APPENDICITIS-A DISCUSSION OF ITS TREATMENT,

WITH REPORT OF CASES.

FELIX P. MILLER, M. D.,

MIDLAND, TEXAS.

In my study of the reports of cases and the discussions as to treatment, I am impressed with the great anomaly of pathological conditions and symptoms met with in appendicitis.

In conversation with a medical friend, a short time ago, he remarked: "I know of no disease where a single case teaches so little as does appendicitis." In reporting my cases, perhaps some new pathological curiosities may be added to the literature, while the subject of treatment will stimulate a discussion that will surely result in benefiting myself and perhaps others.

The medical student who carefully studies a text-boox description of pneumonia or typhoid fever, will always be able to recognize, with little difficulty, the main symptoms and conditions in the great majority of his cases. This can only be said in a general way of appendicitis. It is surely a disease of anomalies, especially after the first attack. No doubt the early conditions are similar, if we could get any reliable information regarding the pathology at such a time. As the hitsory of the case goes on, the conditions change, and I can say that I have never been able to tell with any degree of accuracy what was going on in the appendix or the tissues surrounding it. The symptoms do not keep pace with the pathological changes. Often, when the symptoms seem to be improving, the case suddenly goes on to death, and an autopsy reveals the fact that the symptoms were misleading. The majority of surgeons are agreed that an early operation, say within thirty-six hours, offers, by far, the best chances for the life of the patient, his future freedom from complications, and consequent bad health. The early operation also lightens the work of the surgeon and robs the dis

ease of its anomalous conditions. The mortality of appendicitis must come down if the early operation becomes settled. Those cases which have passed the time for an early operation will become a distinct class and have a variety of symptoms and many methods of treatment, but with a higher mortality and with more frequent complications following all cases that recover. Those cases that reach the interval period, certainly demand an operation, and will have a low mortality. Some surgeons have a mortality of onefourth per cent. No one who has allowed his case to go beyond the thirty-six hour period can show such a low mortality. Still, I do not say that some cases will not get better under an expectant plan of treatment. Some cases refuse operation; some are away from the proper surroundings for an operation, and some treatment must be given them. The best treatment in such cases is perfect rest, with an ice-bag applied over the appendix. The term rest is now made to include rest of the stomach and bowels from food and medicine. The colon should be emptied by enemata, and the patient can be fed by the rectum. Absolutely nothing is given by the mouth. Some cases will improve and the interval will come. Some cases will grow progressively worse. Perforation and diffuse peritonitis will occur even when the bowel is covered with icebags.

This being the case, it is our duty to do all in our power to give the patient the benefit of an early operation. The following case will show that improvement will follow the expectant plan:

R. W. C., male, age 26; cowman. On June 6, 1902, he was taken suddenly with general cramping in abdomen. Pain severe, and patient unable to walk. His friends carried him to a neighbor's house, where I saw him one hour later. Found the symptoms as typical as any case of appendicitis could be. The general cramping was followed by exquisite tenderness over McBurney's point. An ice-bag was applied over the right iliac fossa, all food and medicine was prohibited by mouth, and a hot soap-suds enema given. Operation was advised at once. Consultation was asked for, the diagnosis confirmed and we insisted upon an operation

The patient decided to take the chances, as he was away from home and wanted a more convenient time. The condition rapidly improved and in three days all symptoms were gone, save tenderness over the appendix, which remained for some time. To this day he has never had another attack. At times he talks of having the operation done, and says that he had had occasional pain in that side. His ranch is sixty miles from a physician, and some day you may hear the final report of his case. The most satisfactory time for an operation would be in the interval.

When we see a case in the early period of an attack, and some one speaks of the advisability of waiting for an interval, I always ask: "Can you guarantee that an interval will ever come?" Who would think of waiting to send in a fire-alarm when he saw a small blaze and a big smoke in a building? The following case will show the tedious convalescence, following a postponed operation:

