APPENDICITIS.* BY WILLIAM L. RODMAN, M.D., Professor of the Principles of Surgery and Clinical Surgery depend much upon the severity and type of the inflammation. Catarrhal, ulcerative, and gangrenous appendicitis present different clinical features. In general, we may say that after more or less imprudent eating the patient begins to vomit and complain of abdominal colicky pain that is accentuated about the umbilicus. It soon becomes greater over the McBurney point, which is midway between the anterior, superior, spinous process of the ilium and umbilicus. Tenderness to pressure is nearly always marked at this point. Fever will usually be moderate, tongue furred, and bowels confined. The pulse varies with the type and severity of the disease, and is a far truer index to what is going on than the temperature-curve. An ascending pulse almost demands operative treatment. GENTLEMEN: I shall have the pleasure of bringing before you presently two cases of appendicitis. The first, now being etherized, is one in which we operate principally to prevent future trouble, as he has just gotten over his fifth attack and it was a very severe one. The second operation promises but little, as the man was brought into the hospital an hour ago with general peritonitis, which, in a young man, is presumably due to appendicular disease. The two cases-one recovering, the other almost sure to eventuate fatally-should make an impression upon you and, to a degree, guide you in your future practice. It will be imAs to prognosis, we can say that a vast possible for me to review the subject of majority of cases survive the first attack; appendicitis to-day, but in the few moments but, unfortunately, many of these will have we have while our patient is being etherized second, third, and more attacks, until one we can give you a few practical hints as to proves fatal. Post-mortem examinations the cause, diagnosis, prognosis, and treat- show that one-third of all people examined ment of appendicitis. have had sometime during life appendicular The causes are mechanical and bacterio-inflammation. This is more than is claimed logical: the former, thought to be so com- clinically, frequent as we know the disease mon formerly, are now known to be comto be. paratively rare, constituting only about 5 per cent. of the cases. The bacterium coli commune is the germ supposed to be active in the causation of appendicular inflammation. It is always present in the gut, and when, from any cause, as mechanical interference with the circulation of the appendix, diarrhoea, constipation, the normal physiological resistance of the mucous membrane is diminished, this germ at once begins its destructive work. It may be assisted by the streptococcus pyogenes. Appendicitis is, by far, more common in young adults than the extremes of life, and many times more frequent in men than women: due, according to Claudo, to a better blood-supply in the appendix of women. The symptoms of appendicitis will * Delivered in the Medico-Chirurgical Hospital. The treatment is to be medical and surgical. Early in the disease a purgative may be given-and of all calomel is best-and its result awaited. When the bowels have been well emptied the vomiting, pain, and other symptoms may disappear quickly. Opium should not be given at this stage, for it masks symptoms and obscures the diagnosis. If the purge has not brought about a decided amelioration in the symptoms, and if, in addition, the pulse is ascending, I feel that the case will sooner or later demand operation and prefer to offer surgical relief early when conditions are favorable to suc cess. But, the patient is now before us, and I must postpone further discussion until another time. Our first patient is a man who was sent to us by Dr. Brown. He was attacked by appendicitis two weeks ago. He was at once purged by means of castor-oil. As the tympanites was but moderate, the temperature not more than 100° or 100.5°, the pulse good and not much over 80, it was thought safe to treat him medically for a short time. Free purgation caused a marked and almost sudden improvement. This is, however, the patient's fourth or fifth attack. For this reason the medical attendant, the patient, and his family felt that radical methods should be adopted and the appendix removed. With that view I coincide, and therefore bring him before you for operation. The results are more satisfactory when the operation is done between attacks, during a period f quiescence, and not at the height of the inflammatory process. The latter course I shall unfortunately be compelled to pursue in a second case of the same disease, admitted to the hospital this morning. The incision is usually made not quite midway between the spine of the ilium and umbilicus, but rather nearer to the spinous process. The tendency, in fact, is to approach more and more closely to the spine. The knife is carried in the direction of the fibres of the external oblique muscle. Lately the McBurney incision has become popular. According to this method, the abdominal wall