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distended with pus, and covered with a plastic exudate. Upon application of forceps, previous to making incision through the appendix, the increased pressure caused an ulcer near the tip to bulge the wall, almost to the point of rupture. Would another interval have ever come to this young man? I think not.
P. H. B., age 52, a chronic drunkard, who had suffered for years with all types of gastric and intestinal indigestion and had received treatment from all the neighboring physicians, came to me suffering with pain in the right iliac fossa. Pulse 86 and temperature normal. There was a slight tympanitic condition of abdomen and tenderness over the appendix. These attacks would return sometimes every two weeks, sometimes go a month, but grew worse from time to time, yet were always relieved by some simple remedy. They were so annoying as to prevent him securing a position for any length of time, and, although an unfavorable case, I decided to operate, and on May 17, 1902, operation was performed. The appendix came easily into view and was quickly removed. It contained seven foreign bodies, which proved to be small seeds. They were arranged almost equi-distant from one another. The short period required for operation, due to the absence of adhesions or other complications, made me feel sure that he would soon be convalescent. After the operation, the nurse and I counted all the sponges and accounted for them all. In fact there had been no necessity for using but one inside the abdomen, and we know it was removed. The nurse was told not to give any water by mouth, but to moisten the lips and tongue frequently with water, to prevent vomiting after the anæesthetic. One of the clean, unused gauze pads was utilized for this purpose. The next day the patient was having very severe cramps in the epigastrium, and was vomiting. These symptoms continued all day. Pulse went up to 100, and I was at a loss to understard the condition. That night I gave onefourth grain morphia; symptoms disappeared; patient slept well. The next morning he felt no pain, said his old appendix trouble was gone, but complained of being full of gas. The wound healed nicely, and the patient was soon up. Every now and then he would
come to me, complaining of gaseous detention ond eructations, sometimes constipation and at one time the symptoms pointed to obstruction; at other times he would have diarrhea. Never any pain about the wound. Finally, he went out on a ranch in New Mexico, where he still had indigestion, and several months after the operation he sent me one of my gauze pads and a letter, saying that he had suffered a severe cramping spell, and had passed “a rag witch” from the bowel on November 20, 1902. All of his old symptoms had disappeared, and he was a well man. The fact existing beyond all doubt that this gauze sponge remained in the intestinal tract for a period of six months, makes this case unique.
In consultation with Drs. Estes and Sorter, of Baird, Texas, I operated upon H. T., age 28, who had suffered for seven years with cramp colic, indigestion and bilious colic, and had been treated for them all. His last attack had been diagnosed as appendicitis. I was asked to operate. The appendix was found closely adherent to the posterior wall of the colon. The distal end was very much distended, and a cystic like tumor about the size of an almond, was in the meso-appendix. Fearing that the appendix contained pus, we proceeded very carefully in breaking down adhesions and separating it from the colon. After its removal, the appendix was cut open and a thick, clear mucoid material escaped. It had no odor or resemblance to pus. When pressure was made upon the tumor in the meso-appendix, a similar material came through a small opening in the floor of the appendix. In the specimen, you will notice a bristle through the opening. The patient has never had the slightest pain or indigestion since, and has gained in weight and strength.
Regarding the cases of fulminating appendicitis, with rupture or perforation of appendix, and general peritoneal involvement, it would seem that an operation is always demanded. When the diagnosis of this condition is positive, a median incision is best, and we should aim at the complete removal of all infectious material. The appendix will receive first attention. If it has sloughed off, the opening of the colon should be closed. To facilitate drainage, another opening should be made in the right side. Every portion of the visceral and parietal peritoneum should be cleaned by sponging, and then flushed with normal salt solution. Gauze packing should be used for drainage. Several cases of iodoform poisoning have occurred, and I have decided to use only sterile gauze. A few sutures should be used to help retain the intestines. These cases are usually fatal.
In January last I was called to see R. C., male, age 12, who had been suffering from so-called cramp colic. He had been up and about all day. His breathing was rapid, pulse 120, and wiry; temperature, 99. Had several chills, and incessant vomiting. Patient looked like he had been sick for some time. Thigh flexed on abdomen, and would hardly allow an examination. Both recti were tense and there was no doubt as to his condition. No hope was offered his family, but they asked for an operation. A hasty operation was performed; found the belly full of pus, the omentum and appendix in a mass of adhesions. The appendix contained no concretions or foreign matter, but had gangrenous opening, which the omentum had apparently tried to wall off, but had been unsuccessful. The patient died in less than an hour. How Oschner can obtain such good results in such cases is a mystery to me.
APPENDICITIS, WITH REPORT OF CASES.
H. A. BARR, M, D.,
Appendicitis, a disease which less than a score of years ago was practically unheard of, is now probably one in which the etiology and pathology is more thoroughly comprehended than that of any other disease of equal gravity with which the profession has to contend. It is a disease in which every phase and feature has been carefully studied and exhaustively discussed by the ablest men of a surgical and medical profession. Yet, unfortunately and strange though it may seem, there is probably no other disease to which the human flesh is heir, where there is such a great diversity of opinion as to the proper mode of treatment.
The literature on the subject is most voluminous, and much of it is characterized by ridiculously contradictory assertions.
To the young surgeon just entering upon the threshold of his career, who has delved deep into the present-day literature of this affection, and if, after so doing, he is able to logically arrive at a decision as to the proper method of procedure and feels sure that he is right and ready to go ahead, is indeed a prodigy. To do so, he must be a man who observes closely and profits by it. He must be a man of keen intuition, sound judgment, and possessed of a high order of diagnostic acumen.
Some of the writings on this subject border on the ludricous, as for example, one writer advises that after operating for appendicitis, the patient should be put to bed, giving as his reason for advocating this strange method of procedure, that rest in bed facilitates the healing process. No doubt but that the above advice embraces one feature in the management of these cases upon which all will agree, and should this writer travel extensively, he would, in all likelihood, be surprised to observe how generally his advice has been heeded, and how completely his instructions are being uniformly observed by surgeons throughout the land. Another writer claims to have been so fortunate as to be allowed the privilege of observing a well developed case of the disease in a goat. In operating upon the animal, the surgeon claims to have found the heel of a rubber shoe firmly wedged in the appendix. Notwithstanding the precautions taken, the animal succumbed, but the surgeon feels sure that if he had operated a few hours earlier, the brute's life would have been saved.
To be fully convinced of the existence of the extreme diversity of opinion and practice respectively held and carried out in the diagnosis and management of appendicitis, by many of the best men in the profession, one has only to read a fair amount of the abundant literature on the subject. In arriving at a diagnosis, one writer will tell you that muscular rigidity is an important and prominent clinical feature in appendicitis, while another considers it of only secondary importance, naming a number of other symptoms which he holds to be of far greater significance and value in the diagnosis of this disease. Another, while admitting and commenting on the treacherous nature of the disease, noting the fact that cases often present themselves which are initiated by symptoms indicative of à much more grave condition than really exists. Continue your reading, and you will learn that the pulse and temperature are often especially misleading, yet a little farther on, the same writer will lay down a rule to be observed and followed, something like the following: If the temperature continues to rise and the pulse to increase in frequency after the first twenty-four hours, we are safe in advising that the case demands operative measures. Again, reading from another, probably equal eminent authority, you will find about the following: "In ninety per cent of all cases, nausea and vomiting are present and should be considered most valuable and important symptoms." Another: "Nausea and vomiting may be present, but are by no means constant." From another: “The pulse and temperature are of little value in making a diagnosis in