APPENDICITIS IN RELATION TO DISEASE OF THE UTERINE ADNEXE AND PREGNANCY.

BY JOHN B. DEAVER, M.D.,

PHILADELPHIA.

A PAPER upon the subject of appendicitis, with its fatality and many complications, and the close relationship which it may bear to contiguous organs and structures, will be of particular interest to this body of obstetricians and gynecologists. You will, no doubt, agree with me that acute appendicitis is the most common and one of the most fatal of all acute intra-abdominal affections. Furthermore, that this mortality is in a great measure due to a failure to make an early diagnosis and to the character of the treatment instituted. The position which I have held—namely, to operate as soon as the diagnosis is made-I still maintain. Assuming that this is done very shortly after the onset of the attack, I know that this course is attended by the least mortality. My experience in the operative treatment of this dangerous, treacherous, and fatal disease embraces many hundred cases, and I am prepared to make the statement that I have never seen a human life lost where operation was performed immediately following the onset of the disease. While I am aware that to discriminate between cases and to be able to say from the onset which are operative cases and which will recover without operation, or to be able to defer operation with absolute safety for two, three, or more days, rather than to rush in, as some put it, and remove the diseased appendix as soon as the diagnosis is made, may be more scientific, yet I know positively that this course is at the cost of many human lives. When, therefore, it becomes a question of following the lines of theory or that of experience which teaches practical facts and which when instituted will bring practical and favorable results, to my mind no choice is permitted. The ultimate results of inflammation of this organ more than justify early operative interference.

Let us consider for a moment some of the results of appendiceal

inflammation. First and most important, because of the high rate of mortality, is perforation of the appendix with general septic peritonitis. Next, perforation with localized abscess formation which, if not evacuated early, produces general sepsis, a tedious convalescence, a granulating wound, and in many instances ventral hernia or fecal fistula. Appendicitis followed by large localized abscess necessarily means the destruction of a great deal of tissue which in some instances nature fails to repair, to say nothing of the loss of life when it occurs in the young or feeble. I consider the formation of a localized abscess occurring as the result of an appendicitis anything but the most fortunate culmination of the attack, for the following reasons—namely, because the inflammation should not be allowed to reach that stage; and in the hands of the majority of operators it is an excuse to leave the appendix, believing that with the evacuation of the abscess they have accomplished all that can be expected. This practice not only offers an excuse in too many instances for leaving behind an appendix which is more liable to be the cause of subsequent and less favorable attacks, but also exposes the patient to the risk of an undiscovered secondary collection which in my experience is a frequent cause of death. Before a body of operators comprising the membership of this association it would be presumptuous for me to draw a comparison between operation in the absence of and in the presence of pus. I may, however, bring to your attention some complications of pusformation which I have met with.

The presence of pus increases the danger of lymphatic infection. This is also true of infection through the portal system (pyelophlebitis), resulting in miliary abscess of the liver and death. The complications which may arise from an undisturbed localized appendiceal abscess are its rupture into the bladder, thus occasioning an entero-vesical fistula; rupture into a bronchus and evacuation by way of the mouth; rupture into the ascending colon, rectum, or vagina, which is not to be considered a favorable termination, and does not preclude the possibility of a recurrence of the inflammation; rupture into the ureter with evacuation of pus through the bladder. A complication which is not an uncommon sequence of the formation of a localized abscess is intestinal obstruction, due to adhesions which have been formed in the process of localization. Again, secondary obstruction may follow the evacuation of an

abscess, due to the subsequent contraction of its walls. A septic phlebitis, phlegmasia alba dolens, is not an uncommon sequence of localized abscess formation.

A condition of affairs which may arise as the result of a small collection which has remained undisturbed, is when the abscess wall has undergone a cheesy degeneration, involving in the process contiguous structures. When the bowel has been thus included an attempt to remove the degenerated mass will frequently bring to light a perforation of the bowel, often so large as to necessitate excision, enterorrhaphy, or an anastomosis. In operating for appendicitis, the multiplication of the difficulties induced by pus-formation must prepare the surgeon to expect to meet and handle any of the complications of abdominal surgery.

To recapitulate: the large mortality in appendicitis, as I have previously stated, is the result of too conservative measures in the early stage of the disease. Surgeons whose experience in the treatment of appendicitis has been large, I am sure, will to a man agree with me in this statement. To be brief, I have yet to see a human life lost where, in an acute attack of appendicitis, the appendix has been removed within six to eight hours after the onset of the disease, while, on the other hand, I regret to say that I have seen many human lives lost by adopting the so-called conservative methods-namely, opium to relieve the pain, allowing the bowels to remain confined, leeches, fly-blisters, turpentine stupes appliedany or all of which are not only useless but harmful. I cannot make this too strong, as I have seen five deaths in as many days, in all of which cases I am morally certain that had the appendix been removed immediately after the onset of the first pain all would have recovered.

