REPORT OF A CASE OF GANGRENOUS APPENDICITIS, FROM THE SERVICE OF PROF. R. WINSLOW.

By C. C. Smink, '09,

Senior Medical Student.

In selecting a case I have not taken one that is a surgical curiosity, or at all an unusual one, but I have taken this because it is just in these cases that a doubt sometimes exists as to the treatment when diagnosed, and often the condition of the appendix and surrounding peritoneum is in doubt, even if a diagnosis of trouble originating in the appendix is made.

History of Case--Patient, a boy, L. W., age XXIX9 years, schoolboy; admitted December 26, 1908, with a diagnosis of appendicitis.

Family History--Parents well; one brother died in infancy, cause unknown; two brothers living and well; only history of any family disease is tuberculosis in one uncle; no rheumatism, syphilis, gout, haemophilia or other disease bearing on the case.

Past History--Measles at 5 years, with uneventful recovery; whooping-cough at 6, no complications; badly burned two years ago; has had "indigestion" (?) since he was 3 years old; pain but no tenderness during these attacks; treated by different physicians and got better for a time; no history of scarlet fever, influenza, pneumonia, typhoid or other disease of childhood.

Habits--A normal child.

Present Illness--On 20th of December, 1908, patient came home from church complaining of pains in the right side. This was Sunday. Next day he complained of severe pain all over abdomen, but on Tuesday these became localized in the right lower quadrant of the abdomen. Had some fever. Bowels constipated. No nausea or vomiting. There was a localized tenderness in the right lower quadrant from the start. Pains got better on Friday, but temperature and pulse still stayed up, and patient came into hospital on Saturday, December 26. The unusual feature was that there was no nausea or vomiting. It is also to be noted that the pain subsided suddenly on the 24th. The child entered hospital on the 26th, and on entrance the whole right side was rigid, while the left side was comparatively soft. A lump could be felt in the appendical region, the centre of which was above McBurney's point. Temperature was 99 and pulse 78. The leucocyte count, however, was 30,200; urine negative.

Child was put to bed; an ice cap placed on the abdomen. Liquid diet. The next day, December 27th, leucocytes stood at 35,200. Temperature unchanged, but the pulse had risen to 110 beats. A hypodermic of morphine and atropine was given, and patient taken to the operating room, anesthetized, and abdomen cleaned for an aseptic (if possible) operation.

Prof. Winslow made an incision in the abdominal wall, well out toward the crest of the ilium, using the gridiron incision. The caecum was found and pulled over toward the middle line, and in looking for the appendix, which was supposed to be behind the caecum, a great quantity XXXof pus was found. This nasty smelling, grayish pus welled up into the wound and was sponged away. Several pieces of mucous membrane and presumably the tip of the appendix were found in the pus. Also several faecal secretions. The pus was sponged away and carefully a search was made for the appendix, or rather what remained of it. It was found tied down by adhesions and dissected loose. It broke away in pieces, and it was unnecessary to ligate any of the arteries of the meso appendix. The stump of the appendix close to the caecum was crushed, cauterized and ligated. No attempt was made to invert it, as the tissues would not stand it. The pus cavity was found to extend up behind the caecum and over toward the median line for some distance. The puncture, which I will refer to later, was then made in the right lumbar region, and two cigarette drains were introduced extending clear back into the bottom of the abscess cavity. Then a gauze drain was introduced into the anterior wound, and this sutured up. The wound was then dressed and the patient taken to the ward. Recovery from anesthetic without ill effects.

The next morning the patient was unable to pass his water, and had to be catheterized. Aside from this no ill effects were seen, and his temperature and pulse remained practically at the same place. At the end of 48 hours the drains and dressings were changed and the patient was doing well and the wound draining profusely. At no time was the bed elevated and at no time was a stimulant administered, with the exception of a hot normal salt enema on the day following the operation. Several times during his stay a dose of castor oil was given, but no other medication was necessary. As the dressings were reapplied and drains introduced daily the wounds were found to be granulating up, and gradually these closed, first the one in the lumbar region and then the one in the abdomen. By the tenth day a normal temperature was present, and he sat up on the twelfth.

The child went on to an uneventful recovery, and went home on January 21st fully cured.

This was undoubtedly one of those cases of gangrenous appendicitis where, owing either to the intensity of the infection or to a thrombosis of the vessels supplying the appendix, the vitality of the tissues is lost and gangrene results. Now, "even in this, the gravest form of appendicitis, the general peritoneal cavity is often protected against infection by walling off the pus, and the XXXIappendix, detached in the form of a slough, is often found on opening the localized abscess." But "in other cases there is from the beginning the symptoms of peritoneal sepsis and peritonitis."

Now, it seems to me that a great deal depends on the kind of infection--or, rather, the kind of organism infecting--and often the difference between a localized abscess and a general peritonitis is really the difference between a colon and a streptococcus infection. Again, should a general peritonitis develop, I have noticed from a number of cases in the wards that the prognosis practically depends on the organism, although we all know that a general peritonitis is a mighty grave condition, no matter what it is due to.

Another point in favor of the child was the fact that the gangrenous process seemed to start in the tip of the appendix, and it seems that when it starts there, there is greater likelihood of localization, and when it starts in the base a greater likelihood of general peritonitis.

I said that there was often doubt as to the condition in the abdomen in these cases. Now, there can be no doubt that the two main points in the diagnosis of a localized abscess are tumor and an aggravation of the symptoms present. But this case exemplified the fact that there may be cases where there is no aggravation of symptoms, and in a great many cases it may be impossible to feel the tumor until it has become very large, owing to its situation, viz., post caecal. Even in this case, from which a great quantity of pus was evacuated, there was no absolute certainty of finding pus on opening the abdomen, although it was suspected strongly.

I have seen a patient walk into the hospital on Sunday with a temperature of 100 and a pulse of 99, and when the abdomen was opened on Monday morning a most virulent form of general streptococcus peritonitis was found, from which the patient died the next day. It is said that it is much better to depend on the pulse and its variations than on the temperature.

I would like to call attention to several points in the treatment of this case also.

First, the place of incision was, as I said, well up towards the iliac crest, and not in the time-honored McBurney point. The wisdom of this is self-evident.

Second, the care used in not breaking up the wall of the abscess formed by the peritoneum.

XXXIIAlso, the fact that the appendix was carefully dissected up and tied off and allowed to heal by itself, obviating, as much as possible, the danger of a faecal fistula. The older books advised evacuating the abscess and leaving the appendix to slough off, and, while I have seen seven cases where this method was used and not a single faecal fistula, yet it seems to me the more rational treatment to remove the offender, as I have also assisted in three operations where the appendix was removed at the second operation. That is, an operation supposedly an appendectomy was done, and later, at a subsequent period, the diseased appendix was found still causing the same old trouble.

Again, the use of the lumbar puncture, so as to drain the abscess cavity from its very bottom. I wonder this is not done oftener, as it appeals to me as being a most sensible thing.

Then the abscess cavity was sponged out with gauze, and not washed out with the antiseptic fluid that books advise, thus spreading bacteria all over the peritoneal cavity, and really doing no good. Nature was allowed to throw off such things as she deemed necessary, an avenue of escape having been provided.

And, lastly, the omentum was found and brought down, covering in the cavity as much as possible, and thus aiding in the walling off process.