is severed separately in the direction of the fibres of the external and internal oblique muscles. The former are parallel with the incision through the skin, while the latter are transverse. I shall follow this method in the present case. I have now divided the skin and have come down upon the external oblique. Following McBurney, I shall endeavor to separate rather than divide its fibres. The internal oblique and transversalis have practically one direction. I now separate their fibres in the same manner as I did those of the external muscle. This method is more tedious than dividing the three muscles in the same direction, but there are anatomical reasons for the procedure when it can be done. The advantage of McBurney's method is that the danger of ventral hernia is appreciably lessened. Its disadvantages are that it is less rapid and gives the surgeon less room. In a certai - class of cases, therefore, it is not applicable. I have now entered the abdominal cavity and feel for the appendix. Nothing is more variable than the position of this structure. It is usually directed backward and inward, but in this case I find it pointing downward and outward; just the reverse of what might be expected. I say that I have found the appendix. It must be either the appendix or the diverticulum of Meckel which lies beneath my eye. In event of doubt one must search for the longitudinal striæ indicative of the large gut, as the small intestine has no longitudinal folds. These striæ I have not yet detected, but have little doubt that I am in contact with the cæcum. Yes, I have undoubtedly identified the entrance of the appendix into the cæcum. The appendix is distended with a fluid very much like gelatin. It is also adherent and attached at its inner half. Now, I shall dissect up the peritoneal coat of the appendix just as I should reflect the skin and superficial fascia in doing a circular flap amputation of the arm or leg. I wish to cover the end of the appendix with a peritoneal cuff. Beneath the cuff I apply a ligature to the base of the appendix. There are many ways of treating the appendix. Many surgeons ligate it after stripping back the peritoneal layer. The argument in favor of the cuff is that it gives a peritoneal covering to the end of the stump. Many look upon this as no advantage. Other operators, again, cut the appendix on a level with the cæcum and suture the opening with the Lembert suture. The walls of this appendix are very thin. Now you can see the stump before it is returned to the abdominal cavity. There is much evidence of the existence of recent inflammation, the parts being greatly congested. I close the abdominal wall by three rows of sutures, using the running catgut for peritoneum and muscles. In finishing the McBurney operation many do not suture the muscles, but simply let the fibres fall together, as they have been separated and not divided. I prefer, however, to This is the kind of a case in which it is justifiable to wait and try the chance which purgation affords. Many cases are capable of being relieved in this manner. suture them with catgut. Finally, the skin | Why not irrigate the entire abdominal is brought together with silk-worm gut cavity? I reply that irrigation dissemisutures. The ordinary section dressing is nates infection. Nothing would be gained applied. and much might be lost. It is true there is but little effort on the part of nature to circumscribe the inflammation in this case, but I will follow a safe rule and use gauze freely and decline to irrigate; by doing so. I shall not take an active part in spreading the septic inflammation. I have no doubt that the peritonitis has, in this case, become general, and that the man has scarcely a chance in a hundred or even a thousand to survive the attack. Suppurating peritonitis is practically always fatal in such cases. The second case is of a different type and scarcely admits of delay. It is dangerous to give purgatives in appendicitis after the first few days, as they may then cause rupture of the appendix. This is a septic case, and I shall not here attempt McBurney's operation, but incise directly through the wall of the abdomen as I shall need more room than in the preceding case. The muscular fibres will all be cut in the same direction. No, gentlemen, we will not irrigate, but wipe away, as much as possible, the contents of the peritoneal cavity and, as well as we can, wall off the seat of disease with iodoform gauze. A piece of the gut which I have drawn out is deeply engorged and dark-purple lines indicate stasis of the circulation, with threatened sphacelus. I will insert a drainage-tube and close the wound. The abscess had burst into the general our hands too late. It appears that the physician who sent the case to the hospital recognized the extreme danger and I have operated immediately in order to fulfill a duty and give the patient the benefit of the slim chance which surgery offers. This man was taken ill four days ago with severe pain about the umbilicus. The pain is usually in this