SOME UNUSUAL CASES OF APPENDICITIS. By WILLIAM B. VAN LENNEP, A. M., M.D. Philadelphia, Pa. Reprinted from the North American Journal of Homceopathy. April, 1897. SOME UNUSUAL CASES OF APPENDICITIS* By WILLIAM B. VAN LENNEP, A.M., M.D. Philadelphia, Pa. IT fell to my lot during the year 1895 operate fifty-one times for appendicitis and it was my good fortune to have but one fatal case among this number. Any elation over such a record was dispelled by an experience of six deaths in an equal number of cases operated so far this year. I have already given my experience with this disease prior to 1895 an(f hope to make a critical analysis of that of the two subse- quent years a part of a future paper, but there are three among this number which deserve especial mention, the one as a most excep- tional recovery and the other two as pathological rarities. 1. Gangrenous appendicitis; universal septic peritonitis; operation; recovery. Dr.--,24 years old, after feeling uncomfortable in the right iliac fossa for several days was taken with the typical symptoms of acute appendicitis. When seen by me thirty-six hours after the onset, he had been freely purged and was comparatively comfortable-in fact, he expressed himself as feeling decidedly better, the improve- ment having appeared the preceding day after very severe pain. The chart showed a gradually rising temperature and, particularly, a quickening pulse. Palpation demonstrated rigidity and exquisite tenderness running downward and inward, with vague tumefaction and, above all, gave the impression that the belly was becoming distended, this being especially noticeable in the epigastric valley. Auscultation elicited a scarcity of gurgles, and careful observation impressed one with at least an approaching abdominal face. After consultation operation was undertaken, over forty hours from the inception of the attack. The appendix was gangrenous, perforated in spots and but partially protected by adhesions. The abdomen contained a quantity of stinking sero-pus which ran down the lateral gutter, filled the pelvis and was nowhere walled off by protective adhesions. By means of an oblique incision from the ribs *Read before the Inter-State Homoeopathic Medical Society at Scranton, October 29, 1896. Papers in Surgery. 2 to the groin, supplemented by another at right angles running to the umbilicus, complete evisceration was accomplished. Each in- testinal coil was carefully wiped with sublimate mops and replaced, the parietal peritoneum and pelvis were treated in like manner, and the whole abdominal cavity freely packed in every direction with iodoform gauze, six or seven yards being used. The wound was left open and occluded with sterilized bichloride dressings. In similar cases I have drawn out coil after coil of cloudy or flake-covered intestine until glistening ones were found, showing the peritonitis to be limited. Here the peritoneum, parietal and visceral, glistened nowhere and stinking pus was everywhere. To our surprise the patient made an uninterrupted recovery. A week later the extensive wound was sutured and united per primam throughout. Now, nearly seventeen months later, the abdominal wall is strong and firm and the patient is in perfect health with well functionating bowels. 2. Tubercular ulceration of small intestine and appendix-, tuber- cular peritonitis; operation; recovery. Mr. , 26 years old, was seen December 9th, 1895 with Dr. J. Edward Wright, when recovering from the last of a number of at- tacks which had extended over several years. The patient was sallow, emaciated and subject to alternating diarrhoea and constipa- tion. The abdomen was moderately distended, especially so in con- trast with the thin body, and gave a vague impression of contain- ing fluid. The right rectus muscle was rigid, and there was a dis- tinct and tender tumor extending from Me Burney's point downward to the groin. There was a persistent evening rise in temperature. hour days later the abdomen was opened by the oblique inci- sion. A moderate quantity of slightly turbid serum was evacuated and the intestinal coils found intensely congested and covered with miliary tubercles. On separating the mass of adhesions extending from the caput coli to the internal inguinal ring, the appendix ap- peared acutely bent on itself and pointing to the left, perforated near its tip, the opening being surrounded by a grey slough and the leak sealed by an omental adhesion. Two similar perforations and sloughs, involving about half the circumference of the ileum, were also exposed. Following the suggestion of Cliaput {Revue de Chi- rurgie. May, 1891,) these defects were covered with pads of iodoform gauze and the wound left open. The patient made a slow recovery complicated by high tempera- ture and prostrating diarrhoea and sweats. Dangerous obstruction from an acute flexion was relieved by removing the gauze pack. Some Unusual Cases of Appendicitis : Vau Lennep. 3 The wound healed by granulation and the cicatrix is supported by a flat pad. The ultimate result, however, has been remarkable, the bowel functions being perfect and the gain in weight and im- provement in general health striking. 3. Relapsing appendicitis; carcinoma of ccecum; excision; remote death. Mr. , 36 years old, seen with Dr. Wm.W. Van Baun during a subsiding typical attack of relapsing appendicitis. He had been subject to such seizures for several years which had been variously diagnosed by previous attendants. Recently a hard nodular tumor had been developing about the caput coli, which was not tender to pressure except at a definite point on its outer side. Incision showed a large, much thickened, deeply congested and acutely bent appendix curled outward and upward and corresponding with the point of tenderness. Beginning in its base and spreading up the caecum to the ileo-colic junction was a hard growth fungating inward. Several mesenteric glands were infiltrated. The ileum was cut across some inches above its end, the terminal portion sutured, and the proxi- mal end implanted into the colon well above the tumor by means of Murphy buttons. The caecum was turned out and the abdomen packed with iodoform gauze. Eleven days later the caecum, ter- minal ileum and mesentery were excised. The buttons had not become completely detached but were hanging by a shred, producing an ob- struction which caused a faecal leak. Bowel movements, however, were regularly passed per rectum until the day he was to leave the hospital, over six weeks after the first operation, when he vomited, became distended and died. Probably a leak took place from a ster- coral abscess, breaking through the protective adhesions. Dr. P. Sharpes Hall, pathologist to the Hahnemann Hospital and College, found the growth to be an adeno-carcinoma originating in an appendix which had been the seat of chronic inflammatory changes. These cases, while rarities, and as such worthy of record, present each of them to the thoughtful practitioner, a moral-instructive to me I am sure, possibly trite to some members of this society. 1. Recurring attacks of appendicitis call for operation not only on account of the well-known dangers of each succeeding seizure, but because the door is opened to the cousin of epithelial irritation, carcinoma, the cicatricial stroma needing but the alveoli filled with cells to complete the heterologous picture. 2. Tubercular peritonitis, if of the ascitic form, is curable by abdominal section and drainage as is well-known. So is an associ- 4 Papers in Surgery. ated intestinal ulceration which even threatens perforation, as is proven by this case. A tubercular appendicitis is a possibility and one easily removed by operation. 3. General septic peritonitis of appendicular origin is rarely, very rarely cured by operation. My previous report has shown this to be my greatest, in fact my only source of mortality. A study of the surgical literature demonstrates that the same is true with all opera- tors. The result in this case was a most unusual and fortunate one, but the moral is equally impressive. Had Nature succeeded in walling off the infection a comparatively innocuous abscess would have resulted. If we make an immediate diagnosis, exclusive or conclusive of appendicitis, in every case of belly ache; if we operate every such case when an ordinary attack of indigestion should have subsided, or at least given undoubted promise of so doing, say twelve, eighteen or even twenty-four hours after the onset, we will have fully earned the title to which alone we can aspire of being able seconds to the vis medicatrix Natures.