A CASE OF'APPENDICITIS OCCURRING ON THE SEVENTH DAY FOLLOWING LABOR. Rupture into the Bowel. Recovery. BY / REUBEN PETERSON, M.D., GYNECOLOGIST TO ST. MARK'S HOSPITAL, GRAND RAPIDS, MICH. FROM THE MEDICAL NEWS, May 13, 1893. [Reprinted from The Medical News, May 13, 1893.] A CASE OF APPENDICITIS OCCURRING ON THE SEVENTH DAY FOLLOWING LABOR; RUP- TURE INTO THE BOWEL; RECOVERY. By REUBEN PETERSObt M.D., GYNECOLOGIST TO ST. MARK'S HOSPITAL, GRAND RAPIDS, MICH. On November 29, 1892, I attended Mrs. S. in her fourth confinement. The labor was short and perfectly normal, and at 9 p.m. she was safely delivered of a nine- pound infant. The strictest antiseptic precautions were employed during and after the labor. The bowels were moved by an enema on the third day, and on the even- ing of the fifth day a mild laxative was administered, which was followed by a free evacuation the next morn- ing. The temperature for the first week after the con- finement never rose above ioo°, and the patient even remarked that she had never done as well in her previous confinements. On Tuesday, December 6th, I visited the patient at 7 p.m. for the purpose of giving directions about placing the infant upon an artificial food, the maternal milk- supply having proved inadequate. The mother at this time was feeling perfectly well, and was told that she might sit up in two or three days. My surprise, and, I may say, my chagrin, was great when I was hastily sum- moned two hours later to find the patient just recovering from a severe chill, with a temperature of 1030 and a pulse of 120. Naturally my first thought was of sepsis in some form, but a most careful examination failed to reveal anything of this nature. The abdomen was perfectly flaccid, and thorough palpation showed no tenderness. 2 either in the region of the uterus or elsewhere. The lochia were perfectly sweet and normal in every par- ticular. Vaginal examination was also negative, and failed to show evidence of any pus-tube or para- metric inflammation. So sure was I that some other than a septic trouble was the cause of the chill, that I questioned the patient closely in regard to her previous history, and felt relieved when told that she had had " malaria " some years before, although she had never had any chills accompanying it. As she had formerly resided in a malarial district, and as the temperature the next morning was normal, although the pulse was 90, I judged that it might be a case of malaria, and, as not infrequently occurs in women who have been subject to this disease, that it had manifested itself during the puerperium as a chill. This diagnosis I was forced to make from an absence of physical signs indicative of anything else, but I watched closely for any symptoms that would warrant a change of mind as to the cause of the chill. While I was waiting I gave quinine until its physiologic effects were manifest. On Thursday, December 8th, two days after the chill, the temperature, which had been normal during the day following the seizure, rose to 1010, although there were no chilly sensations. There was no abdominal tender- ness, and the lochia remained normal. I ordered two tablespoonfuls of Epsom salts, with the idea that if a septic trouble existed it might be aborted by a thorough depletion of the peritoneum by means of copious watery dejections. During the afternoon and evening of De- cember 8th the bowels moved frequently, in all as many as ten times. The next morning the patient began to be troubled with flatus, and at noon I found the abdomen moderately distended, and for the first time was enabled to locate some tenderness over the right side. The abdomen was not so distended as to 3 prevent me from readily mapping out the uterus. The gas seemed to be collected principally in the ascending colon, which could be plainly outlined beneath the abdominal walls. The tenderness was not especially marked in the region of the appendix, and was at no time severe, but simply sufficient to enable one to detect it upon deep pressure. A moderate degree of dulness could be ob- tained over the whole right side of the abdomen by making use of light percussion and disregarding the tympanitic note. The patient complained of a dull pain in the right hypochondriac region, and noticed that she could not turn from one side to the other with as much freedom as formerly, and that when she lay upon the left side there was a sense of dragging in the opposite side. On Saturday, December loth, there was more pain on the right side, but it was still located high up in the region of the liver. It was not the acute, sharp pain in- dicative of peritoneal inflammation, but more of a dull ache or uncomfortable feeling, and was increased by movement. Although it seemed impossible that the trouble was in any way connected with the uterus, I again examined the pelvic organs thoroughly and found them perfectly normal. On Saturday