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Applications of Artificial Intelligence in
Mining and Geotechnical Engineering
This page intentionally left blank
Applications of Artificial
Intelligence in Mining
and Geotechnical
Engineering

Edited by

Dr. Hoang Nguyen

Hanoi University of Mining and Geology, Hanoi, Viet Nam

Prof. Xuan-Nam Bui

Hanoi University of Mining and Geology, Hanoi, Viet Nam

Prof. Erkan Topal

Mining Engineering, WA School of Mines, Faculty of Science and
Engineering, Curtin University, Bentley, WA, Australia

Assoc. Prof. Jian Zhou

School of Resources and Safety Engineering, Central South University,
Changsha, China

Prof. Yosoon Choi

Pukyong National University, Busan, Republic of Korea

Prof. Wengang Zhang

School of Civil Engineering, Chongqing University, Chongqing, China
Elsevier
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ISBN: 978-0-443-18764-3

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Publisher: Candice Janco

Acquisitions Editor: Jennette McClain
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Production Project Manager: Paul Prasad Chandramohan
Cover Designer: Miles Hitchen
Typeset by STRAIVE, India
Contents

Contributors xvii
Editors’ biography xxiii
Preface xxvii

1. The role of artificial intelligence in smart

mining
Yosoon Choi and Hoang Nguyen
1. Industry 4.0 and smart mining 1
2. Implementation levels of a smart mining site 2
3. Role of artificial intelligence in smart mining 4
4. Future perspectives 5
Acknowledgments 5
References 5

2. Application of artificial neural networks

and UAV-based air quality monitoring sensors
for simulating dust emission in quarries
Long Quoc Nguyen, Luyen K. Bui, Cuong Xuan Cao,
Xuan-Nam Bui, Hoang Nguyen, Van-Duc Nguyen,
Chang Woo Lee, and Dieu Tien Bui
1. Introduction 7
1.1 Motivations 7
1.2 Related works 8
1.3 Contributions 9
2. Proposed UMS-AM system 9
2.1 UAV platform 9
2.2 Sensor networks 10
3. Study site 14
4. Data monitoring measurement and methodology 15
4.1 Air quality monitoring measurement 15
4.2 Multilayer perception neural network 16
5. Results 17
6. Conclusions 21
Conflicts of Interest 21
References 21

v
vi Contents

3. Application of machine learning and metaheuristic

algorithms for predicting dust emission (PM2.5)
induced by drilling operations in open-pit mines
Xuan-Nam Bui, Hoang Nguyen, Yosoon Choi,
Erkan Topal, and Tuan-Ngoc Le
1. Introduction 23
2. Methodology 25
2.1 Gradient boosting machine (GBM) 25
2.2 Differential evolution (DE) algorithm 27
2.3 Particle swarm optimization (PSO) 28
2.4 Integration of DE, PSO and GBM model 30
2.5 Performance metrics for evaluation 33
3. Data acquisition and preparation 33
4. Results and discussion 36
5. Conclusion 40
Acknowledgments 41
References 41

4. Deep neural networks for the estimation

of granite materials’ compressive strength
using non-destructive indices
Danial Jahed Armaghani, Athanasia D. Skentou,
Mehdi Izadpanah, Maria Karoglou, Manoj Khandelwal,
Gerasimos Konstantakatos, Anna Mamou,
Markos Z. Tsoukalas, Basak Zengin, and
Panagiotis G. Asteris
1. Introduction 45
2. Granite materials through history—A short overview 47
3. Materials and methods 49
3.1 Artificial neural networks 49
3.2 Experimental database 52
3.3 Performance indexes 53
4. Results and discussion 55
4.1 Splitting of database datasets 55
4.2 Hyperparameters of ANN models used in this study 60
4.3 Assessment of the trained and developed ANN models 60
4.4 Prediction accuracy comparisons 64
5. Limitations and future works 67
6. Conclusions 67
References 68
 Contents vii

5. Estimating the Cd2+ adsorption efficiency

on nanotubular halloysites in weathered
pegmatites using optimized artificial neural
networks: Insights into predictive model
development
Mark A. Engle, Hoang-Bac Bui, and Hoa Anh Nguyen
1. Introduction 75
2. Materials description 77
3. Artificial neural network 80
4. Optimization algorithms used 81
4.1 Slime mold algorithm 81
4.2 Particle swarm optimization 82
4.3 Differential evolution 83
5. Framework of optimized artificial neural networks 84
6. Estimation of Cd2+ adsorption efficiency of halloysite 84
7. Discussion 85
8. Conclusion 92
Acknowledgments 93
References 93

6. Application of artificial intelligence in predicting

slope stability in open-pit mines: A case study
with a novel imperialist competitive
algorithm-based radial basis function neural
network
Hoang Nguyen, Xuan-Nam Bui, Yosoon Choi,
and Erkan Topal
1. Introduction 97
2. Methodology 98
2.1 Radial basis function neural network (RBFNN) 98
2.2 Imperialist competitive algorithm (ICA) 99
2.3 Proposing the ICA-RBFNN model 99
2.4 Model assessment metrics 100
3. Application 101
3.1 Data preparation 101
3.2 Model development 102
4. Results and discussion 104
5. Conclusion 109
Acknowledgments 109
References 109
viii Contents

7. Application of cubist algorithm, multi-layer

perceptron neural network, and metaheuristic
algorithms to estimate the ore production
of truck-haulage systems in open-pit mines
Sebeom Park, Yosoon Choi, Hoang Nguyen, Erkan Topal,
and Xuan-Nam Bui
1. Introduction 113
2. Dataset used 114
3. Methodology 117
3.1 Selection of input variables using the cubist algorithm 117
3.2 Multi-layer perceptron neural network 118
3.3 Metaheuristic algorithm for optimizing the multi-layer
perceptron 118
4. Results and discussions 120
5. Conclusion 127
Acknowledgments 128
References 128

8. Application of artificial intelligence in estimating

mining capital expenditure using radial basis function
neural network optimized by metaheuristic algorithms
Erkan Topal, Nguyen Thi Kim Ngan, Xuan-Nam Bui, and
Hoang Nguyen
1. Introduction 131
2. Methodology 132
2.1 Radial basis function neural network (RBFNN) 132
2.2 Metaheuristic algorithms 133
2.3 Proposing the metaheuristics-based RBFNN models for
estimating CAPEX 137
2.4 Performance metrics for evaluation 138
3. Data preparation 139
4. Results and discussions 140
5. Conclusions 145
Acknowledgments 146
References 146

