*APPENDICITIS COMPLICATING

PREGNANCY.

GORDON A. BEEDLE, M. D., Kansas City, Mo.

Case.

Mrs. S., Kansas City. Age 26. First consulted me June 1, 1906. One child, 11⁄2 years old, no miscarriages or abortions. History of pregnancy at time, four months' duration. Had been suffering several days, nausea and vomiting. Short cutting pains beginning at the epigastrium, extending down and spreading over entire abdomen and pelvis. Temperature 102, with rapid pulse. Bowels constipated, which condition had been persistent since beginning pregnancy. No chills. Urine scanty and high color. Slight albumen, no casts. Muscular rigidity slight on both sides. Vaginal and rectal examinations revealed only the physiologically enlarged uterus, with exception of slight tenderness when pressing high up toward right iliac fossa.

Patient stated she had had two or

three similar attacks the past few months, but not so severe, and had attributed same to tendency to miscarry. Always seemed to come on after some sudden exertion or heavy day's work. Hot application over abdomen, soap suds enemas, repeated four hours apart, 10-gr. doses of salol internally, followed by a full glass of water, three times daily, left the patient in much improved conditon following morn ing: continued gradual improvement for next two or three days. This rapid improvement left the patient in a mental condition to consider lightly my previous suggestion at the possible necssity of removing a diseased appendix.

I heard from her no more until about two months later, when she called at my office, at which time she stated that she had gone through two similar attacks since my last visit, each being a little more severe than the previous.

*Paper read before the Kansas City Academy of Medicine, November 23, 1907.

Soon after, the patient moved the Springfield, Mo., where on Sept. 24, 1906, gave birth to a child. Baby died four days later. Cause of death, congestion of liver. Full information pertaining to same meager.

The latter part of February or the early part of March last, called to see Mrs. S., having not seen her for nearly a year. Found with a history of having missed menstruation for two months. Complained of sharp pains. in womb, frequent micturation, small quantity, otherwise urine normal. Had been suffering for three days; pains. worse when on feet. Occasional nausea

muscles

and vomiting. Temperature 102, pulse 120, coated tongue and patient constipated with skin slightly jaundiced. History of occasional shooting pains. in region of gall bladder. Careful palpation revealing no tenderness in this region, however; slightly more rigid on right side than left. Vag.. inal examination revealed an enlarged soft uterus, elongated cervix, suspicion of about three months' pregnancy. High digital rectal examination with counter pressure from without elicited extreme pain throughout iliac fossa, with the chief tenderness over the region of the appendix. Patient sent to hospital early next morning. Bowels were relieved by repeated low Ox G. enemas and caster oil.

Leukocyte count 10,000, which gradually rose to 16.000 by evening. Temperature, which had dropped to 100 in the morning, rose to 102.2 by evening, while abdominal pain seemed slightly better after stools were established. Tenderness on palpation over McBurney's point seemed increased, but no mass could be made out. Symptoms little changed the following morning with exception of leukocyte count, which showed 18,000. After customary preparation, operation was performed.

Appendix enlarged about the size of little finger, and pointing down toward the tube, and held there by adhesions, which were not dense and easily parted. Uterus large and felt soft to the finger tip. Appendix removed and ab

domen closed. On opening the appen dix it was found full of fecal matter and purulent looking serum, with two distinct points of apparent ulceration through mucosa. On the second day patient had a few sharp pains and showed slight bloody discharge from the vagina. Hypo. of morphine 4-gr. repeated every 4 hours seemed to completely allay any farther tendency in that direction. The patient making a perfect convalescence with the exception of a persistent slight temperature and rapid pulse, ichor, which finally disappeared, and before leaving the hospital on the fourteenth day. From inquiry I find she continued her gestation in good health and was confined in a normal delivery three weeks ago by Dr. C. F. Roberts, of this city, who tells me that there was no tendency to hernia, the scar not even stretching as a result of the abdominal tension.

Microscopical Examination of

Appendix.

Specimen of appendix from Mrs. S. Slightly above normal in size, somewhatc lub shaped, with visible inflamatory products on peritoneal surface, marked thickening serous coat. Cut section showed thickened and congested condition.

Stained sections microscopically showed thickened wall, due to dilated blood vessels, marked round cell infiltration with some connective tissue hyperplasia. The mucosa much swollen with erosions. In one place the erosion and degeneration of the mucous cells formed an ulcer. The round cell infiltration was so marked that in some areas the mucous coat appeared to be pried away from the membrane.

This appendix was in prime condition for abscess formation if it should have become infected with pyogenic bacteria.

Had just moved to Kansas City when first consulted me on or about May 26, 1907. Gave following symptoms; attacks of vertigo followed by spasmodic cutting pains in sacral region, running out over left iliac fossa and down thigh to knee. Pains commenced to grow more severe about a month previous, occurring more often and more severe each day. No nausea, appetite good; slept poorly, pain worse when on feet. Examination-Uterus

large retroflexed, copious leucorrhea: apparent mass posterior and little to left of fundus. Severe pain to the touch, right appendages normal in size, could not palpate left ovary. Doubted extra uterine pregnancy. Suspicious of pelvic abscess. Patient unable to leave bed next day. Pain excruciating, only relieved by Had bowels by opiate. cleansed. Examined per rectum. Could not locate mass, all seemed one large, soft mass like pregnant uterus. periods for three months, breasts enlarged. Patient could not stand the pain when I attempted to replace uterus, although under hypo. of 1⁄2-gr. morphine.

