Two Cases of Appendicitis. BY ROBERT MILBANK, M. D., VISITING PHYSICIAN TO THE NEW YORK INFANT ASYLUM. REPRINTED FROM ®t)8 Neto Vovk fHeUfcal journal for February 22, 1820. Reprinted from the New York Medical Journal for February 22, 1890. TWO CASES OF APPENDICITIS * By ROBERT MILBANK, M. D., VISITING PHYSICIAN TO THE NEW YORK INFANT ASYLUM. From a number of cases of appendicitis which I have seen I have selected the two following cases in the hope that the report of them might prove interesting and in- structive : Case I. No Operation ; Resolution; Recovery.-On the 29th of July last I was called to see a gentleman who was suf- fering from what he supposed to be an attack of acute indi- gestion, he having frequently suffered after eating different varieties of fruits and vegetables. He was a man of forty-five years of age, apparently in perfect health, excepting the trouble for which he called me. His habits were regular, he had in- dulged in no excesses, and was evidently strong physically as well as mentally. He was a minister of a foreign country to our Government. I found him walking about his room, occa- sionally striking his chest with his hand and complaining of intermittent attacks of pain. He told me that he had eaten, among other things, for his breakfast a saucer of blackberries, and that he had not had any comfort since about an hour after breakfast. He was quite sure that the indigestible berries which he had eaten for breakfast were causing all the trouble. He begged me to give him something, either in the way of a * Read at the annual meeting of the Northwestern Medical and Surgical Society, December 18, 1889. 2 TWO CASES OF APPENDICITIS. cathartic or something to promote the digestion of the offend- ing substance. He said that he occasionally suffered from these attacks of indigestion, and thoroughly understood what was the matter. He only sought medical advice for a remedy, but not for a diagnosis. I assured him that it would be impossible for me to intelligently diagnosticate his case or treat him with- out a careful physical examination. The recollection of sev- eral cases of severe abdominal disease which had passed unrec- ognized caused me to insist upon his going to bed immediately. He at first refused to undress, but proposed to compromise by lying on the lounge. He finally consented, was undressed, and went to bed. Upon examination, I found that he had severe pain extending all over the abdomen, but most severe in the epigastric region. He was tender on pressure at this point, perhaps rather more than at any other. The right iliac region presented another point of tenderness about two inches to the left and above the anterior superior spinous process. I found here a small tumor apparently about an inch and a half in length by three quarters of an inch in width. Light percussion showed dullness over this area. His temperature was 100'5 F. under the tongue; his pulse was 100, and had a sharp, quick, wiry character, somewhat hard to the touch. I suspected that he bad appendicitis, and informed one of his friends who was present that he was suffering from a grave disease, and advised sending for his wife and son, who were several hundred miles from the city. I also suggested a consultation, which was promptly refused, his friends feeling very positive that I had much overrated the severity of the trouble. I, however, per- suaded him to remain in bed and to allow me to procure a nurse for him. I used hot fomentations over the seat of the trouble, and administered enough Magendie's solution to keep him free from pain. I remained with him for a couple of hours, and, finding him very much relieved and somewhat drowsy, I left him for the night. I made an early visit the fol- lowing morning, and found his temperature 101'5°, his pulse 110, his respirations 16, and feeling very much more comforta- ble. He now asked permission to get up and dress. The epi- gastric pain had entirely gone, the abdominal pain was scarcely TWO CASES OF APPENDICITIS. 3 felt at all, but there was a little pain over the appendix. The tenderness on pressure was only present at this point. I insisted upon having a consultation, and called Dr. Charles K. Briddon, who saw him with me about noon. He confirmed my diag- nosis, and announced to the patient that bis life was in danger, and that we both thought an operation would probably have to be performed. The consultation led to the making of an appointment for the following day, unless urgent symptoms presented them- selves before that time. The hot fomentations were kept up, and an occasional small dose of Magendie's solution was given. A scanty liquid diet was ordered, and at mid- night the patient was feeling quite comfortable and was quite jocular over what he considered my unnecessary solicitude. His temperature