9. Application of deep learning techniques for

forecasting iron ore prices: A comparative study of
long short-term memory neural network and
convolutional neural network
Hoang Nguyen, Yoochan (Eugene) Kim, and Erkan Topal
1. Introduction 149
2. Methodology 151
2.1 Long short-term memory neural network (LSTM) 151
2.2 Convolutional neural network (CNN) 153
 Contents ix

3. Dataset used 155

4. Results and discussion 158
5. Conclusion 161
Acknowledgments 162
References 162

10. Optimization of large mining supply

chains through mathematical
programming
Luan Mai and Zenn Saw
1. Overview 165
1.1 Mining supply chain 165
1.2 Optimization using mathematical programming 167
1.3 Solvers 169
2. Modeling challenges 170
3. Mining companies applying advanced analytics 172
4. Optimization model 173
4.1 Indices and sets 173
4.2 Parameters 174
4.3 Decision variables 174
4.4 Objective function 174
4.5 Constraints 174
5. Case study 178
5.1 Simplified operations of the equipment network 178
5.2 Results and discussions 179
6. Conclusions 182
References 182

11. Underground mine planning and scheduling

optimization: Opportunities for embracing machine
learning augmented capabilities
Prosper Chimunhu, Erkan Topal, Ajak Duany Ajak, and
Mohammad Waqar Ali Asad
1. Introduction 183
2. Applications of machine learning in mine planning
and scheduling 185
2.1 Accuracy of schedule parametric inputs 187
2.2 Symbiotic resemblance of model to production
operations (model framing effectiveness) 188
2.3 Suitability of the optimization objective function 190
2.4 Dynamic capability of models to adjust to changing
operating environments 192
3. Conclusions 193
References 193
x Contents

12. Application of artificial intelligence in distinguishing

genuine microseismic events from the noise signals in
underground mines
Roohollah Shirani Faradonbeh,
Muhammad Ghiffari Ryoza, and Mohammadali Sepehri
1. Introduction 197
2. Database and statistical analysis 199
3. Methods 201
3.1 Meta-heuristic algorithm 201
3.2 Linear discriminant analysis 203
3.3 Model construction 203
3.4 Classification performance 209
4. Summary and conclusions 212
Appendix 212
References 219

13. The implementation of AI-based modeling and

optimization in mining backfill design
Hakan Basarir, Ehsan Sadrossadat, Ali Karrech,
Georg Erharter, and Han Bin
1. Introduction 221
2. The use of AI in backfill design 222
3. Case studies 224
3.1 Predictive modeling practice 224
3.2 Optimization practices 233
4. Conclusions 246
References 247

14. Application of artificial intelligence in predicting

blast-induced ground vibration
Clement Kweku Arthur, Ramesh Murlidhar Bhatawdekar,
Victor Amoako Temeng, George Agyei, and
Yao Yevenyo Ziggah
1. Introduction 251
2. Case study 252
3. Methodology 254
3.1 Particle swarm optimization 254
3.2 Backpropagation neural network 255
3.3 Support vector machine 255
3.4 Empirical techniques 256
3.5 Development of various models 257
3.6 Statistical evaluation of model performance 258
4. Results and discussion 259
4.1 PSO results 259
4.2 BPNN and PSO-BPNN models formed 260
4.3 SVM and PSO-SVM models formed 261
 Contents xi

4.4 Empirical models formed 261

4.5 Comparison of all formed models for the prediction
of blast-induced ground vibration 262
5. Conclusion 266
References 266

15. Application of an expert extreme gradient

boosting model to predict blast-induced
air-overpressure in quarry mines
Biao He, Danial Jahed Armaghani, Sai Hin Lai,
and Edy Tonnizam Mohamad
1. Introduction 269
2. Background of case study 272
2.1 Study site 272
2.2 Data collection 272
3. Methodology 275
3.1 Extreme gradient boosting 275
3.2 Bayesian optimization 276
3.3 Optimized extreme gradient boosting model 277
4. Results and discussion 279
4.1 Evaluation criteria 279
4.2 Performance of developed models 280
4.3 Importance analysis 284
5. Conclusions 285
Acknowledgments 286
References 286

16. Application of artificial intelligence in predicting

rock fragmentation: A review
Autar K. Raina, Rishikesh Vajre, Anand Sangode,
and K. Ram Chandar
1. Introduction 291
2. Blasting and fragmentation 295
3. Blastability in traditional literature—The empirical
approach 296
4. Use of AI in blastability 299
4.1 Artificial neural networks for predicting rock
fragmentation 301
4.2 Genetic algorithms for predicting rock
fragmentation 302
4.3 Machine learning for predicting rock fragmentation 302
4.4 Hybrid approaches for predicting rock
fragmentation 303
5. Challenges and future directions 307
6. Conclusion 309
Acknowledgments 310
References 310
xii Contents

17. Underground stope dilution optimization

applying machine learning
Hyongdoo Jang and Erkan Topal
1. Introduction 315
2. Applications of machine learning in underground
stope dilution optimization 317
2.1 Feature range and selection 318
2.2 Studies applied AI methods 321
3. Conclusions 322
References 323

18. Applying a novel hybrid ALO-BPNN model

to predict overbreak and underbreak area
in underground space
Chuanqi Li, Daniel Dias, Jian Zhou, and Ming Tao
1. Introduction 325
2. Methodologies 326
2.1 Backpropagation neural network (BPNN) 326
2.2 Ant lion optimizer (ALO) 327
3. Data preparation and performance evaluation 328
4. Results and discussion 331
4.1 Developing a hybrid ALO-BPNN model for
predicting overbreak and underbreak area 331
4.2 Comparation performance of OUA
prediction 333
4.3 Sensitively analysis 339
5. Conclusion and summary 339
References 340

19. Fragmentation by blasting size

prediction using SVR-GOA and SVR-KHA
techniques
Enming Li, Jian Zhou, Rahul Biswas, and
Zahir Elharith MohammedElamein Ahmed
1. Introduction 343
2. Data analysis and pre-processing 344
3. Method 351
3.1 Support vector regression 351
3.2 Grasshopper optimization algorithm (GOA) 351
3.3 Krill herd algorithm (KHA) 353
4. Model development and discussion 354
5. Conclusion 357
References 358
 Contents xiii