No

Patient running temperature 99 to 100, pulse 100 to 110 during the twenty-four hours. Tearing pains in back and down left thigh, with frequent desire to urinate the predominating symptoms; urinalysis normal, leukocyte count normal.

Diagnosis. Retroflexed. pregnant uterus with adhesions, possibly tubal

involvement on left side. Advised operation, which was performed two days later.

On opening the peritoneum, found omentum adhered to upper anterior surface of large soft uterus, adhesion extending posteriorly, drawing uterus. backward and to the left side, left ovary and tube coiled partially under uterus, and plastered with dense adhesions, requiring incision; tube large and inflamed, with constrictions in two places apparently caused by adhesions. Ovary about twice the normal size, containing a large hematoma, occupying about three-fourths of its entirety. No pus apparent. Removed both tube and ovary after freeing all adhesions binding the uterus. Handling of the uterus was done with great care, hot normal salt solution was used through constant irrigation. Patient left table in good condition, after enema of normal salt solution.

Returned to room; pulse 120, weak and irregular. Nauseated. Temperature 100 by evening, pulse 82.

June 4-Nausea persistent, but not SO severe. Patient resting in short naps. Pulse ranging from 80 to 90; temperature staying at 99.6 to 99.8. Bowels and urine passed voluntarily. Resting, in occasional short naps. Some white mucoid discharge from vagina.

June 5-Slept until 2 a. m., calling for water frequently. Refuses nourishment. Pulse 80, temperature 99. Urine offensive odor and scanty; offensive odor from vagina but no discharge. Considerable nausea during day, complains of some shooting pains in womb. Temperature rose to 99.4 by evening. Toward midnight took some buttermilk. Low enemas relieved the patient of good deal of gas.

June 6-Patient spent fairly good night. Temperature at midnight normal, but rose to 99.4 by noon. Slight milky vaginal discharge, no odor, took buttermilk freely and chewed steak, swallowing juice only. Considerable gas, which passed freely. Urine normal in amount and character. Tempera

ture 4 p. m. 99.6. Patient feeling comfortable.

June 7-Pulse ranging around 80, temperature 99.4 to 99.6. Patient on general semi-solid diet. 4 p. m. pulse 78, temperature 99.4, which continued same til midnight. Bowels and kidneys acted. Patient doing nicely.

June 9 At 4 o'clock pulse 78, temperature, 99 highest point; continued same till midnight. Wound dressed, stitches removed.

June 10-Temperature stationary 99, slight milky vaginal discharge, odor. Some pain through womb. Wound dressed. A transverse incision closed subcutaneously with silkworm suture. Slight gapping of skin edge at center of wound, to the extent of about one-half inch, which filled in readily after the next few subsequent dressings.

June 11-Temperature rose to 99.4 by noon. Continued same till midnight. Pulse 95. Continued slight vaginal discharge. The next few days discharge from vagina entirely disappeared. Uterine and abdominal pains entirely ceased. Patient's appetite and digestion continued good. Bowels and kidneys acted normally. Patient felt better each succeeding day. However, the temperature continued to rise daily reaching from 99.6 to 100 by noon or afternoon of each day. Patient's pulse gradually grew more rapid till on June 29 it reached 126 at 3 p. m. The occasionally intermittency that was noticed in the beginning continued same. throughout. Heart sounds otherwise perfectly normal. Frequent attempts at getting patient up increased the heart action so that same was persisted in very cautiously. Patient was returned home June 30.

After two weeks her temperature and pulse gradually assumed a normal character throughout twenty-four hours. With exception of few hypo. of morphine, given at the beginning of uterine pains or when they showed a tendency to grow severe, occasional rounds of calolactose followed in the morning by salines. Low enemas, re

peated every three or four hours when fermentation was persistent. Hypo. of strychnia when pulse persisted over 100 and weak, was comparatively all the medication administered.

The patient grew strong rapidly and has not had a sick day since and is now nearing her limit of gestation. I took the liberty to call on her at her home about two weeks ago and requested the previlege of examination. I found her enjoying most excelent health in every particular, position normal vortex, fetal heart beat clearly discerned on left side well down toward the fossa. Pulse beat 125 per minute.

Appendicitis Complicating Pregnancy. In reporting the case of appendicitis complicating pregnancy, I do not do so from the standpoint of any good result in such work, as we all recognize today that the pendulum of fear associated with abdominal surgery of pregnant women is fast swinging toward the other extreme. Statistics of experience bearing us out in the statement that there is little more danger in operating on the pregnant over the nonpregnant, barring, of course, conditions pertaining directly to uterine body, but more with the desired intention of bringing under discussion the following points: Does pregnancy influence apendicitis or does it play a part in predispositon toward producing the same. Boije quoted from an article written by Lockyer in the International Clinic, claiming appendicitis is rare in pregnancy, hence the latter cannot be a predisposing cause; also being slightly more common in men, which fact would not be expected if women incurred an additional risk through pregnancy. While this appears logical, do we hear of every case which occurs? Is it not possible that many cases of light recurrent attacks pass through unobserved, shrouded in obscurity by the many shifting vagaries often associated with a progressive getation.

