A BRIEF CONSIDERATION OF THE CASES OF APPENDICITIS OCCURRING IN THE PRACTICE OF PROFESSOR WILLIAM H. CARMALT. BEING A REPORT TO THE COMMITTEE ON MATTERS OF PROFESSIONAL INTEREST OF THE CONNECTICUT STATE MEDICAL SOCIETY FOR 1894. A BRIEF CONSIDERATION OF THE CASES OF APPENDICITIS OCCURRING IN THE PRACTICE OF PROFESSOR WILLIAM H. CARMALT. My experience in Appendicitis relates to forty-one cases all told —not counting Hospital cases under the care of my colleagues which I saw in consultation ;—and while this number is not large enough to justify any positive generalization, it does pre- sent a sufficient variety to show that the clinical aspects are of great diversity and should, for that reason, make us extremely careful not to dogmatize or lay down lwd and fast rules for diagnosis or treatment. I am less disposed to make positive rules the more cases I see, and I fully appreciate the feeling prompting the statement of my friend, Dr. Richardson of Bos- ton, whose experience probably ten-fold outnumbers mine, who finds that writers are disposed to be positive in inverse ratio to their experience.* • In the cursory remarks I have to make in response to the cir- cular letter of your Committee on Matters of Professional Inter- est, I shall not try to follow the series of questions they have issued, however admirably devised for the purpose of bringing out the experience of members of the Society, nor shall I con- fine myself to the cases occurring since 1888 as then suggested, although it goes without saying that by far the greater number have occurred since that time. Indeed the first four cases on my list are diagnoses made by “ hind” sight; in thinking over the experiences of more recent years ; before indeed the term appendicitis became the household word it now is in medical circles, while we still spoke of Typhlitis, Peritypliilitis, and Per- itonitis as separate and definite entities. Of these, one recovered after spontaneous evacuation of an abscess into the vagina; one died of a general suppurative peritonitis, from what I now sup- pose to be the rupture of an appendicecal abscess into the per- itoneal cavity; one died of a general peritonitis without rupture, the autopsy first showing the abscess: the other declined opera- tion for intestinal obstruction, but died from general peritonitis ; the autopsy here also first revealing an appendicecal abscess as * American Journal Medical Sciences, January 1894. p. 2. 2 PROCEEDINGS. the origin of the trouble. Leaving out these four cases which were not considered in the light of the most advanced ideas of the present time with regard to the-asserted imperative neces- sity of operating upon every case, and even upon removing the ap- pendix of children as a hygienic precaution against possible future trouble; we have thirty-six cases to consider and I shall take the liberty of considering them entirely from a clinical standpoint. We can divide them at once, into two main groups, viz.: the suppurative and the non suppurative, and these may again be considered, practically, surgically or therapeutically, each under two heads: the first or suppurative form into exactly when or when not to operate, (for no sane physician in the light of our present knowledge of abscess formation can for an instant hesi- tate as to the advisability of opening an abscess rather than waiting for it to open itself—theonly reasons for delay being either the uncertainty of diagnosis ora concession to the feelings of the patient or friends). The second or non-suppurative form, into whether or not to advise an operation at all. This same divis- ion allows itself to be expressed, according to the clinical features as mild or severe, the former being the non suppurative, the latter, those which go on to suppuration; and there is here also a further subdivision to be made of the mild cases into single and relapsing cases, while the suppurative may be classified into those pursuing a fairly gradual and uniform course, separating the pus from the peritoneal cavity by firm ad- hesions, and those in which no or but slight adhesions are found, and the pus is sooner or later discharged into the peritoneal cav- ity with the almost inevitable result of a fatal suppurative septic peritonitis. These may appropriately be designated the explo- sive or fulminating variety. At the extremes of these cases, the surgeon’s skill does not have much occasion to be exercised. In the first attacks of cases pursuing a mild course, no surgeon with a proper sense of responsibility will advise an operation,—the epigrammatic dictum of “ an inch and a half incision and a week and a half in bed ” as a summary to justify a surgeon in hisadvicetoa patient for every attack of colic, or to quote, “ as soon as the first symptoms of appendicitis occur ”* is too absurd to be * Morris, New York Medical Journal, January 27tli, 1894, 98, second column, first line. APPENDICITIS. 