The question naturally arises, who is largely responsible for this high mortality? Is it our teachers? Personally I feel that it is. What is the alternative? I would suggest that our professors in the different teaching institutions witness a number of operations done early (most of them see them done late), when I know there will no longer be the list of sceptics there are now. This, too, would be a healthful diet for the so-called surgical critic who writes articles condemning too frequent operation. The last-mentioned class evidently is wanting in experience, otherwise those who belong to it could not but entertain different views.

The conditions in the female which call for careful thought in differentiating between one or other of the diseases of the uterine adnexæ and acute or chronic appendicitis are the following:

1. Acute Salpingitis. There is frequently a close relationship between acute catarrhal appendicitis and right-sided acute salpingitis, due to Clado's ligament, and the symptoms may as a result closely resemble each other. The great points of difference, however, are the history of infection, the slight degree of abdominal tenderness and rigidity, the location of the pain, and the absence of vomiting, and in the case of appendicitis the pain migrating from epigastric or periumbilical to the right iliac fossa, the decided tenderness and rigidity of the lower right quadrant of the abdominal wall, suddenness of attack, accompanied by vomiting and no history of infection, the absence of signs by vaginal examination and the presence of a palpably enlarged appendix.

2. Pyosalpinx and Ovarian Abscess. The presence in the rectouterine cul-de-sac of an inflammatory mass in intimate relation with the uterus, which renders it partially or completely immovable, and which can be clearly outlined by vaginal, bimanual, or combined vaginal and rectal examination, together with the history of a vagino-uterine infection and the presence of a septic fever, establishes the diagnosis of pyosalpinx or ovarian abscess. The essential points in the differentiation between these two affectious and appendicitis are the suddenness of onset in the latter, accompanied by vomiting, the characteristic rigidity and tenderness following general abdominal pain.

Inflammation of the right ovary may be confounded with appendicitis, as it is attended with pain, tenderness in the right iliac fossa, nausea, and fever. It is, however, always accompanied by disturbances of the uterine functions, is accompanied by the charactersitic "ovarian" pain, and is demonstrable by vaginal or bimanual examination. The tenderness is never so intense as in appendicitis and is not accompanied by a perceptibly enlarged appendix.

3. Extra-uterine Pregnancy. The history in these cases is usually that of partial or complete cessation of the menstrual flow for one, two, or more periods, generally accompanied by other symptoms of pregnancy, with collapse supervening upon an attack of acute abdominal pain. The pain is long-continued and paroxysmal, but

not colicky. An irregular, bloody, vaginal discharge, generally lighter in color than the normal menstrual flow, and containing shreds of tissue, portions of the decidua, is present. Vaginal examination will detect a tender and sensitive mass in the posterior cul-de-sac, unless the pregnancy be an abdominal one. In the majority of these cases there is a history of sterility for five or six years previous to the abnormal conception.

When the product of conception occupies the fimbriated extremity of the right tube, the points of differentiation are more difficult, owing to the close proximity of the lesion to the position of the appendix and to the negative result of examination per vaginam prior to rupture. Should the two conditions occur coincidently it would be wellnigh impossible to differentiate between them.

The chief points to be borne in mind, however, if the two conditions do not coëxist, are the history and the absence of inflammatory symptoms prior to the rupture of the extra-uterine sac and the presence of inflammatory symptoms in appendicitis.

4. Suppurating Ovarian Cyst. An appendiceal abscess and a small suppurating ovarian cyst on the right side present some symptoms in common which may give rise to difficulties in diagnosis. These symptms are: painful tumor in the right iliac fossa, which may be made out by vaginal, bimanual, and rectal examinations; symptoms of septicemia; hectic temperature, and history of previous gastric and urinary irritation. The differences, however, are marked and can be distinguished by careful consideration. In ovarian cyst the onset is gradual, and a history of infection can generally be elicited. The pain is constant and of a dull character; by pressure the significant" ovarian pain" may be produced, differing from the colicky and paroxysmal pain of appendicitis, while the tumor itself is more elastic, having apparently thinner walls and a more regular outline.

5. Ovarian Cyst with Twisted Pedicle. Ovarian cyst with a twisted pedicle gives, as a rule, a history of a slowly growing tumor, which is so frequently unaccompanied with pain that its presence has been unsuspected until the accident has occurred. The onset of the acute symptoms of a cyst with a twisted pedicle is sudden, and is usually caused by excessive peristalsis of the intestines or from sudden changes of the position of the body, causing the tumor to revolve. If the twisting be complete and shut off