situation at first and subsequently becomes localized at a point midway between the umbilicus and right iliac line. Vomiting has been a marked feature of the case and, indeed, is characteristic of the disease. There is much tympan-peritoneal cavity. The case has come into ites. It is stated that there has been no action of the bowels since the beginning of the attack. The pulse is 120 and weak. The symptoms are urgent. There is no time to give purgatives and wait the results. The man's condition is already critical and he has, I fear, general peritonitis. The line of external incision is the same as in the first case. I carry the knife at once through all the abdominal muscles. I enter the peritoneal cavity and am met with a gush of pus. The whole cavity is filled with pus. We roll the patient upon his side and an abundance of foul-smelling pus escapes. Unfortunately, the abscess has not been shut off from the general abdominal cavity, as occurs in most cases. The entire peritoneum seems to be infected. In such a case as the present it would not be good practice to make prolonged search for the appendix. If it presents, take it out, but, if it be not easily found, give up the search and do not break up adhesions, which are protective. We will carry a rubber drain down to the point pus issues from. You may ask me: These two cases constitute an impressive lesson. The first exemplifies the wisdom of waiting and the second the unwisdom. I have said that in the latter case there is scarcely a hope. Yet, results are sometimes better than we expect. Three mornings ago I had a case of gunshot wound of the abdomen. I cut down and sutured the bowel and expected the patient to die within twenty-four hours. Fifty-two hours had intervened between the injury and operation and there was fæcal extravasation, causing general peritonitis. The patient, however, is doing well, with a pulse of 96 and a temperature of 98.5°. His pulse was 120 and temperature 1011° before the operation. His mind is clear, he seems to have more than a fighting chance, and will probably recover. I do not know see. of recovery in any similar case. I have not | six hours. Union is by first intention examined the statistics lately, but several throughout without a drop of pus, as you years ago I had occasion to do so and found that no successful laparotomy had been performed when more than forty-eight hours had passed before surgical intervention. I was rather sorry to receive the second case of appendicitis at this time, as it interrupted the purposed order of the clinic. I had several interesting cases which I had intended to show. One was that of a boy, a sciagraph of whose arm had been taken. The boy had suffered a fracture of the external condyle of the humerus. Either at the time, or, more probably, since, the musculo-spiral nerve had been bound down by the callus and as a consequence there was paralysis of the forearm and fingers. You can map out the territory supplied by the nerve. The nutrition of all this area is depressed. The boy cannot extend his fingers or supinate his hand. I may call your attention briefly to the breast-case operated upon at the last clinic. The temperature has never been over 99°. There has been an absolutely uneventful convalescence. She has had no worse trouble than a certain discomfort due to the position of the arm, bandaged against the side. I had expected to remove half of the stitches to-day, but shall be able to take them all out, as union is so firm. In the operation the axilla was thoroughly cleaned of all its glands, fat, and everything suspicious, leaving only vessels and nerves. The fascial covering of the great pectoral was removed, but the muscular structure was left intact. It is only necessary to excise the muscle in advanced cases. In a recent case I removed both the great and small pectoral muscles, but that was a third operation. In the present instance the muscular tissue was not involved. Heidenhain has shown that the lymph-current tends rather toward the skin and that it usually suffices to take away the fascia. A last case is that of a man on whom, two weeks ago, I performed suprapubic cystotomy on account of cystitis. The bladder trouble was supposed to be due to disease of one or both kidneys; probably both, to judge from the history. The patient has done well, he is free from symptoms, and wishes to go home. Before discharging him, however, I desire to explore the bladder, catheterize the ureters, and determine positively the condition of the renal organs. If both are diseased he will be allowed to go, as nothing can then be done. But if only one be involved I shall propose a nephrotomy, [making a lumbar incision, draining the organ, and treating it in the same manner as an abscess in any other situation. The history is strongly suggestive of pyelitis. The results of chemical and microscopical examination strengthen this suspicion. When an acid urine contains a large amount of pus, we can generally be reasonably sure that the disease is presumably pyelitis. If the pus come from