, we accept a
defi-nite but unknown risk of incisional hernia, acute
mechanical intestinal obstruction either during the
postoperative period or many years later, sensitivity
or sensitization to antibiotics, or drug reactions,
early or late, reoperations for abscesses, and in
addition the various discomfitures and
complica-tions associated with long continued intravenous
treatment and nasogastric suction, not to mention
the pain, discomfort, worry, and financial cost of a
occa-sional case, perhaps no more than one or two such
in any large service in a year, the ruptured appendix
will not be removed in the course of the first
oper-ation and the patient will have to be readmitted for
an elective operation and run the risk of another
attack of acute appendicitis.
It is therefore my firm conviction that although
the difference between an aggressive policy of
op-eration on suspicion and a delaying policy of
oper-ating only upon certainty is no longer readily
mea-surable in terms of patients’ deaths, it is demonstra-bly so in terms of pain, suffering, expense, nonlethal
complications, and long-term consequences. The
one-day admission for an appendectomy for what
turns out not to be appendicitis is a worthwhile
investment for a child and his family, to avoid the
risk of perforation. No family has ever refused
per-mission for me to operate on their child when told
that their child very possibly did not have
appen-dicitis, but that if I withheld operation on 100
similar children, there would be a number in whom
we would come to regret the delay. Obviously, we
would not suggest that every child with abdominal
pain be operated upon. On the other hand, we are
well aware that the symptomatology and the
phys-ical findings of appendicitis are not necessarily
re-liable. What we seek is a series of criteria that will
represent the minimal requirements for operation
for appendicitis, so designed that we will essentially
be safeguarded from ever missing a case of acute
appendicitis, on the one hand, and on the other, will
not be accumulating a large specimen collection of
normal appendices.
No one misses the diagnosis of acute appendicitis
in a child who wakes up, doesn’t want breakfast,
then says he has pain in the upper part of the
abdominal midline, and then vomits and has a little
fever, is taken to the physician a couple of hours
later and found to have a mild leukocytosis, low
fever, localized and rebound tenderness in the right
lower quadrant, and rectal tenderness. But how
much do we require a typical history, how much do
we require confirmatory laboratory findings, how
many of the numerous physical signs which might
be elicited, do we need?
Vomiting is a common symptom and I am a little
uncomfortable diagnosing appendicitis without it.
Anorexia is commoner still and I am reluctant to
make the diagnosis of appendicitis in a child who is
munching Fritos while I examine him. Older
chil-dren frequently state that they have the urge to
evacuate and feel that evacuation would relieve the
abdominal pain, but if they do evacuate, the pain is
unchanged. All of these are helpful, but they cannot
be required because one or another, or all, may be
absent. In the end, I find that the only thing in the
history that I require is a history of abdominal pain,
and even then that, in the case of early infancy,
may be available, if at all, only in infants with
perceptive mothers. Point tenderness, rebound
tenderness, Murphy’s sign, psoas slap sign, rectal
tenderness, muscle spasm, and rigidity, are all nice
and when they are all present, my cup runneth
over. More often than not, my cup has just a little
wine covering the bottom. In the end, I have come
only to require that there must be some tenderness,
preferably pointing to the right lower quadrant.
Fever is an unreliable symptom. It is cheering to
the surgeon to find a mild temperature elevation,
but one cannot insist upon even a slight elevation.
By the same token, it is comforting to see a mild
leukocytosis, but one cannot require leukocytosis,
or any change in the differential white count. Why,
then, bother with white count or temperature at
all? Principally because, early in the disease, high
fever or a high white count suggests something
other than appendicitis-pyelitis, salpingitis,
pneu-monia.
Are we then to operate on every child with
ab-dominal pain, in whom tenderness, preferably right
lower quadrant, can be elicited? My answer is yes,
provided that there is nothing in the history, in the
physical examination, or in the laboratory studies
that is incompatible with the diagnosis. If the child
is jaundiced, has hematuria, or a fiery red throat
and enlarged cervical nodes, I would think of other
things than appendicitis. If the mother says that it
is funny, but she notices that every second Tuesday
when Willie has to go for his violin lesson, he has
abdominal pain, and today is a Tuesday, my
eye-brows may go up. By the same token, if Susie is 11
or 12 years old and her mother remarks that the
same thing happened a month ago, I would begin
to wonder. Nevertheless, if in these and other cases,
the tenderness, and the child’s behavior are
con-vincing, I will operate, but I may have some
uncer-tainty as to whether I will find an acutely inflamed
appendix.
The mortality of removal of a normal appendix is
a small fraction of 1%, and in a number of patients
another underlying problem will be disclosed by
operation. Although one or two studies have alleged
that carcinoma of the colon is more common in
those without an appendix, that thesis is far from
accepted; no other disadvantage of an absent
ap-pendix has been claimed, and obviously, once the appendix is out, there is no fear of appendicitis.
