Acute Appendicitis with Observations of Fifty Consecutive Cases. JOHN F. SHEA, M.D., BRIDGEPORT. The observations here reported are based upon a study of fifty consecutive cases of acute appendicitis operated upon at the Bridgeport Hospital by myself or Dr. P. W. Bill with whom I am associated, and cover a period of six months ending March Ist, 1918. My paper is not a lengthy or scientific one, simply a presentation of the most important features of an affection that is very common and one upon which more papers have been written than perhaps any other subject in medicine or surgery. In spite of the above, there is no other disease (empyema not excepted) in which the early recognition is so often overlooked as acute appendicitis. In the hospitals to-day there are entirely too many cases of this disease requiring drainage, and the reason for this lies at the door of the medical man, who pays but little attention to the order of development of symptoms occurring so characteristically and which enables one to make a differential diagnosis at a time when that diagnosis permits the best surgical treatment. The symptoms in the order of their appearance are so constant and important that it will be well to enumerate them here: FIRST Pain, which is never absent, colicky in character, usually at first referred to the epigastrium, later at the site of the appendix. The pain reaches its acme in from six to ten hours, then gradually subsides, this subsidence being due to escape of the infective material back of the cecum; to the rupture of the appendix; or to the development of gangrene. SECOND: Nausea or vomiting, a very important symptom in that it never precedes but always follows the pain, and one may say, without fear of contradiction, that if nausea or vomiting comes first it is not appendicitis. This nausea or vomiting is reflex due to distention of the appendix. THIRD: Abdominal sensitiveness and muscular rigidity over the site of the appendix, showing markedly when contrasted with the other side. FOURTH: Elevation of temperature coming on three to twelve hours after the onset of pain. This symptom is so constantly present that here again one can safely say that unless there is some elevation of temperature, the appendix is not at fault. FIFTH Increase of the leucocytes and polymorphonuclear elements of the blood. One should not rely wholly on the leucocytic count for this is deceiving, as you will see when we speak in more detail of the blood changes revealed in the cases studied. In this series 28 were females, 22 males; the youngest seven (7) years and the oldest 83 years. Four occurred during the first decade of life, 17 during the second decade, and 20 during the third. Again emphasizing what has been known for a long time, that appendicitis is essentially a disease of adolescence and is comparatively rare in the young and old. Twenty-two cases were kept at home under a physician's care for a period of three days to two weeks, many of which received internal medication purgatives or local applications. In some cases all three treatments were given and the two patients that died were of this group. It is little short of criminal to administer purgatives to patients with acute appendicitis and often it is fatal. There is no illness that man is subject to in which medication is less warranted than acute appendicitis. If all medical men would recognize this fact, and when they see an acute abdominal condition, call in a surgeon instead of peddling pills, many a sufferer would be spared a tedious convalescence or an untimely death. Eleven cases showed before operation a palpable mass in the right quadrant. When such a mass is present one is dealing with an appendiceal abscess. Much controversy has been waged as to whether an abscess should be opened and appendix left untouched or whether the appendix should be removed at the time. I think it is not good surgery to merely drain an abscess. The appendix should be sought for and removed. When one cuts down on the mass he will find it consists of omentum, cecum, and appendix, the omentum being glued to the surface of the cecum. To attempt to free the omentum would be dangerous as pus lying beneath would escape into the peritoneal cavity. One must therefore completely wall off the abscess and this is done by picking up the omentum to the inner side of the cecum, doubly ligating it and pushing back the healthy omentum into the abdomen, then completely walling off by abdominal pads the abscess to which the distal portion of the omentum is attached. Think of it! More Twenty-nine cases required drainage. than half the cases sent to the surgeon late. Doctor Murphy was right when he said, a short time before his death, "It will be necessary to go over again the diagnosis and treatment of appendicitis. Much as we believed fifteen years ago that the medical men of this country had gotten hold of this subject, it is apparent that there are far too many who do not appreciate its importance." In six of the twenty-nine cases there was free pus in the peritoneal cavity. In the cases where free pus is encountered, it has been our custom to place rubber tubing in addition to cigarette drains. When there is nothing to drain, cigarette drains are enough. They admirably fulfill their requirements of walling off the area from the general peritoneal cavity by exciting a protective peritonitis; but they are insufficient where drainage is required. Their meshes quickly become blocked and the gauze becomes a plug, preventing instead of facilitating escape of pus. The removal of drains is an important one, many being removed too early without having fulfilled their purpose, and if removed prematurely, the patient is certainly worse off than if he were not operated upon. Drains should never be removed until there is a normal temperature, active intestinal peristalsis, and good bowel action. Rubber tubes should be rotated at least once a day. |