3 mentioned otherwise than in condemnation—and the condition of a patient with a suppurative septic peritonitis is so hopeless that the technique of the washing out of the abdomen is not a matter of much fineness of detail. On the other hand however, in the fortunately larger number of intermediate cases, the deter- mination of the presence or absence of pus in a tumor of this region, and the exact relation of this tumor and its contained pus, with the details and technique of the opening of the abscess, when it may be that the peritoneal cavity is not firmly closed off from the pus cavity, and the further question of the advice to give with regard to the propriety of operating, and the method thereof in the relapsing non suppurative cases, are points calling for careful judgment and accurate technical skill. The non suppurative cases are usually regarded as catarrhal in character, and like catarrhal inflammations elsewhere are liable to recurrences and it is in this that their danger lies. It has been a matter of observation since the beginning of the study of diseases that certain persons are liable to attacks of so-called colic, followed by a peritonitis of more or less severe character, but it has been reserved to the present generation to bring cer- tain of these cases into a class of surgical disease, capable of being cured by a conservative operation, or of being altogether averted by an operation of a prophylactic character. In my list of cases appended to this article, fifteen were non-sup - purative ; of these fifteen, eight were not operated upon, of whom four declined the operation, though advised to have it done, and in four no operation was advised, although the symptoms justi- fied the diagnosis of appendicitis, because they were all first at- tacks subsiding in a few days ; of the remaining eleven, four, as above stated, declined the operation for various reasons, some from dread of any operation, others because they could not be convinced of the dangers of delay, and others put it off to a more convenient time. Of the seven who were operated upon in the interval, all presented pathological changes in their appendices of greater or less extent, and there has been an entire cessa- tion of their more or less frequent attacks of colic. This, further- more, most fi'c.qur rrt' fact is also established in cases Nos. 5, 0,14, 19, 20, 29, that the abscess for which the operation was perform- 4 EROCEEDINOS ed, was the culmination of a series of attacks of colic, more or less definitely referable to the caical region, showing that the non- suppurative catarrhal form of the disease may, after a time, be- come suppurative. Indeed this is the legitimate ending of re- peated attacks, and is the reason for the operation during the in- terval between the attacks, when the parts are in a quiescent state, with no infectious material to contend with, ami conse- quently the danger of opening into the peritoneal cavity reduced to a minimum. Limited as is the number of cases here considered, they in- clude illustrations of all the principal varieties that I have seen described by authors, (except a class described by Dr. Fowler, of Brooklyn, who reports four cases of left sided appendicitis, the diagnosis having been verified by or made on autopsy). As already stated these may be readily classified into non-suppurative and suppurative classes, and while pathologically this is a chasm of great width, as a matter of clinical distinction the one passes over into the other by almost imperceptible steps. In many cases we are quite unable to point to a single feature that would distinguish the one class from the other, and we are obliged to have recourse to the doctrine of probabilities and take the chances of operating unneccessarily rather than let the patient run the greater risk of some untoward complication of the puru- lent infection. I have not an over-inclination toward opera tive interference in any case, but in no case have I regretted operating, while in several I have regretted postponing the operation; in two, Nos. 24 and 38, with unfortunately fatal re- sults. As it is .from our ill successes or mistakes that we learn the most, these two cases will hereafter be given in greater detail. By far the greater number of cases l>egin as a catarrhal ap- pendicitis ; the cases operated upon in which a foreign body of any kind, be it a fecal concretion or a seed, or shot, are rare as compared with those in which nothing is found, and appendices removed “ in the interval ” show various changes with more or less thickening of all the coats, indicating a state of chronic in- flammation and tissue hypertrophy with not infrequent circum- scribed collections of mucus or muco-purulent secretions which APPENDICrriS. 