R. O., male, age 23. In October, 1901, I was called to a ranch, eighteen miles in the country. Found patient suffering intensely from a recurrent attack of appendicitis. He had been complaining the previous evening, but for the last six hours had been in agonizing pain. The right thigh was flexed on abdomen; pain localized in right iliac fossa; temperature 99° and pulse 105. Had been given calomel and salts, which were promptly vomited. Explained disease to his friends, and told him that we would have to take him to city for treatment. 'Phoned in to have operating room prepared for an early operation, if required. Prepared a hack with a bed in it, and started for Midland. He complained of pain being very severe, and at the solicitation of his brother, I gave him a hypodermic of one-fourth grain morphia. This soon gave him ease, and he stool the trip nicely. When received at the sanatorium, his temperature was 99 and pulse 108. His pain was masked by the morphia, and vomiting had ceased. His friends were deluded into thinking him much improved, and refused operation. I asked for consultation, and a physician, an old-time family friend, was called from a distance. Ice-bag applied and bowels moved, following enema. Later the symptoms grew worse, vomit

ing, and restlessness returned and the friends grew anxious for the consultation. The train was delayed for some hours. Again had operating room prepared, and again made the mistake of yielding to the demand for opium. As soon as given, patient again improved, to the satisfaction of himself and friends. The consultant thought it only a mild case; that he had gotten over the other attacks, and surely would this one. I explained that his apparent ease was due to the morphia. His pulse was increasing in rapidity, but the consultant and his friends decided to wait for an interval, and give 10-grain doses of calomel by mouth. The surgeon left on early train in evening and agreed to return if symptoms did not improve. His advice was followed, but the calomel came back, and focal vomiting set in the next day. He was fast passing beyond a safe operating period. Enema failed to move the bowel, and later the bowel refused to retain the nutritive enema. Pulse went slowly on to 130 and temperature to 103°. The surgeon failed to return, though repeatedly urged by his friends. Ice-bag kept constantly applied, but the abdomen became tympanitic, and for five days we watched him through the same condition. Upon October 7th, we discovered that an abscess had formed, patient had several chills and pulse was 130, temperature 101. I tried to get his friends to call in some other physician, and relieve me, as they had refused the operation. That night they consented to the operation, and we evacuated a large abscess situated between the colon and right side of abdominal wall. The incision was made well to the outside of the usual line, so as to avoid the possibility of entering the abdominal cavity or the wall of the abscess, and to lessen the danger of hernia. No attempt was made to search for the appendix. In washing out the cavity, a part of the appendix, containing a concretion as large as the end of the little finger, came floating out. Another concretion was found free in the cavity. The cavity was lightly packed with gauze, and an abdominal binder applied. The bowels acted before we got him off the table. He came out from under the anesthetic, and was free from nausea and vomiting. Patient improved and did nicely

for eighteen days, when the pulse began to increase in rapidity, and obstinate constipation, with considerable cramping, occurred. A series of chills with nausea and vomiting made us suspect another abscess. While giving an enema, I noticed the fresh gauze dressing was very much soiled, and upon examination of the cavity, found that when water was forced into the bowel, a small stream of thin watery pus made its way through a small opening into bottom of cavity. This was carefully distended by gently working the end of my finger through the opening, and I found a large pus cavity in the pelvis, extending across to the left side. Two months later patient was discharged, wound completely healed, and to this day shows no tendency to hernia, although he does general ranch work.

When called to any case attended with colic, it has been my plan to never give an opiate until satisfied as to the diagnosis and plan of treatment. To give it simply to relieve pain, is an injustice to the patient and masks the best symptoms for the physician's guidance. It works a temporary miracle, but is apt to do much harm. Again, if you have called a consultant, withhold the opiate until he has seen the case as you have. Of course, if you have a perforation with consequent shock, it is proper to give it at once.

On August 12, 1901, I was called in consultation to see R. H., male, age 20, who was suffering with a severe pain just over the crest of the ilium on the right side. The physician told me that he saw him twelve hours before, patient having had two bad chills. Complained of some nausea, loss of appetite and a severe pain in the right lumbar region. It was more on account of this peculiar position of the pain, that I was in consultation.. As we entered the room, I noticed his peculiar position in bed, with the right thigh flexed upon the abdomen. The pain had changed its peculiar position, and was now in the right iliac fossa. There was exquisite tenderness over McBurney's point, and upon close questioning, I obtained a history of two previous attacks. Pulse was not high, and all symptoms improved rapidly after application of ice-bag. Seventeen days later the patient submitted to operation. Much to our surprise, the appendix was not adherent, but was very much