20. Application of machine vision in two-dimensional

feature characterization of rock engineering
Jiayao Chen, Dingli Zhang, Qian Fang, Hongwei Huang,
and Anthony G. Cohn
1. Introduction 361
2. Rock mass information acquisition method 362
3. Traditional image algorithms 365
4. Deep learning algorithms 367
4.1 Classification and detection of lithology of rock mass 368
4.2 Analysis of rock mass block and particle size 369
4.3 Analysis of rock fracture 371
4.4 Analysis of other rock mass parameters 373
5. Conclusion 375
References 375

21. Groundwater potential assessment in Dobrogea

region of Romania using artificial intelligence and
bivariate statistics
Romulus Costache
1. Introduction 379
2. Study area 381
3. Data 381
3.1 Wells inventory 381
3.2 Groundwater predictors 382
4. Methods 385
4.1 Multicollinearity assessment 385
4.2 Weights of evidence (WOE) 385
4.3 Support vector machine (SVM) 385
4.4 ROC curve for validation 386
5. Results and discussion 387
5.1 Multicollinearity assessment 387
5.2 Weights of evidence 388
5.3 Groundwater potential 390
5.4 Results validation 391
6. Conclusions 391
References 395

22. Application of artificial intelligence techniques for the

verification of pile capacity at construction site: A
review
Chia Yu Huat, Danial Jahed Armaghani, Ehsan Momeni,
and Sai Hin Lai
1. Introduction 397
2. Background of soft computing 399
xiv Contents

2.1 Artificial neural network (ANN) 401

2.2 Support vector machine (SVM) 401
2.3 Decision tree (DT) 403
2.4 Genetic programming and gene expression programming
(GP & GEP) 405
3. Application of AI for pile capacity prediction 405
3.1 Base artificial intelligence (AI) models 406
3.2 Hybrid AI models 409
4. Discussion 409
5. Future perspective 413
6. Conclusion 414
References 415

23. Landslide susceptibility in a hilly region of

Romania using artificial intelligence and
bivariate statistics
Romulus Costache
1. Introduction 419
2. Study area 420
3. Data 421
3.1 Landslide inventory 421
3.2 Landslide predictors 421
4. Methods 425
4.1 Frequency ratio (FR) 425
4.2 Multilayer perceptron 425
4.3 ROC curve for results validation 425
5. Results and discussions 426
5.1 Frequency ratio (FR) analysis 426
5.2 Landslide susceptibility mapping 429
5.3 Results validation 432
6. Conclusions 432
References 434

24. Spatial prediction of bridge displacement using deep

learning models: A case study at Co Luy bridge
Thai Ha Vu, Ngoc Quang Vu, and Nguyen Van Thieu
1. Introduction 437
2. Study area and data used 439
2.1 Co Luy bridge 439
2.2 Data used 440
3. Methods 440
3.1 Long short-term memory (LSTM) 443
3.2 Gated recurrent unit (GRU) 445
Other documents randomly have
different content
 McBurney had assisted Sands in a large number of cases, and in 1889
published his classical paper with an account of “The First Recorded Case
where an Acutely Inflamed Appendix had been Removed while Full of Pus.”
In the same year Weir also published an elaborate paper, making similar
recommendations. It is not necessary to follow the subject later than the
year 1889, since to it every surgeon of note has probably contributed.