5 have become encysted by the occlusion of the canal of the organ. This condition may and undoubtedly does in many individuals persist for many months or years, as is shown in autopsies of persons dying of diseases unconnected with the appendix ; but it is a condition of uncertainty as to the future, and the histories and the pathological investigation show that a certain number of suppurative cases coming either to operation or post-mortem examination have come about by the development of an abscess from one of these chronically inflamed cases. It is not my pur- pose here to describe the pathology of the disease or the cause which brings about the transition from mucus to pus. I pro- pose simply to discuss the clinical features of the disease from the point of view of the practitioner as he meets them in the course of general practice, without reference to the bacteriologi- cal pathology. In by far the greater number the onset is apparently a colic of considerable severity, and in many cases it is quite possible that it passes off without any further development, but as we observe further we find that certain of them have more or less frequent repetitions of the attack, until at some one, (or it may be at the first), the pain localizes itself in the course of a few hours in the right iliac fossa. The colic may or may not, but more fre- quently is accompanied with vomiting; the condition of the lower bowel presents nothing characteristic and is of no value in a diagnostic view; there may be one or two movements, they may respond to the action of a cathartic, they may be inactive, there may be obstinate constipation, amounting to the suspicion of an intestinal obstruction. With the gradual localization of the pain to the right iliac region there is soon felt a sense of resist- ance to manipulation on the part of the physician, and it be- comes a question of importance whether this resistance be due to muscular contraction on the part of the abdominal muscles or to an inflammatory product in or around the appendix, and I have thought there was a difference in the position of the leg in the two conditions. If there be a veritable tumor the patient prefers to keep the leg bent and quiet, while if it be simply a contraction of the abdominal muscles the movements of the leg do not affect the local pain. The situation of the point of great- 6 PROCEEDINGS. est tenderness has its bearing, and while “ McBurney’s point ” is true for a large number of cases of appendicitis, it still is suf- ficiently often the case that the point of greatest tenderness is not so situated, so that nothing positive can be asserted by its absence. When the point of greatest tenderness is exactly on the line from the anterior superior spinous process of the ilium to the umbilicus, and at the distance of one and one half to two inches from the former, we are reasonably sure that we are hav- ing to do with an inflamed appendix in its usual position, but if the inflamed appendix be not in its usual position the point of greatest tenderness is somewhere else, so that this point upon which so much stress as a diagnostic sign has been laid, is only of value as an affirmative—as a negative it is valueless, and the opinion is becoming pretty well established in the minds of surgeons that all inflammations in the right iliac fossa are due to one or the other forms of appendicitis. If the case is pursuing a mild course under a treatment of rest, gentle cathartics, and fomentations, the pain and tenderness subside, the tumor becomes less marked and may entirely dis- appear in the course of a week or so, to be followed at a variable ihterval of weeks or months or years by other attacks of similar or perhaps greater severity; one of which, however, goes on to the formation of pus. No one can tell from a clinical stand- point what determines the change. Indeed, evidence accumu- lates that many people go through life with attack after attack of catarrhal non suppurative appendicitis, but these people are living over a volcano which is liable at any time to an eruption, and when such a thing occurs we have but an uncertain control over its subsequent course. It may give a surgeon time to open the abscess with safety ; it may rupture into the peritoneal cavi- ty almost without warning. In the less explosive class, when the catarrhal form passes over into the suppurative, with the formation of a wall of adhesions around the pus, agglutinating the intestines together and forming a mass which may be felt through the abdominal wall as a fairly firm tumor, we have a condition of things more or less under control; we cau, if we choose, wait until adhesions have taken place between the wall of the abscess and the abdominal wall ; we may, if we feel sure APPENDICITIS. 