RECURRENT APPENDICITIS. Six Operations with Six Recoveries: Treat- ment for Acute Attack in Five Cases. BY S. C. GORDON, M. D„ PORTLAND, ME., Attending Surgeon, Maine General Hospital, etc. Reprinted from the Boston Medical and Surgical Journal of June ij, 18Q3. BOSTON: OAMRELL & UPHAM, PUBLISHERS, 283 Washington Street. 1893. 3. J. PARKHlLL A CO., PRINTERS BOSTON RECURRENT APPENDICITIS; SIX OPERA- TIONS WITH SIX RECOVERIES; TREAT- MENT FOR ACUTE ATTACK IN FIVE CASES. BY 8. C. GORDON, M.D., OF PORTLAND, ME., Attending Surgeon, Maine General Hospital, etc. In an address 1 delivered before the Maine Medical Association, June 10, 1891, and published in the Bos- ton Medical and Surgical Journal, September 3d and 10th, I used the following language in relation to appendicitis : “ I have been satisfied for two years that peritonitis arising from the coecum and appendix should be treated heroically by salines, without regard to the cause. The condition is what immediately demands our atten- tion. The cause has done all the harm it can, when we are called. A free depletion will relieve the con- gested and inflamed vessels, preventing in a majority of cases, suppuration and gangrene, thus allowing the case to terminate by resolution. ‘•If abscess result, then operate and drain with the least possible disturbance to the tissues. It the ap- pendix can be reached, remove it, otherwise leave it. I feel that the theory of early operative interference is untenable, provided we follow the saline plan. It is the plainest common-sense, to my mind.” Since that time, in every case of appendicitis to which I have been called primarily (in the inflamma- tory stage), I have followed this plan. In no case have I operated during this stage, if I have had the management of the case before abscess formed, or signs of gangrene existed. In some of the cases I did not operate even when I felt sure that pus 1 Common Sense in Medicine. 2 formed, and as the subsequent operation (made after the acute attack had entirely passed away) showed. Unless the pus was near enough to the surface to indicate its existence by well marked tumor, circum- scribed and fluctuating, I refrained from operating. I had an opportunity in five of the six following cases to treat the patient through one or more of the acute attacks; and as soon as convalescence was established, I operated. Case I. R. J. M., male, age . I first saw him in Boston, in May, 181)2. lie told me that he had been treated for six attacks within a year — was then just recovering from one; four of them had oc- curred within the previous four months, all in Boston. No suggestion was made of operation by the medical men who had charge of his case during these attacks. I proposed to operate for the removal of the appendix if he came to Portland. lie came soon after; hut circumstances would not permit him to give up for the operation until June 12th. In the mean time, I had almost daily observation of the case. lie suffered more or less every day from pain in the region of the ccecum. June 12th, assisted by Dr. J. F. Thompson, I made the usual incision over the McBurney spot, and found the appendix completely ulcerated off, just holding by a small slip of peritoneal covering to the ccecum, into which was an opening large enough to admit the end of my index finger. Why faecal matter had not come out is difficult to say. I closed this by buried sutures through the muscular and mucous coats, and approxi- mated the serous edges with fine catgut sutures. Ho made a complete recovery. This case was undoubt- edly of tubercular origin, as he then was suffering from pulmonary tuberculosis, from which he died in December last, six months after operation. 3 Case II. Miss R., age twenty-five, was taken with the usual severe pain in the region of the coecum, ac- companied with vomiting and fever. I saw her early, and got free action from salines as soon as possible. The acute symptoms lasted three days, but were so well marked that I had no question as to the nature of the condition. This was about the last of July, 1892, and convalescence was not established until near the middle of August. Indeed, through the entire sum- mer, she suffered at times from severe colic pains. I had advised operation as soon as convalescence was fairly assured; but, being away on vacation myself, and there being some fears on the part of her friends, I delayed any definite time for it. The middle of September she was taken with a sec- ond attack, much more severe than the first, both in pain and fever. A distinct tumor could then be felt. The same course of salines and leeches over the part terminated the case in about the same time as the first. October 7th, I operated, assisted by Dr. II. M. Nickerson. I found the appendix ulcerated half off, three-fourths of an inch from the gut, while immedi- ately at the base were three perforations—debris of pus and exudate all around the part. She made a good recovery, and has been in better health since than for a long time before the acute attack. Case 111. M. II., male, age thirty-six, conductor on the Maine Central Railroad. In August, 1862, he, suffered from a good deal of colic pain for several days, and was “ generally used up.” This occurred while on vacation, and he did not apply to any one for medical treatment. November 1st, he was taken with well marked symptoms of appendicitis—-.severe pain, vomiting, and finally distinct hard tumor in right iliac region, with special tenderness at McBurney’s point. Being a 4 specially nervous man, I did not inform him of the nature of the attack, but put him at once upon the saline plan, and applied leeches. The violent symp- toms soon subsided, leaving the tumor. I applied a large blister, which acted favorably in relieving pain and absorbing exudate. He had lost very much in weight during the month of November. At no time did he experience entire relief from pain and tender- ness on pressure. He improved somewhat in his gen- eral condition, but had little strength or ambition. December 17th, I operated, assisted by Dr. ,J. F. Thompson. I found the ccccum firmly adherent to the iliac wall, and the appendix turned back behind the coecutn, to which it was bound by very strong ad- hesions. It was very friable and teemi-gangrenous, with a perforation about three-fourths of an inch from the free extremity, the whole surrounded and im- bedded in exudate and caseous pus. Carefully dis- secting it from