Anatomy.—The vermiform appendix is an embryonic relic, and,

like all such remains, is not merely superfluous, but
often troublesome. That at some time it may have had an ordinary
function is not to be denied; that now, in quadrupeds at least, it has
one cannot be successfully maintained. Its past importance may,
however, be perhaps indicated by the fact that in the ostrich, for
instance, it is said to assume a length of six feet. Because of its
relatively wide variations in size, length, and emplacement, as well
as because of its mesenteric and other anatomical arrangements, its
affections are often complicated and variable in the symptoms they
produce. The appendix is, in fact, a miniature intestinal tube, having
the same structure as the small intestine, though but greatly
reduced. Its average length should be 8 to 9 Cm., the shortest on
record being 1 Cm., and the longest perhaps 24 Cm. Its average
gross diameter should be that of a No. 16 French catheter, but it may
be found 1.5 Cm. in size. The average diameter of its lumen should
be 1 to 3 Mm. The appendicular artery is given off from the right colic
branch of the ileocolic artery, and it ordinarily divides into four or five
branches, according to the length of the appendix and the extent of
its mesentery. It derives its nerve supply from the superior
mesenteric plexus of the sympathetic ganglia, which itself is
connected with the right pneumogastric, this fact explaining many of
the reflexes accompanying its diseases. In it lymph abounds and
lymph follicles are numerous. Around its neck, as around the origin
of every other embryonic canal (as Sutton has shown), is found a
collar of lymphoid tissue corresponding in structure to that seen in
the pharynx. This tissue is inflammable, and succumbs easily to
infection. Hence probably the apparent ease with which infection and
gangrene occur in this locality. The position of the appendix is
variable, and depends in effect on the development of the cecum
and the degree of its rotation during this process. Its most frequent
location (40 per cent.) is behind the cecum. In 30 per cent. of cases
it occurs on its anterior surface or just at its lower end. It may lie as a
free pouch with a loose mesentery, movable in the abdominal cavity,
or it may be essentially a retroperitoneal affair not only not free, but
even difficult to find. In direction it may vary correspondingly. Thus it
may lie behind the colon, perhaps pointing straight upward toward
the liver; it may hang in the pelvis, it may point toward the sacrum, or
it may coil up anteriorly; and, according to the extent and freedom of
its mesentery, in any of these locations, it may either be unattached
and movable or quite bound down. Again, it may lie nearly straight or
it may be kinked, bent, or coiled. It is necessary that the surgeon
appreciate these possible variations, for they account for vagaries in
symptomatology. In brief it should lie in the iliac fossa, at least, and
to the outer side of the iliac vessels, but it may hang over into the
pelvis in 20 to 25 per cent. of cases, or its tip may rest in a pocket or
even in a subcecal fossa. In other words, it may be found in almost
any attitude or position, these variations being explainable by
peculiarities of fetal development. Furthermore it may even have its
own diverticula, as has been recently shown. Normally it should be
practically empty, save perhaps for a little muddy mucus. Very
frequently, however, it contains fecal matter, and upon this fact
depends much of its importance. If from retained fecal matter fecal
concretions gradually result, then these become irritants and may
produce either appendicular colic or may predispose to acute
infection. Upon the retention of fecal contents should depend also a
miniature peristalsis, and imitation of what goes on in the intestine
above, in the production of a genuine appendicular colic. How
annoying, painful, or even disabling this may be may be learned from
the history of many a patient. On the other hand the appendix may
become gradually occluded or obliterated, in whole or in part. If this
process begin at its distal end and involve the entire tube it might be
considered a fortunate occurrence for the patient. If, however, it be
due to previous inflammation, or to subinvolution of the previous
process, and if fecal concretions be thus imprisoned, it is hardly
desirable and will frequently lead to trouble. More or less occlusion
occurs in probably at least one-fourth of mankind.
 Like the bowel above, the appendix may suffer in various as well
as in similar ways. Thus in it may be seen pathological conditions
which involve the bowel proper. Tuberculosis and actinomycosis may
even occur here as apparently primary lesions, while cysts have
been discovered within its walls, and such tumors as fibromyomas or
primary adenocarcinomas are also met here. I have seen three or
four instances of primary cancer of the appendix, and have now
living one patient from whom six years ago I removed an appendix
and adjoining portion of the cecum involved in most distinct cancer.
Again, the appendix participates in certain hernias and has been
found in instances of strangulated or non-strangulated inguinal and
femoral hernia, and has been seen also in cases of umbilical hernia.
Twice I have found it in the inguinal canal and once in the femoral.
Furthermore when diseased the appendix, like the bowel, may
contract adhesions to certain viscera, while it is now well known that
it may attach itself to the kidney, the bladder, the right ovary, the
tubes, or the uterus. This is of more than mere passing interest, for
by such adhesions cases are not only surgically complicated, but
diagnosis is made difficult, because of associated symptoms pointing
to the organ thus involved.
Foreign Bodies in the Appendix.—Foreign bodies are
occasionally found. This
expression refers not merely to the fecal concretions above
mentioned, which are practically small enteroliths. Thus, Kelly has
mentioned cases in which ordinary pins have been found in this
location, two of these cases being my own. In one instance I found
the appendix to contain a round-worm at least three inches in length,
and other intestinal parasites have been found by other observers.
The laity have been greatly impressed by the reputed frequency with
which grape and other seeds are found in the appendix, these
figuring in their eyes as exciting causes of disease. In truth seeds
are seldom found, that which has been mistaken for them being fecal
concretions of various sizes and degrees of density. I have found
actual seeds two or three times, but probably not oftener.
Bacteriology of Appendicitis.—Acute appendicitis being
essentially an acute infection one
inquires naturally which are the organisms most commonly involved.
Answer to this question should be sought rather in the text-books on
pathology, and should be summarized here by simply saying that the
colon bacillus is perhaps more often found in connection with these
cases than any other one organism. Streptococci and staphylococci
rank perhaps next in frequency, while the pneumococcus, the
capsule coccus, and all of the other pyogenic forms may be present,
either as contaminations or in almost pure cultures. The fauna and
flora of the intestinal tract afford ample opportunities for
contaminations with many forms of microbes. If pus found here be a
pure culture of any one organism it is most often of the colon variety,
which is known to vary much in virulence, even when occurring
alone. Mixed infections, however, are more predominant and more
serious, especially in proportion as the more active pyogenic
organisms appear in greater numbers. The bacteriology of
appendicitis is then of great pathological interest, but concerns the
surgeon very slightly, unless he have to do with some peculiar form,
such as pyocyaneus, or a particularly virulent streptococcus.
PLATE LI
 Illustrating Various Degrees of Involvement of
Appendix Vermiformis. (Richardson.)
A. Chronic, recurring.
B. Chronic, much thickened.
C. Acute, with necrosis and rupture.
D. Showing necrosis of mucous membrane.
E. Gangrene and perforation, permitting fecal extravasation.
F. Total gangrene without perforation.

Appendicular Colic.—Sufficient has been said above regarding

the appendix as a miniature intestine, its
outlet guarded by the little valve of Gerlach, to afford an anatomical
reason why conditions even in the larger bowel should be imitated
here. Some writers have not placed as much stress upon
appendicular colic as I would here. One sees many instances of it if
he will only recognize it, the frequency of its occurrence not only
disturbing the comfort of patients, but keeping ever before their
minds the necessity for operation. An absolutely empty appendix will
be free from all abnormal activity of this kind, but when a little fecal
matter has become imprisoned, and when by its long retention fecal
concretions have formed, they may give rise to considerable
disturbance without actually producing inflammation, the former
being due to the spontaneous effort of the appendix to expel them.
This effort may be excited by other conditions in the bowel adjoining,
but by itself it may be the essentially relatively violent muscular effort
which produces pain and is followed by soreness. That not a few
cases of acute appendicitis commence with an appendicular colic is
extremely probable, and that it may occur at frequent intervals and
never pass the colicky stage is equally true. Appendicular colic, then,
may be a precursor of an infectious appendicitis, acting as a
predisposing cause, or either may occur independently of the other.
 Indications of this form of colic are frequent, viz., nagging pains in
the region of the cecum, which may last a few moments or a few
hours and then subside, leaving a tenderness which persists for a
day or two, after which the patient seems to be free for a longer or
shorter interval, to suffer again and again in the same way. These
attacks may be accompanied by some nausea, will be found
frequently associated with whatever may have disturbed ordinary
intestinal activity, and may even produce a mild degree of fever,
which latter is partly due to mental perturbation and partly to a mild
degree of toxemia, the latter being possible in connection with
abnormal appendicular activity, as the appendix itself is a closed sac
and the very materials which it is trying to expel may furnish the
toxins.
It is difficult to distinguish between appendicular colic and mild
attacks of catarrhal appendicitis. The transitory nature of the former
is its particular diagnostic feature, coupled with absence of all lasting
indications.
The following would seem the simplest working classification of
lesions of the appendix.
Catarrhal. Endo-appendicitis.
Hyperplastic.
Diffuse. Parietal or interstitial. -
Obliterative.
Intertubular.
A. Acute. - Purulent. - Intramural.
Peri-appendicular.
Any of these may lead to
Gangrenous or
Perforative lesions.
B. Subacute. Recurrent or relapsing.
C. Adhesive or obliterative.