7 of our asepsis, open the peritoneal cavity, ancl holding the intes- tines aside open and empty the abscess without contaminating the surrounding tissues. The former method was the universal practice when Typhlitis and Perityphlitis were the terms used to signify the situation of the abscess, and before we felt it was, under any circumstances, permissible or safe to open the peri- toneal cavity—but recent surgery has taught us that in a certain number of cases there is a decided danger in waiting for these adhesions to form, and for the containing pus “to point;” that instead of “ pointing ” to some accessible situation on the ex- ternal surface, it may “ point ” into the peritoneal cavity and, discharging its contents there, set up that almost uncontrolable disease, a suppurative peritonitis. If the pointing involves the wall of an intestine, cicatrices are liable to form, giving rise to complications which may lead to disastrous results years after in the way of intestinal obstruction. For these reasons, the treatment of these abscesses by surgeons who may justly be called ed conservative—in that their practice tends to preserve life—is to open them at the earliest moment that pus can be assured to be present. One may be guided somewhat by the course of pre- vious attacks if such have been present, for if such is the case there is more probability that the adhesions have formed and that the course of the disease will be relatively slow as compared with the fulminating variety in which a fecal concretion formed in the appendix is most frecpiently the cause. Still, we occasionally meet with cases running a rapid course even in recurrent attacks, and one can never feel easy in a given case after pus has form- ed, until it has been given a safe exit through the exter- nal skin. In the milder cases where the attacks pass off without the formation of pus, but in which a tumor has been present which has to a great measure, or even entirely subsided, the question of operating in the interval comes up. These cases, not infre- quently, have been known to recur for years; they have been called various kinds of colic, bilious or otherwise ; or localized peritonitis ; are ascribed to some error in diet; are treated in vari- ous ways to restore the functional activity of the canal, the physi- cian and patient resting in fancied security until one attack de- 8 PROCEEDINGS. velops into a “ peritonitisand abscess, or death, or both puts an end to the tragedy. No. 3 in my list is a case in point, and with some modification, also No. 20 ; in both of whom autopsies first revealed an appen- dicecal abscess appearing after repeated attacks of so-called idiopathic peritonitis, while Nos. 11, 1(5, 23, 25, 20, 32 and 41 show the happy results of removing the appendix in the interval between attacks of various degrees of frequency and intensity, but in all of whom the operation has been followed by a complete cessation of the attacks of “ peritonitis,” or “ bilious colic,” diagnosticated according to the fancy or pathological acumen of the physician. The fourth and last class of cases that 1 have met with are fortunately rare, but as, if properly appreciated in the earlier stages, they are amenable to surgical treatment, within limits, it behooves us to be on the alert to recognize them, and yet it may be that, having the keenest possible sense of the dangers of delay, the symptoms are so uncertain that the true condition is not realized. (Case No. 24). These are the fulminating cases with oc elusion of the canal of the appendix by a foreign body, be it a seed or some such thing, or a fecal concretion which has grown large enough to strangulate the circulation of the tissue and gangrene of the part beyond results. In these cases the suppuration takes place so rapidly that nature has not time to build up the wall of adhesions around the pus and it breaks into the general cavity with a minimum of movement, be it of the abdominal wall or of the intestines, and general septic purulent peritonitis breaks out that rapidly leads to a fatal termination,—forty eight to ninety- six hours being often enough to close the scene. The only safety in these cases is an early operation, and the thorough washing out of the peritoneal cavity with antiseptic or sterilized water, with the use of such other remedies as the general condition de- mands. Desperate cases have been reported cured under these conditions, but the outlook is of the gravest. The unfortunate circumstance that the early symptoms of these desperate cases do not correspond with their gravity—at the outset are not mark edly different from the cases which pursue a mild course and the danger which lies in delay in this fulminating class is the APPENDICITIS. 