Appendicitis: A Year's Experience in Private Practice

J. W. ELLIOT
1891 Boston Medical and Surgical Journal  
saw thirteen cases of appendicitis in private practice, being called in consultation as a surgeon to take the responsibility of operating or not. Of these caseB, six were operated and seven were not operated. Four of the operated, and all of the non-operated recovered ; making a total of thirteen cases, with eleven recoveries and two deaths. Of course, these figures cannot be used to show the comparative mortality of operated aud non-operated cases, as in this instance all the worst cases were
more » ... perated, while the less severe ones were left to recover, and I should consider it a grave error in judgment if any case were allowed to die unoperated on, if seen in time. These results are more favorable than I have had in any previous year. This I attribute partly to increased experience, but principally to the fact that I have seen these cases much earlier than formerly. Seven of the cases were seen within the first three days of the attack, whereas, in former years I have usually been called on tho seventh or eighth day. If practitioners always called their consultations on the second or third day, tho mortality would be much lower than it is at present. PEKFOBATED GANGEENOUS APPENDIX, TOGETHEE WITH PAET OF THE OMENTUM EEMOVED ON THE TIIIBD DAY : EECOVERY. Case II. Miss Mary G., aged fifty, was seen in consultation with Dr. Prior of Maiden, late at night, April 7, 1890. A month earlier she had had a chill. She was taken three days before with sudden acute pain in the right lower abdomen. Chills and vomiting soon followed. Morphia was given. When I saw her she had a listless, drowsy, sick expression. The abdomen was generally swollen and tympanitic. There was tenderness and slight induration on the right side. The bowels were constipated. Temperature 101.2°, pulse 92. The next morning there was no change in symptoms ; abdomen very tense ; bad expression. At a consultation with Drs. Sullivan and Prior an immediate operation was decided on. The operation was difficult on account of a poor light in a small room, and a very fat patieut. The incision was two inches inside the anterior superior spine of tho ilium, in the linea semilunaris. When the peritoneal cavity/vas opened, the omentum presented. It was inflamed, thickened, aud adherent in every direction ; and it was very difficult to get beyond it. It was finally pushed aside, and the finger went into a mesh of adhesions which felt like a cobweb, and seemed to extend in every direction ; the Ciccum was reached, but the appendix could not be found in this mass of adhesions. There was no indication in which direction to search. Finally in desperation I tore the whole omentum free, and pulled it out through the wound. On.its thickened and inflamed edge I noticed a deep gangrenous groove about large enough to hold a finger. From a former experience where I had found the appendix wrapped in the omentum, I immediately realized that this was the mark of the sloughing appendix ; enlarging the wound and searching in the direction whence this part of the omenttuin came, I found tho appendix very low in the iliac fossa, much thickened, so that when free it stood erect on the cicciim, resembling a man's thumb in size and shape. It was so gangrenous that it filled the room with a vile stench. I ligated it at its base, and cut it away. I also cut away a large part of the inflamed omentum which had been lying against the appendix, because it had evidently become infected with the gangrenous process. There was not a drop of pus to be found. After disinfecting the appendix stump, tho region which had been occupied by the appendix was filled with iodoform gauze and drainage-tube and the wound left open. The appendix and its mesentery wero thickened to about the size of a large thumb, and about two inches long. The appendix was gangrenous and perforated. The omentum removed was about the size of a hand, very dense and inflamed, and showed a deep hollow where it had wrapped itself about the appendix. This hollow was intensely inflamed, aud on its surface the gangrenous process was beginning. The temperature fell to normal on the next day. The iodoform gauze was removed on April 10th, when the tympanites had entirely disappeared. The bowels moved spontaneously on the fifth day. The wound healed beautifully without complications. Pier convalescence was retarded and protracted first by a localized pueumonia on the left side on April 21st, the temperature rising to 102°, and by a crural thrombosis also on the left side, which made its appearance on April 27th, just as the lung trouble was beginning to mend. These processes were undoubtedly septic, having their origin in tho already infected omentum, as the wouud always looked healthy. She sat up on May 15th. In July a small point in the wouud opened, and in November the ligature was removed by Dr. Prior. Recovery was complete. BECOVEBY AFTEB TWO MONTHS, WITHOUT OPEBA-TION. Case III. Mrs. N., fifty-four years old, was seen April 27th, for Dr. H. W. Cushing (in his absence from town), on the third day of tho attack. The attack began with sudden, severe pain in tho right side, with vomiting and constipation, and a sharp rise in the temperature (102°). During the first two days there was a gradual abatement of the symptoms, the temperature falling to 100°. On the third and fourth day all the symptoms were worse. There was more pain aud tenderness, and the temperature rose to 102°. The abdomen was somewhat distended, and there was great sensitiveness to pressure in the right side. Operation was advised and refused. On the following day there was a great improvement in ull the symptoms, which lasted for several days. When Been again on May 10th, the pulse was 110, and the temperature 101.8°. The abdomen was swollen and tympanitic. The right iliac region was filled with a hard mass which was tender aud painful. It extended nearly across tho lower part of the abdomen and down into the pelvis, pushing the uterus over to the left side. Drs. Fitz aud Homans saw her, and advised against operation. With the rest in bed, all the symptoms slowly and gradually subsided, and the patient recovered after an illness of over two months.
doi:10.1056/nejm189105211242101 fatcat:jg4e56goizgxzpohgzsckf6ume