Almost any of the above forms may be associated with diseases of

other abdominal viscera, as, for example, with typhoid. Thus out of
119 autopsies on typhoid patients 19 showed changes in the
appendix corresponding to those produced by the typhoid organisms
in other portions of the intestines. (Kelly.) Of 3770 autopsies on
tuberculous patients tuberculous lesions were noted in the appendix
in 44 instances. The appendix may also become involved with any
form of ileocolitis, either in the young or in the adult. Again an
infection of the right tube and ovary may easily extend to and involve
the appendix, just as infection may travel in the opposite direction.
(See Plate LI.)
Before discussing the causes of this condition it is advisable to
take a comprehensive view of the entire subject in its pathological
relations. As Dieulafoy has shown, appendicitis is the consequence
of the transformation of the hollow conduit into a closed cavity,
whose length and narrowness make it liable to such changes, for
which various causes are to be assigned: for example, the formation
of calculi or concretions which are quite comparable to renal or
biliary and which lead to a true appendicular lithiasis. There is even
reason to believe that a calculous appendicitis may be hereditary
and belong to the patrimony of gout. At other times it is the
consequence of local infection, followed by tumefaction, and
corresponding to obstruction of the Eustachian or the Fallopian
tubes. Again it results from slow, progressive fibrous alterations or
from the strangulations due to twisting or formation of adhesions. In
any event the closed cavity varies in size and shape, and does not
necessarily lead to self-destruction unless the bacteria thus pent up
are sufficiently virulent. At all events the attack declares itself only
when the cavity is actually closed, and it is then that imprisoned
bacteria, previously harmless, multiply and intensify their virulence,
as they do in a blocked loop of bowel. At times an acute intoxication
from toxins is produced, and may be so pronounced that patients
succumb to it almost before the characteristic lesions, or any local
peritonitis, has become fairly outlined. On the other hand if retained
bacteria be but slightly virulent, or have been successfully conquered
by phagocytes, or if the canal has become pervious again, the attack
may spontaneously subside, although there is great probability of
recurrence. In many instances the infection ends in ulceration,
abscess, gangrene or perforation, all of which may give rise to
peritonitis of varying extent and severity. Germs may traverse the
walls of an affected appendix without perforation. It may then
become the direct cause of peritonitis, septicemia, or hepatic
abscess.
 Recurrent Appendicitis.—Every attack of appendicitis, no matter
how mild, predisposes to a repetition of
the trouble, in mild or in fulminating form. Every appendix once
inflamed has had its blood supply compromised and may break
down easily upon a second attack. While not every patient who has
once suffered in this way should necessarily suffer again, the
majority who have had one attack may have another. No one can be
prophetic in this regard and no one may truly assert that several mild
attacks may not be followed by another most severe. That an
appendix has been once inflamed is sufficient to justify its
subsequent removal. That it has been several times involved makes
operation next to imperative. Even repeated attacks of appendicular
colic predispose to trouble in this region. In any appendix which has
in this way frequently excited suspicion, or which gives rise to
frequently recurring though mild colicky pain and local tenderness,
especially when coupled with mild stercoremia, indications are for
removal. It may be safely laid down, then, as a rule, to which there
should be few exceptions, that any appendix which causes
frequently recurring or almost continuous trouble should be removed.
Causes.—It is impossible in any brief summary to include all the
possible causes of appendicitis. Those mentioned below
are perhaps those most commonly recognized or pronounced, yet
the list is far from complete. First of all it should be remembered that
the disease occurs in a vestigial organ, containing relatively
considerable lymphoid tissue, especially around its neck, that it is
comparatively poorly supplied with blood, and that such tissue under
such circumstances inflames easily and breaks down quickly.
Doubtless the trouble in some instances commences within the tiny
intestinal tube. At other times its originating cause lies without, as, for
instance, when its blood supply is interfered with by pressure of an
overloaded cecum, by tumors, or by violent intestinal activity; this
especially in connection with an appendix firmly anchored and not
freely movable, it being so fixed in many instances that it cannot
readjust itself easily to varying conditions. Thus an overloaded
cecum may first press upon the appendix and then by violence of
activity so displace it that it may easily succumb. Again in those
appendices which hang downward into the pelvis there is little or no
drainage by gravity, and they may easily become overloaded. A
movable kidney may also disturb the integrity of an appendix in
certain locations. Foreign bodies frequently excite pernicious activity,
especially fecal concretions, and actual calculi or miniature
enteroliths. Traumatism sustains a certain relation to some cases of
violent activity of the psoas muscles in athletes, which may upset the
circulation of appendices which lie directly upon the muscles
involved.
Many of the causes mentioned above are predisposing rather than
actual. The actual exciting causes of acute infection have mainly to
do with germ activity and with vascular supply. It is well known that
the more virulent the organisms the more acute the resulting
inflammation, and it is also well known that colon bacilli and the
ordinary pyogenic organisms vary in virulence within wide limits, and
that mixed are often more acute than simple infections. Typhoid
bacilli, tuberculous bacilli and the like vary in the same way, and, in
company with other germs, may easily light up serious disturbance.
Complications.—Of the complications which may accompany or
ensue upon appendicitis the most common are
those which involve the peritoneum, either local or general. Acute
peritonitis is to be feared not only because of its autotoxic
expressions, but because of the acute obstruction which it may
produce by gluing intestinal loops together and paralyzing their
motility. When to more or less widespread peritonitis are added
general sepsis, with all its possible complications, and such further
local expressions as cellulitis, which may be pericolic, subphrenic,
perineal, or pelvic, or phlebitis which, involving the portal system,
would soon lead to formation of hepatic abscess, it will be seen how
easily the case may become serious. Furthermore not only may the
ovary and tube suffer, but cystitis and nephritis may occur as toxic
complications, while finally, by violence of the ulcerative process, a
fecal fistula may form. This is by no means a complete list, but
includes some of the more frequent complications.
Symptoms of Acute Appendicitis.—Pain with nausea,
tenderness, and rigidity
constitute the triad of the most indicative early signs and symptoms,
each of which needs to be considered by itself.
 Pain.—Pain is at the same time an important yet variable feature. In
few other acute lesions does it vary as much in degree and location.
Generally it is referred at first to the more central portion of the
abdomen, as around the navel or between it and the right side of the