9 excuse and has been the occasion for operating in cases where nothing has been found. The justification of this last statement is not found in published reports, but is based upon personal, ver- bal statements of surgeons who would not care to have me pub- lish their names, but whose names are guarantees that the operation was not undertaken through carelessness or want of consideration, but because, being unable to make up their minds conclusively, they preferred to err on the side of prudence, and have operated. This may seem like an extravagant way of stat- ing the matter, but when one considers the relative dangers of a cleanly cut aseptic incision—even though it lay open the peri- toneal cavity—with the condition of a patient with a quantity of pus loaded with pyogenic and saprophitic bacteria, it cannot be regarded as such. So far as is possible to formulate the views derived from the consideration of these cases, the rules which should govern us are then, viz: First.—Attacks of appendicitis of a mild character, may, and should be, treated without operation. Second.—Recurrence, however, even if of a mild character, should be operated upon in the interval, anti the appendix re- moved as a prophylactic against a possibly dangerous attack in the future. Third.—Appendicecal abscesses should be opened as soon as the diagnosis can be established. Fourthly.—“ When in doubt, lead trumps it is better in at- tacks of any severity to operate rather than to procrastinate, hop- ing that time will reveal something decisive—on the contrary the lapse of time more frequently obscures than clears up the diagnosis. Cases Nos. 24 and 38, previously referred to, are cases in point where delay made inevitably fatal results to cases in which an early operation would possibly, nay, probably, have saved life. No. 24 was a student at college under the immediate care of my friend, Dr. Foster ; the initial constitutional symptoms were severe but the local evidences of appendicitis were not marked. He lived at a distance and word was sent that his father was coming on accompanied by his own surgeon. Not wishing to seem precipitate in operating, I deferred insisting until the evi- 10 I'ltOCKEUlNOS. deuces of serious trouble became so marked that I refused to take the responsibility of delay, and operated before their arrival. Unfortunately, as already stated, the eighteen hours delay was fatal. We found a general septic peritonitis, due to the rupture of a thin walled abscess ; the abscess itself covered by a gan- grenous appendix in which a fecal concretion had lodged. The other case was also of a young man, who was admitted into the New Haven Hospital on the third day of his illness with severe colicy pains, some tenderness in the lower part of his ab- domen, not localized in his right iliac fossa, but with an indefi- nite sense of resistance there. Feeling reasonably sure of what I had to deal with, as is the rule of the Hospital, a consultation of the attending staff was called. Drs. Fleischner, Hawkes, and Bussell, three other members besides myself attended, and it was decided by the majority that there were not sufficient evidences of localized disease to call for operative interference, but he was regarded as having an idiopathic peritonitis, (a condition that I do not believe exists), and no new symptoms developing, he was transferred to the medical side. After a few days, his condition gradually getting worse, he was re-transferred to the surgical side for operation for general suppurative appendicitis, in the forlorn hope that a thorough washing out of his peritoneal cav- ity would save his life. An incision in the median line for this purpose, showed no general peritonitis but an extremely con- gested state of the whole intestinal canal; no fluid in the per- itoneal cavity, but there was a large post-cfecal abscess with the gangrenous appendix embedded in it. He died on the operating table. 1 feel confident that if he had been operated upon in the early period after his admission, his life would have been saved ; and in this case, certainly nothing was gained in diagnosis by waiting. The subsequent symptoms served only to obscure the correct opinion first formed as to the origin of the trouble. X. Miss , Dr. Nickerson—Abscess, discharged into vagina. 2. \[r. , Drs. Nickerson and Bradstreet—General suppura- tive peritonitis. Laparotomy by Dr. Hartley. Death. 3. Mr. P , Dr. F. H. Wheeler—General non suppurative peritonitis; Autopsy, multiple abscesses. APPENDICITIS. 11 4. Mr. P , Dr. Gaylord—Diagnosis; intestinal obstruction ; refused operation—autopsy ; general non-suppura- tive peritonitis ; abscess of appendix found. 