the bladder alone the urine has an alkaline reaction. No tube-casts were discovered. The male ureters can be catheterized, though the operation is not easy, even after suprapubic section. If the bladder be intact. the feat is difficult always or, perhaps, impossible in some cases. The procedure is easy in the female where the urethra is large and distensible. The interior of the bladder can be exposed and we can see the ureters. In the male this can only be done by aid of the cystoscope. The bladder has been drained by means of a rubber tube passed well into the viscus with iodoform gauze and the urine passes through into a bottle placed beneath the bed. Some writers-Treves among others -believe that the bladder cannot be thus After the operation a drainage-tube was drained. Treves says-I quote from memleft in place for thirty-six hours. I am a ory-that "all forms of siphon drainage are believer in drainage. After the wound is a delusion and a snare." My own expericlosed the arm is bound to the side in order ence contradicts this assertion. I have that it shall not tear apart the edges. The found that the bladder can be perfectly limb can be released at the end of thirty- | drained. There has been, in this case, no leakage around the tube and the skin is not gramme or half-gramme of the extract, it even reddened. The manipulation will be painful and I shall have the patient placed under the influence of chloroform; as that is the safer agent to employ in cases of damaged kidney. Professor Senn advises that cystotomy be done in two stages,-first cutting down to the bladder and packing the wound in order to establish a granulating sinus, and incising the bladder upon the fifth day. I am not disposed to think that there is any advantage in thus dividing the operation, at least in most instances. In very septic urine there is an advantage. The edges of the wound are retracted by my assistants and the interior of the bladder is thoroughly cleansed and dried by means of sterilized cotton. Introducing the cystoscope and turning on the current, I can plainly discern the orifices of the ureters. From that of the right side there issues a drop of pus. He has always complained of more pain on the right side. The left ureter is found and the same condition seems to appear. Therefore our original diagnosis of pyelitis, presumably on both sides—for it is usually bilateral, stands, and we will do nothing further. means so much of the filtered infusion that would correspond to that amount of the powder. The second-line in the figures serves also as abscissa-line. ADRENALS. Brown-Séquard found in 1858 that extirpation of the adrenals was followed by death, an observation confirmed by Tizzoni. Pellacani and Foà state that the subcutaneous use of the extract of the adrenals produced death, lowered the temperature, and, in some cases, produced somnolence, general prostration, paralysis, loss of sensibility, frequent and superficial respiration, increased heart-beat, and elevation of temperature. In the frogs it diminished the reflexes. Marino-Zucco found that the extract of the suprarenal capsules contained neurin, and the action of the adrenals was due to neurin. Abelous and Langlois found that the removal of the adrenals was followed by a toxin accumulating in the blood which acted like curare. Oliver and Shäfer* found that it increased the pulse and respiration, and the temperature, which afterward fell. It generally produced death in rabbits. They found that in frogs it produced a paralysis which is not due to any action like curare, but is central in origin. They also discovered Original Communications. that the active principle resides in the ANIMAL EXTRACTS. BY ISAAC OTT, M.D., Professor of Physiology in the Medico-Chirurgical College of Philadelphia. THE animal extracts used by me were in a state of dry powder procured from the house of Armour & Co., of Chicago. When used, the powder was rubbed up in a mortar with a definite amount of water, and then filtered through absorbent cotton. The filtrate was used either per jugular or subcutaneously. The experiments were performed upon frogs and rabbits. Last year I published a short note on the animal extracts, but the pressure of other duties prevented a continuance of experiments. When it is stated in experiments as a medulla of the gland. It increases the tone of all muscular tissue, and chiefly by a direct action. Removal of the adrenals produced a weakness of the heart and muscular system and a great want of tone in the vascular system. They found that it produced invariably a rise of blood-pressure due to a direct action of the active principle of the gland upon the muscular tissue of the blood-vessels. This rise takes place whether the vagi be cut or after an injection of atropine. This rise of blood-pressure is partly caused by increased activity of the heart, but chiefly by an action upon the arterioles. It also inhibits the auricles of the mammalian heart when the vagi are intact; but destruction of the medulla, * Journal of Physiology, 1895. |