evening, Decem- ber 10th, the diagnosis was quite clear, for the tender- ness began to be localized in the right iliac fossa, and a sense of resistance, but no distinct tumor, could be made out. Up to this time there had been no tender- ness over McBurney's point, but now this sign began to show itself, though the tenderness was not marked. During the next three days the symptoms became more severe. The temperature ranged from ioo° in the morning to 102.50 at night, the pulse remaining at about 100 most of the time. The tongue became coated, the appetite poor, but the patient's condition was at no time alarming. The tenderness in the right iliac fossa was most pronounced about one week after the initial chill, when it and the sense of weight in the right side be- 4 came less pronounced after a free evacuation of the bowels following a dose of castor oil. A well-defined, deep-seated tumor could be made out at this time in the region of the appendix, sausage-shaped, and extending down to the brim of the pelvis. It was non-adherent to the abdominal walls, and no fluctuation could be de- tected. The point of maximium tenderness was at the extreme end of the mass, but the sensitiveness was never very great, and deep pressure was necessary in order to make the patient complain of pain. There was but little abdominal distention, and what existed disappeared after each evacuation. The treatment consisted in the administration of ounce- doses of castor oil once or twice a day, and the frequent employment of turpentine enemas, so that from two to four free daily evacuations were secured. The diet was restricted to peptonized milk and broths. Turpentine stupes were applied to the abdomen at the time when the pain was located over the liver, but these were dis- continued upon the cessation of the pain, and local treatment was limited to daily applications of tincture of iodine over the right iliac region. On December 14th, eight days after the initial chill, the tenderness began to subside, and the patient could move from side to side with much more ease. The tumor, however, could still be plainly outlined, but showed no signs of fluctuation. In spite of these encouraging symptoms, the tempera- ture and pulse remained high, and the patient felt most of the time as if bordering upon a chill. On December 16th the conditions remained practi- cally unchanged, and Dr. Eugene Boise was called in consultation, who, after a thorough examination of the patient, confirmed my diagnosis and coincided with me in the opinion that it would be better to await developments than to run the risks attendant upon an endeavor to drain an abscess-cavity in the region of the appendix, when no adhesions to the abdominal wall existed. The 5 dangers and possibilities of a fatal outcome on the ex- pectant plan of treatment were fully considered, but we decided, in view of the absence of alarming symptoms, to wait at least twenty-four hours, and in the meantime to make preparations to operate at any moment in case the necessity arose. The following morning the patient's temperature was normal and her pulse 76, and she passed quite a quan- tity of pus from the bowels. From this time on she made a rapid recovery. The temperature remained normal, the tongue became clear, the tumor gradually disappeared, and an examination made December 27th showed only a slight thickening. I have reported the foregoing case in detail for two reasons : First, because it is uncommon for the puerperal state to be complicated by an attack of appendicitis; and second, because it will place upon record a case of appendicitis with abscess, in which recovery took place without operation. While the diagnosis of appendicitis can usually be quite readily made, it was in this case by no means easy, from the fact of the absence of local signs and of the initial chill occurring seven days after labor. While the rigid requirements of modern antiseptic midwifery are fast reducing the mortality among puerperal women to a minimum, and while the accoucheur can, by a strict observance of these rules, feel almost certain that no germs have been carried from without into the parturient tract during or subsequently to labor, he is by no means as certain that sepsis may not originate from the absorp- tion of the germs lodged in a pus tube which has long existed, but which has not been diagnosticated. That this is not a fanciful cause of puerperal fever is attested by the ever-accumulating list of reported cases. Tait1 thinks it of enough importance to give in detail six cases reported by Dr. McDonald, in which puerperal 1 Abdominal Surgery, vol. i, p. 402. 