5. Mr. Y , Dr. Grannis—Abscess recurrences in Jan., 1891; recovery. Secondary abscess in September follow- ing—death from general peritonitis. 6. Miss M , Dr. Luby—Catarrhal appendicitis, tumor, op- eration advised by self, Drs. Bacon and Russell; refused—recovery; no history of discharge into in- ternal canals or of recurrences. 7. Miss C , (60), Drs. Grannis and Bidwell, of Deep River ; Abscess, operation, recovery. 8. Master L , Dr. Grannis,—Catarrhal appendicitis, tumor; advised non-interference; recovery ; no recurrences. 9. Master F , Drs. Grannis and Hubbard, Essex—Follow ing recurrences ; abscess ; operation ; recovery. 10. Laborer, Hospital patient; sent in by Dr. Mailhouse—Ca- tarrhal appendicitis, tumor; no interference ; re- covery. 11. Mr. B , Dr. Osborne—Three attacks of catarrhal appen- dicitis ; advised intercurrent operation ; performed at Hospital; thickened appendix ; recovery. 12. Colored janitor, sent to Hospital by Dr. DeForest—General adhesive peritonitis; great tympanites; incision in median line, opened into intestine; abscess behind caecum dissecting up to diaphragm ; ap- pendix gangrenous, containing fecal concretion. 18. Mr. G , Dr. C. J. Foote—Abscess; following recur- rences, operation; recovery. 14. Russian Jew, Hospital patient; several recurrences followed by abscess ; long continued sinus ; recovery. 15. , Hospital patient; admitted moribund ; great tympan- ites ; general suppurative peritonitis; abscess be- hind caecum; patient ambulatory until day pre- vious to death. 16. Mr. W , Dr. Osborne—Catarrhal Appendicitis; inter- current operation advised; performed by Dr. Lange; necessity of operation reported by attend- ant. 12 PROCEEDINGS. 17. Master K , Dr. Shelton—Traumatic Appendicitis, ab- scess ; operation ; recovery. 18. Miss , (13), Dr. VV. S. Russell—Abscess ; no operation ; discharge into rectum ; recovery. 19. Mr. S , Drs. Shelton and Richardson—recurrent attacks, abscess; operation; intestinal fistula; recovery. 20. Miss S , Dr. W. G. Daggett—Repeated attacks of peri- tonitis of supposed ovarian origin ; general adhe- sive peritonitis; operation; death; autopsy, appen- dicecal abscess ; no Salpingitis. 21. Mr. M , Dr. J. W. Seaver—Catarrhal Appendicitis; tu- mor ; recovery ; recurrences ; operation advised ; declined. 22. Mr. G——, Dr. J. W. Seaver—Catarrhal Appendicitis; first attack; recovery. 23. Mr. S , Dr. Foster—Catarrhal Appendicitis ; several re- currences ; tumor; recovery; intercurrent opera- tion ; appendix much hypertrophied; no subse- quent attacks. 24. Mr. N , Dr. Foster—Ulcerative Appendicitis ; general septic suppurative peritonitis; operation; fecal concretion; death fifth day. 25. Mr. G , Dr. Wright—Catarrhal Appendicitis ; tumor, recovery—second attack two months, tumor; recovery; intercurrent operation performed, re- covery ; appendix hypertrophied. 26. Mr. DeB , Dr. Foster—-Catarrhal Appendicitis, frequent attacks ; intercurrent operation, recovery ; appen- dix hypertrophied ; no subsequent attacks. 27. Mr. R , Dr. Bellosa—Abscess, operation ; recovery. 28. Mr. G , Dr. Bellosa—Abscess, operation ; recovery. 29. Mrs. P , Drs. Foster and Daggett—Abscesses (multiple), operation, recovery, with long continued sinueses 30. Mr. G , Dr. Fleischner—Abscess, operation ; recovery. 31. Mr. B , Dr. Granniss—Abscess, operation ; recovery. 32. Mr. D , Dr. Foster—Recurrent catarrhal appendicitis; intercurrent operation, small fecal concretion, slight ulceration of mucous membrane ; recovery. APPENDICITIS. 13 33. Mrs. B , (09)—Dr. Tenney—Catarrhal Appendicitis ; re- current, operation advised ; declined. 34. Mr. F , Dr. Foster—Abscess, operation ; recovery. 35. Miss D , Drs. Hubbard and Foster—Recurrent appen- dicitis, ( so-called peritonitis ), operation by Dr. Stimson at New York Hospital; recovery; “ great necessity for operation,” reported. 36. Mr. S , Dr. Madhouse—Diffuse tenderness ; operation advised and refused ; came to hospital under Dr. Bacon’s care ; recovery. 37. Mr. H , Dr. Randall—Abscess, operation ; recovery. 38. Mr. Z , Dr. C. P. Lindsley—Catarrhal Appendicitis, tumor; recovery—intercurrent operation declined, (second attack.) 39. Mr. F , Hospital patient, Drs. Fleischner, Russell and Hawkes in consultation ; clinical diagnosis—non- suppurative general peritonitis ; operation not ad- vised, by consultants; peritonitis treated “med- ically became worse, operation advised as dernier resort for suppurative peritonitis ; death on table; large abscess behind cmcum with no general peri- tonitis. 40. Mrs. , Drs. Fleischner and Mr. Simrow—Recurrent ca- tarrhal appendicitis, intercurrent operation advis- ed ; declined. 41. Mr. W , Dr. L. W. Bacon, Jr.—Catarrhal Appendicitis; mild case ; no tumor ; tenderness disappeared and tumor found on ninth day; on tenth, operation performed, foreign body, Johannisberry or biliary calculus.