DIFFUSE PERITONITIS FROM PERFORATION OF THE APPENDIX: ITS DIAGNOSIS AND TREATMENT, WITH A RECORD OF 14 CASES WITH 12 RECOVERIES
BMJ (Clinical Research Edition)
JAN. 13, i906.J PEIOII FROM PERFORATION OF APPENDIX. [MEDICAL JOCRN-AL 7I abdomen and over the appendix caused no pain. By rectal and bimanual examination there was felt high up an indistinct fullness, nothing definite, and he did not complain of my hurting him. 2 he only symptom that caused Ine any anxiety was his face; it wore an anxious expression. Leaving careful instructions that I was to be called if there was complaint of pain, I went into another ward. In less than half an hour the
... lf an hour the message came. The man was complaining of severe pain in the lower abdomen. I returned to him at once, and found that now there was very decided tenderness on pressure over the hypogastrium. My first examination had probably precipitated the rupture. As soon as possible I opened the abdomen, and found the end of a long appendix haniging over the brim of the pelvis. In the distal end were two concretions, and on the proximal side of the concretion a small perforation. He made an excellent recovery. I might report many more illustrative cases. TTIifortunately many of these are past relief when admitted to the hospital. This is largely due to the difficulty in diagnosis, and perhaps more to their deceptive course. A small perforation may occur, become walled off by adhesions, and lie in such a position that the usual examination of the abdomen does not detect it. How often the consulting surgeon is told by the family physician that at one visit the patient was to all appearances doing well and without ominous symptoms, and at the next visit evidenced more or less generalized pelitonitis, aind the patient in a semi-collapsed state! On December 9th, 1904,1 saw in consultation with Dr. W. Grant Stewart, a man 36 years of age, who gave the following history. Two years ago he had typhoid fever. This was followed by a condition thought to be tuberculous peritonitis. He was off work for seven or eight months. He described the onset of the present attack in the following words: " Tree days ago I was trying to lift a piece of machinery by using a plank as a lever, and resting my stomach against it. I was rather sore that evening, but was all right the next day, Wednesday. Early Thursday morning, while in bed, I vomited. Got up at the usual time, took a cup of coffee and a bit of toast, and went to the factory. Did not feel able to work, and started almost at once to return home. On the way I vomited from the rear end of the tramear." Dr. Stewart saw him at 5 p.m. on Thursday, and fouind him complaining of some epigastric pain; no marked tenderness. Temperature and pulse normal. The following morning his condition was nmich the same; temperature, 99.50; pulse, 100. In the afternoon there was tenderness on deep pressuire lower down over the pelvis; temperature, 100.50; pulse, 112. When I saw him that evening the abdomen was somewhat rounded up, but there was very little tenderness at any point. Deep pressure over the pelvic region caused some uneasiness. By rectal examination the end of the fingers could feel high up an indistinct sense of a mass, which was tender, and, on pressing forward, he said that it hurt him considerably. There being no improvement in his condition on the following morning (Saturday), Dr. Stewart sent him into the hospital, where he could be kept under observation. At noon, Saturday, I examined him most carefully, and could make out no definite tenderness, except per rectum. There was no vomiting, and he felt much better, and asked for more to eat. There was present only two symptoms, slight abdominal fullness and rectal tenderness-these two symptoms and the clinical history. His temperature was 990 and the pulse 80. There was a good deal of distress in urinating. I advised him to submit to immediate operation. " Well," he replied, slapping his abdomen, "II seem pretty well here, to have an operation, but I suppose you know best." Students and house-surgeons showed by their facial expression what they hardly cared to say-that I was most radical in advising an immediate operation with so few symptoms. On opening the abdomen I found an unusually long appendix. The proximal two-thirds seemed almost normal; the distal third dipped down over the brim of the pelvis, and was in part gangrenous, and contained a faecal concretion, on the proximal side of which was a small perforation. This diseased end lay in a small walled-off abscess. Perfect recovery. On Monday, December 26th, 1904, a young man, aged 33, was brought to me by Dr. Edgar of North Hatley. The condition was thought to be appendicitis. The illness was of ten days' duration. There had not been much pain but a good deal of vomiting. He complained of discomfort amounting almost to pain when he vomited. At the onset there had been pretty general abdominal tenderness. Dr. Edgar said, " he had been tender everywhere except over the appendix." On admission to the hospital there was considerable distension of the abdomen, together with a moderate degree of rigidity. The only place where there was any tenderness was on very deep pressure over the pelvic region, and there it was very little *indeed. There was certainly no tenderness over the usual situation of the appendix nor in the right loin. Per rectum there could be felt a distinct mass which was exceedingly *tender. --The slightest pressure of the fingers forward caused .him to: complain loudly and draw away. * peration on .the tenth day of illness and twenty-four hours after recurrence of sharp pain. When I opened the abdomen with the patient in the Trendelenhurg position, and the intestines pushed ouit of the way, I could see nothinig abnormal on looking into the pelvis except that there were two coils of small intestine which, althouigh somewhat reddened and rather distended, were evidently adherent below. After carefully protecting the general peritoneal cavity I gradually separated the coils of intestine from below and found a. perforated gangrenous appendix lying in an abscess cavity behiind the bladder. In this case the caecum had slid down and become a pelvic organ. Pain and distress durinig micturition, especially towards the end of the act, are very generally complained of in this condition. Recovery is sometimes slow. The abscess walls are largely those of the true pelvis and are fixed and unyieldinig. These clinical histories resemble each other in several particulars. There is the usual sudden onset of pain, and generally some inausea and perhaps vomiting. The pail} is ofteni more generalized than is usually the case. There will be only moderate elevation of temperature and acceleration of pulse. Tendernless on pressure, not marked, is complained of more when deep pressuire is made over the pelvic region than over the more usutl situations of the appendix. The diagnosis at the oniset is probably appendicitis, but the attendant does not feel certain about it. In twenty-four or forty-eight hours the symptoms have improved, and the diagnosis becomes still more uncertain. Then there occurs quite suddenly after a period of two, three, or four days of an apparently normal convalescenice, a sharp recrudescence, peritonitis develops, generally rapidly, and the condition of the patient soon becomes alarming. My special plea is that a routine rectal and bimanual examination by fully establishing an uncertain diagnosis, would suggest earlier operative treatment and lower the death-rate in this variety of disease. In operating upon these cases I have found the Trendelenburg position of great value. The small intestines can be carefully protected an-d the deep pelvic cavity brought into view. In this way one is able to proceed to the different stages of the operation with much more assurance of not doing injury to the already inflamed parts and the infected area can be made clean with greater precision and certainty. Drainage is always necessary. Convalescenice is usually slow. In only two instances have I thought it necessary to establish dependent drainage, through the vagina. In onie of these cases another surgeon had operated six weeks before and had carried a drainage tube from the bottom of the pelvis up through his lateral abdominal incision. A considerable cavity persisted with a good deal of purulent discharge. At his request and with his assistance I passed a tube up througlh the vault of the vaginia into the pelvic cavity. We botl thought that the dependent drainiage was an advantage, but the cavity did not close entirely until three months later.