6 fever originated from diseased appendages. Smith1 calls attention to pyosalpinx as a not infrequent cause of puerperal fever. And the number of single cases reported in the journals is considerable. Thus, while the attendant may be perfectly sure of his antisepsis, he is still unable, in the event of fever during the puerperium, to exclude sepsis arising from internal causes. And it was this uncertainty that gave rise to so much anxiety upon the occurrence of the chill in the case just reported, and which led to repeated examina- tions of the appendages before the localization of the tenderness and the appearance of the tumor in the right iliac fossa made the diagnosis of appendicitis clear. The different factors considered at the time were : I. Septic infection, originating in the vagina or endo- metrium. This was excluded by absence of foul lochia and of pathologic conditions, as revealed by careful digital and ocular examinations. 2. Sepsis, arising from some preexisting affection of the appendages. This was excluded by the absence of all signs of such an origin, as revealed by bimanual examination. 3. Latent malaria, manifesting itself during the puerperium in the form of a chill. This was excluded only after the localization of the symptoms in the right iliac fossa. 4. Some obscure renal trouble of the right side. This was excluded by careful palpation of the kidney and examination of the urine. 5. Appendicitis-easily diagnosticated upon the ap- pearance of the local signs. It may be claimed that recovery from an attack of appendicitis by the rupture of the abscess into the bowel is of too common occurrence to merit a detailed description ; but for a number of reasons it would seem as if these cases should be recorded. The accumula- 1 N. Y. Joum. Gyn. and Obst., Nov., 1892, vol. ii. 7 tion of such cases and a careful consideration of the existing conditions may lead to a more conservative treat- ment of the disease than is prevalent in some quarters. In demonstrating the fact that for the lack of surgical interference in cases of appendicitis many valuable lives have been sacrificed, the surgical world may possibly be going to the other extreme, and by a too hasty resort to the knife may be running the risk of not decreasing the mortality from this disease as much as would be possible under a more conservative course. The reasons against an operation and favorable to the expectant plan of treatment were : i. The physical signs indicated but little involvement of the peritoneum by the inflammatory process, and led us to suppose that pus, if present, was extra-peritoneal, and hence that less danger of intra-peritoneal rupture existed. 2. For three days previously to the rupture into the bowel the local signs were decreasing and not increasing. 3. The tumor was unattached to the abdominal wall, and the dangers were considerable of opening the gen- eral peritoneal cavity in an attempt to get at the pus, and thus starting up a general peritonitis. 4. While the general condition of the patient was not improving, it was growing no worse, and as the local tenderness was diminishing, it seemed highly probable that either the abscess would become attached to the abdominal wall, where it could be readily opened, or else be discharged through the bowel. On the other hand the indications calling for an oper- ation were: 1. The probability of the existence of pus, as indi- cated by rise of the temperature, the frequency of the pulse, and the presence of chilly sensations. 2. The advisability of giving exit to the pus through an abdominal incision, for fear the abscess otherwise might rupture into the peritoneal cavity and set up a general peritonitis. 8 The cases one sees most commonly reported are those in which the cure has resulted from surgical interference, and the scores of cases recovering without resort to the knife are likely to be lost sight of because they are not considered worth recording. Fitz, to whom so much credit is due for his researches upon appendicitis, has recently again called attention to the fact "that nearly one-half of the cases of appendi- citis get well without surgical treatment."1 And this statement was called forth by a paper in which the author claimed that every case of appendicitis should be operated upon as soon as the diagnosis was clear. It is against this attempt to establish a universal rule of procedure that we must guard. Every case must be considered separately, and, while fully alive to the dangers of temporizing when the symptoms indicate that the disease is progressing rapidly, we should ever be on the watch for symptoms that will allow us to dis- pense with the knife. " The tendency of the best sur- gical thought in regard to appendicitis is toward an enlightened radicalism."2 1 Boston Medical and Surgical Journal, August 4, 1892. 2 Editorial, MEDICAL NEWS, December 10, 1892. The Medical News. Established in 1843. * A WEEKL YMEDICAL NEWSPAPER. Subscription, $4.00 per Annum. The American Journal OF THE Medical Sciences. Established in 1820 A MONTHLY MEDICAL MAGAZINE. Subscription, $4.00 per Annum. COM MUTA TION RA TE, $7.50 PER ANNUM. LEA BROTHERS & CO. PHILADELPHIA.