pelvis. Later it may be localized at some widely distant point, as, for
instance, far over upon the left side. Such vagaries may be held to
be due to peculiarities of emplacement of the appendix, and would
indicate that the organ will probably not be found in its most common
location, but rather extending to the left or hanging over into the
pelvis. When the appendix is attached to or lies near the bladder
there may be considerable pain in the pelvis and in the bladder. It
should be remembered that the parietal peritoneum is much more
sensitive than the visceral, and in proportion as the lesion
approaches the surface more exact information may be gathered
from location of pain. Occasionally it may be referred to the region of
the gall-bladder, or even to the chest above the diaphragm. In some
instances it is agonizing, almost from the outset; in others it is never
very severe. The rapidity of the process may be measured to some
extent by the intensity and character of the pain. When the disease
resolves slowly and kindly pain gradually subsides, but the sudden
subsidence of pain, especially without equal improvement in other
respects, is a bad rather than a good sign, indicating probably that
perforation has occurred.
Tenderness.—Tenderness is a more constant and persistent and,
therefore, a more reliable indication than pain, and, as well, less
misleading. No matter where the patient may seem to feel pain the
actual tenderness will indicate the location of the appendix itself.
Thus even if pain on the left side be severe, tenderness will not
accompany it, but will be found centred at the location of the
appendix. This is a fact of great importance. In his first paper on
appendicitis McBurney showed that the appendix is most commonly
located at a point beneath a line drawn from the umbilicus to the
anterior superior spine and one and a half or two inches away from
the latter. This has since been known as McBurney’s point. To it,
however, too much importance should not be attached, since the
appendix is often not found under this area, and tenderness may be
found at a distance two or three inches away from it. Over the
actually tender area the skin will also be hypersensitive, and this
intense hyperesthesia is also an indication of considerable value.
Rigidity and Muscle Spasm.—Rigidity and muscle spasm are to be
carefully studied, and upon them much reliance may be placed. With
the first onset of pain they may be general, but they usually become
more and more localized, unilateral, and finally limited, save in those
instances where general peritonitis has begun and is spreading. For
instance, Richardson regards it in this light: “Rigidity with distinctly
localized pain strongly suggests appendicitis; with fever it almost
proves it; with tumor it fully establishes diagnosis.” When to ordinary
abdominal rigidity is added actual muscle spasm, provoked by even
light palpation, and occurring in the rectus or one of the flat muscles
lying in close relation to the appendix, then a still more important
indication has been obtained. When true muscle spasm involves all
the abdominal musculature general peritonitis has probably begun.
Tumor.—The presence of tumor in the suspected area will nearly
always be a corroborative sign, but diagnosis should not depend
upon its presence. It is hardly to be looked for during the early hours
or perhaps days of an ordinary attack. It may be due to fecal
impaction in the cecum, to outpour of exudate, to binding together of
omentum and intestine, or to the presence of pus. If a considerable
mass can be detected within the cecum during the early hours of an
attack this should be regarded rather as an expression of
coprostasis and impaction, to which the attack itself may be due.
Tumor, therefore, is significant when present, while in some
instances its absence is still more so.
Vomiting.—Vomiting is an irregular and uncertain feature. Probably
the majority of cases begin with nausea (after the initial pain) or with
vomiting, either one without the other, or with both combined. Likely
through the course of the disease vomiting may be an occasional
disturbing element, though patients may have no nausea whatever.
Bowels.—The condition of the bowels and their behavior will
depend very much upon their actual state at the moment of attack.
Some attacks seem precipitated by violent intestinal activity; here
diarrhea or dysentery will be an early feature. Others are precipitated
rather by overloading of the cecum; in these cases constipation
would be a well-marked feature. Bowel inactivity is to some extent an
expression of bowel paralysis due to toxemia, which in some
instances is profound, in others slight.
Temperature.—The temperature is also a variable and uncertain
feature. It may be normal at first or very high. At any time it may rise
gradually or suddenly, and may subside in the same atypical way.
Taken by itself it is an unreliable feature. When, however,
temperature steadily rises the surgeon may take alarm, and if the
pulse rate goes up correspondingly the case takes on a serious
aspect. A sudden fall of temperature is almost as serious a feature
as a sudden rise. A normal or subnormal temperature may be seen
when a large amount of pus is present, or but a minimum of
disturbance may be found when operating upon a patient whose
temperature is 104°.
The Pulse.—The pulse is a more reliable guide than any obtained
with the thermometer, its rapidity being proportionate to the gravity of
the disturbance. A constantly rising pulse is a serious indication,
especially if accompanied by vagaries of temperature. Some
operators regard the pulse as a sufficient indication for operation,
holding that when it rises above 112 operation should be made. I
hold this to be a good rule, but would not have it interpreted as
indicating that operation should not be done unless the pulse attains
this figure, and believe that, no matter what the other conditions, the
final indication has arrived when the pulse goes above 112.
Abdominal Distention.—Abdominal distention may be due to gas
formation, to constipation, or may indicate the paralysis of peristalsis.
When it becomes well marked it is a serious indication, and when
toxemia is profound no sound whatever will be heard within the
bowels thus distended. It usually indicates the onset of general
peritonitis. It is unfortunate in more than one respect, since intra-
abdominal conditions are masked by it and operation complicated, it
being sometimes impossible to restore the bowel to the abdomen
without at least partially emptying it.
Jaundice.—Jaundice, when occurring, is a toxic expression,
possibly due to temporary obstruction of distended or paralyzed
bowels.
Finally the general appearance of the patient will be suggestive,
patients with serious conditions having always an anxious or
haggard facial expression, rarely moving themselves easily or freely
in bed, or smiling at anyone or anything, their faces being perhaps
somewhat flushed, their expression and action being apathetic, while
perhaps later there will be delirium with restlessness. When the face
is pinched, the eyes sunken, the nose sharp, the skin dusky, and
respirations rapid and unsatisfying, as well as of thoracic type, any
intra-abdominal infection may be regarded as serious and
unpromising.
What shall be said about the value of the blood count? It is
possible in nearly every instance to make a diagnosis of appendicitis
without the aid of the microscope, as well as even to judge of the
advisability of immediate or postponed operation. Nevertheless an
indicative differential blood count, an affirmative result of the iodine
test, or the discovery of indican in the urine, may afford positive