the ccecum, I ligated it off with catgut, curetted away all the exudate, sponged the cavity with sublimate solution (1-2000), and closed, leaving no drainage-tube. Recovery, without anything of a dis- turbing character. Now entirely well, and running his train since February. Cask IV. F. P., male, age twenty-six. During the summer of 1802, while on vacation, had a very severe attack of colic, near umbilicus, and near right iliac region. Was better before next day, having taken large doses of whiskey. Soreness continued more or less for several days, but no medical aid was sought. His health was more or less impaired during the autumn aud early winter. Had occasional colic pains, and suf- fered somewhat from intestinal indigestion. About the last of December he was attacked with quite severe pain in the abdomen, which compelled him to give up business and remain at home. I saw him in consul- 5 tation, and found that he had been suffering for three days with pain; temperature varying from 101° to 103.5°; pulse in proportion; more or less nausea, with distention and tympanitis in right iliac region. Opiate plan had been pursued up to that time. Being convinced that perforation of the appendix had taken place and pus already formed, I began the free u>e of salines — Seidlitz powders every hour, followed by saline enema, which within twelve hours operated powerfully, reducing temperature and relieving pain. A well-marked tumor existed which like the last case gradually diminished until all actual symptoms ceased and convalescence was well established. January 11, 1893, I operated, assisted by Dr. J. F. Thompson. About a half-inch from the coecum the appendix was perforated entirely through the diameter, and the edges of the opening were entirely sound and cicatrized. I have no doubt that this perforation took place in August when he had the severe pains. About a half-inch from the free extremity was a recent perfo- ration ; and the entire appendix was nearly gangrenous, the whole partially adherent to the coecum behind. Some fresh pus and exudate were found in the immediate vicinity, while deep behind the head of the colon was a large abscess-cavity, which contained caseous pus and exudate, which unquestionably had been there from the first attack. Removing the appendix and curet- ting the entire surface and abscess-cavity, I washed out with sublimate solution (1 to 2000), and closed the wound, with no drainage. The case did well. There were no unpleasant symptoms whatever. In about two months he resumed his business, and is now in perfect health. Case V. Male, age twenty-three. Sent to the Maine General Hospital during my service in Decem- ber, 1892, by Prof. Alfred Mitchell, of the Maine 6 Medical School, who reported that he had suffered from eight attacks within a year, the last more severe than any of the others. The McBurney point showed ten- derness on pressure; and the patient described it as the chief point of pain during an attack. I operated December 30th, assisted by Dr. W. L. Dana, adjunct surgeon, and other members of the sur- gical staff. I found the appendix and ccecum slightly adherent to the wall, the appendix large anti thickened by exudate; no perforation. On being removed and opened there was found a small spot about one inch from the end, where haemorrhage had taken place from the mucous surface, which a good ileal softened. In all probability another attack would have produced perforation. No foreign or other matter was found, and I have no doubt the attacks hail been catarrhal appendicitis. The same course was followed as in the others, and an equally favorable result ensued. He returned to Brunswick, Me., in about four weeks. Cask VI. L. E., male, age eighteen. Called by Dr. B. F. Dunn, January 27, 1893. He had been ill with welJ-pronounced symptoms of appendicitis for nearly a week. I am quite ceitain that pus had al- ready formed, but seemed to be well circumscribed. A distinct exudate, too. now existed at a point be- tween the superior spinous process and umbilicus. Temperature varied from 100° to 103° during this time. I ordered salines and leeches, from which he soon experienced relief. Rest in bed and blister soon established convalescence — within two weeks; and February 11th I operated, assisted by Dr. J. F. Thompson. The appendix was adherent behind the coccum, with a perforation mar the end, the whole mass adherent to the pelvic wall, while the cavity behind the ccecum was filled with exudate and caseous pus. With much difficulty the appendix was dissected 7 off and ligated. I curetted all the parts involved in the exudate, and after sponging with the sublimate solution, I closed without drainage. In one mouth to a day, he was driving about the city. Since these cases were operated upon, I have seen three others in the acute stage, and have followed the same plan of depletion with equally good results. In one I have already advised operation, and shall in the other two when the time comes. Whatever criticisms surgeons have to make upon this plan, it is sufficient for me to feel that this is the proper course to pursue. My experience leads me to believe that nine out of ten cases will convalesce under this plan of treatment, if faithfully followed. I think the time has come when there should be no excuse for not making a diagnosis, even in the early stages, which is the time for best results from medication, before pus forms, if possible. My conclusions are brief: (1) Nearly all cases can be carried through the acute stage, safely, by the saline and depleting plan. (2) A diagnosis should be made even in the early stages. (3) Operation made during the acute stage is al- ways dangerous, inasmuch as it adds unnecessary traumatism to the condition. (4) Removing the appendix does not stop the progress of the disease, as it has done all the mischief that it can. (5) Operation should be made after convalescence is well established, as there is always danger of other attacks. (t») With care the operation is almost entirely free from mortality — ought not to exceed three or four per cent. (7) Properly performed, and the parts thoroughly cleansed, drainage is not only unnecessary, but unsafe. THE BOSTON MedicalandSurgical Journal. A FIRST-CLASS WEEKLY MEDICAL PUBLISHED EVERY THURSDAY. Two Volumes yearly, beginning with the first Nos. in January and July. But Subscriptions may begin at any time. 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