Continuous observation of progress ing pregnancies from an intellectual. much less scientific standpoint is com

partively unknown. The handy nighbor lady of possible multiple experience drops in pours her bounteous wisdom like a soothing ointment over the coming mother. She knows the cause of every ache and pain and knows just what to do for it. The sudden pain from the epigastrium to the iliac fossa is due to womb pressure. Catching cold gives her a little fever, and perfectly natural to vomit when pregnant. course she needs a physic, and so on. They no doubt pass over, never knowing their danger. Such cases I believe are possible, they do exist and are more common than we are inclined to believe. Just as the case above reported, frequently being passed ever as a tendency of the individual to abortion.

Of

In pregnancy few women are free from constipation in the majority it is present and often to a very obstinant degree. Such conditions unquestionably predispose to appendicitis. Through its almost constant presistance cramping or extension of the bowel over and impinging the appendix in a cramped position. In other words acting in a degree as trouma which results in an initial inflammatory stage. Coupled later with circulatory congestion or pressure associated with a rapidly enlarging uterus.

As to the effect of pregnancy on an established chronic, or acutely involved appendix. It varies greatly in respect to the position of the appendix, the degree of involvement and the amount of adhesions. As for instance the case of Lockyer as described in the article above referred to. Wherein the case suffered slight attacks during gestation but no urgent symptoms occurred until the end of the involution period when operation exposed the cecum drawn down into the small pelvis through adhesions to the fundus uteri. The apendix glued to the right tube and ovary. One writer contends that severe cases are seldom seen in connection with pregnancy, freedom from which he credits the stimulation of absolution through increased pelvic circulation. That very theory may re

act in this way. A swollen congested organ does not want more blood pumped into, directly or indirectly, rather would it relieve itself of an overabundance it has on hand. On the other hand, I believe it probable in many cases the origination is due to interference of the circulation to the tissue, increasing the circulation of the pelvic area in such could not benefit the involved tissue.

Again let us cite a case which we have all seen and which is not infre quent, that of a long inflamed appendix, pointing over and glued to the right tube or ovary with adhesion, while we know single tubal involvements are not common and pregnancy under such conditions still less, they do occur and possibly more frequently than we are inclined to believe. At the fourth or fifth month the pregnant uterus rises up into the false pelvis and presses out toward the cecum, mechanical irritation is then added to the diseased tissue through pressure and pulling of the ahesions.

While there may be some slightly involved appendices causing little surrounding disturbances so fortunately. situated, they might pass through at gestation without an increased demonstration of trouble due to the pregnancy, I believe it is more frequently the awakening of the patient to the fact of having a chronic appendix for years. As for operating the earlier the better in reference to pregnancy; I am thankful this patient's pronounced attack and consent to operation occurred before the advanced gestation, because then nature is handicapped in space. The large uterus endangers nature's walling in cases of abscess by pulling and tearing the adhesions, or sudden pressure on the wall by its weight being suddenly shifted to the right side results in rup ture followed by diffuse peritonitis.

Diagnosis: The diagnosis of appendicitis in connection with pregnancy, as a rule, holds out no marked difficulties but at times when especially mild attacks form, the symptoms may

be greatly obscured by the association of those commonly found during gestation. Attacks occurring after fourth month of gestation gives an added difficulty in respect to palpation and percussion. A leukocyte count plays an important part in many uncertain diagnosis and has proven a great benefit to me in determining the exact stage of the disease and consequently timing the surgical interference. While it is true we occasionally see cases with all clinical symptoms absolutely clear, the case presenting a clearly defined walled off abscess, the finding of a normal leukocytosis should not encourage procrastination, as such may be a demonstration of nature's extra effort in walling off infection.

The most reliability obtained from leukocyte counting is through the comparison of repeated specimens taken from one to three hours intervals. With clinical symptoms obscure but suspicious a leukocyte count showing an increase at each counting, especially if the count reaches 20,000 operation is indicated. A tendency to continue. a gradual rise no matter how slight is a very bad omen.

Tubo-Ovarian Disease With Incarceration of Uterus Through Adhesions Complicating Pregnan

cy at Three Months.

A

This case of Mrs. W. brings before us in my opinion a condition of the most grave type. Not alone from the standpoint of a frequent cause of abortion or miscarriage, but the added danger of an interfered miscariage. uterus in normal position is much better able to drain the canal, being in proper axis with gravity whether on the back in bed or on the feet. Take the same uterus and find the fundus o the entire uterus backward and the danger is increased in proportion to the degree of backward misplacement or flexion. Add to this a bundle of cords in the form of adhesions to hold it in the position, then start it to enlarging with a developing fectus and