corroboration in cases where doubt may have existed. In reality,
however, any case which will furnish satisfactory and distinct
responses to these tests should be recognized without them. A
leukocyte count above 12,000, in connection with other indications,
is usually sufficient to justify operation. A very high leukocytosis—
e. g., above 24,000—is a matter of great importance. In the more
chronic cases the leukocytosis is but slight.
Diagnosis.—Obvious and indicative as many cases of acute
appendicitis are from the outset, there are still others
when one may be in serious doubt, even for some days, either
because patients do not clearly state their own symptoms, because
of peculiar reference of pain, or because of the co-existence of
complications, each of which may mask the other.
Colitis of adults and enterocolitis of children will produce
sometimes severe attacks of pain, with cramps and local tenderness,
that may at first mislead. There is a form of mucous colitis which is
now more generally recognized than in time past, in which diagnosis
is sometimes quite difficult. The onset is often sharp, while the right
iliac fossa may be occupied by an elongated, resistant, tender mass,
showing fecal impaction within the cecum. On the other hand the
same condition may be met in the left iliac fossa, and will thus
indicate that the sigmoid is especially at fault. In these conditions
there is often actual exudate around the inflamed bowel, and this
may even break down; it is proper then to speak of a circumscribed
colitis, and there is reason to think that in certain cases it arises from
infection of a diverticulum from the large bowel. The pain is not
infrequently complained of at the so-called McBurney point. In not a
few instances the appendix has been removed when under perfectly
natural suspicion, and found so slightly involved as to show that the
actual trouble was in the cecum rather than in the appendix itself.
Dieulafoy believes, in fact, that formerly the cecum was made too
much of and the appendix disregarded, while today these conditions
are sometimes reversed.
From gallstone disease and cholecystitis its symptoms are
sometimes quite difficult to distinguish. Especially is this true when
pain is not accurately localized, and when, on the other hand,
muscle spasm and tenderness are widespread. The previous history
of the case will give much aid in this matter, while the pain in
gallstone trouble radiates rather toward the right shoulder, in
appendicular disease toward the umbilicus or downward. When
dulness on percussion shades directly into liver dulness the gall-
bladder is naturally the more to be suspected. When patients
themselves cannot make minute distinctions in description of pain
and tenderness the condition may be difficult of recognition.
Peritonitis.—The majority of all attacks of so-called idiopathic
peritonitis spring from appendicular disease, at first and perhaps
throughout unrecognized. A condition of peritonitis, then, for which
other explanation is not found may be considered as, in all
probability, due to appendicitis whose peculiar features may have
been masked. It is not difficult to recognize a condition of general
peritonitis. The great difficulty is to ascribe its proper cause. As
already and elsewhere indicated these conditions merge into
expressions of acute obstruction which still further complicate the
case, and it is by no means infrequent to have this order of events:
an acute gangrenous appendicitis followed by local peritonitis, with
adhesions, which, becoming dense, rapidly produce obstructive
symptoms, the condition going even farther and gangrene spreading
from the appendix proper to any or all of those intestinal loops which
come in contact with the primary focus, so that when the condition is
thoroughly revealed it is found to be one of multiple gangrene of the
bowel as well as of fierce and septic peritonitis.
Gastric and intestinal ulcers with perforation are easily mistaken
for appendicitis, especially when the duodenum is involved. In at
least half of the recorded cases of perforating duodenal ulcer the
condition has been at least at one time supposed to be one of acute
appendicitis, while after perforation has occurred and the matter
which has escaped has worked its way down toward the right iliac
fossa the similarity of conditions will be all the more striking. If an
accurate history can be obtained there will probably be learned from
it that which will tend to avoid mistakes. The exceedingly abrupt and
acute onset of symptoms will also be more pronounced than in most
cases of commencing appendicitis. This is true also of the
perforations of typhoid ulcer, especially of “walking typhoid.” While
acute appendicitis during the course of typhoid is by no means
unknown, the abrupt onset of pain, rigidity, and tenderness during
the third week or later would suggest perforation very much more
than the possibility of an appendical lesion.
Acute obstruction of the bowel due to other causes than
appendicitis—e. g., volvulus or intussusception—might give rise to
symptoms which would be regarded as indicating appendicitis. This
is true also of strangulated hernias, especially the internal forms,
since there will be no excuse for failing to discover an external
strangulation of this kind. Lead colic may simulate some of the milder
and more chronic forms of appendicitis, from which it should not be
difficult to exclude it by its history, the occupation of the patient, and
the appearance of the gums.
The kidneys and ureters are sometimes so involved as to occasion
doubt. A floating kidney, with its possible crises, displaced into the
right iliac fossa, where it might be mistaken for an inflammatory
mass, might thus cause some hesitation. So also might the acutely
suppurative forms, the formation of a sudden phlegmon about the
kidney, or the entanglement of a calculus, either at the hilum or along
the ureter, produce severe pain, tenderness, and fever, which would
at first easily perplex. The pain of renal colic, however, is usually
more agonizing, beginning in the flanks and referred down along the
ureters to the genitals and the inner side of the thigh. It may also be
intense in the back, and may be accompanied by nausea and
vomiting. Renal colic is also nearly always accompanied by frequent
urination and sometimes by the appearance of blood in the urine.
With an impacted calculus at the lower end of the ureter at the level
of the appendix diagnosis may be very difficult. Here the x-rays may
afford some assistance.
Acute pancreatitis begins with intense abdominal pain that may at
first suggest appendicitis. The pain, however, is usually epigastric;
abdominal distention comes on early; vomiting may be profuse, and
the tenderness is most marked along the left costal border. There is,
moreover, a more profound prostration, sometimes accompanied by
cyanosis. An acute suppurative pancreatitis may soon be followed by
peritonitis, which when seen will so completely mask all symptoms
that diagnosis as between the two is quite impossible, but symptoms
which can be accurately localized will usually point to the upper
rather than to the lower abdomen.
Mesenteric thrombosis and embolism are rare conditions which
commence usually with fulminating symptoms and produce intense
agony, with tenderness and rigidity all over the abdomen. Their onset
is so profound that patients fall into a condition of extreme collapse
within the first few hours, and their tendency is so rapidly to the bad
that they are not likely to be mistaken for acute appendicitis.
The pelvic viscera of women also furnish acute inflammations,
such as pyosalpinx, with or without rupture, that sometimes
precipitate very acute symptoms which may point to the abdomen