and pulse at midnight were, respectively, 101'5° and 110. He passed a good night, sleeping fairly well, and in the morning his pulse was 100 and his temperature 101°. This was about his condition when Dr. Briddon saw him with me at noon. We decided to keep up the treatment and see him together again the following day. He rested well that night, and on the following morning his temperature was 100° and his pulse 90. At our consultation we decided that it would not be necessary to meet again the following day unless his symptoms changed. He was entirely free from pain, but still winced at the slightest pressure over the appendix. The mass had become reduced considerably in size and in dullness on percussion. In three days after this time his temperature, which had been normal, had a slight rise, being 100'4o. In a few hours it had fallen to normal. The tenderness over the appendix was very slight, and the patient was in all respects apparently well and desirous of getting up to resume his busi- ness. In a week he was allowed to take solid food in small quantities, and in less than three weeks from the time of the first attack he was walking around. He informed me that he had once had a similar attack while making a short stay in Brazil, and that an English physician who was there pronounced it an inflammation of a part of the large intestine near the point of entrance of the small intestine. 4 TWO CASES OF APPENDICITIS. Case II. Early Laparotomy; Recovery.-Mrs. L., aged twenty-four, married eight months, had menstruated regularly during this period. She gave no history of any previous dis- ease of any kind. She visited one of the theatres in this city on the 19th of November. During the performance she suf- fered somewhat from epigastric pain, which increased very much toward the close of the performance. She returned di- rectly to her home, and, by the advice of some friends, drank brandy and Jamaica ginger. The pain diminished slightly, but was still sufficiently severe to cause her to send for me. I ar- rived about one o'clock in the morning of November 20th, and found her in bed with diffuse abdominal pain radiating from the epigastrium, where it was most severe. Tenderness on press- ure was present all over the abdomen, the most tender point being in the right hypochondriac region. Temperature normal, pulse 72. I gave her five minims of Magendie's solution hypo- dermically. This, affording no relief, was repeated in about three quarters of an hour. By 2.45 she was considerably re- lieved and felt like going to sleep when I left her. At seven o'clock I was again called, the pain having re- turned with much severity. I found her pulse 112 and her sub- lingual temperature 100°. Pain localized over the appendix and slight pressure caused great distress. I made the diagnosis of appendicitis. Two hours later her temperature was 101° and her pulse 120. I announced to the family the gravity of the disease and the probability of the necessity of an operation very soon. I proposed a consultation with Dr. Charles K. Briddon, who saw her with me at 2.00 the same day. ■ After examining the patient, and learning from me the rapid appearance of serious symptoms, he agreed with me as to the diagnosis and as to the propriety of an early operation. I announced the result of our conference to the patient's husband, who, before consenting to any operation, desired the opinion of Dr. Robert W. Taylor, to which 1 gladly assented. Later in the day I met Dr. Taylor, and, after a careful review of the case, we both decided to call in Dr. Charles McBurney, who agreed with the other physicians as to the diagnosis and operation. Owing to the absence of Dr. Briddon from the city in the afternoon, it was not possible TWO CASES OF APPENDICITIS. 5 to perform the operation until late at night, when we all thought it had better be done, even though we should have to forego the advantages of daylight. The result has proved that we were right in losing no time. The operation was com- menced by Dr. Briddon at 12.10. He was assisted by Dr. Mc- Burney, Dr. Taylor, and myself. At this time the patient's temperature was 101'5° and her pulse 124. She had been kept moderately comfortable during the day by the frequent applica- tion of hot flaxseed poultices and an occasional hypodermic in- jection of Magendie's solution. The operation occupied a little over two hours, the ap- pendix being removed and found to be rather longer than usual. About half an inch from its junction with the large intestine a small movable object of about the size of a small pea could be felt. There was an enlargement of the appendix at about its middle, due to the presence of a hard mass in its interior, by which it was distended. About half way between this mass and its free extremity one side was very dark and