It has been my habit for my entire life as a
surgeon to write down exactly where I thought the
appendix would lie and what the stage of
inflam-mation would be. I have certainly had longer or
shorter runs of a very high degree of precision, and
I like
to remember those. On the other hand, I havehad some notable lapses when I was trying too hard
to prove that a patient did not meet my criteria. If
six, you are waiting too long, and allowing some
appendices to burst. I do not admit cases of possible
appendicitis for “observation.” If there is a
reason-able possibility of appendicitis, I operate at once. I
find myselfspending a good deal ofmy time
inveigh-ing against the unspoken, or perhaps unthought
out, philosophy, that inasmuch as we have so many
potent therapeutic weapons, it is not terribly
im-portant to be precise, or to be correct very early. In
this condition, in intestinal obstruction, and in a
good many others, I find this unacceptable as I am
sure you do. The better our results in the treatment
of a disease, the harder must we strive to improve
our results stifi further, and the greater the
chal-lenge to us.
Of greatest concern, I think, to this audience, is
the matter of the significant percentage of children
coming into good children’s hospitals today with
ruptured appendices. I would suppose we are past
the time referred to by Bailey,’5 in the paper “Acute
Appendicitis-A Brief Criticism”, in which he said
that “Nefarious home treatment without medical
aid” consumed 60 to 80 hours before the doctor was
consulted, and “The actual cause of death in acute
appendicitis is public ignorance or disregard of the
potential danger of abdominal pain, and
uninten-tional maltreatment before the physician is
con-sulted.” As you know, a couple of generations ago,
or more, there was a huge public campaign raised
against giving cathartics to children with abdominal
pain. Surgeons were particularly active in
this-among them, Mont Reid in Cincinnati. One would
think that children are brought to physicians much
earlier than they were in those days. How, then, do
we explain the persistence of a 50% or 60% incidence
of ruptured appendices. My own guess is that it has
to do with the mechanics of pediatric practice
to-day. A long time ago, I occasionally took calls for
practicing pediatricians and found no particular
difficulty in doing that. I was much younger, for one
thing. Today, I should be paralyzed with fear to be
at the pediatrician’s end of his morning telephone
hour. A pediatrician is likely to have a large panel
of patients, scattered over a sufficiently wide area
so that it is impossible for him to visit patients who
might, or might not, require a visit, difficult for the
patients to come in to the office, and difficult for
doctor and child to have the patient sent to the
hospital. So far as I know, no one has done a study
at the Children’s Hospital of Pittsburgh, or any
other institution, to see whether there is any
clus-tering of ruptured appendices by pediatrician, or by
type of practice, by given pediatric office hours, or
whatever. I am mindful that when, for instance, one
discusses any kind of complication in surgery, the
chances are that no one at the given staff conference
wifi have had it, but all have seen this happen in
the practice of other people, although the national
statistics are that it happens, let us say, in 5% or 8%
of all cases, “but it never happens to us.” I am
always amazed by the remarkably accurate instinct
by which good pediatricians know which patients
should be brought in promptly and which mother
needs only to be reassured.; but even bringing them
in “promptly” given that the symptoms have
at-ready been going on for six, eight, ten, or more
hours, during the night, let us say, and the next
convenient time for pediatrician and mother to get
together may be another three or four hours,
pro-longs the period before operation is undertaken.
Medicine has other, and perhaps, graver, problems
to deal with, and I do not know that we have yet
studied the nature of this problem. I would suggest
that it would be worthwhile to study several
hundred consecutive cases of appendicitis
prospec-tively by detailed history taking from parent and
from physician to see where the delay arises and
how it can be prevented. The difference between an
overnight or even less than 24-hour stay for a
straightforward appendectomy on the one hand,
and a week or two in the hospital on antibiotics,
nasogastric suction, continuous intravenous
fluids-and the possible consequences-is just too
great for us to permit the existing situation to go
on. The fact that delay is not likely to be lethal
would have been pleasing to our predecessors, but
should be no justification today for not minimizing
the nonfatal consequences of procrastination.
REFERENCES
1. McBurney C: Experience with early operative interference
in cases of disease of the vermiform appendix. NY Med J, Dec 21, 1889, p 676
2. Richardson MH: Appendicitis. Trans Am Surg Assoc 17:72,
1899
3. Deaver JB: In discussion of Richardson MH. Trans Am SurgAs.soc 17:72, 1899
4. Harte RH: In discussion of Richardson MH. Trans Am Surg Assoc 17:72,1899
5. Balfour DC: In discussion of Jopson JH, and Pfeiffer DB.
Trans Am Surg Assoc 40:301, 1922
6. Lehman EP, Parker WH: The treatment of intraperitoneal
abscess arising from appendicitis. Trans Am Surg Assoc
56:345, 1938
7. Coller FA: In discussion of Lehman EP, and Parker WH. Trans Am Surg Assoc 56:345, 1938
8. Horsley JS: In discussion of Lehman EP, and Parker WH. Trans Am Surg Assoc 56:345, 1938
9. Graham RR: In discussion of Lehman EP, and Parker WH. Trans Am Surg Assoc 56:345, 1938
10. Penberthy GC, Benson CD, Weller CN: Appendicitis in infants and children: A fifteen-year study. Trans Am Surg Assoc 60:945, 1942
1 1. Ladd WE: In discussion of Penberthy GC, Benson CD, and
Weller CN. Trans Am Surg Assoc 60:945, 1942
12. Schullinger RN: Observations on mortality from acute
ap-pendicitis at a university hospital. Trans Am Surg Assoc
65:68, 1947
13. Hawk JC, Jr, Becker WF, Lehman EP: Acute appendicitis. III. An analysis of one thousand and threecases. Trans Am Surg Assoc 68:408, 1950
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