rather than to the pelvis. In many of these instances the appendix is
more or less adherent to the adnexa on the right side, and infection
in either one may easily travel to the other, so that both become
ultimately involved. Local examination will reveal the existence of
pelvic conditions, in whose absence there may be justification for
inferring that the trouble has not originated in that cavity.
Ruptured extra-uterine pregnancy has been in numerous cases
mistaken for acute appendicitis. It usually begins with violent pain
and pronounced muscle spasm, with more or less shock. I have
repeatedly been called to operate for appendicitis and found the
other condition present. The operator may be prepared to find it if he
elicit a suggestive history or if a vaginal examination reveals a pelvis
more or less filled with semisolid material. Amenorrhea does not
always signify ectopic gestation, yet when doubt arises it would be
advisable to inquire carefully into the menstrual habit of the patient.
On the other hand it is known that acute appendicitis may bring on
uterine hemorrhage. When, however, the possibility of pregnancy
exists, along with a history of menstrual irregularity, or of
hemorrhages unaccounted for, and one finds within the pelvis the
uterus pushed forward or displaced, or perhaps an irregular tumor,
he may suspect the condition if not actually diagnosticate it.
A peculiarly unfortunate combination is that of acute appendicitis
occurring during pregnancy, or still worse, as I have seen it, e. g., in
a woman with a large uterine myoma, gone to about the seventh
month of pregnancy, and then suffering from an acute peri-
appendicular abscess, the whole proving more than she could
withstand.
With an appendix placed behind the cecum it will usually rest upon
the psoas muscle, where it may be disturbed by violent exercise, or
where it may lead to mistaken diagnosis either in case of acute
inflammation of the muscle itself or of acute appendicitis. When the
right limb is drawn up, and especially when all motions of the limb
give pain, we may believe at least in the participation of the muscle
in the inflammatory activity. On the other hand, an insidious psoas
abscess may give rise to a certain degree of tenderness in the right
iliac fossa, with flexion of the thigh, and gradual development of
tumor, which may be mistaken for chronic appendicitis.
The possibility of appendicitis occurring during typhoid has been
mentioned. Differential diagnosis between the two conditions will
ordinarily not be difficult when one can obtain an accurate history. In
classical appendicitis pain is always the first symptom, and
temperature rarely rises until a number of hours at least after the first
attack of pain. Even the milder typhoid cases may show tenderness
in the right iliac fossa, but one should look for the characteristic
eruption and make a Widal test. The presence of splenic
enlargement would point to typhoid, as would also the occurrence of
bronchitis, epistaxis, or headache, with perhaps albuminuria. The
most perplexing cases will be those of perforation, perhaps even of
typhoid ulcer of the appendix. In these cases acute pain will usually
indicate perforation.
Intrathoracic affections sometimes begin with or are accompanied
by severe pains which are referred to various parts of the abdomen
and cause great confusion. Thus I have repeatedly seen pneumonia,
even on the left side, regarded at least at first as acute appendicitis,
because patients referred most of their pain to the abdomen rather
than to the chest, while the abdominal muscles participated to such
an extent as to produce pronounced rigidity. Here a blood count
would scarcely help, but careful physical examination of the chest
would reveal the difficulty. Such examinations should be made when
respirations become irregular, or when the breathing is evidently in
any way embarrassed. Acute pneumonia and acute pleurisy,
especially diaphragmatic, may have then to be differentiated from
acute appendicitis.
Finally, hysteria is an element not to be disregarded in some of
these cases; not that it is likely often, if ever, to lead to serious doubt,
but that patients with the hysterical or neurotic temperament are
constantly tempted to so seriously exaggerate their complaints as to
lead to at least a more serious view regarding themselves than
circumstances justify. Thus a mild appendicular colic in a neurotic
patient may produce a disproportionate complaint, and one must be
ready to assign to hyperesthesia or exaggerated complaints their
proper value.
The symptomatology of appendicitis may then be summarized
briefly as follows: When pain comes on suddenly and is referred to
the lower part of the abdomen, or even its central region, becoming
perhaps more localized as the hours go by, is shortly followed by
nausea or vomiting, and this by general abdominal sensitiveness,
with an increasing degree of rigidity; and when temperature, which at
first is not elevated, begins to rise in from twelve to twenty hours,
then it may be held that this is a classical picture of an attack of
acute appendicitis. So strongly does Murphy, for instance, hold to
this order of events that he even questions diagnosis when
symptoms are not thus timed, and especially if vomiting precede
pain.
 When pain which has been severe subsides, and comes on afresh
after an interval of perhaps thirty-six hours, it is to be regarded as
due to fresh peri-appendicular involvement, and is an unfavorable
feature. In fact the subsidence of pain and apparent improvement
often noted do not always mean actual improvement, but may be the
forerunners of a still more dangerous condition. Thus the “perilous
calm” of appendicitis should hasten operation, or at least increase
watchfulness, rather than beget confidence. Should one rely too
much upon them and procrastinate he will find that his mortality rate
will rise accordingly. The statement elsewhere quoted in this work
that “the resources of surgery are rarely successful when practised
upon the dying,” will apply here.
There is scarcely any equally limited area of the body in which as
many varied and widely different pathological conditions may be
exemplified as in the appendix and the space immediately around it.
The mildest degree of hyperemia or vascular engorgement, the most
destructive form of inflammation, with fulminating necrosis, may here
be observed. Moreover, conditions commencing under one type may
quickly change and the whole type of an attack may within a short
time be merged from the mildest into the most severe.
In catarrhal or endo-appendicitis it is mainly the mucosa which
suffers. This may undergo merely a congestion, with increase of
discharge, and, so long as the outlet be not completely obstructed,
may be a purely temporary matter of but a few hours’ duration, or it
may extend over a few days. The purulent or more destructive forms
may commence in either of the coats of the appendix. It is no
uncommon thing to find a necrotic mucosa with a still unbroken
serosa, or a perforation of the outer coats and a hernial protrusion of
the inner, perhaps just ready to give way. In location and extent the
suppurative and destructive process may also vary. Whereas
ordinarily the distal portion, being less supplied with blood, will suffer
first, it is not uncommon to find perforation at the junction of the
appendix with the cecum, or even gangrene of a limited area of the
cecal wall itself. Again, at times, the trouble seems limited to
accumulation of pus within the appendix, i. e., an empyema of the
appendix, without great tendency to involve the structures adjoining,
and an appendix may be found containing a few drops of pus or