gangrenous in appearance, with a correspondingly foetid odor. The ulcera- tion did not extend through its coats, but it was the opinion of all of us that a few hours more, perhaps twelve at most, would have terminated in perforation. I presume that the full details of the operation itself have been reported by Dr. Briddon, and I will therefore not take up any time by a description of so well known an operation here. Four hours after the operation the patient's temperature was 100'5°. She had a little pain, which was easily relieved by hypodermic injections of Magendie's solution. At eleven o'clock in the morning it was 101'4°, pulse 130. At 6.25 p. m. IOPS0, pulse 130. At 9.45 p. m. her temperature rose to 102.5°, and her pulse to 136, her respirations being 18. At 12.20 a. m., November 22d, her temperature was 103'5°, pulse 136, respirations 12; she suffered considerable pain, ex- cept when under the influence of Magendie's solution. Iler face was dusky and som© tympanites was present. At 5.10 her tem- perature was 103'8°, her pulse 138, and her respirations 12. Seven o'clock, temperature 103'2°, pulse 138, respirations 12. She did not vomit and had no movement from the bowels. The 6 TWO CASES OF APPENDICITIS. evidences of local peritonitis were very plain. At 9.45 tem- perature had risen to 103'8°, pulse 136, respirations 12. At 11.40, temperature 103'6°, pulse 136, respirations 12. During all this time the patient passed urine only by cathe- ter. She was given a tablespoonful of matzoori every three hours, and ice-wa^er by the teaspoonful to allay thirst. She now received an ounce of sulphate of magnesium in drachm doses every hour. An hour after the last dose the bowels not having moved, an enema of turpentine, soap, and hot water was admin- istered. This was retained about five minutes, when a large, loose, watery movement of the bowels followed. On Novem- ber 23d her temperature was 102°, pulse 120, respirations 18. On this day she again received a drachm of sulphate of magne- sium every hour until eight doses had been given. The bowels moved freely, and the tympanites disappeared partly. From this time her temperature gradually fell until Sunday afternoon, November 24th, when at 3 p. m. it was 99'8°. Two days after- ward she had a slight rise, temperature going to 101°. In twenty four hours it had fallen to normal and has never ex- ceeded that since. The wound healed very well at its upper end, but at the lower end there was some slight gaping, there was some pus at the site of the sutures, which were silk-worm gut, and the granulations were pale and unhealthy. An ointment was used consisting of an ounce of bismuth subnitrate, a drachm of balsam of Peru, and an ounce of zinc ointment. In a few days, suppuration still continuing, the use of this ointment was discontinued, and 1 substituted the subiodide of bismuth in pow- der. Its use caused a rapid discontinuance of the discharge and healing of the wound. Three weeks after the operation the patient was able to be lifted from her bed and placed in a recumbent chair. In the first case mentioned in this paper recovery took place without operation, but it seems to me that there is little in that fact to afford encouragement for delayed opera- tions. When we take into consideration the fact that this gentleman had had, undoubtedly, a similar attack, and that it was followed in a few years by a second attack, it seems TWO CASES OF APPENDICITIS. 7 to give warrant for the prediction that other attacks are likely to follow ; and who shall say that their termination will be as fortunate as those of which we have cognizance ? We all know of the case of a member of our profession who, after having had an attack of appendicitis in which spontaneous cure was effected, was compelled within six months to submit to laparotomy, which was, fortunately, successfully performed. When we come to supplement Case I with Case II and its gangrenous appendix, which gave rise to the rapid supervention of serious symptoms, it seems that we are warranted in adopting the views of those who advocate early operations for appendicitis if we are not willing to go so far as to follow those who take the very advanced view that intermediate operations should be done -namely, those where spontaneous recovery has taken place -and that all chance of future harm shall be shut off by operating as soon as health has been sufficiently restored to permit the appendix to be removed. If we have seen in Case I one of Nature's so-called cures, in Case II we can point to a human life saved by an early diagnosis and an early operation. ® REASONS WHY aHo Physicians Should Subscribe The New York Medical Journal, Edited by FRANK P. FOSTER, M. D., Published by D. APPLETON & CO., 1, 3, & 5 Bond St I. 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